Hip replacement

[Decision for total hip arthroplasty-the surgeons' view]

BACKGROUND

The decision for total hip arthroplasty (THA) is based on pain, loss of function, radiological changes and failed conservative therapy. These criteria are rarely based on systematic research and have not been integrated in generally accepted treatment guidelines. Aim of our study was, therefore, to analyse which decision criteria German orthopaedic and trauma surgeons use in order to recommend THA for patients with hip osteoarthritis.

MATERIALS AND METHODS

From 10/2019 to 07/2020 we conducted a nation-wide survey among 218 orthopaedic and trauma surgeons about their criteria for and against THA surgery, as well as their treatment objectives.

RESULTS

147 fully completed questionnaires were analysed. Pain (99%), limitation of movement (99%), as well as impairment of walking distance (97%), and the subjective burden (97%) were the most frequent criteria. 97% and 96% of surgeons consider prescription of analgesics and physical therapy, as well as a lack of their effectiveness, as criteria for THA. 87% see radiological changes grade Kellgren & Lawrence III as threshold. A recommendation against surgery is triggered by obesity (BMI ≥ 40 kg/m²) in 48% and by the presence of an active infection in 96%.

CONCLUSIONS

Current surgeons' practice criteria of recommendations for THA in Germany seem to reflect widely nationally and internationally discussed recommendations. Particular attention is given to patient factors like pain, loss of function and subjective burden, as well as previous conservative treatment and contraindications, like poorly controlled diabetes or an active infection, whereas morbid obesity is not seen as contraindication by all surgeons.

Three-dimensional analysis of the cortical contact state of short and conventional stems in different stem positions in total hip arthroplasty

BACKGROUND

Despite the increasing use of short cementless stems in total hip arthroplasty, their potential benefits have yet to be confirmed. We evaluated the cortical contact state of short and conventional stems in different femoral canal types and stem positions using a CT-based 3-dimensional templating software.

METHODS

We reviewed 153 hips in 153 patients, grouped according to femoral canal type-normal (68), champagne-flute (41), and stove-pipe canal (44). We investigated the influence of stem position on the contact state by evaluating three situations of stem anteversion (original anteversion, +5°anteverted, and +5°retroverted), three stem positions, neutral +2°extended, and +2°flexed positions using Taperloc Complete Microplasty^Ⓡ stem.

FINDINGS

The contact values of all zones between both stems in all canal types exhibited no significant differences. The values in zones 1, 2, 6, and 7 of both stems in 5° retroverted and anteverted, 2° extended and flexed positions were not significantly different compared to those of the neutral position. However, the values in zones 3, 4, and 5 of both stems were significantly greater compared to those of the neutral position in 2° extended and flexed positions; these values were also significantly larger in all canal types for the conventional stem.

INTERPRETATION

We demonstrated that the short and conventional stems can achieve the same proximal cortical contact in any femoral canal, regardless of the stem position. However, extended and flexed stem positions increase the distal contact, especially in conventional stems. Furthermore, the distal contact increases for the retroverted stem insertions.

An alternative ex vivo method to evaluate the osseointegration of Ti-6Al-4V alloy also combined with collagen

Due to the increasing number of orthopedic implantation surgery and advancements in biomaterial manufacturing, chemistry and topography, there is an increasing need of reliable and rapid methods for the preclinical investigation of osseointegration and bone ingrowth. Implant surface composition and topography increase osteogenicity, osteoinductivity, osteoconductivity and osseointegration of a prosthesis. Among the biomaterials used to manufacture an orthopedic prosthesis, titanium alloy (Ti-6Al-4V) is the most used. Type I collagen (COLL I) induces cell function, adhesion, differentiation and bone extracellular matrix component secretion and it is reported to improve osseointegration if immobilized on the alloy surface. The aim of the present study was to evaluate the feasibility of an alternative ex vivo model, developed by culturing rabbit cortical bone segments with Ti-6Al-4V alloy cylinders (Ti-POR), fabricated through the process of electron beam melting (EBM), to evaluate osseointegration. In addition, a comparison was made with Ti-POR coated with COLL I (Ti-POR-COLL) to evaluate osseointegration in terms of bone-to-implant contact (BIC) and new bone formation (nBAr/TAr) at 30, 60 and 90 d of culture. After 30 and 60 d of culture, BIC and nBAr/TAr resulted significantly higher in Ti-POR-COLL implants than in Ti-POR. No differences have been found at 90 d of culture. With the developed model it was possible to distinguish the biomaterial properties and behavior. This study defined and confirmed for the first time the validity of the alternative ex vivo method to evaluate osseointegration and that COLL I improves osseointegration and bone growth of Ti-6Al-4V fabricated through EBM.

Towards an effective sensing technology to monitor micro-scale interface loosening of bioelectronic implants

Instrumented implants are being developed with a radically innovative design to significantly reduce revision surgeries. Although bone replacements are among the most prevalent surgeries performed worldwide, implant failure rate usually surpasses 10%. High sophisticated multifunctional bioelectronic implants are being researched to incorporate cosurface capacitive architectures with ability to deliver personalized electric stimuli to peri-implant target tissues. However, the ability of these architectures to detect bone-implant interface states has never been explored. Moreover, although more than forty technologies were already proposed to detect implant loosening, none is able to ensure effective monitoring of the bone-implant debonding, mainly during the early stages of loosening. This work shows, for the first time, that cosurface capacitive sensors are a promising technology to provide an effective monitoring of bone-implant interfaces during the daily living of patients. Indeed, in vitro experimental tests and simulation with computational models highlight that both striped and circular capacitive architectures are able to detect micro-scale and macro-scale interface bonding, debonding or loosening, mainly when bonding is weakening or loosening is occurring. The proposed cosurface technologies hold potential to implement highly effective and personalized sensing systems such that the performance of multifunctional bioelectronic implants can be strongly improved. Findings were reported open a new research line on sensing technologies for bioelectronic implants, which may conduct to great impacts in the coming years.

TiO2 bioactive implant surfaces doped with specific amount of Sr modulate mineralization

One of the main problems that remain in the implant industry is poor osseointegration due to bioinertness of implants. In order to promote bioactivity, calcium (Ca), phosphorus (P) and strontium (Sr) were incorporated into a TiO₂ porous layer produced by micro-arc oxidation. Ca and P as bioactive elements are already well reported in the literature, however, the knowledge of the effect of Sr is still limited. In the present work, the effect of various amounts of Sr was evaluated and the morphology, chemical composition and crystal structure of the oxide layer were investigated. Furthermore, in vitro studies were carried out using human osteoblast-like cells. The oxide layer formed showed a triplex structure, where higher incorporation of Sr increased Ca/P ratio, amount of rutile and promoted the formation of SrTiO₃ compound. Biological tests revealed that lower concentrations of Sr did not compromise initial cell adhesion neither viability and interestingly improved mineralization. However, higher concentration of Sr (and consequent higher amount of rutile) showed to induce collagen secretion but with compromised mineralization, possibly due to a delayed mineralization process or induced precipitation of deficient hydroxyapatite. Ca-P-TiO₂ porous layer with less concentration of Sr seems to be an ideal candidate for bone implants.

Calcified cartilage in patients with osteoarthritis of the hip compared to that of healthy subjects. A design-based histological study

OBJECTIVE

Calcified cartilage is suggested to be involved in the pathogenesis of osteoarthritis (OA) by facilitating endochondral ossification at the bone-cartilage unit. Therefore, the objective was to quantify the volume and surface area of the calcified cartilage in the femoral head in OA patients and healthy subjects.

MATERIALS AND METHODS

We used design-based stereological principles, i.e., systematic uniform random sampling and vertical uniform random sections of the entire femoral head. We investigated the articular and calcified cartilage and femoral head surface area and volume, excluding fovea capitis and marginal osteophytes, in 20 patients with OA and 15 healthy subjects.

RESULTS

The volume of the calcified cartilage was significantly larger for the patients with OA compared with the healthy subjects (mean difference [95% CI]) (284 [110,457] mm³, p = 0.002). The upper and lower surface area of the calcified cartilage, i.e. the tidemark and cement line, were both significantly larger for OA patients compared with the healthy subjects (17.8 [8.4,27.3] cm², p < 0.001) and (38.7 [20.8,56.7] cm², p = 0.002), respectively. The volume of the calcified cartilage and the volume of the femoral head were significantly correlated for the patients with OA (Spearman's ρ = 0.51, p = 0.021), but not for the healthy subjects (ρ = 0.41, p = 0.123).

CONCLUSIONS

Patients with OA had a larger femoral head surface area and more calcified cartilage compared to healthy subjects. The volume of the calcified cartilage correlated positively with the volume of the femoral head for patients with OA, but not for healthy subjects. This strongly supports the existing view that bone growth in OA is associated with endochondral ossification.

Risk factors of postoperative delirium in the knee and hip replacement patients: a systematic review and meta-analysis

BACKGROUND

The risk factors of postoperative delirium (POD), a serious while preventable complication, developed by patients undergoing knee and replacement surgery are still under investigation. In this systematic review and meta-analysis, we identified risk factors associated with POD in knee and hip replacement.

METHODS

PubMed, Ovid MEDLINE, and Ovid EMBASE were used to identify original researches. The studies evaluating the risk factors of POD after knee and hip replacement were reviewed, and the qualities of the included studies were assessed with Newcastle-Ottawa Scale. Data were extracted, pooled, and a meta-analysis was completed RESULT: Twenty-two studies were finally included with a total of 11934 patients who underwent knee or hip replacement and 1841 developed POD with an incidence of 17.6% (95% confidential interval (CI) 13.2-22.0%). Eighteen significant risk factors were identified including advanced age (odds ratio (OR) 1.15 95% CI 1.08-1.22), cognitive impairment (OR 6.84, 95% CI 3.27-14.33), history of cerebrovascular events (OR 2.51, 95% CI 1.28-4.91), knee replacement (OR 1.42, 95% CI 1.00-2.02), blood loss (standardized mean difference (SMD) 0.30, 95% CI 0.15-0.44), dementia (OR 3.09, 95% CI 2.10-4.56), neurologic disorders (OR 2.26, 95% CI 1.23-4.15), psychiatric illness (OR 2.74, 95% CI 1.34-5.62), and obstructive sleep apnea (OR 4.17, 95% CI 1.72-10.09) along with several comorbidity evaluation scores and laboratory markers.

CONCLUSION

We identified risk factors consistently associated with the incidence of POD in knee and hip replacement. Strategies and interventions should be implemented to the patients receiving knee or hip replacement with potential risk factors identified in this meta-analysis.

Multi-Site Insufficiency Pelvic Fracture Following Total Hip Arthroplasty

Patient: Female, 47-year-old

Final Diagnosis: Pelvic fracture

Symptoms: Hip pain

Medication: —

Clinical Procedure: —

Specialty: Orthopedics and Traumatology

Usefulness of a Simple Preoperative Planning Technique using Plain X-rays for Direct Anterior Approach for Total Hip Arthroplasty

Objective

To examine the accuracy, reliability, and reproducibility of a simple preoperative planning technique using plain X‐rays.

Methods

A retrospective analysis of 96 consecutive cases of primary direct anterior approach (DAA)‐total hip arthroplasty (THA) from July 2015 to December 2018 was performed. The 96 patients included 24 males and 72 females, with an average age of 70 years. The standard AP pelvis radiographs with the patients' hips extended and internally rotated were obtained pre‐ and postoperatively. The preoperative planning was also completed on the standardized AP pelvic radiographs. The prearranged cup positioning was radiologically measured intraoperatively using fluoroscopy. The correct leg length was assessed intraoperatively, which was compared with the preoperative planning. The component positioning was measured by three independent researchers. Two of the researchers completed the measurements three times, and intra‐observer and inter‐observer reliability were calculated. All patients received at least 6 months follow‐up (6 months–4 years).

Results

In all cases, the median leg length discrepancy (LLD) was 4.4 mm (range 1.6–15.9 mm), and 84 patients had an LLD smaller than 10 mm, of which 58 patients had an LLD of less than 5 mm. None of the patients had a critical LLD of 2 cm or larger. The multivariable logistic regression for LLD (safe range: yes/no) with the co‐variables including gender, ASA classification, type of cup, the surgeon's experience level, and the presence of a total hip arthroplasty (THA) on the contralateral side did not present statistical significance. The median angle of the inclination of the acetabular component (IA) was 42.3° (range: 28.7°–52.2°). Ninety‐one patients were within the defined safe range. The hit ratio for the cup to be within the safe zone was significantly higher for the Pinnacle cups than that for the Continuum cups (P < 0.05). However, there was no significant difference in gender, ASA classification, the surgeon's experience level, and the presence of a total hip arthroplasty (THA) on the contralateral side. The median of its anteversion (AA) was 20.6° (range: 10.6°–40.1°). Only 41 patients were within the defined safe range. None of the co‐variables presented a statistical significance affecting the AA of the cup positioning. Meanwhile, the average fluoroscopy time for the cup positioning (n = 86, missing data in 10 cases) was 4 seconds (range: 1–74), with most of the patients (97.9%) having a fluoroscopy time of fewer than 20 seconds.

Conclusions

The combination of correct preoperative planning and standardized intraoperative measurements can reestablish right leg length and assure the correct cup positioning.

Impingement of the Sciatic Nerve due to a Protruding Acetabular Cage Rim

Sciatic nerve damage is a well-known complication that occurs in 1.5% of patients after primary total hip arthroplasty and in 8% after revision total hip arthroplasty. Yet when considering re-revision arthroplasty and acetabular cage implantation, incidence and management remain unclear. This case report describes a young female patient with sciatic nerve impingement after acetabular cage implantation. Her primary complaint was shooting sciatic left leg pain, worsening on ambulation and when seated. A complete workup was negative for spinal impingement or infection, and axonal nerve damage was confirmed through nerve conduction studies. The intraoperative findings showed that it was the acetabular cage rim that stretched the sciatic nerve. The rim was adjusted using a diamond burr to provide a specific solution without sacrificing the acetabular anchorage. Postoperative findings showed an excellent return to previous mobility and resolution of pain. This case provides a rare example of sciatic nerve impingement, showing that nerve palsies in the revision total hip arthroplasty setting may require patient-specific solutions.

Risk of venous thromboembolism in knee, hip and hand osteoarthritis: a general population-based cohort study

OBJECTIVES

Osteoarthritis is a leading cause of immobility and joint replacement, two strong risk factors for venous thromboembolism (VTE). We aimed to examine the relation of knee, hip and hand osteoarthritis to the risk of VTE and investigate joint replacement as a potential mediator.

METHODS

We conducted three cohort studies using data from The Health Improvement Network. Up to five individuals without osteoarthritis were matched to each case of incident knee (n=20 696), hip (n=10 411) or hand (n=6329) osteoarthritis by age, sex, entry time and body mass index. We examined the relation of osteoarthritis to VTE (pulmonary embolism and deep vein thrombosis) using a multivariable Cox proportional hazard model.

RESULTS

VTE developed in 327 individuals with knee osteoarthritis and 951 individuals without osteoarthritis (2.7 vs 2.0 per 1000 person-years), with multivariable-adjusted HR being 1.38 (95% CI 1.23 to 1.56). The indirect effect (HR) of knee osteoarthritis on VTE through knee replacement was 1.07 (95% CI 1.01 to 1.15), explaining 24.8% of its total effect on VTE. Risk of VTE was higher in hip osteoarthritis than non-osteoarthritis (3.3 vs 1.8 per 1000 person-years; multivariable-adjusted HR=1.83, 95% CI 1.56 to 2.13). The indirect effect through hip replacement yielded an HR of 1.14 (95% CI 1.04 to 1.25), explaining 28.1% of the total effect. No statistically significant difference in VTE risk was observed between hand osteoarthritis and non-osteoarthritis (1.5 vs 1.6 per 1000 person-years; multivariable-adjusted HR=0.88, 95% CI 0.67 to 1.16).

CONCLUSION

Our large population-based cohort study provides the first evidence that knee or hip osteoarthritis, but not hand osteoarthritis, was associated with an increased risk of VTE, and such an association was partially mediated through knee or hip replacement.

Clinical outcome before and after COVID-19 quarantine in patients affect of knee and hip osteoarthritis

BACKGROUND

The emergency caused by COVID-19 Pandemia has resulted in a complete suspension and consequent delay of common planned surgery such total hip replacement in patients affect by osteoarthritis. At the same time, the issue of the quarantine imposed changes to the normal lifestyle of these patients. The purpose of our study is to evaluate how the presence of these two factors affect the quality of live of patients living in the Italian red zone.

METHODS

From outpatient pre-operative assessment we collect data about: demographic data, WOMAC score, NRS (Numeric rating scale 0-10), PCS SF12 and MCS SF12 score. Selected patients were therefore contacted by telephone call and re-assess using the same score. In addition, patients were asked if they intended to undergo the planned surgery again despite the current emergency Results:  14 patient have been recruited for the study. Male/female ration was 10/4, mean age was 70 years. Pre operative outpatient assessment mean WOMAC score was 44,86 (SD ± 8,52) , mean NRS was 8,07 (SD ± 1,33), PCS SF12 was  30,33 (SD ± 5,0) and MCS SF12 was 40,95 (SD ± 3,51).  At re-evalutation the mean WOMAC score was 32,86 (SD ± 17,88) , mean NRS was 5,79 (SD ± 3,66), PCS SF12 was  39,9 (SD ± 3,70) and MCS SF12 was 50,14 (SD ± 6,86) Conclusion:  The exceptionale pandemic from Covid-19 has profoundly changed our lifestyle, impacting normal daily activities but also on regular surgical activity in patients affected by osteoarthritis. Our study suggested that the lifestyle changes imposed by the situation led to an improvement of clinical score. This shows how an exceptional event can affect many aspects of daily life.

In vitro effects of cobalt and chromium nanoparticles on human platelet function

Nanoparticles (NPs) are released from orthopedic and neurosurgical prostheses and can interact with a number of blood components once in the bloodstream. Potential toxic effects of Co and Cr NPs on blood platelets have not been thoroughly investigated. The aim of this study was to analyze the effect of Co and Cr NPs on platelet function in vitro. The ability of the tested NPs to induce platelet activation and aggregation was measured using light transmission aggregometry, flow cytometry, and quartz crystal balance with dissipation (QCM-D). This was confirmed by transmission electron microscopy (TEM), scanning electron microscopy, and optical and immunofluorescence microscopy. Perfusion of QCM-D sensor crystals with platelet-rich-plasma in the presence of Co 28 nm, CoO 50 nm, Co₂O₃ 50 nm, Co₃O₄ 30-50nm, Cr 35-45nm, Cr₂O₃ 60 nm NPs (0.5-5.0 µg/mL) resulted in significant changes in frequency and dissipation, indicating that these NPs caused platelet microaggregation. Transmission electron microscopy also revealed that Cr NPs led to platelet swelling and lysis. Our study shows that both Co and Cr NPs affect platelet function in vitro with two distinct mechanisms. While Co NPs result in standard platelet aggregation, Cr NPs cause both platelet aggregation and decreased platelet membrane integrity and lysis. Based on these findings, monitoring serum NP levels and platelet-mediated hemostasis can be advised in patients with metal-on-metal Co-Cr prostheses.

Repeat Doses of Dexamethasone up to 48 Hours Further Reduce Pain and Inflammation After Total Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

The optimal dose regimen of dexamethasone in total hip arthroplasty (THA) is unclear. This study was conducted to compare the effects among 1-dose, 2-dose, and 3-dose dexamethasone in THA.

METHODS

One hundred fifty patients were randomized to receive a single preoperative dose of 10-mg dexamethasone (group A, 50 patients), or another dose of 10-mg dexamethasone 24 hours later (group B, 50 patients), or another 2 doses of 10-mg dexamethasone 24 and 48 hours later (group C, 50 patients). The primary outcome was postoperative pain level. The use of analgesic and antiemetic rescue; incidence of postoperative nausea and vomiting; C-reactive protein and interleukin-6 levels; range of motion; and complications were also compared.

RESULTS

The dynamic pain scores were lower for groups B and C compared to group A on postoperative days 2 and 3. Such difference was also detected between groups B and C on postoperative day 3. C-reactive protein and interleukin-6 levels were lower in groups B and C than in group A at 48 and 72 hours postoperatively. Such difference was also observed between groups B and C at 72 hours postoperatively. Patients in groups B and C had reduced rescue analgesic use, and improved range of motion compared to patients in group A. There were no differences among 3 groups regarding the rescue antiemetic use, postoperative nausea and vomiting occurrence, and complications.

CONCLUSION

Additional administrations of dexamethasone after THA could provide sustained pain relief and inflammatory control. Besides, the 3-dose regimen was more effective than the 2-dose regimen in terms of the analgesic and anti-inflammatory effects.

LEVEL OF EVIDENCE

I.

Is a split-dose intravenous dexamethasone regimen superior to a single high dose in reducing pain and improving function after total hip arthroplasty? A randomized blinded placebo-controlled trial

Aims

Intravenous dexamethasone has been shown to reduce immediate postoperative pain after total hip arthroplasty (THA), though the effects are short-lived. We aimed to assess whether two equivalent perioperative split doses were more effective than a single preoperative dose.

Methods

A total of 165 patients were randomly assigned into three groups: two perioperative saline injections (Group A, placebo), a single preoperative dose of 20 mg dexamethasone and a postoperative saline injection (Group B), and two perioperative doses of 10 mg dexamethasone (Group C). Patients, surgeons, and staff collecting outcome data were blinded to allocation. The primary outcome was postoperative pain level reported on a ten-point Numerical Rating Scale (NRS) at rest and during activity. The use of analgesic and antiemetic rescue, incidence of postoperative nausea and vomiting (PONV), CRP and interleukin-6 (IL-6) levels, range of motion (ROM), length of stay (LOS), patient satisfaction, and the incidence of surgical site infection (SSI) and gastrointestinal bleeding (GIB) in the three months postoperatively, were also compared.

Results

The pain scores at rest were significantly lower in Groups B and C than in Group A on postoperative days 1 and 2. The dynamic pain scores and CRP and IL-6 levels were significantly lower for Groups B and C compared to Group A on postoperative days 1, 2, and 3. Patients in Groups B and C had a lower incidence of PONV, reduced use of analgesic and antiemetic rescue, improved ROM, shorter LOS, and reported higher satisfaction than in Group A. Patients in Group C had significantly lower dynamic pain scores and IL-6 and CRP levels on postoperative days 2 and 3, and higher ROM and satisfaction on postoperative day 3 than in Group B. No SSI or GIB occurred in any group.

Conclusion

Perioperative dexamethasone provides short-term advantages in reducing pain, PONV, and inflammation, and increasing range of motion in the early postoperative period after THA. A split-dose regimen was superior to a single high dose in reducing pain and inflammation, and increasing ROM, with better patient satisfaction. Level of evidence: I Cite this article: Bone Joint J 2020;102-B(11):1497–1504.

Social Determinants of Health and Patient-Reported Outcomes Following Total Hip and Knee Arthroplasty in Veterans

BACKGROUND

Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age. They are associated with disparities in outcomes following total joint arthroplasty (TJA). These disparities occur even in equal-access healthcare systems such as the Veterans Health Administration (VHA). Our goal was to determine whether SDOH affect patient-reported outcome measures (PROMs) following TJA in VHA patients.

METHODS

Patients scheduled to undergo total hip or knee arthroplasty at VHA Hospitals in Minneapolis, MN, Palo Alto, CA, and San Francisco, CA, prospectively completed PROMs before and 1 year after surgery. PROMs included the Hip disability and Osteoarthritis Outcome Score, the Knee injury and Osteoarthritis Outcome Score, and their Joint Replacement subscores. SDOH included race, ethnicity, marital status, education, and employment status. The level of poverty in each patient's neighborhood was determined. Medical comorbidities were recorded. Univariate and multivariate analyses were performed to determine whether SDOH were significantly associated with PROM improvement after surgery.

RESULTS

On multivariate analysis, black race was significantly negatively correlated with knee PROM improvement and Hispanic ethnicity was significantly negatively correlated with hip PROM improvement compared to whites. Higher baseline PROM scores and lower age were significantly associated with lower PROM improvement. Significant associations were also found based on education, gender, comorbidities, and neighborhood poverty.

CONCLUSION

Minority VHA patients have lower improvement in PROM scores after TJA than white patients. Further research is required to identify the reasons for these disparities and to design interventions to reduce them.

The efficacy of perioperative gabapentin for the treatment of postoperative pain following total knee and hip arthroplasty: a meta-analysis

Background

Postoperative pain after total knee arthroplasty (TKA) and total hip arthroplasty (THA) influence patients’ rehabilitation and life quality. Although gabapentin has been widely used for analgesia, its efficacy is still controversial in TKA and THA. This meta-analysis was performed to assess the efficacy and safety of gabapentin following TKA and THA.

Method

Electronic databases including PubMed, EMBASE, Cochrane Central Register of Controlled Trials, MEDLINE, and ClinicalTrials.gov were comprehensively retrieved for randomized controlled trials from their inception to June 2019. A total of 7 studies, which compared the administration of gabapentin with that of placebo for the treatment of postoperative pain, were included in our meta-analysis. The meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Result

There was no difference in pain score at 24 (P = 0.87), 48 (P = 0.15), and 72 (P = 0.85) h associated with the use of gabapentin. Likewise, no difference in accumulative morphine consumption at 48 h following TKA or THA was found between gabapentin and placebo (DM = − 8.14, 95% CI − 18.55 to 2.28, P = 0.13). The incidence of opioid-related adverse effects, including nausea, pruritus, sedation, and dizziness, is no difference between gabapentin and placebo group. However, subgroup analysis indicated that gabapentin could reduce the incidence of pruritus after TKA (RR = 0.35, 95% CI 0.12 to 0.99, P = 0.05).

Conclusion

Based on our meta-analysis, gabapentin did not decrease postoperative pain, cumulative morphine consumption, and the incidence of adverse effects after TKA and THA. There was not enough evidence to support the administrations of gabapentin for postoperative pain after TKA and THA.

Revision of a Fractured Titanium Modular Revision Hip Stem Without Removal of the Well-Fixed Part of the Stem: A New Approach Using a Cemented Tube

Component fracture is a rare cause for revision in total hip arthroplasty. For a fractured well-fixed long femoral stem, the options are limited. We sought to develop a technique to address this problem with lower morbidity. A newly developed cemented tube was constructed and cemented onto a fractured Revitan revision hip femoral stem to retain the distal well-fixed component. At the 2-year follow-up, the Harris Hip Score, pain level, and radiographic images were analyzed. At the 2-year follow-up, no radiological signs of loosening or failure could be observed. The patient's preoperative Harris Hip Score improved from 42.8 to 97 points. The pain level improved from 7/10 to 0/10. Our case report depicts excellent clinical and radiographic outcomes at 2-year follow-up by a newly developed cemented tube technique. This technique is a potential new option for revision of fractured well-fixed diaphyseal stems without major bone loss. Our successful results suggest this technique is worthy of consideration and further study.

Bactericidal coating to prevent early and delayed implant-related infections

The occurrence of an implant-associated infection (IAI) with the formation of a persisting bacterial biofilm remains a major risk following orthopedic biomaterial implantation. Yet, progress in the fabrication of tunable and durable implant coatings with sufficient bactericidal activity to prevent IAI has been limited. Here, an electrospun composite coating was optimized for the combinatorial and sustained delivery of antibiotics. Antibiotics-laden poly(ε-caprolactone) (PCL) and poly`1q`(lactic-co glycolic acid) (PLGA) nanofibers were electrospun onto lattice structured titanium (Ti) implants. In order to achieve tunable and independent delivery of vancomycin (Van) and rifampicin (Rif), we investigated the influence of the specific drug-polymer interaction and the nanofiber coating composition on the drug release profile and durability of the polymer-Ti interface. We found that a bi-layered nanofiber structure, produced by electrospinning of an inner layer of [PCL/Van] and an outer layer of [PLGA/Rif], yielded the optimal combinatorial drug release profile. This resulted in markedly enhanced bactericidal activity against planktonic and adherent Staphylococcus aureus for 6 weeks as compared to single drug delivery. Moreover, after 6 weeks, synergistic bacterial killing was observed as a result of sustained Van and Rif release. The application of a nanofiber-filled lattice structure successfully prevented the delamination of the multi-layer coating after press-fit cadaveric bone implantation. This new lattice design, in conjunction with the multi-layer nanofiber structure, can be applied to develop tunable and durable coatings for various metallic implantable devices. This is particularly appealing to tune the release of multiple antimicrobial agents over a period of weeks to prevent early and delayed onset IAI.

Which disease-related factors influence patients' and physicians' willingness to consider joint replacement in hip and knee OA? Results of a questionnaire survey linked to claims data

Background

A great heterogeneity in total joint replacement (TJR) rates has been reported for osteoarthritis (OA), most likely arising from a gap between patients’ and physicians’ views on the need for TJR. The purpose of this study therefore was to analyze potential cofactors which might influence the desire of patients to undergo TJR and physicians’ willingness to discuss surgery with their patients.

Methods

A total of 8995 patients in Germany with a claims data diagnosis of hip or knee OA or polyarthrosis were asked to complete a questionnaire for this cross-sectional study of sociodemographic factors, indicators of current joint function (WOMAC score), willingness to undergo TJR and whether they had already discussed TJR with a physician. The overall response rate was 40%. Responders with polyarthrosis and individuals without current or chronic symptoms in the corresponding joints, pain in already replaced joints or simultaneous symptomatic hip and knee OA were excluded. We linked the survey results to claims data. Separate logistic regression models were used to assess which parameters were associated with patients’ willingness to undergo TJR and physicians’ discussion of surgery.

Results

We analyzed 478 hip OA and 932 knee OA patients. Just 17% with hip OA and 14% with knee OA were willing to undergo TJR, although 44 and 45% had already discussed surgery with their physicians.

Patients’ willingness was associated with higher WOMAC scores, a deterioration of symptoms over the last 2 years, and previous TJR for another joint. The discussion with a physician was influenced by the impact on personal life and previous arthroplasty. Older age (odds Ratio (OR) 1.2 per 10 years), male sex (OR 0.69 vs female), longer symptom duration (OR 1.08 per 5 years), deterioration of symptoms (OR 2.0 vs no change/improvement), a higher WOMAC score (OR 1.3 per 10% deterioration) and reduced well-being (OR 1.1 per 10% deterioration) were associated with physician discussion in knee OA patients.

Conclusions

The proportion of patients willing to undergo TJR is lower than the proportion in whom physicians discuss surgery. While previous TJR seems to enhance patients’ and surgeons’ willingness, the influence of other cofactors is heterogeneous.

No Learning Curve of the Direct Superior Approach in Total Hip Arthroplasty

OBJECTIVES

To assess the learning curve of the direct superior approach (DSA) for total hip arthroplasty (THA) and to compare surgical, clinical, and radiological results with a matched control group using the mini posterior approach (MPA).

METHODS

A prospective cohort study was performed from October 2016 to May 2017 including our first 52 patients undergoing THA using the DSA. Patients with primary osteoarthritis or osteonecrosis and a body mass index (BMI) < 35 who were eligible for surgery were included. As a control group, 52 patients who underwent the MPA were included, matched based on age, BMI, and ASA classification. In the DSA group, damage to the iliotibial tract and the distal external rotators, including the external obturator and quadriceps femoris muscles, was avoided. Outcome measures were collected, including surgical time, blood loss, postoperative pain, length of stay, implant position, use of walking aids, patient reported outcome measures (PROM), and complications. Unpaired t-tests were used to analyze differences between the DSA and the MPA group in surgical time, blood loss, length of stay, and acetabular and femoral component position. χ² -tests were used to analyze mobility and the number of complications. Two-way repeated measures ANOVA was used to analyze pain scores and PROM between the DSA and the MPA groups.

RESULTS

The mean surgical time of 61 min (SD 8) in the DSA group was longer (P < 0.001) compared to that in the MPA group, 46 min (SD 12). No differences were found in blood loss, postoperative pain, or mean length of stay in the hospital. After 6 weeks, 94% of the patients in the DSA group were able to walk inside their home without walking aids compared to 90% in the MPA group. The mobility scores were not different after follow up of 6 weeks and 1 year (P = 0.12 and P = 0.36 respectively). All PROM improved postoperatively in both the DSA and the MPA group (P < 0.01). Acetabular cup and femoral stem position were not compromised by the DSA. Complications included two Vancouver B2 periprosthetic fractures in the DSA group, of which there was one surgical-related fracture and one fracture after a traffic accident. Complications in the MPA group included one periprosthetic fracture, two hip dislocations, and one ischial neuropathy. No infections or thromboembolic events were observed. The 1-year complication rate was not different between the MPA and DSA groups (P = 0.40).

CONCLUSION

The DSA can be safely introduced as no learning curve in the prosthesis position or the complication rate was found.

Predictors of the use of analgesic drugs 1 year after joint replacement: a single-center analysis of 13,000 hip and knee replacements

BACKGROUND

Pain persists in a moderate number of patients following hip or knee replacement surgery. Persistent pain may subsequently lead to the prolonged consumption of analgesics after surgery and expose patients to the adverse drug events of opioids and NSAIDs, especially in older patients and patients with comorbidities. This study aimed to identify risk factors for the increased use of opioids and other analgesics 1 year after surgery and focused on comorbidities and surgery-related factors.

METHODS

All patients who underwent a primary hip or knee replacement for osteoarthritis from 2002 to 2013 were identified. Redeemed prescriptions for acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids (mild and strong) were collected from a nationwide Drug Prescription Register. The user rates of analgesics and the adjusted risks ratios for analgesic use 1 year after joint replacement were calculated.

RESULTS

Of the 6238 hip replacement and 7501 knee replacement recipients, 3591 (26.1%) were still using analgesics 1 year after surgery. Significant predictors of overall analgesic use (acetaminophen, NSAID, or opioid) were (risk ratio (95% CI)) age 65-74.9 years (reference < 65), 1.1 (1.03-1.2); age > 75 years, 1.2 (1.1-1.3); female gender, 1.2 (1.1-1.3); BMI 30-34.9 kg/m2 (reference < 25 kg/m2), 1.1 (1.04-1.2); BMI > 35 kg/m2, 1.4 (1.3-1.6); and a higher number of comorbidities (according to the modified Charlson Comorbidity Index score), 1.2 (1.1-1.4). Diabetes and other comorbidities were not significant independent predictors. Of the other clinical factors, the preoperative use of analgesics, 2.6 (2.5-2.8), and knee surgery, 1.2 (1.1-1.3), predicted the use of analgesics, whereas simultaneous bilateral knee replacement (compared to unilateral procedure) was a protective factor, 0.86 (0.77-0.96). Opioid use was associated with obesity, higher CCI score, epilepsy, knee vs hip surgery, unilateral vs bilateral knee operation, total vs unicompartmental knee replacement, and the preoperative use of analgesics/opioids.

CONCLUSIONS

Obesity (especially BMI > 35 kg/m2) and the preoperative use of analgesics were the strongest predictors of an increased postoperative use of analgesics. It is remarkable that also older age and higher number of comorbidities predicted analgesic use despite these patients being the most vulnerable to adverse drug events.

Relationship between body mass index and the risk of periprosthetic joint infection after primary total hip arthroplasty and total knee arthroplasty

Background

Periprosthetic joint infection (PJI) is a disastrous complication after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The relationship between body mass index (BMI) and the incidence of PJI remains controversial. To better understand the impact of increasing BMI on PJI, we conducted this study to investigate the dose-response relationship between BMI and the risk of PJI after primary THA or TKA.

Methods

A systematic search was conducted in PubMed, Embase, and Cochrane Library databases from inception to August 17, 2019. After study selection and data extraction, a dose-response meta-analysis was performed to investigate the relationship between BMI and PJI. Adjusted relative risks (RRs) with 95% confidence intervals (CIs) were pooled using fixed-effects or random-effects models.

Results

Eleven studies comprising 505,303 arthroplasties were included. The dose-response analysis showed a significant non-linear relationship between BMI and the risk of PJI (P_{non-linearity} <0.001). Patients following THA (RR, 1.489; 95% CI, 1.343–1.651; P<0.001) were more likely to suffer from PJI than patients following TKA. Furthermore, American Society of Anesthesiologists (ASA) score ≥3 (RR, 2.287; 95% CI, 1.650–3.170; P<0.001), lung disease (RR, 1.484; 95% CI, 1.208–1.823; P<0.001) and diabetes (RR, 1.695; 95% CI, 1.071–2.685; P=0.024) were identified as risk factors for PJI, but male (RR, 1.649; 95% CI, 0.987–2.755; P=0.056) and hypertension (RR, 0.980; 95% CI, 0.502–1.916; P=0.954) were not recognized as risk factors for PJI.

Conclusions

The J-shaped non-linear relationship demonstrated that increased BMI was associated with an increased risk for PJI after primary THA or TKA. Patients following THA were more likely to suffer from PJI than patients following TKA. Also, patients with ASA score ≥3, lung disease and diabetes have a higher risk of PJI. Gender and hypertension did not influence the incidence of PJI.

Optimal Level of Femoral Neck for Predicting Postoperative Stem Anteversion in Total Hip Arthroplasty for Crowe Type I Dysplastic Hip

OBJECTIVE

This study aimed to investigate the optimal level of femoral neck for measuring femoral anteversion to predict postoperative stem anteversion in Crowe type I developmental dysplasia of the hip.

METHODS

This retrospective study analyzed 108 Crowe type I hips that underwent THA between January 2016 and December 2017, including 70 women and 19 men with a mean age of 63.08 ± 9.13 (range, 41-83) years. The single-wedge stem was used in 37 hips, the double-wedge stem was used in 71 hips. Computed tomography scans were performed pre- and post-operation. Femoral anteversion at six levels of the proximal femur were measured via preoperative two-dimensional computed tomography. Femoral anteversion at the level of the femoral neck osteotomy plane and postoperative stem anteversion were measured via three-dimensional reconstructed models.

RESULTS

The mean follow-up period was 18.5 months (range, 12-27). The mean preoperative Harris Hip Score was 51.5 ± 8.7 and improved to 90.4 ± 7.8 (P < 0.001) by the last follow-up. There were no intraoperative fractures, and no infections occurred during the follow-up period. Two patients developed deep venous thrombosis. There was no sign of prosthetic loosening in all hips. No significant correlations were found between the height of the femoral neck osteotomy plane and postoperative stem anteversion (r = -0.119, P = 0.220). Femoral anteversion decreased gradually from 64.00° ± 10.51° at the center of lesser trochanter to 15.21° ± 13.31° at the head-neck junction, which was changed from more to less than stem anteversion (24.37° ± 13.86°). The femoral anteversion at femoral head-neck junction (15.21° ± 13.31°) was significantly less than postoperative stem anteversion (P = 0.000), with a difference of -9.16° ± 9.27°. The femoral anteversion at the level of the osteotomy plane (28.48° ± 15.34°) was significantly more than the postoperative stem anteversion (P = 0.000), with a difference of 4.11° ± 9.56°. Among all six levels and the level of osteotomy, femoral anteversion at the 10-mm level above the proximal base of lesser trochanter (22.65 ± 12.92) displayed the smallest difference (-1.72° ± 8.90°) and a good correlation (r = 0.764) with postoperative stem anteversion for all 108 hips, with a moderate correlation of 0.465 for single-wedge stem hips and an excellent correlation of 0.821 for double-wedge stem hips.

CONCLUSION

For Crowe type I hips, femoral anteversion would be different if it was measured via different levels of the femoral neck. The 10-mm level above the proximal base of the lesser trochanter could be an optimum choice for measuring femoral anteversion to predict postoperative stem anteversion.

Association Between Surgical Approach and Major Surgical Complications in Patients Undergoing Total Hip Arthroplasty

IMPORTANCE

Controversy exists about the preferred surgical approach for total hip arthroplasty (THA).

OBJECTIVE

To determine whether an anterior approach is associated with lower risk of complications than either a lateral or posterior approach.

DESIGN, SETTING, AND PARTICIPANTS

Population-based retrospective cohort study of all adults in Ontario, Canada, who had undergone primary THA for osteoarthritis between April 1, 2015, and March 31, 2018. All patients were followed up over a 1-year period (study end date, March 31, 2019).

EXPOSURES

Surgical approach (anterior vs lateral/posterior) for THA.

MAIN OUTCOMES AND MEASURES

Major surgical complications within 1 year (composite of deep infection requiring surgery, dislocation requiring closed or open reduction, or revision surgery). Outcomes were compared among propensity-score matched groups using Cox proportional hazards regression.

RESULTS

Of the 30 098 patients (mean [SD] age, 67 years [10.7 years]; 16 079 women [53.4%]) who underwent THA, 2995 (10%) underwent the anterior approach; 21 248 (70%), the lateral approach; and 5855 (20%) the posterior approach performed at 1 of 73 hospitals by 1 of 298 surgeons. All patients were followed up for 1 year. Compared with those undergoing the lateral or posterior approach, patients undergoing an anterior approach were younger (mean age, 65 vs 67 years; standardized difference, 0.17); had lower rates of morbid obesity (4.8% vs 7.6%; standardized difference, 0.12), diabetes (14.2% vs 19.9%; standardized difference, 0.15), and hypertension (53.4% vs 62.9%; standardized difference, 0.19); and were treated by higher-volume surgeons (median range, 111 procedures; interquartile range, 69-172 vs 77 procedures, interquartile range, 50-119 in the prior year; standardized difference, 0.55). Compared with 2993 propensity-score matched patients undergoing a lateral or posterior approach, the 2993 matched patients undergoing anterior approaches had a significantly greater risk of a major surgical complication (61 patients [2%] vs 29 patients [1%]; absolute risk difference, 1.07%; 95% CI, 0.46%-1.69%; hazard ratio, 2.07; 95% CI, 1.48 to 2.88).

CONCLUSIONS AND RELEVANCE

Among patients undergoing total hip arthroplasty, an anterior surgical approach compared with a posterior or lateral surgical approach was associated with a small but statistically significant increased risk of major surgical complications. The findings may help inform decisions about surgical approach for hip arthroplasty, although further research is needed to understand pain and functional outcomes.

Well-Defined Gold Nanorod/Polymer Hybrid Coating with Inherent Antifouling and Photothermal Bactericidal Properties for Treating an Infected Hernia

Biomedical device-associated infection (BAI) is a great challenge in modern clinical medicine. Therefore, developing efficient antibacterial materials is significantly important and meaningful for the improvement of medical treatment and people's health. In the present work, we developed a strategy of surface functionalization for multifunctional antibacterial applications. A functionalized polyurethane (PU, a widely used biomedical material for hernia repairing) surface (PU-Au-PEG) with inherent antifouling and photothermal bactericidal properties was readily prepared based on a near-infrared (NIR)-responsive organic/inorganic hybrid coating which consists of gold nanorods (Au NRs) and polyethylene glycol (PEG). The PU-Au-PEG showed a high efficiency to resist adhesion of bacteria and exhibited effective photothermal bactericidal properties under 808 nm NIR irradiation, especially against multidrug-resistant bacteria. Furthermore, the PU-Au-PEG could inhibit biofilm formation long term. The biocompatibility of PU-Au-PEG was also proved by cytotoxicity and hemolysis tests. The in vivo photothermal antibacterial properties were first verified by a subcutaneous implantation animal model. Then, the anti-infection performance in a clinical scenario was studied with an infected hernia model. The results of animal experiment studies demonstrated excellent in vivo anti-infection performances of PU-Au-PEG. The present work provides a facile and promising approach to develop multifunctional biomedical devices.

Autologous Iliac Bone Graft Compared with Biphasic Hydroxyapatite and Calcium Sulfate Cement for the Treatment of Bone Defects in Tibial Plateau Fractures: A Prospective, Randomized, Open-Label, Multicenter Study

BACKGROUND

Bone-graft substitutes are commonly used for the augmentation of traumatic bone defects in tibial plateau fractures. However, their clinical performance compared with that of autologous bone-grafting, the gold standard in bone defect reconstruction, still remains under debate. This study investigates the differences in quality of life, pain, and radiographic outcomes in the treatment of tibial plateau fracture-associated bone defects with either autologous bone grafts or a bioresorbable hydroxyapatite and calcium sulfate cement (CERAMENT BONE VOID FILLER [CBVF]; BONESUPPORT).

METHODS

In this study, 135 patients with acute depression and split-depression fractures of the proximal part of the tibia (OTA/AO types 41-B2 and 41-B3) were enrolled in a prospective, controlled, randomized, multicenter trial including 20 hospitals in Germany. Patients were randomized to receive either autologous iliac bone graft or CBVF for reconstruction of the bone defect. The primary outcome measures were the Short Form (SF)-12 version 2 Physical Component Summary (PCS) score at week 26 (the study was designed to show noninferiority of the CBVF with regard to the PCS with a prespecified margin of -5 points) and the pain level at 26 weeks postoperatively measured by a visual analog scale (VAS). The secondary outcomes were the SF-12 version 2 Mental Component Summary (MCS) and SF-12 PCS scores at weeks 1, 6, and 12 and bone-healing on radiographs.

RESULTS

Age, sex, fixation methods, and fracture pattern were comparable in both groups. There were no significant differences (p > 0.05) in the SF-12 PCS or VAS scores at postoperative week 26. There was a significant reduction of blood loss (p = 0.007) and pain levels (p = 0.008) at postoperative day 1 in the CBVF group. The rates of fracture-healing, defect remodeling, and articular subsidence were not significantly different (p > 0.05) in both groups.

CONCLUSIONS

Bioresorbable CBVF was noninferior to autologous bone graft with regard to both patient-reported and radiographic outcomes in tibial plateau fractures of OTA/AO types 41-B2 and 41-B3.

LEVEL OF EVIDENCE

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

Using personalized 3D printed Titanium sleeve-prosthetic composite for reconstruction of severe segmental bone loss of proximal femur in revision total hip arthroplasty: A case report

RATIONALE

Allograft-prosthetic composites (APCs) and proximal femoral replacement have been applied for reconstruction of severe segmental femoral bone loss in revision total hip arthroplasty. The outcomes are encouraging but the complication rate is relatively high. Considering the high complication rates and mixed results of APCs and megaprosthesis, we presented a case using personalized 3D printed Titanium sleeve-prosthetic composite for reconstruction of segmental bone defect.

PATIENT CONCERNS

A 73-year-old woman presented to the emergency department on account of acute severe pain of the left hip without history of trauma. She had undergone a cemented total hip arthroplasty for osteonecrosis of femoral head at the left side in 2000. In 2013 she underwent a cemented revision total hip arthroplasty as a result of aseptic loosening of hip prosthesis. She denied obvious discomfort prior to this episode since the revision surgery in 2013.

DIAGNOSIS

According to the clinical history, imaging and physical examination, we confirmed the diagnosis of severe segmental bone loss of proximal femur and fracture of prosthetic stem. The femoral bone defect was evaluated using the Paprosky classification system and rated as Type 3B, and the acetabular bone defect was rated as Type 2C.

INTERVENTIONS

In this study, we present the first case of severe segmental bone loss of proximal femur in revision total hip arthroplasty that was successfully treated using personalized 3D printed Titanium sleeve-prosthetic composite OUTCOMES:: At the 2-year follow-up, the patient was symptom free with a Harris Hip Score of 91. Radiographs showed excellent osteointegration between the interface of sleeve-prosthetic composite and the host bone, with no signs of implant loosening or subsidence.

LESSONS

Despite the absence of long term results of 3D printed Titanium sleeve-prosthetic composite reconstruction, the good clinical and radiological outcome at 2 years follow up implied its potential role for reconstruction of segmental femoral bone defect in revision THA.

Hip stress distribution - Predictor of dislocation in hip arthroplasties. A retrospective study of 149 arthroplasties

Dislocation after hip arthroplasty is still a major concern. Recent study of the volumetric wear of the cup has suggested that stresses studied in a one-legged stance model could predispose arthroplasty dislocation. The aim of this work was to study whether biomechanical parameters of contact stress distribution in total hip arthroplasty during a neutral hip position can predict a higher possibility of the arthroplasty dislocating. Biomechanical parameters were determined using 3-dimensional mathematical models of the one-legged stance within the HIPSTRESS method. Geometrical parameters were measured from standard anteroposterior X-ray images of the pelvis and proximal femora. Fifty-five patients subjected to total hip arthroplasty that later suffered dislocation of the head and, for comparison, ninety-four total hip arthroplasties that were functional at least 10 years after the implantation, were included in the study. Arthroplasties that suffered dislocation had on average a 6% higher resultant hip force than the control group (p = 0.004), 11% higher peak stress on the load-bearing area (p = 0.001) and a 50% more laterally positioned stress pole (p = 0.026), all parameters being less favorable in the group of unstable arthroplasties. There was no statistically significant difference in the gradient index or in the functional angle of the weight bearing. Our study showed that arthroplasties that show a tendency to push the head out of the cup in the representative body position—the one-legged stance—are prone to dislocation. An unfavorable resultant hip force, peak stress on the load bearing and laterally positioned stress pole are predictors of arthroplasty dislocation.

The Effectiveness of Telerehabilitation as a Supplement to Rehabilitation in Patients After Total Knee or Hip Replacement: Randomized Controlled Trial

Background

Telerehabilitation can contribute to the maintenance of successful rehabilitation regardless of location and time. The aim of this study was to investigate a specific three-month interactive telerehabilitation routine regarding its effectiveness in assisting patients with physical functionality and with returning to work compared to typical aftercare.

Objective

The aim of the study was to investigate a specific three-month interactive telerehabilitation with regard to effectiveness in functioning and return to work compared to usual aftercare.

Methods

From August 2016 to December 2017, 111 patients (mean 54.9 years old; SD 6.8; 54.3% female) with hip or knee replacement were enrolled in the randomized controlled trial. At discharge from inpatient rehabilitation and after three months, their distance in the 6-minute walk test was assessed as the primary endpoint. Other functional parameters, including health related quality of life, pain, and time to return to work, were secondary endpoints.

Results

Patients in the intervention group performed telerehabilitation for an average of 55.0 minutes (SD 9.2) per week. Adherence was high, at over 75%, until the 7th week of the three-month intervention phase. Almost all the patients and therapists used the communication options. Both the intervention group (average difference 88.3 m; SD 57.7; P=.95) and the control group (average difference 79.6 m; SD 48.7; P=.95) increased their distance in the 6-minute-walk-test. Improvements in other functional parameters, as well as in quality of life and pain, were achieved in both groups. The higher proportion of working patients in the intervention group (64.6%; P=.01) versus the control group (46.2%) is of note.

Conclusions

The effect of the investigated telerehabilitation therapy in patients following knee or hip replacement was equivalent to the usual aftercare in terms of functional testing, quality of life, and pain. Since a significantly higher return-to-work rate could be achieved, this therapy might be a promising supplement to established aftercare.

Trial Registration

German Clinical Trials Register DRKS00010009; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00010009

Progression and projection for hip surgery in France, 2008-2070: Epidemiologic study with trend and projection analysis

INTRODUCTION

Hip replacement was declared "operation of the century" in tribute to the functional improvement it provides. Frequency is increasing, but it is difficult to estimate the actual number of procedures performed and the expected progression, because of changes in indications and lengthening life-expectancy, and also, in France, because there is no registry. As data are lacking in France, we conducted an investigation 1) to update the number of hip surgeries in France, and 2) to forecast progression over the coming decades, considering extreme scenarios.

HYPOTHESIS

The number of hip procedures can be expected to increase considerably over the coming 50 years.

MATERIAL AND METHOD

A study was conducted to analyze national coding data for the number of hip surgeries performed in France. Two scenarios were defined: one taking account of population progression and age structure, the other also extrapolating trends observed over recent years. Current hip surgery activity in France was measured, and progression estimated according to population changes.

RESULTS

In 2018 in France, 183,139 procedures were coded as principally concerning the hip. There was a clear predominance of reconstruction procedures, with 148,965 primary hip replacements, 124,251 of which were total. There were 19,304 hip replacement revision procedures. There were strong regional differences in revision according to the type of center performing surgery (p<0.0001). Between 2018 and 2050, primary hip replacement could be expected to increase by 41.9% or 114.3% and hip surgery overall by 42.0% or 98.3%, depending on the scenario.

DISCUSSION

The present results are subject to future technological breakthroughs and medical discoveries, but forecast a major increase in hip surgery requirements. These results extend the present state of medical knowledge.

LEVEL OF EVIDENCE

IV, descriptive epidemiological study.

Application of Iterative Metal Artifact Reduction Algorithm to CT Urography for Patients With Hip Prostheses

OBJECTIVE. The purpose of this study is to retrospectively assess the impact of iterative metal artifact reduction (IMAR) with iterative reconstruction (IR) on the image quality and diagnostic performance of CT urography in the evaluation of patients with hip prostheses, compared with IR alone. MATERIALS AND METHODS. CT urography examinations that were reconstructed using IR with and without IMAR were analyzed for 57 patients (29 women and 28 men; mean age, 74 years [range, 22-94 years]) with hip prostheses (40 unilateral and 17 bilateral). For quantitative analysis, image noise within the bladder was measured. Two radiologists (radiologist 1 [RAD1] and radiologist 2 [RAD2]) qualitatively evaluated the images using both a 5-point scale to assess the degree of visualization of artifacts and a 6-point scale to determine diagnostic confidence in visualization of the bladder, ureters, prostate or uterus, pelvic calcifications, and genitourinary abnormalities involving the bladder, distal ureters, prostate, uterus, and ovaries. RESULTS. The combination of IMAR and an IR technique provided improvement in quantitative and qualitative measurements (p < 0.05). Forty-three genitourinary abnormalities were detected in 29 patients. Quantitative and qualitative comparisons of scans obtained with and without the use of IMAR, respectively, revealed image noise of 99.6 versus 173.3 HU and the following radiologist scores: for improvement of artifacts, 3.2 versus 1.6 (for RAD1) and 3.1 versus 1.6 (for RAD2); for visualization of the bladder, 3.6 versus 1.5 (RAD1) and 3.8 versus 1.6 (RAD2); visualization of the ureters, 3.8 versus 1.6 (RAD1) and 3.9 versus 1.7 (RAD2); visualization of the uterus, 4.3 versus 2.8 (RAD1) and 4.3 versus 2.6 (RAD2); visualization of the prostate, 4.5 versus 2.3 (RAD1) and 4.5 versus 2.2 (RAD2); diagnostic confidence for calcifications, 4.7 versus 3.5 (RAD1) and 4.7 versus 3.3 (RAD2); and diagnostic confidence for genitourinary abnormalities, 5.0 versus 3.2 (RAD1) and 4.8 versus 2.9 (RAD2), respectively. CONCLUSION. The addition of IMAR to IR led to statistically significant improvement in the retrospective diagnostic performance and image quality of CT urography for patients with hip prostheses, compared with IR alone.

Dual-Functional Implants with Antibacterial and Osteointegration-Promoting Performances

Multifunctional antibacterial materials have great significance for treating biomedical device-associated infections (BAIs). In the present work, a facile and rational strategy was developed to produce dual-functional implants with antibacterial and osteointegration-promoting properties for the treatment of BAI. A titanium implant, as a representative demo of implants, was first functionalized with ethanediamine-functionalized poly(glycidyl methacrylate) (PGED) brushes. Then, low-molecular-weight quaternized polyethyleneimine (QPEI, a cationic antibacterial agent) and alendronate (ALN, a clinically used drug with high affinity for bone minerals) were covalently conjugated onto PGED brushes to produce dual-functional dental implants (Ti-AQ). The QPEI component imparted Ti-AQ with antibacterial abilities, and the ALN component could balance the cytotoxicity of a cationic antibacterial agent, improving the biocompatibility for osteoblast cells. The effective performances of anti-infection and osteointegration were demonstrated in a BAI animal model. The results indicated that Ti-AQ inhibited bacterial infection at the early stage and enhanced the osteointegration and biomechanical properties between the implants and bone tissues at the late stage. This study will provide one facile and universal strategy for the design and development of novel multifunctional antibacterial implants.

Assessment of functional recovery after total hip and knee arthroplasty: An observational study of 95 patients

BACKGROUND

A significant proportion of patients experience functional limitations following total hip and knee arthroplasty (THA and TKA). The purpose of this study was to investigate prospectively the patient-reported and objectively assessed functional recovery following THA and TKA.

METHODS

Patients were recruited at a regional Danish hospital, using a prospective, observational hypothesis-generating cohort design. Primary outcome measures were performance-based function (30-s chair-stand test) and self-reported physical function measured by the Hip Disability and Osteoarthritis Outcome Score (HOOS) for those who had undergone THA, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) for those who had undergone TKA. In addition, patient expectations, the "forgotten joint" scale and pain catastrophizing were measured. Outcome measures were collected at baseline (preoperatively) and at follow-up (4 months postoperatively).

RESULTS

A total of 95 patients (59 who had undergone THA and 36 who had undergone TKA) were recruited. Performance-based function improved only slightly, with a mean difference of 2.9 (95% confidence interval [CI] 1.9, 4.0) for THAs and 1.6 (95% CI 0.4, 2.8) for TKAs. Self-reported physical function improved significantly, with a mean difference of 37.9 (95% CI 31.5, 44.3) for THAs and 28.6 (95% CI 22.7, 34.4) for TKAs. However, dividing the cohort into "improved" and "non-improved" groups based on changes in performance-based function, no clinically relevant predictors for poor performance-based outcome could be found.

CONCLUSIONS

Self-reported outcome measures improved significantly following THA and TKA, whereas performance-based function improved only slightly by the 4-month follow-up. The subgroup that did not improve in performance-based function still reported significant improvements in self-reported outcome measures, demonstrating the difficulty in predicting optimal rehabilitation strategies after THA and TKA.

Kinematic alignment versus conventional techniques for total hip arthroplasty: A retrospective case control study

BACKGROUND

Residual complications of conventionally implanted hip components have only been partially reduced by improved implant design and higher surgical precision, and their occurrence is poorly predicted by the radiographic standing/supine cup orientation. This has raised awareness that conventional techniques may not aim for the correct component orientation target, and the lumbo-pelvic kinematics, which influences the functional acetabular orientation, may be of interest to further improve THA clinical outcomes. This has led to the development of the Lumbo-Pelvic kinematic alignment (KA) technique for THA that aims to anatomically position and kinematically align hip implants (acetabular and femoral, total and resurfacing components), in order to optimise prosthetic hip biomechanics and hopefully improve prosthetic function, patient satisfaction, and components' lifespan. Therefore, we conducted a case control investigation to assess the early-term safety and efficacy of this new technique by answering the following questions: does the KA technique for THA: (1) better restore the native hip anatomy, (2) generate a different radiographic supine cup position, and (3) improve clinical outcomes in comparison to the conventional mechanical alignment technique?

HYPOTHESES

Using KA technique allows there is no statistically significant difference between the pre to postoperative differential for acetabular medial and vertical offsets, femoral offset, and leg length.

METHODS

We led a case control retrospective study with prospectively collected clinical data. Forty-one consecutive unselected KA-THAs performed with manual instrumentation were paired with 41 mechanically aligned THAs. The 1-year clinical outcomes and radiographical measurements were compared.

RESULTS

Compared to the mechanical alignment technique, the KA technique resulted in a more anatomical restoration of the prosthetic hip centre of rotation with a lower delta pre- to post-operative horizontal acetabular offset (1.47mm for KA versus -5.1mm for MA, p=0.001), and with 74% of KA versus 50% of MA cups (p=0.044) being within 15% of native anatomy for the horizontal acetabular offset. In addition, the KA technique resulted in a higher cup anteversion (22°±7° vs 15°±8°, p<0.001) but similar cup inclination (41°±6° vs. 42°±7°, p=0.25), a similar proportion of cups within the Lewinnek zone (65% vs. 70%, p=0.8), similar excellent functional outcomes (delta Oxford score pre- to follow-up of 24.3 and 23.5 points for KA and MA groups, respectively, p=0.88), similar patient satisfaction scores of 95.4/100 and 89.5/100 for KA and MA groups, respectively, and the same absence of aseptic complications.

CONCLUSION

The KA technique for THA has been demonstrated to be safe, efficacious, and not inferior to the conventional MA technique at early-term. As the concept of the KA technique for THA is only at an early stage, its influence on mid to long-term clinical outcomes remains to be determined and further refinements of the concept are yet to be made.

LEVEL OF EVIDENCE

III; case-control retrospective study.

Descriptive epidemiology of hip and knee replacement in rheumatoid arthritis: An analysis of UK electronic medical records

OBJECTIVE

To provide descriptive data on rates of total hip replacement (THR) and total knee replacement (TKR) within a large RA cohort and describe variation in risk.

METHODS

Incident RA patients (1995 to 2014) were identified from the Clinical Practice Research Datalink (CPRD). First subsequent occurrence of THR and TKR were identified (analysed separately) and incidence rates calculated, stratified by sex, age, BMI, geographic region, and quintiles of the index of multiple deprivation (IMD) score.

RESULTS

There were 27,607 RA patients included, with a total of 1,028 THRs (mean age at surgery: 68.4 years) and 1,366 TKRs (mean age at surgery: 67.6 years), at an overall incidence rate per 1,000 person-years (PYs) [95% CI] of 6.38 [6.00-6.78] and 8.57 [8.12-9.04], respectively. TKR incidence was similar by gender but THR rates were higher in females than males. Rates of TKR but not THR rose according to BMI. An increasing trend was observed in rates of both outcomes according to age (although not ≥75) but of decreasing rates according to socio-economic deprivation. There was some evidence for regional variation in TKR. The 10-year cumulative incidence was 5.2% [4.9, 5.6] and 7.0% [6.6, 7.4] for THR and TKR, respectively.

CONCLUSION

We provide generalizable estimates of THR and TKR incidence in the UK RA patient population and note variation across several key variables. Increased BMI was associated with a large increase in TKR but not THR incidence. Increased deprivation was associated with a downward trend in rates of THR and TKR.

ASA class is associated with early revision and reoperation after total hip arthroplasty: an analysis of the Geneva and Swedish Hip Arthroplasty Registries

Background and purpose - Data from several joint replacement registries suggest that the rate of early revision surgery after primary total hip arthroplasty (THA) is increasing. The ASA class, now widely recorded in arthroplasty registries, may predict early revision. We investigated the influence of ASA class on the risk of revision and other reoperation within 3 months and within 5 years of primary THA. Patients and methods - We used data from the Geneva and Swedish Hip Arthroplasty Registries, on primary elective THAs performed in 1996-2016 and 2008-2016, respectively. 5,319 and 122,241 THAs were included, respectively. Outcomes were all-cause revision and other reoperations evaluated using Kaplan-Meier survival and Cox regression analyses. Results - Within 3 months after surgery, higher ASA class was associated with greater risk of revision and other reoperation. 3-month cumulative incidences of revision by ASA class I, II, and III-IV respectively, were 0.6%, 0.7%, and 2.3% in Geneva and 0.5%, 0.8%, and 1.6% in Sweden. 3-month cumulative incidences of other reoperation were 0.4%, 0.7%, and 0.9% in Geneva and 0.2%, 0.4%, and 0.7% in Sweden. Adjusted hazard ratios (ASA III-IV vs. I) for revision within 3 months were 2.7 (95% CI 1.2-5.9) in Geneva and 3.3 (CI 2.6-4.0) in Sweden. Interpretation - Assessment of ASA class of patients prior to THA will facilitate risk stratification. Targeted risk-reduction strategies may be appropriate during the very early postoperative period for patients identified as at higher risk. Systematically recording ASA class in arthroplasty registries will permit risk adjustment and facilitate comparison of revision rates internationally.

MOTS-c inhibits Osteolysis in the Mouse Calvaria by affecting osteocyte-osteoclast crosstalk and inhibiting inflammation

The Mitochondrial-derived peptide MOTS-c has recently been reported as a 16-amino acid peptide regulating metabolism and homeostasis in different cells. However, its effects on immune cells and bone metabolism are rarely reported. Here we demonstrate that MOTS-c treatment in ultra-high molecular weight polyethylene (UHMWPE) particle-induced osteolysis mouse model alleviated bone erosion and inflammation. MOTS-c increased osteoprotegerin (OPG)/ receptor activator of nuclear factor kappa-B ligand (RANKL) ratio in osteocytes, leading to inhibition of osteoclastogenesis. In primary bone marrow macrophages (BMMs) MOTS-c alleviated STAT1 and NF-κB phosphorylation triggered by UHMWPE particles. Promoting ROS production or suppressing peroxisome proliferator-activated receptor γ (PPARγ) coactivator-1α (PGC-1α) by adenosine 5'-monophosphate (AMP)-activated protein kinase (AMPK) repression blocked these anti-inflammatory effects of MOTS-c treatment. Taken together, these findings provide evidence that the small peptide inhibits osteoclastogenesis by regulating osteocyte OPG/RANKL secretion and suppressing inflammation via restraining NF-κB and STAT1 pathway. Moreover, its effects on NF-κB activation is dependent on the AMPK-PGC-1α-ROS axis, suggesting its potential use in osteolysis and other inflammation disorders.

Acupuncture for perioperative care of total hip arthroplasty: A systemic review of controlled trials and meta-analysis

INTRODUCTION

This protocol is intended to conduct a systematic review and meta-analysis to evaluate the efficacy and safety of acupuncture in perioperative care of total hip arthroplasty patients.

METHODS AND ANALYSIS

The following databases will be searched from their inception to November 2018 without language restrictions: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature, Oriental Medicine Advanced Searching Integrated System, Korean Traditional Knowledge Portal, KoreaMed, DBPIA, Research Information Service System, including the China National Knowledge Infrastructure. Any randomized controlled trials related to perioperative care of total hip arthroplasty will be included. The primary outcomes of this study are dosage of analgesics and pain intensity. For secondary outcomes, Harris hip score, incidence of postoperative cognitive dysfunction, mini-mental state exam score, incidence of deep vein thrombosis, D-dimer and fibrinogen level, adverse events will be assessed. Data analysis and synthesis will be carried out using RevMan version 5.3. The methodological quality will be assessed by the Cochrane Collaboration risk of bias tool.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018112123.