KUWAIT MEDICAL JOURNAL December 2004

Kuwait Medical Journal 2004, 36 (4):250-255

Review Article

Total Hip Replacement: Past, Present and Future

Address correspondence to:Wieslaw Pospula M.D., Ph.D, Al Razi Orthopedic Hospital, P.O. Box 4235, Safat 13043 Kuwait. Fax:4822240. Email:pospulawieslaw@hotmail.com

Wieslaw PospulaDepartment of Orthopedics, Al Razi Hospital, Kuwait

INTRODUCTIONTotal hip replacement has been one of the most

successful operations in orthopedic surg e r y. Byalleviating pain and disability, it has helpedpatients to return to active life. Several hundreds ofthousands hip replacements are conducted everyyear, worldwide. Hip, the second biggest joint ofthe human body with it’s primary role inlocomotion, may be exposed to a number of nontraumatic and traumatic hazards that may result inthe condition known as osteoarthritis. Regardlessof the initial pathology, the end result of thisprocess is nearly always the same, characterized bypain, limitation of movements and impaire dlocomotor function. A number of surgical methodshave been designed and developed for thiscondition in the past including osteotomies, fusionsand resections, but they never provided satisfyingresults for patients and their doctors. Therefore, theidea of prosthetic replacement of the hip hasgradually emerged.

This article is a concise review of thedevelopment of this concept and tre a t m e n tmodality over the last two centuries. The reviewalso identifies the role of hip replacement today andspeculates about its future.

HISTORICAL ASPECTSThe first attempts to replace the hip joint were

made by Gluck from Berlin (Germany) in 1880. Theprosthesis was manufactured from ivory. It wasobviously not a success. A second attempt, byFrench surgeon Jules Pean from Paris in 1890 withthe prosthesis made from platinum also failed[1]. Itwas not until 1925 that a subsequent trial tookplace, this time in the USA by Smith-Petersen fromBoston[2]. The glass and bakelite design that he usedcould not withstand the mechanical demand andinevitably failed. In 1938, the Judet brothers in Parisinvented an acrylic hip prosthesis, but failed again,as it became loose and had to be removed[3]. Itbecame obvious that joint replacement could notsucceed until appropriate materials were found ormanufactured. Milestones on this way have been

the inventions of a chrome-cobalt alloycharacterized by high mechanical and surfaceresistance, high-density polyethylene and bonecement. Initially, only the femoral head wasreplaced using cementless (Moore) and cemented(Thompson) prosthesis[4,5] (Fig. 1). These devices,however, could only be used when the acetabulumwas unchanged, limiting the indications to femoralneck fracture. In prostheses that were introduced inthe fifties by Mc Kee from Norwich in Britain, andlater by Herbert from Aix les Bains in France, firstgeneration metal on metal bearing was used andthey were mostly abandoned due to excessive wearand metal particles release causing metallosis[1,6].The first successful series of implantations of thetotal hip prosthesis (i . e . replacing both hipcomponents) with excellent mid-term results wasreported by Sir John Charnley, a renowned Britishorthopedic surgeon from Wrightington OrthopedicCenter, in the sixties of the last century[7]. The initialprosthesis consisted of a Teflon acetabular cup anda stainless steel monobloc femoral component. Thehead diameter used was 22.2 mm consistent withhis idea of low friction arthroplasty. The prosthesiswas fixed to bone using polymethylmethacrylate, acold curing polymer that bonds the prosthesis withthe bone bed. Teflon proved to be unsuitable as aprosthetic bearing with high wear and tear and wasreplaced by high-density polyethylene in laterdesigns. The Charnley prosthesis was mostsuccessful and long lasting. It became a “goldstandard” for hip replacement and is still used inmodified versions[8].

C O N T E M P O R A RY DESIGNS AND TENDENCIESIN HIP REPLACEMENT

Principally, two types of total hip prostheses arein common use. Depending on the type of bondingwith the host bone the prosthesis may be eithercemented (where bone cement is used to fix thep rosthesis to bone) or cementless (where theimplant is directly fixed to bone by the principle ofp ress-fit followed by bone reaction known asosteointegration that finally stabilizes the implant)

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(Fig. 2, Fig. 3). A combination of cemented andcementless elements of the prosthesis is calledhybrid hip replacement. More commonlycementless cup and cemented stem are used[9] (Fig.4, Fig. 5). For reasons of versatility, modular designshave emerged. In these designs, prosthesis consistsof three or four parts, namely, the acetabular cup,the femoral head and the femoral stem in cementedtypes and acetabular shell, acetabular insert,femoral head and femoral stem in uncemented

types (Fig. 2, Fig. 3). They come in different sizesthat can be assembled according to the need duringsurgery. In special situations when the anatomy issignificantly distorted or if there is significant boneloss or defect, custom made prosthesis is used. It ismanufactured according to the particular clinicalsituation after a detailed three-dimensional studyof the hip using CT scan. The diameter of theprosthetic head is related to range of movement,stability and friction coefficient of the prostheticbearing. Different materials and sizes are in use. Inorder to unify implants’ parameters, generally, adiameter of 28 mm is recommended as it is a goodcompromise between stability and mobility of thejoint and has a relatively low friction coefficient andlow particle release incidence. The material used isa chrome- cobalt alloy and alumina or zirconiaceramic[10]. The main disadvantage of the cementedprosthesis was loosening of the components. Thiswas partially attributed to the generation ofparticles by friction between the pro s t h e t i csurfaces, surgical technique, physical activity ofpatients and the ageing of the cement that lost itsinitial mechanical properties[11].

Fig. 1: General view of Thompson and Austin Moore prosthesisTH: Thompson Prosthesis, AM: Austin Moore Prosthesis

Fig. 2: General view of cemented Exeter Hip Prosthesis and examples ofpreoperative and postoperative X- raysA: Neglected fracture of the femoral neck, B: Cemented acetabular cupC: Cemented femoral stem

Fig 3: General view of cementless Zweymueller Hip Prosthesis andexamples of preoperative and postoperative X-raysAI: Acetabular insert, AS: Acetabular shell, Bicon, FS: Femoral stem, SLPlus, FH: Femoral headA: Avascular necrosis of the femoral head, B: Cementeless threadedacetabular cup in situ, C: SLFemoral Stem in situ

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Cementless total hip replacement has beenintroduced after experimental and clinical studiesby Albrektsson from Sweden proved that titaniumimplants are capable of osteointegrating withoutcement[12]. The porosity of the prosthetic surface,bone friendly properties of implant materials andreduced friction and wear and tear of prostheticsurfaces in contemporary designs (using titaniumas a frame of prosthetic components and aluminaceramic as a prosthetic bearing), are decisive factorsfor firm and long-lasting bonding between theimplant and the host bone. Metal-on-metalarticulating surface, that was once used anddiscarded because of wear of metal and adversetissue reaction, was re i n t roduced with muchsuccess, after surface finishing techniques andselection of appropriate material had dramaticallyi m p roved. Successful osteointegration of thep rosthetic stem and acetabular cup results in

permanent fixation of the implant, which becomesphysically incorporated in bone. Long term results,however, cannot be predicted with accuracy, asfollow up observations are relatively short[ 1 3 . 1 4 ].High functional demand and the incre a s i n gnumber of young patients requiring hip surgerystimulated further changes in the design of the hipprosthesis. The resurfacing, that had once beentried and abandoned, has re a p p e a red withtechnological improvements that assure lastingclinical and radiological results. In this technique,the bone resection is substantially minimized andmetal- on-metal surface and high head diameter areused (Fig. 6). The early results of this procedure areexcellent[15]. The remaining bone stock makes anyfuture revision procedure, if necessary, much easierand with much less surgical impact. The position ofthe prosthetic components has critical importancefor stability. Inaccuracies in the geometricalorientation of the implants may result in itsdislocation and ruin the outcome of the operation.

Fig. 4: Hybrid Total Hip Replacement, cementless Bicon cup, cementedlong Exeter stem, used for non united fracture of the femoral neck withbone defect in the femoral shaft A: Non union of the femoral neck resorption, D1: Proximal femoral bonedefect (after removal of metal fixation), D2: Distal femoral bone defect(after removal of metal fixation), BC: Bicon cementless acetabular cup,LES: Long cemented Exeter femoral stem

Fig. 5: Hybrid Total Hip Replacement, cementless Bicon cup, cementedstandard stem , used for loosening of both components of cemented totalhip replacementA: Loose cemented acetabular component, B: Loose cemented femoralcomponent, BC: Bicon cementless acetabular component, SES:Standard cemented Exeter femoral component

Fig. 6: Mc Minn Hip Resurfacing Prosthesis. General view of the implantand X-ray of the implanted prosthesisA: Cementless acetabular cup, B: Cemented femoral part with short stem,A1: Implanted acetabular cup in AP - view, B1: Implanted femoral parton AP - view, A2: Implanted acetabular cup on lateral view, B2:Implanted femoral cup on lateral view

Fig. 7: Most common pathology of secondary osteoarthritis in KuwaitA: DDH(Developmental Dislocation of the Hip), secondary osteoarthritis,B: Malunited fracture acetabulum, hip ankylosis, C: United fracture of thefemoral neck - avascular necrosis of the femoral head, D: Sickle cellanemia - avascular necrosis of the femoral head

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In recent technical developments, a computerizedguiding system, “navigation”, has beenintroduced[16]. Reference sensors are implanted inthe bone during the pro c e d u re and the thre e -dimensional position of the implant and the limb isconstantly monitored by the computeri n t e r a c t i v e l y, enabling the surgeon to fix theimplant within a 2-3 % margin of error from theoptimal position, eliminating unexpected X-rayand clinical findings. Bone structure in the vicinityof the implant may depend on many factors and

may have prognostic value on the stability of thebonding[17].A general tendency to minimize surgicaltrauma, has also been reflected in hip surgery.Minimal approaches to the hip joint have beendeveloped along with special instruments. Oneincision (posterior) and two incision (anterior andlateral) techniques have been pro p o s e d .Encouraging reports [18,19], however, are followed bycritical opinions[20]. Although still controversial, theso called “day case total hip replacement”, found itsadvocates in the USA. In selected cases, thisoperation, performed through two small incisionswith the help of navigation and image intensifier,allows reduction of the surgical trauma to theextent that patients start mobilization andphysiotherapy in a couple of hours after theprocedure and is discharged home on the sameevening. The costs of treatment are significantlyreduced. However, concerns about possiblecomplications hampers the wider application ofthis method.

ASSESSMENT OF CLINICAL AND RADIO-LOGICAL RESULTS

Clinical and radiological results are rated in hipscore systems that permits one to objectively assessand compare the results in the same patient duringthe time elapsed from the surgery as well ascompare it with other patients and other studies.Two scoring systems are in use, namely, the Harriship score (that is very detailed) and the moreconcise Merle d’Aubigne-Charnley score[21]. Moreattention is being given to the patient’s ownsatisfaction which may not always coincide withthe treating surgeon’s assessment. The WOMACand HOOS system of patient-relevant outcomes ofhip replacement[22] were incorporated in the clinicalassessment and are becoming standardrequirement in rating clinical results. However, it is

Fig. 9: Radiological view of EPF press-fit cementless cup implantedwithout screws and with screws. Case 1 A: Avascular necrosis of the femoral head

B: EPF Cementless Press- fit cup without screws in situC: SL cementless femoral stem in situ

Case 2 A: Avascular necrosis of the femoral headB: EPF cementless Press- fit cup with screws in situC: SLcementless femoral stem in situ

Fig. 10: Loosening of the acetabular component of Exeter prosthesis.(Displacement of the implant and extensive cavitary bone loss. Revisionusing bone graft and metal mesh. Excellent result at Five years).AC: Displaced and loose acetabular cup, UM: Upward migration of thefemoral head with huge cavitary bone defect, BG: Incorporated bone graft

Fig. 8: Graph illustrating frequency of total hip replacement across the lastdecade at Al Razi Hospital, Kuwait

Total Hip Replacement: Past, Present and Future December 2004254

always important that the patient has re a l i s t i cexpectations from the procedure he or she is toundergo. Radiological results include geometricalposition of the implants, possible migration of thecomponents and changes in bone in the vicinity ofthe implant. Lucencies, radiodense lines, bonea t ro p h y, osteolysis and bone hypertrophy areobserved. They indicate bone remodeling as areaction to the foreign material and modifiedtransmission of loading forces. These radiologicalchanges may or may not coincide with the clinicalresults[23-25]. Complications always cast a shadow onany surgical intervention. Total hip replacement isnot an exception in this respect. Complicationsentail general and local events that jeopardize theclinical and radiological result. Thromboemboliccomplications may be life threatening and havebeen successfully reduced or nearly eliminated bythe introduction of new generation anticoagulants[26]. Infection, a catastrophic complication in anyjoint replacement has been successfully reduced bytechnical improvements in the operation theatre,aseptic techniques and implant selection. Still, itcannot be completely eliminated. In best centers itsincidence has fallen below 1 %[27]. Loosening of theprosthetic component, due to aseptic or infectiouscauses, remains a major problem in the total hipreplacement. Many factors play a role. It may berelated to the material used, surgical technique andthe patient’s tissues reaction to the implant, initialpathology, type of activity and many other factors.In cemented designs, significant improvement ofthe loosening rate was achieved in the femoralcomponent. A ten-fold reduction in the looseningrate has been observed in the last 15 years[28]. On theacetabular side, the success is less visible.Improvements in cementing techniques did notsignificantly improve the loosening rate. Muchhope and expectations are placed in the newp rosthetic devices using better materials andcementless bonding. The results, however, stillawait critical analysis and the test of time.

HIP REPLACEMENT IN KUWAITIn Kuwait, the number of total hip replacements

is relatively low. It reflects, contrary to the upperzone of the northern hemisphere, the low incidenceof primary osteoarthritis of the hip joint in thisgeographical area. Most of the cases operated inKuwait at present include variable secondarypathology like Developmental Dislocation of theHip (DDH), idiopathic and secondary avascularnecrosis and trauma (Fig. 7). The first total hipreplacement in Kuwait was performed in 1984 andit was an Exeter cemented design. The number ofoperated cases since then has gradually increasedevery year, affirming improved confidence of

Kuwaiti patients in accepting this demandingsurgery to be performed locally (Fig. 8). Also thenumber of expatriates operated for total hipreplacement is increasing, thanks to theopportunity of partial or total financing of the costof implants by the Patient Helping Fund, managedby the Red Crescent Organization. In Al RaziHospital, two designs of Total Hip Prosthesis areused. Exeter cemented hip prosthesis (Fig. 2) andZweymueller cementless total hip prosthesis (Fig.3). Two types of cementless acetabular shells areused: conical threaded Bicon cup ( Fig. 3, Fig. 4, Fig.5) and press- fit EPF cup (Fig. 9). Indications for useof a particular type of cup depend on theanatomical conditions and the bone quality. On thefemoral side, universal SL Plus rectangular taperedfemoral stem has been used in all cases. Clinicaland radiological outcomes are pro s p e c t i v e l ymonitored and the results are either published orsubmitted for publication[ 2 9 - 3 0 ]. The selection ofimplants is gradually expanding, with thecementless design being used more frequently, ina c c o rdance with this trend worldwide. A ni n c reasing number of primary cases may beanticipated along with ageing of the populationand high demand for functional recovery. We arealso aware of the fact that revisions that areunwanted but inevitable, will follow the primarycases after an interval of a decade (Fig. 5, Fig. 10).Building up the experience of the surgical team anduse of updated technology are required to meetthese demands.

FUTURE PERSPECTIVEThe future of total hip replacement should be

perceived as a divergent tendency for developedand developing countries. Advances in technology,improved materials and better understanding ofnatural tissue reactions will certainly result inbreakthroughs of implant selection. Whereas, theaffluent societies still can afford the rising cost ofresearch and medical expenditure, it is not the casefor the majority of inhabitants of the southernhemisphere. In many medico-economical studies,the expected costs of treatment in a decadeperspective, amounted to a fraction of what theyturned out to be. In other words, these initialanticipations have frequently fallen short of reality.Developing countries cannot afford the expensivefailures of implant surgery that we have witnessedin the past. They should develop strategies that willallow them to tackle the problem of increasingdemand for medical services in a more simplifiedand inexpensive way, as they may not even becapable of absorbing the technology in the absenceof infrastructure, lack of training and know-how.In these communities, prevention may be even

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more important than in the northern hemispheresocieties. Reduction of the heart attack rate in theUSA and Western Europe, as a result of betterunderstanding of the significance of appropriatedietary and life style modifications may be anexample of such attitude. Therefore, we shouldlook forward to the future with wisdom andmoderation.

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