Orthopaedics & Traumatology: Surgery & Research 106 (2020) 1495–1500

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Original article

Mid-term gender-specific differences in periprosthetic bone

remodelling after implantation of a curved bone-preserving hip stem
Julian Stefan Meyer a,b,∗ , Tobias Freitag a , Heiko Reichel a , Ralf Bieger a
a
Department of orthopaedic surgery, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
b
Department of orthopaedic surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstraße 11, 97074 Wuerzburg, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Background: The implant-specific periprosthetic bone remodelling in the proximal femur is considered
Received 6 January 2020 to be an important factor influencing the long-term survival of cementless hip stems. Particularly data
Accepted 17 April 2020 of gender-specific differences regarding bone-preserving stems are very rare in literature and mainly
limited to short-term investigations. Therefore, we investigated at mid-term one arm of a prospective
Keywords: randomised study to evaluate if there is an influence of gender on implant-specific stress shielding after
Arthroplasty implantation of a curved bone preserving hip stem (Fitmore) 5 years postoperatively.
Hip
Hypothesis: We hypothesised there will be no gender-specific differences in periprosthetic bone remod-
DXA
Gender
elling.
Short stem Patients and methods: A total of 20 female and 37 male patients underwent total hip arthroplasty using
the Fitmore stem. Clinical, radiological as well as osteodensitometric examinations were performed pre-
operatively, 7 days and 3, 12 and 60 months postoperatively. Clinical data collection included the Western
Ontario and McMaster Universities Arthritis Index (WOMAC) and the Harris Hip Score (HHS). Peripros-
thetic bone mineral density (BMD) was measured using Dual Energy X-ray Absorptiometry (DXA) and
the periprosthetic bone was divided into 7 regions of interest (ROI) for analysis. The results at 3, 12 and
60 months were compared with the first postoperative measurement after 7 days to obtain a percentage
change.
Results: Periprosthetic BMD showed a decrease in all 7 ROIs for both groups 5 years postoperatively
referred to the baseline value, except ROI 3 (0.8%, p = 0.761), representing the distal lateral part of the
stem, and ROI 5 (0.3%, p = 0.688), representing the distal medial part of the stem in the male cohort.
Significant gender differences were found in ROI 1 (−16.0% vs. −3.5%, p = 0.016) and ROI 6 (−9.9% vs.
−2.1%, p = 0.04) in favour of the male patients. Clinical results showed no significant gender differences
5 years postoperatively with regard to WOMAC (mean 0.4 (± 0.8, 0–3.3) in women vs. 0.3 (± 0.8, 0–4.2)
in men, p = 0.76) and HHS (mean 93.0 (± 9.7, 66.0–100.0) in women vs. 93.9 (± 11.5, 53.0–100.0) in men,
p = 0.36).
Conclusion: Proximal stress shielding was observed independent of gender 5 years postopera-
tively. However, there was a significantly lower bone loss proximal lateral and medial below the
calcar in male patients, indicating a more physiological load transfer. [ClinicalTrials.gov identi-
fier: NCT03147131 (Study ID D.3067-244/10). Registered 10 May 2017 – retrospectively registered,
https://clinicaltrials.gov/ct2/show/NCT03147131?term=Bieger&draw=2&rank=1]
Level of evidence: IV; prospective study without control group.
© 2020 Elsevier Masson SAS. All rights reserved.

1. Introduction
stems after total hip arthroplasty (THA) [1]. The implantation of
The implant-specific periprosthetic bone mineral density (BMD)
femoral hip stems inevitably leads to implant-specific stress shield-
changes in the proximal femur are considered to be an impor-
ing, which may result in aseptic loosening and revision surgery
tant factor influencing the long-term survival of cementless hip
[1]. Bone preserving stems have been developed to address these
effects and achieve a proximal load transfer at the femoral meta-
physis, which is why they are used with increasing numbers lately
∗ Corresponding author at: Department of orthopaedic surgery, Koenig-Ludwig- [2]. Not least, because of the preservation of proximal femoral bone
Haus, University of Wuerzburg, Brettreichstraße 11, 97074 Wuerzburg, Germany. stock and the assumed realisation of tissue-sparing surgery with
E-mail address: jsmeyer@mail.de (J.S. Meyer).
reduced soft-tissue damage [3].
https://doi.org/10.1016/j.otsr.2020.04.023
1877-0568/© 2020 Elsevier Masson SAS. All rights reserved.
J.S. Meyer et al. Orthopaedics & Traumatology: Surgery & Research 106 (2020) 1495–1500

However, the clinical follow-up concerning cementless bone

preserving stems is limited to short- to mid-term [4], compared
to well-evaluated straight stems [5]. Among other factors, such as
age, body mass index (BMI), bone mineral density or stem design,
gender may affect periprosthetic bone remodelling after THA as
well [6]. Particularly data of gender-specific differences regarding
bone-preserving stems are very rare in literature.
Therefore, we investigated at mid-term one arm of a prospec-
tive randomised study to evaluate if there is an influence of gender
on implant-specific stress shielding after implantation of a curved
bone preserving hip stem (Fitmore, Zimmer Biomet, Warsaw, IN,
USA) 5 years postoperatively. We hypothesised there will be no
gender-specific differences in periprosthetic bone remodelling.

2. Patients and Methods

2.1. Patients

The present study is a subproject of a prospective randomised

study evaluating the periprosthetic BMD changes after implanta-
tion of a curved bone preserving hip stem compared to a standard
length straight stem (clinical trials D.3067-244/10) [7]. A power
analysis was performed in the aforementioned prospective ran-
domised trial to evaluate the number of patients needed. In this
study, only the patients receiving the bone-preserving stem were
evaluated. The trial was approved by the local institutional review
board (108/10), and informed consent was obtained from all indi-
vidual participants included in the study. Exclusion criteria were
femoral fractures, metabolic bone diseases, drugs affecting bone Fig. 1. Anteroposterior and sagittal profile of Fitmore stem.

quality, age over 75 years, previous surgery in the same hip and
contralateral THA within the study period.
A total of 20 female and 37 male patients with the diagnosis
of a primary osteoarthritis of the hip underwent total hip arthro-
plasty using the Fitmore stem. The mean age of female patients
was 59.3 years (± 8.0, 45–70 years) with a height of 1.64 m (± 0.05,
1.53–1.76 m), a weight of 80.8 kg (± 17.6, 53–122 kg) and a BMI
of 30.1 kg/m2 (± 6.8, 20.8–44.8 kg/m2 ). The male patients were on
average 55.4 years (± 11.2, 33–44 years) old, with a height of 1.75 m
(± 0.09, 1.54–1.92 m), a weight of 90.6 kg (± 14.2, 63–116 kg) and
a BMI of 29.5 kg/m2 (± 3.5, 20.3–37.9 kg/m2 ). Statistically signifi-
cant gender differences could be found regarding height (p < 0.001)
and weight (p = 0.026), however, with no statistically significant
differences regarding age (p = 0.182) and BMI (p = 0.698).
2.2. Methods
side and the lumbar spine. All scans were performed in supine posi-
tion with a head rest composed of foam and the legs resting in a
jig to ensure a constant internal rotation of 15◦ (Fig. 2). The BMD
(g/cm2 ) data collected at 7 days after surgery served as the baseline
value and changes were expressed in percent. Besides, contralat-
eral hip and lumbar spine also served as a benchmark to detect
BMD changes around the implant. A single observer performed all
scans and analyses, while using the metal-removal hip-scan mode,
and quality checks of the device were carried out daily. Because of
a better evaluation particularly in the proximal femur, the conven-
tional seven regions of interest (ROI) described by Gruen et al. [9]
were adapted. ROIs 1 and 7 were set to a craniocaudal length of
6 cm, whereas ROIs 2 and 6 were adjusted to a length of 4 cm, since
BMD changes in the proximal femur were attached to the high-
est relevance. In addition, the most proximal part of the greater

The cementless curved Fitmore stem (Zimmer Biomet, War-

saw, IN, USA) has a triple-tapered design and can be classified
as a trochanter-sparing stem (Fig. 1). It is available in four dif-
ferent neck angle options (127◦ , 129◦ , 137◦ , 140◦ ). The titanium
alloy contains Vanadium (Ti-6Al-4 V, also called Protasul-64WF)
and has a porolock Ti-VPS coating in the proximal part to enhance
bony ingrowth. The distal part remains rough blasted. The Allofit
Alloclassic press-fit cup (Zimmer Biomet, Warsaw, IN, USA) with a
ceramic-on-polyethylene bearing was used in all cases. All patients
underwent a lateral, transgluteal approach performed by four expe-
rienced surgeons [8], with immediate full weight bearing after
surgery using two crutches.

2.3. Methods of assessment

The patients were examined before surgery and 7 days, 3

months, 12 months, and 60 months postoperatively. A Lunar
Prodigy DXA-device (General Electric Healthcare Medical Systems,
Chalfont St Giles, Buckinghamshire, UK) was applied for the assess- Fig. 2. DXA-device for the assessment of bone mineral density (BMD) with both legs
ment of bone mineral density in the affected hip, the contralateral resting in a jig to ensure a constant internal rotation of 15◦ .

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J.S. Meyer et al. Orthopaedics & Traumatology: Surgery & Research 106 (2020) 1495–1500

Fig. 3. DXA-Scans with the 7 modified (left) and conventional (right) regions of interest (ROI) of Fitmore stem.

trochanter was selected as the starting point of the subdivision, 3. Results

not the proximal part of the lateral stem curvature. ROIs 3 and 5
covered the remaining distance, while the size of ROI 4 was left
unchanged (Fig. 3).
Clinical data collection included the Harris Hip Score (HHS)
[10] and the Western Ontario and McMaster Universities Arthri-
tis Index (WOMAC) [11]. Radiological imaging included an
anterior–posterior X-ray of the pelvis, as well as a lateral view of
the affected hip. All radiographs were reviewed by a single observer
for subsidence > 2 mm, osteolysis and bone resorption.
2.4. Statistical analysis
Descriptive statistics are reported as mean, standard deviation
and range and changes of periprosthetic BMD are described in per-
cent. The Mann–Whitney U-test was used for statistical comparison
of DXA measurements and clinical scores. The level of significance
was set at a p-value of < 0.05. The statistical software package SPSS
(IBM, Armonk, NY, USA) was used throughout.
After five years, 54 patients of the initial 57 patients remained
in the study, which corresponds to a dropout rate of 5.3%. Two male
patients refused an appointment, because clinical-radiological
follow-up had already taken place in an outpatient setting and
another male patient could not keep his follow-up visit because
of a serious illness. All 3 patients were lost to follow-up just 5 years
after surgery.
In both groups, there were decreases in periprosthetic BMD in
all ROIs 1 year postoperatively referred to the baseline value, except
ROI 3 in the female group with a gain of 1.8% (p = 0.131) (Table 1).
The calcar region (ROI 7) was the most concerned area with a BMD
loss of −20.0% (female, p < 0.001) and −15.1% (male, p < 0.001), fol-
lowed by ROI 1 with −8.5% (female, p = 0.004) and −6.2% (male,
p < 0.001) (Table 1). The remaining zones showed rather moderate
BMD losses from −0.1% (ROI 3, p = 0.731) to 5.6% (ROI 4, p < 0.001) in
the male collective and from −2.8% (ROI 4, p = 0.005) to 6.3% (ROI 2,
p = 0.025) in the female collective (Table 1). One year after surgery,

Table 1
Mean gender-specific bone mineral density (BMD) in g/cm2 in the 7 regions of interest (ROI) during 5-year follow-up.
Gender Follow-up Mean BMD in g/cm2 (range)

ROI 1 ROI 2 ROI 3 ROI 4 ROI 5 ROI 6 ROI 7

Female 7 days 0.83 (0.55−1.01) 1.89 (1.56−2.37) 2.13 (1.73−2.58) 2.00 (1.53−2.54) 2.13 (1.51−2.64) 1.82 (1.30−2.50) 1.55 (1.04−2.22)
postoperative
(baseline value)
12 months 0.76a (0.44−1.21) 1.77a (1.27−2.40) 2.16 (1.88−2.61) 1.94a (1.49−2.59) 2.06a (1.53−2.59) 1.72a (0.98−2.52) 1.26a (0.53−2.35)
postoperative
60 months 0.70a,b (0.41−1.14) 1.70a (1.07−2.35) 2.09 (1.68−2.55) 1.86a (1.39−2.58) 2.04 (1.56−2.62) 1.65a,b (0.89−2.67) 1.27a (0.68−2.42)
postoperative
Male 7 days 0.90 (0.65−1.18) 1.93 (1.49−2.31) 2.39 (1.73−2.82) 2.31 (1.83−2.77) 2.36 (1.86−2.74) 1.66 (1.18−2.05) 1.39 (0.87−1.89)
postoperative
(baseline value)
12 months 0.84a (0.54−1.22) 1.84a (1.43−2.24) 2.37 (1.64−2.83) 2.17a (1.64−2.63) 2.34 (1.83−2.73) 1.59a (1.08−2.14) 1.16a (0.51−1.87)
postoperative
60 months 0.86a,b (0.58−1.22) 1.77a (1.05−2.35) 2.39 (1.83−2.75) 2.18a (1.64−2.68) 2.35 (1.87−3.00) 1.61b (0.99−2.26) 1.16a (0.34−2.02)
postoperative
a
Significant change to baseline value 1 week after surgery (Wilcoxon signed-ranks test, p < 0.05).
b
Significant differences between males and females (Mann−Whitney-U-test, p < 0.05)

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J.S. Meyer et al. Orthopaedics & Traumatology: Surgery & Research 106 (2020) 1495–1500

Fig. 4. Mean changes of bone mineral density (BMD) in percentages after 1 year referred to the value 1 week postoperatively in the 7 regions of interest (ROI). One year after
surgery, the comparison of both groups showed, compared to the baseline value, no significant differences (p > 0.05).

the comparison of both groups showed, compared to the baseline
value, no significant differences (p > 0.05) (Fig. 4).
Five years postoperative, periprosthetic BMD showed a decrease
in all 7 ROIs for both groups referred to the baseline value, except
ROI 3 (0.8%, p = 0.761) and ROI 5 (0.3%, p = 0.688) in the male col-
lective (Table 1). The largest periprosthetic BMD losses were still
observed in ROI 7 with −19.6% in the female (p = 0.001) and −14.3%
in the male group (p < 0.001) (Table 1). In the female collective,
further BMD losses, referred to the data 1 year postoperatively,
were observed from ROI 1 through to ROI 6 from a minimum of
−1.8% (ROI 3, p = 0.376) to a maximum of −16.0% (ROI 1, p = 0.001)
(Table 1). The male collective showed a recovery of periprosthetic
BMD in all ROIs, except ROI 2 with further losses (−7.7%, p = 0.004),
with regard to the data 1 year postoperatively. Significant gender
differences were found in ROI 1 (−16.0% vs. −3.5%, p = 0.016) and
ROI 6 (−9.9% vs. −2.1%, p = 0.04) in favour of the male patients,
comparing both groups 5 years postoperatively (Fig. 5).
The contralateral hip and the lumbar spine showed no sig-
nificant changes in BMD during the 5-year follow-up (Table 2).
Radiological examination showed no subsidence greater than 2 mm
or radiolucent lines and all stems were declared stable. No infec-
tions, loosening or periprosthetic fractures were reported.
Clinical results showed significant increases in HHS and WOMAC
scores in both groups at 5-year follow-up compared to preopera-
tive baseline values (p < 0.05). No statistically significant differences
(p > 0.05) could be detected between the female and the male col-
lective in terms of the temporal development of the HHS and the
WOMAC score (Table 3).

Fig. 5. Mean changes of bone mineral density (BMD) in percentages after 5 years referred to the value 1 week postoperatively in the 7 regions of interest (ROI). * Significant
difference between the two groups (Mann–Whitney-U-test, p < 0.05).

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J.S. Meyer et al.
Table 2
Mean gender-specific bone mineral density (BMD) in g/cm2 in the lumbar spine (L1–L4) during 5-year follow-up.
Follow-up Mean BMD in g/cm2 (SD, range)
Female
7 days postoperative 1.26 (± 0.27, 0.86–1.83)
12 months postoperative 1.27 (± 0.25, 0.86–1.79)
60 months postoperative 1.31 (± 0.29, 0.86–1.91)
4. Discussion
In this study, the gender-specific femoral BMD changes were
evaluated 5 years after THA using a cementless bone preserving
stem (Fitmore, Zimmer Biomet, Warsaw, IN, USA). Periprosthetic
BMD showed a decrease in all 7 ROIs for both groups 5 years post-
operatively referred to the baseline value, except ROI 3 and ROI 5
in the male collective. The largest periprosthetic BMD losses were
observed in ROI 7 with −19.6% in the female and −14.3% in the
male group. Significant gender differences were found in ROI 1
(−16.0% vs. −3.5%) and ROI 6 (−9.9% vs. −2.1%) in favour of the male
patients, comparing both groups 5 years postoperatively. Clinical
results showed no significant differences between the female and
the male collective. Concerning long-term survival of cementless
hip stems, the implant-specific periprosthetic bone remodelling,
as a consequence of stress shielding in the proximal femur, is con-
sidered to be an important factor [1]. Regarding the Fitmore stem,
there is data in respect of a delayed but stable settling 2 years
postoperatively compared to early settling within the first post-
operative year described for conventional stems [12], as well as
a high incidence of cortical hypertrophy, though with no clinical
relevance [13,14]. Yet, cementless bone preserving stems showed
already good results at mid-term [4,15].
Besides, the gender of patients receiving THA may also affect
periprosthetic bone remodelling [6]. However, particularly data of
gender-specific differences regarding bone-preserving stems are
very rare in literature.
Jahnke et al. [16] evaluated the changes of periprosthetic BMD
after implantation of a cementless short stem (Metha, BBraun
Aesculap, Tuttlingen, Germany) in 40 patients. The anterolateral
approach was used, except for 2 cases using a lateral, transgluteal
approach because of prior surgeries of the treated hip side. DXA
examination, radiological and clinical follow-up were performed
until 1 year postoperatively. A loss of periprosthetic BMD was
shown mainly in ROIs 1, 4 and 7 after 6 and 12 months with the
positive influence of BMD was higher in males than females [16].
These findings show a large accordance with our results. Peripros-
thetic bone remodelling using a triple-taper polished cemented
stem (C-Stem, DePuy, Warsaw, IN, USA) was investigated by Buck-
land et al. [17]. Periprosthetic BMD was analysed in 103 patients
over a 2-year period using DXA. A statistically significant decrease
Table 3
Mean values of WOMAC and HHS during 5-year follow-up.
Mean (SD, range)
Female
WOMAC
Preoperative 5.0 (± 2.0, 1.5–7.8)
3 months 1.5 (± 1.3, 0.1–6.0)
12 months 1.5 (± 2.1, 0–8.8)
60 months 0.4 (± 0.8, 0–3.3)
HHS
Preoperative 49.2 (± 10.1, 28.6–65.9)
3 months 79.1 (± 17.4, 42.0–100.0)
12 months 82.5 (± 14.6, 56.7–100.0)
60 months 93.0 (± 9.7, 66.0–100.0)
WOMAC: Western Ontario and McMaster Universities Arthritis Index; HHS: Harris Hip Score.
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Orthopaedics & Traumatology: Surgery & Research 106 (2020) 1495–1500
p-value
Male
1.27 (± 0.19, 0.96–1.76) 0.99
1.27 (± 0.21, 0.96–1.84) 0.87
1.31 (± 0.21, 1.01–1.82) 0.87
in BMD was seen in all zones, most marked in zones 1 and 7, with
a reduction in the first 3 to 9 months followed by a slight recovery
of periprosthetic BMD. Men showed a higher BMD in zone 7 at all
postoperative time intervals, while calcar BMD loss was higher in
women than men at up to 24 months [17]. In our study, the most
marked decreases in BMD were also observed in zone 7 with −19.6%
in the female and −14.3% in the male group, however, without a
significant gender-specific difference in ROI 7.
Gasbarra et al. [6] performed a densitometric evaluation around
the Trabecular Metal Primary stem (Zimmer Biomet, Warsaw, IN,
USA) with a 24-month follow-up. DXA scans of 108 patients were
performed directly postoperative, 3 and 6 months, as well as 1 year
and 2 years after implantation. In the group of male patients, a
gradual bone increase was observed while a gradual bone resorp-
tion was seen in the female group in ROIs 1 and 7, only evaluating
the proximal femur. Data for the remaining ROIs was not pre-
sented. However, a statistically significant difference between the
two groups could be observed in ROI 1 two years after implanta-
tion [6], which is in accordance with our findings, even though an
increase in periprosthetic BMD could not be detected. Limitations
of this study are the retrospectively data, as well as BMD values
could be conditioned by the anti-osteoporotic treatment of patients
affected by osteoporosis, which were not excluded [6].
Periprosthetic BMD changes after implantation of a cementless
femoral short stem (MiniHip, Corin Group PLC, Cirencester, UK)
were evaluated by Ercan et al. [18] using DXA up to 1 year post-
operative. In a retrospective study, 62 patients underwent THA,
using the anterolateral approach. Significant BMD decreases were
described in Gruen zones 1, 2, 4 and 7, 6 months postoperative.
Thereafter, periprosthetic BMD recovered up to 12 months postop-
erative. Covariance analysis was unable to establish a connection
of the results with gender [18]. In our study, BMD decreases were
seen in all ROIs 1 year postoperatively, except ROI 3 in the female
group, also, without significant differences comparing both groups
1 year after surgery; however, with significant gender differences
in ROI 1 and 6 in favour of the male patients 5 years postoperatively.
Limitations of the present study are the rather small sample size
with a total of 57 patients and a dropout rate of 5.3%. Moreover, the
classical Gruen zones have been modified with regards to a bet-
ter evaluation particularly in the proximal femur and consequently
constitute a methodical difference from previous published litera-
p-value
Male
4.6 (± 1.7, 1.2–7.4) 0.42
1.4 (± 1.1, 0–4.7) 0.59
1.2 (± 1.5, 0–6.5) 0.43
0.3 (± 0.8, 0–4.2) 0.76
53.7 (± 14.3, 24.5–83.6) 0.19
81.7 (± 15.1, 49.0–100.0) 0.64
86.9 (± 13.7, 50.9–100.0) 0.21
93.9 (± 11.5, 53.0–100.0) 0.36
J.S. Meyer et al.
ture. However, we do not think that these limitations jeopardise the
conclusion of this study, because the dropped-out patients did not
differ systematically with regard to patient demographics. For the
assessment of periprosthetic BMD, DXA is widely recognised as the
method of choice [19], because it is highly reliable and reproducible
with a precision error of a maximum of 5% [1]. This error is mainly
influenced by a varying rotation of the femur in the projection plane
and varies throughout the ROIs [1]. Relevant limitations of DXA are
the low spatial resolution and the two-dimensional depiction of
this imaging technique [20]. Because preoperative measurements
can significantly impair the precision due to arthritic changes and
movement restrictions of the hip rotation, a direct postoperative
measurement, as done here, should serve as a reference [21].
5. Conclusion
Proximal stress shielding was observed independent of gen-
der 5 years postoperatively. However, there was a significantly
lower bone loss proximal lateral and medial below the calcar in
male patients, indicating a more physiological load transfer. There-
fore, the indication for a bone-preserving stem should be carefully
expanded, especially in women. Moreover, the results of this study
refer to a specific stem design and cannot be applicable to all short
stems. Further clinical research is necessary to investigate particu-
larly the long-term survival of bone preserving stems.
Disclosure of interest
The authors declare that they have no competing interest.
Funding
The study was financially supported by Zimmer Biomet, 0178-
2017-3887 Warsaw, IN.
Authors’ contribution
Julian Stefan Meyer and Tobias Freitag contributed to the con-
ception and design of the study, acquisition of data, analysis and
interpretation of data, drafting the article or revising it critically for
important intellectual content, final approval of the version to be
submitted, and statistics. Heiko Reichel was responsible for drafting
the article or revising it critically for important intellectual content,
final approval of the version to be submitted, and surgery perfor-
mance, while Ralf Bieger contributed to the conception and design
of the study, acquisition of data, analysis and interpretation of data,
drafting the article or revising it critically for important intellectual
content, final approval of the version to be submitted, statistics, and
surgery performance.
References
[1] Venesmaa PK, Kroger HP, Miettinen HJ, Jurvelin JS, Suomalainen OT, Alhava EM.
Monitoring of periprosthetic BMD after uncemented total hip arthroplasty with
dual-energy X-ray absorptiometry – a 3-year follow-up study. J Bone Miner Res
2001;16:1056–61.
1500
Orthopaedics & Traumatology: Surgery & Research 106 (2020) 1495–1500
[2] Yan SG, Li D, Yin S, Hua X, Tang J, Schmidutz F. Periprosthetic bone remodeling
of short cementless femoral stems in primary total hip arthroplasty: a sys-
tematic review and meta-analysis of randomised-controlled trials. Medicine
2017;96:e8806.
[3] Stulberg SD, Patel RM. The short stem: promises and pitfalls. Bone Joint J
2013;95:57–62.
[4] van Oldenrijk J, Molleman J, Klaver M, Poolman RW, Haverkamp D. Revision
rate after short-stem total hip arthroplasty: a systematic review of 49 studies.
Acta Orthop 2014;85:250–8.
[5] Garellick G, Kärrholm J, Lindahl H, Malchau H, Rogmark C, Rolfson O.
The Swedish Hip Arthroplasty Register: annual report 2014. Sahlgren-
ska: Sahlgrenska University Hospital; 2015 [https://registercentrum.blob.core.
windows.net/shpr/r/Annual-report-2014-BJv-q8pil.pdf (date of access: 17
March 2020)].
[6] Gasbarra E, Iundusi R, Perrone FL, Saturnino L, Tarantino U. Densitometric eval-
uation of bone remodelling around trabecular metal primary stem: a 24-month
follow-up. Aging Clin Exp Res 2015;27:S69–75.
[7] Meyer JS, Freitag T, Reichel H, Bieger R. Periprosthetic bone mineral density
changes after implantation of a curved bone preserving hip stem compared to
a standard length straight stem: 5-year results of a prospective, randomised
DXA-analysis. J Clin Densitom 2019;22:96–103.
[8] Bauer R, Kerschbaumer F, Poisel S, Oberthaler W. The transgluteal approach to
the hip joint. Arch Orthop Trauma Surg 1979;95:47–9.
[9] Gruen TA, McNeice GM, Amstutz HC. “Modes of failure” of cemented stem-type
femoral components: a radiographic analysis of loosening. Clin Orthop Rel Res
1979;141:17–27.
[10] Harris WH. Traumatic arthritis of the hip after dislocation and acetabular frac-
tures: treatment by mold arthroplasty. An end-result study using a new method
of result evaluation. J Bone Joint Surg Am 1969;51:737–55.
[11] Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation
study of WOMAC: a health status instrument for measuring clinically impor-
tant patient relevant outcomes to antirheumatic drug therapy in patients with
osteoarthritis of the hip or knee. J Rheumatol 1988;15:1833–40.
[12] Freitag T, Fuchs M, Woelfle-Roos JV, Reichel H, Bieger R. Mid-term migration
analysis of a femoral short-stem prosthesis: a five-year EBRA-FCA-study. Hip
Int 2019;29:128–33.
[13] Thalmann C, Kempter P, Stoffel K, Ziswiler T, Frigg A. Prospective 5-year study
with 96 short curved Fitmore hip stems shows a high incidence of cortical
hypertrophy with no clinical relevance. J Orthop Surg Res 2019;14:156.
[14] Innmann MM, Weishorn J, Bruckner T, Streit MR, Walker T, Gotterbarm T, et al.
Fifty-six percent of proximal femoral cortical hypertrophies 6 to 10 years after
total hip arthroplasty with a short cementless curved hip stem – a cause for
concern? BMC Musculoskelet Disord 2019;20:261.
[15] Epinette JA, Brax M, Chammai Y. A predictive radiological analysis of short
stems versus both shortened and long stems in primary hip replacement: a
case-control study of 100 cases of Metha versus ABG II and Omnifit HA at
2–8years’ follow-up. Orthop Traumatol Surg Res 2017;103:981–6.
[16] Jahnke A, Engl S, Altmeyer C, Jakubowitz E, Seeger JB, Rickert M, et al. Changes
of periprosthetic bone density after a cementless short hip stem: a clinical and
radiological analysis. Int Orthop 2014;38:2045–50.
[17] Buckland AJ, Dowsey MM, Stoney JD, Hardidge AJ, Ng KW, Choong PF. Peripros-
thetic bone remodeling using a triple-taper polished cemented stem in total
hip arthroplasty. J Arthroplasty 2010;25:1083–90.
[18] Ercan A, Sokkar SM, Schmid G, Filler TJ, Abdelkafy A, Jerosch J. Periprosthetic
bone density changes after MiniHip(TM) cementless femoral short stem: one-
year results of dual-energy X-ray absorptiometry study. SICOT J 2016;2:40.
[19] Brodner W, Bitzan P, Lomoschitz F, Krepler P, Jankovsky R, Lehr S, et al. Changes
in bone mineral density in the proximal femur after cementless total hip arthro-
plasty. A five-year longitudinal study. J Bone Joint Surg Br 2004;86:20–6.
[20] Ohnaru K, Sone T, Tanaka K, Akagi K, Ju YI, Choi HJ, et al. Hip structural analysis: a
comparison of DXA with CT in postmenopausal Japanese women. Springerplus
2013;2:331.
[21] Nishii T, Sugano N, Masuhara K, Shibuya T, Ochi T, Tamura S. Longitudinal eval-
uation of time related bone remodeling after cementless total hip arthroplasty.
Clin Orthop 1997;339:121–31.