Journal of

Orthopaedic
Review Surger y
Journal of Orthopaedic Surgery
27(2) 1–9
ª The Author(s) 2019
The calcar femorale: A new perspective Article reuse guidelines:
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DOI: 10.1177/2309499019848778
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Alan Hammer

Abstract
It is the role of the hip joint to support the superincumbent body weight while its complex range of movement, under a
variety of stresses, allows the individual to undertake a wide range of physical activities. It is then perhaps not surprising
that a recent anatomical study shows that the upper femur has a structure commensurate with the complexity of its
movements. Mechanically, the upper femur consists of two separate bones: the combined femoral head and neck and the
femoral shaft. Both bones consist of a mixture of two different types: cancellous bone and cortical bone, each with its own
characteristics. Both bones are subjected to two different forces: those of weight bearing and movement and those of
bone modelling. In the face of these complexities, this article tenders some theoretical considerations as to how this
region functions and deals with these particular problems. From an anatomical viewpoint, the calcar femorale plays a
central role in the mechanical structure of the femoral neck and is pivotal in the management of the stresses to which the
region is subjected.

Keywords
calcar femorale, hip anatomy, hip calcar, hip forces, internal structures of upper femur, orthopaedic calcar

Date received: 23 August 2018; Received revised 02 February 2019; accepted: 15 April 2019

Introduction Some of the confusion may have arisen because the term
‘calcar femorale’ has come to mean one of two things,
Numerous studies have attempted to define the bony archi-
depending upon the outlook of the individual.4 The classical
tecture of the proximal femur in terms of human function.1
anatomical ‘calcar femorale’ refers to the vertical, quadrilat-
Traditionally, descriptions of the upper femur include men-
eral plate of dense cancellous bone which develops in the
tion of two bony trabecular columns, one vertical and the
posterior femoral neck, below but separated from, the lesser
other horizontal, which are said to convey the forces gen-
trochanter. It is not to be confused with the ‘orthopaedic
erated during physiological activity of the hip (Figure 1).
calcar’, which is the lowermost and thickest point of the
The vertical column has its base in the lower medial
cortex constituting the medial wall of the femoral neck.3–6
femoral neck and ascends vertically into the femoral head.
Bigelow7 noted that the anatomical calcar was termed as
This column is said to convey a compression force. The
the ‘calcar femorale’, ‘Schenkelsporn’ or ‘thigh spur’ by
horizontal column has its base at a bony buttress in the
Merkel in 1874.8 He stated that, as he understood it, the
inner, anterior upper femoral shaft from which it extends
objective of Merkel’s article was, following the tenets of
horizontally to enter the anterior aspect of the femoral
Wyman,9 ‘to prove the importance of the tissue in support-
head.2 This column is said to carry a tension force. There
is, however, a third cancellous structure which is somewhat ing the weight of the body and that the strength of the femur
enigmatic; the calcar femorale.
Harty3 stated that ‘The calcar femorale was described
over 100 years ago but precise knowledge concerning its Department of Orthopaedics, University of Kwa-Zulu Natal, Durban,
location and nature was later lost, and today many clini- South Africa
cians are still confused on these points’. This may be Corresponding author:
because the literature on the subject is often conflicting, Alan Hammer, 4 Clarendon Close, Maidstone, Kent ME14 4JD, England.
questionable and/or confusing. Email: hammer_alan@hotmail.com

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2 Journal of Orthopaedic Surgery 27(2)
Figure 1. Schematic diagram to show the configuration of the
two trabecular columns within the femoral neck. Presently, the
vertical column and the horizontal column are said to conduct a
compression force and a tension force, respectively.
is due to this tissue and not to the braces of Wolff and
Culmann’. Bigalow7 recorded that this article, perhaps not
surprisingly, leads to a spat between Wolff and Merkel,
conducted through the literature. Wolff10 countered Merkel
by saying that ‘Merkel’s theory in no way agrees with
Culmann’s calculations which may be accepted as beyond
controversy and which prove that the “spur” is not at the
point of greatest strain, nor yet where strength is most
needed’. This being so Wolff felt that ‘Merkel had awarded
to the “cancellous plate under the lesser trochanter” a
wholly erroneous importance’.
This, however, did not seem to have resolved the issue
with regard to the calcar femorale and the other internal
trabecular structures of the upper femur. Dixon11 stated that
There is not yet agreement regarding the arrangement of the
bony lamellae or the significance of their disposition; as to
whether they are associated with the internal strain of weight
bearing in the erect position or whether they are due to mus-
cular action. It has also been urged that the strains and stresses
to which the bone tissue is subjected are so complicated and so
little understood that, at best, we can only guess at the signifi-
cance of the arrangement of the bone elements.
What is the calcar femorale?
The upper end of the thigh bone may be looked upon as a
tubular structure to the surface of which are fixed project-
ing masses (trochanters) for the attachment of muscles and
ligaments.11 The calcar is a vertical plate of dense cancel-
lous bone which lies deep to the lesser trochanter but pos-
terior to the neutral axis of the femoral neck.5,12,13
All the dissections and scans of the calcar were per-
formed by various investigators1,3,7,11,12,14,15 who have,
essentially, dissected the femoral neck in its longitudinal
axis, that is, in the horizontal plane, and their findings have
been relatively constant. They record that the calcar femor-
ale is thick at its origin from the lower portion of the ver-
tical trabecular column and becomes progressively thinner
as it passes laterally through the substance of the trochan-
teric bulges until it reaches the cortical shaft of the femur,
from which point it breaks up into thin, tenuous trabecular
strands as it extends further towards the posterior wall of
the greater trochanter.7
Because of this, Bigelow7 seems to have been in two
minds when he wrote saying
But the purpose of the osseous plate, whose structure and
pathology it is the main object of this paper to discuss, may
be at first a little less obvious. It plainly adds a certain strength
to the bone, and yet in most bones it terminates beneath the
trochanters in papery lamellae wholly inadequate to lend it
material support.
Size and shape
Harty3 noted that the calcar originates medially from the
lower portion of the vertical trabecular column in the
postero-medial portion of the femoral shaft, and it radiates
laterally through the cancellous tissue towards the great
trochanter. The calcar, he said,
reaches its maximum length and thickness at the level of the
upper margin of the lesser trochanter, diminishing progres-
sively in size after that point. Superiorly the calcar femorale
fuses firmly with the cortex of the posterior aspect of the
femoral neck; distantly extends about two inches anterior to
the lesser trochanter and then fuses with the posteromedial
aspect of the diaphysis.
As Griffin12 puts it, ‘the calcar femorale is thickest where it
joints the medial cortical buttress of the femoral neck and
then gradually thins out laterally’.
Development of the calcar
The calcar femorale is present in every femur which has an
ossified lesser trochanter.12 No calcar is visible in the infant
femur but by the time the infant is 3 years old, bony lamel-
lae are present on the deep surface of the cartilaginous
lesser trochanter.3 The calcar appears to be best developed
during early adulthood and then gradually atrophies after
middle age.7,12 Nevertheless, although the distal (lateral)
portion becomes partly resorbed, the system is maintained
throughout life, its presence being revealed by roentgen-
ogram and curettage.12,14
The true neck of the femur
There have been a number of theories pertaining to the
development and function of the calcar, few of which have
Hammer
stood the test of time. The upper portion of the femoral
shaft expands to form the greater and lesser trochanters
which provide muscle attachment to this region. The ante-
rior wall of the femur at this level is thick and strong but the
posterior wall is thin and seemingly very weak. The calcar
femorale develops as an apparent cortical extension of the
shaft into the neck,12 as it attaches posteriorly to the inner
neck of the upper femur in alignment with the medullary
cavity of the femoral shaft. Bigelow7 proposed that the
calcar is, in fact, the true posterior wall of the upper femur
which develops within the cancellous tissue of the region in
order to maintain the continuity of the shaft and which, in
association with the anterior wall, provides mechanical
support to the region as a physiological internal shaft.
He noted that in one of the specimens, which he dis-
sected, the dense plate (of the calcar) was the’continuation
of the neck, completing the interval everywhere except at
its upper part. In this form it adds greatly to the strength of
this part of the femur, while the trochanters and their ridge
erected upon it both reinforce it and give attachment to the
muscles’.
However, maintaining his pessimistic approach, Bige-
low7 continued with the statement that ‘The true neck is
often at best but an ineffectual attempt to bridge the interval
beneath the trochanters while in the latter half of life it
degenerates’.
Nevertheless, this concept of an internal physiological
support was extended by Krause 15 and supported by
Dixon11 who proposed that the calcar was only part of a
longer condensation which they termed as the ‘lamina
femoralis interna’. This, they felt, extended from the lateral
area where the calcar joined the posterior wall of the
femoral neck to the femoral head, in association with the
arching trabeculae of the femoral neck to provide an inter-
nal ‘physiological’ wall which provides the necessary sup-
port for the muscle action upon this region. These ideas do
not seem to have gained much acceptance, particularly as
Newell4 decried theories on the calcar based on a two-
dimensional assessment for the femoral neck by section
or X-ray and there is little evidence to support the idea of
a tubular structure passing through the femoral neck.
Steihl et al.1 state that ‘Simplistic two-dimensional ana-
tomical and force models may not adequately predict the
stresses present in such a three-dimensional model’.4,5,11
All express the need to assess the region three-
dimensionally. In his paper, Garden5 states that in basic
outline the proximal end of the femur is striving towards
a spiral form and, by stereo-radiography, the calcar femor-
ale and the internal weight-bearing system are seen to be an
upward and spiral continuation of laminae of the poster-
omedial cortex of the shaft conducting compression forces.
Dixon11 had a similar theory except that, from stereo-
radiography and plain X-rays of the femoral shaft, he pro-
posed that the internal weight-bearing system is composed
of interdigitating spiral laminae running alternatively in
3
opposite directions and those in each direction conducting
either a compression or tension force, respectively.
Function of the calcar
Despite differing concepts and viewpoints, there is no
doubt that the calcar femorale is involved in the transmis-
sion of forces through the femoral neck.
Farkas et al.14 state that the calcar femorale contributes
to the strength of the femoral neck and is ‘intimately
involved in weight bearing’. They go on to state that roent-
genographically it can be demonstrated that the calcar is the
internal weight bearing system of the neck of the femur form-
ing an angle of from 3 to 8 degrees with the perpendicular
during weight bearing in youth and throughout middle age; a
compression system and apparently the only spongy structure
in the neck which serves weight bearing.
Li and Aspden16 state that
The calcar’s alignment with the stress trajectories in the
femoral neck and its higher radiographical density compared
with the predominantly cancellous bone of the rest of the neck,
indicate a significant mechanical role in the transmission of
loads in the hip. These results suggest that it is capable of
providing a support to the femoral neck and acting as a transi-
tional structure to transfer stress from the trabecular bone of
the femoral head and neck to the cortical bone of the femoral
shaft.
Zhang et al.13 state that
The calcar femorale can bear compression load and redistri-
butes stress or load from the femoral head to the proximal
femur. As part of a truss system, it can transform bending
moment and torsional moment. It plays an important role in
the proximal femoral loading system and is highly significant
in the treatment of proximal femoral fractures.
Using multiple strain gauges, they showed that ‘the cal-
car femorale redistributes stress in the proximal femur by
decreasing the load in the posterior and medial aspects and
increasing the load in the anterior and lateral aspects’. Nev-
ertheless, they add that ‘how the forces transfer inside the
proximal femur, and the exact role of the calcar femorale, is
still unknown’.
Discussion
It is the function of bone to transmit the forces which move
the body. One cannot, however, understand the develop-
ment and shaping of living bone, which constitutes its anat-
omy, without understanding the complex relationships
which exist between it and the forces to which it is
subjected.
4 Journal of Orthopaedic Surgery 27(2)
A pivotal name attached to the present day understand-
ing of the anatomy and function of the upper femur in this
respect is that of Julius Wolff,17 who promulgated two
theories in regard to the relationship of bone to the forces
traversing it – his ‘Law of Bone Remodelling’ and his
‘Trajectorial Theory’. These terms are often used synony-
mously but, conceptually, they are completely different.
Wolff’s ‘Law of Bone Remodelling’ considers the response
of living bone to the physiological forces passing through
it, whereas his ‘Trajectorial Theory’ relates to the actual
path which these forces take through the trabecular bone,
shown by the trabecular formations which depicts the
mechanical processes taking place within it, with particular
reference to the upper femur.
Wolff’s law
Wolff derived his ‘Law’ by studying the effects of
physiological forces on the shape of the bones and their
internal trabeculae after their fractures or osteotomies had
healed.18 His ‘Law of Bone Remodelling’ states: ‘Every
change in the form and function of bone, or of their func-
tion alone, is followed by certain definite changes in their
internal architecture, and equally definite alteration in their
external confirmation, in accordance with mathematical
laws’.
This ‘Law’ relates to the effect of a physiological force
passing repeatedly through living bone and essentially
states that bone will form in relation to the forces to which
it is subjected and is applicable to bone in general.18 ‘The
response of the bone’, says Wolff, ‘is that it will adapt its
shape and architecture in order to meet the physiological
demands upon it’.17
Avrunin and Tses,19 however, note that, in formulating
his ‘Law’, Wolff had incorrect ideas on skeletal biology,
inasmuch as he based it on a static ‘mathematical’ relation
between the trabecular architecture and the stress trajec-
tories. In addition, they say, Wolff also refused to accept
other facts that were available at the time. Despite this,
Wolff promulgated his theories enthusiastically and
widely, the result of which is that his ‘Law’ remains widely
accepted, even today. Looking at the positive aspects,
Avrunin and Tses go on to say that Wolff’s contribution
to the popularization of the scientific discipline which has
emerged, that is, Mechanobiology, is still highly esteemed
as it has not only scientific but also clinical significance.
There is evidence that architectural adaptations follow a
major change in bone loading,20 and the concept and law
which Wolff puts forward forms only one of the existing
models that reflect the characteristics of skeletal mechan-
obiology. The ideas put forward more recently by Frost
hold great sway. All modelling and remodelling of bone,
he wrote, is undertaken by osteoblastic drifts, which add
additional bone to the structure, or by osteoclastic drifts,
which removes bone (Figure 2). The overall effect of the
combined action of both these drifts is to sculpt the bone
Figure 2. Schematic diagram showing how a deformed bone is
remodelled through the tissues to align with the force and
strengthen itself under the action of osteoblastic and osteoclastic
‘bone drifts’.
and ‘move it’ through the tissue space in order to align the
bone with the force acting upon it and to develop the appro-
priate strength to meet the physical demands.20
The modelling of bone is largely controlled by mechan-
ical factors. The feedback mechanism for this process is
governed by the strain within the bone.20–24 Generally,
bone attempts to maintain the strain within it, arising from
normal activities, to lie within a physiological range of
somewhere between 0.0050 and 0.0015 unit strain.20,25
Large mechanical loads deform or strain bone. Where
strains exceed a modelling threshold level of about
0.0015 microstrain, modelling slowly lays down bone in
order to align it with the applied stress and to strengthen it
by increasing its thickness or diameter. As a result of
becoming stronger, the bone will, in turn, reduce the level
of strain within it back into the normal physiological range
and the modelling stops. Nevertheless, if the strains within
the bone remain too high, the probability of failure
increases.20
On the other hand, if the strains become too low, the
bony structures will become, relatively speaking, unneces-
sarily robust in relation to the body’s requirement, and
energy will be wasted in synthesis, maintenance and trans-
port of the bone, and the modelling will stop. There is no
response if the strains are below a minimal level, shown to
be below 0.0008–0.0015 unit strain.20,21 When strains
within the bone stay below a lower remodelling threshold
range, disuse remodelling permanently removes bone.18
Wolff’s trajectorial theory
It has long been known that the upper femur contains the
two trabecular columns, best seen on the anteroposterior
Hammer
Figure 3. Schematic illustration of Ward’s diagrams showing that
the mechanical configuration of the bone within the upper femur
resembles that of the supports for an old fashioned gas lamp, both
having struts to carry the resultant tension and compression
forces.
radiograph of the pelvis (Figure 1), which are of mechan-
ical importance. It was probably Ward, in 1834,26 who first
noted that the configuration of these internal columns
resembled that of the supports holding the gas lamps to
their stanchion, which were commonplace in London at the
time (Figure 3). He proposed that the bony columns within
the femoral neck individually conduct a tension and a com-
pression force as did the gas lamp supports. The concept
that, mechanically, the trabeculae within the femoral neck
act in this way has prevailed until the present time.
These ideas were later enhanced when, in 1866, HG
Meyer, Professor of Anatomy, presented a series of draw-
ings of the internal trabecular structure of various human
bones at a meeting of the Natural Science Society in Zurich
(Figure 4).27 It was there that he began an association with
Professor Carl Culmann, a German structural engineer and
originator of the structural optimizing technique Graphic
Statics. Culmann had told von Meyer that, as shown by
Graphic Statics, his drawings of the trabecular structures
within the upper femur resembled the internal stresses
within a curved loaded Fairbain crane, a project which
Culmann had been working on (Figure 5). Wolff later
entered into association with Culmann and ultimately pub-
lished his Trajectorial Theory which considers that ‘in the
proximal end of the human femur cancellous bone is pres-
ent only along the mathematical stress trajectories’, show-
ing the paths of both tension and compression through the
region. In addition, he was emphatic that in order to meet
the mechanical requirements of Graphic Statics, these
columns have to cross orthogonally (i.e. at 90 ) within the
femoral head so that they are not subjected to any shearing
stress.17
Wolff’s Trajectorial Theory, like Ward’s depiction of
the stresses within the staunchion of the London gas lamps,
considers the vertical trabecular column as conducting a
5
Figure 4. Representation of the trabecular patterns within the
femoral neck from G von Meyer’s dissections.
compression force while the horizontal trabecular column
conducts a reciprocal tension force.
This theory appears to apply reasonably well when the
hip is considered to be in the extended (body upright) posi-
tion during walking and limited hip flexion but it is
acknowledged that it is not known how the bone of the
upper femur conducts the, sometimes major, forces gener-
ated while the hip joint moves from full extension (standing
and walking) to full flexion (squatting and climbing).28–30
In addition, the Trajectorial Theory itself has come in for a
number of diverse criticisms,31 particularly the idea that the
horizontal column conducts a tension force. This has been
rejected by a number of authors who consider that this
column also conducts a compression force.5,11,32–36 As a
final arbiter, the findings of a series of anatomical, three-
dimensional dissections of the upper femur2 question the
Trajectorial Theory by revealing contrary anatomical find-
ings inasmuch as they revealed that the two trabecular col-
umns do not lie in the same coronal plane, rendering
Wolff’s theory mechanically invalid. So, the main problem
with the Trajectorial Theory is its limitations inasmuch as it
only considers the forces within the upper femur two
dimensionally, that is, those arising during standing and
walking, whereas the upper femur is a three-dimensional
structure.1,4,5,11
During physiological activities, such as standing, walk-
ing, running, sitting, squatting and climbing, it is the func-
tion of the hip, with the leg below, to support the
superincumbent body weight, regardless of the position
of the joint. For this purpose, any force between the femur
and pelvis must cross through the dome of the acetabulum.
It is accepted that the force impinging upon the femoral
head is the resultant of those forces arising from both grav-
ity and muscular action.37 As a result of this ‘resultant’
6 Journal of Orthopaedic Surgery 27(2)
Figure 5. Schematic illustration, after K Culmann, of the tension
and compression force lines within a curved Fairbain crane, as
derived by Graphic Statics.
Figure 6. Schematic two-dimensional representation of the
resultant force of weight bearing, showing its relationship to the
internal vertical and horizontal trabecular columns at the times of
full extension and full flexion of the hip joint.
force acting on the femoral head, an equal, ‘reactive’ force
arises within it. Both these forces, ‘resultant’ and ‘reactive’,
are compressive in nature (Figure 6).
According to Wolff’s Law, force precedes bone.
Accordingly, it must be borne in mind that the internal
structures of the femoral neck, namely, the two trabecular
columns and the calcar, form in response to the strains
generated by the (compression) forces traversing the
region. The paths of the forces of weight bearing through
the femoral head and neck can thus be visualized by fol-
lowing the trabecular structures within it.
The vertical trabecular column is associated with stand-
ing and walking. It begins just under the superior surface of
the femoral head and passes down to the medial cortical
wall of the femur at the junction of the femoral neck and
shaft. It is confirmed by the dissections of the upper femur2
and radiographs that, with the hip extended, the vertical
resultant force initiated by standing passes through the
dome of the acetabulum and impinges upon the superior
surface of the femoral head (Figure 6(a)). This force is
straight. On passing through the joint space, it sets up a
reactive force within the femoral head which aligns with it.
This reactive force is also straight and passes almost verti-
cally down through the centre of the femoral head. The
nature of both the resultant and reactive forces is that of
compression, which generates a line of stress within the
bone, the consequence of its passages through the femoral
head and neck being the formation of the vertical trabecular
column.
Following Wolff’s Trajectorial Theory,17 the horizontal
trabecular column is widely associated with a tension force
during standing although it is difficult to see why this is so.
The femoral dissections and radiographs confirm that this
column begins just under the anterior surface of the femoral
head2 and passes horizontally, in a curvilinear fashion,
across the inner cortical surface of the femoral neck to end
in a small buttress on the inner cortex of the antero-superior
femoral shaft. The dissections also show that when the hip
is flexed the femoral head rotates vertically and the erst-
while anterior surface moves up into the femoral acetabular
dome where it is directly under the resultant force of weight
bearing (Figure 6(b)). As with standing, this resultant force
sets up a reactive force within the femoral head which
aligns with the resultant force. Again, both these forces are
straight. The major difference between the standing and
squatting postures is that during active squatting, the bony
tissues of the upper femur move across this line of force. It
is hypothesized that, as a result of this movement, a curved
line of strain is generated within the bone, which stimulates
a line of bone formation reflecting the arc of motion of the
upper femur. It must be noted that, despite the femoral head
rotating, the impinging resultant force remains the same;
that of compression. It is then further hypothesized that it
must be accepted that the horizontal trabecular column
carries a compression force, not a tension force.
The recent three-dimensional anatomical dissections2
showed that the calcar femorale is a thick, broad, strong
plate of bone throughout its length and that its orientation is
predominantly vertical (Figure 7). The photograph also
shows that the calcar femorale has strong attachments to
the lateral ends of both the vertical and horizontal trabecu-
lar columns as well as attachments to the surrounding bone
of the upper femoral shaft. It is hypothesized that the calcar
is involved with the forces traversing the upper femur in
several ways.
Hammer
Figure 7. Photograph of a physical dissection of the upper femur.
Note that the calcar is orientated obliquely upward and has sub-
stantial connections with both the horizontal and vertical trabe-
cular columns and the upper femoral shaft. The double arrowed
line shows the course of the hypothesized compression force
through the calcar generated during the hip flexing and extending
under load.
The junction between the femoral shaft and the femoral
neck is not curved but angular.38 This is demonstrated by
the fact that, on an anteroposterior X-ray image of the
human hip, straight, not curved, lines can be drawn down
the middle of each of their shafts, the angle which they
subtend being known as the ‘neck/shaft angle’. The dissec-
tions 2 show that the calcar lies along the line of this
junction.
The change of direction between the femoral neck and
femoral shaft suggests that, mechanically, this is an area of
strong, as yet undefined, shear and rotatory stress within the
bone, arising from the physiological movements of the hip.
It is suggested that this junction can be classified mechani-
cally as a ‘moment connection’, which is designed to
accommodate such forces.38 This being so, it is hypothe-
sized that the calcar arises partially in response to these
forces and provides a necessary internal support to help
meet the physical strains of this ‘joint’.
The lateral end of the horizontal trabecular column
lies antero-superiorly, and the lateral end of the vertical
trabecular structure lies at the inner aspect of the medial
neck/shaft junction. Figure 7 shows that the calcar
stretches across between these ends of the two trabecu-
lar columns and has strong attachments to the ends of
both. From this, it is hypothesized that the calcar acts to
provide a base for the two trabecular columns, forming
with them a unified internal trabecular structure which
gives a necessary internal support, within the femoral
head and neck, to carry the forces of weight bearing
through them.
7
Figure 8. Two-dimensional depiction of the possible figure of
eight course of the reactive compression force passing through
the femoral head and neck during flexion and extension of the hip
joint.
It is not clear exactly how the reactive force passes
through the femoral neck as the resultant force transits
across the antero-superior surface of the femoral head dur-
ing flexion movements of the hip joint (Figure 8). It is
noted, in Figure 6(b), that it is at full flexion that the resul-
tant force is over the proximal end of the horizontal trabe-
cular column. This suggests that, during flexion of the hip,
the reactive force passes up from the lateral end of this
column rather than going down it. This being the case it
means that at the initiation of flexion, when the hip is fully
extended and the reactive force is in the vertical column,
the reactive force moves up through the calcar from the end
of the vertical column to the lateral end of the horizontal
column, before passing into it, confirming that the calcar
and the two trabecular columns are one unified structure.
The calcar has strong connections with the upper femur
laterally and medially suggesting that it is through these
that the calcar disseminates the compression forces from
the trabecular columns into the femoral shaft, particularly
posteriorly where the cortex is particularly thin.
The upper femur consists of an admixture of cortical and
trabecular bone. Wolff himself states ‘The cortex is
involved in the architectural structure of the bone as much
as is the cancellous tissue’.17 While the trabecular bone
may have formed an internal support structure of cancel-
lous bone, it must be remembered that it is also the role of
cortical bone to transmit forces acting upon it.
The majority of experimental studies of remodelling in
bone have focused on cortical bone.39,40 Only a limited
number of studies have dealt with trabecular bone experi-
mentally. As a result, the mechanisms of bone adaptation to
mechanical forces in this substance are not well
8 Journal of Orthopaedic Surgery 27(2)
understood. Nevertheless, it has been shown that cancel-
lous bone appears to respond in the same way to the applied
forces as cortical bone does.41
This being so the upper femur can be considered, ana-
tomically, as being made up of three different elements –
the cortical bone of the femoral shaft, the cortical bone of
the femoral head and neck and the cancellous bone of the
internal trabecular structures of the femoral head and neck.
Undoubtedly, the forces passing through the upper
femur during activity are complex. Similarly, the forces
responsible for the remodelling of the different elements
of the bone of the upper femur must be equally complex. It
is unlikely that a single force (e.g. that from simply stand-
ing) will satisfy all the remodelling requirements of both
the cortical elements and the cancellous bone constituting
the upper femur.
The actual forces responsible for modelling and remo-
delling the cortical bone of the upper femoral shaft and
femoral neck and maintaining the neck shaft angle, from
foetus to adult, are unknown. It is nevertheless hypothe-
sized that at least two separate resultant forces are required
for the cortical bone alone, one for the shaft and one for the
neck. It is probable that these two forces are constant and
overriding as the shape of the femur and the neck/shaft
angle, once formed, remain relatively constant through life.
It is known that the cortical and cancellous bone of the
upper femur share the load passing through the hip
joint,39,40 although the exact proportions in which they do
it are unclear. It is hypothesized in this present article that,
constrained by the more or less fixed shape of the cortical
bone of the upper femur, which has its own modelling
stimuli, the compression force generated by the physiolo-
gical actions of the hip, in whole or in part, passes through
the region in such a way that (a) the cancellous bone gen-
erated by this force fulfils the need for additional, appro-
priate reinforcement of the upper femur and (b) the
remodelling of both the cortical and the cancellous bone,
in the face of these two different modelling stimuli, is
balanced.
Conclusion
The calcar has a central role in dealing with the complex
forces which occur at the femoral shaft/neck junction of the
femur. The anatomical study suggests that, in addition to
the local stress, it receives a large proportion of the forces
of weight bearing coming down through the femoral neck
and transmits them to the upper femur.
While this is occurring, it must be borne in mind that
both the cortical and trabecular bone of both the upper
femoral shaft and the femoral neck are affected by two
types of forces: constant modelling forces which maintain
the shape of the bone and intermittent motor forces which
bring about the movements of the hip. It is hypothesized
that both have different modelling effects but, as the exter-
nal shape of the upper femur remains much the same, some
compromise between them is present. It is suggested that
this takes the form of developing the system of trabecular
bone within the femoral neck which conducts the forces
moving the body in such a way that the combined model-
ling effects of forces are balanced and have the least
possible effect on the shape of the bone.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Alan Hammer https://orcid.org/0000-0003-4944-8087
References
1. Stiehl JB, Jacobson D and Carrera G. Morphological analysis
of the proximal femur using quantitative computed tomogra-
phy. Int Orthopaedics 2007; 31(3): 287–292.
2. Hammer A. The structure of the femoral neck: a physical
dissection with emphasis on the internal trabecular system.
Annals Anat 2010; 192(3): 168–177.
3. Harty M. The calcar femorale and the femoral neck. J Bone
Joint Surg Am 1957; 39-A(3): 625–630.
4. Newell RLM. The calcar femorale: a tale of historical
neglect. Clin Anat 1997; 10(1): 27–33.
5. Garden RS. The structure and function of the proximal end of
the femur. J Bone Joint Surg Am 1961; 43(3): 576–589.
6. Stiles RG, Lavernia CJ, Resnick D, et al. The calcar femorale:
an anatomic, radiologic, and surgical correlative study. Invest
Radiol 1990; 25(12): 1311–1315.
7. Bigelow HJ. The true neck of the femur: its structure and
pathology. Boston Med Surg J 1875; 92(1): 1–5.
8. Merkel F. Betrachtungen uber das Os femoris. Vircows Arch f
Pathol Anat 1874; 59: 237–256. Quoted by Bigelow 1875 and
Harty 1957.
9. Wyman J. On the cancellated structure of some bones of the
human body. Boston J Natl History 1849; 6: 125–140.
10. Wolff J. Virchows archives. 1874; 61: 417. Quoted by
Bigelow.
11. Dixon AF. The architecture of the cancellous tissue forming
the upper end of the femur. J Anat Physiol 1910; 44(Pt 3):
223–230.
12. Griffin JB. The calcar femorale redefined. Clin Orth 1982;
164: 211–214.
13. Zhang Q, Chen W, Liu HJ, et al. The role of the calcar
femorale in stress distribution in the proximal femur. Orthop
Surg 2009; 1(4): 311–316.
14. Farkas RA, Wilson MJ and Hayner C. An Anatomical study
of the mechanics, pathology, and healing of fracture of the
femoral neck. J Bone Joint Surg Am 1948; 30A(1): 53–59.
Hammer
15. Krause W. Skeleton of the upper and lower extremity. Jena:
Gustav Fischer, 1909, pp. 62–65.
16. Li B and Aspden RM. A comparison of the stiffness, density
and composition of bone from the calcar femorale and the
femoral cortex. J Mater Sci Mater Med 1998; 9(11):
661–666.
17. Wolff J. The law of bone remodelling. In: Maquet P and
Furlong R (eds) The Law of Bone Remodelling. Berlin:
Springer-Verlag, 1986, pp. 1–83.
18. Frost HM. Wolff’s law and bone’s structural adaptations to
mechanical usage: an overview for clinicians. Angle Orthod
1994; 64(3): 175–188.
19. Arunin AS and Tses EA. The birth of a new scientific field–
biomechanics of the skeleton. Julius Wolff and his work “Das
Gesetz der Tranformation de Knochen”. History of Med
2016; 3(4): 372–376.
20. Frost HM. From Wolff’s law to the Utah paradigm: insights
about bone physiology and its clinical applications. Anat Rec
2001; 262(4): 398–419.
21. Backman S. The proximal end of the femur. Acta Radiol
Suppl 1957; (146): 1–166.
22. Goldstein SA, Larry S, and Matthews MD. Trabecular bone
remodeling an experimental model. J Biomech 1991;
24(suppl. 1): 135–150.
23. Osborne D, Effman E, Broda K, et al. The development of the
upper end of the femur, with special reference to its internal
architecture. Radiology 1980; 137(1): 71–76.
24. Cowin S. A resolution restriction for Wolff’s law of trabecu-
lar architecture. Bull Hosp Jt Dis Orthop Inst 1989; 49(2):
205–212.
25. Jacobs CR. The mechanobiology of cancellous bone struc-
tural adaptation. J Rehabil Res Dev 2000; 37(2): 209–216.
26. Ward FO. Outlines of human osteology, 3rd ed. London: Sawill,
Edwards & Co, Printers, Chandes St, Covent Garden, 1875.
27. Meyer GH. Die architektur der spongiosa. Arch Anat Physiol
Wiss Med 1867; 34: 615–628.
9
28. Shelly FJ, Anderson DD, Kolar MJ, et al. Physical modelling
of hip joint forces in stair climbing. Proc Inst Mech Eng 1996;
210(1): 61–68.
29. Heller MO, Bergmann G, Deuretzbacher G, et al. Musculo-
skeletal loading conditions at the hip during walking and stair
climbing. J Biomech 2001; 34(7): 883–893.
30. Stolk J, Verdonschot N and Huiskes R. Stair climbing is
more detrimental to the cement in hip replacement than
walking. Clin Orthop Relat Res 2002; 405: 294–305.
31. Hammer A. The paradox of Wolff’s theories. Ir J Med Sci
2015; 184(1): 13–22.
32. Jansen M. On bone formation. Manchester: The University
Press, 1920.
33. Carey EJ. Studies in dynamics of histogenesis. J Radiology
1929; 13: 127–168.
34. Ling RSM, O’Connor JJ, Lu TW, et al. Muscular activity and
the biomechanics of the hip. Hip Int 1996; 6(3): 91–105.
35. Oxnard CE. Thoughts on bone biomechanics. Folia Primatol
2004; 75(4): 189–201.
36. Rudman KE, Aspden RM, and Meakin JR. Compression or
tension? The stress distribution in the proximal femur. Biomed
Eng Online 2006; 5: 12. https://doi.org/10.1186/1475-
925X-5-12.
37. Pauwels F. Biomechanics of the locomotor apparatus, (Trans.)
Maquet P and Furlong R. Berlin, Heidelberg, New York:
Springer-Verlag, 1980.
38. Hammer A. Wolff: straight not curved. Ir J Med Sci 2017;
186(4): 939–946.
39. Nawathea S, Nguyen BP, Barzanian N, et al. Cortical and
trabecular load sharing in the human femoral neck. J Biomech
2015; 48(5): 816–822.
40. Jang G and Kim Y. Computational simulation of simultaneous
cortical and trabecular bone change in human proximal femur
during bone remodeling. J Biomech 2009; 43(2): 294–301.
41. Van der Meulen MC, Yang X, Morgan TG, et al. The effects
of loading on cancellous bone in the rabbit. Clin Orthop Relat
Res 2009; 467(8): 2000–2006.