THA: Design, selection and

fixation of Femoral
components
 Hip Replacement Components
Femoral components
Head•
Neck
stem
Acetabular component
1. Cup

2. Bearing surfaces/Liner - can be polyethylene,

metal or ceramic
IDEAL FEMORAL COMPONENTS FOR PRIMARY THA
Neck length and offsets:
Neck length and off-set determine the neck-shaft angle and abductor muscle lever arm
The ideal femoral reconstruction reproduces the normal center of rotation of femoral
head, which can be determined by :

Vertical height (vertical offset)

Medial head stem offset ( horizontal offset, simply offset )

Version of the femoral neck (anterior offset)

Vertical offset- LT to center of the femoral head.
Restoration of this distance is essential in
correction of leg length.
Medial offset- distance from the center of the
femoral head to a line through the axis of the
distal part of stem.
If Inadequate: shortens the moment arm –
limp increase, bony impingement and
dislocation.
If Excessive :increase stress on stem and
cement which causes stress fracture or
loosening.
Version of the femoral neck : Important in
achieving stability of the prosthetic joint. The
normal femur has 10-15 degree of anteversion.
Neck length: Measured from the center of head to base of collar.
Change in neck length has a greater effect on leg length than the
abductors muscle lever arm whereas a change in off-set affects the
abductor muscle lever arm more than leg length.
Therefore, to optimize the abductor muscle lever arm, it is better to
increase the offset than the neck of the implant.

Neck length typically ranges from 25 to 50 mm, and adjustment of

8 to 12 mm for a given stem size routinely is available
The vertical height or offset of a prosthetic hip joint is mainly determined by
the length of the prosthetic neck and the additional length provided by the
modular head used.
The depth at which the implant is inserted into the femoral canal also affects
the vertical height. When cement is used, the vertical height can be further
adjusted by changing the level of the femoral neck osteotomy (cutting the
neck of the femur). However, this additional flexibility may not be possible
with a cementless femoral component because the depth of insertion is
determined more by how well it fits within the femoral metaphysis (the
wider part of the femur) rather than the level of the neck osteotomy.
The horizontal offset, also known as the distance from the center
of the femoral head (the ball-shaped part of the hip joint) to a line
through the axis of the lower part of the stem, is primarily
determined by the design of the stem used in hip replacement
surgery. If the offset is not restored properly, it can lead to
problems such as reduced muscle effectiveness, increased joint
reaction force, an abnormal gait, and bone impingement, which
may result in dislocation.
To increase the offset, a longer modular neck can be used. However, this
can also increase the vertical height, which may cause the limb to become
too long. To address the variations in individual femoral anatomy, many
hip replacement components now come in standard and high offset
versions. This can be achieved by reducing the angle between the neck
and stem (typically to around 127 degrees) or by attaching the neck to the
stem in a more inward position. Decreasing the neck-stem angle increases
the offset while slightly reducing the vertical height. When the neck is
attached in a more inward position, the offset is increased without
affecting the leg length.
The version of the femoral neck in hip replacement is its
orientation in relation to the coronal plane. Proper restoration of
version is important for joint stability. The femoral neck should
match the normal anteversion of 10-15 degrees. Rotation of the
component within the femoral canal achieves proper version.
Modular components allow independent adjustment of version,
length, and offset, but dual modular necks have faced issues and
declined in use.
 Head size
The size and proportions of the femoral head and neck impact hip
motion and stability.
Impingement between the neck and socket rim can cause dislocation
and wear.
A larger femoral head improves stability and allows for greater
range of motion before impingement.
Studies show low dislocation rates with head sizes of 36 mm or
larger.
Acetabulum size limits the maximum head diameter regardless of
materials used.
Increasing the femoral head size from 28 to 32 mm improved hip flexion by
8 degrees in a simulation study.
The use of a circular neck and skirted modular head significantly reduced
range of motion.
A trapezoidal neck design allowed for greater range of motion without
impingement.
Impingement between prosthetic components could be largely eliminated
with head sizes larger than 32 mm.
Bone-on-bone impingement was dependent on bony anatomy, not head size.
Neck shaft angle: Typically about 135°.
Longitudinal slots/grooves: Improves rotational stability of the
stem within the cement mantle. Decreases stress shielding, and
increases the interlock between the stem and the cement.
Cement centralizer: Provides a more uniform cement mantle.
Ratio of femoral head diameter to the femoral neck diameter: If
increased there is a greater primary arc of motion.
Stem cross-section (oval or square):
The cross-sectional shape influences the distribution of cement within the femoral canal
and rotational stability of the implant and the stress distribution within the cement
mantle
Stems with an oval cross-section have a better fit within the medullary canal and can
occupy more of the cavity, leaving less room for cement and cancellous bone.
More rectangular cross-section such as the Exeter (Stryker) are limited in size by their
contact agninst the inner cortex of the oval cross-section of the medullary canal.
Stem is under high mechanical stress so its material must have
high mechanical strength and fatigue resistance. Metals only meet
this criteria till effect
Longer stem length provides more stability however,reaming
distally along with cement has to be injected more distally that
will limit to use bone in RTHR surgeries.
Overall shape:
Straight : curved only in the frontal and not in sagittal plane OR
Anatomical: designed to fit the sagittal intramedullary anatomy
Surface finish (matt or polished):
Polished stems are preferred with loaded-taper design since they allow stepwise
subsidence to a stable position, with the associated micromovement producing less
metal and cement debris at the cement–stem interface.
In the composite–beam prostheses, roughening the surface to increase the cement–
stem bonding enhances stability.
Collar or collarless:
May promote direct transfer of load from the
implant to the medial cement mantle and/or
the bone of the medial femoral neck
Shape of the tip: Tapered or blunt.
Modularity (non-modular, modular): Modular
heads allow for adjustment in neck lengths.
 Femoral
Component

Cemented Cementless/
Biological

Composite Taper slip Bone Bone on

beam ingrowth growth
 Cemented fixation
Fixation of THR implants to bones with cement provides immediate stability to the
construct.
Cement functions as grout and not as an adhesive, to provide a mechanical interlock
between implant and bone( microinterlock with endosteal bone)
As cement does not stimulate new bone formation and there is no renewal of bonding at
the cement–bone interface, the quality of cemented fixation degrades with time
Two basic designs of cemented fixation
femoral stem implant
1.

1.

1. Composite beam/‘Charnley’ stem/shape-closed

fixation
2. Taper slip/‘Exeter’ stem,
Composite beam/‘shaped-closed’ fixation
1. Small protrusion, a collar, at the level of the femoral
calcar; prevents distal sinkage of the stem
2. A pre-coated, matt finish with roughened fixation surface
with thick cement mantle for good bonding between stem
and cement
3. A cylindrical profile throughout its length.
4. Concern of loosening at stem-cement interface due to
micromotion and loosening at cement-bone interface due
to excessive stress transfer added by torsional stresses
distally.
Not commonly used now a days
Eg Stanmore stem (Biomet, Bridgend, UK)
 Taper slip/force-closed/Loaded Taper model

1. Collarless
2. Highly polished fixation surface
3. Tapered profile from proximal to distal.
These features prevent the stem from bonding with cement.
The stem therefore settles in cement, re-engaging its taper, and so the
fixation becomes progressively more stable; therefore it is considered a
‘slip and slide’ prosthesis
To prevent stress on cement distally during subsidence air filled
centralizer is used as a cushion.
Eg Exeter stem, CPT stem of Zimmer double tapered or three planes(C-
stem of Depuy)
 Generation cementing techniques

First-generation:
Involved hand mixing of cement and finger packing of bone cement in the doughy phase into an
unplugged, unwashed femoral canal.
Clinical results with first-generation cementing have been variable and in general have produced
some disappointing results due to its inability to produce a consistent cement mantle.
Second-generation:
Involved plugging the medullary canal, cleaning the canal with pulsed lavage and inserting cement
in a retrograde manner using a cement gun.
This reduced the incidence of gross voids and filling defects in the mantle.
Third-generation :
Involves porosity reduction via vacuum
mixing or centrifugation and cement
pressurization.
Fourth-generation:
Include stem centralization both proximally
and distally to ensure an adequate and
symmetrical cement mantle.
This is important as uneven and excessively
thin cement mantles are associated with
early failure and revision
 Cement fixation optimized by
Limited porosity of cement: leads to reduced stress points in cement
Cement mantle: > 2mm
Increased risk of mantle fractures if < 2mm
Femoral stem : Stiff
Flexible stem places stress on cement mantle
Position of Stem: central
Avoid mal-position of stem to decrease stress on cement mantle
Femoral stem: Smooth
Sharp edges produce sites of stress concentration
Absence of mantle defects: (mantle defect-any area where the prosthesis touches cortical bone with no cement
between)
Creates an area of higher concentrated stress and is associated with higher loosening rates
Proper component positioning within femoral canal: varus stem positioning increases stress on cement
mantle
 Cementless fixation

Increasingly used in younger patients to preserve bone stock and avoid problems
associated with cemented fixation.
A biological fixation, which is dynamic because of bone turnover and therefore the quality
of fixation is maintained with time.
Basic design of cementless femoral stem:
1.

1. bone ingrowth and

2. bone on growth designs
In both types, surface can be coated with calcium hydroxyapatite to potentially, aid
Osseo-integration.
 Bone ingrowth design:
Ingrowth is the formation of bone inside a porous surface
Ingrowth surfaces include: sintered beads, fiber mesh, and porous metals.
1. Sintered beads are microspheres of either cobalt chromium or titanium alloy welded to implant
surface with the use of high temperature.
2. Fiber mesh coatings: Involves attached metal pads attached by diffusion bonding to implant.
3. Porous metals have a uniform three dimensional network, with creation of high
interconnectivity of the voids with high porosity (75–85%) compared with that of sintered beads
and fibre metal coatings (30–50%). Tantalum is most commonly used .
4. HA coated stems: Involves plasma spraying calcium phosphate on the porous coated surface
(often grit blasted surface).
5. Whatever the method used surface coating should be circumferential and continuous so
that:
6. Maximum bone can grow and minimize shielding
7. Prevents wear particles from circulating around stem
8. Reduce incidence of thigh pain
 Successful bone Ingrowth requires:
I. Optimal pore size : Between 50 and 150 μm
II.

III. Optimal metal porosity : Porosity of 40% to 50% is best.

IV.

V. Minimal gap distance between prosthesis and bone: less than 50 μm.
VI.

VII. Minimal implant micro motion : less than 150 μm (Increased micromotion may lead to
fibrous ingrowth)
VIII.

IX. Cortical contact with bone : Shear and torsional strength is stronger when implant is
adjacent to cortical bone as opposed to cancellous bone
X.

XI. Viable bone ; Prior irradiation to pelvis and hip increases risk for aseptic loosening of
bone ingrowth/ongrowth implants.
Bone on-growth design
On growth refers to bone growth over a roughened
surface.
On growth surfaces are created by:
1. Grit blasting : Surface roughness (Ra)

Involves high pressure bombarding implant with

small abrasive particles such as corundum to
create microdivots on the surface, which are of
similar size to pores in porous coated designs.
The depth of the divot (distance from peak to
valley) is referred to as the surface roughness
(between 3-5 micrometer)of the stem.
Bone grows into the divots achieving biological
fixation.
2. Plasma spraying :
Involves high temperature metal spray on
surface of implant to create a textured
surface with mixing metal powder with an
inert gas that is pressurized and ionized,
forming a high-energy flame.
The molten material is sprayed onto the
implant to create a textured surface.
 Proximal coating vs extensively coating cementless stem in terms of loading

1. Proximal coating stem : commonly used

2. Extensively coated stem Produces more
stress shielding of proximal bone

useful for Revision arthroplasty where proximal

bone stock may be compromised
Khanuja et al classification of cementless femoral stem
Techniques for Initial rigid fixation in cementless stem

1. Press fit or
2. Frictional fit/ line-to-line fixation
3.

1. Press fit :
Press fit fixation is achieved by
under-reaming of the bone.
Slightly larger implant than what
was reamed is wedged into
position
When the prosthesis is wedged in,
compression hoop stresses
stabilise the implant to achieve a
rigid fixation.
2. Frictional fit:
Achieved by line-to-line reaming of the
bone.
Bone is prepared such that contour of bone
is same size as implant.
The rough surface of the prosthesis
provides enough resistance to motion,
which achieves implant stability when it is
impacted into its final position.
This is also called scratch fit or interference
fit.
 Advantages of cementless femoral stem prosthesis

1. No cement required and problem related to cement to bone and

cement implant interface is reduced
2. More useful in young active patients as they have biologically active bone
and they will require revision surgery where cement may provoke
complications .Further use of cement requires larger bone ,ultimately more
bone loss .
3. Decreased incidence of aseptic loosening
4. Less bone destruction
5. Circumferential porous coating of proximal stem provide effective barrier to
ingress debris particle and thus limit early development of osteolysis of
distal stem
Disadvantage of Bone Cement
I. No osseointegration due to dense polymerized structure of cement,
it doesn’t allow osseointegration for improved bone fixation.
II. Exothermal polymerization reaction causes bone necrosis
III. Monomer toxicity
IV. Shrinkage during polymerization of MMA may compromise fixation
of component.
 Type A: funnel
shape or “champagne
flute” in young,
Dorr classification:Guide indications for cemented or female
uncemented femoral component fixation. Type C: “stovepipe”-
shaped appearance in
post menopausal
female
Thank you