Catastrophic Periprosthetic Osteolysis in Total Hip Arthroplasty at 20 Years: A Case Report and Literature Review

BackgroundPeriprosthetic osteolysis is a serious complication following total hip arthroplasty (THA). However, most orthopedic surgeons only focus on bone loss and hip reconstruction. Thus, it was required to understand the treatment algorithm for periprosthetic osteolysis integrally.Case PresentationA 52‐year‐old Asian male presented with chronic hip pain. A mass appeared on the medial side of the proximal left thigh at more than 20 years after bilateral THA. Radiographs revealed catastrophic periprosthetic osteolysis, especially on the acetabular side. Large amounts of necrotic tissue and bloody fluids were thoroughly debrided during revision THA. A modular hemipelvic prosthesis was used for revision of the left hip. Four years later, the patient presented with right hip pain, where a mass appeared on the medial side of the proximal right thigh. A primary acetabular implant with augment was used for revision of the right hip. Laboratory evaluation of bloody fluid retrieved from surgery revealed elevated levels of inflammatory markers.ConclusionInflammatory responses to polyethylene wear debris can lead to severe bone resorption and aseptic loosening in the long‐term following THA. Therefore, in spite of revision THA, interrupting the cascade inflammatory might be the treatment principle for periprosthetic osteolysis.     

Causes of Revision in Young Patients Undergoing Total Hip Arthroplasty

BackgroundThe purpose of this study was to identify reasons for revision of total hip arthroplasty (THA) in patients who underwent primary THA at or before the age of 35 years. We hypothesized that the reasons for revision in younger patients would be different from the general older population of patients undergoing THA because of the differences in diagnoses, complexity of deformities, and differences in activity level.MethodsData for 108 hips in 82 patients who underwent primary THA at our institution before the age of 35 years from 1982-2007 and subsequently underwent revision THA were reviewed. Operative reports and clinic notes were reviewed to determine baseline characteristics, reason for revision, timing of revision, and components revised.ResultsThe mean age at index surgery was 25.4 years, and mean time from index to revision surgery was 10.1 years. The most common preoperative diagnoses included avascular necrosis, juvenile idiopathic arthritis, developmental dysplasia of the hip, and posttraumatic arthritis. The most common reasons for revision were acetabular loosening (30.1%), femoral loosening (23.7%), and polyethylene wear (24.7%). 8.3% of patients underwent primary THA with highly cross-linked polyethylene, while the remainder of the patients underwent THA when conventional polyethylene was used. There was no statistically significant association between which component(s) were revised and initial fixation (ie cemented or uncemented prosthesis) (P = .26).ConclusionCauses of revision in this population appear to differ from the general THA population. In young patients, acetabular loosening, femur loosening, and polyethylene wear were the most common causes of revision. Instability and infection were less common compared with literature reports of causes of revision in older patients. Findings in this study may be useful in counseling young patients undergoing THA, though results were likely influenced by the use of conventional rather than highly cross-linked polyethylene in this cohort.     

Morbid Obesity Is a Significant Risk of Failure Following Revision Total Hip Arthroplasty

Background

Although it has been shown that morbidly obese patients experience good outcomes following primary total hip arthroplasty (THA), it is unclear whether this also applies to revision surgery. The purpose of this study was to examine the effect of a high body mass index (BMI) on the outcome of revision THA.

人工全髋关节翻修术治疗假体置换术后感染

目的:探讨全髋关节置换术后假体周围感染的治疗方法。方法:1998年1月～2002年6月共收治7例全髋关节置换术后感染患者。采用一期全髋关节翻修术3例,二期全髋关节翻修术4例,术后平均随访14个月。结果:患者髋关节评分平均提高37.6分(Harris评分),经随访无一例感染患者复发。结论:人工全髋关节置换术后感染患者经过彻底清创和使用有效抗生素治疗后,可一期或二期进行全髋关节翻修术,治疗假体周围感染,改善患肢关节功能。     

Medium-Term Results of Cementation of a Highly Cross-Linked Polyethylene Liner Into a Well-Fixed Acetabular Shell in Revision Hip Arthroplasty

The present study was undertaken to document outcomes of cementation of a highly cross-linked polyethylene (PE) liner into a well-fixed acetabular metal shell in 36 hips. All operations were performed by a single surgeon using only one type of liner. Patients were followed for a mean of 6.1 years (range, 3–8 years). Mean Harris hip score improved from 58 points preoperatively to 91 points postoperatively. There were no cases of PE liner dislodgement or progressive osteolysis. 1 hip (2.8%) required revision surgery for acetabular cup loosening with greater trochanteric fracture. Complications included 1 peroneal nerve palsy and 1 dislocation. The results of this study and previous reports demonstrated that cementation of highly cross-linked PE liner into well-fixed metal shell could provide good midterm durability.     

Revision Total Hip Arthroplasty Using an Extensively Porous Coated Femoral Stem

Background

To determine the benefit of an extensively porous coated femoral stem in patients receiving revision total hip arthroplasty.

Methods

This study reviewed the results of 35 patients who received a revision total hip arthroplasty with extensively porous coated femoral stem between August, 1996, and December, 2002. The mean follow-up period was 77.5 months. The clinical and radiological results were evaluated by the Harris hip score and serial roentgenographic findings.

Results

The preoperative and postoperative Harris hip score was 68.3 and 92.5, respectively. Radiographically, none of the acetabular components showed any evidence of migration, tilt, rotation, or shedding of metal particles. In addition, none of the femoral components showed evidence of subsidence, pedestal, or shedding of metal particles. Twenty-two hips had a mild stress shield and 2 hips had a moderate stress shield. The perioperative complications encountered were deep vein thrombosis (1 case), mild heterotopic ossification (4 cases), intraoperative periprosthetic fractures (1 case), and nonunion of the trochanteric osteotomy site (2 cases).

Conclusions

Extensively porous coated femoral stems and acetabular components produce excellent clinical and radiological results in revision total hip arthroplasty.     

Instability After All-Cause Acetabular-Only Revision Total Hip Arthroplasty Remains a Clinical Problem

BackgroundThe purpose of this study is to (1) evaluate the rate of instability and reoperation after acetabular component–only revision, (2) compare instability rates across various head sizes, and (3) determine patient factors correlating with postoperative instability.MethodsWe retrospectively reviewed all isolated acetabular component revisions (n = 200) at our institution between 2007 and 2017. Patients with less than one-year follow-up were excluded. Patients were subdivided into 4 head size groups: (1) 32 mm or less, (2) 36 mm or more, (3) dual mobility, and (4) constrained liners. Factors including the body mass index, cup position, prior revision(s), and subsequent reoperation were compared across groups.Results189 patients (200 hips) met the inclusion criteria. The overall rate of instability was 12% (n = 24), and 37 (18.5%) cases underwent subsequent revision, including 11 cases for recurrent instability. There was no significant difference in postoperative dislocation or reoperation for instability across the various groups. The use of a constrained liner trended toward the highest rate of postoperative instability (36.4%, P = .090). History of preoperative instability was a significant risk factor for postoperative instability with or without history of prior revision (P = .011 and P = .001, respectively).ConclusionContemporary isolated acetabular revision is still associated with significant rates of instability. Surprisingly, the head size was not a predictive factor for postoperative dislocation or reoperation, but a prior history of instability was associated with postoperative instability. Patients revised to a constrained liner experienced highest rates of failure and remain an unsolved clinical problem.     

Total Hip Arthroplasty After Hip Arthroscopy Has Increased Complications and Revision Risk

BackgroundThere has been an increase in hip arthroscopy (HA) over the last decade. After HA, some patients may ultimately require a total hip arthroplasty (THA). However, there is a scarcity of research investigating the outcomes in patients undergoing THA with a history of ipsilateral HA.MethodsThe PearlDiver research program (www.pearldiverinc.com) was queried to capture all patients undergoing THA between 2015 and 2020. Propensity matching was performed to match patients undergoing THA with and without a history of ipsilateral THA. Rates of 30-day medical complications, 1-year surgical complications, and THA revision were compared using multivariate logistic regression. Kaplan-Meier analysis was conducted to estimate survival probabilities of each of the groups with patients undergoing THA .ResultsAfter propensity matching, cohorts of 1940 patients undergoing THA without prior HA and 1940 patients undergoing a THA with prior HA were isolated for analysis. The mean time from HA to THA was 1127 days (standard deviation 858). Patients with a history of ipsilateral HA had an increased risk for dislocation (odds ratio [OR] 1.56, P = .03) and overall decreased implant survival within 4 years of undergoing THA (OR 1.53; P = .05). Furthermore, our data demonstrate the timing of previous HA to be associated with the risk of complications, as illustrated by the increased risk for dislocation (OR 1.75, P = .03), aseptic loosening (OR 2.18, P = .03), and revision surgery at 2 (OR 1.92, P = .02) and 4 years (OR 2.05, P = .01) in patients undergoing THA within 1 year of HA compared twitho patients undergoing THA more than 1 year after HA or with no previous history of HA.ConclusionPatients undergoing THA after HA are at an increased risk for surgical complications, as well as the need for revision surgery.     

Risk Factors for Total Hip Arthroplasty Aseptic Revision

The purpose of this study was to evaluate patient, operative, implant, surgeon, and hospital factors associated with aseptic revision after primary THA in patients registered in a large US Total Joint Replacement Registry. A total of 35,960 THAs registered from 4/2001–12/2010 were evaluated. The 8-year survival rate was 96.7% (95% CI 96.4%–97.0%). Females had a higher risk of aseptic revision than males. Hispanic and Asian patients had a lower risk of revision than white patients. Ceramic-on-ceramic, ceramic-on-conventional polyethylene, and metal-on-conventional polyethylene bearing surfaces had a higher risk of revision than metal-on-highly cross-linked polyethylene. Body mass index, health status, diabetes, diagnosis, fixation, approach, bilateral procedures, head size, surgeon fellowship training, surgeon and hospital volume were not revision risk factors.     

Standing Versus Supine Radiographs to Evaluate Femoral Head Penetration in the Polyethylene Liner After Total Hip Arthroplasty

The linear penetration rates for ceramic femoral heads on conventional and highly cross-linked polyethylene were measured and compared with radiographs taken in the standing and supine position taken three weeks postoperatively and at final follow-up. Seventy-five patients (83 hips) with conventional polyethylene (group-1) and two hundred and seventy five patients (300 hips) with highly cross-linked polyethylene (group-2) were studied. Follow-up periods were 14.5 years in group-1 and 8.6 years in group-2. The average penetration rates in group-1 were 0.17 mm/year in supine position and 0.18 mm/year in standing position (P < 0.05). On the other hand, the rates in group-2 were 0.03 mm/year and 0.04 mm/year respectively (P < 0.05). Although there were statistical differences between groups, 0.01 mm differences are probably not clinically relevant.     

Unexpected Wear of a Uniquely Designed Moderately Cross-Linked Polyethylene in Total Hip Arthroplasty

BackgroundA uniquely designed, non–heat-treated moderately cross-linked acetabular polyethylene liner used in total hip arthroplasty (THA) demonstrated excessive wear during routine follow-up, prompting an evaluation of the linear wear rate.MethodsAll THAs were performed by the senior author. The study group included 38 THAs using the uniquely designed polyethylene in question, compared to a control group of 21 THAs using another moderately cross-linked polyethylene with good 10-year outcomes. Two-dimensional linear head penetration wear measurements were obtained using the Martell Hip Analysis Suite, and retrieval analysis was performed on two liners.ResultsThe study group had a significantly higher average penetration rate of 0.089 mm/y than the control group average rate of 0.047 mm/y (P = .04). Forty-five percent of the study group had a wear rate above the osteolysis threshold (0.1 mm/y), compared to 24% in the control group. Macroscopic analysis of two retrieved liners validated the radiographic findings.ConclusionThe data suggest unexpectedly higher wear rates for a moderately cross-linked polyethylene design, with nearly half of the study group at risk for osteolysis. Further registry or database analyses of this particular moderately cross-linked polyethylene are warranted.     

Prospective Randomized Trial Comparing Alumina Ceramic-on-Ceramic With Ceramic-On-Conventional Polyethylene Bearings in Total Hip Arthroplasty

This prospective randomized study aims to compare the outcome between an alumina ceramic-on-ceramic (CC) articulation with a ceramic on ultra-high-molecular-weight polyethylene articulation (CP). Fifty-six hips in 55 patients with mean age 42.2 (range, 19-56) each received uncemented components, a 28-mm alumina head with randomization of acetabular liner. Mean St Michael's outcome score for each group with up to 10 years follow-up (median, 8 years; range, 1-10) was 22.8 and 22.9, respectively (P = .819). Wear was identified in all but 1 CP replacement, but only 12 of the 23 CC. Mean wear in the CP group was 0.11 mm/y and 0.02 mm/yr in the CC group (P < .001). Other than significantly greater wear in the polyethylene group, there was no significant difference in midterm outcome between the 2 groups.     

Cementless Total Hip Arthroplasty for Patients with Crowe Type III or IV Developmental Dysplasia of the Hip: Two-Stage Total Hip Arthroplasty Following Skeletal Traction after Soft Tissue Release for Irreducible Hips

Background

Total hip arthroplasty (THA) for severe developmental dysplasia of the hip (DDH) is a technically demanding procedure for arthroplasty surgeons, and it is often difficult to reduce the hip joint without soft tissue release due to severe flexion contracture. We performed two-stage THAs in irreducible hips with expected lengthening of the affected limb after THA of over 2.5 cm or with flexion contractures of greater than 30 degrees in order to place the acetabular cup in the true acetabulum and to prevent neurologic deficits associated with acute elongation of the limb. The purpose of this study is to evaluate the outcomes of cementless THA in patients with severe DDH with a special focus on the results of two-stage THA.

Methods

Retrospective clinical and radiological evaluations were done on 17 patients with Crowe type III or IV developmental DDH treated by THA. There were 14 women and 3 men with a mean age of 52.3 years. Follow-ups averaged 52 months. Six cases were treated with two-stage THA followed by surgical hip liberalization and skeletal traction for 2 weeks.

Results

The mean Harris hip score improved from 40.9 to 89.1, and mean leg length discrepancy (LLD) in 13 unilateral cases was reduced from 2.95 to 0.8 cm. In the patients who underwent two-stage surgery, no nerve palsy was observed, and the single one-stage patient with incomplete peroneal nerve palsy recovered fully 4 weeks postoperatively.

Conclusions

The short-term clinical and radiographic outcomes of primary cementless THA for patients with Crowe type III or IV DDH were encouraging. Two-stage THA followed by skeletal traction after soft tissue release could provide alternative solutions to the minimization of limb shortenings or LLD without neurologic deficits in highly selected patients.     

Revision Total Hip Arthroplasty With a Modular Cementless Femoral Stem

We retrospectively reviewed 123 patients who underwent cementless THA with modular femoral stem designs for revision THA or conversion of failed ORIF and found 75 patients available for analysis. The Harris Hip Score (HHS) improved from 52 ± 14 to 86 ± 11 (P < 0.001). The femoral stem was re-revised in eight patients (11%). The mean time to re-revision was 1.1 years (0.13–2.54). Reasons for re-revision included infection (n = 5, 7%), aseptic loosening (n = 2, 3%) and significant pain (n = 1, 1%). There were no failures of the modular junctions. PC stems had an increased rate of intraoperative fractures (PC 28% vs. STS 9%, P = 0.04). Modular cementless femoral stems provide acceptable mid-term results in revision THA.     

Independent Risk Factors for Transfusion in Contemporary Revision Total Hip Arthroplasty

BackgroundThe incidence of transfusion in contemporary revision total hip arthroplasty (THA) remains high despite recent advances in blood management, including the use of tranexamic acid. The purpose of this prospective investigation was to determine independent risk factors for transfusion in revision THA.MethodsSix centers prospectively collected data on 175 revision THAs. A multivariable logistic analysis was performed to determine independent risk factors for transfusion. Revisions were categorized into subgroups for analysis, including femur-only, acetabulum-only, both-component, explantation with spacer, and second-stage reimplantation. Patients undergoing an isolated modular exchange were excluded.ResultsTwenty-nine patients required at least one unit of blood (16.6%). In the logistic model, significant risk factors for transfusion were lower preoperative hemoglobin, higher preoperative international normalized ratio (INR), and longer operative time (P < .01, P = .04, P = .05, respectively). For each preoperative 1g/dL decrease in hemoglobin, the chance of transfusion increased by 79%. For each 0.1-unit increase in the preoperative INR, transfusion chance increased by 158%. For each additional operative hour, the chance of transfusion increased by 74%. There were no differences in transfusion rates among categories of revision hip surgery (P = .23). No differences in demographic or surgical variables were found between revision types.ConclusionDespite the use of tranexamic acid, transfusions are commonly required in revision THA. Preoperative hemoglobin and INR optimization are recommended when medically feasible. Efforts should also be made to decrease operative time when technically possible.     

Thirty-Day Complications in Osteonecrosis Patients Following Total Hip Arthroplasty

BackgroundThirty-day complications in osteonecrosis (ON) patients undergoing total hip arthroplasty (THA) are inconsistently reported. Therefore, the purpose of this study is to evaluate (1) the incidence of THA, (2) operative times, (2) length of stay, (3) reoperation rates, (4) readmission rates, and (5) complication rates, in the general vs ON THA populations. We also substratified and compared these cohorts based on ON-specific risk factors.MethodsUsing the National Surgical Quality Improvement Program database, Current Procedural Terminology code 27130, International Classification of Disease, Ninth Edition code 733.42, and a 1:1 propensity score match, a total of 8344 matched ON and non-ON THA patients were identified. ON patients were also substratified based on key risk factors. The above variables were compared between the matched ON and non-ON cohorts as well as for patients with each risk factor using Pearson’s chi-square and Student t-tests.ResultsThe proportion of THAs performed on ON patients decreased by 35% from 2008 to 2015. Mean operative times were constant between the ON and non-ON patients (102 minutes). ON patients had shorter mean length of stay (3.1 vs 3.4 days, P = .002). Of the 17 different 30-day complications evaluated, superficial surgical site infection (1.2% vs 0.6%, P = .004), pneumonia (0.8% vs 0.2%, P = .001), transfusion (15.6% vs 5.4%, P < .001), and readmission (5.1% vs 2.3%, P = .012) were higher among ON patients. ON patients with a history of corticosteroid use, higher American Society of Anesthesiologists score, and smoking were also found to have higher complication rates compared to non-ON patients with the same risk factors.ConclusionThis is one of the first studies to compare postoperative THA outcomes between matched ON vs non-ON patients, while also taking into consideration specific risk factors between the cohorts.