Early Rate of Revision of Total Hip Arthroplasty Related to Surgical Approach: An Analysis of 122,345 Primary Total Hip Arthroplasties

Why Are Contemporary Primary Ceramic-on-Highly Crosslinked Polyethylene Total Hip Arthroplasties Failing? An Analysis of Over 5,500 Cases

INTRODUCTION

Ceramic-on-highly crosslinked polyethylene (HXLPE) has become the most common bearing surface utilized in primary total hip arthroplasty (THA). The purpose of this study was to determine the implant survivorship and clinical outcomes of THAs with ceramic-on-HXLPE in a large, single institutional, series.

METHODS

We identified 5,536 primary THAs performed from 2007 to 2017 using a ceramic-on-HXLPE bearing through our total joint registry. The mean age was 60 years, 51% were women, and the mean body mass index (BMI) was 30. A cementless femoral component was used in 98% of cases, and a head size of ≥ 36 was used in 75%. Kaplan-Meier survivorship analyses were completed to assess survivorship free of any revision or reoperation. Clinical outcomes were assessed via Harris Hip Scores (HHS). The mean follow-up was 4 years.

RESULTS

The 5-year survivorship free of any revision was 97%. The most common indications for revision were dislocation (41 hips), periprosthetic joint infection (PJI) (39 hips), and periprosthetic femur fracture (18 hips). The 5-year survivorship free of any reoperation was 96%. There were an additional 70 reoperations, with the most common indications being wound dehiscence (32 hips), iliopsoas impingement (11 hips), and periprosthetic femur fracture (11 hips). There were only two bearing surface failures: one HXLPE liner fractured and one dissociated. There were no ceramic head fractures or failures. The mean HHS increased from 57 to 92 (P < 0.0001).

CONCLUSION

In over 5,500 THAs completed with modern ceramic-on-HXLPE bearings, failures of the bearing surface were nearly eliminated at midterm follow-up, and overall 5-year survivorship free of revision was excellent. Dislocation, PJI, and periprosthetic femur fracture were the most common causes of failure. As bearing surfaces have evolved, traditional failure mechanisms such as polyethylene wear, corrosion and metal reactions, and ceramic fractures have become nearly extinct.

Surgeons Experience Greater Physiologic Stress and Strain in the Direct Anterior Approach Than the Posterior Approach for Total Hip Arthroplasty

BACKGROUND

The direct anterior approach (DAA) and posterior approach (PA) for total hip arthroplasty (THA) have advantages and disadvantages, but their physiologic burden to the surgeon has not been quantified. This study was conducted to determine whether differences exist in surgeon physiological stress and strain during DAA in comparison to PA.

METHODS

We evaluated a prospective cohort of 144 consecutive cases (67 DAA and 77 PA). There were 5, high-volume, fellowship-trained arthroplasty surgeons who wore a smart-vest that recorded cardiorespiratory data while performing primary THA DAA or PA. Heart rate (beats/minute), stress index (correlates with sympathetic activations), respiratory rate (respirations/minute), minute ventilation (L/min), and energy expenditure (calories) were recorded, along with patient body mass index and operative time. Continuous data was compared using t-tests or Mann Whitney U tests, and categorical data was compared with Chi-square or Fischer's exact tests.

RESULTS

There were no differences in patient characteristics. Compared to PA, performing THA via DAA had a significantly higher surgeon stress index (17.4 versus 12.4; P < .001), heart rate (101 versus 98.3; P = .007), minute ventilation (21.7 versus 18.7; P < .001), and energy expenditure per hour (349 versus 295; P < .001). However, DAA had a significantly shorter operative time (71.4 versus 82.1; P = .001).

CONCLUSIONS

Surgeons experience significantly higher physiological stress and strain when performing DAA compared to PA for primary THA. This study provides objective data on energy expenditure that can be factored into choice of approach, case order, and scheduling preferences, and provides insight into the work done by the surgeon.

Low revision rate throughout the adoption of the direct superior approach in primary total hip arthroplasty: an analysis based on 1551 total hip arthroplasties from the Dutch Arthroplasty Register

BACKGROUND

Recently, surgeons introduced a minimally invasive modification on the classic posterolateral approach (PLA) in total hip arthroplasty (THA): the direct superior approach (DSA). We investigated the association between surgeon's experience and the risk of early revision of the DSA in primary THA, using data from the Dutch Arthroplasty Register (LROI).

METHODS

We retrieved all primary THAs performed using the DSA in 4 hospitals between 2016 and 2022 (n = 1551). Procedures were sorted in 5 groups using the date of operation and number of previous procedures per surgeon: 1-25; 26-50; 51-75; 76-100; >100. Subsequently, data from different surgeons were pooled together and the risk of revision was calculated via a multilevel time-to-event analysis.

RESULTS

The overall revision rate was 1.5% after a mean follow-up of 2 years. Patients from the 1-25 group had comparable risks of revision compared to patients in the >100 group (hazard ratio [HR] 1.0 [CI, 0.3-3.2]). The risk for patients in groups 26-50, 51-75 and 75-100 was also not statistically different from the >100 group (resp. HR 1.5 [CI, 0.5-5.0], 1.8 [CI, 0.5-6.4] and 0.5 [CI, 0.1-4.0]). Main reasons of revision were dislocation (0.5%) and infection (0.4%).

CONCLUSIONS

We did not identify an association between the surgeon's experience and the early risk of revision for the DSA in primary THA in the Netherlands. The DSA seems safe in the early adoption phases with a low risk of revision due to dislocation and revision for all other causes.

The Posterior Approach is Associated With Lower Total Encounter and 90-Day Costs When Compared to the Direct Anterior Approach

BACKGROUND

The clinical impact of the surgical approach in total hip arthroplasty (THA) has been widely reviewed. This study evaluated the total encounter and 90-day costs of THA for 2 surgical approaches (posterior [P] and direct anterior [DA]) in 1 tertiary health system.

METHODS

This is a retrospective review of 2,101 THAs (1,092 P and 1,009 DA) by 4 surgeons (2 with the highest volume of DA and P, respectively) from 2017 to 2022 at 1 academic center. Demographics, comorbidities, operative time, length of hospital stay, 90-day hospital returns, and complications were compared. The total encounter cost and 90-day postoperative cost were itemized. Multivariable regression analyses evaluated associations with increased cost at each time point.

RESULTS

The DA cohort had a higher median encounter cost ($8,348.66 versus 7,332.42, P < .01), resulting from higher intraoperative (P < .01) and radiology (P < .01) expenses. Regression analyses demonstrated the DA was independently associated with increased encounter costs (odds ratio 1.1; 95% confidence interval 1.1 to 1.1; P < .01). There was a higher incidence of 90-day emergency department visits in the DA cohort (16 versus 12%, P = .02), with a trend toward increased readmissions. There was no difference in 90-day reoperations. Median 90-day cost was higher in the DA cohort ($126.99 versus 0.00, P < .01), and regression analyses demonstrated the DA had an association with increased 90-day cost (odds ratio 2.2; 95% confidence interval 1.5 to 3.0; P < .01).

CONCLUSIONS

Despite a younger patient population, the DA was independently associated with increased encounter and 90-day costs in a single academic hospital system. This study may underestimate the cost difference, as capital costs such as specialized tables were not analyzed.

To further incorporate computer-aided designs to improve preoperative planning in total hip arthroplasty: a cohort study

Background

Hip replacement surgeries are increasing in demand, requiring rigorous improvements to a mature surgical protocol. Postoperative patient dissatisfaction mainly stems from postoperative complications resulting from the inappropriate selection of prostheses to meet the needs of each patient. This results in prosthesis loosening, hospital-related fractures, and postoperative complex pain, which can all be attributed to inappropriate sizing. In this study, we aimed to further explore the intraoperative and postoperative benefits of incorporating computer-aided design (CAD) in preoperative planning for total hip arthroplasty (THA).

Methods

A total of 62 patients requiring total hip replacement surgery from January 2021 to December 2021 were collected and randomly divided into a preoperative computer-aided simulated group and a conventional x-ray interpretation group. The accuracy of implant size selection (femoral and acetabular implant) between the preoperative planning and surgical procedure of the two groups was compared. Patient parameters, perioperative Harris hip scores, operative time (skin-to-skin time), surgical blood loss, and postoperative hospital stay were recorded, and the differences between the two groups were statistically compared using a single sample t-test.

Results

All patients in the study were successfully operated on and achieved good postoperative functional recovery. With CAD, the selection of the most suitable-sized prosthesis was significantly more accurate compared to the control group (accuracy of the acetabular component between the CAD/control: 80.6%/61.3%, and accuracy of the femoral component: 83.9%/67.7%). Intraoperative blood loss (177.4/231.0 ml, P = 0.002), operation time (84.2 ± 19.8 min/100.3 ± 25.9 min, P = 0.008), duration of hospital stay (6.5 ± 3/9.1 ± 3.9 days, P = 0.003), and postoperative Harris hip score (81.9 ± 6.5/74.7 ± 11.1, P = 0.003) were compared to the control group and showed statistical significance.

Conclusion

Incorporating CAD into the preoperative planning of total hip arthroplasty can effectively guide the selection of the most suitable-sized prosthesis, reduce intraoperative blood loss, and promote short-term functional recovery after THA.

The Rise of the Direct Anterior Approach: Trends, Learning Curves, and Patient Characteristics of 63,182 Primary Total Hip Arthroplasties in the Dutch Arthroplasty Register (LROI)

BACKGROUND

The use of the direct anterior approach (DAA) in total hip arthroplasty (THA) has steadily increased in the Netherlands since 2007. The aim of this study was to outline how the DAA has been implemented in the Netherlands. Moreover, we investigated the learning curve of the DAA at a hospital level, and explored patient characteristics of the DAA compared with other approaches and during the learning phase after implementing the DAA.

METHODS

In this population-based cohort study, we included all primary THAs between 2007 and 2020 (n = 342,473) from the Dutch Arthroplasty Register. For hospitals implementing the DAA (n > 20), patients were categorized in 4 experience groups using the date of surgery: 1 to 50, 51 to 100, 101 to 150, or > 150. Subsequently, data from different hospitals were pooled and survival rates were calculated using Kaplan-Meier survival analyses. Adjusted revision rates were calculated using mixed Cox proportional hazard models (frailty).

RESULTS

The use of the DAA gradually rose from 0.2% in 2007 to 41% of all primary THAs in 2020. A total of 64 (56%) hospitals implemented the DAA. However, not all hospitals continued using this approach. After implementation, the 5-year survival rate for the first 50 procedures was significantly lower (96% confidence interval [CI] 95.8 to 97.2) compared to >150 procedures (98% CI 97.7 to 98.1). Multivariable Cox hazard analyses demonstrated a higher risk of revision during the first 50 procedures compared with >150 procedures (hazard ratio 1.6, CI 1.3 to 2.0).

CONCLUSIONS

The use of DAA for primary THA significantly increased. For hospitals implementing DAA, a considerable learning curve with increased revision risk was seen.

Similar incidence of postoperative sciatic nerve palsy in direct anterior and posterior approach total hip arthroplasty

BACKGROUND

Sciatic nerve palsy is a rare but devastating complication following total hip arthroplasty (THA). While the use of the direct anterior approach is increasing, limited data exist regarding sciatic nerve palsy and surgical approach. The purpose of this study was to determine the factors and outcomes associated with sciatic nerve palsy (SNP) after THA.

METHODS

A retrospective analysis was performed at a single institution of 7 SNP that occurred in 4045 THA via direct anterior approach and 10 SNP in 8854 THA via posterior approach, being operated between 01 January 2017 and 12 December 2021. SNP patients were matched 1:5 to patients without SNP. Medical records were reviewed for demographics including age, gender, body mass index (BMI), comorbidities, and preoperative indication. Additional workup of SNP patients including advanced imaging and reoperation were documented. Recovery grades were assigned to all SNP patients at most recent clinical follow-up.

RESULTS

5 of the SNP were complete and 12 partial. They occurred as frequently with the direct anterior (0.17%) and posterior approach (0.11%, p = 0.5). The presence of femur cables and reoperations were associated with SNP (p = 0.04 and p = 0.002, respecitvely). Age, gender, BMI, comorbidities, and surgical indication had no effect on SNP. 4 of the 17 affected patients had almost complete recovery at latest follow-up.

CONCLUSIONS

The incidence of SNP was similar in direct anterior and posterior approach. Surgeons should counsel patients regarding the risks of SNP regardless of the used approach.

Reverse Fragility Index: Comparing Revision Rates Between Direct Anterior and Other Approaches in Total Hip Arthroplasty. A Systematic Review of Randomized Controlled Trials

BACKGROUND

Despite increasing adoption of the direct anterior (DA) approach in total hip arthroplasty (THA), uncertainty persists regarding its outcomes beyond the 1-year mark in comparison to other approaches. We used the reverse fragility index (RFI) to evaluate the robustness of reported findings in the literature.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs) comparing implant revision rates between DA and other approaches in THA, defined as all those different from DA. Our primary outcome was the RFI, which gauges the number of events needed for a nonsignificant result to become significant, in the revision rate between DA and other approaches. We also calculated the reverse fragility quotient by dividing the RFI by each study's sample size. Median values and interquartile ranges (IQRs) were displayed.

RESULTS

A total of 10 RCTs with a total of 971 patients were included. The median RFI was 5 (IQR, 4 to 5), indicating the study's results would be statistically significant if the outcomes of 5 patients in 1 treatment arm were reversed. The median reverse fragility quotient was 0.049 (IQR, 0.04 to 0.057), indicating that a change of outcome in 4.9% of patients would render the revision rate significant. The median number of patients lost to follow-up was 4 (IQR, 0 to 7). Of the 10 RCTs, 6 had more patients lost to follow-up than their respective RFI values.

CONCLUSIONS

Notable fragility was evidenced in most studies comparing DA to other approaches for THA. Surgeons should not solely rely on the P value to determine clinical significance and instead use multiple metrics.

LEVEL OF EVIDENCE

II.

A comparison of cemented femoral fixation via anterior versus posterior approach total hip arthroplasty: an analysis of 60,739 total hip arthroplasties

BACKGROUND

Anterior approach total hip arthroplasty (THA) decreases the rate of dislocation but increases femoral-sided complications in the way of periprosthetic fractures and component loosening. A cemented prosthesis may reduce femoral-sided complications and improve the risk:benefit profile of anterior approach THA.

METHODS

Data from the Australian National Joint Replacement Registry were analysed for patients undergoing primary THA via the anterior or posterior approach using a cemented polished femoral stem from January 2015 to December 2021. The primary outcome measure was the cumulative percent revision (CPR) for all causes and CPR for femoral component loosening and fracture. The CPR for the primary outcome measures were compared between the anterior and posterior approach and adjusted for age, sex, ASA score, BMI and femoral head size.

RESULTS

The study included 60,739 THAs with cemented stems (10,742 anterior, 49,997 posterior). The rate of revision of the anterior versus the posterior approach did not significantly differ (HR 0.87 (95% CI, 0.74-1.03), p = 0.100). Anterior approach THA had a significantly higher rate of revision for femoral component loosening (HR 5.06 [95% CI, 3.08-8.30], p < 0.001); and a decreased rate of revision for infection (HR 0.59 [95% CI, 0.43-0.81], p = 0.001) and dislocation/instability (HR 0-3 months 0.48 [95% CI, 0.27-0.83], p = 0.008; HR >3 months 0.30 [95% CI, 0.15-0.61], p < 0.001). There was no difference in the rate of revision surgery for fracture between the 2 approaches (HR 1.01 [95% CI, 0.71-1.43]), p = 0.975).

CONCLUSIONS

There is no significant difference in overall revision rates with cemented femoral fixation performed with an anterior or posterior approach. Cemented fixation performed with the anterior approach partly mitigates femoral complications with no difference in the revision rate for fracture but an increased rate of femoral component loosening.

A Comparison of Surgical Approaches for Hip Hemiarthroplasty Performed for the Treatment of Femoral Neck Fracture: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

BACKGROUND

Multiple hemiarthroplasty (HA) approaches exist for femoral neck fracture (FNF) treatment. However, there is no consensus on the superiority of one approach for postoperative outcomes. This study assessed outcomes among randomized controlled trials (RCTs) comparing the posterior approach (PA), direct lateral approach (DLA), anterolateral approach (ALA), and the direct anterior approach (DAA) in HA for FNF.

METHODS

PubMed, Ovid/MEDLINE, Scopus, Cochrane Central Registry of Controlled Trials, and Cochrane Database of Systematic Reviews were queried in February 2024. A frequentist model network meta-analysis of eligible prospective RCTs compared outcomes among approaches using P-scores.

RESULTS

Of 1,481 retrieved studies, 11 RCTs totaling 1,513 FNF patients who underwent HA through a PA (n = 446; 29.5%), DLA (n = 481; 31.8%), ALA (n = 296; 19.6%), or DAA (n = 290; 19.2%) with median (interquartile range) follow-up of 6 (4.5-12.0) months were included for meta-analysis. DAA was associated with statistically increased operative duration (mean difference [MD], 1.89 minutes; 95% CI, 0.08 to 3.69 minutes; p < 0.001) compared with a PA, whereas an ALA was associated with statistically greater blood loss compared with a PA (MD, 5.81 mL; 95% CI, 4.11 to 7.50 mL; p < 0.001). There were no differences in the incidence of fracture, dislocation, infection, complications, revision, nor 1-year mortality among approaches. There were also no differences in hip nor pain score improvement at latest follow-up, although with high heterogeneity (I2 = 85.7% and 94.2%, respectively).

CONCLUSION

This study found no clinical difference in improvement in pain, function, nor in revision outcomes and operative characteristics among HA approaches for FNF, and each approach had a similar adverse event profile. Despite limited randomized evidence, these findings suggest comparable short-term efficacy and safety of all approaches.

LEVEL OF EVIDENCE

Therapeutic, Level I. See Instructions for Authors for a complete description of levels of evidence.

Neoplastic pathologic hip fractures are associated with a higher risk of post-operative bleeding and thromboembolic events

INTRODUCTION

Surgical treatment of hip fractures leads to significant post-operative complications. Although pathologic fractures (PF) are associated with worse outcomes, most studies do not differentiate between etiology (neoplastic and non-neoplastic PF). We seek to compare 30-day complication rates between 1) native hip fractures and neoplastic PF, and 2) neoplastic and non-neoplastic PF.

MATERIALS AND METHODS

A total of 127,819 patients with hip fractures and 5104 with PF diagnosed from 2005 to 2021 were retrieved from the NSQIP database. We included 1843 patients with neoplastic PF and 3261 with non-neoplastic PF. Demographics, pre-operative labs and co-morbidities, and post-operative outcomes were analyzed. Propensity-score matching was conducted to control for confounders.

RESULTS

Patients with a neoplastic PF had a significantly higher rate of deep venous thrombosis (DVT) (4 % vs 1.2 %, p = 0.001) and pulmonary embolism (PE) (2.4 % vs 0.7 %, p < 0.001), than native hip fractures. Rates of post-operative bleeding were significantly higher in the neoplastic PF group (29.3 % vs 23.9 %, p < 0.001) than non-neoplastic PF. No differences in soft tissue complications were found. When comparing neoplastic and non-neoplastic PF, the former had a higher rate of PE (2.5 % vs 1.0 %, p = 0.015) and post-operative bleeding (27.6 % vs 22.0 %, p = 0.009). Unplanned readmission rates and 30-day mortality rate were also higher in the neoplastic PF group.

CONCLUSION

Neoplastic PF of the hip are associated with higher risk of thromboembolic event rates and post-operative bleeding than both native hip fractures and non-neoplastic PF. No differences in rates of soft tissue complications were found between groups.

Predictors of Reoperation and Survival Experience (Minimum 1 Year) for Primary Versus Conversion Total Hip Arthroplasty in Young Patients

BACKGROUND

Total hip arthroplasty (THA), including primary and conversion procedures, is commonly used for many types of joint disease in patients aged below 65 years, though few studies have evaluated THA outcomes in young patients (≤ 40 years old). This study examined a large cohort of patients who underwent THA at a young (≤ 40 years old) age to identify predictors of reoperation and compare survivorship between primary and conversion THAs.

METHODS

A retrospective study was conducted on 497 patients who underwent 612 primary and conversion THAs at 40 years old or younger between 1990 and 2020. Medical records were reviewed to collect patient/surgical data. A multivariable logistic regression model identified independent predictors of reoperation, and Kaplan-Meier analysis with log-rank tests was used to compare survival curves by THA type.

RESULTS

The median age at surgery (interquartile range) was 31 years (25 to 36). The median follow-up time was 6.6 years (range, 3.8 to 10.5). Conversion THAs had an increased rate of both revisions (12.3 versus 5.6%, P = 0.02) and nonrevision reoperations (8.9 versus 3.2%, P = 0.03) compared to primary THAs. A ceramic-on-ceramic articulation (odds ratio: 5.17; P = 0.03) and a higher estimated blood loss (odds ratio: 1.0007; P = 0.03) were independent predictors of reoperation for primary and conversion THA, respectively. Conversion THAs had a lower 15-year survival (77.8 versus 90.8%, P = 0.009) compared to primary THAs.

CONCLUSIONS

Patients ≤ 40 years old who underwent primary and conversion THAs demonstrated an impressive 15-year survival comparable to that of older populations (74 to 93%), while conversion procedures had a higher reoperation rate. Although primary THA may be more ideal, there are promising outcomes for patients who need THA at a younger age than typically implemented, especially for those who are very young (≤ 30 years old).

Direct Anterior Approach Total Hip Arthroplasty for Femoral Neck Fractures in the Lateral Position

Objective

To compare the clinical efficacy of artificial total hip arthroplasty(THA) for femoral neck fracture between direct anterior approach(DAA) in lateral position and posterior lateral approach(PLA).

Methods

Comparison of 200 cases of patients who underwent THA collected between September 2019 and August 2021 was done. Incision length, intraoperative bleeding, operative time, difference in postoperative haemoglobin from preoperative levels, length of hospital stay, postoperative time to get off the floor, visual analogue score (VAS) for pain, preoperative and postoperative Harris scores for the hip, and measurements of the acetabular abduction angle and anterior acetabular tilt angle at 6 months postoperatively were collected, and all the cases were followed up for at least 2 years.

Results

Compared with the PLA group, the DAA group had a shorter incision length, less intraoperative blood loss, less postoperative haemoglobin reduction compared with the preoperative period, a shorter hospital stay and an earlier first time to get off the floor after surgery, however, the comparison of operative times was not statistically significant; Patients in the DAA group had a lower VAS in the early postoperative period compared to PLA; Patients in the DAA group had higher hip Harris scores at 6 weeks and 6 months postoperatively; There was no significant difference in acetabular abduction angle and acetabular anterior tilt angle between the two groups at 6 months postoperatively.

Conclusion

Compared to PLA, DAA in THA is minimally invasive, has less pain, less bleeding, earlier time out of bed, shorter hospital stay, better early hip function, faster rehabilitation, and better joint stability.

No Difference in Revision Rates or Patient-Reported Outcome Measures Between Surgical Approaches for Total Hip Arthroplasty Performed for Femoral Neck Fracture: An Analysis of 5,025 Primary Total Hip Arthroplasties From the New Zealand Joint Registry

BACKGROUND

Total hip arthroplasty (THA) for femoral neck fracture (FNF) can be performed through different surgical approaches. This study compared the revision rates and patient-reported outcome measures by surgical approach.

METHODS

Data from the New Zealand Joint Registry were analyzed for patients undergoing primary THA for FNF from January 2000 to December 2021. A total of 5,025 THAs were performed for FNF; the lateral approach was used in 2,499 (49.7%), the posterior in 2,255 (44.9%), and the anterior in 271 (4.3%). The primary outcome measure was the all-cause revision rate. Secondary outcome measures included revision rates for: dislocation, aseptic femoral component loosening, periprosthetic fracture, and infection. Oxford Hip Scores (OHS) were also collected. Age, sex, body mass index, American Society of Anesthesiologists score, femoral head size, dual mobility use, femoral fixation, and surgeon experience were assessed as potential confounding variables.

RESULTS

There was no difference in the revision rates between lateral and posterior (P = .156), lateral and anterior (P = .680), or posterior and anterior (P = .714) approaches. There was no difference in the reasons for revision between the lateral and posterior approaches or 6-month OHS (P = .712). There was insufficient data to compare the anterior approach.

CONCLUSIONS

There is no difference in the overall revision rates, reasons for revision, or OHS between the lateral and posterior surgical approaches for THA performed for FNF. Insufficient data on the anterior approach is available for an accurate comparison.

LEVEL OF EVIDENCE

Level III.

Patients Requiring Both Total Hip Arthroplasty and Lumbar Spinal Fusion Have Lower Hip Functional Outcome Scores: A Matched Case-Control Study

BACKGROUND

While patients who undergo both lumbar spinal fusion (LSF) and total hip arthroplasty (THA) have increased complication rates compared to patients who have not undergone LSF, there is a paucity of literature evaluating THA functional outcomes in patients with a history of LSF. This study was conducted to determine whether patients undergoing THA with a history of LSF have inferior functional outcomes compared to patients having no history of LSF.

METHODS

A retrospective matched case-control study was conducted at an academic center. Patients who underwent both THA and LSF (cases) were matched with controls who underwent THA without LSF. Inclusion criteria required a minimum of 1-year follow-up for the Hip Disability and Osteoarthritis Outcome Score Joint Replacement [HOOS-JR]. Following propensity matching for age, sex, race, body mass index, and comorbidities, 291 cases and 1,164 controls were included, with no demographic differences.

RESULTS

Patients who underwent both THA and LSF had a significantly lower preoperative HOOS-JR (47 versus 50; P < .001), postoperative HOOS-JR (77 versus 85; P < .001), a significant lower rate of achieving the patient acceptable symptom state (55 versus 67%; P < .001), with no significant difference in delta HOOS-JR (34 versus 34; P = .834). When comparing patients undergoing THA before LSF or LSF before THA, no differences existed for preoperative HOOS-JR (50 versus 47; P = .304), but patients undergoing THA before LSF had lower postoperative HOOS-JR scores (74 versus 81; P = .034), a lower-delta HOOS-JR (27 versus 35; P = .022), and a lower rate of reaching the HOOS-JR minimal clinically important difference (62 versus 76%; P = .031).

CONCLUSIONS

Patients who have a history of LSF experience a similar improvement in hip function when undergoing THA compared to patients who do not have a history of LSF. However, due to lower preoperative function, they may have a lower postoperative functional outcome ceiling. Additionally, patients undergoing THA before LSF have worse hip functional outcomes than patients undergoing LSF before THA.

A Cost Analysis of Surgical Approach in Total Hip Arthroplasty

BACKGROUND

With pressures to decrease the financial burden of total hip arthroplasty (THA), it is imperative to understand the cost drivers of this procedure. This study evaluated operative and total encounter costs for two surgical approaches to THA-posterior (P) and direct anterior (DA).

MATERIALS AND METHODS

A total of 233 THAs (134 P and 99 DA) performed by two fellowship-trained arthroplasty surgeons from 2017 to 2022 were reviewed. Demographics, comorbidities, mobility status, operative time, length of stay, implants used, discharge location, and complications until final follow-up were recorded. Total encounter cost was collected and itemized. Multivariable regression analyses evaluated predictors of cost.

RESULTS

There were differences in age (67 years for DA and 63 years for P; P=.03), body mass index (28.0 kg/m2 for DA and 33.8 kg/m2 for P; P<.01), Elixhauser Comorbidity Index score (4.6 for DA and 5.6 for P; P=.04), and operative time (2.1 hours for DA and 1.9 hours for P; P<.01) between the two cohorts. The DA cohort trended toward shorter length of stay, with the highest percentage of patients discharged home (86.9%; P=.02). The P cohort had the lowest encounter ($9601 for DA and $9100 for P; P=.20) and intraoperative (including implant used) ($7268 for DA and $6792 for P; P<.01) costs. The DA cohort had a significantly higher cost of radiology during the encounter ($244; P<.01). Regression analysis demonstrated that length of stay and DA approach were both predictors of increased encounter cost.

CONCLUSION

The DA cohort had improved measures of health; however, this approach was associated with a higher operative cost and was predictive of increased encounter cost despite a shorter length of stay. [Orthopedics. 2024;47(3):e151-e156.].

The Direct Superior Approach in Total Hip Arthroplasty: A Systematic Review

BACKGROUND

Evolution of the surgical approach for total hip arthroplasty (THA) has led to the development of the minimally invasive direct superior approach (DSA). It is hypothesized that the DSA reduces postoperative pain and hospital length of stay (LOS). We aimed to provide an overview of current evidence on clinical, functional, and radiological outcomes with respect to risk of revision, complications, pain scores, physical function, operative time, LOS, blood loss, radiological outcomes, and learning curve.

METHODS

A comprehensive search of Medline, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar, reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search extension guidelines, was conducted to identify studies evaluating clinical, functional, and radiological outcomes of the DSA. Quality assessment was performed using the Cochrane Risk of Bias tool and Newcastle-Ottawa Scale. The review protocol was prospectively registered in the International Prospective Registry of Systematic Reviews.

RESULTS

Seventeen studies were included, generally of moderate quality. Qualitative synthesis evidenced accurate implant positioning, short LOS, and a short learning curve. Conflicting findings were reported for postoperative complications compared with conventional approaches. Better functional outcomes were seen in the early postoperative period than the posterolateral approach (PLA). Outcomes such as blood loss and operative time exhibited conflicting results and considerable heterogeneity.

CONCLUSION

Based on moderate-certainty evidence, it is uncertain if the DSA provides short-term advantages over conventional approaches such as PLA. There is limited evidence on long-term outcomes post-THA using the DSA. Further studies and ongoing registry monitoring is crucial for continuous evaluation of its long-term outcomes.

LEVEL OF EVIDENCE

Level III. See Instructions for Authors for a complete description of levels of evidence.

Editorial Commentary: For Post-Hip Arthroplasty Iliopsoas Tendonitis, Psoas Tenotomy Is the Preferred First-Line Treatment, Even in Cases of Cup Overhang

Iliopsoas impingement pathology is one of the causes of persistent pain after total hip arthroplasty. It is reported as occurring in approximately 4% of cases; this may be significantly greater (in cases of postarthroplasty pain of unknown etiology). Inflammation is a result of impingement of the tendon against the acetabular component. This may occur with anteroinferior prominence when the cup is properly positioned in anteversion or when the cup is oversized. Other causes of impingement include a cup-reinforcement ring or acetabular cage, a collared femoral component, screws penetrating through the ilium, cement extrusion, anterior wall hypoplasia, or increased femoral offset. When conservative treatment does not achieve the best outcome, the 2 main therapeutic options are psoas tenotomy or revision of the cup component. Tenotomy can be performed either arthroscopically or by an open approach and may be considered the best option for many patients, even in cases with anterior component prominence, as it is less invasive, presents fewer complications, and has faster recovery. The debate is open. The level of tenotomy remains controversial, with risks and benefits of both a lesser trochanter and transcapsular approach.

The Impact of Surgical Approach on 90-Day Prosthetic Joint Infection After Total Hip Replacement - A Population-Based, Propensity Score-Matched Cohort Study

BACKGROUND

Prosthetic joint infection (PJI) is a devastating complication of total hip arthroplasty (THA). This study aimed to determine if the anterior approach (AP) influenced the incidence of early PJI in THA compared to posterior approach (PP).

METHODS

Record linkage was performed between state-wide hospitalization data and a national joint replacement registry to identify unilateral THA performed via the AP or PP. Complete data on 12,605 AP and 25,569 PP THAs were obtained. Propensity score matching (PSM) was undertaken to match covariates between the approaches. Outcomes were the 90-day PJI hospital readmission rate(using narrow and broad definitions) and 90-day PJI revision rate (defined as component removal or exchange).

RESULTS

The raw PJI readmission rate for AP was lower than PP (0.8% versus 1.1%, respectively). In the PSM analysis, there was no statistically significant difference in PJI readmission rate between approaches using narrow or broad definition of PJI readmission. In terms of revision for infection, both methods showed AP had a significantly lower rate than PP, with an adjusted odds ratio (OR) of 0.47 (95% confidence interval (CI) 0.30, 0.75) for the 1:1 nearest neighbor method and 0.50 (95% CI 0.32, 0.77) for the subclassification method.

CONCLUSION

After addressing known confounders, there was no significant difference in the 90-day hospital readmission rate for hip PJI between approaches. There was a significantly reduced 90-day PJI revision rate for AP. The difference in revision may reflect differences in the surgical management of PJI between hip approaches rather than a difference in the underlying rate of infection.

Does the Primary Surgical Approach Matter When Choosing the Approach for Revision Total Hip Arthroplasty?

BACKGROUND

Multiple surgical approaches are used for primary total hip arthroplasty (pTHA) and revision total hip arthroplasty (rTHA). This study sought to investigate prevalence of discordance of pTHA and rTHA surgical approaches and to evaluate how approach concordance impacts postoperative outcomes.

METHODS

A retrospective review of patients who underwent rTHA from 2000 to 2021 was conducted at 3 large urban academic centers. Patients who had minimum 1-year follow-up post-rTHA were included and grouped based on whether they received pTHA via a posterior (PA), direct anterior (DA), or laterally based (DL) approach, and by concordance of index rTHA approach with their pTHA approach. Of the 917 patients studied, 839 (91.5%) were included in the concordant cohort and 78 (8.5%) in the discordant cohort. Patient demographics, operative characteristics, and postoperative outcomes were compared.

RESULTS

Discordance was most prevalent in the DA-pTHA subset (29.5%), compared to the DL-pTHA subset (14.7%) or PA-pTHA subset (3.7%). Discordance varied significantly between primary approaches among all revisions, with DA-pTHA patients having the highest discordance rate for patients revised for aseptic loosening (46.3%, P < .001), fracture (22.2%, P < .001), and dislocation (33.3%, P < .001). There were no differences between groups in dislocation rate, re-revision for infection, or re-revision for fracture.

CONCLUSION

The results of this multicenter study showed patients who received pTHA via the DA were more likely to receive rTHA via a discordant approach compared to other primary approaches. Since approach concordance did not impact dislocation, infection, or fracture rates after rTHA, surgeons can feel reassured using a separate approach for rTHA.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Perioperative nursing care for hip arthroplasty patients with concomitant hypertension: A minireview

Hip replacement (HA) is mainly indicated for the elderly, who generally suffer from various underlying diseases such as hypertension. This article provides a review of the key points of perioperative nursing care for patients with hypertension undergoing HA. It analyzes the key points of care during the perioperative period (preoperative, intraoperative, and postoperative) and proposes directions for the development of perioperative nursing care for HA. The prognosis for patients can be improved through the modification of traditional medical approaches and the application of new technologies and concepts.

Complication Rates and Survival of Nonagenarians after Hip Hemiarthroplasty versus Proximal Femoral Nail Antirotation for Intertrochanteric Fractures: A 15-Year Retrospective Cohort Study of 113 Cases

OBJECTIVE

Intertrochanteric fracture is a very common but serious type of hip fracture in nonagenarians. The surgical treatment remains a significant challenge for orthopedists. The objective of this study was to investigate postoperative complications and survival outcomes compared between bipolar hemiarthroplasty (HA) and proximal femoral nail anti-rotation (PFNA) in nonagenarians with intertrochanteric fractures, and to evaluate the efficacy and safety of the two surgical procedures in this patient population.

METHODS

A total of 113 consecutive nonagenarians who underwent bipolar HA or PFNA for the treatment of intertrochanteric fractures from January 2006 to August 2021 were retrospectively studied in the current paper. There were 34 males and 79 females, with a mean age of 92.2 years (range 90-101 years) at the time of operation. The average duration of follow-up was 29.7 months (range 1-120 months). The full cohort was divided into bipolar HA (77 cases) and PFNA (36 cases) groups. Damage control orthopedics was used to determine the optimal surgery time and assist in perioperative management. A restrictive blood transfusion strategy was employed, along with appropriate adjustments under multidisciplinary assessment, throughout the perioperative period. Perioperative clinical information and prognostic data were analyzed. Kaplan-Meier survival curves were used for survival analysis, and landmark analysis divided the entire follow-up period into 1-12 months (short-term), 13-42 months (medium-term) and 43-120 months (long-term) according to the configurations of Kaplan-Meier survival curves.

RESULTS

Both groups had similar general variables except for the proportion of high adjusted Charlson comorbidity index (aCCI) (≥6 points) (6.5% in bipolar HA group and 22.2% in PFNA group, p = 0.024). Intraoperative blood loss and transfusion requirements were greater, and the intraoperative transfusion rates were higher in the bipolar HA group compared to the PFNA group (all p < 0.05). The complications rates, 1- to 60-month cumulative all-cause mortality, postoperative optimal Harris hip score (HHS), and Barthel index (BI) presented no significant difference between the two groups (all p > 0.05). Both groups had similar overall survival curves (p = 0.37). However, landmark analysis revealed that bipolar HA group exhibited higher survival rates in medium-term (p = 0.01), while similar survival rates were observed in the short- and long-term post-operation periods (both p > 0.05). Cox regression with survival-time-dependent covariate calculated the hazard ratio (HR) of bipolar HA was 0.41 in medium-term (p = 0.039).

CONCLUSION

Bipolar HA is equally effective and reliable as PFNA for treating intertrochanteric fractures in nonagenarians. Despite resulting in more intraoperative blood loss and transfusions, bipolar HA therapy is associated with a higher medium-term survival rate compared to PFNA treatment. The application of damage control orthopedics and precise perioperative patient blood management could contribute to the positive clinical outcomes observed in this patient population.

Early Practice All-Cause Complications for Fellowship-Trained Anterior Hip Surgeons Are Not Increased When Compared to "Gold Standard" Experienced Posterior Approach Surgeons

BACKGROUND

Increased complication rates have been reported during the learning curve for direct anterior approach (DAA) total hip arthroplasty (THA). However, emerging literature suggests that complications associated with the learning curve may be substantially reduced with fellowship training.

METHODS

Our institutional database was queried to identify 2 groups: (1) 600 THAs comprised of the first 300 consecutive cases performed by 2 DAA fellowship-trained surgeons; and (2) 600 posterolateral approach (PA) THAs, including the most recent 300 primary cases performed by 2 experienced PA surgeons. All-cause complications, revision rates, reoperations, operative times, and transfusion rates were evaluated.

RESULTS

Comparing DAA and PA cases, there were no significant differences in rates of all-cause complications (DAA = 18, 3.0% versus PA = 23, 3.8%; P = .43), periprosthetic fractures (DAA = 5, 0.8% versus PA = 10, 1.7%; P = .19), wound complications (DAA = 7, 1.2% versus PA = 2, 0.3%; P = .09), dislocations (DAA = 2, 0.3% versus PA = 8, 1.3%, P = .06), or revisions (DAA = 2, 0.3% versus PL = 5, 0.8%; P = .45) at 120 days postoperatively. There were 4 patients who required reoperation for wound complications, all within the DAA group (DAA = 4, 0.67% versus PA = 0; P = .045). Operative times were shorter in the DAA group (DAA <1.5 hours = 93% versus PA <1.5 hours = 86%; P < .01). No blood transfusions were given in either group.

CONCLUSION

In this retrospective study, DAA THAs performed by fellowship-trained surgeons early in practice were not associated with higher complication rates compared to THAs performed by experienced PA surgeons. These results suggest that fellowship training may allow DAA surgeons to complete their learning curve period with complication rates similar to experienced PA surgeons.

Femoral head size and surgical approach affect dislocation and overall revision rates in total hip arthroplasty: up to 9-year follow-up data of 269,280 procedures in the Dutch Arthroplasty Register (LROI)

BACKGROUND

Femoral head size and surgical approach might affect the revision rate for dislocation and for any other reason after total hip arthroplasty (THA). We penetrated this question based on registry data with up to 9-year follow-up.

METHODS

269,280 primary THAs documented in the Dutch Arthroplasty Registry (LROI) between 2007 and 2019 were included. Revision rates were calculated by competing risk analyses. Multivariable Cox proportional hazard regression ratios (HR) were used for comparison.

RESULTS

Revisions for dislocation were rare. They were more frequent after posterolateral (1.4% [95% CI, 1.3-1.5]), compared to straight lateral (0.6% [95% CI, 0.5-0.7]), anterolateral (0.6% [95% CI, 0.5-0.7]) and anterior (0.4% [95% CI, 0.3-0.5]) approach. Larger femoral head size decreased the dislocation revision risk: 1.4% [95% CI, 1.3-1.5) for 22-28-mm heads; 0.9% (95% CI, 0.8-1.0) for 32-mm heads; 0.6% (95% CI, 0.6-0.7) for 36-mm heads. For the anterior approach, the HR for both revision for dislocation (0.3, 95% CI, 0.3-0.4) and any other reason (0.8, 95% CI, 0.8-0.9) were lowest compared to other approaches including posterolateral (HR 1). Revision risk for any other reason was highest with anterolateral (HR 1.3 (95% CI, 1.2-1.4)) and straight lateral approach (1.1 [95% CI, 1.0-1.2]).

CONCLUSIONS

The anterior approach might reduce revision rates for both dislocation and all cause revision. Posterolateral approach is associated with a higher risk of dislocation revision but has a lower risk of any other revision. Increasing femoral head size up to 36 mm reduces revision for dislocation and improves overall revision rates for all approaches.

Direct Anterior Versus Posterior Approach for Total Hip Arthroplasty Performed for Displaced Femoral Neck Fractures

OBJECTIVES

To compare perioperative, 90-day, and 1-year postoperative complications and outcomes between the direct anterior approach (DAA) and the posterior approach for total hip arthroplasty in geriatric patients with displaced femoral neck fractures (FNFs).

DESIGN

Retrospective cohort study.

SETTING

Multicenter Health care Consortium.

PATIENTS

Seven-hundred and nine patients 60 years or older with acute displaced FNFs between 2009 and 2021.

INTERVENTION

Total hip arthroplasty using either DAA or posterior approach.

MAIN OUTCOME MEASUREMENTS

Rates of postoperative complications including dislocations, reoperations, and mortality at 90 days and 1 year postoperatively. Secondary outcome measures included ambulation capacity at discharge, ambulation distance with inpatient physical therapy, discharge disposition, and narcotic prescription quantities (morphine milligram equivalents).

RESULTS

Through a multivariable regression analysis, DAA was associated with significantly shorter operative time ( B = -6.89 minutes; 95% confidence interval [CI] -12.84 to -0.93; P = 0.024), lower likelihood of blood transfusion during the index hospital stay (adjusted odds ratios = 0.54; 95% CI 0.27 to 0.96; P = 0.045), and decreased average narcotic prescription amounts at 90 days (B = -230.45 morphine milligram equivalents; 95% CI -440.24 to -78.66; P = 0.035) postoperatively. There were no significant differences in medical complications, dislocations, reoperations, and mortality at 90 days and 1 year postoperatively.

CONCLUSION

When comparing the DAA versus posterior approach for total hip arthroplasty performed for displaced FNF, DAA was associated with shorter operative time, lower likelihood of blood transfusion, and lower 90-day postoperative narcotic prescription amounts.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical approach had minor association with femoral stem migration in total hip arthroplasty: radiostereometric analysis of 61 patients after 5-year follow-up

BACKGROUND AND PURPOSE

Total hip arthroplasty (THA) is usually performed using 1 of 3 surgical approaches: direct lateral (DLA), posterior (PA), or anterior (AA). AA is different from DLA and PA owing to limited intraoperative visibility of the femoral canal. This could affect stem positioning and therefore migration. We aimed to perform an exploratory radiostereometric analysis (RSA) study with 3 groups for surgical approach assessing stem migration up to 5 years postoperatively.

PATIENTS AND METHODS

61 patients with unilateral osteoarthritis of the hip were included. 21 patients were allocated to the DLA, 20 to the PA, and 20 to the AA group. All patients received an uncemented, collarless, double-tapered, fully hydroxyapatite-coated Profemur Gladiator stem. Migration was measured with model-based RSA. Baseline RSA was on day 1 postoperatively. The follow-ups were at day 8, at 5 weeks, and at 3, 6, 12, 24, and 60 months after surgery. Generalized linear mixed models were used to analyze maximum total point motion (MTPM) migrations.

RESULTS

Group mean differences in MTPM were 0.4 mm (95% confidence interval [CI] -1.5 to 2.4) for DLA vs. PA, 1.1 mm (CI -1.0 to 3.3) for AA vs. DLA, and 1.6 mm (CI -0.8 to 3.9) for AA vs. PA, when adjusted for sex and age as covariates. 2 stems in the AA group had excessive early migration. For all stems the migrations occurred mainly within 5-week follow-up and then stabilized.

CONCLUSION

At 5-year follow-up, there were no statistically significant differences in stem migration associated with the 3 surgical approaches used in this study.

Frank Stinchfield Award: Creation of a Patient-Specific Total Hip Arthroplasty Periprosthetic Fracture Risk Calculator

BACKGROUND

Many risk factors have been described for periprosthetic femur fracture (PPFFx) following total hip arthroplasty (THA), yet a patient-specific risk assessment tool remains elusive. The purpose of this study was to develop a high-dimensional, patient-specific risk-stratification nomogram that allows dynamic risk modification based on operative decisions.

METHODS

We evaluated 16,696 primary nononcologic THAs performed between 1998 and 2018. During a mean 6-year follow-up, 558 patients (3.3%) sustained a PPFFx. Patients were characterized by individual natural language processing-assisted chart review on nonmodifiable factors (demographics, THA indication, and comorbidities), and modifiable operative decisions (femoral fixation [cemented/uncemented], surgical approach [direct anterior, lateral, and posterior], and implant type [collared/collarless]). Multivariable Cox regression models and nomograms were developed with PPFFx as a binary outcome at 90 days, 1 year, and 5 years, postoperatively.

RESULTS

Patient-specific PPFFx risk based on comorbid profile was wide-ranging from 0.4-18% at 90 days, 0.4%-20% at 1 year, and 0.5%-25% at 5 years. Among 18 evaluated patient factors, 7 were retained in multivariable analyses. The 4 significant nonmodifiable factors included the following: women (hazard ratio (HR) = 1.6), older age (HR = 1.2 per 10 years), diagnosis of osteoporosis or use of osteoporosis medications (HR = 1.7), and indication for surgery other than osteoarthritis (HR = 2.2 for fracture, HR = 1.8 for inflammatory arthritis, HR = 1.7 for osteonecrosis). The 3 modifiable surgical factors were included as follows: uncemented femoral fixation (HR = 2.5), collarless femoral implants (HR = 1.3), and surgical approach other than direct anterior (lateral HR = 2.9, posterior HR = 1.9).

CONCLUSION

This patient-specific PPFFx risk calculator demonstrated a wide-ranging risk based on comorbid profile and enables surgeons to quantify risk mitigation based on operative decisions.

LEVEL OF EVIDENCE

Level III, Prognostic.

Patients Who Have Had Three or More Levels Fused During Lumbar Spinal Fusion Have Worse Functional Outcomes After Total Hip Arthroplasty

BACKGROUND

Lumbar spinal fusion (LSF) and total hip arthroplasty (THA) are commonly performed in patients who have concomitant spine and hip pathology. While patients who have three or more levels fused during LSF have increased postoperative opioid consumption after undergoing THA, it is unknown whether the number of levels fused during LSF affects THA functional outcomes.

METHODS

A retrospective study was conducted at a tertiary academic center for patients who underwent LSF first and then had a primary THA performed with a minimum of one-year follow-up for the Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS-JR). Operative notes were reviewed to determine the number of levels fused during LSF. There were 105 patients who underwent one-level LSF, 55 patients underwent two-level LSF, and 48 patients underwent three-or-more-level LSF. No significant differences existed in age, race, body mass index, and comorbidities between the cohorts.

RESULTS

While preoperative HOOS-JR was similar among the three cohorts, patients who had three-or-more-level LSF had significantly lower HOOS-JR scores than patients who had two-level or one-level LSF (71.4 versus 82.4 versus 78.2; P = .010) and a lower delta HOOS-JR (27.2 versus 39.4 versus 35.9; P = .014). Patients who had three-or-more-level LSF had a significantly lower rate of achieving minimal clinically important difference (61.7% versus 87.2% versus 78.7%; P = .011) and the patient acceptable symptom state (37.5% versus 69.1% versus 59.0%; P = .004) for the HOOS-JR, compared to patients who had two-level or one-level LSF, respectively.

CONCLUSIONS

Surgeons should counsel patients who have had three-or-more-level LSF that they may have a lower rate of hip function improvement and symptom acceptability after THA, compared to patients who have had a less number of levels fused during LSF.

Design of a functionally graded porous uncemented acetabular component: Influence of polar gradation

The functionally graded porous metal-backed (FGPMB) acetabular component has the potential to minimize strain-shielding induced bone resorption, caused by stiffness mismatch of implant and host bone. This study is aimed at a novel design of FGPMB acetabular component, which is based on numerical investigations of the mechanical behavior of acetabular components with regard to common failure scenarios, considering various daily activities and implant-bone interface conditions. Both radial and polar functional gradations were implemented, and the effects of the polar gradation exponent on the failure criteria were evaluated. The relationships between porosity and orthotropic mechanical properties of a tetrahedron-based unit cell were obtained using a numerical homogenization method. Strain-shielding in cancellous bone was relatively lesser for the FGPMB than solid metal-backing. Few nodes around the rim were susceptible to implant-bone interfacial debonding, irrespective of the polar gradation exponent. Although the most favorable bone remodeling predictions were obtained for a polar gradation exponent of 0.1, a sudden change in the porosity was observed near the rim of FGPMB. Bone remodeling patterns were similar for polar gradation exponent of 5.0 and solid metal-backing. Moreover, the volumetric wear was maximum and minimum for polar gradation exponents of 0.1 and 5, respectively. Furthermore, the micromotions of different polar gradation exponents were within a range (20-40 μm) that might facilitate bone ingrowth. Considering common failure mechanisms, the FGPMB having polar gradation exponents in the range of 0.1-0.5 appeared to be a viable alternative to the solid acetabular component, within which a gradation exponent of 0.25 seemed the most appropriate design parameter.

Revision risk by using the direct superior approach (DSA) for total hip arthroplasty compared with postero-lateral approach: early nationwide results from the Dutch Arthroplasty Register (LROI)

BACKGROUND AND PURPOSE

The direct superior approach (DSA) is a modification of the classic posterolateral approach (PLA) for total hip arthroplasty (THA), in which the iliotibial band and short external rotators are spared. The revision rate of the DSA has not been investigated previously using arthroplasty registry data. We examined the reasons and risk of revision of the DSA, compared with the direct anterior approach (DAA) and PLA.

PATIENTS AND METHODS

In this population-based cohort study we included 175,543 primary THAs performed between 2014 and 2020 (PLA, n = 117,576; DAA, n = 56,626; DSA, n = 1,341). Competing risk survival analysis and multivariable Cox proportional hazard analyses, adjusted for potential confounders, were performed.

RESULTS

After 3 years, crude revision rates due to any reason were 2.1% (95% confidence interval [CI] 1.3-3.3) for DSA, and 2.9% (CI 2.8-3.0) for PLA. Crude dislocation revision rates were 0.3% (CI 0.1-0.8) for DSA, versus 1.0% (CI 0.9-1.0) for PLA. Dislocation revision rate for DSA did not differ from DAA (0.3% [CI 0.2-0.3]). Multivariable Cox regression analysis demonstrated no overall difference in revision rates for the DSA (HR 0.6 [CI 0.4-1.09) compared with the PLA. Lower risk of revision due to dislocation was found in patients operated on through the DSA (HR 0.3 [0.1-0.9]) compared with the PLA.

CONCLUSION

Early nationwide results suggest that the DSA for total hip arthroplasty seems to show a tendency towards a lower risk of revision for dislocation but no overall reduced revision risk compared with the PLA.

Modernizing Our Understanding of Total Hip Arthroplasty in the Pediatric and Young Adult Patient: A Single-center Experience

INTRODUCTION

Pediatric hip disorders represent a broad range of pathology and remain a significant source of morbidity for children and young adults. Surgical intervention is often required for joint preservation, but when salvage is not possible, joint replacement may be indicated to eliminate pain and preserve function. Although there have been significant updates in the management of both pediatric hip disease and the field of total hip arthroplasty (THA), there is a paucity of literature reflecting advancements in the area of pediatric and young adult (PYA) arthroplasty. No study has investigated the impact of approach on outcomes after PYA THA. The purpose of this study is to describe the indications, techniques, and early outcomes of THA in the PYA population in a modern practice setting.

METHODS

We performed a retrospective descriptive analysis of all patients undergoing primary THA performed at a tertiary care children's hospital from 2004 to 2019. Ninety-three hips in 76 patients were evaluated. Demographics, intraoperative variables, postoperative pain and function ratings, and complication and revision rates were collected.

RESULTS

Eighty-five hips in 69 patients were included. Patients were aged 12 to 23 years old, with males and females represented equally (33 vs. 36, respectively). The most common cause of hip pain was avascular necrosis (AVN, 56/85, 66%), most commonly due to slipped capital femoral epiphysis (13/56, 23%) idiopathic AVN (12/56, 21%), and chemotherapy (12/56, 21%). Half of all hips had been previously operated before THA (43/85). Thirty-six procedures were performed via the posterolateral approach (36/85, 42%), 33 were performed via direct anterior approach (33/85, 39%), and 16 were performed via the lateral approach (LAT, 16/85, 19%). At final follow-up, 98% (83/85) of patients had complete resolution of pain, 82% (70/85) had no notable limp, and 95% (81/85) had returned to all activities. There were 6 complications and 1 early revision. Average Hip disability and Osteoarthritis Outcomes Score for Joint Replacement scores increased by 37 points from 56 to 93. The overall revision-free survival rate for PYA THA was 98.8% (at average 19-mo follow-up).

CONCLUSIONS

Modern PYA THA is dissimilar in indications and surgical techniques to historic cohorts, and conclusions from prior studies should not be generalized to modern practice. In our practice, PYA patients most commonly carry a diagnosis of AVN, and THA can be performed with modern cementless fixation with large cup and head sizes and ceramic-on-cross-linked polyethylene bearings utilizing any approach. Further study is required to better characterize middle-term and long-term results and patient-reported outcomes.

LEVEL OF EVIDENCE

Therapeutic Level IV-retrospective case series.

What Changes in Pelvic Sagittal Tilt Occur 20 Years After THA?

BACKGROUND

Cup orientation in THA in the supine, standing, and sitting positions is affected by pelvic sagittal tilt (PT). Patterns of PT shift between these positions may increase the risk of dislocation and edge loading. The PT has also been reported to change during the aging process; however, there is limited research regarding long-term changes in PT and PT shifts after THA.

QUESTIONS/PURPOSES

(1) What changes occur in PT in the supine, standing, and sitting positions during 20 years of follow-up after THA in patients who have not had revision or dislocation? (2) What factors are associated with the differences between preoperative supine PT and postoperative sitting or standing PT (Δ sitting and Δ standing, respectively) 20 years postoperatively?

METHODS

Between January 1998 and December 1999, 101 consecutive patients underwent THA for appropriate indications. AP radiographs of the pelvis in the supine, standing, and sitting positions preoperatively and at 1, 10, and 20 years after THA were longitudinally performed to evaluate changes in PT. Fifty-nine percent (60 of 101) of patients were lost before 20 years of follow-up or had incomplete sets of imaging tests, leaving 41% (41 of 101) eligible for analysis here. There were no patients who had recurrent dislocation or underwent revision arthroplasty in the cohort; therefore, this analysis regarding postoperative changes in PT indicates the natural course of the change in PT during follow-up of THA. PT was measured based on the anterior pelvic plane. PT shifts with positional changes, Δ standing, and Δ sitting during the follow-up period were calculated. Posterior changes and shifts are represented by negative values. To analyze the factors associated with Δ standing and Δ sitting after 20 years, the correlations between these parameters and preoperative factors (including sex, age, pelvic incidence [PI], lumbar lordosis [LL], preoperative PT, and preoperative PT shift) and postoperative factors (including the occurrence of new lumbar vertebral fractures, lumbar spondylolisthesis, contralateral THA performed during follow-up, and PI-LL 20 years after THA) were determined.

RESULTS

Median (IQR) supine and standing PTs changed (moved posteriorly) by -5° (-11° to -2°; p < 0.01) and -10° (-15° to -7°; p < 0.01), respectively. Sitting PT did not change during the 20-year follow-up period. Median (IQR) PT shift from standing to sitting changed from -34° preoperatively (-40° to -28°) to -23° after 20 years (-28° to -20°). There were posterior changes in median (range) Δ standing (median -12° at 20 years [-19° to -7°]); Δ sitting did not change during the follow-up period (median -36° at 20 years [-40° to -29°]). Patients with a large preoperative posterior PT shift from supine to standing demonstrated larger posterior tilt of Δ standing at 20 years. Patients with lumbar vertebral fractures during follow-up demonstrated larger posterior tilt of Δ standing at 20 years.

CONCLUSION

Patients who demonstrate a large preoperative posterior shift from supine to standing deserve special consideration when undergoing THA. In such circumstances, we recommend that the anteversion of the cup not be excessive, given that there is a relatively high risk of further posterior tilt in PT, which may lead to anterior dislocation and edge loading. Further longitudinal study in a larger cohort of patients with complications including postoperative dislocation and revision, as well as older patients, is needed to verify these assumptions on the potential risk for dislocation and edge loading after THA.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Comparing dislocation rates by approach following elective primary dual mobility total hip arthroplasty: a systematic review

BACKGROUND

Dual mobility components can be implanted during total hip arthroplasty (THA) for primary osteoarthritis via a direct anterior approach (DAA), anterolateral approach (ALA), direct lateral approach (DLA), or posterior/posterolateral approach (PLA). This review compares dual mobility hip dislocation rates using these approaches for elective primary THA.

METHODS

PubMed, Embase, and Cochrane databases were systematically searched for articles published after January 1, 2006 that reported dislocation rates for adult patients after primary THA with dual mobility implants. Articles were excluded if they reported revision procedures, nonelective THA for femoral neck fractures, acetabular defects requiring supplemental implants, prior surgery, or ≤ 5 patients. The primary outcome was hip dislocation rate. Secondary outcomes included infection, Harris Hip Score (HHS), and Postel-Merle d'Aubigné (PMA) score.

RESULTS

After screening 542 articles, 63 met inclusion criteria. Due to study heterogeneity, we did not perform a meta-analysis. Eight studies reported DAA, 5 reported ALA, 6 reported the DLA, and 56 reported PLA. Study size ranged from 41 to 2,601 patients. Mean follow-up time ranged from 6 months to 25 years. Rates of infection and dislocation were low; 80% of ALA, 87.5% of DAA, 100% of DLA, and 82.1% of PLA studies reported zero postoperative dislocations. Studies reporting postoperative HHS and PMA scores showed considerable improvement for all approaches.

CONCLUSIONS

Patients undergoing primary THA with dual mobility implants rarely experience postoperative dislocation, regardless of surgical approach. Additional studies directly comparing DAA, ALA, DLA, and PLA are needed to confirm these findings.

Approaches for Total Hip Arthroplasty: A Systematic Review

These surgical procedures have their own challenges, limitations, and success rate. The choice of surgical approach will depend on many factors including the surgeon's choice, type of pathology, bone stock, age of the patient, and experience of the surgeon. Whichever approach is used for total hip arthroplasty (THA), the primary goals of the surgery would be pain relief and enhancement in the quality of the patient's life suffering from hip pathologies. To further understand the advantages and potential pitfalls associated with different surgical approaches, we conducted a review study comparing different surgical approaches for THA in terms of their clinical and functional outcomes. All the studies done on surgical approaches used in THA published articles in the English language and from 2015 onward were included in the review. The databases searched were COCHRANE, MEDLINE, PEDRO, CINHAL, etc. Search engines that were searched were Google Scholar, Pub Med, and Science Direct. As per the inclusion criteria, out of 50 studies, 26 studies were included in the study which underwent critical analysis. Considering all the factors reviewed from the literature, the posterior approach or posterolateral approach is optimally beneficial.

Arthroscopic iliopsoas tenotomy after total hip arthroplasty: safe method for the right patient

PURPOSE

To evaluate the outcome of arthroscopic treatment for iliopsoas impingement after total hip arthroplasty (THA) 2 years after surgery using patient reported outcomes (PROM).

METHODS

In this study 12 patients (13 hips) were included from a local hip arthroscopy registry. Patients completed web-based PROMs preoperatively and at a minimum of 2 years postoperatively. The PROMs included the International Hip Outcome Tool short version (iHOT-12), the Copenhagen Hip and Groin Outcome Score (HAGOS), the European Quality of Life-5 Dimensions Questionnaire (EQ-5D), the Hip Sports Activity Scale (HSAS) for physical activity level, the Visual Analog Scale (VAS) for overall hip function and a single question regarding overall satisfaction with the surgery.

RESULTS

The mean age was 64.4 years (±15.1SD), mean body mass index (BMI) was 26.6 (±4.3SD), mean follow-up time was 49.8 months (±25SD). Comparing PROMs preoperatively with 2-year follow up showed an improvement for many of the PROMs used. The PROMs scores were iHOT-12 (24.9 vs 34.5, p = 0.13), HAGOS subscales (symptoms 38.2 vs 54.5, p = 0.05; pain 36 vs 53, p = 0.04; sport 14.1 vs 35.1, p = 0.03; daily activity 31 vs 47.5, p = 0.04; physical activity 21.8 vs 24, p = 0.76; quality of life 24 vs 35, p = 0.03), EQ-VAS (57.9 vs 58, p = 0.08), EQ-5D (0.34 vs 0.13, p = 0.07) and VAS for overall hip function (43.1 vs 46.2, p = 0.14). In total, 10 out of the 12 patients (83%) were satisfied with the intervention.

CONCLUSION

Patients undergoing surgery for iliopsoas impingement after previous THA showed improved self-reported hip function where most patients were satisfied with treatment.

A propensity score-matched analysis on the impact of patient and surgical factors on early periprosthetic joint infection in minimally invasive anterolateral and transgluteal total hip arthroplasty

INTRODUCTION

Increased risk of periprosthetic joint infection (PJI) in minimally invasive (MIS) total hip arthroplasty (THA) is still debated. This study aimed to identify differences in surgical and patient-related risk factors for PJI between an MIS anterolateral approach and transgluteal-modified Hardinge approach.

METHODS

A retrospective cohort of 5315 THAs performed between 2006 and 2019 at a single institution was screened. Short stem THAs performed via an MIS anterolateral approach in the supine position and standard straight stem THAs performed via a transgluteal modified Hardinge approach were included. Propensity score matching was performed to control for selection bias. After matching, 1405 (34.3%) short stem THAs implanted via MIS anterolateral approach and 2687 (65.7%) straight stem THAs implanted via a transgluteal modified Hardinge approach were included. The risk of PJI due to patient-specific and surgical factors was retrospectively analyzed using chi-square test and multivariate regression analysis.

RESULTS

PJI occurred in 1.1% in both MIS anterolateral and transgluteal approach (p = 0.823). Multivariate regression showed an increased infection risk for patients with a BMI between 35 and 39.99 kg/m² (OR 6.696; CI 1.799-24.923; p = 0.005), which could not be demonstrated for transgluteal approach (OR 0.900; CI 0.900-4.144; p = 0.93). A BMI ≥ 40 kg/m² (OR 14.150; CI 2.416-82.879; p = 0.003) was detected as a risk factor for PJI only in anterolateral approach. Increased operation time ≥ 121 min showed a significantly increased risk for PJI in the general cohort (OR 6.989; CI1.286-37.972; p = 0.024).

CONCLUSION

Minimally invasive anterolateral and transgluteal THA show a comparable rate of early PJI within the first year of index surgery. A BMI of ≥ 35 kg/m² was detected as a clear risk factor for infection in the anterolateral approach. Prolonged operation time ≥ 121 min increases the risk of PJI regardless of approach.

Does Surgical Approach to the Hip Play a Role in Same-Day Discharge Outcomes?

BACKGROUND

Different approaches for total hip arthroplasty (THA) may offer advantages in regard to achieving same-day-discharge (SDD) success.

METHODS

We retrospectively identified patients aged ≥ 18 years who underwent elective primary THA from 2015 to 2020 who were formally enrolled in a single institution's SDD program. A total of 1,127 and 207 patients underwent THA via direct anterior approach and posterior approach, respectively, were included. Cohorts were assigned based on approach. The primary outcome was failure-to-launch, defined as hospital stay extending past 1 midnight. Secondary outcomes included Forgotten Joint Score-12, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, 90-day readmission and revision rate, and surgical time. Patient-reported outcomes were collected at 3 and 12 months.

RESULTS

After controlling for demographic differences, posterior approach patients had higher rates of failure-to-launch (12.1% versus 5.9%, P = .002) and longer surgical times (99 versus 80 minutes; P < .001) compared to direct anterior approach patients. The cohorts had similar readmission (1.7% versus 1.4%; P = .64) and revision rates (1% versus 1%; P = .88). The magnitude of improvement in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement scores from preoperative to 12 months was similar between cohorts (35.3 versus 34.5; P = .42). The differences in outcome scores between cohorts at each time point were not considered clinically significant.

CONCLUSION

Our analysis suggests that patient selection and surgical approach may be important for achieving SDD. Surgical approach did not significantly impact readmission or revision rates nor did it have a meaningful impact on patient-reported outcomes in the first year after surgery.

A new minimal-invasive approach for total hip replacement in sheep

BACKGROUND

Over the last 50 years arthroplasty became the gold-standard treatment for disabling conditions of the coxofemoral joint. Variations of anterior, lateral, and dorsal incision have been applied, but as each approach requires the incision and reflection of various muscles to gain adequate exposure of the joint results are still controversial.

OBJECTIVE

The purpose of this study was to develop a minimal-invasive, tissue-sparing approach in sheep with reduced risks in animal testing.

METHODS

12 mature sheep underwent hip surgery as part of a study to evaluate a hip resurfacing system. In line with the preliminary cadaveric tests a modified, minimal-invasive, musclepreserving surgical approach was sought after.

RESULTS

We developed a surgical approach to the coxofemoral joint in sheep using only blunt tissue dissection after skin incision without any limitations in joint exposure or increased blood loss/duration of surgery.

CONCLUSION

Even though limitations occur and femoral orientation in sheep differs from man, joint forces have similar relative directions to the bone with similar bony and vascular anatomy. Therefore, this minimal-invasive muscle preserving approach might be a safe and comparable alternative in still inevitable animal testing.

Blood management in direct anterior versus posterior primary total hip arthroplasty using tranexamic acid: a matched cohort study

INTRODUCTION

Proponents of the direct anterior approach (DAA) for THA claim patients recover faster compared to primary THA through the posterior approach (PA). Blood loss and transfusion have substantially declined with the use of tranexamic acid (TXA). However, it is still controversial if hemoglobin drops and transfusion rates are affected by the surgical approach when TXA is routinely used.

MATERIALS AND METHODS

2418 patients undergoing DAA THA were matched 1:1 with patients undergoing PA THA according to preoperative hemoglobin (± 1 g/dl), age (± 5 years), sex, BMI (± 5 kg/m2) and year of surgery (± 2 years). All patients received perioperative TXA. None of the patients donated autologous blood. Hemoglobin levels, drain placement and output, blood transfusion rates and volume as well as length of stay were recorded.

RESULTS

A closed suction drain was used in 121 (5.0%) DAA and in 135 (5.6%) PA THAs (p = 0.369). Mean drain output was higher in the DAA compared to the PA group (134 ml (0-520 ml) versus 92.3 ml (0-600 ml), p = 0.004). There was no difference in hemoglobin drop [2.6 g/dl versus 2.6 g/dl (p = 0.143)] and transfusion rate [n = 31 (1.3%) versus n = 29 (1.2%), p = 0.793)] between DAA and PA THA. Mean transfusion amounts were 421.8 ml (250-1120.8 ml) in the DAA and 353.9 ml (250-560 ml) in the PA group (p = 0.801). The length of stay was shorter in the DAA group with a mean 1.6 days versus 2.1 days in the PA group (p ≤ 0.001).

CONCLUSION

In this large matched cohort study, there was no difference in the perioperative hemoglobin drop, the transfusion rate and the transfusion amount between DAA and PA THA.

Morselized bone autograft for high placement of acetabular component closure with hip arthroplasty revision after 3-years screws and cup loosening: A case report

INTRODUCTION AND IMPORTANCE

Aseptic loosening in high placement of the acetabular component seriously affects the hip and femoral head loads. Surgery revision is highly recommended with defect closure in previous place.

CASE PRESENTATION

A-40-year-old man came with chief complaint of right groin pain and noticeable leg length discrepancy gait. The first hip arthroplasty through pseudo-acetabulum cup was done three years ago after neglected femoral head necrosis due to eight years of unknown hip dislocation in vehicle accident. On hip x-ray there is a screws and cup loosening, without any sign of infection from blood or from soft tissue which undergoes pathological and mold examination. The patient than assessed with periprosthetic aseptic loosening of hip dextra and simple total hip arthroplasty revision using true acetabulum location was done. The pseudo-acetabulum area closed with morselized bone autograft. One weeks after surgery, the wound healed properly. Hence, the patient sent to the rehabilitation.

CLINICAL DISCUSSION

Hip arthroplasty revision of aseptic loosening in high placement acetabular component should perform by returning to anatomical acetabular position. Cancellous morselized bone autograft (MBA) was used to closed the defect formed by previous procedure.

CONCLUSION

Revision of hip arthroplasty combined with morselized bone autograft can be considered for high placement acetabular component defect closure to provide better stability and strength in weight loads transfer.

[Postoperative imaging of the hip]

CLINICAL ISSUE

To assess postoperative imaging of the hip joint regarding possible complications, it is indispensable to have in-depth knowledge of commonly used surgical techniques, access routes, and the implanted materials.

STANDARD RADIOLOGICAL METHODS

While radiography is used to evaluate the position of foreign material and to rule out periprosthetic fractures that have occurred intraoperatively, follow-up examinations might show signs of material failure, aseptic loosening, prosthesis infections, or the occurrence of heterotopic ossifications. If radiographic findings are ambiguous, computed tomography (CT) may be used to clarify findings, whereas magnetic resonance imaging (MRI) is helpful to identify intra- and periarticular soft tissue pathologies such as surgery-associated cartilage and ligament damage, muscle insufficiency, or metallosis.

METHODOLOGICAL INNOVATION AND EVALUATION

To guide clinical decision making in common postoperative complications, various classification systems are available, e.g., for periprosthetic fractures, aseptic loosening, or heterotopic ossification. However, the differentiation between aseptic material loosening and septic endoprosthesis infection remains challenging if based on imaging alone.

PRACTICAL RECOMMENDATIONS

The assessment of postoperative hip imaging should be closely linked to the respective surgical technique and the implanted foreign material, whereby different probabilities of specific complications can be derived.

Periprosthetic joint infection rates across primary total hip arthroplasty surgical approaches: a systematic review and meta-analysis of 653,633 procedures

INTRODUCTION

Evidence demonstrates comparable clinical outcomes across the various surgical approaches to primary total hip arthroplasty (THA). However, high-quality contemporary data regarding periprosthetic joint infection (PJI) risk between direct anterior approach (DAA) and other (THA) approaches is lacking. This systematic review and meta-analysis evaluated PJI rates reported in the literature between the DAA and other approaches.

MATERIALS AND METHODS

Five online databases were queried for all studies published from January 1st, 2000 through February 17th, 2021 that reported PJI rates between DAA and other surgical approaches. Studies reporting on primary THAs for osteoarthritis (OA) and that included PJI rates segregated by surgical approach were included. Articles reporting on revision THA, alternative THA etiologies, or minimally invasive techniques were excluded. Mantel-Haenszel (M-H) models were utilized to evaluate the pooled effect of surgical approach on infection rates. Validated risk of bias and methodological quality assessment tools were applied to each study. Multiple sensitivity analyses were conducted to evaluate the robustness of analyses.

RESULTS

28 articles reporting on 653,633 primary THAs were included. No differences were found between DAA cohorts and combined other approaches (OR: 0.95; 95% CI 0.74-1.21; p = 0.67) as well as segregated anterolateral approach cohorts (OR: 0.82, 95% CI 0.64-1.06; p = 0.13). However, DAA patients had a significantly reduced risk of infection compared to those undergoing posterior (OR: 0.66, 95% CI 0.58-0.74; p < 0.0001) and direct lateral (OR: 0.56, 95% CI 0.48-0.65; p < 0.00001) approaches.

CONCLUSION

The DAA to primary THA had comparable or lower PJI risk when compared to other contemporary approaches. The results of the most up-to-date evidence available serve to encourage adult reconstruction surgeons who have already adopted the DAA. Additionally, orthopaedic surgeons considering adoption or use of the direct anterior approach for other reasons should not be dissuaded over theoretical concern for a general increase in the risk of PJI.

LEVEL OF EVIDENCE

Level III.

A Comparison of Revision Rates and Dislocation After Primary Total Hip Arthroplasty with 28, 32, and 36-mm Femoral Heads and Different Cup Sizes: An Analysis of 188,591 Primary Total Hip Arthroplasties

This article was updated on August 17, 2022, because of previous errors, which were discovered after the preliminary version of the article was posted online. On page 1462, in the first sentence of the Abstract section entitled "Results," the phrase that had read "and 36-mm heads had fewer dislocations than 28-mm (HR = 0.33 [95% CI, 0.16 to 0.68]; p = 0.003), but more dislocations than 32-mm heads (HR for >2 weeks = 2.25 [95% CI, 1.13 to 4.49]; p = 0.021)" now reads "and 36-mm heads had fewer dislocations than 28-mm (HR = 0.33 [95% CI, 0.16 to 0.68]; p = 0.003) and 32-mm heads (HR for ≥2 weeks = 0.44 [95% CI, 0.22 to 0.88]; p = 0.021)." On page 1468, in the last sentence of the section entitled "Acetabular Components with a Diameter of <51 mm," the phrase that had read "and HR for ≥2 weeks = 2.25 [95% CI, 1.13 to 4.49; p = 0.021]) ( Fig. 3 )" now reads "and HR for ≥2 weeks = 0.44 [95% CI, 0.22 to 0.88; p = 0.021]) ( Fig. 3 )." Finally, on page 1466, in the upper right corner of Figure 3 , under "32mm vs 36mm," the second line that had read "2Wks+: HR=2.25 (1.13, 4.49), p=0.021" now reads "2Wks+: HR=0.44 (0.22, 0.88), p= 0.021."

Is the Direct Anterior Approach to THA Cost-effective? A Markov Analysis

BACKGROUND

The use of the direct anterior approach, a muscle-sparing technique for THA, has increased over the years; however, this approach is associated with longer procedure times and a more expensive direct cost. Furthermore, studies have shown a higher revision rate in the early stages of the learning curve. Whether the clinical advantages of the direct anterior compared with the posterior approach-such as less soft tissue damage, decreased short-term postoperative pain, a lower dislocation rate, decreased length of stay in the hospital, and higher likelihood of being discharged home-outweigh the higher cost is still debatable. Determining the cost-effectiveness of the approach may inform its utility and justify its use at various stages of the learning curve.

QUESTIONS/PURPOSES

We used a Markov modeling approach to ask: (1) Is the direct anterior approach more likely to be a cost-effective approach than the posterior approach over the long-term for more experienced or higher volume hip surgeons? (2) How many procedures does a surgeon need to perform for the direct anterior approach to be a cost-effective choice?

METHODS

A Markov model was created with three health states (well-functioning THA, revision THA, and death) to compare the cost-effectiveness of the direct anterior approach with that of the posterior approach in five scenarios: surgeons who performed one to 15, 16 to 30, 31 to 50, 51 to 100, and more than 100 direct anterior THAs during a 6-year span. Procedure costs (not charges), dislocation costs, and fracture costs were derived from published reports, and model was run using two different cost differentials between the direct anterior and posterior approaches (USD 219 and USD 1800, respectively). The lower cost was calculated as the total cost differential minus pharmaceutical and implant costs to account for differences in implant use and physician preference regarding postoperative pain management. The USD 1800 cost differential incorporated pharmaceutical and implant costs. Probabilities were derived from systematic review of the evidence as well as from the Australian Orthopaedic Association National Joint Replacement Registry. Utilities were estimated from best available literature and disutilities associated with dislocation and fracture were incorporated into the model. Quality of life was expressed in quality-adjusted life years (QALYs), which are calculated by multiplying the utility of a health state (ranging from 0 to 1) by the duration of time in that health state. The primary outcome measure was the incremental cost-effectiveness ratio, or the change in costs divided by the change in QALYs when the direct anterior approach was used for THA. USD 100,000 per quality-adjusted life years was used as a threshold for willingness to pay. One-way and probabilistic sensitivity analyses were performed for the scenario in which the direct anterior approach is cost-effective to further account for uncertainty in model inputs.

RESULTS

At a cost differential of USD 219 (95% CI 175 to 263), the direct anterior approach was associated with lower cost and higher effectiveness compared with the posterior approach for surgeons with an experience level of more than 100 operations during a 6-year span. At a cost differential of USD 1800 (95% CI 1440 to 2160), the direct anterior approach remained a cost-effective strategy for surgeons who performed more than 100 operations. At both cost differentials, the direct anterior approach was not cost-effective for surgeons who performed fewer than 100 operations. One-way sensitivity analyses revealed the model to be the most sensitive to fluctuations in the utility of revision THA, probability of revision after the posterior approach THA, probability of dislocation after the posterior approach THA, fluctuations in the probability of dislocation after direct anterior THA, cost of direct anterior THA, and probability of intraoperative fracture with the direct anterior approach. At the cost differential of USD 219 and for surgeons with a surgical experience level of more than 100 direct anterior operations, the direct anterior approach was still the cost-effective strategy for the entire range of values.

CONCLUSION

For high-volume hip surgeons, defined here as surgeons who perform more than 100 procedures during a 6-year span, the direct anterior approach may be a cost-effective strategy within the limitations imposed by our analysis. For lower volume hip surgeons, performing a more familiar approach appears to be more cost-effective.

Activities and participation after primary total hip arthroplasty; posterolateral versus direct anterior approach in 860 patients

BACKGROUND AND PURPOSE

In the past decade, a shift occurred in surgical total hip arthroplasty (THA) approaches to the posterolateral (PLA) and direct anterior approach (DAA). Comparisons of postoperative activities and participation between surgical approaches for THA are sparse. We therefore investigated the association between PLA and DAA for THA regarding the construct "activity and participation" (ICF model) during the first postoperative year.

PATIENTS AND METHODS

This was an observational cohort study on osteoarthritis patients scheduled for primary THA in 2 hospitals. Questionnaires to assess the ICF domain "activity and participation" were completed preoperatively, and 3, 6, and 12 months postoperatively (HOOS Activities of daily living (ADL) and Sport and Recreation Function (SR), Hospital for Special Surgery Hip Replacement Expectations Survey, and questions regarding return to work). Each hospital exclusively performed one approach (PLA [Alloclassic-Zweymüller stem] or DAA [Taperloc Complete stem]) for uncemented THA. Hospital was included as instrumental variable, thereby addressing bias by (un)measured confounders. Adjusted mixed-effect models were used, stratified by employment.

RESULTS

Total population: 238 PLA (24% employed) and 622 DAA (26% employed) patients. At 12 months, the PLA group had a lower ADL score (-7, 95% CI -12 to -2 points). At 6 months, significantly fewer PLA patients had fulfillment of the expectation sports-performance (OR = 0.3, CI 0.2-0.7]. Other outcomes were comparable. Employed population: At 6 and 12 months, PLA patients scored clinically lower on ADL (respectively -10, CI -19 to 0 and -9, CI -19 to 0 points) and SR (respectively -13, CI -21 to -4 and -9, CI -18 to -1 points). At 6 months, fewer PLA patients fulfilled the expectation joining recreational activities (OR = 0.2, CI 0.1-0.7]. Fulfillment of other expectations was comparable between groups. PLA patients less often returned to work within 3 months (31% vs. 45%), but rates were comparable at 12 months (86% vs. 87%).

INTERPRETATION

Overall, functional recovery regarding "activity and participation" was comparable for PLA and DAA. Among employed patients, DAA resulted in better functional recovery and more fulfillment of expectations compared with PLA patients. DAA might also facilitate faster return to work.

Current Trends in Revision Hip Arthroplasty: Indications and Types of Components Revised

BACKGROUND

The materials and techniques for both primary and revision total hip arthroplasty (THA) have changed over time. This study evaluated if the indications for revision THA, rates of components utilized (femoral or acetabulum, both, or head/liner exchange), length of stay (LOS), and payments to surgeons and facilities have also changed.

METHODS

A retrospective study, utilizing the PearlDiver database, of 38,377 revision THA patients from January 2010 through December 2018 was performed. Data included the indication for revision, components revised (femoral or acetabulum, both, or head/liner exchange), LOS, and payments. Indications and components were analyzed by logistic regression (Dunnett's post hoc test). Revision totals were analyzed with a linear regression model. Analysis of variance assessed changes in LOS and payments.

RESULTS

Patients' median age was 67 years (Q1-Q3: 59-74), and 58.7% were female. Revisions for dislocation decreased between 2010 and 2018 (odds ratio [OR] 0.82, 95% confidence interval [CI] 0.68-0.98). Revisions for component loosening increased (OR 1.54, 95% CI 1.25-1.91). Dislocation remained the most common indication (19.3%), followed by PJI (17.3%) and loosening (17.1%). Both-component (OR:1.45; 95% CI:1.25-1.67) and femoral component only revisions increased; acetabular component only and head/liner exchanges decreased. Acetabular (OR 0.57, 95% CI 0.47-0.70) and head/liner exchange (OR 0.29, 95% CI 0.20-0.43) revisions decreased, while both component exchange (OR 1.45, 95% CI 1.25-1.67) and femoral revisions (OR 1.17, 95% CI 0.99-1.37) increased. Average LOS (-0.68 days; P < .001) and surgeon payments decreased (-$261.8; P < .001) while facility payments increased ($4,211; P < .001).

CONCLUSION

Indications for revision THA in this database study changed over time, with revision for dislocation decreasing and revision for loosening increasing over time. Both component and femoral revisions increased, and acetabular component and head/liner exchanges decreased. It is possible that these associations could be attributed to a number of details, the method of femoral fixation, surgical approach, and cementing, all of which require additional study.

Liner Dissociation and Acetabular Erosion Treated by Implant Retention and Dual-Mobility Liner Cementation: A Case Report

CASE

A 56-year-old woman underwent a left total hip arthroplasty (THA) after developing avascular necrosis after chemotherapeutic treatment of breast cancer. She presented approximately 2 years after index THA with left groin pain and complaints of instability. Imaging revealed pseudodislocation of the ceramic femoral head with erosion through the acetabular component. Intraoperative evaluation revealed a dissociated polyethylene liner, damaged acetabular locking mechanism, metallosis, and well-fixed and aligned components. Treatment consisted of component retention, bone grafting, and dual-mobility liner cementation into the acetabular component.

CONCLUSIONS

The two-year follow-up demonstrated a pain-free, well-functioning hip, bone graft incorporation, and no evidence of loosening.

In Revision THA, Is the Re-revision Risk for Dislocation and Aseptic Causes Greater in Dual-mobility Constructs or Large Femoral Head Bearings? A Study from the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

Dislocation is one of the most common causes of a re-revision after a revision THA. Dual-mobility constructs and large femoral head bearings (≥ 36 mm) are known options for mitigating this risk. However, it is unknown which of these choices is better for reducing the risk of dislocation and all-cause re-revision surgery. It is also unknown whether there is a difference between dual-mobility constructs and large femoral head bearings according to the size of the acetabular component.

QUESTIONS/PURPOSES

We used data from a large national registry to ask: In patients undergoing revision THA for aseptic causes after a primary THA performed for osteoarthritis, (1) Does the proportion of re-revision surgery for prosthesis dislocation differ between revision THAs performed with dual-mobility constructs and those performed with large femoral head bearings? (2) Does the proportion of re-revision surgery for all aseptic causes differ between revision THAs performed with dual-mobility constructs and those performed with large femoral head bearings? (3) Is there a difference when the results are stratified by acetabular component size?

METHODS

Data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) were analyzed for 1295 first-revision THAs for aseptic causes after a primary THA performed for osteoarthritis. The study period was from January 2008-when the first dual-mobility prosthesis was recorded-to December 2019. There were 502 dual-mobility constructs and 793 large femoral head bearings. There was a larger percentage of women in the dual-mobility construct group (67% [334 of 502]) compared with the large femoral head bearing group (51% [402 of 793]), but this was adjusted for in the statistical analysis. Patient ages were similar for the dual-mobility construct group (67 ± 11 years) and the large femoral head group (65 ± 12 years). American Society of Anesthesiologists (ASA) class and BMI distributions were similar. The mean follow-up was shorter for dual-mobility constructs at 2 ± 1.8 years compared with 4 ± 2.9 years for large femoral head bearings. The cumulative percent revision (CPR) was determined for a diagnosis of prosthesis dislocation as well as for all aseptic causes (excluding infection). Procedures using metal-on-metal bearings were excluded. The time to the re-revision was described using Kaplan-Meier estimates of survivorship, with right censoring for death or database closure at the time of analysis. The unadjusted CPR was estimated each year of the first 5 years for dual-mobility constructs and for each of the first 9 years for large femoral head bearings, with 95% confidence intervals using unadjusted pointwise Greenwood estimates. The apparent shorter follow-up of the dual-mobility construct group relates to the more recent increase in dual-mobility numbers recorded in the registry. The results were adjusted for age, gender, and femoral fixation. Results were subanalyzed for acetabular component sizes < 58 mm and ≥ 58 mm, set a priori on the basis of biomechanical and other registry data.

RESULTS

There was no difference in the proportion of re-revision for prosthesis dislocation between dual-mobility constructs and large femoral head bearings (hazard ratio 1.22 [95% CI 0.70 to 2.12]; p = 0.49). At 5 years, the CPR of the re-revision for prosthesis dislocation was 4.0% for dual mobility constructs (95% CI 2.3% to 6.8%) and 4.1% for large femoral head bearings (95% CI 2.7% to 6.1%). There was no difference in the proportion of all aseptic-cause second revisions between dual-mobility constructs and large femoral head bearings (HR 1.02 [95% CI 0.76 to 1.37]; p = 0.89). At 5 years, the CPR of dual-mobility constructs was 17.6% for all aseptic-cause second revision (95% CI 12.6% to 24.3%) and 17.8% for large femoral head bearings (95% CI 14.9% to 21.2%). When stratified by acetabular component sizes less than 58 mm and at least 58 mm, there was no difference in the re-revision CPR for dislocation or for all aseptic causes between dual-mobility constructs and large femoral head bearings.

CONCLUSION

Either dual-mobility constructs or large femoral head bearings can be used in revision THA, regardless of acetabular component size, as they did not differ in terms of re-revision rates for dislocation and all aseptic causes in this registry study. Longer term follow-up is required to assess whether complications develop with either implant or whether a difference in revision rates becomes apparent. Ongoing follow-up and comparison in a registry format would seem the best way to compare long-term complications and revision rates. Future studies should also compare surgeon factors and whether they influence decision-making between prosthesis options and second revision rates. Nested randomized controlled trials in national registries would seem a viable option for future research.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Opioid Use Consequences, Governmental Strategies, and Alternative Pain Control Techniques Following Total Hip Arthroplasties

Over the last several decades, rates of opioid use and associated problems have dramatically increased in the United States leading to laws limiting prescription duration for acute pain management. As a result, orthopedic surgeons who perform total hip arthroplasty (THA), a procedure that often leads to significant postoperative pain, have been faced with substantial challenges to adequately mitigate patient pain while also reducing opioid intake. Current strategies include identifying and correcting modifiable risk factors associated with postoperative opioid use such as preoperative opioid use, alcohol and tobacco abuse, and untreated psychiatric illness. Additionally, recent evidence has emerged in the form of Enhanced Recovery After Surgery (ERAS) protocols suggesting that a multidisciplinary focus on patient factors perioperatively can lead to reduced postoperative opioid administration and decreased hospital stays. A cornerstone of ERAS protocols includes multimodal pain regimens with opioid rescue only as needed, which often includes multiple systemic pain therapies such as acetaminophen, gabapentin, non-steroidal anti-inflammatory drugs, as well as targeted pain therapies that include epidural catheters and ultrasound-guided nerve blocks. Many hospital systems and states have also implemented opioid prescribing limitations with mixed success. As the opioid epidemic continues in the United States, while contributing to poor outcomes following elective surgeries, further research is warranted to identify multidisciplinary strategies that mitigate opioid use while also allowing for adequate pain control and rehabilitation.

Minimally invasive anterolateral approach versus direct anterior approach total hip arthroplasty in the supine position: a prospective study based on early postoperative outcomes

BACKGROUND

Minimally anterolateral approach (MAA) and direct anterior approach (DAA) have been reported as beneficial for total hip arthroplasty (THA) due to their ability to reduce postoperative pain and lead to quicker rehabilitation by preserving muscle insertions. As there is an ongoing debate on the effect of these two approaches on early postoperative outcomes, this prospective study aimed to assess the difference in early clinical, radiological, and patient-reported outcomes between the two minimally invasive approaches.

METHODS

A total of 98 patients, 50 in the MAA group and 48 in the DAA group, were included in the study. Patients with complete data were evaluated preoperatively and postoperatively at 2, 6, and 12 weeks. Clinical measurements, including the ability to climb stairs and walk, 6-min walk test (6MWT), the Forgotten Joint Scale (FJS-12), Japanese Orthopedic Association (JOA) Hip scores, radiological evaluation, and complications were analyzed.

RESULTS

There were no significant differences in clinical outcomes and implant alignments between MAA and DAA groups. In regards to patient-reported outcomes, the FJS-12 was significantly higher in the MAA group compared to group DAA at 2 and 6 weeks postoperatively. However, there was no significant difference in the FJS-12 between the two groups 12 weeks after surgery. The differences also included shorter operative times (62.4 ± 9.05 min vs. 71 ± 8.01 min), less blood loss (132.6 ± 43.31 ml vs. 159.23 ± 37.25 ml), lower Hb drop (29.56 ± 8.02 g/L vs. 36.4 ± 7.12 g/L), and fewer blood transfusions in the MAA group (4.0% vs. 18.8%). The incidence of the lateral femoral cutaneous nerve (LFCN) neuropraxia after surgery was 7 (14.6%) in the DAA group and 0 in the MAA group. One fracture was found in each group and managed conservatively.

CONCLUSION

MAA and DAA approach yielded excellent and similar early clinical outcomes. However, better patient-reported outcomes could be achieved by MAA THA. The MAA resulted in a safer approach associated with shorter operative times, less blood loss, lower Hb drop, fewer blood transfusions, and LFCN neuropraxia than DAA. A longer follow-up is needed to further examine differences between these procedures.