The Classic: Revision of Aseptic Loose Total Hip Arthroplasties

Harlan C. Amstutz was born and raised in Santa Monica, CA. After attending local schools, he enrolled in the University of California, Los Angeles where he received his bachelor degree in 1953 and his medical degree in 1956. After interning at the Los Angeles General Hospital and spending 1 year as a surgical resident at the UCLA Medical Center, he began his orthopaedic residency at the Hospital for Special Surgery in New York. On completion of his residency in 1961, he entered the Air Force as the orthopaedic surgeon at the Hospital for the 862nd SAC Division in Minot, ND. After serving in the military, Amstutz went to London where he spent 1 year at the Royal National Orthopaedic Hospital and another year at the Institute of Orthopaedics. He then returned to the Hospital for SpecialSurgery where he spent the next 5 years before returning to Los Angeles. In 1970, Amstutz was appointed Professor and Chief of the Division of Orthopaedic Surgery and Chief of the Joint Replacement Section at UCLA. Since his retirement in 1991, Amstutz became the Director of the Joint Replacement Institute at the Orthopaedic Hospital. A pioneer in the bioengineering of total joint replacements, Amstutz’s vast clinical experience and work in the laboratory have made him a popular lecturer and visiting professor. His contributions to the orthopaedic literature number more than 200. He has received many honors and awards for his work, including the John Charnley Award of the Hip Society and the Nicolas Andry Award. He has been elected president of the American Orthopaedic Association, the Hip Society, and the Orthopaedic Research Society. The following paper on aseptic loosening of total hip prostheses is an early discussion of the problem.Figure.: Dr. Harlan C.AmstutzLeonard F. Peltier, MD, PhD Aseptic loosening is the major cause of failure of conventional hip arthroplasty. The incidence is rising, and revision surgery constitutes 25% of all arthroplasties performed at the University of California at Los Angeles. Although there are few published reports of the results of revision surgery for loose total hip arthroplasties, there is almost universal agreement that the long-term results will be less satisfactory than those of primary index arthroplasty. With each failure there is loss of bone stock, both in quality and quantity, making revision increasingly difficult and results even more unsatisfactory. There are currently reports of Girdlestone procedures being performed for aseptic loosening.6,9 This study analyzes the results following revision surgery during a ten-year period, and relates them critically to those with conventional hip arthroplasty performed by the Joint Replacement Service at UCLA during the same period and using similar techniques. MATERIALS AND METHODS Eighty-eight patients underwent revision for aseptic loosening of total hip arthroplasty at UCLA during the period from October 1970 to October 1980. The criteria for inclusion in the study group were the following: (1) an acrylic fixed conventional hip metal/polyethylene arthroplasty; (2) revision surgery that was performed for suspected loosening (revisions for heterotopic bone, trochanteric problems, and recurrent dislocation were excluded); (3) no evidence of sepsis, including on pre- and intraoperative cultures, or after histologic examination of tissue obtained at surgery.11 Sixty-six of the 88 patients had a one- to nine-year follow-up period (average, 2.1 years). The hospital and surgical records, the UCLA hip evaluation forms, and the serial radiographs were reviewed in detail. Fifteen of the 66 patients underwent original operation at UCLA. The primary diagnoses in these 66 patients included a higher percentage of dysplasia and post-trauma as compared with the overall total hip arthroplasty series at UCLA3 (Table 1). The failure incidence was noticably lower in patients with rheumatoid arthritis.Table 1: Distribution of DiagnosesTwo patients had bilateral failures, but only one hip was included because of inadequate follow-up study on the contralateral hip. There were 31 men and 35 women. The average age at revision was 51.7 years. The average time to surgery was 4.0 years. For the 15 patients whose index surgery was performed at UCLA, the average time to operation was 4.8 years, and for those from “outside,” 3.7 years. Twenty-eight patients (42%) underwent hip operation prior to revision for failed hip arthroplasty: 17 had two operations, five patients had three operations, four had four operations, and two patients had more than five previous operations. Nine patients underwent prior osteotomy, shell procedure, pinning, or arthrodesis. Seventeen patients had had prior cup or hemiarthroplasty, and 13 had previously undergone failed total hip arthroplasty. The failed prosthesis types included 24 Mueller, 18 Charnley, 11 T-28, nine Bechtol, two Harris, and two Aufranc-Turner. At revision surgery, 14 patients (21%) had isolated acetabular loosening, and 25 (38%) had only femoral loosening (including 8 stem fractures). Twenty-three (35%) patients had loosening of both components, and four patients had no “gross” loosening of either component, although two had “obvious” radiographic evidence of loosening consisting of subsidence and migration or lucencies greater than 2 mm wide. The operation was performed or supervised by one of five attending surgeons. The senior author was involved in 47% of cases. The types of femoral prostheses inserted included 52 from the T-28 and TR-28 series. There were 15 wide or hemi conversion, 13 large, nine extralong, eight straight, four extrawide extralarge, two extralarge, and two custom prostheses. There were eight other exchanges, including three Charnley and five Mueller prostheses. The average operative time for revision surgery was 245 minutes. Revision of the isolated acetabular component averaged 216 minutes, while exchange of the femoral component averaged 248 minutes. Revision of both components averaged 285 minutes. Total blood loss, including postoperative suction catheter drainage, averaged 2610 cc (range, 830–8024 cc). The blood loss in eight patients who had acetabular revision only averaged 2500 cc, and in seven patients who had femoral component revision only, blood loss averaged 2316 cc. Those patients with both components revised (n = 40) averaged 2900 cc of blood loss. Hypotensive anesthetic agents were used in 28% of the patients who underwent revisions. Sixty-two per cent of the limbs lengthened, 28% remained unchanged, and 10% lost length. Prior to operation, the average limb-length discrepancy was 1.9 cm. The average gain in those who were lengthened was 1.65 cm (maximum, 5 cm). The maximum loss of length was 2 cm. RESULTS Patients’ pain, walking, and function were evaluated using the UCLA 10-point scale, where a rating of 10 denotes absolutely no pain and excellent walking and function. The average pain rating improved from 3.3 to 7.3 points, which was less than the overall index surgery improvement of 4.4 (4.0–8.4). Walking improved from 5.0 to 6.1 points, and function from 4.5 to 6.1 points, which was notably less than in the index surgery group: walking improved from 4.7 to 7.1 and function from 4.3 to 6.8. The range of motion for revision patients improved: flexion arc increased from 80.6° to 89.8°, abduction increased from 20.2° to 27.8°, and rotation are increased from 37.3° to 60.4°. These results were compared with those from the overall UCLA series, in which flexion arc increased from 76.3° to 107.6°, abduction increased from 17.5° to 28.4°, and rotation arc increased from 24.3° to 58.9°. The final flexion arc of the revision group was 8.8° less than that of the overall series. Although the overall series had less abduction and rotation arc prior to operation, there was no significant difference in the final abduction and rotation arc between the two groups. There was a high complication rate following revision surgery. There were five (7.5%) peroneal nerve palsies, with complete recovery in three and partial recovery in two. There were three nonfatal pulmonary emboli, three wound hematomas (one required evacuation surgically), and seven dislocations (10.6%), with one subsequently requiring revision surgery and component change. There were also seven subluxations, one of which subsequently loosened the acetabular component. Of the seven patients with dislocations, all had undergone at least one prior surgery, as had all but those with subluxation. Three of the patients who had dislocations had complications: two had undergone prior revision for failed total hip arthroplasty, and one had Charcot’s arthropathy. The seven patients with subluxation were similarly complicated by three failed total hip arthroplastics, one arthrodesis take-down, and one failed hemiarthroplasty. There were five trochanteric migrations (7.5%), three additional fibrous unions, and one iliac incisional hernia from a bone graft donor site. There were nine (13.6%) major complications involving the prosthesis. Six (9%) had undergone re-revision of their hip arthroplasties, including one who developed gonococcal septic total hip arthroplasty two years after revision. One patient previously mentioned underwent re-revision one year four months postrevision for recurrent dislocation, one for stem fracture three years postrevision, one for femoral fracture, one for a loose acetabular component in the chronic subluxator at 13 months postrevision, and another for loosening of both components six years postrevision. There were four femoral shaft fractures: two through cortical windows and two at the stem tip. The latter two did not have obvious cortical defects previously. One of these, although neither component was loose, was revised with a longer stem to bridge the fracture. The other was treated conservatively initially, but later required grafting and internal fixation. One patient was a 24-year-old woman with multiple epiphyseal dysplasia who had lateral hip pain and increasing limitation of function. She underwent bilateral total hip arthroplasties and has remained asymptomatic on the left side, despite the use of a small-stem stainless steel T-28 prosthesis for ten years. However, the right side was replaced with a thin-stem T-28, which while was three years eight months after A cortical was used to the femoral component and acrylic in A custom prosthesis was because of the femoral a conventional prosthesis was inserted but the cortical months after operation, the patient and at the stem tip. This was treated conservatively by a The fracture with an and at follow-up six years the patient had returned to a with the of The femoral component is loose, but the has subsidence and She has of the and as of the femoral had bone defects or from prior or loosening at revision surgery. One of these ten patients had been treated conservatively for a femoral shaft fracture through the prior to revision for a loose In six patients the cortical defects were by the stem through the at the original surgery. ten of these patients were to have loose femoral at revision. In femoral cortical windows or defects were made or in ten of the revision arthroplasties to the stem of the ten prior to revision were also had of these patients as has required although two patients four and seven postrevision, the femoral shaft at the cortical The radiographs of patients who had femoral cortical defects and more were in six of the acetabular had one who was a hip and in two of the femoral to cortical and acetabular components were used in revisions. The use of components to bone defects is A woman with pain in left hip femoral and was treated by and subsequently by hemiarthroplasty. She underwent total hip arthroplasty ten years She did for four years, but increasing pain and of left with a range of examination an acetabular of 2 with migration of cm. The femoral component was also These were at operation, and the hip was revised using a cup and an extrawide femoral component from the After operation, the patient is pain and A with rheumatoid to UCLA in with increasing pain one year following revision of a right total hip arthroplasty. At years of a conventional prosthesis was which became loose three years. acrylic fracture, and loosening of the femoral component. At operation, the femoral component was components were revised using a and a custom extralong, extrawide stem femoral component. The patient currently is months postrevision and with no radiographic of in the two years. He has been to use a at all made one and two years or longer after operation, were in The average radiographic follow-up period was two years six months (maximum, 8 years In the postoperative no femoral to at had which increased to at Those who had increased from to at follow-up (Table The incidence of in the UCLA overall group was after operation and to only at with of the postoperative no patients maximum femoral greater than 1 but after two years or had mm and had greater than mm maximum (Table In the overall group at two had mm and had greater than mm maximum of the patients had no in of the three on the acetabular side after operation (Table compared with in the overall conventional arthroplasty There were no at two follow-up that were as compared with in the overall After operation, 10% had complete the increasing to at The by is in per cent of the patients had after operation in of the increasing to more than at In averaged the The maximum of acetabular is in After operation, had maximum of at two years or more to In the overall had of mm and 2 mm or greater at two years. The latter is higher than only patients who had primary surgery had been The clinical results following revision of aseptic loose conventional hip arthroplasties have reviewed his experience with patients in that his clinical results were with those for primary total hip However, of his were revisions. reviewed including and three prostheses on by a group of in and that the clinical results were less than In the group of 66 patients for one to nine years, postoperative pain, walking, and function as as flexion arc were lower as compared with the overall UCLA conventional hip arthroplasty of the series in the including the series, have longer operative increased blood and higher complication than with primary surgery, all of which the and of the revision The literature reports an average blood loss of from to cc for series, although postoperative suction catheter was not included in other series that were There were patients from the series who had loss. One patient who was on early in the revision experience lost more than cc. The operative time also has in the literature (range, to more than 5 an operative time of minutes, that of his primary surgery. The results and those of a operative time only one component was the of each revision on the and those patients who had were the requiring more operative time and blood loss. the experience with revision surgery the to with these with a in operative time and blood loss. the the use and to blood mm the patient has lost 5 of and are to the blood and is using an after This is of in blood A all tissue to the of in blood loss. the operative high blood loss, and of the there have been no in or other series complications have not been greater than with conventional arthroplasties, and no or have There was no between those patients who developed nerve and the of The high incidence of nerve be a of the the hip and the of the at the time of surgery, which were not with and The is to and the nerve as as to the during the procedure, a The literature the of trochanteric to wide the revision The incidence of and migration of trochanteric has been a incidence that of primary With the previously the incidence was failure and migration have been with a or a bone for either acrylic bone or the lateral cortical A of be using a or a wide the be the and the subsequently will be The bone be and for maximum using two 1 cm and by the while the are following the is not at surgery, the patient be to for one or two and also be to using a The high dislocation rate in and other series is of the patients had undergone at least one previous surgery prior to with and There has also been an with trochanteric migration failure to to bone or loss. The use of revision and and the surgeon to the more The their patients on the after operation, with However, trochanteric is or there are other or are patients revision surgery are at higher for is the and The failure rate with recurrent loosening has been high even in series with follow-up a group of patients who had been for six to eight years. the that underwent revision only, required a operation after three years and a required a operation three years a The loosening rate of two other series was and in patients for In series there was a high of loosening to bone The loosening rate requiring revision was with an average follow-up period of more than two years (range, years). is but not in the literature is the evidence of as by the and of the that in the that did not was as as that after primary surgery, although the incidence of was and The are the to a radiographic a incidence of femoral and acetabular mm on the and femoral with or or have been revised for Of additional is the of the group of aseptic loosening patients years). patients had loose prostheses but not be revised were not included in the to was In a series from the University of of patients were to of or a high in series was and in only that of his loosening to be septic at be that evaluation is with prior to operation, obtained and of tissue at surgery, with the tissue obtained for to There is a higher of femoral fracture during and following revision surgery. In series there were four one patient who had aseptic loosening and in revision surgery was at surgery, a fracture which was fixed with an and a Girdlestone was the patient heterotopic bone, and There are on to the acrylic bone and a of and using a and a to but a is to of the cortical and to the acrylic that be The have improved their surgical revision to complications and to more fixation. The of to and of both the femoral and components, with to an acrylic mm in the components, be be by using the of the femoral of the failed component, The and use or femoral prostheses in either or other custom prostheses. The use of an stem and a cup is in a in a Mueller prosthesis loosened and was revised to a arthroplasty three years two months after Three years postrevision with of bone and femoral stem to an extralarge, extrawide TR-28 prosthesis was performed to the cortical the follow-up period was he has not been included in although he had pain His is with his Since even the not for a wide of prostheses and be The stem be to bridge defects or and made from For the with a of are these are made of as are the prostheses. A wide and other TR-28 are made from the or are not a custom length be or the prosthesis to an length before or during surgery. the stem to be is fixed or there is acrylic to be that the use of a then is to at surgery before the prosthesis to length. a is that was or then be use of is not because are difficult to to the femoral and because is difficult to the are even more difficult to be the is to be The be after by all of the tissue to the to a or is because is to However, in a in which only one component is loose, the quality of the of the other component be evaluated to be the acetabular component is not loose, the and of the the age and of the and the of component be the component is not or with the femoral component, be to the acetabular component. for the is in the mm there is bone stock, and the surgeon that a component be and be then there be a in revision. This also the medical of the as is in a There be which the quality of that be the acetabular component is loose but the femoral component is bone, evaluation of the bone stock, quality of and and age and of the patient be for a patient had an early femoral stem a prosthesis made from a and the prosthesis has had a number of years of be to exchange the component there is bone The will on the and the to fixation. These are exchange of components and be One woman in with hip pain one year after a Mueller total hip arthroplasty had been performed for fracture at another She had but pain and obvious loosening of the femoral component The acetabular component developed was not loose at the time of although there was a of 1 mm at the was elected to exchange the femoral component with a Mueller component. At that time on the high loosening with stem were not Although was and the patient returned to an for years, there was increasing pain and femoral The acetabular component was also loose, and both components were using a wide stem In have been to both components and to a femoral component of made from loss of bone stock, a be by with a Those components that are loose be with not to the which fracture the After the has been the acrylic be with an and The which is be using a and acrylic in the is acrylic has the through or be and be by be not to to all acrylic and or be in all of the have been bone be grafting of defects is to the use of or absolutely because of the of and acrylic bone, as as the these to of There are also in the the femoral stem is of the component, even is not loose, is not The acrylic be using an to a the of the The is difficult to because of the of the stem stem with which the surgeon is not be obtained prior to operation and to the with stem is by the acrylic that the stem using a to a of at least 1 cm. The a the stem and the stem as by A is to the acrylic and The the use of windows or which more difficult and to femoral fracture. in series, these defects to femoral there is a be by a stem at least two shaft to a acrylic is by the acrylic be from the using a and The has been for although the to the as the all of the acrylic has been is to and for be to bone grafting for both and lateral defects of the as as the of the bone with fixation. cortical bone be is although a be the of and increasing the be by with bone and be and with and bone is acrylic is used in the and The blood be with at the time of a be the femoral by of bone on a the bone is cortical and the the acrylic be in to the A is to the femoral with acrylic is in the There is no to early acrylic all that is a cortical The femoral component be inserted in or and are a trochanteric be the two These improved surgical developed during the ten years have in revision of aseptic loose conventional hip arthroplasties is will the high complication and However, patients be that are at greater for recurrent be and and be Sixty-six patients were revised for aseptic loosening of their conventional hip follow-up from one to nine years. In them with an overall conventional arthroplasty series, there was a higher failure rate with dysplasia and and a lower incidence in and rheumatoid The average time to revision was four years. The patients were eight years than those in the overall UCLA conventional hip arthroplasty series. per cent had undergone hip surgery prior to the original hip arthroplasty that The average as as the follow-up pain, walking, and function and the flexion arc were less than those in the overall conventional arthroplasty series. The quality of femoral and acetabular obtained at revision was to that of the primary surgery. Six patients (9%) have required re-revision of their hip In a the in and and are Although these patients are is per cent had no complications and are complications included trochanteric migration dislocation (10.6%), and peroneal nerve but there were no or other medical complications and only one of