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Hip, Replacement
Authors
Matthew Varacallo1; Norman A. Johanson2.
Affilations
1 Department of Orthopaedic Surgery, University of Kentucky School of Medicine
2 Drexel Un COM / Hahnemann Un Hospital
Last Update: October 27, 2018.
Introduction
Total hip arthroplasty (THA) is one of the most costeffective and consistently successful surgeries performed in
orthopedics. THA provides reliable outcomes for patients’ suffering from endstage degenerative hip osteoarthritis
(OA), specifically pain relief, functional restoration, and overall improved quality of life. OA affects millions of
Americans, and with an incidence of 88 symptomatic cases per 100,000 patients per year, this translates to hip OA
claiming the top underlying diagnosis leading to THA. Other underlying diagnoses include hip osteonecrosis (ON),
congenital hip disorders, and inflammatory arthritis.
The underlying diagnosis that leads to a degenerative hip is an important consideration as this has been shown to
impact overall outcome. Overall, THA provides consistent shortterm and longterm pain relief and positive patient
reported clinical and functional outcomes. In general, THA provides even more reliable and consistent positive results
compared to its counterpart procedure, the total knee arthroplasty (TKA).
Anatomy
The hip is a ballandsocket type diarthrodial joint. Overall hip joint stability is achieved via a dynamic interplay from
osseous and soft tissue anatomic components. Osseous components include the proximal femur (head, neck,
trochanters), and the acetabulum, which is formed from 3 separate ossification centers (the ilium, ischium, and pubic
bones). The native acetabulum is oriented in 15 to 20 degrees of anteversion and 40 degrees of abduction. The
femoral neck is oriented in 15 to 20 degrees of anteversion and is angled 125 degrees with respect to its diaphysis.
Soft tissue structures involved in hip joint stability include the labrum and joint capsule. The iliofemoral ligament
(IFL) is the strongest of the 3 divisions of capsular ligaments. The IFL functions to restrict extension and external
rotation of the hip. The other 2 components are the ischiofemoral and pubofemoral ligaments. The acetabular labrum
is anchored at the periphery of the outer rim and functions to maintain negative joint pressure and deepen the hip
socket.
Indications
The most common indication for THA includes endstage, symptomatic hip OA. In addition, hip ON, congenital hip
disorders including hip dysplasia, and inflammatory arthritic conditions are not uncommon reasons for performing
THA. Hip ON, on average, presents in the younger patient population (35 to 50 years of age) and accounts for
approximately 10% of annual THAs.
Contraindications
THA is contraindicated in the following clinical scenarios:
Local: Hip infection or sepsis
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Remote (in other words extraarticular or outside the joint) active, ongoing infection or bacteremia
Severe cases of vascular dysfunction
Equipment
Historical Timeline
THA prosthetic designs have been evolving since the late 1800s when Dr. Themistocles Gluck continuously
experimented with various options for joint replacements in preliminary animal experiments. In 1890, one of Dr.
Gluck’s reported 14 total joint arthroplasties included an ivory femoral head replacement in a human patient. In 1940,
Dr. Austin Moore collaborated with trauma surgeon Dr. Harold Bohlman in developing the first hip hemiarthroplasty
(endoprosthesis) for the treatment of displaced femoral neck fractures. In 1952, Dr. Moore developed his prestigious,
“Austin Moore prosthesis” as an offtheshelf joint replacement available worldwide. Sir John Charnley entered the
scene in the 1960s when he introduced the concept of “lowfriction arthroplasty” by utilizing a metallic femoral stem
and small femoral head articulating with a cemented polyethylene acetabular component.
Modern Implants and Bearing Surfaces
Contemporary THA techniques have evolved into pressfit femoral and acetabular components. In general, femoral
stems can be categorized into the following general designs:
Pressfit, proximally coated, distal taper (dual or single tapered in mediallateral and/or anteriorposterior
planes)
Pressfit, extensively coated, diaphyseal engaging
Pressfit, Modular stems: Modularity junction options include: (1) headneck, (2) neckstem, (3) stemsleeve,
and (4) midstem
Cemented femoral stems: Cobaltchrome stems are the preferred material to promote cement bonding
Options for bearing surfaces include:
Metalonpolyethylene (MoP): MoP has the longest track record of all bearing surfaces at the lowest cost
Ceramiconpolyethylene (CoP): becoming an increasingly popular option
Ceramiconceramic (CoC): CoC has the best wear properties of all THA bearing surfaces
Metalonmetal (MoM): Although falling out of favor, MoM has historically demonstrated better wear
properties from its MoP counterpart. MoM has lower linearwear rates and decreased volume of particles
generated. However, the potential for pseudotumor development as well as metallosis reactions (typeIV
delayed hypersensitivity reactions) has resulted in the decline in the use of MoM. MoM is also contraindicated
in pregnant women, patients with renal disease, and patients at risk of metal hypersensitivity
One THA prosthesis includes a pressfit acetabular component, neutral polyethylene liner, and either a MoP, CoP, or
CoC head/liner construct depending on patient age and projected activity level. In addition, patients with poor bone
quality are often considered for a cemented femoral stem option. This concept is particularly relevant in the THA
treatment for active, elderly patients with displaced femoral neck fractures.
Preparation
Nonoperative Treatment Modalities
According to the most recent American Academy of Orthopaedic Surgeons' (AAOS) Guidelines for the treatment of
symptomatic osteoarthritis of the hip or knee, strong or moderately strong recommendations for nonoperative
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treatment was endorsed for the following modalities:
Weight loss programs
Physical activity and physical therapy programs
Nonsteroidal antiinflammatory medications (NSAIDs) and tramadol
Corticosteroid injections can be therapeutic and/or diagnostic for symptomatic patients. This can be particularly
beneficial in patients when confounding conditions of lower back pain and lumbar spinal stenosis with or without
radicular symptoms is in the clinical picture. In addition, a cane has the ability to decrease the joint reaction forces
generated in the hip. When patients present with unilateral hip pain, they should be instructed to use the cane with the
contralateral upper extremity.
Other modalities for symptomatic management that were not supported but are often considered reasonable
alternative treatment measures to help manage symptoms secondary to hip arthritis include but are not limited to
acupuncture, viscoelastic joint injections, and glucosamine and chondroitin supplements.
Preoperative Evaluation: Clinical Examination
A comprehensive history and physical examination are required prior to considering performing a THA in any patient.
Patients should be questioned about prior interventions and treatments. Prior joint replacements, arthroscopic
procedures, or other surgeries around the hip should be considered as prior surgical incisions or the presence of
hardware in the femur or acetabulum can significantly impact the planned surgery and/or prosthesis design utilized.
In addition, a comprehensive medical evaluation should also be performed, and medical clearance and risk
stratification are recommended for all patients prior to THA consideration.
Other considerations include patient body habitus, prior functional activity and goals/expectations following surgery,
the pattern of arthritic involvement, and any history of prior hip trauma. The hip should be inspected for any skin
discoloration, wounds, or previous scars. The soft tissues should be examined for evidence of gross atrophy, overall
symmetry, and stability. The peripheral vascular disease may warrant preoperative vascular surgery consultation.
Physical examination also includes evaluation of the mechanical axis of the limb. It is critical to ensure spine and/or
knee pathology is ruled out or at least considered prior to performing any surgery around the hip. Any leg length
discrepancy (LLD) should also be noted. It is critical to also consider the impact of any of the following conditions in
addition to actual or apparent LLD:
Hyperlordotic spine conditions
Pelvic obliquity
Hip flexion contractures: The patient may not be able to stand upright
Trendelenburg gait or Trendelenburg sign
Preoperative range of motion (ROM) should also be noted. Patients with endstage arthritis more frequently present
with a combination of hip adduction and flexion contractures. Any appreciable flexion contracture greater than 5
degrees and lack of flexion beyond 90 to 100 degrees should be documented. In addition, rotational arc ROM is
typically limited, especially in the internal rotation. The neurovascular exam should also include the positive/negative
status of a straight leg raise test.
Preoperative Evaluation: Radiographs
Preoperative radiographs, including a standing anteroposterior (AP) pelvis plus AP/lateral of the involved hip(s), is
recommended. A false profile view is considered in cases of hip dysplasia. When the surgeon is faced with cases of
severe hip dysplasia, and when considering the use of customized components, we recommend obtaining a
preoperative CT scan with thin (1mm) cuts.
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On imaging, the hip joint is assessed for joint space narrowing, presence of osteophytes, and presence of subchondral
sclerosis and/or degenerative cysts. Particular attention is paid to the planned center of hip rotation (COR) in relation
to the native COR. The surgeon should also have an idea of planned cup medialization and corresponding reaming
required to ensure appropriate medialization of the acetabular implant. Finally, any appreciable LLD can also be
calculated utilizing any combination of described methods.
Technique
Approaches
Any number of approaches can be utilized for the THA procedure. The three most common approaches are as
follows:
Posterolateral
This is the most common approach for primary and revision THA cases. This dissection does not utilize a true
internervous plane. The intermuscular interval involves blunt dissection of the gluteus maximus fibers and sharp
incision of the fascia lata distally. The deep dissection involves meticulous dissection of the short external rotators and
capsule. Care is taken to protect these structures as they are later repaired back to the proximal femur via trans
osseous tunnels.
A major advantage of this approach is the avoidance of the hip abductors. Other advantages include the excellent
exposure provided for both the acetabulum and the femur and the optional extensile conversion in the proximal or
distal direction. Historically, some studies comparing this approach to the direct anterior (DA) approach have cited
higher dislocation rates in the former approach. This remains an inconclusive and controversial as the literature has
not established a definitive consensus, especially when comparing the posterior approach technique that utilizes an
optimal soft tissue repair at the conclusion of the THA procedure.
Direct Anterior (DA)
The DA approach is becoming increasingly popular among THA surgeons. The internervous interval is between the
tensor fascia lata (TFL) and sartorius on the superficial end, and the gluteus medius and rectus femoris (RF) on the
deep side. DA THA advocates cite the theoretical decreased hip dislocation rates in the postoperative period and the
avoidance of the hip abduction musculature.
The disadvantages include the learning curve associated with the approach as the literature documents the decreased
complication rates after a surgeon surpasses the more than 100case mark. Other disadvantages include increased
wound complications in particularly obese patients with large panni (without the use of an abdominal binder), difficult
femoral exposure, the risk of lateral femoral cutaneous nerve (LFCN) paresthesias, and a potentially higher rate of
intraoperative femur fractures. Finally, many surgeons need access to a specialized operating table with appropriately
trained personnel and surgical technicians to assist in the procedure. Although the latter is not always required,
learning to do the procedure on a regular operating table also requires a substantial learning curve that must be
considered.
Anterolateral
Compared to the other approaches, the anterolateral (AL) approach is the least commonly used approach secondary to
its violation of the hip abductor mechanism. The interval exploited includes that of the TFL and gluteus medius
musculature. This may lead to a postoperative limp at the tradeoff of a theoretically decreased dislocation rate.
Procedural steps
After the surgical approach is completed, the next step required prior to visualizing the acetabulum is the femoral
neck osteotomy. This is most commonly with a reciprocating saw beginning at a starting point about 1cm to 2cm
proximal to the lesser trochanter. This is continued in a proximallateral direction toward the base of the greater
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trochanter. Once the neck osteotomy is completed, the femoral head and neck are freed of all soft tissue attachments
and removed.
Acetabular visualization is accomplished with a combination of retractors. Some surgeons prefer the anterior retractor
placement at the 2 o'clock (right hip) or 10 o'clock (left hip) position, in addition to bent Hohmann retractors at the
12’ oclock (both hips) and 8’ oclock (right hip) or 4’ oclock (left hip) positions. A blunt Hohmann (or “No. 3”)
retractor is placed in the extracapsular position at the level of the transacetabular ligament (TAL). The ligamentum
teres/fibrofatty pulvinar remnants are excised to expose the acetabular teardrop, followed by removal of the labrum (if
present) to ensure efficient use of the acetabular reamers.
Preferred reaming methods consist of starting small (i.e., size 44) and focusing on appropriate medialization of the
cup with exposure of the medial wall without protruding. Once medialization is achieved, sequential reaming in the
planned position of the pressfit implanted cup becomes the major focus. Most commonly, this is in the 35 to 40
degrees of inclination and 15 to 20 degrees of anteversion range. Once all sclerotic bone is reamed and a healthy
bleeding bony bed is established, the acetabular component is inserted in pressfit fashion followed by insertion of the
corresponding liner.
The femur is then prepared with a ream and/or broach systemspecific instrumentation. This is continued until
provisional pressfit stability is achieved. Then with the trial femoral stem in place, the hip should be reduced and
evaluated for stability utilizing a combination of standard or increasing neck offset trial implants. The head can also
be adjusted based on the specific system used. Most implants offer a variety of “plus” and “minus” head size options
to add or subtract additional length based on trial total hip stability.
One method for intraoperative THA stability parameters includes the following:
A shuck test is utilized to free any potential interposed soft tissue and to also evaluate stability with axial
traction
Equal leg lengths: The patella and heels are compared to the contralateral extremity via direct palpation
With the hip at zero degrees of extension, the hip is externally rotated, and avoidance of posterior impingement
is ensured
The hip should be ranged in abduction and external rotation to ensure avoidance of posterior impingement and
anterior subluxation
The hip should be brought to 90 degrees of flexion with additional adduction and internal rotation to about 70 to
90 degrees and remain stable
Wound Closure
Attention to detail is required, and a methodical closure is unanimously advocated. A nonabsorbable, braided, sterile,
surgical suture composed of ethylene terephthalate suture is used to repair the capsule and/or short external rotators to
the proximal femur via two transosseous tunnels. One protocol includes the use of a unidirectional or bidirectional
barbed suture for the deep fascial, deep fat, and deep dermal/subcutaneous layers. Staples or monocryl can be used for
the skin. Some surgeons prefer using a running barbed monocrylbased suture augmented by a mesh dressing and skin
glue closure. A sterile dressing is then applied and left in place without being changed for the first seven days. An
abduction pillow placed and patient education about the appropriate hip flexion precautions and activity restrictions in
the early postoperative period is important. Topical tranexamic acid (TXA) application prior to pulsatile saline lavage
and commencement of the closure is also recommended.
Complications
The following are some major complications following THA.
THA Dislocation
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About 70% of THA dislocations occur within the first month following index surgery. The overall incidence is about
1% to 3%. Risk factors include:
Prior hip surgery (most significant independent risk factor for dislocation)
Elderly age (older than 70 years)
Component malpositioning: Excessive anteversion results in anterior dislocation and excessive retroversion
results in posterior dislocation
Neuromuscular conditions/disorders (for example, Parkinson disease)
Drug/alcohol abuse
Recurrent THA dislocations often result in revision THA surgery with component revision.
THA Periprosthetic Fracture
THA periprosthetic fractures (PPFs) are increasing in incidence with the overall increased incidence of procedures in
younger patient populations.
Intraoperative fractures can occur and involve either the acetabulum and/or femur. Acetabular fractures occur in 0.4%
of pressfit acetabular implant components, most often during component impaction. Risk factors include
underreaming more than 2 mm, poor patient bone quality, and dysplastic conditions. Intraoperative femur fractures
occur in up to 5% of primary THA cases as reported in some series. Risk factors include technical errors, pressfit
implants, poor patient bone quality, and revision surgery.
Treatment of fractures surrounding the femoral stem is reliably managed using the Vancouver classification system.
THA Aseptic Loosening
As in its counterpart TKA procedure, aseptic loosening is the result of a confluence of steps involving particulate
debris formation, prosthesis micromotion, and macrophage activated osteolysis. Treatment requires serial imaging and
radiographs and/or CT imaging for preoperative planning. Persistent pain requires revision THA surgery.
Wound Complications
The THA postoperative wound complication spectrum ranges from superficial surgical infections (SSIs) such as
cellulitis, superficial dehiscence, and/or delayed wound healing, to deep infections resulting in fullthickness necrosis.
Deep infections result in returns to the operating room for irrigation, debridement (incision and drainage) and
depending on the timing of the infection, may require explant of THA components.
THA Prosthetic Joint Infection (PJI)
The incidence of prosthetic total hip infection (THA PJI) following primary THA is approximately 1% to 2% as
reported in the literature. Risk factors include patientspecific lifestyle factors (morbid obesity, smoking, intravenous
[IV] drug use and abuse, alcohol abuse, and poor oral hygiene). Other risk factors include patients with a past medical
history consisting of uncontrolled diabetes, chronic renal and/or liver disease, malnutrition, and HIV (CD4 counts less
than 400).
The most common offending bacterial organisms in the acute setting include Staphylococcus aureus, Staphylococcus
epidermidis, and in chronic THA PJI cases, coagulasenegative Staphylococcus bacteria. Treatment in the acute
setting (less than 3 weeks after index surgery) can be limited to I and D, polyethylene exchange, and retention of
components. This is commonly referred to as the “I and D, head/liner exchange” treatment modality. In addition, IV
antibiotics are utilized for up to 4 to 6 weeks duration. Outcomes vary and are often influenced by multiple
intraoperative, patientrelated factors, and offending bacterial organism, but studies site a 55% successful outcome
rate.
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More aggressive treatments, especially in the setting of presentation beyond the acute (3 to 4week time mark)
includes a 1 or 2stage revision THA procedure with interval antibiotic spacer placement. The surgeon must ensure
and document evidence of infection eradication.
Other Complications and Considerations
Other potential THA complications include the following:
Sciatic nerve palsy
Leg Length Discrepancy (LLD)
Iliopsoas impingement
Heterotopic ossification
Vascular injury
Clinical Significance
THA is one of the most successful and costeffective procedures in all of orthopedics. The procedure is most
commonly performed on patients suffering from debilitating, endstage arthritic conditions of the hip. Once
considered a procedure limited to the elderly, lowdemand patients, THA is becoming an increasingly popular
procedure performed in younger patient populations.
The literature, in general, cites superior satisfaction rates in THA patient populations. Outcomes in THA are overall
considered to be even more reliable and predictable compared to the general TKA patient populations. Success
following THA results in significant improvements in patientreported pain and functional outcome scores in the
short and longterm postoperative periods. Although the overall longevity of the THA prosthesis is influenced by a
multitude of patientrelated and prosthetic technicality factors, in general, the lifespan is expected for about 15 to 20
years.
Clinicians are encouraged to ensure that surgical candidates have first exhausted all nonoperative treatment modalities
mentioned earlier in this review. As the rates of surgical procedures in the young and elderly populations continue to
increase, orthopedic surgeons can expect excellent outcomes in the appropriately indicated patient populations.
Questions
To access free multiple choice questions on this topic, click here.
References
1. Varacallo MA, Herzog L, Toossi N, Johanson NA. TenYear Trends and Independent Risk Factors for Unplanned
Readmission Following Elective Total Joint Arthroplasty at a Large Urban Academic Hospital. J Arthroplasty.
2017 Jun;32(6):17391746. [PubMed: 28153458]
2. Singh JA, Chen J, Inacio MC, Namba RS, Paxton EW. An underlying diagnosis of osteonecrosis of bone is
associated with worse outcomes than osteoarthritis after total hip arthroplasty. BMC Musculoskelet Disord. 2017
Jan 09;18(1):8. [PMC free article: PMC5223478] [PubMed: 28068972]
3. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet. 2007 Oct
27;370(9597):150819. [PubMed: 17964352]
4. Myers CA, Register BC, Lertwanich P, Ejnisman L, Pennington WW, Giphart JE, LaPrade RF, Philippon MJ.
Role of the acetabular labrum and the iliofemoral ligament in hip stability: an in vitro biplane fluoroscopy study.
Am J Sports Med. 2011 Jul;39 Suppl:85S91S. [PubMed: 21709037]
5. Hernigou P. Earliest times before hip arthroplasty: from John Rhea Barton to Themistocles Glück. Int Orthop.
2013 Nov;37(11):23138. [PMC free article: PMC3824904] [PubMed: 23881060]
6. Chillag KJ. Giants of Orthopaedic Surgery: Austin T. Moore MD. Clin. Orthop. Relat. Res. 2016
https://www.ncbi.nlm.nih.gov/books/NBK507864/?report=printable 7/8
View publication stats
Dec;474(12):26062610. [PMC free article: PMC5085962] [PubMed: 27752987]
7. Charnley J. The longterm results of lowfriction arthroplasty of the hip performed as a primary intervention.
1970. Clin. Orthop. Relat. Res. 2005 Jan;(430):311; discussion 2. [PubMed: 15662299]
8. Kwon YM, Fehring TK, Lombardi AV, Barnes CL, Cabanela ME, Jacobs JJ. Risk stratification algorithm for
management of patients with dual modular taper total hip arthroplasty: consensus statement of the American
Association of Hip and Knee Surgeons, the American Academy of Orthopaedic Surgeons and the Hip Society. J
Arthroplasty. 2014 Nov;29(11):20604. [PubMed: 25189673]
9. Jämsä P, Jämsen E, Huhtala H, Eskelinen A, Oksala N. Moderate to Severe Renal Insufficiency Is Associated
With High Mortality After Hip and Knee Replacement. Clin. Orthop. Relat. Res. 2018 Jun;476(6):12841292.
[PMC free article: PMC6263598] [PubMed: 29601379]
10. Moretti VM, Post ZD. Surgical Approaches for Total Hip Arthroplasty. Indian J Orthop. 2017 Jul
Aug;51(4):368376. [PMC free article: PMC5525517] [PubMed: 28790465]
11. Senthi S, Munro JT, Pitto RP. Infection in total hip replacement: metaanalysis. Int Orthop. 2011 Feb;35(2):253
60. [PMC free article: PMC3032119] [PubMed: 21085957]
12. Opperer M, Lee YY, Nally F, Blanes Perez A, GoudarzMehdikhani K, Gonzalez Della Valle A. A critical
analysis of radiographic factors in patients who develop dislocation after elective primary total hip arthroplasty.
Int Orthop. 2016 Apr;40(4):7038. [PubMed: 26508498]
13. Lakshmanan P, Ahmed SM, Hansford RG, Woodnutt DJ. Achieving the required medial offset and limb length in
total hip arthroplasty. Acta Orthop Belg. 2008 Feb;74(1):4953. [PubMed: 18411601]
14. de Steiger R, Peng A, Lewis P, Graves S. What Is the Longterm Survival for Primary THA With Smallhead
Metalonmetal Bearings? Clin. Orthop. Relat. Res. 2018 Jun;476(6):12311237. [PMC free article:
PMC6263567] [PubMed: 29432270]
15. Atrey A, Ward SE, Khoshbin A, Hussain N, Bogoch E, Schemitsch EH, Waddell JP. Tenyear followup study of
three alternative bearing surfaces used in total hip arthroplasty in young patients: a prospective randomised
controlled trial. Bone Joint J. 2017 Dec;99B(12):15901595. [PubMed: 29212681]
16. Devane PA, Horne JG, Ashmore A, Mutimer J, Kim W, Stanley J. Highly CrossLinked Polyethylene Reduces
Wear and Revision Rates in Total Hip Arthroplasty: A 10Year DoubleBlinded Randomized Controlled Trial. J
Bone Joint Surg Am. 2017 Oct 18;99(20):17031714. [PubMed: 29040124]
17. Lau YJ, Sarmah S, Witt JD. 3rd generation ceramiconceramic cementless total hip arthroplasty: a minimum 10
year followup study. Hip Int. 2017 Jul 29;:0. [PubMed: 28777383]
18. Shah SM, Walter WL, Tai SM, Lorimer MF, de Steiger RN. Late Dislocations After Total Hip Arthroplasty: Is
the Bearing a Factor? J Arthroplasty. 2017 Sep;32(9):28522856. [PubMed: 28529109]
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