The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 93, Issue 17

Scientific Articles | September 07, 2011

Total Hip Arthroplasty in Patients with High Dislocation: A Concise Follow-up, at a Minimum of Fifteen Years, of Previous Reports*

George Hartofilakidis, MD¹; Theofilos Karachalios, MD²; George Georgiades, MD³; Georgia Kourlaba, MSc⁴

¹ University of Athens Medical School, 21 Fotiou Patriarchou Street, Athens 11471, Greece. E-mail address: geo@hart7.com
² Orthopaedic Department, School of Health Sciences, Faculty of Medicine, University of Thessalia, Larissa, Hellenic Republic, Greece. E-mail address: kar@med.uth.gr
³ Orthopaedic Department, Tripoli Hospital, 31 Kousianofsky Street, North Psychiko, Athens 11525, Greece. E-mail address: gegeorgiades@yahoo.com
⁴ Office of Biostatistics, Harokopio University, 17 Laodikias Street, Athens 11528, Greece. E-mail address: kurlaba@med.uoa.gr

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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Investigation performed at the Department of Orthopaedics, University of Athens Medical School, Athens, Greece

Original Publications

Hartofilakidis G, Stamos K, Karachalios T. Treatment of high dislocation of the hip in adults with total hip arthroplasty. Operative technique and long-term clinical results. J Bone Joint Surg Am. 1998; 80:510-7.

Hartofilakidis G, Karachalios T. Total hip arthroplasty for congenital hip disease. J Bone Joint Surg Am. 2004;86:242-50.

J Bone Joint Surg Am, 2011 Sep 07;93(17):1614-1618. doi: 10.2106/JBJS.J.00875

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Abstract

Abstract:

We report the updated results at a minimum of fifteen years after eighty-four consecutive total hip arthroplasties performed in sixty-seven female patients with high dislocation of the hip. Sixty-four arthroplasties were performed in forty-nine patients, between 1976 and 1994, with Charnley low-friction acetabular and femoral components inserted with cement; nineteen arthroplasties were performed in seventeen patients, between 1990 and 1994, with the hybrid technique (acetabular component inserted without cement and femoral component inserted with cement); and one arthroplasty was done in 1991, with cementless acetabular and femoral components. All patients were followed prospectively on the basis of clinical assessment according to the Merle D'Aubigné and Postel scoring system, as modified by Charnley, and with radiographic analysis. At the time of the latest follow-up, twenty-six hips (41%) in the low-friction arthroplasty series, ten hips (53%) in the hybrid series, and the one hip with the cementless components had been revised for various reasons. The primary reason for revision in the low-friction arthroplasty group was aseptic loosening of the components (twenty-four hips), whereas the predominant reason for the revisions in the hybrid series and in the hip with cementless components was progressive polyethylene liner wear (six hips). After the minimal follow-up of fifteen years, twenty-five low-friction hip replacements and eight hybrid-type hip replacements had remained intact for an average of twenty-one years (range, seventeen to thirty-two years) and sixteen years (range, fifteen to nineteen years), respectively. These findings may be used in comparisons of results with newer techniques and designs.

Level of Evidence:

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Total hip arthroplasty in patients with high dislocation of the hip is technically difficult because of associated anatomical abnormalities. Different techniques have been reported^1-6 for the treatment of these patients.

We previously reported the two to twenty-year and seven to twenty-six-year results of a consecutive series of eighty-four total hip arthroplasties performed by a single surgeon (G.H.) in sixty-seven female patients with high dislocation of the hip⁷⁸. Sixty-four arthroplasties performed with a Charnley low-friction hip replacement involved cemented acetabular and femoral components, and nineteen had a hybrid technique. In one hip, both components were inserted without cement. We defined high dislocation as migration of the femoral head to a varying degree superior and posterior to the hypoplastic true acetabulum. The dislocated femoral head either articulates with a concavity in the iliac wing, which resembles a false acetabulum (Type C1), or moves freely within the gluteal muscles (Type C2)^7-10.

The mean age of the patients at the time of surgery was forty-nine years (range, twenty-three to seventy years). Eighteen patients (27%) had bilateral high dislocation (all except one patient had an arthroplasty in both hips), sixteen (24%) had a low dislocation in the contralateral hip, fifteen (22%) had a dysplastic contralateral hip, and eighteen (27%) had a normal, contralateral hip.

The surgical technique involved osteotomy of the greater trochanter, shortening of the femur with progressive resection of bone from the femoral neck, and placement of the acetabular component in the true acetabulum. Care was taken to keep the resection of the proximal part of the femur cephalad to the lower end of the lesser trochanter.

The purpose of this study was to analyze the clinical and radiographic outcomes and survivorship of the components in these patients with a minimum follow-up of fifteen years (range, fifteen to thirty-three years).

Materials and Methods

This study was approved by the institutional review board of our hospital. Clinical and radiographic data were obtained for all patients preoperatively and at intervals of one to three years postoperatively. For the study, medical record data of the most recent examination were used. The Merle D'Aubigné and Postel scoring system, as modified by Charnley, was used for clinical evaluation¹¹. Radiographic determination of potentially loose acetabular and femoral components was performed with the same methods reported in the earlier follow-up studies^12,13.

Survival analyses were performed by the Kaplan-Meier method¹⁴. The end points were reoperation for any reason, revision because of aseptic loosening of the components, and exchange of the polyethylene liner only, because of progressive wear.

Source of Funding

There was no external funding source for this study.

Results

After a minimum fifteen-year follow-up period, twenty-five low-friction hip replacements in nineteen patients and eight hybrid hip replacements in eight patients had remained intact for an average of twenty-one years (range, seventeen to thirty-two years) and sixteen years (range, fifteen to nineteen years), respectively. Those patients had a mean age of seventy years (range, forty-five to eighty-five years); the mean score for pain had improved from 2.8 points (range, 1 to 4 points) preoperatively to 5.4 points (range, 4 to 6 points); the mean score for function, from 2.5 points (range, 1 to 3 points) to 5.1 points (range, 4 to 6 points); and the mean score for hip range of motion, from 3.2 points (range, 2 to 5 points) to 4.5 points (range, 2 to 6 points).

Of the sixty-seven patients (eighty-four hips) in the original cohort, one patient (one hip) who had a low-friction arthroplasty was lost to follow-up in the third postoperative year. Ten patients (twelve hips) with a low-friction replacement and one patient (one hip) with a hybrid replacement died at a mean of thirteen years (range, six to eighteen years) after the index operation, free of symptoms related to the involved hips; four of those patients (four hips) died since the previous report⁸.

Of the original sixty-three hips that had a low-friction arthroplasty (with the exclusion of one hip in the patient who was lost to follow-up) and the nineteen hips that had a hybrid arthroplasty, twenty-six hips (41%) and ten hips, respectively, required revision for various reasons. In the low-friction arthroplasty group, sixteen hips were revised for aseptic loosening of both components, four for aseptic loosening of the acetabular component only, and four for aseptic loosening of the femoral component only. An infection developed around two hip replacements, one in the third and the other in the fourth postoperative year, and the hips were treated with resection arthroplasty. Thus, the total number of components revised because of aseptic loosening was twenty acetabular cups and twenty femoral stems (32% of each component) at an average of fourteen years (range, six to twenty years) and thirteen years (range, two to twenty-eight years), respectively, after the index operation. The twenty cups revised because of aseptic loosening included fourteen (31%) of the forty-five cups inserted at the primary arthroplasty in combination with cotyloplasty³ and six of the sixteen inserted without cotyloplasty (p = 0.78). The cotyloplasty technique involves medialization of the acetabular floor by the creation of a controlled comminuted fracture of the entire medial wall, impaction of autogenous morselized grafts, and implantation of a small acetabular component with cement fixation^7-9.

In the hybrid series, two hips had both components revised because of aseptic loosening, one hip had the femoral stem revised because of aseptic loosening and had the acetabular liner exchanged, and another hip had the acetabular component revised at two months postoperatively because of vertical malposition, resulting in repeated dislocations. Additionally, in five hips, only the polyethylene acetabular liner was exchanged because of progressive wear and initiation of pelvic osteolysis, at an average of fifteen years (range, fourteen to seventeen years) after the index operation. An infection developed around one hip replacement in the fourth postoperative year, and the hip was debrided and revised in one stage. Thus, in the hybrid series, the components revised for aseptic loosening included two acetabular cups at ten and thirteen years, respectively, and three femoral components, at ten, thirteen, and fifteen years, respectively. In the only hip with cementless components, the polyethylene acetabular liner was exchanged because of progressive wear fourteen years after the index operation.

During the seven years since the last report, ten additional acetabular and eight additional femoral components in the low-friction arthroplasty series and two acetabular and three more femoral components in the hybrid series were revised because of aseptic loosening, whereas only the acetabular liner was exchanged in five hips because of the progressive wear rate and initiation of pelvic osteolysis. In the one hip with the cementless components, the acetabular liner was also exchanged because of wear. Details of the reoperations following the sixty-three low-friction arthroplasties and the nineteen hybrid arthroplasties at different intervals are presented in Tables I and II.

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TABLE I Reoperations After Low-Friction Arthroplasty in Sixty-three Hips*

Type of Reoperation	2 to 20-Yr Follow-up†	7 to 26-Yr Follow-up†	15 to 33-Yr Follow-up†
Revision of acetabular component for aseptic loosening	4 (6)	10 (16)	20 (32)
Revision of femoral component for aseptic loosening	7 (11)	12 (19)	20 (32)
Resection arthroplasty due to infection	2 (3)	2 (3)	2 (3)

*One hip in the patient who was lost to follow-up was excluded.
†The values are given as the number of hips with the percentage in parentheses.

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TABLE I Reoperations After Low-Friction Arthroplasty in Sixty-three Hips*

Type of Reoperation	2 to 20-Yr Follow-up†	7 to 26-Yr Follow-up†	15 to 33-Yr Follow-up†
Revision of acetabular component for aseptic loosening	4 (6)	10 (16)	20 (32)
Revision of femoral component for aseptic loosening	7 (11)	12 (19)	20 (32)
Resection arthroplasty due to infection	2 (3)	2 (3)	2 (3)

*One hip in the patient who was lost to follow-up was excluded.
†The values are given as the number of hips with the percentage in parentheses.

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TABLE II Reoperations After Hybrid Arthroplasty in Nineteen Hips

Type of Reoperation	2 to 6-Yr Follow-up	7 to 12-Yr Follow-up	15 to 19-Yr Follow-up
Revision of acetabular component for aseptic loosening	—	—	2
Revision of acetabular component for repeated dislocation	1	1	1
Revision of femoral component for aseptic loosening	—	1	3
Liner exchange	—	—	5
Resection arthroplasty due to infection	1	1	1

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TABLE II Reoperations After Hybrid Arthroplasty in Nineteen Hips

Type of Reoperation	2 to 6-Yr Follow-up	7 to 12-Yr Follow-up	15 to 19-Yr Follow-up
Revision of acetabular component for aseptic loosening	—	—	2
Revision of acetabular component for repeated dislocation	1	1	1
Revision of femoral component for aseptic loosening	—	1	3
Liner exchange	—	—	5
Resection arthroplasty due to infection	1	1	1

Radiographic Results

Since our previous reports, two of the three acetabular components and one of the nine femoral components classified as probably loose by radiographic analysis became definitely loose and were revised. Additionally, three more acetabular and five more femoral components were classified as probably loose on current radiographs.

Survivorship Analysis

The probability of survival, with reoperation for any reason as the end point, for the total group of eighty-four arthroplasties was 0.53 (95% confidence interval, 0.41 to 0.64) at twenty years, when twenty hips remained in the study (Fig. 1). The survivorship curves, with reoperation for any reason and reoperation for aseptic loosening of either the acetabular or the femoral component as the end point, for the sixty-four hips in the low-friction arthroplasty series and for the nineteen hips in the hybrid series are separately included (see Appendix). In each survivorship curve, the probability of survival is reported at the time when 95% confidence intervals were acceptable because of the high number of hips remaining at risk.

Fig. 1

Survivorship curve for all eighty-four hips, with reoperation for any reason as the end point, and corresponding 95% confidence intervals. The probability of survival of both components, with failure for any reason as the end point, was 0.53 (95% confidence interval, 0.41 to 0.64) at twenty years after the operation when twenty hips were at risk.

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A summary of the probabilities of survival, with reoperation for any reason and reoperation for aseptic loosening of either the acetabular or the femoral component as the end point, is presented in Table III.

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TABLE III Summary of the Probabilities of Survival with Reoperation for Any Reason or with Reoperation for Aseptic Loosening of the Acetabular or the Femoral Component as the End Point

End Point	Probability of Survival	95% Confidence Interval	Hips at Risk
Reoperation for any reason
Total no. of hips at 20 yr	0.53	0.41-0.64	20
Hips with low-friction replacement at 20 yr	0.57	0.43-0.69	19.5
Hips with hybrid replacement at 15 yr	0.53	0.28-0.73	11
Reoperation for aseptic loosening of acetabular component
Hips with low-friction replacement at 20 yr	0.65	0.51-0.76	20.5
Hips with hybrid arthroplasty at 15 yr	0.88	0.59-0.97	14
Reoperation for aseptic loosening of femoral component
Hips with low-friction replacement at 20 yr	0.66	0.52-0.77	22
Hips with hybrid replacement at 15 yr	0.82	0.55-0.94	17

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TABLE III Summary of the Probabilities of Survival with Reoperation for Any Reason or with Reoperation for Aseptic Loosening of the Acetabular or the Femoral Component as the End Point

End Point	Probability of Survival	95% Confidence Interval	Hips at Risk
Reoperation for any reason
Total no. of hips at 20 yr	0.53	0.41-0.64	20
Hips with low-friction replacement at 20 yr	0.57	0.43-0.69	19.5
Hips with hybrid replacement at 15 yr	0.53	0.28-0.73	11
Reoperation for aseptic loosening of acetabular component
Hips with low-friction replacement at 20 yr	0.65	0.51-0.76	20.5
Hips with hybrid arthroplasty at 15 yr	0.88	0.59-0.97	14
Reoperation for aseptic loosening of femoral component
Hips with low-friction replacement at 20 yr	0.66	0.52-0.77	22
Hips with hybrid replacement at 15 yr	0.82	0.55-0.94	17

Conclusions

Compared with our previous reported findings, the patients with high dislocation of the hip who underwent a low-friction arthroplasty showed an increased revision rate with time, equally due to loosening of the acetabular cup or the femoral stem. In the patients with a hybrid total hip replacement, the main reason for revision was progressive wear of the polyethylene acetabular liner.

The long-term findings in this study, in which total hip arthroplasty was performed with specific techniques and implants in a special group of patients with high dislocation of the hip, may be useful for comparison with the results of total hip arthroplasty performed with newer surgical techniques and implant designs in a similar group of patients.

Appendix

Figures showing survivorship curves with reoperation for any reason and reoperation for aseptic loosening of either the acetabular or the femoral component as the end point for the sixty-four hips in the low-friction arthroplasty series and the nineteen hips in the hybrid series are available with the online version of this article as a data supplement at jbjs.org.

References

Kerboull M; Hamadouche M; Kerboull L. Total hip arthroplasty for Crowe type IV developmental hip dysplasia: a long-term follow-up study. J Arthroplasty. 2001;16( 8 Suppl 1):170-6.[CrossRef][PubMed]

Erdemli B; Yilmaz C; Atalar H; Güzel B; Cetin I. Total hip arthroplasty in developmental high dislocation of the hip. J Arthroplasty. 2005;20:1021-8.[CrossRef][PubMed]

Eskelinen A; Helenius I; Remes V; Ylinen P; Tallroth K; Paavilainen T. Cementless total hip arthroplasty in patients with high congenital hip dislocation. J Bone Joint Surg Am. 2006 Jan;88( 1):80-91.[CrossRef]

Krych AJ; Howard JL; Trousdale RT; Cabanela ME; Berry DJ. Total hip arthroplasty with shortening subtrochanteric osteotomy in Crowe type-IV developmental dysplasia. J Bone Joint Surg Am. 2009;91:2213-21.[CrossRef][PubMed]

Nagoya S; Kaya M; Sasaki M; Tateda K; Kosukegawa I; Yamashita T. Cementless total hip replacement with subtrochanteric femoral shortening for severe developmental dysplasia of the hip. J Bone Joint Surg Br. 2009;91:1142-7.[CrossRef][PubMed]

Macheras GA; Kateros K; Koutsostathis SD; Tsakotos G; Galanakos S; Papadakis SA. The Trabecular Metal Monoblock acetabular component in patients with high congenital hip dislocation: a prospective study. J Bone Joint Surg Br. 2010;92:624-8.[CrossRef][PubMed]

Hartofilakidis G; Stamos K; Karachalios T. Treatment of high dislocation of the hip in adults with total hip arthroplasty. Operative technique and long-term clinical results. J Bone Joint Surg Am. 1998;80:510-7.[PubMed]

Hartofilakidis G; Karachalios T. Total hip arthroplasty for congenital hip disease. J Bone Joint Surg Am. 2004;86:242-50.[PubMed]

Hartofilakidis G; Stamos K; Karachalios T; Ioannidis TT; Zacharakis N. Congenital hip disease in adults. Congenital hip disease in adults. Classification of acetabular deficiencies and operative treatment with acetabuloplasty combined with total hip arthroplasty. J Bone Joint Surg Am. 1996;78:683-92.[PubMed]

Hartofilakidis G; Yiannakopoulos CK; Babis GC. The morphologic variations of low and high hip dislocation. Clin Orthop Relat Res. 2008;466:820-4.[CrossRef][PubMed]

Charnley J. The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. J Bone Joint Surg Br. 1972;54:61-76.[PubMed]

Barrack RL; Mulroy RD Jr; Harris WH. Improved cementing techniques and femoral component loosening in young patients with hip arthroplasty. A 12-year radiographic review. J Bone Joint Surg Br. 1992;74:385-9.[PubMed]

Goetz DD; Smith EJ; Harris WH. The prevalence of femoral osteolysis associated with components inserted with or without cement in total hip replacements. A retrospective matched-pair series. J Bone Joint Surg Am. 1994;76:1121-9. [PubMed]

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Topics

hip dislocation ; hip joint ; hip replacement arthroplasty

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George Hartofilakidis, Theofilos Karachalios, George Georgiades, Georgia Kourlaba; Total Hip Arthroplasty in Patients with High DislocationA Concise Follow-up, at a Minimum of Fifteen Years, of Previous Reports*. The Journal of Bone & Joint Surgery. 2011 Sep;93(17):1614-1618.

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