Introduction Varus positioning is the most common femoral malposition in total hip arthroplasty (THA). We compared the long-term outcomes of an anatomical cementless femoral stem positioned in varus versus neutral alignment. Materials and methods Data were retrospectively reviewed for all patients receiving a cementless anatomical femoral stem in THA for osteoarthritis between 1998 and 2008. Exclusion criteria were complex cases, incomplete data or follow-up < 1 year. Primary outcome was survival rate with complications and secondary outcomes were clinical scores, thigh pain, radiological score, cortical hypertrophy and filling rate. Results Of the 283 included patients, 127 stems were classified as varus and 156 neutral. Mean follow-up was 10 years. Femoral stem size was smaller in the varus group (4.1 vs. 4.4, p = 0.047). A stem-filling rate < 80 was more frequent in the varus group (p < 0.001). The long-term survival rate without any revision procedure was 94.8 +/- 2.3 (95CI 88.4-98.7) in the varus group and 94.1 +/- 2.0 (95CI 91.3-99.1) in the neutral group (p = 0.55). There was no difference in clinical scores, thigh pain or complication occurrence between groups. The Engh-Massin score was lower in the varus group (p < 0.01) and cortical hypertrophy was higher (p < 0.001). Conclusions A varus alignment of a cementless anatomic femoral stem does not affect survivorship, clinical outcomes or complication rate on an average follow-up of 10 years, despite increasing stress-shielding rates.
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