TY - JOUR
AU - Yamada, Hisakata
AB - Abstract Objectives: To retrospectively evaluate the long-term results of cementless total hip arthroplasty (THA) in patients with rheumatoid arthritis (RA) and postoperative patient mortality after THA. Methods: This study included 191 hips in 149 RA patients who underwent cementless THA between 1998 and 2005. Mean age at surgery was 54.2 years, and mean follow-up was 12.6 years. Implant and patient survivorships were determined using the Kaplan–Meier method, and the associated influencing factors were determined. Results: Implant survivals at 17 years were 99.5% for stems, 93.9% for cups, and 90.8% for liners. Among the liners used, THAs with highly cross-linked polyethylene showed better survivals compared with those with conventional polyethylene and alumina-bearing surface (93.4%, 90.9%, and 52.2%, respectively). A total of 64 deaths occurred; 45 patients died within 10 years and 19 patients died between 10 and 17 years. Malignancy (25.0%) was the leading cause of death, followed by pneumonia (20.8%) and sepsis (20.8%). The patient survival rate was 36.9% at 17 years after THA. Multivariate analysis exhibited that older age at operation and greater dose of concomitant corticosteroid resulted in shorter patient survivals. Conclusions: Cementless THA worked well in patients with RA. Mortality remained high among RA patients who needed THA. Cementless total hip arthroplasty, Long-term results, Mortality, Rheumatoid arthritis Introduction Rheumatoid arthritis (RA) is a systemic and idiopathic autoimmune disorder. It is characterized by inflammation in multiple joints with destruction and disability. Deformation and contracture of joint restrict activities of daily living and result in loss of quality of life. The frequency of hip involvement was reported to be about 2.0% in patients with early RA; however, it increased to approximately 10% to 33% [1–5] in long-term observations. Given that destruction of hip largely affects daily life, total hip arthroplasty (THA) is a valid treatment. THA for RA hips had been treated with cemented THA due to systemic or periarticular osteoporosis. With the recent development of medication as well as implants, cementless THA has been increasingly performed for RA hips. Although several studies have documented satisfactory short- or mid-term outcomes after cementless THA in RA patients [6–9], there are only a few long-term reports of cementless THA that include sufficient subjects. Therefore, it is necessary that long-term outcomes after cementless THA in RA patients would be reported. RA patients have higher rates of mortality compared with the general population [10–13]. However, the mortality rate of RA patients after THA is less unknown. Considering that greater radiographic joint damage is associated with higher mortality rate in RA patients [14,15], it might be reasonable to expect that RA patients after THA have much shorter expectancy. In this study, we retrospectively evaluated the minimum 10-year result of cementless THA in patients with RA, and postoperative patient mortality after THA. Materials and methods Patients This retrospective study was approved by the local institutional review board. A total of 149 patients underwent 191 primary THAs with cementless components in Kyushu University Hospital (Fukuoka, Japan) and National Kyushu Medical Center (Fukuoka, Japan) between January 1998 and December 2005. Cementless THA was performed in all patients in this period. All patients fulfilled the 1987 revised American College of Rheumatology criteria for RA [16]. Among the 149 patients, 45 died due to causes unrelated to THA before 10 years; 34 patients were lost to follow-up; and 8 patients underwent revision before 10 years. All patients were included in implant and patient survival analyses using the Kaplan–Meier method (Figure 1). The remaining 67 patients were followed up for a minimum of 10 years (average, 12.6 years; range, 10–17 years) and clinically and radiographically evaluated. The mean patient age at surgery was 54.2 years, and the mean body mass index was 21.5 (range, 13.5–32.3). The demographic characteristics of patients are shown in Table 1. Figure 1. Open in new tabDownload slide Patient cohort. THA: total hip arthroplasty; F-U: follow-up. Figure 1. Open in new tabDownload slide Patient cohort. THA: total hip arthroplasty; F-U: follow-up. Table 1. Patients characteristics. Number of patients (hips) 67 (86) Age at THA (years old)* 54.2 ± 11.0 (19–79) Male/Female, n(%) 7 (10.4)/60 (89.6) Height (cm)* 151.7 ± 8.6 (132.0–178.4) Body weight (kg)* 49.5 ± 9.8 (27.3–79.0) BMI (kg/m2)* 21.5 ± 3.8 (13.5–32.3) Follow-up period (years)* 12.6 ± 2.0 (10.0–17.1) Number of patients (hips) 67 (86) Age at THA (years old)* 54.2 ± 11.0 (19–79) Male/Female, n(%) 7 (10.4)/60 (89.6) Height (cm)* 151.7 ± 8.6 (132.0–178.4) Body weight (kg)* 49.5 ± 9.8 (27.3–79.0) BMI (kg/m2)* 21.5 ± 3.8 (13.5–32.3) Follow-up period (years)* 12.6 ± 2.0 (10.0–17.1) *Data were expressed as means ± standard deviation (range). THA: total hip arthroplasty; BMI: body mass index. Open in new tab Table 1. Patients characteristics. Number of patients (hips) 67 (86) Age at THA (years old)* 54.2 ± 11.0 (19–79) Male/Female, n(%) 7 (10.4)/60 (89.6) Height (cm)* 151.7 ± 8.6 (132.0–178.4) Body weight (kg)* 49.5 ± 9.8 (27.3–79.0) BMI (kg/m2)* 21.5 ± 3.8 (13.5–32.3) Follow-up period (years)* 12.6 ± 2.0 (10.0–17.1) Number of patients (hips) 67 (86) Age at THA (years old)* 54.2 ± 11.0 (19–79) Male/Female, n(%) 7 (10.4)/60 (89.6) Height (cm)* 151.7 ± 8.6 (132.0–178.4) Body weight (kg)* 49.5 ± 9.8 (27.3–79.0) BMI (kg/m2)* 21.5 ± 3.8 (13.5–32.3) Follow-up period (years)* 12.6 ± 2.0 (10.0–17.1) *Data were expressed as means ± standard deviation (range). THA: total hip arthroplasty; BMI: body mass index. Open in new tab Implants and operations Cups included AMS (Kyocera, Osaka, Japan) in 178 hips, Harris–Galante II (Zimmer, Warsaw, IN) in 8 hips, and Trilogy® (Zimmer, Warsaw, IN) in 5 hips. Stems included PerFix HA (Kyocera) in 178 hips, VerSys Fiber Metal (Zimmer, Warsaw, IN) in 7 hips, and HA-TCP Multilock (Zimmer, Warsaw, IN) in 6 hips. Liners were changed according to the time periods. Twenty-five hips had alumina-bearing surface (ABS) liner; 32 hips, conventional PE (CPE) liner; and 134 hips, cross-linked polyethylene (XLPE) liner. The femoral head diameters were 22 mm in 13 hips (treated between May 1998 and March 2002), 26 mm in 154 hips (treated between January 1998 and December 2005), and 28 mm in 24 hips (treated between July 1998 and June 2000). Femoral heads composed of cobalt–chromium alloy were used in 13 hips between January 1998 and September 1998, alumina in 23 hips between July 1998 and July 2000, and zirconia in 155 hips between May 1998 and December 2005. All operations were performed using the posterolateral approach. The cup was inserted in a press-fit manner; the diameter of the cup was 1 mm larger than the last reamer used to prepare the acetabulum. Two or three supplemental 6.5 mm diameter screws were used in most cases. Patients were encouraged to walk with walkers or crutches for a few days after THA. Clinical and radiographic analyses The clinical outcome was evaluated using the Japanese Orthopedic Association (JOA) hip score. It is often difficult to record all scores because RA is a joint disease that affects the entire body. Thus, we evaluated only the pain item (range, 0–40). Data regarding the outcomes of all procedures were collected from medical records. According to the method by Engh et al., stable fixation was defined as a femoral stem with no radiolucency along the porous surface, and unstable fixation was defined as a stem with radiolucent line ≧2 mm or progressive subsidence [17]. Femoral subsidence was determined with progressive change of >5 mm from the standard radiograph. Cup loosening was defined as a change in implant acetabular cup tilt >5° or migration >2 mm [17,18]. Stress shielding was classified from 0 (none) to 4 (fourth degree) based on Engh classification [17]. Statistical analysis Statistical analysis was performed with JMP 11.0.0 (SAS Institute, Cary, NC). Mortality and cumulative survivorship of cup, femoral stem, and liners were determined using the Kaplan–Meier method. Patients were censored at the date of last follow-up, including those without a minimum 10-year follow-up. The Kaplan–Meier implant survival analysis was performed for four different end points (i.e. revision for any reason, revision of stem, revision of the cup, and revision of the liner) and compared with a log-rank test. Dislocation rate of femoral head size was compared using the Fisher’s exact test. A matched-pair analysis was performed to compare preoperative and latest values of JOA (pain) scores. We compared death and survival groups using t-statistics for continuous variables and the Fisher test for categorical variables. Risk factor for mortality was analyzed using Cox’s proportional hazard model. Stepwise regression with backward elimination was carried out to determine the best model to predict mortality. For all statistical analyses, p < 0.05 was considered as significant. Results Implant survival rate Among the entire cohort of 191 hips, there were 16 revisions (8.4%). One femoral stem (0.5%) was revised due to periprosthetic femoral fracture. Four acetabular cups (2.1%) were revised; two were due to osteolysis related to PE wear, one due to aseptic loosening, and one due to liner fracture. Among the isolated 11 revised liners (5.8%), 6 were due to dislocation, 4 due to ABS liner fracture, and 1 due to PE wear. Kaplan–Meier survivorship with any revision as the end point showed that the 17-year survival rate was 82.5% (Figure 2a). Each implant survival at 17 years with revision as the end point was 99.5% for stems (Figure 2b), 93.9% for cups (Figure 2c), and 90.8% for liners (Figure 2d). Figure 2. Open in new tabDownload slide Overall Kaplan–Meier survivorship with any revision as the end point shows (a) the 17-year survival rate of 82.5%. (b) Stem survival rate at 17-year was 99.5%. (c) Cup survival rate at 17-year was 93.9%. (d) Liner survival rate at 17-year was 90.8%. Figure 2. Open in new tabDownload slide Overall Kaplan–Meier survivorship with any revision as the end point shows (a) the 17-year survival rate of 82.5%. (b) Stem survival rate at 17-year was 99.5%. (c) Cup survival rate at 17-year was 93.9%. (d) Liner survival rate at 17-year was 90.8%. Furthermore, we compared the implant survival among the XLPE, CPE, and ABS groups. The survival rates of the XLPE, CPE, and ABS groups at 15 years were 93.4%, 90.9%, and 52.2%, respectively (Figure 3). In the log-rank test, the ABS group had a significantly higher risk of revision (p < 0.05) than the XLPE and CPE groups. Figure 3. Open in new tabDownload slide Cup Kaplan–Meier survivorships with any revision as the end point in the cross-linked polyethylene (XLPE), conventional PE (CPE), and alumina-bearing surface (ABS) groups at 15-year survival rate were 93.4%, 90.9%, and 52.2%, respectively. *p < 0.05. Figure 3. Open in new tabDownload slide Cup Kaplan–Meier survivorships with any revision as the end point in the cross-linked polyethylene (XLPE), conventional PE (CPE), and alumina-bearing surface (ABS) groups at 15-year survival rate were 93.4%, 90.9%, and 52.2%, respectively. *p < 0.05. Radiographic and clinical analyses At the mean follow-up of 12.6 years, 1-mm-wide radiolucent line was frequently observed around the smooth portion of the distal stem. However, cases with radiolucency along the porous portion were not found; thus, all femoral stems were evaluated as being stable. With regard to radiographic stress shielding according to Engh classification around the stem, first degree occurred in 8 hips (9.3%), second degree in 75 hips (87.2%), and third degree in 3 hips (3.5%). No hips with fourth degree stress shielding were observed. One acetabular cup was revised due to loosening at 14 years postoperatively, and the remaining 85 cups were evaluated as being stable. The mean JOA pain score was 13.5 points (range, 0–30 points) before THA, which significantly improved to 39.0 points (range, 20–40 points) at the most recent follow-up. Complications Ten periprosthetic fractures (5.2%) occurred during the observation period with nine proximal femoral fractures and one acetabular floor fracture. Among the seven fractures observed during the perioperative period, three proximal femoral fractures and one acetabular floor fracture occurred intraoperatively and three proximal femoral fractures occurred without trauma within 3 weeks after THA. Other three fractures, which occurred at more than 9 years postoperatively, were caused by minor trauma. One periprosthetic femoral fracture subsided more than 5 mm and required revision surgery. The remaining nine fractures did not require revision surgery. Dislocation occurred in 24 hips (12.6%); 3 hips (23.1%) with 22 mm head, 19 hips (12.3%) with 26 mm head, and 2 hips (8.3%) with 28 mm head (Table 2). Among these patients, six hips (3.1%) had recurrent dislocations and subsequently required THA revision. The remaining dislocations were successfully managed using conservative treatment. Five (2.6%) patients had superficial infections and were successfully managed. No patient with deep infection was observed. Table 2. Dislocation rate. Femoral head size 22mm 26mm 28mm Total Hips, n 13 154 24 191 Dislocation, n 3 19 2 24 Dislocation rate(%) 23.1 12.3 8.3 12.6 Femoral head size 22mm 26mm 28mm Total Hips, n 13 154 24 191 Dislocation, n 3 19 2 24 Dislocation rate(%) 23.1 12.3 8.3 12.6 Statistical differences between femoral head size regarding dislocation rate were calculated by Fisher’s exact test. There was no significant difference (p = 0.42). Open in new tab Table 2. Dislocation rate. Femoral head size 22mm 26mm 28mm Total Hips, n 13 154 24 191 Dislocation, n 3 19 2 24 Dislocation rate(%) 23.1 12.3 8.3 12.6 Femoral head size 22mm 26mm 28mm Total Hips, n 13 154 24 191 Dislocation, n 3 19 2 24 Dislocation rate(%) 23.1 12.3 8.3 12.6 Statistical differences between femoral head size regarding dislocation rate were calculated by Fisher’s exact test. There was no significant difference (p = 0.42). Open in new tab Postoperative mortality and the associated factors A total of 64 deaths occurred during the study period. The cause of death could be identified in 48 patients. Malignancy was the leading cause, followed by pneumonia and sepsis (Table 3). An overall patient survivorship was 80.1% at 5 years, 62.4% at 10 years, and 36.9% at 17 years (Figure 4). The mean age at death was 68.0 years (51 to 85). The mean time from primary THA to death was 7.2 years (0 to 15). Univariate analysis showed that operative time, age, height, body weight, and corticosteroid dose were significantly associated with patient mortality (Table 4). In the multivariate analysis, older age at operation (hazard rate 1.07, p < 0.01) and using greater dose of concomitant corticosteroid (hazard rate 1.11, p < 0.01) were independently associated with greater mortality risk (Table 5). Figure 4. Open in new tabDownload slide Kaplan–Meier survival rate after total hip arthroplasty. The 17-year mortality rate was 36.9%. Figure 4. Open in new tabDownload slide Kaplan–Meier survival rate after total hip arthroplasty. The 17-year mortality rate was 36.9%. Table 3. Cause of death. Cause of death n (%) All causes 48 (100)  Malignancy 12 (25.0)  Infection   Infectious pneumonia 10 (20.8)   Sepsis 10 (20.8)  Cardiovascular including stroke   Coronary artery disease 5 (10.5)   Stroke 3 (6.2)   Aortic aneurysm 2 (4.1)   Heart amyloidosis 1 (2.1)  Others   Interstitial pneumonia 1 (2.1)   Hepatic cirrhosis 1 (2.1)   Acute pancreatitis 1 (2.1)   Pleurisy 1 (2.1)   Injury 1 (2.1) Cause of death n (%) All causes 48 (100)  Malignancy 12 (25.0)  Infection   Infectious pneumonia 10 (20.8)   Sepsis 10 (20.8)  Cardiovascular including stroke   Coronary artery disease 5 (10.5)   Stroke 3 (6.2)   Aortic aneurysm 2 (4.1)   Heart amyloidosis 1 (2.1)  Others   Interstitial pneumonia 1 (2.1)   Hepatic cirrhosis 1 (2.1)   Acute pancreatitis 1 (2.1)   Pleurisy 1 (2.1)   Injury 1 (2.1) Open in new tab Table 3. Cause of death. Cause of death n (%) All causes 48 (100)  Malignancy 12 (25.0)  Infection   Infectious pneumonia 10 (20.8)   Sepsis 10 (20.8)  Cardiovascular including stroke   Coronary artery disease 5 (10.5)   Stroke 3 (6.2)   Aortic aneurysm 2 (4.1)   Heart amyloidosis 1 (2.1)  Others   Interstitial pneumonia 1 (2.1)   Hepatic cirrhosis 1 (2.1)   Acute pancreatitis 1 (2.1)   Pleurisy 1 (2.1)   Injury 1 (2.1) Cause of death n (%) All causes 48 (100)  Malignancy 12 (25.0)  Infection   Infectious pneumonia 10 (20.8)   Sepsis 10 (20.8)  Cardiovascular including stroke   Coronary artery disease 5 (10.5)   Stroke 3 (6.2)   Aortic aneurysm 2 (4.1)   Heart amyloidosis 1 (2.1)  Others   Interstitial pneumonia 1 (2.1)   Hepatic cirrhosis 1 (2.1)   Acute pancreatitis 1 (2.1)   Pleurisy 1 (2.1)   Injury 1 (2.1) Open in new tab Table 4. Univariate analysis for predictors of mortality THA in patients with RA. Death (n = 64) Survival (n = 85) p Value Gender, female, n(%) 57 (89.1) 74 (87.1) 0.8 Operated on before 2002, n(%) 42 (65.6) 42 (49.4) 0.04 Age (years)* 62.0 ± 9.7 54.9 ± 11.3 <0.01 Physical examination  Height (cm)* 147.6 ± 8.6 151.7 ± 7.0 <0.01  BW (kg)* 46.2 ± 10.9 49.9 ± 10.8 0.03  BMI (kg/m2)* 21.5 ± 4.4 21.6 ± 4.0 0.44 Laboratory data  CRP (mg/dl)* 2.49 ± 4.1 2.55 ± 2.4 0.35  ESR (mm/h)* 53.9 ± 30.3 57.7 ± 33.3 0.62 Prior medication  Corticosteroid (mg/day)* 6.9 ± 4.1 5.2 ± 3.0 <0.01  Corticosteroid use, n(%) 59 (91.2) 74 (87.1) 0.43  MTX (mg/week)* 5.9 ± 2.1 5.7 ± 1.9 0.96  MTX use, n(%) 15 (23.4) 25 (29.4) 0.46 Death (n = 64) Survival (n = 85) p Value Gender, female, n(%) 57 (89.1) 74 (87.1) 0.8 Operated on before 2002, n(%) 42 (65.6) 42 (49.4) 0.04 Age (years)* 62.0 ± 9.7 54.9 ± 11.3 <0.01 Physical examination  Height (cm)* 147.6 ± 8.6 151.7 ± 7.0 <0.01  BW (kg)* 46.2 ± 10.9 49.9 ± 10.8 0.03  BMI (kg/m2)* 21.5 ± 4.4 21.6 ± 4.0 0.44 Laboratory data  CRP (mg/dl)* 2.49 ± 4.1 2.55 ± 2.4 0.35  ESR (mm/h)* 53.9 ± 30.3 57.7 ± 33.3 0.62 Prior medication  Corticosteroid (mg/day)* 6.9 ± 4.1 5.2 ± 3.0 <0.01  Corticosteroid use, n(%) 59 (91.2) 74 (87.1) 0.43  MTX (mg/week)* 5.9 ± 2.1 5.7 ± 1.9 0.96  MTX use, n(%) 15 (23.4) 25 (29.4) 0.46 *Data were expressed as mean ± standard deviation. BW: body weight; BMI: body mass index; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; MTX: methotrexate. Open in new tab Table 4. Univariate analysis for predictors of mortality THA in patients with RA. Death (n = 64) Survival (n = 85) p Value Gender, female, n(%) 57 (89.1) 74 (87.1) 0.8 Operated on before 2002, n(%) 42 (65.6) 42 (49.4) 0.04 Age (years)* 62.0 ± 9.7 54.9 ± 11.3 <0.01 Physical examination  Height (cm)* 147.6 ± 8.6 151.7 ± 7.0 <0.01  BW (kg)* 46.2 ± 10.9 49.9 ± 10.8 0.03  BMI (kg/m2)* 21.5 ± 4.4 21.6 ± 4.0 0.44 Laboratory data  CRP (mg/dl)* 2.49 ± 4.1 2.55 ± 2.4 0.35  ESR (mm/h)* 53.9 ± 30.3 57.7 ± 33.3 0.62 Prior medication  Corticosteroid (mg/day)* 6.9 ± 4.1 5.2 ± 3.0 <0.01  Corticosteroid use, n(%) 59 (91.2) 74 (87.1) 0.43  MTX (mg/week)* 5.9 ± 2.1 5.7 ± 1.9 0.96  MTX use, n(%) 15 (23.4) 25 (29.4) 0.46 Death (n = 64) Survival (n = 85) p Value Gender, female, n(%) 57 (89.1) 74 (87.1) 0.8 Operated on before 2002, n(%) 42 (65.6) 42 (49.4) 0.04 Age (years)* 62.0 ± 9.7 54.9 ± 11.3 <0.01 Physical examination  Height (cm)* 147.6 ± 8.6 151.7 ± 7.0 <0.01  BW (kg)* 46.2 ± 10.9 49.9 ± 10.8 0.03  BMI (kg/m2)* 21.5 ± 4.4 21.6 ± 4.0 0.44 Laboratory data  CRP (mg/dl)* 2.49 ± 4.1 2.55 ± 2.4 0.35  ESR (mm/h)* 53.9 ± 30.3 57.7 ± 33.3 0.62 Prior medication  Corticosteroid (mg/day)* 6.9 ± 4.1 5.2 ± 3.0 <0.01  Corticosteroid use, n(%) 59 (91.2) 74 (87.1) 0.43  MTX (mg/week)* 5.9 ± 2.1 5.7 ± 1.9 0.96  MTX use, n(%) 15 (23.4) 25 (29.4) 0.46 *Data were expressed as mean ± standard deviation. BW: body weight; BMI: body mass index; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; MTX: methotrexate. Open in new tab Table 5. Multiple regression model to analyze the effect of demographic-related variables in mortality after THA. Hazard ratio 95% CI p Value Age (year) 1.07 1.04–1.10 <0.01 Height (cm) 0.97 0.93–1.01 0.09 Corticosteroid (mg/day) 1.11 1.03–1.18 <0.01 Hazard ratio 95% CI p Value Age (year) 1.07 1.04–1.10 <0.01 Height (cm) 0.97 0.93–1.01 0.09 Corticosteroid (mg/day) 1.11 1.03–1.18 <0.01 CI: confidence interval. Open in new tab Table 5. Multiple regression model to analyze the effect of demographic-related variables in mortality after THA. Hazard ratio 95% CI p Value Age (year) 1.07 1.04–1.10 <0.01 Height (cm) 0.97 0.93–1.01 0.09 Corticosteroid (mg/day) 1.11 1.03–1.18 <0.01 Hazard ratio 95% CI p Value Age (year) 1.07 1.04–1.10 <0.01 Height (cm) 0.97 0.93–1.01 0.09 Corticosteroid (mg/day) 1.11 1.03–1.18 <0.01 CI: confidence interval. Open in new tab Discussion We evaluated the implants and patient survival after cementless THA in RA patients. The survival rates of cementless stems and cups at 17 years were 99.5% and 93.9%, respectively, and worked well for RA patients; however, the high rate of ABS fractures was the limiting factor. The patient survival rate was 36.9% at 17 years after operation with the significant risk factor of older age at operation and using larger dose of corticosteroid. Only a few studies have reported the long-term results of cementless THA in patients with RA. Some studies reported that the long-term results of cup were inferior to those of stem. Eskelinen et al. reported that the survival rates of porous-coated uncemented stems and cups with any revision as the endpoint are 87% and 67% at 15 years, respectively [19]. Matsushita et al. demonstrated that the 14-year survival rates of stems and cups with any revision as the end point are 100% and 70.6%, respectively [20]. Other studies have reported that some cup revision cases were performed due to polyethylene wear and osteolysis [8,20,21]. In accordance with these reports, three cases associated with polyethylene wear required revision surgery in this study. PE wear was a primary factor limiting implant longevity [22]. Kurtz et al. reported that the wear rate in the XLPE group was significantly lower than that in the CPE group, and the risk of osteolysis was decreased by 87% [23]. Nakashima et al. also reported that the wear rate of XLPE is lower than that of CPE, and survival of PE liners in the XLPE group is significantly better than that in the CPE group. These reports suggest that low wear rate with XLPE improved THA longevity [22]. Furthermore, we experienced five revisions associated with ABS liners. Some studies have reported ceramic liner fractures in patients with ceramic-on-ceramic THA using sandwich-type acetabular components, such as ABS liner [24,25]. Hasegawa et al. reported that the fracture rate of ABS liner is 25.1% [26]. Liners had a significant impact on implant longevity. Thus, we showed the difference among the XLPE, CPE, and ABS groups. The present study also observed the higher revision rate of the ABS group. The postoperative periprosthetic fracture rate between 0.1% and 4.5% has been reported with cementless THA [27–30]. Compared with these series, the present study showed a higher incidence rate of periprosthetic fracture (5.2%). The increased periprosthetic fracture frequency of THA in patients with RA is consistent with that reported by Lindahl et al. [31]. In a previous study about cement THA, periprothetic fractures occur in 2.1–10% [32–34]. This incidence rate is similar to our result. In this study, all the patients with fracture were female with a mean age at THA of 58.9 years and treated with concomitant corticosteroid. These factors possibly contributed to the high incidence of periprosthetic fractures. Dislocation is a common complication after THA in patients with RA [35–37]. The prevalence of this complication is between 2.5%–8.2% [36,38–40]. Ravi et al. performed a meta-analysis and reported that RA patients have a 2.16 higher risk of dislocation following THA compared with OA patients [40]. With regard to cement THA, Creighton.et.al reported that dislocation occurs in 11 (11%) of 103 hips [41]. In the present study, the dislocation ratio, which occurred in 24 hips (12.6%), was as high as in previous studies. Among them, six hips (3.1%) required revision surgery. Some studies reported that the use of smaller femoral head size is associated with higher incidence of dislocations [37,42]. Consistent with these reports, patients with bigger femoral heads tended toward a lower dislocation rate than patients with smaller heads in this study (Table 2). In this study, the patient survival rates at 10 and 17 years after THA were 62.4% and 36.9%, respectively. Wolf et al. reported that mortality rates increase at least twofold in RA patients [13]. However, we could not compare the survival rate of RA patients with THA to that without THA; the survival rate was particularly low in RA patients after THA. Additionally, we analyzed the influence of several factors on mortality risk. We found that greater dose of corticosteroids and older age at THA were risk factors for mortality. Some studies have reported that the use of corticosteroid is a risk factor not only for mortality but also for infection and cardiovascular event (CVE) [43–48]. Saag et al. demonstrated that ≥5 mg/day is correlated with the development of adverse events in a dose-dependent manner [49]. In this study, the mean corticosteroid dose of 6.9 mg/day in the death group was significantly greater than that of the survival group at 5.2 mg/day. The cause of death was often infection and CVE (64.6%). The difference in corticosteroid dose may affect the outcome. With regard to the relationship between mortality and patient’s age at operation, we simply understand that older patients tend to have shorter survival period. Hence, we could not conclude that THA should be performed as early as possible in RA patients. This study has several limitations. First, because of its retrospective nature, patients had different follow-up lengths; longer follow-up may increase mortality and revision rate. Second, the patients had been treated by multiple surgeons at two centers. However, many surgeons performed the operation; all the operations were performed by senior surgeons with the same technique. Third, the backgrounds of patients, such as patient’s visual analog scales, were missing. As this is a retrospective study from 1998 to 2005, some detailed data were missing. Fourth, several different implant types were used in this study. In this series of patients, we could confirm the bone ingrowth fixation in almost all cases, regardless of implant type. Nevertheless, describing the long-term outcome of surgical intervention for rheumatoid hip in a large series of 149 patients is important. Conclusions Cementless THA showed excellent implant fixation in managing patients with RA. These results suggest that cementless THA for patients with RA appears to be a promising treatment. Mortality among RA patients after THA remained high. Acknowledgments We thank Junji Kishimoto, a statistician from the Digital Medicine Initiative, Kyushu University, for his valuable comments and suggestions in regards to the statistical analysis. Conflict of interest This work was supported by a Grant-in-Aid for Scientific Research from the Japan Society for the Promotion of Science (No.15K10450). 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TI - Minimum 10-year results of cementless total hip arthroplasty in patients with rheumatoid arthritis
JO - Modern Rheumatology
DO - 10.1080/14397595.2016.1256024
DA - 2017-07-04
UR - https://www.deepdyve.com/lp/oxford-university-press/minimum-10-year-results-of-cementless-total-hip-arthroplasty-in-VCkvA07dQP
SP - 598
EP - 604
VL - 27
IS - 4
DP - DeepDyve
ER -