BOA Guidelines recommend clinical and radiological follow-up after primary total hip arthroplasty (THA) at 1 and 5 years, and every 5 years thereafter to detect asymptomatic failure and allow early intervention. As revision surgery in asymptomatic patients is rare the need for routine follow-up in well-functioning individuals has recently been questioned. To evaluate the role of routine follow-up out-patient appointments (OPA) in identifying failing implants the modes of presentation for patients undergoing revision THA were reviewed. 176 patients who received 183 revision THAs (2003–2010) were identified from an arthroplasty database. 124 patients who received 131 first time revision THAs after primary cemented total hip arthroplasty met inclusion criteria. Retrospective notes review was performed to investigate symptoms at failure and mode of presentation.Background
Methods
British Orthopaedic Association (BOA) Guidelines recommend clinical and radiological follow-up after Total Hip Arthroplasty (THA) at 1 year, 5 years and every 5 years thereafter to detect asymptomatic failure. To evaluate the importance of routine follow-up appointments (OPAs) in detecting failing implants the presentation of patients undergoing revision THA was reviewed. 176 patients who received 183 first-time revision THAs over a seven-year period (2003-2010) were identified from an arthroplasty database. A preliminary study sampled 46 THAs in 45 patients. Retrospective chart review recorded symptoms and mode of presentation. Follow-up OPA costs were calculated to estimate savings. All patients had symptoms at the time of revision (pain 96%, decreased mobility 76%, limp 35%, stiffness 26%, night pain 24%). Route of presentation was 80% new referrals (GP 63%, in-patient 9%, A&E 4%, Rheumatology 4%) vs 20% routine orthopaedic follow-up. The minimum cost for a routine follow-up OPA was £35. Assuming discharge after the earliest review when the patient has returned to full normal activities the estimated saving for the 2009 cohort of 377 primary THAs performed in our hospital is £13195 at 1 year and £52780 over the lifespan of the implants (assuming average 15 year survival). Following uncomplicated primary cemented THA in our hospital asymptomatic implant failure is unlikely. Symptomatic patients tend to present mainly to their GP and other specialities, rather than orthopaedic follow-up OPAs. Early discharge after return to full normal activities would be safe and lead to significant financial savings.
Total hip replacement using components from different manufactures is common and has been known as cross-breed arthroplasty. The implant industry clearly advises against it for primary arthroplasty, even though this has been the accepted practice in revision hip surgery. The response of the Medicine and Healthcare products Regulatory Agency is to agree with the manufacturers. Thus this advice has been implemented in National Institute of Clinical Excellence guidelines without any supportive clinical data. A consecutive series of 206 crossbreed total hip arthroplasties were performed in 192 patients by a single surgeon between 1990 and 1993. These were observed for an average 11.5 years (range, 10–13years). There were 126 women and 80 men with an average age of 69 (range, 41–89) at the time of surgery. There were 9 failures defined as reoperation. Of these, 5 were for aseptic loosening of cup, 2 for deep infection, 1 for recurrent dislocation and 1 for revision of stem for Periprosthetic fracture following a fall. There was no aseptic loosening of stem. With survivorship to date of 94% these data suggest that it is safe to continue using at least one of the common combinations in primary hip arthroplasty.
