Clinical performance of short versus conventional stems in primary cementless total hip arthroplasty

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Short stems were originally designed to be used in total hip arthroplasty (THA) in younger, more active patients who are likely to need future revisions. The idea of a short stem that preserves femoral bone stock both proximally and distally is extremely attractive, but these features should not come at the expense of a shorter lifetime, higher complication rates, worse function, or increased pain. In Part 2 of this series, a review of midterm clinical evidence has shown that short-stem THA has performed well overall, with good implant survivorship and good clinical outcomes. But how do short stems perform in comparison to conventional stems? In Part 3, Carlos Lucero, orthopedic surgeon at the Hospital Italiano de Buenos Aires, Argentina, shares the results of some recent comparative studies examining the performance of short stems and conventional stems.

Carlos Martin Lucero MD

Italian Hospital Buenos Aires, Argentina

How long do short stems have to last?

Some early observations have shown pronounced early migration of short stems. These have caused the concern that, due to their reduced lengths and lack of diaphyseal fixation, these new generation stems may have less primary stability and increased micromotion that interferes with osseointegration and thus increase the risk of aseptic loosening [1]. Even though evidence now shows that short stems may have different settlement patterns from conventional (ie, standard) stems and the settlement period may last as long as 2 years after the procedure (see discussion on short stem subsidence and migration in Part 2), most of the studies were relatively small and may suffer from expertise bias; and ultimately, how well do short stems perform in comparison to conventional stems?

According to the benchmark set by the National Institute for Health and Care Excellence (NICE) (UK) in 2014 [2], "prostheses for total hip replacement … are recommended as treatment options for people with end-stage arthritis of the hip only if the prostheses have rates (or projected rates) of revision of 5% or less at 10 years". As shown in Part 2, several short stems have demonstrated a midterm (4–10 years) survival rate of 97% or greater, and therefore, have potentially met the NICE benchmark.

Population-based comparisons

In its 2021 annual report, the Australian Orthopaedic Association analyzed data extracted from its National Joint Replacement Registry and compared the cumulative revision rate of short stems and other stems (ie, both cemented and uncemented stems) in primary THA due to osteoarthritis. The Australian Orthopaedic Association defined "mini stems" as short cementless femoral stems where fixation is designed to be entirely metaphyseal. To ensure the relevance of the report and make sure the results would not be influenced by older, inferior stems, the analyses were limited mostly to the protheses still in use in 2020 and described as "modern prostheses" [3].

As shown in Table 1, the cumulative 10-year revision rate of mini stems was 2.9% (95% confidence interval [CI] 2.4–3.6)—a lower rate than the 4.4% (95% CI 4.3–4.5) revision rate for other femoral stems [3]. Table 2 further shows the revision rates of different short stems; although one must bear in mind that the analyses were performed without adjusting for any potential confounding factors.

Interestingly, comparing the results from the 2021 report with those from the 2017 one [4], the 10-year revision rate of the mini stems had improved from being inferior to other femoral stems in 2017 (6.2% versus 5.1%, respectively, Table 3) to being superior to other stems (2.9% versus 4.4%, respectively, Table 1). This change could potentially be explained by the exclusion of data from some older short stems in the 2021 report. The short stems included in the 2017 but not the 2021 report were Mayo, CFP, and Silent [4].

Table 1. A comparison of cumulative revision rates between short (mini) stems and conventional stems (2021 report) [4]. All procedures using metal/metal prostheses have been excluded. The analyses were restricted to modern prostheses. Table reproduced with permission under the CC BY-NC-ND 4.0 License terms. https://creativecommons.org/licenses/by-nc-nd/4.0  Source: AOANJRR. Annual report 2021, Australian Orthopaedic Association National Joint Replacement Registry. ADELAIDE, Australia: Australian Orthopaedic Association; 2021.
Table 2. A comparison of cumulative revision rates among seven short (mini) stems currently in use (2021 report) [4]. All procedures using metal/metal prostheses have been excluded. The analyses were restricted to modern prostheses.Table reproduced with permission under the CC BY-NC-ND 4.0 License terms. https://creativecommons.org/licenses/by-nc-nd/4.0 Source: AOANJRR. Annual report 2021, Australian Orthopaedic Association National Joint Replacement Registry. ADELAIDE, Australia: Australian Orthopaedic Association; 2021.
Table 3. A comparison of cumulative revision rates between short (mini) stems and conventional stems (2017 report) [3]. All procedures using metal/metal prostheses with head size larger than 32mm have been excluded. Table reproduced with permission under the CC BY-NC-ND 4.0  License terms. https://creativecommons.org/licenses/by-nc-nd/4.0. Source: AOANJRR. Annual report 2017, Australian Orthopaedic Association National Joint Replacement Registry. ADELAIDE, Australia: Australian Orthopaedic Association; 2017.

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  • Propensity score matched data analysis of a German arthroplasty registry
  • Bone mineral density-based stress shielding comparison
  • X-ray-assessed results for stress-shielding
  • Functional results
  • Thigh pain
  • Intraoperative periprosthetic fractures
  • A final tip

Part 1 | Biomechanical advantages

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Part 2 | Midterm results

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Contributing experts

This series of articles was created with the support of the following specialists (in alphabetical order):

Martin Buttaro

Italian Hospital Buenos Aires, Argentina

Marco Ezechieli

Vincenz Group Paderborn, St Josefs Hospital Salzkotten, Germany

Carlos Martin Lucero MD

Italian Hospital Buenos Aires, Argentina

This issue was written by Maio Chen, AO Innovation Translation Center, Clinical Science, Switzerland.

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