STOP DREAMING, STOP LOOSENING: USE STANDARD LENGTH CEMENTLESS STEMS

1. STOP DREAMING, STOP LOOSENING: USE STANDARD LENGTH CEMENTLESS STEMS Douglas A. Dennis, M.D. Adjunct Professor, Dept. of Biomedical Engineering University of Tennessee Adjunct Professor of Bioengineering University of Denver Assistant Clinical Professor, Dept. of Orthopedic Surgery University of Colorado Health Sciences Center

2. DISCLOSURE • Consultant : • Depuy Synthes / Corin • Royalties: Depuy Synthes • Laboratory Research Support • Depuy Synthes • Porter Adventist Hospital

3. HIP RESURFACING • 2018 Australian Joint Registry • 78.7% Usage Since 2005 • Continues To Decrease • 7.3% In Last Year • Only 2.9% Of All Hip Arthroplasty • ENOUGH SAID !!

4. SHORT FEMORAL COMPONENTS • Numerous Reported Advantages • Bone Preserving • Better Bone Loading • Less Stress Shielding • Less Disruption Of Muscle Attachments Resulting In Better Function • Better Duplication Of Native Femoral Anteversion

5. SHORT STEMS: NUMEROUS TYPES NECK ONLY CALCAR LOADING Khanuja, Mont, et al JBJS 2014

6. SHORT STEMS: NUMEROUS TYPES LATERAL FLARE SHORT CONVENTIONAL • Khanuja, Mont, et al JBJS 2014

7. SHORT FEMORAL COMPONENTS • NOT ALL REPORTED IS GOOD • Stem Malalignment • Incorrect Sizing • Intraop Fracture • Subsidence • Loosening • Thigh Pain

8. SHORT STEMS: CURRENT CONCEPTS REVIEW • High Level Evidence Recommending Use Is Lacking • 70 Studies Reviewed: Level 1 (0) / Level 2 (2) • Primarily Used In Younger Subjects (Mean 53 Years) • Broaching Techniques Are More Demanding • ↑ Malposition, Intraop Fracture, & Subsidence • Stress Shielding Still Occurs • Especially In Zones 1 & 7 • Protected Postop Weight Bearing Is Common • Only 31% Allowed Immediate Full Weight Bearing Khanuja, Mont, et al JBJS 2014

9. SHORT STEMS: CURRENT CONCEPTS REVIEW • Literature Review Incidence: • Coronal Plane Malalignment: 0 -- 68% • Intraop Fracture: 0 -- 5.4% • Improper Sizing: 3.3 – 27.3% • Stem Subsidence: 0 – 4.2% • Thigh Pain: 0 – 14.4% • Stem Survivorship: 83.3 – 100% Khanuja, Mont, et al JBJS 2014

10. WHAT ARE WE TRYING TO FIX ? • 2017 Australian Joint Registry • Failure Of Conventional THA Due To Loosening @ 16 Years Only ≈ 2%

11. 2018 AUSTRALIAN REGISTRY • Mini Vs Standard: 10 Yr Failure Rates Are Similar

12. 2018 AUSTRALIAN REGISTRY • Mini: Loosening Is Predominant Failure Mode • Higher Than With Standard Stems • 10 Years: Mini 2.5% / Standard 1.2%

13. Not All Studies Show Less Bone Loss With A Short Femoral Stem !!

14. DOES A SHORT STEM MAKE A FUNCTIONAL DIFFERENCE ?? • Theory: Short Stem Maintain More Normal Anatomy / Muscle Attachments & Should Improve Function • 22 Bilateral THA • Short Stem / Standard Length Stem • Gait Analysis • Neither Demonstrated Normal Gait Patterns • No Differences In Short Vs Standard Zugner, et al, Hip International 2018

15. META-ANALYSIS / REGISTRY DATA • Neck Harming (Low Cut) • Neck Sparing (Standard) • Neck Retaining (High Cut) • Neck Harming & Sparing Had Equally Good Results • Neck Retaining Group Was Significantly Inferior Hauer, et al, J Arthroplasty 2018

16. MAYO CONSERVATIVE SHORT STEM • NOT ALL RESULTS ARE GOOD !! • 95 Cases / Mean F/U 97 Months • 20.3% Orthopedic Complications • Femoral Fracture (4) • Femoral Loosening (2) • Dislocation (4) • Survivorship Free Of Femoral Revision = 89.5% Rutenberg, et al, Orthopedics 2018

17. MAYO CONSERVATIVE SHORT STEM • NOT ALL RESULTS ARE GOOD !! • 52 Cases • Mean F/U 96.1 Years • 7.6 % Femoral Loosening • 3.8% Incomplete Metaphyseal Fractures Martins, et al, J Arthroplasty 2014

18. SHORT STEM: FEMORALFRACTURE • Multicenter Short Stem Analysis • 1089 Cases / 5.1 Year Mean F/U • 12 /1089: Femoral Fracture (1.1%) • Increased Fx Risk In Elderly • 71 Vs 57 Years In Non-Fracture Cohort • 50% Of All Revisions Due To Femoral Fracture Kim, et al, SICOT 2018

19. SHORT STEM: THIGH PAIN • 226 Cases / 3 Year Mean F/U • Taperloc Bone Preservation Stem • 24.6% Had Thigh Pain • 9% Moderate Or Severe • Abandoned Use Of Stem Amendola, Goetz, Callaghan et al, CORR 2017

20. INTRAOP RADIOGRAPHY IS WISE • 287 Short Stem THAs • Three Levels Of Surgeon Experience • Senior Consultant / Consultant / Residents • IntraopXrays Obtained • How Often Did Xrays→ Stem Adjustment ?? • Overall: 42.2% / Senior Consultants: 32.7% • Consultants: 50.5% / Residents: 65.4% • Most Common Adjustments: Malposition & Undersizing • SUMMARY: • Definite Learning Curve • Experience Matters Loweg, et al, Eur J OrthopSurgTraumatol 2018

21. SHORT STEMS: EXTRACTABILITY • Some Short Stems Have Complex Geometries Which Can Result In Extraction Challenges

22. SHORT STEMS: SUMMARY • Standard Length Press-Fit Stems Work VERY WELL !! • Short Stems Can Work Well • Low Evidence Evaluations • High Evidence Prospectively Randomized Comparative Studies Are Needed

23. SHORT STEMS: SUMMARY • More Technically Demanding • Malposition / Incorrect Sizing • Intraop Fracture • Subsidence & Loosening • Definite Learning Curve • IntraopXrays Are Wise • Effect On Rehab ?? • Majority Delaying Full Weight Bearing

24. SHORT STEMS: SUMMARY • No Functional Benefits • Bone Loading Advantages Have Had No Long Term Outcome Benefits Vs Standard Length Stems • WHY CHANGE ?? • WHAT ARE WE TRYING TO FIX !!

25. THANK YOU

26. Panel: Keeping The Bone, Preservation Is Key For Primary Hip Arthroplasty • Pro: Hip Resurfacing In The Young Athlete With • Arthritis - Ignore The Naysayers • Pro: Short Stems Are The Answer In 2018 - Wake Up! • Pro: Stop Dreaming, Prevent Loosening - Use • Standard Length Cementless Stems • Pro: Avoid The Early Failure! Preserve Bone: I Use • Standard Length Cemented Stems - You Are All • Wrong!