Results of 3,668 primary total hip replacements for primary osteoarthritis in patients under the age of 55 years

Background and purpose In a previous study based on the Finnish Arthroplasty Register, the survival of cementless stems was better than that of cemented stems in younger patients. However, the survival of cementless cups was poor due to osteolysis. In the present study, we analyzed population-based survival rates of the cemented and cementless total hip replacements in patients under the age of 55 years with primary osteoarthritis in Finland.

Patients and methods 3,668 implants fulfilled our inclusion criteria. The previous data included years 1980–2001, whereas the current study includes years 1987–2006. The implants were classified in 3 groups: (1) implants with a cementless, straight, proximally circumferentially porous-coated stem and a porous-coated press-fit cup (cementless group 1); (2) implants with a cementless, anatomic, proximally circumferentially porous-coated stem, with or without hydroxyapatite, and a porous-coated press-fit cup with or without hydroxyapatite (cementless group 2); and (3) a cemented stem combined with a cemented all-polyethylene cup (the cemented group). Analyses were performed separately for 2 time periods: those operated 1987–1996 and those operated 1997–2006.

Results The 15-year survival for any reason of cementless total hip replacement (THR) group 1 operated on 1987–1996 (62%; 95% CI: 57–67) and cementless group 2 (58%; CI: 52–66) operated on during the same time period was worse than that of cemented THRs (71%; CI: 62–80), although the difference was not statistically significant. The revision risk for aseptic loosening of cementless stem group 1 operated on 1987–1996 (0.49; CI: 0.32–0.74) was lower than that for aseptic loosening of cemented stems (p = 0.001).

Interpretation Excessive wear of the polyethylene liner resulted in numerous revisions of modular cementless cups. The outcomes of total hip arthroplasty appear to have been relatively unsatisfactory for younger patients in Finland.     

Metal-on-metal resurfacing of the hip in patients under the age of 55 years with osteoarthritis

The results of conventional hip replacement in young patients with osteoarthritis have not been encouraging even with improvements in the techniques of fixation and in the bearing surfaces. Modern metal-on-metal hip resurfacing was introduced as a less invasive method of joint reconstruction for this particular group. This is a series of 446 hip resurfacings (384 patients) performed by one of the authors (DJWM) using cemented femoral components and hydroxyapatite-coated uncemented acetabular components with a maximum follow-up of 8.2 years (mean 3.3). Their survival rate, Oxford hip scores and activity levels are reviewed. Six patients died due to unrelated causes. There was one revision (0.02%) out of 440 hips. The mean Oxford score of the surviving 439 hips is 13.5. None of the patients were told to change their activities at work or leisure; 31% of the men with unilateral resurfacings and 28% with bilateral resurfacings were involved in jobs that they considered heavy or moderately heavy; 92% of men with unilateral hip resurfacings and 87% of the whole group participate in leisure-time sporting activity. The extremely low rate of failure in spite of the resumption of high level occupational and leisure activities provides early evidence of the suitability of this procedure for young and active patients with arthritis.     

Cemented total hip replacement in patients under 55 years

Background and purpose — About 86,000 total hip replacements (THR) have been registered in patients under 55 years in the National Joint Registry of England and Wales (NJR). The use of uncemented implants has increased, despite their outcomes not having been proven to be significantly better than cemented implants in this registry. We determined the implant survivorship and functional outcomes of cemented THR in patients under 55 years at a minimum follow-up of 22 years.

Patients and methods — 104 hips in 100 patients were included in this prospective study. Functional outcome was assessed using the Harris Hip Score and radiographs were assessed for implant failure and “at risk” of failure. Kaplan–Meier survivorship analysis was performed.

Results — 89% of hips showed good to excellent results at final follow-up with a mean Harris Hip Score of 88 at a mean follow-up of 25 years. Revision was performed in 3/104 hips. 14 acetabular components and 4 femoral components were “at risk” of failure. The survivorship at minimum 22 years with revision for any reason as the end-point was 97% (95% CI 95–98).

Interpretation — Cemented hip replacements perform well in young patients with good long-term functional and radiographic outcomes.     

Hydroxyapatite-coated total hip replacements in patients 65 years of age and over.

Prospective review examined 69 patients aged over 65 years (mean: 73 years; range: 65 to 85 years) who underwent 72 primary hydroxyapatite-coated total hip replacements by one surgeon. The femoral component used was titanium alloy coated by hydroxyapatite on the proximal third and the acetabular component was spherical and unthreaded, coated with hydroxyapatite. All patients were evaluated clinically by Harris Hip Score and radiologically using Engh's criteria with a mean follow-up of 86 months (range: 29 months to 10 years). Preoperative radiologic evaluation for osteoporotic bone using the Singh index was performed. Average Harris Hip Score increased from 45 before surgery to 89 at last follow-up. Two femoral and one-acetabular components were shown to probably be loose, but none was definitely loose or unstable by Engh's criteria. There was no correlation between clinical and radiologic results with respect to age, sex, and preoperative diagnosis. In contrast, significant statistical correlation was demonstrated between Charnley groups A or B, and group C, with regard to the Harris Hip Score (p = 0.047). There was no correlation between Charnley groups and radiological results. There was no statistical difference between patients with osteoporotic bone (Singh 1-3) and non-osteoporotic bone (Singh 4-6) with respect to clinical and radiologic evaluation. These early clinical and radiologic results compare favorably with those of hydroxyapatite-coated total hip replacements for younger patients and cemented total hip replacements in older patients. We recommended that hydroxyapatite-coated total hip replacements should not be reserved for younger patients. They can be used safely in patients over 65 years of age, promising minimal postoperative thigh pain and satisfactory clinical and radiologic results.     

The hydroxyapatite-coated JRI-furlong hip. Outcome in patients under the age of 55 years

We present the clinical and radiographic outcome of 68 consecutive primary total hip replacements performed in 54 patients under the age of 55 years using a hydroxyapatite-coated femoral component and threaded cup with a modular ceramic head (JRI-Furlong). We reviewed 62 (91%) hips at a median follow-up of 8.8 years (5 to 13.8) after implantation; six (9%) were lost to follow-up. At review there had been four (6%) revisions but only one for aseptic loosening (acetabulum). Radiographic review of the remaining hips did not identify any evidence of femoral or acetabular loosening. The median Harris and Merle d'Aubigné and Postel hip scores were 95.9 (42.7 to 100) and 17 (3 to 18) respectively. The JRI-Furlong hip gives promising functional and radiographic results in young patients in the medium term.     

Revision of total hip replacement for primary osteoarthritis

During the 11-year-period from 1970 to 1980, 799 total hip arthroplasties with metal-on-plastic prostheses were performed for primary osteoarthritis. In all cases high viscosity cement was used, but not under pressure; acetabular cartilage was removed, but the femoral canal was not plugged. The rate of revision and risk factors were evaluated by survivorship analysis. The overall cumulative revision rates were 11%, 14% and 19% after 8, 10, and 14 years respectively. When prophylactic antibiotics were not used, there was a significant risk of revision for infection. The risk of revision for mechanical loosening of both the acetabular and femoral components was significantly increased for men, younger patients, and if a snap-fit prosthesis with a 35 mm head and short wedged stem was used. The survivorship findings were validated by multivariate statistical analysis.     

Function after total hip replacement for primary osteoarthritis

Summary We have reviewed 505 cases of surviving total hip replacement for primary osteoarthritis and studied the functional result and pain relief obtained between four and fourteen years after implantation. The risk factors were stratified and evaluated by multivariate statistical analysis. The patients were satisfied with the result of arthroplasty, and long-term function was improved in 95% of cases. The risk of postoperative hip pain was increased by knee pain, a snap-fit prosthesis with a 35 mm head, and a short wedge-shaped femoral stem, and by replacement at an early age. Function was impaired postoperatively by hip pain, bilateral hip disorders, intercurrent disease affecting locomotion and by old age at the time of surgery. The functional result was not related to the time from operation. The functional result after hip arthroplasty can be evaluated in a logical, unbiased and thorough way using multivariate statistical analysis.

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Réumé Les auteurs ont revu 505 arthroplasties totales de hanche métal — plastique cimentées sans reprise, avec un recul de 4 à 14 ans. Ils ont étudié le résultat sur la douleur et la fonction. Les patients sont satisfaits de l'arthroplastie, et la fonction générale de la hanche s'est améliorée à long terme dans 95% des cas. L'importance du temps écoulé après l'opération et les autres facteurs de risque potentiels ont été déterminés par une analyse statistique multi-variée. La douleur du genou, les prothèses avec tête de 35 mm de diamètre et tige courte, et le jeune âge lors de l'intervention augmentent le risque de douleur de hanche. Le risque d'altération fonctionnelle augmente en cas de douleurs de hanche, d'atteinte bilatérale, d'affections intercurrentes altérant la locomotion, et d'un grand âgè lors de l'intervention. Le temps écoulé depuis le remplacement de la hanche n'a pas d'importance. La fonction après arthroplastie de la hanche peut être évaluée d'une façon logique, impartiale et parfaite par une analyse statistique multi-variée.

     

Survivorship analysis of total hip replacements. Results in a series of active patients who were less than fifty-five years old

Between 1971 and 1980, the senior one of us (C.S.R.) performed 101 primary total hip replacements in eighty-five consecutive patients who were less than fifty-five years old. All of the patients had degenerative joint disease. Survivorship analysis was used to calculate a predicted cumulative rate of success for this series of total hip replacements over ten years of follow-up. This method of analysis of the data was chosen because it provides a prediction of the expected durability of a total hip arthroplasty in any individual patient. The need for revision because of loosening or infection or else radiographic evidence of migration of a component was the criterion for failure. Two revisions were performed for aseptic loosening of the acetabular component. One infection necessitated revision, and radiographic evidence of loss of fixation was seen in one additional acetabular component and one femoral stem. Life-table calculations predicted that the survivorship of all of the total hip replacements in this series would be 87.6 per cent at ten years of follow-up. Based on the results of the application of this method of analysis to the current series, we concluded that a primary cemented total hip replacement, when performed for coxarthrosis, can be expected to function durably in an active middle-aged patient.     

Primary total hip replacement in patients over 80 years of age

We have reviewed 107 patients of 80 years or over who underwent primary total hip replacement. They had many more complications than younger patients. Thus, acute dislocation occurred in 15%, and became chronic in 9%; there were femoral shaft fractures in 4.6% and these, with shaft perforation gave universally poor results. Nevertheless, 75% of patients had a satisfactory outcome, with worthwhile relief of pain. It would seem sensible to warn elderly patients and their relatives of the increased risks in this age group.     

Osteoarthritis of the hip in patients under 60 years of age

Summary Pain at rest with osteoarthritis of the hip may be due to increased intraosseous blood pressure, which falls immediately after an intertrochanteric osteotomy [4, 5]. Eighty-five consecutive hips from patients under 60 years of age at the time of operation were studied in order to evaluate if pain at rest was an indication for intertrochanteric osteotomy. Patients who preoperatively were predominantly in pain at rest had a significantly better prognosis than patients with a predominantly weight-bearing pain (P < 0.05). Intertrochanteric osteotomy reduced pain for the group of patients with predominant pain at rest (n = 50) by 81%, 66%, and 56% at 5, 10, and 15 years respectively. In the group where weight-bearing pain was predominant (n = 35), the operation was a success in only 39% at 5 years and after.

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Zusammenfassung Nach Arnoldi et al. [4, 5] wird der Dauerschmerz bei der Coxarthrose durch erhöhten intraossären Druck, der unmittelbar nach einer intertrochanteren Osteotomie abnimmt, verursacht. Mit dem Ziel, die Bedeutung des Vorhandenseins von Dauerschmerzen als Indikation zur intertrochanteren Osteotomie zu beurteilen, untersuchten wir ein konsekutives Material, bestehend aus 78 Patienten unter 60 Jahren (85 Hüften) mit einer Coxarthrose. Patienten mit überwiegend Dauerschmerzen hatten eine signifikant bessere Prognose als Patienten mit hauptsächlich Belastungsschmerzen (P < 0.05). Bei den Patienten mit uberwiegend Dauerschmerzen fand man nach 5, 10 and 15 Jahren ein gutes Ergebnis bei 81% bzw. 66% and 56%, während man bei den Patienten, in denen die Belastungsschmerzen dominierten, nach 5 and folgenden Jahren ein gutes Ergebnis nur bei 39% fand.

     

Elective total hip arthroplasty for patients 75 years of age and older

The increasing life expectancies among octogerians ang nanogerians cause increased need for total hip replacement in this age group. The aim of our study was to analyze final results after total hip arthroplasty in patients 75 years of age and older. Clinical and radiological retrospective study was performed on a group of 59 patients (72 hips) in the mean age of 78 years. Minimal follow-up was 3 years. According to Harris Hip Score hip function improved on an average of 47 points and at final follow-up was 86 points. Patients with medical diseases had poorer hip function improvement. Early dislocation was found in 3 patients with was treated conservatively with good result. Almost 1/4 of patients suffered medical postoperative complications: pneumonia (n = 1), urinary tract infection (n = 4), pulmonary embolism (n = 1), acute myocardial infarction (n = 1), postoperative confusion (n = 5) and mild intestinal occlusion (n = 1). Additionally, one patient died for pulmonary embolism. There were no radiological signs of aseptic loosening or need for revision operation. Three fourth of our patients had satisfactory results after total hip replacement, despite relatively high medical (24%) and local complication rate. Aseptic loosening is rear in this age group.     

Changing incidence of primary total hip arthroplasty and total knee arthroplasty for primary osteoarthritis

This study reports on the incidence of primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) for primary osteoarthritis in Australia. Age-specific and gender-specific numbers for Australia, 1994 through 1998, and South Australia, 1988 through 1998, were obtained. Incidences were calculated per 100,000 population. In Australia, primary THA increased from 50.9/10(5) (1994) to 60.9/10(5) (1998). TKA increased from 56.4/10(5) to 76.8/10(5). Stratified by age and gender, changes in incidence for South Australia with respect to time were tested using regression analysis. South Australia showed a significant increase in the overall incidence of THA (P=.012) and TKA (P<.001), although this was not uniform across all age groups. No significant gender differences were found. The incidence of THA is increasing, and the incidence of TKA is increasing at a greater rate.