Abstract
Background
The increasing number of THAs in younger patients will inevitably result in an increase of revision procedures. However, there is little evidence about the outcome of revision procedures in this patient group. Therefore, we updated a previous study conducted 5 years ago about the outcome of revision procedures in patients younger than 55 years.
Questions/purposes
We sought to provide a concise update on the previously reported (1) long-term failure rate as defined by repeat revision, (2) clinical outcome as defined by the Oxford Hip score and the Harris Hip score, and (3) radiographic outcome of cemented revision THA performed with impaction bone grafting on both the acetabular and femoral sides in one surgery in patients younger than 55 years old.
Methods
Between 1991 and 2007, we performed 86 complete THA revisions in patients younger than 55 years. In 38% (33 of 86) of revisions, bone impaction grafting was used on both the acetabular and femoral side because of acetabular and femoral bone stock loss. Mean age at time of revision was 46 ± 8 years. No patient was lost to follow-up, but six patients died during follow-up, including three since 2015. Still, the hips of all 33 patients were included in analysis at a mean of 17 ± 5 years. Failure was calculated using competing risk analysis. For clinical outcome, we assessed the Harris Hip score and the Oxford Hip score from our longitudinally maintained institutional database. Radiographic analysis was performed to evaluate radiographic loosening, defined as radiolucencies ≥ 2 mm in all zones or ≥ 5 mm migration for both components. The acetabular component was also considered loose with tilting ≥ 5°
Results
The 15-year failure rate of revision THA was 27% (95% CI 13 to 44) for re-revision of any component for any reason and 10% (95% CI 3 to 25) for re-revision of any component for aseptic loosening. The mean Harris Hip score increased from 55 ± 18 preoperatively to 74 ± 22 at latest follow-up. Eight cups were considered radiographically loose, seven of which were re-revised. No stems were considered radiographically loose. Failure rate with endpoint radiographic loosening at 15 years was 23% (95% CI 10 to 39).
Conclusion
We found that impaction bone grafting with a cemented cup and a cemented stem is a valuable biological revision technique that results in a stable and durable solution, after one or even multiple previous revision THAs. Although current implants may prove sufficient in most cases, they do not promote bone stock preservation. We believe that in young patients with bone stock loss, impaction bone grafting can be used as long as the defect can be contained adequately with a metal mesh and viable bone bed is available for revascularization.
Level of Evidence
Level IV, therapeutic study.
Introduction
The number of THAs in patients younger than 55 years is increasing each year [12, 17]. Consequently, an increase in revision hip arthroplasty in younger patients can be expected. Unfortunately, data on survivorship of revision hip arthroplasty performed in patients younger than 55 years is limited, and the data available are not encouraging [1, 8, 10, 14]. The only study reporting the long-term survivorship after revisions in these patients of which we are aware shows a disappointing outcome of 63% at 10 years and 47% at 15 years with an endpoint of re-revision for any reason [14].
The management of bone loss remains a considerable challenge in revision hip surgery and is especially true for young patients facing a revision. These patients still have a long life expectancy after their index primary hip arthroplasty and may undergo several revision procedures. Restoring bone stock may facilitate these further revisions. Impaction bone grafting is a biological reconstruction technique—first described in 1984 by Slooff et al. [22] for the acetabulum and in 1993 by Gie et al. [6] for the femur—which aims to restore these bone stock defects, resulting in a stable construct remaining present over time. Multiple centers have reported satisfactory results, with up to 30 years of follow-up on the acetabular side [2, 4, 7, 19, 24] and 20 years on the femoral side [5, 13, 16, 23, 24]. In a previous study from our center, te Stroet et al. [24] reported on the outcome of 34 revision hip surgeries in 33 patients who underwent revision when they were younger than 55 years. All patients underwent a total revision, receiving both acetabular and femoral bone impaction grafting in one surgery. In that time, mean follow-up was 12 ± 4.6 years. The 10-year survival of revisions with the endpoint of re-revision of any component for any reason was 87%, the survival of revisions with the endpoint of re-revision of any component for aseptic loosening was 97%. Because of the lack of long-term data of hip revisions performed in younger patients, we wished to update the previous study [24].
In this follow-up report, we specifically sought to determine: (1) the long-term risk of re-revision, (2) the clinical outcome as expressed by Harris Hip Score and (3) the risk of radiographic loosening, defined as radiolucencies ≥ 2 mm in all zones or ≥ 5 mm migration for both components of cemented revision THA performed with impaction bone grafting on both the acetabular and femoral sides in one surgery in patients younger than 55 years old.
Patients and Methods
The update of the study was approved by our institutional review board.
All patients were followed as part of a longitudinally maintained institutional database, and the data were retrospectively analyzed. For detailed information on patients and methods, we refer to the previous publication [24]. Briefly, between 1991 and 2007, we performed 86 complete THA revisions in patients younger than 55 years. In 40% (34 of 86) of these revisions, impaction bone grafting was used on both the acetabular and femoral sides. In these revision procedures, the surgeon decided intraoperatively to perform impaction bone grafting, as bone stock at both the acetabular and femoral sides was not sufficient for primary fixation without impaction bone grafting. One revision was excluded as the bilateral revised hip of this particular patient was already included. Therefore, 38% (33 of 86) of hips were included in this update (Fig. 1). At the time of our last review, no patient was lost to follow-up with regard to the risk of failure. During study follow-up, six patients died (three additional deaths since our latest report [24]). No deaths were related to the surgery and the results of these six patients were included in the final analyses.
Fig. 1.
A flowchart of the outcome of all patients is shown here.
The mean age of the 19 women and 14 men at the time of revision was 46 ± 8 years. The indication for revision was aseptic loosening of both components in 19 hips, septic loosening in 14, and one patient also had stem malposition with aseptic cup loosening. In all cases, both acetabular and femoral bone stock loss was present, which was treated with impaction bone grafting on both the acetabular and femoral sides. Both cup and stem were cemented in all cases. Of the 14 hips revised because of septic loosening, 12 were revised with a two-stage procedure.
The current update of these 33 complete revision THAs was performed in July 2019. The minimum follow-up for inclusion was 5 years. The mean follow-up of the surviving hips was 17 ± 5 years.
Bone stock defects have been classified on the acetabular side according to Paprosky et al. [18] (three Type 1, seven Type 2A, 14 Type 2B, three Type 2C, three Type 3A, and three Type 3B), and on the femoral according to Della Valle et al. [3] (seven Type 1, 17 Type 2, six Type 3A, one Type 3B and two Type 4). The surgical technique of impaction bone grafting of both the acetabulum and the femur has been described before [20, 21]. All femoral revisions were performed using the X Change femoral revision system (Stryker-Howmedica, Newbury, UK).
Primary and Secondary Study Outcomes
Our primary study outcome was the probability of re-revision. We assessed this by using competing risk analyses, with re-revision of any component for any reason and reoperation for any reason as an endpoint, where death was considered a competing event. Next, we determined the failure rate of revision procedures with the endpoint re-revision of any component for aseptic loosening, where death and other reasons for re-revision were considered competing events. Lastly, we determined specific cup- and stem failure for the endpoints of re-revision for any reason, re-revision for aseptic loosening, and reoperation for any reason. For all endpoints, the failure rate including 95% confidence interval was determined at 10-, 15- and 20-year follow-up.
Our secondary study outcomes were clinical and radiographic outcome. We assessed the clinical outcome by seeing all patients on a regular basis at our institution. An independent research assistant obtained all clinical and functional scores. We assessed the Harris Hip score (Harris Hip score: worst score 0, best score 100) [9] and the Oxford hip score (Oxford Hip score: worst score 0, best score 48) [15] to measure clinical outcome. The scores provided here were from the latest follow-up visit.
Radiographic loosening was defined as radiolucencies of ≥ 2 mm around the acetabular component in all three zones using the DeLee and Charnley classification, or migration of ≥ 5 mm, or tilting ≥ 5°. For the femoral component, we defined radiographic loosening as radiolucencies of ≥ 2 mm in all seven Gruen zones or subsidence of the femoral component of more than 5 mm. All radiographs were scored based on the consensus of two authors (TN, BWS). Using a competing risk analysis, we determined the failure rate with an endpoint of radiographic loosening; we considered death as a competing event.
Results
Failure Risk
In total, 11 hips were re-revised (compared with six re-revisions in our previous report) (Table 1). Competing risk analysis showed a risk of re-revision of any component for any reason of 27% (95% CI 13 to 44) at 15 years follow-up (Fig. 2A). The risk of re-revision of any component for aseptic loosening, was 10% (95% CI 3 to 25) at 15 years follow-up (Fig. 2B). In total, 12 hips underwent a reoperation (compared with nine in our previous report). The risk of reoperation for any component for any reason was 30% (95% CI 15 to 46) at 15 years follow-up (Fig. 2C). The risk of re-revision of the acetabular component with endpoint aseptic loosening was 10% (95% CI 3 to 25) at 15 years (Fig 3A). For the femoral component, the risk of re-revision with endpoint aseptic loosening was 4% (95% CI 0 to 16) at 15 years (Fig. 3B). We further analyzed the risk of failure for separate components at different times of follow-up (Table 2).
Table 1.
Indications for re-revision in 11 patients
| Components re-revised | Indication for re-revision follow-up | Survival (years) |
| Seven re-revisions of both the acetabular and femoral component | One aseptic loosening | 11.7 |
| Three septic loosening (one with conversion to permanent excision arthroplasty) | 11.3 and 11.2 | |
| 3.6a | ||
| One stem re-revision for malpositioning causing recurrent dislocation (with later re-revision of both components for septic loosening) | 1.6 | |
| 2.9a | ||
| One cup re-revision for traumatic loosening after a fall (with later re-revision of both components for septic loosening) | 8.7 | |
| 9.8a | ||
| One cup re-revision for aseptic loosening (with later re-revision of the stem for periprosthetic fracture) | 24.4 | |
| 24.9a | ||
| Four cup re-revisions | Four aseptic loosening | 2.6, 10.8, 16.2, and 17.4 |
Survival until the event described between parentheses.
Fig. 2.
A-C Shown here is the cumulative failure rate of revisions procedures of any component (A) for any reason and (B) for aseptic loosening and (C) reoperation for any reason.
Fig. 3.
A-B The cumulative failure rate of revision procedures for aseptic loosening of (A) the acetabular components and (B) the femoral components is shown here.
Table 2.
Survival at different times of follow-up for different endpoints
| Re-revision | 10-year failure rate (95% CI) | Number at risk | 15-year failure rate (95% CI) | Number at risk | 20-year failure rate (95% CI) | Number at risk |
| Survival complete revision THA | ||||||
| Re-revision for any reason (events = 11) | 13% (4 to 26) | 22 | 27% (13 to 44) | 13 | 38% (19 to 57) | 4 |
| Re-revision for aseptic loosening (events = 6) | 3% (0 to 13) | 22 | 10% (3 to 25) | 13 | 21% (7 to 40) | 4 |
| Reoperation for any reason (events = 12) | 22% (10 to 37) | 19 | 30% (15 to 46) | 12 | 41% (22 to 60) | 3 |
| Survival acetabular components only | ||||||
| Re-revision for any reason (events = 11) | 13% (4 to 26) | 22 | 27% (13 to 44) | 13 | 38% (19 to 57) | 4 |
| Re-revision for aseptic loosening (events = 6) | 3% (0 to 13) | 22 | 10% (3 to 25) | 13 | 21% (7 to 40) | 4 |
| Reoperation for any reason (events = 12) | 22% (10 to 37) | 19 | 30% (15 to 46) | 12 | 41% (22 to 60) | 3 |
| Survival femoral components only | ||||||
| Re-revision for any reason (events = 7) | 10% (2 to 23) | 23 | 21% (8 to 37) | 14 | 21% (8 to 37) | 4 |
| Re-revision for aseptic loosening (events = 2) | 0% (NA) | 23 | 4% (0 to 16) | 14 | 4% (0 to 16) | 4 |
| Reoperation for any reason (events = 8) | 19% (8 to 34) | 20 | 23% (10 to 39) | 13 | 23% (10 to 39) | 3 |
Clinical Outcome Scores
In our previous report [24], the mean Harris Hip score was 55 ± 18 preoperatively and increased to 80 ± 16 points postoperatively. At latest follow-up, the mean postoperative Harris Hip score was 74 ± 22. The mean postoperative Oxford Hip score was 36 ± 10 in our previous report, and currently 33 ± 11. We did not assess any statistical differences between preoperative and postoperative scores, as postoperative scores were not applicable as 11 patients were re-revised and six patients died at latest follow-up. Therefore, clinical outcome data could not be assessed for these patients. Additionally, due to missing preoperative data, we were only able to compare preoperative and postoperative Harris Hip score for six patients, and Oxford Hip score for three patients. Harris Hip score at final follow-up was available for 15 patients, and Oxford Hip score for 13 patients.
Radiographic Analysis
In total, eight cups were considered radiographically loose (compared with four radiographically loose cups in our previous report). Seven of these eight cups were re-revised. One patient underwent débridement and irrigation and was functioning well on low-dose antibiotics for chronic infection. Of the acetabula that were not re-revised, we could score trabecular incorporation in 99% (68 of 69) zones; one was obscured by metal mesh. In 91% (62 of 68) of zones, we saw incorporation.
Out of all stems, none were considered radiographically loose. Between the two study periods (10-year and 15-year follow-up), 21 stems showed no subsidence, nine showed 1 mm of subsidence and three stems showed 2 mm of subsidence. Therefore, all stems were considered radiographically stable. Mean subsidence of the stem within the mantle was 2.9 ± 2.1 mm. Failure rate with endpoint radiographic loosening at 15 years was 23% (95% CI 10 to 39).
Discussion
THA is increasingly performed in younger patients, many of whom will live long enough to undergo revision. Unfortunately, little is known about survivorship of revision hip arthroplasty performed in patients younger than 55 years, and most of what has been reported is rather discouraging [1, 8, 10, 14]. Since our earlier paper, no new evidence has been published reporting on the long-term survivorship of revision THA implants in patients younger than 55 years. This current study updates our previous paper [24] on the outcome of complete revisions in patients younger than age 55 years using impaction bone grafting on both sides, focusing on the long-term failure rate, clinical outcome, and radiographic outcome in this young patient group. The 15-year risk of failure was 27% with the endpoint of re-revision of any component for any reason, and 10% with the endpoint of re-revision of any component for aseptic loosening. These results are certainly promising for these young patients.
Limitations
This study has several limitations, a few of which have remained the same since our previous report [24]. Several acetabular and femoral zones were treated with mesh for extensive reconstruction. The mesh obscured the view of the bone stock for radiological evaluation. However, no difference in clinical or failure outcome was seen in these cases.
Secondly, the set of data that was available was limited, as 11 patients were re-revised, and six patients died. Therefore, clinical outcome data could not be assessed for these patients. Additionally, due to missing preoperative data, we were only able to compare preoperative and postoperative outcome data for a small group of patients. Therefore, we did not perform a statistical comparison.
Although extensive acetabular and femoral defects were part of this study, the study also includes revisions with less severe defects, and impaction bone grafting was performed at the discretion of the operating surgeon. We also note that impaction bone grafting is technically demanding, and it may not yield the same results in the hands of surgeons who do it less frequently. Thus, our results may be different compared with other surgeons. Further, the environment of implant choices has changed. With newer implants and better bearings, such as highly crosslinked polyethylene, the proportion of young patients going on to revision, particularly for wear-related issues, may decrease considerably. In addition, the revision options available now compared with 20 years ago are substantially more versatile, but none of these newer methods is able to restore bone stock. Especially in these younger patients already facing a revision at a young age, unfortunately future revisions can be expected. The available bone stock at the next revision will determine the outcome of the subsequent revision.
Failure Risk
The 15-year risk of failure was 27% with the endpoint of re-revision of any component for any reason, and 10% with the endpoint of re-revision of any component for aseptic loosening. There are few studies on the outcome of revisions in young patients. One multicenter study included 77 revision procedures in 55 patients, all younger than 30 years, with a mean follow-up of 6.2 years. The authors reported a disappointing 10-year survivorship of 36% for re-revision for any reason [8]. A case-controlled study, comparing mostly uncemented revisions with primary THAs, reported a survival of 69% of revision procedures after a mean follow-up of 6.7 years. However, a loss to follow-up of 29.3% (43 revisions) was reported as well [1]. In a study reporting on 181 mostly uncemented revisions (109 of which were revisions of both components) in 102 patients 50 years of age or younger, a mean follow-up of 11 years was seen. This third study had 27 patients lost to follow-up and 67 lost radiographs. They reported a 10-year survival for re-revision for any reason of 63% [14]. Lastly, a study based on the Dutch Arthroplasty Register on 1037 revision THA procedures in patients younger than 55 years showed a worrisome overall 10-year survival rate of 72%, which decreased to 55% for index revisions due to infection [11]. Our 10-year results were at least comparable to all these studies. At 15 years, we still show results that are at least comparable to the 10-year results described in the studies discussed above.
Outcomes Scores
In our previous report, we found a significant improvement in the Harris Hip score. The Harris Hip score did not appear to have changed at latest follow-up compared with the scores in our previous report. However, no meaningful statistical analysis could be performed at this point; we could only include the scores of patients who were not lost to death and who underwent a re-revision. The slight decrease in the mean Harris Hip score and Oxford Hips score is likely a function of normal aging. The improvement in preoperative and postoperative the Harris Hip score and the Oxford Hip score is still comparable with studies described in our previous report [1, 14, 24].
Radiographic Findings
Similarly, impaction bone grafting provides durable radiographic results, although detailed radiological interpretation of graft incorporation in hips that undergo impaction bone grafting remains difficult; failure risk of radiographic loosening was 23% (95% CI 10 to 39) at 15 years follow-up. In 91% of all acetabular zones, incorporation was seen, whereas in 92% of all femoral zones incorporation was seen. These percentages are comparable with our previous report [24], and other studies where they reported graft union in 64 of 67 surviving acetabular reconstructions performed with irradiated allografts (95.5%) [4], and trabecular incorporation in 87% in 75 femoral bone impaction grafting revisions [25]. Since our previous report, no other studies were published reporting on the outcome of revision in young patients, making a comparison of radiographic findings not possible.
Conclusion
We conclude that impaction bone grafting with a cemented cup and a cemented stem is a valuable biological revision technique that results in a stable and durable solution, after one or even multiple previous revision THAs. Current implants for revision surgery are substantially more versatile than in the past and may prove to be sufficient in most cases. On the acetabular side, these include jumbo cups and highly porous surface geometries; extensively porous coated stems often provide durable femoral fixation. However, we do not yet have long-term data on the use of these options in young patients and none of them promote preservation of bone stock, as is the case with impaction bone grafting. We believe that as long as the defect can be contained adequately with a metal mesh and a viable bone bed is available for revascularization, the impaction bone grafting technique can be used and can facilitate an eventual future revision. We caution, however, that use of impaction bone grafting is technically complex, and should be performed by an experienced surgeon.
Acknowledgments
We thank the independent research assistants for collecting clinical outcome data.
Footnotes
Each author certifies that neither he, nor any member of his immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
Each author certifies that his institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.
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