Can a surgeon predict the longevity of a total hip replacement?

INTRODUCTION: The purpose of this study was to examine the ability of a surgeon to predict survival of a total hip replacement (THR) based on the patient's diagnosis, demographics, postoperative activity level and the surgical technique. METHODS: 4 experienced hip surgeons were asked to predict the longevity of 131 Charnley THRs, performed by the senior author (GH) 22-35 years ago, by providing them with pre- and postoperative radiographs, and data concerning patient's diagnosis, demographics, postoperative activity level and the surgical technique. This process was repeated 3 months later. RESULTS: There was only a slight agreement between the majority of the predictions and actual outcome. The inter-observer agreement was also slight and intra-observer agreement ranged from slight to moderate. CONCLUSION: We confirmed that surgeons are unable to determine the life expectancy of the implants of a THR, based on the aforementioned data, because there are other non-identified factors that affect the survivorship of a THR. For this reason, regular follow-up remains the safest way to evaluate patients' clinical picture and the evolution of radiographic changes, if there are any, in order to accurately advise patients and decide on the appropriate time for revision.

Comparison of the long-term outcome of cemented Charnley low-friction arthroplasty with hybrid arthroplasty in patients with congenital hip disease.

AIMS: To our knowledge, no study has compared the long-term results of cemented and hybrid total hip arthroplasty (THA) in patients with osteoarthritis (OA) secondary to congenital hip disease (CHD). This is a demanding procedure that may require special techniques and implants. Our aim was to compare the long-term outcome of cemented low-friction arthroplasty (LFA) and hybrid THA performed by one surgeon. PATIENTS AND METHODS: Between January 1989 and December 1997, 58 hips (44 patients; one man, 43 woman; mean age 56.6 years (25 to 77)) with OA secondary to CHD were treated with a cemented Charnley LFA (group A), and 55 hips (39 patients; two men, 37 women; mean age 49.1 years (27 to 70)) were treated with a hybrid THA (group B), by the senior author (GH). The clinical outcome and survivorship were compared. RESULTS: At all timepoints, group A hips had slightly better survivorship than those in group B without a statistically significant difference, except for the 24-year survival of acetabular components with revision for aseptic loosening as the endpoint, which was slightly worse. The survivorship was only significantly better in group A compared with group B when considering reoperation for any indication as the endpoint, 15 years postoperatively (74% vs 52%, p = 0.018). CONCLUSION: We concluded that there was not a substantial difference at almost any time in the outcome of cemented Charnley LFAs compared with hybrid THAs when treating patients with OA of the hip secondary to CHD. We believe, however, that after improvements in the design of components used in hybrid THA, this could be the method of choice, as it is technically easier with a shorter operating time. Cite this article: Bone Joint J 2019;101-B:1050-1057.

Overestimation of the risk of revision with Kaplan-Meier presenting the long-term outcome of total hip replacement in older patients.

INTRODUCTION: The purpose of the present study was (i) to review the long-term outcome of cemented Charnley total hip replacements (THRs) performed by 1 surgeon (GH), 20 to 42 years ago, in patients ≥60 years, using both the Kaplan-Meier (KM) and the cumulative incidence (CI) methods, and (ii) to compare the estimations of the 2 statistical methods. METHODS: We evaluated the outcome of 306 consecutive primary cemented THRs that were performed in 265 patients. The final clinical, radiographic assessment and satisfaction of living patients were also included. The survivorship was estimated with the use of KM and CI methods and the relative difference between their estimations was calculated. RESULTS: Living patients' final clinical results were significantly improved in comparison with respective preoperative ones, and all the acetabular and 91% of femoral components considered as well fixed. 95% of these patients reported satisfaction. The risk of revision at 25 years, with revision for aseptic loosening for 1 or both components as the endpoint, with 21 hips at risk, assessed with KM analysis was 6.9% and with CI approach was 3.9%. The relative difference between KM and CI estimations was increasing during follow-up, reaching up to 76.8% at 25 years. CONCLUSIONS: We concluded that fixation of implants with cement in older patients had satisfactory long-term results and can serve as a benchmark with which to compare newer fixation methods (hybrid and uncemented) and materials. However, KM method, in studies that include older population with long-term follow-up, may significantly overestimate the risk of revision and clinicians could consider using besides the cumulative incidence of competing risk method.

An attempt to throw light on congenital hip disease terminology and anticipation of clinical outcomes when treated with total hip arthroplasty.

The terminology of the wide spectrum of hip deformities seen during the neonatal, infantile and adult life period remains controversial, mainly due to the indiscriminate use of the terms dysplasia, subluxation, congenital hip disease, developmental hip disease, congenital dislocation, etc. This has a serious implication on the anticipation of clinical outcomes, complications and comparison of different reconstructive techniques when these patients are treated with total hip arthroplasty in adulthood. Journals, specialising in this field, should publish homogeneous series (type of the disease, reconstruction technique, implants) in order to clarify arguments and anticipate clinical outcomes.

Lessons learned from study of congenital hip disease in adults.

Orthopaedic surgeons specialising in adult hip reconstruction surgery often face the problem of osteoarthritis secondary to congenital hip disease (CHD). To achieve better communication among physicians, better treatment planning and evaluation of the results of various treatment options, an agreed terminology is needed to describe the entire pathology. Furthermore, a generally accepted classification of the deformities is necessary. Herein, the authors propose the use of the term "congenital hip disease" and its classification as dysplasia, low dislocation and high dislocation. Knowledge of the CHD natural history facilitates comprehension of the potential development and progression of the disease, which differs among the aforementioned types. This can lead to better understanding of the anatomical abnormalities found in the different CHD types and thus facilitate preoperative planning and choice of the most appropriate management for adult patients. The basic principles for improved results of total hip replacement in patients with CHD, especially those with low and high dislocation, are: Wide exposure, restoration of the normal centre of rotation and the use of special techniques and implants for the reconstruction of the acetabulum and femur. Application of these principles during total hip replacement in young female patients born with severe deformities of the hip joint has led to radical improvement of their quality of life.

The Outcome of 69 Recemented Hip Femoral Prostheses Performed by One Surgeon 22-40 Years Ago.

BACKGROUND: There is a lack of long-term data on cement-in-cement technique in revision of failed hip femoral stem. METHODS: We present the outcome of 69 consecutive recemented femoral prostheses, performed by one surgeon (GH) 22-40 years ago. Four patients (4 hips) were lost to follow-up. Sixty-three patients (65 hips) were followed for their lifetime or until the time of the preparation of the study. The study population consisted of 18 failed hemiarthroplasties and 47 failed total hip arthroplasties. RESULTS: The 23-year probability of survival for the recemented femoral components, with re-revision for any reason and resection arthroplasty as the end point, was 73.6% (61.8%-85.4%) and, with re-revision for aseptic loosening as the end point, was 82.2% (71.4%-93%). CONCLUSION: Our follow-up study at 22-40 years, after recemented hip femoral prostheses, shows that recementing works well in selected cases.

The Outcome of 241 Charnley Total Hip Arthroplasties Performed by One Surgeon 30 to 40 Years Ago.

We present the outcome of 241 consecutive low friction arthroplasties (LFAs) performed by one surgeon (GH) 30 to 40 years ago. The overall survival rate at 30 years with revision for any reason or removal of the components as the end point was 53% (43.2-62.8%) when 40 hips remained in the study. Cox regression analysis for the possible risk factors of age, gender and diagnosis revealed higher risk of the overall failure in younger patients, and higher risk of failure due to loosening in younger patients and in those with congenital hip disease. Our follow-up study at 30 to 40 years following Charnley LFA can be used as a benchmark for comparison with the newer methods of total hip arthroplasty.

Bilateral character of total hip replacement does not change the overall survival.

The purpose of this study was to compare the long-term survivorship of total hip replacement in unilaterally and bilaterally operated patients and try to answer the question whether analyses of combined unilateral and bilateral cases could result in erroneous interpretations. The material consisted of 266 Charnley's low-friction arthroplasties performed on 193 patients with osteoarthritis of the hip, followed for a minimum of 15 years. The 25-year survivorship of unilaterally operated hips was 69.2% (95% CI 57%-81.4%) and of bilaterally 66.4% (95% CI 57.6%-75.2%), respectively (p = 0.324). Cox regression analysis of unilateral and bilateral cases for confounding factors of gender, age and primary diagnosis confirmed that there was no significant relationship between survival of THR and whether the patient is unilaterally or bilaterally operated. Only age had a significant relationship with the survival of THR. In bilateral cases, Cox analysis for possible predictive factors found that the primary diagnosis, time interval between the two operations and sequence of the operation were not significantly correlated with the survivorship of bilateral THRs. We thus concluded that in analysing a combination of unilateral and bilateral cases, and presenting the long-term THR results, the bilateral character does not change the overall survival.

One-component revision in total hip arthroplasty: the fate of the retained component.

The purpose of the present study was to evaluate the long-term outcome of the unrevised part in one-component total hip arthroplasty revision (index operation). Forty-four patients (46 hips) with a mean age of 58years at the time of the index operation were included. At the final follow-up, 4 of the 19 (21%) unrevised acetabular components and 6 of the 27 (22%) unrevised femoral components were subsequently revised at a mean time of 14 and 11years from the index operation, and 22 and 24years from the primary operation, respectively. We concluded that revision of a stable component is not justifiable on the basis of its long duration in use or non-ideal position or possible loosening on radiographs.

Results of total hip arthroplasty differ in subtypes of high dislocation.

BACKGROUND: In a previous study, we described two subtypes of high dislocation of the hip depending on the presence (C1) or absence (C2) of a false acetabulum, yet we have already presented the concise followup of total hip arthroplasty (THA) in these patients as a group at a minimum of 15 years. QUESTIONS/PURPOSES: In this retrospective study, we investigated differences in the results of THA in the C1 and C2 subtypes of high dislocation such as (1) survivorship of the reconstructions; (2) Merle d'Aubigné-Postel clinical scores; (3) leg lengthening and femoral shortening; and (4) site of reattachment and union rate of the greater trochanter. METHODS: We included 49 hips of the C1 subtype and 30 hips of the C2 subtype operated on from 1976 to 1994. We evaluated survivorship (using reoperation for any reason as the end point) and performed chart and radiographic reviews. RESULTS: The 15-year survival was 84% (± 10% [95% CI]) for the C1 subtype and 60% (± 17% [95% CI]) for the C2 subtype (p = 0.001). Cox regression analysis, after adjustment for confounding factors, showed also statistically significantly worse survivorship in the C2 subtype (p = 0.021) and, after adjustment for possible predictive factors, found a statistically significant relationship of high dislocation subtype (p = 0.018) and trochanteric union (p = 0.005) with survival of THAs. Pain, function, and mobility scores improved from preoperative to last followup in C1 and C2 groups but they did not differ between C1 and C2 hips. C2 hips were lengthened more (p < 0.001) despite greater amounts of femoral shortening (p = 0.006). Site of reattachment and the risk of greater trochanter nonunion were not different between the groups. CONCLUSIONS: We found important differences in fundamental parameters after THA in the high-dislocation subtypes, including the risk of revision, which was higher in patients whose hips did not have a false acetabulum. These findings indicate that while reporting THA results in patients with high dislocation, mixing results of the two subtypes may lead to statistical bias.

Total hip arthroplasty in young females with congenital dislocation of the hip, radically improves their long-term quality of life.

Eighty-two female patients with low dislocation (67 hips) or high dislocation (48 hips) were assessed using clinical scores and EQ-5D quality of life (QoL) questionnaire. Assessment was performed at the first to secondyear postoperatively and at the final follow-up, after a minimum of 12 years (12-37). Patients reported with a high EQ-5D health state VAS scale, VAS index and TTO index at 1 to 2 years follow-up (94,21/0,907/0,931) that remained considerably high despite the long-term follow-up (73,8/0,721/0,746). The scores for pain and range of motion presented with a statistically significant improvement at 1 to 2 years postoperatively and at the time of final follow-up. Function scores have declined with age. Total hip arthroplasty in CHD patients radically improves QoL for a long period of time.

The twenty-year survivorship of two CDH stems with different design features.

UNLABELLED: Previous studies have shown that anatomical abnormalities of the femur in dislocated hips require the application of special CDH prosthesis for the reconstruction of the proximal femur in total hip arthroplasty (THA). We have retrospectively examined the clinical records and radiographs of 50 patients (67 hips) with low and high dislocations treated with THA in our institution, between January 1987 and December 1994. For the reconstruction of the femur, the stainless steel Charnley CDH stem, with polished surface, monoblock and collarless, was used in 32 hips; the Harris CDH stem, made of CoCr, precoated at the proximal part, modular and with collar was used in 35 hips. At the time of the latest follow-up, 11 Charnley and 6 Harris CDH stems had been revised for aseptic loosening at an average of 14 years (range 6-20) and 13 years (range 2-19), respectively. The survival rate at 20 years, with failure for aseptic loosening as the end point, was 63% for the Charnley and 78% for the Harris CDH stems. These results provide a basis for evaluation of newer techniques and designs. LEVEL OF EVIDENCE: Therapeutic study, Level IV.

Total hip arthroplasty in patients with high dislocation: a concise follow-up, at a minimum of fifteen years, of previous reports.

We report the updated results at a minimum of fifteen years after eighty-four consecutive total hip arthroplasties performed in sixty-seven female patients with high dislocation of the hip. Sixty-four arthroplasties were performed in forty-nine patients, between 1976 and 1994, with Charnley low-friction acetabular and femoral components inserted with cement; nineteen arthroplasties were performed in seventeen patients, between 1990 and 1994, with the hybrid technique (acetabular component inserted without cement and femoral component inserted with cement); and one arthroplasty was done in 1991, with cementless acetabular and femoral components. All patients were followed prospectively on the basis of clinical assessment according to the Merle D'Aubigné and Postel scoring system, as modified by Charnley, and with radiographic analysis. At the time of the latest follow-up, twenty-six hips (41%) in the low-friction arthroplasty series, ten hips (53%) in the hybrid series, and the one hip with the cementless components had been revised for various reasons. The primary reason for revision in the low-friction arthroplasty group was aseptic loosening of the components (twenty-four hips), whereas the predominant reason for the revisions in the hybrid series and in the hip with cementless components was progressive polyethylene liner wear (six hips). After the minimal follow-up of fifteen years, twenty-five low-friction hip replacements and eight hybrid-type hip replacements had remained intact for an average of twenty-one years (range, seventeen to thirty-two years) and sixteen years (range, fifteen to nineteen years), respectively. These findings may be used in comparisons of results with newer techniques and designs.

Effect of cementless acetabular component orientation, position, and containment in total hip arthroplasty for congenital hip disease.

We evaluated the effect of the inclination angle, position, and containment of 53 cementless cups inserted in patients with congenital hip disease (CHD), after a minimum of 10 years of follow-up. The polyethylene wear rate was significantly greater when the cup was placed in more than 45° inclination (P=.045) or if the cup was placed lateral to the teardrop position by more than 25 mm (P=.001). Aseptic loosening of the femoral component was significantly greater when the cup was placed more than 25 mm superiorly to the teardrop (P=.049). Cup placement of more than 25 mm lateral to the teardrop affected significantly periacetabular osteolysis (P=.032). In CHD cases, it is preferable to avoid excessive vertical inclination, lateral, and superior placement of cementless cups in an attempt to obtain better containment.

Charnley low-friction arthroplasty in young patients with osteoarthritis: outcomes at a minimum of twenty-two years.

BACKGROUND: We previously reported the outcomes at a minimum of twelve years after eighty-four Charnley low-friction arthroplasties performed in patients with osteoarthritis who were less than fifty-six years old at the time of the surgery. We now update the results of that cohort at a minimum of twenty-two years postoperatively. METHODS: Eighty-four hips (in sixty-nine patients) with osteoarthritis, which was secondary to congenital hip disease in sixty-four (76%) of them, were followed prospectively with use of the Merle D'Aubigné and Postel scoring system as modified by Charnley and with serial radiographs. RESULTS: At the time of the latest follow-up, thirty-seven hips (44%) had failed. Twenty-eight acetabular and thirty femoral components, in a total of thirty-two hips, had been revised because of aseptic loosening; six of the loose femoral components were broken. Three hips were infected and were converted to a resection arthroplasty. A periprosthetic femoral fracture occurred in two additional hips, three and ten years postoperatively, and both were treated with internal fixation. Thirty-seven original acetabular components and thirty-six original femoral components were in place for an average of twenty-nine years. The probability of survival for both components, with failure for any reason as the end point, was 0.51 (95% confidence interval, 0.39 to 0.62) at twenty-five years. CONCLUSIONS: These long-term results can be used as a benchmark with which to compare outcomes of different designs when total hip arthroplasty is performed in young patients when the majority have congenital hip disease.

A comparison of the outcome of cemented all-polyethylene and cementless metal-backed acetabular sockets in primary total hip arthroplasty.

We compared, after a 10-year-minimum follow-up, the outcome of 50 cemented all-polyethylene Charnley acetabular sockets with that of 51 cementless metal-backed sockets in 2 comparable cohorts of young patients. Although the revision rate for the cemented and cementless group was 28% and 35%, respectively, the revision rate for aseptic loosening was 28% for the cemented and 12% for the cementless group. The mean polyethylene wear was 0.112 and 0.114 mm/y, respectively, for the 2 groups. Linear osteolysis was observed in 18 of 50 cemented sockets. Expansile osteolysis presented in 10 of 51 cementless sockets and only in one of the cemented sockets. In conclusion, cementless components had more durable fixation than cemented components. However, they presented more aggressive expansile osteolysis caused by the coexistence of polyethylene and metal debris.

The morphologic variations of low and high hip dislocation.

UNLABELLED: Three different types of congenital hip disease in adults have been distinguished based upon the position of the femoral head relative to the acetabulum and the underlying pathoanatomy of the joint: (1) dysplasia; (2) low dislocation; and (3) high dislocation. To facilitate classification of borderline or ambiguous cases, we studied the morphologic variations of low and high dislocation as observed on the radiographs of 101 hips with low and 74 hips with high dislocation. In low dislocation, 54 hips (53.5%) had extended coverage of the true acetabulum (Type B1) and 47 hips (46.5%) had limited coverage (Type B2). Among the cases with high dislocation, a false acetabulum with an adjacent femoral head occurred in 46 hips (62.2%) (Type C1), and the femoral head was floating within the gluteal muscles in 28 hips (37.8%) (Type C2). The kappa value for interobserver agreement between two raters who made radiographic measurements was 0.963, and for intraobserver agreement between the two evaluations of the same observer it was 0.946 and 0.971, respectively. The two types of low and high dislocation were associated with high intra- and interobserver agreement. Whether these distinctions have clinical utility requires further validation. LEVEL OF EVIDENCE: Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

The 20-year outcome of the charnley arthroplasty in younger and older patients.

The purpose of this study is to present the 20-year outcome of 206 Charnley low-friction arthroplasties done by the same surgeon on 181 patients who were separated into two age groups (younger and older). In Group A (76 patients, 92 hips) the mean age at surgery was 44 years (range, 24-55 years), and in Group B (105 patients, 114 hips) the mean age at surgery was 65 years (range, 56-82 years). All patients were evaluated clinically and radiographically. At final followup, 71 patients (87 hips) in Group A and 90 patients (99 hips) in Group B were available for study. The overall failure rate for the hips of Group A was 37.9%, and the overall failure rate for the hips of Group B was 20%. The main cause of failure in Group A was aseptic loosening of the components and breakage of the femoral stem, whereas in Group B the main cause of failure was deep infection. We concluded that by eliminating the above factors, and using new cementing techniques and improved implants, the 20-year results of this arthroplasty would be better. Our results show that the Charnley arthroplasty is a reliable procedure for hip replacement, even in younger patients.

Total hip arthroplasty for congenital hip disease.

BACKGROUND: It is generally agreed that the clinical and radiographic results of total hip replacement performed for degenerative arthritis secondary to congenital hip disease vary depending on the severity of the anatomical abnormality. In this study, we report the mid-term and long-term clinical and radiographic results of total hip arthroplasty performed for each of the three different types of congenital hip disease. METHODS: Between 1976 and 1994, the senior author performed 229 consecutive primary total hip arthroplasties in 168 patients with osteoarthritis secondary to congenital hip disease. Seventy-six hips were dysplastic, sixty-nine had a low dislocation, and eighty-four had a high dislocation. The Charnley low-friction technique was performed in 178 hips, and the so-called hybrid technique was performed in forty-six hips. Cementless arthroplasty was used in only five hips. RESULTS: After a minimum of seven years of follow-up, the rates of revision of the acetabular components were 15% in the dysplastic hips, 21% in the hips with a low dislocation, and 14% in those with a high dislocation. The rates of revision of the femoral components were 14%, 14%, and 16%, respectively. Survivorship analysis predicted an overall rate of prosthetic survival at fifteen years of 88.8% +/- 4.8% in the dysplastic hips, 73.9% +/- 7.2% in the hips with a low dislocation, and 76.4% +/- 8.1% in those with a high dislocation. CONCLUSIONS: An understanding of the anatomical abnormalities and the use of appropriate techniques and implants make total hip arthroplasty feasible for treatment of the three types of congenital hip disease. In patients with a low dislocation, the major technical problem is reconstruction of the natural acetabulum. In those with a high dislocation, the challenge is to place the acetabular component inside the reconstructed true acetabulum and to use an appropriate femoral implant in the hypoplastic narrow femoral diaphysis.