Hip arthroplasty

doi:10.1016/S0140-6736(12)60607-2

The Lancet

Volume 380, Issue 9855, 17–23 November 2012, Pages 1768-1777

https://doi.org/10.1016/S0140-6736(12)60607-2 Get rights and content

Summary

Total hip arthroplasty is a cost-effective surgical procedure undertaken to relieve pain and restore function to the arthritic hip joint. More than 1 million arthroplasties are done every year worldwide, and this number is projected to double within the next two decades. Symptomatic osteoarthritis is the indication for surgery in more than 90% of patients, and its incidence is increasing because of an ageing population and the obesity epidemic. Excellent functional outcomes are reported; however, careful patient selection is needed to achieve best possible results. The present economic situation in many developed countries will place increased pressure on containment of costs. Future demand for hip arthroplasty, especially in patients younger than 65 years, emphasises the need for objective outcome measures and joint registries that can track lifetime implant survivorship. New generations of bearing surfaces such as metal-on-metal, ceramic-on-ceramic, and metal-on-ceramic, and techniques such as resurfacing arthroplasty have the potential to improve outcomes and survivorship, but findings from prospective trials are needed to show efficacy. With the recall of some metal-on-metal bearings, new bearing surfaces have to be monitored carefully before they can be assumed to be better than traditional bearings.

Introduction

Hip arthroplasty has evolved from a salvage procedure with poor long-term outcomes reserved for the most infirm patients, to one of the most successful and frequently undertaken elective surgeries. The era of modern total hip arthroplasty began in the 1970s, after widespread use of the Charnley prosthesis. More than 500 000 procedures are done ever year in the UK and USA, with excellent clinical outcomes showing greater than 95% survivorship at 10-year follow-up, and greater than 80% implant survivorship at 25-year follow-up.1, 2 However, in the present climate of tightening health-care budgets and debate about fiscal austerity, the implications of increasing demand for hip arthroplasty have led to intense discussion about the cost-effectiveness of new technologies. This Seminar is presented as an update of what is new in the specialty of total hip arthroplasty since this topic was last reviewed in The Lancet in 2007.

Section snippets

Epidemiology

Total hip arthroplasty is common, with more than 1 million procedures undertaken worldwide. Rates for primary and revision total hip arthroplasty have been increasing; between 1990 and 2002, the rate of primary total hip arthroplasties in the USA increased 50% from 47 per 100 000 population to 69 per 100 000 population. Between 2005 and 2010, the number of total hip arthroplasties in the UK increased 16%. Slightly higher utilisation rates have been reported in Finland and Norway, whereas lower

Surgical indication

Surgical indications for hip arthroplasty are guided by pain, functional impairment, physical examination, and radiographic findings (figure 1). However, an initial course of conservative therapy should always be attempted with analgesia, activity modification, ambulatory aids, and weight loss.⁸ Intra-articular injections can be useful to differentiate arthritic pain from referred sources, such as back pain, knee pain, or hernia.9, 10

The US National Institutes of Health 1995 position statement

Patient and implant assessment

Assessment of patient and implant outcomes is necessary to identify which implant designs or surgical techniques provide the best patient benefit. Several studies have focused on the economics of total hip arthroplasty, long-term patient functional outcomes, patient satisfaction, results, and patient perceptions. The appendix provides further discussion about these topics.

National registries

National joint registries have revolutionised the assessment of patient outcomes, implant survivorship, and surgical techniques. By surveying large samples, the statistical power provided to studies using comparative registry data can be used to record differences in outcomes with otherwise extremely low incidence.18, 19 Cases of product recall, changes in treatment protocol, and decreases in revision surgeries have been attributed to registry-based studies.20, 21

Registries are available in the

Revision setting

Total hip arthroplasty has shown excellent short-term and long-term outcomes, but despite advances in surgical technique and implant design, the revision burden has remained unchanged over the past several decades. In one study of primary total hip arthroplasties,²⁸ the most common cause for revision surgery was instability (22% of revision cases), followed by mechanical loosening (20%), infection (15%), implant failure (10%), osteolysis (7%), and periprosthetic fracture (6%). In the revision

Minimally invasive surgery and minimal incision total hip arthroplasty

Minimally invasive total hip arthroplasty is a fairly new approach that has paralleled general interest in less invasive orthopaedic surgery. The theoretical benefits of smaller incisions include less surgical trauma, decreased postoperative pain, and more rapid recovery than with standard techniques.⁸³ The difference between surgery with minimal incisions and minimally invasive surgery is not only semantic—minimally invasive surgery aims to spare soft tissues, and emphasises mobilisation

Bearing surfaces

Metal-on-metal articulations have less linear wear than do traditional metal-on-polyethylene bearings and might be an option for selected younger, more active patients. The use of larger head sizes improves stability and range of motion compared with the smaller head diameters that are used with other bearing surfaces. However, the use of metal bearings has been controversial. Alison Smith and colleagues' analysis¹¹² of data from the National Joint Registry of England and Wales showed that

Total hip arthroplasty in elderly patients

Use of total hip arthroplasty has increased in elderly patients with hip fractures since it gives better outcomes than does internal fixation in displaced femoral neck fractures.134, 135, 136 Previously, most displaced femoral neck fractures were treated with hemiarthroplasty because the hip did not have overt osteoarthritis and fracture; however, patients who undergo internal fixation need further additional surgery compared with those initially treated with arthroplasty.137, 138 In

Conclusions

Total hip arthroplasty has fulfilled the promise of pain relief and restored function to millions of patients with end-stage degenerative joint disease. In the past several decades, advances have been made in implant design, manufacturing, bearing surfaces, surgical technique, technology for component positioning, and long-term postoperative implant surveillance. Nowadays most patients can expect their prosthesis to last well over 20 years. Although there have been failures in both prosthetic

Search strategy and selection criteria

We identified reports published in peer-reviewed published work within the past 5 years by searching Medline, Embase, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science. We used a combination of medical subject heading terms and Boolean search queries with wildcard queries to identify relevant studies and reviews published in the English language. The webappendix provides a list of the search terms used. Preference was given to randomised controlled

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Evaluation of an early-stage prototype polyurethane femoral head implant for hip arthroplasty
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Thi study evalautes a new bone-preserving femoral head cover that mimics the articular cartilage of the femoral head.
A specially developed polyurethane (PU) was evaluated in biocompatibility (cytotoxicity test) and mechanical response to tensile loading. In the cytotoxicity test, steam sterilized (SS) and ethylene oxide sterilized (EtO) PU samples were incubated separately in a cell culture medium. The seeded cell line MG-63 was then added to these sample-incubated cell culture mediums. One negative control group and one positive control group were also evaluated. The cells in each group were cultured for seven days before being quantified using the alamarBlue assay. In the mechanical test, the femoral head cover implants were separated into three groups of three samples. Each group represented a different implant insertion idea: direct insertion (uc sample) and another two insertion modes (is and ss samples) representing implants with enclosure mechanisms. The test consisted of distance-controlled cyclic tensile loadings followed by a failure test.
The cytotoxicity test results show no significant difference in fluorescence intensity between the negative control, the three SS groups, and one EtO group (P > 0.05). However, the other two EtO groups exhibit significantly lower fluorescence intensity compared with the negative control (P < 0.05). In the mechanical test, the is samples have the highest cyclic loading force at 559.50 ± 51.41 N, while the uc samples exhibit the highest force in the failure test at 632.16 ± 50.55 N. There are no significant differences (P > 0.05) among the uc, is, and ss groups in terms of stiffness.
The cytotoxicity test and the mechanical experiment provide initial assessments of the proposed PU femoral head cover implant. The evaluation outcomes of this study could serve as a foundation for developing more functional design and testing methods, utilizing numerical simulations, and developing animal/clinical trials in the future.
TiO2 nanotube topography enhances osteogenesis through filamentous actin and XB130-protein-mediated mechanotransduction
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TiO₂ nanotube topography, as nanomechanical stimulation, can significantly promote osteogenesis and improve the osteointegration on the interface of implants and bone tissue. However, the underlying mechanism has not been fully elucidated. XB130 is a member of the actin filament-associated protein family and is involved in the regulation of cytoskeleton and tyrosine kinase-mediated signalling as an adaptor protein. Whether XB130 is involved in TiO₂ nanotubes-induced osteogenic differentiation and how it functions in mechano-biochemical signalling transduction remain to be elucidated. In this study, the role of XB130 on TiO₂ nanotube-induced osteogenesis and mechanotransduction was systematically investigated. TiO₂ nanotube topography was fabricated via anodic oxidation and characterized. The osteogenic effect was significantly accelerated by the TiO₂ nanotube surface in vitro and vivo. XB130 was significantly upregulated during this process. Moreover, XB130 overexpression significantly promoted osteogenic differentiation, whereas its knockdown inhibited it. Filamentous actin depolymerization could change the expression and distribution of XB130, thus affecting osteogenic differentiation. Mechanistically, XB130 could interact with Src and result in the activation of the downstream PI3K/Akt/GSK-3β/β-catenin pathway, which accounts for the regulation of osteogenesis. This study for the first time showed that the enhanced osteogenic effect of TiO₂ nanotubes could be partly due to the filamentous actin and XB130 mediated mechano-biochemical signalling transduction, which might provide a reference for guiding the design and modification of prostheses to promote bone regeneration and osseointegration.
TiO₂ nanotubes topography can regulate cytoskeletal rearrangement and thus promote osteogenic differentiation of BMSCs. However, how filamentous actin converts mechanical stimulus into biochemical activity remains unclear. XB130 is a member of actin filament-associated protein family and involves in the regulation of tyrosine kinase-mediated signalling. Therefore, we hypothesised that XB130 might bridge the mechano-biochemical signalling transduction during TiO₂ nanotubes-induced osteogenic differentiation. For the first time, this study shows that TiO₂ nanotubes enhance osteogenesis through filamentous actin and XB130 mediated mechanotransduction, which provides new theoretical basis for guiding the design and modification of prostheses to promote bone regeneration and osseointegration.
Engineering innovations in medicine and biology: Revolutionizing patient care through mechanical solutions
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The overlap between mechanical engineering and medicine is expanding more and more over the years. Engineers are now using their expertise to design and create functional biomaterials and are continually collaborating with physicians to improve patient health. In this review, we explore the state of scientific knowledge in the areas of biomaterials, biomechanics, nanomechanics, and computational fluid dynamics (CFD) in relation to the pharmaceutical and medical industry. Focusing on current research and breakthroughs, we provide an overview of how these fields are being used to create new technologies for medical treatments of human patients. Barriers and constraints in these fields, as well as ways to overcome them, are also described in this review. Finally, the potential for future advances in biomaterials to fundamentally change the current approach to medicine and biology is also discussed.
Opioid-free versus opioid-sparing anaesthesia in ambulatory total hip arthroplasty: a randomised controlled trial
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Enhanced recovery after surgery pathways are essential for ambulatory surgery. They usually recommend lower intraoperative opioid use to avoid opioid-related adverse effects. This has led to opioid-sparing anaesthesia (OSA) techniques, with the extreme approach of opioid-free anaesthesia (OFA) mostly with dexmedetomidine. As evidence is lacking in day-case primary total hip arthroplasty, this study was performed to assess the potential benefits in postoperative analgesia of OFA over OSA.
In this single-centre, prospective, triple blind study, we randomly allocated 80 patients undergoing day-case primary THA under general anaesthesia. Patients received a total intravenous anaesthesia with a laryngeal mask and multimodal analgesic regimen with non-opioid analgesics. The OSA group received low dose of sufentanil, and the OFA group received dexmedetomidine The primary outcome was the opioid consumption in the first 24 h in oral morphine equivalents (OME).
There was no difference in median cumulative OME consumption at 24 h between the OSA and OFA groups (12 [0–25] mg vs 16 [0–30] mg, respectively; P=0.7). Pain scores were similar and low in both groups with comparable walking recovery time. Adverse events were sparse and equivalent in both groups except for dizziness, which was more frequent in the OSA group (P<0.05).
In day-case total hip arthoplasty under general anaesthesia, opioid-free anaesthesia and opioid-sparing anaesthesia both provide early recovery and effective postoperative pain relief. When compared with opioid-sparing anaesthesia, opioid-free anaesthesia does not decrease opioid consumption in the first 24 h. These findings do not suggest any significant benefit from complete intraoperative avoidance of opioids.
NCT0507270.
International Delphi Study on Wound Closure and Incision Management in Joint Arthroplasty Part 2: Total Hip Arthroplasty
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This modified Delphi study aimed to develop a consensus on optimal wound closure and incision management strategies for total hip arthroplasty (THA). Given the critical nature of wound care and incision management in influencing patient outcomes, this study sought to synthesize evidence-based best practices for wound care in THA procedures.
An international panel of 20 orthopedic surgeons from Europe, Canada, and the United States evaluated a targeted literature review of 18 statements (14 specific to THA and 4 related to both THA and total knee arthroplasty). There were 3 rounds of anonymous voting per topic using a modified 5-point Likert scale with a predetermined consensus threshold of ≥ 75% agreement necessary for a statement to be accepted.
After 3 rounds of voting, consensus was achieved for all 18 statements. Notable recommendations for THA wound management included (1) the use of barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); (2) the use of subcuticular sutures over skin staples (lower risk of superficial infections and higher patient preferences, but longer closing times); (3) the use of mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); (4) for at-risk patients, the use of negative pressure wound therapy over other dressings (lower wound complications and reoperations, as well as fewer dressing changes); and (5) the use of triclosan-coated sutures (lower risk of surgical site infection) over standard sutures.
Through a structured modified Delphi approach, a panel of 20 orthopedic surgeons reached consensus on all 18 statements pertaining to wound closure and incision management in THA. This study provides a foundational framework for establishing evidence-based best practices, aiming to reduce variability in patient outcomes and to enhance the overall quality of care in THA procedures.
Artificial intelligence technology improves the accuracy of preoperative planning in primary total hip arthroplasty
2024, Asian Journal of Surgery
Successful total hip arthroplasty relies on accurate preoperative planning. However, the conventional preoperative planning, a two-dimensional method using X-ray template, has shown poor reliability of predicting component size. To our knowledge, artificial intelligence technology assisted three-dimensional preoperative planning is promising to improve the accuracy of preoperative planning but there is a dearth of clinical evidence. Therefore, in this study we compared the prediction accuracy of these two maneuvers.
We conducted a prospective study consisting of 117 consecutive patients who underwent a primary cementless total hip arthroplasty to compare the prediction accuracy of these two methods. The two-dimensional and artificial intelligence assisted three-dimensional planning results of the same patient were compared with the definitive implant size respectively.
The prediction accuracy of artificial intelligence assisted three-dimensional planning for cup and the stem sizes were 66.67% (78/117) and 65.81% (77/117), two-dimensional planning was 30.77% (36/117) and 37.61% (44/117) (p < 0.05). There were poor prediction results of two-dimensional planning in patients with hip dysplasia (p = 0.004, OR = 7.143) and excessive femoral anteversion (p = 0.012, OR = 1.052), meanwhile the failure risk of stem side two-dimensional planning increased as patients got older (p = 0.003, OR = 1.118). The accuracy of artificial intelligence assisted three-dimensional planning cannot be affected by above factors.
We confirmed that artificial intelligence assisted three-dimensional preoperative planning showed higher accuracy and stability than two-dimensional preoperative planning in primary cementless total hip arthroplasty. We believe artificial intelligence assisted three-dimensional preoperative planning technology provides surgeons a new reliable choice and offers advantages whether in simple or complicated cases.

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SeminarHip arthroplasty

Summary

Introduction

Section snippets

Epidemiology

Surgical indication

Patient and implant assessment

National registries

Revision setting

Minimally invasive surgery and minimal incision total hip arthroplasty

Bearing surfaces

Total hip arthroplasty in elderly patients

Conclusions

Search strategy and selection criteria

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

Bone

J Arthroplasty

Injury

Orthop Clin North Am

J Arthroplasty

J Arthroplasty

Reg Anesth Pain Med

J Arthroplasty

J Arthroplasty

Arch Phys Med Rehabil

Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030

J Bone Joint Surg Am

Epidemiology of knee and hip arthroplasty: a systematic review

Open Orthop J

Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030

Clin Orthop Relat Res

Epidemiology of osteoarthritis

Rheum Dis Clin North Am

Incidence of symptomatic hand, hip, and knee osteoarthritis among patients in a health maintenance organization

Arthritis Rheum

Prevalence of malformations of the hip joint and their relationship to sex, groin pain, and risk of osteoarthritis: a population-based survey

J Bone Joint Surg Am

The management of osteoarthritis: an overview and call to appropriate conservative treatment

Rheum Dis Clin North Am

Use of fluoroscopically guided intra-articular hip injection in differentiating the pain source in concomitant hip and lumbar spine arthritis

Am J Orthop

Intra-articular bupivacaine hip injection in differentiation of coxarthrosis from referred thigh pain: a 10 year study

Acta Orthop Belg

NIH consensus conference: total hip replacement

JAMA

Total hip replacement: indications for surgery and risk factors for failure

Ann Rheum Dis

Indications for total hip replacement: comparison of assessments of orthopaedic surgeons and referring physicians

Ann Rheum Dis

Orthopaedic practice in total hip arthroplasty and total knee arthroplasty: results from the Global Orthopaedic Registry (GLORY)

Am J Orthop

Total hip arthroplasty

West J Med

Factors and consequences of waiting times for total hip arthroplasty

Clin Orthop Relat Res

Twenty-five-year results after Charnley total hip arthroplasty in patients less than fifty years old: a concise follow-up of a previous report

J Bone Joint Surg Am

Registries for robust evidence

JAMA

The value of arthroplasty registry data

Acta Orthop

The Norwegian Joint Registry

Bull Hosp Jt Dis

Examining the ethical implications of an orthopaedic joint registry

J Bone Joint Surg Am

An analysis of the risk of hip dislocation with a contemporary total joint registry

Clin Orthop Relat Res

Excellent survival of all-polyethylene tibial components in a community joint registry

Clin Orthop Relat Res

Shortcomings of the National Joint Registry: a survey of consultants' views

Ann R Coll Surg Engl

Competing risks survival analysis applied to data from the Australian Orthopaedic Association National Joint Replacement Registry

Acta Orthop

Seminar
Hip arthroplasty