Histological, histomorphometric and microtomographic analyses of retrieval hip resurfacing arthroplasty failed at different times
© Salamanna et al.; licensee BioMed Central Ltd. 2013
Received: 11 April 2012
Accepted: 23 January 2013
Published: 30 January 2013
Metal-on-metal hip resurfacing arthroplasty (HR) has been gaining popularity especially for young and active patients. Although different series report good mid-term results, the long-term outcome and failure mechanisms are still concerning. In this consecutive revision case series, 9 retrieved specimens of a failed Birmingham Hip Resurfacing (BHR) were divided according to the time to fracture: 3 specimens failed at less than 6 months (Group 1), 3 failed between 6 months and 3 years (Group 2) and 3 failed later than 3 years (Group 3). The objective of the study was to examine by a specific quantitative histomorphometry and microtomography (micro-CT) method the characteristics of bone quality and its microarchitecture in retrieved metal-on-metal HR.
A series of 948 BHR were performed between 2001 and 2009. Among these implants 10 failures occurred and nine of these underwent revision surgery and were examined by histomorphometry and micro-CT.
Histomorphometry showed a significant increase in trabecular separation (Tb.Sp) in Group 3 in comparison with Group 1 (113%, p < 0.05). In the top region, micro-CT showed that Groups 2 and 3 presented significant lower bone volume (Group 2: 61%, p < 0.005; Group 3: 1%, p < 0.05), trabecular number (Group 2: 53%, p < 0.005; Group 3: 40%, p < 0.05), and higher Tb.Sp (Group: 71%,p < 0.05) when compared to Group 1. Additionally, histomorphometry showed that the top regions in Group 1 had a significantly lower mean percentage of empty osteocyte lacunae than the top regions in both Group 2 and 3 (p < 0.05).
This study showed that the morphometric parameters considered are crucial for a good understanding of mechanical properties of HR and may be of significant importance in the pathogenesis of HR failure particularly in the development of late fractures.
KeywordsHip resurfacing arthroplasty Failure Histomorphometry Microtomography
Joint replacement is continuously evolving to reduce the invasiveness of surgery, prolong the implant life, decrease complications and improve the patient’s life quality. Resurfacing hip arthroplasty is emerging as an alternative to conventional total hip arthroplasty and has been proposed as an option for the treatment of degenerative hip disease in young, active individuals . HR may present benefits over total hip replacement because femoral bone stock is maintained, there is reduced wear compared with high density polyethylene, it has a large femoral head that could be reduced dislocation rate, it is said to offer the patient increased levels of postoperative activity and is easy to convert into a stemmed prosthesis . The general opinion about this procedure is mainly divided into a favorable one advocated by McMinn et al.  and a negative one supported by Spierings et al. . The mid-term results of Birmingham Hip Resurfacing (BHR) suggest a survival rate of about 98% at five years. However, Spierings et al. still consider resurfacing as an experimental design for investigational use only, until long-term follow up confirms its superiority in comparison with total hip replacement [3, 4]. Recently various complications, such as femoral neck fracture [5–7], avascular necrosis [8, 9] and pseudotumour formation [10, 11], as well as unexplained pain, aseptic loosening , and osteolysis  have been reported. To improve the technique and the success of the treatment, experimental preclinical models can be used to allow the evaluation of biomechanics, biocompatibility, bioactivity and biofunctionality on innovative biomaterials, prosthetic devices and combined therapies. Nevertheless, the retrieval of failed prostheses and the analysis of human implanted devices is one of the most valuable tools to provide information about prostheses that have been submitted to clinical loading and biological and chemical micro-environment during their stay in the body . Indeed, analysis of retrievals can show the histopathological response and the mechanisms of failure . Currently, radiology and histology are the most common procedures to study failed bone implants and some authors have used these techniques to evaluate bone necrosis and fracture risk [6, 10, 15–18]. Although it is clear that we require a better understanding of the failure mechanisms of the current generation of metal-on metal HR implants, no studies have ever used histomorphometric and microtomographic evaluation to evaluate the characteristics of bone quality and its microarchitecture in retrieved metal-on-metal HR. In fact, from a literature search of the entire MEDLINE database (PubMed research engine) using the MeSH database terms (“hip arthroplasty” [Mesh] OR “hip resurfacing” [Mesh]) AND (“histomorphometric evaluations” [Mesh] OR “x ray microtomography” [Mesh]) no studies were found. Histomorphometry provides information regarding bone tissue and cell dynamics. Similarly, a microtomographic evaluation of the bone structure gives a real estimate of its morphology, especially when it is carried out directly on the entire volume without using predefined volumetric models (plate or rod-model) . Moreover, good correlations were found between the structural parameters determined by microtomography (μCT) images and those assessed on histomorphological slices .
Therefore, the main goal of this study was to analyze and examine the characteristics of bone quality and its microarchitecture in retrieved metal-on-metal BHR by a new and specific quantitative histomorphometry and μCT method, never used before. This novel and innovative technique was performed to evaluate whether these 2D and 3D quantitative measurements might be applied to this field of research and give further insight into the failure mechanisms of these implants. This methodology was applied to a small consecutive revision case series taking into account different times to fracture and bone areas located at different distances from the HR dome.
This is a retrospective observational study in which the protocol was explained to the patients and they gave written informed consent before entering the study (Determination of 20 March 2008, Italian Medicines Agency – AIFA).
Summary of the cases: patients gender and age (at the time of the primary operation) implant sizes, operation site, time to revision (F: female; M: male)
Time to Revision
Stem Neck angle
46- mm head −52-mm cup
46-mm head, 52-mm cup
44- mm head −50-mm cup
42- mm head −52-mm cup
46- mm head −52-mm cup
42--mm head-48-mm cup
50- mm head −56-mm cup
42- mm head −48-mm cup
46- mm head −52-mm cup
Fractures were divided into three groups:
– Gross fractures that occurred soon after surgery, earlier than 6 months (Group 1) which presented a pattern involving the implant rim. These fractures were characterized by diffuse reactive changes and varying degrees of perfusion of the proximal bone depending on the vascular injury. It was hypothesized that these aspects may be related to the surgical technique leading to biomechanical changes in the femoral neck by the notch (acute biomechanical fractures);
– Fractures that occurred between 6 months and 3 years (Group 2) and fractures that occurred later than 3 years (Group 3) were defined as late fractures, completely inside the femoral head, with extensive evidence of osteonecrosis. These two groups were divided arbitrarily to highlight the possible presence of a phenomenon that progresses with time. Macroscopically, in each group, necrotic bone tissue appeared pale and white-yellowish with scattered calcifications. One patient of Group 2 experienced a pseudotumor of ileopsoas with an aseptic lymphocytic vasculitis-associated lesions (ALVAL) at 3 years follow up. The acetabular inclination angle was 67°, thus suggesting the presence of edge wear. Metallic debris was evident macroscopically. All patients of Group 3 presented evident macroscopic signs of metallosis without soft tissue involvement, suggesting that osteonecrosis might be also developed by metal corrosion phenomena.
With the patient well secured in the lateral position and under general or spinal anesthesia an extended posterior approach to the hip joint was used in a clean-air operating theatre. The short external rotators were released, the gluteus maximus was detached from its insertion at the linea aspera, and a circumferential capsulotomy was performed. The femoral head was dislocated anteriorly and the acetabulum reamed sequentially. Peripheral acetabular osteophytes were excised and a trial component which was 1 mm smaller than the intended final implant was used to confirm that a tight fit had been obtained. If this fixation was satisfactory, the definitive acetabular component was then impacted. Standard instrumentation was used to align and position the guide rod for the preparation of the femoral head using the lateral cortical pin and out-rigger. The head was reamed to house a femoral component that matched the implanted acetabular component. The femoral implant was positioned and secured with Simplex (Howmedica International, Limerick, Ireland) low viscosity cement. The hip was then reduced and the short external rotators and gluteus maximus tendon repaired.
Histological and histomorphometric analyses
Bone Volume (BV/TV,%): the whole spongy bone area, expressed as a percentage of the total tissue area in the sampling site and converted to a volume;
Trabecular Number (Tb.N, mm-1): index of density of trabeculae;
Trabecular Thickness (Tb.Th, μm): index of the width of trabeculae;
Trabecular Separation (Tb.Sp, μm): index of the distance of trabeculae;
Cement Thickness (Cm.Th): index of the width of the cement on the dome surface.
For each sample, the mean percentage of empty lacunae in five regions of interest in the top, central and bottom part, at a magnification of 20x, was determined by two experienced blinded investigators using the method of Steffen et al. .
Bone volume density (BV/TV,%), expressed as a ratio between the volume of bone measured in the VOI and the total volume of the considered VOI;
Trabecular thickness (TbTh, μm) measured as a true model-independent 3D value;
Trabecular separation (TbSp, μm), derived from the volume-based local thickness just applying the method to the space between trabeculae;
Trabecular number (TbN,mm-1), defined as: 1/(TbTh + TbSp)
Statistical analysis was performed by using the SPSS Inc v.12 software. Data were reported as Mean ± SD at a significant level of p < 0.05. After checking normal distribution (Shapiro-Wilks test) and homogeneity of variance (Levene test), the non-parametric Kruskall-Wallis test followed by Mann–Whitney test with Monte Carlo methods to compute probability were carried out to compare histomorphometric results among groups.
The mean time–to-revision was 28.6 ± 12.7 months. No differences were observed among the 3 analyzed prostheses that had failed from 14 to 36 months (Figure 2c,d). A cement mantle was present at the dome and intraosseous cement penetration was observed in the top region and in a small part of the central region. An absence of osteocyte nuclei within bone lacunae was observed in all cases in all ROIs. Thickened cancellous bone trabeculae were sometimes observed with extensive formation of appositional new bone on the surface of necrotic trabeculae (Figure 2c). Signs of metallosis with infiltration and accumulation of metallic wear debris inside the periprosthetic structures were clearly visible in the two patients that failed at longer follow up times (Figure 2d). At 36 months a considerable amount of connective tissue was observed.
The mean time-to-revision was 6.3 ± 2.1 years. Sectioning of the implant revealed a thin layer of cement at the dome and a penetration of cement deep into the bone was observed in the top and central region. Femoral head section analyses showed a decrease in bone mass with partial necrosis in each examined sample. Histological examination confirmed the presence of a massive metallosis revealing granulomatous tissue with extensive pigmented deposits in all examined cases, which was more evident at 7 and 8 years with bone rarefaction present in all ROIs of the femoral head (Figure 2e,f).
The main goal of this study was to evaluate the characteristics of bone quality and its microarchitecture in a series of femoral heads that failed at different times for different reasons by adopting an innovative and specific quantitative histomorphometry and μCT methodology. To do this nine failures were considered, which were split into groups depending on the failure time: 3 specimens failed at less than 6 months (Group 1), 3 failed between 6 months and 3 years (Group 2) and 3 failed at more than 3 years (Group 3) after HR surgery. In comparison with other studies, in this one the Groups were divided arbitrarily to highlight the possible presence of a phenomenon that progresses over time.
Histological evaluation showed the presence of focal areas of osteonecrosis with empty lacunae in the Group 1. In Group 2 and Group 3 partial osteonecrosis also was present; nevertheless, newly formed bone was visible on the surface of the necrotic bone trabeculae. These data were in agreement with those of Steffen et al. who showed that the necrotic changes were associated with appositional new bone formation and marrow fibrosis . In fact, proliferating cells spread through the narrow spaces between the dead trabeculae, differentiate into osteoblast, and subsequently form appositional new bone on the surface of dead trabeculae. At the same time, they initiate osteoclastic resorption of necrotic bone. Osteoclastic resorption, modulated by cytokines released from osteoblast, is crucial for the balance of the repair processes. The bone may be markedly weakened if resorption occurs at the interface of the viable and dead bone, or if revascularization and new bone formation in necrotic areas is prevented by the formation of a fibrous scar . Bone atrophy was observed at histological analyses only in Groups 2 and 3 and these results were confirmed by micro-CT (BV/TV, Tb.N, Tb.Sp) thus suggesting a possible role of mechanical factors (stress shielding). Metallosis, with infiltration and accumulation of metallic wear debris, was visible in Group 2 and 3. Therefore, as shown by other authors who studied the failure mechanism of HR prostheses by conventional radiography and qualitative histology, the present histological analyses confirmed that aseptic necrosis and bone rarefaction might play a crucial role in late failures of HR [6, 14, 15, 17, 23–25].
Unlike previous studies, the present one took into consideration 3 groups of patients according to failure times (from 3 weeks to 8 years); quantitative measurements were performed with histomorphometry and μCT and 3 peri-implant bone regions at different distances from the HR dome (within 0.8 cm (top), from 0.8 to 1.6 cm (central) and from 1.6 to 2.4 cm (bottom)) were considered. This was possible through resin embedding of the femoral heads containing the prostheses, cutting along the coronal plane of the macro-sections and subsequent removal by pressure of the prosthesis that permitted the accurate evaluation of bone histology and microarchitecture with both 2D (histomorphometry) and 3D (μCT) techniques. A different bone architecture was highlighted within each group and, in particular, between the Group 1 and Group 3. Both 2D and 3D measurements showed that bone density decreases over time especially in Group 3 if compared with Group 2 and Group 1. 3D data of different ROIs (top, central, bottom) of both lateral and medial compartments showed a significant decrease in bone quality over time in the top ROI near the dome. This was confirmed by the significant differences in BV/TV, Tb.N and Tb.Sp between Group 1 versus Group 2 and Group 3 in the top ROI. This tendency was visible also in the lower ROIs but bone values did not reach statistical significance.
In the present study bone resorption was observed within the resurfaced femoral head and around the proximal part of the stem. Whereas bone remodeling is a feature of normal metabolism in healthy and osteoarthritic bone, the BHR may result in stress shielding with consequent resorption and narrowing of the femoral neck due to altered loading conditions. This stress shielding is probably due to the implant design with long-stems. In fact, Bidyut Pal and coworkers showed that bone resorption was considerably less for short-stem designs; the short-stem design having stem-bone contact not only led to a more physiological stress distribution but also to bone apposition in the superior side of the resurfaced head . Moreover, 2D results showed significant differences also in the percentage of empty lacunae between Group 1 versus Group 2 and Group 3 in the top ROI. The proportion of empty lacunae gradually increased over the time after surgery.
The present results were in agreement with those of Steffen et al. who showed that samples from late fractures had a significantly higher proportion (84%) of empty osteocyte lacunae within the trabecular bone compared with those of samples from fractures occurring within the first month (48%) after HR . Moreover, in the present study the higher mean percentage of empty lacunae in the central and bottom regions of Group 1 was probably due to a vascular injury. This controversial result might be explained by analyzing the surgical technique. During femoral head preparation the top region is always removed, thus eliminating the bone volume more subjected to osteonecrosis. Moreover, the residual blood supplied comes from the lateral femoral circumflex artery and a recent report  shows two more possible sources of blood supply to the femoral head. These two vessels were identified as the anterior nutrient artery of the femoral neck which origins from the lateral femoral circumflex artery and the inferior branch of the deep branch of the superior gluteal artery.
In the present series all the operations were performed through a posterior approach which is known to disrupt the medial circumflex artery; nevertheless, the failure rate due to bone necrosis was low. Similar findings were observed by Mcbride et al. who reported the same implant survival regardless of surgical approach . By using a surgical approach that preserves the blood supply it might be possible to obtain an improved implant survival at longer follow up [14, 19, 29].
The BIC measurement should not be considered as an index of osteointegration because the surgical procedure of HR insertion is not aimed at achieving primary fixation between the bone and the stem as for traditional arthroplasties. However, a progressive decrease of bone in contact around the stem was observed and the difference was significant between Group 1 and Group 3 patients. The decrease in BIC was probably due to the bone rarefaction, which involves the femoral head; it remains to be seen whether it might also be related to a progressive prosthesis loosening over time. In the present study histological and microtomographic analyses suggest that both processes, bone rarefaction and osteonecrosis, start from the bottom of the peri-implant bone and reach the top region adjacent to the HR dome in the Group 2 and 3. Osteonecrosis is expected to start from the top ROI which is far away from blood vessels and probably more influenced by the presence of cement but the findings in the present study showed the contrary. In fact, some sort of stress shielding due to its close relationship with the implant might be the true reason for this particular finding.
The current study has several limitations. First of all the small number of cases prevents any solid conclusions to be drawn about the real failure mechanisms of HR and the progression of femoral head damage. The inter-individual variability between patients and osseous changes should also be taken into account. Nevertheless, it was not the primary objective of this study to define the pathophysiology of HR prosthesis failure. To the present authors’ knowledge, quantitative methodologies for measuring bone quality and its microarchitecture have never been used to study retrieved HR prostheses. In the present study the histomorphometric and microtomographic evaluations allowed bone microarchitecture alterations to be quantified.
The objective of the study was to examine the characteristics of bone quality and its microarchitecture in retrieved metal-on-metal HR by a specific quantitative histomorphometry and μCT method. The results showed that the morphometric parameters considered were crucial for a good understanding of the mechanical properties of HR and may be of significant and essential importance in the pathogenesis of HR failure particularly in the development of late fractures. Although there are several good reports on the survival rate of HR at mid-term follow up, the biological changes of the femoral head underlying the implant over time should always be considered. It remains to be seen whether other late failures will occur. HR is still a good indication for young and active patients; nevertheless good bone quality remains the crucial element to support the implant at longer follow-up.
Birmingham Hip Resurfacing
This work was supported by Rete Nazionale di Ricerca TISSUENET (n. RBPR05RSM2). None of the authors has professional and financial affiliations that may be perceived to have biased the presentation.
- McMinn D, Treacy R, Lin K, Pynsent P: Metal on metal surface replacement of the hip: experience of the McMinn prosthesis. Clin Orthop. 1996, 329: 89-98.View Article
- van Gerwen M, Shaerf DA, Veen RM: Hip resurfacing arthroplasty. Acta Orthop. 2010, 81 (6): 680-3. 10.3109/17453674.2010.501742.PubMed CentralView ArticlePubMed
- McMinn DJ, Daniel J, Ziaee H, Pradhan C: Indications and results of hip resurfacing. Int Orthop. 2011, 35 (2): 231-7. 10.1007/s00264-010-1148-8.PubMed CentralView ArticlePubMed
- Spierings PT: Hip resurfacing: expectations and limitations. Acta Orthop. 2008, 79 (6): 727-30. 10.1080/17453670810016777.View ArticlePubMed
- Shimmin AJ, Back D: Femoral neck fractures following Birmingham hip resurfacing: a national review of 50 cases. J Bone Joint Surg Br. 2005, 87-B: 463-474. 10.1302/0301-620X.87B4.15498.View Article
- Zustin J, Krause M, Breer S, Hahn M, von Domarus C, Rüther W, Sauter G, Morlock MM, Amling M: Morphologic analysis of periprosthetic fractures after hip resurfacing arthroplasty. J Bone Joint Surg Am. 2010, 92 (2): 404-10. 10.2106/JBJS.H.01113.View ArticlePubMed
- Prosser GH, Yates PJ, Wood DJ, Graves SE, de Steiger RN, Miller LN: Outcome of primary resurfacing hip replacement: evaluation of risk factors for early revision. Acta Orthop. 2010, 81 (1): 66-71. 10.3109/17453671003685434.PubMed CentralView ArticlePubMed
- Daniel J, Pynsent PB, McMinn DJ: Metal-on-metal versus polyethylene in hip arthroplasty: a randomized clinical trial. Clin Orthop Relat Res. 2004, 422: 271-View ArticlePubMed
- Ullmark G, Sundgren K, Milbrink J, Nilsson O, Sörensen J: Osteonecrosis following resurfacing arthroplasty. Acta Orthop. 2009, 80 (6): 670-4. 10.3109/17453670903278258.PubMed CentralView ArticlePubMed
- Amstutz HC, Campbell PA, Le Duff MJ: Fracture of the neck of the femur after surface arthroplasty of the hip. J Bone Joint Surg Am. 2004, 86: 1874-7.PubMed
- Glyn-Jones S, Pandit H, Kwon YM, Doll H, Gill HS, Murray DW: Risk factors for infammatory pseudotumour formation following hip resurfacing. J Bone Joint Surg Br. 2009, 91 (12): 1566-1574. 10.1302/0301-620X.91B12.22287.View ArticlePubMed
- Campbell P, Shimmin A, Walter L, Solomon M: Metal sensitivity as a cause of groin pain in metal-on-metal hip resurfacing. J Arthroplasty. 2008, 23 (7): 1080-5. 10.1016/j.arth.2007.09.024.View ArticlePubMed
- Daniel J, Ziaee H, Kamali A, Pradhan C, Band T, McMinn DJ: Ten-year results of a double-heat-treated metal-on-metal hip resurfacing. J Bone Joint Surg Br. 2010, 92 (1): 20-7. 10.1302/0301-620X.92B1.21530.View ArticlePubMed
- Carrothers AD, Gilbert RE, Jaiswal A, Richardson JB: Birmingham hip resurfacing: the prevalence of failure. J Bone Joint Surg Br. 2010, 92 (10): 1344-50. 10.1302/0301-620X.92B10.23504.View ArticlePubMed
- Amstutz HC, Beaulé PE, Dorey FJ, Le Duff MJ, Campbell PA, Gruen TA: Metal-on-metal hybrid surface arthroplasty: two to six-year follow-up study. J Bone Joint Surg Am. 2004, 86-A (1): 28-39.PubMed
- Treacy RB, McBryde CW, Shears E, Pynsent PB: Birmingham hip resurfacing: a minimum follow-up of ten years. J Bone Joint Surg Br. 2011, 93 (1): 27-33. 10.1302/0301-620X.93B1.24134.View ArticlePubMed
- Ollivere B, Darrah C, Barker T, Nolan J, Porteous MJ: Early clinical failure of the Birmingham metal-on-metal hip resurfacing is associated with metallosis and soft-tissue necrosis. J Bone Joint Surg Br. 2009, 91 (8): 1025-30. 10.1302/0301-620X.91B8.21701.View ArticlePubMed
- Giannini S, Cadossi M, Chiarello E, Faldini C, Moroni A, Romagnoli M: Hip resurfacing arthroplasty: a series of 140 consecutive hips with a minimum five year follow-up. A clinical, radiological and histological analysis. Hip Int. 2011, 21 (1): 52-58. 10.5301/HIP.2011.6281.View ArticlePubMed
- Hildebrand T, Rüegsegger P: A new method for the model-independent assessment of thickness in three-dimensional images. J Microscopy. 1997, 185: 67-75. 10.1046/j.1365-2818.1997.1340694.x.View Article
- Martini L, Staffa G, Giavaresi G, Salamanna F, Parrilli A, Serchi E, Pressato D, Arcangeli E, Fini M: Long-term Results following a Cranial Hydroxyapatite Prosthesis implantation in a large Skull Defect Model. Plast Reconstr Surg. 2012, 129 (4): 625-35. 10.1097/PRS.0b013e318244220d.View Article
- Parfitt AM: Bone histomorphometry: standardization of nomenclature, symbols and units Summary of proposed system. Bone Miner. 1988, 4 (1): 1-5.PubMed
- Steffen RT, Athanasou NA, Gill HS, Murray DW: Avascular necrosis associated with fracture of the femoral neck after hip resurfacing: histological assessment of femoral bone from retrieval specimens. J Bone Joint Surg Br. 2010, 92 (6): 787-93. 10.1302/0301-620X.92B6.23377.View ArticlePubMed
- Mont MA, Jones LC, Einhorn TA, Hungerford DS, Reddi AH: Osteonecrosis of the femoral head. Potential treatment with growth and differentiation factors. Clin Orthop Relat Res. 1998, 355 (Suppl): 314-335.View Article
- Morlock MM, Bishop N, Rüther W, Delling G, Hahn M: Biomechanical, morphological, and histological analysis of early failures in hip resurfacing arthroplasty. Proc Inst Mech Eng H. 2006, 220 (2): 333-44. 10.1243/095441105X69015.View ArticlePubMed
- Lazarinis S, Milbrink J, Hailer NP: Avascular necrosis and subsequent femoral neck fracture 3.5 years after hip resurfacing: a highly unusual late complication in the absence of risk factors--a case report. Acta Orthop. 2008, 79 (6): 763-768. 10.1080/17453670810016821.View ArticlePubMed
- Pal B, Gupta S, New AM: Influence of the change in stem length on the load transfer and bone remodelling for a cemented resurfaced femur. J Biomech. 2010, 43 (15): 2908-14. 10.1016/j.jbiomech.2010.07.017.View ArticlePubMed
- Zlotorowicz M, Czubak J, Kozinski P, Boguslawska-Walecka R: Imaging the vascularisation of the femoral head by CT angiography. J Bone Joint Surg Br. 2012, 94 (9): 1176-9. 10.1302/0301-620X.94B9.29494.View ArticlePubMed
- McBryde CW, Revell MP, Thomas AM, Treacy RB, Pynsent PB: The influence of surgical approach on outcome in Birmingham hip resurfacing. Clin Orthop Relat Res. 2008, 466 (4): 920-6. 10.1007/s11999-008-0121-y.PubMed CentralView ArticlePubMed
- Ganz R, Gill TJ, Gautier E, Ganz K, Krügel N, Berlemann U: Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br. 2001, 83 (8): 1119-24. 10.1302/0301-620X.83B8.11964.View ArticlePubMed
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/14/47/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.