DECEMBER, $971

CHARNLEY LOW-FRICTION TOTAL

HIP REPLACEMENT*
By ROBERT E. CAMPBELL, M.D., and RICHARD H. ROTHMAN, M.D., PH.D.
PHILADELPHIA, PENNSYLVANIA

U NTIL recently, the surgical manage- total hip replacements to elderly patients
ment of the painful adult hip has con- with incapacitating hip pain usually re-
tinuously challenged and plagued the or- lated to osteoarthritis. Today, if the hip
thopedist. During the past 2 decades the joint has become disorganized as a result of
development and refinement of total hip disease or injury in an adult patient who
replacement procedures appear to be an cannot walk without a cane or crutches,
encouraging solution to this problem. The cannot work, or has severe hip pain, a total
concept of total hip arthroplasty is not new. hip replacement is indicated. Osteoarthri tis
As early as 1890, orthopedists entertained remains the most common cause for total
this idea; however, satisfactory inert mate- hip arthroplasty. Table I lists the various
rials, both chemically and physically suit- hip abnormalities in which total hip re-
able for such a procedure, have only re- placement should be considered as the
American Journal of Roentgenology 1971.113:634-641.

cently become available. method of surgical treatment.

Much later, in 1951, McKee and Farrar8
performed the first successful total hip re- ROENTGENOGRAPHIC FEATURES

placement in Norwick, England, replacing The major components in the Charnley

both the femoral head and acetabulum low-friction total hip replacement are a
with prostheses made of a metal alloy of forged, stainless steel femoral prosthesis
cobalt-chromium. Although more than with a spherical, polished head and a high
5,000 total hip replacements of various molecular weight plastic acetabular pros-
types have now been performed, mostly in thesis, polyethylene (HCiooo) (Fig. i,
Great Britain, the procedure did not be- A-D).
come popular in the United States until Figure 2 represents a Charnley low-fric-
5 years ago. tion total hip arthroplasty in a patient who
The low-friction total hip replacement had incapacitating hip pain and limited
procedure devised, improved, and success- hip motion related to rheumatoid arth-
fully implemented by Sir John Charnley at ritis with associated protrusio acetabuli.
the Centre for Hip Surgery, Wrightington,
England, is the most popular of the various TABLE 1
total hip arthroplasties in the United
INDICATIONS FOR CHARNLEY LOW-FRICTION
States. TOTAL HIP REPLACEMENT
Since total hip arthroplasty is rapidly
gaining popularity in the United States, the 1. Osteoarthritis
purpose of this paper is to acquaint radi- 2. Rheumatoid Arthritis
ologists practicing outside the major ortho- 3. Ankylosing Spondylitis
. Neglected Congenital Dislocation
pedic centers with the indications for,
. Protrusio Acetabuli
roentgenographic features of, and the 6. Fracture Dislocation
roentgenologic follow-up role of the Charn- 7. Previous Operation Failure
ley low-friction total hip replacement. 8. Late Aseptic Necrosis
9. Dysplasia
INDICATIONS 10. Benign Tumors
i I. Slow Growing Malignant Tumors
In the beginning, Charnley limited his

* From the Department of Radiology and Section of Orthopedic Surgery, Pennsylvania Hospital, Philadelphia, Pennsylvania.

634
 Voi. ii;, No. Charnlev Low-Friction Total Hip Replacement 63 5
American Journal of Roentgenology 1971.113:634-641.

femoral component with a spherical, polished, “smaller than life” head. (B-D) Three projections of the
high molecular weight polyethylene acetabular component demonstrate the scalloped, overhanging border,
furrowed exterior surface, and the reference wire.

The radiopaque femoral prosthesis has a curing acrylic which does not act as an ad-
“smaller than life” head, measuring 22 mm. hesive but rather as an accurate cast of the
in diameter. Since the femoral head is interior of the bone to transmit stress
small, the radiolucent polyethylene acetab- evenly over all parts of the interface be-
ular prosthesis can be thick and measures tween the acrylic and cancellous bone. Ini-
approximately 10 mm. in thickness. A semi- tially, there is direct contact between the
circular reference wire is implanted in the acrylic and the exposed cancellous bone,
periphery of the lucent polyethylene ac- but this is later replaced by a fine, 5 to 1 25
etabulum. This wire not only permits accu- micron, radiolucent layer of fibrous tissue.
rate roentgenographic localization of the In addition to the bond formed by the
lucent acetabular component but also per- mold of cement into the roughened surface
mits evaluation of wear in the acetabular of cancellous bone, an additional attempt is
component by measuring the distance from made to stabilize the acetabular component
the femoral head to the reference wire on by drilling “keyholes” into the superior
an an teroposterior roen tgenogram. The dome of the acetabulum, medial wall of the
open end of the acetabular socket has a acetabulum, and the ischium into which
scalloped, overhanging border. cement is introduced to create a mechanical
Both the acetabular and femoral compo- anchor for the acetabular mold. Since the
nentS are fixed to their respective bones by exterior of the acetabular cup is furrowed
an acrylic bone cement, polymethylmeth- and its overhanging border is scalloped
acrylate.6 This bone cement is a cold, self- (Fig. i, 11-D), acrylic bone cement in these
 636 Robert E. Campbell and Richard H. Rothman DECEMBER, 197!

and the
actual location of the cement can-
not bedetermined roentgenographically
unless it is rendered radiopaque by adding
barium sulfate. Polymethylmethacrylate is
still an experimental product in the United
States and its use requires special permis-
sion from the Food and Drug Administra-
tion.
For a better surgical exposure of the hip
joint, the greater trochanter with its abduc-
tor muscles is detached and reflected away
from the femur. At the end of the proce-
dure, the greater trochanter and muscles
are reattached by 2 crossed No. 18 wires in
a new location on the anterolateral aspect
of the proximal femoral shaft-a site which
is advantageous mechanically.
American Journal of Roentgenology 1971.113:634-641.

REPORT OF CASES

The following case reports illustrate the

roentgenographic features of the Charnley
low-friction total hip replacement.
CASE I. M. McC., a 63 year old white female,
had severe right hip pain from osteoarthritis
FIG. 2. Charnley low-friction total hip replacement. (Fig. 3A). For the past 2 years, her hip pain
Radiopaque acrylic cement, polymethylmethacry- increased in severity and recently she required
late, surrounds both the radiolucent acetabular the assistance of a “walker.” Hip motion was
socket and the arm of the femoral prosthesis in the limited to _j0 in all directions, except 8o#{176}
medullary canal. Note the fine radiolucent line of flexion. The patient was discharged from the
fibrous tissue between cancellous bone and the
hospital, without pain in the right hip, 3 weeks
acrylic cement mold of the new acetabulum
following an uncomplicated Charnley low-
superiorly. Cement escaped into pelvis around the
cement restrictor. The osteotomized greater
friction total hip replacement (Fig. 3B).
trochanter is reattached to the proximal femur by
2 crossed No. 18 wires. CASE II. D. W., a 48 year old white female,
developed rheumatoid arthritis at the age of 23
years. Despite medication, pain steadily in-
indentations also facilitates mechanical creased in the hips, knees, hands, and wrists.
bonding of the polyethylene acetabular Five years previously she had synovectomies of
socket. Since the bony acetabulum is often the knees and 2 years previously a left hip cup
thin and easily perforated medially, a fine arthroplasty. Pain persisted in the left hip
wire mesh cement restrictor, resembling a following the cup arthroplasty and subse-
“Gaucho hat,” is often inserted into the quently she required crutches 2 for walking.
medial “keyhole” to prevent escape of For the past year, pain, even at night, also
excessive acrylic cement into the pelvis. progressed in the right hip (Fig. 4i1) and mo-
tion was limited in this hip to 100 abduction
The femoral prosthesis may also be an-
and 200 flexion. The patient was discharged
chored into the femoral medullary canal by
from the hospital without pain in the right hip
the bone cement. Also, in order to obtain a 3 weeks following a successful right Charnley
tight fit for the femoral prosthetic arm, oc- low-friction total hip replacement (Fig. 4B).
casionally a new femoral neck must be
constructed with the acrylic cement. CASE In. M. M., an obese 53 year old white
Polymethylmethacrylate is radiolucent female, sustained a fracture dislocation of her
 \OL. 111, No. Charnley Low-Friction Total Hip Replacement 637

FIG. 3. Case I. (A) Primary osteoarthri ; of right hip. (B) Charnley low-friction hip replacement. The
acetabular component appears press fitted into the bony acetabulum but is actually surrounded by radio-
lucent polymethylmethacrylate.
American Journal of Roentgenology 1971.113:634-641.

right hip in an automobile accident 3 months external rotation 0#{176},adduction 20#{176}, and abduc-
previously. At another hospital, Buck’s trac- Despite
tion #{231}#{176}. the patient’s obesity, a right
tion for 3 weeks did not relieve the severe pain Charnley low-friction hip replacement (Fig.
in the right hip. Following discharge from that #{231}B)was performed without difficulty, and the
hospital, while using crutches at home, she fell; patient was discharged from the hospital 3
a roentgenogram at that time revealed a per- weeks postoperatively with a full range of pain-
sistent fracture dislocation of the right hip less motion in the right hip.
(Fig. sM. All motion in the right hip was pain-
ful. Although flexion and extension in the hip CASE IV. i\I. G., a 54 year old white female,
were not limited, internal rotation was 30#{176}, had a long history of multiple joint involvement

FIG. . Case II. (A) j ieumatoid LLnritis oft right i with protrusio acetab i. (B) Cha ey low-friction
hip replacement. Note the radiolucent line of fibrous tissue between the acetabular acrylic cement mold and
the cancellous bone. Cement is present in the anchoring acetabular “keyholes.”
 638 Robert F. Campbell and Richard H. Rothman l)IcEs!nIR, 1971

FIG. . Case III. (A) l’racture dislocation of right hip. The wedge-shaped fragment of bone above the dis-
located femoral head represents the posterior acetabular wall. (B) Charnley low-friction hip replacement. A
American Journal of Roentgenology 1971.113:634-641.

new posterior acetabulum was reconstructed with radiolucent polymethylmethacrylate.

with rheumatoid arthritis. Medical treatment tient continued to have pain in the hips, par-
with long-term steroids had been relatively un- ticularly at night, and required crutches to
successful; and, over the past years, the hips walk. Although the range of motion in the left
demonstrated rapid destruction. Three years hip was only moderately limited, the patient
previously, a cup arthroplasty was performed actually sought a conversion surgical procedure
on the left hip (Fig. 61) and the following year for relief of her hip pain. Subsequently, the
a similar procedure was done on the right hip. unsuccessful left cup arthroplasty was re-
Neither operation was successful and the pa- placed by a Charnley low-friction total hip

FIG. 6. Case IV. (A) Unsuccessful cup arthroplasty for rheumatoid arthritis of the left hip. Note varus posi-
tion of cup and nonosseous union of greater trochanter. (B) Charnley low-friction hip replacement. Greater
trochanter now attached to femur by 2 crossed No. i8 wires.
 VOL. 113, No. 4 Charnley Low-Friction Total Hip Replacement 639

arthroplasty (Fig. 6B). A sterile hematomain immediate pain relief, Charnley incrimi-
the incisional area slightly complicated and nates as the major cause a technical error in
prolonged the postoperative hospitalization 2
the surgical procedure, usu ally improper
weeks. However, the patient was discharged
acetabular socket orientation. Failure to
from the hospital without pain in the left hip.
improve mobility is usually encountered in
rheumatoid patients since they frequently
CASE v. E. F., a 49 year old white female,
have concomitant severe deformity of other
was born with bilateral hip dysplasia and this
joints in the lower extremity.#{176} Rheumatoid
condition was neglected during infancy. At the
patients, however, do receive
relief of hip
age of 21 years, a “shelf procedure” on the left
hip (Fig. 7A) failed to relieve her hip pain, pain-a factor which makes the hip re-
which recently had become severe, particularly placement procedure worthwhile. Invari-
at night. In the left hip, the range of motion in ably, patients with bilateral hip disease will
all directions was limited to 20#{176}, except $o#{176}request replacement of their con tralateral
flexion. The left hip was reconstructed by a hip soon after the first procedure is com-
Charnley low-friction hip arthroplastv (Fig. pleted.
7B). The patient was discharged from the hos- As in any operative procedure, complica-
pital without pain or complication 3 weeks tions related to the Charnlev low-friction
following the surgical procedure.
American Journal of Roentgenology 1971.113:634-641.

total hip replacement do occur, but the inci-

dence is surprisingly low.7’9 Some complica-
DISCUSSION
tions occur during the operative procedure,
The ultimate goals of total hip replace- some in the immediate postoperative pe-
ment are relief of pain and restoration of riod, and a few are delayed.
motion. The Charnlev low-friction total Fracture of the proximal femur during
hip arthroplasty achieves these goals in a the placement of the femoral prosthetic
constant fashion. Charnlev5 recently re- arm into the femoral medullar canal is the
ported a large series (138 cases) with a most common operative complication. This
year follow-up in which pain relief was ob- complication occurs most often in rheuma-
tained and maintained in 96 per cent and toid patients with demineralized bones.
significantly improved mobility was present Pulmonary embolus, both fatal and non-
in 84 per cent. In those patients without fatal, does occur postoperatively, but the

Fic. 7. Case v. (A) Congenital dysplasia of left hip with “shelf procedure.” (B) Charnley low-friction hip
replacement. Note reconstruction of new acetabulum and femoral neck by radiopaque polymethylmeth-
acrylate.
 640 Robert E. Campbell and Richard H. Rothman DECEMBER, 197$

incidence has diminished with a proper tern or a diffuse, ragged osteitis with irregu-
program of postoperative anticoagulation. lar cortical thickening and sclerosis is seen
Because of the small head of the femoral in the infected bones, particularly the
prosthesis, early critics of the Charnley proximal femur. Most deep infections occur
procedure theoretically suspected a high early, have infrequently developed as late
incidence of postoperative dislocation. as 2 years postoperatively, and are most
However, in fact, dislocation is rare. The commonly found in conversion total hip
lateral relocation on the proximal femoral procedures for previously unsuccessful hip
shaft of the greater trochanter with its surgery.’ If the infection remains uncon-
attached abductor muscles tends to pre- trolled by appropriate antibiotics and in-
vent dislocation. A dislocation (Fig. 8) usu- tolerable pain and drainage persist, the
ally occurs in the ear postoperative pe- entire arthroplasty including cement must
riod and often results an improper
from be removed and substituted by a Girdle-
acetabular socket orientation. In addition, stone pseudoarthrosis. Persistent deep in-
to prevent dislocation, the hip must be fection is, in fact, the only cause of total
maintained in abduction until a fibrous failure of the Charnley low-friction total
capsule forms about the newk recon- hip replacement in its present stage of
structed hip joint. This new devel- development.
American Journal of Roentgenology 1971.113:634-641.

capsule
opS usual within the first postoperative Loosening of the prosthetic compo-
month. nents,’1 especially the acetabular socket,
Deep infection in the hip is a serious was quite common before polymethylmeth-
threat to the success of total hip arthro- acrylate was introduced to cement the pros-
plasty.4 Persistent pain in the hip or persis- thetic components to bone. Now loosening
tent drainage from the operative site sug- is a rare, usually late, complication which
gests deep in fection. Roentgenographically, becomes apparent by the sudden onset of
focal resorption of bone adjacent to the pain on weight bearing or loss of mobility
acr\lic bone cement with a “scalloped” pat- of the hip. An anteropoSterior roentgeno-
gram may demonstrate a change in the po-
sition of the prosthesis as compared to a
previous follow-up roentgenogram or a
widening of the thin radiolucent space be-
tween the radiopaque acrylic cement and
bone. If the cement is radiolucent, injection
of cc. of a soluble radiopaque medium into
the joint will reveal dissection of the opaque
medium between the biologic and prosthe-
tic interface. The low-friction property and
decreased torque of the small femoral pros-
thetic head also play a major role in the
low incidence of prosthetic loosening in the
Charnley total hip procedure.2’3 Deep in-
fection may also produce prosthetic loosen-
ing, and differentiation between infectious
and mechanical loosening may be difficult
roentgenographically.

The detached and relocated greater

trochanter does not always unite to the
l’ic. 8. Dislocation of Charnley low-friction hip
replacement. Acetabular socket properly oriented,
femur with complete bony union, but
but the patient was permitted to adduct the hip on fibrous union is asymptomatic and does not
the first postoperative day. usually produce decreased stability of the
 VOL. 113, No. Charnley Low-Friction Total Hip Replacement 641

joint. Complete postoperative wide dis- centers by an experienced orthopedic

traction of the greater trochanter will pro- team; radiologists outside these centers
duce a painless gluteal limp. Fracture of must be aware of the procedure, not only
the trochanter fixation wires is asympto- to help in the follow-up care, but also to
matic and usually observed coincidentally advise referring physicians about the indi-
on a follow-up roentgenogram. cations and potential of this procedure.
Periarticular calcification and ossification
Robert E. Campbell, M.D.
occur as a late, usually asymptomatic,
Department of Radiology
complication. This atopic calcification is Pennsylvania Hospital
more common following dislocation or in Philadelphia, Pennsylvania 19107
conversion cases.’
In the original Charnley low-friction hip REFERENCES
replacement the acetabular socket was
I.AMSTUTZ, H. C. Complication of total hip re-
teflon. Since the wear resistance of teflon is placement. C/in. Orthop., 1970, 72, 123-137.

poor, the rapid disappearance of the early 2. BUCHOLZ, H. W. Modification of Charnley

sockets prompted a change to the high artificial hip joint. C/in. Orthop., 1970, 72, 69-
78.
density polyethylene used today. In a re-
3. CHARNLEY, J. Factors in design of artificial hip
American Journal of Roentgenology 1971.113:634-641.

cent 5 year follow-up study, Charnley’ has joint. Med. Bio/. Engr., 1968, 6, 104.
reported the wear factor in 72 cases using 4. CHARNLEY, J., and EFTEKHAR, N. Postoperative
polyethylene acetabular sockets. In 35 infection in total prosthetic replacement

cases, no appreciable wear was identified arthroplasty of hip joint. Brit. 7. Surg., 1969,
56, 641-649.
and in 37 cases less than i mm. wear was
. CHARNLEY, J. Total hip replacement by low-
noted. Since the acetabular socket is io friction arthroplasty. C/in. Orthop., 3970, 72,
mm. thick and with the proved wear resis- 7-21.
tance of polyethylene, the low-friction 6. CHARNLEY, J. Acrylic Cement in Orthopaedic
Charnley total hip replacement now can be Surgery. E. & S. Livingstone, Edinburgh,
3970.
undertaken in younger patients with an
7. LAZANSKY, M. G. Complication in total hip re-
expectation of long survival of the arthro-
placement with Charnley technique. C/in.
plasty. Orthop., 1970, 72,40-45.

8. MCKEE, G. K., and WATSON-FARRAR, J. Re-

SUMMARY
placement of arthritic hips by McKee-Farrar
Although total hip replacement proce- prosthesis. 7. Bone & 7oint Surg., 1966, 48-B,
245-259.
dures were pioneered and perfected in
9. STINCHFIELD, F. E. Low-friction total hip re-
Great Britain, the overwhelming success
placement: advantages and pitfalls. C/in.
and dramatic results of this approach to Orthop., 3970, 72, 36-39.
hip disease have lead to its recent acclaim TO. WELCH, R. B., and CHARNLEY, J. Low-friction
in the United States. Of the various types arthroplasty of hips in rheumatoid arthritis
of total hip arthroplasties, the Charnley and ankylosing spondylitis. C/in. Orthop.,
1970, 72, 22-31.
low-friction total hip replacement is the
II. WILSON, J. N.,
and SCALES, J. T. Loosening of
most popular in the United States. total hip replacements with cement fixation:
Although, at present, this procedure clinical findings and laboratory studies. C/in.
should only be undertaken in orthopedic Orthop., 1970, 72, 145160.
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American Journal of Roentgenology 1971.113:634-641.