Cost analysis of revision total hip arthroplasty. A 5-year followup study

A stratified, unselected sample of 30 patients who underwent revision total hip arthroplasty between 1990 and 1992 for whom complete clinical and financial data were available was studied. Clinical data included age, gender, diagnosis, length of stay, operative time and blood loss. Financial data included cost of implants, bone graft and accessories, hospital charge, and surgeon reimbursement. Results were compared with the results of an analogous group of 50 patients who underwent revision total hip arthroplasty at the same institution between 1995 and 1997. Cases were classified as simple (involving revision of only acetabular liner and/or femoral head), routine (revision of acetabular and/or femoral components), or complex (major structural graft, antiprotrusio cage, impacted grafting). For patients undergoing routine revision total hip arthroplasty, a dramatic decline of 52% occurred in length of stay during the 5-year span (10.7 days to 5.1 days). The average operative time also declined significantly (238 minutes to 199 minutes) as did the average implant cost ($4349 to $2827). Despite this, the average hospital charge increased 16% ($29,666 to $34,328). There was a significant and dramatic 35% decline in surgeon reimbursement ($3240 to $2178). There was no significant difference in surgeon reimbursement between simple, routine, and complex total hip arthroplasty. Patients who underwent complex procedures had a significantly greater length of stay (7.3 versus 5.1 days) and operative time (297 versus 199 minutes). The hospital charge was dramatically higher for patients undergoing complex procedures ($51,290 versus $34,328) but the surgeon reimbursement was lower on average, although not statistically significant ($1926 versus $2178). There was a significant increase in the number and complexity of revision total hip arthroplasties between the two periods. Significant decreases were achieved in length of stay, operating room time, and implant cost. Benefits from these changes were accrued to the hospital but not the surgeon because hospital costs decreased significantly whereas surgeon reimbursements declined dramatically.     

Precoated femoral component in total hip arthroplasty. Results of 5- to 9-year followup.

One hundred nineteen consecutive primary hybrid total hip arthroplasties with a precoated femoral component were performed by one surgeon in 100 patients and followed up prospectively. Ninety-eight hips in 82 patients (mean age, 67 years) were evaluated clinically and radiographically at a mean of 6.5 years (range, 5-9 years). The hips were evaluated clinically using the Harris hip score, and radiographs were evaluated for femoral cement grade, loosening, and osteolysis. Ninety-five hips remained in place at the most recent followup. Two femoral components were revised for definite loosening, and one well fixed femoral component was removed because of late hematogenous infection. Excluding the three hips that were revised, the clinical result was excellent or good in 79 hips (83%), fair in 12 hips (13%), and poor in four hips (4%). All other femoral components were well fixed. There were defects of the cement mantles (C1 and C2) in 90 hips. No femoral component had a stem and cement radiolucent line. Focal femoral osteolysis was seen in only two hips. One acetabular component was removed at 5 years because of late hematogenous infection. One acetabular component had asymptomatic migration. The remaining 96 acetabular components were well fixed. Focal acetabular osteolysis was present in four hips. The mean linear polyethylene wear rate was 0.06 (+/- 0.05) mm per year. In contrast to other reports of early failure and osteolysis, the use of a precoated femoral component in this study did not adversely affect the fixation of hybrid total hip arthroplasty, with definite failure of only 2% (two of 98) of the femoral components.     

Omnifit cementless total hip arthroplasty. A 10-year average followup.

Seventy-six hips in 67 patients were evaluated an average of 119 months (range, 61-150 months) after total hip arthroplasty with porous coated Omnifit femoral and acetabular components. The patients were young (average age, 45 years), and most were male (67%). Two stems and one cup were revised for aseptic loosening, for aseptic revision rates of 2.6% on the femoral side and 1.3% on the acetabular side. Thigh pain was present in three cases, one of which was activity limiting. Twenty-five (35.7%) hips had evidence of osteolysis confined to proximal Gruen Zone 1 or 7 or to the acetabulum (22 proximal femoral, three both). There were no cases of intramedullary osteolysis in surviving stems. Thirteen (17.1%) hips have undergone reoperation for bone grafting of progressive proximal osteolysis without component revision, at an average 93 months after the total hip arthroplasty. At an average 40 months after reoperation, all stems remain well fixed, and there has been no recurrence of osteolysis of grafted femoral lesions. These results suggest that a circumferentially proximally porous coated femoral component in cementless total hip arthroplasty can provide stable fixation for as long as 12 years after implantation and caseal the canal from distal osteolysis. Serious concerns remain about the incidence of proximal femoral osteolysis.     

Hydroxyapatite femoral stems for total hip arthroplasty: 10- to 13-year followup.

Three hundred eighty hydroxyapatite-coated titanium alloy stems were implanted in a young and active patient population from 1987 through 1990. Within the population, 274 patients (314 hips) had a minimum 10-year and maximum 13-year followup. The average age of the population was 51 years. Thirty-seven percent of the population was 50 years or younger when operated on (average age, 39 years). Osteoarthritis was seen in 63.7% and avascular necrosis in 16.6% of patients. Fifty-four percent of patients were men. Clinically, these patients had early pain relief and rapid restoration of function. The Harris hip score averaged 92 points, and only 1.6% of patients had mild or moderate activity-related thigh pain. Radiographically, progressive remodeling occurred around the implants, 100% were bone stable, and no patient had endosteal distal osteolysis. Two patients had revision surgery for aseptic loosening: one at 2 years postoperative because of a nonunion of a concomitant subtrochanteric osteotomy and one at 9.5 years postoperative because of polyethylene wear and progressive osteolysis. The mechanical failure rate was 0.5%. The results show excellent lasting fixation of this tapered titanium alloy stem coated proximally with a thin, dense layer of hydroxyapatite. The stem has performed well in a young, active, high-risk population and in the hands of various surgeons.     

The Kessel total shoulder arthroplasty. A 13- to 16-year retrospective followup

Between 1982 and 1985, 23 Kessel total shoulder arthroplasties were performed on 22 patients with rheumatoid arthritis. A clinical and radiographic review of the 5-year experience was evaluated in 1988 and published in 1992. Ten years later a followup study was done. Of the 22 patients, 11 have died and two were seriously ill and could not participate. Of the remaining nine patients, one had revision surgery after 2 years, leaving eight patients with a mean age of 61 years for this followup study. Shoulder function was evaluated subjectively using the Simple Shoulder Test, and pain was evaluated using a visual analog scale. New radiographs were taken. In general, the patients had a low functional level, but they were able to sleep on the surgically treated side and to manage daily hygiene. Five patients were pain free, and the worst recorded pain during the day was 35 mm on the visual analog scale. Two patients had their scapular component cemented at primary surgery. The radiographs showed no radiolucent zones around these components. The six other scapular components had radiolucent zones of 1 to 3 mm. No radiolucent zones were detected around the humeral components.     

Cementless gustilo-kyle and BIAS total hip arthroplasty: 2- to 5-year results

Summary We conducted extensive radiographic and clinical examination of 58 cementless total hip arthroplasties. Forty BIAS femoral stems had heads made of Co-base F 75 alloy and 18 Gustilo-Kyle femoral stems had Ti6A14V alloy heads. The cross-sectional geometry and location of the porous coating pads of the two stem types was identical, the BIAS component being slightly shorter. At the last follow-up, 27.8% of the Gustilo-Kyle femoral components and 2.5% of the BIAS femoral components were unstable. None of the acetabular components in the BIAS group as against 38.9% of the acetabular components in the Gustilo-Kyle group demonstrated wear of more than I mm. All unstable components which did not suffer intraoperative fracture had also acetabular wear of more than 1 mm. The only case with endosteal erosion was seen in a patient with an unstable implant displaying the most extensive wear. Nonparametric statistical analysis showed that the patients with Ti6A14V/polyethylene bearing surfaces had a statistically significantly higher extent of wear and a statistically significant higher incidence of femoral component loosening than patients with CrCoMo/polyethylene bearing surfaces.     

Weber rotation total hip replacement: a prospective 5- to 20-year followup study

Between 1974 and 1989, 315 primary total hip replacements (274 patients) were done using the cemented Weber Rotation prosthesis and standardized operative technique, which was modified for the stem in 1978. After the first postoperative year, all patients had routine clinical and radiologic examinations at 2-year intervals. Twenty-one patients (22 hips) were lost to followup. At the most recent followup, 30 of 293 hips (253 patients) had been revised: 24 hips for aseptic loosening, five hips for infection, and one hip for a femoral fracture. Survivorship analyses with revision for aseptic loosening as an end point for the 315 hips showed 93% and 78% survival after 10 and 15 years, respectively. Separate survival analyses for the socket showed 99% and 89% survival after 10 and 15 years, respectively. The stem had a survival of 94% and 81%, respectively, during the same time. Survival at 15 years with radiologic evidence of loosening as an end point was 85% for the socket and 72% for the stem. The cementing technique and the design of the acetabular component significantly influenced the rate of loosening. Survivorship analyses with revision for aseptic loosening of the socket, using a modified second generation cementing technique and a hemispheric socket, showed 100% survival after 10 years and 98% after 13 years.     

Grit-blasted titanium femoral stem in cementless primary total hip arthroplasty: a 5- to 10-year multicenter study

A total of 133 cementless primary total hip arthroplasties using the Zweymuller-Alloclassic grit-blasted titanium tapered stem were performed in 3 institutions. The patient cohort was divided into 2 subgroups, nonselected and selected, on the basis of excellent bone stock and age (<65 years old at surgery). Acetabular components were all cementless, and bearing surfaces were all alumina-ceramic on polyethylene. After a 7.3-year average follow-up period (range, 5-10 years), 118 primary femoral replacements in 109 patients could be reviewed fully. Mean age at surgery was 55.7 years (range, 27-84 years). According to the Merle d'Aubigne and Charnley rating system, clinical results were graded excellent and good in 89% of hips and fair in 11%. Radiologically, early subsidence >2 mm could be detected in 4 hips (3.4%). Calcar atrophy and spot welds were noted in 77% and 82% of hips. Femoral osteolysis granuloma was noted in 4 hips (3.4%). There has been no stem fracture and no ceramic head breakage. The survivorship at 10 years with definite femoral aseptic loosening (radiographic failure) as the endpoint was 100% (95% Wilson confidence interval, 78.4%-100%; worst scenario, 95.4%). A significant difference between the nonselected and selected patient subgroups was observed only for early reoperation (P =.03) and proximal stress shielding (P =.01). Press-fitting but not filling the femoral canal with a rough titanium, straight, tapered femoral component represents, at intermediate follow-up, a promising cementless option in primary total hip arthroplasty.     

Results of a hydroxyapatite-coated modular femoral stem in primary total hip arthroplasty. A minimum 5-year follow-up

The use of a modular metaphyseal-diaphyseal femoral stem in primary total hip arthroplasty is infrequent. We analyze 94 ESOP (Fournitures Hospitalieres, Heimsbrunn, France) cementless 2-piece modular stems after a minimum 5 years of follow-up. There were 2 aseptic femoral stem loosenings and no cases with thigh pain. Mean femoral canal filling was 90%. Radiographic ingrowth was obtained in 83 (P < .001). At 7 years, the survival rate for femoral aseptic loosening was 97.8% and no stem was at risk for revision (95% confidence interval, 94.8%-100%). This prosthesis provides good clinical results with absence of pain and excellent radiographic results. It is an option in femora with good bone quality. Femoral osteopenia and cortical widening were infrequent, and the modular metaphyseal-diaphyseal junction was not a problem in vivo.     

Metal-on-metal total hip arthroplasty - five- to 11-year follow-up

Metal-on-metal (MoM) total hip arthroplasty (THA) has been introduced in an attempt to reduce the wear rate and the consequent osteolysis around implants. The aim of this study was to present the intermediate to long-term clinical and radiological outcomes and to investigate the metal ion levels in the blood of patients who had undergone primary uncemented MoM THA in our institution. Between July 1997 and November 2003, 166 patients (193 hips), with a mean age of 50 years (range, 18-65 years), underwent primary MoM THA. Clinical data, radiographs, and blood samples were obtained at regular follow-up visits. Cobalt (Co), chromium (Cr), and molybdenum (Mo) ions were measured by inductively coupled plasma-mass spectrometry (ICP-MS) from the patient's whole blood. All patients were prospectively followed for a minimum of 5 years (mean, 7 years; range, 5-11 years). The mean Harris hip score (HHS) and the University of California at Los Angeles (UCLA) activity score at the latest follow-up was 88 ± 11 and 7 ± 1.8 points, respectively. Thirteen hips have been revised. Ten acetabular components had early failure, due to factory manufacturing problems. All other implants have been found stable, with no signs of aseptic loosening. The probability of survival at 11 years, if the hips that were revised due to manufacturing problems were excluded, was 98.4%. The Co and Cr metal ion levels, after increasing significantly during the first 4 to 5 years post-surgery, remained stable, with a tendency to decrease thereafter, but not significantly. During the same follow-up period, Mo ion levels remained stable. In this 5-to-11 year follow-up study of MoM THA patients, excellent survivorship, with low complications rates, was found. Results of longer follow-up studies are necessary to clarify the possible long-term effects of metal ion release.     

9- to 11-year results of cemented titanium mueller straight stem in total hip arthroplasty

This retrospective study reviewed 9- to 11-year results after total hip arthroplasty (THA) with cemented titanium stems (Mueller-Straight-Stem). Ninety-one patients (110 hips) were examined clinically and radiologically at an average 9.5-year follow-up. Revisions for aseptic loosening were performed in 4 (4%) patients. Subsidence or varus position could only be observed in one of these patients. Radiolucent lines were found in 37 patients, mainly located around the proximal zones of the stem (zone 1, 7, 8, and 14). Harris scores were good or excellent in 78% and satisfactory in 20% of patients. The 9.5-year survival rate of the cemented titanium stem with regard to aseptic loosening was 96.4%. Body weight was significantly higher (88 +/- 5.4 kg) in the 4 patients with aseptic loosening, compared to patients without radiolucent lines (75 +/- 15 kg). The body weight to stem surface ratio showed a significant difference (1.5 kg/cm2 versus 1 kg/cm2; P < .05). No significant differences were found in other factors, including sex, size or type of stem, Harris score, heterotopic ossification, or body mass index. Good long-term results can be achieved with cemented titanium stem implants. This titanium implant is recommended for patients with hypersensitivity to chrome, cobalt, and nickel. mplanting the biggest possible stem seems to be most beneficial.     

Tapered titanium cementless total hip replacements: a 10- to 13-year followup study.

The 10- to-13 year performance of 307 Mallory Head cementless tapered total hip replacements in 283 patients was assessed. Eighty-five percent of patients had a diagnosis of osteoarthritis. Fifty-one percent of patients were women. The mean patient age was 64 +/- 10 years. The Hex Loc cementless acetabular component and titanium alloy femoral heads were used in each patient. At final followup, 37 (13%) patients died, 32 (10%) had revision surgery, and two (1%) were lost to followup. No femoral stem was revised for aseptic loosening, but one was revised because of sepsis and one was revised because of a periprosthetic fracture. Wear, osteolysis, and loosening were problems with the Hex Loc cementless acetabular components and 31 (10%) acetabular components required revision because of these mechanisms. The mean Harris hip score at final followup of the remaining patients was 87 +/- 14 points. Three percent of these patients had thigh pain. Radiographic assessment revealed that no femoral stem or acetabular socket was definitely or probably loose. Three-dimensional wear assessment using the Devane technique was 0.35 mm per year. The Mallory Head cementless, tapered femoral component performed well in the patients in the current study, but unfortunately, the clinical results were compromised by the use of a suboptimal cementless acetabular component, the use of polyethylene that was gamma-irradiated in air, and by the use of titanium alloy femoral heads. Future developments obviously will be in the areas of better acetabular component design, alternate polyethylene sterilization methods, and enhancements of the femoral stem in terms of offset choices, neck design, and perhaps ingrowth surface.     

Charnley total hip arthroplasty. A ten- to 14-year follow-up study

The long-term results of 325 consecutive Charnley total hip arthroplasties (THAs) were assessed at an average of 62 and 140 months (five-year and ten-year follow-up examinations) postoperatively. Cases developing deep infection during the first five years were not included. Pain, walking ability, and mobility were rated as advocated by Charnley. The results were then graded as excellent, good, fair (clinically successful), and failure. At the five-year follow-up evaluation, 77 hips were excluded; 92% (228/248) of the results were successful. At the ten-year follow-up examination, interest was focused on the 228 hips graded as successful after five years. Sixty-six were excluded, one that had not been included at the five-year evaluation was traced, and 92% (150/163) were again clinically successful. The failure rate owing to mechanical causes during the first five years and between the five-year and ten-year follow-up examinations was 6.9% and 6.7%, respectively. The clinical results were considered highly satisfactory because only 50% of the hips judged successful at the ten-year examination had roentgenographically intact components. There is good reason to have great confidence in the Charnley THA.     

The stanmore total hip arthroplasty: A 15- to 20-year follow-up study

An ongoing study was made of 804 primary Stanmore total hip prostheses implanted in 839 patients between 1973 and 1991. The earliest surviving implants were brought back for radiologic and clinical review in 1995 at an average of 17 years after surgery. The remainder of the patients still living were sent a questionnaire to assess their current status. Survivorship was 95% at 10 years, 85% at 15 years, and 73% at 20 years. The average Merle d'Aubigné—Postel score was excellent up until 14 years. Patient satisfaction remained high until 22 years. Overall, 10% of the prostheses had failed. The results of this study suggest that the Stanmore prosthesis is capable of producing satisfactory long-term results that compare favorably with those of other cemented prostheses.     

Minimum 5-year results of modular metal-on-metal total hip arthroplasty

This study reports minimum 5-year results of 95 hips implanted with a Pinnacle (DePuy, Warsaw, Ind) modular metal-on-metal acetabular prosthesis. Clinical scores such as the Harris Hip and Western Ontario and McMaster Universities Arthritis Index revealed excellent clinical outcomes at mean 6-year follow-up. With the use of large-diameter femoral heads, dislocation was rare, occurring in only 1 hip. Moreover, no acetabular and only 3 femoral osteolytic lesions were detected. Kaplan-Meier survivorship at 7 years after arthroplasty was 97.8% for the total hip arthroplasty construct and 100% for the acetabular shell. No unexplained pain or other complication attributable to wear debris or the metal-on-metal articulation was observed. These findings indicate that total hip arthroplasty with this specific modular metal-on-metal bearing performed well in a high-demand population at midterm follow-up.     

Pigmented villonodular synovitis of the hip: 2- to 23-year followup study.

Pigmented villonodular synovitis affecting the hip is rare. Seven new patients are presented and 117 cases from the literature are reviewed. Among the new patients, two refused treatment; in one patient, severe bone loss was observed after a radiographic followup of 21 years; the second patient showed no radiographic changes 2 years after diagnosis. One patient underwent a synovectomy and had a recurrence 9 years later, requiring a total hip replacement. The remaining four patients underwent synovectomy and primary total hip replacement with no recurrences detected after an average followup of 13 years (range, 2-23 years). Among 117 cases published, 62 patients (53%) did not have enough information for analysis. A metaanalysis using the remaining 55 patients was done. In nine patients (16%; nine of 55) the diagnosis was made with a preoperative biopsy. Treatment consisted of synovectomy in 26 patients (47%; 26 of 55), arthroplasty in 24 (43%; 24 of 55), arthrodesis in two (4%; two of 55), and hindquarter amputation in a patient misdiagnosed as having synovial sarcoma (2%; one of 55). Two patients (4%; two of 55) were not treated. Ten patients had a recurrence (19%; 10 of 53); nine in the synovectomy group (35 %; nine of 26) and one in the joint replacement group (4%; one of 24). Synovectomy is recommended for patients with preserved articular cartilage and total hip replacement is recommended for patients with secondary osteoarthritis. Removal of all macroscopic tumors including careful curetting of the osteolytic lesions should be done as they may constitute a source of recurrence.     

A 10- to 13-year follow-up study of Harris-Galante type prosthesis in total hip arthroplasty

Long-term clinical results of Harris-Galante type prosthesis in total hip arthroplasty (THA) were evaluated in 27 hip joints of 25 patients (2 men and 23 women). Seventeen joints also received bone grafting on the acetabulum. Mean follow-up period was 11 years and 3 months. Clinical out-come was evaluated using the hip score of the Japanese Orthopaedic Association, and the score was good and stable during the monitoring period. Implant stability, bone changes around the implant, and the occupancy rate of the stem in the medullary space were radiologically examined. As a result of stem, there was subsidence in 3 joints and loosening in 6. There were no cases of cup loosening. A pedestal was found in 12 joints, and 4 of them which were associated with a radiopaque line had stem loosening. Among the 21 joints without loosening, 8 had a pedestal but they were not associated with a radiopaque line. The 2 joints which developed osteolysis did not have loosening. Stem loosening was related to the stem occupancy rate in the distal part of the medullary cavity. Postoperative stem occupancy rate could be an important indicator for long-term clinical results. Stems for cementless THA should be designed to have a high occupancy rate in the distal part, and stems should also be carefully chosen to meet individual differences. Received: February 24, 2000 / Accepted: July 21, 2000     

Unicompartmental knee arthroplasty. Clinical experience at 6- to 10-year followup.

Sixty-two consecutive cemented modular unicompartmental knee arthroplasties in 51 patients were studied prospectively. At surgery, the other compartments had at most Grade 2 chondromalacia. The average age of the patients at arthroplasty was 68 years (range, 51-84 years). One patient was lost to followup and 10 died with less than 6 years followup. The average followup of the remaining 51 knees was 7.5 years (range, 6-10 years). The preoperative Hospital for Special Surgery knee score of 55 points (range, 30-79 points) improved to 92 points (range, 60-100 points) at followup; 78% (40 knees) had excellent and 20% (10 knees) had good results. The mean range of motion at followup was 120 degrees with 26 knees (51%) having range of motion greater than 120 degrees. One patient underwent revision surgery for retained cement, one patient underwent knee manipulation, and one patient underwent revision surgery at 7 years for opposite compartment degeneration and pain. Radiographically, 26 knees (51%) had at least one partial radiolucency. There were no complete femoral radiolucencies, but there were three complete tibial radiolucencies, all less than 2 mm. No component was loose as seen on radiographs. At final followup, five of the opposite compartments (10%) and three of the patellofemoral joints (6%) had some progressive radiographic joint space loss; this was less than a 25% loss in all but one knee component that was revised. At 6- to 10-years followup, cemented unicompartmental knee arthroplasty yielded excellent clinical and radiographic results. The 10-year survival using radiographic loosening or revision as the end point was 98%. Using stringent selection criteria, unicompartmental knee replacement can yield excellent results and represents a superb alternative to total knee replacement.     

Detecting stem debonding in total hip arthroplasty

In total hip arthroplasty, cemented femoral components combined with contemporary insertion techniques have an excellent track record of reliable long-term success. Certain cemented stem designs, however, have high failure rates. As osteolysis and bone destruction are rapid and progressive with certain designs, early detection of failure is imperative. We describe a case in which the common failure pattern of debonding is evident after radiographic evaluation with stress application. Although a single-leg stance was used in this case, a modified standing view might also be used.