The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 91, Issue 12

Scientific Articles | December 01, 2009

Charnley Low-Friction Arthroplasty in Young Patients with Osteoarthritis: Outcomes at a Minimum of Twenty-two Years

George Georgiades, MD¹; George C. Babis, MD²; George Hartofilakidis, MD³

¹ Orthopaedic Department, Tripoli Hospital, 31 Kousianofsky Street, N. Psychiko, Athens 11525, Greece. E-mail address: gegeorgiades@yahoo.com
² First Orthopaedic Department, University of Athens Medical School, 5 Heraklitou Street, Dionysos, Athens 14576, Greece. E-mail address: gebabis@med.uoa.gr
³ University of Athens Medical School, 21 Fotiou Patriarchou Street, Athens 11471, Greece. E-mail address: geo@hart7.com

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

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

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2009 Dec 01;91(12):2846-2851. doi: 10.2106/JBJS.H.00018

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Abstract

Background: We previously reported the outcomes at a minimum of twelve years after eighty-four Charnley low-friction arthroplasties performed in patients with osteoarthritis who were less than fifty-six years old at the time of the surgery. We now update the results of that cohort at a minimum of twenty-two years postoperatively.

Methods: Eighty-four hips (in sixty-nine patients) with osteoarthritis, which was secondary to congenital hip disease in sixty-four (76%) of them, were followed prospectively with use of the Merle D'Aubigné and Postel scoring system as modified by Charnley and with serial radiographs.

Results: At the time of the latest follow-up, thirty-seven hips (44%) had failed. Twenty-eight acetabular and thirty femoral components, in a total of thirty-two hips, had been revised because of aseptic loosening; six of the loose femoral components were broken. Three hips were infected and were converted to a resection arthroplasty. A periprosthetic femoral fracture occurred in two additional hips, three and ten years postoperatively, and both were treated with internal fixation. Thirty-seven original acetabular components and thirty-six original femoral components were in place for an average of twenty-nine years. The probability of survival for both components, with failure for any reason as the end point, was 0.51 (95% confidence interval, 0.39 to 0.62) at twenty-five years.

Conclusions: These long-term results can be used as a benchmark with which to compare outcomes of different designs when total hip arthroplasty is performed in young patients when the majority have congenital hip disease.

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

Figures in this Article

Introduction

We evaluated the long-term survival of eighty-four Charnley low-friction prostheses at a mean of twenty-nine years (range, twenty-two to thirty-four years) after implantation in sixty-nine patients with a mean age of forty-six years (range, twenty-four to fifty-five years) at the time of the index arthroplasty. All patients had osteoarthritis with no comorbidities that affected their activity levels. We previously reported the results in the same group of patients at a minimum of twelve years postoperatively¹.

Materials and Methods

This study was approved by our institutional review board. From January 1973 to December 1984, eighty-four consecutive primary low-friction Charnley total hip arthroplasties were performed in sixty-nine patients (sixty-three women and six men) by the senior author (G.H.). The mean age of the patients at the time of surgery was forty-six years (range, twenty-four to fifty-five years). Sixty-four (76%) of the hips had osteoarthritis secondary to congenital hip disease (dysplasia in thirty-four hips, low dislocation in twenty, and high dislocation in ten hips)², thirteen hips had idiopathic osteoarthritis, and the origin of the osteoarthritis in seven hips was unknown. The mean weight of the patients was 66.6 kg (range, 43 to 98 kg), and the mean height was 154.2 cm (range, 143 to 170 cm). The patients' age, sex, weight, height, duration of follow-up, and preoperative diagnosis are listed in Table I.

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TABLE I Demographic Characteristics of the Sixty-nine Patients Included in the Study

		Average Age (Range) at Index Op. (yr)				Mean Time (Range) from Index Op. (yr)	Diagnosis (no. of hips)
No. of Patients	No. of Hips		Sex (M/F) (no. of patients)	Mean Weight (Range) (kg)	Mean Height (Range) (cm)		Osteoarthritis Secondary to Congenital Hip Disease	Idiopathic Osteoarthritis	Osteoarthritis with Unknown Origin
69	84	46 (24-55)	6/63	66.6 (43-98)	154.2 (143-170)	29 (22-34)	64	13	7

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TABLE I Demographic Characteristics of the Sixty-nine Patients Included in the Study

		Average Age (Range) at Index Op. (yr)				Mean Time (Range) from Index Op. (yr)	Diagnosis (no. of hips)
No. of Patients	No. of Hips		Sex (M/F) (no. of patients)	Mean Weight (Range) (kg)	Mean Height (Range) (cm)		Osteoarthritis Secondary to Congenital Hip Disease	Idiopathic Osteoarthritis	Osteoarthritis with Unknown Origin
69	84	46 (24-55)	6/63	66.6 (43-98)	154.2 (143-170)	29 (22-34)	64	13	7

Standard Charnley implants (C.F. Thackray, Leeds, United Kingdom) and technique^3,4 were used in all patients. An osteotomy of the greater trochanter was performed in all hips. The original Charnley scalloped-edge (nonflanged) all-polyethylene acetabular socket was used in eighty hips; a large Charnley socket with a 50-mm outer diameter was used in sixty-two of these hips, and a small Charnley socket with a 47-mm outer diameter was used in eighteen. An offset-bore socket with a 35-mm outer diameter was used in four hips. The acetabular cement (Simplex P; Howmedica, Rutherford, New Jersey) was finger-packed and was pressurized with use of the component. The cup was placed at the level of the acetabular rim in seventy-nine hips, and it was medialized in five².

A monoblock polished stainless-steel femoral component with a 22-mm head was used in all hips. The original flat-back-design stem was inserted in twenty-one hips, a second-generation round-back stem was used in sixty hips, and a CDH stem was used in three hips. Antegrade finger-packing, without a distal cement plug, was used for insertion of the cement in the first seventy-one hips. A second-generation cementing technique⁵ was used, beginning in 1982, for thirteen hips. Prophylactic antibiotics were not given to twenty-seven patients (thirty-four hips) who underwent total hip arthroplasty between January 1973 and December 1977. All patients were entered in our total hip arthroplasty registry and were routinely followed clinically and radiographically at three and twelve months after the surgery and at one to three-year intervals thereafter.

The Merle d'Aubigné and Postel scoring system, as modified by Charnley⁴, was used as an outcome instrument for clinical evaluation of the patients. Radiographs were reexamined by two observers (G.G. and G.C.B.) who had 95% interobserver and intraobserver agreements with regard to all measurements. Radiographic evidence of loosening of the acetabular component was assessed according to the criteria of Hodgkinson et al.⁶, and radiographic evidence of loosening of the femoral component was assessed according to the criteria of Harris et al.⁵.

Survivorship analysis was performed according to the Kaplan-Meier method⁷. Patients who died before the time of final follow-up or who were lost to follow-up were censored. Survivorship curves with corresponding 95% confidence intervals were generated, with failure defined according to six commonly cited end points⁸.

The associations between categorical variables were evaluated with the chi-square test without the correction of continuity. Improvements of the clinical outcome were assessed with the sign-rank test. A probability value of 5% was considered to be significant.

Source of Funding

There was no external funding source for this study.

Results

Eight patients (eight hips) were lost to follow-up at a mean of eleven years (range, two to sixteen years) after the index operation. The original prosthesis was in place at the time of the last examination of these patients. Ten patients (eleven hips) died at an average of eighteen years (range, one to twenty-eight years) postoperatively. All were free of hip symptoms at the time of the last follow-up. Six patients (six hips) who died after they had been followed for the minimum of twenty-two years were included in the final clinical and radiographic evaluation.

At the time of the latest follow-up, thirty-seven hips (44%) had failed for various reasons. Twenty-eight acetabular and thirty femoral components, in a total of thirty-two hips, had been revised at an average of nineteen years (range, seven to twenty-seven years) and eighteen years (range, six to twenty-seven years), respectively, because of aseptic loosening. Of the thirty revised femoral stems, six had broken at a mean of fifteen years (range, six to twenty-eight years). Three hips presented with infection, on the tenth and twentieth postoperative days and the fourteenth postoperative year, and were converted to resection arthroplasties. Two periprosthetic femoral fractures were sustained, at three and ten years postoperatively, and were treated with internal fixation.

The final clinical and radiographic evaluations were performed on thirty-nine hips (thirty-five patients) in which one or both of the original components were in place. Twenty-nine of these patients (thirty-three hips) were alive at the time of the current study, and six patients (six hips) had died after having been followed for the minimum of twenty-two years postoperatively. The patients who were included in the final evaluation were an average forty-seven years old (range, twenty-five to fifty-five years old) at the time of surgery and seventy-five years old (range, fifty-five to eighty-five years old) at the latest examination.

The score for pain in the group of patients included in the final analysis improved from a preoperative mean of 2.2 points (range, 1 to 4 points) to a mean of 5.3 points (range, 5 to 6 points) at the time of final follow-up (p < 0.001), and the score for the range of motion improved from a mean of 2.1 points (range, 1 to 4 points) to a mean of 4.6 points (range, 0 to 6 points) (p < 0.001) (Table II). The function score improved from a mean of 2.2 points (range, 1 to 4 points) to a mean of 4.2 points (range, 1 to 5 points) (p < 0.001). However, with such a long follow-up, the patients have reduced function as compared with their peak function as a result of advanced age and medical and musculoskeletal comorbidities unrelated to the hip arthroplasties. At the time of our previous report¹, when these patients were ten years younger, their mean score for function was 5.2 points (range, 3 to 6 points). These scores thus declined with age. The scores for pain and range of motion remained the same (Table II).

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TABLE II Comparison of Clinical Results According to the Merle D'Aubigné and Postel Scoring System as Modified by Charnley⁴

Clinical Result	Preoperative*	12 to 24-Yr Follow-up*	22 to 34-Yr Follow-up*
Pain	2.2 (1-4)	5.4 (5-6)	5.3 (5-6)
Function	2.2 (1-4)	5.2 (3-6)	4.2 (1-5)
Motion	2.1 (1-4)	4.6 (0-6)	4.6 (0-6)

The values are given as the mean number of points with the range in parentheses.

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TABLE II Comparison of Clinical Results According to the Merle D'Aubigné and Postel Scoring System as Modified by Charnley⁴

Clinical Result	Preoperative*	12 to 24-Yr Follow-up*	22 to 34-Yr Follow-up*
Pain	2.2 (1-4)	5.4 (5-6)	5.3 (5-6)
Function	2.2 (1-4)	5.2 (3-6)	4.2 (1-5)
Motion	2.1 (1-4)	4.6 (0-6)	4.6 (0-6)

The values are given as the mean number of points with the range in parentheses.

The duration of radiographic follow-up of the thirty-nine hips that retained one or both of the components averaged twenty-five years (range, thirteen to thirty-two years) postoperatively. Of the thirty-seven unrevised acetabular components, twenty-eight were well fixed and nine were probably loose. Of the thirty-six unrevised femoral components, twenty-two were well fixed and fourteen were probably loose.

Thirty-seven hips failed overall. Thirty-two of the sixty-four hips with congenital hip disease failed in contrast with five of the twenty hips that did not have congenital hip disease. This difference was significant (p = 0.049).

Survival Analysis

The probability of survival of both components with failure for any reason as the end point was 0.51 (95% confidence interval, 0.39 to 0.62) at twenty-five years postoperatively, when thirty-five hips were at risk (Fig. 1-A). The survivorship curves with revision secondary to aseptic loosening of either component, revision secondary to aseptic loosening of the acetabular component, revision secondary to aseptic loosening of the femoral component, revision secondary to or radiographic evidence of aseptic loosening of the acetabular component, and revision secondary to or radiographic evidence of aseptic loosening of the femoral component as the end points are shown in Figures 1-B through 1-F. The changes in revision rates and survivorship in comparison with those in our previous report¹ are summarized in Table III.

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Fig. 1-A Fig. 1-B Fig. 1-C Fig. 1-D: Figs. 1-A through 1-F Survivorship curves, with 95% confidence intervals, as determined with the Kaplan-Meier method. Fig. 1-A The probability of survival of both components with failure for any reason as the end point was 0.51 (95% confidence interval, 0.39 to 0.62) at twenty-five years after the operation, when thirty-five hips were at risk. Fig. 1-B The probability of survival with aseptic loosening of either component as the end point was 0.55 (95% confidence interval, 0.42 to 0.66) at twenty-five years after the operation, when thirty-five acetabular or femoral components were at risk. Fig. 1-C The probability of survival with aseptic loosening of the acetabular component as the end point was 0.60 (95% confidence interval, 0.47 to 0.71) at twenty-five years after the operation, when thirty-eight acetabular components were at risk. Fig. 1-D The probability of survival with aseptic loosening of the femoral component as the end point was 0.60 (95% confidence interval, 0.51 to 0.71) at twenty-five years after the operation, when 36.5 femoral components were at risk.

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Fig. 1-E Fig. 1-F: Fig. 1-E The probability of survival with revision due to aseptic loosening, or probable radiographic loosening, of the acetabular component as the end point was 0.60 (95% confidence interval, 0.47 to 0.71) at twenty-five years after the operation, when 38.5 acetabular components were at risk. Fig. 1-F The probability of survival with revision due to aseptic loosening, or probable radiographic loosening, of the femoral component as the end point was 0.60 (95% confidence interval, 0.47 to 0.71) at twenty-five years after the operation, when 36.5 femoral components were at risk.

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TABLE III Comparison of Survivorship and Radiographic Data Between the Twelve to Twenty-four and the Twenty-two to Thirty-four-Year Follow-up Studies

	12 to 24-Yr Follow-up*	22 to 34-Yr Follow-up*
No. of living patients (no. of hips) with components in place	45 (52)	29 (33)
No. of patients (no. of hips) who died with components in place	3 (3)	10 (11)
No. of patients (no. of hips) lost to follow-up	5 (5)	8 (8)
Results*
Resection arthroplasty due to infection	3	3
Periprosthetic femoral fracture treated with internal fixation	2	2
Revision because of aseptic loosening of acetabular component	12	28
Revision because of aseptic loosening of femoral component (broken femoral component)	15 (4)	30 (6)
Evidence of probably loose acetabular component	16†	9
Evidence of probably loose femoral component	11†	14
Probability of survival of both components with failure for any reason as the end point	0.67 (0.58-0.76) at 20 yr	0.47 (0.35-0.59) at 30 yr
No. of hips at risk	20.5	12.5

The values are given as the number of hips except for probability of survival, which is given as the probability with the 95% confidence interval in parentheses.Nine of these acetabular components and four of these femoral components were revised during the next decade.

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TABLE III Comparison of Survivorship and Radiographic Data Between the Twelve to Twenty-four and the Twenty-two to Thirty-four-Year Follow-up Studies

	12 to 24-Yr Follow-up*	22 to 34-Yr Follow-up*
No. of living patients (no. of hips) with components in place	45 (52)	29 (33)
No. of patients (no. of hips) who died with components in place	3 (3)	10 (11)
No. of patients (no. of hips) lost to follow-up	5 (5)	8 (8)
Results*
Resection arthroplasty due to infection	3	3
Periprosthetic femoral fracture treated with internal fixation	2	2
Revision because of aseptic loosening of acetabular component	12	28
Revision because of aseptic loosening of femoral component (broken femoral component)	15 (4)	30 (6)
Evidence of probably loose acetabular component	16†	9
Evidence of probably loose femoral component	11†	14
Probability of survival of both components with failure for any reason as the end point	0.67 (0.58-0.76) at 20 yr	0.47 (0.35-0.59) at 30 yr
No. of hips at risk	20.5	12.5

Only five hips (6%) were revised because of aseptic loosening of the acetabular and/or femoral component in the first decade. Sixteen more hips (24% of the sixty-seven at risk) were revised in the second decade, and eleven more hips (24% of the forty-five at risk) were revised in the third decade. The probability of aseptic loosening of either component or failure for any reason in each postoperative decade, calculated as the ratio of the number of hips with aseptic loosening of either component or failure for any reason in each decade to the number of hips at risk at the beginning of each decade, is presented in Table IV.

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TABLE IV Revisions Due to Aseptic Loosening (Thirty-two Hips) and for Any Reason (Thirty-seven Hips) According to Time After the Operation

Yr After Op.	No. of Hips with Aseptic Loosening of Cup/No. of Hips at Risk* (%)	No. of Hips with Aseptic Loosening of Stem/No. of Hips at Risk* (%)	No. of Hips with Aseptic Loosening of Either Component/No. of Hips at Risk* (%)	No. of Hips with Failure for Any Reason/No. of Hips at Risk* (%)
0-10	3/84 (4%)	5/84 (6%)	5/84 (6%)	10/84 (12%)
11-20	14/70 (20%)	15/67 (22%)	16/67 (24%)	16/67 (24%)
21-30	11/48 (23%)	10/46 (22%)	11/45 (24%)	11/45 (24%)
0-30	28/84 (33%)	30/84 (36%)	32/84 (38%)	37/84 (44%)

At the beginning of each time interval.

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TABLE IV Revisions Due to Aseptic Loosening (Thirty-two Hips) and for Any Reason (Thirty-seven Hips) According to Time After the Operation

Yr After Op.	No. of Hips with Aseptic Loosening of Cup/No. of Hips at Risk* (%)	No. of Hips with Aseptic Loosening of Stem/No. of Hips at Risk* (%)	No. of Hips with Aseptic Loosening of Either Component/No. of Hips at Risk* (%)	No. of Hips with Failure for Any Reason/No. of Hips at Risk* (%)
0-10	3/84 (4%)	5/84 (6%)	5/84 (6%)	10/84 (12%)
11-20	14/70 (20%)	15/67 (22%)	16/67 (24%)	16/67 (24%)
21-30	11/48 (23%)	10/46 (22%)	11/45 (24%)	11/45 (24%)
0-30	28/84 (33%)	30/84 (36%)	32/84 (38%)	37/84 (44%)

At the beginning of each time interval.

Discussion

The patients in this series were treated in the early years of our experience with total hip arthroplasty. Thirty-four arthroplasties were performed without antibiotic prophylaxis, and seventy-one were done with a first-generation cementing technique. Even so, in the current study the probability of survival of both components with failure for any reason as the end point was 0.51 (95% confidence interval, 0.39 to 0.62) at twenty-five years, when thirty-five hips were at risk. Thirty-seven of the original acetabular components (in thirty-four patients) and thirty-six of the original femoral components (in thirty-two patients) were retained for an average of twenty-nine years (range, twenty-four to thirty-four years) postoperatively.

In our previous report¹, sixteen acetabular and eleven femoral components were identified as being probably loose radiographically. Nine of the sixteen acetabular components and four of the eleven femoral components were revised during the next decade because of loosening. This finding suggests that probably loose components can survive for many years but patients should be closely followed for impending failure, especially during the third decade following total hip arthroplasty.

Infection and fracture of the stem were frequent complications in the early years of low-friction arthroplasty (rates of 4% and 8%, respectively, in the present series). The main reason for failure in this extended-follow-up study was aseptic loosening of both the acetabular and the femoral component. However, it is noteworthy that, in the first decade after the surgery, only five hips (6%) were revised because of aseptic loosening of either component. Sixteen more hips (24%) were revised during the second decade, and eleven more hips (24%) were revised during the third decade. These findings support the importance of long-term follow-up for showing the performance and complications of hip arthroplasty over time.

In a similar long-term follow-up study of Charnley low-friction arthroplasty, Keener et al.⁸ reported a probability of prosthetic survival of 0.60 (95% confidence interval, 0.53 to 0.67) at thirty years. In our study, the prosthetic survival rate at twenty-five years was 0.51 (95% confidence interval, 0.39 to 0.62). This difference may be explained by the fact that the majority of the hips (76%) in our series had osteoarthritis secondary to congenital hip disease (dysplasia in thirty-four hips, low dislocation in twenty, and high dislocation in ten), and consequently the technical difficulties during the total hip arthroplasty were greater, bone stock was limited, and smaller-diameter and thinner polyethylene was used².

The present study demonstrates that the long-term survival of Charnley low-friction prostheses was satisfactory in young patients with osteoarthritis, the majority of whom had arthritis secondary to congenital hip disease. These results can serve as a benchmark with which to compare newer techniques and implants. Image Not Available

Acknowledgements

Note: The authors thank Georgia Kourlaba, MSc, for her contribution to the statistical analysis of this study.

References

Hartofilakidis G, Karachalios T, Zacharakis N. Charnley low friction arthroplasty in young patients with osteoarthritis. A 12- to 24-year clinical and radiographic follow-up study of 84 cases. Clin Orthop Relat Res.1997;341:51-4.34151 1997 [PubMed]

Hartofilakidis G, Stamos K, Karachalios T, Ioannidis TT, Zacharakis N. 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;78:683-92.78683 1996

Charnley J. The long-term results of low friction arthroplasty of the hip performed as a primary intervention. J Bone Joint Surg Br.1972;54:61-76.5461 1972

Charnley J. Low friction arthroplasty of the hip: theory and practice. Berlin: Springer-Verlag; 1979. p 20-9. 1979

Harris WH, McCarthy JC Jr, O'Neill DA. Femoral component loosening using contemporary techniques of femoral cement fixation. J Bone Joint Surg Am.1982;64:1063-7.641063 1982

Hodgkinson JP, Shelley P, Wroblewski B. The correlation between the roentgenographic appearance and operative findings at the bone-cement junction of the socket in Charnley low friction arthroplasties. Clin Orthop Relat Res.1988;228:105-9.228105 1988

Kaplan E, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc.1958;53:457-81.53457 1958 [CrossRef]

Keener JD, Callaghan JJ, Goetz DD, Pederson DR, Sullivan PM, Johnston RC. Twenty-five-year results after Charnley total hip arthroplasty in patients less than fifty years old: a concise follow-up of a previous report. J Bone Joint Surg Am.2003;85:1066-72.851066 2003

Topics

femur ; friction ; hip region ; hip joint ; osteoarthritis ; arthroplasty ; hip replacement arthroplasty

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George Georgiades, George C. Babis, George Hartofilakidis; Charnley Low-Friction Arthroplasty in Young Patients with OsteoarthritisOutcomes at a Minimum of Twenty-two Years. The Journal of Bone & Joint Surgery. 2009 Dec;91(12):2846-2851.

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