Long-term results of cemented total hip arthroplasty in patients younger than 30 years and the outcome of subsequent revisions.

0.39 MB·English

by  Schmitz, Marloes WJL

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RESEARCH ARTICLE Open Access
Long-term results of cemented total hip
arthroplasty in patients younger than 30 years
and the outcome of subsequent revisions
Marloes WJL Schmitz1, Vincent JJF Busch1, Jean WM Gardeniers1, Jan CM Hendriks2, René PH Veth1
and B Willem Schreurs1*
Abstract
Background: The number oftotal hip arthroplasties inpatients under 30 years is increasing over theyears. Almost
allof them will face atleast one or more future revisions in their life. Therefore, theimplant used should have a
high survival rate, and needs to be easilyrevisable resulting in a low re-revisionrate. Several studies have evaluated
theoutcome of total hip arthroplasties in patients under 30 years. However,only a few reported onthe follow-up
outcome of10 years or more.In addition, none ofthesereports published data ofthesubsequentrevisions of
theseimplants within their original report.
Methods: We studied historically prospective collected data of48 consecutive patients (69 hips) younger than
30 years, treated with a cemented primary total hip prosthesis between 1988 and 2004. Since thelast evaluation of
this cohort, two patients were lost to follow-up. For allhip revisions in this cohort, again cemented implants were
used, mostlyin combinationwith bone impaction grafting. Kaplan-Meier survival curves at10- and 15 years for the
primary total hip arthroplasties and revisionswere determined.
Results: The mean age attime of primary surgery was 25 years (range, 16 to 29 years). Mean follow-up of the
primary hips was 11.5 years (range, 7 to 23 years). During follow-up 13 revisions were performed;in 3cases a
two-stage total revision was performed for septic loosening and 9cups were revised for aseptic loosening. There
were no aseptic stemrevisions. The 10 and 15-year survival rates with endpoint revision for aseptic loosening of the
primary total hip were 90%(95%CI: 79 to 96) and 82% (95% CI: 65 to 92) respectively.None of our 13 subsequent
revisions needed a re-revision within 10 years after re-implantation.
Conclusions: Cemented total hip implants inpatientsunder 30 years have an encouraging outcome at 10 and
15 years after surgery inthese young patients. The 13 revised hips, treated with bone grafting and thethird
generation cement technique, were performing well withno re-revisions within tenyears after surgery.
Keywords: Total hip arthroplasty, Impactionbone grafting, Young, Revision THA,Cement, Bone, Hip
Background different success rates [1-22]. Obviously, in these very
The number of total hip arthroplasties in very young young patients it is important to use total hip implants
patients isrising.Different solutionsto treat these young with a proven long-term outcome [23]. Additionally, we
patients with secondary osteoarthritis have been used havetokeepinmindthattheseyoungpeople willinevit-
over the last decade. Non-cemented, cemented, hybrids, ably face one or more revisions in their life, due to their
metal-on-metal total hip arthroplasties and resurfacing longer life expectancy. As a result, the implant used
prostheses all have been used in young patients, with should have an acceptable and reliable long-term clinical
outcome and it needs to be easy revisable without creat-
ing a bone stock defect. Both survival of the primary
*Correspondence:[email protected]
1DepartmentofOrthopaedics,RadboudUniversityNijmegenMedicalCentre, THA and subsequent revision THA are important out-
InternalPost357,POBox9101,Nijmegen,HB6500,TheNetherlands come measurements in these young patients. So far, only
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a few reports present long-term results of total hip Methods
arthroplasties in patients under 30 years and none In2011,ataminimumfollow-upof7years(7to23years),
present the outcomes of the first revision THA’s in the we performed a historical prospective study on 48 con-
same cohort (Table1). secutive patients (69 hips) younger than 30 years, who
Although cemented total hip implants are not com- received a primary cemented total hip arthroplasty be-
monly used in young patients, we have always used tween April 1988 and May 2004. All indications except
cemented total hips in all ages, including patients reconstructions for tumors were included. There was no
younger than thirty years. Furthermore, we have one es- selection bias as we used cemented total hips in all cases.
sential addition in young patients: in case of substantial The group consisted of 32 female (46 hips) and 16 male
acetabular bone stock deficiencies, we have reconstructed patients (23 hips). The mean age at surgery was 25 years
this bone stock loss using impaction bone grafting (IBG). (range, 16 to 29). Four patients (6 hips) died during
In these young patients, secondaryosteoarthritis resulting follow-up of causes not related to their hip surgery. The
from underlying diseases is often seen in combination mean age during surgery of these 4 patients was 24 years
with associated loss of the acetabular bone stock (e.g. in (range, 20 to 26). Their mean follow-up until death was
developmental dysplasia of the hips and juvenile rheuma- 9 years (range, 1 to 18). None of them was revised be-
toidarthritis).Thishampersanoptimalinsertionandfixation fore death and all of them were followed up to their
of the cup. We believe that IBG for the reconstruction of death ona regular base. Therefore,weincluded all their
acetabular bone stock deficiencies in young patients is data. Two patients (3 hips) were lost to follow-up since
a biologically attractive approach, which restores bone our first evaluation of this cohort, including one patient
stock already before the inevitable future revision [17]. with 2 THA’s after 3.5 years of follow-up of both hips
In all revisions we applied the same philosophy of and one patient with one THA after 11 years [17].
using IBG on the acetabular side with a cemented cup. Their data were included in the study up to their latest
In case of femoral bone stock loss, femoral grafting was clinical and radiographic control. Table 2 lists the
performed as well in order to achieve a durable recon- indications for theTHA in all patients.
struction [24]. In all cases, a posterolateral approach without a
The purpose of the current study is to present the clin- trochanteric osteotomy was used. Although we used dif-
icalandradiographicalresultsof69consecutivecemented ferent implants over the years, all of them were fully
total hip arthroplasties in 48 patients less than 30 years cemented (Table 3). All cups were made of conventional
old after a mean follow up of more than 10 years, polyethylene and only cobalt-chrome femoral heads of
reporting the survival data with endpoint revision for any 22 mm (9 hips), 28 mm (49 hips) and 32 mm (11 hips)
reason,asepticloosingandradiologicalfailure.Inaddition were used. Up to 1990, all femoral components were
to the results of the primary total hip arthroplasties, the inserted usinga second-generation cementing technique,
current state of our revisions and re-revisions within this while from 1990 onwards the third cementing technique
group after the primary total hip arthroplasty will be was used. Palacos cement was used until 1989 (Merck,
assessed. Results will be compared to results of similar or Darmstadt, Germany); from 1989 on we used Surgical
othertechniquesfoundintheliterature. Simplex(Stryker-Howmedica,Newburry,UK).Antibiotics
Table1CharacteristicsandsurvivorshipofTHAinpatients30yearsoryoungerattimeofoperationwithamean
follow-upofmorethantenyearsinliteratureuptoMarch2011
Study Nohips No Meanageinyears Meanfollow-upinyears Survivorship/revisedhipsforall
patients (range) (range) reasons
Cemented
Cageetal.[4] 29 17* 18.4(15–21) 10.6(8–15) 1revisionat11yrs
Chmeletal.[7] 66 39 19.9(11–29) 15.1(11–22) 70%at15yrs(acetabularrevision)
SochartandPorter[8] 83 55 24.9(17–29) 20(5–30) 89%at10yrs;65%at25yrs
Torchiaetal.[6] 63 50 17(11–19) 12.6(1.6-18.6) 27revisions#
Wittetal.[3] 96 54 16.7(11–27) 11.5(5–18) 24(25%)ataverage9.5yearsfollow-up
Wroblewskietal.[18] 39 28 17.9(12–19) 12.6(2.3–29.0)fornon-revision 16revisionsatmean19.1yrs(8–34)
(currentstudy) 69 48 24.6(16–29) 11.3(2–23.4) 86%at10yrs;75%at15yrs
Uncemented
Wangenetal.[16] 49 44 25(15–30) 13(10–16) 24revisionsofacetabularcomponent#
*mixedgroupofpatientswithtotalhipandtotalkneeprosthesis.
#atmeanfollow-up.
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Table2Indicationfortotalhiparthroplasty(n=69) 1999, oral anticoagulants were prescribed for 3 months
Indication Numberof according to our previous postoperative protocol. Indo-
hips methacin was administered for 7 days to prevent
Juvenilerheumatoidarthritis 18 heterotopic ossification. Alternatively, one dose (7 Gy)
Osteonecrosisoffemoralhead 21 of radiotherapy was given, when indomethacin was
contraindicated. Patients without a defect or a simple
Systemiclupuserythematosus 7
minor cavitary defect were mobilized under the super-
Acutelymphaticleukemia 3
vision of a physiotherapist two days after surgery. In
Crohn’sdisease 3
case of extended reconstructions, 10% touch weight
Nepropathy,kidneytransplantation 2 bearingwithcrutcheswasallowedfor6weeks,followed
Hypothalamicdisorder 1 by 50% touch weight bearing for another 6 weeks, be-
Aplasticanemia 1 fore full weight bearing was allowed. In case of very
Wegener’sdisease 1 extensive acetabular reconstructions, e.g. severe pelvic
dislocation and high dislocation, patients initially had a
Unknownorigin 3
six-week period of bed rest to achieve full graft incorp-
Developmentaldysplasiaofthehip 7
oration before starting mobilization.
Multipleepiphysealdysplasia 2 The antero-posterior pelvic and lateral hip radiographs
Legg-Calvé-Perthesdisease 6 of all hips were analysed on a consensus basis by two of
Ankylosingspondylitis 5 the authors (MWJLS and BWS). Follow-up radiographs
Morquio’sdisease 2 were complete for all hips, except for the two patients
lost to follow-up. Graft incorporation was determined as
Ankylosisofunknownorigin 2
the manifestation of a regular radiodensity and trabecu-
Polycysticdiseaseofthefemoralheadofunknown 2
lar bone structure throughout the graft and host bone
origin
with a continuous trabecular pattern according to Conn
Arthritisandosteomyelitits 2
et al. [27]. Radiolucent lines were described if they were
Posttraumaticosteoarthritis 1 more than 2 mm wide and were defined as stable or as
Psoriaticarthritis 1 progressive lines in time. The criteria of DeLee and
Charnley were used to identify acetabular zones [28].
(cefazolin) were given during a maximum of 24 hours Radiographic failure was defined as radiolucent lines in
postoperativelytopreventinfections. all three zones and/or migration of 5 mm or more in
In case of bone stock deficiency during the primary any direction on the AP-pelvic view relative to the
procedure, we used the IBG technique to reconstruct interteardrop line. The classification of Brooker et al. was
acetabular defects (29 hips) (Figure 1 and 2). This tech- used to describe heterotopic ossification [29].Polyethylene
nique has been described in the literature in detail be- wear was calculated using the method of Dorr and Wan
fore [17,25]. Acetabular defects were classified according [30].Onthefemoralside,theGruenclassificationwasused
to the classification system of the American Academy of to determine radiolucent zones [31]. Femoral prosthetic
Orthopaedic Surgeons (AAOS) Committee on the Hip subsidence was considered if it was more than 2 mm [32]
[26]. In 5hips aType Idefect was present. AType IIde- while definite loosening of the stem was defined as the
fect was seen in 16 hips and aType III defect in 8 hips. appearance of a radiolucent line in all Gruen zones that
In 23 hips, femoral head autografts were used, whereas did not exist on the immediate postoperative radiographs,
fresh-frozen nonirradiated femoral head allografts were orasacrackinthecementorfractureofthestem[33].
used as a source for bone chips in 3 hips with aType III The Harris Hip Score and Oxford Hip Score were
defect. In another 3 hips, both autografts and a fresh determined at each follow-up visit to evaluate clinical
frozenallograftfemoralhead were used. results,asweretheVASscores(onascaleof1to100)for
Postoperatively, patients were treated with subcutane- pain during rest and activity as well as theVAS score for
ous low-molecular-weight heparin for 6 weeks. Before satisfactionaboutthehipfunction(onascaleof1to100).
Table3Typesofimplant
Typeofacetabularimplant Numberofhips Typeoffemoralimplant Numberofhips
MüllerW/AlloproWcup 14 M.E.MüllerWstraightstem 11
Elite™PlusLPW 26 CharnleyElite(Plus)stem™ 13
Exeter/Contemporary™ 29 ExeterStem™ 45
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Figure1In29ofthe69cases,apre-operativebonestockdeficiencyontheacetabularsidewaspresent,whichwasclassified
accordingtotheAAOSclassificationandtreatedwithacementedTHAandIBG.
Cemented total hip arthroplasties with acetabular IBG Kaplan-Meier survival analysis was performed for the
were used in al revision procedures. In case of femoral revisions in our group. HHS and OHQS, as well asVAS-
bonedeficiency,weperformedfemoralIBG [34]. scores were also calculated for the revised total hip
For this study, no ethical approval was required by the arthroplasties. All calculations were made with SPSS
localethicalcommittee. 18.0.2andSASforWindows9.2.
Statisticalanalysis Results
Kaplan-Meier survival analysis were used to determine Clinicalresults
the survivorship of the primary hip implant for the Mean duration of follow-up of all 69 primary total hips
endpointsrevisionofone orbothcomponents for1)any was 11.5 years (range, 7 to 23 years). During follow-up,
reason, 2) aseptic loosening and 3) radiographic failure. 5 patients died (7 hips), two patients were lost to
In addition to analysis for the total group, hips with and follow-up (3 hips) and 13 hips were revised for several
withoutacetabularIBGwerealsoanalysedseparately.The reasons. The average pre-operative HHS score was
HHSandOHQSwereevaluatedin3categories:1)after2 47.0 (range 15 to 81) (n=30), and the average pre-
to 5 years follow-up, 2) after 5 to 10 years follow-up and operative OHQS was 43.2 (range 34 to 52) (n=9). At
3) after more than 10 years follow-up. A‘last observation review the mean HHS of the 49 surviving hips was
carriedforwardanalysis’ wasdonetodeterminethemean 88.3 (n=48) (range 55 to 100) and the mean OHQS
HHS and OHQS scores for the total group of surviving was 17.5 (range, 12 to 34) (n=49) after a mean follow-
hips.VASscoresregardingpaininrest,painduringactiv- up of 11.6 (range 3.0 to 22.0). The mean VAS score for
ityandoverallsatisfactionweredetermined.Inadditionto pain in rest and during activity on a scale from 0–100
the results of our primary total hip arthroplasties, a after a mean follow-up of twelve years were 5.5 and
Figure2Acetabularreconstructionina27-year-oldwomanwithsecondaryosteoarthritisduetocongenitalhipdysplasia.Preoperative
(A),immediatelypostoperative(B),and12yearspostoperative(C).
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16.0, respectively. VAS score for overall satisfaction radiographic characteristics found in the 56 non-revised
was 88.8. totalhiparthroplastiesareshowninTable5.
Revisionsandcomplications Survivorshipanalysis
Three total revisions for septic loosening were performed Regarding the endpoint revision for any reason of both
at 4.8, 5.7 and 6.1 years after the index surgery. All cup and stem, the 10-year survival rate for the primary
were treated with a two stage treatment protocol and total group was 86% (95% CI: 74 to 92 ) and the 15-year
all components were exchanged. One patient, originally survival rate was 75% (95% CI: 59 to 86) (Table 5). For
planned for a one-stage cup revision after 13 years for endpoint revision for aseptic loosening, the 10- and
aseptic loosening had positive cultures at revision, 15-year survival rates for the total group were 90%
suggesting septic loosening. This patient was treated (95%CI:79to96)and82%(95%CI:65to92),respectively
during 3 months with antibiotics and despite partial re-
Table5Radiographiccharacteristicsof56primarytotal
vision, no relapse occurred. Nine cups had been revised
hiparthroplastypatientsthatwerenotrevisedatlast
because of aseptic loosening at 2.3, 3.0, 4.1, 4.9, 7.6, 8.6,
follow-up
13.6, 14.3 and 23.6 years. Except for the three stems
Radiographiccharacteristics
revised for septic loosening, no additional stems had
failed. One highly polished stem had to be exchanged Acetabularradiolucentlines 18
for a same size stem using the cement in cement tech- Progressive 6
nique during a cup revision due to damage to the taper Stable 12
causedduringthatcuprevision.Thiscasewasscoredasa
Osteolysis 9
re-operationbutthisstemexchangeisnotconsideredasa
ZoneI 3
stemfailure.
ZoneII 3
In addition to these revisions mentioned, one early re-
operation after a primary THA was necessary due to a ZoneIII 2
suspected infection. The patient recovered after débride- ZoneI+II 1
ment and antibiotic therapy without implant revision. Socketmigration -
Two early dislocations were seen. In one case an open
Progressivetiltingofthecup -
reduction was needed. One partial femoral nerve deficit
PAO’s 13
was seen, and despite surgical release, recovery was
BrookerclassII 9
incomplete. One periprosthetic fracture, type Vancouver
B1 occured, fifteen years after the primary surgery for BrookerclassIII 4
which open reduction and internal fixation was necessary Polyethelynewear>2mm 3
without exchange of the implant. Other complications Femoralradiolucentlines 3
andtheiroutcomesarelistedinTable4.
Zone7 1
Zone3and5 1
Radiographicresults
6outof7zones 1
Radiolucent lines around the cup were observed in 18 of
the 56 surviving hips, which were progressive in 6 hips. Roundingoffofthecalcar 8
Osteolysis was seen in different zones on the acetabular Corticalatrophy 2
sideas wellas onthefemoral side. The completedetailed Zone4 1
Zone7 1
Table4Complicationsofthe69primarytotalhip
arthroplasties,excludingthe13revisions Corticalhypertrophy 5
Complications N Outcome Zone3 1
Earlyreoperationdueto 1 Fullyrecovered Zone4 3
suspicionofdeepinfection
Zone5 1
Dislocation 2 Onesuccessfulclosedreduction,
Osteolysisoffemoralcomponent 7
howeveronedislocationinamulti
traumapatientneededsurgical Zone1 1
reduction
Zone4 1
Neurologicaldeficit 1 Femoralnerveexploration→
Zone5 1
incompleterecovery
Zone7 1
PeriprostheticFracture 1 Plateosteosynthesiswithcablegrip
VancouverB1 platesystem.Norevisionofthe Zone1and7 4
implant
Note:multipleradiographiccharacteristicsperpatientarepossible.
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(Table 6 and Figure 3). Of the 9 revisions for aseptic
loosening, 7 were primary cemented hips without IBG
while there were only 2 revisions in the IBG group. The
15-year survival rate for the primary cemented hips was
80% (95% CI: 60 to 91) for endpoint aseptic loosening,
whereasthiswas86%(95%CI:48to97)forthetotalhips
that were combined with IBG group. This was not
statistically different (p=0.30). Survival curves for each
type of implant separately did not show any significant
differences.
Outcomeofthethirteenrevisions
All 13 failed primary hips were revised in our institution
andthereasonsforrevisionhavebeenexplainedpreviously.
In all 3 septic loosenings, acetabular bone impaction
grafting and a cemented implant was used in the second Figure3KaplanMeierestimatedsurvivalofthetotalofsixty-
ninehipsregardingendpointrevisionforasepticloosening.
stage.Additionally,in2ofthestemrevisionsfemoralbone
impaction grafting was used. No relapse of infection oc-
curred.Inthe9isolatedcuprevisions,acetabularboneim- patient post-operatively experienced problems of the
paction was used in combination with a cemented cup. In femoral nerve which influences his activity and pain
one case the new cup was simply re-cemented. The 12 scores. This explains the differences of the HHS and
defects seen on the acetabular side were five segmental OHQS scores between the primary and revision total
defects(AAOStypeI),twocavitarydefects(AAOStypeII) hip arthroplasties. VAS scores of the twelve patients
and five combined defects (AAOS type III). All of the seg- after revision for pain during rest and activity were 11.7
mental defects were reconstructed using a wire mesh. Of (range, 0–80) and 36.7 (range, 0 to 100), respectively.
the cavitary defects, one did not need any mesh while the Themean VASsatisfactionscorewas68.3(0to100).
otherwasreconstructedwithamedial and arimmesh.Of The Kaplan Meier survival curve of our revisions with
thecombineddefects,2receivedonlyarimmeshandthree endpoint revision for any reason showed a 100% survival
received both a rim and a medial mesh. The mean follow- at10years.
up of the 13 revisions after the surgery was seven years
(range, 1 to 15 years). Remarkably, the only re-revision in Discussion
this study was performed 13 years after cup revision with- Very young patients with osteoarthritis of the hip are
out acetabular bone impaction grafting. One patient had a still a challenge for orthopaedic surgeons. Frequently,
partial lesion of the femoral nerve after a cup revision, due to the underlying pathology, an acetabular bone
whichrecoveredpartiallywithoutanyinvasivetreatment. stock deficiency in this group is seen. Often large sized
Of the twelve non re-revised cups, we collected the cups are used in order to cover this defect, without re-
postoperativeHHSandOHQSafter ameanfollow-upof storing the bone stock. However, in these younger THA
7 years (range, 0.5 to fifteen years), which were 82.7 patients,futurerevisionswillbeinevitable. Itistherefore
(range 49 to 100) and 22.3 (range 12 to 52), respectively. of extreme importance to create an optimal bone stock
Further analysis of these scores revealed that two situation in order to prepare future (re)-revisions. We
patients had strikingly disappointing HHS and OHQS have described both the technique and outcome of the
scores. One of the patients has a history of sclerodermia, reconstruction of acetabular defects with IBG in young
M. Crohn, and recently received a stoma. The second patientsuptotheageof50before[25,35,36].
Table6The10-yearand15-yearssurvivorshipwiththe95%confidenceintervals(CI)forthethreeendpoints(revision
foranyreason,revisionforasepticloosening,radiographicfailure)ofthe69hipsincluding29totalhiparthroplasties
withimpactionbonegrafting(IBG)and40primarycementedtotalhiparthroplasties
Categoryofpatients Proportionrevisionfreeforany Proportionrevisionsfreefor Proportionfreeofradiographic
reason asepticloosening failure
10-year(95%CI) 15-year(95%CI) 10-year(95%CI) 15-year(95%CI) 10-year(95%CI) 15-year(95%CI)
Allhips(n=69) 86%(74to92) 75%(59to86) 90%(79to96) 82%(65to92) 90%(80to96) 82%(65to92)
Primarycementedhips(n=40) 81%(64to91) 71%(50to84) 86%(70to94) 80%(60to91) 86%(70to94) 80%(60to91)
AcetabularIBG(n=29) 93%(74to98) 83%(49to95) 96%(77to99) 86%(48to97) 96%(77to99) 86%(48to97)
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Although it is not very common in young patients, we revisions and one cup revision), are speculative and
have always used cemented total hip arthroplasties and probably multifactorial. Two of our aseptic failures
cemented revisions in this young population. Further- experienced a fall that could have caused accelerated
more, we used bone grafts in all cases with bone stock loosening.
loss, thereby facilitating a biological reconstruction. Our Onecupthatwaspartofatotalhiparthroplastyrevision
10 year Kaplan Meier estimated survival for endpoint for septic loosening performed thirteen years earlier was
aseptic loosening of 90% (95% CI: 79 to 96) is within the re-revised.Allothertwelverevisedhipswerereconstructed
NICE criteria [37]. Our 15 year estimated survival of ontheacetabularsidewithIBG.Allofthemarestillinsitu
82% is still acceptable in these very young patients but and none of them show radiographic loosening. No
needstobemonitoredcloselyoverthenext years. femoral revisions for aseptic loosening were performed,
At review of the literature in March 2011, there was emphasizing the good results of the cemented femoral
only limited literature available regarding the survival component in this specific young population. The 100%
and complications of a total hip arthroplasty after a survival of our revisions at ten-year follow-up is a
mean follow-up of 10 years or more in patients under promising result for young people. The outcome of the
30 years. None of the reports included the outcome of primary prosthesis and the subsequent revision out-
their revisions in the same report as well. It should be come are equally important to determine the best solu-
noted that for young patients both outcome of the pri- tion in young patients.
mary and revision THA, are equally important. More- IBGwasassociatedwithattractivesurvivalresultsboth
over, we assume that the outcome of the revision THA in primary THA and revisions. Of the 9 primary total
can be influenced by the primary THA procedure. Our hip arthroplasties that needed a revision for aseptic
results are at least comparable to the cohorts treated loosening, only 2 had received IBG. The results as
with a cemented THA, mentioned in Table 1. Compared shown in Table 5 clearly outpoint a trend that IBG
to the studies reporting on cohorts of the same size shows better results compared to non-IBG. Even after
there seems to be a trend that the survival rates we ob- 15 years of follow-up,the survival rate for endpoint revi-
tain by using the biological IBG technique are more sion for any reason is still 83% (95% CI: 49 to 95) and
favourable, as can be seen in Table 1. For the non- foraseptic looseningeven86%(CI: 48to97).
cemented total hip arthroplasty, only Wangen et al. [16] The number of hips in this study is acceptable with a
reported the survival rates in patients less than 30 years regarding the longterm follow-up. In addition, the out-
old after a mean follow-up of more than 10 years. They come of all revisions is known. In all patients, the same
reported 24 acetabular revisions in 49 hips at a mean philosophy was used. As a referral centre we have
follow-up of 13 years. McCullough et al. reported the included all indications except oncologic cases, which
survival rates in patients with a mean age of 24 years makes this an unique cohort. However, this study has
(range, 11 to 35) and showed a survival rate for the some limitations. First, two patients were lost to follow-
THA of 71% at 13 years [13]. Both these studies do not up. Often patients lost to follow-up are presented as
equal our satisfying long-term survival rates. Over time, censored cases. But as described by Murray, this might
othertechniquesliketheresurfacingprosthesisandlarge underestimate the revision rate [41]. Secondly, several
head metal-on-metal THA, have been introduced to different implants are used in our relatively small group
treat young people with osteoarthritis. Unfortunately, of patients, however, all were cemented and all patients
theresurfacing prosthesishasshownitslimitations,even were treated in the same way according to our protocol.
before a large number of long-term follow-up studies Survival curves for each type of implant separately
were finished [38]. A higher revision risk for younger fe- showed no significant differences, and two of the
male patients is observed, possibly related to their lower components are still widely used (Exeter and Müller,
neck-head ratio, restricting the indications to younger Table 2) [42]. Furthermore, when reporting on surgery
males [39]. Furthermore, the formation of pseudotumors performed over a period of time, the use of different
and elevated ion levels which have been described for implants is almost inevitable. One can argue that 26 of
largeheadMetal-on-MetalTHAaswell,causelimitations our patients were treated for rheumatic diseases and
totheapplicationofthesetypesofarthroplasties[40]. therefore may be low-demand patients. However, most
The study of Girard et al. shows a very acceptable series on hip arthroplasty outcome in very young
10-year survival rate of 94.5% (95% CI: 80 to 98.6) for patients include a significant number of patients with
the non-cemented total hip arthroplasty with metal-on rheumatic disease. Lastly, it would be interesting to have
-metal bearings in patients younger than 30 years at more information about the activity level of all patients
time of surgery, but includes only 28 mm heads [22]. in addition to the collected HHS, OHS and VAS scores,
In our study we observed 13 revisions. Reasons for as these scores might not completely satisfactorily
failure, in addition to the 4 septic revisions (3 complete describe level and duration for sport activity etc. In
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Competinginterest
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thesubmittedarticle.
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MWJLSparticipatedinthedesignofthestudy,collectedthedataand arthroplastyinteenagepatients:theultimatechallenge.JBoneJointSurg
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JWMGcollectedinthedesignofthestudy,criticallyrevisedthedraftsand 19. ClohisyJC,OryhonJM,SeylerTM,WellsCW,LiuSS,CallaghanJJ,etal:
draftedfinalversionofthemanuscript.JCMHparticipatedinthedesignof Functionandfixationoftotalhiparthroplastyinpatients25yearsof
thestudyandperformedthestatisticalanalysis.RPHVparticipatedinthe ageoryounger.ClinOrthopRelatRes2010,468(12):3207–13.
designofthestudy,criticallyrevisedthedraftsanddraftedfinalversionof 20. RaphaelBS,DinesJS,AkermanM,RootL:Long-termfollowupoftotalhip
themanuscript.BWSparticipatedinthedesignofthestudy,draftedthe arthroplastyinpatientswithcerebralpalsy.ClinOrthopRelatRes2010,
manuscript,participatedinthecoordinationofthestudy.Allauthorsread 468(7):1845–54.
andapprovedthefinalmanuscript. 21. SimonJP,MaesM,RobbensE,BellemansJ:Totalhiparthroplastyin
inflammatoryarthritisinpatientsunder35years.A7to19yearfollow-
Authordetails up.HipInt2010,20(2):163–70.
1DepartmentofOrthopaedics,RadboudUniversityNijmegenMedicalCentre, 22. GirardJ,BocquetD,AutissierG,FouilleronN,FronD,MigaudH:Metal-on-
InternalPost357,POBox9101,Nijmegen,HB6500,TheNetherlands. metalhiparthroplastyinpatientsthirtyyearsofageoryounger.
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NijmegenMedicalCentre,P.O.Box9101,Nijmegen,HB6500,The 23. McAuleyJP,SzuszczewiczES,YoungA,EnghCASr:Totalhiparthroplasty
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doi:10.1186/1471-2474-14-37
Citethisarticleas:Schmitzetal.:Long-termresultsofcementedtotal
hiparthroplastyinpatientsyoungerthan30yearsandtheoutcomeof
subsequentrevisions.BMCMusculoskeletalDisorders201314:37.
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