Case Reports

Asymptomatic but Time for a Hip Revision

Fed Pract. 2016 February;33(2):39-43

References

1. Knight SR, Aujla R, Biswas SP. Total hip arthroplasty--over 100 years of operative history. Orthop Rev (Pavia). 2011;3(2):e16.

2. Centers for Disease Control and Prevention. FastStats: inpatient surgery. Centers for Disease Control and Prevention Website. http://www.cdc.gov/nchs/fastats/inpatient-surgery.htm. Updated April 29, 2015. Accessed January 18, 2016.

3. Joint Revision Surgery-When do I need it? American Academy of Orthopedic Surgeons Website. http://www.tlhoc.com/uploads/documents/when_do_I_need_it.pdf. Accessed January 18, 2016.

4. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785.

5. Nunley RM, Della Valle CJ, Barrack RL. Is patient selection important for hip resurfacing? Clin Orthop Relat Res. 2009;467(1):56-65.

6. Dattani R. Femoral osteolysis following total hip replacement. Postgrad Med J. 2007;83(979):312-316.

7. Engesæter IØ, Lehmann T, Laborie LB, Lie SA, Rosendahl K, Engesæter LB. Total hip replacement in young adults with hip dysplasia: age at diagnosis, previous treatment, quality of life, and validation of diagnoses reported to the Norwegian Arthroplasty Register between 1987 and 2007. Acta Orthop. 2011;82(2):149-154.

8. Salter RB. Etiology, pathogenesis and possible prevention of congenital dislocation of the hip. Can Med Assoc J. 1968;98(20):933-945.

9. Storer SK, Skaggs DL. Developmental dysplasia of the hip. Am Fam Physician. 2006;74(8):1310-1316.

10. Pace TB, Keith KC, Alvarez E, Snider RG, Tanner, SL, Desjardins JD. Comparison of conventional polyethylene wear and signs of cup failure in two similar total hip designs. Adv Orthop. 2013;2013:710621.

11. Kurtz SM. The UHMWPE Handbook: Ultra-High Molecular Weight Polyethylene in Total Joint Replacement. Academic Press: London; 2014.

12. Babovic N, Trousdale RT. Total hip athroplasty using highly cross-linked polyethylene in patients younger than 50 years with minimum 10-year follow-up. J Arthroplasty. 2013;29(5):815-817.

13. Dorr LD, Wan Z, Shahrdar C, Sirianni L, Boutary M, Yun A. Clinical performance of a Durasal highly cross-linked polyethylene acetabular liner for total hip arthroplasty at five years. J Bone Joint Surg Am. 2005;87(8):1816-1821.

14. Thomas G, Simpson D, Mehmmod S, et al. The seven-year wear of highly cross-linked polyethylene in total hip arthroplasty: a double-blind, randomized controlled trial using radiostereometric analysis. J Bone Joint Surg Am. 2011;93(8):716-722.

15. Callary SA, Field JR, Campbell DG. Low wear of a second-generation highly crosslinked polyethylene liner: a 5-year radiostereometric analysis study. Clin Orthop Relat Res. 2013;471(11):3596-3600.

16. Tateiwa T, Clarke IC, Williams PA, et al. Ceramic total hip arthroplasty in the United States: safety and risk issues revisited. Am J Orthop (Belle Mead NJ). 2008;37(2):E26-E31.

17. Traina F, De Fine M, Di Martino A, Faldini C. Fracture of ceramic bearing surfaces following total hip replacement: a systematic review. BioMed Res Int. 2013;2013:157247.

18. Haidukewych GJ, Petrie J. Bearing surface considerations for total hip arthroplasty in young patients. Orthop Clin N Am. 2012;43(3):395-402.

19. Cohen D. How safe are metal-on-metal hip implants? BMJ. 2012;344:e1410.

20. Campbell P, Ebramzadeh E, Nelson S, Takamura K, De Smet K, Amstutz HC. Histological features of pseudotumor-like tissues from metal-on-metal hips. Clin Orthop Relat Res. 2010;468(9):2321-2327.

21. Pritchett JW. Adverse reaction to metal debris: metallosis of the resurfaced hip. Curr Orthop Pract. 2012;23(1):50-58.

22. Smith AJ, Dieppe P, Porter M, Blom AW; National Joint Registry of England and Wales. Risk of cancer in first seven years after metal-on-metal hip replacement compared with other bearings and general population: linkage study between the National Joint registry of England and Wales and hospital episode statistics. BMJ. 2012;344:e2383.

23. Kretzer JP, Jakubowitz E, Krachler M, Thomsen M, Heisel C. Metal release and corrosion effects of modular neck total hip arthroplasty. Int Orthop. 2009;33(6):1531-1536.

24. Cash, D, Khanduja V. The case for ceramics-on-polyethylene as the preferred bearing for a young adult hip replacement. Hip Int. 2014;24(5):421-427.

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26. Lombardi AV, Berend KR. Isolated acetabular liner exchange. J Am Acad Orthop Surg. 2008;16(5):243-248.

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The orthopedic surgeon Sir John Charnley, who worked at the Manchester Royal Infirmary, is considered the father of the modern THA.¹ His low friction arthroplasty, designed in the early 1960s is identical, in principle, to the M-on-PE prosthesis used today.¹ The PE liner used was ultrahigh molecular weight polyethylene (UHMWPE).¹

Due to the early success of the Charnley prosthesis, the M-on-PE prosthesis became the most widely used. Although PE is the most studied and understood of all acetabular liner materials, it will eventually wear and shed debris. Acetabular cup wear is the most frequent reason for mid-to-long-term revisions, especially in young and active patients.¹⁰ More active patients shed more debris.³ The PE debris instigates the release of inflammatory mediators, which results in chronic inflammation and tissue damage that erodes the supporting bone and can lead to implant loosening or fracture.⁶Ongoing studies seek to optimize and improve properties of the UHMWPE and to develop alternative bearings. After FDA approval in 1999, highly cross-linked polyethylene liners (HXLPE) rapidly became the standard of care for THAs, at least in the U.S.¹¹ Highly cross-linked polyethylene liners are created from UHMWPE through a process of cross-linking by exposure to gamma radiation, and subsequent heat treatment to neutralize free radicals and limit oxidative degradation.¹²

In one study, the 5-year annual linear wear rate for a HXLPE liner was only 45% of that seen with the UHMWPE liner, although the qualitative wear pattern was the same.¹³In a study that followed patients for 7 years postoperatively, the mean steady-state wear rate of the HXLPE was 0.005 mm/y compared with 0.037 mm/y for UHMWPE.¹⁴ In a long-term study (a minimum follow-up of 10 years) of 50 patients who were aged < 50 years and underwent THA using HXLPE liners, there was no radiographic evidence of osteolysis or component loosening, and liner wear was 0.020 ± 0.0047 mm/y.¹²In 2005, second-generation HXLPE liners were introduced clinically and have been shown to further reduce wear in vitro compared with both UHMWPE and first-generation HXLPE liners. Callary and colleagues calculated that the wear rates between 1 year and 5 years were all < 0.001 mm/y.¹⁵

The use of ceramic for THAs began in 1970, and ceramic heads on polyethylene (C-on-PE) liners and ceramic-on-ceramic (C-on-C) bearings have been in continual use for > 30 years in Europe. Premarket FDA approval based on European data was granted in 1983; however, the manufacturer voluntarily removed it from the market because of a high incidence of stem loosening (> 30% within 3 years in some series).¹⁶FDA approvals came much later for C-on-PE (1989) and C-on-C (2003) bearings.

Ceramic is the hardest implant material used, and it can be concluded from many clinical and laboratory reports that C-on-PE and C-on-C combinations confer a potentially significant reduction in wear on THA bearings.¹⁶ Ceramic hips initially had 2 concerns: catastrophic shattering and squeaking. Current ceramic hips have been substantially improved, and some experts feel shattering has been essentially eliminated.¹⁶ Other experts note that ceramic brittleness remains a major concern.¹⁷ Squeaking remains a problem for some, but it usually abates over time. No study has correlated squeaking with impending failure or increased pain or disability.

While C-on-C bearings are now felt to be a good implant for young active patients, these bearings have generally not resulted in significantly lower wear rates and fewer revisions.¹⁸ High rates of wear and osteolysis have been sporadically documented over the 35-year history of ceramic implants.¹⁶ The FDA approved the first ceramic-on-metal total hip replacement system on June 13, 2011.

Metal-on-metal (M-on-M) implants have been used by some for decades, although they were not approved by the FDA until the late 1990s. However, some device recalls have brought negative attention to M-on-M implants.¹⁹ It was felt that they would generate less wear debris than PE, but reports of pseudotumors (from inflammatory mediators) and metallosis have significantly tempered enthusiasm for these products.^20,21 The wear rates are very low, estimated to be only 0.01 mm/y, but concerns about the carcinogenetic potential of systemically increased metal ions remains a possible and much debated concern.^19,22,23In January 2013, FDA issued a safety communication on M-on-M implants.

Many experts feel that modern ceramic or metal on second-generation HXLPE represents the gold standard and the most predictable bearing choice for young, active patients.¹⁸ Others feel that the optimal choice of bearing surfaces in THA, particularly in the younger and more active patient, remains controversial.²⁴

Follow-Up

Intermittent orthopedic monitoring is recommended for all patients who have undergone a THA. The frequency of hip X-rays on follow-up appointments is left to the orthopedic surgeon. After the initial recovery, serial images every 2 to 5 years can identify progressive failure, and annual X-rays may be used for closer follow-up in high-risk patients.