Total Hip Arthroplasty: Past, Present, and Future. What Has Been Achieved?

Is the increase in the number of total hip arthroplasties in Japan due to an aging society?

BACKGROUND

The number of total hip arthroplasty (THA) is increasing globally, including Japan. The Japanese Orthopaedic Association has been conducting a registry of joint replacement surgery, but there may be a gap between the reported numbers of THA in the registry and the actual number. This study aimed to investigate the exact number of THA and assess the trends in Japan using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB).

METHODS

We downloaded data from 2014 to 2019 from the NDB Open Data. Data on primary THA were extracted, and we calculated the annual number and number for each 10-year age group and sex. We also compared the number and trends between elderly and non-elderly groups.

RESULTS

During the study period, number of THAs increased by approximately 20,000, showing a continuous upward trend. The highest number of THAs were performed on patients in their 60s, except for the years 2014 and 2019. Comparison of the numbers in 2014 and 2019 by age group showed an increase in the number in patients in their 90s (by 2.05 times). There were significantly a greater number of elderly patients (P < 0.001). The number of THAs performed was higher in women than in men (P < 0.001).

CONCLUSION

The number of THAs in Japan increased substantially from 2014 to 2019, despite a decrease in population. Significantly higher number of THAs were performed on elderly patients in Japan, which might be due to an aging society. The NDB data is highly valuable for epidemiological research in Japan, as it might enable the early detection of issues occurring during THA, facilitating their prompt integration into daily clinical practice.

Press-fit vs threaded acetabulum components for total hip arthroplasty - A systematic review with metanalysis

Background

Threaded acetabular components (TACs) have been shown to offer greater initial stability compared to press-fit acetabular components (PFACs). Despite these biomechanical advantages, the use of threaded cups remains. This study compares the outcomes of TACs to PFACs in total hip arthroplasty (THA), providing evidence-based data regarding their failure rates and radiological evaluation.

Methods

A meticulous research of PubMed and MEDLINE databases, following the PRISMA guidelines, was conducted, to identify all articles regarding the outcome of the use of TCAs compared to PFACs in THA. Subsequently, statistical analysis with metanalysis concerning: 1) the instances of revision due to aseptic loosening and 2) the radiological evaluations of TACs compared to PFACs and sensitivity analysis were performed.

Results

This metanalysis encompassed seven studies, enrolling 7878 cases of THA utilizing PFAC, and 6684 cases using TAC. The overall odds ratio (OR) for revision due to aseptic loosening in THA using PFAC compared to TAC was 3.10 (95 % CI 0.37-25.72). Additionally, when assessing radiolucency findings across the same categories, the pooled OR was 0.53 (95 % CI 0.26-1.08). An examination of studies with larger sample sizes revealed no statistically significant variance. After adjusting for age, no substantial difference was detected. However, upon gender adjustment, it was observed that females undergoing THA with PFAC had a 5-fold risk of revision (OR = 5.26, 95 % CI 0.25-111.91, p-value = 0.29) compared to females with TAC, although without reaching statistical significance. Moreover, females exhibited a slightly elevated risk for revision due to aseptic loosening post-PFAC THA compared to males [(OR = 5.26, 95 % CI 0.25-111.91) (OR = 2.51, 95 % CI 0.01-1051.68) respectively], and for radiolucency findings [(OR 0.74, 95 % CI 0.20-1.11) (OR 0.29, 95 % CI 0.03-3.36) respectively].

Conclusions

The PFACs remain the main option for total hip reconstruction, while TACs might be a viable alternative, especially in cases of osteoporosis.

Satisfaction rates, function, and return to activity following young adult total hip arthroplasty

Aims

Young adults undergoing total hip arthroplasty (THA) largely have different indications for surgery, preoperative function, and postoperative goals compared to a standard patient group. The aim of our study was to describe young adult THA preoperative function and quality of life, and to assess postoperative satisfaction and compare this with functional outcome measures.

Methods

A retrospective cohort analysis of young adults (aged < 50 years) undergoing THA between May 2018 and May 2023 in a single tertiary centre was undertaken. Median follow-up was 31 months (12 to 61). Oxford Hip Score (OHS) and focus group-designed questionnaires were distributed. Searches identified 244 cases in 225 patients. Those aged aged under 30 years represented 22.7% of the cohort. Developmental dysplasia of the hip (50; 45.5%) and Perthes' disease (15; 13.6%) were the commonest indications for THA.

Results

Preoperatively, of 110 patients, 19 (17.2%) were unable to work before THA, 57 (52%) required opioid analgesia, 51 (46.4%) were reliant upon walking aids, and 70 (63.6%) had sexual activity limited by their pathology. One patient required revision due to instability. Mean OHS was 39 (9 to 48). There was a significant difference between the OHS of cases where THA met expectation, compared with the OHS when it did not (satisfied: 86 (78.2%), OHS: 41.2 (36.1%) vs non-satisfied: 24 (21%), OHS: 31.6; p ≤ 0.001). Only one of the 83 patients (75.5%) who returned to premorbid levels of activity did so after 12 months.

Conclusion

Satisfaction rates of THA in young adults is high, albeit lower than commonly quoted figures. Young adults awaiting THA have poor function with high requirements for mobility aids, analgesia, and difficulties in working and undertaking leisure activities. The OHS provided a useful insight into patient function and was predictive of satisfaction rates, although it did not address the specific demands of young adults undertaking THA. Function at one year postoperatively is a good indication of overall outcomes.

Change of joint line convergence angle and other coronal alignments after total hip arthroplasty

BACKGROUND

The purpose of this study was to determine the unloading effect of total hip arthroplasty (THA) on the ipsilateral knee joint through the joint line convergence angle (JLCA) change and determine the changes in other coronal radiographic parameters after THA, and evaluate the sensitivity of JLCA.

PATIENTS AND METHODS

We retrospectively assessed 70 patients who underwent unilateral THA. Hip parameters such as neck shaft angle (NSA), neck length, and femoral offset and coronal alignment parameters of the lower extremity such as hip-knee-ankle angle (HKA), femur length, mechanical lateral distal femoral angle (mLDFA), JLCA, medial proximal tibial angle (MPTA), lateral distal tibial angle (LDTA), and plafond talus angle (PTA) were measured in the operative and non-operative sides. We compared all hip and coronal alignment parameters between before and 1 year after THA, and the amount of standardized changes (Δ) between all hip and coronal alignment parameters on the operative side, respectively.

RESULTS

All mean hip and coronal alignment parameters on the operative side changed significantly 1-year after THA; however, those on the non-operative side did not. On the operative side, mean JLCA and PTA changed in the direction of closing the joint lateral space, from 1.81° and 0.47° to 1.22° and 0.11°, respectively (p<0.001 and 0.046, respectively). Mean NSA, HKA, and mLDFA changed in the valgus direction, from 129.39°, 2.62°, and 86.69° to 133.54°, 1.53°, and 85.91°, respectively (p<0.001). Mean femoral offset, neck length, and femur length increased from 36.45mm, 47.83mm, and 429.20mm to 39.85mm, 55.06mm, and 436.33mm, respectively (p<0.001). Mean MPTA and LDTA increased from 85.43° and 87.50° to 86.73° and 90.38, respectively (p<0.001). JLCA was more vulnerable to change than HKA, femur length, mLDFA, MPTA, and PTA (p<0.05).

DISCUSSION

JLCA change on the operative side was more sensitive than changes of other coronal alignments after THA. According to the cohort, THA might have an unloading effect on the medial compartment of the knee joint.

LEVEL OF EVIDENCE

IV; retrospective case-control and cohort studies.

Anatomical cup implantation assisted with dynamic 3D planning improves functional outcomes in primary total hip arthroplasty: A retrospective study

BACKGROUND

Anatomical cup implantation is a promising approach in primary total hip arthroplasty (THA) and improves functional outcomes.

OBJECTIVE

We aimed to evaluate the cup position and functional outcomes in primary THA with preoperative dynamic 3D planning.

METHODS

We retrospectively reviewed 54 hips in 48 patients who underwent primary THA with anatomical cup implantation (mean follow-up time: 52 months). Cup positions were evaluated based on patient-specific morphology, the acetabular fossa and the combined anteversion test. Functional outcomes were assessed after THA. The paired-sample t-test was performed for surgical and contralateral native hips among 42 patients who underwent unilateral THA.

RESULTS

Two hips suffered intraoperative trochanteric fracture, but no hip dislocations occurred. No patients reported groin or thigh pain, and all patients were capable of deep squatting and one-leg standing. The mean Harris hip score, WOMAC score, and physical SF-36 score were 94.46 ± 6.16, 10.41 ± 3.62, and 95.19 ± 8.74, respectively. Except for acetabular offset, THA restored biomechanics to those of contralateral native hip, including cup anteversion, abduction, femoral offset and acetabular height (P> 0.05).

CONCLUSION

This study provided evidence for the application of anatomical cup implantation assisted with dynamic 3D planning in primary THA, which restored morphology and improved functional outcomes.

Outcomes Following Total Hip Arthroplasty in Patients Who Have Charcot Neuroarthropathy of the Hip

BACKGROUND

Historically, Charcot neuroarthropathy hip (CNH) was deemed a contraindication for total hip arthroplasty (THA). However, as implant design and surgical techniques advance, THA for CNH has been performed and documented in literature. Information regarding the outcomes of THA for CNH is limited. The objective of the study was to assess outcomes following THA in patients who have CNH.

METHODS

Patients who have CNH underwent primary THA and had at least 2 years of follow-up were identified in a national insurance database. For comparison, a 1:10 matched control cohort of patients who did not have CNH was created based on age, sex, and relevant comorbidities. Eight hundred and ninety-five CNH patients who underwent primary THA were compared to 8,785 controls. Medical outcomes, emergency department visits, hospital readmissions, and surgical outcomes including revisions between cohorts were evaluated using multivariate logistic regressions.

RESULTS

The CNH patients were found to have higher risks of 90-day wound complications (P = .014), periprosthetic joint infection (P = .013) (P = .021), dislocation (P < .001) (P < .001), aseptic loosening (P = .040) (P = .002), periprosthetic fracture (P = .003) (P < .001), and revision (P < .001) (P < .001) at 1-year and 2-year follow-up, respectively.

CONCLUSION

While patients who have CNH are at a higher risk of wound and implant-related complications, they are comparatively lower than previously reported in literature. Orthopaedic surgeons should be cognizant of the increased risk in this population to provide appropriate preoperative counseling and enhanced perioperative medical management.

The Top Three Burning Questions in Total Hip Arthroplasty

Total hip arthroplasty (THA) for end-stage osteoarthritis is one of the most effective surgical treatments in medicine. Impressive outcomes have been well documented in the literature with patients gaining ambulation and recovery of hip joint function. Nevertheless, there are still debatable issues and controversies that the orthopedic community has not been able to provide a definitive answer for. This review is focused on the current three most debatable issues surrounding the THA procedure: (1) new cutting-edge technology, (2) spinopelvic mobility, and (3) fast-track protocols. The scope of the herein narrative review is to analyze the debatable issues surrounding the three aforementioned topics and conclude the best contemporary clinical approaches regarding each issue.

The modern state of femoral, acetabular, and global offsets in total hip arthroplasty: a narrative review

Offsets in the frontal plane are important for hip function. Research on total hip arthroplasty (THA) surgery agrees that increasing femoral offset up to 5 mm could improve functional outcome measures. The literature indicates that global offset is a key parameter that physicians should restore within 5 mm during surgery and avoid decreasing. Substantiated findings on acetabular offset are lacking despite its recognized importance, and the medialization approach must be assessed in light of its shortcomings. Future research, possibly through improved measurement, unified definitions, patient-specific surgical planning, and technology-enhanced surgical control, with specific focus on acetabular offset, is needed to better understand its impact on THA outcomes.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

[Analgesic effect of a new "cocktail" of local infiltration analgesia after total hip arthroplasty-A prospective randomized controlled study]

Objective

To study the analgesic effect of a new "cocktail" of local infiltration analgesia (LIA) with Deprosone after total hip arthroplasty (THA).

Methods

In a prospective randomized controlled study, 100 patients with hip joint disease requiring unilateral primary THA in West China Hospital of Sichuan University between January 2018 and December 2018 were enrolled and randomly divided into observation group and control group, with 50 cases in each group. There was no significant difference in age, gender, operative side, disease type, body mass index, American Society of Anesthesiologists (ASA) classification, preoperative rest and activity visual analogue scale (VAS) score, hip Harris score (HHS), quality of life scale (SF-12) score, and other general data between the two groups ( P>0.05). The patients in the observation group were treated with a new "cocktail" LIA around the hip joint before suturing the incision, and the drug formula was ropivacaine 200 mg, Diprospan 1 mL, morphine 10 mg, and added normal saline to 80 mL; the patients in the control group were not treated with LIA. The operation time, postoperative hospital stay, the amount of morphine used during hospitalization, and the range of motion of hip joint at discharge were recorded, and the complications were counted. The VAS score at rest and activity, HHS score, and SF-12 score [physiological score (PCS) and psychological score (MCS)] of the hip joint were recorded before and after operation, and the postoperative analgesic effect and the recovery of hip joint function were evaluated.

Results

There was no significant difference in the operation time between the two groups ( P>0.05), and the postoperative hospital stay in the observation group was significantly shorter than that in the control group ( P<0.05). The postoperative morphine consumption in the observation group was significantly less than that in the control group ( P<0.05), and the total morphine consumption in the observation group was less than that in the control group during hospitalization, but the difference was not significant ( P>0.05). Patients in both groups were followed up to 6 months after operation. The resting VAS scores of the observation group were significantly lower than those of the control group at 2, 6, 12 hours after operation and in the morning and afternoon of the first day after operation, and the active VAS scores of the observation group were significantly lower than those of the control group at 6, 12 hours after operation and in the morning of the first day after operation, and the differences were significant ( P<0.05). There was no significant difference in the resting and active VAS scores between the two groups on the day of discharge and at 3 and 6 months after operation ( P>0.05). At discharge, the flexion range of motion of hip joint in the observation group was significantly greater than that in the control group ( P<0.05), but there was no significant difference in the abduction range of motion of hip joint between the two groups ( P>0.05). There was no significant difference in HHS score and SF-12 score between the two groups at 3 and 6 months after operation ( P>0.05). There was no significant difference in analgesic satisfaction and functional satisfaction between the two groups at last follow-up ( P>0.05). There was no complication such as skin pruritus, superficial and deep infection of incision, skin necrosis, deep venous thrombosis of lower extremity, and pulmonary embolism in both groups. There was no significant difference in the incidence of complications such as nausea and vomiting, urine retention, fat liquefaction of incision, local hematoma, and large fluctuation of blood sugar between the two groups ( P>0.05).

Conclusion

The new "cocktail" LIA with Diprospan can effectively reduce the early postoperative pain of THA, reduce the dosage of opioids, shorten the length of hospital stay, and is conducive to the early functional rehabilitation of patients.

The Utilization of Postoperative Inpatient Ultrasound for Lower Extremity Deep Venous Thrombosis Following Total Hip Arthroplasty has Decreased Dramatically Over the Past Decade With No Obvious Negative Impact on Patient Care

BACKGROUND

Surgeons are increasingly performing total hip arthroplasty (THA) in the outpatient setting. Lower lengths of stay (LOS) could result in fewer lower extremity ultrasounds for deep vein thromboses (DVT). The objective of this study was to evaluate the incidence of lower extremity ultrasounds ordered and positive DVT results in the immediate postoperative period.

METHODS

All patients undergoing elective primary THA at an academic tertiary care center from January 2010 to February 2020 were included. Primary outcome of interest was incidence of postoperative DVT ultrasounds while inpatient and within 2 weeks following THA. Statistical analysis, including descriptive statistics and significance testing, was performed.

RESULTS

A total of 3,665 patients were included, of which, 2.0% (N = 72) of patients received a lower extremity ultrasound while inpatient, with only 2 being positive (2.8%), for an overall positivity rate of 0.05% of the entire cohort. The incidence of postoperative inpatient ultrasounds decreased from 7.0% in 2010 to 0.3% in 2020 (P < .001) whereas, the incidence of ultrasounds at 2 weeks and 2-week positivity rate remained stable. LOS was identified as a risk factor for postoperative inpatient ultrasound (P < .001).

CONCLUSIONS

Postoperative ultrasounds to evaluate for DVT are associated with a low yield and appear to be a consequence of reduced LOS in the hospital. Given the stable diagnosis rate of DVT at 2 weeks, our data suggests that the increasing trend toward outpatient arthroplasty will not result in missed opportunities to diagnose postoperative DVTs or lead to adverse outcomes and may provide benefit to patients by eliminating unnecessary testing.

LEVEL III EVIDENCE

Retrospective cohort study.

Peripheral Nerve Block for Pain Management after Total Hip Arthroplasty: A Retrospective Study with Propensity Score Matching

This study aimed to evaluate the effect of a peripheral nerve block (PNB) on immediate postoperative analgesia and the early functional outcomes for patients who underwent total hip arthroplasty (THA). From January 2016 to August 2021, 353 patients who underwent THA were divided into two groups: the patient-controlled analgesia (PCA) group (n = 217) who received only intravenous (IV) analgesia, and others who received IV PCA and PNB (PCA + PNB group) (n = 136). After propensity score matching for age and sex, 136 patients from each group were included in the study. Primary outcomes were the visual analogue scale (VAS) at rest, activity status at postoperative 6, 24, 48 h. Secondary outcomes were functional scores by the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, Harris Hip Score (HHS) and rescue medications used. The postoperative VAS at 6, 24, 48 h at rest and 6 h at activity were significantly lower in the PCA + PNB group (p = 0.000, 0.001, 0.000, 0.004 in order). There was no significant difference for postoperative 3-month HHS (p = 0.218), except for 3-month WOMAC index (p = 0.001). There were no significant differences for VAS between the PNB methods except femoral nerve block (FNB) and fascia iliaca compartment block (FICB) at postoperative activity 48 h (p = 0.028). There was no significant difference in the total count and amount of rescue medication (p = 0.091, 0.069) and difference in the quadriceps weakness was not noted. Therefore, PNB is beneficial for patients who undergo THA as it provides sufficient postoperative analgesia, especially during immediate postoperative resting pain without quadriceps weakness.

A new cocktail formula with diprospan of local infiltration analgesia in primary total hip arthroplasty: A prospective, randomized, controlled, observer-blinded study

OBJECTIVE

This study aimed to observe the analgesic effect of the cocktail formulation with diprospan during total hip arthroplasty (THA).

METHODS

From September 2018 to April 2019, 120 patients undergoing primary unilateral THA were included in this prospective, randomized, observer-blinded study. Patients were randomized into three groups, according to the different local infiltration analgesia (LIA) strategies: LIA with ropivacaine (the ropivacaine group, n = 40), LIA with a new cocktail containing ropivacaine, diprospan, and morphine (the cocktail group, n = 40), and the control group (n = 40). The primary outcomes included postoperative pain scores. The resting visual analogue scale (VAS) scores were measured at 2, 6, and 12 h after the surgery (a.m. and p.m.) on postoperative day (POD) 1, POD2, and the day of discharge. Movement VAS scores were assessed at 6 h, 12 h after the operation (a.m. and p.m.) on POD1, POD2, and the day of discharge. The secondary outcomes included opioid consumption, postoperative hospital stay, range of motion of the hip at discharge, patient satisfaction, and the results of the follow-up.

RESULTS

After the screening, 120 patients were randomized into three groups (40 patients in each group). All of the patients completed the trial. The resting VAS scores in the ropivacaine group and cocktail group at 2 h were lower than those in the control group (P < 0.001 and P < 0.001, respectively, F = 17.054), and the same trend was also postoperatively found at 6 h (p = 0.005 and P = 0.002, F = 6.212). Twelve hours after the operation, the pain score in the cocktail group was lower than that in the other two groups, but only the difference between the cocktail group and the control group was statistically significant (P = 0.018, F = 3.144). From the morning of the first postoperative day to the a.m. on POD 2, the VAS scores in the cocktail group were significantly lower than those in the ropivacaine group and the control group. Furthermore, the movement VAS scores in the ropivacaine group and the cocktail group were better than those in the control group at 6 and 12 h post-operation (P < 0.05). The per capita opioid consumption in the cocktail group was less than that in the ropivacaine group and the control group within 24 h post-operation. There were no significant differences in the comparison of additional indicators among the three groups.

CONCLUSION

The new cocktail with diprospan had a better result and longer duration time for early postoperative pain control in primary THA via the posterolateral approach under general anesthesia, especially for treating resting pain.

Risk Factors and Outcomes Associated with Intraoperative Fractures during Short-Stem Total Hip Arthroplasty for Osteonecrosis of the Femoral Head

Background

Young age in osteonecrosis of the femoral head (ONFH) demands bone-preserving, short-stem arthroplasty. Several designs including neck-preserving stems and neck-resecting, shortened, standard stems are classified as short stems. There is a paucity of literature investigating risk factors and outcomes of intraoperative complications of neck preserving, short-stem arthroplasty in ONFH.

Methods

A total of 107 hips operated with METHA short-stem arthroplasty for ONFH were retrospectively evaluated. The mean age of patients was 43.7 years (range, 27–60 years). Nine patients had an intraoperative fracture. Seven hips received prophylactic cerclage wiring for poor bone quality. Patients were invited for clinical and radiological evaluation at the latest follow-up.

Results

The mean follow-up of patients was 47.2 months. Significant association with intraoperative fractures and the need for prophylactic cerclage wiring were found in steroids-, alcohol-, and chronic renal failure-induced ONFH. However, patient sex, body mass index, traumatic/idiopathic ONFH, previous implant in situ, prosthesis size, and single-sitting bilateral total hip replacement (THA) were not the risk factors. All hips showed signs of osteointegration at final follow-up. No revision was done during the study period for any cause.

Conclusions

METHA short-stem THA offers excellent functional and radiological outcomes in ONFH. However, precaution must be exercised in patients with steroids-, alcohol-, and renal disorders-induced ONFN due to poor bone quality and higher chances of intraoperative fractures. Also, additional measures such as the use of a high-speed burr and prophylactic cerclage wiring in ONFH may allow predictable and safe use of short stems.

Different Designs of Proximal Femoral Stems for Total Hip Arthroplasty: Mid-Term Clinical and Patient-Reported Functional Outcomes

INTRODUCTION

A comprehensive comparison of the performance of different femoral stem geometries in total hip arthroplasty (THA) is yet to be described. The primary aim of this study was to evaluate objective and subjective outcome measures in primary THA with different femoral implant styles.

METHODS

Stems were classified into the following five classes: cemented, conical, fit and fill, modular, and wedge. The objective outcomes of interest were the length of inpatient hospital stay (LOS), 90-day readmission rate, one-year revision rate, and two-year mortality rate. Preoperative and postoperative patient-reported outcome measures (PROMs), including hip disability and osteoarthritis outcome score (HOOS) - physical function shortform (HOOS-PS), patient-reported outcomes measurement information system physical function short form 10a (PROMIS PF-10a), and patient-reported outcomes measurement information system - short form - mental 10a (PROMIS M-10a) were recorded and compared between different classes.

RESULTS

Patients with a wedge stem had a significantly lower LOS versus every other stem group, while patients with a cemented stem had the highest LOS, approximately twofold that of the wedge stem group. Accounting for potential confounders, the conical and fit and fill groups had a significantly higher two-year mortality rate than the wedge stem group. Fit and fill stems conferred a slight risk of revision THA at one-year compared to wedge stems. There was no significant difference in the rates of failure to achieve the minimal clinically important difference (MCID) for the PROMs.

CONCLUSION

Placement of wedge stems resulted in a significantly lower LOS compared to every other stem class and a lower mortality rate than the conical, fit and fill, and modular stems. As for the 90-day readmission, one-year revision, and the rates of failure to achieve the MCID for general or hip-specific PROMs, stem design had no meaningful effect.

Sclerostin-Mediated Impaired Osteogenesis by Fibroblast-Like Synoviocytes in the Particle-Induced Osteolysis Model

Engineered biomaterials are envisioned to replace, augment, or interact with living tissues for improving the functional deformities associated with end-stage joint pathologies. Unfortunately, wear debris from implant interfaces is the major factor leading to periprosthetic osteolysis. Fibroblast-like synoviocytes (FLSs) populate the intimal lining of the synovium and are in direct contact with wear debris. This study aimed to elucidate the effect of Ti particles as wear debris on human FLSs and the mechanism by which they might participate in the bone remodeling process during periprosthetic osteolysis. FLSs were isolated from synovial tissue from patients, and the condition medium (CM) was collected after treating FLSs with sterilized Ti particles. The effect of CM was analyzed for the induction of osteoclastogenesis or any effect on osteogenesis and signaling pathways. The results demonstrated that Ti particles could induce activation of the NFκB signaling pathway and induction of COX-2 and inflammatory cytokines in FLSs. The amount of Rankl in the conditioned medium collected from Ti particle–stimulated FLSs (Ti CM) showed the ability to stimulate osteoclast formation. The Ti CM also suppressed the osteogenic initial and terminal differentiation markers for osteoprogenitors, such as alkaline phosphate activity, matrix mineralization, collagen synthesis, and expression levels of Osterix, Runx2, collagen 1α, and bone sialoprotein. Inhibition of the WNT and BMP signaling pathways was observed in osteoprogenitors after the treatment with the Ti CM. In the presence of the Ti CM, exogenous stimulation by WNT and BMP signaling pathways failed to stimulate osteogenic activity in osteoprogenitors. Induced expression of sclerostin (SOST: an antagonist of WNT and BMP signaling) in Ti particle–treated FLSs and secretion of SOST in the Ti CM were detected. Neutralization of SOST in the Ti CM partially restored the suppressed WNT and BMP signaling activity as well as the osteogenic activity in osteoprogenitors. Our results reveal that wear debris–stimulated FLSs might affect bone loss by not only stimulating osteoclastogenesis but also suppressing the bone-forming ability of osteoprogenitors. In the clinical setting, targeting FLSs for the secretion of antagonists like SOST might be a novel therapeutic approach for preventing bone loss during inflammatory osteolysis.

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

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

Preclinical evaluation of a mini-arthroplasty implant based on polyetheretherketone and Ti6AI4V for treatment of a focal osteochondral defect in the femoral head of the hip

A mini or partial arthroplasty may offer the advantages of reduced pain, shorter hospital stay, and increased range of motion, which are beneficial for the treatment of large-sized focal osteochondral defects. We aimed to evaluate the in vivo histologic response and function of our nonresorbable, composite structure implant, developed using polyetheretherketone (PEEK) and Ti6AI4V alloy, as a treatment for full-thickness osteochondral defects in the femoral head of the hip using a goat model. The gross and imaging appearance and histologic results were compared to those of a similar size cobalt-chromium-molybdenum (CoCrMo) alloy implant placed in a defect in the femoral head and evaluated up to 12 weeks. The X radiographs showed that there was no evidence of loosening of the implants for both the PEEK-Ti6AI4V and CoCrMo groups. Magnetic resonance imaging results showed no inflammatory signal findings in both PEEK-Ti6AI4V and CoCrMo implants. Macroscopically and histologically, there was lesser cartilage degeneration in the PEEK-Ti6AI4V implant than in the CoCrMo implant. The modified macroscopic articular evaluation score was lower in the PEEK-Ti6AI4V group than in the CoCrMo group (p < 0.05), and the histological score of the periprosthetic and acetabular cartilage was lower in the PEEK-Ti6AI4V group than in the CoCrMo group (P < 0.05). The micro-computed tomography results showed that the uncemented PEEK-Ti6AI4V implant has better osseointegration and higher bone-implant contact than the cemented CoCrMo implant. The peri-implant bone mass was higher in the PEEK-Ti6AI4V implant(p < 0.05). Meanwhile, the optical profile analytical results showed that the surface roughness of the cartilage in the acetabulum was higher in the CoCrMo group. In conclusion, the mini-arthroplasty implant based on PEEK-Ti6AI4V was superior to an identical CoCrMo alloy implant as a treatment for local osteochondral defect in the femoral head, owing to its in vivo cartilage protection and better osseointegration.

Fibroblast-Like-Synoviocytes Mediate Secretion of Pro-Inflammatory Cytokines via ERK and JNK MAPKs in Ti-Particle-Induced Osteolysis

Biomaterials are designed to replace and augment living tissues in order to provide functional support to skeletal deformities. However, wear debris produced from the interfaces of metal implants initiates inflammatory bone loss, causing periprosthetic osteolysis. Lately, fibroblast-like synoviocytes (FLS) have been shown to play a role in wear-debris-induced osteolysis. Thus, here we have tried to understand the underlying mechanism of FLS involvement in wear-debris-induced osteolysis. Our results demonstrate that the effects of Ti particle (1:100 cell-to-Ti particle ratio) on FLS can induce Cox-2 expression and activate NFkB signaling. Moreover, the mRNA expression of pro-inflammatory cytokines such as IL-6, IL-8, IL-11, IL-1β, and TNFα was found to be elevated. However, among these pro-inflammatory cytokines, the mRNA and protein levels of only IL-6, IL-1β, and TNFα were found to be significantly higher. Ti particles activated extracellular signal-regulated kinase (ERK) and c-Jun N-terminal kinase (JNK) mitogen-activated protein kinases (MAPKs) as an early response in FLS. Co-inhibition of ERK and JNK signaling pathways by their specific inhibitors (PD9805 and SP600125, respectively) resulted in the suppression of mRNA and protein levels of IL-6, IL-1β, and TNFα in FLS. Taken together, targeting ERK and JNK MAPKs in FLS might provide a therapeutic option for reducing the secretion of bone-resorbing pro-inflammatory cytokines, thus preventing periprosthetic osteolysis.

Preoperative meloxicam versus postoperative meloxicam for pain control, patients' satisfaction and function recovery in hip osteoarthritis patients who receive total hip arthroplasty: a randomized, controlled study

This study aimed to compare the analgesic effect, patients’ satisfaction, tolerance and hip-joint function recovery by preoperative meloxicam versus postoperative meloxicam in treating hip osteoarthritis (OA) patients receiving total hip arthroplasty (THA). 132 hip OA patients who underwent THA surgery were allocated into postoperative analgesia (POST) and preoperative analgesia (PRE) groups at a 1:1 ratio. In the PRE group, patients took meloxicam 15 mg at 24 h pre-operation, 7.5 mg at 4 h, 24 h, 48 h and 72 h post-operation; in the POST group, patients received meloxicam 15 mg at 4 h post-operation, then 7.5 mg at 24 h, 48 h and 72 h post-operation. Furthermore, postoperative pain, consumption of patient-controlled analgesia (PCA), overall satisfaction and adverse events were evaluated within 96 h post-operation; meanwhile, Harris hip score was assessed within 6 months post-operation. Pain VAS at rest at 6 h, 12 h, 24 h, and pain VAS at passive movement at 6 h, 12 h were decreased in PRE group compared to POST group. In addition, additional consumption of PCA and the total consumption of PCA were both reduced in PRE group compared to POST group. Additionally, overall satisfaction in PRE group was higher at 24 h, 48 h and 72 h compared to POST group. While Harris hip score was of no difference between POST group and PRE group at M3 or M6. Besides, no difference in adverse events incidence was found between the two groups. In conclusion, preoperative meloxicam achieves better efficacy and similar tolerance compared to postoperative meloxicam in hip OA patients post THA.