Total Hip Arthroplasty in Teenagers: A Systematic Literature Review

BACKGROUND

Total hip arthroplasty (THA) in teenagers is generally avoided. Nevertheless, recent THA procedures in a very young patient show improved functional outcomes and implant survival, resulting in lower revision rates. This review aims to present an overview of the available literature on THA in teenagers and to provide evidence to inform caregivers.

METHODS

In this systematic review, studies required a primary THA method and a teenage patient population. Studies must report at least one of the following outcome measures: functional outcomes, implant survival, and complications. In addition, demographic and surgical data were collected.

RESULTS

Sixteen studies were analyzed, including 2040 patients and 2379 hips, with an average 7.7-year follow-up. The mean patient age was 18 years, with an average revision rate of 11.7%. The overall average relative improvement of the 2 most frequently used patient-reported (functional) outcome measures were 84.3 and 92.3% at the latest follow-up. Prosthesis, or liner loosening, was the cause of revision in 50.2% of the cases. Loosening was the most frequent complication (14.8%), together with prosthesis/liner wear (14.8%). Cementless fixation (70.7%), ceramic-on-ceramic articulation (34.7%), and the posterior surgical approach (82.3%) were the most applied techniques.

CONCLUSIONS

The functional outcomes after THA in teenagers improved at follow-up. The average revision rate is relatively high, especially in the pre-1995 studies, with post-1995 studies reporting similar revision rates to the adult patient group. Research to further improve implant survival as well as the ease of revisions in teenagers is needed.

LEVEL OF EVIDENCE

Level III-systematic review.

Load-induced deformation of the tibia and its effect on implant loosening detection

CT imaging under external valgus and varus loading conditions and consecutive image analysis can be used to detect tibial implant loosening after total knee arthroplasty. However, the applied load causes the tibia to deform, which could result in an overestimation of implant displacement. This research evaluates the extent of tibia deformation and its effect on measuring implant displacement. Ten cadaver specimen with TKA were CT-scanned under valgus/varus loading (20 Nm), first implanted without bone cement fixation (mimicking a loose implant) and subsequently with bone cement fixation (mimicking a fixed implant). By means of image analysis, three relative displacements were assessed: (1) between the proximal and distal tibia (measure of deformation), (2) between the implant and the whole tibia (including potential deformation effect) and (3) between the implant and the proximal tibia (reduced deformation effect). Relative displacements were quantified in terms of translations along, and rotations about the axes of a local coordinate system. As a measure of deformation, the proximal tibia moved relative to the distal tibia by, on average 1.27 mm (± 0.50 mm) and 0.64° (± 0.25°). Deformation caused an overestimation of implant displacement in the cemented implant. The implant displaced with respect to the whole tibia by 0.45 mm (± 0.22 mm) and 0.79° (± 0.38°). Relative to the proximal tibia, the implant moved by 0.23 mm (± 0.10 mm) and 0.62° (± 0.34°). The differentiation between loose and fixed implants improved when tibia deformation was compensated for by using the proximal tibia rather than the whole tibia.

Promising results of an non-invasive measurement of knee implant loosening using a loading device, CT-scans and 3D image analysis

BACKGROUND

After total knee arthroplasty up to 13% requires revision surgery to address loosening. No current diagnostic modalities have a sensitivity or specificity higher than 70-80% to detect loosening, leading to 20-30% of patients undergoing unnecessary, risky and expensive revision surgery. A reliable imaging modality is required to diagnose loosening. This study presents a new and non-invasive method and evaluates its reproducibility and reliability in a cadaveric study.

METHODS

Ten cadaveric specimens were implanted with a loosely fitted tibial components and CT scanned under load towards valgus and varus using a loading device. Advanced three-dimensional imaging software was used to quantify displacement. Subsequently, the implants were fixed to the bone and scanned to determine the differences between the fixed and the loose state. Reproducibility errors were quantified using a frozen specimen in which displacement was absent.

FINDINGS

Reproducibility errors, expressed as mean target registration error, screw-axis rotation and maximum total point motion were 0.073 mm (SD 0.033), 0.129 degrees (SD 0.039) and 0.116 mm (SD 0.031), respectively. In the loose condition, all displacements and rotation changes were larger than the reported reproducibility errors. Comparing the mean target registration error, screw axis rotation and maximum total point motion in the loose condition to the fixed condition resulted in mean differences of 0.463 mm (SD 0.279; p = 0.001), 1.769 degrees (SD 0.868; p < 0.001) and 1.339 mm (SD 0.712; p < 0.001), respectively.

INTERPRETATION

The results of this cadaveric study show that this non-invasive method is reproducible and reliable for detection of displacement differences between fixed and loose tibial components.

Incidence and survival of patients with oligometastatic esophagogastric cancer: a multicenter cohort study

PURPOSE /OBJECTIVE

This multicenter study assessed the incidence and survival of patients with esophagogastric cancer and oligometastatic disease (OMD) in two tertiary referral cancer centers in The Netherlands and Switzerland.

MATERIALS /METHODS

Between 2010-2021, patients with metastatic esophagogastric cancer were identified. Patients with de-novo OMD were included (first-time diagnosis of ≤5 distant metastases on ¹⁸F-FDG-PET/CT). Control of the primary tumor was considered in patients who underwent primary tumor resection or definitive chemoradiotherapy without locoregional recurrence. Treatment of OMD was categorized into 1) systemic therapy, 2) local treatment (stereotactic body radiotherapy or metastasectomy), 3) local plus systemic therapy, or 4) best supportive care. The primary outcomes were overall survival (OS) and independent prognostic factors for OS. Independent prognostic factors for OS were analyzed using multivariable Cox proportional hazard models.

RESULTS

In total, 830 patients with metastatic esophagogastric cancer were identified of whom 200 patients with de-novo OMD were included (24%). The majority of included patients had esophageal cancer (73%) with adenocarcinoma histology (79%) and metachronous OMD (52%). The primary tumor was controlled in 68%. Treatment of OMD was systemic therapy (25%), local treatment (43%), local plus systemic therapy (13%), or best supportive care (18%). Median follow-up was 14 months (interquartile range: 7-27). Median OS was 16 months (95% CI: 13-21). Improved OS was independently associated with local plus systemic therapy compared with systemic therapy alone (hazard ratio [HR] 0.47, 95% confidence interval [CI]: 0.25-0.87). Worse OS was independently associated with squamous cell carcinoma (HR 1.70, 95% CI: 1.07-2.74), bone oligometastases (HR 2.44, 95% CI: 1.28-4.68), brain oligometastases (HR 1.98, 95% CI: 1.05-4.69), and two metastatic locations (HR 2.07, 95% CI: 1.04-4.12). Median OS after local plus systemic therapy was 35 months (95% CI: 22-NA) as compared with 13 months (95% CI: 9-21, p<0.001) after systemic therapy alone for OMD.

CONCLUSION

Patients with metastatic esophagogastric cancer present in 25% with de-novo OMD. Local treatment of OMD plus systemic therapy was independently associated with long-term OS and independently improved OS when compared with systemic therapy alone. Randomized controlled trials are warranted to confirm these results.

Metastasectomy or Stereotactic Body Radiation Therapy With or Without Systemic Therapy for Oligometastatic Esophagogastric Cancer

Background

The primary goal of this study was to determine overall survival (OS) in patients who underwent local treatment (metastasectomy or stereotactic body radiotherapy [SBRT]) or systemic therapy (chemotherapy or targeted therapy) for oligometastatic esophagogastric cancer. The secondary goal was to determine prognostic factors for OS.

Methods

Patients with synchronous or metachronous oligometastatic esophagogastric cancer who underwent local treatment or systemic therapy were included in this single-center, retrospective cohort study. Oligometastatic disease (OMD) included 1 organ or 1 extraregional lymph node station with ≤ 3 lesions. OS was determined after OMD detection. Treatment for OMD was categorized as (1) local treatment, (2) local plus systemic, (3) systemic therapy. The primary tumor was controlled after resection or definitive chemoradiotherapy.

Results

In total, 85 patients were included. Treatment for OMD was local treatment (58%), local plus systemic (14%), or systemic therapy (28%). The primary tumor was controlled in 68% of patients. Most patients were diagnosed with distal esophageal cancer (61%), with adenocarcinoma histology (76%), and presented with synchronous OMD (51%). OS after local treatment was 17 months (95% confidence interval [CI] 12–40), after local plus systemic therapy 35 months (95% CI 29–NA), and after systemic therapy 16 months (95% CI 11–NA). Better OS was independently associated with local plus systemic compared with local treatment (hazard ratio [HR] 2.11, 95% CI 1.05–5.07) or systemic therapy (HR 2.28, 95% CI 1.04–6.07).

Conclusions

Local plus systemic therapy for oligometastatic esophagogastric cancer was independently associated with improved OS and better OS compared with either systemic therapy or local treatment.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-022-11541-0.