Heterotopic ossification after hemiarthroplasty of the hip - A comparison of three common approaches

Free bone fragments are associated with the development of heterotopic ossification after hemiarthroplasty for femoral neck fracture: a retrospective observational study

PURPOSE

Heterotopic ossification (HO) can occur after hemiarthroplasty (HA) for femoral neck fractures (FNF). This study aimed to investigate the frequency and factors contributing to the development of HO after HA.

METHODS

The study included data from 92 of 183 patients (26 male and 66 female) who sustained FNF and underwent HA between April 2019 and January 2022. HO was identified on postoperative radiographic images. Patient background, operative duration, blood loss, and presence of free bone fragments immediately after surgery were compared between the HO and non-HO groups. Statistical analyses included the independent-sample t-test for continuous variables and the chi-squared test for categorical variables. A multivariate logistic regression analysis was performed using HO as an objective variable.

RESULTS

HO occurred in 50 of the 92 (54%) patients. There were no statistically significant differences in patient backgrounds. Univariate analysis revealed significantly longer mean operative duration and greater blood loss in the HO group. Free bone fragments in the immediate postoperative period were observed in 29 of 50 (58%) patients in the HO group and in 3 of 42 (7.1%) patients in the non-HO group, a statistically significant difference. Logistic regression analysis revealed that the presence of free bone fragments was an independent explanatory factor for HO development.

CONCLUSION

The presence of free bone fragments immediately after surgery may be significantly associated with the development of HO. Therefore, it is necessary to sufficiently remove such fragments during surgery because they may trigger HO.

Complications of Hip Hemiarthroplasty

Hip hemiarthroplasty is a commonly performed orthopedic surgery, used to treat proximal femur fractures in the elderly population. Although hip hemiarthroplasty is frequently successful in addressing these injuries, complications can occur. Commonly seen complications include dislocation, periprosthetic fracture, acetabular erosion, and leg-length inequality. Less frequently seen complications include neurovascular injury and capsular interposition. This article presents a comprehensive review of the complications associated with the management of hip hemiarthroplasty. [Orthopedics. 2023;46(4):e199-e209.].

Does Surgical Approach Influence Complication Rate of Hip Hemiarthroplasty for Femoral Neck Fractures? A Literature Review and Meta-Analysis

Background: Femoral neck fractures are an epidemiologically significant issue with major effects on patients and health care systems, as they account for a large percentage of bone injuries in the elderly. Hip hemiarthroplasty is a common surgical procedure in the treatment of displaced femoral neck fractures. Several surgical approaches may be used to access the hip joint in case of femoral neck fractures, each with its own benefits and potential drawbacks, but none of them has consistently been found to be superior to the others. This article aims to systematically review and compare the different approaches in terms of the complication rate at the last follow-up. Methods: an in-depth search on PubMed/Scopus/Web of Science databases and a cross-referencing search was carried out concerning the articles comparing different approaches in hemiarthroplasty and reporting detailed data. Results: A total of 97,576 hips were included: 1030 treated with a direct anterior approach, 4131 with an anterolateral approach, 59,110 with a direct lateral approach, and 33,007 with a posterolateral approach. Comparing the different approaches, significant differences were found in both the overall complication rate and the rate of revision surgery performed (p < 0.05). In particular, the posterolateral approach showed a significantly higher complication rate than the lateral approach (8.4% vs. 3.2%, p < 0.001). Furthermore, the dislocation rate in the posterolateral group was significantly higher than in the other three groups considered (p < 0.026). However, the posterolateral group showed less blood loss than the anterolateral group (p < 0.001), a lower intraoperative fractures rate than the direct anterior group (p < 0.035), and shorter mean operative time than the direct lateral group (p < 0.018). Conclusions: The posterolateral approach showed a higher complication rate than direct lateral approach and a higher prosthetic dislocation rate than the other three types of surgical approaches. On the other hand, patients treated with posterolateral approach showed better outcomes in other parameters considered, such as mean operative time, mean blood loss and intraoperative fractures rate. The knowledge of the limitations of each approach and the most common associated complications can lead to choosing a surgical technique based on the patient's individual risk.

Heterotopic Ossification after Trauma

Heterotopic ossification (HO) refers to benign ectopic bone formation in soft tissue and is common following trauma surgery. HO bone can restrict movement and progress into ankylosis that may necessitate surgical intervention. This article discusses the current literature on the pathophysiology, prophylaxis, treatment, and epidemiology of postoperative HO following orthopedic trauma.

Increased risk of high-grade heterotopic ossification using direct lateral approach versus a muscle-sparing anterolateral approach to the hip: radiological results from a randomised trial in patients with a femoral neck fracture treated with hemiarthroplasty

BACKGROUND AND PURPOSE

Hemiarthroplasty is a common treatment in patients with displaced femoral neck fracture. Due to positive claims of less pain, earlier mobilisation and favourable functional outcome, the anterior approaches to the joint are gaining in popularity. This randomised controlled trial investigated if component placement and heterotopic ossification differed between a muscle sparing anterior approach and a direct lateral approach.

PATIENTS AND METHODS

150 patients operated with an uncemented hemiarthroplasty, were randomised to anterolateral or direct lateral approach and assessed postoperatively radiologically. Measurements included leg-length discrepancy, femoral offset, femoral stem position, canal fill ratio and the presence of heterotopic ossification after 12 months.

RESULTS

There was an increased risk of high-grade heterotopic ossification in the direct lateral approach (p < 0.05). We found no statistically significant differences in leg-length discrepancy, femoral stem position or femoral offset.

CONCLUSIONS

Hemiarthroplasty performed in the direct lateral approach resulted in a higher incidence of Brooker grade 3 heterotopic ossification. Our results support equal geometrical restoration and similar component placement with both approaches.

CLINICAL TRIAL REGISTRY

ClinicalTrials.gov Identifier: NCT03974698Uncemented Hemiarthroplasty, Radiological Features Comparing Lateral Versus Anterolateral Approach https://www.clinicaltrials.gov/ct2/show/NCT03974698?term=raymond+tellefsen…draw=2…rank=1.

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.

Heterotopic Ossification Following Direct Anterior Total Hip Arthroplasty With and Without Postoperative Analgesic Nonsteroidal Anti-inflammatories

BACKGROUND

Heterotopic ossification (HO) can result in poorer clinical outcomes following total hip arthroplasty (THA). Multiple modes of intervention have been evaluated for HO prevention, including the use of nonsteroidal anti-inflammatories. Additionally, multimodal pain management strategies including celecoxib have become more prominent. Therefore, this study aims to evaluate the influence of celecoxib as part of postoperative analgesia on the risk of developing HO following the direct anterior approach (DA) for THA.

METHODS

A retrospective query identified primary DA THAs performed by a single surgeon between 2013 and 2020. Patients were grouped according to those who received 3 weeks celecoxib upon discharge, and those who did not. Radiographs were used to categorize patients according to the Brooker classification system for HO. Preoperative and 2-week, 6-week, 3-month, and 1-year postoperative X-rays were evaluated.

RESULTS

A total of 688 DA THAs were included, demonstrating a 9.6% (n = 66) incidence of HO with Brooker classification: 1: 5.7% (n = 39); 2: 2.6% (n = 18); 3: 1.2% (n = 8); and 4: 0.1% (n = 1). Patients who did not receive celecoxib had a 14.3% (52/364) rate of HO following THA (odds ratio 4.53, P < .001) vs only 4.3% (14/324) in the celecoxib group (odds ratio 0.22, P < .001). Overall, 9 patients (1.3%) went on to develop significant HO (Booker 3 or greater): 8 (2.2%) in the control group and 1 (0.3%) in the celecoxib group (P < .001).

CONCLUSION

Our findings suggest a significant reduction in the formation of HO following DA THA when using postoperative analgesic celecoxib as part of a multimodal pain protocol. Future prospective randomized studies are needed to identify ideal dosage, duration, and formulation to reduce the risk of HO while optimizing multimodal pain management.

Cementless Hemiarthroplasty for Intracapsular Femoral Neck Fractures in the Octa- and Nonagenarians

Backgroud

Current evidence supports the use of cemented hemiarthroplasty for treatment of intracapsular femoral neck fractures since it is associated with a lower risk of implant-related complications. However, many medical centers employ the cementless technique for the frail elderly population because it is faster and has lower cardiovascular risks and perioperative mortality. This observational study reports the outcomes of cementless bipolar hemiarthroplasty for intracapsular femoral neck fractures in patients aged 80 years and older.

Methods

A total of 424 patients (female, 77.1%) with a mean age of 86.9 years were operated for intracapsular femoral neck fractures between January 2009 and December 2017. Of those, 66.7% had an American Society of Anaesthesiologists (ASA) score of 3 or more. All operations were performed with the posterolateral surgical approach and all patients received a cementless stem. Intraoperative and perioperative values and in-hospital outcomes were evaluated, and clinical and radiographical follow-up was done at 40 days, 90 days, and when possible between 5 months and 12 months postoperatively. Multivariate analysis was performed to evaluate if there were factors affecting mortality.

Results

The mean operative time was 50 minutes. There were no deaths intraoperatively. Intraoperative periprosthetic fractures occurred in 2.1% of the cases with 66.7% of them fixed through cerclage wires intraoperatively. The median length of hospitalization was 11 days (interquartile range, 8.75–15) and 2.4% of patients died while in hospital after surgery. Approximately 91.5% of patients presented with perioperative anemia. Only 1.9% of the complications were related to the implant, 62.5% of which were dislocations. More than 90% of patients were ambulatory either autonomously or with support at each follow-up assessment. Age, male sex, and higher ASA score were related to increased mortality.

Conclusions

Despite some limitations, this observational study underlines that a cementless femoral stem of modern design can give good clinical outcomes, thus being an appropriate solution especially for the frail elderly.

Early results of displaced femoral neck fragility fractures treated with supercapsular percutaneous-assisted total hip arthroplasty

Background

Total hip arthroplasty (THA) is the preferred treatment for displaced femoral neck fractures in select patients, although dislocation remains a concern. In some studies, the supercapsular percutaneously assisted (SuperPATH) approach has demonstrated early mobilization, short hospital stay, and low dislocation rates in primary THA, but there are little data on its use for fractures. This study describes the perioperative outcomes and early dislocation rate of SuperPATH THA for displaced femoral neck fragility fractures.

Methods

A retrospective review was performed of previous ambulatory patients with a displaced femoral neck fragility fracture treated with THA using the SuperPATH approach. Demographic data, time to ambulation, length of stay, and in-hospital complications during the hospital stay and follow-up period were recorded. Phone interviews were conducted to check for dislocations 1 year after surgery.

Results

Thirty-seven consecutive patients were included with an average age of 75.0 years. Hospital stay averaged 5.5 days, and patients were discharged on average postoperative day 3.6. About 83.8% of patients were ambulatory by postoperative day 1, and 94.6% ambulatory before discharge. Twenty-seven percent of patients were discharged home, 46% to inpatient rehabilitation, 24% to skilled nursing facility, and 1 patient to hospice. At follow-up, there was no symptomatic heterotopic ossification and no infections. Thirty-two patients were available for telephone interviews at 1 year, with no dislocations reported.

Conclusions

In this small cohort, the SuperPATH approach for THA appears to be safe and effective for use in femoral neck fragility fractures, resulting in early ambulation and a low dislocation rate.

Comparison between Cementless and Cemented Bipolar Hemiarthroplasty for Treatment of Unstable Intertrochanteric Fractures: Systematic Review and Meta-analysis

Purpose

This study was conducted to compare cemented and cementless bipolar hemiarthroplasty in elderly patients with unstable intertrochanteric fractures via meta-analysis and systematic review of relevant studies.

Materials and Methods

Systematic review and meta-analysis were performed on 31 available clinical studies; 19 of these studies used cemented stems, 12 used cementless stems, one used both types of stems, and two studies involved a comparative analysis of both stem types.

Results

There were statistically significant differences in rates of leg length discrepancy (LLD) greater than 1 cm between the cemented (event rate, 0.089) and cementless groups (event rate, 0.015 and 0.047; P=0.03).

Conclusion

Cemented bipolar hemiarthroplasty and cementless bipolar hemiarthroplasty performed on elderly patients with unstable intertrochanteric fracture revealed similar mortality and complication rates; however, the rate of LLD greater than 1 cm was significantly higher in the cemented group compared with the cementless group.

Shoelace capsular and external rotators closure techniques in posterior (southern) approach to hip joint

The possible increased risk of dislocation with a posterior approach for femoral hemiarthroplasty is attributed to disruption of the posterior soft-tissue structures, including the posterior capsular ligament structure and short external rotators of the hip. In this surgical technical note, we demonstrate the surgical technique for shoelace suturing of the external rotators and the capsule with use of ULTRATAPE. After prosthesis stem insertion, shoelace suturing using ULTRATAPE was performed between the great trochanter and the external rotators for preventing the external rotators from tearing. Also, ULTRATAPE was sewed alternately on the split capsule like shoe lacing, and it was laced up from proximal to distal in line with the split as shoelaces tied down. The shoelace suturing technique using ULTRATAPE after a posterior approach to the hip joint, possibly lowers risks of tearing hip capsular ligament and external rotators and stabilizes the posterior wall.

Posterior hip approach yields better functional results vis-à-vis anterolateral approach in total hip arthroplasty for patients with severe hip dysplasia: A prospective randomized controlled clinical study

OBJECTIVES

We aimed to compare functional outcomes of two common hip approaches for patients with severe hip dysplasia in total hip replacement (THR) surgery.

MATERIALS AND METHODS

Seventy hips of 68 patients randomized into two groups with regard to hip approach as posterior (group I) and anterolateral (group II). All patients underwent THR surgery with femoral shortening osteotomy. The groups were compared for operation time, preoperative and 6 months after abductor muscle strengths (AMSs), gait disorders, union time of the osteotomied site and dislocation rates.

RESULTS

There were two early dislocations in group I, and two early and one late dislocations in group II. No significant difference was observed regarding hip dislocations. Mean union time of the osteotomied site was 113.9 ± 51 days in group I while 111.1 ± 29.3 days in group II ( p = 0.774). Six months after surgery, group I had higher AMS than group II ( p < 0.0001). More patients in group II had Trendelenburg gait pattern ( p = 0.043), while no difference was observed regarding antalgic and deviated gait patterns between groups.

CONCLUSION

THR surgery for patients with severe developmental dysplasia of hip is a challenging procedure, and posterior approach provides better functional outcomes regarding gait and AMSs.

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.