JBJS | Charnley Total Hip Arthroplasty in Patients Less Than Fifty Years Old. A Twenty to Twenty-five-Year Follow-up Note*

The Journal of Bone & Joint Surgery, Volume 80, Issue 5

Articles | May 01, 1998

Charnley Total Hip Arthroplasty in Patients Less Than Fifty Years Old. A Twenty to Twenty-five-Year Follow-up Note*

JOHN J. CALLAGHAN, M.D.†; ERIN E. FOREST, M.D.†; JASON P. OLEJNICZAK, B.A.†, IOWA CITY; DEVON D. GOETZ, M.D.‡, WEST DES MOINES; RICHARD C. JOHNSTON, M.D.†, IOWA CITY, IOWA

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Investigation performed at the Iowa Methodist Medical Center, Des Moines, and the University of Iowa College of Medicine, Iowa City

The Journal of Bone & Joint Surgery. 1998; 80:704-14

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Abstract

We evaluated the results twenty to twenty-five years after ninety-three consecutive, non-selected Charnley total hip arthroplasties performed with cement by the senior one of us in sixty-nine patients who were less than fifty years old at the time of the procedure. Seventy of the seventy-two hips in the living patients were followed radiographically for at least twenty years.Twenty-seven hips (29 per cent) had a revision or a resection of the prosthesis during the follow-up period. The revision or the resection was performed because of aseptic loosening in twenty-one hips (23 per cent), infection in four (4 per cent), dislocation in one (1 per cent), and fracture of the femur in one. Eighteen acetabular components (19 per cent) and five femoral components (5 per cent) were revised because of aseptic loosening, and an additional fourteen acetabular components (15 per cent) and seven femoral components (8 per cent) demonstrated definite or probable radiographic loosening.The present study demonstrates the long-term durability of total hip arthroplasty performed with cement in an active population of patients. The fixation of the femoral component was found to perform better than that of the acetabular component at twenty to twenty-five years after the procedure.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

The ultimate challenge for orthopaedic surgeons who perform total hip arthroplasties is providing long-term function of the hip in young patients. In a previous study, Sullivan et al.²⁹ reported the results of Charnley total hip arthroplasties performed with cement by the senior one of us (R. C. J.) in patients who were less than fifty years old at the time of the operation and had been followed for an average of eighteen years (range, sixteen to twenty-two years). The purpose of the present study was to evaluate the results of the Charnley total hip arthroplasties in the same population of patients twenty to twenty-five years (average, twenty-three years) after the procedure.

*One or more of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. In addition benefits have been or will be directed to a research fund, foundation, educational institution, or other non-profit organization with which one or more of the authors is associated. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was National Institutes of Health Grant AR43314.

†Department of Orthopaedic Surgery, University of Iowa College of Medicine, Iowa City, Iowa 52242. E-mail address for Dr. Callaghan: john-callaghan@uiowa.edu.

‡Des Moines Orthopaedic Surgeons, 6001 Westown Parkway, West Des Moines, Iowa 50266-7702.

†Department of Orthopaedic Surgery, University of Iowa College of Medicine, Iowa City, Iowa 52242. E-mail address for Dr. Callaghan: john-callaghan@uiowa.edu.

‡Des Moines Orthopaedic Surgeons, 6001 Westown Parkway, West Des Moines, Iowa 50266-7702.

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Figs. 1-A, 1-B, and 1-C: Radiographs of a patient with congenital dysplasia of the hip who had a Charnley total hip replacement at the age of forty-seven years. Fig. 1-A: Radiograph made immediately after the operation.

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Fig. 1-B: Radiograph made ten years postoperatively, demonstrating a small radiolucent line (arrow) at the prosthesis-cement interface in zone 1 of Gruen et al.¹⁴.

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Fig. 1-C: Radiograph made twenty years postoperatively, demonstrating widening of the radiolucent line (arrow) but no changes in the bone-cement interface. The patient had occasional pain, performed light labor, used no support for walking, and was able to walk for at least thirty minutes. He walked with a slight abduction lurch. Flexion of the hip measured 0 to 125 degrees; abduction, 45 degrees; internal rotation, 20 degrees; and external rotation, 50 degrees.

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Figs. 2-A, 2-B, and 2-C: Radiographs of a patient with bilateral congenital dysplasia of the hip who had a bilateral Charnley total hip arthroplasty at the age of forty-seven years. Fig. 2-A: Preoperative radiograph.

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Fig. 2-B Radiograph made immediately after the operation.

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Fig. 2-C Radiograph made twenty-one years postoperatively, showing defects of the cement mantle (grade C2), medially at the tips of the femoral prostheses, with the bone-cement interface maintained throughout the follow-up period. The patient had no pain, performed light labor, and was able to walk an unlimited distance without a limp. Bilaterally, flexion measured 0 to 120 degrees; abduction, 40 degrees; internal rotation, 20 degrees; and external rotation, 45 degrees.

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Figs. 3-A, 3-B, and 3-C: Radiographs of a patient with bilateral primary osteoarthrosis who had a bilateral Charnley total hip arthroplasty at the age of forty-eight years. Fig. 3-A: Preoperative radiograph.

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Fig. 3-B Radiograph made immediately after the operation.

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Fig. 3-C Radiograph made twenty-two years postoperatively, showing maintenance of the bone-cement interfaces but marked wear of the acetabular component (0.27 millimeter a year) in the left hip. The patient performed light labor, walked an unlimited distance without support or a limp, and had slight pain. Flexion of the hips measured 0 to 120 degrees; abduction, 40 degrees; internal rotation, 25 degrees; and external rotation, 45 degrees.

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Figs. 4-A through 4-F: Survivorship curves, with 95 per cent confidence intervals, as determined with the Kaplan-Meier method^11,12,21. Fig. 4-A: Survivorship curve with revision for any reason as the end point.

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Fig. 4-B Survivorship curve with revision of either component because of aseptic loosening as the end point.

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Fig. 4-C Survivorship curve with revision of the femoral component because of aseptic loosening as the end point.

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Fig. 4-D Survivorship curve with revision of the acetabular component because of aseptic loosening as the end point.

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Fig. 4-E Survivorship curve with definite or probable radiographic loosening of the femoral component or revision because of aseptic loosening as the end point.

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Fig. 4-F Survivorship curve with definite or probable radiographic loosening of the acetabular component or revision because of aseptic loosening as the end point.

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TABLE I OUTCOMES AT THE LATEST FOLLOW-UP EVALUATION

*The numbers of the hips according to the different reasons for revision (loosening with infection, aseptic loosening, dislocation, and fracture of the femur) are in parentheses. Both hips that had a resection arthroplasty had an attempt at reimplantation before the resection. †One hip that had a resection had also had a revision.

Outcome	All Hips (N = 93)	Hips of Patients Who Were Alive at Least 20 Yrs. after Index Operation (N = 72)
Original prosthesis retained	66 (71%)	53 (74%)
Revision*
One	22 (1, 20, 0, 1)	16 (1, 14, 0, 1)
Two	4 (2, 1, 1, 0)	3 (1, 1, 1, 0)
Three	0	0
Resection arthroplasty†	2 (2, 0, 0, 0)	1 (1, 0, 0, 0)

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TABLE I OUTCOMES AT THE LATEST FOLLOW-UP EVALUATION

Outcome	All Hips (N = 93)	Hips of Patients Who Were Alive at Least 20 Yrs. after Index Operation (N = 72)
Original prosthesis retained	66 (71%)	53 (74%)
Revision*
One	22 (1, 20, 0, 1)	16 (1, 14, 0, 1)
Two	4 (2, 1, 1, 0)	3 (1, 1, 1, 0)
Three	0	0
Resection arthroplasty†	2 (2, 0, 0, 0)	1 (1, 0, 0, 0)

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Between the beginning of 1970 and the end of 1976, ninety-three Charnley total hip arthroplasties were performed with cement by the senior one of us in sixty-nine patients who were less than fifty years old. No other types of prostheses were used by the surgeon during this period. As mentioned, the results at an average of eighteen years were reported previously²⁹. The present study differs from the previous report in three ways. First, the present report includes four additional hips (two patients) that were treated with a narrow flatback Charnley stem that had been modified to fit a small femoral canal. Inclusion of these hips allows this series to be called consecutive and non-selective. Second, the observers who reviewed the radiographs in the present study were different than those who had reviewed the radiographs in the previous study. However, one of the new observers (J. J. C.) had been responsible for reviewing the radiographs in all of the other series, involving Charnley prostheses used in the general population, reported by the senior one of us^1,2,24,28,31. Thus, the present study may be compared more readily with those studies. Finally, the criteria used in the present study to determine loosening of the femoral and acetabular components were changed to conform to those in previous reports in which the Charnley prosthesis had been used in the general population^24,28.

A Charnley hip prosthesis (Thackray, Leeds, England, or Zimmer, Warsaw, Indiana) was used in all patients. A stainless-steel polished flatback or narrow femoral stem (modified to a thinner diameter in four hips) with a twenty-two-millimeter-diameter head and an ultra-high molecular weight polyethylene acetabular component with an outer diameter of either forty or forty-four millimeters were inserted with Simplex P cement (Howmedica, Rutherford, New Jersey). The cement was hand-packed, and the procedures were done through the transtrochanteric approach. No antibiotics were used perioperatively.

Charnley total hip arthroplasty was performed in ninety-three hips in sixty-nine patients. The average age at the time of the index operation was forty-two years (range, eighteen to forty-nine years). Thirty-five patients were women and thirty-four were men. Forty-four patients were in the fifth decade of life; fifteen, in the fourth decade; nine, in the third decade; and one was in the second decade. The diagnosis at the time of the operation was congenital dysplasia of the hip (twenty-eight hips), osteoarthrosis (eleven), post-traumatic osteoarthrosis (eleven), arthritis secondary to infection (eleven), rheumatoid arthritis (eight), slipped capital femoral epiphysis (eight), osteonecrosis (seven), previous poliomyelitis (four), Legg-Calvé-Perthes disease (two), and another condition (three).

The latest follow-up was performed at a minimum of twenty years after the index arthroplasty. We attempted to interview all living patients and the families of the patients who had died. The living patients either returned for a clinical and radiographic follow-up evaluation or, if they were unable to return, were asked to send radiographs (made locally) to us. All living patients were evaluated by one of us or were interviewed by telephone with use of a standard system of terminology for reporting results as described by and one of us and colleagues¹⁹. Twenty of the fifty-four living patients were interviewed by telephone, and thirty-four were interviewed and examined at the office of the senior one of us (R. C. J.). Radiographs made at least twenty years postoperatively (average, 23.3 years; range, twenty to twenty-five years) were available for seventy of the seventy-two hips in the living patients. Radiographs made fifteen years postoperatively were available for the two patients (two hips) who declined to have a radiograph made at twenty years. For the entire group of ninety-three hips, the average time from the operation to the latest radiograph was twenty years (range, five to twenty-five years). Fifty-four patients (seventy-two hips) were still alive twenty years or more after the operation, and fifteen patients (twenty-one hips) were not. None of the patients were lost to follow-up.

Radiographic Evaluation

Observations and measurements were based on anteroposterior radiographs of the pelvis, made early in the postoperative period and usually at five-year intervals thereafter until the latest follow-up visit. In order to correct for magnification, all measurements were standardized against the magnification of the measured size of the femoral head compared with the known size. Osteolysis was defined as any non-linear radiolucency at the bone-cement interface that was at least five millimeters long and was recorded according to the three acetabular zones described by DeLee and Charnley¹⁰ and the seven femoral zones delineated by Gruen et al.¹⁴. The position of the femoral stem was determined on the basis of the angle formed between the central axis of the prosthesis and the lateral endosteal cortex. Heterotopic ossification was graded according to the criteria of Brooker et al.⁵.

Loosening of the Femoral Component

The femoral cementing technique was graded according to the criteria of Schmalzried and Harris²⁷. Loosening of the femoral component was classified according to the criteria of Harris and McGann¹⁷. Definite loosening was defined as subsidence of the femoral component, a fracture of the cement or the stem, or a radiolucent line at the cement-prosthesis interface as seen on serial radiographs. (The last criterion was modified to include only radiolucent lines of more than one millimeter in width). These radiolucent lines always occurred in zone 1 of Gruen et al.¹⁴. Probable loosening was characterized by a continuous radiolucent line along the entire bone-cement interface. Possible loosening was indicated by a radiolucent line at the bone-cement interface that encompassed more than 50 but less than 100 per cent of the circumference of the stem on the anteroposterior radiograph. Any radiolucency between the prosthesis and the cement in zone 1, regardless of width, was recorded as debonding because this finding signified that, at least in that one area, the prosthesis was no longer in contact with the cement. However, many patients who had less than one millimeter of radiolucency between the cement and the prosthesis in zone 1 never had additional evidence of loosening (Figs. 1-A, 1-B, and 1-C). It is for this reason that this criterion was modified in all of our other studies^1,2,24,28,31.

Subsidence of the femoral component was determined with use of the method of Loudon and Charnley²³. It was defined as a decrease of at least five millimeters (with magnification taken into account), between the initial postoperative radiographs and those made at the latest follow-up evaluation, in the distance from a line drawn perpendicular to the central axis of the femoral stem and intersecting the tip of the stem and a line drawn perpendicular to the central axis and intersecting the point where the trochanteric wire passed through the lesser trochanter.

Loosening of the Acetabular Component

Definite loosening of the acetabular component was defined as migration of the component or any new fracture in the cement mantle; probable loosening, as radiolucency around 100 per cent of the component at the bone-cement interface; and possible loosening, as radiolucency around 50 to 99 per cent of the component at the bone-cement interface^17,18. Migration of the acetabular component was evaluated with use of the criteria of Massin et al.²⁵. On each radiograph, the vertical distance between the center of the cup and a line joining the two teardrops was measured, as was the horizontal distance between the center of the cup and a vertical line through the teardrop. The acetabular component was considered to have migrated if these distances varied by more than five millimeters, after correction for magnification, between the immediate postoperative radiographs and those made at the latest follow-up evaluation.

Wear

The amount of linear wear was determined by measuring the change in the shortest distance between the center of the femoral head and the periphery of the acetabular component as seen on the immediate postoperative radiographs compared with that seen on those made at the latest follow-up evaluation, as described by Livermore et al.²². Volumetric wear was calculated by multiplying pr² (where r is the radius of the femoral head) by the amount of linear wear. Measurements were made with a digitized stylus and tablet (Sigma Scan; Jandel Scientific, La Jolla, California) that had an accuracy of 0.25 millimeter. Magnification was standardized against the known circumference of the femoral head. All wear measurements were made by the same observer, who was experienced with this technique. We reported on intraobserver and interobserver variability with this technique in a previous study⁶.

Statistical Analysis

The Kaplan-Meier method was used to evaluate survival of the implant with regard to revision or radiographic loosening, or both^11,12,21. Survivorship curves with corresponding confidence intervals were generated, with failure defined according to six end points: (1) revision for any reason, (2) revision because of aseptic loosening of either component, (3) revision because of aseptic loosening of the acetabular component, (4) revision because of aseptic loosening of the femoral component, (5) definite or probable radiographic loosening of the acetabular component or revision because of aseptic loosening, and (6) definite or probable radiographic loosening of the femoral component or revision because of aseptic loosening.

The clinical and radiographic results were analyzed with the use of the two-tailed Fisher exact test for categorical variables. The Wilcoxon rank-sum test was used to compare rates of wear according to categorical variables as these rates were not normally distributed. The Spearman correlation coefficient was used to analyze the association between age and wear.

Results

Introduction | Materials and Methods | Results | Discussion | References

Clinical Results

At the time of follow-up, a minimum of twenty years after the operation, fifty-four patients (seventy-two hips) were alive and fifteen patients (twenty-one hips) had died. The average duration from insertion of the prosthesis to the time of death was eighteen years and eight months (range, one year and six months to twenty-three years). The average age of the fifty-four living patients was sixty-four years (range, thirty-nine to seventy-six years) at the time of the most recent evaluation.

Revision of the Original Prosthesis

Of the ninety-three hips, twenty-seven (29 per cent) had had a revision or a resection by the time of the latest follow-up evaluation. The revision or the resection was performed because of aseptic loosening in twenty-one hips (23 per cent), infection in four (4 per cent), dislocation in one (1 per cent), and fracture of the femur in one (Table I). Of the seventy-two hips in the fifty-four patients who were alive at least twenty years after the index operation, fifteen (21 per cent) had a revision because of aseptic loosening; two (3 per cent), because of infection; one (1 per cent), because of dislocation; and one, because of fracture of the femur. Thus, of the seventy-two hips in the patients who were still alive at least twenty years after the procedure, 26 per cent had had a revision.

Relief of Pain

Of the seventy-two hips in the patients who had survived at least twenty years after the index procedure, forty-one caused no pain, twenty-four caused slight pain, and seven caused occasional pain. None of the hips caused moderate pain that led the patient to modify his or her activities, and none caused severe pain. At the time of the most recent follow-up, two patients performed strenuous labor, eight performed moderate labor, thirty-three performed light labor, eleven were semi-sedentary, and none were sedentary. With the numbers available, neither pain nor activity was found to be associated with radiographic loosening (p > 0.05).

Satisfaction

Of the fifty-four patients who were still alive twenty years after the procedure, fifty-two considered the hip to have better function than before the operation, fifty-two considered the hip to be less painful, and fifty-two considered the result to be satisfactory. Two patients were dissatisfied with the result; one patient who had had a resection arthroplasty was dissatisfied because of multiple infections and attempts at revision, and the other patient was dissatisfied for reasons that were unclear.

Radiographic Results

Radiographs were made at least twenty years after the arthroplasty in seventy of the seventy-two hips in the patients who were still alive. The average time from the operation to the latest radiographic evaluation of these hips was 23.3 years (range, twenty to twenty-five years). For the two patients (two hips) who had declined to have a radiograph made twenty years after the operation, a radiograph made fifteen years postoperatively was available. For all ninety-three hips, the average time to the latest radiographic evaluation was twenty years (range, five to twenty-five years).

Grading of the Cementing Technique

The immediate postoperative radiographs were used to grade the cementing technique according to the criteria of Schmalzried and Harris²⁷. Eleven hips (12 per cent) were grade A; forty-four (47 per cent), grade B; two (2 per cent), grade C1 (cement voids); thirty-one (33 per cent), grade C2 (defects in the cement mantle) (Figs. 2-A, 2-B, and 2-C); and five (5 per cent), grade D. As has been stated, a hand-packing technique of cementing was used. We could detect no association, with use of the Fisher exact test, between the grade of the cementing technique and aseptic loosening of the femoral component (p = 0.559) or revision performed because of aseptic loosening of the femoral component (p = 1.000).

Wear and Osteolysis

Wear of the acetabular component was measured in all hips. The average amount of linear wear was 0.0928 millimeter (range, 0.0167 to 0.2754 millimeter) a year (Figs. 3-A, 3-B, and 3-C). The calculated volumetric wear averaged 104 cubic millimeters (range, eighteen to 342 cubic millimeters) a year. Revision because of aseptic loosening of the acetabular component was possibly associated with linear wear (average rate of wear, 0.113 millimeter a year for the revised components compared with 0.077 millimeter a year for the stable components), but, with the numbers available, the association could not be shown to be significant (p = 0.14) according to the Wilcoxon signed rank-sum test. The rate of wear of the acetabular components that had evidence of aseptic loosening was significantly higher than that of the stable acetabular components (0.113 compared with 0.072 millimeter of wear; p = 0.0293). With the numbers available, we could not detect an association between linear wear and the level of activity (p = 0.448) or gender (p = 0.473). We also could not detect a correlation between increased linear wear of the acetabular component and decreasing age, with use of the Spearman correlation coefficient (p = 0.7921, r = 0.04073). Of the seventy-two hips in the patients who had survived at least twenty years, ten (14 per cent) had femoral osteolysis in zone 7 and four (6 per cent) had femoral osteolysis in one (or more) of the other six zones. Expansile osteolysis developed around five acetabular components (7 per cent). Osteolysis was associated with acetabular revision (p = 0.04), acetabular loosening (p = 0.01), and wear (linear and volumetric) (p = 0.03).

Aseptic Loosening

Of the seventy-two hips in the fifty-four patients who were alive at least twenty years after the procedure, sixty-eight had not been revised because of deep infection, dislocation, or femoral fracture and sixty-six of them had been followed radiographically for at least twenty years. Of the sixty-eight hips, thirty had loosening of the acetabular component (definite in twenty-five and probable in five) and sixteen of those had been revised. Nine hips had definite loosening of the femoral component, and four of those had been revised (two because of fracture of the femoral stem and two because of loosening). Seven hips had possible loosening of the acetabular component, and no hip had possible loosening of the femoral component. Of all ninety-three hips (excluding the six that had been revised because of infection, dislocation, or fracture), thirty-two had loosening of the acetabular component (definite in twenty-five and probable in seven), and eighteen of those had been revised. In addition, twelve hips had definite loosening of the femoral component and five of those had been revised. Eight acetabular components and no femoral components had possible loosening.

The combined prevalence of definite and probable radiographic loosening of the femoral component, according to the modified criteria of Harris and McGann¹⁷, and of aseptic loosening of the femoral component that necessitated revision was 13 per cent (twelve hips) overall and 13 per cent (nine hips) in the group that had been followed for at least twenty years. The combined prevalence of definite and probable radiographic loosening of the acetabular component and of aseptic loosening of the acetabular component that necessitated a revision was 34 per cent (twenty-nine hips) overall and 46 per cent (thirty hips) in the group that had been followed radiographically for at least twenty years. There was a trend toward a significant relationship between aseptic loosening of the femoral component and osteolysis in zone 7 (p = 0.082). Twenty hips (22 per cent) in the entire group and seventeen (24 per cent) of the hips in the patients who had survived at least twenty years were found to have a radiolucent line at the femoral prosthesis-cement interface in zone 1 (so-called debonding) on radiographs made at the latest follow-up visit (Fig. 1-C).

Survivorship Analysis

Of the original ninety-three prostheses, sixty-six (71 per cent) were functioning at the latest follow-up evaluation or had been in place when the patient died. Of the seventy-two hips in the living patients, fifty-three (74 per cent) were functioning with the index prosthesis in place at least twenty years after the operation (Table I). No patient needed more than two revisions, and only two patients ultimately needed a resection arthroplasty (both because of infection after an attempt at reimplantation) during the minimum twenty-year follow-up period. Kaplan-Meier survivorship analysis^11,12,21, with 95 per cent confidence intervals, demonstrated that the probability of retention of the prosthesis at twenty-five years was 69 ± 10 per cent (Fig. 4-A). The probability of survival was 72 ± 10 per cent with revision because of aseptic loosening of either component as the end point (Fig. 4-B), 94 ± 5 per cent with revision because of aseptic loosening of the femoral component as the end point (Fig. 4-C), and 76 ± 10 per cent with revision because of aseptic loosening of the acetabular component as the end point (Fig. 4-D). With radiographic evidence of definite or probable loosening or revision because of aseptic loosening as the end point, the probability of survival was 89 ± 4 per cent for the femoral component and 68 ± 5 per cent for the acetabular component at twenty years and 75 ± 15 per cent and 54 ± 13 per cent, respectively, at twenty-five years (Figs. 4-E and 4-F).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

As Charnley⁸ stated, "The challenge comes when patients between 45 and 50 years of age are to be considered for the operation, because then every advance in technical detail must be used if there is to be a reasonable chance of 20 or more years of trouble-free activity." Long-term follow-up of this group of young patients is important in determining the optimum total hip arthroplasty as these patients have a long active life with use of the artificial hip. In the present study, we attempted to determine the long-term durability of the implant in this active population by evaluating the results an average of twenty years after the performance of Charnley total hip arthroplasty, by the same surgeon, in patients who were less than fifty years old. Although most patients were in the fourth or fifth decade of life, unlike those in many studies of younger populations^{3,4,7,9,13,15,16,20,26,30}, few had rheumatoid arthritis. Thus, other than the problem with the hip, our patients had few impairments that prevented activity. We consider this factor as well as the fact that no patients were lost to follow-up and that all of the operations were performed by the same surgeon to be the strengths of our study. The weaknesses include its retrospective nature, the use of only anteroposterior radiographs for evaluation, and the fact that radiographic evaluation was done by different observers than those in the previous study of this cohort. However, one of the observers was involved in the radiographic evaluation in all of the other studies, performed in the general population, that were done by the senior one of us^1,2,24,28,31. Thus, the present series can be readily compared with the other groups that were studied.

Twenty-one hips (23 per cent) were revised because of aseptic loosening during the follow-up interval. This outcome is remarkable when one considers the duration of follow-up in this active population, the fact that cementing was done with a hand-packing technique, and the fact that many hips demonstrated defects in the cement mantle. The prevalence of acetabular revision because of aseptic loosening increased from eleven (13 per cent) of eighty-four components at an average of eighteen years in the earlier study²⁹ to eighteen (19 per cent) of ninety-three components in the present study. The prevalence of femoral revision because of aseptic loosening increased from two (2 per cent) of eighty-four components in the earlier study to five (5 per cent) of ninety-three components. These results can be compared with those achieved by the senior one of us in another study²⁸, of 257 patients (322 hips) in the general population who had been followed for at least twenty years. In that study, eighteen (6 per cent) of 322 acetabular components and eight (2 per cent) of 322 femoral components were revised because of aseptic loosening. Thus, in both the general population and the younger patients, the frequency at which the acetabular components were revised because of loosening was approximately three times that of the femoral components. However, as we expected, the process was accelerated (approximately threefold) in the younger population. These results provide a comparison and a benchmark for future long-term studies in which different designs of components (both those inserted with cement and those inserted without it) and newer cementing techniques are used. Only with such comparisons, with variables such as the size of the femoral head, the surface finish of the femoral component, the cementing technique (when components are inserted with cement), and fixation of the components without cement, will it be possible to validate the potential benefits of newer procedures.

References

Introduction | Materials and Methods | Results | Discussion | References

Ash, S. A.; Callaghan, J. J.; and Johnston, R. C.: Revision total hip arthroplasty with cement after cup arthroplasty. Long-term follow-up. J. Bone and Joint Surg.,78-A: 87-93, Jan. 1996.78-A87 1996

Ballard, W. T.; Callaghan, J. J.; Sullivan, P. M.; and Johnston, R. C.: The results of improved cementing techniques for total hip arthroplasty in patients less than fifty years old. A ten-year follow-up study. J. Bone and Joint Surg.,76-A: 959-964, July 1994.76-A959 1994

Barrack, R. L.; Mulroy, R. D., Jr.; and Harris, W. H.: Improved cementing techniques and femoral component loosening in young patients with hip arthroplasty. A 12-year radiographic review. J. Bone and Joint Surg.,74-B(3): 385-389, 1992.74-B(3)385 1992

Bisla, R. S.; Inglis, A. E.; and Ranawat, C. S.: Joint replacement surgery in patients under thirty. J. Bone and Joint Surg.,58-A: 1098-1104, Dec. 1976.58-A1098 1976

Brooker, A. F.; Bowerman, J. W.; Robinson, R. A.; and Riley, L. H., Jr.: Ectopic ossification following total hip replacement. Incidence and a method of classification. J. Bone and Joint Surg.,55-A: 1629-1632, Dec. 1973.55-A1629 1973

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Fig. 1-B: Radiograph made ten years postoperatively, demonstrating a small radiolucent line (arrow) at the prosthesis-cement interface in zone 1 of Gruen et al.¹⁴.

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Fig. 2-B Radiograph made immediately after the operation.

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Fig. 3-B Radiograph made immediately after the operation.

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Fig. 4-B Survivorship curve with revision of either component because of aseptic loosening as the end point.

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Fig. 4-C Survivorship curve with revision of the femoral component because of aseptic loosening as the end point.

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Fig. 4-D Survivorship curve with revision of the acetabular component because of aseptic loosening as the end point.

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Fig. 4-E Survivorship curve with definite or probable radiographic loosening of the femoral component or revision because of aseptic loosening as the end point.

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Fig. 4-F Survivorship curve with definite or probable radiographic loosening of the acetabular component or revision because of aseptic loosening as the end point.

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TABLE I OUTCOMES AT THE LATEST FOLLOW-UP EVALUATION

Outcome	All Hips (N = 93)	Hips of Patients Who Were Alive at Least 20 Yrs. after Index Operation (N = 72)
Original prosthesis retained	66 (71%)	53 (74%)
Revision*
One	22 (1, 20, 0, 1)	16 (1, 14, 0, 1)
Two	4 (2, 1, 1, 0)	3 (1, 1, 1, 0)
Three	0	0
Resection arthroplasty†	2 (2, 0, 0, 0)	1 (1, 0, 0, 0)

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TABLE I OUTCOMES AT THE LATEST FOLLOW-UP EVALUATION

Outcome	All Hips (N = 93)	Hips of Patients Who Were Alive at Least 20 Yrs. after Index Operation (N = 72)
Original prosthesis retained	66 (71%)	53 (74%)
Revision*
One	22 (1, 20, 0, 1)	16 (1, 14, 0, 1)
Two	4 (2, 1, 1, 0)	3 (1, 1, 1, 0)
Three	0	0
Resection arthroplasty†	2 (2, 0, 0, 0)	1 (1, 0, 0, 0)