Cemented polyethylene and cementless porous-coated acetabular components have similar outcomes at a mean of seven years after total hip replacement: a prospective randomised study

Clinical Outcomes and Complications Following Hip Fusion Conversion to Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Efficacy, clinical outcomes, and complications following hip fusion conversion to total hip arthroplasty (THA) surgery have been explored in several studies with controversial findings and no consensus.

METHODS

Comprehensive search of online databases was performed through December 2022 for prepost clinical trials using MeSH keywords. Harris hip score (HHS), leg length discrepancy (LLD), pain score, and range of motion (ROM) were considered as clinical outcomes along with implant survival and complications. The retrieved studies were assessed for methodologic quality. Weighted mean difference (WMD) with 95% confidence interval (CI) were calculated using random effects meta-analysis taking into account for heterogeneity. Subgroup meta-analysis as well as sensitivity analysis were performed.

RESULTS

Findings of meta-analysis on 34 trials showed that HHS increase after THA (WMD: 42.3; 95% confidence interval (CI): 38 to 47). Subgroup analyses indicated that cementless prosthesis, length of arthrodesis <12 years, age <45 years, and studies with good quality have more HHS improvement. The LLD decreased 21 mm (95% CI: 19 to 24 mm) based on 21 trials. The range of motion (ROM) reached to 89 (95% CI: 84 to 95) for flexion, 32 (95% CI: 27 to 37) for abduction, 25 (95% CI: 21 to 29) for adduction, 29 (95% CI: 25 to 33) for external rotation, and 25 (95% CI: 20 to 31) for internal rotation after surgery. The most common complication was heterotopic ossification (14%).

CONCLUSION

Conversion of an ankylosed hip to THA leads to improved hip function and leg discrepancy with relatively notable rate of complications. Our findings could provide a framework to guide surgeons and decision makers.

[Postoperative mobilization after total hip arthroplasty : Measured by Fitbit activity trackers]

BACKGROUND

Patients are becoming increasingly more independent and self-determined, in addition to having shorter post-operative hospitalization. This is why it is more important than ever to actively involve patients in the follow-up treatment. The question arises as to whether post-operative rehabilitation can be improved with modern devices.

METHODS

As part of a prospective study, the post-operative mobilization was recorded and analyzed by Fitbit®-activity-trackers between 05/2016 and 08/2017 in 100 patients who received a THA. 50 men (Ø 70.6y) and 50 women (Ø 71.1y) were included. Furthermore, the patients were interviewed about their acceptance of the Fitbit®-wristband.

RESULTS

The average hospital stay was 7.98 days (SD ± 1.76). The number of steps on the first post-operative day was 712 (SD ± 617). On average (during total hospitalization), 1528 (SD ± 1076) steps were completed daily. One day before discharge, the average number of steps was 2165 (SD ± 1570) on that particular day. There were no gender differences in age and pre-operative Harris hip scores (♂55.3 vs. ♀53.9). Also, there were no statistically significant differences in the number of steps on the first postoperative day (♂745 vs. ♀678). A statistically significant result can be found in the number of steps prior to discharge: on this day, the men took 2483 and the women 1846 steps (p = 0.04). 42% of our patients own a modern smartphone and are able to operate software applications. 52% of the patients found the activity tracker to be motivating, 65% were open to new technologies (e.g. activity trackers) in the hospital. 14% did not check at all or only queried their wristband data once a day, 65% queried 2-4 times/day, and 21% retrieved the data >5 times/day.

DISCUSSION

On average, 1528 steps were completed daily. In a comparison of the men and women, the men were only able to demonstrate significantly more steps than the women on the day prior to discharge. The men had significantly shorter hospital stays than the women. The younger the patients, the more mobile they were. A majority of patients are familiar with and/or interested in new technologies. This interest and curiosity should be consciously used for integration in the post-operative treatment.

Systematic review of the clinical effectiveness for long-term follow-up of total hip arthroplasty

Objectives: Total hip arthroplasty (THA) is highly successful but national registries indicate that average age has lowered and that younger patients are at higher risk of revision. Long-term follow-up of THA was historically recommended to identify aseptically failing THA, minimising the risks associated with extensive changes, but follow-up services are now in decline. A systematic review was conducted to search for evidence of the clinical or cost-effectiveness of hip arthroplasty surveillance. Methods: The study was registered with PROSPERO International Prospective Register of Systematic Reviews and conducted according to PRISMA guidelines; databases included MEDLINE and Embase, and all studies were quality assessed. Original studies (2005 to 2017) reporting follow-up of adults with THA in situ >5 years were included. Researchers extracted quantitative and qualitative data from each study. Results: For eligibility, 4,137 studies were screened: 114 studies were included in the final analysis, representing 22 countries worldwide. Data extracted included study endpoint, patient detail, loss to follow-up, revisions, scores and radiographic analysis. Six themes were derived from inductive content analysis of text: support for long-term follow-up, subgroups requiring follow-up, effect of materials/techniques on THA survival, effect of design, indicators for revision, review process. Main findings-follow-up was specifically recommended to monitor change (eg asymptomatic loosening), when outcomes of joint construct are unknown, and for specific patient subgroups. Outcome scores alone are not enough, and radiographic review should be included. Conclusion: There were no studies directly evaluating the clinical effectiveness of the long-term follow-up of THA but expert opinions from a range of international authors advocated its use for defined subgroups to provide patient-centred care. In the absence of higher level evidence, these opinions, in conjunction with emerging outputs from the national joint registries, should be used to inform services for long-term follow-up of THA.

A bias-adjusted evidence synthesis of RCT and observational data: the case of total hip replacement

Evaluation of clinical effectiveness of medical devices differs in some aspects from the evaluation of pharmaceuticals. One of the main challenges identified is lack of robust evidence and a will to make use of experimental and observational studies (OSs) in quantitative evidence synthesis accounting for internal and external biases. Using a case study of total hip replacement to compare the risk of revision of cemented and uncemented implant fixation modalities, we pooled treatment effect estimates from OS and RCTs, and simplified existing methods for bias-adjusted evidence synthesis to enhance practical application. We performed an elicitation exercise using methodological and clinical experts to determine the strength of beliefs about the magnitude of internal and external bias affecting estimates of treatment effect. We incorporated the bias-adjusted treatment effects into a generalized evidence synthesis, calculating both frequentist and Bayesian statistical models. We estimated relative risks as summary effect estimates with 95% confidence/credibility intervals to capture uncertainty. When we compared alternative approaches to synthesizing evidence, we found that the pooled effect size strongly depended on the inclusion of observational data as well as on the use bias-adjusted estimates. We demonstrated the feasibility of using observational studies in meta-analyses to complement RCTs and incorporate evidence from a wider spectrum of clinically relevant studies and healthcare settings. To ensure internal validity, OS data require sufficient correction for confounding and selection bias, either through study design and primary analysis, or by applying post-hoc bias adjustments to the results. © 2017 The Authors. Health Economics published by John Wiley & Sons, Ltd.

The monitoring of activity at home after total hip arthroplasty

AIMS

Total hip arthroplasty (THA) has well known subjective benefits, but little is known objectively about the recovery of mobility in the early post-operative period.

PATIENTS AND METHODS

A total of 33 patients aged > 60 years who underwent elective primary THA had their activity monitored for 30 days post-operatively using an at-home (Fitbit) ankle accelerometer. Their mean age was 70.7 years (61 to 86); 15 (45.5%) were female. The rate of compliance and the mean level of activity were determined. Comparisons between subgroups based on age, body mass index (BMI), surgical approach, and the destination of the patients when discharged were also performed.

RESULTS

The mean compliance over the 30 days was 26.7 days (16 to 30; 89%) of use. The mean number of steps increased from 235 (5 to 1152) to 2563 (87 to 7280) (p < 0.001) between the first and the 30th post-operative day. Age < 70 years and an anterior surgical approach were significantly associated with higher levels of activity (1600 to 2400 (p = 0.016 to 0.031) and 1000 to 1800 (p = 0.017 to 0.037) more steps per day, respectively) between the second and the fourth week post-operatively. There was also a trend towards higher levels of activity in those who were discharged to their home rather than to a nursing facility (a mean of 1500 more steps per day, p = 0.02). BMI greater or less than 30 kg/m² was not predictive of activity (p = 0.45 to 0.98).

CONCLUSION

At-home remote mobility monitoring using existing commercially available technology is feasible in patients who have undergone THA. It showed a clear trend towards increased activity with the passage of time. Additionally, the remote device was able to detect differences in levels of activity clearly between patients in relation to variables of interest including age, BMI, surgical approach, and the destination of the patient at the time of discharge from hospital. Such monitoring may allow for the early identification and targeted intervention in patients who recover slowly. Cite this article: Bone Joint J 2016;98-B:1450-4.

Outcomes of delayed total hip arthroplasty in patients with a previous ipsilateral acetabular fracture

Post-traumatic arthritis of the hip can develop in 12-57% of patients after an acetabular fracture. Once it develops, salvage treatment options include arthroplasty or arthrodesis. Delayed total hip arthroplasty (THA) has been shown to be a viable treatment option to decrease pain, improve stability and increase functional outcomes. Using cemented designs, earlier long-term studies reported satisfactory functional outcomes of delayed THA used to treat previously failed acetabular fractures. However, high aseptic loosening rates were also observed. Recent advances in cementless acetabular designs have shown comparable functional outcomes and loosening rates compared to those undergoing THA for non-traumatic arthritis. However, even with improvements in functional and radiographic outcomes, unique complications are commonly encountered in patients with previous acetabular fractures, including heterotopic bone around the hip, increased operative times and blood loss, aseptic loosening, sciatic nerve injury and dislocation. The outcomes and complications of delayed THA in patients with previous acetabular fracture will be reviewed.

Total hip replacement and surface replacement for the treatment of pain and disability resulting from end-stage arthritis of the hip (review of technology appraisal guidance 2 and 44): systematic review and economic evaluation

BACKGROUND

Total hip replacement (THR) involves the replacement of a damaged hip joint with an artificial hip prosthesis. Resurfacing arthroplasty (RS) involves replacement of the joint surface of the femoral head with a metal surface covering.

OBJECTIVES

To undertake clinical effectiveness and cost-effectiveness analysis of different types of THR and RS for the treatment of pain and disability in people with end-stage arthritis of the hip, in particular to compare the clinical effectiveness and cost-effectiveness of (1) different types of primary THR and RS for people in whom both procedures are suitable and (2) different types of primary THR for people who are not suitable for hip RS.

DATA SOURCES

Electronic databases including MEDLINE, EMBASE, The Cochrane Library, Current Controlled Trials and UK Clinical Research Network (UKCRN) Portfolio Database were searched in December 2012, with searches limited to publications from 2008 and sample sizes of ≥ 100 participants. Reference lists and websites of manufacturers and professional organisations were also screened.

REVIEW METHODS

Systematic reviews of the literature were undertaken to appraise the clinical effectiveness and cost-effectiveness of different types of THR and RS for people with end-stage arthritis of the hip. Included randomised controlled trials (RCTs) and systematic reviews were data extracted and risk of bias and methodological quality were independently assessed by two reviewers using the Cochrane Collaboration risk of bias tool and the Assessment of Multiple Systematic Reviews (AMSTAR) tool. A Markov multistate model was developed for the economic evaluation of the technologies. Sensitivity analyses stratified by sex and controlled for age were carried out to assess the robustness of the results.

RESULTS

A total of 2469 records were screened of which 37 were included, representing 16 RCTs and eight systematic reviews. The mean post-THR Harris Hip Score measured at different follow-up times (from 6 months to 10 years) did not differ between THR groups, including between cross-linked polyethylene and traditional polyethylene cup liners (pooled mean difference 2.29, 95% confidence interval -0.88 to 5.45). Five systematic reviews reported evidence on different types of THR (cemented vs. cementless cup fixation and implant articulation materials) but these reviews were inconclusive. Eleven cost-effectiveness studies were included; four provided relevant cost and utility data for the model. Thirty registry studies were included, with no studies reporting better implant survival for RS than for all types of THR. For all analyses, mean costs for RS were higher than those for THR and mean quality-adjusted life-years (QALYs) were lower. The incremental cost-effectiveness ratio for RS was dominated by THR, that is, THR was cheaper and more effective than RS (for a lifetime horizon in the base-case analysis, the incremental cost of RS was £11,284 and the incremental QALYs were -0.0879). For all age and sex groups RS remained clearly dominated by THR. Cost-effectiveness acceptability curves showed that, for all patients, THR was almost 100% cost-effective at any willingness-to-pay level. There were age and sex differences in the populations with different types of THR and variations in revision rates (from 1.6% to 3.5% at 9 years). For the base-case analysis, for all age and sex groups and a lifetime horizon, mean costs for category E (cemented components with a polyethylene-on-ceramic articulation) were slightly lower and mean QALYs for category E were slightly higher than those for all other THR categories in both deterministic and probabilistic analyses. Hence, category E dominated the other four categories. Sensitivity analysis using an age- and sex-adjusted log-normal model demonstrated that, over a lifetime horizon and at a willingness-to-pay threshold of £20,000 per QALY, categories A and E were equally likely (50%) to be cost-effective.

LIMITATIONS

A large proportion of the included studies were inconclusive because of poor reporting, missing data, inconsistent results and/or great uncertainty in the treatment effect estimates. This warrants cautious interpretation of the findings. The evidence on complications was scarce, which may be because of the absence or rarity of these events or because of under-reporting. The poor reporting meant that it was not possible to explore contextual factors that might have influenced study results and also reduced the applicability of the findings to routine clinical practice in the UK. The scope of the review was limited to evidence published in English in 2008 or later, which could be interpreted as a weakness; however, systematic reviews would provide summary evidence for studies published before 2008.

CONCLUSIONS

Compared with THR, revision rates for RS were higher, mean costs for RS were higher and mean QALYs gained were lower; RS was dominated by THR. Similar results were obtained in the deterministic and probabilistic analyses and for all age and sex groups THR was almost 100% cost-effective at any willingness-to-pay level. Revision rates for all types of THR were low. Category A THR (cemented components with a polyethylene-on-metal articulation) was more cost-effective for older age groups. However, across all age-sex groups combined, the mean cost for category E THR (cemented components with a polyethylene-on-ceramic articulation) was slightly lower and the mean QALYs gained were slightly higher. Category E therefore dominated the other four categories. Certain types of THR appeared to confer some benefit, including larger femoral head sizes, use of a cemented cup, use of a cross-linked polyethylene cup liner and a ceramic-on-ceramic as opposed to a metal-on-polyethylene articulation. Further RCTs with long-term follow-up are needed.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003924.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Periprosthetic Fractures: A Common Problem with a Disproportionately High Impact on Healthcare Resources

The present study evaluated the frequency of periprosthetic fractures and tested the hypothesis that this population's demographics and outcomes are unique as compared with other arthroplasty patients. The National Hospital Discharge Survey provided the raw data. Individuals admitted with a primary TKA, primary THA, or revision TJA were selected. Annual rates were then calculated and demographics and outcomes compared. 30,624 patients were reviewed. The proportion of admissions for periprosthetic fractures ranged from 4.2% to 7.4% annually. As compared to patients admitted for other TJA diagnoses, individuals admitted with periprosthetic fracture were older, were more often female, were more often admitted emergently/urgently, had longer lengths of stay, had higher rates of discharge to places other than home, and had a significantly elevated mortality.

Total hip replacement for the treatment of end stage arthritis of the hip: a systematic review and meta-analysis

Background

Evolvements in the design, fixation methods, size, and bearing surface of implants for total hip replacement (THR) have led to a variety of options for healthcare professionals to consider. The need to determine the most optimal combinations of THR implant is warranted. This systematic review evaluated the clinical effectiveness of different types of THR used for the treatment of end stage arthritis of the hip.

Methods

A comprehensive literature search was undertaken in major health databases. Randomised controlled trials (RCTs) and systematic reviews published from 2008 onwards comparing different types of primary THR in patients with end stage arthritis of the hip were included.

Results

Fourteen RCTs and five systematic reviews were included. Patients experienced significant post-THR improvements in Harris Hip scores, but this did not differ between impact types. There was a reduced risk of implant dislocation after receiving a larger femoral head size (36 mm vs. 28 mm; RR = 0.17, 95% CI: 0.04, 0.78) or cemented cup (vs. cementless cup; pooled odds ratio: 0.34, 95% CI: 0.13, 0.89). Recipients of cross-linked vs. conventional polyethylene cup liners experienced reduced femoral head penetration and revision. There was no impact of femoral stem fixation and cup shell design on implant survival rates. Evidence on mortality and complications (aseptic loosening, femoral fracture) was inconclusive.

Conclusions

The majority of evidence was inconclusive due to poor reporting, missing data, or uncertainty in treatment estimates. The findings warrant cautious interpretation given the risk of bias (blinding, attrition), methodological limitations (small sample size, low event counts, short follow-up), and poor reporting. Long-term pragmatic RCTs are needed to allow for more definitive conclusions. Authors are encouraged to specify the minimal clinically important difference and power calculation for their primary outcome(s) as well CONSORT, PRISMA and STROBE guidelines to ensure better reporting and more reliable production and assessment of evidence.

Intention-to-treat analyses for interventional studies

The importance for observing the intention-to-treat approach in clinical studies is explained.

Cite this article: Bone Joint J 2013;95-B:1443–4.