Assessment and management of chronic pain in patients with stable total hip arthroplasty

Minimum effective concentration of ropivacaine for ultrasound-guided transmuscular quadratus lumborum block in total hip arthroplasty: a randomized clinical trial

OBJECTIVE

This trial aimed to identify the Minimum Effective Concentration (MEC90, defined as the concentration which can provide successful block in 90% of patients) of 30 mL ropivacaine for single-shot ultrasound-guided transmuscular Quadratus Lumborum Block (QLB) in patients undergoing Total Hip Arthroplasty (THA).

METHODS

A double-blind, randomized dose-finding study using the biased coin design up-and-down sequential method, where the concentration of local anesthetic administered to each patient depended on the response from the previous one. Block success was defined as a Numeric Rating Scale (NRS) score during motion ≤ 3 at 6 hours after arrival in the ward. If the block was successful, the next subject received either a 0.025% smaller dose (probability of 0.11) or the same dose (probability of 0.89); otherwise, the next subject received a 0.025% higher ropivacaine concentration. MEC90, MEC95 and MEC99 were estimated by isotonic regression, and the corresponding 95% Confidence Intervals (95% CIs) were calculated by the bootstrapping method.

RESULTS

Based on the analysis of 52 patients, MEC90, MEC95, and MEC99 of ropivacaine for QLB were estimated to be 0.352% (95% CI 0.334-0.372%), 0.363% (95% CI 0.351-0.383%), and 0.373% (95% CI 0.363-0.386%). The concentration of ropivacaine at 0.352% in a volume of 30 ml can provide a successful block in 90% of patients.

CONCLUSIONS

For ultrasound-guided transmuscular QLB in patients undergoing THA, 0.352% ropivacaine in a volume of 30 ml can provide a successful block in 90% of patients. Further dose-finding studies and large sample size are required to verify the concentration.

A Comprehensive Review of Total Hip Arthroplasty Outcomes in Post-traumatic Hip Arthritis: Insights and Perspectives

Post-traumatic hip arthritis presents a challenging condition characterized by degenerative changes in the hip joint following traumatic injury. Total hip arthroplasty (THA) is a cornerstone in managing this condition, offering significant pain relief, functional improvement, and enhanced quality of life. This comprehensive review aims to synthesize existing literature to elucidate the outcomes of THA in post-traumatic hip arthritis, exploring factors influencing surgical success and identifying areas for further research. Key findings reveal favourable clinical outcomes associated with THA, though considerations such as patient characteristics, surgical techniques, and implant selection impact outcomes. Implications for clinical practice underscore the importance of tailored preoperative assessment and ongoing advancements in surgical approaches and implant technology. Furthermore, opportunities for future research lie in long-term durability studies, patient-reported outcomes assessment, and exploration of innovative surgical techniques. Overall, THA emerges as a promising intervention for post-traumatic hip arthritis, yet continual refinement through research and innovation remains imperative to optimize patient care in this population.

Improvement of Hip Pain After Total Hip Arthroplasty With Dry Needling as an Adjunct to Conventional Physiotherapy: A Case Series

While total hip arthroplasty (THA) is one of the most common and successful orthopedic surgeries, some patients may experience persistent, recurrent, or new hip pain despite successful THA. Dry needling (DN) is a common treatment for musculoskeletal pain, yet little data has been published on the use of DN on hip pain after THA. This series highlights two patients with prior THA and current hip pain that improved with DN used alongside conventional physiotherapy exercises. Patient 1, a 70-year-old male four years post left THA, presented to a physical therapist with a three-year history of left hip pain. Patient 2, a 65-year-old female 10 years post right THA, presented with a one-month history of right hip pain after a fall. Both patients were reported to have a stable prosthesis without clinical or radiological evidence of loosening or other major complications. Examination of both patients revealed decreased hip range of motion, decreased hip strength, and lateral hip trigger points suggestive of a muscular origin of pain. The physical therapist treated both patients with DN alongside strengthening and stretching exercises, yielding significant improvements in pain severity, function, and range of motion. These cases illustrate the successful use of DN alongside conventional physiotherapy to alleviate hip pain in patients with previous THA. Further research is needed to examine the efficacy and safety of DN for hip pain in individuals with prior THA.

Accuracy of a Three-Dimensional (3D)-Printed Patient-Specific (PS) Femoral Osteotomy Guide: A Computed Tomography (CT) Study

Femoral neck osteotomy creates a critical anatomical landmark for surgeons performing primary Total Hip Arthroplasty (THA); it affects the final height and position of the femoral component. Patient Specific Instrumentation (PSI) has been developed to guide the osteotomy. We aimed to assess the accuracy of a patient-specific (PS) femoral osteotomy guide in primary THA using three-dimensional (3D) computed tomography (CT) analysis. We included pre- and post-operative CT data of 103 THAs. All patients underwent 3D planning to define the optimal femoral neck osteotomy level. Our primary objective was to quantify the discrepancy between the achieved and planned osteotomy level; our secondary objective was to evaluate the clinical outcome. The median (Interquartile Range—IQR) discrepancy between the achieved and planned osteotomy level was 0.3 mm (−1 mm to 2 mm). We found a strong positive correlation between the planned and achieved osteotomy level (R2 = 0.9, p < 0.001). A satisfactory clinical outcome was recorded. Our findings suggest that surgeons can use 3D-printed PS guides to achieve a femoral neck osteotomy with a high level of accuracy to the plan.

Screw penetration of the iliopsoas muscle causing late-onset pain after total hip arthroplasty: A case report

BACKGROUND

Postoperative pain following total hip arthroplasty (THA) may occur in a few patients but may pose a significant challenge to surgeons if the etiology is not identified. Herein, we report the case of a patient who developed late-onset pain following THA due to screw penetration of the iliopsoas tendon.

CASE SUMMARY

We report the case of a 77-year-old man who developed inguinal pain 7 years after THA. While the symptoms resembled that of iliopsoas impingement by the acetabular cup, the pain resolved only when the supplementary acetabular screw protruding through the ilium was decompressed. Decompression was performed using the pararectus approach. The patient was able to ambulate pain-free immediately after surgery.

CONCLUSION

A protruded screw through the ilium may penetrate the iliopsoas muscle, causing pain following THA. Pain may resolve with the decompression of the protruded screw.

Fluorodeoxyglucose Positron-Emission Tomography/Computed Tomography and Magnetic Resonance Imaging for Adverse Local Tissue Reactions near Metal Implants after Total Hip Arthroplasty: A Preliminary Report

Background

Plain computed tomography (CT) and magnetic resonance imaging (MRI) are useful for diagnosing adverse local tissue reactions after metal-on-metal total hip arthroplasty (THA), but metal artifacts can hamper radiological assessments near the implants. We sought to clarify the usefulness of 18F-fluorodeoxyglucose positron-emission tomography (18F-FDG-PET) CT and MRI in the periprosthetic region, which is difficult to assess after THA due to metal artifacts.

Methods

We performed preoperative 18F-FDG-PET/CT and 18F-FDG-PET/MRI, as well as plain CT and MRI, in 11 metal-on-metal THA patients who underwent revision surgery.

Results

Most patients showed high FDG uptake in the metal artifact areas and pseudotumors in the 18-F-FDG-PET/CT and 18-F-FDG-PET/MRI scans. Intraoperative intra-articular macroscopic and histopathological intra-articular granulation tissue findings were suggestive of adverse local tissue reaction.

Conclusions

The enhanced uptake in the metal artifact areas seemed to reflect adverse local tissue reaction. Therefore, 18F-FDG-PET/CT and 18-F-FDG-PET/MRI can be useful for the auxiliary diagnosis of adverse local tissue reactions after metal-on-metal THA.

Supercapsular percutaneously-assisted total hip (SuperPath) versus mini-incision posterolateral total hip arthroplasty for hip osteoarthritis: a prospective randomized controlled trial

Background

Supercapsular percutaneously-assisted total hip (SuperPath) arthroplasty has been proposed to be minimally invasive and tissue sparing, with possible superior postoperative outcomes compared with conventional approaches for total hip arthroplasty (THA). However, previous studies have underlined the shortcomings of conventional THA approaches, including higher dislocation, more blood loss, longer incisions, more tissue damage, and delayed postoperative rehabilitation. In the present study, we compared the short-term outcomes of unilateral THA with those of SuperPath and the mini-incision posterolateral approach (PLA) for hip osteoarthritis (OA).

Methods

Patients with unilateral hip OA were prospectively recruited and underwent either SuperPath (SuperPath group) or mini-incision PLA THA (PLA group). Perioperative status [operative time, incision length, intraoperative blood loss, soft tissue damage, and length of hospital stay (LOS)], and postoperative function outcomes, including range of motion (ROM), pain visual analog scale (VAS), and Harris Hip Score (HHS), were evaluated and compared between the groups at scheduled time points within 12 months postoperatively.

Results

Compared with the PLA group, the SuperPath group yielded a significantly shorter incision length (7.83 vs. 12.45 cm, P<0.001), longer operative time (102.72 vs. 66.22 min, P<0.001), more blood loss (1,007.38 vs. 844.55 mL, P=0.005), and more soft tissue damage (creatine kinase: 1,056.05 vs. 821.50 U/L, P=0.006) on postoperative day 3. The SuperPath group also showed deficient acetabular cup positioning (abduction angle: 36.94° vs. 42.66°, P=0.004) and a greater decrease in ROM (flexion: 107.66° vs. 114.44°, P=0.004; 109.83° vs. 116.11°, P=0.002; 111.66° vs. 118.88°, P<0.001) on postoperative days 1, 3, and 14, as well as severe early-term pain symptoms (pain VAS on postoperative day 3: 7.05 vs. 6.55, P=0.041). However, the LOS, C-reactive protein levels, erythrocyte sedimentation rate (within 2 weeks postoperatively), and HHS were comparable between the groups during the 12 months postoperatively.

Conclusions

SuperPath may be a promising, minimally invasive technique for the treatment of OA in the future. Further investigation is necessary to evidence the possible superiority of SuperPath over other conventional mini-incision THA approaches.

Three-dimensional pre-operative planning of primary hip arthroplasty: a systematic literature review

Three-dimensional (3D) pre-operative planning in total hip arthroplasty (THA) is being recognized as a useful tool in planning elective surgery, and as crucial to define the optimal component size, position and orientation. The aim of this study was to systematically review the existing literature for the use of 3D pre-operative planning in primary THA.A systematic literature search was performed using keywords, through PubMed, Scopus and Google Scholar, to retrieve all publications documenting the use of 3D planning in primary THA. We focussed on (1) the accuracy of implant sizing, restoration of hip biomechanics and component orientation; (2) the benefits and barriers of this tool; and (3) current gaps in literature and clinical practice.Clinical studies have highlighted the accuracy of 3D pre-operative planning in predicting the optimal component size and orientation in primary THAs. Component size planning accuracy ranged between 34-100% and 41-100% for the stem and cup respectively. The absolute, average difference between planned and achieved values of leg length, offset, centre of rotation, stem version, cup version, inclination and abduction were 1 mm, 1 mm, 2 mm, 4°, 7°, 0.5° and 4° respectively.Benefits include 3D representation of the human anatomy for precise sizing and surgical execution. Barriers include increased radiation dose, learning curve and cost. Long-term evidence investigating this technology is limited.Emphasis should be placed on understanding the health economics of an optimized implant inventory as well as long-term clinical outcomes. Cite this article: EFORT Open Rev 2020;5:845-855. DOI: 10.1302/2058-5241.5.200046.

Effectiveness of 18F-fluoro-deoxyglucose Positron Emission Tomography/Computed Tomography and Magnetic Resonance Imaging to Detect Iliopsoas Tendonitis after Total Hip Arthroplasty: A Case Report

Disorders involving artificial joints are difficult to evaluate due to metal artifacts hindering plain computed tomography (CT) or magnetic resonance imaging (MRI). In the current case study 18F-fluoro-deoxyglucose positron emission tomography (18F-FDG-PET)/CT and MRI were used to confirm iliopsoas tendonitis within the metal artifact area following total hip arthroplasty (THA). The patient was a 61-year-old woman who developed hip pain on flexion of the ipsilateral hip after THA. Imaging studies were performed to evaluate for iliopsoas tendonitis due to impingement with the cup. Assessment of the iliopsoas muscle near the artificial joint was difficult due to the metal artifact on plain CT and MRI. Imaging using 18F-FDG-PET/CT and 18F-FDG-PET/MRI showed uptake along the iliopsoas muscle. Therefore, revision was performed to resolve iliopsoas tendon impingement, and the preoperative pain resolved. The result of the current case study suggest 18F-FDG-PET/CT or 18F-FDG-PET/MRI will be useful to detect iliopsoas tendonitis within metal artifact areas after THA.

Arthroscopic Diagnosis and Treatment of Chronic Hip Pain After Total Hip Arthroplasty and the Role of Anterior Capsule Disruption in Iliopsoas Tendinopathy

Background:

The use of hip arthroscopic surgery in patients suffering from chronic hip pain after total hip arthroplasty (THA) has a limited presence in the literature, with most studies having limited follow-up.

Purpose:

The first goal of this study was to evaluate hip arthroscopic surgery in the diagnosis and management of patients with chronic hip pain after THA. The second goal was to describe a new cause of iliopsoas tendinopathy (IPT) involving disruption of the anterior capsule.

Study Design:

Case series; Level of evidence, 4.

Methods:

We conducted a retrospective analysis with prospectively collected clinical outcomes of patients after THA who underwent hip arthroscopic surgery for chronic hip pain without an identifiable cause. The patients were at least 18 years old and had a minimum follow-up of 24 months.

Results:

The retrospective analysis found that hip arthroscopic surgery led to new diagnostic information in 8 patients (80%). Of the 10 patients diagnosed with IPT, 4 (40%) lacked an anatomic cause; however, these patients had a history of difficult exposure of the anterior capsule and/or a lack of capsular repair during index THA. The mean modified Harris Hip Score (mHHS) was 71.9 ± 15.6, and the mean 6-month postoperative visual analog scale (VAS) pain score was 0.8 ± 2.2, which was significantly lower than preoperatively (P = .0055). There was also significantly improved forward flexion range of motion (P = .0183) and straight leg raise (SLR) strength test results (P = .0263). Hip arthroscopic surgery resulted in 8 patients (80%) continuing to be pain-free at a mean follow-up of 6.8 ± 1.4 years, while 2 patients (20%) progressed to revision arthroplasty. There were no major or minor complications.

Conclusion:

Hip arthroscopic surgery was found to have an important role in the diagnostic and therapeutic management of patients with chronic hip pain after THA, with good clinical outcomes at a mean follow-up of 6.8 years and no complications. We believe that disruption of the anterosuperior acetabular capsule, including the reflected head of the rectus femoris, can allow the iliopsoas tendon to move intra-articularly and precipitate IPT. This disruption may be appreciated on the SLR strength test. Although this study presents a small sample size that cannot substantiate a cause-effect relationship, orthopaedic surgeons performing THA should consider minimizing disruption and/or ensuring repair of the anterior capsule to decrease this potential cause of IPT.

[Synovial biomarkers for differential diagnosis of painful arthroplasty]

BACKGROUND

The diagnosis and treatment of periprosthetic joint infection (PJI) remain true clinical challenges. PJI diminishes therapeutic success, causes dissatisfaction for the patient and medical staff, and often requires extensive surgical revision(s). At the present time, an extensive multimodal algorithmic approach is used to avoid time- and cost-consuming diagnostic aberrations. However, especially in the case of the frequent and clinically most relevant "low-grade" PJI, the current diagnostic "gold standard" has reached its limits.

EVALUATION

Synovial biomarkers are thought to close this diagnostic gap, hopefully enabling the safe differentiation among aseptic, (chronic) septic, implant allergy-related and the arthrofibrotic genesis of symptomatic arthroplasty. Therefore, joint aspiration for obtaining synovial fluid is preferred over surgical synovial tissue biopsy because of the faster results, greater practicability, greater patient safety, and lower costs. In addition to the parameters synovial IL-6, CRP, and leukocyte esterase, novel biomarkers such as antimicrobial peptides and other proinflammatory cytokines are currently highlighted because of their very high to excellent diagnostic accuracy.

CONCLUSION

Independent multicenter validation studies are required to show whether a set of different innovative synovial fluid biomarkers rather than a few single parameters is favorable for a safe "one-stop shop" differential diagnosis of PJI.

The natural history of unexplained early poor function following total hip replacement

PURPOSE

The majority of patients experience a significant improvement in quality of life and function after total hip replacement (THR). It has recently been shown that age and good pre-operative function are the best predictors of postoperative function. When patients fail to achieve a satisfactory outcome, a cause is often identified. Where there is no identifiable cause, advice, follow-up and management is not clear. The aim of this study was to determine the long-term outcome of patients who had early poor function, but no identifiable cause.

METHODS

From a regional database, we identified 1,564 patients who underwent unilateral THR between 1998 and 2004 and who were without complication or subsequent bilateral procedure at six months. These patients were divided into two groups according to their Harris hip score (HHS) at this stage: group A consisted of 270 patients with a 'poor' result (HHS less than 70). Group B consisted of 1,294 patients with a 'good' or 'excellent' result (HHS 70 or above). The patients were reviewed at five years. One hundred and ten patients from group A and 980 from group B completed five-year follow-up without further identifiable complication.

RESULTS

Those with poor or fair function at six months were at an increased risk of developing an identified complication by five years including dislocation (OR 5.7, 95% CI 1.8-18.2), deep infection (OR 9.8, 95%CI 2.9-37.7) and death (OR 1.6, 95% CI 1.1-2.3). There was a greater rate of revision in group A versus group B (OR 5.7, 95% CI 2.9-11). The overall function measured by the Harris hip score significantly improved in group A, but never reached that of those with good or excellent function at six months (HHS 76.2 versus 90.3, P < 0.001).

CONCLUSIONS

Patients with poor function at six months, but no obvious cause, are at higher risk of developing complications by five years. This group may benefit from more regular arthroplasty review and intervention.

Clinical applications of SPECT/CT in imaging the extremities

Today, SPECT/CT is increasingly used and available in the majority of larger nuclear medicine departments. Several applications of SPECT/CT as a supplement to or replacement for traditional conventional bone scintigraphy have been established in recent years. SPECT/CT of the upper and lower extremities is valuable in many conditions with abnormal bone turnover due to trauma, inflammation, infection, degeneration or tumour. SPECT/CT is often used in patients if conventional radiographs are insufficient, if MR image quality is impaired due to metal implants or in patients with contraindications to MR. In complex joints such as those in the foot and wrist, SPECT/CT provides exact anatomical correlation of pathological uptake. In many cases SPECT increases the sensitivity and CT the specificity of the study, increasing confidence in the final diagnosis compared to planar images alone. The CT protocol should be adapted to the clinical question and may vary from very low-dose (e.g. attenuation correction only), to low-dose for anatomical correlation, to normal-dose protocols enabling precise anatomical resolution. The aim of this review is to give an overview of SPECT/CT imaging of the extremities with a focus on the hand and wrist, knee and foot, and for evaluation of patients after joint arthroplasty.