Low Reinfection Rates But a High Rate of Complications in THA for Infection Sequelae in Childhood: A Systematic Review

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.

Total hip arthroplasty in patients with common pediatric hip orthopedic pathology

Purpose

Literature regarding total hip arthroplasty for pediatric hip diseases is scarce. This review aims to portray the various orthopedic conditions of childhood that can lead to significant impairment of the hip joint and, ultimately, to total hip arthroplasty in adolescence and adulthood.

Methods

In total, 61 out of 3666 articles were selected according to (1) the diagnosis of one of the 12 pediatric hip pathologies (Legg-Perthes-Calvé disease, developmental dysplasia of the hip, slipped capital femoral epiphysis, neuromuscular hip dysplasia, post-traumatic avascular necrosis of the proximal femur, juvenile rheumatoid arthritis, achondroplasia, spondyloepiphyseal dysplasia, mucopolysaccharidosis, mucolipidosis, hip infections, and tumors) that required total hip arthroplasty; (2) minimum follow-up of 16 months; (3) assessed outcome with a clinical or radiologic score; (4) Methodological Items for Non-Randomized Studies quality score of 9 or higher. The following information for each pathology was retrieved: mean age at total hip arthroplasty, reason for total hip arthroplasty, type of total hip arthroplasty, surgical technique, mean follow-up, and outcomes.

Results

Overall, the mean age at total hip arthroplasty for pediatric hip disease is in the sixth and seventh decade, except for tumors and skeletal dysplasias. The reason for performing total hip arthroplasty is often osteoarthrosis and abnormal anatomy. Prosthesis types change based on patient's conditions and technological advances; custom-made implants are used for tumors, juvenile rheumatoid arthritis, and skeletal dysplasias; for other diseases, the most frequent are modular cementless implants. Outcomes are generally good, and all studies portray functional and pain improvements.

Conclusion

Total hip arthroplasty is performed more frequently than in the past in patients with pediatric hip pathologies; it enhances patients' quality of life by reducing pain and improving function. However, revision rate in these patients is not negligible.

Long-Term Follow-Up of Management of the Hypoplastic Femur With Femoral Episiotomy and Onlay Allograft During Total Hip Arthroplasty

BACKGROUND

To insert the regular-sized stem for a dysplastic femoral canal, controlled episiotomy of the femur can be performed. The purpose of this study is to determine the long-term (up to 19 years) results of total hip arthroplasties (THAs) using strut allografts combined with an episiotomy over an extensively porous-coated stem.

METHODS

We reviewed the results of 65 total hip arthroplasties in 63 patients (mean age 42.1 years; range 21-61) with dysplastic femur after childhood sepsis. The patients were treated using controlled episiotomy of the femur to widen the femoral canal, extensively porous-coated femoral stems, and cortical strut allografts because primary axial or rotational stability could not be achieved without grafting. The mean follow-up was 17.1 years (range 15-19).

RESULTS

The mean Harris Hip Score at the final follow-up was 85 ± 15 points (range 45-100). The mean Western Ontario and McMaster Universities Osteoarthritis Index score was 23 ± 15 points (range 13-53). The mean University of California, Los Angeles score was 6.3 points (range 5-8). A Kaplan-Meier survivorship analysis at 19 years of follow-up showed that the survival rate of the femoral components was 92% (95% confidence interval 89-98), and it was 88% (95% confidence interval 85-92) for the acetabular component with aseptic loosening or revision for any reason.

CONCLUSION

We found good results in terms of longevity and functional outcome using this technique. Future mechanical studies, in addition to controlled clinical studies, are warranted.

The benefits of systematic intraoperative sampling during lower limb arthroplasties due to sequelae from prior osteoarticular infections: A retrospective study of 92 cases

INTRODUCTION

Osteoarticular infections (OAIs) of native joints lead to cartilage damage which may require subsequent arthroplasty. There is no consensus on systematic intraoperative microbiological sampling when performing an arthroplasty on a native joint with a history of OAI. We carried out a retrospective study to: (1) identify the frequency of the persistence of the microorganism(s) involved during the initial, presumed cured OAI, when performing an arthroplasty for sequelae of osteoarthritis, (2) to find an association between the length of time between the OAI and arthroplasty, and the recurrence of bacterial infection, (3) to assess the influence of the presence of hardware on the risk of infectious recurrence.

HYPOTHESIS

Systematic sampling is justified during a subsequent arthroplasty after an OAI, even after a prolonged period.

MATERIAL AND METHOD

This single-center, retrospective descriptive study included all patients whose indication for arthroplasty resulted from osteoarthritis, osteitis or bacterial osteomyelitis of a native joint, or in the aftermath of an infection post osteosynthesis. All patients were considered to have recovered from the initial infection at the time of the arthroplasty. Between 2008 and 2019, 92 patients were included in the study, with an average age of 56.5years (range: 21-97years). OAI occurred at a mean age of 35years (range: 1-84years). The average time from OAI to implantation was 15years (range: 1-65years). The bacteria most frequently found in the initial OAI was Staphylococcus aureus, involved in 35.8% of cases (n=33/92).

RESULTS

The intraoperative samples came back positive in 17% of cases (n=16/92), including 9 positive for the same bacteria as the OAI (56%, n=9/16). For these 16 cases, the time between the OAI and the arthroplasty was 1year for 5 patients, between 1 and 15years for 5 patients and greater than 15years for 6 patients. For 3 positive patients, the information on the initial microorganism was not known and 4 patients were positive for a bacterium different from the initial one. The time from the initial OAI to the arthroplasty was not associated with positive results (p=0.38). There was no significant difference between a positive culture at the time of arthroplasty and the initial type of OAI [native joint versus presence of hardware and/or open fracture (p=0.41)].

CONCLUSION

The results of this work suggest there is value in microbiological sampling when performing an arthroplasty on a previously infected joint, regardless of the duration of the infection.

LEVEL OF EVIDENCE

IV; retrospective study.

Clinical outcome in total hip arthroplasty for septic sequelae in childhood

Aims

Adult patients with history of childhood infection pose a surgical challenge for total hip arthroplasty (THA) due to distorted bony anatomy, soft-tissue contractures, risk of reinfection, and relatively younger age. Therefore, the purpose of the present study was to determine clinical outcome, reinfection rate, and complications in patients with septic sequelae after THA.

Methods

A retrospective analysis was conducted of 91 cementless THAs (57 male and 34 female) performed between 2008 and 2017 in patients who had history of hip infection during childhood. Clinical outcome was measured using Harris Hip Score (HHS) and Modified Merle d’Aubigne and Postel (MAP) score, and quality of life (QOL) using 12-Item Short Form Health Survey Questionnaire (SF-12) components: Physical Component Score (PCS) and Mental Component Score (MCS); limb length discrepancy (LLD) and radiological assessment of the prosthesis was performed at the latest follow-up. Reinfection and revision surgery after THA for any reason was documented.

Results

There was significant improvement in HHS, Modified Merle d’Aubigne Postel hip score, and QOL index SF 12-PCS and MCS (p < 0.001) and there was no case of reinfection reported during the follow-up. The minimum follow-up for the study was three years with a mean of 6.5 (SD 2.3; 3 to 12). LLD decreased from a mean of 3.3 cm (SD 1) to 0.9 cm (SD 0.8) during follow-up. One patient required revision surgery for femoral component loosening. Kaplan-Meier survival analysis estimated revision-free survivorship of 100% at the end of five years and 96.9% (95% confidence interval 79.8 to 99.6) at the end of ten years.

Conclusion

We found that cementless THA results in good to excellent functional outcomes in patients with a prior history of childhood infection. There is an exceedingly low rate of risk of reinfection in these patients, even though complications are not uncommon. Cite this article: Bone Jt Open 2022;3(4):314–320.

Outcomes of primary total hip arthroplasty following septic arthritis of the hip : a case-control study

AIMS

Septic arthritis of the hip often leads to irreversible osteoarthritis (OA) and the requirement for total hip arthroplasty (THA). The aim of this study was to report the mid-term risk of any infection, periprosthetic joint infection (PJI), aseptic revision, and reoperation in patients with a past history of septic arthritis who underwent THA, compared with a control group of patients who underwent THA for OA.

METHODS

We retrospectively identified 256 THAs in 244 patients following septic arthritis of the native hip, which were undertaken between 1969 and 2016 at a single institution. Each case was matched 1:1, based on age, sex, BMI, and year of surgery, to a primary THA performed for OA. The mean age and BMI were 58 years (35 to 84) and 31 kg/m² (18 to 48), respectively, and 100 (39%) were female. The mean follow-up was 11 years (2 to 39).

RESULTS

The ten-year survival free of any infection was 91% and 99% in the septic arthritis and OA groups, respectively (hazard ratio (HR) = 13; p < 0.001). The survival free of PJI at ten years was 93% and 99% in the septic arthritis and OA groups, respectively (HR = 10; p = 0.002). There was a significantly higher rate of any infection at ten years when THA was undertaken within five years of the diagnosis of septic arthritis compared with those in whom THA was undertaken > five years after this diagnosis was made (14% vs 5%, respectively; HR = 3.1; p = 0.009), but there was no significant difference in ten-year survival free of aseptic revision (HR = 1.14; p = 0.485). The mean Harris Hip Scores at two and five years postoperatively were significantly lower in the septic arthritis group compared with the OA group (p = 0.001 for both).

CONCLUSION

There was a ten-fold increased risk of PJI in patients with a history of septic arthritis who underwent THA compared with those who underwent THA for OA with a ten-year cumulative incidence of 7%. The risk of any infection had a strong downward trend as the time interval between the diagnosis of septic arthritis and THA increased, highlighted by a 3.1-fold higher risk when THAs were performed within five years of the diagnosis being made. Cite this article: Bone Joint J 2022;104-B(2):227-234.