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 Table of Contents  
ORIGINAL ARTICLE
Year : 2023  |  Volume : 6  |  Issue : 1  |  Page : 111-114

Causes of revision after total hip arthroplasty in patients undergoing revision total hip arthroplasty younger than 50 years of age


Department of Orthopedics, Medical College Baroda, Vadodara, Gujarat, India

Date of Submission17-Oct-2022
Date of Decision13-Nov-2022
Date of Acceptance13-Nov-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Kashyap Laxmanbhai Zala
B-9, Snehsagar Society Part 2, Near Vastrapur Railway Station, Vejalpur, Ahmedabad - 380 051, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_100_22

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  Abstract 


Background and Aims: Young patients undergoing revision total hip arthroplasty (THA) have different indications and causes of failure of THA. This retrospective cohort study examines the causes of failure of THA in a patient younger than 50 years. Subjects and Methods: Clinical and demographic data of 146 revision THA (130 patients) were gathered from case records of patients who underwent revision THA at our institute between January 1, 2018, and December 31, 2021. Fifty-two hips (46 patients) were younger than 50 years at the time of revision. Baseline characteristics, cause for revision, implants revised, and duration of survival were noted. Statistical Analysis: Chi-squared test was implemented to find a correlation, and P < 0.05 was considered statistically significant. Results: We had 52 hips, 46 patients (28 females), and the mean age at primary THA was 33.9 years, the mean age at revision THA was 44.5 years, and the mean survival of implants was 10.6 years. The most common diagnosis for primary THA was avascular necrosis of the femoral head (21 hips, 40.38%), followed by inflammatory arthritis. The most common cause of failure was aseptic loosening (27 hips, 51.92%). As compared to the overall population undergoing revision THA (60/146 hips, 41.09%), patients younger than 50 years having more frequency of aseptic loosening as a cause of failure of THA and less frequency of periprosthetic joint infection, instability, and fracture; but statistically significant difference was not found (P = 0.38). No correlation was found between the type of implants used (P = 0.84) and diagnosis at index THA (P = 0.78), with the cause of failure of THA. Conclusions: Aseptic loosening of THA is the most common mode of failure in patients younger than 50 years.

Keywords: Revision total hip arthroplasty, total hip arthroplasty, total hip replacement, young patient


How to cite this article:
Mathur H, Zala KL, Chokshi JJ. Causes of revision after total hip arthroplasty in patients undergoing revision total hip arthroplasty younger than 50 years of age. J Orthop Dis Traumatol 2023;6:111-4

How to cite this URL:
Mathur H, Zala KL, Chokshi JJ. Causes of revision after total hip arthroplasty in patients undergoing revision total hip arthroplasty younger than 50 years of age. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jan 30];6:111-4. Available from: https://jodt.org/text.asp?2023/6/1/111/365273




  Introduction Top


Younger patients having end-stage arthritis of the hip are treated by total hip arthroplasty (THA), more frequently than ever before,[1] Longevity of the implants is the major concern for these patients, as they are more active than their aged counterparts.[2] In this study, we are trying to review the causes of revision after THA in patients younger than 50 years. To know the causes of failure of THA in our patients will give more precision in clinical decision-making of the surgical interventions for hip arthritis.


  Subjects and Methods Top


We gathered information of all patients who underwent revision THA in our hospital from January 1, 2018, to December 31, 2021. Out of this cohort, patients with an age <50 years at the time of revision surgery were included in the study. Demographic data and diagnosis were collected from the case records. Duration of survival, components revised, and details about surgery were recorded from the case records. Index surgery was done in our hospital in 30 hips, while 22 hips were operated for THA at other hospitals. This study was approved by the institutional ethical committee. Patient's personal details were concealed appropriately.

Hips were divided according to the use of cement in the fixation of implants at the time of index surgery of THA. In cementless THA, both the femoral stem and acetabular shell were cementless, in cemented THA, both the femoral stem and acetabular shell were cemented, while in hybrid THA, the femoral stem was cemented and the acetabular shell was cementless. A relation between the cause of failure and the type of arthroplasty was observed.


  Results Top


A total of 146 revision total hip arthroplasties in 117 patients were done during this period. Within this cohort, 52 hips (35.61%) and 46 patients (39.31%) were under the age of 50 years. The mean age of the study sample was 44.5 years, range (24.8–49.7 years), 28 patients (60.86%) were females, 6 patients were operated on both hip revisions during the study period. Preoperative diagnoses of the study patients were avascular necrosis of the femoral head in 21 hips, inflammatory arthritis in 15 patients (6 ankylosing spondylitis, 5 rheumatoid arthritis, and 4 juvenile-onset idiopathic arthritis), 5 posttraumatic arthritis (4 postfracture acetabulum and 1 posthip dislocation), 5 developmental dysplasia of the hip, 3 was nonunion of neck of femur fracture, and 3 were osteoarthritis of hip [Table 1] and [Table 2].
Table 1: Demographic details of the patients

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Table 2: Relation between cause of failure of total hip arthroplasty and diagnosis at the time of primary total hip arthroplasty

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The mean time from index surgery to revision was 10.6 years (range: 16 days–17 years). The initial fixation for our study subjects was cementless stem and cementless acetabular shell in 21 hips, cemented femoral stem and cementless acetabular shell in 14 hips, and cemented femoral stem and cemented acetabular shell in 17 hips. Initial bearing surfaces for primary hip replacement in these patients were metal on polyethylene in 48 hips and ceramic on polyethylene in 4 hips. Causes of revision were aseptic loosening of one or both components in 27 hips (7 acetabular loosenings, 5 stem loosening, 15 both acetabulum, and femur loosening), periprosthetic fracture in 7 hips, infection in 13 hips, and instability in 5 hips. Only acetabular shell revision was done in 3 hips, while only stem revision was done in 4 hips, head and liner exchange was done in 3 hips, and all components were revised in 32 hips.

[Table 2] shows the relation between the causes of failure of THA with the diagnosis at primary THA surgery. While aseptic loosening is the most common cause for the failure mode, no significant correlation was found between the variables (Chi-squared value 10.88, degrees of freedom 15, P = 0.78). [Table 3] shows the mode of failure in relation to the use of cementless or cemented implants at the time of primary THA. Aseptic loosening was the most common cause for failure regardless, of which types of femoral and acetabular implants were used. No significant correlation was found between causes of failure and type of arthroplasty (cementless, cemented, or hybrid) (Chi-squared value 2.66, degrees of freedom 6, P = 0.84). [Table 4] shows the comparison between our study population cohort of patients <50 years of age with the cohort of all patients undergoing revision THA during the study period. Aseptic loosening is more in patients <50 years of age, while infection and instability are more common causes of revision in the other group. Weak correlation is found between the age of the patient and the cause of revision after THA (Chi-squared value 3.05, degrees of freedom 3, P = 0.38).
Table 3: Relation between cause of failure of total hip arthroplasty and type of arthroplasty

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Table 4: Comparison of our study cohort of patient younger than 50 years with all patients operated for revision total hip arthroplasty during the same time period

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  Discussion Top


In 2007, a review article published in the Lancet journal by Learmonth et al. described THA as the operation of the century.[3] Since the last 5 decades, THA is improving the quality of life of patients with end-stage hip arthritis. Primary diagnosis in young patients tends to differ than in older patients. Out of 20,000 total hip arthroplasties registered with the Indian Society of Hip and Knee Surgeons, more than 30% of patients are younger than 40 years of age at the time of primary THA. Many of these younger patients will receive revision hip arthroplasty before the age of 50 years. Avascular necrosis of the femoral head is the cause for nearly half of the hip arthroplasties in India. During the pandemic of novel coronavirus 2019, many young patients who survived COVID-19, developed steroid-induced avascular necrosis of the femoral head, and more than 5% of individuals receiving high-dose steroids were developing changes of avascular necrosis of the femoral head of varying degrees.[4],[5],[6] Majority of the patients in this subgroup were younger. Hartofilakidis and Lampropoulou-Adamidou published in March 2022, about 11 cases of THA that survived 40 years or more, concluding that THA can last for life for young patients also.[7]

The most common cause of revision THA in our cohort was aseptic loosening. In 2020, the annual report of the American Joint Replacement Registry shows the most common causes to be infection and instability.[1] Aseptic loosening is due to polyethylene wear and osteolysis associated with that, and that may be the reason for more frequency of aseptic loosening in younger patients undergoing THA, as younger patients are known to be more active than older patients.[8],[9] Patients having inflammatory arthritis tend to be less mobile than other patients due to the more common involvement of other joints.[2] Bergmann et al. identified many high-lading activities that can result into early loosening.[8] Manley et al. reviewed 377 patients under the age of 50 years requiring revision THA, and have advised that in the early postoperative phase, younger patients should avoid high-loading activities.[10] Advice of putting extrascrews for the uncemented acetabular shell fixation is also not shown to be effective at medium-term follow-up. Quality of polyethylene used in primary total hip arthropasty was not known for most of the cases. Hence, that can confound our results. While using conventional polyethylene, the wear rate tends to be higher for younger patients. However, recent studies have shown improvement in wear rate in young patients also with the use of highly cross-linked polyethylene.[11] Our study did not show a significant difference between cemented, cementless, and hybrid THA survival, but a recent review of the New Zealand Joint Registry shows that cemented arthroplasties are having longer survival in patients younger than 40 years of age.[12] While study by Kim et al. showed no significant difference in survival of cemented and cementless THA survival in young patients up to 25 years of follow-up.[13] Periprosthetic joint infection is reported to be a major cause of revision of THA in patients with inflammatory arthritis, but in our cohort, there was no significant relationship between having inflammatory arthritis as a primary diagnosis and infection as a cause of revision.[14] Only 5 out of 15 patients were revised due to infection.

Limitations

This study is of limited value in determining the causes of failure of THA, because we have included patients coming to our hospital only, which comprised various types of implants used. Exact data about polyethylene liners were missing. The study was very low powered to determine any effect of receiving of steroids or biologics in the case of inflammatory arthritis patients. We did not have a comparison group and the study was retrospective, and the sample size was very low. Further prospective cohort studies for longer duration will be more determining for the causes of failure after THA.


  Conclusions Top


Although statistical significance is not found, the data suggests aseptic loosening is more common in patients younger than 50 years; while infection, instability, and periprosthetic fractures are less common than in the general population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Springer BD, Levine BR, Golladay GJ. Highlights of the 2020 American joint replacement registry Annual report. Arthroplast Today 2021;9:141-2.  Back to cited text no. 1
    
2.
Schmalzried TP, Szuszczewicz ES, Northfield MR, Akizuki KH, Frankel RE, Belcher G, et al. Quantitative assessment of walking activity after total hip or knee replacement. J Bone Joint Surg Am 1998;80:54-9.  Back to cited text no. 2
    
3.
Learmonth ID, Young C, Rorabeck C. The operation of the century: Total hip replacement. Lancet 2007;370:1508-19.  Back to cited text no. 3
    
4.
Agarwala SR, Vijayvargiya M, Pandey P. Avascular necrosis as a part of 'long COVID-19'. BMJ Case Rep 2021;14:e242101.  Back to cited text no. 4
    
5.
Snowden GT, Clement ND, Zhang S, Xue Q, Simpson AH. Orthopaedic long COVID – The unknown unknowns: Are we facing a pandemic of avascular necrosis following COVID-19? Bone Joint Res 2022;11:10-1.  Back to cited text no. 5
    
6.
Banerjee I, Robinson J, Sathian B. Corticosteroid induced avascular necrosis and COVID-19: The drug dilemma. Nepal J Epidemiol 2021;11:1049-52.  Back to cited text no. 6
    
7.
Hartofilakidis G, Lampropoulou-Adamidou K. The operation of the century almost half-century later. Report of eleven total hip replacements survived 40 years and more. Acta Orthop Traumatol Hellenica 2022;3:2-8.  Back to cited text no. 7
    
8.
Bergmann G, Bender A, Dymke J, Duda GN, Damm P, Physical activities that cause high friction moments at the cup in hip implants. JBJS 2018;100:1637-44.  Back to cited text no. 8
    
9.
Cherian JJ, Jauregui JJ, Banerjee S, Pierce T, Mont MA. What host factors affect aseptic loosening after THA and TKA? Clin Orthop Relat Res 2015;473:2700-9.  Back to cited text no. 9
    
10.
Manley MT, Capello WN, D'Antonio JA, Edidin AA, Geesink RG. Fixation of acetabular cups without cement in total hip arthroplasty. A comparison of three different implant surfaces at a minimum duration of follow-up of five years. J Bone Joint Surg Am 1998;80:1175-85.  Back to cited text no. 10
    
11.
Babovic N, Trousdale RT. Total hip arthroplasty using highly cross-linked polyethylene in patients younger than 50 years with minimum 10-year follow-up. J Arthroplasty 2013;28:815-7.  Back to cited text no. 11
    
12.
Boyle AB, Zhu M, Frampton C, Vane A, Poutawera V. Comparing uncemented, hybrid and cemented primary total hip arthroplasty in young patients, a New Zealand joint registry study. Arch Orthop Trauma Surg 2022;142:2371-80.  Back to cited text no. 12
    
13.
Kim YH, Park JW, Jang YS. The 22 to 25-year survival of cemented and cementless total knee arthroplasty in young patients. J Arthroplasty 2021;36:566-72.  Back to cited text no. 13
    
14.
Cordtz RL, Zobbe K, Højgaard P, Kristensen LE, Overgaard S, Odgaard A, et al. Predictors of revision, prosthetic joint infection and mortality following total hip or total knee arthroplasty in patients with rheumatoid arthritis: A nationwide cohort study using Danish healthcare registers. Ann Rheum Dis 2018;77:281-8.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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