Which implant should we use for primary total hip replacement? A systematic review and meta-analysis

Validating Orthopaedic Data Evaluation Panel (ODEP) Ratings Across 9 Orthopaedic Registries: Total Hip Implants with an ODEP Rating Perform Better Than Those without an ODEP Rating

BACKGROUND

Orthopaedic Data Evaluation Panel (ODEP) ratings of total hip (TH) and total knee (TK) implants are informative for assessing implant performance. However, the validity of ODEP ratings across multiple registries is unknown. Therefore, we aimed to assess, across multiple registries, whether TH and TK implants with a higher ODEP rating (i.e., an A* rating) have lower cumulative revision risks (CRRs) than those with a lower ODEP rating (i.e., an A rating) and the extent to which A* and A-rated implants would be A*-rated on the basis of the pooled registries' CRR.

METHODS

Implant-specific CRRs at 3, 5, and 10 years that were reported by registries were matched to ODEP ratings on the basis of the implant name. A meta-analysis with random-effects models was utilized for pooling the CRRs. ODEP benchmark criteria were utilized to classify these pooled CRRs.

RESULTS

A total of 313 TH cups (54%), 356 TH stems (58%), 218 TH cup-stem combinations (34%), and 68 TK implants (13%) with unique brand names reported by registries were matched to an ODEP rating. Given the low percentage that matched, TK implants were not further analyzed. ODEP-matched TH implants had lower CRRs than TH implants without an ODEP rating at all follow-up time points, although the difference for TH stems was not significant at 5 years. No overall differences in CRRs were found between A* and A-rated TH implants, with the exception of TH cup-stem combinations, which demonstrated a significantly lower CRR for A*A*-rated cup-stem combinations at the 3-year time point. Thirty-nine percent of A*-rated cups and 42% of A*-rated stems would receive an A* rating on the basis of the pooled registries' CRR at 3 years; however, 24% of A-rated cups and 31% of A-rated stems would also receive an A* rating, with similar findings demonstrated at longer follow-up.

CONCLUSIONS

At all follow-up time points, ODEP-matched TH implants had lower CRRs than TH implants without an ODEP rating. Given that the performance of TH implants varied across countries, registries should first validate ODEP ratings with use of country-specific revision data to better guide implant selection in their country. Data source transparency and the use of revision data from multiple registries would strengthen the ODEP benchmarks.

LEVEL OF EVIDENCE

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

Restoration of hip geometry after total hip arthroplasty: retrospective comparison of two short stems and one straight stem

BACKGROUND

The preservation or restoration of hip geometry following total hip arthroplasty (THA) is of importance, considering that alterations in the centrum-collum-diaphysis (CCD)-angle, femoral offset (FO), acetabular offset (AO) and total offset (TO) change hip biomechanics. Therefore, the most suitable implant should be used. The aim of this study was to compare the ability of two short-stem-systems and one straight-stem-system to reconstruct hip geometry.

METHODS

Two-hundred-fifty-one patients (mean age: 62.0 ± 10.0 years; 51.8% males) undergoing THA with three different stem types were retrospectively included, after excluding 11 patients with missing radiological follow-up. Pre- and postoperative radiographic images (group I, ANA.NOVA Alpha Schaft Proxy®, ImplanTec, 12 options: n = 99; group II, Optimys® Mathys, 24 options: n = 62; group III: Corail®-System, DePuy-Synthes, 76 options: n = 90) were analyzed. Differences in pre- and postoperative hip geometry (i.e. CCD, FO, AO, TO) were compared between groups with one-way-analysis-of-variance (ANOVA), and post-hoc t-tests.

RESULTS

The CCD-angle increased by a mean of 8.4° ± 7.2° from pre-to postoperative, with no significant difference between groups (p = 0.097). Significantly larger increases in FO were observed for groups II (4.1 mm ± 7.8 mm) and III (4.9 ± 7.2 mm), in comparison to group I (1.6 ± 6.9 mm; p = 0.006). AO decreased by a mean of 2.2 ± 4.5 mm, with the largest decrease observed in group III (-3.3 ± 5.3 mm), and the smallest for group I (-1.4 ± 3.6 mm; p = 0.011). There was no significant difference in change of TO between groups (p = 0.177).

CONCLUSIONS

Reconstruction of hip geometry using a single-version novel short-stem-system is achievable with comparable results to stem-systems offering multiple options.

How to Prevent Aseptic Loosening in Cementless Arthroplasty: A Review

Aseptic loosening is the main late postoperative complication of cementless total hip arthroplasties (THAs), leading to pain and functional impairment. This article aims to update the orthopedic surgeon on the various methods by which the aseptic loosening rate can be reduced. We performed a systematic review by searching the PubMed database for hip aseptic loosening. We included meta-analysis, randomized controlled trials, reviews, and systematic reviews in the last 10 years, which provided information on techniques that can prevent aseptic loosening in total hip arthroplasty. From a total of 3205 articles identified, 69 articles (2%) met the inclusion criteria, leading to a total of 36 recommendations. A lot of research has been conducted in terms of septic loosening in the last decade. Currently, we have various techniques by which we can reduce the rate of aseptic loosening. Nevertheless, further randomized clinical trials are needed to expand the recommendations for aseptic loosening prevention.

Mid-Term Results After 517 Primary Total Hip Arthroplasties With a Shortened and Shoulderless Double-Taper Press-Fit Stem: High Rates of Aseptic Loosening

BACKGROUND

Shorter double-taper stems with reduced lateral shoulders facilitate implantation via the muscle-sparing direct anterior approach and are becoming increasingly popular. We observed an unusually high number of cases of aseptic loosening with the use of a modified stem. Therefore, the aim of this prospective single-center study was to assess safety and efficacy of this cementless stem.

METHODS

A total of 486 consecutive patients receiving 517 primary total hip arthroplasties using the MonoconMIS stem were prospectively followed up for a mean period of 5.29 years (standard deviation [SD], 1.47). Surgical and clinical data, complications, and revision surgeries were analyzed. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) score was recorded before surgery and at one year and five years after surgery.

RESULTS

The overall 5-year implant survival rate was 95.2%. The individual component survival rates were 96.1% for the stem, 99.4% for the acetabular cup, and 99.0% for the isolated mobile component exchange. The most common reasons for revision were periprosthetic fracture (1.5%), aseptic stem loosening (1.4%), and infection (1.0%). The WOMAC score improved significantly from 49.57 (SD, 21.42) at baseline to 13.33 (SD, 16.47) at one year and 9.84 (SD, 14.45) at five years after surgery. Aseptic stem loosening occurred only in patients with Dorr type A proximal femur morphology.

CONCLUSION

The evaluated femoral stem is associated with revision rates higher than what has been reported for other implants. The WOMAC scores suggest adequate efficacy. Our data do not support the use of the MonoconMIS for primary total hip arthroplasty in patients with Dorr type A proximal femur morphology.

The rise of registry-based research: a bibliometric analysis

Background and purpose - The main purpose of arthroplasty registries is to collect information on patients, techniques, and devices to monitor and improve the outcome of the specific procedure. This study analyses the role played by registries in the orthopedic research community and describes publication trends, characteristics, and patterns of this field of research.Patients and methods - A descriptive-bibliometric review was conducted. Scopus was the database used for the research. All articles published from 1991 to December 2020 containing keywords related to registries and arthroplasty were considered. In particular, the following dimensions were analyzed in detail: (i) papers/year; (ii) journals; (iii) countries; (iv) research growth rate; (v) collaboration among countries. VOSviewer software was used to perform the bibliometric analysis. Finally, the 50 most cited papers of the last 10 years were briefly analyzed.Results - 3,933 articles were identified. There has been growing interest in the topic since 2010. Acta Orthopaedica ranked first for the number of articles published. The country with the largest number of articles citing registries was the United States, followed by the United Kingdom and Sweden. The relative number of articles per 100,000 inhabitants is 0.60 for Europe and 0.38 for the United States. The literature in this research area has an average yearly growth rate of 28%.Interpretation - The publication rate in the field of arthroplasty registries is constantly growing with a noteworthy impact in the evolution of this research and clinical area. The growth rate is significantly higher than that of arthroplasty literature (28% vs. 10%) and the collaboration among countries is strong and increasing with time.

Role of real-world digital data for orthopedic implant automated surveillance: a systematic review

INTRODUCTION

Data collection automation through the reuse of real-world digital data from clinical data warehouses (CDW) could represent a great opportunity to improve medical device monitoring. For instance, this approach is starting to be used for the design of automated decision support systems for joint replacement monitoring. However, a number of obstacles remains, such as data quality and interoperability through the use of common and regularly updated terminologies, and the use of a Unique Device Identifier (UDI).

AREAS COVERED

To present the existing models of automated surveillance of orthopedic devices, a systematic review of initiatives using real-world digital health data to monitor joint replacement surgery was performed following the PRISMA 2020 guidelines. The main objective was to identify the data sources, the target populations, the population size, the device location, and the main results of studies on such initiatives.

EXPERT OPINION

Analysis of the identified studies showed that real-world digital data offer many opportunities for improving the automation of monitoring in orthopedics. The contribution of real-world data, especially through natural language processing, UDI use in CDW and the integration of device databases, is needed for automated and more robust health surveillance.

Correction of pelvic adduction during total hip arthroplasty reduces variability in radiographic inclination: findings of a randomised controlled trial

INTRODUCTION

The study aims were to identify the incidence of pelvic adduction during total hip arthroplasty (THA) in lateral decubitus and to determine, when aiming for 35° of apparent operative inclination (AOI), which of 3 operating table positions most accurately obtained a target radiographic inclination (RI) of 42°: (1) horizontal; (2) 7° head-down; (3) patient-specific position based on correction of pelvic adduction.

METHODS

With patients seated on a levelled theatre table, a ruler incorporating a spirit level was used to draw transverse pelvic lines (TPLs) on the skin overlying the pelvis and sacrum. Subsequently, when positioned in lateral decubitus these lines provided a measure of pelvic adduction. 270 participants were recruited, with 90 randomised to each group for operating table position. In all cases target AOI was 35°, aiming to achieve a target RI of 42°. The primary outcome measure was absolute (unsigned) deviation from the target RI of 42°.

RESULTS

266/270 patients demonstrated pelvic adduction (overall mean 4.4°, range 0- 9.2°). No patients demonstrated pelvic abduction. There were significant differences in RI between each of the 3 groups. The horizontal table group displayed the highest mean RI. The patient specific table position group achieved the smallest absolute deviation from target RI of 42°.

DISCUSSION

In lateral decubitus, unrecognised pelvic adduction is common and is an important contributor to unexpectedly high RI. The use of preoperative TPLs helps identify pelvic adduction and its subsequent correction reduces variability in RI. Clinical Trial Protocol number: NCT01831401.

Advances in hip arthroplasty surgery: what is justified?

Total hip arthroplasty (THA) surgery has shown dramatic changes in terms of increased number of procedures and of technical development in recent years. It has been described as “the operation of the 20^th century” for the excellent results, the high satisfaction of the patients and the improvement of the quality of life.

A lot of variations have been introduced over the last few decades in THA especially in terms of indications (both in younger and older patients), techniques and devices (approaches, tissue preservation, biomaterials and industrial finishing), per-operative management (blood loss and pain control) and post-operative protocols (the so called “fast track” surgery). Looking at all these advances the emerging question is: have all of them been justified both in terms of improvement of the results for the patients and of the cost/benefit ratio from an economical point of view?

The purpose of this paper is to critically analyse the advantages and the disadvantages of the theoretically proposed “advances in hip arthroplasty” and attempt to understand which are justified of such “advances” nowadays, based on the international and the European perspective with a focus on the author’s personal clinical experience.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.170008. Originally published online at www.efortopenreviews.org

SIRT1 protects osteoblasts against particle-induced inflammatory responses and apoptosis in aseptic prosthesis loosening

We hypothesized that SIRT1 downregulation in osteoblasts induced by wear particles was one of the reasons for particle-induced osteolysis (PIO) in total joint arthroplasty failure. In the present study, the expression of SIRT1 was examined in osteoblasts treated with TiAl6V4 particles (TiPs) and CoCrMo particles (CoPs) from materials used in prosthetics and specimens from PIO animal models. To address whether SIRT1 downregulation triggers inflammatory responses and apoptosis in osteoblasts, the effect of a SIRT1 activator, resveratrol on the expression of inflammatory cytokines and apoptosis in particle-treated osteoblasts was tested. The results demonstrated that SIRT1 expression was significantly downregulated in particle-treated osteoblasts and PIO animal models. Both pharmacological activation and overexpression of SIRT1 dramatically reduced the particle-induced expression of inflammatory cytokines and osteoblast apoptosis through NF-κB and p53 signaling, respectively. Furthermore, in PIO animal models, resveratrol significantly reduced the severity of osteolysis. Collectively, the results of the present study indicated that SIRT1 plays a vital role in the pathogenesis of aseptic loosening, and further treatment targeted at SIRT1 possibly lead to novel approaches for prevention of aseptic prosthesis loosening.

STATEMENT OF SIGNIFICANCE

Aseptic loosening is the most common cause of total hip arthroplasty (THA) and total knee arthroplasty (TKA) failure and revision surgery. However, there is still no effective therapeutic target in the clinical treatment. Besides, the underlying mechanism of aseptic loosening is largely unknown. The result of our study indicated that SIRT1 has the ability to effectively regulate the wear particle-induced inflammatory responses, apoptosis, osteolysis in particle-stimulated osteoblasts and particle-induced osteolysis animal models. Our study provides a potential target for the prevention and treatment of aseptic loosening and further investigated the underlying mechanism of aseptic loosening, which may make contribution to decrease the incidence of THA and TKA failure in the clinical practice.

Smoking and alcohol behaviours in people following hip and knee arthroplasty: Data from the Osteoarthritis Initiative

BACKGROUND

Smoking and alcohol consumption has a negative effect on overall health. Limited evidence has been presented as to how these health behaviours may change between pre- and postoperative intervals in the initial 12 months post-arthroplasty. The purpose of this study was to address this uncertainty.

HYPOTHESIS

Smoking and alcohol consumption differs between pre- and post-THA/TKA and it differs between non-arthroplasty cohorts.

MATERIALS AND METHODS

Data from the Osteoarthritis Initiative (OAI), a population-based observational study in the USA, were gathered. In total, data from 287 people who had undergone THA or TKA from baseline to month 48 OAI follow-up assessments were analysed. Data on this cohort were compared to 287 age- and gender-matched people with osteoarthritis. Mean change from pre- to post-arthroplasty, and differences between arthroplasty and non-arthroplasty participants for smoking and alcohol consumption were assessed descriptively and through Wilcoxin-matched pairs test and Student t-tests (as appropriate).

RESULTS

The lifetime prevalence of smoking was high for people who received THA (99%) and TKA (96%). Prevalence of current smoking significantly decreased from 5 to 3% across the THA and TKA cohort in the initial 12 months post-arthroplasty (P<0.05). Similarly, there was a statistically significant decrease in weekly alcohol consumption post-arthroplasty for people who underwent THA and TKA (P<0.01), although the mean difference was only by 0.9 alcoholic drinks. The only statistically significant difference in smoking and alcohol consumption for arthroplasty to non-arthroplasty participants was in weekly alcohol consumption, which was higher by 0.3 drinks in the non-arthroplasty cohort (P=0.04).

CONCLUSIONS

Smoking and alcohol consumption decreased in the initial 12 months post-THA and TKA. This was not significantly different to an age- and gender-matched non-arthroplasty cohort. Whilst this is positive, a small group of patients still present with unhealthy lifestyle choices in relation to these behaviours post-arthroplasty.

LEVEL OF EVIDENCE

Level III - prospective case control study.

Comparison of mouse and human ankles and establishment of mouse ankle osteoarthritis models by surgically-induced instability

OBJECTIVE

Prevalence of ankle osteoarthritis (OA) is lower than that of knee OA, however, the molecular mechanisms underlying the difference remain unrevealed. In the present study, we developed mouse ankle OA models for use as tools to investigate pathophysiology of ankle OA and molecular characteristics of ankle cartilage.

DESIGN

We anatomically and histologically examined ankle and knee joints of C57BL/6 mice, and compared them with human samples. We examined joints of 8-week-old and 25-month-old mice. For experimental models, we developed three different ankle OA models: a medial model, a lateral model, and a bilateral model, by resection of respective structures. OA severity was evaluated 8 weeks after the surgery by safranin O staining, and cartilage degradation in the medial model was sequentially examined.

RESULTS

Anatomical and histological features of human and mouse ankle joints were comparable. Additionally, the mouse ankle joint was more resistant to cartilage degeneration with aging than the mouse knee joint. In the medial model, the tibiotalar joint was markedly affected while the subtalar joint was less degenerated. In the lateral model, the subtalar joint was mainly affected while the tibiotalar joint was less altered. In the bilateral model, both joints were markedly degenerated. In the time course of the medial model, TdT-mediated dUTP nick end labeling (TUNEL) staining and Adamts5 expression were enhanced at early and middle stages, while Mmp13 expression was gradually increased during the OA development.

CONCLUSION

Since human and mouse ankles are comparable, the present models will contribute to ankle OA pathophysiology and general cartilage research in future.