
COPYRIGHT © 2002
BY
THE JOURNAL
OF
BONE
AND JOINT
SURGERY, INCORPORATED
Twenty-five-Year Survivorship
of Two Thousand Consecutive
Primary Charnley
Total Hip Replacements
FACTORS AFFECTING SURVIVORSHIP
OF
ACETABULAR
AND
FEMORAL COMPONENTS
BY DANIEL J. BERRY, MD, W. SCOTT HARMSEN, MS, MIGUEL E. CABANELA, MD, AND BERNARD F. MORREY, MD
Investigation performed at the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
Background: Charnley total hip arthroplasty has been demonstrated to provide good clinical results and a high
rate of implant survivorship for twenty years and longer. Most long-term series are not large enough to stratify
the many demographic factors that influence implant survivorship. The purpose of this study was to analyze the
effects of demographic factors and diagnoses on the long-term survivorship of the acetabular and femoral components used in Charnley total hip arthroplasty.
Methods: Two thousand primary Charnley total hip arthroplasties (1689 patients) were performed at one institution from 1969 to 1971. Patients were contacted at five-year intervals after the arthroplasty. Twenty-five years after the surgery, 1228 patients had died and 461 patients were living. Hips that had not had a reoperation,
revision or removal of a component for any reason, or revision or removal for aseptic loosening were considered to
have survived. Survivorship data were calculated with use of the method of Kaplan and Meier. Patients were stratified by age, gender, and underlying diagnosis to determine the influence of these factors on implant survivorship.
Results: The twenty-five year rates of survivorship free of reoperation, free of revision or removal of the implant
for any reason, and free of revision or removal for aseptic loosening were 77.5%, 80.9% and 86.5%, respectively. The twenty-five-year survivorship free of revision for aseptic loosening was poorer for each decade earlier
in life at which the procedure was performed; this survivorship ranged from 68.7% for patients who were less
than forty years of age to 100% for patients who were eighty years of age or older. Men had a twofold higher
rate of revision for aseptic loosening than did women.
Conclusions: Age, gender, and underlying diagnosis all affected the likelihood of long-term survivorship of the
acetabular and femoral components used in Charnley total hip arthroplasty.
T
otal hip arthroplasty with cement, pioneered by Sir
John Charnley, is acknowledged to be one of the most
successful surgical interventions ever developed. The
Charnley hip replacement has been reported to provide good
clinical results1-14, with lasting pain relief and a survivorship of
>80% at twenty years after surgery9,15,16. Since the introduction
of total hip arthroplasty with cement, much has been learned
about the factors that contribute to success or failure of the procedure. However, limited sample sizes, multiple prosthetic designs, and limited follow-up periods have precluded a rigorous
analysis of the factors that govern long-term survivorship of the
components and complications associated with this widely performed operation. The purpose of this study was to analyze
how the age and gender of the patient as well as the diagnosis
affect the long-term survivorship of the acetabular and femoral
components of the Charnley total hip prosthesis.
Materials and Methods
he study group consisted of 2000 consecutive primary
Charnley total hip arthroplasties that were performed on
1689 patients at one institution from March 10, 1969, through
September 27, 1971. Eight hundred and twenty-eight men (996
hips) and 861 women (1004 hips) were included in the study.
The mean age of the patients at the time of surgery was 63.5
years (range, twenty-four to ninety-two years). Forty-three of
the hips were in patients who were younger than forty years
old, 144 were in patients who were forty to forty-nine years old,
476 were in patients who were fifty to fifty-nine years old, 779
were in patients who were sixty to sixty-nine years old, 497 were
in patients who were seventy to seventy-nine years old, and
sixty-one were in patients who were eighty years of age or older.
The diagnosis that led to the total hip arthroplasty was
osteoarthrosis in 1647 hips; rheumatoid arthritis in 166 hips;
T
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Fig. 1
Survivorship to death for the study group compared with the predicted
survivorship for an age and gender-matched population of white United
States citizens (most comparable with the patient cohort).
developmental dysplasia in 116 hips; osteonecrosis of the femoral head in 103 hips; acute fracture, nonunion of a fracture,
or posttraumatic degenerative disease in 207 hips; and miscellaneous causes (including a slipped capital femoral epiphysis
and Legg-Calvé-Perthes disease) in twelve hips. Two hundred
and fifty-one hips had more than one diagnosis.
The operative approach was transtrochanteric in all
cases. An all-polyethylene socket (inside diameter, 22.25 mm)
was cemented into the pelvis after anchoring holes were made
in the ilium, ischium, and pubis. The femoral canal was prepared with broaches, and no pulsatile lavage was used. A
smooth-surfaced stainless-steel monoblock, so-called flatback Charnley component with a 22.25-mm head (DePuy International, Leeds, United Kingdom) was cemented into the
femur with use of hand-packed radiopaque methylmethacrylate cement and no plug in the medullary canal. Perioperative
antibiotics were administered routinely.
Patients were followed prospectively and were asked to
return to our institution at one year, two years, five years, and
every five years thereafter for an interview and a clinical examination. When this was not possible, patients were asked to
answer a standardized letter questionnaire and to send radiographs. Patients who did not answer the letter questionnaire
were contacted by telephone and interviewed with use of a
standardized telephone questionnaire. Patients were specifically queried about whether they had had additional surgery
on the hip. If they had had additional surgery at another institution, a request was made to obtain operative reports and information concerning the indication for the surgery, the
surgical findings, and the components that were revised. The
most recent follow-up evaluation was conducted by interview
and examination for 309 hips, letter questionnaire for 1042
hips, and telephone questionnaire for 649 hips. Dates of death
were obtained either by direct communication with the patient’s family or by way of the Social Security network.
Implant survivorship was estimated with use of the Cox
proportional-hazards model and was adjusted for correlated
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data—that is, for two hips in patients who underwent bilateral
total hip arthroplasty17. Patients were censored at death or at
revision. End points considered in these analyses included reoperation, removal or revision of an acetabular and/or femoral component for any reason, and revision or removal of an
acetabular and/or femoral component for aseptic loosening.
For each end point, the risk factors that were considered included gender, underlying diagnosis, and age (decade of life)
at the time of the total hip arthroplasty. Ninety-five percent
confidence intervals were calculated for the survivorship estimates. The rate of survival until death was also compared with
the expected rate of survival in an age-and-gender-matched
population of white United States citizens18. A one-sample logrank test was used to test for significance19.
Results
welve hundred and twenty-eight patients (1459 hips) had
died by the time of the twenty-five-year follow-up after
the total hip arthroplasty. For the first twenty years after the
procedure, our patients lived longer than the predicted life
spans of an age and gender-adjusted population of white citizens in the United States (the group most similar to the study
group) (p < 0.0001). After twenty years, the rate of survival of
the study cohort was poorer than predicted (Fig. 1).
Of the 2000 hips, 1942 (97%) were followed for at least
twenty-five years or until a revision operation, removal of the
component, or death, and 1980 (99%) were followed for at
least twenty years or until a revision operation, removal of the
component, or death. The longest follow-up period was 28.4
years. Of the 372 unrevised hips in patients alive at the last
follow-up evaluation, 323 had been followed for at least
twenty-five years and thirty-two had been followed for twenty
to twenty-four years. The mean age of the patients still living
at the end of the study was eighty years at the time of their last
follow-up evaluation. Five hundred and forty-one of the 2000
hips were in patients who subsequently lived at least twentyfive years after the operation. For patients who died, the mean
T
Fig. 2
Survivorship free of a reoperation for any reason, free of component
removal or revision for any reason, and free of component removal or
revision for aseptic loosening.
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TABLE I Survivorship of Two Thousand Hips
Survivorship* (%)
Time After
Total Hip
Arthroplasty
Free of Any
Reoperation
Free of Component
Removal or Revision
for Any Reason
Free of Component
Removal or Revision
for Aseptic Loosening
5 yr
96.1 (95.1-96.9)
98.0 (97.2-98.5)
99.6 (99.3-99.8)
10 yr
91.8 (90.6-93.3)
94.0 (93.0-95.0)
97.1 (96.1-97.8)
15 yr
87.1 (85.3-88.7)
89.8 (88.3-91.2)
93.8 (92.3-94.9)
20 yr
81.3 (79.2-83.6)
84.1 (82.2-85.9)
89.4 (87.4-91.0)
25 yr
77.5 (74.9-80.3)
80.9 (78.4-83.0)
86.5 (84.0-88.4)
*The 95% confidence intervals are shown in parentheses.
length of time between the last clinical follow-up examination
and death was 0.6 year; it was more than two years for only
fifty-one patients.
During the twenty-five-year study period, 296 hips were
known to have had a reoperation. The type of surgery was revision or removal of a component in 242 hips and a reoperation without revision or removal of a component (for
example, trochanteric wire removal) in fifty-four hips. Of the
hips treated with removal or revision of a component, 151 had
the reoperation because of aseptic loosening. The acetabular
component alone was removed or revised in forty-five hips,
the femoral component alone was removed or revised in
ninety-five hips, and both components were removed or revised in 102 hips. Thus, the acetabular component was removed or revised in a total of 147 hips (because of aseptic
loosening in 100), and the femoral component was removed
or revised in a total of 197 hips (because of aseptic loosening
in 118). Among the forty-seven acetabular components that
were removed or revised for reasons other than aseptic loosening, the reason was recurrent dislocation in nineteen hips,
deep infection in seventeen hips, fracture of a component in
seven hips, and miscellaneous reasons in four hips. Among the
seventy-nine femoral components that were removed or revised for reasons other than aseptic loosening, the reason was
fracture of the prosthetic stem in forty-five hips, deep infection in seventeen hips, recurrent dislocation or subluxation in
eleven hips, periprosthetic femoral fracture in four hips, and
miscellaneous reasons in two hips.
For the 2000 hips, the twenty-five-year rates of survivorship free of reoperation, free of revision or removal of the implant for any reason, and free of revision or removal for aseptic
loosening were 77.5% (95% confidence interval, 74.9% to
80.3%), 80.9% (95% confidence interval, 78.4% to 83.0%),
and 86.5% (95% confidence interval, 84.0% to 88.4%), respectively (Fig. 2, Table I).
Survivorship free of revision for aseptic loosening was
better for the female patients than for the male patients: at
twenty-five years, the survivorship was 91.0% (95% confidence
interval, 88.2% to 93.4%) for hips in women and 80.9% (95%
confidence interval, 76.9% to 84.8%) for hips in men (p <
0.0001). With this end point, women had better twenty-fiveyear survivorship of both the acetabular component (93.0%
[95% confidence interval, 90.2% to 95.2%] compared with
86.0% [95% confidence interval, 82.0% to 89.4%] for the men;
Fig. 3
Survivorship free of revision for aseptic loosening of either the acetabular
or the femoral component by patient
age at the time of the arthroplasty.
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Fig. 4
Twenty-five-year survivorship free of acetabular revision for aseptic loosening by patient age at the time of the arthroplasty.
p < 0.0001) and the femoral component (93.2% [95% confidence interval, 90.8% to 95.3%] compared with 85.8% [95%
confidence interval, 82.4% to 88.8%] for the men; p < 0.0001).
At twenty-five years, survivorship free of revision for
any reason (p < 0.0001) and survivorship free of revision for
aseptic loosening (p < 0.0001) were strongly associated with
the age of the patient at the time of the total hip arthroplasty;
the rate was better for older patients. For each decade earlier
in life at which the procedure was performed, the survivorship
free of revision for aseptic loosening was poorer (Fig. 3, Table
II). No patient who was eighty years of age or older at the time
of surgery had a subsequent revision for aseptic loosening of
the implant. For younger patients, survivorship of the acetabular component free of revision for aseptic loosening was
poorer than survivorship of the femoral component to the
same end point. In contrast, for older patients, survivorship of
both the acetabular and the femoral component free of revision for aseptic loosening was high (Figs. 4 and 5, Table II).
For the whole study group, the twenty-five-year survivorship of the acetabular component free of removal or revision for any reason (87.0% [95% confidence interval, 84.6% to
88.9%]) was a little better than that of the femoral component
to the same end point (84.6% [95% confidence interval, 82.3%
to 86.7%]), whereas the twenty-five-year survivorship free of
revision for aseptic loosening was almost identical for the acetabular component (89.9% [95% confidence interval, 87.5% to
91.8%]) and the femoral component (89.8% [95% confidence
interval, 88.0% to 91.6%]). These rates became similar by the
twenty-five-year mark, although femoral survivorship declined
earlier than acetabular survivorship did (Table III). There were
more femoral revisions than acetabular revisions for aseptic
loosening in the first fifteen years of the study (seventy-seven
femoral revisions compared with forty-four acetabular revisions), but there were fewer femoral revisions than acetabular
revisions in the last ten years of the study (forty-one femoral
revisions compared with fifty acetabular revisions). Thus, the
rate of femoral revision for aseptic loosening was nearly linear,
or decreased with time, whereas the rate of acetabular revision
for aseptic loosening was low during the early follow-up period
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but increased in the later period (Fig. 6).
The diagnosis leading to the primary total hip arthroplasty had an effect on the survivorship of the prosthesis. Patients with rheumatoid arthritis had significantly better
twenty-five-year survivorship free of revision for any reason
(91.8% [95% confidence interval, 83.0% to 95.2%]) compared
with the rest of the group (80.1% [95% confidence interval,
77.4% to 82.4%]) (p = 0.047). Patients with developmental
dysplasia of the hip had significantly poorer twenty-five-year
survivorship free of revision for any reason (65.9% [95% confidence interval, 53.9% to 74.7%]) compared with the rest of the
group (82.4% [95% confidence interval, 79.6% to 84.5%]) (p =
0.0006). Developmental dysplasia of the hip had an adverse effect on survivorship free of revision for any reason for both
the acetabular component (74.3% [95% confidence interval,
61.7% to 82.7%] compared with 88.3% [95% confidence interval, 85.8% to 90.2%] for the rest of the cohort; p = 0.0008) and
the femoral component (74.5% [95% confidence interval,
63.7% to 82.6%] compared with 85.4% [95% confidence interval, 83.2% to 87.6%] for the rest of the cohort; p = 0.015).
Multivariate survivorship analysis was performed with an
end point of aseptic loosening of either the femoral or acetabular component, the femoral component alone, or the acetabular component alone for the risk factors of age (continuous
variable), male gender, and diagnosis (relative to osteoarthrosis). Highly significant associations were identified (p < 0.001)
for age and gender (Table IV). Patients who were older at the
time of arthroplasty were at a lower risk of needing revision for
aseptic loosening (the odds ratio was 0.5 for each ten-year increase in patient age), whereas men were at a higher risk (odds
ratio, 2.7). Compared with patients with osteoarthrosis, patients with inflammatory arthritis were at a lower risk of needing revision for aseptic loosening (odds ratio, 0.3). In contrast,
patients with dysplasia had a higher risk of needing revision for
aseptic acetabular loosening (odds ratio, 2.1) (Table IV).
Discussion
o determine the factors that govern component survivorship over a long period of time, we followed a large series
T
Fig. 5
Twenty-five-year survivorship free of femoral revision for aseptic loosening by patient age at the time of the arthroplasty.
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TABLE II Survivorship as a Function of Patient Age at Total Hip Arthroplasty
Twenty-Five-Year Survivorship* (%)
Age at
Total Hip
Arthroplasty
Free of Revision
for Any Reason
Free of Revision
for Aseptic
Loosening
Free of Revision
for Aseptic
Femoral Loosening
Free of Revision
for Aseptic
Acetabular Loosening
<40 yr
63.7 (45.9-80.6)
68.7 (47.6-84.9)
82.4 (65.3-96.7)
73.7 (54.5-90.5)
40-49 yr
62.0 (51.5-71.6)
72.7 (62.2-81.8)
82.6 (74.2-89.7)
80.7 (71.3-89.2)
50-59 yr
75.9 (70.9-80.3)
81.0 (76.2-84.9)
84.6 (80.1-89.1)
86.1 (81.9-90.2)
60-69 yr
86.9 (83.6-89.8)
92.2 (88.3-94.4)
92.9 (89.8-95.0)
93.6 (90.2-95.7)
70-79 yr
92.6 (89.1-95.4)
95.9 (92.9-98.1)
96.8 (94.0-98.5)
98.6 (95.9-99.6)
≥80 yr†
95.8 (86.0-98.6)
100
100
100
*The 95% confidence intervals are shown in parentheses. For each column, age was a significant determinant of survivorship to the given
end point (p < 0.0001 in each case). †The survivorship estimate was censored at twenty years because of a decreasing number of patients
at risk.
of consecutive primary total hip arthroplasties performed
with the same type of well-designed prosthesis. The inclusion
of 2000 hips permitted us to analyze the cohort by age, gender,
and underlying diagnosis with a sufficient number of hips
in each category to provide meaningful and statistically
valid comparisons. By following the cohort for a minimum of
twenty-five years or until a revision or the death of the patient,
we were able to determine the lifetime risk of revision for most
of the patients and, in the smaller cohort still living at the end
of the study period, to determine survivorship of the implant
until the patients had reached a mean age of eighty years. The
high rate of follow-up, the large number of patients, and the
fact that most patients were followed until death or to within a
mean of 0.6 year of the time that they died improved the accuracy and validity of the survivorship estimates.
Although not all patients were able to return to the
treating institution for follow-up assessment, the end points
selected in this study allowed determination of implant survival with use of a questionnaire and telephone contact and
are thus independent of clinical examination. For these end
Fig. 6
Twenty-five-year survivorship free of revision for aseptic loosening of
the acetabular or femoral component.
points, the clinical information obtained from responses to
the questionnaire has been demonstrated to be significantly
comparable with that obtained through physician interaction20.
The mean age of the patient population in whom total hip arthroplasty was performed between 1969 and 1971 is similar to
that of the present-day patient population treated with total
hip arthroplasty; however, other features of the present-day
population may be different. With the success of total hip arthroplasty, more patients are at the very youngest and very
oldest ends of the age spectrum. Furthermore, at present, patients with multiple medical comorbidities and patients with
more complex and difficult acetabular and femoral anatomic
problems are considered candidates for arthroplasty, whereas
they were not at the beginning of this study.
During the first twenty years after total hip arthroplasty,
patients were found to have a lower rate of death than was predicted from United States population-based survivorship data.
This finding probably in part represents a selection bias imposed by the decision to perform surgery: because total hip arthroplasty was elective in most patients, the sicker patients in
the population would have been excluded from the cohort on
the basis of operative risk. It is also possible, however, that patients who underwent hip replacement were able to stay more
active and hence to improve their overall health. Greater longevity of patients who received elective total hip arthroplasty
was previously demonstrated in one other study 21, and we consider this finding to be important. As surgeons anticipate the
needed durability of joint prostheses, they need to be aware
that patients may outlive general population-based estimates.
More than twenty years after hip replacement, the overall survivorship of our cohort of patients was poorer than that predicted for the United States population. The relevance of this
finding is not known; however, the long-term rates of death
may be increased because of comorbidities or inactivity in the
subgroup of patients who require total hip arthroplasty at a
young age (for example, patients with rheumatoid arthritis).
As previously demonstrated at twenty years9,15, survivor-
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TABLE III Survivorship of the Acetabular and Femoral Components Free of Revision for Aseptic Loosening
Survivorship* (%)
Time After
Total Hip
Arthroplasty
Acetabular
Component
Femoral
Component
5 yr
99.8 (99.6-100)
99.7 (99.4-99.9)
10 yr
98.7 (97.9-99.1)
97.4 (96.6-98.2)
15 yr
96.5 (95.2-97.4)
94.8 (93.6-95.9)
20 yr
92.9 (91.1-94.3)
91.5 (90.0-93.2)
25 yr
89.9 (87.5-91.8)
89.8 (88.0-91.6)
*The 95% confidence intervals are shown in parentheses.
ship free of revision for aseptic loosening continued to be
nearly linear over the first twenty-five years and the failure
rate did not decrease exponentially with time. As a cohort
of patients ages, the decreasing levels of activity and demands
probably partially offset the effects of the prolonged time in
service on the prosthesis. In addition, as patients age, the
threshold for the performance of another operation rises,
since the decision to perform surgery is made subjectively by
the patient and surgeon on the basis of the relative risks and
benefits of the procedure.
Younger age has been recognized to have a negative effect on the durability of a total hip prosthesis in most previous
studies22-29, but not in all30. Previous studies have also demonstrated that, in younger patients, cemented sockets fare worse
than cemented femoral implants31-34. Our results confirm and
extend those findings by providing specific survivorship information for the acetabular and femoral implants for each de-
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cade of life. This experience shows that the performance of
cemented acetabular and femoral components is dependent
on the age of the patient at the time of implantation but that
the effect of age is more profound on the performance of the
acetabular component. Gender has been shown to have an effect on the durability of total hip prostheses9,15,26, and this finding was confirmed in the present study. Compared with
women, men had a twofold increase in the rate of implant failure from aseptic loosening.
The rates of survivorship free of revision for aseptic
loosening were virtually identical for the acetabular and femoral components. The acetabular component was revised for
aseptic loosening more frequently than was the femoral component in young patients, but the femoral component required revision for aseptic loosening more frequently than the
acetabular component in older patients. More femoral than
acetabular components were revised during the first fifteen
years of the study, whereas more acetabular than femoral
components were revised during the last ten years of the study.
Except for aseptic loosening, the most common reason
for femoral revision in this series was fracture of the femoral
component. The fractures are explained in part by the metallurgy of the first-generation implants. However, the fracture
rate was higher in this series than in some others in which the
same implants were used9. This difference is probably due to a
specific technique used at our institution during the time of
the study. Trochanteric wires were implanted by placing drillholes into the lateral aspect of the femur and allowing the
metallic femoral implant to deflect the drill. This technique
frequently led to a notch in the lateral aspect of the femoral
stem, which served as a stress riser through which many of the
broken stems subsequently fractured.
Specific diagnoses were associated with higher rates of
TABLE IV Relative Risk of Revision for Aseptic Loosening
Femoral or Acetabular Component
Demographic
Factors and
Diagnoses
Odds
Ratio
95%
Confidence
Interval
Age (per each increase of 10 yr
in age at surgery)
0.5
Male gender
Diagnosis (relative
to diagnosis of
osteoarthrosis)
Inflammatory
Femoral Component
P Value
Odds
Ratio
95%
Confidence
Interval
0.4-0.6
<0.001
0.6
2.7
1.9-3.9
<0.001
Acetabular Component
P Value
Odds
Ratio
95%
Confidence
Interval
P Value
0.5-0.7
<0.001
0.5
0.4-0.7
<0.001
2.6
1.7-3.9
<0.001
2.7
1.7-4.2
<0.001
0.3
0.1-0.6
0.004
0.2
0.1-0.6
0.006
0.3
0.1-1.0
0.049
Osteonecrosis
Developmental
hip dysplasia
Posttraumatic
0.9
1.7
0.4-1.7
1.0-2.9
0.645
0.072
0.8
1.4
0.4-1.7
0.7-2.6
0.616
0.335
0.8
2.1
0.4-1.9
1.1-4.2
0.665
0.028
1.1
0.6-2.1
0.755
1.1
0.6-2.3
0.735
1.2
0.6-2.7
0.590
Other diagnosis
0.5
0.1-2.2
0.338
0.6
0.1-2.9
0.537
*
*
<0.001
*No hip with the “other” diagnosis was revised for acetabular aseptic loosening.
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revision. In our study as well as in others, patients with rheumatoid arthritis did better than the rest of the cohort, probably because of a reduced level of activity27,34-37. Conversely,
patients with developmental dysplasia of the hip exhibited
poorer implant survivorship, a finding that may be explained
in part by abnormalities in acetabular and femoral bone geometry in dysplastic hips.
By rigorously defining the patient populations at risk for
revision and by quantitating the risks to the acetabular and
femoral components independently in each patient population, the information in this paper helps to identify patients
at risk for failure of Charnley total hip arthroplasty. This information also helps to identify patient populations that may
TW E N T Y - F IVE -YE A R S U R V IVO R S H I P O F TW O T H O U S A N D
C O N S E C U T IVE P R I M A R Y C H A R N L E Y TO T A L H I P R E P L A C E M E N T S
benefit most from newer technologies intended to improve on
the remarkable results of Charnley total hip arthroplasty. Daniel J. Berry, MD
W. Scott Harmsen, MS
Miguel E. Cabanela, MD
Bernard F. Morrey, MD
Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W.,
Rochester, MN 55905. E-mail address for D.J. Berry:
[email protected]
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
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