Randomised clinical trial assessing migration of uncemented primary total hip replacement stems, with and without autologous impaction bone grafting



Uncemented stems in primary total hip replacement (THR) are concerning in the elderly due to ectatic femoral canals and cortical thinning resulting in higher incidence of fracture and subsidence in this population. To obviate this concern, the authors developed a technique using autologous impaction bone grafting to achieve a better fitting femoral stem. The aim of this randomised clinical trial was to assess the efficacy of the technique.


From 2013 to 2015, a total of 98 consecutive participants (100 primary THR procedures) were inducted into a single-institution, single-blinded, randomised clinical trial assessing, with radiostereometric analysis (RSA), the efficacy of autologous impaction bone grafting in uncemented primary THR compared with traditional uncemented primary THR technique. The primary outcome measure was femoral component migration using RSA. Secondary outcomes were post-operative proximal femoral bone density (using DEXA), hip function and quality of life using Oxford Hip Score (OHS) and Short Form-12 Health Survey (SF-12), hip pain and patient satisfaction.


There was no difference in femoral component stability (p > 0.5) or calcar resorption between the Graft and No Graft Groups at two years. There was also no difference in OHS, SF-12, pain or satisfaction between the Graft and No Graft Groups at two years (p > 0.39).


Autologous impaction bone grafting in uncemented primary THR has shown its short-term post-operative outcomes to be equivalent to standard uncemented technique, whilst offering a better fit in patients who are between femoral stem sizes.

Australian clinical trial registration number


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  1. 1.

    Australian Orthopaedic Association National Joint Replacement Registry (2017) Hip, knee & shoulder arthroplasty: 2017 annual report. Australian Orthopaedic Association, Adelaide, Australia

  2. 2.

    American Joint Replacement Registry (2017) Annual report. AJRR, Rosemont, Illinois

    Google Scholar 

  3. 3.

    National Joint Registry (2017) National Joint Registry for England, Wales, Northern Ireland and the Isle of Man: 14th annual report NJR, Hertfordshire, England

  4. 4.

    Kärrholm J, Lindahl H, Malchau H, Mohaddes M, Rogmark C, Rolfson O (2016) The Swedish hip arthroplasty register annual report 2015. Institute of Clinical Sciences, Section for Anesthesiology, Biomaterials and Orthopaedics, University of Gothenburg, Gothenburg, Sweden

  5. 5.

    Garino JP, Beredjiklian PK (2007) Core knowledge in orthopedics: adult reconstruction and arthroplasty. Mosby, Philadelphia

    Google Scholar 

  6. 6.

    Hooper GJ, Rothwell AG, Stringer M, Frampton C (2009) Revision following cemented and uncemented primary total hip replacement: a seven-year analysis from the New Zealand Joint Registry. J Bone Joint Surg Br 91(4):451–458. https://doi.org/10.1302/0301-620X.91B4.21363

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Donaldson AJ, Thomson HE, Harper NJ, Kenny NW (2009) Bone cement implantation syndrome. Br J Anaesth 102(1):12–22. https://doi.org/10.1093/bja/aen328

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Girard J, Roche O, Wavreille G, Canovas F, Le Beguec P (2011) Stem subsidence after total hip revision: 183 cases at 5.9 years follow-up. Orthop Traumatol Surg Res: OTSR 97(2):121–126. https://doi.org/10.1016/j.otsr.2010.10.006

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Ostbyhaug PO, Klaksvik J, Romundstad P, Aamodt A (2009) An in vitro study of the strain distribution in human femora with anatomical and customised femoral stems. J Bone Joint Surg Br 91(5):676–682. https://doi.org/10.1302/0301-620x.91b5.21749

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Aldinger PR, Sabo D, Pritsch M, Thomsen M, Mau H, Ewerbeck V, Breusch SJ (2003) Pattern of periprosthetic bone remodeling around stable uncemented tapered hip stems: a prospective 84-month follow-up study and a median 156-month cross-sectional study with DXA. Calcif Tissue Int 73(2):115–121. https://doi.org/10.1007/s00223-002-2036-z

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Trevisan C, Bigoni M, Cherubini R, Steiger P, Randelli G, Ortolani S (1993) Dual X-ray absorptiometry for the evaluation of bone density from the proximal femur after total hip arthroplasty: analysis protocols and reproducibility. Calcif Tissue Int 53(3):158–161

    CAS  Article  Google Scholar 

  12. 12.

    Trevisan C, Bigoni M, Randelli G, Marinoni EC, Peretti G, Ortolani S (1997) Periprosthetic bone density around fully hydroxyapatite coated femoral stem. Clin Orthop Relat Res 340:109–117

    Article  Google Scholar 

  13. 13.

    Alm JJ, Makinen TJ, Lankinen P, Moritz N, Vahlberg T, Aro HT (2009) Female patients with low systemic BMD are prone to bone loss in Gruen zone 7 after cementless total hip arthroplasty. Acta Orthop 80(5):531–537. https://doi.org/10.3109/17453670903316801

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Skoldenberg OG, Boden HS, Salemyr MO, Ahl TE, Adolphson PY (2006) Periprosthetic proximal bone loss after uncemented hip arthroplasty is related to stem size: DXA measurements in 138 patients followed for 2-7 years. Acta Orthop 77(3):386–392. https://doi.org/10.1080/17453670610046307

    Article  PubMed  Google Scholar 

  15. 15.

    Kobayashi S, Saito N, Horiuchi H, Iorio R, Takaoka K (2000) Poor bone quality or hip structure as risk factors affecting survival of total-hip arthroplasty. Lancet (London, England) 355(9214):1499–1504. https://doi.org/10.1016/s0140-6736(00)02164-4

    CAS  Article  Google Scholar 

  16. 16.

    Schewelov T, Ahlborg H, Sanzen L, Besjakov J, Carlsson A (2012) Fixation of the fully hydroxyapatite-coated Corail stem implanted due to femoral neck fracture: 38 patients followed for 2 years with RSA and DEXA. Acta Orthop 83(2):153–158. https://doi.org/10.3109/17453674.2011.641107

    Article  PubMed  Google Scholar 

  17. 17.

    Simon J-P, Fowler JL, Gie GA, Ling RS, Timperley AJ (1991) Impaction cancellous grafting of the femur in cemented total hip revision arthroplasty. J Bone Joint Surg [Br];73-B(Suppl 1)

  18. 18.

    Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ, Elbourne D, Egger M, Altman DG (2010) CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. BMJ (Clin Res ed) 340:c869. https://doi.org/10.1136/bmj.c869

    Article  Google Scholar 

  19. 19.

    Dorr LD, Faugere MC, Mackel AM, Gruen TA, Bognar B, Malluche HH (1993) Structural and cellular assessment of bone quality of proximal femur. Bone 14(3):231–242

    CAS  Article  Google Scholar 

  20. 20.

    Dupont W, Plummer W (1990) Power and sample size calculations: a review and computer program. Control Clin Trials 11:116–128

    CAS  Article  Google Scholar 

  21. 21.

    Murray DW, Fitzpatrick R, Rogers K, Pandit H, Beard DJ, Carr AJ, Dawson J (2007) The use of the Oxford hip and knee scores. J Bone Joint Surg Br 89(8):1010–1014. https://doi.org/10.1302/0301-620x.89b8.19424

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Karrholm J, Borssen B, Lowenhielm G, Snorrason F (1994a) Does early micromotion of femoral stem prostheses matter? 4-7-year stereoradiographic follow-up of 84 cemented prostheses. J Bone Joint Surg Br 76(6):912–917

    CAS  Article  Google Scholar 

  23. 23.

    Ryd L, Albrektsson BE, Carlsson L, Dansgard F, Herberts P, Lindstrand A, Regner L, Toksvig-Larsen S (1995) Roentgen stereophotogrammetric analysis as a predictor of mechanical loosening of knee prostheses. J Bone Joint Surg Br 77(3):377–383

    CAS  Article  Google Scholar 

  24. 24.

    Valstar ER, Gill R, Ryd L, Flivik G, Borlin N, Karrholm J (2005) Guidelines for standardization of radiostereometry (RSA) of implants. Acta Orthop 76(4):563–572. https://doi.org/10.1080/17453670510041574

    Article  PubMed  Google Scholar 

  25. 25.

    Engh CA (1994) Porous-coated fixation forever. Orthopedics 17(9):775–776

    CAS  PubMed  Google Scholar 

  26. 26.

    Ilyas J, Khan RJK, Fick DP, Haebich S, Rutherford M, Nivbrant NO (2018) Operative technique: autologous impaction bone grafting with uncemented Corail stem in primary total hip arthroplasty. Techniques in Orthopaedics Published online ahead of print. https://doi.org/10.1097/bto.0000000000000302

    Article  Google Scholar 

  27. 27.

    Vidalain J-P, Ait Si Selmi T, Beverland D, Young S, Board T, Boldt JG, Brumby SA (eds) (2011) The CORAIL® Hip System. Springer-Verlag, Berlin Heidelberg. https://doi.org/10.1007/978-3-642-18396-6_3

    Google Scholar 

  28. 28.

    Rohrl SM, Li MG, Pedersen E, Ullmark G, Nivbrant B (2006) Migration pattern of a short femoral neck preserving stem. Clin Orthop Relat Res 448:73–78. https://doi.org/10.1097/01.blo.0000224000.87517.4c

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    Cohen B, Rushton N (1995) Accuracy of DEXA measurement of bone mineral density after total hip arthroplasty. J Bone Joint Surg Br 77(3):479–483

    CAS  Article  Google Scholar 

  30. 30.

    Gruen TA, McNeice GM, Amstutz HC (1979) “Modes of failure” of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res 141:17–27

    Google Scholar 

  31. 31.

    Dawson J, Fitzpatrick R, Carr A, Murray D (1996) Questionnaire on the perceptions of patients about total hip replacement. J Bone Joint Surg Br 78(2):185–190

    CAS  Article  Google Scholar 

  32. 32.

    Ware JE, Kosinski M, Keller SD (1995) How to score the SF-12 physical and mental summary scales. The health institute, New England Medical Center, Boston, Massachusetts

    Google Scholar 

  33. 33.

    Williamson A, Hoggart B (2005) Pain: a review of three commonly used pain rating scales. J Clin Nurs 14(7):798–804. https://doi.org/10.1111/j.1365-2702.2005.01121.x

    Article  PubMed  Google Scholar 

  34. 34.

    Campbell D, Mercer G, Nilsson KG, Wells V, Field JR, Callary SA (2011) Early migration characteristics of a hydroxyapatite-coated femoral stem: an RSA study. Int Orthop 35(4):483–488. https://doi.org/10.1007/s00264-009-0913-z

    Article  PubMed  Google Scholar 

  35. 35.

    Sudhahar TA, Morapudi S, Branes K (2009) Evaluation Of subsidence between collarless and collared corail femoral cement less total hip replacement. J Orthopaedics 6(2)e3

  36. 36.

    Skoldenberg OG, Salemyr MO, Boden HS, Lundberg A, Ahl TE, Adolphson PY (2011) A new uncemented hydroxyapatite-coated femoral component for the treatment of femoral neck fractures: two-year radiostereometric and bone densitometric evaluation in 50 hips. J Bone Joint Surg Br 93(5):665–677. https://doi.org/10.1302/0301-620x.93b5.25374

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    Krismer M, Biedermann R, Stockl B, Fischer M, Bauer R, Haid C (1999) The prediction of failure of the stem in THR by measurement of early migration using EBRA-FCA. Einzel-Bild-roentgen-analyse-femoral component analysis. J Bone Joint Surg Br 81(2):273–280

    CAS  Article  Google Scholar 

  38. 38.

    Strom H, Nilsson O, Milbrink J, Mallmin H, Larsson S (2007) The effect of early weight bearing on migration pattern of the uncemented CLS stem in total hip arthroplasty. J Arthroplast 22(8):1122–1129. https://doi.org/10.1016/j.arth.2006.11.015

    Article  Google Scholar 

  39. 39.

    Van der Wal BC, Rahmy AI, Grimm B, Blake GM, Heyligers IC, Tonino AJ (2006) The influence of implant design on periprosthetic bone remodelling of two types of uncemented HA-coated hip stems. A two-year follow-up study using DEXA. Hip Int 16(1):8–17

    Article  Google Scholar 

  40. 40.

    Miladi M, Villain B, Mebtouche N, Begue T, Auregan JC (2018) Interest of short implants in hip arthroplasty for osteonecrosis of the femoral head: comparative study “uncemented short” vs “cemented conventional” femoral stems. Int Orthop. https://doi.org/10.1007/s00264-018-3981-0

    Article  Google Scholar 

  41. 41.

    Schaller G, Black J, Asaad A, Harper N, Webb S, Muirhead-Allwood S (2015) Primary collared uncemented total hip arthroplasties in the elderly: a safe and reliable treatment option. J Arthroplast 30(3):407–410. https://doi.org/10.1016/j.arth.2014.10.004

    Article  Google Scholar 

  42. 42.

    Jameson SS, Mason JM, Baker PN, Gregg PJ, Deehan DJ, Reed MR (2015) No functional benefit of larger femoral heads and alternative bearings at 6 months following primary hip replacement. Acta Orthop 86(1):32–40. https://doi.org/10.3109/17453674.2014.972259

    Article  PubMed  PubMed Central  Google Scholar 

  43. 43.

    Budde S, Seehaus F, Schwarze M, Hurschler C, Floerkemeier T, Windhagen H, Noll Y, Ettinger M, Thorey F (2016) Analysis of migration of the Nanos(R) short-stem hip implant within two years after surgery. Int Orthop 40(8):1607–1614. https://doi.org/10.1007/s00264-015-2999-9

    Article  PubMed  Google Scholar 

  44. 44.

    Mee WD, Ilyas J, Khan RJK, Fick DP, Nivbrant NO, Haebich SJ (2018) Prospective clinical trial assessing a short femoral stem prosthesis in total hip arthroplasty. Int J Sci Res 7(5):18–21

    Google Scholar 

  45. 45.

    Sariali E, Knaffo Y (2017) Three-dimensional analysis of the proximal anterior femoral flare and torsion. Anatomic bases for metaphyseally fixed short stems design. Int Orthop 41(10):2017–2023. https://doi.org/10.1007/s00264-017-3435-0

    Article  PubMed  Google Scholar 

  46. 46.

    Boese CK, Lechler P, Rose L, Dargel J, Oppermann J, Eysel P, Geiges H, Bredow J (2015) Calibration markers for digital templating in total hip arthroplasty. PLoS One 10(7):e0128529. https://doi.org/10.1371/journal.pone.0128529

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  47. 47.

    Hwang BH, Lee WS, Park KK, Yang IH, Han CD (2011) Straight tapered titanium stem with alumina bearing in cementless primary total hip arthroplasty: a minimum 5-year follow-up. J Arthroplast 26(8):1310–1317. https://doi.org/10.1016/j.arth.2010.12.015

    Article  Google Scholar 

Download references


DEXA imaging: SKG Radiology Hollywood Hospital, Perth, WA, Australia.

Data collection: Hollywood Private Hospital Physiotherapy Department, Perth, WA, Australia.

Statistical analysis: V.K. Bowden, PhD, School of Psychological Science, the University of Western Australia, 35 Stirling Highway, Perth, WA, Australia.


This work was supported by the Hollywood Private Hospital Research Fund, Perth, Australia (grant number: RF074).

Author information




TK prepared research proposal. RJKK and DF performed surgery. ON collected and analysed RSA data. SKG Radiology and MR collected DEXA data. Hollywood Private Hospital Physiotherapy Department and SH collected patient reported outcome measure data. VKB performed statistical analysis. MR, RJKK, DF and SH prepared the manuscript.

Corresponding author

Correspondence to Michael Rutherford.

Ethics declarations

Approval for the study was obtained from the Hospital Research Ethics Committee, with its conduct in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.

Conflict of interest

Prof. Khan reports personal fees from Global Orthopaedic Technology, personal fees from Zimmer Biomet, grants from AMPLITUDE, and Smith & Nephew, outside the submitted work.

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Rutherford, M., Khan, R.J.K., Fick, D.P. et al. Randomised clinical trial assessing migration of uncemented primary total hip replacement stems, with and without autologous impaction bone grafting. International Orthopaedics (SICOT) 43, 2715–2723 (2019). https://doi.org/10.1007/s00264-019-04290-5

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  • Uncemented total hip arthroplasty
  • Cementless total hip arthroplasty
  • THR
  • Autologous impaction bone grafting
  • Radiostereometric analysis
  • Dual X-ray absorptiometry