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How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up
Abstract
Background
Total hip replacement is a common and highly effective operation. All hip replacements would eventually fail if in situ long enough and it is important that patients understand when this might happen. We aimed to answer the question: how long does a hip replacement last?
Methods
We did a systematic review and meta-analysis with a search of MEDLINE and Embase from the start of records to Sept 12, 2017. We included articles reporting 15-year survival of primary, conventional total hip replacement constructs in patients with osteoarthritis. We extracted survival and implant data and used all-cause construct survival as the primary outcome. We also reviewed reports of national joint replacement registries, and extracted data for a separate analysis. In the meta-analyses, we weighted each series and calculated a pooled survival estimate for each source of data. This study was registered with PROSPERO (CRD42018085642).
Findings
We identified 140 eligible articles reporting 150 series, and included 44 of these series (13 212 total hip placements). National joint replacement registries from Australia and Finland provided data for 92 series (215 676 total hip replacements). The 25-year pooled survival of hip replacements from case series was 77·6% (95% CI 76·0–79·2) and from joint replacement registries was 57·9% (95% CI 57·1–58·7).
Interpretation
Assuming that estimates from national registries are less likely to be biased, patients and surgeons can expect a hip replacement to last 25 years in around 58% of patients.
Funding
National Institute for Health Research, National Joint Registry for England, Wales, Northern Ireland and Isle of Man, and The Royal College of Surgeons of England.
Supplementary resources (2)
Data
February 2019
Data
February 2019
... Osteoarthritis of the hip and knee is the eleventh largest contributor to global disability [18], and as the population ages, this burden will rise. Hip replacements are one of the most successful surgical procedures performed, with a reported 10-year failure rate of only 4.56%, and PJI is the most feared complication [19]. ...
... Recent reports of septic patients have shown a correlation between circulating levels of PTX3 and other indicators of bacterial infections, including procalcitonin and D-dimer [24,25]. Procalcitonin procalcitonin and D-dimer both showed low diagnostic accuracy as PJI markers [19], and further study is required to properly appreciate their potential in this condition. Because PTX3 lies at the intersection of infection immunology and bone biology, it is therefore a great choice for research into novel PJI biomarkers [15]. ...
One of the most dangerous and difficult side effects to treat after total hip arthroplasty (THA) is periprosthetic or superficial site infection. Blood and synovial fluid biomarkers have recently come into focus in addition to conventional systemic indicators of inflammation in order to assess their potential utility in the diagnosis of infections. Long pentraxin 3 (PTX3) appears to be a sensitive biomarker of acute-phase inflammation. The purpose of this study is to determine plasma PTX3 in patients undergoing THA and compare its trend with other common serum markers, such as CRP, D-dimer, procalcitonin, and ESR up to 30 days post-operatively. Patients with hip arthritis or avascular necrosis of the femoral head were consecutively enrolled in a single-center study. Each patient underwent blood testing for ESR, CRP, procalcitonin, D-dimer, and PTX3 levels before surgery and at 1, 3, 5, 15, and 30 days after THA. PTX3 was measured using the ELISA method. Other markers’ values and trends were compared with PTX3’s. A total of 50 patients met our inclusion criteria. When different trends were evaluated, PTX3 was found to have a trajectory and sensitivity comparable to other inflammatory markers. Notably, PTX3 changed more quickly than the other markers, with a sharp increase immediately post-operatively, followed by normalization at the 5-, 15-, and 30-day follow-ups, corresponding to the resolution of the inflammatory condition. However, 30 days post surgery, no patients exhibited signs or symptoms of early prosthetic infection. PTX3 is confirmed as a reliable and promising serum biomarker for tracking the level of inflammation in patients undergoing total hip replacements. Blood PTX3 values rise even more rapidly than CRP and procalcitonin and then quickly return to normal values when the inflammatory process resolves. One of the primary barriers to PTX3’s inclusion in routine studies on early periprosthetic infections is the waiting period for PTX3 sample analysis.
... Arthroplasty represents a successful elective surgical procedure for patients affected by arthritis, fractures, or oncological conditions with a survivorship of about 88% at more than 15 years of follow up [1]. When properly performed, this procedure enhances the quality of life of patients, providing pain relief and restoration of joint function [1]. ...
... Arthroplasty represents a successful elective surgical procedure for patients affected by arthritis, fractures, or oncological conditions with a survivorship of about 88% at more than 15 years of follow up [1]. When properly performed, this procedure enhances the quality of life of patients, providing pain relief and restoration of joint function [1]. ...
Background: Periprosthetic joint infections (PJIs) are a significant issue in joint replacement surgery patients, affecting results and mortality. Recent research focuses on developing hydrogels (HG) and antimicrobial coatings to reduce pressure injuries, with DAC™ HG showing lower infection risk in hip revision surgery. However, the effectiveness of DAC™ hydrogel in PIJs is still unknown. Here, we attempt to update the literature in this field, pointing out methodological flaws and providing guidance for further research. Methods: We conducted a systematic literature review using the PRISMA guidelines. Quality assessment was performed with the Newcastle–Ottawa Scale (NOS) and the Coleman Methodology Score (CMS). Results: Among 27 records from the initial search, 3 studies resulted eligible for final evaluation. It was observed that following the three surgical procedures performed in combination with DAC™ loaded with specific antibiotics, the quality of life of the treated patients had improved. No side effects associated with DAC™ treatment were in fact observed. Conclusions: The amount and quality of scientific evidence are yet insufficient to either encourage or dissuade the use of such hydrogels in hip prosthesis, despite some intriguing first results. These challenges will be better addressed by randomized controlled trials or longitudinal prospective investigations.
... Additionally, Fig. 2(b) appears to be a timeline depicting the evolution of hip implants from the 1915s to the present. The diagram highlights key milestones in the development of hip implant design, showing how different designs and technologies have evolved [37][38][39][40][41][42][43]. ...
... Some of the widely used metallic materials for hip implants are highlighted subsequently. Fig. 3. shows the elastic modulus of different materials used in implant [58][59][60][61][62]. Hip implantation process, history, and development; (a) step-wise process to restore hip functionality with hip implants, and (b) evolution of hip implants for more than two centuries [37][38][39][40][41][42][43]. ...
The recent advancement of additive manufacturing (AM) offers many benefits for the medical sector, which is revolutionizing modern bone repair surgery for patients, including those with damaged hip joints. Consequently, AM enables the fabrication of hip replacements made of alloys like titanium, cobalt-chromium, stainless steel, and their alloys. Porous additive-manufactured hip implants possess various advantages, including patient-specific implant design, reduced production cost, mass reduction, and a longer implant life by alleviating stress shielding. Mass and stress shielding reduction of the implants can be achieved through topology optimization techniques incorporating cellular structures. Therefore, porous implant design, topology optimization, and additive manufacturing can merge to improve patient health and medical advancement. Hence, by integrating these three elements, this review represents the recent advancements in the topology optimization of hip implants using the AM technique for designing and fabricating porous hip implants.
... Although associated with large improvements in joint function and health-related quality of life (QoL) [4], complications have been reported with a mean short-term risk of 2.4% that can raise up to 12% after 10 years of surgery [5]. In 2019, a metaanalysis carried out on 13.212 patients with and average age of 58 years demonstrated THA failures in 25% of cases between 15 to 20 years and 42% within 25 years, demonstrating the need for continuous strategies re-evaluations and technological advances to prevent an economic burden on the health care system [6]. ...
... The mean age was 63±11 years. Evans et al. [6] showed in a meta-analysis that the mean age for a THA was 58 years and by that we should question the durability of our arthroplasties. Life expectancy at Santa Catarina has reached 80 years of age [15]. ...
... Total hip arthroplasty (THA) is one of the most successful orthopedic procedures and involves resection of disease articular surfaces of the hip with subsequent replacement with prosthetic hip components. In a population-based cohort study with over 60,000 patients who underwent THA, over 90% of patients had successful results, were pain-free, and developed no complications within a 15-year postoperative period (9). ...
Introduction
This retrospective cohort study investigated the “Hajeer score” (age/BMI) as a predictor of 30-day postoperative outcomes pertaining to morbidity and mortality following total hip arthroplasty.
Methods
Using the National Surgical Quality Improvement Project database from 2011 to 2021, this study analyzed perioperative factors and 30-day postoperative complications in relation to age, BMI, and the Hajeer score. The complications evaluated included venous thromboembolism, pneumonia, acute myocardial infarction, readmission rates, and 30-day mortality. Patients were categorized based on their age, BMI, and Hajeer score and adjusted odds ratios (aORS) for morbidities and mortality were calculated by multivariate logistic regression.
Results
A total of 321,973 patients who underwent total hip arthroplasty were included in this study. Risk of mortality and various other outcomes (including cardiac, respiratory, urinary, and central nervous system diseases, thromboembolism, sepsis, blood transfusion, and composite morbidity) increased with age. Conversely, a higher BMI was linked to a lower risk of mortality, cardiac and respiratory diseases, and blood transfusion. A higher Hajeer score (>3) was strongly associated with an increased risk of mortality [adjusted odds ratio [OR]: 20.06, 95% confidence interval [CI]: 2.81–143.08, p < 0.05], cardiac diseases (adjusted OR: 8.53, 95% CI: 1.19–60.96, p < 0.0001), respiratory diseases (adjusted OR: 1.40, 95% CI: 1.40–1.41, p < 0.0001), and blood transfusion (adjusted OR: 2.12, 95% CI: 1.73–2.60, p < 0.05).
Conclusion
The Hajeer score could be a more effective predictor of short-term (30-day) postoperative outcomes than either age or BMI alone.
... However, their findings with regard to prosthesis materials and fixation method, while favouring the use of cement, were inconclusive, and this could be attributed primarily to the methodology employed, which excluded studies of small sample sizes and those examining the failure of a specific component, such as the stem. In contrast to the available evidence suggesting that youth predisposes patients to exceeding the lifetime risk of revision surgery, 27,28 our study focused on a specific reason for short-term (up to one year) secondary surgery due to femoral fracture; thus, our augmented one-year implant failure risk with increasing age is likely attributed to the underlying physiological processes of ageing. 29,30 With regard to comorbid status and BMI, our findings support the available evidence indicating increased odds of early revision THA with higher comorbidity indices 31,32 and BMI. ...
Aims
While cementless fixation offers potential advantages over cemented fixation, such as a shorter operating time, concerns linger over its higher cost and increased risk of periprosthetic fractures. If the risk of fracture can be forecasted, it would aid the shared decision-making process related to cementless stems. Our study aimed to develop and validate predictive models of periprosthetic femoral fracture (PPFF) necessitating revision and reoperation after elective total hip arthroplasty (THA).
Methods
We included 154,519 primary elective THAs from the Swedish Arthroplasty Register (SAR), encompassing 21 patient-, surgical-, and implant-specific features, for model derivation and validation in predicting 30-day, 60-day, 90-day, and one-year revision and reoperation due to PPFF. Model performance was tested using the area under the curve (AUC), and feature importance was identified in the best-performing algorithm.
Results
The Lasso regression excelled in predicting 30-day revisions (area under the receiver operating characteristic curve (AUC) = 0.85), while the Gradient Boosting Machine (GBM) model outperformed other models by a slight margin for all remaining endpoints (AUC range: 0.79 to 0.86). Predictive factors for revision and reoperation were identified, with patient features such as increasing age, higher American Society of Anesthesiologists grade (> III), and World Health Organization obesity classes II to III associated with elevated risks. A preoperative diagnosis of idiopathic necrosis increased revision risk. Concerning implant design, factors such as cementless femoral fixation, reverse-hybrid fixation, hip resurfacing, and small (< 35 mm) or large (> 52 mm) femoral heads increased both revision and reoperation risks.
Conclusion
This is the first study to develop machine-learning models to forecast the risk of PPFF necessitating secondary surgery. Future studies are required to externally validate our algorithm and assess its applicability in clinical practice.
Cite this article: Bone Joint Res 2025;14(1):46–57.
... Non-pharmacological interventions, such as physiotherapy and structured exercise programs, demonstrated efficacy in improving function and reducing pain [9]. Surgical options, such as joint replacement, are reserved for severe cases where conservative treatments fail [10]. ...
Musculoskeletal diseases (MDs) are a wide range of conditions affecting bones, muscles, joints, and connective tissues and are among the leading causes of disability worldwide [...]
... In the past, treatment outcomes of THA for end-stage hip osteoarthritis have been mostly defined by implant survival, which suggest a successful treatment in > 95% of cases [6][7][8]. However, from a patient perspective, success is defined as satisfactory relief of symptoms, and by this measure, success rates of THA are only 80%-90% [9][10][11]. ...
Purpose
Proximal femoral fractures are common within the elderly population and are associated with a high risk of mortality and reduced quality of life. Hemiarthroplasty or osteosynthesis (extramedullary or intramedullary) is the primary treatment option for these fractures. However, within this fragile patient population many comorbidities, among others dementia, are seen. Therefore, predicting patients with a high mortality risk after surgery may lead to adopting alternative treatment options with less risks. This paper proposes a new model to distinguish patients with high postoperative mortality risk with adequate follow-up time in combination with a wide set of useful and available variables.
Methods
Patients treated with hemiarthroplasty or osteosynthesis for proximal femoral fractures were studied, with a follow-up period of 6 months. Patients who died within this follow-up period were compared to survivors, and predicting variables were assessed in logistic regression: The Zuyderland Hip Inference for Survival and Lifetime Expectancy (ZHISLE). The model was validated internally against a held-out dataset. Furthermore, the model performance was compared against the Almelo Hip Fracture Score (AHFS) on the same sample.
Results
Out of 2463 patients undergoing surgical treatment for proximal femoral fractures, 415 (16.8%) died within 183 days. Predictors for early mortality included old age, male sex, high heartbeat, KATZ-ADL and GFI scores, C-reactive protein and urea concentrations and low albumin concentration. Our model showed satisfactory predictive and discriminatory power (ROC curve = 0.81). Internal validation was good (ROC in validation dataset = 0.81), and better than the AHFS (ROC = 0.57).
Conclusions
The ZHISLE model demonstrates good predictive power concerning mortality risk for old patients with a proximal femoral fracture. The model could benefit patients by indicating if a conservative, non-invasive policy might be a better option for those patients.
... (67.7 and 69.9 years at surgery, respectively) [2,55,56]. Age at the time of surgery is an important factor when evaluating the impact of smoking, as the harmful effects of long-term tobacco use are amplified over the years [57]. This is compounded by the higher prevalence of comorbid factors such as elevated BMI, previous complications from surgeries, and medical history, particularly in older patients who smoke [57]. ...
Purpose
This study evaluates the impact of smoking on clinical outcomes following hip arthroscopy (HA) through a systematic review and meta-analysis.
Methods
This systematic review and meta-analysis queried PubMed, Scopus, Cochrane, and CINAHL from inception to April 30, 2024, for articles related to smoking and HA outcomes. A random-effects model meta-analysis using relative risk (RR) and 95% confidence intervals was performed to compare smokers and nonsmokers for conversion to total hip arthroplasty (THA) and revision hip arthroscopy (RHA).
Results
Twenty observational studies (n = 115,203 patients; 66.95% female; mean age: 36.93 ± 6.53 years; mean follow-up: 22.10 ± 7.56 months) were included. Nine studies investigated smoking and conversion to THA, six examined smoking and RHA, eight assessed smoking and postoperative patient-reported outcomes, and eight evaluated smoking and postoperative complications. Regarding conversion to THA, 5 studies (55.56%) found a significant association, while 4 (44.44%) did not. Meta-analysis from four studies found no significant association between smoking and THA conversion (p = 0.48, OR: 1.02; 95% CI: [0.98–1.06]) or smoking and RHA (p = 0.305, OR: 1.00; 95% CI: [0.97–1.03]). Only 2 studies (33.33%) found a significant association between smoking and RHA, whereas four did not. Six studies found smoking significantly implicated in complications such as HA failure, increased opioid use, infection risk, and venous thromboembolism (VTE). THA conversion rates were 6.54% (n = 14/214) among smokers versus 3.57% (n = 13/364) among nonsmokers.
Conclusion
This study found no statistically significant association between smoking and THA conversion, though smokers were observed to experience higher conversion rates overall. Similarly, no significant association was observed for smoking and RHA at 2-year follow-up. However, trends suggest that smokers experience greater risks of adverse outcomes, particularly VTE and HA failure, which should be considered in clinical decision-making.
Level of Evidence
Level III
... Despite being in use for more than three decades, the long-term survival of CMPs has not been extensively studied. Only one study reported a survival rate of 83% at 15 years and 68% at 20 years, indicating a less durable survivorship compared to hip or knee arthroplasties [45,46]. However, CMPs have demonstrated comparable survival rates to other types of TEAs [37,38]. ...
Background
The Coonrad-Morrey prosthesis (CMP) is a widely applied semi-constrained implant that effectively counteracts compression and thrust on the hinge. The aim of this systematic review was to evaluate the indications and outcomes of CMP across different aetiologies for which it was implanted.
Materials and methods
Selected articles were reviewed to extract: population data, surgical indications, preoperative and postoperative clinical outcomes, survival rate, and complications.
Results
A total of 873 TEAs were analysed. The majority of implants (74.8%) were in female, with a mean age of 62.8 years. Rheumatoid arthritis (RA) was the most common indication (69.9%), followed by post-traumatic sequelae (PTS) (12.1%) and acute fractures (FR) (12.1%). Improvement in functional scores were registered with a mean postoperative flexion–extension of 99.0° and a mean pronation-supination of 137.7°. A mean rate of 29.5% (range, 13.3%-71.4%) complications occurred, mechanical failure (9.04%) being the most frequent.
Conclusion
CMP showed favourable medium- to long-term clinical outcomes for patients with RA and FR, especially when osteosynthesis is not deemed feasible in elderly patients with low joint workload. Although CMP offered restored range of motion and functional improvements, the implant's low overall survival rate and high complication rate require careful consideration, especially in assessing individual patient factors which are then necessary to determine the suitability of CMP as a therapeutic option.
... 5,6 The gold-standard treatment for hip OA is a total hip arthroplasty (THA) and over the past several decades, implants have become increasingly advanced and durable, which allows this procedure to be performed in younger more active patients. 7,8 In addition, the advent and use of online resources have allowed patients to be more well-informed about recent developments in medicine, as well as give them the con dence to be greater advocates for the treatments they desire. 9 As a result, there is an increasing number of young patients who present to the clinic, having failed non-operative measures and requesting a surgical solution for their hip pain. ...
Introduction: Total hip arthroplasty (THA) is increasingly used in less severe cases of hip osteoarthritis (OA).This paper aimed to determine 1) The prevalence of different degrees of OA before THA, 2) The association of pre-operative OA severity with the severity of baseline symptoms and 3) The association of pre-operative OA severity with outcomes post-THA. Methods: A retrospective study of a prospective database of all THAs at two tertiary academic centers between 2020 and 2021 was conducted. There were 803 patients in the database, with 109 being excluded due to incomplete data. There were 694 patients included, and the mean age and body mass index were 64.50±12.80 years and 28.45±5.90 kg/m2, respectively. Most patients were women (n=361; 52.0%). Radiographic analysis was performed to assess the degree of hip OA with the Tönnis grade (0 – 3; no OA – complete degradation). Patients had pre-operative patient-reported outcome measures (PROMs) of hip function via the Oxford Hip Score (OHS) and their overall well-being via the EQ-5D-5L, with follow-up and post-operative PROMs 12 months after surgery. Data analysis was performed using SPSS (IBM, Armonk, NY). Results: There were no differences in pre-operative OHS between Tönnis groups (18±6.26, n=14 in Tönnis 1, 21.19±8.27, n=260 in Tönnis 2 and 18.18±7.09, n=420 in Tönnis 3, p=0.14) After one year, the increase in OHS was 18.03±11.95, 18.32±10.96, and 24.32±9.98, respectively for Tönnis 1,2, and 3 (p<0.001). Thus, the percentage meeting the patient acceptable symptom state (PASS) was 57.1%, 60.8% and 72.6%. One year EQ-5D-5L was also highest in Tönnis 3 (47.5 ± 4.03, 79.6 ± 13.25 and 82.12 ± 11.67, p<0.001). Conclusion: The highest-grade OA before THA was correlated with the greatest improvements in hip function and quality of life. This study demonstrates that a conservative approach and re-education should be attempted in patients who have an absence of advanced radiographic OA.
... 9 Evans JT concluded that surgeons can expect THA to last 25 years in around 58% of patients. 10 Understanding the epidemiology of hip arthroplasty in young individuals is crucial for healthcare professionals to provide appropriate care and develop preventive measures. Current literature does not specifically mention cutoff age to differentiate between young and old population, but quite a few articles have reported on 45,55 and 65 years as arbitrary cutoff. ...
Objective
To report on causes and treatment options of hip arthroplasty in younger population in a single center.
Methods
Data was accessed retrospectively from hospital information system (HIS) and charts were reviewed. All patients younger than 50 years, who had hip arthroplasty for any indication during January 2020 to July 2023 time period at Lady Reading Hospital, Peshawar, were included in this study.
Results
We identified 61 patients, comprising of 33 male and 28 female patients. Mean age was 36.98 ± 7.792 years. Non-cemented hip arthroplasty was performed in 88.5% of patients. Avascular necrosis (49.2%) was the leading indication for hip arthroplasty in younger patients, followed by neglected fracture neck of femur (24.6%), inflammatory arthritis (3.2%), and other causes (23%). Metal on highly cross-linked polyethylene was the commonest bearing surface.
Conclusion
Non-cemented hip arthroplasty was the commonest treatment method in younger population in this study.
... Total hip replacement (THR) is widely used to treat diseased and damaged joints with over 100,000 performed annually in the United Kingdom [1,2]. Although 58% to 78% of THRs last more than 25 years [3], many still fail resulting in 5,073 revisions annually in the UK in 2021 [1,4]. People experience worse pain and function after revision compared with primary THRs and often require further revision [5,6]. ...
Background
The risk of re-operation, otherwise known as revision, following primary hip replacement depends in part on the prosthesis implant materials used. Current performance evidences are based on a broad categorisation grouping together different materials with potentially varying revision risks.
We investigated the revision rate of primary total hip replacement (THR) reported in the National Joint Registry by specific types of bearing surfaces used.
Methods and findings
We analysed THR procedures across all orthopaedic units in England and Wales. All patients who received a primary THR between 2003 and 2019 in the public and private sectors were included. We investigated the all-cause and indication-specific risks of revision using flexible parametric survival analyses to estimate adjusted hazard ratios (HRs). We identified primary THRs with heads and monobloc cups or modular acetabular component THRs with head and shell/liner combinations.
A total of 1,026,481 primary THRs were analysed (Monobloc: n = 378,979 and Modular: n = 647,502) with 20,869 (2%) of these primary THRs subsequently undergoing a revision episode (Monobloc: n = 7,381 and Modular: n = 13,488).
For monobloc implants, compared to implants with a cobalt chrome head and highly crosslinked polyethylene (HCLPE) cup, the all-cause risk of revision for monobloc acetabular implant was higher for patients with cobalt chrome (hazard rate at 10 years after surgery: 1.28 95% confidence intervals [1.10, 1.48]) or stainless steel head (1.18 [1.02, 1.36]) and non-HCLPE cup. The risk of revision was lower for patients with a delta ceramic head and HCLPE cup implant, at any postoperative period (1.18 [1.02, 1.36]).
For modular implants, compared to patients with a cobalt chrome head and HCLPE liner primary THR, the all-cause risk of revision for modular acetabular implant varied non-constantly. THRs with a delta ceramic (0.79 [0.73, 0.85]) or oxidised zirconium (0.65 [0.55, 0.77]) head and HCLPE liner had a lower risk of revision throughout the entire postoperative period.
Similar results were found when investigating the indication-specific risks of revision for both the monobloc and modular acetabular implants.
While this large, nonselective analysis is the first to adjust for numerous characteristics collected in the registry, residual confounding cannot be rule out.
Conclusions
Prosthesis revision is influenced by the prosthesis materials used in the primary procedure with the lowest risk for implants with delta ceramic or oxidised zirconium head and an HCLPE liner/cup. Further work is required to determine the association of implant bearing materials with the risk of rehospitalisation, re-operation other than revision, mortality, and the cost-effectiveness of these materials.
... With a rejuvenation of the THA population [11], daily life activities are becoming more intense and frequent, thus modifying the joint contact forces and sliding velocities applied to the implant. For this reason and due to greater implant longevity [12], there is an increasing risk of wear which needs to be measured in a personalised way to improve THA followup. Some studies have addressed implant wear during daily life activity, using mechanical tests on a hip simulator [13,14] or numerical tests with finite element (FE) models [15]. ...
The dual mobility cup (DMC) was developed to decrease wear, increase stability, and restore patients’ hip range of motion compared to the traditional single mobility cup (SMC) in total hip arthroplasty (THA). A rejuvenation of the THA population is increasing the risk of wear, and more personalised follow-up of patients is required. The aim of this study was to estimate DMC-THA wear during daily life activities based on 3D motion capture data. Using a musculoskeletal and a stem–liner contact model, a wear factor was computed for 16 participants with SMC-THA and compared to virtual DMC-THA. The force–velocity factor was estimated for slow, self-selected, and fast gait, as well as sit-to-stand and stand-to-sit activities. A significantly lower factor was found for DMC-THA than for SMC-THA during gait at the different speeds and during sit-to-stand. In the stand-to-sit task, the potential advantage of DMC-THA was not demonstrated, likely because the liner kinematics was simulated during intervals in the activity when hip contact force and sliding velocity were high. This study suggests the potential lower risk of wear of the DMC-THA, based on 3D motion capture data and multibody dynamics simulations. It also showed that an in vivo risk of wear can be estimated to help stratifying patients.
... Osteoarthritis (OA) is a common and disabling condition, characterized by joint pain and stiffness due to gradual cartilage erosion [1]. Among its forms, hip OA is particularly debilitating, significantly limiting locomotor activity and functional ability, often progressing to a severity that necessitates joint replacement [2,3]. In the past 30 years, the prevalence of hip OA has risen from 17.02 to 18.70 per 100,000 persons [4], a trend reflecting broader demographic changes such as an aging global population and increasing obesity rates [1]. ...
Background/objectives
While weight loss is recommended for managing hip osteoarthritis (OA), most evidence comes from knee OA studies, limiting its applicability to hip OA. This study addresses this gap by examining the effects of weight loss on hip OA symptoms.
Design and setting
A retrospective audit of routinely collected healthcare data from participants enrolled in the Osteoarthritis Healthy Weight for Life (OAHWFL) program, designed for individuals with knee or hip OA.
Participants
In total, 1714 adults with hip OA were selected from the OAHWFL program; 1408 completed the initial 18-week weight loss phase, while 306 did not complete it. After 18 weeks, participants transitioned to an indefinite weight maintenance phase.
Exposure
Percentage change in body weight from baseline at 18 weeks.
Outcomes
Changes in the five subscales of the Hip Disability and Osteoarthritis Outcome Score (HOOS) (Pain, Activity Limitations in Daily Living, Stiffness and Range of Motion, Sports and Recreation Function, and Hip-related Quality of Life) from baseline to 18 weeks.
Statistics
Linear regression, adjusted for sex and baseline values of age, weight, and respective HOOS scores, assessed the relationship between percentage weight change (analyzed as both a continuous variable and in categories: ≤2.5%, >2.5–5.0%, >5.0–7.5%, >7.5–10%, and >10% of baseline weight) and changes in all five HOOS subscales.
Results
At baseline, participants had a mean age of 65.14 years, 70% were female, and 78% were individuals with obesity (Body Mass Index ≥30 kg/m²). A statistically significant dose-response relationship was observed between weight loss and improvements in all HOOS subscales, with the greatest improvement in the Hip-related Quality of Life subscale (14.42 points, 31.14%) for >10% weight loss.
Conclusion
Our findings suggest that weight loss is associated with reduced symptoms of hip OA, supporting weight loss as an effective treatment strategy for hip OA.
... The longevity of a prosthesis depends on several factors related to the patient and the surgery; a meta-analysis from the University of Britol published in 2019 stated that 58% of patients could expect a hip replacement to last 25 years [4]. ...
Periprosthetic joint infections are still a challenge in orthopedics and traumatology. Nowadays, genomics comes to the aid of diagnosis and treatment, in addition to traditional methods. Recently, a key role of the intestinal microbiota has been postulated, and great efforts are aimed at discovering its interconnection, which shows to be at different levels. Firstly, the gut microbiome influences the immune system through the gut-associated lymphoid tissue (GALT). A balanced microbiome promotes a strong immune response, which is essential to prevent all local and systemic infections, including PJI. Thus, a dysbiosis, i.e., the disruption of this system, leads to an imbalance between the various strains of microorganisms co-existing in the gut microbiome, which can result in a weakened immune system, increasing susceptibility to infections, including PJI. Additionally, the dysbiosis can result in the production of pro-inflammatory mediators that enter the systemic circulation, creating a state of chronic inflammation that can compromise the immune system’s ability to fend off infections. Furthermore, the microbiome maintains the integrity of the gut barrier, preventing the translocation of harmful bacteria and endotoxins into the bloodstream; dysbiosis can compromise this protective “wall”. In addition, the gut microbiome may harbor antibiotic-resistance genes; during antibiotic treatment for other infections or prophylaxis, these genes may be transferred to pathogenic bacteria, making the treatment of PJI more difficult. In this complex landscape, next-generation sequencing (NGS) technology can play a key role; indeed, it has revolutionized the study of the microbiome, allowing for detailed and comprehensive analysis of microbial communities. It offers insights into the functional potential and metabolic capabilities of the microbiome, studies the collective genome of the microbiome directly from environmental samples sequencing DNA without isolating individual organisms, analyzes the RNA transcripts to understand gene expression and functional activity of the microbiome, analyzes the RNA transcripts to understand gene expression and functional activity of the microbiome, investigates the metabolites produced by the microbiome and studies the entire set of proteins produced by the microbiome. NGS technology, the study of the micromyoma and its implications in the field of orthopedic trauma are innovative topics on which few publications are yet to be found in the international scientific literature. The costs are still high, the focus of research is maximum, and it will certainly change our approach to infections. Our study is an up-to-date review of the hot topic application of NGS in the study and investigation of periprosthetic infections and the microbiome.
... Total hip replacement (THR) is the mainstay of treatment for end stage osteoarthritis of the hip and, in general, is safe and effective [1]. While most hip replacements are expected to last over 25 years, failures do occur and this results in severe pain and disability for the patient as well as the need for revision surgery [2], which is costly to both the patient and the health service [3,4]. Hip replacements can fail and need revision for several reasons including infection, joint instability, wear and/or loosening of the hip replacement components, unexplained pain, or when the femur supporting the hip replacement fractures [5]. ...
Background
Postoperative periprosthetic femoral fracture (POPFF) after total hip replacement (THR) requires complex surgery and is associated with a high morbidity, mortality, and cost. Although the United Kingdom based National Joint Registry (NJR) captures over 95% of THRs treated with revision, before June 2023 it did not capture POPFF treated with fixation. We aimed to estimate the incidence and epidemiology of POPFF treated with either surgery in England.
Methods and findings
We performed a retrospective analysis of a mandatory, prospective database (NJR) linked to Hospital Episode Statistics (HES). All linkable primary THRs between 01/01/2004 and 31/12/2020 were included. Revision or fixation of POPFF were identified using a combination of procedural and diagnosis codes.
We identified 809,832 THRs representing 5,542,332 prosthesis years at risk. A total of 5,100 POPFF were identified that had been surgically treated by revision, fixation, or both, and 2,831 of these fractures were treated with fixation alone, meaning 56% were not represented with revision data alone. The incidence of POPFF needing surgery was 0.92 (95% CI 0.90, 0.95) per 1,000 prostheses years. This incidence was higher in patients over the age of 70 at the time of primary THR (1.31 [95% CI 1.26, 1.35] per 1,000 prostheses years) and for patients who underwent THR for hip fracture (2.19 [95% CI 1.97, 2.42] per 1,000 prostheses years). This incidence appears to be increasing year on year. The cumulative probability of sustaining a POPFF within 10 years of THR was 1% and over 15% of patients died within 1 year of surgery for a POPFF.
Conclusions
To date, the incidence of POPFF may have been underestimated with over 50% of cases missed if the case identification in this study is correct. After including these cases, we observed that POPFF is the largest reason for major reoperation following THR and patients sustaining these injuries have a high risk of death. The prevention and treatment of POPFF and requires further resource allocation and research.
... or 89.4% (95% CI 89.2-89.6), respectively [34]. However, more recent reports from the NJR suggest the 15-year revision risk of fully cemented primary THA to be significantly better with a cumulative incidence of revision of 5.15% (95% CI 4.99-5.31). ...
Background: This study reports the long-term survivorship of primary total hip arthroplasty (THA) for protrusio acetabuli. Methods: Patients undergoing THA utilising cement and bone graft acetabular reconstruction for protrusio acetabuli in a university teaching hospital during the period 2003 to 2014 were included. Kaplan–Meier survival estimates were calculated with 95% confidence intervals (CI) up to 15 years following surgery. PROMs were collected pre- and post-operatively for hip-specific function (Oxford Hip Score [OHS]) and health-related quality of life (HRQoL) using the EQ-5D-3L. Results: 129 consecutive THAs (96 patients) performed for protrusio acetabuli were identified (median age 69, IQR 61–75; female 115 [89.1%]; 38 [29.5%] inflammatory arthritis) with a mean follow-up of 15.7 years (range: 10.1–20.1 years). At the final follow-up, fifty-six (43.4%) patients had died and there were eleven (8.5%) reoperations, of which eight (6.2%) involved the revision of the acetabular component. The fifteen-year Kaplan–Meier any-reoperation survival estimate was 91.3% (95% CI 85.9–97.0). When considering all-cause acetabular revision only, the 15-year survival estimate was 93.1% (95% CI 88.2–98.3). The median pre-operative OHS improved significantly from baseline to 1 year post-THA, beyond the minimal important change (mean difference 28, 95% CI 25–30, p < 0.001). Similarly, there were clinically relevant improvements in HRQoL at 1 year post surgery (mean difference 0.10, 95% CI 0.06–0.15, p < 0.001). Conclusions: This study demonstrates that primary cemented THA utilising acetabular bone graft for reconstruction in patients with protrusio acetabuli was associated with 15-year survival rates of 93.1% and clinically relevant improvements in hip-specific function and HRQoL.
... Total hip arthroplasty (THA) is a highly reliable surgical procedure that significantly improves patient's quality of life by restoring mobility and reducing pain [1][2][3]. THA yields excellent outcomes and is considered one of the best treatment options for end-stage hip osteoarthritis (OA) patients [4][5][6]. Recent developments in THA have focused on lowering failure rates while meeting the highactivity level of modern patients [7][8][9]. It has been referred to as the orthopaedic operation of the century [10,11]. ...
Introduction
In orthopaedic research, it is crucial to determine changes that are statistically significant and clinically meaningful. One approach to accomplish this is by calculating the Minimal Clinically Important Difference (MCID), the Clinically Important Differences (CID), the Minimum Detectable Change (MDC), the Minimal Important Change (MIC), and the Patient Acceptable Symptom State (PASS) values. These tools assist medical professionals in comprehending the patient’s viewpoint, enabling them to establish treatment objectives that align with patients’ desires and expectations. The present systematic review investigated the MCID, MIC, CID, MDC, and PASS of the most used PROMs to assess patients who have undergone THA.
Methods
This systematic review followed the 2020 PRISMA guidelines. Web of Science, Embase, and PubMed were accessed in March 2024 without time constraints or additional filters. All the clinical investigations which evaluated data tools (MCID, MIC, CID, MDC, and PASS) to assess the clinical relevance of PROMs in THA were accessed. Articles in Spanish, Italian, German, and English were eligible. Studies with levels of evidence I to III were eligible.
Results
Data from 100,824 patients were collected. All relevant demographic data were analysed and summarised. In addition, the MCID, MIC, CID, MDC and PASS of the COMI, HOOS, SF-36, OHS, Oxford-12, PROMIS-PF, SF-12, and WOMAC scores for THA were determined.
Conclusion
Current evidence recommends to collect MCIDs based on anchors routinely. These values should be used as complementary tools to determine the clinical effectiveness of a treatment instead of solely relying on statistically significant improvements.
Level of evidence
Level IV, systematic review and meta-analysis.
... Due to high patient satisfaction and excellent survival of modern hip implants, the margin for improvement by utilizing robotassisted total hip arthroplasty (raTHA) may be less appreciable. 13,34 Nevertheless, the prevalence of raTHA increased from less than 0.1% in 2008e2.1% in 2018. ...
... Total hip arthroplasty (THA) is a widely performed surgical procedure that is known to relieve pain and improve function in patients with hip joint disorders [5,9]. To ensure optimal outcomes following THA, accurate restoration of hip anatomy is crucial [30,31], particularly in patients with a high native femoral offset [2]. ...
Purpose
To compare clinical and radiographic outcomes of total hip arthroplasty (THA) using standard offset versus high offset short cementless stems.
Methods
We reviewed a consecutive series of 204 primary THAs performed over 5 years using a short cementless collared stem. At a minimum follow-up of 2 years, 6 patients had deceased, 6 were not evaluated radiographically and, 2 were lost to follow-up. This left a final cohort of 190 hips, of which 72 had received a standard offset stem and 118 had received a high offset stem. Outcomes collected included: Oxford hip score (OHS), forgotten joint score (FJS), canal fill ratio (CFR), canal-bone ratio (CBR), stem subsidence (≥ 3 mm), stem misalignment (> 5°), radiolucent lines (≥ 2 mm), cortical hypertrophy, and calcar modifications.
Results
There were no significant differences in postoperative clinical and radiographic outcomes between the standard offset and high offset groups, except for incidence of stems in varus (6% vs 17%; p = 0.001). Multivariable analyses revealed that OHS was significantly worse for patients of greater age (β = 0.1; p = 0.001), higher BMI (β = 0.2; p = 0.018), or with inflammatory arthropathy (β = 4.7; p = 0.005); while FJS was significantly worse for patients with higher BMI (β = − 0.7; p = 0.003); and cortical hypertrophy was significantly associated with CBR (OR > 100; p = 0.008).
Conclusions
There were little to no differences in clinical or radiographic outcomes of THA performed using standard offset versus high offset short cementless stems. Although high offset stems are more frequently aligned in varus, while cortical hypertrophy occurs in wider intramedullary canals.
Osseointegration is an innovative procedure to improve the mobility and quality of life of amputees by connecting exoprostheses to the bone as a replacement for the conventional socket prosthesis. This article highlights two main approaches: the osseointegrated prosthesis for the rehabilitation of amputees (OPRA) system, which uses a thread-based implant and the integral leg prosthesis (ILP) and osseointegrated prosthetic limb (OPL) systems, which rely on the press-fit method. While osseointegration offers benefits such as better prosthesis fixation and fewer skin problems, there are also challenges, particularly the increased risk of infections. Research and studies have shown that the procedure can substantially improve the quality of life of amputees when used correctly. The systems OPRA, ILP and OPL are analyzed with respect to the effectiveness and complications, noting that complication rates decrease with increasing experience and improved design. Overall, osseointegration represents a promising alternative for amputees who experience discomfort and cannot cope with traditional socket prostheses.
Objectives
Total hip replacement (THR) is one of the most common elective orthopaedic surgeries performed, with increasing demand among younger individuals. Few evidence-based guidelines exist on safe activity participation following THR, including whether high-intensity sport participation is safe for individuals. The purpose of this study was to identify if increased intensity of physical activity following THR was associated with increased activity-related pain and increased revision rates.
Methods
Two groups undergoing THR were recruited: preoperative (cohort 1) and 5–7 years postsurgery (cohort 2); both followed for 5 years. Activity was self-reported through validated questionnaires and grouped into categories from ‘A’ (low intensity, eg, aquafit) to ‘F’ (high intensity, eg, tennis). The primary outcome was the presence of hip pain during activity (binary variable, Y/N), measured by the association between hip pain and intensity of activity (categories A–F). Secondary outcomes included activity duration, revision rate or a change in patient-reported outcome measures (PROMs).
Results
1098 individuals were included in this study (cohort 1: n=588, cohort 2: n=510). Regression analysis showed no significant interaction between activity intensity and hip pain across all time points. Approximately 20.6% of all activity (11.0% of participants) occurred in the highest intensity categories (E and F); these subjects showed no decrease in activity duration, worsening PROMs or increased revision rates compared with lower intensity activity groups (all p>0.05). When analysing by individual activities, certain activities (eg, snowboarding, squash, tennis and backpacking) were more correlated with hip pain (r>0.60), while others (eg, snorkelling, swimming, home weights, aquafit, cross-country skiing and sledding) were less likely to have hip pain (r<−0.60).
Conclusions
This study showed that higher-intensity activities do not lead to decreased activity duration, worsening patient-reported outcomes or increased revision rates following THR, although certain activities may be associated with increased pain. These findings can inform patient counselling after THR.
Total hip arthroplasty and hip preservation surgeries have substantially increased over the past few decades. Musculoskeletal imaging and interventions are cornerstones of comprehensive postoperative care and surveillance in patients undergoing established and more recently introduced hip surgeries. Hence the radiologist's role continues to evolve and expand. A strong understanding of hip joint anatomy and biomechanics, surgical procedures, expected normal postoperative imaging appearances, and postoperative complications ensures accurate imaging interpretation, intervention, and optimal patient care. This article presents surgical principles and procedural details pertinent to postoperative imaging evaluation strategies after common hip surgeries, such as radiography, ultrasonography, computed tomography, and magnetic resonance imaging. We review and illustrate the expected postoperative imaging appearances and complications following chondrolabral repair, acetabuloplasty, osteochondroplasty, periacetabular osteotomy, realigning and derotational femoral osteotomies, and hip arthroplasty.
Introduction: Total hip arthroplasty (THA) is recognized as one of the most effective surgical procedures for the treatment of end-stage hip arthritis. However, the increasing number of primary THA cases has led to a corresponding rise in the frequency of revision surgeries, which are often more complex and challenging due to severe acetabular bone loss. In such cases, managing Paprosky type 3A and 3B defects requires precise implant design and advanced surgical techniques. Standard acetabular augments and anti-protrusio cages are commonly used, but they often fail to provide the necessary stability, leading to re-revision rates as high as 36% within 10 years. This case series explores the efficacy of custom-made 3D-printed acetabular augments and cages in managing severe acetabular bone loss during revision THA.
Materials and Methods: This retrospective case series includes seven patients who underwent revision THA for Paprosky grade 3 acetabular bone loss between January 2023 and April 2024 at two high-volume tertiary care centers. The mean age of the patients was 45 years, with three males and four females included in the study. Pre-operative planning involved advanced imaging techniques, including 3D-computed tomography scans and custom virtual modeling, to design the acetabular components tailored to each patient’s specific anatomical requirements. During the surgeries, custom-made 3D-printed titanium augments and cages were used. These implants were fabricated using in-house software, and the turnaround time from the decision to surgery was approximately 10 days. Post-operatively, the planned 3D model was superimposed on post-operative radiographs to assess implant placement accuracy. The Harris hip score at the final follow-up averaged 69.16, with no signs of implant loosening observed.
Conclusion: Custom-made 3D-printed acetabular augments and cages offer a reliable and cost-effective solution for managing severe acetabular bone loss in revision THA. Despite the small sample size and short follow-up period, the results demonstrate the potential of these custom implants to improve outcomes in complex acetabular reconstructions. Further studies with larger sample sizes and longer follow-up periods are needed to confirm these findings and establish long-term efficacy.
Background
Survival at 25 years’ follow-up for total hip arthroplasty (THA) has been reported at 5%–77%, with hydroxyapatite (HA) coating, due to its osteo-conductive properties, used to enhance implant fixation and survival. The progressive increase in life expectancy raises doubts regarding HA-coated THA survival and THA revision surgery risk. The aim of our study was to retrospectively analyse survival for primary uncemented fully HA-coated THA after 28 years’ follow-up.
Methods
Our cohort survival study of the JRI Furlong HA-coated system retrospectively included patients aged 18–75 years who had undergone THA between 1992 and 1998 at our centre and who were followed up according to clinical records by orthopaedic surgeons to 2022. Data on THA revision surgery and its causes, follow-up, and death were analysed using Kaplan-Meier survival and Cox regression modelling.
Results
The cohort included 196 patients (268 hips) followed up to a maximum of 27.5 years (mean 15.54 (SD 6.01) years) with 62 patients (88 hips) >25 years. THA revision surgery was performed in 7.5% of cases, occurring a mean of 11.1 years following primary surgery. Aseptic loosening accounted for 4.4% of these revisions, affecting both the acetabular component (2.2%) and the femoral stem (1.3%). THA survival at 15 years’, 20 years’, and 27.5 years’ follow-up was 95.5%, 88.3%, and 79.3%, respectively. According to the log-rank and Cox regression analysis, no significant relationships were found.
Conclusions
Furlong HA-coated stem provides excellent long-term bone fixation for a long-term follow-up over 27.5 years with an aseptic loosening stem revision rate of 1.3%.
Background: The burden of osteoarthritis (OA) in multiple joints is high. For patients with bilateral knee OA there is no clear recommendation when to time the second surgery. The purpose of this study was therefore to compare revision and mortality rate in bilateral unicondylar and bicondylar knee arthroplasties after different strategies of surgical timing in bilateral knee OA from the German Arthroplasty Registry (EPRD). Methods: Data from the German Arthroplasty Registry (EPRD) was used. Since 2012 a total of 15,154 patients had bilateral knee arthroplasty within one year. Patellofemoral arthroplasties and constraint total knee arthroplasties (TKA) were excluded. 1,144 TKA and 682 unicondylar arthroplasties (UKA) were simultaneously performed, 772 TKA and 292 UKA between 1 and 90 days (short interval) and 24,496 TKA and 2,922 UKA between 91 and 365 days (intermediate interval). Revision and mortality rates were analyzed up to 7 years after surgery. Cox regression was performed to evaluate the influence of different patient characteristics on these outcomes. Results: The highest cumulative revision rate for any of the bilateral TKA was found for simultaneous surgery with 3.4% (95% CI 2.1 – 5.5). Lower risk for revision was seen in two-staged surgery in short interval (HR 0.42; 95% CI 0.20 – 0.90) and intermediate interval (HR 0.58; 95% CI 0.39 – 0.85). The cumulative one year mortality rate for TKA was comparable in all three groups with 0.8% for simultaneous TKA, 1.3% for short interval two-staged and 0.7% for intermediate interval. In UKA there were no differences between the groups regarding cumulative revision rate and mortality rate. Conclusion: TKA should be performed simultaneously in selected patients only, the two-staged procedure demonstrated lower revision risks. For UKA we found no differences in timing, simultaneous surgery seems to be a safe option. Trial registration: Clinical trial number not applicable.
This study proposes a new type of femoral neck reinforcement implant for patients suffering from osteoporosis. The aim of the implant is to prevent fractures of this part of the bone. Implant designs in six variants have been simulation-tested in two situations: a typical static load and a simulated dynamic load, in which the force was applied in a manner corresponding to a sideways fall. The tests were carried out for six different biocompatible materials, i.e., three polymeric and three titanium alloys from which the implants could be made. The obtained results tentatively demonstrated the validity of the proposed concept and allowed the design with the best properties to emerge. In addition, they showed that the use of a polymeric material, in particular polylactide, leads to a more substantial reduction in maximum stress values.
Introduction:
Surgeons allocate an indication(s) for revision surgery on NJR Minimum Data Set forms in the immediate perioperative period, when results from intraoperative histology and microbiology samples are not available. We evaluated to what extent the postoperative diagnostics obtained for patients undergoing metal-on-metal hip arthroplasty (MoMHA) revision surgery align with the indication for revision listed in the NJR.
Methods:
NJR data for MoMHA revision patients (2004-2015) at a single centre were linked to hospital records of microbiology and histology testing for prosthetic joint infection (PJI) and adverse reaction to metal debris (ARMD). The Musculoskeletal Infection Society and Mirra classifications were used as "gold standards' to classify PJI and ARMD respectively and to assess the diagnostic accuracy of the clinician selected revision indication recorded on MDS forms.
Results:
Of 301 cases, 5.6% (n = 17) and 3.7% (n = 11) were revised for PJI and ARMD respectively. In a further 6.6% (n = 20, PJI) and 15.6% (n = 47, ARMD) the indication for revision selected at the time of surgery did not corroborate with the test results from intraoperative samples. Diagnostic accuracy analysis revealed sensitivity and specificity of indication for surgery at the time of revision for PJI of 35.5% (95% CI, 19.2-54.6) and 97.8% (CI, 54.6-95.2) respectively, and for ARMD of 7.41% (CI, 2.06-17.9) and 97.2% (CI, 94.3-98.9) respectively.
Conclusions:
We observed that the results of histology and microbiology analyses of intraoperative samples may provide evidence to support alternative diagnoses in 20% of cases. This indicates a need for a change in the work-up of these cases to allow a more accurate prediction of the indication for revision. Alternatively, if there was evidence of a difference in outcome for patients where the indication may be changed when such data becomes available, the feasibility of a facility to add additional information from samples taken intraoperatively when it becomes available should be explored.
Introduction:
Previous studies have demonstrated the use of technology in total hip arthroplasty (THA) provided favorable outcomes. This study sought to describe the effect preoperative two-dimensional low-dose (2DLD) full-body radiographs had on the prevention of adverse outcomes following THA.
Methods:
We reviewed 11,814 cases of patients who underwent primary, elective THA from 2016 to 2021. Patient demographics and clinical data were compared between patients who did or did not have preoperative standing and sitting 2DLD images (29.5% vs. 70.5%, respectively) using Chi-squared test and multivariate logistic regressions.
Results:
The rate of patients with preexisting spinal fusion was higher in the 2DLD cohort (2.2 vs. 0.6%, respectively, p < 0.001). Preoperative 2DLD images were favored in outcomes including length of stay (40.15 vs. 67.16 hours; p < 0.001), rate of discharge to home (94.1 vs. 80.0%; p < 0.001), and 90-day readmission rate (3.5 vs. 6.0%; p < 0.001). Multivariate analysis demonstrated preoperative 2DLD images to be significantly associated with lower odds of dislocation, independent from surgical approach, coexisting spinal fusion, and utilization of dual-mobility implants.
Conclusion:
Preoperative 2DLD images were independently associated with decreased risk for dislocations. Even in a higher risk cohort with spinal fusion, the rate of dislocation in the 2DLD cohort was significantly lower.
The hip prosthesis, used to repair or recreate the diseased or damaged hip joint's articulation functionality, greatly influences the outcome of total hip arthroplasty (THA). Currently, the limited lifespan (10-15 years) of hip prostheses presents a serious challenge stemming from poor materials selection, design, as well as manufacturing techniques and this has been amplified further by the rising human life expectancy. Today's hip prostheses are predominantly made of Ti-6Al-4V alloy, which frequently fail owing to wear, modulus mismatch, corrosion, and poor osseointegration. To prolong hip implants’ useful life within the body system, it is crucial to comprehend human hip anatomy and biomechanics, investigate the modes and mechanisms of prosthesis failure, and identify mitigation measures pertaining to materials selection, prosthesis design, and production processes. From this point of view, this article firstly explores the intricate hip joint's structural anatomy in the context of biomechanics principles that influence joint movement and weight bearing. Then, hip implant failure modes and mechanisms are discussed and lastly, the failure mitigation measures are proposed. From this review, Ti-6Al-7Nb known for its excellent corrosion resistance and superior biocompatibility is considered a promising substitute for the mostly used cytotoxic Ti-6Al-4V, functionally graded porosity design mimicking the human bone to enhance mechanical and biomedical properties, more precisely osseointegration and stress shielding, and utilization of the selective laser melting technique capable of fabricating Ti-6Al-7Nb components with intricate shapes and high geometrical accuracy can play a significant role in preventing current hip implant failures.
Background
Osteochondral allograft (OCA) transplantation with or without labral reconstruction is considered a hip preservation surgical treatment option for young, active patients. This study aims to report early outcomes for use of OCA and labrum allograft transplants for patients treated for symptomatic femoral head chondral damage and/or acetabular labrum deficiency after implementation of a comprehensive joint restoration approach.
Methods
33 patients from a lifelong registry were included for analysis. Outcomes were compared for statistically significant ( p < 0.05) differences based on graft preservation methodology (standard preservation [SP] vs. Missouri Osteochondral Preservation System [MOPS]), and based on surfaces treated (femoral head only, labrum only, or femoral head and labrum).
Results
Mean follow-up duration was 44.8 (range 12–95) months. Success was documented in 28 (84.8%) patients. For the SP cohort, successful outcomes were documented in 5 cases (50%), while all 23 MOPS cases (100%) were deemed successful at least 1 year after surgery. Hip preservation surgeries performed using MOPS grafts were associated with significantly ( p = 0.001; OR = 47x) higher success rates, including significant and clinically meaningful improvements in PROMs at 1 and 2 years after surgery. Revision was performed in 2 patients in the SP cohort and failure requiring total hip arthroplasty was documented in 3 SP patients. Mean time to revision or failure was 23.6 (range 4–43) months. The surfaces treated were significantly associated with failure when comparing patients undergoing a femoral head OCA with or without labral reconstruction to those undergoing labral reconstruction only ( p = 0.03; OR = 8.3x).
Conclusions
Patients with symptomatic femoral head cartilage loss and/or irreparable acetabular labrum deficiency undergoing femoral head OCA transplantation and/or labral reconstruction with meniscus allografts using MOPS-preserved tissues experienced statistically significant and clinically meaningful improvements in pain and function through at least 2 years after surgery.
Titanium and its alloys are the most commonly used biometals for developing orthopedic implants to treat various forms of bone fractures and defects, but their clinical performance is still challenged by the unfavorable mechanical and biological interactions at the implant-tissue interface, which substantially impede bone healing at the defects and reduce the quality of regenerated bones. Moreover, the impaired osteogenesis capacity of patients under certain pathological conditions such as diabetes and osteoporosis may further impair the osseointegration of Ti-based implants and increase the risk of treatment failure. To address these issues, various modification strategies have been developed to regulate the implant-bone interactions for improving bone growth and remodeling in situ. In this review, we provide a comprehensive analysis on the state-of-the-art synthetic nanointerfacial bioengineering strategies for designing Ti-based biofunctional orthopedic implants, with special emphasis on the contributions to (1) promotion of new bone formation and binding at the implant-bone interface, (2) bacterial elimination for preventing peri-implant infection and (3) overcoming osseointegration resistance induced by degenerative bone diseases. Furthermore, a perspective is included to discuss the challenges and potential opportunities for the interfacial engineering of Ti implants in a translational perspective. Overall, it is envisioned that the insights in this review may guide future research in the area of biometallic orthopedic implants for improving bone repair with enhanced efficacy and safety.
Ceramic materials have played an important role in the development of modern total hip replacements. Following the introduction of the modular low-friction total hip (THA) in the 1960s, subsequent improvements have addressed the various failure modes for this prosthetic implant. Over the past two decades, clinical practitioners have generally moved away from hard-on-hard articulation couples (i.e., metal-on-metal or ceramic-on-ceramic (CoC)) to hard-on-soft bearing pairs (i.e., ceramic or metal on advanced polyethylene). Zirconia-toughened alumina (ZTA) femoral heads have emerged as a preferred choice due to their demonstrably improved strength, toughness, and polyethylene wear resistance, as supported by significant clinical data. Yet, despite these advancements, the longevity of modern THA has not improved significantly over that of the earliest cemented hip systems. This review chapter compares the performance of two biomaterials, ZTA and silicon nitride, for use in total hip arthroplasty. While silicon nitride currently lacks clinical data in THA due to its FDA approval for spinal fusion devices only, in vitro studies suggest potential advantages. These include the possible development of future THA designs that exceed the lifespan of young, active patients, and potentially reduce the need for revision surgeries due to polyethylene wear, deep infections, and other complications typically encountered after 15–20 years of service. The mechanical properties of silicon nitride femoral heads are at least as favorable as ZTA, with greater resistance to hydrothermally induced degradation. Silicon nitride also has a bioactive surface chemistry that makes the material highly biocompatible, and resistant to bacterial infection. In articulation against the most advanced polyethylene liner, silicon nitride exhibits wear properties comparable to, if not superior to ZTA. Additionally, it possesses the potential to mitigate long-term polyethylene oxidation and embrittlement, a contributing factor to THA failure. While ZTA femoral heads boast established clinical success, advancements in bearing materials are crucial for extending THA longevity to match the lifespans of the most demanding patients. In this context, silicon nitride emerges as a promising candidate, supported by its favorable in vitro performance.
Aims
This study evaluates the association between consultant and hospital volume and the risk of re-revision and 90-day mortality following first-time revision of primary hip arthroplasty for aseptic loosening.
Methods
We conducted a cohort study of first-time, single-stage revision hip arthroplasties (RHAs) performed for aseptic loosening and recorded in the National Joint Registry (NJR) data for England, Wales, Northern Ireland, and the Isle of Man between 2003 and 2019. Patient identifiers were used to link records to national mortality data, and to NJR data to identify subsequent re-revision procedures. Multivariable Cox proportional hazard models with restricted cubic splines were used to define associations between volume and outcome.
Results
Among 12,961 RHAs there were 513 re-revisions within two years, and 95 deaths within 90 days of surgery. The risk of re-revision was highest for a consultant’s first RHA (hazard ratio (HR) 1.56 (95% CI 1.15 to 2.12)) and remained significantly elevated for their first 24 cases (HR 1.26 (95% CI 1.00 to 1.58)). Annual consultant volumes of five/year were associated with an almost 30% greater risk of re-revision (HR 1.28 (95% CI 1.00 to 1.64)) and 80% greater risk of 90-day mortality (HR 1.81 (95% CI 1.02 to 3.21)) compared to volumes of 20/year. RHAs performed at hospitals which had cumulatively undertaken fewer than 167 RHAs were at up to 70% greater risk of re-revision (HR 1.70 (95% CI 1.12 to 2.59)), and those having undertaken fewer than 307 RHAs were at up to three times greater risk of 90-day mortality (HR 3.05 (95% CI 1.19 to 7.82)).
Conclusion
This study found a significantly higher risk of re-revision and early postoperative mortality following first-time single-stage RHA for aseptic loosening when performed by lower-volume consultants and at lower-volume institutions, supporting the move towards the centralization of such cases towards higher-volume units and surgeons.
Cite this article: Bone Joint J 2024;106-B(10):1050–1058.
The present Bayesian network meta-analysis compared different types of polyethylene liners in total hip arthroplasty (THA) in terms of wear penetration (mm/year) and rate of revision. The type of liners compared were the crosslinked ultra-high molecular weight polyethylene (CPE/UHMWPE), Vitamin E infused highly cross-linked polyethylene (HXLPE-VEPE), modified cross-linked polyethylene (MXLPE), highly cross-linked polyethylene (HXLPE), Cross-linked polyethylene (XLPE). This study was conducted according to the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of healthcare interventions. In June 2024, PubMed, Scopus, Embase, Google Scholar, and Cochrane databases were accessed. A time constraint was set from January 2000. All investigations which compared two or more types of polyethylene liners for THA were accessed. Only studies that clearly stated the nature of the liner were included. Data from 60 studies (37,352 THAs) were collected. 56% of patients were women. The mean age of patients was 60.0 ± 6.6 years, the mean BMI was 27.5 ± 2.0 kg/m². The mean length of follow-up was 81.6 ± 44.4 months. Comparability was found at baseline between groups. XLPE and HXLPE liners in THA are associated with the lowest wear penetration (mm/year) and the lowest revision rate at approximately 7 years of follow-up.
As the number of total hip arthroplasties have steadily increased, one would expect a concomitant increase in catastrophic postoperative events such as periprosthetic fractures. This study evaluates the surgical and functional outcome, along with the associated complication rates in patients undergoing revision arthroplasty following Vancouver type B2 post-operative periprosthetic femoral fracture. We studied 14 Clinically and radiologically diagnosed patients with Vancouver type B2 Post-operative Periprosthetic femoral fracture. The post-operative VAS score has decreased to 2.23±0.92 from a pre-operative score of 8.30±0.9, p<0.001. The average Harris Hip Score has improved from 44.05±7.71 pre-operatively to 83.63±7.75 post-operatively at 6 months, p<0.001. At 6-month follow-up, we had 57% excellent results, 29% good results, 7% fair results, and 7% poor results based on Harris Hip Score. The revision arthroplasty of Vancouver type B2 post-operative periprosthetic femoral fracture with revision arthroplasty and coxa femoral bypass has excellent-good surgical as well as functional outcomes in terms of regaining abductor function by an increase in range of motion at the affected hip joint, significant pain relief leading to improved quality of life after surgery at short term follow up period.
The polymer‐based acetabular cup prosthesis, a vital component of hip replacement surgery, significantly contributes to the recovery of patients afflicted with osteoarthritic conditions. Nevertheless, the current clinical usage of polymer acetabular cup prostheses commonly encounters the challenge of balancing wear resistance and oxidation resistance, significantly impacting both their lifespan and patients′ quality of life. Consequently, researchers have persistently enhanced the attributes of polymer acetabular cup prosthetic materials. These enhancements, including irradiation and filler modifications, are intended to concurrently bolster both the wear and oxidation resistance of the prosthesis materials. This comprehensive approach aims to address wear‐associated clinical complications like osteolysis and oxidative brittleness, ultimately extending their in vivo service life. For this reason, this paper retrospectively discusses the progress of research on the modification of polymer acetabular cup prosthesis materials for high wear and oxidation resistance and explores potential design methods for optimising artificial acetabular cup materials, with a view to providing new ideas for extending the service life of artificial joint implants.
To clarify the relevance of physical activity (PA) with respect to a decrease in minimal joint space (MJS) of the nonoperative hip in female patients at 24 months post‐contralateral total hip arthroplasty (THA). This prospective cohort study was conducted from six to 24 months post‐THA. The subjects were 85 female patients with hip osteoarthritis (OA) who had undergone unilateral THA. The primary outcome was a change in MJS (ΔMJS). Daily step counts and moderate to vigorous physical activity were measured. To identify factors related to ΔMJS, a generalized linear model approach was used, with adjustment factors, Kellgren–Lawrence (KL) grade, PA, and interaction terms between PA and KL grade as explanatory variables. The interaction term between daily step count and KL grade was significant. The regression coefficient of the daily step count for ΔMJS was significant in the KL ≥ 1 group, but not in the KL = 0 group. A model with adjustment factors, an interaction term, and PA showed that the daily step count increased ΔMJS. PA was related to ΔMJS of the nonoperative hip in female patients with KL grade ≥1, but was not related to ΔMJS in patients without OA post‐THA. Excessive daily step count may be a risk factor for a decrease in MJS of the nonoperative hip.
Background and purpose — The use of competing risks models is widely advocated in the arthroplasty literature due to a perceived bias in comparison of simple Kaplan–Meier estimates. Proponents of competing risk models in the arthroplasty literature appear to be unaware of the subtle but important differences in interpretation of net and crude failure estimated by competing risk and Kaplan–Meier methods respectively.
Methods — Using a simple simulation we illustrate the differences between competing risks and Kaplan–Meier methods.
Results — Competing risk and Kaplan–Meier methods estimate different survival quantities, i.e., crude and net failure respectively. Estimates of crude failure estimated using competing risk methods will be less than net failure as estimated using Kaplan–Meier methods.
Interpretation — Kaplan–Meier methods are appropriate for describing implant failure, whereas crude survival estimated using competing risk methods estimates the risk of surgical revision as it depends on both implant failure and mortality. Both competing risk models and Kaplan–Meier methods are useful in arthroplasty, and both provide unbiased estimates of crude and net failure in the absence of any confounding or selection respectively. Surgeons and researchers should carefully consider whether the use of competing risks is always justified. Lower estimates of failure from competing risk models may be misleading to surgeons who are attempting to select the best implants with the lowest failure rates for their patients.
Annual Report of the Swedish Hip Arthroplasty Register 2016
Objective
To identify postoperative patient-related risk factors for chronic pain after total knee replacement (TKR).
Design
The systematic review protocol was registered on the International Prospective Register of Systematic Reviews (CRD42016041374). MEDLINE, Embase and PsycINFO were searched from inception to October 2016 with no language restrictions. Key articles were also tracked in the Institute for Scientific Information (ISI) Web of Science. Cohort studies evaluating the association between patient-related factors in the first 3 months postoperatively and pain at 6 months or longer after primary TKR surgery were included. Screening, data extraction and assessment of methodological quality were undertaken by two reviewers. The primary outcome was pain severity in the replaced knee measured with a patient-reported outcome measure at 6 months or longer after TKR. Secondary outcomes included adverse events and other aspects of pain recommended by the core outcome set for chronic pain after TKR.
Results
After removal of duplicates, 16 430 articles were screened, of which 805 were considered potentially relevant. After detailed evaluation of full-text articles, 14 studies with data from 1168 participants were included. Postoperative patient-related factors included acute pain (eight studies), function (five studies) and psychosocial factors (four studies). The included studies had diverse methods for assessment of potential risk factors and outcomes, and therefore narrative synthesis was conducted. For all postoperative factors, there was insufficient evidence to draw firm conclusions about the association with chronic pain after TKR. Selection bias was a potential risk for all studies, as none were reported to be conducted at multiple centres.
Conclusion
This systematic review found insufficient evidence to draw firm conclusions about the association between any postoperative patient-related factors and chronic pain after TKR. Further high-quality research is required to provide a robust evidence base on postoperative risk factors, and inform the development and evaluation of targeted interventions to optimise patients’ outcomes after TKR.
Material and methods:
The implants used are among the oldest. On the acetabular side, we used the BG spiked acetabular component (Fig. 1), containing 4 teeth for primary fixation, 3 equatorial armatures and a surface treatment. This metal back in two sizes 50 and 54 mm, initially permitted the insertion of a polyethylen insert of an interior diameter of 32 mm with a peripheric thickness of 5.5 mm; since 1979, the insert had a 22.2 mm diameter, assuring 10 mm minimal thickness of. The femoral implant (Fig. 2) for 62 hips was the Huchet prothesis, then in 16 cases, the minimadreporic prothesis composed of a morse cone and a head of 22.2, the Huchet prothesis was one-piece femoral implant.The dominant etiology was coxarthrosis (56 cases) of which 50 % had major dysplasis. The average age at the time of the intervention was 41 years old (18-50 years), the follow-up of this series is 17 years, and 8 months (15-21 years). Resumption of former activities was the rule.Results of the rehabitable pro thesis up to 12.31.1995: Of the 83 cases, the outcome of 55 of them (66.3%) is known : 49 (59%) were examined for this study; the evolution has been documented; 28 (33.7%) were uncontactable, 6 patients (7.3%) were deceased between 8 and 9 years following the operation, without having had the hip revised.Among the 49 protheses which were evaluated, 22 (44.9%) have not been revised to date. Clinically, the function is normal and there are no radiological signs of attrition of the insert or mobilisation of implants. There are 10 Huchet Protheses and 12 minimadreporic protheses in this group. The average age at the time of the intervention was 42 years old (30-50 years old), the follow-up was 16 years and 7 months (15-19 years) (Fig. 3a-d).27 hips (51%) needed to be revised, but the causes of reoperationn include different reasons tied to the failure of biological fixation but particularly to errors in the initial concept of the Huchet prothesis.Reoperation linked to the failure of the biological fixation: Out of 7 acetabular implant reoperations, one was carried out systematically on a cup which was perfectly bone-integrated during the changing of a femoral component, 3 were necessary due to perforation (attrition of the insert). Only 3 acetabular implants (6.1%) required reoperation for symptomatic loosening.Four femoral implants (8.6%) have been taken out because of failure of biological fixation between 2 and 11 years follow-up. Finally, for one patient the persistance of the incapacitating crural pain which lasted for more than one year led to the removal of the femoral stem, nevertheless perfectly integrated.Reoperation linked to the concept of the Huchet prothesis: These were undertaken in two sets of circumstances.Changing only the polyethylene insert was only called for in the Huchet prosthesis and concerned 18 hips (36.7%); the delay to reoperation varied from 11 to 18 years with an average of 14 years delay. Changing of the insert had a simple short post-operative outcome and functional recuperation was between 6 and 8 weeks (Fig. 4a-c).Removal for perforative attrition of polyethylene insert causing metal-to-metal wear between head and metal back. Five Huchet prostheses are included in this group, with an average delay to reoperation of 16 years and 3 months (14-19 years).
Comments:
This retrospective study with a 66.3 % rate of re-examination permits three types of comments.The principal cause of revision (23 cases), is linked to polyethylene attrition and is only found in the group with Huchet prosthesis. More than the quality of the polyethylene used at this time, it is its thickness in contact with a 32 mm head which led to the complete removal of the prosthesis in 10.2% of the cases.The second comment argues for the modularisation of the femoral implant. The presence of a stem with a cone and a removable head would have avoided the removal of 5 perfectly bone-integrated femoral implants. Certainly, the literature demonstrates the risk of corrosion generated by the morse cone but it is up to the manufacturers to improve their procedures.Finally, the third comment concerns the current state of the long term of the biological fixation by rehabilitation with surface treatment. With 17 years 8 months follow-up (15-21 years), 81.6% of components are still fixed, the real failure of the bony ingrowth of 10.2% is comparable to the rate of failure in long term follow-up of totally cemented prothesis found in young subjects.
Conclusion:
With more than 20 years follow-up for the older cases, the concept of the biological fixation of an implant by bony ingrowth using surface treatment seems to be very reliable.The experience of this long term study argues for the thickness of polyethylene to be at least 10 mm for all metal back acetabular component and the future of this kind of implant seems to lie in modularisation made possible by the morse cone which would allow the replacement of the bearing surfaces.
Background:
Total joint replacements for end-stage osteoarthritis of the hip and knee are cost-effective and demonstrate significant clinical improvement. However, robust population based lifetime-risk data for implant revision are not available to aid patient decision making, which is a particular problem in young patient groups deciding on best-timing for surgery.
Methods:
We did implant survival analysis on all patients within the Clinical Practice Research Datalink who had undergone total hip replacement or total knee replacement. These data were adjusted for all-cause mortality with data from the Office for National Statistics and used to generate lifetime risks of revision surgery based on increasing age at the time of primary surgery.
Findings:
We identified 63 158 patients who had undergone total hip replacement and 54 276 who had total knee replacement between Jan 1, 1991, and Aug 10, 2011, and followed up these patients to a maximum of 20 years. For total hip replacement, 10-year implant survival rate was 95·6% (95% CI 95·3-95·9) and 20-year rate was 85·0% (83·2-86·6). For total knee replacement, 10-year implant survival rate was 96·1% (95·8-96·4), and 20-year implant survival rate was 89·7% (87·5-91·5). The lifetime risk of requiring revision surgery in patients who had total hip replacement or total knee replacement over the age of 70 years was about 5% with no difference between sexes. For those who had surgery younger than 70 years, however, the lifetime risk of revision increased for younger patients, up to 35% (95% CI 30·9-39·1) for men in their early 50s, with large differences seen between male and female patients (15% lower for women in same age group). The median time to revision for patients who had surgery younger than age 60 was 4·4 years.
Interpretation:
Our study used novel methodology to investigate and offer new insight into the importance of young age and risk of revision after total hip or knee replacement. Our evidence challenges the increasing trend for more total hip replacements and total knee replacements to be done in the younger patient group, and these data should be offered to patients as part of the shared decision making process.
Background
Synthesis of multiple randomized controlled trials (RCTs) in a systematic review can summarize the effects of individual outcomes and provide numerical answers about the effectiveness of interventions. Filtering of searches is time consuming, and no single method fulfills the principal requirements of speed with accuracy. Automation of systematic reviews is driven by a necessity to expedite the availability of current best evidence for policy and clinical decision-making.
We developed Rayyan (http://rayyan.qcri.org), a free web and mobile app, that helps expedite the initial screening of abstracts and titles using a process of semi-automation while incorporating a high level of usability. For the beta testing phase, we used two published Cochrane reviews in which included studies had been selected manually. Their searches, with 1030 records and 273 records, were uploaded to Rayyan. Different features of Rayyan were tested using these two reviews. We also conducted a survey of Rayyan’s users and collected feedback through a built-in feature.
Results
Pilot testing of Rayyan focused on usability, accuracy against manual methods, and the added value of the prediction feature. The “taster” review (273 records) allowed a quick overview of Rayyan for early comments on usability. The second review (1030 records) required several iterations to identify the previously identified 11 trials. The “suggestions” and “hints,” based on the “prediction model,” appeared as testing progressed beyond five included studies. Post rollout user experiences and a reflexive response by the developers enabled real-time modifications and improvements. The survey respondents reported 40% average time savings when using Rayyan compared to others tools, with 34% of the respondents reporting more than 50% time savings. In addition, around 75% of the respondents mentioned that screening and labeling studies as well as collaborating on reviews to be the two most important features of Rayyan.
As of November 2016, Rayyan users exceed 2000 from over 60 countries conducting hundreds of reviews totaling more than 1.6M citations. Feedback from users, obtained mostly through the app web site and a recent survey, has highlighted the ease in exploration of searches, the time saved, and simplicity in sharing and comparing include-exclude decisions. The strongest features of the app, identified and reported in user feedback, were its ability to help in screening and collaboration as well as the time savings it affords to users.
Conclusions
Rayyan is responsive and intuitive in use with significant potential to lighten the load of reviewers.
Background and Purpose
Patients report similar or better pain and function before revision hip arthroplasty than before primary arthroplasty but worse results are reported after revision surgery than after primary surgery. The trajectory of post-operative recovery during the first months and any differences by type of surgery have received little attention. We explored the trajectories of change in pain and function after revision hip arthroplasty to 12-months post-operatively and compare them with those observed after primary hip arthroplasty.
Methods
This study is a prospective cohort study of patients undergoing primary (n = 80 with 92% for an indication of osteoarthritis) and revision (n = 43) hip arthroplasties. WOMAC pain and function scores and walking speed were collected pre-operatively, at 3 and 12-months post-operatively. Multilevel regression models were used to chart and compare the trajectories of change (0–3 months and 3–12 months) between types of surgery.
Results
The improvements in pain and function following revision arthroplasty occurred within the first 3-months with no evidence of further change beyond this initial period. While the pattern of recovery was similar to the one observed after primary arthroplasty, improvements in the first 3-months were smaller after revision compared to primary arthroplasty. Patients listed for revision surgery reported lower pre-operative pain levels but similar post-operative levels compared to those undergoing primary surgery. At 12-months post-operation patients who underwent a revision arthroplasty had not reached the same level of function achieved by those who underwent primary arthroplasty.
Conclusion
The post-operative improvements in pain and function are larger following primary hip arthroplasty than following revision hip arthroplasty. Irrespectively of surgery type, most of the improvements occur in the first three post-operative months. More research is required to identify whether the recovery following revision surgery could be improved with specific post-operative interventions.
Background and purpose An earlier Nordic Arthroplasty Register Association (NARA) report on 280,201 total hip replacements (THRs) based on data from 1995–2006, from Sweden, Norway, and Denmark, was published in 2009. The present study assessed THR survival according to country, based on the NARA database with the Finnish data included.
Material and methods 438,733 THRs performed during the period 1995–2011 in Sweden, Denmark, Norway, and Finland were included. Kaplan-Meier survival analysis was used to calculate survival probabilities with 95% confidence interval (CI). Cox multiple regression, with adjustment for age, sex, and diagnosis, was used to analyze implant survival with revision for any reason as endpoint.
Results The 15-year survival, with any revision as an endpoint, for all THRs was 86% (CI: 85.7–86.9) in Denmark, 88% (CI: 87.6–88.3) in Sweden, 87% (CI: 86.4–87.4) in Norway, and 84% (CI: 82.9–84.1) in Finland. Revision risk for all THRs was less in Sweden than in the 3 other countries during the first 5 years. However, revision risk for uncemented THR was less in Denmark than in Sweden during the sixth (HR = 0.53, CI: 0.34–0.82), seventh (HR = 0.60, CI: 0.37–0.97), and ninth (HR = 0.59, CI: 0.36–0.98) year of follow-up.
Interpretation The differences in THR survival rates were considerable, with inferior results in Finland. Brand-level comparison of THRs in Nordic countries will be required.
Background and purpose
An earlier Nordic Arthroplasty Register Association (NARA) report on 280,201 total hip replacements (THRs) based on data from 1995–2006, from Sweden, Norway, and Denmark, was published in 2009. The present study assessed THR survival according to country, based on the NARA database with the Finnish data included.
Material and methods
438,733 THRs performed during the period 1995–2011 in Sweden, Denmark, Norway, and Finland were included. Kaplan-Meier survival analysis was used to calculate survival probabilities with 95% confidence interval (CI). Cox multiple regression, with adjustment for age, sex, and diagnosis, was used to analyze implant survival with revision for any reason as endpoint.
Results
The 15-year survival, with any revision as an endpoint, for all THRs was 86% (CI: 85.7–86.9) in Denmark, 88% (CI: 87.6–88.3) in Sweden, 87% (CI: 86.4–87.4) in Norway, and 84% (CI: 82.9–84.1) in Finland. Revision risk for all THRs was less in Sweden than in the 3 other countries during the first 5 years. However, revision risk for uncemented THR was less in Denmark than in Sweden during the sixth (HR = 0.53, CI: 0.34–0.82), seventh (HR = 0.60, CI: 0.37–0.97), and ninth (HR = 0.59, CI: 0.36–0.98) year of follow-up.
Interpretation
The differences in THR survival rates were considerable, with inferior results in Finland. Brand-level comparison of THRs in Nordic countries will be required.
Total hip or knee replacement is highly successful when judged by prosthesis-related outcomes. However, some people experience long-term pain.
To review published studies in representative populations with total hip or knee replacement for the treatment of osteoarthritis reporting proportions of people by pain intensity.
MEDLINE and EMBASE databases searched to January 2011 with no language restrictions. Citations of key articles in ISI Web of Science and reference lists were checked. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS: Prospective studies of consecutive, unselected osteoarthritis patients representative of the primary total hip or knee replacement population, with intensities of patient-centred pain measured after 3 months to 5-year follow-up.
Two authors screened titles and abstracts. Data extracted by one author were checked independently against original articles by a second. For each study, the authors summarised the proportions of people with different severities of pain in the operated joint.
Searches identified 1308 articles of which 115 reported patient-centred pain outcomes. Fourteen articles describing 17 cohorts (6 with hip and 11 with knee replacement) presented appropriate data on pain intensity. The proportion of people with an unfavourable long-term pain outcome in studies ranged from about 7% to 23% after hip and 10% to 34% after knee replacement. In the best quality studies, an unfavourable pain outcome was reported in 9% or more of patients after hip and about 20% of patients after knee replacement.
Other studies reported mean values of pain outcomes. These and routine clinical studies are potential sources of relevant data. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: After hip and knee replacement, a significant proportion of people have painful joints. There is an urgent need to improve general awareness of this possibility and to address determinants of good and bad outcomes.
Over the past 20 years, several changes in treatment policy and treatment options have taken place regarding hip replacement. For this reason, we wanted to investigate the results after hip replacement in terms of revision rate, during a 21-year period among hip replacements reported to the Norwegian Arthroplasty Register.
110,882 primary total hip replacements were reported to the Norwegian Arthroplasty Register from 1987 through 2007. Risk of revision during the time periods 1993-1997, 1998-2002, and 2003-2007 was compared to that of the reference period 1987-1992. Adjusted Cox regression analyses were performed to compare the risk of revision in different time periods and extended analyses were done to investigate revision within the first postoperative year and after the first year.
There was an overall reduced risk of revision in the time periods 1993-1997, 1998-2002, and 2003-2007 compared to the reference period: RR = 0.81 (95% CI 0.77-0.86), 0.51 (CI 0.47-0.55), and 0.77 (CI 0.68-0.85), respectively. The improved results were due to a marked reduction in aseptic loosening of the femoral and acetabular components in all time periods and in all subgroups of prostheses. A change in the timing of revision took place, with more early revisions and fewer late revisions in the later time periods. Revision due to dislocation and infection increased over time.
The risk of revision decreased during the study period, due to fewer cases of aseptic loosening of prosthetic components. The best results were obtained with the use of cemented prostheses. Prevention of dislocation and infection should be a major goal in the future, as revision due to these causes increased during the study period.
High survival rates have been reported for the uncemented CLS® Spotorno® stem up to 10 years. To confirm survival at longer followup we report the minimum 15-year (mean, 17 years; range, 15–20 years) for 257 hips using this stem. We retrospectively evaluated the clinical and radiographic results of all 326 patients (354 THAs) operated between 1985 and 1989. The patients had a mean age of 57 years using an uncemented grit-blasted, tapered titanium femoral stem. Eighty-six patients (89 hips) died and eight patients (eight hips) were lost to followup, leaving 240 patients (257 hips) for evaluation. The femoral component was revised in 35 hips: eight for infection, nine for periprosthetic fracture, one for traumatic loosening, and 17 for aseptic loosening. Survival of the stem was 88% at 17 years (95% confidence interval, 84%–92%), and survival with femoral revision for aseptic loosening as an end point was 94% (95% confidence interval, 91%–97%). The median Harris hip score at followup was 80 points. No thigh pain was reported. Small osteolytic lesions (< 1 cm2) were found in the proximal Gruen zones (1 or/and 7) in 28 hips (15%). No distal femoral osteolysis was found. The long-term survival with this type of femoral component remains high in the second decade.
Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Background:
New medical technologies are often used widely without adequate supporting data, a practice that can lead to widespread catastrophic failure such as occurred with metal-on-metal (MoM) hip replacements. We determined both how revision rates would have differed if, instead of receiving MoM hip replacements, patients had received existing alternatives and the subsequent cumulative re-revision rates of the patients who did receive MoM hip replacements compared with alternatives.
Methods:
This study is a population-based longitudinal cohort study of patient data recorded in the National Joint Registry (NJR) for England, Wales and Northern Ireland between April 2003 and December 2014. We ascertained implant failure rates separately among stemmed MoM total hip replacement (THR) and hip-resurfacing procedures and, using flexible parametric survival modeling, compared them with the failure rates that would have been expected had existing alternatives been used. We used Kaplan-Meier survivorship analysis to compare cumulative re-revision of patients who received stemmed MoM primary replacements that failed and of those who underwent hip resurfacing that failed with those whose non-MoM THRs had failed.
Results:
In all, 37,555 patients underwent MoM hip resurfacing, with a 10-year revision rate of 12.6% (95% confidence interval [CI]: 12.2% to 13.1%) compared with a predicted revision rate of 4.8% if alternative implants had been used. The 32,024 stemmed MoM THRs had a 19.8% (95% CI: 18.9% to 20.8%) 10-year failure rate compared with an expected rate of 3.9% if alternatives had been used. For every 100 MoM hip-resurfacing procedures, there were 7.8 excess revisions by 10 years, and for every 100 stemmed MoM THR procedures, there were 15.9, which equates to 8,021 excess first revisions. Seven-year re-revision rates were 14.9% (95% CI: 13.8% to 16.2%) for stemmed non-MoM THRs, 18.0% (95% CI: 15.7% to 20.7%) for MoM hip resurfacing, and 19.8% (95% CI: 17.0% to 23.0%) for stemmed MoM THRs.
Conclusions:
This study highlights the consequences of widespread and poorly monitored adoption of a medical technology. Over 1 million MoM hip prostheses were implanted worldwide. The excess failure on a global scale will be enormous. This practice of adopting new technologies without adequate supporting data must not be repeated.
Level of evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
The trend in arthroplasty of the hip joint to implement new models is partly based on theoretical considerations. In order to verify to which extent the philosophy of individual models is ultimately successful, the presentation of long-term results is required. In the years 1991 and 1992, 433 patients with primary implantation of an uncemented total hip replacement in primary coxarthrosis with a stem type AML (anatomic medullary locking) were treated surgically. 283 of them got a cementless cup type Duraloc. In 311 (71.8 %) patients the mean survival rate of the prosthesis could be determined at a mean follow-up of 15.5 years. 145 (33.5 %) patients were followed up completely both clinically and radiologically. Radiographically, the stem position, changes of the periprosthetic bone of the stem and the cup, as well as the wear of the cups were examined. The cumulative survival rate of the AML stem after 15.5 years was 97.5 %, of the Duraloc cup 88.2 %. The clinical results of the hip scores according to Harris and Merle d'Aubigné were good and excellent and patient satisfaction was very high. There was no relationship between stem position, stress shielding and surrounding lyses at the femur and the acetabulum and survival of stem or cup. There was no correlation between inlay wear and survival of the Duraloc cup. A subsiding of the stem in 2 cases had no effect on the clinical symptoms and quality of life. The press-fit implanted AML stem and the Duraloc cup revealed very good results during the investigation period. Like other implants, the survival rate is limited at the presented implant mainly by the cup.
Georg Thieme Verlag KG Stuttgart · New York.
Background:
Implant survival after conventional total hip replacement (THR) is often poor in younger patients, so alternatives such as hip resurfacing, with various sizes to fit over the femoral head, have been explored. We assessed the survival of different sizes of metal-on-metal resurfacing in men and women, and compared this survival with those for conventional stemmed THRs.
Methods:
We analysed the National Joint Registry for England and Wales (NJR) for primary THRs undertaken between 2003 and 2011. Our analysis involved multivariable flexible parametric survival models to estimate the covariate-adjusted cumulative incidence of revision adjusting for the competing risk of death.
Findings:
The registry included 434,560 primary THRs, of which 31,932 were resurfacings. In women, resurfacing resulted in worse implant survival than did conventional THR irrespective of head size. Predicted 5-year revision rates in 55-year-old women were 8·3% (95% CI 7·2-9·7) with a 42 mm resurfacing head, 6·1% (5·3-7·0) with a 46 mm resurfacing head, and 1·5% (0·8-2·6) with a 28 mm cemented metal-on-polyethylene stemmed THR. In men with smaller femoral heads, resurfacing resulted in poor implant survival. Predicted 5-year revision rates in 55-year-old men were 4·1% (3·3-4·9) with a 46 mm resurfacing head, 2·6% (2·2-3·1) with a 54 mm resurfacing head, and 1·9% (1·5-2·4) with a 28 mm cemented metal-on-polyethylene stemmed THR. Of male resurfacing patients, only 23% (5085 of 22076) had head sizes of 54 mm or above.
Interpretation:
Hip resurfacing only resulted in similar implant survivorship to other surgical options in men with large femoral heads, and inferior implant survivorship in other patients, particularly women. We recommend that resurfacing is not undertaken in women and that preoperative measurement is used to assess suitability in men. Before further new implant technology is introduced we need to learn the lessons from resurfacing and metal-on-metal bearings.
Funding:
National Joint Registry for England and Wales.
To evaluate clinical and radiaographic results and influencing factors of hybrid total hip arthroplasty (THA).
Totally 126 patients (135 hips) from January 1999 to December 2001 accepted hybrid THA were followed up. Components migration, periprosthetic bone changes, the polyethylene wear rate were measured radiologically. Kaplan-Meier analysis was performed to evaluate the survivalship of the acetabular and femoral components. End point was obvious radiological loosening or revision either or both of the acetabular and femoral components for aseptic loosening, infection or osteolysis debridement surgery.
A total of 79 cases (85 hips) had been given follow-up. Using revision as the end point, the survival rate of acetabular was 95.2%, cemented femoral components was 98.8%. Using loosening as the end point for failure, the survival rate of acetabular was 97.6%, cemented femoral components was 100%.
The hybrid total hip prothesis long-term survival rate was satisfactory, especially in the femoral side. As a result of third-cement technology, the long-term survival rate of the femoral components was close to the modern cementless prosthesis.
Revision arthroplasty of the hip is expensive owing to the increased cost of pre-operative investigations, surgical implants and instrumentation, protracted hospital stay and drugs. We compared the costs of performing this surgery for aseptic loosening, dislocation, deep infection and peri-prosthetic fracture. Clinical, demographic and economic data were obtained for 305 consecutive revision total hip replacements in 286 patients performed at a tertiary referral centre between 1999 and 2008. The mean total costs for revision surgery in aseptic cases (n = 194) were £11 897 (sd 4629), for septic revision (n = 76) £21 937 (sd 10 965), for peri-prosthetic fracture (n = 24) £18 185 (sd 9124), and for dislocation (n = 11) £10 893 (sd 5476). Surgery for deep infection and peri-prosthetic fracture was associated with longer operating times, increased blood loss and an increase in complications compared to revisions for aseptic loosening. Total inpatient stay was also significantly longer on average (p < 0.001). Financial costs vary significantly by indication, which is not reflected in current National Health Service tariffs.
Total hip replacement (THR) is extremely common. Some prostheses fail, particularly in younger patients, and need to be revised, most commonly for loosening secondary to wear or dislocation. Surgeons have tried to address these problems by implanting large diameter metal-on-metal bearing surfaces. Our aim was to assess if metal-on-metal bearing surfaces lead to increased implant survival compared with other bearing surfaces in stemmed THR and, additionally, if larger head sizes result in improved implant survival.
We analysed the National Joint Registry of England and Wales for primary hip replacements (402,051, of which 31,171 were stemmed metal-on-metal) undertaken between 2003 and 2011. Our analysis was with a multivariable flexible parametric survival model to estimate the covariate-adjusted cumulative incidence of revision adjusting for the competing risk of death.
Metal-on-metal THR failed at high rates. Failure was related to head size, with larger heads failing earlier (3·2% cumulative incidence of revision [95% CI 2·5-4·1] for 28 mm and 5·1% [4·2-6·2] for 52 mm head at 5 years in men aged 60 years). 5 year revision rates in younger women were 6·1% (5·2-7·2) for 46 mm metal-on-metal compared with 1·6% (1·3-2·1) for 28 mm metal-on-polyethylene. By contrast, for ceramic-on-ceramic articulations larger head sizes were associated with improved survival (5 year revision rate of 3·3% [2·6-4·1] with 28 mm and 2·0% [1·5-2·7] with 40 mm for men aged 60 years).
Metal-on-metal stemmed articulations give poor implant survival compared with other options and should not be implanted. All patients with these bearings should be carefully monitored, particularly young women implanted with large diameter heads. Since large diameter ceramic-on-ceramic bearings seem to do well we support their continued use.
National Joint Registry of England and Wales.
The optimal method for acetabular socket fixation remains controversial. We present a critical analysis of the current evidence from a systemic literature review of comparative studies, long-term case series, prior literature reviews, meta-analysis, and national arthroplasty registry data for cemented and uncemented acetabular components to determine the respective survivorship rates, overall risk of re-operation, dislocation rates, and wear-related complications. Using contemporary techniques, both cemented and uncemented sockets can yield good long-term results, but our evaluation suggests that the overall/all cause re-operation risk is lower for cemented fixation. Until and unless crosslinked polyethylene (PE) liners or alternative bearings can prove to yield superior outcome in the future, the cemented PE cup remains the gold standard, in all age groups, by which every acetabular component should be compared.
The aim of the study was to evaluate the results of Poldi-Čech femoral stem implantation in primary total hip arthroplasty after 25 years.
A group of 65 patients (90 hips) with Poldi-Čech total hip arthroplasty carried out between 1974 and 1984 was evaluated at the end of 2009. The mean follow-up of all patients was 28 years (25 to 35). There were seven men and 58 women. The mean age at the time of implantation was 43 years (26 to 60) and at the latest follow-up it was 72 years. In all patients the cemented UHMW PE acetabular component (RCH 1000) was used together with AKV Ultra 2 Poldi steel femoral stems (1st, 2nd and 3rd generations). The stem was a monoblock with a 32-mm head. The evaluation of the results was based on the Harris hip score and X ray with an A-P view of the pelvis and the affected hip. Statistical analysis was made using the life-table method.
At the latest follow up the mean Harris score was 69.7 points (40 to 88). There were 69 hips with an original Poldi-Čech femoral component still in situ, 64 of them were stable and five with radiological evidence of aseptic loosening. Five patients had undergone Girdlestone resection arthroplasty for septic loosening. Thirteen patients (16 hips) had femoral stem revision. The cumulative proportion of clinical survivorship of the Poldi-Čech femoral stem, with revision for any reason as the endpoint, .was 0.93 at 6 years, 0.84 at 12 years, and 0.77 at 18, 24 and 30 years after the index surgery. Radiographic findings revealed 64 hips with stable stems, five hips with ;aseptic loosening (probable, 0 possible, 2, definite, 3). Six- teen hips were after revision surgery for aseptic loosening of the stem and five hips were after Girdlestone resection arthroplasty for septic failure. The cumulative proportion of radiological survivorship of the Poldi-Čech femoral stem with any reason as the endpoint was 0.92 at 6 years, 0.78 at 12 years, 0.72 at 18 years, 0.69 at 24 years and 0.69 at 30 years.
The Poldi-Čech stem with its anatomical shape and a highly polished surface meets the principles of successful composite beam stems. Its disadvantage is a valgus neck- shaft angle of 140° giving lower femoral offset and the risk of development of valgus deformity of the ipsilateral knee. In most cases osteolysis, radiolucent lines and bone rarefaction of the femur resulted from polyethylene wear of the acetabular component.
This study demonstrates a long-term survivorship of the Poldi-Čech femoral component in patients undergoing total hip arthroplasty 25 to 35 years ago.
The aim of the study was to evaluate the results of primary total hip arthroplasty with the use of the CLS stem at 11 to 17 years after implantation.
A total of 108 patients (122 hips) in whom a CLS stem was used in the 1991-1996 period were evaluated. The group included 34 men and 74 women, with an average age of 48 years (range, 28-63). The CLS stem with a neck-shaft angle of 145 degrees and the CLS expansion cup were used in all patients. Clinical outcomes were evaluated by Merle d'Aubigné-Postel score and Harris hip score, radiological examination was completed on AP and lateral views of the pelvis and the operated hip.
The average follow-up was 16.4 years (range, 11-17). The average Merle d'Aubigné-Postel score was 14.5 (range, 13.9-17.0) points and the average Harris hip score was 84.8 (range, 70-99) points. Very good or good outcomes were found in 81% of the patients. Three patients underwent revision surgery, in one for septic loosening, in one for aseptic loosening and in one for varus stem position leading to instability. The radiographs evaluated as described by Engh showed 116 stable stems, three fibrous stable and three unstable stems. Subsidence of more than 3 mm, without any further deterioration, was found in five hips at 12 months post-operatively. Seven hips showed one radiolucent line, four showed two radiolucent lines and three hips showed three radiolucent lines, all of them being less than 2 mm wide.
Radiographic evidence of a stable stem in 116 hips (116/122) suggests a high reliability of the implant. Assessment of radiolucent lines showed 108 hips without radiographic demarcation and 11 hips with slight demarcation. The signs of stress-shielding grade 1 were found in 28 hips. Good results of arthroplasty with the CLS stem can be attributed to its three-dimensional wedge-shaped design that allows for an optimal press-fit in the metaphyseal region. The porous surface provides reliable osteointegration. Stress-shielding is prevented by optimal stress distribution in the metaphyseal region and by a modulus of elasticity of titanium alloy which closely approximates the modulus of elasticity of bone.
At 15 years post-operatively, the cumulative probability of clinical survivorship of the CLS stem was 98.3 %, and cumulative probability of radiographic survivorship was 87.7 %. The advantages of this stem include a technically simple implantation, reliable osteointegration and long-term stability even in high demanding patients.
The hydroxyapatite coating of an implant surface provides osteoactive conditions that can support osteointegration of cementless joint arthroplasties. However, the possibilities of hydroxyapatite degradation, resorption and delamination that may become responsible for failure of total hip arthroplasty (THA) have been reported. The aim of the study was to assess the properties of Arbond hydroxyapatite coating by comparing the long-term survival of implants identical in construction but different in surface coating.
One group (HA) comprised 86 patients (100 THAs) with an average age of 45.14 years (range, 22.3 to 77.4 years) at the time of surgery who received a femoral stem (Walter) with a coating of Arbond sprayed over the proximal half. The other group (control) included 92 patients (100 THAs) with an average age of 49.7 years (range, 33 to 68.7) who had an identical femoral component without coating. In both groups the conical-shaped acetabular cup (Walter) and femoral head made of sintered ceramics were used. The patients in whom one or both components were replaced or extracted were not included in the final clinical evaluation (Harris Hip Score). For the statistical analysis of survival, a stable component still in place at the date of the revision procedure was regarded as surviving; a lose component at the same date was considered a failure. Finally, 71 hips of the HA group followed up for an average of 15.51 (range, 5.6 to 18.56) years and 39 control hips at an average follow-up of 14.19 (range, 6.24 to 18.48) years were clinically evaluated. The data of patients who died in the course of study (HA group, 11; control group, 14) were included in the clinical evaluation with the date of their last follow-up.
For both groups, the Kaplan-Meier survival curves were constructed for overall survival and for the survival of acetabular and femoral components separately. Differences in survival curves were evaluated with the use of Gehan's Wilcoxon test. Component survival was also calculated using 15-year life-table survivorship analysis. Differences in variables under study were assessed with the use of the two-tailed Student's t-test. A p value of less than 0.05 was considered significant.
A total of 29% hips were revised in the HA group, 27% for aseptic loosening of the acetabular cup, in 2% both components were removed because of deep infection. In the control group revision procedures were performed in 61% of the hips. Except for one case of deep infection (1%), the reason was cup loosening in 30%, stem loosening in 12% and both components loosening in 18% of the hips. The HA group showed a significantly longer survival of both total hip prostheses and individual components. The final HHS was significantly better than the initial score in both groups. There was no difference in the degree of improvement between the two groups. The radiographic data showed full osteointegration of stems in the HA group. The control group, on the other hand, had 87% of the stems with translucent lines in zone I and zone VII according to Gruen's classification.
The significantly longer survival of hips in the HA group gives support to the use of hydroxyapatite coating in total hip arthroplasty. The poorer results in grit-blasted implants, as compared with the literature data, can be explained by allow degree of roughness of the Walter implant surfaces.
The combined Arbond hydroxyapatite coating improves conditions for implant osteointegration in the bone.
Femoral stem loosening in total hip arthroplasty has a multifactorial etiology. T28 femoral stems have been made both roughed and polished-finish types, and differences in design are of interest in their effect on survival.
One hundred and sixty-seven stems (84 polished and 83 roughed-finish) placed between 1975 and 1982 were evaluated. Gruen zones were used to determine loosening and survival was determined by the Kaplan-Meier method.
Revision was made in 24.8% of the cases. Twenty-year survival rates were of 85.2% for roughed-finish stems and of 64.2% for polished-finish stems.
We were able to confirm our hypothesis concerning the longer survival rate of the roughed-finish implant which was of 87.95% at 17 years of follow-up. The survival-time of the implant was independent of diagnosis, cementation, age and positioning. The survival-time of the T28 cemented implant does not only depend on its texture but it has a multifactorial origin.
The purpose of this study was to evaluate the long-term results of a retrospective series of primary arthroplasty with a cementless dual mobility socket and a cemented Charnley type femoral component.
This study included 437 hip replacements performed between 1984 and 1990, in 388 patients. The Bousquet's acetabular component, an original concept of cementless dual mobility socket has been used, associated with a cemented Charnley type femoral component. A clinical and radiologic analysis was done.
The outcome is known for 345 hips (79%): 164 alive without revision at a mean of 16,5 years follow-up, 137 died without revision and 44 failures. Ninety-two (21%) were lost at follow-up. According to Kaplan-Meier analysis, the 5-year survival rate, was 84,4%+/-4,5 with revision for any reason (infection, dislocation, osteolysis...) for end point. Revision, for aseptic loosening of femoral or acetabular component, was performed in 30 hips (6,8%). Five dislocations occurred and were revised: two early related to technical errors and three after 10 years or more of follow-up. The young age of the patients at the time of the index surgery was correlated with higher rate of aseptic loosening.
The prevalence of revision for dislocation is very low in our series. This concept does not avoid wear, osteolysis and aseptic loosening, especially in young active patients but the long-term stability is confirmed. We recommend this type of prosthesis for patients over 70 years and for younger patients with high risk of dislocation Q.
As part of the 2006 symposium of the French Hip and Knee Society devoted to the dual mobility socket, we report a retrospective multicentric series of 438 first-intention total hip prostheses with a dual mobility socket at a mean 17 years follow-up. The purpose of our report was to ascertain the 15-year survival of this socket and analyze failures.
The series included 438 primary replacements. This was a homogeneous multicentric series. The cementless sockets were 80 Novae-1 titanium Serf cups and 358 Novae-1 stainless steel Serf cups. All stems were inserted without cement: 185 Pf((R)) stainless steel screwed Serf stems, 228 PRO titanium screwed Serf stems, and 25 Corail stems. The mobile polyethylene insert was retaining. All of the heads were 22.2-mm chromium-cobalt heads. Degenerative hip disease was the main etiology and mean follow-up was 17 years (range, 12-20). Mean age at implantation was 54.8 years (range, 23-87). The actuarial method with a 95% confidence interval was used to determine the 15-year cup survival rate.
At the last follow-up, none of the patients had presented an episode of early or late instability. Analysis of the socket at last follow-up showed 13 aseptic loosenings, 23 intraprosthetic dislocations, and seven replacements of the polyethylene insert for wear. The overall 15-year prosthesis survival rate was 89.2+/-8.7%. The overall 15-year socket survival rate was 96.3+/-3.7%.
The fact that, at last follow-up, none of the implants had shown instability confirms the long-term stability of the dual mobility socket. The results in terms of 15-year survival confirm earlier reports. The main cause of failure was cup fixation, which is the weak point of this technique with the initial Novae cup design, which did not have hydroxyapatite coating. The second leading cause was intraprosthetic dislocation, which can be divided into three main categories. The first is intraprosthetic dislocation in a context of pure wear with normal function of the dual mobility socket; the retaining feature of the insert loses its efficacy due to wear. The second category is intraprosthetic dislocation in a context of cup loosening with a third-body effect and increased retention wear, in which case we consider that cup loosening is the primary event leading to rapid secondary wear and subsequent intraprosthetic dislocation. The third category is intraprosthetic dislocation caused by a blockage in a context of fibrosis or impingement involving severe heterotopic ossifications. We had only two femoral failures related to aseptic loosening, most certainly related to use of noncemented implants, which limits the extension of granulomas to the polyethylene. Studying the three series from Saint-Etienne more specifically, where three different configurations were used, it would appear that the titanium cup has a better survival rate and that the titanium used for the thinner necks may be an unfavorable factor for intraprosthetic dislocation.
In 1988 we reported a ten-year review of 83 surviving patients from a group of 135 (146 prostheses) who had undergone primary hip replacement using the Stanmore prosthesis. We have now reviewed 44 of these patients at 15 to 16 years. Four patients had undergone revision, but the other 40 were all satisfied with the result of their hip replacement, 36 having little or no pain. Functional activities had decreased, but were still adequate for their average age of 81 years. There had been definite migration of the cup and/or femoral component in three hips, wear of the cup in ten and resorption of the calcar in six. Of the 24 hips inserted with radiopaque cement, eight showed an increase in radiolucent lines at the acetabular interface. The cumulative survival rate of the prosthesis was 91% at 15 to 16 years.
The aim of this study was to appreciate the long term result of 309 acetabular components of total hip arthroplasty.
All were performed using Charnley's prosthesis and cement, by one surgeon, between January 1972 and December 1975. Clinical function was graded according to Postel-Merle-d' Aubigné's scoring system (PMA score). We measured wear of polythylene using a personal method, on anteroposterior radiographs of the pelvis. Radiolucent line were appreciated by Delee and Charnley's criteria, migration by Massin's criteria. Survivorship curves were calculated with radiolucent lines, as migration, on 15 years. We compared the effect of different parameters on wear and loosening of the sockets.
At 15 years follow-up, we found 51.5 per cent hips with the highest PMA score (18). Revision for socket loosening was 3.88 per cent, the same for dislocations. Concerning 25 per cent of the sockets, wear of polyethylene was evaluated less than 0.065 mm a year, concerning 50 per cent of them, it was evaluated less than 0.11 mm a year, at last concerning 75 per cent of them, it was evaluated less than 0.16 mm a year. No significant correlation was established between the tilt of the acetabular component and the wear of polyethylene. We observed no radiolucent lines for 60 per cent of the implants, nor migration for 83 per cent of them. Statistical analysis proved the influence of the wear on radiolucent lines and migration.
The analysis confirms a moderate wear of polyethylene during 15 years. We introduce an original method for its measurement and its formulation. This method allows a truly description of wear in long term results. This analysis confirms also that several parameters intercede on loosening; these are different if one considers radiolucent lines or migration. We do think at last, that the best positionning of the socket in the A.P. view should approach 35 degrees.
We made a prospective study of 241 Charnley total hip replacements performed between 1968 and 1974. In 1990 we reviewed 92 patients with 103 hips or 96% of surviving hips at a mean follow-up of 17.6 years (15 to 20.6). The clinical results were excellent with Charnley scores of four or more for pain in 95% of the cases, for function in 73% and for movement in 93%. Of the whole series, 8.3% had been revised and Kaplan Meier survival analysis showed a probability of revision at 20 years of 10.7%. No significant difference concerning the results was found between young patients operated between the ages of 34 to 55, and older patients operated between the ages of 56 to 79 years. These results are similar to those from the few other series with extended follow-up and make it difficult to justify the present widespread use of uncemented hip prostheses.
We evaluated the results of 309 femoral components of total hip arthroplasties performed using Charnley prosthesis and cement, by one surgeon, between January 1972 and December 1975.
Observations and measurements were based on standard pelvic X-rays. Survivorship curves were calculated to evaluate femoral component failures at twenty years of follow-up. We compared the effect of different parameters on the femoral implant loosening.
At 20 years of follow-up, 82 hips were included in the study, 227 were expelled: 109 by death, 52 by revision and 66 by loss for follow-up. Probability for death, at 20 years follow-up, was 40.7 per cent, probability for revision was 33.9 per cent, for femoral loosening was 16 per cent. The rate of aseptic femoral loosening was higher for men, with high activity and varus position of the femoral stem. Statistical analysis showed correlation between calcar resorption and femoral loosening, between polyethylene wear and calcar resorption. No directly significant correlation was established between polyethylene wear and femoral loosening.
This study confirms relations between polyethylene wear, calcar resorption and femoral loosening and underlines the influence of mechanical factors on femoral loosening. Femoral stem positioning is very important for femoral loosening. Varus position is clearly unfavourable. According to ours results, the best position is with a slight valgus.
Because of specific methodological difficulties in conducting randomized trials, surgical research remains dependent predominantly on observational or non-randomized studies. Few validated instruments are available to determine the methodological quality of such studies either from the reader's perspective or for the purpose of meta-analysis. The aim of the present study was to develop and validate such an instrument.
After an initial conceptualization phase of a methodological index for non-randomized studies (MINORS), a list of 12 potential items was sent to 100 experts from different surgical specialties for evaluation and was also assessed by 10 clinical methodologists. Subsequent testing involved the assessment of inter-reviewer agreement, test-retest reliability at 2 months, internal consistency reliability and external validity.
The final version of MINORS contained 12 items, the first eight being specifically for non-comparative studies. Reliability was established on the basis of good inter-reviewer agreement, high test-retest reliability by the kappa-coefficient and good internal consistency by a high Cronbach's alpha-coefficient. External validity was established in terms of the ability of MINORS to identify excellent trials.
MINORS is a valid instrument designed to assess the methodological quality of non-randomized surgical studies, whether comparative or non-comparative. The next step will be to determine its external validity when used in a large number of studies and to compare it with other existing instruments.
Determination of long-term results of hip replacements in patients who, at the time of operation, were under the age of 50. Procedures whereby an existing acetabulum defect was filled with bone chips that were impacted into a strong layer, after which a cemented total hip prosthesis was implanted.
Descriptive.
Prospectively collected data from patients who were under the age of 50, and had undergone a hip replacement operation at our hospital between 1 July 1979 and 31 December 1987 were analysed. Data were collected up to 31 December 2002. The main outcome was time to revision. Survival was calculated by the Kaplan-Meier method.
The study group consisted of 25 patients, 17 women and 8 men with 29 prosthetic hips. The average age at operation was 37.6 years (range: 20-49). Follow-up time was 15-23 years (median: 18.7 years). 1 patient (1 hip) was lost to follow-up. 3 patients (4 hips) died within 15 years after the operation; none of them had undergone revision. 4 revisions had been performed: I septic loosening (14 years p.o.) and 3 aseptic loosenings (6, 15, 20 years p.o.). The cumulative survival with the end-point 'revision for any reason' was 96% (95% CI: 88-100) at to years and 88% (95% CI: 74-100) at 20 years; after exclusion of the septic loosening the survival at 20 years was 92% (95% CI: 80-100).
Hip replacement including a reconstruction technique for an acetabulum defect in patients under the age of 50 was regarded as successful if after 10 years, at least 90% of the prostheses were still in situ.
In the 1960s, total hip replacement revolutionised management of elderly patients crippled with arthritis, with very good long-term results. Today, young patients present for hip-replacement surgery hoping to restore their quality of life, which typically includes physically demanding activities. Advances in bioengineering technology have driven development of hip prostheses. Both cemented and uncemented hips can provide durable fixation. Better materials and design have allowed use of large-bore bearings, which provide an increased range of motion with enhanced stability and very low wear. Minimally invasive surgery limits soft-tissue damage and facilitates accelerated discharge and rehabilitation. Short-term objectives must not compromise long-term performance. Computer-assisted surgery will contribute to reproducible and accurate placement of implants. Universal economic constraints in healthcare services dictate that further developments in total hip replacement will be governed by their cost-effectiveness.
- J Kärrholm
- H Lindahl
- H Malchau
Kärrholm J, Lindahl H, Malchau H, et al. Swedish Hip Arthroplasty
Register annual report 2016. DOI:10.18158/SJy6jKyrM.
Long term results of a series of cementless total hip prostheses on patients of less than 50 years old
- D Schmitt
- F Bresler
- X Nicolay
Schmitt D, Bresler F, Nicolay X, et al. Long term results of a series
of cementless total hip prostheses on patients of less than 50 years
old. Eur J Orthop Surg Traumatol 1996; 6: 261-66 (in French).
Long term results of a series of cementless total hip prostheses on patients of less than 50 years old
- Schmitt