The Journal of Arthroplasty Vol. 27 No.

7 2012

Does Osteoporosis Increase Early Subsidence of

Cementless Double-Tapered Femoral Stem in
Hip Arthroplasty?
Kee Hyung Rhyu, MD,* Se Min Lee, MD,y Young Soo Chun, MD,*
Kang Il Kim, MD,* Yoon Je Cho, MD,y and Myung Chul Yoo, MD*

Abstract: Among 320 hip arthroplasties performed between January 2007 and March 2008,
patients younger than 50 years old and patients older than 70 with a T-score at the proximal femur
less than −2.5 made up the control and study group, respectively. There were 40 patients in each
group. We measured stem subsidence, both digital and manual methods. Measurements were
made from radiographs taken serially from 2 weeks to 1 year after surgery. The amount of mean
subsidence for each group was not different, and all stems showed stable fixation in the final
radiographs. Our study suggests that even in osteoporotic proximal femurs, press-fit fixation of
double-tapered stems for hip arthroplasty can be safe and effective without excessive early
subsidence. Keywords: osteoporosis, subsidence, tapered stem, total hip arthroplasty.
© 2012 Elsevier Inc. All rights reserved.

As the elderly population has increased, so have the ages
of patients undergoing hip arthroplasty including bipolar
hemiarthroplasty (BHA) [1]. Hip arthroplasty for elderly
patients may have several theoretical problems. Among
them, the decreased bone quality of the elderly would be
a major concern. Although our knowledge of osteopo-
rosis has grown enormously, there is still much left to
learn. We know that osteoporosis can increase the risk of
fracture, is painful when it is severe and can increase
mortality indirectly by increasing morbidity in fractured
patients [2]. However, we still do not have thorough
understandings of its effects on fracture healing and
bone ingrowth to the implants [2,3].
Historically, the choice for implant fixation in total hip
arthroplasty (THA) to an osteoporotic femur has been
cemented fixation. However, because of the ease of
surgical procedure and increasing number of predict-
ably, good results have made the cementless THA more
popular recently [4,5]. Moreover, increasing concerns
about the medical consequences during cementing,
including sudden death [6] and increased fatal cardio-
pulmonary complications [7], have recently led to
reconsideration of cementless fixation in elderly pa-
tients. Unfortunately, press-fitting a wedge-shaped stem
to an osteoporotic femur is difficult. Moreover, we do
not know the most appropriate rehabilitation program
for these osteoporotic patients, especially in terms of the
timing and the amount of weight-bearing after surgery.
Bottner et al [8] suggested that early weight-bearing
after a cementless THA showed no adverse effect in
young and healthy patients. They also recommended
against early weight-bearing in osteoporotic elderly
patients. However, few studies have dealt with this
issue. We performed the current study to investigate the
effects of osteoporosis on the early stabilities of double-
tapered cementless stems in hip arthroplasty, under the
hypothesis that the amount of early subsidence would
not increase in an osteoporotic patient even during and
after early tolerable weight-bearing.

Patients and Methods

From the *Department of Orthopaedic Surgery, Kyung Hee University
hospital at Gangdong, Seoul, South Korea; and yDepartment of Orthopaedic
Surgery, Kyung Hee University Hospital, Seoul, South Korea.
Submitted February 21, 2011; accepted October 24, 2011.
The Conflict of Interest statement associated with this article can be
found at doi:10.1016/j.arth.2011.10.026.
Reprint requests: Kee Hyung Rhyu, MD, Department of Orthopae-
dic Surgery, Kyung Hee University Hospital at Gangdong, 149 Sangil-
dong, Gangdong-Ku, Seoul, South Korea.
© 2012 Elsevier Inc. All rights reserved.
0883-5403/2707-0008$36.00/0
doi:10.1016/j.arth.2011.10.026
Patients
A total of 320 hip arthroplasties were performed
between January 2007 and March 2008 at our institute.
Among them, the number of total hip resurfacing
arthroplasty was 143. In the remaining 177 arthroplas-
ties, 132 cases were THA, and 45 were BHA. Among
132 THA, 52 cases were younger than 50 years old, 9
were 70 years or older, and 71 cases were in between. In
cases of BHA, 33 cases were 70 years or older, and 1 case

1305
1306 The Journal of Arthroplasty Vol. 27 No. 7 August 2012
was younger than 50 years. This left 42 patients who
were 70 years old or older and 53 cases who were
younger than 50 years old. The study group was defined
that the patient who were 70 years or older with T-score
for the proximal femur was −2.5 or less. The control
group included patients younger than 50 years old who
had no systemic disease known to affect the bone
quality. All but 1 patient who were 70 years or older fit
the inclusion criteria. Among the patients younger than
50 years old, 5 cases of rheumatoid arthritis, 4
ankylosing spondylitis, and 3 sequelae of childhood hip
diseases were excluded. One patient in each group was
excluded because they were not ambulatory or were not
able to follow the rehabilitation protocol for any reason.
Thus, after more than a 1-year follow-up, complete
radiographs were available in 40 patients in each group.
The average age of the patients in the study group was
79.1 years (range, 70-95 years) and was 38.6 years in the
control group (range, 23-49 years). There were 13 men
and 27 women in the study group and 22 men and
18 women in the control group (P = .07). The average
T-score of the patients in the study group was −3.2
(−2.5 to −4.8). Examination for bone mineral density
in the control group was incomplete because the group
consisted of young patients without a likelihood of
osteoporosis. The average follow-up periods were 26
months (17-39 months) for the study group and 30
months (16-40 months) for the control group. In the
study group, the diagnoses leading to hip arthroplasty
included femoral neck fracture (n = 31), osteonecrosis
of the femoral head (n = 6), secondary osteoarthritis
(n = 2), and cutout of the fixative device after fixation
of intertrochanteric fracture (n = 1), whereas in the
control group, they were osteoarthritis by any reason
other than osteonecrosis (n = 23), osteonecrosis of the
femoral head (n = 16), and high-energy femoral neck
fracture (n = 1). The types of arthroplasty performed in
the study group were THA (n = 11) and BHA (n = 29),
whereas those in the control group were THA (n = 39)
and hemiarthroplasty (n = 1). Surgery was performed
by 2 orthopedic specialists using the same femoral stem
made with the beta titanium alloy (Accolade TMZF;
Stryker, Mahwah, NJ) for all patients in both groups. In
all cases, the surgery was done via posterolateral
approach with lateral position. The femoral canals
were all prepared with sequential manual rasping
with broaches. After the operation, tolerable weight-
bearing was permitted as soon as the pain was
alleviated. The same rehabilitation protocol was used
in both groups. The average sizes of the femoral stems
were number 3 in the study group and number 2 in the
control group. Intraoperative radiographs were checked
to confirm the size and alignment of the implants. The
patients were allowed to sit up at the day after surgery,
to move in a wheelchair at 1 or 2 days postoperatively,
and, thereafter, to bear tolerable body weight with the
use of crutches or a walker. All patients were able to
start tolerable weight-bearing at least 3 days after the
surgery. Regardless of the degree of tolerable weight-
bearing, we recommended using crutches or walker
until 6 weeks after the surgery.
Method of Assessment
Radiographic assessments were performed by 2 differ-
ent orthopedic doctors who did not participate in the
surgeries. Measurements were made electrically using a
built-in instrument in a digital imaging system (Infinitt,
Seoul, Korea) and manually using digital calipers (Mitu-
toyo, Kawasaki, Japan) with a 0.005-mm error limit. With
the 2 methods, the distance between the most proximal
point of the greater trochanter and the proximal apex of
the shoulder of the prosthesis along the axis of the
proximal part of the femoral stem on anteroposterior
images of the hip joint was measured. To avoid possible
errors caused by magnification, we used a template of the
acetabular cup. We adjusted the anteroposterior radio-
graph images in the digital imaging system until the outer
diameter of the cup exactly fit the known size of the
template. After the adjustment, the magnification was
corrected. Measurements were conducted using images
taken 2 and 6 weeks, 3 and 6 months, and 1 year after
surgery. We measured the amount of subsidence during
each period. The measurements were then repeated 1
month after initial data collection to obtain intraobserver
and interobserver errors. We compared them between the
study and control groups, between THA and bipolar
groups, according to the proximal femoral geometry
classified according to the Dorr index [9] and, finally,
according to the presence or absence of cerclage wire.
Clinical analysis was also carried out using the patients'
Harris Hip Scores [10].
Statistics
For statistical analyses, we used the Student t test for
the comparison of the data between the groups, the
paired t test for the comparison of the data of the
individuals according to the observing period, analysis of
variance for the comparison of the data from the patients
of the 3 groups according to the proximal femoral
geometry, and Fisher exact test for the comparison of the
categorical data. To investigate the errors between and
within observers, the interclass correlations were calcu-
lated with a 95% confidence interval. After confirming
the significant interobserver and intraobserver agree-
ments, we used the median of the 4 measured data as a
single representative value for each measurement.
Because the number of values for each single radiograph
was only 8 (twice by 2 rater with 2 methods) and
because not all values were found to follow the normal
distribution, we choose median rather than mean or
average to determine the representative value. All
statistical assessments were made using bundled soft-
ware (SPSS version 11.0; SPSS Inc, Chicago, Ill).
 Cementless Double-Tapered Femoral Stem in Hip Arthroplasty  Rhyu et al
Results
Radiographic Results
Mean intraobserver and interobserver correlations
for measurements using both methods were summa-
rized in Table 1. Intermethod correlation was 0.85 for
rater 1 and 0.78 for rater 2. All correlations met
significant agreement.
The average subsidence at 1 year was 1.19 ± 1.18 mm
(0.17-4.83 mm) for the control group and 0.94 ± 0.74
mm (0.10-2.82 mm) for the study group, with no
significant difference between the groups (P = .30).
Three hips in the control group and none in the study
group showed migrations of more than 3 mm. No
statistical difference was detected between the groups
in terms of the occurrence of migration more than 3 mm
(P = .24). The average subsidence during each period in
the control and study groups were 0.40 ± 0.48 mm
(0.00-2.02 mm) and 0.35 ± 0.29 mm (0.00-0.93 mm)
(at 2-6 weeks postoperatively), 0.19 ± 0.39 mm (0.00-
1.81 mm) and 0.17 ± 0.23 mm (0.00-0.79) (at 6 weeks to
3 months), 0.10 ± 0.24 mm (0.00-0.92 mm) and 0.22 ±
0.32 mm (0.00-1.21 mm) (at 3-6 months postopera-
tively), and 0.11 ± 0.20 mm (0.00-0.57 mm) and 0.15 ±
0.18 mm (0.00-0.71 mm) (at 6 months to 1 year
postoperatively). Except for the difference in sub-
sidence at 6 weeks after the operation in the control
group (P = .01), no differences were noted in the average
migrations during each period within each group or
between groups.
The average subsidence was 0.91 ± 0.79 mm (0.10-
2.84 mm) in the BHA group and was 1.15 ± 1.10 mm
(0.12-4.85 mm) in the THA group, with no significant
difference between the groups (P = .33). Regarding the
proximal femoral geometry based on the Dorr index, the
numbers of proximal femurs in types A, B, and C were
12 (30%), 22 (55%), and 6 (15%), respectively, in the
control group. Those of the study group were 2 (5%),
6 (15%), and 32 (80%), respectively. The distribution
was significantly different (P = .01). Mean subsidence at
1 year was 1.23 ± 1.09 mm (0.08-4.21 mm) in type A
femur, 0.93 ± 1.04 mm (0.17-4.83 mm) in type B,
and 1.14 ± 0.97 mm (0.10-3.22 mm) in type C. No
difference was observed in the subsidence of the femoral
stem according to the geometry of the proximal femur
(P = .82). Prophylactic cerclage wires were used in 6
Table 1. Interclass Correlations (Ranges in 95% Confidence
interval) According to Raters and Methods
Embedded Intermethod
Caliper Digital Calipers Correlation
Rater 1 0.99 (0.98-0.99) * 0.98 (0.97-0.99) * 0.85 (0.75-0.91)
Rater 2 0.97 (0.96-0.99) * 0.97 (0.96-0.99) * 0.78 (0.65-0.87)
Interrater 0.70 (0.52-0.82) 0.66 (0.45-0.80)
correlation
All values were statistically significant (P b .01).
* Intrarater correlations for each given method.
1307
cases in the control group and in 11 cases in the study
group. Among those cases, intraoperative femoral
fracture occurred in 3 cases in the control group and in
5 in the study group (P = .71). No difference in average
subsidence was observed between the wired and
nonwired groups (P = .95). Final follow-up radiography
showed stable osseous fixation in all femoral stems.
Clinical Results
The patients' Harris Hip Scores increased from 51
preoperatively to 87 postoperatively in the study group
and from 53 to 90 in the control group. The preoperative
Harris Hip Scores were not significantly different (P =
.78), and the scores significantly improved postopera-
tively in both groups (P b .01 in both groups), with no
difference in the scores between the groups at the final
follow-up (P = .55). There were no cases of loosening of
the prosthesis, severe pain, or surgical site infection.
There was no patient-complained thigh pain at the final
follow-up. Other than incomplete intraoperative femo-
ral fractures, 2 complications related to surgery were
noted in the study group. There were a dislocation that
occurred 20 months after surgery, which was treated by
closed reduction, and a periprosthetic fracture that
occurred 29 months after the operation, which was
treated with open reduction and internal fixation. The
male patient with periprosthetic fracture initially re-
ceived BHA because of femoral neck fracture. He had
deformed femoral shaft because of preexisting malunion
of femoral fracture. The fracture occurred at the apex of
the deformity after fall from a height.
Discussion
Cemented stems may be preferred for femoral fixation
in hip arthroplasty of elderly patients because the
cement can provide strong and immediate stability in
the operating room and requires no additional time for
biologic fixation, enabling patients to be ambulatory
immediately after surgery. Because of these advantages,
the cemented stem has been used with good results and
with no particular long-term problems [11,12]. As the
age of the patients who need arthroplasty has increased,
however, more problems related to the use of cement
have been reported. Parvizi et al [6] investigated cases of
in-hospital mortality in patients who underwent arthro-
plasty and found that mortality primarily occurred
during the application of cement in patients with
femoral neck fractures, highlighting the risks related to
the use of cement in such procedures. Issak et al [7]
reported that the reduced cardiovascular reserve of
elderly patients could make them unable to adapt to or
overcome the problems related with the use of cement
in arthroplasty, possibly leading to serious complica-
tions. Because of these concerns as well as technical
simplicity and recent good tract records, cementless hip
arthroplasty has recently attracted more attention from
orthopedic surgeons and patients [13-17].
1308 The Journal of Arthroplasty Vol. 27 No. 7 August 2012
Considerations regarding the use of cementless
femoral stems in elderly patients can be divided into
long- and short-term results. Short-term considerations
include whether the weakened femoral cortical bone
can provide the strength required for the insertion of
wedge-shaped press-fit stems and whether the initial
stability required for bone ingrowth can be maintained
if they are successfully fitted. Long-term considerations
include whether a severely osteoporotic femur can
maintain stable bone ingrowth and sustainable stabil-
ity. These long-term considerations have been rela-
tively well studied, with reports that the bone
ingrowth capability in osteoporosis patients needed
for stable fixation of the prosthesis was maintained
[18] and that various stem designs have been clinically
successful [16,17]. Dutton and Rubash [5] reported
that cementless femoral stem fixation was successful in
elderly patients, and Bhalodiya and Singh [19]
described the advantages of cementless wedge-shaped
femoral stems by comparing them with those of
cemented THA. Few studies, however, have examined
the short-term considerations regarding the use of
cementless femoral stems in elderly patients. Although
they are widely used because of their strong press-fit
effect, wedge-shaped stems can cause slight initial
subsidence with weight-bearing before obtaining bio-
logic fixation [20]. Bottner et al [8] reported that
young patients with relatively good bone quality
showed good results even when they bear weight
immediately after surgery, whereas patients who were
older or who had osteoporosis needed to exercise
caution. In a clinical setting, however, a patient's age
or osteoporosis rarely affects the course of postopera-
tive rehabilitation. Thus, studies on the short-term
considerations regarding the use of cementless femoral
stems in elderly patients are important for optimizing
the course of postoperative rehabilitation for osteopo-
rotic patients.
In this study, our initial hypothesis was that there
would be no statistical difference in early subsidence
between the groups. To reduce the possible errors
during the study, blinded measurements were con-
ducted by 2 unrelated orthopedic surgeons who did
not participate in the surgery and were unaware of the
study design. Repeated measurements were performed
1 month after the initial measurements. After these
subsequent trials and statistical considerations, the
final results showed no differences between the groups.
The intrarater correlations of both methods were
excellent. Although the exact range for each degree of
agreement has not been clearly defined, the interrater
correlations of both methods were relatively low. How-
ever, all of the values of interclass correlations showed
statistically significant agreement. Thus, we choose
the median of the measured data as a representative
value for each patient.
The rate of subsidence during each period in the early
postoperative stage was not found to be different in
the study group. In the control group, however, it was
significantly higher during the first 6 weeks after the
surgery than during the following time points. This is
perhaps because the younger patients in the control
group began bearing their full weight (without assis-
tance) earlier than those in the study group or because
the activity level of the patients in the control group was
higher after discharge, although the same rehabilitation
program and time table were suggested. In addition to
bone mineral density, we wanted to investigate possible
correlations between early subsidence and proximal
femoral geometry, type of arthroplasty, and the occur-
rence of incomplete femoral fracture during the oper-
ation. With an ordinary viewpoint, the amount of total
subsidence was expected to increase in the elderly study
group, the bipolar group, the type C (lead pipe) femur
group, and the wired group. However, none of the
differences were statistically significant. The results
suggest that, as long as the initial fit in the operating
room is good, initial subsidence does not increase. In
addition, it appears that tolerable weight-bearing in the
early postoperative stage does not create problems for
the stability of this specific prosthesis even in osteopo-
rotic patients. Because the early subsidence started
theoretically just after the weight-bearing, one might
argue that the first measurement would have been a
radiograph taken immediately after the surgery. How-
ever, we found that the most of the radiographs taken
with portable devices during or just after the operation
were not standardized enough to measure the length.
Thus, we decided the radiograph taken 2 weeks after
the surgery as our initial one.
Although this study provided clinically meaningful
information, it has several limitations. The first and
probably the most important limitation is that there
can be a certain degree of error because we did not
perform a radiosterometric analysis. Although we made
multiple measurements using 2 different methods,
verified them, and then used the median values, we
could not tell that we completely eliminated all mea-
surement errors. The second limitation was the limited
data for bone mineral density. Because our national
medical insurance did not cover the bone densitometry
for young and otherwise healthy patients, the data for
the control group below the age 45 years were mostly
unavailable. To overcome this limitation, we added the
proximal femoral geometry as another indicator to
divide the groups. Second, from the viewpoint of reha-
bilitation, possible differences may exist between the
rehabilitation courses of each patient after discharge
from the hospital, which could not be well controlled.
Moreover, we did not analyze the activity levels of
patients according to the time elapsed. And the last,
the number of cases in each group was relatively small.
 Cementless Double-Tapered Femoral Stem in Hip Arthroplasty  Rhyu et al
Post hoc power analysis revealed that if we set the effect
size as high, this study showed significant statistical
power as 0.94. However, if the effect size is medium, the
power of this study falls 0.67. To meet the sufficient
power (≥0.80) at the medium effect size, the number of
patients in each group should be at least 65. Further
studies with more patients and longer term follow-up
with strict control of activity would be helpful to derive a
more definitive result.
In conclusion, hip arthroplasty performed to osteopo-
rotic patients using this cementless, double-tapered
wedge stem showed low subsidence until 1 year after
the surgery with excellent fixation despite early toler-
able weight-bearing. Thus, we believe that osteoporosis
itself is not a contraindication for the use of this specific
cementless stem.
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