The Journal of Arthroplasty xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org

Outcome of Total Hip Arthroplasty for Avascular Necrosis of the Femoral Head in Systemic Lupus Erythematosus Min Su Woo, MD, Joon Soon Kang, MD, PhD, Kyoung Ho Moon, MD, PhD Department of Orthopedic Surgery, School of Medicine, Inha University, Incheon, South Korea

a r t i c l e

i n f o

Article history: Received 6 August 2013 Accepted 20 December 2013 Available online xxxx Keywords: total hip arthroplasty systemic lupus erythematosus Harris hip score avascular necrosis of femoral head corticosteroid

a b s t r a c t This study evaluated the result of total hip arthroplasty (THA) for avascular necrosis of the femur head (AVNFH) in systemic lupus erythematosus (SLE) patients. Nineteen THAs were performed on 13 patients with SLE. The results of these patients were compared with the results of the control group (19 patients) who had THR due to AVNFH with none-SLE conditions. The Harris hip score increased from a preoperative average of 65.3 points to 94.9 at the most recent follow-up. In the control group, the mean HHS was 67.2 preoperatively and 96.1 postoperatively at the last follow-up. No significant difference was found between SLE patients and non-SLE patients who underwent hip arthroplasty. In conclusion, THA is an acceptable treatment for achieving functional improvement in patients who had SLE and AVNFH. © 2013 Elsevier Inc. All rights reserved.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect multiple organ systems and cardiovascular, musculoskeletal, urinary, central nervous system involvement [1]. Lupus can affect anyone, but it is more prevalent in women than in men; 9 out of 10 people with lupus are women. African–American women are three times more likely to get lupus than Caucasian women and it’s also more common in Hispanic/Latino, Asian, and American Indian women. Osteonecrosis in systemic lupus erythematosus was first described by Dubois and Cozen in 1960 [2] and since then has been frequently reported for complications within the disease. Avascular osteonecrosis of the femoral head (AVNFH) is one of the most frequently reported complications of SLE [2–4] and has been reportedly developed in patients with SLE, ranging from 4% to 40% with an overall average of 10% [4–9]. Petri [10] reported a 14.5% prevalence of AVN in a cohort of 407 SLE patients. Although the exact mechanisms of AVNFH have not been fully understood yet, a recent study has indicated that it may be highly related to the long-term use of steroids, microvascular thrombosis and vasculitis [11]. AVNFH may result in pathological fractures and severe hip pain with progressive collapse of the femoral head. Therefore, prosthetic arthroplasty is often necessary in patients who have severe dysfunction and disability due to a collapsed joint. Core decompression, bipolar hemiarthroplasty, total hip arthroplasty and other similar treatments have been performed for the condition and there have been a few conflicting reports on the results of the treatment [12–16]. This paper was supported by the research fund from Inha university. The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2013.12.028. Reprint requests: Kyoung Ho Moon, MD, PhD, Department of Orthopedic Surgery, School of Medicine, Inha University, Shinheung-Dong, Jung-Gu, Incheon 400-712, South Korea.

The purpose of this study is to compare the clinical outcomes, radiologic results, and complications associated with the procedures between the SLE groups and non-SLE groups in the treatment of AVNFH. Material and Methods Patient Characteristics Between May 1997 and September 2011, 21 consecutive prosthetic hip arthroplasties were performed in 14 Asian patients with SLE. We studied patients who had undergone operations more than 18 months ago. Therefore one patient (2 hips) was excluded because of a short follow-up period (11 months). The remaining 19 hips in 13 patients, including 12 women (18 hips) and 1 man (1 hip) with a mean age of 41.3 years (range, 25–59 years), were available for this retrospective study. The average duration of follow-up was 97.8 months (range 20.0–190.0). The average BMI was 23.3 (range 19.3–28.5). There were 10 right hips and 9 left hips. Patients were divided into heavy, moderate, light, semi-sedentary, and sedentary for their activity level by using a hip sheet in the Anderson clinic [17]. Three patients (6 hips) were heavy, nine patients (12 hips) were moderate and one (1 hip) was assigned to the light group of the SLE groups. Five patients (7 hips) were taking methylprednisolone at 4 mg/day, two patients (3 hips) were taking at 6 mg/day and another two patients (3 hips) were taking the drug at 8 mg/day. One patient (1 hip) was taking prednisolone at 5 mg/day, another patient (2 hips) was taking dexamethasone at 10 mg/day, and another patient (2 hips) was taking deflazarcort at 6 mg/day. Three patients (3 hips) had Ficat stage III and ten patients (16 hips) had Ficat stage IV necrosis of the femoral head (Table 1), that is, x-rays, computed tomography (CT), or magnetic resonance imaging (MRI) showed sclerosis and

0883-5403/0000-0000$36.00/0 – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.arth.2013.12.028

Please cite this article as: Woo MS, et al, Outcome of Total Hip Arthroplasty for Avascular Necrosis of the Femoral Head in Systemic Lupus Erythematosus, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2013.12.028

2

M.S. Woo et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx

Table 1 Patients’ Demographic Data of the SLEa Group. Case

Gender

Age (year)

BMI (kg/m2)

1 (Rt) 1(Lt) 2(Rt) 2(Rt) 3(Rt) 4(Rt) 4(Lt) 5(Lt) 6(Lt) 6(Rt) 7(Rt) 8(Lt) 9(Lt) 10(Rt) 11(Lt) 11(Rt) 12(Lt) 12(Rt) 13(Rt)

F F F F F F F F F F F F F F F F F F M

36 36 49 54 34 53 53 29 23 23 25 29 32 38 53 54 57 59 47

20.7 20.7 28.5 28.5 22.4 22.7 22.7 25.3 21.8 21.8 26.7 22.2 22.8 28.0 22.2 22.2 19.3 19.3 25.9

a b c d

Activity Heavy Heavy Moderate Moderate Moderate Moderate Moderate Moderate Heavy Heavy Moderate Moderate Moderate Moderate Heavy Heavy Moderate Moderate Light

F/Ub Period (month)

Preoperative HHSc

Dose of Steroid

F-Ad Stage

75 75 98 33 190 174 174 169 107 99 104 129 82 20 97 90 71 40 31

65 65 63 62 62 65 65 72 68 64 57 54 69 72 73 61 74 68 62

8 mg/d 8 mg/d 10 mg/d 10 mg/d 4 mg/d 6 mg/d 6 mg/d 4 mg/d 6 mg/d 6 mg/d 6 mg/d 8 mg/d 4 mg/d 5 mg/d 4 mg/d 4 mg/d 4 mg/d 4 mg/d 4 mg/d

4 4 4 4 4 4 4 3 4 4 4 4 4 3 4 4 4 3 4

SLE: Systemic Lupus erythematosus. F/U: follow up. HHS: Harris hip score. F-A stage: Ficat and Arlet stage.

cystic or configurational changes of the femoral head which were associated with hip pains or not [18]. Surgical Characteristics The indication for surgery was severe, disabling pain in the hip that was unresponsive to nonsurgical treatment. The acetabular and femoral components were inserted without cement (Fig. 1). Six of the 13 patients underwent bilateral THAs. All procedures were performed through the posterolateral approach by the corresponding author who specializes in hip surgery. As an acetabular component, a Duraloc 100 series model (Depuy, Warsaw, IN, USA) was used in 3 hips, an Option Cup (Depuy, Warsaw, IN, USA) was implanted in 11 hips and a Pinnacle Cup (Depuy, Warsaw, IN, USA) was employed in 3 hips. A Duraloc 1200 series (Depuy, Warsaw, IN, USA) and Trilogy (Zimmer, Warsaw, IN, USA) were used in 1 hip for each. As a femoral component, an Anatomical Medullary Locking Stem (Depuy, Warsaw, IN, USA) was used in 13 hips, a Summit Stem (Depuy, Warsaw, IN, USA) in 5 hips and a Versys Fiber Metal Taper Stem(Zimmer, Warsaw, IN, USA)) in 1 hip. Evaluation All patients were followed up after the surgery at 6 weeks, 3 months, 6 months and 12 months post-operatively, and then yearly for a radiologic review. The Harris hip score (HHS) was used to evaluate the functional recovery of the hip after THAs and was checked in all cases pre-operatively and post-operatively [19]. Post-operative radiographs were used to evaluate the position, fixation, and loosening of the uncemented components, radiolucent lines, and osteolysis. The femur was divided into the seven Gruen zones [20]. Radiolucencies with a scalloped or cystic appearance, or greater than 2 mm in width, were defined as osteolysis. Subsidence was determined by a comparison of two measurements between serial radiographs. The amount of the subsidence was checked by measuring the distance from the tip of the greater trochanter to the distal tip of the implant and distance from the medial corner of the implant to the lesser trochanter [21]. A difference of more than 4 mm between radiographs on both measurements was considered to establish subsidence. A modified Engh classification was used to grade femoral component stabilities [22]. The fixation by bony ingrowth was defined as an implant with

no subsidence or no formation of radio-opaque lines around the stem. The stable fibrous ingrowth was defined as an implant with no progressive migration or no formation of extensive radio-opaque lines around the stem. An unstable stem demonstrated progressive subsidence or migration within the canal as well as partial surrounding with a divergent radio-opaque line. Stress shielding is the redistribution of the load that occurs when the femoral head is replaced by the femoral component. And a lack of uniform stress transfer leads to the reduction in bone density. Engh et al [22] had mentioned the classification of stress shielding. First-degree stress shielding was defined as a slight rounding off of the proximal medial edge of the cut femoral neck and second-degree as rounding off of the proximal medial femoral neck combined with loss of medial cortical density at level one. Third-degree stress shielding was more extensive resorption of the cortical bone extending from level one into level two, and fourth-degree severe resorption of cortical bone extending below levels one and two into the diaphysis. A pedestal sign is indicative of the prosthetic loosening of the femoral stem in cementless total hip arthroplasties [23]. The presence of radioopaque lines within a radiolucent area, separated from the prosthetic tip by at least 2 mm, is defined as the “Pedestal sign”. Since the sample size was not big enough, we employed nonparametric tests. We used the Wilcoxon rank sum test (Mann–Whitney U test) for the analysis of continuous data, and the Chi-square test or the Fisher's exact test for ratio data by using SPSS 19.0 (SPSS Inc, Chicago, IL, USA). A value of P b 0.05 was considered to indicate statistical significance. In principle, we employed the Chi-square test. However, we used the Fisher's exact test for the analysis of the cases in which the expected frequency was not attained. We expressed the continuous variables as the mean and standard deviation (SD), and the ratio data as N and %. A control group of 19 patients had AVNFH and underwent THAs. They were matched for gender, activity level, body mass index(BMI), follow-up period, the type of implant with SLE patients. There were twelve women (17 hips) and one men (2 hips) with a mean age of 58.1 years (range, 40–72 years) in the control group. The average duration of follow-up was 81.2 months (range 40.0–148.0) and the average BMI was 24.7 (range 19.9–29.1). 11 hips were on the right and 8 hips were on the left. Six patients (8 hips) were heavy, six patients (9 hips) were moderate and one patient (2 hips) was categorized into the light category. Other variables did not show significant differences between the two groups (Table 2).

Please cite this article as: Woo MS, et al, Outcome of Total Hip Arthroplasty for Avascular Necrosis of the Femoral Head in Systemic Lupus Erythematosus, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2013.12.028

M.S. Woo et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx

3

Results The Harris hip scores increased from a preoperative average of 65.3 points (range 57–74) to 94.9 (range 87–99) at the final followup. The SLE group was followed up for 97.8 months on average and the average duration between the onset of SLE and surgery was 51.7 months (range, 9–158). Six of 13 patients had received bilateral replacements. A statistically significant improvement in all scores was found post-operatively as compared to preoperative values. One patient received a revision arthroplasty due to osteolysis 9 years after surgery. There were no significant complications related to the surgery such as nerve palsy, dislocation, infection, fracture, or thromboembolic events in any patient. Radiographs of at least 12 months post-operatively were available for all patients. Osteolysis had developed in one patient who received a revision arthroplasty at 33 months post-operatively. Radiologically, 19 hips had fixation with bone ingrowth and the stress shielding was observed in 13 hips 45.1 months after THAs. Radiolucent lines at Gruen zones 1 and 7 were seen in two patient (2 hips) at 54-month follow-up. At 85 months after operation, the liner wear was seen in 2 patients (3 hips) who used 10° polyethylene liners. There were no evidence of acetabular cup malpositioning, tilting, rotation or shedding on metal particles and no evidence of femoral stem subsidence, pedestal or shedding on metal particles. In the control group, the mean HHS was 67.2 (range 56–78) preoperatively and 96.1 (range 89–99) postoperatively at the last follow-up. This group was followed up for 81.2 months on average. There were no meaningful differences in Harris hip scores between the SLE and general patients. No serious complications had occurred, and all patients had good or excellent results in the control group. Fixation by bone ingrowth was shown radiologically in 17 hips where two showed a fibrous ingrowth. Stress shielding was observed in 14 hips 49.2 months after THA. At the 61-month follow-up, radiolucent lines were seen in two patients (2 hips) at Gruen zone 1 and Gruen zones 1, 2 and 7 each. Subsidence was seen in one patient (1 hip) and pedestal formations were found in one patient (2 hips) at 58.3 months after surgery. At 94 months post-operatively, a linear wear was seen in 1 patient (1 hip) who used 10° polyethylene liners. There were no evidence of acetabular cup malpositioning, tilting, rotation or shedding on metal particles and no shedding on metal particles in femoral stem (Table 3). Discussion At the present time, it is known that total hip arthroplasty (THA) is the treatment of choice for advanced AVNFH, and high success rates Table 2 Comparison of the Two Groups. SLE Age (years) Gender Activity

Male Female Heavy Moderate Light

BMI (kg/m2) Follow-up period (month) Ficat stage Stage 3 Stage 4 Implant type Fig. 1. (A) An anteroposterior radiograph reveals severe disruption of both femoral heads. (B) Double line signs were seen on T2-weighted magnetic resonance images of both femoral heads. (C) The femoral and acetabular components were stable, postoperatively.

Liner type

41.3 ± 12.5 1 (5.3%) 18 (94.7%) 6 (31.6%) 12 (63.1%) 1 (5.3%) 23.3 ± 2.9 97.8 ± 50.8

3 (15.8%) 16 (84.2%) All noncemented type Polyethylene (10°) 4 (21.1%) Ceramic 15 (78.9%)

Non-SLE 58.1 ± 10.4 2 (10.5%) 17 (89.5%) 8 (42.1%) 9 (47.4%) 2 (10.5%) 24.7 ± 2.7 81.2 ± 30.0

P Value b.001a 1.000b 0.615b

0.140a 0.231a

6 (31.6%) 0.447b 13 (68.4%) All non1.000a cemented type 1 (5.3%) 0.340b 18 (94.7%)

Mean ± s.d./n(%). a Wilcoxon rank sum test(Mann–Whitney U test). b Fisher's exact test.

Please cite this article as: Woo MS, et al, Outcome of Total Hip Arthroplasty for Avascular Necrosis of the Femoral Head in Systemic Lupus Erythematosus, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2013.12.028

4

M.S. Woo et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx

support of the theory that THAs can be a good choice in SLE patients with satisfactory outcomes.

Table 3 Clinical and Radiologic Results.

HHS increment Stability

Stress shield Liner wear Acetabular component Femoral component

Complication

SLE

Non-SLE

P Value

28.9 ± 6.3 17 (89.5%) 2 (10.5%) 0 (0.0%) 14 (73.7%) 3.0 [n = 1] 19 (100.0%)

0.588a 0.486b

Normal

29.6 ± 5.8 19 (100.0%) 0 (0.0%) 0 (0.0%) 13 (68.4%) 2.33 ± 0.58 [n = 3] 19 (100.0%)

1.000c 0.317a 1.000b

Normal

17 (89.5%)

15 (78.9%)

0.796b

Pedestal Radiolucent line Subsidence

0 2 0 0

1 (5.3%) 2 (10.5%) 1 (5.3%) 0 (0.0%)

1.000b

Bone ingrowth Fibrous ingrowth Unstable

(0.0%) (10.5%) (0.0%) (0.0%)

Mean ± s.d./n(%). a Wilcoxon rank sum test(Mann–Whitney U test). b Fisher's exact test. c Chi-square test.

have been reported [24,25]. In this study, 13 SLE patients (19 hips) had excellent results after THAs with an average follow-up of 97.8 months. Patients generally had dramatic improvements in HHS and no other significant complications. We had a control group of 19 patients who were matched for genders, activity levels, body mass indexes(BMI), follow-up periods, and types of implant but could not be matched for ages because of the young ages of the disease onset in patients with SLE. No differences were observed in postoperative clinical and radiological results between SLE patients and AVNFH patients of other etiologies. This suggests that the hip arthroplasty for SLE patients may not invite particular complications. The strong points of this study include the fact that all procedures were performed by the same surgeon and with the same approach. However, a small and single-race population, short follow-up periods, a retrospective study and the difference in ages between the two groups are limitations of this study. Therefore, future studies with a larger population, other-races, longer periods and similar age groups are needed. Complications after THA included infections at the surgical sites, deep vein thrombosis (DVT), pulmonary embolism, nerve injuries, periprosthetic fractures, dislocations, heterotopic ossifications and transfusion reactions. Hanssen et al [15] reported delayed wound healings (approximately 15%) and superficial wound infections (approximately 10%) but there were no such complications in our study. Variable results of THA for AVNFH in SLE patients were reported. Prupas et al [26] reported satisfactory short-term results of six THAs without complications at 23- to 76-month follow-up. Chen et al [27] also reported satisfactory short-term results of 20 THAs in 12 patients who had systemic lupus erythematosus with an average follow-up of 30 months. Hanssen et al [15] reported on 31 SLE patients (43 hips) who underwent arthroplasty for the treatment of AVNFH and 93.02% patients had good or excellent results. Huo et al [28] reported a 94.6% five-year survival rate and an 81.8% nine-year survival rate in 33 THAs in 25 patients, in which one patient required a revision for recurrent dislocations and one patient required a revision for an aseptic loosening. Zagger et al [1] also reported short-term to medium-term results of 19 SLE patients (26 hips) with an average follow-up of 55 months and concluded that the results were similar in patients who had hip replacement for other diagnoses. Although the degenerative processes of the disease and the underlying concomitant medical problems could make us hesitate to perform THAs in SLE patients, our study offers proper evidence in

Conclusion We had described short and medium term results of THA for avascular necrosis in patients with SLE. Statistically significant improvements in clinical and radiological value were found postoperatively as compared to preoperative values. Moreover there were no significant differences between SLE patients and non-SLE patients who underwent hip arthroplasty. Therefore, on the basis of this study, THA is an adequate treatment for achieving functional improvement in patient who had SLE and AVNFH. References 1. Zangger P, et al. Outcome of total hip replacement for avascular necrosis in systemic lupus erythematosus. J Rheumatol 2000;27(4):919. 2. Dubois EL, Cozen L. Avascular (aseptic) bone necrosis associated with systemic lupus erythematosus. JAMA 1960;174:966. 3. Weiner ES, Abeles M. Aseptic necrosis and glucocorticosteroids in systemic lupus erythematosus: a reevaluation. J Rheumatol 1989;16:604. 4. Zizic TM, et al. Corticosteroid therapy associated with ischemic necrosis of bone in systemic lupus erythematosus. Am J Med 1985;79:596. 5. Mont MA, et al. Risk factors for osteonecrosis in systemic lupus erythematosus. J Rheumatol 1997;24(4):654. 6. Mok MY, Farewell VT, Isenberg DA. Risk factors for avascular necrosis of bone in patients with systemic lupus erythematosus: is there a role for antiphospholipid antibodies? Ann Rheum Dis 2000;59(6):462. 7. Nagasawa K, et al. Very early development of steroid-associated osteonecrosis of femoral head in systemic lupus erythematosus: prospective study by MRI. Lupus 2005;14(5):385. 8. Orban H, Cirstoiu C, Adam R. Total hip arthroplasty in secondary systemic lupus erythematosus femoral head avascular necrosis. Rom J Intern Med 2007;45(1):123. 9. Gladman DD, et al. Predictive factors for symptomatic osteonecrosis in patients with systemic lupus erythematosus. J Rheumatol 2001;28(4):761. 10. Petri M. Musculoskeletal complications of systemic lupus erythematosus in the Hopkins Lupus Cohort: an update. Arthritis Care Res 1995;8(3):137. 11. Danchenko N, Satia JA, Anthony MS. Epidemiology of systemic lupus erythematosus: a comparison of worldwide disease burden. Lupus 2006;15(5):308. 12. Bentze D, et al. Total endoprosthesis of the hip joint in patients with systemic lupus erythematosus. Ter Arkh 1983;55(7):91. 13. Kunec JR. Total hip replacement in patients under thirty-five years of age. Orthopedics 1983;6:1432. 14. Kaslow RA, Masi AT. Age, sex, and race effects on mortality from systemic lupus erythematosus in the United States. Arthritis Rheum 1978;21(4):473. 15. Hanssen AD, Cabanela ME, Michet Jr CJ. Hip arthroplasty in patients with systemic lupus erythematosus. J Bone Joint Surg Am 1987;69(6):807. 16. Fairbank AC, et al. Long-term results of core decompression for ischemic necrosis of the femoral head. J Bone Joint Surg [Br] 1995;77(1):42. 17. Von Knoch M, et al. Incidence of late bead shedding from uncemented porous coated cups. A radiographic evaluation. Clin Orthop Relat Res 1997;342:99. 18. Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg [Br] 1985;67(1):3. 19. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end result study using a new method of result evaluation. J Bone Joint Surg Am 1969;51(4):737. 20. Gruen TA, McNeice GM, Amstutz HC. Mode of failure of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res 1979;141:17. 21. Fowler JL, et al. Experience with the Exeter total hip replacement since 1970. Orthop Clin North Am 1988;19(3):477. 22. Engh CA, Bobyn JD, Glassman AH. Porous-coated hip replacement. The factors governing bone ingrowth, stress shielding and clinical results. J Bone Joint Surg [Br] 1987;69(1):45. 23. Parpan D, Ganz R. Cementless implantation of a modified Mueller straight-stem prosthesis. In: Morscher E, editor. The cementless fixation of hip endoprostheses. Berlin Heidelberg: Springer-Verlag; 1984. p. 156. 24. Cheng T, et al. Minimally invasive total hip arthroplasty: a systematic review. Int Orthop 2009;33(6):1473. 25. Baron JA, et al. Total hip arthroplasty: use and select complications in the US medicare population. Am J Public Health 1996;86(1):70. 26. Prupas HM, Patzakis M, Quismorio Jr FP. Total hip arthroplasty for avascular necrosis of the femur in systemic lupus erythematosus. Clin Orthop Relat Res 1981;161:186. 27. Chen PG, Lin CC. Total hip arthroplasty in patients with systemic lupus erythematosus. Taiwan Yi Xue Hui Za Zhi 1987;86(3):299. 28. Huo MH, et al. Primary total hip arthroplasty in systemic lupus erythematosus. J Arthroplasty 1992;7(1):51.

Please cite this article as: Woo MS, et al, Outcome of Total Hip Arthroplasty for Avascular Necrosis of the Femoral Head in Systemic Lupus Erythematosus, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2013.12.028

Outcome of total hip arthroplasty for avascular necrosis of the femoral head in systemic lupus erythematosus.

This study evaluated the result of total hip arthroplasty (THA) for avascular necrosis of the femur head (AVNFH) in systemic lupus erythematosus (SLE)...
519KB Sizes 0 Downloads 0 Views