The effect of posterior capsule repair in total hip arthroplasty: a systematic review and meta-analysis

Dislocation of primary total hip arthroplasty: Analysis of risk factors and preventive options

Total hip arthroplasty (THA) is one of the most successful elective operations in orthopedic surgery for improving pain and functional disability in patients with end-stage joint disease. However, dislocation continues to be a troublesome complication after THA, as it is a leading cause of revision and is associated with substantial social, health, and economic costs. It is a relatively rare, usually early occurrence that depends on both the patients' characteristics and the surgical aspects. The most recent and important finding is the special attention to be given preoperatively to spinopelvic mobility, which is closely related to the incidence of dislocation. Consequently, clinical and radiographic assessment of the lumbar spine is mandatory to identify an altered pelvic tilt that could suggest a different positioning of the cup. Lumbar spinal fusion is currently considered a risk factor for dislocation and revision regardless of whether it is performed prior to or after THA. Surgical options for its treatment and prevention include the use of prostheses with large diameter of femoral head size, dual mobility constructs, constrained liners, and modular neck stems.

Is tranexamic acid safe for the hip joint?

To show the effects of tranexamic acid, which is a drug frequently used to control bleeding, on the hip joint and sciatic nerve in animal experiments. There were 15 rats in each of the 3 groups, with a total of 45 rats. Topical saline injections were applied to the first group, topical TXA injections to the second group, and intravenous (IV) TXA injections to the third group. In the samples taken from the hip joint 3 weeks later, femoral head cartilage, sciatic nerve, and joint capsule thicknesses were analyzed histologically. Statistically significantly more cartilage degradation was detected in the femoral head cartilage in both the IV and intraarticular TXA group when compared to the control group. The groups were also compared in terms of acetabular cartilage; however, no histological difference was found between the groups. It was seen that when the femoral head cartilage thickness (the average of the measurements made from 3 different points were used) was examined, the cartilage thickness in the topical TXA group was less when compared to the other 2 groups. However, this difference was determined to not be statistically significant. The data of the hip joint capsule thickness measurement, it was found that the capsule thickness in the topical TXA applied group was less when compared to the other 2 groups. However, this difference was not statistically significant. When the sciatic nerves in all 3 groups were compared, no different staining characteristics were found in the immunofluorescence examination. TXA, which is frequently used in orthopedic practice, shows negative effects on hip joint cartilage in both topical and intravenous application.

Instantaneous Generation of Subject-Specific Finite Element Models of the Hip Capsule

Subject-specific hip capsule models could offer insights into impingement and dislocation risk when coupled with computer-aided surgery, but model calibration is time-consuming using traditional techniques. This study developed a framework for instantaneously generating subject-specific finite element (FE) capsule representations from regression models trained with a probabilistic approach. A validated FE model of the implanted hip capsule was evaluated probabilistically to generate a training dataset relating capsule geometry and material properties to hip laxity. Multivariate regression models were trained using 90% of trials to predict capsule properties based on hip laxity and attachment site information. The regression models were validated using the remaining 10% of the training set by comparing differences in hip laxity between the original trials and the regression-derived capsules. Root mean square errors (RMSEs) in laxity predictions ranged from 1.8° to 2.3°, depending on the type of laxity used in the training set. The RMSE, when predicting the laxity measured from five cadaveric specimens with total hip arthroplasty, was 4.5°. Model generation time was reduced from days to milliseconds. The results demonstrated the potential of regression-based training to instantaneously generate subject-specific FE models and have implications for integrating subject-specific capsule models into surgical planning software.

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.

Surgical Approaches in Total Hip Arthroplasty

The Total Hip Arthroplasty (THA) has become one of the most reliable surgical interventions that has improved the quality of life in many patients. THA allows patients to have increased mobility, range of motion, and reduced pain in patients with degenerative hip joints. This surgical procedure has become an effective treatment option for several chronic conditions affecting the hip joint. Although this surgery has been shown to give promising results in patients with hip pathology, selecting the approach for THA is a critical step in pre-operative planning. The best approach for this surgical procedure depends on multiple factors and each present with their own challenges, success rates, and limitations. To further elucidate the advantages and disadvantages associated with different surgical approaches, we critically review each surgical approach along with the different causes of failure of the THA procedure.

Short term outcomes (average follow up of 2.4 years) of a constrained acetabular liner in primary and revision total hip arthroplasty

BACKGROUND

As instability continues to be a burden post total hip arthroplasty (THA), there has been a controversial discussion on the ideal implant choice. We report here the outcomes of a modern constrained acetabular liner (CAL) system in primary and revision THA at an average follow up of 2.4 years.

METHODS

We performed a retrospective study of all patients undergoing primary and revision hip arthroplasty and being implanted with the modern CAL system from 2013 to 2021. We identified 31 hips, of which 13 underwent primary THA and the remaining 18 underwent revision THA for instability.

RESULTS

Of those implanted with CAL primarily, 3 had concomitant abductor tear repair and gluteus maximus transfer, 5 had Parkinson's disease, 2 had inclusion body myositis, 1 had amyotrophic lateral sclerosis, and the remaining 2 were above 94 years of age. All patients implanted with the CAL were as a result of active instability post-primary THA and underwent only liner and head exchange without revision of the acetabular or femoral components. At an average follow up of 2.4 years (range, 9 months to 5 years and 4 months), we had 1 case (3.2 %) of dislocation post-CAL implantation. None of the patients undergoing surgery with CAL for active instability had a re-dislocation.

CONCLUSION

In conclusion, a constrained acetabular liner provides excellent stability in both primary THA in high risk individuals and revision THA in cases of active instability. There were no dislocations when using a constrained acetabular liner to treat active instability post THA.

Is there any clinical advantage of capsular repair over capsular resection for total hip arthroplasty? An updated systematic review and meta-analysis

INTRODUCTION

Although several surgical approaches, with or without capsular repair, can be used during total hip arthroplasty (THA), there is no clear evidence that capsular repair provides a clinical advantage post-surgery, regardless of surgical approach. This systematic review and meta-analysis evaluated whether capsular repair using various surgical approaches provides a clinical advantage over capsular resection post-THA.

METHODS

This study was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 checklist for systematic reviews and meta-analyses. Multiple comprehensive literature searches were performed. Results were summarized qualitatively as meta-analysis of pooled odds ratios, and the standardized mean difference, with 95% confidence intervals for each group: capsular repair or capsular resection. A P value < 0.05 was considered statistically significant. Each study was evaluated for the risk of bias. Publication bias was also assessed.

RESULTS

A total of 12 studies were included after screening and eligibility assessment. The odds ratio for hip dislocation after capsular repair was 0.14 (P < 0.00001). The standard mean difference of the Harris Hip Score (HHS) after capsular repair was 1.11 (P = 0.02). There were no significant differences between groups with respect to operation time (P = 0.79) and blood loss (P = 0.42).

CONCLUSION

The current meta-analysis suggests that capsular repair leads to lower dislocation rates and a better HHS after THA.

Using mesh in capsule anatomical reconstruction to enhance the stability of high-dislocation-risk hip arthroplasty: a randomized controlled trial

BACKGROUND

Dislocation is a common complication after total hip arthroplasty (THA). This study aimed to compare the outcomes of mesh reconstruction versus conventional capsular repair in maintaining capsular integrity and preventing dislocation after THA.

METHODS

This was a prospective, randomized controlled study of consecutive patients. A total of 124 high-dislocation-risk THAs were identified and randomized into two groups, one using mesh reconstruction and the other using the conventional capsular repair method. Perioperative data and radiological data were collected. Patients were followed up regularly. The main indices were the capsular integrity assessed by magnetic resonance imaging (MRI) and hip dislocation rate. The secondary indices included the Harris hip score (HHS), complications, and satisfaction.

RESULTS

A total of 106 patients completed the follow-up and the average follow-up times were 19 ± 3.1 and 18 ± 3.3 months. The operation time of the mesh group was longer than that of the conventional group (P < 0.001). There were minor differences in acetabular anteversion and abduction angle, and the other data showed no differences. MRI results indicated that the success rate of capsular repair was higher in the mesh group (50 hips, 98%) than in the conventional group (37 hips, 67%) (P < 0.001), and the others failed the repair. Three dislocations occurred in the conventional group, while none occurred in the mesh group. The preoperative HHS (30 points) and postoperative HHS (82 points) of the mesh group were similar to those (35 points, 83 points) of the conventional group (P = 0.164, P = 0.328). Satisfaction had no difference (P = 0.532).

CONCLUSIONS

Compared to conventional repair, mesh reconstruction can effectively maintain capsular integrity and decrease dislocation risk after THA without increasing complications.

LEVEL OF EVIDENCE

Therapeutic study, Level IA.

[Strategies for stem revision : Surgery planning, implant removal and reimplantation]

BACKGROUND AND PLANNING

Femoral revision represents a challenging procedure in its surgical planning and technical execution. The results are mainly dependent on the bone loss present, the quality of the implant removal and the choice of revision system. Patient-specific factors such as age, comorbidities, bone quality or even the localization of the cement have a decisive influence on the surgical strategy. Appropriate preoperative preparation, including the presence of the necessary special instruments, which are essential for gentle implant removal, is indispensable to achieve the best possible result.

THERAPY

A bone-sparing implant removal can be particularly challenging, especially in the case of well-fixed stems and cement residues, which may extend far beyond the isthmus. In such situations, a transfemoral approach should be considered. Cementless reimplantation using modular or non-modular titanium stems is currently the preferred treatment of choice for most revisions. In elderly, low-demand patients or with poor bone quality, cemented revision remains a good alternative treatment option.

Reducing Complications and Enhancing the Functional Outcome of Total Hip Arthroplasty without Increasing Operation Time by Repairing Posterolateral Soft Tissues

Total hip arthroplasty (THA) surgeries are increasing annually. Despite continuous improvements in the surgical technique and prosthetic design, there is still no consensus on whether it is beneficial to reconstruct the posterolateral soft tissue. This paper systematically reviews randomized controlled trials (RCTs) addressing the efficacy and safety of posterolateral soft tissue during total hip replacement to provide evidence-based guidance for clinical practice. We searched PubMed, EMBASE, Cochrane Library, CNKI, and Wanfang databases for RCTs. Experimental results show that repair of the posterolateral soft tissue can reduce complications and improve the function of total hip arthroplasty without increasing operative time.

Impact of capsular preservation on patient-reported outcomes and complication rates in total hip arthroplasty using the direct anterior approach

AIMS

It is not known whether preservation of the capsule of the hip positively affects patient-reported outcome measures (PROMs) in total hip arthroplasty using the direct anterior approach (DAA-THA). A recent randomized controlled trial found no clinically significant difference at one year postoperatively. This study aimed to determine whether preservation of the anterolateral capsule and anatomical closure improve the outcome and revision rate, when compared with resection of the anterolateral capsule, at two years postoperatively.

METHODS

Two consecutive groups of patients whose operations were performed by the senior author were compared. The anterolateral capsule was resected in the first group of 430 patients between January 2012 and December 2014, and preserved and anatomically closed in the second group of 450 patients between July 2015 and December 2017. There were no other technical changes between the two groups. Patient characteristics, the Charlson Comorbidity Index (CCI), and surgical data were collected from our database. PROM questionnaires, consisting of the Oxford Hip Score (OHS) and Core Outcome Measures Index (COMI-Hip), were collected two years postoperatively. Data were analyzed with generalized multiple regression analysis.

RESULTS

The characteristics, CCI, operating time, and length of stay were similar in both groups. There was significantly less blood loss in the capsular preservation group (p = 0.037). The revision rate (n = 3, (0.6%) in the resected group, and 1 (0.2%) in the preserved group) did not differ significantly (p = 0.295). Once adjusted for demographic and surgical factors, the preserved group had significantly worse PROMs: + 0.24 COMI-Hip (p < 0.001) and -1.6 OHS points (p = 0.017). However, the effect sizes were much smaller than the minimal clinically important differences (MCIDs) of 0.95 and 5, respectively). The date of surgery (influencing, for instance, the surgeon's age) was not a significant factor.

CONCLUSION

Based on the MCID, the lower PROMs in the capsular preservation group do not seem to have clinical relevance. They do not, however, confirm the expected benefit of capsular preservation reported for the posterolateral approach. Cite this article: Bone Joint J 2022;104-B(7):826-832.

Total Hip Arthroplasty After Hip Arthroscopy Has Increased Complications and Revision Risk

BACKGROUND

There has been an increase in hip arthroscopy (HA) over the last decade. After HA, some patients may ultimately require a total hip arthroplasty (THA). However, there is a scarcity of research investigating the outcomes in patients undergoing THA with a history of ipsilateral HA.

METHODS

The PearlDiver research program (www.pearldiverinc.com) was queried to capture all patients undergoing THA between 2015 and 2020. Propensity matching was performed to match patients undergoing THA with and without a history of ipsilateral THA. Rates of 30-day medical complications, 1-year surgical complications, and THA revision were compared using multivariate logistic regression. Kaplan-Meier analysis was conducted to estimate survival probabilities of each of the groups with patients undergoing THA .

RESULTS

After propensity matching, cohorts of 1940 patients undergoing THA without prior HA and 1940 patients undergoing a THA with prior HA were isolated for analysis. The mean time from HA to THA was 1127 days (standard deviation 858). Patients with a history of ipsilateral HA had an increased risk for dislocation (odds ratio [OR] 1.56, P = .03) and overall decreased implant survival within 4 years of undergoing THA (OR 1.53; P = .05). Furthermore, our data demonstrate the timing of previous HA to be associated with the risk of complications, as illustrated by the increased risk for dislocation (OR 1.75, P = .03), aseptic loosening (OR 2.18, P = .03), and revision surgery at 2 (OR 1.92, P = .02) and 4 years (OR 2.05, P = .01) in patients undergoing THA within 1 year of HA compared twitho patients undergoing THA more than 1 year after HA or with no previous history of HA.

CONCLUSION

Patients undergoing THA after HA are at an increased risk for surgical complications, as well as the need for revision surgery.

Key performance and training parameters in primary total hip arthroplasty - an expert consensus using the Delphi technique

AIMS

Primary total hip arthroplasty (THA) is a commonly performed and successful operation which orthopaedic trainees must demonstrate competence in prior to completion of surgical training. An assessment of agreement between surgical trainers regarding the critical steps of a primary THA has never been undertaken. The aim of this study was to define and rank the key steps of a primary THA regards ease of teaching and their importance in achieving the best patient outcome.

MATERIALS AND METHODS

The Delphi technique with 3 iterative rounds was used to establish expert group consensus. The benchmark for consensus was set at an 80% agreement in any category for each step of a THR. The intra-class correlation coefficient (ICC) was used to report on the inter- and intra-rater reliabilities between and within participants responses respectively in rounds 2 and 3.

RESULTS

50 consultant orthopaedic hip surgeons completed round 2, and 28 completed round 3. Overall, 27 steps (54 parameters) were identified, with 16 parameters achieving consensus agreement for their impact on patient outcome, and 17 for ease of teaching. The inter-rater ICC for patient outcome parameters was 0.89 and 0.92 in rounds 2 and 3 respectively while for teaching parameters it was 0.82 and 0.73. 50% of surgeons agreed that acetabular reaming, assessing and accurately restoring leg length, and acetabular cup anteversion were the 3 most difficult steps to teach trainees, while 90% agreed these 3 steps were substantially important to patient outcome. Another 5 steps achieved consensus for their substantial impact on patient outcome but failed to achieve consensus for ease of teaching.

CONCLUSIONS

The results of this expert consensus have produced a rank-order list of the key steps in primary THA, which may be used for orthopaedic curriculum development and guiding focused improvements for surgical training in primary THR including simulation.

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.

Preventing postoperative prosthetic joint dislocation by repairing obturator externus in total hip arthroplasty performed via the posterior approach

Background

In total hip arthroplasty performed via the posterior approach, repairing the posterior soft tissues is a conventional method for preventing postoperative prosthetic joint dislocation. The aim of this study was to verify whether obturator externus repair played the main role and what was the mechanism of the repair preventing the dislocation.

Methods

Included were 188 patients who underwent primary cementless total hip arthroplasty via the posterior approach. The patients were divided into a repair group (n = 94) and a non-repair group (n = 94). Patients of repair group received additional obturator externus repair while patients of non-repair group did not. The range of motion of hip joint was assessed before and after operation. Data were compared between the two groups. A p value < 0.05 was considered statistically significant.

Results

Before operation and under anesthesia, with regard to internal rotation of hip joint, the mean values of repair and non-repair groups were 24° ± 16/28° ± 15 (p = 0.2933). The mean values of the groups were 13° ± 8/15° ± 9 immediately after repair (p = 0.5672). Range of internal rotation 1 year after operation were 15° ± 8/19° ± 9 (p = 0.0139). Specifically, the values in repair group were lower than those in non-repair group. During a 5-year period of postoperative follow-up, hip joint dislocation occurred in one patient of non-repair group. No dislocation was observed in repair group.

Conclusion

When THA is performed via the posterior approach, repairing the obturator externus may decrease the risk of postoperative prosthetic joint dislocation by reinforcing the posterior soft tissues of the hip joint.

Level of evidence

Therapeutic study, Level IVa.

Transosseous versus transmuscular repair of the posterior soft tissue in primary hip arthroplasty: a meta-analysis

Background

During the posterior approach, it has been shown that a significant reduction in dislocation rate can be achieved with the repair of the posterior soft tissue. However, no consensus exists about the best way to perform this repair. This review aimed to compare the transosseous with transmuscular repair of the posterior soft tissue in total hip arthroplasty (THA).

Methods

We conducted a meta-analysis to identify studies involving transosseous versus transmuscular repair of the posterior soft tissue in THA in electronic databases, including Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, Wanfang database, up to July 2020. Finally, we identified 1417 patients (1481 hips) assessed in seven studies.

Results

Compared with transmuscular repair, transosseous repair resulted in less incidence of dislocation (P = 0.003), less blood loss during operation (P < 0.00001) and lower VAS score within 3 months (P = 0.02). There were no significant differences in terms of trochanteric fracture rate (P = 0.56), Harris hip score at 3 months (P = 0.35) and 6 months (P = 0.89), VAS score within 6 months (P = 0.53), and operation time (P = 0.70) between two groups.

Conclusion

The lower dislocation rate, less blood loss, and lower VAS scores after operation supported transosseous repair's superiority to transmuscular repair. Besides, no additional medical cost and operating time were associated with transosseous repair compared with transmuscular repair. Hence, we recommend that transosseous repair be chosen first by orthopedists when performing reconstruction of the posterior soft tissue in THA via a posterolateral approach. Given the relevant possible biases in our meta-analysis, we required more adequately powered and better-designed RCT studies with long-term follow-up to reach a firmer conclusion.