Background

The number of individuals participating in athletic activities is continually increasing, whether these individuals are highly competitive
athletes or weekend sports enthusiasts.[1, 2] Stress fractures of the femoral neck are uncommon injuries (see image depicted below). In
general, these injuries occur in 2 distinct populations, (1) young, active individuals with unaccustomed strenuous activity or changes in
activity, such as runners or endurance athletes, and (2) elderly individuals with osteoporosis. [3] Elderly individuals may also
sustain femoral neck stress fractures; however, hip fractures are much more common and are often devastating injuries.
Classification of femoral neck stress fractures.
Femoral neck fractures in young patients are usually caused by high-energy trauma. These
fractures are often associated with multiple injuries and high rates of avascular necrosis and
nonunion. Results of this injury depend on (1) the extent of injury (ie, amount of displacement,
amount of comminution, whether circulation has been disturbed), (2) the adequacy of the
reduction, and (3) the adequacy of fixation. Recognition of the disabling complications of
femoral neck fractures requires meticulous attention to detail in their management.
The femoral aspect of the hip is made up of the femoral head with its articular cartilage and the femoral neck, which connects the head
to the shaft in the region of the lesser and greater trochanters. The synovial membrane incorporates the entire femoral head and the
anterior neck, but only the proximal half of the posterior neck. The shape and size of the femoral neck vary widely.
Crock standardized the nomenclature of the vessels around the base of the femoral neck. The blood supply to the proximal end of the
femur is divided into 3 major groups. The first is the extracapsular arterial ring located at the base of the femoral neck. The second is
the ascending cervical branches of the arterial ring on the surface of the femoral neck. The third is the arteries of the ligamentum teres.
A large branch of the medial femoral circumflex artery forms the extracapsular arterial ring posteriorly and anteriorly by a branch from
the lateral femoral circumflex artery (see images shown below). The ascending cervical branches ascend on the surface on the femoral
neck anteriorly along the intertrochanteric line. Posteriorly, the cervical branches run under the synovial reflection toward the rim of the
articular cartilage, which demarcates the femoral neck from its head. The lateral vessels are the most vulnerable to injury in femoral
neck fractures.
Posterior view of the extraosseous blood supply to the
femoral head.Anterior view of the extraosseous blood
supply to the femoral head.
A second ring of vessels is formed as the ascending
cervical vessels approach the articular margin of the
femoral head. From this second ring of vessels, the
epiphyseal arteries are formed. The lateral epiphyseal
arterial group supplies the lateral weight-bearing
portion of the femoral head. The epiphyseal vessels
are joined by the inferior metaphyseal vessels and
vessels from the ligamentum teres.
Femoral neck fractures frequently disrupt the blood
supply to the femoral head (see images below). The superior retinacular and lateral epiphyseal vessels are the most important sources
of this blood supply. Widely displaced intracapsular hip fractures tear the synovium and the surrounding vessels. The progressive
disruption of the blood supply can lead to serious clinical conditions and complications, including osteonecrosis and nonunion.

Posterior view of the extraosseous blood supply to the

femoral head.Anterior view of the extraosseous blood
supply to the femoral head.
In 1961, Garden described the classification of femoral
neck fractures. In this classification, femoral neck fractures
are divided into the following 4 grades based on the degree
of displacement of the fracture fragment:
Grade I is an incomplete or valgus impacted fracture.
Grade II is a complete fracture without bone displacement.
Grade III is a complete fracture with partial displacement of
the fracture fragments.
Grade IV is a complete fracture with total displacement of
the fracture fragments.
Frandersen et al concluded that clinically differentiating the 4 grades of fractures is difficult. Multiple observers were able to completely
agree on the Garden classification in only 22% of the cases. Hence, classifying femoral neck fractures as nondisplaced (Garden grades
I or II) or displaced (Garden grades III or IV) is more accurate. See the illustration depicted below.

Garden fracture classification.

Femoral neck fractures are usually intracapsular. The femoral neck has essentially no periosteal
layer; hence, all healing is endosteal in origin. The synovial fluid bathing the fracture may interfere
with the healing process. Angiogenic-inhibiting factors in synovial fluid can inhibit fracture repair.
These factors, along with the precarious blood supply to the femoral head, make healing
unpredictable and nonunions fairly frequent.
Bone physiology
Bone is a dynamic tissue, which continually reacts to stressful events. According to data from Maitra
and Johnson, stress fractures result from an imbalance between bone resorption and bone
deposition during the host bone response to repeated stressful events.[11] Most cortical stress involves
tension or torsion; however, bone is weaker in tension and tends to fail by fracturing along a cement
line.
Maitra and Johnson went on to report that tension forces promote osteoclastic resorption, whereas compressive forces promote an
osteoblastic response.[11]With repeated stress, new bone formation cannot keep pace with bone resorption. This inability to keep up
results in thinning and weakening of cortical bone, with propagation of cracks through cement lines, and, eventually, the development of
microfractures. Without proper rest to correct this imbalance, these microfractures can progress to clinical fractures, the sine qua non of
overuse.
A stress fracture is the result of a dynamic process over time, unlike an acute fracture, which is usually the result of a single
supraphysiologic event. Markey reported that stress fractures can be described as a normal host response to abnormal stress, and this
is different from insufficiency fractures, which are an abnormal host response to normal stresses.[12]
Devas, in 1965, classified stress fractures into 2 types that differ radiologically and have different clinical outcomes. [13] The first is the
tension stress fracture, which results in a transverse fracture directed perpendicular to the line of force transmitted in the femoral neck
and originates at the superior surface of the femoral neck. This fracture pattern is at increased risk for displacement. These fractures
carry a risk for further advancement of the fracture line superiorly and eventual displacement, leading to nonunion and avascular
necrosis. Hence, early diagnosis and treatment are essential.
The second type is a compression type of femoral neck stress fracture, which has evidence of internal callus formation on radiographic
images. The fracture is usually located at the inferior margin of the femoral neck without cortical discontinuity. This fracture pattern is
thought to be mechanically stable. The compression fracture occurs mostly in younger patients, and continued stress does not usually
cause displacement. The earliest radiographic evidence of a compression stress fracture is
usually a haze of internal callus in the inferior cortex of the femoral neck. Eventually, a small
fracture line appears in this area, and it gradually scleroses.
Fullerton and Snowdy described a femoral neck stress fracture classification with the following 3
categories[ : (1) tension, (2) compression, and (3) displaced, as depicted below. Tension fractures
occur on the superolateral aspect of femoral neck and are at high risk for displacement.
Compression fractures are similar to those described by Devas, which occur on the inferomedial
aspect of the femoral neck and have a low risk for displacement.

Hip Hemiarthroplasty
A hip hemiarthroplasty is the word used to describe a half of a hip replacement. In this procedure, the ball of the ball-and-socket joint is removed, and
a metal prosthesis is implanted into the joint. Hip hemiarthroplasty is favored in patients with displaced fractures because of the complications
described above with trying to rapir these fractures.
A hip hemiarthroplasty is performed under general anesthesia or spinal anesthesia. An incision is made over the outside of the hip. The fractured
femoral head is removed, and replaced with a metal implant. In a normal hip replacement surgery, the socket of the pelvis would also be replaced. This
can be done in patients with pre-existing arthritis of the hip, but in most cases of femoral neck fractures the socket is left alone. The prosthetic stem
can be cemented into the bone in patients with thinner, more osteoporotic bone, or press-fit into patients with better bone quality.
Rehabilitation is initiated immediately and patients can usually walk with their full weight on the implant. Patients tend to feel much better after the
surgery, and usually return to walking quite quickly.
Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant. Hip replacement surgery can be
performed as a total replacement or a hemi (half) replacement. Such joint replacement orthopaedic surgery is generally conducted to
relieve arthritis pain or fix severe physical joint damage as part of hip fracture treatment. A total hip replacement (total hip arthroplasty)
consists of replacing both the acetabulum and the femoral head while hemiarthroplasty generally only replaces the femoral head. Hip
replacement is currently the most common orthopaedic operation, though patient satisfaction short and long term varies widely.

Medical uses
Total hip replacement is most commonly used to treat joint failure caused by osteoarthritis. Other indications include rheumatoid arthritis, avascular
necrosis, traumatic arthritis,protrusio acetabuli, certain hip fractures, benign and malignant bone tumors, arthritis associated with Paget's
disease, ankylosing spondylitis and juvenile rheumatoid arthritis. The aims of the procedure are pain relief and improvement in hip function. Hip
replacement is usually considered only after other therapies, such as physical therapy and pain medications, have failed.

Risks
Dislocated artificial hip
Hip prosthesis displaying aseptic loosening
Risks and complications in hip replacement are similar to those associated with all joint replacements. They can
include dislocation, loosening, impingement, infection, osteolysis, metal sensitivity, nerve palsy, pain and death.
Vein thrombosis
Venous thrombosis such as deep vein thrombosis and pulmonary embolism are relatively common following hip
replacement surgery. Standard treatment with anticoagulants is for 710 days; however treatment for more than
21 days may be superior.
Some physicians and patients may consider having lower limbs venous ultrasonography to screen for deep vein
thrombosis after hip replacement. However, this kind of screening should only be done when indicated because
to perform it routinely would be unnecessary health care.
Dislocation
Dislocation is the most common complication of hip replacement surgery. At surgery the femoral head is taken out of the socket, hip implants are placed
and the hip put back into proper position. It takes eight to twelve weeks for the soft tissues injured or cut during surgery to heal. During this period, the hip
ball can come out of the socket. The chance of this is diminished if less tissue is cut, if the tissue cut is repaired and if large diameter head balls are used.
Surgeons who perform more of the operations each year tend to have fewer patients dislocate. Doing the surgery from an anterior approach seems to
lower dislocation rates when small diameter heads are used, but the benefit has not been shown when compared to modern posterior incisions with the
use of larger diameter heads. Patients can decrease the risk further by keeping the leg out of certain positions during the first few months after surgery.
Use of alcohol by patients during this early period is also associated with an increased rate of dislocation.
Fracture
Bones with internal fixation devices in situ are at risk of periprosthetic fractures at the end of the implant, an area of relative mechanical stress. Postoperative femoral fractures are graded by the Vancouver classification.
Osteolysis
Many long-term problems with hip replacements are the result of osteolysis. This is the loss of bone caused by the body's reaction to polyethylene wear
debris, fine bits of plastic that come off the cup liner over time. An inflammatory process causes bone resorption that may lead to subsequent loosening of
the hip implants and even fractures in the bone around the implants. In an attempt to eliminate the generation of wear particles, ceramic bearing surfaces
are being used in the hope that they will have less wear and less osteolysis with better long term results. Metal cup liners joined with metal heads (metalon-metal hip arthroplasty) were also developed for similar reasons. In the lab these show excellent wear characteristics and benefit from a different mode
of lubrication. At the same time that these two bearing surfaces were being developed, highly cross linked polyethylene plastic liners were also developed.
The greater cross linking significantly reduces the amount of plastic wear debris given off over time. The newer ceramic and metal prostheses do not
always have the long term track record of established metal on poly bearings. Ceramic pieces can break leading to catastrophic failure. This occurs in
about 2% of the implants placed. They may also cause an audible, high pitched squeaking noise with activity. Metal-on-metal arthroplasty releases metal
debris into the body raising concerns about the potential dangers of these accumulating over time. Highly cross linked polyethylene is not as strong as
regular polyethylene. These plastic liners can crack or break free of the metal shell that holds them.
Metal sensitivity
Concerns are being raised about the metal sensitivity and potential dangers of metal particulate debris. New publications [3][4] have demonstrated
development of pseudotumors, soft tissue masses containing necrotic tissue, around the hip joint. It appears these masses are more common in women
and these patients show a higher level of iron in the blood. The cause is unknown and is probably multifactorial. There may be a toxic reaction to an
excess of particulate metal wear debris or a hypersensitivity reaction to a normal amount of metal debris.
Metal hypersensitivity is a well-established phenomenon and is common, affecting about 1015% of the population.Contact with metals can cause
immune reactions such as skin hives, eczema, redness and itching. Although little is known about the short and long term pharmacodynamics and
bioavailability of circulating metal degradation products in vivo, there have been many reports of immunologic type responses temporally associated with
implantation of metal components. Individual case reports link hypersensitivity immune reactions with adverse performance of metallic clinical
cardiovascular, orthopedic and plastic surgical and dental implants.

Metal toxicity
Most hip replacements consist of cobalt and chromium alloys, or titanium. Stainless steel is no longer used. All implants release their constituent ions into
the blood. Typically these are excreted in the urine, but in certain individuals the ions can accumulate in the body. In implants which involve metal-onmetal contact, microscopic fragments of cobalt andchromium can be absorbed into the patient's bloodstream. There are reports of cobalt toxicity with hip
replacement patients.
Nerve palsy
Post operative sciatic nerve palsy is another possible complication. The incidence of this complication is low. Femoral nerve palsy is another but much
more rare complication. Both of these will typically resolve over time, but the healing process is slow. Patients with pre-existing nerve injury are at greater
risk of experiencing this complication and are also slower to recover.
Chronic pain
A few patients who have had a hip replacement suffer chronic pain after the surgery. Groin pain can develop if the muscle that raises the hip ( iliopsoas)
rubs against the edge of the acetabular cup. Bursitis can develop at the trochanter where a surgical scar crosses the bone, or if the femoral component
used pushes the leg out to the side too far. Also some patients can experience pain in cold or damp weather Incision made in the front of the hip (anterior
approach) can cut a nerve running down the thigh leading to numbness in the thigh and occasionally chronic pain at the point where the nerve was cut (a
neuroma)
Death
Rates of death for elective hip replacements are much less than 1%.
Leg length inequality
The leg can be lengthened or shortened during surgery. Unequal legs are the most common complaint by patients after surgery with over lengthening the
most common problem. Sometimes the leg seems long immediately after surgery when in fact both are equal length. An arthritic hip can develop
contractures that make the leg behave as if it is short. When these are relieved with replacement surgery and normal motion and function are restored,
the body feels that the limb is now longer than it was. If the legs are truly equal, the sense of inequality resolves within a month or two of surgery. If the leg
is unequal, it will not. A shoe lift for the short leg, or in extreme cases, a corrective operation may be needed.
True leg length inequality may sometimes be caused by improper implant selection. The femoral component may be too large and stick out of the femur
further than needed. The head ball selected may sit too proud on the stem. Stiffness in the lower back from arthritis or previous fusion surgery seems to
magnify the perception of leg length inequality.
Techniques
There are several incisions, defined by their relation to the gluteus medius. The approaches are posterior (Moore), lateral (Hardinge or Liverpool), [
antero-lateral (Watson-Jones),[ anterior (Smith-Petersen) and greater trochanter osteotomy. There is no compelling evidence in the literature for any
particular approach, but consensus of professional opinion favours either modified anterolateral (Watson-Jones) or posterior approach.
Posterior approach[
The posterior (Moore or Southern) approach accesses the joint and capsule through the back, taking piriformis muscle and the short external rotators off
the femur. This approach gives excellent access to the acetabulum and femur and preserves the hip abductors and thus minimises the risk of abductor
dysfunction post operatively. It has the advantage of becoming a more extensile approach if needed. Critics cite a higher dislocation rate, although repair
of the capsule, piriformis and the short external rotators along with use of modern large diameter head balls reduces this risk.
Lateral approach
The lateral approach is also commonly used for hip replacement. The approach requires elevation of the hip abductors (gluteus medius and gluteus
minimus) to access the joint. The abductors may be lifted up by osteotomy of the greater trochanter and reapplying it afterwards using wires (as per
Charnley),[ or may be divided at their tendinous portion, or through the functional tendon (as per Hardinge) and repaired using sutures. Although this
approach has a lower dislocation risk than the posterior approach, critics note that occasionally the abductor muscles do not heal back on, leading to pain
and weakness which is often very difficult to treat.
Antero-lateral approach
The anterolateral approach develops the interval between the tensor fasciae latae and the gluteus medius.
Anterior approach
The anterior approach uses an interval between the sartorius muscle and tensor fascia latae. Dr. Joel Matta and Dr. Bert Thomas have adapted this
approach, which was commonly used for pelvic fracture repair surgery, for use when performing hip replacement. When used with older hip implant
systems that had a small diameter head, dislocation rates were reduced compared to surgery performed through a posterior approach. With modern
implant designs, dislocation rates are lower because supporting muscle tissue, Including the iliotibial tract, receives very little damage during the surgery.
There is a 10% rate of numbness in the thigh following this approach, due to injury to the lateral femoral cutaneous nerve. The anterior approach results
in a quicker and less painful recovery. Immediately following surgery patients are instructed to go about their normal hip function, including weight bearing
activity and bending their hip freely.
Minimally invasive approach

The double incision surgery and minimally invasive surgery seeks to reduce soft tissue damage through reducing the size of the incision. However,
component positioning accuracy and visualization of the bone structures is significantly impaired. This can result in unintended fractures and soft tissue
injury. Surgeons using these approaches are advised to use intraoperative x-ray fluoroscopy or computer guidance systems.
Computer Assisted Surgery techniques are also available to guide the surgeon to provide enhanced accuracy. Several commercial CAS systems are
available for use worldwide.HipNav was the first system developed specifically for total hip replacement, and included navigation and preoperative
planning based on a preoperative CT scan of the patient. Improved patient outcomes and reduced complications have not been demonstrated when
these systems are used when compared to standard techniques.
Implants[edit]

Cement free implant 16 days after surgery. Femoral component is cobalt chromium combined with titanium
which induces bone growth into the implant. Ceramic head. Acetabular cup coated with bone growth inducing
material and held temporarily in place with a single screw.
The prosthetic implant used in hip replacement consists of three parts: the acetabular cup, the femoral
component, and the articular interface. Options exist for different patients and indications. Correct selection of
the prosthesis is important.
Acetabular Cup
The acetabular cup is the component which is placed into the acetabulum (hip socket). Cartilage and bone are
removed from the acetabulum and the acetabular cup is attached using friction or cement. Some acetabular
cups are one piece, while others are modular. One piece (monobloc) shells are either UHMWPE ( ultra-highmolecular-weight polyethylene) or metal, they have their articular surface machined on the inside surface of the
cup and do not rely on a locking mechanism to hold a liner in place. A monobloc polyethylene cup is cemented
in place while a metal cup is held in place by a metal coating on the outside of the cup. Modular cups consist of
two pieces, a shell and liner. The shell is made of metal, the outside has a porous coating while the inside
contains a locking mechanism designed to accept a liner. Two types of porous coating used to form a friction fit
are sintered beads or a foam metal design to mimic the trabeculae of cancellous bone. Additional fixation is
achieved as bone grows onto or into the porous coating. Screws can be used to lag the shell to the bone providing even more fixation. Polyethylene liners
are placed into the shell and connected by a rim locking mechanism, ceramic and metal liners are attached with a Morse taper.
Femoral Component
The femoral component is the component that fits in the femur (thigh bone). Bone is removed and the femur is shaped to accept the femoral stem with
attached prosthetic femoral head (ball). There are two types of fixation: cemented and uncemented. Cemented stems use acrylic bone cement to form a
mantle between the stem and to the bone. Uncemented stems use friction, shape and surface coatings to stimulate bone to remodel and bond to the
implant. Stems are made of multiple materials (titanium, cobalt chromium, stainless steel, and polymer composites) and they can be monolithic or
modular. Modular components consist of different head dimensions and/or modular neck orientations; these attach via a taper similar to a Morse taper.
These options allow for variability in leg length, offset and version. Femoral heads are made of metal or ceramic material. Metal heads, made of cobalt
chromium for hardness, are machined to size and then polished to reduce wear of the socket liner. Ceramic heads are more smooth than polished metal
heads, have a lower coefficient of friction than a cobalt chrome head, and in theory will wear down the socket liner more slowly. As of early 2011, follow up
studies in patients have not demonstrated significant reductions in wear rates between the various types of femoral heads on the market. Ceramic
implants are more brittle and may break after being implanted.
Articular Interface
The articular interface is not actually part of either implant, rather it is the area between the acetabular cup and femoral component. The articular interface
of the hip is a simple ball and socket joint. Size, material properties and machining tolerances at the articular interface can be selected based on patient
demand to optimise implant function and longevity whilst mitigating associated risks. The interface size is measured by the outside diameter of the head
or the inside diameter of the socket. Common sizes of femoral heads are 28 mm, 32 mm and 36 mm. While a 22.25 mm was common in the first modern
prostheses, now even larger sizes are available 3854+. Larger diameter heads lead to increased stability and range of motion whilst lowering the risk of
dislocation. At the same time they are also subject to higher stresses such as friction and inertia. Different combinations of materials have different
physical properties which can be coupled to reduce the amount of wear debris generated by friction. Typical pairings of materials include metal on
polyethylene (MOP), metal on crosslinked polyethylene (MOXP), ceramic on ceramic (COC), ceramic on crosslinked polyethylene (COXP) and metal on
metal (MOM). Each combination has different advantages and disadvantages.
Metal-on-metal hip implant failure
By 2010, reports in the orthopaedic literature have increasingly cited the problem of early failure of metal on metal prostheses in a small percentage of
patients. Failures may relate to release of minute metallic particles or metal ions from wear of the implants, causing pain and disability severe enough to
require revision surgery in 13% of patients.Design deficits of some prothesis models, especially with heat-treated alloys and a lack of special surgical

experience accounts for most of the failures. Surgeons at leading medical centers such as the Mayo Clinic have reported reducing their use of metal-onmetal implants by 80 percent over the last year in favor of those made from other materials, like combinations of metal and plastic. The cause of these
failures remain controversial, and may include both design factors, technique factors, and factors related to patient immune responses (allergy type
reactions). In the United Kingdom the Medicines and Healthcare Products Regulatory Agency commenced an annual monitoring regime for metal-onmetal hip replacement patients from May 2010.Data which is shown in The Australian Orthopaedic Association's 2008 National Joint Replacement
Registry, a record of nearly every hip implanted in that country over the previous 10 years, tracked 6,773 BHR (Birmingham Hip Resurfacing) Hips and
found that less than one-third of one percent may have been revised due to the patient's reaction to the metal component. Other similar metal-on-metal
designs have not fared as well, where some reports show 76% to 100% of the people with these metal-on-metal implants and have aseptic implant
failures requiring revision also have evidence of histological inflammation accompanied by extensive lymphocyte infiltrates, characteristic of delayed type
hypersensitivity responses. It is not clear to what extent this phenomenon negatively affects orthopedic patients. However for patients presenting with
signs of an allergic reactions, evaluation for sensitivity should be conducted. Removal of the device that is not needed should be considered, since
removal may alleviate the symptoms. Patients who have allergic reactions to cheap jewelry are more likely to have reactions to orthopedic implants.
There is increasing awareness of the phenomenon of metal sensitivity and many surgeons now take this into account when planning which implant is
optimal for each patient.
On March 12, 2012, The Lancet published a study, based on data from the National Joint Registry of England and Wales, finding that metal-on-metal hip
implants failed at much greater rates than other types of hip implants and calling for a ban on all metal-on-metal hips. The analysis of 402,051 hip
replacements showed that 6.2% of metal-on-metal hip implants had failed within five years, compared to 1.7% of metal-on-plastic and 2.3% of ceramicon-ceramic hip implants. Each 1mm increase in head size of metal-on-metal hip implants was associated with a 2% increase of failure Surgeons of the
British Hip Society are recommending that large head metal-on-metal implants should no longer be performed
On February 10, 2011, the U.S. FDA issued a patient advisory on metal-metal hip implants, stating it was continuing to gather and review all available
information about metal-on-metal hip systems. ] On June 2728, 2012, an advisory panel met to decide whether to impose new standards, taking into
account the The Lancet findings. No new standards, such as routine checking of blood metal ion levels, were set, but guidance was updated. Currently,
FDA has not required hip implants to be tested in clinical trials before they can be sold in the U.S. Instead, companies making new hip implants only need
to prove that they are "substantially equivalent" to other hip implants already on the market. The exception is metal-on-metal implants, which were not
tested in clinical trials but because of the high revision rate of metal-on-metal hips, in the future the FDA has stated that clinical trials will be required for
approval and that post-market studies will be required to keep metal on metal hip implants on the market.
Alternatives and variations.
Conservative management
The first line approach as an alternative to hip replacement is conservative management which involves a multimodal approach of medication, activity
modification and physical therapy. Conservative management can prevent or delay the need for hip replacement.
Hemiarthroplasty[edit]
Hemiarthroplasty is a surgical procedure which replaces one half of the joint with an artificial surface and leaves the other part in its natural (preoperative) state. This class of procedure is most commonly performed on the hip after a subcapital (just below the head) fracture of the neck of the femur
(a hip fracture). The procedure is performed by removing the head of the femur and replacing it with a metal or composite prosthesis. The most commonly
used prosthesis designs are the Austin Moore prosthesis and the Thompson Prosthesis. More recently a composite of metal and HDPE which forms two
interphases (bipolar prosthesis) has also been used. The bipolar prosthesis has not been shown to have any advantage over monopolar designs. The
procedure is recommended only for elderly and frail patients, due to their lower life expectancy and activity level. This is because with the passage of time
the prosthesis tends to loosen or to erode the acetabulum.
Hip resurfacing
Hip resurfacing is an alternative to hip replacement surgery. It has been used in Europe for over 17 years and become a common procedure.
The minimally invasive hip resurfacing procedure is a further refinement to hip resurfacing.
Viscosupplementation
Current alternatives also include viscosupplementation, or the injection of artificial lubricants into the joint. Use of these medications in the hip is off label.
The cost of treatment is typically not covered by health insurance organizations.
Some believe that the future of osteoarthritis treatment is bioengineering, targeting the growth and/or repair of the damaged, arthritic joint. Centeno et al.
have reported on the partial regeneration of an arthritic human hip joint using mesenchymal stem cells in one patient. It is yet to be shown that this result
will apply to a larger group of patients and result in significant benefits. The FDA has stated that this procedure is being practiced without conforming to
regulations, but Centeno claims that it is exempt from FDA regulation. It has not been shown in controlled clinical trials to be effective, and costs over
$7,000.

AIDS
AIDS is an infectious disorder that suppresses the normal function of the immune system. It is caused by the human immunodeficiency virus (HIV),
which destroys the body's ability to fight infections. Specific cells of the immune system that are responsible for the proper response to infections (T
cells) are destroyed by this virus. Characteristically a person infected with HIV initially experiences no symptoms for a variable period of time. This
may be followed by the development of persistent generalized swelling of the lymph nodes (AIDS-related lymphadenopathy). Eventually most
patients infected with HIV experience a syndrome of symptoms that includes excessive fatigue, weight loss, and/or skin rashes.
The later stages of HIV infection are characterized by the progressive depression of T cells and repeated infections that can even occur during a course
of antibiotic therapy for another infection (superinfections). People with AIDS are particularly vulnerable to "opportunistic infections" from bacteria
that other people normally fight off. Pneumocystis carinii, which causes severe inflammation of the lungs(pneumonia), is a common infection that
affects people with AIDS. Cancers (malignant neoplasms), and a wide variety of neurological abnormalities, most notably the
AIDS dementia complex, may also occur. These neurological symptoms when of HIV, infects the nervous system.
Acquired immunodeficiency syndrome (AIDS) facts
AIDS stands for "acquired immunodeficiency syndrome."
AIDS is an advanced stage of infection with the human immunodeficiency virus (HIV). HIVusually is spread from person to person

through contact with infected sexual secretions or blood.

People with AIDS have weakened immune systems that make them vulnerable to selected conditions and infections.
For people infected with HIV, the risk of progression to AIDS increases with the number of years the person has been infected. The risk of

progression to AIDS is decreased by using highly effective antiretroviral therapy (ART) regimens.
In people with AIDS, ART therapy improves the immune system and substantially increases life expectancy. Many patients who are treated

with ART have near-normal life expectancies.

ART is a treatment that must be continued for life. It is not a cure.
It is possible for HIV to become resistant to some antiretroviral medications. The best way to prevent resistance is for the patient to take

their ART as directed. If the patient wants to stop a drug because of side effects, he or she should call the physician immediately.
If a person is exposed to blood or potentially infectious fluids from a source patient with HIV, the exposed person can take medications to

reduce the risk of getting HIV.

Research is under way to find a vaccine and cure for HIV.

What does AIDS stand for? What causes AIDS?

AIDS is an acronym for acquired immunodeficiency syndrome." AIDS is caused by the human immunodeficiency virus (HIV) and represents the most
advanced stage of HIV infection.
HIV is spread through contact with infected blood or fluids such as sexual secretions. Over time, the virus attacks the immune system, focusing on
special cells called "CD4 cells" which are important in protecting the body from infections and cancers, and the number of these cells starts to fall.
Eventually, the CD4 cells fall to a critical level and/or the immune system is weakened so much that it can no longer fight off certain types of
infections and cancers. This advanced stage of HIV infection is called AIDS.
HIV is a very small virus that contains ribonucleic acid (RNA) as its genetic material. When HIV infects animal cells, it uses a special enzyme, reverse
transcriptase, to turn (transcribe) its RNA into DNA. (Viruses that use reverse transcriptase are sometimes referred to as "retroviruses.") When HIV
reproduces, it is prone to making small genetic mistakes or mutations, resulting in viruses that vary slightly from each other. This ability to create
minor variations allows HIV to evade the body's immunologic defenses, essentially leading to lifelong infection, and has made it difficult to make an
effective vaccine. The mutations also allow HIV to become resistant to antiretroviral medications.
What are symptoms and signs of AIDS?
AIDS is an advanced stage of HIV infection. Because the CD4 cells in the immune system have been largely destroyed, people with AIDS often
develop symptoms and signs of unusual infections or cancers. When a person with HIV infection gets one of these infections or cancers, it is referred
to as an "AIDS-defining condition." Examples of AIDS-defining conditions are listed in Table 1. Significant, unexplained weight loss also is an AIDSdefining condition. Because common conditions like cancer or other viral conditions like infectious mononucleosisalso can cause weight loss
and fatigue, it is sometimes easy for a physician to overlook the possibility of HIV/AIDS. It is possible for people without AIDS to get some of these
conditions, especially the more common infections like tuberculosis.
People with AIDS may develop symptoms ofpneumonia due to Pneumocystis jiroveci, which is rarely seen in people with normal immune systems.
They also are more likely to get pneumonia due to common bacteria. Globally, tuberculosis is one of the most common infections associated with
AIDS. In addition, people with AIDS may develop seizures, weakness, or mental changes due to toxoplasmosis, a parasite that infects the brain.
Neurological signs also may be due tomeningitis caused by the fungusCryptococcus. Complaints of painful swallowing may be caused by a yeast
infection of the esophagus called candidiasis. Because these infections take advantage of the weakened immune system, they are called "opportunistic
infections."

The weakening of the immune system associated with HIV infection can lead to unusual cancers like Kaposi's sarcoma. Kaposi's sarcoma develops as
raised patches on the skin which are red, brown, or purple. Kaposi's sarcoma can spread to the mouth, intestine, or respiratory tract. AIDS also may be
associated with lymphoma (a type of cancer involving white blood cells).
In people with AIDS, HIV itself may cause symptoms. Some people experience relentless fatigue and weight loss, known as "wasting syndrome."
Others may develop confusion or sleepiness due to infection of the brain with HIV, known as HIV encephalopathy. Both wasting syndrome and HIV
encephalopathy are AIDS-defining illnesses.
What are risk factors for developing AIDS?
Developing AIDS requires that the person acquire HIV infection. Risks for acquiring HIV infection include behaviors that result in contact with
infected blood or sexual secretions pose the main risk of HIV transmission. These behaviors include sexual intercourse and injection drug use. The
presence of sores in the genital area, like those caused by herpes, makes it easier for the virus to pass from person to person during intercourse. HIV
also has been spread to health care workers through accidental sticks with needles contaminated with blood from HIV-infected people, or when broken
skin has come into contact with infected blood or secretions. Blood products used for transfusions or injections also may spread infection, although
this has become extremely rare (less than one in 2 million transfusions in the U.S.) due to testing of blood donors and blood supplies for HIV. Finally,
infants may acquire HIV from an infected mother either while they are in the womb, during birth, or by breastfeeding after birth.
The risk that HIV infection will progress to AIDS increases with the number of years since the infection was acquired. If the HIV infection is
untreated, 50% of people will develop AIDS within 10 years, but some people progress in the first year or two and others remain completely
asymptomatic with normal immune systems for decades after infection. The risk of developing one of the complications that define AIDS is associated
with declining CD4 cells, particularly to below 200 cells/uL.
Antiretroviral treatment substantially reduces the risk that HIV will progress to AIDS. In developed countries, use of ART has turned HIV into a
chronic disease that may never progress to AIDS. Conversely, if infected people are not able to take their medications or have a virus that has
developed resistance to several medications, they are at increased risk for progression to AIDS. If AIDS is not treated, 50% of people will die within
nine months of the diagnosis.
How is AIDS diagnosed?
To diagnose AIDS, the doctor will need (1) a confirmed, positive test for HIV ("HIV positive" test) and (2) evidence of an AIDS-defining condition or
severely depleted CD4 cells.
Testing for HIV is a two-step process involving a screening test and a confirmatory test. The first step is usually a screening test that looks for
antibodies against the HIV. Specimens for testing come from blood obtained from a vein or a finger stick, an oral swab, or a urine sample. Results can
come back in minutes (rapid tests) or can take several days, depending on the method that is used. If the screening HIV test is positive, the results are
confirmed by a special test called a Western blot or indirect immunofluorescence assay test. A Western blot detects antibodies to specific components
of the virus. The confirmatory test is necessary because the screening test is less accurate and occasionally will be positive in those who do not have
HIV.
Another way to diagnose HIV infection is to do a special test to detect viral particles in the blood. These tests detect RNA, DNA, or viral antigens.
However, these tests are more commonly used for guiding treatment rather than for diagnosis.
Merely having HIV does not mean a person has AIDS. AIDS is an advanced stage of HIV infection and requires that the person have evidence of a
damaged immune system. That evidence comes from at least one of the following:
The presence of an AIDS-defining condition
Measuring the CD4 cells in the body and showing that there are fewer than 200 cells per milliliter of blood
A laboratory result showing that fewer than 14% of lymphocytes are CD4 cells
It is important to remember that any diagnosis of AIDS requires a confirmed, positive test for HIV.
What is the treatment for HIV/AIDS?
Medications that fight HIV are called antiretroviral medications. Different antiretroviral medications target the virus in different ways. When used in
combination with each other, they are very effective at suppressing the virus. It is important to note that there is no cure for HIV. ART only suppresses
reproduction of the virus and stops or delays the disease from progressing to AIDS. Most guidelines currently recommend that all HIV-infected people
who are willing to take medications should have them initiated shortly after being diagnosed with the infection. This delays or prevents disease
progression, improves overall health of an infected person, and makes it less likely that they will transmit the virus to their partners.
There are six major classes of antiretroviral medications: (1) nucleoside reverse transcriptase inhibitors (NRTIs), (2) non-nucleoside reverse
transcriptase inhibitors (NNRTIs), (3) protease inhibitors (PIs), (4) fusion (entry) inhibitors, (5) integrase inhibitors, and (6) CCR5 antagonists. These
drugs are used in different combinations according to the needs of the patient and depending on whether the virus has become resistant to a specific
drug or class of drugs. Treatment regimens usually consist of three to four medications at the same time. Combination treatment is essential because

using only one class of medication by itself allows the virus to become resistant to the medication. There are now available pills that contain multiple
drugs in a single pill, making it possible for many people to be treated with a single pill per day.
Before starting ART, blood tests usually are done to make sure the virus is not already resistant to the chosen medications. These resistance tests may
be repeated if it appears the drug regimen is not working or stops working. Patients are taught the importance of taking all of their medications as
directed and are told what side effects to watch for. Noncompliance with medications is the most common cause of treatment failure and can cause the
virus to develop resistance to the medication. Because successful therapy often depends on taking several pills, it is important for the patient to
understand that this is an "all or nothing" regimen. If the person cannot tolerate one of the pills, then he or she should call their physician, ideally prior
to stopping any medication. Taking just one or two of the recommended medications is strongly discouraged because it allows the virus to mutate and
become resistant. It is best to inform the HIV health care provider immediately about any problems so that a better-tolerated combination can be
prescribed.
What is the treatment for HIV during pregnancy?
There are two goals of treatment for pregnant women with HIV infection: to treat maternal infection and to reduce the risk of HIV transmission from
mother to child. Women can pass HIV to their babies duringpregnancy, during delivery, or after delivery by breastfeeding. Without treatment of the
mother and without breastfeeding, the risk of transmission to the baby is about 25%. With treatment of the mother before and during birth and with
treatment of the baby after birth, the risk decreases to less than 2%. Because of this benefit, it is recommended that all pregnant women be routinely
tested for HIV as part of theirprenatal care. Once diagnosed, there are several options for treatment, although some antiretroviral medications cannot
be used in pregnancy and others have not been studied in pregnancy. For example, the medication efavirenz (Sustiva) is usually avoided in early
pregnancy or in women who are likely to become pregnant. Fortunately, there are treatment regimens that have been shown to be well-tolerated by
most pregnant women, significantly improving the outcome for mother and child. The same principles of testing for drug resistance and combining
antiretrovirals that are used for nonpregnant patients are used for pregnant patients. All pregnant women with HIV should be treated with ART
regardless of their CD4 cell count, although the choice of drugs may differ slightly from nonpregnant women. In developed countries, women also are
instructed not to breastfeed their children.
Compliance with medications is important to provide the best outcome for mother and child. Even though a physician might highly recommend a
medication regimen, the pregnant woman has a choice of whether or not to take the medicines. Studies have shown that compliance is improved when
there is good communication between the woman and her doctor, with open discussions about the benefits and side effects of treatment. Compliance
also is improved with better social support, including friends and relatives.
Medications are continued throughout pregnancy, labor, and delivery. Some medicines, such as zidovudine (also known as AZT), can be given
intravenously during labor, particularly for those women who do not have good viral suppression at the time of delivery. Other medications are
continued orally during labor to try to reduce the risk of transmission to the baby during delivery. If the quantity of virus in the mother's blood (viral
load) is more than 1,000 copies/mL near the time of delivery, scheduled cesarean delivery is done at 38 weeks gestation to reduce the risk of
transmitting the virus during vaginal delivery. Women with HIV who otherwise meet criteria for starting antiretroviral therapy, per local guidelines or
the patient's preference, should continue taking ART after delivery for their own health.
If a pregnant woman with HIV infection does not take ART during pregnancy and goes into labor, medications are still given during labor. This
reduces the risk of transmission of HIV. After delivery, the infant will be given medication(s) for at least six weeks to reduce the risk of transmission of
HIV. If the mother did not take HAART during pregnancy or if the mother has a drug-resistant virus, infants will be treated with multiple medications.
Infants are tested periodically in the first six months to ensure they have not acquired the virus.
What are the complications of HIV?
The complications of HIV infection result mainly from a weakened immune system. The virus also infects the brain, causing degeneration, problems
with thinking, or even dementia. This makes the person more vulnerable to certain types of conditions and infections (see Table 1). Treatment with
ART can prevent, reverse, or mitigate the effects of HIV infection. Some patients on ART may be at risk for developing cholesterol or blood-sugar
problems.
Although many effective medications are on the market, the virus can become resistant to any drug. This can be a serious complication if it means that
a less effective medicine must be used. To reduce the risk of resistance, patients should take their medications as prescribed and call their physician
immediately if they feel they need to stop one or more drugs.
What is the prognosis for HIV infection?
Left untreated, HIV is almost always a fatal illness with half of people dying within nine months of diagnosis of an AIDS-defining condition. The use
of ART has dramatically changed this grim picture. People who are on an effective ART regimen have life expectancies that are similar to or only
moderately less than the uninfected population. Unfortunately, many people with HIV deal with socioeconomic issues, substance-abuse issues, or
other problems that interfere with their ability or desire to take medications.

Can HIV infection be prevented?

Sexual abstinence is completely effective in eliminating sexual transmission, but educational campaigns have not been successful in promoting
abstinence in at-risk populations. Monogamous sexual intercourse between two uninfected partners also eliminates sexual transmission of the virus.
Using barrier methods, such as condoms, during sexual intercourse markedly reduces the risk of HIV transmission. These measures have had some
success in blunting the rate of new cases, especially in high-risk areas such as sub-Saharan Africa or Haiti. As discussed above, medications may be
used to reduce the risk of HIV infection if used within hours of an exposure. There also is data that if uninfected people can take antiretroviral
medications, in particular tenofovir disoproxil fumarate plus emtricitabine (TDF/FTC or Truvada) once daily, that it markedly reduces the risk of
sexual transmission. Perhaps the most effective way to reduce HIV transmission is for the HIV-infected partner to be on ART with undetectable levels
of virus in their blood. As noted above, a pregnant woman with HIV can reduce the risk of passing the infection to her baby by taking medications
during pregnancy and labor and avoiding breastfeeding.
Needle-stick injuries can be prevented by touching syringes with only one hand and by using more modern needles that have retractable sleeves. Use
of gowns, gloves, masks, and eye protection can reduce the risk of exposure to infected secretions in high-risk settings. For intravenous-drug abusers,
use of clean needles and elimination of needle sharing reduces the risk of transmission.
Scientists Snipped HIV Out of Human DNA
MONDAY, July 21, 2014 (HealthDay News) -- A recently developed molecular tool allowed researchers to remove HIV from cultured human cells in
the lab.
The team of scientists at Temple University School of Medicine in Philadelphia said their approach may one day lead to a permanent treatment for
HIV. They added that this technique might also be used to develop a vaccine to offer protection against the disease in the future.
"Since HIV-1 is never cleared by the immune system, removal of the virus is required in order to cure the disease," Kamel Khalili, chair of the
department of neuroscience at Temple, explained in a university news release.
"It's an exciting discovery, but it's not yet ready to go into the clinic. It's a proof of concept that we're moving in the right direction," added Khalili,
who is also director of the Comprehensive NeuroAIDS Center at Temple.
The study was published online July 21 in the Proceedings of the National Academy of Sciences.
The research focused on a type of HIV known as HIV-1. This is the most common type of AIDS-causing HIV worldwide, according to the U.S.
Centers for Disease Control and Prevention. The virus inserts its genetic material into the DNA of human cells, where it remains throughout a person's
lifetime.
That means people with HIV-1 must take a drug regimen for the rest of their lives to keep the virus under control. If treatment is stopped, the virus
returns.
But, if it were possible to remove HIV's genetic material from human cells, the researchers believe they might be able to rid people of the virus for
good.
To do this, the researchers developed a molecular tool that could hunt down HIV-1's genetic material and snip it out of human cells. Once the viral
DNA was removed, the cells were able to repair themselves and put loose ends back together. The result: virus-free cells.
This deletion process was successful in several types of human cells known to harbor HIV-1, according to Khalili.
This technique could potentially be used against a variety of other viruses, the study's authors pointed out. They also suggested that the same
molecular tools used to remove HIV genetic material might lead to an HIV vaccine. The treated cells, which were armed with the ability to snip out
HIV, were resistant to new HIV infection, the study revealed.
There are still many challenges associated with this approach that researchers must overcome before it could be used on people, including how to
deliver the agent to every single infected cell. HIV-1 also tends to mutate, the researchers noted. As a result, treatment may need to be individualized to
each person.
More than 33 million people around the world have HIV, including more than 1 million in the United States. Each year, 50,000 Americans are infected
with the virus, according to the CDC.
More information
The U.S. Department of Health and Human Services provides more information on HIV/AIDS.
SOURCE: Temple University Health System, news release, July 21, 2014
HIV Meds May Also Help Control Hepatitis C, Study Finds
WEDNESDAY, July 23, 2014 (HealthDay News) -- For patients infected with both HIV and hepatitis C, HIV antiretroviral therapy may help control
both viruses, a small study suggests.
Researchers said doctors could use their findings to improve treatment strategies for people with the two diseases.
"The findings suggest that HIV suppression with antiretroviral medications plays an important role in the management of individuals with [hepatitis
C] and HIV infection," said study leader Dr. Kenneth Sherman, a professor of medicine at the University of Cincinnati College of Medicine. "It
supports the concept that in those with HCV/HIV infection, early and uninterrupted HIV therapy is a critical part of preventing liver disease."
The researchers conducted the study to address concerns that treating patients who have HIV -- the AIDS-causing virus -- and hepatitis C with HIV
antiretroviral therapy would damage the liver and cause more harm than good.

To put this theory to the test, they closely examined 17 patients infected with both viruses for two years. The patients received approved HIV
antiretroviral drugs. They were also examined frequently, and their blood was routinely tested to track any changes in the viruses and their immune
response.
The findings were published July 23 in the journal Science Translational Medicine.
Some patients experienced an initial increase in a blood test that shows changes in liver injury, hepatitis C or both in the first 16 weeks of the study.
Over 18 months, however, the study revealed that "viral loads" for hepatitis C dropped back down to levels expected for a patient infected with only
hepatitis C and not HIV.
"The drop in [hepatitis C] viral levels was a big surprise, and not what we necessarily expected," said Sherman in a university news release. "There is
a complex interaction of biological effects when patients are infected with both HIV and the hepatitis C virus." He explained that initially HIV
treatment results in a transient increase in hepatitis C viral replication and evidence of liver injury. However, over time, HIV suppression leads to
reduced hepatitis C viral replication.
In the United States, up to 300,000 people are infected with both hepatitis C and HIV. Globally, that number increases to between 4 million and 8
million, the researchers said.
Drug makers Bristol-Myers Squibb and Gilead Sciences supplied the antiretroviral medications used in the study at no charge. One of the scientists
involved in the research, Dr. Judith Feinberg, a professor of infectious diseases at the University of Cincinnati, is a Bristol-Myers Squibb investigator
and speaker.
More information
The U.S. Department of Health and Human Services provides more information on antiretroviral therapy.
SOURCE: University of Cincinnati Academic Health Center, news release, July 23, 2014
Those With HIV Living Longer, International Study Finds
By Steven Reinberg
HealthDay Reporter
THURSDAY, July 17, 2014 (HealthDay News) -- Overall death rates for HIV-positive adults living in Australia, Europe and the United States have
been cut 28 percent since 1999, according to new international research.
Deaths from AIDS-related causes dropped more than one-third among the HIV-positive adults in the study. Cardiovascular disease deaths declined by
almost two-thirds, while deaths from liver disease were nearly halved, the study authors found.
"It is reassuring that death rates continue to decrease amongst HIV-positive people," said lead researcher Colette Smith, a lecturer in biostatistics at
the University College London in England.
Not all the news was positive, however. Rates of cancer deaths remained stable, the researchers noted.
Antiretroviral drugs are credited with making HIV into what some now call a chronic disease rather than a death sentence. This is particularly true in
developed countries where treatment is readily available.
"Unfortunately, we do not currently have a cure for HIV, and it seems likely that people will have to take antiretroviral drugs for life," Smith said.
She noted that death rates among HIV-positive people need to be monitored to be sure antiretroviral drugs remain effective and safe over years of
treatment.
"We are not yet sure whether decades of antiretroviral treatment will lead to unexpected side effects. Therefore, we must continue to investigate what
HIV-positive people die of, to pick up these potential side effects as quickly as possible," Smith said.
In addition, it's likely that HIV-positive people are at an increased risk for non-AIDS diseases, including liver disease, heart disease and cancer, she
noted.
"Reasons for this may include side effects of the antiretroviral treatment and lifestyle factors, such as smoking, which is more common among HIVpositive people, or the HIV infection itself is increasing the risk," Smith said.
The report was released online July 17 and published in the July 19 print issue of The Lancet.
For the current study, Smith and her colleagues reviewed data on nearly 50,000 people who were HIV-positive. Specifically, they looked at deaths
between 1999 and 2011. The researchers adjusted the data to account for factors such as age, sex, ethnicity, smoking, weight and whether or not
someone had additional illnesses.
Despite the success of antiretroviral therapy, AIDS-related death was still the most common cause of death, accounting for 29 percent of the nearly
4,000 deaths seen over the study period, the researchers found.
Although deaths from most causes dropped, deaths from non-AIDS cancers remained the same from 1999 to 2011. In fact, non-AIDS cancers are the
leading cause of non-AIDS deaths in those with HIV, making up 23 percent of all deaths, the study authors pointed out.
Among those who died from non-AIDS conditions, 15 percent died from lung cancer, 13 percent died from liver disease (mainly hepatitis) and 11
percent died from heart disease, they noted.
"We all know that getting HIV patients into care, getting them on their medicines, will lead to better outcomes," said Dr. Michael Horberg, director of
HIV/AIDS at Kaiser Permanente in California. "The decline in deaths is really remarkable."
People are living longer with HIV, but the treatment is not easy and no one should think of HIV as a chronic disease without consequences, Horberg
said.
"You can have side effects from your medicine. A number of patients do get those bad AIDS-related cancers and non-AIDS-related cancers and liver
disease, even with taking their medication," he explained.
Horberg noted that to reduce deaths, patients need to take medications consistently. "And you have to work very closely with your doctor," he said.
But the effort is clearly worth it. HIV patients can live almost a normal lifespan, according to Horberg. And, he added, "It's not just lifespan, it's a
productive lifespan with good quality of life."