Mid-to long-term results of revision total hip replacement in patients aged 50 years or younger

Contemporary Aseptic Revision Total Hip Arthroplasty in Patients ≤50 Years of Age: Results of >500 Cases

BACKGROUND

There has been a paucity of long-term outcomes data on aseptic revision total hip arthroplasties (THAs) in the young adult population. The purpose of this study was to evaluate implant survivorship, complications, and clinical outcomes in a large cohort of contemporary aseptic revision THAs in patients ≤50 years of age at the time of the surgical procedure.

METHODS

We identified 545 aseptic revision THAs performed at a single academic institution from 2000 to 2020 in patients who were 18 to 50 years of age. Patients who underwent conversion THAs and patients with a history of any ipsilateral hip infection were excluded. The mean age was 43 years, the mean body mass index (BMI) was 29 kg/m 2 , and 63% were female. The index indication for revision THA was aseptic loosening in 46% of cases, polyethylene wear or osteolysis in 28% of cases (all revisions of conventional polyethylene), and dislocation in 11% of cases. There were 126 hips (23%) that had undergone at least 1 previous revision (median, 1 revision [range, 1 to 5 revisions]). The mean follow-up was 10 years.

RESULTS

In the entire cohort, the 20-year survivorship free of any re-revision was 76% (95% confidence interval [95% CI], 69% to 82%). There were 87 re-revisions, with 31 dislocations, 18 cases of aseptic loosening of the femoral component, and 16 periprosthetic joint infections (PJIs) being the most common reasons for re-revision. Dislocation as the indication for the index revision was associated with an increased risk of re-revision (hazard ratio, 2.9; p < 0.001). The 20-year survivorship free of any reoperation was 73% (95% CI, 66% to 78%). There were 75 nonoperative complications (14%), including 32 dislocations. The mean Harris hip score significantly improved (p < 0.001) from 65 preoperatively to 81 at 10 years postoperatively.

CONCLUSIONS

Contemporary aseptic revision THAs in patients ≤50 years of age demonstrated a re-revision risk of approximately 1 in 4 at 20 years. Dislocation, aseptic loosening of the femoral component, and PJI were the most common reasons for re-revision. Index revision THAs for dislocation had a 3 times higher risk of re-revision.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Examining the "revisability" benefit of hip resurfacing arthroplasty

BACKGROUND

Hip resurfacing arthroplasty (HRA) is an alternative to total hip arthroplasty (THA) that is typically reserved for young active patients because it preserves bone. However, the benefits of HRA only hold true if conversion THA after failed HRA provides acceptable outcomes.

AIM

To compare patient reported outcomes for conversion THA after HRA failure to primary THA.

METHODS

A retrospective review of 36 patients (37 hips) that underwent conversion THA for failed HRA between October 2006 and May 2019 by a single surgeon was performed. Patient reported outcomes [modified Harris Hip Score (mHHS), University of California Los Angeles (UCLA) activity score] were obtained via an email-based responder-anonymous survey. Outcomes were compared to normative data of a primary THA cohort with similar demographics. Subgroup analysis was performed comparing outcomes of conversion THA for adverse local tissue reaction (ALTR) vs all other causes for failure.

RESULTS

The study group had a lower mHHS than the control group (81.7 ± 13.8 vs 90.2 ± 11.6, P < 0.01); however, both groups had similar UCLA activity levels (7.5 ± 2.3 vs 7.2 ± 1.6, P = 0.51). Patients that underwent conversion for non-ATLR causes had similar mHHS (85.2 ± 11.5 vs 90.2 ± 11.6, P = 0.11) and higher UCLA activity levels (8.5 ± 1.8 vs 7.2 ± 1.6, P < 0.01) compared to the control group. Patients that underwent conversion for ATLR had worse mHHS (77.1 ± 14.5 vs 90.2 ± 11.6, P < 0.01) and UCLA activity levels (6.1 ± 2.3 vs 7.2 ± 1.6, P = 0.05) when compared to the control group.

CONCLUSION

Patient outcomes equivalent to primary THA can be achieved following HRA conversion to THA. However, inferior outcomes were demonstrated for ALTR-related HRA failure. Patient selection and perhaps further studies examining alternative HRA bearing surfaces should be considered.

[Tips and tricks of cement removal in the case of revision surgery]

BACKGROUND

In Germany, current revision rates after arthroplasty range between 28-37%. In particular, remaining cement residues are causative for additional revision surgery after periprosthetic joint infection, which is why complete cement removal is of high importance. However, the removal of remaining cement residues often confronts the surgeon with technical challenges. Complication-free and complete cement removal requires extensive preoperative preparation in order to develop the best possible surgical strategy.

TREATMENT

Special instrument sets to facilitate cement removal in revision cases are available from various manufacturers. In addition to endoluminal approaches, access enhancements such as extended osteotomies exist to facilitate complete cement removal. Finally, the surgeon should be able to give the indication for an intraoperative procedural change after a defined time interval.

Total Hip Arthroplasty in the Ultrayoung

Background

Total hip arthroplasty (THA) procedures provide a surgical option for "ultrayoung" patients ≤30 years old with end-stage hip arthropathy. This has historically been coupled with concerns over early component failure and challenging surgical technique leading to increased risk of overall morbidity. The purpose of this study is to better elucidate the poorly defined indications and outcomes for THA in ultrayoung patients with end-stage hip disease.

Methods

A total of 40 THAs in 35 patients ≤30 years old performed at our institution from 2009 to 2016 were retrospectively followed for an average of 2 years (median 11 months, interquartile range 1-31.25). Primary outcome measure was THA revision. Patient demographics were compared against outcomes. The effects on revision rate of hip joint pathology and type of bearing surface were investigated. T-test, chi-square test, and bivariate correlation were performed to determine statistical significance (P < .05). Machine learning was used to determine the normalized important factor leading to THA revision.

Results

Fifteen male and 25 female patients were included. Median patient age was 23 (interquartile range 19-27) years, with an average body mass index of 27.0 ± 7.9. A majority of THAs were indicated for osteonecrosis (32) and bearing surface type was predominantly metal-on-highly cross-linked polyethylene (36). The overall revision rate was 7.5%, without a correlation between revision and demographic characteristics. Revision surgery was significantly correlated with bearing surface type (P = .028). Important factors for revision were age (100%), bearing surface type (84.7%), and body mass index (52.1%).

Conclusions

In patients ≤30 years old, THAs performed with the use of modern implants and surgical methods show satisfactory survivorship and functional outcomes with short-term follow-up.

A significant change towards cemented fixation in revision total hip arthroplasty in patients younger than 55 years in the Netherlands: results of an observational cohort study in the Dutch Arthroplasty Register in 28,516 primary hip replacements and 1285 revision procedures

BACKGROUND

Worldwide, the majority of total hip arthroplasties (THAs) placed in patients <55 years are uncemented. However, little is known about the preferred method of fixation in revision hip arthroplasty in young patients. The aim of this study was to assess potential differences in the method of fixation used between primary and revision THA in young patients using data from the Dutch Arthroplasty Register.

METHODS

All primary THA placed in patients younger than 55 years, registered in the LROI between 2007 and 2019 were included n = 28,516). Kaplan-Meier survival analyses were used to estimate the survival of primary THA by method of fixation. Additionally, survival of revision procedures that changed or did not change in method of fixation were estimated. McNemar's test was used to assess differences in the proportion of cemented and uncemented fixation between primary and revision THA.

RESULTS

In all acetabular revisions, the use of cemented fixation increased statistically significant with 39% (95% CI, 34-45, p < 0.001) from 23% in primary THA to 62% in revision procedures. In all femoral revisions, the increase of cemented fixation was also statistically significant with 25% (95% CI, 19-31, p < 0.001), from 11% in primary THA to 36% in revision surgery. For both revised acetabular and femoral components, we found no statistically significant difference in the 5-year survival between revision procedures that changed or did not change in method of fixation.

CONCLUSIONS

There was a significant change towards cemented fixation between primary and revision THA in young patients in the Netherlands, which was especially pronounced in acetabular revisions. No significant difference in short-term survival was found between revision procedures that changed or did not change in method of fixation. Long-term follow-up data are needed to evaluate the effect of this change in fixation method on the outcome of revision procedures in young patients.

[Pitfalls in revision hip arthroplasty]

Significant key points for a successful revision surgery in hip arthroplasty are as follows: identification of the implants, preoperative clinical diagnoses, planning (including alternatives) as well as establishing a surgical strategy, selection of revision implants and provision with special tools, secure fixation of acetabular and femoral components and the reconstruction of a stable joint without risk of dislocation or impingement. It seems to be obvious that most problems can be avoided by clear and concise decision-making. Some tips and tricks are also presented.

Monobloc press-fit cups with large-diameter bearings are safe in revision total hip arthroplasty

BACKGROUND

Instability is a major cause of failure of revision total hip arthroplasty (THA) which can be avoided with the use of monobloc press-fit cups with large diameter heads (LDH).

OBJECTIVE

This consecutive case series analyses whether LDH monobloc components are a safe and clinically beneficial option for revision THA.

METHODS

This consecutive case series includes 47 revision THA with LDH monobloc acetabular cup. Acetabular bone defects were Paprosky type I (42), type IIA (2) and type IIC (3). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Forgotten Joint Score (FJS) and the Patient's Joint Perception (PJP) scores were analysed and a radiographic evaluation for signs of implant dysfunction was performed.

RESULTS

After a mean follow-up of 4.5 years, there were 5 (10.6%) acetabular cup re-revisions: 2 loss of primary fixation and 3 instabilities. Implant survivorship at 4-years was 89.4% (95% CI: 89.3 to 89.5). Recurrent hip dislocation was reported in 1 patient (2.1%) and remains under conservative treatment. The mean WOMAC and FJS were 19.5 (16.8; 0.0 to 58.3) and 57.3 (28.9; 6.3 to 100.0), respectively. Regarding the PJP, 3 (8.8%) patients perceived their hip as natural, 8 (23.5%) as an artificial joint with no restriction, 14 (41.2%) with minor restriction and 9 (26.5%) with major restriction.

CONCLUSION

In cases of revision THA with limited bone loss, press-fit primary fixation with LDH monobloc acetabular components are valuable options that offer excellent mid-term out-comes with low re-revision and joint instability rates.

Comparing uncemented, hybrid and cemented primary total hip arthroplasty in young patients, a New Zealand Joint Registry study

BACKGROUND

Despite increasing use of uncemented implants in young patients undergoing total hip arthroplasty (THA), there is minimal evidence for specific implant combinations in this group. We analysed the most commonly used uncemented (Corail-Pinnacle), hybrid (Exeter-Trident/Tritanium), and fully cemented (Exeter) implant combinations in the New Zealand Joint Registry (NZJR) in patients aged under 40 and between 40 and 55 years.

METHODS

All THAs recorded in the NZJR between 1999 and 2018 were included. The 40-55 and < 40 age groups were analysed separately. Demographic data, implant type, and outcome data including implant survival, reason for revision, and post-operative Oxford Hip Scores were obtained from the NZJR, and detailed survival analyses were performed. The primary outcome was revision for any reason.

RESULTS

We identified 4152 THAs in the 40-55 group and 422 in the < 40 group. In the 40-55 group, revision rates and patient-reported outcome measure scores were comparable between the uncemented implant combination (0.70/100 component years) and the hybrid implant combination (0.62/100 component years), whereas the cemented implant combination exhibited a statistically significant higher revision rate (1.75/100 component years) (p < 0.001). In the < 40 group, revision rate for the hybrid implant combination (0.46/100 component years) was significantly lower than the uncemented implant combination (1.54/100 component years).

CONCLUSION

The most commonly used hybrid and uncemented implant combinations provided equivalent survival and functional outcomes in patients aged 40-55 years. More research is required to guide implant selection in patients aged < 40 years. The authors suggest a transition away from comparing classes of implants (cemented, uncemented, hybrid) given the diverse product range within these categories.

A Patient and Public Involvement Study to Explore the Need for Further Research into the Experience of Younger Patients Undergoing Total Hip Arthroplasty

Background: Total Hip Arthroplasty (THA) is one of the most commonly performed operations in orthopaedics. It is an operation usually performed in older patients, however the need for THA in younger patients is increasing. There is a lack of literature examining whether current recovery pathways address the specific needs of younger patients. Public and Patient Involvement (PPI) is a core aspect of good research practice and is recommended throughout the research process, including the formulation and refinement of pertinent research questions. Therefore, the explicit aim of this PPI study was to collect qualitative data from patients on the feasibility and requirement for further research into the experience of younger hip arthroplasty patients. Methods: Qualitative data was collected via an online questionnaire that was advertised on social media, requesting the input of anybody who had experienced a lower limb musculoskeletal injury or condition before the age of 50. The survey asked the respondents to describe their experiences and reflect on their priorities and goals throughout their recovery. Results: There were 71 respondents, of which 90% were female, with an average age of 43. Qualitative responses identified many concerns that were issues that could be translated across all patient ages. However, other priorities were raised that are not always recognised as important when measuring successful outcomes after a THA. Furthermore, many respondents described not feeling listened to by clinicians or treatment options not being sufficiently addressed and explored. Multiple respondents reported being told they were too young to have anything serious or that nothing could be done until they were older. Conclusions: The responses to the survey indicate that current care pathways are not fulfilling the needs and priorities in younger patients. Further research is required to explore these priorities and goals in more depth in order to understand how healthcare professionals can address them.

The outcome of subsequent revisions after primary total hip arthroplasty in 1,049 patients aged under 50 years : a single-centre cohort study with a follow-up of more than 30 years

AIMS

The aim of this study was to determine the outcome of all primary total hip arthroplasties (THAs) and their subsequent revision procedures in patients aged under 50 years performed at our institution.

METHODS

All 1,049 primary THAs which were undertaken in 860 patients aged under 50 years between 1988 and 2018 in our tertiary care institution were included. We used cemented implants in both primary and revision surgery. Impaction bone grafting was used in patients with acetabular or femoral bone defects. Kaplan-Meier analyses were used to determine the survival of primary and revision THA with the endpoint of revision for any reason, and of revision for aseptic loosening.

RESULTS

The mean age of the patients at the time of the initial THA was 38.6 years (SD 9.3). The mean follow-up of the THA was 8.7 years (2.0 to 31.5). The rate of survival for all primary THAs, acetabular components only, and femoral components only at 20 years' follow-up with the endpoint of revision for any reason, was 66.7% (95% confidence interval (CI) 60.5 to 72.2), 69.1% (95% CI 63.0 to 74.4), and 83.2% (95% CI 78.1 to 87.3), respectively. A total of 138 revisions were performed. The mean age at the time of revision was 48.2 years (23 to 72). Survival of all subsequent revision procedures, revised acetabular, and revised femoral components at 15 years' follow-up with the endpoint of revision for any reason was 70.3% (95% CI 56.1 to 80.7), 69.7% (95% CI 54.3 to 80.7), and 76.2% (95% CI 57.8 to 87.4), respectively. A Girdlestone excision arthroplasty was required in six of 860 patients (0.7%).

CONCLUSION

The long-term outcome of cemented primary and subsequent revision THA is promising in these young patients. We showed that our philosophy of using impaction bone grafting in patients with acetabular and femoral defects is a very suitable option when treating young patients. Surgeons should realize that knowledge of the outcome of subsequent revision surgery, which is inevitable in young patients, must be communicated to this group of patients prior to their initial THA. Cite this article: Bone Joint J 2022;104-B(3):368-375.

Early, Mid-Term, and Late-Term Aseptic Femoral Revisions After THA: Comparing Causes, Complications, and Resource Utilization

BACKGROUND

Registry data suggest increasing rates of early revisions after total hip arthroplasty (THA). We sought to analyze modes of failure over time after index THA to identify risk factors for early revision.

METHODS

We identified 208 aseptic femoral revision THAs performed between February 2011 and July 2019 using an institutional database. We compared demographics, diagnoses, complications, and resource utilization between aseptic femoral revision THA occurring within 90 days (early), 91 days to 2 years (mid), and greater than 2 years (late) after index arthroplasty.

RESULTS

Early revisions were 33% of revisions at our institution in the time period analyzed. Periprosthetic fractures were 81% of early, 27% of mid, and 21% of late femoral revisions (P < .01). Women were more likely to have early revisions than men (75% vs 53% of mid and 48% of late revisions; P < .01). Patients who had early revisions were older (67.97 ± 10.06) at the time of primary surgery than those who had mid and late revisions (64.41 ± 12.10 and 57.63 ± 12.52, respectively, P < .01). Index implants were uncemented in 99% of early, 96% of mid, and 64% of late revisions (P < .01). Early revisions had longer postoperative length of stay (4.4 ± 3.3) than mid and late revisions (3.0 ± 2.2 and 3.7 ± 2.1, respectively, P = .02). In addition, 58% of early revisions were discharged to an inpatient facility compared with 36% of mid and 41% of late revisions (P = .03).

CONCLUSION

Early aseptic femoral revisions largely occur in older women with uncemented primary implants and primarily due to periprosthetic fractures. Reducing the incidence of periprosthetic fractures is critical to decreasing the large health care utilization of early revisions.

Total Hip Arthroplasty Revision Surgery: Impact of Morbidity on Perioperative Outcomes

BACKGROUND

Primary and revision total hip arthroplasty (THA) is increasingly performed in patients with high comorbidity burden. Its predominantly negative effects on outcomes are well understood in primary THA; however, the effects of morbidity on revision THA are unknown. Since revision procedures account for about 10% of the total surgical volume, we set out to investigate the effects of physical health status on perioperative outcomes in this setting.

METHODS

We queried our prospectively collected institutional database for patients who underwent revision THA at our institution (Orthopedic University Hospital Friedrichsheim, Frankfurt) between 2007 and 2011. Patients were classified according to American Society of Anesthesiologists (ASA) category and number of comorbidities. Subsequently, their impact on perioperative parameters was analyzed.

RESULTS

Our database revealed 294 cases of revision THA during the study period. Patients preoperatively classified as ASA 3 and 4 showed significantly higher rates of intraoperative and postoperative complications, transfusions, prolonged intensive care unit (ICU) stay, and total length of stay (LOS) compared to patients classified as ASA 1 and 2. Similarly, patients with >3 comorbidities presented with significantly elevated postoperative complications, ICU stay, and LOS. Particularly, preoperative cardiac diseases were associated with increased blood loss, transfusions, duration of surgery, postoperative complications, ICU stay, LOS, and re-revisions.

CONCLUSION

Poor physical health condition is associated with negative perioperative outcomes in revision THA. Especially cardiac comorbidities are linked to unfavorable outcomes, which have important implications for assessment of perioperative risk.

What Are the Long-term Results of Cemented Revision THA with Use of Both Acetabular and Femoral Impaction Bone Grafting in Patients Younger Than 55 Years?

BACKGROUND

The increasing number of THAs in younger patients will inevitably result in an increase of revision procedures. However, there is little evidence about the outcome of revision procedures in this patient group. Therefore, we updated a previous study conducted 5 years ago about the outcome of revision procedures in patients younger than 55 years.

QUESTIONS/PURPOSES

We sought to provide a concise update on the previously reported (1) long-term failure rate as defined by repeat revision, (2) clinical outcome as defined by the Oxford Hip score and the Harris Hip score, and (3) radiographic outcome of cemented revision THA performed with impaction bone grafting on both the acetabular and femoral sides in one surgery in patients younger than 55 years old.

METHODS

Between 1991 and 2007, we performed 86 complete THA revisions in patients younger than 55 years. In 38% (33 of 86) of revisions, bone impaction grafting was used on both the acetabular and femoral side because of acetabular and femoral bone stock loss. Mean age at time of revision was 46 ± 8 years. No patient was lost to follow-up, but six patients died during follow-up, including three since 2015. Still, the hips of all 33 patients were included in analysis at a mean of 17 ± 5 years. Failure was calculated using competing risk analysis. For clinical outcome, we assessed the Harris Hip score and the Oxford Hip score from our longitudinally maintained institutional database. Radiographic analysis was performed to evaluate radiographic loosening, defined as radiolucencies ≥ 2 mm in all zones or ≥ 5 mm migration for both components. The acetabular component was also considered loose with tilting ≥ 5°.

RESULTS

The 15-year failure rate of revision THA was 27% (95% CI 13 to 44) for re-revision of any component for any reason and 10% (95% CI 3 to 25) for re-revision of any component for aseptic loosening. The mean Harris Hip score increased from 55 ± 18 preoperatively to 74 ± 22 at latest follow-up. Eight cups were considered radiographically loose, seven of which were re-revised. No stems were considered radiographically loose. Failure rate with endpoint radiographic loosening at 15 years was 23% (95% CI 10 to 39).

CONCLUSION

We found that impaction bone grafting with a cemented cup and a cemented stem is a valuable biological revision technique that results in a stable and durable solution, after one or even multiple previous revision THAs. Although current implants may prove sufficient in most cases, they do not promote bone stock preservation. We believe that in young patients with bone stock loss, impaction bone grafting can be used as long as the defect can be contained adequately with a metal mesh and viable bone bed is available for revascularization.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Outcome of tantalum rod insertion in the treatment of osteonecrosis of the femoral head with minimum follow-up of 1 year: a meta-analysis and systematic review

Osteonecrosis of the femoral head (ONFH) is a debilitating disease that can cause deformity and collapse of the femoral head, thus leading to the development of degenerative joint disease that can incapacitate the patient with pain and reduction in hip mobility. This study aims to determine the safety and efficacy of tantalum rod insertion in the treatment of ONFH with a minimum follow-up period of 1 year. A multi-database search was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Data from studies assessing the clinical and radiological outcomes as well as complications of tantalum rod insertion in the treatment of ONFH with a minimum follow-up period of 1 year were extracted and analyzed. Ten studies were included in this meta-analysis, consisting of 550 hips. There was a statistically significant increase in HHS (MD = 30.35, 95% CI: 20.60-40.10, P < 0.001) at final follow-up versus pre-operative scores. The weighted pooled proportion (PP) of radiographic progression of ONFH was 0.221 (95% CI: 0.148-0.316), while that of progression into femoral head collapse was 0.102 (95% CI: 0.062-0.162). Conversion to total hip arthroplasty (THA) had a PP of 0.158 (95% CI: 0.107-0.227) with a mean weighted period of 32.4 months (95% CI: 24.9-39.9 months). Subgroup analysis of conversion to THA when tantalum rods were used in conjunction with bone grafting (PP = 0.150, 95% CI: 0.092-0.235) showed a marginal risk reduction than when compared with subgroup analysis of tantalum rods being used alone (PP = 0.154, 95% CI: 0.078-0.282). Tantalum rod is a safe alternative option to the current joint-preserving procedures available in the treatment of ONFH. However, more studies are needed to investigate and identify the most appropriate patients who would benefit most and the synergistic effect brought on by the use of complementary biological augmentation of bone grafting or stem cells with tantalum rods.

Primary Total Hip Arthroplasty in Patients 20 Years Old and Younger

BACKGROUND

Historically, total hip arthroplasty (THA) performed in patients ≤20 years old has been associated with poor survivorship because of bearing-surface wear with conventional polyethylene, acetabular loosening with cemented sockets, and liner fracture in ceramic-on-ceramic (CoC) THA. For this population, there is a paucity of data regarding outcomes of THAs performed with use of modern implants and bearing surfaces. The purpose of the present study was to examine the mid- to long-term outcomes of modern THA in patients ≤20 years old.

METHODS

Utilizing a single-institution, prospectively collected total joint registry, we retrospectively identified 91 primary THAs performed in 78 patients ≤20 years old from 1998 to 2016. The average patient age was 17 years (range, 11 to 20 years), and the average body mass index was 26 kg/m (range, 16 to 49 kg/m). Forty-eight THAs (53%) were performed in male patients, and 47 (52%) were performed on the right hip. Bearing surfaces included CoC (53 THAs, 58%), metal-on-highly cross-linked polyethylene (MoP; 28 THAs, 31%), and ceramic-on-highly cross-linked polyethylene (CoP; 10 THAs, 11%). Outcome measures included reoperations, revisions, complications, clinical outcome scores, and bearing-surface wear.

RESULTS

At an average follow-up of 8 years (range, 2 to 18 years), the average modified Harris hip score was 92 (range, 54 to 100), and 95% of patients reported feeling "much better" following the surgical procedure. Survivorship at 2, 5, and 10 years postoperatively was 96.7%, 96.7%, and 95.0% for reoperation; 98.9%, 98.9%, and 97.2% for revision; and 91.2%, 91.2%, and 89.5% for complications, respectively. The most common complications were instability (3 THAs, 3%), aseptic acetabular loosening (2 THAs, 2%), and postoperative foot drop (2 THAs, 2%). Linear articular wear averaged 0.019 mm/yr. There were no correlations between age, sex, body mass index, bearing surface, femoral head size, use of cement, or operative time and survivorship from complications, reoperations, or revisions. There were no differences in linear wear among CoC, CoP, and MoP bearing surfaces.

CONCLUSIONS

In patients ≤20 years old, THAs performed with use of modern implants exhibit excellent clinical outcome scores and survivorship at mid- to long-term follow-up. CoC, CoP, and MoP bearing surfaces have similar survivorship, clinical outcomes, and bearing-surface wear in this population.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

An Ultra-Short Femoral Neck-Preserving Hip Prosthesis: A 2-Year Follow-up Study with Radiostereometric Analysis and Dual X-Ray Absorptiometry in a Stepwise Introduction

BACKGROUND

Total hip arthroplasty (THA) with a diaphyseal stem may risk bone loss. In order to save proximal bone stock in young patients with a high activity level and a long life expectancy, the interest in short stems has evolved. The purpose of this prospective observational cohort study was to evaluate the fixation of, and bone remodeling around, the Primoris femoral neck-preserving hip implant.

METHODS

Fifty younger patients with end-stage osteoarthritis were managed with the Primoris hip implant. We evaluated bone mineral density (BMD) using dual x-ray absorptiometry (DXA) and implant migration using radiostereometric analysis (RSA). A region-of-interest (ROI) protocol for 4 ROIs was applied to assess BMD. The association between BMD and migration was evaluated to determine the fixation of the Primoris implant and bone remodeling in the proximal part of the femur. Follow-up evaluation was performed at regular intervals from day 1 (baseline) until 24 months after surgery.

RESULTS

The major stem migrations were subsidence (Y axis; mean, 0.38 mm) at 6 weeks and varus tilt (rotation) (Z axis; mean, 0.93°) at 6 to 12 months. In ROI4 (the calcar area), a significant gain in bone was found with a mean difference of 4.1% (95% confidence interval [CI], 0.8% to 7.4%; p < 0.02) at 24 months postoperatively. Significant bone loss was found in ROI1 and ROI2, with a mean difference of -4.9% (95% CI, -7.4% to -2.4%; p = 0.0003) and -8.9% (95% CI, -11.5% to -6.2%; p = 0.0001), respectively. Linear regression and multivariate regression analysis showed a significant negative association between maximal total point motion and BMD (p = 0.02, R = 15%; and p < 0.05, R = 26%, respectively).

CONCLUSIONS

The Primoris component showed satisfactory primary stability with promising results at the 24-month follow-up. DXA scans showed limited stress-shielding with the proximal loading pattern of the Primoris. Better bone quality was associated with less implant migration.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcome of revision hip arthroplasty in patients younger than 55 years: an analysis of 1,037 revisions in the Dutch Arthroplasty Register

Background and purpose - The increasing use of hip arthroplasties in young patients will inevitably lead to more revision procedures at younger ages, especially as the outcome of their primary procedures is inferior compared with older patients. However, data on the outcome of revision hip arthroplasty in young patients are limited. We determined the failure rates of revised hip prostheses performed in patients under 55 years using Dutch Arthroplasty Register (LROI) data.Patients and methods - All 1,037 revised hip arthroplasty procedures in patients under 55 years at the moment of revision registered in the LROI during the years 2007-2018 were included. Kaplan-Meier survival analyses were used to calculate failure rates of revised hip arthroplasties with endpoint re-revision for any reason. Competing risk analyses were used to determine the probability of re-revision for the endpoints infection, dislocation, acetabular and femoral loosening, while other reasons for revisions and death were considered as competing risks.Results - Mean follow-up of revision procedures was 3.9 years (0.1-12). 214 re-revisions were registered. The most common reason for the index revision was dislocation (20%); the most common reason for re-revision was infection (35%). The 5-year failure rate of revised hip prostheses was 22% (95% CI 19-25), and the 10-year failure rate was 28% (CI 24-33). The 10-year cumulative failure rates of index revisions with endpoint re-revision for infection was 7.8% (CI 6.1-9.7), acetabular loosening 7.0% (CI 4.1-11), dislocation 3.8% (CI 2.6-5.2), and femoral loosening 2.7% (CI 1.6-4.1). The 10-year implant failure rate of index revisions for infection was 45% (CI 37-55) with endpoint re-revision for any reason.Interpretation - Failure rate of revised hip prostheses in patients under 55 years is worrisome, especially regarding index revisions due to infection. This information facilitates realistic expectations for these young patients at the time of primary THA.

The risk of revision after total hip arthroplasty in young patients depends on surgical approach, femoral head size and bearing type; an analysis of 19,682 operations in the Dutch arthroplasty register

Background

Total hip arthroplasty (THA) is used increasingly in younger patients. There is little knowledge about the effect of THA characteristics on risk of revision, especially in young patients. Therefore, we studied the influence of both patient-related and surgical factors on the risk of revision using data from the Dutch Arthroplasty Registry (LROI).

Methods

All patients younger than 55 years with a primary THA implanted in the Netherlands between 2007 and 2017 were selected (n = 19,682). The covariates age, sex, primary diagnosis, ASA-classification, surgical approach, fixation method, bearing type, head size and year of surgery were entered into Cox proportional hazards models to calculate hazard ratios for the risk of revision.

Results

The overall 5-year survival of primary THA was 95.3% (95% CI, 94.9–95.6). Use of the anterior approach resulted in a lower risk of revision than the use of the posterolateral approach (HR: 0.66, 95% CI: 0.47–0.92). THAs with a head diameter ≥ 38 mm had a higher risk of revision (HR: 1.90, 95% CI: 1.33–2.72) than THAs with 32 mm heads. Use of MoM bearings resulted in an increased risk when compared to C-PE (HR: 1.76, 95% CI: 1.27–2.43).

Conclusion

The risk of revision in patients younger than 55 years depends on surgical approach, head size and bearing type. The anterior approach resulted in a decreased risk of revision, whereas use of ≥38 mm heads and MoM bearings resulted in an increased risk of revision for any reason.

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.

Total Hip Arthroplasty in Young Patients in The Netherlands: Trend Analysis of >19,000 Primary Hip Replacements in the Dutch Arthroplasty Register

BACKGROUND

Total hip arthroplasty (THA) is one of the most successful interventions in medical care. Because of shifting trends in THA and failure rates being higher in younger patients, we aimed to assess trends in implant fixation, bearing type, head diameter, and surgical approach in patients younger than 55 years in the Netherlands using data from the Dutch Arthroplasty Register.

METHODS

Trends in the method of implant fixation, bearing type, head diameter, and surgical approach were analyzed over year of surgery (2007-2016) and over age groups (<25, 25-29, 30-34, 35-39, 40-44, 45-49, and 50-54 years).

RESULTS

Between 2007 and 2016, a total of 19,915 primary THAs were performed in patients <55 years. Osteoarthritis was the most prevalent diagnosis (66.1%). Uncemented fixation was used in 79.5% of all performed THAs. The use of 32-mm head diameters increased (from 32.6% in 2007 to 50.1% in 2016), where an increasing trend toward the use of ceramic-on-polyethylene as most frequently used bearing type was present (from 37.5% in 2007 to 53.8% in 2016). The posterolateral surgical approach was the most frequently used approach; however, the anterior approach is used increasingly (0.1% in 2007 to 21.1% in 2016). Ceramic-on-polyethylene bearing surfaces, 32-mm head diameters, and the anterior approach were most commonly used in patients between 50 and 54 years.

CONCLUSION

There was a clear preference for uncemented fixation in young patients. In head diameter, bearing type, and surgical approach, clear trends were visible. Characteristics of THA in young patients were subject to changing perspectives.

Concomitant Arthroscopy With Labral Reconstruction and Periacetabular Osteotomy for Hip Dysplasia

In the setting of true hip dysplasia, the high prevalence of intra-articular pathology may lead to recurrent symptoms and failure after periacetabular osteotomy (PAO). Femoral neck osteochondroplasty, microfracture, removal of loose bodies, and labral repair are examples of procedures that are performed with concomitant arthroscopy. When damage to the labrum is too severe to repair, reconstruction instead of extensive debridement before PAO can be more effective in restoring the labral seal to maintain joint lubrication and chondral protection. This Technical Note describes a method for concomitant hip arthroscopy with circumferential labral reconstruction with allograft and PAO.

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.

Systematic review: lack of evidence for the success of revision arthroplasty outcome in younger patients

INTRODUCTION

Total hip arthroplasties (THAs) in younger patients are becoming increasingly popular. However, the outcome of subsequent revisions in younger patients is not well known and, therefore, their success (subsequent revision prosthesis survival) might be overestimated. We investigated available data on the outcome of primary- and subsequent revision THAs performed in the same cohort of patients who underwent primary THA under the age of 50.

METHODS

Medline, Embase and the Cochrane Library (CENTRAL) were searched up until April 13, 2016 for studies that reported both the survival of primary and subsequent revisions THA of single cohorts of patients younger than 50. Eligible articles had to include Kaplan Meier analysis or competing risk analysis for survival of the primary THA at a mean follow-up of 10 years, as well as for the subsequent revision THA within the same cohort.

RESULTS

We found 4,799 unique records; 43 of which were potentially eligible. Only 1 paper met our inclusion criteria. It reported on the survival of 69 primary prostheses at a mean of more than 10 years follow-up and 13 subsequent revisions.

CONCLUSIONS

There is a clear lack of evidence about the outcomes of the revision arthroplasty in younger patients. Only 1 study reported the survival-rate of subsequent revision arthroplasty with the minimum 10-year survival rate of the original THA cohort. In the future, this serious lack of knowledge could result in a large number of patients with no further reconstructive options after failed THA, and a large medical burden for society.

Acetabular Reconstructions with Impaction Bone-Grafting and a Cemented Cup in Patients Younger Than 50 Years of Age: A Concise Follow-up, at 27 to 35 Years, of a Previous Report

We present an update of 19 acetabular reconstructions, performed with a cemented total hip arthroplasty and impaction bone-grafting, in situ at the time of our previous report. At a mean follow-up of 30 years (range, 27 to 35 years), no additional patients were lost to follow-up. Two patients (3 reconstructions) died for reasons unrelated to the hip surgery. Five reconstructions (5 patients) were revised, 4 for aseptic loosening and 1 for septic loosening, after a mean of 24 years (range, 22 to 27 years), leaving 11 surviving hips (11 patients) that were clinically and radiographically evaluated. Kaplan-Meier survival at 30 years was 0.40 (95% confidence interval [CI], 0.23 to 0.56) for revision for any reason, 0.56 (95% CI, 0.35 to 0.73) for aseptic loosening, and 0.53 (95% CI, 0.33 to 0.69) for radiographic loosening. Competing risk analysis showed that Kaplan-Meier analysis overestimates the revision risk by 18% for revision for any reason and 22% for aseptic loosening. Cemented impaction bone-grafting is a reasonable long-term solution for demanding primary and revision acetabular reconstructions in young patients with acetabular bone defects.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Advantages in Using Cemented Polished Tapered Stems When Performing Total Hip Arthroplasty in Very Young Patients

BACKGROUND

The risk of revision following primary total hip arthroplasty (THA) is increased in young patients who undergo THA for pathologies other than primary osteoarthritis. We report the results of primary THA performed with cemented polished stems in patients aged 40 years and younger for pathologies other than primary osteoarthritis.

METHODS

We investigated 52 patients (65 hips) who underwent primary THA for secondary osteoarthritis with a cemented tapered polished stem between 1990 and 2007. Clinical and radiographic outcomes, available in 46 patients (57 hips), included the Harris Hip Scores, Societe Internationale de Chirurgie Orthopedique et de Traumatologie activity, patient satisfaction, stem survival and reoperations, and assessment of prosthesis-cement-bone radiolucencies, osteolysis, and femoral bone deficiencies.

RESULTS

Median patient age was 34 years (16-40) and follow-up was 14 years (mean 13, range 5-22). Stem survival to the endpoint revision for loosening was 100% and to the endpoint revision for any reason, excluding infection was 88% (95% confidence interval 78-98) at 16 years. No stem was revised for aseptic loosening. Nine stems were revised for other reasons. Radiographically, one stem was definitely loose at 16 years. The median patient Harris pain score improved from marked pain to no pain at latest follow-up. Patient activity level improved, albeit minimally, for 8 years after surgery. At latest follow-up, 98% of the patients remained satisfied with their surgery.

CONCLUSION

Primary THA with a cemented polished stem shows excellent results in young patients with pathology other than primary osteoarthritis. In addition, the stem design facilitates cement within cement exchange and therefore preservation of proximal femoral bone stock at revision surgery.

The Choice Between Total Hip Arthroplasty and Arthrodesis in Adolescent Patients: A Survey of Orthopedic Surgeons

For adolescent patients with end-stage hip disease, the choice between total hip arthroplasty (THA) and arthrodesis is complex; the clinical evidence is not definitive, and there are difficult trade-offs between clear short-term benefits from THA and uncertain long-term risks. We surveyed nearly 700 members of the Pediatric Orthopedic Society of North America and the American Association of Hip and Knee Surgeons. Respondents chose between a recommendation of THA or arthrodesis in four clinical vignettes. A clear majority of surgeons recommended THA in two of the vignettes, however opinion was somewhat divided in one vignette (overweight adolescent) and deeply divided in another (adolescent destined for manual labor job). Across all vignettes, recommendations varied systematically according to surgeons' age and their attitudes regarding tradeoffs between life stages.

Satisfying outcomes scores and survivorship achieved with impaction grafting for revision THA in young patients

BACKGROUND

The increasing number of total hip arthroplasties (THAs) performed in younger patients will inevitably generate larger numbers of revision procedures for this specific group of patients. Unfortunately, no satisfying revision method with acceptable survivorship 10 years after revision has been described for these patients so far.

QUESTIONS/PURPOSES

The purposes of this study were to (1) analyze the clinical outcome; (2) complication rate; (3) survivorship; and (4) radiographic outcome of cemented revision THA performed with impaction bone grafting (IBG) on both the acetabular and femoral sides in one surgery in patients younger than 55 years old.

METHODS

During the period 1991 to 2007, 86 complete THA revisions were performed at our institution in patients younger than 55 years. In 34 of these 86 revisions (40%), IBG was used on both the acetabular and femoral sides in 33 patients. Mean patient age at revision surgery was 46.4 years (SD 7.6). No patient was lost to followup, but three patients died during followup. None of the deaths were related to the revision surgery. The mean followup for the surviving hips was 11.7 years (SD 4.6). We also analyzed complication rate.

RESULTS

The mean Harris hip score improved from 55 (SD 18) preoperatively to 80 points (SD 16) at latest followup (p = 0.009). Six hips underwent a rerevision (18%): in four patients, both components were rerevised; and in two hips, only the cup was revised. Patient 10-year survival rate with the endpoint of rerevision for any component for any reason was 87% (95% confidence interval [CI], 67%-95%) and with the endpoint of rerevision for aseptic loosening, the survival rate was 97% (95% CI, 80%-100%). In total six cups were considered radiographically loose, of which four were rerevised. Three stems were radiographically loose, of which none was rerevised.

CONCLUSIONS

IBG is a valuable biological revision technique that may restore bone stock in younger patients. Bone stock reconstruction is important, because these patients likely will outlive their revision implants. Bone reconstruction with impaction grafting may facilitate future revisions.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Hydroxyapatite ceramic-coated femoral components in young patients followed up for 17 to 25 years: an update of a previous report

This study reports the results of 38 total hip arthroplasties (THAs) in 33 patients aged < 50 years, using the JRI Furlong hydroxyapatite ceramic (HAC)-coated femoral component. This represents an update of previous reports of the same cohort at ten and 16 years, which were reported in 2004 and 2009, respectively. We describe the survival, radiological and functional outcomes at a mean follow-up of 21 years (17 to 25). Of the surviving 34 THAs, one underwent femoral revision for peri-prosthetic fracture after 21 years, and one patient (one hip) was lost to follow-up. Using aseptic loosening as the end-point, 12 hips (31.5%) needed acetabular revision but none needed femoral revision, demonstrating 100% survival (95% confidence interval 89 to 100). In young patients with high demands, the Furlong HAC-coated femoral component gives excellent long-term results.