Hybrid total hip replacement: outcome after a mean follow up of 10 years

Satisfaction rates, function, and return to activity following young adult total hip arthroplasty

Aims

Young adults undergoing total hip arthroplasty (THA) largely have different indications for surgery, preoperative function, and postoperative goals compared to a standard patient group. The aim of our study was to describe young adult THA preoperative function and quality of life, and to assess postoperative satisfaction and compare this with functional outcome measures.

Methods

A retrospective cohort analysis of young adults (aged < 50 years) undergoing THA between May 2018 and May 2023 in a single tertiary centre was undertaken. Median follow-up was 31 months (12 to 61). Oxford Hip Score (OHS) and focus group-designed questionnaires were distributed. Searches identified 244 cases in 225 patients. Those aged aged under 30 years represented 22.7% of the cohort. Developmental dysplasia of the hip (50; 45.5%) and Perthes' disease (15; 13.6%) were the commonest indications for THA.

Results

Preoperatively, of 110 patients, 19 (17.2%) were unable to work before THA, 57 (52%) required opioid analgesia, 51 (46.4%) were reliant upon walking aids, and 70 (63.6%) had sexual activity limited by their pathology. One patient required revision due to instability. Mean OHS was 39 (9 to 48). There was a significant difference between the OHS of cases where THA met expectation, compared with the OHS when it did not (satisfied: 86 (78.2%), OHS: 41.2 (36.1%) vs non-satisfied: 24 (21%), OHS: 31.6; p ≤ 0.001). Only one of the 83 patients (75.5%) who returned to premorbid levels of activity did so after 12 months.

Conclusion

Satisfaction rates of THA in young adults is high, albeit lower than commonly quoted figures. Young adults awaiting THA have poor function with high requirements for mobility aids, analgesia, and difficulties in working and undertaking leisure activities. The OHS provided a useful insight into patient function and was predictive of satisfaction rates, although it did not address the specific demands of young adults undertaking THA. Function at one year postoperatively is a good indication of overall outcomes.

Comparison of clinical outcomes between total hip replacement and total knee replacement

BACKGROUND

Total hip replacements (THR) and total knee replacements (TKR) are effective treatments for severe osteoarthritis (OA). Some studies suggest clinical outcomes following THR are superior to TKR, the reason for which remains unknown. This study compares clinical outcomes between THR and TKR.

AIM

To compare the clinic outcomes of THR anad TKR using a comprehensive range of patient reported outcome measures (PROMs).

METHODS

A prospective longitudinal observational study of patients with OA undergoing THR and TKR were evaluated using a comprehensive range of generic and joint specific PROMs pre- and post-operatively.

RESULTS

A total of 131 patients were included in the study which comprised the THR group (68 patients) and the TKR group (63 patients). Both groups demonstrated significant post-operative improvements in all PROM scores (P < 0.001). There were no significant differences in post-operative PROM scores between the two groups: Hip and Knee Osteoarthritis Outcome scores (P = 0.140), Western Ontario and McMaster Universities Osteoarthritis Index pain (P = 0.297) stiffness (P = 0.309) and function (P = 0.945), Oxford Hip and Knee Score (P = 0.076), EuroQol-5D index (P = 0.386) and Short-Form 12-item survey physical component score (P = 0.106). Subgroup analyses showed no significant difference (P > 0.05) between cruciate retaining and posterior stabilised prostheses in the TKR group and no significant difference (P > 0.05) between cemented and uncemented fixation in the THR group. Obese patients had poorer outcomes following TKR but did not significantly influence the outcome following THR.

CONCLUSION

Contrary to some literature, THR and TKR are equally efficacious in alleviating the pain and disability of OA when assessed using a comprehensive range of PROMs. The varying knee prosthesis types and hip fixation techniques did not significantly influence clinical outcome. Obesity had a greater influence on the outcome following TKR than that of THR.

Smoking Increases the Rate of Reoperation for Infection within 90 Days After Primary Total Joint Arthroplasty

BACKGROUND

The relationship between smoking and complications after total joint arthroplasty is unclear. Prior studies have been limited by relatively small sample sizes or investigation of select cohorts. The purpose of this study was to investigate the association between smoking and readmission and/or reoperation within 90 days of total joint arthroplasty in a large, non-select cohort of patients.

METHODS

Using our institutional database, we retrospectively identified patients who underwent primary total joint arthroplasty between 2000 and 2014. Patients were stratified into 1 of 3 groups: current smokers, former smokers, and nonsmokers. The association between smoking status and subsequent readmission and/or reoperation within 90 days was investigated using multivariate regression analysis.

RESULTS

We retrospectively identified 15,264 patients (6,749 male and 8,515 female) who underwent 17,394 total joint arthroplasties during the study period. Of these patients, 1,371 (9.0%) were current smokers, 5,195 (34.0%) were former smokers, and 8,698 (57.0%) were nonsmokers. Former smokers reported a median of 22.2 years (range, 0.2 to 60 years) of abstinence prior to the surgical procedure. Current smokers were significantly younger (p < 0.001) at a mean age (and standard deviation) of 57.7 ± 10.3 years than nonsmokers at 63.2 ± 11.8 years. Current smokers were significantly more likely than nonsmokers to undergo reoperation for infection (odds ratio [OR], 1.82 [95% confidence interval (CI), 1.03 to 3.23]; p = 0.04), and former smokers were at no increased risk (OR, 1.11 [95% CI, 0.73 to 1.69]; p = 0.61). Packs per decade were independently associated with an increased risk of 90-day nonoperative readmission regardless of smoking status (OR, 1.12 [95% CI, 1.03 to 1.20]). Lastly, neither smoking status nor packs per decade were associated with aseptic or total reoperations.

CONCLUSIONS

This study, after controlling for confounding factors, demonstrated not only that current smokers have a significantly increased risk of reoperation for infection within 90 days of a surgical procedure compared with nonsmokers, but also that the amount that one has smoked, regardless of current smoking status, significantly contributed to increased risk of nonoperative readmission.

LEVEL OF EVIDENCE

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

Hip resurfacing versus total hip arthroplasty: a systematic review comparing standardized outcomes

BACKGROUND

Metal-on-metal hip resurfacing was developed for younger, active patients as an alternative to THA, but it remains controversial. Study heterogeneity, inconsistent outcome definitions, and unstandardized outcome measures challenge our ability to compare arthroplasty outcomes studies.

QUESTIONS/PURPOSES

We asked how early revisions or reoperations (within 5 years of surgery) and overall revisions, adverse events, and postoperative component malalignment compare among studies of metal-on-metal hip resurfacing with THA among patients with hip osteoarthritis. Secondarily, we compared the revision frequency identified in the systematic review with revisions reported in four major joint replacement registries.

METHODS

We conducted a systematic review of English language studies published after 1996. Adverse events of interest included rates of early failure, time to revision, revision, reoperation, dislocation, infection/sepsis, femoral neck fracture, mortality, and postoperative component alignment. Revision rates were compared with those from four national joint replacement registries. Results were reported as adverse event rates per 1000 person-years stratified by device market status (in use and discontinued). Comparisons between event rates of metal-on-metal hip resurfacing and THA are made using a quasilikelihood generalized linear model. We identified 7421 abstracts, screened and reviewed 384 full-text articles, and included 236. The most common study designs were prospective cohort studies (46.6%; n = 110) and retrospective studies (36%; n = 85). Few randomized controlled trials were included (7.2%; n = 17).

RESULTS

The average time to revision was 3.0 years for metal-on-metal hip resurfacing (95% CI, 2.95-3.1) versus 7.8 for THA (95% CI, 7.2-8.3). For all devices, revisions and reoperations were more frequent with metal-on-metal hip resurfacing than THA based on point estimates and CIs: 10.7 (95% CI, 10.1-11.3) versus 7.1 (95% CI, 6.7-7.6; p = 0.068), and 7.9 (95% CI, 5.4-11.3) versus 1.8 (95% CI, 1.3-2.2; p = 0.084) per 1000 person-years, respectively. This difference was consistent with three of four national joint replacement registries, but overall national joint replacement registries revision rates were lower than those reported in the literature. Dislocations were more frequent with THA than metal-on-metal hip resurfacing: 4.4 (95% CI, 4.2-4.6) versus 0.9 (95% CI, 0.6-1.2; p = 0.008) per 1000 person-years, respectively. Adverse event rates change when discontinued devices were included.

CONCLUSIONS

Revisions and reoperations are more frequent and occur earlier with metal-on-metal hip resurfacing, except when discontinued devices are removed from the analyses. Results from the literature may be misleading without consistent definitions, standardized outcome metrics, and accounting for device market status. This is important when clinicians are assessing and communicating patient risk and when selecting which device is most appropriate for individual patients.

Do monoblock cups improve survivorship, decrease wear, or reduce osteolysis in uncemented total hip arthroplasty?

BACKGROUND

Monoblock acetabular components used in uncemented total hip arthroplasty (THA) have certain mechanical characteristics that potentially reduce acetabular osteolysis and polyethylene wear. However, the degree to which they achieve this goal is not well documented.

QUESTIONS/PURPOSES

The purpose of this study was to use a systematic review of controlled trials to test the hypothesis that monoblock cups have superior (1) polyethylene wear rate; (2) frequency of cup migration; (3) frequency of acetabular osteolysis; and (4) frequency of aseptic loosening compared with modular components used in uncemented THA.

METHODS

A systematic search was conducted in the Medline, Embase, and Cochrane electronic databases to assemble all controlled trials comparing monoblock with modular uncemented acetabular components in primary THA. Included studies were considered "best evidence" if the quality score was either ≥ 50% on the Cochrane Back Review Group checklist or ≥ 75% the Newcastle-Ottawa quality assessment scale. A total of seven publications met our inclusion criteria.

RESULTS

Best evidence analysis showed no difference in polyethylene wear rate, the frequency of cup migration, and aseptic loosening between monoblock and modular acetabular components. No convincing evidence was found for the claim that lower frequencies of acetabular osteolysis are observed with the use of monoblock cups compared with modular uncemented cups.

CONCLUSIONS

The purported benefits of monoblock cups were not substantiated by this systematic review of controlled studies in that polyethylene wear rates and frequencies of cup failure and acetabular osteolysis were similar to those observed with modular implants. Other factors should therefore drive implant selection in cementless THA.

Smoking and outcomes after knee and hip arthroplasty: a systematic review

OBJECTIVE

Studies have suggested higher rates of perioperative and postoperative complications in smokers compared to nonsmokers. The objective of this systematic review was to assess the association of smoking and postoperative outcomes following total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

A search of 6 databases (The Cochrane Library, Scopus, Proquest Dissertation abstracts, CINAHL, Ovid Medline, and Embase) was performed by a Cochrane librarian. All titles and abstracts were screened by 2 independent reviewers with expertise in performing systematic reviews. Studies were included if they were fully published reports that included smoking and any perioperative or postoperative clinical outcome in patients with TKA or THA.

RESULTS

A total of 21 studies were included for the review, of which 6 provided multivariable-adjusted analyses, 14 univariate analyses, and one statistical modeling. For most outcomes, results from 1-2 studies could be pooled. Current smokers were significantly more likely to have any postoperative complication (risk ratio 1.24, 95% CI 1.01 to 1.54) and death (risk ratio 1.63, 95% CI 1.06 to 2.51) compared to nonsmokers. Former smokers were significantly more likely to have any post-operative complication (risk ratio 1.32, 95% CI 1.05 to 1.66) and death (risk ratio 1.69, 95% CI 1.08 to 2.64) compared to nonsmokers.

CONCLUSION

This systematic review found that smoking is associated with significantly higher risk of postoperative complication and mortality following TKA or THA. Studies examining longterm consequences of smoking on implant survival and complications are needed. Smoking cessation may improve outcomes after THA or TKA.

Kurz titanium prostheses in paediatric ossiculoplasty--short term results

OBJECTIVE

The objective of this study is to assess the efficacy of ossiculoplasty procedures in the paediatric population when the Kurz titanium ossicular prosthesis is used.

PATIENTS AND METHODS

Data was collected prospectively upon 14 ossiculoplasty cases using Kurz titanium prostheses. Audiological parameters using four frequency average (FFA(0.5, 1, 2 and 4kHz)) were assessed pre- and post-operatively.

RESULTS

In the case of patients reconstructed using partial ossicular reconstruction prostheses, 7/9 (78%) achieved an air bone gap (<20dB) using FFA criteria. Parameters at 12-month follow-up suggested 4/5 (80%) patients reconstructed using total ossicular reconstruction prostheses achieved an air bone gap (<20dB) using FFA.

CONCLUSION

The question of age and presence of co-existing cholesteatoma or tympanic membrane perforation does not appear to mitigate against performing ossicular reconstruction in this age group. Consequently, the results of this study suggest that the use of Kurz titanium prostheses is a feasible option to augment hearing in paediatric cases involving chronic otitis media. This is a significant finding especially in view of the added psychological burden of hearing difficulties carried by the paediatric population.