Corresponding Author: Andriessanto
Ceelvin Lengkong�
E-mail: [email protected]
INTRODUCTION
Total hip replacement is a surgical procedure often
performed to treat severe pain and functional disorders of the hip joint. Total
hip arthroplasty (THA) is a frequently chosen treatment option for hip
pathology in younger patients (Karachalios et al.,
2018). Data from the arthroplasty registry show an increase
in the use of THA to treat hip pathology in patients under 50 years of age in
the last two years (Kahlenberg et al.,
2019).
Although this surgery is generally considered safe and
effective in restoring normal pelvic function and reducing pain, there is still
a risk of associated complications, one of which is revision. Revision refers
to a follow-up surgical procedure that is required if problems or failure occur
with the first total hip replacement performed (Khatod et al., 2015). Various studies have investigated epidemiological
trends related to THA failure in the general population. Bozic and colleagues
reported that more than 50,000 THAs were performed in the United States. They
found that the most common reason for revision was instability, followed by
mechanical loosening and infection (Gwam et al., 2017).
THA failure imposes a high economic burden, as well as
causing significant levels of morbidity for patients. The importance of
minimizing the risk of THA failure is especially emphasized in patients who are
young and require implants that can survive decades of use throughout their
lifetime (Kahlenberg et al.,
2019). The frequency of THA revisions is projected to
double by 2026, likely due to increased demand for higher activity and
increased implant durability. Despite advances in implant design and surgical
techniques over the past 40 years, the revision burden has remained unchanged.
Therefore, orthopedists must understand the factors contributing to these
challenges (Gwam et al., 2017).
In an era of innovation in surgical approaches for
total hip arthroplasty (THA), there is concern for increasing trends of early
failure. Based on this background description, researchers are interested in
conducting research titled "Revision Rates and Causes in Total Hip
Replacement: A Systematic Review." A deeper understanding of the factors
influencing THA revision rates can assist medical practitioners in planning
more effective prevention strategies, including identifying high-risk patients
and implementing appropriate preventive measures. This study aimed to
systematically review the literature to analyze revision rates and causes of
total hip replacement.
METHOD
This research uses
a systematic literature review method following PRISMA guidelines. The PRISMA
method consists of 5 stages: 1) defining eligibility criteria, 2) determining
information sources, 3) data selection, 4) data collection, and 5) data
retrieval. The systematic literature review (SLR) method is a structured and
organized research approach to investigate and synthesize the evidence
available in the scientific literature on a particular topic. This approach
involves systematic searching, selecting, assessing, and analyzing literature
relevant to predetermined research objectives. The data collection technique in
this research uses literature study techniques. Literature searches were
conducted in electronic databases such as PubMed, Scopus, and Google Scholar.
The data used in this research has several inclusion criteria, including being
in Indonesian or English, with a publication period of 2014-2024. Based on the
established criteria, the research flow and results that will be used in this
research are depicted in the following PRISMA diagram:
Figure 1. PRISMA Diagram
The data that has been collected is then analyzed in
three stages, namely data reduction, data presentation, and conclusion.
RESULTS AND DISCUSSION
This result is extracted from the
data and relevant sources that meet the eligibility criteria (Liberati et al., 2009).
Table
1. Research Results
|
No
|
Name and Year of Research
|
Research Title
|
Research Result
|
|
1
|
(Dilogo, 2019)
|
Realizing Breakthroughs and Independence in
Reparation, Restoration, Regeneration, Reconstruction, and Replacement of
Bones, Pelvic Joints, and Knees in Indonesia
|
The increasing cases and complexity of fractures and
degenerative diseases of the hip and knee joints require a comprehensive and
innovative approach. For this reason, the Department of Orthopaedics and
Traumatology, SCTE-RC IMERI, UPT PTK Stem Cell FKUI-RSCM has conducted basic,
translational, clinical research and innovation to medical services. With
these efforts, it is hoped that the Indonesian people will be pain-free, free
to move, have no bone and joint defects, function well, and continue to be
productive.
|
|
2
|
(Balato et al., 2021)
|
Management of septic arthritis of the hip joint in
adults. A systematic review of the literature
|
Staphylococcus aureus was the most common
microorganism isolated, followed by culture-negative infections.
Arthroscopic, single- and two-stage procedures can effectively treat septic
arthritis of the hip if the indications are consistent with the type of
infection picked up. Eradication rates for two-stage revision arthroplasty
range between 85 and 100%, for the single-stage approach between 94 and 100%,
and arthroscopic debridement/lavage, between 89 and 100%.
|
|
3
|
(Chaudhry et al., 2022)
|
Transfusion Rates in the Operative Treatment of
Prosthetic Hip and Knee Infection
|
ABT rate and number of units transfused were
assessed. Factors associated with ABT were evaluated with a multilevel
mixed-effects regression model. Of all cases, 77 (54%) required ABT. The
highest ABT rates occurred during explantation (74%) and spacer exchange
(72%), followed by reimplantation (36%) and modular component exchange (33%).
Lower preoperative haemoglobin levels were associated with a higher
likelihood of ABT. Explantation, reimplantation, and spacer exchange were
associated with a greater likelihood of ABT. Antibiotic spacer exchange and
explantation were associated with greater odds of multiple unit transfusion.
ABT rates remain high in the surgical treatment of PJI. Antibiotic spacer exchange
and explantation procedures have high multiple-unit transfusion rates, and
additional blood units should be available. Preoperative anaemia should be
treated if possible, and further refinement of blood management protocols for
prosthetic joint infections is needed.
|
|
4
|
(Nafisah et al., 2022)
|
Hip Abduction Pillow untuk Menurunkan Resiko
Dislokasi pada Pasien Pasca Operasi Total Hip Replacement
|
Dislocation is the most common complication in
patients after total hip replacement surgery. Factors leading to dislocation
or re-revision of THR consist of patient factors (number of previous revision
surgeries, abductor muscle deficiency/non-union trochanterica, history of at
least one episode of instability before revision surgery, osteonecrosis of
the femoral head (ONFH), severe acetabular and femoral bone loss, age, BMI,
and usual activity level). Procedure factors (small femoral head diameter,
single component revision, use of standard rim liner).
|
|
5
|
(Tikhilov et al., 2022)
|
Standard Versus Custom-Made Acetabular Implants in
Revision Total Hip Arthroplasty
|
The incidence of aseptic loosening of the acetabular
component after RTHA in unfilled acetabulum bone stock loss (type III-IV as
per Gross and Saleh classification) using CMAI was less than that using SAI
(2.4% and 10.0%, respectively). The most significant difference in aseptic
loosening rate was noted after CMAI and SAI implantation in pelvic
discontinuities with uncontaminated bone defects (0% and 60.0%, respectively;
P<.001).
|
|
6
|
(Descamps et al., 2023)
|
Managing early complications in total hip
arthroplasty: the safety of immediate revision
|
No infections were observed within two years after
index arthroplasty. Limb length discrepancy (88%, n=37) and dislocation
(7.1%, n=3) were the leading causes of immediate revision. In most mismatched
cases, the limb was clinically and radiologically longer before immediate
revision. The mean operative time was 48 � 14 minutes for the primary
procedure and 23.6 � 9 minutes for revision. The time between the first
incision and the last skin closure they were ranged from 1 to 3 hours. No
patient was extubated between the two procedures. Two patients had a National
Nosocomial Infection Surveillance score of 2, 13 had a score of 1, and 27 had
a score of 0. Immediate revision is safe for correcting clinical and
radiological abnormalities. It may not be associated with increased
complication or infection rates.
|
|
7
|
(Southgate & Li, 2022)
|
Registry Data Show Complication Rates and Cost in
Revision Hip Arthroplasty
|
Overall, 46.3% of patients presented due to
infection. Patients presenting with infection were 5.6 times more likely to
have recurrent rTHA than aseptic patients. Septic cases (4.3 days) had a
longer length of stay than aseptic cases (2.4) (P<.0001). However, 31% of
patients were discharged to a skilled nursing facility. The highest direct
cost was for a two-stage exchange ($37,642), and the lowest was for liner
revision ($8,979). Septic revision ($17,696) was more expensive than aseptic
revision ($11,204) (P<.0001). The 90-day re-hospitalization rate was
21.8%. Septic revision had more re-hospitalizations (13.5%) than aseptic
revision (8.3%).
|
|
8
|
(Israel et al., 2023)
|
Preclosure povidone-iodine lavage in total hip replacement
surgery: Infection outcomes and cost-benefit analysis
|
Pre-treatment povidone-iodine rinses appear to be
efficacious in decreasing THR infection rates and safe for this use based on
the 102 cases we reviewed. PrePIL costs are minimal compared to addressing
THR infection and the potential effect on hip function prognosis. The
developed mathematical formulas can be used by surgeons to calculate
cost-effectiveness and break-even costs based on THR infection rates and to
compare them with the expenses of THR revision and infection resolution.
|
Hip replacement is a joint and effective surgery.
However, patients undergoing this intervention are at risk of hip replacement
failure, requiring expensive and often complicated revision surgery with poorer
outcomes than primary surgery (Deere et al., 2021). Total hip replacement is a long-lasting operation
for most people who undergo this surgery. A hip replacement is an implanted
mechanical device with components-commonly called a "ball and socket"
- assembled before and during surgery. After surgery, the ball-and-socket
prosthesis (implant) restores hip movement throughout the life of the
prosthesis.
The main indication for total hip replacement is
pain. Patients who are unable to sleep due to pain will generally have great
results from THA and will most likely wake up after surgery and realize that
their pain has been resolved. Pain in the hip joint is usually located in the
groin or buttocks, radiating to the thigh and often to the knee. Hip arthritis
may only present with symptoms of knee pain, a common finding in elderly
patients. All patients with knee pain should undergo a physical examination of the
hip, and appropriate radiographs should be obtained if abnormalities are found
during the hip examination (Ashman et al., 2016). The accepted indications for total hip replacement
changed and expanded over the years. An operation intended as a salvage
procedure in elderly patients with low need has evolved into the operation of
choice for various pathological conditions of the hip. The main indication for
THR is end-stage osteoarthritis (Bucholz, 2014).
The location of the pain may give a clue as to the
problem. Groin pain is characteristic of hip pathology and may stem from
acetabular problems, whereas thigh pain may indicate trunk loosening. Pain in
the trochanter may result from tendinopathy, tendon rupture, or bursitis, and
buttock pain may radiate from the back. Posterior pseudotumors or collections
that irritate the sciatic nerve can also cause buttock pain. If pain is present
early on, it may indicate an infection or periprosthetic fracture. Impingement
or early failure of osseointegration may also cause pain from the first day of
surgery. Pain-free intervals followed by pain may indicate loosening or late
infection. Acetabular loosening is often asymptomatic. Night pain or persistent
pain suggests infection or malignancy. Early onset pain occurs when the patient
rises from a seated position and starts walking. A typical history of the
patient banging/striking the foot firmly on the ground several times to relieve
the pain is characteristic of loosening. Progressive loss of length may
indicate a weakening of the trunk and subsidence (Aqil & Shah,
2020).
�SimBTHA is
associated with lower total blood loss, length of hospital stay, and total
surgery cost. Reduced hospital length of stay and total cost of surgery are
essential advantages of simBTHA over stgBTHA, and they may attract the
attention of healthcare providers and policymakers. However, simBTHA remains
non-inferior to stgBTHA on most postoperative outcomes. However, we recommend
that a well-designed randomized controlled trial be conducted to elucidate the
advantages of each operation to help surgeons choose the correct surgical
method based on their point of view and the patient's benefit (Mittal et al., 2020).
Many factors contribute to dislocation after primary
THA, and its prevention requires individualized therapeutic strategies to
reduce the risk of instability. Low-volume surgeons, in particular, must be
aware of skill limitations and appropriately refer at-risk patients. In
particular, inexperienced operators can use intraoperative assistive techniques
to ensure proper placement of acetabular and femoral components. Intraoperative
assistive techniques facilitate accurate placement, thereby reducing the risk
of dislocation. The surgical goal of THA is to recreate the natural hip centre
of rotation with an appropriate combination of offset and leg length (Takahashi et al.,
2023). The implant must remain firmly attached to the
bone for a total hip replacement to function correctly. During the initial
surgery, the hip replacement components are cemented in place or "press
fit" into the bone to allow the bone to grow over it. However, the bone
may fail to grow into the press-fit component. In addition, the cemented or
pressed component that was once firmly attached to the bone may eventually
loosen, causing hip pain. The cause of looseness is only sometimes clear.
However, repetitive high-impact activities, excessive body weight, and wear of
the plastic lining between the ball and metal housing are possible contributing
factors (Khatod et al., 2015).
The leading cause of hip revision in our centre for
the past seven years has been Prosthetic Joint Infections. Due to inadequate
microbiological support and unstructured use of empirical antibiotic regimens,
no causative organism is found in many septic revisions, complicating their
management. Even in cases with positive cultures, unlike in Western countries,
the predominant organisms are hospital-acquired gram-negative microorganisms,
thus making treatment more difficult (Mittal et al., 2020).
This study presents a systematic review of the revision
rates and causes of total hip replacement (THR) based on several recent
studies. The research findings highlight the increasing cases of fractures and
degenerative diseases of the hip and knee joints, encouraging a comprehensive
and innovative approach to management. Factors such as infection, dislocation,
limb length discrepancy, and other complications are essential in determining
revision rates and replacement success. Research also highlights the importance
of preventive measures such as using pre-treatment povidone-iodine rinses to
reduce the risk of infection and implementing better blood management protocols
to optimize total hip replacement outcomes.
CONCLUSION
The results showed that infection,
dislocation, limb length discrepancy, and other complications significantly
influence total hip replacement revision rate and success. To overcome the risk
of infection, preventative measures such as using a povidone-iodine mouthwash
before treatment can be effective. Additionally, implementing better blood
management protocols can help optimize the outcomes of total hip replacement
procedures. Thus, these preventive measures are essential to consider in
clinical practice to increase the success of total hip replacement surgery and
reduce revision rates.
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