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

Cementless/
Cemented
Biological

Composite Bone Bone on

Taper slip
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. 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. 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).
Whatever the method used surface coating should be circumferential and continuous
so that:
 Maximum bone can grow and minimize shielding
 Prevents wear particles from circulating around stem
 Reduce incidence of thigh pain
 Successful bone Ingrowth requires:
I. Optimal pore size : Between 50 and 150 μm

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

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

IV.Minimal implant micro motion : less than 150 μm (Increased micromotion

may lead to fibrous ingrowth)

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

VI.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:
Surface roughness (Ra)
1. Grit blasting :
• 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

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
Dorr classification: flute” in young, female
Type C: “stovepipe”-
Guide indications for cemented or uncemented femoral shaped appearance in
component fixation. post menopausal
female
• Thank you