Implant survival and patient-reported outcomes after total hip arthroplasty in young patients with juvenile idiopathic arthritis

Outcome and complication rate of total hip arthroplasty in patients younger than twenty years: which bearing surface should be used?

PURPOSE

Total hip arthroplasty (THA) in younger patients remains controversial due to concerns regarding long-term implant survival and potential complications. This study aimed to evaluate long-term clinical outcomes, complications, differences in complication and revision rates by bearing surfaces, and Kaplan-Meier survival curves for THA in patients under 20 years old.

METHODS

A retrospective review was conducted for 65 patients (78 hips) who underwent THA between 1991 and 2018. Their mean age was 18.9 years. Their clinical outcomes were assessed using the Harris Hip Score (HHS). Radiological outcomes were evaluated based on the presence of loosening, osteolysis, and heterotopic ossification. Complications such as dislocation, periprosthetic fractures, and infections were assessed. The mean follow-up period was 13.2 years (range, 5.0-31.2 years).

RESULTS

The mean HHS improved from 44.6 to 90.1. There were two cases of dislocation. However, no periprosthetic fracture, deep infection, or ceramic component fracture was noted. There were 19 revisions of implants. Eighteen of 19 hips were operated with hard-on-soft bearings in the index surgery (p < 0.01). The 23-year survivorship was 97.8% for THA using ceramic-on-ceramic bearings, while the 31-year survivorship was 36.7% using hard-on-soft bearings.

CONCLUSION

THA in patients under 20 years old yielded promising clinical and radiological outcomes, although polyethylene-bearing-related concerns persisted. Previously operated patients with hard-on-soft bearing should be meticulously examined during the follow-up. As ceramic-on-ceramic bearing showed excellent survivorship in this particular cohort, we recommend the use of this articulation as the bearing of choice.

Primary Total Hip Arthroplasty in Juvenile Idiopathic Arthritis: Survivorship After a Median Follow-Up of 12 Years

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory condition of childhood that frequently affects the hip. Total hip arthroplasty (THA) in JIA can be challenging due to the patient's young age, small proportion, complex anatomy, and bone loss. Outcome data are limited.

METHODS

We reviewed prospectively collected data in 57 JIA patients (83 hips) who underwent THA between 1986 and 2020 by a single surgeon. The median patient age at surgery was 26 years (range, 14 to 62). Reoperation-free survival was assessed via the cumulative incidence function, accounting for the competing risk of death. Relationships between patient and implant factors and survivorship were evaluated by stratification of the cumulative incidence function and Gray's tests. Wilcoxon signed rank tests were used to assess the preoperative to latest postoperative change in patient-reported outcome measures.

RESULTS

At a median (interquartile range) of 12 (4, 20) years of follow-up, 13 (16%) patients underwent reoperation, most commonly for polyethylene wear and osteolysis (7 hips). The estimated incidence of 10-year, 20-year, and 30-year revision (95% confidence interval) were 11.3% (4.5, 21.6%), 18.5% (8.9, 30.9%), and 40.6% (19.4, 60.9%), respectively. There were no differences in survival based on patient age, sex, implant fixation method, polyethylene type, or thickness. All patient-reported outcome measures improved from preoperative to latest follow-up.

CONCLUSIONS

Primary THA is a durable and effective treatment for JIA patients with severe hip involvement and results in major improvements in pain and function. We did not identify any factors predictive of failure.

Predictors of Reoperation and Survival Experience (Minimum 1 Year) for Primary Versus Conversion Total Hip Arthroplasty in Young Patients

BACKGROUND

Total hip arthroplasty (THA), including primary and conversion procedures, is commonly used for many types of joint disease in patients aged below 65 years, though few studies have evaluated THA outcomes in young patients (≤ 40 years old). This study examined a large cohort of patients who underwent THA at a young (≤ 40 years old) age to identify predictors of reoperation and compare survivorship between primary and conversion THAs.

METHODS

A retrospective study was conducted on 497 patients who underwent 612 primary and conversion THAs at 40 years old or younger between 1990 and 2020. Medical records were reviewed to collect patient/surgical data. A multivariable logistic regression model identified independent predictors of reoperation, and Kaplan-Meier analysis with log-rank tests was used to compare survival curves by THA type.

RESULTS

The median age at surgery (interquartile range) was 31 years (25 to 36). The median follow-up time was 6.6 years (range, 3.8 to 10.5). Conversion THAs had an increased rate of both revisions (12.3 versus 5.6%, P = 0.02) and nonrevision reoperations (8.9 versus 3.2%, P = 0.03) compared to primary THAs. A ceramic-on-ceramic articulation (odds ratio: 5.17; P = 0.03) and a higher estimated blood loss (odds ratio: 1.0007; P = 0.03) were independent predictors of reoperation for primary and conversion THA, respectively. Conversion THAs had a lower 15-year survival (77.8 versus 90.8%, P = 0.009) compared to primary THAs.

CONCLUSIONS

Patients ≤ 40 years old who underwent primary and conversion THAs demonstrated an impressive 15-year survival comparable to that of older populations (74 to 93%), while conversion procedures had a higher reoperation rate. Although primary THA may be more ideal, there are promising outcomes for patients who need THA at a younger age than typically implemented, especially for those who are very young (≤ 30 years old).

Acetabular Distraction Technique: A Multicenter Study With a Minimum 2-Year Radiographic Follow-Up

BACKGROUND

Chronic pelvic discontinuity is a challenge during revision total hip arthroplasty due to the loss of structural continuity of the superior and inferior aspects of the acetabulum from severe acetabular bone loss. Acetabular distraction provides an alternative surgical treatment by stabilizing the acetabular component through elastic recoil of the pelvis, which may be supplemented with modular porous augments for addressing major acetabular defects. This study reports 2-year radiographic findings following acetabular distraction for the treatment of chronic pelvic discontinuity.

METHODS

Patients undergoing acetabular distraction performed by 5 surgeons from 2002 to 2021 were identified across 5 institutions. Demographic, surgical, and postoperative outcomes, including radiographic component stability, were recorded. There were 53 of 91 (58.2%) patients (5 deceased, 33 lost to follow-up) consisting of 4 Paprosky IIC (7.5%), 8 Paprosky IIIA (15.1%), and 41 Paprosky IIIB (77.4%) defects included, with a mean follow-up time of 4.8 years (range, 2 to 13.5). Modular porous augments were used in 33 (62.3%) cases. Failure was defined as a subsequent revision of the acetabular construct.

RESULTS

Among the 13 (24.5%) patients who returned to the operating room, 6 (46.2%) had a prior history of revision total hip arthroplasty before undergoing acetabular distraction. Only 5 (9.4%) patients underwent acetabular revision following acetabular distraction, leading to an overall cup survivorship of 90.6%. Of the remaining 48 patients, 46 (95.8%) had evidence of radiographic bridging callus of the chronic pelvic discontinuity at their last clinical follow-up.

CONCLUSIONS

To our knowledge, in the largest series to date, acetabular distraction has proven to be a viable treatment for acetabular bone loss with a chronic pelvic discontinuity, with excellent early survivorship and radiographic evidence of bridging callus. Future studies with longer follow-ups are needed to further monitor the efficacy of this technique.

LEVEL OF EVIDENCE

Level III, Retrospective Comparative Study.

What has changed in total hip arthroplasty in patients of juvenile idiopathic arthritis since 2000? A systematic review and pooled data analysis

PURPOSE

The prevalence of juvenile idiopathic arthritis (JIA) is estimated to be 16-150 per 100,000 children worldwide. The hip joint may be involved in over 50% of children leading to significant morbidity which may require surgical intervention in the form of arthroplasty. The literature lacks a concise overview of the outcomes, including complication and implant survival of total hip arthroplasty (THA) in juvenile idiopathic arthritis (JIA). The aim of this study is to systematically analyze the literature and report the outcomes of THA in JIA.

METHODS

Search was conducted in the online databases PubMed, Embase and Cochrane database. It included all original studies which evaluated clinical and/or radiological outcomes of THA in JIA with a minimum sample size of 5 patients and published in English. The level of evidence of the included studies was graded according to the Oxford Centre for Evidence Based Medicine. The Institute of Health Economics checklist was used to assess the quality of the studies included.

RESULTS

The nine studies included were retrospective in nature with all being Level IV according to Oxford Centre for Evidence Based Medicine. 475 hips in 304 patients with majority of them being females (241/304, 79.2%) were included in this review. All the studies reported the outcome objectively using various scores. The proportion of revision surgeries (92/378), either femoral or acetabular, noted was 22% (95% CI 10-33%). The proportion of acetabular revisions (72/378) was 16% (95% CI 8-25%) as compared to 4% (95% CI 1-6%) for femoral revisions (20/378). There was no difference in survivorship when cemented and uncemented implants were compared.

CONCLUSION

JIA patients with advanced hip disease represent a unique population with need for extra-long implant longevity. THA in patients of JIA leads to improved pain relief as well as mobility but the conversion of the same outcomes to functional activity is not proportionally improved. The current trend is the use of uncemented and ceramic-on-ceramic implants. Acetabular implants require earlier revision as compared to femoral implants. Age at surgery can be delayed by early institution of methotrexate which indirectly improves implant survival.

LEVEL OF EVIDENCE

IV.

Factors associated with poor prognosis of hip arthritis in juvenile idiopathic arthritis: Data from the JIR cohort

OBJECTIVES

Hip involvement remains a predictor of severe juvenile idiopathic arthritis (JIA) course and carries a high risk of disability. This study aims to determine the factors of poor prognosis of hip involvement in patients with JIA and to assess the treatment response.

METHODS

This is a multicenter observational cohort study. Patients were selected from the JIR Cohort database. Hip involvement was defined as clinically suspected and confirmed by an imaging tool. Follow-up data were collected during 5 years.

RESULTS

Among the 2223 patients with JIA, 341(15%) patients had hip arthritis. Male gender, enthesitis-related arthritis, and North African origin were factors associated with hip arthritis. Hip inflammation was associated with disease activity parameters during the first year, particularly Physician Global Assessment, joint count, and inflammatory marks. Structural hip progression was associated with early onset of the disease, a longer time to diagnosis, geographic origin, and JIA subtypes. Anti-TNF therapy was found to be the only treatment able to effectively reduce structural damage progression.

CONCLUSION

The early onset diagnostic delay, origin, and systemic subtype of JIA predict a poor prognosis of hip arthritis in children with JIA. The use of anti-TNF was associated with a better structural prognosis.

Pipkin type III femoral head fracture: which treatment strategy can be recommended?

BACKGROUND

Pipkin type III femoral head fractures are relatively rare injuries. Few studies have explored and described the treatment and outcomes of Pipkin type III femoral head fractures. The purpose of this study was to evaluate the efficacy of open reduction and internal fixation (ORIF) in treating Pipkin type III femoral head fractures.

METHODS

We retrospectively reviewed 12 patients with Pipkin type III femoral head fractures who underwent ORIF from July 2010 and January 2018. The complications and reoperations were recorded. The visual analog scale (VAS) pain score, Harris hip score (HHS), Thompson-Epstein criteria, and SF-12 score [including the physical component summary (PCS) and the mental component summary (MCS)] were used for functional assessment.

RESULTS

Among the 12 patients, ten were males and two were females, with a mean age of 34.2 ± 11.9 years. The median follow-up time was 6 years (range 4-8 years). Five patients (42%) developed osteonecrosis of the femoral head, and one patient (8%) developed nonunion. These six patients (50%) underwent total hip arthroplasty (THA). One patient (8%) developed heterotopic ossification and underwent ectopic bone excision; this patient also presented with post-traumatic arthritis. The mean final VAS pain score and HHS were 4.1 ± 3.1 points and 62.8 ± 24.4 points, respectively. According to the Thompson-Epstein criteria, there was one patient (8%) with excellent, four patients (33%) with good, one patient (8%) with fair, and six patients (50%) with poor outcomes. The PCS score and MCS score were 41.7 ± 34.7 points and 63.2 ± 14.5 points, respectively.

CONCLUSION

Limited by the high incidence of osteonecrosis of the femoral head, it is difficult to achieve satisfactory functional outcomes when treating Pipkin type III femoral head fractures using ORIF, and a primary THA may be considered. However, for younger patients, considering the survivorship of prosthesis, ORIF may be recommended with the proviso that the patient is fully informed of the high complication rate associated with this procedure.

LEVEL OF EVIDENCE

IV.

Surgical Treatment of Juvenile Idiopathic Arthritis in the Era of Novel Drug Therapies

Juvenile idiopathic arthritis is the most common chronic rheumatic disease encountered in children under the age of sixteen and causes significant impairments in daily life. Over the last two decades, the introduction of new drug treatments (including disease-modifying antirheumatic drugs and biologics) has changed the course of this disease, thus reducing the indication for surgery. However, some patients fail to respond to drug therapy and thus require personalized surgical management, e.g., the local reduction of joint effusion or a synovial pannus (via intra-articular corticosteroid injections, synovectomy, or soft tissue release), and management of the sequelae of arthritis (such as growth disorders and joint degeneration). Here, we provide an overview of the surgical indications and outcomes of the following interventions: intra-articular corticosteroid injections, synovectomy, soft tissue release, surgery for growth disorders, and arthroplasty.

[Midterm follow-up outcomes of total hip arthroplasty in treatment for patients with juvenile-onset ankylosing spondylitis]

OBJECTIVE

To assess the midterm follow-up outcomes of total hip arthroplasty (THA) for the treatment of patients with juvenile-onset ankylosing spondylitis (JAS).

METHODS

The clinical data of 81 patients (127 hips) with JAS (age≤16 years, JAS group) and 267 patients (391 hips) with adult onset ankylosing spondylitis (AAS) (age>16 years, AAS group) between January 2004 and March 2018 were retrospectively analysed. The baseline demographics, clinical, radiographic, and laboratory parameters were collected. Before operation and at last follow-up, the overall disease activity [Bath ankylosing spondylitis disease activity index (BASDAI)] and function status [Bath ankylosing spondylitis functional index (BASFI)], hip subjective score [Harris hip score (HHS)] and objective score [12-item short form health survey (SF-12), including physical component score (PCS) and mental component score (MCS)], and patient satisfaction for THA were reviewed. The major orthopedic complications, including periprosthetic infection, dislocation, periprosthetic fractures, and poor incision healing, were also recorded during the follow-up period.

RESULTS

The comparison of preoperative baseline parameters showed that the body mass, body mass index, age of onset, age of surgery, disease duration, and the proportion of combined smoking history in the JAS group were significantly lower than those in the AAS group ( P<0.05), the proportion of bilateral surgeries, proportion of uveitis, proportion of combined family history, C-reactive protein, albumin, and preoperative BASFI were significantly higher than those in the AAS group ( P<0.05). Both groups were followed up. The follow-up time in the JAS group was 29-199 months, with an average of 113 months; in the AAS group was 35-199 months, with an average of 98 months. Incisions in both groups healed by first intention. During the follow-up period, there were 1 case of periprosthetic fracture, 1 case of dislocation, and 1 case of ceramic fragmentation in the JAS group, 1 case of periprosthetic infection and 6 cases of periprosthetic fracture in the AAS group. There was no significant difference in the incidence of complications between the two groups ( P>0.05). At last follow-up, the BASDAI, BASFI, SF-12 MCS, SF-12 PCS, and HHS score of the two groups were significantly improved when compared with those before operation ( P<0.05); but there was no significan difference in the difference of the above parameters before and after operation and the patient satisfaction between the two groups ( P>0.05).

CONCLUSION

The midterm follow-up outcomes of THA for the treatment of JAS patients were reliable. A low age at disease onset did not exert a significant negative effect on THA reconstruction for the treatment of ankylosing spondylitis.

Hyaluronic Acid Therapy in Hip OA Does Not Perform Equally in Osteoarthritis Secondary to Juvenile Idiopathic Arthritis When Compared to Primary Osteoarthritis: A 2-Year Preliminary Evaluation

OBJECTIVE

Hip involvement in juvenile idiopathic arthritis (JIA) is one of most important causes of pain and disability. Total hip arthroplasty (THA) is considered the standard when medical approaches fail to relieve pain. However, THA is problematic for many reasons. As current literature lacks studies valuating medical management of osteoarthritis (OA) secondary to JIA, we assessed the long-term pain relief effect of US-guided intra-articular viscosupplementation in hip osteoarthritis secondary to JIA versus primary OA under different etiological conditions.

METHODS

Patients in both groups received intra-articular Hylan G-F 20 2 ml once a month for 3 consecutive months and every 6 months for 2 years as maintenance. Effectiveness (VAS and WOMAC), NSAID/analgesic consumption, tolerability, withdrawals and reason for discontinuation were collected at each time point. An inverse probability weighting was used to balance the two groups.

RESULTS

We retrospectively retrieved data of 14 JIA patients and 26 primary OA. Weighting successfully accounted for differences between the disease groups supporting the results. Viscosupplementation led to an early and significant improvement of pain and function and concomitant decrease in NSAIDs consumption, while the response diverged over 1 year with loss of benefits in JIA. The worst outcome was observed in active JIA.

CONCLUSIONS

Duration of symptom relief after intra-articular injection of hyaluronic acid depends on the nature of arthritis. Multiple courses of viscosupplementation are required to maintain low-dose NSAIDs consumption in patients responsive to treatment while shortening the time between consecutive injections might provide persistent positive results in patients suffering from JIA.

Use of Total Hip Arthroplasty in Patients Under 21 Years Old: A US Population Analysis

BACKGROUND

The purpose of this study is to evaluate trends in the use of total hip arthroplasty (THA) in the United States in patients under 21 years of age. Specifically, we examined the frequency of THA in this patient population over the past 2 decades, the epidemiologic characteristics of patients under 21 who underwent THA, and the characteristics of the hospitals where these procedures were performed.

METHODS

We retrospectively reviewed the Kids' Inpatient Database, an inpatient US national weighted sample of hospital admissions in patients under 21 from approximately 4200 hospitals in 46 states. We queried the database using Current Procedural Terminology codes for elective and non-elective primary THA for the years 2000-2016. We utilized the International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes to determine primary diagnoses.

RESULTS

The weighted total number of THAs performed in patients under 21 in the Kids' Inpatient Database increased from 347 in 2000 to 551 in 2016. The most common diagnoses were osteonecrosis, osteoarthritis, and inflammatory arthritis. The frequency of THA for osteonecrosis increased from 24% in 2000 to 38% in 2016, while the frequency of THA for inflammatory arthritis decreased from 27% in 2000 to 4% in 2016.

CONCLUSION

The number of THAs in patients under 21 in the United States has increased over the past 2 decades and these procedures are increasingly performed in urban teaching hospitals. The decrease in THA for inflammatory arthritis in this population likely reflects improvements in medical management during the study period.

Early Joint Replacement in Juvenile Idiopathic Arthritis: Trend Over Time and Factors Influencing Implant Survival

OBJECTIVE

To describe early prosthesis implantations in a cohort of patients with juvenile idiopathic arthritis (JIA) followed in a tertiary referral hospital and to analyze possible factors influencing implant survival.

METHODS

This was a retrospective cohort study. Charts of all patients with JIA who underwent total joint replacement at Gaetano Pini Hospital, Milan, Italy from January 1992 to June 2019 were retrieved, and relevant data were analyzed.

RESULTS

Eighty-five patients met the inclusion criteria for this study, with a median follow-up period of 17.2 years. The median age at first prosthesis was 22.7 years. The total number of replaced joints was 198 over a period of 27 years. The hip was the most frequently replaced joint, accounting for almost two-thirds of the total number of implants; the other one-third refers mostly to knee implants. Polyarticular JIA and systemic JIA were the most represented JIA categories in the study cohort. A significant upward trend of the age at arthroplasty and of disease duration before arthroplasty over decades was found. The rates of implant survival at 5, 10, and 15 years were comparable (from 84% to 89%); 50% of implants lasted ≥20 years.

CONCLUSION

We reported retrospective data on early joint replacement in a cohort of patients with JIA. We observed a progressive and significant upward trend of both age at arthroplasty and disease duration before the first arthroplasty over time. The JIA category, year of implant, and presence of complications significantly affected implant survivorship.

Long-term survival after cemented versus uncemented total hip arthroplasty for treatment of acute femoral neck fracture: a retrospective study with a mean 10-year follow-up

Objective

To compare the long-term survivorship and Harris hip scores (HHSs) between cemented total hip arthroplasty (CTHA) and uncemented total hip arthroplasty (UTHA) for treatment of acute femoral neck fractures (FNFs).

Methods

Data of 224 hips (CTHA, n = 112; UTHA, n = 112) that underwent primary surgery in our medical institution from 2005 to 2017 were retrospectively analysed. The primary endpoint was the risk of all-cause revision. The difference in the risk of all-cause revision between the two groups was assessed by Kaplan–Meier survival analysis with a log-rank test and Cox regression analysis.

Results

The mean postoperative follow-up was 10 years (range, 3–13 years). The Kaplan–Meier estimated 10-year implant survival rate was significantly higher in the CTHA than UTHA group (98.1% vs. 96.2%, respectively). The adjusted Cox regression analysis demonstrated a significantly lower risk of revision in the CTHA than UTHA group. At the final follow-up, the mean HHS was significantly higher in the CTHA than UTHA group (85.10 vs. 79.11, respectively).

Conclusion

This retrospective analysis demonstrated that CTHA provided higher survival, lower revision risk, and higher functional outcome scores than UTHA. Further follow-up is necessary to verify whether these advantages of CTHA persist over time.

Ceramic-on-ceramic cementless total hip arthroplasty in patients aged 40 years or under: Do preoperative conditions affect long-term results?

INTRODUCTION

Underlying diseases, bone deformities and polyethylene wear affect outcome in young patients undergoing total hip arthroplasty (THA). These issues are not widely confirmed for ceramic - on-ceramic THA, particularly regarding cup fixation. Therefore, we did a retrospective long-term investigation on a large population of cementless ceramic-on-ceramic THA in patients aged 40 years or younger aiming to analyze: 1) the complication rate; 2) clinical results; and 3) survival for cup loosening with regard to their preoperative conditions.

HYPOTHESIS

Cup loosening could be related to preoperative diagnosis in young patients with a cementless ceramic-on-ceramic THA.

PATIENTS AND METHODS

Two hundred and seven hips in 171 patients (97 men and 74 women) underwent a cementless ceramic-on-ceramic THA at a mean age of 31.6±6.8 years. The most frequent diagnoses were avascular necrosis (AVN) of the femoral head (74 hips), pediatric hip diseases (35 hips), severe congenital hip dysplasia (CHD) (31 hips), juvenile rheumatoid arthritis (30 hips) and mild CHD (26 hips). The prosthesis included a press-fit metal backed cup with a hydroxyapatite coating and a macrotexture surface on either the equatorial region (93 cups) or the entire surface of the shell (114 cups). Ceramics were made of pure alumina and had a femoral head size of 28 (60 hips) or 32mm (147 hips). In all cases same the straight cementless tapered stem was inserted.

RESULTS

There were three early dislocations, one requiring cup revision No hip was revised due to infection, ceramic fracture, or femoral component loosening. Eight cups were revised for aseptic loosening (3,8%). The mean preoperative Harris Hip score was 52.8±6.2 and 93.4±6.9 at the end of follow-up. It was better in AVN (95.7±2.3) and worst in severe CHD (88.8±11.8) (p=0.001). If the end-point was cup aseptic loosening, the survival rate at 17 years was 95.1% (95% CI: 91.3-98.9), 100% for AVN and post-traumatic arthritis, and 86.8% (95% CI: 74.9-98.7) for severe CHD.

CONCLUSIONS

Despite diagnoses frequently causing technical difficulties at the surgery, outcome of cementless ceramic-on-ceramic THA in patients under the age of 40 years is satisfactory over ten years of follow up. Cup aseptic loosening was the main cause of failure and appears more related to the initial hip diseases than the age of the patient.

LEVEL OF EVIDENCE

III; retrospective comparative study.

General Principles of the Surgical Management of Juvenile Inflammatory Arthritis

Surgical management of Juvenile Inflammatory Arthritis (JIA) presents many challenges for the patient, healthcare team and especially the orthopedic surgeon. Collaborative care efforts must be endorsed early on in order to facilitate maximal postoperative functional ability. Developmental levels, both physically and emotionally must be established preoperatively. It is important to determine bone age and growth plate closure to establish the best surgical intervention and avoid leg-length discrepancies later in life. Emotional maturity may impede the ability of the patient to manage pain or follow directions throughout the recuperative process. Surgical challenges require a team approach that includes rheumatologists who can manage disease modifying agents and the effects of discontinuing medications or planning surgery around dosing regimens in order to decrease immunosuppression. Managing multiple joint issues will require an expert team of occupational and physical therapists to prepare adaptive devices and rehabilitate patients who have significant functional limitations and decreased muscular strength. Because of an anticipated longer and more difficult recovery for JIA patients, case managers must engage in support systems and plan for postoperative care prior to surgery. Implant specific devices need to accommodate small bone structure, bone loss and complex deformities along with diaphyseal or epiphyseal dysplasia. Neurologic assessments will avoid cervical spine compromise during anesthesia administration. Bilateral procedures in the lower extremities should be considered whenever flexion contractures are present and should take place prior to upper extremity joint replacements. Restoring function to the hand and wrist takes priority over elbow and shoulder replacement, respectively. The key factors of appropriate surgical management in JIA patients are to decrease pain, restore function and avoid loss of ambulation at a young age. Extensive preoperative planning and communication with the patient, support system and healthcare team are warranted to address the complexities in this patient population.

The Hip in Juvenile Idiopathic Arthritis

The hip joint is commonly affected in Juvenile Idiopathic Arthritis (JIA), especially in cases of systemic polyarticular disease. Chronic synovitis of the hip leads to joint destruction, therefore, systemic and local control of the disease is of paramount importance. Non-steroidal anti-inflammatory drugs, Disease Modifying Anti-Rheumatic Drugs (DMARDs), biologics, intra-articular corticosteroid injections, and physical therapy are the mainstay for controlling ongoing inflammation and hip joint contractures. Synovectomy with soft tissue releases is useful in the early stages of the disease, when the joint cartilage is largely preserved. Total joint arthroplasty (THA) is successful in relieving pain, and improving function, ambulation and range of motion in end-stage degenerative arthritis. With improved designs of smaller prostheses and modern bearing couples, it is hoped that the longevity of THA will facilitate a more normal and enduring lifestyle.

Juvenile idiopathic arthritis is associated with higher healthcare utilization after total knee or hip replacement

Objective: To assess whether juvenile idiopathic arthritis (JIA) is associated with healthcare utilization and in-hospital complications after total hip or knee arthroplasty (THA/TKA). Method: We used the 1998-2014 US National Inpatient Sample. We performed multivariable-adjusted logistic regression, adjusted for age, race/ethnicity, gender, income, Deyo-Charlson comorbidity index, insurance payer, and the underlying diagnosis. Results: Of the 4 116 485 THAs and 8 127 282 TKAs, 1882 people with JIA had THAs (0.02%) and 1388 had TKAs (0.01%). Compared to people without JIA, people with JIA post-THA and post-TKA had higher odds ratio [OR (95% confidence interval), respectively] of total hospital charges above the median [1.30 (1.05, 1.60) and 1.37 (1.08, 1.74)], length of hospital stay > 3 days [1.64 (1.27, 2.12) and 1.44 (1.07, 1.93)], and discharge to non-home settings [1.37 (1.07, 1.76)] post-THA, but not post-TKA [1.02 (0.77, 1.36)]. People with JIA also had higher OR of transfusion post-TKA [1.92 (1.44, 2.55)], but not post-THA [1.00 (0.77, 1.30)]. Sensitivity analyses that adjusted for hospital characteristics confirmed the main study findings with minimal or no attenuation of OR. Conclusions: People with JIA utilized more healthcare services post-THA/TKA and were more likely to receive transfusions post-TKA. Interventions to reduce the risk of higher resource utilization are needed in people with JIA.

Long-term results of custom-made femoral stems

BACKGROUND

The progress of 3D imaging and manufacturing of implants has made it possible to achieve a custom-made concept in THA. The custom-made cementless femoral stem provides optimal implant stability combined with restoration of the native hip mechanics.

OBJECTIVE

The purpose of this study was to evaluate the long-term survivorship of custom-made hip femoral stems in two populations of patients undergoing THA: patients under 50 years old (young patients group) and patients with high-grade developmental dysplasia of the hip (DDH group).

METHODS

A series of 232 primary custom-made cementless THA stems were retrospectively evaluated in patients less than 50 years old at the time of surgery and at follow-up after an average of 20 years. A second series of 26 custom-made cementless stem THAs for late DDH (21 patients) including only Crowe grade III and grade IV were also retrospectively evaluated with an average follow-up of 16 years. The clinical and radiological evaluations were performed preoperatively and at yearly intervals.

RESULTS

For the young patient group, the follow-up ranged from 14 to 27 years. The HHS and the Merle D'Aubigne-Postel score significantly improved from preoperatively to a mean of 94.1 (range 48-100) and 15.9 (range 9-18), respectively. Taking stem revision for aseptic loosening as an endpoint, survivorship was 96.8% at 20 years (95% confidence interval, CI 95.1-98.5). For the DDH group, the follow-up ranged from 10 to 22 years. The mean HHS increased significantly from preoperative 49 ± 22 points to the most recent follow-up examination with 86 13 points and survivorship was 96.1% (95% CI, 92.7-99.9).

CONCLUSION

Custom-made femoral stems provide good functional outcome and long-term survivorship in two specific populations of patients undergoing THAs: patients under 50 years old with high expectations and patients with high-grade DDH.

No effect of delivery on total hip replacement survival: a nationwide register study in Finland

Background and purpose - Previous small studies have suggested that delivery does not adversely affect the survivorship of total hip replacement (THR). We investigated whether delivery after primary THR affects hip implant survivorship in a large population-based study sample Patients and methods - In this register-based nationwide cohort study, all women aged 15-45 who underwent primary THR in Finland from 1987 to 2007 were included from the Finnish Arthroplasty Register. Data on deliveries were obtained from the medical birth register. After primary THR, 111 women (133 THRs) delivered and formed the delivery group. In the reference group, 1,878 women (2,343 THRs) had no deliveries. We used Kaplan-Meier analysis with 95% confidence intervals (CI) to study implant survivorship at 6 and 13 years, and Cox multiple regression to assess survival and hazard ratios (HRs), with revision for any reason as an endpoint with adjustment for age, rheumatoid arthritis, and stem and cup fixation. Results - 51 (38%) revisions were recorded in the delivery group and 645 (28%) revisions in the reference group. The 6-year implant survivorship was 91% (CI 85-96) in the delivery group and 88% (CI 87-90) in the reference group. The 13-year survival rates were 50% (CI 39-62) and 61% (CI 59-64). The adjusted HR for revision after delivery was 0.7 (CI 0.4-1.2) in ≤ 6.8 years' follow-up and 1.1 (CI 0.8-1.6) in > 6.8 years' follow-up. Interpretation - Based on the findings in this nationwide study of hip replacement in fertile-aged women, delivery does not seem to decrease THR implant survivorship; women should not be afraid of or avoid becoming pregnant after THR.

Juvenile Idiopathic Arthritis for the Pediatric Orthopedic Surgeon

Juvenile idiopathic arthritis includes conditions characterized by joint inflammation of unknown etiology lasting longer than 6 weeks in patients younger than 16 years. Diagnosis and medical management are complex and best coordinated by a pediatric rheumatologist. The mainstay of therapy is anti-inflammatory and biologic medications to control pain and joint inflammation. Orthopedic surgical treatment may be indicated for deformity, limb length inequality, or end-stage arthritis. Evaluation of the cervical spine and appropriate medication management in consultation with a patient's rheumatologist are essential in perioperative care. Preoperative planning should take into account patient deformity, contracture, small size, osteopenia, and medical comorbidities.

A 20-year follow-up evaluation of total hip arthroplasty in patients younger than 50 using a custom cementless stem

AIM

The purpose of this study is to report the 20-year follow-up of a continuous series of 232 total hip arthroplasties (THAs) performed in patients aged less than 50 at the index surgery.

PATIENTS AND METHODS

This is a retrospective monocentric study which reports the clinical, radiographical and survival results of 232 THAs performed with a custom cementless femoral stem in 212 patients evaluated at follow-up ranging from 14 to 27 years.

RESULTS

At the time of follow-up, the mean Harris Hip Score was 94.1 (range 48-100). The Hip disability and Osteoarthritis Outcome Score was >80 points in all 5 categories for 146 patients (68.9%). 18 hips (8.5%) showed radiographical femoral abnormalities. 23 hips (10.8%) underwent revision of the implants. 13 were isolated cup revisions. 3 more hips had bipolar revisions for aseptic loosening at 15, 20 and 21 years. Taking stem revision for aseptic loosening as an endpoint, survivorship was 96.8% at 20 years (95% confidence interval, 95.1-98.5; patients at risk 76) and 94.5% at 25 years (91.7-97.3; patients at risk 12).

CONCLUSIONS

The results of this study confirm that THA using this custom-designed stem can provide excellent clinical and radiographical outcomes at a mean follow-up of 20 years in patients younger than 50. The individual 3D femoral stem and prosthetic neck has been able to restore extra- and intramedullary functional anatomy in this young and active cohort of patients.

Total Hip Arthroplasty Performed for Coxarthrosis Preserves Long-Term Physical Function: A 40-Year Experience

BACKGROUND

Measures of long-term success of total hip arthroplasty (THA) over the past 50 years have focused primarily on implant survival, with less evidence on long-term functional outcomes.

QUESTIONS/PURPOSES

We aimed to study 20-to-40-year functional outcomes after primary THA. We investigated the extent to which (1) functional outcomes after THA are maintained long term; (2) patient characteristics such as age, hip disease diagnosis, and comorbidities affect recovery of function and survivorship after THA; and (3) patients' overall function after THA is affected by the need for revision, the aging process, and associated comorbidities.

METHODS

We retrospectively reviewed outcomes of the senior author's patients between 1968 and 1993. Of 1207 patients, we identified 167 patients (99 female, 68 male; 276 primary THAs) who were at least 65 years old at follow-up and had at least 20 years of follow-up. Mean age at surgery was 55 years; mean follow-up time was 27 years. Bilateral THAs were performed in 109 patients (65%), and revisions in 81 patients (48.5%). Clinical outcomes including pain level, walking ability, range of motion, and overall function were determined by the Hospital for Special Surgery (HSS) hip scoring system. Contralateral and revision surgery, as well as patient age, sex, and body mass index, were included as covariates. To account for unequally spaced follow-up time points and competing causes of functional decline (e.g., age, contralateral hip disease, and need for revision THA), a latent class mixed model approach was used to identify unobserved classes of patients who had similar outcomes. Linear, quadratic, and piecewise-polynomial growth models were considered for class identification. The best fitting model was determined based on Bayesian information criterion.

RESULTS

A four-class model of this patient population was identified: (1) the Elderly Class, who had a mean age of 62 years at the time of primary THA; (2) the Bilateral Class, who underwent simultaneous or staged bilateral THA; (3) the Revision Class, who required at least one revision; and (4) the Youngest Class, who had a mean age of 49 years. After an initial period of improvement in all groups, the functional trajectory diverged according to classifications. Age was the strongest determinant of long-term outcome, with HSS hip scores in the Elderly Class declining after about 20 years. The Youngest Class maintained good-to-excellent hip function for over 30 years. Revision THA and contralateral THA accounted for a temporary decline in function, after which overall good function was regained for the long term.

CONCLUSIONS

All classes in the study population enjoyed good-to-excellent outcomes after THA for about 20 years. Thereafter, functional decline was attributed more to aging than to the need for revision. One or more revision THA did not negatively influence long-term clinical outcomes, suggesting that, even for younger patients, symptoms, rather than the avoidance of possible revision, should be the primary determining factor when indicating THA.

Implant Survival and Patient-Reported Outcomes After Total Hip Arthroplasty in Young Patients

BACKGROUND

Younger patients are undergoing total hip arthroplasty (THA) for various conditions that affect the hip joint. This study evaluates the implant survival and long-term patient-reported outcomes of THA in patients aged 35 years or younger.

METHODS

Data were collected through a retrospective chart review, and follow-up surveys were conducted to determine implant survival and patient-reported outcomes. Kaplan-Meier survival analysis was performed to evaluate implant survival, and the hip disability and osteoarthritis outcome score (HOOS) was used to describe patient-reported outcomes. Descriptive statistics were used to summarize baseline and follow-up data, and univariate and multivariate analyses were used to compare implant survival and patient-reported outcomes.

RESULTS

This study included 400 patients (548 THAs). The average age at the time of surgery was 27 (range: 8-35) years, and the mean time to follow-up was 14 (range: 2-29.7) years. The 10- and 20-year implant survival was 87% and 61%, respectively. Implant survival differed based on primary diagnosis (P = .05), and it was significantly better in patients aged 25 years or older at the time of surgery, male patients, and patients with ceramic-on-ceramic or ceramic-on-plastic implants (P < .05). Mean HOOS scores at follow-up were 86 for pain, 84 for symptoms, 86 for ADLs, and 77 for sports. All HOOS scores were significantly worse after revision THA (P < .01).

CONCLUSION

Young patients have good implant survival and favorable long-term outcomes after THA. There are several predictors of implant survival and patient-reported outcomes after THA in young patients.

Resurfacing hemiarthroplasty of the shoulder for patients with juvenile idiopathic arthritis

BACKGROUND

This study reports the outcome of resurfacing hemiarthroplasty (RHA) in a cohort of patients with juvenile idiopathic arthritis (JIA) affecting the shoulder joint METHODS: Fourteen uncemented RHA procedures were performed for 11 consecutive patients who required surgery because of JIA. Mean age at surgery was 36.4 years. Mean clinical follow-up was 10.4 years (range, 5.8-13.9 years). A significant humeral head defect (up to 40% surface area) was found in 5 shoulders and filled with autograft from the distal clavicle or femoral head allograft.

RESULTS

At latest follow-up, no patient required revision. There was excellent relief from pain. The mean Oxford Shoulder Score and Constant-Murley Score improved significantly. No shoulder had a poor outcome, and 6 had a very good or excellent outcome. Worse outcome was associated with an intraoperative finding of significant humeral head erosion. Two shoulders required early arthroscopic subacromial decompression, but there were no other reoperations. There were no instances of radiographic implant loosening or proximal migration. Painless glenoid erosion was seen in 5 shoulders but was not associated with worse outcome.

CONCLUSIONS

The midterm results of RHA for JIA are at least comparable to those for stemmed hemiarthroplasty, with the added benefit of bone conservation.

Ten-year survivorship of primary total hip arthroplasty in patients 30 years of age or younger

Aims

For this retrospective cohort study, patients aged ≤ 30 years (very young) who underwent total hip arthroplasty (THA) were compared with patients aged ≥ 60 years (elderly) to evaluate the rate of revision arthroplasty, implant survival, the indications for revision, the complications, and the patient-reported outcomes.

Patients and Methods

We retrospectively reviewed all patients who underwent primary THA between January 2000 and May 2015 from our institutional database. A total of 145 very young and 1359 elderly patients were reviewed. The mean follow-up was 5.3 years (1 to 18). Logistic generalized estimating equations were used to compare characteristics and the revision rate. Survival was evaluated using Kaplan-Meier curves and hazard rates were created using Cox regression.

Results

The overall revision rate was 11% (16/145) in the very young and 3.83% (52/1359) in the elderly groups (odds ratio (OR) 2.58, 95% confidence interval (CI) 1.43 to 4.63). After adjusting for the American Society of Anesthesiologists (ASA) score, gender, and a history of previous surgery in a time-to-event model, the risk of revision remained greater in the very young (adjusted hazard ratio (HR) 2.48, 95% CI 1.34 to 4.58). Survival at ten years was 82% (95% CI, 71 to 89) in the very young and 96% (95% CI, 94 to 97) in the elderly group (p < 0.001). The very young had a higher rate of revision for complications related to metal-on-metal (MoM) bearing surfaces (p < 0.001). At last follow-up, the very young group had higher levels of physical function (p = 0.002), lower levels of mental health (p = 0.001), and similar levels of pain (p = 0.670) compared with their elderly counterparts.

Conclusion

The overall revision rate was greater in very young THA patients. This was largely explained by the use of MoM bearings. Young patients with non-MoM bearings had high survivorship with similar complication profiles to patients aged ≥ 60 years. Cite this article: Bone Joint J 2018;100-B:867-74.

Influence of Prior Hip Salvage Surgery on Outcomes After Total Hip Arthroplasty in Young Patients

BACKGROUND

As the indications for total hip arthroplasty (THA) have expanded, this procedure is being increasingly performed in young patients. Oftentimes, this population has undergone one or more salvage procedures in an attempt to delay or forestall a THA. However, it is unclear whether patients with prior salvage procedure have higher risk of adverse events.

METHODS

From 2004 to 2014, 215 THAs performed in patients less than 30 years at a single institution were identified. These patients were screened to identify 37 THAs in which one or more salvage procedures were performed prior to the THA (salvage group). The prior salvage procedures were open in 30 (pelvic osteotomy = 5, femoral osteotomy = 15, combined osteotomy = 2, core decompression = 7, bone graft = 1) and arthroscopic in 7. Medical and surgical complications within 90 days and overall survivorship at a minimum follow-up of 2 years were recorded. Nonparametric tests and Kaplan-Meier survival curves were used to compare the groups.

RESULTS

Salvage group had a higher rate of wound complications (P = .037), superficial infections (P = .005), and reoperations (P = .015). The 5-year survivorships in the salvage and nonsalvage groups were 97.1% and 96.7%, respectively (P = .787).

CONCLUSION

Patients less than 30 years who undergo THA after a previous salvage procedure have a higher risk of wound complications, superficial infections, and reoperations, but similar survivorship, compared to those who did not have any prior salvage procedures. This information is helpful in counseling young patients while offering various surgical options for the management of various hip pathologies.

Total hip arthroplasty in young patients with post-traumatic arthritis of the hip

BACKGROUND

Post-traumatic arthritis of the hip is a degenerative condition that commonly affects young patients. In this study, we evaluate long-term implant survival and patient-reported outcomes after primary total hip arthroplasty (THA) in patients aged 35 or younger with post-traumatic arthritis of the hip.

METHODS

We conducted a retrospective study with follow-up. A chart review was performed to identify young patients with post-traumatic arthritis of the hip treated with primary THA. Follow-up surveys were conducted to determine implant survival and patient-reported outcomes. Implant survival was assessed using Kaplan-Meier survival analysis, and patient outcomes were determined using the hip disability and osteoarthritis outcome score (HOOS).

RESULTS

We studied 42 patients (44 THAs) with a mean time to follow-up of 14 years. The 10-year implant survival rate was 87% and 20-year implant survival rate was 41%. Implant survival did not differ based on patient age, gender, implant type, bearing surface, or use of cement for implant fixation (p>0.05). The mean HOOS scores at follow-up were 87 for pain, 85 for symptoms, 89 for ADLs, and 76 for sports. HOOS scores were significantly worse in patients that had undergone revision THA (p<0.05).

CONCLUSIONS

Young patients with post-traumatic arthritis of the hip have good long-term outcomes after THA. However, revision THA is predictive of worse long-term outcomes.

Outcomes after total hip arthroplasty in young patients with osteonecrosis of the hip

BACKGROUND

Osteonecrosis of the hip is a clinical, radiographic, and pathologic entity that commonly affects young patients. This study evaluates long-term implant survival and patient-reported outcomes after primary total hip arthroplasty (THA) in patients with osteonecrosis aged 35 or younger.

METHODS

A retrospective study with prospective follow-up was conducted at a major academic medical center. Chart review was performed to identify young THA patients with osteonecrosis, and follow-up surveys were conducted to determine implant survival and patient-reported outcomes. Kaplan-Meier survival analysis was performed to evaluate implant survival, and the hip disability and osteoarthritis outcome score (HOOS) was used to describe patient-reported outcomes.

RESULTS

The study included 135 patients (204 THAs) with a mean time to follow-up of 14 years. In this group, 10-year implant survival was 86% and 20-year implant survival was 66%. Implant survival was longer in male patients (p = 0.02) and patients that were over the age of 25 at the time of surgery (p = 0.03). The mean HOOS scores at follow-up were 87 for pain, symptoms, and ADLs, and 77 for sports. All HOOS measures were lower in patients that underwent a revision THA, and HOOS-Pain and HOOS-Sport scores were lower in patients that were over the age of 25 at the time of surgery (p<0.05).

CONCLUSIONS

Young patients with osteonecrosis have good implant survival and long-term outcomes after THA. Patient factors and implant characteristics should be considered when predicting implant survival and outcomes after THA in young patients with osteonecrosis.

Implant survival and patient-reported outcomes after total hip arthroplasty in young patients with developmental dysplasia of the hip

BACKGROUND

Developmental dysplasia of the hip (DDH) is a common cause of hip pain in young patients, and may require treatment with total hip arthroplasty (THA). This study evaluates implant survival and describes patient-reported outcomes after primary THA in DDH patients aged 35 or younger.

METHODS

A retrospective study with prospective follow-up was conducted at a major academic medical centre. Patient charts were reviewed to identify young THA patients with DDH, and follow-up surveys were conducted to determine implant survival and patient-reported outcomes. Kaplan-Meier survival analysis was performed to evaluate implant survival, and the hip disability and osteoarthritis outcome score (HOOS) was used to describe patient-reported outcomes.

RESULTS

This study included 61 patients (75 THAs, 75% follow-up), and the mean time to follow-up was 13 years (range 3-25 years). The 10-year and 20-year implant survival was 87% (95% CI, 78%-94%) and 55% (95% CI, 37%-72%), respectively, and implant survival was significantly better in patients over the age of 25 at the time of surgery (p value &lt;0.01). The mean HOOS patient scores were 83 for pain (SD 20.29), 78 for symptoms (SD 19.72), 83 for ADLs (SD 20.89), and 74 for sports (SD 25.92). Patients that were younger at the time of surgery or required custom implants reported worse HOOS-Symptom scores at follow-up (p value = 0.02).

DISCUSSIONS

Young patients with DDH have good outcomes after surgery. Patient factors and implant characteristics should be considered when predicting implant survival and outcomes after THA in young patients with DDH.

Using Patient-Reported Outcome Measures to Capture the Patient's Voice in Research and Care of Juvenile Idiopathic Arthritis

Patient-reported outcome (PRO) measures provide a valuable window into how patients with juvenile idiopathic arthritis and their parents perceive their functioning, quality of life, and medication side effects in the context of their disease and treatment. Momentum behind adoption of PRO measures is increasing as these patient-relevant tools capture information pertinent to taking a patient-centered approach to health care and research. This article reviews the clinical and research utility of obtaining PROs across domains applicable to the experience of juvenile idiopathic arthritis and summarizes available self-report and parent-proxy PRO measures. Current challenges and limitations of PRO usage are discussed.