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

An Evaluation of the Safety of Half-Dose Direct Oral Anticoagulants Following Total Joint Arthroplasty: A Pilot Study

Background Total joint arthroplasty (TJA) patients on preoperative anticoagulation therapy present a challenge for adult reconstruction surgeons. The goal in managing such patients is to limit bleeding complications associated with administering the medications while preventing medical complications from withholding them. At our institution, we began a protocol in 2017 that utilizes a half-dose direct oral anticoagulant (DOAC) regimen for one week followed by resuming of the full-dose regimen in select patients who underwent TJA. This study investigated the 90-day safety profile associated with this protocol compared to previous literature. Methodology A retrospective review of 898 patients from a single institution was conducted including all patients receiving a half-dose DOAC protocol for one week followed by resuming of the full-dose regimen after total knee and total hip arthroplasty between 2017 and 2022. Data were collected on patient demographics, type of surgery, and DOAC dosage. Ninety-day complications were collected and separated into reduced dose complications of DOAC (such as cerebrovascular accidents (CVAs) or venothrombotic events (VTEe)) and DOAC therapy-related complications (including wound and bleeding complications). Results In the total hip arthroplasty (THA) subgroup (n = 396, 44.10%), there were four major VTE occurrences, aligning with the range seen in historical protocols. Deep vein thrombosis (DVT) and pulmonary embolism (PE) incidents were three and one, respectively, both within the historical range. In the total knee arthroplasty (TKA) subgroup of 502 (55.90%) patients, there were seven major VTE events, with five DVTs and two PEs, also aligning with historical ranges. Medical complications in the THA group included no CVA events and one myocardial infarction, with the latter slightly higher than the historical range. In the TKA group, there were two medical complications, both being CVAs. Regarding bleeding complications, THA patients showed four major bleeding incidents, two blood transfusions, and two hemorrhages, with these numbers comparable to or lower than historical ranges. There were seven minor bleeding events. For TKA, there were two major bleeding events, two blood transfusions, no hemorrhages, and five minor bleeding events. Wound complications in THA included five surgery-related complications, two cases of wound dehiscence, and three infections. TKA patients experienced 17 surgery-related complications, six cases of wound dehiscence, and 11 infections. Conclusions This study suggests that the half-dose DOAC protocol in patients undergoing TJA is non-inferior to historical full-dose DOAC protocols warranting further investigation to generalize across broader populations.

Comparative postoperative prognosis of ceramic-on-ceramic and ceramic-on-polyethylene for total hip arthroplasty: an updated systematic review and meta-analysis

Objective

To compare the clinical outcomes between ceramic-on-ceramic (CoC) and ceramic-on-polyethylene (CoP) bearing surfaces in patients undergoing total hip arthroplasty (THA) through a pooled analysis and evidence update.

Methods

We performed a systematic literature search using PubMed, Embase, Cochrane Library and Web of Science up to March 2023 for studies that compared the bearing surfaces of CoC and CoP in patients undergoing THA. The primary outcomes were the incidence of common postoperative complications and the rate of postoperative revision. The secondary outcome was the Harris Hip Score.

Results

A total of 10 eligible studies involving 1,946 patients (1.192 CoC-THA versus 906 CoP-THA) were included in the evidence synthesis. Pooled analysis showed no significant difference in the rates of common postoperative complications (dislocation, deep vein thrombosis, infection, wear debris or osteolysis) and of revision. After eliminating heterogeneity, the postoperative Harris Hip Score was higher in the CoC group than in the CoP group. However, the strength of evidence was moderate for the Harris Hip Score.

Conclusion

CoC articulations are more commonly used in younger, healthier, and more active patients. While the performance of conventional polyethylene is indeed inferior to highly cross-linked polyethylene, there is currently a lack of sufficient research comparing the outcomes between highly cross-linked polyethylene and CoC bearing surfaces. This area should be a focal point for future research, and it is hoped that more relevant articles will emerge. Given the limited number of studies included, the heterogeneity and potential bias of those included in the analysis, orthopaedic surgeons should select a THA material based on their experience and patient-specific factors, and large multicentre clinical trials with >15 years of follow-up are needed to provide more evidence on the optimal bearing surface for initial THA.

Association of surgeon volume with complications following direct anterior approach (DAA) total hip arthroplasty: a population-based study

BACKGROUND AND PURPOSE

 Total hip arthroplasty (THA) can be performed through various surgical approaches, including direct anterior (DAA). DAA-THA may offer faster recovery but carries a higher risk of complications, which may be mitigated by surgeon volume and experience. We examined the association of surgeons' annual surgical volume with major complications after DAA-THA in a population-based sample.

METHODS

 A population-based retrospective cohort study was carried out on primary DAA-THA patients in Ontario between April 2016 and March 2021. We used restricted cubic splines to visually define the association between annual DAA surgeon volume and the risk of major surgical complications (fractures, dislocations, infections, and revisions) within 1 year of surgery. We further compared the complication rates amongst different DAA volume categories (< 30, 30-60, and > 60 cases/year).

RESULTS

The study encompassed 9,672 DAA-THA patients (52% female, median age 67 years). We showed a sharp decline in the probability of complications as the surgical volume of DAA-THA increased within the lower range of 0-30 cases/year; the probability slightly increased after the surgical volume exceeded 60 cases/year. The overall complication rates were 3.09%, 2.24%, and 2.18% for the surgical experience group of < 30 cases/year, 30-60 cases/year, and > 60 cases/year, respectively.

CONCLUSION

 There was an inverse relationship between surgical volume and complication rates in DAA-THA within the lower volume ranges. Maintaining a surgical volume of at least 30 DAA-THA cases/year can minimize complications, emphasizing the importance of surgical volume in this approach.

Does Surgical Approach Affect Dislocation Rate After Total Hip Arthroplasty in Patients Who Have Prior Lumbar Spinal Fusion? A Retrospective Analysis of 16,223 Cases

BACKGROUND

Lumbar spinal fusion (LSF) is a risk factor for dislocation following total hip arthroplasty (THA). The effect of the surgical approach on this association has not been investigated. This study examined the association between the surgical approach and dislocation following THA in patients who had prior LSF.

METHODS

We retrospectively reviewed 16,223 primary elective THAs at our institution from June 2011 to September 2022. Patients who had LSF prior to THA were identified using International Classification of Diseases (ICD) codes. Patients were stratified by LSF history, surgical approach, and intraoperative robot or navigation use to compare dislocation rates. There were 8,962 (55.2%) posterior, 5,971 (36.8%) anterior, and 1,290 (8.0%) laterally based THAs. Prior LSF was identified in 323 patients (2.0%). Binary logistic regressions were used to assess the association of patient factors with dislocation risk.

RESULTS

There were 177 dislocations identified in total (1.1%). In nonadjusted analyses, the dislocation rate was significantly higher following the posterior approach among all patients (P = .003). Prior LSF was associated with a significantly higher dislocation rate in all patients (P < .001) and within the posterior (P < .001), but not the anterior approach (P = .514) subgroups. Multivariate regressions demonstrated anterior (OR [odds ratio] = 0.64, 95% CI [confidence interval] 0.45 to 0.91, P = .013), and laterally based (OR = 0.42, 95% CI 0.18 to 0.96, P = .039) approaches were associated with decreased dislocation risk, whereas prior LSF (OR = 4.28, 95% CI 2.38 to 7.69, P < .001) was associated with increased dislocation risk. Intraoperative technology utilization was not significantly associated with dislocation in the multivariate regressions (OR = 0.72, 95% CI 0.49 to 1.06, P = .095).

CONCLUSIONS

The current study confirmed that LSF is a significant risk factor for dislocation following THA; however, anterior and laterally based approaches may mitigate dislocation risk in this population. In multivariate analyses, including surgical approach, LSF, and several perioperative variables, intraoperative technology utilization was not found to be significantly associated with dislocation risk.

Time to Achieve the Minimal Clinically Important Difference in Primary Total Hip Arthroplasty: Comparison of Anterior and Posterior Surgical Approaches

BACKGROUND

Controversy remains over outcomes between total hip arthroplasty approaches. This study aimed to compare the time to achieve the minimal clinically important difference (MCID) for the Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form (HOOS-PS) and the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-Physical for patients who underwent anterior and posterior surgical approaches in primary total hip arthroplasty.

METHODS

Patients from 2018 to 2021 with preoperative and postoperative HOOS-PS or PROMIS Global-Physical questionnaires were grouped by approach. Demographic and MCID achievement rates were compared, and survival curves with and without interval-censoring were used to assess the time to achieve the MCID by approach. Log-rank and weighted log-rank tests were used to compare groups, and Weibull regression analyses were performed to assess potential covariates.

RESULTS

A total of 2,725 patients (1,054 anterior and 1,671 posterior) were analyzed. There were no significant differences in median MCID achievement times for either the HOOS-PS (anterior: 5.9 months, 95% confidence interval [CI]: 4.6 to 6.4; posterior: 4.4 months, 95% CI: 4.1 to 5.1, P = .65) or the PROMIS Global-Physical (anterior: 4.2 months, 95% CI: 3.5 to 5.3; posterior: 3.5 months, 95% CI: 3.4 to 3.8, P = .08) between approaches. Interval-censoring revealed earlier times of achieving the MCID for both the HOOS-PS (anterior: 1.509 to 1.511 months; posterior: 1.7 to 2.3 months, P = .87) and the PROMIS Global-Physical (anterior: 3.0 to 3.1 weeks; posterior: 2.7 to 3.3 weeks, P = .18) for both surgical approaches.

CONCLUSIONS

The time to achieve the MCID did not differ by surgical approach. Most patients will achieve clinically meaningful improvements in physical function much earlier than previously believed.

LEVEL OF EVIDENCE

Level III, Retrospective Comparative Study.

Collared Cementless Femoral Components Reduce the Revision Rates in Primary Total Hip Arthroplasty Using the Direct Anterior Approach: An Australian Orthopaedic Association National Joint Replacement Registry Study

BACKGROUND

An increased risk of periprosthetic fracture and aseptic loosening is reported when the direct anterior approach (DAA) is used for total hip arthroplasty (THA), especially with cementless implants. We assessed the rate of revision comparing collared and collarless femoral stems when using the DAA for THA.

METHODS

We used data from the Australian Orthopaedic Association National Joint Replacement Registry for primary THA for osteoarthritis inserted with the DAA between January 2015 and December 2022. There were 48,567 THAs that used the DAA (26,690 collarless cementless, 10,161 collared cementless, and 11,716 cemented). Cumulative percent revision was calculated for all-cause revision, revision for periprosthetic femoral fractures, and aseptic femoral stem loosening. Cox proportional hazard ratios [HRs] were used to compare the revision of collared and collarless cementless stems. We also compared collared cementless stems and cemented stems.

RESULTS

A higher rate of all-cause revision within 3 months of surgery was observed with collarless compared to collared cementless implants (HR: 1.99 [95% confidence interval (CI), 1.56 to 2.54]; P < .001). Similarly, collarless cementless implants were associated with a greater rate of revision for fracture in the first 6 months (HR: 2.90 [95% CI, 1.89 to 4.45]; P < .001) and after 6 months (HR 10.04 [95% CI 1.38 to 73.21]; P = .02), as well as an increased rate of revision for aseptic loosening after 2 years (HR: 5.76 [95% CI, 1.81 to 18.28], P = .003). Collared cementless and cemented stems performed similarly.

CONCLUSION

Collared stems were associated with a reduced rate of all-cause revision for cementless THA performed via the DAA. The reduction in risk may be due to protection from periprosthetic femoral fracture and aseptic loosening.

Mid-term outcomes of total hip arthroplasty in patients younger than 30 years

INTRODUCTION

Total hip arthroplasty (THA) has predominantly been utilized to treat older patients with primary osteoarthritis. However, recent improvements in surgical technique and implant materials have increased implant longevity, making THA a viable option for younger patients (< 30 years old). While trend analyses indicate an expanding utilization of THA in younger patients with non-OA diagnoses, current data on mid- and long-term THA outcomes in this population are limited. This study aims to describe the demographics, perioperative data, and implant survivorship of patients younger than 30 years undergoing THA.

METHODS

A retrospective study across two large urban academic medical institutions identified 135 patients aged < 30 years who underwent 155 primary THAs between 2012 and 2017, with up to 10-year clinical follow-up. Baseline demographics, surgical indications, intraoperative details, and postoperative outcomes were analyzed.

RESULTS

The mean age at surgery was 24.9 years (range 18-29). Osteonecrosis of the femoral head (55.5%), developmental hip dysplasia (28.3%), and arthritis (15.5%) were the primary indications. Most surgeries utilized the posterior approach (64.5%), manual technique (65.8%), and Ceramic-on-Polyethylene articulation (71.6%). Seven patients (4.5%) were readmitted within 90-days of surgery, including three non-orthopedic-related readmissions (1.9%) and four orthopedic-related readmissions (2.6%). Dislocations were reported in two patients (1.3%). There were six all-cause revisions (3.9%), four aseptic (2.6%) and two septic (1.3%). Kaplan-Meier analysis showed 10-year survival from implant retaining reoperation was 98.7%, 10-year survival from all-cause revision was 96.1%, and 10-year survival from aseptic revision was 97.4%.

CONCLUSION

With a 10-year aseptic implant survivorship rate of 97.4%, THA is a reliable surgical intervention for patients younger than 30 years of age who have severe hip pathology. Further studies are warranted for a more comprehensive understanding of mid- and long-term survivorship risk factors in this demanding population, facilitating improved risk assessment and informed surgical decisions.

Intramedullary Total Femur via a Direct Anterior Approach for Complex Revision Total Hip and Knee Arthroplasty

Total femur replacement is a well-recognized salvage procedure and an alternative to hip disarticulation in patients with massive femoral bone loss. Compared to conventional total femur replacement, intramedullary total femur (IMTF) requires less soft tissue dissection and preserves femoral bone stock and soft-tissue attachments. Despite these advantages, patients can still anticipate compromised functional outcomes and high complication rates following IMTF. Prior studies describe IMTF with the patient positioned laterally and utilizing posterior or anterolateral approaches to the hip. We describe our IMTF technique performed via the direct anterior approach in the supine position. In our experience, this is an effective method, with potential benefits including intraoperative limb length and rotational assessment, use of fluoroscopy, more convenient exposure of the knee, and potential lower rates of hip instability.

Learning curve and initial outcomes of a novel percutaneously endoscopic-assisted total hip arthroplasty through mini bikini direct anterior approach: an observational cohort study

OBJECTIVE

Although the direct anterior approach can reduce muscle damage and ensure accurate prosthesis placement, the steep learning curve and increased risk of complications associated with DAA necessitate careful consideration. Therefore, we describe a technique for a novel percutaneously endoscopic-assisted total hip arthroplasty through mini bikini direct anterior approach (mDAA) and report the learning curve and initial outcomes.

METHODS

The first 125 THA performed by a single surgeon between September 2020 and February 2022 using the anterior approach were included, comprising the initial 41 cases of bikini DAA (bDAA) and the subsequent 84 cases of mDAA. Outcome measures included perioperative outcomes and postoperative complications. The cumulative sum analysis (CUSUM) was used to determine the learning curve of anterior approach THA for each patient's ORT. Multivariable analysis was performed to determine risk correlation.

RESULTS

A total of 125 anterior approach THA completed between 2020 and 2022 were identified. Among these, 41 were performed via bDAA and 84 via mDAA. No statistically significant differences were observed between the groups in terms of age, gender distribution, BMI or follow-up time. A significant reduction in ORT was noted, from 140 min for bDAA to 130 min for mDAA. Furthermore, there was a consistent decrease in LOI, LOS, and wound-healing problems. There was no statistically significant difference between groups with respect to Harris Hip Scores and other postoperative complications. The curve inflection points of the learning curve for the bDAA and mDAA group were located in the 22nd and 68th cases, respectively. The reduction of hemoglobin indicated a predicted increase in ORT.

CONCLUSIONS

In this study, ORT, LOI, LOS, and wound-healing problems decreased overall in mDAA group. After mastering the bDAA technique, approximately 27 mDAA cases are needed to acquire proficiency in this technique. Hence, mDAA is a valuable alternative for those seeking smaller incisions, resolving wound healing problems, and aiming for enhanced recovery after surgery.

The "true" 1-year incidence of dislocation after primary total hip arthroplasty: validation of an algorithm identifying dislocations in the Danish National Patient Register based on 5,415 patients from the Danish Hip Arthroplasty Register

BACKGROUND AND PURPOSE

Dislocations continue to be a serious complication after primary total hip arthroplasty (THA). Our primary aim was to report the "true" incidence of dislocations in Denmark and secondarily to validate a previously developed algorithm designed to identify THA dislocations in the updated version of the Danish National Patient Register (DNPR), based on data from the Danish Hip Arthroplasty Register (DHR).

METHODS

We included 5,415 primary THAs from the DHR performed from July 1 to December 31, 2019. Version 3 of the DNPR was launched in February 2019, and a combination of data from the DNPR and a comprehensive national review of 1,762 hospital contacts enabled us to identify every dislocation occurring during the 1st year after THA to determine the "true" 1-year incidence of dislocation. The results were presented as proportions with 95% confidence intervals (CI), and validation was performed by calculating sensitivity and predictive values.

RESULTS

The "true" 1-year incidence of dislocation was 2.8% (CI 2.4-3.3). Of these, 37% suffered recurrent dislocations during the follow-up period. Between-hospital variation ranged from 0.0% to 9.6%. The algorithm demonstrated a sensitivity close to 95%, while maintaining a positive predictive value of above 94%.

CONCLUSION

The "true" 1-year incidence of dislocation of 2.8% is comparable to earlier findings, and large variation among hospitals continues to be evident. We have proven the algorithm to be valid in the latest DNPR (version 3), enabling it to be employed as a new quality indicator in future annual DHR reports.

Impact of diabetic kidney disease on post-operative complications after primary elective total hip arthroplasty: a nationwide database analysis

BACKGROUND

The high prevalence of diabetic kidney disease (DKD) in the United States necessitates further investigation into its impact on complications associated with total hip arthroplasty (THA). This study utilizes a large nationwide database to explore risk factors in DKD cases undergoing THA.

METHODS

This research utilized a case-control design, leveraging data from the national inpatient sample for the years 2016 to 2019. Employing propensity score matching (PSM), patients diagnosed with DKD were paired on a 1:1 basis with individuals free of DKD, ensuring equivalent age, sex, race, Elixhauser Comorbidity Index (ECI), and insurance coverage. Subsequently, comparisons were drawn between these PSM-matched cohorts, examining their characteristics and the incidence of post-THA complications. Multivariate logistic regression analysis was then employed to evaluate the risk of early complications after surgery.

RESULTS

DKD's prevalence in the THA cohort was 2.38%. A 7-year age gap separated DKD and non-DKD patients (74 vs. 67 years, P < 0.0001). Additionally, individuals aged above 75 exhibited a substantial 22.58% increase in DKD risk (49.16% vs. 26.58%, P < 0.0001). Notably, linear regression analysis yielded a significant association between DKD and postoperative acute kidney injury (AKI), with DKD patients demonstrating 2.274-fold greater odds of AKI in contrast with non-DKD individuals (95% CI: 2.091-2.473).

CONCLUSIONS

This study demonstrates that DKD is a significant risk factor for AKI in patients undergoing total hip arthroplasty. Optimizing preoperative kidney function through appropriate interventions might decrease the risk of poor prognosis in this population. More prospective research is warranted to investigate the potential of targeted kidney function improvement strategies in reducing AKI rates after THA. The findings of this study hold promise for enhancing preoperative counseling by surgeons, enabling them to provide DKD patients undergoing THA with more precise information regarding the risks associated with their condition.

Does-dual mobility still offer improved stability in smaller cup sizes? A computer modelling comparison of stability with 22-mm versus 28-mm inner heads in dual-mobility versus single-bearing constructs

PURPOSE

Dislocation remains 1 of the leading causes of revision after primary total hip arthroplasty (THA) and there is clear evidence the dual-mobility (DM) is used more frequently to minimise this. But in smaller cups, whether the use of DM with smaller 22-mm heads imparts any increased stability compared to standard bearing is unknown; especially when those smaller cups now allow for large single-bearing (SB) heads.

METHODS

3 primary cup sizes (48 mm, 50 mm, 52 mm) were chosen a priori for modelling. Head sizes trialled for the standard bearing (SB) constructs group were 28-0 mm, 32-0 mm and 36-0 mm against neutral polyethylene liners. In the modular sub-hemispheric DM constructs the inner head sizes for the DM constructs were altered where appropriate (22-0 mm vs. 28-0 mm). Cup position, stem offset, and stem size were standardised.

RESULTS

Both DM constructs outperformed all SB constructs because of a statistically significant jump distance increase (p < 0.001). However, there was no difference in range of motion (ROM) or jump distances between the 22-mm and 28-mm DM inner heads.The ROM angle before impingement between the DM (with 22-mm or 28-mm heads) and SB (with different head sizes where appropriate) showed no statistically significant difference. However, DM constructs presented significantly larger jump distances than SB constructs for both provocative dislocation tests across all 3 cup sizes.Of interest, for 50-mm and 52-mm cup sizes (for which this particular DM construct design can accommodate both 22-mm and 28-mm inner heads), there were no differences in ROM or jump distance between 22-mm versus 28-mm inner heads.

CONCLUSIONS

In this computer-modelling study, DM constructs are advantageous over SB constructs for improving jump distances in clinically provocative positions, but not range of motion angles. Inner head diameter of DM has no effect on stability.

The Rise of the Direct Anterior Approach: Trends, Learning Curves, and Patient Characteristics of 63,182 Primary Total Hip Arthroplasties in the Dutch Arthroplasty Register (LROI)

BACKGROUND

The use of the direct anterior approach (DAA) in total hip arthroplasty (THA) has steadily increased in the Netherlands since 2007. The aim of this study was to outline how the DAA has been implemented in the Netherlands. Moreover, we investigated the learning curve of the DAA at a hospital level, and explored patient characteristics of the DAA compared with other approaches and during the learning phase after implementing the DAA.

METHODS

In this population-based cohort study, we included all primary THAs between 2007 and 2020 (n = 342,473) from the Dutch Arthroplasty Register. For hospitals implementing the DAA (n > 20), patients were categorized in 4 experience groups using the date of surgery: 1 to 50, 51 to 100, 101 to 150, or > 150. Subsequently, data from different hospitals were pooled and survival rates were calculated using Kaplan-Meier survival analyses. Adjusted revision rates were calculated using mixed Cox proportional hazard models (frailty).

RESULTS

The use of the DAA gradually rose from 0.2% in 2007 to 41% of all primary THAs in 2020. A total of 64 (56%) hospitals implemented the DAA. However, not all hospitals continued using this approach. After implementation, the 5-year survival rate for the first 50 procedures was significantly lower (96% confidence interval [CI] 95.8 to 97.2) compared to >150 procedures (98% CI 97.7 to 98.1). Multivariable Cox hazard analyses demonstrated a higher risk of revision during the first 50 procedures compared with >150 procedures (hazard ratio 1.6, CI 1.3 to 2.0).

CONCLUSIONS

The use of DAA for primary THA significantly increased. For hospitals implementing DAA, a considerable learning curve with increased revision risk was seen.

Clinical, functional, and radiological outcomes of robotic assisted versus conventional total hip arthroplasty: a systematic review and meta-analysis of randomized controlled trials

This systematic review of randomized controlled trials (RCTs) aims to compare important clinical, functional, and radiological outcomes between robotic-assisted total hip arthroplasty (RATHA) and conventional total hip arthroplasty (COTHA) in patients with hip osteoarthritis. We identified published RCTs comparing RATHA with COTHA in Ovid MEDLINE, EMBASE, Scopus, and Cochrane Library. Two reviewers independently performed study screening, risk of bias assessment and data extraction. Main outcomes were major complications, revision, patient-reported outcome measures (PROMs), and radiological outcomes. We included 8 RCTs involving 1014 patients and 977 hips. There was no difference in major complication rate (Relative Risk (RR) 0.78; 95% Confidence Interval (CI) 0.22 to 2.74), revision rate (RR 1.33; 95%CI 0.08 to 22.74), and PROMs (standardized mean difference 0.01; 95%CI - 0.27 to 0.30) between RATHA and COTHA. RATHA resulted in little to no effects on femoral stem alignment (mean difference (MD) - 0.57 degree; 95%CI - 1.16 to 0.03) but yielded overall lower leg length discrepancy (MD - 4.04 mm; 95%CI - 7.08 to - 1.0) compared to COTHA. Most combined estimates had low certainty of evidence mainly due to risk of bias, inconsistency, and imprecision. Based on the current evidence, there is no important difference in clinical and functional outcomes between RATHA and COTHA. The trivial higher radiological accuracy was also unlikely to be clinically meaningful. Regardless, more robust evidence is needed to improve the quality and strength of the current evidence.PROSPERO registration: the protocol was registered in the PROSPERO database (CRD42023453294). All methods were carried out in accordance with relevant guidelines and regulations.

Individualized Surgeon Reports in a Statewide Registry

ABSTRACT

Despite progress with the development of joint replacement registries in the United States, surgeons may have limited opportunities to determine the cumulative outcome of their own patients or understand how those outcomes compare with their peers; this information is important for quality improvement. In order to provide surgeons with accurate data, it is first necessary to have a registry with complete coverage and patient matching. Some international registries have accomplished this. Building on a comprehensive statewide registry in the United States, a surgeon-specific report has been developed to provide surgeons with survivorship and complication data, which allows comparisons with other surgeons in the state. This article describes funnel plots, cumulative sum reports, complication-specific data, and patient-reported outcome measure data, which are provided to hip and knee arthroplasty surgeons with the goal of improving quality, decreasing variability in the delivery of care, and leading to improved value and outcomes for hip and knee arthroplasty in the state of Michigan.

Incision Closure for Direct Anterior Total Hip Arthroplasty: Is There a Difference in the Rate of Superficial Wound Complications With Suture Versus Staples?

Background Direct anterior total hip arthroplasty (DA-THA) has increased in popularity over recent decades. However, DA-THA has been reported to have a higher incidence of superficial wound complications, including infection and incisional dehiscence, compared to other surgical approaches to hip arthroplasty. While this indicates a need for optimal wound closure, little research exists on the preferred method of skin closure following DA-THA. This study aimed to determine if there was any difference in rates of superficial infection, wound dehiscence, or overall wound complications with skin closure using a running subcuticular 3-0 Monocryl® suture compared to surgical staples following DA-THA.  Methods Records of patients who underwent DA-THA at our institution between July 2017 to July 2022 were retrospectively reviewed. Data were abstracted on patient demographics, comorbidities, skin closure method, and wound complications from the electronic medical record. Superficial infection and wound dehiscence were classified based on explicit diagnosis in post-operative records and incision photographs taken during follow-up visits. Overall wound complications were classified in patients who experienced either superficial infection, incisional dehiscence, or both complications following surgery. Descriptive statistics and chi-squared measures were obtained from post-operative patient data, and significance was set at p [Formula: see text] 0.05. Results A total of 365 DA-THAs were completed in 349 patients. A running subcuticular 3-0 Monocryl® suture closed 207 surgeries (56.7%), while surgical staples closed 158 surgeries (43.3%). There was no significant difference in independent rates of superficial infection (p = 0.076) or wound dehiscence (p = 0.118) between suture and staple cohorts; however, suture closure (10, 2.7%) was associated with a significantly higher rate of overall wound complications compared to staple closure (1, 0.3%) (p = 0.020). Conclusion DA-THA carries the risk of overall wound complications, including superficial infection and wound dehiscence. Our findings suggest superficial skin closure with staples may be preferred over sutures due to lower rates of overall wound complications. Further studies are needed to determine the optimal method of skin closure following DA-THA.

A Comparison of Wound Complications Following Total Hip Arthroplasty Performed Through the Direct Anterior Versus Direct Lateral Approach

Background

Some studies have suggested the risk of wound complications may be higher using the direct anterior (DA) approach to total hip arthroplasty (THA). This study aimed to compare the risk of early postoperative wound complications between the DA and direct lateral (DL) approaches to THA and to determine patient risk factors that may contribute to this problem.

Methods

All patients who underwent primary THA with a single surgeon over a 5-year period were retrospectively reviewed. All patients were treated with either the DA or DL approach. Data collected included patient demographics, surgical approach, and wound status. There was a minimum follow-up of 6 weeks to allow for an adequate assessment of surgical wound healing. Univariate and multivariate analyses were used to compare the 2 approaches.

Results

Five hundred seventy-nine patients (77.6%) who underwent DA approach and 167 patients (22.4%) who underwent DL approach were included. Patients who underwent DL approach had a higher body mass index and a higher rate of diabetes than those treated with the DA approach. Forty patients (6.9%) in the DA cohort and 14 (8.4%) in the DL cohort experienced early wound complications, P = .523. After controlling for potential confounding variables, the surgical approach was not an independent risk factor for early postoperative wound complications.

Conclusions

While there have been concerns regarding use of the DA approach in patients with higher body mass index and certain medical comorbidities, the results of this study suggest the choice of surgical approach may have minimal effect on the rate of early postoperative wound complications.

Hardware Removal and Conversion Hip Arthroplasty via a Single Interval Anterior Approach: Surgical Technique

The supine 'off-table' anterior-based muscle-sparing (ABMS) approach is an established approach for primary total hip arthroplasty. The approach is performed with the patient positioned supine on a regular operating room table. It combines utilizing the Watson-Jones interval (without disrupting the abductor muscles) with principles of capsular management borrowed from the direct anterior approach. The approach may also be utilized for complex primary and revision hip arthroplasties. One clinical scenario the ABMS approach may be particularly well-suited to is conversion hip arthroplasty when retained hardware requires removal. The approach enables the surgeon to remove proximal femoral hardware and perform hip arthroplasty within the same muscle interval. This is in contrast to direct anterior approach, which entails separate windows being created on either side of the tensor fascia lata muscle to remove hardware and insert hip arthroplasty components, respectively. In this article, we describe our surgical technique for performing conversion total hip arthroplasty with hardware removal (sliding hip screw and plate in the discussed case) via a single interval with the supine off-table ABMS approach.

Five-Year Survivorship of Total Hip Arthroplasty With a Proximally Coated, Medially Collared, Triple-Tapered Femoral Stem: A Retrospective, Multicenter Registry Review

Background The anterior approach for total hip arthroplasty (THA) has gained popularity in recent years. Some surgeons have been hesitant to adopt the approach due to concerns over increased complications such as intraoperative fracture, stem loosening, and stem revision. This study aims to evaluate the all-cause revision rate and survivorship of a collared, triple-tapered stem that was designed specifically for use with the anterior approach in THA to enhance outcomes and reduce adverse events. Methodology A retrospective outcomes review was conducted to assess survivorship and clinical outcomes for a specific proximally coated, medially collared triple-tapered (MCTT) femoral stem. Results In a cohort of 5,264 hips, Kaplan-Meier survivorship estimates (95% confidence interval [CI]; N with further follow-up), with survivorship defined as no revision of any component for any reason at five years after the index procedure, were 98.9% (97.8%-99.4%; 43) under the clinical assumption and 99.6% (99.4%-99.7%; 894) under the registry assumption. With survivorship defined as stem revision for any reason, survivorship estimates at five years postoperatively were 99.6% (99.3%-99.8%; 43) under the clinical assumption and 99.8% (99.7%-99.9%; 894) under the registry assumption. The mean follow-up time was 94.52 days (standard deviation [SD] 2.24, range 90.03-96.02). At five years postoperatively, the mean Harris Hip Score was 95.19, and the mean Hip Disability and Osteoarthritis Outcome Score Junior (HOOS JR) score was 98.66. Conclusions Our evaluation demonstrates excellent construct and stem survivorship and very low complication rates at midterm postoperative follow-up.

Improved patient reported outcomes with the direct anterior approach versus the posterior approach for total hip arthroplasty in the early post-operative period

BACKGROUND

Patients undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA) may experience faster recovery but may also have better baseline health than those who undergo THA with the posterior approach (PA). This study aimed to compare patient-reported outcome measures (PROMs) between the DAA and PA while controlling for baseline factors.

METHODS

This is a secondary data analysis from a prospective cohort study of patients utilizing a smartphone-based care management platform following THA. The primary outcomes were HOOS JR and EQ-5D-5L through 1 year and change from baseline. Longitudinal regression models were created to control for baseline characteristics and investigate the impact of surgical approach on PROMs.

RESULTS

Of 1364 THAs evaluated, 731 (53.6%) were female, and 840 (61.6%) used the PA. Patients in the PA group were of similar age but had higher body mass index and comorbidity scores. Pre-operative HOOS JR and EQ-5D-5L were comparable, but higher post-operatively in the DAA group through 6 months (p = 0.03 and p = 0.005). At 1 year post-operatively, HOOS JR and EQ-5D-5L did not vary between groups (p = 0.48 and p = 0.56), nor did changes from baseline (p = 0.47 and p = 0.11). After controlling baseline characteristics, DAA was significantly associated with higher average HOOS JR through 6 months (p = 0.03) and EQ-5D-5L through 3 months (p  = 0.005), but not at 12 months (p = 0.89 and p = 0.56).

CONCLUSION

THA patients undergoing DAA demonstrate earlier improvements in HOOS JR and EQ-5D-5L. However, these differences may not be clinically significant and are not evident at 1-year post-operative. Patient selection and surgeon training may continue to affect outcomes by surgical approach.

No benefit of direct anterior over posterolateral approach in total hip arthroplasty using dual-mobility acetabular component for femoral neck fracture

Aims

Dual-mobility acetabular components (DMCs) have improved total hip arthroplasty (THA) stability in femoral neck fractures (FNFs). In osteoarthritis, the direct anterior approach (DAA) has been promoted for improving early functional results compared with the posterolateral approach (PLA). The aim of this study was to compare these two approaches in FNF using DMC-THA.

Methods

A prospective continuous cohort study was conducted on patients undergoing operation for FNF using DMC by DAA or PLA. Functional outcome was evaluated using the Harris Hip Score (HHS) and Parker score at three months and one year. Perioperative complications were recorded, and radiological component positioning evaluated.

Results

There were 50 patients in the DAA group and 54 in the PLA group. The mean HHS was 85.5 (SD 8.8) for the DAA group and 81.8 (SD 11.9) for the PLA group (p = 0.064). In all, 35 patients in the DAA group and 40 in the PLA group returned to their pre-fracture Parker score (p = 0.641) in both groups. No statistically significant differences between groups were found at one year regarding these two scores (p = 0.062 and p = 0.723, respectively). The DAA was associated with more intraoperative complications (p = 0.013). There was one dislocation in each group, and four revisions for DAA and one for PLA, but this difference was not statistically significant. There were also no significant differences regarding blood loss, length of stay, or operating time.

Conclusion

In DMC-THA for FNF, DAA did not achieve better functional results than PLA, either at three months or at one year. Moreover, DAA presented an increased risk of intra-operative complications.

In-hospital complications and readmission patterns in 13,937 patients with developmental dysplasia of the hip undergoing total hip arthroplasty: Evidence from the Chinese national database

PURPOSE

Clarifying the prognosis and readmission patterns of patients with developmental dysplasia of the hip (DDH) following total hip arthroplasty (THA) would provide important references for clinical management for this population. Using the Chinese national inpatient database (i.e., Hospital Quality Monitoring System [HQMS]), we aimed to compare in-hospital complications and readmission patterns following THA in patients with DDH and primary osteoarthritis (OA).

METHODS

Patients undergoing THA for DDH and OA between 2013 and 2019 were identified using the HQMS. Demographics and clinical characteristics were compared between the two groups. After propensity score matching, in-hospital complications and readmission patterns were compared using a logistic regression model.

RESULTS

According to the analysis of 13,937 propensity-score matched pairs, there were no significant differences in the incidence of in-hospital death (0.01 % vs 0.04 %, P = 0.142), transfusion (8.09 % vs 7.89 %, P = 0.536), wound infection (0.31 % vs 0.25 %, P = 0.364), deep venous thrombosis (0.45 % vs 0.43 %, P = 0.786), pulmonary embolism (0.03 % vs 0.05 %, P = 0.372) or all-cause readmission (2.87 % vs 3.12 %, P = 0.219) between two groups. However, DDH patients had higher surgical readmission rates than OA patients (1.43 % vs 1.14 %, P = 0.033). When analyzing causes of surgical readmission, DDH patients had increased risk of dislocation (0.37 % vs 0.21 %, P = 0.011) and aseptic loosening (0.17 % vs 0.07 %, P = 0.024) than OA patients.

CONCLUSION

DDH patients had an increased risk of surgical readmission following THA, mainly driven by dislocation and aseptic loosening, which should be recognized and appropriately prevented.

A prospective and consecutive study assessing short-term clinical and radiographic outcomes of Chinese domestically manufactured 3D printing trabecular titanium acetabular cup for primary total hip arthroplasty: evaluation of 236 cases

Purpose

We prospectively evaluate the short-term clinical and radiographic outcomes of the only Chinese domestically produced trabecular titanium acetabular cup(3D ACT™ cup) in primary total hip arthroplasty (THA), aiming to provide evidence-based support for its clinical application.

Methods

A total of 236 patients, who underwent primary THA using 3D ACT™ cup in the Department of Joint Surgery at our hospital between January 2017 and June 2019, were included in this study. General patient data, imaging information, functional scores, and complications were collected to evaluate the early clinical efficacy.

Results

All patients were followed up for 33-52 months, with an average of (42.2 ± 9.2) months. At the last follow-up, the preoperative HHS score increased significantly from 43.7 ± 6.8 to 85.6 ± 9.3 points (P < 0.01). Similarly, the preoperative WOMAC scores showed significant improvement from 59.2 ± 5.8 to 13.1 ± 3.5 points (P < 0.01). 92.3% of the patients expressed satisfaction or high satisfaction with the clinical outcome. Furthermore, 87.7% of the acetabular cups were positioned within the Lewinnek safe zone, achieving successful reconstruction of the acetabular rotation center. The cup survival rate at the last follow-up was 100%.

Conclusions

The utilization of the only Chinese domestically manufactured 3D printing trabecular titanium acetabular cup in primary THA demonstrated favorable short-term clinical and radiographic outcomes. The acetabular cup exhibits excellent initial stability, high survival rate, and favorable osseointegration, leading to a significant enhancement in pain relief and functional improvement. In the future, larger sample sizes and multicenter prospective randomized controlled trials will be required to validate the long-term safety and effectiveness of this 3D ACT™ cup.

Trends and benefits of early hip arthroplasty for femoral neck fracture in China: a national cohort study

BACKGROUND

Limited studies have examined the benefits of early arthroplasty within 48 h from admission to surgery for femoral neck fractures (FNFs). Using the national inpatient database, the authors aimed to investigate the trends in early arthroplasty within 48 h for FNFs in China and to assess its effect on in-hospital complications and 30-day readmission patterns.

MATERIALS AND METHODS

This was a retrospective cohort study. Patients receiving primary total hip arthroplasty (THA) or hemiarthroplasty (HA) for FNFs in the Hospital Quality Monitoring System between 2013 and 2019 were included. After adjusting for potential confounders with propensity score matching, a logistic regression model was performed to compare the differences in in-hospital complications [i.e. in-hospital death, pulmonary embolism, deep vein thrombosis (DVT), wound infection, and blood transfusion], rates and causes of 30-day readmission between early and delayed arthroplasty.

RESULTS

During the study period, the rate of early THA increased from 18.0 to 19.9%, and the rate of early HA increased from 14.7 to 18.4% ( P <0.001). After matching, 11 731 pairs receiving THA and 13 568 pairs receiving HA were included. Compared with delayed THA, early THA was associated with a lower risk of pulmonary embolism [odds ratio (OR) 0.51, 95% CI: 0.30-0.88], DVT (OR 0.59, 95% CI: 0.50-0.70), blood transfusion (OR 0.62, 95% CI: 0.55-0.70), 30-day readmission (OR 0.82, 95% CI: 0.70-0.95), and venous thromboembolism-related readmission (OR 0.50, 95% CI: 0.34-0.74). Similarly, early HA was associated with a lower risk of DVT (OR 0.70, 95% CI: 0.61-0.80) and blood transfusion (OR 0.74, 95% CI: 0.68-0.81) than delayed HA.

CONCLUSION

Despite a slight increase, the rate of early arthroplasty remained at a low level in China. Given that early arthroplasty can significantly improve prognosis, more efforts are needed to optimize the procedure and shorten the time to surgery.

[Translated article] Clinical results of total hip arthroplasty assisted by robotic arm in Spain: Preliminary study

OBJECTIVES

Clinical, radiological and functional results of the first Spanish series of patients undergoing total hip arthroplasty assisted by Mako® (Stryker) robotic arm at the Hospital Clínico San Carlos (HCSC) in Madrid.

MATERIAL AND METHODS

Prospective and descriptive study analyzing the first 25 patients who underwent robotic-assisted THA at the HCSC, with a minimum follow-up of 4 months. Demographics, imaging studies (Mako® processing, Rx and CT), clinical parameters, functionality (modified Harris) and associated complications were evaluated.

RESULTS

Average age was 67.2 years (min 47, max 88), being 56% male population sample. 88% involves primary coxarthrosis, 4% post-traumatic coxarthrosis, 4% secondary avascular necrosis and 4% secondary femoroacetabular impingement. Average surgery time was 116.9min (min 92, max 150). The average time of the first five surgeries was 122.6min, and, regarding the last five interventions, it was 108.2min. Found medical intraoperative complications were four intraoperative markers loss. Average admission time was 4.4days (min 3, max 7), with an average postoperative haemoglobin decrease of 3.08±1.08g/dl, requiring a transfusion in 12% of the cases. Three medical complications have been registered in the meantime of the admission, with a relevant case of a confusional syndrome and a fall, which resulted in a non-displaced AG1 periprosthetic fracture. The analysis of the positioning of registered implants with Mako® system shows 40.55±1.53 acetabular inclination degrees and 12.2±3.6 acetabular anteversion degrees. The postoperative image study carried out on patients, are consistent with Mako® results, as it shows an acetabular inclination of 41.2±1.7 in Rx, as well as acetabular anteversion of 16±4.6 in CT. Hip length variance ranges depending on preoperative values of 3.91mm (SD: 3.9; min -12, max 3) to 1.29mm (SD: 1.96) after surgery registered with Mako®, with an increase of an average hip length of 5.64mm (SD: 3.35). Rx simple study results show a postoperative difference between both hips of 0.5±3.08mm, which is consistent with Mako® results. Native femoral offset was stable after surgery with a showing difference both pre and post operative of the intervened hip of 0.1mm (SD: 3.7), registered with Mako®. Preoperatory modified Harris punctuation was 41.6±13.3, improving to postoperative values of 74.6±9.7 after four months since the surgery. No complications were registered in immediate postoperative (4 months).

CONCLUSIONS

Total hip arthroplasty robot-assisted achieves an adequate precision and repeatability of the implant positioning and the postoperative hip dysmetry without showing an increase of associated complications to the technique applied. Surgery time, complications and functional results in a short-time period are similar to conventional techniques applied to great series previously published.

Clinical results of total hip arthroplasty assisted by robotic arm in Spain: Preliminary study

OBJECTIVES

Clinical, radiological and functional results of the first Spanish series of patients undergoing total hip arthroplasty assisted by Mako® (Stryker) robotic arm at the Hospital Clínico San Carlos (HCSC) in Madrid.

MATERIAL AND METHODS

Prospective and descriptive study analyzing the first 25 patients who underwent robotic-assisted THA at the HCSC, with a minimum follow-up of 4months. Demographics, imaging studies (Mako® processing, Rx and CT), clinical parameters, functionality (modified Harris) and associated complications were evaluated.

RESULTS

Average age was 67.2years (min 47, max 88), being 56% male population sample. 88% involves primary coxarthrosis, 4% post-traumatic coxarthrosis, 4% secondary avascular necrosis and 4% secondary femoroacetabular impingement. Average surgery time was 116.9min (min 92, max 150). The average time of the first five surgeries was 122.6min, and, regarding the last five interventions, it was 108.2min. Found medical intraoperative complications were four intraoperative markers loss. Average admission time was 4.4days (min 3, max 7), with an average postoperative hemoglobin decrease of 3.08±1.08g/dL, requiring a transfusion in 12% of the cases. Three medical complications have been registered in the meantime of the admission, with a relevant case of a confusional syndrome and a fall, which resulted in a non-displaced AG1 periprosthetic fracture. The analysis of the positioning of registered implants with Mako® system shows 40.55±1.53 acetabular inclination degrees and 12.2±3.6 acetabular anteversion degrees. The postoperative image study carried out on patients, are consistent with Mako® s results, as it shows an acetabular inclination of 41.2±1.7 in Rx, as well as acetabular anteversion of 16±4.6 in CT. Hip length variance ranges depending on preoperative values of 3.91mm (SD: 3.9; min -12, max 3) to 1.29mm (SD: 1.96) after surgery registered with Mako®, with an increase of an average hip length of 5.64mm (SD: 3.35). Rx simple study results show a postoperative difference between both hips of 0.5±3.08mm, which is consistent with Mako® results. Native femoral offset was stable after surgery with a showing difference both pre and post operative of the intervened hip of 0.1mm (SD: 3.7), registered with Mako®. Preoperatory modified Harris punctuation was 41.6±13.3, improving to postoperative values of 74.6±9.7 after four months since the surgery. No complications were registered in immediate postoperative (4month).

CONCLUSIONS

Total hip arthroplasty robot-assisted achieves an adequate precision and repeatability of the implant positioning and the postoperative hip dysmetry without showing an increase of associated complications to the technique applied. Surgery time, complications and functional results in a short-time period are similar to conventional techniques applied to great series previously published.

Trends, complications, and readmission of allogeneic red blood cell transfusion in primary total hip arthroplasty in china: a national retrospective cohort study

INTRODUCTION

Decrease in allogenic red blood cell (RBC) transfusion rates following total hip arthroplasty (THA) has been reported in the United States, but whether other countries share the same trend remains unclear. Additionally, the relation of allogenic RBC transfusion to the risk of complications in THA remains controversial. Using the Chinese national inpatient database, the current study aimed to examine trends, complications, charges, and readmission patterns of allogeneic RBC transfusion in THA.

MATERIALS AND METHODS

Patients undergoing primary THA between 2013 and 2019 were included, and then stratified into the transfusion and the non-transfusion group based on the database transfusion records. A generalized estimating equation model was used to investigate trends in transfusion rates. After propensity-score matching, a logistic regression model was used to compare the complications, rates and causes of 30-day readmission between two groups.

RESULTS

A total of 10,270 patients with transfusion and 123,476 patients without transfusion were included. Transfusion rates decreased from 19.11% in 2013 to 9.94% in 2019 (P for trend < 0.001). After matching, no significant differences in the risk of of in-hospital death (odds ratio [OR], 4.00; 95% confidence interval [CI] 0.85-18.83), wound infection (OR 0.72; 95%CI 0.45-1.17), myocardial infarction (OR 1.17; 95%CI 0.62-2.19), deep vein thrombosis (OR 1.25; 95%CI 0.88-1.78), pulmonary embolism (OR 2.25; 95%CI 0.98-5.17), readmission rates (OR 1.07; 95%CI 0.88-1.30) and readmission causes were observed between two groups. However, the transfusion group had higher hospitalization charges than the non-transfusion group (72,239.89 vs 65,649.57 Chinese yuan [CNY], P < 0.001).

CONCLUSIONS

This study found that allogeneic RBC transfusion in THA was not associated with the increased risk of complications and any-cause readmission. However, the currently restrictive transfusion policy should be continued because excessive blood transfusion may increase the socioeconomic burden.

No clinically significant differences in patient-reported outcome measures across total hip arthroplasty approaches

INTRODUCTION

As recent studies demonstrate an ongoing debate surrounding outcomes and complications with respect to different total hip arthroplasty (THA) approaches, patient-reported outcome measures (PROMs) may provide valuable information for clinician and patient decision-making. Therefore, our systematic review aimed to assess how surgical approach influences patient-reported outcomes.

METHODS

5 online databases were queried for all studies published between January 1, 1997 and March 4, 2022 that reported on PROMs across various surgical approaches to THA. Studies reporting on PROMs in primary THA patients segregated by surgical approach were included. Articles reporting on revision THA, hip resurfacing, and arthroscopy were excluded. Mantel-Haenszel (M-H) models were utilised to calculate the pooled mean difference (MDs) and 95% confidence interval (CIs).

RESULTS

No differences between the DAA and other approaches were observed when evaluating HOOS (MD -0.28; 95% CI, -1.98-1.41; p = 0.74), HHS (MD 2.38; 95% CI, -0.27-5.03; p = 0.08), OHS (MD 1.35; 95% CI, -2.00-4.71; p = 0.43), FJS-12 (MD 5.88; 95% CI, -0.36-12.12; p = 0.06), VAS-pain (MD -0.32; 95% CI, -0.68-0.04; p = 0.08), and WOMAC-pain (MD -0.73; 95% CI, -3.85-2.39; p = 0.65) scores. WOMAC (MD 2.47; 95% CI, 0.54-4.40; p = 0.01) and EQ-5D Index (MD 0.03; 95% CI, 0.01-0.06; p = 0.002) scores were found to significantly favour the DAA cohort over the other approaches. Only the EQ-5D index score remained significant following sensitivity analysis.

CONCLUSIONS

Superiority of any 1 approach could not be concluded based on the mixed findings of the present analysis. Although our pooled analysis found no significant differences in outcomes except for those measured by the EQ-5D index, a few additional metrics, notably the WOMAC, HHS, FJS-12, and VAS-pain scores, leaned in favour of the DAA.

The Effect of Obesity on Hemiarthroplasty and Total Hip Arthroplasty for Femoral Neck Fractures

Obesity is a well-recognized global epidemic that can lead to longer operative times as well as a greater technical demand. Despite this, the available literature evaluating the impact of obesity on hip hemiarthroplasty (HA) and total hip arthroplasty (THA) when treating fractures about the femoral neck is scarce. Between 2015 and 2018, we retrospectively reviewed all patients that had a HA or THA performed as treatment for an isolated fracture of the femoral neck. Patients were classified as obese and nonobese depending on current body mass index (BMI) when the index procedure was performed. Preoperative and postoperative variable were obtained from the electronic medical record. A total of 157 patients underwent hip HA or THA for an isolated fracture of the femoral neck. In those patients undergoing HA, obesity was associated with an increase in operative times (P = 0.021) and was associated with a nonsignificant increase in total operating room time (P = 0.088) and duration of anesthesia (P = 0.14). In those patients undergoing THA, obesity was associated with longer operative times (P = 0.043), total operating room time (P = 0.032), and duration of anesthesia (P = 0.045). There were no significant differences in complication rates postoperatively between obese and non-obese patients undergoing either procedure. The treatment of isolated fractures of the femoral neck with HA or THA leads to an increase in operative time without an increase in postoperative complications in obese patients.

Incidence and Clinical Risk Factors of Post-Operative Complications following Primary Total Hip Arthroplasty: A 10-Year Population-Based Cohort Study

Background: Total hip arthroplasty (THA) has become a growing treatment procedure for debilitating hip pathologies. Patients experienced post-operative complications and revision surgeries according to large THA registries. To fully understand the short-term and long-term post-operative outcomes following THA, the purpose of this study is to examine the incidence of post-operative complications following primary THA and to examine how this trend has changed over 10 years within community hospitals in the US using large databases. Methods: This study queried the State Inpatient Database (SID) for primary THA between 2006 and 2015. Individual patients were followed forward in time until the first instance of a post-operative complication. The multivariable logistic regression analyses were computed to examine which post-operative complications were independent predictors of pre-operative comorbidities. Results: Median age of patients was 67 years, and 56% of patients were female. Females with avascular necrosis (AVN) as an indication for THA had a 27% higher risk of complication. Females with osteoarthritis (OA) as an indication for THA had a 6% higher risk of complication. Post-operative complications occurred with higher frequencies in the first two months of THA and the highest risks of THA complications within the first 6 months. Conclusion: The most common indication is OA in elders with primary THA. Females and those of black ethnicity showed the greatest risks of THA complications. Data from our large study can be used to understand post-operative complications and readmissions after THA. Our study also provides data on risk factors associated with these complications.

Femoral head size and surgical approach affect dislocation and overall revision rates in total hip arthroplasty: up to 9-year follow-up data of 269,280 procedures in the Dutch Arthroplasty Register (LROI)

BACKGROUND

Femoral head size and surgical approach might affect the revision rate for dislocation and for any other reason after total hip arthroplasty (THA). We penetrated this question based on registry data with up to 9-year follow-up.

METHODS

269,280 primary THAs documented in the Dutch Arthroplasty Registry (LROI) between 2007 and 2019 were included. Revision rates were calculated by competing risk analyses. Multivariable Cox proportional hazard regression ratios (HR) were used for comparison.

RESULTS

Revisions for dislocation were rare. They were more frequent after posterolateral (1.4% [95% CI, 1.3-1.5]), compared to straight lateral (0.6% [95% CI, 0.5-0.7]), anterolateral (0.6% [95% CI, 0.5-0.7]) and anterior (0.4% [95% CI, 0.3-0.5]) approach. Larger femoral head size decreased the dislocation revision risk: 1.4% [95% CI, 1.3-1.5) for 22-28-mm heads; 0.9% (95% CI, 0.8-1.0) for 32-mm heads; 0.6% (95% CI, 0.6-0.7) for 36-mm heads. For the anterior approach, the HR for both revision for dislocation (0.3, 95% CI, 0.3-0.4) and any other reason (0.8, 95% CI, 0.8-0.9) were lowest compared to other approaches including posterolateral (HR 1). Revision risk for any other reason was highest with anterolateral (HR 1.3 (95% CI, 1.2-1.4)) and straight lateral approach (1.1 [95% CI, 1.0-1.2]).

CONCLUSIONS

The anterior approach might reduce revision rates for both dislocation and all cause revision. Posterolateral approach is associated with a higher risk of dislocation revision but has a lower risk of any other revision. Increasing femoral head size up to 36 mm reduces revision for dislocation and improves overall revision rates for all approaches.

Direct Anterior Versus Posterior Approach for Total Hip Arthroplasty Performed for Displaced Femoral Neck Fractures

OBJECTIVES

To compare perioperative, 90-day, and 1-year postoperative complications and outcomes between the direct anterior approach (DAA) and the posterior approach for total hip arthroplasty in geriatric patients with displaced femoral neck fractures (FNFs).

DESIGN

Retrospective cohort study.

SETTING

Multicenter Health care Consortium.

PATIENTS

Seven-hundred and nine patients 60 years or older with acute displaced FNFs between 2009 and 2021.

INTERVENTION

Total hip arthroplasty using either DAA or posterior approach.

MAIN OUTCOME MEASUREMENTS

Rates of postoperative complications including dislocations, reoperations, and mortality at 90 days and 1 year postoperatively. Secondary outcome measures included ambulation capacity at discharge, ambulation distance with inpatient physical therapy, discharge disposition, and narcotic prescription quantities (morphine milligram equivalents).

RESULTS

Through a multivariable regression analysis, DAA was associated with significantly shorter operative time ( B = -6.89 minutes; 95% confidence interval [CI] -12.84 to -0.93; P = 0.024), lower likelihood of blood transfusion during the index hospital stay (adjusted odds ratios = 0.54; 95% CI 0.27 to 0.96; P = 0.045), and decreased average narcotic prescription amounts at 90 days (B = -230.45 morphine milligram equivalents; 95% CI -440.24 to -78.66; P = 0.035) postoperatively. There were no significant differences in medical complications, dislocations, reoperations, and mortality at 90 days and 1 year postoperatively.

CONCLUSION

When comparing the DAA versus posterior approach for total hip arthroplasty performed for displaced FNF, DAA was associated with shorter operative time, lower likelihood of blood transfusion, and lower 90-day postoperative narcotic prescription amounts.

LEVEL OF EVIDENCE

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

Comparison between supra-inguinal fascia iliaca and pericapsular nerve group blocks on postoperative pain and functional recovery after total hip arthroplasty: A noninferiority randomised clinical trial

BACKGROUND

Pain after a posterolateral approach for total hip arthroplasty (THA) may affect early functional recovery. Supra-inguinal fascia iliaca (SFIB) and pericapsular nerve group (PENG) blocks have been proposed as promising analgesia techniques.

OBJECTIVES

This trial was conducted to compare a PENG with a SFIB for controlling postoperative pain and for providing functional recovery.

DESIGN

Noninferiority monocentric randomised controlled study.

SETTING

One hundred and two patients scheduled for a total hip arthroplasty via the posterolateral approach under spinal anaesthesia were prospectively allocated to two groups. Data acquisition occurred between October 2021 and July 2022 at the University Hospital of Liege.

PATIENTS

One hundred and two patients completed the trial.

INTERVENTIONS

Group SFIB received supra-inguinal fascia iliaca block (SFIB) (40 ml ropivacaine 0.375%), whereas group PENG received a PENG block (20 ml ropivacaine 0.75%).

MAIN OUTCOME MEASURES

Rest and mobilisation pain on a 0 to 10 numeric rating scale at fixed time points: 1 and 6 h after surgery, on day-1 and day-2 at 8 a.m.,1 p.m. and 6 p.m. On day-1 and day-2, evolution of quality-of-recovery-15 score was assessed, and timed-up-and-go, 2 and 6 min-walking tests. The noninferiority margin was set as 1 numeric rating scale point 6 h after surgery.

RESULTS

Six hours after surgery, pain scores in group PENG were noninferior to those of group SFIB, with a difference between medians at 0 (95% CI -0.93 to 0.93). There were no significant differences between the groups regarding rest and dynamic pain trajectories during the first 48 postoperative hours, with no significant effects of group (rest P  = 0.800; dynamic P  = 0.708) or interaction between group and time (rest P  = 0.803; dynamic P  = 0.187). Similarly, no significant differences were observed regarding motor and functional recovery as assessed by timed-up-and-go ( P  = 0.197), 2 min ( P  = 0.364), and 6 min walking ( P  = 0.347) tests and quality-of-recovery-15 ( P  = 0.417) score.

CONCLUSION

Following a total hip arthroplasty via the posterolateral approach, a PENG block is noninferior to SFIB regarding postoperative pain control 6 h after surgery, and functional recovery.

TRIAL REGISTRATION

European Clinical Trial Register under EudraCT-number 2020-005126-28 ( https://www.clinicaltrialsregister.eu/ctr-search/trial/2020-005126-28/BE ).

Surgical approach had minor association with femoral stem migration in total hip arthroplasty: radiostereometric analysis of 61 patients after 5-year follow-up

BACKGROUND AND PURPOSE

Total hip arthroplasty (THA) is usually performed using 1 of 3 surgical approaches: direct lateral (DLA), posterior (PA), or anterior (AA). AA is different from DLA and PA owing to limited intraoperative visibility of the femoral canal. This could affect stem positioning and therefore migration. We aimed to perform an exploratory radiostereometric analysis (RSA) study with 3 groups for surgical approach assessing stem migration up to 5 years postoperatively.

PATIENTS AND METHODS

61 patients with unilateral osteoarthritis of the hip were included. 21 patients were allocated to the DLA, 20 to the PA, and 20 to the AA group. All patients received an uncemented, collarless, double-tapered, fully hydroxyapatite-coated Profemur Gladiator stem. Migration was measured with model-based RSA. Baseline RSA was on day 1 postoperatively. The follow-ups were at day 8, at 5 weeks, and at 3, 6, 12, 24, and 60 months after surgery. Generalized linear mixed models were used to analyze maximum total point motion (MTPM) migrations.

RESULTS

Group mean differences in MTPM were 0.4 mm (95% confidence interval [CI] -1.5 to 2.4) for DLA vs. PA, 1.1 mm (CI -1.0 to 3.3) for AA vs. DLA, and 1.6 mm (CI -0.8 to 3.9) for AA vs. PA, when adjusted for sex and age as covariates. 2 stems in the AA group had excessive early migration. For all stems the migrations occurred mainly within 5-week follow-up and then stabilized.

CONCLUSION

At 5-year follow-up, there were no statistically significant differences in stem migration associated with the 3 surgical approaches used in this study.

Total Hip Arthroplasty in Patients with Bilateral Upper-Limb Amelia: A Report of 2 Cases

CASE

We report two patients, a 43-year-old man and a 26-year-old woman, with bilateral absence of the upper extremity and severe hip osteoarthritis. The involved hip was the dominant extremity for both patients. Total hip arthroplasty (THA) was performed using a posterior approach with dual-mobility implants. Both patients report satisfactory outcomes including the ability to perform the significant range of motion required for daily activities such as toe-to-head motion.

CONCLUSION

In patients with extreme range of motion requirements such as those affected with bilateral upper-limb amelia, a posterior THA with a dual-mobility implant may be safely and successfully performed to treat disabling hip osteoarthritis.

The Fate of the Patient With Superficial Dehiscence Following Direct Anterior Total Hip Arthroplasty

BACKGROUND

Direct anterior approach (DAA) total hip arthroplasty (THA) has been associated with higher rates of superficial incisional dehiscence. However, limited data are available regarding the outcomes following initial treatment of this complication. This study aimed to evaluate patient risk factors, reoperations, and revisions in those who developed superficial wound dehiscence following DAA THA.

METHODS

We identified 3,687 patients who underwent a primary DAA THA between 2010 and 2019 from our enterprise total joint registry. Of these, 98 (2.7%) patients developed a superficial wound dehiscence requiring intervention [irrigation and debridement (n = 42) or wound care with or without antibiotics (n = 56)]. Dehiscence was noted at a median of 27 (range, 2-105) days. These patients were compared to patients who did not have a superficial wound complication (n = 3,589). Landmark survivorship analysis was performed to account for immortal time bias with a 45-day landmark time.

RESULTS

Patients who had superficial wound dehiscence compared to those who did not, were more often women (64 versus 53%, P = .02) and had increased mean body mass index (33 versus 29, P < .001). There was no difference in 4-year survivorship free from any revision between cohorts (97 versus 98%, respectively, P = .14). There were 2 (2.0%) revisions in the superficial dehiscence group: 1 for periprosthetic joint infection and 1 for aseptic femoral loosening.

CONCLUSION

Superficial wound dehiscence following DAA THA was associated with higher body mass index and was more common in women. Fortunately, with proper index management, the risk of revision THA and periprosthetic joint infection was not increased for these patients.

Defining major surgical complications using administrative data in Ontario: a validation study

BACKGROUND

Although surgical complications are often included as an outcome of surgical research conducted using administrative data, little validation work has been performed. We sought to evaluate the diagnostic performance of an algorithm designed to capture major surgical complications using health administrative data.

METHODS

This retrospective study included patients who underwent high-risk elective general surgery at a single institution in Ontario, Canada, from Sept. 1, 2016, to Sept. 1, 2017. Patients were identified for inclusion using the local operative database. Medical records were reviewed by trained clinicians to abstract postoperative complications. Data were linked to administrative data holdings, and a series of code-based algorithms were applied to capture a composite indicator of major surgical complications. We used sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy to evaluate the performance of our administrative data algorithm, as compared with data abstracted from the institutional charting system.

RESULTS

The study included a total of 270 patients. According to the data from the chart audit, 55% of patients experienced at least 1 major surgical complication. Overall sensitivity, specificity, PPV, NPV and accuracy for the composite outcome was 72%, 80%, 82%, 70% and 76%, respectively. Diagnostic performance was poor for several of the individual complications.

CONCLUSION

Our results showed that administrative data holdings can be used to capture a composite indicator of major surgical complications with adequate sensitivity and specificity. Additional work is required to identify suitable algorithms for several specific complications.

No Difference in the Rate of Periprosthetic Joint Infection in Patients Undergoing the Posterolateral Compared to the Direct Anterior Approach

BACKGROUND

There remains inconsistent data about the association of surgical approach and periprosthetic joint infection (PJI). We sought to evaluate the risk of reoperation for superficial infection and PJI after primary total hip arthroplasty (THA) in a multivariate model.

METHODS

We reviewed 16,500 primary THAs, collecting data on surgical approach and all reoperations within 1 year for superficial infection (n = 36) or PJI (n = 70). Considering superficial infection and PJI separately, we used Kaplan-Meier survivorship to assess survival free from reoperation and a Cox Proportional Hazards multivariate models to assess risk factors for reoperation.

RESULTS

Between direct anterior approach (DAA) (N = 3,351) and PLA (N = 13,149) cohorts, rates of superficial infection (0.4 versus 0.2%) and PJI (0.3 versus 0.5%) were low and survivorship free from reoperation for superficial infection (99.6 versus 99.8%) and PJI (99.4 versus 99.7%) were excellent at both 1 and 2 years. The risk of developing superficial infection increased with high body mass index (BMI) (hazard ratio [HR] = 1.1 per unit increase, P = .003), DAA (HR = 2.7, P = .01), and smoking status (HR = 2.9, P = .03). The risk of developing PJI increased with the high BMI (HR = 1.04, P = .03), but not surgical approach (HR = 0.68, P = .3).

CONCLUSION

In this study of 16,500 primary THAs, DAA was independently associated with an elevated risk of superficial infection reoperation compared to the PLA, but there was no association between surgical approach and PJI. An elevated patient BMI was the strongest risk factor for superficial infection and PJI in our cohort.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Functional Outcomes of Anterior-Based Muscle Sparing Approach Compared to Direct Lateral Approach for Total HIP Arthroplasty Following Acute Femoral Neck Fractures

Introduction

Total hip arthroplasty (THA) performed for femoral neck fractures (FNFs) is becoming a more frequent treatment in the active elderly population. Since there is limited research available presenting clinical outcomes after THA using the anterior-based muscle sparing (ABMS) approach, the aim of this study was to compare this surgical approach to the direct lateral (DL) approach in patients treated by THA for FNFs.

Materials and Methods

We retrospectively reviewed the data prospectively collected as a part of our "Hip Fracture Unit" and included 163 patients who underwent THA from January 2016 to January 2019 for acute displaced FNFs.

Results

A total of 132 patients who completed a minimum 2-years follow up (69 in the ABMS group and 63 in DL group) were included. The ABMS group demonstrated significantly shorter time to reach milestone for hospital discharge (1.5 Days vs 2.1 days, P = .018), while no statistically significant differences were detected in peri-operative complications. At 3 months, the timed up and go test, the Harris Hip Score (HHS) and the Oxford ip Score (OHS) were significantly better (P = .024, .032 and .034, respectively) in the ABMS group compared to the DL group. No differences were found in functional outcomes (HHS and OHS) nor in complication rate at 6, 12 and 24 months.

Discussion

This is one of the first studies to analyze functional results of THA performed for FNFs through an ABMS approach. Results are in line with those already present in the Literature.

Conclusion

ABMS approach allows earlier mobilization and better early functional outcomes, compared to DL approach, in patients undergoing THA for acute displaced FNF. No differences are found after 6 months in functional results and complications rate.

Comparison of Perioperative Outcomes and Early Complications Between a Direct Anterior Approach or Posterolateral Approach in Simultaneous Bilateral Total Hip Arthroplasty: A Retrospective Study

Background: Controversies remain on the best surgical approaches for unilateral total hip arthroplasty (THA). There are little data on simultaneous bilateral THA via direct anterior approach (SimBDAA-THA) or posterolateral approach (SimBPA-THA). Purpose: We sought to assess differences in perioperative outcomes and early medical and surgical complications between SimBDAA-THA and SimBPA-THA. Methods: This retrospective study involved patients who underwent either SimBDAA-THA in a supine position (n = 73) or SimBPA-THA in a lateral position (n = 162) at our institution from January 2015 to November 2021. The 2 groups were compared in terms of clinical and demographic characteristics, surgical parameters, and complications during 6-months of follow-up. Results: There were no differences in clinical and demographic characteristics between the 2 groups prior to surgery. Simultaneous bilateral THA via direct anterior approach significantly shortened the length of both the operation (117.50 ±19.42 vs 143.97 ± 32.20 min) and the hospitalization (140.64 ± 43.22 vs 156.24 ± 56.64 h) but increased perioperative loss of hemoglobin (3.28 ± 1.01 vs 3.21 ± 2.26 g/dL). There were no significant differences between the two groups in transfusion rate; levels of interleukin-6, C-reactive protein or creatine kinase; or complications. Conclusion: This retrospective study of patients at a single institution found minimal differences in perioperative outcomes or early medical and surgical complications between SimBDAA-THA and SimBPA-THA except operative time and length of hospitalization. Larger studies with longer follow-up should be conducted to identify whether a direct anterior approach is superior to a posterolateral one.

A Comparison of Radiographic Outcomes after Total Hip Arthroplasty between the Direct Lateral Approach and Posterior Lateral Approach with EOS 2D/3D X-Ray Imaging System

OBJECTIVE

The classical approaches for total hip arthroplasty (THA) are the direct lateral approach (DLA) and posterior lateral approach (PLA). There are few studies comparing implant orientation with these two approaches, and the impact of surgical approaches on implant orientation remains controversial. With the rise of the EOS imaging system, we aimed to use it to identify the differences between and factors associated with implant orientation after THA using DLA and PLA.

METHODS

In our department from January 2019 to December 2021, 321 primary unilateral THAs that used PLA and DLA were enrolled. A total of 201 patients who received PLA and 120 patients who received DLA were included in this study. Two blinded observers measured each case using EOS imaging data. Postoperative imaging metrics and other relevant influencing factors of the two surgical approaches were compared. Postoperative imaging metrics, including the anteversion and inclination of the cup, anteversion of the stem, and combined anteversion were measured based on EOS. Other relevant influencing factors included age, approach, gender, laterality, BMI, anterior pelvic plane inclination, femoral head diameter, femoral offset, lateral pelvic tilt, pelvic incidence, pelvis axial rotation, sacral slope, sagittal pelvic tilt, and surgery time. Multiple linear regression analyses were performed to identify the predictors of acceptability for each imaging data point.

RESULTS

No dislocation was found in the 321 patients who underwent primary THA during this period. The mean anteversion and combined anteversion of the cups using the DLA were 21.33° ± 17.31° (-51.7°-60.8°) and 33.71° ± 20.85° (-38.8°-77.6°) and PLA were 25.34° ± 12.76° (-5.5°-57.0°) and 42.37° ± 18.85° (-8.7°-84.7°), respectively. The DLA group had smaller anteversion (p = 0.038) and combined anteversion (p < 0.001). We found that surgical approach (p < 0.05), anterior pelvic plane inclination (p < 0.001), gender (p < 0.001), and femoral head diameter (p < 0.001) were important factors affecting acetabular cup anteversion (R2  = 0.375) and combined anteversion (R2  = 0.525).

CONCLUSIONS

In total hip arthroplasty, different prosthesis installation directions should be made according to different surgical approaches. Compared with the direct lateral approach, the acetabular anteversion can be intentionally enlarged when using the posterolateral approach. Surgical approach, anterior pelvic plane inclination (APPI), gender, and femoral head diameter were significant predictors of prosthesis orientation. The anterior pelvic plane inclination may be a useful standard for assessing the position of the prosthesis using EOS.

Is the Direct Anterior Approach for Total Hip Arthroplasty Effective in Obese Patients? Early Clinical and Radiographic Results from a Retrospective Comparative Study

Background and objectives: Total hip arthroplasty (THA) in obese patients (BMI > 30) is considered technically demanding, and it is associated with higher rates of general and specific complications including infections, component malpositioning, dislocation, and periprosthetic fractures. Classically, the Direct Anterior Approach (DAA) has been considered less suitable for performing THA surgery in the obese patient, but recent evidence produced by high-volume DAA THA surgeons suggests that DAA is suitable and effective in obese patients. At the authors' institution, DAA is currently the preferred approach for primary and revision THA surgery, accounting for over 90% of hip surgeries without specific patient selection. Therefore, the aim of the current study is to evaluate any difference in early clinical outcomes, perioperative complications, and implant positioning after primary THAs performed via DAA in patients who were divided according to BMI. Material and methods: This study is a retrospective review of 293 THA implants in 277 patients that were performed via DAA from 1 January 2016 to 20 May 2020. Patients were further divided according to BMI: 96 patients were normal weight (NW), 115 were overweight (OW), and 82 were obese (OB). All the procedures were performed by three expert surgeons. The mean follow-up was 6 months. Patients' data, American Society of Anesthesiologists (ASA) score, surgical time, days in rehab unit, pain at the second post-operative day recorded by using a Numerical Rating Scale (NRS), and number of blood transfusions were recorded from clinical charts and compared. Radiological evaluation of cup inclination and stem alignment was conducted on post-operative radiographs; intra- and post-operative complications at latest follow-up were recorded. Results: The average age at surgery of OB patients was significantly lower compared to NW and OW patients. The ASA score was significantly higher in OB patients compared to NW patients. Surgical time was slightly but significantly higher in OB patients (85 ± 21 min) compared to NW (79 ± 20 min, p = 0.05) and OW patients (79 ± 20 min, p = 0.029). Rehab unit discharge occurred significantly later for OB patients, averaging 8 ± 2 days compared to NW patients (7 ± 2 days, p = 0.012) and OW patients (7 ± 2 days; p = 0.032). No differences in the rate of early infections, number of blood transfusions, NRS pain at the second post-operative day, and day of post-operative stair climbing were found among the three groups. Acetabular cup inclination and stem alignment were similar among the three groups. The perioperative complication rate was 2.3%; that is, perioperative complication occurred in 7 out of 293 patients, with a significantly higher incidence of surgical revisions required in obese patients compared to the others. In fact, OB patients showed a higher revision rate (4.87%) compared to other groups, with 1.04% for NW and 0% for OW (p = 0.028, Chi-square test). Causes for revision in obese patients were aseptic loosening (2), dislocation (1), and clinically significant post-operative leg length discrepancy (1), with a revision rate of 4/82 (4.87%) during follow-up. Conclusions: THA performed via DAA in obese patients could be a solid choice of treatment, given the relatively low rate of complications and the satisfying clinical outcomes. However, surgical expertise on DAA and adequate instrumentation for this approach are required to optimise the outcomes.

An Interpretable Machine Learning Model for Predicting 10-Year Total Hip Arthroplasty Risk

BACKGROUND

As the demand for total hip arthroplasty (THA) rises, a predictive model for THA risk may aid patients and clinicians in augmenting shared decision-making. We aimed to develop and validate a model predicting THA within 10 years in patients using demographic, clinical, and deep learning (DL)-automated radiographic measurements.

METHODS

Patients enrolled in the Osteoarthritis Initiative were included. DL algorithms measuring osteoarthritis- and dysplasia-relevant parameters on baseline pelvis radiographs were developed. Demographic, clinical, and radiographic measurement variables were then used to train generalized additive models to predict THA within 10 years from baseline. A total of 4,796 patients were included (9,592 hips; 58% female; 230 THAs (2.4%)). Model performance using 1) baseline demographic and clinical variables 2) radiographic variables, and 3) all variables were compared.

RESULTS

Using 110 demographic and clinical variables, the model had a baseline area under the receiver operating curve (AUROC) of 0.68 and area under the precision recall curve (AUPRC) of 0.08. Using 26 DL-automated hip measurements, the AUROC was 0.77 and AUPRC was 0.22. Combining all variables, the model improved to an AUROC of 0.81 and AUPRC of 0.28. Three of the top five predictive features in the combined model were radiographic variables including minimum joint space along with hip pain and analgesic use. Partial dependency plots revealed predictive discontinuities for radiographic measurements consistent with literature thresholds of osteoarthritis progression and hip dysplasia.

CONCLUSION

A machine learning model predicting 10-year THA performed more accurately with DL radiographic measurements. The model weighted predictive variables in concordance with clinical THA-pathology assessments.

Comparison of the early clinical efficacy of the SuperPath approach versus the modified Hardinge approach in total hip arthroplasty for femoral neck fractures in elderly patients: a randomized controlled trial

PURPOSE

To investigate the clinical efficacy and advantages of the SuperPath approach for total hip arthroplasty in the treatment of femoral neck fractures in the elderly population.

METHODS

From February 2018 to March 2019, 120 patients were randomly divided into two groups with 60 patients each: the SuperPath group and the conventional group. The results evaluated included the general operation situation, serum markers, blood loss, pain score, hip function and prosthesis location analysis.

RESULTS

There was no demographic difference between the two groups. Compared with the conventional group, the SuperPath group had a shorter operation time (78.4 vs. 93.0 min, p = 0.000), a smaller incision length (5.8 vs. 12.5 cm, p = 0.000), less intraoperative blood loss (121.5 vs. 178.8 ml, p = 0.000), a shorter hospitalization time (8.0 vs. 10.8 days, p = 0.000) and less drainage volume (77.8 vs. 141.2 ml, p = 0.000). The creatine kinase level in the SuperPath group was significantly lower than that in the conventional group, while there was no difference in the C-reactive protein level and erythrocyte sedimentation rate level. The visual analog scale score was lower one month postoperatively, and the Harris hip score was higher three months postoperatively in the SuperPath group (p < 0.05). There was no difference in the cup abduction angle or anteversion angle of the two groups.

CONCLUSION

We found better clinical efficacy after using the SuperPath approach with less muscle damage, less postoperative pain and better postoperative function than after using the modified Hardinge approach. Trial registration The randomized clinical trial was retrospectively registered at the Chinese Clinical Trial Registry on 31/12/2020 (ChiCTR-2000041583, http://www.chictr.org.cn/showproj.aspx?proj=57008 ).

Posterior Approach Total Hip Arthroplasty Utilizing a Monoblock Dual-Mobility Construct Without Posterior Hip Precautions: A Series of 580 Hips with One Dislocation

BACKGROUND

Instability remains a devastating complication following total hip arthroplasty (THA). Here we describe a mini-posterior approach with a monoblock dual-mobility implant without "traditional posterior hip precautions" yielding excellent results.

METHODS

There were 580 consecutive hips in 575 patients who underwent THA utilizing a monoblock dual-mobility implant and a mini-posterior approach. With this technique, the acetabular component positioning does not rely on tradition intra-operative radiographic abduction and anteversion goals, but rather uses patient-specific anatomic landmarks (anterior acetabular rim and, when visible, the transverse acetabular ligament) to set cup position; stability is assessed with a significant, dynamic intra-operative test of range of motion. Patients' mean age was 64 years (range, 21 to 94) and 53.7% were women.

RESULTS

Mean abduction was 48.4° (range, 29° to 68°) and mean anteversion was 24.7° (range, -1 to 51°). Patient Reported Outcomes Measurement Information System scores improved in every measured domain from preoperative to final postoperative visit. There were seven (1.2%) patients who required reoperation, with mean time to reoperation of 1.3 months (range, one to 176 days). Only one patient (0.2%) who had a pre-operative history of spinal cord injury and Charcot arthropathy dislocated.

CONCLUSION

A posterior approach hip surgeon may want to consider using a monoblock dual-mobility construct and avoidance of traditional posterior hip precautions to achieve early hip stability with an extremely low dislocation rate and high patient satisfaction scores.

Correlation analysis of Blood TM, TG and D-dimer with deep venous Thrombosis formation in patients after Total Hip Arthroplasty

Objective

To explore the correlation of blood thrombomodulin (TM), triglyceride (TG) and D-Dimer (D-D) with the formation of deep vein thrombosis (DVT) in patients after total hip arthroplasty (THA).

Methods

A retrospective analysis was carried out focusing on the clinical data of 150 patients with THA who were admitted to Sichuan Provincial Orthopedic Hospital from May 2019 to May 2022 (the study group). These patients were then subdivided into Group-A (46 cases with DVT) and Group-B (104 cases without DVT) according to whether DVT occurred after an operation. Meanwhile, another 70 patients who received physical examination in this hospital in the same period were selected as the control group. Furthermore, the levels of TM, TG, D-D, fibrinogen (Fb) and C-reactive protein (CRP) were compared between the groups. Pearson correlation was used to analyze the relationship between the levels of TM, TG, D-D, Fb, CRP and the formation of DVT.

Result

The levels of TM, TG, D-D, Fb and CRP in the study group were significantly higher than those in the control group (p<0.05). The above indicators in Group-A were higher than those in Group-B one day after the operation (p<0.05). Pearson correlation analysis showed that the levels of TM, TG, D-D, Fb and CRP were significantly positively correlated with the formation of DVT.

Conclusion

Patients with DVT after THA show an increase in the levels of TM, TG, D-D, Fb and CRP, indicating their diagnostic value for the formation of DVT. Findings in our study suggest that clinical tests of these indicators can be carried out according to the actual situation of patients.

Peripheral Arterial Disease and Prosthetic Joint Infection Resulting in Hip Disarticulation: A Case Report

Introduction

The aim of this study was to report a patient with refractory prosthetic joint infection (PJI) and severe peripheral arterial disease that necessitated hip disarticulation (HD), a rare and aggressive procedure. While this is not the first HD performed due to PJI, this is the first reported incidence that deals with profound infection burden along with immense vascular disease that has failed all other treatment options.

Case Report

We report a case of an elderly patient with a prior history of the left total hip arthroplasty, PJI, and severe peripheral arterial disease who underwent a rare HD procedure and was discharged with minimal complications. Before this major surgery, several surgical revisions and antibiotic regimens were attempted. The patient had also failed a revascularization procedure to treat an occlusion stemming from the peripheral arterial disease and had developed a necrotic wound at the surgical site. Irrigation and debridement of associated necrotic tissue was unsuccessful and due to concerns such as cellulitis, HD was performed with patient consent.

Conclusion

HD is a rare procedure that comprises only 1-3% of all lower limb amputations and is reserved for extremely deleterious indications such as infection, ischemia, and trauma. Complication and 5 year mortality rates have been reported to be as high as 60% and 55%, respectively. Despite these rates, the patient case illustrates a situation, in which early detection of indications for HD prevented further negative outcomes. Based on this case, we believe that HD is a reasonable treatment of choice in patients with severe peripheral arterial disease who fail revascularization and prior moderate treatment options. However, the limited availability of data involving HD and variety of comorbid conditions necessitate further analysis in terms of outcomes.

The Safety and Efficacy of the Anterior Approach Total Hip Arthroplasty as per Body Mass Index

BACKGROUND

Obesity is associated with component malpositioning and increased revision risk after total hip arthroplasty (THA). With anterior approaches (AAs) becoming increasingly popular, the goal of this study was to assess whether clinical outcome post-AA-THA is affected by body mass index (BMI).

METHODS

This multicenter, multisurgeon, consecutive case series used a prospective database of 1,784 AA-THAs (1,597 patients) through bikini (n = 1,172) or standard (n = 612) incisions. Mean age was 63 years (range, 20-94 years) and there were 57.5% women, who had a mean follow-up of 2.7 years (range, 2.0-4.1 years). Patients were classified into the following BMI groups: normal (BMI < 25.0; n = 572); overweight (BMI: 25.0-29.9; n = 739); obese (BMI: 30.0-34.9; n = 330); and severely obese (BMI ≥ 35.0; n = 143). Outcomes evaluated included hip reconstruction (inclination/anteversion and leg-length, complications, and revision rates) and patient-reported outcomes including Oxford Hip Scores (OHS).

RESULTS

Mean postoperative leg-length difference was 2.0 mm (range: -17.5 to 39.0) with a mean cup inclination of 34.8° (range, 14.0-58.0°) and anteversion of 20.3° (range, 8.0-38.6°). Radiographic measurements were similar between BMI groups (P = .1-.7). Complication and revision rates were 2.5% and 1.7%, respectively. The most common complications were fracture (0.7%), periprosthetic joint infection (PJI) (0.5%), and dislocation (0.5%). There was no difference in dislocation (P = .885) or fracture rates (P = .588) between BMI groups. There was a higher rate of wound complications (1.8%; P = .053) and PJIs (2.1%; P = .029) among obese and severely obese patients. Wound complications were less common among obese patients with the 'bikini' incision (odds ratio 2.7). Preoperative OHS was worse among the severely obese (P < .001), which showed similar improvements (Change in OHS; P = .144).

CONCLUSION

AA-THA is a credible option for obese patients, with low dislocation or fracture risk and excellent ability to reconstruct the hip, leading to comparable functional improvements among BMI groups. Obese patients have a higher risk of PJIs. Bikini incision for AA-THA can help minimize the risk of wound complications.

The Dopamine D1 Receptor Attenuates Titanium Particle-Induced Inhibition of Osteogenesis by Activating the Wnt Signaling Pathway

Periprosthetic osteolysis (PPO), caused by wear particles, has become a major cause of joint replacement failure. Secondary surgery after joint replacement poses a serious threat to public health worldwide. Therefore, determining how to effectively inhibit wear particle-induced PPO has become an urgent issue. Recently, the interaction between osteogenic inhibition and wear particles at the biological interface of the implant has been found to be an important factor in the pathological process. Previous studies have found that the central nervous system plays an important role in the regulation of bone formation and bone remodeling. Dopamine (DA), an important catecholamine neurotransmitter, plays an integral role in the physiological and pathological processes of various tissues through its corresponding receptors. Our current study found that upregulation of dopamine first receptors could be achieved by activating the Wnt/β-catenin pathway, improving osteogenesis in vivo and in vitro, and significantly reducing the inhibition of titanium particle-induced osteogenesis. Overall, these findings suggest that dopamine first receptor (D1R) may be a plausible target to promote osteoblast function and resist wear particle-induced PPO.