Femur first surgical technique: a smart non-computer-based procedure to achieve the combined anteversion in primary total hip arthroplasty

Simultaneous vs staged bilateral hip arthroplasty: monocentric analysis of satisfaction rate and complications

PURPOSE

Interest in bilateral total hip arthroplasty (THA) has been increasing over the past decade. This study aims to compare postoperative local and systemic complications, hospital readmissions, and satisfaction assessment in patients undergoing simultaneous versus staged bilateral THA.

METHODS

A retrospective observational study was conducted among patients who underwent simultaneous or staged bilateral THA between 2017 and 2020. Data on perioperative parameters, local and systemic complications, and 30-day hospital readmissions were collected. Patient satisfaction was assessed using Forgotten Joint Score (FJS). The comparison of continuous variables with normal distribution of variance was performed by ANOVA; for variables with abnormal distribution, the nonparametric test Mann-Whitney U was adopted. The distribution of dichotomous variables was analyzed by chi-square test, and statistical significance was calculated by Fisher exact test.

RESULTS

The study included 199 patients, of whom 156 underwent staged and 43 simultaneous bilateral THA. A total of 44 patients developed complications (21 systemics, 12 locals, and 20 postoperative anemia). There were no significant differences regarding local (simultaneous 5% vs. staged 6%; p = 0.999) or systemic complications (simultaneous 14% vs. staged 10%; p = 0.408). Only the incidence of postoperative anemia was significantly higher in simultaneous group compared with staged group (p = 0.003). There were no significant differences in FJS between the two groups (p = 0.258).

CONCLUSION

No differences in local or systemic complications nor readmission rates were observed following simultaneous or staged bilateral THA. Simultaneous bilateral THA is non-inferior to staged implants in terms of safety and patient satisfaction.

Clinical and Radiographic Outcomes of Hip Revision Surgery and Cerclage Wires Fixation for Vancouver B2 and B3 Fractures: A Retrospective Cohort Study

BACKGROUND

The number of patients presenting with periprosthetic hip fractures has increased in recent decades.

METHODS

Patients who underwent hip revision arthroplasty procedures for Vancouver type B2 and B3 fractures between 2010 and 2021 were included. The primary intended outcome of this study was to determine the reintervention-free survival rate. The secondary intended outcome was to determine clinical and radiographic assessment outcomes at the time of follow-up, and the correlation between time to surgery and postoperative Harris hip score (HHS).

RESULTS

A total of 49 patients with mean age of 71.2 ± 2.3 (37-88) years old were included. Overall, the Kaplan-Meier method estimated a survival rate of 95.8% (CI 84.2% to 98.9%) at one year, 91.1% (CI 77.9% to 96.6%) at two years, and 88.5% (CI 74.4% to 95.1%) at three, and up to 10, years. The mean limb length discrepancy (LLD) improved from -13.3 ± 10.5 (range -39 to +10) mm at the preoperative stage to -1.16 ± 6.7 (range -17 to +15) mm, p < 0.001 postoperative. The mean HHS improved from 31.1 ± 7.7 (range 10 to 43) preoperative to 85.5 ± 14.8 (range 60 to 100), p < 0.001 postoperative. Postoperative HHS was not affected by preoperative time to surgery.

CONCLUSIONS

Revision arthroplasty is an effective treatment for Vancouver type B2 and B3 fractures.

AI-based hip prosthesis failure prediction through evolutional radiological indices

INTRODUCTION

This study aimed to develop artificial intelligence models for predicting hip implant failure from radiological features. Analyzing the evolution of the periprosthetic bone and implant's position throughout the entire follow-up period has shown the potential to be more relevant in outcome prediction than simply considering the latest radiographic images. Thus, we investigated an AI-based model employing a small set of evolutional parameters derived from conventional radiological features to predict hip prosthesis failure.

MATERIALS AND METHODS

One hundred sixty-nine radiological features were annotated from historical anteroposterior and lateral radiographs for 162 total hip arthroplasty patients, 32 of which later underwent implant failure. Linear regression on each patient's chronologically sorted radiological features was employed to derive 169 corresponding evolutional parameters per image. Three sets of machine learning predictors were developed: one employing the original features (standard model), one the evolutional ones (evolutional model), and the last their union (hybrid model). Each set included a model employing all the available features (full model) and a model employing the few most predictive ones according to Gini importance (minimal model).

RESULTS

The evolutional and hybrid predictors resulted highly effective (area under the ROC curve (AUC) of full models = 0.94), outperforming the standard one, whose AUC was only 0.82. The minimal hybrid model, employing just four features, three of which evolutional, scored an AUC of 0.95, proving even more accurate than the full one, exploiting 173 features. This tool could be shaped to be either highly specific (sensitivity: 80%, specificity: 98.6%) or highly sensitive (sensitivity: 90%, specificity: 92.4%).

CONCLUSION

The proposed predictor may represent a highly sensitive screening tool for clinicians, capable to predict THA failure with an advance between a few months and more than a year through only four radiological parameters, considering either their value at the latest visit or their evolution through time.

Results of Utilizing Cerclage Wires in the Management of Intraoperative Vancouver B1 Fractures in Primary Total Hip Arthroplasties: A Retrospective Cohort Investigation into Clinical and Radiographic Outcomes

BACKGROUND

Due to an increase in total hip arthroplasties (THAs), the incidence of periprosthetic hip fractures (PPHFs) is forecast to rise considerably in the next decades, with Vancouver B1 fractures (VB1) accounting for one third of total cases. Femur fixation with cerclages (with or without screws) is considered the current treatment option for intraoperative VB1.

METHODS

The study retrospectively includes data from patients who developed VB1 PPHFs during THAs from 3 December 2020 to 30 November 2022. The primary outcome of this study was to identify the reintervention-free survival rate. The secondary aim was to determine clinical and radiographic assessment at follow-up, based on Harris hip score (HHS) and limb length discrepancy (LLD).

RESULTS

Thirty-seven patients with a mean age of 60.03 ± 15.49 (22 to 77) years old were included. Overall, the Kaplan-Meier analysis estimated a reoperation-free survival rate of 99% (CI 95%) at 6 months. The mean limb length discrepancy (LLD) improved from -3.69 ± 6.07 (range -27.9 to 2.08) mm to 0.10 ± 0.67 (range -1.07 to 1.20) mm. The mean HHS improved from 42.72 ± 14.37 (range 21.00-96.00) to 94.40 ± 10.32 (range 56.00-100.00).

CONCLUSIONS

The employment of cerclage wires represents an effective strategy for handling intraoperative VB1 fractures. Level III retrospective cohort study.

Using Three-Dimensional Printing Technology to Solve Complex Primary Total Hip Arthroplasty Cases: Do We Really Need Custom-Made Guides and Templates? A Critical Systematic Review on the Available Evidence

The burden of osteoarthritis (OA) is around 300 million people affected worldwide, with the hip representing a commonly affected joint. Total hip arthroplasty (THA) has been used with notable success as a definitive treatment to improve pain and function in hip OA patients. The recent advent of new technologies, such as 3D printing, has pushed the application of these new concepts toward applications for the well-known THA. Currently, the evidence on the use of 3D printing to aid complex primary THA cases is still scarce.

METHODS

An extensive literature review was conducted to retrieve all articles centered on the use of 3D printing in the setting of primary THA.

RESULTS

A total of seven studies were included in the present systematic review. Four studies investigated the use of 3D-printed surgical guides to be used during surgery. The remaining three studies investigated the benefit of the use of 3D-printed templates of the pelvis to simulate the surgery.

CONCLUSIONS

The use of 3D printing could be a promising aid to solve difficult primary total hip arthroplasty cases. However, the general enthusiasm in the field is not supported by high-quality studies, hence preventing us from currently recommending its application in everyday practice.

Clinical and radiological outcomes of an uncemented metaphyseal short stem at minimum 10 years of follow-up: a prospective observational study

PURPOSE

There is growing interest around short stems as they provide a less invasive approach for total hip arthroplasty preserving bone stock for a possible revision surgery if required. The main purpose of this work was to assess the long-term performance of an uncemented metaphyseal short stem in terms of survival rate and in addition its clinical and radiological outcomes.

MATERIALS AND METHODS

From January to December 2010, we prospectively enrolled all consecutive patients undergoing primary total hip arthroplasty with an uncemented metaphyseal short stem in our institution with a minimum follow-up of 10 years. The radiographic features investigated were the varus-valgus stem orientation, areas of osteolysis and radiolucencies, stress shielding, and heterotopic calcifications. The clinical outcomes were measured using the HHS.

RESULTS

A total of 163 patients (172 hips) were finally included and the measured survival rate at 10 years was 99.6%. The average HHS increased from 55.0 preoperatively to 97.8 at the last follow-up (p < 0.0001). Among them, 137 patients (164 hips) were also available for radiographic assessment. Mild varus malalignment was observed in 40% of cases and remained stable in the serial X-rays and was not associated with step loosening. Mild stress shielding was observed around 13 stems (9%) and moderate only around 3 implants.

CONCLUSION

In conclusion, the uncemented metaphyseal short stems showed excellent survival and clinical results at 10 years and at a radiographical level very low stress shielding was observed; moreover, besides the high frequency of varus alignment the implanted stems was not associated with revision surgery or with worse clinical outcomes.

Cemented or uncemented fixation: Which allows a more acceptable prosthetic femoral version in total hip arthroplasty?

BACKGROUND

Three-dimensional computed-tomography (3D-CT) planning for primary Total Hip Arthroplasty (THA) typically uses the external femoral surface; as a result, it is difficult to predict the prosthetic femoral version (PFV) for uncemented femoral stems that press-fit to the internal surface of the bone. Cemented fixation allows the surgeon to adjust the version independent of the internal femoral anatomy. We aimed to better understand the effect of the fixation type on PFV.

METHODS

This was a case series study including a total of 95 consecutive patients (106 hips), who underwent uncemented (n = 81 hips) and cemented (n = 25 hips) primary THA using the posterior approach. The surgeon aimed for a PFV of 20°. Our primary objective was to compare PFV in both groups; our secondary objective was to evaluate the clinical outcomes.

RESULTS

The mean (± SD) PFV was 13° (± 9°) and 23° (± 8°) for the uncemented and cemented THA groups (P < 0.001), respectively. In the uncemented THA group, 36% of the patients had a PFV of < 10°. In the cemented THA group, this clinically important threshold dropped to 8%. Similarly, the Bland-Altman (BA) plots showed wider 95% limits of agreement for the uncemented group. Satisfactory clinical outcomes were recorded.

CONCLUSION

We found that the PFV was more clinically acceptable, for the posterior surgical approach, in the cemented group when compared to the uncemented group. Both THA groups reported high variability indicating the need to develop surgical tools to guide the PFV closer to the surgical target.

Creating Consensus in the Definition of Spinopelvic Mobility

INTRODUCTION

The term "spinopelvic mobility" is most often applied to motion within the spinopelvic segment. It has also been used to describe changes in pelvic tilt between various functional positions, which is influenced by motion at the hip, knee, ankle and spinopelvic segment. In the interest of establishing a consistent language for spinopelvic mobility, we sought to clarify and simplify its definition to create consensus, improve communication, and increase consistency with research into the hip-spine relationship.

METHODS

A literature search was performed using the Medline (PubMed) library to identify all existing articles pertaining to spinopelvic mobility. We reported on the varying definitions of spinopelvic mobility including how different radiographic imaging techniques are used to define mobility.

RESULTS

The search term "spinopelvic mobility" returned a total of 72 articles. The frequency and context for the varying definitions of mobility were reported. 41 papers used standing and upright relaxed-seated radiographs without the use of extreme positioning, and 17 papers discussed the use of extreme positioning to define spinopelvic mobility.

DISCUSSION

Our review suggests that the definitions of spinopelvic mobility is not consistent in the majority of published literature. We suggest descriptions of spinopelvic mobility independently consider spinal motion, hip motion, and pelvic position, while recognizing and describing their interdependence.

Clinical Outcomes and Complication Rate after Single-Stage Hardware Removal and Total Hip Arthroplasty: A Matched-Pair Controlled Study

BACKGROUND

Single-stage hardware removal and total hip arthroplasty is a complex surgical procedure, comparable to revision surgery. The purpose of the current study is to evaluate single-stage hardware removal and THA outcomes, compare this technique with a matched control group that has undergone primary THA and assess the risk of periprosthetic joint infection with a 24-month minimum follow-up.

METHODS

This study included all those cases treated with THA and concomitant hardware removal from 2008 to 2018. The control group was selected on a 1:1 ratio among patients who underwent THA for primary OA. The Harris Hip (HHS) and University of California at Los Angeles Activity (UCLA) scores, infection rate and early and delayed surgical complications were recorded.

RESULTS

One hundred and twenty-three consecutive patients (127 hips) were included, and the same number of patients was assigned to the control group. The final functional scores were comparable between the two groups; a longer operative time and transfusion rate were recorded in the study group. Finally, an increased incidence of overall complications was reported (13.8% versus 2.4%), but no cases of early or delayed infection were found.

CONCLUSIONS

Single-stage hardware removal and THA is a safe and effective but technically demanding technique, with a higher incidence of overall complications, making it more similar to revision THA than to primary THA.

Incidence and predictors of blood transfusions in one-stage bilateral total hip arthroplasty: a single center prospective cohort study

INTRODUCTION

The safety of performing one-stage bilateral total hip arthroplasty (THA) remains controversial among the orthopedic community. The aim of the present study was to determine the incidence and predictors of blood transfusions in one-stage bilateral THA performed in a high-volume single center.

PATIENTS AND METHODS

Patients undergoing one-stage bilateral THA between 2015 and 2017 were included. The following data were collected from the hospital medical records: age, body mass index (BMI), American Society of Anaesthesiologists (ASA) score, smoking habit, comorbidities, preoperative serum creatinine, serum iron, ferritin, C-reactive protein (CRP), and hemoglobin (Hb). The Hb levels at postoperative day 1 and 3 were also collected.

RESULTS

A total of 367 patients with a mean age of 56.1 years (range, 32-79) were included. Forty-eight (13%) patients were transfused with a mean number of 1.6 blood units per patient. In non-transfused patients, the average Hb drop was 3.6 (SD ± 1) g/dL and 4.9 g/dL (SD ± 1.3) at postoperative day 1 and day 3, respectively. The average preoperative Hb level was 14.64 (SD ± 1.21) g/dL. In the univariate logistic regression, the following variables were predictive factors for transfusions: male gender (OR 0.447; P = 0.01), preoperative hemoglobin level (OR 0.622; P = 0.001), preoperative ferritin level (OR 0.995; P = 0.016), BMI (OR 0.837; P = 0.001), cardiopathy (OR 3.534; P = 0.046), preoperative anaemia (OR 10.54; P = 0.011). In the multivariate logistic regression only preoperative hemoglobin level (OR 0.666; P = 0.01), and BMI (OR 0.868; P = 0.007) were statistically significant.

CONCLUSIONS

The incidence of blood transfusions after one-stage bilateral THA is low in non-anemic patients operated on at a high-volume arthroplasty center. The main predictors of blood transfusions are preoperative Hb level and BMI.

Influence of Depression and Sleep Quality on Postoperative Outcomes after Total Hip Arthroplasty: A Prospective Study

The trend of Total Hip Arthroplasty (THA) is projected to grow. Therefore, it has become imperative to find new measures to improve the outcomes of THA. Several studies have focused attention on the influence of psychological factors and sleep quality on surgical outcomes. The consequences of depressive states may affect outcomes and also interfere with rehabilitation. In addition, sleep quality may be an essential factor in determining surgical outcomes. To our knowledge, few articles focus on the influence of these factors on THA results. The present study investigates a possible correlation between preoperative depression or sleep quality and postoperative outcomes of THA. This study was conducted with 61 consecutive patients undergoing THA from January 2020 to January 2021. Patients were assessed preoperatively using GDS and PSQI, and six months postoperatively using FJS-12, SF-36, WOMAC, PSQI, and GDS. To simplify comparisons, the overall scores were normalized to range from 0 (worst condition) to 100 points (best condition). A total of 37 patients (60.7%) were classified as depressed and 24 as not depressed (39.3 %) in the preoperative assessment. A low–moderate positive correlation between preoperative GDS score and FJS-12 (rho = 0.22, p = 0.011), SF-36-PCS (rho = 0.328, p = 0.01), and SF-36-MCS (rho = 0.293, p = 0.022) scores at six-month follow-up was found. When the normalized preoperative GDS score was high (no depression), the FJS-12, SF-36-PCS, and SF-36-MCS scores tended to increase more compared to the other group. Statistically significant differences between the two groups were found in postoperative FJS-12 (p = 0.001), SF-36-PCS (p = 0.017), and SF-36-MCS scores (p = 0.016). No statistically significant correlation between preoperative PSQI score and postoperative outcome measures was found. Preoperatively depressed patients had a low–moderate positive correlation with postoperative SF-36 and FJS-12 scores. There was no correlation between sleep quality and postoperative outcome measures of THA.

Pelvic tilt and functional acetabular position after total hip arthroplasty: an EOS 2D/3D radiographic study

PURPOSE

In total hip arthroplasty (THA), the functional anatomy of the spinopelvic unit should be taken into account to provide the correct functional positioning of the implant. The relationship between the spine and the pelvis in the sagittal plane is represented by pelvic tilt (PT). The sacral slope (SS) has been proposed as a more reliable parameter than the anterior pelvic plane (APP) to express the PT. This study investigated the relationship between the APP and the SS; and the relationship between the APP and the SS, respectively, with the postoperative acetabular orientation.

METHODS

45 patients undergoing primary THA were prospectively enrolled. The EOS 2D/3D system was used to perform the radiographic evaluation before and 3 months after surgery. The following parameters were measured in both standing and sitting position: SS, APP, acetabular anteversion (AA) and inclination (AI).

RESULTS

The SS values did not show any correlation with the values of the APP angle. The changes of the SS in the transition from the standing to the sitting position significantly correlated with the changes of the AA (r = -0.61; p < 0.0001). A weak correlation was found between the APP angle and the AA in standing position (r = -0.35; p = 0.02).

CONCLUSIONS

The SS accurately expresses the functional orientation of the pelvis in the sagittal plane, and the functional orientation of the cup after hip replacement. Therefore, SS could be taken into account by navigation systems in order to achieve a patient-specific functional position of the acetabular cup.

A Modeling Study of a Patient-specific Safe Zone for THA: Calculation, Validation, and Key Factors Based on Standing and Sitting Sagittal Pelvic Tilt

BACKGROUND

Lumbar-pelvic stiffness and sagittal imbalance have been reported to increase the risk of dislocation and wear after THA. One potential way to approach this concern is by identifying patient-specific safe zones for THA components based on the standing and sitting sagittal pelvic tilt. However, there is no algorithm to integrate the standing and sitting pelvic tilt into the surgical plan of component orientations.

QUESTIONS/PURPOSES

We established a new mathematical algorithm for determining a patient-specific safe zone for THA by integrating the impingement-free ROM requirements of standing and sitting while preventing edge loading while standing. We aimed to determine (1) the accuracy of this new method for predicting the impingement-free ROM for a given component orientation, (2) the sensitivity and specificity of detecting an impingement-free acetabular cup position for standing and sitting, and (3) the influences of key factors including pelvic tilt while standing and pelvic tilt while sitting and implant parameters on patient-specific safe zones.

METHODS

A strategy for calculating the intersection of standing and sitting impingement-free safe zones and the zone of a standing radiographic inclination of ≤ 45° was used to develop patient-specific safe zones. We conducted a computer simulation study including the pelvis and THA prosthesis to answer the three study questions. We enrolled 10 patients who underwent robot-assisted THA for avascular necrosis of the femoral head (mean age 49 ± 19 years; five were women) from October 2019 to December 2019. We used a prosthesis model with a conical stem neck and a non-hooded liner, with the femoral head diameter ranging between 28 mm and 40 mm, and the corresponding head-neck ratio ranging between 2.33 and 3.33. We tested 1680 movements for the accuracy of impingement-free ROM (Question 1), and 80 marginal points and 120 non-marginal points of the comprehensive impingement-free safe zone, which combines the standing and sitting postures (Question 2). For Question 3, we explored the influences of standing and sitting pelvic tilt, femoral head diameter, and ROM criteria on the size of the patient-specific safe zone.

RESULTS

With the simulation method as a reference for detecting impingement, the mean absolute error (arithmetic mean of all the absolute errors) of the calculated impingement-free ROM was 1.4° ± 2.3°, and the limit of agreement of errors was between -3.6° and 3.7°. The sensitivity of detecting a safe cup orientation within the comprehensive impingement-free safe zone for a given ROM criterion was 98.9% (95% CI 93.6% to 99.9%), and specificity was 97.1% (95% CI 91.0% to 99.2%). There were no impingement-free safe zones for 29% (pelvic tilt combinations without an impingement-free safe zone and all tested combinations) and no patient-specific safe zones for 46% (pelvic tilt combinations without a patient-specific safe zone and all tested combinations) of the tested combinations of standing and sitting pelvic tilt. The patient-specific safe zone was sensitive to changes in standing and sitting pelvic tilt, femoral head diameter, stem version, and ROM criteria. Stem anteversions beyond 10° to 20° dramatically reduced the size of the patient-specific safe zone to 0 within a change of 10° to 20°.

CONCLUSION

The patient-specific safe zone algorithm can be an accurate method for determining the optimal orientation for acetabular cups and femoral stems in THA. The patient-specific safe zone is sensitive to changes in standing and sitting pelvic tilt, stem version, ROM criteria, and the femoral head diameter. A narrow zone of 10° to 20° for stem anteversion is recommended to maximize the size of the patient-specific safe zone.

CLINICAL RELEVANCE

This study suggests the potential of a mathematical algorithm to optimize the orientation of THA components and illustrates how key parameters affect the patient-specific safe zone.

The role of the femoral component orientation on dislocations in THA: a systematic review

INTRODUCTION

Dislocation remains a major complication in total hip arthroplasty (THA), in which femoral component orientation is considered a key parameter. New imaging modalities and definitions on femoral component orientation have been introduced, describing orientation in different planes. This study aims to systematically review the relevance of the different orientation parameters on implant stability.

METHODS

A systematic review was performed according to the PRISMA guidelines to identify articles in the PubMed and EMBASE databases that study the relation between any femoral component orientation parameters and implant stability in primary THA.

RESULTS

After screening for inclusion and exclusion criteria and quality assessment, nine articles were included. Definitions to describe the femoral component orientation and methodologies to assess its relevance for implant stability differed greatly, with lack of consensus. Seven retrospective case-control studies reported on the relevance of the transversal plane orientation: Low femoral- or low combined femoral and acetabular anteversion was statistical significantly related with more posterior dislocations, and high femoral- or combined femoral and acetabular anteversion with anterior dislocations in two studies. There were insufficient data on sagittal and coronal component orientation in relation to implant stability.

CONCLUSION

Because of incomparable definitions, limited quality and heterogeneity in methodology of the included studies, there is only weak evidence that the degree of transverse component version is related with implant stability in primary THA. Recommendations about the optimal orientation of the femoral component in all three anatomical planes cannot be provided. Future studies should uniformly define the three-dimensional orientation of the femoral component and systematically describe implant stability.

A Workflow Change in Anterior Approach Total Hip Arthroplasty Leads to Improved Accuracy of Biomechanical Reconstruction Without Increased Risk of Complications

Background

During anterior approach total hip arthroplasty (THA), the femur may be an impediment for acetabular access, pushing reamers proximally and consequently altering the hip center. In an effort to address this, the senior author changed the surgical workflow from acetabulum first (AF) to femur first (FF). The objective of this study was to compare the precision of biomechanical hip reconstruction and clinical outcomes between the FF and AF techniques.

Methods

This is a retrospective, case-control study of 267 anterior THAs (132 AF and 135 FF). A normal, contralateral hip was used to determine the native biomechanical parameters. Using a calibrated software program, radiographic measurements were performed to calculate the hip center position, femoral offset, global offset, and leg length of the operative and native hips using 2-week postoperative anteroposterior pelvis radiographs. Demographics, operative information, hemoglobin change, and complication data were obtained. Functional outcomes were assessed with the Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement survey at 1 year postoperatively.

Results

The groups exhibited similar demographic characteristics. The FF group demonstrated significantly more accurate and more precise reconstruction of horizontal and vertical hip centers, femoral offset, and leg length. There was no significant difference in operative time, hemoglobin change, complication rate, or Hip Disability and Osteoarthritis Outcome Score, Joint Replacement scores between groups.

Conclusions

The FF technique allowed for more accurate and precise reconstruction of the hip center, leg length, and offset in THA than the AF workflow. Furthermore, the FF approach demonstrated no significant differences in complication rate or blood loss, nor in clinical outcomes.

Level of Evidence

Therapeutic Study Level III.

Complications, readmission and reoperation rates in one-stage bilateral versus unilateral total hip arthroplasty: a high-volume single center case-control study

The study aimed to assess the safety of one-stage bilateral total hip arthroplasty (THA) compared with unilateral THA. In this retrospective observational case–control study were included patients undergoing unilateral (group 1) and one-stage bilateral (group 2) THA in a high-volume center. The groups were matched for gender, age at surgery, and pre-operative American Society of Anesthesiology score. The following variables were assessed: local and systemic complications, postoperative anemia, 30-day and 1-year readmission and reoperation rates, length of hospital stay, and ambulation time. Group 1 reported a significantly higher rate of local and systemic complications compared with group 2 (5.4% versus 3.9% and 29.6% versus 4.7%, respectively). Postoperative anemia was significantly lower in group 1 compared with group 2 (8.1% versus 30%). There was no significant difference in terms of 30-day and 1-year readmission rates between the two groups. The average length of hospital stay was 5.1 ± 2.3 days in group 1, and 5.3 ± 1.9 days in group 2 (p = 0.78). Ambulation time was significantly lower for group 1 (day 0.9 ± 0.9 in group 1, and day 1 ± 0.8 in group 2, p = 0.03). In a high-volume center, one-stage bilateral THA is a safe procedure compared with unilateral THA in terms of postoperative local and systemic complications, 30-day readmission and 1-year reoperation rates, and length of hospital stay.

Total Hip Arthroplasty With a Monoblock Conical Stem in Dysplastic Hips: A 20-Year Follow-Up Study

BACKGROUND

Total hip arthroplasty in patients with hip dysplasia is challenging as a result of complex anatomic deformities in the hip. The aim of the study was to evaluate the survivorship, the clinical and radiographic outcomes of cementless Wagner Cone stem in patients with dysplastic hip.

METHODS

This retrospective study reports on 102 patients (135 hips) who have undergone total hip arthroplasty between 1993 and 1997. The mean age of patients was 51 years (range, 21-73). Minimum follow-up was 20 years. According to the Crowe classification, 38 hips presented dysplasia of grade I, 41 of grade II, 37 of grade III, and 19 of grade IV.

RESULTS

Kaplan-Meier survivorship for aseptic loosening was 97% (95% confidence interval, 94.4-99.6) at 20 years. The average Harris hip score increased from 43.4 points (range, 22-51) to 86.4 points (range, 39-100) (P < .0001) and average Merle d'Aubignè score increased from 8.4 (range, 4-13) to 15 (range, 5-18) (P < .0001); at the last follow-up, average University of California at Los Angeles activity score and visual analog score were 4.53 (range, 1-9) and 1.25 (range, 0-6), respectively; 17% of heterotopic ossification and 19.2% of radiolucency lines around the stem were reported.

CONCLUSION

Monoblock Wagner Cone stem is a reliable option in dysplastic hip with an excellent survivorship and good clinical and radiographic outcome in the long term.

Blood loss in primary total hip arthroplasty with a short versus conventional cementless stem: a retrospective cohort study

INTRODUCTION

To evaluate the impact of short cementless stem on several clinical and radiographic outcomes, with particular focus on blood loss, in comparison with conventional cementless stem in total hip arthroplasty (THA).

MATERIALS AND METHODS

Patients undergoing THA with GTS short stem or CLS conventional stem were included. Clinical data were retrospectively collected including preoperative and postoperative day 1 value for haemoglobin (HB); rate of postoperative blood transfusions; intraoperative bone infractions; stem alignment; 5-year follow-up Harris Hip Score (HHS) and rate of stem revision at 5 years of follow-up of the short and conventional cementless stem.

RESULTS

GTS and CLS stem group included 374 and 321 patients, respectively. The mean difference between the preoperative and postoperative day 1 HB value was 3.98 g/dL (SD 1.12) and 3.67 g/dL (SD 1.19) in the GTS and CLS group, respectively, which correspond to a crude effect (β) of 0.32 (95% CI 0.15; 0.49) and adjusted effect of 0.11 (95% CI - 0.08; 0.3). GTS group reported a significantly higher number of patients with excellent results in terms of HHS (p = 0.001). The rate of intraoperative bone infractions was 1.6% and 0.3% in the GTS and CLS group, respectively (p = 0.013). At radiographic assessment, the rate of varus position of the stem was 14% in the GTS group and 6% in the CLS group (p < 0.0001). The rate of stem revision at 5 years of follow-up was 0.8% and 0.4% in the GTS and CLS group, respectively (p = 0.63).

CONCLUSIONS

GTS short stem was not associated with a clinically significant lower blood loss in the immediately postoperative period. Unadjusted exploratory analyses show that GTS stem provides the same results of CLS stem in terms of HHS and rate of stem revision at 5 years of follow-up.

The Direct Anterior Approach Total Hip Arthroplasty Reliably Achieves "Safe Zones" for Combined Anteversion

Background

In total hip arthroplasty (THA), component position is critical to avoid instability and improve longevity. Appropriate combined femoral and acetabular component anteversion is important for improved THA stability and increased impingement-free range of motion. In direct anterior THA (DA-THA), concern has been expressed regarding the accuracy of femoral component positioning. This study seeks to quantify acetabular, femoral, and combined component orientation relative to the accepted “safe zones” in patients who have undergone DA-THA.

Methods

Twenty-nine patients who had THA performed via direct anterior approach had postoperative computerized tomography scans done to assess femoral anteversion. Stem rotational alignment was measured relative to the transepicondylar axis (TEA) and the posterior condylar axis (PCA) of the femur at the knee. Acetabular abduction and version were recorded on anteroposterior pelvis radiographs.

Results

The mean stem anteversion was 17.5° (standard deviation = 10.8°) from the TEA and 21.7° (standard deviation = 11.3°) from the PCA. Ten of 30 cups were appropriately anteverted; however, all the cups had appropriate abduction. Combined version when using the TEA resulted in 79% (23/29) of patients within the “safe zone” of 25°-50°. Pearson correlation coefficients were high for both stem anteversion from the TEA (R = 0.96) and PCA (R = 0.98); however, interobserver reliability for combined component anteversion was greater for the TEA (kappa, 0.83 vs 0.65).

Conclusions

Combined anteversion within the “safe zone” was achieved 79% of the time with DA-THA. Interestingly, most of the “excessive” combined anteversion appears to be related to increased anteversion of the acetabular component with only 10 patients within the acetabular cup “safe zone” of 5°-25°.

Uncemented femoral stem orientation and position in total hip arthroplasty: A CT study

In total hip arthroplasty (THA), accurate positioning of components is important for the functionality and long life of the implant. Femoral component version has been underinvestigated when compared with the acetabular cup. Accurate prediction of the femoral version on the preoperative plan is particularly important because a well-fitting uncemented stem will, by definition, press-fit into a version that is dictated by the anatomy of the proximal femur. A better understanding of this has recently become an unmet need because of the increased use of uncemented stems and of preoperative image-based planning. We present the first, three-dimensional (3D) comparison between the planned and achieved orientation and position of the femoral components in THA. We propose a comparison method that uses the 3D models of a, computed tomography-generated (CT-generated), preoperative plan and a postoperative CT to obtain the discrepancy in the six possible degrees of freedom. We ran a prospective study (level 2 evidence) of 30 patients undergoing uncemented THA to quantify the discrepancy between planned and achieved femoral stem orientation and position. The discrepancy was low for femoral stem vertical position and leg length, and varus-valgus and anterior-posterior orientation. The discrepancy was higher for femoral version with a mean (±SD) of -1.5 ± 7.8 deg. Surgeons should be aware of the variability of the eventual position of uncemented stems in THA and acknowledge the risk of achieving a less-than-optimal femoral version, different from the preoperative 3D CT plan.

Hip scores: A current concept review

INTRODUCTION

During the past decades, several rating scales have been developed to assess the functional status of patients with hip pain.

SOURCE OF DATA

A search in Medline, PubMed, Cochrane and CINAHL was performedusing combinations of the following'hip', 'scoring system', 'scale', 'scores', 'outcome assessment', 'arthroplasty', 'arthroscopy' and 'clinical evaluation'.

AREAS OF AGREEMENT

A total 16 scoring systems are currently available for the evaluation of the hip.

AREAS OF CONTROVERSY

Two types of questionnaires are available: physician-rated and patient-rated questionnaires.

GROWING POINTS

Each hip score consists of different domains. Interpreting these domains becomes sometimes difficult, because, even though they can be common to more than one scoring system, each stresses them in a different way.

AREAS TIMELY FOR DEVELOPING RESEARCH

Although many scoring systems have been used to evaluate hip function, we are still far from a single outcome evaluation system which is reliable, valid and sensitive.

Double-trabecular metal cup technique for the management of Paprosky type III defects without pelvic discontinuity

INTRODUCTION:

Modular reconstruction systems based on trabecular metal (TM) prosthetic components have been increasingly used in the last decade for the management of severe acetabular bone defects. The aim of this study was to assess the clinical and radiographic outcomes of double-cup technique for the management of Paprosky type III defects without pelvic discontinuity.

METHODS:

A retrospective review was performed for all patients undergoing acetabular reconstruction with 2 TM cups at a tertiary referral centre between 2010 and 2015. Harris Hip Scores (HHS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were evaluated preoperatively and at the latest follow-up. Radiographic assessment of the hip centre of rotation (COR) position and leg length discrepancy (LLD) was performed preoperatively and postoperatively. Osteolysis and radiolucencies, loosening of the implants, and heterotopic ossifications were evaluated with the latest follow-up radiographs.

RESULTS:

Patients included 5 men and 11 women (16 hips) with an average age of 68 (45-81) years. Acetabular bone defects included 9 Paprosky type IIIB and 7 type IIIA defects. No pelvic discontinuities were registered. The mean follow-up was 34 (24-72) months. HHS and WOMAC scores, LLD and COR position significantly improved after surgery. In only 1 (6.3%) hip a not progressive radiolucent line adjacent the acetabular construct was noted. Heterotopic ossifications were found in 2 (12.5%) hips. No patients underwent acetabular components revision surgery for any reason.

CONCLUSION:

The double-cup technique could be considered an effective management of selected Paprosky type III defects without pelvic discontinuity providing excellent clinical and radiographic outcomes in the short term.

Total hip arthroplasty with a monoblock conical stem and subtrochanteric transverse shortening osteotomy in Crowe type IV dysplastic hips

PURPOSE

This series assessed the clinical and radiographic outcomes of total hip arthroplasty (THA) with femoral shortening osteotomy for the management of patients with Crowe type IV hip dysplasia.

METHODS

Only patients with Crowe type IV hip dysplasia who underwent primary THA combined with a subtrochanteric transverse osteotomy with an uncemented monoblock conical stem were included. The clinical and radiographic evaluations were performed before and immediately after surgery, and at last follow-up. The hip function was assessed with the Harris Hip Score (HHS).

RESULTS

Seventy-four patients (102 hips) with a mean age of 53.9 (range, 20-83) were evaluated at an average follow-up of 11.3 years (range, 5-25). Stem revision occurred in two (1.9%) cases, with a survivorship of 95.9% (95%IC, 91.9-99.9%) at ten years. The average HHS increased from 44 (range, 15-78) pre-operatively to 90.3 (range, 62-100) at last follow-up (p < 0.001). Osteotomy site non-union and early dislocation were observed in 3.9 and 3.8%, respectively. No cases of nerve palsy were reported.

CONCLUSIONS

THA with a monoblock conical stem associated with subtrochanteric transverse osteotomy provides good long-term survival, clinical and radiographic results. It may be considered an effective management of patients with Crowe IV hip dysplasia.

Prevention of Dislocation After Total Hip Arthroplasty

BACKGROUND

Prevention of dislocation after primary total hip arthroplasty (THA) begins with patient preoperative assessment and planning.

METHODS

We performed a literature search to assess historical perspectives and current strategies to prevent dislocation after primary THA. The search yielded 3458 articles, and 154 articles are presented.

RESULTS

Extremes of age, body mass index >30 kg/m², lumbosacral pathology, surgeon experience, and femoral head size influence dislocation rates after THA. There is mixed evidence regarding the effect of neuromuscular disease, sequelae of pediatric hip conditions, and surgical approach on THA instability. Sex, simultaneous bilateral THA, and restrictive postoperative precautions do not influence the dislocation rates of THA. Navigation, robotics, lipped liners, and dual-mobility acetabular components may improve dislocation rates.

CONCLUSIONS

Risks for dislocation should be identified, and measures should be taken to mitigate the risk. Reliance on safe zones of acetabular component positioning is historical. We are in an era of bespoke THA surgery.