Mid- to long-term outcome of cementless total hip arthroplasty in younger patients

Analysis on association between sagittal stem alignment and early functional and radiological outcome following primary cementless total hip replacement

INTRODUCTION

Accurate reconstruction of hip anatomy and biomechanics is mandatory for achieving good clinical outcomes following total hip replacement (THR). Optimal stem alignment is essential to avoid impingement or loosening. This study aimed to evaluate sagittal stem position following cementless THR and its relationship with patient's functional outcome and post-operative radiological parameters.

METHOD

We performed analytical observational study with cross-sectional design on 71 hips (67 patients, ranged 18-85 years old) that underwent primary cementless THR in two orthopedic centers in Jakarta, Indonesia. All hips were operated through either anterolateral or posterior approach using either extended/full-coating wedge-tapered stem or proximal-coated wedge-tapered stem. Clinical outcomes were evaluated at follow-up time using mHHS questionnaire, VAS level of thigh pain, and hip ROM. Stem sagittal alignment and other radiological parameters, including combined anteversion and offset, were measured from conventional radiograph.

RESULTS

There were no significant differences on mHHS score, VAS level on thigh pain, and ROM between stem alignment groups. Post-operative anteversion and offset of the implant were not affected by the stem sagittal position. All influencing factors have significant effect on sagittal stem alignment. Linear regression test on femur morphology showed 0.69° increase in stem posterior tilt for every 1° increase in the anterior bowing (coeff. = 0.502).

CONCLUSION

Stem tilting in sagittal plane did not affect patient's functional outcome or post-operative radiological parameters. In addition, for every degree of increased anterior femoral bowing, 0.69° increase in posterior stem tilting can be expected.

Revision rate of THA in patients younger than 40 years depends on primary diagnosis - a retrospective analysis with a minimum follow-up of 10 years

Background

Treating osteoarthritis in elderly patients with THA is very successful. However, surgeons hesitate to recommend THA in younger patients. The spectrum of etiologies for end stage hip disease in the younger population is diverse and therefore different courses may be assumed. Our objective was to evaluate THA revision rate within a minimum follow-up period of 10 years in young patients and to analyze the difference between different primary diagnoses.

Methods

We included 144 consecutive hips in 127 patients younger than 40 years, who received a primary THA from 01/1996 to 12/2007. Operative reports, clinical and radiographic documentation were reviewed to determine primary diagnosis, prior hip surgery, component specifications and revision surgery. 111 hips in 97 patients were available for outcome analysis with a minimum follow-up of 10 years.

Results

The mean age was 33 years (range 15–40 years) at the time of the index THA, 68 patients were female and 59 were male. Ten years revision rate on the prosthetic components was 13%. The most common primary diagnosis was DDH. DDH was associated with a risk of 17% for requiring a reoperation on the prosthetic components because of mechanical fatigue and therefore, significantly higher than for any other primary diagnosis (p = 0.005).

Conclusion

THA in young patients is associated with a high revision rate of 13% in 10 years. 17% of patients with DDH required revision surgery for mechanical fatigue within 10 years, which was significantly higher than for any other primary diagnosis (1.2%, OR 16.8).

Early results of a high friction surface coated uncemented socket in revision hip arthroplasty

BACKGROUND

Revision hip arthroplasty with high friction trabecular metal sockets has resulted in good medium-term results. Many manufacturers have therefore introduced higher friction coatings to their implants to meet a growing demand for similar implants. The Pinnacle Gription was introduced in 2007 as an evolution of the standard Pinnacle socket. This study aimed to assess the early results of this socket in a revision setting.

METHODS

Between August 2009 and December 2016, the Gription socket was used in 146 revision hip replacements. The mean age was 63 (19-88) years. Defects were classified as Paprosky Grade 2 in 71(2A [28], 2B [19], 2C [24]) and grade 3 in 20 (3A [18], 3B [2]). Bearing combinations were ceramic-on-ceramic in 23, metal-on-polyethylene in 71, ceramic-on-polyethylene in 52. Screws were used in 112 cases, impaction bone grafting in 34 and metal augments in 1 case. Radiographs were analysed for progressive radiolucent lines and migration.

RESULTS

Mean follow-up was 43.5 (range 25-62) months. There were 6 re-revisions (2 for deep infection, 2 for recurrent dislocation and 2 for aseptic loosening). None of the other cases had evidence of socket migration or progressive radiolucent lines. There were no intraoperative or postoperative periprosthetic fractures. The crude survivorship for all-cause failure was 95.8% and the survivorship for aseptic loosening was 98.6%. at 43.5 months follow-up.

CONCLUSIONS

This is the largest reported series of Gription socket use in revision arthroplasty and demonstrates encouraging early results. We therefore advocate the continued cautious use of this implant.

Bilaterally Primary Cementless Total Hip Arthroplasty for Severe Hip Ankylosis with Ankylosing Spondylitis

OBJECTIVES

Total hip arthroplasty is a reliable therapeutic intervention in patients with ankylosing spondylitis, in whom the aims of surgery are to reduce pain, restore hip function and improve quality of life. The current study is a retrospective analysis of the clinical and radiographic findings in a consecutive series of patients with hip ankylosis associated with severe ankylosing spondylitis who underwent bilateral primary total hip arthroplasty using non-cemented components.

METHODS

From June 2008 to May 2012, total hip arthroplasty was performed on 34 hips in 17 patients with bilateral ankylosis caused by ankylosing spondylitis. The study patients included 13 men and 4 women with a mean age of 24.2 years. The mean duration of disease was 8.3 years and the average duration of hip involvement was 7.6 years. All patients had severe hip pain and dysfunction with bilateral bony ankylosis and no range of motion preoperatively and all underwent bilateral cementless total hip arthroplasty performed by a single surgeon. Joint pain, range of motion (ROM), and Harris hip scores were assessed to evaluate the postoperative results.

RESULTS

At a mean follow-up of 31.7 months, all patients had experienced significant clinical improvement in function, ROM, posture and ambulation. At the final follow-up, the mean postoperative flexion ROM was 134.4° compared with 0° preoperatively. Similar improvements were seen in hip abduction, adduction, internal rotation and external rotation. Postoperatively, 23 hips were completely pain-free, six had only occasional discomfort, three mild to moderate pain and two severe pain. The average Harris Hip Score improved from 23.7 preoperatively to 65.8 postoperatively. No stems had loosened at the final follow-up in any patient, nor had any revision surgery been required.

CONCLUSIONS

Bilateral severe hip ankylosis in patients with ankylosing spondylitis can be treated with cementless bilateral synchronous total hip arthroplasty, which can greatly improve hip joint function and relieve pain without significant complications. Provided the overall physical condition of a patient and their economic situation make surgery a feasible option and the surgeon is experienced, this treatment is a worthwhile surgical intervention for bilateral hip bony ankylosis. However, the technically demanding nature of the procedure and potential pre- and post-operative problems should not be underestimated.

Dual-mobility cup in total hip arthroplasty in patients less than fifty five years and over ten years of follow-up : A prospective and comparative series

PURPOSE

We report clinical and radiological outcome of a dual mobility cup (DMC) of 2nd generation after a minimum of ten year-follow-up (FU). The goal of this work was to compare the results of this DMC in patients aged less than 55 years and in patients aged more than 55 years.

METHODS

From 2000 to 2005, a prospective and consecutive series of 119 THAs with a cementless DMC of 2nd generation (GIROS) were performed in patients aged less than 55 years and 444 in patients aged more than 55 years.

RESULTS

The mean FU was 11 years (8 to 15 years). Survivorships (failure of both components or cup loosening) were not different between patients aged less than 55 years and patients aged more than 55 years. There was no dislocation. DEVANE classification, Harris, PMA and Oxford scores improved after THA but no difference could be found between between < 55 years and > 55 years patients.

CONCLUSION

These results are better than those of first generation (BOUSQUET) DMC (77 % of survival rate at 20 years of FU). These results are in the same agreement than those of the literature: 99 % of survival rate at 14.2 years of FU for KERBOULL with a low friction arthroplasty and 96.5 % at ten years of FU for ceramic/ceramic bearing (R CHANA). The DMC for young patient is a relevant surgical option with no dislocation and excellent clinical results and survival rate at more than ten years of FU.

Total Hip Arthroplasty With an Uncemented Tapered Femoral Component in Patients Younger Than 50 Years of Age: A Minimum 20-Year Follow-Up Study

BACKGROUND

Previously, we reported the mean 16-year results of primary uncemented total hip arthroplasty using a tapered femoral component in patients <50 years. The purpose of this study was to update our previous report using the Taperloc femoral component in young patients who had been followed for a minimum of 20 years postoperatively.

METHODS

Between 1983 and 1990, 108 consecutive uncemented total hip arthroplasties were performed in 91 patients of age <50 years, with use of the Taperloc femoral component. Every patient was followed for a minimum of 20 years after surgery or until death. At a mean of 25 (range, 20-29 years) postoperatively, 76 patients (91 hips) were living. The Harris Hip Score, radiographic results, complications, and Kaplan-Meier survivorship were evaluated.

RESULTS

In the entire cohort of 108 hips, 9 femoral components (8%) have been revised, none for aseptic loosening. Five well-fixed stems were removed during acetabular revision, 3 stems were revised for infection, and 1 stem was exchanged because of a peroneal nerve palsy. Distal femoral osteolysis was identified around 1 hip. With failure defined as stem removal for any reason, implant survival was 90% (CI = 82-95) at 29 years. With failure defined as stem removal for aseptic loosening, implant survival was 100% at 29 years.

CONCLUSION

Primary total hip arthroplasty with the Taperloc femoral component in young patients was associated with a high rate of survival at 29 years.

Thirteen year follow-up of a cementless femoral stem and a threaded acetabular cup in patients younger than fifty years of age

PURPOSE

Compared to older patients undergoing total hip arthroplasty (THA) younger patients are considered to be more active, thereby exposing the implant to significantly higher loads over a much longer period of time. Additionally, cases of secondary osteoarthritis caused by hip dysplasia, femoral head necrosis or rheumatic diseases are much more frequent than among the average patient population. Therefore, durable implant fixation and low wear rates are extremely important to achieve good long-term implant survival in this group of patients.

OBJECTIVE

The aim of this retrospective study was to evaluate the mid- to long-term survival of a cementless femoral stem (Zweymüller® SL stem) and a threaded cup (Bicon SL®) in patients younger than 50 years of age.

METHODS

Therefore, a consecutive series of 100 patients (111 hips) aged 50 years or younger (range: 30 to 50 years) was analysed at a mean follow up of 13.5 years. Follow-up assessment included physical examination and radiographic workup. Hip disability osteoarthritis and outcome score (HOOS) and Harris hip score (HHS) were used to evaluate the pre- and post-operative functional outcome, respectively. Patient satisfaction with the surgical result was assessed by standardized questionnaires.

RESULTS

The overall survival rate with any revision as endpoint was 96.8 % (95 % CI: 90.5 % to 98.9 %) at ten years. Gender, operation time and the occurence of osteolyses had no influence on joint function or patient satisfaction. We recorded an overall failure rate of 7.4 % (six cases). In four cases (5 %) the prosthesis had to be revised due to aseptic loosening of the cup after 12 years, eight years, 12 years and 11 years, in one case (1.2 %) recurrent luxation led to a revision operation (acetabular cup and head) after three years of primary implantation. In one case an implant failure was recorded (acetabular cup breakage after eight years of implantation). We recorded the occurence of asymptomatic radiolucent lines of the cup in 21 % and of the stem in 35 % in our series. The HOOS was influenced by the presence or abscence of radiolucent lines of the stem. Patients with radiolucent lines of the stem had a median HOOS score of (74 points) compared to those without radiolucent lines (89 points). Other factors, such as "diagnosis led to operation" and "previous operations" had no influence on the HHS and HOOS.

CONCLUSION

Our study demonstrates excellent long-term survival of cementless femoral stem in combination with a threaded cup in young patients undergoing total hip arthroplasty.

A technique for decision-making in cementless femoral revision hip arthroplasty

Classification systems for femoral revision of a failed THA fail to address several of the more critical determinants. The aim of the present study was to assess the reliability of a simplified algorithm for decision making during cementless reconstruction for femoral loosening with respect to stem length, stem design and the need for an extended trochanteric osteotomy. Four observers with different levels of clinical experience blindly assessed 40 X-rays of hips scheduled for a femoral revision. Intra-observer and inter-observer reliability of 4 radiographic criteria were assessed: 1) diaphyseal bone loss extension to the isthmus; 2) proximal femoral remodelling; 3) presence of cement; and 4) cortical thickness. Inter-observer agreement relating to the four criteria was good (κ = 0.66) for the extension to isthmus, moderate (κ = 0.57) for proximal femoral remodelling and very good for presence of cement (κ = 1) and cortical thickness (κ = 0.88). Intra-observer agreement was good for extension to isthmus and proximal femoral remodelling and very good for presence of cement and cortical thickness. Based on these criteria, an algorithm has been developed to describe 4 reconstruction options. The algorithm seems reliable for decision making during femoral cementless revision, but research into comparison with intraoperative findings is still required.

LEVEL OF EVIDENCE

Level II, Development of diagnostic criteria on consecutive patients.

Hip resurfacing versus total hip arthroplasty: a systematic review comparing standardized outcomes

BACKGROUND

Metal-on-metal hip resurfacing was developed for younger, active patients as an alternative to THA, but it remains controversial. Study heterogeneity, inconsistent outcome definitions, and unstandardized outcome measures challenge our ability to compare arthroplasty outcomes studies.

QUESTIONS/PURPOSES

We asked how early revisions or reoperations (within 5 years of surgery) and overall revisions, adverse events, and postoperative component malalignment compare among studies of metal-on-metal hip resurfacing with THA among patients with hip osteoarthritis. Secondarily, we compared the revision frequency identified in the systematic review with revisions reported in four major joint replacement registries.

METHODS

We conducted a systematic review of English language studies published after 1996. Adverse events of interest included rates of early failure, time to revision, revision, reoperation, dislocation, infection/sepsis, femoral neck fracture, mortality, and postoperative component alignment. Revision rates were compared with those from four national joint replacement registries. Results were reported as adverse event rates per 1000 person-years stratified by device market status (in use and discontinued). Comparisons between event rates of metal-on-metal hip resurfacing and THA are made using a quasilikelihood generalized linear model. We identified 7421 abstracts, screened and reviewed 384 full-text articles, and included 236. The most common study designs were prospective cohort studies (46.6%; n = 110) and retrospective studies (36%; n = 85). Few randomized controlled trials were included (7.2%; n = 17).

RESULTS

The average time to revision was 3.0 years for metal-on-metal hip resurfacing (95% CI, 2.95-3.1) versus 7.8 for THA (95% CI, 7.2-8.3). For all devices, revisions and reoperations were more frequent with metal-on-metal hip resurfacing than THA based on point estimates and CIs: 10.7 (95% CI, 10.1-11.3) versus 7.1 (95% CI, 6.7-7.6; p = 0.068), and 7.9 (95% CI, 5.4-11.3) versus 1.8 (95% CI, 1.3-2.2; p = 0.084) per 1000 person-years, respectively. This difference was consistent with three of four national joint replacement registries, but overall national joint replacement registries revision rates were lower than those reported in the literature. Dislocations were more frequent with THA than metal-on-metal hip resurfacing: 4.4 (95% CI, 4.2-4.6) versus 0.9 (95% CI, 0.6-1.2; p = 0.008) per 1000 person-years, respectively. Adverse event rates change when discontinued devices were included.

CONCLUSIONS

Revisions and reoperations are more frequent and occur earlier with metal-on-metal hip resurfacing, except when discontinued devices are removed from the analyses. Results from the literature may be misleading without consistent definitions, standardized outcome metrics, and accounting for device market status. This is important when clinicians are assessing and communicating patient risk and when selecting which device is most appropriate for individual patients.