Between July 1970 and December 1982, the senior author (R.C.J.)
performed sixty-six total hip replacements in fifty-three patients with severe
(Crowe type-II, III, or IV) developmental dysplasia of the hip. The results of
retrospective studies of those patients were previously published after
minimum durations of follow-up of two
years1 and ten
years2.
The original patient series was consecutive and consisted of forty-seven
women (89%) and six men (11%) with an average age of fifty-three years (range,
thirty-three to eighty years) at the time of the surgery. The indication for
the operation was severe, disabling pain in the hip that was unresponsive to
nonoperative measures. A Charnley stainless-steel polished-stem prosthesis
(Thackray, Leeds, England) with a 22.25-mm head and an all-polyethylene 40 or
44-mm acetabular component was used in sixty-four hips, and an Iowa femoral
stem with a 28-mm head and a TiBac acetabular component (Zimmer, Warsaw,
Indiana) was used in the remaining two hips. The operative technique, which
was described in detail in the previous
reports1,2,
included a transtrochanteric approach with an osteotomy of the greater
trochanter, a complete capsulectomy, placement of the acetabular component in
the anatomic position, filling of the superolateral defect with cement, and no
acetabular bone-grafting.
We now report the results of clinical and radiographic follow-up of this
series performed at twenty to thirty years postoperatively. In addition, we
have compared the results with the outcomes of hip replacements performed by
the same surgeon for other diagnoses and evaluated after a comparable
follow-up period.
At twenty to thirty years postoperatively, twenty-four patients
(thirty-four hips) were still living and twenty-nine patients (thirty-two
hips) had died. Clinical and radiographic information was not available for
one patient who had died, and that patient was deemed to be lost to follow-up;
thus, there were twenty-eight patients (thirty-one hips) in the deceased
group. The average age of the living patients at the time of the index
arthroplasty was forty-eight years (range, thirty-three to sixty-six years).
The average age of the entire cohort at the time of the index arthroplasty was
fifty-three years (range, thirty-three to eighty years).
Revision of the Original Prosthesis
Fifty-one (78%) of the original cohort of sixty-five hips had the original
total hip replacement in place at the time of death or final follow-up. There
were twenty-three intact prostheses in the living patients and twenty-eight in
the patients who had died. In the entire cohort, eleven revision
arthroplasties (17%) were performed because of aseptic loosening of one or
both components; two, because of infection; and one, because of recurrent
dislocation.
Of the thirty-four hips in the twenty-four patients who were alive at a
minimum of twenty years after the index arthroplasty, twenty-three (68%) had
retained the original components. Revision arthroplasty had been performed
because of aseptic loosening in ten hips (29%) and because of recurrent
dislocation in one hip. Since the time of the follow-up evaluation performed
at a minimum of ten
years2, five
additional hips had been revised because of aseptic loosening and one hip had
been revised because of recurrent dislocations. The final outcomes for all of
the patients and for the living patients are summarized in Tables
I and
II.
With the numbers available, revision for aseptic loosening was not
associated with age (p = 0.746), Crowe classification (p = 0.159), or gender
(p = 0.628). Various techniques and components were used for the revisions
performed because of aseptic loosening. At the time of the latest follow-up,
only one of the nine revised hips had required a second revision (see
Appendix). Four of the hips were revised to a high hip center, and a bilobed
cup was used in one hip.
Functional Results
Clinical information on all twenty-four living patients was obtained with a
telephone interview. Eighteen of the twenty-four living patients also had a
physical examination at a minimum of twenty years postoperatively. All of the
living patients were satisfied with the result. Twenty-eight (82%) of the
thirty-four hips caused no pain. Information regarding pain and activity is
summarized in the Appendix.
Radiographic Results
Radiographs of thirty-three (97%) of the thirty-four hips in the living
patients were available at a minimum of twenty years postoperatively. The
average duration of radiographic follow-up was sixteen years (range, five to
thirty-one years) for all of the patients in the study and twenty-five years
(range, fifteen to thirty-one years) for the living patients. Thirteen hips
(38%) had aseptic acetabular loosening; eight of those hips (24% of the
thirty-four in the living patients) were revised, and five hips (15%) were
not. Two of the unrevised loose acetabular components (6%) were definitely
loose, and three (9%) were probably loose. None of the hips that were probably
loose was painful. In the living patients, five hips (15%) had evidence of
aseptic femoral loosening; three were revised and two were not. The two
unrevised loose femoral components (6%) were definitely loose but
asymptomatic.
Eighteen (28%) of the sixty-five hips in the entire series and thirteen
(38%) of the thirty-four hips in the living patients had revision of the
acetabular component because of aseptic loosening or radiographic evidence of
definite or probable aseptic loosening of the acetabular component
(Table III).
With the numbers available, radiographic signs of aseptic acetabular
loosening were not associated with patient age (p = 0.602), Crowe
classification (p = 0.434), or gender (p = 0.195).
The average cement coverage of the acetabular component in the living
patients was 23.8% (range, 0% to 50%) (Fig.
1). No association between the percentage of the cup covered with
cement and revision was found at a minimum of twenty years postoperatively (p
= 0.362), but there was a significant association between greater cup coverage
with cement and aseptic acetabular loosening (p = 0.014). The linear
head-penetration wear rate averaged 0.166 mm/yr (range, 0.017 to 1.42 mm/yr)
in the entire cohort. Wear was significantly associated with male gender (p =
0.015) but, with the numbers available, it was not associated with age (p =
0.452), cement coverage of the cup (p = 0.294), revision because of aseptic
loosening (of any component) (p = 0.136), or revision because of aseptic
loosening of the acetabular component (p = 0.058).
Survivorship Analysis
The twenty-year cumulative survivorship curves derived with the
Kaplan-Meier method are presented in Figures
2-A and
2-B and the Appendix. The
comparison of the survivorship curves with the twenty-year outcomes of
Charnley total hip arthroplasties with cement performed previously by the
senior author for diagnoses other than
dysplasia14 are
also presented in the Appendix. There was no significant difference between
these two groups with regard to the acetabular revision rate (p = 0.945), and
the prevalence of acetabular loosening was lower in the present group (p =
0.0001).
Tables showing the Crowe classification of the hips in the study, details
of each acetabular revision for loosening, and pain and activity levels for
the living patients as well as figures showing additional survivorship curves
are available with the electronic versions of this article, on our web site at
(go to
the article citation and click on "Supplementary Material") and on
our quarterly CD-ROM (call our subscription department, at 781-449-9780, to
order the CD-ROM). ?