Lateral trochanteric pain following primary total hip arthroplasty

[An update on clinical gait analysis : Current developments and applications]

The objective acquisition and assessment of joint movements and loads using instrumented gait analysis has become an established tool in clinical diagnostics. In particular, marker-based 3D gait analyses make use of an increasingly comprehensive database for the assessment of orthopaedic or neurological questions. Based on this data and medical-scientific experience, increasingly reliable approaches and evaluation strategies are emerging, which also draw on methods from artificial intelligence and musculoskeletal modelling. This article focusses on marker-based gait analyses of the lower extremity (hip, knee, foot) and how these can be used in a clinically relevant way using current methods, e.g. for determining indications or optimization of surgical planning. Finally, current developments and applications by using alternative methods from sensor technology and optical motion capture will be briefly discussed.

Risk Factors for Trochanteric Bursitis Following Total Hip Arthroplasty: A Radiographic Analysis

BACKGROUND

Trochanteric bursitis (TB) is a prevalent complication following total hip arthroplasty (THA), with increased offset hypothesized as a potential risk factor. This study investigated potential TB predictors in THA patients, including radiographic measurements of offset and leg length, comorbidities, and patient characteristics.

METHODS

In this retrospective cohort study, all THA patients from a single academic tertiary care center between 2005 and 2021 were reviewed. Exclusion criteria included less than one-year follow-up, osteonecrosis, or fracture. Manual radiographic measurements of offset (acetabular, femoral, and total) and leg length from preoperative and postoperative antero-posterior pelvis X-rays were taken, with scaling using femoral cortical diameter. Univariable and multivariable Cox proportional hazard models were employed to estimate TB risk.

RESULTS

Of 1,094 patients, 103 (9.4%) developed TB, with a median (Q1, Q3) time to presentation of 41.8 weeks (25.5, 66.9). In univariable models, only sex was associated with increased TB risk, with women exhibiting a 1.79 times increased risk (hazard ratio: 1.79 (1.16, 2.76), P = .009). Changes in acetabular offset, femoral offset, total offset, and leg length between preoperative and postoperative radiographs were not associated with an increased risk of developing TB in the univariate or multivariate models. Furthermore, various offset thresholds were evaluated, with no amount of increased offset showing increased TB risk.

CONCLUSIONS

This study found no relationship between femoral, acetabular, or total offset and TB following THA. These findings suggest that surgeons may consider adding offset for increased prosthetic stability in high-risk cases. However, given that this is a retrospective study, the authors are not advocating for the routine use of increased offset. The study identified women as a risk factor with a 1.79 times higher TB risk, highlighting the importance of counseling women patients on this heightened risk.

Decreasing Hip Offset in Total Hip Arthroplasty Results in Decreased Physical Function Scores

BACKGROUND

Acetabular and femoral offset play an important role in total hip arthroplasty (THA) for postoperative stability and biomechanical function. However, it is unknown whether offset impacts patient-reported outcomes (PROs). This study evaluated patients undergoing direct anterior (DA) THA with the hypothesis that patients who have a decrease in hip offset postoperatively would have lower physical function scores and higher pain interference.

METHODS

There were 499 patients who underwent DA THA at a single tertiary academic institution who were retrospectively evaluated. Preoperative and postoperative hip offset was measured by 2 reviewers using the Sundsvall method on standing anteroposterior pelvis radiographs. Postoperative changes in hip offset were categorized as increased (> 5 mm), matched (within 5 mm of the preoperative offset measurement), or decreased ( >5 mm). Postoperative PROs with a minimum 1-year follow-up were recorded. A one-way analysis of variance was utilized to compare postoperative pain and PROs between groups.

RESULTS

Patients who had decreased offset had the lowest mean postoperative physical function scores at 39.4 (8.0), followed by the increased offset group at 42.2 (10.4) and the matched offset group at 42.8 (9.8) (P < .01). There were significant differences in postoperative physical function scores between matched offset (42.8) and decreased offset (39.4) groups (P < .01), as well as between increased offset (42.2) and decreased offset (39.4) groups (P = .04). There was no difference between matched and increased offset cohorts.

CONCLUSIONS

Our data suggests that reducing hip offset may result in worse physical function scores compared to those who have matched or increased hip offset. This should be considered intraoperatively, and efforts should be made to avoid reduced offset even in the presence of hip stability.

Femoral anteversion change is associated with ischiofemoral impingement after total hip arthroplasty: a retrospective CT evaluation

OBJECTIVES

We evaluated the relationship between femoral anteversion (FA), FA change, and ischiofemoral impingement (IFI) and the relationship between FA, femoral offset (FO), and greater trochanteric pain syndrome (GTPS) after total hip arthroplasty (THA).

MATERIALS AND METHODS

In this retrospective study, two readers assessed FA and FO on CT images of 197 patients following primary THA with an anterior surgical approach between 2014 and 2021. FA change was calculated relative to preoperative CT, while FO change was calculated relative to preoperative radiographs and classified as decreased (≥-5 mm), increased (≥ + 5 mm), or restored (± 5 mm). Clinical and imaging data were analyzed for IFI and GTPS after surgery. Group differences were evaluated using Student's t-test, chi-square analysis, and receiver operating characteristic (ROC) analysis.

RESULTS

The change in FA was 3.6 ± 3.3° to a postoperative FA of 22.5 ± 6.8°, while FO increased by 1.7 ± 3.5 mm to a postoperative FO of 42.9 ± 7.1 mm. FA and FA change were higher in patients with IFI (p ≤ 0.006), while no significant difference was observed for patients with and without GTPS (p ≥ 0.122). IFI was more common in females (p = 0.023). In the ROC analysis, an AUC of 0.859 was observed for FA change to predict IFI, whereas the AUC value was 0.726 for FA alone. No significant difference was found for FO change in patients with and without IFI or GTPS (p ≥ 0.187).

CONCLUSION

Postoperative FA, FA change, and female sex were associated with IFI after anterior-approached THA. The change in FA was a better predictor of IFI than absolute postoperative FA alone.

CLINICAL RELEVANCE STATEMENT

The findings of this study suggest that preservation of the preoperative femoral anteversion may reduce postoperative ischiofemoral impingement in patients undergoing total hip arthroplasty.

KEY POINTS

• Higher postoperative femoral anteversion and anteversion change were associated with ischiofemoral impingement. • Femoral anteversion change was a better predictor of impingement than absolute postoperative anteversion. • No significant association was found between femoral offset and postoperative hip pain.

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.

An Unconventional Solution for Persistent Lateral Hip Prosthetic Friction Syndrome (LHPFS) after Revision Total Hip Arthroplasty

We report on a 77-year-old male patient, who presented with excessive bone loss at the area of the greater trochanter after several hip revision surgeries resulting in a persistent friction syndrome caused directly by the rough surface and sharp edges of the prosthetic shoulder of a well-fixed Wagner-type revision stem. Surgery was performed by creating a cemented neotrochanter with an attached polyester patch around the proximal lateral shaft and performing a Z-plasty of the iliotibial tract. Twelve months postoperatively, the patient reported a reduction in subjective pain of 50% and improvement of the Harris Hip Score from 45 to 75 points. Without a definition in the current literature, the authors propose the term "lateral hip prosthetic friction syndrome" (LHPFS) to describe this medical condition.

Management of Greater Trochanteric Pain Syndrome After Total Hip Arthroplasty: Practice Patterns and Surgeon Attitudes

INTRODUCTION

Greater trochanteric pain syndrome (GTPS) or trochanteric bursitis is described as pain on the lateral side of the hip that does not involve the hip joint and can be elicited clinically by palpation over the greater trochanter. To date, there remains no consensus on clinical guidelines for either diagnosis or management of GTPS.

METHODS

To understand the practice patterns, beliefs, and attitudes relating to the management of GTPS after total hip arthroplasty, a survey was developed and completed by Canadian arthroplasty surgeons. The final survey consisted of 23 questions divided into three sections: 1) screening questions; 2) demographic information; and 3) practice patterns, attitudes, and beliefs.

RESULTS

Most surgeons use physical examination alone for diagnosis. A detailed analysis indicates that surgeons primarily treat GTPS with oral anti-inflammatories (57.1%), structured physiotherapy (52.4%), and steroid injections (45.2%). Management options are typically nonsurgical and comprise a combination of either unstructured or targeted physiotherapy, corticosteroid injections, or platelet-rich plasma.

DISCUSSION

There remains an absence of clinical consensus for the diagnosis and management of GTPS after total hip arthroplasty. Physical examination is most often relied on, regardless of the availability of imaging aids. While common treatments of GTPS were identified, up to one-third of patients fail initial therapy.

Are There Any Significant Risk Factors Associated with Lateral Trochanteric Pain in Patients Who Have Undergone Primary Hip Replacement?

Introduction Lateral pain around the greater trochanter (LTP) is a common complication after total hip arthroplasty (THA) that can significantly reduce quality of life. The aim of this study was to analyze the relationship between lateral trochanteric bursa repair, subcutaneous fat thickness, and trochanteric pain during the THA procedure. Materials and methods A total of 98 patients who underwent THA for hip arthrosis between 2021 and 2022 were evaluated retrospectively. For all evaluated patients, subcutaneous thickness was measured between the fascia and the skin at the incision site. Bursa repair was performed in 47 patients, while bursa excision was done in 51 patients. The data obtained included demographic information, functional scores, comorbidities, bursa repair and skin thickness values, radiographic evaluations, and other specific markers. These were compared between patients diagnosed with LTP following THA and the controls. Results No difference was observed between the study groups in terms of subcutaneous fat thickness, bursa repair, and other demographic or radiographic evaluations. As expected, there were statistically significant differences between the groups in terms of the visual analog scale (VAS) score (p=0.030) and the Harris hip score (HHS) (p=0.045). When comparing the groups with and without LTP, the VAS score was higher in the group with LTP, while the HHS was found to be lower. Conclusion Trochanteric pain is not associated with bursa repair or subcutaneous thickness. LTP cannot be predicted based on comorbidities such as smoking, BMI, or radiographic measurements.

The Role of Global Femoral Offset in Total Hip Arthroplasty with High Hip Center Technique

OBJECTIVE

The high hip center (HHC) technique has been proposed for the treatment of patients with developmental dysplaisa of the hip (DDH) who have an acetabular bone defect. However, the importance of global femoral offset (FO) in the application of this technique has not been sufficiently appreciated. Our goals were to confirm that the HHC technique is feasible in the treatment of patients with DDH and to assess the function of global FO in this procedure.

METHODS

We retrospectively analyzed 73 patients who underwent total hip arthroplasty using high hip center technique for unilateral DDH at our hospital between January 2014 and June 2019. According to global FO, the patients were split into three groups: increased FO group (increment greater than 5 mm), restored FO group (restoration within 5 mm) and decreased FO group (reduction greater than 5 mm). Patients' medical records and plain radiographs were reviewed. One-way ANOVA was used to compare radiographic outcomes and Harris hip score (HHS). Paired t-test was used to assess preoperative and postoperative HHS and leg length discrepancy. Trochanteric pain syndrome, Trendelenburg sign and postoperative limp was evaluated with Fisher's exact test.

RESULTS

The average follow-up time was 7.5 ± 1.4 years. The patients' HHS and leg length discrepancy were significantly improved (p < 0.05). In terms of vertical acetabular height, abductor arm, postoperative leg length difference, and acetabular cup inclination, there was no statistically significant difference between the three groups. At the last follow-up, HHS was significantly higher in the restored FO group than in the decreased FO and increased FO groups. Trochanteric pain syndrome occurred in 15.0% and Trendelenburg sign and postoperative limp in 8.2% of all patients, respectively. Trochanteric pain syndrome, Trendelenburg sign and postoperative limp did not differ significantly across the three groups. One patient in increased FO group underwent revision for dislocation 6 years after surgery.

CONCLUSION

The HHC technique is an alternative technique for total hip arthroplasty in patients with acetabular bone abnormalities, according to the results of the mid-term follow-up. Also, controlling the correction of the global femoral offset to within 5 mm may lead to better clinical outcomes.

Excision of trochanteric bursa during total hip replacement: Does it reduce the incidence of post-operative trochanteric bursitis?

BACKGROUND

Trochanteric bursitis is a common complication following total hip replacement (THR), and it is associated with high level of disability and poor quality of life. Excision of the trochanteric bursa prophylactically during THR could reduce the occurrence of post-operative trochanteric bursitis.

AIM

To evaluate whether synchronous trochanteric bursectomy at the time of THR affects the incidence of post-operative trochanteric bursitis.

METHODS

This retrospective cohort study was conducted in the secondary care setting at a large district general hospital. Between January 2010 and December 2020, 954 patients underwent elective primary THR by two contemporary arthroplasty surgeons, one excising the bursa and the other not (at the time of THR). All patients received the same post-operative rehabilitation and were followed up for 1 year. We reviewed all cases of trochanteric bursitis over this 11-year period to determine the incidence of post-THR bursitis. Two proportion Z-test was used to compare incidences of trochanteric bursitis between groups.

RESULTS

554 patients underwent synchronous trochanteric bursectomy at the time of THR whereas 400 patients did not. A total of 5 patients (incidence 0.5%) developed trochanteric bursitis following THR; 4 of whom had undergone bursectomy as part of their surgical approach, 1 who had not. There was no statistically significant difference between the two groups (Z value 1.00, 95%CI: -0.4% to 1.3%, P = 0.32). There were also 8 other patients who had both trochanteric bursitis and hip osteoarthritis prior to their THR; all of whom were treated with THR and synchronous trochanteric bursectomy, and 7 had resolution of their lateral buttock pains but 1 did not.

CONCLUSION

Synchronous trochanteric bursectomy during THR does not materially affect the incidence of post-operative bursitis. However, it is successful at treating patients with known trochanteric bursitis and osteoarthritis requiring THR.

Isokinetic performance and function are similar after total hip arthroplasty applied with a posterior or anterolateral approach: a randomised controlled trial

BACKGROUND

There are ongoing debates on the effects of surgical approach on outcome after total hip arthroplasty (THA). It was hypothesised that with the anterolateral approach, trauma to the abductor arm can occur and related detrimental effects can diminish the postoperative outcomes. In this first randomised controlled trial in the literature on this subject, isokinetic performance and patient-reported functional outcomes were evaluated in patients undergoing THA with a posterior approach (PA) and an anterolateral approach (ALA).

METHODS

A total of 48 patients scheduled to undergo THA were randomised to ALA or PA groups. The patients were evaluated preoperatively and at 6 and 12 months postoperatively, with flexion, extension and abduction strength measurements and the Harris Hip Score (HHS). The physiatrist performing isokinetic tests and the patients were blinded to the study groups.

RESULTS

Both groups were similar in respect of age, body mass index (BMI), gender and preoperative isokinetic performance and HHS. Both groups demonstrated similar isokinetic performance (p < 0.05) and there was no difference in HHS (p < 0.05) at the 6- and 12-months follow-up evaluations.

CONCLUSION

Although there is concern about potential abductor muscle damaging during ALA, the results of this randomised controlled study demonstrated that ALA can produce similar isokinetic performance and functional outcome to PA at 6 and 12 months, despite the close proximity to the abductor arm.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT04640740 (retrospectively registered).

Impact of fatty degeneration on the functional outcomes of 38 patients undergoing surgical repair of gluteal tendon tears

BACKGROUND

Gluteal tendon tears (GTT) can cause pain and weakness of the hip. We analyze the impact of gluteal muscle fatty degeneration, atrophy and tear morphology on clinical outcomes of surgical repair.

METHODS

All sequential patients receiving surgical repair of GTTs via anchor sutures between 1/2015 and 11/2018 were retrospectively identified. MRIs were reviewed by a radiologist for tendon retraction, muscle atrophy and tear size. The Goutallier-Fuchs Classification (GFC) was used to quantify fatty degeneration as < 2° or ≥ 2°. Demographic and clinical variables were abstracted from the electronic records. The surveys HHS Section 1 and HOOS Jr. were obtained at last follow-up. The Pearson correlation and one-way ANOVA tests served for statistical analysis of clinical variance.

RESULTS

38 patients were identified, 29 (76.3%) were female. The average age was 67. Of the 11 (28.9%) patients with a prior hip arthroplasty 87.5% of primary THAs had a direct lateral approach. 29 (76.3%) patients were treated open and 9 (23.7%) arthroscopically. At an average follow-up of 20.9 months, patients reported a significant improvement in pain (97%), analgesic use (85.7%), limp (52.6%) and abduction strength (54.2%) (all: P ≤ 0.01). GFC ≥ 2° were associated with significantly worse outcomes in terms of limp (0.19/3 vs. 1.2/3, P = 0.05), HHS-S1 (58.19 vs. 71.68, P = 0.04) and complication rates (37.5% vs. 0%, P = 0.02). There was a strong correlation between tear retraction (P = 0.005), tear size (P = 0.009) and muscle atrophy (P = 0.001) with GFC ≥ 2° but not with clinical outcomes. GFC ≥ 2° was strongly related to lateral THA exposures (P < 0.001). Surgical approach had no impact on clinical outcomes.

CONCLUSION

While fatty degeneration can negatively impact functional outcomes, pain relief is reliably achieved. Tear morphology and muscle atrophy did not correlate with outcomes in this patient cohort. Patients should be counseled to expect a residual limp after surgery if they have GFC ≥ 2° on MRI.

Lateral trochanteric bursa repair improves early hip function after posterior approach total hip arthroplasty: a prospective randomized control trial

BACKGROUND

The trochanteric bursa (TB) is an anatomic structure, which is dissected during posterior/lateral hip approaches in Total Hip Arthroplasty (THA). Some surgeons prefer to simply resect the bursa as they believe that it may be responsible for postoperative lateral trochanteric pain (LTP). Others advocate that this tissue acts as a buffer minimizing friction between soft tissue and bone, and therefore its repair may prevent LTP after THA.

AIM

The purpose of this prospective randomized controlled trial was to compare the clinical results of either resecting or repairing the TB during posterior approach THA.

METHODS

Forty-two patients with primary hip osteoarthritis undergoing THA via a posterior hip approach were randomly assigned to two groups; Group A, or TB resection group and Group B, or TB repair group. All patients in both groups were evaluated postoperatively in terms of hip function, measured by the Harris Hip Score (HHS), at 6 weeks, 3 months, 6 months, and 12 months after surgery, as well as LTP during daily routine activities and lying on the operative side.

RESULTS

Forty patients completed the study. Postoperative difference in terms of leg length and femoral offset was similar among the two groups (P = 0.467 and P = 0.39, respectively). At 6 weeks, patients in Group B had higher HHS (P = 0.052) and experienced less LTP when lying on the operative side (P = 0.046) but not during activities (P = 0.759). Thereafter, all functional parameters measured had comparable values in both groups. Subgroup analysis failed to identify any correlation between high offset stems and LTP.

CONCLUSION

TB repair in posterior approach THA improves hip functional recovery as well as patients' ability to lie on the operative side during the early postoperative period.

Attachment and Growth of Fibroblasts and Tenocytes Within a Porous Titanium Scaffold: A Bioreactor Approach

Background

Direct attachment of tendons to metallic implants is important in orthopedics. Tissue integration depends on scaffold microstructure and composition. This study evaluated the effect of pore size of titanium on the viability and function of fibroblasts and tenocytes in a dynamic bioreactor.

Methods

Standardized Ti porous cylinders with 3 pore sizes (400, 700, and 1000 μm) were seeded with fibroblasts or tenocytes (4500 cells/μL) in silicon tubes. Cells were analyzed via alamarBlue (AB) assay in addition to scanning electron microscopy at day 7 (fibroblasts) or day 8 (tenocytes) and day 15. AB functions as a cell health indicator where functional living cells reduce the resazurin dye (blue) in the solution to resorufin (pink), and cell viability can be quantified via spectroscopy.

Results

At day 7, fibroblasts cultured on all sizes reduced AB, with significant differences noted between 400 vs 1000 μm (P = .013) and 700 vs 1000 μm (P = .001). At day 15, fibroblasts reduced AB on all sizes with a significant difference noted between 700 vs 1000 μm (P = .004). Fibroblasts on all 3 pore sizes increased AB reduction from day 7 to day 15. Tenocytes reduced AB with significant differences between the 400 vs 700 μm (P = .049) and the 400 vs 1000 μm pore sizes at day 8. In contrast, tenocyte reduction of AB decreased from day 8 to day 15. Scanning electron microscopy performed on fibroblast cylinders showed fibroblasts reached the surface of the cylinders, confirming interconnectivity.

Conclusions

While both fibroblasts and tenocytes penetrated the pores, fibroblasts preferred larger size, whereas tenocytes favored smaller size. Results are encouraging since soft-tissue attachment to a metallic scaffold is difficult but clinically desirable. Future studies could be performed in an in vivo animal model.

Incidence of and Risk Factors for Lateral Trochanteric Pain After Direct Anterior Approach Total Hip Arthroplasty

Lateral trochanteric pain (LTP) is a common complication after total hip arthroplasty (THA). The goals of this study were to report the incidence of LTP after direct anterior approach (DAA) THA, describe the treatment course and outcomes, and examine patient-specific and implant-related potential risk factors. A retrospective review identified patients who underwent primary DAA THA with at least 1-year follow-up. Postoperative functional outcome scores and LTP occurrence were recorded. Patient demographics, surgical indications, implant characteristics, medical comorbidities, and radiographic parameters were obtained. Logistic regression analysis was used to identify risk factors. A total of 610 THA procedures were performed for 563 patients (mean follow-up, 30.9±15.2 months). The overall incidence of LTP was 11.6%. All cases of LTP were successfully treated conservatively, although these patients, compared with patients who did not have postoperative LTP, experienced significantly lower functional outcome scores (Harris Hip Score, 96.6±4.7 [range, 55-100] vs 89.9±8.5 [range, 42-100], respectively; P<.001). Logistic regression analysis identified female sex (odds ratio, 2.30; 95% CI, 1.32-4.02), diabetes mellitus (odds ratio, 2.32; 95% CI, 1.11-4.88), hypertension (odds ratio, 1.94; 95% CI, 1.15-3.28), and the use of an offset acetabular liner (odds ratio, 2.50; 95% CI, 1.06-5.91) as independent risk factors for LTP. There was no correlation between LTP and radiographic parameters. The incidence of LTP after DAA THA is similar to reported rates for other THA surgical approaches. Female sex, medical comorbidities, and the use of offset acetabular liners are likely associated, and patients should be counseled appropriately. Postoperative LTP results in worse functional outcomes, although all cases can be treated conservatively. [Orthopedics. 2022;45(2):e79-e85.].

Do serum markers correlate with invasiveness of the procedure in THA? A prospective randomized study comparing direct anterior and lateral approaches

BACKGROUND

Advantages of minimally invasive approaches for total hip arthroplasty are still matter of debate. Serum markers have been assessed as objective method to quantify muscle damage after surgery but in literature ambiguous results have been reported. The aim of this prospective randomized study was to: 1) compare serum markers elevation between a minimally invasive direct anterior approach (DAA) and a direct lateral approach (DLA); 2) to establish a correlation between serum markers increase and other perioperative variables.

HYPOTHESIS

A lesser elevation of markers could be found in patients who underwent a minimally invasive DAA.

PATIENTS AND METHODS

Seventy patients were enrolled and randomly divided in two groups according to the type of the approach. All patients were treated with the same implant by the same surgeon and received the same rehabilitation protocol. Demographic data, preoperative Harris Hip Score (HHS) and operative time were recorded. Myoglobin, creatine kinase MB (CK-MB), troponin I, C-reactive protein (CRP), haemoglobin (HB) and pain levels were measured pre- and postoperatively.

RESULTS

Mean postoperative rise were 524.9±134.6 and 667.8±409.5 for myoglobin, 4.8±2.5 and 6.6±3.7 for CK-MB, and 16.9±5.3 and 15.4±6.4 for PCR, in DAA and DLA groups, respectively. In both groups, postoperatively values were significantly higher than preoperatively (p<0.05). Comparing the two groups, no significant differences in serum markers elevations were found. A significantly lower postoperative pain was found in DAA group than in DLA group (2.9 vs. 4.2 and 2.7 vs. 3.6 in second and third day, respectively (p<0.05)). No significant correlation was present between the serum marker elevations and age, BMI, HHS, operative time, HB or pain levels (p>0.05).

CONCLUSION

Serum markers of muscle damage and inflammation increased in the postoperative period without significant differences between DAA and DLA, even though overall trend was higher in DLA group. The DAA group had significantly lower levels of postoperative pain. No significant correlation between pain and serum markers levels was found.

LEVEL OF EVIDENCE

I; randomized study.

Greater trochanteric pain after primary total hip replacement, comparing the anterior and posterior approach: A secondary analysis of a randomized trial

BACKGROUND

Greater trochanteric pain (GTP) after total hip replacement is a common cause of residual lateral hip pain, regardless of the approach used. The goal of our study was to evaluate GTP after a direct anterior approach (DAA) compared to a posterior approach (PA) as well as the clinical outcomes of both approaches and answer the following: 1) What is the incidence of trochanteric pain after primary THA with two different surgical approaches? 2) What is the functional outcome of patients with GTP? 3) What proportion of patients with GTP resort to peritrochanteric injections?

HYPOTHESIS

Our hypothesis is that GTP is present with both approaches but satisfaction is lower with the PA.

PATIENTS AND METHODS

A secondary analysis of a previously published clinical trial with 55 total hip arthroplasty patients randomized in one of two surgical approaches: 27 patients underwent the anterior modified Hueter approach, while the other group of 28 patients were operated using the posterior approach. Study outcomes were Modified Harris Hip Score (MHHS), satisfaction score, pain when lying on the affected side, and requiring an injection. Hip offset, femur lateralization and leg lengthening were measured before and after surgery.

RESULTS

Forty-five patients were available for complete follow-up at a mean of 62 months (range: 48-74). The incidence of GTP was higher in the posterior approach [PA: 6/21 (29%) vs DAA 4/24 (17%)) (p=0.3). Patients operated through a PA experienced more pain [5/21 (24%) of patients; VAS=mean 5.3] when lying on their operated side, compared to DAA patients [2/24 (8%) of patients; VAS=mean 2) (p=0.2)]. However, MHHS, patient satisfaction with surgery, radiological assessment for hip offset, femur lateralization or leg lengthening, and injections required were similar for both approaches. Overall, satisfaction and functional outcome with surgery was significantly lower in GTP patients, regardless of the approach.

CONCLUSIONS

GTP impacts patient satisfaction and functional outcome in total hip arthroplasty patients. PA patients reported more trochanteric pain than DAA patients, which affected their clinical outcome.

LEVEL OF EVIDENCE

III.

Management of femoral neck fractures with the ALMIS approach in elderly patients: Outcomes compared to posterior approach

INTRODUCTION

Over the last 2 decades, several minimally invasive surgical techniques and approaches have been introduced for hip arthroplasty, including anterolateral minimally invasive surgery (ALMIS) introduced by Röttinger in 2004. As described, this muscle sparing approach promises faster recovery and lower dislocation rates. Although there has been a peaked recent interest in minimally invasive surgery (MIS) hip arthroplasty, few studies support the superiority of ALMIS compared to the more traditional posterior approach. The present study examines the safety and early complications of elderly patients undergoing ALMIS compared to a posterior approach for hemiarthroplasty of displaced femoral neck fractures.

METHODS

In a retrograde level III case-control study, 100 consecutive elderly patients with primary hip arthroplasty were divided into two groups. The first group consisted of 50 consecutive cases operated with the ALMIS approach and the second group of 50 consecutive cases operated through a posterior approach. Operative time, postoperative complication rates, length of hospitalization, blood loss, and leg-length discrepancy, were reviewed retrospectively.

RESULTS

No differences were observed in post-operative complications. Overall, the operative time was significantly greater in the ALMIS group compared to the posterior approach group (75 ± 12 vs 67.5 ± 16 min, respectively; p ≤ 0.01). However, the operating time of the second half of the ALMIS cohort (N = 25), did not differ from the posterior approach group (72.7 ± 10.5 vs 67.5 ± 16, respectively; p = 0.19). Leg length discrepancy was significantly less in the ALMIS group compared to the posterior exposure group (1.5 ± 3.2 vs 3.2 ± 3.3, respectively; P≤0.1).

CONCLUSIONS

The results of the retrograde analysis, although limited in sample size, shows no major differences in ALMIS compared to a more traditional posterior approach in terms of immediate post-operative complications. Although the overall operating time was longer in the patients treated with ALMIS, the second cohort of patients treated with this method had an operating time that was similar to that observed with posterior approach. Leg-length discrepancies were significantly less in patients treated with ALMIS.

Distal femoral cortical hypertrophy not associated with thigh pain using a short stem femoral implant

BACKGROUND

Thigh pain following a well-fixed total hip arthroplasty (THA) remains problematic and a source of patient dissatisfaction. The purpose of this study is to evaluate if the development of distal femoral cortical hypertrophy (DFCH) is associated with postoperative thigh pain after THA.

METHODS

All patients who underwent an uncomplicated primary THA via a direct anterior approach with the Taperloc Microplasty (Zimmer Biomet, Warsaw, IN, USA) implant between 2011 and 2015 were mailed a pain drawing questionnaire. Radiographs were reviewed at 1 year minimum to determine cortical thickness change from immediate post-op. Thigh pain was compared to DFCH. 293 patients were included in the study.

RESULTS

Mean follow-up was 3.2 years. A total of 218 hips (74%) had cortical hypertrophy in Gruen zone 3 and 165 hips (56%) had cortical hypertrophy in Gruen zone 5. 52 hips (18%) had ⩾25% cortical hypertrophy in zone 3 and 91 hips (31%) had ⩾25% cortical hypertrophy in zone 5. A total of 44 patients (15%) reported anterior thigh pain and 43 patients (15%) reported lateral thigh pain. Development of DFCH in either Gruen zone 3 or 5 was not associated with anterior or lateral thigh pain. Stem size was positively correlated with zone 3 hypertrophy and inversely related to zone 5 hypertrophy. Thigh pain was not associated with patient age, gender, activity level or stem size.

CONCLUSIONS

The development of distal femoral cortical hypertrophy after THA with a short stem implant was high, but not associated with patient-reported anterior or lateral thigh pain.

Non-surgical treatment as the first step to manage peritrochanteric space disorders

PURPOSE

Greater trochanter pain syndrome (GTPS) or lateral hip pain terms include external snapping hip, trochanteric bursitis and gluteus medius or minimus pathology. The aim of this review is to update the most recent knowledge about non-surgical management of peritrochanteric disorders.

METHODS

A literature review was performed including articles most relevant in the last years that were focused in non-surgical treatment of peritrochanteric disorders.

RESULTS

Conservative treatment still has a place and includes activity modification, NSAIDs, analgesics, physiotherapy, home training, local corticosteroid injection (CSI) and shock wave therapy (SWT). These non-surgical alternatives have demonstrated good clinical results with low rate of complications.

CONCLUSION

Most patients tend to resolve GTPS or lateral hip pain with non-surgical management in the mid-term but when everything failed, surgical options should be evaluated. The next frontier that will be a game changer is to determine an individualized treatment plan based on the exact pathology.

LEVEL OF EVIDENCE

V.

Mismatch between Conventional Femoral Arthroplasty Stems and Hip Morphology in the Elderly Chinese Hip Fracture Population

INTRODUCTION

The morphology of the proximal femur differs in various populations. Based on our clinical experience, conventional femoral stems used in hip arthroplasty do not fit the Chinese population well. Hence, this study aims to evaluate the suitability of conventional femoral stems in the elderly Chinese hip fracture population requiring hip arthroplasty and to establish if gender and age related differences exist within this population.

MATERIAL AND METHODS

We retrospectively analysed radiographic data of 300 patients from a tertiary hospital's geriatric hip fracture database who underwent either hip hemi-arthroplasties or total hip arthroplasties. Proximal femur morphological measurements were recorded, analysed and compared to that of commonly used femoral stems. Subgroup analysis was performed to compare age and gender related differences.

RESULTS

A total of 18.3% of the study population had a medial femoral offset (MFO) of less than 30mm, which is the smallest available offset for the implants studied. 22.6% of female and 3% of male subjects had MFOs that were less than 30mm. In our subgroup analysis, males had significantly larger femoral head diameters, MFO and vertical femoral offsets compared to females. Older subjects (75-90 years old) had significantly smaller femoral head diameters, vertical femoral offsets and neck shaft angles compared to younger subjects (60-75 years old).

CONCLUSION

Commonly used femoral stem implants have measurements that do not suit our Chinese population with small medial femoral offsets. In addition, elderly males have significantly larger femoral head diameters, medial and vertical femoral offsets whereas older subjects have significantly smaller femoral head diameters, vertical femoral offsets and neck shaft angles.

Greater trochanteric pain syndrome: Evaluation and management of a wide spectrum of pathology

Greater trochanteric pain syndrome is a common cause of lateral hip pain, encompassing a spectrum of disorders, including trochanteric bursitis, abductor tendon pathology, and external coxa saltans. Greater trochanteric pain syndrome is primarily a clinical diagnosis, and careful clinical examination is essential for accurate diagnosis and treatment. A thorough history and physical exam may be used to help differentiate greater trochanteric pain syndrome from other common causes of hip pain, including osteoarthritis, femoroacetabular impingement, and lumbar stenosis. Although not required for diagnosis, plain radiographs and magnetic resonance imaging may be useful to exclude alternative pathologies or guide treatment of greater trochanteric pain syndrome. The majority of patients with greater trochanteric pain syndrome respond well to conservative management, including physical therapy, non-steroidal anti-inflammatory drugs, and corticosteroid injections. Operative management is typically indicated in patients with chronic symptoms refractory to conservative therapy. A wide range of surgical options, both open and endoscopic, are available and should be guided by the specific etiology of pain. The purpose of this review is to highlight pertinent clinical and radiographic features used in the diagnosis and management of greater trochanteric pain syndrome. In addition, treatment indications, techniques, and outcomes are described.

Lateral Trochanteric Pain Following Primary Total Hip Arthroplasty: Incidence and Success of Nonoperative Treatment

BACKGROUND

Our study aimed at quantifying the overall incidence of lateral trochanteric pain (LTP) following total hip arthroplasty (THA) and risk based on surgical approach. The success of conservative treatment and potential risk factors for failure of conservative treatment were evaluated.

METHODS

This is a retrospective review of patients who underwent primary THA between 2010 and 2019 and had a postoperative diagnosis of ipsilateral LTP. Chart review revealed patient demographics/comorbidities, preoperative diagnosis, surgical approach, femoral components, and nonoperative treatment modalities. Radiographic analysis was performed to measure leg length discrepancy, femoral offset, and femoral head lateralization.

RESULTS

The incidence of LTP following primary THA was 1.70% (573/33,761) with an average time to diagnosis of 27.3 months. The direct anterior approach demonstrated the highest risk and the direct lateral demonstrated the lowest risk for LTP (P < .001). Also, 82.4% (472/573) were diagnosed greater than 6 months postoperatively (P < .001). Of 573 patients, 95 (16.6%) were treated with physical therapy, home exercises, or oral medications with a success rate of 96.8% (92/95). Remaining 478 (83.4%) were treated with corticosteroid injection (CSI). And 89.5% (428/478) of the CSI cohort demonstrated clinical improvement with 3 or less CSIs. Risk factors for failure of conservative treatment were depression (P = .034), kidney disease (P = .040), and osteoporosis (P = .007).

CONCLUSION

Postoperative LTP after THA is rare with an incidence of 1.70%. The direct anterior approach presented higher risk of LTP. Non-CSI modalities and CSIs were both successful treatment options. In patients with depression, kidney disease, and osteoporosis, conservative treatment may be less efficacious.

Relationship of the Pelvic-Trochanteric Index with greater trochanteric pain syndrome

OBJECTIVES

This study aimed to correlate a higher Pelvic-Trochanteric Index (PTI) with an increased varus of the femoral neck with greater trochanteric pain syndrome (GTPS). The secondary objective was to check whether the pelvic width changes with age.

METHODS

A prospective study was conducted to compare female patients diagnosed with GTPS (case group) with asymptomatic female participants (control group) from March 2011 to June 2017. On an anteroposterior pelvic radiograph, lines were drawn by two radiologists, and the PTI (ratio of the distance between the greater trochanters and distance between the iliac crests) was defined and the femoral neck-shaft angle was measured.

RESULTS

Data collected based on radiographs of 182 female patients (cases) and 150 female participants (controls) showed that the mean PTI was 1.09 (SD=0.01) in the case group and 1.07 (SD=0.01) in the control group (p<0.05), regardless of age. The distance between iliac crests increased with age (p<0.05) in symptomatic and asymptomatic individuals. It was also found that the mean femoral neck-shaft angle was 130.6° (SD=0.59) and progression of the varus angulation occurred with age in both groups, with a significance level of 5%.

CONCLUSIONS

The PTI was higher in patients with GTPS. The femoral neck-shaft angle does not differ between individuals with and without GTPS; however, it does decrease with age. The pelvic width tends to increase with aging in symptomatic or asymptomatic individuals; therefore, the increase in the pelvic width and decrease in the femoral neck-shaft angle can be interpreted as normal in aging women, which could alter the biomechanics of the hips and pelvis.

Changes in femoral offset is not associated with increased incidence of lateral hip pain following total hip arthroplasty

PURPOSE

Increased femoral offset following total hip arthroplasty allows for greater stability of the hip joint. However, the increase in femoral offset can cause an impingement of local structures resulting in persistent lateral hip pain. There is conflicting evidence whether changes in femoral offset increases the rates of lateral hip pain following total hip arthroplasty.

METHODS

This was a retrospective case control study that grouped patients based on the presence of persistent lateral hip pain following total hip arthroplasty. Patients were then stratified according to their change in femoral offset (<-5 mm, -5 mm < x < 5 mm, and 5 mm<). A chi squared analysis was then performed to see if there was a statistical difference in the rates of lateral hip pain amongst these groups.

RESULTS

A change in femoral offset of the implanted hip relative to the native hip was not associated with increased rates of lateral hip pain following total hip arthroplasty (p = 0.35). A change in femoral offset of the implanted hip relative to the contralateral hip was not associated with increased rates of lateral hip pain following total hip arthroplasty (p = 0.40).

CONCLUSION

This study found that there was no association between increased femoral offset and rates of postoperative lateral hip pain following total hip arthroplasty. Future investigations should look at a larger sample size with multiple institutions to further assess the impact on femoral offset changes on rates of persistent lateral hip pain.

The use of pelvic radiographs as a predictor for gluteal tendinopathy and bursitis

AIM

To evaluate the relationship between radiographic measurements of the hip and sonographic evidence of gluteal tendinopathy and bursitis in patients with lateral hip pain.

METHODS AND MATERIALS

Patients with lateral hip pain referred for ultrasound of the hip in our institution over a 5-year period were identified. Findings of gluteal tendinopathy and subgluteal or trochanteric bursitis on ultrasound were recorded. Radiographs of the hip were also evaluated and femoral offset (FO), global offset (GO), abductor lever arm (ALA) and trochanteric impingement distance (TID) were recorded. The mean of each measurement was compared between patients with gluteal tendinopathy and subgluteal or trochanteric bursitis.

RESULTS

273 patients were included in the study. 107 patients (39.2%) had a THA. In the asymptomatic hip, a range of normal measurements were obtained: FO 22.4-76.5 mm, GO 40.1-116.1 mm, ALA 45.0-98.4 mm and TID 13.8-63.1 mm. In the native hip and post THA, there was no statistically significant relationship between FO, GO, ALA and TID in patients with gluteal tendinopathy or trochanteric or subgluteal bursitis.

CONCLUSIONS

Lateral hip pain is a common presenting complaint in patients with hip pain and is reported in a small proportion of patients post THA. No statistically significant relationship was found between radiographic measurements and ultrasound findings in our patient cohort. However, we describe the range of measurements obtained from the normal asymptomatic hip in this large cohort of patients, which may aid in the evaluation and management of patients with lateral hip pain.

Gluteus Maximus Transfer as an Augmentation Technique for Patients With Severe Abductor Deficiency of the Hip

Impaired abductor function of the hip following severe abductor deficiencies can be devastating for functionality and quality of life. Recently, gluteus maximus transfer has been proposed as a solution to these difficult problems. However, outcome results are sparse. The aim of this study was to evaluate the effects of gluteus maximus transfer on improvement of pain, disability, and quality of life in patients with severe hip abductor deficiencies. Gluteus maximus transfer was performed in 16 patients with severe disruption of the abductor muscles of the hip. Data were collected preoperatively and at 6 weeks, 3 and 6 months, and 1 to 2 years after surgery. The measurements pertained to complications, healing of the flap based on magnetic resonance imaging (MRI) findings (in 10 patients), evaluation of Trendelenburg gait and sign, and patient-reported outcome measures of pain, disability, and quality of life. Preoperatively, all patients had a positive Trendelenburg sign and reported severe pain at the level of the greater trochanter. At a mean follow-up of 20 months, the Trendelenburg sign was negative in 7 patients and the Trendelenburg gait had disappeared in 7 patients. There was an improvement in patient-reported outcome measures but not to a significant level except for the pain subscores. Two patients had a postoperative seroma that resulted in a visible bump on the lateral side. Seven of 10 repairs with MRI follow-up showed perfect ingrowth on MRI without signs of rerupture. Gluteus maximus transfer for abductor deficiency of the hip may be effective for pain relief and functional improvements. Most patients showed an improved quality of life but were not completely pain free. [Orthopedics. 2020;43(4):e299-e305.].

Restoration of leg length and offset correlates with trochanteric pain syndrome in total hip arthroplasty

Persistent pain around the greater trochanter is a common complication after total hip arthroplasty. Restoration of biomechanics such as leg length, femoral und acetabular offset is crucial in THA. The purpose of this study was to evaluate postoperative differences of these parameters after THA and to analyze their association to greater trochanteric pain syndrome. Furthermore, we aimed to evaluate the clinical relevance of trochanteric pain syndrome compared to patient reported outcome measures. 3D-CT scans of 90 patients were analyzed after minimalinvasive total hip arthroplasty and leg length, femoral and acetabular offset differences were measured. Clinical evaluation was performed three years after THA regarding the presence of trochanteric pain syndrome and using outcome measures. Furthermore, the patients' expectation were evaluated. Patients with trochanteric pain syndrome showed a higher absolute discrepancy of combined leg length, femoral and acetabular offset restoration compared to the non-operated contralateral side with 11.8 ± 6.0 mm than patients without symptoms in the trochanteric region with 7.8 ± 5.3 mm (p = 0.01). Patients with an absolute deviation of the combined parameters of more than 5 mm complained more frequently about trochanteric symptoms (29.2%, 19/65) than patients with a biomechanical restoration within 5 mm compared to the non-affected contralateral side (8.0%, 2/25, p = 0.03). Clinical outcome measured three years after THA was significantly lower in patients with trochanteric symptoms than without trochanteric pain (p < 0.03). Similarly, fulfillment of patient expectations as measured by THR-Survey was lower in the patients with trochanteric pain (p < 0.005). An exact combined restoration of leg length, acetabular and femoral offset reduces significantly postoperative trochanteric pain syndrome and improves the clinical outcome of the patients.

Does low back pain or leg pain in gluteus medius syndrome contribute to lumbar degenerative disease and hip osteoarthritis and vice versa? A literature review

[Purpose] Gluteus medius syndrome is one of the major causes of back pain or leg pain and is similar to greater trochanteric pain syndrome, which also presents with back pain or leg pain. Greater trochanteric pain syndrome is associated with lumbar degenerative disease and hip osteoarthritis. The objective of this review was to demonstrate gluteus medius syndrome as a disease entity by reviewing relevant articles to elucidate the condition. [Methods] Gluteus medius syndrome was defined as myofascial pain syndrome arising from the gluteus medius. We performed a search of the literature using the following keywords: “back pain”, “leg pain”, “greater trochanteric pain syndrome”, “degenerative lumbar disease”, “hip osteoarthritis”, and “gluteus medius”. We reviewed articles related to gluteus medius syndrome and described the findings in terms of diagnosis and treatment based on the underlying pathology. [Results] A total of 135 articles were included in this review. Gluteus medius syndrome is similar as a disease entity to greater trochanteric pain syndrome, which presents with symptoms of low back pain and leg pain. Gluteus medius syndrome is also related to lumbar degenerative disease, hip osteoarthritis, knee osteoarthritis, and failed back surgery syndrome. [Conclusion] Accurate diagnosis of gluteus medius syndrome and appropriate treatment could possibly improve lumbar degenerative disease and osteoarthritis of the hip and knee, as well as hip-spine syndrome and failed back surgery syndrome.

Influence of Hip Geometry Reconstruction on Frontal Plane Hip and Knee Joint Moments During Walking Following Primary Total Hip Replacement

BACKGROUND

Following total hip replacement (THR), hip geometry reconstruction parameters such as the femoral offset (FO) correlate with hip stability and wear. The purpose of this study is to determine the relationship between hip geometry parameters and knee and hip joint loading during walking.

METHODS

Forty-one patients were examined before and a minimum of 1 year after primary THR. Pearson correlation coefficient (r) was performed to identify relationships between radiographic parameters and gait data. In addition, we divided patients into 2 groups according to the restoration of the FO (within ±5 mm vs more than 5 mm increment).

RESULTS

The FO and global offset (GO) showed a positive correlation with the first (r = 0.469, P = .002; r = 0.542, P < .001) and second (r = 0.365, P = .019; r = 0.484, P = .001) knee adduction moment (KAM). The neck-shaft angle revealed a negative correlation with the first hip adduction moment (r = -0.375, P = .047). The reconstruction of FO with an increment of more than 5 mm was associated with a significant higher first KAM (+16%, P = .045) compared to the restored group.

CONCLUSION

Our findings suggest that abnormal hip and knee joint loading during walking after THR have a biomechanical background originating from hip geometry reconstruction. Patients with a high FO/GO were more likely to have an increased KAM during walking or vice versa. Surgeons need to be aware that an accurate control of FO, GO, and neck-shaft angle restoration in THR has an impact on hip and knee joint loading that may influence degenerative changes of the knee and higher wear of the artificial hip joint, respectively.

High risk of positive Trendelenburg test after using the direct lateral approach to the hip compared with the anterolateral approach: a single-centre, randomized trial in patients with femoral neck fracture

Aims

The aim of this randomized trial was to compare the functional outcome of two different surgical approaches to the hip in patients with a femoral neck fracture treated with a hemiarthroplasty.

Patients and Methods

A total of 150 patients who were treated between February 2014 and July 2017 were included. Patients were allocated to undergo hemiarthroplasty using either an anterolateral or a direct lateral approach, and were followed for 12 months. The mean age of the patients was 81 years (69 to 90), and 109 were women (73%). Functional outcome measures, assessed by a physiotherapist blinded to allocation, and patient-reported outcome measures (PROMs) were collected postoperatively at three and 12 months.

Results

A total of 11 patients in the direct lateral group had a positive Trendelenburg test at one year compared with one patient in the anterolateral group (11/55 (20%) vs 1/55 (1.8%), relative risk (RR) 11.1; p = 0.004). Patients with a positive Trendelenburg test reported significantly worse Hip Disability Osteoarthritis Outcome Scores (HOOS) compared with patients with a negative Trendelenburg test. Further outcome measures showed few statistically significant differences between the groups.

Conclusion

The direct lateral approach in patients with a femoral neck fracture appears to be associated with more positive Trendelenburg tests than the anterolateral approach, indicating a poor clinical outcome.

Cite this article: Bone Joint J 2019;101-B:793–799.

Does patient-reported perception of pain differ based on surgical approach in total hip arthroplasty?

Aims

Whether patient-reported pain differs among surgical approaches in total hip arthroplasty (THA) remains unclear. This study’s purposes were to determine differences in pain based on surgical approach (direct anterior (DA) vs posterolateral (PL)) and PL approach incision length.

Patients and Methods

This was a retrospective investigation from two centres and seven surgeons (three DA, three PL, one both) of primary THAs. PL patients were categorized for incision length (6 cm to 8 cm, 8 cm to 12 cm, 12 cm to 15 cm). All patients had cementless femoral and acetabular fixation, at least one year’s follow-up, and well-fixed components. Patients completed a pain-drawing questionnaire identifying the location and intensity of pain on an anatomical diagram. Power analysis indicated 800 patients in each cohort for adequate power to detect a 4% difference in pain (alpha = 0.05, beta = 0.80).

Results

A total of 1848 patients (982 DA, 866 PL) were included. PL patients were younger (59.4 years, sd 12.9 vs 62.7 years, sd 9.7; p < 0.001) and had shorter follow-up (3.3 years, sd 1.3 vs 3.7 years, sd 1.3; p < 0.001). DA patients reported decreased moderate to severe trochanteric (14% vs 21%; p < 0.001) and groin pain (19% vs 24%; p = 0.004) than PL patients. There were no differences in anterior, lateral, or posterior thigh, back, or buttock pain between cohorts (p = 0.05 to 0.7). PL approach incision length did not impact the incidence or severity of pain (p = 0.3 to 0.7).

Conclusion

A significant proportion of patients perceive persistent pain following THA regardless of approach. DA patients reported less trochanteric and groin pain versus PL patients. PL incision length did not influence the incidence or severity of patient-reported pain. Cite this article: Bone Joint J 2019;101-B(6 Supple B):31–36.

Arthroscopic techniques for treating ilio-psoas tendinopathy after hip arthroplasty

Impingement of hip arthroplasty components on soft tissues may adversely affect outcomes. An example is impingement of the cup on the ilio-psoas tendon, which has been reported in 0.4% to 8.3% of patients. Contributors to ilio-psoas tendon impingement (IPTI) can be categorised as anatomic (hypoplastic anterior wall), technical (inadequate anteversion and/or lower inclination, oversized cup, cement in contact with the tendon, and intra-muscular screw), and prosthetic (e.g., aggressive cup design, large-diameter head, resurfacing, and collared femoral prosthesis). IPTI manifests as groin pain, raising diagnostic challenges since this symptom lacks specificity. Physical findings of value for the diagnosis include pain exacerbation during active hip flexion, groin pain upon straight-leg raise to 30°, and/or snapping hip syndrome. Confirmation is then provided by ultrasonography and, most importantly, computed tomography. Once the diagnosis is confirmed, non-operative treatment combining physical therapy and local corticosteroid injections is prescribed. When these measures fail, endoscopic or arthroscopic surgery is generally effective. In patients with major cup malposition, revision of the cup is the preferred option, despite the higher complication rate. When cup position is adequate, ilio-psoas tenotomy can be performed either extra-articularly at the lesser trochanter (by endoscopy) or intra-articularly (by arthroscopy). The arthroscopic technique is more demanding but useful when the diagnosis is in doubt, as it allows examination of the prosthetic bearing surfaces. Both techniques and the risks inherent in each are discussed in detail. Tenotomy, whether performed endoscopically or arthroscopically, promptly provides good outcomes in over 85% of patients, usually with full recovery of hip flexor strength over time. These minimally invasive techniques, while as effective as conventional surgery, are associated with lower morbidity rates.

Do Postoperative Results Differ in a Randomized Trial Between a Direct Anterior and a Direct Lateral Approach in THA?

BACKGROUND

The direct lateral approach to THA provides good exposure and is associated with a low risk of dislocations, but can result in damage to the abductor muscles. The direct anterior approach does not incise muscle, and so recovery after surgery may be faster, but it has been associated with complications (including fractures and nerve injuries), and it involves a learning curve for surgeons who are unfamiliar with it. Few randomized trials have compared these approaches with respect to objective endpoints as well as validated outcome scores.

QUESTIONS/PURPOSES

The purpose of this study was to compare the direct anterior approach with the direct lateral approach to THA with respect to (1) patient-reported and validated outcomes scores; (2) frequency and persistence of abductor weakness, as demonstrated by the Trendelenburg test; and (3) major complications such as infection, dislocation, reoperation, or neurovascular injury.

METHODS

We performed a randomized controlled trial recruiting patients from January 2012 to June 2013. One hundred sixty-four patients with end-stage osteoarthritis were included and randomized to either the direct anterior or direct lateral approach. Before surgery and at 3, 6, 12, and 24 months, a physiotherapist recorded the Harris hip score (HHS), 6-minute walk distance (6MWD), and performed the Trendelenburg test directly after the 6MWD. The patients completed the Oxford Hip Score (OHS) and the EQ-5D. The groups were not different at baseline with respect to demographic data and preoperative scores. Both groups received the same pre- and postoperative regimes. Assessors were blinded to the approach used. One hundred fifty-four patients (94%) completed the 2-year followup; five patients from each group were lost to followup.

RESULTS

There were few statistical differences and no clinically important differences in terms of validated or patient-reported outcomes scores (including the HHS, 6MWD, OHS, or EQ-5D) between the direct anterior and the lateral approach at any time point. A higher proportion of patients had a persistently positive Trendelenburg test 24 months after surgery in the lateral approach than the direct anterior approach (16% [12 of 75] versus 1% [one of 79]; odds ratio, 15; p = 0.001). Irrespective of approach, those with a positive Trendelenburg test had statistically and clinically important worse HHS, OHS, and EQ-5D scores than those with a negative Trendelenburg test. There were four major nerve injuries in the direct anterior group (three transient femoral nerve injuries, resolved by 3 months after surgery, and one tibial nerve injury with symptoms that persist 24 months after surgery) and none in the lateral approach.

CONCLUSIONS

Based on our findings, no case for superiority of one approach over the other can be made, except for the reduction in postoperative Trendelenburg test-positive patients using the direct anterior approach compared with when using the direct lateral approach. Irrespective of approach, patients with a positive Trendelenburg test had clinically worse scores than those with a negative test, indicating the importance of ensuring good abductor function when performing THA. The direct anterior approach was associated with nerve injuries that were not seen in the group treated with the lateral approach.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Trochanteric Bursitis Following Primary Total Hip Arthroplasty: Incidence, Predictors, and Treatment

BACKGROUND

Trochanteric bursitis (TB) remains a common complication after total hip arthroplasty (THA), with an incidence between 3% and 17%, depending on the surgical approach, with the posterior approach (PA) being relatively protective compared to the lateral approach. The purposes of this study were to determine the incidence of TB after primary THA, identify potential risk factors for TB, and examine the utility of different modes of treatment.

METHODS

Retrospective cohort data of 990 primary THAs performed in a single institution, including 613 PAs and 377 direct anterior approaches (DAAs), were analyzed. Data abstracted included demographic data, operative diagnosis, comorbidities, radiographic assessment, and other specific predictors of interest that were compared between patients diagnosed with TB following THA and controls.

RESULTS

The incidence of TB following primary THA was 5.4% (54/990) for the entire cohort. The incidence did not differ significantly between the PA and DAA (5% vs 6.1%, respectively; P = .47). Charlson comorbidity index and American Society of Anesthesiology did not differ significantly in the TB group. Lumbar spinal stenosis and history of past smoking were significantly more common in patients who developed TB (P = .03, P = .01, respectively), but did not continue to be significant risk factors on multivariate analysis. All patients were treated nonoperatively by the time of final follow-up. Seventy-four percent required a local steroid injection and 30% required treatment with more than one modality.

CONCLUSION

The occurrence of TB is not influenced by the surgical approach (PA or DAA), and could not be predicted by specific comorbidities or radiographic measurements. However, it can be effectively treated conservatively in most cases.

Treatment of Extensive Gluteus Muscle Tears With Transosseous Fixation and a Nonresorbable Collagen Patch

BACKGROUND

Extensive tearing of the gluteus muscles (spontaneous or subsequent to hip arthroplasty) is difficult to treat. We are carrying out osseous fixation with securement of the suture anchor by a nonresorbable collagen patch. The objective of this study is to examine the follow-up data of 30 patients and to assess whether the clinical outcomes depended on the extent of the fatty degeneration of the gluteus medius.

METHODS

Thirty patients (28 female and 2 male) with a mean age of 76.8 ± 4.3 years (68-83 years) were followed for a mean of 46.8 ± 23.1 months (24-101 months).

RESULTS

Pain improved significantly from a preoperative visual analog scale score of 7.0 ± 1.52 (6-10) to 0.83 ± 0.77 (0-3) 24-month postoperative. The gluteus medius muscle force increased from 2.09 ± 0.81 to 3.3 ± 0.78 using the British Medical Research Council Scale. All patients exhibited a severe limp before the operation. Postoperatively, only 5 patients had a severe limp, while 14 exhibited a mild limp and 11 no limp at all. The modified Harris Hip Score increased from a preoperative value of 44.5 ± 4.2 (26-66) to a value of 81.1 ± 7.79 (60-100) 24-month postoperative. The functional results were dependent on the level of fatty degeneration of the muscle.

CONCLUSION

The first results for this surgical technique appear to be very promising for the treatment of extensive tearing of the gluteus musculature that has a degree of fatty degeneration less than 75%.

Lateral trochanteric pain following total hip arthroplasty: radiographic assessment of altered biomechanics as a potential aetiology

INTRODUCTION

Lateral trochanteric pain (LTP) complicates up to 17% of cases of total hip arthroplasty (THA). Studies have refuted underlying trochanteric bursitis. Restoration of the femoral offset and reproduction of the natural femoral centre of rotation are important in successful arthroplasty. LTP is believed to be associated with their alteration.

AIM

The aim of our study was to evaluate the effect of femoral offset and centre of rotation on the incidence of LTP post-THA.

METHODS

A retrospective case control study was developed from 158 patients who underwent a THA over a two-year period to form two patient cohorts. Twenty-nine patients diagnosed with LTP were matched with 110 control subjects. The direct lateral approach was used in all cases. Anterior-posterior pelvic radiographs before and after surgery were compared to assess the femoral, cup and global offsets and limb length discrepancies between the two groups. Statistical analyses were performed using the Mann-Whitney U test and independent samples t test.

RESULTS

Twenty-nine diagnosed with post-operative LTP. Sixty-two percent of symptomatic patients were female (p = 0.13). The median ages were 74.33 (symptomatic) and 70.71 (control) (p = 0.11). The differences (pre-post) of the femoral (p = 0.17), cup (p = 0.5) and global offsets (p = 0.99) and mean of limb length discrepancy (LLD) (p = 0.83) were not significant between the two groups.

CONCLUSION

No relationship was found between LTP and femoral offset or femoral centre of rotation. Disruption of the soft tissues during a lateral approach with resultant abductor tear, tendon defects and tendinitis might play a role in LTP and explain the apparent efficacy of corticosteroid injections.

Greater trochanteric pain syndrome and gluteus medius and minimus tendinosis: nonsurgical treatment

Greater trochanteric pain syndrome (GTPS) affects 10–25% of people in developed countries. The underlying etiology for GTPS is most commonly the tendinosis or a tendon tear of the gluteus medius, minimus or both at the greater trochanter; the inflammation of the tendon is not a major feature. We critically evaluated conservative treatment, for which we reviewed 76 publications, grading them according to four levels of evidence. We identified a wide variety of conservative treatment options: home therapy (insoles, walking sticks/crutches, orthotic devices, stretching exercises and preventive measures); physiotherapy (massage and stretching exercises); infiltrations (corticosteroids and local anesthetics); image-guided infiltrations (fluoroscopy and ultrasound); shockwave therapy; platelet-rich plasma injection; and drug therapy. Severe complications associated with infiltrations are extremely rare, as are those associated with shockwave therapy. The most effective treatments were infiltrations with corticosteroids and shockwave therapy. We propose a graded treatment schedule for patients with GTPS.

The Röttinger approach for total hip arthroplasty: technique, comparison to the direct lateral approach and review of literature

Background

Multiple approaches to the hip joint have been developed utilizing various intervals and/or intermuscular planes when performing a total hip arthroplasty (THA), each proposing certain advantages. Of these, the Röttinger approach (modified anterolateral or Watson-Jones) is potentially muscle-sparing. Multiple studies have demonstrated favorable outcomes with this approach. However, others showed more complications with a slow learning curve. Due to the paucity of evidence we conducted this study to: (I) present our operative experience and technique of the Röttinger approach; (II) compare short-term complications and operative room (OR) times of this approach to the direct lateral; and (III) review the available literature.

Methods

This was a review of a longitudinally maintained single-surgeon database of patients who underwent primary THA using either the Röttinger or direct lateral approach. A total of 100 consecutive patients (100 hips) who underwent primary unilateral THA using the Röttinger approach between April 1^st, 2012 and April 30^th, 2015 were identified. These patients were compared to another cohort of 147 consecutive patients (147 hips) who underwent the procedure using the direct lateral approach (of Hardinge). The operative technique for the Röttinger approach involves accessing the hip joint through muscle-sparing technique between the tensor fascia lata and gluteus medius muscles. We evaluated and compared the short-term complications and the mean operative times for each cohort. In addition, we performed a literature search on the clinical studies that reported on the Röttinger approach using the following databases; PubMed, EMBASE, EBSCO Host, and SCOPUS. Studies published between January 1^st of 2000 and September 1^st of 2017 were reviewed. We included only studies that compared this approach to other standard approaches and excluded single-cohort case series, case reports, cadaveric studies, and studies not in English language.

Results

At mean follow-up time of 12 weeks (range, 6 to 24 weeks), there were two patients in the Röttinger cohort who experienced lateral femoral cutaneous nerve palsies (2%), which were self-limited and resolved at 6 and 12 weeks. In the direct lateral cohort, there was one hip dislocation (2%) at 6 weeks post-operatively, which was successfully managed by a closed reduction. In patients who received the Röttinger approach, mean OR time was 130 minutes (range, 74 to 202 minutes), compared to the direct lateral cohort mean of 111 minutes (range, 71 to 222 minutes). Our literature analysis covered 2,252 patients who received the Röttinger approach vs. 19,941 patients who underwent variety of other standard approaches including anterior, direct lateral, and posterior. At final follow up (range, 6 to 52 months), patients who underwent the Röttinger approach demonstrated comparable clinical outcomes and complications to patients who underwent primary THA using other approaches.

Conclusions

In this analysis of a single-surgeon experience of the Röttinger approach compared to the direct lateral, we presented our experience with the technique and demonstrated the safety and feasibility of this relatively novel approach. Our study results demonstrated that patients who underwent this approach had similar short-term complications and OR times to those who underwent the direct lateral approach. Additionally, our findings agree with previous comparative studies that demonstrated similar outcomes of this approach. Therefore, it can be used as an alternative for primary THA.

Effect of changes of femoral offset on abductor and joint reaction forces in total hip arthroplasty

BACKGROUND

Anatomical reconstruction in total hip arthroplasty (THA) allows for physiological muscle function, good functional outcome and implant longevity. Quantitative data on the effect of a loss or gain of femoral offset (FO) are scarce. The aim of this study was to quantitatively describe the effect of FO changes on abductor moment arms, muscle and joint reactions forces.

METHODS

THA was virtually performed on 3D models built from preoperative CT scans of 15 patients undergoing THA. Virtual THA was performed with a perfectly anatomical reconstruction, a loss of 20% of FO (-FO), and a gain of 20% of FO (+FO). These models were combined with a generic musculoskeletal model (OpenSim) to predict moment arms, muscle and joint reaction forces during normal gait cycles.

RESULTS

In average, with -FO reconstructions, muscle moment arms decreased, while muscle and hip forces increased significantly (p < 0.001). We observed the opposite with +FO reconstructions. Gluteus medius was more affected than gluteus minimus. -FO had more effect than +FO. A change of 20% of FO induced an average change 8% of abductor moment arms, 16% of their forces, and 6% of the joint reaction force.

CONCLUSIONS

To our knowledge, this is the first report providing quantitative data on the effect of FO changes on muscle and joint forces during normal gait. A decrease of FO necessitates an increase of abductor muscle force to maintain normal gait, which in turn increases the joint reaction force. This effect underscores the importance of an accurate reconstruction of the femoral offset.

Tendon Disorders After Total Hip Arthroplasty: Evaluation and Management

BACKGROUND

Most patients who undergo total hip arthroplasty are very satisfied with their outcomes. However, there is a small subset of patients who have persistent pain after surgery. The etiology of pain after total hip arthroplasty varies widely; however, tendon disorders are a major cause of debilitating pain that often go unrecognized.

METHODS

We performed a literature review to identify the most common tendon pathologies after total hip arthroplasty which include iliopsoas tendinitis, greater trochanteric pain syndrome, snapping hip syndrome, and abductor tendinopathy.

RESULTS

We present a simplified approach highlighting the presentation and management of patients with suspected tendinopathies after total hip arthroplasty. These tendinopathies are treatable, and management begins with nonoperative modalities; however, in cases not responsive to conservative management, operative intervention may be necessary.

CONCLUSION

Tendinopathies after total hip arthroplasty sometimes go unrecognized but when treated can result in higher surgeon and patient satisfaction.

Surgery for greater trochanteric pain syndrome after total hip replacement confers a poor outcome

PURPOSE

Surgery for greater trochanteric pain syndrome (GTPS) may be indicated for cases refractory to conservative measures. We aim to evaluate patient reported outcomes and adverse events following surgery.

METHODS

Postal questionnaires were used to evaluate a consecutive series of 61 bursectomy and gluteal fascia transposition (GFT) procedures. Study outcomes were Oxford hip score, satisfaction score, visual analogue score, pain lying on the affected side, and the duration of pain relief after surgery.

RESULTS

We received responses regarding 52 procedures at a median of 34 months follow-up; 40% of cases of GTPS occurred following THA. We observed a bimodal distribution of satisfaction scores. The early post-operative complication rate was 13%; an additional seven cases (12%) required further surgery at a later date. Idiopathic GTPS had significantly better post-operative satisfaction than GTPS following THA, 87.5 vs. 37.5 (p = 0.006); Oxford hip scores, 35 vs. 15 (p = 0.015); and visual analogue scores, 20 vs. 73 (p = 0.005).

CONCLUSION

We observed overall poor outcomes, significant complications and concerning reoperation rates. Cases with previous joint replacement were associated with the worst outcomes.

Posterior versus lateral approach for hemiarthroplasty after femoral neck fracture: Early complications in a prospective cohort of 583 patients

AIM

To compare early complications after the posterior and the direct lateral (transgluteal) approach, when using hemiarthroplasty in the treatment of displaced femoral neck fractures in the elderly.

PATIENTS AND METHODS

A prospective clinical study from four Norwegian hospitals, consisting of 583 patients with 1year follow-up. All the hospitals used the same uncemented femoral stem and bipolar heads. Data were collected for gender, age, surgical approach, prosthetic dislocation, postoperative infection, perioperative fracture, duration of surgery, ASA score, diabetes, alcoholism, cognitive failure, BMI, 30-day mortality and 1-year mortality.

RESULTS

Mean age was 83 years (SD 7.8) and 434/583 (74%) were female. There were no relevant differences between the treatment groups. A higher risk was found for prosthetic dislocation in the posterior group compared to the lateral group (15/186 (8%) vs. 4/397 (1%); RR=8.0, 95% CI 2.7-23.8, p-value<0.001), both as a one-time event and for the risk of recurrent dislocations (9/186 (5%) vs. 2/395 (0.5%); RR 9.6, 95% CI 2.1-44.0, p-value=0.001). 11/19 patients with dislocation had recurrent dislocations. 10/11 patients with more than one dislocation needed further open surgery. Of those 6/10 needed more than one additional open procedure. Three patients had a resection arthroplasty and one patient had a chronic infection as final result after a dislocation. No other risk factor for dislocation than surgical approach was identified. There were no differences between the approach groups for other complications.

CONCLUSION

There was an 8-fold increased risk for prosthetic dislocations after the posterior approach compared to lateral approach. There was a high risk for recurrent prosthetic dislocations and a subsequent risk for further surgeries and a poor end result. The potential advantages of the posterior approach have not been demonstrated after femoral neck fractures and we advise against its continued use.

Implant Survival After Minimally Invasive Anterior or Anterolateral Vs. Conventional Posterior or Direct Lateral Approach: An Analysis of 21,860 Total Hip Arthroplasties from the Norwegian Arthroplasty Register (2008 to 2013)

BACKGROUND

Since 2008, there has been an increase in the use of minimally invasive surgery (MIS) through an anterior or anterolateral approach for total hip arthroplasty (THA) in Norway. We compared the MIS approaches with the conventional posterior and direct lateral approaches in terms of revision rates and risk of revision.

METHODS

On the basis of data in the Norwegian Arthroplasty Register, 21,860 THAs with an uncemented stem, performed between 2008 and 2013, were identified and included in the cohort. Of these THAs, 2,017 were done through an MIS anterior approach; 2,087, through an MIS anterolateral approach; 5,961, through a posterior approach; and 11,795, through a direct lateral approach. Follow-up ended on December 31, 2015. Two and 5-year survival rates were calculated using Kaplan-Meier survival analysis. Relative risk (RR) was calculated using Cox regression analysis, with adjustment for age, sex, primary diagnosis, American Society of Anesthesiologists (ASA) grade, femoral head size, cup fixation, type of articulation, and duration of surgery and using 6 revision end points based on cause: any cause, infection, dislocation, femoral fracture, aseptic loosening, and other/unknown cause. The median duration of follow-up was 4.3 years.

RESULTS

There were no significant differences among the surgical approaches with regard to the 2 and 5-year survival rates or RR of revision due to any cause. The RR of revision due to infection was 0.53 (95% confidence interval [CI] = 0.36 to 0.80, p = 0.002) for the MIS anterior and anterolateral approaches and 0.57 (95% CI = 0.40 to 0.80, p = 0.001) for the posterior approach compared with the direct lateral approach. The RR of revision due to dislocation was 2.1 (95% CI = 1.5 to 3.1, p < 0.001) for the posterior approach compared with the direct lateral approach but no significant difference in risk was found when the MIS anterior and anterolateral approaches were compared with the direct lateral approach (RR = 0.71, 95% CI = 0.40 to 1.3, p = 0.25).

CONCLUSIONS

The revision rates and risk of revision associated with the MIS anterior and anterolateral approaches were not increased compared with those of the conventional posterior and direct lateral approaches.

LEVEL OF EVIDENCE

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

Effect of Acetabular Component Positioning on Functional Outcomes in Primary Total Hip Arthroplasty

BACKGROUND

Acetabular component positioning is crucial to a successful total hip arthroplasty (THA). This study evaluated the effect of absolute acetabular component position as well as acetabular position relative to bony anatomy on patient-reported functional outcomes after primary THA.

METHODS

Primary, press fit, hemispherical metal-on-polyethylene THA performed between 2003 and 2011 were analyzed. Western Ontario and McMaster Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), Short Form-12 scores, and radiographs between 2 and 3 years after the index procedure were assessed.

RESULTS

Of the 1241 primary THA included, the mean abduction and anteversion angles were 44.4 ± 6.94 and 21.7 ± 11.9 degrees, respectively. The mean anterior and lateral overhang were 1.9 ± 3.6 and 2.5 ± 3.4 mm, respectively. There was no correlation between functional outcomes and acetabular inclination. A weak positive correlation between anteversion and HHS (P < .001) and WOMAC (P = .02) scores was found. For relative position, anterior overhang of the acetabular component beyond the bone resulted in inferior Short Form-12 physical function (P = .001), HHS (P = .004), and WOMAC (P < .001) scores compared to those with bony coverage. Mean HHS pain score was 41.20 ± 5.69 in patients with lateral overhang and 41.97 ± 5.04 in those who had bony coverage of the lateral edge of the acetabular component (P = .02).

CONCLUSION

The tribology and biomechanics of acetabular component position have been extensively studied without examination of how it affects patient function. Although statistical significance was seen, clinical outcome scores were not sensitive enough to show a clinically significant effect of the absolute or relative position of the acetabular component.

Lesion of the hip abductor mechanism

Introduction: The disruption of the abductor muscles of the hip after hip revision surgery often causes limping, pain, and instability of the implant. The purpose of our paper is to describe a mesh technique to repair hip abductor mechanism injuries after hip revision.

Patients and methods: Forty-six patients with hip abductor damage after prosthetic revision were treated. Inclusion criteria were: patients presenting with prosthetic loosening, complaint of pain, and with a positive Trendelenburg sign due to deficient abductor muscle mechanisms. Thirty-one were women (67.39%) with an average age of 64 years (34–82 years). The number of previous revision surgeries was three (two to seven). The Merle d’Aubigné score and variants before and after treatment were also reported.

Results: In the postoperative follow-up after hip revision with the mesh technique, the Merle d’Aubigné score improved and the Trendelenburg sign was negative in 78.3% of the patients (p < 0.001). Also, the Trendelenburg test with the knee flexed was negative in 60.9% (p < 0.001) and the stair-climbing test was negative in 60.9% of cases (p < 0.001). The gluteus medius test in the lateral position was negative in 52.2% of patients, and in the lateral position with the knee flexed it was negative in 47.8% of patients (p < 0.001).

Discussion: Repair of the abductor mechanism with the mesh technique has proven effective for both partial and total lesions.

Results following repair of gluteus medius defects following total hip arthroplasty

13 patients with tears in the gluteus medius tendon following total hip arthroplasty were studied. The diagnosis of a gluteal tear was made on the basis of clinical signs and a positive arthrogram of the hip in all cases. 11 patients underwent gluteus medius repair and two patients declined surgery. 10 patients attended a review clinic (eight gluteal repair patients and two conservatively managed patients) and three were reviewed by telephone and medical notes. The mean follow up was 61 months (range 12-116 months). The mean age at follow up was 71.42 years (69-79 years) and the male to female ratio was 5:8. The mean duration of symptoms prior to repair was 16 months. An anterolateral transgluteal approach had been used for primary surgery in nine cases and in four cases the original surgical approach was unknown. The mean Harris Hip score prior to repair was 77.4 (range 55-87), which improved to a mean post operative Harris hip score of 86.97 (range 79-96) following repair. The Oxford hip score prior to repair was 20 (range 16-25) which improved to a mean of 14.2 after repair (range 4-29). 9 out of 11 patients who had the repair were satisfied and would recommend the procedure. We believe an accurate and timely diagnosis together with repair can reduce the morbidity associated with this post-operative complication following THA.

Incidence and Location of Pain in Young, Active Patients Following Hip Arthroplasty

Persistent pain following hip arthroplasty remains a concern, especially in young, active patients. Four hundred twenty patients less than 60 years of age with a pre-symptomatic UCLA score ≥ 6 (196 total hip arthroplasty [THA]; 224 surface replacement arthroplasty [SRA]) completed a pain-drawing questionnaire investigating the location, severity, and frequency of pain around the hip. At a mean of 2.9 years of follow-up, 40% reported pain in at least one location around the hip. There was no difference in the incidence of groin pain between SRA and THA patients (32% vs. 29%, P=0.6), but THA patients had a greater incidence of anterior (25% vs. 8%, P<0.001) and lateral (20% vs. 10%, P=0.01) thigh pain. A high percentage of young, active patients experience persistent pain following hip arthroplasty.