Hip resurfacing arthroplasty in inflammatory arthritis a 3- to 5-year follow-up study

Older Patients May Fare Better Following Hip Resurfacing Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Since its inception, activity level and bone quality have been essential considerations for patients undergoing hip resurfacing arthroplasty (HRA). Moreover, younger patients tend to experience fewer complications, lower revision rates, and better outcomes after any surgery. This study aims to compare the clinical outcomes, complication rates, and survivorship rates between younger and older patients undergoing HRA, providing insights into whether active older patients with appropriate bone quality can still achieve significant benefits from HRA.

METHODS

A literature search was conducted using PubMed, Embase, and Scopus databases. Articles were screened by title and abstract, followed by full-text review. A meta-analysis was performed using a random effects model to compare UCLA scores and odds of prosthesis survivorship between younger (<50 years of age) and older (>50 years of age) patients in studies comparing both age groups. Statistical significance was defined as a 95% confidence interval that does not include 1. In addition, the average complication and prosthesis survivorship rates were calculated and compared between younger and older hips using both comparative and noncomparative studies.

RESULTS

From an initial pool of 1,286 articles, 31 met inclusion criteria, encompassing 22,691 patients. Analysis revealed a pooled mean age of 33.65 years for the younger cohort and 63 years for the older cohort, and a complication rate of 5.37% in younger compared with 3.83% in older hips. The difference in postoperative UCLA scores was deemed statistically insignificant based on meta-analysis. However, the difference in mean survivorship rates was found to be statistically significant at 86% for younger and 94.9% for older patients through univariate analysis and meta-analysis.

CONCLUSION

There is no significant difference in postoperative outcomes between younger and older patients undergoing HRA. In fact, older patients seem to experience higher prosthesis survivorship rates compared with younger cohorts. Older patients who are active and possess good bone quality can achieve outcomes comparable to their younger counterparts, indicating that HRA may be viable for a broader age range than previously considered.

LEVEL OF EVIDENCE

Level III, systematic review of Level II, III, and IV studies. See Instructions for Authors for a complete description of levels of evidence.

Functional and clinical outcome with modified lateral approach total hip arthroplasty in stiff hips with ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis at total hip arthroplasty (THA) has significant hip stiffness with flexion deformity, restricted mobility, and function. Range of movement (ROM) improvement with good functional outcome is seen following THA in these hips. The modified Hardinge approach without abductor compromise is helpful in these stiff hips with associated flexion deformity.

AIM

To assess improvement in ROM and functional outcomes with a modified lateral approach THA in ankylosing spondylitis with stiff hips.

METHODS

A total of 69 hips that underwent THA with a modified Hardinge approach in 40 patients were evaluated at a mean follow-up of 38.33 mo. All individuals ambulated with weight-bearing as tolerated and ROM exercises from the 1st postoperative day. Modified Harris hip score and ROM were assessed during follow-up. Quality of life assessments using the 36-item and 12-item short form health surveys were done along with clinical and functional outcomes at follow-up. SPSS 22.0 was used for statistical analysis. The correlation of ROM and functional score change was performed using Pearson's correlation coefficient.

RESULTS

Sixty-nine hips with a significant decrease in ROM preoperatively with 32 clinically fused hips showed significant improvement in flexion range. The mean flexion in 69 hips improved from 29.35 ± 31.38 degrees to 102.17 ± 10.48 degrees. The mean difference of 72.82 with a P value < 0.0001 was significant. In total, 45 out of 69 hips had flexion deformity, with 13 hips having a deformity above 30 degrees. The flexion during the follow-up was below 90 degrees in 3 hips. Eleven hips had flexion of 90 degrees at follow-up, while the remaining 55 hips had flexion above 100 degrees. Modified Harris hip score improved from 17.03 ± 6.02 to 90.66 ± 7.23 (P value < 0.0001). The 36-item short form health survey at the follow-up indicated health status in 40 patients as excellent in 11, very good in 20, good in 5, fair in 3, and poor in 1. The mean mental health score was 84.10 ± 11.58. Pain relief was good in all 69 hips. Altogether, 28/40 patients (70%) had no pain, 9 patients (22%) had occasional pain, and 3 patients (8%) had mild to moderate pain with unusual activity. Heterotopic ossification was seen in 21 hips with Brooker class 1 in 14 hips.

CONCLUSION

Modified Hardinge approach THA in ankylosing spondylitis with stiff hips with flexion deformity significantly improved ROM, Harris hip score, and quality of life indicated by the 36-item and 12-item short form health surveys.

Total hip arthroplasty in fused hips with spine stiffness in ankylosing spondylitis

Ankylosing spondylitis (AS) is characterized by involvement of the spine and hip joints with progressive stiffness and loss of function. Functional impairment is significant, with spine and hip involvement, and is predominantly seen in the younger age group. Total hip arthroplasty (THA) for fused hips with stiff spines in AS results in considerable improvement of mobility and function. Spine stiffness associated with AS needs evaluation before THA. Preoperative assessment with lateral spine radiographs shows loss of lumbar lordosis. Spinopelvic mobility is reduced with change in sacral slope from sitting to standing less than 10 degrees conforming to the stiff pattern. Care should be taken to reduce acetabular component anteversion at THA in these fused hips, as the posterior pelvic tilt would increase the risk of posterior impingement and anterior dislocation. Fused hips require femoral neck osteotomy, true acetabular floor identification and restoration of the hip center with horizontal and vertical offset to achieve a good functional outcome. Cementless and cemented fixation have shown comparable long-term results with the choice dependent on bone stock at THA. Risks at THA in AS include intraoperative fractures, dislocation, heterotopic ossification, among others. There is significant improvement of functional scores and quality of life following THA in these deserving young individuals with fused hips and spine stiffness.

Hip resurfacing arthroplasty for patients with inflammatory arthritis: a systematic review

INTRODUCTION

Modern metal-on-metal hip resurfacing arthroplasty has led to decreased revision rates and high implant survival rates as compared to prior generations of resurfacing. Many of the series that report on resurfacing outcomes focus upon patients treated with a diagnosis of osteoarthritis. Patients with inflammatory arthritis such as rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are also treated in these series, however, their outcomes following resurfacing are underreported. The aim of this study was to determine complications that may occur following hip resurfacing in patients with inflammatory arthritis. A secondary aim was to determine functional outcomes following resurfacing.

METHODS

A search was performed in MEDLINE (PubMed/OVID), Cochrane Library, and Google Scholar. 5 studies met eligibility criteria. This review includes 196 hips; 120 had a diagnosis of AS or seronegative spondyloarthropathy and 76 had a diagnosis of RA or juvenile RA. 8 revisions were reported at a mean time of 64.2 (8.67-275.58) weeks.

RESULTS

Femoral neck fracture was the most common indication for revision, occurring in 3.06% of all hips at 34.5 weeks (16.0-52.0). 2 infections, 2 reports of acetabular radiolucency, and no dislocations were reported. The University of California at Los Angeles score, Harris Hip Score, and Range of Motion were the most common functional outcomes measured, which increased in the majority of studies following resurfacing.

CONCLUSIONS

Femoral neck fracture was the most common reason for revision in patients with inflammatory arthritis following resurfacing and there were no dislocations reported. Following resurfacing, these patients have improved functional outcomes.

10-year results of the Birmingham Hip Resurfacing: a non-designer case series

INTRODUCTION

Recent controversies surrounding metal-on-metal (MoM) hip resurfacing has led to a substantial decline in its use. Despite this, there is good evidence to support the use of specific implants in select patients.

PATIENTS AND METHODS

A retrospective analysis of Birmingham Hip Resurfacing (BHR) patients with a minimum of 10 years follow-up was performed. Functional scoring was performed with the Oxford Hip Score (OHS) and failure was defined as revision for any cause. 111 patients underwent 121 BHR procedures. All patients had a minimum follow-up of 10 years. 70 patients (63%) were male. Mean patient age at surgery was 52.5 years (male 53.9 years, female 48.8 years).

RESULTS

Overall survival at 10 years was 91% (97% male, 80% female). There was a statistically significant improvement in OHS postoperatively which remains at 10-year follow-up (p = <0.05). There was no significant difference in scores between the male and female groups. Revisions were most often in patients with smaller component sizes but this was not found to be statistically significant.

CONCLUSIONS

Our results reflect that of the wider literature in that good outcomes can be obtained with this implant in a select group of patients and results are comparable to that of conventional hip arthroplasty in patients of a similar age.

Outcomes of the Recalled Articular Surface Replacement Metal-on-Metal Hip Implant System: A Systematic Review

BACKGROUND

The aim of this review was to synthesize the main findings of clinical studies that have evaluated outcomes of the articular surface replacement (ASR) Hip System.

METHODS

We performed a systematic literature search to identify all articles published between January 2008 and June 2015 that included ASR hip resurfacing arthroplasty (ASR HRA) or ASR total hip arthroplasty (ASR XL THA) outcomes according to the PRISMA statement.

RESULTS

A total of 56 studies were assessed. The prevalence of adverse local tissue reactions (ALTRs) and revision rates were found to be high. ALTR prevalence varied from 12.5% to 69% (mean, 33.5%). Mean revision rate for any reason at 4-year to 7-year follow-up was 13.8% (range, 5.6%-31%) for ASR HRA and 14.5% (range, 0%-37%) for ASR XL THA. Femoral head size <53 mm was found to correlate with higher blood metal ion levels. Femoral head size >44 mm was not associated with higher ALTR prevalence or revision rates in ASR XL THA. High blood metal ion levels (>7 μg/L Co, >7 μg/L Cr) were associated with higher failure rates and bearing-related complications. The role of cup positioning was found to be controversial.

CONCLUSION

ALTR prevalence and failure rates were high. High blood metal ion levels were a risk factor for ALTR and failure. Surprisingly, the role of cup positioning and large femoral head size in ASR XL THA were controversial. These findings should be considered in the clinical follow-up and risk stratification of patients with the ASR Hip System.

Prevalence of Failure due to Adverse Reaction to Metal Debris in Modern, Medium and Large Diameter Metal-on-Metal Hip Replacements--The Effect of Novel Screening Methods: Systematic Review and Metaregression Analysis

Metal-on-metal (MoM) hip replacements were used for almost a decade before adverse reactions to metal debris (ARMD) were found to be a true clinical problem. Currently, there is a paucity of evidence regarding the usefulness of systematic screening for ARMD. We implemented a systematic review and meta-analysis to establish the prevalence of revision confirmed ARMD stratified by the use of different screening protocols in patients with MoM hip replacements. Five levels of screening were identified: no screening (level 0), targeted blood metal ion measurement and/or cross-sectional imaging (level 1), metal ion measurement without imaging (level 2), metal ion measurement with targeted imaging (level 3) and comprehensive screening (both metal ions and imaging for all; level 4). 122 studies meeting our eligibility criteria were included in analysis. These studies included 144 study arms: 100 study arms with hip resurfacings, 33 study arms with large-diameter MoM total hip replacements (THR), and 11 study arms with medium-diameter MoM THRs. For hip resurfacing, the lowest prevalence of ARMD was seen with level 0 screening (pooled prevalence 0.13%) and the highest with level 4 screening (pooled prevalace 9.49%). Pooled prevalence of ARMD with level 0 screening was 0.29% and with level 4 screening 21.3% in the large-diameter MoM THR group. In metaregression analysis of hip resurfacings, level 4 screening was superior with regard to prevalence of ARMD when compared with other levels. In the large diameter THR group level 4 screening was superior to screening 0,2 and 3. These outcomes were irrespective of follow-up time or study publication year. With hip resurfacings, routine cross-sectional imaging regardless of clinical findings is advisable. It is clear, however, that targeted metal ion measurement and/or imaging is not sufficient in the screening for ARMD in any implant concepts. However, economic aspects should be weighed when choosing the preferred screening level.

A Literature Review of Total Hip Arthroplasty in Patients with Ankylosing Spondylitis: Perioperative Considerations and Outcome

Ankylosing spondylitis is a spondyloarthropathy affecting the sacro-iliac joints with subsequent progression to the spine and the hip joints. The hip joints are affected by synovitis, enthesial inflammation, involvement of medullary bone, progressive degeneration and secondary osteoarthritis. Clinical presentation is usually in the form of pain and stiffness progressing to disabling fixed flexion contractures and in some instances, complete ankylosis. Hip arthroplasty should be considered for hip pain, postural and functional disability, or pain in adjacent joints due to hip stiffness. We conducted a literature review to determine peri-operative considerations and outcome in ankylosing spondylitis patients undergoing hip arthroplasty. In this review, we have discussed pre-operative surgical planning, thromboprophylaxis, anaesthetic considerations and heterotopic ossification. Outcomes of arthroplasty include range of movement, pain relief, survivorship and complications.

Survivorship and clinical outcome of Birmingham hip resurfacing: a minimum ten years' follow-up

INTRODUCTION

Resurfacing as a percentage of total hip arthroplasty rose from 5.6 % in 2001 to 8.9 % in 2005 in Australia. During the same period the resurfacing to conventional prosthesis rose from 19.6 % to 29 % in the younger age group (less than 55 years). Long term (more than ten years) functional results of BHR are sparingly documented. Among the literatures available, the patient selection criteria vary from osteoarthritis, avascular necrosis, and dysplastic hip to slipped capital femoral epiphysis. The objective of the current study is to evaluate long term survivorship and functional outcome of Birmingham hip resurfacing surgery in osteoarthritic hip patients performed by a single surgeon.

PATIENTS AND METHODS

In this retrospective clinical study, all patients who underwent hip resurfacing for osteoarthritis of hip between 1999 and 2004 are included. All surgeries were performed by single surgeon (SJM) and in all patients Smith & Nephew system (Midland Medical Technologies, Birmingham, United Kingdom)) was used. Revision surgery is considered the end point of survivorship. Means, standard deviations, and confidence interval were calculated for all continuous measures. Survival analysis was performed with the Kaplan-Meier method and 95 % confidence intervals were calculated.

RESULT

The result is based on 222 patients (244 hips). This included 153 males and 69 females. Our mean follow up was 12.05 years and overall survival was 93.7 %. In terms of gender, survival in males was 95.43 % while in females it was 89.86 %. Failure was seen in 14 patients (16 hips), which included seven female (10.14 %) and seven male (4.57 %) patients. Failure of femoral components due to aseptic loosening and varus collapse was seen in eight patients after a mean 9.6 years. Metal allergy was seen in three patients (five hips), all of them were female of which two had bilateral resurfacing. Other complications included femoral neck stress fractures in two patients and acetabular component loosening in one patient. We observed that the failure rate is higher if the BHR femoral component size is 46 or less (ten out of 16 hips revised).

CONCLUSION

If patient selection is judiciously done and surgical technique is meticulously followed, hip resurfacing offers acceptable survivorship, satisfactory range of motion and enables patients to resume high demand activities including sports. Future improvements in the bearing surfaces, and possibly in the design, might alleviate concerns posed by high serum metal level and provide options that continue to benefit younger patients in future.

The outcomes of hip resurfacing compared to standard primary total hip arthroplasty in Men

Background

The purpose of this study was to evaluate the clinical and radiographic outcomes of hip resurfacing patients and compare them to standard primary total hip arthroplasty procedures performed during the same period of time.

Methods

One hundred and fourteen consecutive men who had a mean age of 50 years (range, 20 to 85 years) and who had undergone 120 hip resurfacing arthroplasties between 2007 and 2009 were compared to 117 consecutive men (120 hips) who had undergone a standard total hip arthroplasty during the same time period. The mean follow-up was 42 months (range, 24 to 55 months) for both groups. Outcomes evaluated included implant survivorship, hip scores, activity levels, and complication rates.

Results

In the resurfacing hip arthroplasty cohort, implant survivorship was 98% with two patients requiring a revision surgery one for femoral neck fracture and another for femoral head loosening. In comparison, implant survivorship was 99% in the standard total hip arthroplasty cohort, with 1 revision due to peri-prosthetic fracture which was successfully treated with a femoral component revision. In the resurfacing and standard hip arthroplasty cohorts, the mean post-operative Harris hip scores had improved to 96 and 94 points, respectively and were statistically similar. The resurfacing cohort had achieved a significantly higher mean post-operative University of California Activity Score (6.7 versus 5 points). There were no differences in the complication rates between the two cohorts.

Conclusion

When patients meet the appropriate selection criteria in the hands of experienced and high-volume arthroplasty surgeons, hip resurfacing provides excellent results at short- to mid-term follow-up.

Hip resurfacing: a systematic review of literature

PURPOSE

We conducted a systematic review of the literature in order to take stock of hip resurfacing according to the principle of "evidence based medicine". Our main objective was to compare the rate of revision of resurfacing implants with survival limits set by the National Institute of Clinical Excellence (NICE).

METHODS

A systematic review was undertaken of all published (Medline, Cochrane, EMBASE) literature research databases up to July 2012 as recommended by the PRISMA statement. Data extraction focused on functional outcomes, complications and survival rates. The survival rates of implants were analysed according to the mean of the series in comparison to the NICE criteria.

RESULTS

Fifty-three studies were identified and included 26,456 cases with an average of 499.17 ± 856.7 (range, 38-5000) cases per study. The median survival was 95.57 % ± 3.7 % (range, 84-100). The percentage of studies which satisfied the criteria set by NICE was 69.8 %. In terms of cumulative revision rates pondered by the number of implants, BHR®, Conserve Plus® and Cormet® showed the best results. The mean postoperative score was 91.2 ± 7.72 (range, 68.3-98.6). There was no statistically significant difference between implants in terms of functional outcomes.

CONCLUSION

On the basis of the current evidence base, this review of the literature emphasises the importance of certain parameters that can improve the results of resurfacing. The type of implant seems to play an important role as does patient selection.