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

Table 1 The general characteristics of the included studies

Ref.	Country	Study design	Follow-up (years)	Participations	AL (n)	AL rates, %	Age (years)	NOS
Davis et al[61], 2020	United Kingdom	Cohort study	≥ 7.5	290770	1260	0.43	73.17	7
Amstutz et al[49], 2015	United States	Case-control study	8.58	1375	27	1.96	46.5	7
Benson et al[35], 2022	Denmark	Cohort study	4.4 (1.1-5.9)	53605	479	0.89	NA	7
Bordini et al[15], 2007	Italy	Cohort study	≥ 6	4750	134	2.82	NA	6
Jud et al[42], 2024	Switzerland	Cohort study	NA	2459	14	0.56	63.8 ± 12.7 (18-92)	7
Wagener et al[62], 2024	Germany	Cohort study	2-10	255	255	NA	73	7
Budin et al[34], 2024	United States	Cohort study	2	32811	721	2.19	69.1 ± 8.3	8
Magruder et al[32], 2024	United States	Cohort study	≤ 2	11025	160	1.45	NA	6
Aro et al[13], 2012	Finland	Cohort study	2	39	NA	NA	61.5 (41-78)	6
Electricwala et al[23], 2016	United States	Cohort study	8.7 ± 8.1	257	NA	NA	67 ± 13	7
Münger et al[14], 2006	Sweden	Case-control study	5.3 ± 3.1	50534	725	1.43	63 ± 9.5	8
Layson et al[29], 2024	United States	Cohort study	2	55601	NA	1.91	68-72	7
Clauss et al[58], 2013	Switzerland	Cohort study	≥ 16	156	139	NA	NA	7
Khatod et al[43], 2014	United States	Cohort study	2.2 (1.2-5.1)	36834	635	1.72	65.5 ± 11.7	8
Stelmach et al[45], 2015	Germany	Cohort study	NA	465	234	NA	52.80 ± 12.8	7
Wedemeyer et al[44], 2009	Germany	Cohort study	7.17-8.41	87	87	NA	69.31 ± 10.27	7
Lee et al[56], 2024	China	Cohort study	≥ 1	1995	4	0.2	61.9 ± 13.8	7
Lunn et al[33], 2005	Ireland	Case-control study	5.7 (2-11)	217	101	NA	67.6 ± 9.6	6
Halawi et al[26], 2016	United States	Cohort study	7.6 ± 2.56	426	28	6.57	46.9 ± 7.1	7
Boyer et al[19], 2019	France	Cohort study	5.5	30733	NA	NA	NA	6

AL: Aseptic loosening; NOS: Newcastle Ottawa Scale; NA: Not available.

Table 2 The statistics information of the included studies

Ref.	Statistics	Factors
Davis et al[61], 2020	KM survival analysis and Cox regression analyses	Age, sex, head composition, and stem fixation method
Amstutz et al[49], 2015	Multivariate analysis and Cox proportional hazard ratio	Age, gender, BMI, abduction arc, UCLA activity score, center-edge angle, cup abduction, component size, and diagnosis
Benson et al[35], 2022	KM survival analysis and Cox proportional hazards regression model	Age, sex, CCI, fixation type, duration and start of thromboprophylaxis, use of vitamin K antagonists, NOAC, aspirin, and platelet inhibitors
Bordini et al[15], 2007	Multivariate survival analysis and Cox proportional -hazards model	Age, gender, diagnosis, Charnley score, right or left side, surgeon’s skill, and type of components
Jud et al[42], 2024	Multivariate logistic regression analysis	Age, non-steroidal antirheumatics, and nicotine
Wagener et al[62], 2024	KM method and Cox proportional hazards model	Age, sex, BMI, ASA, diagnosis, comorbidities, surgerical approach, duration of surgery, hip type, Dorr type, revision time and type
Budin et al[34], 2024	Multivariable logistic regression	Age, sex, tobacco use, and LOS
Magruder et al[32], 2024	Logistical regression	Age, sex, and CCI
Aro et al[13], 2012	KM and logistic-regression model	Age, BMI, local BMD, T-score of the operated hip, and canal flare index
Electricwala et al[23], 2016	Bonferroni correction for multiple comparisons	BMI
Münger et al[14], 2006	Multivariate conditional logistic regressions	Age, sex, indication for surgery, height, weight, BMI, and mobility level
Layson et al[29], 2024	Multivariate logistic regressions	Age, sex, alcohol abuse, CCI, diabetes, obesity, CKD, history of cancer and tumors, CHF, CVD, RA, liver disease, and tobacco use
Clauss et al[58], 2013	Multivariable Cox regression analysis with stepwise variable selection	Age, sex, primary diagnosis, type of implant, implant material, stem offset, stem size, type of cup, and head diameter
Khatod et al[43], 2014	Multivariate Cox models	Age, gender, race, BMI, diabetes, ASA, implants, techniques, surgeons, and hospital factors
Stelmach et al[45], 2015	Cox regression models	Age, BMI, gender, BCL2-938 polymorphisms
Wedemeyer et al[44], 2009	Cox regression models	Age, gender, weight, height, BMI, BCL2-938C>A and CALCA-1786T>C polymorphisms, defects of acetabular and femoral
Lee et al[56], 2024	Multivariate logistic regression model	Age, stem type, sex, BMI, diagnosis, CCI, stem alignment, and canal fill ratio
Lunn et al[33], 2005	Logistic regression analysis	Age, HFE gene mutations C282Y and H63D genotype
Halawi et al[26], 2016	Multivariate logistic regression	Age, sex, BMI, CCI, diagnosis, approach, prior surgery, head size, articulation
Boyer et al[19], 2019	Cox multivariate regression model	BMI, gender, age, diabetes, weight, height

KM: Kaplan-Meier; BMI: Body mass index; CCI: Charlson Comorbidity Index; NOAC: Non-vitamin K oral anticoagulants; ASA: American Society of Anesthesiologists; LOS: Length of stay; BMD: Bone mineral density; CKD: Chronic kidney disease; CHF: Congestive heart failure; CVD: Cerebrovascular disease; RA: Rheumatoid arthritis.

Table 3 Quality assessment of included cohort studies

Ref.	Selection			Comparability		Outcome			Total
	Item 1	Item 2	Item 3	Item 4	Item 5	Item 6	Item 7	Item 8
Davis et al[61], 2020	1	N/A	1	0	N/A	1	1	1	5
Benson et al[35], 2022	1	1	0	1	1	1	1	1	7
Bordini et al[15], 2007	1	0	N/A	1	1	1	1	1	6
Jud et al[42], 2024	1	1	1	1	N/A	1	1	1	7
Wagener et al[62], 2024	1	0	1	1	N/A	1	1	1	6
Budin et al[34], 2024	1	1	1	1	1	1	1	1	8
Magruder et al[32], 2024	1	1	1	1	N/A	1	1	1	7
Aro et al[13], 2012	1	1	1	1	1	1	0	0	6
Electricwala et al[23], 2016	1	0	0	1	1	1	1	1	6
Layson et al[29], 2024	1	1	N/A	1	1	1	1	1	7
Clauss et al[58], 2013	1	1	1	1	N/A	1	1	1	7
Khatod et al[43], 2014	1	1	1	1	1	1	1	1	8
Stelmach et al[45], 2015	1	1	1	1	N/A	1	1	1	7
Wedemeyer et al[44], 2009	1	0	1	1	N/A	1	1	1	6
Lee et al[56], 2024	1	1	1	1	1	1	1	1	8
Halawi et al[26], 2016	1	N/A	0	1	1	1	1	1	6
Boyer et al[19], 2019	1	1	1	0	1	1	1	1	7

For cohort studies: Selection: Item 1, representativeness of the exposed cohort; item 2, selection of the non-exposed cohort; item 3, ascertainment of exposure; item 4, demonstration that outcome of interest was not present at start of study; Comparability: Item 5, comparability of cohorts on the basis of the design or analysis; Outcome: Item 6, assessment of outcome; item 7, was follow-up long enough for outcomes to occur; item 8, adequacy of follow up of cohorts. N/A: Not applicable.

Table 4 Quality assessment of included case-control studies

Ref.	Item 1	Item 2	Item 3	Item 4	Item 5	Item 6	Item 7	Item 8	Item 9	Item 10	Item 11
Amstutz et al[49], 2015	Yes	No	No	Yes	Unclear	Yes	No	Yes	Unclear	Unclear	Yes
Münger et al[14], 2006	Yes	Yes	Yes	Yes	Unclear	Yes	No	Yes	Unclear	Yes	Yes
Lunn et al[33], 2005	Yes	Yes	No	Yes	Unclear	Yes	Unclear	Yes	Unclear	Yes	Yes

For case-control studies: Item 1, Define the source of information (survey, record review); item 2, list inclusion and exclusion criteria for exposed and unexposed subjects (cases and controls) or refer to previous publications; item 3, indicate period used for identifying patients; item 4, indicate whether or not subjects were consecutive if not population-based; item 5, indicate if evaluators of subjective components of the study were masked to other aspects of the status of the participants; item 6, describe any assessments undertaken for quality assurance purposes; item 7, explain any patient exclusions from analysis; item 8, describe how confounding was assessed and/or controlled; item 9, if applicable, explain how missing data were handled in the analysis; item 10, summarize patient response rates and completeness of data collection; item 11, clarify what follow-up, if any, was expected and the percentage of patients for which incomplete data or follow-up was obtained.

Table 5 Summary of meta-analysed factors for the aseptic loosening after primary total hip arthroplasty

Factors	Pooled OR	LL 95%CI	UL 95%CI	P value	I2	Effects model
Age	0.998	0.911	1.093	0.964	86.033	R
Gender (male)	1.232	1.039	1.460	0.016	87.230	R
BMI	1.116	1.059	1.175	< 0.001	91.057	R
CCI	1.378	1.182	1.606	< 0.001	88.230	R
Lifestyle	2.198	1.048	4.611	0.037	99.140	R
Diagnosis	1.162	1.009	1.338	0.037	61.546	R
Anatomy	1.082	0.876	1.336	0.466	82.582	R
Race	0.445	0.302	0.655	< 0.001	0.000	F
Genetype	0.723	0.617	0.849	< 0.001	0.000	F
Surgical skills	1.048	1.021	1.075	< 0.001	12.78	F
Prosthesis	1.497	1.203	1.864	< 0.001	89.958	R

I² was defined as the proportion of heterogeneity not due to chance or random error. OR: Odds ratio; LL: Lower limit; UL: Upper limit; BMI: Body mass index; CCI: Charlson Comorbidity Index; R: Random-effects model was performed; F: Fixed-effects model was performed.