Clinical Radiology (2009) 64, 954e960

REVIEW

Hip arthroplasty. Part 1: prosthesis terminology

and classification
E. Pluota, E.T. Davisb, M. Revellb, A.M. Daviesa, S.L.J. Jamesa,*

Departments of aRadiology, and bOrthopaedic Surgery, The Royal Orthopaedic Hospital NHS Foundation
Trust, Birmingham, UK

Received 29 January 2009; received in revised form 23 March 2009; accepted 31 March 2009

Hip arthroplasty is an extremely common orthopaedic procedure and there is a wide array of implants that are in cur-
rent use in the UK. The follow-up of patients who have undergone insertion of a hip prosthesis is shifting from a con-
sultant-lead hospital service towards primary care. As this change in patient care continues it becomes increasingly
important that an accurate description of the radiographic features is communicated to the primary-care practitioner
so appropriate specialist input can be triggered. This review focuses on the terminology and classification of hip pros-
theses. This acts as a precursor for Part 2 of this series, which describes the normal and abnormal radiographic findings
following hip prosthesis insertion.
ª 2009 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction hospital service towards primary care provides

Hip replacement is a commonly performed ortho-
paedic procedure; more than 55,000 are per-
formed annually in the UK and this number is
expected to increase.1 There have been multiple
recent publications in the radiology literature
regarding advanced imaging techniques to identify
component failure, including the use of computed
tomography (CT), magnetic resonance imaging
(MRI), and bone scintigraphy.2e8 However, radio-
graphs still provide the mainstay for the initial
diagnosis of component failure, both in the
immediate postoperative period and at long-term
follow-up. They are also likely to remain the
primary screening tool for interval follow-up of
these prostheses.
The present trend for a shift in emphasis of
patient care in orthopaedics from consultant-lead
* Guarantor and correspondent: S.L.J. James, Department of
Radiology, The Royal Orthopaedic Hospital NHS Foundation
Trust, Bristol Road, Northfield, Birmingham B31 2AP, UK.
Tel.: þ44 121 685 4135; fax: þ44 121 685 4134.
E-mail address: steven.james@roh.nhs.uk (S.L.J. James).
challenges in the management of patients follow-
ing hip arthroplasty. One difficulty is how to trigger
appropriate specialist review of potentially failing
implants. The decision of when to refer a patient
for specialist input is increasingly taken by the
general practitioner, initiated by the radiological
report. Therefore, it is vital that a concise and
accurate description of the radiographic features
is provided in order that referrals are made for
appropriate reasons. There are many prosthetic
components available in the UK and recognition
can be challenging. A number of asymptomatic
radiographic abnormalities require prompt surgical
referral. Different component designs, materials,
fixations, articulations, and surgical techniques
alter considerably the normal and abnormal find-
ings on radiographs.9
Part 1 of this series of articles reviews the
terminology and features of common prostheses
currently used in the UK. It is important that all
professionals reporting such examinations have an
adequate knowledge of the spectrum of radiological
appearances, both normal and abnormal. The arti-
cles are aimed at the general radiologist and trainees,

0009-9260/$ - see front matter ª 2009 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.crad.2009.03.011
Prosthesis terminology and classification
who frequently encounter such cases in their day-to-
day reporting rather than at the specialist. With the
aim being to discourage reports such as ‘‘Hip pros-
thesis in situ. Please see films for position’’.
Terminology
Total hip replacement (THR)
Hip replacement including replacement of both
the femoral head and acetabular cup (Fig. 1).
Hybrid and reverse hybrid THR
Replacement of both the femoral head and ace-
tabular cup, with one cemented component and
one uncemented component. ‘‘Hybrid hip replace-
ment’’ designates a combination of a cemented
femoral stem with an uncemented acetabular cup.
A combination of a cemented acetabular cup and
cementless stem is termed a ‘‘reverse hybrid hip
replacement’’.
Hemiarthroplasty
A surgical procedure that replaces one half of the
hip joint with an artificial surface, usually the
femoral component. This is most commonly per-
formed after femoral neck fractures. The frac-
tured head of the femur is removed and replaced
by a femoral prosthesis, cemented or uncemented.
Unipolar hemiarthroplasty
Unipolar hemiarthroplasty comprises a combina-
tion of a femoral component articulating directly
with the native cartilage surface of the acetabu-
lum (Fig. 2a).
Bipolar hemiarthroplasty
Bipolar hemiarthroplasty comprises a combination
of a femoral component articulating with a cup
inserted into the native acetabulum without fixa-
tion. This cup is usually made of polyethylene with
a metal backing and can normally move within the
native acetabular cavity as a result of the absence
of fixation (Fig. 2b).
Hip resurfacing
Hip resurfacing consists of replacing the surface of
the femoral head by a metallic ‘‘cap’’ without
removing the femoral neck or instrumenting the
femoral diaphysis. The cap used on the femoral
head is virtually the same size as the natural head
and articulates with an acetabular prosthetic cup,
usually made of metal (Fig. 3). This type of bone
955
preserving hip joint replacement is favoured in
younger and highly active patients and in theory
allows easier revision on the femoral side to a total
hip replacement in later years.
Types of hip joint replacements:
components
A number of components may be required to build
the implant: the cup replacing the hip socket, the
ball replacing the femoral head, and the stem,
which fits into the proximal metaphysis and
diaphysis of the femur.
Acetabular cup
Construction
The acetabular cup is usually made of ultra-high
molecular-weight polyethylene, metal or a metal-
backed shell in combination with a bearing-surface
liner (metal, ceramic or polyethylene).
Fixation
Cemented fixation
The bone cement most commonly used to attach
the acetabular cup to the bone is polymethylme-
thacrylate (PMMA; Fig. 1).
Cementless fixation
Cementless acetabular cups have a coated or
roughened surface to stimulate bone growth into
Figure 1 Anteroposterior view of the pelvis demon-
strating bilateral cemented acetabular and femoral
components (Exeter stem) with a ceramic right femoral
head and a metal left femoral head articulating on bilat-
eral polyethylene acetabular components. A radio-opa-
que indicator in the cement restrictor is shown (white
arrow) and the centralizer is indicated by the lucency
at the tip of the femoral stem (white arrowhead).
956 E. Pluot et al.

Figure 2 (a) Anteroposterior view of a right hip demonstrating a cemented unipolar hemiarthroplasty (Thompson).
The head does not move in relation to the femoral stem and the head is, therefore, located centrally to the femoral
stem (white arrow). (b) Anteroposterior radiograph of the right hip showing a cemented bipolar hemiarthroplasty
(JRI). The cup articulates with the stem and, therefore, may be visualized in an eccentric position on an anteropos-
terior radiograph (white arrow).

the surface. They usually have a polyethylene liner Fixation

and a metal outer shell (Fig. 4). Surface coatings,
such as hydroxyapatite (HA), are often added to
the outer metal shell to enhance this bone in-
growth. The fixation into the bone can be rein-
forced by screws, pegs, or fins until bone
ingrowth occurs.
Design
Acetabular components can be constructed of
a single piece (non-modular) or with two inter-
changeable parts (modular), which allows more
flexibility in the choice of the device. Modular
components consist of a metallic intra-osseous
insert and a shell, which receives the femoral
ball. The shell is usually made of polyethylene,
metal, or alternatively ceramic.
Cemented fixation
PMMA is currently the cement used to bind the
femoral stem to the cancellous femoral bone.
Cemented fixation often requires the use of
cement restrictors or distal plugs placed 10 mm
distal to the intended level of the tip of the
stem. The primary goal of plugging the intramedul-
lary canal during total hip arthroplasty is to in-
crease penetration of cement into the cancellous
bone proximal to the intramedullary plug. They
seal the femoral canal, improve fixation and pre-
vent the bone cement from leaking during delivery
and pressurization. They are made of polyethyl-
ene, titanium, or biodegradable components and
contain embedded radio-opaque indicators
(Fig. 1).

Femoral stem Cementless fixation

Bone ingrowth is a frequent alternative to ce-
Construction mented fixation and requires a textured surface on
Femoral stems are made of titanium alloys, cobalt all or part of the stem. The proximal part of the
echromium-based alloys, or stainless steel. stem is usually roughened in order to attract new
Prosthesis terminology and classification
Figure 3 Anteroposterior radiograph of a right hip
illustrating a hip resurfacing.
bone growth (Fig. 5). Additional surface coating by
HA is common to promote osseous integration.
Design
Design features and surface finishes of femoral
stems depend on the method of fixation chosen
by the surgeon. The different designs and fixa-
tions produce different patterns of loading forces
to the native bone. Therefore, an adequate
knowledge of the major types of designs is
required.
Cemented femoral stems
Two types of design based on the surface finish and
the shape of the distal part of the stem are
available: tapered, polished and composite beam
stems.
Tapered, polished femoral stem. Tapered, pol-
ished femoral stems are currently extensively used
(Fig. 1). At the time of insertion, this design of
stems requires the use of a ‘‘stem centralizer’’.
This usually consists of a small cylindrical device
installed on the distal tip of the stem to avoid
malposition of the stem in mediolateral and
anteroposterior planes and to help establish
a uniform cement mantle around the tip. The
combination of a polished surface and a narrower
957
Figure 4 Anteroposterior view of a right hip showing
an uncemented acetabular and femoral component
(Corail stem) with a metal femoral head articulating on
polyethylene liner within a uncemented metal shell.
tip in both mediolateral and anteroposterior dimen-
sions allows the stem to engage the cement and
convert the axially directed shear forces at the
implantecement interface into radially directed
hoop stresses with reinforcement of periprosthetic
bone. A degree of subsidence within the cement
mantle in the first postoperative months is thus
an essential feature of stem function and does not
predict failure.10
Composite beam femoral stem. This type of
stem is not tapered and does not have a polished
finish (Fig. 6). The aim is to create a firm bond at
the stemecement interface. Composite beam
fixation relies on perfect bonding between stem
and cement at all times and for all loading
directions.
Uncemented femoral stems
Uncemented femoral stems have usually a much
larger proximal portion compared with cemented
stems. They have a textured surface involving the
proximal part or all the surface of the implant
958
Figure 5 Anteroposterior radiograph of a right hip
demonstrates a tapered, uncemented femoral stem
and an uncemented acetabular component. Also shown
is a large metal on metal articulation. There is a subtle
transition point in the femoral stem which represents
the junction between the proximal area of roughened
finish and the smooth portion of the tapered stem infe-
riorly (arrow).
(Figs. 4, 5). As for acetabular components, an
additional coating of HA is common in order to
promote bone ingrowth. Their general shape can
be cylindrical or tapered.
Other features
In addition to the distinction between tapered and
cylindrical stems, other geometrical features are
encountered. The long axis of femoral stems can be
either straight or curved in order to mirror the shape
of the femoral shaft. Additional characteristics like
proximal collars may also be encountered in both
uncemented and cemented femoral stems (Fig. 7).
Cross-sectional geometry of cemented prostheses
is also variable and can be round shaped or
quadrangular. These different patterns imply
differences in the distribution of cement and in
forces applied to the native bone.
E. Pluot et al.
Figure 6 Anteroposterior radiograph of a right hip il-
lustrating a cemented acetabular and a cemented com-
posite beam femoral stem (Charnley). The femoral head
is incorporated in the stem (non-modular) and articu-
lates with a polyethylene acetabulum.
Femoral head
The ball replacing the femoral head can be inbuilt
with the femoral stem or be part of a modular
femoral prosthesis. If part of a modular implant,
the ball is usually made of cobaltechromium-
based alloys or ceramic materials (aluminum ox-
ide, zirconium oxide; Fig. 1).
Hip resurfacing
At present, hip resurfacing usually consists of
a metallic acetabular socket, press-fit with
a rough back surface coated with HA, and a large
femoral metallic head inserted onto the
preserved femoral head with a short, narrow
cemented or uncemented stem passing down
the femoral neck.
Prosthesis terminology and classification
Figure 7 Anteroposterior radiograph of a left hip dem-
onstrating an uncemented femoral stem with a proximal
collar (white arrow) and an uncemented acetabular
component.
Bearing surfaces
As a result of the multiplicity of the different
components, several combinations of bearings
between femoral balls and acetabular cups are
possible. Metal-on-polyethylene, referring to a me-
tallic head rotating on a polyethylene liner, is the
commonest bearing. Other options are metal-
on-metal, ceramic-on-polyethylene, and ceramic-
on-ceramic.
Current hip joint replacements in the UK
Population
According to the 4th annual report of the National
Joint Registry released in September 2007, more
than 55,000 hip joint replacements are performed
959
annually in the UK.1 The mean age of patients
undergoing hip joint replacement is 68 years.
Patients undergoing hip resurfacing tend to
be younger, with a mean age of 55 years. The
male:female ratio is 2:3. Osteoarthritis is the com-
monest indication and accounts for approxi
mately 94% of cases. Other indications include
avascular necrosis of the femoral head, congenital
hip dysplasia, fracture of the neck of the femur,
and rheumatoid arthritis.1
THR
Cemented femoral stems
Cemented stems in THR account for approximately
69% of all hip joint replacements. The most
frequent type of prosthesis is a tapered, polished
femoral stem, labelled Exeter (Stryker How-
medica Osteonics, Newbury, UK), accounting for
approximately 50% of all cemented THR. The
second most commonly inserted prosthesis,
accounting for approximately 15% of cemented
femoral stems, is the composite beam hip prosthe-
sis Charnley (DePuy, Warsaw, USA).
Uncemented femoral stems
Uncemented stems in THR represent 31% of all hip
joint replacements. The two commonest types of
femoral stems implanted are the Furlong (Joint
Replacement Instrumentation Ltd, London, UK),
a fully HA coated, cylindrical stem, and the Corail
(Depuy, Warsaw, USA), a fully HA coated tapered
stem, each representing approximately 25% of all
uncemented THR.
Acetabular cups
Cemented acetabular cups are slightly predomi-
nant, accounting for 53% of all implanted cups
versus 47% of uncemented cups.
Hybrid and reverse hybrid THR
Hybrid and reverse hybrid THR account for approx-
imately 15% of all hip joint replacement, with
a predominance of hybrid THR.
Hip resurfacing
With more than 6000 procedures per year,1 hip
resurfacing accounts for approximately 10% of all
hip joint replacements.
Revision of hip arthroplasty
Approximately 4000 hip prosthesis revisions and
other re-operations are performed annually in the
960
UK. Aseptic loosening of one or both components
and bone lysis represent in excess of 60% of in-
dications for hip revision surgery. Wear of the
acetabular component and dislocation each
account for approximately 15% of re-operations.
Infection, periprosthetic fracture, and malalign-
ment each make up 6e8% of indications. The
components removed during hip revision proce-
dures are both acetabular and femoral components,
acetabular component with or without the femoral
head, and femoral component alone in 54, 24, and
16% of cases, respectively. Re-implanted acetabular
and/or femoral components are uncemented in two
thirds of hip revisions.1
References
1. National Joint Registry. 4th Annual report. Hemel Hemp-
stead: NJR Centre, Northgate Information Solutions; 2007.
2. Hardy DC, Reinus WR, Totty WG, et al. Arthrography after
total hip arthroplasty: utility of postambulation radio-
graphs. Skeletal Radiol 1988;17:20e3.
E. Pluot et al.
3. Keogh CF, Munk PL, Gee R, et al. Imaging of the painful hip
arthroplasty. AJR Am J Roentgenol 2003;180:115e20.
4. Leung S, Naudie D, Kitamura N, et al. Computed tomogra-
phy in the assessment of periacetabular osteolysis. J Bone
Joint Surg Am 2005;87:592e7.
5. Puri L, Wixson RL, Stern SH, et al. Use of helical computed
tomography for the assessment of acetabular osteolysis
after total hip arthroplasty. J Bone Joint Surg Am 2002;
84-A:609e14.
6. Stumpe KD, Notzli HP, Zanetti M, et al. FDG PET for differ-
entiation of infection and aseptic loosening in total hip
replacements: comparison with conventional radiography
and three-phase bone scintigraphy. Radiology 2004;231:
333e41.
7. Sugimoto H, Hirose I, Miyaoka E, et al. Low-field-strength
MR imaging of failed hip arthroplasty: association of femo-
ral periprosthetic signal intensity with radiographic, surgi-
cal, and pathologic findings. Radiology 2003;229:718e23.
8. Walde TA, Weiland DE, Leung SB, et al. Comparison of CT,
MRI, and radiographs in assessing pelvic osteolysis: a cadav-
eric study. Clin Orthop Relat Res 2005:138e44.
9. Bauer TW, Schils J. The pathology of total joint arthroplasty
1. Mechanisms of implant fixation. Skeletal Radiol 1999;28:
423e32.
10. Huiskes R, Verdonschot N, Nivbrant B. Migration, stem
shape, and surface finish in cemented total hip arthro-
plasty. Clin Orthop Relat Res 1998:103e12.