Total Hip Arthroplasty With an Uncemented Tapered Femoral Component in Patients Younger Than 50 Years of Age: A Minimum 20-Year Follow-Up Study

Total Hip Arthroplasty With an Uncemented Tapered Femoral Component in Patients Younger Than 50 Years of Age: A Minimum 20-Year Follow-Up Study

The Journal of Arthroplasty 31 (2016) 1275e1278 Contents lists available at ScienceDirect The Journal of Arthroplasty journal homepage: www.arthropl...

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The Journal of Arthroplasty 31 (2016) 1275e1278

Contents lists available at ScienceDirect

The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org

Primary Arthroplasty

Total Hip Arthroplasty With an Uncemented Tapered Femoral Component in Patients Younger Than 50 Years of Age: A Minimum 20-Year Follow-Up Study Jeffrey R. McLaughlin, MD a, *, Kyla R. Lee, MD b a b

The Kennedy Center, Mercy Medical Center, Oshkosh, Wisconsin Gundersen Lutheran Medical Center, LaCrosse, Wisconsin

a r t i c l e i n f o

a b s t r a c t

Article history: Received 10 September 2015 Received in revised form 24 November 2015 Accepted 14 December 2015 Available online 20 December 2015

Background: Previously, we reported the mean 16-year results of primary uncemented total hip arthroplasty using a tapered femoral component in patients <50 years. The purpose of this study was to update our previous report using the Taperloc femoral component in young patients who had been followed for a minimum of 20 years postoperatively. Methods: Between 1983 and 1990, 108 consecutive uncemented total hip arthroplasties were performed in 91 patients of age <50 years, with use of the Taperloc femoral component. Every patient was followed for a minimum of 20 years after surgery or until death. At a mean of 25 (range, 20-29 years) postoperatively, 76 patients (91 hips) were living. The Harris Hip Score, radiographic results, complications, and Kaplan-Meier survivorship were evaluated. Results: In the entire cohort of 108 hips, 9 femoral components (8%) have been revised, none for aseptic loosening. Five well-fixed stems were removed during acetabular revision, 3 stems were revised for infection, and 1 stem was exchanged because of a peroneal nerve palsy. Distal femoral osteolysis was identified around 1 hip. With failure defined as stem removal for any reason, implant survival was 90% (CI ¼ 82-95) at 29 years. With failure defined as stem removal for aseptic loosening, implant survival was 100% at 29 years. Conclusion: Primary total hip arthroplasty with the Taperloc femoral component in young patients was associated with a high rate of survival at 29 years. © 2015 Elsevier Inc. All rights reserved.

Keywords: uncemented total hip arthroplasty Taperloc young results aseptic survivorship

Primary total hip arthroplasty in young patients presents several challenges. Difficult anatomic considerations including developmental dysplasia, posttraumatic osteoarthritis, and prior femoral or acetabular osteotomy increase surgical complexity [1-7]. High patient expectations, active lifestyles, and longer life expectancies place extreme demands on prosthetic components. In addition, because of the increased stress placed on arthroplasty components, there is an increased risk of polyethylene wear and periprosthetic osteolysis [8-10]. To determine the long-term durability of

One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.12.026. * Reprint requests: Jeffrey R. McLaughlin, MD, The Kennedy Center, Mercy Medical Center, Suite 125, 2700 W. Ninth Avenue, Oshkosh, WI, 54901. http://dx.doi.org/10.1016/j.arth.2015.12.026 0883-5403/© 2015 Elsevier Inc. All rights reserved.

uncemented femoral components in young and active patients, studies with a minimum of 20 years are needed. Previously, we reported the mean 16-year results using the Taperloc femoral component (Zimmer Biomet, Warsaw, IN) in a consecutive series of 108 total hip arthroplasties in 91 patients <50 years [11]. In that review, 3 femoral components (3%) had been revised. One stem had been revised during acetabular revision, 1 stem for sepsis, and 1 for excessive leg lengthening. Distal osteolysis was identified in 1%. The purpose of the present study was to determine the 29-year survivorship of the femoral component in this group of patients. In addition, we evaluated the clinical outcomes, radiographic results, and complications.

Materials and Methods We reviewed 108 consecutive primary total hip arthroplasties performed in 91 patients <50 years. All surgeries were performed

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by a single surgeon using the Taperloc femoral component between October 1983 and January 1990. All 91 patients (108 hips) were followed until death, femoral component revision, or a minimum of 20 years. Fifteen patients (17 hips) died before obtaining a minimum 20-year follow-up. All 15 patients died with their femoral components in place. This left 91 hips in 76 patients. Among those living patients. 9 femoral components have undergone revision surgery. In the remaining 82 hips in 67 patients, complete clinical and radiographic follow-up was obtained at a mean of 25 (range, 20-29) years. The mean age of the 34 women (43 hips) and 33 men (39 hips) at the time of surgery was 36.4 (range, 20-49) years. The average weight of the 67 living patients at the time of surgery was 86 (range, 50-134 kg), and the average body mass index was 29 (range, 20-43) kg/m2. The indication for primary total hip arthroplasty was osteoarthritis in 27 hips (33%), developmental dysplasia of the hip in 29 hips (35%), avascular necrosis in 19 hips (23%), _ rheumatoid arthritis in 6 hips (7%), and Legg-Calve-Perthes disease in 1 hip (1%). The Taperloc femoral component was used in all hips in this series. The stem has a tapered rectangular shape designed to achieve fixation mediolaterally with the proximal femur. The implant is noncollared and made of wrought titanium alloy Ti-6Al-4V. The proximal 40% of the implant is coated with the identical titanium alloy applied with a pressure plasma spray technique. The distal noneporous-coated portion of the stem has a satin surface finish. All of the femoral components had a 28-mm articulating head. Thirty-nine femoral components had a monoblock design and a titanium femoral head. Fifty-two femoral components had a modular head-neck articulation and a cobalt chromium femoral head (Fig. 1). The acetabular component consisted of a conically shaped, threaded-ring titanium shell (T-tap; Biomet). The

articulating surface was 28 mm in diameter. In the first 29 acetabular components, ultrahigh-molecular-weight polyethylene powder HiFax 1900 (Himont USA, Wilmington, DE) was directly compression molded into the shell. In 62 acetabular components, a modular liner consisting of ram-extruded bar stock polyethylene (GUR 415; Hoechst-Celanese, Houston, TX) was used. Clinical Follow-Up and Radiographic Analysis One author, who was not the operating surgeon, performed the clinical evaluation. The Harris Hip Score [12] was used to determine functional level and evaluate pain. Activity level was evaluated by the classification of Johnston et al [13]. We performed radiographic analysis with use of anterior-posterior radiographs of the hip and pelvis and a true lateral view of the hip. Postoperatively, we evaluated the hips with respect to radiolucencies and osteolysis in each of the 7 Gruen zones [14,15]. Osteolysis was defined as a radiolucency >2 mm in width, which was not present on the immediate postoperative radiograph, or as a radiolucency with a scalloped or cystic appearance. Femoral component loosening was evaluated by the criteria of Engh et al [16]. Definite femoral component loosening was defined as progressive migration of the implant. Statistical Analysis Data analysis was calculated using the SAS software version 9.3 (SAS Institute Inc., Carey, NC). The Kaplan-Meier method [17] was used to generate survivorship curves with corresponding 95% CIs. The end points were revision of the femoral component for any reason and revision of the femoral component for aseptic loosening. All 108 hips in this series were included in the survivorship analysis.

Fig. 1. The Taperloc femoral component used in this study. (A) A nonmodular stem was used in 39 total hip arthroplasties. (B) A modular stem was used in 52 total hip arthroplasties.

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Multivariate logistic regression was used to determine the statistical significance of the relationships between the variables [18]. Results Survivorship Since the minimum 11-year follow-up report [11], 6 additional femoral components have been revised for a total of 9 revisions (8%). In 5 hips, a well-fixed femoral component was revised during acetabular revision. The femoral component was removed because the nonmodular head obstructed acetabular exposure or resulted in instability of the hip after acetabular revision. Three well-fixed stems were removed for late periprosthetic joint infection, and 1 femoral component was exchanged immediately postoperatively because of a peroneal nerve palsy secondary to excessive leg lengthening. This exchanged femoral component was still in place at 27 years postoperatively but was considered as revised for this review. With revision of the femoral component for any reason as the end point, Kaplan-Meier analysis demonstrated a survival rate of 90% (95% CI ¼ 82-95) at 29 years (Fig. 2). With revision of the stem for aseptic loosening as the end point, the 29-year survivorship was 100%.

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minimum of 20 years postoperatively. Radiolucent lines occurred in the porous-coated region of the stem in 13 hips (16%) most commonly in Gruen zone 1. In 9 hips, the radiolucencies measured 1.5 mm; in 4 hips, the radiolucencies measured 1 mm. Radiolucencies in the noneporous-coated region of the femoral component occurred in 25 hips (30%). In all 25 hips, the radiolucencies measured 1 mm. No radiolucencies in the porous or nonporous portion of the stem had progressed. Osteolysis was identified in 8 hips (10%) most commonly in zone 1. Distal osteolysis occurred in one hip (1%) in zone 6. This distal osteolytic lesion demonstrated a minimal increase in size when compared to our prior report at 16 years. Of the 82 hips in 67 living patients who had not undergone revision of the femoral component, 80 stems (98%) were rated as having fixation by bone ingrowth. Two femoral components (2%) had subsided 3 mm each in the first month postoperatively and had remained stable at 22 and 26 years postoperatively. No femoral component was loose by radiographic criteria. With the numbers available, statistical analysis showed no significant relationship between femoral component revision and radiolucencies in the porous-coated region of the stem, radiolucencies in the noneporous-coated portion of the stem, or osteolysis. Complications

Clinical Outcome The Harris Hip Score at a minimum follow-up of 20 years was available for all 82 hips that had not undergone femoral component revision. The mean Harris Hip Score increased from 55 (range, 2074) points preoperatively to 92 (range, 70-100) points at final follow-up. The mean Harris Hip Score in our prior report was 93 (range, 68-100) points. Two patients with 2 hips were engaged in strenuous manual labor, 22 patients with 32 hips were engaged in moderate manual labor, 39 patients with 44 hips were semisedentary, and 4 patients with 4 hips were sedentary. The clinical outcome of 52 hips was graded as excellent; 24 hips as good; 6 hips as fair. None of the patients were rated as having a poor result at their last review. Radiographic Analysis Radiographs of all 82 hips in 67 living patients who had not undergone femoral component revision were available at a

Fig. 2. Survivorship curves with 95% CIs as determined with the Kaplan-Meier method. With revision of the femoral component for any reason as the end point, the survivorship was 90% (95% CI ¼ 82-95).

In the entire cohort of 91 patients (108 hips), intraoperative and postoperative complications occurred in 6 hips. In 3 patients (3 hips), late periprosthetic joint infection occurred, treated with explantation. In all 3 cases, the femoral component was found to be well fixed. Two patients developed pulmonary emboli. Both were treated medically without sequelae. One patient sustained a peroneal nerve palsy secondary to excessive leg lengthening and required revision of the femoral component in the immediate postoperative period. Discussion Previously, we reported our mean 16-year results using the Taperloc femoral component in 91 patients (108 hips) of age <50 years [11]. In that review, no femoral component had been revised for aseptic loosening and only 3 stems (3%) had been revised for any reason. We now report continuous follow-up on this cohort of patients at a mean of 25 years. An additional 6 femoral components have required revision, for a total of 9 stems (8%). In the entire cohort of 108 hips (91 patients) living and deceased, no femoral component had required revision for aseptic loosening and none were loose by radiographic criteria. The present study has both strengths and limitations. Strengths include the high rate of follow-up. Complete clinical and radiographic follow-up was obtained on every living patient who survived a minimum of 20 years after index procedure. Another strength of this study was the independent method of review. All clinical data were collected by an orthopedic surgeon who was not the operating surgeon. All radiographs were evaluated by an author from an independent center. The retrospective design of the present study was a limitation; however, we used prospectively obtained clinical and radiographic data to update our results. The most significant limitation of this report was use of a nonmodular femoral component in 43% of the hips in this series. Seven of the 9 femoral component revisions were in patients with a nonmodular stem. Achieving long-term durable fixation in young patients who require primary total hip arthroplasty is difficult. Santaguida et al [19] reported a threefold increase in the rate of revision in young patients compared to old patients undergoing primary total hip

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arthroplasty. Warth et al [20] reported the minimum 35-year results in patients aged 50 years using the cemented Charnley femoral component (Thackray, Leeds, England). In the entire cohort of 69 patients (93 hips) living and deceased, 17 femoral components (18%) were loose or had been revised for aseptic loosening. Of the 31 patients (40 hips) who had survived a minimum of 35 years, 10 stems (24 %) demonstrated aseptic loosening. They concluded that their results should be considered a benchmark for comparison for total hip arthroplasty in young patients. The results of uncemented stems in young patients have varied. Biemond et al [21] reported their results in 85 patients (100 hips) aged <50 years using the CLS Spotorno stem (Zimmer GmbH, Winterthur, Switzerland). This tapered stem has a trapezoid cross section similar to the Taperloc. At a mean follow-up of 18.4 years, they reported that 4 hips (4%) required revision for aseptic loosening and a total of 6 hips (6%) had required revision for any reason. No additional femoral components were loose by radiographic criteria. Similar excellent results have been reported by Archibeck et al [22] using the Multilock femoral component (Zimmer, Warsaw, IN) and by Bedard et al [23] using the AML and Prodigy stem (DePuy, Warsaw IN). Although several studies have shown excellent results in young patients requiring total hip arthroplasty, other reports have found a higher incidence of revision, loosening, and osteolysis. Kim et al [24] reported on the 27- to 29-year results using the porous coated anatomic femoral component (Howmedica, Rutherford, NJ) in 88 hips (70 patients). Nine femoral components (10%) required revision and femoral osteolysis was reported in 45%. Almeida et al [25] reported their 7- to 14-year results using the hydroxyapatite (HA)coated Corail stem (Landos Biomecanique, Switzerland) in 60 patients (73 hips) whose mean age was 38 (range, 18-50) years. Femoral osteolysis was reported in 38%. Clohisy and Harris [26] reported their 10.5-year results using the noncircumferential porous-coated Harris-Galante stem (Zimmer) in 72 patients (77) whose mean age was 54.1 years. Femoral osteolysis was reported in 52%. Femoral component revision for any reason was 19%, and an additional 11% were reported as loose. The ideal femoral component for use in primary total hip arthroplasty in young patients remains unresolved. Excellent results using cemented femoral components have been reported out to 20 years [9,27]; however, the incidence of aseptic loosening with cemented stems significantly increases in the third and fourth decades after implantation [20]. The current report using an uncemented tapered femoral component in young patients extends the follow-up of our previous review to the third decade. At an average follow-up of 25 years, the durability of fixation using the Taperloc femoral component remains excellent. In the group of 91 hips that had been followed for a minimum of 20 years, no femoral component had been revised for aseptic loosening and none were loose by radiographic criteria. In the entire cohort of 108 hips, no femoral component had been revised for aseptic loosening and only 9 stems (8%) had been revised for any reason. Based on these findings, we believe that the Taperloc femoral component can provide durable long-term fixation in young patients undergoing primary total hip arthroplasty.

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