[page 72] [Orthopedic Reviews 2011; 3:e16]

Total Hip Arthroplasty - over100 years of operative history Stephen Richard Knight,1 Randeep Aujla,2

Satya Prasad Biswas3

1University of Leicester; 2UniversityHospitals of Leicester, Medical School,Leicester; 3Kettering General Hospital,Kettering, UK

Abstract

Total hip arthroplasty (THA) has completelyrevolutionized the nature in which the arthrit-ic hip is treated, and is considered to be one ofthe most successful orthopaedic interventionsof its generation. With over 100 years of oper-ative history, this review examines the pro-gression of the operation from its origins,together with highlighting the materials andtechniques that have contributed to its devel-opment. Knowledge of its history contributesto a greater understanding of THA, such as thereasons behind selection of prosthetic materi-als in certain patient groups, while demon-strating the importance of critically analyzingresearch to continually determine best opera-tive practice. Finally, we describe current areasof research being undertaken to furtheradvance techniques and improve outcomes.

Past

Total hip arthroplasty (THA) is considered tobe one of the most successful orthopaedicinterventions of its generation.1 The earliestrecorded attempts at hip replacement occurredin Germany in 1891, with results presented atthe 10th International Medical Conference.Professor Themistocles Glück presented theuse of ivory to replace femoral heads ofpatients whose hip joints had been destroyedby tuberculosis. Later, surgeons experimentedwith interpositional arthroplasty in the late19th and early 20th century, which involvedplacing various tissues (fascia lata, skin, pigbladders submucosa) between articulating hipsurfaces of the arthritic hip.2

In 1925, the American surgeon MariusSmith-Petersen created the first mold arthro-plasty out of glass. This consisted of a hollowhemisphere which could fit over the femoralhead and provide a new smooth surface formovement. Despite glass being a biocompati-ble material, it failed to withstand the greatforces going through the hip joint and shat-tered. Marius Smith-Petersen, along withPhilip Wiles, later went on to trial the current

material of choice - stainless steel - to createthe first total hip replacement that was fitted tobone with bolts and screws.3,4

The first to use a metal-on-metal prosthesison a regular basis was English surgeon GeorgeMcKee. In 1953, he began by using the modi-fied Thompson stem (a cemented hemiarthro-plasty used for neck of femur fracture treat-ment) with a new one-piece cobalt-chromesocket as the new acetabulum. This prosthesishad a good survival rate, with one study recent-ly showing a 28 year survival rate of 74%.5 Yetthis method grew unpopular by the mid-1970‘sdue to local effects of metal particles seen dur-ing revision surgery for prosthetic failure.6

The orthopaedic surgeon Sir John Charnley,who worked at the Manchester RoyalInfirmary, is considered the father of the mod-ern THA. His low friction arthroplastydesigned in the early 1960‘s is identical, inprinciple, to the prostheses used today. It con-sisted of three parts; a metal femoral stem, apolyethylene acetabular component and acrylicbone cement - which was borrowed from den-tists.7 It was called the low friction arthroplas-ty as Charnley advocated the use of a smallfemoral head which reduces wear due to itssmaller surface area.

Present

Currently, in the 5th decade of modern THA,over 75,000 joint replacements are performedeach year within the NHS.8 As the number ofsuccessful operations has increased, tech-niques have become standardised and theaverage age of those receiving hip replace-ments has reduced. As a result, this magnifiedthe problems of implant failure due to wear ofbearings. Thus there are a variety of bearing(Table 1) and techniques currently used in anattempt to find the combination that yields thefewest complications and best long-term sur-vival.

Metal-on-polyethylene Metal-on-polyethylene (M-on-PE) (Figure 1)

bearings are the most widely used and rigor-ously followed up of all the prostheses, makingup the majority of THA undertaken in the UKtoday.9 Popularised by the early success of theCharnley prosthesis in the 1970’s, polyethyl-ene-based implants almost completely dis-placed all other bearing surfaces. So much sothat a large proportion of research was aimedat developing design and improving implanta-tion techniques purely for the M-on-PE pros-thesis.10 Currently the M-on-PE bearing pro-vides a safe, predictable and cost-effectivebearing for the majority of patients, and formany represent the gold standard in THA.9

The main concern for M-on-PE prosthesis isPE debris which creates periprosthetic osteoly-sis by the release of cytokines and proteolyticenzymes - ultimately leading to implant fail-ure.11 PE wear debris is cited as the ultimatecause of most total joint arthroplasty failurestoday,12 leading to an increased frequency ofhip revision due to aseptic loosening. Althoughdebris may be minimised through the irradia-tion of PE with gamma particles, greatlyimproving the materials wear resistance,implant failure has led to renewed interest inmetal-on-metal bearings.

Metal-on-metal Metal-on-metal (M-on-M) (Figure 2) pros-

theses are experiencing a revival after fallingout of favour in the 1970‘s. Previously, con-cerns were raised of the bearings potential togenerate metal ions (metallosis), which had atheoretical carcinogenic risk, as well as associ-ated hypersensitivity reactions and prostheticloosening. It is now thought that the cause foraseptic loosening in first generation modelswas due to poor design and improper implanta-tion technique rather than the M-on-M bear-ings themselves.

Prosthetic wear in M-on-M has been report-ed to be 60 times less than expected with con-ventional M-on-PE prostheses.13 In addition, asthe metal femoral heads are less brittle thanother materials they can have a larger diame-ter, increasing joint stability, and therefore theincidence of dislocation in these arthroplastiesis lower.14 M-on-M implants also reduce osteol-ysis and peri-prosthetic inflammatory tissuecompared to its polyethylene counterpart.15

An unknown entity in M-on-M bearings isthe long-term effects of metal ions liberated,with cobalt and chromium ion blood levelstending to be 3-5 times higher than thosepatients with M-on-PE prostheses,13

Furthermore, many patients who receive M-

Orthopedic Reviews 2011; volume 3:e16

Correspondence: Stephen Richard Knight,Maurice Shock Building, University of Leicester,University Road, Leicester, LE1 7RH, UK.E-mail: sk271@le.ac.uk

Key words: total hip arthroplasty, polyethylene,Metal-on-metal, ceramic, minimally-invasive.

Received for publication: 13 August 2011.Accepted for publication: 23 September 2011.

This work is licensed under a Creative CommonsAttribution NonCommercial 3.0 License (CC BY-NC 3.0).

©Copyright S.R. Knight et al., 2011Licensee PAGEPress, ItalyOrthopedic Reviews 2011; 3:e16doi:10.4081/or.2011.16

[Orthopedic Reviews 2011; 3:e16] [page 73]

on-M implants are younger (due to its wearcharacteristics), therefore potentially increas-ing the total length of the exposure to thesemetal ions over their lifetime. But such a car-cinogenic risk from these metal ions remainstheoretical, with only a few case reports ofmalignancies (mainly sarcomas) in publica-tion to date.16

There is currently insufficient clinical fol-low- up to draw firm conclusions about the cur-rent new generation of M-on-M implants.Studies into the long-term outcomes are cur-rently being conducted and results eagerlyawaited.

Ceramic-on-Ceramic First introduced by the French surgeon

Pierre Boutin in 1970, half of the hip arthro-plasties in central Europe use ceramic heads(Figure 3), but there is a much lower usage inthe UK and USA (<10%).9,15 Developed toaddress the problems of friction and wearreported in other materials, the ceramic usedin orthopaedics consist of either alumina orzirconia.

The benefits of ceramic-on-ceramic (C-on-C) bearings are its high level of hardness,scratch resistance and the inert nature ofdebris compared to metal or PE versions.17

Furthermore these hydrophilic prostheses cre-ate improved lubrication, therefore resultingin a lower coefficient of friction and excellentwear resistance.18 Hence C-on-C bearings area good choice of implant in young, activepatients due to reduced wearing. However, thecost of ceramic implants is significant and forthis reason these bearings are used infre-quently in NHS orthopaedic units.

The risk of fracture in first generation alu-mina ceramic bearings was highly published.Chipping of the contact surfaces caused oninsertion of the prosthesis, or as a result of dis-location due to the small femoral heads used inthe ceramic implants, can lead to devastatingthird body wear so excellent surgical insertiontechnique is vital.9

Hybrid prosthesis A hybrid hip prosthesis is formed from a

cemented femoral stem and acetabular cupfixed in place with cementless techniques.This is an option for young, active patients asit prevents pelvic bone loss, to aid revision, yetstill providing solid fixation and good usage. Amajor study in Norway showed that the use ofhybrid systems offer better survivorship than acemented socket in younger patients.19 It isthough a technique seldom used in the UKgiven the poor clinical data for long-term fol-low-up.

Cementless techniques Cementing hip arthroplasties was first

described by Glück in 1891, using methacrylatebone cement to improve prosthetic fixation,but it was Charnley in the late 1950‘s that pop-ularised this technique with a cement takenfrom dentists.7 Between these dates cement-ing often failed and attention was placed in thedevelopment of cementless techniques. Therole of cement is to act as a grout rather thana glue to improve the fit of the prosthesis – andtheoretically its survival. Cementless prosthe-sis have a specialized coating, hydroxyapatite,that allows ingrowth of bone and thus fixationof the prosthesis.

Cementless techniques allow for easierplanning of hip revision surgery, particularly inthe younger patients, with greater preserva-tion of bone tissue. However, better short tomedium-term clinical outcomes were found forcemented over uncementless techniques, withno radiological differences seen.20 Long-termcomparison is difficult to make due to lack oflarge randomized controlled trials.

Future

Minimally invasive surgery Gaining popularity in recent years, minimal-

ly invasive techniques are currently being

Review

Table 1. Comparison of materials used in total hip arthroplasty.

Prosthesis Advantages Disadvantages

Metal-on-polyethylene Large volume of evidence to support use Polyethylene debrisPredictable lifespan leading to aseptic looseningCost effective

Metal-on-metal Potentially longer lifespan than polyethylene Metallosisdue to reduced wear Potential carcinogenicLarger femoral head - therefore lower effect of metal ionsdislocation rate

Ceramic-on-ceramic Low friction ExpensiveLow debris particles Require expert insertion toInert substance prevent early damage

Can produce noise on movement

Figure 1. A polyethylene liner within acementless titanium acetabular cup.Regenerex®.

Figure 2. A metal-on-metal femoral stemand cup. Note the hydroxyapatite coatingover the proximal half of the femoral stem,constituting an uncentered femoral stem.Optimom®.

Figure 3. A ceramic-on-ceramic prosthesis.Note the small head diameter. Stryker®.

[page 74] [Orthopedic Reviews 2011; 3:e16]

developed. The use of a single-incision, lessthan 10 cm in length using conventional surgi-cal approaches, provides soft-tissue sparingand bone conservation options. Studies havedemonstrated that it provides the possibility ofreduced intra-operative blood loss, shorterhospital stay, faster rehabilitation and animproved cosmetic result while not compro-mising complication rates or physical functionpost-op.21,22 Meanwhile opponents cite therisks of such an approach, including limitedvisibility of anatomical landmarks and vitalstructures.23 There also remains a question asto whether using such a technique increasesthe chance of component malposition.

Computer-assisted surgery Entering its second decade of use, comput-

er-assisted total hip replacement utilizes digi-tal image systems to map the position of surgi-cal instruments in relation to anatomical land-marks, helping to obtain reproducible andaccurate placement of implants. Computernavigation may improve the accuracy of pros-thesis positioning but, despite its obviousadvantage with respects to reducing asymmet-ric wear, this has not yet been shown to have aclinical benefit.21

In actuality navigation leads to increasedsurgical time, elevated costs and operativecomplexity.21 On the other hand it is a usefultool in order to conduct research into prosthe-sis positioning and clinical outcome. Some dis-cussion as to whether the combination of com-puter-assisted surgery with a minimally inva-sive approach can help to improve outcomes isongoing – but at present greater qualitydesigned studies and the mastering of thissurgical technique is required before suchtechniques can be formally analysed.24

Conclusions

Since the first total hip arthroplasty in 1891,research has developed from perfecting surgi-cal technique to advances in technology (withrespects to both prosthesis design and materi-als) in order to provide a reproducible tech-nique that provides a good range of motion,stability and most importantly adequate life

span. As the average age of those receiving hiparthroplasty decreases, such considerationswill continue to be of great value to increaseimplant longevity in highly active patients.Despite over a 100 year history of total hiparthroplasty, a technique and material to suitall patient characteristics is not yet a reality.

References

1. Callaghan JJ, Albright JC, Goetz DD et al.Charnley total hip arthroplasty withcement. Minimum twenty-five-year follow-up. J Bone Joint Surg Am 2000;82:487-97.

2. Learmonth ID, Young C, Rorabeck C. Theoperation of the century: total hip replace-ment. Lancet 2007;370:1508-19.

3. Smith-Petersen MN. The classic: evolutionof mould arthroplasty of the hip joint. JBone Joint Surg 1948;30B:L59.

4. Wiles P. The surgery of the osteo-arthritiship. Br J Surg 1957;45:488-97.

5. Brown SR, Davies WA, DeHeer DH,Swanson AB. Long-term survival of Mckee-Farrar total hip prosthesis. Clin OrthopRelat Res 2002;402:157-63.

6. McKellop H, Park SH, Chiesa R et al. Invivo wear of three types of metal on metalhip prostheses during two decades of use.Clin Orthop Relat Res 1996;329:S128-40.

7. Charnley J. Arthroplasty of the hip: a newoperation. Lancet 1961;1:1129-32.

8. The NHS Information Centre, HospitalEpisode Statistics for England. Inpatientstatistics, 2009-10. Available from:www.hesonline.nhs.uk

9. Sandhu HS, Middleton RG. Controversialtopics in orthopaedics: ceramic-on-ceram-ic. Ann R Coll Surg Engl 2005;87:415-6.

10. Amstutz HC, Grigoris P. Metal on metalbearings in hip arthroplasty. Clin OrthopRelat Res 1996;329:S11-34.

11. Bizot P, Nizard R, Hamadouche M et al.Prevention of wear and osteolysis: alumi-na-on-alumina bearing. Clin Orthop RelatRes 2001;393:85-93.

12. Amstutz HC. Editorial Comment. ClinOrthop Relat Res. Metal on Metal HipProtheses: Past Performance and FutureDirections 1996;329:S2-S3.

13. Cuckler JM. The rationale for metal-on-

metal total hip arthroplasty. Clin OrthopRelat Res 2005;441:132-6.

14. Archibeck MJ, Jacobs JJ, Roebuck KA,Glant TT. The basic science of peripros-thetic osteolysis. Instr Course Lect 2001;50:185-95.

15. Boutin P. Total arthroplasty of the hip byfritted aluminum prosthesis. Experimentalstudy and 1st clinical applications. RevChir Orthop Reparatrice Appar Mot 1972;58:229-46.

16. Tharani R, Dorey FJ, Schmalzried TP. Therisk of cancer following total hip or kneearthroplasty. J Bone Joint Surg Am2001;83:774-80.

17. Bierbaum BE, Nairus J, Kuesis D et alCeramic-on-ceramic bearings in total hiparthroplasty. Clin Orthop Relat Res2002;405:158-63.

18. Christel PS. Biocompatibility of surgical-grade dense polycrystalline alumina. ClinOrthop Relat Res 1992;282:10-8.

19. Havelin LI, Engesaeter LB, Espehaug B etal. The Norwegian Arthroplasty Register:11 years and 73,000 arthroplasties. ActaOrthop Scand 2000;71:337-53.

20. Ni GX, Lu WW, Chiu KY, Fong DYT. Reviewarticle: Cemented or uncemented femoralcomponent in primary total hip replace-ment? A review from a clinical and radio-logical perspective. J Orthop Surg 2005;13:96-105.

21. Reininga IH, Zijlstra W, Wagenmakers R etal. Minimally invasive and computer-navi-gated total hip arthroplasty: a qualitativeand systematic review of the literature.BMC Musculoskeletal Disorders 2010;11:92.

22. Berry DJ, Berger RA, Callaghan JJ, et al.Minimally invasive total hip arthroplasty:development, early results, and a criticalanalysis - presented at the Annual Meetingof the American Orthopaedic Association,Charleston, South Carolina, USA, June 14,2003. J Bone Joint Surg Am 2003;85A:2235-46.

23. Callaghan J. Skeptical perspectives onminimally invasive total hip arthroplasty. JBone Joint Surg Am 2006;85:2242-3.

24. Archibeck MJ, White RE,Jr. Learning curvefor the two-incision total hip replacement.Clin Orthop Relat Res 2004;429:232-8.

Review