Defining ‘undersizing’ in short-stem total hip arthroplasty: the importance of sufficient contact with the lateral femoral cortex

Undersizing is 1 of the main reasons for early implant failure. Adequate sizing in short-stem total hip arthroplasty can be challenging and, so far, lacks key decision criteria.

We included 191 calcar-guided short stems. All patients underwent standardised digital anteroposterior imaging pre- and post-surgery and during follow-up. Preoperative planning was performed digitally. Planned stem sizes were retrospectively assessed and compared with the implanted sizes. Additionally, adequate sizing was analysed by determining whether the stem made intraoperative contact with the lateral distal femoral cortex. Implant migration was assessed by Ein-Bild-Roentgen-Analysis Femoral-Component-Analysis 5 years after surgery. Influence of different Dorr types and postoperative centrum-collum-diaphyseal angle (CCD) categories on lateral femoral cortical contact were analysed. Additionally, the Harris Hip Score (HHS) was assessed at final follow-up. Stem-revision rate was documented.

Implanted stems were at least 2 sizes smaller than those at the preoperative planning in 49 (25.7%) cases. The stem made contact with the lateral distal femoral cortex in only 130 hips (68.1%). Mean subsidence was significantly higher in the no-contact group (2.07 mm, range −7.7 to 1.7) than in the contact group (1.23 mm, range −4.5 to 1.8) at the final follow-up (p = 0.0018). Stems at least 2 sizes smaller than those at preoperative planning showed a significantly higher prevalence of non-contact (46.9% vs. 26.8%) (p = 0.009). Those undersized stems were more likely found in varus hips. No influence of the Dorr classification and the different CCD categories on the probability of achieving sufficient cortical contact was found. HHS showed no intergroup differences.

Stems that did not make intraoperative contact with the lateral femoral cortex showed significantly increased axial migration at mid-term follow-up. Thus, the investigated criteria regarding the definition of undersizing in short-stem THA should be acknowledged. No obvious mid-term consequences were noted regarding revision rate. Long-term results are mandatory.