Systematic review of total hip arthroplasty in patients under 30 years old

Case Report: Hip arthroplasty after fracture-related joint infection caused by extensively drug-resistant Klebsiella pneumoniae

This case-report focuses on a 23-year-old soldier suffering from a fracture-related hip joint infection (FRI) due to extensively drug-resistant Klebsiella pneumoniae and S. epidermidis. The patient underwent multiple septic revision surgeries including the removal of remaining shrapnel accompanied by last-resort antimicrobial therapy with cefiderocol and colistin. Additionally, the surgeries included repeated tissue sampling for microbiological and histopathological analysis. An antibiotic-loaded cemented filler containing cefiderocol was used to improve local antimicrobial therapy. The biopsies prior to and during hip replacement surgery confirmed successful microbe eradication. Hip arthroplasty restored hip joint function and significantly improved patient's quality of life. The utilization of a trabecular metal shell and a meta-diaphyseally anchored cementless hip stem ensured secure implant fixation and early patient mobilisation. An adjusted biofilm active oral antimicrobial therapy after arthroplasty intervention was continued to prevent early periprosthetic joint infection. This case emphasizes the difficulties of managing FRI and multidrug-resistant pathogens. It contributes valuable insight into navigating complex orthopedic cases while ensuring successful hip arthroplasty outcomes. In conclusion, early interdisciplinary collaboration, appropriate antimicrobial therapy along with tailored surgical interventions are crucial for managing such complex cases successfully.

Characteristics of Very Young Patients Undergoing Total Hip Arthroplasty: A Contemporary Assessment

Background

This study aims to compare indications, patient characteristics, hospital factors, and complication rates between total hip arthroplasty (THA) patients aged 30 years or younger and those older than 30 years using a large national database.

Methods

The Premier Healthcare Database was utilized to identify primary THA patients from 2015 to 2021 who were aged ≤30 or >30 years. Patient demographics, hospital factors, and primary indications were compared for each cohort. Rates of complications and readmissions were assessed for each cohort by primary indication. Differences were assessed through univariate analysis.

Results

Overall, 539,173 primary THA patients were identified (age ≤30: 1849; >30: 537,234). Compared to the >30 cohort, the ≤30 cohort was more likely to be male (56.5% vs 44.9%, P < .001) and non-White (34.0% vs 14.2%, P < .001). The most common indications for THA in the ≤30 cohort were osteonecrosis (49.3%), osteoarthritis (17.8%), and congenital hip deformities (16.0%), and in the >30 cohort, they were osteoarthritis (77.0%), other arthritis (11.3%), and osteonecrosis (5.4%). Patients aged ≤30 years had lower rates of respiratory failure (0.16% vs 0.57%, P < .001), acute renal failure (0.32% vs 1.72%, P < .001), and urinary tract infection (0.38% vs 1.11%, P = .003) than those aged >30 years, but higher rates of wound dehiscence (0.59% vs 0.29%, P = .015) and transfusion (3.68% vs 2.21%, P < .001). There were no differences in 90-day readmission rates (P = .811) or 90-day in-hospital death (P = .173) between cohorts.

Conclusions

Younger patients undergoing THA differed significantly in indication, patient characteristics, and hospital factors compared to the older population on univariate analysis. Despite differences in indications, the cohorts did not differ markedly with regard to complication rates in this study.

Evolution of total hip arthroplasty in patients younger than 30 years of age: A systematic review and meta-analysis

INTRODUCTION

While surgical technique and implant technology for total hip arthroplasty (THA) has improved over the years, it is unclear whether recent progress has translated to improved clinical outcomes for young patients. The goal of this study is to determine trends in (1) indications, (2) surgical technique (3) clinical and radiographic outcomes, and (4) survivorship for THA in patients younger than 30 years of age.

METHODS

MedLine, Cochrane, EMBASE, and Google Scholar were searched using several key phrases for articles focusing on THA performed on patients younger than 30 years of age between 1971 and 2020. A total of 34 qualifying articles were identified and stratified into three groups according to operative years and compared to one another on the basis of (1) indications; (2) fixation technique; (3) implant design; (4) clinical and radiographic outcomes; and (7) survivorship.

RESULTS

The mean patient age at index THA were 20.5 (9-30), 22.1 (11-30) and 21.5 (10-30) years, respectively, for each study group. Over time, patients underwent fewer THAs for JRA (Juvenile Rheumatoid Arthritis) (p < 0.001) but more for post-treatment and iatrogenic avascular necrosis (p < 0.001; p < 0.001). Early THAs primarily used metal on UHMWPE (Ultra high molecular weight polyethylene) (71.7%, p < 0.001), modern THA predominantly use ceramic on HXLPE (Highly cross-linked polyethylene) (42.5%, p < 0.001). Early fixation methods used cement (60.4%, p < 0.001), and modern fixation primarily use press fit technology (95.9%, p < 0.001). Prevalence of radiographic loosening decreased significantly (p < 0.001) over time. There was no significant difference in clinical improvement on HHS. Lastly, fewer patients required THA revision in recent decades (p < 0.001).

CONCLUSIONS

Advances in surgical technique and technology have served to improve implant longevity. Surprisingly, subjective clinical scores showed no significant improvement over time, suggesting that early iterations of THA were extremely successful.

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.

Survival and complications of total hip arthroplasty using third-generation dual-mobility cups with non-cross-linked polyethylene liners in patients younger than 55years

BACKGROUND

In younger patients, total hip prostheses are subjected to wide motion ranges and wear-inducing forces. Dual-mobility cups (DMCs) are effective in decreasing the risk of dislocation. However, wear and osteolysis have been reported with first-generation DMCs. These complications have not been assessed in younger patients managed with third-generation DMCs associated with a lower risk of intra-prosthetic dislocation (IPD). We therefore designed a retrospective study of patients younger than 55years at THA with third-generation DMCs. Our objectives were to evaluate (1) the complication rate, and (2) the survival rate.

HYPOTHESIS

The rate of complications of THA with third-generation DMCs in patients younger than 55years of age is comparable to that in the general population of THA patients.

MATERIAL AND METHODS

This retrospective study included 79 consecutive patients (91 hips) who had total hip arthroplasty (THA) between 2007 and 2012. We included all patients younger than 55years who underwent primary THA with a third-generation DMC and a liner made of non-cross-linked polyethylene. The patients were evaluated clinically and radiologically.

RESULTS

Mean follow-up was 9.8years (range: 2-13years). At last follow-up, no patient had experienced prosthetic dislocation or IPD. Aseptic and septic cup loosening each occurred in 1 patient. In all, 7 (7.7%) patients required revision surgery with exchange of at least one component (cup loosening, n=2; neck fracture with a short stem fixed to the neck, n=1; peri-prosthetic femoral fracture, n=1; infection, n=1; and femoral-stem loosening, n=2). Peri-acetabular osteolysis developed in 2 (2.2%) hips. Cup survival to aseptic loosening was 98.9% (95% confidence interval, 97%-100%) and survival to revision for any reason except infection was 95.6% (95% confidence interval, 82%-100%).

DISCUSSION

In patients younger than 55years, third-generation DMCs were associated with absence of prosthetic dislocation, absence of IPD, and a low revision rate for cup loosening, in the medium term. These implants therefore constitute a viable treatment option in younger patients requiring THA.

LEVEL OF EVIDENCE

IV, retrospective study.

Primary total hip arthroplasty: mid-term outcomes of dual-mobility cups in patients at high risk of dislocation

INTRODUCTION

Dual-mobility cups (DMC) are currently used in patients having risk factors of instability. Most of the studies report the use of DMC in patients having a single high-risk variable. The aim of the study was to analyse a continuous series of patients treated with primary total hip arthroplasty (THA) and DMC with different high risk for dislocation.

METHODS

This is a retrospective study analysing the outcomes of primary THA with DMC in patients at high-risk of dislocation. The sample consisted of 215 patients having 1 of 3 aetiologies or risk factors: (1) young subjects (<55 years); (2) osteonecrosis of the femoral head (ONFH); and (3) femoral neck fracture (FNF).

RESULTS

With a mean follow-up duration of 70 ± 24.7 months, the findings showed the following: 2 patients had dislocated their hip following motor vehicle accidents; 1 patient had a traumatic femoral peri-prosthetic fracture; and 1 patient had an acute infection. No intra-prosthetic dislocation or aseptic loosening were encountered. No radiolucent lines were observed on the acetabular side. The mean modified Hip Harris Score was 96.6 ± 7.4%. Out of 186 patients, 170 (90.1%) would label their operated hip as a "forgotten hip". 78 out of the 84 patients (92.8%) who used to practice oriental sitting and/or ablution for prayers were able to return to their usual daily activities of extreme hip position and 74 out of the 84 patients (88%) described their operated hip as "a forgotten hip". No correlation was found between any of the studied variables.

DISCUSSION

The findings of this series of patients at high risk of dislocation showed excellent clinical and radiological results with very few complications. The use of DMC seems to counteract the impact of some aetiologies/risk factors that could lead to higher instability. Most patients practising extreme hip positions resumed their usual practices.

Outcome of 881 total hip arthroplasties in 747 patients 21 years or younger: data from the Nordic Arthroplasty Register Association (NARA) 1995-2016

Background and purpose - The literature is scarce on the outcome of the youngest patients with total hip arthroplasties (THAs). We analyzed register data, revision risk, and related factors in patients 21 years or younger with THAs in the Nordic Arthroplasty Register Association (NARA). Patients and methods - We included all THA patients 21 years or younger reported during 1995 through 2016 to the Danish, Finnish, Norwegian, and Swedish hip arthroplasty registers and merged these into the NARA dataset. Primary outcome was any implant revision. Results - We identified 881 THAs in 747 patients. Mean age at primary surgery was 18 years (9-21). The indications for THA were pediatric hip diseases (33%), systemic inflammatory disease (23%), osteoarthritis (4%), avascular necrosis (12%), hip fracture sequelae (7%), and other diagnoses (21%). Unadjusted 10-year survival for all THAs was 86%. Comparison between indications showed no differences in survival. Uncemented implants were used most frequently. Survival for uncemented and cemented implants was the same adjusted for sex, indication, head size, and time period for primary surgery. Aseptic loosening was the main cause of revision. Interpretation - Both cemented and uncemented fixations seem to be a viable option in this age group, but with a lower implant survival than in older patient groups.

Application and preliminary validation of the hip inflammation MRI scoring system (HIMRISS) in spondyloarthritis

AIMS

Spondyloarthritis (SpA) is an inflammatory rheumatic disease and hip involvement often results in severe deformities and functional impairment. Magnetic resonance imaging (MRI) is a powerful imaging tool for detecting early hip lesions in SpA. The aims of this study are to apply the hip inflammation MRI scoring system (HIMRISS) in SpA patients and to evaluate its reproducibility and validity.

METHODS

Four readers new to HIMRISS (two radiologists and two rheumatologists) scored the MRI scans obtained from a total of 55 SpA patients with hip lesions in two separate exercises (33 patients in exercise 1 and 22 patients in exercise 2). After the training and review process for exercise 1, these well-trained readers with expertise in the HIMRISS method scored the scans obtained from 22 patients and evaluated the association between HIMRISS and clinical activity of SpA, including Ankylosing Spondylitis Disease Activity Score (ASDAS), laboratory features, Bath Ankylosing Spondylitis Disease Activity Index and Harris hip scores.

RESULTS

HIMRISS is a reliable MRI scoring method for bone merrow lesions (BML) and synovitis in SpA. After 2 training exercises, the reliability improved from 0.67 to 0.90. The reliability for detecting femoral BML, acetabular BML, and synovitis effusion was very good after the 2 exercises (overall intraclass correlation coefficient = 0.73, 0.84 and 0.88, respectively). The clinical correlations between HIMRISS and ASDAS were most significant, and the correlations were closer to summed bilateral HIMRISS scores than just the worse side. HIMRISS was found to be an excellent tool for the early diagnosis of inflammation before the occurrence of structural damage, which was not significantly reflected in the systemic diagnosis.

CONCLUSION

HIMRISS offers a reliable MRI scoring method for hip joint in SpA, and it is beneficial for early detection and fast quantification in disease activity assessment.

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.

Temporal trends and survivorship of total hip arthroplasty in very young patients

Aims

The aim of this study was to describe temporal trends and survivorship of total hip arthroplasty (THA) in very young patients, aged ≤ 20 years.

Patients and Methods

A descriptive observational study was undertaken using data from the National Joint Registry (NJR) for England, Wales, Northern Ireland and the Isle of Man between April 2003 and March 2017. All patients aged ≤ 20 years at the time of THA were included and the primary outcome was revision surgery. Descriptive statistics were used to summarize the data and Kaplan–Meier estimates calculated for the cumulative implant survival.

Results

A total of 769 THAs were performed in 703 patients. The median follow-up was 5.1 years (interquartile range (IQR) 2.6 to 7.8). Eight patients died and 35 THAs were revised. The use of metal-on-metal (MoM) bearings and resurfacing procedures declined after 2008. The most frequently recorded indications for revision were loosening (20%) and infection (20%), although the absolute risk of these events occurring was low (0.9%). Factors associated with lower implant survival were MoM and metal-on-polyethylene (MoP) bearings and resurfacing arthroplasty ( vs ceramic-on-polyethylene (CoP) and ceramic-on-ceramic (CoC) bearings, p = 0.002), and operations performed by surgeons who undertook few THAs in this age group as recorded in the NJR ( vs those with five or more recorded operations, p = 0.030). Kaplan–Meier estimates showed 96% (95% confidence interval (CI) 94% to 98%) survivorship of implants at five years.

Conclusion

Within the NJR, the overall survival for very young patients undergoing THA exceeded 96% during the first five postoperative years. In the absence of studies that can better account for differences in the characteristics of the patients, surgeons should consider the association between early revision and the type of implant, the number of THAs performed in these patients, and the bearing surface when performing THA in very young patients. Cite this article: Bone Joint J 2018;100-B:1320–9.

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

Aims

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

Patients and Methods

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

Results

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

Conclusion

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

Results of the cemented Exeter femoral component in patients under the age of 40 : an update at ten to 20 years' follow-up

AIMS

We carried out a further study of the long-term results of the cemented Exeter femoral component in patients under the age of 40 with a mean follow-up of 13.6 years (10 to 20).

PATIENTS AND METHODS

We reviewed our original cohort of 104 cemented Exeter stems in 78 consecutive patients with a mean age of 31 years (16 to 39). Only one patient was lost to radiological follow-up.

RESULTS

A total of six patients (eight hips) had died for reasons unrelated to their surgery. There had been one further periprosthetic fracture from a fall and one fractured femoral stem. No revisions for aseptic loosening were undertaken during the whole study period. Overall, 11 hips had progressive radiolucent lines in one or more zones. The Kaplan Meier survival percentages at ten and 17 years were 97.1% (95% confidence interval (CI) 91.3 to 99.1) and 92.1% (95% CI 74.1 to 97.8) with revision for any reason as the endpoint, and 100% at both ten and 17 years with aseptic loosening (95% CI 83.8 to 100) as the endpoint. No additional hips were classified as radiologically loose.

CONCLUSION

The Exeter femoral component continues to function satisfactorily in young patients for up to 17 years after surgery. Cite this article: Bone Joint J 2017;99-B:192-8.

Influence of trabecular bone quality and implantation direction on press-fit mechanics

Achieving primary stability of uncemented press-fit prostheses in patients with poor quality bone can involve axial implantation forces large enough to cause bone fracture. Radial implantation eliminates intraoperative impaction forces and could prevent this damage. Platens of two commercial implant surfaces ("Beaded" and "Flaked") were implanted onto trabecular bone specimens of varying quality in a press-fit simulator. Samples were implanted with varying interference, either axially (shear) or radially (normal). Push-in and pull-out forces were measured to assess stability. Microstructural changes in the bone were determined from μCT analysis. For force-defined implantation analysis, push-in and pull-out forces both increased proportionally with increasing radial force, independent of implantation direction, bone quality or implant surface. For position-defined implantation analysis, pull-out forces were generally found to increase with interference and to be greater for radial than axial implantation direction, and to be lower for poor quality bone. Bone density increased locally at the tested interface due to implantation, in particular for the Beaded surface under axial implantation. If a safe radial stress can be determined for cortical bone in a particular patient, the associated implantation force, and pull-out force which represents primary stability, can be directly derived, regardless of implantation direction, bone quality or implant surface. Radial implantation delivers primary stability that is no worse than that for axial implantation and may eliminate potentially damaging impaction forces. Development of implant designs based on this principal might improve implant fixation. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:224-233, 2017.

Functional outcomes of total hip arthroplasty in patients aged 30 years or less: a systematic review and meta-analysis

INTRODUCTION

Young adult hip surgery is a growing subspecialty. Increasingly total hip arthroplasty (THA) is offered to patients aged 30 or less suffering from end-stage hip arthropathy from a variety of congenital, developmental and acquired conditions. There is a paucity of evidence to advise such patients and surgeons alike on the functional outcomes of THA in this age group, as individual studies tend to include small cohorts.

METHODS

A systematic review and meta-analysis was performed to assess whether THA in patients aged 30 years or less provides significant functional improvement. The primary outcome measure was change in Harris Hip Score. Secondary outcome measures were implant survivorship and the effect of fixation type and bearing surface.

RESULTS

The results of 743 primary THA procedures were included. Weighted mean patient age was 22.7 years. Harris Hip Score improved by a weighted mean difference of 42.17 points out of 100 (95% confidence interval, 36.48-47.86 points, p&lt;0.001) after THA at a weighted mean follow-up of 8.4 years. Pooled revision rate was 5.0% for the same time period.

CONCLUSIONS

This is the largest review to date of THA in patients aged 30 or less. The results show significant functional improvement measured by Harris Hip Score. The revision rate of 5% at 8.4 years is comparable to the general THA population. This contrasts high revision rates reported in older reviews of the literature, suggesting adoption of improved techniques and implants in the more recent literature.

A Literature Review of Total Hip Arthroplasty in Patients with Ankylosing Spondylitis: Perioperative Considerations and Outcome

Ankylosing spondylitis is a spondyloarthropathy affecting the sacro-iliac joints with subsequent progression to the spine and the hip joints. The hip joints are affected by synovitis, enthesial inflammation, involvement of medullary bone, progressive degeneration and secondary osteoarthritis. Clinical presentation is usually in the form of pain and stiffness progressing to disabling fixed flexion contractures and in some instances, complete ankylosis. Hip arthroplasty should be considered for hip pain, postural and functional disability, or pain in adjacent joints due to hip stiffness. We conducted a literature review to determine peri-operative considerations and outcome in ankylosing spondylitis patients undergoing hip arthroplasty. In this review, we have discussed pre-operative surgical planning, thromboprophylaxis, anaesthetic considerations and heterotopic ossification. Outcomes of arthroplasty include range of movement, pain relief, survivorship and complications.