Total Hip Arthroplasty - over 100 years of operative history

Sex-Specific Association of Clinical Parameters and Components of Femoral Bone Quality in Patients Undergoing Total Hip Arthroplasty

Poor bone quality is a critical factor associated with an increased risk of complications after total hip arthroplasty (THA). However, no consistent recommendations have yet been established for assessing indicators of bone quality preoperatively. Thus, it remains unclear which preoperatively available and readily accessible parameters are most closely associated with femoral bone quality. Here, we obtained femoral neck specimens from 50 patients undergoing THA. Preoperative Dual-energy X-ray absorptiometry (DXA) scans, pelvic radiographs, and laboratory parameters were analyzed. In the obtained specimens, bone microstructure was assessed using micro-CT and histomorphometry. Additionally, matrix mineralization and osteocyte lacunar morphology were evaluated using quantitative backscattered electron imaging. Our analysis revealed that DXA-derived T-scores correlated with trabecular microstructure. Furthermore, radiographic indices and body mass index correlated differentially with aspects of bone quality in women and men. Contrary to previous observations, no correlation was found between serum vitamin D levels and osteoid indices, nor between clinical parameters and matrix mineralization. Age was strongly associated with the number of mineralized osteocyte lacunae, a factor that appeared to be independent of sex. Taken together, our study demonstrates that no single preoperatively available parameter exhibits a strong and consistent association with femoral bone quality. However, DXA remains a reliable preoperative measure for determining the trabecular microstructure of the femoral neck. In clinical practice, surgeons should adopt an individualized approach to preoperative assessments by considering age, sex, BMI, and radiographic indices to enhance their insight into femoral bone quality, particularly when DXA is unavailable.

Continuing Home Oral Hypoglycemic Medications Was Associated With Superior Postoperative Glycemic Control Versus Initiating Sliding Scale Insulin After Total Hip Arthroplasty

BACKGROUND

This retrospective study investigated the impact of continuing vs discontinuing home oral hypoglycemic medications for patients with diabetes undergoing total hip arthroplasty.

MATERIALS AND METHODS

Patients who were not exclusively receiving home oral hypoglycemic regimens were excluded. Additionally, patients whose diabetes was not managed inpatient postoperatively were excluded. Included patients were retrospectively evaluated for early postoperative glycemic control, renal function, and metabolic abnormalities. Patients were then compared based on whether their home oral hypoglycemic regimen was continued vs discontinued in favor of initiating insulin while inpatient and analyzed using multivariable regression analysis.

RESULTS

A total of 532 patients undergoing total hip arthroplasty met inclusion criteria, with 78.6% continuing their home oral hypoglycemic regimen. Those who continued showed significantly lower median maximum inpatient blood glucose (178.5 mg/dL vs 249.5 mg/dL; P<.001) and median average inpatient blood glucose (138.4 mg/dL vs 178.6 mg/dL; P<.001). Linear regression analysis, adjusting for various potential confounding factors, revealed a positive correlation between discontinuation of home hypoglycemic medications and higher maximum in-patient blood glucose (β=70.15 [95% CI, 59.27-81.03]; P<.001). Patients in the continuation group had lower proportions of acute kidney injury (18.7% vs 41.2%; P<.001) and metabolic acidosis (4.3% vs 17.5%; P<.001), along with a shorter length of stay (1.0 vs 2.0 days; P<.001).

CONCLUSION

These findings suggest that continuing a home oral hypoglycemic regimen for patients with diabetes after total hip arthroplasty is associated with superior glycemic control without exacerbating renal abnormalities or increasing metabolic complications. [Orthopedics. 2024;47(5):276-282.].

Technical Note on the Role of Kambin's Triangle in the Evolution of Total Joint Replacement of the Lumbar Spine

We provide a historical and technical perspective on the evolution of Kambin's triangle as a safe working corridor for percutaneous access to the intervertebral disc to an anatomically expanded space to accommodate and facilitate open lumbar total joint replacement. The nearly 6-decade progression from intradiscal access in the intact lumbar spine to an enlarged working space following facetectomy to accommodate a transforaminal lumbar interbody fusion, and eventual further expansion via pedicle vertebral body osteotomy to support motion preservation with total joint replacement, represents a unique evolutionary pathway in surgical technique development. For each of these steps in evolution, we detail and provide the historical context of the corresponding surgical modifications required to expand the original anatomical boundaries of Kambin's triangle. It is postulated that the introduction of machine learning technologies coupled with innovations in robotics, materials science, and advanced imaging will further accelerate and refine the adaptation of more complex, precise, and efficacious surgical procedures to treat spinal degeneration via this working corridor.

Does Lack of Initial Collar-Calcar Contact Influence Performance of Collared Cementless Femoral Stems?

Background

Initial stability of cementless stems is important to minimize the risk of subsidence, pain, and periprosthetic fracture after total hip arthroplasty (THA). Collared stems improve initial component stability when contacting the femoral calcar. Direct contact is not always achieved, and collared stem performance has not been studied in this context. We hypothesized that collared stems achieving direct contact would demonstrate reduced subsidence.

Methods

A single-surgeon retrospective study of 482 consecutive primary THAs implanted between February 2020 and May 2023 using collared cementless stems was performed. The 2 cohorts included stems with initial collar-calcar contact vs stems without. Subsidence was evaluated by comparing intraoperative fluoroscopy to postoperative 8-week radiographs. Binary logistic regression identified independent risk factors for subsidence. Chi-square tests were used for categorical variables and t-tests for continuous variables.

Results

Of stems, 63.9% achieved initial collar-calcar contact, while 36.1% did not. The rate (1.3% vs 19.0%; P < .001) and magnitude (0.02 mm, range 0-3 mm vs 0.35 mm, range 0-3 mm; P < .001) of subsidence were significantly higher among stems without initial contact. Stems without initial collar-calcar contact (P < .001) and male gender (P = .007) were independent risk factors for subsidence. Two patients with initial contact had nondisplaced calcar cracks and <3 mm of subsidence at 4 weeks, which healed with protected weight-bearing. Stem survivorship was 100% in both groups, with all achieving osteointegration and none needing revision.

Conclusions

Excellent performance of collared cementless stems was observed at 8 weeks after primary THA. Initial collar-calcar contact lowered the risk and magnitude of minor subsidence but did not affect survivorship or fracture risk.

Level of Evidence

Level III.

Sexual activity at 1 year after total hip arthroplasty in Indian patients

PURPOSE

This study aimed to report changes in sexual activity and related difficulties and concerns among Indian patients at the end of 1-year after primary total hip arthroplasty (THA).

MATERIALS AND METHODS

A detailed questionnaire related to sexual difficulty, frequency, position, satisfaction, stress, and concerns pre- and postoperatively was administered through an in-person interview at 1-year post-THA.

RESULTS

Preoperatively, 77% of patients reported difficulties in sexual activities, which reduced significantly (p < 0.0001) to 30% at the end of 1-year post-operatively. A majority of patients reported no change in the frequency (56.5%) or satisfaction with their sexual activity (54%), and moderate to severe stress (53%) related to sexual activity at 1 year postoperatively. A significantly higher percentage (p = 0.01) of female patients (63%) reported changing their coital position postoperatively due to difficulty in leg positioning when compared to male patients (37.5%). Most patients (69%) were not able to procure information on sexual activity after THA surgery. and only 17.5% of patients discussed the topic with their surgeon.

CONCLUSION

Although THA significantly reduced difficulty in sexual activity, most patients reported no change in the frequency of sexual activity or sexual satisfaction, had moderate to severe stress regarding sex, and were primarily concerned about safety of coital position and fear of dislocation at the end of 1-year postoperatively. Pre- and postoperative counselling by their surgeons will provide the patient with relevant information and help reduce anxiety and stress, improve satisfaction, and enhance the overall sexual health of the patient undergoing primary THA.

Are We Finally Ready for Total Joint Replacement of the Spine? An Extension of Charnley's Vision

Professor Sir John Charnley has been rightfully hailed as a visionary innovator for conceiving, designing, and validating the Operation of the Century-the total hip arthroplasty. His groundbreaking achievement forever changed the orthopedic management of chronically painful and dysfunctional arthritic joints. However, the well-accepted surgical approach of completely removing the diseased joint and replacing it with a durable and anatomically based implant never translated to the treatment of the degenerated spine. Instead, decompression coupled with fusion evolved into the workhorse intervention. In this commentary, the authors explore the reasons why arthrodesis has remained the mainstay over arthroplasty in the field of spine surgery as well as discuss the potential shift in the paradigm when it comes to treating degenerative lumbar disease.

A Comprehensive Review of Total Hip Arthroplasty Outcomes in Post-traumatic Hip Arthritis: Insights and Perspectives

Post-traumatic hip arthritis presents a challenging condition characterized by degenerative changes in the hip joint following traumatic injury. Total hip arthroplasty (THA) is a cornerstone in managing this condition, offering significant pain relief, functional improvement, and enhanced quality of life. This comprehensive review aims to synthesize existing literature to elucidate the outcomes of THA in post-traumatic hip arthritis, exploring factors influencing surgical success and identifying areas for further research. Key findings reveal favourable clinical outcomes associated with THA, though considerations such as patient characteristics, surgical techniques, and implant selection impact outcomes. Implications for clinical practice underscore the importance of tailored preoperative assessment and ongoing advancements in surgical approaches and implant technology. Furthermore, opportunities for future research lie in long-term durability studies, patient-reported outcomes assessment, and exploration of innovative surgical techniques. Overall, THA emerges as a promising intervention for post-traumatic hip arthritis, yet continual refinement through research and innovation remains imperative to optimize patient care in this population.

Two-Year Outcomes of Novel Dual-Mobility Implant in Primary Total Hip Arthroplasty

Introduction

Dual-mobility (DM) implants for total hip arthroplasty (THA) have gained popularity due to their potential to reduce hip instability and dislocation events that may lead to revision surgery. These implants consist of a femoral head articulated within a polyethylene liner, which articulates within an outer acetabular shell, creating a dual-bearing surface. Our study aimed to report our observations on the survivorship of a novel DM implant for primary total hip arthroplasty at two years.

Methods

We conducted a retrospective, multicenter study to assess the clinical outcomes of patients undergoing a THA with a novel DM implant (OR3O acetabular system™, Smith & Nephew, Inc., Memphis, TN) from January 2020 to September 2021. Patient demographics, surgical information, and survivorship data were collected from medical records for patients with a minimum of two years of follow-up. Primary outcomes included overall implant survivorship at two years as well as aseptic survivorship, revision rates of the DM acetabular shell, and average time to revision. Patient-reported outcomes were collected in the form of HOOS JR.

Results

A total of 250 hips in 245 patients had a minimum two-year follow-up. Primary osteoarthritis (80%) was the most common indication for index THA. The average aseptic survivorship of the DM acetabular components at two years for the cohort was 98.4% and survivorship of the acetabular implants overall was 97.6%. There were a total of four (1.6%) aseptic revisions of the DM acetabular component. Reasons for aseptic acetabular revision included one case of instability, one intraprosthetic dislocation, one periprosthetic acetabular fracture, and one malpositioned acetabular cup resulting in impingement. The mean time of follow-up was 893.9 days. Eighty-seven patients had preoperative and two-year HOOS JR available. HOOS JR improved by an average of 38.5 points.

Conclusion

This novel DM acetabular implant demonstrates excellent survivorship at two years follow-up with low rates of instability and intraprosthetic dislocation and no episodes of metal-on-metal corrosion. Use of the DM implant demonstrated clinically relevant improvements in patient-reported outcomes at two years.

Clinical reasoning for the continuation or discontinuation of hip precautions after total hip arthroplasty in Switzerland: a qualitative study

BACKGROUND

Growing evidence raises doubts about the need for routine hip precautions after primary total hip replacements to reduce the risk of postoperative dislocation. However, hip precautions are still routinely and widely prescribed in postoperative care in Switzerland. We aimed to investigate experts' clinical reasoning for hip precaution recommendations after total hip arthroplasty.

METHODS

Using a convenience sampling strategy, 14 semi-structured expert interviews were conducted with surgeons, physiotherapists, and occupational therapists in the vicinity of an inpatient rehabilitation clinic in Switzerland. Data analysis followed Mayring's principle of inductive and deductive structuring content analysis.

RESULTS

Expert statements from the interviews were summarised into four main categories and 10 subcategories. Categories included statements on the incidences of dislocation and underlying risk factors; current preferences and use of hip precautions; their effect on physical function, anxiety, or costs; and patient's adherence to the movement restrictions. Hip surgeons routinely prescribed hip precautions, although in different variations. Fear of dislocation and caution are barriers to changing current practice. Some surgeons are considering individualised prescribing based on patients' risk of dislocation, which therapists would welcome.

CONCLUSION

A lack of clear instructions from the surgeon leads to ambiguity among therapists outside the acute hospital. A shared understanding of the need for and nature of hip precautions, guidelines from societies, or at least specific instructions from surgeons to therapists are warranted.

Failure of Total Hip Arthroplasty due to Delamination and Wear of Titanium Nitride-coated Titanium Heads: A Case Series

Introduction

We present the case studies of three patients requiring revision for premature failure of total hip arthroplasty (THA).

Case Report

All patients received titanium nitride (TiN)-coated heads made of titanium alloy TiALV as part of their index total hip replacements. At the time of revision surgery, intraoperative findings included partial or complete delamination of the TiN head coating and wear/deformation of the TiALV heads.

Conclusion

In addition to PE wear as a known mechanism for THA failure, titanium wear appears to play a major role in contributing to early THA failure and acceleration of PE wear. As a result, the choice of TiN-coated TiALV heads for use in THA should be approached with caution. It is thought that manufacturers of hip implants are aware of this potential problem. However, in a global community, this paper simply aims to bring this knowledge to general attention, while the manufacture of the presented heads does not exist anymore.

A Radiographic Evaluation of Uncemented Total Hip Replacements and the Role of Uncemented Implants in the Management of Hip Osteoarthritis in the Elderly Population

Introduction The idea of an uncemented, fully coated hydroxyapatite (HA) stem was introduced almost 40 years ago, aiming to achieve a solid biological fixation by preserving natural bone activity. While many studies underline the longevity of uncemented total hip replacement (THR), NHS England's Best Practice Tariff (BPT) recommends using cemented implants in patients over the age of 69, with financial penalties when this policy is not met. At the same time, the 'paradox' of increased use of uncemented implants worldwide has been well described, with many surgeons using them regardless of the age group of the patient. Materials and methods This study focuses on the radiographic evaluation of the uncemented Pinnacle/Corail total hip replacement construct in 123 patients of all age groups who underwent an elective procedure, with a minimum radiographic follow-up of two years. Implant information (collared or non-collared stem), femur type (Dorr classification), age, gender, and revision rate were collected and radiographic analysis of the femoral stem and acetabular component was performed for the immediate post-operative, six-month, one- to two-year follow-up radiograph of all patients. We conducted a statistical analysis, dividing the patients into two groups based on age: those above or below 69 years old. Results There was no statistically significant difference in rates of radiographic lucency after two years with regard to the femoral component. Both collared and non-collared stems seem to perform equally well, with no significant difference detected. However, a statistically significant difference in rates of radiographic lucency of the acetabular cup was noted between the two age groups (p=0.018), with higher rates detected in the under-69-year-old age group. Conclusion This study demonstrates that, radiographically, the uncemented Pinnacle/Corail construct performs equally well in all age groups. In our cohort of patients, the age of the patient did not predict the osseointegration of the implant in the short-term follow-up.

Intraoperative blood loss and haemoglobin drop in patients with developmental dysplasia of the hip in Jordan undergoing total hip arthroplasty

PURPOSE

Developmental dysplasia of the hip is still a prevailing secondary cause of early hip osteoarthritis in Jordan. Dysplastic coxarthrosis can result in significant and disabling hip pain with impaired patient's functionality. Due to this significant morbidity, patients ultimately need total hip arthroplasty, which offers the best functional outcome. Significant anatomical aberrances do exist in such hips as a result of old dysplasia; such pathoanatomical changes can complicate an already difficult surgery and lead to significant intraoperative blood loss and haemoglobin drop postoperatively. So, the aim of this research was to investigate on the intraoperative blood loos, and postoperative haemoglobin drop in these patients.

METHODS

A cross-sectional study design was adopted, and 162 patients with advanced hip osteoarthrosis secondary to developmental dysplasia of the hip (DDH) were studied. We studied predictors of hemoglobin drop and blood loss and linked some variables to this outcome variable using different statistical tests.

RESULTS

Our results showed a positive correlation between blood loss and BMI (r = 0.27, p = 0.73), haemoglobin drop and duration of surgery (r = 0.14, p = 0.07), length of hospital stay and duration of surgery (r = 0.25, p = 0.001). No significant differences between outcome measures (blood loss, haemoglobin drop, and duration of surgery) between males and females (p = 0.38, 0.93, 0.77 respectively). However, there was a statistically significant differences in haemoglobin drop among patients underwent general versus spinal anaesthesia (p = 0.03). additionally, there was a statistically significant association in length of hospital stay among smokers (p = 0.03), and patients who didn't prescribed anxiolytic preoperatively (p = 0.008).

CONCLUSION

Haemoglobin drop and blood loss in patients with dysplastic coxarthrosis were linked to increased preoperative BMI. Use of preoperative anxiolytics, and being non-smoker decreased the length of hospital stays. General anaesthesia was associated with more haemoglobin drop as well.

Cost-effectiveness of implant movement analysis in aseptic loosening after hip replacement: a health-economic model

OBJECTIVE

To investigate the cost-effectiveness of using Implant Movement Analysis (IMA) to follow up suspected aseptic loosening when the diagnosis after an initial X-ray is not conclusive, compared with a diagnostic pathway with X-ray follow-up.

METHODS

A health-economic model in the form of a decision tree was developed using quality-adjusted life years (QALY) from the literature, cost-per-patient data from a university hospital and the probabilities of different events from expert physicians' opinions. The base case incremental cost-effectiveness ratio (ICER) was compared with established willingness-to-pay thresholds and sensitivity analyses were performed to account for assumptions and uncertainty.

RESULTS

The base case ICER indicated that the IMA pathway was cost effective (SEK 99,681, compared with the SEK 500,000 threshold). In the sensitivity analysis, the IMA pathway remained cost effective during most changes in parameters. ICERs above the threshold value occurred in cases where a larger or smaller proportion of people receive immediate surgery.

CONCLUSION

A diagnostic pathway using IMA after an inconclusive X-ray for suspected aseptic loosening was cost effective compared with a pathway with X-ray follow-up.

Comprehensive Review on Biomaterials and Their Inherent Behaviors for Hip Repair Applications

Developing biomaterials for hip prostheses is challenging and requires dedicated attention from researchers. Hip replacement is an inevitable and remarkable orthopedic therapy for enhancing the quality of patient life for those who have arthritis as well as trauma. Generally, five types of hip replacement procedures are successfully performed in the current medical market: total hip replacements, hip resurfacing, hemiarthroplasty, bipolar, and dual mobility systems. The average life span of artificial hip joints is about 15 years, and several studies have been conducted over the last 60 years to improve the performance and thereby increase the lifespan of artificial hip joints. Present-day prosthetic hip joints are linked to the wide availability of biomaterials. Metals, ceramics, and polymers are some of the most promising types of biomaterials; nevertheless, each biomaterial has advantages and disadvantages. Metals and ceramics fail in most applications owing to stress shielding and the emission of wear debris; ongoing research is being carried out to find a remedy to these unfavorable responses. Recent research found that polymers and composites based on polymers are significant alternative materials for artificial joints. With growing research and several biomaterials, recent reviews lag in effectively addressing hip implant materials' individual mechanical, tribological, and physiological behaviors. This Review comprehensively investigates the historical evolution of artificial hip replacement procedures and related biomaterials' mechanical, tribological, and biological characteristics. In addition, the most recent advances are also discussed to stimulate and guide future researchers as they seek more effective methods and synthesis of innovative biomaterials for hip arthroplasty application.

A review of robotic-assisted total hip arthroplasty

Total hip arthroplasty (THA) is a successful surgical method for hip replacement but still poses challenges and risks. Robotic-assisted THA (rTHA) using new generation robotic systems has emerged to improve surgical precision and outcomes. The purpose of this paper is to review the literature on rTHA, with a focus on its advantages, such as individualized preoperative planning, intraoperative assistance, and improved accuracy in implantation, especially in complex cases. Additionally, it aims to explore the disadvantages associated with the use of rTHA, including high costs, the learning curve, and prolonged operation time compared to manual THA (mTHA), which are critical drawbacks that require careful consideration and efforts for minimization. Some financial analyses suggest that rTHA may offer cost-effectiveness and reduced postoperative costs compared to mTHA. While technological advancements are expected to reduce technical complications, there are still debates surrounding long-term outcomes. Practical limitations, such as limited availability and accessibility, also warrant attention. Although the development of rTHA shows promise, it is still in its early stages, necessitating critical evaluation and further research to ensure optimal patient benefits.

Predicting the Risk of Total Hip Replacement by Using A Deep Learning Algorithm on Plain Pelvic Radiographs: Diagnostic Study

BACKGROUND

Total hip replacement (THR) is considered the gold standard of treatment for refractory degenerative hip disorders. Identifying patients who should receive THR in the short term is important. Some conservative treatments, such as intra-articular injection administered a few months before THR, may result in higher odds of arthroplasty infection. Delayed THR after functional deterioration may result in poorer outcomes and longer waiting times for those who have been flagged as needing THR. Deep learning (DL) in medical imaging applications has recently obtained significant breakthroughs. However, the use of DL in practical wayfinding, such as short-term THR prediction, is still lacking.

OBJECTIVE

In this study, we will propose a DL-based assistant system for patients with pelvic radiographs to identify the need for THR within 3 months.

METHODS

We developed a convolutional neural network-based DL algorithm to analyze pelvic radiographs, predict the hip region of interest (ROI), and determine whether or not THR is required. The data set was collected from August 2008 to December 2017. The images included 3013 surgical hip ROIs that had undergone THR and 1630 nonsurgical hip ROIs. The images were split, using split-sample validation, into training (n=3903, 80%), validation (n=476, 10%), and testing (n=475, 10%) sets to evaluate the algorithm performance.

RESULTS

The algorithm, called SurgHipNet, yielded an area under the receiver operating characteristic curve of 0.994 (95% CI 0.990-0.998). The accuracy, sensitivity, specificity, and F1-score of the model were 0.977, 0.920, 0932, and 0.944, respectively.

CONCLUSIONS

The proposed approach has demonstrated that SurgHipNet shows the ability and potential to provide efficient support in clinical decision-making; it can assist physicians in promptly determining the optimal timing for THR.

Postoperative Load Bearing in Periprosthetic Femoral Fractures Around Hip Arthroplasty: A Survey Among Orthopedic Surgeons in the Netherlands

INTRODUCTION

Permissive weight bearing (PWB) has relatively recently been implemented to optimize rapid clinical recovery and restoration of function in patients suffering lower extremity fractures. PWB shows outcome advantages in this patient category. Currently, there are no decisive recommendations on postoperative load-bearing management after surgically treated periprosthetic femoral fractures (PPFF) around hip arthroplasty. The objective is to investigate the current postoperative practice of weight-bearing instructions for patients with surgically treated PPFF, accounting for differences in types of periprosthetic fractures and treatment options among Dutch orthopedic surgeons.

MATERIALS AND METHODS

An online survey was distributed among the members of the hip and trauma working groups of the Dutch Orthopedic Association.

RESULTS

The response rate was 13% (n=75). The main finding was that postoperative load bearing regimes in Vancouver A, B, and C PPFFs differed greatly among Dutch orthopedic surgeons, and there was no decisive guideline or consensus in postoperative load bearing regimes after surgically treated PPFF was used in the Netherlands.

CONCLUSION

In the absence of decisive guidelines or consensus, more research is needed to explore the efficacy of PWB after surgically treated PPFF.

What Is Important to the Younger Person (≤50 Years) When Having a Total Hip Arthroplasty: A Systematic Literature Review

Total hip arthroplasties (THAs) are usually performed in older patients. Despite a growing number of THAs in younger adults, it is unclear whether they have similar priorities in recovery compared with their older counterparts. The purpose of this systematic review was to explore younger patients' priorities when undergoing a THA. Multiple databases were searched in September 2021 prioritizing qualitative data. This review was reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Of 14,495 articles screened, nine remained for analysis. Four common themes were discovered: improving function and mobility; pain; relationships; and patient expectations and education. However, there was insufficient information to clarify whether these themes could be attributed directly to younger adults undergoing a THA. The absence of research on THA patients younger than 50 years results in the loss of the voices of these patients. Further research is essential to ensure their needs are identified, addressed, and met.

Long-term survivorship and results in lower limb arthroplasty: a registry-based comparison study

INTRODUCTION

Popularity of joint replacement surgery due to ever aging population surges the demand for a proper national joint registry. Our Chinese University of Hong Kong - Prince of Wales Hospital (CUHK-PWH) joint registry has passed the 30^th year. The aims of this study are 1) summarize our territory-wide joint registry which has passed the 30th year since establishment and 2) compare our statistics with other major joint registries.

METHODS

Part 1 was to review the CUHK-PWH registry. Demographic characteristics of our patients who underwent knee and hip replacements had been summarized. Part 2 was a series of comparisons with registries from Sweden, UK, Australia and New Zealand.

RESULTS

CUHK-PWH registry captured 2889 primary total knee replacements (TKR) (110 (3.81%) revision) and 879 primary total hip replacements (THR) (107 (12.17%) revision). Median Surgery time of TKR was shorter than THR. Clinical outcome scores were much improved after surgery in both. Uncemented of hybrid in TKR were most popular in Australia (33.4%) and 40% in Sweden and UK. More than half of TKR and THR patients showed the highest percentage with ASA grade 2. New Zealand reflected the best cumulative percentage survival 20 years after surgery of 92.2%, 76.0%, 84.2% survivorship 20 years after TKR, unicompartmental knee replacement (UKR) and Hip.

CONCLUSION

A worldwide accepted patient-reported outcome measure (PROM) is recommended to develop to make comparisons among registries and studies feasible. Completeness of registry data is important and useful to improve surgical performance through data comparisons from different regions. Funding from government on sustaining registries is reflected. Registries from Asian countries have yet to be grown and reported.

A New Classification System for Cementless Femoral Stems in Total Hip Arthroplasty

BACKGROUND

The growing variety of total hip arthroplasty implants necessitates a standardized, simple, and brand-neutral language to precisely classify femoral components. Although previous classifications have been useful, they need updating to include stems that have current surface treatment technologies, modularity, collar features, and other geometric characteristics.

METHODS

To accomplish this, we propose a new classification system for stems based on 3 distinguishing stem features: (1) geometry, (2) location of modularity, and (3) length.

RESULTS

Our system allows for the easy classification of all currently used stem types.

CONCLUSIONS

One goal of this endeavor is to improve clinical record keeping to facilitate study comparisons as well as literature reviews.

Unexpected Repercussions of the COVID-19 Pandemic on Total Hip Arthroplasty with Cemented Hip Prosthesis versus Cementless Implants

(1) Background: Total hip arthroplasty (THA) is one of the most common procedures used for adult hip reconstruction, employing mainly two types of prostheses: cemented (CHP) and cementless (CLHP). This study aims to analyze the impact of the COVID-19 pandemic on THA with CHP and CLHP, in terms of the benefit/cost ratio. (2) Methods: This article represents a retrospective analysis of the differences concerning the benefit/cost ratio between THA with the two types of prostheses in 2950 patients admitted for THA in the two orthopedic clinics of our hospital between 1 January 2015-1 March 2020 in comparison with 1005 THA subjects seen between 1 April 2020-31 December 2022. (3) Results: In the first period, THA with CHP was performed in 45.83% of cases, while CLHP was used in 54.16% of patients. During the COVID-19 period, CHP was inserted in 52% of THA patients, while the other 48% had CLHP inserted, with a hospitalization duration reduced by over 50% for both types of implants (p ˂ 0.001). (4) Conclusions: CHP offered good outcomes, with quicker mobilization, and shorter hospitalization duration, compared to CLHP, but optimization of the patients' management can be achieved mainly by reducing the length of hospitalization through an appropriate preoperative patient evaluation through a multidisciplinary approach, an aspect that was proven during the COVID-19 pandemic.

What Patient and Implant Factors Affect Trunnionosis Severity? An Implant Retrieval Analysis of 664 Femoral Stems

BACKGROUND

Corrosion at the modular head-neck taper interface of total and hemiarthroplasty hip implants (trunnionosis) is a cause of implant failure and thus a clinical concern. Patient and device factors contributing to the occurrence of trunnionosis have been investigated in prior implant retrieval studies but generally with limited sample sizes and a narrow range of models. The purpose of the present investigation was to determine which patient and device factors were associated with corrosion damage on the femoral stem taper across a large collection of different implant models retrieved following revision hip arthroplasty.

METHODS

A retrieval study of 664 hip arthroplasty modular stem components was performed. Patient and device information was collected. Trunnions were imaged under digital microscopy and scored for corrosion damage using a scaling system. Damage was related to patient and device factors using regression analyses.

RESULTS

Greater duration of implantation (P = .005) and larger head size (P < .001) were associated with an elevated corrosion class. Older age at index surgery (P = .035), stainless steel stem material (P = .022), indication for revision as bone or periprosthetic fracture (P = .017), and infection (P = .018) and certain larger taper geometries were associated with a decreased corrosion class.

CONCLUSION

Factors identified as contributing to a higher or lower risk of more severe corrosion are consistent with most prior smaller retrieval studies. Surgeons should be aware of these risk factors when selecting implants for their patients and when diagnosing trunnionosis in symptomatic hip arthroplasty patients.

Developing Patient-Specific Statistical Reconstructions of Healthy Anatomical Structures to Improve Patient Outcomes

There are still numerous problems with modern joint replacement prostheses, which negatively influence patient health and recovery. For example, it is especially important to avoid failures and complications following hip arthroplasty because the loss of hip joint function is commonly associated with increased demand on the healthcare system, reoperation, loss of independence, physical disability, and death. The current study uses hip arthroplasty as a model system to present a new strategy of computationally generating patient-specific statistical reconstructions of complete healthy anatomical structures from computed tomography (CT) scans of damaged anatomical structures. The 3D model morphological data were evaluated from damaged femurs repaired with prosthetic devices and the respective damaged femurs that had been restored using statistical reconstruction. The results from all morphological measurements (i.e., maximum femoral length, Hausdorff distance, femoral neck anteversion, length of rotational center divergence, and angle of inclination) indicated that the values of femurs repaired with traditional prostheses did not fall within the +/-3 standard deviations of the respective patient-specific healthy anatomical structures. These results demonstrate that there are quantitative differences in the morphology of femurs repaired with traditional prostheses and the morphology of patient-specific statistical reconstructions. This approach of generating patient-specific statistical reconstructions of healthy anatomical structures might help to inform prosthetic designs so that new prostheses more closely resemble natural healthy morphology and preserve biomechanical function. Additionally, the patient-specific statistical reconstructions of healthy anatomical structures might be valuable for surgeons in that prosthetic devices could be selected and positioned to more accurately restore natural biomechanical function. All in all, this contribution establishes the novel approach of generating patient-specific statistical reconstructions of healthy anatomical structures from the CT scans of individuals' damaged anatomical structures to improve treatments and patient outcomes.

[Histopathological diagnostics of arthrofibrosis]

Joint surgery is one of the most important and successful disciplines in surgery; nevertheless, complications still occur, especially in total knee arthroplasty and surgery of the anterior cruciate ligament. A significant disease in this context is arthrofibrosis. This review article presents the cellular and molecular pathogenetic concept of arthrofibrosis, the spectrum of histopathological diagnostics and differential diagnostics and a classification into joint endoprosthesis-associated and non-joint endoprosthesis-associated arthrofibrosis is proposed. The basis of the histopathological diagnostics is the standardized tissue removal with subsequent fixation in formalin. In the case of joint implant failure and the problem of endoprosthesis-associated arthrofibrosis, the histopathological diagnostics can be carried out according to the consensus classification of synovia-like interface membrane (SLIM). Arthrofibrosis is characterized by fibrosis, a high fibroblast cellularity with immunohistochemical detection of cytoplasmic beta catenin expression. The presence of endoprosthesis-associated arthrofibrosis is probable above a threshold of 20 beta catenin positive fibroblasts per high-power field (HPF). The diagnosis of a non-endoprosthesis-associated arthrofibrosis can be classified according to the joint pathology algorithm. Diffuse non-endoprosthesis-associated arthrofibrosis is characterized by generalized proliferation of connective tissue in the whole joint and localized circumscribed arthrofibrosis is characterized by a nodose cyclops-like fibrosis. The clarification of the cause of arthrofibrosis is based on an interdisciplinary cooperation. In addition to the histopathological diagnostics, this includes clinical, surgical, biomechanical, arthroscopic, microbiological, laboratory parameter and radiological findings.

Trabecular Titanium for Orthopedic Applications: Balancing Antimicrobial with Osteoconductive Properties by Varying Silver Contents

Periprosthetic joint infection (PJI) and implant loosening are the most common complications after joint replacement surgery. Due to their increased surface area, additively manufactured porous metallic implants provide optimal osseointegration but they are also highly susceptible to bacterial colonization. Antibacterial surface coatings of porous metals that do not inhibit osseointegration are therefore highly desirable. The potential of silver coatings on arthroplasty implants to inhibit PJI has been demonstrated, but the optimal silver content and release kinetics have not yet been defined. A tight control over the silver deposition coatings can help overcome bacterial infections while reducing cytotoxicity to human cells. In this regard, porous titanium sputtered with silver and titanium nitride with increasing silver contents enabled controlling the antibacterial effect against common PJI pathogens while maintaining the metabolic activity of human primary cells. Electron beam melting additively manufactured titanium alloys, coated with increasing silver contents, were physico-chemically characterized and investigated for effects against common PJI pathogens. Silver contents from 7 at % to 18 at % of silver were effective in reducing bacterial growth and biofilm formation. Staphylococcus epidermidis was more susceptible to silver ions than Staphylococcus aureus. Importantly, all silver-coated titanium scaffolds supported primary human osteoblasts proliferation, differentiation, and mineralization up to 28 days. A slight reduction of cell metabolic activity was observed at earlier time points, but no detrimental effects were found at the end of the culture period. Silver release from the silver-coated scaffolds also had no measurable effects on primary osteoblast gene expression since similar expression of genes related to osteogenesis was observed regardless the presence of silver. The investigated silver-coated porous titanium scaffolds may thus enhance osseointegration while reducing the risk of biofilm formation by the most common clinically encountered pathogens.

Additively manufactured metallic biomaterials

Metal additive manufacturing (AM) has led to an evolution in the design and fabrication of hard tissue substitutes, enabling personalized implants to address each patient's specific needs. In addition, internal pore architectures integrated within additively manufactured scaffolds, have provided an opportunity to further develop and engineer functional implants for better tissue integration, and long-term durability. In this review, the latest advances in different aspects of the design and manufacturing of additively manufactured metallic biomaterials are highlighted. After introducing metal AM processes, biocompatible metals adapted for integration with AM machines are presented. Then, we elaborate on the tools and approaches undertaken for the design of porous scaffold with engineered internal architecture including, topology optimization techniques, as well as unit cell patterns based on lattice networks, and triply periodic minimal surface. Here, the new possibilities brought by the functionally gradient porous structures to meet the conflicting scaffold design requirements are thoroughly discussed. Subsequently, the design constraints and physical characteristics of the additively manufactured constructs are reviewed in terms of input parameters such as design features and AM processing parameters. We assess the proposed applications of additively manufactured implants for regeneration of different tissue types and the efforts made towards their clinical translation. Finally, we conclude the review with the emerging directions and perspectives for further development of AM in the medical industry.

Functionally graded additive manufacturing for orthopedic applications

Background

Additive Manufacturing due to its benefits in developing parts with complex geometries and shapes, has evolved as an alternate manufacturing process to develop implants with desired properties. The structure of human bones being anisotropic in nature is biologically functionally graded i,e. The structure possesses different properties in different directions. Therefore, various orthopedic implants such as knee, hip and other bone plates, if functionally graded can perform better. In this context, the development of functionally graded (FG) parts for orthopedic application with tailored anisotropic properties has become easier through the use of additive manufacturing (AM).

Objectives

and Rationale: The current paper aims to study the various aspects of additively manufactured FG parts for orthopedic applications. It presents the details of various orthopedic implants such as knee, hip and other bone plates in a structured manner. A systematic literature review is conducted to study the various material and functional aspects of functionally graded parts for orthopedic applications. A section is also dedicated to discuss the mechanical properties of functionally graded parts.

Conclusion

The literature revealed that additive manufacturing can provide lot of opportunities for development of functionally graded orthopedic implants with improved properties and durability. Further, the effect of various FG parameters on the mechanical behavior of these implants needs to be studied in detail. Also, with the advent of various AM technologies, the functional grading can be achieved by various means e.g. density, porosity, microstructure, composition, etc. By varying the AM parameters. However, the current limitations of cost and material biocompatibility prevent the widespread exploitation of AM technologies for various orthopedic applications.

Patients are Most Interested in Which Hip Arthroplasty Approach? A 15-year Google Trends Analysis

Background

Methods

Results

Conclusions

Poor Patient Follow-up After Metal-on-Metal Total Hip Arthroplasty

Routine follow-up approximately every 2 to 5 years after total hip arthroplasty (THA) is a common practice. However, although patients are informed of the importance of follow-up, our mean follow-up rate for patients after standard non-metal-on-metal (MOM) THA is only 19%. The US Food and Drug Administration has released several statements on the importance of follow-up every 2 years after MOM THA. With the potential risks of MOM THA apparently widely known, we report on our ability to obtain timely follow-up at 2 separate centers. Two separate centers performed 570 MOM THA procedures between 2002 and 2010. An attempt was made to reach every patient by either telephone or letter to obtain ion levels, radiographs, and examinations. Repeat telephone calls and/or letters to those not reached were made annually. Patients were told of the unique importance of follow-up at each contact. Of the patients, 43% had not been seen within the past 5 years, and only 26% had been seen within the past 2 years. Only 61% had their first measurement of ion levels, and only 30% of patients had a second set of measurement of ion levels. A total of 48 revisions occurred in this group, and 36 patients died. Despite the apparent widespread dissemination of information regarding the potential risks of MOM THA and concerted efforts to contact patients for follow-up, we have been able to achieve a follow-up rate of only 26%. This rate is only marginally better than the mean follow-up for non-MOM THA in our practices. The implications of this poor follow-up are unknown. [Orthopedics. 2022;45(4):e196-e200.].

A brief human history of ankylosing spondylitis: A scoping review of pathogenesis, diagnosis, and treatment

Background

Ankylosing spondylitis (AS) is a chronic, progressive, inflammatory disease of the spine and SI joints. Diagnostic criteria and treatments have continued to evolve, necessitating a historical compendium of AS and its management. This paper aims to review the historical context underlying the discovery of AS, as well as the major diagnostic and therapeutic discoveries in the last two centuries.

Methods

A scoping review of the literature pertaining to AS was performed via the Pubmed, Scopus, and Web of Science databases. Future directions of AS treatments were assessed by querying the clinicaltrials.gov website.

Results

The history of AS can be traced as far back as ancient Egypt (as evidenced by the discovery of its presence in ancient Egyptian mummies) to the late 20th century, when the inherited nature of AS was linked to a genetic factor, HLA-B27. Each discovery made throughout the years led to further investigations into the pathophysiology, diagnosis, and treatment of AS. The criteria to differentiate AS from rheumatoid arthritis were first reported in 1893. Since then, diagnostic criteria for AS have undergone a series of changes before the present-day diagnostic criteria for AS were ultimately determined in 2009 by the Assessment of Spondyloarthritis International Society.

Conclusion

As the pathophysiology of AS is better understood, healthcare providers are able to diagnose and treat the condition more effectively. In particular, earlier diagnosis and multiple treatment options have facilitated efficient and more effective treatment.

Probing lubricated sliding wear properties of HDPE/UHMWPE hybrid bionanocomposite

Ultra-high molecular weight polyethylene (UHMWPE) and its derivatives have been clinically used as an acetabular liner material in total hip joint replacement (THR) over last six decades. Despite significant efforts, the longevity of UHMWPE implants is still impaired due to their compromised tribological performance, leading to osteolysis and aseptic loosening. The present study aims to critically evaluate and analyze the tribological performance, of the next generation acetabular liner material, that is, a chemically modified graphene oxide (GO) reinforced HDPE/UHMWPE (HU) bionanocomposite (HUmGO), against stainless steel (SS 316L) counterface in lubricated conditions. This work also provides a performance comparative assessment of HUmGO with respect to medical grades, UHMWPE (UC) and crosslinked UHMWPE (XL-UC). Significant attempts have been made to correlate the tribological properties (frictional behavior, wear rate, wear debris shape and size, wear mechanism) with the physicomechanical conditions (contact stresses) at sliding contact and the variation in molecular architecture of different UHMWPE materials. Additionally, an emphasis is put forward to critically anlyze the nature of lubrication regime based on the bearing characterstic parameters. HUmGO exhibited a lower COF (0.07) and specific wear rate (2.86 × 10^-8 mm³/Nm) than UC and XL-UC under identical sliding conditions. The worn surfaces on HUmGO revealed the signatures of less abrasive wear and limited deformation. Based on the estimated lambda (λ) ratio and Sommerfield number, all the investigated sliding contacts exhibited boundary lubrication. Taken together, the modified GO reinforced HDPE/UHMWPE bionanocomposite can be considered as a new generation biomaterial for the fabrication of acetabular liner for hip-joint prosthesis.

Demand Matching Total Joint Replacement Patients Results in Reduction of Post-Discharge Costs

BACKGROUND

The shift from fee-for-service to value-based care has focused payers and providers on resource utilization. One important component of value-based care is to reduce the use of post-discharge (PD) services in a clinically appropriate manner following total joint arthroplasty (TJA). Demand matching in healthcare is the process of tailoring appropriate medical care to a patient with respect to that patient's specific medical needs and social determinants. Outcomes following the implementation of a demand-matching algorithm for coordinating PD services after TJA were analyzed in this study.

METHODS

Payment data from all Medicare patients undergoing primary unilateral TJA between July 2014 and December 2018 from a single orthopedic practice were included. These payments were separated into acute and PD care. The initial acute and PD costs were compared to costs at the end of the 4-year study period using multiple linear regression and chi-square.

RESULTS

A total of 9,638 patients (4,212 total hip arthroplasties and 5,430 total knee arthroplasties) were included. Acute costs of TJA were stable averaging $13,712.00. PD costs fell steadily from a baseline average of $7,319.00 in July 2014 to $4,678.00 in December 2018 (P < .001), representing a 36.1% decline. Discharge to home increased steadily from 45.8% to 79.9% during the same interval (P < .001.) CONCLUSION: Our results demonstrate a statistically significant reduction in PD costs over a 4-year period using a demand-matching strategy to align with the Centers for Medicare and Medicaid Services mandate for value-based care. Based on these data, we conclude that thoughtful preoperative assessment of patient factors such as social determinants and medical comorbidities could allow for cost reduction through better utilization of PD services.

When the Total Hip Replacement Fails: A Review on the Stress-Shielding Effect

Total hip arthroplasty is one of the most common and successful orthopedic surgeries. Sometimes, periprosthetic osteolysis occurs associated with the stress-shielding effect: it results in the reduction of bone density, where the femur is not correctly loaded, and in the formation of denser bone, where stresses are confined. This paper illustrates the stress shielding effect as a cause of the failing replacement of the hip joint. An extensive literature survey has been accomplished to describe the phenomenon and identify solutions. The latter refer to the design criteria and the choice of innovative materials/treatments for prosthetic device production. Experimental studies and numerical simulations have been reviewed. The paper includes an introduction to explain the scope; a section illustrating the causes of the stress shielding effect; a section focusing on recent attempts to redefine prosthetic device design criteria, current strategies to improve the osteointegration process, and a number of innovative biomaterials; functionally graded materials are presented in a dedicated section: they allow customizing prosthesis features with respect to the host bone. Conclusions recommend an integrated approach for the production of new prosthetic devices: the “engineering community” has to support the “medical community” to assure an effective translation of research results into clinical practice.

Iliopsoas Hematoma After Total Hip Arthroplasty Using a Minimally Invasive Modified Direct Anterior Approach: A Case Report

CASE

The modified direct anterior approach (MDAA) is a recently popular surgical technique for total hip arthroplasty (THA), with well-documented challenges. Characterized as acute hip and back pain, we present the case of a 78-year-old woman who developed an iliopsoas hematoma after an MDAA THA and discuss the management of this incident.

CONCLUSIONS

Iliopsoas hematoma after THA poses a unique challenge and should be considered in patients with acute hip and back pain, with loss of strength on the affected limb after an MDAA THA.

Spinopelvic alignment and low back pain after total hip arthroplasty: a scoping review

OBJECTIVE

Spinopelvic alignment is increasingly considered as an essential factor for maintaining an energy-efficient posture in individuals with normal or pathological status. Although several previous studies have shown that changes in the sagittal spinopelvic alignment may occur in patients undergoing total hip arthroplasty (THA), no review of this area has been completed so far. Thus, the objective of this scoping review was to summarize the evidence investigating changes in spinopelvic alignment and low back pain (LBP) following THA.

DATA SOURCES

We adhered to the established methodology for scoping reviews. Four electronic databases were systematically searched from inception-December 31, 2021.

STUDY SELECTION

We selected prospective or retrospective observational or intervention studies that included patients with THA.

DATA EXTRACTION

Data extraction and levels of evidence were independently performed using standardized checklists.

DATA SYNTHESIS

A total of 45 papers were included in this scoping review, involving 5185 participants with THA. Pelvic tilt was the most common parameter measured in the eligible studies (n = 26). The results were not consistent across all studies; however, it was demonstrated that the distribution of pelvic tilt following THA had a range of 25° posterior to 20° anterior. Moreover, decreased sacral slope and lower pelvic incidence were associated with increased risk of dislocation in patients with THA. Lumbar spine scoliosis did not change significantly after THA in patients with bilateral hip osteoarthritis (5.50°(1.16°) vs. 3.73°(1.16°); P-value = 0.29). Finally, one study indicated that LBP improvement was not correlated with postoperative changes in spinopelvic alignment parameters. Several methodological issues were addressed in this study, including no sample size calculation and no type-I error adjustment for outcome multiplicity.

CONCLUSIONS

Changes in spinopelvic alignment may occur after THA and may improve with time. Patients with a THA dislocation usually show abnormal spinopelvic alignment compared to patients without a THA dislocation. LBP usually improves markedly over time following THA.

Overview of Methods to Quantify Invasiveness of Surgical Approaches in Orthopedic Surgery—A Scoping Review

Background

There is a trend toward minimally invasive and more automated procedures in orthopedic surgery. An important aspect in the further development of these techniques is the quantitative assessment of the surgical approach. The aim of this scoping review is to deliver a structured overview on the currently used methods for quantitative analysis of a surgical approaches' invasiveness in orthopedic procedures. The compiled metrics presented in the herein study can serve as the basis for digitization of surgery and advanced computational methods that focus on optimizing surgical procedures.

Methods

We performed a blinded literature search in November 2020. In-vivo and ex-vivo studies that quantitatively assess the invasiveness of the surgical approach were included with a special focus on radiological methods. We excluded studies using exclusively one or multiple of the following parameters: risk of reoperation, risk of dislocation, risk of infection, risk of patient-reported nerve injury, rate of thromboembolic event, function, length of stay, blood loss, pain, operation time.

Results

The final selection included 51 articles. In the included papers, approaches to 8 different anatomical structures were investigated, the majority of which examined procedures of the hip (57%) and the spine (29%). The different modalities to measure the invasiveness were categorized into three major groups “biological” (23 papers), “radiological” (25), “measured in-situ” (14) and their use “in-vivo” or “ex-vivo” was analyzed. Additionally, we explain the basic principles of each modality and match it to the anatomical structures it has been used on.

Discussion

An ideal metric used to quantify the invasiveness of a surgical approach should be accurate, cost-effective, non-invasive, comprehensive and integratable into the clinical workflow. We find that the radiological methods best meet such criteria. However, radiological metrics can be more prone to confounders such as coexisting pathologies than in-situ measurements but are non-invasive and possible to perform in-vivo. Additionally, radiological metrics require substantial expertise and are not cost-effective. Owed to their high accuracy and low invasiveness, radiological methods are, in our opinion, the best suited for computational applications optimizing surgical procedures. The key to quantify a surgical approach's invasiveness lies in the integration of multiple metrics.

Polydopamine Codoped BaTiO3-Functionalized Polyvinylidene Fluoride Coating as a Piezo-Biomaterial Platform for an Enhanced Cellular Response and Bioactivity

For a number of clinical applications, Ti6Al4V implants with bioactive coatings are used. However, the deposition of a functional polymeric coating with desired physical properties, biocompatibility, and long-term stability remains largely unexplored. Among widely investigated synthetic biomaterials, polyvinylidene fluoride (PVDF) with β-polymorph and barium titanate (BaTiO₃, BT) are considered as good examples of piezo-biopolymers and bioceramics, respectively. In this work, an adherent PVDF-based nanocomposite coating is deposited onto a Ti6Al4V substrate to explore the impact of its functional characteristics (piezoactivity) on cellular behavior and bioactivity (apatite growth and mineralized matrix formation). The precursor solution was prepared by physically grafting PVDF with polydopamine (pDOPA), forming mPVDF. Subsequently, mPVDF was reinforced with BaTiO₃ nanoparticles in dimethylformamide/acetone solution, and the resulting nanocomposite (mPVDF-BT) was then spray-coated onto a roughened Ti6Al4V substrate using an airbrush at 140 °C under a pressure of 2 bar. The reproducibility of this simple yet effective processing approach to deposit chemically stable and adherent coatings was established. Remarkably, the modification with pDOPA and reinforcement with BaTiO₃ nanoparticles resulted in an enhanced β-fraction of PVDF up to 96%. This nanocomposite encouraged cellular viability of preosteoblasts (∼158% at day 5) and characteristic spreading, in vitro. Our findings indicate that the mPVDF-BT coating facilitated faster nucleation and growth of the biomineralized apatite layer with ∼70% coverage within 3 days of incubation in the simulated body fluid. In addition, the coupling among surface polar energy (5.5 mN/m), fractional polarity (∼117%), roughness (8.7 μm), and fibrous morphology also endorsed better cellular behavior. Taken together, this coating deposition strategy will pave the pathway toward designing cell-instructive surface-modified Ti6Al4V biomaterials with tailored biomineralization and bioactivity properties for musculoskeletal reconstruction and regeneration applications.

Proof of concept study for using UR10 robot to help total hip replacement

BACKGROUND

The demand for total hip replacement (THR) for treating osteoarthritis has grown substantially worldwide. The existing robotic systems used in THR are invasive and costly. This study aims to develop a less-invasive and low-cost robotic system to assist THR surgery.

METHODS

A preliminary robotic reaming system was developed based on a UR10 robot equipped with a reamer to cut acetabulum. A novel approach was proposed to cut through a 5 mm hole in femur such that the operation is less invasive to the patients.

RESULTS

The average error of the cutting hemisphere by the robotic reaming system is 0.1182 mm which is smaller than the average result reaming by hand (0.1301 mm).

CONCLUSION

The robotic reaming can help make THR procedures less invasive and more accurate. Moreover, the system is expected to be significantly less expensive than the robotic systems available in the market at present.

Prevention of early complications following total hip replacement

Total hip arthroplasty (THA) has been quoted as "the operation of the century", owing to its efficacy and the substantial improvements evidenced with respect to functional patient outcomes and quality of life. However, early postoperative complications are often inevitable, hence it is imperative to take every step to prevent them and minimise morbidity and mortality. This manuscript focuses on the most common early complications following THA, namely venous thromboembolism (VTE), prosthetic joint infection, periprosthetic fracture, instability, and leg length inequality. It aims to outline effective risk stratification strategies and prevention measures that could apply to the wider Orthopaedic community.

Dislocation of a McMinn-Like Prosthesis with Distinctive Metallosis and Fracture of the Os Ilium

Osteoarthritis of the hip joint (coxarthrosis) is the most common hip disease in adults. Since the 1960s, total hip arthroplasty (THA) has made great progress and is nowadays one of the most frequently used procedures in orthopedic surgery. Different bearing concepts exist in various implant designs. A metal-on-metal bearing can create metal debris and lead to metallosis. We present a unique case of a 78-year old woman, who received hip resurfacing with a McMinn-like prosthesis 15 years ago. Over the cause of time, metallosis developed and created a bone cyst in the Os ilium, and osteolysis led to a dislocation of the femoral implant. A minor stumble fall led to a fracture of the Os ilium. We present our treatment method with implantation of a cemented THA and refill of the bone cyst with bone from allogene femoral heads. The surgery led to a reconstruction of the physiological center of rotation in the hip. Consequently, to the inpatient stay, the patient took part in a follow-up treatment with intensive physiotherapy. Taken together, the results after total hip arthroplasty are more superior to other hip surface replacements in terms of longevity and patient satisfaction. Especially, metal-on-metal bearing couples carry a great risk of metallosis, which goes a long with pseudotumors, osteolysis, and the elevated metal ions in the blood. Since this case is unique in the literature, no guidelines are noted for surgical treatment. In our opinion, a periprosthetic fracture of this type should be performed in a hospital using extensive endoprosthetic expertise.

A Comparison of Risks and Benefits Regarding Hip Arthroplasty Fixation

Since the field-changing invention of noncemented hip arthroplasty fixation in the 1980s, noncemented fixation has been progressively replacing cemented fixation. However, analyses of fixation frequencies reveal new patterns in cement versus noncemented preferences. Although cementation is again gaining ground in the United States, noncemented models remain the dominant fixation mode, seen in more than 90% of all hip arthroplasties. This stark preference is likely driven by concerns regarding implant durability and patient safety. Although advances in surgical techniques, intensive perioperative care, and improved instrument have evolved in both methods, data from large arthroplasty registries reveal shifting risks in contemporary hip arthroplasty, calling the use of noncemented fixation into question. Varying risk profiles regarding sex, age, or health comorbidities and morphological and functional differences necessitate personalized risk assessments. Furthermore, certain patient populations, based on the literature and data from large registries, have superior outcomes from cemented hip arthroplasty techniques. Therefore, we wanted to critically evaluate the method of arthroplasty fixation in primary hip arthroplasties for unique patient populations.

Biomaterials and Their Biomedical Applications: From Replacement to Regeneration

The history of biomaterials dates back to the mists of time: human beings had always used exogenous materials to facilitate wound healing and try to restore damaged tissues and organs. Nowadays, a wide variety of materials are commercially available and many others are under investigation to both maintain and restore bodily functions. Emerging clinical needs forced the development of new biomaterials, and lately discovered biomaterials allowed for the performing of new clinical applications. The definition of biomaterials as materials specifically conceived for biomedical uses was raised when it was acknowledged that they have to possess a fundamental feature: biocompatibility. At first, biocompatibility was mainly associated with biologically inert substances; around the 1970s, bioactivity was first discovered and the definition of biomaterials was consequently extended. At present, it also includes biologically derived materials and biological tissues. The present work aims at walking across the history of biomaterials, looking towards the scientific literature published on this matter. Finally, some current applications of biomaterials are briefly depicted and their future exploitation is hypothesized.

What Are the Long-term Outcomes of Mortality, Quality of Life, and Hip Function after Prosthetic Joint Infection of the Hip? A 10-year Follow-up from Sweden

BACKGROUND

Prosthetic joint infection (PJI) is a complication after arthroplasty that negatively affects patient health. However, prior reports have not addressed the long-term consequences of hip PJI in terms of patient mortality, quality of life, and hip function.

QUESTIONS/PURPOSES

At a minimum of 10 years after PJI in patients undergoing primary THA, in the context of several large, national databases in Sweden, we asked: (1) Is mortality increased for patients with PJI after THA compared with patients with a noninfected THA? (2) Does PJI of the hip have a negative influence on quality of life as measured by the Euro-QoL-5D-5L (EQ-5D-5L), ambulatory aids, residential status, and hip function as measured by the Oxford Hip Score (OHS)? (3) Which factors are associated with poor patient-reported outcome measures (PROMs) for patients with PJI after primary THA?

METHODS

This study included 442 patients with a PJI after primary THA, from a previously published national study, including all patients with a THA performed from 2005 to 2008 in Sweden (n = 45,570) recruited from the Swedish Hip Arthroplasty Registry (SHAR). Possible deep PJIs were identified in the Swedish Dispensed Drug Registry and verified by review of medical records. Mortality in patients with PJI was compared with the remaining cohort of 45,128 patients undergoing primary THA who did not have PJI. Mortality data were retrieved from the SHAR, which in turn is updated daily from the population registry. A subgroup analysis of patients who underwent primary THA in 2008 was performed to adjust for the effect of comorbidities on mortality, as American Society of Anesthesiologists (ASA) scores became available in the SHAR at that time. For the PROM analysis, we identified three controls matched by age, gender, indication for surgery, and year of operation to each living PJI patient. A questionnaire including EQ-5D-5L, ambulatory aids, residential status, and OHS was collected from patients with PJI and controls at a mean of 11 years from the primary procedure. Apart from age and gender, we analyzed reoperation data (such as number of reoperations and surgical approach) and final prosthesis in situ to explore possible factors associated with poor PROM results.

RESULTS

After controlling for differences in sex, age, and indication for surgery, we found the all-cause 10-year mortality higher for patients with PJI (45%) compared with patients undergoing THA without PJI (29%) (odds ratio 1.4 [95% CI 1.2 to 1.6]; p < 0.001). The questionnaire, with a minimum of 10 years of follow-up, revealed a lower EQ-5D-5L index score (0.83 versus 0.94, -0.13 [95% CI -0.18 to -0.08; p < 0.001]), greater proportion of assisted living (21% versus 12%, OR 2.0 [95% CI 1.2 to 3.3]; p = 0.01), greater need of ambulatory aids (65% versus 42%, OR 3.1 [95% 2.1 to 4.8]; p < 0.001), and a lower OHS score (36 versus 44, -5.9 [-7.7 to -4.0]; p < 0.001) for patients with PJI than for matched controls. Factors associated with lower OHS score for patients with PJI were three or more reoperations (-8.0 [95% CI -13.0 to -3.2]; p = 0.01) and a direct lateral approach used at revision surgery compared with a posterior approach (-4.3 [95% CI -7.7 to -0.9]; p = 0.01).

CONCLUSION

In this study, we found that PJI after THA has a negative impact on mortality, long-term health-related quality of life, and hip function. Furthermore, the subgroup analysis showed that modifiable factors such as the number of reoperations and surgical approach are associated with poorer hip function. This emphasizes the importance of prompt, proper initial treatment to reduce repeated surgery to minimize the negative long-term effects of hip PJI.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Acetabular Exposure Is Enhanced With Self-Retaining Retractors During Direct Anterior Total Hip Arthroplasty

Acetabular exposure for direct anterior (DA) total hip arthroplasty (THA) can be performed using hands-free, self-retaining retractors. No current study quantitatively compares this self-retaining technique with the traditional manual technique. In 65 consecutive DA THA hips, two "best-view" digital photographs were taken of the exposure-one using Charnley/self-retaining retractors and one using a traditional three-retractor manual technique. Percent exposure of the polyethylene liner was calculated. Percent acetabular exposure averaged 80.0% using the Charnley/self-retaining technique, compared with 73.1% using the manual technique (P=.0002). A hands-free technique provides superior acetabular exposure compared with the manual technique. Increasing body mass index predicts decreasing exposure with both techniques. [Orthopedics. 2021;44(2):e309-e313.].

Systemic toxicity eliciting metal ion levels from metallic implants and orthopedic devices - A mini review

The metal/metal alloy-based implants and prostheses are in use for over a century, and the rejections, revisions, and metal particle-based toxicities were reported concurrently. Complications developed due to metal ions, metal debris, and organo-metallic particles in orthopedic patients have been a growing concern in recent years. It was reported that local and systemic toxicity caused by such released products from the implants is one of the major reasons for implant rejection and revision. Even though the description of environmental metal toxicants and safety limits for their exposure to humans were well established in the literature, an effort was not adequately performed in the case of implant-based metal toxicology. Since the metal ion concentration in serum acts as a possible indicator of the systemic toxicity, this review summarizes the reported human serum safe limits, toxic limits, and concentration range (μg/L, ppb, etc.) for mild to severe symptoms of six (cardiac, hepatic, neuro, nephron, dermal and endocrine) systemic toxicities for twelve most commonly used metallic implants. It also covers the widely used metal ion quantification techniques and systemic toxicity treatments reported.

Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery

Enhanced recovery after surgery (ERAS) protocols are applied in orthopedic surgery and are intended to reduce perioperative stress by implementing combined evidence-based practices with the cooperation of various health professionals as an interdisciplinary team. ERAS pathways include pre-operative patient counselling, regional anesthesia and analgesia techniques, post-operative pain management, early mobilization and early feeding. Studies have shown improvement in the recovery of patients who followed an ERAS program after hip or knee arthroplasty, compared with those who followed a traditional care approach. ERAS protocols reduce post-operative stress, contribute to rapid recovery, shorten length of stay (LOS) without increasing the complications or readmissions, improve patient satisfaction and decrease the hospital costs. We suggest that the ERAS pathway could reduce the LOS in hospital for patients undergoing total hip replacement or total knee replacement. These programs require good organization and handling by the multidisciplinary team. ERAS programs increase patient's satisfaction due to their active participation which they experience as personalized treatment. The aim of the study was to develop an ERAS protocol for oncology patients who undergo bone reconstruction surgeries using massive endoprosthesis, with a view to improving the surgical outcomes.

Biomaterial Properties of Femur Implant on Acetabulum Erosion: A Review

The hip is one in every of the various joint at intervals the body. The correct operating of this joint is essential. For the aim once the hip is injured whole, a substitution procedure of the entire joint ought to be done to reinstate its operating, that is known as absolute hip surgical process. It is finished with the assistance of inserts of various biomaterials, as an example, polymers, metals, and pottery. The primary issues with regard to the utilization of various biomaterials are the reaction of the body's instrument to wear trash. Throughout this audit, biomaterials that are developing is talked regarding aboard the wear and tear and tear conduct and instrument. To boot, the numerous properties of the biomaterials are talked regarding aboard the expected preferences and drawbacks of their utilization. Further, the blends of various biomaterials at intervals the articulating surfaces are cleft and so the problems regarding their utilization are assessed. This paper hopes to passes away an in depth review of the trauma fringe of bearing surfaces of hip prosthetic devices. Additionally, this paper can offer AN ordered blueprint of the materials nearby their favorable circumstances and detriments and besides the conceivable outcomes of use. Keywords: - Hip implant; Biomaterials; Wear mechanism; Bearing surfaces; Polymers