REVIEW ARTICLE

The design features of cemented femoral

hip implants

T. Scheerlinck, We undertook a review of the literature relating to the two basic stem designs in use in
P.-P. Casteleyn cemented hip replacement, namely loaded tapers or force-closed femoral stems, and the
composite beam or shape-closed designs. The associated stem fixation theory as
From the Vrije understood from in vitro studies and finite element modelling were examined with
Universiteit Brussel, reference to the survivorship results for each of the concepts of fixation.
Brussels, Belgium It is clear that both design principles are capable of producing successful long-term
results, providing that their specific requirements of stem metallurgy, shape and surface
finish, preparation of the bone and handling of the cement are observed.

Since the advent of cemented stem fixation in ‘composite-beam’or ‘shaped-closed’ fixation3,4

the early 1960s, surgical techniques and the (Fig. 1).
design of implants have evolved dramatically. In the loaded-taper model epitomised by
Some of these changes have resulted in the Exeter implant (Stryker, Mahwah, New
improved survival while others have not.1,2 Jersey), the stem is tapered in two (CPT, Zim-
Mechanical studies in vitro and mathematical mer, Warsaw, Indiana) or three planes (C-
simulations with finite-element analysis are stem, DePuy International Ltd., Leeds,
essential in evaluating the function of hip United Kingdom) and becomes lodged as a
implants. However, predictions based entirely wedge in the cement mantle during axial
on these findings have not always been success- loading,5-7 reducing peak stresses in the prox-
ful, illustrating the complexity of the inter- imal and distal cement mantle.8 The stem is
actions involved in the loosening of a cemented allowed to subside initially until “radial com-
stem and the difficulty of reproducing the real- pressive forces are created in the adjacent
life situation.1,2 cement and transferred to the bone as hoop
We have reviewed the different surface char- stress”.4 An air-filled distal centraliser is used
acteristics of implants, the shapes of the stem to facilitate subsidence of the stem to a stable
and the various options in geometrical stem- position without creating excessive stresses in
broach sizing which have been adopted in an the distal cement mantle.9
attempt to improve survival. In order to deter- In the composite-beam concept, the stem

T. Scheerlinck, MD, mine which of these combinations are satisfac- needs to be rigidly bound to the cement since
Orthopaedic Surgeon, tory, experimental data have been related to subsidence or impairment of the stem-cement
Associate Clinical Professor

P.-P. Casteleyn, MD, PhD, clinical evidence of long-term success. The interface may result in damage to the cement,
Professor, Chairman of understanding of these concepts may help in with the generation of polymethylmetha-
Orthopaedic Surgery
Department of Orthopaedic and the selection of potentially successful implants crylate (PMMA) and/or metal debris and ulti-
Trauma Surgery and of operative techniques. mately failure of the implant.10 Because these
Academic Hospital of the Vrije
Universiteit Brussel, implants are not intended to subside, the
Laarbeeklaan 101, 1090 Stem philosophies presence of a void at the tip of the stem is
Brussels, Belgium.
The optimal shape of a stem should transmit considered to be detrimental since it weakens
Correspondence should be sent
to Dr T. Scheerlinck; e-mail:
torsional as well as axial load to the cement the cement mantle. Such voids can appear
Thierry.Scheerlinck@az.vub.ac. and to the bone without creating damaging when air trapped by the implant in the recess
be
peak stresses and without excessive micro- meant to fix the distal centraliser undergoes
©2006 British Editorial Society movement. The stem should remain mechani- thermal expansion during curing of the
of Bone and Joint Surgery
doi:10.1302/0301-620X.88B11.
cally stable in the long term despite being cement. For that reason, it is advised to
17836 $2.00 subjected to repetitive loading. Two methods always use a distal centraliser when such a
J Bone Joint Surg [Br]
have been adopted to achieve these goals: hole in the stem is present or to plug that hole
2006;88-B:1409-18. ‘loaded-taper’ or ‘force-closed’ fixation and with the in-stem portion of the centraliser, a

VOL. 88-B, No. 11, NOVEMBER 2006 1409

1410 T. SCHEERLINCK, P.-P. CASTELEYN

Fig. 1a Fig. 1b Fig. 1c

Radiographs showing stems of a) the loaded-taper type (CPT; Zimmer, Warsaw, Indiana) and b) the composite-beam type (Centralign, Zimmer)
cemented undersized compared with the last broach, resulting in a thick cement mantle. Cementing a stem using a line-to-line technique gives a thin
cement mantle and relies on c) the composite-beam fixation principle (Vectra; Biomet, Warsaw, Indiana).

plastic plug or cement which is allowed to cure before with mean migration ranging between 0.1 mm and 0.5 mm
insertion of the stem.11-14 during the first year.3,15,16,20,21 However, some tend to
Loaded-taper and composite-beam stems behave differ- migrate also into retroversion, generally between 0.28 mm
ently in terms of migration over time when studied by and 0.8 mm,15,20,21 but sometimes up to 1.0 mm and even
radiostereometric analysis (RSA). Loaded-taper stems in 2.0 mm22,23 during the first year. In some instances migra-
the first year of implantation show initial migration with tion at the cement-bone interface has also been seen.16,21,23
reported mean subsidence ranging from 0.9 mm to 1.4 mm Both factors are worrying since excessive and continuous
and retroversion between 0.4 mm and 0.5 mm.3,7,15-19 After migration,23,24 may be considered to be predictive of fail-
the initial year, these stems tend to stabilise.3,15,17 Initial ure.20,22
migration seems to be independent of the type of cement, its
viscosity17,18 and the thickness of the cement mantle.17 Stem philosophy and surface finish
Although tapered implants tend to stabilise only second- Polished stems are preferred with the loaded-taper design
arily, they remain relatively stable over time.7 The cement since they allow stepwise subsidence to a stable position,3,25
mantle surrounding these stems does not migrate,3,16,19 or with the associated micromovement producing less metal
does so only slightly7 within the femur, which does not and cement debris at the cement-stem interface.9,26,27 By
appear to compromise the long-term results. However, the contrast, in the composite-beam prostheses, it may be logi-
degree of long-term migration which loaded-taper stems cal to optimise stability by roughening the surface to
can tolerate is not known.7 increase the cement-stem bonding.
Stems relying on the composite-beam principle have Mechanical effect of the surface finish. From a mechanical
more initial stability especially in the longitudinal direction perspective, a weak cement-stem bond with a polished stem

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 THE DESIGN FEATURES OF CEMENTED FEMORAL HIP IMPLANTS 1411

Table I. Details of studies showing the relation between the surface finish of cemented femoral hip implants with a similar stem geometry and clinical
outcome

Number Mean Outcome of

Authors Implants* of stems Surface finish† µm)‡
Ra (µ follow-up (yrs) stem (%)§
Collis and Mohler67 Iowa 122 Polished 0.1 6.0 AL 0.0; RL 0.8
Iowa 122 Matt + PMMA¶ 2.1 5.3 AL 3.3; RL 1.6
Iowa 36 Satin 0.8 11.3 AL 5.5; RL 5.5

Sporer et al68 Iowa 45 Matt + PMMA 2.1 8.2 AL 17.7; RL 4.4

Collis and Mohler48 Iowa 220 Satin 0.8 10.5 AL 3.5

Iowa 343 Matt + PMMA 2.1 7.2 AL 3.1
T-28 209 Polished 0.02 to 0.1 11.0 AL 1.9
TR-28 227 Satin 0.8 10.5 AL 2.2

Meding et al69 T-28 378 Polished < 0.1 12.4 AL 11.1; RL 0.0
TR-28 171 Matt 1.6 10.8 AL 12.8; RL 3.0

Howie et al70 Exeter 20 Polished 0.02 to 0.0427 > 9.0 AL 0.0; RL 0.0
Exeter 20 Matt 1.03 to 1.8327 > 9.0 AL 20.0; RL 5.0

Crawford et al71 Exeter 56 Polished 0.01 9.0 AL 0.0; RL 1.8

Exeter 23 Matt 1.2 9.5 AL 4.3; RL 13.0

Middleton et al72 Exeter 55 Polished 0.02 to 0.0427 7.8 AL 0.0; RL 1.8

Exeter 25 Matt 1.03 to 1.8327 12.0 AL 24.0; RL 4.0

Dall et al73 Charnley first generation 264 Polished 0.02 to 0.0327 8.8 AL 1.6; RL 1.6
Charnley second generation 402 Satin-Matt 0.66 to 1.2127 7.8 AL 6.7; RL 4.7

Kerboull et al74 Kerboull 165 Polished 0.03 to 0.0537 9.0 AL 0.0

Kerboull 141 Satin 0.6121 9.0 AL 1.5

Morscher et al75 MS-30 325** Polished - 8.8 AL 0.9; RL 24.1

MS-30 586** Satin-Matt 0.5 to 1.5 7.3 AL 0.7; RL 22.6

Della Valle et al76 Versys 138 Satin 0.5 5.4 AL 0.0; RL 2.2
Versys 64 Matt 1.75 to 2.25 5.9 AL 10.9; RL 12.5
* Iowa, Zimmer, Warsaw, Indiana; T-28, Zimmer; TR-28, Zimmer; Exeter, Stryker, Mahwah, New Jersey; Charnley (first and second generation), DePuy
International, Leeds, United Kingdom; Kerboull, unknown; MS-30, Zimmer; Versys, Zimmer
† according to Crowninshield et al55
‡ Ra: average surface roughness (1 µm = 39.37 µinch)
§ AL, revision rate for aseptic loosening of the stem; RL, radiological loosening, osteolysis or radiolucent lines in unrevised hips
¶ PMMA, polymethylmethacrylate
** summary from four different series

has little effect on the distal, but increases proximal, cement Failure of the implant due to accumulated mechanical
strains.28 When the cement-stem bond increases, compres- damage to the cement-bone interface has been described
sion stresses decrease, but higher tensile and shear stresses both in vitro32 and in vivo.10,33,34 Because weakly-bound
appear in the cement mantle and at the cement-bone inter- stems transfer less shear force and tensile stress to the
face.29 Poorly-bound polished stems do not create tensile cement-bone interface, that interface may be less dam-
stresses and decrease shear stresses in the cement and the aged.29 This explains why implants with a strong cement-
cement-bone interface.29 In contrast to compression stem bond may be more sensitive to the presence of incom-
strains, which can be transmitted without a reliable cement- plete and thin cement mantles with a poor cement-bone
stem bond, transmission of tensile strains relies largely on a interface than polished stems.34-38
good bond.30 Since this tensile bond may be unreliable over Wear and surface finish. Despite efforts to enhance the
time, Crowninshield et al30 have suggested that “it is cement-stem bond by pre-coating or roughening of the
unwise to design prostheses that rely heavily on the pres- stem, micromovement between the stem and cement seems
ence of a good (stem-cement) bond”. Moreover, because to be inevitable. This is due to differences in elasticity
PMMA tolerates compressive loads well, but is more vul- between the stem, cement, cancellous and cortical bone and
nerable to tensile stresses and shear forces,31 weakly-bound to the repetitive axial and torsional loads applied to the
stems may load the cement in a less damaging way. stem-cement-bone composite by the body-weight and by

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1412 T. SCHEERLINCK, P.-P. CASTELEYN

Thick cement mantle:

cement has cortical support
Undersized implant
stem has no cortical support
Example: Capital hip, Centralign

Oval-shaped broach Thin cement mantle:

cement has cortical support
Line-to-line implant stem has some cortical support
Cortex Example: Kerboull CMK II and III, Vectra

Cancellous
bone
Thick cement mantle:
cement has poor cortical support
Undersized implant
stem has no cortical support
Example: Exeter, Charnley
Box-shaped broach

Thin cement mantle:

cement has poor cortical support
Line-to-line implant stem has cortical support at the corners
Example: Kerboull CK I and II, Müller

Box-shaped broach
Line-to-line Thin cement mantle:
and curette
implant cement has cortical support
stem has cortical support at the corners
Example: Kerboull CK I and II, Müller with
removal of lose cancellous bone

Fig. 2

Diagram showing the influence of the stem-broach matching and cross-sectional shape of the stem on the appearance of the cement mantle (Cap-
ital Hip, 3M Health Care Ltd, Loughborough, United Kingdom; Centralign, Zimmer, Warsaw, Indiana; Kerboull CMK II, Smith & Nephew, Memphis,
Tennessee; Kerboull CMK III, Vecteur Orthpédique, Marne la Vallée, France; Vectra, Biomet, Warsaw, Indiana; Exeter, Stryker, Mahwah, New Jer-
sey; Charnley, DePuy International Ltd, Leeds, United Kingdom; Kerboull CK I, Stryker; Kerboull CK II, Stryker; Müller, Zimmer).

the action of the muscles on the proximal femur.39,40 account for the poor performance of unpolished cemented
Mechanical testing in vitro,41-44 as well as RSA studies in titanium stems33,51,56,59-63 while polished or smooth
vitro and in vivo,35,45,46 have shown that perfect stability of cemented stems of this material have survived well.37,64-66
the stem is improbable. When debonding finally occurs at It can be concluded that ‘rougher’ stems need a thick,
the pre-coated or roughened cement-stem interface, there continuous cement mantle of good quality with a strong
will be damage to the cement and large quantities of cement-bone interface and should be made of wear-
PMMA and/or metal particles will be generated25,47 caus- resistant materials, whereas polished stems may be more
ing osteolysis, loss of bony support and loosening of the tolerant to suboptimal cementing and manufactured from
implant.10,26,36,48-53 This seems less critical for polished less wear-resistant materials. This may also explain why the
stems because, compared with non-polished implants, gap same design of stem but with a smoother surface finish per-
formation at the cement-stem interface25 and migration of forms better than its rougher equivalent, even if they are of
particles along that interface are reduced,54 and micro- the composite-beam design (Table I).48,67-76
movement between the implant and cement produces less Geometry of the stem. Several features of the shape of the
debris.25,27,47,55 Moreover, whereas unpolished stems stem influence the in vivo behaviour of femoral compon-
become polished at the surface with release of debris, pol- ents, including the overall shape (straight or anatomical),
ished stems mostly show pitting, with retention of debris on the cross-section (oval or square), the presence of a collar,
their surface.27 the shape of the tip of the stem, the length of the stem and
Wear at the cement-stem interface will be even greater if whether the edges are rounded to a greater or lesser degree.
unpolished stems, made of materials with less wear- Straight and anatomical stems. In contrast to symmetrical
resistance such as titanium alloy, loosen.53,56-58 This may stems14 such as the Charnley (DePuy International Limited,

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 THE DESIGN FEATURES OF CEMENTED FEMORAL HIP IMPLANTS 1413

Leeds, United Kingdom), Exeter (Stryker), Müller (Zimmer, polished Charnley-Kerboull stem with a quadrangular
Warsaw, Indiana), Versys (Zimmer) and Spectron (Smith & cross-section performed better than a later matt version
Nephew, Memphis, Tennessee), anatomically-shaped com- with an oval cross-section.37,86 However, it is unclear
ponents like the Lubinus SP2 (Waldemar Link GmbH, whether that underperformance could be attributed to the
Hamburg, Germany), ABG (Stryker), Olympia (Biomet, oval cross-section and/or the matt surface finish.
Warsaw, Indiana), Aura II (Biomet), SHP (Biomet) and APR The addition of proximal anteroposterior cobra-shaped
II (Zimmer) are designed to fit the sagittal intra-medullary dorsal flanges to the stem has been advocated in order to
anatomy.77 This allows better centralisation of the stem and decrease stress shielding, to enhance stability of the stem
more even thickness of the cement mantle.78 Compared and to increase the interlock between the stem and the
with symmetrical stems, anatomical stems generate differ- cement.87 However, dorsal flanges caused higher cement-
ent strains within the cement mantle because of their spe- bone micromovement in vitro87 and are associated with
cific shape.79 They are of the shape-closed or composite- more cement-bone radiolucencies in vivo.60 In clinical prac-
beam type since their shape limits the subsidence required tice, a dorsal flange reduced subsidence of the stem and the
to achieve a stable position. However, it remains question- incidence of fractures of the distal cement.88 However, the
able if these characteristics are key advantages since both survival rates of the flanged grit-blasted cobra-shaped
types of stem have performed equally well in the long Charnley stem at 15 and 25 years were less satisfactory
term.9,46,80-83 Nevertheless, an anatomical stem, which can than those of the non-flanged polished version.60 It is
be inserted more anteriorly in the shaft without creating an unclear if this was attributable to the flange, the rougher
area of anterior proximal cortical contact and posterior dis- stem surface or to both.
tal point contact, could be an advantage, especially for the In order to improve the rotational stability of polished
less experienced surgeon using an anterior approach. tapered stems, the CPS-plus stem (Endoplus) was designed
The cross-sectional shape of the stem. The cross-sectional to fill the canal to a greater extent and had a broader shoul-
shape influences the distribution of cement within the fem- der and a more rectangular cross-section compared with
oral canal, the rotational stability of the implant84 and the the original Exeter stem (Stryker). Two years after implant-
stress distribution within the cement mantle.30 Broaches ation RSA confirmed a similar pattern of subsidence but
and stems with an oval cross-section as found in the Ker- with improved rotational stability and decreased valgus
boull CMK II (Smith & Nephew) and III (Vecteur migration compared with the original Exeter design.89 This
Orthopédique, Marne la Vallée, France), Vectra (Biomet) is expected to improve the long-term outcome but remains
and Centralign (Zimmer) have a better fit within the med- to be proven by clinical follow-up studies.
ullary canal and can occupy more of the cavity, leaving less Geometry of the proximal stem. Experimental79,90-92 and
room for cement and cancellous bone. By contrast, the finite-element analysis studies29,90,92,93 both found high
broaches and stems with a more rectangular cross-section focal strains in the cement mantle at the level of the medial
such as the Exeter (Stryker), CPT (Zimmer), CPS-plus femoral neck and/or near the tip of the implants. These
(Endoplus, Swindon, United Kingdom) and the Kerboull regions are vulnerable to damage to the cement during ini-
CK I (Stryker), are limited in size by their contact against tial loading.94 When cracks in the cement extend from the
the inner cortex of the oval cross-section of the medullary region of the medial femoral neck and from the tip of the
canal. This may result in additional space for pressurisation stem over the complete length of the stem, failure of the
of cement into the remaining cancellous bone beyond the implant is imminent.94 Therefore, it is important to reduce
reach of the broaches. However, if cement is not or cannot cement strains in these regions, and to obtain a cement
be fully pressurised into that layer, mechanically weak can- mantle of good quality removing mechanically-weak can-
cellous bone will be interposed between the cement and cellous bone between the cement and the cortex, especially
cortical bone. This can be avoided by removing this cancel- in the region of the medial femoral neck. This last point has
lous bone with a curette before cementing the stem, taking been supported by mechanical testing,95,96 finite-element
care to leave a minimal amount of well-fixed cancellous analysis97 and clinical data.98-102
bone attached to the cortex to allow proper interdigitation Theoretically, the collar of the cemented femoral
of the cement (Fig. 2). Since modern cementing techniques component has two functions. First, it has the potential to
allow pressurisation of cement into cancellous bone over a promote direct transfer of load from the implant to the
distance of 3 mm,85 that amount of remaining cancellous medial cement mantle and/or the bone of the medial femo-
bone should be adequate. ral neck, at least when a close contact is achieved initially
Stems with a square cross-section offer more rotational and maintained over time. Moreover, direct collar-bone
stability than oval stems. However, sharp edges create peak contact can unload the vulnerable proximal cement
stresses in the cement, which could lead to microfractures. mantle.91,103 The presence of a collar can also reduce tensile
Mann and Kim84 calculated, based on a finite-element stresses in the stem104 and reduce overall migration.21,105
model, that optimal rotational stability with acceptable However, a collar has a negative effect on the final rate of
peak stresses in the cement was obtained when the corners migration,105 preventing the stem from ‘settling’ during
had a fillet radius of 2 mm. In clinical practice, the original cyclic loading, and does not avoid micromovement of the

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1414 T. SCHEERLINCK, P.-P. CASTELEYN

Table II. Stem-broach mismatch of different femoral stems according to a manufacturer’s survey
performed by us in 2002

Stems > 1 mm undersized compared with broach Stems ≤ 1 mm undersized compared with broach
*
Brand Stem Brand* Stem
Zimmer CPT Zimmer Metabloc
Zimmer Versys Zimmer Müller
Zimmer Harris Zimmer Exofit
Zimmer MS 30 Zimmer Weber
DePuy Charnley, Elite/Elite DePuy Modulor
plus
DePuy C-stem Céraver Ostéal
Stryker Exeter Stryker Kerboull MK III
Stryker Contemporary hip Stryker Legend V40
Endoplus CPS-Plus Stryker ABG cemented
Biomet Mallory Head interlock Biomet Vectra III
Biomet Stanmore Biomet Aura II
Biomet Answer, Alliance SEM SEM III
Wright Medical Helianthe Wright Medical PTC
Smith & Nephew Spectron Waldemar Link Lubinus
Smith & Nephew Synergy Smith & Nephew CMK 21
* Zimmer, Warsaw, Indiana; DePuy International Ltd, Leeds, United Kingdom; Stryker, Mahwah,
New Jersey; Endoplus, Swindon, United Kingdom; Biomet, Warsaw, Indiana; Wright Medical,
Arlington, Tennessee; Smith & Nephew, Memphis, Tennessee; Céraver, Roissy, France; SEM, Mon-
trouge, France; Waldemar Link GmbH, Hamburg, Germany

stem105 or the production of wear debris from the cement- cracks but more full-thickness cracks than the other
stem interface.27 Neither does a collar prevent early resorp- regions.114 Finally, from a biological point of view full-
tion of the medial femoral neck,106-110 which could be due thickness cracks together with defects in the cement consti-
to debris generated by attrition of the collar against bone tute a possible pathway for migration of particles from the
and cement,108 and could jeopardise the loading function of cement-stem interface to the bone. This could be a source of
the medial femoral neck. A collar is also counter-productive particle-induced osteolysis even in well-fixed implants.26,38,119,120
in loaded-taper stems since they need to subside within the In order to favour a ‘thick and flawless’ cement mantle,
cement mantle to reach a stable final position.108 some systems use stems which are undersized compared
The second function of the collar is to control insertion, with the corresponding broach. However, in addition to
especially when the stem is undersized compared with the these undersized stems most manufacturers also market
broach, so that the final implant is inserted to exactly the stems which have the same size as the broach system and
same level as the broach. For implants which are not under- which are cemented ‘line-to-line’ (Table II).
sized, this is not crucial since the stem will automatically be Recently, the old debate concerning the appropriateness
directed to the broach position by contact with the bone. of undersizing the stem has been raised again by Langlais et
A collar should only be considered in composite-beam al37,121 as the ‘French paradox’. These authors, among
stems which are undersized compared with the broach. others,64,86 have presented and reviewed excellent long-
However, even then, survival of the stem has not been term results obtained with different polished and rectangu-
improved as demonstrated in series comparing the same lar canal-filling stems cemented line-to-line after using the
geometry with and without a collar.111,112 largest possible broach. These stems aim at a direct load
Stem-broach mismatch. From a biomechanical92,97,113,114 transfer to bone by close cortical contact. As such, they are
and clinical99,115,116 point of view it has been recommended not meant to subside within the cement mantle and can be
that a cement mantle which is subjected to high stresses considered as ‘shape-closed’. Comparing the results at ten
should be between 2 mm and 5 mm thick, especially in the years of the Freeman hip replacement, cemented line-to-line
proximomedial part of the implant and around the tip of or undersized, Skinner et al122 concluded that a line-to-line
the distal stem. However, cement mantles thicker than technique “is not worse and may produce better long-term
5 mm to 10 mm could increase micromovement and could results than current teaching suggests”. Müller123 reported
be detrimental.99,113 Retrieval studies have reported more similar findings, and 10 to 15 years after introducing his
cracks in areas of thin cement.117 Mechanical and finite- straight stem he noted that: “The closer the contact
element studies of the propagation of fatigue cracks in the between the stem and the bone, the better were the results”.
cement showed that the rate of growth of the crack was Therefore, despite a potentially suboptimal cement mantle,
independent of the thickness of the cement mantle.114,118 some stems inserted line-to-line with the largest broach have
However, cracks in thin cement reached full-thickness in performed very well clinically (Table III).66,74,86,100,122,124-128
fewer loading cycles.118 After loading of cemented stems, Canal-filling stems offer many theoretical advantages.
regions of thin cement (< 2 mm) presented fewer cement First, removal of a maximal amount of mechanically-weak

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 THE DESIGN FEATURES OF CEMENTED FEMORAL HIP IMPLANTS 1415

Table III. Details of studies reporting results of femoral-canal-filling stems inserted with a minimal cement mantle

Number
of Surface Mean Outcome of stem
Authors Implants* stems Cross-section finish† Ra (in µm)‡ Material follow-up (yrs) (%)§
Delaunay et al124 Kerboull 215 Rectangular Polished 0.03 and 0.6121 Stainless-steel 14.2 AL 2.8; RL 5.6
and oval and satin

Kerboull et al86 Kerboull MKI & MKIII 166 Rectangular Polished 0.03121 Stainless-steel 14.5 AL 0.6; RL 4.9¶
Kerboull CMKII 51 Oval Satin 0.6121 Stainless-steel 14.5 AL 10.0; RL 4.9¶
Kerboull CMKIII 70 Oval Satin 0.6121 Stainless-steel 14.5 AL 3.9; RL 4.9¶
Kerboull et al74 Kerboull 141 Oval Satin 0.6121 Stainless-steel 9.0 AL 1.5

Arama et al100 Kerboull 481 Rectangular Polished 0.03121 Stainless-steel 250 hips > 5.0 AL 0.0; RL 2.8

Delaunay et al124 Céraver Ostéal 165 Rectangular Smooth 0.2** Titanium 8.0 AL 2.4; RL 11.2††

Rousseau et al125 Céraver Ostéal 104 Rectangular Smooth 0.2** Titanium 11.0 AL 1.0; RL 2.9

Hamadouche et Céraver Ostéal 89 Rectangular Smooth 0.2** Titanium 19.7 AL 12.7; RL 63.4††
al126

Le Mouel et al127 Céraver Ostéal 156 Rectangular Smooth 0.2** Titanium 7.4 AL 0.0; RL 1.7
Céraver Ostéal 61 Rectangular Smooth 0.2** Titanium 5.3 AL 0.0

Osorovitz and Céraver Ostéal 124 Rectangular Smooth 0.2** Titanium 5.4 AL 0.0; RL 2.5
Goutallier128

Nizard et al66 Céraver Ostéal 187 Rectangular Smooth 0.2** Titanium 10.9 AL 0.7; RL 3.0

Skinner et al122 Freeman 97 Mixed‡‡ Mixed§§ Cobalt-Chrome 10.0 AL 1.2; RL 7.3

* Kerboull, unknown; Kerboull MKI & III, Stryker, Mahwah, New Jersey; Kerboull CMK II, Smith & Nephew, Memphis, Tennessee; Kerboull CMK
III, Vecteur Orthopédique, Marne la Vallée, France; Céraver Ostéal, Céraver, Roissy, France; Freeman, Corin Medical Ltd, Cirencester, United
Kingdom and Finsbury Instruments Ltd., Leatherhead, United Kingdom
† according to Crowninshield et al55
‡ Ra: average surface roughness (1 µm = 39.37 µinch)
§ AL, revision rate for aseptic loosening of the stem; RL, radiological loosening, osteolysis or radiolucent lines in unrevised hips
¶ data mentioned are for all stem types as a group
** values provided by the manufacturer
†† including radiolucent lines < 1 mm or non-evolving radiolucent lines
‡‡ proximally, rectangular and neck preserving; distally round
§§ proximally, textured and sand-blasted; distally, polished

cancellous bone favours direct load transfer to the cortex. A recent study85 using CT and polymeric Charnley-
This occurs either through direct point contacts between Kerboull replicas showed that these stems, when cemented
the implant and cortical bone or through a thin cement line-to-line with the largest broach, created a cement mantle
layer between the implant and cortex without interposition of which averaged over 3 mm in thickness. Because of pressuri-
weak cancellous bone. This concept may improve the stabil- sation of the cement into cancellous bone, defects (< 1 mm of
ity of the implant.29,30 Secondly, points of contact between cement thickness) were found in only 6% of the interface, but
implant and cortex could facilitate stem insertion by con- areas with a cement thickness < 2 mm were found in 26%.
trolling stem alignment and insertion depth and by stabilis- These were noted mostly in the distal two-thirds and at the
ing the implant during cement curing. Finally, insertion of a corners of the stem. Because areas of thin cement appeared to
stem with similar dimensions as the largest possible broach be supported mainly by cortical bone, they might be less det-
creates high intramedullary cement pressures,129 which rimental than initially believed.
could favour interdigitation of the cement into the remain-
ing cancellous bone and cement penetration up to the cor- Summary and conclusions
tex. Since larger quantities of cancellous bone remain in the Cemented femoral implants have been developed to function
proximal part of the femur after broaching, the effect is either as loaded-tapers or composite-beams. Stems of the
more marked in that region.122 This could improve the loaded-taper type should be polished to favour stepwise sub-
quality of the cement mantle, especially if a suboptimal sidence to a stable position. They are very sensitive to a rough
cementing technique is used without adequate pressurisa- surface finish and are incompatible with the use of a collar as
tion. Therefore it is possible that cemented line-to-line a positioning device, an anatomical shape or canal-filling
implants could be more ‘user-friendly’ for less experienced design of the stem, since these features prevent subsidence
surgeons. within the cement mantle.

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A stem relying on the composite-beam principle can be 7. Stefansdottir A, Franzen H, Johnsson R, Ornstein E, Sundberg M. Movement
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ported by cortical bone help to stabilise the implant. In clin- 11. Hanson PB, Walker RH. Total hip arthroplasty cemented femoral component distal
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work well.
12. Smith SG, Kabo JM, Kilgus DJ. Effects of distal femoral centralizers on bone-
In the composite-beam design the use of a rough surface fin- cement in total hip arthroplasty: an experimental analysis of cement-centralizer bond-
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Additionally, a rough surface finish increases tensile and shear ponents be designed to subside: a radiostereometric analysis study of the Charnley
Elite and Exeter stems. J Arthroplasty 2001;16:598-606.
stresses in the cement mantle and at the cement-bone interface.
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be favoured even for implants relying on the composite-beam oral stem within the cement mantle in primary arthroplasties and in revisions
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