Eur J Orthop Surg Traumatol (2007) 17:263–266 DOI 10.1007/s00590-006-0170-4
O RI G I NAL ART I C LE
Are cementless acetabular components contra-indicated in the elderly? A. Wahab · J. F. Quinlan · S. Sherif · I. P. Kelly
Received: 20 May 2006 / Accepted: 25 July 2006 / Published online: 8 September 2006 © Springer-Verlag 2006
Abstract The long-term success of primary total hip arthroplasty in elderly patients has been well documented. In addition, the use of uncemented acetabular components in younger patients has been well established. However, as yet, there has not been widespread use of uncemented acetabular components in older patients. This study reviews a single surgeon series of 179 consecutive primary total hip replacements using an uncemented acetabular component. Patients were followed up clinically, radiologically and by means of a postal questionnaire. Patients were divided into under70 years (n = 80) and 70 years and older (n = 99). There were 88 males and 91 females who were followed up to a mean of 24.1 months. There were no signiWcant diVerences between the groups with respect to the need for additional screw Wxation, post-operative complications or implant loosening. Functionally, no diVerences were recorded in terms of pain, limp, mobility or ability to put on shoes and socks post-operatively. There was no signiWcant diVerence between the two groups in the levels of satisfaction reported. These results justify the use of uncemented acetabular components in older patients.
A. Wahab · J. F. Quinlan · S. Sherif · I. P. Kelly Department of Orthopaedic Surgery, Lourdes Regional Orthopaedic Hospital, Kilcreene, Kilkenny, Co. Kilkenny, Republic of Ireland J. F. Quinlan (&) 35 Rockford Manor, Stradbrook, Blackrock, Co. Dublin, Republic of Ireland e-mail:
[email protected]
Keywords Total hip arthroplasty · Cementless components · Functional outcomes
Les cupules acétabulaires non cimentées sont-elles contre-indiquées chez les patients âgés? Résumé Les succès à long terme de l’arthroplastie totale de hanche de première intention chez les personnes âgées a été bien analysée et documentée. De plus l’utilisation de cupules acétabulaires non cimentées chez des sujets plus jeunes est bien établie. Cependant à ce jour l’utilisation large de cupules non cimentées chez les patients âgés n’a pas été prônée. Cette étude porte sur 179 poses consécutives de prothèses de hanche par le même chirurgien avec utilisation d’une cupule acétabulaire non cimentée. Les patients ont été suivis cliniquement, radiologiquement et grâce à un questionnaire envoyé par la poste. Les patients ont été regroupés en deux groupes, âge inférieur à 70 ans (n = 80) et âge de 70 ans et au-delà (n = 99). Il y avait 88 hommes et 91 femmes qui ont été suivis en moyenne 24.1 mois. Il n’ a pas été noté de diVérence signiWcative entre les deux groupes concernant la nécessité de vis additionnelles, les complications post-opératoires ou le descellement des implants. Au point de vue fonctionnel aucune diVérence n’a pas non plus été notée concernant les douleurs, la boiterie, la mobilité, la possibilité de se chausser et de mettre ses bas ou chaussettes. EnWn aucune diVérence n’est apparue entre les deux groupes quant au degré de satisfaction. Ces résultats justiWent l’utilisation de cupules acétabulaires non cimentées chez les personnes âgées. Mots clés Arthroplastie totale de hanche · Composants non cimentés · Résultats fonctionnels
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Eur J Orthop Surg Traumatol (2007) 17:263–266
Introduction The use of cementless acetabular components in total hip arthroplasty (THA) has gained increasing popularity because of the increased incidence of loosening seen with the use of cemented components [2]. The Wrst generation of cementless cups was associated with complications pertaining to design, implantation and the manufacturing process [7]. In addition, early use of these components was associated with high rates of osteolysis [19]. However, second generation cementless acetabular components have seen the use of limited or no holes, improved locking mechanisms, polished inner surfaces and increased conformity with liners. These cementless components have a low incidence of revision for loosening and osteolysis [7]. While the cementless option in THA is a well accepted practice for younger patients [9, 21], their use is still a matter of debate in elderly patients [14] in whom the use of cemented components is well proven [3, 4, 10, 15, 18]. However, a variety of misgivings have led to the belief that uncemented acetabular components should be reserved for use in younger patients [8, 12, 23]. There are, however, theoretical advantages associated with the use of cementless components in the elderly such as the ease of the technique and partial prevention of fat emboli [5, 17] and shorter surgical time because of not having to wait for the cement to harden [14]. This study set out to review a single surgeon series of 179 consecutive cementless acetabular cup implantations between November 2000 and April 2004 inclusive and to compare results in patients younger than and older than 70 years of age.
Patients and methods A posterior approach, under spinal anaesthesia was used in all cases. In all cases, a Duraloc (DePuy, Leeds, UK) porous coated non-cemented cup was inserted with a 10-deg ultra high molecular weight polyethylene lipped liner. Twelve patients required the use of the Duraloc Option cup with screw Wxation. All patients had an Elite Plus (DePuy, Leeds, UK) stem cemented in situ with an Elite modular cobalt chrome head (Fig. 1). Plain Wlm radiographs were taken of each patient post-operatively and at 1 week (prior to discharge) and at follow up at 6 weeks, 6 months and 1 year after surgery. Changes around the acetabular cup were determined according to the criteria of Massin [16]
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Fig. 1 Duraloc-Elite total hip arthroplasty
and migration was noted for changes in position of 3 mm or 3°. In addition, all patients were sent a custom made questionnaire (Fig. 2). One hundred and seventy two patients (96.1%) returned these questionnaires. All statistical analysis was performed using univariate ANOVA testing for parametric data and Fisher’s
1.
Are you satisfied with the results of your surgery
2.
In what way has this operation helped you: Pain Limp
Yes/No
Better/Worse/No change No limp/Better/Worse/No change
Mobility
Improved/No change
Shoes and socks
Easier/No change
3.
Did you suffer dislocation of your hip
Yes/No
4.
Did you suffer a peri-prosthetic fracture
Yes/No
5.
Did you suffer any hip or thigh pain
Yes/No
6.
Did you suffer a clot (calf/lung)
Yes/No
7.
Did you suffer from any wound problem
Yes/No
Fig. 2 Clinical questionnaire sent to all patients
Eur J Orthop Surg Traumatol (2007) 17:263–266
exact test for non-parametric data from the Microsoft Excel programme (Microsoft Corporation, Seattle WA, USA). Statistical signiWcance was taken for all values of P · 0.05.
Results There were 179 consecutive patients in this study. The mean age of the cohort was 70 § 9 years (mean § standard deviation) with a range of 44–91 years. There were 88 male and 91 female patients. The patients were divided into two groups—the Wrst group consisted of those aged younger than 70 years and the second contained the patients aged 70 years and older. In the under-70 years group, there were 80 patients with a mean age of 61 § 6 years (range 44–69 years). There were 38 males and 42 females in this group. In the 70 years and older group, there were 99 patients. This group had a mean age of 76 § 5 years (range 70– 91 years) with 50 male and 49 female patients. The diVerence in mean ages (15 years) between the two groups was found to be statistically signiWcant (P < 0.001, ANOVA). The mean follow-up period for the study was 24.1 § 10.7 months (range 3–42 months). Eight patients had died at time of follow up leaving us with a total study group of 171 patients. None of these patients died from causes directly related to their THA. There was one patient in the under-70 group and the other seven were aged 70 years and over. There was no signiWcant diVerence between the two groups. There were no thrombo-embolic complications, peri-prosthetic fractures or neuro-vascular injuries. No patient required revision for loosening. There were two revisions—one was for recurrent dislocation and one was for deep infection. There was one patient in each group, and therefore, there was no signiWcant diVerence recorded. Radiologically, there was no evidence of any loosening seen on any plain Wlm radiograph at any of the follow-up points in this study. Screws were required for additional Wxation of the cementless cup in 12 cases. Four of these were in the under-70 group and eight in the 70 years and older. Nine patients complained of post-operative thigh pain of which four were in the under-70 year group and Wve in the older group. Neither of these comparisons represented any signiWcant diVerence. There were two patients who complained of a noticeable limb length discrepancy, one in each grouping (no signiWcant diVerence). In terms of limb length discrepancy greater than 1 cm not noticed by the patient but observed on clinical follow up, there were
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19 patients identiWed. These were divided into 11 in the under-70 year group and eight in the older group. There was no signiWcant diVerence between these two groups. There was only one case of infection and that occurred in a patient in the under 70-years group. Only three dislocations were recorded, two in the under70 years group and one in the older group. This diVerence again did not display any statistical signiWcance. With respect to function, the patients in this study were asked about four parameters—pain, limp, mobility and ability to put on shoes and socks. Only one patient recorded no diVerence in pain in the younger group and none in the 70 years and older group. Similarly, only one patient reported no change in their limp post-operatively, this time in the older group. Two patients said that they had noticed no change in their mobility and these were aged 67 and 63 years. Finally, only one patient claimed to have noticed no diVerence in their ability to put on their shoes and socks. This patient was in the 70 years and older group. In all cases, no signiWcant diVerences were observed between the two groups. In relation to patient satisfaction, all but four patients declared that they were satisWed with the overall outcome of their primary hip arthroplasty procedure. In three cases, patients recorded that they did not know if they were satisWed—two patients in the under70 years group and one patient in the older group. In addition, a further patient aged 57 years stated that he was dissatisWed with his outcome. However, no signiWcant diVerences were recorded between the two groups in relation to patient satisfaction.
Discussion The long-term success of primary THA in elderly patients has been well documented [4, 10, 18]. In addition, the use of uncemented acetabular components in younger patients has been well established [9, 21]. However, as yet, there has not been widespread use of uncemented acetabular components in older patients for a variety of reasons including concerns about the manufacturing of the cups [7], revision rates and diYculty [19] and cost [12]. This study set out to examine if there were any signiWcant diVerences in the use of cementless acetabular cups between patients aged under 70 years and patients aged 70-years and older in a single surgeon series of 179 consecutive primary total hip arthroplasties. We have shown that there were no diVerences between the two groups in relation to the standard
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complications relating to total hip replacements namely, dislocation, peri-prosthetic fractures, hip/thigh pain and thromboembolic events. In addition, there were no observed diVerences between the two groups in relation to post-operative limb length discrepancy, both patients observed and surgeon observed. The functional outcome seen in the two groups in respect of pain, limp, mobility and ease of putting on shoes and socks also showed no signiWcant diVerences between the two groups. From an overall patient satisfaction viewpoint, again there were no signiWcant diVerences between the groups at a follow up approaching 2 years. While the results of this study support the use of cementless acetabular components in older patients, the increased cost of these components [13] has to be borne in mind in addition to speciWc complications in relation to their insertion such as acetabular fractures [20]. However, the relative advantages of cementless components include faster operative time [14], the option of additional screw Wxation [1, 6], decreased rates of embolic phenomena [11] and the use of the press-Wt technique for stability [22]. In conclusion, the authors feel that this study justiWes the use of cementless acetabular components in elderly patients.
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