Abstract
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Scepticism is still the most common attitude of orthopaedic surgeons toward short stems, despite the excellent survival rate reported in the International Registry, together with an acceptable complication risk.
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In surgical centres where these types of implants are commonly utilised, they account for a significant percentage of procedures (up to 50% of total hip replacements performed).
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Potential benefits of bone preservation were evident from the very early phase of introduction. Some complications have been experienced, especially with modular short stems.
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Some limitations and weak points during the evolution from early designs to modern short stems have been identified.
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With few exceptions, clinical results and survivorship were very good, despite widened indications (age- and pathology-related), giving an overall retrospective evaluation of our experience with short stems similar to primary hip implants.
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Failure of short stems is mostly related to the validity of bone preservation in terms of revision strategy.
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Standard surgical revision was generally performed with two-stage revisions in PJI and stem revision in periprosthetic fracture.
Introduction
The title is a self-ironic definition regarding our own surgical experience: short stems in total hip replacement are a philosophy, a religion or finally, an alternative and effective approach to total hip replacement.
(A) CFP stem: the first short stem introduced in routine clinical practice. (B) Mayo Stem from the Mayo Clinic introduced by B Morrey for treatment of elderly patients to reduce surgical invasiveness.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0056
Malpositioned Mayo stem at 10 years post-op with no sign of loosening or subsidence.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0056
Nanos stem could obtain different CCD angle by changing its position in femoral neck.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0056
SMF metaphiseal stem improved mechanical stability with a 5 mm higher neck resection.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0056
X-fit stem required a subcapital osteotomy for complete neck retention.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0056
Metha monolithic stem was introduced to overcome neck fracture issue with this component.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0056
Friendly short: a cemented short stem for patients with severe osteoporosis.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0056
Profemur Preserve stem : used in combination with anterior path appoach.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0056
Periprostetic fracture in a Pulcra stem.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0056
The orthopaedic community around the world has shown general perplexity in terms of early and late complications. Regarding their survivorship, diffidence is, in fact, the most common attitude.
A supposed inferior long-term outcome, together with a more challenging operative technique (compared to conventional stems), are the main reasons for remaining within the comfort zone offered by standard primary total hip replacement.
However, in Europe (Italy, Germany and Switzerland above all), short stems are a slow but growing reality. For example, the German Arthroplasty Register 2023 reveals that in almost two-thirds of hospitals, short stems account for less than 5% of THA cases. However, there are also over 50 hospitals that use them in more than half of such procedures. In total, 13.3% of all primary procedures are performed with short stems (double, if compared to 2015 data, when their use was limited to 6.6% of procedures (1).
In the same registry, short stems have a revision rate from year 1 to year 8 after primary intervention inferior to standard stems (1).
In the Swisse Registry, short stems have an inferior expected failure rate compared to standard stems up to 11 years after primary intervention (2).
Even in Australia and New Zealand, the use of short stems (or mini-hip stems) is becoming an increasingly common procedure, and clinical results reported are surprisingly good, with a cumulative percentage of revision inferior to standard stems up to 13 years after primary intervention, even if stratified above and below 65 years of age (3).
Our study group has been a pioneer in our country regarding conservative total hip replacement, starting in 1999 with the Mayo stem (Zimmer) and pursuing this philosophy with several hip designs (taking part in the developing board of some of them and contributing to short stem classification (4)).
We are proud to share in this paper our 25-year experience with conservative total hip arthroplasty, using long-term follow-up, when available, to discuss clinical behaviour in comparison with conventional hip replacement.
Furthermore, we would contribute to overcoming mistrust about clinical indications or surgical complexity, giving a role to short stems in the Happy Hip Replacement scenario.
Short stems: methodology and clinical results
We informally divide our clinical practice with short stems into three phases (Table 1):
Phases of short stem experience. Implants evolution.
| The discovery | The enthusiasm | The wisdom |
|---|---|---|
| MAYO | SMF modular | PROFEMUR PRESERVE |
| NANOS | PROXIMA | PULCHRA |
| METHA modular | METHA monoblock | |
| FRIENDLY SHORT | SMF monoblock | |
| FITMORE |
i) Early phase, the discovery.
ii) Middle phase, the enthusiasm.
iii) Late phase, the wisdom.
In our EARLY PHASE, as mentioned above, we approached short stems with the Mayo stem (Zimmer, USA): a very short femoral component, designed by B Morrey and introduced in clinical practice in 1989, with completely new concepts in terms of fit and alignment (5). It was a metaphyseal stem with cancellous bone preservation, where the distal tip of the component was intended for alignment only (along the lateral endosteal surface of the proximal diaphysis): proximal-to-distal taper, together with a different surface finish between the proximal body and distal tail, were functional to this rationale (Fig. 1).
Fibre mesh pads around the metaphyseal portion of the stem, as a result of the technology and knowledge available at that time, were intended to promote bone ingrowth. Femoral neck osteotomy with preservation of the lateral neck cortex was essential to ensure initial stability, both torsional and coronal.
Our first implant was dated to late 1999. Since that time, we have implanted 180 Mayo short stems, initially for osteoarthritic young patients (mean age: 59 years, range: 37–79 years), then extending indications to elderly patients (as originally suggested by Morrey himself) and to several different diagnoses: avascular necrosis of the femoral head, post-traumatic OA and low-grade dysplastic hip.
The last implant with the Mayo stem was dated to 2006.
We followed up, until the present day, 122 cases (58 patients lost to follow-up because they passed away during the years, and because part of them were from a rural region near Rome and were not interested in clinical follow-up). Mean follow-up was 19.15 years (range: 12–24 years).
We revised four implants after detection of ‘metallosis’, out of 41 stems coupled with a large diameter metal head (Durom, Zimmer) at a mean follow-up of 6.5 years; two implants for prosthetic joint infection (PJI): one early infection at 3 months, one late infection occurred 8 years after implantation; three implants for periprosthetic fracture (one early fracture within 2 months from surgery, two late fractures occurred respectively at 14 and 17 years after surgery). An intra-operative perforation (‘via falsa’) was detected at post-operative X-ray control: the stem was left in place and showed no migration or loosening at the available follow-up for the specific case (the patient died 8 years after surgery for unrelated problems, with no further surgery on the involved hip; Fig. 2). Six cases were revised during the follow-up for aseptic loosening or severe stress shielding (mean follow-up: 9 years, range: 4–13 years).
Survivorship was 97.5% at 5 years of follow-up (results previously published) (6), 92.17% at 10 years, 87.71% at 15 years. This component showed good reliability in terms of mechanical and biological behaviour, and if we could exclude revisions caused by large metal diameter heads (in all cases the trunnion showed corrosion and wear), the survival rate would be much better.
The main limit related to the stem itself was the tendency to load the proximal femur in varus, transmitting many forces through the distal tip of the implant to the proximal-lateral cortex of the femur (in Gruen’s Region 3): this varus loading led to several cases of lateral cortex hypertrophy and stress shielding involving the greater trochanter. The limited preservation of the femoral neck (circumferential at the base of the neck only) may explain the lack of load transmission to the greater trochanter and Gruen’s Region 1.
Encouraged by the good results obtained with the previous component, a few years later we started to use a short neck-preserving implant: the Nanos stem (Smith-Nephew, UK; Fig. 3).
Perspectives of bone preservation and enhanced fixation offered by the femoral neck, together with a fully hydroxyapatite surface finishing, were the most appealing features of that component.
Between 2004 and 2020 we implanted 134 Nanos stems (in OA and AVN, with some sporadic cases of femoral neck fracture). For 118 stems available for investigation, mean follow-up was 14.42 years (range: 5–18 years).
We recorded an extremely low revision rate with this conservative stem (2.54%): two cases for severe early subsidence and one for delayed septic loosening.
One periprosthetic fracture was detected in the post-operative period (0.74%), while four stable proximal fractures were observed intraoperatively and treated with cables (2.98%). Neck preservation may play a role in intra-operative fracture incidence, with a similar reported rate of 3.3% for a middle-length component such as CFP (7) (Waldemar Link, AG, Germany).
Survivorship was 98.31% at 5 years, 97.46% at 10 years. Our results are similar to clinical reports available in the literature for Nanos stem, reporting a very good survivorship both at mid- and long-term follow-up (8, 9, 10).
Despite the experience gained with these two components, they were implanted in a limited number of our patients compared to other stems because they have only a fixed neck-shaft angle: templating the x-ray before surgery, we often excluded them for unsatisfactory biomechanical parameter restoration. The Nanos offered the possibility to vary the level of osteotomy (achieving a more varus or valgus final positioning) but it was poorly reproducible intraoperatively.
The ‘ENTHUSIASTIC PHASE’ started in 2006 with the introduction of modular short stems, with multiple neck options, to solve the issue mentioned above.
Our study group took part in the scientific board of some modular designs, such as SMF (Smith-Nephew, UK) (Fig. 4) and X-Fit (Fig. 5) (Samo, Cadriano di Granarolo Emilia (BO), Italy), and their use in clinical practice. Together with Metha modular stem (Fig. 6) (Aesculap AG, Germany), they represented a full range of short stem implants: total neck preservation (X-Fit), mid-neck resection (Metha) and trochanter sparing resection (SMF). This wide range of solutions expanded considerably the indications to use conservative stems, and these three designs accounted for a total of 594 implants (respectively 298 SMF, 245 Metha, 51 X-Fit) between 2006 and 2015.
After terrific early follow-up results, unfortunately our series has been penalised by complications specifically related to modularity itself: we had four prosthetic neck fractures in the first generation of Metha modular necks (Ti alloy) (Fig. 7) at a mean follow-up of 3.33 years (min 2.5 – max 5 years) and three cases of ALVAL/pseudotumour with SMF modular necks at a mean follow-up of 7 years (min 6.2 – max 9 years).
Regarding Metha modular necks, results reported in the literature support a higher revision rate for titanium necks (7, 11).
One more case was revised after detection of pseudotumour in a ceramic on metal coupling (during standard follow-up a high cobalt ion levels were detected and required further investigation with MRI): it was a 2nd generation modular Metha (CoCr).
Other revisions were related to PJI: two SMF and one Metha stem; aseptic loosening (subsidence > a 3 mm and pain or complete radiolucency around the implant) for a total of five implants (three SMF and two Metha); periprosthetic fracture in three cases (two SMF and one Metha).
Remarkably no X-Fit stem has been revised for any of the reasons mentioned above, even if one is under investigation for high cobalt ion levels.
Then cumulative revision rate for modular conservative stems, in our clinical experience, was 3.19% at a 10- to 15-year follow-up (3.35% for SMF, 3.67% for Metha, 0% for X-Fit).
However, Metha stems showed (as reported in the literature) (12) a tendency to distal lateral cortex hypertrophy in Gruen’s Region 2 and 3 and partial bone resorption in Gruen Region 1 along the years (less pronounced if compared to Mayo stem: our interpretation is an intraoperative variability in neck preservation).
During this enthusiastic phase, we started to implant a short, cemented stem: Friendly Short stem (Lima) (Fig. 8), monolithic but with two neck options (standard 132° and lateralized 127°); we developed this choice mainly in the presence of a poor bone stock. The rationale was to combine the bone stock preservation of short stems with a supposed protective effect of cement against postoperative periprosthetic fractures in patients under the age of 80 years (above that, a conventional cemented stem was our first choice).
From 2013 we performed 92 hybrid total hip replacements using a Friendly Short stem. Seventy-eight were available to follow-up (14 patients died of unrelated causes). Despite a reported short-term 100% survivorship for aseptic loosening (13), we observed later a survival rate of 89.14% at a mean follow-up of 9 years: three revisions for PJI, four revisions for aseptic loosening (both cement and bone interface failure), three revisions for periprosthetic fracture.
Then survivorship appears inferior if compared to other short stems and conventional stems, probably related to patient selection (age, poor bone stock and comorbidities).
After withdrawal from the market of both SMF and Metha modular stems (respectively in 2016 and 2011) and the introduction of monolithic femoral components, we may say that we entered our ‘WISDOM ERA’.
We gave our preference to short metaphyseal stems, an ‘all-weather’ type of stem, suitable for most femoral morphologies, a wide range of patient ages and surgical techniques.
With reference to the last point, in the same years we began to use the direct anterior approach (DAA) to the hip: short metaphyseal stems are, in our opinion, the perfect match to minimally invasive soft tissue approach (keeping the femoral resection to a level not hindering acetabular preparation and capsular release and making femoral preparation quite easier).
For these reasons (and, unfortunately, after temporary withdrawal of X-Fit stem from the market despite the exceptional clinical results), we considerably reduced our use of neck-preserving implants (i.e. only ten Metha monolithic stems, six Nanos, 22 miniHip stems and one X-Fit were implanted during this phase).
Between 2016 and present days we implanted 192 SMF monolithic (Smith-Nephew, UK), 187 Profemur Preserve (Microport, USA) (Fig. 9), 81 Fitmore stems (Zimmer, USA) and 49 Pulchra stems (AdlerOrtho, Italy).
They were implanted, as mentioned above, mainly through a minimally invasive approach (DAA, in its classical fashion and with bikini or anterior path variations) except for Pulchra, which has been implanted in 30 cases through a minimally invasive posterolateral approach.
Our results of short monoblock metaphyseal stems were similar in terms of aseptic loosening and PJI to modular short stems but were spared from failure related to large metal-on-metal (MoM) or ceramic-on-metal (CoM) coupling and neck modularity.
We recorded a total of five PJI in this specific group of implants (one Fitmore stem, one Pulchra stem, one Profemur Preserve and two SMF monolithic) with an overall incidence of 1%. Mean follow-up at the moment of implant removal (all cases were treated with a two-stage revision) was 18.7 months from surgery (range: 1.5 to 36 months).
We revised for aseptic loosening two SMF monolithic stems, one Fitmore stem and one Pulchra stem, keeping the revision rate for this failure mode at 0.78%) at a mid-term follow-up of 5.2 years (range: 1–9 years).
Periprosthetic fracture occurred post-operatively in two Pulchra stems, (Fig. 10) one SMF monolithic and one Fitmore stem with an incidence of 0.78%.
Discussion
Our experience with short stems started a long time ago as love at first sight, despite the Mayo stem appearing the ‘ugly duckling’ in front of already well-established conventional stems.
We saw clearly the potential advantages related to limited femoral violation during femoral component implantation: bone stock sparing, both in the neck and cancellous metaphyseal region.
We may say that the latter two aspects are directly related to each other, as the more cortical neck we remove, the more proximal bone stock needs to be sacrificed to gain initial torsional and axial stability (primary fixation).
The importance of the level of neck resection has been underlined in several classifications of short stems (4), for its implication in primary stability and surgical technique: the less neck is preserved, the more the surgical technique resembles a standard stem and more metaphyseal fill (or proximal diaphysis engagement) is required.
Conversely, surgical technique (from planning to broaching and final positioning) becomes more challenging with neck preserving implants, and an increased risk of leg discrepancy and femoral neck cracks may be expected.
Accurate templating of our cases consistently reduced leg discrepancy using neck preserving implants (leading, however, on more than one occasion to a switch of indication to a different implant): a completely different achievement compared to our experience with the CFP stem (a middle-size stem with neck preservation and collar, not included in this overview because of its length) where a leg discrepancy between 5 and 15 mm occurred in a non-negligible number of cases.
Some papers available in the literature support this finding, reporting a higher rate of leg discrepancy >10 mm with the CFP stem compared to standard stems implanted after a conventional osteotomy (respectively 13.7 versus 2.7%) (14).
We experienced some intra-operative proximal neck fractures (treated in all cases with a single cable after intra-operative recognition): four Nanos stems during the early phase, four Metha in the enthusiastic phase, one Metha and two MiniHip in the third phase. Out of a total of 461 cases implanted, a 2.38% of intraoperative fractures was observed. Provided that fractures were recognised intra-operatively (and treated appropriately), none of them was revised later, making this complication annoying but quite irrelevant (as well-established both for standard (15) and short stems (16)).
As mentioned above, the DAA influenced the choice of conservative stems: a lower femoral neck preservation needed for short metaphyseal stems made femoral release easier (in terms of access to the ‘digital fossa’ at the base of the neck itself) compared to neck preserving implants. Moreover, better visualisation of the acetabulum and easier introduction of acetabular reamers were accessory to the choice of a short metaphyseal stem together with DAA. In occasional implantation of neck preserving implants through a DAA, we noticed quite consistently a partial damage at the anterior edge of the cortical neck (related to the difficult introduction of acetabular reamers).
We now overcome the issue of neck preserving implants using the ‘Anterior Path’ technique (17) with a mixed surgical technique for cup and stem preparation.
Except for the short, cemented stem, that showed in our series a survivorship of 89.14% at a mean follow-up of 7.5 years, other components had a revision rate comparable to standard stems. For the last generation of short stems (monolithic, metaphyseal or calcar guided), the survival rate appears to be even better. This appearance is supported by the Australian Joint Registry (3), where the revision rate for any cause for ‘Mini-stems’ is lower than standard stems at 5 and 10 years. Remarkably, the components with this optimal behaviour are short monolithic stems.
A bias in patient selection may explain a lower performance of our short cemented stems: even if the age of the patient at the date of surgery was not significantly different, comorbidities and poorer bone quality may have influenced the durability of the bone-cement interface.
A brief summary of components utilised through the years with their survivorship at the available follow-up is reported in Table 2.
Different stems and their survival rate in our series.
| Stem | Number of cases | Mean follow-up (years) | Survival rate (%) |
|---|---|---|---|
| Mayo | 122 | >15 | 87.71 |
| Nanos | 118 | >10 | 96.72 |
| SMF modular | 298 | >10 | 96.65 |
| Metha modular | 245 | >10 | 96.33 |
| Friendly short | 92 | >5 | 89.14 |
| Profemur preserve | 187 | >5 | 99.47 |
| Pulchra | 49 | >10 | 91.84 |
| SMF monoblock | 192 | >10 | 97.40 |
| Fitmore | 81 | >10 | 96.30 |
The cemented stem we chose in our ‘ENTHUSIASTIC PHASE’ had an ‘ultra- short’ design, with a large cement restrictor intended to be positioned very close to the lesser trochanter: it relies mainly on cement interdigitation with proximal cancellous bone. Limited cement fixation in cortical bone makes this component potentially vulnerable to an improper cementing technique or bone stock senescence. Endosteal reaming of the proximal femur, needed to position the femoral plug, may explain the occurrence of post-operative peri-prosthetic fractures in spite of the use of cement.
However, we did not give up the idea of a short cemented stem (to reduce the risks of peri-prosthetic fractures): actually, our preference is for a ‘non-ultra’ short component, with a more distal femoral preparation and, consequently, a more stable cemented fixation on cortical bone and the use of a standard cement restrictor (Tris Stem, AdlerOrtho, Italy).
We deliberately excluded from this overview mid-length stems, such as CFP, Trilock, Accolade II, Trifit, Core Hip and Actis.
In our opinion, they have some characteristics that bridge the distance between short and standard stems and differences among these two groups are blurred in terms of stem design and length. Clinical results are expected to be quite similar, as well as biomechanical behaviour. We are investigating the mechanical failure mode of one of them (Core Hip, BBraun, Melsungen AG, Germany), in particular evaluating fracture loads, and results are not diverging from shorter and longer components.
Conversely, short stems should offer a potential benefit in terms of bone preservation in case of revision. Based on our experience, we can confirm it, especially in cases of aseptic loosening of neck preserving implants: a ‘conservative revision’ may still be possible if residual proximal bone stock after implant removal is still supportive for a metaphyseal short stem or a conventional primary stem.
Because bone deficiency classifications conceived for standard stem failure may be insufficient to describe bone stock and revision strategy in short stem revision, in 2019 a classification focused exactly on this issue (18) was published.
For most cases of septic loosening and all Vancouver B2-B3 peri-prosthetic fractures (PPF), we generally perform surgery using a distal fixation stem.
In case of a two-stage procedure, the interstage was usually managed with a ‘standard’ length spacer and, subsequently, the second stage faced a ‘standard’ femoral bone defect.
After a PPF with a loosened short femoral component, if the metaphysis was assessed as unsupportive, then a distal fixation (plus cables or plate) became an obvious choice in most of the cases.
In some selected cases, where an extreme ‘fluted’ femoral morphology led to a significant undersize of a standard component (that appeared stuck distally and loosened proximally), we were able to de-escalate stem length after endofemoral removal: a short metaphyseal filling stem matched more appropriately the inner femoral morphology, achieving optimal primary stability.
Conclusions
Short stems are a heterogeneous group of implants, with the common intent to preserve bone stock at the time of primary surgery, to keep bone stock through the years and to make an eventual revision less invasive (at least in terms of zone of fixation).
A very accurate systematic review of literature based upon DEXA analysis, published in 2021 (1,098 short stems, 19 studies included) (19), showed better results in bone preservation of short stems compared to anatomic standard stems, in particular in Gruen’s Region 7 at 1 year of follow-up.
Another review performed by Knutsen (20) reported an increased worse bone resorption, potentially an expression of less physiologic loading, in proximal femoral regions (1 and 7) for conventional straight stems.
These findings suggest the ability to keep bone stock initially preserved. Very good clinical results and survival rate, as strongly supported by international registries, underline the validity of short stem as a strong alternative for primary option in total hip replacement.
A better accessibility to ‘endo-femoral’ extraction makes short stem revision (in case of single staged procedures) more conservative, relying fixation strategy on a more proximal portion of the femur (compared to standard stems).
ICMJE Statement of Interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding Statement
This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.
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