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Total Hip Arthroplasty with Cement in Patients Who Have Rheumatoid Arthritis. A Minimum Ten-Year Follow-up Study*

MARK G. CREIGHTON, M.D., JOHN J. CALLAGHAN, M.D., JASON P. OLEJNICZAK, B.A., IOWA CITY and RICHARD C. JOHNSTON, M.D., DES MOINES, IOWA

Investigation performed at Iowa Methodist Hospital, Des Moines, and the Department of Orthopaedics, University of Iowa College of Medicine, Iowa City

	Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
One hundred and six consecutive total hip arthroplasties with cement were performed by one surgeon, at least ten years before the time of the present clinical and radiographic review, in seventy-five patients who had adult-onset rheumatoid arthritis. Two patients (three hips) were lost to follow-up. Seven (7 per cent) of the remaining 103 hips were revised. The revisions were performed because of infection (three hips), dislocation (two hips), or aseptic loosening (two hips). Of the ninety-eight hips that were not lost to follow-up or revised because of infection or dislocation, eight (8 per cent) had radiographic loosening of the acetabular component and two (2 per cent) had radiographic loosening of the femoral component. Although the prevalence of radiographic loosening of the acetabular component was four times greater than the prevalence of radiographic loosening of the femoral component, the prevalence of revision because of aseptic loosening of the acetabular component was identical to that for the femoral component (one component each). These results compared favorably with those of total hip arthroplasty with cement, performed by the same surgeon, for the treatment of other diagnoses. Loosening of the acetabular component was significantly associated with a younger age at the time of the index operation (p = 0.03) and with acetabular osteolysis (p = 0.0006). Of forty-eight hips in thirty-two patients who survived for at least ten years, 96 per cent (forty-six hips) were considered by the patients to have a satisfactory result. At the time of the latest follow-up, twenty-four (75 per cent) of the patients had no pain in the hip. Although eighteen patients (56 per cent) could walk without support at a minimum of ten years after the operation, we found that the functional results for patients who had rheumatoid arthritis were inferior to those observed for patients who had had a total hip arthroplasty with cement, performed by the same surgeon, for the treatment of other diagnoses.

	Introduction

Top Abstract Introduction Materials and Methods Results Discussion References

 
Although several studies have documented satisfactory long-term outcomes after total hip arthroplasty with cement, few have specifically examined the long-term results of such procedures in patients who had rheumatoid arthritis^17,26. The purposes of the present study were to determine the outcomes at a minimum of ten years after total hip arthroplasty with cement in patients who had adult-onset rheumatoid arthritis and to compare the results with those of the same types of procedures, performed by the same surgeon, in patients who had other underlying diagnoses.

	Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion References

 
Between July 1, 1970, and December 31, 1984, 106 consecutive total hip arthroplasties with cement were performed by the senior one of us (R. C. J.) in seventy-five patients who had adult-onset rheumatoid arthritis. There were fifteen men (twenty-one hips) and sixty women (eighty-five hips). The mean age of the patients at the time of the index arthroplasty was sixty-two years (range, thirty-three to eighty-four years). The mean weight of the patients was sixty-five kilograms (range, thirty-three to 106 kilograms). All patients had severe pain in the hip and met the criteria of the American Rheumatism Association for a diagnosis of adult-onset rheumatoid arthritis¹. The patients were grouped according to the functional classification of the American Rheumatism Association¹. Class I indicates complete functional capacity; class II, adequate functional capacity for normal activities despite the impairment; class III, limited functional capacity for self-care; and class IV, functional incapacity. No patient had class-I functional capacity; thirty-three patients (44 per cent) had class-II capacity; thirty-eight patients (51 per cent), class-III; and four patients (5 per cent), class-IV. Sixty (80 per cent) of the seventy-five patients had received corticosteroids systemically at some time before the arthroplasty, and fifty-one (48 per cent) of the 106 hips demonstrated protrusio acetabuli²⁰. Fifty-five total hip arthroplasties were performed on the left hip, and fifty-one were done on the right hip. Six hips (six patients) had been treated with an operative procedure before the index arthroplasty; five had had a previous cup arthroplasty, and one had had open reduction and internal fixation of a fracture.

All operations were performed through a lateral approach, with osteotomy of the greater trochanter. A complete capsulectomy was done in all hips. The acetabular component was placed as far inferiorly and medially as possible. Protrusio acetabuli defects were filled with polymethylmethacrylate to restore the normal hip center. Bone graft was not used in the acetabulum.

Before 1980, a Charnley flat-back hip prosthesis (Charles F. Thackray, Leeds, Great Britain, or Zimmer, Warsaw, Indiana), consisting of a stainless-steel polished stem with a 22.25-millimeter-diameter head and an all-polyethylene acetabular component with an outer diameter of forty or forty-four millimeters, was implanted in seventy-six hips. From 1980 to 1984, an Iowa femoral component (Zimmer), a cobra-shaped cobalt-chromium stem with a twenty-eight-millimeter-diameter head, was used in thirty hips. Of those thirty total hip replacements, eighteen had an ultra-high molecular weight all-polyethylene acetabular component (Zimmer) and twelve had a Tibac metal-backed acetabular component (Zimmer). All components were inserted with Simplex-P cement (Northhill Plastics, Great Britain, or Howmedica, Rutherford, New Jersey). A so-called first-generation cementing technique (hand-packing of cement during the doughy phase) was used in the forty-eight hips that were treated before 1976. A so-called second-generation cementing technique (use of a medullary plug, medullary lavage, and a cement gun to fill the canal with cement in a retrograde fashion) was employed in the fifty-eight hips that were treated since 1976. Perioperative systemic administration of antibiotics was not routinely used until 1980. The operation was performed in a standard (1950s-vintage) operating room until 1976. Beginning in January 1976, a laminar airflow ventilation system was used. The senior one of us and the members of the operating team began to wear body-exhaust suits in 1980.

All patients had a thorough clinical and radiographic evaluation preoperatively and in the early postoperative period. Patients were asked to return at regular follow-up intervals, and all living patients were specifically asked to return for an evaluation at the time of the study. An interval of ten years after the index total hip arthroplasty was required for inclusion of the hip in the study. The mean duration of follow-up was 14.6 years (range, two to twenty-two years) for all patients (both the living patients and those who had died). Two patients (three hips) were lost to follow-up. All patients who were alive at the time of the study, and had not been lost to follow-up and had not had a revision, were followed clinically for at least ten years.

We attempted to contact all of the original seventy-five patients (106 hips) or their families. The living patients either returned for clinical and radiographic evaluation or, if they were unable to return, were asked to send current radiographs (made locally) to us for evaluation. All living patients whom we were able to contact were evaluated clinically in person or by telephone with use of the standard system of terminology for reporting results described by Johnston et al. Family members of the patients who had died were interviewed to determine the function of the hip at the time of death.

Radiographic evaluation was performed by two of us (M. G. C. and J. J. C.), who assessed standard low anteroposterior radiographs of the pelvis that included the tip of the femoral component. The radiographs had been made preoperatively, postoperatively, and at regular intervals thereafter until the time of the latest follow-up. Variations in magnification were corrected by comparing the known size of the femoral head with that measured on the radiograph¹².

Postoperative radiographs were used to determine the grade of the cement on the femoral side according to the criteria of Schmalzried and Harris. Loosening of the femoral component was classified according to the criteria of Harris and McGann. Definite loosening was defined as subsidence of the femoral component, fracture of the cement or the stem, or the appearance of a radiolucent line between the stem and the cement that was not present on the immediate postoperative radiograph. When the patient had a polished Charnley component, the last criterion was modified to include only radiolucent lines that were more than one millimeter in width. Probable loosening was defined as the presence of a continuous radiolucent line along the entire bone-cement interface on the anteroposterior radiograph. Possible loosening was indicated by a radiolucent line at the bone-cement interface that encompassed more than 50 but less than 100 per cent of the circumference of the stem on the anteroposterior radiograph.

Subsidence of the femoral component was determined with use of the method of Loudon and Charnley. A vertical line was drawn through the central axis of the femoral stem. Another line was drawn perpendicular to this axis, at the distal tip of the stem, and one was drawn at the point where the trochanteric wire passed through the lateral femoral cortex. The distance between these two horizontal lines on the initial postoperative radiograph was compared with the distance on the radiograph made at the most recent follow-up evaluation. Subsidence was defined as a difference of at least five millimeters in the measured values (after correction for magnification). Any femoral construct that had a fracture of the cement mantle, any Iowa stem with a radiolucent line at its interface with the cement, or any Charnley component with a radiolucent line of more than one millimeter in width at the superolateral aspect of its interface with the cement was considered to have subsided. Debonding of a femoral stem was defined as any radiolucent line at the prosthesis-cement interface in zone 1 of Gruen et al. Osteolysis was defined as a non-linear radiolucent area along the bone-cement interface that was at least five millimeters wide.

Migration of the acetabular component was evaluated with use of the criteria of Massin et al. The vertical distance between a horizontal line joining the two teardrops and the center of the cup was measured on the radiographs. The horizontal distance between a vertical line through the teardrop and the center of the cup was also measured. The acetabular component was considered to have migrated if a difference of at least five millimeters in these distances was demonstrated on a comparison of the initial postoperative radiograph and that made at the most recent follow-up evaluation or if there was a fracture of the cement. We defined definite loosening of the acetabular component as migration of the component or the presence of a fracture of the cement. Probable loosening was indicated by a continuous radiolucent line at the bone-cement interface along the entire circumference of the component on the anteroposterior radiographs. Possible loosening was defined as a radiolucent line at the bone-cement interface around more than 50 but less than 100 per cent of the component. Protrusio acetabuli was defined as protrusion of the femoral head medial to the Kohler line on the preoperative radiograph^19,20.

Linear wear of the acetabular component was measured with use of the technique described by Livermore et al. The shortest distance between the center of the femoral head and the periphery of the acetabular component on the immediate postoperative radiograph was compared with that seen on the radiograph made at the latest follow-up evaluation; any change between these distances was considered linear wear. Volumetric wear was calculated by multiplying r² by the amount of linear wear.

Heterotopic ossification, if present, was graded according to the classification system of Brooker et al. The position of the femoral stem (varus, valgus, or neutral alignment) was determined on the basis of the angle formed between the central axis of the prosthesis and the lateral endosteal cortex. Radiolucent lines at the bone-cement interface were recorded in the three acetabular zones described by DeLee and Charnley and in the seven femoral zones described by Gruen et al.

Statistical analysis was done by an independent statistician. The clinical and radiographic variables were analyzed with use of the two-tailed Fisher exact test when both variables were categorical and with use of the two-tailed Student t test when one variable was continuous. The Wilcoxon rank-sum test was used to compare rates of wear according to categorical variables. The Pearson correlation coefficient was used to analyze the association between age and rates of wear.

Kaplan-Meier survivorship curves with corresponding 95 per cent confidence intervals were calculated with failure defined according to six end points: (1) revision or resection of all or part of the original prosthesis, (2) aseptic loosening of the acetabular component (defined as definite or probable radiographic loosening or revision because of aseptic loosening), (3) aseptic loosening of the femoral component (defined as definite or probable radiographic loosening or revision because of aseptic loosening), (4) aseptic loosening necessitating revision of either component or both components, (5) aseptic loosening of the acetabular component necessitating revision, and (6) aseptic loosening of the femoral component necessitating revision. For comparison, similar survivorship curves were calculated for the results of a previously reported series of 315 total hip arthroplasties, also performed by the senior one of us, in patients with diagnoses other than rheumatoid arthritis; those patients had been followed for at least twenty years²³. Log-rank analysis was used to compare the two series.

	Results

Top Abstract Introduction Materials and Methods Results Discussion References

 
Two patients (three hips) were lost to follow-up, leaving seventy-three patients (103 hips) for evaluation. Thirty-two patients (forty-eight hips) were still alive at the time of the latest follow-up, and forty-one patients (fifty-five hips) had died. The clinical outcome was determined for the thirty-two living patients. The mean duration of clinical follow-up for all hips, including those in the patients who had died, was thirteen years (range, one to twenty-two years), and the mean duration of radiographic follow-up was eleven years (range, one to twenty-two years).

Radiographs made after at least ten years of follow-up were available for forty (83 per cent) of the forty-eight hips in the patients who were still alive as well as for twelve (22 per cent) of the fifty-five hips in the patients who subsequently died. One hip that had been revised because of infection and two that had been revised because of recurrent dislocation were excluded from the analysis. Therefore, the radiographic evaluation after a minimum of ten years was based on forty-nine hips, which had been followed radiographically for a mean of 14.6 years (range, ten to twenty-two years).

Loosening of the components was evaluated in ninety-eight of the 106 hips in the study; the three hips that had been revised because of infection, the two that had been revised because of dislocation, and the three that had been lost to follow-up were excluded. Loosening of the components was also evaluated in the forty-nine hips that had had at least ten years of radiographic follow-up and had not been revised because of infection or dislocation.

At the most recent follow-up evaluation, twenty-four (75 per cent) of the thirty-two living patients had no pain in the hip, seven patients (22 per cent) had mild pain in the hip, none had moderate pain in the hip, and one (3 per cent) had severe pain in the hip. Of the sixteen patients who had a bilateral replacement, twelve had no pain in either hip and four had mild pain in one hip.

At the latest follow-up examination, eighteen (56 per cent) of the living patients walked without support, seven (22 per cent) used a cane, two (6 per cent) used crutches, four (13 per cent) used a walker, and one (3 per cent) was unable to walk. Of the sixteen patients who had a bilateral replacement, six used no support, six used a cane, and four used a walker.

Of the thirty-two patients who were alive at the time of the latest follow-up, none were able to perform heavy manual labor, one (3 per cent) could perform moderate manual labor, five (16 per cent) could perform light manual labor, sixteen (50 per cent) were semi-sedentary, nine (28 per cent) were sedentary, and one was bedridden (Table I). Of the patients who had a bilateral replacement, eight were semi-sedentary and eight were sedentary.

Two patients were not satisfied with the result at the time of the latest follow-up. In one patient, a deep infection had developed and had eventually led to a resection arthroplasty. This patient rated the pain as severe. The second patient was not satisfied, despite the fact that the hip was pain-free, because of a perceived limb-length discrepancy of five millimeters.

The immediate postoperative radiographs were used to grade the cement in the forty-nine hips that had been followed radiographically for at least ten years. The cement on the acetabular side was grade A (no radiolucent line or a radiolucent line only in zone I according to the system of DeLee and Charnley) in twenty-four hips (49 per cent), grade B (an incomplete radiolucent line in any zone other than zone I) in nineteen (39 per cent), and grade C (a complete radiolucent line) in six (12 per cent). The cement on the femoral side was grade A in six hips (12 per cent), grade B in twenty-eight (57 per cent), grade C in fourteen (29 per cent), and grade D in one (2 per cent). We could not detect a significant association between the grade of the cement and loosening of the acetabular component (p = 0.888) or the femoral component (p > 0.90). Twenty-six femoral stems (53 per cent) were in valgus alignment, fifteen (31 per cent) were in neutral alignment, and eight (16 per cent) were in varus alignment.

Overall, seven (7 per cent) of all 103 hips and five (10 per cent) of the fifty-two hips for which radiographs had been made at least ten years postoperatively were revised. Three (3 per cent) of the 103 hips were revised because of infection; two (2 per cent), because of recurrent dislocation; one (1 per cent), because of aseptic loosening of the acetabular component; and one, because of aseptic loosening of the femoral component. Of the hips in the patients who had survived ten years, one was revised because of infection; two, because of recurrent dislocation; one, because of loosening of the acetabular component; and one, because of loosening of the femoral component.

In addition to the hip that was revised because of aseptic loosening of the acetabular component, seven (7 per cent) of the ninety-eight hips that were evaluated for loosening had definite radiographic loosening of the acetabular component, none had probable radiographic loosening, and nine (9 per cent) had possible loosening. Therefore, overall loosening of the acetabular component occurred in eight hips (8 per cent), including the one hip that was revised because of aseptic loosening and the seven that had definite radiographic loosening. Radiographic loosening of the acetabular component occurred at a mean of 12.1 years (range, four to twenty years) postoperatively. Of the forty-nine hips in the patients who had survived ten years postoperatively and had radiographs available, eight (16 per cent) had a radiographically loose acetabular component. One of the eight hips was revised because of loosening, and seven demonstrated evidence of loosening on radiographs. Radiographic evidence of loosening of the acetabular component was associated with a younger age (p = 0.03) and with acetabular osteolysis (p = 0.0006).

In addition to the one hip (1 per cent) that was revised because of aseptic loosening of the femoral component, one (1 per cent) of the ninety-eight hips had definite loosening of the femoral component but none had either probable or possible loosening. Therefore, loosening of the femoral component occurred in two (2 per cent) of the hips. Of the forty-nine hips that had been assessed radiographically at least ten years postoperatively, two (4 per cent) had loosening of the femoral component; one hip was revised because of the aseptic loosening, and the other hip demonstrated radiographic loosening. Fifteen (15 per cent) of the ninety-eight hips had evidence of debonding at the interface between the stem and the cement. Fourteen of the fifteen stems with debonding were Charnley prostheses. The radiolucent line was less than one millimeter wide in these fourteen hips. The fifteenth stem with debonding was a matte-finish Iowa femoral component, which was considered radiographically loose.

The mean linear wear of the polyethylene was 0.102 millimeter per year (range, 0.0079 to 0.0363 millimeter per year). The mean volumetric wear was 43.15 cubic millimeters per year (range, 3.07 to 223.5 cubic millimeters per year). The mean linear wear of the twenty-eight-millimeter Iowa components (0.150 millimeter per year) was greater than that of the twenty-two-millimeter Charnley components (0.093 millimeter per year); however, this difference was not found to be significant with the numbers available (p = 0.37).

Five (10 per cent) of the forty-nine hips that were available for radiographic analysis after a minimum of ten years had acetabular osteolysis. We detected a strong association between acetabular osteolysis and aseptic loosening of the acetabular component (p = 0.0006). Femoral osteolysis was noted in zone 7 in eighteen hips (37 per cent). Only two hips (4 per cent) had osteolysis in any of the other six zones. Femoral osteolysis in zone 7 was associated with linear acetabular wear (p = 0.06).

Deep infection occurred in three (3 per cent) of the 103 hips. An infection with Pseudomonas aeruginosa developed in one patient within three months after the arthroplasty. This patient had had two operative procedures (a Schanz femoral osteotomy and a cup arthroplasty) before the total hip arthroplasty. The infection was treated with a one-stage revision with antibiotic-impregnated cement, and the patient had no pain in the hip for fifteen years. A deep infection with Staphylococcus aureus developed in another patient, 1.5 years postoperatively. He was managed with a one-stage revision with antibiotic-impregnated cement, and the hip did well until the patient died four years after the reimplantation arthroplasty. A deep infection with Staphylococcus aureus developed in the third patient, ten years postoperatively. A resection arthroplasty was performed, and a chronically draining sinus tract developed. This patient was the only one who rated the pain in the hip as severe at the latest follow-up evaluation.

Dislocation occurred in eleven (11 per cent) of the 103 hips; however, only two hips were revised because of recurrent dislocation. Heterotopic ossification was noted in thirteen (13 per cent) of the hips. According to the classification system of Brooker et al., seven hips (7 per cent) had grade-I ossification; two hips (2 per cent), grade-II; two hips, grade-III; and two hips, grade-IV ossification.

The Kaplan-Meier method was used to calculate the probability of survival of the original prosthesis from the time of the initial arthroplasty to one of six end points. The survivorship curves generated in the present study were compared with those from a study in which the results of Charnley arthroplasties performed by the senior one of us for the treatment of other diagnoses were followed for twenty years²³. All patients who had rheumatoid arthritis in the earlier study were omitted for the comparison with the present study.

With use of the log-rank test, we were able to detect no significant differences between the rates of survival of the original prostheses (with any end point) in the present study and those in the study of Charnley total hip arthroplasties after the patients who had rheumatoid arthritis were omitted from that series²³. In the present study, the mean probability of survival of the prosthesis (with 95 per cent confidence interval) at ten years was 93 ± 3 per cent with revision for any reason as the end point (p = 0.40); 97 ± 2 per cent with aseptic loosening of the acetabular component necessitating revision as the end point (p = 0.3876); 95 ± 3 per cent with definite or probable loosening of the acetabular component, or aseptic loosening of the acetabular component necessitating revision, as the end point (p = 0.8013); 100 per cent with aseptic loosening of the femoral component necessitating revision as the end point (p = 0.7563); 97 ± 3 per cent with definite or probable loosening of the femoral component, or aseptic loosening of the femoral component necessitating revision, as the end point (p = 0.2281); and 97 ± 3 per cent with aseptic loosening of one component or both components necessitating revision as the end point (p = 0.6021).

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
After primary and secondary osteoarthrosis, rheumatoid arthritis is the most common diagnosis in patients who have a total hip replacement. Despite this fact, there have been surprisingly few studies of the long-term outcomes of this procedure in this particular population of patients. Most investigations have been relatively short-term, have included several surgeons, have involved a variety of prostheses and operative approaches, and have been conducted in large referral centers for the treatment of rheumatoid arthritis^{5,11,17,18,24,26}. In addition, most studies have not distinguished between patients who have juvenile-onset rheumatoid arthritis and those who have adult-onset rheumatoid arthritis. In contrast, we evaluated the long-term results of total hip arthroplasties with cement performed by one surgeon in patients who had adult-onset rheumatoid arthritis in a community-based orthopaedic practice.

Severt et al. reported the results of seventy-five total hip arthroplasties with cement in fifty-three patients who had rheumatoid arthritis. After follow-up of at least four years, nine hips (12 per cent) were revised. Four hips (5 per cent) were revised because of aseptic loosening of the acetabular component, and four were revised because of infection. Only one hip (1 per cent) was revised because of aseptic loosening of the femoral component. A younger age at the time of the procedure was associated with a higher rate of loosening in that study. Clinical assessment showed that pain was the variable that had improved the most and function and activity levels had improved the least after total hip arthroplasty in patients who had rheumatoid arthritis.

Poss et al. reviewed the results of 138 total hip arthroplasties in ninety-eight patients who had rheumatoid arthritis. At a minimum of six years after the operation, only two hips had been revised, both because of loosening of the femoral component. Although no acetabular components had been revised, 107 sockets (78 per cent) had progressive radiolucent lines at the interface between the bone and the cement. This finding suggested that, with longer follow-up, aseptic loosening of the acetabular component would have become the major source of failure in these patients who had rheumatoid arthritis. Despite the acetabular components with progressive radiolucent lines, ninety-four (96 per cent) of the ninety-eight patients had clinical improvement after the arthroplasty. Poss et al. found an association between an increased rate of loosening of the socket and the failure to restore the normal acetabular position in hips that had protrusio acetabuli. Finally, they emphasized that the risk of infection associated with total hip arthroplasty was higher for patients who have rheumatoid arthritis than for those who have osteoarthrosis.

Unger et al. reported the results at a minimum of ten years after the performance of eighty-three total hip arthroplasties with cement in fifty-one patients who had rheumatoid arthritis. The prevalence of revision was 17 per cent (fourteen hips). Eleven hips (13 per cent) were revised because of aseptic loosening. In addition, the hips that were not revised had a high rate of radiographic loosening of the acetabular component. Again, however, despite the impending failure of the sockets, sixty-six (80 per cent) of the eighty-three hips were rated as satisfactory at a minimum of ten years after the index arthroplasty.

In the only series (to our knowledge) with an age and gender-matched control group, Onsten et al. compared the results of 201 Charnley arthroplasties in patients who had rheumatoid arthritis with those of 201 Charnley arthroplasties in patients who had osteoarthrosis. At a minimum of ten years after the procedures, the rate of survival of the prosthesis, with radiographic loosening of the acetabular component as the end point, was 79 ± 11 per cent in the group that had rheumatoid arthritis and 95 ± 4 per cent in the group that had osteoarthrosis. However, only fourteen (7 per cent) of the 201 hips in the group that had rheumatoid arthritis needed revision of the acetabular component compared with twenty-two (11 per cent) of the 201 hips in the patients who had osteoarthrosis. Onsten et al. reported a marked decrease (p < 0.026) in radiographic loosening of the acetabular component after 1981, when the use of a so-called second-generation cementing technique was introduced. In fact, they found that the rate of radiographic loosening of the acetabular component after 1981 in the patients who had rheumatoid arthritis was almost identical to that seen in the patients who had osteoarthrosis. In addition, the survivorship curves in that study were calculated only for the hips that were not revised.

The findings of the present study confirm the long-term durability of cemented total hip prostheses in patients who have adult-onset rheumatoid arthritis, and the results compare favorably with those in other reports of total hip arthroplasty with cement in patients who had rheumatoid arthritis^17,18,24,26. In our study, radiographic loosening of the acetabular component was significantly associated with a younger age at the time of the index operation (p = 0.03). Sullivan et al. as well as Ballard et al. studied patients who were less than fifty years old at the time of the arthroplasty, and the prevalence of loosening (most notably of the acetabular construct) in those patients was higher than it was in the patients who were more than fifty years old when they had an arthroplasty performed by the senior one of us. Sarmiento et al. reported a higher percentage of loosening after a total hip replacement in patients who had rheumatoid arthritis and were less than fifty years old than in patients who had rheumatoid arthritis and were more than fifty years old. In the present study, the mean age at the time of the index operation was sixty-two years, which is considerably older than that in studies of patients with rheumatoid arthritis that included those with juvenile-onset rheumatoid arthritis^24,26. The younger mean age of the patients in those studies may, in part, account for the higher prevalence of aseptic loosening compared with that in the present study. The long-term finding of radiographic loosening of cemented acetabular components in patients who have rheumatoid arthritis raises the issue of whether fixation of the acetabular component without cement might prove more durable. The senior one of us now routinely uses a hybrid total hip arthroplasty (a femoral component inserted with cement and an acetabular component inserted without cement) in patients who have rheumatoid arthritis. Other authors have recently reported favorable short-term results for prostheses inserted without cement in patients who have rheumatoid arthritis^5,11, but the long-term results are not yet available. The findings of the present study can be used for comparison with the results of these other techniques if the results are followed for the same long-term interval.

In our study, the prevalence of radiographic loosening of the acetabular component was 8 per cent (eight of ninety-eight) for all hips and 16 per cent (eight of forty-nine) for those in the patients who had survived at least ten years. Radiographic loosening of the femoral component was found in 2 per cent (two) of the ninety-eight hips and in 4 per cent (two) of the forty-nine hips that had been followed for at least ten years. These results were found to be comparable with those of the twenty-year follow-up study of Charnley arthroplasties performed by the senior one of us for the treatment of other diagnoses (with exclusion of the hips in the patients who had rheumatoid arthritis in that study). As was noted in that study²³, we found that radiographic loosening of the acetabular component was more common than that of the femoral component. However, in contrast to that study, the rates of revision because of loosening of the acetabular and femoral components were identical in our series; thus, the results of the present study were comparable with if not better than those seen in patients who had had total hip arthroplasty for other diagnoses.

In contrast to the findings of other investigations^18,26, we detected no association between protrusio acetabuli and aseptic loosening of the acetabular component. Some investigators have advocated the use of bone-grafting in hips that have protrusio acetabuli^2,3,14,18. The senior one of us used polymethylmethacrylate instead of bone graft to fill the protrusio defects and to restore the normal hip center, with excellent results (Figs. 1-A, 1-B, and 1-C).

View larger version (121K): [in this window] [in a new window]   FIG1-A: Figs. 1-A, 1-B, and 1-C: Radiographs of a female clerical worker who had a right total hip arthroplasty performed with cement for the treatment of rheumatoid arthritis with protrusio acetabuli when she was thirty-three years old. Twenty-one years after the procedure, the patient was able to work and to walk an unlimited distance without support. She had no limp and only mild pain in the hip, and she was satisfied with the result of the arthroplasty. Fig. 1-A: Preoperative radiograph demonstrating destruction of the right hip joint with protrusio acetabuli, which is typical of rheumatoid arthritis.

View larger version (100K): [in this window] [in a new window]   FIG1-B: Fig. 1-B: Early postoperative radiograph of the Charnley total hip arthroplasty construct, demonstrating lateralization of the acetabular component and filling of the medial wall defect with cement.

View larger version (119K): [in this window] [in a new window]   FIG1-C: Fig. 1-C: Radiograph, made twenty-one years after the procedure, demonstrating no change in the interfaces compared with those on the early postoperative radiograph.

In summary, the findings of the present study confirm the long-term durability of cemented total hip prostheses in patients who have rheumatoid arthritis. Most patients were satisfied with the hip replacement and had no pain at a minimum of ten years. Functional improvement, however, was less dramatic compared with that for patients who had had total hip arthroplasty performed by the senior one of us for the treatment of other underlying diagnoses²³. Radiographic loosening of the acetabular component is the major long-term problem associated with total hip arthroplasty performed with cement in patients who have rheumatoid arthritis. However, the prevalences of loosening of the acetabular and femoral components in patients who had rheumatoid arthritis were comparable with or lower than those in patients who had a total hip arthroplasty performed by the same surgeon for the treatment of other underlying diagnoses²³.

	Footnotes

 
*One or more of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. In addition, benefits have been or will be directed solely to a research fund, foundation, educational institution, or other non-profit organization with which one or more of the authors is associated. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was Grant AR43314 from the National Institutes of Health.

Department of Orthopaedics, University of Iowa College of Medicine, Iowa City, Iowa 52242. E-mail address for Dr. Callaghan: john-callaghan@uiowa.edu.

	References

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