The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 90, Issue Supplement 3

Clinical Issues | August 01, 2008

Anatomic Diameter Femoral Heads in Total Hip Arthroplasty: A Preliminary Report

Steven A. Stuchin, MD¹

¹ NYU Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003. E-mail address: Steven.Stuchin@nyumc.org

Disclosure: The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2008 Aug 01;90(Supplement 3):52-56. doi: 10.2106/JBJS.H.00690

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (2)

text A A A

Abstract

Background: The stability of total hip replacements has been directly related to the diameter of the femoral head in several studies; however, durability has necessitated the use of femoral heads with a relatively small diameter. Recent developments in metal-on-metal technology have allowed for the use of femoral head bearings that are anatomic in diameter. In this case series, we report on the early results of patients who were at greater risk for dislocation because of anatomic deficiencies or increased range-of-motion activities and underwent hip arthroplasty with implants that had articulating surfaces approaching anatomic dimensions.

Methods: Thirty-four patients underwent forty total hip arthroplasties with use of a modular metal-on-metal articulation with an anatomic diameter femoral head and a press-fit stem. Thirty patients were active, and four patients were profoundly disabled and had bone or soft-tissue deficiencies that would increase the risk for dislocation. Dislocation precautions were maintained for six weeks, and patients were allowed extreme ranges of motion at three months.

Results: There were no dislocations. Active patients continued in extreme range-of-motion activities. Disabled patients improved but were limited by their comorbidities.

Conclusions: Anatomic diameter femoral heads offer distinct theoretical advantages in total hip arthroplasty. These short-term results are encouraging, and further study of this new technology in a larger series with a longer follow-up period is warranted.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Dislocation after total hip arthroplasty remains a difficult problem in 0.4% to 3.9% of reported series¹. Patient-related factors increasing the risk for postoperative instability have included prior hip surgery, neuromuscular disorders, tissue laxity, age, female sex, hip dysplasia, compliance with postoperative protocols, alcohol abuse, and a score of 3 or 4 according to the system of the American Society of Anesthesiologists. Mechanical and surgical technique-related factors have included implant design, head-neck ratios, component positioning, and the contribution of spinal and pelvic mobility^2-4.

The direct relationship between head-neck ratio, hip stability, and range of motion after total hip arthroplasty is well recognized in the biomechanical literature^5-7. Crowninshield et al. studied prosthetic impingement-free range of motion as a function of femoral head diameter and determined that this range of motion increased by 30° as the femoral component diameter increased from 22 to 40 mm⁵. D'Lima et al. demonstrated the relationship between the head-neck ratio and component positioning with lower ratios decreasing the range of motion because of impingement⁶. Historically, materials and anatomic restrictions have limited implant designs from taking full advantage of this relationship. Recently, enhanced polyethylene and ceramics have allowed for the development of large femoral head sizes of up to 40 mm⁸.

Clinical verification of the advantages of an enhanced head-neck ratio in total hip arthroplasties is limited. Beaulé et al. reported on a small series of twelve hips that were successfully revised for instability with use of bipolar and jumbo prosthetic heads⁹. Smith et al. reported on the short-term dislocation rate in 377 total hip arthroplasties with use of a 38-mm metal-on-metal bearing¹⁰. There were no dislocations in that group of patients, whom the authors considered high demand and at high risk for dislocation.

Hip resurfacing has led to advances in metal-on-metal technology and the development of femoral head diameters that approximate the anatomic dimensions of the patient. Revision of resurfacing because of femoral side failure has necessitated the creation of modular metal femoral heads that maintain the diameter of the resurfacing component but engage a conventional femoral stem component of a total hip prosthesis. The head-neck ratio of these constructs is profoundly greater than that of a traditional 28 or 32-mm implant. Hip motion also improves with range of motion. For example, with a 50-mm head in a 56-mm socket, close to 170° of flexion is obtainable¹¹. To date, we know of no report detailing the use of these anatomic diameter components.

While all patients might benefit from increased motion, those approaching both extremes of the activity spectrum may be most appropriate for the advantages of increased motion or stability. The present study describes the use of these hip-resurfacing salvage femoral head components as primary implants in a group of patients who were extremely active and in a group with a high risk of dislocation.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

With approval from the institutional review board, we reviewed the records of patients who had undergone total hip arthroplasty with use of an anatomic diameter femoral component. Between October 2006 and September 2007, thirty-four patients underwent forty total hip arthroplasties with use of a resurfacing socket, a modular metal head component, and a cementless femoral stem.

There were eighteen men and sixteen women who had a mean age of fifty-seven years (range, thirty-nine to seventy-five years). The primary diagnosis included osteoarthritis in sixteen patients, inflammatory arthritis in five, osteonecrosis in three, failed fixation of a hip fracture in three hips, and hip dysplasia in two. There were thirty patients who were extremely active but did not desire or qualify for resurfacing (Fig. 1), and four patients were profoundly disabled (Fig. 2). For the active group, the presumed benefit of increased range of motion was the principal justification for the use of this implant. For the disabled group, enhanced stability in patients who were at risk for dislocation was the indication for the use of this device.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1-A Fig. 1-B: Figs. 1-A and 1-B A sixty-one-year-old man with arthritis of the right hip and spinal deformity. The spine problems made high-impact sports an unrealistic long-term goal for this otherwise very active man. Fig. 1-A Preoperative anteroposterior radiograph. Fig. 1-B Postoperative anteroposterior radiograph showing a total hip replacement with a 50-mm prosthetic head. It is within a few millimeters of the diameter of the unreplaced left femoral head. Hip replacement made it possible to adjust the limb length and offset to compensate for the spine-related obliquity.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2-A Fig. 2-B: Figs. 2-A and 2-B A sixty-seven-year-old woman with Parkinson disease and failed fixation of an intertrochanteric fracture. Fig. 2-A Preoperative radiograph. Fig. 2-B Postoperative radiograph demonstrating reconstruction with total hip replacement. Extensive soft tissue releases were required for exposure.

The implant used for all procedures was a Birmingham hip resurfacing socket (Smith and Nephew, Memphis, Tennessee) and the corresponding modular metal femoral head. Porous ingrowth press-fit stems with a compatible taper were used in all hips. These included collarless Anthology and Emperion and collared Echelon stems (Smith and Nephew). The Birmingham hip resurfacing sockets ranged from 44 to 66 mm, and the corresponding modular heads ranged from 38 to 58 mm. The socket and head are a cobalt-chromium metal-on-metal bearing. The socket has a hydroxyapatite-coated beaded surface designed for press-fit fixation.

All procedures were performed through a posterior approach with an enhanced repair of the external rotators and the posterior capsular ligamentous structures, similar to the technique described by Pellicci et al.¹².

Even with the presumed enhanced stability of the implant, patients were instructed to avoid flexion of >90° or adduction beyond the midline for six weeks. Full weight-bearing was encouraged from the first postoperative day, but patients were given walking aids as needed for balance and muscle control. All routine activities of daily living were allowed at that point. Extreme ranges of motion were allowed at three months. Active patients were advised against high-impact activities, including jogging, contact sports, and high-impact aerobics.

All patients were examined at six, twelve, twenty-four, and fifty-two weeks after surgery. Clinical evaluations were performed with use of the Harris hip scoring system¹³. Standard radiographs, including an anteroposterior radiograph of the pelvis and anteroposterior and cross-table lateral radiographs of the index hip, were made. These radiographs were evaluated for component position, radiolucent lines, migration and component subsidence, osteolysis, and loosening. Complications were recorded.

Results

Introduction | Materials and Methods | Results | Discussion | References

The mean Harris hip score was 40 points (range, 8 to 58 points) prior to surgery and 88 points (range, 54 to 100 points) at the time of the last follow-up. All thirty active patients had scores of >90 points and were able to continue activities requiring an extreme range of motion. The profoundly disabled patients had no pain, but they had severe score reductions related to limited function and comorbidities. There were no dislocations.

One patient, a sixty-four-year-old woman with rheumatoid arthritis and multiple joint contractures who was bedridden, had a wound infection with multiple gram-negative organisms which developed four weeks after surgery. She was treated with open irrigation, débridement, and intravenous antibiotics. She remained on oral antibiotics and retained the implant, but the outcome was considered a failure. Two patients with failed hip-fracture fixation, Parkinson disease, and limited mobility had improvement, but they were not able to walk well or far. At one year, follow-up radiographs showed stable acetabular and femoral component fixation in all patients. There was no evidence of loosening, subsidence, or osteolysis.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The success of total hip arthroplasty has been measured by the criteria of implant survival, pain relief, and return to basic walking ability. Historically, concerns about fixation failure, bearing surface wear, or material failure have led surgeons to limit the activities of patients after surgery^14,15. It is not known how many cycles of repetitive loading a femoral implant can sustain. Accordingly, it is not without justification that surgeons continue to advise restraint in activities following arthroplasty. Nevertheless, while it is not always documented, most total hip arthroplasty surgeons know of patients who routinely exceed activity precautions. Hip resurfacing offers the promise of high-impact activity, bone preservation, and anatomic hip reconstruction. These advantages are counterbalanced by the recognized contraindications to the procedure including poor bone stock and bone deformity. The additional surgical skills required to perform resurfacing at this time also limit its application. The large, anatomic diameter femoral heads described in this study may allow for activities that require greater range of motion and may be as durable as resurfacing without many of its drawbacks.

Many authors have advocated increasing femoral head size as a theoretical method of reducing the dislocation rate because of the advantages of the increased jump distance and enhanced head-neck ratios^5,8-10. However, because this technology has been developed only recently, there are few clinical confirmatory studies. Smith et al. reported no dislocations after thirty-five hip arthroplasties done through a posterior approach and after 342 hip arthroplasties performed through an anterolateral approach with use of a metal-on-metal implant with a large (38-mm) head¹⁰. The authors considered 16% of these patients to be at risk for postoperative dislocation because of a diagnosis of posttraumatic arthritis or hip dysplasia or the procedure was a revision arthroplasty.

If dislocation alone were the only reason to use a large femoral head, then 38 mm might be sufficient. Whether a head size of >38 mm is necessary is worthy of consideration. The implants used in the present study increased in diameter directly with the socket size such that the head size was within 4 mm of the natural femoral head that it replaced in all cases. These large head dimensions (ranging from 38 to 58 mm) lead to head-neck ratios and jumping distances that allow for range of motion beyond the physiologic range. Their effect on in vivo hip motion and gait has not been explored. There is some evidence that an anatomic head size may be beneficial in this regard. Mont et al. performed gait analyses in which they compared patients with resurfaced hips, standard total hip replacements, and osteoarthritic hips¹⁶. Patients who had hip resurfacing walked with a normalized gait, whereas patients who had a standard hip arthroplasty showed reduced velocity and abduction moments. The authors suggested that not only resurfacing but also the use of large diameter femoral heads might more closely approach the kinematics of the normal hip. Resurfacing maintains the anatomic dimensions of the femoral head and bone, but it requires extensive soft-tissue release. Total hip arthroplasty may better preserve soft tissues at the expense of the femoral bone. Additionally, limb length and offset may be better manipulated with hip arthroplasty. No gait studies have been done with only prosthetic head size as the variable. Whether head size and tissue preservation are important variables for gait remain to be determined.

Postoperative instability of total hip replacements performed for femoral neck fracture or failed fixation of intertrochanteric fracture is well recognized. The extensive soft-tissue release required for some of these procedures coupled with the poor muscle tone in many of these patients are risk factors for dislocation^17,18. Smith et al. described fifteen patients who underwent hip arthroplasty with a 38-mm head for failed hip fracture surgery¹⁰. No patient experienced a dislocation. The sizes of the anatomic diameter femoral heads used in the three fracture patients in the present study might be comparable with bipolar endoprosthetic femoral heads in relation to enhanced hip stability.

A major limitation of this series is the short follow-up period. This is somewhat mitigated by the knowledge that most dislocations occur in the first three months after total hip arthroplasty¹².

In conclusion, increased head-neck ratios with anatomic femoral heads offer substantial theoretical advantages in total hip arthroplasty. Recent technological advances allow for the use of implants that optimize this ratio. The use of these anatomic metal-on-metal implants may offer stability, durability, and long-term pain relief. Further clinical confirmation with larger series and longer-term reports is necessary, although the early results are quite encouraging. Image Not Available

References

Introduction | Materials and Methods | Results | Discussion | References

Joshi A, Lee CM, Markovic L, Vlatis G, Murphy JC. Prognosis of dislocation after total hip arthroplasty. J Arthroplasty.1998;13:17-21.1317 1998 [PubMed][CrossRef]

Jolles BM, Zangger P, Leyvraz PF. Factors predisposing to dislocation after primary total hip arthroplasty: a multivariate analysis. J Arthroplasty.2002;17:282-8.17282 2002 [CrossRef]

McCollum DE, Gray WJ. Dislocation after total hip arthroplasty. Causes and prevention. Clin Orthop Relat Res.1990;261:159-70.261159 1990

Padgett DE, Warashina H. The unstable total hip replacement. Clin Orthop Relat Res.2004;420:72-9.42072 2004 [CrossRef]

Crowninshield RD, Maloney WJ, Wentz DH, Humphrey SM, Blanchard CR. Biomechanics of large femoral heads: what they do and don't do. Clin Orthop Relat Res.2004;429:102-7.429102 2004 [CrossRef]

D'Lima DD, Urquhart AG, Buehler KO, Walker RH, Colwell CW Jr. The effect of the orientation of the acetabular and femoral components on the range of motion of the hip at different head-neck ratios. J Bone Joint Surg Am.2000;82:315-21.82315 2000

Amstutz HC, Lodwig RM, Schurman DJ, Hodgson AG. Range of motion studies for total hip replacements. A comparative study with a new experimental apparatus. Clin Orthop Relat Res.1975;111:124-30.111124 1975 [CrossRef]

Burroughs BR, Rubash HE, Harris WH. Femoral head sizes larger than 32 mm against highly cross-linked polyethylene. Clin Orthop Relat Res.2002;405:150-7.405150 2002 [CrossRef]

Beaulé PE, Schmalzried TP, Udomkiat P, Amstutz HC. Jumbo femoral head for the treatment of recurrent dislocation following total hip replacement. J Bone Joint Surg Am.2002;84:256-63.84256 2002

Smith TM, Berend KR, Lombardi AV Jr, Emerson RH Jr, Mallory TH. Metal-on-metal total hip arthroplasty with large heads may prevent early dislocation. Clin Orthop Relat Res.2005;441:137-42.441137 2005 [CrossRef]

Allen CW. Smith and Nephew personal communication, 2007. 2007

Pellicci PM, Bostrom M, Poss R. Posterior approach to total hip replacement using enhanced posterior soft tissue repair. Clin Orthop Relat Res.1998;355:224-8.355224 1998 [CrossRef]

Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am.1969;51:737-55.51737 1969

Youm T, Maurer SG, Stuchin SA. Postoperative management after total hip and knee arthroplasty. J Arthroplasty.2005;20:322-4.20322 2005 [CrossRef]

Klein GR, Levine BR, Hozack WJ, Strauss EJ, D'Antonio JA, Macaulay W, Di Cesare PE. Return to athletic activity after total hip arthroplasty. Consensus guidelines based on a survey of the Hip Society and American Association of Hip and Knee Surgeons. J Arthroplasty.2007;22:171-5.22171 2007 [CrossRef]

Mont MA, Seyler TM, Ragland PS, Starr R, Erhart J, Bhave A. Gait analysis of patients with resurfacing hip arthroplasty compared with hip osteoarthritis and standard total hip arthroplasty. J Arthroplasty.2007;22:100-8.22100 2007

Mabry TM, Prpa B, Haidukewych GJ, Harmsen WS, Berry DJ. Long-term results of total hip arthroplasty for femoral neck fracture nonunion. J Bone Joint Surg Am.2004;86:2263-7.862263 2004

Mehlhoff T, Landon GC, Tullos HS. Total hip arthroplasty following failed internal fixation of hip fractures. Clin Orthop Relat Res.1991;269:32-7.26932 1991

Topics

dislocations ; femur ; head of femur ; hip joint ; metals ; range of motion ; hip replacement arthroplasty

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

Accreditation Statement

These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Comment Title*

Comment*

Cancel

Steven A Stuchin

Posted on September 01, 2008

Dr. Stuchin responds to Drs Kini and Maduri

NYU Hospital for Joint Diseases

Sir,

I thank Drs.Kini and Maduri for their interest in our article.

Von Knoch et,al.(1) detailed several factors that make hip arthroplasties vulnerable to late dislocation. These include longstanding problems such as component malposition and recurrent subluxation, and new onset problems such as trauma, polyethylene wear, and neurologic changes.

These factors considered individually or in combination contribute to the clinical picture of instability or stability. The use of anatomic dimension femoral heads with minute wear rates theoretically should alter this balance in the favorable direction of stability. Clearly any estimation of the influence of this alteration over time can only be speculative. Still, the nature of this response invites speculation. I would suggest that for dislocation to occur early or late there must be a failure of the soft tissue restraints. Absent competent hip ligaments, a total hip will always be vulnerable to dislocation. A greater head/neck ratio increases the range of motion to dislocation, but does not prevent it.

Socket malposition leads to early catastrophic failure for implants with hard on hard bearings. When these implants are well positioned, they do not seem subject to extensive early wear. Late dislocation because of gross or cumulative wear remains to be demonstrated over time.

Recurrent subluxation like dislocation may be multifactorial, but clearly cannot occur if there are adequate soft tissue stabilizing elements. Trauma may lead to soft tissue failure or loss of fixation with ensuing malposition. Neurologic changes compromise dynamic stability.

Given the above, I would suggest that the factors leading to late dislocation must perforce include impingement, but impingement alone does not cause dislocation. The greater the impingement free range of motion and enhanced jumping distance that larger femoral heads offer may lower the chances of any particular hip motion leading to dislocation, but absent soft tissue constraint, at some point dislocation will still occur.

The field of hip arthroplasty is replete with brilliant technology that did not stand the test over the long term. I agree follow up over time is paramount.

We did not perform serum and urine metal ion studies because we deemed that they were not necessary given the attention this subject has received in the literature.

The patients with dysplasia in this study had Crowe I deformities and were not a challenge for pure pressfit fixation.(2) Amstutz et al have reported on hip resurfacing in Crowe I and II deformities.(3) Since this report, I have performed this surgery in Crowe II deformity but in my experience, the adjuvant fixation offered by a dysplasia socket was helpful to secure the cup.

I cannot comment on this type of implant in Crowe III or IV problems, but suggest such surgery is technically feasible as evidenced by the reports of hip resurfacing in patients with advanced dysplasia. (4) Again I would speculate that the conceptual initial stability benefits this class of implant offers would be advantageous in these cases that are notable for early dislocation.

No objective quantitative range of motion study was done. In spite of the enhanced in vitro range of motion that an increased head/neck ratio offers, in vivo results may not correspond. In this study, the post operative dislocation precautions included limitation of hip flexion for six weeks. This proscription may lead to soft tissue restriction of motion no matter the head/neck ratio.

References:

1. Von Knoch M,Berry DJ,Harmsen S etal:Late dislocation after total hip arthroplasty.J Bone Joint Surg 84A:1949,2002

2. Crowe JF. Mani VJ, Ranawat CR. Total hip replacement in congenital dislocation and dysplasia of the hip. J Bone Joint Surg(A) 1979;61-A:15- 23.

3. Amstutz HC, Le Duff MJ, Harvey N, Hoberg M. Improved survivorship of hybrid metal-on-metal hipresurfacing with second generation techniques for Crowe-I and Crowe-II Developmental dysplasia of the hip. L Bone Joint Surg (A) 2008;90(Supplement_3):12-20.

4. McMinn DJW, Daniel J, Ziaee H, Pradhan C. Results of the Birmingham hip resurfacing dysplasia component in severe acetabular insufficiency. J Bone Joint Surg(Br) 2008; 90-B:715-23.

Dr Sunil Gurpur Kini

Posted on August 12, 2008

Anatomic Diameter Femoral Heads in Total Hip Arthroplasty:A Preliminary Report

Siddhartha Academy of Higher Education, Karnataka,India

To The Editor

We read with interest the article by Dr.Stuchin and we would like to pose a few queries:

The selection criteria for metal on metal anatomical head included patients who were considered to be at high risk for dislocation due to their involvement in high range of motion activities.What was the mean (and range) postoperative range of motion in these patients?

2)What were the grades of dysplasia in the 2 cases in the series.Is a large head recommended in severe dysplasia ?

3)Was post operative monitoring for the level of metal ions in serum and urine carried out in the study and if so did it show any significantly increased levels during the one year follow up?

We believe that a longer term follow up will be necessary to more fully evaluate this concept because late dislocations due to impingement occur, they can be recurrent, and the majority of them require surgery (1).

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

References

1. Von Knoch M,Berry DJ,Harmsen S etal:Late dislocation after total hip arthroplasty.J Bone Joint Surg 84A:1949,2002

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Anatomic Diameter Femoral Heads in Total Hip Arthroplasty: A Preliminary Report'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Anatomic Diameter Femoral Heads in Total Hip Arthroplasty: A Preliminary Report'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

Steven A. Stuchin; Anatomic Diameter Femoral Heads in Total Hip Arthroplasty: A Preliminary Report. The Journal of Bone & Joint Surgery. 2008 Aug;90(Supplement_3):52-56.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment