Survivorship of C e m e n t e d Total Hip Arthroplasty in Patients 50 Years of Age or Younger M i c h a e l I. S o l o m o n , M B , C h B , * D e s m o n d M . Dall,-[- M C h ( O r t h ) , F R C S , I a n D. L e a r m o n t h , : [ : a n d J. M i c h a e l D a v e n p o r t , M S * *
Abstract: One hundred fifty-six Charnley low-friction arthroplasties performed in
patients 50 years of age or younger are reviewed. Excluding sepsis, survivorship analysis showed a 12% probability of mechanical failure at 10 years. The detailed clinical and radiological results of 130 hips with a 3-16-year follow-up period are presented. Revision surgery was required in 14 hips (10.8%), for the following reasons: sepsis (2.3%), loose sockets (2.3%), loose stems (5.4%), and stem fracture (0.8%). Evidence of radiological loosening indicative of pending failure was present in 14 hips (12.0%). At 10 years the predicted failure rate of the surviving hips was 12%. Key words: hip, arthroplasty, cement, survivorship, younger patients.
There have been several r e p o r t s 1-5'7-9'11"12'14-17 of the results of c e m e n t e d total hip arthroplasty (THA) in the younger patient. Some of these have had a relatively short follow-up period and the anticipated clinical outcome remains contentious. The past decade has seen an increasing tendency among surgeons in Europe and North America to perform cementless THAs in younger patients to avoid the complications attributed to c e m e n t - - t h e so-called "cement disease." The short- to medium-term results of cementless arthroplasty clearly identify residual problems. Polyethylene wear is c o m m o n to both cementless and cemented arthroplasty. We therefore believe that this series of cemented THAs in younger patients is relevant. Previous reports have presented series of patients younger than 30, 40, 45, and 55 years. Our approach during the past 5 years has been to perform cementless
arthroplasties in patients younger than 50 years and cemented arthroplasties in those older than 60. The nature of the pathology, the physiological age, and the expectant activity level of the patient has influenced our choice of cementless or c e m e n t e d arthroplasties for patients between the ages of 50 and 60. Therefore it seemed logical to include in this study all patients 50 years or younger at the time of surgery. One h u n d r e d fifty-six Charnley low-friction arthroplasties in patients 50 years of age or younger were studied. Survivorship analysis techniques were performed on the whole group. Of these, 130 hips with a 3 - 1 6 - y e a r follow-up period were reviewed clinically and radiologically. All operations w e r e either primary or conversion for a previously failed surgery other than THA. Revision procedures were not included in this series. The clinical results were evaluated according to the method of Merl D'Aubigne and Postel as modified by Charnley. Pain, function, and range of motion were each scored on a scale of 1-6. A score of 6 represented no pain, normal function, and normal range of movement. The patients were graded into three categories: A, unilateral hip disease (29.1%); B, bi-
*From St. George Hospital, Syndey, Australia. t-From the Hospital of the Good Samaritan and The University of Southern California, Los Angeles, California. ~fFromPrincessAlice Orthopaedic Hospital and The University of Cape Town, South Africa. **From Research Statistics and Data Services, DePuy Inc., Warsaw, Indiana. Reprint requests: Desmond M. Dall, MCh (Orth), FRCS, Hospital of the Good Samaritan, 616 South Witmer Street, Los Angeles, CA 90017.
347
348
The Journal of Arthroplasty Vol. 7 Supplement 1992 Table 1. Low-friction in Arthroplasty Patients
Younger Than 50 Years Old Age
1
r I _ _
0.9
% of Group
l
_
_
0.8 0,7
10-20 21-30 31-40 41-50
2.3 17.7 26.9 53.1
0.6 0.5 0.4 0.3 0.2
lateral hip disease (38.5%); and C, unilateral or bilateral hip disease complicated by systemic disease or other conditions in the lower extremities that would limit function even if the hip arthroplasties were perfect (32.4%). All patients were clinically evaluated and had recent follow-up radiographs available at the time of review. The CART nomenclature of radiological reporting was adopted. The ages of the patients are shown in Table i; the m e a n age was 38 years. The male:female ratio was 5 0 : 5 0 . The preoperative diagnoses are s h o w n in Table 2. The incidence of rheumatoid arthritis, ankylosing spondylitis, and avascular necrosis was much higher in this than in other series with older patients.
Results Survivorship Analysis The Kaplan-Meier survivorship analysis, based on revisions excIuding sepsis, is shown in Figure 1. This represents the mechanical failure rate (loosening of sockets, stems, recurrent dislocation, and stem fracture). At 1 0 - 1 2 years the survivorship predictability is 88% (ie, 12% failure rate).
0.1
- -
0
Revised
components
i
i
i
r
i
i
i
2
4
6
8
10
12
14
16
Time [Years] Fig. 1. Kaplan-Meier survivorship analysis: revisions, excluding sepsis. Represents the mechanical failure rate.
Clinical Results One hundred thirty hips with a 3 - 1 6 - y e a r followup period were reviewed. F o u r t e e n hips w e r e revised. The clinical results of the remaining 116 unrevised hips are shown in Table 4. The average grade for pain was 4.9%, function was 5.0% (excluding category C hips), and motion was 4.9%. The relatively low average grade for pain was due in part to the high incidence of polyarthritic and category C cases.
Radiological Results The immediate postoperative orientation of components is shown in Table 5. The results of the detailed radiological evaluation are s h o w n in Tables 6 and 7.
Sockets
Failures Revision of one or both components was required in i 4 ( i 0 . 8 % ) hips for the following reasons: 3 (2.3%) for sepsis; 3 (2.3%) for loose sockets; 7 (5.4%) for loose stems; and 1 (0.8%) for stern fracture (Table 3).
Cement-bone radiolucency was present in 54.1% of sockets. The majority of these changes were type 1 with a width of 1 ram. However, 16.2% showed type 3 demarcation. Significant migration (3 + mm) was present in 3.6% of sockets. Cup wear was present in 23.4% (Table 6.)
Table 2. Preoperative Diagnosis
Diagnosis Osteoarthrosis R h e u m a t o i d arthritis Ankylosing spondylitis Congenital dislocation Protrusio Avascular necrosis Bone disease Other Failed surgery
Table 3. Hip Revisions % of
Group
34.6 28.5 8.5 3.1 0.8 13.1 1.5 2.2 7.7
Sepsis Recurrent dislocations Loose socket Loose stern Loose socket + stem Stem fracture Total n=
130.
No. of H i p s
%
3 0 3 7 0 1 14
2.3 0.0 2.3 5.4 0.0 0.8 10.8
Cemented THA in Young Patients
•
Solomon et al.
349
T a b l e 6D. Radiological Features of U n r e v i s e d Hips ( S o c k e t s ) : (n = 116; N I L = 76.6)
T a b l e 4. C l i n i c a l R e s u l t s (n = 130) Grade
Pain
Function
Motion
1 2 3 4 5 6 Average
2.7 6.2 9.7 8.0 25.7 47.8 4.9
1.8 4.5 8.2 9.1 33.6 42.8 5.0
0.o 2.8 7.3 16.5 40.3 33.1 4.9
Wear
T a b l e 5. P o s t o p e r a t i v e P o s i t i o n o f C o m p o n e n t s (n = 130)
1-2 3-4 5+
19.8 3.6 0.0
T a b l e 7A. Radiological Features of U n r e v i s e d Hips (n = 116; N I L = 80.2) (%)
Sockets Inclination 400-50 ° >50 °
Abstract: One hundred fifty-six Charnley low-friction arthroplasties performed in
patients 50 years of age or younger are reviewed. Excluding sepsis, survivorship analysis showed a 12% probability of mechanical failure at 10 years. The detailed clinical and radiological results of 130 hips with a 3-16-year follow-up period are presented. Revision surgery was required in 14 hips (10.8%), for the following reasons: sepsis (2.3%), loose sockets (2.3%), loose stems (5.4%), and stem fracture (0.8%). Evidence of radiological loosening indicative of pending failure was present in 14 hips (12.0%). At 10 years the predicted failure rate of the surviving hips was 12%. Key words: hip, arthroplasty, cement, survivorship, younger patients.
There have been several r e p o r t s 1-5'7-9'11"12'14-17 of the results of c e m e n t e d total hip arthroplasty (THA) in the younger patient. Some of these have had a relatively short follow-up period and the anticipated clinical outcome remains contentious. The past decade has seen an increasing tendency among surgeons in Europe and North America to perform cementless THAs in younger patients to avoid the complications attributed to c e m e n t - - t h e so-called "cement disease." The short- to medium-term results of cementless arthroplasty clearly identify residual problems. Polyethylene wear is c o m m o n to both cementless and cemented arthroplasty. We therefore believe that this series of cemented THAs in younger patients is relevant. Previous reports have presented series of patients younger than 30, 40, 45, and 55 years. Our approach during the past 5 years has been to perform cementless
arthroplasties in patients younger than 50 years and cemented arthroplasties in those older than 60. The nature of the pathology, the physiological age, and the expectant activity level of the patient has influenced our choice of cementless or c e m e n t e d arthroplasties for patients between the ages of 50 and 60. Therefore it seemed logical to include in this study all patients 50 years or younger at the time of surgery. One h u n d r e d fifty-six Charnley low-friction arthroplasties in patients 50 years of age or younger were studied. Survivorship analysis techniques were performed on the whole group. Of these, 130 hips with a 3 - 1 6 - y e a r follow-up period were reviewed clinically and radiologically. All operations w e r e either primary or conversion for a previously failed surgery other than THA. Revision procedures were not included in this series. The clinical results were evaluated according to the method of Merl D'Aubigne and Postel as modified by Charnley. Pain, function, and range of motion were each scored on a scale of 1-6. A score of 6 represented no pain, normal function, and normal range of movement. The patients were graded into three categories: A, unilateral hip disease (29.1%); B, bi-
*From St. George Hospital, Syndey, Australia. t-From the Hospital of the Good Samaritan and The University of Southern California, Los Angeles, California. ~fFromPrincessAlice Orthopaedic Hospital and The University of Cape Town, South Africa. **From Research Statistics and Data Services, DePuy Inc., Warsaw, Indiana. Reprint requests: Desmond M. Dall, MCh (Orth), FRCS, Hospital of the Good Samaritan, 616 South Witmer Street, Los Angeles, CA 90017.
347
348
The Journal of Arthroplasty Vol. 7 Supplement 1992 Table 1. Low-friction in Arthroplasty Patients
Younger Than 50 Years Old Age
1
r I _ _
0.9
% of Group
l
_
_
0.8 0,7
10-20 21-30 31-40 41-50
2.3 17.7 26.9 53.1
0.6 0.5 0.4 0.3 0.2
lateral hip disease (38.5%); and C, unilateral or bilateral hip disease complicated by systemic disease or other conditions in the lower extremities that would limit function even if the hip arthroplasties were perfect (32.4%). All patients were clinically evaluated and had recent follow-up radiographs available at the time of review. The CART nomenclature of radiological reporting was adopted. The ages of the patients are shown in Table i; the m e a n age was 38 years. The male:female ratio was 5 0 : 5 0 . The preoperative diagnoses are s h o w n in Table 2. The incidence of rheumatoid arthritis, ankylosing spondylitis, and avascular necrosis was much higher in this than in other series with older patients.
Results Survivorship Analysis The Kaplan-Meier survivorship analysis, based on revisions excIuding sepsis, is shown in Figure 1. This represents the mechanical failure rate (loosening of sockets, stems, recurrent dislocation, and stem fracture). At 1 0 - 1 2 years the survivorship predictability is 88% (ie, 12% failure rate).
0.1
- -
0
Revised
components
i
i
i
r
i
i
i
2
4
6
8
10
12
14
16
Time [Years] Fig. 1. Kaplan-Meier survivorship analysis: revisions, excluding sepsis. Represents the mechanical failure rate.
Clinical Results One hundred thirty hips with a 3 - 1 6 - y e a r followup period were reviewed. F o u r t e e n hips w e r e revised. The clinical results of the remaining 116 unrevised hips are shown in Table 4. The average grade for pain was 4.9%, function was 5.0% (excluding category C hips), and motion was 4.9%. The relatively low average grade for pain was due in part to the high incidence of polyarthritic and category C cases.
Radiological Results The immediate postoperative orientation of components is shown in Table 5. The results of the detailed radiological evaluation are s h o w n in Tables 6 and 7.
Sockets
Failures Revision of one or both components was required in i 4 ( i 0 . 8 % ) hips for the following reasons: 3 (2.3%) for sepsis; 3 (2.3%) for loose sockets; 7 (5.4%) for loose stems; and 1 (0.8%) for stern fracture (Table 3).
Cement-bone radiolucency was present in 54.1% of sockets. The majority of these changes were type 1 with a width of 1 ram. However, 16.2% showed type 3 demarcation. Significant migration (3 + mm) was present in 3.6% of sockets. Cup wear was present in 23.4% (Table 6.)
Table 2. Preoperative Diagnosis
Diagnosis Osteoarthrosis R h e u m a t o i d arthritis Ankylosing spondylitis Congenital dislocation Protrusio Avascular necrosis Bone disease Other Failed surgery
Table 3. Hip Revisions % of
Group
34.6 28.5 8.5 3.1 0.8 13.1 1.5 2.2 7.7
Sepsis Recurrent dislocations Loose socket Loose stern Loose socket + stem Stem fracture Total n=
130.
No. of H i p s
%
3 0 3 7 0 1 14
2.3 0.0 2.3 5.4 0.0 0.8 10.8
Cemented THA in Young Patients
•
Solomon et al.
349
T a b l e 6D. Radiological Features of U n r e v i s e d Hips ( S o c k e t s ) : (n = 116; N I L = 76.6)
T a b l e 4. C l i n i c a l R e s u l t s (n = 130) Grade
Pain
Function
Motion
1 2 3 4 5 6 Average
2.7 6.2 9.7 8.0 25.7 47.8 4.9
1.8 4.5 8.2 9.1 33.6 42.8 5.0
0.o 2.8 7.3 16.5 40.3 33.1 4.9
Wear
T a b l e 5. P o s t o p e r a t i v e P o s i t i o n o f C o m p o n e n t s (n = 130)
1-2 3-4 5+
19.8 3.6 0.0
T a b l e 7A. Radiological Features of U n r e v i s e d Hips (n = 116; N I L = 80.2) (%)
Sockets Inclination 400-50 ° >50 °
