A conservative femoral replacement for total
hip arthroplasty
A PROSPECTIVE STUDY
B. F. Morrey, R. A. Adams, Mary Kessler
From the Mayo Clinic, Rochester, USA
etween 1985 and 1993, 146 patients (162 hips) had
B total hip replacement (THR) using a conservative
uncemented femoral component. The mean age of the
patients was 50.8 years and the mean follow-up was
6.2 years (2 to 13). One patient was lost to follow-up,
one died within two years of surgery and one had a
revision procedure after a fracture sustained in a
road-traffic accident.
For the remaining 159, Kaplan-Meier survival
analysis was calculated for the incidence of revision
because of mechanical loosening or osteolysis. Survival
without mechanical loosening at both five and ten
years was 98.2%. Survival without osteolysis was 99%
at five and 91% at ten years. The Harris hip score
improved from a mean of 66.3 before to 90.4 at
follow-up. Of particular note is the lack of thigh pain
in this group. Radiological analysis showed that 139
stems (88%) had no measurable subsidence, 8 (5%)
had less than 2 mm and 12 (7%) had more than
2 mm. Two of the eight and one of the 12 were revised
for mechanical loosening. Nine hips were revised for
late loosening associated with osteolysis. No reaming
of the femoral canal was associated with statistically
significant less blood loss compared with a comparable
control group of uncemented implants (p < 0.0001).
Our study suggests that using a conservative
femoral implant does not protect against wear debris
but the reliable mechanical stability (98.2%) makes
this an attractive design of implant particularly for
young patients.
J Bone Joint Surg [Br] 2000;82-B:952-8.
Received 30 July 1999; Accepted after revision 7 February 2000
B. F. Morrey, MD, Professor
R. A. Adams, RPA
M. Kessler
Department of Orthopaedics, Mayo Clinic, 200 First Street SW, Rochester,
Minnesota 55905, USA.
Correspondence should be sent to Professor B. F. Morrey.
©2000 British Editorial Society of Bone and Joint Surgery
0301-620X/00/710420 $2.00
952
The management of the young patient with severe osteo-
arthritis of the hip is controversial.
1-6
A ‘conservative’
uncemented femoral implant with satisfactory proximal
4,6
fixation is still being sought. In the early 1980s we
developed a femoral device which differed in concept from
7
the traditional design. A number of other types of un-
cemented proximally fixed femoral components have been
developed, mainly in Europe. These allow resurfacing the
head and the stabilisation of components within the neck
with or without augmentation with a side plate. We
describe our experience with a double-tapered device
which, after FDA approval, has been termed the Mayo
Conservative Hip (Zimmer International, Warsaw,
Indiana).
The goals of joint replacement include relief of pain with
immediate rigid fixation, long-term biocompatibility,
favourable remodelling characteristics, a minimum of bone
resection, reproducible results by different surgeons and
ready revision should the implant fail.
A wedge-shaped device in both the anteroposterior and
lateral planes should give immediate stability from mul-
tiple-point contact when inserted into an irregularly shaped
cavity (Fig. 1).
In 1982 these features were incorporated into a short,
60 mm, double-tapered titanium alloy proximal femoral
replacement with a modular head and neck. This basic
design has not changed since it was first used in 1985 (Fig.
7
2). The mechanical rigidity of its fixation has been inves-
tigated in regard to torque and displacement. When com-
pared with an uncemented revision implant used routinely,
no statistical difference in displacement was observed.
Both showed less than 10
m, well below the threshold of
30
m which is felt to be needed for bony
8
incorporation.
Patients and Methods
Between April 1985 and February 1993, we inserted 162
conservative implants into 146 patients. This is a consec-
utive series and thus includes the ‘learning curve’ for this
device. The selection criteria included age of less than 65
years with adequate quality of bone as determined by rigid
fixation of the rasp, and a body-weight of less than 90 kg.
There were 72 women with a mean age of 48.6 years (19 to
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 A CONSERVATIVE FEMORAL REPLACEMENT FOR TOTAL HIP ARTHROPLASTY 953

Fig. 1
A double-tapered wedge will attain fixation at several sites in the AP
and lateral projection of the contoured cylinders simulating the prox-
imal femur.

68) and 74 men with a mean age of 53.2 years (20 to 72).
Their mean weight was 74.6 ± 15 kg, 65.2 kg in the women
and 83.8 kg in the men. The underlying pathology was
osteoarthritis (99, 61%), osteonecrosis (23, 14%), devel-
opmental dysplasia (14, 9%), rheumatoid arthritis (13, 8%),
traumatic arthritis (7, 4%) and slipped epiphysis (5, 3%).
One patient was lost to follow-up, one died within two
years of surgery and one underwent revision because of
fracture as a result of a road-traffic accident. This left 159
hips available for review.
Operative technique. We use an anterolateral approach
with resection of the neck of the femur and preservation of
the lateral aspect without involvement of the greater tro-
chanter. The femoral rasp is initially inserted in varus (Fig.
3) and is impacted until no further advancement is possible.
Three different designs of uncemented acetabular cup were
used: in eight (1985 to 1986) Dual Geometry (Osteonics,
Allenhurst, New Jersey); in 21 (1986 to 1988) the Harris/
Galante I (Zimmer, Warsaw, Indiana); and in 131 (1988 to
1993) the Harris Galante II (Zimmer).

Fig. 2a Fig. 2b Fig. 3

Photographs showing a) the short-stemmed, double-tapered conservative
device first used in 1985 and b) the current version which has circum-
ferential surface treatment by corundumisation. Photograph of the position of the rasp in the proximal femur.

VOL. 82-B, NO. 7, SEPTEMBER 2000

954 B. F. MORREY, R. A. ADAMS, MARY KESSLER

The patients were routinely contacted at 2, 5, 10 and 15 Table I. Radiological changes occurring around the stem in 159
years after surgery. Complete clinical and radiological data implants
were obtained at our institution in 83 (52%), by local Zone Neocortex Lucency/lysis Increased/density
physicians in 51 (32%), and by questionnaire or telephone None 127 145 104
surveillance with radiographs in 25 (16%). All radiographs 1 27 15 0
were reviewed by the senior author (BFM). Clinical fea- 2 8 7 9
tures such as pain, limp, the use of walking aids, walking 3 2 1 20
distance and the Harris hip score, were assessed for each 4 0 0 1
patient. Subjective satisfaction was also evaluated. Clinical 5 3 2 6
data were available at a mean of 6.5 years after surgery (2
6 0 4 53
to 13) and radiological information at a mean of 6.2
7 1 1 0
years.
Radiological analysis. Five features were recorded, as
follows: 1) the development of a neocortex or radiolucent Results
line; 2) remodelling in the zones of Gruen, McNeice and
9
Amstutz; 3) osteolysis at the femoral or acetabular inter- Before operation 144 hips (91.2%) had moderate or severe
faces; 4) acetabular wear measured according to the method pain. At follow-up there was no or only slight pain in 144
10
of Livermore, Ilstrup and Morrey; and 5) subsidence (91.2%). At one year, 106 of 111 (95%) had no or slight
determined by recording the relationship between the prox- limp. At final assessment or before revision 149 of 159
imal aspect of the medial pad of the implant and the mid- (94%) had no or slight limp. No patient had significant
line of the lesser trochanter measured on the radiograph thigh pain.
taken three months after operation and on the most Radiological changes. These are summarised in Table I.
recent. Of the 159 hips, 127 showed no evidence of a neocortex or
Statistical analysis. We used the Wilcoxon rank-sum test lucent line. In the remaining 32, most changes occurred in
to test for significance between the study and control zones 1 and 2. Evidence of femoral remodelling was
groups. Statistical significance was a p value of less than considered when there was an increase in bone density in at
0.05. Survivorship analysis was performed according to the least one of the seven zones. This occurred in 55 implants,
11
method of Kaplan and Meier using the endpoint for the mostly in zone 6 but also in zone 3.
femoral component of revision for loosening. Both the neocortex and increased cortical density are

Radiographs at a) one and b) six years showing that the

neocortex has matured in zone 1. Increased density and
remodelling are observed in zones 3 and 6.

Fig. 4a Fig. 4b

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 A CONSERVATIVE FEMORAL REPLACEMENT FOR TOTAL HIP ARTHROPLASTY
considered favourable since they indicate proximal femoral
remodelling rather than stress shielding (Fig. 4).
Proximal femoral osteolysis was observed in 11 of the
159 hips (6%) and was circumferential in two. This was
observed in both of the latter more than seven years after
surgery and required revision. The process was almost
exclusively proximal. Eight of the 11 had osteolysis in
zones 1 or 2 and six in zones 6 and 7. Distal osteolysis was
rare, occurring in only three patients, all with extensive
acetabular wear.
Of the nine patients with acetabular osteolysis, this
occurred in zone 1 in five, in zone 2 in four and in zone 3
in one. One patient had osteolysis in zones 1 and 2, but the
cup had not changed position at six years. This radiological
appearance was first detected after five years in two, after
Fig. 6a Fig. 6b
VOL. 82-B, NO. 7, SEPTEMBER 2000
955
Fig. 5
The Kaplan-Meier survival curve without revision of
the femoral component. The number of procedures in
each group is shown in parentheses.
six years in three and after ten years in four.
We estimated wear using the technique of Livermore et
10
al. In 120 hips (75%) no wear could be measured, in 30
(19%) 1 mm of wear was observed, in five 2 mm (3%) and
in four (2%) more than 2 mm. In 37 of the 39 with
measurable wear, this was first observed after five or more
years. In the four cases of extensive wear this was observed
at five years in one, and after ten years in two. In one the
cup was quite vertical (55°) and the valgus deformity of the
femur caused excessive wear at the superior margin of the
cup at seven years.
In 141 hips (89%) no measurable subsidence was
observed on the AP radiograph. Less than 2 mm of sub-
sidence was seen in eight (5%) and more than 2 mm in 12
(7%).
Radiographs at a) three months and b) five years after
operation in a patient with a type-IA fracture. There is
increased density and remodelling.
956 B. F. MORREY, R. A. ADAMS, MARY KESSLER

Table II. Delayed complications requiring If those who had a component revised were removed, the
revision mean Harris hip score was 92.5 at a mean of 6.4 years after
Complication Number (%) operation. The Kaplan-Meier probability of survival with-
Cup out revision for mechanical loosening was 98.2% both at
Loose 1 (0.6) five and ten years (Fig. 5).
Unstable 1 (0.6)
Wear 2 (1.2) Complications. There were three complications not
Total 4 (2.5) requiring further surgery, one haematoma and two pulmo-
Stem nary emboli.
Mechanically loose 3 (1.8) There were 12 (7%) intraoperative complications. In ten,
Pain 1 (0.6) 12
Trauma/fx femur 2 (1.2)
there was an undisplaced, type-IA, proximal femoral
Total 6 (3.7) fracture which did not compromise the result and was not
Cup and stem associated with subsidence or reoperation. Each was treated
Wear/lysis 9 (5.6) by cerclage wire (Fig. 6). In one patient palsy of the sciatic
nerve was noted in the recovery room. The hip was imme-
Blood replacement. Low blood loss may be expected in diately re-explored and a short-neck implant was inserted.
view of the minimal preparation of the femoral canal and There was complete recovery at two years.
the short operating time. The first 117 consecutive pro- Deep infection with Streptococcus viridens occurred two
cedures in our series were compared with 135 performed years after operation in one patient. Six years after debride-
during the same period but using conventional uncemented ment the patient was asymptomatic. Delayed complications
designs. In the former 20.5% received no transfusion com- requiring revision occurred in 19 hips (12%) (Table II).
pared with 4.4% of the control group. The difference in the Problems with the cup alone accounted for four revision
amount of transfused blood between the two groups was procedures (2.5%) (Fig. 7).
statistically significant (exact Wilcoxon rank-sum test, The stem alone was revised in six cases (3.8%), two for
p < 0.0001). femoral fracture, one as a result of a road-traffic accident,
Harris hip score and survival data. The mean pre- and one because of a fall. Three cases of mechanical
operative Harris hip score was 66.3, and at follow-up 90.4. loosening occurred due to inadequate fixation (1.8%). In

Radiographs showing a) an
extensively worn cup at sev-
en years in a 35-year-old
woman with b) a good result
seven years after revision of
the cup and bone grafting of
the greater trochanter.

Fig. 7a Fig. 7b

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 A CONSERVATIVE FEMORAL REPLACEMENT FOR TOTAL HIP ARTHROPLASTY
two the device subsided in the first three months after
operation, and in one an initially stable implant at six
months became loose when the patient jumped three feet
from a step and landed on the operated limb. All three
required revision. In nine (5.6%) delayed femoral osteo-
lysis occurred in association with wearing of the cup and
revision was required for both components. The mean time
to revision was seven years (4 to 11).
Discussion
Although the reported rate of failure of cemented implants
has decreased in recent years with improved cementing
13,14
techniques, an uncemented, more ‘conservative’ option
for the younger patient continues to be a desirable
6,15,16
goal. The double-tapered contour and absence of a
collar allow the implant to be inserted until it is firmly
stabilised. Metaphyseal femoral loading independent of
fixation of the stem lessens the resorption of proximal bone
1,17-19
from stress shielding. Others have sought to obtain
20
fixation with a ‘macrolock’ interference fit. Our design
features both elements: the multiple-point contact in both
planes results in an immediate ‘macrolock’ and fibre metal
8,21
pads give osseous integration with rigid fixation. The
value of a tapered device in optimising bone remodelling in
the lateral plane has recently been demonstrated by Kuiper
11
and Huiskes.
The clinical results of this procedure seem acceptable in
the young active population. The relative lack of thigh pain
and proximal resorption which has been reported in other
1,22-25
biologically fixed systems is encouraging. As increas-
ing surveillance becomes available, the lucent line observed
in zone 1 appears to become more dense, confirming that it
26
represents remodelling and is not evidence of loosening.
Pain, with progressive lucency, in this system as with
others, is indicative of loosening and occurred in three
cases. Subsidence of 2 mm or more was measured in three
patients who have not been revised and who are asympto-
matic. This may be explained by the macrolock nature of
the tapered implant which provides increasing stability with
increasing depth of insertion.
These data compare favourably with a multicentre Swed-
ish study reporting migration greater than 5 mm in 22% of
539 PCA implants (Howmedica, Rutherford, New Jersey)
5 1990;260:215-9.
and requiring 41 femoral revisions (8%). Furthermore,
24
Mallory et al reported stress shielding in 6% of 150
patients with a mean follow-up of 6.3 years, and an incid-
24
ence of thigh pain of 8%.
The incidence of femoral fractures is also comparable
27,28
with other series with uncemented implants particularly
during the time that these prostheses were being intro-
duced. While fracture may not be as innocuous as once
29
supposed, no patient in our series had measurable sub-
sidence or loosening associated with an intraoperative
undisplaced fracture of the femoral neck.
The most important consideration which directly corre-
VOL. 82-B, NO. 7, SEPTEMBER 2000
957
lates with considerations of design is the incidence of initial
rigid fixation. In our series, 156 of the 159 hips (98.2%)
had pain-free initial stable fixation. In 20 (12%) there was
subsidence without pain. Most of the revisions were asso-
ciated with wear, as may be expected in a group of patients
with a mean age of less than 52 years.
It should also be noted that these implants have a fibre
metal pad which reflects the technology available at the
time of design in 1982. In some designs the non-wrap-
around pad has been associated with periprosthetic osteo-
lysis. We did not see this often in our series, possibly
because of the absence of a canal filling stem which
reduces the chances of the development of a biologically
active periprosthetic membrane and subsequent osteolysis.
Nonetheless, since FDA approval was granted, a circum-
ferential treatment by corundumisation has been used to
‘seal’ the proximal femur and shield the implant from wear
30,31
debris.
The current technique also preserves the lateral neck of
the femur, thus reducing the access of wear debris to the
proximal femur. While the generation of wear particles
remains an unsolved problem, the present design has shown
that preservation of bone at the initial operation is possible
and subsequent revisions may be achieved with conven-
tional designs of primary implant.
The immediate outcome with this implant is comparable
to that of many cemented and uncemented devices. Early
mechanical loosening (1.8%) is greater than that observed
with some designs. Nonetheless, the implant has attained
most of the initial goals such as preservation of the lateral
neck, simplified technique, reduced blood loss (p < 0.001),
short operating time, avoidance of stress shielding, favour-
able proximal femoral remodelling, ease of revision using
primary replacement stem designs, and a limited inventory.
It appears to be an attractive choice for the young patient
requiring hip replacement.
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
article.
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