Thirty-five-Year Results After Charnley Total Hip Arthroplasty in Patients Less Than Fifty Years Old

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1 1814 COPYRIGHT Ó 2014 BY THE JOURAL OF BOE AD JOIT SURGERY, ICORPORATED Thirty-five-Year Results After Charnley Total Hip Arthroplasty in Patients Less Than Fifty Years Ol A Concise Follow-up of Previous Reports* Lucian C. Warth, MD, John J. Callaghan, MD, Steve S. Liu, MD, Alison L. Klaassen, MA, Devon D. Goetz, MD, an Richar C. Johnston, MD Investigation performe at the Department of Orthopaeic Surgery, University of Iowa Hospitals an Clinics, Iowa City, an Des Moines Orthopaeic Surgeons, West Des Moines, Iowa Abstract: We report the upate results for a previously escribe cohort of patients who were less than fifty years ol at the time of the inex Charnley total hip arthroplasty with cement. The original cohort consiste of ninety-three consecutive hips in sixty-nine patients. The patients were followe for a minimum of thirty-five years after surgery or until eath. At the latest follow-up evaluation, there were forty-one total hip replacements (44%) in thirty-two living patients. Thirty-four (37%) of the ninety-three total hip replacements in the original cohort ha been revise or remove. Twenty acetabular (22%) an seven femoral (8%) components ha been revise for aseptic loosening. Since the twenty-five-year follow-up, the average six-minute-walk istance ecrease from 395 m to 171 m, an this ecrease correlate with increasing comorbiity. This stuy emonstrates the urability of cemente total hip replacements in a young patient population. Although 63% (fiftynine) of the ninety-three original hip replacements were functioning at the latest follow-up or at the time of eath, a significant ecrease in activity level was seen over time (p < 0.001). Of the forty-one original implants in the patients who were alive at the time of the thirty-five-year follow-up, only 46% (nineteen) were retaine. Level of Evience: Therapeutic Level IV. See Instructions for Authors for a complete escription of levels of evience. Peer Review: This article was reviewe by the Eitor-in-Chief an one Deputy Eitor, an it unerwent bline review by two or more outsie experts. It was also reviewe by an expert in methoology an statistics. The Deputy Eitor reviewe each revision of the article, an it unerwent a final review by the Eitor-in-Chief prior to publication. Final corrections an clarifications occurre uring one or more exchanges between the author(s) an copyeitors. Backgroun The purpose of the present stuy was to evaluate the results thirty-five years after Charnley total hip arthroplasty in a previously reporte group of patients less than fifty years ol at the time of inex arthroplasty 1-3. We inclue ata on patient function an raiographic follow-up. This series of patients represents a consecutive, nonselecte cohort with all arthroplasties performe by a single surgeon (R.C.J.). In the original cohort, Charnley total hip arthroplasty was performe in ninety-three hips in sixty-nine patients. The *Original Publications Sullivan PM, MacKenzie JR, Callaghan JJ, Johnston RC. Total hip arthroplasty with cement in patients who are less than fifty years ol. A sixteen to twentytwo-year follow-up stuy. J Bone Joint Surg Am Jun;76(6): Callaghan JJ, Forest EE, Olejniczak JP, Goetz DD, Johnston RC. Charnley total hip arthroplasty in patients less than fifty years ol. A twenty to twenty-fiveyear follow-up note. J Bone Joint Surg Am May;80(5): Keener JD, Callaghan JJ, Goetz DD, Peerson DR, Sullivan PM, Johnston RC. Twenty-five-year results after Charnley total hip arthroplasty in patients less than fifty years ol: a concise follow-up of a previous report. J Bone Joint Surg Am Jun;85(6): Disclosure: One or more of the authors receive payments or services, either irectly or inirectly (i.e., via his or her institution), from a thir party in support of an aspect of this work. In aition, one or more of the authors, or his or her institution, has ha a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomeical arena that coul be perceive to influence or have the potential to influence what is written in this work. Also, one or more of the authors has ha another relationship, or has engage in another activity, that coul be perceive to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitte by authors are always provie with the online version of the article. J Bone Joint Surg Am. 2014;96:

2 1815 T HE J OURAL OF B OE &JOIT SURGERY JBJS. ORG THIRTY- FIVE-YEAR R ESULTS A FTER C HARLEY TOTAL H IP A RTHROPLASTY I PATIETS <50 YEARS O LD TABLE I umber of Revisions at Time of Final Follow-up Outcome All Hips* ( = 93) Hips of Patients Alive at 35 Years Following Inex Surgery* ( = 41) Original prosthesis retaine 59 (63%) 19 (46%) Revision One 24 (3, 10, 0, 0) 16 (5, 11, 0, 0) Two 7 (2, 2, 1, 2) 5 (0, 2, 1, 2) Three 1 (0, 1, 0, 0) 1 (0, 1, 0, 0) Resection arthroplasty 2 (2, 0, 0, 0) 2 (2, 0, 0, 0) *The numbers of hips accoring to the ifferent reasons for revision (infection, aseptic loosening, islocation, an femoral fracture) are given in parentheses. average age at the time of the inex proceure was forty-two years (range, eighteen to forty-nine years). Thirty five patients were women, an thirty-four patients were men. A Charnley hip prosthesis (Thackray, Lees, Englan, or Zimmer, Warsaw, Iniana) was use in all patients. A stainless-steel polishe flatback or narrow femoral stem (moifie to a thinner iameter in four hips) with a 22-mm-iameter hea an an ultra-high molecular weight polyethylene acetabular component were inserte with cement. The cement was han-packe, with surgery performe through the transtrochanteric approach. o antibiotics were use perioperatively (Fig. 1). Methos Raiographs were mae at a minimum of thirty-five years (range, 35.1 to 40.8 years; average, 36.9 years) postoperatively for thirty-one of thirty-nine hips in living patients (excluing two previously explante hips). Observations an serial measurements were base on anteroposterior pelvic raiographs mae early in the postoperative perio an usually at five-year intervals thereafter until the latest follow-up visit. Raiographic analysis of heterotopic ossification, femoral Fig. 1 Preoperative (left), postoperative (center), an thirty-five-year follow-up raiographs (right) of a female patient who unerwent Charnley total hip arthroplasty at the age of forty-five years for en-stage arthritis seconary to evelopmental ysplasia of the hip. Although there is a broken trochanteric fixation wire, the trochanter remains unite an there are no substantial raiolucencies aroun the acetabular or femoral components. The Harris hip score was 86 points at both the twenty-five an thirty-five-year follow-up evaluations.

3 1816 T HE J OURAL OF B OE &JOIT SURGERY JBJS. ORG THIRTY- FIVE-YEAR R ESULTS A FTER C HARLEY TOTAL H IP A RTHROPLASTY I PATIETS <50 YEARS O LD an the cement in zone 1 of Gruen et al. 5, regarless of with, was recore as eboning. We quantifie eboning accoring to the system escribe by Berry et al. 11. All patients complete a self-aministere Western Ontario an McMaster Universities Osteoarthritis Inex (WOMAC) test 12 (paper questionnaire form), an Harris hip scores 13 were calculate for each patient at his or her current level of function. All available patients ha a supervise sixminute walk test that was compare with previously reporte ata for this cohort 14, as well as preicte istance using reference formulas generate from a group of selecte, healthy, age-matche subjects as reporte by Enright an Sherrill 15. Activity was further assesse using a StepWatch Activity Monitor (StepWatch; Orthocare Innovations, Mountlake Terrace, Washington) 16,17. Statistical Analysis The Kaplan-Meier metho was use to evaluate the survival of the implant with regar to revision, raiographic loosening, or both Survivorship curves, with corresponing confience intervals, were generate, with failure efine accoring to six commonly cite en points (Fig. 2; see Appenix). The Stuent t test was use to analyze normally istribute functional scores. Source of Funing The Bierbaum Research Fun (institutional funs) was the source of funing for this stuy. Fig. 2 Kaplan-Meier survivorship curve with revision for any reason as the en point. The calculate Kaplan-Meier implant survivorship at the thirty-fiveyear follow-up with revision for any reason as the en point was 57.6% (95% confience interval, 45.7% to 69.5%). cement grae, osteolysis, an loosening of the acetabular an femoral components were performe with the same methos reporte in earlier follow-up stuies of the same patient cohort Any raiolucency between the prosthesis Results At the time of clinical follow-up at a minimum of thirty-five years after the inex arthroplasty, thirty-two patients (fortyonehips;44%)werealiveanthirty-sevenpatients(fifty-two hips) ha ie. The average age of the thirty-two living patients was seventy-eight years an six months. One patient (one hip) was lost to follow-up, leaving thirty-one patients (forty hips) available for stuy inclusion. The patient lost to follow-up previously ha a resection arthroplasty for eep infection (Fig. 3). Twenty (65%) of thirty-one patients wore a peometer. Twenty patients (65%) complete a six-minute walk. Twenty-two (71%) of thirty-one patients complete the Short Form (SF)-36, WOMAC, an Harris hip score questionnaires. Raiographs were mae at a minimum of thirty-five years (average, 36.9 years) postoperatively for thirty-one (79%) of thirty-nine hips in living patients (two hips were exclue seconary to resection arthroplasty for infection). Fig. 3 Raiographic an clinical follow-up flowchart.

4 1817 T HE J OURAL OF B OE &JOIT SURGERY JBJS. ORG THIRTY- FIVE-YEAR R ESULTS A FTER C HARLEY TOTAL H IP A RTHROPLASTY I PATIETS <50 YEARS O LD Revision of the Original Prosthesis Of the ninety-three original hips, thirty-four (37%) ha unergone either a revision or resection arthroplasty at the latest clinical follow-up. The revision (thirty-two hips) or resection (two hips) was performe because of aseptic loosening in twentyfour hips (26%); infection in seven (8%), incluing the two that ha resection; periprosthetic fracture in two (2%); an recurrent islocationinonehip(1%). Of the forty-one hips in thirty-two patients living thirtyfive years after the inex operation, twenty-two hips (54%) ha ha a revision or resection arthroplasty. The reason for revision or resection was aseptic loosening in fourteen hips (34%); infection in five hips (12%), incluing the two that ha resection; fracture of the femur in two (5%); an recurrent islocation in one hip (2%). A single patient require more than two revisions (Table I). Since the minimum twenty-five-year follow-up 3, eight aitional revisions were performe, with three being rerevisions. Two hips were revise for infection; one was revise for aseptic acetabular loosening; one, for aseptic femoral loosening; an one, for both femoral an acetabular aseptic loosening (see Appenix). Function Functional evaluations were complete for twenty-two patients with at least thirty-five years of follow-up since the inex arthroplasty. The SF-36 physical component summary scores of the stuy group ecrease significantly over the twenty-five-year to thirty-five-year follow-up interval from 43.3 to 33.9 (p = ). The SF-36 mental component summary score i not emonstrate an appreciable ecline (53.1 an 53.6 at the twentyfive an thirty-five-year follow-up, respectively). The Harris hip scores of the stuy group were significantly ecrease over the twenty-five to thirty-five-year follow-up interval from 86.9 to 61.9 points (p < 0.001). The WOMAC subscales for pain an stiffness i not emonstrate any significant change between the follow-up time points (p = 0.62 an p = 0.17, respectively), while the WOMAC subscale for function emonstrate a ecline from 13.6 to 22.7 over the interval (p = 0.03) (see Appenix). Activity A six-minute-walk performance test was obtaine for twenty (65%) of thirty-one available patients. Average walking istance for all patients was 171 m. This compares with the results of the same cohort at the twenty-five-year follow-up time point of 395 m, suggesting that function ha ecrease significantly, by approximately 57% (p < 0.001). In patients with two or more comorbiities, walking istance was less than half of that of the healthier subgroup (112 m versus 242 m; p = 0.002) (see Appenix). This corroborates the significant ifference in sixminute-walk istance base on increasing meical an musculoskeletal comorbiity in these patients emonstrate at the twenty-five-year follow-up. StepWatch Activity Monitor ata were collecte for twenty (65%) of thirty-one patients. The average calculate yearly step count for all patients was 705,000 steps. Increasing comorbiity was significantly correlate with ecreasing peometer performance. The subgroup with two or more comorbiities ha an average calculate yearly step count of 469,000 steps (range, 17,000 to 1,205,000 steps), while the healthier subgroup ha a step count of 942,000 steps (range, 195,000 to 1,494,000 steps) (p = 0.003). Raiographic Results Of the original ninety-three hips (excluing the ten that ha been revise because of infection, periprosthetic fracture, or islocation), thirty-five ha loosening of the acetabular component, an twenty of those ha been revise. Seventeen hips ha raiographic loosening of the femoral components, an seven of them ha been revise. Since the time of the twentyfive-year follow-up, in aition to the three hips that were revise for aseptic loosening, there were two hips with acetabular loosening an two with femoral loosening. The combine prevalence of efinite or probable raiographic loosening of the femoral component an aseptic loosening of the femoral componentthatrequirerevisionwas18%(seventeenhips) overall an 24% (ten hips) in patients with a minimum followup of thirty-five years. The combine prevalence of efinite or probable raiographic loosening of the acetabular component an aseptic loosening of the acetabular component that necessitate revision was 38% (thirty-five hips) overall an 49% (twenty hips) in patients with a minimum follow-up of thirtyfive years. Component Survivorship Analysis Of the original ninety-three prosthetic hips, fifty-nine (63%) were functioning at the latest follow-up evaluation or at the time of eath of the patient. Of the forty-one hips in living patients, nineteen (46%) were functioning with the inex prosthesis in place at least thirty-five years after implantation. We were unable to emonstrate a significant relationship between the ecae of life at the time of inex surgery an the prevalence of aseptic loosening or revision of either component (p > 0.05). The changes in revision an raiographic survivorship since the twenty-five-year follow-up evaluation are summarize in a table (see Appenix). Conclusions Compare with the finings in our previous reports on this cohort of young patients who unerwent Charnley total hip arthroplasty 1-3,14, acetabular component loosening continues to progress with time. Two aitional hips (2%) require revision because of acetabular component loosening, an an aitional two hips (2%) ha raiographic signs of acetabular component loosening. Femoral sie failure was emonstrate in two patients (2%) requiring revision. At a minimum thirty-five-year follow-up, overall component failure for aseptic loosening was twice as high on the acetabular sie as on the femoral sie (38% versus 18%). Compare with the twenty-five-year follow-up report, patientfunction atthethirty-five-year follow-up, as emonstrate

5 1818 T HE J OURAL OF B OE &JOIT SURGERY JBJS. ORG THIRTY- FIVE-YEAR R ESULTS A FTER C HARLEY TOTAL H IP A RTHROPLASTY I PATIETS <50 YEARS O LD by the six-minute walk, ha ecrease by >50% (see Appenix). Decrease six-minute-walk time was again associate with increasing patient comorbiity, suggesting that ecrease six-minute-walk times can be attribute both to increase age an to increase comorbiity. We were unable to correlate increase walk times or peometer finings with loosening or nee for revision. Aitionally, SF-36 physical component summary scores, WOMAC functional scores, an Harris hip scores all ecline significantly. The ecrease in the average Harris hip score from 86.9 to 61.9 points between the twentyfive an thirty-five-year follow-up time points is especially impressive, even in this aging population. The majority of this ecrease appeare to be in the functional subscale of the Harris hip score. In our cohort, the average age at the time of surgery was forty-one years, an 44% (forty-one) of the ninety-three prostheses were in patients who were still alive an able to be evaluate thirty-five years after the inex proceure. This compares favorably with the only other thirty-five-year follow-up stuy of total hip replacements 21, to our knowlege, in which the average age at the time of surgery was sixty-five years, an only 4.5% (fifteen) of the 330 hips were in patients who were still alive at the time of the thirty-five-year follow-up (see Appenix). This represents a nearly tenfol ifference in the percentage (44% versus 4.5%) of total hip replacements availabletobeevaluateatthirty-five years of follow-up. Aitionally, survivorship analysis at the thirty-five-year follow-up in this young cohort (fifty years ol an uner) compare with that in an oler population (an average of sixty-five years at the time of inex arthroplasty), previously reporte by Callaghan et al. 21, emonstrate significantly increase rates of failure on the acetabular sie, with excellent results for both cohorts on the femoral sie. With nearly universal excellence of reporte short an mi-term outcomes after total hip arthroplasty between ifferent implants, we believe that the present stuy emonstrate that a younger patient cohort is important to follow to efinitively evaluate long-term ifferences in component function an survival. The present stuy emonstrate that total hip replacements in this relatively young patient group have satisfactory long-term function an urability. early two-thirs (63%) of the original implants were retaine at the time of eath or thirty-five-year follow-up. For the patients living at the time of the thirty-five-year follow-up, the results were less urable, as approximately half (46%) of the patients retaine their original prosthesis. These results shoul be consiere a stanar for comparison with the outcomes of newer esigns use in this younger age-group. The functional results in the stuy group, as measure by the SF-36, WOMAC, an especially the Harris hip scores, were significantly poorer than the reporte values from the same stuy group at the twenty-five-year follow-up. There was minimal eterioration between twenty-five an thirty-five years in terms of fixation. This stuy emonstrates that total hip replacement can be safely performe in younger patients an that urable function an fixation can be maintaine in many of these patients. Appenix Figures emonstrating Kaplan-Meier survivorship curves, with revision for aseptic loosening, revision for aseptic loosening of the acetabular component, revision for aseptic loosening of the femoral component, raiographic loosening of the acetabular component, an raiographic loosening of the femoral component as the en points, an tables showing a comparison of raiographic an survivorship ata at twenty-five an thirtyfive years, a comparison of functional ata at twenty-five an thirty-five years, a functional comparison accoring to the results of the six-minute walk test, an a comparison of patient an implant survivorship are available with the online version of this article as a ata supplement at jbjs.org. n OTE: The authors thank Yubo Gao, PhD, for assistance with statistics. Lucian C. Warth, MD John J. Callaghan, MD Steve S. Liu, MD Alison L. Klaassen, MA Richar C. Johnston, MD Department of Orthopaeic Surgery, University of Iowa Hospitals an Clinics, 200 Hawkins Drive, UIHC, JPP, Iowa City, IA aress for J.J. Callaghan: john-callaghan@uiowa.eu Devon D. Goetz, MD Des Moines Orthopaeic Surgeons, 6001 Westown Parkway, West Des Moines, IA References 1. Callaghan JJ, Forest EE, Olejniczak JP, Goetz DD, Johnston RC. Charnley total hip arthroplastyin patients less than fifty years ol. A twenty to twenty-five-year follow-up note. J Bone Joint Surg Am May;80(5): Sullivan PM, MacKenzie JR, Callaghan JJ, Johnston RC. Total hip arthroplasty with cement in patients who are less than fifty years ol. A sixteen to twenty-two-year follow-up stuy. J Bone Joint Surg Am Jun;76(6): Keener JD, Callaghan JJ, Goetz DD, Peerson DR, Sullivan PM, Johnston RC. Twenty-five-year results after Charnley total hip arthroplasty in patients less than fifty years ol: a concise follow-up of a previous report. J Bone Joint Surg Am Jun;85(6): DeLee JG, Charnley J. 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