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Uncemented total hip arthroplasty in patients younger than 20 years
Journal of Orthopaedic Science xxx (2016) 1e7
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Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Original article
Uncemented total hip arthroplasty in patients younger than 20 years Riccardo D'Ambrosi a, b, *, Luca Marciandi c, Piero Vittorio Frediani c, Renato Mario Facchini a, b degli Studi di Milano, Italy Universita Centro Traumatologico Ortopedico, U.O. Clinica Ortopedica e Traumatologica, Milano, Italy c A.O.S. Antonio Abate, U.O. di Ortopedia e Traumatologia, Gallarate, Varese, Italy a
b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 14 December 2015 Received in revised form 22 February 2016 Accepted 16 March 2016 Available online xxx
Background: Several diseases may lead to advanced hip disease and cause disabling symptoms in adolescents. In literature there is no consensus which is the optimal surgical treatment for young adults with end-stage osteoarthritis. The purpose of this study was to assess the clinical and radiological outcomes of uncemented total hip arthroplasty for the treatment of end-stage hip arthritis in patients younger than 20 years at a minimum follow-up of ten years. Methods: We have retrospectively evaluated 24 patients who were 20 years or younger and underwent uncemented total hip arthroplasty. Minimum follow-up was 10 years. Clinical outcome was measured using the Harris Hip Score, Western Ontario McMaster, and the Short-Form 36. Hip calcification was evaluated using Brooker classification, while osteolysis was examined at the final follow-up according to the subdivision of Gruen. Results: The mean preoperative Harris Hip Score was 36.94 points and improved to 92.3, and the mean preoperative WOMAC score improved from 84.72 to 28.45 The Mental Component score-SF-36 improved from a preoperative mean of 26.23 points to 58.96, while the Physical Component score-SF-36 improved from a preoperative mean of 26.38e49.95. All components were stable and osseo-integrated. Radiolucent lines were not present in any hips. We noted the presence of 4 calcifications. No patient needed implant revision. The only complication was an intraoperative femoral fracture. Conclusion: Total hip arthroplasty is a safe and reliable procedure for the treatment of end-stage arthritis in the young that provides good to excellent mid-term results. © 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction Total hip arthroplasty (THA) is considered the gold standard for the treatment of end-stage degenerative hip osteoarthritis [1]. Development of surgical technique and improvement of the design such as cementless fixation and highly crosslinked polyethylene, have led to a longer survivorship of prosthetic implants, to a decrease in pain, improved range of motion and a faster recovery [2]. THA was initially designed for the elderly, with low functional demands, and only in recent years has the number of surgical procedures performed in young patients greatly increased [3]. Several diseases such as avascular necrosis (AN), juvenile idiopathic arthritis (JIA), infection, and chronic dislocation, may
degli Studi di Milano, Italy. Tel.: þ39 * Corresponding author. Universita 3397066151; fax: þ39 0270633611. E-mail address: [email protected] (R. D'Ambrosi).
lead to advanced hip disease and cause disabling symptoms in adolescents [4,5]. To date in the literature there is no consensus which is the optimal surgical treatment for adolescents and young adults with end-stage osteoarthritis. Surgical options include arthrodesis, resection arthroplasty, resurfacing arthroplasty, and THA [5e7]. Hip resection arthroplasty and arthrodesis are functionally unappealing and are considered unacceptable options for these patients with high functional demands [8,9]. THA allows these young patients who have a high activity level, repetitive loading, and excessive demand placed, to regain mobility, improving their social and personal quality of life in this particularly important phase of life. In some cases it seems to be the only surgical option [10]. There are many potential problems related to the survival of the implanted prostheses in a young adult. Age, functional requirements, patient expectations and systemic disease can lead to accelerated failure of implants [11].
http://dx.doi.org/10.1016/j.jos.2016.03.009 0949-2658/© 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: D'Ambrosi R, et al., Uncemented total hip arthroplasty in patients younger than 20 years, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.03.009
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R. D'Ambrosi et al. / Journal of Orthopaedic Science xxx (2016) 1e7
The aim of this study was to determine and report clinical and radiographic outcomes, after uncemented THA in patients younger than 20 years, with a minimum follow-up of ten years.
2. Patients & methods We have retrospectively evaluated 24 patients (30 hips) who were 20 years or younger and underwent uncemented THA procedure between the years 1998e2005. All primary THA was performed by senior Authors. The cohort included 13 (54.17%) females and 11 (45.83%) males who were between the ages of 15 and 20 at the time of index operation. The mean age was 19.7. The radiological classification was performed with anteroposterior pelvic radiography according to the Kellgren score [12]. Kellgren described 4 grades of hip OA: grade 1 (doubtful OA), possible narrowing of the joint space medially and possible osteophytes around femoral head; grade 2 (mild OA), definite narrowing of the joint space inferiorly, definite osteophytes, and slight sclerosis; grade 3 (moderate OA), marked narrowing of the joint space, slight osteophytes, some sclerosis and cyst formation, and deformity of the femoral head and acetabulum; and grade 4 (severe OA), gross loss of joint space with sclerosis and cysts, marked deformity of the femoral head and acetabulum, and large osteophytes [12]. 23 (76.67%) hips presented grade 4 of OA, while 7 (23.33%) grade 3 according to Kellgren classification. The underlying diagnoses were JIA (10 hips e 33.3%), AN (4 hips e 13.3%), septic arthritis (4 hips e 13.3%), chondrodysplasia (3 hips e 10%), post-traumatic osteoarthritis (3 hips e 10%), developmental dysplasia of the hip (DDH) (3 hips e 10%), CharcoteMarieeTooth disease (2 hips e 6.6%) and arthrogryposis (1 hip e 3.3%). All patients had failed conservative treatment which consisted in active and passive physiotherapy exercises and muscle strengthening to improve the motion and partially relieve pain. Moreover patients with systemic diseases such as rheumatoid arthritis were given to systemic and local treatment with cortisone for control of rheumatic disease. 7 hips had a history of previous operations, which consisted of open reduction and internal fixation in 2 hips due to femoral fracture, 4 acetabular osteotomy and one femoral osteotomy plus adductor tenotomy (Table 1). Surgical procedure in all patients was performed in lateral decubitus and through a posterolateral approach. All components were inserted press fit and supplemental screw fixation of the acetabulum was used in 4 cases. Operative time ranged from 75 to 120 min with a mean time of 80 min 18 (60%) THAs
Table 1 Patient demographics. No. of patients (hips) Age Sex Underlying diagnosis (no. of hips)
Previous surgery
Kellgren Lawrence [12] grade
24 (30) 19.7 13 Femalee 11 male 10 juvenile idiopathic arthritis 4 avascular necrosis 4 septic arthritis 3 chondrodysplasia 3 post-traumatic osteoarthritis 3 development dysplasia of the hip 2 Charcot-Marie-Tooth disease 1 arthrogryposis 4 acetabular osteotomy 2 open reduction and internal fixation 1 femural osteotomy plus adductor tenotomy 23 grade 4 7 grade 3
were performed using ceramic on ceramic bearing, while the other 12 (40%) were performed using ceramic on cross-linked polyethylene. In our series we used two different cementless implant: modular stem type and rectangular type. Modular design allows independent preparation and separate component for the metaphysis and diaphysis. We reserved this combination of proximal and distal fixation for complex operations. Indications include anatomic abnormalities and rotational malalignments, such as in hip dysplasia. Rectangular type is tapered conical stem that is grit-blasted across its entire length. The implant provides three-point fixation in the metaphysealediaphyseal junction and proximal part of the diaphysis. Its cross provides four point rotational support. Clinical and radiographic data was collected on all patients preoperatively, on the day after surgery, at 1, 3, 12 months and every year thereafter. No patients were lost at follow-up. Minimum follow-up was 10 years (range: 10e17, mean 12.5). Serial anteroposterior and lateral radiographs of the operated joint were reviewed to assess the position of the prosthesis, loosening, calcifications and osteolysis. Definitely loose components were defined as those that demonstrated a complete lucent line on any radiograph, a femoral subsidence of 2 mm or more, or acetabular component migration or tilt [13]. Hip calcification was evaluated using Brooker classification [14] (Table 2). Osteolysis, defined as areas of bone loss, localized in areas in direct contact with the prosthesis, not present in the immediate post-operative X-rays, but which appeared to subsequent evaluations, were examined at the final follow-up according to the subdivision of Gruen [15]. Gruen divides the femoral component in fourteen areas, seven evaluable in anteroposterior radiograph and seven evaluable in axial view; however acetabular component is divided into six areas (Fig. 1a and b). Osteolysis is caused by wear of the polyethylene and its debridement that starts as an inflammatory reaction [15]. Clinical outcome was measured using the Harris Hip Score (HHS) for total hip arthroplasties, Western Ontario McMaster (WOMAC), and the Short-Form 36 to evaluate quality of life (SF-36). The purpose of HHS is to quantify the initial functional impairment and measure improvement after surgery [16]. It is made up of an evaluation board to evaluate pain, function, motion and deformity. A score less than 70 is considered a poor result, is considered sufficient between 70 and 79, between 80 and 89 is good and between 90 and 100 is excellent. The WOMAC index is a self-administered questionnaire for the evaluation of patients with osteoarthritis of the knee and hip [17]. It measures changes in health after the surgical procedure. Higher scores indicate worse outcome. SF-36 is a generic questionnaire on quality of life. That is not disease, age or treatment specific. It evaluates the subjective perception of the individual in relation to the concepts of health and wellness [18]. To simplify the assessment is divided into a
Table 2 Brooker classification for heterotopic ossification of the hip. Class I Class II
Class III
Class IV
Represents islands of bone in soft tissues about hip Includes bone spurs in pelvis or proximal end of femur leaving at least 1 cm between the opposing bone surfaces Represents bone spurs that extend from pelvis or the proximal end of femur, which reduce the space between the opposing bone surfaces to less than 1 cm Indicates radiographic ankylosis of the hip
Please cite this article in press as: D'Ambrosi R, et al., Uncemented total hip arthroplasty in patients younger than 20 years, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.03.009
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Fig. 1. Gruen zones to identify areas of osteolysis in anteroposterior (a) and axial view (b) radiograph of the hip.
Physical Component Summary (PCS) and Mental Component summary (MCS). The statistical analysis was performed using dedicated statistical software (SPSS version 17, SPSS Inc., IBM, Chicago, IL, USA). Continuous variables were reported as mean (range). For continuous variable a T test for dependent samples/a paired samples t test was performed to compare pre-op and post-operative values. For all the tests, p values < 0.001 were considered statistically significant. This study was approved by our hospital's institutional review board (Protocol number: 4-2015), and all patients signed an informed consent form prior to enrollment in the study and prior to any study procedures being completed.
in patients with DDH, with previous acetabular osteotomy, is essential a minimum joints space to obtain excellent clinical and radiographic results; excellent congruity is an important predictor for a stable and well-positioned implant [19]. All femoral
3. Results The mean preoperative HHS was 36.94 points (range: 20.75e44.9) and improved significantly to 92.3 (range: 89.65e100) at the final follow-up (p < 0.001). The mean preoperative WOMAC score was 84.72 (range: 72.8e93.4) points and improved significantly to 28.45 (range: 15.2e40.8) (p < 0.001). The MCS-SF-36 improved from a preoperative mean of 26.23 (range: 23.4e31.5) points to 58.96 (range: 47.4e62.1) at the latest follow-up (p < 0.001). The PCS-SF-36 component improved from a preoperative mean of 26.38 (range: 19.6e31.3) to 49.92 (range: 25.2e57.9) at the latest follow-up (p < 0.001) (Table 3). All radiological measurements were made using the standard tools in our Picture Archiving and Communication System (PACS) and evaluated by two orthopedic surgeons. On preoperative radiographs, joint space ranged from 0 to 4 mm. In fact, in particular
Table 3 Clinical data pre-operative and at last follow-up.
Pre-operatively Last follow-up p-Value
Harris hip score
WOMAC
MCS
PCS
36.94 92.3 <0.001*
84.72 28.45 <0.001*
26.23 58.96 <0.001*
26.38 49.92 <0.001*
*Statistically significant.
Fig. 2. Preoperative (a) anteroposterior radiograph of a 19-year-old girl who underwent THA for arthrogryposis of the right hip. (b) Follow-up radiograph taken at 11 years shows well-fixed components.
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Fig. 3. Preoperative (a) AP radiograph of a 16-year-old boy who underwent THA for avascular necrosis of the left hip. (b) Preoperative 3d-reconstruction of the femoral head with avascular necrosis. (c) Plain anteroposterior radiograph 10 years after surgery shows well-fixed components, no osteolysis or mobilization of the prosthesis.
components were well-positioned. At the final follow-up, all components were deemed to be stable and osseo-integrated (Figs. 2a, b and 3aec). Progressive, complete radiolucent lines,
indicating a loose prosthesis, were not present in any hips. Incomplete radiolucent lines were detected in five hips in Gruen zones 1 (2 hips e 6.7%), 2 (1 hip e 3.3%), 6 (1 hip e 3.3%) and 7 (1
Fig. 4. (a) Intraoperative plain radiograph shows femoral fracture in a 16-year old girl treated with metal cerclage (b).
Please cite this article in press as: D'Ambrosi R, et al., Uncemented total hip arthroplasty in patients younger than 20 years, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.03.009
R. D'Ambrosi et al. / Journal of Orthopaedic Science xxx (2016) 1e7
hip e 3.3%) respectively. Gross polyethylene wear, indicated by eccentric position of the femoral head, was not present in any hips. Femoral stem subsidence greater than 2 mm had not occurred in any hips. According to Broker we noted the presence of 4 calcifications, two grade 1 (6.7%), one grade 2 (3.3%) and one grade 3 (3.3%) respectively. At the latest follow-up, no patient needed implant revision. The only complication was an intraoperative femoral fracture which was treated with metal cerclage that did not compromise the success of the prosthesis (Fig. 4a, b). 4. Discussion THA is considered the gold standard with excellent long-term outcome in older patients [20]. Results of total hip arthroplasty in young adults has not to date been equally rewarding due to the high activity level and the excessive demand imposed on the prosthetic hip [3,5]. In our retrospective study, with a minimum follow-up at 10 years, we report good to excellent results in a cohort of 30 hips. The Harris Hip Score improved from 36.94 to 92.3. The WOMAC score ranged from 84.72 to 28.45 points showing a good functionality of the prosthetic implant. The quality of life, both physical and mental components, as measured by the SF-36, showed significant improvement in our cohort of patients, demonstrating how THA can influence their daily life. Furthermore at last follow-up radiographs showed no signs of loosening or polyethylene wear and no revision was required, confirming the excellent results seen in older patients. In our cohort of young patients the most frequent reason for medical intervention was juvenile idiopathic arthritis (33.3%),
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followed by avascular necrosis (13.3%), septic arthritis (13.3%), chondrodysplasia (10%), posttraumatic osteoarthritis (10%), developmental dysplasia of the hip (10%), bilateral CharcoteMarieeTooth disease (6.6%) and arthrogryposis (13.3%). These results can be compared to those present in the literature as recently reported in a review of Adelani [3] of 2013 in which, the most common primary hip diagnosis in patients younger than 30 years was juvenile rheumatoid arthritis (36.3%) followed by avascular necrosis (22.6%) and developmental dysplasia of the hip (12.8%). As regards, in particular, Abdel and Figgie [21] show how THA can provide relief of pain and improved function even if skeletal maturity has not yet occurred in juvenile idiopathic arthritis. The patients in our study were all subjected to uncemented prosthesis due to their age. Their young age means these patients most likely will require a revision of the prosthesis in the future. Revision of a non-cemented prosthesis is technically simpler and less demolitive [22]. Several studies [23,24] in the literature report the use of cement in young patients with systemic diseases, this is mainly due to bone stock after prolonged treatment with steroid drugs [25]. In our series, with a similar number of cases, we did not find differences between the two types of prosthesis implanted (ceramic or polyethylene). Literature reports few studies on the long-term results of THA performed in adolescents or very young adults (Table 4). Bessette [10] in 2003 evaluated clinical and radiographic results in patients younger than 21 years with at least a 10-year follow-up. Eleven arthroplasties were cementless, 2 were hybrid and 2 were cemented. At follow-up Harris Hip Score ranged from 34.2 to 97.2. Four (26%) acetabular components were revised and required
Table 4 Literature results in patients under 25 years with total hip arthroplasty. Author
Journal - year
Patients
Mean age (yy)
Follow-up (yy)
Type of implant
Results
Complication
Revisions
Bessette BJ [10]
Can J Surg. 2003
12 (16 hips)
16.5
13.6
11 cementless 2 hybrids 2 cemented
2 hips dislocations 1 intraoperative fracture 1 dropfoot due to sciatic nerve injury
4 acetabular components 1 femoral stem
Restrepo C [26]
Acta Orthop. Belg. 2008
25 (35 hips)
17.64
6.6
Press fit
No complications
Bilateral polyethylene exchange
Busch V [27]
Clin Orthop Relat Res 2010
48 (69 hips)
24.6
8.4
Cemented
Clin Orthop Relat Res 2010
88 (102 hips)
20
4.2
Finkbone PR [29]
Journal of Arthroplasty 2012
20 (24 hips)
16.4
52 months
All patients received a cementless acetabular component and all except five received a cementless femoral stem. Five hips had cemented stems implanted because of poor femoral bone quality Ceramic Bearings All press-fit with the exception of 2 cases
1 suspected infection 2 traumatic dislocation 1 femoral nerve exploration 4 dislocations (3 revised) 1 periprosthetic fracture 2 peroneal nerve palsies 1 femoral artery intimal tear 1 deep implant infection.
8 revisions
Clohisy JC [28]
HHS from 34.2 to 97.2 10 arthroplasties continued their function after 13.6 yy HHS from 51.9 to 77.3 SF-36: PCS from 43.5 to 63.8 MCS from 58.5 to 80.2 Survivorship of 90% HHS 89 OHQS 19 HHS from 42 to 83
Survival rate 96% HHS from 47.7 to 93.4
1 revision
Kamath AF [30]
Journal of Arthroplasty 2012
18 (21 hips)
18
49 months
1 loosening of acetabular component 1 post-operative instability 1 acetabular screw rupture 1 peroneal nerve palsy 1 cracked ceramic liner
14 ceramic-on-ceramic 6 metal on highly cross-linked polyethylene 1 metal-on-metal
HHS from 43.6 to 83.6 No radiographic loosening
7 revisions
1 revision
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revision. Only 1 (7%) femoral stem was revised. Overall, 67% (10 of 15) of the THAs continued to function well at a mean of 13.6 years postoperatively. The author concludes that THA remains a reasonable option in adolescence and early adulthood in selected patients with severe debility from multiple joint disease. In 2008 Restrepo [26] reported the results of 35 uncemented THAs on 25 patients with a mean age of 17.6 years, and a mean follow-up of 6.6 years. The main diagnosis was avascular necrosis. All patients had a significant improvement in function and relief of pain as measured by the Harris Hip Score and SF-36 and no complications, or reoperations were reported. Only one patient needed revision secondary to severe polyethylene wear. This study confirms our results reporting how uncemented THA confers a significant improvement in function in very young patients with endstage arthritis of the hip. Subsequently Busch [27] in 2010 determined the survival rates and radiological failures of cemented THA in patients with a mean age of 24.6 years reporting clinical scores, complications and current reoperations. At minimum follow-up of 2 years, eight hips were revised (three for infection and five for aseptic loosening) and one hip dislocated for which open reduction was necessary. The 10year survival rate was 83% with revision for any reason as the end point and 90% with revision for aseptic loosening. This study shows a high survival rate for cemented THA in young patients. In the same year, Clohisy [28] reviewed 102 hips had underwent THA, in patients 25 years or younger at surgery. The most common diagnosis was osteonecrosis of the femoral head (44%). The minimum follow-up was 2 years and mean Harris Hip Score improved from 42 preoperatively to 83 postoperatively. Seven hips (7%) underwent revision. There were nine (9%) major complications. All femoral stems and 98% of acetabular components were well-fixed at last follow-up. THA in patients 25 years of age and younger is associated with improved hip function, and secure fixation of cementless implants at early followup. Finkbone [29] evaluated results of ceramic-on-ceramic THA in patients younger than 20 years. 24 THAs were performed using ceramic bearing surfaces in patients 20 years old or younger. Average follow-up was 52 months. The survival rate was 96%, with 1 revision for a loose acetabular component. Postoperatively, the Modified Harris Hip Score mean was 93.4. This study shows promising results at short-term to midterm follow-up in very young patients who undergo THA using ceramic-on-ceramic components. Kamath [30] in 2012 reported results of 21 modern alternativebearing THAs in patients younger than 21 years at a mean follow-up of 49 months. Underlying etiology was chemotherapy-induced osteonecrosis (33%), steroid induced osteonecrosis (29%), sickle cell disease (24%), and chronic dislocation (14%). Articulation bearings were ceramic/ceramic (67%), metal/highly cross-linked polyethylene (29%), and metal resurfacing (5%). Harris Hip Score improved from 43.6 to 83.6. At final follow-up, there was no radiographic loosening; one THA was revised for a cracked ceramic liner. At intermediate-term follow-up, clinical and radiographic results are favorable for alternative-bearing THA in patients younger than 21 years. Our study presents some limitations. Despite long-term followup and a high number of patients as compared with other studies, the series presents a heterogeneity in underlying diagnosis, and prior surgeries may confound results. Moreover, prostheses were implanted by two different surgeons, increasing inter-operator errors. In addition to HHS, which may not be an ideal scoring system for the adolescent patient undergoing THA, we also decided to use the WOMAC scale for better clinical evaluation of patients [31]. All procedures were performed through a posterolateral. Compared with the lateral approach, the posterior approach conferred a
significant reduction in the risk of Trendelenburg and stem malposition, and a non-significant reduction in dislocation and heterotopic ossification [32]. To date, literature reports no studies with a wide cohort of patients younger than 20 years and long-term follow-up. This study represents the longest follow-up to date and a conclusion that THA is a safe and reliable procedure for the treatment of end-stage arthritis in the young, that provides good to excellent results in the mid-term. THA can be considered an important alternative in specific diseases such as JIA, or AN where it is the only acceptable surgical procedure that allows good mobility, a returns to activity of daily living and high quality of life. Clinic and radiographic midterm follow-up, report promising results of uncemented THA in younger adults. Conflict of interest No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. References [1] Shan L, Shan B, Graham D, Saxena A. Total hip replacement: a systematic review and meta-analysis on mid-term quality of life. Osteoarthr Cartil 2014 Mar;22(3):389e406. [2] Corten K, Bourne RB, Charron KD, Au K, Rorabeck CH. What works best, a cemented or cementless primary total hip arthroplasty?: minimum 17-year followup of a randomized controlled trial. Clin Orthop Relat Res 2011 Jan;469(1):209e17. [3] Adelani MA, Keeney JA, Palisch A, Fowler SA, Clohisy JC. Has total hip arthroplasty in patients 30 years or younger improved? A systematic review. Clin Orthop Relat Res 2013 Aug;471(8):2595e601. [4] Colomb-Lippa D. Avascular necrosis of the femoral head. JAAPA 2014 Jul;27(7):40e1. [5] Polkowski GG, Callaghan JJ, Mont MA, Clohisy JC. Total hip arthroplasty in the very young patient. J Am Acad Orthop Surg 2012 Aug;20(8):487e97. PE, Matta JM, Mast JW. Hip arthrodesis: a procedure for the [6] Stover MD, Beaule new millennium? Clin Orthop Relat Res 2004 Jan;418:126e33. [7] Amstutz HC, Su EP, Le Duff MJ. Surface arthroplasty in young patients with hip arthritis secondary to childhood disorders. Orthop Clin North Am 2005 Apr;36(2):223e30. [8] Jain S, Giannoudis PV. Arthrodesis of the hip and conversion to total hip arthroplasty: a systematic review. J Arthroplasty 2013 Oct;28(9):1596e602. [9] Malcolm TL, Gad BV, Elsharkawy KA, Higuera CA. Complication, survival, and reoperation rates following Girdlestone resection arthroplasty. J Arthroplasty 2015 Jul;30(7):1183e6. [10] Bessette BJ, Fassier F, Tanzer M, Brooks CE. Total hip arthroplasty in patients younger than 21 years: a minimum, 10-year follow-up. Can J Surg 2003 Aug;46(4):257e62. [11] Raphael BS, Dines JS, Akerman M, Root L. Long-term followup of total hip arthroplasty in patients with cerebral palsy. Clin Orthop Relat Res 2010 Jul;468(7):1845e54. [12] Kellgren JH, Lawrence JS. Radiological assessment of osteoarthritis. Ann Rheum Dis 1957;16:495e501. [13] Engh CA, Massin P, Suthers KE. Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. Clin Orthop Relat Res 1990 Aug;257:107e28. [14] Brooker AF, Bowerman JW, Robinson RA, Riley Jr LH. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Jt Surg Am 1973 Dec;55(8):1629e32. [15] Gruen TA, McNeice GM, Amstutz HC. “Modes of failure” of cemented stemtype femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res 1979 Jun;141:17e27. [16] Dettoni F, Pellegrino P, La Russa MR, Bonasia DE, Blonna D, Bruzzone M, Castoldi F, Rossi R. Validation and cross cultural adaptation of the Italian version of the Harris hip score. Hip Int 2015 Jan-Feb;25(1):91e7. [17] Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 1988 Dec;15(12): 1833e40. [18] Apolone G, Mosconi P. The Italian SF-36 Health Survey: translation, validation and norming. J Clin Epidemiol 1998 Nov;51(11):1025e36. [19] Hasegawa Y, Kanoh T, Seki T, Matsuoka A, Kawabe K. Joint space wider than 2 mm is essential for an eccentric rotational acetabular osteotomy for adult hip dysplasia. J Orthop Sci 2010 Sep;15(5):620e5.
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[27] Busch V, Klarenbeek R, Slooff T, Schreurs BW, Gardeniers J. Cemented hip designs are a reasonable option in young patients. Clin Orthop Relat Res 2010 Dec;468(12):3214e20. [28] Clohisy JC, Oryhon JM, Seyler TM, Wells CW, Liu SS, Callaghan JJ, Mont MA. Function and fixation of total hip arthroplasty in patients 25 years of age or younger. Clin Orthop Relat Res 2010 Dec;468(12):3207e13. [29] Finkbone PR, Severson EP, Cabanela ME, Trousdale RT. Ceramic-on-ceramic total hip arthroplasty in patients younger than 20 years. J Arthroplasty 2012 Feb;27(2):213e9. [30] Kamath AF, Sheth NP, Hosalkar HH, Babatunde OM, Lee GC, Nelson CL. Modern total hip arthroplasty in patients younger than 21 years. J Arthroplasty 2012 Mar;27(3):402e8. [31] Soren A, Klein W, Huth F. Microscopic comparison of the synovial changes in posttraumatic synovitis and osteoarthritis. Clin Orthop Relat Res 1976 NoveDec;121:191e5. [32] Berstock JR, Blom AW, Beswick AD. A systematic review and meta-analysis of complications following the posterior and lateral surgical approaches to total hip arthroplasty. Ann R Coll Surg Engl 2015 Jan;97(1):11e6.
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Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Original article
Uncemented total hip arthroplasty in patients younger than 20 years Riccardo D'Ambrosi a, b, *, Luca Marciandi c, Piero Vittorio Frediani c, Renato Mario Facchini a, b degli Studi di Milano, Italy Universita Centro Traumatologico Ortopedico, U.O. Clinica Ortopedica e Traumatologica, Milano, Italy c A.O.S. Antonio Abate, U.O. di Ortopedia e Traumatologia, Gallarate, Varese, Italy a
b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 14 December 2015 Received in revised form 22 February 2016 Accepted 16 March 2016 Available online xxx
Background: Several diseases may lead to advanced hip disease and cause disabling symptoms in adolescents. In literature there is no consensus which is the optimal surgical treatment for young adults with end-stage osteoarthritis. The purpose of this study was to assess the clinical and radiological outcomes of uncemented total hip arthroplasty for the treatment of end-stage hip arthritis in patients younger than 20 years at a minimum follow-up of ten years. Methods: We have retrospectively evaluated 24 patients who were 20 years or younger and underwent uncemented total hip arthroplasty. Minimum follow-up was 10 years. Clinical outcome was measured using the Harris Hip Score, Western Ontario McMaster, and the Short-Form 36. Hip calcification was evaluated using Brooker classification, while osteolysis was examined at the final follow-up according to the subdivision of Gruen. Results: The mean preoperative Harris Hip Score was 36.94 points and improved to 92.3, and the mean preoperative WOMAC score improved from 84.72 to 28.45 The Mental Component score-SF-36 improved from a preoperative mean of 26.23 points to 58.96, while the Physical Component score-SF-36 improved from a preoperative mean of 26.38e49.95. All components were stable and osseo-integrated. Radiolucent lines were not present in any hips. We noted the presence of 4 calcifications. No patient needed implant revision. The only complication was an intraoperative femoral fracture. Conclusion: Total hip arthroplasty is a safe and reliable procedure for the treatment of end-stage arthritis in the young that provides good to excellent mid-term results. © 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction Total hip arthroplasty (THA) is considered the gold standard for the treatment of end-stage degenerative hip osteoarthritis [1]. Development of surgical technique and improvement of the design such as cementless fixation and highly crosslinked polyethylene, have led to a longer survivorship of prosthetic implants, to a decrease in pain, improved range of motion and a faster recovery [2]. THA was initially designed for the elderly, with low functional demands, and only in recent years has the number of surgical procedures performed in young patients greatly increased [3]. Several diseases such as avascular necrosis (AN), juvenile idiopathic arthritis (JIA), infection, and chronic dislocation, may
degli Studi di Milano, Italy. Tel.: þ39 * Corresponding author. Universita 3397066151; fax: þ39 0270633611. E-mail address: [email protected] (R. D'Ambrosi).
lead to advanced hip disease and cause disabling symptoms in adolescents [4,5]. To date in the literature there is no consensus which is the optimal surgical treatment for adolescents and young adults with end-stage osteoarthritis. Surgical options include arthrodesis, resection arthroplasty, resurfacing arthroplasty, and THA [5e7]. Hip resection arthroplasty and arthrodesis are functionally unappealing and are considered unacceptable options for these patients with high functional demands [8,9]. THA allows these young patients who have a high activity level, repetitive loading, and excessive demand placed, to regain mobility, improving their social and personal quality of life in this particularly important phase of life. In some cases it seems to be the only surgical option [10]. There are many potential problems related to the survival of the implanted prostheses in a young adult. Age, functional requirements, patient expectations and systemic disease can lead to accelerated failure of implants [11].
http://dx.doi.org/10.1016/j.jos.2016.03.009 0949-2658/© 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: D'Ambrosi R, et al., Uncemented total hip arthroplasty in patients younger than 20 years, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.03.009
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The aim of this study was to determine and report clinical and radiographic outcomes, after uncemented THA in patients younger than 20 years, with a minimum follow-up of ten years.
2. Patients & methods We have retrospectively evaluated 24 patients (30 hips) who were 20 years or younger and underwent uncemented THA procedure between the years 1998e2005. All primary THA was performed by senior Authors. The cohort included 13 (54.17%) females and 11 (45.83%) males who were between the ages of 15 and 20 at the time of index operation. The mean age was 19.7. The radiological classification was performed with anteroposterior pelvic radiography according to the Kellgren score [12]. Kellgren described 4 grades of hip OA: grade 1 (doubtful OA), possible narrowing of the joint space medially and possible osteophytes around femoral head; grade 2 (mild OA), definite narrowing of the joint space inferiorly, definite osteophytes, and slight sclerosis; grade 3 (moderate OA), marked narrowing of the joint space, slight osteophytes, some sclerosis and cyst formation, and deformity of the femoral head and acetabulum; and grade 4 (severe OA), gross loss of joint space with sclerosis and cysts, marked deformity of the femoral head and acetabulum, and large osteophytes [12]. 23 (76.67%) hips presented grade 4 of OA, while 7 (23.33%) grade 3 according to Kellgren classification. The underlying diagnoses were JIA (10 hips e 33.3%), AN (4 hips e 13.3%), septic arthritis (4 hips e 13.3%), chondrodysplasia (3 hips e 10%), post-traumatic osteoarthritis (3 hips e 10%), developmental dysplasia of the hip (DDH) (3 hips e 10%), CharcoteMarieeTooth disease (2 hips e 6.6%) and arthrogryposis (1 hip e 3.3%). All patients had failed conservative treatment which consisted in active and passive physiotherapy exercises and muscle strengthening to improve the motion and partially relieve pain. Moreover patients with systemic diseases such as rheumatoid arthritis were given to systemic and local treatment with cortisone for control of rheumatic disease. 7 hips had a history of previous operations, which consisted of open reduction and internal fixation in 2 hips due to femoral fracture, 4 acetabular osteotomy and one femoral osteotomy plus adductor tenotomy (Table 1). Surgical procedure in all patients was performed in lateral decubitus and through a posterolateral approach. All components were inserted press fit and supplemental screw fixation of the acetabulum was used in 4 cases. Operative time ranged from 75 to 120 min with a mean time of 80 min 18 (60%) THAs
Table 1 Patient demographics. No. of patients (hips) Age Sex Underlying diagnosis (no. of hips)
Previous surgery
Kellgren Lawrence [12] grade
24 (30) 19.7 13 Femalee 11 male 10 juvenile idiopathic arthritis 4 avascular necrosis 4 septic arthritis 3 chondrodysplasia 3 post-traumatic osteoarthritis 3 development dysplasia of the hip 2 Charcot-Marie-Tooth disease 1 arthrogryposis 4 acetabular osteotomy 2 open reduction and internal fixation 1 femural osteotomy plus adductor tenotomy 23 grade 4 7 grade 3
were performed using ceramic on ceramic bearing, while the other 12 (40%) were performed using ceramic on cross-linked polyethylene. In our series we used two different cementless implant: modular stem type and rectangular type. Modular design allows independent preparation and separate component for the metaphysis and diaphysis. We reserved this combination of proximal and distal fixation for complex operations. Indications include anatomic abnormalities and rotational malalignments, such as in hip dysplasia. Rectangular type is tapered conical stem that is grit-blasted across its entire length. The implant provides three-point fixation in the metaphysealediaphyseal junction and proximal part of the diaphysis. Its cross provides four point rotational support. Clinical and radiographic data was collected on all patients preoperatively, on the day after surgery, at 1, 3, 12 months and every year thereafter. No patients were lost at follow-up. Minimum follow-up was 10 years (range: 10e17, mean 12.5). Serial anteroposterior and lateral radiographs of the operated joint were reviewed to assess the position of the prosthesis, loosening, calcifications and osteolysis. Definitely loose components were defined as those that demonstrated a complete lucent line on any radiograph, a femoral subsidence of 2 mm or more, or acetabular component migration or tilt [13]. Hip calcification was evaluated using Brooker classification [14] (Table 2). Osteolysis, defined as areas of bone loss, localized in areas in direct contact with the prosthesis, not present in the immediate post-operative X-rays, but which appeared to subsequent evaluations, were examined at the final follow-up according to the subdivision of Gruen [15]. Gruen divides the femoral component in fourteen areas, seven evaluable in anteroposterior radiograph and seven evaluable in axial view; however acetabular component is divided into six areas (Fig. 1a and b). Osteolysis is caused by wear of the polyethylene and its debridement that starts as an inflammatory reaction [15]. Clinical outcome was measured using the Harris Hip Score (HHS) for total hip arthroplasties, Western Ontario McMaster (WOMAC), and the Short-Form 36 to evaluate quality of life (SF-36). The purpose of HHS is to quantify the initial functional impairment and measure improvement after surgery [16]. It is made up of an evaluation board to evaluate pain, function, motion and deformity. A score less than 70 is considered a poor result, is considered sufficient between 70 and 79, between 80 and 89 is good and between 90 and 100 is excellent. The WOMAC index is a self-administered questionnaire for the evaluation of patients with osteoarthritis of the knee and hip [17]. It measures changes in health after the surgical procedure. Higher scores indicate worse outcome. SF-36 is a generic questionnaire on quality of life. That is not disease, age or treatment specific. It evaluates the subjective perception of the individual in relation to the concepts of health and wellness [18]. To simplify the assessment is divided into a
Table 2 Brooker classification for heterotopic ossification of the hip. Class I Class II
Class III
Class IV
Represents islands of bone in soft tissues about hip Includes bone spurs in pelvis or proximal end of femur leaving at least 1 cm between the opposing bone surfaces Represents bone spurs that extend from pelvis or the proximal end of femur, which reduce the space between the opposing bone surfaces to less than 1 cm Indicates radiographic ankylosis of the hip
Please cite this article in press as: D'Ambrosi R, et al., Uncemented total hip arthroplasty in patients younger than 20 years, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.03.009
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Fig. 1. Gruen zones to identify areas of osteolysis in anteroposterior (a) and axial view (b) radiograph of the hip.
Physical Component Summary (PCS) and Mental Component summary (MCS). The statistical analysis was performed using dedicated statistical software (SPSS version 17, SPSS Inc., IBM, Chicago, IL, USA). Continuous variables were reported as mean (range). For continuous variable a T test for dependent samples/a paired samples t test was performed to compare pre-op and post-operative values. For all the tests, p values < 0.001 were considered statistically significant. This study was approved by our hospital's institutional review board (Protocol number: 4-2015), and all patients signed an informed consent form prior to enrollment in the study and prior to any study procedures being completed.
in patients with DDH, with previous acetabular osteotomy, is essential a minimum joints space to obtain excellent clinical and radiographic results; excellent congruity is an important predictor for a stable and well-positioned implant [19]. All femoral
3. Results The mean preoperative HHS was 36.94 points (range: 20.75e44.9) and improved significantly to 92.3 (range: 89.65e100) at the final follow-up (p < 0.001). The mean preoperative WOMAC score was 84.72 (range: 72.8e93.4) points and improved significantly to 28.45 (range: 15.2e40.8) (p < 0.001). The MCS-SF-36 improved from a preoperative mean of 26.23 (range: 23.4e31.5) points to 58.96 (range: 47.4e62.1) at the latest follow-up (p < 0.001). The PCS-SF-36 component improved from a preoperative mean of 26.38 (range: 19.6e31.3) to 49.92 (range: 25.2e57.9) at the latest follow-up (p < 0.001) (Table 3). All radiological measurements were made using the standard tools in our Picture Archiving and Communication System (PACS) and evaluated by two orthopedic surgeons. On preoperative radiographs, joint space ranged from 0 to 4 mm. In fact, in particular
Table 3 Clinical data pre-operative and at last follow-up.
Pre-operatively Last follow-up p-Value
Harris hip score
WOMAC
MCS
PCS
36.94 92.3 <0.001*
84.72 28.45 <0.001*
26.23 58.96 <0.001*
26.38 49.92 <0.001*
*Statistically significant.
Fig. 2. Preoperative (a) anteroposterior radiograph of a 19-year-old girl who underwent THA for arthrogryposis of the right hip. (b) Follow-up radiograph taken at 11 years shows well-fixed components.
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Fig. 3. Preoperative (a) AP radiograph of a 16-year-old boy who underwent THA for avascular necrosis of the left hip. (b) Preoperative 3d-reconstruction of the femoral head with avascular necrosis. (c) Plain anteroposterior radiograph 10 years after surgery shows well-fixed components, no osteolysis or mobilization of the prosthesis.
components were well-positioned. At the final follow-up, all components were deemed to be stable and osseo-integrated (Figs. 2a, b and 3aec). Progressive, complete radiolucent lines,
indicating a loose prosthesis, were not present in any hips. Incomplete radiolucent lines were detected in five hips in Gruen zones 1 (2 hips e 6.7%), 2 (1 hip e 3.3%), 6 (1 hip e 3.3%) and 7 (1
Fig. 4. (a) Intraoperative plain radiograph shows femoral fracture in a 16-year old girl treated with metal cerclage (b).
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hip e 3.3%) respectively. Gross polyethylene wear, indicated by eccentric position of the femoral head, was not present in any hips. Femoral stem subsidence greater than 2 mm had not occurred in any hips. According to Broker we noted the presence of 4 calcifications, two grade 1 (6.7%), one grade 2 (3.3%) and one grade 3 (3.3%) respectively. At the latest follow-up, no patient needed implant revision. The only complication was an intraoperative femoral fracture which was treated with metal cerclage that did not compromise the success of the prosthesis (Fig. 4a, b). 4. Discussion THA is considered the gold standard with excellent long-term outcome in older patients [20]. Results of total hip arthroplasty in young adults has not to date been equally rewarding due to the high activity level and the excessive demand imposed on the prosthetic hip [3,5]. In our retrospective study, with a minimum follow-up at 10 years, we report good to excellent results in a cohort of 30 hips. The Harris Hip Score improved from 36.94 to 92.3. The WOMAC score ranged from 84.72 to 28.45 points showing a good functionality of the prosthetic implant. The quality of life, both physical and mental components, as measured by the SF-36, showed significant improvement in our cohort of patients, demonstrating how THA can influence their daily life. Furthermore at last follow-up radiographs showed no signs of loosening or polyethylene wear and no revision was required, confirming the excellent results seen in older patients. In our cohort of young patients the most frequent reason for medical intervention was juvenile idiopathic arthritis (33.3%),
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followed by avascular necrosis (13.3%), septic arthritis (13.3%), chondrodysplasia (10%), posttraumatic osteoarthritis (10%), developmental dysplasia of the hip (10%), bilateral CharcoteMarieeTooth disease (6.6%) and arthrogryposis (13.3%). These results can be compared to those present in the literature as recently reported in a review of Adelani [3] of 2013 in which, the most common primary hip diagnosis in patients younger than 30 years was juvenile rheumatoid arthritis (36.3%) followed by avascular necrosis (22.6%) and developmental dysplasia of the hip (12.8%). As regards, in particular, Abdel and Figgie [21] show how THA can provide relief of pain and improved function even if skeletal maturity has not yet occurred in juvenile idiopathic arthritis. The patients in our study were all subjected to uncemented prosthesis due to their age. Their young age means these patients most likely will require a revision of the prosthesis in the future. Revision of a non-cemented prosthesis is technically simpler and less demolitive [22]. Several studies [23,24] in the literature report the use of cement in young patients with systemic diseases, this is mainly due to bone stock after prolonged treatment with steroid drugs [25]. In our series, with a similar number of cases, we did not find differences between the two types of prosthesis implanted (ceramic or polyethylene). Literature reports few studies on the long-term results of THA performed in adolescents or very young adults (Table 4). Bessette [10] in 2003 evaluated clinical and radiographic results in patients younger than 21 years with at least a 10-year follow-up. Eleven arthroplasties were cementless, 2 were hybrid and 2 were cemented. At follow-up Harris Hip Score ranged from 34.2 to 97.2. Four (26%) acetabular components were revised and required
Table 4 Literature results in patients under 25 years with total hip arthroplasty. Author
Journal - year
Patients
Mean age (yy)
Follow-up (yy)
Type of implant
Results
Complication
Revisions
Bessette BJ [10]
Can J Surg. 2003
12 (16 hips)
16.5
13.6
11 cementless 2 hybrids 2 cemented
2 hips dislocations 1 intraoperative fracture 1 dropfoot due to sciatic nerve injury
4 acetabular components 1 femoral stem
Restrepo C [26]
Acta Orthop. Belg. 2008
25 (35 hips)
17.64
6.6
Press fit
No complications
Bilateral polyethylene exchange
Busch V [27]
Clin Orthop Relat Res 2010
48 (69 hips)
24.6
8.4
Cemented
Clin Orthop Relat Res 2010
88 (102 hips)
20
4.2
Finkbone PR [29]
Journal of Arthroplasty 2012
20 (24 hips)
16.4
52 months
All patients received a cementless acetabular component and all except five received a cementless femoral stem. Five hips had cemented stems implanted because of poor femoral bone quality Ceramic Bearings All press-fit with the exception of 2 cases
1 suspected infection 2 traumatic dislocation 1 femoral nerve exploration 4 dislocations (3 revised) 1 periprosthetic fracture 2 peroneal nerve palsies 1 femoral artery intimal tear 1 deep implant infection.
8 revisions
Clohisy JC [28]
HHS from 34.2 to 97.2 10 arthroplasties continued their function after 13.6 yy HHS from 51.9 to 77.3 SF-36: PCS from 43.5 to 63.8 MCS from 58.5 to 80.2 Survivorship of 90% HHS 89 OHQS 19 HHS from 42 to 83
Survival rate 96% HHS from 47.7 to 93.4
1 revision
Kamath AF [30]
Journal of Arthroplasty 2012
18 (21 hips)
18
49 months
1 loosening of acetabular component 1 post-operative instability 1 acetabular screw rupture 1 peroneal nerve palsy 1 cracked ceramic liner
14 ceramic-on-ceramic 6 metal on highly cross-linked polyethylene 1 metal-on-metal
HHS from 43.6 to 83.6 No radiographic loosening
7 revisions
1 revision
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revision. Only 1 (7%) femoral stem was revised. Overall, 67% (10 of 15) of the THAs continued to function well at a mean of 13.6 years postoperatively. The author concludes that THA remains a reasonable option in adolescence and early adulthood in selected patients with severe debility from multiple joint disease. In 2008 Restrepo [26] reported the results of 35 uncemented THAs on 25 patients with a mean age of 17.6 years, and a mean follow-up of 6.6 years. The main diagnosis was avascular necrosis. All patients had a significant improvement in function and relief of pain as measured by the Harris Hip Score and SF-36 and no complications, or reoperations were reported. Only one patient needed revision secondary to severe polyethylene wear. This study confirms our results reporting how uncemented THA confers a significant improvement in function in very young patients with endstage arthritis of the hip. Subsequently Busch [27] in 2010 determined the survival rates and radiological failures of cemented THA in patients with a mean age of 24.6 years reporting clinical scores, complications and current reoperations. At minimum follow-up of 2 years, eight hips were revised (three for infection and five for aseptic loosening) and one hip dislocated for which open reduction was necessary. The 10year survival rate was 83% with revision for any reason as the end point and 90% with revision for aseptic loosening. This study shows a high survival rate for cemented THA in young patients. In the same year, Clohisy [28] reviewed 102 hips had underwent THA, in patients 25 years or younger at surgery. The most common diagnosis was osteonecrosis of the femoral head (44%). The minimum follow-up was 2 years and mean Harris Hip Score improved from 42 preoperatively to 83 postoperatively. Seven hips (7%) underwent revision. There were nine (9%) major complications. All femoral stems and 98% of acetabular components were well-fixed at last follow-up. THA in patients 25 years of age and younger is associated with improved hip function, and secure fixation of cementless implants at early followup. Finkbone [29] evaluated results of ceramic-on-ceramic THA in patients younger than 20 years. 24 THAs were performed using ceramic bearing surfaces in patients 20 years old or younger. Average follow-up was 52 months. The survival rate was 96%, with 1 revision for a loose acetabular component. Postoperatively, the Modified Harris Hip Score mean was 93.4. This study shows promising results at short-term to midterm follow-up in very young patients who undergo THA using ceramic-on-ceramic components. Kamath [30] in 2012 reported results of 21 modern alternativebearing THAs in patients younger than 21 years at a mean follow-up of 49 months. Underlying etiology was chemotherapy-induced osteonecrosis (33%), steroid induced osteonecrosis (29%), sickle cell disease (24%), and chronic dislocation (14%). Articulation bearings were ceramic/ceramic (67%), metal/highly cross-linked polyethylene (29%), and metal resurfacing (5%). Harris Hip Score improved from 43.6 to 83.6. At final follow-up, there was no radiographic loosening; one THA was revised for a cracked ceramic liner. At intermediate-term follow-up, clinical and radiographic results are favorable for alternative-bearing THA in patients younger than 21 years. Our study presents some limitations. Despite long-term followup and a high number of patients as compared with other studies, the series presents a heterogeneity in underlying diagnosis, and prior surgeries may confound results. Moreover, prostheses were implanted by two different surgeons, increasing inter-operator errors. In addition to HHS, which may not be an ideal scoring system for the adolescent patient undergoing THA, we also decided to use the WOMAC scale for better clinical evaluation of patients [31]. All procedures were performed through a posterolateral. Compared with the lateral approach, the posterior approach conferred a
significant reduction in the risk of Trendelenburg and stem malposition, and a non-significant reduction in dislocation and heterotopic ossification [32]. To date, literature reports no studies with a wide cohort of patients younger than 20 years and long-term follow-up. This study represents the longest follow-up to date and a conclusion that THA is a safe and reliable procedure for the treatment of end-stage arthritis in the young, that provides good to excellent results in the mid-term. THA can be considered an important alternative in specific diseases such as JIA, or AN where it is the only acceptable surgical procedure that allows good mobility, a returns to activity of daily living and high quality of life. Clinic and radiographic midterm follow-up, report promising results of uncemented THA in younger adults. Conflict of interest No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. References [1] Shan L, Shan B, Graham D, Saxena A. Total hip replacement: a systematic review and meta-analysis on mid-term quality of life. Osteoarthr Cartil 2014 Mar;22(3):389e406. [2] Corten K, Bourne RB, Charron KD, Au K, Rorabeck CH. What works best, a cemented or cementless primary total hip arthroplasty?: minimum 17-year followup of a randomized controlled trial. Clin Orthop Relat Res 2011 Jan;469(1):209e17. [3] Adelani MA, Keeney JA, Palisch A, Fowler SA, Clohisy JC. Has total hip arthroplasty in patients 30 years or younger improved? A systematic review. Clin Orthop Relat Res 2013 Aug;471(8):2595e601. [4] Colomb-Lippa D. Avascular necrosis of the femoral head. JAAPA 2014 Jul;27(7):40e1. [5] Polkowski GG, Callaghan JJ, Mont MA, Clohisy JC. Total hip arthroplasty in the very young patient. J Am Acad Orthop Surg 2012 Aug;20(8):487e97. PE, Matta JM, Mast JW. Hip arthrodesis: a procedure for the [6] Stover MD, Beaule new millennium? Clin Orthop Relat Res 2004 Jan;418:126e33. [7] Amstutz HC, Su EP, Le Duff MJ. Surface arthroplasty in young patients with hip arthritis secondary to childhood disorders. Orthop Clin North Am 2005 Apr;36(2):223e30. [8] Jain S, Giannoudis PV. Arthrodesis of the hip and conversion to total hip arthroplasty: a systematic review. J Arthroplasty 2013 Oct;28(9):1596e602. [9] Malcolm TL, Gad BV, Elsharkawy KA, Higuera CA. Complication, survival, and reoperation rates following Girdlestone resection arthroplasty. J Arthroplasty 2015 Jul;30(7):1183e6. [10] Bessette BJ, Fassier F, Tanzer M, Brooks CE. Total hip arthroplasty in patients younger than 21 years: a minimum, 10-year follow-up. Can J Surg 2003 Aug;46(4):257e62. [11] Raphael BS, Dines JS, Akerman M, Root L. Long-term followup of total hip arthroplasty in patients with cerebral palsy. Clin Orthop Relat Res 2010 Jul;468(7):1845e54. [12] Kellgren JH, Lawrence JS. Radiological assessment of osteoarthritis. Ann Rheum Dis 1957;16:495e501. [13] Engh CA, Massin P, Suthers KE. Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. Clin Orthop Relat Res 1990 Aug;257:107e28. [14] Brooker AF, Bowerman JW, Robinson RA, Riley Jr LH. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Jt Surg Am 1973 Dec;55(8):1629e32. [15] Gruen TA, McNeice GM, Amstutz HC. “Modes of failure” of cemented stemtype femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res 1979 Jun;141:17e27. [16] Dettoni F, Pellegrino P, La Russa MR, Bonasia DE, Blonna D, Bruzzone M, Castoldi F, Rossi R. Validation and cross cultural adaptation of the Italian version of the Harris hip score. Hip Int 2015 Jan-Feb;25(1):91e7. [17] Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 1988 Dec;15(12): 1833e40. [18] Apolone G, Mosconi P. The Italian SF-36 Health Survey: translation, validation and norming. J Clin Epidemiol 1998 Nov;51(11):1025e36. [19] Hasegawa Y, Kanoh T, Seki T, Matsuoka A, Kawabe K. Joint space wider than 2 mm is essential for an eccentric rotational acetabular osteotomy for adult hip dysplasia. J Orthop Sci 2010 Sep;15(5):620e5.
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[27] Busch V, Klarenbeek R, Slooff T, Schreurs BW, Gardeniers J. Cemented hip designs are a reasonable option in young patients. Clin Orthop Relat Res 2010 Dec;468(12):3214e20. [28] Clohisy JC, Oryhon JM, Seyler TM, Wells CW, Liu SS, Callaghan JJ, Mont MA. Function and fixation of total hip arthroplasty in patients 25 years of age or younger. Clin Orthop Relat Res 2010 Dec;468(12):3207e13. [29] Finkbone PR, Severson EP, Cabanela ME, Trousdale RT. Ceramic-on-ceramic total hip arthroplasty in patients younger than 20 years. J Arthroplasty 2012 Feb;27(2):213e9. [30] Kamath AF, Sheth NP, Hosalkar HH, Babatunde OM, Lee GC, Nelson CL. Modern total hip arthroplasty in patients younger than 21 years. J Arthroplasty 2012 Mar;27(3):402e8. [31] Soren A, Klein W, Huth F. Microscopic comparison of the synovial changes in posttraumatic synovitis and osteoarthritis. Clin Orthop Relat Res 1976 NoveDec;121:191e5. [32] Berstock JR, Blom AW, Beswick AD. A systematic review and meta-analysis of complications following the posterior and lateral surgical approaches to total hip arthroplasty. Ann R Coll Surg Engl 2015 Jan;97(1):11e6.
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