JBJS | Total Hip Arthroplasty with Cement in Patients Less Than Twenty Years Old. Long-Term Results*

The Journal of Bone & Joint Surgery, Volume 78, Issue 7

Articles | July 01, 1996

Total Hip Arthroplasty with Cement in Patients Less Than Twenty Years Old. Long-Term Results*

M. E. TORCHIA, M.D.†; R. A. KLASSEN, M.D.†; A. J. BIANCO, M.D.†, ROCHESTER, MINNESOTA

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Investigation performed at the Mayo Clinic and Mayo Foundation, Rochester

The Journal of Bone & Joint Surgery. 1996; 78:995-1003

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Abstract

Sixty-three consecutive total hip arthroplasties were performed with cement in fifty adolescent patients from 1972 through 1980, and the results were determined after a minimum of ten years. A polyethylene cup without a metal backing and a non-modular femoral component with a collar and a fixed neck length were inserted, with use of so-called first-generation cementing techniques, in each hip. Kaplan-Meier survival analysis of all sixty-three hips demonstrated that the probability of failure (defined as revision or symptomatic loosening) increased steadily over time and reached 45 per cent after fifteen years. A number of specific variables were associated with a significantly higher probability of failure: a history of more than one previous procedure involving the hip (p = 0.0002), unilateral arthroplasty (p = 0.006), previous trauma involving the hip (p = 0.01), the absence of other disease that limited function of the ipsilateral lower extremity (p = 0.03), a high postoperative level of activity (involving moderate or strenuous manual labor) (p = 0.03), and a preoperative weight of more than sixty kilograms (p = 0.03). The probability of failure in the patients who had inflammatory arthritis (11 per cent) was significantly lower than that in those who had previous trauma involving the hip (47 per cent) (p = 0.0006).Fifty-two hips (forty patients) were followed for a minimum of ten years or until revision. The mean duration of follow-up for these fifty-two hips was 12.6 years (range, 1.6 to 18.6 years). The result was evaluated clinically and radiographically with use of the Mayo hip-scoring system and was graded as excellent in ten hips (19 per cent), good in sixteen (31 per cent), fair in one (2 per cent), and poor in twenty-five (48 per cent). Most of the poor results were due to symptomatic loosening of the acetabular component.The probability of radiographic loosening after fifteen years was 60 per cent for the acetabular component and 20 per cent for the femoral component. Radiographic evidence of polyethylene wear was associated with probable loosening of the acetabular component (p = 0.03).The findings of the present study suggest that total hip arthroplasty in adolescents should be reserved for carefully selected patients for whom alternative procedures are contraindicated or unacceptable. Fixation of the acetabular component with cement is not recommended in this setting.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

A variety of disorders of the hip that occur during childhood may result in disabling secondary osteoarthrosis of the hip during adolescence. When options for treatment such as osteotomy or arthrodesis are not possible or not acceptable, total hip arthroplasty may be considered. While there has been some concern regarding the durability and fixation of components^{6,7,12,15,16,21}, there is little information in the literature to guide clinical decision-making in this setting. Although the results of total hip arthroplasty with cement in young patients have been reported by several authors^{1-3,8,9,12,15-18,21,22,27,29,30,33,38,39,41-43,46,49,50,52-55,58-60,62}, only five studies have been limited to patients who were less than twenty years old^{38,39,49,50,54}. Three of these series^49,50,54 were composed entirely of patients who had inflammatory arthritis and limited follow-up (Table I). The two reports by Klassen et al.^38,39 included many patients for whom the preoperative diagnosis was something other than inflammatory arthritis, but the implants were heterogeneous in design. In addition, unipolar, bipolar, and surface-replacement implants were included in their analysis of standard total hip components. Thus, the long-term results of standard total hip arthroplasty with cement in a large group of patients who were less than twenty years old and who primarily had non-inflammatory arthritis have not been reported previously, to our knowledge. This led us to review our experience with total hip arthroplasty with cement in adolescents in order to determine the results, the rates of failure, and the factors associated with satisfactory and unsatisfactory outcomes after at least ten years.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopedics, Mayo Clinic and Mayo Foundation, 200 First Street, S.W., Rochester, Minnesota 55905.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopedics, Mayo Clinic and Mayo Foundation, 200 First Street, S.W., Rochester, Minnesota 55905.

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TABLE I PUBLISHED SERIES OF TOTAL HIP ARTHROPLASTY WITH CEMENT IN YOUNG PATIENTS

*The methods used to calculate follow-up intervals varied among the studies.†The data are given as the mean, with the range in parentheses.‡NR - not reported.§Inflammatory arthritis includes juvenile rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis, dermatomyositis, arthritis of inflammatory bowel disease, and other collagen vascular diseases.¶The definitions of loosening varied among the studies. The rate includes all hips in which the component was considered to be loose regardless of the revision status.#The rate is given as the number of hips revised during the follow-up interval/the total number of hips in the series. The rates are not based on Kaplan-Meier survival analysis, except for those in the study by Joshi et al.³³ Revision is defined as removal of one or both components for any reason.**These percentages are based on the subgroup of fifty-two hips that had adequate radiographic follow-up (see text).

Study	Year of Publication	No. of Hips	Durat. of Follow-up*† (Yrs.)‡	Age†‡ (Yrs.)	Hips with Inflammatory Arthritis§ (Per cent)	Rate of Loosening‡¶ (Per cent)			Rate of Revision‡# (Per cent)
Over-All	Acetabular Compon.	Femoral Compon.	Over-All	Acetabular Compon.	Femoral Compon.
Arden et al.¹	1972	66	NR (<1—4)	28.8 (15—49)	100	3	3	0	0	0	0
Halley and Charnley²⁹	1975	68	3.3 (0.5—8.3)	25.9 (17—30)	82	1.5	1.5	0	2.9	0	2.9
Bisla et al.³	1976	67	2.7 (1—7)	24.8 (12—29)	87	1.5	NR	NR	0	0	0
Singsen et al.⁵⁴	1978	29	2.2 (1—4)	NR (12—18)	100	6.7	6.7	0	0	0	0
Colville and Raunio¹⁷	1979	59	2.5 (1—4.5)	30.5 (18—47)	100	0	0	0	0	0	0
Klassen et al.³⁹	1979	60	NR (1—15)	15 (12—19)	38	0	0	0	1.6	1.6	1.6
Chandler et al.¹²	1981	33	5.6 (4.8—7)	23 (14—36)	18	58	45	21	21.2	15.2	12.1
Dorr et al.²²	1983	108	4.5 (2—9.8)	30.5 (14—45)	33	33.3	14.8	24.1	17.6	13.9	12.9
Kunec⁴¹	1983	16	5.2 (3.8—10.5)	22 (17—33)	100	19	6.3	19	25	19	25
Collis¹⁵	1984	45	7.3 (5—11)	40.7 (23—49)	18	NR	8.9	8.9	8.9	2.2	6.6
Roach and Paradies⁴⁹	1984	10	7.9 (6—8)	13.2 (9—16)	100	33	33	0	33	33	0
Scott et al.⁵²	1984	64	5 (NR)	NR (>10)	100	9.4	6.3	6.3	6.3	6.3	3.1
Sharp and Porter⁵³	1985	73	6.6 (5—12)	32.7 (16—40)	38	19.2	16.4	5.5	19.2	17.8	9.6
Cornell and Ranawat¹⁸	1986	78	7.0 (4—13)	48.6 (NR—54)	0	5.1	3.8	1.2	3.8	3.8	1.2
Lachiwiecz et al.⁴²	1986	83	6.0 (2—11)	26 (NR)	100	NR	26	8	3.2	3.2	1.6
Ruddlesdin et al.⁵⁰	1986	75	5.4 (1—12)	14 (11—17)	100	2.7	1.3	1.3	1.3	0	1.3
Halley and Wroblewski³⁰	1986	49	9.5 (5—15.5)	26 (17—30)	74	16.3	14.3	4	20	18.4	10.2
White⁵⁹	1988	44	7.5 (5—10)	38 (24—44)	39	45	34	25	14	11.4	9.1
Learmonth et al.⁴³	1989	14	8.5 (4—11)	16 (12—22)	100	57	57	35.7	0	0	0
Gudmundsson et al.²⁷	1989	27	5.3 (3—10)	18 (13—26)	100	3.7	0	3.7	11.1	11.1	11.1
Dorr et al.²¹	1990	81	9.2 (5—16.5)	30 (NR—45)	33	63.6	NR	NR	40.9	33	33
Witt et al.⁶²	1991	96	11.5 (5.3—18.3)	16.7 (11—26)	100	NR	29	21.5	25	22	20
Klassen and Bianco³⁸	1991	65	8.0 (5—11)	16.8 (12—19)	34	NR	26.2	NR	15	10.8	6.2
Collis¹⁶	1991	51	NR (3—18)	40.7 (23.49)	18	NR	34.1	25	30	30	23
Cage et al.⁸	1992	29	10.6 (NR)	18.4 (15—21)	94	32	23	27	3.4	NR	NR
Barrack et al.²	1992	50	12 (10—14.8)	40.9 (18—50)	4	46	44	2	22	22	6
Solomon et al.⁵⁵	1995	130	7.3 (3—16)	38 (10—50)	37	19.2	9.2	11.5	10.8	4.6	8.5
Williams and McCullough⁶⁰	1993	57	4.7 (1.7—9)	16.4 (13.4—24)	100	24.6	24.6	7	4	2	2
Maric and Haynes⁴⁶	1993	13	11 (NR)	18 (14—20)	100	NR	18	29	7.7	0	7.7
Joshi et al.³³	1993	218	NR (<1—24)	32 (16—40)	53	NR	8	20	25	16	14
Sullivan et al.⁵⁸	1994	89	18 (16—22)	42 (18—49)	9	58	50	8	20	13	2
Current study	1996	63	11.0 (0.3—18.6)	17 (11—19)	32	69.2**	67.3**	19.2**	42.9	38.1	25.4

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TABLE I PUBLISHED SERIES OF TOTAL HIP ARTHROPLASTY WITH CEMENT IN YOUNG PATIENTS

Study	Year of Publication	No. of Hips	Durat. of Follow-up*† (Yrs.)‡	Age†‡ (Yrs.)	Hips with Inflammatory Arthritis§ (Per cent)	Rate of Loosening‡¶ (Per cent)			Rate of Revision‡# (Per cent)
Over-All	Acetabular Compon.	Femoral Compon.	Over-All	Acetabular Compon.	Femoral Compon.
Arden et al.¹	1972	66	NR (<1—4)	28.8 (15—49)	100	3	3	0	0	0	0
Halley and Charnley²⁹	1975	68	3.3 (0.5—8.3)	25.9 (17—30)	82	1.5	1.5	0	2.9	0	2.9
Bisla et al.³	1976	67	2.7 (1—7)	24.8 (12—29)	87	1.5	NR	NR	0	0	0
Singsen et al.⁵⁴	1978	29	2.2 (1—4)	NR (12—18)	100	6.7	6.7	0	0	0	0
Colville and Raunio¹⁷	1979	59	2.5 (1—4.5)	30.5 (18—47)	100	0	0	0	0	0	0
Klassen et al.³⁹	1979	60	NR (1—15)	15 (12—19)	38	0	0	0	1.6	1.6	1.6
Chandler et al.¹²	1981	33	5.6 (4.8—7)	23 (14—36)	18	58	45	21	21.2	15.2	12.1
Dorr et al.²²	1983	108	4.5 (2—9.8)	30.5 (14—45)	33	33.3	14.8	24.1	17.6	13.9	12.9
Kunec⁴¹	1983	16	5.2 (3.8—10.5)	22 (17—33)	100	19	6.3	19	25	19	25
Collis¹⁵	1984	45	7.3 (5—11)	40.7 (23—49)	18	NR	8.9	8.9	8.9	2.2	6.6
Roach and Paradies⁴⁹	1984	10	7.9 (6—8)	13.2 (9—16)	100	33	33	0	33	33	0
Scott et al.⁵²	1984	64	5 (NR)	NR (>10)	100	9.4	6.3	6.3	6.3	6.3	3.1
Sharp and Porter⁵³	1985	73	6.6 (5—12)	32.7 (16—40)	38	19.2	16.4	5.5	19.2	17.8	9.6
Cornell and Ranawat¹⁸	1986	78	7.0 (4—13)	48.6 (NR—54)	0	5.1	3.8	1.2	3.8	3.8	1.2
Lachiwiecz et al.⁴²	1986	83	6.0 (2—11)	26 (NR)	100	NR	26	8	3.2	3.2	1.6
Ruddlesdin et al.⁵⁰	1986	75	5.4 (1—12)	14 (11—17)	100	2.7	1.3	1.3	1.3	0	1.3
Halley and Wroblewski³⁰	1986	49	9.5 (5—15.5)	26 (17—30)	74	16.3	14.3	4	20	18.4	10.2
White⁵⁹	1988	44	7.5 (5—10)	38 (24—44)	39	45	34	25	14	11.4	9.1
Learmonth et al.⁴³	1989	14	8.5 (4—11)	16 (12—22)	100	57	57	35.7	0	0	0
Gudmundsson et al.²⁷	1989	27	5.3 (3—10)	18 (13—26)	100	3.7	0	3.7	11.1	11.1	11.1
Dorr et al.²¹	1990	81	9.2 (5—16.5)	30 (NR—45)	33	63.6	NR	NR	40.9	33	33
Witt et al.⁶²	1991	96	11.5 (5.3—18.3)	16.7 (11—26)	100	NR	29	21.5	25	22	20
Klassen and Bianco³⁸	1991	65	8.0 (5—11)	16.8 (12—19)	34	NR	26.2	NR	15	10.8	6.2
Collis¹⁶	1991	51	NR (3—18)	40.7 (23.49)	18	NR	34.1	25	30	30	23
Cage et al.⁸	1992	29	10.6 (NR)	18.4 (15—21)	94	32	23	27	3.4	NR	NR
Barrack et al.²	1992	50	12 (10—14.8)	40.9 (18—50)	4	46	44	2	22	22	6
Solomon et al.⁵⁵	1995	130	7.3 (3—16)	38 (10—50)	37	19.2	9.2	11.5	10.8	4.6	8.5
Williams and McCullough⁶⁰	1993	57	4.7 (1.7—9)	16.4 (13.4—24)	100	24.6	24.6	7	4	2	2
Maric and Haynes⁴⁶	1993	13	11 (NR)	18 (14—20)	100	NR	18	29	7.7	0	7.7
Joshi et al.³³	1993	218	NR (<1—24)	32 (16—40)	53	NR	8	20	25	16	14
Sullivan et al.⁵⁸	1994	89	18 (16—22)	42 (18—49)	9	58	50	8	20	13	2
Current study	1996	63	11.0 (0.3—18.6)	17 (11—19)	32	69.2**	67.3**	19.2**	42.9	38.1	25.4

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TABLE II REASON FOR FAILURE IN TWENTY-NINE HIPS

*In thirteen hips, both components were revised.†The data are given as the number of hips.‡Five hips that were revised elsewhere because of loosening of the acetabular component also had revision of the femoral component; the reason for the revision on the femoral side could not be determined.§One hip that was revised with an arthrodesis because of symptomatic loosening of the femoral component had a well fixed acetabular component at the time of the revision.

Reason for Failure (N = 29*)	Acetabular Component† (N = 26)	Femoral Component† (N = 16)
Symptomatic loosening	22	8 (5 fractured stems)

Instability	1	1

Pain without loosening	1	1

Acute infection	1	1

Unknown	0	5‡

Other	1§	0

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TABLE II REASON FOR FAILURE IN TWENTY-NINE HIPS

Reason for Failure (N = 29*)	Acetabular Component† (N = 26)	Femoral Component† (N = 16)
Symptomatic loosening	22	8 (5 fractured stems)

Instability	1	1

Pain without loosening	1	1

Acute infection	1	1

Unknown	0	5‡

Other	1§	0

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TABLE III RADIOGRAPHIC DATA ON TOTAL HIP COMPONENTS IMPLANTED WITH CEMENT IN PATIENTS LESS THAN TWENTY YEARS OLD

*The number of hips for which sequential radiographs were available for review.†The data are given as the number of components.‡As defined in the text.§The score was determined with use of the Mayo hip-scoring system³⁵; a maximum radiographic score of 10 points was possible for each component.¶According to the system described by Brooker et al.⁵.#According to the system described by Gruen et al.²⁶.

Acetabular component (n = 52*)
Migration†	31
Radiolucent line at bone-cement interface†
Incomplete	18
Complete	30
Polyethylene wear†	32
Mean wear (mm)	2
Probable loosening†‡	35
Mean score§ (points)	3

Femoral component (n = 52)
Migration†	9
Cement fracture†	4
Radiolucent line at prosthesis-cement interface†	4
Radiolucent line at bone-cement interface†
Incomplete	17
Complete	4
Resorption of proximal-medial portion of femoral neck†	15
Heterotopic ossification†¶
Class I	21
Class II	0
Class III	2
Class IV	3
Probable loosening†‡	10
Mode of failure†#
Type Ia	3
Type Ib	1
Type II	1
Type III	0
Type IV	5
Mean scores§ (points)	8

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TABLE III RADIOGRAPHIC DATA ON TOTAL HIP COMPONENTS IMPLANTED WITH CEMENT IN PATIENTS LESS THAN TWENTY YEARS OLD

Acetabular component (n = 52*)
Migration†	31
Radiolucent line at bone-cement interface†
Incomplete	18
Complete	30
Polyethylene wear†	32
Mean wear (mm)	2
Probable loosening†‡	35
Mean score§ (points)	3

Femoral component (n = 52)
Migration†	9
Cement fracture†	4
Radiolucent line at prosthesis-cement interface†	4
Radiolucent line at bone-cement interface†
Incomplete	17
Complete	4
Resorption of proximal-medial portion of femoral neck†	15
Heterotopic ossification†¶
Class I	21
Class II	0
Class III	2
Class IV	3
Probable loosening†‡	10
Mode of failure†#
Type Ia	3
Type Ib	1
Type II	1
Type III	0
Type IV	5
Mean scores§ (points)	8

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TABLE IV RESULTS AT TIME OF MOST RECENT FOLLOW-UP

*According to both the clinical and radiographic portions of the Mayo hip score³⁵.†The data are given as the number of hips.‡Includes three revised hips that were excluded from the clinical and radiographic analysis, as discussed in the text with regard to exclusions and follow-up intervals.§Includes nineteen hips that subsequently were revised.

Result*	Unrevised Hips†‡ (N = 28)	All Hips† (N = 52)
Excellent	10 (36%)	10 (19%)
Good	11 (39%)	16 (31%)
Fair	1 (4%)	1 (2%)
Poor	6 (21%)	25§ (48%)

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TABLE IV RESULTS AT TIME OF MOST RECENT FOLLOW-UP

Result*	Unrevised Hips†‡ (N = 28)	All Hips† (N = 52)
Excellent	10 (36%)	10 (19%)
Good	11 (39%)	16 (31%)
Fair	1 (4%)	1 (2%)
Poor	6 (21%)	25§ (48%)

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Fig. 1. Kaplan-Meier survival curve, with failure (revision or symptomatic loosening) as the end point, for patients who were less than twenty years old and in whom a total hip arthroplasty (THA) had been performed with cement.

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Fig. 2. Kaplan-Meier survival curves, with radiographic evidence of probable loosening as the end point, for patients who were younger than twenty years old and in whom a total hip arthroplasty (THA) had been performed with cement.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Patients

Sixty-three total hip arthroplasties were performed with cement, in fifty patients who were less than twenty years old, at the Mayo Clinic from 1972 through 1980. The patients were identified with use of a computerized database that includes the files of all patients who have had a total hip arthroplasty at the Mayo Clinic; patients who were more than nineteen years old, who had been managed with a surface-replacement arthroplasty, or in whom the procedure had been performed after December 31, 1980, were excluded from the study.

The study included twenty-seven male and twenty-three female patients who were eleven to nineteen years old (mean, seventeen years old) at the time of the operation. Thirteen patients had a bilateral procedure. The preoperative diagnoses included juvenile rheumatoid arthritis (sixteen hips); congenital dysplasia (ten hips); slipped capital femoral epiphysis (eight hips); trauma (a displaced fracture of the femoral neck complicated by avascular necrosis) or tumor (seven hips each); spondyloepiphyseal dysplasia (three hips); previous infection, Legg-Calvé-Perthes disease, steroid-induced avascular necrosis, ankylosing spondylitis, or systemic lupus erythematosus (two hips each); and neurofibromatosis or idiopathic protrusio acetabuli (one hip each).

A total of sixty-five previous operative procedures (range, one to five procedures per hip) had been performed in thirty-three hips. The procedures included pinning (twelve hips); cup arthroplasty (nine hips); subtrochanteric osteotomy (eight hips); debridement because of an infection (seven hips); acetabular osteotomy (six hips); open reduction (four hips); bipolar arthroplasty (one hip); and miscellaneous procedures (eighteen hips), such as the removal of hardware, core decompression, synovectomy, and adductor tenotomy.

Indications

The indications for the total hip arthroplasty were disabling pain or ankylosis with malposition. It should be noted that extensive discussions were held with the patients and their parents preoperatively. Arthrodesis of the hip was advised when the contralateral hip, the ipsilateral knee, and the lumbar spine were normal, but this procedure was refused by the patients in the present series to whom it was recommended. The decision to proceed with total hip arthroplasty was made with the realization that the durability of the components and of the fixation were unknown.

Operative Procedure

The operation was performed with use of the technique of Charnley as modified by Coventry³⁶. A lateral approach with trochanteric osteotomy was used in fifty-four hips; an anterior approach, in two; and a posterior approach, in one. An en bloc excision of a malignant bone tumor was performed in six hips; the tumors included an osteogenic sarcoma in three hips and a Ewing sarcoma, a high-grade chondrosarcoma, and a high-grade fibrosarcoma in one hip each. All femoral components had a collar and a fixed neck length (that is, they were non-modular), and all acetabular components were polyethylene without a metal backing. Twenty-seven Charnley (Howmedica, Rutherford, New Jersey), fourteen trapezoidal-28 (Zimmer, Warsaw, Indiana), six Aufranc-Turner (Zimmer), three computer-assisted-design (Howmedica), three Harris Design-2 (Zimmer), three Charnley-Müller (Howmedica), and three Protasul-10 (DePuy, Warsaw, Indiana) prostheses were used. A proximal femoral replacement implant (Howmedica) was used in the remaining four hips, all of which had a tumor (Ewing sarcoma, chondrosarcoma, fibrosarcoma, and Gorham disease in one hip each). Ten implants—eight Charnley prostheses, one computer-assisted-design prosthesis, and one Protasul-10 prosthesis—were miniature components. All components were inserted with use of so-called first-generation cementing technique^2,9,36,51. Specifically, the cement was packed by hand in an antegrade fashion during the doughy phase of polymerization. Pulsatile lavage, cement plugs, retrograde filling of the canal, and pressurization techniques were not used.

Follow-up

Patients were asked to return for an interview, an examination, and a radiographic evaluation at regular follow-up intervals. The most recent follow-up examination took place at a minimum of ten years after the operation or just before a revision (defined as removal of one or both components for any reason). Fourteen patients who were unable to return for follow-up at a minimum of ten years postoperatively either completed a questionnaire or were interviewed by telephone. Eleven of these patients sent recent radiographs.

Clinical Analysis

Clinical data were reviewed to determine the outcome of the arthroplasty and to document complications. The standard system of terminology for reporting results as suggested by The American Academy of Orthopaedic Surgeons Committee on the Hip³² was used to describe clinical parameters, including pain, function, mobility, muscle power, ability to work, and walking capacity. The subjective satisfaction of the patient was determined by asking him or her to respond to the question: "Are you satisfied with the results of your surgery?"

Radiographic Analysis and Definitions

Serial radiographs were reviewed to determine the presence of radiolucent lines, fractures in the cement, migration of the components, osteolysis, and polyethylene wear. Zones of radiolucency were assessed on the anteroposterior radiographs with the method of DeLee and Charnley²⁰ as well as that of Gruen et al.²⁶. Migration of the components and linear wear of the polyethylene were estimated with use of the techniques described by Wilson et al.⁶¹ and by Charnley and Halley¹⁴. The radiographic analysis was carried out with the realization that certain sources of error (magnification, rotation of the hip, and the angle of the x-ray beam) were unavoidable. We attempted to minimize this error by selecting radiographs made with similar projections (when possible) and by using magnification factors that were based on the known size of the head of the femoral component.

Loosening was determined according to current definitions³⁶. Probable loosening was defined as migration of the component, a fracture of the cement, a radiolucent line at the prosthesis-cement interface, a complete radiolucent line at the bone-cement interface that was wider than one millimeter in at least one zone, or a combination of these findings. Symptomatic loosening was considered to be present when there was radiographic evidence of probable loosening and the patient had moderate or severe pain. Failure of the arthroplasty was defined as revision or symptomatic loosening.

Grading of Results

The over-all clinical and radiographic result was assessed at the time of the latest follow-up examination with use of the Mayo hip-scoring system³⁵. The maximum clinical score is 80 points; this portion of the score is based on pain (40 points), function (20 points), and mobility and muscle power (20 points). The maximum radiographic score is 20 points (10 points for each component); points are deducted for migration of the component, a radiolucent line, and fracture of the cement. The result is graded as excellent (90 to 100 points), good (80 to 89 points), fair (70 to 79 points), or poor (less than 70 points).

Survival Analysis and Statistical Methods

The survival of the prostheses free of failure and probable loosening was estimated with use of the method described by Kaplan and Meier³⁴. Individual survivorships were compared with use of log-rank tests⁴⁷. The association of continuous and ordinal variables with survivorship was estimated with use of the Cox proportional-hazards model¹⁹. P values of less than 0.05 were considered significant.

Exclusions and Follow-up Intervals

All sixty-three hips were included in the Kaplan-Meier survival analysis, with failure (revision or symptomatic loosening) defined as the end point. The failures occurred 3.5 months to 17.9 years after the operation.

Eleven of the sixty-three hips that were included in the survival analysis were excluded from the analysis of clinical and radiographic results because of inadequate follow-up. The components were removed from one patient (one hip) 3.5 months after implantation because of an acute infection that had persisted despite multiple operative debridements. The result in this hip was considered to be a failure and was included as such in the survival analysis. Five patients (five hips) who had metastatic bone tumors and one patient (two hips) who had systemic lupus erythematosus died, from causes unrelated to the arthroplasty, at a mean of twenty-six months (range, six to forty-eight months) after the operation. Although the hospital records and correspondence with the families indicated that these six patients (seven hips) had been free of pain and that the prosthesis had been functioning well before the time of death, detailed clinical and radiographic data were lacking. One patient (one hip) returned a questionnaire but did not send radiographs, and the radiographs of two patients (two hips) who had had a revision elsewhere had been discarded.

The remaining fifty-two hips (forty patients) were followed for a minimum of ten years or until revision. The mean duration of follow-up was 12.6 years (range, 1.6 to 18.6 years). Of these fifty-two hips, a subgroup of twenty-eight that were not revised was followed for a mean of 15.0 years (range, 10.6 to 18.6 years).

Results

Introduction | Materials and Methods | Results | Discussion | References

Failure

Twenty-nine (46 per cent) of the sixty-three arthroplasties failed: twenty-seven hips were revised, and two others had symptomatic loosening of the acetabular component. The probability of failure was 27 per cent after ten years and 45 per cent after fifteen years (Fig. 1). Univariate analysis identified several variables that were associated with a significantly higher probability of failure: a history of more than one previous procedure involving the hip (p = 0.0002), unilateral arthroplasty (p = 0.006), previous trauma involving the hip (p = 0.01), the absence of other disease that limited function of the ipsilateral lower extremity (p = 0.03), a high postoperative level of activity (involving moderate or strenuous manual labor) (p = 0.03), and preoperative weight (as a continuous variable) (p = 0.03). The probability of failure after fifteen years was 17 per cent in patients who had weighed less than forty-seven kilograms preoperatively and 38 per cent in those who had weighed more than sixty kilograms preoperatively. Multivariate analysis identified two independent factors that were associated with a higher probability of failure: a history of more than one previous procedure involving the hip (p = 0.0001) and unilateral arthroplasty (p = 0.02). The type of prosthesis, the size of the head of the femoral component, the position of the stem, the gender of the patient, and a history of previous cup arthroplasty did not affect the probability of failure or the end result. The probability of failure in the patients who had inflammatory arthritis (11 per cent) was significantly lower than that in those who had previous trauma involving the hip (47 per cent) (p = 0.0006).

An analysis of the failures revealed that symptomatic loosening of the acetabular component (twenty-two hips) was nearly three times more common than that of the femoral component (eight hips) (Table II). Loosening of the femoral component necessitating revision was associated with a fracture of the stem in five hips (three that had a trapezoidal-28 prosthesis, one that had a Charnley prosthesis, and one that had a proximal femoral replacement prosthesis); the fractures occurred a mean of 6.5 years (range, 1.6 to 10.6 years) after implantation. In five of the hips that had symptomatic loosening of the acetabular component, both components were revised elsewhere and the indication for the revision of the femoral component could not be determined. None of these five hips had had radiographic evidence of loosening of the femoral component before the revision, and a review of the available operative records for two of the hips revealed no obvious reason for the revision of the femoral component. It is plausible that intraoperative problems related to exposure, the length of the limb, or stability may have necessitated the revision of these femoral components, all of which had a fixed neck length.

Clinical Results

Twenty hips were moderately or severely painful at the time of the latest follow-up; eighteen of these hips subsequently were revised. The other two patients (two hips) who had pain were considering a revision because of symptomatic loosening of the acetabular component. Thirty-eight (95 per cent) of the forty patients who were followed clinically were employed. In most patients, the level of activity was very high both at work and during recreation: twenty-four (46 per cent) of the fifty-two hips were in patients who performed manual labor, and another sixteen hips (31 per cent) were in patients who performed light labor (yard work, assembly-line work, and light sports activity). Few patients had difficulties with activities of daily living, used assistive devices for walking, or had a notable limp. All forty patients stated that they were satisfied with the results of the arthroplasty. The mean clinical score increased from 32 points (range, 0 to 80 points) preoperatively to 61 points (range, 23 to 80 points) at the time of the most recent follow-up.

Radiographic Results (Table III)

A radiolucent line was noted at the acetabular bone-cement interface of forty-eight (92 per cent) of the fifty-two hips. Migration of the acetabular component was seen in thirty-one hips (60 per cent) and was more common in manual laborers than in patients who were less active (p = 0.03). The relationship between migration of the acetabular component and a history of previous cup arthroplasty approached significance (p = 0.07). Probable loosening of the acetabular component was noted in thirty-five hips (67 per cent), and the probability of such loosening was 60 per cent after fifteen years (Fig. 2). Polyethylene wear was detected in thirty-two hips (62 per cent) and was associated with both acetabular loosening (p = 0.03) and resorption of the proximal-medial portion of the femoral neck (p = 0.01). Probable loosening of the femoral component was noted in ten hips (19 per cent), five of which had a fracture of the stem; the probability of such loosening was 20 per cent after fifteen years (Fig. 2).

Grading of Results (Table IV)

The result was graded as satisfactory (excellent or good) in twenty-six hips and as unsatisfactory (fair or poor) in twenty-six hips at the time of the most recent follow-up. Twenty-two of the twenty-six hips that had an unsatisfactory result had had radiographic evidence of loosening of the acetabular component; in addition, four painless hips (two patients) had an unsatisfactory result because the patient was unable to walk. The hips that were associated with a history of previous trauma had a lower mean score than those that were associated with other preoperative diagnoses (56 points compared with 76 points; p = 0.02).

Complications

Early postoperative complications included a subcutaneous hematoma that necessitated evacuation (three hips); a superficial infection, a deep infection, or a temporary peroneal palsy (two hips each); and instability or a temporary sciatic palsy (one hip each). The two superficial infections resolved after operative débridement. One deep (subfascial) infection persisted despite intravenous administration of antibiotics as well as multiple operative débridements; a resection arthroplasty was performed 3.5 months after the implantation of the prosthesis. The other deep infection was treated successfully with multiple operative debridements and the administration of antibiotics. Class-III heterotopic ossification⁵ was noted in two hips (two patients), and class-IV heterotopic ossification necessitated late excision to improve motion in three hips (two patients).

Miscellaneous Observations

Nearly all patients gained weight during the follow-up period; the mean weight increased from fifty-six kilograms (range, twenty-seven to 103 kilograms) preoperatively to sixty-seven kilograms (range, thirty-two to 141 kilograms) at the time of the most recent follow-up. Several women reported normal pregnancy, labor, and delivery⁴⁸.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The purpose of the present study was to document the long-term results of total hip arthroplasty with cement in adolescents. The relatively large number of patients and the variation in diagnostic categories enabled us to identify factors that were associated with satisfactory and unsatisfactory outcomes. The present study is the first of its kind, to our knowledge.

Kaplan-Meier survival analysis demonstrated a progressive increase in the probability of failure over time. An analysis of the failures revealed that problems were more common on the acetabular side. Symptomatic loosening of the acetabular component was responsible for 76 per cent (twenty-two) of the twenty-nine failures, and the probability of probable loosening after fifteen years was nearly three times higher for the acetabular component than it was for the femoral component (Fig. 2). In fact, forty (77 per cent) of fifty-two hips had absolutely no radiographic evidence of loosening³⁶ of the femoral component. It should be noted that reliable long-term fixation of the femoral component was achieved in this series with use of so-called first-generation cementing techniques^2,9,36,51. In addition, the results on the femoral side might have been even better if we had not included five hips in which the stem had fractured in the total of eight hips that were revised because of loosening of the femoral component (Table II). Although fractures of the stem commonly were associated with the early types of stainless-steel femoral components that had a high head-stem offset, this complication now occurs infrequently because of improvements in design and materials^11,13,23.

We compared the results of the present study with those reported by Kavanagh et al.³⁶ for a group of 300 adults (mean age, sixty-four years) who had had a similar procedure during a similar time-period at our institution. We purposely used the same definitions for clinical failure and radiographic loosening in order to allow for a more accurate comparison of survival rates. The probability of failure of the arthroplasty after fifteen years was much higher in the adolescents than it was in the adults (45 per cent compared with 13 per cent; p = 0.0001). Despite the limitations of a comparison with a historical control group, it was clear that the main reason for the significant difference was that the probability of loosening of the acetabular component was much higher in the adolescents than it was in the adults (60 per cent compared with 9 per cent; p = 0.0001). The probability of loosening of the femoral component in the adolescents actually was lower than that in the adults (20 per cent compared with 26 per cent; p = 0.03).

A number of authors have reported good results in association with cemented femoral components in young patients^{2,12,28,42,58}. The reason for this success is not well understood, as young patients routinely place high demands on the prosthesis. The superior quality of femoral bone stock in young patients may allow for more secure and durable fixation with cement than is possible in older patients^12,42.

The factors that are responsible for the high rates of loosening of the acetabular component in young patients^{2,12,18,31,38,39} are better understood. Adequate support for the acetabular component may be compromised by osseous defects resulting from dysplasia, previous infection, excessive reaming, and the erosive effect of cup arthroplasty^{12,15,16,22,38,39}. In the present series, six of the nine hips in which a previous cup arthroplasty had been performed had subsequent loosening of the cemented acetabular component. We also found that the probability of migration of the acetabular component was significantly higher among hips that were subjected to the demands of manual labor postoperatively than among those that were not (p = 0.03). In addition, radiographic evidence of polyethylene wear^44,63 was associated with probable loosening of the acetabular component (p = 0.03); this finding has not been reported previously, to our knowledge. Finally, some authors have speculated that growth of the immature pelvis after a total hip arthroplasty also may contribute to loosening of the acetabular component^43,52,60.

Although risk factors for the failure of cemented total hip prostheses in young patients have been proposed in the literature, significant associations have not been demonstrated^12,15,22. The significant risk factors identified in the present study provide a basis for rational decision-making when a young patient has a disabling disease involving the hip. Favorable candidates for total hip arthroplasty during adolescence are those who have a sedentary level of function because of some other musculoskeletal disease, who have a form of bilateral hip disease that is not treatable with an osteotomy, and who weigh sixty kilograms or less. These characteristics describe so-called low-demand patients, who usually have a systemic inflammatory disorder such as juvenile rheumatoid arthritis or ankylosing spondylitis. Not surprisingly, less favorable candidates are those who will place greater demands on the prosthesis. These so-called high-demand patients typically have unilateral hip disease, do not have other musculoskeletal disorders that limit activity, often have a history of post-traumatic avascular necrosis with multiple previous operative procedures, and weigh more than sixty kilograms. Our data and those of others^{6,7,10,19,34,35} suggest that either an arthrodesis or an osteotomy, when indicated, is a preferable option in this setting.

When planning an arthrodesis or an osteotomy for a young patient, the surgeon should consider the possible need for an eventual conversion to a total hip arthroplasty^{4,8,24,25,37,40,45,56,57}. Methods of arthrodesis that leave the abductor muscles and the greater trochanter intact are preferable^16,37. In addition, methods of proximal femoral osteotomy that preserve the intramedullary canal facilitate subsequent preparation of the femur for the insertion of a stemmed implant^6,7,12,57.

In the rare instance in which an adolescent is to be managed with a total hip arthroplasty, we currently avoid the use of acetabular components that are designed to be inserted with cement. This preference is based on the poor results that we have found with use of such components. Data regarding the long-term outcome of acetabular components that were inserted without cement in young patients are not yet available. Although our findings and those of others^2,9,10,14 indicate that cement can provide reliable long-term fixation of the femoral component in young patients, similar long-term studies of femoral components that were inserted without cement in such patients have not yet been published, to our knowledge. When this information becomes available, the present report may serve as a database for comparison.

Fixation of the femoral component aside, the long-term results of total hip arthroplasties performed with cement in adolescents were not encouraging. The probability of failure increased over time and reached nearly 50 per cent after fifteen years. The patients uniformly were satisfied despite this finding, probably because the disorders were severe and their expectations were limited. As a result of preoperative counseling, most patients viewed the arthroplasty realistically as a salvage procedure; while they appreciated its benefits, they fully expected eventual failure. Our findings suggest that total hip arthroplasty in adolescents should be reserved for carefully selected patients for whom alternative procedures are contraindicated or unacceptable.

References

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TABLE I PUBLISHED SERIES OF TOTAL HIP ARTHROPLASTY WITH CEMENT IN YOUNG PATIENTS

Study	Year of Publication	No. of Hips	Durat. of Follow-up*† (Yrs.)‡	Age†‡ (Yrs.)	Hips with Inflammatory Arthritis§ (Per cent)	Rate of Loosening‡¶ (Per cent)			Rate of Revision‡# (Per cent)
Over-All	Acetabular Compon.	Femoral Compon.	Over-All	Acetabular Compon.	Femoral Compon.
Arden et al.¹	1972	66	NR (<1—4)	28.8 (15—49)	100	3	3	0	0	0	0
Halley and Charnley²⁹	1975	68	3.3 (0.5—8.3)	25.9 (17—30)	82	1.5	1.5	0	2.9	0	2.9
Bisla et al.³	1976	67	2.7 (1—7)	24.8 (12—29)	87	1.5	NR	NR	0	0	0
Singsen et al.⁵⁴	1978	29	2.2 (1—4)	NR (12—18)	100	6.7	6.7	0	0	0	0
Colville and Raunio¹⁷	1979	59	2.5 (1—4.5)	30.5 (18—47)	100	0	0	0	0	0	0
Klassen et al.³⁹	1979	60	NR (1—15)	15 (12—19)	38	0	0	0	1.6	1.6	1.6
Chandler et al.¹²	1981	33	5.6 (4.8—7)	23 (14—36)	18	58	45	21	21.2	15.2	12.1
Dorr et al.²²	1983	108	4.5 (2—9.8)	30.5 (14—45)	33	33.3	14.8	24.1	17.6	13.9	12.9
Kunec⁴¹	1983	16	5.2 (3.8—10.5)	22 (17—33)	100	19	6.3	19	25	19	25
Collis¹⁵	1984	45	7.3 (5—11)	40.7 (23—49)	18	NR	8.9	8.9	8.9	2.2	6.6
Roach and Paradies⁴⁹	1984	10	7.9 (6—8)	13.2 (9—16)	100	33	33	0	33	33	0
Scott et al.⁵²	1984	64	5 (NR)	NR (>10)	100	9.4	6.3	6.3	6.3	6.3	3.1
Sharp and Porter⁵³	1985	73	6.6 (5—12)	32.7 (16—40)	38	19.2	16.4	5.5	19.2	17.8	9.6
Cornell and Ranawat¹⁸	1986	78	7.0 (4—13)	48.6 (NR—54)	0	5.1	3.8	1.2	3.8	3.8	1.2
Lachiwiecz et al.⁴²	1986	83	6.0 (2—11)	26 (NR)	100	NR	26	8	3.2	3.2	1.6
Ruddlesdin et al.⁵⁰	1986	75	5.4 (1—12)	14 (11—17)	100	2.7	1.3	1.3	1.3	0	1.3
Halley and Wroblewski³⁰	1986	49	9.5 (5—15.5)	26 (17—30)	74	16.3	14.3	4	20	18.4	10.2
White⁵⁹	1988	44	7.5 (5—10)	38 (24—44)	39	45	34	25	14	11.4	9.1
Learmonth et al.⁴³	1989	14	8.5 (4—11)	16 (12—22)	100	57	57	35.7	0	0	0
Gudmundsson et al.²⁷	1989	27	5.3 (3—10)	18 (13—26)	100	3.7	0	3.7	11.1	11.1	11.1
Dorr et al.²¹	1990	81	9.2 (5—16.5)	30 (NR—45)	33	63.6	NR	NR	40.9	33	33
Witt et al.⁶²	1991	96	11.5 (5.3—18.3)	16.7 (11—26)	100	NR	29	21.5	25	22	20
Klassen and Bianco³⁸	1991	65	8.0 (5—11)	16.8 (12—19)	34	NR	26.2	NR	15	10.8	6.2
Collis¹⁶	1991	51	NR (3—18)	40.7 (23.49)	18	NR	34.1	25	30	30	23
Cage et al.⁸	1992	29	10.6 (NR)	18.4 (15—21)	94	32	23	27	3.4	NR	NR
Barrack et al.²	1992	50	12 (10—14.8)	40.9 (18—50)	4	46	44	2	22	22	6
Solomon et al.⁵⁵	1995	130	7.3 (3—16)	38 (10—50)	37	19.2	9.2	11.5	10.8	4.6	8.5
Williams and McCullough⁶⁰	1993	57	4.7 (1.7—9)	16.4 (13.4—24)	100	24.6	24.6	7	4	2	2
Maric and Haynes⁴⁶	1993	13	11 (NR)	18 (14—20)	100	NR	18	29	7.7	0	7.7
Joshi et al.³³	1993	218	NR (<1—24)	32 (16—40)	53	NR	8	20	25	16	14
Sullivan et al.⁵⁸	1994	89	18 (16—22)	42 (18—49)	9	58	50	8	20	13	2
Current study	1996	63	11.0 (0.3—18.6)	17 (11—19)	32	69.2**	67.3**	19.2**	42.9	38.1	25.4

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TABLE I PUBLISHED SERIES OF TOTAL HIP ARTHROPLASTY WITH CEMENT IN YOUNG PATIENTS

Study	Year of Publication	No. of Hips	Durat. of Follow-up*† (Yrs.)‡	Age†‡ (Yrs.)	Hips with Inflammatory Arthritis§ (Per cent)	Rate of Loosening‡¶ (Per cent)			Rate of Revision‡# (Per cent)
Over-All	Acetabular Compon.	Femoral Compon.	Over-All	Acetabular Compon.	Femoral Compon.
Arden et al.¹	1972	66	NR (<1—4)	28.8 (15—49)	100	3	3	0	0	0	0
Halley and Charnley²⁹	1975	68	3.3 (0.5—8.3)	25.9 (17—30)	82	1.5	1.5	0	2.9	0	2.9
Bisla et al.³	1976	67	2.7 (1—7)	24.8 (12—29)	87	1.5	NR	NR	0	0	0
Singsen et al.⁵⁴	1978	29	2.2 (1—4)	NR (12—18)	100	6.7	6.7	0	0	0	0
Colville and Raunio¹⁷	1979	59	2.5 (1—4.5)	30.5 (18—47)	100	0	0	0	0	0	0
Klassen et al.³⁹	1979	60	NR (1—15)	15 (12—19)	38	0	0	0	1.6	1.6	1.6
Chandler et al.¹²	1981	33	5.6 (4.8—7)	23 (14—36)	18	58	45	21	21.2	15.2	12.1
Dorr et al.²²	1983	108	4.5 (2—9.8)	30.5 (14—45)	33	33.3	14.8	24.1	17.6	13.9	12.9
Kunec⁴¹	1983	16	5.2 (3.8—10.5)	22 (17—33)	100	19	6.3	19	25	19	25
Collis¹⁵	1984	45	7.3 (5—11)	40.7 (23—49)	18	NR	8.9	8.9	8.9	2.2	6.6
Roach and Paradies⁴⁹	1984	10	7.9 (6—8)	13.2 (9—16)	100	33	33	0	33	33	0
Scott et al.⁵²	1984	64	5 (NR)	NR (>10)	100	9.4	6.3	6.3	6.3	6.3	3.1
Sharp and Porter⁵³	1985	73	6.6 (5—12)	32.7 (16—40)	38	19.2	16.4	5.5	19.2	17.8	9.6
Cornell and Ranawat¹⁸	1986	78	7.0 (4—13)	48.6 (NR—54)	0	5.1	3.8	1.2	3.8	3.8	1.2
Lachiwiecz et al.⁴²	1986	83	6.0 (2—11)	26 (NR)	100	NR	26	8	3.2	3.2	1.6
Ruddlesdin et al.⁵⁰	1986	75	5.4 (1—12)	14 (11—17)	100	2.7	1.3	1.3	1.3	0	1.3
Halley and Wroblewski³⁰	1986	49	9.5 (5—15.5)	26 (17—30)	74	16.3	14.3	4	20	18.4	10.2
White⁵⁹	1988	44	7.5 (5—10)	38 (24—44)	39	45	34	25	14	11.4	9.1
Learmonth et al.⁴³	1989	14	8.5 (4—11)	16 (12—22)	100	57	57	35.7	0	0	0
Gudmundsson et al.²⁷	1989	27	5.3 (3—10)	18 (13—26)	100	3.7	0	3.7	11.1	11.1	11.1
Dorr et al.²¹	1990	81	9.2 (5—16.5)	30 (NR—45)	33	63.6	NR	NR	40.9	33	33
Witt et al.⁶²	1991	96	11.5 (5.3—18.3)	16.7 (11—26)	100	NR	29	21.5	25	22	20
Klassen and Bianco³⁸	1991	65	8.0 (5—11)	16.8 (12—19)	34	NR	26.2	NR	15	10.8	6.2
Collis¹⁶	1991	51	NR (3—18)	40.7 (23.49)	18	NR	34.1	25	30	30	23
Cage et al.⁸	1992	29	10.6 (NR)	18.4 (15—21)	94	32	23	27	3.4	NR	NR
Barrack et al.²	1992	50	12 (10—14.8)	40.9 (18—50)	4	46	44	2	22	22	6
Solomon et al.⁵⁵	1995	130	7.3 (3—16)	38 (10—50)	37	19.2	9.2	11.5	10.8	4.6	8.5
Williams and McCullough⁶⁰	1993	57	4.7 (1.7—9)	16.4 (13.4—24)	100	24.6	24.6	7	4	2	2
Maric and Haynes⁴⁶	1993	13	11 (NR)	18 (14—20)	100	NR	18	29	7.7	0	7.7
Joshi et al.³³	1993	218	NR (<1—24)	32 (16—40)	53	NR	8	20	25	16	14
Sullivan et al.⁵⁸	1994	89	18 (16—22)	42 (18—49)	9	58	50	8	20	13	2
Current study	1996	63	11.0 (0.3—18.6)	17 (11—19)	32	69.2**	67.3**	19.2**	42.9	38.1	25.4

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TABLE II REASON FOR FAILURE IN TWENTY-NINE HIPS

Reason for Failure (N = 29*)	Acetabular Component† (N = 26)	Femoral Component† (N = 16)
Symptomatic loosening	22	8 (5 fractured stems)

Instability	1	1

Pain without loosening	1	1

Acute infection	1	1

Unknown	0	5‡

Other	1§	0

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TABLE II REASON FOR FAILURE IN TWENTY-NINE HIPS

Reason for Failure (N = 29*)	Acetabular Component† (N = 26)	Femoral Component† (N = 16)
Symptomatic loosening	22	8 (5 fractured stems)

Instability	1	1

Pain without loosening	1	1

Acute infection	1	1

Unknown	0	5‡

Other	1§	0

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TABLE III RADIOGRAPHIC DATA ON TOTAL HIP COMPONENTS IMPLANTED WITH CEMENT IN PATIENTS LESS THAN TWENTY YEARS OLD

Acetabular component (n = 52*)
Migration†	31
Radiolucent line at bone-cement interface†
Incomplete	18
Complete	30
Polyethylene wear†	32
Mean wear (mm)	2
Probable loosening†‡	35
Mean score§ (points)	3

Femoral component (n = 52)
Migration†	9
Cement fracture†	4
Radiolucent line at prosthesis-cement interface†	4
Radiolucent line at bone-cement interface†
Incomplete	17
Complete	4
Resorption of proximal-medial portion of femoral neck†	15
Heterotopic ossification†¶
Class I	21
Class II	0
Class III	2
Class IV	3
Probable loosening†‡	10
Mode of failure†#
Type Ia	3
Type Ib	1
Type II	1
Type III	0
Type IV	5
Mean scores§ (points)	8

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TABLE III RADIOGRAPHIC DATA ON TOTAL HIP COMPONENTS IMPLANTED WITH CEMENT IN PATIENTS LESS THAN TWENTY YEARS OLD

Acetabular component (n = 52*)
Migration†	31
Radiolucent line at bone-cement interface†
Incomplete	18
Complete	30
Polyethylene wear†	32
Mean wear (mm)	2
Probable loosening†‡	35
Mean score§ (points)	3

Femoral component (n = 52)
Migration†	9
Cement fracture†	4
Radiolucent line at prosthesis-cement interface†	4
Radiolucent line at bone-cement interface†
Incomplete	17
Complete	4
Resorption of proximal-medial portion of femoral neck†	15
Heterotopic ossification†¶
Class I	21
Class II	0
Class III	2
Class IV	3
Probable loosening†‡	10
Mode of failure†#
Type Ia	3
Type Ib	1
Type II	1
Type III	0
Type IV	5
Mean scores§ (points)	8

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TABLE IV RESULTS AT TIME OF MOST RECENT FOLLOW-UP

Result*	Unrevised Hips†‡ (N = 28)	All Hips† (N = 52)
Excellent	10 (36%)	10 (19%)
Good	11 (39%)	16 (31%)
Fair	1 (4%)	1 (2%)
Poor	6 (21%)	25§ (48%)

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TABLE IV RESULTS AT TIME OF MOST RECENT FOLLOW-UP

Result*	Unrevised Hips†‡ (N = 28)	All Hips† (N = 52)
Excellent	10 (36%)	10 (19%)
Good	11 (39%)	16 (31%)
Fair	1 (4%)	1 (2%)
Poor	6 (21%)	25§ (48%)