Original Article

Differences between two sequential uncemented stem sizes in total hip arthroplasty: A comparative biomechanical study and potential clinical implications

¹ Department of Mechanical Engineering, University College London, Torrington Place, London WC1E 7JE, UK
² Academic Orthopaedic Department, Papageorgiou General Hospital & CORE Lab at CIRI AUTH, Aristotle University Medical School, University Campus, 54 124 Thessaloniki, Greece
³ DePuy Synthes, St. Anthony’s Road, Leeds LS11 8DT, UK

^* Corresponding author: M.Moazen@ucl.ac.uk

Received: 7 June 2022
Accepted: 14 October 2022

Abstract

Background: Early failure of uncemented femoral stems associated with incorrect sizing is a known postoperative complication. Surgeons are often faced with the question of whether an uncemented stem of adequate stability or a larger-sized stem should be implanted, especially when the proximal femoral cancellous bone is adequate. The biomechanical effect of sub-optimal stem sizing in the femur remains unclear. This study investigated the mechanical behaviour of two sequential sized uncemented stems of the same type. Methods: Six laboratory models of synthetic non-osteoporotic femora were randomly divided into two groups and implanted with either a nominal or oversized uncemented hydroxyapatite-coated nonporous titanium collarless stem. Stiffness, uniaxial strain, and pattern of strain distribution were measured under an anatomical one-legged stance. Results: Oversized stems demonstrated a higher overall stiffness compared to nominal; however, this was not statistically significant. The nominal stem showed a higher strain in the neck and the proximal medial diaphyseal region. The oversized stem showed higher strains in the distal region around the implant tip. Conclusion: Opting to use a larger stem may potentially increase primary stability, thus allowing safer early mobility. However, higher stiffness may lead to stress shielding, bone loss, and thigh pain in the long term. In addition, strains in the diaphysis and the tip of the stem may predispose to periprosthetic fractures, especially in osteoporotic bones, making this a relatable aspect for users and biomechanical loading. Given the wide range of complex factors that need to be considered when choosing stem size in uncemented THA surgery, this study’s results should be interpreted cautiously.