Primary total hip arthroplasty failure: aseptic loosening remains the most common cause of revision

Abstract

Objective: Revision total hip arthroplasty (THA) imposes physical and financial burdens on patients and depletes limited medical resources. Causes for revision THAs can change as technology changes. Therefore, understanding contemporary causes is essential for clinical decision-making. We analyzed causes and trends associated with revision THA in the 2010s.

Methods: We retrospectively identified 803 revision cases after primary THAs were performed at our center from January 2011 to December 2020. Causes for revision were reviewed and compared among patients who were grouped by the date of revision and interval between primary and revision THA.

Results: The most common causes were aseptic loosening (66.6%), infection (11.0%), osteolysis (6.0%), periprosthetic fracture (5.5%), and instability (3.5%). The values for incidence of infection, fracture, and instability were higher in the early revision group than in the late revision group (threshold, 2 years after primary surgery, all P<0.05). The proportion of revision THAs increased by 25.6% from 2011-2015 to 2016-2020, and the time between primary and revision THAs increased from 8.8 ± 7.0 years to 10.2 ± 6.8 years (P=0.003). In the last 5 years of the study period, the incidence of aseptic loosening decreased and the rates of osteolysis, acetabular wear by hemiarthroplasty, and instability increased, compared to 2011-2015 (all P<0.05).

Conclusions: Aseptic loosening was the most common cause of revision THA. Revisions due to infection, fracture, and instability occurred more frequently during the early post-THA period after primary THA. Revisions due to osteolysis, instability, and acetabular wear have increased in recent years.

Keywords: Total hip arthroplasty; aseptic loosening; infection; instability; periprosthetic fracture; revision THA.

Figure 1

In one case with multiple causes for revision, aseptic loosening was identified as the main cause: (A) preoperative anteroposterior radiograph, polyethylene wear, osteolysis, and prosthesis loosening are present, (B) postoperative anteroposterior radiograph, (C) intraoperative conditions, adverse local tissue reactions (ALTR), and prosthesis loosening are present, and (D) retrieved prosthesis, tribocorrosion of head-neck junction is present, ALTR was an additional failure mode.

Figure 2

Anteroposterior (AP) radiographs of some causes. (A) pre- and (B) postoperative AP radiographs of periprosthetic fracture (blue arrow), (C) pre- and (D) postoperative AP radiographs of instability, (E) pre- and (F) postoperative AP radiographs of periprosthetic infection, (G) pre- and (H) postoperative AP radiographs of ceramic fracture (green arrow).

Figure 3

Survival analysis of each cause of revision using the Kaplan-Meier method. Instability (red line, mean time: 4.7 ± 7.3 years) and infection (green line, 4.7 ± 4.9 years) occurred early, whereas osteolysis (purple line, 13.8 ± 4.7 years) occurred late during the postoperative period.

Figure 4

Survival analysis for date of revision, using the Kaplan-Meier method. The mean time between primary and revision THA was 9.6 ± 7.0 years (yellow line) for all revisions. The mean time was longer in 2016-2020 (green line, 10.2 ± 6.8 years) than in 2011-2015 (blue line, 8.8 ± 7.0 years, P=0.003).

Figure 5

Comparison of proportion of causes of revision total hip arthroplasty (grouped by date of revision) *P<0.05 **P<0.001 (Fisher’s exact test); ALTR/ARMD, adverse local tissue reactions/adverse reaction to metal debris.