Does Ultra-Short Anatomic Cementless Stem Increase Revision Rates Compared to Contemporary Cemented Femoral Stem in Patients with Dorr Type C Femur?

Young-Hoo Kim^1*, Jang-Won Park², Young-Soo Jang¹, Eun-Jung Kim¹

¹The Joint Replacement Center of Seoul Metropolitan Government, SeoNam Hospital, Seoul, Republic of Korea
²Department of Orthopedic Surgery, Ewha Womans University, Seoul Hospital, Seoul, Republic of Korea

*Correspondence author: Young-Hoo Kim, MD, The Joint Replacement Center of Seoul Metropolitan Government, SeoNam Hospital, Seoul, Republic of Korea; Email: [email protected]

Citation: Kim YH, et al. Does Ultra-Short Anatomic Cementless Stem Increase Revision Rates Compared to Contemporary Cemented Femoral Stem in Patients with Dorr Type C Femur? J Ortho Sci Res. 2025;6(3):1-12.

Copyright^© 2025 by Kim YH, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Table 1: Patient characteristics.

Results

Clinical Outcomes

No statistically significant differences were identified between the 2 groups with respect to Harris Hip scores, pain scores, function scores, WOMAC scores, activity levels, and thigh pain severity (Table 2). In the cementless group, the mean preoperative Harris hip score was 48 ± 9 points (range, 9 to 51 points), which improved to a mean of 92 ± 11 points (range, 75 to 100 points) at the time of the final follow-up. In the cemented group, the mean preoperative Harris hip score was 45 ± 8 points (range, 7 to 56 points), which improved to a mean of 93 ± 9 points (range, 71 to 100 points) at the final follow-up. In the cementless group, the mean preoperative WOMAC score was 65 ± 15 points (range, 41 to 89 points), which improved to 15 ± 6 points (range, 4 to 29 points) at the final follow-up. In the cemented group, the mean preoperative WOMAC score was 68 ± 14 points (range, 38 to 91 points), which improved to 12 ± 8 points (range, 4 to 31 points) at the final follow-up. The UCLA activity score was 3 points (range, 1 to 4 points) preoperatively in the cementless group and improved to 8 points (range, 6 to 10 points) at the final follow-up. In the cemented group, the preoperative UCLA activity score was 2.4 points (range, 1 to 4 points) and improved to 7.6 points (range, 6 to 9 points) at the final follow-up. The prevalence of severe (10 point) thigh pain at the final follow-up was 3% (3 hips) due to aseptic loosening of the stem in the cementless group, and it was 4% (4 hips) due to aseptic loosening of the stem in the cemented group at the final follow-up. Seventeen hips (15%) in the cementless group and 16 hips (14%) in the cemented group displayed a clicking sound, and 9 hips (8%) in the cementless group, and 11 hips (10%) in the cemented group displayed squeaking sound.

Radiographic Findings

Radiologic comparisons revealed no major intergroup differences (Table 3). Cortical Thickness Index (CTI) was 0.71 in the cementless group and 0.73 in the cemented group (p=0.528). In the cementless group, as seen on the postoperative radiographs, 91 femoral stems (81%) were neutral, 19 (17%) were in varus (<5°), and 2 (2%) were in valgus (<5°). The mean inclination and anteversion of the acetabular component were 44° (range, 37° to 49°) and 21° (range, 17° to 25°), respectively. All acetabular components and all but 3 femoral components had osseous integration. Three femoral coponents were subsided due to aseptic loosening. One hundred and five (94%) hips exhibited Grade 1 stress shielding in the calcar region and 7 (6%) hips had Grade 2 stress shielding. No acetabular or femoral osteolysis was identified in any hip (Fig. 2-4).

In the cemented group, 104 femoral stems (93%) were neutral, 5 (4%) were in varus (<5°), and 3 (3%) were in valgus (<5°). The mean inclination and anteversion of the acetabular component were 41° (range, 36° to 50°) and 23° (range, 19° to 28°), respectively. One hundred five hips (94%) had the Grade A cementing technique; 5 hips (4%), Grade B; 2 hips (2%), Grade C. All cementless acetabular components had osseous-integration (Fig. 4,5). Four hips (4%) had >2 mm radiolucent line around the femoral component and subsided femoral component due to aseptic loosening. No acetabular component had osteolysis. Four femoral stems (4%) had osteolysis in zones 1, 2, 5, 6, and 7.

Table 2: Clinical results.

Table 3: Radiographic results.

Complications

In the cementless group, an early deep postoperative infection developed in 2 hips (1.8%), and these 2 hips were revised in 2 stages. Three hips (2.7%) had an aseptic loosening of the femoral component and these 3 hips were revised. Two hips (1.8%) had intraoperative calcar femoral fractures, which were fixed with a cable. No hip had any postoperative femoral fracture. Two hips (1.8%) had a recurrent dislocation, and these 2 hips were revised with a constrained cup. There was no further dislocation.

In the cemented group, an early, deep postoperative infection developed in 3 hips (2.7%). Open debridement and exchange of an acetabular liner and a femoral head were performed, and intravenous antibiotics were administered for 6 weeks. There were no recurrent infections in these 3 hips. Four hips (3.5%) had an aseptic loosening of the femoral component and these 4 hips were revised using a cementless stem (Solution; DePuy, Warsaw, Indiana). Four hips (3.5%) had an intraoperative calcar femoral fracture, which was fixed with a cable. All of these revised 4 hips had a rigid fixation by osseonintegration. Three hips (2.7%) had a recurrent dislocation, and these 3 hips were revised with a constrained cup. There was no further dislocation.

Revision Procedures

In the cementless groups, 5 femoral stems (4.5%) were revised, 2 (1.8%) for infection and 3 (2.7%) for aseptic loosening. Two hips (1.8%) had a revision of the acetabular component for a recurrent dislocation. Two (1.8%) acetabular components were revised for infection. In the cemented group, 3 hips (2.7%) were revised for an aseptic loosening of the femoral component. Two acetabular components (1.8%) were revised for a recurrent dislocation.

Survivorship

In the cementless group, Kapaln-Meier survivorship analysis at 10 years reveald that the survival rate of the femoral component was 98.5%  (95% confidence interval, 93% to 100%) and 98% (95% confidence interval, 93% to 100%) at 15 years and 95.5% (95% confidence interval, 91% to 100%) at 20 years, with loosening or revision considered the end point for failure (Fig.6) [18]. The rate of survival of the acetabular component was 99% (CI, 95% to 100%) at 10 years and 97% (CI, 92% to 100%) at 15 years and 96.4% at 20 years (95% CI, 92% to 100%). In the cemented group, Kaplan-Meier survivorship analysis at 10 years revealed that the survival rate of the femoral component was 98% (95% CI, 94% to 100%), 96% (95% CI, 94% to 100%) at 15 years and 94% (95%CI, 92% to 100%) at 22 years, with loosening or revision considered the end point for failure. The survival rate of the acetabular component was 98.5% (95% CI, 93% to 100%) at 10 years, and 97.5% (95% CI, 93% to 100%) at 15 years, and 97.3% (95% CI, 95.5% to 100%) at 22 years, with loosening or revision considered the end point for failure (Fig. 7).

Figure 1: The Consolidated Standards of Reporting Trials (CONSORT) flow diagram of patient in this study.

Figure 2: Anteroposterior and lateral radiographs of a 48-year-old man with osteonecrosis of left femoral head. A:       Preoperative radiograph of left hip demonstrates collapse of left femoral head (Ficat stage Ⅳ) and Dorr type C femur; B: Postoperative radiograph of left hip obtained. 17 years after the operation. The acetabular component and a calcar loading with a lateral flare anatomic cementless femoral component are well fixed in a satisfactory position without radiolucent line or osteolysis.

Figure 3: Anteroposteiror and lateral radiograph of a 57-year-old woman with osteoarthritis of right hip. A: Preoperative anterioposterior view of right hip reveals osteoarthritis hip (Dorr type C femur); B: Postoperative anteroposterior view of right hip obtained. 18 years after the operation. The cementless acetabular and cemented femoral components are well fixed in a satisfactory position without radiolucent line or osteolysis.

Figure 4: Radiographs of a 68-year-old man who had osteonecrosis of both femoral heads. A: Preoperative radiograph of both hips demonstrates collapse of both femoral heads (Ficat stage Ⅲ) and Dorr type C bone; B: Postoperative radiograph of both hips obtained 20 years after surgery demonstrates that the proximal stem is rigidly fixed in a satisfactory position of both hips.

Figure 5: Radiographs of a 55-year-old man who had osteoarthritis due to childhood pyogenic arthritis of the right hip. A: Preoperative radiograph of the right hip reveals complete loss of articular cartilage of the hip joint and Dorr type C bone; B: Anteroposterior radiograph of the right hip, made 19 years after the operation, demonstrating that both components are well fixed. There is no evidence of acetabular or femoral osteolysis.

Figure 6: The Kaplan-Meier curve shows the acetabular and femoral components at a mean of 17.5 years in the cementless THA group.

Figure 7: The Kaplan-Meier curve shows the acetabular and femoral component at a mean of 18.8 years in the cemented THA group.

Discussion

In this trial with extended follow-up to 20-22 years, both fixation strategies demonstrated favorable outcomes, including reliable implant stability, reduced adaptive bone resorption, low complication and revision rates, and excellent long-term survivorship. These findings align closely with previously published reports [2-7, 17-31]. Kim, et al., previously reported no significant differences in outcomes between cemented and cementless stems, a result echoed by our analysis [17]. Several factors likely contributed to these strong outcomes in our cohort: refinements in cementing technique (grades A, B, and C), improved stem designs, advances in implantation technique for the cementless stems, and the relatively small body size and weight of our patient population. Published literature on cementless tapered stems in Dorr type C femora remains limited and often involves small patient series with shorter follow-up [32-34]. Reitman, et al., reported favorable outcomes with the Mallory-Head (Zimmer Biomet, Warsaw, Indiana) stems in 81 patients followed for an average of 13.21 years, with no revision required for aseptic loosening [32]. Similarly, Kelly, et al., described their results using the hydroxyapatite-coated Omnifit HA stem (Stryker, Mahwah, New Jersey) in 15 patients followed for a mean of 11.5 years (9 to 14), with only one early revision for infection [33]. Dalury, et al., also demonstrated survivorship at 6 years using the proximally porous-coated Summit stem (DePuy Synthes, Warsaw, Indiana) in 40 patients (45 hips) [34]. Modern cementless stems, particularly straight-tapered models have provided excellent results when appropriately implanted in this challenging population. Kim, et al., observed consistent osseointegration even in patients with compromised bone quality, including femoral neck fracture, when treated with either a conventional cementless long stem (Solution stem; Zimmer, Warsaw, Indiana) or an ultra-short anatomic cementless design (DePuy, Leeds, UK). Our findings are consistent with these observations [35].

Although contemporary cemented stems have also demonstrated strong long-term outcomes, reports in Dorr type C femora remain mixed. Kobayashi, et al., documented a 16-year survival rate of only 81.6% with Charnley cemented stems, whereas Williams, et al., reported 100% survival of 325 Exter stems (Stryker) in this same bone type [36,37]. The Charnley Elite stem has been particularly debated: some authors report comparable performance to the original Charnley stem while others have suggested inferior durability [38-41]. In our series, we attributed our excellent cemented results to careful cementing technique combined with the smaller body habitus of our patient population. This investigation has several limitations. First, despite prospectively collected data, the analysis was retrospective. Second, unusually high follow-up rates at a minimum follow-up of 15 years strengthen our conclusions but may not be generalizable. Third, radiostereometric analysis was not utilized. Finally, the absence of interobserver assessments may introduce bias in radiographic interpretation.

Conclusion

In conclusion, our findings demonstrate that both proximally loading ultra-short anatomic cementless stems and contemporary cemented stems provide secure fixation and long-term durability in patients with Dorr type C femora. Concerns regarding compromised bone quality in this morphology did not translate into reduced implant stability or survivorship. These results indicate that either fixation approach can be reliably employed in this challenging bone type.

Conflict of Interests

The authors declare that there is no conflict of interest related to this study.

Funding/Sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

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