Minimum ten-year results of a 28-mm metal-on-metal bearing in cementless total hip arthroplasty in patients fifty years of age and younger

Purpose

Concerns have been raised in relation to metal-on-metal (MoM) articulations with catastrophic soft-tissue reactions due to metal debris. We reviewed how small head MoM articulations perform in primary uncemented total hip arthroplasty (THA) in young patients at a minimum of ten years.

Methods

We retrospectively evaluated the clinical and radiographic results of the first 100 consecutive primary cementless THAs using the 28-mm Metasul MoM articulation in 91 patients younger than 50 years of age at the time of surgery.

Results

After 13 years, survival for the endpoint revision due to any reason was 90.9 % and 98.9 % for revision due to aseptic implant loosening. The cumulative incidence of MoM related revisions was 1.2 %. Small proximal femoral osteolysis was found in 18 % of hips. No acetabular osteolysis or loosening was detected. Two hips showed signs of femoral neck impingement with severe damage to the neck.

Conclusions

Early in the second decade, MoM-associated complications were rare using the 28-mm Metasul articulation, and aseptic loosening was not a major mode of failure in this cohort of young patients.

Level of evidence

Therapeutic Level IV.     

非骨水泥型全髋关节成形术在小于60岁国人中应用的研究（英文）

目的探讨非骨水泥型全髋关节成形术（THA）在小于60岁国人中应用的长期结果。方法从1998年到2001年,一项前瞻性调查58例初次THA在小于60岁患者的结果,平均随访时间为11.1年（3.3~13.3年）。结果本组患者手术前的Harris评分平均为36.9（6~62）分,在最后评估的Harris评分平均为88.3（35~100）分。采用无菌性松动为失败标准,这种非骨水泥型THA在13.3年的假体生存率为97.9%。结论非骨水泥型THA在小于60岁患者有优良的长期结果。     

Total hip replacement with a cementless acetabular component and a cemented femoral component in patients younger than fifty years of age

BACKGROUND: We have been using hybrid total hip arthroplasty (a cementless acetabular component and a cemented stem) in young patients. The purpose of this study was to determine the prevalence of aseptic loosening, polyethylene wear, and osteolysis after the use of this technique. METHODS: We studied a prospective consecutive series of sixty-four primary hybrid total hip replacements in fifty-five patients younger than fifty years old. There were forty-three men and twelve women; the average age at the time of the index operation was 43.4 years. The average duration of follow-up was 9.4 years. We used a cementless acetabular component without screw-holes and a cemented femoral component with a 22-mm head in all hips. Clinical follow-up with use of Harris hip ratings and radiographic follow-up were performed at six weeks; at three, six, and twelve months; and yearly thereafter. The sequential annual linear and volumetric wear rates were measured, and bone-remodeling and osteolysis were assessed. RESULTS: The mean preoperative Harris hip score was 44 points, which increased to 95 points at the time of final follow-up. No hip had aseptic loosening. One hip (2%) was revised because of late infection. The average linear wear (and standard deviation) was 0.96 +/- 0.066 mm, with an average annual rate of 0.096 +/- 0.013 mm. The average volumetric wear was 364.7 +/- 25.2 mm (3), with an average annual rate of 43.4 +/- 3.5 mm (3). Six hips (9%) had an osteolytic lesion of <1 cm in diameter in the calcar femorale (zone 7). CONCLUSIONS: Our results show that a hybrid arthroplasty with a cementless acetabular component and a smooth cemented femoral component (Ra, 0.6 mm) is effective for primary total hip replacement in young patients. Although there was no aseptic loosening and a low prevalence of osteolysis at the latest follow-up evaluation, the high rates of linear and volumetric wear of the polyethylene liner in these young patients remain a concern.     

Modern total hip arthroplasty in patients younger than 21 years

Total hip arthroplasty (THA) is not commonly performed in adolescents. However, it may be the only option for pain control with continued mobility for advanced disease. We report our experience with modern alternative-bearing THA in patients younger than 21 years. Twenty-one THAs (18 patients) were followed. Preoperative and postoperative Harris hip scores were recorded, and radiographs were reviewed. Average follow-up was 49 months (range, 25-89). Underlying etiology was chemotherapy-induced osteonecrosis (33%), steroid-induced osteonecrosis (29%), sickle cell disease (24%), and chronic dislocation (14%). Articulation bearings were ceramic/ceramic (67%), metal/highly cross-linked polyethylene (29%), and metal resurfacing (5%). Mean age was 18 years (range, 13-20). Harris hip scores improved from 43.6 to 83.6 (P < .001). At final follow-up, there was no radiographic loosening; 1 THA was revised for a cracked ceramic liner. At intermediate-term follow-up, clinical and radiographic results are favorable after alternative-bearing THA in patients younger than 21 years.     

Ceramic-on-ceramic total hip arthroplasty in patients younger than 20 years

Total hip arthroplasty (THA) in the adolescent patient has historically shown relatively poor survivorship. This study reports the results of THA in young patients using contemporary ceramic bearings. Twenty-four THAs were performed using ceramic bearing surfaces in patients 20 years old or younger (mean, 16.4; range, 12-20). Average follow-up was 52 months (range, 25-123 months). The survival rate was 96%, with 1 revision for a loose acetabular component. Other complications included a peroneal nerve palsy that resolved and 2 dislocations in 1 patient. Postoperatively, the Modified Harris Hip Score mean was 93.4 (range, 66-100). This study shows promising results at short-term to midterm follow-up in very young patients who undergo THA using ceramic-on-ceramic components.     

Cementless total hip arthroplasty with a metal-on-metal bearing in patients younger than 50 years

Total hip arthroplasty (THA) longevity is the primary concern in young patients. Metal-on-metal articulations were reintroduced to reduce polyethylene particle-induced osteolysis and improve survivorship; to date, based on issued reports, this strategy appears to have been successful. In this study, the authors investigated metal-on-metal articulation survivorship and osteolysis incidence in young patients (19-50 years old at index operations) and retrospectively reviewed cementless metal-on-metal THAs in 70 patients (78 hips) with a mean follow-up of 12.4 years. Metasul articulation was used with the Wagner acetabular component in all. Survivorship with revision for any cause was 98.7% (95% confidence interval, 98%-100%), and survivorship due to the development of osteolysis for any lesion was 97.5% (95% confidence interval, 95%-99%). Mean Harris hip score improved from 51 to 95 points at final follow-up. The findings of this study indicate that outcomes of cementless THA with a metal-on-metal bearing in young patients are satisfactory. However, longer-term studies in larger cohorts are required to determine whether metal-on-metal articulations are really a favorable option in young patients.     

Primary total hip arthroplasty with Asian-type AML total hip prosthesis: follow-up for more than 10 years

BACKGROUND: We retrospectively reviewed 137 consecutive total hip arthroplasties performed with AML-A stems and Tri-Lock cups to see whether design modifications made to these components would achieve durable biological fixation in the Japanese population in whom developmental dysplasia of the hip (DDH) is relatively common. Patients from our initial clinical series using these components are available for more than 10 years' follow-up. METHODS: Between April 1988 and June 1994, we performed 137 total hip arthroplasties using the AML-A prosthesis for the patients with osteoarthritis of the hip joint. We excluded 26 hips with less than 10 years' follow-up and five hips from patients who died before the 10-year follow-up. The mean follow-up for the 105 remaining THAs is 155.2 months (range 120-237 months). The average age of these patients at the time of surgery was 53.1 years (range 22-81 years). RESULTS: In total, 17 THAs required component revisions. In seven cases, the first revision was limited to a liner exchange for polyethylene wear or osteolysis. Another seven hips underwent revision surgery for recurrent dislocation. Three cups have been revised owing to aseptic loosening. Because of the high incidence of wear-related revisions, Kaplan-Meier survivorship at the 15-year follow-up, using acetabular component revision for any reason as an endpoint, was 75.0% (95% CI 69.4%-83.8%). In contrast, no revision of the femoral stem was performed. Severe stress shielding occurred in 12 hips. Thigh pain was mild, however, and all of the femoral stems remained stable. CONCLUSIONS: Despite revisions for wear-related complications, the fixation achieved with these porous-coated components remained durable throughout the 15-year follow-up. Acetabular osteolysis has been associated with cup reoperation, but femoral stress shielding has never resulted in stem loosening.     

Cementless Metasul metal-on-metal total hip arthroplasty in patients less than fifty years old

BACKGROUND: Durable results of total hip arthroplasty have been difficult to achieve in young patients. We reviewed the intermediate-term clinical and radiographic results in a series of active, higher-demand patients who were less than fifty years old when they underwent cementless total hip arthroplasty with the use of the Metasul metal-on-metal articulation. METHODS: Seventy total hip arthroplasties were performed in sixty-two patients who were younger than fifty years of age (average age, thirty-seven years). Two patients (two hips) had had a resection arthroplasty because of deep infection less than five years postoperatively and were excluded. Sixty patients (sixty-eight hips) were available for complete clinical and radiographic analysis after a mean duration of follow-up of seven years. RESULTS: The mean preoperative Harris hip score of 49 points improved to 95 points at the time of final follow-up; fifty-six patients (93%) had an excellent result. No component was seen to be loose radiographically at the time of final follow-up. Only one focal area of pelvic osteolysis in one patient and two small focal areas of femoral osteolysis in another patient were identified. The hip with focal pelvic osteolysis underwent revision surgery with a liner change and bone-grafting of the osteolytic lesion around a stable component. CONCLUSIONS: At a mean of seven years after arthroplasties with a Metasul metal-on-metal articulation, there was a low rate of osteolysis and aseptic loosening in this group of young patients. However, additional follow-up is necessary to determine any possible long-term deleterious effects associated with this metal-on-metal articulation.     

Uncemented total hip arthroplasty in patients 50 years of age or younger

The results of a consecutive series of uncemented total hip arthroplasties in patients 50 years or younger are reviewed. There were 41 total hip arthroplasties in 36 patients at an average follow-up period of 5.3 years. Average patient age was 42 years at the time of implantation. Preoperative Harris hip score (HHS) averaged ; the final HHS averaged 93. Radiographic evaluation revealed that the femoral stems were all solid, with no progressive subsidence, reactive lines, or osteolysis. Twenty of the hips (49%) demonstrated evidence of polyethylene wear. There was significant acetabular osteolysis in 12 of these 20 hips. Five of the acetabular cups were definitely loose; 1 was possibly loose. Three of the patients underwent revision surgery for acetabular loosening and/or osteolysis. It is concluded from this study that the femoral stem is excellent but that the original acetabular component and polyethylene locking mechanism are poor and made even worse with the use of a titanium femoral head.     

Total hip arthroplasty with cement. A long-term radiographic analysis in patients who are older than fifty and younger than fifty years

The long-term performance of a total of 712 Charnley and STH prostheses was evaluated as a function of the patient's age (older than fifty years or younger than fifty years) and of the underlying disease (osteoarthrosis, rheumatoid arthritis, or avascular necrosis). In patients who were older than fifty years, there were lower incidences of continuous cement-bone radiolucency about the acetabular component (p = 0.04), wear of the polyethylene acetabular cup (p = 0.03), and resorption of the calcar (p = 0.03). However, larger percentages of younger patients had rheumatoid arthritis or avascular necrosis. In the cohort of patients who had osteoarthrosis, the performance of the prosthesis did not differ significantly between older and younger patients; therefore we attributed the differences that were observed to the disease--that is, to rheumatoid arthritis or avascular necrosis.     

陶瓷-陶瓷全髋关节置换术治疗年龄<40岁患者的疗效观察

目的探讨陶瓷-陶瓷全髋关节置换术(THA)治疗年龄40岁髋关节疾病患者的疗效。方法回顾性分析52例年龄40岁因髋关节疾病采用陶瓷-陶瓷THA治疗患者的临床资料。临床疗效评估重点观察手术前后Harris评分;影像学评估重点观察术后脱位率、骨溶解及陶瓷碎裂发生率等。结果 52例均获得随访,时间8~16(12.1±3.7)年。Harris评分由术前9~68(49.3±9.7)分提高到末次随访时68~98(95.1±6.7)分(P0.05)。除1例(1.9%)在术后7 d出现髋关节后脱位外,其余患者均无脱位。2例(3.8%)随访中出现关节异响,1例(1.9%)术后8年出现陶瓷碎裂。至末次随访,未出现假体松动及假体周围骨溶解。结论采用陶瓷-陶瓷THA治疗年龄40岁髋关节疾病患者可以获得满意的临床疗效。     

Total hip arthroplasty after childhood septic hip in patients younger than 25 years of age

Childhood septic hip should usually be treated immediately by arthrotomy and antibiotic. Even if treated correctly, the affected hip may become osteoarthritic and functionally disabling. Usually the literature is not in favor of total hip arthroplasty in young patients, and the reports are on patients older than 32 years of age. We present here a unique group of very young patients with early coxarthrosis caused by septic hip in childhood, with an average age of 19.14 years (range, 14-25) at the time of the arthroplasty. The Harris hip score improved from a preoperative mean of 58.43 to a postoperative mean of 94.14. The follow-up period ranged between 2 and 24 years, with an average of 8.14 years. We conclude that total hip arthroplasty in young people with early coxarthrosis caused by septic hip in childhood provides good functional results.     

Elective total hip arthroplasty in patients older than 80 years of age

Elective total hip arthroplasties (THA) were performed in 91 patients (101 hips) older than 80 years of age at operation. A control group of 87 patients (102 hips) aged 64 to 67 years who had elective THA was chosen statistically to represent the average THA patient. There were 51 minor and eight major perioperative complications in the elderly group and 26 minor and two major complications in the control group. The only in-hospital death was in the control group. The mean hospital stay was two days longer in the elderly group. Five years postoperatively, 83% of the patients in both groups were ambulating without pain. The mean hip score improved from 49 to 84 points in the elderly group and from 52 to 88 points in the control group. These functional results justify elective THA in patients older than 80 years of age.     

Cementless total hip arthroplasty in patients older than 80 years of age

We reviewed 80 patients (87 hips) who were older than 80 years of age at the time of cementless total hip arthroplasty. An Alloclassic SL stem had been implanted in all patients. A variety of cementless acetabular components was used. After a mean follow-up of 69.3 months (39.2 to 94.1) 48 hips in 43 patients were analysed clinically and radiologically. One patient had sustained a traumatic periprosthetic fracture of the femur with subsequent exchange of the stem 73 months after operation. Thirty-two patients (34 hips) had died and five patients (five hips) were unavailable for follow-up because of health reasons (four patients) or lack of co-operation (one patient). If the endpoint is defined as removal of the prosthesis because of aseptic loosening, the survival rate was 100% for the cup and stem after 78 months. The mean Harris hip score was 81.9 points. Radiolucent lines and osteolysis were seldom found.     

Primary total hip arthroplasty with the AML total hip prosthesis

Primary total hip arthroplasty using an uncemented AML total hip prosthesis (trispiked cup and a 4/5 porous coated stem) was performed in 50 patients (52 hips). The average age of the patients at the time of surgery was 47.6 years (range, 19-68 years), and the diagnosis was osteonecrosis of the femoral head in 18 hips, osteoarthritis in 16, fracture of the femoral neck in 14, osteoarthrosis secondary to childhood pyogenic arthritis in two, childhood tuberculous arthritis in one, and traumatic arthritis in one. The average followup was 11.3 years (range, 11-12 years). The average preoperative Harris Hip Score was 59 points, which improved to 90 points. Twenty-five (48%) hips had excellent results, 14 (27%) had good results, three (6%) had fair results, and 10 (19%) had poor results. The overall rate of revision was 15% (eight hips). The rate of revision of the femoral component was 2% (one hip), and the rate of revision of the acetabular component was 15% (eight hips). Twenty (38%) hips had acetabular and femoral osteolysis. Nine (17%) hips had femoral osteolysis only. Thirty-four (65%) hips had an average of 3.3 mm (range, 2-12 mm) of wear in the polyethylene liner. The average wear rate was 0.29 mm (range, 0.17 to 1.04 mm) per year.