Total joint arthroplasty in younger patients: heading for trouble?

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are safe and effective surgical procedures for advanced degenerative osteoarthritis.1Carr AJ Robertsson O Graves S et al.Knee replacement.Lancet. 2012; 379: 1331-1340Summary Full Text Full Text PDF PubMed Scopus (703) Google Scholar, 2Learmonth ID Young C Rorabeck C The operation of the century: total hip replacement.Lancet. 2007; 370: 1508-1519Summary Full Text Full Text PDF PubMed Scopus (1443) Google Scholar Traditionally, the success of total hip and knee arthroplasty has been determined by the measurement of survival. In the Lancet, Lee Bayliss and colleagues3Bayliss LE Culliford D Monk AP et al.The effect of patient age at intervention on risk of implant revision after total replacement of the hip or knee: a datalink study.Lancet. 2016; (published online Feb 13.)http://dx.doi.org/10.1016/S0140-6736(17)30059-4PubMed Google Scholar now introduce the use of lifetime risk as a novel approach to illustrate the risk of revision surgery following joint replacement. Lifetime risk data, which describe the probability of an event occurring over the course of a lifetime, is useful to patients, clinicians, and other health-care professionals because it is easier to convey and understand than the commonly used survival rates.4Zipkin DA Umscheid CA Keating NL et al.Evidence-based risk communication: a systematic review.Ann Intern Med. 2014; 161: 270-280Crossref PubMed Scopus (231) Google Scholar The lifetime risk of revision (LTRR) for patients over 70 years of age, most of the arthroplasty patient population, is low. Bayliss and colleagues3Bayliss LE Culliford D Monk AP et al.The effect of patient age at intervention on risk of implant revision after total replacement of the hip or knee: a datalink study.Lancet. 2016; (published online Feb 13.)http://dx.doi.org/10.1016/S0140-6736(17)30059-4PubMed Google Scholar report an LTRR around 5% for both THA and TKA patients at age 70 years, and LTRR of reduced further above this age. However, a potential threat for less successful long-term outcome in patients over 70 years of age is the worldwide trend of increased use of cementless implants instead of cemented ones, which is paradoxical, as more and more reports show that in older patients this leads to higher revision rates and re-operation rates than with cemented hips.5Makela KT Matilainen M Pulkkinen P et al.Failure rate of cemented and uncemented total hip replacements: register study of combined Nordic database of four nations.BMJ. 2014; 348: f7592Crossref PubMed Scopus (133) Google Scholar, 6Troelsen A Malchau E Sillesen N Malchau H A review of current fixation use and registry outcomes in total hip arthroplasty: the uncemented paradox.Clin Orthop Relat Res. 2013; 471: 2052-2059Crossref PubMed Scopus (134) Google Scholar Explanations for this trend are the intensive marketing of the more expensive cementless implants by the orthopaedics industry, and the willingness of orthopaedic surgeons to adopt to the less time-consuming cementless surgical technique.5Makela KT Matilainen M Pulkkinen P et al.Failure rate of cemented and uncemented total hip replacements: register study of combined Nordic database of four nations.BMJ. 2014; 348: f7592Crossref PubMed Scopus (133) Google Scholar The introduction of larger heads, in an attempt to overcome dislocations, might also generate higher revision rates.7Bozic KJ Browne J Dangles CJ et al.Modern metal-on-metal hip implants.J Am Acad Orthop Surg. 2012; 20: 402-406Crossref PubMed Scopus (37) Google Scholar However, the real problem highlighted by Bayliss and colleagues is the increasing failure rates of both hip and knee implants at younger ages. This information is not new, but by using the LTRR, the problems faced by younger patients become painfully exposed. For patients aged 50–54 years, LTRR increases up to 29% for patients with THA and 35% for those with TKA, compared with the LTRR of around 5% in patients aged 70 years with large differences between male and female patients (approximately 15% lower LTRR for women). What makes the situation even worse is the trend, partly driven by patient request, to perform THA and TKA in ever younger patients. By the year 2030, 52% of primary THAs and 55% of TKAs are projected to be implanted in patients younger than 65 years, with the strongest increase in patents aged 45–55 years.8Kurtz SM Lau E Ong K Zhao K Kelly M Bozic KJ Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030.Clin Orthop Relat Res. 2009; 467: 2606-2612Crossref PubMed Scopus (997) Google Scholar As a consequence, the number of revisions is expected to increase dramatically.8Kurtz SM Lau E Ong K Zhao K Kelly M Bozic KJ Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030.Clin Orthop Relat Res. 2009; 467: 2606-2612Crossref PubMed Scopus (997) Google Scholar, 9Kurtz S Ong K Lau E Mowat F Halpern M Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.J Bone Joint Surg Am. 2007; 89: 780-785Crossref PubMed Scopus (5856) Google Scholar The reasons for the higher LTRR for young patients having THA and TKA are that these are often more complicated primary surgeries, because many patients have congenital, developmental, or traumatic anatomical abnormalities causing the early osteoarthritis, and the higher demands leading to wear and secondary loosening. Revisions performed within 5 years after surgery are associated with higher re-revision risks,10National Joint Registry for EnglandWalesNorthern Ireland and the Isle of Man12th Annual Report.http://www.njrcentre.org.uk/njrcentre/Portals/0/Documents/England/Reports/12th%20annual%20report/NJR%20Online%20Annual%20Report%202015.pdfGoogle Scholar and orthopaedic surgeons have very little data on the outcome of revision THA and TKA in young patients. To our knowledge, there are only two papers on the long-term outcome of revision THA in patients who were younger than 55 years at the time of their revision.11Lee PT Lakstein DL Lozano B Safir O Backstein J Gross AE Mid-to long-term results of revision total hip replacement in patients aged 50 years or younger.Bone Joint J. 2014; 96-B: 1047-1051Crossref PubMed Scopus (30) Google Scholar, 12Te Stroet MA Rijnen WH Gardeniers JW van Kampen A Schreurs BW Satisfying outcomes scores and survivorship achieved with impaction grafting for revision THA in young patients.Clin Orthop Relat Res. 2015; 473: 3867-3875Crossref PubMed Scopus (23) Google Scholar One study reported an alarming survival rate of 63% at 10 years,11Lee PT Lakstein DL Lozano B Safir O Backstein J Gross AE Mid-to long-term results of revision total hip replacement in patients aged 50 years or younger.Bone Joint J. 2014; 96-B: 1047-1051Crossref PubMed Scopus (30) Google Scholar and the other, using a biological reconstruction technique with impaction bone grafting, showed more promising results with a 10 year survival of 87%.12Te Stroet MA Rijnen WH Gardeniers JW van Kampen A Schreurs BW Satisfying outcomes scores and survivorship achieved with impaction grafting for revision THA in young patients.Clin Orthop Relat Res. 2015; 473: 3867-3875Crossref PubMed Scopus (23) Google Scholar The current trend to implant total hip and knee implants in ever younger patients, driven by the fact that the short-term outcomes in the first few years after surgery are mostly acceptable, could lead to many patients ceasing to be revisable, and these patients might become a large burden to society in terms of cost and disability. Both patients and surgeons need to be aware of this possibility, and postponing this kind of surgery, despite the realistic limitations of patients with osteoarthritis, should be considered more frequently. This online publication has been corrected. The corrected version first appeared at thelancet.com on April 6, 2017 This online publication has been corrected. The corrected version first appeared at thelancet.com on April 6, 2017 BWS is President of the European Hip Society, and reports educational grants from Stryker. GH declares no competing interests. The effect of patient age at intervention on risk of implant revision after total replacement of the hip or knee: a population-based cohort studyOur study used novel methodology to investigate and offer new insight into the importance of young age and risk of revision after total hip or knee replacement. Our evidence challenges the increasing trend for more total hip replacements and total knee replacements to be done in the younger patient group, and these data should be offered to patients as part of the shared decision making process. Full-Text PDF Open AccessDepartment of ErrorSchreurs BW, Hannink G. Total joint arthroplasty in younger patients: heading for trouble? Lancet 2017; 389: 1374–755—This Comment should have been published with an Open Access copyright licence. This correction has been made to the online version as of April 6, 2017 and the printed Comment is correct. Full-Text PDF