Primary stability of calcar-guided short-stem total hip arthroplasty in the treatment of osteonecrosis of the femoral head: migration analysis using EBRA-FCA

Same same but different: Introduction of a classification system in calcar-guided short-stem total hip arthroplasty

BACKGROUND

The concept of calcar-guided short-stem THA (ssTHA) has largely emerged over the last decade, especially in Europe, and today modern calcar-guided short stems are among the most successful primary femoral implants in terms of complications and revision rates as indicated by multiple registry data. The philosophy originally comprised an individualised reconstruction of the hip anatomy by following the calcar of the femoral neck providing bone- and soft-tissue-sparing characteristics. However, as the stem design allows either metaphyseal fixation alone or additional diaphyseal anchoring, depending on the stem alignment and indication, distinct knowledge is required regarding the implantation technique, the broad variation of positioning and fixation and its potential clinical consequences.

AIM

To report on and highlight the characteristics of different ways of performing calcar-guided ssTHA as well as to introduce a classification in order to systematically account for the variety of strategies and the respective implications on the type of fixation.

SURGICAL TECHNIQUE

Already when templating preoperatively, surgeons need to weigh up the different fixation types taking into account a number of patient-related factors. Intraoperatively, by individually controlling the level of osteotomy, the intended type of anchorage can be implemented. Intraoperative radiography to confirm the result, is mandatory.

RESULTS

Despite numerous options of stem alignment, depending on the patient's anatomy, the bone quality or the indication for operation, a total of 4 categories were identified to characterise different fixation strategies in calcar-guided ssTHA.

CONCLUSIONS

The classification system should be used for the preoperative determination of the intended type of anchorage. Whenever a short-stem philosophy with metaphyseal fixation (Type I (M)) is possible, it should be pursued.

Subsidence and Clinical Impact of Obesity in Short-Stem Total Hip Arthroplasty Using a Collarless, Triple-Tapered, Cementless Stem

Background: Short-stem total hip arthroplasty (THA) has gained popularity due to its bone-sparing technique, but its outcomes in patients with obesity remain uncertain. The aim of this study was to investigate the impact of obesity on postoperative subsidence and clinical outcomes after short-stem THA. Methods: A retrospective cohort study with a minimum follow-up of 24 months was conducted on 163 patients who underwent short-stem THA with a collarless, triple-tapered, cementless stem achieving fixation in the metaphyseal region. Patients were categorized into obesity (Body Mass Index, BMI ≥ 30 kg/m2) and nonobesity (BMI < 30 kg/m2) groups. Subsidence rates, clinical outcomes, and complications were analyzed to assess the influence of BMI on the outcome of short stem THA. Regression analysis was performed to assess the influence of the independent variables (BMI, stem size, deviation from planning) on subsidence. Results: The obesity group (mean follow-up 58.6 months) exhibited significantly greater subsidence rates than did the nonobesity group (mean follow-up 38.9 months; 2.6 mm vs. 2.2 mm, p = 0.015). After removal of outliers, regression analysis revealed no linear relationship between BMI and subsidence (p = 0.35), but planned stem size was significantly correlated with subsidence (p = 0.005). Moreover, patients with obesity and larger planned stem sizes experienced greater subsidence. Clinical outcomes improved significantly in both groups. Conclusions: Obesity is associated with increased subsidence in short-stem THA, particularly in patients with larger planned stem sizes. Although BMI alone may not predict subsidence, careful selection of stem size and precise imaging techniques are crucial for minimizing subsidence risk in patients with obesity.

Calcar-guided short-stem total hip arthroplasty in fractures of the femoral neck: a prospective observational study of 68 hips

INTRODUCTION

The indications for cementless short-stem total hip arthroplasty (THA) have been expanded due to encouraging results. However, no evidence in cases of femoral neck fractures (FNFs) is available. We aimed to prospectively obtain data on the safety and the clinical outcomes of a cementless calcar-guided short stem in patients with FNFs.

MATERIALS AND METHODS

We conducted a prospective observational study of 68 patients diagnosed with FNFs who underwent short-stem THA between 2016 and 2019 with a calcar-guided stem. Complications during follow-up leading to revision were documented, and patient reported outcome measurements recorded. Stem migration was analyzed using the Einzel-Bild-Röntgen-Analysis Femoral Component Analysis software.

RESULTS

The mean follow-up was 33.8 ± 14.8 months. The patient mortality at last follow-up was 10.6%. Two patients required stem revision, due to periprosthetic fracture and late aseptic loosening, respectively, corresponding to 96.2% stem survival. Survivorship for the endpoint of revision for any reason was 91.1% at 6 years. All revisions occurred in females. The mean Harris Hip Score at the last follow-up was 93.0 ± 8.9. The mean axial migration at last follow-up was 1.90 ± 1.81 mm. No significant influence on migration was found regarding gender, age, weight, and body mass index.

CONCLUSIONS

The clinical and radiological findings were satisfying and most patients benefited from the minimally invasive procedure. However, as for conventional THA as well, implant survivorship and mortality were markedly worse compared to results regarding osteoarthritis. Especially in elderly female patients with FNF, cementless short-stem THA is a concern and a cemented THA should be the first choice.

Short stem hip arthroplasty with the optimys prosthesis is a safe and effective option for obese patients: a mid-term follow-up multicenter study

INTRODUCTION

Short stems are a valuable option in young patients undergoing total hip arthroplasty (THA) because of their bone stock preserving properties facilitating revision hip arthroplasty. Although the effect of obesity on conventional THA is well studied, data about short stem THA in obese patients are lacking. Therefore, this study aimed to investigate the influence of obesity on complications, revisions, and outcome after short stem THA.

MATERIALS AND METHODS

This multicenter, observational cohort study included patients undergoing short stem THA with the optimys prosthesis. Follow-up examinations were performed at specific intervals up to 7 years postoperatively. Operation characteristics, general and specific complications, revisions, VAS rest pain, VAS load pain, VAS patient satisfaction, and Harris Hip Score (HHS) were recorded and statistically compared between obese (BMI ≥ 30 kg/m2) and non-obese (BMI < 30 kg/m2) patients.

RESULTS

Of the 224 patients included with a mean follow-up of 87.2 months (range 81.9-104.0), 69 were assigned to the OB group and 155 to the non-OB group. A minimally invasive approach was significantly less often selected in obese patients (p = 0.049), whereas operating time and length of hospital stay were not significantly different. The rate of general and specific complications did not significantly differ between both groups. Survival of the optimys prosthesis was 99.1% at 7-year follow-up and one patient per group had to undergo revision surgery. VAS rest pain, load pain, and satisfaction improved from preoperatively to postoperatively in both groups without a significant difference between both groups. While the HHS was improved from preoperatively to postoperatively, obese patients showed a significantly lower HHS at the 7-year follow-up (p = 0.01) but still exhibited an excellent scoring above the PASS threshold.

CONCLUSION

Short stem THA with the optimys prosthesis is a safe and effective option also in obese patients with an excellent clinical outcome and a low complication rate.

An isoelastic monoblock cup versus a modular metal-back cup: a matched-pair analysis of clinical and radiological results using Einzel-Bild-Röntgen-Analyse software

INTRODUCTION

Bone preservation and long-term survival are the main challenges in cementless total hip arthroplasty (THA). A good bone stock is especially important for adequate anchorage of the cup in revision cases. However, the optimal acetabular cup design for preserving good bone stock is still unclear. We aimed to compare clinical outcome, radiological alterations, migration, and wear at mid-term for two different cup types.

MATERIALS AND METHODS

This retrospective matched-pair study was performed using the data for 98 THA cases treated with a monoblock cup composed of vitamin E-blended highly cross-linked polyethylene (VEPE; monoblock group) or a modular cup composed of a highly cross-linked polyethylene (HXLPE) without an antioxidant (modular group). Clinical results were evaluated using the Harris Hip Score (HHS). The obtained radiographs were analyzed for radiological alterations, migration, and wear using Einzel-Bild-Röntgen-Analyse (EBRA) software.

RESULTS

The mean follow-up duration was 73.2 ± 19.2 months (range: 32-108 months) and 60.5 ± 12.2 months (range: 20-84 months) in the monoblock and modular groups, respectively. HHS improved to 95.7 points in the monoblock group and 97.6 points in the modular group, without significant differences (p = 0.425). EBRA measurements were obtained in all cases. Acetabular bone alterations were not detected on radiological assessments. Mean cup migration was 1.67 ± 0.92 mm (range: 0.46-3.94 mm) and 1.24 ± 0.87 mm (range: 0.22-3.62 mm) in the monoblock and modular groups. The mean wear rate was 0.21 ± 0.18 mm (range: 0.00-0.70 mm) and 0.20 ± 0.13 mm (range: 0.00-0.50 mm) in the monoblock and modular groups. Both migration and wear pattern showed no significant differences (p = 0.741 and 0.243). None of the cases required revision surgery, yielding an implant survival rate of 100% in both groups.

CONCLUSION

The isoelastic press-fit monoblock VEPE cup and modular metal-back HXLPE cup showed equivalent mid-term wear and cup migration. Long-term studies are required to determine the effects of modularity, isoelasticity, and polyethylene stabilization with vitamin E on cup loosening and survival rates.

Subsidence analysis of a cementless short stem THA using EBRA-FCA - A seven-year prospective multicentre study

Background

Metaphyseal fixation of short stem THA allows for minimally invasive surgery, less bone removal, improved bone load transfer and reduced stress shielding. Short stems facilitate the anatomic restoration i.a. of leg length, femoroacetabular offset, and center of rotation. However, metaphyseal fixation might cause impaired primary and/or secondary stability resulting in an inherent tendency for early axial migration and aseptic loosening eventually. The objective of this study was to investigate the long-term outcome and migration pattern of a calcar-guided short stem.

Methods

In a prospective multicenter study, 213 patients (224 THAs) were enrolled. Patients were followed for up to 84 months postoperatively. Clinical outcome was assessed using the Harris Hip Score and the VAS for pain and satisfaction. Standardized and calibrated radiographs were screened i.a. for stress shielding and loosening. Einzel-Bild-Roentgen-Analyse - femoral component analysis (EBRA-FCA) was used to detect longitudinal subsidence.

Results

At 7 year follow-up, n = 139/224 cases were available for analysis. All clinical parameters improved significantly (p < 0.001) and improvement persisted. There were no radiographic changes indicating stress shielding. EBRA-FCA revealed a mean subsidence of -1.44 mm followed by a stabilization. Weight >80 kg (p = 0.115), BMI <30 kg/m2 (p = 0.282), male gender (p = 0.246), and age <65 years (p = 0.304) seemed to be associated with a higher risk for migration. The cumulative revision rate was 2.23%. Revisions due to stem migration (0.89%) occurred early (mean time between index surgery and revision: 3.3 months).

Conclusions

If at all, there appears to be a pronounced initial subsidence, which stabilizes thereafter. Stem migration was rarely a compelling reason for failure or revision. Demographics do not seem to have a significant effect on migration pattern. The absence of radioluce lines, resorption or hypertrophy of the proximal femora support the hypothesis of a reduced stress shielding for metaphyseal anchoring short stems.

Cementless Short Stems in Total Hip Arthroplasty: Chances and Limits

In recent decades, a large number of cementless short stems have been introduced to the market. The concept aims at saving soft tissue using minimally invasive surgery and at the same time preserving as much bone as possible. In particular, the latest generation of short stems, which are implanted using a calcar-guided round-the-corner technique, are attracting increasing attention. An individualised resection level allows individual stem alignment and thus an ideal reconstruction of the hip anatomy. The early clinical results of short-stem total hip arthroplasty (THA) are promising and have led to an expansion of the indications and limitations for the use of short stems. In particular, the individual positioning in valgus or varus and the resulting individual metaphyseal or metadiaphyseal anchorage offers various possibilities to reconstruct even abnormal joint morphologies. Consequently, short stems are increasingly used in patients with complex anatomical variations or in cases of osteonecrosis of the femoral head. In some various cases, they can also be used in revision or conversion arthroplasty. In some patients, short stems can also be used after femoral neck fracture. Currently, scientific data on those areas of indication of short-stem THA is scarce.

The short-term outcomes of cementless stem for hip arthroplasty in the elderly patients: comparison with patients < 65 years

OBJECTIVE

The use of cement or cementless femoral stem prosthesis for hip arthroplasty in elderly patients has been controversial. This study investigated the efficacy and safety of cementless femoral stem in elderly patients (age ≥ 65 years).

METHODS

The short-term efficacy of primary hip arthroplasty with cementless femoral stem in our hospital from January 2014 to June 2021 was retrospectively analyzed. Patients were divided into two groups according to age: young group (< 65 years) and the elder group (≥ 65 years). The evaluation index was the Harris Hip score (Harris), postoperative femoral stem prosthesis sinking distance and femoral plant-related complications (periprosthetic fracture, prosthesis loosening, infection, dislocation, etc.).

RESULTS

There were 72 cases of 86 hips in the young group and 83 cases of 92 hips in the elder group. The recovery trend of functional score in the elder group was similar to that in the young group, and the Harris score increased from (38.35 ± 18.21) before surgery to (86.91 ± 12.55) at last follow-up (p < 0.01). Compared with the two groups at the same time of 3 months, 6 months and 12 months after operation, the sinking distance of the elder group was significantly greater (P < 0.05). Even in the elder group, there was a significant difference in sinking distance between 6 and 3 months after surgery (2.44 ± 0.49 mm vs 2.10 ± 0.65 mm, P = 0.004). However, there was no significant difference between 12 and 6 months (2.53 ± 0.53 mm vs 2.44 ± 0.49 mm, P = 0.40). A total of 10 patients in the elder group and 6 patients in the young group had a complication event (P = 0.36).

CONCLUSIONS

Elderly patients with cementless femoral stems can achieve metal-bone integration slightly longer than young patients, but short-term clinical outcomes can be restored to a satisfactory level with adequate safety. However, the long-term efficacy still needs to be verified by multicenter, large sample size and prospective clinical follow-up results.

Three-year migration analysis of a new metaphyseal anchoring short femoral stem in THA using EBRA-FCA

Cementless calcar-guided femoral short stems in total hip arthroplasty (THA) have become increasingly popular over the years. Early distal migration of femoral stems measured by Einzel-Bild-Roentgen Analyse, Femoral Component Analyse (EBRA-FCA) has been reported to be a risk factor for aseptic loosening. The aim of this study was to analyse axial migration behavior and subsidence of a new short stem (launched in 2015) over a follow-up period of 3 years. According to the study protocol, 100 hip osteoarthritis patients who consecutively received an unilateral cementless calcar-guided short stem (ANA.NOVA proxy) at a single department were prospectively included in this mid-term follow-up study. Thirteen patients were lost to follow-up, resulting in 87 patients with unilateral THA who fulfilled the criteria for migration analysis with EBRA-FCA. The cohort comprised 41 males (mean age: 60 ± 16.5; mean BMI (Body Mass Index): 30 ± 13) and 46 females (mean age: 61 ± 15.5; mean BMI: 27 ± 10). Seven standardized radiographs per patient were analyzed with EBRA-FCA. An average migration of 2.0 mm (0.95-3.35) was observed within the first 3 years. The median increase during the first year was higher than in the second and third year (1.2 mm [IQR: 0.5-2.15] vs. 0.3 mm [IQR: 0.1-0.6 mm] vs. 0.25 mm [IQR: 0.1-0.5 mm]. Detected migration did not lead to stem loosening, instability, dislocation, or revision surgery in any patient. A higher risk for subsidence was observed in male and heavyweight patients, whereas the female gender was associated with a lower risk. No correlation between migration and revision could be observed. Although moderate subsidence was detectable, the performance of the short stem ANA.NOVA proxy is encouraging. Yet, its use may be re-considered in overweight and male patients due to more pronounced subsidence.

[Short hip stem for THA in avascular necrosis of the femoral head]

INTRODUCTION

Osteonecrosis of the femoral head or avascular necrosis of the femoral head (HKN) is a complex disease that, without treatment, leads to infraction of the femoral head in most cases. In these cases, only replacement of the hip joint will help, although there is no clear recommendation of an arthroplasty type. In the last two decades, the treatment of primary and secondary coxarthrosis with short-shaft prostheses with different anchoring philosophies has increased. Since short-shaft fitting is a possible option especially in younger patients, the question arises about possible fittings of advanced HKN with these stem types, especially with metaphyseal anchorage. The aim of this study was to review the existing literature on the results of short stem prosthesis in HKN and to present the advantages and disadvantages of short stem prosthesis in osteonecrosis of the femoral head.

MATERIAL AND METHODS

This review analyzes the existing studies on short stem arthroplasty for HKN.

RESULTS

Only a few studies exist that have analyzed clinical and radiologic outcomes of short stem replacement in HKN.

CONCLUSION

The existing short- and medium-term results show mostly good outcomes. However, it is difficult to draw a general conclusion due to differences in stem design and fixation. Short stems with primary diaphyseal fixation do not show an increased risk of failed osseointegration or loosening. Constructions with primary metaphyseal fixation should undergo MRI to rule out the possibility of necrosis extending beyond the femoral neck.

Conversion of failed internal fixation in proximal femur fractures using calcar-guided short-stem total hip arthroplasty

PURPOSE

Reoperations for secondary osteoarthritis, osteonecrosis, or hardware failure following failed internal fixation after intertrochanteric fracture (ITF) or femoral neck fracture (FNF) are common. An effective salvage treatment often involves complete removal of the hardware followed by total hip arthroplasty (THA). Almost no data are available regarding conversion to short-stem THA. This study aimed to evaluate clinical and radiological outcomes, potential complications, and the survival rate of short-stem THA following revision surgery.

METHODS

We investigated 27 patients who underwent conversion THA using a calcar-guided short stem. Patient-reported outcome measurements were obtained, including the Harris hip score, the Western Ontario and McMaster Universities Osteoarthritis Index, as well as pain and satisfaction on the visual analogue scale. Radiological follow-up was also performed.

RESULTS

We identified 18 (66.7%) patients diagnosed with FNF and 9 (33.3%) patients with ITF. Clinical and radiological outcomes were satisfactory at the last follow-up (30.56 ± 11.62 months). One patient required early revision surgery due to dislocation and greater trochanter fracture. At the last follow-up, none of the short stems required revision. No other major complications occurred.

CONCLUSION

Given the low rate of complications and 100% survival, our findings indicate that short stems for conversion THA due to failed internal fixation may be considered an option in a properly selected patient population. However, it should not be considered a standard procedure and should only be performed by experienced surgeons.

Uncemented total hip arthroplasty using alumina ceramic bearings at a minimum of 14 years of follow-up

INTRODUCTION

The effectiveness of modern ceramic bearings has been well established in reducing the osteolysis associated with wear of the bearing surfaces in total hip arthroplasty (THA). However, there are limited mid- to long-term follow-up data for complications associated with ceramic bearings.

MATERIALS AND METHODS

This case series analyzed 124 consecutive primary uncemented THAs in 108 patients with a mean age of 61 years using alumina ceramic-on-alumina ceramic bearing couples. Seventy THAs (56%) were evaluated at a minimum 14 years of follow-up; the mean follow-up period was 16 ± 1 years (14-20 years). Kaplan-Meier survivorship was determined with revision surgery for any reason as the end point. Complications were recorded focusing on osteolysis, ceramic fracture, and abnormal sounds until the final follow-up. Clinical data were scored according to the Merle d'Aubigne and Postel hip score at 14 years after THA.

RESULTS

The survivorship was 93.5% (95% CI 86.7-97.0%) at 14-years postoperatively. Five patients (4.0%) underwent revision surgery due to instability or infection before 1-year postoperatively. Two patients (1.6%) underwent revision surgery due to ceramic liner fracture at 9- and 12-years postoperatively, respectively. There was no radiographic evidence of osteolysis. A total of 27 complications occurred: dislocations (n = 7/124), squeaking sounds (n = 3/124), clicking sounds (n = 6/124), ceramic liner fractures (n = 2/124), periprosthetic fractures (n = 4/124), deep infections (n = 2/124), transient sciatic nerve palsy (n = 2/124), and femoral stem breakage (n = 1/124). The Merle d'Aubigne and Postel hip score was 16.8 ± 1.4 points.

CONCLUSIONS

The survivorship analysis demonstrates the uncemented THA using alumina ceramic bearings may provide favorable clinical outcome and can offer minimal wear at a minimum 14-year follow-up. Revision surgery was mostly required due to instability and infection in the short-term, and implant breakage in the mid- to long-term.

A neck-preserving short stem better reconstructs the centre of rotation than straight stems: a computed tomography-based cadaver study

INTRODUCTION

Short femoral hip stems with a metaphyseal anchoring concept have been designed to treat younger patients with good bone quality. The aim of this study was to reconstruct the centre of rotation and soft tissue balancing and preserve bone in the long-term perspective.

MATERIALS AND METHODS

Eighteen human femurs were randomised into three groups: (1) metaphyseal anchoring short stem, (2) shortened straight stem, (3) straight stem). Prior to the implantation of the hip stems, a computed tomography (CT) of the bones was performed and the femoral ante-torsion and ante-tilt was measured and compared to the results of the post-implantation CT. This could be calculated based on the 3D coordinates taken from the pre- and post-op CT scans, which were transformed into the same coordinate systems.

RESULTS

The mean preoperative caput-collum-diaphyseal (CCD) angle for the three groups was 126.87° ± 3.50° (Group 3: 129.64° ± 3.53°, Group 1: 123.76° ± 5.56°, Group 2: 127.53° ± 1.42°) and was consistent with published reports. The postoperative CCD angles with 126.85° ± 3.43° were within a very good reconstruction range for all three groups. The anterior offset comparison among these three groups showed significant difference in reconstruction. The smallest difference between the anatomical (preoperative) and postoperative condition was seen in Group 1 (1.47° ± 0.60°), followed by Group 2 (3.60° ± 0.23°) and Group 3 (8.00° ± 0.70°) groups. The horizontal offset showed no significant difference among the groups and was within the window of ± 5 mm.

CONCLUSION

In this cadaver study, we found that the metaphyseal anchoring, partially neck-preserving short hip stem best reconstructs the ante-torsion and the ante-tilt of the femoral neck. Therefore, it can be a useful stem in younger or active middle-aged patients.

One-stage bilateral versus unilateral short-stem total hip arthroplasty: A matched-pair analysis of 216 hips

Background

One-stage, bilateral, short-stem total hip arthroplasty (1B-ssTHA) represents an alternative to staged, unilateral, short-stem total hip arthroplasty (U-ssTHA); however, the safety and reliability of 1B-ssTHA remain unknown. The objective of the present study was to compare the functional outcomes, complications, and mortality rates between 1B-ssTHA and U-ssTHA at mid-term.

Methods

A retrospective, matched-pair study was performed, including 216 short stems implanted in 162 patients. Among the study population, 54 patients were treated with 1B-ssTHA. Patients were matched by gender, age, body mass index (BMI), and American Society of Anesthesiologists (ASA) classification. A total of 46 full matches could be accomplished. The mean follow-up time for the 1B-ssTHA group was 61.7 months (standard deviation [SD] 6.2 months), compared with was 63.4 months (SD 8.0 months) for the U-ssTHA group. Mortality, complication, and revision rates were documented. For clinical examinations, the visual analogue scale (VAS) was used to evaluate satisfaction, rest pain, and load pain, and the Harris Hip Score (HHS) was determined.

Results

No surgery-related deaths were observed. At mid-term, none of the 1B-ssTHA patients required stem revision. The rate of complications for both groups was low. The mean drop in haemoglobin measured in the 1B-ssTHA group was 4.42 mg/dl, compared with 3.18 mg/dl in the U-ssTHA group. The mean HHS in the 1B-ssTHA group was 98.3 points (SD 2.80), whereas, in the U-ssTHA group, the mean HHS was 97.9 points (SD 3.44) (p = 0.478). Satisfaction rates were significantly higher in the 1B-ssTHA group (p = 0.04) than in the U-ssTHA group, whereas no significant differences were found for pain at rest and pain at load (p = 0.56 and p = 0.26, respectively).

Conclusion

Our findings indicate that 1B-ssTHA is an effective and beneficial procedure for a select population. Mortality, complications, implant survival, and clinical outcomes were comparable to those for a matched group with unilateral osteoarthritis treated with U-ssTHA. However, an increase in blood loss must be acknowledged for the 1B-ssTHA procedure.

Calcar-guided short-stem total hip arthroplasty: Will it be the future standard? Review and perspectives

Short stems in total hip arthroplasty (THA) are becoming increasingly popular. In Germany, already 10.4% of all primary THAs are performed using a cementless short stem. The concept of modern, calcar-guided, short stems aims for an individualized reconstruction of the hip anatomy by following the calcar of the femoral neck, a bone- and soft-tissue-sparing implantation technique, and physiological loading. The stem design uses either metaphyseal fixation alone or additional diaphyseal anchoring, depending on the stem alignment and indication. These individualized anchorage types increase the potential indications for the safe use of a short stem. The design features may account for potential advantages of current short stem implants compared with earlier short-stem designs, particularly in cases of reduced bone quality or osteonecrosis of the femoral head and femoral neck fractures. The implantation technique, however, requires distinct knowledge regarding the characteristics of varus and valgus positioning, with the potential for clinical consequences. A learning curve for surgeons new to this technique must be taken into account. Cortical contact with the distal lateral cortex appears to be crucial to provide sufficient primary stability, and the use of intraoperative imaging to identify “undersizing” is highly recommended. Current results of several national registries indicate that calcar-guided short stems are among the most successful implants in terms of mid-term survivorship. However, long-term data remain scarce. This review introduces the characteristics of calcar-guided short-stem THA and summarizes the current evidence.