Speaker discusses hip stem selection based on biomechanics, anatomy, bone quality
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LAS VEGAS — The use of fit-and-fill collared proximal-tapered stems for total hip arthroplasty in some older patients was among the hip stem options a presenter reviewed during the American Academy of Orthopaedic Surgeons Annual Meeting.
Adolph V. Lombardi Jr., MD, discussed appropriate hip stem selection based on patient factors, such as hip biomechanics, anatomy and bone quality, and presented his rationale for the stems he now chooses and uses in various patients.
“So at the end of the day, my take-home message to you is that a single, tapered, reduced distal — a standard high-offset and coxa vara offset — has been my go-to stem. However, I have started to adopt the utilization of a fit-and-fill collared, proximal-tapered stem in a certain patient population,” he said. “I am cementing my elderly patients, and most of them females. And there is a need, I think, to have a splined or modular stem.”
In discussing hip biomechanics and anatomy as factors to consider with stem selection, Lombardi said he uses various styles of stems to address deformity, including short stems for proximal deformity, which have helped him “get out of Dodge” in a few challenging arthroplasty cases.
In addition, he uses coxa vara stems and certain short-neck stems for other patients with hip deformity. “I’ve had to use short, splined stems for [Legg-Calve-Perthes disease], like you see here,” as well as for patients with developmental dysplastic hips, Lombardi said.
Modular stems also play a role in addressing any variations in hip biomechanics and anatomy, he said.
“I’ve also sometimes had to use modular stems to address femoral shortening, and you could either use a traditional modular stem, that you see here, or you can actually use some of the newer-design modular stems,” Lombardi said. During his presentation, he showed an example of a revision modular stem he now uses.
Regarding hip bone quality, Lombardi said patients with Dorr C-type bone typically need a cemented stem. Published data regarding the role of patient bone quality in stem selection have shown good results with Mallory-Head hip stems (Biomet), he said.
“We just had accepted our 25-year results, and also the [Taperloc Hip Stems] (Zimmer Biomet) have done well – so a proximally porous-coated stem. But I do argue the fact that we did need to reduce distally,” Lombardi said.
An analysis of outcomes with long and short stems that Keith R. Berend, MD, who is Lombardi’s partner, performed showed “a periprosthetic fracture rate of 0.9%. Increasing age was the only significant variable and only in women,” Lombardi said.
“So that has brought us into thinking more about maybe a calcar collar that may be protective against periprosthetic fracture in cementless stems,” he said and noted this style of stem is now available.
“These fit-and-fill collared proximal stems may be the answer in some of your patients that are perhaps a little older and maybe you’re not cementing,” Lombardi said.
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Lombardi AV. Femoral stem selection: Anatomy, bone quality and biomechanics. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 7-11, 2023; Las Vegas.
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