Satisfying outcomes scores and survivorship achieved with impaction grafting for revision THA in young patients

Abstract

Background: The increasing number of total hip arthroplasties (THAs) performed in younger patients will inevitably generate larger numbers of revision procedures for this specific group of patients. Unfortunately, no satisfying revision method with acceptable survivorship 10 years after revision has been described for these patients so far.

Questions/purposes: The purposes of this study were to (1) analyze the clinical outcome; (2) complication rate; (3) survivorship; and (4) radiographic outcome of cemented revision THA performed with impaction bone grafting (IBG) on both the acetabular and femoral sides in one surgery in patients younger than 55 years old.

Methods: During the period 1991 to 2007, 86 complete THA revisions were performed at our institution in patients younger than 55 years. In 34 of these 86 revisions (40%), IBG was used on both the acetabular and femoral sides in 33 patients. Mean patient age at revision surgery was 46.4 years (SD 7.6). No patient was lost to followup, but three patients died during followup. None of the deaths were related to the revision surgery. The mean followup for the surviving hips was 11.7 years (SD 4.6). We also analyzed complication rate.

Results: The mean Harris hip score improved from 55 (SD 18) preoperatively to 80 points (SD 16) at latest followup (p = 0.009). Six hips underwent a rerevision (18%): in four patients, both components were rerevised; and in two hips, only the cup was revised. Patient 10-year survival rate with the endpoint of rerevision for any component for any reason was 87% (95% confidence interval [CI], 67%-95%) and with the endpoint of rerevision for aseptic loosening, the survival rate was 97% (95% CI, 80%-100%). In total six cups were considered radiographically loose, of which four were rerevised. Three stems were radiographically loose, of which none was rerevised.

Conclusions: IBG is a valuable biological revision technique that may restore bone stock in younger patients. Bone stock reconstruction is important, because these patients likely will outlive their revision implants. Bone reconstruction with impaction grafting may facilitate future revisions.

Level of evidence: Level IV, therapeutic study.

Fig. 1A–C

Kaplan-Meier survival curve shown for complete revision THAs (acetabular and femoral components) with (A) rerevision for any reason; (B) rerevision for aseptic loosening; and (C) reoperation for any reason of one or both components as the endpoint.

Fig. 2A–C

(A) Preoperative radiograph of a female patient, about to undergo THA, showing aseptic loosening and bone loss of both the acetabulum and proximal femur. The patient had previously undergone total cemented revision implantation. The revision components were in situ for 11 years. The patient was 19 years old when the primary total hip prosthesis was implanted after a coxitis. The primary THA was revised after 15 years. (B) Radiograph after the index revision surgery with IBG of both the acetabulum and the femur. The patient was 45 years old at the time of the revision. Segmental bone defects of the medial and lateral acetabular wall were reconstructed with metal meshes and screws. On the femoral side, a distal cortical perforation was covered with a metal mesh and cerclage wires, and the dorsal calcar region was also reconstructed. (C) Radiograph at final followup 19 years after the index revision with IBG. Both revision implants are stable with incorporation of the bone grafts, although a small osteolytic area can be seen in Gruen Zone 1 of the femur. The patient was 64 years old at last followup and still has an excellent functioning hip (HHS 95) 45 years after the first THA.