Complications After Revision Total Hip Arthroplasty in the Medicare Population

Background

The purpose of this study was to identify the incidence and types of complications after revision total hip arthroplasty (THA) within the first year, and determine the relative risk factors for these complications and of re-revision.

Extended Antibiotic Prophylaxis Confers No Benefit Following Aseptic Revision Total Hip Arthroplasty: A Matched Case-Controlled Study

BackgroundAdministration of perioperative antibiotic prophylaxis is one of the most important practices for prevention of periprosthetic joint infection (PJI) in patients undergoing total hip arthroplasty (THA). It is common to continue perioperative antibiotic prophylaxis for 48 hours or longer in patients undergoing revision arthroplasty, until results of intraoperative culture samples become available. However, the utility of this practice remains unclear. We examined whether extended antibiotic prophylaxis following aseptic revision THA reduces the risk of subsequent PJI.MethodsWe retrospectively reviewed records of patients undergoing aseptic revision THA between January 2000 and December 2015. At our institution, some surgeons administer prophylactic antibiotics to revision patients for only 24 hours while others prefer to extend until intraoperative culture results become available. We matched 209 patients undergoing revision THA who received extended antibiotic prophylaxis (>24 hours) in a 1:1 ratio with 209 patients receiving standard antibiotic prophylaxis (≤24 hours). The matching criteria were age, sex, body mass index, Charlson comorbidity index, and operative time.ResultsThe incidence of subsequent PJI was 4.8% in patients receiving extended antibiotic prophylaxis vs 2.4% in patients receiving standard. After adjusting for all cofounders and using multivariate logistic regression, the administration of extended prophylactic antibiotics did not reduce the incidence of subsequent infection. When stratified by postoperative antibiotic regimens, the 2 groups had similar infection-free implant survival rate (95.2% in extended and 97.6% in standard).ConclusionIt appears that extending perioperative prophylactic antibiotics until intraoperative culture results become available in patients undergoing revision THA for aseptic failures does not provide any additional benefit in terms of reducing the risk of subsequent PJI.     

Highly Porous Titanium Acetabular Components in Primary and Revision Total Hip Arthroplasty: A Systematic Review

BackgroundA number of papers have been published reporting on the clinical performance of highly porous coated titanium acetabular cups in primary and revision total hip arthroplasty (THA). However, no systematic review of the literature has been published to date.MethodsThe US National Library of Medicine (PubMed/MEDLINE), Embase, and the Cochrane Database of Systematic Reviews were queried for publications utilizing the following keywords: “tritanium” OR “highly-porous” AND “titanium” OR “acetabular” AND “trabecular” AND “titanium”.ResultsOverall, 16 studies were included in this review (11,366 cases; 60% females, 2-7 years mean follow-up). The overall survival rate of highly porous titanium acetabular components in primary cases was 99.3% (10,811 of 10,886 cases), whereas the rate of aseptic loosening was 0.1%. The overall survival rate of the highly porous titanium acetabular components in revision THA cases was 93.5% (449 of 480 cases), whereas the rate of aseptic loosening was 2.1%.ConclusionThere was moderate quality evidence to show that the use of highly porous titanium acetabular components in primary and revision THA cases is associated with satisfactory clinical outcomes in the short- and medium-term, without showing any evidence of cup migration or radiolucency. Taking into consideration that there is no evidence yet regarding the long-term survivorship of these components, we feel that further research of higher quality is required to generate more evidence-based conclusions regarding the longevity of highly porous titanium acetabular implants compared with conventional titanium counterparts.     

Risk of Prosthetic Joint Infection Increases Following Early Aseptic Revision Surgery of Total Hip and Knee Arthroplasty

BackgroundIt is important to identify risk factors for periprosthetic joint infection (PJI) following total joint arthroplasty in order to mitigate the substantial social and economic burden. The objective of this study is to evaluate early aseptic revision surgery as a potential risk factor for PJI following total hip (THA) and total knee arthroplasty (TKA).MethodsPatients who underwent primary THA or TKA with early aseptic revision were identified in 2 national insurance databases. Control groups of patients who did not undergo revision were identified and matched 10:1 to study patients. Rates of PJI at 1 and 2 years postoperatively following revision surgery were calculated and compared to controls using a logistic regression analysis.ResultsIn total, 328 Medicare and 222 Humana patients undergoing aseptic revision THA within 1 year of index THA were found to have significantly increased risk of PJI at 1 year (5.49% vs 0.91%, odds ratio [OR] 5.61, P < .001 for Medicare; 7.21% vs 0.68%, OR 11.34, P < .001 for Humana) and 2 years (5.79% vs 1.10%, OR 4.79, P < .001 for Medicare; 8.11% vs 1.04%, OR 9.05, P < .001 for Humana). Similarly for TKA, 190 Medicare and 226 Humana patients who underwent aseptic revision TKA within 1 year were found to have significantly higher rates of PJI at 1 year (6.48% vs 1.16%, OR 7.69, P < .001 for Medicare; 6.19% vs 1.28%, OR 4.89, P < .001 for Humana) and 2 years (8.42% vs 1.58%, OR 6.57, P < .001 for Medicare; 7.08% vs 1.50%, OR 4.50, P < .001 for Humana).ConclusionEarly aseptic revision surgery following THA and TKA is associated with significantly increased risks of subsequent PJI within 2 years.     

Trabecular Metal Augments for Severe Acetabular Defects in Revision Hip Arthroplasty: A Long-Term Follow-Up

BackgroundPaprosky type IIIa and IIIb acetabular defects remain technically challenging during revision hip arthroplasty. Numerous surgical options exist to counter extensive acetabular bone loss with high postoperative complication and revision rates reported. Our aim was to report comprehensive long-term outcomes of our experience with Trabecular Metal (TM) augments for these difficult cases.Methods38 patients underwent revision total hip arthroplasty at our institution from 2009 to 2014 where a TM augment was used for acetabular deficiency. Prospective radiographic and Patient-Reported Outcome Measures were recorded and analyzed to a mean of 7.3 years (range: 5.4 to 10.8).ResultsNo patient was excluded or lost to follow-up. Complications included 3 intraoperative fractures, 1 early infection requiring washout with implant retention, 1 early revision due to allograft resorption, and 6 patients who required late repeat revision surgery: 3 for late infection, 2 for aseptic loosening with augment fracture or dislocation, and 1 for recurrent dislocation. The estimated mean implant survivorship was 8.99 years. 93.5% of augments remaining were well osseointegrated while 97% of the acetabular shells were osseointegrated. Hip center of rotation was restored by a mean of 14 mm inferiorly without significant medialization. Short Form-12 (SF-12) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were significantly reduced postoperatively to a level comparable to the average individual.ConclusionThis long-term study details our experience of TM augments for the most severe acetabular defects. For such cases, no excellent surgical solution exists; in comparison to alternative methods, we advocate that this technique is reasonably safe and effective.     

Conical Primary Cementless Stem in Revision Hip Arthroplasty: 94 Consecutive Implantations at a Mean Follow-Up of 12.7 years

BackgroundRevision of a failed total hip arthroplasty (THA) poses technical challenges. The use of primary stems for revision can be advantageous for maintaining bone stock and reducing complications: small case series have reported promising results in the short-term to mid-term follow-up. The aim of this study was to evaluate the long-term clinical and functional results and survivorship of a consecutive series of THA femoral component revisions using a conical primary cementless stem (PCS).MethodsNinety-four stem revisions with a preoperative Paprosky I or II defect were analyzed at an average follow-up of 12.7 ± 5.4 years. Aseptic loosening was the reason for revision in 92.5% of cases. Twenty patients were lost to follow-up. Two subgroups were created: Group 1 (n = 59) underwent isolated stem revision; Group 2 (n = 15) underwent complete THA revision. All were evaluated preoperatively and postoperatively based on the Harris Hip Score (HHS), the Western Ontario and McMaster Universities Index (WOMAC) score, and the visual analog scale for pain (VAS). Residual trochanteric pain and length discrepancies were recorded. Radiographic evaluation included signs of osteolysis, subsidence, loosening, and heterotopic ossification.ResultsPCS survivorship was 100% at 5 years and 95.9% at 10 years. Overall, significant postoperative improvements (P < .01) were observed on the HHS (44.3 vs 86.9), WOMAC (42.8 vs 82.8), and VAS (7.0 vs 3.0). Postoperative scores on all scales were higher for Group 1 (P < .01). Three patients (4.1%) underwent further stem revision. Demarcation lines (1 mm) were found in 12 (16.2%) patients and significant heterotopic ossifications in 22 (29.7%).ConclusionThe use of PCS for stem revision in failed THA with a limited femoral bone defect is a reliable option for both isolated stem revision and concomitant cup revision in well-selected patients.     

Revision for Aseptic Loosening of Highly Porous Acetabular Components in Primary Total Hip Arthroplasty: An Analysis of 20,993 Total Hip Replacements

BackgroundHighly porous-coated titanium acetabular components have a high coefficient of friction and ultraporous surfaces to enhance bone ingrowth and osseointegration in total hip arthroplasty (THA). There have been concerns with the development of early radiolucent lines and aseptic loosening of highly porous acetabular components. It is unclear whether these concerns relate to a specific implant or the entire class. The aim of this study is to compare the revision rates for aseptic loosening of highly porous acetabular combinations in primary THA using data from a large joint replacement registry.MethodsData were retrieved from the Australian Orthopedic Association National Joint Replacement Registry for the study period September 1999 to December 2019. All primary THA procedures recorded and performed for osteoarthritis using the most common combinations for each highly porous acetabular component with highly cross-linked polyethylene and a 32-mm or 36-mm femoral head were included. The primary outcome measure was revision for aseptic loosening of the acetabular component. Results were adjusted for patient age and gender.ResultsThere were 20,993 primary THA procedures performed for osteoarthritis using a highly porous acetabular component across 6 combinations. Relative to the POLARSTEM/R3 (StikTite), the Exeter V40/Tritanium had a significantly higher risk of revision for aseptic loosening of the acetabular component (hazard ratio 0.21, 95% confidence interval 0.06-0.74, P = .014). There was no difference between any other highly porous acetabular component combination and no late revisions for aseptic loosening.ConclusionHighly porous-coated titanium acetabular components have low rates of aseptic loosening with long-term follow-up. A difference between components may exist.Level of EvidenceLevel III.     

Revision Risk of Total Hip Arthroplasty With Vitamin E Doped Liners: Results From the Danish Hip Arthroplasty Register

BackgroundVitamin E-doped cross-linked polyethylene (VEPE) liners were introduced in total hip arthroplasty (THA) to reduce wear and risk of aseptic loosening and liner fracture. We report this nationwide population-based study to investigate the safety of VEPE liners for THA compared to cross-linked annealed or remelted polyethylene (XLPE).MethodsWe included THAs from The Danish Hip Arthroplasty Register from January 1, 2008 to June 30, 2019, with uncemented cup, VEPE or XLPE liner, and metal or ceramic head. The outcome was revision due to (1) polyethylene-related endpoints (aseptic loosening, granuloma, osteolysis, or liner fractures) and (2) other endpoints.ResultsA total of 110,803 THAs were assessed for eligibility and 53,842 THAs (46,645 patients) were included in the study: 5069 (9.4%) THAs with a VEPE liner and 48,773 (91.6%) with a XLPE liner. Median observation time was 5.48 (interquartile range 3.80-7.15) years for VEPE and 4.85 (interquartile range 2.68-7.76) for XLPE. VEPE had a lower risk of revision for polyethylene-related endpoints compared to XLPE (hazard ratio [HR] 0.60, 95% confidence interval 0.36-0.98) during complete follow-up. THAs with VEPE liners were associated with increased risk of any revision within the first 3 months (HR 1.62, 1.36-1.94), revision recorded as aseptic loosening within 3 months (HR 4.46, 2.26-8.80), and periprosthetic fracture within 3 months (HR 2.57, 1.98, 3.33).ConclusionVEPE liners had a lower risk of revision due to polyethylene-related endpoints, but a higher risk of all-cause revision within 3 months.     

Fate of the Retained Acetabular Component During Revision Total Hip Arthroplasty: A Meta-Analysis and Systematic Review

BackgroundThe aim of this meta-analysis and systematic review is to estimate re-revision rates due to aseptic loosening of retained acetabular components after revision total hip arthroplasty.MethodsPubMed, EMBASE, Cochrane Library, and Web of Science were searched until June 11, 2018. Data were extracted by 2 independent investigators and consensus was reached with the involvement of a third investigator. Rates of re-revision due to aseptic loosening from 6 studies were aggregated using random effects model after a logit transformation and were grouped by study and population level characteristics.ResultsAn assessment of the re-revision rates of retained acetabular components due to aseptic loosening in revision total hip arthroplasty was reported in 6 studies involving 669 cases. The pooled re-revision rate was 12.6% (95% confidence interval 8.4-18.4) with a mean study follow-up of 8.6 years. The rate of re-revision due to aseptic loosening of retained acetabular components was 6.8% (95% confidence interval 3.4-13.3). In the univariate meta-regression analysis, mean age at index revision surgery was significantly associated with the rate of re-revision due to aseptic loosening (R² = 99.98%, P < .0001).ConclusionBased on this exploratory analysis, revision hip procedures with retentions of well-fixed acetabular components generally have a low risk of failure during mid-term to long-term follow-ups.     

Obesity Is Independently Associated With Early Aseptic Loosening in Primary Total Hip Arthroplasty

Background

Obesity affects millions of patients in the United States and is associated with several complications after total hip arthroplasty (THA). The effect of obesity on the rate and mode of primary THA failure remains poorly understood, especially given other potentially confounding patient characteristics. We hypothesized that, among patients with a failed primary THA, obesity is independently associated with aseptic loosening and a higher rate of early revision.

Satisfactory Results of the Exeter Revision Femoral Stem Used for Primary Total Hip Arthroplasty

Background

The Exeter cemented femoral stem has demonstrated excellent clinical and radiographic outcomes as well as long-term survivorship free from aseptic loosening. A shorter revision stem (125 mm) with a 44 offset became available for the purpose of cement-in-cement revision situations. In certain cases, this shorter revision stem may be used for various primary total hip arthroplasties (THAs) where the standard length stem would require distally reaming the femoral canal. We sought to report on the early to midterm results of this specific stem when used for primary THA regarding (1) clinical and radiographic outcomes, (2) complications, and (3) survivorship.

Loosening After Acetabular Revision: Comparison of Trabecular Metal and Reinforcement Rings. A Systematic Review

The best method of revision acetabular arthroplasty remains unclear. Consequently, we reviewed the literature on the treatment of revision acetabular arthroplasty using revision rings (1541 cases; mean follow-up (FU) 5.7 years) and Trabecular Metal, or TM, implants (1959 cases; mean FU 3.7 years) to determine if a difference with regard to revision failure could be determined. Failure rates of the respective implants were compared statistically using a logistic regression model with adjustment for discrepancies in FU time. In our study, TM shows statistically significant decreased loosening rates relative to revision rings for all grades including severe acetabular defects and pelvic discontinuity. The severe defects appear to benefit the most from TM.     

Acetabular Component Position and the Risk of Dislocation Following Primary and Revision Total Hip Arthroplasty: A Matched Cohort Analysis

Background

Recently, the importance of acetabular component positioning in the Lewinnek “safe zone” in preventing prosthetic dislocation following total hip arthroplasty (THA) has been questioned. The purpose of this study was to determine the proportion of acetabular components within the Lewinnek safe zone between primary and revision THAs that have sustained a dislocation vs matched controls without a dislocation event.

Risk Factors for Periprosthetic Joint Infection Following Primary Total Hip Arthroplasty: A Case Control Study

The purpose of this study was to identify the specific comorbidities and demographic factors that are independently associated with an increased risk of periprosthetic joint infection (PJI) in total hip arthroplasty (THA) patients. A case–control study design was used to compare 88 patients who underwent unilateral primary THA and developed PJI with 499 unilateral primary THA patients who did not develop PJI. The impact of 18 comorbid conditions and other demographic factors on PJI was examined. Depression, obesity, cardiac arrhythmia, and male gender were found to be independently associated with an increased risk of PJI in THA patients. This information is important to consider when counseling patients on the risks associated with elective THA, and for risk-adjusting publicly reported THA outcomes.     

Mortality Following Revision Total Knee Arthroplasty: A Matched Cohort Study of Septic versus Aseptic Revisions

We report the medium-term mortality after septic versus aseptic revision total knee arthroplasty (TKA) and factors that can contribute to mortality in revision TKA. Mortality rates of 88 patients undergoing septic revision (septic group) were compared with age- and year of surgery-matched 88 patients of aseptic revision (aseptic group). The overall mortality after revision TKA was 10.7% at a median of 4 years of follow-up (range, 2–7 years). However, the mortality after septic revision (18%, 16/88) was six times higher than that of aseptic revision (3%, 3/88) (P = 0.003). Infections with Staphylococcus aureus and/or methicillin resistance was not associated with higher mortality rates. Multivariate analysis indicated that increased age (P < 0.001), higher ASA class (P = 0.002), and septic revision (P < 0.001) were identified as independent predictors of increased mortality after revision TKA.     

Revision Total Hip and Knee Arthroplasties After Solid Organ Transplant

Background

As solid organ transplant (SOT) patients' survival improves, the number undergoing total hip (THA) and total knee arthroplasty (TKA) is increasing. Accordingly, the number of revision procedures in this higher-risk group is also increasing. The goals of this study were to identify the most common failure mechanisms, associated complications, clinical outcomes, and patient survivorship of SOT patients after revision THA or TKA.

The Association Between Cement Viscosity and Revision Risk After Primary Total Knee Arthroplasty

BackgroundRecent case series have reported early failure with the use of high-viscosity cement (HVC) in total knee arthroplasty (TKA). We evaluated revision risk after TKA with HVC compared with medium-viscosity cement (MVC) in a large cohort.MethodsWe conducted a cohort study using data from Kaiser Permanente’s Total Joint Replacement Registry. Patients who underwent fully cemented primary TKA for osteoarthritis were identified (2001-2018). Only posterior-stabilized, fixed-mobility designs of the 3 highest-volume implant systems (DePuy PFC, Zimmer NexGen, and Zimmer Persona) were included to mitigate confounding from implant characteristics. Palacos (Zimmer/Heraeus) and Simplex (Stryker) cements comprised the HVC and MVC exposure groups, respectively. Propensity score–weighted Cox proportional hazards regression was used to evaluate risk for any revision during follow-up and risk for revision from aseptic loosening specifically.ResultsThe final cohort comprised 76,052 TKAs, 41.1% using MVC. The crude 14-year cumulative revision probability was 4.55% and 5.12% for TKA with MVC and HVC, respectively. In propensity score–weighted Cox models, MVC compared with HVC had a lower risk of any revision (hazard ratio = 0.82, 95% confidence interval = 0.70-0.95) while no difference was observed for revision from aseptic loosening (hazard ratio = 0.80, 95% confidence interval = 0.56-1.13).ConclusionWhile we observed a lower risk for any revision with the use of Simplex MVC compared with Palacos HVC, we did not observe a difference in revision for aseptic loosening specifically. Given the widespread use of HVC, additional research to investigate other HVC and potential mechanisms for failure outside of loosening is warranted.Level of EvidenceLevel III.     

Outcomes and Risk Factors of Extended Trochanteric Osteotomy in Aseptic Revision Total Hip Arthroplasty: A Systematic Review

BackgroundAlthough extended trochanteric osteotomy (ETO) is an effective technique for femoral stem removal and for the concomitant management of proximal femoral deformities, complications including persistent pain, trochanteric nonunion, and painful hardware can occur.MethodsThe US National Library of Medicine (PubMed/MEDLINE) and the Cochrane Database of Systematic Reviews were queried for publications utilizing the following keywords: “extended” AND “trochanteric” AND “osteotomy.”ResultsNineteen articles were included in the present study with 1478 ETOs. The mean overall union rate of the ETO was 93.1% (1377 of 1478 cases), while the overall rate of radiographic femoral stem subsidence >5 mm was 7.1% (25 of 350 cases). ETO union rates and femoral stem subsidence rates were similar between patients with periprosthetic fractures treated with total hip arthroplasty (THA) revision and ETO and patients treated with THA revision and ETO for reasons other than fractures. There was limited evidence that prior femoral cementation and older age might negatively influence ETO union rates.ConclusionThere was moderate quality evidence to show that the use of ETO in aseptic patients undergoing single-stage revision THA is safe and effective, with a 7% rate of ETO nonunion and subsidence >5 mm in 7%. ETO can be safely used in cases with periprosthetic fractures in which stem fixation is jeopardized and a reimplantation is required. A well-conducted ETO should be preferred in selective THA revision cases to prevent intraoperative femoral fractures which are associated with deteriorated clinical outcomes. The use of trochanteric plate with cables should be considered as the first choice for ETO fixation.     

Prosthetic Dislocation and Revision After Primary Total Hip Arthroplasty in Lumbar Fusion Patients: A Propensity Score Matched-Pair Analysis

Background

Lumbar-pelvic fusion reduces the variation in pelvic tilt in functional situations by reducing lumbar spine flexibility, which is thought to be important in maintaining stability of a total hip arthroplasty (THA). We compared dislocation and revision rates for patients with lumbar fusion and subsequent THA to a matched comparison cohort with hip and spine degenerative changes undergoing only THA.

Contemporary Porous Titanium Acetabular Components for Total Hip Arthroplasty After Pelvic Radiation

BackgroundPatients undergoing primary total hip arthroplasty (THA) following pelvic radiation have historically had poor survivorship free of aseptic acetabular component loosening. However, several series have reported improved results with tantalum acetabular components. The purpose of this study is to assess implant survivorship, radiographic results, and clinical outcomes of contemporary, porous titanium acetabular components in the setting of prior pelvic radiation.MethodsWe retrospectively reviewed 33 patients (38 hips) with prior pelvic radiation between 2006 and 2016 who underwent primary THA. The mean overall pelvic radiation dose was 6300 cGy with a mean latency period to THA of 5 years. The most common acetabular component was Pinnacle (DePuy Synthes) in 76%. Eight-seven percent of cups were fixed with screws. The mean age at primary THA was 74 years, 76% were male, and the mean body mass index was 30 kg/m². Mean follow-up was 5 years.ResultsThe 10-year survivorship free of revision for aseptic loosening, free of any revision, and free of any reoperation were 100%, 89%, and 89%, respectively, when accounting for death as a competing risk. There were 3 revisions; one each for taper corrosion, recurrent dislocation, and infection. Radiographically, all cups had evidence of osteointegration and none had radiographic evidence of loosening. The mean Harris Hip Score improved from 50 to 84 postoperatively (P < .0001).ConclusionContemporary porous titanium acetabular components with supplemental screws provided excellent implant fixation in patients with prior therapeutic pelvic radiation. At 10 years, 100% of these components were free of revision for aseptic loosening and 100% were radiographically well-fixed.Level of EvidenceLevel IV, Therapeutic.