Abstract
Purpose
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Total hip arthroplasty (THA) is performed commonly for various end-stage diseases of the hip joint. However, the likelihood of a subsequent contralateral THA (cTHA) after primary unilateral index THA (iTHA) remains insufficiently defined, with reported rates of 13–29.1% after 5 years and 8.7–54% after 10 years of follow-up. This review aims to determine the long-term likelihood over time of cTHA after iTHA.
Methods
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Systematic review of the literature with meta-analysis, including any clinical study published until July 2022, evaluating or documenting the likelihood over time of cTHA after iTHA, independently of the etiology. Excluded were cTHA within 12 months. A total of 21 studies, including 1,456,071 patients, who subsequently received 249,117 cTHA, were analyzed. Kaplan–Meier analysis was performed, weighting data on sample size, considering death as competing risk.
Results
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At 5 years after iTHA, likelihood of cTHA was 17.8% (95% confidence interval 12.3–23.3%). At 10 years, this likelihood increased to 22.7% (16.1–29.4%), with a marginal subsequent increase. The likelihood increased slightly considering death as competing risk.
Conclusion
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Nearly every fourth THA patient will require cTHA within 10 years. The likelihood of cTHA in this review appears to fall within the lower third of previously published ranges. However, most cTHA are required within the first years. Our findings suggest that the likelihood of requiring cTHA within the initial 10 years is approximately twice as high as the likelihood of requiring revision of the iTHA.
Introduction
Total hip arthroplasty (THA) is a cost-effective and well-established intervention for various end-stage diseases of the hip joint (1, 2, 3, 4, 5). In addition to its impact on enhancing quality of life (QoL) and quality-adjusted life years, THA has even been shown to improve cognitive function in patients suffering from end-stage osteoarthritis (OA) (3, 4, 5, 6, 7). The lifetime likelihood of requiring THA for OA in high-income countries is reported to range from 8.7 to 15.9% for females and from 6.3 to 8.6% for males (8). This likelihood is expected to increase significantly in the future, particularly due to aging populations and increasing functional demands (8, 9, 10, 11).
We defined the first THA on one side as index total hip arthroplasty (iTHA), independent of the etiology. Any subsequent THA of the contralateral hip is referred to as contralateral THA (cTHA). The likelihood of requiring a subsequent cTHA after iTHA has not been assessed conclusively so far. The results of previous studies show great discrepancy between reported likelihoods, varying from 13 to 29.1% at 5 years after iTHA, respectively, from 8.7 to 54% at 10 years follow-up (12, 13, 14). There is, however, a wide range of inclusion criteria and differences in study design between publications reporting or assessing the likelihood of cTHA, limiting comparability and risk assessment. Variations in study size, design (retrospective vs prospective) and data extraction methods further contribute to the differing results. This may be exemplified by Amstutz et al., who focused on patients with idiopathic osteoarthritis without contralateral symptoms, while Sayeed et al. analyzed patients aged 50–75 after Charnley THA (12, 13). Ritter et al. examined both unilateral and bilateral osteoarthritic hips, leading to broader variability in outcomes (14).
To the best of our knowledge, this is the first systematic review and meta-analysis investigating the likelihood for requirement of cTHA after iTHA. As health systems are exposed worldwide to growing demands and financial pressure, estimating the risk of future cTHA is crucial to improve healthcare planning, optimizing resource allocation and ensuring timely follow-up for patients (5, 8, 9, 10, 11, 15). The primary aim of this study was to quantify the likelihood of cTHA following iTHA, providing a foundation for future adjustments in healthcare strategies. This could result in more efficient scheduling of follow-up care, timely interventions and overall cost savings, while also enhancing patient outcomes and satisfaction.
Methods
Studies were identified in two databases according to the AMSTAR guidelines (16), once in the Medline database from the National Library of Medicine (NLM) using the search engine PubMed and once in the Cochrane Library. Inclusion criteria were any clinical study, published until July 2022 inclusively, evaluating or documenting the likelihood over time of cTHA after primary, unilateral iTHA, independent of etiology. We excluded studies, respectively results, if cTHA was performed obviously within 12 months of iTHA. Furthermore, we excluded studies when the full text was unavailable, abstract-only publications, articles in press, conference abstracts, editorials, author responses or publications in books. Studies with data not reliably extractable, duplicate or overlapping data were also excluded.
Our search strategy followed the PRISMA 2020 guidelines for systematic reviews (see Fig. 1). The following Medical Subject Headings (MeSH) and terms were used in the search process (see Tables 1 and 2). To include any potentially relevant study, we applied a text word search (tw) with truncation of the key words (*). The language of the publications was limited to English, and in PubMed, the species filter ‘human’ was applied. The bibliographies of any relevant publications were also cross-checked for potentially eligible references. Screening of the potential studies was done and recorded by the first author without any automation tools. All records were collected into one EndNote library (version 20.4, Clarivate, USA) to manually delete duplicates. Both the first and the second author then reviewed the publications regarding inclusion and exclusion criteria. The first round was done by the first author, screening title and abstract only. The second round was done by both the first and the second author, applying inclusion/exclusion criteria to the full text of the publication. Reasons for exclusion are documented (Fig. 1). Inclusion and exclusion of a study was decided on a consensus basis between both evaluators.
Flowchart showing the process of study identification and inclusion, respectively exclusion, using the PRISMA (preferred reporting items for systematic reviews and meta-analyses) synthesis methods.
Citation: EFORT Open Reviews 10, 5; 10.1530/EOR-2024-0026
If available, data were extracted from tables or figures (17). In some of the studies, data were automatically extracted from the Kaplan–Meier (KM) survivorship figures (18, 19) using the juicr package (version 0.1) within R statistical software (v4.2.1; R Core Team 2022).
Data weighting was performed based on the number of patients included in each study. KM analysis was performed, considering the likelihood of cTHA following iTHA over time as a percentage. To simulate elimination through the competing risk of death, the global death rate of industrialized countries according to the World Health Organization was used, assuming the average patient age of 65–69 at iTHA (‘world bank income group’ = HIGH INCOME). To assess the role of the death rate, the following models were applied (Fig. 2). The first model, the red curve, represents the likelihood of cTHA including death rate and the statistical assumption that a deceased patient will not undergo subsequent cTHA. This model represents the baseline likelihood of cTHA, while the two other models incorporated additional factors. The green curve represents a scenario where patients would not die but continue to receive cTHA with the same likelihood as all survivors. The blue curve considers the likelihood of cTHA with censored death and the assumption that every deceased patient would have undergone subsequent cTHA. This model combines the baseline likelihood of the red curve, with addition of the percentage of deceased patients over time.
Kaplan–Meier analysis showing the likelihood of cTHA following iTHA over time as a percentage. The data were weighted according to the sample size of the studies included, illustrated by a dot size proportional to the number of patients. Kβ (yellow dot) represent data of patients suffering only from AVNFH. The red curve represents the likelihood of cTHA including death rate and the statistical assumption that a deceased patient would not undergo subsequent cTHA. This model represents the baseline with the average likelihood of cTHA, while the two other models incorporated additional factors. The green curve represents a scenario where patients would not die but continue to receive cTHA with the same likelihood as all survivors. The blue curve considers the likelihood of cTHA with censored death and the assumption that every deceased patient would have undergone subsequent cTHA. This model combines the baseline likelihood of the red curve, with addition of the percentage of deceased patients over time. This hypothetical scenario represents the upper limit of potential cTHA occurrence. To simulate elimination through the competing risk of death, the global death rate according to the World Health Organization was used, assuming the average patient age of 65–69 at iTHA. The dotted lines indicate the 95% confidence interval. G1: Australian Orthopaedic Arthroplasty Association National Joint Replacement Registry (AOA NJRR); G2: Norwegian Arthroplasty Register (NAR); Kβ: Primary diagnosis: Avascular necrosis of the femoral head (AVNFH); P1: Bilateral osteoarthritis (OA); P2: Unilateral osteoarthritis (OA).
Citation: EFORT Open Reviews 10, 5; 10.1530/EOR-2024-0026
Secondary parameters such as age, gender, body mass index, American Society of Anaesthesiology (ASA) score and diagnosis leading to THA were also collected, if available.
Results
Data were available from 21 studies, including a total of 1,456,071 patients who underwent iTHA and subsequently received 249,117 cTHA, at least 12 months later (Table 3). One study included only cases with avascular necrosis of the femoral head (AVNFH) as primary diagnosis (20). Data coverage of secondary parameters was insufficient, prohibiting further analysis.
The following are the Medical Subject Headings (MeSH) and terms utilized in the PubMed search process for this study.
| Search | Query | Items found | Explanation of the search |
|---|---|---|---|
| #9 | ((‘hip prosthesis’[MeSH terms] OR ‘arthroplasty, replacement, hip’[MeSH terms]) AND (‘contralateral*’[text word] OR ‘subsequent*’[text word] OR ‘bilateral*’[text word])) AND (humans[filter]) | 3,680 | Search: (#6) AND (#7); filters: humans |
| #8 | (‘Hip prosthesis’[MeSH terms] OR ‘arthroplasty, replacement, hip’[MeSH terms]) AND (‘contralateral*’[text word] OR ‘subsequent*’[text word] OR ‘bilateral*’[text word]) | 3,825 | Search: (#6) AND (#7) |
| #7 | ‘contralateral*’[text word] OR ‘subsequent*’[text word] OR ‘bilateral*’[text word] | 1,300,300 | Search: ((#3) OR (#4)) OR (#5) |
| #6 | ‘Hip prosthesis’[MeSH terms] OR ‘arthroplasty, replacement, hip’[MeSH terms] | 45,802 | Search: (#1) OR (#2) |
| #5 | ‘bilateral*’[text word] | 311,069 | |
| #4 | ‘subsequent*’[text word] | 930,810 | |
| #3 | ‘contralateral*’[text word] | 95,840 | |
| #2 | ‘Arthroplasty, replacement, hip’[MeSH terms] | 32,559 | |
| #1 | ‘Hip prosthesis’[MeSH terms] | 24,978 |
The following are the Medical Subject Headings (MeSH) and terms utilized in the Cochrane search process for this study.
| Search | Query | Items found | Explanation of the search |
|---|---|---|---|
| #8 | ((MeSH descriptor: [hip prosthesis] explode all trees) OR (MeSH descriptor: [arthroplasty, replacement, hip] explode all trees)) AND (((contralateral):ti,ab,kw) OR ((bilateral):ti,ab,kw) OR ((subsequent):ti,ab,kw)) | 241 | Search #3 AND #7 |
| #7 | ((contralateral):ti,ab,kw) OR ((bilateral):ti,ab,kw) OR ((subsequent):ti,ab,kw) | 66,373 | Search #4 OR #5 OR #6 |
| #6 | (subsequent):ti,ab,kw | 40,466 | |
| #5 | (bilateral):ti,ab,kw | 20,682 | |
| #4 | (contralateral):ti,ab,kw | 7,113 | |
| #3 | (MeSH descriptor: [hip prosthesis] explode all trees) OR (MeSH descriptor: [arthroplasty, replacement, hip] explode all trees) | 2,771 | Search #1 OR #2 |
| #2 | MeSH descriptor: [arthroplasty, replacement, hip] explode all trees | 2,092 | |
| #1 | MeSH descriptor: [hip prosthesis] explode all trees | 1,168 |
Summary of studies included.
| Reference | Year published | Country | Observation | Mean FU, years | iTHA, n | cTHA, n |
|---|---|---|---|---|---|---|
| Amstutz et al. (12) | 2016 | USA | 1998–2010 | 11; 8.5 † | 367 | 59 |
| Cnudde et al. (49) | 2018 | Sweden | 1999–2012 | 5.6 † | 133,654 | 32,077 |
| Espinosa et al. (40) | 2019 | Sweden | 1992–2014 | 8, 6 † | 177,834 | 39,676 |
| Garland et al. (48) | 2015 | Sweden | 1992–2012 | N/A | 189,276 | 40,558 |
| Gazendam et al. (58) | 2022 | Canada | 1999–2019 | 1* | 8,273 | 1,213 |
| Gillam et al. (38) | 2012 | Australia | 2002–2008 | N/A | 84,759 | 9,997 |
| Gillam et al. (46) | 2013 | Australia | 2002–2010 | N/A | 78,634 | 12,668 |
| Gillam et al. (46) | 2013 | Norway | 2002–2010 | N/A | 19,786 | 3,867 |
| Goker et al. (59) | 2000 | USA | 1984–1985 | 8.7 | 99 | 21 |
| Husted et al. (60) | 1996 | Denmark | 1981–1994 | 5.6 | 1,199 | 356 |
| Kim et al. (20) | 2019 | South Korea | 2003–2011 | 7 | 121 | 59 |
| Lamplot et al. (39) | 2018 | USA | 2006–2013 | >5 | 24,946 | 5,198 |
| Lie et al. (18) | 2004 | Norway | 1987–2000 | 5.3 † | 47,355 | 8,427 |
| Moore et al. (61) | 2022 | USA | 2010–2020 | N/A | 640,418 | 87,593 |
| Ravi et al. (62) | 2013 | Canada | 2002–2009 | 2 | 37,670 | 4,571 |
| Ritter et al. (14) | 1996 | USA | 1970–1980 | N/A | 179 | 96 |
| Ritter et al. (14) | 1996 | USA | 1970–1980 | N/A | 664 | 58 |
| Sanders et al. (19) | 2017 | USA | 1969–2008 | 12 | 1933 | 422 |
| Santana et al. (17) | 2020 | USA | 2004–2006 | 4 | 132 | 42 |
| Sayeed et al. (13) | 2009 | USA | 1969–1984 | 21.9 | 2,547 | 903 |
| Sayeed et al. (41) | 2012 | USA | 2001–2008 | 8.6 | 332 | 74 |
| Shakoor et al. (37) | 2002 | USA | 1981–2001 | N/A | 3,458 | 439 |
| Shao et al. (63) | 2013 | China | 1987–2000 | 17.8 | 2,435 | 743 |
N/A, data not available; FU, follow-up; iTHA, index THA; cTHA, contralateral THA.
Follow-up data given in the text without connection to extracted data.
Values are median.
The overall likelihood of cTHA, considering death rate for the age group 65–69 years old in industrialized countries as a competing risk, was 17.8% (95% confidence interval 12.3–23.3%) within 5 years after iTHA and increased to 22.7% (16.1–29.4%) within 10 years, respectively (Fig. 2, red curve). At 15 and 20 years, this likelihood increased further to 25.6% (18.3–32.9%) and 27.7% (19.9–35.5%), respectively. Assuming deceased patients would continue to receive cTHA with the same likelihood as indicated above (red curve), the likelihood of cTHA increased to 18.1% (12.6–23.6%) after 5 years and 23.4% (16.8–30.1%) after 10 years, respectively (Fig. 2, green curve). The hypothetical scenario where every deceased patient would have undergone subsequent cTHA over time (blue curve) showed a likelihood of 19.7% (14.2–25.2%) within 5 years after iTHA and 25.7% (19.1–32.4%) after 10 years (Fig. 2, blue curve).
Patients undergoing iTHA due to AVNFH exhibited notably elevated likelihood of requiring cTHA of 49% within a mean of 7 years of follow-up (20).
Discussion
To the best of our knowledge, this study is the first systematic review of the literature with meta-analysis performed to assess the likelihood of cTHA over time. Most of the cTHAs were required within the first years and nearly every fourth THA patient required cTHA within 10 years.
Considering the necessary duration of follow-up to evaluate the outcome, death must be considered as a competing risk. As patients die, they are no longer at risk for cTHA, which inherently lowers the observed rates of contralateral surgery. Ignoring this factor could lead to an overestimation of the likelihood of cTHA, especially in older populations, by definition more likely to suffer this outcome. Respectively, cTHA rates would be underestimated in younger populations exempt from significant mortality during the relevant follow-up. Therefore, mortality data from the global WHO database were integrated into the analysis. We chose the index mortality rate from the group 65–69 years of age, as this corresponds to the typical average age of THA patients (21, 22, 23, 24). Thus, patients are old enough to reflect the most common THA demographic, yet young enough that mortality does not overwhelmingly bias the results. However, it is important to recognize that the evaluation of death as a competing risk using the high-income group, as defined by the World Bank, is only an approximation and results may vary among countries. Nonetheless, our decision to focus on high-income countries aligns with the population represented in the studies included (Table 3).
Our basic model (Fig. 2, red curve) represents the likelihood of cTHA, assuming deceased patients would not undergo subsequent cTHA. As mortality risks may vary, this must be considered when counseling individual patients. It shows the minimal likelihood of cTHA over time, varying from 17.8% after 5 years to 22.7% after 10 years, which appears to fall within the lower third of previously published ranges (13–29% at 5 years after iTHA and 8.7–54% at 10 years after iTHA) (12, 13, 14). Most of the patients analyzed suffered OA as primary diagnosis, while the lifetime likelihood of requiring THA for OA in high-income countries is reported to range from 8.7 to 15.9% for females and from 6.3 to 8.6% for males (8), and while other diagnoses such as AVNFH may be associated with much higher rates of cTHA (20). The discrepancies between our findings and previous studies can be attributed to several factors. We defined iTHA and cTHA independently of the etiology. The variability in reported likelihoods may be due to differences in inclusion criteria not only linked to etiology, but also to age of the patients. Furthermore, different study designs and data extraction methods may also contribute to the varying reported outcomes.
The second model (Fig. 2, green curve) considers a scenario where patients would not die but continue to receive cTHA with the same likelihood as in the basic red model. This is particularly applicable to younger patients than the group aged 65 – 69 years considered for incorporation of the mortality risk. Although the difference between the minimal likelihood (Fig. 2, red curve) and the potential likelihood without mortality (Fig. 2, green curve) is small, it may also represent a realistic increase in cTHA due to rising life expectancy in the future, as life expectancies are calculated on current mortality data and thus suffer from a time lag.
The third model (Fig. 2, blue curve) is a hypothetical scenario, considering the likelihood of cTHA with censored death and the assumption that every deceased patient would have undergone subsequent cTHA over time. It represents the upper limit of potential cTHA occurrence in our analysis. This model presents a valuable framework for the assessment of younger patients with much lower mortality than the reference group incorporated into the analysis. The National Joint Registry of the UK showed that younger patients had lower risk of death at time of iTHA, with approximately half the risk of death for male patient below the age of 55, in comparison to their counterparts aged 65–69 years (25). Thus, they have more time to potentially undergo cTHA over the remaining lifespan. Analyzing a younger cohort with a lower risk of death in our study would likely result in the three curves aligning over time. This hypothetical convergence underlines the role of age as a pivotal determinant in this analysis. However, age distribution of elective primary iTHA varies, even if the mean age is similar among the various reports. The American Joint Replacement Registry (AJRR) reports 19.7% of patients being within the age of 50–59 years, with a mean age of 65.7 years, whereas the German Arthroplasty Registry (EPRD) reports 20.9% of patients aged 55–64 years, with a higher mean age of 72 years (23, 24). The Swiss National Hip and Knee Joint Registry (SIRIS) Report 2022 shows stable age groups since 2016, with 66.8% of THAs performed in patients older than 65 years of age (21). As delineated in the 2022 Annual Report of the Australian Orthopaedic Association National Joint Replacement Registry, an estimated 35% of patients undergoing THA within the period spanning from 2003 to 2021 were under the age of 65 (22).
Meanwhile, the incidence of primary THA is rising, varying in the Australian arthroplasty registry report from 86.6 per 100,000 inhabitants in 2003 to 160.9 in 2021, and from 208 per 100,000 inhabitants in 2013 to 250 in 2021 in the Swiss arthroplasty registry report (21, 22). THA projections for the United States show total numbers increasing by up to 174% until the year 2030 (9, 26). In Organization for Economic Co-operation and Development (OECD) countries, numbers of THA are expected to grow from 1.8 million per year in 2015 to 2.8 million in 2050 (15). Numbers of THA performed in Australia, New Zealand, Ireland, Norway and Switzerland are expected to double until 2050 (15). Despite these predictions, the crucial inquiry of the optimal postoperative follow-up strategy for these individuals remains unresolved, with a large variation in timing of postoperative follow-up examinations (27). Current guidelines recommend routine follow-up at 10 years after iTHA. However, there is significant variability in the number of intermediate examinations leading up to this 10-year timeframe. Recommendations range from the two to six examinations until the 10-year follow-up (27, 28, 29, 30, 31). Our findings suggest that the likelihood of requiring cTHA within the initial 10 years is approximately twice as high as the likelihood of requiring revision (32, 33, 34, 35, 36). Interestingly, despite this observation, the existing literature tends to focus on the latter aspect (32, 33, 34, 35, 36). One might consider more frequent follow-up examinations during the first 3–5 years to assess patient needs for cTHA and provide adequate counseling and treatment rather than basing the follow-up schedule primarily on the less probable need for revision of the iTHA. Waiting for these patients to spontaneously present themselves might be inadequate, especially among the elderly and cognitively impaired patients, considering the costs and the cognitive decline induced by OA (3, 7). Furthermore, it remains unclear whether a more satisfied patient presents for earlier cTHA than a less satisfied patient. With rising financial pressure on healthcare systems, our data may affirm proactive assessment for potential total joint arthroplasty (TJA) necessity (5).
Our analysis of likelihood of cTHA extended beyond patients with OA to encompass all etiologies. However, OA remains the most common diagnosis leading to THA and usually is not a process affecting solely a single joint (37, 38). In a large database study of over 85,000 patients who underwent THA, total knee arthroplasty (TKA) and total shoulder arthroplasty, 23% underwent contralateral arthroplasty of the same joint within 5–8 years after the index operation (39). Obesity was reported as the greatest risk factor (39). According to a recent analysis of the Swedish Hip and Knee Register (SHAR and SKAR), with over 300,000 patients included, the highest risk for subsequent TJA affects the same joint on the contralateral side (40). Therefore, it is important to consider the risk of contralateral joint deterioration and the potential need for future surgery when considering iTHA for patients with primary OA. Based on combined severity of clinical symptoms and radiographic findings, low-risk patients showed only 1% chance of contralateral progression of OA, whereas high-risk patients had a 97% chance of OA progression, resulting in cTHA (41). However, cohorts with cTHA due to less common primary diagnosis other than OA, e.g., AVNFH only, showed a particularly high risk of cTHA (20, 42), whereas patients with developmental dysplasia of the hip (DDH) have a higher probability of progressing to end-stage osteoarthritis or THA at 10- and 20-year follow-up compared with femoroacetabular impingement (FAI) and normal morphology (43). In contrast, patients undergoing periacetabular osteotomy (PAO) for hip dysplasia typically have lower rates of advanced osteoarthritis and are significantly younger at the time of surgery, which results in a lower and less comparable risk for cTHA (44). These patients show long-term survivorship of the treated hip joint, with a 30-year cumulative survival rate free from THA of 29%, a rate which may not automatically be transposed to the contralateral hip joint.
This study has some limitations. There were single institution studies and multicenter registry analysis, retrospective and prospective study designs, small studies and population or national registry reports with large sample sizes. Data had to be extracted from tables, figures and KM survivorship curves, the latter being a possible source of error. However, data extraction from Kaplan–Meier (KM) graphs was conducted using an automated method to limit measurement bias and reduce the inaccuracies often associated with manual data extraction. An inherent risk of this meta-analysis is the issue of selection bias, since the investigated groups cannot be equal with respect to primary diagnosis, distribution of ethnicities or access to medical care, to name only a few. The large sample size of this review, including data from over a million patients, minimizes the impact of outliers or smaller studies. However, all studies included were conducted in industrialized countries with presumably similar – or at least comparable – access to the healthcare system, which should enhance the generalizability of our findings (45). Although most arthroplasty registries do not routinely include data on comorbidities, it is essential to recognize their impact. Patients with significant comorbidities may face challenges for secondary operations, potentially affecting the observed likelihood of cTHA.
Furthermore, a small part of the studies documented the first and second TJA procedures, including both hips and knees (40, 46). Even though it was not possible to determine if later TJA involved cTHA or TKA, these studies were included in the analysis. This should have no relevant effect on our results, considering that overall, the outcomes of more than a million patients could be in our analysis. In addition, data coverage of the included hip arthroplasty registries, which represent the predominant part of the data analyzed, is high to almost complete (18, 38, 40, 46, 47, 48, 49). The possibility of overlapping data between different studies cannot be ruled out completely. However, this factor should be considered irrelevant in terms of the overall distribution of the included studies since there is no direct geographical overlap among them.
This study is strengthened by its design. Published studies have been identified through searches of two different databases. Three models have been constructed to consider the competing risk of death and the influence of age at iTHA on the likelihood of cTHA. However, KM analysis provides only an estimate, with a potential for deviation in case of competing risks, since the KM method treats those who died (having no more risk of cTHA) similarly to those who are lost to follow-up (who could still be subject to cTHA). Thus, KM findings may suffer from underestimation (50). The notable strength of the green curve model lies in its mitigation of this bias. It illustrates the scenario, where patients would not die but continue to receive cTHA with the same likelihood, as indicated in the red curve.
To determine the long-term likelihood over time of cTHA after iTHA more accurately, we arbitrarily did not include patients with cTHA within 12 months. This affected two studies (19, 39). Those patients most probably presented from the beginning with bilateral disease, leading to cTHA shortly after recovery from iTHA, not corresponding to the study question of requirement for later cTHA. Particularly, since there is no uniform definition for simultaneously or planned staged bilateral THA (48), misclassification and/or insufficient data documentation may otherwise have biased this analysis. The debate about the role of simultaneous bilateral THA (sbTHA) goes beyond the scope of this review (51, 52, 53, 54).
To the best of our knowledge, no other study has analyzed the risk of cTHA within the scope of a meta-analysis. The results suggest that every sixth patient receiving iTHA undergoes cTHA within 5 years and about every fourth patient within 10 years. Addressing patient concerns regarding the risk of cTHA may be relevant to improve patient satisfaction. Moreover, it may decrease healthcare burden, as OA reduces QoL, impairs cognitive function and conservative treatment also induces costs (1, 2, 3, 4, 5, 6, 7). The increasing incidence rate of primary THA worldwide emphasizes the importance of understanding and addressing the likelihood of cTHA (9, 15, 45, 55, 56, 57). This knowledge can help in implementing cost-effective strategies, optimizing THA follow-up, especially considering the higher likelihood of requiring a cTHA than the risk for revision of iTHA, according to our data (32, 33, 34, 35, 36). Conducting a prospective study to analyze the risk of cTHA within 3–12 months after iTHA would be important to refine the analysis. We therefore emphasize the necessity of further studies investigating the risk of cTHA.
ICMJE Statement of Interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the work reported.
Funding Statement
This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.
Author contribution statement
Conceptualization was done by CM, PW and JL. All authors helped in methodology. Formal analysis was done by MS. JL and MS helped in investigation. Writing of the original draft was done by JL. CM, PW and MS helped in review writing and editing. MS helped in visualization. Supervision was done by PW.
References
- 1↑
Learmonth ID , Young C & Rorabeck C . The operation of the century: total hip replacement. Lancet 2007 370 1508–1519. (https://doi.org/10.1016/s0140-6736(07)60457-7)
- 2↑
Kandala NB , Connock M , Pulikottil-Jacob R , et al. Setting benchmark revision rates for total hip replacement: analysis of registry evidence. BMJ 2015 350 h756. (https://doi.org/10.1136/bmj.h756)
- 3↑
Ethgen O , Bruyere O , Richy F , et al. Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature. J Bone Joint Surg Am 2004 86 963–974. (https://doi.org/10.2106/00004623-200405000-00012)
- 4↑
Judge A , Arden NK , Kiran A , et al. Interpretation of patient-reported outcomes for hip and knee replacement surgery: identification of thresholds associated with satisfaction with surgery. J Bone Joint Surg Br 2012 94 412–418. (https://doi.org/10.1302/0301-620x.94b3.27425)
- 5↑
Wilson RA , Gwynne-Jones DP , Sullivan TA , et al. Total hip and knee arthroplasties are highly cost-effective procedures: the importance of duration of follow-up. J Arthroplast 2021 36 1864–1872.e10. (https://doi.org/10.1016/j.arth.2021.01.038)
- 6↑
Pennington MW , Grieve R & van der Meulen JH . Lifetime cost effectiveness of different brands of prosthesis used for total hip arthroplasty: a study using the NJR dataset. Bone Joint Lett J 2015 97-B 762–770. (https://doi.org/10.1302/0301-620x.97b6.34806)
- 7↑
Strahl A , Kazim MA , Kattwinkel N , et al. Mid-term improvement of cognitive performance after total hip arthroplasty in patients with osteoarthritis of the hip : a prospective cohort study. Bone Joint Lett J 2022 104-B 331–340. (https://doi.org/10.1302/0301-620x.104b3.bjj-2020-2021.r2)
- 8↑
Ackerman IN , Bohensky MA , de Steiger R , et al. Lifetime risk of primary total hip replacement surgery for osteoarthritis from 2003 to 2013: a multinational analysis using national registry data. Arthritis Care Res 2017 69 1659–1667. (https://doi.org/10.1002/acr.23197)
- 9↑
Kurtz S , Ong K , Lau E , et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007 89 780–785. (https://doi.org/10.2106/00004623-200704000-00012)
- 10↑
Pilz V , Hanstein T & Skripitz R . Projections of primary hip arthroplasty in Germany until 2040. Acta Orthop 2018 89 308–313. (https://doi.org/10.1080/17453674.2018.1446463)
- 11↑
Singh JA , Yu S , Chen L , et al. Rates of total joint replacement in the United States: future projections to 2020–2040 using the national inpatient sample. J Rheumatol 2019 46 1134–1140. (https://doi.org/10.3899/jrheum.170990)
- 12↑
Amstutz HC & Le Duff MJ . The natural history of osteoarthritis: what happens to the other hip? Clin Orthop Relat Res 2016 474 1802–1809. (https://doi.org/10.1007/s11999-016-4888-y)
- 13↑
Sayeed SA , Trousdale RT , Barnes SA , et al. Joint arthroplasty within 10 years after primary charnley total hip arthroplasty. Am J Orthop 2009 38 E141–E143.
- 14↑
Ritter MA , Carr K , Herbst SA , et al. Outcome of the contralateral hip following total hip arthroplasty for osteoarthritis. J Arthroplast 1996 11 242–246. (https://doi.org/10.1016/s0883-5403(96)80073-8)
- 15↑
Pabinger C , Lothaller H , Portner N , et al. Projections of hip arthroplasty in OECD countries up to 2050. Hip Int 2018 28 498–506. (https://doi.org/10.1177/1120700018757940)
- 16↑
Shea BJ , Reeves BC , Wells G , et al. Amstar 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017 358 j4008. (https://doi.org/10.1136/bmj.j4008)
- 17↑
Santana DC , Anis HK , Mont MA , et al. What is the likelihood of subsequent arthroplasties after primary TKA or THA? Data from the osteoarthritis initiative. Clin Orthop Relat Res 2020 478 34–41. (https://doi.org/10.1097/corr.0000000000000925)
- 18↑
Lie SA , Engesæter LB , Havelin LI , et al. Dependency issues in survival analyses of 55,782 primary hip replacements from 47,355 patients. Stat Med 2004 23 3227–3240. (https://doi.org/10.1002/sim.1905)
- 19↑
Sanders TL , Maradit Kremers H , Schleck CD , et al. Subsequent total joint arthroplasty after primary total knee or hip arthroplasty: a 40-year population-based study. J Bone Joint Surg Am 2017 99 396–401. (https://doi.org/10.2106/jbjs.16.00499)
- 20↑
Kim SC , Lim YW , Kwon SY , et al. Effect of leg-length discrepancy following total hip arthroplasty on collapse of the contralateral hip in bilateral non-traumatic osteonecrosis of the femoral head. Bone Joint Lett J 2019 101-B 303–310. (https://doi.org/10.1302/0301-620x.101b3.bjj-2018-1053.r1)
- 21↑
SIRIS – Foundation for Quality Assurance in Implant Surgery . SIRIS report 2022 annual report of the Swiss national joint registry. In Hip and Knee. SIRIS – Foundation for Quality Assurance in Implant Surgery. (https://www.siris-implant.ch/en/Downloads?download=272)
- 22↑
AOANJRR . Demographics of Hip, Knee and Shoulder Arthroplasty: Supplementary Report in Hip, Knee & Shoulder Arthroplasty: 2022 Annual Report. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). (https://aoanjrr.sahmri.com/documents/10180/732916/AOA+2022+AR+Digital/f63ed890-36d0-c4b3-2e0b-7b63e2071b16)
- 23↑
American Academy of Orthopaedic Surgeons (AAOS) . American Joint Replacement Registry (AJRR): 2022 Annual Report. American Academy of Orthopaedic Surgeons American Joint Replacement Registry. (https://connect.registryapps.net/hubfs/PDFs%20and%20PPTs/2022%20AJRR%20Annual%20Report.pdf)
- 24↑
EPRD TGAR . Annual Report 2022 the German Arthroplasty Registry (EPRD). The German Arthroplasty Registry (EPRD). (https://www.eprd.de/fileadmin/user_upload/Dateien/Publikationen/Berichte/AnnualReport2022-Web_2023-03-30_F.pdf)
- 25↑
Ben-Shlomo Y , Blom A , Boulton C , et al. The national joint registry 19th annual report 2022. In National Joint Registry Annual Reports. London: National Joint Registry. (https://pubmed.ncbi.nlm.nih.gov/36516281/)
- 26↑
Lovelock TM & Broughton NS . Follow-up after arthroplasty of the hip and knee : are we over-servicing or under-caring? Bone Joint Lett J 2018 100-B 6–10. (https://doi.org/10.1302/0301-620x.100b1.bjj-2017-0779.r1)
- 27↑
Loppini M , Gambaro FM , Nelissen R , et al. Large variation in timing of follow-up visits after hip replacement: a review of the literature. EFORT Open Rev 2022 7 200–205. (https://doi.org/10.1530/eor-21-0016)
- 28↑
Broughton NLT , De Steiger R , Page R , et al. Guidelines for long term follow-up of joint replacement patients (Arthroplasty Society of Australia) 2019 17th July 2023. (https://aoa.org.au/docs/default-source/advocacy/2019-asa-guidelines-for-long-term-follow-up-of-joint-replacement-patients.pdf?sfvrsn=c9bac204_10)
- 29↑
Registry AOANJR . Annual Report 2006. Australian Orthopaedic Association. (https://aoanjrr.sahmri.com/documents/10180/75132/Annual+Report+2006.pdf/01333a47-e762-4d32-a822-df3064516fa9?t=1349440962263&download=false)
- 30↑
Association BO . Primary total hip replacement: a guide to good practice 2012 17th July 2023, 1999. Revised Aug 2006, Nov 2012. (https://britishhipsociety.com/wp-content/uploads/2020/12/2012-Nov_BOA-Blue-Book.pdf)
- 31↑
Care AAoHaKSAHaK . American association of hip and knee surgeons (AAHKS), 2023. (https://hipknee.aahks.org/dont-take-your-new-joint-for-granted-follow-up-care/)
- 32↑
Sadoghi P , Schroder C , Fottner A , et al. Application and survival curve of total hip arthroplasties: a systematic comparative analysis using worldwide hip arthroplasty registers. Int Orthop 2012 36 2197–2203. (https://doi.org/10.1007/s00264-012-1614-6)
- 33↑
Nugent M , Young SW , Frampton CM , et al. The lifetime risk of revision following total hip arthroplasty. Bone Joint Lett J 2021 103-B 479–485. (https://doi.org/10.1302/0301-620x.103b3.bjj-2020-0562.r2)
- 34↑
Evans JT , Evans JP , Walker RW , et al. How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet 2019 393 647–654. (https://doi.org/10.1016/s0140-6736(18)31665-9)
- 35↑
Bayliss 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 population-based cohort study. Lancet 2017 389 1424–1430. (https://doi.org/10.1016/s0140-6736(17)30059-4)
- 36↑
Gademan MGJ , Van Steenbergen LN , Cannegieter SC , et al. Population-based 10-year cumulative revision risks after hip and knee arthroplasty for osteoarthritis to inform patients in clinical practice: a competing risk analysis from the Dutch Arthroplasty Register. Acta Orthop 2021 92 280–284. (https://doi.org/10.1080/17453674.2021.1876998)
- 37↑
Shakoor N , Block JA , Shott S , et al. Nonrandom evolution of end-stage osteoarthritis of the lower limbs. Arthritis Rheum 2002 46 3185–3189. (https://doi.org/10.1002/art.10649)
- 38↑
Gillam MH , Ryan P , Salter A , et al. Multi-state models and arthroplasty histories after unilateral total hip arthroplasties: introducing the Summary Notation for Arthroplasty Histories. Acta Orthop 2012 83 220–226. (https://doi.org/10.3109/17453674.2012.684140)
- 39↑
Lamplot JD , Bansal A , Nguyen JT , et al. Risk of subsequent joint arthroplasty in contralateral or different joint after index shoulder, hip, or knee arthroplasty: association with index joint, demographics, and patient-specific factors. J Bone Joint Surg Am. 2018 100 1750–1756. (https://doi.org/10.2106/jbjs.17.00948)
- 40↑
Espinosa P , Weiss RJ , Robertsson O , et al. Sequence of 305,996 total hip and knee arthroplasties in patients undergoing operations on more than 1 joint. Acta Orthop 2019 90 450–454. (https://doi.org/10.1080/17453674.2019.1638177)
- 41↑
Sayeed SA , Johnson AJ , Jaffe DE , et al. Incidence of contralateral THA after index THA for osteoarthritis. Clin Orthop Relat Res 2012 470 535–540. (https://doi.org/10.1007/s11999-011-2110-9)
- 42↑
Goker B & Block JA . Risk of contralateral avascular necrosis (AVN) after total hip arthroplasty (THA) for non-traumatic AVN. Rheumatol Int 2006 26 215–219. (https://doi.org/10.1007/s00296-004-0554-x)
- 43↑
Wyles CC , Heidenreich MJ , Jeng J , et al. The john charnley award: redefining the natural history of osteoarthritis in patients with hip dysplasia and impingement. Clin Orthop Relat Res 2017 475 336–350. (https://doi.org/10.1007/s11999-016-4815-2)
- 44↑
Lerch TD , Steppacher SD , Liechti EF , et al. One-third of hips after periacetabular osteotomy survive 30 years with good clinical results, no progression of arthritis, or conversion to THA. Clin Orthop Relat Res 2017 475 1154–1168. (https://doi.org/10.1007/s11999-016-5169-5)
- 45↑
Pabinger C & Geissler A . Utilization rates of hip arthroplasty in OECD countries. Osteoarthr Cartil 2014 22 734–741. (https://doi.org/10.1016/j.joca.2014.04.009)
- 46↑
Gillam MH , Lie SA , Salter A , et al. The progression of end-stage osteoarthritis: analysis of data from the Australian and Norwegian joint replacement registries using a multi-state model. Osteoarthr Cartil 2013 21 405–412. (https://doi.org/10.1016/j.joca.2012.12.008)
- 47↑
Bulow E , Nemes S & Rolfson O . Are the first or the second hips of staged bilateral THAs more similar to unilateral procedures? A study from the Swedish hip arthroplasty register. Clin Orthop Relat Res 2020 478 1262–1270. (https://doi.org/10.1097/corr.0000000000001210)
- 48↑
Garland A , Rolfson O , Garellick G , et al. Early postoperative mortality after simultaneous or staged bilateral primary total hip arthroplasty: an observational register study from the Swedish Hip Arthroplasty Register. BMC Musculoskelet Disord 2015 16 77. (https://doi.org/10.1186/s12891-015-0535-0)
- 49↑
Cnudde PHJ , Nemes S , Bülow E , et al. Risk of further surgery on the same or opposite side and mortality after primary total hip arthroplasty: a multi-state analysis of 133,654 patients from the Swedish Hip Arthroplasty Register. Acta Orthop 2018 89 386–393. (https://doi.org/10.1080/17453674.2018.1475179)
- 50↑
Martin CT , Callaghan JJ , Gao Y , et al. What can we learn from 20-year followup studies of hip replacement? Clin Orthop Relat Res 2016 474 402–407. (https://doi.org/10.1007/s11999-015-4260-7)
- 51↑
Hooper GJ , Hooper NM , Rothwell AG , et al. Bilateral total joint arthroplasty: the early results from the New Zealand National Joint Registry. J Arthroplast 2009 24 1174–1177. (https://doi.org/10.1016/j.arth.2008.09.022)
- 52↑
Lindberg-Larsen M , Joergensen CC , Husted H , et al. Simultaneous and staged bilateral total hip arthroplasty: a Danish nationwide study. Arch Orthop Trauma Surg 2013 133 1601–1605. (https://doi.org/10.1007/s00402-013-1829-z)
- 53↑
Glait SA , Khatib ON , Bansal A , et al. Comparing the incidence and clinical data for simultaneous bilateral versus unilateral total hip arthroplasty in New York state between 1990 and 2010. J Arthroplast 2015 30 1887–1891. (https://doi.org/10.1016/j.arth.2015.05.046)
- 54↑
Berend ME , Ritter MA , Harty LD , et al. Simultaneous bilateral versus unilateral total hip arthroplasty an outcomes analysis. J Arthroplast 2005 20 421–426. (https://doi.org/10.1016/j.arth.2004.09.062)
- 55↑
Klug A , Pfluger DH , Gramlich Y , et al. Future burden of primary and revision hip arthroplasty in Germany: a socio-economic challenge. Arch Orthop Trauma Surg 2021 141 2001–2010. (https://doi.org/10.1007/s00402-021-03884-2)
- 56↑
Culliford D , Maskell J , Judge A , et al. Future projections of total hip and knee arthroplasty in the UK: results from the UK Clinical Practice Research Datalink. Osteoarthr Cartil 2015 23 594–600. (https://doi.org/10.1016/j.joca.2014.12.022)
- 57↑
Ackerman IN , Bohensky MA , Zomer E , et al. The projected burden of primary total knee and hip replacement for osteoarthritis in Australia to the year 2030. BMC Musculoskelet Disord 2019 20 90. (https://doi.org/10.1186/s12891-019-2411-9)
- 58↑
Gazendam AM , Patel M , Ekhtiari S , et al. Are Functional Outcomes of a Total Hip Arthroplasty Predictive of a Contralateral Total Hip Arthroplasty: A Retrospective Cohort Study. J Arthroplasty 2022 37 298–302. (https://doi.org/10.1016/j.arth.2021.09.024)
- 59↑
Goker B , Doughan AM , Schnitzer TJ , et al. Quantification of progressive joint space narrowing in osteoarthritis of the hip: longitudinal analysis of the contralateral hip after total hip arthroplasty. Arthritis Rheum 2000 43 988–994. (https://doi.org/10.1002/1529-0131(200005)43:5<988::AID-ANR5>3.0.CO;2-X)
- 60↑
Husted H , Overgaard S , Laursen JO , et al. Need for bilateral arthroplasty for coxarthrosis. 1,477 replacements in 1,199 patients followed for 0-14 years. Acta Orthop Scand 1996 67 421–423. (https://doi.org/10.3109/17453679608996660)
- 61↑
Moore HG , Schneble CA , Kahan JB , et al. What Factors Affect Whether Patients Return to the Same Surgeon to Replace the Contralateral Joint? A Study of Over 200,000 Patients. J Arthroplasty 2022 37 425–430. (https://doi.org/10.1016/j.arth.2021.11.036)
- 62↑
Ravi B , Croxford R & Hawker G . Exclusion of patients with sequential primary total joint arthroplasties from arthroplasty outcome studies biases outcome estimates: a retrospective cohort study. Osteoarthritis Cartilage 2013 21 1841–1848. (https://doi.org/10.1016/j.joca.2013.08.020)
- 63↑
Shao Y , Zhang C , Charron KD , et al. The fate of the remaining knee(s) or hip(s) in osteoarthritic patients undergoing a primary TKA or THA. J Arthroplasty 2013 28 1842–1845. (https://doi.org/10.1016/j.arth.2012.10.008)
