Healio
Healio
August 01, 2005
21 min read
Save

The Cemented Femoral Stem: Selecting the Ideal Patient

Abstract

A woman who is elderly, lightweight, and low demand has traditionally been considered an ideal candidate for a cemented femoral stem. Patients who are young, heavy, and high demand have been considered higher risk for failure and, therefore, better suited for cementless femoral stems. However, modern cement techniques and implants have improved outcomes in high-risk cohorts, and stress shielding, thigh pain, and osteolysis have emerged as long-term challenges for cementless femoral stems. Recently reported positive bone remodeling around a cemented, triple-tapered, polished, collarless stem behaving according to the taper-slip philosophy of femoral stem fixation may widen the traditional indications for cemented femoral stems. Paradoxically, patients initially thought to be poor candidates for cemented fixation may benefit most from the long-term bone preservation and positive loading characteristics of this new generation of cemented stem technology.

The choice of fixation affects the longevity and durability of total hip arthroplasty (THA). The chosen method must achieve stable initial fixation and resist and withstand the repetitive forces that can disrupt the fixation interfaces and cause loosening over time. Traditionally, cement has been considered the gold standard for fixation of the stem.1 Recently, with the proliferation of cementless designs and longer favorable follow-up, cementless fixation has become popular. Cementless fixation is the preferred approach in the United States for the acetabulum.1

However, significant controversy regarding the stem remains. Some surgeons favor cementless fixation for most patients.2-5 For others, cement is the fixation technique of choice.6-8 Still other surgeons individualize fixation to a patient, weighing a multitude of factors in making the decision. To choose the best candidate for a cemented femoral stem in THA, a surgeon must consider cement technique and implant design, the history and evolution of fixation in THA, patient factors, and emerging data on the impact of fixation on the surrounding bone stock.

Cement Technique and Implant Design

The durability of a cemented femoral stem relies on the quality of the cement technique and the design of the implant. The first-generation cement technique, which involved finger packing to introduce cement into an open medullary canal combined with early generation cemented stems, often resulted in early failure. The mechanical interlock of cement into cancellous bone was often inadequate and led to loosening at the bone-cement interface.9 Debonding of the component from the cement occurred, and the sharp edges of the implants created regions of high stress concentration, which fractured the cement mantle and disrupted the implant-cement interface.10 Modern cement technique and stem designs have overcome these obstacles.9,11-15

Modern cement technique involves choice of cement and correct application. Cemented fixation occurs at two interfaces: the bone-cement interface and the cement-implant interface. The foundation for durable cemented fixation is the bone-cement interface. Cement is a grout, not an adhesive, which achieves fixation by the mechanical strength of intrusion and interdigitation into the cancellous bone structure. Therefore, accurate preparation of the femoral canal, removal of debris that may interfere with cement interdigitation, minimization of bleeding that can hydrostatically prevent cement intrusion, and meticulous delivery of a proven cement formulation at an appropriate viscosity and pressurization of that cement are elements essential to achieving reliable and durable cement fixation.16-20 These factors are within the control of a surgeon when creating this foundation.

Divergent philosophies regarding the optimal design of the cemented stem and how it achieves fixation at the implant- cement interface exist.21 Charnley’s original flat-back design was polished and tapered in the anteroposterior dimension and, in retrospect, was the progenitor of the taper-slip philosophy. Other subsequent designs following this philosophy include Ling’s Exeter design (Stryker, Kalamazoo, Mich) and its progeny, such as the CPT (Zimmer, Warsaw, Ind), and Wroblewski’s C-stem (DePuy Orthopaedics, Warsaw, Ind) and C-stem-AMT (DePuy).

  Figure 1A Figure 1B
 

Figure 1: Force transmission of a composite beam stem (A). Force transmission of a taper-slip stem (B).

These prostheses engage the cement through tapers. Theoretically, the stems convert the shear forces generated at the implant-cement interface from axial loading into radial hoop stresses, which favorably load the bone, stimulate remodeling, and reduce stress shielding (Figure 1). The viscoelasticity of cement allows for a small amount of creep to accommodate the taper’s engagement, and the polished surface prevents binding and bonding at the cement-implant interface.22

The taper-slip philosophy was not appreciated during the early years of THA design. Charnley perceived the subsidence he observed in his early series as undesirable, despite its long-term clinical silence relative to symptoms of loosening.23,24 Therefore, he introduced design features such as the Cobra flange and surface texturing to resist subsidence. This was the birth of the composite beam philosophy of cemented stems, which ultimately led to stems with design features and surface texturing specifically intended to not only resist subsidence, but to achieve fixation of the implant to the cement.25 The strength of this implant-cement interface became critical, as it needed to resist the shear forces generated by weight bearing and loading of the prosthesis. Rupture of this interface defines loosening and failure of a composite beam stem, in contrast to the taper-slip stems that never achieve nor are meant to achieve true fixation at this interface.

Researchers pursuing the taper-slip philosophy also modified the original Charnley design to reduce subsidence. First, Ling added a second taper in the medial-lateral dimension and created the Exeter stem. Then, Wroblewski added a third taper from broad lateral to narrow medial to create the C-stem (Figure 2). These features enable engagement of the taper in cement with the resultant potential positive bone loading; however, axial stability, especially with the third taper, has been significantly enhanced and subsidence reduced.26 The polished surface of these stems minimizes any debris formation as the taper engages the cement mantle during the service life of the prosthesis.

In contrast, as composite beam stems loosen and the cement-implant interface is disrupted, the textured surface of the implant acts as an abrasive, generating both cement and metal debris, which become sources of third body wear at the bearing surface and cause periprosthetic osteolysis.27-31 When the composite beam stem remains well fixed, it does not transmit forces to the surrounding bone, but rather bypasses the proximal femur. As the stiffest element in the construct, the composite beam stem carries the majority of the axial loads, resulting in stress shielding and periprosthetic osteopenia rather than favorably transmitting forces to the surrounding bone as does the taper-slip stem.32,33

Figure 2A Figure 2B Figure 2C

Figure 2: C-stem taper in mediolateral dimension (A), anteroposterior dimension (B), and from lateral to medial (C). The large arrows indicate the width of the stem laterally, and the small arrows indicate the width of the stem medially.

History and Evolution of Fixation in THA

Regardless of philosophy, the long-term results of cemented THA are positive, with more than 30 years of follow-up in some series.8,34-39 Nevertheless, certain lessons have been learned about failure mechanisms of cemented stems and the risk factors for failure.

Inferior cement technique is associated with early failure.11 Later generation Charnley designs have a higher failure rate than the original flat-back design, presumably due to a change in the bonding characteristics at the cement-implant interface.40 Component malposition increases the incidence of loosening.41,42 Early debonding of a composite beam stem may result in massive osteolysis as a result of the loosening,29,30,43,44 and strengthening the cement-implant interface of a stem designed to function according to the taper-slip philosophy can similarly generate debris and cause massive osteolysis.45,46

The evidence that certain patient factors are associated with higher failure rates specifically for cemented THA is less compelling. Berry et al34 recently reported in their long-term follow-up of Charnley total hip replacements performed at the Mayo Clinic that male sex, young age, and osteoarthritis are risk factors for early failure. Presumably, this defines a cohort of patients that is more active and not only accumulates more repetitive cycles on the hip, but also with more force or impact.

Conventional wisdom concludes that the same risk factors would potentiate early loosening of cementless stems, as well. However, long-term series of young patients treated either with cemented femoral stems performed with modern cement technique or with cementless femoral stems have demonstrated excellent results with minimal loosening.4,11,47-49

In a matched pair analysis of cemented vs cementless stems with regard to gender, age, diagnosis, and weight, outcome data statistically favored cemented over cementless stems.50 Weight has similarly been implicated as a risk factor for early failure.51 This risk factor should pertain to cemented and cementless devices. No specific risk factors for implant loosening and failure have been independently proven to affect cemented or cementless devices differently. Mechanical forces that stress and disrupt the fixation interfaces exert equal forces on cemented and cementless devices. A difference in the interfacial strength that resists these forces between cemented and cementless devices has not been proven.

Despite a paucity of hard data, these patient factors became strong determinants of the ideal candidate for THA during the early years of the technology application. Older, more sedentary, and lightweight individuals were the best candidates, while younger, heavier and more active patients were generally advised to adjust their risk factors for rupture of the interfaces and loosening before undergoing surgery.

As loosening in cemented THA began to occur, and as there became a need for an effective implant technology for younger, more active individuals with debilitating hip arthrosis, development of cementless fixation emerged. Although some of the motivation for the development of this technology may have been based on incorrect assumptions about the etiology for the failure of cemented components, the desirability of biologically fixing stems without cement, the perceived ease of implantation, and an intuitive sense that cementless fixation may provide more durable fixation for the younger, more active individual combined to create immediate and sustained enthusiasm for this technology.

  Figure 3A Figure 3B
  Figure 3C Figure 3D
  Figure 3E Figure 3F
 

Figure 3: Door bone types. Type A, anteroposterior (A) and lateral (B). Type B, anteroposterior (C) and lateral (D). Type C, anteroposterior (E) and lateral (F).

Although some surgeons advocate the use of cementless or cemented fixation in all patients, most surgeons attempt to choose rationally between the two fixation methodologies. Algorithms were created to match the patient with the technology most likely to give the most durable and reliable result. In addition to patient factors, bone quality emerged as an important determinant of fixation technique. Dorr et al52 developed a classification of bone quality by correlating radiograph appearance of bone and cortical index with bone mineral density and provided a widely used tool for matching fixation to patient. Strong, dense bone with thick cortices (Dorr type A-B) was thought to be a better substrate for cementless fixation, whereas more osteoporotic bone (Dorr type B-C) was thought to provide the ideal substrate for optimum cement technique (Figure 3).

Because of the progressive osteopenia that is encountered as patients age,53 cement was chosen in the elderly and cementless fixation was preferred for the young. In addition, as the era of cost containment arrived and the cost of implants increased, particularly for newer cementless designs, surgeons and institutions turned to these algorithms to assist in implant choice for any patient. So called demand-matching protocols considered age, activity level, and bone quality as key factors for deciding between cemented and cementless fixation.54-56 Cemented fixation became insidiously relegated to an inferior status, reserved for the old patients who had minimal needs and expectations, while cementless fixation became the luxury and “top of the line” product choice.

With longer follow-up, however, additional issues emerged for both fixation techniques. Parvizi et al57 identified the risks for cardiovascular collapse with the use of cement in elderly patients and suggested techniques to reduce these risks. In addition, particulate disease, causing third body wear at the bearing surface and resulting osteolysis, was originally believed to be due to cement and was named cement disease.58 Cement removal at revision also presents significant challenges. Cementless fixation was able to provide durable and reliable long-term results. However, stress shielding and periprosthetic osteopenia, and chronic thigh pain were seen in some patients, and loosening was not entirely eliminated as a complication. The interface between the bone and implant still had to withstand shear and sometimes failed under the burden of multiple cycles of repetitive loading. The impact of progressive cortical thinning and endosteal widening with age has not been elucidated.53 Furthermore, “cement disease,” now properly understood as particulate disease, paradoxically occurred with cementless stems, as well.2,59,60 Finally, whether a cemented or cementless device was used, excessive weight and impact-loading activities were discouraged to protect the fixation interfaces. Therefore, the intended benefits of cementless fixation in the young and active population had not been clearly achieved.

With a recognition that both fixation techniques are successful but have their respective liabilities, those who initially argued that either all patients should be cemented, or that all patients should have cementless implants have begun to converge toward an understanding that both technologies have a role, and the choice should be based on how effectively and expertly the particular fixation technology can be applied to the individual patient and by the individual surgeon, and how well the fixation philosophy satisfies the needs of the individual patient.

Implicit in this argument, however, is the prerequisite that the technology must be applied skillfully, meticulously employing the details essential to the success of the chosen technique. However, the choice for fixation ought to be based on more than a surgeon’s ability to apply the technology, and evidence-based algorithms are still unavailable.

Bone Remodeling Around a Cemented Taper-Slip Stem

The final chapter in the evolution of fixation has not been completed. In fact, recent data have helped to frame the question as to fixation choice even further. With more widespread understanding and acceptance of the taper-slip philosophy, and with more extensive use, a previously unseen phenomenon in THA has appeared. All well-fixed implants have been shown to cause some degree of periprosthetic stess shielding and osteopenia.3,32,61-63 As noted above, the stiffer implant carries the majority of the load and the forces bypass the surrounding bone. Cemented stems are thought to be less offensive in this regard, because the thickness of the cement mantle mandates a smaller and therefore less stiff stem. Nevertheless, stress shielding still occurs.

However, stems designed according to the taper-slip philosophy should convert the axially directed shear forces at the implant-cement interface into radially directed hoop stresses, promoting positive bone remodeling along these lines of stress with reinforcement of periprosthetic bone according to Wolff’s law. Incorporation of impacted bone graft has been demonstrated in revision THA with the use of such stems.64-71 However, this phenomenon has only recently been demonstrated in primary THA, as well (Figure 4). Wroblewski et al72 in their series of C-stems demonstrated positive remodeling of bone in up to 20% of their patients at a mean follow-up of 3.5 years (range: 1-7 years), with no aseptic loosening. Ongoing studies using DEXA scanning should further define and quantify this effect.

Figure 4A Figure 4B Figure 4C

Figure 4: Positive bone remodeling around a C-stem at 3 months’ postoperatively (A), 1 year postoperatively (B), and 3 years’ postoperatively (C).

With this new information, the traditional question of which fixation to choose must be reformulated. Given the fact that durable fixation can be achieved using a variety of methods, the key issue is no longer which method will provide sustainable fixation, but rather which method over time will provide the most favorable loading of the bone to preserve bone stock and strength and, especially for young patients, provide the healthiest substrate for possible future revision surgery. Paradoxically, the patients thought at one time to be poor candidates for cemented fixation because of their young age and high activity levels may benefit most from this bone-preserving feature of a well-cemented, well-designed taper-slip femoral stem.

Recommendations

The goals of fixation in THA can be classified as short-term and long-term. The short-term goal is to achieve immediate fixation to enable rapid unassisted mobilization, particularly in patients unable or unwilling to cooperate with weight-bearing restrictions. This goal can be achieved with good cementing technique and with any modern cemented stem design in the majority of patients undergoing total hip replacement, regardless of age, weight, activity level, or bone quality. The possible exception to this would be the Dorr type A, champagne flute femur in which the diaphysis is so narrow that a cemented stem of sufficient size with adequate offset will not fit without reaming all cancellous bone and burnishing the endosteum. In this instance, the cement has no microstructure into which to interdigitate, the shear strength of the bone cement interface is compromised, and even the early success of a cemented construct would be imperiled. A cementless stem would better serve this patient.

For an elderly, low-demand patient, achievement of the short-term goal may be all that is required. Although careful cement technique is critical, pressurization must be carried out with caution, using venting techniques to avoid cardiovascular collapse. A stem of either taper-slip or composite-beam philosophy would most likely be sufficient for the majority of bone types in this patient cohort. However, the extremely osteoporotic femur deserves special attention.

The Dorr type C, stovepipe-shaped femur presents a number of challenges (Figure 5). It is poorly suited to a cementless stem. A large cemented stem is required to fill this canal, and even gentle preparation can easily denude the endosteum of remaining cancellous structure. Even when the cancellous bone survives, the severe osteopenia that characterizes this bone type may compromise cement intrusion and interdigitation. A high incidence of loosening has been documented when cementing into this envelope.73 Primary impaction allografting or compaction of the native cancellous bone may facilitate cement fixation in this bone type.74 A taper-slip stem should be used to effectively load this impacted bone and stimulate bony healing and positive bone remodeling.

Figure 5A Figure 5B

Figure 5: A 67-year-old woman with multiple osteochondromatosis and severe Dorr type C bone.

The long-term goals of THA include durable fixation that will provide longevity in the face of repetitive loading and favorable bone loading, which will preserve or augment bone for ongoing prosthetic support as well as successful revision surgery when necessary. While the durability of cemented fixation in the femur is well-established, careful attention to the details of cement technique along with the choice of an ideal prosthetic design are mandatory to ensure an optimal result. A patient in his or her 6th to 7th decade (50-70 years of age), who has an indeterminate life expectancy and maintains an active life style, often with Dorr type B bone, benefits from such an optimal result.

In this patient population, meticulous cementing technique coupled with a taper-slip stem should provide a reliable long-term outcome, favorably loading and therefore preserving the periprosthetic bone, which otherwise is subjected to a climate of aging and declining bone mass.53,62 Should revision become necessary, the preserved bone may better support a standard revision prosthesis, rather than requiring a salvage operation. Furthermore, a cemented stem may spare a patient the potential complications of cementless fixation, including thigh pain and periprosthetic stress shielding and the complexities they add to revision surgery.3

A patient <60 years of age, with premature hip arthrosis in need of a total hip replacement is perhaps the biggest challenge. This patient is likely to outlive any prosthesis, and the higher activity level may shorten the life expectancy of an otherwise durable prosthesis. Planning for the revision during the primary surgery is essential, while still implanting prostheses likely to provide a long service life. There is no perfect solution. Therefore, a surgeon must choose between cemented and cementless fixation, with a full appreciation for the long-term challenges of each. Cementless fixation will provide durable fixation; however, when revision becomes necessary, stress shielding and bone loss associated with component removal may limit reconstructive options. In contrast, a well-cemented, taper-slip stem such as the C-stem, with a proven track record of favorable bone loading and positive bone remodeling may preserve vital bone over the long-term. Nevertheless, cement removal at the time of revision may be tedious and challenging.

Although young patients have traditionally received a cementless femoral component, preservation of bone with a cemented device is enticing. As more experience is gained with the taper-slip stems, the pendulum may again swing. Ironically, cement may become the fixation method of choice in these patients, who require the most durable, solid long-term fixation, and for whom bone conservation and preservation may be critical to the success of inevitable subsequent revision surgeries.

Conclusions

The choice of fixation technique must be individualized to a patient’s immediate and long-term needs, bone quality, and a surgeon’s ability to technically execute the chosen fixation method. Cement is a reliable and durable first-line choice for immediate and sustained fixation of the femur in THA. It is highly technique sensitive and requires skillful application if long-term successful results are to be achieved. Implants within the taper-slip philosophy are preferred for their positive bone loading characteristics and relative lack of debris generation. Precautions such as intramedullary lavage and canal venting should be undertaken when using cement in the elderly with extremely osteoporotic bone to avoid cardiovascular collapse. Ironically, cemented fixation of a tapered polished stem may be particularly applicable to younger, more active individuals to avoid rupture of the implant-cement interface by repetitive shear and to preserve periprosthetic bone for an extended duration of implant support and eventual revision. Cement should not be relegated as an inferior fixation option that can be used if necessary, but rather should be the fixation of choice in most patients undergoing THA.

References

  1. NIH consensus conference: total hip replacement. NIH Consensus Development Panel on Total Hip Replacement. JAMA. 1995; 273:1950-1956. Review.
  2. Engh CA Jr, Claus AM, Hopper RH Jr, et al. Long-term results using the anatomic medullary locking hip prosthesis. Clin Orthop. 2001; 393:137-146.
  3. McAuley JP, Moore KD, Culpepper WJ 2nd, et al. Total hip arthroplasty with porous-coated prostheses fixed without cement in patients who are sixty-five years of age or older. J Bone Joint Surg Am. 1998; 11:1648-1655.
  4. McAuley JP, Szuszczewicz ES, Young A, et al. Total hip arthroplasty in patients 50 years and younger. Clin Orthop. 2004; 418:119-125.
  5. Mont MA, Maar DC, Krackow KA, et al. Total hip replacement without cement for non-inflammatory osteoarthrosis in patients who are less than forty-five years old. J Bone Joint Surg Am. 1993; 5:740-751.
  6. Harris WH. The case for cemented fixation of the femur in every patient. Instr Course Lect. 1994; 43:367-371.
  7. Harris WH. The case for cementing all femoral components in total hip replacement. Can J Surg. 1995; 38 (Suppl 1):S55-S60.
  8. Harris WH. Options for primary femoral fixation in total hip arthroplasty. Cemented stems for all. Clin Orthop. 1997; 344:118-123.
  9. Klapach AS, Callaghan JJ, Goetz DD, et al. Charnley total hip arthroplasty with use of improved cementing techniques: a minimum twenty-year follow-up study. J Bone Joint Surg Am. 2001; 83:1840-1848.
  10. Jasty M, Maloney WJ, Bragdon CR, et al. The initiation of failure in cemented femoral components of hip arthroplasties. J Bone Joint Surg Br. 1991; 73:551-558.
  11. Barrack RL, Mulroy RD Jr, Harris WH. Improved cementing techniques and femoral component loosening in young patients with hip arthroplasty. A 12-year radiographic review. J Bone Joint Surg Br. 1992; 74:385-389.
  12. Mulroy RD Jr, Harris WH. The effect of improved cementing techniques on component loosening in total hip replacement. An 11-year radiographic review. J Bone Joint Surg Br. 1990; 5:757-760.
  13. Mulroy WF, Estok DM, Harris WH. Total hip arthroplasty with use of so-called second-generation cementing techniques. A fifteen-year-average follow-up study. J Bone Joint Surg Am. 1995; 12:1845-1852.
  14. Sanchez-Sotelo J, Berry DJ, Harmsen S. Long-term results of use of a collared matte-finished femoral component fixed with second-generation cementing techniques. A fifteen-year-median follow-up study. J Bone Joint Surg Am. 2002; 9:1636-1641.
  15. Stauffer RN. Ten-year follow-up study of total hip replacement. J Bone Joint Surg Am. 1982; 64:983-990.
  16. Berry DJ, Duffy GP. Cemented femoral components. In: Morrey BF, ed. Joint Replacement Arthroplasty. Philadelphia, Pa: Churchill-Livingstone; 2003:617-636.
  17. DiGiovanni CW, Garvin KL, Pellicci PM. Femoral preparation in cemented total hip arthroplasty: reaming or broaching? J Am Acad Orthop Surg. 1999; 7:349-357.
  18. DiMaio FR. The science of bone cement: a historical review. Orthopedics. 2002; 25:1399-1407.
  19. Maloney WJ, Hartford JM. The cemented femoral component. In: Callaghan JJ, Rosenberg AG, Rubash HE, eds. The Adult Hip. Philadelphia, Pa: Lippincott-Raven Publishers; 1998:959-979.
  20. Ranawat CS, Ranawat AS, Rasquinha VJ. Mastering the art of cemented femoral stem fixation. J Arthroplasty. 2004; 19(4 Suppl 1):85-91.
  21. Shen G. Femoral stem fixation. J Bone Joint Surg. 1998; 5:754-756.
  22. Dunlop DJ, Masri BA, Greidanus NV, et al. Tapered stems in cemented primary total hip replacement. Instr Course Lect. 2002; 51:81-91.
  23. Berry DJ, Harmsen WS, Ilstrup DM. The natural history of debonding of the femoral component from the cement and its effect on long-term survival of Charnley total hip replacements. J Bone Joint Surg Am. 1998; 80:715-721.
  24. Charnley J. Low Friction Arthroplasty of the Hip. Theory and Practice. New York, NY: Springer; 1979.
  25. Harris WH. Is it advantageous to strengthen the cement-metal interface and use a collar for cemented femoral components of total hip replacements? Clin Orthop. 1992; 285:67-72.
  26. Depuy. C-Stem Total Hip System - Product Rationale. On file at DePuy Orthopaedics, Warsaw, Ind.
  27. Barrack RL. Early failure of modern cemented stems. J Arthroplasty. 2000; 15:1036-1050.
  28. Collis D, Mohler C. Loosening rates and bone lysis with rough finished and polished stems. Clin Orthop. 1998; 355:113-122.
  29. Dowd JE, Cha CW, Trakru S, et al. Failure of total hip arthroplasty with a precoated prosthesis. 4- to 11-year results. Clin Orthop. 1998; 355:123-136.
  30. Mohler CG, Callaghan JJ, Collis DK, et al. Early loosening of the femoral component at the cement-prosthesis interface after total hip replacement. J Bone Joint Surg Am. 1995; 9:1315-1322.
  31. Schmalzried TP, Zahiri CA, Woolson ST. The significance of stem-cement loosening of grit-blasted femoral components. Orthopedics. 2000; 23:1157-1164.
  32. Maloney WJ, Sychterz C, Bragdon C, et al. The Otto Aufranc Award. Skeletal response to well fixed femoral components inserted with and without cement. Clin Orthop. 1996; 333:15-26.
  33. Venesmaa PK, Kroger HP, Jurvelin JS, et al. Periprosthetic bone loss after cemented total hip arthroplasty: a prospective 5-year dual energy radiographic absorptiometry study of 15 patients. Acta Orthop Scand. 2003; 74:31-36.
  34. Berry DJ, Harmsen WS, Cabanela ME, et al. Twenty-five-year survivorship of two thousand consecutive primary Charnley total hip replacements: factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg Am. 2002; 84:171-177.
  35. Callaghan JJ, Templeton JE, Liu SS, et al. Results of Charnley total hip arthroplasty at a minimum of thirty years. A concise follow-up of a previous report. J Bone Joint Surg Am. 2004; 4:690-695.
  36. Ling RS. Clinical experience with primary cemented total hip arthroplasty. Chir Organi Mov. 1992; 4:373-381.
  37. Williams HD, Browne G, Gie GA, et al. The Exeter universal cemented femoral component at 8 to 12 years. A study of the first 325 hips. J Bone Joint Surg Br. 2002; 84:324-334.
  38. Wroblewski BM, Fleming PA, Siney PD. Charnley low-frictional torque arthroplasty of the hip. 20-to-30 year results. J Bone Joint Surg Br. 1999; 81:427-430.
  39. Wroblewski BM, Siney PD, Fleming PA. Charnley low-frictional torque arthroplasty in patients under the age of 51 years. Follow-up to 33 years. J Bone Joint Surg Br. 2002; 84:540-543.
  40. Dall DM, Learmonth ID, Solomon MI, et al. Fracture and loosening of Charnley femoral stems. Comparison between first-generation and subsequent designs. J Bone Joint Surg Br. 1993; 2:259-265.
  41. Ebramzadeh E, Sarmiento A, McKellop HA, et al. The cement mantle in total hip arthroplasty. Analysis of long-term radiographic results. J Bone Joint Surg Am. 1994; 76:77-87.
  42. Kobayashi S, Eftekhar NS, Terayama K. Predisposing factors in fixation failure of femoral prostheses following primary Charnley low friction arthroplasty. A 10- to 20-year follow up study. Clin Orthop. 1994; 306:73-83.
  43. Ong A, Wong KL, Lai M, et al. Early failure of precoated femoral components in primary total hip arthroplasty. J Bone Joint Surg Am. 2002; 5:786-792.
  44. Sylvain GM, Kassab S, Coutts R, et al. Early failure of a roughened surface, precoated femoral component in total hip arthroplasty. J Arthroplasty. 2001; 16:141-148.
  45. Gie G. Long term experience with smooth stems. Presented at: Twenty-Sixth Open Scientific Meeting and The Fourth Combined Open Meeting of the Hip Society and AAHKS; 1998; New Orleans, La.
  46. Ling R. The History and Development of the Exeter Hip. Rutherford, NJ: Howmedica; 1997.
  47. Ballard WT, Callaghan JJ, Sullivan PM, et al. The results of improved cementing techniques for total hip arthroplasty in patients less than fifty years old. A ten-year follow-up study. J Bone Joint Surg Am. 1994; 76:959-964.
  48. Keener JD, Callaghan JJ, Goetz DD, et al. Twenty-five-year results after Charnley total hip arthroplasty in patients less than fifty years old: a concise follow-up of a previous report. J Bone Joint Surg Am. 2003; 85:1066-1072.
  49. Kim YH, Oh SH, Kim JS, et al. Contemporary total hip arthroplasty with and without cement in patients with osteonecrosis of the femoral head. J Bone Joint Surg Am. 2003; 85:675-681.
  50. D'Lima DD, Oishi CS, Petersilge WJ, et al. 100 cemented versus 100 noncemented stems with comparison of 25 matched pairs. Clin Orthop. 1998; 348:140-148.
  51. Schurman DJ, Bloch DA, Segal MR, et al. Conventional cemented total hip arthroplasty. Assessment of clinical factors associated with revision for mechanical failure. Clin Orthop. 1989; 40:173-180.
  52. Dorr LD, Faugere MC, Mackel AM, et al. Structural and cellular assessment of bone quality of proximal femur. Bone. 1993; 3:231-242.
  53. Poss R. Natural factors that affect the shape and strength of the aging human femur. Clin Orthop. 1992; 274:194-201.
  54. Healy WL. Hip implant selection for total hip arthroplasty in elderly patients. Clin Orthop. 2002; 405:54-64.
  55. Healy WL, Kirven FM, Iorio R, et al. Implant standardization for total hip arthroplasty. An implant selection and cost reduction program. J Arthroplasty. 1995; 10:177-183.
  56. Iorio R, Healy WL, Appleby D. Preoperative demand matching is a valid indicator of patient activity after total hip arthroplasty. J Arthroplasty. 2004; 19:825-828.
  57. Parvizi J, Holiday AD, Ereth MH, et al. The Frank Stinchfield Award. Sudden death during primary hip arthroplasty. Clin Orthop. 1999; 369:39-48.
  58. Jacobs JJ, Roebuck KA, Archibeck M, et al. Osteolysis: basic science. Clin Orthop. 2001; 393:71-77.
  59. Bojescul JA, Xenos JS, Callaghan JJ, et al. Results of porous-coated anatomic total hip arthroplasty without cement at fifteen years: a concise follow-up of a previous report. J Bone Joint Surg Am. 2003; 85:1079-1083.
  60. Duffy P, Sher JL, Partington PF. Premature wear and osteolysis in an HA-coated, uncemented total hip arthroplasty. J Bone Joint Surg Br. 2004; 86:34-38.
  61. Engh CA Jr, Young AM, Engh CA Sr, et al. Clinical consequences of stress shielding after porous-coated total hip arthroplasty. Clin Orthop. 2003; 417:157-163.
  62. Harris WH. Will stress shielding limit the longevity of cemented femoral components of total hip replacement? Clin Orthop. 1992; 274:120-123.
  63. Waide V, Cristofolini L, Toni, A. An experimental analogue to model the fibrous tissue layer in cemented hip replacements. J Biomed Mater Res. 2004; 2:232-240.
  64. Cabanela ME,Trousdale RT, Berry DJ. Impacted cancellous graft plus cement in hip revision. Clin Orthop. 2003; 417:175-182.
  65. Duncan CP, Masterson EL, Masri BA. Impaction allografting with cement for the management of femoral bone loss. Orthop Clin North Am. 1998; 29:297-305.
  66. Halliday BR, English HW, Timperley AJ, et al. Femoral impaction grafting with cement in revision total hip replacement. Evolution of the technique and results. J Bone Joint Surg Br. 2003; 85:809-817.
  67. Linder L. Cancellous impaction grafting in the human femur: histological and radiographic observations in 6 autopsy femurs and 8 biopsies. Acta Orthop Scand. 2000; 6:543-552.
  68. Ling RS, Timperley AJ, Linder L. Histology of cancellous impaction grafting in the femur. A case report. J Bone Joint Surg Br. 1993; 5:693-696.
  69. Nelissen RG, Bauer TW, Weidenhielm LR, et al. Revision hip arthroplasty with the use of cement and impaction grafting. Histological analysis of four cases. J Bone Joint Surg Am. 1995; 3:412-422.
  70. Sorensen J, Ullmark G, Langstrom B, et al. Rapid bone and blood flow formation in impacted morselized allografts: positron emission tomography (PET) studies on allografts in 5 femoral component revisions of total hip arthroplasty. Acta Orthop Scand. 2003; 74:633-643.
  71. Ullmark G, Obrant KJ. Histology of impacted bone-graft incorporation. J Arthroplasty. 2002; 17:150-157.
  72. Wroblewski BM, Siney PD, Fleming PA. Triple taper polished cemented stem in total hip arthroplasty: rationale for the design, surgical technique, and 7 years of clinical experience. J Arthroplasty. 2001; 16(8 Suppl 1):37-41.
  73. Kobayashi S, Takaoka K, Saito N, et al. Factors affecting aseptic failure of fixation after primary Charnley total hip arthroplasty. Multivariate survival analysis. J Bone Joint Surg Am. 1997; 11:1618-1627.
  74. Chareancholvanich K, Bourgeault CA, Schmidt AH, et al. In vitro stability of cemented and cementless femoral stems with compaction. Clin Orthop. 2002; 394:290-302.

Author

From Kerlan-Jobe Orthopaedic Clinic, Los Angeles, Calif.