The impact of capsular repair on the risk for dislocation after revision total hip arthroplasty - a retrospective cohort-study of 259 cases

Wound closure after knee and hip replacement (TKA and THA): Survey results on the clinical practice in Spain

BACKGROUND AND OBJECTIVE

In orthopedic surgery, it is clear that an optimal standardized closure technique has not yet been developed. Locally, there are no objective data describing the standard surgical practice in wound closure. The aim of this study is to analyze the clinical practice of surgical wound closure in orthopedic surgery by means of a survey of a representative local sample and thus obtain information on the context of closure in Spain.

METHOD

an ad hoc group of specialists in orthopedic surgery and traumatology was formed. The group of experts, after analyzing the literature, developed a questionnaire of 32 closed multiple-choice questions divided into the following blocks: hemostasis, surgical wound closure (deep, superficial, and cutaneous), and dressings.

RESULTS

A total of 471 surgeons responded to the survey completely and with sufficient information to perform the descriptive analysis. 79% believe that ATX can influence the decrease in surgical site infection rate. 96% believe that the type of deep closure at the level of the arthrotomy could influence outcomes and complications after hip and/or knee replacements. 85% believe that the type of shallow closure at the subcutaneous level may influence outcomes and complications after hip and/or knee replacement. 64% of surgeons use single-use incisional negative pressure therapy for the treatment of surgical wound complications (seroma, prolonged drainage, dehiscence).

CONCLUSIONS

There is a high level of variability in wound closure in our setting and a low level of training on the subject. The authors recommend that the different scientific societies invest resources to improve training in this field and reduce the percentage of surgeons who are considered inadequately trained, as well as adapting closure techniques to those considered gold standard according to the evidence.

[Translated article] Wound closure after knee and hip replacement (TKA and THA): Survey results on the clinical practice in Spain

BACKGROUND AND OBJECTIVE

In orthopaedic surgery, it is clear that an optimal standardised closure technique has not yet been developed. Locally, there are no objective data describing the standard surgical practice in wound closure. The aim of this study is to analyse the clinical practice of surgical wound closure in orthopaedic surgery by means of a survey of a representative local sample and thus obtain information on the context of closure in Spain.

MATERIAL AND METHOD

An ad hoc group of specialists in orthopaedic surgery and traumatology was formed. The group of experts, after analyzing the literature, developed a questionnaire of 32 closed multiple-choice questions divided into the following blocks: hemostasis, surgical wound closure (deep, superficial, and cutaneous), and dressings.

RESULTS

A total of 471 surgeons responded to the survey completely and with sufficient information to perform the descriptive analysis. 79% believe that ATX can influence the decrease in surgical site infection rate. 96% believe that the type of deep closure at the level of the arthrotomy could influence outcomes and complications after hip and/or knee replacements. 85% believe that the type of shallow closure at the subcutaneous level may influence outcomes and complications after hip and/or knee replacement. 64% of surgeons use single-use incisional negative pressure therapy for the treatment of surgical wound complications (seroma, prolonged drainage, dehiscence).

CONCLUSIONS

There is a high level of variability in wound closure in our setting and a low level of training on the subject. The authors recommend that the different scientific societies invest resources to improve training in this field and reduce the percentage of surgeons who are considered inadequately trained, as well as adapting closure techniques to those considered gold standard according to the evidence.

Microstructural analysis on the innervation of the anterior, medial, and lateral human hip capsule: Preliminary evidence on its neuromechanical contribution

OBJECTIVE

Capsular repair aims to minimize damage to the hip joint capsular complex (HJCC) and subsequent dislocation risk following total hip arthroplasty (THA). Numerous explanations for its success have been advocated, including neuromuscular feedback loops originating from within the intact HJCC. This research investigates the hypothesis that the HJCC contributes to hip joint stability by analyzing HJCC innervation.

METHOD

Twenty-nine samples from the anterior, medial, and lateral aspects of the midportion HJCC of 29 individuals were investigated stereologically and immunohistochemically to identify encapsulated mechanoreceptors according to a modified Freeman and Wyke classification, totaling 11,745 sections. Consecutive slices were observed to determine the nerve course within the HJCC.

RESULTS

Few encapsulated mechanoreceptors were found in the HJCC subregions and overlying tissues across the cohort studied. Of regions studied, no significant regional differences in the density of mechanoreceptors were found. No significant difference in mechanoreceptor density was found between sides (left, 10.2×10-4/mm3, 4.0×10-4 - 19.0×10-4/mm3; right 12.9×10-4/mm3, 5.0×10-4 - 22.0×10-4/mm3; mean, 95% confidence intervals) sexes (female 10.4×10-4/mm3, 4.0×10-4 - 18.0×10-4/mm3; male 11.6×10-4/mm3, 5.0×10-4 - 20.0×10-4/mm3; mean, 95% confidence intervals), nor in correlation with age demographics. Myelinated nerves coursed consistently within the HJCC in various orientations.

CONCLUSION

Sparse mechanoreceptor density suggests that the HJCC contributes to a limited extent to hip joint stabilization. HJCC nerve terminals may potentially contribute to neuromuscular feedback loops with associated muscles to mediate joint stability in tandem with the active and passive components of the joint.

Patient-Specific Risk Factors Exist for Hip Fractures After Arthroscopic Femoroacetabular Impingement Surgery, But Not for Dislocation—An Analysis of More Than 25,000 Hip Arthroscopies

Purpose

To identify postoperative complications and risk factors associated with hip fracture and dislocation following primary arthroscopic surgical management of femoroacetabular impingement (FAI) syndrome.

Methods

MarketScan was queried to identify patients who underwent FAI surgery from 2007 to 2016. Patients were stratified into 2 groups: acetabuloplasty only or femoroplasty only. A subanalysis of combined acetabuloplasty and femoroplasty also was undertaken. Surgical outcomes were followed postoperatively for 180 days. Multivariate logistic regression was used to control for with an alpha value of 0.05 set as significant.

Results

This study identified 13,809 patients (mean age, 36.3 years) who underwent primary acetabuloplasty or femoroplasty. We also identified 10,026 patients who underwent both procedures. Postoperative complication rates were similar between the cohorts (acetabuloplasty 17.1%, femoroplasty 19.9%, P = .0622). Rates of hip fracture (femoroplasty: 2.4% vs acetabuloplasty: 2.0%, P = .0302) and heterotopic ossification (femoroplasty: 11.3% vs acetabuloplasty: 8.8%, P < .0001) were greater in the femoroplasty-only cohort. Combined acetabuloplasty and femoroplasty was associated with the greatest complication burden of 21.6% (P < .0001). After multivariate regression, differences in age, sex, comorbid status, or procedure type did not influence odds in risk for postoperative hip dislocation. Adjusted data showed that neither femoroplasty nor acetabuloplasty influenced odds of hip fracture (P > .05). Patients who were aged younger than 20 years old were significantly less likely to fracture their hips postoperatively than patients aged 60+ years (odds ratio 0.3, 95% confidence interval 0.1-0.8). Hypertension was independently associated with increased odds of hip fracture (odds ratio 1.7, 95% confidence interval 1.2-3.5).

Conclusions

Older age, male sex, and hypertension all carry increased risk for a hip fracture following acetabuloplasty or femoroplasty. Patient- and procedure-specific factors that could be assessed with this database did not influence risk for hip dislocation.

Level of Evidence

Level III; retrospective comparative observation trial.

Capsular repair vs capsulectomy in total hip arthroplasty

BACKGROUND

A major complication of total hip arthroplasty is dislocation. The hip joint capsule can be incised and repaired, or can be excised.

SOURCES OF DATA

We performed a systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines focusing on capsular repair and capsulectomy.

AREAS OF AGREEMENT

We identified 31 articles (17 272 patients). Capsular repair produced a lower blood loss (465.2 vs 709.2 ml), and the procedure lasted 102.5 vs 96.08 min in patients who underwent capsulectomy. The patients undergoing capsulectomy experienced a dislocation rate of 3.06%, whereas in the patients undergoing capsular repair, the dislocation rate was 0.65%.

AREAS OF CONTROVERSY

Most studies are retrospective observational studies, with no prospective randomized trials.

GROWING POINTS

Capsular preservation is association with a lower dislocation rate and a lower blood loss. Capsular excision does take statistically less time, but it is uncertain how a 6 min difference is clinically relevant.

AREAS TIMELY FOR DEVELOPING RESEARCH

Appropriately powered randomized clinical trials should be conducted to better define the association between the chosen implants, approach and outcome.

A systematic review and meta-analysis of the hip capsule innervation and its clinical implications

Detailed understanding of the innervation of the hip capsule (HC) helps inform surgeons’ and anaesthetists’ clinical practice. Post-interventional pain following radiofrequency nerve ablation (RFA) and dislocation following total hip arthroplasty (THA) remain poorly understood, highlighting the need for more knowledge on the topic. This systematic review and meta-analysis focuses on gross anatomical studies investigating HC innervation. The main outcomes were defined as the prevalence, course, density and distribution of the nerves innervating the HC and changes according to demographic variables. HC innervation is highly variable; its primary nerve supply seems to be from the nerve to quadratus femoris and obturator nerve. Many articular branches originated from muscular branches of the lumbosacral plexus. It remains unclear whether demographic or anthropometric variables may help predict potential differences in HC innervation. Consequently, primary targets for RFA should be the anterior inferomedial aspect of the HC. For THA performed on non-risk patients, the posterior approach with capsular repair appears to be most appropriate with the lowest risk of articular nerve damage. Care should also be taken to avoid damaging vessels and muscles of the hip joint. Further investigation is required to form a coherent map of HC innervation, utilizing combined gross and histological investigation.

Capsular resection versus capsular repair in direct anterior approach for total hip arthroplasty: a randomized controlled trial

AIMS

Optimal exposure through the direct anterior approach (DAA) for total hip arthroplasty (THA) conducted on a regular operating theatre table is achieved with a standardized capsular releasing sequence in which the anterior capsule can be preserved or resected. We hypothesized that clinical outcomes and implant positioning would not be different in case a capsular sparing (CS) technique would be compared to capsular resection (CR).

METHODS

In this prospective trial, 219 hips in 190 patients were randomized to either the CS (n = 104) or CR (n = 115) cohort. In the CS cohort, a medial based anterior flap was created and sutured back in place at the end of the procedure. The anterior capsule was resected in the CR cohort. Primary outcome was defined as the difference in patient-reported outcome measures (PROMs) after one year. PROMs (Harris Hip Score (HHS), Hip disability and Osteoarthritis Outcome Score (HOOS), and Short Form 36 Item Health Survey (SF-36)) were collected preoperatively and one year postoperatively. Radiological parameters were analyzed to assess implant positioning and implant ingrowth. Adverse events were monitored.

RESULTS

At one year, there was no difference in HSS (p = 0.728), HOOS (Activity Daily Life, p = 0.347; Pain, p = 0.982; Quality of Life, p = 0.653; Sport, p = 0.994; Symptom, p = 0.459), or SF-36 (p = 0.338). Acetabular component inclination (p = 0.276) and anteversion (p = 0.392) as well as femoral component alignment (p = 0.351) were similar in both groups. There were no dislocations, readmissions, or reoperations in either group. The incidence of psoas tendinitis was six cases in the CS cohort (6%) and six cases in the CR cohort (5%) (p = 0.631).

CONCLUSION

No clinical differences were found between resection or preservation of the anterior capsule when performing a primary THA through the DAA on a regular theatre table. In case of limited visibility during the learning curve, it might be advisable to resect a part of the anterior capsule. Cite this article: Bone Joint J 2021;103-B(2):321-328.

Innervation of the hip joint capsular complex: A systematic review of histological and immunohistochemical studies and their clinical implications for contemporary treatment strategies in total hip arthroplasty

The hip joint capsule contributes to the stability of the hip joint and lower extremity, yet this structure is incised and often removed during total hip arthroplasty (THA). Increasing incidence of osteoarthritis is accompanied by a dramatic rise in THAs over the last few decades. Consequently, to improve this treatment, THA with capsular repair has evolved. This partial restoration of physiological hip stability has resulted in a substantial reduction in post-operative dislocation rates compared to conventional THA without capsular repair. A further reason for the success of this procedure is thought to be the preservation of the innervation of the capsule. A systematic review of studies investigating the innervation of the hip joint capsular complex and pseudocapsule with histological techniques was performed, as this is not well established. The literature was sought from databases Amed, Embase and Medline via OVID, PubMed, ScienceDirect, Scopus and Web of Science; excluding articles without a histological component and those involving animals. A total of 21 articles on the topic were identified. The literature indicates two primary outcomes and potential clinical implications of the innervation of the capsule. Firstly, a role in the mechanics of the hip joint, as mechanoreceptors may be present in the capsule. However, the nomenclature used to describe the distribution of the innervation is inconsistent. Furthermore, the current literature is unable to reliably confirm the proprioceptive role of the capsule, as no immunohistochemical study to date has reported type I-III mechanoreceptors in the capsule. Secondly, the capsule may play a role in pain perception, as the density of innervation appears to be altered in painful individuals. Also, increasing age may indicate requirements for different strategies to surgically manage the hip capsule. However, this requires further study, as well as the role of innervation according to sex, specific pathology and other morphometric variables. Increased understanding may highlight the requirement for capsular repair following THA, how this technique may be developed and the contribution of the capsule to joint function and stability.

Proceeding from direct lateral to anterolateral approach in total hip arthroplasty: A closer look on radiological and clinical aspects

Introduction

Since less invasive approaches for total hip arthroplasty (THA) are promoted, our aim was to compare direct lateral (DLA) and anterolateral approach (ALA) under otherwise identical conditions.

Methods

Pre - and postoperative x-rays from 200 propensity matched patients (DLA vs. ALA) were evaluated for anatomical reconstruction.

Results

Overall, the cup position was within the safe zone in both group while the mean center of rotation (COR) was placed more medial and cranial in both groups compared to preoperative anatomy (p > 0.05). The mean leg elongation was comparable between both approaches (p > 0.05). Postoperatively the WOMAC improved about 90%.

Conclusion

This study confirmed that the ALA can be safely used for THA in minimal invasive setting.

Causes of and treatment options for dislocation following total hip arthroplasty

The second most common complication following total hip arthroplasty (THA) is dislocation. The majority of dislocations occur early in the post-operative period and are due to either patient-associated or surgical factors. The patient-associated factors that have been implicated as causes of post-operative dislocation include previous surgery, lumbar spine fusion surgery and/or neurological impairment. The surgical factors include surgical approach, component orientation and prosthetic and/or bony impingement. In order to delineate the cause of the hip instability a thorough history and physical and a radiographic assessment (possibly including advanced imaging) needs to be performed. Approximately two thirds of cases are successfully treated; one third of cases will require surgical treatment (e.g., revision arthroplasty (including constrained liners, the use of elevated rim liners and dual mobility implants or trochanteric advancement). In this review, we discuss the causes leading to dislocation following THA and evaluate the different treatment options available.