Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation

The push-through total femoral prosthesis for revision of a total hip or knee replacement with extreme bone loss

PURPOSE

The aim of the present study was to assess outcomes of using the push-through total femoral prothesis (PTTF) for revision total hip replacement with extreme bone loss.

METHODS

10 consecutive patients who received PTTF between 2012 and 2018 for revision hip arthroplasty were included in the study. Primary functional outcomes were assessed using Harris Hip Score (HHS), Toronto Extremity Salvage Score (TESS) and Musculoskeletal Tumor Society (MSTS) scores. Range of motion, complications, and ambulatory status were also recorded to assess secondary outcomes.

RESULTS

2 of 10 patients underwent surgery with PTTF for both knee and hip arthroplasty revision. The mean time between index surgery and PTTF was 15 years (3-32 yrs). Acetabular components were revised in 6 of 10 patients during PTTF application. After a mean follow-up of 5.9 years, hip dislocations occurred in 3 patients. All of the dislocated hips were ones with retained conventional non-constrained acetabular bearings. Patient satisfaction was high (MSTS: 67%, HHS: 61.2%, TESS 64.6%) despite high re-operation rate (40%) and minor postoperative problems.

CONCLUSIONS

PTTF should be considered for hip and knee arthroplasty revision procedures in patients with an extreme bone defect. Consistent usage of constrained liners should be considered to avoid hip dislocation, which was our main problem following the procedure.

First 100 total hip arthroplasties performed by a young surgeon using the direct anterior approach: learning curve and complications

INTRODUCTION

Most of the reported discussions about the learning curve for the direct anterior approach (DAA) in total hip arthroplasty (THA) have been by experienced surgeons. The study's aim was to describe the learning curve, short-term outcomes, complications, and adaptations to the DAA used in the first 100 THA cases experienced by a young surgeon who had received DAA training for trauma surgeries.

MATERIALS AND METHODS

This retrospective study summarizes the first 100 consecutive cases experienced by a young surgeon who performed the unilateral DAA for THA between 2019 and 2021. Cumulative sum (CUSUM) analysis was performed to evaluate the learning curve on the basis of operative time and overall complications. The demographics data, short-term outcomes, and complications of the first 50 and second 50 cases were compared.

RESULTS

The CUSUM curve declined after 49 and 55 cases, measured by operative time and overall complications, respectively. The median operative time (104 vs. 80 min) and intraoperative fluoroscopic time (38 vs. 12 s) increased significantly in the first 50 cases compared with the times in the second 50 cases. Complications tended to occur in the first 50 cases (12% vs. 6%), and the overall rate was 9%. Major complications all occurred in the first 50 cases, with a rate of 4%. Only one case, which involved a complicated periprosthetic fracture around the stem that extended to the tip, required the intervention of a senior surgeon.

CONCLUSIONS

Even after receiving training on the DAA for trauma surgeries, the young surgeon experienced a steep learning curve and more complications in the first 50 cases. The DAA for THA is a technically demanding procedure and may require guidance from an experienced surgeon to manage unexpected complications.

The Development and Early Experience of a Destination Center of Excellence Program for Total Joint Arthroplasty

High-volume total joint arthroplasty centers are becoming designated as destination centers of excellence to ensure quality of care while containing costs. This study aimed to evaluate the surgical patient journey through a new destination center of excellence program, review acute perioperative course trajectories, and report clinical outcomes. Our institution developed and implemented a destination center of excellence program to integrate into the existing total joint arthroplasty practice. A retrospective record review and analysis were performed for the first 100 destination center of excellence total knee arthroplasties and total hip arthroplasties enrolled in the program to evaluate program efficacy at a minimum 1-year follow-up. The study initially screened 213 patients, of whom 100 (47%) met program criteria and completed surgery (67 total knee arthroplasties and 33 total hip arthroplasties). The complication rate was 2%, and five patients (7.5%) required manipulation under anesthesia for stiffness after total knee arthroplasty. Two reoperations were needed: a neurectomy after total knee arthroplasty and a revision after total hip arthroplasty. The early experience of a destination center of excellence program has been favorable, with low complication rates and excellent outcomes.

Driving Simulator Brake Reaction Parameters After Total Hip Arthroplasty According to Different Surgical Approaches

BACKGROUND

The aim of this study is to validate the point of normalization of braking following total hip arthroplasty (THA) and to determine the relevance of the surgical approach.

METHODS

Brake reaction parameters (BRPs), including brake reaction time, total brake time, and brake pedal depression force were measured in 90 patients who underwent primary arthroplasty of the right hip (42 with direct anterior approach and 48 with posterolateral approach) using a modern driving simulator. The driving parameters were measured preoperatively and every 2 weeks postoperatively until the eighth week. BRPs were measured in 40 subjects without hip problems, and the results were used as a control. Statistical assessment was performed to analyze when the patients' reaction to braking recovered to that of the control group with respect to different surgical approaches and also according to the pain.

RESULTS

Preoperative BRPs of the patients undergoing THA were prolonged compared to the control group and were normalized at the sixth week following the operation. Although BRPs of the direct anterior approach group showed significantly better improvement compared to the posterolateral approach group (total brake time at week 2, brake reaction time and brake pedal depression at week 4), both groups reached baseline value at week 6. In addition, we found no correlation between the pain score and BRPs.

CONCLUSION

The results of the current study indicate that the response to braking events normalizes at 6 weeks following THA in young active patients and is irrelevant to the surgical approach.

Long-term survival of CLS Spotorno femoral stem: a systematic review of literature

BACKGROUND

CLS Spotorno is a time-tested femoral stem design with excellent early results; the present review was designed to assess the published evidence on CLS Spotorno stem in the literature to evaluate its long-term outcomes and compare it to two other popular stem designs the uncemented Corail™ and the cemented Exeter™ stems.

RESEARCH QUESTION

Do CLS Spotorno stems provide adequate long-term rates of survival in terms of revisions and functional outcomes?

METHODOLOGY

Medline, EMBASE and SCOPUS databases were searched for relevant articles and a total number of 670 hits were obtained, out of which 14 relevant studies were included in this review. Pooled analysis of revisions rates, subsidence and Harris Hip scores (HHS) were done.

RESULTS

All the 14 studies were retrospective in design but had sufficiently large follow-up periods (12.3-27 years, mean 17.1 years). Of the 2459 hips reviewed, the documented revision rate was only 6.2%, with aseptic loosening reported in 3.1% and subsidence > 2 mm in 2.6% cases. The overall survival was similar to reported smaller cohorts of Corail (95% at 12 years) and Exeter stems (100% at 17 years). Varus malposition was seen in 10.6% cases, but it did not show any influence on implant survival or revision rates. Distal pedestal formation was seen in 172 of 805 hips across seven studies, while distal cortical hypertrophy was seen in 70 cases out of 398 hips; these were not related with stem malposition. The overall functional outcome was good, with mean HHS of 88.65 (95% CI = 86.08-91.23, p < 0.01). The improvement in scores from preoperative values (of 43.9 points) were comparable to Corail (43.8) and Exeter (45) stems. Thigh pain was seen in only 41 cases out of 1097 hips.

CONCLUSION

Despite the limitations due to high heterogeneity of the cumulative data, the review suggests that CLS Spotorno femoral stems provides excellent long-term survival and good hip function. These outcomes are comparable to other commonly utilized femoral stems like the Corail and Exeter.

LEVEL OF EVIDENCE

IV.

Proximal Femoral Nail versus Proximal Femoral Nail Antirotation: Functional and Radiological Outcome in Intertrochanteric Fractures of Femur

Introduction

Newer implant designs such as Proximal Femoral Nail (PFN) and Proximal Femoral Nail Antirotation (PFN-A) have shown promising results in the treatment of intertrochanteric fractures. Despite the availability of various implants for the treatment of these fractures, there is no common consensus as to which implant would be ideal. Therefore, there is a need for further clinical trials to establish the biomechanical and functional outcome superiority of implants such as PFN and PFN-A, especially among osteoporotic patients.

Aim

To compare the functional and radiological outcomes in intertrochanteric patients treated with PFN and PFN-A.

Methodology

A total of 152 intertrochanteric fracture patients were included in this retrospective study, 94 in the PFN group and 58 in the PFN-A group. The postoperative radiological outcome was assessed and compared using parameters such as tip-apex distance (TAD), Cleveland index, neck-shaft angle, and type of reduction. Operative time for the procedure, pre and postoperative hemoglobin levels were recorded and compared. Fracture union rates were compared at six weeks and six months. Functional outcome was compared between the two groups at follow-up period of 6 months using Harris Hip Score (HHS) and pre and postoperative Parker Palmer Mobility Score (PPS). Complication rates were compared between the two groups. Also, osteoporotic patients were evaluated using the same parameters.

Results

The radiological parameters were similar in both groups. There was a shorter operative time and better hemoglobin levels after surgery in the PFN-A group. The complication rate in the PFN group was 7.4% when compared to the PFN-A group which was just 1.7%. The functional outcome based on HHS and PPS was alike in the two groups. In osteoporotic patients randomized based on Singh’s index, better union rates were observed in the PFN-A group and a higher complication rate was seen in the PFN group.

Conclusion

Cephalomedullary nailing using PFN-A is superior to PFN in terms of a lesser procedure time, minimal blood loss, and fewer complications even among osteoporotic patients. The radiological specifications such as neck-shaft angle post-surgery, reduction type, TAD, and Cleveland index is of paramount importance which is established in this study.

Functional and radiological outcomes after treatment with custom-made acetabular components in patients with Paprosky type 3 acetabular defects: short-term results

BACKGROUND

Severe acetabular defects require special treatment with either impaction bone grafting, metal augmented cups or cup-cage constructs. Even these options are often not adequate, especially in hips with Paprosky type 3 defects with loss of anterior and posterior columns. This study investigates the clinical and radiological outcomes of custom-made acetabular components (© Materialise NV, Leuven, Belgium) for Paprosky type 3 defects.

METHODS

Sixteen patients were eligible for this trial, nine of whom agreed to be included. All of them completed one year of follow-up. The Harris hip score and the Oxford hip score were used to compare pre- and postoperative functional outcomes. Radiological follow-up comprised anteversion and inclination of the implanted cup and offset measurements in both hips (femoral, medial, ischial offset and center of rotation). Statistical analyses were performed with IBM SPSS Statistics.

RESULTS

The mean follow-up time of the nine patients was 12.2 months (range: 10-18). The Oxford hip score and Harris hip score improved from 19.8 and 50.1 to 29.4 and 68.8, respectively (p = 0.009 and 0.01). There were complications in three cases (33.3%), which led to one re-revision (11.1%). Radiologic follow-up showed restoration of the height of the center of rotation and of the global offset. Significant difference was detected in the femoral offset.

CONCLUSIONS

The functional and radiological outcomes are promising. However, long-term outcomes still need to be examined.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Outcomes of Femoral Neck Fractures Treated with Cannulated Internal Fixation in Elderly Patients: A Long-Term Follow-Up Study

Objectives

To evaluate the long‐term efficacy of cannulated internal fixation in patients who sustain femoral neck fracture (FNF) and risk factors influencing the outcomes.

Methods

This retrospective study analyzed data from 73 elderly patients aged ≥60 years old, hospitalized for FNF and treated with cannulated internal fixation between August 2008 and July 2016. The inclusion criteria were: (i) patients aged ≥60 years; (ii) patients with recent femoral neck fracture, with times of injury ranging from 12–72 h; and (iii) patients who underwent Garden II–IV closed reduction and internal fixation. Patients were classified based on the Garden fracture type and Pauwels angle. Clinical data and radiographs before and after the surgery were collected. Subsequently, surgery was performed with the patient in supine position, under general or lumbar epidural anesthesia. Closed reduction was performed until satisfactory fracture reduction quality was achieved. The weight of all included patients were <75 kg, and thus, minimal internal fixation was performed. The ischemic necrosis of the femoral head was diagnosed by considering the symptoms, signs, and radiological findings. Harris hip scores were used to evaluate postoperative recovery of hip function. Furthermore, relationships between Garden fracture type and necrosis rate of the femoral head, Pauwels angle and necrosis rate of the femoral head, Garden fracture type and Harris hip score, and age and Harris hip score were analyzed.

Results

The mean duration of surgery was 1 ± 0.17 h and blood loss for all the patients was approximately 15 mL. The included patients were followed up for 13–128 months, with an average follow‐up of 61 months. Among the included 73 patients, 65 (89.0%) exhibited satisfactory union, seven (9.6%) had femoral head necrosis, and one (1.4%) had nonunion. For seven patients with femoral head necrosis, there were two, two, and three patients classified as Garden IV, Garden III, and Garden II, respectively, and two and five patients classified as Pauwels II and Pauwels III, respectively. Among the seven cases, four underwent hip replacement. Garden fracture type was not significantly associated with femoral head necrosis (χ² = 0.44, P > 0.05) or Harris score (χ² = 1.43, P > 0.05). Patients with Pauwels I (0%) and II (4.3%) fractures exhibited a significantly lower necrosis rate than those with Pauwels III fractures (41.7%) (P < 0.05).

Conclusions

Cannulated internal fixation was more suitable for older Chinese patients with Pauwels I/II fractures than those with Pauwels III fractures.

Three-year results of a polycarbonate urethane acetabular bearing in total hip arthroplasty

BACKGROUND

Polycarbonate urethane (PCU) is a bearing surface with a lower modulus of elasticity than polyethylene or ceramic and is thought to more closely replicate the tribology of native hyaline cartilage. The purpose of this study was to determine the clinical outcomes with the use of PCU in elective total hip arthroplasty (THA).

METHODS

We carried out a prospective observational study in which 157 patients underwent elective THA with a metal-on-PCU hip system. Patients had radiographic follow-up at 6 months and 3 years after surgery. Oxford Hip Scores and EuroQol scores were obtained annually and Harris Hip Scores were obtained at 6 months and 3 years after surgery.

RESULTS

180 hips were implanted, of which, 149 hips reached 3-year review with no revisions. There was an increase in Harris Hip Scores, Oxford Hip Scores and EuroQol scores (p < 0.001). 12 patients (12 hips) reported painless hip squeaking. There were no dislocations and no other adverse events were reported.

CONCLUSION

Our results showed satisfactory survivorship and improvements in patient reported outcomes with metal on PCU THA. Long-term data are still being collected to confirm these findings. We recommend further tribological research into the squeaking phenomenon we observed.

Reconstruction of Paprosky type IIIB acetabular bone defects using a cup-on-cup technique: A surgical technique and case series

BACKGROUND

Paprosky type IIIB acetabular bone defects are very difficult to reconstruct. For severe defects, we developed our own cup-on-cup technique. We defined the tantalum metal (TM) revision shell with the peripheral titanium ring removed as a TM-cup augment and the cementless hemispherical acetabulum component combined with a TM-cup augment as the cup-on-cup technique.

AIM

To report the short-term results of patients with type IIIB acetabular bone defects reconstructed using the cup-on-cup technique.

METHODS

We retrospectively reviewed six patients (six hips) with a mean age of 59 years who underwent acetabular reconstruction using our cup-on-cup technique between January 2015 and January 2017. All acetabular bone defects were classified as type IIIB without pelvic discontinuity using the system of Paprosky. All patients were followed both clinically and radiographically for a mean duration of 42 mo.

RESULTS

The mean Harris hip score improved from 32.4 pre-operatively to 80.7 at the last follow-up. The mean vertical position of the hip rotation centre changed from 60.9 mm pre-operatively to 31.7 mm post-operatively, and the mean horizontal position changed from 33.6 mm pre-operatively to 38.9 mm post-operatively. Greater trochanteric migration after extended trochanteric osteotomy occurred in one of six hips at 3 mo. There was no evidence of component migration at the last follow-up.

CONCLUSION

The short-term results suggest that our cup-on-cup technique could be considered an effective management option for Paprosky type IIIB acetabular bone defects without pelvic discontinuity.

PROMIS Versus Legacy Patient-Reported Outcome Measures in Patients Undergoing Surgical Treatment for Symptomatic Acetabular Dysplasia

BACKGROUND

No previous study has investigated how the Patient-Reported Outcomes Measurement Information System (PROMIS) performs compared with legacy patient-reported outcome measures in patients with symptomatic acetabular dysplasia treated with periacetabular osteotomy (PAO).

PURPOSE

To (1) measure the strength of correlation between the PROMIS and legacy outcome measures and (2) assess floor and ceiling effects of the PROMIS and legacy outcome measures in patients treated with PAO for symptomatic acetabular dysplasia.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

This study included 220 patients who underwent PAO for the treatment of symptomatic acetabular dysplasia. Outcome measures included the Hip disability and Osteoarthritis Outcome Score (HOOS) pain, HOOS activities of daily living (ADL), modified Harris Hip Score (mHHS), PROMIS pain, and PROMIS physical function subsets, with scores collected preoperatively and/or postoperatively at a minimum 12-month follow-up. The change in mean scores from preoperatively to postoperatively was calculated only in a subgroup of 57 patients with scores at both time points. Distributions of the PROMIS and legacy scores were compared to evaluate floor and ceiling effects, and Pearson correlation coefficients were calculated to evaluate agreement.

RESULTS

The mean age at the time of surgery was 27.7 years, and 83.6% were female. The mean follow-up time was 1.5 years. Preoperatively, neither the PROMIS nor the legacy measures showed significant floor or ceiling effects. Postoperatively, all legacy measures showed significant ceiling effects, with 15% of patients with a maximum HOOS pain score of 100, 29% with a HOOS ADL score of 100, and 21% with an mHHS score of 100. The PROMIS and legacy instruments showed good agreement preoperatively and postoperatively. The PROMIS pain had a moderate to strong negative correlation with the HOOS pain (r = -0.66; P < .0001) and mHHS (r = -0.60; P < .0001) preoperatively and the HOOS pain (r = -0.64; P < .0001) and mHHS (r = -0.64; P < .0001) postoperatively. The PROMIS physical function had a moderate positive correlation with the HOOS ADL (r = 0.51; P < .0001) and mHHS (r = 0.49; P < .0001) preoperatively and a stronger correlation postoperatively with the HOOS ADL (r = 0.56; P < .0001) and mHHS (r = 0.56; P < .0001).

CONCLUSION

We found good agreement between PROMIS and legacy scores preoperatively and postoperatively. PROMIS scores were largely normally distributed, demonstrating an expanded ability to capture variability in patients with improved outcomes after treatment.

The outcome of arthroscopic repair of acetabular labral tears using the iHOT-33

Background

The purpose of this study was to determine patient reported outcome measures (PROMS) after arthroscopic repair of an isolated labral tear using the validated International Hip Outcome Tool (iHOT-33). The iHOT-33 specifically measures (1) symptoms and functional limitations, (2) sport and recreation limitations, (3) job related concerns and social and (4) emotional and lifestyle concerns.

Methods

A retrospective review was performed on 45 procedures in 43 patients between September 2012 and September 2015. Two patients had bilateral isolated labral tears. Patients were excluded if they were younger than 18 years, had prior ipsilateral hip surgery and had radiological or arthroscopic evidence of femoroacetabular impingement (FAI), hip dysplasia or other bony dysmorphism.

Results

Of the 43 patients undergoing arthroscopy there were 29 right and 16 left hips repaired. There were 34 females and 9 males. The mean age at surgery was 37.4 years (range 19–63 years) with a mean follow up of 1.7 years (range 1.0–2.6 years). At follow up the mean total iHOT-33 score improved from 34.1 to 67.3 (p < 0.02). The mean improvement was 33.2 (p = < 0.02). Significant improvements were described in all 4 iHOT-33 sub sections.

Conclusion

The study showed statistically significant favourable outcomes in selected patients with short follow-up for patients that underwent hip arthroscopy for an isolated labral tear using the validated iHOT-33.

Level of Evidence

IV, retrospective non-randomised study.

Development of the Italian version of the High-Activity Arthroplasty Score (HAAS-I) following hip and knee total arthroplasty: cross-cultural adaptation, reliability, validity and sensitivity to change

BACKGROUND

The number of physically active individuals who develop knee and hip arthritis and who undergo arthroplasties of these joints ie ever increasing. It has become necessary to develop evaluation scales which address the specific issues raised by such individuals. The High Activity Arthroplasty Score is one such scales, originally developed in English.

METHODS

The HAAS-I was developed by means of forward-backward translation, a final review by an expert committee and a test of the pre-final version to establish its correspondence with the original English version. The psychometric testing included reliability by means of internal consistency (Cronbach's alpha) and test-retest reliability (intraclass correlation coefficients) and construct validity by Pearson's correlations with a pain intensity numerical rating scale (NRS), the Western Ontario and McMaster University index (WOMAC, for THA subjects), the Knee injury and Osteoarthritis Outcome Scale (KOOS; for TKA subjects) and the Short-Form 36 Health Survey (SF-36).

RESULTS

The questionnaire was administered to 67 subjects with THA and 61 with TKA and proved to be acceptable. The questionnaire showed good internal consistency (0.85 for THA and 0.91 for TKA) and a high level of test-retest reliability (ICC = 0.97 with 95% CI 0.95-0.98 for THA; ICC = 0.95 with 95% CI 0.92-0.98 for TKA). There was a moderate correlation between the HAAS-I and NRS (r = - 0.40), there was a high correlation between the HAAS-I and WOMAC (r = - 0.68) and there were moderate to high correlations between the HAAS-I and SF-36 subscales (r = 0.34 to 0.63) for THA. There was a moderate correlation between the HAAS-I and NRS (r = - 0.77); there was a high correlation between the HAAS-I and KOOS subscales (r = - 0.79 to r = - 0.91); and there were low correlations between the HAAS-I and SF-36 subscales (r = 0.01 to 0.29) for TKA.

CONCLUSIONS

The HAAS-I was successfully translated into Italian and proved to have good psychometric properties that replicated the results of existing versions. Its use is recommended for clinical and research purposes.

Nineteen Years Review of Hydroxyapatite Ceramic Coated Hip Implants: A Clinical and Histological Evaluation

The goal of hip arthroplasty is to restore the patient to an active and pain free life for ever. Unfortunately, prosthetic implants fail because of loosening, wear or infection. This study sets out to ascertain whether or not Hydroxyapatite hip arthroplasty (HA) will produce long-lasting function of at least ten years in unselected patients of all ages and all diagnoses. Cemented implants used in hip arthroplasty often loosen after ten or more years of use. This is partly mechanical but also associated with debris disease arising from plastic wear products. Cementing techniques have been improved and the Swedish Hip Register [1] demonstrates that the revision rates have been reduced with improved cementing techniques. Revision surgery after cemented arthroplasty is difficult and may be complicated by fracture of the host bone Bioactive materials are being used to secure joint implants [2,3] and this paper presents the results of a consecutive series of hip arthroplasties carried out over a total period of over 19 years using the Furlong Hydroxyapatite Ceramic Coated hip prosthesis.[4, 5]

16 Year Review of Hydroxyapatite Ceramic Coated Hip Implants - A Clinical and Histological Evaluation

Traditionally implants for hip arthroplasty are secured with bone cement. Problems have been encountered with cement fixation with loosening and osteolysis attributed to the reaction to particulate cement material and also polyethylene debris from wear. Cementing techniques have been improved and the Swedish Hip Register [1] demonstrates that the revision rates have been reduced with improved cementing techniques. However, uncemented hip arthroplasty is now having a revival. In particular, bioactive materials are being used and this paper presents the results of a consecutive series of hip arthroplasties carried out over a total period of just 16 years. All the patients are included, including primary and revision hip arthroplasty. Patients are assessed using the Harris Hip Score [2]. 13% of the hips scored less than 80 on the Harris Hip Score but only 9.4% scored poor pain scores. These represent the results of poor hip arthroplasty, of which an even smaller percentage are related to failed HA hip arthroplasty.