Early to medium-term outcomes of uncemented ceramic-bearing total hip arthroplasty in teenagers for paediatric hip conditions

An in-depth analysis of young adults with osteonecrosis secondary to developmental dysplasia of the hip who underwent total hip arthroplasty

BACKGROUND

Patients with osteonecrosis of the femoral head secondary to DDH frequently require total hip arthroplasty (THA), but it is not well understood which factors necessitate this requirement. We determined the incidence of THA in patients who have osteonecrosis secondary to DDH and factors associated with need for THA.

METHODS

We included patients who received closed or open reductions between 1995 and 2005 with subsequent development of osteonecrosis. We determined osteonecrosis according to Bucholz and Ogden; osteoarthritis severity (Kellgren-Lawrence), subluxation (Shenton's line); neck-shaft angle; and acetabular dysplasia (centre-edge and Sharp angles). We also recorded the number of operations of the hip in childhood and reviewed case notes of patients who received THA to describe clinical findings prior to THA. We assessed the association between radiographic variables and the need for THA using univariate logistic regression.

RESULTS

Of 140 patients (169 hips), 22 patients received 24 THA (14%) at a mean age of 21.3 ± 3.7 years. Associated with the need for THA were grade III osteonecrosis (OR 4.25; 95% CI 1.70-10.77; p = 0.0019), grade IV osteoarthritis (21.8; 7.55-68.11; p < 0.0001) and subluxation (8.22; 2.91-29.53; p = 0.0003). All patients who required THA reported at least 2 of: severe pain including at night, stiffness, and reduced mobility. Acetabular dysplasia and number of previous operations were not associated with the need for THA.

CONCLUSIONS

We identified a 14% incidence of THA by age 34 years in patients with osteonecrosis secondary to DDH. Grade III osteonecrosis (global involvement femoral head and neck) was strongly associated with THA, emphasising the importance to avoid osteonecrosis when treating DDH.

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.

Bilateral Acrylic Hip Mold Arthroplasty in a Child With a Revision 60 years After Implantation: Clinical Case and Chemical Analysis of Endoprosthetic Material

A 68-year-old man was referred due to bilateral hip pain and gradual deterioration of walking. He had mold arthroplasties on both hips at the age of 7 years and has been functioning well for more than 5 decades. However, the original data on operative report and the prostheses were missing. The radiological examination revealed bilateral broken prosthetic material. Thus, stage bilateral revision total hip arthroplasty was performed. A detailed chemical analysis of retrieved mold arthroplasty implants proved that the acrylic material was noted to be the same composition with the difference in appearance likely being related to different thermal treatments originally applied to the implants. As presented in our clinical case, even obsolete implants may have good survivorship. According to the case presented, total hip arthroplasty could be considered an effective option with the desired functional outcome when conservative and joint-preserving measures are exhausted.

Total hip arthroplasty in adolescents: a systematic review and meta-analysis

PURPOSE

Total hip arthroplasty (THA) has demonstrated excellent results in elderly patients, however, the indications, outcomes, and long-term results in adolescent patients are less understood. This study aims to assess the outcomes of THA in patients under 21, providing insights for clinical decision-making in this exceptional population.

METHODS

A systematic review in PubMed, Ovid MEDLINE, and Embase database was performed. We included studies reporting clinical, radiological, and functional outcomes of THA in patients younger than 21 years, for any cause, with a with a minimum follow-up of one year. The ten year survivorship estimate was pooled using a meta-analysis methodology and each study was weighted according to its standard error, calculated from published confidence intervals.

RESULTS

We included 25 studies involving 1166 hips. Median age was 17 years old, 60% were females, and the average follow-up was 8.1 years. Juvenile inflammatory arthritis was the main indication for total hip arthroplasty (THA). The all-cause revision rate was 14.4% and aseptic loosening was the most common cause. Only eight studies reported ten year survival rates and form the pooled analysis an 84.91% survival rate (95% CI 70.56 - 99.27) was obtained. An average score of 88.08 in the Harris Hip Score (HHS) was observed. We found a 3.43% complication rate.

CONCLUSIONS

Hip arthroplasty is an acceptable option for adolescents with end-stage arthritis. However, the altered hip anatomy, the elevated revision rate, and the long-term implant survival must be considered before performing a THA in adolescent patients.

The Minimum 5-Year Follow up of a Highly Versatile Distally Anchored Femoral Revision System With Hydroxyapatite Coating

Background

Total hip arthroplasty is one of the most successful operations medicine can offer. As more patients undergo total hip arthroplasty the revision burden increases proportionately. This is a cohort study of the Arcos Modular Femoral Revision System.

Methods

The primary outcome was rerevision of the femoral component. Secondary outcomes include complications and radiological and clinical outcomes over 5 years.

Results

A total of 74 patients were recruited, and the femoral survival rate was 100% at 5 years with 12 censorships. A total of 31 patients were given Proprosky 3/4 preoperatively. Eleven patients underwent further procedures; however, no femoral components were revised. Kaplan-Meier analysis was performed by a biostatistician. Patients demonstrated a consistent and sustained improvement in Harris hip score, Oxford hip score, and EQ-5D. Radiological review revealed minimal and stable lysis around the femoral components.

Conculsion

The ARCOS Modular Femoral Revision System was designed to offer a range of options to allow femoral bone stock preservation and avoiding conversion to an endoprosthetic and seems to be effective in the medium term.

Can Patients Who Have Low-Grade Hip Osteoarthritis Expect the Same Outcome After Total Hip Arthroplasty Compared to Those Who Have End-Stage Osteoarthritis? - A Matched Case-Control Study

BACKGROUND

Total hip arthroplasty (THA) is an effective procedure for patients with end-stage hip osteoarthritis (OA). In addition, when hip preservation surgery is no longer indicated due to the presence of early or mild arthritic changes, THA can also be considered. Whether these patients can expect the same outcome after THA as patients who have end-stage OA remains unclear. The goal of this study was to compare the clinical outcomes after THA of patients who have low-grade OA versus a matched cohort with end-stage OA.

METHODS

This is a retrospective, single-center, multisurgeon case-control study in a high-volume referral center. Based on a cohort of 2,189 primary anterior approach THAs (1,815 patients), 50 low-grade OA cases were matched 1:1 by age, sex, and body mass index to 50 controls who have end-stage OA. Patient-reported outcome measures (PROMs) were Hip Disability and Osteoarthritis Outcome Scores and Short Form-36.

RESULTS

No significant differences in preoperative PROMs between low-grade and end-stage OA patients were found, except for 36-item Short Form Survey pain (33.0 versus 41.0; P = .045). In both groups a significant improvement of all PROMs was found postoperatively. However, all Hip Disability and Osteoarthritis Outcome Scores were significantly lower in the low-grade OA group compared to the end-stage OA group. In the group with low-grade OA, a significantly lower percentage of patients achieved the minimal clinically important difference and substantial clinical benefit after THA compared to the group with end-stage OA.

CONCLUSIONS

Patients who have low-grade OA can expect substantial clinical improvement after THA. However, the improvement is lower compared to patients who have end-stage OA. A thorough understanding of the factors that may lead to inferior clinical outcomes is imperative to improving the indications for THA in individuals who have low-grade OA.

Total Hip Arthroplasty in Teenagers: A Systematic Literature Review

BACKGROUND

Total hip arthroplasty (THA) in teenagers is generally avoided. Nevertheless, recent THA procedures in a very young patient show improved functional outcomes and implant survival, resulting in lower revision rates. This review aims to present an overview of the available literature on THA in teenagers and to provide evidence to inform caregivers.

METHODS

In this systematic review, studies required a primary THA method and a teenage patient population. Studies must report at least one of the following outcome measures: functional outcomes, implant survival, and complications. In addition, demographic and surgical data were collected.

RESULTS

Sixteen studies were analyzed, including 2040 patients and 2379 hips, with an average 7.7-year follow-up. The mean patient age was 18 years, with an average revision rate of 11.7%. The overall average relative improvement of the 2 most frequently used patient-reported (functional) outcome measures were 84.3 and 92.3% at the latest follow-up. Prosthesis, or liner loosening, was the cause of revision in 50.2% of the cases. Loosening was the most frequent complication (14.8%), together with prosthesis/liner wear (14.8%). Cementless fixation (70.7%), ceramic-on-ceramic articulation (34.7%), and the posterior surgical approach (82.3%) were the most applied techniques.

CONCLUSIONS

The functional outcomes after THA in teenagers improved at follow-up. The average revision rate is relatively high, especially in the pre-1995 studies, with post-1995 studies reporting similar revision rates to the adult patient group. Research to further improve implant survival as well as the ease of revisions in teenagers is needed.

LEVEL OF EVIDENCE

Level III-systematic review.

Hip Resurfacing in Teenagers

BACKGROUND

The goals of hip resurfacing are to relieve pain, restore function, and preserve future reconstructive options. Hip resurfacing is an attractive and sometimes the only option when the femoral canal is blocked, making total hip arthroplasty (THA) difficult. Hip resurfacing also can be an attractive option for a teenager on the rare occasion when a hip implant is needed.

METHODS

A cementless ceramic-coated femoral resurfacing implant matched with a highly cross-linked polyethylene acetabular bearing was used in 105 patients (117 hips) aged 12 to 19 years. The mean follow-up was 14 years (range, 5 to 25). No patients were lost to follow-up before 19 years. Osteonecrosis, residuals of trauma, developmental dysplasia, and childhood hip diseases were the common reasons requiring surgery. Patients were evaluated using patient-reported outcomes, patient acceptable symptom states (PASS), and implant survivorships. Radiographs and retrievals were also examined.

RESULTS

There were 2 revisions (polyethylene liner exchange at 12 years and femoral revision for osteonecrosis at 14 years). The mean postoperative Hip Disability Osteoarthritis Outcome Score (HOOS) was 94 points (range, 80 to 100) and the mean Harris Hip Score (HHS) score was 96 points (range, 80 to 100). All patients achieved Minimal Clinically Important Difference improvement in their HHS and HOOS scores. There were 99 (85%) hip resurfacing procedures achieving a satisfactory PASS and 72 (69%) patients were active in sports.

CONCLUSION

Hip resurfacing is a highly technical procedure. Careful implant selection is required. The meticulous preoperative planning, careful extensile surgical exposure, and exacting implant placement in this study likely contributed to the favorable results achieved. Hip resurfacing allows THA as a future option in patients where the lifetime revision rate is a major consideration.

Functional and Patient-related Outcomes of Total Hip Arthroplasty in Patients Younger Than 20 Years

Background

Total hip arthroplasty (THA) in adolescent and young adults represent only about 10% of all THAs. Despite the advances in hip conservation surgery, there are still adolescents and young adults who progress to severe joint degeneration. THA seems to be the last solution in these cases. We aimed to assess the clinical and patient-related outcomes at short-term to midterm follow-up for THAs performed before the age of 20 years.

Material and methods

We performed a retrospective monocentric study including all patients that underwent a THA before the age of 20 years between January 2008 and December 2018 at our tertiary orthopaedic center with a minimum follow-up of 2 years. Demographic data were recorded. The Harris and Oxford hip scores were used to assess clinical and patient-related outcomes.

Results

A total of 11 patients (12 THAs) were included. Juvenile inflammatory arthritis and avascular necrosis due to slipped capital femoral epiphysis were the most commonly encountered etiologies. The mean age at surgery was 16 years (minimum 13, maximum 19 years). The mean follow-up duration was 6 years (minimum 2, maximum 9 years) without any revision. Regarding the Harris and Oxford hip scores, the mean score were 81 and 39.5 for clinical and patient-related outcomes respectively. The Spearman correlation test revealed a statistically significant positive correlation between the 2 scores of ρ = 0.811 with a P value < .001.

Conclusions

THA in adolescents and young adults suffering from end-stage osteoarthritis due to pediatric hip disorders provides improved hip function and notable pain relief at short-term to midterm follow-up.

Outcome measures and survivorship following total hip arthroplasty in adolescent population

BACKGROUND

The most frequent indication for total hip arthroplasty (THA) in adolescent patients has been juvenile idiopathic arthritis (JIA). However, in recent years, other causes have become more prevalent.

QUESTIONS/PURPOSES

(1) What is the survivorship following THA across the diagnostic spectrum in adolescent population? (2) How are quality of life results affected by systemic medical conditions?

METHODS

We retrospectively reviewed all consecutive THA in patients under 21 years of age, performed at our Institution between 1993 and 2018. There were 34 prostheses implanted in 26 patients with a mean age of 18.4 years (range 11 to 21). The most frequent diagnosis was JIA (14 hips), followed by avascular necrosis (10 hips). Patient reported outcomes were assessed using Harris and Oxford Hip Scores (HHS and OHS), Visual Analogue Scale (VAS) and EuroQol-5D. Survivorship for revision and aseptic loosening was determined with Kaplan Meier analysis.

RESULTS

At final follow-up, the overall survival rate was of 89.3% at 12-year follow-up. Three acetabular components underwent revision surgery for aseptic loosening. Clinical HHS significantly improved from 37.5 to 90.6 points (p < 0.001). Mean OHH was 37.4 points, with a final VAS of 1.64 points. Mean 5Q-5D was 0.704 with an interquartile range of 0.4 to 1.0. JIA patients displayed worse pre-operative HHS scores, and at final follow-up had worse HHS, OHS, VAS and EQ-5D scores compared to the rest of the patients. Complications included three intra-operative femoral fractures, one sciatic nerve palsy and one adductor contracture.

CONCLUSION

THA in adolescent patients provides improved functional outcomes with acceptable revision rates at mid-term follow-up.

Leg length discrepancy in patients with Perthes' disease : a note of caution for the arthroplasty surgeon

AIMS

Perthes' disease (PD) often results in femoral head deformity and leg length discrepancy (LLD). Our objective was to analyze femoral morphology in PD patients at skeletal maturity to assess where the LLD originates, and evaluate the effect of contralateral epiphysiodesis for length equalization on proximal and subtrochanteric femoral lengths.

METHODS

All patients treated for PD in our institution between January 2013 and June 2020 were reviewed retrospectively. Patients with unilateral PD, LLD of ≥ 5 mm, and long-leg standing radiographs at skeletal maturity were included. Total leg length, femoral and tibial length, articulotrochanteric distance (ATD), and subtrochanteric femoral length were compared between PD side and the unaffected side. Furthermore, we compared leg length measurements between patients who did and who did not have a contralateral epiphysiodesis.

RESULTS

Overall, 79 patients were included, of whom 21 underwent contralateral epiphysiodesis for leg length correction. In the complete cohort, the mean LLD was 1.8 cm (95% confidence interval (CI) 1.5 to 2.0), mean ATD difference was 1.8 cm (95% CI -2.1 to -1.9), and mean subtrochanteric difference was -0.2 cm (95% CI -0.4 to 0.1). In the epiphysiodesis group, the mean LLD before epiphysiodesis was 2.7 cm (95% CI 1.3 to 3.4) and 1.3 cm (95% CI -0.5 to 3.8) at skeletal maturity. In the nonepiphysiodesis group the mean LLD was 2.0 cm (95% CI 0.5 to 5.1; p = 0.016). The subtrochanteric region on the PD side was significantly longer at skeletal maturity in the epiphysiodesis group compared to the nonepiphysiodesis group (-1.0 cm (95% CI -2.4 to 0.6) vs 0.1 cm (95% CI -1.0 to 2.1); p < 0.001).

CONCLUSION

This study demonstrates that LLD after PD originates from the proximal segment only. In patients who had contralateral epiphysiodesis to balance leg length, this is achieved by creating a difference in subtrochanteric length. Arthroplasty surgeons need to be aware that shortening of the proximal femur segment in PD patients may be misleading, as the ipsilateral subtrochanteric length in these patients can be longer. Therefore, we strongly advise long-leg standing films for THA planning in PD patients in order to avoid inadvertently lengthening the limb. Cite this article: Bone Joint J 2021;103-B(11):1736-1741.

Cementless Ceramic-on-Ceramic Total Hip Replacement in Children and Adolescents

Background: total hip replacement (THR) is a rare surgical option in children and adolescents with disabling hip diseases. The aim of this study is to report results from a retrospective cohort of patients aged 18 years or less who underwent cementless Ceramic-on-Ceramic (CoC) THR at a single institution, investigating clinical and radiographic outcomes, survival rates, and reasons for revision of the implants. Materials and methods: we queried the Registry of Prosthetic Orthopedic Implants (RIPO) to identify all children and adolescents undergoing THR between 2000 and 2019 at a single Institution. Inclusion criteria were patients undergoing cementless CoC THR, aged less than 18 years at surgery, followed for at least 2 years. Sixty-eight patients (74 hips) matched all the inclusion criteria and were enrolled in the study. We assessed the clinical and radiographic outcomes, the rate of complications, the survival rate, and reasons for revision of the implants. Results: The mean follow-up was 6.6 ± 4.4 years (range 2-20). The most frequent reason for THR was post-traumatic or chemotherapy-induced avascular necrosis (38%). The overall survival rate of the cohort was 97.6% (95% CI: 84.9-99.7%) at 5 years of follow-up, 94.4% (95% CI: 79.8-98.6%) at 10 years and 15 years of follow-up. Two THR in two patients (2.7%) required revision. With the numbers available, Cox regression analysis could not detect any significant interaction between preoperative or intraoperative variables and implant survivorship (p-value 0.242 to 0.989)." The average HOOS was 85 ± 14.3 (range 30.6-100). Overall, 23 patients (48%) reported excellent HOOS scores (>90 points), 21 patients (44%) reported acceptable HOOS scores (60-90 points) while 4 patients (8%) reported poor outcomes (<60 points). Twenty-one patients (43%) were regularly involved into moderate- to high-intensity sport activities (UCLA ≥ 6). Conclusions: Cementless CoC THR is a successful procedure in children and teenagers, having demonstrated high implant survivorship and low rates of complications and failure. A meticulous preoperative planning and implant selection is mandatory, to avoid implant malposition, which is the main reason of failure and revision in these cases. Further studies are needed to assess the impact of the THR on the psychosocial wellbeing of teenagers, as well as risks and benefits and cost-effectiveness in comparison to the hip preserving surgical procedures.

The Effect of the COVID-19 Pandemic on Total Hip and Knee Arthroplasty Surgical Volume in 2020 in Poland

The aim of this study was to analyse the effect of the first year of the COVID-19 pandemic on total hip arthroplasty (THA) and total knee arthroplasty (TKA) surgical volume in Poland. A retrospective analysis of data concerning THA and TKA collected by the National Health Fund in Poland in 2019 and in 2020 has been conducted. The number of primary hip or knee arthroplasties in 2020 was around 71% and 67% of the number registered in 2019, respectively. There was also a decline in the volume of revision arthroplasties observed, with 65% and 63% of THA and TKA revisions performed in 2019. The most significant decrease was observed in April and May, and during the second wave of the pandemic in November 2020, with a decline of 87%, 55% and 56%, respectively. The results of this study show the significant impacts that the COVID-19 pandemic had on the volume of elective hip and knee arthroplasties in Poland in 2020. In comparison with 2019, a decrease of around 30% for primary and of 40% for revision arthroplasties was observed. The most significant decline was observed in April and May 2020, and during the second wave of the COVID-19 pandemic in Poland in November 2020.

Outcomes of Hip Arthroscopy in Patients with Femoroacetabular Impingement and Concomitant Tönnis Grade II Osteoarthritis or Greater: Protocol for a Systematic Review

Introduction

Outcomes of hip arthroscopy for femoroacetabular impingement and concomitant moderate- to advanced hip osteoarthritis (Tönnis Grade II or greater) is still a matter of debate as findings in the literature are controversial. This study aims to investigate whether hip arthroscopy is effective in treating patients with femoroacetabular impingement and Tönnis hip osteoarthritis Grade II or greater.

Methods and Analysis

The protocol follows the PRISMA-P guidelines. The systematic review is registered in the International Prospective Register for Systematic Reviews and Meta-analysis (PROSPERO) under the registration number: CRD42020210936. The search will include multiple databases: MEDLINE, EMBASE, Web of Science Core Collection and Cochrane library. The screening and selection process will be performed by two independent researchers based on predefined criteria. All studies published in English or German from inception to 1^st of December 2020 that investigated outcomes of hip arthroscopy in patients with Tönnis grade II or greater of hip osteoarthritis will be considered eligible. The risk of bias and quality of articles will be assessed using the MINORS tool. Methodological inconsistency and heterogeneity will be explored using the I² test. This assessment will be used to provide recommendations using the GRADE system.

Ethics and Dissemination

Separate ethical approval is not required. This study will be a comprehensive and rigorous systematic review on all published articles reporting on outcomes of hip arthroscopy for femoroacetabular impingement and concomitant hip osteoarthritis Tönnis Grade II or greater. It will explore patient reported outcomes as well as radiological outcomes, complications, rates of revision surgery and rates of conversion to total hip replacement (THR). Results of the current review will be published in a peer-reviewed scientific journal and disseminated on research platforms according to copyright rules and rights.

Highlights

Hip arthroscopy is used to treat femoroacetabular impingement and is effective in patients that have concomitant hip osteoarthritis Tönnis Grade 0 or 1.Outcomes of hip arthroscopy in patients with femoroacetabular impingement and in moderate to advanced osteoarthritis - Tönnis Grade 2 or greater, is a matter of debate.The purpose of the current systematic review is to elucidate, stratify and critical appraise the current evidence on outcomes in this patient subpopulation.