Intact Femur Research Articles

Influence of extracorporeal shock-wave application on normal bone in an animal model in vivo. Scintigraphy, MRI and histopathology.

There is little information about the effects of extracorporeal shock-wave application (ESWA) on normal bone physiology. We have therefore investigated the effects of ESWA on intact distal rabbit femora in vivo. The animals received 1500 shock-wave pulses each of different energy flux densities (EFD) on either the left or right femur or remained untreated. The effects were studied by bone scintigraphy, MRI and histopathological examination. Ten days after ESWA (0.5 mJ/mm2 and 0.9 mJ/mm2 EFD), local blood flow and bone metabolism were decreased, but were increased 28 days after ESWA (0.9 mJ/mm2). One day after ESWA with 0.9 mJ/mm2 EFD but not with 0.5 mJ/mm2, there were signs of soft-tissue oedema, epiperiosteal fluid and bone-marrow oedema on MRI. In addition, deposits of haemosiderin were found epiperiosteally and within the marrow cavity ten days after ESWA. We conclude that ESWA with both 0.5 mJ/mm2 and 0.9 mJ/mm2 EFD affected the normal bone physiology in the distal rabbit femur. Considerable damaging side-effects were observed with 0.9 mJ/mm2 EFD on periosteal soft tissue and tissue within the bone-marrow cavity.

Influence of extracorporeal shock-wave application on normal bone in an animal model in vivo

There is little information about the effects of extracorporeal shock-wave about application the effects (ESWA) of on normal bone physiology. We have therefore investigated the effects of ESWA on intact distal rabbit femora in vivo. The animals received 1500 shock-wave pulses each of different energy flux densities (EFD) on either the left or right femur or remained untreated. The effects were studied by bone scintigraphy, MRI and histopathological examination. Ten days after ESWA (0.5 mJ/mm2 and 0.9 mJ/mm2 EFD), local blood flow and bone metabolism were decreased, but were increased 28 days after ESWA (0.9 mJ/mm2). One day after ESWA with 0.9 mJ/mm2 EFD but not with 0.5 mJ/mm2, there were signs of soft-tissue oedema, epiperiosteal fluid and bone-marrow oedema on MRI. In addition, deposits of haemosiderin were found epiperiosteally and within the marrow cavity ten days after ESWA. We conclude that ESWA with both 0.5 mJ/mm2 and 0.9 mJ/mm2 EFD affected the normal bone physiology in the distal rabbit femur. Considerable damaging side-effects were observed with 0.9 mJ/mm2 EFD on periosteal soft tissue and tissue within the bone-marrow cavity.

THE BIOMECHANICS OF INTRAMEDULLARY NAILING: A PROTOCOL FOR LABORATORY TESTING

In this work, a testing protocol has been set up, in order to quantify the load-sharing imposed near the fracture site by an interlocking-type intramedullary nail. A simulated single-leg stance has been applied to a composite fiberglass femur in three different configurations simulating: an intact femur, a fractured nailed femur and a fully healed nailed femur. The repeatability of the measurements and the influence of ilio-tibial band muscle force have been investigated. The tested nail proved to share with the femoral shaft an amount of the total applied load ranging from 50% immediately after the nailing to 80% at full healing.

The influence of design parameters on cortical strain distribution of a cementless titanium femoral stem

The strain distribution imposed on a femur following a total joint replacement is an important factor, in proximal bone loss due to stress shielding, and long term clinical success. This study investigated how five different design parameters of a cementless titanium femoral prosthesis influenced cortical strains. Test loads were applied and strains were measured with and without an abductor force simulation, using six human cadaveric femora. The cementless design used demonstrated significant calcar loading proximally and a similar strain distribution to the intact femur distally. Implant gross geometry was the major factor in determining the cortical strain distributions under abductor simulation in both axial and torsional loading.

Strain distribution in the proximal human femur

Six pairs of human cadaver femora were divided equally into two groups one of which received a non-cemented reference implant and the other a very short non-dependent experimental implant. Thirteen strain-gauge rosettes were attached to the external surface of each specimen and, during application of combined axial and torsional loads to the femoral head, the strains in both groups were measured. After the insertion of a non-cemented femoral component, the normal pattern of a progressive proximal-to-distal increase in strains was similar to that in the intact femur and the strain was maximum near the tip of the prosthesis. On the medial and lateral aspects of the proximal femur, the strains were greatly reduced after implantation of both types of implant. The pattern and magnitude of the strains, however, were closer to those in the intact femur after insertion of the experimental stem than in the reference stem. On the anterior and posterior aspects of the femur, implantation of both types of stem led to increased principal strains E1, E2 and E3. This was most pronounced for the experimental stem. Our findings suggest that the experimental stem, which has a more anatomical proximal fit without having a distal stem and cortex contact, can provide immediate postoperative stability. Pure proximal loading by the experimental stem in the metaphysis, reduction of excessive bending stiffness of the stem by tapering and the absence of contact between the stem and the distal cortex may reduce stress shielding, bone resorption and thigh pain.

Shear-load carrying capacities of the distal rat femora after osteotomy fixed with self-reinforced polyglycolic acid and poly-L-lactic acid pins.

Distal femora of 40 rats were osteotomized and fixed with self-reinforced polyglycolide (SR-PGA) and self-reinforced polylactide (SR-PLLA) pin 2.0 mm in diameter and 15 mm in length. The shear-load carrying capacities of the osteotomized bones were compared with each other and with the intact control rat distal femora of the same age of 20 pairs. The follow-up times were 1, 3, 6, 12, 24, 36, 48, and 52 weeks. After killing all operated and control femora were examined macroscopically and radiographically. The shear-load carrying capacities reached their highest values at 24 weeks in the SR-PGA-fixed specimens, after that decreasing to the level where they remained. In the SR-PLLA-fixed specimens the strength values of the pins increased after three weeks, but there was a decrease at 24 weeks. After that the shear-load carrying capacities started to raise because of the influence of the healed osteotomy. In the control bones the shear-load carrying capacities were weaker than in the SR-PGA-and SR-PLLA-fixed specimens except at three weeks, as the osteotomies had not yet healed. During the whole follow-up period the mean shear-load carrying capacity of the SR-PGA-fixed specimens was 199.1 N, in the SR-PLLA-fixed specimens 214.6 N, the corresponding value of the control specimens being 148.2 N.

Strength retention of drawn self-reinforced polyglycolide rods and fixation properties of the distal femoral osteotomies with these rods. An experimental study on rats.

Drawn self-reinforced polyglycolide (SR-PGA) rods, Ø 2 mm and 26 mm long, were implanted in the dorsal subcutaneus tissue of 16 rats. Osteotomies of the distal femur were fixed with SR-PGA rods (2 mm by 15 mm) in another 38 rats. The follow-up times varied from one week to one year. After sacrifice, three-point bending and shear tests were performed for subcutaneously placed rods. Radiological, histological, histomorphometrical, microradiographic, and oxytetracycline-fluorescence studies of osteotomized and intact control femora were also performed. At three weeks the flexural strength of the rods was 50% of the initial value, and the flexural modulus was 46% of the initial value. Five osteotomy specimens had to be excluded due to dislocation or non-union. One of the 33 evaluated osteotomy specimens showed signs of postoperative infection. Thirty-two osteotomies healed uneventfully. No gross signs of inflammatory or foreign-body reaction were observed. The amount of osteoid surface and active osteoid formation surface reached their highest value in the histomorphometrical analysis at 24 weeks. The present investigation demonstrated that the mechanical strength and fixation properties of the drawn SR-PGA rods are suitable for fixation of cancellous bone osteotomies in rats. The present article is the first report on the successful application of drawn SR-PGA rods for fixation of cancellous bone osteotomies.

Composite poly(lactide)/hydroxylapatite screws for fixation of osteochondral osteotomies. A morphometric, histologic and radiographic study in sheep

The aim of this study was to evaluate the healing of an osteochondral fragment created in the distal sheep femur in response to fixation with a biodegradable polylactide/hydroxylapatite composite screw. Poly(L-lactide) screws were used for comparison. At follow-up times of 4 and 8 weeks, the specimens were examined with standard radiography and computed tomography, as well as with macro- and micro-histomorphometry. The intact contralateral femur served as a control. Only minimal signs of degradation of the polymer could be seen in the histologic specimens. At 8 weeks, nearly all osteotomies had healed completely and an association between implant type and delayed osteotomy healing was found. The width of the repair tissue at the tissue–implant interface was 250 ± 48 μm, representing a clear transition zone of newly formed trabecular bone separating the implant from the surrounding plexiform bone. This study showed that large polylactide implants which are buffered with hydroxylapatite show benign tissue responses and good implant osteointegration. The osteotomy healing in a weight-bearing osteochondral fragment model in sheep utilizing a composite polylactide/hydroxylapatite screw was equivalent to a similar polylactide screw implant, indicating that hydroxylapatite-buffered screw implants could be used for similar indications in current clinical use.

Intracranial pressure-alterations during controlled intramedullary reaming of femoral fractures: an animal study

Reaming during intramedullary nailing increases the intramedullary pressure (IMP) and can cause fat intravasation and subsequently lead to pulmonary dysfunction, especially in polytraumatized patients with lung contusion as well as increases in intracranial pressure (ICP). ICP changes were measured in two groups consisting of 12 sheep each with either a fractured or intact femur. The animals were exposed to haemorrhagic shock and were resuscitated by autoinfusion. Transverse midshaft fractures were created bilaterally in one group before reaming of both femoral shafts. Controlled reaming was performed at 15 and 50 mm/s driving speed (DS) and at 150 and 450 revolutions per minute (RPM) with a reaming control system using AO-Reamers. Fat intravasation was measured by transoesophageal sonography (TES) and Gurd test. ICP monitoring was performed with a piezo-electric epidural catheter. Haemodynamic and respiratory parameters, ICP, and cerebral perfusion pressure were measured continuously. High DS and low RPM caused higher IMP and ICP increases in both groups. Significantly higher microemboli were observed in TES in the fractured group as compared to the unfractured group with the same reaming parameters ( P=0.021). However, the existence of a femoral fracture did not show a significant influence on changes in ICP ( P-value=0.057). Reaming should be performed at a low DS and high RPM to minimize the risk of fat intravasation and the subsequent ICP increase.

Intramedullary Pressure in Reamed Femoral Nailing with Two Different Reamer Designs

Background and Objective: Reaming increases intramedullary pressure and can cause fat intravasation. A new generation of reamers have been developed to minimize these effects. This prospective consecutive nonrandomized clinical trial compares the intramedullary pressure changes of a modern reamer with a conventional one. Objective was to investigate whether intramedullary pressures are different in the use of a new Howmedica reamer compared to a conventionel AO reamer. Patients and Methods: Intramedullary pressures were measured in the distal femoral fracture fragment at the supracondylar region in nine patients and in the intact femur with an impending fracture in two patients with metastatic disease. Monitoring was carried out in 5 AO and 6 Howmedica intramedullary reaming procedures. Results: Significant differences between the two treatment groups could be shown for 9.5 mm, 10 mm, 10.5 mm, 11 mm and 13.5 mm reamers. Analysis of variance for repeated measurements of all diameters showed signigficant more increase of intramedullary pressure with the use of the AO compared to the Howmedica reamer. No clinical symptoms of fat embolism could be detected in both groups. Conclusions: The intramedullary pressures increased substantially with the use of both reamer designs but the highest peak pressures were measured during the reaming of an intact femur. Intramedullary pressure increased significantly with the AO reamer more than with the Howmedica reamer.

Application of an anisotropic bone-remodelling model based on a damage-repair theory to the analysis of the proximal femur before and after total hip replacement

In this work, a new model for internal anisotropic bone remodelling is applied to the study of the remodelling behaviour of the proximal femur before and after total hip replacement (THR). This model considers bone remodelling under the scope of a general damage-repair theory following the principles of continuum damage mechanics. A “damage-repair” tensor is defined in terms of the apparent density and Cowin's “fabric tensor”, respectively, associated with porosity and directionality of the trabeculae. The different elements of a thermodynamically consistent damage theory are established, including resorption and apposition criteria, evolution law and rate of remodelling. All of these elements were introduced and discussed in detail in a previous paper (Garcı́a, J. M., Martinez, M. A., Doblaré, M., 2001. An anisotrophic internal–external bone adaptation model based on a combination of CAO and continuum damage mechanics technologies. Computer Methods in Biomechanics and Biomedical Engineering 4(4), 355–378.), including the definition of the proposed mechanical stimulus and the qualitative properties of the model. In this paper, the fundamentals of the proposed model are briefly reviewed and the computational aspects of its implementation are discussed. This model is then applied to the analysis of the remodelling behaviour of the intact femur obtaining densities and mass principal values and directions very close to the experimental data. The second application involved the proximal femoral extremity after THR and the inclusion of an Exeter prosthesis. As a result of the simulation process, some well-known features previously detected in medical clinics were recovered, such as the stress yielding effect in the proximal part of the implant or the enlargement of the cortical layer at the distal part of the implant. With respect to the anisotropic properties, bone microstructure and local stiffness are known to tend to align with the stress principal directions. This experimental fact is mathematically proved in the framework of this remodelling model and clearly shown in the results corresponding to the intact femur. After THR the degree of anisotropy decreases tending, specifically in the proximal femur, to a more isotropic behaviour.

Changes in proximal femoral strain after insertion of uncemented standard and customised femoral stems. An experimental study in human femora.

We have compared the changes in the pattern of the principal strains in the proximal femur after insertion of eight uncemented anatomical stems and eight customised stems in human cadaver femora. During testing we aimed to reproduce the physiological loads on the proximal femur and to simulate single-leg stance and stair-climbing. The strains in the intact femora were measured and there were no significant differences in principal tensile and compressive strains in the left and right femora of each pair. The two types of femoral stem were then inserted randomly into the left or right femora and the cortical strains were again measured. Both induced significant stress shielding in the proximal part of the metaphysis, but the deviation from the physiological strains was most pronounced after insertion of the anatomical stems. The principal compressive strain at the calcar was reduced by 90% for the anatomical stems and 67% for the customised stems. Medially, at the level of the lesser trochanter, the corresponding figures were 59% and 21%. The anatomical stems induced more stress concentration on the anterior aspect of the femur than did the customised stems. They also increased the hoop strains in the proximomedial femur. Our study shows a consistently more physiological pattern of strain in the proximal femur after insertion of customised stems compared with standard, anatomical stems.

Changes in proximal femoral strain after insertion of uncemented standard and customised femoral stems

We have compared the changes in the pattern of the principal strains in the proximal femur after insertion of eight uncemented anatomical stems and eight customised stems in human cadaver femora. During testing we aimed to reproduce the physiological loads on the proximal femur and to simulate single-leg stance and stair-climbing. The strains in the intact femora were measured and there were no significant differences in principal tensile and compressive strains in the left and right femora of each pair. The two types of femoral stem were then inserted randomly into the left or right femora and the cortical strains were again measured. Both induced significant stress shielding in the proximal part of the metaphysis, but the deviation from the physiological strains was most pronounced after insertion of the anatomical stems. The principal compressive strain at the calcar was reduced by 90% for the anatomical stems and 67% for the customised stems. Medially, at the level of the lesser trochanter, the corresponding figures were 59% and 21%. The anatomical stems induced more stress concentration on the anterior aspect of the femur than did the customised stems. They also increased the hoop strains in the proximomedial femur. Our study shows a consistently more physiological pattern of strain in the proximal femur after insertion of customised stems compared with standard, anatomical stems.

Comments on "Femoral surface strain in intact composite femurs: A custom computer analysis of the photoelastic coating technique" [with reply

Cristofolini and Viceconti read with great interest the title paper by Grecula et al. (see ibid., vol. 47, p. 926-33, 2000). Cristofolini and Viceconti were pleased to see an increasing interest toward new tools to improve in vitro investigations in orthopedics. In fact there still a strong need to improve the way hip prostheses are tested. The work Grecula et al. presented definitely gives a positive contribution in this direction, since they developed a new approach to assess the state of strains in the femur. In fact Grecula et al. proposed to use a novel indicator, the average strain areas, rather than looking at local information only. However, Cristofolini and Viceconti feel that Grecula et al. might have overlooked some methodological details that can possibly undermine the validity of the actual results they present, introducing both a significant bias, and a large scatter of the results. In reply Grecula et al. say that the goal of the project reported in the original paper was to improve on the methods available for measuring the surface strains in the proximal femur. Visualizing the complete topography of surface strains with the photoelastic coating technique is appealing but frustrating due to limits in its quantitative utility. Grecula et al. incorporated the advantages of computer imaging and software interpretation to improve the quantitative results of this technique. As with any new technique, Grecula et al. designed the protocol to be as simple as possible to reduce possible errors and variability. While the loading configuration was not necessarily physiologic and possibly over-constrained, it did allow the repeatable load transfer through the femur that was necessary for validating the computer techniques that Grecula et al. were testing.

The E11 osteoblastic lineage marker is differentially expressed during fracture healing

Given the complexity of the fracture healing process and the involvement of a multitude of cells, we hypothesize that a very large number of genes would be transcriptionally regulated during the repair process. To identify genes that play a role during bone regeneration in cellular events, such as proliferation, migration, adhesion, and differentiation, we employed differential display and compared mRNA populations isolated from postfracture (PF) day 3 calluses to those of intact (contralateral) rat femurs. One such gene whose expression was upregulated at PF day 3 is identified as the osteoblastic lineage marker, E11 antigen. E11 is a cell membrane protein localized predominantly on osteoblasts and osteocytes. In this study we show that E11 mRNA expression is consistently upregulated during fracture repair, with elevated levels (tenfold) seen as early as PF day 3. These high levels of expression were maintained throughout all of the early stages of repair examined (PF day 3–21 calluses) and paralleled those of another osteoblastic marker, osteopontin. Similarly, high protein levels were detected throughout the reparative phase of the callus, particularly in osteoblasts, preosteocytes, and osteocytes, localized within the newly made osteoid. No labeling was detected in fibroblasts, proliferating chondrocytes, or hypertrophic chondrocytes, consistent with previous results. Taken together, these results suggest that the E11 antigen is indeed a suitable marker for both osteoblasts and osteocytes and that it plays a significant role in osteogenesis.

Shear-load carrying capacity of cancellous bone after implantation of self-reinforced polyglycolic acid and poly- l-lactic acid pins: experimental study on rats

Both distal femora of 40 rats were implanted with a self-reinforced polyglycolic acid (SR-PGA) pin in the right femur and with a self-reinforced poly- l-lactic acid (SR-PLLA) pin in the left femur. The intact femora of 20 rats served as controls. The follow-up times were 1, 3, 6, 12, 24, 36, 48, and 52 weeks. After killing all operated and control femora were examined macroscopically and radiographically. The shear-load carrying capacities of all the femurs were investigated, and the SR-PGA and SR-PLLA fixed specimens were compared with each other and with the control specimens. The shear-load carrying capacities reached their highest values at 36 weeks in the SR-PGA and SR-PLLA fixed and control specimens. Thereafter they gradually decreased. At 52 weeks both the SR-PGA fixed specimens and the control specimens had statistically significantly ( p<0.001) higher values than the SR-PLLA fixed specimens, when the influence of the pins had ceased. Otherwise, the shear-load capacities showed higher values in the SR-PLLA fixed specimens, as the pins carried the load. During the whole follow-up period the mean shear-load carrying capacity of the SR-PGA fixed specimens was 171.2 N and that of the SR-PLLA fixed specimens 180.9 N, the corresponding value of the control specimens was 148.2 N.

Age and ovariectomy impair both the normalization of mechanical properties and the accretion of mineral by the fracture callus in rats

The impact of age and ovariectomy on the healing of femoral fractures was studied in three groups of female rats at 8, 32 and 50 weeks of age at fracture. In the two older groups, the rats had been subjected to ovariectomy or sham surgery at random at 26 weeks of age. At fracture, all rats received unilateral intramedullary pinning of one femur and a middiaphyseal fracture. Rigidity and breaking load of the femora were evaluated at varying times up to 24 weeks after fracture induction by three-point bending to failure. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry. In the youngest group, 8-week-old female rats regained normal femoral rigidity and breaking load by 4 weeks after fracture. They exceeded normal contralateral values by 8 weeks after fracture. In the middle group, at 32 weeks of age, fractures were induced, and the femora were harvested at 6 and 12 weeks after fracture. At 6 weeks after fracture there was partial restoration of rigidity and breaking load. At 12 weeks after fracture, only the sham-operated rats had regained normal biomechanical values in their fractured femora, while the fractured femora of the ovariectomized rats remained significantly lower in both rigidity and breaking load. In contrast, for the oldest group of rats, 50 weeks old at fracture, neither sham-operated nor ovariectomized rats regained normal rigidity or breaking load in their fractured femora within the 24 weeks in which they were studied. In all fractured bones, there was a significant increase in BMD over the contralateral intact femora due to the increased bone tissue and bone mineral in the fracture callus. Ovariectomy significantly reduced the BMD of the intact femora and also reduced the gain in BMD by the fractured femora. In conclusion, age and ovariectomy significantly impair the process of fracture healing in female rats as judged by measurements of rigidity and breaking load in three-point bending and by accretion of mineral into the fracture callus.

The effect of freezing and intraosseous fluid on the stiffness behavior of canine trabecular bone.

The effect of disrupting the intraosseous fluid compartment and freezing on the mechanical stiffness of trabecular bone in intact canine femoral head specimens was investigated. Twenty-four skeletally mature dogs were divided into two groups. Twelve paired fresh femora were tested and 12 paired femora were tested after freezing at -20 degrees C. The intact femoral head specimens were subjected to a load of physiologic magnitude, and then the stiffness of the underlying trabecular bone was determined in intact femora, in drilled femora with a disrupted intraosseous fluid compartment, and subsequently after refilling the compartment with fluid. Drilling of the femoral head and disrupting its bony fluid compartment resulted in a 40% decrease in stiffness (P<.001). This effect was seen only with fresh specimens and not frozen specimens. Refilling the bony compartment with fluid restored the stiffness of the fresh femoral head. These results demonstrate the mechanical properties of trabecular bone in canine femoral head specimens in vitro are affected by intraosseous fluid and freezing. Removal of the intraosseous fluid decreases the mechanical stiffness of canine trabecular bone, and freezing the specimens appears to alter the intraosseous fluid compartment behavior. It is necessary to gain a better understanding of the dynamic mechanical properties of intact bone to improve the existing analytical and experimental mechanical bone models. The effect of intraosseous fluid and freezing should be considered in these models.

A metaphyseal defect model of the femur for studies of murine bone healing

A bone defect model was developed in the distal metaphysis of the femur for studies on bone healing in the mouse. The circular defect involving 20% of the bone circumference resulted in a 34% reduction in the bending moment compared to intact bone. The healing process was followed using histomorphometry, peripheral quantitative computed tomography (pQCT), biomechanical testing, and molecular biological analyses. Histologically, healing of the defect was characterized by filling of the medullary cavity with trabecular new bone during the first week of healing, and by closing of the cortical window by 6 weeks. Small areas of periosteal chondrogenesis were frequently observed during defect healing. In pQCT, bone mineral content (BMC) of the defect area approached that of intact control bone already by 3 weeks, reflecting the production of trabecular bone. Similarly, the bending strength and stiffness of the healing femur reached the level of intact control femur already at 3 weeks. Bone formation and remodeling was followed by Northern analyses, which demonstrated elevated mRNA levels for bone components (type I collagen and osteocalcin), and for osteoclastic enzymes (cathepsin K, matrix metalloproteinase-9, and tartrate-resistant acid phosphatase) throughout the healing period. Finally, the applicability of the defect model for gene therapy experiments was tested using adenovirus-mediated transfer of the LacZ reporter gene. Both histochemistry and mRNA analyses demonstrated that the gene was expressed in the repair tissue with the highest expression during the first week of healing. The present model thus provides a standardized environment for studies on induction and remodeling of trabecular new bone in normal and genetically engineered mice.

Strain distribution in the proximal human femur

Six pairs of human cadaver femora were divided equally into two groups one of which received a non-cemented reference implant and the other a very short non-dependent experimental implant. Thirteen strain-gauge rosettes were attached to the external surface of each specimen and, during application of combined axial and torsional loads to the femoral head, the strains in both groups were measured. After the insertion of a non-cemented femoral component, the normal pattern of a progressive proximal-to-distal increase in strains was similar to that in the intact femur and the strain was maximum near the tip of the prosthesis. On the medial and lateral aspects of the proximal femur, the strains were greatly reduced after implantation of both types of implant. The pattern and magnitude of the strains, however, were closer to those in the intact femur after insertion of the experimental stem than in the reference stem. On the anterior and posterior aspects of the femur, implantation of both types of stem led to increased principal strains E1, E2 and E3. This was most pronounced for the experimental stem. Our findings suggest that the experimental stem, which has a more anatomical proximal fit without having a distal stem and cortex contact, can provide immediate postoperative stability. Pure proximal loading by the experimental stem in the metaphysis, reduction of excessive bending stiffness of the stem by tapering and the absence of contact between the stem and the distal cortex may reduce stress shielding, bone resorption and thigh pain.