1.

Why is the incidence of total hip replacement likely to increase in the next 10–40
years? Give two reasons.

The increased in incidence of Total Hip Replacement (THR) is likely to increase in next 10-
40 years because of various systematic factors (age, gender, lifespan) and biomechanical
factors (obesity, weakness in muscles, nutritional value).

Among many reasons, the first reason is the obesity. Obesity is rapidly increasing among
children and adults and it has tripled in 1975. Obesity and overweight is the factor that
increases the risk of osteoarthritis in individuals. The arthritis foundation notes that Hip joint
bears an additional 6 pounds pressure for every pound gained i.e. even the increase of 10
pounds over a period can add significant pressure on hip resulting in excessive wear and tear.
Therefore, the childhood obesity and adult obesity is one of the main reasons for the total hip
replacement (Flegal et al., 2016, Felson and Zhang, 1998).

The second reason for the high incidence of THR is the nutritional deficiencies due to the
poor eating habits. Vitamin D and Vitamin A deficiency is becoming a global health issue
and even the countries on low altitude have high risks of Vitamin D deficiency in the
population. Vitamin D and Vitamin A deficiency results in high risk of hip osteoarthritis. The
Vitamin A is present in vegetable and fruits while Vitamin D is drawn from sun exposure.
However, the poor dietary habits, unbalanced diets, and lack of exposure to daylight results in
deficiencies, resulting in the need for THR (Felson and Zhang, 1998, Palacios and Gonzalez,
2014, WHO, 2017).

2. Specific design features are incorporated into components to improve their

performance. Briefly describe the reasons why each of the following features are
deemed useful:

2.1. Low-friction articulating surfaces:

The use of low friction articulating surfaces in the THR is deemed necessary because it
reduces the friction in joint which ultimately reduces the wear rates. With polyethylene liner
for the cup, the low-friction articulation delays the aseptic loosening of joint i.e. mechanical
loosening (28).

2.2. Highly polished stem surface in combination with cemented prosthesis.

The highly polished stem surface was commonly used with cemented prosthesis in the early
days. The high polished stem cannot fix itself in the bone and the cementing ensures
mechanical locking. It is used for older and less active individuals (46). The cemented hip
joints result in immediate mechanical fixation (39)
2.3. Hydroxyapatite coating on a press-fit component

The hydroxyapatite is the material which is made up on the same minerals as bone. So, it is
used on the press-fit (uncemented) component or direct contact of bone with the implanted
component to result in a biological bonding with the bone which is known as osseous
integration (39).

2.4. Collar on the shoulder of a femoral stem

The collar on the shoulder of the femoral stem helps to balance axial and proximal loading of
the joint. The collar prevents loosening of cemented joints through reducing bone resorption
and thereby loading of proximal cement (Wheeless, 1996).

2.5. Porous coating on a press-fit acetabular cup

Porous coating helps to form bone ingrowth or mechanical locking of bone into the pores of
prosthetic joint. It is used in uncemented hip replacement to form bone to pores bonding (39).

3. List the four leading failure mechanisms for hip joint replacements that leading to
revision.

The following are the four leading failure mechanisms for hip joint replacement leading to
revision (52)

 Loosening/Osteolysis (27.6%)
 Dislocation (23.5%)
 Fracture (18.7%)
 Infection (17.5%)

4. Aseptic loosening is a leading cause for the failure of total hip implants leading to
revision. Explain the events that precede this situation by describing two avenues
for the formation of wear particles or debris in a cemented hip joint.

Aseptic loosening/osteolysis is the primary reason behind failure leading to revisions in THR.
It results from the accumulation of fibrous tissue between the bone and prosthetic component
(54). In the cemented hip joint, it occurs due to

Wearing of particles form debris between surfaces. It can be because of the degradation of
PMMA cement or due to the wear between polyethylene liner and acetabular component
(55).

The second way of failure is that as particle debris is formed, the loading pumps biological
joint fluids around the debris. It promotes bone resorption due to biological reaction between
particulates and results in mechanical loosening of prosthesis (56).

References

FELSON, D. T. & ZHANG, Y. 1998. An update on the epidemiology of knee and hip
osteoarthritis with a view to prevention. Arthritis & Rheumatology, 41, 1343-1355.
FLEGAL, K. M., KRUSZON-MORAN, D., CARROLL, M. D., FRYAR, C. D. & OGDEN, C. L. 2016.
Trends in obesity among adults in the United States, 2005 to 2014. Jama, 315, 2284-
2291.
PALACIOS, C. & GONZALEZ, L. 2014. Is vitamin D deficiency a major global public health
problem? The Journal of steroid biochemistry and molecular biology, 144, 138-145.
WHEELESS, C. R. 1996. Wheeless' textbook of orthopaedics, CR Wheeless, MD.
WHO 2017. Global prevalence of vitamin A deficiency in population at risk: 1995-2005.
Vitamin and Mineral Nutrition Information System (VMNIS).