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{{Infobox medical intervention
| Name = Hip replacement
| synonyms = Hip arthroplasty
| Image = X-ray of pelvis with total arthroplasty.jpg
| Caption = An [[X-ray]] showing a left hip (right of image) that has been replaced, with the ball of this ball-and-socket joint replaced by a metal head that is set in the [[femur]] and the socket replaced by a cup
| ICD10 =
| ICD9 = {{ICD9proc|81.51}}–{{ICD9proc|81.53}}
| MeshID = D019644
| OPS301 =
| OtherCodes =
| MedlinePlus = 002975
}}
'''Hip replacement''' is a [[surgery|surgical]] procedure in which the [[hip]] joint is replaced by a prosthetic [[implant (medicine)|implant]], that is, a '''hip prosthesis'''. Hip replacement surgery can be performed as a total replacement or a hemi/semi(half) replacement. Such [[joint replacement]] [[orthopaedic surgery]] is generally conducted to relieve [[arthritis]] [[pain]] or in some [[hip fracture]]s. A total hip replacement (total hip arthroplasty or THA) consists of replacing both the [[acetabulum]] and the femoral head while [[hemiarthroplasty]] generally only replaces the femoral head. Hip replacement is one of the most common orthopaedic operations, though patient satisfaction varies widely. Approximately 58% of total hip replacements are estimated to last 25 years.<ref>{{cite journal | vauthors = Evans JT, Evans JP, Walker RW, Blom AW, Whitehouse MR, Sayers A | title = How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up | journal = Lancet | volume = 393 | issue = 10172 | pages = 647–654 | date = February 2019 | pmid = 30782340 | pmc = 6376618 | doi = 10.1016/S0140-6736(18)31665-9 }}</ref> The average cost of a total hip replacement in 2012 was $40,364 in the United States, and about $7,700 to $12,000 in most European countries.<ref name="ifhp">{{cite web |url=http://hushp.harvard.edu/sites/default/files/downloadable_files/IFHP%202012%20Comparative%20Price%20Report.pdf |title=2012 comparative price report|publisher=International Federation of Health Plans|access-date=4 October 2015}}</ref>
==Medical uses==
Total hip replacement is most commonly used to treat joint failure caused by [[osteoarthritis]]. Other indications include [[rheumatoid arthritis]], [[avascular necrosis]], [[Post-traumatic arthritis|traumatic arthritis]], [[protrusio acetabuli]], certain [[hip fracture]]s, benign and malignant [[bone tumor]]s, arthritis associated with [[Paget's disease of bone|Paget's disease]], [[ankylosing spondylitis]] and [[juvenile rheumatoid arthritis]]. The aims of the procedure are pain relief and improvement in hip function. Hip replacement is usually considered only after other therapies, such as [[physical therapy]] and pain medications, have failed.{{citation needed|date=February 2022}}
==Risks==
Risks and complications in hip replacement are similar to those associated with all [[Joint replacement#Risks and complications|joint replacements]]. They can include infection, dislocation, limb length inequality, loosening, impingement, osteolysis, metal sensitivity, nerve palsy, chronic pain and death. [[Bariatric surgery|Weight loss surgery]] before a hip replacement does not appear to change outcomes.<ref>{{cite journal | vauthors = Smith TO, Aboelmagd T, Hing CB, MacGregor A | title = Does bariatric surgery prior to total hip or knee arthroplasty reduce post-operative complications and improve clinical outcomes for obese patients? Systematic review and meta-analysis | journal = The Bone & Joint Journal | volume = 98-B | issue = 9 | pages = 1160–1166 | date = September 2016 | pmid = 27587514 | doi = 10.1302/0301-620x.98b9.38024 | url = http://openaccess.sgul.ac.uk/108614/1/Bariatric_surgery_paper_ACCEPTED_10.05.2016.pdf }}</ref>
Follow-up assessments are conducted to examine the need for revision surgery. However, a UK study showed that only 3-6% of hip replacements needed a revision. Researchers recommended that routine follow-up may not be needed for up to 10 years. At this point, x-rays should be used to assess the joint, and there should be a clinical assessment of pain and mobility.<ref>{{Cite journal |date=11 January 2023 |title=Joint replacements: many people can safely wait 10 years for follow-up |url=https://evidence.nihr.ac.uk/alert/joint-replacement-many-people-can-safely-wait-10-years-for-follow-up/ |journal=NIHR Evidence|doi=10.3310/nihrevidence_55501 |s2cid=257843402 }}</ref><ref>{{cite journal | title = Safety of disinvestment in mid- to late-term follow-up post primary hip and knee replacement: the UK SAFE evidence synthesis and recommendations | journal = Health and Social Care Delivery Research | volume = 10 | issue = 16 | pages = 1–172 | date = 2022-06-01 | pmid = 35767667 | doi = 10.3310/KODQ0769 | s2cid = 250133111 | vauthors = Kingsbury SR, Smith LK, Czoski Murray CJ, Pinedo-Villanueva R, Judge A, West R, Smith C, Wright JM, Arden NK, Thomas CM, Kolovos S, Shuweihdi F, Garriga C, Bitanihirwe BK, Hill K, Matu J, Stone M, Conaghan PG | display-authors = 6 | doi-access = free }}</ref>
[[Edema]] appears around the hip in the hours or days following the surgery. This swelling is typically at its maximum 7 days after the operation,<ref>{{cite journal | vauthors = Holm B, Kristensen MT, Husted H, Kehlet H, Bandholm T | title = Thigh and knee circumference, knee-extension strength, and functional performance after fast-track total hip arthroplasty | journal = PM&R | volume = 3 | issue = 2 | pages = 117–24; quiz 124 | date = February 2011 | pmid = 21333950 | doi = 10.1016/j.pmrj.2010.10.019 | s2cid = 21003271 }}</ref> then decreases and disappears over the course of weeks. Only 5% of patients still have swelling 6 months after the operation.<ref>{{cite journal | vauthors = Heo SM, Harris I, Naylor J, Lewin AM | title = Complications to 6 months following total hip or knee arthroplasty: observations from an Australian clinical outcomes registry | journal = BMC Musculoskeletal Disorders | volume = 21 | issue = 1 | pages = 602 | date = September 2020 | pmid = 32912197 | pmc = 7488141 | doi = 10.1186/s12891-020-03612-8 | doi-access = free }}</ref>
===Dislocation===
[[File:Dislocated hip replacement.jpg|thumb|upright|Dislocated artificial hip]]
[[File:Hip prosthesis liner creep and wear.png|thumb|160px|Liner wear, particularly when over 2 mm, increases the risk of dislocation.<ref name=berry2012/> Liner creep, on the other hand, is normal remoulding.<ref name=Watt/>]]
Dislocation (the ball coming out of the socket) is the most common complication. The most common causes vary by the duration since the surgery.{{citation needed|date=February 2022}}
Hip prosthesis [[joint dislocation|dislocation]] mostly occurs in the first three months after insertion, mainly because of incomplete scar formation and relaxed soft tissues.<ref name=berry2012>{{cite book|title=Surgery of the Hip|url=https://books.google.com/books?id=Kc-AhYLnIF4C&pg=PA1035| vauthors = Berry DJ, Lieberman J |publisher=Elsevier Health Sciences|year=2012|isbn=9781455727056|page=1035}}</ref> It takes eight to twelve weeks for the soft tissues injured or cut during surgery to heal. The chance of this is diminished if less tissue is cut, if the cut tissue is repaired and if large diameter head balls are used.
Dislocations occurring between three months and five years after insertion usually occur due to malposition of the components, or dysfunction of nearby muscles.<ref name=berry2012/>
Risk factors of late dislocation (after five years) mainly include:<ref name=berry2012/>
* Female sex
* Younger age
* Previous [[subluxation]] without complete dislocation
* Previous trauma
* Substantial weight loss
* Recent onset or progression of [[dementia]] or a [[neurological disorder]]
* Malposition of the cup
* Liner wear, particularly when it allows head movement of more than 2 mm within the cup compared to its original position
* Prosthesis loosening with migration
Surgeons who perform more operations tend to have fewer dislocations. An anterior approach seems to lower dislocation rates when small diameter heads are used, but that benefit has not been shown when compared to modern posterior incisions with the use of larger diameter heads. The use of larger diameter head size in itself decreases dislocation risk, even though this correlation is only found in head sizes up to 28 mm: larger heads do not result in a statistically significant decrease in dislocation rate.<ref>{{cite journal | vauthors = Hailer NP, Weiss RJ, Stark A, Kärrholm J | title = The risk of revision due to dislocation after total hip arthroplasty depends on surgical approach, femoral head size, sex, and primary diagnosis. An analysis of 78,098 operations in the Swedish Hip Arthroplasty Register | journal = Acta Orthopaedica | volume = 83 | issue = 5 | pages = 442–448 | date = October 2012 | pmid = 23039167 | pmc = 3488169 | doi = 10.3109/17453674.2012.733919 }}</ref> Keeping the leg out of certain positions during the first few months after surgery further reduces risk.{{citation needed|date=February 2022}}
=== Infection ===
Infection is one of the most common causes for revision of a total hip replacement. The incidence of infection in primary hip replacement is 1% or less in the United States.<ref>{{cite journal | vauthors = Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ | title = The epidemiology of revision total hip arthroplasty in the United States | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 91 | issue = 1 | pages = 128–133 | date = January 2009 | pmid = 19122087 | doi = 10.2106/JBJS.H.00155 }}</ref> Risk factors for infection include obesity, diabetes, smoking, immunosuppressive medications or diseases, and history of infection.{{citation needed|date=February 2022}}
In revision surgery, infected tissue surrounding the joint is removed, and the artificial joint replaced. Typically, this is carried out in 2 stages: infected tissue and all joint replacement implants are removed in the first stage, and, after the infection is completely cleared, a new artificial joint is inserted in the second stage. One-stage surgery is also available whereby infected tissue and implants are removed, and the new joint inserted, in a single procedure. One-stage hip revisions were found to be as effective as two-stage procedures at relieving pain and improving hip stiffness and function. One-stage procedures were also better value for money.<ref>{{Cite journal |date=2023-04-25 |title=One-stage hip revisions are as good as 2-stage surgery to replace infected artificial hips |url=https://evidence.nihr.ac.uk/alert/one-stage-hip-revisions-are-as-good-as-2-stage-surgery-to-replace-infected-artificial-hips/ |journal=NIHR Evidence |language=en |doi=10.3310/nihrevidence_57776|s2cid=258340248 }}</ref><ref>{{cite journal | vauthors = Blom AW, Lenguerrand E, Strange S, Noble SM, Beswick AD, Burston A, Garfield K, Gooberman-Hill R, Harris SR, Kunutsor SK, Lane JA, MacGowan A, Mehendale S, Moore AJ, Rolfson O, Webb JC, Wilson M, Whitehouse MR | display-authors = 6 | title = Clinical and cost effectiveness of single stage compared with two stage revision for hip prosthetic joint infection (INFORM): pragmatic, parallel group, open label, randomised controlled trial | journal = BMJ | volume = 379 | pages = e071281 | date = October 2022 | pmid = 36316046 | pmc = 9645409 | doi = 10.1136/bmj-2022-071281 }}</ref>
===Limb length inequality===
Most adults have a limb length inequality of 0–2 cm which causes no deficits.<ref>{{cite journal | vauthors = Knutson GA | title = Anatomic and functional leg-length inequality: a review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance | journal = Chiropractic & Osteopathy | volume = 13 | issue = 1 | pages = 11 | date = July 2005 | pmid = 16026625 | pmc = 1232860 | doi = 10.1186/1746-1340-13-11 | doi-access = free }}</ref> It is common for people to sense a larger limb length inequality after total hip replacement.<ref>{{cite journal | vauthors = Maloney WJ, Keeney JA | title = Leg length discrepancy after total hip arthroplasty | journal = The Journal of Arthroplasty | volume = 19 | issue = 4 Suppl 1 | pages = 108–110 | date = June 2004 | pmid = 15190563 | doi = 10.1016/j.arth.2004.02.018 }}</ref> Sometimes the leg seems long immediately after surgery when in fact both are equal length. An arthritic hip can develop contractures that make the leg behave as if it is short. When these are relieved with replacement surgery and normal motion and function are restored, the body feels that the limb is now longer than it was. This feeling usually subsides by six months after surgery as the body adjusts to the new hip joint. The cause of this feeling is variable, and usually related to abductor muscle weakness, pelvic obliquity, and minor lengthening of the hip during surgery (<1 cm) to achieve stability and restore the joint to pre-arthritic mechanics. If the limb length difference remains bothersome to the patient more than six months after surgery, a shoe lift can be used. Only in extreme cases is surgery required for correction.{{citation needed|date=February 2022}} The perceived difference in limb length for a patient after surgery is a common cause for lawsuits against the healthcare provider.<ref>{{cite journal | vauthors = McWilliams AB, Douglas SL, Redmond AC, Grainger AJ, O'Connor PJ, Stewart TD, Stone MH | title = Litigation after hip and knee replacement in the National Health Service | journal = The Bone & Joint Journal | volume = 95-B | issue = 1 | pages = 122–126 | date = January 2013 | pmid = 23307685 | doi = 10.1302/0301-620X.95B1.30908 | url = http://eprints.whiterose.ac.uk/81565/1/Paper%20Final.pdf }}</ref><ref>{{cite journal | vauthors = Hofmann AA, Skrzynski MC | title = Leg-length inequality and nerve palsy in total hip arthroplasty: a lawyer awaits! | journal = Orthopedics | volume = 23 | issue = 9 | pages = 943–944 | date = September 2000 | pmid = 11003095 | doi = 10.3928/0147-7447-20000901-20 }}</ref><ref>{{cite journal | vauthors = Upadhyay A, York S, Macaulay W, McGrory B, Robbennolt J, Bal BS | title = Medical malpractice in hip and knee arthroplasty | language = English | journal = The Journal of Arthroplasty | volume = 22 | issue = 6 Suppl 2 | pages = 2–7 | date = September 2007 | pmid = 17823005 | doi = 10.1016/j.arth.2007.05.003 }}</ref><ref>{{cite journal | vauthors = Konyves A, Bannister GC | title = The importance of leg length discrepancy after total hip arthroplasty | journal = The Journal of Bone and Joint Surgery. British Volume | volume = 87 | issue = 2 | pages = 155–157 | date = February 2005 | pmid = 15736733 | doi = 10.1302/0301-620X.87B2.14878 | doi-access = free }}</ref><ref>{{cite journal | vauthors = O'Leary R, Saxena A, Arguelles W, Hernandez Y, Osondu CU, Suarez JC | title = Digital Fluoroscopic Navigation for Limb Length Restoration During Anterior Total Hip Arthroplasty | language = English | journal = Arthroplasty Today | volume = 18 | pages = 11–15 | date = December 2022 | pmid = 36267390 | pmc = 9576486 | doi = 10.1016/j.artd.2022.08.021 }}</ref>
===Fracture===
[[File:Intraoperative acetabular fracture, annotated.jpg|thumb|150px|Intraoperative acetabular fracture]]
Intraoperative fractures may occur. After surgery, bones with internal fixation devices in situ are at risk of [[periprosthetic]] fractures at the end of the implant, an area of relative mechanical stress. Post-operative femoral fractures are graded by the [[Vancouver classification]].
===Vein thrombosis===
[[Venous thrombosis]] such as [[deep vein thrombosis]] and [[pulmonary embolism]] are relatively common following hip replacement surgery. Standard treatment with [[anticoagulant]]s is for 7–10 days; however, treatment for 21+ days may be superior.<ref>{{cite journal | vauthors = Sobieraj DM, Lee S, Coleman CI, Tongbram V, Chen W, Colby J, Kluger J, Makanji S, Ashaye AO, White CM | display-authors = 6 | title = Prolonged versus standard-duration venous thromboprophylaxis in major orthopedic surgery: a systematic review | journal = Annals of Internal Medicine | volume = 156 | issue = 10 | pages = 720–727 | date = May 2012 | pmid = 22412039 | doi = 10.7326/0003-4819-156-10-201205150-00423 | s2cid = 22797561 }}</ref><ref name=":0">{{cite journal | vauthors = Forster R, Stewart M | title = Anticoagulants (extended duration) for prevention of venous thromboembolism following total hip or knee replacement or hip fracture repair | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | issue = 3 | pages = CD004179 | date = March 2016 | pmid = 27027384 | doi = 10.1002/14651858.CD004179.pub2 | pmc = 10332795 | hdl-access = free | collaboration = Cochrane Vascular Group | hdl = 20.500.11820/3f5a887a-031a-43bd-8406-b85ab02d6618 }}</ref> Extended-duration anticoagulants (up to 35 days following surgery) may prevent VTE in people undergoing hip replacement surgery.<ref name=":0" /> Other research suggested that anticoagulants in otherwise healthy patients undergoing a so-called fast track protocol with hospital stays under five days, might only be necessary while in the hospital.<ref>{{cite journal | vauthors = Jørgensen CC, Jacobsen MK, Soeballe K, Hansen TB, Husted H, Kjærsgaard-Andersen P, Hansen LT, Laursen MB, Kehlet H | display-authors = 6 | title = Thromboprophylaxis only during hospitalisation in fast-track hip and knee arthroplasty, a prospective cohort study | journal = BMJ Open | volume = 3 | issue = 12 | pages = e003965 | date = December 2013 | pmid = 24334158 | pmc = 3863129 | doi = 10.1136/bmjopen-2013-003965 }}</ref> Emerging evidence supports the use of aspirin for venous thromboembolism prophylaxis. Large randomised control trials suggested that aspirin is not inferior to low-molecular weight [[heparins]] and [[rivaroxaban]].<ref>{{cite journal | vauthors = Anderson DR, Dunbar MJ, Bohm ER, Belzile E, Kahn SR, Zukor D, Fisher W, Gofton W, Gross P, Pelet S, Crowther M, MacDonald S, Kim P, Pleasance S, Davis N, Andreou P, Wells P, Kovacs M, Rodger MA, Ramsay T, Carrier M, Vendittoli PA | display-authors = 6 | title = Aspirin versus low-molecular-weight heparin for extended venous thromboembolism prophylaxis after total hip arthroplasty: a randomized trial | journal = Annals of Internal Medicine | volume = 158 | issue = 11 | pages = 800–806 | date = June 2013 | pmid = 23732713 | doi = 10.7326/0003-4819-158-11-201306040-00004 | s2cid = 207536641 }}</ref><ref>{{cite journal | vauthors = Anderson DR, Dunbar M, Murnaghan J, Kahn SR, Gross P, Forsythe M, Pelet S, Fisher W, Belzile E, Dolan S, Crowther M, Bohm E, MacDonald SJ, Gofton W, Kim P, Zukor D, Pleasance S, Andreou P, Doucette S, Theriault C, Abianui A, Carrier M, Kovacs MJ, Rodger MA, Coyle D, Wells PS, Vendittoli PA | display-authors = 6 | title = Aspirin or Rivaroxaban for VTE Prophylaxis after Hip or Knee Arthroplasty | journal = The New England Journal of Medicine | volume = 378 | issue = 8 | pages = 699–707 | date = February 2018 | pmid = 29466159 | doi = 10.1056/NEJMoa1712746 | s2cid = 3625978 | doi-access = free }}</ref> However, aspirin may not be appropriate in all cases, especially for patients who have additional risk factors for venous thromboembolisms or may have an inadequate response to aspirin.<ref>{{cite journal | vauthors = van Oosterom N, Barras M, Bird R, Nusem I, Cottrell N | title = A Narrative Review of Aspirin Resistance in VTE Prophylaxis for Orthopaedic Surgery | journal = Drugs | volume = 80 | issue = 18 | pages = 1889–1899 | date = December 2020 | pmid = 33037568 | doi = 10.1007/s40265-020-01413-w | s2cid = 222234431 }}</ref>
Some physicians and patients may consider having an [[ultrasonography for deep vein thrombosis]] after hip replacement.<ref name="AAOSfive">{{Citation |author1 = American Academy of Orthopaedic Surgeons |author1-link = American Academy of Orthopaedic Surgeons |date = February 2013 |title = Five Things Physicians and Patients Should Question |publisher = American Academy of Orthopaedic Surgeons |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url = http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-orthopaedic-surgeons/ |access-date = 19 May 2013}}, which cites
* {{cite journal | vauthors = Mont M, Jacobs J, Lieberman J, Parvizi J, Lachiewicz P, Johanson N, Watters W | title = Preventing venous thromboembolic disease in patients undergoing elective total hip and knee arthroplasty | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 94 | issue = 8 | pages = 673–674 | date = April 2012 | pmid = 22517384 | pmc = 3326687 | doi = 10.2106/JBJS.9408edit }}</ref> However, this kind of screening should only be done when indicated because to perform it routinely would be [[unnecessary health care]].<ref name="AAOSfive"/>
[[Intermittent pneumatic compression]] (IPC) devices are sometimes used for prevention of blood clots following total hip replacement.<ref>{{cite journal | vauthors = Zhao JM, He ML, Xiao ZM, Li TS, Wu H, Jiang H | title = Different types of intermittent pneumatic compression devices for preventing venous thromboembolism in patients after total hip replacement | journal = The Cochrane Database of Systematic Reviews | volume = 2014 | issue = 12 | pages = CD009543 | date = December 2014 | pmid = 25528992 | pmc = 7100582 | doi = 10.1002/14651858.CD009543.pub3 | collaboration = Cochrane Vascular Group }}</ref>
===Osteolysis===
Many long-term problems with hip replacements are the result of [[osteolysis]]. This is the loss of bone caused by the body's reaction to polyethylene wear debris, fine bits of plastic that wear off the cup liner over time. An [[inflammation|inflammatory]] process causes bone resorption that may lead to subsequent loosening of the hip implants and even fractures in the bone around the implants. Ceramic bearing surfaces may eliminate the generation of wear particles. Metal cup liners joined with metal heads (metal-on-metal hip arthroplasty) were developed for similar reasons. In the lab these show excellent wear characteristics and benefit from a different mode of lubrication.
Highly cross-linked polyethylene plastic liners experience significantly reduced plastic wear debris. The newer ceramic and metal prostheses may not have long-term performance records. Ceramic piece breakage can lead to catastrophic failure. This occurs in about 2% of implants. They may also cause an audible, high pitched squeaking noise with activity. Metal-on-metal arthroplasty can release metal debris into the body. Highly cross linked polyethylene is not as strong as regular polyethylene. These plastic liners can crack or break free of the metal shell that holds them.{{citation needed|date=February 2022}}
===Loosening===
[[File:Hip joint aseptic loosening ar1938-1.png|thumb|upright|Hip prosthesis displaying aseptic loosening (arrows)]]
[[File:Hip prosthesis zones by DeLee and Charnley system, and Gruen system.jpg|thumb|210px|[[Hip prosthesis zones]] according to DeLee and Charnley,<ref>{{cite book|title=The Adult Hip, Volume 1|url=https://books.google.com/books?id=-fwULYB1gJIC&pg=PA958| vauthors = Callaghan JJ, Rosenberg AG, Rubash HE |publisher=Lippincott Williams & Wilkins|year=2007|isbn=978-0-7817-5092-9|page=958}}</ref> and Gruen.<ref>{{cite journal | vauthors = Neumann DR, Thaler C, Hitzl W, Huber M, Hofstädter T, Dorn U | title = Long-term results of a contemporary metal-on-metal total hip arthroplasty: a 10-year follow-up study | journal = The Journal of Arthroplasty | volume = 25 | issue = 5 | pages = 700–708 | date = August 2010 | pmid = 19596544 | doi = 10.1016/j.arth.2009.05.018 }}</ref> These are used to describe the location of for example areas of loosening.]]
On radiography, it is normal to see thin radiolucent areas of less than 2 mm around hip prosthesis components, or between a cement mantle and bone. These may indicate loosening of the prosthesis if they are new or changing, while areas greater than 2 mm may be harmless if they are stable.<ref name="RothMaertz2012"/> The most important prognostic factors of cemented cups are absence of radiolucent lines in DeLee and Charnley zone I, as well as adequate cement mantle thickness.<ref>{{cite book|title=The Well-Cemented Total Hip Arthroplasty: Theory and Practice|url=https://books.google.com/books?id=PQ6NZAeJUXcC&pg=PA337| vauthors = Breusch S, Malchau H |publisher=Springer Science & Business Media|year=2005|isbn=978-3-540-24197-3|page=336}}</ref> In the first year after insertion of uncemented femoral stems, it is normal to have mild subsidence (less than 10 mm).<ref name="RothMaertz2012">{{cite journal | vauthors = Roth TD, Maertz NA, Parr JA, Buckwalter KA, Choplin RH | title = CT of the hip prosthesis: appearance of components, fixation, and complications | journal = Radiographics | volume = 32 | issue = 4 | pages = 1089–1107 | year = 2012 | pmid = 22786996 | doi = 10.1148/rg.324115183 }}</ref> The direct anterior approach has been shown to itself be a risk factor for early femoral component loosening.<ref name="James I 2016"/><ref>{{cite journal | vauthors = Angerame MR, Fehring TK, Masonis JL, Mason JB, Odum SM, Springer BD | title = Early Failure of Primary Total Hip Arthroplasty: Is Surgical Approach a Risk Factor? | journal = The Journal of Arthroplasty | volume = 33 | issue = 6 | pages = 1780–1785 | date = June 2018 | pmid = 29439894 | doi = 10.1016/j.arth.2018.01.014 | s2cid = 29149705 }}</ref><ref name="Direct Anterior Approach"/>
===Metal sensitivity===
Concerns were raised in the early 2000s regarding metal sensitivity and the potential dangers of metal particulate debris from hip prostheses, including the development of ''pseudotumors'', [[soft tissue]] masses containing necrotic tissue, around the hip joint. It appears these masses were more common in women, and these patients showed a higher level of iron in the blood. The cause was then unknown, and was probably multifactorial. There may have been a toxic reaction to an excess of particulate metal wear debris or a hypersensitivity reaction to a "normal" amount of metal debris.<ref>{{cite journal | vauthors = Pandit H, Glyn-Jones S, McLardy-Smith P, Gundle R, Whitwell D, Gibbons CL, Ostlere S, Athanasou N, Gill HS, Murray DW | display-authors = 6 | title = Pseudotumours associated with metal-on-metal hip resurfacings | journal = The Journal of Bone and Joint Surgery. British Volume | volume = 90 | issue = 7 | pages = 847–851 | date = July 2008 | pmid = 18591590 | doi = 10.1302/0301-620X.90B7.20213 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Boardman DR, Middleton FR, Kavanagh TG | title = A benign psoas mass following metal-on-metal resurfacing of the hip | journal = The Journal of Bone and Joint Surgery. British Volume | volume = 88 | issue = 3 | pages = 402–404 | date = March 2006 | pmid = 16498023 | doi = 10.1302/0301-620X.88B3.16748 | doi-access = free }}<br />{{cite journal | vauthors = Korovessis P, Petsinis G, Repanti M, Repantis T | title = Metallosis after contemporary metal-on-metal total hip arthroplasty. Five to nine-year follow-up | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 88 | issue = 6 | pages = 1183–1191 | date = June 2006 | pmid = 16757749 | doi = 10.2106/JBJS.D.02916 }}</ref><!--It's important to update this section to reflect the fact that there was a product recall of metal-on-metal prostheses shortly after the discovery of this phenomenon.-->
Metal hypersensitivity is a well-established phenomenon and is not uncommon, affecting about 10–15% of the population.<ref name=Hallab01>{{cite journal | vauthors = Hallab N, Merritt K, Jacobs JJ | title = Metal sensitivity in patients with orthopaedic implants | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 83 | issue = 3 | pages = 428–436 | date = March 2001 | pmid = 11263649 | doi = 10.2106/00004623-200103000-00017 }}</ref> Skin contact with certain metals can cause immune reactions such as [[hives]], [[eczema]], redness and itching. Although little is known about the short- and long-term pharmacodynamics and bioavailability of circulating metal degradation products ''in vivo'', there have been many reports of immunologic-type responses temporally associated with implantation of metal components. Individual case reports link immune hypersensitivity reactions with adverse performance of metallic cardiovascular, orthopedic and plastic surgical and dental implants.<ref name=Hallab01/>
===Metal toxicity===
{{Main|Metallosis}}
Most hip replacements consist of cobalt and chromium alloys, or titanium. [[Stainless steel]] is no longer used. Any metal implant releases its constituent [[ions]] into the blood. Typically, these are excreted in the urine, but in certain individuals the ions can accumulate in the body. In implants which involve metal-on-metal contact, microscopic fragments of [[cobalt]] and [[chromium]] can be absorbed into the person's bloodstream. There are reports of [[cobalt toxicity]] with hip replacement, particularly metal-on-metal hip replacements, which are no longer in use.<ref>{{cite web|url=http://www.epi.hss.state.ak.us/bulletins/docs/b2010_14.pdf|title=Cobalt Toxicity in Two Hip Replacement Patients|date=May 28, 2010|work=State of Alaska Epidemiology Bulletin No. 14|vauthors=Tower SS|access-date=January 13, 2011|archive-date=September 18, 2020|archive-url=https://web.archive.org/web/20200918125225/http://www.epi.hss.state.ak.us/bulletins/docs/b2010_14.pdf|url-status=dead}}</ref><ref name=reuters-20120329/>
Use of metal-on-metal hip replacements from the 1970s was discontinued in the 1980s and 1990s, particularly after the discovery of aseptic lymphocyte-dominant vasculitis-associated lesions (ALVAL). However, the [[Federal Food, Drug, and Cosmetic Act#Premarket notification .28510.28k.29.2C PMN.29|FDA's 510k approval process]] allowed companies to have new and "improved" metal-on-metal hips approved without much clinical testing.<ref>{{cite web | work = Center for Devices and Radiological Health |title=510(k) Clearances |url=https://www.fda.gov/medical-devices/device-approvals-denials-and-clearances/510k-clearances |publisher = FDA |access-date=15 April 2020 |language=en |date=9 February 2019}}</ref> Some people with these prostheses experienced similar reactions to the metal debris as occurred in the 20th century; some devices were recalled.<ref>{{cite journal | vauthors = Triclot P | title = Metal-on-metal: history, state of the art (2010) | journal = International Orthopaedics | volume = 35 | issue = 2 | pages = 201–206 | date = February 2011 | pmid = 21234564 | pmc = 3032111 | doi = 10.1007/s00264-010-1180-8 }}</ref><ref>{{Cite web|url=https://www.fda.gov/medical-devices/device-approvals-denials-and-clearances/510k-clearances|title=510(k) Clearances|website=Health Center for Devices and Radiological|publisher=FDA|date=2019-02-09|language=en|access-date=2020-04-15}}</ref>
===Nerve palsy===
Post operative [[sciatic nerve]] palsy is another possible complication. The frequency of this complication is low. [[Femoral nerve]] palsy is another, but much rarer, complication. Both of these will typically resolve over time, but the healing process is slow. Patients with pre-existing nerve injury are at greater risk of experiencing this complication and are also slower to recover.{{citation needed|date=February 2022}}
===Chronic pain===
A few patients who have had a hip replacement suffer chronic pain after the surgery. Groin pain can develop if the muscle that raises the hip ([[iliopsoas]]) rubs against the edge of the acetabular cup. Bursitis can develop at the trochanter where a surgical scar crosses the bone, or if the femoral component used pushes the leg out to the side too far. Also some patients can experience pain in cold or damp weather.{{citation needed|date=October 2012}} Incision made in the front of the hip (anterior approach) can cut a nerve running down the thigh leading to numbness in the thigh and occasionally chronic pain at the point where the nerve was cut (a neuroma).
===Death===
The rate of [[perioperative mortality]] for elective hip replacements is significantly less than 1%.<ref>{{cite news| vauthors = Coté J |title=Hip replacement is not viewed as high-risk surgery; Death is rare, but underlying medical condition a factor|newspaper=San Francisco Chronicle|date=July 22, 2007|url=http://articles.sfgate.com/2007-07-22/news/17254067_1_hip-replacement-hip-replacement-surgery-blood-clot}}</ref><ref>[http://www.medscape.com/viewarticle/588980 Medscape Conference Coverage], American Academy of Orthopaedic Surgeons (AAOS) 2009 Annual Meeting, AAOS 2009: Certain Factors Increase Risk for Death After Total Hip Arthroplasty, Barbara Boughton, March 3, 2009.</ref>
===Metal-on-metal hip implant failure===
{{See also|Implant failure}}
By 2010, reports in the orthopaedic literature increasingly cited the problem of early failure of metal-on-metal prostheses in a small percentage of patients.<ref>{{cite journal | vauthors = Mikhael MM, Hanssen AD, Sierra RJ | title = Failure of metal-on-metal total hip arthroplasty mimicking hip infection. A report of two cases | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 91 | issue = 2 | pages = 443–446 | date = February 2009 | pmid = 19181991 | doi = 10.2106/JBJS.H.00603 }}</ref> Failures may have related to the release of minute metallic particles or metal ions from [[wear]] on the implants, causing pain and disability severe enough to require revision surgery in 1–3% of patients.<ref><!--needs double-checking against this and other Meier NYT source-->{{cite news| vauthors = Meier B |url=https://www.nytimes.com/2010/03/04/health/04metalhipside.html|title=As Use of Metal-on-Metal Hip Implants Grows, Studies Raise Concerns|date=March 3, 2010|work=The New York Times|name-list-style=vanc}}</ref> Design deficits of some prothesis models, especially with heat-treated alloys and a lack of specialized surgical experience, accounted for most of the failures. In 2010, surgeons at medical centers such as the [[Mayo Clinic]] reported curtailing their use of metal-on-metal implants by 80 percent over the previous year, in favor of those made from other materials, such as combinations of metal and plastic.<ref><!--separate from other Meier NYT story of same date?-->{{cite news | vauthors = Meier B |date=March 3, 2010 |title=Concerns Over 'Metal on Metal' Hip Implants |work=The New York Times |url=https://www.nytimes.com/2010/03/04/health/04metalhip.html }}</ref> The cause of these failures remains controversial, and may include both design factors, operative technique factors, and factors related to patient [[immune response]]. In the United Kingdom, the [[Medicines and Healthcare products Regulatory Agency]] commenced an annual monitoring regime for metal-on-metal hip replacement patients from May 2010.<ref>{{cite web |url=http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON079157 |title=Medical Device Alert: All metal-on-metal (MoM) hip replacements |date=22 April 2010 |publisher=Medicines and Healthcare products Regulatory Agency |id=MDA/2010/033 |access-date=2010-05-07 |url-status=dead |archive-url=https://web.archive.org/web/20100425160456/http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON079157 |archive-date=25 April 2010 }}</ref> Data which are shown in The Australian Orthopaedic Association's 2008 National [[Joint replacement registry]], a record of nearly every hip implanted in that country over the previous 10 years, tracked 6,773 BHR (Birmingham Hip Resurfacing) hips and found that less than 0.33% may have been revised due to the patient's reaction to the metal component.<ref>Table HT 46. Australian Orthopaedic Association National Joint Replacement Registry Annual Report. Adelaide: AOA; 2008</ref> Other, similar, metal-on-metal designs have not fared as well, with some reports showing that 76–100% of people with these metal-on-metal implants with aseptic implant failures and needing revision surgery also had histological evidence of inflammation, accompanied by extensive lymphocyte infiltrates characteristic of [[delayed-type hypersensitivity]] reactions.<ref>{{cite journal | vauthors = Milosev I, Trebse R, Kovac S, Cör A, Pisot V | title = Survivorship and retrieval analysis of Sikomet metal-on-metal total hip replacements at a mean of seven years | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 88 | issue = 6 | pages = 1173–1182 | date = June 2006 | pmid = 16757748 | doi = 10.2106/JBJS.E.00604 }}</ref> It is not clear to what extent this phenomenon negatively affects orthopedic implant patients. However, for patients presenting with signs of allergic reaction, testing for sensitivity should be conducted. Removal of the device should be considered, since removal may alleviate the symptoms. Patients who have allergic reactions to [[metal alloy|alloy]] jewelry are more likely to have reactions to orthopedic implants. There is increasing awareness of the phenomenon of metal sensitivity, and many surgeons now take this into account when planning which implant is optimal for each patient.
On March 12, 2012, ''[[The Lancet]]'' published a study, based on data from the National Joint Registry of England and Wales, finding that metal-on-metal hip implants failed at much higher rates than other types of hip implants, and calling for a ban on all metal-on-metal hip prostheses.<ref>{{cite journal | vauthors = Smith AJ, Dieppe P, Vernon K, Porter M, Blom AW | title = Failure rates of stemmed metal-on-metal hip replacements: analysis of data from the National Joint Registry of England and Wales | journal = Lancet | volume = 379 | issue = 9822 | pages = 1199–1204 | date = March 2012 | pmid = 22417410 | doi = 10.1016/S0140-6736(12)60353-5 | s2cid = 9913872 }}</ref> The analysis of 402,051 hip replacements showed that 6.2% of metal-on-metal hip implants had failed within five years, compared to 1.7% of metal-on-plastic and 2.3% of ceramic-on-ceramic hip implants. Each {{convert|1|mm|abbr=on}} increase in head size of metal-on-metal hip implants was associated with a 2% increase in failure rate.<ref>{{cite news |url=https://www.bbc.co.uk/news/health-17337993 |title=Metal-on-metal hip replacements 'high failure rate' | vauthors = Gallagher J |publisher=BBC |date=13 March 2012 |access-date=20 May 2012}}</ref> Surgeons of the British Hip Society recommended that large head metal-on-metal implants should no longer be implanted.<ref>{{cite journal | vauthors = Pijls BG, Meessen JM, Schoones JW, Fiocco M, van der Heide HJ, Sedrakyan A, Nelissen RG | title = Increased Mortality in Metal-on-Metal versus Non-Metal-on-Metal Primary Total Hip Arthroplasty at 10 Years and Longer Follow-Up: A Systematic Review and Meta-Analysis | journal = PLOS ONE | volume = 11 | issue = 6 | pages = e0156051 | year = 2016 | pmid = 27295038 | pmc = 4905643 | doi = 10.1371/journal.pone.0156051 | doi-access = free | bibcode = 2016PLoSO..1156051P }}</ref><ref>{{cite news |url=https://www.bbc.co.uk/news/health-17261234 |title=Surgeons call for end to metal hip replacements | vauthors = Roberts M |publisher=BBC |date=5 March 2012 |access-date=20 May 2012}}</ref>
On February 10, 2011, the U.S. [[Food and Drug Administration|FDA]] issued an advisory on metal-on-metal hip implants, stating it was continuing to gather and review all available information about metal-on-metal hip systems.<ref>{{cite web |url=https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/default.htm |title=Metal-on-Metal Hip Implants |publisher=Food and Drug Administration |date=February 10, 2011 |access-date=January 4, 2012}}</ref> On June 27–28, 2012, an advisory panel met to decide whether to impose new standards, taking into account findings of the study in ''The Lancet''.<ref name=reuters-20120329>{{cite news |url=https://www.reuters.com/article/usa-fda-hips-idUSL3E8ET6X820120329 |title=FDA seeks more advice on metal hip implants |work=Reuters |date=29 March 2012 |access-date=20 May 2012}}</ref><ref>{{cite web |url=https://www.fda.gov/AdvisoryCommittees/Calendar/ucm297884.htm |title=Orthopaedic and Rehabilitation Devices Panel of the Medical Devices Advisory Committee Meeting Announcement |publisher=Food and Drug Administration |id=FDA-2012-N-0293 |date=27 March 2012 |access-date=20 May 2012}}</ref><ref name=FDA-summary-memo>{{cite report |url=https://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/OrthopaedicandRehabilitationDevicesPanel/UCM309302.pdf |title=FDA Executive Summary Memorandum – Metal-on-Metal Hip Implant System |publisher=Food and Drug Administration |date=27 June 2012 |access-date=15 March 2013}}</ref> No new standards, such as routine checking of blood levels of metal ions, were set, but guidance was updated.<ref>{{cite web |url=https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/ucm241604.htm |title=Concerns about Metal-on-Metal Hip Implants |publisher=Food and Drug Administration |date=17 January 2013 |access-date=15 March 2013}}</ref> The U.S. FDA does not require hip implants to be tested in clinical trials before they can be sold in the U.S.<ref>{{cite web|url=http://media.jamanetwork.com/news-item/study-suggests-women-have-higher-risk-of-hip-implant-failure/|title=Study Suggests Women Have Higher Risk of Hip Implant Failure |website=media.jamanetwork.com}}</ref> Instead, companies making new hip implants only need to prove that they are "substantially equivalent" to other hip implants already on the market. The exception is metal-on-metal implants, which were not tested in clinical trials, but, due to the high revision rate of metal-on-metal hips, the FDA has stated that, in the future, clinical trials will be required for approval, and that post-market studies will be required to keep metal-on-metal hip implants on the market.<ref>{{cite journal | vauthors = Rising JP, Reynolds IS, Sedrakyan A | title = Delays and difficulties in assessing metal-on-metal hip implants | journal = The New England Journal of Medicine | volume = 367 | issue = 1 | pages = e1 | date = July 2012 | pmid = 22716934 | doi = 10.1056/NEJMp1206794 }}</ref>
==Modern process==
[[File:Hip Prosthesis.gif|thumb|Hip prosthesis 3D model]]
[[File:Hip Prostesis.png|thumb|Different parts of hip prosthesis]]
[[File:Hip prosthesis.jpg|thumb|A [[titanium]] hip prosthesis, with a [[ceramic]] head and [[polyethylene]] acetabular cup]]
The modern artificial joint owes much to the 1962 work of Sir [[John Charnley]] at Wrightington Hospital in the United Kingdom. His work in the field of [[tribology]] resulted in a design that almost completely replaced the other designs by the 1970s. Charnley's design consisted of three parts:
# [[Stainless Steel|stainless steel]] one-piece femoral stem and head
# [[polyethylene]] (originally [[Teflon]]), acetabular component, both of which were fixed to the bone using
# [[Poly(methyl methacrylate)|PMMA]] (acrylic) [[bone cement]]
The replacement joint, which was known as the Low Friction [[Arthroplasty]], was lubricated with [[synovial fluid]]. The small femoral head ({{convert|7/8|in|sigfig=3|abbr=on}}) was chosen for Charnley's belief that it would have lower friction against the acetabular component and thus wear out the acetabulum more slowly. Unfortunately, the smaller head dislocated more easily. Alternative designs with larger heads such as the Mueller prosthesis were proposed. Stability was improved, but acetabular wear and subsequent failure rates were increased with these designs. The Teflon acetabular components of Charnley's early designs failed within a year or two of implantation. This prompted a search for a more suitable material. A German salesman showed a polyethylene gear sample to Charnley's machinist, sparking the idea to use this material for the acetabular component. The [[Ultra-high-molecular-weight polyethylene|UHMWPE]] acetabular component was introduced in 1962. Charnley's other major contribution was to use polymethylmethacrylate (PMMA) bone cement to attach the two components to the bone. For over two decades, the Charnley Low Friction Arthroplasty, and derivative designs were the most used systems in the world. It formed the basis for all modern hip implants. An example can be seen at the Science Museum, London.<ref>{{Cite web |date=2022 |title=Charnley-type artificial hip prosthesis, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co179829/charnley-type-artificial-hip-prosthesis-artificial-hip-joint}}</ref>
The Exeter hip stem was developed in the United Kingdom during the same time as the Charnley device. Its development occurred following a collaboration between Orthopaedic Surgeon [[Robin Ling]] and [[University of Exeter]] engineer [[Clive Lee]] and it was first implanted at the Princess Elizabeth Orthopaedic Hospital in Exeter in 1970.<ref>{{cite news|url=https://www.theguardian.com/science/2017/oct/20/robin-ling-obituary|title=Robin Ling obituary|work=[[The Guardian]]|date=20 October 2017| vauthors = Timperley AJ |access-date=22 October 2017}}</ref> The Exeter Hip is a cemented device, but with a slightly different stem geometry. Both designs have shown excellent long-term durability when properly placed and are still widely used in slightly modified versions.
Early implant designs had the potential to loosen from their attachment to the bones, typically becoming painful ten to twelve years after placement. In addition, erosion of the bone around the implant was seen on x-rays. Initially, surgeons believed this was caused by an abnormal reaction to the cement holding the implant in place. That belief prompted a search for an alternative method to attach the implants. The Austin Moore device had a small hole in the stem into which bone graft was placed before implanting the stem. It was hoped bone would then grow through the window over time and hold the stem in position. Success was unpredictable and the fixation not very robust. In the early 1980s, surgeons in the United States applied a coating of small beads to the Austin Moore device and implanted it without cement. The beads were constructed so that gaps between beads matched the size of the pores in native bone. Over time, bone cells from the patient would grow into these spaces and fix the stem in position. The stem was modified slightly to fit more tightly into the femoral canal, resulting in the Anatomic Medullary Locking (AML) stem design. With time, other forms of stem surface treatment and stem geometry have been developed and improved.
Initial hip designs were made of a one-piece femoral component and a one-piece acetabular component. Current designs have a femoral stem and separate head piece. Using an independent head allows the surgeon to adjust leg length (some heads seat more or less onto the stem) and to select from various materials from which the head is formed. A modern acetabulum component is also made up of two parts: a metal shell with a coating for bone attachment and a separate liner. First the shell is placed. Its position can be adjusted, unlike the original cemented cup design which are fixed in place once the cement sets. When proper positioning of the metal shell is obtained, the surgeon may select a liner made from various materials.
To combat loosening caused by polyethylene wear debris, hip manufacturers developed improved and novel materials for the acetabular liners. [[Ceramic]] heads mated with regular polyethylene liners or a ceramic liner were the first significant alternative. Metal liners to mate with a metal head were also developed. At the same time these designs were being developed, the problems that caused polyethylene wear were determined and manufacturing of this material improved. Highly crosslinked UHMWPE was introduced in the late 1990s. The most recent data comparing the various bearing surfaces has shown no clinically significant differences in their performance. Potential early problems with each material are discussed below. Performance data after 20 or 30 years may be needed to demonstrate significant differences in the devices. All newer materials allow use of larger diameter femoral heads. Use of larger heads significantly decreases the chance of the hip dislocating, which remains the greatest complication of the surgery.
When available implants are used, cemented stems tend to have a better longevity than uncemented stems. No significant difference is observed in the clinical performance of the various methods of surface treatment of uncemented devices. Uncemented stems are selected for patients with good quality bone that can resist the forces needed to drive the stem in tightly. Cemented devices are typically selected for patients with poor quality bone who are at risk of fracture during stem insertion. Cemented stems are less expensive due to lower manufacturing cost, but require good surgical technique to place them correctly. Uncemented stems can cause pain with activity in up to 20% of patients during the first year after placement as the bone adapts to the device. This is rarely seen with cemented stems.{{citation needed|date=March 2024}}
==Techniques==
There are several incisions, defined by their relation to the gluteus medius. The approaches are posterior (Moore), lateral (Hardinge or Liverpool),<ref name="pmid9498150">{{cite journal | vauthors = Pai VS | title = A comparison of three lateral approaches in primary total hip replacement | journal = International Orthopaedics | volume = 21 | issue = 6 | pages = 393–398 | year = 1997 | pmid = 9498150 | pmc = 3619565 | doi = 10.1007/s002640050193 | url = http://link.springer.de/link/service/journals/00264/bibs/8021006/80210393.htm | url-status = dead | archive-url = https://web.archive.org/web/20020108155635/http://www.link.springer.de/link/service/journals/00264/bibs/8021006/80210393.htm | archive-date = 2002-01-08 }}</ref> antero-lateral (Watson-Jones),<ref name="titleAnterolateral Approach to Hip Joint: (Watson Jones) - Wheeless' Textbook of Orthopaedics">{{Cite web|url=http://www.wheelessonline.com/ortho/anterolateral_approach_to_hip_joint_watson_jones |title=Anterolateral Approach to Hip Joint: (Watson Jones) – Wheeless' Textbook of Orthopaedics |access-date=2007-11-26 }}</ref> anterior (Smith-Petersen)<ref name="titleAnterior Approach to the Hip (Smith Petersen) – Wheeless' Textbook of Orthopaedics">{{Cite web|url=http://www.wheelessonline.com/ortho/anterior_approach_to_the_hip_smith_peterson |title=Anterior Approach to the Hip (Smith Petersen) – Wheeless' Textbook of Orthopaedics |access-date=2007-11-26 }}</ref> and [[greater trochanter]] osteotomy. There is no compelling evidence in the literature for any particular approach.
===Posterior approach===
The ''posterior'' (''Moore'' or ''Southern'') ''approach'' accesses the joint and capsule through the back, taking [[piriformis muscle]] and the short external rotators of the femur. This approach gives excellent access to the acetabulum and femur and preserves the hip [[Abduction (kinesiology)|abductors]] and thus minimizes the risk of abductor dysfunction post operatively. It has the advantage of becoming a more extensile approach if needed. Critics cite a higher dislocation rate, although repair of the capsule, piriformis and the short external rotators along with use of modern large diameter head balls reduces this risk. Limited evidence suggests that the posterior approach may cause less nerve damage.<ref>{{cite journal | vauthors = Jolles BM, Bogoch ER | title = Posterior versus lateral surgical approach for total hip arthroplasty in adults with osteoarthritis | journal = The Cochrane Database of Systematic Reviews | volume = 2006 | issue = 3 | pages = CD003828 | date = July 2006 | pmid = 16856020 | pmc = 8740306 | doi = 10.1002/14651858.cd003828.pub3 }}</ref>
===Lateral approach===
The ''lateral approach'' is also commonly used for hip replacement. The approach requires elevation of the hip abductors ([[gluteus medius]] and [[gluteus minimus]]) to access the joint. The abductors may be lifted up by osteotomy of the greater trochanter and reapplying it afterwards using wires (as per Charnley),{{Citation needed|date=December 2007}} or may be divided at their tendinous portion, or through the functional tendon (as per Hardinge) and repaired using [[surgical suture|sutures]]. Although this approach has a lower dislocation risk than the posterior approach, critics note that occasionally the abductor muscles do not heal back on, leading to pain and weakness which is often very difficult to treat.
=== Antero-lateral approach ===
The ''anterolateral approach'' develops the interval between the [[tensor fasciae latae]] and the gluteus medius. The Gluteus medius, gluteus minimus and hip capsule are detached from the anterior (front) for the greater trochanter and femoral neck and then repaired with heavy suture after the replacement of the joint.
=== Anterior approach ===
The ''anterior approach'' uses an interval between the [[sartorius muscle]] and tensor fasciae latae. This approach, which was commonly used for pelvic fracture repair surgery, has been adapted for use when performing hip replacement. When used with older hip implant systems that had a small diameter head, dislocation rates were reduced compared to surgery performed through a posterior approach. With modern implant designs, dislocation rates are similar between the anterior and posterior approaches.<ref>{{cite journal | vauthors = Maratt JD, Gagnier JJ, Butler PD, Hallstrom BR, Urquhart AG, Roberts KC | title = No Difference in Dislocation Seen in Anterior Vs Posterior Approach Total Hip Arthroplasty | journal = The Journal of Arthroplasty | volume = 31 | issue = 9 Suppl | pages = 127–130 | date = September 2016 | pmid = 27067754 | doi = 10.1016/j.arth.2016.02.071 }}</ref> The anterior approach has been shown in studies to variably improve early functional recovery, with possible complications of femoral component loosening and early revision compared to other approaches.<ref name="Direct Anterior Approach">{{cite journal | vauthors = Meneghini RM, Elston AS, Chen AF, Kheir MM, Fehring TK, Springer BD | title = Direct Anterior Approach: Risk Factor for Early Femoral Failure of Cementless Total Hip Arthroplasty: A Multicenter Study | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 99 | issue = 2 | pages = 99–105 | date = January 2017 | pmid = 28099299 | doi = 10.2106/JBJS.16.00060 | s2cid = 6299470 }}</ref><ref name="James I 2016">{{cite journal | vauthors = Eto S, Hwang K, Huddleston JI, Amanatullah DF, Maloney WJ, Goodman SB | title = The Direct Anterior Approach is Associated With Early Revision Total Hip Arthroplasty | journal = The Journal of Arthroplasty | volume = 32 | issue = 3 | pages = 1001–1005 | date = March 2017 | pmid = 27843039 | doi = 10.1016/j.arth.2016.09.012 }}</ref><ref>{{cite journal | vauthors = Christensen CP, Jacobs CA | title = Comparison of Patient Function during the First Six Weeks after Direct Anterior or Posterior Total Hip Arthroplasty (THA): A Randomized Study | journal = The Journal of Arthroplasty | volume = 30 | issue = 9 Suppl | pages = 94–97 | date = September 2015 | pmid = 26096071 | doi = 10.1016/j.arth.2014.12.038 }}</ref><ref>{{cite journal | vauthors = Higgins BT, Barlow DR, Heagerty NE, Lin TJ | title = Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis | journal = The Journal of Arthroplasty | volume = 30 | issue = 3 | pages = 419–434 | date = March 2015 | pmid = 25453632 | doi = 10.1016/j.arth.2014.10.020 }}</ref><ref>{{cite journal | vauthors = Meermans G, Konan S, Das R, Volpin A, Haddad FS | title = The direct anterior approach in total hip arthroplasty: a systematic review of the literature | journal = The Bone & Joint Journal | volume = 99-B | issue = 6 | pages = 732–740 | date = June 2017 | pmid = 28566391 | doi = 10.1302/0301-620X.99B6.38053 | s2cid = 21287407 }}</ref><ref>{{cite journal | vauthors = Graves SC, Dropkin BM, Keeney BJ, Lurie JD, Tomek IM | title = Does Surgical Approach Affect Patient-reported Function After Primary THA? | journal = Clinical Orthopaedics and Related Research | volume = 474 | issue = 4 | pages = 971–981 | date = April 2016 | pmid = 26620966 | pmc = 4773324 | doi = 10.1007/s11999-015-4639-5 }}</ref>
=== Minimally invasive approaches ===
The dual incision approach and other minimally invasive surgery seeks to reduce soft tissue damage through reducing the size of the incision. However, component positioning accuracy and visualization of the bone structures can be significantly impaired as the approaches get smaller. This can result in unintended fractures and soft tissue injury. The majority of current orthopedic surgeons use a "minimally invasive" approach compared to traditional approaches which were quite large comparatively.
[[Computer-assisted surgery]] and robotic surgery techniques are also available to guide the surgeon to provide enhanced component accuracy.<ref>{{cite journal | vauthors = Perets I, Walsh JP, Mu BH, Mansor Y, Rosinsky PJ, Maldonado DR, Lall AC, Domb BG | display-authors = 6 | title = Short-term Clinical Outcomes of Robotic-Arm Assisted Total Hip Arthroplasty: A Pair-Matched Controlled Study | journal = Orthopedics | volume = 44 | issue = 2 | pages = e236–e242 | date = 2021-03-01 | pmid = 33238012 | doi = 10.3928/01477447-20201119-10 | s2cid = 227176201 }}</ref> Several commercial CAS and robotic systems are available for use worldwide. Improved patient outcomes and reduced complications have not been demonstrated when these systems are used when compared to standard techniques.<ref>{{cite journal | vauthors = Parsley BS | title = Robotics in Orthopedics: A Brave New World | journal = The Journal of Arthroplasty | volume = 33 | issue = 8 | pages = 2355–2357 | date = August 2018 | pmid = 29605151 | doi = 10.1016/j.arth.2018.02.032 | s2cid = 4557610 }}</ref><ref>{{cite journal | vauthors = Jacofsky DJ, Allen M | title = Robotics in Arthroplasty: A Comprehensive Review | journal = The Journal of Arthroplasty | volume = 31 | issue = 10 | pages = 2353–2363 | date = October 2016 | pmid = 27325369 | doi = 10.1016/j.arth.2016.05.026 }}</ref>
==Implants==
[[File:MetalonmetalhipreplaceMark.png|thumb|Metal on metal prosthetic hip]]
[[File:Hip-replacement.jpg|thumb|upright|Cement-free implant sixteen days after surgery. Femoral component is cobalt chromium combined with titanium which induces bone growth into the implant. Ceramic head. Acetabular cup coated with bone growth-inducing material and held temporarily in place with a single screw.]]
The prosthetic implant used in hip replacement consists of three parts: the acetabular cup, the femoral component, and the articular interface. Options exist for different people and indications. The evidence for a number of newer devices is not very good, including: ceramic-on-ceramic bearings, modular femoral necks, and uncemented monoblock cups.<ref>{{cite journal | vauthors = Nieuwenhuijse MJ, Nelissen RG, Schoones JW, Sedrakyan A | title = Appraisal of evidence base for introduction of new implants in hip and knee replacement: a systematic review of five widely used device technologies | journal = BMJ | volume = 349 | issue = sep09 1 | pages = g5133 | date = September 2014 | pmid = 25208953 | pmc = 4159610 | doi = 10.1136/bmj.g5133 }}</ref> Correct selection of the prosthesis is important.
===Acetabular cup===
The acetabular cup is the component which is placed into the [[acetabulum]] (hip socket). Cartilage and bone are removed from the acetabulum and the acetabular cup is attached using friction or cement. Some acetabular cups are one piece, while others are modular. One-piece (monobloc) shells are either [[ultra-high-molecular-weight polyethylene]] (UHMWPE) or metal, they have their articular surface machined on the inside surface of the cup and do not rely on a locking mechanism to hold a liner in place. A monobloc polyethylene cup is cemented in place while a metal cup is held in place by a metal coating on the outside of the cup. Modular cups consist of two pieces, a shell and liner. The shell is made of metal; the outside has a porous coating while the inside contains a locking mechanism designed to accept a liner. Two types of porous coating used to form a friction fit are [[sintering|sintered]] beads and a [[foam metal]] design to mimic the trabeculae of cancellous bone and initial stability is influenced by under-reaming and insertion force.<ref name="Amirouche">{{cite journal | vauthors = Amirouche F, Solitro G, Broviak S, Gonzalez M, Goldstein W, Barmada R | title = Factors influencing initial cup stability in total hip arthroplasty | journal = Clinical Biomechanics | volume = 29 | issue = 10 | pages = 1177–1185 | date = December 2014 | pmid = 25266242 | doi = 10.1016/j.clinbiomech.2014.09.006 | url = https://figshare.com/articles/journal_contribution/10757246 }}</ref> Permanent fixation is achieved as bone grows onto or into the porous coating. Screws can be used to lag the shell to the bone providing even more fixation. Polyethylene liners are placed into the shell and connected by a rim locking mechanism; ceramic and metal liners are attached with a [[Morse taper]].{{citation needed|date=July 2012}}
===Femoral component===
{{Original research|section|date=April 2016}}The femoral component is the component that fits in the [[femur]] (thigh bone). Bone is removed and the femur is shaped to accept the femoral stem with attached prosthetic femoral head (ball). There are two types of fixation: cemented and uncemented. Cemented stems use acrylic [[bone cement]] to form a mantle between the stem and to the bone. Uncemented stems use friction, shape and surface coatings to stimulate bone to remodel and bond to the implant. Stems are made of multiple materials (titanium, cobalt chromium, stainless steel, and polymer composites) and they can be monolithic or modular. Modular components consist of different head dimensions and/or modular neck orientations; these attach via a taper similar to a [[Morse taper]]. These options allow for variability in leg length, offset and version. Femoral heads are made of metal or ceramic material. Metal heads, made of cobalt chromium for hardness, are machined to size and then polished to reduce wear of the socket liner. Ceramic heads are more smooth than polished metal heads, have a lower coefficient of friction than a cobalt chrome head, and in theory will wear down the socket liner more slowly. As of early 2011, follow-up studies in patients have not demonstrated significant reductions in wear rates between the various types of femoral heads on the market. Ceramic implants are more brittle and may break after being implanted.
===Articular interface===
{{Original research|section|date=April 2016}}The articular interface is not part of either implant, rather it is the area between the acetabular cup and femoral component. The articular interface of the hip is a simple ball and socket joint. Size, material properties and machining [[Engineering tolerance|tolerances]] at the articular interface can be selected based on patient demand to optimise implant function and longevity whilst mitigating associated risks. The interface size is measured by the outside diameter of the head or the inside diameter of the socket. Common sizes of femoral heads are {{convert|28|mm|abbr=on}}, {{convert|32|mm|abbr=on}} and {{convert|36|mm|abbr=on}}. While {{convert|22.25|mm|frac=8|abbr=on}} was common in the first modern prostheses, now even larger sizes are available from 38 to over 54 mm. Larger-diameter heads lead to increased stability and range of motion whilst lowering the risk of dislocation. At the same time they are also subject to higher stresses such as friction and inertia. Different combinations of materials have different physical properties which can be coupled to reduce the amount of wear debris generated by friction. Typical pairings of materials include metal on polyethylene (MOP), metal on crosslinked polyethylene (MOXP), ceramic on ceramic (COC), ceramic on crosslinked polyethylene (COXP), and metal on metal (MOM). Each combination has different advantages and disadvantages.
Dual mobility hip replacements reduce the risk of dislocation.<ref name="Dual mobility total hip arthroplast">{{cite journal | vauthors = Blakeney WG, Epinette JA, Vendittoli PA | title = Dual mobility total hip arthroplasty: should everyone get one? | journal = EFORT Open Reviews | volume = 4 | issue = 9 | pages = 541–547 | date = September 2019 | pmid = 31598332 | pmc = 6771074 | doi = 10.1302/2058-5241.4.180045 }}</ref><ref>{{cite journal | vauthors = Horriat S, Haddad FS | title = Dual mobility in hip arthroplasty: What evidence do we need? | journal = Bone & Joint Research | volume = 7 | issue = 8 | pages = 508–510 | date = August 2018 | pmid = 30258569 | pmc = 6138808 | doi = 10.1302/2046-3758.78.BJR-2018-0217 }}</ref>
==Configuration==
Post-operative [[projectional radiography]] is routinely performed to ensure proper configuration of hip prostheses.
The direction of the acetabular cup influences the range of motion of the leg, and also affects the risk of dislocation.<ref name=Watt/> For this purpose, the ''acetabular inclination'' and the ''acetabular anteversion'' are measurements of cup angulation in the [[coronal plane]] and the [[sagittal plane]], respectively.
<gallery widths="230">
File:Acetabular inclination of hip prosthesis.jpg|Acetabular inclination.<ref name=Vanrusselt2015/> This parameter is calculated on an anteroposterior radiograph as the angle between a line through the lateral and medial margins of the acetabular cup and the ''transischial line'' which is tangential to the inferior margins of the [[ischium]] bones.<ref name=Vanrusselt2015>{{cite journal | vauthors = Vanrusselt J, Vansevenant M, Vanderschueren G, Vanhoenacker F | title = Postoperative radiograph of the hip arthroplasty: what the radiologist should know | journal = Insights into Imaging | volume = 6 | issue = 6 | pages = 591–600 | date = December 2015 | pmid = 26487647 | pmc = 4656234 | doi = 10.1007/s13244-015-0438-5 }}</ref>
File:Range of acetabular inclination.png|Acetabular inclination is normally between 30 and 50°.<ref name=Vanrusselt2015/> A larger angle increases the risk of dislocation.<ref name=Watt>{{cite web|url=http://www.radiologyassistant.nl/en/p431c8258e7ac3/hip-arthroplasty.html|title=Hip – Arthroplasty – Normal and abnormal imaging findings| vauthors = Watt I, Boldrik S, van Langelaan E, Smithuis R |website=Radiology Assistant |access-date=2017-05-21 }}</ref>
File:Acetabular anteversion of hip prosthesis.jpg|Acetabular anteversion.<ref name="ShinLee2015"/> This parameter is calculated on a lateral radiograph as the angle between the [[transverse plane]] and a line going through the (anterior and posterior) margins of the acetabular cup.<ref name="ShinLee2015">{{cite journal | vauthors = Shin WC, Lee SM, Lee KW, Cho HJ, Lee JS, Suh KT | title = The reliability and accuracy of measuring anteversion of the acetabular component on plain anteroposterior and lateral radiographs after total hip arthroplasty | journal = The Bone & Joint Journal | volume = 97-B | issue = 5 | pages = 611–616 | date = May 2015 | pmid = 25922453 | doi = 10.1302/0301-620X.97B5.34735 }}</ref>
File:Range of acetabular anteversion.png|Acetabular anteversion is normally between 5 and 25°.<ref name=Watt/> An anteversion below or above this range increases the risk of dislocation.<ref name=Watt/> There is an [[intra-individual variability]] in this method because the pelvis may be tilted in various degrees in relation to the transverse plane.<ref name=Watt/>
File:Leg length discrepancy after hip replacement.jpg|''Leg length discrepancy'' after hip replacement is calculated as the vertical distance between the middle of the minor trochanters, using the acetabular tear drops<ref name=Vanrusselt2015/> or the transischial line<ref name=Watt/> as references for the horizontal plane. A discrepancy of up to 1 cm is generally tolerated.<ref name=Vanrusselt2015/><ref name=Watt/>
File:Center of rotation of hip prosthesis.jpg|''Center of rotation'': The horizontal center of rotation is calculated as the distance between the acetabular teardrop and the center of the head (or caput) of the prosthesis and/or the native femoral head on the contralateral side.<ref name=Vanrusselt2015/> The vertical center of rotation instead uses the transischial line for reference.<ref name=Vanrusselt2015/> The parameter should be equal on both sides.<ref name=Vanrusselt2015/>
</gallery>
==Alternatives and variations==
===Conservative management===
The first line approach as an alternative to hip replacement is conservative management which involves a multimodal approach of oral medication, injections, activity modification and [[physical therapy]].<ref>{{cite journal | vauthors = Cibulka MT, White DM, Woehrle J, Harris-Hayes M, Enseki K, Fagerson TL, Slover J, Godges JJ | display-authors = 6 | title = Hip pain and mobility deficits--hip osteoarthritis: clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American Physical Therapy Association | journal = The Journal of Orthopaedic and Sports Physical Therapy | volume = 39 | issue = 4 | pages = A1-25 | date = April 2009 | pmid = 19352008 | pmc = 3963282 | doi = 10.2519/jospt.2009.0301 }}</ref> Conservative management can prevent or delay the need for hip replacement.
=== Preoperative care ===
Preoperative education is an important part of patient care. Some evidence indicates that it may slightly reduce anxiety before hip or knee replacement, with low risk of negative effects.<ref>{{cite journal | vauthors = McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A | title = Preoperative education for hip or knee replacement | journal = The Cochrane Database of Systematic Reviews | volume = 2014 | issue = 5 | pages = CD003526 | date = May 2014 | pmid = 24820247 | pmc = 7154584 | doi = 10.1002/14651858.CD003526.pub3 | publication-date = 13 May 2014 }}</ref>
===Hemiarthroplasty===
[[File:Femoral offset in hemiarthroplasty (crop).jpg|thumb|170px|Femoral (neck) offset is defined as the perpendicular distance between the intramedullary or longitudinal axis of the femur and the center of rotation of the native or prosthetic femoral head. An offset of less than 33 mm is associated with hip dislocation.<ref name="JonesBriffa2017">{{cite journal | vauthors = Jones C, Briffa N, Jacob J, Hargrove R | title = The Dislocated Hip Hemiarthroplasty: Current Concepts of Etiological factors and Management | journal = The Open Orthopaedics Journal | volume = 11 | issue = Suppl-7, M4 | pages = 1200–1212 | year = 2017 | pmid = 29290857 | pmc = 5721319 | doi = 10.2174/1874325001711011200 |doi-access=free}}</ref><ref name="NinhSethi2009">{{cite journal | vauthors = Ninh CC, Sethi A, Hatahet M, Les C, Morandi M, Vaidya R | title = Hip dislocation after modular unipolar hemiarthroplasty | journal = The Journal of Arthroplasty | volume = 24 | issue = 5 | pages = 768–774 | date = August 2009 | pmid = 18555648 | doi = 10.1016/j.arth.2008.02.019 }}</ref>]]
Hemiarthroplasty is a surgical procedure that replaces one half of the joint with an artificial surface and leaves the other part unchanged. This class of procedure is most commonly performed on the hip after an intracapsular fracture of the femur neck ([[hip fracture]]). The procedure is performed by removing the head of the femur and replacing it with a metal or composite [[prosthesis]]. The most commonly used prosthesis designs are the Austin Moore and Thompson prostheses. A [[composite material|composite]] of [[metal]] and [[HDPE]] that forms two interphases (bipolar prosthesis) can be used. The monopolar prosthesis has not been shown to offer any advantage over bipolar designs. The procedure is recommended only for elderly/frail patients, due to their lower life expectancy and activity level. This is because over time the prosthesis tends to loosen or to erode the [[acetabulum]].<ref>{{cite web | vauthors = van der Meulen MC, Allen WA, Giddings VL, Athanasiou KA, Poser RD, Goodman SB, Smith RL, Beaupré GS | display-authors = 6 |title=Effect of hemiarthroplasty on acetabular cartilage |work=1996 Project Reports |publisher=VA Palo Alto Health Care System's Bone and Joint Rehabilitation Research and Development Center |url=http://www.stanford.edu/group/rrd/96reports/96dev5.html}}</ref> Independently mobile older adults with hip fractures may benefit from a total hip replacement instead of hemiarthroplasty.<ref name="Metcalfe">{{cite journal | vauthors = Metcalfe D, Judge A, Perry DC, Gabbe B, Zogg CK, Costa ML | title = Total hip arthroplasty versus hemiarthroplasty for independently mobile older adults with intracapsular hip fractures | journal = BMC Musculoskeletal Disorders | volume = 20 | issue = 1 | pages = 226 | date = May 2019 | pmid = 31101041 | pmc = 6525472 | doi = 10.1186/s12891-019-2590-4 | doi-access = free }}</ref>
<gallery mode="packed" heights="160">
File:Bipolar hip prosthesis.jpg|Hip prosthesis for hemiarthroplasty. This example is bipolar, meaning that the head has two separate articulations.
File:X-ray of hips with a hemiarthroplasty.jpg|[[Projectional radiography|X-ray]] of the hips, with a right-sided hemiarthroplasty
</gallery>
===Hip resurfacing===
[[Hip resurfacing]] is an alternative to hip replacement surgery. It has been used in Europe since 1998 and became a common procedure. Health-related quality of life measures are markedly improved and patient satisfaction is favorable after hip resurfacing arthroplasty.<ref>{{cite journal | vauthors = Koutras C, Antoniou SA, Talias MA, Heep H | title = Impact of Total Hip Resurfacing Arthroplasty on Health-Related Quality of Life Measures: A Systematic Review and Meta-Analysis | journal = The Journal of Arthroplasty | volume = 30 | issue = 11 | pages = 1938–1952 | date = November 2015 | pmid = 26067708 | doi = 10.1016/j.arth.2015.05.014 }}</ref>
The [[minimally invasive hip resurfacing]] procedure is a further refinement to hip resurfacing.
===Viscosupplementation===
Viscosupplementation is the injection of artificial lubricants into the joint.<ref name="pmid17874246">{{cite journal | vauthors = van den Bekerom MP, Lamme B, Sermon A, Mulier M | title = What is the evidence for viscosupplementation in the treatment of patients with hip osteoarthritis? Systematic review of the literature | journal = Archives of Orthopaedic and Trauma Surgery | volume = 128 | issue = 8 | pages = 815–823 | date = August 2008 | pmid = 17874246 | doi = 10.1007/s00402-007-0447-z | s2cid = 9983894 }}</ref> Use of these medications in the hip is off label. The cost of treatment is typically not covered by health insurance.
Some authorities claim that the future of osteoarthritis treatment is [[bioengineering]], targeting the growth and/or repair of the damaged, arthritic joint. Centeno et al. reported on the partial regeneration of an arthritic human hip joint using mesenchymal [[stem cell]]s.<ref name="pmid16886034">{{cite journal | vauthors = Centeno CJ, Kisiday J, Freeman M, Schultz JR | title = Partial regeneration of the human hip via autologous bone marrow nucleated cell transfer: A case study | journal = Pain Physician | volume = 9 | issue = 3 | pages = 253–256 | date = July 2006 | pmid = 16886034 | url = http://www.painphysicianjournal.com/linkout_vw.php?issn=1533-3159&vol=9&page=253 | url-status = dead | archive-url = https://web.archive.org/web/20090212142425/http://www.painphysicianjournal.com/linkout_vw.php?issn=1533-3159&vol=9&page=253 | archive-date = 2009-02-12 }}</ref> It is yet to be shown that this result will apply to a large group of patients and result in significant benefits. The FDA stated that this procedure does not conform to regulations, but Centeno claims that it is exempt from FDA regulation. It has not been shown in controlled clinical trials to be effective.{{citation needed|date=May 2014}}
==Prevalence and cost==
Total hip replacement incidence varies in developed countries between 30 (Romania) and 290 (Germany) procedures per 100,000 population per year.<ref>{{cite journal | vauthors = Kurtz SM, Ong KL, Lau E, Widmer M, Maravic M, Gómez-Barrena E, de Pina M, Manno V, Torre M, Walter WL, de Steiger R, Geesink RG, Peltola M, Röder C | display-authors = 6 | title = International survey of primary and revision total knee replacement | journal = International Orthopaedics | volume = 35 | issue = 12 | pages = 1783–1789 | date = December 2011 | pmid = 21404023 | pmc = 3224613 | doi = 10.1007/s00264-011-1235-5 }}</ref> Approximately 0.8% of Americans have undergone the procedure.<ref>{{cite journal | vauthors = Maradit Kremers H, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA, Jiranek WA, Berry DJ | display-authors = 6 | title = Prevalence of Total Hip and Knee Replacement in the United States | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 97 | issue = 17 | pages = 1386–1397 | date = September 2015 | pmid = 26333733 | pmc = 4551172 | doi = 10.2106/JBJS.N.01141 }}</ref>
According to the International Federation of Healthcare Plans, the average cost of a total hip replacement in 2012 was $40,364 in the United States, $11,889 in the United Kingdom, $10,987 in France, $9,574 in Switzerland, and $7,731 in Spain.<ref name="ifhp"/> In the United States, the average cost of a total hip replacement varies widely by geographic region, ranging from $11,327 (Birmingham, Alabama) to $73,927 (Boston, Massachusetts).<ref>{{cite web|url=http://www.bcbs.com/healthofamerica/BCBS_BHI_Report-Jan-_21_Final.pdf|title=A study of cost variations for knee and hip replacement surgeries in the U.S.|publisher=Blue Cross Blue Shield Association|date=21 January 2015|access-date=4 October 2015|url-status=dead|archive-url=https://web.archive.org/web/20151022105614/http://www.bcbs.com/healthofamerica/BCBS_BHI_Report-Jan-_21_Final.pdf|archive-date=22 October 2015}}</ref>
==History==
[[File:Hip prosthesis, England, 1958-1960 Wellcome L0057818.jpg|thumb|Gosset-style hip prosthesis from 1960]]
The earliest recorded attempts at hip replacement were carried out in Germany in 1891 by [[Themistocles Gluck]] (1853–1942),<ref>{{cite web|url=http://slideplayer.com/slide/1659480/|title=History of Artificial Joints |format= ppt video online download|website=slideplayer.com}}</ref><ref>{{cite journal | vauthors = Brand RA, Mont MA, Manring MM | title = Biographical sketch: Themistocles Gluck (1853-1942) | journal = Clinical Orthopaedics and Related Research | volume = 469 | issue = 6 | pages = 1525–1527 | date = June 2011 | pmid = 21403990 | pmc = 3094624 | doi = 10.1007/s11999-011-1836-8 }}</ref> who used ivory to replace the [[femoral head]] (the ball on the femur), attaching it with nickel-plated screws.<ref name="pmid16089067">{{cite journal | vauthors = Gomez PF, Morcuende JA | title = Early attempts at hip arthroplasty--1700s to 1950s | journal = The Iowa Orthopaedic Journal | volume = 25 | pages = 25–29 | year = 2005 | pmid = 16089067 | pmc = 1888777 }}</ref> Subsequently, he used a cement made from plaster of Paris, powdered pumice and glue.<ref name=":1">{{cite journal | vauthors = Bota NC, Nistor DV, Caterev S, Todor A | title = Historical overview of hip arthroplasty: From humble beginnings to a high-tech future | journal = Orthopedic Reviews | volume = 13 | issue = 1 | pages = 8773 | date = March 2021 | pmid = 33897987 | pmc = 8054655 | doi = 10.4081/or.2021.8773 }}</ref>
Molded-glass implants were introduced in the 1920s by Smith-Peterson in the USA. Although these showed good bio-compatibility, they were mechanically fragile so he started experiments with metallic prostheses in the 1930s.<ref name=":1" /><ref name=":2">{{cite journal | vauthors = Knight SR, Aujla R, Biswas SP | title = Total Hip Arthroplasty - over 100 years of operative history | journal = Orthopedic Reviews | volume = 3 | issue = 2 | pages = e16 | date = September 2011 | pmid = 22355482 | pmc = 3257425 | doi = 10.4081/or.2011.e16 }}</ref> In 1938, Philip Wiles of Middlesex General Hospital, UK carried out a total hip replacement using a stainless-steel prosthesis attached by bolts.<ref name=":8">{{Cite book | vauthors = Reynolds LA |title= Early Development of Total Hip Replacement |publisher=Wellcome Trust Centre for the History of Medicine, University College London, UK |year=2006 |isbn=978-085484-111-0}}</ref> In 1940, Dr. Austin T. Moore (1899–1963)<ref>{{cite news|url=http://orthopedics.about.com/cs/jointreplacement1/p/austinmoore.htm|title=What You Need to Know About Joint Replacement Surgery|newspaper=Verywell Health}}</ref> at Columbia Hospital in [[Columbia, South Carolina]] performed a hip replacement using a prototype prosthesis made of the cobalt-chrome alloy [[Vitallium|Vitallium; it was]] inserted into the medullary canal and "fenestrated" to promote bone regrowth. A commercial version known as the "Austin Moore Prosthesis" was introduced in 1952; it is still in use today, typically for femoral neck fractures in the elderly.<ref name=":1" /> Following the lead of Wiles, several UK general hospitals including [[Norwich]], [[Wrightington, Wigan and Leigh NHS Foundation Trust|Wrightington]], [[Stanmore]], [[Redhill, Surrey|Redhill]] and [[Exeter]] developed metal-based prostheses during the 1950s and 1960s.<ref name=":8" />
Robert Juditt was the first to perform hip replacements via the anterior approach in 1947 in Paris. He taught this method to {{ill|Émile Letournel|fr}}. Joel Matta, who had studied with Letournel, brought this approach to the United States and went on to popularize it.<ref>{{cite web|url=https://www.thesteadmanclinic.com/news/dr-matta-and-anterior-approach|title=Dr. Matta and Anterior Approach|publisher=Steadman Clinic|date=September 5, 2017|access-date=March 26, 2023}}</ref>
Metal/Acrylic prostheses were tried in the 1950s <ref name=":1" /><ref name=":3" /> but were found to be susceptible to wear. In the 1960s, [[John Charnley]]<ref>{{cite journal | vauthors = Gomez PF, Morcuende JA | title = A historical and economic perspective on Sir John Charnley, Chas F. Thackray Limited, and the early arthoplasty industry | journal = The Iowa Orthopaedic Journal | volume = 25 | pages = 30–37 | date = 2005 | pmid = 16089068 | pmc = 1888784 }}</ref><ref name=":1" /><ref name=":2" /> at Wrightington General Hospital combined a metal prosthesis with a [[Polytetrafluoroethylene|PTFE]] acetabular cup before settling on a metal/[[polyethylene]] design. Ceramic bearings were developed in the late 1970s.<ref name=":1" /><ref name=":2" />
The means of attachment have also diversified.<ref name=":1" /><ref name=":2" /> Early prostheses were attached by screws (e.g. Gluck, Wiles) with later developments using dental or bone cements (e.g. Charnley, Thompson<ref name=":4" /><ref name=":5" />) or cementless systems which relied on bone regrowth (Austin-Moore,<ref name=":6" /> Ring<ref name=":2" />). The choice of alloy, bearing material, attachment and detailed geometry has led to the wide variety of prosthesis designs available today.<ref name=":1" /><ref name=":2" /><ref name=":8" />
The London [[Science Museum, London|Science Museum]] has a collection of hip prostheses which reflect developments in the US, UK and elsewhere. These show the use of different materials and different designs for different circumstances (e.g. cemented and uncemented arthroplasty.) Some are on display in the museum's "Medicine: The Wellcome Galleries".
[[File:Hip prostheses on display in London Science Museum 2022.jpg|thumb|Hip prostheses on display in the London Science Museum]]
The items include:
* '''Prosthesis from 1960''': The "Gosset-style" prosthesis was first introduced in 1949, although the specific example was made by Lusterlite Ltd of [[Leeds]] in 1960. It has a perspex "ball" and simple rod-like shaft made of nickel-plated stainless-steel.<ref name=":3">{{Cite web |date=2022 |title=Vitallium Hip prosthesis, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co177040/hip-prosthesis-artificial-hip-joint}}</ref>
* '''Examples of prostheses from 1970 to 1985''': Examples provided by [[Ipswich]] Hospital, UK are made of [[Vitallium]] (Co/Cr alloy) with curved standard or slender femoral stems.<ref>{{Cite web |date=2022 |title=Vitallium Hip Prosthesis, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co179831/vitallium-hip-prosthesis-prosthesis}}</ref><ref>{{Cite web |date=2022 |title=Vitallium Hip prosthesis, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co179832/vitallium-hip-prosthesis-prosthesis}}</ref> One example has a studded cup.<ref>{{Cite web |date=2022 |title=Vitallium total hip prosthesis, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co179830/vitallium-total-hip-prosthesis-prosthesis}}</ref>
* '''Examples of prostheses from the 1990s''': Examples, some of which were developed at the Redhill Group of Hospitals and Dorking Hospital, include a ringed titanium hip prosthesis with a screw stem and porous cup,<ref name=":7">{{Cite web |date=2022 |title=Ringed titanium hip prosthesis with screw stem, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8601390/ringed-titanium-hip-prosthesis-with-screw-stem-hip-prosthesis}}</ref> a modular hip prosthesis with a textured femoral stem to aid bone grafting (material unspecified),<ref>{{Cite web |date=2022 |title=Modular hip prosthesis with textured femoral stem, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8601379/modular-hip-prosthesis-with-textured-femoral-stem-hip-prosthesis}}</ref> two Thompson-type prostheses made of [[Vitallium]] alloy<ref name=":4">{{Cite web |date=2022 |title=Thompson type prosthesis for hip replacement, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8601382/thompson-type-prosthesis-for-hip-replacement-hip-prosthesis}}</ref><ref name=":5">{{Cite web |date=2022 |title=Thompson type prosthesis for hip replacement, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8601383/thompson-type-prosthesis-for-hip-replacement-hip-prosthesis}}</ref> and an Austin Moore type prosthesis (material unspecified), with a porous metal femoral stem.<ref name=":6">{{Cite web |date=2022 |title=Austin Moore type prosthesis for hip replacement, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8601387/austin-moore-type-prosthesis-for-hip-replacement-hip-prosthesis}}</ref>
* '''Example of acetabular cup prosthesis from 1998:''' Example of a prosthetic socket, from Sulzer Orthopedics Inc., is the Inter-Op Hemispherical Shell. This is made from materials not recognised by the human body, so the body's immune system does not attack and reject the joint.<ref>{{Cite web |date=2022 |title=Replacement hip joint, United States, 1998, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co503279/replacement-hip-joint-united-states-1998-artificial-hip-joint}}</ref>
* '''Examples of prostheses from 2006''': Examples made by [[Smith & Nephew|Smith & Nephew Orthopedics]] include an "Anthology" titanium prosthesis, which has a flat-tapered stem placed in the thigh bone, and an "Echelon" (cobalt-chrome prosthesis for both cementless and cemented [[arthroplasty]]. Both have porous coating to promote bone adhesion.<ref>{{Cite web |date=2022 |title=ANTHOLOGY Hip System, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8082322/anthology-hip-system-artificial-hip-joint}}</ref><ref>{{Cite web |date=2022 |title=ECHELON Hip System, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8082323/echelon-hip-system-artificial-hip-joint}}</ref>
The Science Museum's collection also includes specialised surgical tools for hip operations:
* '''Instrument sets''' made by Downs Ltd for the City Hospital, [[Nottingham University Hospitals NHS Trust|Nottingham University Hospitals]] UK.<ref>{{Cite web |date=2022 |title=Instrument set for Austin-Moore hip replacement, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co178705/instrument-set-for-austin-moore-hip-replacement-orthopaedic-instrument-sets}}</ref><ref>{{Cite web |date=2022 |title=Instrument set by Downs Ltd. for ring hip prosthesis, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co178700/instrument-set-by-downs-ltd-for-ring-hip-prothesi-orthopaedic-instrument-sets}}</ref> Tools include head punches, reamers, drills and rasps.
* '''Prototype oscillating bone saws''' made by Kenneth Dobbie in the 1960s.<ref>{{Cite web |date=2022 |title=Prototype version of the Dobbie bone saw, England, 1966, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8002596/prototype-version-of-the-dobbie-bone-saw-england-1966-surgical-saw}}</ref><ref>{{Cite web |date=2022 |title=Prototype version of the Dobbie bone saw, England, 1967, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8002598/prototype-version-of-the-dobbie-bone-saw-england-1967-surgical-saw |access-date=}}</ref> Dobbie was electrical engineer at the [[Royal National Orthopaedic Hospital]], Stanmore, UK. He worked closely with the hip surgeon [[John Charnley|Sir John Charnley]] to develop the saws eventually leading to a commercial product made by De Soutter Brothers Ltd.<ref>{{Cite web | vauthors = Hurley S |date=2011 |title="Prototypes", Science Museum Blog (April 2011) |url=https://blog.sciencemuseum.org.uk/prototypes/ |access-date=}}</ref>
==Other animals==
{{Main|Hip replacement (animal)}}
== See also ==
* [[2010 DePuy Hip Recall]]
* [[Abductor wedge]]
* [[Femoroacetabular impingement]]
* [[Gruen zone]]
* [[Hip examination]]
== References ==
{{Reflist}}
== External links ==
* [https://web.archive.org/web/20060619082711/http://www.edheads.org/activities/hip/ Edheads Virtual Hip Surgery + Surgery Photos]
{{Operations and other procedures on the musculoskeletal system}}
{{Authority control}}
{{DEFAULTSORT:Hip Replacement}}
[[Category:Implants (medicine)]]
[[Category:Orthopedic surgical procedures]]
[[Category:Pelvis]]
[[Category:Prosthetics]]
[[Category:Orthopedic implants]]' |
New page wikitext, after the edit (new_wikitext) | '{{Short description|Surgery replacing hip joint with prosthetic implant}}
{{Infobox medical intervention
| Name = Hip replacement
| synonyms = Hip arthroplasty
| Image = X-ray of pelvis with total arthroplasty.jpg
| Caption = An [[X-ray]] showing a left hip (right of image) that has been replaced, with the ball of this ball-and-socket joint replaced by a metal head that is set in the [[femur]] and the socket replaced by a cup
| ICD10 =
| ICD9 = {{ICD9proc|81.51}}–{{ICD9proc|81.53}}
| MeshID = D019644
| OPS301 =
| OtherCodes =
| MedlinePlus = 002975
}}
'''Hip replacement''' is a [[surgery|surgical]] procedure in which the [[hip]] joint is replaced by a prosthetic [[implant (medicine)|implant]], that is, a '''hip prosthesis'''. Hip replacement surgery can be performed as a total replacement or a hemi/semi(half) replacement. Such [[joint replacement]] [[orthopaedic surgery]] is generally conducted to relieve [[arthritis]] [[pain]] or in some [[hip fracture]]s. A total hip replacement (total hip arthroplasty or THA) consists of replacing both the [[acetabulum]] and the femoral head while [[hemiarthroplasty]] generally only replaces the femoral head. Hip replacement is one of the most common orthopaedic operations, though patient satisfaction varies widely. Approximately 58% of total hip replacements are estimated to last 25 years.<ref>{{cite journal | vauthors = Evans JT, Evans JP, Walker RW, Blom AW, Whitehouse MR, Sayers A | title = How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up | journal = Lancet | volume = 393 | issue = 10172 | pages = 647–654 | date = February 2019 | pmid = 30782340 | pmc = 6376618 | doi = 10.1016/S0140-6736(18)31665-9 }}</ref> The average cost of a total hip replacement in 2012 was $40,364 in the United States, and about $7,700 to $12,000 in most European countries.<ref name="ifhp">{{cite web |url=http://hushp.harvard.edu/sites/default/files/downloadable_files/IFHP%202012%20Comparative%20Price%20Report.pdf |title=2012 comparative price report|publisher=International Federation of Health Plans|access-date=4 October 2015}}</ref>
==Medical uses==
Total hip replacement is most commonly used to treat joint failure caused by [[osteoarthritis]]. Other indications include [[rheumatoid arthritis]], [[avascular necrosis]], [[Post-traumatic arthritis|traumatic arthritis]], [[protrusio acetabuli]], certain [[hip fracture]]s, benign and malignant [[bone tumor]]s, arthritis associated with [[Paget's disease of bone|Paget's disease]], [[ankylosing spondylitis]] and [[juvenile rheumatoid arthritis]]. The aims of the procedure are pain relief and improvement in hip function. Hip replacement is usually considered only after other therapies, such as [[physical therapy]] and pain medications, have failed.{{citation needed|date=February 2022}}
==Risks==
Risks and complications in hip replacement are similar to those associated with all [[Joint replacement#Risks and complications|joint replacements]]. They can include infection, dislocation, limb length inequality, loosening, impingement, osteolysis, metal sensitivity, nerve palsy, chronic pain and death. [[Bariatric surgery|Weight loss surgery]] before a hip replacement does not appear to change outcomes.<ref>{{cite journal | vauthors = Smith TO, Aboelmagd T, Hing CB, MacGregor A | title = Does bariatric surgery prior to total hip or knee arthroplasty reduce post-operative complications and improve clinical outcomes for obese patients? Systematic review and meta-analysis | journal = The Bone & Joint Journal | volume = 98-B | issue = 9 | pages = 1160–1166 | date = September 2016 | pmid = 27587514 | doi = 10.1302/0301-620x.98b9.38024 | url = http://openaccess.sgul.ac.uk/108614/1/Bariatric_surgery_paper_ACCEPTED_10.05.2016.pdf }}</ref>
Follow-up assessments are conducted to examine the need for revision surgery. However, a UK study showed that only 3-6% of hip replacements needed a revision. Researchers recommended that routine follow-up may not be needed for up to 10 years. At this point, x-rays should be used to assess the joint, and there should be a clinical assessment of pain and mobility.<ref>{{Cite journal |date=11 January 2023 |title=Joint replacements: many people can safely wait 10 years for follow-up |url=https://evidence.nihr.ac.uk/alert/joint-replacement-many-people-can-safely-wait-10-years-for-follow-up/ |journal=NIHR Evidence|doi=10.3310/nihrevidence_55501 |s2cid=257843402 }}</ref><ref>{{cite journal | title = Safety of disinvestment in mid- to late-term follow-up post primary hip and knee replacement: the UK SAFE evidence synthesis and recommendations | journal = Health and Social Care Delivery Research | volume = 10 | issue = 16 | pages = 1–172 | date = 2022-06-01 | pmid = 35767667 | doi = 10.3310/KODQ0769 | s2cid = 250133111 | vauthors = Kingsbury SR, Smith LK, Czoski Murray CJ, Pinedo-Villanueva R, Judge A, West R, Smith C, Wright JM, Arden NK, Thomas CM, Kolovos S, Shuweihdi F, Garriga C, Bitanihirwe BK, Hill K, Matu J, Stone M, Conaghan PG | display-authors = 6 | doi-access = free }}</ref>
[[Edema]] appears around the hip in the hours or days following the surgery. This swelling is typically at its maximum 7 days after the operation,<ref>{{cite journal | vauthors = Holm B, Kristensen MT, Husted H, Kehlet H, Bandholm T | title = Thigh and knee circumference, knee-extension strength, and functional performance after fast-track total hip arthroplasty | journal = PM&R | volume = 3 | issue = 2 | pages = 117–24; quiz 124 | date = February 2011 | pmid = 21333950 | doi = 10.1016/j.pmrj.2010.10.019 | s2cid = 21003271 }}</ref> then decreases and disappears over the course of weeks. Only 5% of patients still have swelling 6 months after the operation.<ref>{{cite journal | vauthors = Heo SM, Harris I, Naylor J, Lewin AM | title = Complications to 6 months following total hip or knee arthroplasty: observations from an Australian clinical outcomes registry | journal = BMC Musculoskeletal Disorders | volume = 21 | issue = 1 | pages = 602 | date = September 2020 | pmid = 32912197 | pmc = 7488141 | doi = 10.1186/s12891-020-03612-8 | doi-access = free }}</ref>
===Dislocation===
[[File:Dislocated hip replacement.jpg|thumb|upright|Dislocated artificial hip]]
[[File:Hip prosthesis liner creep and wear.png|thumb|160px|Liner wear, particularly when over 2 mm, increases the risk of dislocation.<ref name=berry2012/> Liner creep, on the other hand, is normal remoulding.<ref name=Watt/>]]
Dislocation (the ball coming out of the socket) is the most common complication. ADOLF HITLER HAD HIP REPLACEMENT The most common causes vary by the duration since the surgery.{{citation needed|date=February 2022}}
Hip prosthesis [[joint dislocation|dislocation]] mostly occurs in the first three months after insertion, mainly because of incomplete scar formation and relaxed soft tissues.<ref name=berry2012>{{cite book|title=Surgery of the Hip|url=https://books.google.com/books?id=Kc-AhYLnIF4C&pg=PA1035| vauthors = Berry DJ, Lieberman J |publisher=Elsevier Health Sciences|year=2012|isbn=9781455727056|page=1035}}</ref> It takes eight to twelve weeks for the soft tissues injured or cut during surgery to heal. The chance of this is diminished if less tissue is cut, if the cut tissue is repaired and if large diameter head balls are used.
Dislocations occurring between three months and five years after insertion usually occur due to malposition of the components, or dysfunction of nearby muscles.<ref name=berry2012/>
Risk factors of late dislocation (after five years) mainly include:<ref name=berry2012/>
* Female sex
* Younger age
* Previous [[subluxation]] without complete dislocation
* Previous trauma
* Substantial weight loss
* Recent onset or progression of [[dementia]] or a [[neurological disorder]]
* Malposition of the cup
* Liner wear, particularly when it allows head movement of more than 2 mm within the cup compared to its original position
* Prosthesis loosening with migration
Surgeons who perform more operations tend to have fewer dislocations. An anterior approach seems to lower dislocation rates when small diameter heads are used, but that benefit has not been shown when compared to modern posterior incisions with the use of larger diameter heads. The use of larger diameter head size in itself decreases dislocation risk, even though this correlation is only found in head sizes up to 28 mm: larger heads do not result in a statistically significant decrease in dislocation rate.<ref>{{cite journal | vauthors = Hailer NP, Weiss RJ, Stark A, Kärrholm J | title = The risk of revision due to dislocation after total hip arthroplasty depends on surgical approach, femoral head size, sex, and primary diagnosis. An analysis of 78,098 operations in the Swedish Hip Arthroplasty Register | journal = Acta Orthopaedica | volume = 83 | issue = 5 | pages = 442–448 | date = October 2012 | pmid = 23039167 | pmc = 3488169 | doi = 10.3109/17453674.2012.733919 }}</ref> Keeping the leg out of certain positions during the first few months after surgery further reduces risk.{{citation needed|date=February 2022}}
=== Infection ===
Infection is one of the most common causes for revision of a total hip replacement. The incidence of infection in primary hip replacement is 1% or less in the United States.<ref>{{cite journal | vauthors = Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ | title = The epidemiology of revision total hip arthroplasty in the United States | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 91 | issue = 1 | pages = 128–133 | date = January 2009 | pmid = 19122087 | doi = 10.2106/JBJS.H.00155 }}</ref> Risk factors for infection include obesity, diabetes, smoking, immunosuppressive medications or diseases, and history of infection.{{citation needed|date=February 2022}}
In revision surgery, infected tissue surrounding the joint is removed, and the artificial joint replaced. Typically, this is carried out in 2 stages: infected tissue and all joint replacement implants are removed in the first stage, and, after the infection is completely cleared, a new artificial joint is inserted in the second stage. One-stage surgery is also available whereby infected tissue and implants are removed, and the new joint inserted, in a single procedure. One-stage hip revisions were found to be as effective as two-stage procedures at relieving pain and improving hip stiffness and function. One-stage procedures were also better value for money.<ref>{{Cite journal |date=2023-04-25 |title=One-stage hip revisions are as good as 2-stage surgery to replace infected artificial hips |url=https://evidence.nihr.ac.uk/alert/one-stage-hip-revisions-are-as-good-as-2-stage-surgery-to-replace-infected-artificial-hips/ |journal=NIHR Evidence |language=en |doi=10.3310/nihrevidence_57776|s2cid=258340248 }}</ref><ref>{{cite journal | vauthors = Blom AW, Lenguerrand E, Strange S, Noble SM, Beswick AD, Burston A, Garfield K, Gooberman-Hill R, Harris SR, Kunutsor SK, Lane JA, MacGowan A, Mehendale S, Moore AJ, Rolfson O, Webb JC, Wilson M, Whitehouse MR | display-authors = 6 | title = Clinical and cost effectiveness of single stage compared with two stage revision for hip prosthetic joint infection (INFORM): pragmatic, parallel group, open label, randomised controlled trial | journal = BMJ | volume = 379 | pages = e071281 | date = October 2022 | pmid = 36316046 | pmc = 9645409 | doi = 10.1136/bmj-2022-071281 }}</ref>
===Limb length inequality===
Most adults have a limb length inequality of 0–2 cm which causes no deficits.<ref>{{cite journal | vauthors = Knutson GA | title = Anatomic and functional leg-length inequality: a review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance | journal = Chiropractic & Osteopathy | volume = 13 | issue = 1 | pages = 11 | date = July 2005 | pmid = 16026625 | pmc = 1232860 | doi = 10.1186/1746-1340-13-11 | doi-access = free }}</ref> It is common for people to sense a larger limb length inequality after total hip replacement.<ref>{{cite journal | vauthors = Maloney WJ, Keeney JA | title = Leg length discrepancy after total hip arthroplasty | journal = The Journal of Arthroplasty | volume = 19 | issue = 4 Suppl 1 | pages = 108–110 | date = June 2004 | pmid = 15190563 | doi = 10.1016/j.arth.2004.02.018 }}</ref> Sometimes the leg seems long immediately after surgery when in fact both are equal length. An arthritic hip can develop contractures that make the leg behave as if it is short. When these are relieved with replacement surgery and normal motion and function are restored, the body feels that the limb is now longer than it was. This feeling usually subsides by six months after surgery as the body adjusts to the new hip joint. The cause of this feeling is variable, and usually related to abductor muscle weakness, pelvic obliquity, and minor lengthening of the hip during surgery (<1 cm) to achieve stability and restore the joint to pre-arthritic mechanics. If the limb length difference remains bothersome to the patient more than six months after surgery, a shoe lift can be used. Only in extreme cases is surgery required for correction.{{citation needed|date=February 2022}} The perceived difference in limb length for a patient after surgery is a common cause for lawsuits against the healthcare provider.<ref>{{cite journal | vauthors = McWilliams AB, Douglas SL, Redmond AC, Grainger AJ, O'Connor PJ, Stewart TD, Stone MH | title = Litigation after hip and knee replacement in the National Health Service | journal = The Bone & Joint Journal | volume = 95-B | issue = 1 | pages = 122–126 | date = January 2013 | pmid = 23307685 | doi = 10.1302/0301-620X.95B1.30908 | url = http://eprints.whiterose.ac.uk/81565/1/Paper%20Final.pdf }}</ref><ref>{{cite journal | vauthors = Hofmann AA, Skrzynski MC | title = Leg-length inequality and nerve palsy in total hip arthroplasty: a lawyer awaits! | journal = Orthopedics | volume = 23 | issue = 9 | pages = 943–944 | date = September 2000 | pmid = 11003095 | doi = 10.3928/0147-7447-20000901-20 }}</ref><ref>{{cite journal | vauthors = Upadhyay A, York S, Macaulay W, McGrory B, Robbennolt J, Bal BS | title = Medical malpractice in hip and knee arthroplasty | language = English | journal = The Journal of Arthroplasty | volume = 22 | issue = 6 Suppl 2 | pages = 2–7 | date = September 2007 | pmid = 17823005 | doi = 10.1016/j.arth.2007.05.003 }}</ref><ref>{{cite journal | vauthors = Konyves A, Bannister GC | title = The importance of leg length discrepancy after total hip arthroplasty | journal = The Journal of Bone and Joint Surgery. British Volume | volume = 87 | issue = 2 | pages = 155–157 | date = February 2005 | pmid = 15736733 | doi = 10.1302/0301-620X.87B2.14878 | doi-access = free }}</ref><ref>{{cite journal | vauthors = O'Leary R, Saxena A, Arguelles W, Hernandez Y, Osondu CU, Suarez JC | title = Digital Fluoroscopic Navigation for Limb Length Restoration During Anterior Total Hip Arthroplasty | language = English | journal = Arthroplasty Today | volume = 18 | pages = 11–15 | date = December 2022 | pmid = 36267390 | pmc = 9576486 | doi = 10.1016/j.artd.2022.08.021 }}</ref>
===Fracture===
[[File:Intraoperative acetabular fracture, annotated.jpg|thumb|150px|Intraoperative acetabular fracture]]
Intraoperative fractures may occur. After surgery, bones with internal fixation devices in situ are at risk of [[periprosthetic]] fractures at the end of the implant, an area of relative mechanical stress. Post-operative femoral fractures are graded by the [[Vancouver classification]].
===Vein thrombosis===
[[Venous thrombosis]] such as [[deep vein thrombosis]] and [[pulmonary embolism]] are relatively common following hip replacement surgery. Standard treatment with [[anticoagulant]]s is for 7–10 days; however, treatment for 21+ days may be superior.<ref>{{cite journal | vauthors = Sobieraj DM, Lee S, Coleman CI, Tongbram V, Chen W, Colby J, Kluger J, Makanji S, Ashaye AO, White CM | display-authors = 6 | title = Prolonged versus standard-duration venous thromboprophylaxis in major orthopedic surgery: a systematic review | journal = Annals of Internal Medicine | volume = 156 | issue = 10 | pages = 720–727 | date = May 2012 | pmid = 22412039 | doi = 10.7326/0003-4819-156-10-201205150-00423 | s2cid = 22797561 }}</ref><ref name=":0">{{cite journal | vauthors = Forster R, Stewart M | title = Anticoagulants (extended duration) for prevention of venous thromboembolism following total hip or knee replacement or hip fracture repair | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | issue = 3 | pages = CD004179 | date = March 2016 | pmid = 27027384 | doi = 10.1002/14651858.CD004179.pub2 | pmc = 10332795 | hdl-access = free | collaboration = Cochrane Vascular Group | hdl = 20.500.11820/3f5a887a-031a-43bd-8406-b85ab02d6618 }}</ref> Extended-duration anticoagulants (up to 35 days following surgery) may prevent VTE in people undergoing hip replacement surgery.<ref name=":0" /> Other research suggested that anticoagulants in otherwise healthy patients undergoing a so-called fast track protocol with hospital stays under five days, might only be necessary while in the hospital.<ref>{{cite journal | vauthors = Jørgensen CC, Jacobsen MK, Soeballe K, Hansen TB, Husted H, Kjærsgaard-Andersen P, Hansen LT, Laursen MB, Kehlet H | display-authors = 6 | title = Thromboprophylaxis only during hospitalisation in fast-track hip and knee arthroplasty, a prospective cohort study | journal = BMJ Open | volume = 3 | issue = 12 | pages = e003965 | date = December 2013 | pmid = 24334158 | pmc = 3863129 | doi = 10.1136/bmjopen-2013-003965 }}</ref> Emerging evidence supports the use of aspirin for venous thromboembolism prophylaxis. Large randomised control trials suggested that aspirin is not inferior to low-molecular weight [[heparins]] and [[rivaroxaban]].<ref>{{cite journal | vauthors = Anderson DR, Dunbar MJ, Bohm ER, Belzile E, Kahn SR, Zukor D, Fisher W, Gofton W, Gross P, Pelet S, Crowther M, MacDonald S, Kim P, Pleasance S, Davis N, Andreou P, Wells P, Kovacs M, Rodger MA, Ramsay T, Carrier M, Vendittoli PA | display-authors = 6 | title = Aspirin versus low-molecular-weight heparin for extended venous thromboembolism prophylaxis after total hip arthroplasty: a randomized trial | journal = Annals of Internal Medicine | volume = 158 | issue = 11 | pages = 800–806 | date = June 2013 | pmid = 23732713 | doi = 10.7326/0003-4819-158-11-201306040-00004 | s2cid = 207536641 }}</ref><ref>{{cite journal | vauthors = Anderson DR, Dunbar M, Murnaghan J, Kahn SR, Gross P, Forsythe M, Pelet S, Fisher W, Belzile E, Dolan S, Crowther M, Bohm E, MacDonald SJ, Gofton W, Kim P, Zukor D, Pleasance S, Andreou P, Doucette S, Theriault C, Abianui A, Carrier M, Kovacs MJ, Rodger MA, Coyle D, Wells PS, Vendittoli PA | display-authors = 6 | title = Aspirin or Rivaroxaban for VTE Prophylaxis after Hip or Knee Arthroplasty | journal = The New England Journal of Medicine | volume = 378 | issue = 8 | pages = 699–707 | date = February 2018 | pmid = 29466159 | doi = 10.1056/NEJMoa1712746 | s2cid = 3625978 | doi-access = free }}</ref> However, aspirin may not be appropriate in all cases, especially for patients who have additional risk factors for venous thromboembolisms or may have an inadequate response to aspirin.<ref>{{cite journal | vauthors = van Oosterom N, Barras M, Bird R, Nusem I, Cottrell N | title = A Narrative Review of Aspirin Resistance in VTE Prophylaxis for Orthopaedic Surgery | journal = Drugs | volume = 80 | issue = 18 | pages = 1889–1899 | date = December 2020 | pmid = 33037568 | doi = 10.1007/s40265-020-01413-w | s2cid = 222234431 }}</ref>
Some physicians and patients may consider having an [[ultrasonography for deep vein thrombosis]] after hip replacement.<ref name="AAOSfive">{{Citation |author1 = American Academy of Orthopaedic Surgeons |author1-link = American Academy of Orthopaedic Surgeons |date = February 2013 |title = Five Things Physicians and Patients Should Question |publisher = American Academy of Orthopaedic Surgeons |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url = http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-orthopaedic-surgeons/ |access-date = 19 May 2013}}, which cites
* {{cite journal | vauthors = Mont M, Jacobs J, Lieberman J, Parvizi J, Lachiewicz P, Johanson N, Watters W | title = Preventing venous thromboembolic disease in patients undergoing elective total hip and knee arthroplasty | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 94 | issue = 8 | pages = 673–674 | date = April 2012 | pmid = 22517384 | pmc = 3326687 | doi = 10.2106/JBJS.9408edit }}</ref> However, this kind of screening should only be done when indicated because to perform it routinely would be [[unnecessary health care]].<ref name="AAOSfive"/>
[[Intermittent pneumatic compression]] (IPC) devices are sometimes used for prevention of blood clots following total hip replacement.<ref>{{cite journal | vauthors = Zhao JM, He ML, Xiao ZM, Li TS, Wu H, Jiang H | title = Different types of intermittent pneumatic compression devices for preventing venous thromboembolism in patients after total hip replacement | journal = The Cochrane Database of Systematic Reviews | volume = 2014 | issue = 12 | pages = CD009543 | date = December 2014 | pmid = 25528992 | pmc = 7100582 | doi = 10.1002/14651858.CD009543.pub3 | collaboration = Cochrane Vascular Group }}</ref>
===Osteolysis===
Many long-term problems with hip replacements are the result of [[osteolysis]]. This is the loss of bone caused by the body's reaction to polyethylene wear debris, fine bits of plastic that wear off the cup liner over time. An [[inflammation|inflammatory]] process causes bone resorption that may lead to subsequent loosening of the hip implants and even fractures in the bone around the implants. Ceramic bearing surfaces may eliminate the generation of wear particles. Metal cup liners joined with metal heads (metal-on-metal hip arthroplasty) were developed for similar reasons. In the lab these show excellent wear characteristics and benefit from a different mode of lubrication.
Highly cross-linked polyethylene plastic liners experience significantly reduced plastic wear debris. The newer ceramic and metal prostheses may not have long-term performance records. Ceramic piece breakage can lead to catastrophic failure. This occurs in about 2% of implants. They may also cause an audible, high pitched squeaking noise with activity. Metal-on-metal arthroplasty can release metal debris into the body. Highly cross linked polyethylene is not as strong as regular polyethylene. These plastic liners can crack or break free of the metal shell that holds them.{{citation needed|date=February 2022}}
===Loosening===
[[File:Hip joint aseptic loosening ar1938-1.png|thumb|upright|Hip prosthesis displaying aseptic loosening (arrows)]]
[[File:Hip prosthesis zones by DeLee and Charnley system, and Gruen system.jpg|thumb|210px|[[Hip prosthesis zones]] according to DeLee and Charnley,<ref>{{cite book|title=The Adult Hip, Volume 1|url=https://books.google.com/books?id=-fwULYB1gJIC&pg=PA958| vauthors = Callaghan JJ, Rosenberg AG, Rubash HE |publisher=Lippincott Williams & Wilkins|year=2007|isbn=978-0-7817-5092-9|page=958}}</ref> and Gruen.<ref>{{cite journal | vauthors = Neumann DR, Thaler C, Hitzl W, Huber M, Hofstädter T, Dorn U | title = Long-term results of a contemporary metal-on-metal total hip arthroplasty: a 10-year follow-up study | journal = The Journal of Arthroplasty | volume = 25 | issue = 5 | pages = 700–708 | date = August 2010 | pmid = 19596544 | doi = 10.1016/j.arth.2009.05.018 }}</ref> These are used to describe the location of for example areas of loosening.]]
On radiography, it is normal to see thin radiolucent areas of less than 2 mm around hip prosthesis components, or between a cement mantle and bone. These may indicate loosening of the prosthesis if they are new or changing, while areas greater than 2 mm may be harmless if they are stable.<ref name="RothMaertz2012"/> The most important prognostic factors of cemented cups are absence of radiolucent lines in DeLee and Charnley zone I, as well as adequate cement mantle thickness.<ref>{{cite book|title=The Well-Cemented Total Hip Arthroplasty: Theory and Practice|url=https://books.google.com/books?id=PQ6NZAeJUXcC&pg=PA337| vauthors = Breusch S, Malchau H |publisher=Springer Science & Business Media|year=2005|isbn=978-3-540-24197-3|page=336}}</ref> In the first year after insertion of uncemented femoral stems, it is normal to have mild subsidence (less than 10 mm).<ref name="RothMaertz2012">{{cite journal | vauthors = Roth TD, Maertz NA, Parr JA, Buckwalter KA, Choplin RH | title = CT of the hip prosthesis: appearance of components, fixation, and complications | journal = Radiographics | volume = 32 | issue = 4 | pages = 1089–1107 | year = 2012 | pmid = 22786996 | doi = 10.1148/rg.324115183 }}</ref> The direct anterior approach has been shown to itself be a risk factor for early femoral component loosening.<ref name="James I 2016"/><ref>{{cite journal | vauthors = Angerame MR, Fehring TK, Masonis JL, Mason JB, Odum SM, Springer BD | title = Early Failure of Primary Total Hip Arthroplasty: Is Surgical Approach a Risk Factor? | journal = The Journal of Arthroplasty | volume = 33 | issue = 6 | pages = 1780–1785 | date = June 2018 | pmid = 29439894 | doi = 10.1016/j.arth.2018.01.014 | s2cid = 29149705 }}</ref><ref name="Direct Anterior Approach"/>
===Metal sensitivity===
Concerns were raised in the early 2000s regarding metal sensitivity and the potential dangers of metal particulate debris from hip prostheses, including the development of ''pseudotumors'', [[soft tissue]] masses containing necrotic tissue, around the hip joint. It appears these masses were more common in women, and these patients showed a higher level of iron in the blood. The cause was then unknown, and was probably multifactorial. There may have been a toxic reaction to an excess of particulate metal wear debris or a hypersensitivity reaction to a "normal" amount of metal debris.<ref>{{cite journal | vauthors = Pandit H, Glyn-Jones S, McLardy-Smith P, Gundle R, Whitwell D, Gibbons CL, Ostlere S, Athanasou N, Gill HS, Murray DW | display-authors = 6 | title = Pseudotumours associated with metal-on-metal hip resurfacings | journal = The Journal of Bone and Joint Surgery. British Volume | volume = 90 | issue = 7 | pages = 847–851 | date = July 2008 | pmid = 18591590 | doi = 10.1302/0301-620X.90B7.20213 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Boardman DR, Middleton FR, Kavanagh TG | title = A benign psoas mass following metal-on-metal resurfacing of the hip | journal = The Journal of Bone and Joint Surgery. British Volume | volume = 88 | issue = 3 | pages = 402–404 | date = March 2006 | pmid = 16498023 | doi = 10.1302/0301-620X.88B3.16748 | doi-access = free }}<br />{{cite journal | vauthors = Korovessis P, Petsinis G, Repanti M, Repantis T | title = Metallosis after contemporary metal-on-metal total hip arthroplasty. Five to nine-year follow-up | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 88 | issue = 6 | pages = 1183–1191 | date = June 2006 | pmid = 16757749 | doi = 10.2106/JBJS.D.02916 }}</ref><!--It's important to update this section to reflect the fact that there was a product recall of metal-on-metal prostheses shortly after the discovery of this phenomenon.-->
Metal hypersensitivity is a well-established phenomenon and is not uncommon, affecting about 10–15% of the population.<ref name=Hallab01>{{cite journal | vauthors = Hallab N, Merritt K, Jacobs JJ | title = Metal sensitivity in patients with orthopaedic implants | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 83 | issue = 3 | pages = 428–436 | date = March 2001 | pmid = 11263649 | doi = 10.2106/00004623-200103000-00017 }}</ref> Skin contact with certain metals can cause immune reactions such as [[hives]], [[eczema]], redness and itching. Although little is known about the short- and long-term pharmacodynamics and bioavailability of circulating metal degradation products ''in vivo'', there have been many reports of immunologic-type responses temporally associated with implantation of metal components. Individual case reports link immune hypersensitivity reactions with adverse performance of metallic cardiovascular, orthopedic and plastic surgical and dental implants.<ref name=Hallab01/>
===Metal toxicity===
{{Main|Metallosis}}
Most hip replacements consist of cobalt and chromium alloys, or titanium. [[Stainless steel]] is no longer used. Any metal implant releases its constituent [[ions]] into the blood. Typically, these are excreted in the urine, but in certain individuals the ions can accumulate in the body. In implants which involve metal-on-metal contact, microscopic fragments of [[cobalt]] and [[chromium]] can be absorbed into the person's bloodstream. There are reports of [[cobalt toxicity]] with hip replacement, particularly metal-on-metal hip replacements, which are no longer in use.<ref>{{cite web|url=http://www.epi.hss.state.ak.us/bulletins/docs/b2010_14.pdf|title=Cobalt Toxicity in Two Hip Replacement Patients|date=May 28, 2010|work=State of Alaska Epidemiology Bulletin No. 14|vauthors=Tower SS|access-date=January 13, 2011|archive-date=September 18, 2020|archive-url=https://web.archive.org/web/20200918125225/http://www.epi.hss.state.ak.us/bulletins/docs/b2010_14.pdf|url-status=dead}}</ref><ref name=reuters-20120329/>
Use of metal-on-metal hip replacements from the 1970s was discontinued in the 1980s and 1990s, particularly after the discovery of aseptic lymphocyte-dominant vasculitis-associated lesions (ALVAL). However, the [[Federal Food, Drug, and Cosmetic Act#Premarket notification .28510.28k.29.2C PMN.29|FDA's 510k approval process]] allowed companies to have new and "improved" metal-on-metal hips approved without much clinical testing.<ref>{{cite web | work = Center for Devices and Radiological Health |title=510(k) Clearances |url=https://www.fda.gov/medical-devices/device-approvals-denials-and-clearances/510k-clearances |publisher = FDA |access-date=15 April 2020 |language=en |date=9 February 2019}}</ref> Some people with these prostheses experienced similar reactions to the metal debris as occurred in the 20th century; some devices were recalled.<ref>{{cite journal | vauthors = Triclot P | title = Metal-on-metal: history, state of the art (2010) | journal = International Orthopaedics | volume = 35 | issue = 2 | pages = 201–206 | date = February 2011 | pmid = 21234564 | pmc = 3032111 | doi = 10.1007/s00264-010-1180-8 }}</ref><ref>{{Cite web|url=https://www.fda.gov/medical-devices/device-approvals-denials-and-clearances/510k-clearances|title=510(k) Clearances|website=Health Center for Devices and Radiological|publisher=FDA|date=2019-02-09|language=en|access-date=2020-04-15}}</ref>
===Nerve palsy===
Post operative [[sciatic nerve]] palsy is another possible complication. The frequency of this complication is low. [[Femoral nerve]] palsy is another, but much rarer, complication. Both of these will typically resolve over time, but the healing process is slow. Patients with pre-existing nerve injury are at greater risk of experiencing this complication and are also slower to recover.{{citation needed|date=February 2022}}
===Chronic pain===
A few patients who have had a hip replacement suffer chronic pain after the surgery. Groin pain can develop if the muscle that raises the hip ([[iliopsoas]]) rubs against the edge of the acetabular cup. Bursitis can develop at the trochanter where a surgical scar crosses the bone, or if the femoral component used pushes the leg out to the side too far. Also some patients can experience pain in cold or damp weather.{{citation needed|date=October 2012}} Incision made in the front of the hip (anterior approach) can cut a nerve running down the thigh leading to numbness in the thigh and occasionally chronic pain at the point where the nerve was cut (a neuroma).
===Death===
The rate of [[perioperative mortality]] for elective hip replacements is significantly less than 1%.<ref>{{cite news| vauthors = Coté J |title=Hip replacement is not viewed as high-risk surgery; Death is rare, but underlying medical condition a factor|newspaper=San Francisco Chronicle|date=July 22, 2007|url=http://articles.sfgate.com/2007-07-22/news/17254067_1_hip-replacement-hip-replacement-surgery-blood-clot}}</ref><ref>[http://www.medscape.com/viewarticle/588980 Medscape Conference Coverage], American Academy of Orthopaedic Surgeons (AAOS) 2009 Annual Meeting, AAOS 2009: Certain Factors Increase Risk for Death After Total Hip Arthroplasty, Barbara Boughton, March 3, 2009.</ref>
===Metal-on-metal hip implant failure===
{{See also|Implant failure}}
By 2010, reports in the orthopaedic literature increasingly cited the problem of early failure of metal-on-metal prostheses in a small percentage of patients.<ref>{{cite journal | vauthors = Mikhael MM, Hanssen AD, Sierra RJ | title = Failure of metal-on-metal total hip arthroplasty mimicking hip infection. A report of two cases | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 91 | issue = 2 | pages = 443–446 | date = February 2009 | pmid = 19181991 | doi = 10.2106/JBJS.H.00603 }}</ref> Failures may have related to the release of minute metallic particles or metal ions from [[wear]] on the implants, causing pain and disability severe enough to require revision surgery in 1–3% of patients.<ref><!--needs double-checking against this and other Meier NYT source-->{{cite news| vauthors = Meier B |url=https://www.nytimes.com/2010/03/04/health/04metalhipside.html|title=As Use of Metal-on-Metal Hip Implants Grows, Studies Raise Concerns|date=March 3, 2010|work=The New York Times|name-list-style=vanc}}</ref> Design deficits of some prothesis models, especially with heat-treated alloys and a lack of specialized surgical experience, accounted for most of the failures. In 2010, surgeons at medical centers such as the [[Mayo Clinic]] reported curtailing their use of metal-on-metal implants by 80 percent over the previous year, in favor of those made from other materials, such as combinations of metal and plastic.<ref><!--separate from other Meier NYT story of same date?-->{{cite news | vauthors = Meier B |date=March 3, 2010 |title=Concerns Over 'Metal on Metal' Hip Implants |work=The New York Times |url=https://www.nytimes.com/2010/03/04/health/04metalhip.html }}</ref> The cause of these failures remains controversial, and may include both design factors, operative technique factors, and factors related to patient [[immune response]]. In the United Kingdom, the [[Medicines and Healthcare products Regulatory Agency]] commenced an annual monitoring regime for metal-on-metal hip replacement patients from May 2010.<ref>{{cite web |url=http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON079157 |title=Medical Device Alert: All metal-on-metal (MoM) hip replacements |date=22 April 2010 |publisher=Medicines and Healthcare products Regulatory Agency |id=MDA/2010/033 |access-date=2010-05-07 |url-status=dead |archive-url=https://web.archive.org/web/20100425160456/http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON079157 |archive-date=25 April 2010 }}</ref> Data which are shown in The Australian Orthopaedic Association's 2008 National [[Joint replacement registry]], a record of nearly every hip implanted in that country over the previous 10 years, tracked 6,773 BHR (Birmingham Hip Resurfacing) hips and found that less than 0.33% may have been revised due to the patient's reaction to the metal component.<ref>Table HT 46. Australian Orthopaedic Association National Joint Replacement Registry Annual Report. Adelaide: AOA; 2008</ref> Other, similar, metal-on-metal designs have not fared as well, with some reports showing that 76–100% of people with these metal-on-metal implants with aseptic implant failures and needing revision surgery also had histological evidence of inflammation, accompanied by extensive lymphocyte infiltrates characteristic of [[delayed-type hypersensitivity]] reactions.<ref>{{cite journal | vauthors = Milosev I, Trebse R, Kovac S, Cör A, Pisot V | title = Survivorship and retrieval analysis of Sikomet metal-on-metal total hip replacements at a mean of seven years | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 88 | issue = 6 | pages = 1173–1182 | date = June 2006 | pmid = 16757748 | doi = 10.2106/JBJS.E.00604 }}</ref> It is not clear to what extent this phenomenon negatively affects orthopedic implant patients. However, for patients presenting with signs of allergic reaction, testing for sensitivity should be conducted. Removal of the device should be considered, since removal may alleviate the symptoms. Patients who have allergic reactions to [[metal alloy|alloy]] jewelry are more likely to have reactions to orthopedic implants. There is increasing awareness of the phenomenon of metal sensitivity, and many surgeons now take this into account when planning which implant is optimal for each patient.
On March 12, 2012, ''[[The Lancet]]'' published a study, based on data from the National Joint Registry of England and Wales, finding that metal-on-metal hip implants failed at much higher rates than other types of hip implants, and calling for a ban on all metal-on-metal hip prostheses.<ref>{{cite journal | vauthors = Smith AJ, Dieppe P, Vernon K, Porter M, Blom AW | title = Failure rates of stemmed metal-on-metal hip replacements: analysis of data from the National Joint Registry of England and Wales | journal = Lancet | volume = 379 | issue = 9822 | pages = 1199–1204 | date = March 2012 | pmid = 22417410 | doi = 10.1016/S0140-6736(12)60353-5 | s2cid = 9913872 }}</ref> The analysis of 402,051 hip replacements showed that 6.2% of metal-on-metal hip implants had failed within five years, compared to 1.7% of metal-on-plastic and 2.3% of ceramic-on-ceramic hip implants. Each {{convert|1|mm|abbr=on}} increase in head size of metal-on-metal hip implants was associated with a 2% increase in failure rate.<ref>{{cite news |url=https://www.bbc.co.uk/news/health-17337993 |title=Metal-on-metal hip replacements 'high failure rate' | vauthors = Gallagher J |publisher=BBC |date=13 March 2012 |access-date=20 May 2012}}</ref> Surgeons of the British Hip Society recommended that large head metal-on-metal implants should no longer be implanted.<ref>{{cite journal | vauthors = Pijls BG, Meessen JM, Schoones JW, Fiocco M, van der Heide HJ, Sedrakyan A, Nelissen RG | title = Increased Mortality in Metal-on-Metal versus Non-Metal-on-Metal Primary Total Hip Arthroplasty at 10 Years and Longer Follow-Up: A Systematic Review and Meta-Analysis | journal = PLOS ONE | volume = 11 | issue = 6 | pages = e0156051 | year = 2016 | pmid = 27295038 | pmc = 4905643 | doi = 10.1371/journal.pone.0156051 | doi-access = free | bibcode = 2016PLoSO..1156051P }}</ref><ref>{{cite news |url=https://www.bbc.co.uk/news/health-17261234 |title=Surgeons call for end to metal hip replacements | vauthors = Roberts M |publisher=BBC |date=5 March 2012 |access-date=20 May 2012}}</ref>
On February 10, 2011, the U.S. [[Food and Drug Administration|FDA]] issued an advisory on metal-on-metal hip implants, stating it was continuing to gather and review all available information about metal-on-metal hip systems.<ref>{{cite web |url=https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/default.htm |title=Metal-on-Metal Hip Implants |publisher=Food and Drug Administration |date=February 10, 2011 |access-date=January 4, 2012}}</ref> On June 27–28, 2012, an advisory panel met to decide whether to impose new standards, taking into account findings of the study in ''The Lancet''.<ref name=reuters-20120329>{{cite news |url=https://www.reuters.com/article/usa-fda-hips-idUSL3E8ET6X820120329 |title=FDA seeks more advice on metal hip implants |work=Reuters |date=29 March 2012 |access-date=20 May 2012}}</ref><ref>{{cite web |url=https://www.fda.gov/AdvisoryCommittees/Calendar/ucm297884.htm |title=Orthopaedic and Rehabilitation Devices Panel of the Medical Devices Advisory Committee Meeting Announcement |publisher=Food and Drug Administration |id=FDA-2012-N-0293 |date=27 March 2012 |access-date=20 May 2012}}</ref><ref name=FDA-summary-memo>{{cite report |url=https://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/OrthopaedicandRehabilitationDevicesPanel/UCM309302.pdf |title=FDA Executive Summary Memorandum – Metal-on-Metal Hip Implant System |publisher=Food and Drug Administration |date=27 June 2012 |access-date=15 March 2013}}</ref> No new standards, such as routine checking of blood levels of metal ions, were set, but guidance was updated.<ref>{{cite web |url=https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/ucm241604.htm |title=Concerns about Metal-on-Metal Hip Implants |publisher=Food and Drug Administration |date=17 January 2013 |access-date=15 March 2013}}</ref> The U.S. FDA does not require hip implants to be tested in clinical trials before they can be sold in the U.S.<ref>{{cite web|url=http://media.jamanetwork.com/news-item/study-suggests-women-have-higher-risk-of-hip-implant-failure/|title=Study Suggests Women Have Higher Risk of Hip Implant Failure |website=media.jamanetwork.com}}</ref> Instead, companies making new hip implants only need to prove that they are "substantially equivalent" to other hip implants already on the market. The exception is metal-on-metal implants, which were not tested in clinical trials, but, due to the high revision rate of metal-on-metal hips, the FDA has stated that, in the future, clinical trials will be required for approval, and that post-market studies will be required to keep metal-on-metal hip implants on the market.<ref>{{cite journal | vauthors = Rising JP, Reynolds IS, Sedrakyan A | title = Delays and difficulties in assessing metal-on-metal hip implants | journal = The New England Journal of Medicine | volume = 367 | issue = 1 | pages = e1 | date = July 2012 | pmid = 22716934 | doi = 10.1056/NEJMp1206794 }}</ref>
==Modern process==
[[File:Hip Prosthesis.gif|thumb|Hip prosthesis 3D model]]
[[File:Hip Prostesis.png|thumb|Different parts of hip prosthesis]]
[[File:Hip prosthesis.jpg|thumb|A [[titanium]] hip prosthesis, with a [[ceramic]] head and [[polyethylene]] acetabular cup]]
The modern artificial joint owes much to the 1962 work of Sir [[John Charnley]] at Wrightington Hospital in the United Kingdom. His work in the field of [[tribology]] resulted in a design that almost completely replaced the other designs by the 1970s. Charnley's design consisted of three parts:
# [[Stainless Steel|stainless steel]] one-piece femoral stem and head
# [[polyethylene]] (originally [[Teflon]]), acetabular component, both of which were fixed to the bone using
# [[Poly(methyl methacrylate)|PMMA]] (acrylic) [[bone cement]]
The replacement joint, which was known as the Low Friction [[Arthroplasty]], was lubricated with [[synovial fluid]]. The small femoral head ({{convert|7/8|in|sigfig=3|abbr=on}}) was chosen for Charnley's belief that it would have lower friction against the acetabular component and thus wear out the acetabulum more slowly. Unfortunately, the smaller head dislocated more easily. Alternative designs with larger heads such as the Mueller prosthesis were proposed. Stability was improved, but acetabular wear and subsequent failure rates were increased with these designs. The Teflon acetabular components of Charnley's early designs failed within a year or two of implantation. This prompted a search for a more suitable material. A German salesman showed a polyethylene gear sample to Charnley's machinist, sparking the idea to use this material for the acetabular component. The [[Ultra-high-molecular-weight polyethylene|UHMWPE]] acetabular component was introduced in 1962. Charnley's other major contribution was to use polymethylmethacrylate (PMMA) bone cement to attach the two components to the bone. For over two decades, the Charnley Low Friction Arthroplasty, and derivative designs were the most used systems in the world. It formed the basis for all modern hip implants. An example can be seen at the Science Museum, London.<ref>{{Cite web |date=2022 |title=Charnley-type artificial hip prosthesis, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co179829/charnley-type-artificial-hip-prosthesis-artificial-hip-joint}}</ref>
The Exeter hip stem was developed in the United Kingdom during the same time as the Charnley device. Its development occurred following a collaboration between Orthopaedic Surgeon [[Robin Ling]] and [[University of Exeter]] engineer [[Clive Lee]] and it was first implanted at the Princess Elizabeth Orthopaedic Hospital in Exeter in 1970.<ref>{{cite news|url=https://www.theguardian.com/science/2017/oct/20/robin-ling-obituary|title=Robin Ling obituary|work=[[The Guardian]]|date=20 October 2017| vauthors = Timperley AJ |access-date=22 October 2017}}</ref> The Exeter Hip is a cemented device, but with a slightly different stem geometry. Both designs have shown excellent long-term durability when properly placed and are still widely used in slightly modified versions.
Early implant designs had the potential to loosen from their attachment to the bones, typically becoming painful ten to twelve years after placement. In addition, erosion of the bone around the implant was seen on x-rays. Initially, surgeons believed this was caused by an abnormal reaction to the cement holding the implant in place. That belief prompted a search for an alternative method to attach the implants. The Austin Moore device had a small hole in the stem into which bone graft was placed before implanting the stem. It was hoped bone would then grow through the window over time and hold the stem in position. Success was unpredictable and the fixation not very robust. In the early 1980s, surgeons in the United States applied a coating of small beads to the Austin Moore device and implanted it without cement. The beads were constructed so that gaps between beads matched the size of the pores in native bone. Over time, bone cells from the patient would grow into these spaces and fix the stem in position. The stem was modified slightly to fit more tightly into the femoral canal, resulting in the Anatomic Medullary Locking (AML) stem design. With time, other forms of stem surface treatment and stem geometry have been developed and improved.
Initial hip designs were made of a one-piece femoral component and a one-piece acetabular component. Current designs have a femoral stem and separate head piece. Using an independent head allows the surgeon to adjust leg length (some heads seat more or less onto the stem) and to select from various materials from which the head is formed. A modern acetabulum component is also made up of two parts: a metal shell with a coating for bone attachment and a separate liner. First the shell is placed. Its position can be adjusted, unlike the original cemented cup design which are fixed in place once the cement sets. When proper positioning of the metal shell is obtained, the surgeon may select a liner made from various materials.
To combat loosening caused by polyethylene wear debris, hip manufacturers developed improved and novel materials for the acetabular liners. [[Ceramic]] heads mated with regular polyethylene liners or a ceramic liner were the first significant alternative. Metal liners to mate with a metal head were also developed. At the same time these designs were being developed, the problems that caused polyethylene wear were determined and manufacturing of this material improved. Highly crosslinked UHMWPE was introduced in the late 1990s. The most recent data comparing the various bearing surfaces has shown no clinically significant differences in their performance. Potential early problems with each material are discussed below. Performance data after 20 or 30 years may be needed to demonstrate significant differences in the devices. All newer materials allow use of larger diameter femoral heads. Use of larger heads significantly decreases the chance of the hip dislocating, which remains the greatest complication of the surgery.
When available implants are used, cemented stems tend to have a better longevity than uncemented stems. No significant difference is observed in the clinical performance of the various methods of surface treatment of uncemented devices. Uncemented stems are selected for patients with good quality bone that can resist the forces needed to drive the stem in tightly. Cemented devices are typically selected for patients with poor quality bone who are at risk of fracture during stem insertion. Cemented stems are less expensive due to lower manufacturing cost, but require good surgical technique to place them correctly. Uncemented stems can cause pain with activity in up to 20% of patients during the first year after placement as the bone adapts to the device. This is rarely seen with cemented stems.{{citation needed|date=March 2024}}
==Techniques==
There are several incisions, defined by their relation to the gluteus medius. The approaches are posterior (Moore), lateral (Hardinge or Liverpool),<ref name="pmid9498150">{{cite journal | vauthors = Pai VS | title = A comparison of three lateral approaches in primary total hip replacement | journal = International Orthopaedics | volume = 21 | issue = 6 | pages = 393–398 | year = 1997 | pmid = 9498150 | pmc = 3619565 | doi = 10.1007/s002640050193 | url = http://link.springer.de/link/service/journals/00264/bibs/8021006/80210393.htm | url-status = dead | archive-url = https://web.archive.org/web/20020108155635/http://www.link.springer.de/link/service/journals/00264/bibs/8021006/80210393.htm | archive-date = 2002-01-08 }}</ref> antero-lateral (Watson-Jones),<ref name="titleAnterolateral Approach to Hip Joint: (Watson Jones) - Wheeless' Textbook of Orthopaedics">{{Cite web|url=http://www.wheelessonline.com/ortho/anterolateral_approach_to_hip_joint_watson_jones |title=Anterolateral Approach to Hip Joint: (Watson Jones) – Wheeless' Textbook of Orthopaedics |access-date=2007-11-26 }}</ref> anterior (Smith-Petersen)<ref name="titleAnterior Approach to the Hip (Smith Petersen) – Wheeless' Textbook of Orthopaedics">{{Cite web|url=http://www.wheelessonline.com/ortho/anterior_approach_to_the_hip_smith_peterson |title=Anterior Approach to the Hip (Smith Petersen) – Wheeless' Textbook of Orthopaedics |access-date=2007-11-26 }}</ref> and [[greater trochanter]] osteotomy. There is no compelling evidence in the literature for any particular approach.
===Posterior approach===
The ''posterior'' (''Moore'' or ''Southern'') ''approach'' accesses the joint and capsule through the back, taking [[piriformis muscle]] and the short external rotators of the femur. This approach gives excellent access to the acetabulum and femur and preserves the hip [[Abduction (kinesiology)|abductors]] and thus minimizes the risk of abductor dysfunction post operatively. It has the advantage of becoming a more extensile approach if needed. Critics cite a higher dislocation rate, although repair of the capsule, piriformis and the short external rotators along with use of modern large diameter head balls reduces this risk. Limited evidence suggests that the posterior approach may cause less nerve damage.<ref>{{cite journal | vauthors = Jolles BM, Bogoch ER | title = Posterior versus lateral surgical approach for total hip arthroplasty in adults with osteoarthritis | journal = The Cochrane Database of Systematic Reviews | volume = 2006 | issue = 3 | pages = CD003828 | date = July 2006 | pmid = 16856020 | pmc = 8740306 | doi = 10.1002/14651858.cd003828.pub3 }}</ref>
===Lateral approach===
The ''lateral approach'' is also commonly used for hip replacement. The approach requires elevation of the hip abductors ([[gluteus medius]] and [[gluteus minimus]]) to access the joint. The abductors may be lifted up by osteotomy of the greater trochanter and reapplying it afterwards using wires (as per Charnley),{{Citation needed|date=December 2007}} or may be divided at their tendinous portion, or through the functional tendon (as per Hardinge) and repaired using [[surgical suture|sutures]]. Although this approach has a lower dislocation risk than the posterior approach, critics note that occasionally the abductor muscles do not heal back on, leading to pain and weakness which is often very difficult to treat.
=== Antero-lateral approach ===
The ''anterolateral approach'' develops the interval between the [[tensor fasciae latae]] and the gluteus medius. The Gluteus medius, gluteus minimus and hip capsule are detached from the anterior (front) for the greater trochanter and femoral neck and then repaired with heavy suture after the replacement of the joint.
=== Anterior approach ===
The ''anterior approach'' uses an interval between the [[sartorius muscle]] and tensor fasciae latae. This approach, which was commonly used for pelvic fracture repair surgery, has been adapted for use when performing hip replacement. When used with older hip implant systems that had a small diameter head, dislocation rates were reduced compared to surgery performed through a posterior approach. With modern implant designs, dislocation rates are similar between the anterior and posterior approaches.<ref>{{cite journal | vauthors = Maratt JD, Gagnier JJ, Butler PD, Hallstrom BR, Urquhart AG, Roberts KC | title = No Difference in Dislocation Seen in Anterior Vs Posterior Approach Total Hip Arthroplasty | journal = The Journal of Arthroplasty | volume = 31 | issue = 9 Suppl | pages = 127–130 | date = September 2016 | pmid = 27067754 | doi = 10.1016/j.arth.2016.02.071 }}</ref> The anterior approach has been shown in studies to variably improve early functional recovery, with possible complications of femoral component loosening and early revision compared to other approaches.<ref name="Direct Anterior Approach">{{cite journal | vauthors = Meneghini RM, Elston AS, Chen AF, Kheir MM, Fehring TK, Springer BD | title = Direct Anterior Approach: Risk Factor for Early Femoral Failure of Cementless Total Hip Arthroplasty: A Multicenter Study | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 99 | issue = 2 | pages = 99–105 | date = January 2017 | pmid = 28099299 | doi = 10.2106/JBJS.16.00060 | s2cid = 6299470 }}</ref><ref name="James I 2016">{{cite journal | vauthors = Eto S, Hwang K, Huddleston JI, Amanatullah DF, Maloney WJ, Goodman SB | title = The Direct Anterior Approach is Associated With Early Revision Total Hip Arthroplasty | journal = The Journal of Arthroplasty | volume = 32 | issue = 3 | pages = 1001–1005 | date = March 2017 | pmid = 27843039 | doi = 10.1016/j.arth.2016.09.012 }}</ref><ref>{{cite journal | vauthors = Christensen CP, Jacobs CA | title = Comparison of Patient Function during the First Six Weeks after Direct Anterior or Posterior Total Hip Arthroplasty (THA): A Randomized Study | journal = The Journal of Arthroplasty | volume = 30 | issue = 9 Suppl | pages = 94–97 | date = September 2015 | pmid = 26096071 | doi = 10.1016/j.arth.2014.12.038 }}</ref><ref>{{cite journal | vauthors = Higgins BT, Barlow DR, Heagerty NE, Lin TJ | title = Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis | journal = The Journal of Arthroplasty | volume = 30 | issue = 3 | pages = 419–434 | date = March 2015 | pmid = 25453632 | doi = 10.1016/j.arth.2014.10.020 }}</ref><ref>{{cite journal | vauthors = Meermans G, Konan S, Das R, Volpin A, Haddad FS | title = The direct anterior approach in total hip arthroplasty: a systematic review of the literature | journal = The Bone & Joint Journal | volume = 99-B | issue = 6 | pages = 732–740 | date = June 2017 | pmid = 28566391 | doi = 10.1302/0301-620X.99B6.38053 | s2cid = 21287407 }}</ref><ref>{{cite journal | vauthors = Graves SC, Dropkin BM, Keeney BJ, Lurie JD, Tomek IM | title = Does Surgical Approach Affect Patient-reported Function After Primary THA? | journal = Clinical Orthopaedics and Related Research | volume = 474 | issue = 4 | pages = 971–981 | date = April 2016 | pmid = 26620966 | pmc = 4773324 | doi = 10.1007/s11999-015-4639-5 }}</ref>
=== Minimally invasive approaches ===
The dual incision approach and other minimally invasive surgery seeks to reduce soft tissue damage through reducing the size of the incision. However, component positioning accuracy and visualization of the bone structures can be significantly impaired as the approaches get smaller. This can result in unintended fractures and soft tissue injury. The majority of current orthopedic surgeons use a "minimally invasive" approach compared to traditional approaches which were quite large comparatively.
[[Computer-assisted surgery]] and robotic surgery techniques are also available to guide the surgeon to provide enhanced component accuracy.<ref>{{cite journal | vauthors = Perets I, Walsh JP, Mu BH, Mansor Y, Rosinsky PJ, Maldonado DR, Lall AC, Domb BG | display-authors = 6 | title = Short-term Clinical Outcomes of Robotic-Arm Assisted Total Hip Arthroplasty: A Pair-Matched Controlled Study | journal = Orthopedics | volume = 44 | issue = 2 | pages = e236–e242 | date = 2021-03-01 | pmid = 33238012 | doi = 10.3928/01477447-20201119-10 | s2cid = 227176201 }}</ref> Several commercial CAS and robotic systems are available for use worldwide. Improved patient outcomes and reduced complications have not been demonstrated when these systems are used when compared to standard techniques.<ref>{{cite journal | vauthors = Parsley BS | title = Robotics in Orthopedics: A Brave New World | journal = The Journal of Arthroplasty | volume = 33 | issue = 8 | pages = 2355–2357 | date = August 2018 | pmid = 29605151 | doi = 10.1016/j.arth.2018.02.032 | s2cid = 4557610 }}</ref><ref>{{cite journal | vauthors = Jacofsky DJ, Allen M | title = Robotics in Arthroplasty: A Comprehensive Review | journal = The Journal of Arthroplasty | volume = 31 | issue = 10 | pages = 2353–2363 | date = October 2016 | pmid = 27325369 | doi = 10.1016/j.arth.2016.05.026 }}</ref>
==Implants==
[[File:MetalonmetalhipreplaceMark.png|thumb|Metal on metal prosthetic hip]]
[[File:Hip-replacement.jpg|thumb|upright|Cement-free implant sixteen days after surgery. Femoral component is cobalt chromium combined with titanium which induces bone growth into the implant. Ceramic head. Acetabular cup coated with bone growth-inducing material and held temporarily in place with a single screw.]]
The prosthetic implant used in hip replacement consists of three parts: the acetabular cup, the femoral component, and the articular interface. Options exist for different people and indications. The evidence for a number of newer devices is not very good, including: ceramic-on-ceramic bearings, modular femoral necks, and uncemented monoblock cups.<ref>{{cite journal | vauthors = Nieuwenhuijse MJ, Nelissen RG, Schoones JW, Sedrakyan A | title = Appraisal of evidence base for introduction of new implants in hip and knee replacement: a systematic review of five widely used device technologies | journal = BMJ | volume = 349 | issue = sep09 1 | pages = g5133 | date = September 2014 | pmid = 25208953 | pmc = 4159610 | doi = 10.1136/bmj.g5133 }}</ref> Correct selection of the prosthesis is important.
===Acetabular cup===
The acetabular cup is the component which is placed into the [[acetabulum]] (hip socket). Cartilage and bone are removed from the acetabulum and the acetabular cup is attached using friction or cement. Some acetabular cups are one piece, while others are modular. One-piece (monobloc) shells are either [[ultra-high-molecular-weight polyethylene]] (UHMWPE) or metal, they have their articular surface machined on the inside surface of the cup and do not rely on a locking mechanism to hold a liner in place. A monobloc polyethylene cup is cemented in place while a metal cup is held in place by a metal coating on the outside of the cup. Modular cups consist of two pieces, a shell and liner. The shell is made of metal; the outside has a porous coating while the inside contains a locking mechanism designed to accept a liner. Two types of porous coating used to form a friction fit are [[sintering|sintered]] beads and a [[foam metal]] design to mimic the trabeculae of cancellous bone and initial stability is influenced by under-reaming and insertion force.<ref name="Amirouche">{{cite journal | vauthors = Amirouche F, Solitro G, Broviak S, Gonzalez M, Goldstein W, Barmada R | title = Factors influencing initial cup stability in total hip arthroplasty | journal = Clinical Biomechanics | volume = 29 | issue = 10 | pages = 1177–1185 | date = December 2014 | pmid = 25266242 | doi = 10.1016/j.clinbiomech.2014.09.006 | url = https://figshare.com/articles/journal_contribution/10757246 }}</ref> Permanent fixation is achieved as bone grows onto or into the porous coating. Screws can be used to lag the shell to the bone providing even more fixation. Polyethylene liners are placed into the shell and connected by a rim locking mechanism; ceramic and metal liners are attached with a [[Morse taper]].{{citation needed|date=July 2012}}
===Femoral component===
{{Original research|section|date=April 2016}}The femoral component is the component that fits in the [[femur]] (thigh bone). Bone is removed and the femur is shaped to accept the femoral stem with attached prosthetic femoral head (ball). There are two types of fixation: cemented and uncemented. Cemented stems use acrylic [[bone cement]] to form a mantle between the stem and to the bone. Uncemented stems use friction, shape and surface coatings to stimulate bone to remodel and bond to the implant. Stems are made of multiple materials (titanium, cobalt chromium, stainless steel, and polymer composites) and they can be monolithic or modular. Modular components consist of different head dimensions and/or modular neck orientations; these attach via a taper similar to a [[Morse taper]]. These options allow for variability in leg length, offset and version. Femoral heads are made of metal or ceramic material. Metal heads, made of cobalt chromium for hardness, are machined to size and then polished to reduce wear of the socket liner. Ceramic heads are more smooth than polished metal heads, have a lower coefficient of friction than a cobalt chrome head, and in theory will wear down the socket liner more slowly. As of early 2011, follow-up studies in patients have not demonstrated significant reductions in wear rates between the various types of femoral heads on the market. Ceramic implants are more brittle and may break after being implanted.
===Articular interface===
{{Original research|section|date=April 2016}}The articular interface is not part of either implant, rather it is the area between the acetabular cup and femoral component. The articular interface of the hip is a simple ball and socket joint. Size, material properties and machining [[Engineering tolerance|tolerances]] at the articular interface can be selected based on patient demand to optimise implant function and longevity whilst mitigating associated risks. The interface size is measured by the outside diameter of the head or the inside diameter of the socket. Common sizes of femoral heads are {{convert|28|mm|abbr=on}}, {{convert|32|mm|abbr=on}} and {{convert|36|mm|abbr=on}}. While {{convert|22.25|mm|frac=8|abbr=on}} was common in the first modern prostheses, now even larger sizes are available from 38 to over 54 mm. Larger-diameter heads lead to increased stability and range of motion whilst lowering the risk of dislocation. At the same time they are also subject to higher stresses such as friction and inertia. Different combinations of materials have different physical properties which can be coupled to reduce the amount of wear debris generated by friction. Typical pairings of materials include metal on polyethylene (MOP), metal on crosslinked polyethylene (MOXP), ceramic on ceramic (COC), ceramic on crosslinked polyethylene (COXP), and metal on metal (MOM). Each combination has different advantages and disadvantages.
Dual mobility hip replacements reduce the risk of dislocation.<ref name="Dual mobility total hip arthroplast">{{cite journal | vauthors = Blakeney WG, Epinette JA, Vendittoli PA | title = Dual mobility total hip arthroplasty: should everyone get one? | journal = EFORT Open Reviews | volume = 4 | issue = 9 | pages = 541–547 | date = September 2019 | pmid = 31598332 | pmc = 6771074 | doi = 10.1302/2058-5241.4.180045 }}</ref><ref>{{cite journal | vauthors = Horriat S, Haddad FS | title = Dual mobility in hip arthroplasty: What evidence do we need? | journal = Bone & Joint Research | volume = 7 | issue = 8 | pages = 508–510 | date = August 2018 | pmid = 30258569 | pmc = 6138808 | doi = 10.1302/2046-3758.78.BJR-2018-0217 }}</ref>
==Configuration==
Post-operative [[projectional radiography]] is routinely performed to ensure proper configuration of hip prostheses.
The direction of the acetabular cup influences the range of motion of the leg, and also affects the risk of dislocation.<ref name=Watt/> For this purpose, the ''acetabular inclination'' and the ''acetabular anteversion'' are measurements of cup angulation in the [[coronal plane]] and the [[sagittal plane]], respectively.
<gallery widths="230">
File:Acetabular inclination of hip prosthesis.jpg|Acetabular inclination.<ref name=Vanrusselt2015/> This parameter is calculated on an anteroposterior radiograph as the angle between a line through the lateral and medial margins of the acetabular cup and the ''transischial line'' which is tangential to the inferior margins of the [[ischium]] bones.<ref name=Vanrusselt2015>{{cite journal | vauthors = Vanrusselt J, Vansevenant M, Vanderschueren G, Vanhoenacker F | title = Postoperative radiograph of the hip arthroplasty: what the radiologist should know | journal = Insights into Imaging | volume = 6 | issue = 6 | pages = 591–600 | date = December 2015 | pmid = 26487647 | pmc = 4656234 | doi = 10.1007/s13244-015-0438-5 }}</ref>
File:Range of acetabular inclination.png|Acetabular inclination is normally between 30 and 50°.<ref name=Vanrusselt2015/> A larger angle increases the risk of dislocation.<ref name=Watt>{{cite web|url=http://www.radiologyassistant.nl/en/p431c8258e7ac3/hip-arthroplasty.html|title=Hip – Arthroplasty – Normal and abnormal imaging findings| vauthors = Watt I, Boldrik S, van Langelaan E, Smithuis R |website=Radiology Assistant |access-date=2017-05-21 }}</ref>
File:Acetabular anteversion of hip prosthesis.jpg|Acetabular anteversion.<ref name="ShinLee2015"/> This parameter is calculated on a lateral radiograph as the angle between the [[transverse plane]] and a line going through the (anterior and posterior) margins of the acetabular cup.<ref name="ShinLee2015">{{cite journal | vauthors = Shin WC, Lee SM, Lee KW, Cho HJ, Lee JS, Suh KT | title = The reliability and accuracy of measuring anteversion of the acetabular component on plain anteroposterior and lateral radiographs after total hip arthroplasty | journal = The Bone & Joint Journal | volume = 97-B | issue = 5 | pages = 611–616 | date = May 2015 | pmid = 25922453 | doi = 10.1302/0301-620X.97B5.34735 }}</ref>
File:Range of acetabular anteversion.png|Acetabular anteversion is normally between 5 and 25°.<ref name=Watt/> An anteversion below or above this range increases the risk of dislocation.<ref name=Watt/> There is an [[intra-individual variability]] in this method because the pelvis may be tilted in various degrees in relation to the transverse plane.<ref name=Watt/>
File:Leg length discrepancy after hip replacement.jpg|''Leg length discrepancy'' after hip replacement is calculated as the vertical distance between the middle of the minor trochanters, using the acetabular tear drops<ref name=Vanrusselt2015/> or the transischial line<ref name=Watt/> as references for the horizontal plane. A discrepancy of up to 1 cm is generally tolerated.<ref name=Vanrusselt2015/><ref name=Watt/>
File:Center of rotation of hip prosthesis.jpg|''Center of rotation'': The horizontal center of rotation is calculated as the distance between the acetabular teardrop and the center of the head (or caput) of the prosthesis and/or the native femoral head on the contralateral side.<ref name=Vanrusselt2015/> The vertical center of rotation instead uses the transischial line for reference.<ref name=Vanrusselt2015/> The parameter should be equal on both sides.<ref name=Vanrusselt2015/>
</gallery>
==Alternatives and variations==
===Conservative management===
The first line approach as an alternative to hip replacement is conservative management which involves a multimodal approach of oral medication, injections, activity modification and [[physical therapy]].<ref>{{cite journal | vauthors = Cibulka MT, White DM, Woehrle J, Harris-Hayes M, Enseki K, Fagerson TL, Slover J, Godges JJ | display-authors = 6 | title = Hip pain and mobility deficits--hip osteoarthritis: clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American Physical Therapy Association | journal = The Journal of Orthopaedic and Sports Physical Therapy | volume = 39 | issue = 4 | pages = A1-25 | date = April 2009 | pmid = 19352008 | pmc = 3963282 | doi = 10.2519/jospt.2009.0301 }}</ref> Conservative management can prevent or delay the need for hip replacement.
=== Preoperative care ===
Preoperative education is an important part of patient care. Some evidence indicates that it may slightly reduce anxiety before hip or knee replacement, with low risk of negative effects.<ref>{{cite journal | vauthors = McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A | title = Preoperative education for hip or knee replacement | journal = The Cochrane Database of Systematic Reviews | volume = 2014 | issue = 5 | pages = CD003526 | date = May 2014 | pmid = 24820247 | pmc = 7154584 | doi = 10.1002/14651858.CD003526.pub3 | publication-date = 13 May 2014 }}</ref>
===Hemiarthroplasty===
[[File:Femoral offset in hemiarthroplasty (crop).jpg|thumb|170px|Femoral (neck) offset is defined as the perpendicular distance between the intramedullary or longitudinal axis of the femur and the center of rotation of the native or prosthetic femoral head. An offset of less than 33 mm is associated with hip dislocation.<ref name="JonesBriffa2017">{{cite journal | vauthors = Jones C, Briffa N, Jacob J, Hargrove R | title = The Dislocated Hip Hemiarthroplasty: Current Concepts of Etiological factors and Management | journal = The Open Orthopaedics Journal | volume = 11 | issue = Suppl-7, M4 | pages = 1200–1212 | year = 2017 | pmid = 29290857 | pmc = 5721319 | doi = 10.2174/1874325001711011200 |doi-access=free}}</ref><ref name="NinhSethi2009">{{cite journal | vauthors = Ninh CC, Sethi A, Hatahet M, Les C, Morandi M, Vaidya R | title = Hip dislocation after modular unipolar hemiarthroplasty | journal = The Journal of Arthroplasty | volume = 24 | issue = 5 | pages = 768–774 | date = August 2009 | pmid = 18555648 | doi = 10.1016/j.arth.2008.02.019 }}</ref>]]
Hemiarthroplasty is a surgical procedure that replaces one half of the joint with an artificial surface and leaves the other part unchanged. This class of procedure is most commonly performed on the hip after an intracapsular fracture of the femur neck ([[hip fracture]]). The procedure is performed by removing the head of the femur and replacing it with a metal or composite [[prosthesis]]. The most commonly used prosthesis designs are the Austin Moore and Thompson prostheses. A [[composite material|composite]] of [[metal]] and [[HDPE]] that forms two interphases (bipolar prosthesis) can be used. The monopolar prosthesis has not been shown to offer any advantage over bipolar designs. The procedure is recommended only for elderly/frail patients, due to their lower life expectancy and activity level. This is because over time the prosthesis tends to loosen or to erode the [[acetabulum]].<ref>{{cite web | vauthors = van der Meulen MC, Allen WA, Giddings VL, Athanasiou KA, Poser RD, Goodman SB, Smith RL, Beaupré GS | display-authors = 6 |title=Effect of hemiarthroplasty on acetabular cartilage |work=1996 Project Reports |publisher=VA Palo Alto Health Care System's Bone and Joint Rehabilitation Research and Development Center |url=http://www.stanford.edu/group/rrd/96reports/96dev5.html}}</ref> Independently mobile older adults with hip fractures may benefit from a total hip replacement instead of hemiarthroplasty.<ref name="Metcalfe">{{cite journal | vauthors = Metcalfe D, Judge A, Perry DC, Gabbe B, Zogg CK, Costa ML | title = Total hip arthroplasty versus hemiarthroplasty for independently mobile older adults with intracapsular hip fractures | journal = BMC Musculoskeletal Disorders | volume = 20 | issue = 1 | pages = 226 | date = May 2019 | pmid = 31101041 | pmc = 6525472 | doi = 10.1186/s12891-019-2590-4 | doi-access = free }}</ref>
<gallery mode="packed" heights="160">
File:Bipolar hip prosthesis.jpg|Hip prosthesis for hemiarthroplasty. This example is bipolar, meaning that the head has two separate articulations.
File:X-ray of hips with a hemiarthroplasty.jpg|[[Projectional radiography|X-ray]] of the hips, with a right-sided hemiarthroplasty
</gallery>
===Hip resurfacing===
[[Hip resurfacing]] is an alternative to hip replacement surgery. It has been used in Europe since 1998 and became a common procedure. Health-related quality of life measures are markedly improved and patient satisfaction is favorable after hip resurfacing arthroplasty.<ref>{{cite journal | vauthors = Koutras C, Antoniou SA, Talias MA, Heep H | title = Impact of Total Hip Resurfacing Arthroplasty on Health-Related Quality of Life Measures: A Systematic Review and Meta-Analysis | journal = The Journal of Arthroplasty | volume = 30 | issue = 11 | pages = 1938–1952 | date = November 2015 | pmid = 26067708 | doi = 10.1016/j.arth.2015.05.014 }}</ref>
The [[minimally invasive hip resurfacing]] procedure is a further refinement to hip resurfacing.
===Viscosupplementation===
Viscosupplementation is the injection of artificial lubricants into the joint.<ref name="pmid17874246">{{cite journal | vauthors = van den Bekerom MP, Lamme B, Sermon A, Mulier M | title = What is the evidence for viscosupplementation in the treatment of patients with hip osteoarthritis? Systematic review of the literature | journal = Archives of Orthopaedic and Trauma Surgery | volume = 128 | issue = 8 | pages = 815–823 | date = August 2008 | pmid = 17874246 | doi = 10.1007/s00402-007-0447-z | s2cid = 9983894 }}</ref> Use of these medications in the hip is off label. The cost of treatment is typically not covered by health insurance.
Some authorities claim that the future of osteoarthritis treatment is [[bioengineering]], targeting the growth and/or repair of the damaged, arthritic joint. Centeno et al. reported on the partial regeneration of an arthritic human hip joint using mesenchymal [[stem cell]]s.<ref name="pmid16886034">{{cite journal | vauthors = Centeno CJ, Kisiday J, Freeman M, Schultz JR | title = Partial regeneration of the human hip via autologous bone marrow nucleated cell transfer: A case study | journal = Pain Physician | volume = 9 | issue = 3 | pages = 253–256 | date = July 2006 | pmid = 16886034 | url = http://www.painphysicianjournal.com/linkout_vw.php?issn=1533-3159&vol=9&page=253 | url-status = dead | archive-url = https://web.archive.org/web/20090212142425/http://www.painphysicianjournal.com/linkout_vw.php?issn=1533-3159&vol=9&page=253 | archive-date = 2009-02-12 }}</ref> It is yet to be shown that this result will apply to a large group of patients and result in significant benefits. The FDA stated that this procedure does not conform to regulations, but Centeno claims that it is exempt from FDA regulation. It has not been shown in controlled clinical trials to be effective.{{citation needed|date=May 2014}}
==Prevalence and cost==
Total hip replacement incidence varies in developed countries between 30 (Romania) and 290 (Germany) procedures per 100,000 population per year.<ref>{{cite journal | vauthors = Kurtz SM, Ong KL, Lau E, Widmer M, Maravic M, Gómez-Barrena E, de Pina M, Manno V, Torre M, Walter WL, de Steiger R, Geesink RG, Peltola M, Röder C | display-authors = 6 | title = International survey of primary and revision total knee replacement | journal = International Orthopaedics | volume = 35 | issue = 12 | pages = 1783–1789 | date = December 2011 | pmid = 21404023 | pmc = 3224613 | doi = 10.1007/s00264-011-1235-5 }}</ref> Approximately 0.8% of Americans have undergone the procedure.<ref>{{cite journal | vauthors = Maradit Kremers H, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA, Jiranek WA, Berry DJ | display-authors = 6 | title = Prevalence of Total Hip and Knee Replacement in the United States | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 97 | issue = 17 | pages = 1386–1397 | date = September 2015 | pmid = 26333733 | pmc = 4551172 | doi = 10.2106/JBJS.N.01141 }}</ref>
According to the International Federation of Healthcare Plans, the average cost of a total hip replacement in 2012 was $40,364 in the United States, $11,889 in the United Kingdom, $10,987 in France, $9,574 in Switzerland, and $7,731 in Spain.<ref name="ifhp"/> In the United States, the average cost of a total hip replacement varies widely by geographic region, ranging from $11,327 (Birmingham, Alabama) to $73,927 (Boston, Massachusetts).<ref>{{cite web|url=http://www.bcbs.com/healthofamerica/BCBS_BHI_Report-Jan-_21_Final.pdf|title=A study of cost variations for knee and hip replacement surgeries in the U.S.|publisher=Blue Cross Blue Shield Association|date=21 January 2015|access-date=4 October 2015|url-status=dead|archive-url=https://web.archive.org/web/20151022105614/http://www.bcbs.com/healthofamerica/BCBS_BHI_Report-Jan-_21_Final.pdf|archive-date=22 October 2015}}</ref>
==History==
[[File:Hip prosthesis, England, 1958-1960 Wellcome L0057818.jpg|thumb|Gosset-style hip prosthesis from 1960]]
The earliest recorded attempts at hip replacement were carried out in Germany in 1891 by [[Themistocles Gluck]] (1853–1942),<ref>{{cite web|url=http://slideplayer.com/slide/1659480/|title=History of Artificial Joints |format= ppt video online download|website=slideplayer.com}}</ref><ref>{{cite journal | vauthors = Brand RA, Mont MA, Manring MM | title = Biographical sketch: Themistocles Gluck (1853-1942) | journal = Clinical Orthopaedics and Related Research | volume = 469 | issue = 6 | pages = 1525–1527 | date = June 2011 | pmid = 21403990 | pmc = 3094624 | doi = 10.1007/s11999-011-1836-8 }}</ref> who used ivory to replace the [[femoral head]] (the ball on the femur), attaching it with nickel-plated screws.<ref name="pmid16089067">{{cite journal | vauthors = Gomez PF, Morcuende JA | title = Early attempts at hip arthroplasty--1700s to 1950s | journal = The Iowa Orthopaedic Journal | volume = 25 | pages = 25–29 | year = 2005 | pmid = 16089067 | pmc = 1888777 }}</ref> Subsequently, he used a cement made from plaster of Paris, powdered pumice and glue.<ref name=":1">{{cite journal | vauthors = Bota NC, Nistor DV, Caterev S, Todor A | title = Historical overview of hip arthroplasty: From humble beginnings to a high-tech future | journal = Orthopedic Reviews | volume = 13 | issue = 1 | pages = 8773 | date = March 2021 | pmid = 33897987 | pmc = 8054655 | doi = 10.4081/or.2021.8773 }}</ref>
Molded-glass implants were introduced in the 1920s by Smith-Peterson in the USA. Although these showed good bio-compatibility, they were mechanically fragile so he started experiments with metallic prostheses in the 1930s.<ref name=":1" /><ref name=":2">{{cite journal | vauthors = Knight SR, Aujla R, Biswas SP | title = Total Hip Arthroplasty - over 100 years of operative history | journal = Orthopedic Reviews | volume = 3 | issue = 2 | pages = e16 | date = September 2011 | pmid = 22355482 | pmc = 3257425 | doi = 10.4081/or.2011.e16 }}</ref> In 1938, Philip Wiles of Middlesex General Hospital, UK carried out a total hip replacement using a stainless-steel prosthesis attached by bolts.<ref name=":8">{{Cite book | vauthors = Reynolds LA |title= Early Development of Total Hip Replacement |publisher=Wellcome Trust Centre for the History of Medicine, University College London, UK |year=2006 |isbn=978-085484-111-0}}</ref> In 1940, Dr. Austin T. Moore (1899–1963)<ref>{{cite news|url=http://orthopedics.about.com/cs/jointreplacement1/p/austinmoore.htm|title=What You Need to Know About Joint Replacement Surgery|newspaper=Verywell Health}}</ref> at Columbia Hospital in [[Columbia, South Carolina]] performed a hip replacement using a prototype prosthesis made of the cobalt-chrome alloy [[Vitallium|Vitallium; it was]] inserted into the medullary canal and "fenestrated" to promote bone regrowth. A commercial version known as the "Austin Moore Prosthesis" was introduced in 1952; it is still in use today, typically for femoral neck fractures in the elderly.<ref name=":1" /> Following the lead of Wiles, several UK general hospitals including [[Norwich]], [[Wrightington, Wigan and Leigh NHS Foundation Trust|Wrightington]], [[Stanmore]], [[Redhill, Surrey|Redhill]] and [[Exeter]] developed metal-based prostheses during the 1950s and 1960s.<ref name=":8" />
Robert Juditt was the first to perform hip replacements via the anterior approach in 1947 in Paris. He taught this method to {{ill|Émile Letournel|fr}}. Joel Matta, who had studied with Letournel, brought this approach to the United States and went on to popularize it.<ref>{{cite web|url=https://www.thesteadmanclinic.com/news/dr-matta-and-anterior-approach|title=Dr. Matta and Anterior Approach|publisher=Steadman Clinic|date=September 5, 2017|access-date=March 26, 2023}}</ref>
Metal/Acrylic prostheses were tried in the 1950s <ref name=":1" /><ref name=":3" /> but were found to be susceptible to wear. In the 1960s, [[John Charnley]]<ref>{{cite journal | vauthors = Gomez PF, Morcuende JA | title = A historical and economic perspective on Sir John Charnley, Chas F. Thackray Limited, and the early arthoplasty industry | journal = The Iowa Orthopaedic Journal | volume = 25 | pages = 30–37 | date = 2005 | pmid = 16089068 | pmc = 1888784 }}</ref><ref name=":1" /><ref name=":2" /> at Wrightington General Hospital combined a metal prosthesis with a [[Polytetrafluoroethylene|PTFE]] acetabular cup before settling on a metal/[[polyethylene]] design. Ceramic bearings were developed in the late 1970s.<ref name=":1" /><ref name=":2" />
The means of attachment have also diversified.<ref name=":1" /><ref name=":2" /> Early prostheses were attached by screws (e.g. Gluck, Wiles) with later developments using dental or bone cements (e.g. Charnley, Thompson<ref name=":4" /><ref name=":5" />) or cementless systems which relied on bone regrowth (Austin-Moore,<ref name=":6" /> Ring<ref name=":2" />). The choice of alloy, bearing material, attachment and detailed geometry has led to the wide variety of prosthesis designs available today.<ref name=":1" /><ref name=":2" /><ref name=":8" />
The London [[Science Museum, London|Science Museum]] has a collection of hip prostheses which reflect developments in the US, UK and elsewhere. These show the use of different materials and different designs for different circumstances (e.g. cemented and uncemented arthroplasty.) Some are on display in the museum's "Medicine: The Wellcome Galleries".
[[File:Hip prostheses on display in London Science Museum 2022.jpg|thumb|Hip prostheses on display in the London Science Museum]]
The items include:
* '''Prosthesis from 1960''': The "Gosset-style" prosthesis was first introduced in 1949, although the specific example was made by Lusterlite Ltd of [[Leeds]] in 1960. It has a perspex "ball" and simple rod-like shaft made of nickel-plated stainless-steel.<ref name=":3">{{Cite web |date=2022 |title=Vitallium Hip prosthesis, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co177040/hip-prosthesis-artificial-hip-joint}}</ref>
* '''Examples of prostheses from 1970 to 1985''': Examples provided by [[Ipswich]] Hospital, UK are made of [[Vitallium]] (Co/Cr alloy) with curved standard or slender femoral stems.<ref>{{Cite web |date=2022 |title=Vitallium Hip Prosthesis, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co179831/vitallium-hip-prosthesis-prosthesis}}</ref><ref>{{Cite web |date=2022 |title=Vitallium Hip prosthesis, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co179832/vitallium-hip-prosthesis-prosthesis}}</ref> One example has a studded cup.<ref>{{Cite web |date=2022 |title=Vitallium total hip prosthesis, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co179830/vitallium-total-hip-prosthesis-prosthesis}}</ref>
* '''Examples of prostheses from the 1990s''': Examples, some of which were developed at the Redhill Group of Hospitals and Dorking Hospital, include a ringed titanium hip prosthesis with a screw stem and porous cup,<ref name=":7">{{Cite web |date=2022 |title=Ringed titanium hip prosthesis with screw stem, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8601390/ringed-titanium-hip-prosthesis-with-screw-stem-hip-prosthesis}}</ref> a modular hip prosthesis with a textured femoral stem to aid bone grafting (material unspecified),<ref>{{Cite web |date=2022 |title=Modular hip prosthesis with textured femoral stem, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8601379/modular-hip-prosthesis-with-textured-femoral-stem-hip-prosthesis}}</ref> two Thompson-type prostheses made of [[Vitallium]] alloy<ref name=":4">{{Cite web |date=2022 |title=Thompson type prosthesis for hip replacement, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8601382/thompson-type-prosthesis-for-hip-replacement-hip-prosthesis}}</ref><ref name=":5">{{Cite web |date=2022 |title=Thompson type prosthesis for hip replacement, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8601383/thompson-type-prosthesis-for-hip-replacement-hip-prosthesis}}</ref> and an Austin Moore type prosthesis (material unspecified), with a porous metal femoral stem.<ref name=":6">{{Cite web |date=2022 |title=Austin Moore type prosthesis for hip replacement, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8601387/austin-moore-type-prosthesis-for-hip-replacement-hip-prosthesis}}</ref>
* '''Example of acetabular cup prosthesis from 1998:''' Example of a prosthetic socket, from Sulzer Orthopedics Inc., is the Inter-Op Hemispherical Shell. This is made from materials not recognised by the human body, so the body's immune system does not attack and reject the joint.<ref>{{Cite web |date=2022 |title=Replacement hip joint, United States, 1998, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co503279/replacement-hip-joint-united-states-1998-artificial-hip-joint}}</ref>
* '''Examples of prostheses from 2006''': Examples made by [[Smith & Nephew|Smith & Nephew Orthopedics]] include an "Anthology" titanium prosthesis, which has a flat-tapered stem placed in the thigh bone, and an "Echelon" (cobalt-chrome prosthesis for both cementless and cemented [[arthroplasty]]. Both have porous coating to promote bone adhesion.<ref>{{Cite web |date=2022 |title=ANTHOLOGY Hip System, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8082322/anthology-hip-system-artificial-hip-joint}}</ref><ref>{{Cite web |date=2022 |title=ECHELON Hip System, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8082323/echelon-hip-system-artificial-hip-joint}}</ref>
The Science Museum's collection also includes specialised surgical tools for hip operations:
* '''Instrument sets''' made by Downs Ltd for the City Hospital, [[Nottingham University Hospitals NHS Trust|Nottingham University Hospitals]] UK.<ref>{{Cite web |date=2022 |title=Instrument set for Austin-Moore hip replacement, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co178705/instrument-set-for-austin-moore-hip-replacement-orthopaedic-instrument-sets}}</ref><ref>{{Cite web |date=2022 |title=Instrument set by Downs Ltd. for ring hip prosthesis, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co178700/instrument-set-by-downs-ltd-for-ring-hip-prothesi-orthopaedic-instrument-sets}}</ref> Tools include head punches, reamers, drills and rasps.
* '''Prototype oscillating bone saws''' made by Kenneth Dobbie in the 1960s.<ref>{{Cite web |date=2022 |title=Prototype version of the Dobbie bone saw, England, 1966, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8002596/prototype-version-of-the-dobbie-bone-saw-england-1966-surgical-saw}}</ref><ref>{{Cite web |date=2022 |title=Prototype version of the Dobbie bone saw, England, 1967, Science Museum Group Collection |url=https://collection.sciencemuseumgroup.org.uk/objects/co8002598/prototype-version-of-the-dobbie-bone-saw-england-1967-surgical-saw |access-date=}}</ref> Dobbie was electrical engineer at the [[Royal National Orthopaedic Hospital]], Stanmore, UK. He worked closely with the hip surgeon [[John Charnley|Sir John Charnley]] to develop the saws eventually leading to a commercial product made by De Soutter Brothers Ltd.<ref>{{Cite web | vauthors = Hurley S |date=2011 |title="Prototypes", Science Museum Blog (April 2011) |url=https://blog.sciencemuseum.org.uk/prototypes/ |access-date=}}</ref>
==Other animals==
{{Main|Hip replacement (animal)}}
== See also ==
* [[2010 DePuy Hip Recall]]
* [[Abductor wedge]]
* [[Femoroacetabular impingement]]
* [[Gruen zone]]
* [[Hip examination]]
== References ==
{{Reflist}}
== External links ==
* [https://web.archive.org/web/20060619082711/http://www.edheads.org/activities/hip/ Edheads Virtual Hip Surgery + Surgery Photos]
{{Operations and other procedures on the musculoskeletal system}}
{{Authority control}}
{{DEFAULTSORT:Hip Replacement}}
[[Category:Implants (medicine)]]
[[Category:Orthopedic surgical procedures]]
[[Category:Pelvis]]
[[Category:Prosthetics]]
[[Category:Orthopedic implants]]' |
Unified diff of changes made by edit (edit_diff) | '@@ -28,5 +28,5 @@
[[File:Hip prosthesis liner creep and wear.png|thumb|160px|Liner wear, particularly when over 2 mm, increases the risk of dislocation.<ref name=berry2012/> Liner creep, on the other hand, is normal remoulding.<ref name=Watt/>]]
-Dislocation (the ball coming out of the socket) is the most common complication. The most common causes vary by the duration since the surgery.{{citation needed|date=February 2022}}
+Dislocation (the ball coming out of the socket) is the most common complication. ADOLF HITLER HAD HIP REPLACEMENT The most common causes vary by the duration since the surgery.{{citation needed|date=February 2022}}
Hip prosthesis [[joint dislocation|dislocation]] mostly occurs in the first three months after insertion, mainly because of incomplete scar formation and relaxed soft tissues.<ref name=berry2012>{{cite book|title=Surgery of the Hip|url=https://books.google.com/books?id=Kc-AhYLnIF4C&pg=PA1035| vauthors = Berry DJ, Lieberman J |publisher=Elsevier Health Sciences|year=2012|isbn=9781455727056|page=1035}}</ref> It takes eight to twelve weeks for the soft tissues injured or cut during surgery to heal. The chance of this is diminished if less tissue is cut, if the cut tissue is repaired and if large diameter head balls are used.
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0 => 'Dislocation (the ball coming out of the socket) is the most common complication. The most common causes vary by the duration since the surgery.{{citation needed|date=February 2022}}'
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221 => 'https://doi.org/10.4081%2For.2021.8773',
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229 => 'https://www.thesteadmanclinic.com/news/dr-matta-and-anterior-approach',
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231 => 'https://api.semanticscholar.org/CorpusID:257843402',
232 => 'https://evidence.nihr.ac.uk/alert/one-stage-hip-revisions-are-as-good-as-2-stage-surgery-to-replace-infected-artificial-hips/',
233 => 'https://doi.org/10.3310%2Fnihrevidence_57776',
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241 => 'https://pubmed.ncbi.nlm.nih.gov/32912197',
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Parsed HTML source of the new revision (new_html) | '<div class="mw-content-ltr mw-parser-output" lang="en" dir="ltr"><div class="shortdescription nomobile noexcerpt noprint searchaux" style="display:none">Surgery replacing hip joint with prosthetic implant</div>
<style data-mw-deduplicate="TemplateStyles:r1218072481">.mw-parser-output .infobox-subbox{padding:0;border:none;margin:-3px;width:auto;min-width:100%;font-size:100%;clear:none;float:none;background-color:transparent}.mw-parser-output .infobox-3cols-child{margin:auto}.mw-parser-output .infobox .navbar{font-size:100%}body.skin-minerva .mw-parser-output .infobox-header,body.skin-minerva .mw-parser-output .infobox-subheader,body.skin-minerva .mw-parser-output .infobox-above,body.skin-minerva .mw-parser-output .infobox-title,body.skin-minerva .mw-parser-output .infobox-image,body.skin-minerva .mw-parser-output .infobox-full-data,body.skin-minerva .mw-parser-output .infobox-below{text-align:center}html.skin-theme-clientpref-night .mw-parser-output .infobox-full-data div{background:#1f1f23!important;color:#f8f9fa}@media(prefers-color-scheme:dark){html.skin-theme-clientpref-os .mw-parser-output .infobox-full-data div{background:#1f1f23!important;color:#f8f9fa}}</style><table class="infobox"><tbody><tr><th colspan="2" class="infobox-above" style="background-color: lightblue">Hip replacement</th></tr><tr><td colspan="2" class="infobox-image"><span class="mw-default-size" typeof="mw:File/Frameless"><a href="/info/en/?search=File:X-ray_of_pelvis_with_total_arthroplasty.jpg" class="mw-file-description"><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/9/9c/X-ray_of_pelvis_with_total_arthroplasty.jpg/280px-X-ray_of_pelvis_with_total_arthroplasty.jpg" decoding="async" width="280" height="233" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/9/9c/X-ray_of_pelvis_with_total_arthroplasty.jpg/420px-X-ray_of_pelvis_with_total_arthroplasty.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/9/9c/X-ray_of_pelvis_with_total_arthroplasty.jpg/560px-X-ray_of_pelvis_with_total_arthroplasty.jpg 2x" data-file-width="2591" data-file-height="2155" /></a></span><div class="infobox-caption">An <a href="/info/en/?search=X-ray" title="X-ray">X-ray</a> showing a left hip (right of image) that has been replaced, with the ball of this ball-and-socket joint replaced by a metal head that is set in the <a href="/info/en/?search=Femur" title="Femur">femur</a> and the socket replaced by a cup</div></td></tr><tr><th scope="row" class="infobox-label">Other names</th><td class="infobox-data">Hip arthroplasty</td></tr><tr><th scope="row" class="infobox-label"><a href="/info/en/?search=ICD-9-CM_Volume_3" title="ICD-9-CM Volume 3">ICD-9-CM</a></th><td class="infobox-data"><a class="external text" href="https://icd9cm.chrisendres.com/index.php?srchtype=procs&srchtext=81.51&Submit=Search&action=search">81.51</a>–<a class="external text" href="https://icd9cm.chrisendres.com/index.php?srchtype=procs&srchtext=81.53&Submit=Search&action=search">81.53</a></td></tr><tr><th scope="row" class="infobox-label"><a href="/info/en/?search=Medical_Subject_Headings" title="Medical Subject Headings">MeSH</a></th><td class="infobox-data"><span class="reflink plainlinks nourlexpansion"><a class="external text" href="https://meshb.nlm.nih.gov/record/ui?ui=D019644">D019644</a></span></td></tr><tr><th scope="row" class="infobox-label"><a href="/info/en/?search=MedlinePlus" title="MedlinePlus">MedlinePlus</a></th><td class="infobox-data"><span class="reflink plainlinks nourlexpansion"><a class="external text" href="https://medlineplus.gov/ency/article/002975.htm">002975</a></span></td></tr><tr class="noprint"><td colspan="2" class="infobox-full-data"><div style="text-align: right;">[<a href="https://www.wikidata.org/wiki/Q32333487" class="extiw" title="d:Q32333487">edit on Wikidata</a>]</div></td></tr></tbody></table>
<p><b>Hip replacement</b> is a <a href="/info/en/?search=Surgery" title="Surgery">surgical</a> procedure in which the <a href="/info/en/?search=Hip" title="Hip">hip</a> joint is replaced by a prosthetic <a href="/info/en/?search=Implant_(medicine)" title="Implant (medicine)">implant</a>, that is, a <b>hip prosthesis</b>. Hip replacement surgery can be performed as a total replacement or a hemi/semi(half) replacement. Such <a href="/info/en/?search=Joint_replacement" title="Joint replacement">joint replacement</a> <a href="/info/en/?search=Orthopaedic_surgery" class="mw-redirect" title="Orthopaedic surgery">orthopaedic surgery</a> is generally conducted to relieve <a href="/info/en/?search=Arthritis" title="Arthritis">arthritis</a> <a href="/info/en/?search=Pain" title="Pain">pain</a> or in some <a href="/info/en/?search=Hip_fracture" title="Hip fracture">hip fractures</a>. A total hip replacement (total hip arthroplasty or THA) consists of replacing both the <a href="/info/en/?search=Acetabulum" title="Acetabulum">acetabulum</a> and the femoral head while <a href="/info/en/?search=Hemiarthroplasty" class="mw-redirect" title="Hemiarthroplasty">hemiarthroplasty</a> generally only replaces the femoral head. Hip replacement is one of the most common orthopaedic operations, though patient satisfaction varies widely. Approximately 58% of total hip replacements are estimated to last 25 years.<sup id="cite_ref-1" class="reference"><a href="#cite_note-1">[1]</a></sup> The average cost of a total hip replacement in 2012 was $40,364 in the United States, and about $7,700 to $12,000 in most European countries.<sup id="cite_ref-ifhp_2-0" class="reference"><a href="#cite_note-ifhp-2">[2]</a></sup>
</p>
<div id="toc" class="toc" role="navigation" aria-labelledby="mw-toc-heading"><input type="checkbox" role="button" id="toctogglecheckbox" class="toctogglecheckbox" style="display:none" /><div class="toctitle" lang="en" dir="ltr"><h2 id="mw-toc-heading">Contents</h2><span class="toctogglespan"><label class="toctogglelabel" for="toctogglecheckbox"></label></span></div>
<ul>
<li class="toclevel-1 tocsection-1"><a href="#Medical_uses"><span class="tocnumber">1</span> <span class="toctext">Medical uses</span></a></li>
<li class="toclevel-1 tocsection-2"><a href="#Risks"><span class="tocnumber">2</span> <span class="toctext">Risks</span></a>
<ul>
<li class="toclevel-2 tocsection-3"><a href="#Dislocation"><span class="tocnumber">2.1</span> <span class="toctext">Dislocation</span></a></li>
<li class="toclevel-2 tocsection-4"><a href="#Infection"><span class="tocnumber">2.2</span> <span class="toctext">Infection</span></a></li>
<li class="toclevel-2 tocsection-5"><a href="#Limb_length_inequality"><span class="tocnumber">2.3</span> <span class="toctext">Limb length inequality</span></a></li>
<li class="toclevel-2 tocsection-6"><a href="#Fracture"><span class="tocnumber">2.4</span> <span class="toctext">Fracture</span></a></li>
<li class="toclevel-2 tocsection-7"><a href="#Vein_thrombosis"><span class="tocnumber">2.5</span> <span class="toctext">Vein thrombosis</span></a></li>
<li class="toclevel-2 tocsection-8"><a href="#Osteolysis"><span class="tocnumber">2.6</span> <span class="toctext">Osteolysis</span></a></li>
<li class="toclevel-2 tocsection-9"><a href="#Loosening"><span class="tocnumber">2.7</span> <span class="toctext">Loosening</span></a></li>
<li class="toclevel-2 tocsection-10"><a href="#Metal_sensitivity"><span class="tocnumber">2.8</span> <span class="toctext">Metal sensitivity</span></a></li>
<li class="toclevel-2 tocsection-11"><a href="#Metal_toxicity"><span class="tocnumber">2.9</span> <span class="toctext">Metal toxicity</span></a></li>
<li class="toclevel-2 tocsection-12"><a href="#Nerve_palsy"><span class="tocnumber">2.10</span> <span class="toctext">Nerve palsy</span></a></li>
<li class="toclevel-2 tocsection-13"><a href="#Chronic_pain"><span class="tocnumber">2.11</span> <span class="toctext">Chronic pain</span></a></li>
<li class="toclevel-2 tocsection-14"><a href="#Death"><span class="tocnumber">2.12</span> <span class="toctext">Death</span></a></li>
<li class="toclevel-2 tocsection-15"><a href="#Metal-on-metal_hip_implant_failure"><span class="tocnumber">2.13</span> <span class="toctext">Metal-on-metal hip implant failure</span></a></li>
</ul>
</li>
<li class="toclevel-1 tocsection-16"><a href="#Modern_process"><span class="tocnumber">3</span> <span class="toctext">Modern process</span></a></li>
<li class="toclevel-1 tocsection-17"><a href="#Techniques"><span class="tocnumber">4</span> <span class="toctext">Techniques</span></a>
<ul>
<li class="toclevel-2 tocsection-18"><a href="#Posterior_approach"><span class="tocnumber">4.1</span> <span class="toctext">Posterior approach</span></a></li>
<li class="toclevel-2 tocsection-19"><a href="#Lateral_approach"><span class="tocnumber">4.2</span> <span class="toctext">Lateral approach</span></a></li>
<li class="toclevel-2 tocsection-20"><a href="#Antero-lateral_approach"><span class="tocnumber">4.3</span> <span class="toctext">Antero-lateral approach</span></a></li>
<li class="toclevel-2 tocsection-21"><a href="#Anterior_approach"><span class="tocnumber">4.4</span> <span class="toctext">Anterior approach</span></a></li>
<li class="toclevel-2 tocsection-22"><a href="#Minimally_invasive_approaches"><span class="tocnumber">4.5</span> <span class="toctext">Minimally invasive approaches</span></a></li>
</ul>
</li>
<li class="toclevel-1 tocsection-23"><a href="#Implants"><span class="tocnumber">5</span> <span class="toctext">Implants</span></a>
<ul>
<li class="toclevel-2 tocsection-24"><a href="#Acetabular_cup"><span class="tocnumber">5.1</span> <span class="toctext">Acetabular cup</span></a></li>
<li class="toclevel-2 tocsection-25"><a href="#Femoral_component"><span class="tocnumber">5.2</span> <span class="toctext">Femoral component</span></a></li>
<li class="toclevel-2 tocsection-26"><a href="#Articular_interface"><span class="tocnumber">5.3</span> <span class="toctext">Articular interface</span></a></li>
</ul>
</li>
<li class="toclevel-1 tocsection-27"><a href="#Configuration"><span class="tocnumber">6</span> <span class="toctext">Configuration</span></a></li>
<li class="toclevel-1 tocsection-28"><a href="#Alternatives_and_variations"><span class="tocnumber">7</span> <span class="toctext">Alternatives and variations</span></a>
<ul>
<li class="toclevel-2 tocsection-29"><a href="#Conservative_management"><span class="tocnumber">7.1</span> <span class="toctext">Conservative management</span></a></li>
<li class="toclevel-2 tocsection-30"><a href="#Preoperative_care"><span class="tocnumber">7.2</span> <span class="toctext">Preoperative care</span></a></li>
<li class="toclevel-2 tocsection-31"><a href="#Hemiarthroplasty"><span class="tocnumber">7.3</span> <span class="toctext">Hemiarthroplasty</span></a></li>
<li class="toclevel-2 tocsection-32"><a href="#Hip_resurfacing"><span class="tocnumber">7.4</span> <span class="toctext">Hip resurfacing</span></a></li>
<li class="toclevel-2 tocsection-33"><a href="#Viscosupplementation"><span class="tocnumber">7.5</span> <span class="toctext">Viscosupplementation</span></a></li>
</ul>
</li>
<li class="toclevel-1 tocsection-34"><a href="#Prevalence_and_cost"><span class="tocnumber">8</span> <span class="toctext">Prevalence and cost</span></a></li>
<li class="toclevel-1 tocsection-35"><a href="#History"><span class="tocnumber">9</span> <span class="toctext">History</span></a></li>
<li class="toclevel-1 tocsection-36"><a href="#Other_animals"><span class="tocnumber">10</span> <span class="toctext">Other animals</span></a></li>
<li class="toclevel-1 tocsection-37"><a href="#See_also"><span class="tocnumber">11</span> <span class="toctext">See also</span></a></li>
<li class="toclevel-1 tocsection-38"><a href="#References"><span class="tocnumber">12</span> <span class="toctext">References</span></a></li>
<li class="toclevel-1 tocsection-39"><a href="#External_links"><span class="tocnumber">13</span> <span class="toctext">External links</span></a></li>
</ul>
</div>
<h2><span class="mw-headline" id="Medical_uses">Medical uses</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=1" title="Edit section: Medical uses"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h2>
<p>Total hip replacement is most commonly used to treat joint failure caused by <a href="/info/en/?search=Osteoarthritis" title="Osteoarthritis">osteoarthritis</a>. Other indications include <a href="/info/en/?search=Rheumatoid_arthritis" title="Rheumatoid arthritis">rheumatoid arthritis</a>, <a href="/info/en/?search=Avascular_necrosis" title="Avascular necrosis">avascular necrosis</a>, <a href="/info/en/?search=Post-traumatic_arthritis" title="Post-traumatic arthritis">traumatic arthritis</a>, <a href="/info/en/?search=Protrusio_acetabuli" title="Protrusio acetabuli">protrusio acetabuli</a>, certain <a href="/info/en/?search=Hip_fracture" title="Hip fracture">hip fractures</a>, benign and malignant <a href="/info/en/?search=Bone_tumor" title="Bone tumor">bone tumors</a>, arthritis associated with <a href="/info/en/?search=Paget%27s_disease_of_bone" title="Paget's disease of bone">Paget's disease</a>, <a href="/info/en/?search=Ankylosing_spondylitis" title="Ankylosing spondylitis">ankylosing spondylitis</a> and <a href="/info/en/?search=Juvenile_rheumatoid_arthritis" class="mw-redirect" title="Juvenile rheumatoid arthritis">juvenile rheumatoid arthritis</a>. The aims of the procedure are pain relief and improvement in hip function. Hip replacement is usually considered only after other therapies, such as <a href="/info/en/?search=Physical_therapy" title="Physical therapy">physical therapy</a> and pain medications, have failed.<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">[<i><a href="/info/en/?search=Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (February 2022)">citation needed</span></a></i>]</sup>
</p>
<h2><span class="mw-headline" id="Risks">Risks</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=2" title="Edit section: Risks"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h2>
<p>Risks and complications in hip replacement are similar to those associated with all <a href="/info/en/?search=Joint_replacement#Risks_and_complications" title="Joint replacement">joint replacements</a>. They can include infection, dislocation, limb length inequality, loosening, impingement, osteolysis, metal sensitivity, nerve palsy, chronic pain and death. <a href="/info/en/?search=Bariatric_surgery" title="Bariatric surgery">Weight loss surgery</a> before a hip replacement does not appear to change outcomes.<sup id="cite_ref-3" class="reference"><a href="#cite_note-3">[3]</a></sup>
</p><p>Follow-up assessments are conducted to examine the need for revision surgery. However, a UK study showed that only 3-6% of hip replacements needed a revision. Researchers recommended that routine follow-up may not be needed for up to 10 years. At this point, x-rays should be used to assess the joint, and there should be a clinical assessment of pain and mobility.<sup id="cite_ref-4" class="reference"><a href="#cite_note-4">[4]</a></sup><sup id="cite_ref-5" class="reference"><a href="#cite_note-5">[5]</a></sup>
</p><p><a href="/info/en/?search=Edema" title="Edema">Edema</a> appears around the hip in the hours or days following the surgery. This swelling is typically at its maximum 7 days after the operation,<sup id="cite_ref-6" class="reference"><a href="#cite_note-6">[6]</a></sup> then decreases and disappears over the course of weeks. Only 5% of patients still have swelling 6 months after the operation.<sup id="cite_ref-7" class="reference"><a href="#cite_note-7">[7]</a></sup>
</p>
<h3><span class="mw-headline" id="Dislocation">Dislocation</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=3" title="Edit section: Dislocation"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<figure class="mw-default-size" typeof="mw:File/Thumb"><a href="/info/en/?search=File:Dislocated_hip_replacement.jpg" class="mw-file-description"><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/7/76/Dislocated_hip_replacement.jpg/170px-Dislocated_hip_replacement.jpg" decoding="async" width="170" height="226" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/7/76/Dislocated_hip_replacement.jpg/255px-Dislocated_hip_replacement.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/7/76/Dislocated_hip_replacement.jpg/340px-Dislocated_hip_replacement.jpg 2x" data-file-width="1340" data-file-height="1780" /></a><figcaption>Dislocated artificial hip</figcaption></figure>
<figure typeof="mw:File/Thumb"><a href="/info/en/?search=File:Hip_prosthesis_liner_creep_and_wear.png" class="mw-file-description"><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/d/d9/Hip_prosthesis_liner_creep_and_wear.png/160px-Hip_prosthesis_liner_creep_and_wear.png" decoding="async" width="160" height="153" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/d/d9/Hip_prosthesis_liner_creep_and_wear.png/240px-Hip_prosthesis_liner_creep_and_wear.png 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/d/d9/Hip_prosthesis_liner_creep_and_wear.png/320px-Hip_prosthesis_liner_creep_and_wear.png 2x" data-file-width="975" data-file-height="930" /></a><figcaption>Liner wear, particularly when over 2 mm, increases the risk of dislocation.<sup id="cite_ref-berry2012_8-0" class="reference"><a href="#cite_note-berry2012-8">[8]</a></sup> Liner creep, on the other hand, is normal remoulding.<sup id="cite_ref-Watt_9-0" class="reference"><a href="#cite_note-Watt-9">[9]</a></sup></figcaption></figure>
<p>Dislocation (the ball coming out of the socket) is the most common complication. ADOLF HITLER HAD HIP REPLACEMENT The most common causes vary by the duration since the surgery.<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">[<i><a href="/info/en/?search=Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (February 2022)">citation needed</span></a></i>]</sup>
</p><p>Hip prosthesis <a href="/info/en/?search=Joint_dislocation" title="Joint dislocation">dislocation</a> mostly occurs in the first three months after insertion, mainly because of incomplete scar formation and relaxed soft tissues.<sup id="cite_ref-berry2012_8-1" class="reference"><a href="#cite_note-berry2012-8">[8]</a></sup> It takes eight to twelve weeks for the soft tissues injured or cut during surgery to heal. The chance of this is diminished if less tissue is cut, if the cut tissue is repaired and if large diameter head balls are used.
</p><p>Dislocations occurring between three months and five years after insertion usually occur due to malposition of the components, or dysfunction of nearby muscles.<sup id="cite_ref-berry2012_8-2" class="reference"><a href="#cite_note-berry2012-8">[8]</a></sup>
</p><p>Risk factors of late dislocation (after five years) mainly include:<sup id="cite_ref-berry2012_8-3" class="reference"><a href="#cite_note-berry2012-8">[8]</a></sup>
</p>
<ul><li>Female sex</li>
<li>Younger age</li>
<li>Previous <a href="/info/en/?search=Subluxation" title="Subluxation">subluxation</a> without complete dislocation</li>
<li>Previous trauma</li>
<li>Substantial weight loss</li>
<li>Recent onset or progression of <a href="/info/en/?search=Dementia" title="Dementia">dementia</a> or a <a href="/info/en/?search=Neurological_disorder" title="Neurological disorder">neurological disorder</a></li>
<li>Malposition of the cup</li>
<li>Liner wear, particularly when it allows head movement of more than 2 mm within the cup compared to its original position</li>
<li>Prosthesis loosening with migration</li></ul>
<p>Surgeons who perform more operations tend to have fewer dislocations. An anterior approach seems to lower dislocation rates when small diameter heads are used, but that benefit has not been shown when compared to modern posterior incisions with the use of larger diameter heads. The use of larger diameter head size in itself decreases dislocation risk, even though this correlation is only found in head sizes up to 28 mm: larger heads do not result in a statistically significant decrease in dislocation rate.<sup id="cite_ref-10" class="reference"><a href="#cite_note-10">[10]</a></sup> Keeping the leg out of certain positions during the first few months after surgery further reduces risk.<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">[<i><a href="/info/en/?search=Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (February 2022)">citation needed</span></a></i>]</sup>
</p>
<h3><span class="mw-headline" id="Infection">Infection</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=4" title="Edit section: Infection"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>Infection is one of the most common causes for revision of a total hip replacement. The incidence of infection in primary hip replacement is 1% or less in the United States.<sup id="cite_ref-11" class="reference"><a href="#cite_note-11">[11]</a></sup> Risk factors for infection include obesity, diabetes, smoking, immunosuppressive medications or diseases, and history of infection.<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">[<i><a href="/info/en/?search=Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (February 2022)">citation needed</span></a></i>]</sup>
</p><p>In revision surgery, infected tissue surrounding the joint is removed, and the artificial joint replaced. Typically, this is carried out in 2 stages: infected tissue and all joint replacement implants are removed in the first stage, and, after the infection is completely cleared, a new artificial joint is inserted in the second stage. One-stage surgery is also available whereby infected tissue and implants are removed, and the new joint inserted, in a single procedure. One-stage hip revisions were found to be as effective as two-stage procedures at relieving pain and improving hip stiffness and function. One-stage procedures were also better value for money.<sup id="cite_ref-12" class="reference"><a href="#cite_note-12">[12]</a></sup><sup id="cite_ref-13" class="reference"><a href="#cite_note-13">[13]</a></sup>
</p>
<h3><span class="mw-headline" id="Limb_length_inequality">Limb length inequality</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=5" title="Edit section: Limb length inequality"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>Most adults have a limb length inequality of 0–2 cm which causes no deficits.<sup id="cite_ref-14" class="reference"><a href="#cite_note-14">[14]</a></sup> It is common for people to sense a larger limb length inequality after total hip replacement.<sup id="cite_ref-15" class="reference"><a href="#cite_note-15">[15]</a></sup> Sometimes the leg seems long immediately after surgery when in fact both are equal length. An arthritic hip can develop contractures that make the leg behave as if it is short. When these are relieved with replacement surgery and normal motion and function are restored, the body feels that the limb is now longer than it was. This feeling usually subsides by six months after surgery as the body adjusts to the new hip joint. The cause of this feeling is variable, and usually related to abductor muscle weakness, pelvic obliquity, and minor lengthening of the hip during surgery (<1 cm) to achieve stability and restore the joint to pre-arthritic mechanics. If the limb length difference remains bothersome to the patient more than six months after surgery, a shoe lift can be used. Only in extreme cases is surgery required for correction.<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">[<i><a href="/info/en/?search=Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (February 2022)">citation needed</span></a></i>]</sup> The perceived difference in limb length for a patient after surgery is a common cause for lawsuits against the healthcare provider.<sup id="cite_ref-16" class="reference"><a href="#cite_note-16">[16]</a></sup><sup id="cite_ref-17" class="reference"><a href="#cite_note-17">[17]</a></sup><sup id="cite_ref-18" class="reference"><a href="#cite_note-18">[18]</a></sup><sup id="cite_ref-19" class="reference"><a href="#cite_note-19">[19]</a></sup><sup id="cite_ref-20" class="reference"><a href="#cite_note-20">[20]</a></sup>
</p>
<h3><span class="mw-headline" id="Fracture">Fracture</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=6" title="Edit section: Fracture"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<figure typeof="mw:File/Thumb"><a href="/info/en/?search=File:Intraoperative_acetabular_fracture,_annotated.jpg" class="mw-file-description"><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/f/f8/Intraoperative_acetabular_fracture%2C_annotated.jpg/150px-Intraoperative_acetabular_fracture%2C_annotated.jpg" decoding="async" width="150" height="154" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/f/f8/Intraoperative_acetabular_fracture%2C_annotated.jpg/225px-Intraoperative_acetabular_fracture%2C_annotated.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/f/f8/Intraoperative_acetabular_fracture%2C_annotated.jpg/300px-Intraoperative_acetabular_fracture%2C_annotated.jpg 2x" data-file-width="602" data-file-height="617" /></a><figcaption>Intraoperative acetabular fracture</figcaption></figure>
<p>Intraoperative fractures may occur. After surgery, bones with internal fixation devices in situ are at risk of <a href="/info/en/?search=Periprosthetic" title="Periprosthetic">periprosthetic</a> fractures at the end of the implant, an area of relative mechanical stress. Post-operative femoral fractures are graded by the <a href="/info/en/?search=Vancouver_classification" title="Vancouver classification">Vancouver classification</a>.
</p>
<h3><span class="mw-headline" id="Vein_thrombosis">Vein thrombosis</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=7" title="Edit section: Vein thrombosis"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p><a href="/info/en/?search=Venous_thrombosis" title="Venous thrombosis">Venous thrombosis</a> such as <a href="/info/en/?search=Deep_vein_thrombosis" title="Deep vein thrombosis">deep vein thrombosis</a> and <a href="/info/en/?search=Pulmonary_embolism" title="Pulmonary embolism">pulmonary embolism</a> are relatively common following hip replacement surgery. Standard treatment with <a href="/info/en/?search=Anticoagulant" title="Anticoagulant">anticoagulants</a> is for 7–10 days; however, treatment for 21+ days may be superior.<sup id="cite_ref-21" class="reference"><a href="#cite_note-21">[21]</a></sup><sup id="cite_ref-:0_22-0" class="reference"><a href="#cite_note-:0-22">[22]</a></sup> Extended-duration anticoagulants (up to 35 days following surgery) may prevent VTE in people undergoing hip replacement surgery.<sup id="cite_ref-:0_22-1" class="reference"><a href="#cite_note-:0-22">[22]</a></sup> Other research suggested that anticoagulants in otherwise healthy patients undergoing a so-called fast track protocol with hospital stays under five days, might only be necessary while in the hospital.<sup id="cite_ref-23" class="reference"><a href="#cite_note-23">[23]</a></sup> Emerging evidence supports the use of aspirin for venous thromboembolism prophylaxis. Large randomised control trials suggested that aspirin is not inferior to low-molecular weight <a href="/info/en/?search=Heparins" class="mw-redirect" title="Heparins">heparins</a> and <a href="/info/en/?search=Rivaroxaban" title="Rivaroxaban">rivaroxaban</a>.<sup id="cite_ref-24" class="reference"><a href="#cite_note-24">[24]</a></sup><sup id="cite_ref-25" class="reference"><a href="#cite_note-25">[25]</a></sup> However, aspirin may not be appropriate in all cases, especially for patients who have additional risk factors for venous thromboembolisms or may have an inadequate response to aspirin.<sup id="cite_ref-26" class="reference"><a href="#cite_note-26">[26]</a></sup>
</p><p>Some physicians and patients may consider having an <a href="/info/en/?search=Ultrasonography_for_deep_vein_thrombosis" class="mw-redirect" title="Ultrasonography for deep vein thrombosis">ultrasonography for deep vein thrombosis</a> after hip replacement.<sup id="cite_ref-AAOSfive_27-0" class="reference"><a href="#cite_note-AAOSfive-27">[27]</a></sup> However, this kind of screening should only be done when indicated because to perform it routinely would be <a href="/info/en/?search=Unnecessary_health_care" title="Unnecessary health care">unnecessary health care</a>.<sup id="cite_ref-AAOSfive_27-1" class="reference"><a href="#cite_note-AAOSfive-27">[27]</a></sup>
</p><p><a href="/info/en/?search=Intermittent_pneumatic_compression" title="Intermittent pneumatic compression">Intermittent pneumatic compression</a> (IPC) devices are sometimes used for prevention of blood clots following total hip replacement.<sup id="cite_ref-28" class="reference"><a href="#cite_note-28">[28]</a></sup>
</p>
<h3><span class="mw-headline" id="Osteolysis">Osteolysis</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=8" title="Edit section: Osteolysis"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>Many long-term problems with hip replacements are the result of <a href="/info/en/?search=Osteolysis" title="Osteolysis">osteolysis</a>. This is the loss of bone caused by the body's reaction to polyethylene wear debris, fine bits of plastic that wear off the cup liner over time. An <a href="/info/en/?search=Inflammation" title="Inflammation">inflammatory</a> process causes bone resorption that may lead to subsequent loosening of the hip implants and even fractures in the bone around the implants. Ceramic bearing surfaces may eliminate the generation of wear particles. Metal cup liners joined with metal heads (metal-on-metal hip arthroplasty) were developed for similar reasons. In the lab these show excellent wear characteristics and benefit from a different mode of lubrication.
</p><p>Highly cross-linked polyethylene plastic liners experience significantly reduced plastic wear debris. The newer ceramic and metal prostheses may not have long-term performance records. Ceramic piece breakage can lead to catastrophic failure. This occurs in about 2% of implants. They may also cause an audible, high pitched squeaking noise with activity. Metal-on-metal arthroplasty can release metal debris into the body. Highly cross linked polyethylene is not as strong as regular polyethylene. These plastic liners can crack or break free of the metal shell that holds them.<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">[<i><a href="/info/en/?search=Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (February 2022)">citation needed</span></a></i>]</sup>
</p>
<h3><span class="mw-headline" id="Loosening">Loosening</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=9" title="Edit section: Loosening"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<figure class="mw-default-size" typeof="mw:File/Thumb"><a href="/info/en/?search=File:Hip_joint_aseptic_loosening_ar1938-1.png" class="mw-file-description"><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/b/b7/Hip_joint_aseptic_loosening_ar1938-1.png/170px-Hip_joint_aseptic_loosening_ar1938-1.png" decoding="async" width="170" height="254" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/b/b7/Hip_joint_aseptic_loosening_ar1938-1.png/255px-Hip_joint_aseptic_loosening_ar1938-1.png 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/b/b7/Hip_joint_aseptic_loosening_ar1938-1.png/340px-Hip_joint_aseptic_loosening_ar1938-1.png 2x" data-file-width="709" data-file-height="1058" /></a><figcaption>Hip prosthesis displaying aseptic loosening (arrows)</figcaption></figure>
<figure typeof="mw:File/Thumb"><a href="/info/en/?search=File:Hip_prosthesis_zones_by_DeLee_and_Charnley_system,_and_Gruen_system.jpg" class="mw-file-description"><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/0/00/Hip_prosthesis_zones_by_DeLee_and_Charnley_system%2C_and_Gruen_system.jpg/210px-Hip_prosthesis_zones_by_DeLee_and_Charnley_system%2C_and_Gruen_system.jpg" decoding="async" width="210" height="215" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/0/00/Hip_prosthesis_zones_by_DeLee_and_Charnley_system%2C_and_Gruen_system.jpg/315px-Hip_prosthesis_zones_by_DeLee_and_Charnley_system%2C_and_Gruen_system.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/0/00/Hip_prosthesis_zones_by_DeLee_and_Charnley_system%2C_and_Gruen_system.jpg/420px-Hip_prosthesis_zones_by_DeLee_and_Charnley_system%2C_and_Gruen_system.jpg 2x" data-file-width="2400" data-file-height="2456" /></a><figcaption><a href="/info/en/?search=Hip_prosthesis_zones" title="Hip prosthesis zones">Hip prosthesis zones</a> according to DeLee and Charnley,<sup id="cite_ref-29" class="reference"><a href="#cite_note-29">[29]</a></sup> and Gruen.<sup id="cite_ref-30" class="reference"><a href="#cite_note-30">[30]</a></sup> These are used to describe the location of for example areas of loosening.</figcaption></figure>
<p>On radiography, it is normal to see thin radiolucent areas of less than 2 mm around hip prosthesis components, or between a cement mantle and bone. These may indicate loosening of the prosthesis if they are new or changing, while areas greater than 2 mm may be harmless if they are stable.<sup id="cite_ref-RothMaertz2012_31-0" class="reference"><a href="#cite_note-RothMaertz2012-31">[31]</a></sup> The most important prognostic factors of cemented cups are absence of radiolucent lines in DeLee and Charnley zone I, as well as adequate cement mantle thickness.<sup id="cite_ref-32" class="reference"><a href="#cite_note-32">[32]</a></sup> In the first year after insertion of uncemented femoral stems, it is normal to have mild subsidence (less than 10 mm).<sup id="cite_ref-RothMaertz2012_31-1" class="reference"><a href="#cite_note-RothMaertz2012-31">[31]</a></sup> The direct anterior approach has been shown to itself be a risk factor for early femoral component loosening.<sup id="cite_ref-James_I_2016_33-0" class="reference"><a href="#cite_note-James_I_2016-33">[33]</a></sup><sup id="cite_ref-34" class="reference"><a href="#cite_note-34">[34]</a></sup><sup id="cite_ref-Direct_Anterior_Approach_35-0" class="reference"><a href="#cite_note-Direct_Anterior_Approach-35">[35]</a></sup>
</p>
<h3><span class="mw-headline" id="Metal_sensitivity">Metal sensitivity</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=10" title="Edit section: Metal sensitivity"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>Concerns were raised in the early 2000s regarding metal sensitivity and the potential dangers of metal particulate debris from hip prostheses, including the development of <i>pseudotumors</i>, <a href="/info/en/?search=Soft_tissue" title="Soft tissue">soft tissue</a> masses containing necrotic tissue, around the hip joint. It appears these masses were more common in women, and these patients showed a higher level of iron in the blood. The cause was then unknown, and was probably multifactorial. There may have been a toxic reaction to an excess of particulate metal wear debris or a hypersensitivity reaction to a "normal" amount of metal debris.<sup id="cite_ref-36" class="reference"><a href="#cite_note-36">[36]</a></sup><sup id="cite_ref-37" class="reference"><a href="#cite_note-37">[37]</a></sup>
</p><p>Metal hypersensitivity is a well-established phenomenon and is not uncommon, affecting about 10–15% of the population.<sup id="cite_ref-Hallab01_38-0" class="reference"><a href="#cite_note-Hallab01-38">[38]</a></sup> Skin contact with certain metals can cause immune reactions such as <a href="/info/en/?search=Hives" title="Hives">hives</a>, <a href="/info/en/?search=Eczema" class="mw-redirect" title="Eczema">eczema</a>, redness and itching. Although little is known about the short- and long-term pharmacodynamics and bioavailability of circulating metal degradation products <i>in vivo</i>, there have been many reports of immunologic-type responses temporally associated with implantation of metal components. Individual case reports link immune hypersensitivity reactions with adverse performance of metallic cardiovascular, orthopedic and plastic surgical and dental implants.<sup id="cite_ref-Hallab01_38-1" class="reference"><a href="#cite_note-Hallab01-38">[38]</a></sup>
</p>
<h3><span class="mw-headline" id="Metal_toxicity">Metal toxicity</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=11" title="Edit section: Metal toxicity"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<style data-mw-deduplicate="TemplateStyles:r1033289096">.mw-parser-output .hatnote{font-style:italic}.mw-parser-output div.hatnote{padding-left:1.6em;margin-bottom:0.5em}.mw-parser-output .hatnote i{font-style:normal}.mw-parser-output .hatnote+link+.hatnote{margin-top:-0.5em}</style><div role="note" class="hatnote navigation-not-searchable">Main article: <a href="/info/en/?search=Metallosis" title="Metallosis">Metallosis</a></div>
<p>Most hip replacements consist of cobalt and chromium alloys, or titanium. <a href="/info/en/?search=Stainless_steel" title="Stainless steel">Stainless steel</a> is no longer used. Any metal implant releases its constituent <a href="/info/en/?search=Ions" class="mw-redirect" title="Ions">ions</a> into the blood. Typically, these are excreted in the urine, but in certain individuals the ions can accumulate in the body. In implants which involve metal-on-metal contact, microscopic fragments of <a href="/info/en/?search=Cobalt" title="Cobalt">cobalt</a> and <a href="/info/en/?search=Chromium" title="Chromium">chromium</a> can be absorbed into the person's bloodstream. There are reports of <a href="/info/en/?search=Cobalt_toxicity" class="mw-redirect" title="Cobalt toxicity">cobalt toxicity</a> with hip replacement, particularly metal-on-metal hip replacements, which are no longer in use.<sup id="cite_ref-39" class="reference"><a href="#cite_note-39">[39]</a></sup><sup id="cite_ref-reuters-20120329_40-0" class="reference"><a href="#cite_note-reuters-20120329-40">[40]</a></sup>
</p><p>Use of metal-on-metal hip replacements from the 1970s was discontinued in the 1980s and 1990s, particularly after the discovery of aseptic lymphocyte-dominant vasculitis-associated lesions (ALVAL). However, the <a href="/info/en/?search=Federal_Food,_Drug,_and_Cosmetic_Act#Premarket_notification_.28510.28k.29.2C_PMN.29" title="Federal Food, Drug, and Cosmetic Act">FDA's 510k approval process</a> allowed companies to have new and "improved" metal-on-metal hips approved without much clinical testing.<sup id="cite_ref-41" class="reference"><a href="#cite_note-41">[41]</a></sup> Some people with these prostheses experienced similar reactions to the metal debris as occurred in the 20th century; some devices were recalled.<sup id="cite_ref-42" class="reference"><a href="#cite_note-42">[42]</a></sup><sup id="cite_ref-43" class="reference"><a href="#cite_note-43">[43]</a></sup>
</p>
<h3><span class="mw-headline" id="Nerve_palsy">Nerve palsy</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=12" title="Edit section: Nerve palsy"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>Post operative <a href="/info/en/?search=Sciatic_nerve" title="Sciatic nerve">sciatic nerve</a> palsy is another possible complication. The frequency of this complication is low. <a href="/info/en/?search=Femoral_nerve" title="Femoral nerve">Femoral nerve</a> palsy is another, but much rarer, complication. Both of these will typically resolve over time, but the healing process is slow. Patients with pre-existing nerve injury are at greater risk of experiencing this complication and are also slower to recover.<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">[<i><a href="/info/en/?search=Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (February 2022)">citation needed</span></a></i>]</sup>
</p>
<h3><span class="mw-headline" id="Chronic_pain">Chronic pain</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=13" title="Edit section: Chronic pain"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>A few patients who have had a hip replacement suffer chronic pain after the surgery. Groin pain can develop if the muscle that raises the hip (<a href="/info/en/?search=Iliopsoas" title="Iliopsoas">iliopsoas</a>) rubs against the edge of the acetabular cup. Bursitis can develop at the trochanter where a surgical scar crosses the bone, or if the femoral component used pushes the leg out to the side too far. Also some patients can experience pain in cold or damp weather.<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">[<i><a href="/info/en/?search=Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (October 2012)">citation needed</span></a></i>]</sup> Incision made in the front of the hip (anterior approach) can cut a nerve running down the thigh leading to numbness in the thigh and occasionally chronic pain at the point where the nerve was cut (a neuroma).
</p>
<h3><span class="mw-headline" id="Death">Death</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=14" title="Edit section: Death"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>The rate of <a href="/info/en/?search=Perioperative_mortality" title="Perioperative mortality">perioperative mortality</a> for elective hip replacements is significantly less than 1%.<sup id="cite_ref-44" class="reference"><a href="#cite_note-44">[44]</a></sup><sup id="cite_ref-45" class="reference"><a href="#cite_note-45">[45]</a></sup>
</p>
<h3><span class="mw-headline" id="Metal-on-metal_hip_implant_failure">Metal-on-metal hip implant failure</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=15" title="Edit section: Metal-on-metal hip implant failure"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1033289096"><div role="note" class="hatnote navigation-not-searchable">See also: <a href="/info/en/?search=Implant_failure" title="Implant failure">Implant failure</a></div>
<p>By 2010, reports in the orthopaedic literature increasingly cited the problem of early failure of metal-on-metal prostheses in a small percentage of patients.<sup id="cite_ref-46" class="reference"><a href="#cite_note-46">[46]</a></sup> Failures may have related to the release of minute metallic particles or metal ions from <a href="/info/en/?search=Wear" title="Wear">wear</a> on the implants, causing pain and disability severe enough to require revision surgery in 1–3% of patients.<sup id="cite_ref-47" class="reference"><a href="#cite_note-47">[47]</a></sup> Design deficits of some prothesis models, especially with heat-treated alloys and a lack of specialized surgical experience, accounted for most of the failures. In 2010, surgeons at medical centers such as the <a href="/info/en/?search=Mayo_Clinic" title="Mayo Clinic">Mayo Clinic</a> reported curtailing their use of metal-on-metal implants by 80 percent over the previous year, in favor of those made from other materials, such as combinations of metal and plastic.<sup id="cite_ref-48" class="reference"><a href="#cite_note-48">[48]</a></sup> The cause of these failures remains controversial, and may include both design factors, operative technique factors, and factors related to patient <a href="/info/en/?search=Immune_response" title="Immune response">immune response</a>. In the United Kingdom, the <a href="/info/en/?search=Medicines_and_Healthcare_products_Regulatory_Agency" title="Medicines and Healthcare products Regulatory Agency">Medicines and Healthcare products Regulatory Agency</a> commenced an annual monitoring regime for metal-on-metal hip replacement patients from May 2010.<sup id="cite_ref-49" class="reference"><a href="#cite_note-49">[49]</a></sup> Data which are shown in The Australian Orthopaedic Association's 2008 National <a href="/info/en/?search=Joint_replacement_registry" title="Joint replacement registry">Joint replacement registry</a>, a record of nearly every hip implanted in that country over the previous 10 years, tracked 6,773 BHR (Birmingham Hip Resurfacing) hips and found that less than 0.33% may have been revised due to the patient's reaction to the metal component.<sup id="cite_ref-50" class="reference"><a href="#cite_note-50">[50]</a></sup> Other, similar, metal-on-metal designs have not fared as well, with some reports showing that 76–100% of people with these metal-on-metal implants with aseptic implant failures and needing revision surgery also had histological evidence of inflammation, accompanied by extensive lymphocyte infiltrates characteristic of <a href="/info/en/?search=Delayed-type_hypersensitivity" class="mw-redirect" title="Delayed-type hypersensitivity">delayed-type hypersensitivity</a> reactions.<sup id="cite_ref-51" class="reference"><a href="#cite_note-51">[51]</a></sup> It is not clear to what extent this phenomenon negatively affects orthopedic implant patients. However, for patients presenting with signs of allergic reaction, testing for sensitivity should be conducted. Removal of the device should be considered, since removal may alleviate the symptoms. Patients who have allergic reactions to <a href="/info/en/?search=Metal_alloy" class="mw-redirect" title="Metal alloy">alloy</a> jewelry are more likely to have reactions to orthopedic implants. There is increasing awareness of the phenomenon of metal sensitivity, and many surgeons now take this into account when planning which implant is optimal for each patient.
</p><p>On March 12, 2012, <i><a href="/info/en/?search=The_Lancet" title="The Lancet">The Lancet</a></i> published a study, based on data from the National Joint Registry of England and Wales, finding that metal-on-metal hip implants failed at much higher rates than other types of hip implants, and calling for a ban on all metal-on-metal hip prostheses.<sup id="cite_ref-52" class="reference"><a href="#cite_note-52">[52]</a></sup> The analysis of 402,051 hip replacements showed that 6.2% of metal-on-metal hip implants had failed within five years, compared to 1.7% of metal-on-plastic and 2.3% of ceramic-on-ceramic hip implants. Each 1 mm (0.039 in) increase in head size of metal-on-metal hip implants was associated with a 2% increase in failure rate.<sup id="cite_ref-53" class="reference"><a href="#cite_note-53">[53]</a></sup> Surgeons of the British Hip Society recommended that large head metal-on-metal implants should no longer be implanted.<sup id="cite_ref-54" class="reference"><a href="#cite_note-54">[54]</a></sup><sup id="cite_ref-55" class="reference"><a href="#cite_note-55">[55]</a></sup>
</p><p>On February 10, 2011, the U.S. <a href="/info/en/?search=Food_and_Drug_Administration" title="Food and Drug Administration">FDA</a> issued an advisory on metal-on-metal hip implants, stating it was continuing to gather and review all available information about metal-on-metal hip systems.<sup id="cite_ref-56" class="reference"><a href="#cite_note-56">[56]</a></sup> On June 27–28, 2012, an advisory panel met to decide whether to impose new standards, taking into account findings of the study in <i>The Lancet</i>.<sup id="cite_ref-reuters-20120329_40-1" class="reference"><a href="#cite_note-reuters-20120329-40">[40]</a></sup><sup id="cite_ref-57" class="reference"><a href="#cite_note-57">[57]</a></sup><sup id="cite_ref-FDA-summary-memo_58-0" class="reference"><a href="#cite_note-FDA-summary-memo-58">[58]</a></sup> No new standards, such as routine checking of blood levels of metal ions, were set, but guidance was updated.<sup id="cite_ref-59" class="reference"><a href="#cite_note-59">[59]</a></sup> The U.S. FDA does not require hip implants to be tested in clinical trials before they can be sold in the U.S.<sup id="cite_ref-60" class="reference"><a href="#cite_note-60">[60]</a></sup> Instead, companies making new hip implants only need to prove that they are "substantially equivalent" to other hip implants already on the market. The exception is metal-on-metal implants, which were not tested in clinical trials, but, due to the high revision rate of metal-on-metal hips, the FDA has stated that, in the future, clinical trials will be required for approval, and that post-market studies will be required to keep metal-on-metal hip implants on the market.<sup id="cite_ref-61" class="reference"><a href="#cite_note-61">[61]</a></sup>
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<h2><span class="mw-headline" id="Modern_process">Modern process</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=16" title="Edit section: Modern process"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h2>
<figure class="mw-default-size" typeof="mw:File/Thumb"><a href="/info/en/?search=File:Hip_Prosthesis.gif" class="mw-file-description"><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/9/9c/Hip_Prosthesis.gif/220px-Hip_Prosthesis.gif" decoding="async" width="220" height="220" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/9/9c/Hip_Prosthesis.gif/330px-Hip_Prosthesis.gif 1.5x, //upload.wikimedia.org/wikipedia/commons/9/9c/Hip_Prosthesis.gif 2x" data-file-width="346" data-file-height="346" /></a><figcaption>Hip prosthesis 3D model</figcaption></figure>
<figure class="mw-default-size" typeof="mw:File/Thumb"><a href="/info/en/?search=File:Hip_Prostesis.png" class="mw-file-description"><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/a/a5/Hip_Prostesis.png/220px-Hip_Prostesis.png" decoding="async" width="220" height="220" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/a/a5/Hip_Prostesis.png/330px-Hip_Prostesis.png 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/a/a5/Hip_Prostesis.png/440px-Hip_Prostesis.png 2x" data-file-width="800" data-file-height="800" /></a><figcaption>Different parts of hip prosthesis</figcaption></figure>
<figure class="mw-default-size" typeof="mw:File/Thumb"><a href="/info/en/?search=File:Hip_prosthesis.jpg" class="mw-file-description"><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/0/0a/Hip_prosthesis.jpg/220px-Hip_prosthesis.jpg" decoding="async" width="220" height="165" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/0/0a/Hip_prosthesis.jpg/330px-Hip_prosthesis.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/0/0a/Hip_prosthesis.jpg/440px-Hip_prosthesis.jpg 2x" data-file-width="2592" data-file-height="1944" /></a><figcaption>A <a href="/info/en/?search=Titanium" title="Titanium">titanium</a> hip prosthesis, with a <a href="/info/en/?search=Ceramic" title="Ceramic">ceramic</a> head and <a href="/info/en/?search=Polyethylene" title="Polyethylene">polyethylene</a> acetabular cup</figcaption></figure>
<p>The modern artificial joint owes much to the 1962 work of Sir <a href="/info/en/?search=John_Charnley" title="John Charnley">John Charnley</a> at Wrightington Hospital in the United Kingdom. His work in the field of <a href="/info/en/?search=Tribology" title="Tribology">tribology</a> resulted in a design that almost completely replaced the other designs by the 1970s. Charnley's design consisted of three parts:
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<ol><li><a href="/info/en/?search=Stainless_Steel" class="mw-redirect" title="Stainless Steel">stainless steel</a> one-piece femoral stem and head</li>
<li><a href="/info/en/?search=Polyethylene" title="Polyethylene">polyethylene</a> (originally <a href="/info/en/?search=Teflon" class="mw-redirect" title="Teflon">Teflon</a>), acetabular component, both of which were fixed to the bone using</li>
<li><a href="/info/en/?search=Poly(methyl_methacrylate)" title="Poly(methyl methacrylate)">PMMA</a> (acrylic) <a href="/info/en/?search=Bone_cement" title="Bone cement">bone cement</a></li></ol>
<p>The replacement joint, which was known as the Low Friction <a href="/info/en/?search=Arthroplasty" title="Arthroplasty">Arthroplasty</a>, was lubricated with <a href="/info/en/?search=Synovial_fluid" title="Synovial fluid">synovial fluid</a>. The small femoral head (<style data-mw-deduplicate="TemplateStyles:r1154941027">.mw-parser-output .frac{white-space:nowrap}.mw-parser-output .frac .num,.mw-parser-output .frac .den{font-size:80%;line-height:0;vertical-align:super}.mw-parser-output .frac .den{vertical-align:sub}.mw-parser-output .sr-only{border:0;clip:rect(0,0,0,0);clip-path:polygon(0px 0px,0px 0px,0px 0px);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px}</style><span class="frac"><span class="num">7</span>⁄<span class="den">8</span></span> in (22.2 mm)) was chosen for Charnley's belief that it would have lower friction against the acetabular component and thus wear out the acetabulum more slowly. Unfortunately, the smaller head dislocated more easily. Alternative designs with larger heads such as the Mueller prosthesis were proposed. Stability was improved, but acetabular wear and subsequent failure rates were increased with these designs. The Teflon acetabular components of Charnley's early designs failed within a year or two of implantation. This prompted a search for a more suitable material. A German salesman showed a polyethylene gear sample to Charnley's machinist, sparking the idea to use this material for the acetabular component. The <a href="/info/en/?search=Ultra-high-molecular-weight_polyethylene" title="Ultra-high-molecular-weight polyethylene">UHMWPE</a> acetabular component was introduced in 1962. Charnley's other major contribution was to use polymethylmethacrylate (PMMA) bone cement to attach the two components to the bone. For over two decades, the Charnley Low Friction Arthroplasty, and derivative designs were the most used systems in the world. It formed the basis for all modern hip implants. An example can be seen at the Science Museum, London.<sup id="cite_ref-62" class="reference"><a href="#cite_note-62">[62]</a></sup>
</p><p>The Exeter hip stem was developed in the United Kingdom during the same time as the Charnley device. Its development occurred following a collaboration between Orthopaedic Surgeon <a href="/info/en/?search=Robin_Ling" title="Robin Ling">Robin Ling</a> and <a href="/info/en/?search=University_of_Exeter" title="University of Exeter">University of Exeter</a> engineer <a href="/info/en/?search=Clive_Lee" title="Clive Lee">Clive Lee</a> and it was first implanted at the Princess Elizabeth Orthopaedic Hospital in Exeter in 1970.<sup id="cite_ref-63" class="reference"><a href="#cite_note-63">[63]</a></sup> The Exeter Hip is a cemented device, but with a slightly different stem geometry. Both designs have shown excellent long-term durability when properly placed and are still widely used in slightly modified versions.
</p><p>Early implant designs had the potential to loosen from their attachment to the bones, typically becoming painful ten to twelve years after placement. In addition, erosion of the bone around the implant was seen on x-rays. Initially, surgeons believed this was caused by an abnormal reaction to the cement holding the implant in place. That belief prompted a search for an alternative method to attach the implants. The Austin Moore device had a small hole in the stem into which bone graft was placed before implanting the stem. It was hoped bone would then grow through the window over time and hold the stem in position. Success was unpredictable and the fixation not very robust. In the early 1980s, surgeons in the United States applied a coating of small beads to the Austin Moore device and implanted it without cement. The beads were constructed so that gaps between beads matched the size of the pores in native bone. Over time, bone cells from the patient would grow into these spaces and fix the stem in position. The stem was modified slightly to fit more tightly into the femoral canal, resulting in the Anatomic Medullary Locking (AML) stem design. With time, other forms of stem surface treatment and stem geometry have been developed and improved.
</p><p>Initial hip designs were made of a one-piece femoral component and a one-piece acetabular component. Current designs have a femoral stem and separate head piece. Using an independent head allows the surgeon to adjust leg length (some heads seat more or less onto the stem) and to select from various materials from which the head is formed. A modern acetabulum component is also made up of two parts: a metal shell with a coating for bone attachment and a separate liner. First the shell is placed. Its position can be adjusted, unlike the original cemented cup design which are fixed in place once the cement sets. When proper positioning of the metal shell is obtained, the surgeon may select a liner made from various materials.
</p><p>To combat loosening caused by polyethylene wear debris, hip manufacturers developed improved and novel materials for the acetabular liners. <a href="/info/en/?search=Ceramic" title="Ceramic">Ceramic</a> heads mated with regular polyethylene liners or a ceramic liner were the first significant alternative. Metal liners to mate with a metal head were also developed. At the same time these designs were being developed, the problems that caused polyethylene wear were determined and manufacturing of this material improved. Highly crosslinked UHMWPE was introduced in the late 1990s. The most recent data comparing the various bearing surfaces has shown no clinically significant differences in their performance. Potential early problems with each material are discussed below. Performance data after 20 or 30 years may be needed to demonstrate significant differences in the devices. All newer materials allow use of larger diameter femoral heads. Use of larger heads significantly decreases the chance of the hip dislocating, which remains the greatest complication of the surgery.
</p><p>When available implants are used, cemented stems tend to have a better longevity than uncemented stems. No significant difference is observed in the clinical performance of the various methods of surface treatment of uncemented devices. Uncemented stems are selected for patients with good quality bone that can resist the forces needed to drive the stem in tightly. Cemented devices are typically selected for patients with poor quality bone who are at risk of fracture during stem insertion. Cemented stems are less expensive due to lower manufacturing cost, but require good surgical technique to place them correctly. Uncemented stems can cause pain with activity in up to 20% of patients during the first year after placement as the bone adapts to the device. This is rarely seen with cemented stems.<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">[<i><a href="/info/en/?search=Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (March 2024)">citation needed</span></a></i>]</sup>
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<h2><span class="mw-headline" id="Techniques">Techniques</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=17" title="Edit section: Techniques"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h2>
<p>There are several incisions, defined by their relation to the gluteus medius. The approaches are posterior (Moore), lateral (Hardinge or Liverpool),<sup id="cite_ref-pmid9498150_64-0" class="reference"><a href="#cite_note-pmid9498150-64">[64]</a></sup> antero-lateral (Watson-Jones),<sup id="cite_ref-titleAnterolateral_Approach_to_Hip_Joint:_(Watson_Jones)_-_Wheeless'_Textbook_of_Orthopaedics_65-0" class="reference"><a href="#cite_note-titleAnterolateral_Approach_to_Hip_Joint:_(Watson_Jones)_-_Wheeless'_Textbook_of_Orthopaedics-65">[65]</a></sup> anterior (Smith-Petersen)<sup id="cite_ref-titleAnterior_Approach_to_the_Hip_(Smith_Petersen)_–_Wheeless'_Textbook_of_Orthopaedics_66-0" class="reference"><a href="#cite_note-titleAnterior_Approach_to_the_Hip_(Smith_Petersen)_–_Wheeless'_Textbook_of_Orthopaedics-66">[66]</a></sup> and <a href="/info/en/?search=Greater_trochanter" title="Greater trochanter">greater trochanter</a> osteotomy. There is no compelling evidence in the literature for any particular approach.
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<h3><span class="mw-headline" id="Posterior_approach">Posterior approach</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=18" title="Edit section: Posterior approach"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>The <i>posterior</i> (<i>Moore</i> or <i>Southern</i>) <i>approach</i> accesses the joint and capsule through the back, taking <a href="/info/en/?search=Piriformis_muscle" title="Piriformis muscle">piriformis muscle</a> and the short external rotators of the femur. This approach gives excellent access to the acetabulum and femur and preserves the hip <a href="/info/en/?search=Abduction_(kinesiology)" class="mw-redirect" title="Abduction (kinesiology)">abductors</a> and thus minimizes the risk of abductor dysfunction post operatively. It has the advantage of becoming a more extensile approach if needed. Critics cite a higher dislocation rate, although repair of the capsule, piriformis and the short external rotators along with use of modern large diameter head balls reduces this risk. Limited evidence suggests that the posterior approach may cause less nerve damage.<sup id="cite_ref-67" class="reference"><a href="#cite_note-67">[67]</a></sup>
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<h3><span class="mw-headline" id="Lateral_approach">Lateral approach</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=19" title="Edit section: Lateral approach"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>The <i>lateral approach</i> is also commonly used for hip replacement. The approach requires elevation of the hip abductors (<a href="/info/en/?search=Gluteus_medius" title="Gluteus medius">gluteus medius</a> and <a href="/info/en/?search=Gluteus_minimus" title="Gluteus minimus">gluteus minimus</a>) to access the joint. The abductors may be lifted up by osteotomy of the greater trochanter and reapplying it afterwards using wires (as per Charnley),<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">[<i><a href="/info/en/?search=Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (December 2007)">citation needed</span></a></i>]</sup> or may be divided at their tendinous portion, or through the functional tendon (as per Hardinge) and repaired using <a href="/info/en/?search=Surgical_suture" title="Surgical suture">sutures</a>. Although this approach has a lower dislocation risk than the posterior approach, critics note that occasionally the abductor muscles do not heal back on, leading to pain and weakness which is often very difficult to treat.
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<h3><span class="mw-headline" id="Antero-lateral_approach">Antero-lateral approach</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=20" title="Edit section: Antero-lateral approach"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>The <i>anterolateral approach</i> develops the interval between the <a href="/info/en/?search=Tensor_fasciae_latae" class="mw-redirect" title="Tensor fasciae latae">tensor fasciae latae</a> and the gluteus medius. The Gluteus medius, gluteus minimus and hip capsule are detached from the anterior (front) for the greater trochanter and femoral neck and then repaired with heavy suture after the replacement of the joint.
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<h3><span class="mw-headline" id="Anterior_approach">Anterior approach</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=21" title="Edit section: Anterior approach"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>The <i>anterior approach</i> uses an interval between the <a href="/info/en/?search=Sartorius_muscle" title="Sartorius muscle">sartorius muscle</a> and tensor fasciae latae. This approach, which was commonly used for pelvic fracture repair surgery, has been adapted for use when performing hip replacement. When used with older hip implant systems that had a small diameter head, dislocation rates were reduced compared to surgery performed through a posterior approach. With modern implant designs, dislocation rates are similar between the anterior and posterior approaches.<sup id="cite_ref-68" class="reference"><a href="#cite_note-68">[68]</a></sup> The anterior approach has been shown in studies to variably improve early functional recovery, with possible complications of femoral component loosening and early revision compared to other approaches.<sup id="cite_ref-Direct_Anterior_Approach_35-1" class="reference"><a href="#cite_note-Direct_Anterior_Approach-35">[35]</a></sup><sup id="cite_ref-James_I_2016_33-1" class="reference"><a href="#cite_note-James_I_2016-33">[33]</a></sup><sup id="cite_ref-69" class="reference"><a href="#cite_note-69">[69]</a></sup><sup id="cite_ref-70" class="reference"><a href="#cite_note-70">[70]</a></sup><sup id="cite_ref-71" class="reference"><a href="#cite_note-71">[71]</a></sup><sup id="cite_ref-72" class="reference"><a href="#cite_note-72">[72]</a></sup>
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<h3><span class="mw-headline" id="Minimally_invasive_approaches">Minimally invasive approaches</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=22" title="Edit section: Minimally invasive approaches"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>The dual incision approach and other minimally invasive surgery seeks to reduce soft tissue damage through reducing the size of the incision. However, component positioning accuracy and visualization of the bone structures can be significantly impaired as the approaches get smaller. This can result in unintended fractures and soft tissue injury. The majority of current orthopedic surgeons use a "minimally invasive" approach compared to traditional approaches which were quite large comparatively.
</p><p><a href="/info/en/?search=Computer-assisted_surgery" title="Computer-assisted surgery">Computer-assisted surgery</a> and robotic surgery techniques are also available to guide the surgeon to provide enhanced component accuracy.<sup id="cite_ref-73" class="reference"><a href="#cite_note-73">[73]</a></sup> Several commercial CAS and robotic systems are available for use worldwide. Improved patient outcomes and reduced complications have not been demonstrated when these systems are used when compared to standard techniques.<sup id="cite_ref-74" class="reference"><a href="#cite_note-74">[74]</a></sup><sup id="cite_ref-75" class="reference"><a href="#cite_note-75">[75]</a></sup>
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<h2><span class="mw-headline" id="Implants">Implants</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=23" title="Edit section: Implants"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h2>
<figure class="mw-default-size" typeof="mw:File/Thumb"><a href="/info/en/?search=File:MetalonmetalhipreplaceMark.png" class="mw-file-description"><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/3/33/MetalonmetalhipreplaceMark.png/220px-MetalonmetalhipreplaceMark.png" decoding="async" width="220" height="183" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/3/33/MetalonmetalhipreplaceMark.png/330px-MetalonmetalhipreplaceMark.png 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/3/33/MetalonmetalhipreplaceMark.png/440px-MetalonmetalhipreplaceMark.png 2x" data-file-width="954" data-file-height="792" /></a><figcaption>Metal on metal prosthetic hip</figcaption></figure>
<figure class="mw-default-size" typeof="mw:File/Thumb"><a href="/info/en/?search=File:Hip-replacement.jpg" class="mw-file-description"><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/f/f8/Hip-replacement.jpg/170px-Hip-replacement.jpg" decoding="async" width="170" height="294" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/f/f8/Hip-replacement.jpg/255px-Hip-replacement.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/f/f8/Hip-replacement.jpg/340px-Hip-replacement.jpg 2x" data-file-width="1020" data-file-height="1761" /></a><figcaption>Cement-free implant sixteen days after surgery. Femoral component is cobalt chromium combined with titanium which induces bone growth into the implant. Ceramic head. Acetabular cup coated with bone growth-inducing material and held temporarily in place with a single screw.</figcaption></figure>
<p>The prosthetic implant used in hip replacement consists of three parts: the acetabular cup, the femoral component, and the articular interface. Options exist for different people and indications. The evidence for a number of newer devices is not very good, including: ceramic-on-ceramic bearings, modular femoral necks, and uncemented monoblock cups.<sup id="cite_ref-76" class="reference"><a href="#cite_note-76">[76]</a></sup> Correct selection of the prosthesis is important.
</p>
<h3><span class="mw-headline" id="Acetabular_cup">Acetabular cup</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=24" title="Edit section: Acetabular cup"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>The acetabular cup is the component which is placed into the <a href="/info/en/?search=Acetabulum" title="Acetabulum">acetabulum</a> (hip socket). Cartilage and bone are removed from the acetabulum and the acetabular cup is attached using friction or cement. Some acetabular cups are one piece, while others are modular. One-piece (monobloc) shells are either <a href="/info/en/?search=Ultra-high-molecular-weight_polyethylene" title="Ultra-high-molecular-weight polyethylene">ultra-high-molecular-weight polyethylene</a> (UHMWPE) or metal, they have their articular surface machined on the inside surface of the cup and do not rely on a locking mechanism to hold a liner in place. A monobloc polyethylene cup is cemented in place while a metal cup is held in place by a metal coating on the outside of the cup. Modular cups consist of two pieces, a shell and liner. The shell is made of metal; the outside has a porous coating while the inside contains a locking mechanism designed to accept a liner. Two types of porous coating used to form a friction fit are <a href="/info/en/?search=Sintering" title="Sintering">sintered</a> beads and a <a href="/info/en/?search=Foam_metal" class="mw-redirect" title="Foam metal">foam metal</a> design to mimic the trabeculae of cancellous bone and initial stability is influenced by under-reaming and insertion force.<sup id="cite_ref-Amirouche_77-0" class="reference"><a href="#cite_note-Amirouche-77">[77]</a></sup> Permanent fixation is achieved as bone grows onto or into the porous coating. Screws can be used to lag the shell to the bone providing even more fixation. Polyethylene liners are placed into the shell and connected by a rim locking mechanism; ceramic and metal liners are attached with a <a href="/info/en/?search=Morse_taper" class="mw-redirect" title="Morse taper">Morse taper</a>.<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">[<i><a href="/info/en/?search=Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (July 2012)">citation needed</span></a></i>]</sup>
</p>
<h3><span class="mw-headline" id="Femoral_component">Femoral component</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=25" title="Edit section: Femoral component"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<style data-mw-deduplicate="TemplateStyles:r1097763485">.mw-parser-output .ambox{border:1px solid #a2a9b1;border-left:10px solid #36c;background-color:#fbfbfb;box-sizing:border-box}.mw-parser-output .ambox+link+.ambox,.mw-parser-output .ambox+link+style+.ambox,.mw-parser-output .ambox+link+link+.ambox,.mw-parser-output .ambox+.mw-empty-elt+link+.ambox,.mw-parser-output .ambox+.mw-empty-elt+link+style+.ambox,.mw-parser-output .ambox+.mw-empty-elt+link+link+.ambox{margin-top:-1px}html body.mediawiki .mw-parser-output .ambox.mbox-small-left{margin:4px 1em 4px 0;overflow:hidden;width:238px;border-collapse:collapse;font-size:88%;line-height:1.25em}.mw-parser-output .ambox-speedy{border-left:10px solid #b32424;background-color:#fee7e6}.mw-parser-output .ambox-delete{border-left:10px solid #b32424}.mw-parser-output .ambox-content{border-left:10px solid #f28500}.mw-parser-output .ambox-style{border-left:10px solid #fc3}.mw-parser-output .ambox-move{border-left:10px solid #9932cc}.mw-parser-output .ambox-protection{border-left:10px solid #a2a9b1}.mw-parser-output .ambox .mbox-text{border:none;padding:0.25em 0.5em;width:100%}.mw-parser-output .ambox .mbox-image{border:none;padding:2px 0 2px 0.5em;text-align:center}.mw-parser-output .ambox .mbox-imageright{border:none;padding:2px 0.5em 2px 0;text-align:center}.mw-parser-output .ambox .mbox-empty-cell{border:none;padding:0;width:1px}.mw-parser-output .ambox .mbox-image-div{width:52px}html.client-js body.skin-minerva .mw-parser-output .mbox-text-span{margin-left:23px!important}@media(min-width:720px){.mw-parser-output .ambox{margin:0 10%}}</style><table class="box-Original_research plainlinks metadata ambox ambox-content ambox-Original_research" role="presentation"><tbody><tr><td class="mbox-image"><div class="mbox-image-div"><span typeof="mw:File"><span><img alt="" src="https://upload.wikimedia.org/wikipedia/en/thumb/b/b4/Ambox_important.svg/40px-Ambox_important.svg.png" decoding="async" width="40" height="40" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/en/thumb/b/b4/Ambox_important.svg/60px-Ambox_important.svg.png 1.5x, //upload.wikimedia.org/wikipedia/en/thumb/b/b4/Ambox_important.svg/80px-Ambox_important.svg.png 2x" data-file-width="40" data-file-height="40" /></span></span></div></td><td class="mbox-text"><div class="mbox-text-span">This section <b>possibly contains <a href="/info/en/?search=Wikipedia:No_original_research" title="Wikipedia:No original research">original research</a></b>.<span class="hide-when-compact"> Please <a class="external text" href="https://en.wikipedia.org/?title=Hip_replacement&action=edit">improve it</a> by <a href="/info/en/?search=Wikipedia:Verifiability" title="Wikipedia:Verifiability">verifying</a> the claims made and adding <a href="/info/en/?search=Wikipedia:Citing_sources#Inline_citations" title="Wikipedia:Citing sources">inline citations</a>. Statements consisting only of original research should be removed.</span> <span class="date-container"><i>(<span class="date">April 2016</span>)</i></span><span class="hide-when-compact"><i> (<small><a href="/info/en/?search=Help:Maintenance_template_removal" title="Help:Maintenance template removal">Learn how and when to remove this template message</a></small>)</i></span></div></td></tr></tbody></table><p>The femoral component is the component that fits in the <a href="/info/en/?search=Femur" title="Femur">femur</a> (thigh bone). Bone is removed and the femur is shaped to accept the femoral stem with attached prosthetic femoral head (ball). There are two types of fixation: cemented and uncemented. Cemented stems use acrylic <a href="/info/en/?search=Bone_cement" title="Bone cement">bone cement</a> to form a mantle between the stem and to the bone. Uncemented stems use friction, shape and surface coatings to stimulate bone to remodel and bond to the implant. Stems are made of multiple materials (titanium, cobalt chromium, stainless steel, and polymer composites) and they can be monolithic or modular. Modular components consist of different head dimensions and/or modular neck orientations; these attach via a taper similar to a <a href="/info/en/?search=Morse_taper" class="mw-redirect" title="Morse taper">Morse taper</a>. These options allow for variability in leg length, offset and version. Femoral heads are made of metal or ceramic material. Metal heads, made of cobalt chromium for hardness, are machined to size and then polished to reduce wear of the socket liner. Ceramic heads are more smooth than polished metal heads, have a lower coefficient of friction than a cobalt chrome head, and in theory will wear down the socket liner more slowly. As of early 2011, follow-up studies in patients have not demonstrated significant reductions in wear rates between the various types of femoral heads on the market. Ceramic implants are more brittle and may break after being implanted.
</p><h3><span class="mw-headline" id="Articular_interface">Articular interface</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=26" title="Edit section: Articular interface"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1097763485"><table class="box-Original_research plainlinks metadata ambox ambox-content ambox-Original_research" role="presentation"><tbody><tr><td class="mbox-image"><div class="mbox-image-div"><span typeof="mw:File"><span><img alt="" src="https://upload.wikimedia.org/wikipedia/en/thumb/b/b4/Ambox_important.svg/40px-Ambox_important.svg.png" decoding="async" width="40" height="40" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/en/thumb/b/b4/Ambox_important.svg/60px-Ambox_important.svg.png 1.5x, //upload.wikimedia.org/wikipedia/en/thumb/b/b4/Ambox_important.svg/80px-Ambox_important.svg.png 2x" data-file-width="40" data-file-height="40" /></span></span></div></td><td class="mbox-text"><div class="mbox-text-span">This section <b>possibly contains <a href="/info/en/?search=Wikipedia:No_original_research" title="Wikipedia:No original research">original research</a></b>.<span class="hide-when-compact"> Please <a class="external text" href="https://en.wikipedia.org/?title=Hip_replacement&action=edit">improve it</a> by <a href="/info/en/?search=Wikipedia:Verifiability" title="Wikipedia:Verifiability">verifying</a> the claims made and adding <a href="/info/en/?search=Wikipedia:Citing_sources#Inline_citations" title="Wikipedia:Citing sources">inline citations</a>. Statements consisting only of original research should be removed.</span> <span class="date-container"><i>(<span class="date">April 2016</span>)</i></span><span class="hide-when-compact"><i> (<small><a href="/info/en/?search=Help:Maintenance_template_removal" title="Help:Maintenance template removal">Learn how and when to remove this template message</a></small>)</i></span></div></td></tr></tbody></table><p>The articular interface is not part of either implant, rather it is the area between the acetabular cup and femoral component. The articular interface of the hip is a simple ball and socket joint. Size, material properties and machining <a href="/info/en/?search=Engineering_tolerance" title="Engineering tolerance">tolerances</a> at the articular interface can be selected based on patient demand to optimise implant function and longevity whilst mitigating associated risks. The interface size is measured by the outside diameter of the head or the inside diameter of the socket. Common sizes of femoral heads are 28 mm (1.1 in), 32 mm (1.3 in) and 36 mm (1.4 in). While <link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1154941027">22.25 mm (<span class="frac"><span class="num">7</span>⁄<span class="den">8</span></span> in) was common in the first modern prostheses, now even larger sizes are available from 38 to over 54 mm. Larger-diameter heads lead to increased stability and range of motion whilst lowering the risk of dislocation. At the same time they are also subject to higher stresses such as friction and inertia. Different combinations of materials have different physical properties which can be coupled to reduce the amount of wear debris generated by friction. Typical pairings of materials include metal on polyethylene (MOP), metal on crosslinked polyethylene (MOXP), ceramic on ceramic (COC), ceramic on crosslinked polyethylene (COXP), and metal on metal (MOM). Each combination has different advantages and disadvantages.
</p><p>Dual mobility hip replacements reduce the risk of dislocation.<sup id="cite_ref-Dual_mobility_total_hip_arthroplast_78-0" class="reference"><a href="#cite_note-Dual_mobility_total_hip_arthroplast-78">[78]</a></sup><sup id="cite_ref-79" class="reference"><a href="#cite_note-79">[79]</a></sup>
</p>
<h2><span class="mw-headline" id="Configuration">Configuration</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=27" title="Edit section: Configuration"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h2>
<p>Post-operative <a href="/info/en/?search=Projectional_radiography" title="Projectional radiography">projectional radiography</a> is routinely performed to ensure proper configuration of hip prostheses.
</p><p>The direction of the acetabular cup influences the range of motion of the leg, and also affects the risk of dislocation.<sup id="cite_ref-Watt_9-1" class="reference"><a href="#cite_note-Watt-9">[9]</a></sup> For this purpose, the <i>acetabular inclination</i> and the <i>acetabular anteversion</i> are measurements of cup angulation in the <a href="/info/en/?search=Coronal_plane" title="Coronal plane">coronal plane</a> and the <a href="/info/en/?search=Sagittal_plane" title="Sagittal plane">sagittal plane</a>, respectively.
</p>
<ul class="gallery mw-gallery-traditional">
<li class="gallerybox" style="width: 265px">
<div class="thumb" style="width: 260px; height: 150px;"><span typeof="mw:File"><a href="/info/en/?search=File:Acetabular_inclination_of_hip_prosthesis.jpg" class="mw-file-description" title="Acetabular inclination.[80] This parameter is calculated on an anteroposterior radiograph as the angle between a line through the lateral and medial margins of the acetabular cup and the transischial line which is tangential to the inferior margins of the ischium bones.[80]"><img alt="Acetabular inclination.[80] This parameter is calculated on an anteroposterior radiograph as the angle between a line through the lateral and medial margins of the acetabular cup and the transischial line which is tangential to the inferior margins of the ischium bones.[80]" src="https://upload.wikimedia.org/wikipedia/commons/thumb/9/92/Acetabular_inclination_of_hip_prosthesis.jpg/230px-Acetabular_inclination_of_hip_prosthesis.jpg" decoding="async" width="230" height="110" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/9/92/Acetabular_inclination_of_hip_prosthesis.jpg/345px-Acetabular_inclination_of_hip_prosthesis.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/9/92/Acetabular_inclination_of_hip_prosthesis.jpg/460px-Acetabular_inclination_of_hip_prosthesis.jpg 2x" data-file-width="2900" data-file-height="1388" /></a></span></div>
<div class="gallerytext">Acetabular inclination.<sup id="cite_ref-Vanrusselt2015_80-0" class="reference"><a href="#cite_note-Vanrusselt2015-80">[80]</a></sup> This parameter is calculated on an anteroposterior radiograph as the angle between a line through the lateral and medial margins of the acetabular cup and the <i>transischial line</i> which is tangential to the inferior margins of the <a href="/info/en/?search=Ischium" title="Ischium">ischium</a> bones.<sup id="cite_ref-Vanrusselt2015_80-1" class="reference"><a href="#cite_note-Vanrusselt2015-80">[80]</a></sup></div>
</li>
<li class="gallerybox" style="width: 265px">
<div class="thumb" style="width: 260px; height: 150px;"><span typeof="mw:File"><a href="/info/en/?search=File:Range_of_acetabular_inclination.png" class="mw-file-description" title="Acetabular inclination is normally between 30 and 50°.[80] A larger angle increases the risk of dislocation.[9]"><img alt="Acetabular inclination is normally between 30 and 50°.[80] A larger angle increases the risk of dislocation.[9]" src="https://upload.wikimedia.org/wikipedia/commons/thumb/9/91/Range_of_acetabular_inclination.png/230px-Range_of_acetabular_inclination.png" decoding="async" width="230" height="103" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/9/91/Range_of_acetabular_inclination.png/345px-Range_of_acetabular_inclination.png 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/9/91/Range_of_acetabular_inclination.png/460px-Range_of_acetabular_inclination.png 2x" data-file-width="1523" data-file-height="684" /></a></span></div>
<div class="gallerytext">Acetabular inclination is normally between 30 and 50°.<sup id="cite_ref-Vanrusselt2015_80-2" class="reference"><a href="#cite_note-Vanrusselt2015-80">[80]</a></sup> A larger angle increases the risk of dislocation.<sup id="cite_ref-Watt_9-2" class="reference"><a href="#cite_note-Watt-9">[9]</a></sup></div>
</li>
<li class="gallerybox" style="width: 265px">
<div class="thumb" style="width: 260px; height: 150px;"><span typeof="mw:File"><a href="/info/en/?search=File:Acetabular_anteversion_of_hip_prosthesis.jpg" class="mw-file-description" title="Acetabular anteversion.[81] This parameter is calculated on a lateral radiograph as the angle between the transverse plane and a line going through the (anterior and posterior) margins of the acetabular cup.[81]"><img alt="Acetabular anteversion.[81] This parameter is calculated on a lateral radiograph as the angle between the transverse plane and a line going through the (anterior and posterior) margins of the acetabular cup.[81]" src="https://upload.wikimedia.org/wikipedia/commons/thumb/2/28/Acetabular_anteversion_of_hip_prosthesis.jpg/104px-Acetabular_anteversion_of_hip_prosthesis.jpg" decoding="async" width="104" height="120" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/2/28/Acetabular_anteversion_of_hip_prosthesis.jpg/156px-Acetabular_anteversion_of_hip_prosthesis.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/2/28/Acetabular_anteversion_of_hip_prosthesis.jpg/208px-Acetabular_anteversion_of_hip_prosthesis.jpg 2x" data-file-width="2361" data-file-height="2721" /></a></span></div>
<div class="gallerytext">Acetabular anteversion.<sup id="cite_ref-ShinLee2015_81-0" class="reference"><a href="#cite_note-ShinLee2015-81">[81]</a></sup> This parameter is calculated on a lateral radiograph as the angle between the <a href="/info/en/?search=Transverse_plane" title="Transverse plane">transverse plane</a> and a line going through the (anterior and posterior) margins of the acetabular cup.<sup id="cite_ref-ShinLee2015_81-1" class="reference"><a href="#cite_note-ShinLee2015-81">[81]</a></sup></div>
</li>
<li class="gallerybox" style="width: 265px">
<div class="thumb" style="width: 260px; height: 150px;"><span typeof="mw:File"><a href="/info/en/?search=File:Range_of_acetabular_anteversion.png" class="mw-file-description" title="Acetabular anteversion is normally between 5 and 25°.[9] An anteversion below or above this range increases the risk of dislocation.[9] There is an intra-individual variability in this method because the pelvis may be tilted in various degrees in relation to the transverse plane.[9]"><img alt="Acetabular anteversion is normally between 5 and 25°.[9] An anteversion below or above this range increases the risk of dislocation.[9] There is an intra-individual variability in this method because the pelvis may be tilted in various degrees in relation to the transverse plane.[9]" src="https://upload.wikimedia.org/wikipedia/commons/thumb/1/1f/Range_of_acetabular_anteversion.png/230px-Range_of_acetabular_anteversion.png" decoding="async" width="230" height="106" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/1/1f/Range_of_acetabular_anteversion.png/345px-Range_of_acetabular_anteversion.png 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/1/1f/Range_of_acetabular_anteversion.png/460px-Range_of_acetabular_anteversion.png 2x" data-file-width="1361" data-file-height="625" /></a></span></div>
<div class="gallerytext">Acetabular anteversion is normally between 5 and 25°.<sup id="cite_ref-Watt_9-3" class="reference"><a href="#cite_note-Watt-9">[9]</a></sup> An anteversion below or above this range increases the risk of dislocation.<sup id="cite_ref-Watt_9-4" class="reference"><a href="#cite_note-Watt-9">[9]</a></sup> There is an <a href="/info/en/?search=Intra-individual_variability" class="mw-redirect" title="Intra-individual variability">intra-individual variability</a> in this method because the pelvis may be tilted in various degrees in relation to the transverse plane.<sup id="cite_ref-Watt_9-5" class="reference"><a href="#cite_note-Watt-9">[9]</a></sup></div>
</li>
<li class="gallerybox" style="width: 265px">
<div class="thumb" style="width: 260px; height: 150px;"><span typeof="mw:File"><a href="/info/en/?search=File:Leg_length_discrepancy_after_hip_replacement.jpg" class="mw-file-description" title="Leg length discrepancy after hip replacement is calculated as the vertical distance between the middle of the minor trochanters, using the acetabular tear drops[80] or the transischial line[9] as references for the horizontal plane. A discrepancy of up to 1 cm is generally tolerated.[80][9]"><img alt="Leg length discrepancy after hip replacement is calculated as the vertical distance between the middle of the minor trochanters, using the acetabular tear drops[80] or the transischial line[9] as references for the horizontal plane. A discrepancy of up to 1 cm is generally tolerated.[80][9]" src="https://upload.wikimedia.org/wikipedia/commons/thumb/d/d7/Leg_length_discrepancy_after_hip_replacement.jpg/230px-Leg_length_discrepancy_after_hip_replacement.jpg" decoding="async" width="230" height="93" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/d/d7/Leg_length_discrepancy_after_hip_replacement.jpg/345px-Leg_length_discrepancy_after_hip_replacement.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/d/d7/Leg_length_discrepancy_after_hip_replacement.jpg/460px-Leg_length_discrepancy_after_hip_replacement.jpg 2x" data-file-width="2355" data-file-height="955" /></a></span></div>
<div class="gallerytext"><i>Leg length discrepancy</i> after hip replacement is calculated as the vertical distance between the middle of the minor trochanters, using the acetabular tear drops<sup id="cite_ref-Vanrusselt2015_80-3" class="reference"><a href="#cite_note-Vanrusselt2015-80">[80]</a></sup> or the transischial line<sup id="cite_ref-Watt_9-6" class="reference"><a href="#cite_note-Watt-9">[9]</a></sup> as references for the horizontal plane. A discrepancy of up to 1 cm is generally tolerated.<sup id="cite_ref-Vanrusselt2015_80-4" class="reference"><a href="#cite_note-Vanrusselt2015-80">[80]</a></sup><sup id="cite_ref-Watt_9-7" class="reference"><a href="#cite_note-Watt-9">[9]</a></sup></div>
</li>
<li class="gallerybox" style="width: 265px">
<div class="thumb" style="width: 260px; height: 150px;"><span typeof="mw:File"><a href="/info/en/?search=File:Center_of_rotation_of_hip_prosthesis.jpg" class="mw-file-description" title="Center of rotation: The horizontal center of rotation is calculated as the distance between the acetabular teardrop and the center of the head (or caput) of the prosthesis and/or the native femoral head on the contralateral side.[80] The vertical center of rotation instead uses the transischial line for reference.[80] The parameter should be equal on both sides.[80]"><img alt="Center of rotation: The horizontal center of rotation is calculated as the distance between the acetabular teardrop and the center of the head (or caput) of the prosthesis and/or the native femoral head on the contralateral side.[80] The vertical center of rotation instead uses the transischial line for reference.[80] The parameter should be equal on both sides.[80]" src="https://upload.wikimedia.org/wikipedia/commons/thumb/2/25/Center_of_rotation_of_hip_prosthesis.jpg/229px-Center_of_rotation_of_hip_prosthesis.jpg" decoding="async" width="229" height="120" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/2/25/Center_of_rotation_of_hip_prosthesis.jpg/344px-Center_of_rotation_of_hip_prosthesis.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/2/25/Center_of_rotation_of_hip_prosthesis.jpg/458px-Center_of_rotation_of_hip_prosthesis.jpg 2x" data-file-width="2074" data-file-height="1088" /></a></span></div>
<div class="gallerytext"><i>Center of rotation</i>: The horizontal center of rotation is calculated as the distance between the acetabular teardrop and the center of the head (or caput) of the prosthesis and/or the native femoral head on the contralateral side.<sup id="cite_ref-Vanrusselt2015_80-5" class="reference"><a href="#cite_note-Vanrusselt2015-80">[80]</a></sup> The vertical center of rotation instead uses the transischial line for reference.<sup id="cite_ref-Vanrusselt2015_80-6" class="reference"><a href="#cite_note-Vanrusselt2015-80">[80]</a></sup> The parameter should be equal on both sides.<sup id="cite_ref-Vanrusselt2015_80-7" class="reference"><a href="#cite_note-Vanrusselt2015-80">[80]</a></sup></div>
</li>
</ul>
<h2><span class="mw-headline" id="Alternatives_and_variations">Alternatives and variations</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=28" title="Edit section: Alternatives and variations"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h2>
<h3><span class="mw-headline" id="Conservative_management">Conservative management</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=29" title="Edit section: Conservative management"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>The first line approach as an alternative to hip replacement is conservative management which involves a multimodal approach of oral medication, injections, activity modification and <a href="/info/en/?search=Physical_therapy" title="Physical therapy">physical therapy</a>.<sup id="cite_ref-82" class="reference"><a href="#cite_note-82">[82]</a></sup> Conservative management can prevent or delay the need for hip replacement.
</p>
<h3><span class="mw-headline" id="Preoperative_care">Preoperative care</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=30" title="Edit section: Preoperative care"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>Preoperative education is an important part of patient care. Some evidence indicates that it may slightly reduce anxiety before hip or knee replacement, with low risk of negative effects.<sup id="cite_ref-83" class="reference"><a href="#cite_note-83">[83]</a></sup>
</p>
<h3><span class="mw-headline" id="Hemiarthroplasty">Hemiarthroplasty</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=31" title="Edit section: Hemiarthroplasty"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<figure typeof="mw:File/Thumb"><a href="/info/en/?search=File:Femoral_offset_in_hemiarthroplasty_(crop).jpg" class="mw-file-description"><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/f/f0/Femoral_offset_in_hemiarthroplasty_%28crop%29.jpg/170px-Femoral_offset_in_hemiarthroplasty_%28crop%29.jpg" decoding="async" width="170" height="329" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/f/f0/Femoral_offset_in_hemiarthroplasty_%28crop%29.jpg/255px-Femoral_offset_in_hemiarthroplasty_%28crop%29.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/f/f0/Femoral_offset_in_hemiarthroplasty_%28crop%29.jpg/340px-Femoral_offset_in_hemiarthroplasty_%28crop%29.jpg 2x" data-file-width="382" data-file-height="740" /></a><figcaption>Femoral (neck) offset is defined as the perpendicular distance between the intramedullary or longitudinal axis of the femur and the center of rotation of the native or prosthetic femoral head. An offset of less than 33 mm is associated with hip dislocation.<sup id="cite_ref-JonesBriffa2017_84-0" class="reference"><a href="#cite_note-JonesBriffa2017-84">[84]</a></sup><sup id="cite_ref-NinhSethi2009_85-0" class="reference"><a href="#cite_note-NinhSethi2009-85">[85]</a></sup></figcaption></figure>
<p>Hemiarthroplasty is a surgical procedure that replaces one half of the joint with an artificial surface and leaves the other part unchanged. This class of procedure is most commonly performed on the hip after an intracapsular fracture of the femur neck (<a href="/info/en/?search=Hip_fracture" title="Hip fracture">hip fracture</a>). The procedure is performed by removing the head of the femur and replacing it with a metal or composite <a href="/info/en/?search=Prosthesis" title="Prosthesis">prosthesis</a>. The most commonly used prosthesis designs are the Austin Moore and Thompson prostheses. A <a href="/info/en/?search=Composite_material" title="Composite material">composite</a> of <a href="/info/en/?search=Metal" title="Metal">metal</a> and <a href="/info/en/?search=HDPE" class="mw-redirect" title="HDPE">HDPE</a> that forms two interphases (bipolar prosthesis) can be used. The monopolar prosthesis has not been shown to offer any advantage over bipolar designs. The procedure is recommended only for elderly/frail patients, due to their lower life expectancy and activity level. This is because over time the prosthesis tends to loosen or to erode the <a href="/info/en/?search=Acetabulum" title="Acetabulum">acetabulum</a>.<sup id="cite_ref-86" class="reference"><a href="#cite_note-86">[86]</a></sup> Independently mobile older adults with hip fractures may benefit from a total hip replacement instead of hemiarthroplasty.<sup id="cite_ref-Metcalfe_87-0" class="reference"><a href="#cite_note-Metcalfe-87">[87]</a></sup>
</p>
<ul class="gallery mw-gallery-packed">
<li class="gallerybox" style="width: 242.66666666667px">
<div class="thumb" style="width: 240.66666666667px;"><span typeof="mw:File"><a href="/info/en/?search=File:Bipolar_hip_prosthesis.jpg" class="mw-file-description" title="Hip prosthesis for hemiarthroplasty. This example is bipolar, meaning that the head has two separate articulations."><img alt="Hip prosthesis for hemiarthroplasty. This example is bipolar, meaning that the head has two separate articulations." src="https://upload.wikimedia.org/wikipedia/commons/thumb/4/47/Bipolar_hip_prosthesis.jpg/361px-Bipolar_hip_prosthesis.jpg" decoding="async" width="241" height="160" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/4/47/Bipolar_hip_prosthesis.jpg/541px-Bipolar_hip_prosthesis.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/4/47/Bipolar_hip_prosthesis.jpg 2x" data-file-width="553" data-file-height="368" /></a></span></div>
<div class="gallerytext">Hip prosthesis for hemiarthroplasty. This example is bipolar, meaning that the head has two separate articulations.</div>
</li>
<li class="gallerybox" style="width: 215.33333333333px">
<div class="thumb" style="width: 213.33333333333px;"><span typeof="mw:File"><a href="/info/en/?search=File:X-ray_of_hips_with_a_hemiarthroplasty.jpg" class="mw-file-description" title="X-ray of the hips, with a right-sided hemiarthroplasty"><img alt="X-ray of the hips, with a right-sided hemiarthroplasty" src="https://upload.wikimedia.org/wikipedia/commons/thumb/e/e0/X-ray_of_hips_with_a_hemiarthroplasty.jpg/320px-X-ray_of_hips_with_a_hemiarthroplasty.jpg" decoding="async" width="214" height="160" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/e/e0/X-ray_of_hips_with_a_hemiarthroplasty.jpg/480px-X-ray_of_hips_with_a_hemiarthroplasty.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/e/e0/X-ray_of_hips_with_a_hemiarthroplasty.jpg/639px-X-ray_of_hips_with_a_hemiarthroplasty.jpg 2x" data-file-width="1244" data-file-height="934" /></a></span></div>
<div class="gallerytext"><a href="/info/en/?search=Projectional_radiography" title="Projectional radiography">X-ray</a> of the hips, with a right-sided hemiarthroplasty</div>
</li>
</ul>
<h3><span class="mw-headline" id="Hip_resurfacing">Hip resurfacing</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=32" title="Edit section: Hip resurfacing"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p><a href="/info/en/?search=Hip_resurfacing" title="Hip resurfacing">Hip resurfacing</a> is an alternative to hip replacement surgery. It has been used in Europe since 1998 and became a common procedure. Health-related quality of life measures are markedly improved and patient satisfaction is favorable after hip resurfacing arthroplasty.<sup id="cite_ref-88" class="reference"><a href="#cite_note-88">[88]</a></sup>
</p><p>The <a href="/info/en/?search=Minimally_invasive_hip_resurfacing" title="Minimally invasive hip resurfacing">minimally invasive hip resurfacing</a> procedure is a further refinement to hip resurfacing.
</p>
<h3><span class="mw-headline" id="Viscosupplementation">Viscosupplementation</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=33" title="Edit section: Viscosupplementation"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h3>
<p>Viscosupplementation is the injection of artificial lubricants into the joint.<sup id="cite_ref-pmid17874246_89-0" class="reference"><a href="#cite_note-pmid17874246-89">[89]</a></sup> Use of these medications in the hip is off label. The cost of treatment is typically not covered by health insurance.
</p><p>Some authorities claim that the future of osteoarthritis treatment is <a href="/info/en/?search=Bioengineering" class="mw-redirect" title="Bioengineering">bioengineering</a>, targeting the growth and/or repair of the damaged, arthritic joint. Centeno et al. reported on the partial regeneration of an arthritic human hip joint using mesenchymal <a href="/info/en/?search=Stem_cell" title="Stem cell">stem cells</a>.<sup id="cite_ref-pmid16886034_90-0" class="reference"><a href="#cite_note-pmid16886034-90">[90]</a></sup> It is yet to be shown that this result will apply to a large group of patients and result in significant benefits. The FDA stated that this procedure does not conform to regulations, but Centeno claims that it is exempt from FDA regulation. It has not been shown in controlled clinical trials to be effective.<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">[<i><a href="/info/en/?search=Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (May 2014)">citation needed</span></a></i>]</sup>
</p>
<h2><span class="mw-headline" id="Prevalence_and_cost">Prevalence and cost</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=34" title="Edit section: Prevalence and cost"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h2>
<p>Total hip replacement incidence varies in developed countries between 30 (Romania) and 290 (Germany) procedures per 100,000 population per year.<sup id="cite_ref-91" class="reference"><a href="#cite_note-91">[91]</a></sup> Approximately 0.8% of Americans have undergone the procedure.<sup id="cite_ref-92" class="reference"><a href="#cite_note-92">[92]</a></sup>
</p><p>According to the International Federation of Healthcare Plans, the average cost of a total hip replacement in 2012 was $40,364 in the United States, $11,889 in the United Kingdom, $10,987 in France, $9,574 in Switzerland, and $7,731 in Spain.<sup id="cite_ref-ifhp_2-1" class="reference"><a href="#cite_note-ifhp-2">[2]</a></sup> In the United States, the average cost of a total hip replacement varies widely by geographic region, ranging from $11,327 (Birmingham, Alabama) to $73,927 (Boston, Massachusetts).<sup id="cite_ref-93" class="reference"><a href="#cite_note-93">[93]</a></sup>
</p>
<h2><span class="mw-headline" id="History">History</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=35" title="Edit section: History"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h2>
<figure class="mw-default-size" typeof="mw:File/Thumb"><a href="/info/en/?search=File:Hip_prosthesis,_England,_1958-1960_Wellcome_L0057818.jpg" class="mw-file-description"><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/a/a8/Hip_prosthesis%2C_England%2C_1958-1960_Wellcome_L0057818.jpg/220px-Hip_prosthesis%2C_England%2C_1958-1960_Wellcome_L0057818.jpg" decoding="async" width="220" height="331" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/a/a8/Hip_prosthesis%2C_England%2C_1958-1960_Wellcome_L0057818.jpg/330px-Hip_prosthesis%2C_England%2C_1958-1960_Wellcome_L0057818.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/a/a8/Hip_prosthesis%2C_England%2C_1958-1960_Wellcome_L0057818.jpg/440px-Hip_prosthesis%2C_England%2C_1958-1960_Wellcome_L0057818.jpg 2x" data-file-width="2832" data-file-height="4256" /></a><figcaption>Gosset-style hip prosthesis from 1960</figcaption></figure>
<p>The earliest recorded attempts at hip replacement were carried out in Germany in 1891 by <a href="/info/en/?search=Themistocles_Gluck" title="Themistocles Gluck">Themistocles Gluck</a> (1853–1942),<sup id="cite_ref-94" class="reference"><a href="#cite_note-94">[94]</a></sup><sup id="cite_ref-95" class="reference"><a href="#cite_note-95">[95]</a></sup> who used ivory to replace the <a href="/info/en/?search=Femoral_head" title="Femoral head">femoral head</a> (the ball on the femur), attaching it with nickel-plated screws.<sup id="cite_ref-pmid16089067_96-0" class="reference"><a href="#cite_note-pmid16089067-96">[96]</a></sup> Subsequently, he used a cement made from plaster of Paris, powdered pumice and glue.<sup id="cite_ref-:1_97-0" class="reference"><a href="#cite_note-:1-97">[97]</a></sup>
</p><p>Molded-glass implants were introduced in the 1920s by Smith-Peterson in the USA. Although these showed good bio-compatibility, they were mechanically fragile so he started experiments with metallic prostheses in the 1930s.<sup id="cite_ref-:1_97-1" class="reference"><a href="#cite_note-:1-97">[97]</a></sup><sup id="cite_ref-:2_98-0" class="reference"><a href="#cite_note-:2-98">[98]</a></sup> In 1938, Philip Wiles of Middlesex General Hospital, UK carried out a total hip replacement using a stainless-steel prosthesis attached by bolts.<sup id="cite_ref-:8_99-0" class="reference"><a href="#cite_note-:8-99">[99]</a></sup> In 1940, Dr. Austin T. Moore (1899–1963)<sup id="cite_ref-100" class="reference"><a href="#cite_note-100">[100]</a></sup> at Columbia Hospital in <a href="/info/en/?search=Columbia,_South_Carolina" title="Columbia, South Carolina">Columbia, South Carolina</a> performed a hip replacement using a prototype prosthesis made of the cobalt-chrome alloy <a href="/info/en/?search=Vitallium" title="Vitallium">Vitallium; it was</a> inserted into the medullary canal and "fenestrated" to promote bone regrowth. A commercial version known as the "Austin Moore Prosthesis" was introduced in 1952; it is still in use today, typically for femoral neck fractures in the elderly.<sup id="cite_ref-:1_97-2" class="reference"><a href="#cite_note-:1-97">[97]</a></sup> Following the lead of Wiles, several UK general hospitals including <a href="/info/en/?search=Norwich" title="Norwich">Norwich</a>, <a href="/info/en/?search=Wrightington,_Wigan_and_Leigh_NHS_Foundation_Trust" title="Wrightington, Wigan and Leigh NHS Foundation Trust">Wrightington</a>, <a href="/info/en/?search=Stanmore" title="Stanmore">Stanmore</a>, <a href="/info/en/?search=Redhill,_Surrey" title="Redhill, Surrey">Redhill</a> and <a href="/info/en/?search=Exeter" title="Exeter">Exeter</a> developed metal-based prostheses during the 1950s and 1960s.<sup id="cite_ref-:8_99-1" class="reference"><a href="#cite_note-:8-99">[99]</a></sup>
</p><p>Robert Juditt was the first to perform hip replacements via the anterior approach in 1947 in Paris. He taught this method to <a href="https://en.wikipedia.org/?title=%C3%89mile_Letournel&action=edit&redlink=1" class="new" title="Émile Letournel (page does not exist)">Émile Letournel</a><span class="noprint" style="font-size:85%; font-style: normal;"> [<a href="https://fr.wikipedia.org/wiki/%C3%89mile_Letournel" class="extiw" title="fr:Émile Letournel">fr</a>]</span>. Joel Matta, who had studied with Letournel, brought this approach to the United States and went on to popularize it.<sup id="cite_ref-101" class="reference"><a href="#cite_note-101">[101]</a></sup>
</p><p>Metal/Acrylic prostheses were tried in the 1950s <sup id="cite_ref-:1_97-3" class="reference"><a href="#cite_note-:1-97">[97]</a></sup><sup id="cite_ref-:3_102-0" class="reference"><a href="#cite_note-:3-102">[102]</a></sup> but were found to be susceptible to wear.  In the 1960s, <a href="/info/en/?search=John_Charnley" title="John Charnley">John Charnley</a><sup id="cite_ref-103" class="reference"><a href="#cite_note-103">[103]</a></sup><sup id="cite_ref-:1_97-4" class="reference"><a href="#cite_note-:1-97">[97]</a></sup><sup id="cite_ref-:2_98-1" class="reference"><a href="#cite_note-:2-98">[98]</a></sup> at Wrightington General Hospital combined a metal prosthesis with a <a href="/info/en/?search=Polytetrafluoroethylene" title="Polytetrafluoroethylene">PTFE</a> acetabular cup before settling on a metal/<a href="/info/en/?search=Polyethylene" title="Polyethylene">polyethylene</a> design. Ceramic bearings were developed in the late 1970s.<sup id="cite_ref-:1_97-5" class="reference"><a href="#cite_note-:1-97">[97]</a></sup><sup id="cite_ref-:2_98-2" class="reference"><a href="#cite_note-:2-98">[98]</a></sup>
</p><p>The means of attachment have also diversified.<sup id="cite_ref-:1_97-6" class="reference"><a href="#cite_note-:1-97">[97]</a></sup><sup id="cite_ref-:2_98-3" class="reference"><a href="#cite_note-:2-98">[98]</a></sup>  Early prostheses were attached by screws (e.g. Gluck, Wiles) with later developments using dental or bone cements (e.g. Charnley, Thompson<sup id="cite_ref-:4_104-0" class="reference"><a href="#cite_note-:4-104">[104]</a></sup><sup id="cite_ref-:5_105-0" class="reference"><a href="#cite_note-:5-105">[105]</a></sup>) or cementless systems which relied on bone regrowth (Austin-Moore,<sup id="cite_ref-:6_106-0" class="reference"><a href="#cite_note-:6-106">[106]</a></sup> Ring<sup id="cite_ref-:2_98-4" class="reference"><a href="#cite_note-:2-98">[98]</a></sup>). The choice of alloy, bearing material, attachment and detailed geometry has led to the wide variety of prosthesis designs available today.<sup id="cite_ref-:1_97-7" class="reference"><a href="#cite_note-:1-97">[97]</a></sup><sup id="cite_ref-:2_98-5" class="reference"><a href="#cite_note-:2-98">[98]</a></sup><sup id="cite_ref-:8_99-2" class="reference"><a href="#cite_note-:8-99">[99]</a></sup>
</p><p>The London <a href="/info/en/?search=Science_Museum,_London" title="Science Museum, London">Science Museum</a> has a collection of hip prostheses which reflect developments in the US, UK and elsewhere. These show the use of different materials and different designs for different circumstances (e.g. cemented and uncemented arthroplasty.)  Some are on display in the museum's "Medicine: The Wellcome Galleries". 
</p>
<figure class="mw-default-size" typeof="mw:File/Thumb"><a href="/info/en/?search=File:Hip_prostheses_on_display_in_London_Science_Museum_2022.jpg" class="mw-file-description"><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/b/bd/Hip_prostheses_on_display_in_London_Science_Museum_2022.jpg/220px-Hip_prostheses_on_display_in_London_Science_Museum_2022.jpg" decoding="async" width="220" height="247" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/commons/thumb/b/bd/Hip_prostheses_on_display_in_London_Science_Museum_2022.jpg/330px-Hip_prostheses_on_display_in_London_Science_Museum_2022.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/b/bd/Hip_prostheses_on_display_in_London_Science_Museum_2022.jpg/440px-Hip_prostheses_on_display_in_London_Science_Museum_2022.jpg 2x" data-file-width="3111" data-file-height="3495" /></a><figcaption>Hip prostheses on display in the London Science Museum</figcaption></figure>
<p>The items include:
</p>
<ul><li><b>Prosthesis from 1960</b>: The "Gosset-style" prosthesis was first introduced in 1949, although the specific example was made by Lusterlite Ltd of <a href="/info/en/?search=Leeds" title="Leeds">Leeds</a> in 1960.  It has a perspex "ball" and simple rod-like shaft made of nickel-plated stainless-steel.<sup id="cite_ref-:3_102-1" class="reference"><a href="#cite_note-:3-102">[102]</a></sup></li>
<li><b>Examples of prostheses from 1970 to 1985</b>: Examples provided by <a href="/info/en/?search=Ipswich" title="Ipswich">Ipswich</a> Hospital, UK are made of <a href="/info/en/?search=Vitallium" title="Vitallium">Vitallium</a> (Co/Cr alloy) with curved standard or slender femoral stems.<sup id="cite_ref-107" class="reference"><a href="#cite_note-107">[107]</a></sup><sup id="cite_ref-108" class="reference"><a href="#cite_note-108">[108]</a></sup> One example has a studded cup.<sup id="cite_ref-109" class="reference"><a href="#cite_note-109">[109]</a></sup></li>
<li><b>Examples of prostheses from the 1990s</b>: Examples, some of which were developed at the Redhill Group of Hospitals and Dorking Hospital, include a ringed titanium hip prosthesis with a screw stem and porous cup,<sup id="cite_ref-:7_110-0" class="reference"><a href="#cite_note-:7-110">[110]</a></sup> a modular hip prosthesis with a textured femoral stem to aid bone grafting (material unspecified),<sup id="cite_ref-111" class="reference"><a href="#cite_note-111">[111]</a></sup> two Thompson-type prostheses made of <a href="/info/en/?search=Vitallium" title="Vitallium">Vitallium</a> alloy<sup id="cite_ref-:4_104-1" class="reference"><a href="#cite_note-:4-104">[104]</a></sup><sup id="cite_ref-:5_105-1" class="reference"><a href="#cite_note-:5-105">[105]</a></sup> and an Austin Moore type prosthesis (material unspecified), with a porous metal femoral stem.<sup id="cite_ref-:6_106-1" class="reference"><a href="#cite_note-:6-106">[106]</a></sup></li>
<li><b>Example of acetabular cup prosthesis from 1998:</b> Example of a prosthetic socket, from Sulzer Orthopedics Inc., is the Inter-Op Hemispherical Shell. This is made from materials not recognised by the human body, so the body's immune system does not attack and reject the joint.<sup id="cite_ref-112" class="reference"><a href="#cite_note-112">[112]</a></sup></li>
<li><b>Examples of prostheses from 2006</b>: Examples made by <a href="/info/en/?search=Smith_%26_Nephew" title="Smith & Nephew">Smith & Nephew Orthopedics</a> include an "Anthology" titanium prosthesis, which has a flat-tapered stem placed in the thigh bone, and an "Echelon" (cobalt-chrome prosthesis for both cementless and cemented <a href="/info/en/?search=Arthroplasty" title="Arthroplasty">arthroplasty</a>. Both have porous coating to promote bone adhesion.<sup id="cite_ref-113" class="reference"><a href="#cite_note-113">[113]</a></sup><sup id="cite_ref-114" class="reference"><a href="#cite_note-114">[114]</a></sup></li></ul>
<p>The Science Museum's collection also includes specialised surgical tools for hip operations:
</p>
<ul><li><b>Instrument sets</b> made by Downs Ltd for the City Hospital, <a href="/info/en/?search=Nottingham_University_Hospitals_NHS_Trust" title="Nottingham University Hospitals NHS Trust">Nottingham University Hospitals</a> UK.<sup id="cite_ref-115" class="reference"><a href="#cite_note-115">[115]</a></sup><sup id="cite_ref-116" class="reference"><a href="#cite_note-116">[116]</a></sup> Tools include head punches, reamers, drills and rasps.</li>
<li><b>Prototype oscillating bone saws</b> made by Kenneth Dobbie in the 1960s.<sup id="cite_ref-117" class="reference"><a href="#cite_note-117">[117]</a></sup><sup id="cite_ref-118" class="reference"><a href="#cite_note-118">[118]</a></sup>  Dobbie was electrical engineer at the <a href="/info/en/?search=Royal_National_Orthopaedic_Hospital" title="Royal National Orthopaedic Hospital">Royal National Orthopaedic Hospital</a>, Stanmore, UK.  He worked closely with the hip surgeon <a href="/info/en/?search=John_Charnley" title="John Charnley">Sir John Charnley</a> to develop the saws eventually leading to a commercial product made by De Soutter Brothers Ltd.<sup id="cite_ref-119" class="reference"><a href="#cite_note-119">[119]</a></sup></li></ul>
<h2><span class="mw-headline" id="Other_animals">Other animals</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=36" title="Edit section: Other animals"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h2>
<link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1033289096"><div role="note" class="hatnote navigation-not-searchable">Main article: <a href="/info/en/?search=Hip_replacement_(animal)" title="Hip replacement (animal)">Hip replacement (animal)</a></div>
<h2><span class="mw-headline" id="See_also">See also</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=37" title="Edit section: See also"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h2>
<ul><li><a href="/info/en/?search=2010_DePuy_Hip_Recall" title="2010 DePuy Hip Recall">2010 DePuy Hip Recall</a></li>
<li><a href="/info/en/?search=Abductor_wedge" title="Abductor wedge">Abductor wedge</a></li>
<li><a href="/info/en/?search=Femoroacetabular_impingement" title="Femoroacetabular impingement">Femoroacetabular impingement</a></li>
<li><a href="/info/en/?search=Gruen_zone" class="mw-redirect" title="Gruen zone">Gruen zone</a></li>
<li><a href="/info/en/?search=Hip_examination" title="Hip examination">Hip examination</a></li></ul>
<h2><span class="mw-headline" id="References">References</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=38" title="Edit section: References"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h2>
<style data-mw-deduplicate="TemplateStyles:r1217336898">.mw-parser-output .reflist{font-size:90%;margin-bottom:0.5em;list-style-type:decimal}.mw-parser-output .reflist .references{font-size:100%;margin-bottom:0;list-style-type:inherit}.mw-parser-output .reflist-columns-2{column-width:30em}.mw-parser-output .reflist-columns-3{column-width:25em}.mw-parser-output .reflist-columns{margin-top:0.3em}.mw-parser-output .reflist-columns ol{margin-top:0}.mw-parser-output .reflist-columns li{page-break-inside:avoid;break-inside:avoid-column}.mw-parser-output .reflist-upper-alpha{list-style-type:upper-alpha}.mw-parser-output .reflist-upper-roman{list-style-type:upper-roman}.mw-parser-output .reflist-lower-alpha{list-style-type:lower-alpha}.mw-parser-output .reflist-lower-greek{list-style-type:lower-greek}.mw-parser-output .reflist-lower-roman{list-style-type:lower-roman}</style><div class="reflist">
<div class="mw-references-wrap mw-references-columns"><ol class="references">
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<li id="cite_note-ifhp-2"><span class="mw-cite-backlink">^ <a href="#cite_ref-ifhp_2-0"><sup><i><b>a</b></i></sup></a> <a href="#cite_ref-ifhp_2-1"><sup><i><b>b</b></i></sup></a></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://hushp.harvard.edu/sites/default/files/downloadable_files/IFHP%202012%20Comparative%20Price%20Report.pdf">"2012 comparative price report"</a> <span class="cs1-format">(PDF)</span>. International Federation of Health Plans<span class="reference-accessdate">. Retrieved <span class="nowrap">4 October</span> 2015</span>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=2012+comparative+price+report&rft.pub=International+Federation+of+Health+Plans&rft_id=http%3A%2F%2Fhushp.harvard.edu%2Fsites%2Fdefault%2Ffiles%2Fdownloadable_files%2FIFHP%25202012%2520Comparative%2520Price%2520Report.pdf&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-3"><span class="mw-cite-backlink"><b><a href="#cite_ref-3">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite id="CITEREFSmithAboelmagdHingMacGregor2016" class="citation journal cs1">Smith TO, Aboelmagd T, Hing CB, MacGregor A (September 2016). <a class="external text" href="https://openaccess.sgul.ac.uk/108614/1/Bariatric_surgery_paper_ACCEPTED_10.05.2016.pdf">"Does bariatric surgery prior to total hip or knee arthroplasty reduce post-operative complications and improve clinical outcomes for obese patients? Systematic review and meta-analysis"</a> <span class="cs1-format">(PDF)</span>. <i>The Bone & Joint Journal</i>. <b>98-B</b> (9): 1160–1166. <a href="/info/en/?search=Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a class="external text" href="https://doi.org/10.1302%2F0301-620x.98b9.38024">10.1302/0301-620x.98b9.38024</a>. <a href="/info/en/?search=PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a class="external text" href="https://pubmed.ncbi.nlm.nih.gov/27587514">27587514</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=The+Bone+%26+Joint+Journal&rft.atitle=Does+bariatric+surgery+prior+to+total+hip+or+knee+arthroplasty+reduce+post-operative+complications+and+improve+clinical+outcomes+for+obese+patients%3F+Systematic+review+and+meta-analysis&rft.volume=98-B&rft.issue=9&rft.pages=1160-1166&rft.date=2016-09&rft_id=info%3Adoi%2F10.1302%2F0301-620x.98b9.38024&rft_id=info%3Apmid%2F27587514&rft.aulast=Smith&rft.aufirst=TO&rft.au=Aboelmagd%2C+T&rft.au=Hing%2C+CB&rft.au=MacGregor%2C+A&rft_id=http%3A%2F%2Fopenaccess.sgul.ac.uk%2F108614%2F1%2FBariatric_surgery_paper_ACCEPTED_10.05.2016.pdf&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-4"><span class="mw-cite-backlink"><b><a href="#cite_ref-4">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation journal cs1"><a class="external text" href="https://evidence.nihr.ac.uk/alert/joint-replacement-many-people-can-safely-wait-10-years-for-follow-up/">"Joint replacements: many people can safely wait 10 years for follow-up"</a>. <i>NIHR Evidence</i>. 11 January 2023. <a href="/info/en/?search=Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a class="external text" href="https://doi.org/10.3310%2Fnihrevidence_55501">10.3310/nihrevidence_55501</a>. <a href="/info/en/?search=S2CID_(identifier)" class="mw-redirect" title="S2CID (identifier)">S2CID</a> <a class="external text" href="https://api.semanticscholar.org/CorpusID:257843402">257843402</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=NIHR+Evidence&rft.atitle=Joint+replacements%3A+many+people+can+safely+wait+10+years+for+follow-up&rft.date=2023-01-11&rft_id=info%3Adoi%2F10.3310%2Fnihrevidence_55501&rft_id=https%3A%2F%2Fapi.semanticscholar.org%2FCorpusID%3A257843402%23id-name%3DS2CID&rft_id=https%3A%2F%2Fevidence.nihr.ac.uk%2Falert%2Fjoint-replacement-many-people-can-safely-wait-10-years-for-follow-up%2F&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-5"><span class="mw-cite-backlink"><b><a href="#cite_ref-5">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite id="CITEREFKingsburySmithCzoski_MurrayPinedo-Villanueva2022" class="citation journal cs1">Kingsbury SR, Smith LK, Czoski Murray CJ, Pinedo-Villanueva R, Judge A, West R, et al. (2022-06-01). <a class="external text" href="https://doi.org/10.3310%2FKODQ0769">"Safety of disinvestment in mid- to late-term follow-up post primary hip and knee replacement: the UK SAFE evidence synthesis and recommendations"</a>. <i>Health and Social Care Delivery Research</i>. <b>10</b> (16): 1–172. <a href="/info/en/?search=Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<span class="id-lock-free" title="Freely accessible"><a class="external text" href="https://doi.org/10.3310%2FKODQ0769">10.3310/KODQ0769</a></span>. <a href="/info/en/?search=PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a class="external text" href="https://pubmed.ncbi.nlm.nih.gov/35767667">35767667</a>. <a href="/info/en/?search=S2CID_(identifier)" class="mw-redirect" title="S2CID (identifier)">S2CID</a> <a class="external text" href="https://api.semanticscholar.org/CorpusID:250133111">250133111</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=Health+and+Social+Care+Delivery+Research&rft.atitle=Safety+of+disinvestment+in+mid-+to+late-term+follow-up+post+primary+hip+and+knee+replacement%3A+the+UK+SAFE+evidence+synthesis+and+recommendations&rft.volume=10&rft.issue=16&rft.pages=1-172&rft.date=2022-06-01&rft_id=https%3A%2F%2Fapi.semanticscholar.org%2FCorpusID%3A250133111%23id-name%3DS2CID&rft_id=info%3Apmid%2F35767667&rft_id=info%3Adoi%2F10.3310%2FKODQ0769&rft.aulast=Kingsbury&rft.aufirst=SR&rft.au=Smith%2C+LK&rft.au=Czoski+Murray%2C+CJ&rft.au=Pinedo-Villanueva%2C+R&rft.au=Judge%2C+A&rft.au=West%2C+R&rft.au=Smith%2C+C&rft.au=Wright%2C+JM&rft.au=Arden%2C+NK&rft.au=Thomas%2C+CM&rft.au=Kolovos%2C+S&rft.au=Shuweihdi%2C+F&rft.au=Garriga%2C+C&rft.au=Bitanihirwe%2C+BK&rft.au=Hill%2C+K&rft.au=Matu%2C+J&rft.au=Stone%2C+M&rft.au=Conaghan%2C+PG&rft_id=https%3A%2F%2Fdoi.org%2F10.3310%252FKODQ0769&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-6"><span class="mw-cite-backlink"><b><a href="#cite_ref-6">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite id="CITEREFHolmKristensenHustedKehlet2011" class="citation journal cs1">Holm B, Kristensen MT, Husted H, Kehlet H, Bandholm T (February 2011). "Thigh and knee circumference, knee-extension strength, and functional performance after fast-track total hip arthroplasty". <i>PM&R</i>. <b>3</b> (2): 117–24, quiz 124. <a href="/info/en/?search=Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a class="external text" href="https://doi.org/10.1016%2Fj.pmrj.2010.10.019">10.1016/j.pmrj.2010.10.019</a>. <a href="/info/en/?search=PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a class="external text" href="https://pubmed.ncbi.nlm.nih.gov/21333950">21333950</a>. <a href="/info/en/?search=S2CID_(identifier)" class="mw-redirect" title="S2CID (identifier)">S2CID</a> <a class="external text" href="https://api.semanticscholar.org/CorpusID:21003271">21003271</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=PM%26R&rft.atitle=Thigh+and+knee+circumference%2C+knee-extension+strength%2C+and+functional+performance+after+fast-track+total+hip+arthroplasty&rft.volume=3&rft.issue=2&rft.pages=117-24%2C+quiz+124&rft.date=2011-02&rft_id=https%3A%2F%2Fapi.semanticscholar.org%2FCorpusID%3A21003271%23id-name%3DS2CID&rft_id=info%3Apmid%2F21333950&rft_id=info%3Adoi%2F10.1016%2Fj.pmrj.2010.10.019&rft.aulast=Holm&rft.aufirst=B&rft.au=Kristensen%2C+MT&rft.au=Husted%2C+H&rft.au=Kehlet%2C+H&rft.au=Bandholm%2C+T&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-7"><span class="mw-cite-backlink"><b><a href="#cite_ref-7">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite id="CITEREFHeoHarrisNaylorLewin2020" class="citation journal cs1">Heo SM, Harris I, Naylor J, Lewin AM (September 2020). <a class="external text" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488141">"Complications to 6 months following total hip or knee arthroplasty: observations from an Australian clinical outcomes registry"</a>. <i>BMC Musculoskeletal Disorders</i>. <b>21</b> (1): 602. <a href="/info/en/?search=Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<span class="id-lock-free" title="Freely accessible"><a class="external text" href="https://doi.org/10.1186%2Fs12891-020-03612-8">10.1186/s12891-020-03612-8</a></span>. <a href="/info/en/?search=PMC_(identifier)" class="mw-redirect" title="PMC (identifier)">PMC</a> <span class="id-lock-free" title="Freely accessible"><a class="external text" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488141">7488141</a></span>. <a href="/info/en/?search=PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a class="external text" href="https://pubmed.ncbi.nlm.nih.gov/32912197">32912197</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=BMC+Musculoskeletal+Disorders&rft.atitle=Complications+to+6+months+following+total+hip+or+knee+arthroplasty%3A+observations+from+an+Australian+clinical+outcomes+registry&rft.volume=21&rft.issue=1&rft.pages=602&rft.date=2020-09&rft_id=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC7488141%23id-name%3DPMC&rft_id=info%3Apmid%2F32912197&rft_id=info%3Adoi%2F10.1186%2Fs12891-020-03612-8&rft.aulast=Heo&rft.aufirst=SM&rft.au=Harris%2C+I&rft.au=Naylor%2C+J&rft.au=Lewin%2C+AM&rft_id=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC7488141&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-berry2012-8"><span class="mw-cite-backlink">^ <a href="#cite_ref-berry2012_8-0"><sup><i><b>a</b></i></sup></a> <a href="#cite_ref-berry2012_8-1"><sup><i><b>b</b></i></sup></a> <a href="#cite_ref-berry2012_8-2"><sup><i><b>c</b></i></sup></a> <a href="#cite_ref-berry2012_8-3"><sup><i><b>d</b></i></sup></a></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite id="CITEREFBerryLieberman2012" class="citation book cs1">Berry DJ, Lieberman J (2012). <a class="external text" href="https://books.google.com/books?id=Kc-AhYLnIF4C&pg=PA1035"><i>Surgery of the Hip</i></a>. Elsevier Health Sciences. p. 1035. <a href="/info/en/?search=ISBN_(identifier)" class="mw-redirect" title="ISBN (identifier)">ISBN</a> <a href="/info/en/?search=Special:BookSources/9781455727056" title="Special:BookSources/9781455727056"><bdi>9781455727056</bdi></a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=book&rft.btitle=Surgery+of+the+Hip&rft.pages=1035&rft.pub=Elsevier+Health+Sciences&rft.date=2012&rft.isbn=9781455727056&rft.aulast=Berry&rft.aufirst=DJ&rft.au=Lieberman%2C+J&rft_id=https%3A%2F%2Fbooks.google.com%2Fbooks%3Fid%3DKc-AhYLnIF4C%26pg%3DPA1035&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-RothMaertz2012-31"><span class="mw-cite-backlink">^ <a href="#cite_ref-RothMaertz2012_31-0"><sup><i><b>a</b></i></sup></a> <a href="#cite_ref-RothMaertz2012_31-1"><sup><i><b>b</b></i></sup></a></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite id="CITEREFRothMaertzParrBuckwalter2012" class="citation journal cs1">Roth TD, Maertz NA, Parr JA, Buckwalter KA, Choplin RH (2012). "CT of the hip prosthesis: appearance of components, fixation, and complications". <i>Radiographics</i>. <b>32</b> (4): 1089–1107. <a href="/info/en/?search=Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a class="external text" href="https://doi.org/10.1148%2Frg.324115183">10.1148/rg.324115183</a>. <a href="/info/en/?search=PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a class="external text" href="https://pubmed.ncbi.nlm.nih.gov/22786996">22786996</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=Radiographics&rft.atitle=CT+of+the+hip+prosthesis%3A+appearance+of+components%2C+fixation%2C+and+complications&rft.volume=32&rft.issue=4&rft.pages=1089-1107&rft.date=2012&rft_id=info%3Adoi%2F10.1148%2Frg.324115183&rft_id=info%3Apmid%2F22786996&rft.aulast=Roth&rft.aufirst=TD&rft.au=Maertz%2C+NA&rft.au=Parr%2C+JA&rft.au=Buckwalter%2C+KA&rft.au=Choplin%2C+RH&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-32"><span class="mw-cite-backlink"><b><a href="#cite_ref-32">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite id="CITEREFBreuschMalchau2005" class="citation book cs1">Breusch S, Malchau H (2005). <a class="external text" href="https://books.google.com/books?id=PQ6NZAeJUXcC&pg=PA337"><i>The Well-Cemented Total Hip Arthroplasty: Theory and Practice</i></a>. Springer Science & Business Media. p. 336. <a href="/info/en/?search=ISBN_(identifier)" class="mw-redirect" title="ISBN (identifier)">ISBN</a> <a href="/info/en/?search=Special:BookSources/978-3-540-24197-3" title="Special:BookSources/978-3-540-24197-3"><bdi>978-3-540-24197-3</bdi></a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=book&rft.btitle=The+Well-Cemented+Total+Hip+Arthroplasty%3A+Theory+and+Practice&rft.pages=336&rft.pub=Springer+Science+%26+Business+Media&rft.date=2005&rft.isbn=978-3-540-24197-3&rft.aulast=Breusch&rft.aufirst=S&rft.au=Malchau%2C+H&rft_id=https%3A%2F%2Fbooks.google.com%2Fbooks%3Fid%3DPQ6NZAeJUXcC%26pg%3DPA337&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-95"><span class="mw-cite-backlink"><b><a href="#cite_ref-95">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite id="CITEREFBrandMontManring2011" class="citation journal cs1">Brand RA, Mont MA, Manring MM (June 2011). <a class="external text" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3094624">"Biographical sketch: Themistocles Gluck (1853-1942)"</a>. <i>Clinical Orthopaedics and Related Research</i>. <b>469</b> (6): 1525–1527. <a href="/info/en/?search=Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a class="external text" href="https://doi.org/10.1007%2Fs11999-011-1836-8">10.1007/s11999-011-1836-8</a>. <a href="/info/en/?search=PMC_(identifier)" class="mw-redirect" title="PMC (identifier)">PMC</a> <span class="id-lock-free" title="Freely accessible"><a class="external text" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3094624">3094624</a></span>. <a href="/info/en/?search=PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a class="external text" href="https://pubmed.ncbi.nlm.nih.gov/21403990">21403990</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=Clinical+Orthopaedics+and+Related+Research&rft.atitle=Biographical+sketch%3A+Themistocles+Gluck+%281853-1942%29&rft.volume=469&rft.issue=6&rft.pages=1525-1527&rft.date=2011-06&rft_id=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC3094624%23id-name%3DPMC&rft_id=info%3Apmid%2F21403990&rft_id=info%3Adoi%2F10.1007%2Fs11999-011-1836-8&rft.aulast=Brand&rft.aufirst=RA&rft.au=Mont%2C+MA&rft.au=Manring%2C+MM&rft_id=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC3094624&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-pmid16089067-96"><span class="mw-cite-backlink"><b><a href="#cite_ref-pmid16089067_96-0">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite id="CITEREFGomezMorcuende2005" class="citation journal cs1">Gomez PF, Morcuende JA (2005). <a class="external text" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888777">"Early attempts at hip arthroplasty--1700s to 1950s"</a>. <i>The Iowa Orthopaedic Journal</i>. <b>25</b>: 25–29. <a href="/info/en/?search=PMC_(identifier)" class="mw-redirect" title="PMC (identifier)">PMC</a> <span class="id-lock-free" title="Freely accessible"><a class="external text" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888777">1888777</a></span>. <a href="/info/en/?search=PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a class="external text" href="https://pubmed.ncbi.nlm.nih.gov/16089067">16089067</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=The+Iowa+Orthopaedic+Journal&rft.atitle=Early+attempts+at+hip+arthroplasty--1700s+to+1950s&rft.volume=25&rft.pages=25-29&rft.date=2005&rft_id=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC1888777%23id-name%3DPMC&rft_id=info%3Apmid%2F16089067&rft.aulast=Gomez&rft.aufirst=PF&rft.au=Morcuende%2C+JA&rft_id=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC1888777&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-:1-97"><span class="mw-cite-backlink">^ <a href="#cite_ref-:1_97-0"><sup><i><b>a</b></i></sup></a> <a href="#cite_ref-:1_97-1"><sup><i><b>b</b></i></sup></a> <a href="#cite_ref-:1_97-2"><sup><i><b>c</b></i></sup></a> <a href="#cite_ref-:1_97-3"><sup><i><b>d</b></i></sup></a> <a href="#cite_ref-:1_97-4"><sup><i><b>e</b></i></sup></a> <a href="#cite_ref-:1_97-5"><sup><i><b>f</b></i></sup></a> <a href="#cite_ref-:1_97-6"><sup><i><b>g</b></i></sup></a> <a href="#cite_ref-:1_97-7"><sup><i><b>h</b></i></sup></a></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite id="CITEREFBotaNistorCaterevTodor2021" class="citation journal cs1">Bota NC, Nistor DV, Caterev S, Todor A (March 2021). <a class="external text" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8054655">"Historical overview of hip arthroplasty: From humble beginnings to a high-tech future"</a>. <i>Orthopedic Reviews</i>. <b>13</b> (1): 8773. <a href="/info/en/?search=Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a class="external text" href="https://doi.org/10.4081%2For.2021.8773">10.4081/or.2021.8773</a>. <a href="/info/en/?search=PMC_(identifier)" class="mw-redirect" title="PMC (identifier)">PMC</a> <span class="id-lock-free" title="Freely accessible"><a class="external text" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8054655">8054655</a></span>. <a href="/info/en/?search=PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a class="external text" href="https://pubmed.ncbi.nlm.nih.gov/33897987">33897987</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=Orthopedic+Reviews&rft.atitle=Historical+overview+of+hip+arthroplasty%3A+From+humble+beginnings+to+a+high-tech+future&rft.volume=13&rft.issue=1&rft.pages=8773&rft.date=2021-03&rft_id=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC8054655%23id-name%3DPMC&rft_id=info%3Apmid%2F33897987&rft_id=info%3Adoi%2F10.4081%2For.2021.8773&rft.aulast=Bota&rft.aufirst=NC&rft.au=Nistor%2C+DV&rft.au=Caterev%2C+S&rft.au=Todor%2C+A&rft_id=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC8054655&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-:2-98"><span class="mw-cite-backlink">^ <a href="#cite_ref-:2_98-0"><sup><i><b>a</b></i></sup></a> <a href="#cite_ref-:2_98-1"><sup><i><b>b</b></i></sup></a> <a href="#cite_ref-:2_98-2"><sup><i><b>c</b></i></sup></a> <a href="#cite_ref-:2_98-3"><sup><i><b>d</b></i></sup></a> <a href="#cite_ref-:2_98-4"><sup><i><b>e</b></i></sup></a> <a href="#cite_ref-:2_98-5"><sup><i><b>f</b></i></sup></a></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite id="CITEREFKnightAujlaBiswas2011" class="citation journal cs1">Knight SR, Aujla R, Biswas SP (September 2011). <a class="external text" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3257425">"Total Hip Arthroplasty - over 100 years of operative history"</a>. <i>Orthopedic Reviews</i>. <b>3</b> (2): e16. <a href="/info/en/?search=Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a class="external text" href="https://doi.org/10.4081%2For.2011.e16">10.4081/or.2011.e16</a>. <a href="/info/en/?search=PMC_(identifier)" class="mw-redirect" title="PMC (identifier)">PMC</a> <span class="id-lock-free" title="Freely accessible"><a class="external text" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3257425">3257425</a></span>. <a href="/info/en/?search=PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a class="external text" href="https://pubmed.ncbi.nlm.nih.gov/22355482">22355482</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=Orthopedic+Reviews&rft.atitle=Total+Hip+Arthroplasty+-+over+100+years+of+operative+history&rft.volume=3&rft.issue=2&rft.pages=e16&rft.date=2011-09&rft_id=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC3257425%23id-name%3DPMC&rft_id=info%3Apmid%2F22355482&rft_id=info%3Adoi%2F10.4081%2For.2011.e16&rft.aulast=Knight&rft.aufirst=SR&rft.au=Aujla%2C+R&rft.au=Biswas%2C+SP&rft_id=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC3257425&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-:8-99"><span class="mw-cite-backlink">^ <a href="#cite_ref-:8_99-0"><sup><i><b>a</b></i></sup></a> <a href="#cite_ref-:8_99-1"><sup><i><b>b</b></i></sup></a> <a href="#cite_ref-:8_99-2"><sup><i><b>c</b></i></sup></a></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite id="CITEREFReynolds2006" class="citation book cs1">Reynolds LA (2006). <i>Early Development of Total Hip Replacement</i>. Wellcome Trust Centre for the History of Medicine, University College London, UK. <a href="/info/en/?search=ISBN_(identifier)" class="mw-redirect" title="ISBN (identifier)">ISBN</a> <a href="/info/en/?search=Special:BookSources/978-085484-111-0" title="Special:BookSources/978-085484-111-0"><bdi>978-085484-111-0</bdi></a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=book&rft.btitle=Early+Development+of+Total+Hip+Replacement&rft.pub=Wellcome+Trust+Centre+for+the+History+of+Medicine%2C+University+College+London%2C+UK&rft.date=2006&rft.isbn=978-085484-111-0&rft.aulast=Reynolds&rft.aufirst=LA&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-100"><span class="mw-cite-backlink"><b><a href="#cite_ref-100">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation news cs1"><a class="external text" href="https://orthopedics.about.com/cs/jointreplacement1/p/austinmoore.htm">"What You Need to Know About Joint Replacement Surgery"</a>. <i>Verywell Health</i>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=Verywell+Health&rft.atitle=What+You+Need+to+Know+About+Joint+Replacement+Surgery&rft_id=http%3A%2F%2Forthopedics.about.com%2Fcs%2Fjointreplacement1%2Fp%2Faustinmoore.htm&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-101"><span class="mw-cite-backlink"><b><a href="#cite_ref-101">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://www.thesteadmanclinic.com/news/dr-matta-and-anterior-approach">"Dr. Matta and Anterior Approach"</a>. Steadman Clinic. September 5, 2017<span class="reference-accessdate">. Retrieved <span class="nowrap">March 26,</span> 2023</span>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=Dr.+Matta+and+Anterior+Approach&rft.pub=Steadman+Clinic&rft.date=2017-09-05&rft_id=https%3A%2F%2Fwww.thesteadmanclinic.com%2Fnews%2Fdr-matta-and-anterior-approach&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-:3-102"><span class="mw-cite-backlink">^ <a href="#cite_ref-:3_102-0"><sup><i><b>a</b></i></sup></a> <a href="#cite_ref-:3_102-1"><sup><i><b>b</b></i></sup></a></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co177040/hip-prosthesis-artificial-hip-joint">"Vitallium Hip prosthesis, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=Vitallium+Hip+prosthesis%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco177040%2Fhip-prosthesis-artificial-hip-joint&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-103"><span class="mw-cite-backlink"><b><a href="#cite_ref-103">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite id="CITEREFGomezMorcuende2005" class="citation journal cs1">Gomez PF, Morcuende JA (2005). <a class="external text" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888784">"A historical and economic perspective on Sir John Charnley, Chas F. Thackray Limited, and the early arthoplasty industry"</a>. <i>The Iowa Orthopaedic Journal</i>. <b>25</b>: 30–37. <a href="/info/en/?search=PMC_(identifier)" class="mw-redirect" title="PMC (identifier)">PMC</a> <span class="id-lock-free" title="Freely accessible"><a class="external text" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888784">1888784</a></span>. <a href="/info/en/?search=PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a class="external text" href="https://pubmed.ncbi.nlm.nih.gov/16089068">16089068</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=The+Iowa+Orthopaedic+Journal&rft.atitle=A+historical+and+economic+perspective+on+Sir+John+Charnley%2C+Chas+F.+Thackray+Limited%2C+and+the+early+arthoplasty+industry&rft.volume=25&rft.pages=30-37&rft.date=2005&rft_id=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC1888784%23id-name%3DPMC&rft_id=info%3Apmid%2F16089068&rft.aulast=Gomez&rft.aufirst=PF&rft.au=Morcuende%2C+JA&rft_id=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC1888784&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-:4-104"><span class="mw-cite-backlink">^ <a href="#cite_ref-:4_104-0"><sup><i><b>a</b></i></sup></a> <a href="#cite_ref-:4_104-1"><sup><i><b>b</b></i></sup></a></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co8601382/thompson-type-prosthesis-for-hip-replacement-hip-prosthesis">"Thompson type prosthesis for hip replacement, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=Thompson+type+prosthesis+for+hip+replacement%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco8601382%2Fthompson-type-prosthesis-for-hip-replacement-hip-prosthesis&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-:5-105"><span class="mw-cite-backlink">^ <a href="#cite_ref-:5_105-0"><sup><i><b>a</b></i></sup></a> <a href="#cite_ref-:5_105-1"><sup><i><b>b</b></i></sup></a></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co8601383/thompson-type-prosthesis-for-hip-replacement-hip-prosthesis">"Thompson type prosthesis for hip replacement, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=Thompson+type+prosthesis+for+hip+replacement%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco8601383%2Fthompson-type-prosthesis-for-hip-replacement-hip-prosthesis&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-:6-106"><span class="mw-cite-backlink">^ <a href="#cite_ref-:6_106-0"><sup><i><b>a</b></i></sup></a> <a href="#cite_ref-:6_106-1"><sup><i><b>b</b></i></sup></a></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co8601387/austin-moore-type-prosthesis-for-hip-replacement-hip-prosthesis">"Austin Moore type prosthesis for hip replacement, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=Austin+Moore+type+prosthesis+for+hip+replacement%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco8601387%2Faustin-moore-type-prosthesis-for-hip-replacement-hip-prosthesis&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-107"><span class="mw-cite-backlink"><b><a href="#cite_ref-107">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co179831/vitallium-hip-prosthesis-prosthesis">"Vitallium Hip Prosthesis, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=Vitallium+Hip+Prosthesis%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco179831%2Fvitallium-hip-prosthesis-prosthesis&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
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<li id="cite_note-108"><span class="mw-cite-backlink"><b><a href="#cite_ref-108">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co179832/vitallium-hip-prosthesis-prosthesis">"Vitallium Hip prosthesis, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=Vitallium+Hip+prosthesis%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco179832%2Fvitallium-hip-prosthesis-prosthesis&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
</li>
<li id="cite_note-109"><span class="mw-cite-backlink"><b><a href="#cite_ref-109">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co179830/vitallium-total-hip-prosthesis-prosthesis">"Vitallium total hip prosthesis, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=Vitallium+total+hip+prosthesis%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco179830%2Fvitallium-total-hip-prosthesis-prosthesis&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
</li>
<li id="cite_note-:7-110"><span class="mw-cite-backlink"><b><a href="#cite_ref-:7_110-0">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co8601390/ringed-titanium-hip-prosthesis-with-screw-stem-hip-prosthesis">"Ringed titanium hip prosthesis with screw stem, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=Ringed+titanium+hip+prosthesis+with+screw+stem%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco8601390%2Fringed-titanium-hip-prosthesis-with-screw-stem-hip-prosthesis&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
</li>
<li id="cite_note-111"><span class="mw-cite-backlink"><b><a href="#cite_ref-111">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co8601379/modular-hip-prosthesis-with-textured-femoral-stem-hip-prosthesis">"Modular hip prosthesis with textured femoral stem, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=Modular+hip+prosthesis+with+textured+femoral+stem%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco8601379%2Fmodular-hip-prosthesis-with-textured-femoral-stem-hip-prosthesis&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
</li>
<li id="cite_note-112"><span class="mw-cite-backlink"><b><a href="#cite_ref-112">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co503279/replacement-hip-joint-united-states-1998-artificial-hip-joint">"Replacement hip joint, United States, 1998, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=Replacement+hip+joint%2C+United+States%2C+1998%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco503279%2Freplacement-hip-joint-united-states-1998-artificial-hip-joint&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
</li>
<li id="cite_note-113"><span class="mw-cite-backlink"><b><a href="#cite_ref-113">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co8082322/anthology-hip-system-artificial-hip-joint">"ANTHOLOGY Hip System, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=ANTHOLOGY+Hip+System%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco8082322%2Fanthology-hip-system-artificial-hip-joint&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
</li>
<li id="cite_note-114"><span class="mw-cite-backlink"><b><a href="#cite_ref-114">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co8082323/echelon-hip-system-artificial-hip-joint">"ECHELON Hip System, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=ECHELON+Hip+System%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco8082323%2Fechelon-hip-system-artificial-hip-joint&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
</li>
<li id="cite_note-115"><span class="mw-cite-backlink"><b><a href="#cite_ref-115">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co178705/instrument-set-for-austin-moore-hip-replacement-orthopaedic-instrument-sets">"Instrument set for Austin-Moore hip replacement, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=Instrument+set+for+Austin-Moore+hip+replacement%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco178705%2Finstrument-set-for-austin-moore-hip-replacement-orthopaedic-instrument-sets&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
</li>
<li id="cite_note-116"><span class="mw-cite-backlink"><b><a href="#cite_ref-116">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co178700/instrument-set-by-downs-ltd-for-ring-hip-prothesi-orthopaedic-instrument-sets">"Instrument set by Downs Ltd. for ring hip prosthesis, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=Instrument+set+by+Downs+Ltd.+for+ring+hip+prosthesis%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco178700%2Finstrument-set-by-downs-ltd-for-ring-hip-prothesi-orthopaedic-instrument-sets&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
</li>
<li id="cite_note-117"><span class="mw-cite-backlink"><b><a href="#cite_ref-117">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co8002596/prototype-version-of-the-dobbie-bone-saw-england-1966-surgical-saw">"Prototype version of the Dobbie bone saw, England, 1966, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=Prototype+version+of+the+Dobbie+bone+saw%2C+England%2C+1966%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco8002596%2Fprototype-version-of-the-dobbie-bone-saw-england-1966-surgical-saw&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
</li>
<li id="cite_note-118"><span class="mw-cite-backlink"><b><a href="#cite_ref-118">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite class="citation web cs1"><a class="external text" href="https://collection.sciencemuseumgroup.org.uk/objects/co8002598/prototype-version-of-the-dobbie-bone-saw-england-1967-surgical-saw">"Prototype version of the Dobbie bone saw, England, 1967, Science Museum Group Collection"</a>. 2022.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=Prototype+version+of+the+Dobbie+bone+saw%2C+England%2C+1967%2C+Science+Museum+Group+Collection&rft.date=2022&rft_id=https%3A%2F%2Fcollection.sciencemuseumgroup.org.uk%2Fobjects%2Fco8002598%2Fprototype-version-of-the-dobbie-bone-saw-england-1967-surgical-saw&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
</li>
<li id="cite_note-119"><span class="mw-cite-backlink"><b><a href="#cite_ref-119">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1215172403"><cite id="CITEREFHurley2011" class="citation web cs1">Hurley S (2011). <a class="external text" href="https://blog.sciencemuseum.org.uk/prototypes/">"<span class="cs1-kern-left"></span>"Prototypes", Science Museum Blog (April 2011)"</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=unknown&rft.btitle=%22Prototypes%22%2C+Science+Museum+Blog+%28April+2011%29&rft.date=2011&rft.aulast=Hurley&rft.aufirst=S&rft_id=https%3A%2F%2Fblog.sciencemuseum.org.uk%2Fprototypes%2F&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHip+replacement" class="Z3988"></span></span>
</li>
</ol></div></div>
<h2><span class="mw-headline" id="External_links">External links</span><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="https://en.wikipedia.org/?title=Hip_replacement&action=edit&section=39" title="Edit section: External links"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></h2>
<ul><li><a class="external text" href="https://web.archive.org/web/20060619082711/http://www.edheads.org/activities/hip/">Edheads Virtual Hip Surgery + Surgery Photos</a></li></ul>
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.navbar-collapse{float:left;text-align:left}.mw-parser-output .navbar-boxtext{word-spacing:0}.mw-parser-output .navbar ul{display:inline-block;white-space:nowrap;line-height:inherit}.mw-parser-output .navbar-brackets::before{margin-right:-0.125em;content:"[ "}.mw-parser-output .navbar-brackets::after{margin-left:-0.125em;content:" ]"}.mw-parser-output .navbar li{word-spacing:-0.125em}.mw-parser-output .navbar a>span,.mw-parser-output .navbar a>abbr{text-decoration:inherit}.mw-parser-output .navbar-mini abbr{font-variant:small-caps;border-bottom:none;text-decoration:none;cursor:inherit}.mw-parser-output .navbar-ct-full{font-size:114%;margin:0 7em}.mw-parser-output .navbar-ct-mini{font-size:114%;margin:0 4em}</style><div class="navbar plainlinks hlist navbar-mini"><ul><li class="nv-view"><a href="/info/en/?search=Template:Bone,_cartilage,_and_joint_procedures" title="Template:Bone, cartilage, and joint procedures"><abbr title="View this template" style=";;background:none transparent;border:none;box-shadow:none;padding:0;">v</abbr></a></li><li class="nv-talk"><a href="/info/en/?search=Template_talk:Bone,_cartilage,_and_joint_procedures" title="Template talk:Bone, cartilage, and joint procedures"><abbr title="Discuss this template" style=";;background:none transparent;border:none;box-shadow:none;padding:0;">t</abbr></a></li><li class="nv-edit"><a href="/info/en/?search=Special:EditPage/Template:Bone,_cartilage,_and_joint_procedures" title="Special:EditPage/Template:Bone, cartilage, and joint procedures"><abbr title="Edit this template" style=";;background:none transparent;border:none;box-shadow:none;padding:0;">e</abbr></a></li></ul></div><div id="Procedures_involving_bones_and_joints" style="font-size:114%;margin:0 4em">Procedures involving <a href="/info/en/?search=Bone" title="Bone">bones</a> and joints</div></th></tr><tr><td class="navbox-abovebelow" colspan="2"><div><a href="/info/en/?search=Orthopedic_surgery" title="Orthopedic surgery">Orthopedic surgery</a></div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/info/en/?search=Bone" title="Bone">Bones</a></th><td class="navbox-list-with-group navbox-list navbox-odd hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%">Face</th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em">
<ul><li><a href="/info/en/?search=Jaw_reduction" title="Jaw reduction">Jaw reduction</a></li>
<li><a href="/info/en/?search=Orthognathic_surgery" title="Orthognathic surgery">Orthognathic surgery</a></li>
<li><a href="/info/en/?search=Chin_augmentation" title="Chin augmentation">Chin augmentation</a></li></ul>
</div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Spine</th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em">
<ul><li><a href="/info/en/?search=Coccygectomy" title="Coccygectomy">Coccygectomy</a></li>
<li><a href="/info/en/?search=Laminotomy" title="Laminotomy">Laminotomy</a></li>
<li><a href="/info/en/?search=Laminectomy" title="Laminectomy">Laminectomy</a></li>
<li><a href="/info/en/?search=Laminoplasty" title="Laminoplasty">Laminoplasty</a></li>
<li><a href="/info/en/?search=Corpectomy" title="Corpectomy">Corpectomy</a></li>
<li><a href="/info/en/?search=Facetectomy" title="Facetectomy">Facetectomy</a></li>
<li><a href="/info/en/?search=Foraminotomy" title="Foraminotomy">Foraminotomy</a></li>
<li><a href="/info/en/?search=Vertebral_fixation" title="Vertebral fixation">Vertebral fixation</a></li>
<li><a href="/info/en/?search=Vertebral_augmentation" title="Vertebral augmentation">Vertebral augmentation</a></li></ul>
</div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Arm</th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em">
<ul><li><a href="/info/en/?search=Acromioplasty" title="Acromioplasty">Acromioplasty</a></li></ul>
</div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Leg</th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em">
<ul><li><a href="/info/en/?search=Femoral_head_ostectomy" title="Femoral head ostectomy">Femoral head ostectomy</a></li>
<li><a href="/info/en/?search=Astragalectomy" title="Astragalectomy">Astragalectomy</a></li>
<li><a href="/info/en/?search=Distraction_osteogenesis" title="Distraction osteogenesis">Distraction osteogenesis</a></li>
<li><a href="/info/en/?search=Ilizarov_apparatus" title="Ilizarov apparatus">Ilizarov apparatus</a></li>
<li><a href="/info/en/?search=Phemister_graft" title="Phemister graft">Phemister graft</a></li></ul>
</div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">General</th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em">
<ul><li><a href="/info/en/?search=Ostectomy" title="Ostectomy">Ostectomy</a></li>
<li><a href="/info/en/?search=Bone_grafting" title="Bone grafting">Bone grafting</a></li>
<li><a href="/info/en/?search=Osteotomy" title="Osteotomy">Osteotomy</a></li>
<li><a href="/info/en/?search=Epiphysiodesis" title="Epiphysiodesis">Epiphysiodesis</a></li>
<li><a href="/info/en/?search=Reduction_(orthopedic_surgery)" title="Reduction (orthopedic surgery)">Reduction</a></li>
<li><a href="/info/en/?search=Internal_fixation" title="Internal fixation">Internal fixation</a></li>
<li><a href="/info/en/?search=External_fixation" title="External fixation">External fixation</a></li>
<li><a href="/info/en/?search=Tension_band_wiring" title="Tension band wiring">Tension band wiring</a></li></ul>
</div></td></tr></tbody></table><div></div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/info/en/?search=Cartilage" title="Cartilage">Cartilage</a></th><td class="navbox-list-with-group navbox-list navbox-even hlist" style="width:100%;padding:0"><div style="padding:0 0.25em">
<ul><li><a href="/info/en/?search=Articular_cartilage_repair" title="Articular cartilage repair">Articular cartilage repair</a>
<ul><li><a href="/info/en/?search=Microfracture_surgery" title="Microfracture surgery">Microfracture surgery</a></li></ul></li>
<li><a href="/info/en/?search=Knee_cartilage_replacement_therapy" title="Knee cartilage replacement therapy">Knee cartilage replacement therapy</a></li>
<li><a href="/info/en/?search=Autologous_chondrocyte_implantation" title="Autologous chondrocyte implantation">Autologous chondrocyte implantation</a></li></ul>
</div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/info/en/?search=Joint" title="Joint">Joints</a></th><td class="navbox-list-with-group navbox-list navbox-odd hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/info/en/?search=Human_vertebral_column" class="mw-redirect" title="Human vertebral column">Spine</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em">
<ul><li><a href="/info/en/?search=Arthrodesis" title="Arthrodesis">Arthrodesis</a>
<ul><li><a href="/info/en/?search=Spinal_fusion" title="Spinal fusion">Spinal fusion</a></li></ul></li>
<li><a href="/info/en/?search=Intervertebral_disc" title="Intervertebral disc">Intervertebral discs</a>
<ul><li><a href="/info/en/?search=Discectomy" title="Discectomy">Discectomy</a></li>
<li><a href="/info/en/?search=Intervertebral_disc_annuloplasty" title="Intervertebral disc annuloplasty">Annuloplasty</a></li>
<li><a href="/info/en/?search=Intervertebral_disc_arthroplasty" title="Intervertebral disc arthroplasty">Arthroplasty</a></li></ul></li></ul>
</div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Arm</th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em">
<ul><li><a href="/info/en/?search=Shoulder_surgery" title="Shoulder surgery">Shoulder surgery</a>
<ul><li><a href="/info/en/?search=Shoulder_replacement" title="Shoulder replacement">Shoulder replacement</a></li>
<li><a href="/info/en/?search=Bankart_repair" title="Bankart repair">Bankart repair</a></li>
<li><a href="/info/en/?search=Weaver%E2%80%93Dunn_procedure" title="Weaver–Dunn procedure">Weaver–Dunn procedure</a></li></ul></li>
<li><a href="/info/en/?search=Ulnar_collateral_ligament_reconstruction" title="Ulnar collateral ligament reconstruction">Ulnar collateral ligament reconstruction</a></li>
<li><a href="/info/en/?search=Hand_surgery" title="Hand surgery">Hand surgery</a>
<ul><li><a href="/info/en/?search=Brunelli_procedure" title="Brunelli procedure">Brunelli procedure</a></li>
<li><a href="/info/en/?search=Finger_joint_replacement" title="Finger joint replacement">Finger joint replacement</a></li></ul></li></ul>
</div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Leg</th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em">
<ul><li><a href="/info/en/?search=Hip_resurfacing" title="Hip resurfacing">Hip resurfacing</a></li>
<li><a class="mw-selflink selflink">Hip replacement</a></li>
<li><a href="/info/en/?search=Rotationplasty" title="Rotationplasty">Rotationplasty</a></li>
<li><a href="/info/en/?search=Anterior_cruciate_ligament_reconstruction" title="Anterior cruciate ligament reconstruction">Anterior cruciate ligament reconstruction</a></li>
<li><a href="/info/en/?search=Knee_replacement" title="Knee replacement">Knee replacement</a>/<a href="/info/en/?search=Unicompartmental_knee_arthroplasty" title="Unicompartmental knee arthroplasty">Unicompartmental knee arthroplasty</a></li>
<li><a href="/info/en/?search=Ankle_fusion" title="Ankle fusion">Ankle fusion</a></li>
<li><a href="/info/en/?search=Ankle_replacement" title="Ankle replacement">Ankle replacement</a></li>
<li><a href="/info/en/?search=Brostr%C3%B6m_procedure" title="Broström procedure">Broström procedure</a></li>
<li><a href="/info/en/?search=Triple_arthrodesis" title="Triple arthrodesis">Triple arthrodesis</a></li></ul>
</div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">General</th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em">
<ul><li><a href="/info/en/?search=Arthrotomy" title="Arthrotomy">Arthrotomy</a></li>
<li><a href="/info/en/?search=Arthroplasty" title="Arthroplasty">Arthroplasty</a></li>
<li><a href="/info/en/?search=Synovectomy" title="Synovectomy">Synovectomy</a></li>
<li><a href="/info/en/?search=Arthroscopy" title="Arthroscopy">Arthroscopy</a></li>
<li><a href="/info/en/?search=Joint_replacement" title="Joint replacement">Joint replacement</a></li>
<li><i>imaging:</i>
<ul><li><a href="/info/en/?search=Arthrogram" title="Arthrogram">Arthrogram</a></li>
<li><a href="/info/en/?search=Arthrocentesis" title="Arthrocentesis">Arthrocentesis</a></li></ul></li>
<li><a href="/info/en/?search=Arthroscopic_lavage" title="Arthroscopic lavage">Arthroscopic lavage</a></li></ul>
</div></td></tr></tbody></table><div></div></td></tr></tbody></table></div>
<div class="navbox-styles"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1129693374"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1061467846"></div><div role="navigation" class="navbox authority-control" aria-label="Navbox" style="padding:3px"><table class="nowraplinks hlist navbox-inner" style="border-spacing:0;background:transparent;color:inherit"><tbody><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/info/en/?search=Help:Authority_control" title="Help:Authority control">Authority control databases</a>: National <span class="mw-valign-text-top noprint" typeof="mw:File/Frameless"><a href="https://www.wikidata.org/wiki/Q32333487#identifiers" title="Edit this at Wikidata"><img alt="Edit this at Wikidata" src="https://upload.wikimedia.org/wikipedia/en/thumb/8/8a/OOjs_UI_icon_edit-ltr-progressive.svg/10px-OOjs_UI_icon_edit-ltr-progressive.svg.png" decoding="async" width="10" height="10" class="mw-file-element" srcset="https://upload.wikimedia.org/wikipedia/en/thumb/8/8a/OOjs_UI_icon_edit-ltr-progressive.svg/15px-OOjs_UI_icon_edit-ltr-progressive.svg.png 1.5x, //upload.wikimedia.org/wikipedia/en/thumb/8/8a/OOjs_UI_icon_edit-ltr-progressive.svg/20px-OOjs_UI_icon_edit-ltr-progressive.svg.png 2x" data-file-width="20" data-file-height="20" /></a></span></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em">
<ul><li><span class="uid"><a class="external text" href="https://olduli.nli.org.il/F/?func=find-b&local_base=NLX10&find_code=UID&request=987007549038905171">Israel</a></span></li>
<li><span class="uid"><a class="external text" href="https://id.loc.gov/authorities/sh90001569">United States</a></span></li></ul>
</div></td></tr></tbody></table></div></div>' |
Whether or not the change was made through a Tor exit node (tor_exit_node) | false |
Unix timestamp of change (timestamp) | '1713887186' |