ARE YOU  TOO YOUNG 

FOR  A  TOTAL HIP   REPLACEMENT?

CONTENTS

More questions

What are the long term results?

What is the main problem of the total hip

(1)

Are you too young ?

"I have a terrible pain in my hips, I am unable to work, tried numerous medicines but nothing works. But my doctor says that I am too young for total hip operation. Why will the doctor hinder me to enjoy my life with a new joint?"

Studies shoved that about 60 % of all surgeons are reluctant to carry out a total hip replacement on young patients ( arbitrarily < 50 years of age). (Mancuso 1996)

Here is why:

1)Total hips fail more often in young patients, whereas the young patients live longer.

The net effect of this biological fact is that the young patients outlive their total hips.

Look at the following Table for facts. This Table shows how many patients are still alive 15 years after the total hip operation   and how many of their original total hip prostheses are still in function 15 years after the operation.  

Sources: Barry 2002, Swedish Life tables

(2) Young patients wear off their total joints more

than their older colleagues. Wear of bearing surfaces in artificial joints  is dependent on the amount of movements in the joint. The more you are walking on your total hip / knee joint   the more you wear away the joint surfaces. ( It is about the same phenomenon as wearing off the tires - the more you drive your car, the more you wear the tires).

This table demonstrates that "young" patients after THR and TKR  walk on average up to  50 % more than the "older" patients and wear correspondingly more their artificial joint surfaces.

It follows that young patients' total hips produce also comparatively more wear particles.

The more of fine dust particles the total hip prosthesis produces  the greater is  the risk that the patient will develop osteolysis (bone dissolving disease). Osteolysis is the most frequent cause of total hip / knee joint failure. (Zahri, 1998)

• Together, these two Tables demonstrate  that there is   appreciably higher risk  that  a young patient will return to  his / her surgeon  with a failed total hip during the next 15 years after the surgery than an "old" patient.
• The surgeons  know well these facts. Moreover, the surgeons also know  that   the second operation (revision operation ) of the   total hip  will be technically more difficult and the result not so good as with the first total hip  operation.

So if a surgeon meets a "young" patient (arbitrary < 50 years) he  may persuade the patient to reduce  his / her activity and  to postpone the operation

There are, however, arguments in favor of total joint replacements in young patients

• The surgeon may carry out a total hip   operation with a hip prosthesis that wears out more slowly. There are many such total hip prostheses on the market, although for many of them there is no long track evidence that they really wear out more slowly.

• Young patients often seek total hip  replacement surgery both to get rid of their joint pain and to return to recreational or athletic activity whereas they are still young.

   

  As long as the patients understand the increased risks associated with  recreational or  athletic activity after total hip replacement and

  as long as the patients are specially  training to diminish these risks

  there is no reason to discourage the young patients from having a total hip  replacement surgery. (Healy 2001)

  About 40 % of all surgeons operate  on patients < 50 years, if the pain and disability warrants the surgery. (Mancuso et al)

  ---

   

  • "So at the age of 39 I had  total hip replacement on my right hip. It was the best thing I have ever done for myself. Yes, there are lots of things I can never do again but it is all worth it not to wake up with that ghastly pain".

  (2)    

MORE QUESTIONS

FROM  THE   YOUNG PATIENTS

Who is considered a young   patient?

Usually patients younger than 50 years of age, and patients with life expectancy of greater than 20 years and with a family history of longevity.

 

Are the hip diseases in young patients different?

Yes, the young patients are more often operated on for another hip diseases than the old patients. Hip conditions that frequently lead to total hip replacement in the young patients are the following:

rheumatoid arthritis

secondary osteoarthritis (worn cartilage) due to

congenital hip dysplasia

previous hip fracture

slipped epiphysis & Perthes disease.

        ankylosing spondylitis (ossification of the spine and the hips)

         avascular necrosis of the femoral head

         fused hip joint

All these hip diseases may be treated with  success by total hip replacement.

Idiopathic osteoarthritis (arthritis without known cause) of the hip joint, on the other hand, which is so common (> 70%) in older patients,   is rare in young patients

Look for more details in the chapter on Hip diseases.

When is the  young patient   a  candidate for a  total hip   replacement?

The indications for operation of young patients with a total hip replacement do not differ from indications for  older patients. These are:

•    severe pain and stiffness in the hip   joint,
•     impaired quality of life,
•     failure of previous treatments of the painful hip / knee  joint.
• patients with severe changes of the hip joint surfaces and bad range of motion
•     specially suitable candidate is a young patient with severe impairment of both hips and knees

If you will answer yes on these questions you  are probably a candidate for total hip replacement. You must then decide

• whether you wish to spend the most promising years of your life in severe pain and disability, while waiting for the  effect of different "conservative treatments"

•   or whether you wish to accept the higher risks of failure that are connected with the total hip  replacement in young patients and go forward with surgical treatment of your hip.

Are there  alternative hip operations for the young patients?

Yes, but these operations are most useful in certain young patients only.

In general, young patients with only small destruction of hip joint surfaces and with flexion up to 90 degrees may be much better candidates for the alternative operations

than patients with grossly destructed hip joint surfaces and severe stiffness in the hip joint.

What are these alternative operations?

Some of the alternative  operations are:

Hip osteotomy 

surface hip replacement 

other operations for avascular necrosis of femoral head 

core decompression

vascularized  bone graft

arhrodesis of the hip

For more information please visit the chapters  Surface hip replacement and  Alternative hip operations

For recent reports on surface hip replacement visit also the chapter  More details on recent reports on surface replacement

For information on metal levels in patients with metal on metal surface hip replacements visit the chapter Metal-on-metal total hips

There are patient support groups on Internet providing   personal experiences of  patients operated on with double-cup prostheses and addresses of the surgeons who perform this operation.

http://members.tripod.com/totallyhip1/index1.htm

  www.activejoints.com/faq.html

               (3)

What are the long term results of total hip replacement in the young patients?

The young patients wish to receive a total hip joint that will last long. What are the long term results ( >10 years) with total hip replacements in young patients.

This question has no simple answer,  mainly because not many surgeons have operated on  many young patients and followed them for a sufficiently long time after the surgery.

One of the most reliable statistics with 25 years of follow up showed following rates of total hips still in function (Berry 2002) 25 years after the operation

All patients were operated on with only one model of cemented total hip prosthesis. The operation technique used in this report is, actually, > 25 years old.  Obviously, the only factor responsible for the lower rate of total hips still in function in young patients is their young age.

Bad results with with "modern and improved designs" of total hips in young patients may be, however, an effect of a bad prosthesis rather than the effect of the young age. Studies demonstrated that many of these  "new and improved" models have been failing not only in the young but  also in the older patients.  (Furnes 2001).

Ask always your surgeon about  the long term results of the total hip model that he / she recommends to you.

(4)

Should you have a cementless total hip prosthesis?

The rationale for the use of cementless total hips in the  young patients is following:

The  bone cement, that has been used for the fixation of total hips to the skeleton in the past, ages, cracks, and loses its fixation capacity as the time goes. In young patients, who put large stresses on their total hips for several years, the bone cement is of course a  weak link.

In theory, total hip prosthesis  anchored to the skeleton by direct bone ingrowth, would escape this weak link - the bone cement.

One Web site states:  "The good thing about the cementless total hip replacement is that, once the bone tissue heals onto the surface of the total hip prosthesis, there is little chance of the prosthesis ever developing loosening". (www.rothmaninstitute.com)

What have been the results of cementless total hips in comparison with cemented total hips in young patients? This, again, is  a difficult question.

• There are different types of cementless prostheses with different performance

• Surgeons often have experience with only few total hip operations done on young patients.

The Norwegian Arthroplasty Register provides  a reliable statistics on large number of total hip operations done on young patients with different types of total hip prostheses both cemented and cementless.

  (http://info.haukeland.no/nrl). 

The failure rate during the ten postoperative years for the cups in this study were higher then the failure rate of the prosthetic stems.  I  thus compiled the results in two Tables.

Moreover, the word "cementless" actually does not define the type of a cementless total hip sufficiently.

Depending on the surface of the prosthesis, the surface of a cementless total hip for anchorage in the skeleton may be

smooth,

porous coated,

apatite coated.

It is obvious, that the best results showed the total hip prostheses with  cementless, apatite-coated stems. The uncoated, smooth cementless stems have had catastrophic rates of failure.

The results are slightly different for  the cup components.

 The cemented cups demonstrated the best results, followed by the apatite coated cementless cups. The difference between these two types of prostheses is, however, small and without statistic significance. Smooth, screw-in cups shoved catastrophic rates of failure.

Conclusions:

 1) Not all "cementless" total hip prostheses perform alike

  2) The 10 year results of the modern, apatite coated total hip prostheses in young patients are equally good  or even better  better   than the results of cemented total hips.

   3) You should discuss the question of the cementless prosthesis with your surgeon carefully.

(5)

Results of total hip operation depend on the diagnosis

The results of total hip operations done on young patients depend on the diagnosis of the hip joint disease.

(Furnes, 2001). The most important fact appearing from this Table is the high failure rate of total hip prostheses for young patients with previous hip fracture.  The bad results of total hip operation in patients with previous hip fracture appear  also in other reports.

(6)

What is the main problem of the total hip  replacement in the young patient?

Main problem of the total hip   replacement in the young patients is  that their total hip  prostheses are loosing fixation to the skeleton too often and too early.  The surgeons  offer the following explanation:

Young patients are more active and put more stress on their total hips and on the interface that secures the hip prosthesis to the skeleton.  Total hips  and their fixation to the skeleton, as all man made objects, wear with time. Because the young patients live longer, the increased stresses act on the total hips  longer time.

The increased stresses wear off  mechanically the fixation of the hip joint prosthesis to the skeleton.  The increased stresses also increase the wear of small particles from  the gliding articulating surfaces of the artificial hip  joints.

The increasing quantities of the wear particles produced in the total hips of young patients  trigger the bone dissolving  disease (osteolysis) that is today considered the main cause of loosening of artificial joints.

Probably only a few  of the today's total hip prostheses will be in  function 30+ years, the time span the modern young patients are expected to live. Thus, young patients should expect that they will probably have a second, revision operation, with a new prosthesis during their lifetime.

It is thus important, that the first total hip prosthesis should make the second replacement operation easy and likely successful. The less skeleton is removed, distorted, and changed at  the first operation, the better

You should also know that for many of the models of total hip prostheses, no clinical data exist at this time to prove that one concept or prosthesis model is better than another.

You should consult carefully your surgeon and ask him to provide you with data about the results of the chosen type of your total hip prosthesis.

Before you take any action, please read the Disclaimer

References:

Berry  et al.  J Bone Joint Surg-Am 2002; 84-A: 171- 7

Mancuso et al.  Indications for Total Hip and Total Knee Arhroplasties. J  Arthroplasty, 1996, 11, 34 - 46)

Malchau et al.: Prognosis of total hip replacement, AAOS Meeting, Orlando 2002

Norvegian Arthroplasty Register.: Survival of the Uncemented Primary Total Hip Prostheses. AAOS Meeting, March 15-19,2000, Orlando, Florida

  Furnes et al,: Hip disease and prognosis of total hip replacement.  J Bone Joint Surg-Br, 2001, 83-B; 579- 86

Healy WL et al. Athletic Activity after Joint Replacement. Am Journal Sports Medicine; 2001, 29: 377 - 88

  Zahri CA et al. Assessing activity in joint replacement patients. J Arthroplasty, 1998,13, 890-95.

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