Aims

The aim of this study was to examine whether socioeconomic status (SES) is associated with a higher risk of infections following total hip arthroplasty (THA) at 30 and 90 days.

Young patients are at increased risk of revision after primary THA (THA). The bearing surface may be of importance for the longevity of the joint.

We aimed to compare the risk of revision of primary stemmed cementless THA with MoM and CoC with metal-on-highly-crosslinked-polyethylene (MoXLP) bearings in patients between 20–54 years.

From NARA, we included 2,153 MoM, 4,120 CoC and 10,329 MoXLP THA operated between 1995 and 2017. Kaplan-Meier estimator was used for calculation of THA survivorship and Cox regression to estimate the hazard ratio (HR) of revision (95% CI) due to any and specific causes. MoXLP was reference.

The median follow-up was 10.3 years for MoM, 6.6 years for CoC and 4.8 years for MoXLP. 15 years postoperatively the Kaplan-Meier survival estimates were 80% (78–83%) for MoM, 92% (91–93%) for CoC and 94% (93–95%) for MoXLP. The 0–2, 2–7 and 7–15 years adjusted HRs of revision by any cause were 1.4 (0.9–2.4), 3.2 (2.1–5.1) and 3.9 (1.9–7.9) for MoM and 1.1 (0.8–1.4), 1.0 (0.7–1.3) and 2.5 (1.3–4.8) for CoC bearings. After 7–15 years follow-up, the unadjusted HR of revision due to aseptic loosening was 5.4 (1.2–24) for MoM and 4.2 (0.9–20) for CoC THA. MoM and CoC had a 7–15 year adjusted HR of revision due to ‘other’ causes of 4.8 (1.6–14) and 2.1 (0.8–5.8).

MoXLP bearings were associated with better survival than MoM and CoC bearings, mainly because of lower risk of revision due to aseptic loosening and ‘other’ causes.

Aim

To study whether revision for prosthetic joint infection (PJI) after early PJI in primary Total Hip Arthroplasty (THA) is associated with a high mortality, when compared with:

Patients, who did not undergo revision for any reason and Patients who underwent an aseptic revision.

Introduction: There are ongoing concerns regarding metal wear debris following the use of metal-on-metal (MonM) bearings for hip surface and total arthroplasty. A Type IV Hypersensitivity reaction to MonM articulations has previously been identified (aseptic lymphocyte dominated vasculitis associated lesion, ALVAL) but little is known of its incidence, diagnosis or management. Persisting groin pain in MonM patients may be undiagnosed ALVAL. At our single centre we have reviewed and compared three types of MonM articulations to examine the incidence of ALVAL and to identify trends.

Methods: The resurfacing group comprised 250 patients with the ASR prosthesis. In the resurfacing hybrid total hip replacement (THR) group there were 86 patients implanted with an ASR head on a stem. The final group comprised of 625 patients with a MonM THR using a 36mm Pinnacle head. Both the S-ROM and the Corail stems were used in the THR groups. Patients with persisting and activity-restricting groin pain had tests for infection. Patients were counselled and revision was offered if ALVAL was suspected from the clinical picture, blood results and the aspiration result. Specimens for microbiological and histological analysis were taken at the time of revision.

Results: We found 5 cases of histologically proven ALVAL in the absence of infection in 961 patients. The incidence was: 1.2% in the resurfacing group, 2.3% of Resurfacing Hybrid THR group and 0 in the 36 mm THR group. All 5 cases were in female patients. Only 1 case had any radiological abnormality. One patient was initially revised from a resurfacing to a 36mm MonM THR without clinical success. All patients have now been revised to ceramic-on-ceramic bearings with improvements in outcome.

Discussion: ALVAL may be under-diagnosed. The 5 patients we describe showed good clinical recovery following their primary procedure. However, activity levels decreased and pain increased at 6–12 months post-op. All described non-specific systemic symptoms. On examination, a painful straight leg raise was a characteristic finding. This may result from the significant effusion found around the hip at each revision. Fluid aspirated from these hips was of a characteristic colour (green grey) and viscosity. The failure of the revision of a resurfacing to a smaller MonM bearing highlights the problem of sensitisation to the metal debris. Any subsequent revision to a MonM bearing is unlikely to improve clinical outcome. This finding is consistent with previous reports in the literature. Our results suggest the incidence of ALVAL may be higher that previously thought. We suggest all patients with significant groin pain should have inflammatory markers tests and a hip aspiration performed. In the absence of infection, revision to an alternative bearing surface may be indicated.