Advances in hip arthroplasty surgery: what is justified?

Pain management after total hip arthroplasty: comparative study of analgesic efficacy and tolerability between oral tramadol/dexketoprofen and injectable paracetamol + tramadol

BACKGROUND

Multimodal analgesia for total hip arthroplasty (THA) is increasingly employed to reduce early postoperative pain and promote fast patient discharge. The aim of this study was to compare the efficacy and tolerability of tramadol/dexketoprofen (TRAM/DKP, Group A) versus paracetamol + tramadol (PARA+TRAM, Group B) in patients undergoing THA using minimally invasive direct anterior approach (DAA).

METHODS

A single-centre, randomised, single-blind, parallel, interventional study conducted in 323 patients undergoing primary THA with DAA was performed. Group A consisted of 188 patients and Group B of 135. The primary endpoints were the change from baseline (measured 2 hours postoperatively) in pain intensity (PI) during the treatment period (48 hours), assessed by visual analogue scale (VAS) at pre-specified postoperative time-points (2, 8, 24, 48 hours) and the total rescue medication (RM) use during the first 24 hours postoperatively.

RESULTS

As early as 2 hours after baseline, Group A showed a greater PI reduction from baseline compared to Group B (-26.24% vs. -6.87%; p < 0.001). A lower mean PI (VAS) score was consistently found over the entire observation period following treatment with TRAM/DKP than with PARA+TRAM as well as more than 2-fold higher proportion of responders at the end of treatment period. More patients in Group B required RM in comparison to those in Group A (15.6% vs. 3.7%, p < 0.001). Both treatments were well tolerated.

CONCLUSIONS

After THA, oral TRAM/DKP provides faster and greater pain relief when compared to intravenous PARA+TRAM with limited consumption of RM and favourable tolerability profile. Our study expands the use of TRAM/DKP in the setting of major orthopaedic surgeries.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov (NCT04178109).

Selective laser melting of low-alloyed titanium based alloy with a large solidification range

In this work, thermodynamic calculations for α + β Type Ti-Fe-Cu-Sn alloy were carried out by the Thermo-Calc software. Powders from this alloy were obtained by plasma sputtering and used for subsequent 3D printing of experimental samples. The effect of various selective laser melting (SLM) parameters on porosity and hot cracking susceptibility as well as the electrochemical characteristics of the alloy have been studied. The optimal technological regime for the manufacture of samples by the SLM method was determined. It has been established that to obtain relatively dense samples without cracks, regimes with volumetric energy density Ev = 250-300 J/mm3 are required. It has been established that a change in the electrochemical behavior of the Ti94Fe1Cu1Sn4 alloy is related to the formation of a nonequilibrium Ti2Cu phase. Based on the findings we recomended directions for further research.

Finite element analysis of elliptical shaped stem profile of hip prosthesis using dynamic loading conditions

Patient-specific dynamic loadings are seldom considered during the evaluation of hip implants. The primary objective of this study is to check for the feasibility of the use of UHMWPE as the material for an acetabular cup o CoCr Alloy that is reported to produce a squeaking sound after replacement. An elliptical shaped stem with three different cross-sectional profiles is considered for simulation. Using a commercial finite element method, patient-specific dynamic forces were applied for the quantitative analysis. The loading and boundary conditions are used as per ISO and ASTM standards. The walking gait cycle is used with two widely used biocompatible materials: titanium and cobalt-chromium. Initially, only the stem is considered for the analysis to finalize the best out of the three profiles, along with the better material for the stem. Later the complete implant is used for the analysis. Profile 1 exhibits 1.25 and 1.17 times greater stress than Profile 2 for CoCr Alloy and Ti-6Al-4V, respectively. Similarly, Profile 3 displays stresses 1.26 and 1.25 times greater than Profile 2 for CoCr Alloy and Ti-6Al-4V, respectively. Comparatively, displacement in stem Profile 2 is 1.75 times higher in Ti-6Al-4V than CoCr Alloy. The full implant displacement at 14% gait cycle is 1.15% higher for the CoCr-acetabular column material combination when compared to UHMWPE. It can be concluded that UHMWPE can be used as the acetabular cup material instead of CoCr for the Profile 2 elliptical shaped hip implant to prevent squeaking after replacement.

Perioperative safety and efficacy of robot-assisted total hip arthroplasty in ERAS-managed patients: a pilot study

AIMS

Robot-assisted total hip arthroplasty (rTHA) boasts superior accuracy in implant placement, but there is a lack of effective assessment in perioperative management in the context of enhanced recovery after surgery (ERAS). This study aimed to compare the effectiveness and safety of rTHA versus conventional total hip arthroplasty (cTHA) in ERAS-managed patients.

METHODS

In this prospective trial, a total of 60 eligible patients aged between 18 and 80 years were randomly divided into two groups to undergo either rTHA or cTHA. The primary outcomes included blood loss parameters. Secondary outcomes were the duration of the operation, surgical time, WOMAC pain score, WOMAC stiffness score, WOMAC physical function score, Harris score, and postoperative complications.

RESULTS

The study cohort analyzed 59 eligible participants, 30 of whom underwent rTHA and 29 of whom underwent cTHA. Analysis could not be conducted for one patient due to severe anemia. Notably, the cTHA group had a significantly shorter surgical time than the rTHA group (69.49 ± 18.97 vs. 104.20 ± 19.63 min, P < 0.001). No significant differences were observed between the rTHA and cTHA groups for blood loss parameters, including total blood loss (1280.30 ± 404.01 vs. 1094.86 ± 494.39 ml, P = 0.137) and drainage volume (154.35 ± 121.50 vs. 159.13 ± 135.04 ml, P = 0.900), as well as intraoperative blood loss (126.67 ± 38.80 vs. 118.52 ± 60.68 ml, P = 0.544) and hidden blood loss (982.43 ± 438.83 vs. 784.00 ± 580.96 ml, P = 0.206). Only one patient in the cTHA group required allogeneic blood transfusion. At 3 months postoperatively, both groups showed improvements in WOMAC pain score, WOMAC stiffness score, WOMAC physical function score, and Harris score, with no significant differences found between the two groups. Few complications were reported in both groups without significant differences.

CONCLUSIONS

Despite the longer surgical time, rTHA did not negatively affect blood loss, pain, or functional recovery or lead to an increased risk of complications in ERAS-managed patients, suggesting that rTHA can be safely and effectively incorporated into an ERAS program for primary THA.

Perioperative Concerns and Complaints of Patients Undergoing Total Hip Arthroplasty

Background

Preoperative concerns of patients undergoing total hip arthroplasty (THA) and their complaints during the initial postoperative period are not well investigated. We evaluated preoperative concerns of patients and patient-perceived problems during the operation and initial 5 days after the operation.

Methods

One hundred and thirty-two patients, who underwent primary THA at a tertiary referral hospital, were surveyed using a questionnaire and a face-to-face interview 1 day before the operation, operation day, and postoperative days 1, 2, 3, and 4. The severity of pain was assessed daily using a visual analog scale.

Results

The most common preoperative concern was the severity of pain after the surgery (65.2%), followed by the need of transfusion (34.8%) and postoperative rehabilitation (32.6%). Among 29 patients who could recall the experience during the operation, 12 (41.4%) suffered from shoulder pain on the contralateral side, and 6 (20.7%) answered that hammering sound had been annoying. After returning to the ward, 29 patients (22.0%) suffered from nausea, 8 (6.1%) complained of back pain, and 7 (5.3%) had ipsilateral knee pain. On postoperative day 1, 7 patients (5.3%) had persistent back pain, 8 (6.1%) had headache, and 5 (3.8%) suffered from nausea. On postoperative day 2, nine patients (6.8%) complained of radiating pain due to aggravation of pre-existing spinal stenosis, 7 (5.3%) complained of weakness of the hip flexor due to periarticular injection of ropivacaine during the operation, and 5 (3.8%) had dressing-related skin problem at the wound. On postoperative days 3 and 4, patients had no problem other than hip pain. The mean pain score was the highest (3.1 ± 1.0) on postoperative day 1.

Conclusions

The results of this study might provide information needed to solve problems and improve satisfaction of patients undergoing THA.

Impact of Perioperative Dexamethasone on Hospital Length of Stay and Glycemic Control in Patients With Type 2 Diabetes Undergoing Total Hip Arthroplasty

Purpose

This study aimed to evaluate effects of perioperative dexamethasone on hospital length of stay (LOS) and glycemic control for patients with type 2 diabetes mellitus undergoing total hip arthroplasty (THA).

Methods

We performed retrospective case review of THA performed in adults (≥18 years old) with type 2 diabetes at Springfield Memorial Hospital (Springfield, IL) immediately before (2013), during (2014), and after (2015) publication of consensus guidelines for use of perioperative dexamethasone. Hospital LOS was the primary endpoint. Capillary blood glucose by hospital day, proportion of patients treated with insulin, and median insulin dose by hospital day were secondary endpoints.

Results

A total of 209 patients were included: 109 not dosed with dexamethasone ("no dexamethasone"), and 100 treated with perioperative dexamethasone. The most common dose of dexamethasone was 4 mg (63% of patients). Mean (95% CI) reduction in adjusted hospital LOS for dexamethasone-treated patients, compared to controls, was -2.8 (-3.7 to -1.9) days for all patients, -1.6 (-2.7 to -0.5) days for those with arthritis as the indication for THA, and -4.0 (-5.9 to -2.1) days for those with fracture as indication for THA (P<0.001 for all). Glycemic control measured by median capillary blood glucose was no different or slightly better in the dexamethasone group than the no dexamethasone group, except for postoperative day 1 among patients treated with insulin prior to surgery.

Conclusions

Perioperative dexamethasone significantly reduces hospital LOS for patients with type 2 diabetes undergoing THA, with modest effects on hyperglycemia.

The Role of Wearable Technology in Measuring and Supporting Patient Outcomes Following Total Joint Replacement: Review of the Literature

BACKGROUND

The incidence rate of total joint replacement (TJR) continues to increase due to the aging population and the surgery that is very successful in providing pain relief to and improving function among patients with advanced knee or hip arthritis. Improving patient outcomes and patient satisfaction after TJR remain important goals. Wearable technologies provide a novel way to capture patient function and activity data and supplement clinical measures and patient-reported outcome measures in order to better understand patient outcomes after TJR.

OBJECTIVE

We examined the current literature to evaluate the potential role of wearable devices and compare them with existing methods for monitoring and improving patient rehabilitation and outcomes following TJR.

METHODS

We performed a literature search by using the research databases supported by the University of Massachusetts Chan Medical School's Lamar Soutter Library, including PubMed and Scopus, supplemented with the Google Scholar search engine. A specific search strategy was used to identify articles discussing the use of wearable devices in measuring and affecting postoperative outcomes of patients who have undergone TJR. Selected papers were organized into a spreadsheet and categorized for our qualitative literature review to assess how wearable data correlated with clinical measures and patient-reported outcome measures.

RESULTS

A total of 9 papers were selected. The literature showed the impact of wearable devices on evaluating and improving postoperative functional outcomes. Wearable-collected data could be used to predict postoperative clinical measures, such as range of motion and Timed Up and Go times. When predicting patient-reported outcomes, specifically Hip Disability and Osteoarthritis Outcome Scores/Knee Injury and Osteoarthritis Outcome Scores and Veterans RAND 12-Item Health Survey scores, strong associations were found between changes in sensor-collected data and changes in patient-reported outcomes over time. Further, the step counts of patients who received feedback from a wearable improved over time when compared to those of patients who did not receive feedback.

CONCLUSIONS

These findings suggest that wearable technology has the potential to remotely measure and improve postoperative orthopedic patient outcomes. We anticipate that this review will facilitate further investigation into whether wearable devices are viable tools for guiding the clinical management of TJR rehabilitation.

The effect of varus stem placement on joint offset during total hip arthroplasty: a virtual study

INTRODUCTION AND AIMS

With total hip replacement (THR), varus alignment of an uncemented stem will increase offset which can have significant detrimental effects on muscular balance, leg length and overall satisfaction. Thus, we used 3D planning software to determine the change in joint offset with increasing varus stem placement.

METHODS

Eight patients undergoing THR had routine computed tomography (CT) scans to allow for 3D hip planning. Each set of CTs was templated with a straight stem and an uncemented acetabular cup. Initial templating was performed to reproduce native leg length and offset. The templated stem was then rotated into varus at 1° intervals, up to 6° varus while offset changes for all varus positions were noted. This was repeated for each of 3 neck angles, 125°, 135° and 135° lateral and for each stem sizes 1, 3, 5 and 7.

RESULTS

Overall, there was a mean 1.5 mm increase in offset for every 1° of varus. The stems with a 125° neck angle had the greatest increase in mean offset at 1.6 mm for every 1° of varus. The stem neck angles of 135° lateral offset and 135° standard offset, had a mean increase in offset of 1.5 mm and 1.4 mm respectively for every 1° of varus. A greater mean increase in offset for every 1° of varus was observed with increasing stem size.

CONCLUSIONS

We have quantified the relationship between alignment and offset with every 1° of varus placement increasing hip offset for straight stems by 1.5 mm. This can be used as a guide for surgeons during THR so that they have a better quantitative understanding of how varus placement of the stem affects the hip offset.

Ask Patients What They Expect! A Survey Among Patients Awaiting Total Hip Arthroplasty in Germany

BACKGROUND

Total hip arthroplasty (THA) is an elective surgery. Therefore, patient satisfaction with the results of surgery is paramount. The association between fulfillment of patients' expectations and satisfaction is well known. The aim of this study was to identify key expectations of patients with hip osteoarthritis awaiting THA.

METHODS

A mixed-methods approach was used, consisting of two sequential parts. The questionnaire was developed based on literature review and focus group interviews. A nationwide survey was conducted in 21 orthopedic departments within Germany.

RESULTS

Out of 691 obtained questionnaires, 636 were analyzed (mean age = 65.7 years (±11.3), 56.1% female). A majority of patients (≥75%) reported more than 20 complaints as 'present' due to hip osteoarthritis. A total of 9 key expectations were identified, which were reported by more than 75% of the patients as 'mandatory' for a successful THA. The identified key expectations were related to pain, range of motion, walking abilities, gait pattern, transitions, leisure and sports activities, awareness of the affected hip, satisfaction with health or life, and compensatory posture. A consistently high correlation was found between the complaints and the corresponding expectations.

CONCLUSION

The expectations of patients have greatly expanded. In this study, a set of mandatory key expectations shared by the majority of patients was identified. The likelihood of fulfillment of key expectations should be assessed for weighing benefits and harms of available treatment options during the indication process. In addition, the results of this study might be used as a resource for shared decision-making.

The Surgical Treatment of Osteoarthritis

Osteoarthritis is a degenerative condition affecting the whole joint with the underlying bone, representing a major source of pain, disability, and socioeconomic cost worldwide. Age is considered the strongest risk factor, albeit abnormal biomechanics, morphology, congenital abnormality, deformity, malalignment, limb-length discrepancy, lifestyle, and injury may further increase the risk of the development and progression of osteoarthritis as well. Pain and loss of function are the main clinical features that lead to treatment. Although early manifestations of osteoarthritis are amenable to lifestyle modification, adequate pain management, and physical therapy, disease advancement frequently requires surgical treatment. The symptomatic progression of osteoarthritis with radiographical confirmation can be addressed either with arthroscopic interventions, (joint) preservation techniques, or bone fusion procedures, whereas (joint) replacement is preferentially reserved for severe and end-stage disease. The surgical treatment aims at alleviating pain and disability while restoring native biomechanics. Miscellaneous surgical techniques for addressing osteoarthritis exist. Advanced computer-integrated surgical concepts allow for patient personalization and optimization of surgical treatment. The scope of this article is to present an overview of the fundamentals of conventional surgical treatment options for osteoarthritis of the human skeleton, with emphasis on arthroscopy, preservation, arthrodesis, and replacement. Contemporary computer-assisted orthopaedic surgery concepts are further elucidated.

MINIMA Short Stem Versus Standard Profemur (TL) Stem in Primary Total Hip Replacement: A Comparative Study

Background: The objective of our study was to compare a novel squared section, tapered design - with four conicity - short stem, the MINIMA® short stem with the cementless Profemur® TL standard femoral stem in primary total hip arthroplasty (THA) in terms of functional outcomes, radiologic evaluation and other peri-operative and post-operative data.

Material and methods: This is a comparative study including 46 patients undergoing primary THA. In 23 patients, the MINIMA® short stem was used. These patients were matched with another 23 patients in whom a cementless Profemur® TL standard femoral stem was used. The levels of the pain were evaluated according to the Visual Analog Scale/Numerical Rating Scale (VAS/NRS). The functional and clinical evaluation of the patients was performed with Harris Hip Score (HHS), Charnley’s Hip score, EuroQol (EQ-5D)-(EQ-100), Patient Health Questionnaire (PHQ-9), and neuropathic pain questionnaire (DN-4). The rest of the comparison data included demographic data, the American Society of Anesthesiologists score (ASA), Charlson Index score, the pre-operative diagnosis, radiographic evaluation, the days of hospitalization, the operating time, incision length, blood loss, and blood transfusion requirements and complication rates.

Results: The two cohorts had comparable results regarding all patients’ peri-operative data. The radiographic assessment revealed considerable higher levels of femoral offset and femoral subsidence for the MINIMA group, but within acceptable limits for both cohorts. The majority of the functional and other scores did not give strong prominence to one specific femoral stem.

Conclusion: Our comparative study underlined the efficacy of the MINIMA® short stem, due to the fact that it revealed comparable and, in some cases, relatively better short-term outcomes compared with the TL standard femoral stem. Yet, more well-designed long-term research is required in order to further establish its effectiveness.

Correlation between Harris, modified Harris hip, and Oxford hip scores of patients who underwent hip arthroplasty and hemiarthroplasty following hip fracture

BACKGROUND

Harris hip score (HHS), modified HHS (MHHS), and Oxford hip score (OHS) were designed to determine the functional outcomes after primary total hip arthroplasty (THA). The aim of this study was to evaluate the correlation between MHHS, HHS, and OHS in different populations of arthroplasty such as primary THA, revision THA, THA for Crowe Type IV developmental dysplasia of the hip (DDH), and hip hemiarthroplasty (HA).

METHODS

A total of 399 patients (254 females and 145 males) that included 128 cases of primary THA, 36 of revision THA, 200 of HA, and 35 of THA with femoral shortening osteotomy with a minimum of 24 months of follow-up were included. HHS, MHHS, and OHS were calculated for each patient and the correlation between theses scores was evaluated for each subgroup.

RESULTS

The overall mean age was 67.5±14.3 years. The mean HHS, MHHS, and OHS were 74.9±17.9, 75.7±18.7, and 38.7±12.5, respectively. A very strong correlation was observed between HHS and MHHS (r=0.995, p=0.000) as well as between HHS and OHS (r=0.845, p=0.003) in the general study population. In subgroup analysis, there was a very strong correlation between HHS and MHHS in primary THA, revision THA, THA in hip HA, and Crowe Type IV DDH groups (r=0.984, p=0.000; r=0.977, p=0.000; r=0.984, p=0.000; and r=0.995, p=0.000; respectively). However, there was a significant correlation between HHS and OHS in these groups except revision THA group (r=0.851, p=0.023; r=0.587, p=0.069; r=0.989, p=0.002; and r=0.965, p=0.000; respectively).

CONCLUSION

This is the first study to investigate the usefulness of MHHS and OHS in hip HA and THA in patients with Crowe Type IV DDH. Our findings suggest that MHHS and OHS are useful for evaluating functional outcomes with HA, primary and revision THA, and THA with femoral shortening osteotomy for Crowe type IV DDH.

EFORT recommendations for off-label use, mix & match and mismatch in hip and knee arthroplasty

Off-label use is frequently practiced in primary and revision arthroplasty, as there may be indications for the application of implants for purposes outside the one the manufacturers intended.

Under certain circumstances, patients may benefit from selective application of mix & match. This can refer to primary hip arthroplasty (if evidence suggests that the combination of devices from different manufacturers has superior results) and revision hip or knee arthroplasty (when the exchange of one component only is necessary and the invasiveness of surgery can be reduced).

Within the EFORT ‘Implant and Patient Safety Initiative’, evidence- and consensus-based recommendations have been developed for the safe application of off-label use and mix & match in primary as well as revision hip and knee arthroplasty.

Prior to the application of a medical device for hip or knee arthroplasty off-label and within a mix & match situation, surgeons should balance the risks and benefits to the patient, obtain informed consent, and document the decision process appropriately.

Nevertheless, it is crucial for surgeons to only combine implants that are compatible. Mismatch of components, where their sizes or connections do not fit, may have catastrophic effects and is a surgical mistake.

Surgeons must be fully aware of the features of the components that they use in off-label indications or during mix & match applications, must be appropriately trained and must audit their results.

Considering the frequent practice of off-label and mix & match as well as the potential medico-legal issues, further research is necessary to obtain more data about the appropriate indications and outcomes for those procedures.

Cite this article: EFORT Open Rev 2021;6:982-1005. DOI: 10.1302/2058-5241.6.210080

Clinical and surgical outcomes of robot-assisted versus conventional total hip arthroplasty: a systematic overview of meta-analyses

Robot-assisted total hip arthroplasty (THA), in comparison to conventional THA, improves radiographic outcomes, but it remains unclear whether it alters complication rates, clinical and functional outcomes, and implant survival.

The purpose of this systematic overview was to summarize the findings of the most recent meta-analyses that compare clinical and surgical outcomes of robot-assisted versus conventional THA.

Two readers independently conducted an electronic literature search, screening and data extraction from five electronic databases. Inclusion criteria were: meta-analyses evaluating robot-assisted versus conventional THA in terms of radiographic outcomes, clinical and functional scores, and complications and revision rates. The literature search returned 67 records, of which 14 were duplicates and 49 were excluded, leaving three meta-analyses published within the past two years for data extraction and analysis.

The present overview of meta-analyses suggests that, compared to conventional THA (n = 3011), robot-assisted THA (n = 1813) improves component placement and reduces intraoperative complications. The overview also affirms that robot-assisted THA could extend surgery by 20 minutes, and increases risks of postoperative heterotopic ossification, dislocation, and revision. None of the meta-analyses found significant differences in clinical or functional scores between robot-assisted and conventional THA.

Future studies and reviews should make a clear distinction between active and semi-active robotic assistance, address technology matureness, and describe the experience of surgeons with robotic assistance.

Cite this article: EFORT Open Rev 2021;6:1157-1165. DOI: 10.1302/2058-5241.6.200121

Benefits of Combining Physical Therapy with Occupational Therapy in Hip Arthroplasty

(1) Background: Hip arthroplasty (HA) is a surgery that replaces the damaged hip joint with an artificial implant called a hip prosthesis. The increase in life expectancy correlated with the population aging level, to which the increase in the number of prosthetic interventions among the young population is added, translates to the imperative need to analyze the quality of life beyond the immediate postoperative period. Strict adherence to an individualized rehabilitation program (IRP), and adapted to each patient, is followed by an improved quality of life. The main goal is the recovery of the patient with HA. This study was aimed to demonstrate that an IRP, represented by physical therapy associated with occupational therapy, improves the quality of life of patients with HA; (2) Methods: In this study, conducted between 2019 and 2021, 50 patients with HA were divided into two groups: study group-group A (25 subjects compliant with the IRP) and control group-group B (25 subjects, non-compliance with the IRP). To evaluate the two study groups, we monitored the evolution of the modified Harris hip score (mHHS) in both hips (arthroplasty hip (AH), contra lateral hip (CH)), for four months, respectively 30 days before the surgery (T0) and at 90 days after the surgery (T1); (3) Results: We notice significant differences in mHHS values at 90 days-T1 after surgery, both on AH in favor of subjects from group A vs. group B (p = 0.030) and on CH, where mHHS values were statistically higher in group A compared to group B (p < 0.001). The results of our study outline at T1 moment, both on the AH (p = 0.030) and on the CH (p < 0.001), the fact that mHHS values were statistically higher in patients included in group A compared to group B. In terms of the results for mHHS, comparing AH with CH, it is noted that the number of subjects who had a good or excellent mHHS result in group A versus group B is statistically significant in the case of CH (group A: 23 (92%) vs. group B: 11 (44%), p = 0.039); (4) Conclusions: The study reveals clear advantages of HA in both hips, both in subjects who complied with the IRP and those who did not comply; the higher therapeutic benefits of IRP are outlined at the level of CH compared to AH; in patients who comply with the IRP, the mHHS parameters that have improved in both CH and AH are pain, leaning, and shoes and socks activities; in addition, limping was reduced in CH.

The morphological variation of acetabular defects in revision total hip arthroplasty-A statistical shape modeling approach

Classification and evaluation of acetabular defects remain challenging and are primarily based on qualitative classification methods. That is because quantitative techniques describing variations of acetabular defects and accompanying bone loss volume are not available. This study introduces a new method based on statistical shape models (SSMs) to quantitively describe acetabular defects. This method is then applied to 87 acetabular defects to objectively describe the variations in acetabular defects typically encountered during revision total hip arthroplasty. The absolute bone loss volume, relative bone loss volume, and relative bone loss surface area with respect to the SSM-based pre-diseased anatomy were used to quantify the acetabular bone defects in different segments of the acetabular surface. The absolute bone loss volume of the average defect shape was equal to 37.0 cm³ . The first three principal modes, accounting for 62% of the total shape variation, were found to represent variations in acetabular defect morphology. The first, second, and third principal modes described, respectively, the size of the bone defects, the difference between superomedially and superolaterally migrated defects, and the degree of involvement of the posterior or anterior column. The developed SSM and the introduced approach could be used to create automated and unbiased classification methods based on quantitative data. Moreover, the proposed model and the underlying data provide the basis for a quantitative design approach where the shape and size of new acetabular implants are determined according to clinical variation present in acetabular defects.

Impact of sickle cell disease on postoperative outcomes following total hip arthroplasty

INTRODUCTION

Osteonecrosis (ON) of the femoral head is a common complication of sickle cell disease (SCD), frequently necessitating total hip arthroplasty (THA). Although THA is a common procedure with few complications when indicated for osteoarthritis (OA), patients with SCD have increased rates of complications. The purpose of this study is to determine the impact of SCD on outcomes and complications following THA.

METHODS

Subjects were retrospectively identified using a national insurance claims database (PearlDiver Technologies) using CPT and ICD-9/10. Patients were included if they underwent THA with at least 2-year follow-up and were diagnosed with SCD and ON, ON without SCD, or OA without SCD. The SCD cohort was matched based on age, gender, Charlson Comorbidity Index, and obesity to the other 2 cohorts. 2-year revision rate and 90-day complication rates were analyzed using chi-square tests.

RESULTS

Each cohort had 881 patients. The SCD cohort had significantly higher 90-day medical complications when compared to the ON without SCD and OA cohorts (p < 0.001). The SCD cohort had a higher rate of 2-year revision for PJI (5.0%) compared to the ON without SCD (2.8%) and OA (2.5%) groups (p = 0.019 and 0.005 respectively) and a higher rate of aseptic loosening (1.94%) compared to the ON without SCD cohort (0.68%; p = 0.021).

CONCLUSIONS

Patients with SCD who undergo THA have an increased risk for short-term postoperative medical complications and 2-year aseptic loosening and PJI compared to ON patients without SCD and patients with OA. Given the magnitude of these risks, patient counseling and optimised perioperative care are essential.

Modular neck stems in total hip arthroplasty: current concepts

Modular neck (MN) implants can restore the anatomy, especially in deformed hips such as sequelae of development dysplasia.

Early designs for MN implants had problems with neck fractures and adverse local tissue, so their use was restricted to limited indications.

Results of the latest generation of MN prostheses seem to demonstrate that these problems have been at least mitigated.

Given the results of the studies presented in this review, surgeons might consider MN total hip arthroplasty (THA) for a narrower patient selection when a complex reconstruction is required.

Long MN THA should be avoided in case of body mass index > 30, and should be used with extreme caution in association with high offset femoral necks with long or extra-long heads. Cr-Co necks should be abandoned, in favour of a titanium alloy connection.

Restoring the correct anatomic femoral offset remains a challenge in THA surgeries.

MN implants have been introduced to try to solve this problem. The MN design allows surgeons to choose the appropriate degree and length of the neck for desired stability and range of motion.

Cite this article: EFORT Open Rev 2021;6:751-758. DOI: 10.1302/2058-5241.6.200064

Finite element analysis of hip implant with varying in taper neck lengths under static loading conditions

BACKGROUND AND OBJECTIVE

Total hip arthroplasty is known as one of the best advancements in orthopedics in the 20th century. Due to age or trauma hip joint has to replace by an artificial implant. After the hip arthroplasty, the patients can return to normal day-to-day activities with a normal range of motion. There are several types and designs are currently available. These designs usually depend upon the anatomy of the patients. There is a need for revision surgery due to dislocation and aseptic loosening in these joints over time in actively younger patients. Minor changes in the design stage can certainly improve the life expectancy of the implant and will also further reduce the revision rate.

METHODS

In this current work, finite element analysis is carried out by varying the neck length with a change in femoral head size for a circular-shaped stem. The effects of using a shorter neck are analyzed. A total of nine combinations are considered for analysis. Modeling is carried out in CATIA V-6 and analysis is performed in ANSYS R-19. A femoral head of 36, 40, and 44 mm and taper neck length of 18, 16, and 14 mm is considered. CoPE is considered as the material combination for all the models.

RESULTS

It was observed that the von Mises stresses in the complete implant tend to decrease with an increase in the femoral head size. Maximum 5% variation in stress values when 36 mm femoral head is compared with 44 mm. The stresses in the taper neck region tend to decrease with a decrease in the neck length. Minimum von Mises stress of 161.83 MPa was found for the complete implant and in the head-neck region, a minimum von Mises stress found 91.9 MPa.

CONCLUSIONS

Performance evaluation of hip implant under static loading conditions gives a clear idea about the behavior of implant. It was found that a decrease in the von Mises stresses with a decrease in the taper length. However, these variations won't affect much in the performance of the hip implant. Also, a reduction in taper length can significantly increase the dislocation in the implant. So it is advised to consider the optimal taper length with an increase in the femoral head size.

Industry Payments and Their Association With Academic Influence in Total Joint Arthroplasty

BACKGROUND

The relationship between industry payments and academic influence, as measured by the Hirsch index (h-index) and number of publications, among adult reconstruction surgeons is not well characterized. The aims of the present study are to determine the relationship between an adult reconstruction surgeons' academic influence and their relevant industry payments and National Institutes of Health (NIH) funding.

METHODS

Adult reconstruction surgeons were identified through the websites for the orthopedic surgery residency programs in the United States during the 2019-2020 academic year. Academic influence was approximated by each physician's h-index and total number of publications. Industry payment data were obtained through the Open Payments Database, and NIH funding was determined through the NIH website. Mann-Whitney U testing and Spearman correlations were performed to examine relevant associations.

RESULTS

Surgeons who received industry research payments had a higher mean h-index (16.1 vs 10.2, P < .001) and mean number of publications (79.1 vs 35.9, P < .001) than physicians who received no industry research payments. Surgeons receiving NIH funding had a higher mean h-index (48.1 vs 10.4, P < .001) and mean number of publications (294.5 vs 36.8, P < .001) than surgeons who did not receive NIH funding. There was no association between the average h-index (P = .668) and number of publications (P = .387) among adult reconstruction surgeons receiving industry nonresearch funding.

CONCLUSION

h-index and total publications do not seem to be associated with industry nonresearch payments in the field of total joint arthroplasty. Altogether, these data suggest that industry bias may not play a strong role in total joint arthroplasty.

Return to Sports After Total Hip Arthroplasty: A Survey Among Members of the European Hip Society

BACKGROUND

The study's aim was to summarize the recommendations given by members of the European Hip Society (EHS) regarding sport activities after total hip arthroplasty (THA).

METHODS

Members of the EHS were invited to complete an online web-based questionnaire including recommendations for 47 sports disciplines. The questions regarding the specific sports were also divided into 4 subcategories: "allowed," "allowed when experienced," "not allowed", and "no opinion." Four intervals for resuming the sports activities after THA were evaluated: within 6 weeks after THA, 6 to 12 weeks after THA, 12 weeks to 6 months after THA, and more than 6 months after THA. Consensus on resuming sports was analyzed.

RESULTS

A total of 150 (32.9%) EHS members participated in the survey. Agreement was found for 5 sports activities in the first 6 weeks after THA, for 10 activities, 6 to 12 weeks after surgery, for 26 activities, 3 to 6 months after THA, and for 37 of 47 activities, 6 months after surgery. Sports activities which were not allowed after THA were handball, soccer and football, basketball, full contact sports, and martial arts.

CONCLUSION

This is the first report describing the recommendations of European hip arthroplasty surgeons on resuming sport activity after THA. Most physical activities were allowed for the patients 6 months after THA. The experience of the patient in performing a distinct sport activity did not influence the recommendations to return to former sports activities. European surgeons are progressively mitigating restrictions to sports after THA. Further studies should evaluate the effects of this trend on patients' outcome and implant survival.

Advances and innovations in total hip arthroplasty

Total hip arthroplasty (THA) has been quoted as one of the most successful and cost-effective procedures in Orthopaedics. The last decade has seen an exponential rise in the number of THAs performed globally and a sharp increase in the percentage of young patients hoping to improve their quality of life and return to physically demanding activities. Hence, it is imperative to review the various applications of technology in total hip arthroplasty for improving outcomes. The development of state-of-the-art robotic technology has enabled more reproducible and accurate acetabular positioning, while long-term data are needed to assess its cost-effectiveness. This opinion piece aims to outline and present the advances and innovations in total hip arthroplasty, from virtual reality and three-dimensional printing to patient-specific instrumentation and dual mobility bearings. This illustrates and reflects the debate that will be at the centre of hip surgery for the next decade.

Historical overview of hip arthroplasty: From humble beginnings to a high-tech future

Surgery of the arthritic hip was not an easy task in the previous centuries, lots of operations being followed very closely by complications and failures. Nowadays, hip arthroplasty is considered "the operation of the century". This review follows the evolution of surgery on the arthritic hip, with emphasis on arthroplasty. Acknowledging the history of this operation, one can better prepare its evolution and future directions of research. The final chapter briefly describes the current trends and future perspectives.

BIOMECHANICAL ASSESSMENT OF WEAR IN CERAMIC ON CERAMIC AND CERAMIC ON XLPE THAs

Total Hip Arthroplasty (THA) is an effective treatment for severe hip arthritis, with patients reporting high rates of satisfactory results postoperatively. There are a variety of choices regarding THA implant designs. Ceramic on Ceramic and Ceramic on Highly Cross-Linked Polyethylene (XLPE) THAs are the materials of choice nowadays. The purpose of this study is to review the effect of kinematics and kinetics on wear (in vivo and in vitro testing) that affect wear in Ceramic on Ceramic and Ceramic on XLPE total hip arthroplasties and identify possible advantages amongst them. The study hypothesis was that THA kinematics and/or kinetics, since they directly affect THA wear, could provide data for possible advantages between the examined implant designs. A systematic review of the literature identified no significant evidence for biomechanical advantages between these two prostheses in terms of wear. Further research is proposed with the use of gait analysis systems combined with surface electromyography to further investigate THA biomechanics at a laboratory set up. Wearable sensors technology could also identify detailed biomechanical parameters in more complex daily activities.

Global diversity in bearings in primary THA

Choice of articulating materials, head size and the design of the articulation will become decisive for the long-term performance of a total hip arthroplasty (THA) and especially in terms of risk for dislocation and wear-related problems. Here we account for common alternatives based on available studies and the evidence that can be derived from them.Metal or ceramic femoral heads articulating against a liner or cup made of highly cross-linked polyethylene and ceramic-on-ceramic articulations have about similar risk for complications leading to revision, whereas the performance of metal-on-metal articulations, especially with use of big heads, is inferior. The clinical significance of problems related to ceramic-on-ceramic articulations such as squeaking remains unclear. With use of current technology ceramic fractures are rare.Large femoral heads have the potential to increase the range of hip movement before impingement occurs and are therefore expected to reduce dislocation rates. On the other hand, issues related to bearing wear, corrosion at the taper-trunnion junction and groin pain may arise with larger heads and jeopardize the longevity of THA. Based on current knowledge, 32-mm heads seem to be optimal for metal-on-polyethylene bearings. Patients with ceramic-on-ceramic bearings may benefit from even larger heads such as 36 or 40 mm, but so far there are no long-term reports that confirm the safety of bearings larger than 36 mm.Assessment of lipped liners is difficult because randomized studies are lacking, but retrospective clinical studies and registry data seem to indicate that this liner modification will reduce the rate of dislocation or revision due to dislocation without clear evidence of clinically obvious problems due to neck-liner impingement.The majority of studies support the view that constrained liners and dual mobility cups (DMC) will reduce the risk of revision due to dislocation both in primary and revision THA, the latter gaining increasing popularity in some countries. Both these devices suffer from implant-specific problems, which seem to be more common for the constrained liner designs. The majority of studies of these implants suffer from various methodological problems, not least selection bias, which calls for randomized studies preferably in a multi-centre setting to obtain sufficient power. In the 2020s, the orthopaedic profession should place more effort on such studies, as has already been achieved within other medical specialties, to improve the level of evidence in the choice of articulation when performing one of the most common in-hospital surgical procedures in Europe. Cite this article: EFORT Open Rev 2020;5:763-775. DOI: 10.1302/2058-5241.5.200002.

Good long-term outcomes for Direct Anterior Approach Total Hip Arthroplasty in South Africa

This study aims to assess long-term outcomes of Total Hip Arthroplasty (THA) through Direct Anterior Approach (DAA) in a developing country using traditional and novel Patient-Reported Outcomes. There were 522 patients (mean age, 56.5 years; 66.3% female) after mean follow-up 7.35 years. There were 13 revisions. Overall 5-year implant survival rate was 97.5%. Patient Joint Perception scores of 65.5% perceived a completely natural joint. Mean Hip Disability and Osteoarthritis Score was 89.1. Median Forgotten Joint Score-12 was 90 and modified Harris Hip Score was 88. Primary DAA THA in sub-Saharan Africa allows good clinical outcomes at minimum 5 years follow-up.

Value of multidetector computed tomography for the differentiation of delayed aseptic and septic complications after total hip arthroplasty

OBJECTIVE

The differentiation between delayed aseptic and septic complications of total hip arthroplasty is crucial to allow appropriate surgical planning and timely antimicrobial treatment. The aim of this study was to investigate the utility of multidetector computed tomography (CT) findings to diagnose aseptic mechanical loosening, granulomatous reaction, and periprosthetic joint infection in patients who underwent total hip arthroplasty before revision surgery.

MATERIALS AND METHODS

Ninety-six consecutive patients with a clinical suspicion of periprosthetic complications underwent revision surgery over an 8-year period. All patients had been evaluated preoperatively using multidetector CT without contrast media. Two blinded musculoskeletal radiologists reviewed multidetector CT images, including periprosthetic soft-tissue accumulation, prosthetic acetabular malposition, periprosthetic osteolysis, enlarged iliac lymph nodes, and heterotopic ossification. Risk factors for aseptic and septic loosening were identified using multivariate analysis.

RESULTS

Multidetector CT-related variables independently associated with periprosthetic joint infection were high periprosthetic soft-tissue accumulation, periprosthetic osteolysis without expansile periosteal reaction and enlarged iliac lymph nodes. On the other hand, the absence of the following radiological signs: low or high periprosthetic soft-tissue accumulation, mild or severe periprosthetic osteolysis, and enlarged iliac lymph nodes, were predictors of aseptic mechanical loosening. Low periprosthetic soft-tissue accumulation, severe periprosthetic osteolysis with expansile periosteal reaction, and mild acetabular malposition were significant variables associated with granulomatosis.

CONCLUSION

Multidetector CT findings are useful to differentiate between aseptic and septic complications before revision surgery. The presence of osteolysis with expansile periosteal reaction appeared to be a time-dependent variable.

Current Preclinical Testing of New Hip Arthroplasty Technologies Does Not Reflect Real-World Loadings: Capturing Patient-Specific and Activity-Related Variation in Hip Contact Forces

BACKGROUND

Total hip arthroplasty (THA) implants are routinely tested for their tribological performance through regulatory preclinical wear testing (eg, ISO-14242). The standardized loading conditions defined in these tests consist of simplified waveforms, which do not specifically represent in vivo loads in different groups of patients. The aim of this study is to investigate, through musculoskeletal modeling, patient-specific and activity-related variation in hip contact forces (HCFs) in a large cohort of THA patients during common activities of daily living (ADLs).

METHODS

A total of 132 THA patients participated in a motion-capture analysis while performing different ADLs, including walk, fast walk, stair ascent, and descent (locomotor); sit to stand, stand to sit, squat, and lunge (nonlocomotor). HCFs were then calculated using the AnyBody Modeling System and qualitatively compared across all activities. The influence of gender on HCFs was analyzed through statistical parametric mapping analysis.

RESULTS

Systematic differences were found in HCF magnitudes and individual components in both locomotor and nonlocomotor ADLs. The qualitative analysis of the ADLs revealed a large range and a large variability in forces experienced at the hip during different activities. Significant differences in the 3-dimensional loading patterns were observed between males and females across most activities.

CONCLUSION

THA patients present a large variability in the forces experienced at the hip joint during their daily life. The interpatient variation might partially explain the heterogeneity observed in implant survival rates. A more extensive preclinical implant testing standard under clinically relevant loading conditions has been advocated to better predict and avoid clinical wear problems.

Changes in expression of serum chemokine CXCL13 and IL-6 after hip replacement, and the relationship with lower limb vein thrombus

Changes in the expression of serum chemokine CXC ligand 13 (CXCL13) and interleukin-6 (IL-6), and the relationship with lower limb vein thrombus were explored. A total of 128 patients undergoing hip replacement in The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine from May 2017 to June 2019 were selected, and the patients suffering from lower limb vein thrombus were enrolled as group A and other patients not suffering from it were enrolled as group B. Enzyme-linked immuno-sorbent assay was employed to determine the levels of serum chemokine CXCL13 and IL-6, and receiver operating characteristic curves of serum chemokine CXCL13 and IL-6 levels in diagnosing restenosis after surgery were drawn. Pearson's correlation coefficient was adopted to analyze the correlation between serum chemokine CXCL13 and IL-6, and the logistic regression analysis to analyze the risk factors affecting hip replacement in patients. The levels of serum CXCL13 and IL-6 in group A were significantly higher than those in group B (both P<0.001). The specificity and sensitivity of serum CXCL13 level in diagnosis of lower limb vein thrombus after hip replacement were 61.76 and 80.00%, respectively, and those of serum IL-6 level in diagnosis were 70.59 and 66.67%, respectively. Serum CXCL13 level was positively correlated with serum IL-6 level (P<0.001), and age, body mass index (BMI), CXCL13 level and IL-6 level of the patients were independent risk factors affecting the efficacy of hip replacement. Serum CXCL13 level and serum IL-6 level can be used as biological indexes for prediction of early lower limb vein thrombus after hip replacement, and logistic regression analysis revealed that the age of the patients, BMI, diabetes history, hyperlipidemia history, hypertension history, CXCL13 level and IL-6 level are independent risk factors affecting the efficacy of hip replacement.

Blood management in fast-track orthopedic surgery: an evidence-based narrative review

BACKGROUND AND PURPOSE

Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research.

METHODS AND MATERIALS

We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital.

RESULTS

Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction.

CONCLUSION

The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens.

Clinical efficacy of orthopilot navigation system versus conventional manual of total hip arthroplasty: A systematic review and meta-analysis

BACKGROUND

To compare the clinical efficacy between Orthopilot navigation system and conventional manual surgery in total hip arthroplasty (THA).

METHODS

Electronic databases were searched to identify randomized controlled trials (RCTs) investigating Orthopilot navigation system versus conventional manual in patients undergoing THA. Outcome measurements include anteversion angle, inclination angle, preoperative leg length discrepancy, postoperative leg length discrepancy and femoral offset. Statistical software Stata 12.0 was used for data-analysis.

RESULTS

A total of 5 studies were finally included in this meta-analysis. The results showed that the conventional manual group have a less anteversion angle than that in Orthopilot navigation system group (weighted mean difference (WMD) = 4.67, 95% confidence interval (CI) = 3.53, 5.82, P = .000). And pooled analysis showed that the inclination angle in Orthopilot navigation group was less than that in conventional manual group (WMD = -4.19, 95% CI = -8.00, -0.37, P = .031). There was no significant difference between the preoperative leg length discrepancy and postoperative leg length discrepancy (P > .05). Orthopilot navigation system compared with conventional manual procedure was associated with decreased of femoral offset by 2.76 (WMD = -2.76, 95%CI = -3.90, -1.62, P = .000).

CONCLUSION

Both Orthopilot navigation system and conventional THA result in significant improvements in patient function with similar overall complication rates and have their own edges in cup position.

Clinical efficacy of OrthoPilot navigation system versus conventional manual total hip arthroplasty: A systematic review and meta-analysis

Objective

This study was performed to compare the clinical efficacy between the OrthoPilot navigation system and conventional manual surgery in patients undergoing total hip arthroplasty.

Methods

The Embase, PubMed, CINAHL, and Cochrane databases were searched for clinical trials. The outcome measurements were the anteversion angle, inclination angle, and complications. Review Manager 5.3 statistical software was used for the data analysis.

Results

Significant differences were found in the femoral offset and overall complication rate between the conventional and navigation groups. Additionally, the conventional group had significantly less anteversion than the navigation group. However, the navigation group had significantly better inclination. The operation time was significantly shorter in the conventional than navigation group.

Conclusion

Both the OrthoPilot navigation system and conventional total hip arthroplasty result in significant improvements in patient function with similar overall complication rates and have their own advantages in achieving good cup position. The conventional procedure has a shorter operation time than does use of a navigation system.

Bearing surfaces in primary total hip arthroplasty

Total hip arthroplasty (THA) is widely considered one of the most successful surgical procedures in orthopaedics. It is associated with high satisfaction rates and significant improvements in quality of life following surgery. On the other hand, the main cause of late revision is osteolysis and wear, often a result of failure of bearing surfaces.Currently, several options are available to the surgeon when choosing the bearing surface in THA (ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoPE), metal-on-polyethylene (MoPE)), each with advantages and drawbacks.Very few studies have directly compared the various combinations of bearings at long-term follow-up. Randomized controlled trials show similar short- to mid-term survivorship among the best performing bearing surfaces (CoC, CoXLPE and MoXLPE). Selection of the bearing surface is often 'experience-based' rather than 'evidence-based'.The aim of this paper is therefore to evaluate the main advantages and drawbacks of various types of tribology in THA, while providing practical suggestions for the surgeon on the most suitable bearing surface option for each patient. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.180300.

Have the annual trends of total hip arthroplasty in rheumatoid arthritis patients decreased?

Background

Rheumatoid arthritis (RA) is characterized by chronic systemic and synovial inflammation, resulting in damage to both cartilage and bone. Medical treatment, which has increasingly relied upon disease modifying anti-rheumatic drugs (DMARDs), may fail to slow disease progression and limit joint damage, ultimately warranting surgical intervention. Up to 25% of RA patients will require lower extremity total joint arthroplasty. Though total hip arthroplasty (THA) is known to improve quality of life and functional measures, clarification is still required with respect to the impact of increased DMARD use on annual rates of THA. Thus, the purpose of this study was to evaluate: (I) the annual trends of THAs due to RA in the United States population; (II) the annual trends in the proportion of THAs due to RA in the United States.

Methods

This study utilized the Nationwide Inpatient Sample (NIS) to identify all patients who underwent THA between 2002 and 2013 (n=3,135,904). Then, THA patients who had a diagnosis of RA, which was defined by the International Classification of Disease 9^th revision diagnosis code 714.0, were identified. The incidence of THAs with a diagnosis of RA in the United States was calculated using the United States population as the denominator. Regression models were used to analyze the annual trends of RA in patients who underwent THA.

Results

Review of the database identified 90,487 patients who had a diagnosis of RA and underwent THA from 2002 to 2013. The annual prevalence of RA in those who underwent THA slightly decreased over the specified time period, with 28.7 per 1,000 THAs in 2002 and 28.6 per 1,000 THAs in 2013; however, this change was not statistically significant (R²=0.158, P=0.200).

Conclusions

The annual rates of THA among RA patients did not show any significant change between 2002 and 2013. DMARD use has decreased both disease progression and joint destruction, and DMARDs are now often utilized as primary treatment. The increase in population of the country during the study period may have overestimated THA trends. Moreover, patients may be more likely to opt for surgical management, given the advances in operative techniques as well as peri- and post-operative course.

Biological effects of metal degradation in hip arthroplasties

Metals and metal alloys are the most used materials in orthopedic implants. The focus is on total hip arthroplasty (THA) that, though well tolerated, may be associated with local and remote adverse effects in the medium-long term. This review aims to summarize data on the biological consequences of the metal implant degradation that have been attributed predominantly to metal-on-metal (MoM) THA. Local responses to metals consist of a broad clinical spectrum ranging from small asymptomatic tissue lesions to severe destruction of bone and soft tissues, which are designated as metallosis, adverse reactions to metal debris (ARMD), aseptic lymphocytic vasculitis associated lesion (ALVAL), and pseudotumors. In addition, the dissemination of metal particles and ions throughout the body has been associated with systemic adverse effects, including organ toxicity, cancerogenesis, teratogenicity, and immunotoxicity. As proved by the multitude of studies in this field, metal degradation may increase safety issues associated with THA, especially with MoM hip systems. Data collection regarding local, systemic and long-term effects plays an essential role to better define any safety risks and to generate scientifically based recommendations.