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Periprosthetic femoral fractures in minimally-invasive anterolateral short stem versus transgluteal straight stem cementless total hip arthroplasty: What are the differences in the femoral and pelvic morphology?

Journal of Orthopaedic Surgery and Research volume 20, Article number: 110 (2025) Cite this article

Abstract

Background

The occurrence of periprosthetic femoral fractures (PFFs) in cementless total hip arthroplasty (THA) might be associated with the proximal femoral morphology and the pelvis. PFFs in short stem THA are associated with an increased Canal Flare Index. PFFs in straight stem THA show a decreased Canal Flare Index. Therefore, this study aims to compare the femoral and pelvic geometry in PFFs between short stem and straight stem THA.

Methods

A retrospective comparative propensity-score matched study was performed. An institutional database of 5358 THAs was screened for early PFFs within the first 90 days after surgery. All cases of 136 PFFs in primary cementless THA were collected and matched, resulting in 67 PFFs in the straight stem and 37 PFFs in the short stem group. Both groups were analyzed regarding several parameters for femoral and pelvic morphology.

Results

A significantly lower distance from the anterior superior iliac spine to the greater trochanter (AGT) was detected in the straight stem group (96.4 vs. 104.8 mm, p = 0.024). All other femoral and pelvic parameters did not differ between both groups. Postoperative Vancouver A PFFs were significantly higher in straight stem THA, while postoperative Vancouver B PFFs were significantly higher in short stem THA.

Conclusion

The morphology of the proximal femur and the pelvis do not differ in several radiological parameters in patients sustaining a PFF between cementless short stem implanted via an anterolateral approach and straight stem THA implanted via a transgluteal approach. While there are differences in the Vancouver types of PFFs, these differences do not reflect any difference in the morphology of the proximal femur and the pelvis.

Introduction

Periprosthetic femoral fracture (PFF) is a serious complication in total hip arthroplasty (THA) that is associated with increased need for revision arthroplasty with high failure and readmission rates, as well as limited functional outcomes [1,2,3]. The risk of PFFs depend on several different risk factors such as implant design, the surgical approach [4,5,6], bone quality and the presence of osteoporosis [7, 8], implant position [7, 8], increasing age [7,8,9], gender [7, 8, 10], BMI [9], and secondary osteoarthritis (OA) due to rheumatoid arthritis [6, 8]. Additionally, cementless fixation is also associated with an increased risk of PFFs [6]. Carli et al. [6] report a threefold increase in PFF rates (p < 0.001) for single-wedge and double-wedge (fit-and-fill) femoral implants compared to anatomical, fully coated and tapered/rounded stems. An influential factor might be the broaching process, as ream-and-broach designs generally remove more cancellous bone compared to broach-only systems [6]. The difference in preparation could affect the risk of occurrence of PFFs [6].

The incidence of PFFs in primary cementless THA differs in the literature ranging from 0.2 to 6.8% for intraoperative [4, 11,12,13,14] and from 0.5 to 7.7% for postoperative fractures [11,12,13,14,15]. Cementless short stems are associated with a reduced rate of PFFs in minimally-invasive (MIS) THA [4, 5]. Dietrich et al. [4] reported a reduced rate of PFFs in the direct anterior approach (DAA) with cementless short stems (1.6%) compared to cementless straight stems (6.8%) in a 2-year study period (p = 0.027). Luger et al. [5] reported a reduced rate of PFFs of 1.7% for short stem THA compared to 3.2% for straight stem THA within the first year after index surgery (p = 0.015).

Despite an overall reduced rate of early PFFs of short stems compared to standard straight stem in cementless THA, selective patients might have an increased risk for a PFF and may not be suitable for the use of a cementless short stem [16]. The morphology of the proximal femur and the pelvis may play a role in the occurrence of PFFs [16, 17]. Bigart et al. [17] compared several parameters of the morphology of the proximal femur in a propensity-score-matched analysis between fracture and non-fracture patients in cementless straight stem THA. Fracture patients showed thinner distal cortices and a decreased meta-diaphyseal taper compared to matched non-fracture cases [17]. McGoldrick et al. [16] compared the morphology of the proximal femur and the pelvis in cementless short stem THA in DAA in a propensity-score-matched comparison between fracture and non-fracture patients. In contrast to data for straight stem THA [17, 18], a canal flare index greater than 3.17 and an ilium-ischial ratio > 3 were associated with an increased risk for a PFF in short stem THA via the DAA [16].

The morphology of the proximal femur and the pelvis can play a significant role in the occurrence of PFFs in cementless short stem THA [16] and straight stem [17, 18]. However, the available data mostly focuses on comparisons between fracture and non-fracture patients treated with the same type of implant. As there are differences between the influence of femoral and pelvic anatomy between cementless short and straight stems, we conducted this study to evaluate differences in the morphology of the proximal femur and the pelvis between patients that sustained a PFF in cementless short stem THA compared to patients that sustained a PFF in cementless straight stem THA with different stem lengths and fixation principles. The hypothesis was that there would be a significant difference in the radiographic parameters between both stem types in patients with an early PFF.

Material and methods

Study design

A retrospective, single-center, multi-surgeon, propensity-score-matched comparative study was conducted to evaluate PFFs in cementless short stem total hip arthroplasty compared to cementless straight stem total hip arthroplasty Cohort.

The institutional electronic database was used to obtain information on patients who underwent THA between July 1, 2007, and December 31, 2021. In total, 5358 THAs were performed in 5206 patients during this period. From this database, all primary THAs meeting the following inclusion criteria were selected. All primary THAs cementless short stem THA using Fitmore® hip stem (ZimmerBiomet, Warsaw, IN, USA) implanted via a minimally-invasive anterolateral approach in supine positioning [19] and cementless straight stem THA using a Zweymüller straight stem (Alloclassic SL/SLO®; Alloclassic SLV®; both ZimmerBiomet, Warsaw, IN, USA) implanted via a modified Hardinge approach [20] were included for the screening. Cases of primary THAs due primary osteoarthritis of the hip, or osteonecrosis or mild hip dysplasia (Crowe 1) were included. All other cases of secondary forms of osteoarthritis and all cases with previous surgeries were excluded. Primary THA with a cemented stem and the preoperatively planned use of deviating implants such as revision cups or stems led to exclusion. A cemented stem was only implanted once for primary THA in the full study period. To avoid mixed implant combinations regarding stem type and approach, we only included cementless short stems implanted via the anterolateral approach group and cementless straight stems implanted via a transgluteal modified Hardinge approach. All cases of intraoperative and early postoperative periprosthetic femoral fractures within the first 90 days of index surgery were included in the propensity score matching. Figure 1 displays the inclusion and exclusion of patients.

Fig. 1
figure 1

Consort diagram

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The study was approved by the institutional review board (No.: 1275/2022). Because of the retrospective anonymized evaluation of pre-existing medical records, an informed consent was not required. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Surgical procedure

In total, 35 surgeons performed the surgeries. All cases by consultants and resident were included. All consultants performed at least 50 arthroplasty surgeries per year. Residents performed the surgeries with the presence of a consultant.

Minimally invasive anterolateral approach was performed in supine positioning [19, 21]. Full weight-bearing was allowed immediately on the day of surgery. The direct lateral approach by Hardinge was first described in 1982 [22]. The modified Hardinge approach has previously been described by Frndak et al. [20]. Full weight-bearing was allowed on the first postoperative day after surgery.

Apart from the allowance of weight-bearing and mobilization, there was a standardized peri- and postoperative protocol was identical in all cases, including single-shot antibiotics (Cefuroxime 1.5 g i.v. directly pre-operatively), Indomethacin 75 mg twice daily for the prevention of heterotopic ossification on day one to four post-operatively, and 40 mg low-molecular-weight heparin or Rivaroxaban 10 mg for 28 days post-operatively as venous thromboembolic event prophylaxis and the same pain control regimen.

In the case of suspected or apparent intraoperative PFF, fluoroscopy was draped and utilized. Fractures of the greater trochanter were treated either nonoperatively or with a cerclage wire, depending on the stability of the fracture and stem. Each patient was mobilized with touch weight-bearing for 6 weeks. Postoperatively detected fractures of the greater trochanter were treated conservatively with touch weight-bearing for 6 weeks. In case of intraoperative fractures of the calcar, medial, or lateral cortex, a reduction around the implanted stem using cerclage wires was performed. In the case of primary stability, the hip stem was kept in situ. Patients were mobilized with touch weight-bearing for 4 weeks. If primary stability was not achieved with the short stem in situ, a cementless straight stem or a cementless monoblock revision straight stem was used. If primary stability was not achieved with the straight stem in situ, a cementless monoblock revision straight stem or a modular revision stem was used. In the case of stem revision, patients were mobilized with touch weightbearing for 4 weeks. In the case of intraoperative or postoperative PFF, patients received a clinical and radiological follow-up prior to permission of full weight-bearing. [5]

Implants

As a cementless short stem, Fitmore® hip stem (ZimmerBiomet, Warsaw, IN, USA) was used. Fitmore® hip stem is a titanium alloy stem (Ti Al6V4) that has a porolock Ti-VPS coating in the proximal part to enhance bone ingrowth and is available in four different neck angle options (127°, 129°, 137°, 140°) with stem lengths ranging from 84 up to 135 mm. The stem has a triple-tapered design to achieve press-fit fixation at the metaphyseal/diaphyseal level [23]. The reported survival rate ranges from 99.2% (95%-CI 94.1–99.9%) at 5 years of follow-up with endpoint defined as stem revision [24], up to a survival rate after 8.6 years with 99.6% (95%-CI 97.1–99.9%) with stem revision due to aseptic loosening defined as the endpoint [23]. A cementless titanium press-fit cup with or without screws (Allofit®/-S, ZimmerBiomet, Warsaw, IN, USA) or two types of cementless threaded cups (Alloclassic CSF®/ Alloclassic Variall®, both ZimmerBiomet, Warsaw, IN, USA) were used. As a cementless straight stem, a Zweymüller straight stem in two variations was used (Alloclassic SL/SLO; Alloclassic SLV; both ZimmerBiomet, Warsaw, IN, USA). The Alloclassic SL/SLO® stem is manufactured from a Ti–6A1–7Nb alloy, has a rectangular cross-section with a conical form in both the sagittal and horizontal planes [25]. The stem achieves a press-fit fixation at the metaphyseal-diaphyseal junction and proximal diaphyseal [26]. The Alloclassic SLV® is a modified version of the Alloclassic Zweymüller system, that has an additional surface macrostructure with grooves at the proximal part of the stem to increase the intertrochanteric initial press-fit [27]. Stem lengths range from 110 to 168 mm available in 12 different sizes [28]. A cementless titanium press-fit cup with or without screws (Allofit®/-S/IT, ZimmerBiomet, Warsaw, IN, USA) or two types of cementless threaded cups (Alloclassic CSF®/ Alloclassic Variall®, both ZimmerBiomet, Warsaw, IN, USA) were used. The survival rate for the Zweymüller type Alloclassic® stem is reported with 8548% at a 30-year follow-up with the endpoint defined by revision for any reason [29]. Both presented stems can be considered as broach-only stems.

Radiographic measurements

The preoperative Dorr type was evaluated according to the classification by Dorr et al. [30]. In all cases of PFFs the type of fracture, detection, cause of fracture, treatment and revision were recorded. The type of fracture was recorded by localization of the fracture and by classification according to the Vancouver classification for intra- and postoperative PFFs [31,32,33] (see Appendix).

The measurements of the morphological parameters of the proximal femur and pelvis were measured on digital low-centered AP radiographs of the pelvis using mediCAD® version 5.1 (Hectec GmbH, Altdorf, Germany). Radiographs were taken with the patient in standing position and with both legs in 15° internal rotation and the central beam was directed on the symphysis pubis with a film focus distance of 1.15 m. The magnification error was corrected with a 25 mm radiopaque ball as the templating reference at the level of the hip between the legs or within the field of view. Proximal femoral geometry was analyzed using previously described radiographic parameters (see Fig. 2) [16, 17]. The parameters for analyzing the morphology of the proximal femur include the canal-flare index (CFI) [34], the canal-calcar ratio (CCR) [35], canal-bone ratio (CBR) [36], the morphological cortical index (MCI) [37] and the femoral cortical index (CI) [30]. Additionally, the Metaphyseal Morphologic Index according to Alpaugh et al. [38] was measured at three different levels: + 2 cm above the Mid-Lesser Trochanter (MMI (+ 2 cm)), at the level of the Mid-Lesser Trochanter (MMI (LT)) and −2 cm below the Mid-Lesser Trochanter (MMI (−2 cm)) (see Fig. 3). The lateral views of the hips were assessed for two radiological parameters: the Lateral Metaphyseal canal-bone ratio at two centimeters distal the level of the Mid-Lesser Trochanter (LCBR (2 cm)) and ten centimeters distal the level of the Mid-Lesser Trochanter (LCBR (10 cm)) (see Fig. 4) [38].For analysis of the pelvis the ilium-ischial ratio (IIR) [16] and the distance from the anterior superior iliac spine (ASIS) of the tip of the greater trochanter (AGT) [16] were measured (see Fig. 5). The measurements of the parameters are described in detail in Table 1 [17, 39]. All measurements were conducted by two observers (S.F., C.S.). Intraobserver and interobserver correlation coefficients (ICC) were obtained with excellent agreements (ICC 0.754–0.976).

Fig. 2
figure 2

Schematic measurements of the parameters of the proximal femur: Canal Flare Index (CFI) = A/E; Canal-calcar ratio (CCR) = E/C; Canal-bone ratio (CBR) = E/F; Morphological cortical index (MCI) = B/D; Femoral Cortical Index (CI) = (F-E)/F

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Fig. 3
figure 3

Additional schematic measurements of the Metaphyseal Morphologic Indicis: Metaphyseal Morphologic Index + 2 cm above Mid-Lesser Trochanter (MMI (+ 2 cm)) = Ratio between the inner and outer cortical width 20 mm above the lesser trochanter at G; Metaphyseal Morphologic Index Mid-Lesser Trochanter MMI (LT) = Ratio between the inner and outer cortical width at the level of the lesser trochanter at H; Metaphyseal Morphologic Index -2 cm below Mid-Lesser Trochanter = Ratio between the inner and outer cortical width 20 mm beneath the lesser trochanter at I

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Fig. 4
figure 4

Schematic measurements of the parameters of the proximal femur in lateral view: Lateral Metaphyseal Canal-bone ratio 20 mm beneath the lesser trochanter (LCBR (2 cm)) = J/K; Lateral Metaphyseal Canal-bone ratio 100 mm beneath the lesser trochanter (LCBR (10 cm)) = L/M

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Fig. 5
figure 5

Pelvic morphological parameters on an antero-posterior pelvic radiograph: Ilium-ischial ratio (IIR) = A/B; distance anterior superior iliac spine to the tip of the greater trochanter (AGT)

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Table 1 Radiographic Measurements
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Data analyses

Descriptive analyses were performed for patient demographics. Shapiro–Wilk tests for normality were performed to determine whether continuous data were normally distributed. As the variables were not normally distributed, a Fisher’s Exact test was used for categorial variables and a Mann–Whitney U-Test was performed for comparison of continuous data. Because of statistically significant differences in the patient demographics, propensity score matchings were performed for gender, indication for surgery, side, American Society of Anesthesiologists (ASA) Score, surgical experience of the surgeon, age at operation, Body Mass Index (BMI), height, weight and the Dorr Classification. A 2:1 propensity score matching using the caliper technique with a caliper set at 0.2 was performed to create a 2:1 distribution of straight stem THA and short stem THA.

Propensity score matching

In total, 4515 THAs met the inclusion criteria. In 1826 THAs a cementless short stem THA was implanted, while in 2689 THAs a cementless straight stem was implanted. All cases were screened for the occurrence of PFFs. In the study period 136 PFFs were detected, with 97 cases (3.6%) in straight stem THA and 39 cases (2.1%) in short stem THA. Two cases had to be excluded due to poor quality of the x-rays with insufficient measurements. Before the propensity score matching both groups differed in the ASA scores (p = 0.030) and the surgical experience of the surgeons (p = 0.005) (see Table 2). After propensity score matching both groups did not differ regarding the baseline parameters (see Table 2). In the straight stem group 67 THAs were included and in the short stem group 37 patients have been included. The pre- and postoperative patient demographics of both groups are presented in Table 2.

Table 2 Patient demographics for fracture groups for straight stem and short stem total hip arthroplasty before and after matching
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Results

The occurrence of PFFs for intra- and postoperative occurrence did not differ between both stem groups before and after matching (p = 0.171; p = 0.132, respectively), see Table 3. The occurrence of intraoperative Vancouver A PFFs was significantly different before matching (p = 0.035), see Table 3. As a possible consequence of reduced sample size due to the propensity score matching, the rate of intraoperative Vancouver A PFFs was still increased for the straight stem group approaching almost statistical significance (p = 0.056) after the matching, see Table 3. The rate of postoperative Vancouver A fractures weas significantly higher for the straight stem group before and after matching (p < 0.001; p = 0.001; respectively), see Table 3. Vancouver B PFFs were significantly increased in the short stem group before and after matching (p < 0.001; p < 0.001; respectively), see Table 3. The rates of revision were also significantly higher in the short stem group before and after matching (p < 0.001; p < 0.001; respectively), see Table 3. Figure 6 illustrates a typical Vancouver B2 fracture in short stem THA and a typical Vancouver Ag fracture in straight stem THA.

Table 3 Type of fractures, intra- or postoperative occurrence and distribution according to the Vancouver Classification for pre-matched and post-matched cohort
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Fig. 6
figure 6

Illustrative cases for postoperatively detected periprosthetic femoral fractures: Vancouver B2 fracture in short stem total hip arthroplasty (A); Vancouver Ag fracture in straight stem total hip arthroplasty (B)

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All femoral parameters did not show any statistical significance between both groups, see. Table 4. The pelvic geometry did only differ significantly in the AGT between both groups (p = 0.024), see Table 4. The separate analysis of both stem groups depending on the Vancouver classification did not show any differences for Vancouver A and Vancouver B PFFs for both stem types, see Table 5. The separate analysis depending on the Dorr classification is shown in detail in Table 6. In Dorr B type both groups differed significantly in the AGT (p = 0.030), see Table 6. In Dorr C type both groups differed significantly in the Canal-bone ratio (p = 0.030) and the Cortical Index (p = 0.040), see Table 6.

Table 4 Pelvic and femoral morphological parameters between both stem types
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Table 5 Distribution of Dorr classification, pelvic and femoral morphological parameters between both stem types by Vancouver Type A and B
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Table 6 Pelvic and femoral morphological parameters between both stem types by Dorr type A, B and C
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Discussion

In the current study, differences in the geometry of the proximal femur and pelvis in cases of PFFs in cementless short stem and straight stem THA were analyzed. The results do not show significant differences in the morphology of the proximal femur and pelvis, which were also analyzed in subgroups for Vancouver A and B PFFs, as well as for the various Dorr types.

Studies investigating the differences of the proximal femur and the pelvic geometry have been recently published for cementless short stem and cementless straight stem THA [16,17,18]. McGoldrick et al. [16] published data on short stem THA with a Type 4 short stem according to Khanuja et al. [40] implanted via a DAA. In the fracture group a significantly higher CFI with 3.69 compared to 2.93 in the non-fracture was found (p < 0.001) [16]. The risk for PFFs was 29 times higher in patients with a CFI > 3.17 [16]. Griffiths et al. [18] report opposing data in cementless THA via a DAA. A lower CFI was predictive for an early PFF with a mean CFI of 2.75 in the fracture group compared to 3.2 in the control group [18]. Similarly, Bigart et al.[17] also report a significantly lower CFI of 3.05 in the fracture group compared to 3.28 in a matched control group in cementless straight stem THA. The results by Bigart et al. [17] and Griffiths et al. [18] show an increased risk of PFFs in cementless straight stem THA in patients with thinner distal cortices and a decreased meta-diaphyseal taper. However, both studies [16, 18] mainly include Vancouver B1 or Vancouver B2 PFFs, while McGoldrick et al. [16] included alsoVancouver A PFFs. The results in the presented study do not show any differences in the measured parameters of the proximal femur between both groups with short stem PFFs and straight stem PFFs. Both groups showed a similar CFI of 3.2 and 3.31. The short stem examined in the presented study can be also be classified as a type 4 short stem according to Khanuja et al. [40] similarly to the short stem examined by McGoldrick et al. [16]. One possible explanation between both short stems might be explained by the approach, as a MIS anterolateral approach was used in the presented study compared to the DAA used by McGoldrick et al. [16]. McGoldrick explain the increased risk of PFFs in patients with a high CFI by a possible metaphyseal-diaphyseal mismatch [16]. This might be related to the early engagement of the femoral short stem in the femoral canal resulting in an implant undersized relative to the metapyhsis [16]. The reduced susceptibility of the short stem to this phenomenon aligns with subgroup analysis of proximal femur parameters. When analyzed for differences between both stem types in Vancouver A and B PFFs there was no significant difference between both stem types. However, the short stem group showed a CFI of 3.21 and 3.37 in Vancouver A and B PFFs respectively, while the straight stem group showed a CFI of 2.97 in Vancouver B PFFs. This may indicate that a higher CFI plays a role in PFFs in short stem THA with a short stem, but it still depends on the geometry of the short stem that is used and the approach that is performed.

Interestingly, the straight stem group in the presented study also shows higher values of the CFI in case of PFFs. Bigart et al. [17] and Griffiths et al. [18] report lower CFI for patients with a PFF in cementless straight stem THA. However, both studies [16, 18] report mainly on Vancouver B PFFs, while in the presented study mainly Vancouver A PFFs occurred in the straight stem group. This might be indicated by the lower CFI of 2.97 in the subgroup of Vancouver B PFFs in the straight stem group in the presented study, while the CFI was higher with a mean value of 3.29 in Vancouver A PFFs. All other femoral parameters in the straight stem group showed almost similar mean values in the current study when compared to the values reported by Bigart et al. [17]. The findings in the present study indicate that a higher CFI plays a role in cementless short stem THA in Vancouver A and B PFFs and in straight stem THA in Vancouver A PFFs, while a lower CFI is seen in Vancouver B PFFs.

Additionally, the geometry of the pelvis might attribute to an increased risk of PFFs [16]. McGoldrick et al. [16] report a higher IIR as well as a lower AGT in patients sustaining a PFF in short stem THA. In the presented study the AGT was significantly lower in the straight stem group, while the IIR shows no significant difference between both stem types. McGoldrick et al. [16] associated a significantly increased risk with an IIR > 3. In several subgroups an IIR > 3 was found for both stem types. Vanouver B PFFs showed an IIR > 3 in both stem types, as well as PFFs in proximal femurs with a Dorr A type. While a higher IIR may suggest an association with PFFs, no significant differences were observed between the stem types. Still, the AGT is the only significantly different parameter regarding the pelvis between stem types. A lower distance between the ASIS and the greater trochanter might play a role in straight stem THA due to the increased length and the geometry of a straight stem component.

The results in our study show a difference regarding the fracture types between both stem types. Intraoperative Vancouver A PFFs as well as postoperatively detected Vancouver A PFFs were higher in the straight stem group, however only with statistical significance for postoperative Vancouver A PFFs after matching. Nevertheless, the intraoperatively detected Vancouver A PFFs showed a rate two times higher than to the short stem group, which was significant before matching and almost approached significance after matching. In contrast the short stem group showed a significantly higher rate of postoperative Vancouver B fractures. The higher revision rate in the short stem group might be associated with a higher rate of stem revision due to the fracture type of Vancouver B2 fractures. The higher rate of Vancouver A PFFs in the straight stem group were mainly treated conservatively resulting in a lower revision rate in this group. The results in the presented study show coherent data compared to already published data of a similar cohort [5]. The same institutional database was retrospectively analyzed for PFFs until 2019 and showed a rate of PFFs of 3.2% in the straight stem group and 1.7% in the short stem group with a similar distribution of PFFs according to the Vancouver classification [5]. The cohort in the presented study was updated with the cases until the end of 2021 to ensure a higher cohort size. The results in the presented study show a similar rate of PFFs with 3.6% in straight stem THA and 2.1% in short stem THA, however in a pre-matched cohort and still with a lower rate of PFFs in the short stem group. This lower rate of PFFs might be attributed to the easier insertion in the broaching procedure due to their reduced length [16]. Dietrich et al. [4] report a lower rate of PFFs when using short stem compared to standard straight stem in cementless THA with a DAA (1.6% vs 6.8%). Similarly, Molli et al. [41] report a lower rate of intraoperative PFFs by using a shortened femoral stem in cementless THA via a DAA.

Limitations of the study consist of the retrospective collective and study design, which may lead to a selection bias. However, both stem types were used over a long period of time resulting in a high number of performed cases in both groups. In the study group, cemented THA was rarely performed for a primary THA. Major limitation consists of the two different approaches used in both groups. Also, the high number of surgeons included in the study presents a major limitation. Additionally, after the learning curve the short stem was used irrespective of patients age, gender or indication and became the standard implant for primary THA at the authors’ institution. Both groups differed between the patient demographics, which was addressed by a propensity score matching due to several known risk factors for PFFs. The mobilization differed between both groups, which might be a limitation as well. Furthermore, the measurements were conducted on anterior–posterior radiographs. Computed tomography (CT) might provide a higher quality in imaging and would also report a higher number of occult early PFFs that might be undetected on standard x-rays. However, CT imaging would result in a significantly increased exposure to radiation for the patient. Additionally, the study methods are well described in the literature and were used in comparable studies giving it sufficient comparability to other studies. The measurements on plain radiographs are easy to perform and pose the possibility to repeat the study design also for other stem types or approaches.

Conclusion

The morphology of the proximal femur and the pelvis do not differ in several radiological parameters in patients sustaining a PFF between cementless short stem implanted via an anterolateral approach and straight stem THA implanted via a transgluteal approach. While there are differences in the Vancouver types of PFFs, these differences do not reflect in any difference in the morphology of the proximal femur and the pelvis.

Availability of data and materials

Data and materials are available on request.

Abbreviations

AGT:

The distance from the anterior superior iliac spine of the tip of the greater trochanter

ASA:

American society of anesthesiologists

ASIS:

Anterior superior iliac spine

BMI:

Body mass index

CBR:

Canal-bone ratio

CCR:

Canal-calcar ratio

CI:

Femoral cortical index

CFI:

Canal-flare index

DAA:

Direct anterior approach

IIR:

Ilium-ischial ratio

LCBR (2 cm):

Lateral metaphyseal canal-bone ratio at two centimeters distal the level of the mid-lesser trochanter

LCBR (10 cm):

Lateral metaphyseal canal-bone ratio ten centimeters distal the level of the mid-lesser trochanter

MCI:

Morphological cortical index (MCI)

MIS:

Minimally-invasive

MMI (+ 2 cm):

 + 2Cm mid-lesser trochanter

MMI (LT):

At the level of the mid-lesser trochanter

MMI (−2 cm):

−2 Cm below the mid-lesser trochanter

OA:

Osteoarthritis

PFF:

Periprosthetic femoral fracture

THA:

Total hip arthroplasty

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Acknowledgements

Supported by Johannes Kepler Open Access Publishing Fund and the federal state Upper Austria.

Funding

The study was conducted without any funding or benefits from a commercial party.

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Authors and Affiliations

  1. Department for Orthopedics and Traumatology, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020, Linz, Austria

    Matthias Luger, Sandra Feldler, Manuel Gahleitner, Lorenz Pisecky, Tobias Gotterbarm & Christian Stadler

  2. Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria

    Matthias Luger, Sandra Feldler, Manuel Gahleitner, Lorenz Pisecky, Tobias Gotterbarm & Christian Stadler

  3. Kepler University Hospital Linz, Krankenhausstrasse 9, 4020, Linz, Austria

    Matthias Luger

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Contributions

M. Luger: Wrote the manuscript, performed the statistical analysis, designed the study, acquisition of data, interpretation of the data. S. Feldler: Performed radiographic measurements, revised and edited the manuscript M. Gahleitner: Interpretation of the data, revised and edited the manuscript. L. Pisecky: Interpretation of the data, revised and edited the manuscript. T. Gotterbarm: Jointly conceived the study, interpretation of the data, revised and edited the manuscript. C. Stadler: Performed radiographic measurements, interpretation of the data, revised and edited the manuscript.

Corresponding author

Correspondence to Matthias Luger.

Ethics declarations

Ethical approval

This study received ethical approval from the local institutional review board (No.: 1275/2022) of the “Ethikkommission OÖ” of the Johannes Kepler University Linz (JKU Linz).

Consent to participate

Because of the retrospective anonymized evaluation of pre-existing medical records, an informed consent was not required. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent for publication

Consent for publication was given by the all authors.

Informed consent

Informed consent was obtained from every participant prior to inclusion in the study. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained by all participating patients.

Competing interest

We report personal fees paid to one co-author (T.G.) during the conduct of the study from Zimmer Biomet, Europe and from Depuy Synthes Orthopädie Gmbh, Peter Brehm GmbH, ImplanTec GmbH outside the submitted work. We report research grants paid to our institution during the conduct of the study from Zimmer Biomet, Europe, Mathys AG Switzerland, Anika Therapeutics outside the submitted work.

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Luger, M., Feldler, S., Gahleitner, M. et al. Periprosthetic femoral fractures in minimally-invasive anterolateral short stem versus transgluteal straight stem cementless total hip arthroplasty: What are the differences in the femoral and pelvic morphology?. J Orthop Surg Res 20, 110 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13018-025-05502-y

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Keywords

Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X