The effect of bone mineral density on femoral stem subsidence in primary cementless total hip arthroplasty: A prospective study

The effect of bone mineral density on femoral stem subsidence in primary cementless total hip arthroplasty: A prospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The effect of bone mineral density on femoral stem subsidence in primary cementless total hip arthroplasty: A prospective study Ahmet Sinan Kalyenci, Ibrahim Doğan, Saltuk Bugra Tekin, Zana Ozmen, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5298016/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Dec, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 17 You are reading this latest preprint version Abstract Background: The success of primary total hip arthroplasty (THA) in patiens with primary osteoarthritis (OA) of hip is significantly inflenced by stem osteointegration, migration and placement. Additionally, the bone mineral density (BMD) of the proximal femur and the femoral morphology play important roles in these outcomes. We aimed to prospectively evaluate the effect of BMD on subsidence who underwent primary cementless THA for primary OA of hip. Methods: We conducted a prospective observational study on 70 hip (65 patients) diagnosed with primary OA of hip who underwent primary cementless THA. Patients were grouped according to preoperative BMD and proximal femur anatomy based on Dorr classificaiton. Harris hip score (HHS) and radiological subsidence values ​​were used for postoperative clinical evaluation. Results: The mean follow-up was 24.6 ± 5.8 months. Of the 70 hips, 22 (31.43%) were Dorr type A, 44 (62.86%) type B, and 4 (5.71%) type C. According to total femur T scores, 43 patients (61.43%) had normal BMD, while 27 patients (38.57%) were identified as osteopenic or osteoporotic. The mean axial migration at last follow-up was 1.04 ± 0.69 mm. No significant influence on migration was found regarding total femur T score levels and femoral morphologies. Conclusions: In our study, we investigated the early results of cementless THA in patients with low BMD and advanced age group. We evaluated the clinical and radiological results in groups with different bone density and femoral morphology. In our results, evaluated in light of similar studies, we found that HHS, subsidence values and Engh scores were comparable between patients with normal and low BMD, with no statistically significant differences observed. Subsidence cementless total hip arthroplasty bone mineral density Dorr classification osteointegration Figures Figure 1 Figure 2 Introduction The success and worldwide acceptance of THA began with the use of polymethylmethacrylate (PMMA) cement, also known as acrylic, for low-friction arthroplasty and component fixation, developed and popularized by Sir John Charnley [ 1 ]. The emergence of problems with the use of acrylic cement in the 1970s led to the beginning of studies to eliminate the use of cement and provide biological fixation. Stability in the cementless femoral component is achieved by bone growth into the pores on the component [ 2 ]. With increasing life expectancy, the number of THA procedures performed in older patients is also on the rise. Although many theoretical problems arise in hip arthroplasty with advancing age, the greatest concern is decreasing bone density [ 3 ]. Although cementless techniques are designed for individuals with normal bone density and healing capacity in THA applications, it is possible to use cementless components in patients with impaired bone quality and limited healing capacity with improved implant designs and bioactive coating materials [ 4 ]. In patients with primary OA of hip undergoing primary THA, stem osteointegration, stem migration and stem placement have a significant effect on long-term functional results and pain. Although many factors are effective in bone and stem compatibility, proximal femur BMD and femoral morphology significantly affect these variables [ 5 ]. Considering that early implant stability has an important role in the success of cementless THA, low BMD and age-related changes in proximal femoral anatomy may compromise femoral stem stabilisation and osteointegration [ 4 ]. Subsidence in the femoral stem is expected to some extent in the early stages of THA. Less subsidence is expected in cemented femoral stems compared to cementless stems due to the use of cement in the initial stabilization; however, it has been stated that both methods have similar results in the long term. In cementless hip arthroplasty, the fixation of the stem depends on osteointegration, and it is believed that this osteointegration depends on the bone density around the stem [ 6 ]. OA and osteoporosis are orthopedic conditions whose prevalence increases with advancing age. It is accepted that there is an inverse relationship between these two diseases; it has been suggested that a person with OA will be protected from osteoporosis [ 7 ]. Regarding THA application in patients with osteoporosis there are several important issues, especially early osteointegration, intraoperative fractures, late periprosthetic fractures, and long-term survival of the implant. Research on these problems in cemented and cementless applications has been found limited [ 8 ]. The aim of this study was to evaluate the effect of BMD and femur morphology according to Dorr classification on early clinical and radiological outcomes in patients who underwent primary cementless THA for primary OA of hip. Materials and methods For the prospectively designed study, ethical approval was obtained from Ethics Committee of Istanbul Training and Research Hospital (date: 12/04/2019 and no: 1790). The study was applied in accordance with the ethical standards of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study. Inclusion and exclusion criteria Patients aged 50–85 years diagnosed with primary OA of hip, who had an indication for THA, volunteered for the study, and provided written consent were included. Patients were excluded if they had a history of previous hip surgery, severe deformity, revision hip arthroplasty, severe osteoporosis requiring or undergoing medical treatment, or if they had received or were currently receiving treatment affecting BMD. Additionally, patients with hereditary skeletal disorders and those who did not attend routine check-ups were also excluded. Preoperative femoral and lumbar bone density measurements were obtained for all patients meeting the inclusion criteria. These patients were informed that they would be required to attend clinical and radiological follow-up appointments after surgery. Surgical procedure All patients underwent surgery in the lateral decubitus position using a posterolateral approach. The largest femoral stem size that provided sufficient bone support and appropriate rotational stability was chosen for each patient. The surgeon made intraoperative decisions regarding the suitable femoral head and liner to ensure joint stability. The same acetabular (Smith & Nephew EP-HIT PLUS®) and femoral (Smith & Nephew SYNERGY®) components were implanted in all patients. One patient experienced a major trochanter fracture, and another sustained a distal femur fracture during the procedure. These fractures were treated in the same session. However, these two patients were excluded from the study because the established postoperative treatment and rehabilitation protocols could not be applied to them. All patients received the same rehabilitation program determined for the study, which included early mobilization with a walker as soon as possible, allowing weight-bearing as tolerated, along with range of motion and isometric exercises. Patients were mobilized with full weight-bearing on the first postoperative day, and the rest of the rehabilitation program was initiated accordingly. Radiographic measurements Bone density was measured in the proximal femur, femoral neck on the side to be operated, and lumbar vertebrae. Based on the World Health Organization (WHO) criteria, patients were classified as either having normal bone density or low bone density (osteopenic/osteoporotic; T scores < -1) according to the lowest values ​​of bone density, defined by the WHO as lumbar vertebrae, proximal femur and femoral neck bone density values. The bone density measurements of the proximal femoral region covered approximately 25 cm of the proximal femur, as specified by the device used, and were defined as the ‘total femoral T score’(Horizon DXA System; Hologic®). Antero–posterior(AP) radiographs of the pelvis were taken in a standardized standing position with the centralized beam focused on the symphysis. Postoperative radiological assessments were performed on the 2nd to 3rd day after surgery and last follow up also in a standing position. All radiographs were meticulously examined using the Picture Archiving and Communication System (PACS) provided by the institutional hospital information management system (PROBEL®, İzmir, Turkey). The measurements were calibrated based on the size of the implanted femoral head using images obtained from the same X-ray device. Two independent investigators (orthopedic surgeons) performed the measurements. All measurements were made by two orthopedic surgeons who blinded to the demographic and group information of patients. In case of disagreement between examiners, consensus was reached by calculating the arithmetic average of both measurements. Parameters were measured according to the specified measurement methods: (1) The distance in ‘mm’ was measured using parallel lines passing through the greater trochanter and the femoral stem, matching femoral head size distance, the subsidence value was determined as ‘mm’ [ 9 ] (Figure-1). (2) The endosteal points at 3 cm and 10 cm distally were determined using the mid-lesser trochanteric line as a reference, as defined by Dorr et al. By comparing these lines to each other, the canal calcar ratio was found and classification was made according to these values [ 10 ] (Figure-2). (3) To evaluate femoral component osteointegration, Engh et al. The scoring system defined by was used. Fixation, stability and total scores were evaluated and according to this scoring, bone ingrowth for the prosthesis ( > + 10), suspicious bone ingrowth (0 to + 10), inadequate but stable (-10 to 0), unstable (<-10). 4 classes are defined as [ 11 ]. (4) True pelvic AP radiographs of the patients in the preoperative period, early postoperative period and last follow-up were evaluated, and the 'teardrop figures', 'ischial tuberculums' and 'trochaner minors' determined on the radiographs were used as guides and leg length differences were calculated [ 12 ] . Patient-reported outcome measures Patients were evaluated in terms of pain, function, joint range of motion and deformity with the 'modified HHS' before surgery and at their last follow-up. According to this scoring system, a score below 70 out of 100 is considered bad, between 70–79 points is considered a fair result, between 80–89 points is considered a good result, and between 90–100 points is considered an excellent result [ 13 ] . Differences were evaluated using the visual analog scale (VAS) in the preoperative period and at the last postoperative follow-up to evaluate the pain intensity of the patients. Statistical analysis Statistical analyzes were carried out with the help of SPSS version 23.0 program. The suitability of the variables to normal distribution was examined using histogram graphics and the Kolmogorov-Smirnov/Shapiro-Wilk test. Mean, standard deviation, median, minimum and maximum values ​​were used when presenting descriptive analyses. Mann Whitney U Test was used when evaluating non-normally distributed (nonparametric) variables between two groups, and Kruskal Wallis Test was used when evaluating between more than two groups. While investigating the reason for the significant difference between the groups, Benferroni multiple comparison test was used. While presenting categorical variables, the frequency and percentage values ​​of the variables were used and the analysis of categorical variables was carried out with the Chi-Square (Exact) Test. Spearman Correlation test was used to evaluate the relationships between quantitative variables. Situations where the 'p' value was below 0.05 were considered statistically significant results. Results In our study, 65 patients were included, with 5 patients undergoing bilateral hip arthroplasty in different sessions, resulting in a total of 70 hips. Among the patients, 44 (62.86%) were female and 26 (37.14%) were male. The mean age of the patients was 65.99 ± 8.10 years, with an age range of 52 to 83 years. The mean follow-up period was 24.62 ± 5.81 months. 40 (57.14%) of the operated hips were on the left side and 30 (42.86%) were on the right side (Table 1 ). Table 1 Descriptive statistics of demographic characteristics Min -Max Median Av. ±s.s. Age 52- 83 67 65.99 ± 8.10 Gender, n (%) Female 44(62.86) Male 26(37.14) Follow-up period (Month) 12- 34 24.5 24.62 ± 5.81 Operated leg Right 30 (42.86) Left 40 (57.14) During the follow-up period, two surgical complications were observed. One case of a trochanter major fracture (observed in the 18th month of follow-up) was managed conservatively. A patient who occured a distal femur fracture (observed in the 22nd month of follow-up) underwent surgical treatment, and their follow-up was subsequently terminated. During the follow-up periods, no stem revisions were performed in any of the patients. There is no statistically significant difference in clinical scores between males and females groups except stem subsidence. Subsidence values were found to be statistically significantly better in female group (p = 0.047) (Table 2 ). Table 2 Comparison of clinical scores of patients by gender Male Female Mean SD Max-Min Mean SD Max-Min p Subsidende(mm) 1.25 0.86 3.10–0.00 0.91 0.54 1.80–0.00 0.047* µ Engh score 23.7 3.5 27.0–14.0 22.3 3.0 27.0–16.5 0.088 ¥ Harris hip score postoperative 94.03 5.05 100.0 -83.85 91.63 6.30 100.0–75.0 0.126 ¥ VAS score postoperative 0.6 1.0 2.0–0.00 1.0 1.2 4.0–0.00 0.204 ¥ ¥: Mann Whitney U test, µ: Independent sample t test Patients were classified according to T scores and Dorr classification (Table 3 ). Table 3 Descriptive statistics of clinical characteristics Min Max Medyan Ort. ±s.s. Femoral neck T-score -5.2 5.2 -0.9 -0.42 ± 1.93 Total femoral T-score -2.5 2.6 -0.0 -0.23 ± 1.28 T-score(Lowest value) -6 0.7 -1.95 -2.00 ± 1.27 Dorr type A 22 (31.43) B 44 (62.86) C 4 (5.71) Femoral neck T-score Osteopenic/ osteoporotic 33 (47.14) Normal Bone Density 37 (52.86) Total femoral T-score Osteopenic/ osteoporotic 27 (38.57) Normal Bone Density 43 (61.43) T-score (Lowest value) Osteoporotic 26 (37.14) Osteopenic 30 (42.86) Normal Bone Density 14 (20.00) When examining whether clinical measurements of patients differ according to total femur T-score levels, no statistically significant difference was found between the measurement levels for low and normal bone density (p > 0.05) (Table 4 ). Table 4 Comparison of clinical measurement scores in terms of T score Total femoral T score p Low bone density Normal bone density Av. ±s.s. Median Av. ±s.s. Median VAS score preop 8.74 ± 0.98 8.00 8.70 ± 0.96 8.00 0.751 VAS score postop 0.72 ± 0.98 0.00 0.98 ± 1.18 0.00 0.157 Harris hip Score preop 42.86 ± 7.95 42.60 43.57 ± 10.13 43.40 0.795 Harris hip score postop 93.4 ± 5.44 93.85 92.42 ± 6.22 93.80 0.745 Subsidence(mm) 1.08 ± 0.73 1.10 1.02 ± 0.69 1.10 0.853 Engh score(fixation) 7.00 ± 3.06 5.00 6.28 ± 2.91 5.00 0.360 Engh score(stability) 16.02 ± 2.37 17.00 16.65 ± 1.31 17.00 0.427 Engh score(Total) 22.82 ± 3.99 22.00 22.91 ± 2.89 22.00 0.832 Evaluating whether clinical scores and subsidence values differ based on femoral neck T-score and the lowest T-score levels revealed that the results were statistically similar between the low and normal bone density groups (p > 0.05). Upon examining the clinical measurements of patients based on Dorr type levels, statistically significant differences were observed in postoperative HHS and subsidence measurements among groups A, B, and C (p < 0.05). Considering the number of patients in each group, subsidence measurement levels were evaluated between the Dorr A and Dorr B groups. No statistically significant difference was found between the subsidence measurement levels of Dorr B type patients (mean 1.10 ± 0.66) and those of Dorr A type patients (mean 0.81 ± 0.69) (p > 0.05) . Relationships between subsidence and Engh scores with T-scores were investigated; however, no statistically significant correlation was found (p > 0.05) . Discussion It has been previously reported that osteoporosis is common and inadequately treated in patients with primary OA assessed prior to arthroplasty. Furthermore, it is still unclear whether BMD measured using dual-energy X-ray absorptiometry (DXA) aids in the decision making process for choosing between cemented and uncemented total joint arthroplasty. Actually this decision is more significantly affected by factors such as age, bone geometry and the Dorr classification as seen in standard radiographs. While specific patient groups may be better suited for either cemented or uncemented options, studies have shown that survival rates for both cemented and uncemented hip and knee arthroplasties are generally comparable in patients with primary OA. Nevertheless, the broader connections between bone health -especially BMD- and the choice between cemented and uncemented total joint arthroplasty remain unclear [ 14 ]. Cementless femoral components; it was used to reduce cement-related complications such as loosening and osteolysis during periods when cementing techniques were inadequate. However, neither the use of cementless femoral components nor the development of cementing techniques have been fully successful against these complications [ 15 ]. Throughout historical development, implant designs and fixation preferences have varied greatly among countries, and no clear consensus has been reached regarding these discussions [ 16 ]. In cemented femoral stems, less subsidence is expected initially due to the use of cement for initial stabilization compared to cementless stems; however, it has been reported that both methods yield similar long-term results. In hip arthroplasty where the cementless method is preferred, the fixation of the stem depends on osseointegration, which is believed to be influenced by the bone density surrounding the stem [ 6 ]. Osteoporosis presents several key challenges during THA, including early osseointegration, intraoperative fractures, late periprosthetic fractures, and the long-term survival of the implant. Research addressing these issues in both cemented and cementless techniques remains limited [ 8 ]. A comprehensive study investigated the prevalence of osteoporosis in elderly patients undergoing THA, retrospectively evaluating 268 patients over the age of 70. Of these, 159 patients were found to be osteopenic or osteoporotic [ 17 ]. Factors influencing subsidence in patients undergoing cementless THA were investigated in postmenopausal women with a high prevalence of osteoporosis. It was suggested that reduced BMD after menopause complicates axial and rotational stability of the femoral stem. However, a prospective study involving 65 postmenopausal women with an average age of 68 found no statistically significant difference in subsidence between groups with normal and low BMD [ 18 ]. In a prospective study involving 211 patients with 218 hips, the subsidence measurements of cementless femoral stems were evaluated over a 5-year period. Factors such as age, gender, body mass index (BMI), stem type, surface coating material, and femoral head size were assessed. The average subsidence value was found to be 0.75 mm, with only 16 patients reporting subsidence greater than 2 mm. No differences were observed between groups based on age and gender [ 19 ]. However, our results indicated statistically significant lower subsidence values in the female group. The average BMD in the female group included in our study was found to be lower compared to the male group. Considering that elderly women generally have lower BMD than the general population, the authors present two potential explanations for the more pronounced initial femoral stem subsidence noted in the male group, which exhibited higher bone density. One potential explanation is that patients with osteoporosis exhibit diminished cancellous bone, resulting in the stem being primarily anchored and stabilized within the cortical bone during the surgical procedure. In contrast, patients with normal BMD maintain intact cancellous bone, which is compacted using rasps during the preparation of the stem. This process leaves a cancellous bone layer between the cortical bone and the stem, which could contribute to subsidence. Another potential explanation is that; surgeons, upon observing poor bone quality during the operation, might exercise increased caution in stem preparation and fixation. This heightened vigilance could influence the outcome and contribute to the observed subsidence patterns [ 20 ]. In a study by Dyreborg et al., the relationship between proximal femoral BMD and subsidence was examined in 62 patients. The patients were divided into two groups based on T-score values: >-1 and ≤-1. Subsidence measurements were assessed using postoperative radiostereometric analysis (RSA). No significant relationship was found between subsidence values and BMD; however, it was noted that the study was conducted in patients under 75 years of age with a T-score above − 2.5 [ 6 ]. On the other hand, a study involving 39 female patients aimed to evaluate early stability and osseointegration in patients with low bone density. The study assessed the proximal femoral bone density and femoral morphology of the patients and categorized them based on their bone density. Stem migration and osseointegration were evaluated using RSA and clinical outcomes were assessed using the HHS. Although stem migration was numerically higher in the low bone density group during the first 3 months, the 2-year follow-up showed similar results in both groups, consistent with our study [ 4 ]. In a study conducted by Rhyu et al., early subsidence values were assessed in a cohort of 320 patients. Patients over the age of 70 with proximal femur T-scores below − 2.5 were compared to a control group of patients under the age of 50. At the 1-year follow-up, no statistically significant differences in subsidence values were found between the two groups. While no patients in the study group experienced subsidence greater than 3 mm, 3 patients in the control group had subsidence exceeding 3 mm; however, this difference was not statistically significant. The study reported that low subsidence and excellent fixation were achieved after 1 year of follow-up in osteoporotic patients undergoing cementless hip arthroplasty. The study concluded that, consistent with our findings, cementless femoral stems are not contraindicated in osteoporotic patients [ 3 ]. According to our findings and perspective, no significant relationship was found between BMD and HHS or VAS scores. However, in the literature, a study evaluating the outcomes of THA in osteoporotic patients, irrespective of cement use in femoral stem fixation, found that patients with low BMD had lower clinical scores. Although inadequate osseointegration was suggested as a possible reason in this study, no evaluation of osseointegration was conducted [ 8 ]. Although early osseointegration is valuable for long-term prosthesis survival and subsidence, studies related to osseointegration in the literature are limited. In one study evaluating osseointegration, the prosthesis design was examined and Engh scores were assessed. The results indicated that prosthesis design was considered more valuable for osseointegration than BMD [ 21 ]. Another study found that osseointegration scores and clinical outcomes were related to canal fill ratio (CFR) rather than femoral morphology. It was even reported that CFR was lower in Dorr type A femurs [ 22 ]. In our study, no statistically significant relationship was found between the Engh osseointegration scores and femoral bone density. According to our view, initial stability is more important than bone density for osseointegration, just as it is for stem subsidence. This study has several limitations. In this study, only one type of prosthesis was used, and patients who underwent cemented THA were not evaluated. The radiological assessments in our study were performed using standard, non-computer-assisted methods with AP and lateral X-rays. The error margin of these methods is reported as 2 mm in the literature [ 23 ]. Given that recent studies suggest RSA would provide more accurate results. Further research with larger sample sizes is required to assess the hypothesis regarding the safety of cementless prosthesis use in patients with low bone density. Conclusion According to the results of this study, subsidence and clinical scores were found to be similar in both the normal and low bone density groups. In our view, the use of cementless femoral stems is equally reliable for both groups. Impaired osseointegration and early subsidence have been anticipated to be more related to initial stabilization than to BMD. Therefore, in cementless femoral stem applications, initial stabilization should be prioritized over bone density and femoral morphology. Abbreviations AP, antero-posterior; BMD, bone mineral density; CFR, canal fill ratio; HHS, Harris hip score; OA, osteoarthritis; PMMA, polymethylmethacrylate; RSA, radiostereometric analysis; THA, total hip arthroplasty; VAS, visual analog scale; WHO, World Health Organization Declarations Ethics approval and consent to participate: This study was performed in line with the principles of the Declaration of Helsinki. The study involved human participants and approved by the Ethics Committee of Istanbul Training and Research Hospital. (Date: 12/04/2019 No: 1790). Informed consent was obtained from all participants prior to their involvement in the study. Clinical trial number: Not applicable. Consent for publication: Not applicable. Availability of data and materials : The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests: The authors declare no competing interests. Funding: The authors declare that no funds, grants, or other support was received during the preparation of this manuscript. Authors' contributions: All authors contributed to the study. Conceptualization/Methodology: Ahmet Sinan KALYENCI and Yusuf OZTURMEN. Data Collection: Saltuk Bugra TEKIN and Zana OZMEN. Statistical analyses: Ahmet SENEL and Saltuk Bugra TEKIN. Literature research: Ahmet Sinan KALYENCI, Ibrahım DOGAN and Zana OZMEN. Writing - Original Draft: Ahmet Sinan KALYENCI. Writing - Review & Editing: Yusuf OZTURKMEN. Visualization: Ahmet Sinan KALYENCI and Ibrahım DOGAN. Supervision: Ahmet SENEL and Yusuf OZTURKMEN. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgements: Not applicable. References Charnley J. The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. J Bone Joint Surg Br. 1972;54(1):61–76. Harkess JW, Crockarell JR. Arthroplasty of the hip. In: Canale ST, Beaty JH, editors. Campbell's operative orthopaedics. 11th ed. Mosby Elsevier: Philadelphia;; 2008. Rhyu KH, Lee SM, Chun YS, Kim KI, Cho YJ, Yoo MC. Does osteoporosis increase early subsidence of cementless double-tapered femoral stem in hip arthroplasty? J Arthroplasty. 2012;27(7):1305–9. 10.1016/j.arth.2011.10.026 . Aro HT, Alm JJ, Moritz N, Mäkinen TJ, Lankinen P. 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Cite Share Download PDF Status: Published Journal Publication published 26 Dec, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 13 Nov, 2024 Reviews received at journal 10 Nov, 2024 Reviews received at journal 09 Nov, 2024 Reviews received at journal 09 Nov, 2024 Reviewers agreed at journal 04 Nov, 2024 Reviews received at journal 04 Nov, 2024 Reviewers agreed at journal 04 Nov, 2024 Reviews received at journal 03 Nov, 2024 Reviewers agreed at journal 31 Oct, 2024 Reviewers agreed at journal 30 Oct, 2024 Reviewers agreed at journal 30 Oct, 2024 Reviewers agreed at journal 30 Oct, 2024 Reviewers invited by journal 30 Oct, 2024 Editor invited by journal 29 Oct, 2024 Editor assigned by journal 28 Oct, 2024 Submission checks completed at journal 28 Oct, 2024 First submitted to journal 20 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5298016","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":374111096,"identity":"79038b4e-453f-4c68-ac85-0c9cfb76186d","order_by":0,"name":"Ahmet Sinan Kalyenci","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYFACNgaGByCamfkAkJSQIU5LAlgLG4iS4CFBCwOPAZgkqIG//1jih8Q2mzz+dp7Pr27UWPAwsB8+ugGfFokbaYclEtvSiiUO826zzjkGdBhPWtoNvNbcYG8AajmcuIGZd5txDhtQiwSPGV4t8uePN/9IbPsP1MLzzDjnHxFaDA6kHQPacgCkhflxbhsRWgxvpKVZJJxLTpxxmM2MObdPgoeNkF/kzh8zvvGhzC6xv//w48853+rk+NkPH8PvfRBgZANTbBJgkqByMPgDJpk/EKd6FIyCUTAKRhoAAONRR5HYD4SzAAAAAElFTkSuQmCC","orcid":"","institution":"Istanbul Training and Research Hospital","correspondingAuthor":true,"prefix":"","firstName":"Ahmet","middleName":"Sinan","lastName":"Kalyenci","suffix":""},{"id":374111098,"identity":"bd17f684-ad4e-4b63-ba1f-5543571e5180","order_by":1,"name":"Ibrahim Doğan","email":"","orcid":"","institution":"Erzincan University","correspondingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"","lastName":"Doğan","suffix":""},{"id":374111099,"identity":"4fd4ff9c-7917-4bb5-b155-1f68a3bc3ebc","order_by":2,"name":"Saltuk Bugra Tekin","email":"","orcid":"","institution":"Istanbul Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Saltuk","middleName":"Bugra","lastName":"Tekin","suffix":""},{"id":374111101,"identity":"c9581c6d-0682-4c21-970c-fdebfc93d74b","order_by":3,"name":"Zana Ozmen","email":"","orcid":"","institution":"Kagizman State Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zana","middleName":"","lastName":"Ozmen","suffix":""},{"id":374111102,"identity":"6715af00-28b7-4e4d-9d31-1ee84eed8cec","order_by":4,"name":"Ahmet Senel","email":"","orcid":"","institution":"Istanbul Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ahmet","middleName":"","lastName":"Senel","suffix":""},{"id":374111103,"identity":"471131a1-d1c3-4ac9-a86c-aa4eff062f03","order_by":5,"name":"Yusuf Ozturkmen","email":"","orcid":"","institution":"Istanbul Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yusuf","middleName":"","lastName":"Ozturkmen","suffix":""}],"badges":[],"createdAt":"2024-10-20 11:08:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5298016/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5298016/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-025-09432-y","type":"published","date":"2025-12-26T15:58:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69353987,"identity":"9bebaefb-13bc-4db9-9cac-514cb8afa4d5","added_by":"auto","created_at":"2024-11-19 13:32:36","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":445591,"visible":true,"origin":"","legend":"\u003cp\u003eDetermination of subsidence distance \u003cstrong\u003ea:\u003c/strong\u003epostoperative and \u003cstrong\u003eb:\u003c/strong\u003e at follow up\u003c/p\u003e\n\u003cp\u003eThe femoral stem axis (A) and the passing perpendicularly through the apex of trochanter major (B). The distance calibration has been performed based on the ratio of the 'y' values, and subsidence is defined as the change in the 'x' distances.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5298016/v1/7e36ee5409c84abd2c213d2c.jpeg"},{"id":69353988,"identity":"010a45b5-a573-447d-8e2f-9321f4722023","added_by":"auto","created_at":"2024-11-19 13:32:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":308755,"visible":true,"origin":"","legend":"\u003cp\u003eMeasuremenet of Canal calcar ratio (AA/CC)\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5298016/v1/5d9e10f4023b810810d55a43.png"},{"id":99172842,"identity":"4f555988-bee2-4942-a477-91e04c017098","added_by":"auto","created_at":"2025-12-29 16:11:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1544376,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5298016/v1/fe0c49b0-1911-4e0b-a853-d4162e75a265.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The effect of bone mineral density on femoral stem subsidence in primary cementless total hip arthroplasty: A prospective study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe success and worldwide acceptance of THA began with the use of polymethylmethacrylate (PMMA) cement, also known as acrylic, for low-friction arthroplasty and component fixation, developed and popularized by Sir John Charnley [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The emergence of problems with the use of acrylic cement in the 1970s led to the beginning of studies to eliminate the use of cement and provide biological fixation. Stability in the cementless femoral component is achieved by bone growth into the pores on the component [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith increasing life expectancy, the number of THA procedures performed in older patients is also on the rise. Although many theoretical problems arise in hip arthroplasty with advancing age, the greatest concern is decreasing bone density [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Although cementless techniques are designed for individuals with normal bone density and healing capacity in THA applications, it is possible to use cementless components in patients with impaired bone quality and limited healing capacity with improved implant designs and bioactive coating materials [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn patients with primary OA of hip undergoing primary THA, stem osteointegration, stem migration and stem placement have a significant effect on long-term functional results and pain. Although many factors are effective in bone and stem compatibility, proximal femur BMD and femoral morphology significantly affect these variables [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Considering that early implant stability has an important role in the success of cementless THA, low BMD and age-related changes in proximal femoral anatomy may compromise femoral stem stabilisation and osteointegration [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSubsidence in the femoral stem is expected to some extent in the early stages of THA. Less subsidence is expected in cemented femoral stems compared to cementless stems due to the use of cement in the initial stabilization; however, it has been stated that both methods have similar results in the long term. In cementless hip arthroplasty, the fixation of the stem depends on osteointegration, and it is believed that this osteointegration depends on the bone density around the stem [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOA and osteoporosis are orthopedic conditions whose prevalence increases with advancing age. It is accepted that there is an inverse relationship between these two diseases; it has been suggested that a person with OA will be protected from osteoporosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Regarding THA application in patients with osteoporosis there are several important issues, especially early osteointegration, intraoperative fractures, late periprosthetic fractures, and long-term survival of the implant. Research on these problems in cemented and cementless applications has been found limited [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe aim of this study was to evaluate the effect of BMD and femur morphology according to Dorr classification on early clinical and radiological outcomes in patients who underwent primary cementless THA for primary OA of hip.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e For the prospectively designed study, ethical approval was obtained from Ethics Committee of Istanbul Training and Research Hospital (date: 12/04/2019 and no: 1790). The study was applied in accordance with the ethical standards of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003ePatients aged 50\u0026ndash;85 years diagnosed with primary OA of hip, who had an indication for THA, volunteered for the study, and provided written consent were included. Patients were excluded if they had a history of previous hip surgery, severe deformity, revision hip arthroplasty, severe osteoporosis requiring or undergoing medical treatment, or if they had received or were currently receiving treatment affecting BMD. Additionally, patients with hereditary skeletal disorders and those who did not attend routine check-ups were also excluded.\u003c/p\u003e \u003cp\u003ePreoperative femoral and lumbar bone density measurements were obtained for all patients meeting the inclusion criteria. These patients were informed that they would be required to attend clinical and radiological follow-up appointments after surgery.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical procedure\u003c/h3\u003e\n\u003cp\u003eAll patients underwent surgery in the lateral decubitus position using a posterolateral approach. The largest femoral stem size that provided sufficient bone support and appropriate rotational stability was chosen for each patient. The surgeon made intraoperative decisions regarding the suitable femoral head and liner to ensure joint stability. The same acetabular (Smith \u0026amp; Nephew EP-HIT PLUS\u0026reg;) and femoral (Smith \u0026amp; Nephew SYNERGY\u0026reg;) components were implanted in all patients. One patient experienced a major trochanter fracture, and another sustained a distal femur fracture during the procedure. These fractures were treated in the same session. However, these two patients were excluded from the study because the established postoperative treatment and rehabilitation protocols could not be applied to them.\u003c/p\u003e \u003cp\u003eAll patients received the same rehabilitation program determined for the study, which included early mobilization with a walker as soon as possible, allowing weight-bearing as tolerated, along with range of motion and isometric exercises. Patients were mobilized with full weight-bearing on the first postoperative day, and the rest of the rehabilitation program was initiated accordingly.\u003c/p\u003e\n\u003ch3\u003eRadiographic measurements\u003c/h3\u003e\n\u003cp\u003eBone density was measured in the proximal femur, femoral neck on the side to be operated, and lumbar vertebrae. Based on the World Health Organization (WHO) criteria, patients were classified as either having normal bone density or low bone density (osteopenic/osteoporotic; T scores \u0026lt; -1) according to the lowest values ​​of bone density, defined by the WHO as lumbar vertebrae, proximal femur and femoral neck bone density values. The bone density measurements of the proximal femoral region covered approximately 25 cm of the proximal femur, as specified by the device used, and were defined as the \u0026lsquo;total femoral T score\u0026rsquo;(Horizon DXA System; Hologic\u0026reg;).\u003c/p\u003e \u003cp\u003eAntero\u0026ndash;posterior(AP) radiographs of the pelvis were taken in a standardized standing position with the centralized beam focused on the symphysis. Postoperative radiological assessments were performed on the 2nd to 3rd day after surgery and last follow up also in a standing position. All radiographs were meticulously examined using the Picture Archiving and Communication System (PACS) provided by the institutional hospital information management system (PROBEL\u0026reg;, İzmir, Turkey). The measurements were calibrated based on the size of the implanted femoral head using images obtained from the same X-ray device. Two independent investigators (orthopedic surgeons) performed the measurements. All measurements were made by two orthopedic surgeons who blinded to the demographic and group information of patients. In case of disagreement between examiners, consensus was reached by calculating the arithmetic average of both measurements.\u003c/p\u003e \u003cp\u003eParameters were measured according to the specified measurement methods:\u003c/p\u003e \u003cp\u003e(1) The distance in \u0026lsquo;mm\u0026rsquo; was measured using parallel lines passing through the greater trochanter and the femoral stem, matching femoral head size distance, the subsidence value was determined as \u0026lsquo;mm\u0026rsquo; [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] (Figure-1).\u003c/p\u003e \u003cp\u003e(2) The endosteal points at 3 cm and 10 cm distally were determined using the mid-lesser trochanteric line as a reference, as defined by Dorr et al. By comparing these lines to each other, the canal calcar ratio was found and classification was made according to these values [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] (Figure-2).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e(3) To evaluate femoral component osteointegration, Engh et al. The scoring system defined by was used. Fixation, stability and total scores were evaluated and according to this scoring, bone ingrowth for the prosthesis (\u0026thinsp;\u0026gt;\u0026thinsp;+\u0026thinsp;10), suspicious bone ingrowth (0 to +\u0026thinsp;10), inadequate but stable (-10 to 0), unstable (\u0026lt;-10). 4 classes are defined as [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e(4) True pelvic AP radiographs of the patients in the preoperative period, early postoperative period and last follow-up were evaluated, and the 'teardrop figures', 'ischial tuberculums' and 'trochaner minors' determined on the radiographs were used as guides and leg length differences were calculated [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] .\u003c/p\u003e\n\u003ch3\u003ePatient-reported outcome measures\u003c/h3\u003e\n\u003cp\u003ePatients were evaluated in terms of pain, function, joint range of motion and deformity with the 'modified HHS' before surgery and at their last follow-up. According to this scoring system, a score below 70 out of 100 is considered bad, between 70\u0026ndash;79 points is considered a fair result, between 80\u0026ndash;89 points is considered a good result, and between 90\u0026ndash;100 points is considered an excellent result [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eDifferences were evaluated using the visual analog scale (VAS) in the preoperative period and at the last postoperative follow-up to evaluate the pain intensity of the patients.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyzes were carried out with the help of SPSS version 23.0 program. The suitability of the variables to normal distribution was examined using histogram graphics and the Kolmogorov-Smirnov/Shapiro-Wilk test. Mean, standard deviation, median, minimum and maximum values ​​were used when presenting descriptive analyses. Mann Whitney U Test was used when evaluating non-normally distributed (nonparametric) variables between two groups, and Kruskal Wallis Test was used when evaluating between more than two groups. While investigating the reason for the significant difference between the groups, Benferroni multiple comparison test was used. While presenting categorical variables, the frequency and percentage values ​​of the variables were used and the analysis of categorical variables was carried out with the Chi-Square (Exact) Test. Spearman Correlation test was used to evaluate the relationships between quantitative variables. Situations where the 'p' value was below 0.05 were considered statistically significant results.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn our study, 65 patients were included, with 5 patients undergoing bilateral hip arthroplasty in different sessions, resulting in a total of 70 hips. Among the patients, 44 (62.86%) were female and 26 (37.14%) were male. The mean age of the patients was 65.99\u0026thinsp;\u0026plusmn;\u0026thinsp;8.10 years, with an age range of 52 to 83 years. The mean follow-up period was 24.62\u0026thinsp;\u0026plusmn;\u0026thinsp;5.81 months. 40 (57.14%) of the operated hips were on the left side and 30 (42.86%) were on the right side (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics of demographic characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMin\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-Max\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAv.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026plusmn;s.s.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e65.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;8.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e44(62.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e26(37.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFollow-up period (Month)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e24.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;5.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOperated leg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e(42.86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e(57.14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDuring the follow-up period, two surgical complications were observed. One case of a trochanter major fracture (observed in the 18th month of follow-up) was managed conservatively. A patient who occured a distal femur fracture (observed in the 22nd month of follow-up) underwent surgical treatment, and their follow-up was subsequently terminated. During the follow-up periods, no stem revisions were performed in any of the patients. There is no statistically significant difference in clinical scores between males and females groups except stem subsidence. Subsidence values were found to be statistically significantly better in female group (p\u0026thinsp;=\u0026thinsp;0.047) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of clinical scores of patients by gender\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMax-Min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMax-Min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubsidende(mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.10\u0026ndash;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.80\u0026ndash;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.047*\u003csup\u003e\u0026micro;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEngh score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.0\u0026ndash;14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e27.0\u0026ndash;16.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.088\u003csup\u003e\u0026yen;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHarris hip score postoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0 -83.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e91.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100.0\u0026ndash;75.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.126\u003csup\u003e\u0026yen;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS score postoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.0\u0026ndash;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.0\u0026ndash;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.204\u003csup\u003e\u0026yen;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026yen;: Mann Whitney U test, \u0026micro;: Independent sample t test\u003c/p\u003e \u003cp\u003ePatients were classified according to T scores and Dorr classification (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics of clinical characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMin\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMax\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMedyan\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOrt.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026plusmn;s.s.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFemoral neck T-score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;1.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTotal femoral T-score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eT-score(Lowest value)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;1.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDorr type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e(31.43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e(62.86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e(5.71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFemoral neck T-score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOsteopenic/\u003c/p\u003e \u003cp\u003eosteoporotic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e(47.14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal Bone Density\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e(52.86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal femoral T-score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOsteopenic/\u003c/p\u003e \u003cp\u003eosteoporotic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e(38.57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal Bone Density\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e(61.43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT-score\u003c/p\u003e \u003cp\u003e(Lowest value)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOsteoporotic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e(37.14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOsteopenic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e(42.86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal Bone Density\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e(20.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen examining whether clinical measurements of patients differ according to total femur T-score levels, no statistically significant difference was found between the measurement levels for low and normal bone density (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of clinical measurement scores in terms of T score\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003eTotal femoral T score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eLow bone density\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eNormal bone density\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAv.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;s.s.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAv.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026plusmn;s.s.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS score preop\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.751\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS score postop\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.157\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHarris hip Score preop\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;7.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e43.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;10.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e43.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.795\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHarris hip score postop\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e93.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;5.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e93.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e92.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;6.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e93.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.745\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubsidence(mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.853\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEngh score(fixation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;3.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;2.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.360\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEngh score(stability)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;2.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e17.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.427\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEngh score(Total)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;3.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;2.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e22.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.832\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEvaluating whether clinical scores and subsidence values differ based on femoral neck T-score and the lowest T-score levels revealed that the results were statistically similar between the low and normal bone density groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eUpon examining the clinical measurements of patients based on Dorr type levels, statistically significant differences were observed in postoperative HHS and subsidence measurements among groups A, B, and C (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Considering the number of patients in each group, subsidence measurement levels were evaluated between the Dorr A and Dorr B groups. No statistically significant difference was found between the subsidence measurement levels of Dorr B type patients (mean 1.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66) and those of Dorr A type patients (mean 0.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69) (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) .\u003c/p\u003e \u003cp\u003eRelationships between subsidence and Engh scores with T-scores were investigated; however, no statistically significant correlation was found (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) .\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIt has been previously reported that osteoporosis is common and inadequately treated in patients with primary OA assessed prior to arthroplasty. Furthermore, it is still unclear whether BMD measured using dual-energy X-ray absorptiometry (DXA) aids in the decision making process for choosing between cemented and uncemented total joint arthroplasty. Actually this decision is more significantly affected by factors such as age, bone geometry and the Dorr classification as seen in standard radiographs. While specific patient groups may be better suited for either cemented or uncemented options, studies have shown that survival rates for both cemented and uncemented hip and knee arthroplasties are generally comparable in patients with primary OA. Nevertheless, the broader connections between bone health -especially BMD- and the choice between cemented and uncemented total joint arthroplasty remain unclear [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCementless femoral components; it was used to reduce cement-related complications such as loosening and osteolysis during periods when cementing techniques were inadequate. However, neither the use of cementless femoral components nor the development of cementing techniques have been fully successful against these complications [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Throughout historical development, implant designs and fixation preferences have varied greatly among countries, and no clear consensus has been reached regarding these discussions [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn cemented femoral stems, less subsidence is expected initially due to the use of cement for initial stabilization compared to cementless stems; however, it has been reported that both methods yield similar long-term results. In hip arthroplasty where the cementless method is preferred, the fixation of the stem depends on osseointegration, which is believed to be influenced by the bone density surrounding the stem [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOsteoporosis presents several key challenges during THA, including early osseointegration, intraoperative fractures, late periprosthetic fractures, and the long-term survival of the implant. Research addressing these issues in both cemented and cementless techniques remains limited [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A comprehensive study investigated the prevalence of osteoporosis in elderly patients undergoing THA, retrospectively evaluating 268 patients over the age of 70. Of these, 159 patients were found to be osteopenic or osteoporotic [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFactors influencing subsidence in patients undergoing cementless THA were investigated in postmenopausal women with a high prevalence of osteoporosis. It was suggested that reduced BMD after menopause complicates axial and rotational stability of the femoral stem. However, a prospective study involving 65 postmenopausal women with an average age of 68 found no statistically significant difference in subsidence between groups with normal and low BMD [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a prospective study involving 211 patients with 218 hips, the subsidence measurements of cementless femoral stems were evaluated over a 5-year period. Factors such as age, gender, body mass index (BMI), stem type, surface coating material, and femoral head size were assessed. The average subsidence value was found to be 0.75 mm, with only 16 patients reporting subsidence greater than 2 mm. No differences were observed between groups based on age and gender [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, our results indicated statistically significant lower subsidence values in the female group. The average BMD in the female group included in our study was found to be lower compared to the male group. Considering that elderly women generally have lower BMD than the general population, the authors present two potential explanations for the more pronounced initial femoral stem subsidence noted in the male group, which exhibited higher bone density. One potential explanation is that patients with osteoporosis exhibit diminished cancellous bone, resulting in the stem being primarily anchored and stabilized within the cortical bone during the surgical procedure. In contrast, patients with normal BMD maintain intact cancellous bone, which is compacted using rasps during the preparation of the stem. This process leaves a cancellous bone layer between the cortical bone and the stem, which could contribute to subsidence. Another potential explanation is that; surgeons, upon observing poor bone quality during the operation, might exercise increased caution in stem preparation and fixation. This heightened vigilance could influence the outcome and contribute to the observed subsidence patterns [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a study by Dyreborg et al., the relationship between proximal femoral BMD and subsidence was examined in 62 patients. The patients were divided into two groups based on T-score values: \u0026gt;-1 and \u0026le;-1. Subsidence measurements were assessed using postoperative radiostereometric analysis (RSA). No significant relationship was found between subsidence values and BMD; however, it was noted that the study was conducted in patients under 75 years of age with a T-score above \u0026minus;\u0026thinsp;2.5 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. On the other hand, a study involving 39 female patients aimed to evaluate early stability and osseointegration in patients with low bone density. The study assessed the proximal femoral bone density and femoral morphology of the patients and categorized them based on their bone density. Stem migration and osseointegration were evaluated using RSA and clinical outcomes were assessed using the HHS. Although stem migration was numerically higher in the low bone density group during the first 3 months, the 2-year follow-up showed similar results in both groups, consistent with our study [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a study conducted by Rhyu et al., early subsidence values were assessed in a cohort of 320 patients. Patients over the age of 70 with proximal femur T-scores below \u0026minus;\u0026thinsp;2.5 were compared to a control group of patients under the age of 50. At the 1-year follow-up, no statistically significant differences in subsidence values were found between the two groups. While no patients in the study group experienced subsidence greater than 3 mm, 3 patients in the control group had subsidence exceeding 3 mm; however, this difference was not statistically significant. The study reported that low subsidence and excellent fixation were achieved after 1 year of follow-up in osteoporotic patients undergoing cementless hip arthroplasty. The study concluded that, consistent with our findings, cementless femoral stems are not contraindicated in osteoporotic patients [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to our findings and perspective, no significant relationship was found between BMD and HHS or VAS scores. However, in the literature, a study evaluating the outcomes of THA in osteoporotic patients, irrespective of cement use in femoral stem fixation, found that patients with low BMD had lower clinical scores. Although inadequate osseointegration was suggested as a possible reason in this study, no evaluation of osseointegration was conducted [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough early osseointegration is valuable for long-term prosthesis survival and subsidence, studies related to osseointegration in the literature are limited. In one study evaluating osseointegration, the prosthesis design was examined and Engh scores were assessed. The results indicated that prosthesis design was considered more valuable for osseointegration than BMD [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Another study found that osseointegration scores and clinical outcomes were related to canal fill ratio (CFR) rather than femoral morphology. It was even reported that CFR was lower in Dorr type A femurs [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In our study, no statistically significant relationship was found between the Engh osseointegration scores and femoral bone density. According to our view, initial stability is more important than bone density for osseointegration, just as it is for stem subsidence.\u003c/p\u003e \u003cp\u003eThis study has several limitations. In this study, only one type of prosthesis was used, and patients who underwent cemented THA were not evaluated. The radiological assessments in our study were performed using standard, non-computer-assisted methods with AP and lateral X-rays. The error margin of these methods is reported as 2 mm in the literature [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Given that recent studies suggest RSA would provide more accurate results. Further research with larger sample sizes is required to assess the hypothesis regarding the safety of cementless prosthesis use in patients with low bone density.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAccording to the results of this study, subsidence and clinical scores were found to be similar in both the normal and low bone density groups. In our view, the use of cementless femoral stems is equally reliable for both groups. Impaired osseointegration and early subsidence have been anticipated to be more related to initial stabilization than to BMD. Therefore, in cementless femoral stem applications, initial stabilization should be prioritized over bone density and femoral morphology.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAP, antero-posterior; BMD, bone mineral density; CFR, canal fill ratio; HHS, Harris hip score; OA, osteoarthritis; PMMA, polymethylmethacrylate; RSA, radiostereometric analysis; THA, total hip arthroplasty; VAS, visual analog scale; WHO, World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis study was performed in line with the principles of the Declaration of Helsinki. The study involved human participants and approved by the Ethics Committee of Istanbul Training and Research Hospital. (Date: 12/04/2019 No: 1790). Informed consent was obtained from all participants prior to their involvement in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe authors declare that no funds, grants, or other support was received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u0026nbsp;\u003c/strong\u003eAll authors contributed to the study. Conceptualization/Methodology: Ahmet Sinan KALYENCI and Yusuf OZTURMEN. Data Collection: Saltuk Bugra TEKIN and Zana OZMEN. \u0026nbsp;Statistical analyses: Ahmet SENEL and Saltuk Bugra TEKIN. Literature research: Ahmet Sinan KALYENCI, Ibrahım DOGAN and Zana OZMEN. Writing - Original Draft: Ahmet Sinan KALYENCI. Writing - Review \u0026amp; Editing: Yusuf OZTURKMEN. Visualization: Ahmet Sinan KALYENCI and Ibrahım DOGAN. Supervision: Ahmet SENEL and Yusuf OZTURKMEN. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCharnley J. The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. 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Clin Orthop. 2018;476:1428\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/01.blo.0000533621.57561.a4\u003c/span\u003e\u003cspan address=\"10.1097/01.blo.0000533621.57561.a4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelsmann MM, Strahl A, M\u0026uuml;hlenfeld M, et al. High prevalence and undertreatment of osteoporosis in elderly patients undergoing total hip arthroplasty. Osteoporos Int. 2021;32(8):1661\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00198-021-05881-y\u003c/span\u003e\u003cspan address=\"10.1007/s00198-021-05881-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNazari-Farsani S, Vuopio M, L\u0026ouml;yttyniemi E, Aro HT. 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Bone Joint Res. 2020;9(4):182\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1302/2046-3758.94.BJR-2019-0149.R2\u003c/span\u003e\u003cspan address=\"10.1302/2046-3758.94.BJR-2019-0149.R2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eK\u0026auml;rrholm J, Borss\u0026eacute;n B, L\u0026ouml;wenhielm G, Snorrason F. Does early micromotion of femoral stem prostheses matter? 4-7-year stereoradiographic follow-up of 84 cemented prostheses. J Bone Joint Surg Br. 1994;76(6):912\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Subsidence, cementless total hip arthroplasty, bone mineral density, Dorr classification, osteointegration","lastPublishedDoi":"10.21203/rs.3.rs-5298016/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5298016/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The success of primary total hip arthroplasty (THA) in patiens with primary osteoarthritis (OA) of hip is significantly inflenced by stem osteointegration, migration and placement. Additionally, the bone mineral density (BMD) of the proximal femur and the femoral morphology play important roles in these outcomes. We aimed to prospectively evaluate the effect of BMD on subsidence who underwent primary cementless THA for primary OA of hip.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We conducted a prospective observational study on 70 hip (65 patients) diagnosed with primary OA of hip who underwent primary cementless THA. Patients were grouped according to preoperative BMD and proximal femur anatomy based on Dorr classificaiton. \u0026nbsp;Harris hip score (HHS) and radiological subsidence values ​​were used for postoperative clinical evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The mean follow-up was 24.6 ± 5.8 months. Of the 70 hips, 22 (31.43%) were Dorr type A, 44 (62.86%) type B, and 4 (5.71%) type C. According to total femur T scores, 43 patients (61.43%) had normal BMD, while 27 patients (38.57%) were identified as osteopenic or osteoporotic. The mean axial migration at last follow-up was 1.04 ± 0.69 mm. No significant influence on migration was found regarding total femur T score levels and femoral morphologies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eIn our study, we investigated the early results of cementless THA in patients with low BMD and advanced age group. We evaluated the clinical and radiological results in groups with different bone density and femoral morphology. In our results, evaluated in light of similar studies, we found that HHS, subsidence values and Engh scores were comparable between patients with normal and low BMD, with no statistically significant differences observed.\u003c/p\u003e","manuscriptTitle":"The effect of bone mineral density on femoral stem subsidence in primary cementless total hip arthroplasty: A prospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-19 13:32:31","doi":"10.21203/rs.3.rs-5298016/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-13T07:22:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-10T07:37:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-09T20:54:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-09T09:17:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80218667176491783274670807453948038041","date":"2024-11-05T02:00:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-04T19:57:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"226914373900648086211210530273298423634","date":"2024-11-04T17:51:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-03T14:26:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"195049566657561324178414245231167114053","date":"2024-10-31T05:11:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294459918858180338811166165933622447964","date":"2024-10-30T14:57:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"137136581246384837260515188999232172688","date":"2024-10-30T12:40:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2024-10-30T11:36:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-30T11:33:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-10-29T10:30:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-28T05:28:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-28T05:25:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2024-10-20T10:53:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3bba5000-6cdc-442b-bca7-391f3b969eae","owner":[],"postedDate":"November 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-29T16:09:24+00:00","versionOfRecord":{"articleIdentity":"rs-5298016","link":"https://doi.org/10.1186/s12891-025-09432-y","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2025-12-26 15:58:30","publishedOnDateReadable":"December 26th, 2025"},"versionCreatedAt":"2024-11-19 13:32:31","video":"","vorDoi":"10.1186/s12891-025-09432-y","vorDoiUrl":"https://doi.org/10.1186/s12891-025-09432-y","workflowStages":[]},"version":"v1","identity":"rs-5298016","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5298016","identity":"rs-5298016","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}