SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Update
article
Total
hip
arthroplasty:
a
still
evolving
technique
夽
Carlos
Roberto
Galia
a,∗,
Cristiano
Valter
Diesel
a,c,
Marcelo
Reuwsaat
Guimarães
a,c,
Tiango
Aguiar
Ribeiro
baUniversidadeFederaldoRioGrandedoSul(UFRGS),FaculdadedeMedicina(FAMED),GrupodeCirurgiadoQuadrildoHospitaldas
ClínicasdePortoAlegre(HCPA),PortoAlegre,RS,Brazil
bUniversidadeFederaldeSantaMaria(UFSM),DepartamentodeCirurgia,Servic¸odeOrtopediaeTraumatologiadoHospital
UniversitáriodeSantaMaria(SOT-HUSM),SantaMaria,RS,Brazil
cUniversidadeFederaldoRioGrandedoSul(UFRGS),ProgramadePós-Graduac¸ãoemMedicina-CiênciasCirúrgicas,PortoAlegre,RS,
Brazil
a
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t
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c
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e
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n
f
o
Articlehistory:
Received16August2016 Accepted5September2016 Availableonline14September2017
Keywords:
Arthroplasty,replacement, hip/methods
Arthroplasty,replacement, hip/surgery
Arthroplasty,replacement, hip/instrumentation Hipprosthesis
a
b
s
t
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Ithasbeenadvocatedthattotalhiparthroplasty(THA)isprobablythemostsuccessful surgi-calinterventionperformedinMedicine.Inthe1960s,SirJohnCharnleynotonlyintroduced, butalsomodifiedandimprovedthetechniqueofcementedarthroplasties.Theconcepts onbiologicalfixationestablishedbyPillarandGalanteservedasthefoundationforthe developmentofuncementedimplantsthatarenowusedworldwide.Currently,THAisa worldwidewidespreadsurgeryperformedonmillionsofpeople.However,keepingabreast ofthelargenumberofinformationavailableontheseprocedures,especiallyonimplant fix-ation,designs,differenttribologicalpairings,andthelong-termresultscanbechallenging attimes.ThisarticleisabriefupdateonthemainaspectsofTHA.
©2017PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileiradeOrtopedia eTraumatologia.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Atualizac¸ão
em
artroplastia
total
de
quadril:
uma
técnica
ainda
em
desenvolvimento
Palavras-chave:
Artroplastiadequadril/métodos Artroplastiadequadril/cirurgia Artroplastiade
quadril/instrumentac¸ão Prótesedequadril
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e
s
u
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o
A artroplastiatotal doquadril(ATQ) éuma dascirurgiasde maiorsucessona história da medicina.Nosanos1960,SirJohnCharnleyintroduziueaperfeic¸oouasartroplastias cimentadas. PillareGalanteestabeleceramosconceitos dafixac¸ãobiológica,basepara odesenvolvimentodasartroplastiasnãocimentadas.Atualmente,aATQéumacirurgia mundialmentedifundidaefeitaemmilhõesdepessoas.Noentanto,ograndenúmerode
夽
PaperdevelopedatHospitaldeClínicasdePortoAlegre,DepartamentodeCirurgia,Servic¸odeTraumatologiaeOrtopedia,PortoAlegre, RS,Brazil.
∗ Correspondingauthor.
E-mail:[email protected](C.R.Galia). http://dx.doi.org/10.1016/j.rboe.2016.09.011
informac¸õesdisponíveissobreasartroplastias,especialmentequantoàformadefixac¸ãodo implanteaoosso,aosdiferentesdesignsdashastesedosacetábulos,aosdiferentespares tribológicoseaosresultadosnolongoprazoporvezesdificultaatomadadedecisão.Este artigoéumabreveatualizac¸ãosobreosprincipaisaspectosdaATQ.
©2017PublicadoporElsevierEditoraLtda.emnomedeSociedadeBrasileirade OrtopediaeTraumatologia.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Hiparthroplastyisconsideredoneofthemajoradvancesin thetreatment oforthopedicdiseases,andoneofthe most performedsurgeriesintheworld.1Duetorapidrecoveryand
returntomostactivitiesofdailyliving,itisconsideredoneof thefewmedicalproceduresthatbenefitthepatientasawhole, andtheoperationwithbestresultsinorthopedics.2
Thebasisofthissurgerydatesbacktotheendofthe19th century, whenThemistoclesGluck demonstrated the toler-anceofthehumanbodytoforeignbodies.Smith-Petersen,in 1923,apudCallaghanetal.,3developedstudieswith
prosthe-siscoatedwithglass,bakeliteandsyntheticresins,andPhilipe Wiles,in1938,elaboratedtheconceptofthefirstTHA.
SirJohnCharnleywasresponsibleforthegreatprogress ofTHA,4who developedthe conceptoflowfriction
arthro-plastybytheuseoffemoralheadswith22mmofdiameter, and theassociation ofhigh molecularweight polyethylene withmethylmethacrylate,withthislattermaterialbeingused underthe influenceofLeon Wiltsie apudCharnley.5 There
hasbeenagrowingsearchtoimprove cementationquality. Krauseetal.6developedthelowviscositycement;Harrisetal.7
describedtechniquestoimprovecementation,andLeeetal.8
emphasizedtheimportanceofcementpressurizing.
For a long time, the failures ofarthroplastiesand large osteolyseswereattributedtobonecement, andwerecalled “cementdisease”.Thishasmotivatedseveralresearchersto developuncementedprostheses.
Bobyn et al.9 and Galante10 introduced the concepts of
uncementedarthroplasties,hadpressfitandboneintegration asformsoffixationbetweentheboneandtheimplant.This modeoffixationisknownasbiologicalfixation.Severalother authorshaveproposedandintroducedprostheticmaterials, devicesanddesignstofacilitatebiologicalfixation.
Despite the success of this surgery, the search for its improvementandbetterresults,especiallylongtermresults continues,mainlyinthedevelopmentofnewsurfaces, mate-rialswithgreaterbiocompatibility,andlessaggressivesurgery techniques.
Accessroutes
THAbeginswiththeselectionofthetypeofapproach.The mainaccessroutesaretheposterior,anterolateralandlateral ones.
Theposteriorapproach, alsocalledMoore’s approach,is currently the most widely used. This route was popular-ized due to the ease of exposure of the acetabulum and femoralcanal.Inaddition,thereisnointerferencewiththe
hip abductor (gluteusmediusmuscle), and italso showsa lower prevalenceofdeepvein thrombosis(DVT).11 Thereis
agreatertheoreticalpotentialofdislocation,andmore diffi-cultyinmeasuringlowerlimbslength.Intheliterature,the riskofinstabilityiscontroversial,whichcanbeminimizedby reinsertionoftheposteriorcapsule.12,13
Theclassicalanteriorapproachwasdescribedby Smith-Petersen14andO’Brien.15Oneofitspositiveissuesisthatit
does notviolatetendonsand muscles insertions.However, inpatientswithanatomicalchanges,itcanbemoredifficult. Thereisariskofinjurytothelateralcutaneousnerveofthe thigh.Morerecently,theconceptsofthepreviousapproach havebeenadaptedtoanewform,theanteriorrightapproach. Thisroutewouldhavealowertheoreticalriskofdislocation ofthearthroplasty.Itsmorewidespreaduseimpliestheneed forangular(offset)femoralandacetabulardrills,thetraction tableandalonglearningcurve.16
ThelateralorHardinge17approachhasasastrong
argu-ment the ease for implant placement and,theoretically, a lowerriskofinstability.Itwasthemainapproachtothehip foralongtime.However,thereisthepossibilityofinjuryto theinsertionoftheabductormuscles.Insomecases,partial detachmentofthegluteusmediusmuscleisnecessaryfor bet-terexposure.Thismaycauselimpingduetodeficiencyofthe abductivemusculature,thatistransientinmostcases.
Typesofimplantsandtribologicpairing
Basically, implants can be divided into two groups: the cementedandnon-cementedones.Thisdivisionrepresents thedifferentwaysofimplant fixationtothebone,withthe maindifferencebeingthepresenceorabsenceofbonecement (polymethylmethacrylate–PMMA).
The cemented implants use the interposition ofPMMA between boneand implant.PMMAmodulus ofelasticityis veryclosetothatofthebone(cementmodulusofelasticity
±2GPaversus±0.5–1GPaoftrabecularbone),andisresistant tocompressiveforces,butnottostrainorshearforces.18
techniquesofcementmixing(vacuummixingor centrifuga-tion)wereintroduced;however,thesemixingtechniquesare controversialand donotseemtoimprovePMMA mechani-calproperties.20Theintroductionofaproximalcentralizer,
inadditiontothechangesalreadyadopted,characterizedthe fourthgenerationofcementation.21
The absence of bubbles or radiolucent lines between theboneandthecementcharacterizesgoodcementation.22
Anotherparameteristhemantlethickness,considered ade-quatewhenithas2mminthefemoralcanal,22and3mmin
theacetabulum.23Thisroutinepatternofcementationdiffers
fromthecontroversial“Frenchparadox”,awayofcementation inwhichthefemoralcanalisfilledwiththelongest possi-blestem,PMMAoccupyingtheremainingspaces.Thecement mantleisthinandnon-uniform.24
Somefeaturesofcementedfemoralstemsmayinterfere withresults,andshouldbecloselyobserved:
1) Design–thecemented stemscanbeclassifiedassingle wedge,doublewedgeortriple wedge,dependingonthe implantgeometry.ExamplesaretheCharnley,Exeterand C-Stem,respectively.25 Althoughthe triple wedgestems
haveless stress in thecement mantle, theyare related toagreater posteriorrotation26; sofar this stemmodel
hasnotshowntobebetterthan theothers.27Currently,
double-wedgestemsarethemostused.
2) Implantcoverage–thebestresultsareobtainedwith pol-ished(smooth)implants.Therearefemoralstemswitha roughsurface,buttheyarenotwidelyacceptedandtheir long-termresultsarecontroversial.28
3) Material – they are usually manufactured in cobalt–chromium or stainless steel alloy. The implants produced in titanium have shown poorer results than thoseobtainedwithtraditionalmetalalloys.29
Uncementedimplantsaimatobtainingabiologicalfixation betweentheimplantandthebone.Briefly,thereisexpectation ofbonegrowthtotheporositiesofthecomponentsandthus theirdefinitivefixationtothebone.Thepresenceofporosities isanindispensablerequirementintheseimplants.
Anotherrequirementforbonegrowthtooccuristhe imme-diateprimarystabilityobtainedwithcomponentimpaction. Evenverydiscretemovementsattheboneimplantinterface maydelayorhinderosseointegrationandfavortheformation offibroustissue.30–32
Thus,thesuccessofuncementedprosthesesdependson animmediateprimaryfixation(macrolocking)andisensured bythesecondaryfixation(microlocking).Macrolockingshould occuratthe timeofinsertion, and isobtainedbythe inti-mateadjustmentoftheimplanttothebone.Microlockingis theresultofboneingrowth, that is,theformation ofbone bridgesbetweentheboneandtheporesofthecomponent.31
Ultimately,itisthefactorthatdeterminesuncementedTHA longevityandsuccess.
Macrolockingcanbeaidedbyseveralresources, suchas fixationwithscrews,finsorgrooves.Currently,themostused technique is the press-fit, which means the prosthesis is insertedunderpressureinanundersizedcavity.The unce-mentedacetabulumisalsofixedbypress-fit,andscrewsmay ormaynotbeusedasauxiliariesinprimaryfixation.31,32
Osseointegrationalsodependsontheporosity character-istics present in the implant cover. Its size, geometry and interconnectionareimportant.Studieshaveshownthatpore sizeshouldbebetween100mand400m.Poressmallerthan
50morgreaterthan500mfacilitatethegrowthoffibrous
tissue,ratherthanbonetissue.30Therearethreetraditional
typesofcoating:plasmaspray,microspheresandfibermesh.30
inrecentyears,surfacesderivedfromtrabecularmetalhave showntobepromising,butresultswithlongerfollow-upare expected.Itisestimatedthatthepercentageofporosityatthe implantsurfaceisgreaterinthefibermesh–between40%and 50%–andinthetrabecularmetal–between75%and80%.33
Theinterconnectionbetweenporesalsoplaysakeyrole. Thegreatertheinterconnection,thegreaterthebondstrength betweenthebonebridgesandtheprosthesis.Theoretically, the fibermeshandtrabecularmetalcoverageallowsbetter interconnection betweenthe poresincomparisonwiththe othertypes.
Anothercommonlyusedtypeofarthroplastyisthehybrid one.Inthiscase,oneofthecomponentsiscemented,andthe otherisnot.Theprosthesisinwhichtheacetabulumis unce-mented and the femoral stem cemented is conventionally calledhybridarthroplasty.Whentheacetabulumiscemented and thestemisuncemented,itisknownasreversehybrid arthroplasty.
Regarding the weight-bearing surfaces, the most used and studied tribological pairing is the metal-polyethylene one.Ceramic-on-polyethylene,metal-on-metaland ceramic-on-ceramic are alsoused, with the lattertwo being called hard-on-hard.
Currentlythereisatrendforthereplacementofultra-high molecularweightpolyethyleneforcrosslinkedpolyethylene. Thecrosslinkedpolyethyleneresultsfromaseriesof manu-facturinginterventionsthatseektochangethebondsbetween theirmolecules,producingaharderandmorewear-resistant material.34Thelinearwearratewithcrosslinkedisestimated
at0.04mm/yearcomparedto0.22mm/yearofconventional polyethylene.35
Allthenewtribologicalpairsshowlessvolumetricwear, a factthat intheorycan bringbenefitstothe arthroplasty longevity. There are, however, some peculiarities in these pairs.
The metal-on-metalsurface shows extremely low volu-metricwearbutcanreleasechromiumandcobaltionswith potentiallocalandsystemiceffects.Themainlocal complica-tionistheformationofso-calledpseudotumors.36Systemic
effectsincludeneurologicalandcardiacdamage.37Thereisa
carcinogenicpotentialforsystemicreleaseofchromiumand cobalt, althoughthe exact repercussionofthis exposureis notwellknown.Itiscontraindicatedforpatientswithmetal allergyand,duetotransplacentaltransfer,alsoforwomenof childbearingage.38
manufacture, although the triggering factor is not always recognized.39Theriskoffractureoftheceramicliesbetween
0.004%and0.010%,andisusuallyassociatedwithpoor posi-tioningofthecomponents.40Stripewearmayoccurwhenthe
areaofcontactbetweenthefemoralheadandtheacetabular surfacedecreases,causingsmalldisplacementsbetweenthe femoralhead andtheacetabulum;it mayoccurduringthe swingphaseofgait,orwhenthereisanimpactbetweenthe neckandtheacetabulum.Itcancausegreatvolumetricwear. Individualswithtissuehyperlaxity,orwitharangeofmotion thatisaboveexpectations,andthosewhorequireawiderange ofmotionofthehipintheiractivitiesarepronetoimpactand consequentstripewear.41
Thecrosslinkedceramic-on-polyethylenesurfacehasthe benefitsof notreleasing metal ions, it presents no risk of squeaking, and has a very low volumetric wear, although higherthanthatofhard-on-hardsurfaces.Thereisa mini-malriskofceramicheadfracture.Itmayrepresentasuitable optionforyoungpatientswithelementsthatmaycomplicate theuseofothertypesoftribologicalpairs.
The appropriate selection of the implant, whether cementedor not,aswellasthe differenttribologicalpairs, shouldtakethetheoreticalknowledgeaboutthe characteris-ticsofthedesign,materialandlong-termresultsintoaccount, aswellasthepatient’scharacteristicsandthesurgeon’s expe-rience.
Complications
ThecomplicationsassociatedwithTHAmayvaryinspecific groupsofpatients,areinfluencedbyage,gender,bonequality andthepresenceofcomorbidities.Regardingtime,theymay beintraoperative,acute(between30and90daysofsurgery) orchronic.
The number of THAs has increased greatly in recent years,whetherinyoungoroldpeople.Elderlypatientsareat increasedriskofseriousclinicalcomplications.Recentstudies attributedamortalityrateof6.9%inpatientsundergoingTHA. Thisnumbersufferssignificantinterferencefrompre-existing diseasesandfunctionalreserve.
Deep vein thrombosis (DVT) is another important and relativelyfrequentcomplication.Thepercentageof hospital-izationduringthefirst90dayscanreach0.7%ofpatientsand casesofpulmonaryembolismcanaddupto0.3%.When pro-phylaxiswasnotused,theprevalenceofthiseventwasclose to50%incasesofTHA.Atthe6thConferenceofthe Amer-icanCollegeofThoracicSurgery,itwasestablishedthatall patientsundergoingTHAshouldbeconsideredathighriskfor DVT.42Currently,guidelineshavebeendevelopedto
standard-izetheuseofdrugstopreventDVTafterarthroplasty,suchas lowmolecularweightheparins,oralanticoagulants,aspirin, aswellasmechanicalprophylaxis(stockingsandintermittent calfcompressiondevices).Despiteefforts,theidealmethodof thromboprophylaxisremainscontroversial.Theonly consen-susseemstobethebeneficialeffectofearlymobilization,that is,theshortestpossiblereturntoambulation.
THAdislocationisoneofthemostfearedcomplications, andoneofthemaincausesofsurgicalrevision.Itsincidence isestimatedbetween1%and3%,andmostepisodestakeplace inthefirstthreemonthsofsurgery.43Themainriskfactorsare
poorcomponentpositioning,obesity,previoussurgeries,and insufficientabdominalmuscles.44Someriskfactorsaremore
controversial,suchastheposterioraccessroute.Theinitial treatmentisbloodlessreduction,whichissuccessfulinmost cases.Whenitbecomesrecurring,theoption,inmostcases, issurgicaltreatment.
Theincidenceofmajorneurologicallesionsrangesfrom 0.8%to3.5%,thesciaticnervelesionisthemostcommon, fol-lowedbythatofthefemoralnerve.Thefrequencyofthistype oflesionisusuallyinfluencedbythetypeofaccessroute.45
Neurologicallesionswithlessrepercussion,suchasthelateral cutaneousnerveofthethigh,canoccurinupto15%,especially inthedirectanteriorapproach.
VascularlesionsareextremelyrareinTHA,andaremore frequentwhenstructuralbonegrafting,reinforcingrings,or otherdevicesarerequiredincomplexcases,suchaship dys-plasiasandacetabularprotrusions.45Thereisapotentialrisk
of vascular injury during the placement of the screws for acetabularfixation,minimizedbytheknowledgeofthesafety zones,thatis,theposteroinferiorandposterosuperior quad-rants,describedbyWasielewskietal.46
Anothercomplicationisthatoffractures,withthefemur beingthemostaffectedsegment,especiallywhentheimplant ofchoiceisuncemented.Thereare situationsinwhichthe chanceofintraoperativefractureisgreater,suchasinelderly patients with rheumatoid arthritis, inextremely rigid hips whenmorevigorousjointdislocationmaneuversareused.On theacetabularside,fracturesaremuchrarerandrelatedtoan undersizedmillingfortheacetabularcomponentthatwillbe implanted.
Infectionoccursinapproximately1%ofcasesofTHA.Asit isadevastatingcomplication,theidentificationofriskfactors is fundamental for its prevention. International consensus wasmadetodefinediagnosticcriteriaandtherapeutic meas-ures.Mostofthetime,thetreatmentissurgical.When the infection israpidly identified in the immediate postopera-tiveperiod,andistreatedwithdebridementandreplacement oftheprosthesisinterchangeablecomponents,thechanceof cureishigh.Inlate-onsetinfections,THAshouldbereviewed inasinglestageorintwostages.Irrespectiveoftheoption chosen,germidentification,thoroughlocalcleaning,and pro-longedantibiotictreatmentareessential.47
Discussion
Inarthroplasties,aswithanysurgery,theinitialstepisthe carefulselectionofthepatient,theknowledgeofthepatient’s expectationsregardingtreatment,thecloseguidingfor arthro-plastycare,andanaccuratepreoperativeplanning.
that,theimplantitselfischosenbasedonimagingtests, basi-callyhipradiography.
Oneofthegoals ofsurgeryistoreproduce thepatient’s anatomy. The properly performed hip radiography is fun-damental and invaluable for this. It helps identifying specificbonemorphologycharacteristics,suchasthe cervico-diaphyseal angle and the femoral offset, femoral canal diameter, and acetabular cavity size, as well as other aspects such as bone quality, coverage and acetabular depth.
It is well known that the number of complications decreaseswiththesurgeon’sexperienceandtheinstitution wherethesurgerywasperformed.Briefly,thegreaterthe num-berofproceduresperformedbythesurgeonperannum,the lesschanceofcomplicationsandgreaterlikelihoodofsuccess. OneoftheconcernsthatshouldalwaysbepresentisTHA long-termresults.Themostreliableandincreasinglycited ref-erencesisthe nationalarthroplasty registry.Withthedata obtainedinthem,amuchbroaderandatthesametimemuch morein-depthview ofthecauses offailureand successof certainimplantshasbeenpossible.
Themostcommoncausesofhiparthroplastyrevisionare the same in the records and publications. Sometimes the outcomesvaried,dependingonthespecificpopulation stud-ied,but in generalthe reasons and causes forrevisionare thesame:asepticrelease,dislocation,infection,and peripros-theticfractures.48,49
Aworldwidetrendtowardtheuseofuncementedimplants hasbeenobserved.TheNationalRegisterofEngland,Wales andNorthernIreland,publishedin2014,reportedthatin2003, cementedimplantswereusedin60.5%oftheTHAcompared to33.2%intheyear2013;theuncementedimplantsshowed anincreasefrom16.8%to42.5%inthesameperiod.48Thisis
probablyduetothegreaterreproducibilityoftheresultswith uncementedimplantsandthedifficultyintheexecutionofa perfectcementation.
Severalnational registrieshaveobserved thatcemented THAshowedbetterresultsinolderpatients.49,50However,
ref-erencecentersthroughouttheworlddemonstratedupto99% survivalinuncementedfemoralstemsafter12andupto26 yearsoffollow-up.51,52
Studies on the position of the acetabular component point to a better positioning of the cemented acetabula whencompared tothe uncemented acetabula,sincethese would tend to deviate from their original position during impaction.Thisfactshouldbetakenintoconsiderationand all care should be observed during surgery to avoid this problem.Itisalwaysgoodtorememberthatimproper posi-tioningof the acetabulum can bringseveral risks, such as instability, increased polyethylene wear and early aseptic loosening.
The incidence of intraoperative femoral fractures has increasedwiththeuseofuncementedstems.Thighpainis alsomorecommononuncementedstems.However, knowl-edgeoftheimplant,itshabitualuse,andtheexperienceofthe surgeonminimizetheserisks.
The greatest questioning regarding cemented implants relates to reproducibility. To achieve the excellent results publishedbycentersusingcementedimplants,the cement-ing technique should be perfectly performed. For this,
the use of pulsatile lavage irrigation, proper pressur-ization, and a uniform cement mantle are considered prerequisites.
When THAs are performed for treating degenerative osteoarthritis,thenationalregistriespresentsimilardata.The overallrevisionrateforallagesovera10-yearperiodranges from5to6%.Whenwedivideitbythetypeofimplant,the Britishreportarateof3.2%fortotallycemented,7.68%for uncemented,and 3.95%forhybridarthroplasties,whilethe Australianreportratesof6%,5.4%and4.8%respectively.Ifwe separatetheoperationsbygenderandage,youngwomenare atgreaterriskofrevisionintenyears.Areversaloccursifthe arthroplastyisperformedaroundage65,whentheincidence ofrevisionatthatageisslightlyhigherinmen.48,49
Regardingthetribologicalpairs,ifweputasidecostsand somelaboratorytests,thereisnorealevidencefororagainst any ofthese surfaces, exceptforthe metal-on-metal com-bination, whichpresentedinferioroutcomes invirtually all publications. Intheir 2014report, the Australians recorded a very similar10-year revision rateforthe combination of ceramicheadwithceramicorpolyethyleneacetabulum:4.7% and4.5%,respectively.Thelowestrevisionratewouldbefor thecombinationofmetalandcrosslinkedpolyethylene,not toofarfromtheothers,with4.3%overthesameperiod.49In
theBritishreport,ahybridassemblywiththecombinationof crosslinkedceramic–polyethyleneshowedthebest outcome with2.19% offailuresin 10years.48 Thisway,the best
tri-bologicalpairtobeusedremainsopen;webelievethatthe ceramicheadassociatedwithcrosslinkedpolyethylenemay bethebestchoiceatthistime,consideringtherisksand ben-efits.
Thematerialwithwhichthefemoralstemsareproduced, aswellasthesizeoftheheads,alsoinfluencestheresults. Theexclusiveuseoftitaniumseemstopresentalower fail-ureratewhencomparedtocomponentsmadefromtitanium andcobalt-chromium.Theheadsof32mmindiametershow alowerrevisionratewhencomparedtothoseof28mm. How-ever,thereisnodifferencebetweenthoseof32mmcompared tolargerheads.Ithasbeensuggestedthatthisdatamaybe relatedtothehigherincidenceofdislocationfoundwithheads 28mmorsmaller.
Patientreportsregardingtheirsatisfactionwithresults,or PROMs(patient-reportedoutcome)havebecomeincreasingly important.53 In a2012 Swedish report, patient satisfaction
afteroneyearoftotalhiparthroplastyin2010–2011ranged from 82.8 to93.4%.Depression and anxietywere indicated asimportantpredictorsofpost-surgicalpain,painrelief,and overall satisfactionwiththeprocedure.53Thereisnodoubt
thatinthenearfuturepatient’sreportswillplayakeyrolein theprogressofhiparthroplastyandshouldbeinthecenterof attentionbythesurgicalteam.
Conflicts
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Theauthorsdeclarenoconflictsofinterest.
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