JBJS | Charnley Total Hip Arthroplasty with Cement : Minimum Twenty-five-Year Follow-up*

The Journal of Bone & Joint Surgery, Volume 82, Issue 4

Articles | April 01, 2000

Charnley Total Hip Arthroplasty with Cement : Minimum Twenty-five-Year Follow-up*

John J. Callaghan, M.D.†; Jay C. Albright, M.D.†; Devon D. Goetz, M.D.‡; Jason P. Olejniczak, B.A.†; Richard C. Johnston, M.D.†

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Investigation performed at Iowa Methodist Medical Center, Des Moines, and the University of Iowa College of Medicine, Iowa City, Iowa
*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 nonprofit 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 Orthopaedics, University of Iowa College of Medicine, Iowa City, Iowa 52242. E-mail address for J. J. Callaghan: john-callaghan@uiowa.edu.
‡Des Moines Orthopaedic Associates, 6001 Westown Parkway, West Des Moines, Iowa 50266.

The Journal of Bone & Joint Surgery. 2000; 82:487-487

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Abstract

Background: This report presents the results of the senior author's initial twenty-five-year experience with the use of Charnley total hip arthroplasty with cement. The purpose of this paper was to evaluate the long-term results of total hip arthroplasty.

Methods: Between July 1970 and April 1972, the senior author (R. C. J.) performed 330 Charnley total hip replacements with cement using a hand-packing cement technique in 262 patients. Fifty-one patients (sixty-two hips) who were alive at least twenty-five years postoperatively were evaluated from a clinical standpoint with use of a standard-terminology questionnaire. The average age of this group at the time of surgery was fifty-six years (range, thirty-five to seventy-one years) compared with sixty-five years (range, twenty-one to eighty-nine years) for the entire group. All patients were evaluated for radiographic changes at the time of their most recent follow-up. Of the fifty-one patients (sixty-two hips) who were alive at least twenty-five years postoperatively, thirty-one (thirty-six hips) had a follow-up radiograph made at a minimum of twenty-five years after the surgery. The average duration of radiographic follow-up for the fifty-one patients was 22.7 years (range, two to twenty-seven years).

Results: Of the sixty-two hips in the fifty-one patients who were alive at least twenty-five years postoperatively, fourteen (23 percent) had been revised. Three (5 percent) had the revision because of loosening with infection; eleven (18 percent), because of aseptic loosening; and none, because of dislocation. The prevalence of revision due to aseptic loosening of the acetabular component in all 316 hips (excluding those that were lost to follow-up or that were revised for infection or dislocation) was 6 percent (eighteen hips), whereas the prevalence in the fifty-nine hips (excluding the three revised for infection) in the patients who were alive at least twenty-five years after the arthroplasty was 15 percent (nine hips). The prevalence of revision because of aseptic loosening of the femoral component in all 316 hips was 3 percent (nine hips), and the prevalence in the fifty-nine hips in the living patients was 7 percent (four hips). In the group of living patients, osteolysis occurred in Gruen zone 1 or 7 in thirty-three hips and in Gruen zones 2 through 6 in two hips. Ballooning acetabular osteolysis occurred in five hips.

Of the 327 hips for which the outcome was known after a minimum of twenty-five years, 295 (90 percent) had retained the original implants until the patient died or until the most recent follow-up examination. Of the sixty-two hips in patients who lived for at least twenty-five years after the surgery, forty-eight (77 percent) had retained the original prosthesis.

Conclusions: Our follow-up study at twenty-five years following Charnley total hip arthroplasty with cement demonstrates the durability of the results of the procedure. These results should provide a means for comparison with the results of newer cementing techniques as well as those associated with newer cemented and cementless hip designs.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Evaluation of the long-term outcome of an operative procedure is important to determine the durability of the results of the procedure. In addition, it provides a means for comparison with the results of any changes in the procedure, including alterations in operative technique and implant design, that occur over time. This is especially true for the total hip arthroplasty procedure. The purpose of the present study was to evaluate the results at a minimum of twenty-five years after Charnley total hip arthroplasties performed by a single surgeon using a hand-packing cement technique. The hips had been previously evaluated at twenty years³⁴ as well as at earlier follow-up intervals^20,21.

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Fig. 1-A:: Figs. 1-A through 1-F: Survivorship curves as determined with the Kaplan-Meier method.
Fig. 1-A: Survivorship curve with revision for any reason as the end point.

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Fig. 1-B:: Survivorship curve with revision because of aseptic loosening as the end point.

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Fig. 1-C:: Survivorship curve with revision because of aseptic acetabular loosening as the end point.

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Fig. 1-D:: Survivorship curve with revision because of aseptic femoral loosening as the end point.

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Fig. 1-E:: Survivorship curve with definite or probable radiographic acetabular loosening as the end point.

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Fig. 1-F:: Survivorship curve with definite or probable radiographic femoral loosening as the end point.

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Fig. 2-A:: Figs. 2-A, 2-B, and 2-C: Radiographs of a semi-sedentary female homemaker who had a Charnley total hip arthroplasty because of osteoarthritis of the hip when she was fifty years of age and who was seventy-six years of age at the time of the most recent follow-up.
Fig. 2-A: Preoperative radiograph.

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Fig. 2-B: Early postoperative radiograph.

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Fig. 2-C:: Radiograph made twenty-six years after the index procedure. The patient had no pain in the hip and a slight limp for walks of as long as thirty minutes with a cane. The hip flexed from 0 to 120 degrees, abducted 40 degrees, externally rotated 30 degrees, and internally rotated 10 degrees.

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Fig. 3-A:: Figs. 3-A, 3-B, and 3-C: Radiographs of a female homemaker who had a Charnley total hip arthroplasty because of osteoarthritis of the hip when she was fifty-eight years of age and who was eighty-three years of age at the time of the most recent follow-up.
Fig. 3-A: Preoperative radiograph.

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Fig. 3-B: Early postoperative radiograph.

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Fig. 3-C: Radiograph made twenty-five years after the procedure, demonstrating intact acetabular and femoral bone-cement interfaces. The patient had occasional hip pain with prolonged activity. She was able to perform light labor, including gardening. She could walk for thirty to sixty minutes, and she used a cane for long walks.

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: TABLE ICombined Prevalence of Definite and Probable Aseptic Loosening*

*The values represent the numbers of hips.†At the time of death or of the latest follow-up evaluation.‡Of the original 330 hips, three were lost to follow-up, three were revised because of dislocation, and eight were revised because of infection, leaving 316 hips.§Three hips that were revised for infection were excluded.

Determinant of Loosening	All Hips† (N = 316‡)	Hips in Patients Alive = 25 Yrs. After Index Op. (N = 59§)
Acetabular component
Revision	18 (6%)	9 (15%)
Radiographic	27 (9%)	12 (20%)
Total	45 (14%)	21 (36%)
Femoral component
Revision	9 (3%)	4 (7%)
Radiographic	12 (4%)	1 (2%)
Total	21 (7%)	5 (8%)

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: TABLE ICombined Prevalence of Definite and Probable Aseptic Loosening*

Determinant of Loosening	All Hips† (N = 316‡)	Hips in Patients Alive = 25 Yrs. After Index Op. (N = 59§)
Acetabular component
Revision	18 (6%)	9 (15%)
Radiographic	27 (9%)	12 (20%)
Total	45 (14%)	21 (36%)
Femoral component
Revision	9 (3%)	4 (7%)
Radiographic	12 (4%)	1 (2%)
Total	21 (7%)	5 (8%)

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: TABLE IIReasons for Revisions

*One patient had acetabular revision secondary to dislocation and then sustained a fracture of the femoral component.

Reason	Hips for Which Outcome was Known at Latest Follow-up Visit* (N = 327)	Hips in Patients Alive = 25 Yrs. After Index Op. (N = 62)
Septic loosening	8 (2%)	3 (5%)
Aseptic loosening	22 (7%)	11 (18%)
Dislocation	3 (1%)	0
Total	33 (10%)*	14 (23%)

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: TABLE IIReasons for Revisions

*One patient had acetabular revision secondary to dislocation and then sustained a fracture of the femoral component.

Reason	Hips for Which Outcome was Known at Latest Follow-up Visit* (N = 327)	Hips in Patients Alive = 25 Yrs. After Index Op. (N = 62)
Septic loosening	8 (2%)	3 (5%)
Aseptic loosening	22 (7%)	11 (18%)
Dislocation	3 (1%)	0
Total	33 (10%)*	14 (23%)

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: TABLE IIIMost Recent Outcomes

*The reasons for the revisions are in parentheses (the number of hips with loosening associated with infection, the number with aseptic loosening, the number with dislocation).

Outcome	Hips for Which Outcome Was Known at Latest Follow-up Visit (N = 327)	Hips in Patients Alive = 25 Yrs. After Index Op. (N = 62)
Original prosthesis retained	295 (90%)	48 (77%)
Revision*
1	22 (0, 20, 2) (7%)	10 (0, 10, 0) (16%)
2	1 (0, 1, 0) (<1%)	1 (0, 1, 0) (2%)
3	2 (2, 0, 0) (1%)	2 (2, 0, 0) (3%)
Girdlestone resection*	7 (6, 0, 1) (2%)	1 (1, 0, 0) (2%)

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: TABLE IIIMost Recent Outcomes

*The reasons for the revisions are in parentheses (the number of hips with loosening associated with infection, the number with aseptic loosening, the number with dislocation).

Outcome	Hips for Which Outcome Was Known at Latest Follow-up Visit (N = 327)	Hips in Patients Alive = 25 Yrs. After Index Op. (N = 62)
Original prosthesis retained	295 (90%)	48 (77%)
Revision*
1	22 (0, 20, 2) (7%)	10 (0, 10, 0) (16%)
2	1 (0, 1, 0) (<1%)	1 (0, 1, 0) (2%)
3	2 (2, 0, 0) (1%)	2 (2, 0, 0) (3%)
Girdlestone resection*	7 (6, 0, 1) (2%)	1 (1, 0, 0) (2%)

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Between July 1970 and April 1972, 330 Charnley total hip arthroplasties in 262 patients were performed by the senior author (R. C. J.). The average age of the 128 men (159 hips) and 134 women (171 hips) was sixty-five years (range, twenty-one to eighty-nine years) at the time of the index arthroplasty. Fifty-one patients (sixty-two hips) were alive at least twenty-five years postoperatively; they had had an average age of fifty-six years (range, thirty-five to seventy-one years) at the time of the operation. The preoperative diagnosis was osteoarthritis in 245 (74 percent) of the 330 hips, rheumatoid arthritis in fifteen (5 percent), degenerative osteoarthritis secondary to congenital dysplasia of the hip in twenty-one (6 percent), traumatic osteoarthritis in twenty-five (8 percent), slipped capital femoral epiphysis in seven (2 percent), osteonecrosis in four (1 percent), Legg-Calvç¬erthes disease in one (less than 1 percent), ankylosing spondylitis in three (1 percent), acromegaly in three (1 percent), juvenile Otto pelvis in four (1 percent), and osteoarthritis with infection in childhood in two (1 percent). The arthroplasties were equally distributed between right and left hips (165 each).

A Charnley hip prosthesis was used in all patients. A stainless-steel polished stem with a 22.25-millimeter-diameter head (Charles F. Thackray, Leeds, Great Britain, or Zimmer, Warsaw, Indiana) and an ultra-high molecular weight polyethylene acetabular component with an outer diameter of either forty or forty-four millimeters were inserted with the use of Simplex P cement (Northhill Plastics, Great Britain, or Howmedica, Rutherford, New Jersey).

All operations were performed with the use of a lateral approach through an osteotomy of the greater trochanter. Complete capsulectomy was done routinely. The acetabular component was placed as far medially and inferiorly as possible. All loose cancellous bone was removed from the proximal part of the femur, and the cement was hand-packed, in the doughy phase, into the acetabulum and the femoral canal independently. The trochanter was reattached as far laterally as possible. All of the operations were performed in a standard (1950-vintage) operating room. Neither systemic antibiotics nor a body-exhaust system was used.

Postoperatively, the involved extremity was placed in balanced suspension for four to seven days. The patients were subsequently taught to walk with crutches, which they did for six weeks after discharge. They used a cane for an additional two to six months, until they could walk well without support.

All patients had been thoroughly evaluated preoperatively, with documentation of pain, gait, activity level, range of motion of the hip, and ability to perform activities of daily living. Most patients were followed at regular intervals; the short-term, ten-year, and twenty-year results have been reported previously^20,21,34.

Sixty-eight hips (21 percent) had been operated on before the index arthroplasty; eight of these hips had had more than one previous procedure. A cup arthroplasty had been performed in thirty-two hips; an endoprosthesis had been inserted without cement in twenty; an osteotomy had been performed in six; fixation of a fracture had been done in fifteen; and one hip each had had insertion of a Phemister bone graft for treatment of osteonecrosis, irrigation and dè¡²idement for treatment of infection in childhood, and an arthrodesis for treatment of osteoarthritis with infection.

Attempts were made to interview all 262 patients in the initial series or to contact their families. The surviving patients were asked to return for clinical and radiographic evaluation. Those who were unable to return were asked to have radiographs made locally and sent to us for evaluation. All of the living patients were evaluated either clinically or by telephone by us, with use of the standard system of terminology for the reporting of results that was described by Johnston et al.²². Members of the families of the patients who had died were interviewed to determine the function of the hip at the time of death. A complete functional assessment, through either a personal interview or an interview with a family member, was possible for 240 patients (298 hips); only the status of the hip with regard to whether it had been revised was known for twenty patients (twenty-nine hips).

After twenty-five years, of the 262 patients (330 hips), fifty-one (sixty-two hips) were still living. Two hundred and nine patients (265 hips) had died. Only two patients (three hips) were lost to follow-up. Thus, the status of 327 (99 percent) of the original 330 hips was known at the most recent follow-up examination. Thirty-one of the fifty-one living patients (thirty-six [58 percent] of the sixty-two hips) were evaluated clinically and with the use of an anteroposterior radiograph of the pelvis that included the tip of the femoral stem and was made at a minimum of twenty-five years after the index arthroplasty. Twenty-two of these patients (twenty-five hips) returned for examination, and nine (eleven hips) sent radiographs that had been made elsewhere. The twenty remaining patients (twenty-six hips) refused to have follow-up radiographs made and were evaluated on the basis of a telephone interview only. For these twenty remaining patients, the most recent radiographs had been made at a minimum of twenty years (fifteen hips), a minimum of ten years (five hips), a minimum of five years (four hips), or a minimum of two years (two hips) after the operation. In the group of 209 patients who were known to have died, the average interval from the index operation to the time of death was twelve years (range, 0.1 to twenty-five years) and the average interval from the index operation to the time that the most recent radiographs were made was nine years (range, zero to twenty-three years).

Radiographic Evaluation

Observations and measurements were based on anteroposterior radiographs of the pelvis that had been made early postoperatively and at the latest follow-up evaluation. All measurements and observations were agreed upon by two of us (J. J. C. and J. C. A.) who were not involved in the operations. In addition, interval radiographs were used to determine the time that various radiographic changes had occurred. Correction for magnification was made with use of a template with measured concentric circles, and the known diameter of the femoral head of the implant was compared with the diameter measured on the radiograph.

Radiolucent lines between the cement and bone, as seen on the anteroposterior radiograph, were recorded on the basis of the three acetabular zones described by DeLee and Charnley¹¹ and the seven femoral zones delineated by Gruen et al.^1,15.

Loosening of the femoral component was classified according to the criteria of Harris and McGann¹⁸. Definite loosening was defined as subsidence of the femoral component, fracture of the cement or stem, or the presence of a radiolucent line at the interface between the stem of the prosthesis and the cement that had not been seen on the immediate postoperative radiograph. (The third criterion was modified to apply to any radiolucency between the stem of the prosthesis and the cement of more than one millimeter in width.) Probable loosening was defined as the presence of a continuous radiolucent line along the entire bone-cement interface. Possible loosening was defined as a radiolucent line at the bone-cement interface that encompassed more than 50 percent but less than 100 percent of the circumference of the stem on at least one radiograph.

Subsidence of the femoral component was determined with the use of the method of Loudon and Charnley²⁶. A vertical line drawn through two measured midpoints on the distal (straight) part of the stem defined the central axis of the stem. Lines were then drawn perpendicular to this, at the distal tip of the stem and at the point where the trochanteric wire passed through the lateral cortex of the femur. The distance between these two lines was measured on the initial postoperative radiograph and on the radiograph that was made at the latest follow-up evaluation. Subsidence was defined as a difference in measurement (taking magnification into account) of more than five millimeters when the two radiographs were compared, fracture of the cement, or the presence of a superolateral radiolucent line of more than one millimeter in width at the cement-prosthesis interface.

Migration of the acetabular component was evaluated with the use of the criteria of Massin et al.²⁷. On each radiograph, the vertical distance between the center of the cup and a horizontal line through the teardrops was measured. Also, the distance between a vertical line through the teardrop and one through the center of the head (made at right angles to the horizontal line through the teardrops) was measured. If this distance varied by more than five millimeters between the radiograph that had been made immediately postoperatively and that made at the latest follow-up evaluation, or if any new crack was detected in the cement mantle around the prosthesis, the acetabular component was considered to have migrated. Definite loosening of the acetabular component was defined as migration of the component or the presence of a new fracture in the cement mantle; probable loosening, as a circumferential radiolucent line around 100 percent of the component at the bone-cement interface; and possible loosening, as a radiolucent line around 50 to 99 percent of the component at the bone-cement interface¹⁹.

The amount of wear of the acetabular component was determined with the use of the technique described by Livermore et al.²⁵. The linear wear rate was determined by measurement of the width of the acetabular cup along a line connecting the center of the femoral head to the acetabular cup-cement interface at its shortest distance. This measurement was made on the latest follow-up radiograph and then compared with the width on the initial postoperative radiograph. The radiographic measurements were made with the use of a digitizing pad (Sigma Scan, Jandel, California). The difference between the measured values determined the distance of linear migration of the femoral head, with the difference in magnification between the two radiographs taken into account.

Any bone loss in the periacetabular region of at least five millimeters in size that appeared cystic was recorded as osteolysis, as was any localized loss of the endosteal cortex of the femur. The position of the stem (varus, valgus, or neutral) was measured on each radiograph, by extension of the previously described line along the central axis of the stem distally and by determination of whether this line was parallel (neutral), divergent (valgus), or convergent (varus) in relation to a line drawn along the endosteal lateral cortex distally. Heterotopic bone, when present, was graded according to the classification system of Brooker et al.⁵.

The clinical and radiographic findings were analyzed with the use of a chi-square test with Yates correction when both variables were categorical and with the use of a one-way analysis of variance and a two-tailed t test when one variable was continuous. Multivariate regression analysis also was performed. Kaplan-Meier survivorship curves^12,13,23,30 with corresponding confidence intervals were calculated with failure defined according to six end points: revision or resection of all or part of the original prosthesis; aseptic loosening of either component or both components necessitating revision; aseptic loosening of the acetabular component necessitating revision; aseptic loosening of the femoral component necessitating revision; radiographic evidence of definite or probable loosening of the acetabular component, or aseptic loosening of the acetabular component necessitating revision; and radiographic evidence of definite or probable loosening of the femoral component, or aseptic loosening of the femoral component necessitating revision.

Results

Introduction | Materials and Methods | Results | Discussion | References

Clinical Results

At the time of the minimum twenty-five-year follow-up evaluation, the average age of the fifty-one patients who were still alive was eighty-one years (range, sixty-one to ninety-seven years). In the group of 209 patients who had died, the average age at the time of death had been eighty-seven years (range, seventy-three to 105 years). Twenty-five patients had died in the first five years after the index arthroplasty; forty-six, between five and ten years; sixty, between ten and fifteen years; forty-four, between fifteen and twenty years; and thirty-four, between twenty and twenty-five years.

A deep infection had developed in eight (2 percent) of the 327 hips for which the outcome at the last follow-up evaluation was known and in three (5 percent) of the sixty-two hips in the patients who were still alive at least twenty-five years after the arthroplasty. Fourteen (4 percent) of the 327 hips and none of the sixty-two hips had had a dislocation by the time of the latest follow-up. The trochanteric wire had been removed because of trochanteric bursitis in twenty-one (6 percent) of the 327 hips and six (10 percent) of the sixty-two hips.

Of the sixty-two hips in the patients who were still alive at least twenty-five years after the index arthroplasty, fifty (81 percent) caused no pain; nine (15 percent), slight pain; two (3 percent), moderate pain; and one (2 percent), severe pain. Of the fifty-one patients who were alive at least twenty-five years after the index arthroplasty, none performed heavy manual labor, four (8 percent) performed moderate manual labor, seventeen (33 percent) performed at least light labor on a regular basis, eleven (22 percent) were semi-sedentary, twelve (24 percent) were sedentary, and only seven (14 percent) were bedridden at the time of the latest follow-up. Eighteen (35 percent) of the fifty-one patients were able to walk without limitation, two (4 percent) could walk for thirty to sixty minutes, seven (14 percent) could walk for ten to thirty minutes, six (12 percent) could walk for two to ten minutes, four (8 percent) could walk for less than two minutes, and fourteen (27 percent) could not walk other than for transfers. Thirty (59 percent) of the fifty-one patients were able to maintain their own home, six (12 percent) lived in their own home with assistance, and fifteen (29 percent) needed someone to care for them full-time.

Sixty (97 percent) of the sixty-two hips in the group that survived for at least twenty-five years were considered satisfactory by the patient. One patient was dissatisfied because of the need for a revision secondary to infection, and the hip continued to be painful after the revision. Another patient was dissatisfied because of the need for two revisions secondary to aseptic loosening of the acetabular component.

Radiographic Results

Radiographs were made at a minimum of twenty-five years postoperatively for thirty-six (58 percent) of the sixty-two hips in the patients who were still alive. Of the other twenty-six hips, fifteen had been evaluated radiographically at least twenty years postoperatively; five, at least ten years postoperatively; four, at least five years postoperatively; and two (the infected hips), early postoperatively (at two years). The average interval between the index arthroplasty and the time that the most recent radiographs were made was 22.7 years for the patients who were alive at least twenty-five years postoperatively. Radiographs that had been made after a reasonably long-term follow-up interval (minimum, five years) were available for 251 of the 330 hips in the entire series. The average interval between the index arthroplasty and the time that the most recent radiographs were made for the entire series was twelve years (range, 0.1 to 27.4 years).

Acetabular wear was measured in the thirty-six hips that had been followed radiographically for at least twenty-five years. The average rate of linear acetabular wear was 0.0986 millimeter per year (range, 0.0 to 0.2449 millimeter per year). As determined with a Wilcoxon rank-sum test, the rate of acetabular wear was associated with the prevalence of revision because of aseptic loosening (p = 0.0006) and with the prevalence of radiographic loosening of the acetabular component (p = 0.012). There was no association between acetabular wear and loosening of the femoral component (p = 0.259) or osteolysis of the femur in Gruen zone 7 (p = 0.309).

Of the fifty-nine hips (excluding three revised for infection) in the patients who had survived for at least twenty-five years and who had been followed radiographically for at least five years, thirty-three (56 percent) had femoral osteolysis in zone 1 or 7 (the calcar area). Femoral osteolysis was uncommon (two hips [3 percent]) in zones 2 through 6. There was an association between femoral osteolysis and aseptic loosening that led to revision (chi-square test with Yates correction, p = 0.0184). Ballooning osteolysis of the acetabulum was also uncommon (five hips [8 percent]); it was associated with aseptic loosening that led to revision (chi-square test with Yates correction, p < 0.0001). The prevalence of radiolucent lines (of any thickness) at the prosthesis-cement interface (so-called debonding) in zone 1 of the femoral component was 22 percent (thirteen of the fifty-nine hips).

As mentioned, radiographic loosening was determined according to the modified criteria of Harris and McGann¹⁸ and the criteria of Hodgkinson et al.¹⁹, and the definition included revision of a component because of aseptic loosening. In the group of fifty-nine hips in the patients who had survived for at least twenty-five years after the index arthroplasty, had been followed radiographically for at least five years, and had not had revision because of infection, there was definite radiographic loosening of fourteen acetabular components (24 percent) and five femoral components (8 percent), probable loosening of seven acetabular components (12 percent) and no femoral components, and possible loosening of five acetabular components (8 percent) and two femoral components (3 percent). In the group of thirty-six hips that had long-term radiographic follow-up, nine acetabular components (25 percent) and four femoral components (11 percent) were definitely loose, five acetabular components (14 percent) and no femoral components were probably loose, and four acetabular components (11 percent) and two femoral components (6 percent) were possibly loose.

The combined prevalence of definite or probable radiographic loosening of the femoral component, according to the modified criteria of Harris and McGann¹⁸, and of aseptic loosening of the femoral component necessitating revision was 7 percent (twenty-one of the 316 hips that had not been lost to follow-up or revised because of infection or dislocation). The combined prevalence of definite or probable radiographic loosening of the acetabular component, as defined by Hodgkinson et al.¹⁹, and of aseptic loosening necessitating revision was 14 percent (forty-five of the 316 hips) (Table I).

Revision of the Original Prosthesis

Of the initial group of 327 hips, thirty-two (10 percent) had had a revision arthroplasty or a resection arthroplasty (Girdlestone procedure) at the time of the latest follow-up. The revision or Girdlestone procedure had been performed because of aseptic loosening in twenty-two hips (7 percent), loosening with infection in eight hips (2 percent), and dislocation in three hips (1 percent). (One patient had had a revision of only the acetabular component because of recurrent dislocations, two years after the index arthroplasty. Only the femoral component was revised, because of a fracture of the stem, at a second revision four years later. [As a side note, only three fractures of the stem occurred in the entire series.] For statistical purposes, the data for this patient were entered as one revision in the categories of both aseptic loosening and dislocation. [This accounts for the total number of thirty-two rather than thirty-three.]) Of the sixty-two hips in the patients who survived for at least twenty-five years after the index operation, eleven (18 percent) had had a revision because of aseptic loosening; three (5 percent), because of loosening with infection; and none, because of dislocation. The total prevalence of revision in these hips was 23 percent (Table II).

Five infections developed early (less than five years) after the operation. These infections developed at nine months, 1.3 years, 1.8 years, 2.5 years, and 4.5 years and were caused by Staphylococcus epidermidis, Escherichia coli, Staphylococcus aureus, alpha-hemolytic streptococcus, and microaerophilic peptostreptococci. In addition, three infections developed more than five years postoperatively: two, caused by Staphylococcus epidermidis, developed between five and six years postoperatively, and one, caused by beta-hemolytic streptococcus, developed at 6.5 years. The average interval between the index arthroplasty and revision done because of aseptic loosening was 14.2 years (range, 9.6 to 18.3 years) for the acetabular components and 14.6 years (range, 5.4 to 23.6 years) for the femoral components.

Of the eight hips that had loosening with infection, six eventually were treated with a Girdlestone procedure. The two remaining hips were subsequently revised three times. According to the chi-square test with Yates correction, the prevalence of loosening with infection was not associated with that of previous operations on the affected hip (p = 0.414) or with the type of the previous operation (p = 0.28).

The radiographs and operative notes for each hip that had been revised because of aseptic loosening were reviewed to determine whether the cause of failure had been loosening of the acetabular component or the femoral component, or both. Of the 316 hips (excluding those revised for infection or dislocation) for which the outcome was known at the latest follow-up evaluation, thirteen (4 percent) had been revised because of aseptic loosening of the acetabular component; four (1 percent), because of aseptic loosening of the femoral component; and five (2 percent), because of aseptic loosening of both components. Of the fifty-nine hips (excluding those revised for infection) in the patients who were still alive at least twenty-five years after the initial arthroplasty, seven (12 percent) had been revised because of aseptic loosening of the acetabular component; two (3 percent), because of aseptic loosening of the femoral component; and two (3 percent), because of aseptic loosening of both components. According to the chi-square test with Yates correction, aseptic loosening leading to revision was associated with male gender (p = 0.0018 for loosening of the acetabular component and p = 0.00117 for loosening of the femoral component) and with an age of less than fifty years at the time of the index arthroplasty (p = 0.0008). Although the prevalence of aseptic loosening leading to revision was higher in patients who had had a previous operation on the affected hip (9 percent compared with 6 percent in patients who had not had a previous operation), this was not a significant factor (p = 0.28, chi-square test with Yates correction). The rate of definite or probable aseptic loosening of the femoral component was higher in the twenty hips that had had previous insertion of an endoprosthesis without cement (p < 0.001): it occurred in five of these hips. However, it should be noted that at the time of the conversion of the femoral endoprosthesis no attempt was made to remove the entire fibrous membrane and neocortex, although we currently do this routinely.

Survivorship Analysis

The Kaplan-Meier method²³ was used to calculate the probability of retention of the original prosthesis from the time of the initial Charnley total hip arthroplasty to one of the six end points described in Materials and Methods. Survivorship curves, with 95 percent confidence intervals, were calculated (Fig. 1-A,Fig. 1-B,Fig. 1-C,Fig. 1-D,Fig. 1-E,andFig. 1-F).

The probability of retention of the prosthesis at the latest follow-up evaluation was 76 13 percent with revision for any reason as the end point, 83 8 percent with revision for aseptic loosening as the end point, 87 6 percent with aseptic loosening of the acetabular component necessitating revision as the end point, and 91 8 percent with aseptic loosening of the femoral component necessitating revision as the end point. With radiographic evidence of definite or probable loosening or aseptic loosening necessitating revision as the end point, the probability of survival of the femoral component was 75 23 percent and that of survival of the acetabular component was 48 19 percent.

The implant was retained in 295 (90 percent) of the 327 hips for which the outcome was known and in forty-eight (77 percent) of the sixty-two hips in the patients who were still alive at least twenty-five years after the index procedure (Table III). Other than one patient who had a resection arthroplasty for a dislocation, only patients in whom an infection of the hip had developed had a resection arthroplasty as the most recent outcome. Other than two hips that had an infection, only one hip had a second or third revision as the most recent outcome in this closely followed group of patients.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Few operations have been evaluated with regard to their results more than twenty-five years after they had been performed. The present study demonstrates the quarter-of-a-century durability of cemented Charnley total hip prostheses (Fig. 2-A,Fig. 2-B,Fig. 2-C,Fig. 3-A,Fig. 3-B,and Fig. 3-C). Ninety percent (295) of 327 hips functioned without the need for revision during the patient's lifetime or for at least twenty-five years after the procedure. Seventy-seven percent (forty-eight) of the sixty-two hips in patients still living at least twenty-five years after the procedure were still functioning with their original prosthesis, and only three hips had required more than one additional procedure. Only one hip revision (for fracture of the femoral component) was performed between the twenty and twenty-five-year follow-up intervals. This finding is probably partially related to the decreasing activity level with time.

The long-term problem associated with the Charnley total hip arthroplasty was revision for aseptic loosening, which was performed in 7 percent (twenty-two) of the 316 hips in the series (excluding those revised for infection or dislocation) and in 19 percent (eleven) of the fifty-nine hips in patients who were alive at least twenty-five years after the operation (excluding those revised for infection). In the patients who were alive at least twenty-five years postoperatively, acetabular revision was required twice as frequently as femoral revision, with prevalences of 15 percent (nine hips) and 7 percent (four hips), respectively. Radiographic loosening was also more common on the acetabular side (prevalence, 36 percent [twenty-one hips]) than on the femoral side (prevalence, 8 percent [five hips]) in this group of patients. These rates of radiographic loosening may be an underestimation of the twenty-five-year rates as not all living patients had a twenty-five-year follow-up radiograph. Revision because of aseptic loosening was associated with male gender, an age of less than fifty years, and previous insertion of an endoprosthesis without cement.

Penetration of the femoral head into the polyethylene acetabular component (with nine or eleven millimeters of polyethylene thickness) averaged 0.1 millimeter per year (range, 0.0 to 0.24 millimeter per year). Wear was associated with the prevalence of acetabular revision done because of aseptic loosening (p = 0.0006) and with the prevalence of radiographic loosening of the acetabular component (p = 0.012). Considering that the femoral head was 22.25 millimeters in diameter, the volumetric wear was remarkably low (average, thirty-nine cubic millimeters; range, zero to ninety-three cubic millimeters).

In addition to demonstrating the remarkable durability of the results of total hip arthroplasty, this study should provide the means for comparison with procedures performed with newer cementing techniques and newer designs, cemented and cementless, after there has been a similar duration of follow-up^{2-4,6-10,14,16-18,24,28,29,31-38}.

References

Introduction | Materials and Methods | Results | Discussion | References

Amstutz, H. C.; Markolf, K. L.; McNeice, G. M.; and Gruen, T. A.: Loosening of total hip components: cause and prevention. In The Hip. Proceedings of the Fourth Open Scientific Meeting of The Hip Society, pp. 102-116. St. Louis, C. V. Mosby, 1976.

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 Joint Surg, 76-A: 959-964, July 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 Joint Surg, 74-B(3): 385-389, 1992.

Beckenbaugh, R. D., and Ilstrup, D. M.: Total hip arthroplasty. A review of three hundred and thirty-three cases with long follow-up. J Bone Joint Surg, 60-A: 306-313, April 1978.

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

Carlsson, A. S., and Gentz, C.-F.: Postoperative dislocation in the Charnley and Brunswik total hip arthroplasty. Clin. Orthop., 125: 177-182, 1977.

Charnley, J.: Anchorage of the femoral head prosthesis to the shaft of the femur. J Bone Joint Surg, 42-B(1): 28-30, 1960.

Charnley, J.: The bonding of prostheses to bone by cement. J Bone Joint Surg, 46-B(3): 518-529, 1964.

Charnley, J., and Cupic, Z.: The nine and ten year results of the low-friction arthroplasty of the hip. Clin. Orthop., 95: 9-25, 1973.

Charnley, J.: Low Friction Arthroplasty of the Hip. Theory and Practice. New York, Springer, 1979.

DeLee, J. G., and Charnley, J.: Radiological demarcation of cemented sockets in total hip replacement. Clin. Orthop., 121: 20-32, 1976.

Dorey, F., and Amstutz, H. C.: Survivorship analysis in the evaluation of joint replacement. J. Arthroplasty, 1: 63-69, 1986.

Dorey, F., and Amstutz, H. C.: The validity of survivorship analysis in total joint arthroplasty. J. Bone and Joint Surg., 71-A: 544-548, April 1989.

García-Cimbrelo, E., and Munuera, L.: Early and late loosening of the acetabular cup after low-friction arthroplasty. J Bone Joint Surg, 74-A: 1119-1129, Sept. 1992.

Gruen, T. A.; McNeice, G. M.; and Amstutz, H. C.: "Modes of failure" of cemented stem-type femoral components. A radiographic analysis of loosening. Clin. Orthop., 141: 17-27, 1979.

Harris, W. H.: A new approach to total hip replacement without osteotomy of the greater trochanter. Clin. Orthop., 106: 19-26, 1975.

Harris, W. H.; McCarthy, J. C., Jr.; and O'Neill, D. A.: Femoral component loosening using contemporary techniques of femoral cement fixation. J Bone Joint Surg, 64-A: 1063-1067, Sept. 1982.

Harris, W. H., and McGann, W. A.: Loosening of the femoral component after use of the medullary-plug cementing technique. Follow-up note with a minimum five-year follow-up. J Bone Joint Surg, 68-A: 1064-1066, Sept. 1986.

Hodgkinson, J. P.; Shelley, P.; and Wroblewski, B. M.: The correlation between the roentgenographic appearance and operative findings at the bone-cement junction of the socket in Charnley low friction arthroplasties. Clin. Orthop., 228: 105-109, 1988.

Johnston, R. C.: Clinical follow-up of total hip replacement. Clin. Orthop., 95: 118-126, 1973.

Johnston, R. C., and Crowninshield, R. D.: Roentgenologic results of total hip arthroplasty. A ten-year follow-up study. Clin. Orthop., 181: 92-98, 1983.

Johnston, R. C.; Fitzgerald, R. H., Jr.; Harris, W. H.; Poss, R.; Muller, M. E.; and Sledge, C. B.: Clinical and radiographic evaluation of total hip replacement. A standard system of terminology for reporting results. J Bone Joint Surg, 72-A: 161-168, Feb. 1990.

Kaplan, E. L., and Meier, P.: Nonparametric estimation from incomplete observations. J. Am. Statist. Assn., 53: 457-481, 1958.

Kavanagh, B. F.; Dewitz, M. A.; Ilstrup, D. M.; Stauffer, R. N.; and Coventry, M. B.: Charnley total hip arthroplasty with cement. Fifteen-year results. J. Bone and Joint Surg., 71-A: 1496-1503, Dec. 1989.

Livermore, J.; Ilstrup, D.; and Morrey, B. F.: Effect of femoral head size on wear of the polyethylene acetabular component. J Bone Joint Surg, 72-A: 518-528, April 1990.

Loudon, J. R., and Charnley, J.: Subsidence of the femoral prosthesis in total hip replacement in relation to the design of the stem. J Bone Joint Surg, 62-B(4): 450-453, 1980.

Massin, P.; Schmidt, L.; and Engh, C. A.: Evaluation of cementless acetabular component migration. An experimental study. J. Arthroplasty, 4: 245-251, 1989.

Mulroy, R. D., Jr., and Harris, W. H.: The effect of improved cementing techniques on component loosening in total hip replacement. An 11-year radiographic review. J. Bone and Joint Surg., 72-B(5): 757-760, 1990.

Mulroy, W. F.; Estok, D. M.; and Harris, W. H.: Total hip arthroplasty with use of so-called second-generation cementing techniques. A fifteen-year-average follow-up study. J. Bone and Joint Surg., 77-A: 1845-1852, Dec. 1995.

Nelissen, R. G. H. H.; Brand, R.; and Rozing, R. M.: Survivorship analysis in total condylar knee arthroplasty. A statistical review. J Bone Joint Surg, 74-A: 383-389, March 1992.

Oh, I.; Carlson, C. E.; Tomford, W. W.; and Harris, W. H.: Improved fixation of the femoral component after total hip replacement using a methacrylate intramedullary plug. J Bone Joint Surg, 60-A: 608-613, July 1978.

Russotti, G. M.; Coventry, B.; and Stauffer, R. N.: Cemented total hip arthroplasty with contemporary techniques. A five-year minimum follow-up study. Clin. Orthop., 235: 141-147, 1988.

Schmalzried, T. P., and Harris, W. H.: Hybrid total hip replacement. A 6.5-year follow-up study. J. Bone and Joint Surg., 75-B(4): 608-615, 1993.

Schulte, K. R.; Callaghan, J. J.; Kelley, S. S.; and Johnston, R. C.: The outcome of Charnley total hip arthroplasty with cement after a minimum twenty-year follow-up. The results of one surgeon. J Bone Joint Surg, 75-A: 961-975, July 1993.

Smith, S. W.; Estok, D. M., II; and Harris, W. H.: Total hip arthroplasty with use of second-generation cementing techniques. An eighteen-year-average follow-up study. J Bone Joint Surg, 80-A: 1632-1640, Nov. 1998.

Stauffer, R. N.: Ten-year follow-up study of total hip replacement with particular reference to roentgenographic loosening of the components. J Bone Joint Surg, 64-A: 983-990, Sept. 1982.

Wroblewski, B. M.: 15-21-year results of the Charnley low-friction arthroplasty. Clin. Orthop., 211: 30-35, 1986.

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Fig. 1-A:: Figs. 1-A through 1-F: Survivorship curves as determined with the Kaplan-Meier method.
Fig. 1-A: Survivorship curve with revision for any reason as the end point.

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Fig. 1-B:: Survivorship curve with revision because of aseptic loosening as the end point.

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Fig. 1-C:: Survivorship curve with revision because of aseptic acetabular loosening as the end point.

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Fig. 1-D:: Survivorship curve with revision because of aseptic femoral loosening as the end point.

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Fig. 1-E:: Survivorship curve with definite or probable radiographic acetabular loosening as the end point.

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Fig. 1-F:: Survivorship curve with definite or probable radiographic femoral loosening as the end point.

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Fig. 2-B: Early postoperative radiograph.

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Fig. 3-B: Early postoperative radiograph.

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: TABLE ICombined Prevalence of Definite and Probable Aseptic Loosening*

Determinant of Loosening	All Hips† (N = 316‡)	Hips in Patients Alive = 25 Yrs. After Index Op. (N = 59§)
Acetabular component
Revision	18 (6%)	9 (15%)
Radiographic	27 (9%)	12 (20%)
Total	45 (14%)	21 (36%)
Femoral component
Revision	9 (3%)	4 (7%)
Radiographic	12 (4%)	1 (2%)
Total	21 (7%)	5 (8%)

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: TABLE ICombined Prevalence of Definite and Probable Aseptic Loosening*

Determinant of Loosening	All Hips† (N = 316‡)	Hips in Patients Alive = 25 Yrs. After Index Op. (N = 59§)
Acetabular component
Revision	18 (6%)	9 (15%)
Radiographic	27 (9%)	12 (20%)
Total	45 (14%)	21 (36%)
Femoral component
Revision	9 (3%)	4 (7%)
Radiographic	12 (4%)	1 (2%)
Total	21 (7%)	5 (8%)

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: TABLE IIReasons for Revisions

*One patient had acetabular revision secondary to dislocation and then sustained a fracture of the femoral component.

Reason	Hips for Which Outcome was Known at Latest Follow-up Visit* (N = 327)	Hips in Patients Alive = 25 Yrs. After Index Op. (N = 62)
Septic loosening	8 (2%)	3 (5%)
Aseptic loosening	22 (7%)	11 (18%)
Dislocation	3 (1%)	0
Total	33 (10%)*	14 (23%)

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: TABLE IIReasons for Revisions

*One patient had acetabular revision secondary to dislocation and then sustained a fracture of the femoral component.

Reason	Hips for Which Outcome was Known at Latest Follow-up Visit* (N = 327)	Hips in Patients Alive = 25 Yrs. After Index Op. (N = 62)
Septic loosening	8 (2%)	3 (5%)
Aseptic loosening	22 (7%)	11 (18%)
Dislocation	3 (1%)	0
Total	33 (10%)*	14 (23%)

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: TABLE IIIMost Recent Outcomes

*The reasons for the revisions are in parentheses (the number of hips with loosening associated with infection, the number with aseptic loosening, the number with dislocation).

Outcome	Hips for Which Outcome Was Known at Latest Follow-up Visit (N = 327)	Hips in Patients Alive = 25 Yrs. After Index Op. (N = 62)
Original prosthesis retained	295 (90%)	48 (77%)
Revision*
1	22 (0, 20, 2) (7%)	10 (0, 10, 0) (16%)
2	1 (0, 1, 0) (<1%)	1 (0, 1, 0) (2%)
3	2 (2, 0, 0) (1%)	2 (2, 0, 0) (3%)
Girdlestone resection*	7 (6, 0, 1) (2%)	1 (1, 0, 0) (2%)

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: TABLE IIIMost Recent Outcomes

*The reasons for the revisions are in parentheses (the number of hips with loosening associated with infection, the number with aseptic loosening, the number with dislocation).

Outcome	Hips for Which Outcome Was Known at Latest Follow-up Visit (N = 327)	Hips in Patients Alive = 25 Yrs. After Index Op. (N = 62)
Original prosthesis retained	295 (90%)	48 (77%)
Revision*
1	22 (0, 20, 2) (7%)	10 (0, 10, 0) (16%)
2	1 (0, 1, 0) (<1%)	1 (0, 1, 0) (2%)
3	2 (2, 0, 0) (1%)	2 (2, 0, 0) (3%)
Girdlestone resection*	7 (6, 0, 1) (2%)	1 (1, 0, 0) (2%)