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Luigi Zagra and Enrico Gallazzi

  • Total hip arthroplasty (THA) is widely considered one of the most successful surgical procedures in orthopaedics. It is associated with high satisfaction rates and significant improvements in quality of life following surgery. On the other hand, the main cause of late revision is osteolysis and wear, often a result of failure of bearing surfaces.

  • Currently, several options are available to the surgeon when choosing the bearing surface in THA (ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoPE), metal-on-polyethylene (MoPE)), each with advantages and drawbacks.

  • Very few studies have directly compared the various combinations of bearings at long-term follow-up. Randomized controlled trials show similar short- to mid-term survivorship among the best performing bearing surfaces (CoC, CoXLPE and MoXLPE). Selection of the bearing surface is often ‘experience-based’ rather than ‘evidence-based’.

  • The aim of this paper is therefore to evaluate the main advantages and drawbacks of various types of tribology in THA, while providing practical suggestions for the surgeon on the most suitable bearing surface option for each patient.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.180300.

Georgios Tsikandylakis, Maziar Mohaddes, Peter Cnudde, Antti Eskelinen, Johan Kärrholm, and Ola Rolfson

  • The use of larger femoral head size in total hip arthroplasty (THA) has increased during the past decade; 32 mm and 36 mm are the most commonly used femoral head sizes, as reported by several arthroplasty registries.

  • The use of large femoral heads seems to be a trade-off between increased stability and decreased THA survivorship.

  • We reviewed the literature, mainly focussing on the past 5 years, identifying benefits and complications associated with the trend of using larger femoral heads in THA.

  • We found that there is no benefit in hip range of movement or hip function when head sizes > 36 mm are used.

  • The risk of revision due to dislocation is lower for 36 mm or larger bearings compared with 28 mm or smaller and probably even with 32 mm.

  • Volumetric wear and frictional torque are increased in bearings bigger than 32 mm compared with 32 mm or smaller in metal-on-cross-linked polyethylene (MoXLPE) THA, but not in ceramic-on-XLPE (CoXLPE).

  • Long-term THA survivorship is improved for 32 mm MoXLPE bearings compared with both larger and smaller ones.

  • We recommend a 32 mm femoral head if MoXLPE bearings are used. In hips operated on with larger bearings the use of ceramic heads on XLPE appears to be safer.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170061.

Theofilos Karachalios, George Komnos, and Antonios Koutalos

  • Total hip arthroplasty (THA) is a very satisfactory surgical procedure for end-stage hip disorders.

  • Implant modifications, such as large femoral heads to improve stability, porous metals to enhance fixation and alternative bearings to improve wear, have been introduced over the last decade in order to decrease the rate of early and late failures.

  • There is a changing pattern of THA failure modes.

  • The relationship between failure modes and patient-related factors, and the time and type of revision are important for understanding and preventing short and late failure of implants.

  • The early adoption of innovations in either technique or implant design may lead to an increased risk of early failure.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170068

Mattia Loppini and Guido Grappiolo

  • Over the last two decades, several conservative femoral prostheses have been designed. The goals of conservative stems include: the spearing of the trochanteric bone stock; a more physiological loading in the proximal femur reducing the risk of stress shielding; and to avoid a long stem into the diaphysis preventing impingement with the femoral cortex and thigh pain.

  • All stems designed to be less invasive than conventional uncemented stems are commonly named ‘short stems’. However, this term is misleading because it refers to a heterogeneous group of stems deeply different in terms of design, biomechanics and bearing. In the short-term follow-up, all conservative stems provided excellent survivorship. However, variable rates of complications were reported, including stem malalignment, incorrect stem sizing and intra-operative fracture.

  • Radiostereometric analysis (RSA) studies demonstrated that some conservative stems were affected by an early slight migration and rotation within the first months after surgery, followed by a secondary stable fixation. Dual-energy x-ray absorptiometry (DEXA) studies demonstrated an implant-specific pattern of bone remodelling.

  • Although the vast majority of stems demonstrated a good osseointegration, some prostheses transferred loads particularly to the lateral and distal-medial regions, favouring proximal stress shielding and bone atrophy in the great trochanter and calcar regions.

Cite this article: EFORT Open Rev 2018;3:149-159. DOI: 10.1302/2058-5241.3.170052

Stefan Lazic, Oliver Boughton, Catherine F. Kellett, Deiary F. Kader, Loïc Villet, and Charles Rivière

  • Multimodal protocols for pain control, blood loss management and thromboprophylaxis have been shown to benefit patients by being more effective and as safe (fewer iatrogenic complications) as conventional protocols.

  • Proper patient selection and education, multimodal protocols and a well-defined clinical pathway are all key for successful day-case arthroplasty.

  • By potentially being more effective, cheaper than and as safe as inpatient arthroplasty, day-case arthroplasty might be beneficial for patients and healthcare systems.

Cite this article: EFORT Open Rev 2018;3:130-135. DOI: 10.1302/2058-5241.3.170031

Charles Rivière, Stefan Lazic, Loïc Villet, Yann Wiart, Sarah Muirhead Allwood, and Justin Cobb

  • Conventional techniques for hip and knee arthroplasty have led to good long-term clinical outcomes, but complications remain despite better surgical precision and improvements in implant design and quality.

  • Technological improvements and a better understanding of joint kinematics have facilitated the progression to ‘personalized’ implant positioning (kinematic alignment) for total hip (THA) and knee (TKA) arthroplasty, the true value of which remains to be determined.

  • By achieving a true knee resurfacing, the kinematic alignment (KA) technique for TKA aims at aligning the components with the physiological kinematic axes of the knee and restoring the constitutional tibio-femoral joint line frontal and axial orientation and soft-tissue laxity.

  • The KA technique for THA aims at restoring the native ‘combined femoro-acetabular anteversion’ and the hip’s centre of rotation, and occasionally adjusting the cup position and design based on the assessment of the individual spine-hip relation.

  • The key element for optimal prosthetic joint kinematics (hip or knee) is to reproduce the femoral anatomy.

  • The transverse acetabular ligament (TAL) is the reference landmark to adjust the cup position.

Cite this article: EFORT Open Rev 2018;3:98-105. DOI: 10.1302/2058-5241.3.170022

Luigi Zagra

  • Total hip arthroplasty (THA) surgery has shown dramatic changes in terms of increased number of procedures and of technical development in recent years. It has been described as “the operation of the 20th century” for the excellent results, the high satisfaction of the patients and the improvement of the quality of life.

  • A lot of variations have been introduced over the last few decades in THA especially in terms of indications (both in younger and older patients), techniques and devices (approaches, tissue preservation, biomaterials and industrial finishing), per-operative management (blood loss and pain control) and post-operative protocols (the so called “fast track” surgery). Looking at all these advances the emerging question is: have all of them been justified both in terms of improvement of the results for the patients and of the cost/benefit ratio from an economical point of view?

  • The purpose of this paper is to critically analyse the advantages and the disadvantages of the theoretically proposed “advances in hip arthroplasty” and attempt to understand which are justified of such “advances” nowadays, based on the international and the European perspective with a focus on the author’s personal clinical experience.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.170008. Originally published online at

Torben Bæk Hansen

  • ‘Fast-track’ surgery was introduced more than 20 years ago and may be defined as a co-ordinated peri-operative approach aimed at reducing surgical stress and facilitating post-operative recovery.

  • The fast-track programmes have now been introduced into total hip arthroplasty (THA) surgery with reduction in post-operative length of stay, shorter convalescence and rapid functional recovery without increased morbidity and mortality. This has been achieved by focusing on a multidisciplinary collaboration and establishing ‘fast-track’ units, with a well-defined organisational set-up tailored to deliver an accelerated peri-operative course of fast-track surgical THA procedures.

  • Fast-track THA surgery now works extremely well in the standard THA patient. However, all patients are different and fine-tuning of the multiple areas in fast-track pathways to get patients with special needs or high co-morbidity burden through a safe and effective fast-track THA pathway is important.

  • In this narrative review, the principles of fast-track THA surgery are presented together with the present status of implementation and perspectives for further improvements.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160060. Originally published online at

Martin Krismer

  • Performing sports after total hip arthroplasty (THA) may be associated with a risk of

    • Trauma (fracture and dislocation)

    • Shorter implant survival

  • There is no proof that trauma occurs more often than in healthy individuals, but sequelae may be more severe.

  • Shorter implant survival due to repetitive high contact forces is a fact, due to increased wear. The 15 year survival in highly active patients seems to be around 80%.

  • Surgeons can address the needs of active patients by using bearings with low wear rates, and femoral heads up to 36 mm in diameter.

  • The data provided in this review may help to fully inform active patients of the risks. The patient has to balance the pros and cons of sports after THA and to decide the best way for themselves.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160059. Originally published online at

Oliver Marin-Peña, Marc Tey-Pons, Luis Perez-Carro, Hatem G. Said, Pablo Sierra, Pedro Dantas, and Richard N. Villar

  • Hip arthroscopy is an evolving surgical technique that has recently increased in popularity.

  • Although femoroacetabular impingement was an important launch pad for this technique, extra-articular pathology has been described through hip endoscopy.

  • Good clinical results in the medium term will allow improvements in this technique and increase its indications.

Cite this article: EFORT Open Rev 2017;2:58-65. DOI: 10.1302/2058-5241.2.150041