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A Scoping Review of Total Hip Arthroplasty Survival and Reoperation Rates in Patients of 55 Years or Younger: Health Services Implications for Revision Surgeries
Total hip arthroplasty (THA) in younger patients is projected to increase by a factor of 5 by 2030 and will have important implications for clinical practice, policymaking, and research. This scoping review aimed to synthesize and summarize THA implants' survival, reoperation, and wear rates and identify indications and risk factors for reoperation following THA in patients ≤55 years old.
Material and methods
Standardized scoping review methodology was applied. We searched 4 electronic databases (Medline, Embase, CINAHL, and Web of Science) from January 1990 to May 2019. Selection criteria were patients aged ≤55 years, THA survival, reoperation, and/or wear rate reported, a minimum of 20 reoperations included, and minimum level III based on the Oxford Level of Evidence. Two authors independently reviewed the citations, extracted data, and assessed quality.
Results
Of the 2255 citations screened, 35 retrospective cohort studies were included. Survival rates for THA at 5 and 20 years were 90%-100% and 60.4%-77.7%, respectively. Reoperation rates at ≤5-year post THA ranged from 1.6% to 5.4% and increased at 10-20 years post THA (8.2%-67%). Common causes for reoperation were aseptic loosening of hip implants, osteolysis, wear, and infection. Higher reoperation and lower survival rates were seen with hip dysplasia and avascular necrosis than with other primary diagnoses.
Conclusions
Over time, THA prosthetic survival rates decreased, and reoperation increased in patients ≤55 years. Aseptic loosening of hip implants, osteolysis, wear, and infection were the most frequent reasons for the reoperation.
]. THA provides substantial pain relief and resumption of many activities, including sporting activities such as hiking, skiing, swimming, and cycling in younger patients [
How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up.
], including a recent systematic review, reported a 15-year survival rate of 87.9% (95% confidence interval [CI]: 87.2 to 88.5) for patients aged between 58 and 74 years [
How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up.
]. The 15- to 20-year survival rate for THA, however, poses a challenge for young patients who likely will need multiple reoperations in their lifetime [
Uncemented total hip arthroplasty for primary osteoarthritis in young patients: a mid-to long-term follow-up study from the Finnish arthroplasty register.
]. Besides the longer duration that young patients will have with their THA, they tend to adopt an active lifestyle when pain and stiffness are relieved after THA.
Unlike older patients who often require THA for OA, indications in patients younger than 55 years include pathologies such as rheumatoid arthritis, avascular necrosis (AVN) of the hip, and developmental dysplasia of the hip (DDH) [
]. Thus, a greater proportion of younger patients undergo complex primary THA, which can be more technically demanding due to anatomic abnormalities and bone loss [
]. With different THA indications and procedures in the younger patient population, survivorship and reoperation rates may differ from older patients with THA [
How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up.
Uncemented total hip arthroplasty for primary osteoarthritis in young patients: a mid-to long-term follow-up study from the Finnish arthroplasty register.
]. It is also uncertain if younger patients with more active lifestyle accelerate polyethylene wear rates (annual erosion of polyethylene of THA implant based on radiographic view), leading to increased reoperation rate [
Although systematic reviews have determined survivorship and reoperation rates in the general THA population, examining a younger subset with unique characteristics is needed to develop appropriate surgical indications, inform care planning, and develop monitoring strategies. The financial and economic impact of revision THA is substantially greater than that of primary THA [
], due to longer times of surgery, more expensive prostheses, longer length of stay, and higher rates of complications and burden on the healthcare system [
]. Studies examining survival rates of THA in younger adults are needed to provide an outlook on the future burden of revision THA. Based on the rising number of primary THA, it is hypothesized that the volume of revision procedures will rapidly increase in the future, which will place an immense burden on future healthcare systems and also raises the question if current clinical standards and treatment strategies have to be reconsidered.
The overall aim of this scoping review is to synthesize evidence regarding THA in younger patients and identify any existing gaps in knowledge. Specifically, the objectives are to 1) summarize the survival, reoperation, and wear rates of THA and 2) identify indications for reoperation following THA, including factors associated with reoperation in individuals who are 55 years of age or younger.
Material and methods
As our overall aim was to provide a detailed overview of studies that examined the survival, reoperation, and wear rates in THA in younger patients, the scoping review methodology best fit our objectives [
] was used to guide the scoping review methodology. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines were followed to ensure a high and consistent quality of research reporting [
]. This review's protocol was registered a priori on the Open Science Framework (OSF) (Protocol ID#:osf.io/u4gpn).
Development of research questions
The main concept of interest is THA survival, reoperation, and wear rates, regardless of the implant used or surgical approach in adults aged 55 years or younger who underwent THA. The outcomes of interest were 1) survival, reoperation, and wear rate of THA and 2) reasons for THA reoperation and factors associated with reoperation.
Survivorship of THA is defined by the cumulative incidence of any surgical procedure that involves removal or exchange of an implant (the cup and/or stem or the liner) [
], while reoperation rates are defined as surgical procedures after the primary THA for any reason but do not necessarily involve implant removal. Reoperation reasons can be patient-related, implant-related, and failures related to surgical technique [
A health sciences librarian developed and implemented literature searches in Medline, Embase, CINAHL, and Web of Science from 1990 to May 31, 2019. The search dates were chosen to reflect more recent implants and surgical techniques. Our multidisciplinary study members helped conceptualize the search strategy, which was based on the concepts of joint replacement, reoperation, adults 55 years old or younger, with multiple text words and subject headings (eg, Medical Subject Headings) describing each concept. This search strategy was limited to English. The search strategies are detailed in Appendix A.
Selection criteria
Studies were included if 1) the patient group was ≤55 years of age or the cohort reported findings stratified by age groups with a group meeting the age requirement; 2) THA survival, reoperation, or wear rate for any reason was reported; 3) there was a minimum of 20 reoperations reported; and 4) the minimum level III evidence (based on the Oxford Level of Evidence) was attained. Studies of hemiarthroplasty surgical procedures were excluded.
Screening and study selection
Search results were uploaded to the Covidence platform [
]. After removing duplicates, 2 team members independently reviewed the titles and abstracts and applied the inclusion and exclusion criteria. If there were insufficient details to make an informed decision, the article was retrieved for review. To confirm eligibility, 2 team members independently assessed the full-text articles using the same inclusion and exclusion criteria. Any disagreement was resolved through consensus or third-party adjudication.
Data extraction
A standardized data abstraction form was created by the research team. Two team members then used the pretested data abstraction form to abstract data from included full-text articles.
Quality assessment
One reviewer evaluated the quality of selected full-text articles using the Oxford Level of Evidence [
]. The Scottish Intercollegiate Guidelines Network guidelines were used to assess study quality through the completion of their cohort checklist, including items such as subject selection, assessment, confounding, and statistical analysis [
Data were organized to report information regarding authors, study design, population characteristics, THA indication, THA surgical characteristics (implant and surgical approach), outcome measures, and tools used to measure the outcome of interest.
Results
Of the 4887 citations retrieved, 2255 were eligible for screening after deduplication, of which 2150 were excluded based on the title and the abstract. Of the 105 full-text articles assessed, 70 were excluded, leaving 35 studies included in the review [
Uncemented total hip arthroplasty for primary osteoarthritis in young patients: a mid-to long-term follow-up study from the Finnish arthroplasty register.
Total hip arthroplasty for primary osteoarthrosis in younger patients in the Finnish arthroplasty register. 4,661 primary replacements followed for 0-22 years.
The long-term results of Charnley low-friction arthroplasty in young patients who have congenital dislocation, degenerative osteoarthrosis, or rheumatoid arthritis.
Association between fixation technique and revision risk in total hip arthroplasty patients younger than 55 years of age. Results from the Nordic Arthroplasty Register Association.
What is the lifetime risk of revision for patients undergoing total hip arthroplasty? a 40-year observational study of patients treated with the Charnley cemented total hip arthroplasty.
In 33 of the 35 included studies, 69,219 THAs were performed. Two studies did not report the number of THAs in patients 55 years old or younger. The authors of these studies were contacted by email to request the number of patients of this subgroup, but they did not respond. All included studies were published between 1994 and 2019, with 18 (51.4%) conducted in Europe [
Uncemented total hip arthroplasty for primary osteoarthritis in young patients: a mid-to long-term follow-up study from the Finnish arthroplasty register.
Total hip arthroplasty for primary osteoarthrosis in younger patients in the Finnish arthroplasty register. 4,661 primary replacements followed for 0-22 years.
The long-term results of Charnley low-friction arthroplasty in young patients who have congenital dislocation, degenerative osteoarthrosis, or rheumatoid arthritis.
Association between fixation technique and revision risk in total hip arthroplasty patients younger than 55 years of age. Results from the Nordic Arthroplasty Register Association.
What is the lifetime risk of revision for patients undergoing total hip arthroplasty? a 40-year observational study of patients treated with the Charnley cemented total hip arthroplasty.
]. All articles were prognostic retrospective articles with level III quality, of which 11 studies used national or international data registries. Four studies used the Finnish Arthroplasty Register, 2 used the nationwide hip arthroplasty registries in Sweden, Norway, Denmark, and Finland; and another 2 studies used the National Joint Registry of England and Wales. The New Zealand Joint Registry, Australian Orthopaedic Association National Joint Replacement Registry, and the Norwegian Arthroplasty Register were used in 1 study.
After assessing the quality of the included studies using the Scottish Intercollegiate Guidelines Network guidelines, 16 (45.7%) articles were classified as good quality [
Uncemented total hip arthroplasty for primary osteoarthritis in young patients: a mid-to long-term follow-up study from the Finnish arthroplasty register.
Total hip arthroplasty for primary osteoarthrosis in younger patients in the Finnish arthroplasty register. 4,661 primary replacements followed for 0-22 years.
The long-term results of Charnley low-friction arthroplasty in young patients who have congenital dislocation, degenerative osteoarthrosis, or rheumatoid arthritis.
What is the lifetime risk of revision for patients undergoing total hip arthroplasty? a 40-year observational study of patients treated with the Charnley cemented total hip arthroplasty.
Association between fixation technique and revision risk in total hip arthroplasty patients younger than 55 years of age. Results from the Nordic Arthroplasty Register Association.
] often due to incomplete reporting or not conducting multivariate analyses (Appendix B, Table B.1).
Cohort characteristics
Different age groupings were used as inclusion criteria. While several studies evaluated patients who were 55 years old or younger (n = 10, 28.6%; 57,401 THAs) [
Uncemented total hip arthroplasty for primary osteoarthritis in young patients: a mid-to long-term follow-up study from the Finnish arthroplasty register.
Total hip arthroplasty for primary osteoarthrosis in younger patients in the Finnish arthroplasty register. 4,661 primary replacements followed for 0-22 years.
Association between fixation technique and revision risk in total hip arthroplasty patients younger than 55 years of age. Results from the Nordic Arthroplasty Register Association.
What is the lifetime risk of revision for patients undergoing total hip arthroplasty? a 40-year observational study of patients treated with the Charnley cemented total hip arthroplasty.
]. Ten studies (n = 10) did not report the mean or median age of the included participants; however, an age-related inclusion criterion of 55 years or younger was reported. Of those reporting age, the mean (standard deviation) age of participants was 36.76 (10.39) years. Males comprised 40.8%-100% [
Association between fixation technique and revision risk in total hip arthroplasty patients younger than 55 years of age. Results from the Nordic Arthroplasty Register Association.
What is the lifetime risk of revision for patients undergoing total hip arthroplasty? a 40-year observational study of patients treated with the Charnley cemented total hip arthroplasty.
Uncemented total hip arthroplasty for primary osteoarthritis in young patients: a mid-to long-term follow-up study from the Finnish arthroplasty register.
Total hip arthroplasty for primary osteoarthrosis in younger patients in the Finnish arthroplasty register. 4,661 primary replacements followed for 0-22 years.
The long-term results of Charnley low-friction arthroplasty in young patients who have congenital dislocation, degenerative osteoarthrosis, or rheumatoid arthritis.
Association between fixation technique and revision risk in total hip arthroplasty patients younger than 55 years of age. Results from the Nordic Arthroplasty Register Association.
What is the lifetime risk of revision for patients undergoing total hip arthroplasty? a 40-year observational study of patients treated with the Charnley cemented total hip arthroplasty.
Total hip arthroplasty for primary osteoarthrosis in younger patients in the Finnish arthroplasty register. 4,661 primary replacements followed for 0-22 years.
Uncemented total hip arthroplasty for primary osteoarthritis in young patients: a mid-to long-term follow-up study from the Finnish arthroplasty register.
Association between fixation technique and revision risk in total hip arthroplasty patients younger than 55 years of age. Results from the Nordic Arthroplasty Register Association.
The Nordic Arthroplasty Register Association (a collaboration between the national joint replacement registers in Denmark, Finland, Norway, and Sweden)
What is the lifetime risk of revision for patients undergoing total hip arthroplasty? a 40-year observational study of patients treated with the Charnley cemented total hip arthroplasty.
The long-term results of Charnley low-friction arthroplasty in young patients who have congenital dislocation, degenerative osteoarthrosis, or rheumatoid arthritis.
Uncemented total hip arthroplasty for primary osteoarthritis in young patients: a mid-to long-term follow-up study from the Finnish arthroplasty register.
Total hip arthroplasty for primary osteoarthrosis in younger patients in the Finnish arthroplasty register. 4,661 primary replacements followed for 0-22 years.
Association between fixation technique and revision risk in total hip arthroplasty patients younger than 55 years of age. Results from the Nordic Arthroplasty Register Association.
The long-term results of Charnley low-friction arthroplasty in young patients who have congenital dislocation, degenerative osteoarthrosis, or rheumatoid arthritis.
What is the lifetime risk of revision for patients undergoing total hip arthroplasty? a 40-year observational study of patients treated with the Charnley cemented total hip arthroplasty.
The long-term results of Charnley low-friction arthroplasty in young patients who have congenital dislocation, degenerative osteoarthrosis, or rheumatoid arthritis.
Rheumatoid arthritis (37%, n = 87) Degenerative arthrosis (25.1%, n = 59) Congenital dislocation the hip (24.3%, n = 57) Ankylosing spondylitis (13.6%, n = 32)
Implant fracture (3%, n = 8) Dislocation with marked acetabular wear (1.3%, n = 3)
Total hip arthroplasty for primary osteoarthrosis in younger patients in the Finnish arthroplasty register. 4,661 primary replacements followed for 0-22 years.
Aseptic loosening (82%, n = 581) Fracture of the implant (3%, n = 21) Infection (2.7%, n = 19) Prosthesis dislocation (2.7%, n = 19) Malposition of the prosthesis (2.3%, n = 16) Periprosthetic fracture (1.1%, n = 8) Other miscellaneous reasons (6.3%, n = 45)
Uncemented total hip arthroplasty for primary osteoarthritis in young patients: a mid-to long-term follow-up study from the Finnish arthroplasty register.
Aseptic loosening (range from 0.2%-23%) Infection (range from 0.2%-2.4%) Dislocation (range from 0.7%-12%) Malposition (range from 0.3%-1.6%) Fracture of stem (range from 0.6%-3%) Fracture of bone (range from 0.1%-0.9%) Other reasons for cup reoperation including exchange of liner (range from 0.6%-15%)
Aseptic loosening (46.2%, n = 232) Dislocation (5.1%, n = 46) Malposition (4.8%, n = 24) Fracture of the prosthesis (4.4%, n = 22) Infection (3.8%, n = 19) Periprosthetic fracture (3%, n = 15) Other reasons (including, liner revisions due to excessive wear) (30.7%, n = 154)
Association between fixation technique and revision risk in total hip arthroplasty patients younger than 55 years of age. Results from the Nordic Arthroplasty Register Association.
Aseptic loosening (53.4%, n = 1290) Unspecified (17.2%, n = 415) Dislocation (11.9%, n = 288) Deep infection (9.1%, n = 219) Periprosthetic fracture (3.8%, n = 91) Pain only (3.2%, n = 78)
Osteoarthritis Dysplastic hip AVN Fracture Rheumatoid arthritis
Any reason Wear/aseptic loosening (54.2%, n = 13) Wear (12.5%, n = 3) Infection (4.2%, n = 1) Malpositioning cup (4.2%, n = 1) Femoral head fracture (4.2%, n = 1)
Pediatric disease (40.9%, n = 54) Systemic inflammatory disease (34.1%, n = 45) sequelae of trauma (8.3%, n = 11) sequelae of infection (5.3%, n = 7)
Aseptic loosening (44.9%, n = 31) Wear (20.3%, n = 14) Infection (11.6%, n = 8) Osteolysis (8.7%, n = 6) Dislocation (5.8%, n = 4) Pain only (1.5%, n = 1) 2-stage reoperation (1.5%, n = 1) Fracture (1.4%, n = 1) Other (4.3%, n = 3)
What is the lifetime risk of revision for patients undergoing total hip arthroplasty? a 40-year observational study of patients treated with the Charnley cemented total hip arthroplasty.
Primary osteoarthritis (49.7%) AVN (23.7%) Dysplastic hip (14.3%) Slipped capital femoral epiphysis (5.5%) Posttraumatic arthritis (3.7%) Inflammatory arthritis (3.1%)
Periprosthetic infection (4.9%) Aseptic loosening of the acetabular component (4.6%) Periprosthetic fractures (1.5%) Aseptic loosening of the femoral component (0.9%)
Secondary osteoarthritis (49.4%, n = 115) Developmental dysplasia of the hip (37.8%, n = 88) AVN (33%, n = 77) Primary osteoarthritis (11.6%, n = 41) Post-traumatic (11.6%, n = 27)
13 were isolated cup revisions: Loosening (3%, n = 7) Isolated polyethylene wear (2.6%, n = 6) Deep infection (2.6%, n = 6) Aseptic loosening of both components (1.3, n = 3) Chronic instability (0.4%, n = 1)
Pediatric (33%) Systemic inflammatory disease (23%) AVN (12%) Hip fracture (6.5%) Osteoarthritis (4.1%) Other (22%)
Aseptic loosening (52%, n = 61) Dislocation (9.3%, n = 11) Deep infection (5.1%, n = 6) Periprosthetic fracture (2.5%, n = 3) Pain only (0.8%, n = 1) Other (31%, n = 36)