Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis

The direct anterior approach to the hip: a useful tool in experienced hands or just another approach?

The direct anterior approach (DAA) to the hip was initially described in the nineteenth century and has been used sporadically for total hip arthroplasty (THA). However, recent increased interest in tissue-sparing and small incision arthroplasty has given rise to a sharp increase in the utilization of the DAA. Although some previous studies claimed that this approach results in less muscle damage and pain as well as rapid recovery, a paucity in the literature exists to conclusively support these claims. While the DAA may be comparable to other THA approaches, no evidence to date shows improved long-term outcomes for patients compared to other surgical approaches for THA. However, the advent of new surgical instruments and tables designed specifically for use with the DAA has made the approach more feasible for surgeons. In addition, the capacity to utilize fluoroscopy intraoperatively for component positioning is a valuable asset to the approach and can be of particular benefit for surgeons during their learning curve. An understanding of its limitations and challenges is vital for the safe employment of this technique. This review summarizes the pearls and pitfalls of the DAA for THA in order to improve the understanding of this surgical technique for hip replacement surgeons.

Postoperative Patient-reported Pain and Opioid Consumption After Total Hip Arthroplasty: A Comparison of the Direct Anterior and Posterior Approaches

INTRODUCTION

Although one of the touted benefits of the direct anterior approach (DAA) includes decreased postoperative pain, there is no consensus on the effect of surgical approach on postoperative pain and subsequent analgesic consumption.

METHODS

Consecutive patients undergoing total hip arthroplasty by a single surgeon from May 2016 to March 2020 were identified. Procedures were categorized as DAA or posterior approach. Patient demographics and surgical details were assessed. Patient-reported maximum pain by postoperative day (POD), total opioid consumption during hospitalization, and whether the patient required a refill of opioid prescription within 3 months after discharge were compared between the two surgical approaches through multivariate analyses.

RESULTS

A total of 611 patients were included in this study (447 DAA and 164 posterior approaches). On multivariate analyses that controlled for preoperative/intraoperative differences, patients in the DAA group had lower average maximum reported pain (0 to 10 scale) on POD #0 (6.5 versus 6.8, P = 0.034) and POD #1 (5.4 versus 6.1, P = 0.018). However, the DAA was not associated with a statistically significant reduction in total inpatient oral morphine equivalents consumed (79.8 versus 100.1, P = 0.486). Furthermore, there was no association between surgical approach and opioid prescription refill within 3 months after discharge (P = 0.864).

DISCUSSION

The DAA was associated with slightly lower patient-reported pain. Furthermore, statistical analysis did not provide the necessary evidence to reject the null hypothesis, which was that there would be no difference in opioid utilization between the two approaches. Other perioperative factors may be more important to opioid use reduction than the surgical approach alone.

Direct anterior approach vs. SuperPATH vs. conventional approaches in total hip replacement: A network meta-analysis of randomized controlled trials

BACKGROUND

Two minimally invasive approaches showed some advantages in outcomes compared to conventional approaches (CAs) - the direct anterior approach (DAA) and the supercapsular percutaneously assisted approach in THA (SuperPATH). To the best of our knowledge, these three approaches have never been ranked in a network meta-analysis (NMA) before. Therefore, we conducted a systematic review and NMA of randomized controlled trials comparing short-term outcomes of DAA, SuperPATH and CAs in total hip joint arthroplasty (THA), using CAs as common comparator.

METHODS

A systematic literature search up to February 2021 was performed to identify randomized controlled trials (RCTs) comparing DAA with CAs and SuperPATH with CAs in THA. We measured surgical, functional and radiological outcomes. A NMA, using frequentist methods was performed to assess treatment effects between DAA, SuperPATH and CAs. Information was borrowed from the above-mentioned RCTs, using the CA group as a common comparator.

RESULTS

A total of 24 RCTs involving 2,074 patients met the inclusion criteria, six trials with a level I evidence, 18 trials with level II evidence. SuperPATH reduced operation time (fixed effects model: MD=8.1, 95% CI: 5.7 to 10.4), incision length (fixed effects model: MD=2.7, 95%CI: 2.5 to 2.9; random effects model: MD=4.1, 95%CI: 0.6 to 7.6), intraoperative blood loss (fixed effects model: MD=157, 95%CI: 139.2 to 174.2; random effects model: MD=129, 95%CI: 11.5 to 245.7) and early pain intensity (VAS 1 day postoperatively with a fixed effects model: MD=0.8, 95%CI: 0.4 to 1.2) compared to DAA. The two approaches did not differ in functional outcome and in acetabular cup inclination positioning.

CONCLUSIONS

Our overall findings suggest that short-term outcomes of THA through SuperPATH were superior to DAA and CAs and that short-term outcomes of THA through DAA were superior to CAs.

LEVEL OF EVIDENCE

II; systematic review with level I studies and level II studies.

Use of Surgical Approach Is Not Associated With Instability After Primary Total Hip Arthroplasty: A Meta-analysis Comparing Direct Anterior and Posterolateral Approaches

INTRODUCTION

Posterolateral approach (PA) has been historically associated with an increased risk of dislocation after primary total hip arthroplasty (THA), especially when compared with the direct anterior approach (DAA). However, current evidence is inconsistent regarding the risk of dislocation with either approach. The purpose of this study is to determine whether surgical approach influences joint stability.

METHODS

A systematic search in PubMed, MEDLINE, and Embase databases was performed. Randomized controlled trials (RCTs) and non-RCTs comparing DAA with PA in primary THA were included. Pooled effect measure of risk differences, relative risk and mean differences for postoperative dislocation, acetabular implant positioning, and leg length discrepancy were calculated.

RESULTS

Twenty-five studies (5 RCTs and 20 non-RCTs) of 7,172 THAs were assessed. There were no significant differences in dislocation rates between approaches (risk difference = -0.00, 95% confidence interval: -0.01 to 0.00; P = 0.92; I2 = 0%). Results were similar in the subgroup analysis of RCTs (P = 0.98), posterior soft-tissue repair (P = 0.50), and learning curve (P = 0.77). The acetabular implant was better positioned within the safe zone in the DAA group (relative risk = 1.17; 95% confidence interval: 1.03 to 1.33; P = 0.01), but no significant differences were found in cup inclination (P = 0.8), anteversion (P = 0.10), and leg length discrepancy (P = 0.54).

CONCLUSION

Dislocation rates after THA are not different between DAA and PA. Furthermore, no differences in the rate of dislocation were associated with cup positioning or surgical factors related with hip instability. Therefore, the surgical approach has little influence in prosthesis instability after primary THA.

LEVEL OF EVIDENCE

Level III.

A novel efficient and precise technique for removing acetabular osteophytes in patients undergoing total hip arthroplasty: the SH-9Hospital acetabular edge file

Background

Total hip arthroplasty (THA) is frequently performed in patients with end-stage hip disease. Periacetabular osteophytes are common during THA; however, these osteophytes should be removed intraoperatively to avoid potential impingement between osteophytes and femoral prostheses and decrease dislocation risk. There are no current standard procedures or surgical technique criteria to remove these osteophytes. Osteophytes around the acetabulum are usually removed with an osteotome, yet this presents certain disadvantages. Hence, this study aimed to introduce a novel and more efficient technique than the aforementioned one, the SH-9Hospital acetabular edge file.

Methods

Fifty-four patients (54 hips) who underwent primary THA using osteotome and the SH-9Hospital acetabular edge file to remove periacetabular osteophytes intraoperatively were retrospectively studied. Clinical and radiographic data were obtained for all patients intra- and postoperatively.

Results

The mean osteophyte removal time was 274.6±102.7 s and 51.3±21.1 s in the osteotome and SH-9Hospital acetabular edge file groups, respectively. Intraoperative images and postoperative radiographs showed that acetabular osteophytes were removed thoroughly and precisely by the acetabular edge file and that there was no iatrogenic injury and prostheses malposition in both groups.

Conclusions

The SH-9Hospital acetabular edge file was a novel, efficient, highly precise, and repeatable method for removing periacetabular osteophytes in patients undergoing total hip arthroplasty.

POSTERIOR VERSUS ANTERIOR APPROACH TO TOTAL HIP ARTHROPLASTY: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

OBJECTIVE

To perform a systematic review and meta-analysis to compare clinical and surgical outcomes of posterior versus anterior approach to primary total hip arthroplasty (THA).

METHODS

This study followed the standard methodology established by the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two independent reviewers searched for randomized controlled trials comparing posterior an anterior approach to primary THA with at least one quantifiable functional outcome published in the PubMed, Cochrane, and Virtual Health Library databases.

RESULTS

The analysis included ten randomized controlled trials conducted with 774 patients. The posterior approach was associated with shorter operative time (mean of 15.98 minutes shorter, 95% CI 11.21 to 20.76, p < 0.00001) while the anterior approach was associated with shorter length of hospital stay (0.31 days or about eight hours shorter, 95% CI 0.12 to 0.51, p = 0.002) and greater earlier improvement in functional outcomes up to six months from the procedure (mean Harris Hip Score of 4.06 points greater, 95% CI 2.23 to 5.88, p < 0.0001).

CONCLUSION

Whereas the posterior approach to primary THA is associated with a shorter operative time, the anterior approach has the potential to decrease the length of stay and provide greater short-term functional restoration. Level of evidence I, Systematic Review and Meta-Analysis.

Predicting the Exception-CRP and Primary Hip Arthroplasty

BACKGROUND

While primary hip arthroplasty is the most common operative procedure in orthopedic surgery, a periprosthetic joint infection is its most severe complication. Early detection and prediction are crucial. In this study, we aimed to determine the value of postoperative C-reactive protein (CRP) and develop a formula to predict this rare, but devastating complication.

METHODS

We retrospectively evaluated 708 patients with primary hip arthroplasty. CRP, white blood cell count (WBC), and several patient characteristics were assessed for 20 days following the operative procedure.

RESULTS

Eight patients suffered an early acute periprosthetic infection. The maximum CRP predicted an infection with a sensitivity and specificity of 75% and 56.9%, respectively, while a binary logistic regression reached values of 75% and 80%. A multinominal logistic regression, however, was able to predict an early infection with a sensitivity and specificity of 87.5% and 78.9%. With a one-phase decay, 71.6% of the postoperative CRP-variance could be predicted.

CONCLUSION

To predict early acute periprosthetic joint infection after primary hip arthroplasty, a multinominal logistic regression is the most promising approach. Including five parameters, an early infection can be predicted on day 5 after the operative procedure with 87.5% sensitivity, while it can be excluded with 78.9% specificity.

A meta-analysis on RCTs of direct anterior and conventional approaches in total hip arthroplasty

To conduct a systematic review and meta-analyses on short-term outcomes between total hip arthroplasty (THA) through direct anterior approach (DAA) compared to THA through conventional approaches (CAs) in treatment of hip diseases and fractures. We performed a systematic literature search up to March 1, 2021 to identify RCTs, comparing THA through DAA with THA through CAs. We calculated mean differences (MDs) with 95% confidence intervals (CIs) for continuous outcomes, using the DerSimonian and Laird method and a random effects model. We calculated odds ratios (ORs) with 95% CIs for dichotomous outcomes, using the Mantel–Haenszel method and a random effects model. Ten RCTs met the criteria for final meta-analysis, involving 1053 patients. Four studies were blinded RCTs with a level I evidence, the other 6 studies were non-blinded RCTs with a level II evidence. DAA had a longer operation time than CAs (MD = 17.8, 95% CI  4.8 to 30.8); DAA had similar results compared to CAs for incision length (MD = − 1.1, 95% CI − 4.1 to 1.8), for intraoperative blood loss (MD = 67.2, 95% CI − 34.8 to 169.1), for HHS 3 months postoperatively (MD = 2.4, 95% CI − 0.7 to 5.5), for HHS 6 months postoperatively (MD = 0.8, 95% CI − 1.9 to 3.5), for HHS 12 months postoperatively (MD = 0.9, 95% CI − 0.7 to 2.5), for pain VAS 1 day postoperatively (MD = − 0.9, 95% CI − 2.0 to 0.15), for acetabular cup anteversion angle (MD = − 4.3, 95% CI − 5.2 to − 3.5), for acetabular cup inclination angle (MD = − 0.5, 95% CI − 2.1 to 1.1) and for postoperative complications (OR = 2.4, 95% CI 0.5 to 12.4). Considering the overall results of our meta-analysis, we can conclude that THA through DAA showed similar short-term surgical, functional, radiological outcomes and postoperative complications compared to THA through CAs.

How Does Implant Survivorship Vary with Different Corail Femoral Stem Variants? Results of 51,212 Cases with Up to 30 Years Of Follow-up from the Norwegian Arthroplasty Register

BACKGROUND

The Corail® cementless stem (DePuy Synthes) has been used in Norway since 1987 and is one of the most frequently used stems in THA worldwide. Although the published survival results of the standard Corail stem have been good, little is known about the long-term (more than 20 years) survival of other stem design variants. Further, some changes were made to the extramedullary part of the stem in 2003, and the effect of these changes on survival is unknown.

QUESTIONS/PURPOSES

(1) What is the survival up to 30 years of the standard collarless Corail femoral stem, and were extramedullary changes (slimmer, polished and rectangular neck, shorter taper) associated with differences in survivorship? (2) How does the 10-year survival and the risk of revision of other Corail stem variants, including the standard collared stem, coxa vara collared stem, and high offset collarless stem, compare with those of the standard collarless stem? (3) Which factors are associated with an increased risk of revision of the Corail stem, and are there any differences in those factors among the four stem variants?

METHODS

Data for this study were drawn from the Norwegian Arthroplasty Register. Since 1987, THAs have been registered in the Norwegian Arthroplasty Register with completeness of data greater than 97% for primary THAs and 93% for revisions. To study survivorship with up to 30 years of follow-up (1987 to 2018; median 7.7-year follow-up), and to compare the original stem with stems with extramedullary modifications, we included 28,928 standard collarless Corail stems in 24,893 patients (mean age at time of implantation 62 years; 66% [16,525 of 24,893] were women). To compare the newer stem variants with the standard collarless stem (2008 to 2018), we included 20,871 standard collarless, 10,335 standard collared, 6760 coxa vara collared, and 4801 high offset collarless stems. Survival probabilities were estimated using the Kaplan-Meier method with endpoints of stem revision, revision due to aseptic stem loosening, and periprosthetic fracture. The endpoint of all noninfectious causes of THA revision (including cup revision) was additionally analyzed for the long-term comparison. The proportion of patients who died was limited, and there was no difference in death rate between the groups compared. Therefore, we believe that competing events were not likely to influence survivorship estimates to a large degree. To compare different stem variants and evaluate factors that could be associated with the risk of revision, we calculated hazard ratios using Cox regression analyses with adjustments for gender, age group, surgical approach, diagnosis, and stem size.

RESULTS

The 30-year Kaplan-Meier survival of the standard collarless stem was 88.4% (95% confidence interval 85.4% to 91.4%), 93.3% (95% CI 91.1% to 95.5%), and 94.4% (95% CI 92.0% to 96.8%) using stem revision for any noninfectious cause, aseptic loosening, and periprosthetic fracture of the femur as endpoints, respectively. There was no difference in survival between the original stem and the modified stem. The 10-year Kaplan-Meier survivorship free of stem revision (all causes including infection) was 97.6% (95% CI 97.2% to 98.0%) for the standard collarless stem, 99.0% (95% CI 98.8% to 99.2%) for the standard collared stem, 97.3% (95% CI 96.3% to 98.3%) for the coxa vara collared stem, and 95.0% (95% CI 93.6% to 96.4%) for the high offset collarless stem. Compared with the standard collarless stem, the standard collared stem performed better (HR 0.4 [95% CI 0.3 to 0.6]; p < 0.001) and the high offset collarless stem performed more poorly (HR 1.4 [95% CI 1.1 to 1.7]; p = 0.006) with any stem revision as the endpoint, and similar results were found with revision for aseptic stem loosening and periprosthetic fracture as endpoints. Controlling for the noted confounders, the standard collared stem had a lower revision risk. The high offset collarless stem had an increased stem revision risk for any reason (HR 1.4 [95% CI 1.1 to 1.7]; p = 0.006) and aseptic loosening (HR 1.6 [95% CI 1.1 to 2.3]; p = 0.022). Other factors associated with an increased risk of stem revision for all stem variants were being a man (HR 1.7 [95% CI 1.4 to 2.0]; p < 0.001), age 70 to 79 years and 80 years and older compared with the age group of 50 to 59 years (HR 1.6 [95% CI 1.2 to 2.0]; p < 0.001 and HR 1.9 [95% CI 1.4 to 2.6]; p < 0.001, respectively), the anterior approaches (direct anterior Smith-Petersen and anterolateral Watson-Jones combined) compared with the posterior approach (HR 1.4 [95% CI 1.1 to 1.7]; p = 0.005), as well as a preoperative nonosteoarthritis diagnosis (HR 1.3 [95% CI 1.0 to 1.6]; p = 0.02) and small stem sizes (sizes 8-11) compared with the medium sizes (sizes 12-15) (HR 1.4 [95% CI 1.1 to 1.6]; p = 0.001). The very small sizes (8 and 9) were associated with a 2.0 times higher risk of revision (95%. CI 1.4 to 2.6; p < 0.01) compared with all other sizes combined.

CONCLUSION

When using the uncemented Corail stem, surgeons can expect good results with up to 30 years of follow-up. Our results should be generalizable to the typical surgeon at the average hospital in a comparable setting. From our results, using a collared variant would be preferable to a collarless one. Due to an increased risk of periprosthetic fracture, caution with the use of the uncemented Corail stem in patients older than 70 years, especially in women, is warranted. Poorer stem survival should also be expected with the use of small stem sizes. The risk of periprosthetic fractures for the Corail uncemented stem versus cemented stems in different age categories has not been extensively examined, nor has the use of a collar for different age groups and genders, and both should be subjects for further investigation.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Heterotopic Ossification Following Direct Anterior Total Hip Arthroplasty With and Without Postoperative Analgesic Nonsteroidal Anti-inflammatories

BACKGROUND

Heterotopic ossification (HO) can result in poorer clinical outcomes following total hip arthroplasty (THA). Multiple modes of intervention have been evaluated for HO prevention, including the use of nonsteroidal anti-inflammatories. Additionally, multimodal pain management strategies including celecoxib have become more prominent. Therefore, this study aims to evaluate the influence of celecoxib as part of postoperative analgesia on the risk of developing HO following the direct anterior approach (DA) for THA.

METHODS

A retrospective query identified primary DA THAs performed by a single surgeon between 2013 and 2020. Patients were grouped according to those who received 3 weeks celecoxib upon discharge, and those who did not. Radiographs were used to categorize patients according to the Brooker classification system for HO. Preoperative and 2-week, 6-week, 3-month, and 1-year postoperative X-rays were evaluated.

RESULTS

A total of 688 DA THAs were included, demonstrating a 9.6% (n = 66) incidence of HO with Brooker classification: 1: 5.7% (n = 39); 2: 2.6% (n = 18); 3: 1.2% (n = 8); and 4: 0.1% (n = 1). Patients who did not receive celecoxib had a 14.3% (52/364) rate of HO following THA (odds ratio 4.53, P < .001) vs only 4.3% (14/324) in the celecoxib group (odds ratio 0.22, P < .001). Overall, 9 patients (1.3%) went on to develop significant HO (Booker 3 or greater): 8 (2.2%) in the control group and 1 (0.3%) in the celecoxib group (P < .001).

CONCLUSION

Our findings suggest a significant reduction in the formation of HO following DA THA when using postoperative analgesic celecoxib as part of a multimodal pain protocol. Future prospective randomized studies are needed to identify ideal dosage, duration, and formulation to reduce the risk of HO while optimizing multimodal pain management.

Improving Acetabular Component Positioning in Supine Direct Anterior Total Hip Arthroplasty with a Transparency Template: A Novel, Simple, and Cost-effective Technique

Purpose

A novel and simple method to ensure accurate acetabular component anteversion and inclination intraoperatively with the use of a transparency template is described.

Materials and Methods

Patients who underwent total hip arthroplasty (THA) via direct anterior approach (DAA) from June 2019 to January 2020 were included. A transparency template that can be placed over the image intensifier monitor to allow surgeons an accurate reading of the acetabular component position intraoperatively was designed, developed and utilized to determine effectiveness. The first template consists of two perpendicular lines indicating the “trans-ischial line” and the “pubic symphysis/coccyx”. The second template consist of a line indicating 45° inclination and parallel lines of corresponding distances apart required to achieve 20° anteversion based on Lewinnek's formula: version=sin^-1 (D1/D2), where D1: minor axis and D2: major axis of the component. This template was used throughout the acetabular part of the surgery, from reaming to impaction of component. Postoperative acetabular inclination, anteversion, surgical duration, length of stay, as well as complications were recorded.

Results

Twenty-six patients were included in this study. Mean postoperative acetabular cup inclination was 43.46±3.09° and mean version was 19.98±2.89°. A total of 21 patients (80.8%) fell within the Callanan safe zone and all 26 patients (100%) were within the Lewinnek safe zone.

Conclusion

The transparency template is a simple, reproducible, and effective tool with a minimal learning curve and no requirement for expensive equipment. This template has the potential to assist surgeons, especially those who are less experienced with DAA THA, in obtaining better postoperative radiographic outcomes.

Low dislocation rates with the use of patient specific "Safe zones" in total hip arthroplasty

Introduction

The purpose of this study was to compare patient-specific acetabular cup target orientation using functional simulation to the Lewinnek Safe Zone (LSZ) and determine associated rates of postoperative dislocation.

Methods

A retrospective review of 1500 consecutive primary THAs was performed. Inclination, anteversion, pelvic tilt, pelvic incidence, lumbar flexion, and dislocation rates were recorded.

Results

56% of dynamically planned cups were within LSZ (p < 0.05). 6/1500 (0.4%) of these cups dislocated at two year follow-up, and all were within LSZ.

Conclusion

Optimal acetabular cup positioning using dynamic imaging differs significantly from historical target parameters but results in low rates of dislocation.

Level of evidence

Level III: Retrospective.

Is Surgical Approach for Primary Total Hip Arthroplasty Associated With Timing, Incidence, and Characteristics of Periprosthetic Femur Fractures?

BACKGROUND

Periprosthetic femur fractures (PFF) involving primary total hip arthroplasty (THA) remain a significant concern. The purpose of this study was to evaluate the effect of surgical approach during primary THA on early PFF with respect to fracture timing, incidence, radiographic parameters, and surgery-related factors.

METHODS

A retrospective review of all patients with PFF during or after primary THA from 2011 to 2019 was conducted at a single, urban academic institution. Of the study cohort of 11,915 patients, 79 patients with PFF were identified (0.66%). Direct anterior (DA), posterior anterior (PA), and laterally based (LA) cohorts were formed based on the surgical approach. PA and LA groups were combined to form a nonanterior (NA) cohort. Radiographic parameters, surgical factors, and fracture mechanism were analyzed.

RESULTS

The incidence of fracture across approaches was 0.70% (33/4707; DA), 0.63% (35/5600; PA), and 0.68% (11/1608; LA) (P = .97). Time from THA to fracture was significantly shorter in the DA cohort (12.5 ± 14.1 days) than the NA cohort (48.2 ± 120.6 days) (P = .05). Postoperatively identified, atraumatic PFFs were more common in the DA cohort (78.3%, 18/23) than the NA cohort (51.6%, 16/31) (P = .045). There were no differences between groups in radiographic or other clinical parameters.

CONCLUSION

Patients who underwent DA THA have significantly shorter time to PFF and were more often identified postoperatively with an atraumatic mechanism than patients who underwent NA approaches. The known difficulty in femoral exposure and stem placement with the DA approach may play a role in contributing to a higher rate of intraoperative or early postoperative PFF.

Differences in outcomes of mandatory motorcycle helmet legislation by country income level: A systematic review and meta-analysis

BACKGROUND

The recent Lancet Commission on Legal Determinants of Global Health argues that governance can provide the framework for achieving sustainable development goals. Even though over 90% of fatal road traffic injuries occur in low- and middle-income countries (LMICs) primarily affecting motorcyclists, the utility of helmet laws outside of high-income settings has not been well characterized. We sought to evaluate the differences in outcomes of mandatory motorcycle helmet legislation and determine whether these varied across country income levels.

METHODS AND FINDINGS

A systematic review and meta-analysis were completed using the PRISMA checklist. A search for relevant articles was conducted using the PubMed, Embase, and Web of Science databases from January 1, 1990 to August 8, 2021. Studies were included if they evaluated helmet usage, mortality from motorcycle crash, or traumatic brain injury (TBI) incidence, with and without enactment of a mandatory helmet law as the intervention. The Newcastle-Ottawa Scale (NOS) was used to rate study quality and funnel plots, and Begg's and Egger's tests were used to assess for small study bias. Pooled odds ratios (ORs) and their 95% confidence intervals (CIs) were stratified by high-income countries (HICs) versus LMICs using the random-effects model. Twenty-five articles were included in the final analysis encompassing a total study population of 31,949,418 people. There were 17 retrospective cohort studies, 2 prospective cohort studies, 1 case-control study, and 5 pre-post design studies. There were 16 studies from HICs and 9 from LMICs. The median NOS score was 6 with a range of 4 to 9. All studies demonstrated higher odds of helmet usage after implementation of helmet law; however, the results were statistically significantly greater in HICs (OR: 53.5; 95% CI: 28.4; 100.7) than in LMICs (OR: 4.82; 95% CI: 3.58; 6.49), p-value comparing both strata < 0.0001. There were significantly lower odds of motorcycle fatalities after enactment of helmet legislation (OR: 0.71; 95% CI: 0.61; 0.83) with no significant difference by income classification, p-value: 0.27. Odds of TBI were statistically significantly lower in HICs (OR: 0.61, 95% CI 0.54 to 0.69) than in LMICs (0.79, 95% CI 0.72 to 0.86) after enactment of law (p-value: 0.0001). Limitations of this study include variability in the methodologies and data sources in the studies included in the meta-analysis as well as the lack of available literature from the lowest income countries or from the African WHO region, in which helmet laws are least commonly present.

CONCLUSIONS

In this study, we observed that mandatory helmet laws had substantial public health benefits in all income contexts, but some outcomes were diminished in LMIC settings where additional measures such as public education and law enforcement might play critical roles.

Direct anterior approach (DAA) vs. conventional approaches in total hip arthroplasty: A RCT meta-analysis with an overview of related meta-analyses

OBJECTIVES

Several systematic reviews and meta-analyses on short-term outcomes between total hip arthroplasty (THA) through direct anterior approach (DAA) compared to THA through conventional (including anterior, anterolateral, lateral transgluteal, lateral transtrochanteric, posterior, and posterolateral) approaches (CAs) in treatment of hip diseases and fractures showed contradicting conclusions. Our aim was to draw definitive conclusions by conducting both a fixed and random model meta-analysis of quality randomized controlled trials (RCTs) and by comparison with related meta-analyses.

DESIGN

We performed a systematic literature search up to May 2020 to identify RCTs, comparing THA through DAA with THA through CAs and related meta-analyses. We conducted risk of bias and level of evidence assessment in accordance with the Cochrane's Risk of Bias 2 tool and with the guidelines of the Centre for Evidence-Based Medicine. We estimated mean differences (MD) with 95% confidence intervals (CI) through fixed and random effects models, using the DerSimonian and Laird method. Heterogeneity was assessed using tau-square (τ2). Our conclusions take into account the overall results from related meta-analyses.

RESULTS

Nine studies on THA through DAA met the criteria for final meta-analysis, involving 998 patients. Three studies were blinded RCTs with a level I evidence, the other 6 studies were non-blinded RCTs with a level II evidence. We came to the following results for THA through DAA compared to THA through CAs: operation time (I2 = 92%, p<0.01; fixed: MD = 15.1, 95% CI 13.1 to 17.1; random: MD = 18.1, 95% CI 8.6 to 27.5); incision length (I2 = 100%, p<0.01; fixed: MD = -2.9, 95% CI -3.0 to -2.8; MD = -1.1, 95% CI -4.3 to 2.0); intraoperative blood loss (I2 = 87%, p<0.01; fixed: MD = 51.5, 95% CI 34.1 to 68.8; random: MD = 51.9, 95% CI -89.8 to 193.5); VAS 1 day postoperatively (I2 = 79%, p = 0.03; fixed: MD = -0.8, 95% CI -1.2 to -0.4; random: MD = -0.9, 95% CI -2.0 to 0.15); HHS 3 months postoperatively (I2 = 52%, p = 0.08; fixed: MD = 2.8, 95% CI 1.1 to 4.6; random: MD = 3.0, 95% CI -0.5 to 6.5); HHS 6 months postoperatively (I2 = 0%, p = 0.67; fixed: MD = 0.9, 95% CI -1.1 to 2.9; random: MD = 0.9, 95% CI -1.1 to 2.9); HHS 12 months postoperatively (I2 = 0%, p = 0.79; fixed: MD = 0.7, 95% CI -0.9 to 2.4; random: MD = 0.7, 95% CI -0.9 to 2.4). We compared our findings with 7 related meta-analyses.

CONCLUSIONS

Considering the results of our meta-analysis and the review of related meta-analyses, we can conclude that short-term outcomes of THA through DAA were overall better than THA through CAs. THA through DAA had a shorter incision length, a tendency towards a lower pain VAS 1 day postoperatively and better early postoperative functional outcome than THA through CAs. The intraoperative blood loss showed indifferent results. THA through DAA had a longer operation time than THA through CAs.

Return to Competitive Level of Play and Performance in Regular Golfers After Total Hip Arthroplasty: Analysis of 599 Patients at Minimum 2-Year Follow-Up

BACKGROUND

Total hip arthroplasty (THA) is performed in an increasingly younger and athletic population. Regular and competitive golfers are concerned with the likelihood of recovering their preoperative level of play. The purpose of this study was to assess the impact of primary THA on golfers' game, with a minimum follow-up of two years.

METHODS

Questionnaires were sent to the French Golf Federation's golfing members. Those who were older than 40 years and had undergone a unilateral primary THA provided information on the timing of return to play, pain during golfing, transportation mode, drive length, handicap and weekly playtime, before hip replacement, and postoperatively. In addition, data relating to the surgical procedure were collected.

RESULTS

Surveys were completed by 883 competitive golfers of which 599 were eligible for inclusion. The mean time to return to a complete 18-hole course was 4.73 months (SD 4.15, range: 0.7-36). Participants surveyed at a minimum 2 years after THA played at a higher level than before surgery with a handicap improvement of 1.8 (P < .01) and increased their mean weekly playtime from 8.8 to 9.3 hours (P = .24, NS). Eighty-eight percent reported an increased or no change in drive distance. Hip pain while playing golf decreased after surgery (6.8 to 2.5 on the visual analog scale, P < .001).

CONCLUSION

This study highlighted that hip arthroplasty allowed regular and competitive golfers to return to the course with better golfing comfort than before surgery and with an objective improvement in driving distance and level of play.

A Workflow Change in Anterior Approach Total Hip Arthroplasty Leads to Improved Accuracy of Biomechanical Reconstruction Without Increased Risk of Complications

Background

During anterior approach total hip arthroplasty (THA), the femur may be an impediment for acetabular access, pushing reamers proximally and consequently altering the hip center. In an effort to address this, the senior author changed the surgical workflow from acetabulum first (AF) to femur first (FF). The objective of this study was to compare the precision of biomechanical hip reconstruction and clinical outcomes between the FF and AF techniques.

Methods

This is a retrospective, case-control study of 267 anterior THAs (132 AF and 135 FF). A normal, contralateral hip was used to determine the native biomechanical parameters. Using a calibrated software program, radiographic measurements were performed to calculate the hip center position, femoral offset, global offset, and leg length of the operative and native hips using 2-week postoperative anteroposterior pelvis radiographs. Demographics, operative information, hemoglobin change, and complication data were obtained. Functional outcomes were assessed with the Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement survey at 1 year postoperatively.

Results

The groups exhibited similar demographic characteristics. The FF group demonstrated significantly more accurate and more precise reconstruction of horizontal and vertical hip centers, femoral offset, and leg length. There was no significant difference in operative time, hemoglobin change, complication rate, or Hip Disability and Osteoarthritis Outcome Score, Joint Replacement scores between groups.

Conclusions

The FF technique allowed for more accurate and precise reconstruction of the hip center, leg length, and offset in THA than the AF workflow. Furthermore, the FF approach demonstrated no significant differences in complication rate or blood loss, nor in clinical outcomes.

Level of Evidence

Therapeutic Study Level III.

Dislocation rates following total hip arthroplasty via the direct anterior approach in a consecutive, non-selective cohort

AIMS

Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years due to proposed benefits, including a lower risk of dislocation and improved early functional recovery. This study investigates the dislocation rate in a non-selective, consecutive cohort undergoing THA via the DAA without any exclusion or bias in patient selection based on habitus, deformity, age, sex, or fixation method.

METHODS

We retrospectively reviewed all patients undergoing THA via the DAA between 2011 and 2017 at our institution. Primary outcome was dislocation at minimum two-year follow-up. Patients were stratified by demographic details and risk factors for dislocation, and an in-depth analysis of dislocations was performed.

RESULTS

A total of 2,831 hips in 2,205 patients were included. Mean age was 64.9 years (24 to 96), mean BMI was 29.2 kg/m² (15.1 to 53.8), and 1,595 patients (56.3%) were female. There were 11 dislocations within one year (0.38%) and 13 total dislocations at terminal follow-up (0.46%). Five dislocations required revision. The dislocation rate for surgeons who had completed their learning curve was 0.15% compared to 1.14% in those who had not. The cumulative periprosthetic infection and fracture rates were 0.53% and 0.67%, respectively.

CONCLUSION

In a non-selective, consecutive cohort of patients undergoing THA via the DAA, the risk of dislocation is low, even among patients with risk factors for instability. Our data further suggest that the DAA can be safely used in all hip arthroplasty patients without an increased risk of wound complications, fracture, infection, or revision. The inclusion of seven surgeons increases the generalizability of these results. Cite this article: Bone Joint J 2021;103-B(7 Supple B):38-45.

Acetabular Exposure Is Enhanced With Self-Retaining Retractors During Direct Anterior Total Hip Arthroplasty

Acetabular exposure for direct anterior (DA) total hip arthroplasty (THA) can be performed using hands-free, self-retaining retractors. No current study quantitatively compares this self-retaining technique with the traditional manual technique. In 65 consecutive DA THA hips, two "best-view" digital photographs were taken of the exposure-one using Charnley/self-retaining retractors and one using a traditional three-retractor manual technique. Percent exposure of the polyethylene liner was calculated. Percent acetabular exposure averaged 80.0% using the Charnley/self-retaining technique, compared with 73.1% using the manual technique (P=.0002). A hands-free technique provides superior acetabular exposure compared with the manual technique. Increasing body mass index predicts decreasing exposure with both techniques. [Orthopedics. 2021;44(2):e309-e313.].

Anterior Supine Intermuscular Total Hip Arthroplasty at an Ambulatory Surgery Center Versus Hospitalization: Cost and Adverse Events

This study compares anterior supine intermuscular total hip arthroplasty performed at an ambulatory surgery center with the same procedure performed in a hospital setting in regard to complications and costs. The ambulatory surgery center had significantly shorter postoperative stays and superior visual analog pain scores at 3 months. No differences were noted in operative time, blood loss, or complications. Costs were significantly different between groups, with significant cost savings noted in the ambulatory surgery center group.

Do Patients With Higher Preoperative Functional Outcome Scores Preferentially Seek Direct Anterior Approach Total Hip Arthroplasty?

Background

There is focus on the direct anterior approach (DAA) for total hip arthroplasty because of perceived postoperative functional improvement. We compared baseline, short-term, and long-term outcomes between the DAA and the posterior approach focusing on baseline function.

Material and methods

Multivariate linear and logistic regression models were used to analyze prospective data on 1457 total hip arthroplasties comparing baseline characteristics, operative time, 90-day reoperation, length of stay (LOS), extended LOS (>3 days), and facility discharge. The Patient-Reported Outcome Measurement Information System-Global Health (PROMIS-10) was used to determine physical component score (PCS) and mental component score (MCS), with clinically significant improvement defined as >5 points. Adjusters included age, sex, race/ethnicity, year, Charlson Comorbidity Index, body mass index, alcohol, and tobacco use.

Results

DAA patients had higher preoperative MCS (DAA 50.4 vs posterior approach 47.4, P < .001), PCS (40.7 vs 38.5, P < .001), and postoperative PCS scores (48.9 vs 46.7, P < .001). There was no difference in mean PCS improvement (8.1 vs 8.2; P = .798) or clinically significant PCS change (P = .963). DAA was associated with shorter LOS by 0.49 days (95% confidence interval [CI] = 0.32-0.65, P < .001), lower odds of extended LOS (odds ratio = 0.33, 95% CI = 0.21-0.50, P < .001), and lower odds of facility discharge (odds ratio = 0.54, 95% CI = 0.37-0.79, P < .001). No difference in operative time (86 vs 87 minutes; P = .812) or 90-day reoperations (1 vs 1%; P = .347) was observed.

Conclusion

DAA patients presented with higher preoperative PCS and MCS scores, yet both groups experienced significant improvement. DAA was associated with decreased LOS and lower odds of extended LOS and facility discharge. There was no difference in operative time or reoperation.

Minimum Five-Year Outcomes of Hip Resurfacing: Propensity-Score Matched Against Total Hip Arthroplasty Control Groups

BACKGROUND

The aim of this study is to evaluate clinical outcomes of patients undergoing Birmingham hip resurfacing (BHR) with a minimum 5-year follow-up and compare these outcomes to 2 matched control groups of patients undergoing either direct anterior approach (DAA) or posterior approach (PA) total hip arthroplasty (THA).

METHODS

Data between September 2008 and April 2015 were retrospectively reviewed. Male patients were included if they underwent a THA or BHR with minimum 5-year patient-reported outcomes. BHR patients were propensity-score matched in a 1:1 ratio to 2 control groups of patients: one group who underwent DAA THA and one group who underwent PA THA.

RESULTS

Fifty BHR patients were propensity-score matched to 2 control groups: 50 cases of PA THA and 50 cases of DAA THA. Both control groups were well matched with respect to demographics. The BHR 5-year patient-reported outcomes were comparable to both control groups. The BHR cohort compared favorably to the PA THA group with no significant differences in their average Forgotten Joint Score (77.9, 79.4, P = .84 respectively) and the number of patients reporting a score greater than or equal to 50 were also comparable, 41 (82%), 42 (84%), P = .79 respectively.

CONCLUSION

BHR yielded good functional status and outcomes, which compared favorably with control groups of DAA THA and PA THA. Decision-making should be based upon other factors such as potential risk factors, the surgeon's and patient's preferences, and the patient's physical demand.

Patient Factors That Matter in Predicting Hip Arthroplasty Outcomes: A Machine-Learning Approach

BACKGROUND

Despite the success of total hip arthroplasty (THA), approximately 10%-15% of patients will be dissatisfied with their outcome. Identifying patients at risk of not achieving meaningful gains postoperatively is critical to pre-surgical counseling and clinical decision support. Machine learning has shown promise in creating predictive models. This study used a machine-learning model to identify patient-specific variables that predict the postoperative functional outcome in THA.

METHODS

A prospective longitudinal cohort of 160 consecutive patients undergoing total hip replacement for the treatment of degenerative arthritis completed self-reported measures preoperatively and at 3 months postoperatively. Using four types of independent variables (patient demographics, patient-reported health, cognitive appraisal processes and surgical approach), a machine-learning model utilizing Least Absolute Shrinkage Selection Operator (LASSO) was constructed to predict postoperative Hip Disability and Osteoarthritis Outcome Score (HOOS) at 3 months.

RESULTS

The most predictive independent variables of postoperative HOOS were cognitive appraisal processes. Variables that predicted a worse HOOS consisted of frequent thoughts of work (β = -0.34), frequent comparison to healthier peers (β = -0.26), increased body mass index (β = -0.17), increased medical comorbidities (β = -0.19), and the anterior surgical approach (β = -0.15). Variables that predicted a better HOOS consisted of employment at the time of surgery (β = 0.17), and thoughts related to family interaction (β = 0.12), trying not to complain (β = 0.13), and helping others (β = 0.22).

CONCLUSIONS

This clinical prediction model in THA revealed that the factors most predictive of outcome were cognitive appraisal processes, demonstrating their importance to outcome-based research.

LEVEL OF EVIDENCE

Prognostic Level 1.

Comparison of short-term outcomes between direct anterior approach (DAA) and SuperPATH in total hip replacement: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Two minimally invasive approaches showed some advantages in outcomes compared to conventional approaches (CAs)-the direct anterior approach (DAA) and the supercapsular percutaneously assisted approach in THA (SuperPATH). To the best of our knowledge, DAA and SuperPATH have never been compared, neither in clinical studies, nor in a meta-analysis. To conduct a systematic review and network meta-analysis of randomized controlled trials comparing short-term outcomes of DAA and SuperPATH in total hip joint arthroplasty (THA).

METHODS

A systematic literature search up to May 2020 was performed to identify randomized controlled trials (RCTs) comparing SuperPATH with CAs and DAA with CAs in THA. We measured surgical, functional, and radiological outcomes. A network meta-analysis, using frequentist methods, was performed to assess treatment effects between DAA and SuperPATH. Information was borrowed from the above-mentioned RCTs, using the CA group as a common comparator.

RESULTS

A total of 16 RCTs involving 1392 patients met the inclusion criteria, three trials with a level I evidence, 13 trials with a level II evidence. The overall network meta-analysis showed that SuperPATH reduced operation time (fixed effect model: MD = 12.8, 95% CI 9.9 to 15.7), incision length (fixed effect model: MD = 4.3, 95% CI 4.0 to 4.5; random effect model: MD = 4.3, 95% CI 0.2 to 8.4), intraoperative blood loss (fixed effect model: MD = 58.6, 95% CI 40.4 to 76.8), and early pain intensity (VAS 1 day postoperatively with a fixed effect model: MD = 0.8, 95% CI 0.4 to 1.2). The two approaches did not differ in acetabular cup positioning angles and in functional outcome.

CONCLUSIONS

Our overall findings suggested that the short-term outcomes of THA through SuperPATH were superior to DAA. SuperPATH showed better results in decreasing operation time, incision length, intraoperative blood loss, and early pain intensity. DAA and SuperPATH were equal in functional outcome and acetabular cup positioning.

Dual Mobility and Conventional Bearings Have Comparably Low Dislocation Rates for Anterior-Based Approaches in Total Hip Arthroplasty

BACKGROUND

Dual mobility (DM) bearings for total hip arthroplasty (THA) have been proposed to reduce the risk of instability in select patients, especially those undergoing revision surgery. The use of DM bearings has not been studied as extensively for use in primary THA. The purpose of this study is to compare outcomes following primary THA with anterior-based approaches between patients receiving DM bearings vs standard bearing hip implants.

METHODS

We retrospectively reviewed a consecutive series of patients undergoing primary THA through an anterior-based approach. A 3:1 propensity score match was performed between the standard and DM bearing patients to control for possible risk factors for instability. Functional outcomes, dislocations, and aseptic revisions were identified for each patient. The effect of DM on postoperative outcomes was determined using univariate statistical analyses.

RESULTS

In total, 250 DM bearings were compared to 753 standard bearings. We found no difference in dislocation rate between single bearings and DM bearings (0.53% vs 0.4%). There was 1 DM dislocation occurring in a liner with outer diameter of 38 mm. There were no DM dislocations with outer diameter >38 mm. Aseptic revision surgery was more common in DM. This difference was driven by higher incidence of femoral periprosthetic fracture. There were no differences in functional outcomes.

CONCLUSION

Dislocation rates are comparably low between DM bearings and standard bearings for THA done using an anterior approach to the hip. Further investigation is needed to determine if specific patient populations may benefit from DM implants for primary THA when an anterior approach to the hip is being used.

Comparison of direct anterior approach and posterior approach total hip arthroplasty: More than 5-year follow-up

Purpose

In this study we compare the surgical outcome of DAA and PA more than 5-year follow-up evaluation.

Materials and methods

This is a retrospective cohort single-surgeon study of consecutive primary THAs using the DAA or PA.

Results

There was no significant difference in HHS and JHEQ score. Posterior dislocation occurred in 4 cases in PA group (9.5%, p = 0.038) while there was no dislocation in DAA group.

Conclusion

Both DAA and PA yield good results at the final follow-up in terms of function, quality of life, and survivorship. However dislocation was significantly higher in PA group.

Late Anterior Prosthetic Hip Dislocation Due to Yoga

The popularity of yoga and the prevalence of total hip arthroplasty (THA) have simultaneously increased in the United States. Accordingly, one can assume that the number of THA patients practicing yoga has increased. Certain yoga poses reach the extremes of hip range of motion, potentially leaving patients vulnerable to dislocation. To date, 2 cases of late posterior prosthetic hip dislocations during yoga have been reported; however, there have been no reports of anterior prosthetic hip dislocations. We present one case of late anterior prosthetic hip dislocation during yoga in a patient who underwent THA via the direct anterior approach. Prosthetic hip dislocation during yoga may be a growing concern. We provide additional evidence in support of recommendations for THA patients to safely practice yoga.

Effects of body mass index and range of motion on intraoperative change in pelvic tilt during total hip arthroplasty using the direct anterior approach

BACKGROUND

Intraoperative pelvic tilt changes that occurs during total hip arthroplasty (THA) in the supine position affects cup placement and sometimes causes malalignment. The relationship between body mass index (BMI) and pelvic movement has been reported for some procedures, but not the direct anterior approach (DAA). The purpose of this study was to investigate intraoperative pelvic tilt changes that occurs during DAA.

METHODS

In this single-center, retrospective study, we reviewed 200 hips that underwent primary THA via DAA in the supine position using an accelerometer-based navigation system. Intraoperative changes in pelvic tilt and axial rotation from the start of surgery to cup placement were assessed using the navigation system. Preoperative clinical factors that increased pelvic tilt and axial rotation toward the surgical side by > 10° were analyzed via univariate and multiple logistic regression analyses.

RESULTS

The mean pelvic tilt value increased by 7.6° ± 3.8° (95% confidence interval [CI], 7.1-8.2; range, - 5.0-19.0) intraoperatively, and the axial rotation increased by 3.2° ± 2.7° (95% CI, 2.7-3.7; range, - 13.0-12.0). Univariate analysis revealed that the group with increased pelvic tilt showed significantly greater range of abduction and internal rotation, and significantly lower BMI than the group with no increased tilt. Pre-incisional pelvic tilt was significantly greater in the group with increased axial rotation than in the group with no increased rotation. On logistic regression analysis, BMI (odds ratio [OR], 0.889; 95% CI, 0.809-0.977; p = 0.014) and the range of internal rotation (OR, 1.310; 95% CI, 1.002-1.061; p = 0.038) were predictors of large increases in pelvic tilt. No predictors of large increases in axial rotation were identified.

CONCLUSION

Significant forward pelvic tilt was observed in patients with a low BMI values and high ranges of internal rotation via THA using the DAA. Findings indicated that surgeons should pay attention to intraoperative pelvic movements, which may help identify patients with significant pelvic tilt changes.

Comparison of short-term outcomes of anterolateral supine approach and posterolateral approach for primary total hip arthroplasty: a retrospective study

Background

This study aims to evaluate postoperative pain and functional and clinical outcomes of anterolateral supine (ALS) and posterolateral (PL) approaches for primary total hip arthroplasty.

Materials and methods

We retrospectively examined the joints of 110 patients who underwent primary total hip arthroplasty (THA). The ALS group was compared with the PL group using the pain visual analog scale (VAS) and narcotic consumption as pain outcomes. Functional outcomes included postoperative range of motion (ROM) of hip flexion, day on which patients could perform straight leg raising (SLR), day on which patients began using a walker or cane, duration of hospital stay, rate of transfer, and strength of hip muscles. Clinical outcomes included pre and postoperative Harris Hip Scores.

Results

No significant differences were found in the pain VAS scores or narcotic consumption between the two groups. The PL group could perform SLR earlier than the ALS group (P < 0.01). The ALS group started using a cane earlier (P < 0.01) and had a shorter hospital stay (P < 0.01) than the PL group. Degrees of active ROM of flexion at postoperative day (POD) 1 were significantly lower in the ALS group than in the PL group (P < 0.01). Regarding hip muscle strength, hip flexion was significantly weaker in the ALS group than in the PL group until 1-month POD (P < 0.01). External rotation from 2 weeks to 6 months postoperatively was significantly weaker in the PL group than in the ALS group (P < 0.01).

Conclusion

The ALS approach was more beneficial than the PL approach because ALS enabled better functional recovery of the strength of external rotation, improved rehabilitation, and involved a shorter hospital stay.

Level of Evidence

Level IV retrospective observational study.

Evaluation of muscle volume and degeneration after total hip arthroplasty: a comparison of the posterolateral approach and the anterolateral supine approach

Background

Muscle strength around the hip after total hip arthroplasty (THA) is crucial for preventing dislocation and limping. This study aimed to assess and compare muscle volume and degeneration after THA using the posterolateral (PL) and anterolateral (AL) approaches.

Methods

Sixty-four hips in 64 patients who underwent primary THA were retrospectively analyzed. Patients were segregated into the PL group (35 hips) and AL group (29 hips) for evaluating pre- and postoperative muscle volumes and degeneration around the hip. Computed tomography (CT) examinations were performed preoperatively and 6 months post THA. The muscle volume and Hounsfield units (HU) of the gluteus maximus (G-max), gluteus medius (G-med), tensor fasciae latae, internal obturator muscle, and external obturator muscle were measured.

Results

In the PL group, the postoperative muscle volume of the G-max significantly increased than the preoperative muscle volume. In contrast, the postoperative muscle volume of the internal obturator muscle was significantly lower than the preoperative muscle volume. The postoperative HU of the internal and external obturator muscles were significantly lower than the preoperative HU. In the AL group, the postoperative muscle volumes of the G-max, G-med, and tensor fasciae latae significantly increased than their preoperative muscle volumes. The postoperative HU of the G-med and tensor fasciae latae were significantly higher than the preoperative HU values.

Conclusion

The PL approach can lead to degeneration of the internal and external obturator. The AL approach is more beneficial for recovering the G-med, tensor fasciae latae, and internal obturator muscle than the PL approach.

"True" Cumulative Incidence of and Risk Factors for Hip Dislocation within 2 Years After Primary Total Hip Arthroplasty Due to Osteoarthritis: A Nationwide Population-Based Study from the Danish Hip Arthroplasty Register

BACKGROUND

Hip dislocation is one of the leading indications for revision of total hip arthroplasty (THA) implants, and the extent of this complication is often measured by the number of revisions. The exact incidence of dislocation can be difficult to establish as closed reductions may not be captured in available registers. The purpose of this study was to identify the "true" cumulative incidence of hip dislocation (revisions and closed reductions) after primary THA, and the secondary aim was to identify risk factors for dislocation.

METHODS

From the Danish Hip Arthroplasty Register, we identified 31,105 primary THAs indicated by primary osteoarthritis that had been performed from 2010 to 2014 and had 2 years of follow-up. Dislocations were identified through extraction from the Danish National Patient Register. Matching diagnosis and procedure codes were deemed correct while non-matching codes were reviewed through a comprehensive, nationwide review of patient files. Risk factors were analyzed with multiple logistic regression analysis and presented as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Our review of patient files identified 1,861 dislocations in 1,079 THAs, which corresponds to a 2-year cumulative incidence of 3.5% (CI = 3.3% to 3.7%). This was a 50% increase compared with the correctly coded dislocations captured by administrative register data only. Patients who were <65 years of age had a lower dislocation risk (OR = 0.70; CI = 0.59 to 0.83) and those who were >75 years of age had a higher risk (OR = 1.32; CI = 1.14 to 1.52) compared with those who were 65 to 75. Male sex (OR = 0.86; CI = 0.75 to 0.98), cemented fixation (OR = 0.71; CI = 0.58 to 0.87), and lateral approach (OR = 0.28; CI = 0.16 to 0.49) were all associated with a lower risk. A head size of 32 mm was associated with a higher risk of dislocation (OR = 1.27; CI = 1.10 to 1.46) than 36-mm heads, whereas dual-mobility cups had a reduced risk (OR = 0.13; CI = 0.05 to 0.36).

CONCLUSIONS

We found the "true" cumulative incidence of dislocations within 2 years after primary THAs performed between 2010 and 2014 in Denmark to be 3.5%. Age, sex, American Society of Anesthesiologists (ASA) score, head size and type, fixation method, and surgical approach were independent significant factors for dislocation. Comprehensive search algorithms are needed in order to identify all dislocations so that this complication can be accurately reported in national registers.

Usefulness of Perioperative Laboratory Tests in Total Hip and Knee Arthroplasty: Are They Necessary for All Patients?

BACKGROUND

Laboratory studies are routinely obtained preoperatively and postoperatively for total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study evaluates the necessity of routine, perioperative laboratory tests and identifies risk factors for laboratory-associated interventions.

METHODS

This retrospective review evaluated 967 consecutive patients scheduled for primary, unilateral TKAs (n = 593) or THAs (n = 374) over an 18-month period at a single institution. Preoperative prothrombin time (PT) and International Normalized Ratio (INR), complete blood count (CBC), complete metabolic panel (CMP), and postoperative CBC and basic metabolic panel (BMP) were recorded along with any laboratory-associated intervention. Patient demographics and comorbidities identified risk factors for abnormal or actionable laboratory studies.

RESULTS

Preoperatively, the actionable rates for PT/INR, CMP, and CBC were 0.3%, 1.4%, and 0.5%, respectively. Vascular, renal, and immunologic diseases were risk factors for an actionable CBC. Risk factors for an actionable CMP include cardiac arrhythmia and diabetes. There were no risk factors for an actionable PT/INR. Postoperatively, only 1.5% of BMPs and 1.5% of CBCs were actionable. Congestive heart failure, renal disease vascular disease, or history of cancer (P = .030) were risk factors for an actionable CBC. There were no risk factors for an actionable BMP. Patients with an abnormal preoperative lab were 2.4 times more likely to have an actionable postoperative lab. Patients with an actionable preoperative lab were 11.3 times more likely to have an actionable postoperative lab.

CONCLUSION

Routine preoperative and postoperative labs may not be necessary on all patients undergoing a TKA or THA. Comorbid risk factors and abnormal or actionable preoperative CMPs and CBCs can help determine the usefulness of postoperative laboratory assessments.

Does total hip arthroplasty via the direct anterior approach using dual mobility increase leg length discrepancy compared with single mobility?

Background

Total hip arthroplasty (THA) via the direct anterior approach (DAA) using dual mobility cup (DMC) is considered to effectively prevent postoperative dislocation. However, the dislocation and reduction procedure using a trial implant during the surgery is difficult because of high soft tissue tension. Thereby, leg length discrepancy (LLD) is difficult to assess when using DM via the DAA.

Purpose

To compare the LLD between cases using conventional SM and those using DMC in THA via the DAA with fluoroscopy.

Patients and methods

We retrospectively investigated 34 hips treated with DMC (DMC-DAA group) and 31 hips treated with SM (SM-DAA group). The LLD was defined as the difference in the distance from the teardrop to the medial-most point of the lesser trochanter between the operative and nonoperative sides at immediate postoperative X-ray.

Results

The mean LLD in the DMC-DAA group and SM-DAA group was 0.68 ± 7.7 mm and 0.80 ± 5.5, respectively, with no significant difference. The absolute value of the LLD in the DMC-DAA group and SM-DAA group was 6.3 ± 4.4 mm and 5.9 ± 5.5, respectively, with no significant difference.

Conclusion

Despite the difficulty in assessment of the LLD during THA via the DAA using DMC, this technique does not increase the LLD compared with the use of SM.

Level of evidence

III, matched case-control study.

Direct anterior approach versus posterolateral approach in total hip arthroplasty: a meta-analysis of results on early post-operative period

Background

This study was performed to compare the advantage and disadvantage of posterolateral approach (PLA) and direct anterior approach (DAA) in total hip arthroplasty (THA).

Methods

Relevant trials were identified via a search of the Cochrane Central Register of Controlled Trials and PubMed from inception to 1 June 2019. A meta-analysis was performed to compare postoperative perioperative and radiographic outcomes between DAA and PLA in THA with respect to the hospital stay, blood loss, incision length, operative time, complications, and femoral and cup component position. The Harris Hip Score (HHS) was also assessed before and after 6 months postoperatively.

Results

Nine eligible studies involving 22698 adult patients (DAA group, n = 2947; PLA group, n = 19751) were identified for analysis. Compared with the PLA group, the DAA group had shorter hospital stay and achieved better HHS within 6 months after operation (P < 0.05), but the HHS was no significant differences between the two groups over 6 months (P > 0.05). The DAA group had significantly longer operative time, more blood loss, and complications than the PLA group (P < 0.05). In addition, the femoral component positioned in neutral and cup component inclination angle was comparable between both groups (P > 0.05); however, cup component anteversion angle was significantly larger in the PLA group (P < 0.05).

Conclusion

Patients in the DAA group had higher HHS within 6 months and shorter hospital stay. The DAA could offer rapid early functional recovery after THA compared with the PLA. However, the DAA group often required longer operative time and had more blood loss. Furthermore, there was a higher early complication rate. Therefore, we believe that the direct anterior approach was a more difficult technique. The surgeon should be a well-trained joint surgeon with extensive prior hip replacement experience before performing THA through a DAA, and DAA was not suitable for beginners performing THA. In addition, we did not observe the difference with regard to the femoral component position and cup component inclination angle except for the smaller cup component anteversion angle in DAA group.

Minimizing complications in bikini incision direct anterior approach total hip arthroplasty: A single surgeon series of 865 cases

PURPOSE

The purpose of this study was to report all complications during the first consecutive 865 cases of bikini incision direct anterior approach (DAA) total hip arthroplasty (THA) performed by a single surgeon. The secondary aims of the study are to report our clinical outcomes and implant survivorship. We discuss our surgical technique to minimize complication rates during the procedure.

METHODS

We undertook a retrospective analysis of our complications, clinical outcomes and implant survivorship of 865 DAA THA's over a period of 6 years (mean = 3.9yrs from 0.9 to 6.8 years).

RESULTS

The complication rates identified in this study were low. Medium term survival at minimum 2-year survival and revision as the end point, was 99.53% and 99.84% for the stem and acetabular components respectively. Womac score improved from 49 (range 40-58) preoperatively to 3.5(range 0-8.8) and similarly, HHS scores improved from 53(range 40-56) to 92.5(range 63-100) at final follow-up (mean = 3.9 yrs) when compared to preoperative scores.

CONCLUSIONS

These results suggest that bikini incision DAA technique can be safely utilised to perform THA.

Time efficiency of direct anterior hip arthroplasty compared to postero-lateral approach in elderly patients

INTRODUCTION

Primary arthroplasty of the hip joint is currently one of the most commonly performed procedures in orthopedics. In Poland we are observing significant changes in the age structure. With the prolonged life more and more elderly patients require musculoskeletal surgery to maintain comfortable and painless mobility. Reducing the duration of the procedure reduces the costs of anesthesiology, surgical and instrument teams, as well as the operating room technical team. The aim of the study was to compare the time required to perform hip joint arthroplasty by the direct anterior approach (DAA) with the postero-lateral approach (PLA) in our hospital.

MATERIAL AND METHODS

A retrospective analysis of 559 total and bipolar cemented and cementless hip replacement procedures based on two operative approaches - the minimally invasive DAA over the course of 2 years, and the standard PLA over the course of 3 years - was performed.

RESULTS

Statistically significant differences were observed between the approaches used for cementless total arthroplasty with regard to the mean treatment times: 51.9 min for the 272 DAA cases, and 78.3 min for the 190 PLA cases (p < 0.0001). For the cementless hemi-arthroplasty procedure, the mean treatment times were 46.9 min in 36 patients for DAA, and 48.2 min for 61 patients for PLA (p = 0.57).

CONCLUSIONS

Minimally invasive DAA significantly shortens the time of the procedure in elderly patients compared to PLA. Further study is needed to analyze other aspects of those two approaches.

Radiographic factors to predict operation time of direct anterior total hip arthroplasty for dysplastic hips

BACKGROUND

This study aimed to identify radiographic factors that could predict surgical difficulty in direct anterior total hip arthroplasty (THA) for dysplastic hips.

PATIENTS AND METHODS

The clinical records of 160 patients (204 hips) who underwent primary THA for the treatment of developmental dysplasia of the hip were retrospectively investigated. All THAs were performed through a direct anterior approach by a single surgeon. A multiple regression analysis was developed to identify the independent predictor of operation time, including variables such as age, sex, height, body mass index (BMI), the use of bone cement, previous hip surgery, and radiographic references, including the pelvic horizontal to vertical ratio, the extent of proximal and horizontal migration of the femoral head, flatness of the femoral head, and the vertical distance between the tips of the greater trochanter and the femoral head.

RESULTS

A multiple regression analysis revealed that as radiographic factors, proximal migration of the femoral head, and lower position of the femoral head related to the greater trochanter were significantly associated with longer operation time. In addition, our results revealed that younger age, male sex, height, high BMI, cement use, and previous hip surgery were also significantly associated with longer operation time.

CONCLUSIONS

Our findings indicate that proximal migration of the femoral head and high-riding greater trochanter are isolated radiographic predictors of the longer operation time of direct anterior THA for dysplastic hips.

Outcome and EBRA migration analysis of a reconstruction cage in acetabular revision arthroplasty: a clinical and radiological study

PURPOSE

Restoration cages and bone allografts have been proposed to manage severe acetabular bone defects. We aimed to investigate the migration behaviour of a restoration cup and impacted allograft bone in severe acetabular defects with Einzel-Bild-Röntgen-Analyse (EBRA).

METHODS

Applying a retrospective study design, 64 cases treated between 2009 and 2016 were reviewed. We determined the preoperative Charlson Comorbidity Index (CCI), pre- to postoperative WOMAC score, blood loss and functional outcome. From preoperative x rays, the acetabular deficiencies were classified according to Paprosky. Cup migration analyses were performed with EBRA.

RESULTS

Mean age at surgery was 73 (range: 38-93) years. According to the classification by Paprosky et al., 50% (n = 32) of our patients showed a type III B and 28.1% (n = 18) a type III A defect. Radiological follow-up for migration analysis was 35 (range: 4-95) months. Migration analysis showed a mean cup migration of 0.7 mm (range: 5.7-9.6) medial and 1.8 mm (range: 1.7-12.6) cranial.

CONCLUSION

In conclusion, acetabular restoration cages in combination with bone impaction grafting showed a low revision rate at a mean follow-up of 35 months. Mean cup migration revealed low rates after 2 years and suggested a stable postoperative implant position.

Outpatient Hip Safety in an Ambulatory Surgery Center Is Independent of Approach

BACKGROUND

There are few data comparing the direct anterior approach (DAA) and posterior approach (PA) for total hip arthroplasty (THA) in the outpatient setting. The purpose of this study is to compare 90-day complications between the 2 approaches. We hypothesized that they would be equally safe and effective.

METHODS

Retrospective review identified 432 THAs (346 DAA, 86 PA) performed at a single ambulatory surgery center (ASC). Outcomes compared included demographics, comorbidities, preoperative and discharge pain scores (visual analog scale [VAS]), overall time spent in the ASC, overnight stay, emergency room visits, admission, reoperation, and complications within a 90-day period.

RESULTS

There were no differences in mean preoperative VAS (DAA 4.7, PA 4.5), mean discharge VAS (DAA 0.8, PA 0.7), overall time spent in the ASC (DAA 9.0 hours, PA 9.3 hours), total number of overnight stays (DAA 0.9%, PA 1.2%), emergency room visits (DAA 1.7%, PA 1.2%), admissions (DAA 1.4%, PA 1.2%), reoperations (DAA 1.4%, PA 1.2%), or complications (DAA 3.5%, PA 2.3%).

CONCLUSION

There were no differences in the safety outcomes, and overall there were few complications in the 90-day period, regardless of the surgeon's preferred approach. This study indicates both DAA and PA are equally safe for THA in the outpatient setting, and the choice of surgical approach should be based on patient and surgeon preference.

No Differences in Midterm Sports Participation or Functional Scores After Total Hip Arthroplasty by Posterolateral Vs Anterolateral Approach

BACKGROUND

Patients undergoing total hip arthroplasty (THA) frequently question surgeons on return to sports. We compared midterm sports participation and functional scores after THA by posterolateral approach (PLA) vs anterolateral approach (ALA).

METHODS

Of 1381 patients who underwent uncemented ceramic-on-ceramic THA for primary osteoarthritis, 503 were excluded because of preoperative or postoperative lower limb surgery, leaving 594 operated by PLA and 284 by ALA. Forgotten Joint Score (FJS), Oxford Hip Score (OHS), satisfaction, as well as motivation, participation, and discomfort regarding 22 sports were collected. A 1:1 matching was performed to obtain 2 groups of PLA and ALA patients with similar age, gender, body mass index, and sports motivation.

RESULTS

Matching yielded 2 equal groups of 259 patients. There were no significant differences in FJS (P = .057), OHS (P = .685), satisfaction (P = .369), or rates of participation in light (P = .999), moderate (P = .632), or strenuous sports (P = .284). Participation in strenuous sports was reported by 50 PLA (19%) and 61 ALA (24%) patients, with differences for downhill skiing (22 vs 39), running (10 vs 19), and cross-country skiing (18 vs 10). More than 50% of motivated patients practiced most of their sports. Severe discomfort was reported similarly in PLA and ALA patients, mainly during running (13 vs 11), team ball games (9 vs 7), and downhill skiing (7 vs 8).

CONCLUSION

There were no significant differences between PLA and ALA patients in terms of OHS, FJS, satisfaction, or sports participation rates. There is little or no evidence to promote an approach based on sports participation or functional improvement.

LEVEL OF EVIDENCE

Level III, comparative study.

Minimally invasive posterolateral hip approach with SPARTAQUUS (Spare the Piriformis And Respect The Active QUadratus femoris and gluteus mediUS) technique

Interest in the different surgical approaches to total hip arthroplasty remains high, but without any real consensus on which approach is the most beneficial. Several recent technical innovations have made it possible to reduce the risk of dislocation, therefore improving the efficacy of the posterolateral approach. Since 2003, we have been using a modified minimally invasive posterolateral approach called SPARTAQUUS (Spare the Piriformis And Respect The Active QUadratus femoris and gluteus mediUS), which spares the piriformis tendon, the quadratus femoris muscle and the gluteus medius muscle, and involves direct capsular repair. The "active posterosuperior hammock" effect of the piriformis tendon is therefore coupled with the "passive posterosuperior hammock" effect of the capsular repair, thus limiting the risks of posterior dislocation of the prosthetic hip joint.

Hip precautions after primary total hip arthroplasty: a qualitative exploration of clinical reasoning

PURPOSE

Hip precautions are movement restrictions that are often advised following primary total hip arthroplasty (PTHA) for osteoarthritis (OA), but there is limited evidence supporting their effectiveness in preventing dislocation. This study aimed to explore the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA.

MATERIALS AND METHODS

Semi-structured interviews were conducted with therapists and surgeons at six centres using precautions and six centres not using precautions across secondary or tertiary NHS sites in England. Interviews were transcribed verbatim and thematically analysed.

RESULTS

Interviews were conducted with fourteen surgeons and eighteen therapists. Of these clinicians, eight surgeons and ten therapists routinely advised precautions. Clinicians continued to use precautions to avoid dislocation by creating a boundary to movement, particularly important when dealing with patients who "push" these boundaries. Clinicians discontinued precautions because of a perceived negative impact on patients and the lack of supporting evidence. In the absence of a rise in dislocation rates for these centres, others have now changed practice.

CONCLUSION

This study offers insight into the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA. The use of precautions remains controversial and further work is required to determine whether or not they should be advised.IMPLICATIONS FOR REHABILITATIONRedesign of future rehabilitation pathways for primary total hip arthroplasty should take into account viewpoints from across the multidisciplinary team to aid decision making.Concern for patient behaviours, dislocation and litigation may be barriers to changing practice for rehabilitation after primary total hip arthroplasty.Clinicians may be discontinuing hip precautions because of known surgical advances, a perceived negative impact on patients and a lack of supporting evidence for historical practice.Individualised rehabilitation considerations are necessary for patients with risk factors that predispose them to dislocation after primary total hip arthroplasty, regardless of whether hip precautions are advised as standard at their given centre.

Direct anterior versus posterior approach for total hip arthroplasty: a multicentre, prospective, randomized clinical trial

BACKGROUND

The ideal approach for a total hip arthroplasty (THA) would be kind to soft tissues, have the lowest complication rates and be easily reproducible. Although there have been several attempts to find the best approach for THA in the last decade, a definitive answer has not been found. We performed a prospective study to compare the direct anterior and posterior approaches for THA in terms of hospital length of stay, functional outcome, pain, implant position, complications and surgical time.

METHODS

A prospective, randomized, multicentre clinical study was conducted between February 2011 and July 2013, with an average follow-up of 55 months. Patients undergoing the direct anterior or posterior approach for THA were enrolled. Hospital length of stay, surgical time and complications were documented. The Harris Hip Score and visual analogue scale were used to monitor functional outcome and pain until 5 years postoperatively. Radiologic analysis was used to assess implant position.

RESULTS

Fifty-five patients (28 undergoing the direct anterior approach, 27 undergoing the posterior approach) were enrolled in this study. Length of stay, functional outcome, pain, implant position and complications were similar for the 2 approaches. There was a trend toward a better functional outcome for patients who underwent the direct anterior approach in the first 3 months postoperatively, with a peak at 4 weeks (Harris Hip Score 76.7 v. 68.7; p = 0.08). Average surgical time for the direct anterior approach was significantly longer (69.9 v. 45.7 min; p = 0.002).

CONCLUSION

The direct anterior approach for THA appears to be a safe and effective option. However, there is no significant difference in hospital length of stay or postoperative recovery between the 2 approaches.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, no. NCT03673514.

The short external rotators dissection during the posterior approach in total hip arthroplasty did not change the blood flow

OBJECTIVES

The posterior approach in total hip arthroplasty (THA) often requires dissection of the short external rotators (SERs), which could increase the postoperative dislocation rate. The reattachment of the dissected SERs has been reported to reduce the dislocation rate, while such repair generally causes progression of muscle atrophy. 1 of the suggested causes of atrophy is reduced blood flow to the repaired SERs. The present study aimed to measure the blood flow of the SERs before dissection (pre-tenotomy) and after reattachment (post-reattachment) during the posterior approach in THA.

METHODS

This prospective study included 26 patients who underwent THA via the posterior approach. A laser-Doppler rheometer was used to measure the blood flow in the following SERs at the time of pre-tenotomy and post-reattachment: the piriformis muscle (PM), superior gemellus (SG), inferior gemellus (IG), obturator internus (OI), and subcutaneous tissue as a control.

RESULTS

The average pre-tenotomy and post-reattachment blood flows (mL/minutes/100 g) were: 1.90 ± 0.28 and 1.92 ± 0.40 in the PM, 1.94 ± 0.20 and 1.99 ± 0.39 in the SG, 1.91 ± 0.21 and 1.94 ± 0.30 in the IG, 1.93 ± 0.22 and 1.98 ± 0.36 in the OI, and 1.94 ± 0.24 and 1.87 ± 0.38 in the subcutaneous tissue. The pre-tenotomy and post-reattachment blood flows did not show significant difference in any muscle.

CONCLUSIONS

Laser-Doppler blood flow measurements showed that the blood flow is preserved, even when the SERs are dissected and reattached in THA via the posterior approach.

The Effect of Total Hip Arthroplasty Surgical Technique on Postoperative Muscle Atrophy

A variety of surgical approaches are used for total hip arthroplasty (THA). Controversy still exists regarding whether the direct anterior approach truly minimizes muscle damage. The purpose of this study was to determine the effect of surgical approach for THA on muscle atrophy quantified through magnetic resonance imaging (MRI). The study included 25 hips in patients with a mean age of 64.72±8.35 years who underwent a primary unilateral THA for severe osteoarthritis. Patients were grouped according to surgical approach: direct anterior (n=9), direct lateral (n=9), and posterior (n=7). Magnetic resonance images were collected at the 24-week postoperative time point to assess atrophy/fatty infiltration of the hip musculature. All MRIs were assessed by a fellowship-trained radiologist who was blinded to all clinical information. There were no significant differences preoperatively and 1 year postoperatively between the surgical approach groups in terms of patient-reported outcome measures (P>.05). Significant differences in fatty infiltration differences between surgical approaches were observed in the gluteus medius, gluteus minimus, iliacus, obturator externus, obturator internus, pectineus, psoas, quadratus femoris, sartorius, and vastus intermedius (P<.05). The direct anterior approach to THA resulted in less atrophy of the hip musculature compared with a direct lateral or posterior approach; however, there were no differences in patient-reported clinical outcome scores at 1 year between the surgical approaches. [Orthopedics. 2020;43(6):361-366.].

Serum miRNA-142 and BMP-2 are markers of recovery following hip replacement surgery for femoral neck fracture

The present study aimed to investigate the changes in miRNA-142 and bone morphogenetic protein-2 (BMP-2) expression before and after hip replacement surgery, and to determine their association with receptor activator of NF-κB ligand (RANKL) and osteoprotegerin (OPG). For this purpose, 142 cases of hip arthroplasty in patients with femoral neck fracture were selected as the research group, and 50 cases of healthy individuals who underwent a physical examination during the same time period were selected the control group. Serum miR-142 and BMP-2 levels were measured by RT-qPCR before and after surgery in the research group and the control group. Serum RANKL and OPG levels were detected before and after surgery by enzyme-linked immunosorbent assay (ELISA). The levels of serum miR-142 and BMP-2 in the research group were significantly lower than those in the control group. At 1 month after surgery, the levels of serum miR-142 and BMP-2 in the research group were significantly higher than those before surgery, and at 6 months after surgery, and they were higher than those in the control group. Pearson's correlation analysis revealed that the serum levels of miR-142 positively correlated with the BMP-2 levels before surgery, at 1 month after surgery, and at 6 months after surgery in the research group. The results of ROC curve analysis revealed that the AUC values of serum miR-142 and BMP-2 were 0.911 and 0.861, respectively. At 1 month after surgery, the levels of serum miR-142 and BMP-2 in group A (patients with a good or excellent recovery) were significantly higher than those in group B (patients with a fair or poor recovery). The levels of serum RANKL and OPG in the research group significantly increased at 1 month after surgery. The serum levels of miR-142 and BMP-2 positively correlated with those of RANKL and OPG before surgery and at 1 month after surgery. On the whole, the findings of the present study indicate that pre-operative serum miR-142 and BMP-2 levels are valuable for evaluating the post-operative recovery of patients with femoral neck fracture undergoing hip replacement surgery. In addition, in the present study, at 1 month after surgery, the levels of both miR-142 and BMP-2 were related to the recovery of the patients, and positively correlated with the RANKL and OPG levels.

Sequential ilioinguinal or anterior intrapelvic approach with anterior approach to the hip during combined internal fixation and total hip arthroplasty for acetabular fractures

PURPOSE

This study examined the complications and outcomes of geriatric acetabular fractures treated with open reduction internal fixation (ORIF) and total hip arthroplasty (THA) performed via combined ilioinguinal or anterior intrapelvic (AIP) approach to acetabulum and anterior approach to the hip.

METHODS

Eight patients with a fracture of the acetabulum were treated at a Level I trauma center between 2010 and 2019 with combined ORIF/THA using an ilioinguinal or AIP approach for the acetabulum and a separate anterior approach to the hip. Wound dehiscence, peri-incisional skin necrosis, surgical site infection, dislocation, fracture union, acetabular component stability, and heterotopic ossification (HO) were utilized as outcome measures. Merle d'Aubigné-Postel scores were collected for the six patients that had one-year minimum follow-up.

RESULTS

The mean patient age was 77 years. Four patients had anterior wall fractures, two had associated both column fractures, and two had anterior column-posterior hemitransverse fractures. All fractures healed with stable fixation of the acetabular component by 6 months. There were no instances of skin necrosis, dislocation, infection, or re-operation. One patient had a superficial wound dehiscence that resolved with local wound care. One patient developed radiographic HO but was clinically asymptomatic. The mean Merle d'Aubigné-Postel score was 15.8 (range = 14-16).

CONCLUSIONS

Our small series of geriatric patients with fracture of the acetabulum treated with combined ORIF/THA, via the ilioinguinal or AIP approach with a separate anterior approach to the hip, demonstrates satisfactory outcomes with low complications after one-year of follow-up. Further research of these challenging injuries with more patients is warranted in order to determine the subset of fracture types best treated with this method and THA survivorship.

Surgical Approach to Total Hip Arthroplasty Affects the Organism Profile of Early Periprosthetic Joint Infections

The optimal approach for total hip arthroplasty (THA) remains hotly debated. While wound complications following the direct anterior approach are higher than with other approaches, the organism profile of periprosthetic joint infections (PJIs) by approach remains unknown. Our goal was to compare the organism profiles of PJIs following direct anterior and non-anterior THA.

METHODS

We retrospectively reviewed 12,549 primary THAs (4,515 direct anterior and 8,034 non-anterior) that had been performed between January 2012 and September 2019 at a university-affiliated single-specialty orthopaedic hospital to identify patients with an early postoperative PJI. Criteria used for the diagnosis of a PJI were the National Healthcare Safety Network, which screens for PJI that occurs within 90 days of index arthroplasty, and the Musculoskeletal Infection Society guidelines. Patient demographic information and organism characteristics were recorded for analysis.

RESULTS

We identified 84 patients (38 who underwent the direct anterior approach and 46 who underwent the non-anterior approach) with an early postoperative PJI following primary THA (0.67% total THA PJI rate, 0.84% direct anterior THA PJI rate, and 0.57% non-anterior THA PJI rate). The direct anterior THA cohort had a significantly lower body mass index and American Society of Anesthesiologists score than the non-anterior THA cohort (29.5 versus 35.2 kg/m2, p < 0.0001; 2.29 versus 2.63, p = 0.016, respectively). Regarding organism profile, patients in the direct anterior THA cohort had significantly more monomicrobial gram-negative infections than the non-anterior THA cohort (4 versus 0, p = 0.038). We did not identify any demographic risk factors other than approach for gram-negative PJI. There were no significant differences in methicillin-resistant Staphylococcus aureus, methicillin-sensitive Staphylococcus aureus, coagulase-negative Staphylococcus, obligate anaerobes, polymicrobial, or PJIs due to other organisms by approach.

CONCLUSIONS

Direct anterior THA approaches have a greater risk of monomicrobial gram-negative PJI, likely due to the unique microbiome of the inguinal region. While targeted infection prophylaxis may reduce these infections, it is not entirely effective on its own. Future studies with larger sample sizes are required to help us develop more targeted perioperative infection prophylaxis.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Good long-term outcomes for Direct Anterior Approach Total Hip Arthroplasty in South Africa

This study aims to assess long-term outcomes of Total Hip Arthroplasty (THA) through Direct Anterior Approach (DAA) in a developing country using traditional and novel Patient-Reported Outcomes. There were 522 patients (mean age, 56.5 years; 66.3% female) after mean follow-up 7.35 years. There were 13 revisions. Overall 5-year implant survival rate was 97.5%. Patient Joint Perception scores of 65.5% perceived a completely natural joint. Mean Hip Disability and Osteoarthritis Score was 89.1. Median Forgotten Joint Score-12 was 90 and modified Harris Hip Score was 88. Primary DAA THA in sub-Saharan Africa allows good clinical outcomes at minimum 5 years follow-up.