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
ReviewThe operation of the century: total hip replacement
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
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