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Charnley Low-Frictional Torque Arthroplasty for Avascular Necrosis of the Femoral Head
The Journal of Arthroplasty Vol. 20 No. 7 2005
Charnley Low-Frictional Torque Arthroplasty for Avascular Necrosis of the Femoral Head B.M. Wroblewski, FRCS, Paul D. Siney, BA, and Patricia A. Fleming
Abstract: Forty-nine patients (mean age, 37 years; 20-50 years) had had 69 Charnley low-frictional arthroplasties for avascular necrosis of the femoral head. Their mean follow-up was 13.4 years (2-25 years). Five patients (8 hips) had no continuing follow-up, 5 (8 hips) are known to have died, 6 (7 hips) had had a revision at a mean follow-up of 16.4 years (11-25 years): 6 for cup loosening and 1 for a fractured stem and a loose cup. The remaining 33 patients (46 hips) had an excellent clinical result with all stems remaining soundly fixed, but 6 cups were radiologically loose at a mean follow-up of 16 years and 4 months. Wear and cup loosening are the main problems limiting the survival of the arthroplasty. Key words: avascular necrosis, total hip arthroplasty, young patients. n 2005 Elsevier Inc. All rights reserved.
group. At a mean follow-up of 7.6 and 7.1 years, the results were satisfactory and comparable in the 2 groups. In a series of 27 hips of patients with AVN due to sickle cell anemia, the results were less encouraging. The revision rate for loosening of components in both cemented and uncemented prostheses was 59% over a cumulative period of 5.5 years, the mean time to revision being 43 months [3]. We present our results of the Charnley lowfrictional arthroplasty (LFA) in young patients with AVN of the femoral head.
Avascular necrosis (AVN) of the femoral head is not a common indication for total-hip arthroplasty (THA). Diversity of underlying pathology does not allow accumulation of large numbers. Patients’ young age, expected high activity level, and life expectancy may all be against this form of treatment. Salvati and Cornell [1], in their instructional course lecture, stated that the failure rate after THA was 4 times higher than in patients with osteoarthritis. They recommended weight reduction and restriction of activities but thought it would be reasonable to accept patients for THA in the fifth decade of life [1]. Xenakis et al [2] compared the results of uncemented THA in patients with AVN and osteoarthritis. There were 29 patients in each
Materials and Method The policy of indefinite follow-up of all patients 50 years or younger at the time of the operation was put into practice in January 1974. The group includes all patients operated on between November 1962 and December 1990 [4]. From this group, we have extracted all the information on patients with AVN of the femoral head. The routine follow-up is at 3 months and 1 year after surgery, then every 1 or 2 years depending on the clinical results that were assessed according to Merle d’Aubigne and Postel [5] as modified by
From the The John Charnley Research Institute, Wrightington Hospital, Nr Wigan, UK. Submitted April 16, 2004; accepted February 3, 2005. This research was supported by the Peter Kershaw and John Charnley Trusts. Reprint requests: B.M. Wroblewski, FRCS, The John Charnley Research Institute, Wrightington Hospital, Hall Lane, Appley Bridge, WN6 9EP Nr Wigan, UK. n 2005 Elsevier Inc. All rights reserved. 0883-5403/05/1906-0004$30.00/0 doi:10.1016/j.arth.2005.02.006
870
Charnley LFA for Avascular Necrosis ! Wroblewski et al 871 Table 1. Underlying Pathology as a Cause of AVN of the Femoral Head Pathology
No. of Patients
No. of LFAs
Idiopathic Steroids Alcohol Trauma Lupus Sickle cell Trauma and steroids Alcohol and steroids Caisson disease Alcohol and trauma Gaucher’s disease
11 8 7 9 5 2 2 2 1 1 1
14 14 11 9 9 4 3 2 1 1 1
Charnley [6] or radiographic appearance with follow-up being available on request. A standard anterior-posterior (AP) radiograph, centered over the symphysis pubis, is taken at each visit. The radiographic appearances on the acetabular side are recorded according to Hodgkinson et al [7] and on the femoral side according to Pacheco et al [8]. Wear was measured as penetration according to the method previously described [9]—all readings being corrected for magnification.
We continue our practice of early revision, the indications being progressive loosening, deteriorating function, but above all, preservation of bone stock.
Results Forty-nine patients (33 males and 16 females), 69 hips, were identified. Their mean age at LFA was 37 years (20-50 years) and their mean weight was 70.3 kg (43-99 kg). Twenty patients (7 consecutive and 13 staged) had had bilateral LFAs. The left hip was operated on in 32 patients and the right in 37. The mean follow-up for the whole group was 13.4 years (2-25 years). The underlying hip pathology resulting in AVN is shown in Table 1. Ten hips had been previously operated on: 4 by an intertrochanteric osteotomy, 6 by drilling the neck of the femur. Complications within 1 year included 2 cases of trochanteric nonunion, 1 case of dislocation, 1 case of clinically diagnosed deep vein thrombosis, and 1 case each of urinary retention and paralytic ileus. At the latest review of information (16/01/04),
Table 2. Survivorship Analysis Confidence Limits Follow-up (y) 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
No. at Start
Withdrawn
Failure
No. at Risk
Cumulative Success Rate
Higher
Lower
69 69 69 69 67 65 63 60 55 52 50 50 48 45 40 34 32 29 21 20 18 13 12 10 9 5 4 1
0 0 0 2 2 2 3 5 3 2 0 2 2 5 5 1 1 8 1 2 4 1 2 1 4 1 2 1
0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1 2 0 0 0 1 0 0 0 0 0 1 0
69 69 69 68 66 64 61.5 57.5 53.5 51 50 49 47 42.5 37.5 33.5 31.5 25 20.5 19 16 12.5 11 9.5 7 4.5 3 0.5
100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 97.87 97.87 95.21 92.22 85.87 85.87 85.87 85.87 79.62 79.62 79.62 79.62 79.62 79.62 46.29 46.29
100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 97.14 98.52 99.84 100.00 97.23 99.55 100.00 100.00 100.00 100.00 84.68 100.00
100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 93.79 93.58 88.53 83.51 74.60 73.22 71.90 71.36 62.01 59.70 58.38 56.76 52.99 46.41 7.90 0.00
Endpoint—revision for any reason.
872 The Journal of Arthroplasty Vol. 20 No. 7 October 2005 % Survivorship 100 80 60 40 20 0 0
4
8
12
16
20
24
Follow-up (years) Fig. 1. Survivorship analysis. Endpoint—revision for any reason.
5 patients, 8 LFAs, had no continuing follow-up because they lived abroad and their mean followup was 4.8 years. Five patients (eight LFAs) are known to have died at a mean follow-up of 7.6 years. No hips in these 2 groups showed radiographic evidence of failure at the last followup. Six patients, 7 LFAs, have been revised with a mean age of 33 years and a mean follow-up of 16.4 years (11-25 years): 6 had a loose cup whereas 1 had a fractured stem and a loose cup. The total mean penetration of the cup for this group of
patients was 3.3 mm (1.2-5.1) (mean penetration rate, 0.21 mm/y; 0.06-0.29 mm/y). The remaining 33 patients (46 LFAs) have a mean age of 37 years and a mean follow-up of 16.4 years (11-25 years). We have used the Kaplan-Meier method [10] for survivorship with revision for any reason as the end point. The details are shown in Table 2 and Fig. 1. Their clinical results are excellent; their pain, function, and range of movement improved from 3.0, 3.0, and 3.1 to 5.9, 5.9, and 5.8, respectively. The mean total penetration depth is 1.7 mm (0-7.5 mm) and the mean rate of cup penetration in this group is 0.1 mm/y (0-0.55 mm/y), and this is comparable with the penetration rate in our larger series [4]. Six cups are radiologically loose, but all stems remain well fixed. An example of this is shown in Fig. 2.
Discussion
Fig. 2. Long-term follow-up showing a loose cup with a well-fixed stem.
Diversity of the underlying hip pathology does not allow a collection of a large number of patients within a single diagnostic group. In a large proportion, the underlying pathology remains in doubt, whereas in some of the others, more than a single cause was suspected. The reluctance to operate by THA is understandable, especially when the acetabulum still appears relatively normal whereas the head of the femur has passed the stage of any limited procedure. In our series, with a relatively long follow-up, the femoral side, other than a single stem fracture, is holding very well. Wear and loosening of the cup are the main long-term problem [11-13]. With the Charnley LFA now more than 43 years of clinical experience, the answer must come from
Charnley LFA for Avascular Necrosis ! Wroblewski et al 873
materials to reduce the cup wear to a minimum and thus extend the survival of the arthroplasty still further in this group of young patients.
References 1. Salvati EA, Cornell CN. Long term follow-up of total hip replacement in patients with avascular necrosis. Instr Course Lect 1988;37:67. 2. Xenakis TA, Beris AE, Malizos KK, et al. Total hip arthroplasty for avascular necrosis and degenerative osteoarthritis of the hip. Clin Orthop 1997; 341:62. 3. Clarke HJ, Jinnah RH, Brooker AF, et al. Total replacement of the hip for avascular necrosis in sickle cell disease. J Bone Joint Surg Br 1989;71:465. 4. Wroblewski BM, Siney PD, Fleming PA. Charnley low frictional torque arthroplasty in patients under the age of 51 years. J Bone Joint Surg Br 2002; 84:540. 5. Merle d’Aubigne R, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am 1954;36:451. 6. Charnley J. The long term results of low-friction arthroplasty of the hip performed as a primary intervention. J Bone Joint Surg Br 1972;54:61.
7. Hodgkinson JP, Shelley P, Wroblewski BM. The correlation between the roentgenographic appearance and the operative findings at the bone cement junction of the socket in Charnley low friction arthroplasties. Clin Orthop 1988;228:105. 8. Pacheco V, Shelley P, Wroblewski BM. Mechanical loosening of the stem in Charnley arthroplasties: identification of the bat riskQ factors. J Bone Joint Surg Br 1988;70:596. 9. Griffith MJ, Seidenstein MK, Williams D, et al. Socket wear in Charnley low friction arthroplasty of the hip. Clin Orthop 1978;137:37. 10. Kaplan M, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958; 53:457. 11. Wroblewski BM, Siney PD, Fleming PA. Charnley low-frictional torque arthroplasty of the hip: 20-30 year results. J Bone Joint Surg Br 1999;81:427. 12. Wroblewski BM, Siney PD, Fleming PA. Charnley low-frictional torque arthroplasty of the hip in patients under the age of 51 years. Follow-up to 33 years. J Bone Joint Surg Br 2002;84:540. 13. Wroblewski BM. Charnley low-friction arthroplasty in patients under the age of 40 years. In Sevastik J, Goldie I, editors. The young patient with degenerative hip disease. Stockholm: Almquist & Wiksell; 1985. p. 197.
Charnley Low-Frictional Torque Arthroplasty for Avascular Necrosis of the Femoral Head B.M. Wroblewski, FRCS, Paul D. Siney, BA, and Patricia A. Fleming
Abstract: Forty-nine patients (mean age, 37 years; 20-50 years) had had 69 Charnley low-frictional arthroplasties for avascular necrosis of the femoral head. Their mean follow-up was 13.4 years (2-25 years). Five patients (8 hips) had no continuing follow-up, 5 (8 hips) are known to have died, 6 (7 hips) had had a revision at a mean follow-up of 16.4 years (11-25 years): 6 for cup loosening and 1 for a fractured stem and a loose cup. The remaining 33 patients (46 hips) had an excellent clinical result with all stems remaining soundly fixed, but 6 cups were radiologically loose at a mean follow-up of 16 years and 4 months. Wear and cup loosening are the main problems limiting the survival of the arthroplasty. Key words: avascular necrosis, total hip arthroplasty, young patients. n 2005 Elsevier Inc. All rights reserved.
group. At a mean follow-up of 7.6 and 7.1 years, the results were satisfactory and comparable in the 2 groups. In a series of 27 hips of patients with AVN due to sickle cell anemia, the results were less encouraging. The revision rate for loosening of components in both cemented and uncemented prostheses was 59% over a cumulative period of 5.5 years, the mean time to revision being 43 months [3]. We present our results of the Charnley lowfrictional arthroplasty (LFA) in young patients with AVN of the femoral head.
Avascular necrosis (AVN) of the femoral head is not a common indication for total-hip arthroplasty (THA). Diversity of underlying pathology does not allow accumulation of large numbers. Patients’ young age, expected high activity level, and life expectancy may all be against this form of treatment. Salvati and Cornell [1], in their instructional course lecture, stated that the failure rate after THA was 4 times higher than in patients with osteoarthritis. They recommended weight reduction and restriction of activities but thought it would be reasonable to accept patients for THA in the fifth decade of life [1]. Xenakis et al [2] compared the results of uncemented THA in patients with AVN and osteoarthritis. There were 29 patients in each
Materials and Method The policy of indefinite follow-up of all patients 50 years or younger at the time of the operation was put into practice in January 1974. The group includes all patients operated on between November 1962 and December 1990 [4]. From this group, we have extracted all the information on patients with AVN of the femoral head. The routine follow-up is at 3 months and 1 year after surgery, then every 1 or 2 years depending on the clinical results that were assessed according to Merle d’Aubigne and Postel [5] as modified by
From the The John Charnley Research Institute, Wrightington Hospital, Nr Wigan, UK. Submitted April 16, 2004; accepted February 3, 2005. This research was supported by the Peter Kershaw and John Charnley Trusts. Reprint requests: B.M. Wroblewski, FRCS, The John Charnley Research Institute, Wrightington Hospital, Hall Lane, Appley Bridge, WN6 9EP Nr Wigan, UK. n 2005 Elsevier Inc. All rights reserved. 0883-5403/05/1906-0004$30.00/0 doi:10.1016/j.arth.2005.02.006
870
Charnley LFA for Avascular Necrosis ! Wroblewski et al 871 Table 1. Underlying Pathology as a Cause of AVN of the Femoral Head Pathology
No. of Patients
No. of LFAs
Idiopathic Steroids Alcohol Trauma Lupus Sickle cell Trauma and steroids Alcohol and steroids Caisson disease Alcohol and trauma Gaucher’s disease
11 8 7 9 5 2 2 2 1 1 1
14 14 11 9 9 4 3 2 1 1 1
Charnley [6] or radiographic appearance with follow-up being available on request. A standard anterior-posterior (AP) radiograph, centered over the symphysis pubis, is taken at each visit. The radiographic appearances on the acetabular side are recorded according to Hodgkinson et al [7] and on the femoral side according to Pacheco et al [8]. Wear was measured as penetration according to the method previously described [9]—all readings being corrected for magnification.
We continue our practice of early revision, the indications being progressive loosening, deteriorating function, but above all, preservation of bone stock.
Results Forty-nine patients (33 males and 16 females), 69 hips, were identified. Their mean age at LFA was 37 years (20-50 years) and their mean weight was 70.3 kg (43-99 kg). Twenty patients (7 consecutive and 13 staged) had had bilateral LFAs. The left hip was operated on in 32 patients and the right in 37. The mean follow-up for the whole group was 13.4 years (2-25 years). The underlying hip pathology resulting in AVN is shown in Table 1. Ten hips had been previously operated on: 4 by an intertrochanteric osteotomy, 6 by drilling the neck of the femur. Complications within 1 year included 2 cases of trochanteric nonunion, 1 case of dislocation, 1 case of clinically diagnosed deep vein thrombosis, and 1 case each of urinary retention and paralytic ileus. At the latest review of information (16/01/04),
Table 2. Survivorship Analysis Confidence Limits Follow-up (y) 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
No. at Start
Withdrawn
Failure
No. at Risk
Cumulative Success Rate
Higher
Lower
69 69 69 69 67 65 63 60 55 52 50 50 48 45 40 34 32 29 21 20 18 13 12 10 9 5 4 1
0 0 0 2 2 2 3 5 3 2 0 2 2 5 5 1 1 8 1 2 4 1 2 1 4 1 2 1
0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1 2 0 0 0 1 0 0 0 0 0 1 0
69 69 69 68 66 64 61.5 57.5 53.5 51 50 49 47 42.5 37.5 33.5 31.5 25 20.5 19 16 12.5 11 9.5 7 4.5 3 0.5
100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 97.87 97.87 95.21 92.22 85.87 85.87 85.87 85.87 79.62 79.62 79.62 79.62 79.62 79.62 46.29 46.29
100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 97.14 98.52 99.84 100.00 97.23 99.55 100.00 100.00 100.00 100.00 84.68 100.00
100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 93.79 93.58 88.53 83.51 74.60 73.22 71.90 71.36 62.01 59.70 58.38 56.76 52.99 46.41 7.90 0.00
Endpoint—revision for any reason.
872 The Journal of Arthroplasty Vol. 20 No. 7 October 2005 % Survivorship 100 80 60 40 20 0 0
4
8
12
16
20
24
Follow-up (years) Fig. 1. Survivorship analysis. Endpoint—revision for any reason.
5 patients, 8 LFAs, had no continuing follow-up because they lived abroad and their mean followup was 4.8 years. Five patients (eight LFAs) are known to have died at a mean follow-up of 7.6 years. No hips in these 2 groups showed radiographic evidence of failure at the last followup. Six patients, 7 LFAs, have been revised with a mean age of 33 years and a mean follow-up of 16.4 years (11-25 years): 6 had a loose cup whereas 1 had a fractured stem and a loose cup. The total mean penetration of the cup for this group of
patients was 3.3 mm (1.2-5.1) (mean penetration rate, 0.21 mm/y; 0.06-0.29 mm/y). The remaining 33 patients (46 LFAs) have a mean age of 37 years and a mean follow-up of 16.4 years (11-25 years). We have used the Kaplan-Meier method [10] for survivorship with revision for any reason as the end point. The details are shown in Table 2 and Fig. 1. Their clinical results are excellent; their pain, function, and range of movement improved from 3.0, 3.0, and 3.1 to 5.9, 5.9, and 5.8, respectively. The mean total penetration depth is 1.7 mm (0-7.5 mm) and the mean rate of cup penetration in this group is 0.1 mm/y (0-0.55 mm/y), and this is comparable with the penetration rate in our larger series [4]. Six cups are radiologically loose, but all stems remain well fixed. An example of this is shown in Fig. 2.
Discussion
Fig. 2. Long-term follow-up showing a loose cup with a well-fixed stem.
Diversity of the underlying hip pathology does not allow a collection of a large number of patients within a single diagnostic group. In a large proportion, the underlying pathology remains in doubt, whereas in some of the others, more than a single cause was suspected. The reluctance to operate by THA is understandable, especially when the acetabulum still appears relatively normal whereas the head of the femur has passed the stage of any limited procedure. In our series, with a relatively long follow-up, the femoral side, other than a single stem fracture, is holding very well. Wear and loosening of the cup are the main long-term problem [11-13]. With the Charnley LFA now more than 43 years of clinical experience, the answer must come from
Charnley LFA for Avascular Necrosis ! Wroblewski et al 873
materials to reduce the cup wear to a minimum and thus extend the survival of the arthroplasty still further in this group of young patients.
References 1. Salvati EA, Cornell CN. Long term follow-up of total hip replacement in patients with avascular necrosis. Instr Course Lect 1988;37:67. 2. Xenakis TA, Beris AE, Malizos KK, et al. Total hip arthroplasty for avascular necrosis and degenerative osteoarthritis of the hip. Clin Orthop 1997; 341:62. 3. Clarke HJ, Jinnah RH, Brooker AF, et al. Total replacement of the hip for avascular necrosis in sickle cell disease. J Bone Joint Surg Br 1989;71:465. 4. Wroblewski BM, Siney PD, Fleming PA. Charnley low frictional torque arthroplasty in patients under the age of 51 years. J Bone Joint Surg Br 2002; 84:540. 5. Merle d’Aubigne R, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am 1954;36:451. 6. Charnley J. The long term results of low-friction arthroplasty of the hip performed as a primary intervention. J Bone Joint Surg Br 1972;54:61.
7. Hodgkinson JP, Shelley P, Wroblewski BM. The correlation between the roentgenographic appearance and the operative findings at the bone cement junction of the socket in Charnley low friction arthroplasties. Clin Orthop 1988;228:105. 8. Pacheco V, Shelley P, Wroblewski BM. Mechanical loosening of the stem in Charnley arthroplasties: identification of the bat riskQ factors. J Bone Joint Surg Br 1988;70:596. 9. Griffith MJ, Seidenstein MK, Williams D, et al. Socket wear in Charnley low friction arthroplasty of the hip. Clin Orthop 1978;137:37. 10. Kaplan M, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958; 53:457. 11. Wroblewski BM, Siney PD, Fleming PA. Charnley low-frictional torque arthroplasty of the hip: 20-30 year results. J Bone Joint Surg Br 1999;81:427. 12. Wroblewski BM, Siney PD, Fleming PA. Charnley low-frictional torque arthroplasty of the hip in patients under the age of 51 years. Follow-up to 33 years. J Bone Joint Surg Br 2002;84:540. 13. Wroblewski BM. Charnley low-friction arthroplasty in patients under the age of 40 years. In Sevastik J, Goldie I, editors. The young patient with degenerative hip disease. Stockholm: Almquist & Wiksell; 1985. p. 197.