Kelmer, J Am Acad Orthop Surg 2020 - Reasons for Revision: Primary Total Hip Arthroplasty Mechanisms of Failure - Article Summary

Reasons for Revision: Primary Total Hip Arthroplasty Mechanisms of Failure

Kelmer, King, et al.·J Am Acad Orthop Surg·2020·140 citations·Hip & Knee

Retrospective single-institution review of 535 revision surgeries on 444 primary THAs performed from 2010 to 2019. The study examines which failure mechanisms drove revision and when each failure type typically occurred relative to the index procedure. It captures a critical era when both conventional polyethylene and metal-on-metal implants were in widespread use.

Key Findings

Mechanical failure was the single most common reason for revision overall at 36.5%, and its dominance grew with time, representing 41.1% of late revisions (P < 0.001). This is the default late-failure diagnosis to rule in or out when a THA patient presents years after their index surgery.
Metallosis was the second most common cause overall (21.4%) and was almost exclusively a late phenomenon. 96.8% of metallosis-driven revisions occurred ≥2 years post-op, with a mean time to late revision of 7.66 years — a direct consequence of the metal-on-metal implant wave of the 2000s.
Infection and periprosthetic fracture were statistically concentrated in the early postoperative window (both P < 0.001), making them the top diagnoses to rule out in any THA patient presenting within 2 years:
- Infection: 59.1% of cases presented as early revisions
- Periprosthetic fracture: 50.0% of cases presented as early revisions
Hard-on-hard implants reached late revision nearly twice as fast as hard-on-soft constructs (7.31 vs. 14.01 years). By the 10-year mark, 79.4% of hard-on-hard late revisions had already occurred, compared with only 28.5% of hard-on-soft late revisions. The bearing surface choice made at the index operation determines the failure timeline.
Nearly one-third of all revisions (30.6%) occurred within 2 years, with a median time to early revision of just 1.92 months. This short interval indicates most early failures were direct consequences of the index procedure, not progressive biological wear.
Metal-on-polyethylene implants lasted a mean of 13.46 years before late revision, compared with 7.31 years for metal-on-metal. A 6.15-year difference that explains why MoM patients are already failing while their metal-on-poly peers are still asymptomatic.
The overall revision burden at this institution was 7.71% over the study period, with a median time from primary THA to revision of 6.0 years across all cases.

Board PearlWithin 2 years of THA, suspect infection or periprosthetic fracture; beyond 2 years with MoM implant history, aggressively evaluate for metallosis.

Supplemental

Reasons for Revision: Primary Total Hip Arthroplasty Mechanisms of Failure

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