ARTICLE IN PRESS

Current Orthopaedics (2005) 19, 255262

www.elsevier.com/locate/cuor

MINI-SYMPOSIUM: HIP REPLACEMENT

(ii) Conservative hip implants

Ian D. Learmonth
University of Bristol, Bristol Royal Infirmary, Bristol, BS2 8HW, UK

Summary Arthritis of the hip primarily involves the articulation between the
femoral head and the acetabulum. The primary surgical objective is to replace these
articular surfaces. In achieving this it is desirable to attempt to obtain a
homogeneous transfer of forces to the proximal femur. This is best provided by
retention of the femoral neck.
Survivorship of the implant is determined by the durability of fixation and of the
articular interface. Early attempts to achieve a conservative hip replacement were
betrayed by poor materials, inadequate fixation and failure of the articulation. This
paper explores how these shortcomings were addressed during the evolution of total
hip arthroplasty to produce the contemporary designs of conservative hip implants.
& 2005 Elsevier Ltd. All rights reserved.

Introduction
Arthritis of the hip affects predominantly the joint
itself. Early attempts at surgical treatment of hip
arthritis were directed at replacing the joint
surfaceseither by interpositional or resurfacing
arthroplasty (RA). While there were a few good
long-term outcomes, material and design deficiencies generally led to poor results. However,
improved materials, better fixation and a greater
understanding of the tribological imperatives have
generated a resurgence of interest in metal-onmetal resurfacing arthroplasty (Fig. 1). Encouraging
early results have been reported.1 The limits of the
clinical application are yet to be defined. However,
resurfacing arthroplasty does not fall within the
scope of this article.
Tel.: +44 0 117 928 2658; fax: +44 0 117 929 4217.

E-mail address: ian.learmonth@bristol.ac.uk.

In 1987 Jones and Hungerford2 coined the term

cement disease to describe osteolysis. While this
proved to be a misnomer, it added impetus to the
swing towards cementless fixation. Long-term
success of hip implants is determined by both
durability of fixation and articulation. Early cementless implants obtained reproducible fixation
distally. However this was associated with thigh
pain,3 and the distal off-loading predisposed to
stress shielding with loss of proximal bone stock.4,5
Indeed, when considering the efficacy of porouscoated cementless fixation, Amstutz noted The
incidence of thigh pain, radiographic stress shielding and removal problems must still be solvedy.6
All these issues are addressed by conservative
implants.
Patients today are better informed than ever
before. They are politically empowered to demand
early surgical intervention to restore quality of life.
Ever younger cohorts are presenting for total hip

0268-0890/$ - see front matter & 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cuor.2005.04.002

Hip arthritis;
Surgery;
Conservative
arthroplasty;
Femoral component

KEYWORDS

ARTICLE IN PRESS
256
arthroplasty.7 The high probability of revision in
these younger more active patients has been one of
the main factors driving the quest for more bonesparing conservative options at total hip replacement (THR). More bone would then be available in

I.D. Learmonth
the proximal femur for any subsequent revision
surgery. Conservative implants also appeal to those
surgeons embracing the increasingly popular concept of minimally invasive surgery with accelerated
rehabilitation regimens.8
This paper will review the development of
conservative implants over the years.

Conservative implants

Figure 1 Radiograph of a metal-on-metal resurfacing

arthroplasty.

There are a variety of short-stemmed prostheses

that obtain proximal fixation, such as the CFP
(Waldemar-Link), Stellcor (Sulzer) and SHO (Biomechanica). However this paper will principally
consider only those implants that are virtually
confined to the metaphysis.
Huggler and Jacobs designed the thrust plate
prosthesis (TPP), which was first implanted in
1978.9 They reviewed their results in 1993.10 The
implant (Fig. 2a) is designed to load the medial
cortex of the femoral neck as physiologically as
possible. The TPP has evolved through three
generations. The latest version has an oval thrust
plate attached to the mandrel. A central bolt
passes through the lateral plate just below the
greater trochanter and engages with a screw thread

Figure 2 (a) Radiograph showing replacement of the femoral head using a thrust plate prosthesis. (b) Radiograph of the
femoral prosthesis used by Wiles in 1937. Note the similarity to the thrust plate.

ARTICLE IN PRESS
Conservative hip implants

257

contained within the mandrel thrust plate unit. It is

of interest how closely this implant resembles the
implant designed by Philip Wiles first inserted in
1938 (Fig. 2b).
In seeking a conservative uncemented implant
with proximal fixation, surgeons at the Mayo Clinic
recognised that a wedge-shaped device which
tapered in both the sagittal and coronal planes
should give stability when inserted into an irregularly shaped cavity by providing multiple point
contact. In 1982 these features were incorporated
into a short double-tapered titanium alloy proximal
femoral replacementthe Mayo Conservative Hip
(Fig. 3). The distal end of the implant was curved
inferiorly to provide a flat surface to contact the
lateral cortex. The rigidity of mechanical fixation in
all planes was found to be similar to that of a
conventional cementless implant.
The ESKA femoral neck endoprosthesis (CUT) is a
mini-prosthesis which is anchored in the metaphysis
and provides proximal physiological stress trans

Figure 4 The ESKA femoral neck endoprosthesis.

Figure 3 The Mayo conservative femoral prosthesis

(illustration kindly provided by Dr. B Morrey).

mission, thus avoiding stress shielding (Fig. 4). It

lends itself to minimal access surgery and is itself
minimally invasive as only the femoral head is
removed. It has been recommended for young
arthritic patients with good bone quality.11
The IPS (DePuy) femoral stem (Fig. 5a) was
developed approximately 10 years ago. This anatomic stem was designed to provide pure proximal
loading, thus optimising load transfer in the
metaphyseal region and reducing stress shielding.
The stem was used principally for alignment and
was designed to have no contact in the diaphysis,
thus avoiding distal off-loading. In 1999 Walker et
al.12 noted that a lateral flare which loaded the
lower region of the greater trochanter would assist
in transmitting loads to the proximal femur. They
also suggested that stems with a lateral flare could
be made shorter than designs not incorporating a
lateral flare.
In 1995 Santori designed a customised shortstemmed implant with the team at Stanmore
Customs. This stem provided an anatomic fit in

ARTICLE IN PRESS
258

I.D. Learmonth

Figure 5 (a) The proximally fixed IPS. Note that the stem makes no contact with the diaphyseal cortex, thus loading the
metaphysis. (b) Radiograph of the Santori customised femoral implant. (c) Combining the design features of the IPS and
the Santori stemthe Proxima, a conservative metaphyseal implant.

the metaphysis with longitudinal slots for rotational

stability, a pronounced lateral flare and no distal
stem. The design and manufacture of this implant
was taken over by DePuy International in 2002
(Fig. 5b).
The similarity of the design of the metaphyseal
region between the IPS and the Santori stem was
recognised and the Proxima stem was evolved as a
result of the combination of these philosophies.

The Proxima is a stemless, proximally fixed anatomic implant (Fig. 5c). Appropriate sizing and
the anatomic shape provide rotational and axial
stability.
DePuy have also developed a wedge-shaped
cylindrical implantthe Silent Hipwhich has a
textured surface and is impacted into the neck to
provide initial stability (Fig. 6). Long-term stability
is provided by bone ingrowth. This is a very

ARTICLE IN PRESS
Conservative hip implants

259

Figure 6 (a, b) The Silent femoral neck prosthesis.

Results
Buergi et al.13 reported on the radiological and
clinical outcome of 102 consecutive THRs in which
the third generation of thrust plate was used.12 The
mean follow-up was 58 months (range 26100).

Eighty per cent of patients were younger than 60

years of age. Four implants were revisedtwo for
infection and two for aseptic loosening. They noted
that in 85% of cases load transmission occurred
through the most proximal part of the medial
cortex. Huggler et al. reviewed their long-term
results in 1993 and noted that the basic feature of
the thrust plate is direct load transfer to the medial
cortical bone of the femoral neck. They reported
that histological examination of an implant removed at 8 years confirmed that newly formed

conservative implant and is not dissimilar to the

ESKA cigar prosthesis.

ARTICLE IN PRESS
260

I.D. Learmonth

bone is in direct contact with the thrust plate with

no interposed fibrous tissue.
Ishaqui et al.14 reviewed 170 thrust plate
prostheses clinically and radiologically at a mean
follow-up of 58 years. KaplanMeier survivorship
at 8 years was 90.5%. However they noted that
good to excellent clinical results were achieved
after revising the thrust plate.
Morrey et al.15 reported on 162 total hip
replacements in which the Mayo conservative
uncemented femoral component was used. The
mean age of the patients was 50.8 years and the
mean follow-up 6.2 years (range 213). Survival
without mechanical loosening was 98.2% at both 5
and 10 years, while survival without osteolysis was
99% at 5 and 91% at 10 years. While recognising the
problem of osteolysis associated with wear debris,
the authors note that its reliable mechanical
stability makes this implant an attractive design,
particularly for use in younger patients. They also
observed a statistically significant reduction in the
amount of blood loss compared with a control group
of uncemented implants and ascribe this to the
absence of reaming of the femoral canal. In
addition they frequently saw increased bone
density in zones 3 and 6.
Kim16 prospectively followed up a consecutive
series of 60 hips (50 patients) for a minimum of 6
years in which a close proximal fit and short
tapered distal stem prosthesis (IPS) was used. The
mean age was 46.6 years with a mean follow-up of
6.3 years. Transitory thigh pain was present in 2% of
cases. No component had been revised and there
was no radiological evidence of aseptic loosening.
However, a metal-on-polyethylene couple was used
in all hips and a higher rate of polyethylene wear
was noted in these younger patients.
We have reviewed 81 consecutive IPS stems
followed up for a mean of 3 years 9 months (range
26 years). One hip was revised for deep infection.
There have been no other revisions and there was
no radiological evidence of aseptic loosening.
Indeed good buttressing of the bone was routinely
encountered in the metaphyseal region. No patient
complained of thigh pain. This review is due to be
presented at the 7th EFORT Congress in Lisbon in
June 2005.
The author reviewed 106 Santori customised
femoral stems. The mean age of the patients was
55 years. There were no revisions at a mean followup of 2 years (range 19 years). Good condensation
of bone was noted circumferentially around those
implants that were confined to the metaphysis with
no stem. There was no evidence of bone resorption
in any zone in these implants. Early results are
encouraging.

Discussion
There has been a recent tremendous resurgence of
interest in resurfacing arthroplasty. This is the only
surgical treatment for arthritis of the hip which
preserves the femoral head. However, RA does not
lend itself to minimal access surgery and clinical
concerns remain regarding the vascularity of the
femoral head and the incidence of femoral neck
fractureboth in the short and the longer term. In
addition there are well-identified contra-indications for RA. These can be broadly defined as
follows:





Anatomical: excessive anteversion, severe slip of

the femoral epiphysis, etc.
Biomechanical: inability to restore offset
and limb length (valgus neck, coxa breva, coxa
plana, etc.).
Pathological: poor supporting bone (osteonecrosis, multiple large cysts, etc.).

There is therefore a need for alternative conservative prostheses. There are two major contemporary issues that are driving the development
of conservative implants. Firstly the increasing
popularity of minimally invasive surgery and secondly the desire to optimise the loading of the
proximal femur and to preserve bone stock.
Ever younger cohorts of patients are presenting
for total hip replacement. These patients demand
restoration of their quality of life, which is
reflected by their ability to pursue their recreational activities such as golf, tennis, skiing, etc.
Implants inserted in these patients will not only
have to last longer, they will also be exposed to an
increased level of activity.
Minimally invasive surgery should be associated
with reduced soft tissue damage, shorter hospitalisation and an accelerated programme of rehabilitation and recovery. Minimally invasive should also
relate to conservation of bone stockalthough this
is seldom the practice of surgeons carrying out this
surgical technique. A concept relating to both the
soft tissue and the bone is to be applauded, but
should be embraced with caution. Few mid-term
and long-term results are available for the conservative implants. In addition the mini-incision
may be associated with an increased risk of
complications. Woolson et al.17 compared THRs
performed with a standard or a mini-incision and
found that the mini-incision group had a significantly higher risk of wound complications, acetabular component malposition and poor fit and fill
of cementless femoral components.

ARTICLE IN PRESS
Conservative hip implants

261

Conclusion

Wroblewski et al.18 noted that the successful

long-term clinical results with the Charnley low
friction torque arthroplasty identified proximal
femoral shielding as a long-term problem. They
ascribed this problem to distal load transfer in a
stiffer stem that no longer fractured. Wroblewski
introduced the triple taper polished cemented
stem to address this problem.18
Proximal stress protection is encountered earlier
with cementless stems, particularly those which
gain fixation in the diaphysis.
Many surgeons have therefore sought a more
bone preserving, bone conserving option for
younger more active patients. It has been
shown that forces developed on weightbearing
are more evenly distributed to the proximo-medial
femur if the femoral neck is preserved. This
also allows for anatomical reconstruction of
the proximal femur and provides enhanced
rotational stability. However a disadvantage
of these femoral neck implants is that they
cannot adjust for or accommodate anatomic
abnormalities of the proximal femur (e.g. excessive
anteversion, etc.).
Achieving initial stability may also present
a problem and this initial stability is essential
for osseointegration and subsequent durable
fixation. This led Santori19 to develop the twostep solution in which a titanium femoral
neck prosthesis was initially inserted through the
lateral cortex. At 3 months, having achieved secure
bony fixation, the femoral head is removed, the
acetabulum is replaced and a prosthetic femoral
head is applied. While this highlights the potential
problem of achieving adequate initial stability
in those cigar-shaped prostheses that rely on
impaction into the femoral neck for fixation,
I doubt if this two-stage solution would find wide
acceptance.
Significant cortical bone mass has been demonstrated at the proximo-lateral flare of the femur.20
Experiments have shown that if a femoral stem has
a medial and lateral flare proximally, the loads are
transferred to the proximal femur and stress
protection in this area is avoided. This is particularly true if there is no stem contact distally, which
could promote distal off-loading. Indeed, the
results suggest that a stem below the lesser
trochanter is unnecessary.12
Another important benefit of a bone-sparing and
preserving proximal femoral implant is the relative
ease with which this can be converted to a
conservative revision prosthesis, which need
only invade the proximal diaphysis. This provides
one extra step in the revision programme of a
younger patient.

There is an old surgical aphorism the ability to

perform an operation is not an indication to do it.
Similarly the mere ability to manufacture and to
insert a conservative femoral implant is not
necessarily an indication to use it. If the surgeon
is confident that the implant that he routinely uses
will outlast the patientthen he should use it.
Otherwise he should think about the next operation
and consider a bone-sparing option. Conservative
proximal femoral implants offer such an option.

Acknowledgements
I would like to thank Alison Foxwell and Martha van
der Lem for their assistance in the preparation of
this manuscript.

References
1. McMinn DJW, Pynsent PB, De Cock CAEM, Isbister ES, Treacy
RBC. Results of metal on metal hip resurfacing. J Bone Joint
Surg Br 2000;82(B Supp II):125.
2. Jones LC, Hungerford DS. Cement disease. Clin Orthop
1987;225(Dec):192206.
3. Callaghan JJ, Dysart SH, Savory CG. The uncemented
porous-coated anatomic total hip prosthesis. Two-year
results of a prospective consecutive series. J Bone Joint
Surg Am 1988;70-A:33746.
4. Engh CA, Bobyn JD, Glassman AH. Porous coated hip
replacement. The factors governing bone ingrowth, stress
shielding and clinical results. J Bone Joint Surg Br 1987;
69-B:4455.
5. Malchau H, Herberts P, Wang YX, Karrholm J, Romanus B.
Long-term clinical and radiological results of the Lord total
hip prosthesis. A prospective study. J Bone Joint Surg Br
1996;78-B:88491.
6. Amstutz HC, Namba R. Cementless femoral fixation using
porous ingrowth fixation. In: Amstutz HC, editor. Hip
arthroplasty. New York: Churchill Livingstone; 1991.
p. 285293.
7. Tennent TD, Goddard NJ. Current attitudes to total hip
replacement in the younger patient: results of a national
survey. Ann R Coll Surg Engl 2000;82:338.
8. Irving JF. Direct two-incision total hip replacement without
fluoroscopy. Orthop Clin North Am 2004;35:17381.
9. Huggler AH, Jacob HA. A new approach towards hip
prosthesis design. Arch Orthop Trauma Surg 1980;97:1414.
10. Huggler AH, Jacob HA, Bereiter H, Haferkom M, Ryf C,
Schenk R. Long-term results with the uncemented thrust
plate prosthesis (TTP). Acta Orthop Belg 1993;59
(Supp 1):21523.
11. Thomas W, Lucente L, Mantegna N, Grundei H. ESKA (CUT)
endoprosthesis. Orthopaedics 2004;33:12438.
12. Walker PS, Culligan SG, Hua J, Muirhead-Allwood SK, Bentley
G. The effect of a lateral flare feature on uncemented hip
stems. Hip Int 1999;9:7180.
13. Buergi ML, Stoffel KK, Jacob HA, Bereiter HH. Radiological
findings and clinical results of 102 thrust plate femoral hip

ARTICLE IN PRESS
262
prostheses. A follow-up of 28 years. J Arthroplasty
2005;20:10817.
14. Ishaque BA, Wienbeck S, Sturz H. Midterm results and
revisions of the thrust plate prosthesis (TPP). Z Orthop Ihre
Grenzgeb 2004;142:2532.
15. Morrey BF, Adams RA, Kessler M. A conservative
femoral replacement for total hip arthroplasty.
A prospective study. J Bone Joint Surg Br 2000;82-B:
9528.
16. Kim YH. Cementless total hip arthroplasty with a close
proximal fit and short tapered distal stem (third-generation)
prosthesis. J Arthroplasty 2002;17:84150.

I.D. Learmonth
17. Woolson ST, Mow CS, Syquia JF, Lannin JV, Schurman DJ.
Comparison of primary hip replacements performed with a
standard incision or a mini-incision. J Bone Joint Surg Am
2004;86-A:13538.
18. Wroblewski BM, Siney PD, Fleming PA. Triple taper polished
stem in total hip arthroplasty: rationale for the design,
surgical technique and seven years of clinical experience.
J Arthroplasty 2001;16(Supp 1):3741.
19. Santori F. Personal communication; 2004.
20. Fetto JF, Bettinger P, Austin K. Reexamination of hip
biomechanics during unilateral stance. Am J Orthop
1995(Aug):60512.