This manuscript reviews the development of femoral stem prostheses in the biomedical field. After a brief introduction on the development of these prostheses and the associated problems, we describe the standard design of these systems. We review the different materials, constructions, and surfaces used in the development of femoral stems, in order to solve and avoid various problems associated with their use. Femoral stem prostheses have undergone substantial changes and design optimizations since their introduction. Common materials include stainless steel, cobalt–chromium alloy, titanium alloy, and composites. The structural development of femoral stem prostheses, including their length, shape, porosity, and functional gradient construction, is also reviewed. The performance of these prostheses is affected not only by individual factors, but also by the synergistic combination of multiple effects; therefore, several aspects need to be optimized. The main purpose of this study is to summarize various strategies for the material and construction optimization of femoral stem prostheses, and to provide a reference for the combined optimization of their performance. Substantial research is still needed to develop prostheses emulating the behavior of a real human femoral stem.