Stulberg v. Dorr: The Short Stem: Proven Solution for ALL Primary Hips
OTW Staff • Tue, February 6th, 2018
This week’s Orthopaedic Crossfire® debate was part of the 33rd Annual Current Concepts in Joint Replacement® (CCJR®) - Winter meeting, which took place in Orlando. This week’s topic is “The Short Stem: Proven Solution for ALL Primary Hips.” For is S. David Stulberg, M.D., Northwestern University, Chicago, Illinois. Opposing is Lawrence D. Dorr, M.D., Keck Medical Center of USC, Los Angeles, California. Moderating is Clive P. Duncan, M.D., F.R.C.S.(C), University of British Columbia, Vancouver, British Columbia, Canada.
Dr. Stulberg: Let me start by making sure everybody in the audience knows what kind of a deal Seth dealt me in debating Larry. He’s a very accomplished surgeon. Has published well over several hundred articles. Established the Master Series, which was the first real opportunity to see surgeons doing arthroplasties live. One of the founders of AAHKS, the Knee Society and Operation Walk.
I think the obvious question is “The guy that’s this accomplished, why would he oppose something as obvious as a short stem?”
While it’s true that cementless femoral stems, among a number of designs, inserted by surgeons with a variety of experiences, are working well, there are a number of issues. One is bone remodeling around the proximal femur and bone loss around the proximal femur. Another is mismatch which the short stem made what could have been a difficult situation relatively easy.
But this is the real problem, young patients with Dorr Type A bone, very narrow diaphyses and large metaphyses. Of course, the association of cementless stems with periprosthetic fractures is real.
Then there’s the issue of removing stems, while rare, it can happen because of infection and device failure. And perhaps what’s most relevant to the current climate is the use of stems in the direct anterior approach where stem selection is critical to avoid a problem.
For purposes of this discussion we’re talking about really shortened standard stems, which means that the distal portion of stem is tapered and doesn’t engage the diaphysis. These stems are 120mm in length or less. And they get their fixation primarily in the metaphysis.
In general, if you sort of parse through the current literature, what you find is that these stems seem to work in all age groups. These stems work in active, young patients as well as standard stems. And the outcomes when you look at meta-analyses suggest that fixation is not the issue. If there is an issue, it has to do with correctly inserting these devices and getting the right size.