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
SeminarHip arthroplasty
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
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