Cementless THA for the treatment of osteonecrosis at 10-year follow-up: have we improved compared to cemented THA?

Trends in prevalence and complications for smokers who underwent total hip arthroplasty from 2011 to 2019: an analysis of 243,163 patients

BACKGROUND

Smoking is an established risk factor for postoperative complications after total hip arthroplasty (THA). It is unknown if the decreasing prevalence of adult smoking in the United States is reflected in the elective THA patient population. We aimed to investigate recent trends in: (1) the prevalence of smoking pre-THA, stratified by patient demographics; and (2) rates of 30-day complications and increased healthcare utilisation post-THA in smokers versus non-smokers.

METHODS

Patients who underwent primary elective THA (2011-2019) were identified using the National Surgical Quality Improvement Program database. A total of 243,163 cases (Smokers: n = 30,536; Non-smokers: n = 212,627) were included. Trends analyses were performed for smoking prevalence across the study period. Smokers were propensity score-matched (1:1) to a cohort of non-smokers (n = 29,628, each), and rates of 30-day complications, readmission, and non-home discharge were compared.

RESULTS

The rate of preoperative smoking significantly decreased from 14.0% in 2011 to 11.6% in 2019 (p-trend = 0.0286). When stratified, a significant decreasing trend in smoking was found for males and all races; within races, American-Indian/Alaska-Native race had the sharpest decline (2011:36.3% vs. 2019:23.2%). No significant change in 30-day complication rates among smokers or non-smokers was observed (p-trend > 0.05), but non-home discharge significantly decreased for both smokers (p-trend = 0.001) and non-smokers (p-trend < 0.001). After matching, higher rates of superficial surgical site infections (SSI) (0.9% vs. 0.5%; p < 0.001), deep SSI (0.5% vs. 0.3%; p < 0.001), wound disruption (0.2% vs. 0.1%; p = 0.006), and readmission (4.2% vs. 3.1%; p = <0.001) were found in smokers versus non-smokers.

CONCLUSIONS

The present study is encouraging that national efforts to reduce the prevalence of smoking may be successful within the THA population, but there is a persistently elevated risk of postoperative complications in smokers after THA.

The Preserved Thickness Ratio of the Femoral Head Contributes to the Collapse Predictor of Osteonecrosis

OBJECTIVES

The collapse of femoral head is a serious symptom of osteonecrosis of the femoral head (ONFH), resulting in hip pain and deformity. However, it is hardly possible to reestablish the femoral head nonoperatively once the collapse happens. Predicting femoral head collapse is of great value for the prognosis of ONFH. This study aimed to develop a new method to quantify the preserved thickness of femoral head and to assess its diagnostic contribution in predicting femoral head collapse on plain radiographs.

METHODS

This was a single-center retrospective study. A total of 101 hips (85 patients) with ARCO stage II from January 2008 to December 2016 were included in this study. The preserved thickness was measured on standard anteroposterior (AP) and frog-leg (FL) radiographs. The anteroposterior view's preserved thickness ratio (APTR) and the frog-leg view's preserved thickness ratio (FPTR) were calculated to show the preserved thickness ratio of the femoral head anteriorly and laterally. Univariate and multivariate logistic regression was performed to determine the risk factors for collapse. Sensitivity, specificity, and cut-off values for APTR and FPTR were determined by the receiver operating characteristic (ROC) curve analysis. Kaplan-Meier (K-M) analysis was applied to determine femoral head survival in ONFH patients.

RESULTS

The mean age of the 27 females and 58 males was 38.93 years old. The mean follow-up time was 74.62 (36-124) months in the non-collapse group and 18.66 (3-82) months in the collapse group. Femoral head collapse was observed in 62 hips during the follow-up period. Logistic regression analysis and ROC results showed that APTR <24.79% and FPTR <10.62% were significantly correlated with femoral head collapse. The Kaplan-Meier survival curve suggested that the overall survival rate of APTR ≥24.79% was 68.2% at 5 and 10 years and FPTR ≥10.62% was 71.63% at 5 and 10 years. At the last follow-up, 26 hips had collapse on the anterior side of the femoral head, 12 hips occurred on the lateral side, and 24 hips happened to collapse on both anterior and lateral sides.

CONCLUSION

Femoral head collapse predominantly occurred anteriorly rather than laterally in ONFH patients. The measurements of APTR and FPTR have noticeable implications for the prediction of femoral head collapse, and contribute to the selection of treatment options for ONFH patients with types B and C1 according to the JIC classification.

Increased Risk of In-Hospital Complications and Costs After Total Hip Arthroplasty for Primary and Secondary Osteonecrosis

BACKGROUND

An increasing proportion of patients are undergoing total hip arthroplasty (THA) for osteonecrosis (ON). Comorbid conditions and surgical risk factors are known to be greater in ON patients compared with patients who have osteoarthritis (OA) alone. The purpose of our study was to quantify the specific in-hospital complications and resource utilization associated with patients undergoing THA for ON versus OA.

METHODS

A large national database was queried to identify patients undergoing primary THA from January 1, 2016 to December 31, 2019. A total of 1,383,880 OA, 21,080 primary ON, and 54,335 secondary ON patients were identified. Demographics, in-hospital complications, costs, lengths of stay, and discharge dispositions for primary and secondary ON cohorts were compared to OA only. Age, race, ethnicity, comorbidities, Medicaid, and income status were controlled with binary logistic regression analyses.

RESULTS

The ON patients were often younger, African American or Hispanic, and had more comorbidities. Those undergoing THA for primary and secondary ON had a significantly higher risk of perioperative complications, including myocardial infarction, postoperative blood transfusion, and intraoperative bleeding. Total hospital costs and lengths of stay were significantly higher for both primary ON and secondary ON and both cohorts were less likely to be discharged home.

CONCLUSION

While rates of most complications have decreased over recent decades in ON patients undergoing THA, the ON patients still have worse outcomes even when controlling for comorbidity differences. Bundled payment systems and perioperative management strategies for these different patient cohorts should be considered separately.

Cemented versus Cementless Total Hip Arthroplasty for Femoral Head Osteonecrosis: A Study Based on National Claim Data in South Korea

INTRODUCTION

The purpose of this study was to compare the rates of revision, periprosthetic joint infection (PJI), and periprosthetic fracture (PPF) between patients with osteonecrosis of the femoral head (ONFH) undergoing noncemented total hip arthroplasty (THA) and cemented THA using a national claim data in South Korea.

METHODS

We identified patients who received THA for ONFH from January 2007 to December 2018 using ICD diagnosis codes and procedural codes. Patients were categorized into two groups according to the fixation method: with or without cement. The survivorship of THA was calculated using the following end points: revision of both the cup and stem, revision of the single component, any type of revision, PJI, and PPF.

RESULTS

A total of 40,606 patients: 3,738 patients (9.2%) with cement and 36,868 patients (90.7%) without cement, received THA for ONFH. The mean age of the noncemented fixation group (56.2 ± 13.2 years) was significantly lower than that of the cemented fixation group (57.0 ± 15.7 years, P = 0.003). The risk of revision and PJI was notably higher in cemented THA (hazard ratio: 1.44 [1.21 to 1.72] and 1.66 [1.36 to 2.04], respectively). Noncemented THA had a higher 12-year survivorship compared with cemented THA with any revision and PJI as the end point.

DISCUSSION

Noncemented fixation had better survivorship than cemented fixation in patients with ONFH.

Does an Ultra-Short Anatomic Cementless Femoral Stem Improve Long-Term (Up to 17 Years) Results in Patients Younger Than 30 Years?

BACKGROUND

The purpose of this long-term (up to 17 years) follow-up study was to determine: (1) clinical results and evidence of clicking or squeaking sounds; (2) radiographic results, including rates of osseointegration, bone remodeling, and osteolysis; (3) rates of complications including thigh pain, periprosthetic fracture, and ceramic fracture; (4) rates of revision; and (5) survival rates of implants in patients younger than 30 years.

METHODS

We analyzed the results of 240 consecutive primary total hip arthroplasty in 180 patients (118 men and 62 women who had a mean age of 27 years (range, 21 to 30 years)). The mean follow-up was 16 years (range, 14 to 17 years).

RESULTS

Mean Harris hip score, Western Ontario and McMaster Universities score, and University of California, Los Angeles activity score were 93 points, 18 points, and 7 points, respectively, at final follow-up. Radiographically, all of the acetabular components and all but two femoral components were well-fixed at the final follow-up. No hip had osteolysis or exhibited Grade 3 stress shielding. All but two patients had no groin or thigh pain. No hip had a periprosthetic or ceramic fracture. Eight hips (3%) exhibited squeaking sounds. Two acetabular components and two femoral stems were revised. The survival of the acetabular and femoral component was 99.2% (95% confidence interval, 94 to 100%).

CONCLUSION

The results of the present long-term study of ultra-short anatomic cementless femoral stems suggest excellent clinical and radiographic results in patients younger than 30 years.

An early experience of the use of dual mobility cup uncemented total hip arhroplasty in young patients with avascular necrosis of the femoral head

Introduction

THA (Total hip arthroplasty) in advanced grade (grade 4) avascular necrosis (AVN) is a challenge to the treating surgeon as it affects young patients who have high functional demands and increased dislocation risk. The aim of the study was to evaluate the efficacy, survivorship, and dislocation rate of uncemented dual mobility cups (DMC) in advanced grade IV AVN young patients.

Methods

Retrospective cohort study involving 204 DMC THA for advanced grade IV AVN from January 2013 to December 2015. The sample size of the study was estimated to be 188 hips with an α error of 0.05 and β error of 0.2. Inclusion criterion was patients less than 55 years of age with advanced grade IV AVN. Patients >55 years of age, patients diagnosed with primary osteoarthritis of the hip and hip fracture were excluded from the study. 172 patients (32 with bilateral & 140 with unilateral affection) with 204 DMC THA were evaluated clinically by Harris Hip Score (HHS) and radiologically at a follow up of 60 months. P value < 0.05 was considered significant.

Results

Mean age of the patients was 42.5 ± 5.3. Preoperative HHS was 50.6 ± 10.5. Postoperative HHS at 5 years follow up was 96.4 ± 2.6. None of the operated patient had any dislocation episode or had undergone hip revision surgery (statistically significant against historical control of 2%, p value = 0.042). The radiological evaluation at 5 years showed no signs of radiolucent lines, periprosthetic osteolysis, polyethylene wear and signs of displacement or migration of the DMC. Cumulative survivorship rate at 5 years follow up was 100% without any revision/dislocation.

Conclusion

Use of DMC THA in young, advanced grade IV AVN patients was found to be a reliable option showing excellent early functional results with no dislocation. Ongoing follow up of this cohort is required to confirm the maintenance of these excellent functional results at follow up in the long term.

Outcomes of surgical hip dislocation combined with bone graft for adolescents and younger adults with osteonecrosis of the femoral head: a case series and literature review

Background

Osteonecrosis of the femoral head (ONFH) may occur in the adolescent and younger adults (AYAs). Total hip arthroplasty (THA) is not the best treatment option for younger patients. Surgical hip dislocation (SHD) combined with bone graft can be used in patients at different stages to reconstruct the bone structure in the head and delay the replacement time. The purpose of this study was to evaluate the effect and potential influencing factors of this surgery for ONFH in AYA patients. 

Methods

We conducted a literature review and a retrospective research of our own cases. The Pubmed, Cochrane Library, EMBASE and CNKI databases were searched from 1 January 2001 to 1 October 2021, for clinical studies. A retrospective case series study of 34 patients (38 hips) treated with SHD combined with bone graft was performed.

Results

A total of 13 studies were included and the results showed that SHD combined with bone grafts had better clinical results for patients with pre- or early post-collapse. In the case series study, we retrospectively analyzed 34 patients (38 hips), and the mean follow-up time was 40.77 ± 15.87 months. One patient died and three patients were converted to THA finally. The post-collapse degree and post-lesion size were better than those before the operation (P < 0.05). The iHOT-12 at the last follow-up was significantly higher than that before the operation (P < 0.05). There were significant differences in the results of hip Harris score (HHS), visual analogue scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) before the operation, 2 years after the operation and at the last follow-up, but the difference was not related to the follow-up time (P < 0.05). There were no significant differences in the final clinical score and arthritic changes among different Japanese Investigation Committee (JIC) classification, the degree of collapse and the size of the necrotic (P > 0.05).

Conclusions

In AYA patients, SHD combined with bone grafting is a potentially good option for hip preservation in ONFH. The differences in JIC classification, collapse degree and lesion size did not affect the final clinical function and the risk of osteoarthritis. Even for very severe cases at collapsed stage, good short-term clinical effects can still be achieved by SHD combined with bone graft.

Trial registration

ChiCTR2100055079.retrospectively registered. 

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05456-w.

Evolutionary course of the femoral head osteonecrosis: Histopathological - radiologic characteristics and clinical staging systems

Osteonecrosis of the femoral head (ONFH) is a recalcitrant ischemic disorder, which could be classified into two major categories: traumatic and nontraumatic. Regardless of different risk factors, it has been testified that ONFH results from primitive vascular problems, leading to temporary or permanent loss of blood supply to bone tissue. Histopathological and microarchitectural alterations ensues, which is a gradual evolutionary process involving bone marrow and osteocyte necrosis, progressive destruction of subchondral bone, unsuccessful reparative process, and eventual articular collapse and degenerative arthritis. Based on the imaging features of ONFH, different classification systems have been developed to evaluate the severity and prognosis of the disease, which is pivotal for implementation of treatment strategy, especially the joint-preserving surgery. However, patients classified with the same severity stage, especially in the peri-collapse stage, sometimes responded differently after similar joint-preserving surgery. The unusual phenomenon may be attributed to the limitation of the current imaging classification systems, which might underestimate the disease severity, especially when referring to the early stages. In this review, we briefly summarize the etiology and pathogenesis of ONFH. The imaging features and staging classification systems of ONFH are also described. More importantly, we focus on histopathological and microstructural alterations of the femoral head, and provide an overview of their essential contribution to ONFH progression. Given the observation of discordance between imaging characteristics and histopathological alterations, a substantial amount of research on the relationship between imaging and histopathological features is required to further modify and revise the current wide-accepted classification systems.

Cell therapy for osteonecrosis of femoral head and joint preservation

Osteonecrosis of femoral head (ONFH) is a disease of the femoral head and can cause femoral head collapse and arthritis. This can lead to pain and gait disorders. ONFH has various risk factors, it is often progressive, and if untreated results in secondary osteo-arthritis. Biological therapy makes use of bone marrow concentrate, cultured osteoblast and mesenchymal stem cell (MSC) obtained from various sources. These are often used in conjunction with core decompression surgery. In this review article, we discuss the current status of cell therapy and its limitations. We also present the future development of biological approach to treat ONFH.

Simultaneous primary bilateral hip resection arthroplasty

Hip resection arthroplasty is a useful procedure for the management of complex hip problems and in patients with high surgical and anesthetic risk factors. Unilateral procedures performed for failed total hip arthroplasty have been shown to be successful for pain relief with acceptable functional outcomes; however, to our knowledge, no research exists on simultaneous bilateral hip resection arthroplasty for femoral head osteonecrosis. We present two cases of single-stage bilateral hip resection arthroplasty performed under singular anesthetic procedures for femoral head osteonecrosis. The patients were each able to stand for transfers postoperatively and had no deterioration in pain or function. These two cases demonstrate that satisfactory pain control with preservation of function may be achievable with bilateral hip resection arthroplasty procedures in patients who are not a candidate for more advanced reconstructive procedures.

Clinical Follow-up Study of the Reconstruction of the Femoral Head With Transferred Vascularized Greater Trochanter Bone Graft for Association Research Circulation Osseous III-IV Osteonecrosis of the Femoral Head

PURPOSE

The aim of the study was to investigate the curative efficacy of osteonecrosis of the femoral head (ONFH) in a hip-preserving operative approach, by transferring a vascularized greater trochanter graft combined with osteotomy of the upper third of femoral head, in an attempt to seek an innovative approach for patients who experienced middle- to late-stage ONFH with femoral head's weight-bearing area severely collapsed.

METHOD

Our research included a total of 23 patients (23 hips) who accepted hip-preserving surgery by reconstructing the femoral head with transferred vascularized greater trochanter bone graft for ONFH from January 2013 to December 2017. The definition of reconstructing the femoral head is that we do the osteotomy on the upper third of the femoral head with weight-bearing area severely collapsed, and the remnant femoral head requires a hemispherical bone graft to recover the shape. A vascularized greater trochanter bone graft was next transferred and fixed at the upper portion of the remnant femoral head, and then, the shape and vascular supply of the femoral head are successfully reconstructed. The clinical assessment was performed with Harris Hip Score system. Kaplan-Meier survival curves with femoral head collapse as the end point showing the probability of progression in collapsed femoral head based on the gender, age and body mass index.

RESULTS

Twenty-three patients (23 hips) were eventually contacted by telephone for an outpatient clinic follow-up, with a mean follow-up time of 41.35 months (varied from 16 to 72 months), no patients lost contact. Seven patients (7 hips) had radiographic stage progress. One patient (1 hip) had conversion to total hip arthroplasty at 24 months postoperatively because of progressive femoral head collapse and severely pain. The image success rate was 69.6%, clinical success rate was 65.2%, and the clinical survival rate was 96%. The average Harris Hip Score was 82.5 ± 5.5 points at the last follow-up, representing a great improvement compared with the 51.9 ± 7.2 points obtained preoperatively (P<0.05). Kaplan-Meier survival curves with femoral head collapsed as the end point showing the probability of progression in collapsed femoral head based on the sex, age, and body mass index.

CONCLUSIONS

Reconstructing the femoral head with transferred vascularized greater trochanter bone graft provides a new method for the treatment of the young Association Research Circulation Osseous stage III-IV ONFH patients with severely femoral head collapsed, which can better improve the patient's symptoms, the quality of life, and delay the age of undergoing arthroplasty in young patients.

Long-Term Survival (up to 34 Years) of Retained Cementless Anatomic Femoral Stem in Patients <50 Years Old

BACKGROUND

There is a paucity of studies longer than 30 years to determine clinical and radiographic results of retained cementless anatomic stem. The purpose of this study is to determine the long-term (up to 34 years) survival rate of the retained cementless anatomic femoral stem in patients <50 years of age.

METHODS

Isolated cup revision was performed with retaining primary cementless anatomic femoral stem in 206 patients (149 men and 57 women). Clinical and radiographic results were monitored at each follow-up. At the latest follow-up, computed tomography scans were carried out in all hips to determine the prevalence of osteolysis. The mean follow-up of the retained femoral stem was 30.3 years (range 27-34). The mean follow-up of the revised cup was 25.5 years (range 22-29).

RESULTS

The mean Harris Hip Score was 91 ± 7.8 points (range 71-100) and the mean Western Ontario and McMaster Universities Osteoarthritis score was 16 ± 7 points (range 7-34) at the final follow-up. The mean University of California, Los Angeles activity score was 7 ± 4 points (range 5-10) at the final follow-up. The overall survival rate of retained cementless femoral stems was 98.9% (95% confidence interval 91-100) at 30.3 years. The survival rate of the revised cup was 93% (95% confidence interval 89-98) at 25.5 years.

CONCLUSION

The rate of aseptic loosening of already osseointegrated femoral stem remains low with ceramic-on-ceramic bearing in young active patients.

Total Hip Arthroplasty in Adolescents and Young Adults for Management of Advanced Corticosteroid-Induced Osteonecrosis Secondary to Treatment for Hematologic Malignancies

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a potentially severe toxicity associated with glucocorticoid treatment for pediatric hematologic malignancy. We examined clinical outcomes of THA in adolescents and young adults treated for hematologic malignancies who developed advanced ONFH.

METHODS

In a single-institution cohort, we retrospectively reviewed medical records and imaging for perioperative complications, reoperations, functional assessment at last follow-up, and radiological outcomes. Twenty-seven patients (41 hips) underwent THA (bilateral in 14 patients). There were 11 males. Median (interquartile range [IQR]) age at primary diagnosis was 14.9 years [1.8-18.9]. The median (IQR) age at THA was 19.8 years [14.6-30.3]. Mean (range) post-THA follow-up was 111.5 months (65.4-165.8).

RESULTS

Perioperative complications included one intraoperative calcar fracture that was secured with a cerclage wire and one posterior hip dislocation that occurred 6 days postoperatively, requiring closed reduction. One hip required a revision 21.1 months post-THA due to a fractured ceramic liner. The radiographic review was available for 38 of 41 hips and demonstrated none with loosening, subsidence, or osteolysis; nine developed periacetabular stress shielding. Incidence of stress shielding was associated with increased postoperative pain (P = .0130). There was a significant functional improvement in range of motion (ROM), pain, use of supports, participation in school, work, and sports, and use of pain medication from preoperative to postoperative clinical visits (P < .001).

DISCUSSION

Total hip arthroplasty in adolescents and young adults offers symptomatic and functional improvement in patients with ONFH. We found it to be safe with low perioperative complication rates even in patients undergoing active treatment for malignancy.

LEVEL OF EVIDENCE

Level IV, case series study. See Instructions for authors for a complete description of levels of evidence.

Japanese Orthopaedic Association 2019 Guidelines for osteonecrosis of the femoral head

PURPOSE

The Clinical Practice Guidelines for Osteonecrosis of the Femoral Head (ONFH) 2019 Edition, written by the working group for ONFH guidelines of the Japanese Investigation Committee (JIC) for ONFH under the auspices of the Japanese Ministry of Health, Labour, and Welfare and endorsed by the Japanese Orthopaedic Association, were published in Japanese in October 2019. The objective of this guideline is to provide a support tool for decision-making between doctors and patients.

METHODS

Procedures for developing this guideline were based on the Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014, which proposed an appropriate method for preparing clinical guidelines in Japan.

RESULTS

This clinical practice guideline consists of 7 chapters: epidemiology; pathology; diagnosis; conservative therapy; surgical treatment: bone transplantation/cell therapy; surgical treatment: osteotomy; and surgical treatment: hip replacement. Twelve background questions and 13 clinical questions were determined to define the basic features of the disease and to be addressed when deciding treatment in daily practice, respectively.

CONCLUSIONS

The clinical practice guidelines for the ONFH 2019 edition will be useful for physicians, investigators, and medical staff in clinical practice, as well as for patients, during the decision-making process when defining how to treat ONFH.

Thirty-Day Complications in Osteonecrosis Patients Following Total Hip Arthroplasty

BACKGROUND

Thirty-day complications in osteonecrosis (ON) patients undergoing total hip arthroplasty (THA) are inconsistently reported. Therefore, the purpose of this study is to evaluate (1) the incidence of THA, (2) operative times, (2) length of stay, (3) reoperation rates, (4) readmission rates, and (5) complication rates, in the general vs ON THA populations. We also substratified and compared these cohorts based on ON-specific risk factors.

METHODS

Using the National Surgical Quality Improvement Program database, Current Procedural Terminology code 27130, International Classification of Disease, Ninth Edition code 733.42, and a 1:1 propensity score match, a total of 8344 matched ON and non-ON THA patients were identified. ON patients were also substratified based on key risk factors. The above variables were compared between the matched ON and non-ON cohorts as well as for patients with each risk factor using Pearson's chi-square and Student t-tests.

RESULTS

The proportion of THAs performed on ON patients decreased by 35% from 2008 to 2015. Mean operative times were constant between the ON and non-ON patients (102 minutes). ON patients had shorter mean length of stay (3.1 vs 3.4 days, P = .002). Of the 17 different 30-day complications evaluated, superficial surgical site infection (1.2% vs 0.6%, P = .004), pneumonia (0.8% vs 0.2%, P = .001), transfusion (15.6% vs 5.4%, P < .001), and readmission (5.1% vs 2.3%, P = .012) were higher among ON patients. ON patients with a history of corticosteroid use, higher American Society of Anesthesiologists score, and smoking were also found to have higher complication rates compared to non-ON patients with the same risk factors.

CONCLUSION

This is one of the first studies to compare postoperative THA outcomes between matched ON vs non-ON patients, while also taking into consideration specific risk factors between the cohorts.

Management of osteonecrosis of the femoral head

Aims

Earlier studies dealing with trends in the management of osteonecrosis of the femoral head (ONFH) identified an increasing rate of total hip arthroplasties (THAs) and a decreasing rate of joint-preserving procedures between 1992 and 2008. In an effort to assess new trends in the management of this condition, this study evaluated the annual trends of joint-preserving versus arthroplasties for patients aged < or > 50 years old, and the incidence of specific operative management techniques.

Methods

A total of 219,371 patients with ONFH were identified from a nationwide database between 1 January 2009 and 31 December 2015. The mean age was 54 years (18 to 90) and 105,298 (48%) were female. The diagnosis was made using International Classification of Disease, Ninth revision, Clinical Modification (ICD-9-CM) and Tenth Revision, Clinical Modification (ICD-10-CM) procedure codes. The percentage of patients managed using each procedure during each year was calculated and compared between years. The trends in the use of the types of procedure were also evaluated.

Results

The rate of joint-preserving procedures was significantly higher in patients aged < 50 years compared with those aged > 50 years (4.93% vs 1.52%; p < 0.001). For the overall cohort, rates of arthroplasty were far greater than those for joint-preserving procedures. THA was the most commonly performed procedure (291,114; 94.03%), while osteotomy (3,598; 1.16%), partial arthroplasty (9,171; 2.96%), core decompression (1,200; 0.39%), and bone graft (3,026; 0.98%) were performed markedly less frequently. The annual percentage of patients managed using a THA (93.56% to 89.52%; p < 0.001), resurfacing (1.22% to 0.19%; p < 0.001), and osteotomy (1.31% to 1.05%; p < 0.001) also decreased during the study period.

Conclusion

We found that patients with ONFH have been most commonly managed with non-joint-preserving procedures. Our findings provide valuable insight into the current management of this condition and should increase efforts being made to save the hip joint. Cite this article: Bone Joint J 2020;102-B(7 Supple B):122–128.

Guidelines for clinical diagnosis and treatment of osteonecrosis of the femoral head in adults (2019 version)

Osteonecrosis of the femoral head (ONFH) is a common and refractory disease in orthopaedic clinics. The number of patients with ONFH is increasing worldwide every year. There are an estimated 8.12 million patients with nontraumatic osteonecrosis in China alone. Treatment of nontraumatic osteonecrosis has always been a clinical challenge for orthopaedic surgeons. To further standardize diagnosis and treatment of ONFH, these guidelines provide not only basic diagnosis, treatment, and evaluation systems for ONFH but also expert advice and standards in many aspects, including epidemiology, aetiology, diagnostic criteria, pathological staging, prevention and treatment options, and postoperative rehabilitation. The aetiological factors of ONFH can currently be divided into two major categories: traumatic and nontraumatic; however, the specific pathological mechanism of ONFH is not completely clear. Currently, the staging system of ONFH formulated by the Association Research Circulation Osseous is widely used in clinical practice. Based on the changes in the intraosseous blood supply at different stages, the corresponding nonsurgical and surgical treatments are recommended, and when there are risk factors for possible ONFH, certain preventive measures to avoid the occurrence of osteonecrosis are recommended. These guidelines provide brief classification criteria and treatment regimen for osteonecrosis. Specification of the aetiology, treatment plan based on comprehensive consideration of the different stages of osteonecrosis, hip function, age, and occupation of the patients are important steps in diagnosis and developing treatment strategies.

TRANSLATIONAL POTENTIAL OF THIS ARTICLE

New advances in the epidemiology, etiology, pathophysiology, imaging, diagnosis and treatment of ONFH have been renewed in this revision. This guideline can be used for reference by orthopedic professionals and researchers, and for standardized diagnosis and treatment management under the clinical guidance, which is conducive to the prevention, treatment and further research of ONFH, improving the diagnosis and treatment level, making patients' symptoms under good control, and improving their quality of life.

Ultra-Short Anatomic Uncemented Femoral Stem and Ceramic-on-Ceramic Bearing in Patients With Idiopathic or Ethanol-Induced Femoral Head Osteonecrosis

BACKGROUND

Long-term result of the ultra-short anatomic cementless stem in the patients with idiopathic or ethanol-induced osteonecrosis of the femoral head has not been assessed. The aim of this study is to evaluate the long-term clinical, radiographic, computed tomography scan, and dual-energy X-ray absorptiometry scanning results, and survivorship of this specific femoral stem in patients with idiopathic or ethanol-induced femoral head osteonecrosis.

METHODS

Two hundred fifty-six patients (335 hips) with an average age of 49.8 years (range 20-63) were enrolled in the current study. All patients underwent dual-energy X-ray absorptiometry scanning of the acetabulum and proximal femur preoperatively and at final follow-up. Computed tomography scan was obtained in all patients at final follow-up. The mean follow-up was 14.7 years (range 13-16).

RESULTS

At final follow-up, the average Harris hip score, Western Ontario and McMaster Universities Osteoarthritis Index score, and University of California, Los Angeles activity score were 94 points, 12 points, and 8 points, respectively. Four stems (1%) underwent revision for aseptic loosening. One acetabular component (0.3%) was revised for recurrent dislocation. No hip was revised for squeaking or clicking sound. Survivorship of the femoral stem was 99.0% (95% confidence interval 94-100) and that of the acetabular component was 99.4% (95% confidence interval 95-100) at 14.7 years.

CONCLUSION

Ultra-short proximal loading anatomic uncemented femoral stems with ceramic-on-ceramic bearings have excellent survivorship free from aseptic loosening and good clinical results at long term.

LEVEL OF EVIDENCE

Level IV.

[Total hip replacement in avascular femoral head necrosis]

BACKGROUND

Avascular necrosis of the femoral head is a progressive perfusion disorder of the hip joint. Progress in avascular necrosis causes structural damage to the affected joint, often requiring total hip replacement.

AIM

This article is intended to give the reader an overview of the current literature on total hip replacement of patients with an avascular necrosis of the femoral head.

RESULTS

Before 1990, patients with avascular necrosis of the femoral head had significantly higher revision rates after total hip replacement. Recent studies, however, showed no significant differences in clinical outcomes after total hip replacement in femoral head necrosis and primary osteoarthritis. Despite the young age of the patients, good long-term clinical results can be expected even in patients with an avascular necrosis of the femoral head after total hip replacement.

Long-Term Survivorship of Total Hip Arthroplasty with Highly Cross-Linked Polyethylene for Osteonecrosis

BACKGROUND

Osteonecrosis of the hip is the underlying etiology for 3% to 12% of total hip arthroplasties (THAs). Compared with patients who undergo THA because of osteoarthritis, those who do so because of osteonecrosis typically are younger, have a greater number of underlying diagnoses, and have inferior clinical outcomes and implant survivorship. The purpose of this study was to compare the long-term implant survivorship (median follow-up, 10 years), functional outcomes, and radiographic results of contemporary THAs with a highly cross-linked polyethylene (HXLPE) liner between patients with osteonecrosis and those with osteoarthritis.

METHODS

All patients who underwent primary THA with an HXLPE liner from 1999 to 2007 were identified from our institutional total joint registry. Patients with a primary diagnosis of osteonecrosis were matched 1:1, on the basis of age, sex, and body mass index (BMI), to patients with a diagnosis of osteoarthritis. This resulted in 461 hips in 413 patients with osteonecrosis matched to 461 hips in 427 patients with osteoarthritis (mean age, 59 years; 47% female; and mean BMI, 29 kg/m). Long-term implant survivorship, patient-reported outcomes, and radiographic findings were compared. In addition, a subgroup analysis of the osteonecrosis group was performed to see whether certain underlying etiologies portended poor outcomes. The median follow-up was 10 years.

RESULTS

The 15-year cumulative rates of revision were 6.6% and 4.5% in the osteonecrosis and osteoarthritis groups, respectively (hazard ratio [HR] = 1.8, p = 0.09). The 15-year cumulative rates of any reoperation were 10.5% and 6.4% in the osteonecrosis and osteoarthritis groups, respectively (HR = 2.2, p = 0.008). There were no radiographic signs of component loosening or osteolysis in the entire cohort. Despite a lower median preoperative Harris hip score (HHS) for patients with osteonecrosis, both groups had marked improvements in their scores, which were similar at all time points after surgery. The cumulative rate of reoperations at 15 years was 0% for hips with radiation-induced osteonecrosis, 6.3% for those with alcohol-induced osteonecrosis, 9.0% for those with posttraumatic osteonecrosis, 12.1% for those with steroid-induced osteonecrosis, and 25% for those with idiopathic osteonecrosis.

CONCLUSIONS

Contemporary THA with an HXLPE liner offers excellent long-term implant survivorship and functional outcomes for patients with osteonecrosis; however, the risk of a reoperation is higher when compared with patients with osteoarthritis.

LEVEL OF EVIDENCE

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

Cross-Linked Versus Conventional Polyethylene for Long-Term Clinical Outcomes After Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

Background: Cross-linked polyethylene (HXLPE) liners have been used for total hip arthroplasty (THA) to address the problem of osteolysis and revision surgery associated with conventional polyethylene (CPE) liners. This systematic review and meta-analysis investigated the long-term efficacy of HXLPE in preventing revision surgery and radiological osteolysis in comparison to CPE. Materials and Methods: A comprehensive search of PubMed, Embase, and the Cochrane Library from their respective inception to September 2018 was conducted to identify potential candidate articles. Data were pooled using Stata software 14.0. The quality of randomized controlled trials (RCTs) and observational studies was assessed by two different authors using the Cochrane risk-of-bias tool and the Newcastle-Ottawa scale (NOS), respectively. Results: Eight RCTs and six observational studies were included in this review. The pooled results significantly favored HXLPE over CPE in terms of total number of revisions and radiological osteolysis, with a risk reduction of 78% (95% confidence interval [CI] 0.13-0.36; p < 0.001) and 80% (95% CI 0.13-0.29; p < 0.001), respectively. Additionally, subgroup analyses of pooled data from RCTs and observational studies both showed the efficacy of HXLPE in the prevention of revision and osteolysis. Polyethylene wear in the HXLPE group was significantly less than that in the CPE group in terms of linear wear rates and head penetration rates (both p < 0.001). No significant differences were observed with regard to functional outcomes. Conclusions: The current evidence shows that HXLPE significantly improved the clinical and radiographic outcomes, but not the functional outcomes, in comparison to CPE in long-term follow-up.

Total Hip Arthroplasty in Human Immunodeficiency Virus-Positive Patients: A Concise Follow-Up at 10 to 14 Years

BACKGROUND

Advancements in the management of human immunodeficiency virus (HIV) now permit HIV-positive patients to have longer life spans, increasing their cumulative risk of developing an advanced degenerative joint disease, necessitating total hip arthroplasty (THA). The purpose of this study was to provide an extended follow-up on a previously published study on a cohort of HIV-positive THA recipients in an effort to confirm the safety and longevity of THA in this population.

METHODS

This study is a follow-up on a previous study comprised of 41 hips in 31 HIV-positive THA recipients. At this follow-up, 5 patients from the original cohort required contralateral THA. Postoperative complications were recorded up to the patient's last follow-up date. A survivorship analysis was performed using the Kaplan-Meier method with revision THA as the end point.

RESULTS

Since the last report, 2 additional hips were revised (one for aseptic loosening and one for a periprosthetic fracture), and 5 patients underwent contralateral THA. This resulted in a total of 5 (13.8%) hips requiring revision THA at the latest follow-up. The mean follow-up interval for the original cohort and for the contralateral 5 hips was 78.9 ± 50.2 months and 54.6 ± 45.3 months, respectively. Kaplan-Meier survivorship analysis with revision THA for any reason as the end point demonstrated survivorship of 93% (2 years), 90% (5 years), and 81% (10 and 14 years) after primary THA, respectively.

CONCLUSION

Our study suggests that it is possible to achieve a low incidence of postoperative infection in HIV-positive THA recipients. In addition, our study demonstrates that non-hemophiliac HIV-positive patients have comparable revision rates to previously published reports on HIV-negative patients of similar age, underscoring the clinical efficacy of highly active antiretroviral therapy.

Pericollapse Stage of Osteonecrosis of the Femoral Head: A Last Chance for Joint Preservation

Objective:

To propose a new definition of the pericollapse stage of osteonecrosis of the femoral head (ONFH) and review its significance in disease diagnosis and treatment selection.

Data Sources:

A search for eligible studies was conducted in three electronic databases including PubMed, Cochrane Library, and Embase up to August 10, 2018, using the following keywords: “osteonecrosis”, “prognosis”, and “treatment”.

Study Selection:

Investigations appraising the clinical signs, symptoms, and imaging manifestations in different stages of ONFH were included. Articles evaluating the prognosis of various joint-preserving procedures were also reviewed.

Results:

The pericollapse stage refers to a continuous period in the development of ONFH from the occurrence of subchondral fracture to early collapse (<2 mm), possessing specific imaging features that mainly consist of bone marrow edema and joint effusion on magnetic resonance imaging (MRI), crescent signs on X-ray films, and clinical manifestations such as the sudden worsening of hip pain. Accumulating evidence has indicated that these findings may be secondary to the changes after subchondral fractures. Of note, computed tomography provides more information for identifying possible subchondral fractures than does MRI and serves as the most sensitive tool for grading the pericollapse lesion stage. The pericollapse stage may indicate a high possibility of progressive disease but also demonstrates satisfactory long- and medium-term outcomes for joint-preserving techniques. In fact, if the articular surface subsides more than 2 mm, total hip arthroplasty is preferable.

Conclusions:

The pericollapse stage with distinct clinical and imaging characteristics provides a last good opportunity for the use of joint-preserving techniques. It is necessary to separate the pericollapse stage as an independent state in evaluating the natural progression of ONFH and selecting an appropriate treatment regimen.

Cementless total hip arthroplasty for osteonecrosis and osteoarthritis produce similar results at ten years follow-up when matched for age and gender

PURPOSE

The aim of this study was to compare the clinical outcomes of cementless total hip arthroplasty (THA) used for the treatment of osteonecrosis of the femoral head (ONFH) and for osteoarthritis (OA) at a mean ten years follow-up.

METHODS

Case-control study of 78 patients (86 hips) who underwent THA for ONFH treatment (ONFH group). Patients were matched for age and sex to 78 patients (86 hips) who underwent THA for OA (OA group). We compared the clinical and patient-reported outcomes, implant survival rates, and rates of complications between the groups.

RESULTS

There were no between-group differences in the Harris Hip Score and in the following patient-reported outcomes at the last follow-up: Japanese Orthopedic Association Hip-Disease Evaluation Questionnaire (JHEQ) pain and movement scores and the Physical Component Summary and Role/Social Component Summary scores of Short Form-36 (SF-36). However, the mental score of the JHEQ, the Mental Component Summary score of SF-36, and The Visual Analog Scale score for satisfaction were lower for the ONFH group than for OA group. The rate of complication was equivalent between the groups: 5% for the ONFH group and 3% for the OA group. The ten year implant survival rate was equivalent between the groups, at 97.5% for the ONFH group and 98.2% for the OA group.

CONCLUSION

The functional outcomes, implant survival, and rate of complications for cementless THAs are comparable at a mean follow-up of ten years for ONFH and OA.

Early results of total hip arthroplasty using dual-mobility cup in patients with osteonecrosis of the femoral head

INTRODUCTION

Osteonecrosis of the femoral head (ONFH) remains a therapeutic challenge for patients undergoing total hip arthroplasty (THA). The majority of these patients are young with high functional demand, and show an increased risk of dislocation following surgery than patients with osteoarthritis. The use of double mobility cup (DMC) has been linked with lower rates of complications when compared to conservative cups; however, the literature is scarce over DMC results in patients with ONFH. The aim of the study is to report the early outcomes of patients with ONFH treated with THA-DMC.

MATERIALS

A retrospective analysis of patients suffering from ONFH who underwent THA using DMC (THA-DMC) from 2006 to 2015 were evaluated for functional status and risk of post-operative complications. Thirty THA-DMC in 26 patients with a mean follow-up of 51 months were evaluated clinically (modified Hip Harris Score) and radiologically.

RESULTS

The mean age of the included patients was 54.9 years. At final follow-up, the mean modified Hip Harris score was 98.7 ± 2.7 and no dislocation episodes or revision surgeries were recorded. The radiological assessment revealed no signs of migration/tilting, radiolucent lines, periprosthetic osteolysis or heterotopic ossification over the DMC component and the femoral stem. The survival rate over 51 months of follow-up was 100%.

DISCUSSION

The use of the new generation of dual mobility cup in patients with ONFH showed excellent functional early results with no major complications such as dislocation.

Three-Year Outcomes of a Highly Porous Acetabular Shell in Primary Total Hip Arthroplasty

This multicenter study evaluated survivorship, functional outcomes, complications, and radiographic outcomes for patients who underwent total hip arthroplasty using a newly developed highly porous 3-dimensional titanium implant. Excellent aseptic (99.6%) and all-cause (98%) survivorship and functional outcomes were found at 3-year follow-up. This highly porous acetabular shell holds promise in total hip arthroplasty. [Orthopedics. 2018; 41(1):e154-e157.].

Are Trends in Total Hip Arthroplasty Bearing Surface Continuing to Change? 2007-2015 Usage in a Large Database Cohort

BACKGROUND

Bearing surface issues related to trunnionosis or metal-on-metal (MoM) articulations have likely impacted recent trends in bearing surface choice. The purpose of this study is to evaluate trends in total hip arthroplasty (THA) bearing surface use, including 2015 data, with respect to the date of operation and patient demographics.

METHODS

The Humana dataset was reviewed from 2007 through 2015 to analyze bearing surface usage in primary THA. Four bearing surface types were identified by International Classification of Disease, 10th Revision codes and trended throughout the years: metal-on-polyethylene (MoP), ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoP), and MoM. Prevalence was analyzed as a function of age and sex.

RESULTS

Of the 28,504 primary THA procedures, the most commonly used bearing was MoP (46.1%), followed by CoP (33.2%), MoM (17.1%), and ceramic-on-ceramic (3.6%). The use of CoP bearings significantly increased from 6.4% in 2007 to 52.0% in 2015, while MoM bearings decreased during this period. MoP bearings decreased over 2012-2015 (P < .001). CoP usage decreased with age, while MoP bearings increased with a transition occurring at 65-69 years of age. Women were more likely to receive MoP bearings (odds ratio [OR] 1.2), while men were more likely to receive MoM and CoP bearings (OR 1.1). Multivariate logistic regression showed age to be an independent predictor of bearing surface choice with patients 65 and older more likely to receive MoP bearings (OR 3.2).

CONCLUSION

Bearing surface choice in primary THA has changed tremendously from 2007 to 2015. MoM bearing use has decreased as a result of adverse effects. Age continues to remain a significant factor in bearing surface choice.

Chinese Guideline for the Diagnosis and Treatment of Osteonecrosis of the Femoral Head in Adults

The treatment of adult osteonecrosis of the femoral head (ONFH), with 8.12 million patients in China, remains a challenge to surgeons. To standardize and improve the efficacy of the treatment of ONFH, Chinese specialists updated the experts' suggestions in March 2015, and an experts' consensus was given to provide a current basis for the diagnosis, treatment and evaluation of ONFH. The current guideline provides recommendations for ONFH with respect to epidemiology, etiology, diagnostic criteria, differential diagnosis, staging, treatment, as well as rehabilitation. Risk factors of non-traumatic ONFH include corticosteroid use, alcohol abuse, dysbarism, sickle cell disease and autoimmune disease and others, but the etiology remains unclear. The Association Research Circulation Osseous (ARCO) staging system, including plain radiograph, magnetic resonance imaging, radionuclide examination, and histological findings, is frequently used in staging ONFH. A staging and classification system was proposed by Chinese scholars in recent years. The major differential diagnoses include mid-late term osteoarthritis, transient osteoporosis, and subchondral insufficiency fracture. Management alternatives for ONFH consist of non-operative treatment and operative treatment. Core decompression is currently the most common procedure used in the early stages of ONFH. Vascularized bone grafting is the recommended treatment for ARCO early stage III ONFH. This guideline gives a brief account of principles for selection of treatment for ONFH, and stage, classification, volume of necrosis, joint function, age of the patient, patient occupation, and other factors should be taken into consideration.

An evidence-based guide to the treatment of osteonecrosis of the femoral head

Non-traumatic osteonecrosis of the femoral head is a potentially devastating condition, the prevalence of which is increasing. Many joint-preserving forms of treatment, both medical and surgical, have been developed in an attempt to slow or reverse its progression, as it usually affects young patients. However, it is important to evaluate the best evidence that is available for the many forms of treatment considering the variation in the demographics of the patients, the methodology and the outcomes in the studies that have been published, so that it can be used effectively. The purpose of this review, therefore, was to provide an up-to-date, evidence-based guide to the management, both non-operative and operative, of non-traumatic osteonecrosis of the femoral head. Cite this article: Bone Joint J 2017;99-B:1267-79.

The Results of Total Hip Arthroplasty After Sugioka Transtrochanteric Anterior Rotational Osteotomy for Osteonecrosis

BACKGROUND

Since Sugioka transtrochanteric anterior rotational osteotomy (ARO) for osteonecrosis of the femoral head (ONFH) changes the morphology of the proximal femur, total hip arthroplasty (THA) after previous ARO is considered a technically demanding procedure. The purpose of this study was to compare the clinicoradiologic outcomes of THA after ARO with those of THA without any antecedent surgery for ONFH.

METHODS

Twenty-four hips in 20 patients who underwent cementless THA after ARO (postosteotomy group) were retrospectively reviewed and compared with patients who underwent cementless THA without any antecedent surgery for ONFH during the same period (primary group). In the postosteotomy group, the mean duration from ARO to THA was 19.7 years. All patients were followed for at least 5 years (mean, 8.3 years; follow-up rate, 78.5%). A clinical assessment was performed preoperatively and at the latest follow-up using the Harris Hip Score. A radiographic examination was performed at 3 months after THA and at the latest follow-up.

RESULTS

The Harris Hip Score at the latest follow-up in the postosteotomy group was equivalent to that in the primary group, but longer operation time and greater intraoperative blood loss were observed in the postosteotomy group. There were no significant differences in postoperative complications, including dislocation (2 hips in each group). The leg lengthening in the postosteotomy group tended to be longer. No hips showed implant malpositioning, loosening, or required any revision surgery.

CONCLUSION

The clinicoradiologic outcomes of THA after ARO are considered to be comparable with those of THA without any antecedent surgery for ONFH.

Midterm Outcomes of Revision Total Hip Arthroplasty With the Use of a Multihole Highly-Porous Titanium Shell

BACKGROUND

We are reporting on the minimum 5-year outcomes of patients who underwent revision total hip arthroplasty (THA) using a specific highly-porous titanium shell. We assessed (1) aseptic and all-cause survivorship; (2) functional outcomes; (3) complications; and (4) radiographic outcomes.

METHODS

Two hospital databases were evaluated for patients who underwent revision THA due to component instability or aseptic loosening using a cementless highly-porous titanium shell between September 2006 and December 2011. This yielded 35 patients who had a mean age of 61 years (range 14-88 years). Patients had a mean follow-up of 6 years (minimum 5 years). All-cause and aseptic survivorship of the shell was calculated. Functional outcomes were assessed using the Harris Hip Score. We determined the incidence of postoperative complications and performed radiographic evaluation of pelvic radiographs from regular office visits.

RESULT

The aseptic survivorship of the acetabular component was 97% (95% confidence interval; 8.1-9.5). The all-cause survivorship of the acetabular component was 91% (95% confidence interval; 7.3-8.1). One patient had an aseptic failure and 2 patients had septic failures. The mean postoperative Harris Hip Score was 76 points (range, 61-91 points). Excluding the aseptic and septic failures, there was no osteolysis or progressive radiolucencies present on radiographic evaluation at final follow-up.

CONCLUSION

At a minimum of 5-year follow-up, the highly-porous titanium acetabular revision shell has excellent survivorship and functional outcomes. Although long-term follow-up is needed to further monitor these implants, the results are promising and demonstrate that this prosthesis may be an excellent option for patients undergoing revision THA.

Radial Extracorporeal Shock Wave Therapy in a Person With Advanced Osteonecrosis of the Femoral Head

Supplemental digital content is available in the text.

This case report describes the first patient with avascular necrosis of the femoral head of Association Research Circulation Osseous stage IV, treated with radial extracorporeal shock wave therapy. By contrast, previous studies demonstrated the efficacy of a single treatment of focused extracorporeal shock wave therapy in improving pain and Harris Hip Scale in patients with avascular necrosis of the femoral head of Association Research Circulation Osseous stage I to III. The affected hip was treated with 6000 impulses of radial extracorporeal shock wave therapy at 10 Hz and an intensity ranging from 2.5 to 4.0 bar at 7-day intervals for 24 mos. The Harris Hip Scale values were 33, 43, 56, 77, 81, 88, and 92 at baseline and 1, 3, 6, 12, 18, and 24 mos, respectively. The radiographs showed that the subluxation of the right hip was slightly aggravated. Joint effusion was reduced, bone marrow edema disappeared, the density became more uniform, and the gluteal muscles were more developed based on magnetic resonance imaging. Increased tracer uptake was evident along the joint margin and superolateral aspect of the head both before and after radial extracorporeal shock wave therapy. This case report demonstrates the feasibility of long-term radial extracorporeal shock wave therapy in Association Research Circulation Osseous stage IV patients.

Total hip arthroplasty survival in femoral head avascular necrosis versus primary hip osteoarthritis: Case-control study with a mean 10-year follow-up after anatomical cementless metal-on-metal 28-mm replacement

BACKGROUND

Total hip arthroplasty is the most widely used procedure to treat avascular necrosis (AVN) of the femoral head. Few studies have compared the outcomes of THA in femoral head AVN and primary hip osteoarthritis. Therefore we performed a case-control study to compare THA for femoral head AVN vs. primary hip osteoarthritis in terms of: (1) prosthesis survival, (2) complication rates, (3) functional outcomes and radiographic outcomes, (4) and to determine whether specific risk factors for THA failure exist in femoral head AVN.

HYPOTHESIS

THA survival is similar in femoral head AVN and primary hip osteoarthritis.

MATERIAL AND METHODS

We compared two prospective cohorts of patients who underwent THA before 65 years of age, one composed of cases with femoral head AVN and the other of controls with primary hip osteoarthritis. In both cohorts, a cementless metal-on-metal prosthesis with a 28-mm cup and an anatomical stem was used. Exclusion criteria were THA with other types of prosthesis, posttraumatic AVN, and secondary osteoarthritis. With α set at 5%, to obtain 80% power, 246 patients were required in all. Prosthesis survival was assessed based on time to major revision (defined as replacement of at least one implant fixed to bone) and time to aseptic loosening. The other evaluation criteria were complications, Postel-Merle d'Aubigné (PMA) score, and the Engh and Agora Radiographic Assessment (ARA) scores for implant osseointegration.

RESULTS

The study included 282 patients, 149 with AVN and 133 with osteoarthritis. Mean age was 47.8±10.2 years (range, 18.5-65) and mean follow-up was 11.4±2.8 years (range, 4.5-18.3 years). The 10-year survival rates were similar in the two groups: for major revision, AVN group, 92.5% (95% confidence interval [95% CI], 90.2-94.8) and osteoarthritis group, 95.3% (95% CI, 92.9-97.7); for aseptic loosening, AVN group, 98.6% (95% CI, 97.6-98.6) and osteoarthritis, 99.2% (95% CI, 98.4-100). The AVN group had higher numbers of revision for any reason (19 vs. 6, P=0.018) and for dislocation (8 vs. 1, P=0.031). Mean PMA scores at last follow-up were comparable in the AVN group (17.65±1.27 [range, 10-18]) and osteoarthritis group (17.59±1.32 [range, 14-18]) (P=0.139). Osseointegration was also similar in the two groups: global Engh score, 26.51±1.81 (range, 14-27) for AVN and 26.84±0.91 (range, 19.5-27) for osteoarthritis (P=0.065); femoral ARA score, 5.83±0.46 (range, 3-6) for AVN and 5.90±0.42 (range, 3-6) for osteoarthritis (P=0.064); and cup ARA score, 5.74±0.67 (range, 3-6) for AVN and 5.78±0.66 (range, 3-6) for osteoarthritis (P=0.344).

DISCUSSION

Survival in this study was good and consistent with recent data on AVN, with no difference between AVN and osteoarthritis. Revisions for any cause or for dislocation were more common after THA for AVN. Functional outcomes were similar in the AVN and osteoarthritis groups. An anatomical cementless prosthesis combined with metal-on-metal 28-mm bearing provides durable good outcomes.

LEVEL OF EVIDENCE

III, non-randomized comparison of two prospective cohorts.

Total hip arthroplasty with dual mobility cup in osteonecrosis of the femoral head in young patients: over ten years of follow-up

Osteonecrosis of the femoral head affects mainly young patients with high functional needs this increases the risk of dislocation. Dual mobility cups known for low rate of dislocation and high mobility range seems indicated. We evaluate functional efficiency, survival and dislocation rate of dual mobility cup for total hip arthroplasty for osteonecrosis in young patients. Monocentric retrospective clinical study, from 2000 to 2008. With a clinical analysis in pre-operative and over ten years of follow-up of one cohort of patients under 55 years old with an indication of THA for ONFH. The judgement criteria was: clinical scores at the maximal follow-up, the dislocation rate, and the cumulate survival rate over ten years follow-up. Forty THA in 31 patients, nine bilateral cases, 23 males and eight females with average age of 44 (±4) years old. In pre-operative: PMA 11 (±3.3), HHS 50,8 (±15.5). At the final follow-up of 129.8 (±33.8) months: PMA (17.4 ± 1.12), HHS (95.7 ± 6.9), no dislocation. We had 11 deaths on average at 95.2 ± 47.3 months. The cumulate survival rate over ten years follow-up is 100% without revisions or long-term dislocation. Analysis concludes to very significant functional improvement without any dislocation despite the young population with high level of activity. Thus, dual mobility cups is a reliable choice preventing dislocation with a very good survival rate without premature wear, preserving mobility and activity.

Hip resurfacing for osteonecrosis

Aims

Hip resurfacing arthroplasty (HRA) is an alternative to conventional total hip arthroplasty for patients with osteonecrosis (ON) of the femoral head. Our aim was to report the long-term outcome of HRA, which is not currently known.

Patients and Methods

Long-term survivorship, clinical scores and radiographic results for 82 patients (99 hips) treated with HRA for ON over a period of 18 years were reviewed retrospectively. The mean age of the 67 men and 15 women at the time of surgery was 40.8 years (14 to 64). Patients were resurfaced regardless of the size of the osteonecrotic lesion.

Results

The mean clinical follow-up was 10.8 years (2 to 18). The mean University of California, Los Angeles hip scores at the last follow-up were 9.3, 9.4, 9.2 and 6.8 for pain, walking, function and activity, respectively. A total of six hips underwent revision surgery, four for loosening of the femoral component and two for loosening of the acetabular component. Using any revision as an end point, the 15-year Kaplan-Meier survivorship was 90.3%. There were no wear-related failures. There were no femoral failures among the hips reconstructed with a cemented metaphyseal stem. A total of five hips showed narrowing of the femoral neck; all stabilised and remain asymptomatic, 21 showed signs of femoral neck impingement.

Conclusion

To our knowledge, this is the first report of a series of HRA performed for ON with 15-year survivorship. Our data confirm that patients with advanced stages of ON of the femoral head are excellent candidates for HRA. Cite this article: Bone Joint J 2016;98-B:901–9.

Total Hip Arthroplasty With an Uncemented Tapered Femoral Component in Patients Younger Than 50 Years of Age: A Minimum 20-Year Follow-Up Study

BACKGROUND

Previously, we reported the mean 16-year results of primary uncemented total hip arthroplasty using a tapered femoral component in patients <50 years. The purpose of this study was to update our previous report using the Taperloc femoral component in young patients who had been followed for a minimum of 20 years postoperatively.

METHODS

Between 1983 and 1990, 108 consecutive uncemented total hip arthroplasties were performed in 91 patients of age <50 years, with use of the Taperloc femoral component. Every patient was followed for a minimum of 20 years after surgery or until death. At a mean of 25 (range, 20-29 years) postoperatively, 76 patients (91 hips) were living. The Harris Hip Score, radiographic results, complications, and Kaplan-Meier survivorship were evaluated.

RESULTS

In the entire cohort of 108 hips, 9 femoral components (8%) have been revised, none for aseptic loosening. Five well-fixed stems were removed during acetabular revision, 3 stems were revised for infection, and 1 stem was exchanged because of a peroneal nerve palsy. Distal femoral osteolysis was identified around 1 hip. With failure defined as stem removal for any reason, implant survival was 90% (CI = 82-95) at 29 years. With failure defined as stem removal for aseptic loosening, implant survival was 100% at 29 years.

CONCLUSION

Primary total hip arthroplasty with the Taperloc femoral component in young patients was associated with a high rate of survival at 29 years.

Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today? A Ten-Year Update

➤ Although multiple theories have been proposed, no one pathophysiologic mechanism has been identified as the etiology for the development of osteonecrosis of the femoral head. However, the basic mechanism involves impaired circulation to a specific area that ultimately becomes necrotic.➤ A variety of nonoperative treatment regimens have been evaluated for the treatment of precollapse disease, with varying success. Prospective, multicenter, randomized trials are needed to evaluate the efficacy of these regimens in altering the natural history of the disease.➤ Joint-preserving procedures are indicated in the treatment of precollapse disease, with several studies showing successful outcomes at mid-term and long-term follow-up.➤ Studies of total joint arthroplasty, once femoral head collapse is present, have described excellent outcomes at greater than ten years of follow-up, which is a major advance and has led to a paradigm shift in treating these patients.➤ The results of hemiresurfacing and total resurfacing arthroplasty have been suboptimal, and these procedures have restricted indications in patients with osteonecrosis of the femoral head.

Outcomes of total hip arthroplasty in patients with osteonecrosis of the femoral head-a current review

The purpose of this review was to analyze (1) patient-reported outcomes and implant survivorship of osteonecrosis (ON) patients following total hip arthroplasty (THA), (2) if prior hip-preserving procedures influence these outcomes, (3) if resurfacing procedures alter outcomes; and (4) how these outcomes may have been impacted by the choice of different bearing surfaces. Today, with implant innovations such as cementless constructs, ceramic bearing surfaces, and highly cross-linked polyethylene, ON patients derive great benefit and have high survivorship following THA. Most studies have shown that previous hip-preserving procedures do not have a deleterious effect on outcomes. Literature on the use of ceramic and highly cross-linked polyethylene bearing surfaces have shown that these implant designs are useful in younger and more active patients. Future research should evaluate the long-term outcomes and survivorship of these new THA constructs.

Total hip arthroplasty in the treatment of osteonecrosis of the femoral head: then and now

The objective of this review is to summarize and analyze the survivorship and the reported results of the use of total hip arthroplasty (THA) in patients with osteonecrosis of the femoral head. In the past, THA was thought to have poor survivorship and poor clinical and radiological results in patients with this diagnosis. However, more recent reports have suggested an improvement in the survivorship, radiological results, and outcomes of THAs when performed for this condition. Surgeons have incorporated THA into their practice patterns to the point that an increasing percentage of patients with this particular diagnosis are currently being treated with it. When collapse and/or arthrosis of the necrotic femoral head are present, THA seems to be the most reliable and proven option for its treatment.

Managing AVN following internal fixation: treatment options and clinical results

Avascular necrosis (AVN) after internal fixation of intracapsular hip fractures is a progressive multifactorial disease that ultimately results in local ischemia with ensuing osteocyte necrosis and structural compromise. This disease can cause significant clinical morbidity and affects patients of any age, including young and active patients. Effective treatment of this condition among young adults is challenging due to their high functional demands. The aim of managing AVN is to relieve pain, preserve range of movement and improve function. Treatment methods vary depending on the stage of the disease and can be broadly categorised into two options, hip preserving surgery and hip arthroplasty. Although, hip preserving techniques are attractive in the young adult, they may alter the morphology of the proximal femur and make subsequent arthroplasty more challenging. Conversely, arthroplasty in the young adult may require repeat revision procedures throughout the patient's life. Current evidence suggests that modifications of prevailing treatments, in addition to new technologies, have led to the development of management strategies that may be able to alter the course of femoral head osteonecrosis. This review aims to summarise the options available for treatment of AVN in the young adult and review the clinical results.

Osteonecrosis of the femoral head: evaluation and treatment

Osteonecrosis of the femoral head may lead to progressive destruction of the hip joint. Although the etiology of osteonecrosis has not been definitely delineated, risk factors include corticosteroid use, alcohol consumption, trauma, and coagulation abnormalities. Size and location of the lesion are prognostic factors for disease progression and are best assessed by MRI. The efficacy of medical management of osteonecrosis with pharmacologic agents and biophysical modalities requires further investigation. Surgical management is based on patient factors and lesion characteristics. Preservation of the femoral head may be attempted in younger patients without head collapse by core decompression with vascularized bone grafts, avascular grafts, bone morphogenetic proteins, stem cells, or combinations of the above or rotational osteotomies. The optimal treatment modality has not been identified. When the femoral head is collapsed, arthroplasty is the preferred option.