The Fate of Revised Uncemented Acetabular Components in Patients
With Rheumatoid Arthritis
Mont, Michael A. MD**; Domb, Benjamin BA*,**; Rajadhyaksha, Amar D. MD*,**; Padden, David A. MD*,†;
Jones, Lynne C. PhD*,‡; Hungerford, David S. MD*,‡
Author Information
From *The Johns Hopkins University School of Medicine, Department of Orthopaedic Surgery,
Baltimore, MD; the **Department of Orthopaedics, Sinai Hospital, Baltimore, MD; †Cleveland Clinic
Florida, Department of Orthopaedics, Ft. Lauderdale, FL; and the ‡Division of Arthritis Surgery, Good
Samaritan Hospital, Baltimore, MD.
Reprint requests to Michael A. Mont, MD, Institute for Advanced Orthopaedics, 2411 West Belvedere
Avenue, Baltimore, MD 21215.
Received: March 16, 2001.
Revised: May 18, 2001; October 11, 2001.
Accepted: October 17, 2001.
Abstract
The results of patients with rheumatoid arthritis who had revision
hip arthroplasty have been studied infrequently. The purpose of this
study was to review the authors’ clinical and radiographic experiences
and outcomes with revision hip arthroplasty. Revision total hip
arthroplasties were done on 28 patients (30 hips). All hips had
morselized bone grafting and four hips had bulk allografts for segmental
defects. The mean age of the patients at the time of surgery was 50
years (range, 20–74 years). Patients were followed up for 4 to 15 years
(mean, 7 years). At the latest followup, 14 hips (13 patients) of the 30
hips (47%) had good and excellent Harris hip score ratings. Mechanical
failures included six hips (five patients) that had revision arthroplasty
and two hips (two patients) that had resection arthroplasty. Six other
hips (five patients) had poor Harris hip score ratings. The Kaplan-Meier
survivorship curve for failure of the acetabular component revealed an
89% chance of survivorship curve for failure of the acetabular
component revealed an 89% chance of survival at 60 months and a 44%
chance of survival at 108 months. Based on the results of this study,
revision hip arthroplasty for acetabular loosening with a cementless
acetabular prosthesis has a low rate of success in patients with
rheumatoid arthritis.
Success rates greater than 90% for primary total hip arthroplasty
have been reported in various large series with 5 to 10 years followup in
patients with rheumatoid arthritis (10%–20% of most
series). 7,19,20,21,23,29,30,36,40,41 A recent literature search
revealed only one study specifically examining outcomes of revision
arthroplasty in patients with rheumatoid arthritis. 31 Raut et
al 31reported good clinical results in 43 of 47 hips at a mean followup of
7 years (range, 2–19 years) with 45 cemented stems reported to be well
fixed (96%). However, 15 cemented sockets (37%) were determined to
be loose radiologically in their study. Their conclusions questioned
additional acetabular fixation in patients with rheumatoid arthritis. In
other studies reporting on revision hip
arthroplasty.2,4,8,13,16,32,37 there have been small numbers of
patients with rheumatoid arthritis (usually a subgroup of a larger study
involving fewer than five patients). These studies have not allowed
adequate determination of outcomes to guide additional treatment.
Because of the paucity of information concerning this subject and
with no study analyzing the results of cementless acetabular fixation in
patients with rheumatoid arthritis, this investigation was done. The
purpose of this report was to examine the results of cementless
acetabular revision total hip arthroplasty in patients with rheumatoid
arthritis.
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MATERIALS AND METHODS
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Patients
Between July 1, 1984 and December 31, 1995, 406 revision hip
arthroplasties were done on 364 patients at the authors’ institution. Of
these, 38 hips were revised (34 patients) in patients with rheumatoid
arthritis. One patient (one hip) was excluded from this study because
revision was done after a bipolar hemiarthroplasty, rather than revision
of a total hip replacement. Other patients excluded from this study
were two patients (three hips) who had revision of the femoral
component only, both of whom had clinical and radiographic success
(Harris hip scores 17 of 92, 95, and 96 points at 5-, 11-and 12-year
followups). Another patient who was excluded (two hips) had an
acetabular polyethylene liner insert change. Two other patients (two
hips) were lost to followup within 1 year of the procedure. This left 28
patients (30 hips) who had revision of acetabular components or
acetabular and femoral components. There were 18 women and 10 men
with a mean age at revision arthroplasty of 50 years (range, 20–84
years). The reason for revision surgery was aseptic loosening in all
patients. Twenty-two patients (23 hips) had adult-onset rheumatoid
arthritis and six patients (seven hips) had juvenile-onset rheumatoid
arthritis.
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Operative Technique
An anterolateral approach was used in all patients and all patients
received a cementless acetabular socket (Howmedica, Rutherford, NJ,
currently Stryker-Howmedica- Osteonix, Allendale, NJ). The surgical
technique was the same for the two senior authors throughout the
study. Twelve hips (11 patients) had a cemented stem implanted and 18
hips (17 patients) had a cementless stem implanted (PCA-E-Series,
Howmedica). For the sockets, impacted, morselized, allograft bone was
used to fill cavitary defects in all patients. 11,14 Bulk allograft was not
used in any patient where at least 50% of the cup made contact with
host bone. For segmented defects, four patients required the use of
ancillary bulk allograft bone. In all cups, the fixation was secured by
press-fitting a cup that was underreamed by 1 or 2 mm, with the
additional use of one to three ancillary cancellous bone screws. The
acetabular components remained the same throughout the study. The
femoral head size of the prostheses also differed, as 17 of 30 hips were
fitted with 26-mm heads and the remaining 13 hips received 32-mm
femoral heads.
After surgery, the patients were kept in balanced suspension for 2
to 3 weeks and then began nonweightbearing ambulation with crutches
for 6 weeks. At Week 6, patients were advanced to 50% weightbearing
for another 6 weeks, and then allowed weightbearing as tolerated at 12
weeks.
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Data Collection
A prospective clinical and radiographic study was done with the
help of a computerized database. This study was approved by the
Institutional Review Board Committee for the Protection of the Rights of
Human Subjects. The database was supplemented as necessary with a
careful review of hospital outpatient records to analyze demographic
data including corticosteroid use, associated diseases or medical
conditions, arthritic involvement of other joints, and height and weight
(obesity index). All of the patients were examined clinically and
radiographically by all of the coauthors, and the clinical data were
obtained at the time of revision surgery and at the most recent
followup. Final followups were done by two of the authors (ADR, BD)
who were not operating surgeons.
Harris hip scores 17 were used to evaluate each hip for the level
of function at the most recent followup. A score of 80 to 100 points was
considered good function and a clinical success, and a score less than 80
points was considered poor function and a clinical failure. Clinical
outcome also was evaluated subjectively based on whether the patient
was satisfied with the revision surgery at the last followup.
Use of corticosteroids was assigned, according to dosage, to two
categories to assess the association between use and eventual clinical
and radiographic outcomes. These categories were based on accepted
levels of corticosteroid use from published studies. 10,27 Category 1
included patients who had taken less than 2 g prednisone (or equivalent
other corticosteroid medication) in their lifetime or had never taken
corticosteroids. Category 2 included patients who had taken more than 2
g prednisone or its equivalent corticosteroid in their lifetime. The
degree of multiple joint arthritis was described using Charnley
types 5,26 A, B, and C (one joint, bilateral joints, and multijoint
involvement, respectively). The effect of obesity was assessed by
determining the patient’s obesity index 22:
for women, EQUATION
Equation
U1
and for men, EQUATION
Equation
U2
Patients with an index greater than 120 were considered obese.
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Radiographic Analysis
The radiographic review included plain radiographs
(anteroposterior and lateral views) obtained before surgery, after
surgery, and during the annual followups. Three of the coauthors (MAM,
ADR, BD) interpreted the radiographs in a blinded manner for all
patients and had complete agreement, concerning classification of
acetabular bone stock and osteolysis, and progressive radiolucencies.
The quality of the acetabular bone stock at revision arthroplasty was
evaluated using two classification systems: the American Academy of
Orthopaedic Surgeons system, 6 and the system of Gustilo and
Pasternak. 16 The American Academy of Orthopaedic Surgeons system
distinguishes two regions of bone defects. Segmental defects (Class I)
are not contained and involve bone loss of the acetabular rim, and
cavitary defects (Class II) are contained bone deficiencies that do not
involve the rim. This system additionally stratifies defects as combined
deficiencies (Class III) that involve segmental and cavitary defects,
pelvic discontinuity (Class IV), in which the superior and inferior parts of
the acetabulum are not connected, and hip arthrodesis (Class V). In the
Gustilo and Pasternak system, classification of defects include those
having minimal loosening and acetabular wall defects (Class I), marked
enlargement and wall thinning without wall defects (Class II), local wall
defects in anterior, posterior, superior, or central regions (Class III), or
massive defects of two or more walls of the acetabulum (Class IV).
The bone around the acetabular prosthesis was examined for
osteolysis and radiolucencies in the three zones defined by DeLee and
Fig
Fig
Charnley. 9 Significant osteolysis or radiolucencies of at least 2 mm in
1AC
all three zones were considered indications of radiographic failure (Figs
1, 2). Radiolucent and radiosclerotic lines were recorded using the
method of Gruen et al 15 for the femoral component.
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Data Analysis
Success rates were calculated and stratified by multiple clinical
and radiographic parameters such as age groups older and younger than
50 years, obesity index (greater than and less than 120), acetabular
bone stock classes, femoral head size, and other demographic factors.
The data were tabulated using an Access 7.0 database (Microsoft
Corporation, Redmond, WA). Descriptive statistics were calculated.
Parametric and nonparametric statistical analyses of the results were
done using the computer program for Epidemiologic Analysis (PEPI)
Software Package Version 2.03 (USD, Incorporated, Stone Mountain, GA).
Statistical significance was determined using Pearson’s chi square test
(using Yates correction). Using reoperation or postoperative death as
the criteria for failure, a Kaplan-Meier survivorship analysis 1 was done
to estimate the probability that the implant would fail as a function of
time since the initial revision procedure.
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RESULTS
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Clinical Results
The mean followup after revision was 84 months (range, 48–180
months). Of the 28 patients (30 hips), five patients (six hips) had repeat
revision arthroplasties (20%) and two patients (two hips) had resection
arthroplasties (7%). Three of the repeat revision arthroplasties were
necessary because of loosening of the acetabular component, two
because of massive osteolysis around the cup, and one for a loosened
femoral stem. One of the resection arthroplasties was done because of
loosening of both components and massive osteolysis, and the other
because of massive osteolysis around the cup. Six hips (20%) in five
patients were clinical failures based on Harris hip scores less than 80
points. One additional patient (one hip) died after revision surgery from
Table 1
2AC
a pulmonary embolism. One patient (one hip) had a deep hip infection
at 6 years necessitating two-stage reimplantation. Overall, 16 of the 30
hips (53%) had unsuccessful clinical or radiologic results or both. The
relationship between results and various parameters are shown in Table
1.
The Kaplan-Meier survivorship curve for failure of the acetabular
component revealed an 89% (95% confidence interval, 89 ± 6.3 [standard
error %]) chance of survival at 60 months and a 44% chance of survival at
Fig
3
108 months (95% confidence interval, 44 ± 14.7 [standard error %]) (Fig
3).
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Operative Technique Results
The size of the prosthetic femoral head used did not have an
impact on outcome as eight of 17 (47%) 26-mm heads and six of 13 (46%)
32-mm heads were successful (p = 1.00).
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Radiographic Results
Of the clinically successful hips, there were two additional
acetabular cups with complete radiolucencies that were categorized as
impending radiographic failures. The six hips that had low Harris hip
scores (less than 80 points) but which had not been revised all had
complete radiolucencies. The 12 other hips had no evidence of any
progressive radiolucencies around the cups in any of the three
acetabular zones.
Hips were less acetabular bone deficiency had higher success
rates; 53% of American Academy of Orthopaedic Surgeons Class II hips
were successful (nine of 17 hips) and only 39% of American Academy of
Orthopaedic Surgeons Class III hips were successful (five of 13 hips).
Gustilo and Pasternak Class I and Class II hips had a 56% success rate
(nine of 16 hips) whereas Class III and Class IV had only 36% success (five
of 14 hips) (Table 2).
Radiographic results of femoral stem fixation showed that none of
the six cemented stems and one of the 18 cementless stems (5.6%) had
Table 2
evidence of stem loosening.
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Complications
One patient experienced dislocation of the hip in the recovery
room and a closed reduction was done. The patient also had an infection
of the hip develop that required irrigation and debridement, although
the prosthesis was salvaged. The patient died 2 years later. Another
patient has had two dislocations of the hip since surgery. A closed
reduction was done and the patient was placed in an abduction brace.
This patient had an additional revision at 1 year after surgery. A deep
hip infection developed in another patient that required irrigation and
debridement and the prosthesis also was salvaged. The patient was
doing well at the 4-year followup (Harris hip score of 86 points). The
two patients who had resection arthroplasties are doing well clinically at
7 and 12 years followup (Harris hip scores greater than 80 points). One
patient died 1 month after the original revision surgery from a
pulmonary embolism.
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DISCUSSION
The best method for fixation for revision hip arthroplasty for
patients with rheumatoid arthritis remains to be determined. A previous
report by Raut et al,32 revealed excellent or satisfactory clinical results
for 79 of 87 hips (91%) using cemented fixation, but radiographically
there was a high failure rate on the acetabular side (37%, 15 of 41) at a
similar followup (mean, 7 years, 4 months) to the current study. The
current study had similar acetabular failure rates (37%, 11 of 30 cups),
using cementless fixation of the acetabular component at a followup
mean of 7 years (range, 4–15 years).
Although there were only 28 patients (30 hips) in the current
study, this represents the largest group of cementless acetabular
revisions in patients with rheumatoid arthritis. These numbers do not
make the conclusions drawn in this study less valid. There are problems
with acetabular fixation for these patients, whether cementless (current
study) or cemented fixation 32 is used. The poor results found in both
studies may be attributed in part to rheumatoid disease. Although some
of the cases were variable for differing degrees of bone loss, use of bone
graft, and activity of rheumatoid disease in all of these variable
subgroups, the results were worse than for other diagnoses. Young
patient age may have played a role (mean age, 50 years in the current
study). However, in studies3,26,29 of patients with other diagnoses in
this same age group, the results are consistently superior.
The current study also highlights the relatively high morbidity in
doing revision hip arthroplasty on patients with rheumatoid arthritis.
Not only was the overall 7-year clinical and radiologic followup success
rate low (45%), but there were multiple perioperative and postoperative
complications. Early major complications included one death
attributable to a pulmonary embolus, three dislocations (10%), and two
postoperative infections.
Radiographic results of femoral stem fixation were satisfactory;
none of the six cemented stems and 5.6% (one of 18) of the cementless
stems had evidence of stem loosening. These results also are similar to
those of Raut et al 32 who had an incidence of 5.1% cemented stem
loosening.
Although, in general, the success rate of revision hip arthroplasty
for patients with all diagnoses does not approach the success rate of
primary total hip arthroplasty, there are multiple reports of high success
rates at mean 5-to 10-year followups in patients who had revision hip
arthroplasty. Leopold et al 25 reported on 138 consecutive cementless
acetabular revisions in 131 patients with primary osteoarthritis. The
Kaplan-Meier survivorship of these components was 84% at 11.5 years. In
another study 3 from the same institution, of 74 consecutive primary hip
replacements in patients younger than 50 years, there was a KaplanMeier 10-year survival of the acetabular prostheses of 98.8%. Other
reports using the Porous Coated Anatomic cup have shown high failure
rates in patients with primary osteoarthritis. 18,39 Hastings et
al 18 found a 13% acetabular failure rate at a mean followup of 10.3
years in a study of 100 hips (89 patients).
Although not entirely analogous to the revision situation, the
various studies of primary total hip arthroplasty for patients with
rheumatoid arthritis also have found high failure rates on the acetabular
side. Poss et al 28 reported excellent function at the 7-year followup
(96%, 133 of 138 cups), but concluded that with longer followup,
mechanical loosening of the acetabular component might be a
significant problem. Unger et al, 40 at a followup of 12.1 years of 83
hips, found that seven cups needed revision and 11 others had radiologic
loosening resulting in a combined failure rate of 30%. Lachiewicz et
al 24 found similar rates of failure of acetabular components in patients
with juvenile rheumatoid arthritis (26% in 83 hips at followup at a mean
of 6 years). Results may be improved with the use of cementless
sockets. Cracchiolo et al 7 did 40 uncemented total hip arthroplasties in
patients with rheumatoid arthritis and had no clinical and radiographic
failures at a mean followup of 3.7 years (range, 2–6 years).
In the current study, despite the fact that a stable interface was
achieved at surgery in all patients with cementless acetabular
components with greater than 50% of host bone contact and the use of
morselized bone grafting, there still was a 53% acetabular failure rate.
This is in contradistinction to the use of morselized bone grafting for
acetabular protrusion in primary hip arthroplasties as reported by
Rosenberg et al. 33 They had a 90% survival rate at 12 years in 20 hips.
Other options that could have been used would have included the use of
various cementing techniques, with or without structural allografts or
protrusion rings.12,34,35 These studies have shown variable failures
rates of these other techniques, so it is not known whether they would
have improved the results found in the current study. Another technique
that might be more successful would be the use of impacted allograft
bone in conjunction with cups that are inserted with cement. Sloof et
al 38 reported excellent clinical and radiographic results for 78 of 88
(89%) hips that had revision surgery at a mean followup of 70 months in
patients with osteoarthritis. Additional studies are necessary to
determine the best techniques and fixation methods for the acetabulum
for patients with rheumatoid arthritis having revision hip arthroplasty.
Some of the poor results in the current study must be attributed
to the Porous Coated Anatomic prosthesis which has had problems with
premature acetabular polyethylene wear. However, the results in this
study still are inferior to those achieved with this prosthesis for patients
with other diagnoses from the authors’ institution. From the database of
406 revision surgeries using Porous Coated Anatomic cups in patients
with hip osteoarthritis, the acetabular revision rate was 8% at a similar
followup (7-year mean), which is superior to the acetabular revision rate
of 37% for patients with rheumatoid arthritis in the current study.
Poor bone quality and deficient acetabular structures combined
with the Porous Coated Anatomic cup were critical risk factors for
acetabular socket survival after revision surgery in patients with
rheumatoid arthritis. These findings highlight the need for early revision
in patients with rheumatoid arthritis who may have impending
radiographic failure or osteolysis so that as much acetabular bone stock
can be preserved as possible. Therefore, regular radiographic followups
of patients with rheumatoid arthritis are important to allow for early
diagnosis and treatment. Acetabular revision in patients with
rheumatoid arthritis is a difficult procedure with high morbidity rates.
The development of treatment protocols in this patient group are
evolving with cross-linked polyethylene, or various ceramic and metal
interfaces or both, leading to more successful outcomes in the future.
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