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(i) Design of Total Hip Replacement

P. S. Walker

are the consequences of long-term osteopaenia and


Introduction
the ease of revision. This article will discuss recent
While some of the traditional designs of total hip such knowledge of the mechanical behaviour of total hip
as the Charnley continue to be widely used, new stems, the biological response, and laboratory
designs are being steadily introduced. The relative methods to both evaluate and predict the in vivo
clinical performance of cemented and uncemented performance of present and new designs.
designs are under constant review while individualised
custom hips are receiving increasing attention. Both
Forces on the Hip
experimental and theoretical studies are becoming
more sophisticated and are attempting to become In the normal hip, the forces which act on the femoral
more accurate predicters of clinical performance. New head, on the greater trochanter, and at other muscle
materials for the components themselves together sites, are transmitted through the cancellous and
with coatings for osseointegration and wear resistance cortical bone, producing a changing set of stresses and
expand the possibilities, especially of uncemented strains in the bone tissue. It is these stresses and
designs. The basis for comparison of any new design strains which are responsible for the maintenance of
is the cemented total hip which gives a low com- bone density and trabecular patterns. After excision
plication rate in the early years and survivorship at of the femoral head and implantation of a total hip,
IO-20 years in the region of 90%, although many of the femoral head force is transmitted from the stem
the surviving hips are not necessarily performing to the bone, producing unnatural stresses and strains
optimally. In contrast, uncemented stems have so far in the bone, including a set of stresses on the endosteal
shown a higher early complication rate, due to thigh interface which are not normally experienced. Any
pain, sinkage, and bone fracture, but there may be analysis of the force transfer requires a description of
significant long-term advantages. The surgical tech- the forces on the femoral head in various activities.
nique of insertion of uncemented stems is more Early data were obtained from direct measurements
demanding because when fitting a rigid stem into an carried out by Rydell in Sweden, and by calculations
almost rigid bone, a small geometrical mismatch can from kinematic and e.m.g. data by Paul and co-
mean the difference between the fit being too tight and workers at Strathclyde University. More recently,
too loose. The long-term results of uncemented stems direct measurements have been carried out on total
such as the Austin Moore were reasonably good, but hip patients using telemetrised stem components., It
did not match the cemented results. However, some of has been found that the line of action of the resultant
the more recent uncemented designs have the benefits force, acting at the centre of pressure of the joint
of more anatomically derived shapes, various coatings contact area, stays within a region over the upper
for osseointegration, and improved instrumentation. surface of the head, with a bias towards the anterior
Some of the factors still to be resolved with all designs aspect (Fig. 1). For level walking at 0.5 m per s, the
peak force was 2.8 times body weight (BW). Straight
leg raising and single leg stance produced forces of
Peter S. Walker PhD, Department of Biomedical Engineering.
Royal National Orthopaedic Hospital Trust (University College
twice body weight. During the stance phase of
London & Middlesex School of Medicine). Stanmore. UK. walking, the force acted at 20 anterior to the vertical