Modified posterior soft tissue repair for the prevention of early postoperative dislocation in total hip arthroplasty

Clinical effects of combined anteversion and offset on postoperative dislocation in total hip arthroplasty

BACKGROUND

Implant impingement and soft tissue tension are factors involved in dislocation after total hip arthroplasty (THA). Combined anteversion (CA) has been used as an indicator for implant placement. However, optimal implant placement remains a challenge. Moreover, the effect of changes in offset on dislocation is still unclear. In this study, we aimed to clarify the effects of postoperative CA and pre- and postoperative changes in offset on dislocation.

METHODS

Included were patients who underwent primary cementless THA between 2013 and 2020. The mean values of CA and offset in the dislocation and non-dislocation groups were compared. The CA values within ± 10% of the recommended values were defined as good CA, and those outside the range were rated as poor CA. The dislocation rates were compared between the good and poor CA groups and between the groups with and without increased offset.

RESULTS

A total of 283 hips were included. The mean values of CA in the dislocation and non-dislocation groups were significantly different (P < 0.05). The dislocation rate was significantly lower in the good CA group (P < 0.05). The dislocation rates in the groups with and without increased total offset were 0.5% and 4.3%, respectively (P = 0.004). There were no dislocations in patients with good CA and increased offset.

CONCLUSIONS

The dislocation rate was significantly lower when implants were placed within ± 10% of the recommended CA value. Our results suggest that dislocation can be avoided by placing the implant in the good CA range and considering the increase in total offset on the operative side.

"Incidence of Instability Following Primary Total Hip Arthroplasty Continues to Decline in the Medicare Population"

BACKGROUND

Instability has been the primary cause of failure following primary total hip arthroplasty (THA) leading to revision hip surgery. The purpose of this study was to determine if instability rates have further declined following advances in primary THA including dual mobility articulations, direct anterior approaches, advanced technologies, and improved knowledge of the hip-spine relationships.

METHODS

Using the 5% Medicare Part B claims data from 1999 to 2019, we identified 81,573 patients who underwent primary THA for osteoarthritis. Patients who experienced instability at 3 months, 6 months, 1 year, and 2 years were identified. Multivariate cox regression analyses evaluated the effect of patient and procedure characteristics on the risk for instability.

RESULTS

Instability at 1 year following primary THA declined from approximately 4% in 2000 to 2.3% in 2010 and 1.6% in 2018. The leading cause of revision surgery was infection (18.6%), followed by peri-prosthetic fracture (14%), mechanical loosening (11.5%), and instability (9.4%). High risk groups for instability continue to include increased age, higher Charlson index, obesity, lumbar spine pathology, and neurocognitive disorders.

CONCLUSION

Instability is no longer the leading etiology of failure following primary THA with a decline of approximately 40% over the past decade. Infection, periprosthetic fracture, mechanical loosening, and then instability are now the leading causes of failure. Multiple factors may play a role in the decline of instability including increased use of dual mobility articulations, direct anterior approaches, improved knowledge of the hip-spine relationships, and use of advanced technologies.

Using mesh in capsule anatomical reconstruction to enhance the stability of high-dislocation-risk hip arthroplasty: a randomized controlled trial

BACKGROUND

Dislocation is a common complication after total hip arthroplasty (THA). This study aimed to compare the outcomes of mesh reconstruction versus conventional capsular repair in maintaining capsular integrity and preventing dislocation after THA.

METHODS

This was a prospective, randomized controlled study of consecutive patients. A total of 124 high-dislocation-risk THAs were identified and randomized into two groups, one using mesh reconstruction and the other using the conventional capsular repair method. Perioperative data and radiological data were collected. Patients were followed up regularly. The main indices were the capsular integrity assessed by magnetic resonance imaging (MRI) and hip dislocation rate. The secondary indices included the Harris hip score (HHS), complications, and satisfaction.

RESULTS

A total of 106 patients completed the follow-up and the average follow-up times were 19 ± 3.1 and 18 ± 3.3 months. The operation time of the mesh group was longer than that of the conventional group (P < 0.001). There were minor differences in acetabular anteversion and abduction angle, and the other data showed no differences. MRI results indicated that the success rate of capsular repair was higher in the mesh group (50 hips, 98%) than in the conventional group (37 hips, 67%) (P < 0.001), and the others failed the repair. Three dislocations occurred in the conventional group, while none occurred in the mesh group. The preoperative HHS (30 points) and postoperative HHS (82 points) of the mesh group were similar to those (35 points, 83 points) of the conventional group (P = 0.164, P = 0.328). Satisfaction had no difference (P = 0.532).

CONCLUSIONS

Compared to conventional repair, mesh reconstruction can effectively maintain capsular integrity and decrease dislocation risk after THA without increasing complications.

LEVEL OF EVIDENCE

Therapeutic study, Level IA.

Randomized Clinical Study on the Efficacy of Direct Anterior Approach Combined With Tendon Release and Repair After Total Hip Arthroplasty

Background

To study the effect of reconstruction of the joint capsule and conjoint tendon on the functional recovery of the hip joint during direct anterior approach (DAA) total hip arthroplasty.

Methods

A total of 60 patients who underwent their first total hip arthroplasty surgery were selected. According to the set criteria, the selected patients were divided into observation group A (n = 30) and control group B (n = 30). In group A, the joint capsule and conjoint tendon (superior muscle, internal obturator muscle, and inferior muscle) were repaired in situ, while in group B, only the joint capsule was repaired in situ, and the conjoint tendon was not repaired. The surgical indicators, including hip joint function and clinical efficacy of the two groups, were compared.

Results

After 6 months of follow-up in groups A and B, no dislocation occurred. The Harris Hip scores of group A were higher than those of group B at 1-month post-operation, i.e., p < 0.05, as well as the valid muscle strength and conjoint tendon valid tension, were higher in group A than group B at 1-month postoperative follow-up, i.e., p < 0.05.

Conclusion

DAA for total hip arthroplasty on the premise of reconstructing the joint capsule structure can rebuild the tension of the conjoint tendon, enhance its muscle strength, and significantly improve the joint stability and function of the patient early stage. It is beneficial for the patient's rapid recovery and is worth implementing.

Capsular repair vs capsulectomy in total hip arthroplasty

BACKGROUND

A major complication of total hip arthroplasty is dislocation. The hip joint capsule can be incised and repaired, or can be excised.

SOURCES OF DATA

We performed a systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines focusing on capsular repair and capsulectomy.

AREAS OF AGREEMENT

We identified 31 articles (17 272 patients). Capsular repair produced a lower blood loss (465.2 vs 709.2 ml), and the procedure lasted 102.5 vs 96.08 min in patients who underwent capsulectomy. The patients undergoing capsulectomy experienced a dislocation rate of 3.06%, whereas in the patients undergoing capsular repair, the dislocation rate was 0.65%.

AREAS OF CONTROVERSY

Most studies are retrospective observational studies, with no prospective randomized trials.

GROWING POINTS

Capsular preservation is association with a lower dislocation rate and a lower blood loss. Capsular excision does take statistically less time, but it is uncertain how a 6 min difference is clinically relevant.

AREAS TIMELY FOR DEVELOPING RESEARCH

Appropriately powered randomized clinical trials should be conducted to better define the association between the chosen implants, approach and outcome.

A novel single myocapsular sleeve (SMS) repair technique to reduce dislocation in posterior approach to the hip: A clinico-radiographic study

BACKGROUND

To assess a new modification of posterior approach to the hip and its effect on stability and functional outcome in total hip arthroplasty.

MATERIAL & METHODS

A comparative retrospective study was done to assess the functional outcome and rate of dislocation among 233 hips (Group A) operated by conventional posterior approach and 567 hips (Group B) by our novel modified posterior approach. In this technique, 2-3 stay sutures are applied in external rotators, then a single conjoint-myocapsular sleeve is raised linearly over the capsule with adherent fibers of gluteus minimus to piriformis tendon, short rotators and part of quadratus for exposure of femoral head. After inserting the definite prosthesis, upper part of sleeve (capsule, piriformis tendon) is sutured at the lower part of tip of greater trochanter & lower part with lateral trochanteric bone. Fifty patients, using randomised tables, in group B underwent MRI to evaluate the efficacy of the repair at 1 and 12 weeks postoperatively.

RESULTS

Average Harris hip score at minimum 3.9 year follow up was 83.2 in Group A & 88.7 in Group B. Group B had only one dislocation (0.176%) while Group A had 12 dislocations (5.15%). MRI showed intact repair in 47 patients (94%); fibrous continuity in 2 patients (6%) in group B patients.

CONCLUSION

Intermediate results shows that this technique provides enhanced stability and improved functional outcome. But more prospective and randomised controlled studies with long term followup are required to confirm its role in prevention of hip dislocations.

Comparison of Two Posterior Soft Tissue Repair Techniques to Prevent Dislocation after Total Hip Arthroplasty via the Posterolateral Approach

BACKGROUND

Although the posterolateral approach is considered to carry a higher early dislocation rate after total hip arthroplasty, posterior soft tissue repair techniques make up for this limitation. Through-bone and through-tendon repair techniques are the two most commonly used techniques. This study aimed to comprehensively compare these techniques and give more evidence-based references for orthopedists. Methods: This retrospective study enrolled 87 patients who underwent posterior soft tissue repair with total hip arthroplasty via the posterolateral approach. The posterior capsular and external rotators were reconstructed to the greater trochanter through drill holes (through-bone, n = 46) or gluteus medius tendon (through-tendon, n = 41). Early dislocation rate, repair-related complications, postoperative pain (visual analog scale, VAS), hip joint function (Harris Hip Scale, HHS), patient satisfaction, and operation-related indexes were evaluated. Results: The discrepancy in early dislocation between the two cohorts was not statistically significant. Operation-related indexes were not significantly different between the two cohorts, except for the postoperative drainage volume (229.46 mL vs. 172.07 mL, p=.013). No patient sustained greater trochanteric fracture and sciatic nerve injury. Each group achieved significant improvements in HHS and VAS scores compared with preoperative values. No statistically significant discrepancy was found in HHS scores between the two groups at the same period, while VAS scores were significantly lower in the through-bone group at 1 week (4.93 vs. 5.68, p=.026) and 1 month (1.72 vs. 1.99, p=.038) after surgery. Higher patient satisfaction was observed in the through-bone group. Conclusions: Although no statistical discrepancy in the early dislocation rate between through-bone and through-tendon repair techniques was observed, lower pain scores and higher patient satisfaction supported the former. We recommend that through-bone repair technique should be chosen first by orthopedists when performing reconstruction of the posterior soft tissue in total hip arthroplasty via a posterolateral approach.

Early dislocation in primary total hip arthroplasty using a posterior approach with repair of capsule and external rotators

OBJECTIVE

To determine the incidence of dislocation after primary total hip arthroplasty using a posterior approach with repair of capsule and transosseous external rotators.

MATERIAL AND METHOD

Historical cohort study between January 2009 and December 2015 of all the cases of dislocation of primary total hip arthroplasty operated using a posterior approach with repair of capsule and transosseous external rotators. Demographic and clinical data concerning the patient, surgery and dislocation were collected and analyzed. A descriptive analysis and a study of survival and risk function were performed by Kaplan Meier's method considering the appearance of a hip dislocation as the final event.

RESULTS

The incidence of dislocation in our study was 1.2% (23 patients). In our study, the highest probability of dislocation occurred in the first 120 days. Forty-three point 5percent of the dislocated patients needed revision surgery.

CONCLUSIONS

Capsular repair and transosseous reattachment of the external rotators can help to reduce the incidence of dislocation in patients undergoing primary total hip arthroplasty through a posterior approach.

Surgical injury and repair of hip external rotators in THA via posterior approach: a three-dimensional MRI-evident quantitative prospective study

BACKGROUND

As one of the classical total hip arthroplasty (THA) approaches, the posterior approach is widely used. However, there is a lack of in-depth quantitative researches on the surgical-related injury to the hip external rotators. The purpose of this study is to quantificationally analyse the surgical injury of hip external rotators after posterior THA and explore the effect of the muscle repair on the muscle recovery using the MRI three-dimensional reconstruction technique combined with the clinical assessment.

METHODS

Sixty five patients were eligible to receive a unilateral cementless THA via the posterior approach. During operation, the piriformis tendon was reattached but it was not applicable for the internal obturator muscle. We performed three-dimensional MRI reconstruction of bilateral piriformis and internal obturator muscle along with clinical assessment preoperatively, 6, 12 and 52 weeks postoperatively.

RESULTS

Bilateral piriformis and internal obturator muscle were homogeneous preoperatively. Compared with the contralateral side, the volume atrophy and fat-muscle ratio of the piriformis on the operated side increased inconspicuously by 1.64%, 0.26% (p = 0.062, p = 0.071) at 6 weeks and 1.33%, 0.20% (p = 0.057, p = 0.058) at 12 weeks, while 7.28%, 2.09% and 15.71%, 5.14% for the internal obturator muscle (p < 0.01). Up to 52 weeks, the pirformis also showed significant muscle atrophy as well as fatty infiltration (increased by 7.79%, 4.21%; p < 0.01), and 24.18%, 11.91% for the internal obturator muscle (p < 0.01).

CONCLUSION

The THA via posterior approach significantly harms the hip external rotators and the early hip external rotation function. The effective repair could be conducive to the early postoperative recovery of the hip external rotators.

TRAIL REGISTRATION

The study has been registered in Chinese Clinical Trial Registry (ChiCTR) before the clical trial started, the Clinical Trial Registry Number is ChiCTR-IOR-17013007 . Registered 17 October 2017. The Trial registration is prospective registration.

A Novel Fast Mobile-Window Small Incision Technique for Hip Arthroplasty in the Elderly and Comparison with Conventional Incision

Background

We deeloped a novel technique – fast mobile-window small incision (FMWSI) – a modification of minimally invasive surgery for total hip arthroplasty, which we believe is particularly suited to elderly patients with hip fractures. The present article aimed to introduce this technique and compare the clinical effects between the FMWSI technique and conventional incision (CI) for hip arthroplasty in elderly patients.

Material/Methods

This study included 240 consecutive patients who underwent hip arthroplasty. Half received total hip arthroplasty and half received hemi hip arthroplasty. The 120 patients in each group were further divided into FMWSI and CI groups. The following parameters were compared between the FMWSI and CI groups: length of incision, operation time, bleeding volume, drainage volume, postoperative ambulation time, and Harris score.

Results

Compared with the CI group, the FMWSI group had a significantly shorter incision length, operation time, and postoperative ambulation time, as well as lower bleeding and drainage volumes, irrespective of whether the treatment was total or hemi hip arthroplasty (P<0.05). However, no significant difference was found in the Harris score between the FMWSI and CI groups (P>0.05).

Conclusions

The novel FMWSI technique introduced in this study is a useful method for hip arthroplasty, especially for elderly patients with poor constitutions or tolerance to surgery.

The result of transmuscular versus transosseous repair of the posterior capsule on early dislocations in primary hip arthroplasty

PURPOSE

Dislocation is a concerning complication of the posterolateral approach for total hip arthroplasty (THA). Use of a larger size femoral head and a correct repair of the posterior structures can reduce the risk on dislocation of the hip prosthesis. In this study we investigated if there was a difference in dislocation rate between transmuscular and transosseous repair of the posterior soft tissues with use of 36 mm heads.

METHODS

A power analysis showed that with a standardised effect size of 0.3 and p-value of 0.05, each group should include at least 174 patients. A total of 465 consecutive primary THAs with a posterolateral approach were performed in patients with primary osteoarthritis by 3 orthopaedic surgeons. There were 246 patients operated using transmuscular repair, the other 219 by using transosseous repair. All patients were given the same prostheses.

RESULTS

Dislocation rate was 1.7% in all patients with at least 1 year follow-up. No significant difference was found in dislocation between both reconstruction techniques. Clinical outcome scores were comparable between the groups.

CONCLUSIONS

Transosseous and transmuscular repair were equally effective techniques in closing the posterior soft tissues after THA through the posterolateral approach, without difference in dislocation rate or complication rate.

Complications Following Direct Anterior Hip Procedures: Costs to Both Patients and Surgeons

A systematic review of the literature on clinical outcomes following direct anterior approach (DAA) hip arthroplasty was performed. An aggregated 11,810 hip procedures were analyzed for intraoperative and early postoperative complications. The most common complication following DAA hip arthroplasty was nerve dysfunction (2.8%) followed by intraoperative fractures (2.3%). Postoperative dislocation, wound complications, and revision THA within the first 12 months were reported in 1.2% of cases. Thus, while DAA hip arthroplasty can be successfully performed, it is not without complications. Without definitive evidence of clinical superiority, surgeons considering switching to DAA should benchmark their personal complication rates against published reports.

Combined anteversion technique reduced the dislocation in cementless total hip arthroplasty

PURPOSE

The combined anteversion (CA) technique is a method in which the cup is placed according to the stem anteversion in total hip arthroplasty (THA). We examined whether the CA technique reduced the dislocation rate, and the distribution of CA with the manual placement of the cup.

METHODS

We retrospectively reviewed 634 hips in 579 patients with primary cementless THA. In 230 hips using the CA technique [CA(+)], a CA of 50 ± 10° was the aim. In the remaining 404 hips [CA(-)], the cup was first placed targeting 20° of anteversion. The post-operative CA was measured using the computed tomography (CT) images in 111 hips.

RESULTS

One hip (0.4%) had a dislocation in the CA(+) group, whereas ten hips (2.5%) had a dislocation in the CA(-) group. A multivariate analysis showed that primary diagnosis, head size and CA technique significantly influenced the dislocation rate. Patients in the CA(-) group were 5.8 times more likely to have a dislocation compared to the CA(+) group. In the 111 hips with CT images, 81 hips (73.0%) achieved the intended CA.

CONCLUSIONS

Although the manual placement of the cup resulted in 27% of outliers from the intended CA, the CA technique significantly reduced the dislocation after primary THA.

The mini postero-postero-lateral mini incision in total hip arthroplasty

PURPOSE

Mini invasive incisions in THA and femoral hip prostheses tend to minimise healing and recovery time. We have used a very posterior approach with technical modifications and precise skin landmarks to decrease surgical complexity, and we describe this experience here.

METHODS

From 2010 to 2012, 140 patients aged 79 years (range 53-93 years) were operated upon by the same surgeon in a continuous series using the same minimally invasive skin incision and six different types of implants. The incision was very posterior in the hip allowing direct visualisation of the acetabulum in the hip flexion position and visualisation of the femoral shaft extremity in a leg flexion position.

RESULTS

The mean operating time was 100 minutes (range 75-110 min). Estimated blood loss was 385 cc (20-585 cc). Twenty-six patients had blood transfusion. The mean hospital stay was 6.8 days (5-20 days) including the time waiting for a rehabilitation centre. No operative complications related to the technique were recorded. On the postoperative radiograph, the femoral stem was aligned with the femoral axis within 3° in all patients. The mean acetabular angle to the ground plane was 40° (35-48°). No patient had a leg length discrepancy of more than four millimetres. The mean skin incision length was seven centimetres (six to eight centimetres). All patients were seen at the clinic after six weeks and the data were unchanged at this time point.

CONCLUSION

The method and skin landmarks we describe appear to be a safe way to perform minimally invasive total hip replacement.