Factors associated with aseptic loosening after primary total hip arthroplasty: A systematic review and meta-analysis

doi:10.5312/wjo.v17.i1.114482

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World Journal of Orthopedics

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2218-5836

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Systematic Reviews

World J Orthop. Jan 18, 2026; 17(1): 114482
Published online Jan 18, 2026. doi: 10.5312/wjo.v17.i1.114482

Factors associated with aseptic loosening after primary total hip arthroplasty: A systematic review and meta-analysis

Guo-Qing Li, Ji Zhang, Yong Huang

Guo-Qing Li, Department of Orthopedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China

Ji Zhang, Yong Huang, Department of Orthopedics, National Center for Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China

Author contributions: Li GQ contributed to investigation, methodology, writing-original draft, editing; Zhang J contributed to review; Huang Y contributed to writing-review.

Supported by the National Natural Science Foundation of China, No. 82402789; Beijing Jishuitan Hospital Youcai Plan, No. KYYC202402; Beijing Jishuitan Research Funding, No. HL202402; and Beijing Natural Science Foundation, No. L232062, and No. L222063.

Conflict-of-interest statement: All authors declare that they have no conflict of interest.

PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Check-list.

Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Corresponding author: Guo-Qing Li, MD, Principal Investigator, Senior Scientist, Department of Orthopedics, Beijing Jishuitan Hospital, Capital Medical University, No. 31 Xinjiekou East Street, Xicheng District, Beijing 100035, China. guoqingli@pku.edu.cn

Received: September 22, 2025
Revised: October 21, 2025
Accepted: December 1, 2025
Published online: January 18, 2026
Processing time: 111 Days and 1.1 Hours

Abstract

BACKGROUND

Aseptic loosening remains the leading cause of revision in primary total hip arthroplasty (pTHA). However, the literature demonstrates significant variability regarding the relative contributions of different factors.

AIM

To investigate the key determinants of aseptic loosening, we performed a systematic review and meta-analysis.

METHODS

A comprehensive search of PubMed, Web of Science, EMBASE, and the Cochrane Library was conducted, encompassing studies from database inception to January 1, 2025. Meta-analyses were performed to evaluate factors associated with aseptic loosening following pTHA. Inclusion and exclusion criteria were systematically applied at each stage to ensure methodological transparency and reproducibility. Study quality was assessed using standardized categories. Pooled odds ratio (OR) with corresponding 95% confidence interval were calculated with random- or fixed-effects models to generate reliability estimates, and study heterogeneity was visualized using forest plots. Ten factors, categorized into patient-, surgeon-, and device-related domains, were reviewed and meta-analyzed. Funnel plot analysis demonstrated a relatively symmetrical distribution, suggesting minimal publication bias.

RESULTS

A meta-analysis of 20 studies (520789 participants) found a pooled prevalence of 1.96%. Significant risk factors for aseptic loosening after pTHA included elevated body mass index (OR = 1.116, P < 0.001), higher Charlson comorbidity index (OR = 1.378, P < 0.001), prosthesis-related factors (OR = 1.497, P < 0.001), and adverse lifestyles (OR = 2.198, P = 0.037). Protective factors were non-white race (OR = 0.445, P < 0.001) and favorable genetics (OR = 0.723, P < 0.001). Male sex increased risk (OR = 1.232, P = 0.016), while age and anatomy were not significant. Surgical expertise showed a slight protective effect (OR = 1.048, P < 0.001). A comprehensive understanding of the modifiable and non-modifiable factors contributing to aseptic loosening after pTHA requires consideration of patient-related factors, surgical expertise, and prosthesis characteristics.

CONCLUSION

The identification of these factors is critical for risk mitigation. High-risk patients should receive targeted counseling regarding individualized profiles. Further studies are warranted to establish clearer causal relationships and identify additional contributing factors.

Keywords: Factors; Aseptic loosening; Primary total hip arthroplasty; Systematic review; Meta-analysis

Core Tip: Aseptic loosening is the main cause of failure in primary total hip arthroplasty, yet the key risk factors remain unclear. Our meta-analysis of 20 studies clarifies this: Modifiable factors like high body mass index, comorbidity burden, and prosthesis choice significantly increase risk, while surgical expertise is protective. This evidence enables surgeons to identify high-risk patients and prioritize modifiable factors, paving the way for personalized prevention strategies and improved implant longevity.