Elsevier

The Lancet

Volume 370, Issue 9597, 27 October–2 November 2007, Pages 1508-1519
The Lancet

Review
The operation of the century: total hip replacement

https://doi.org/10.1016/S0140-6736(07)60457-7Get rights and content

Summary

In the 1960s, total hip replacement revolutionised management of elderly patients crippled with arthritis, with very good long-term results. Today, young patients present for hip-replacement surgery hoping to restore their quality of life, which typically includes physically demanding activities. Advances in bioengineering technology have driven development of hip prostheses. Both cemented and uncemented hips can provide durable fixation. Better materials and design have allowed use of large-bore bearings, which provide an increased range of motion with enhanced stability and very low wear. Minimally invasive surgery limits soft-tissue damage and facilitates accelerated discharge and rehabilitation. Short-term objectives must not compromise long-term performance. Computer-assisted surgery will contribute to reproducible and accurate placement of implants. Universal economic constraints in healthcare services dictate that further developments in total hip replacement will be governed by their cost-effectiveness.

Section snippets

Cemented total hip replacement

Glück, a German surgeon, was the first researcher to use cement “for a better fixation” of both components of an ivory total knee replacement in 1891.21 However, Charnley introduced and popularised use of polymethyl methacrylate bone cement for fixation of total hip prostheses in the late 1950s.22 Although cemented fixation includes both bone-cement and cement-implant interfaces, the bone-cement surface is the one that provides the foundation for durable fixation. Cemented total hip replacement

Uncemented total hip replacement

Early failure of cemented stems implanted by first-generation cementation techniques was frequent. These failures were associated with localised areas of bone destruction and resorption (osteolysis). Their cause was initially believed to be infection40 but was subsequently attributed to a local inflammatory response initiated by cement particles. In the 1970s, histological examination of tissue taken from these localised areas of osteolysis showed the presence of polymethyl methacrylate debris,

Bone-conserving femoral implants

Arthritis of the hip mainly affects articular surfaces of the joint and subchondral bone. Intuitively, resurfacing of the joint is the logical conservative surgical option. Resurfacing prostheses that were popular in the early 1970s had a large diameter head articulating with a cemented polyethylene acetabular component. The polyethylene was very thin, and this aspect—together with the high frictional torque generated by the large diameter head—produced catastrophic wear of the plastic,

Minimally invasive surgery

There is a current trend towards minimally invasive surgery, either through one mini-incision or with a two-incision technique. The claim is that mini-incision procedures reduce pain, blood loss, rehabilitation time, and hospital stay.119 Single-incision surgery—using the same surgical approach as conventional procedures but with a skin incision of less than 10 cm—has been approved by the UK's National Institute for Clinical Excellence (NICE)120 based on data from two randomised controlled

Outcome assessment

30 years ago, the main indications for total hip replacement were pain, disability, or both. Outcome assessment was surgeon-based with hip scores. Charnley's modification of the Merle d'Aubigné and Postel score129 and the Harris hip score130 remain two of the most widely used methods. An inherent difficulty of most surgeon-based scoring systems for assessment of outcomes is that they are composite scores, which include clinical and radiological data together with patient-based subjective

Discussion

Biological resurfacing of the hip joint with engineered tissue is at present no more than a theoretical possibility. Total hip replacement will therefore remain the treatment of choice for arthritis of the hip for the foreseeable future. Both cemented and cementless implants can provide good fixation with favourable long-term results. Today, uncemented prostheses are preferred globally, although this choice is not evidence based and might be less cost effective than cemented implants.

Search strategy and selection criteria

We searched PubMed and Medline from 1966 to April, 2006, with the terms: “total hip arthroplasty”, “cemented femoral stems OR acetabular cups”, “cementless femoral stems OR acetabular cups”, “bearing surfaces in hip replacement”, “metal-on-metal”, “ceramic bearings in hip replacement”, “outcomes OR survivorship in hip replacement”, and “minimally invasive hip surgery”. Websites of arthroplasty hip registries and the National Institute for Clinical Excellence were searched, and, when

References (144)

  • VJ Rasquinha et al.

    Hydroxyapatite: catalyst or conjuror?

    J Arthroplasty

    (2002)
  • TR Green et al.

    Polyethylene particles of a ‘critical size’ are necessary for the induction of cytokines by macrophages in vitro

    Biomaterials

    (1998)
  • TP Schmalzried et al.

    Long-duration metal-on-metal total hip arthroplasties with low wear of the articulating surfaces

    J Arthroplasty

    (1996)
  • D Naudie et al.

    Metal-on-metal versus metal-on-polyethylene bearings in total hip arthroplasty: a matched case-control study

    J Arthroplasty

    (2004)
  • I Harding et al.

    Serum levels of cobalt and chromium in a complex modular total hip arthroplasty system

    J Arthroplasty

    (2002)
  • WW Buchanan et al.

    History of rheumatic diseases (ch 1)

  • J Berato et al.

    [Epidemiology of rheumatic diseases in an ancient population: study of the Necropole du Haut-Empire de Saint-Lambert (Frejus, Var)]

    Rev Rhum Mal Osteoartic

    (1990)
  • MN Smith-Petersen

    The classic: evolution of mould arthroplasty of the hip joint

    J Bone Joint Surg

    (1948)
  • P Wiles

    The surgery of the osteoarthritic hip

    Br J Surg

    (1958)
  • DJ Berry et al.

    Twenty-five-year survivorship of two thousand consecutive primary Charnley total hip replacements: factors affecting survivorship of acetabular and femoral components

    J Bone Joint Surg Am

    (2002)
  • JJ Callaghan et al.

    Charnley total hip arthroplasty with cement: minimum twenty-five-year follow-up

    J Bone Joint Surg Am

    (2000)
  • BM Wroblewski et al.

    Charnley low-frictional torque arthroplasty of the hip: 20-to-30 year results

    J Bone Joint Surg Br

    (1999)
  • MB Coventry

    Foreword

  • D Fender et al.

    Outcome of Charnley total hip replacement across a single health region in England: the results at five years from a regional hip register

    J Bone Joint Surg Br

    (1999)
  • J Charnley

    Fracture of femoral prostheses in total hip replacement: a clinical study

    Clin Orthop Relat Res

    (1975)
  • J Charnley

    Long-term clinical results

    Low friction arthroplasty of the hip: theory and practice

    (1979)
  • NS Eftekhar

    Long-term results of cemented total hip arthroplasty

    Clin Orthop Relat Res

    (1987)
  • BM Wroblewski

    Direction and rate of socket wear in Charnley low-friction arthroplasty

    J Bone Joint Surg Br

    (1985)
  • RY Woo et al.

    Dislocations after total hip arthroplasty

    J Bone Joint Surg Am

    (1982)
  • LD Dorr et al.

    Total hip arthroplasties in patients younger than 45 years: a nine- to ten-year follow-up study

    Clin Orthop Relat Res

    (1990)
  • Malchau H, Herberts P, Garellick G, Soderman P, Eisler T. Prognosis of total hip replacement: update of results and...
  • HP Chandler et al.

    Total hip replacement in patients younger than thirty years old: a five-year follow-up study

    J Bone Joint Surg Am

    (1981)
  • T Glück

    Referat über die durch das moderne chirurgische experiment gewonnenen positiven resultaten, betreffende die naht und den ersatz von defekten hőherer gewebe, sowie über die verwerthung resorbirbarer und lebendiger tampons in der chirurgie

    Arch Klin Chir

    (1891)
  • J Charnley

    Anchorage of the femoral head prosthesis to the shaft of the femur

    J Bone Joint Surg Br

    (1960)
  • MJ Askew et al.

    Effect of cement pressure and bone strength on polymethylmethacrylate fixation

    J Orthop Res

    (1984)
  • WR Krause et al.

    Strength of the cement-bone interface

    Clin Orthop Relat Res

    (1982)
  • RS Majkowski et al.

    Bone surface preparation in cemented joint replacement

    J Bone Joint Surg Br

    (1993)
  • C Gozzard et al.

    An in-vitro investigation of the CPS-Plus femoral stem: influence of the proximal centraliser on cement pressurisation during stem insertion

    Acta Orthop Scand

    (2003)
  • P Herberts et al.

    Long-term registration has improved the quality of hip replacement: a review of the Swedish THR Register comparing 160 000 cases

    Acta Orthop Scand

    (2000)
  • RD Mulroy et al.

    The effect of improved cementing techniques on component loosening in total hip replacement: an 11-year radiographic review

    J Bone Joint Surg Br

    (1990)
  • HD Williams et al.

    The Exeter universal cemented femoral component at 8 to 12 years: a study of the first 325 hips

    J Bone Joint Surg Br

    (2002)
  • F Langlais et al.

    The ‘French paradox’

    J Bone Joint Surg Br

    (2003)
  • J Charnley

    The long-term results of low-friction arthroplasty of the hip performed as a primary intervention

    J Bone Joint Surg Br

    (1972)
  • DM Dall et al.

    Fracture and loosening of Charnley femoral stems: comparison between first-generation and subsequent designs

    J Bone Joint Surg Br

    (1993)
  • Malchau H, Herberts P. Prognosis of total hip replacement: surgical and cementing technique in THR—a revision-risk...
  • SN Massoud et al.

    Early femoral loosening in one design of cemented hip replacement

    J Bone Joint Surg Br

    (1997)
  • LI Havelin et al.

    The performance of two hydroxyapatite-coated acetabular cups compared with Charnley cups: from the Norwegian Arthroplasty Register

    J Bone Joint Surg Br

    (2002)
  • Gie GA, Hoe F, Timperley AJ, Ling RSM. The Exeter polished stem in the longer term: a survivorship study to the 33rd...
  • AI Spitzer

    The cemented femoral stem: selecting the ideal patient

    Orthopedics

    (2005)
  • J Charnley

    Long-term radiological results

    Low friction arthroplasty of the hip: theory and practice

    (1979)
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