Surgical Treatment of Severe Heterotopic Ossification After Total Hip Arthroplasty Over the Last 25 Years: A Systematic Review of the Literature and a New Case Series

BACKGROUND

Severe heterotopic ossification (HO) (grades III and IV) after total hip arthroplasty (THA) over the last 25 years requiring excision is very uncommon. We performed a systematic review of the literature and reported a new case series with operative treatment after primary uncemented THA.

METHODS

A systematic review identified papers describing patients who had excision of HO after THA performed after 1988. Concepts of hip arthroplasty, HO, and surgical excision were searched in MEDLINE, Embase, and Scopus from database inception to November 2022. The inclusion criteria were articles that included specific patient data on the grade of HO, operative procedure, and prophylaxis. Studies were screened for inclusion by 2 independent reviewers. The extracted data included demographic data, the interval from index surgery to excision, clinical results, and complications. There was one surgeon who performed reoperation for ankylosis of primary THA in 3 men who had severe pain and hip deformity.

RESULTS

Data from 7 studies were included. There were 41 patients who had grade III or IV HO who had excision, and in 5 patients, revision of a component was also performed. Perioperative prophylaxis was irradiation alone in 10 patients, irradiation and indomethacin in 10 patients, and indomethacin alone in 21 patients. At a mean follow-up time of 14.8 months, the definition of the results was not uniform, and range of motion was improved, but relief of pain was inconsistent. There was one dislocation after resection without revision, one gastrointestinal complication, and 2 recurrences. Treatment of the 3 new patients, with wide excision of periarticular bone, selective exchange of components, and perioperative irradiation prophylaxis, was successful in improving pain, motion, and deformity.

CONCLUSIONS

There is insufficient good-quality data on the operative treatment of severe symptomatic HO after THA performed over the last 25 years. Prophylaxis with low-dose irradiation prevented a recurrence. Multicenter studies are needed to determine the optimum timing and prognosis for treatment.

Trabecular titanium cups in hip revision surgery: a systematic review of the literature

Background

Hip revision surgery in extensive acetabular bone defects represents a complex challenge for hip surgeons. The primary goal is to obtain a stable acetabular component and restore the hip biomechanics. Through the years, different prosthetic implants have been developed to perform acetabular revision depending on bone loss location and extension. This systematic review aims to summarize the clinical outcomes and complications reported with trabecular titanium (TT) cups in hip revision surgery.

Methods

A literature search of four databases (PubMed, Embase, Scopus and the Cochrane Database of systematic reviews) was performed according to the PRISMA guideline from January 2008 to December 2022. All studies written in English and reporting the clinical outcome of patients undergoing revision total hip arthroplasty using Delta TT cups were included. The initial screening identified 378 studies. Each eligible clinical article was analyzed according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence (LoE), and the papers' methodological quality was evaluated using The Methodological Index for Non-Randomized Studies Criteria (MINORS) score.

Results

Eight clinical studies were included in the analysis. A total of 523 hip revisions were analyzed. Delta TT cups were used in 3.9%, Delta TT one cups in 46.8%, and Delta TT revisions in 49.3%. Paprosky IIIa was the most frequent acetabular bone defect reported in 26.4% of cases. The overall survival rate of TT cups was 93.4%. The dislocation was the most frequent complication in 4.1% of patients, while the prevalence of aseptic loosening was 1.5.

Conclusions

Managing severe acetabular bone defects remains a complex challenge for hip surgeons. Since their introduction, TT cups have exhibited good clinical results, with complication rates in line with or lower than those reported by similar implants.

Total Hip Arthroplasty After Hip Arthroscopy Has Increased Complications and Revision Risk

BACKGROUND

There has been an increase in hip arthroscopy (HA) over the last decade. After HA, some patients may ultimately require a total hip arthroplasty (THA). However, there is a scarcity of research investigating the outcomes in patients undergoing THA with a history of ipsilateral HA.

METHODS

The PearlDiver research program (www.pearldiverinc.com) was queried to capture all patients undergoing THA between 2015 and 2020. Propensity matching was performed to match patients undergoing THA with and without a history of ipsilateral THA. Rates of 30-day medical complications, 1-year surgical complications, and THA revision were compared using multivariate logistic regression. Kaplan-Meier analysis was conducted to estimate survival probabilities of each of the groups with patients undergoing THA .

RESULTS

After propensity matching, cohorts of 1940 patients undergoing THA without prior HA and 1940 patients undergoing a THA with prior HA were isolated for analysis. The mean time from HA to THA was 1127 days (standard deviation 858). Patients with a history of ipsilateral HA had an increased risk for dislocation (odds ratio [OR] 1.56, P = .03) and overall decreased implant survival within 4 years of undergoing THA (OR 1.53; P = .05). Furthermore, our data demonstrate the timing of previous HA to be associated with the risk of complications, as illustrated by the increased risk for dislocation (OR 1.75, P = .03), aseptic loosening (OR 2.18, P = .03), and revision surgery at 2 (OR 1.92, P = .02) and 4 years (OR 2.05, P = .01) in patients undergoing THA within 1 year of HA compared twitho patients undergoing THA more than 1 year after HA or with no previous history of HA.

CONCLUSION

Patients undergoing THA after HA are at an increased risk for surgical complications, as well as the need for revision surgery.

Custom Made Monoflange Acetabular Components for the Treatment of Paprosky Type III Defects

PURPOSE

Patient-specific, flanged acetabular components are used for the treatment of Paprosky type III defects during revision total hip arthroplasty (THA). This monocentric retrospective cohort study analyzes the outcome of patients treated with custom made monoflanged acetabular components (CMACs) with intra- and extramedullary iliac fixation.

METHODS

14 patients were included who underwent revision THA with CMACs for the treatment of Paprosky type III defects. Mechanism of THA failure was infection in 4 and aseptic loosening in 10 patients. Seven patients underwent no previous revision, the other seven patients underwent three or more previous revisions.

RESULTS

At a mean follow-up of 35.4 months (14-94), the revision rate of the implant was 28.3%. Additionally, one perioperative dislocation and one superficial wound infection occurred. At one year postoperatively, we found a significant improvement of the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score (p = 0.015). Postoperative radiographic analysis revealed good hip joint reconstruction with a mean leg length discrepancy of 3 mm (-8-20), a mean lateralization of the horizontal hip center of rotation of 8 mm (-8-35), and a mean proximalization of the vertical hip center of rotation of 6 mm (13-26). Radiolucency lines were present in 30%.

CONCLUSION

CMACs can be considered an option for the treatment of acetabular bone loss in revision THA. Iliac intra- and extramedullary fixation allows soft tissue-adjusted hip joint reconstruction and improves hip function. However, failure rates are high, with periprosthetic infection being the main threat to successful outcome.

Double-tapered conical taper in primary and revision surgery: rationale and short-term follow-up

BACKGROUND:

The new double-conical tapered stem is a novel cementless modular system, which is indicated for both primary and revision surgeries. It has been designed with different angles at the proximal (5°) and distal sections (1° 36') in order to obtain optimal fixation by proximal and distal fit and fill of the femoral canal.

AIM:

The aim of this prospective study was to evaluate the short-term clinical and radiographic outcomes of primary and revision hip surgery with the new double-conical stem.

METHODS:

61 stems were implanted (December 2013 to September 2016) in 42 cases of primary and in 19 cases of revision surgery. The mean age of patients was 64.7 (17-94; standard deviation [SD] 21.9) years.

RESULTS:

The mean body mass index of the patients was 24.6 (17-34.6). In 3 cases of developmental dysplasia of the hip we performed femoral shortening osteotomy. The mean follow-up was 26 (8-40) months. 3 patients died due to causes unrelated to surgery. Postoperative complications included 3 hip dislocations, 2 infections and 1 case of stem explant for metastatic tumour. For all other cases, at the last follow-up radiographs showed no loosening, no radiolucent lines nor subsidence. The mean Harris Hip Score significantly improved from 45 (range 35-58) preoperatively to 87 (range 75-94). Leg length discrepancy was found in 10% of cases but never >1 cm.

CONCLUSIONS:

Radiographic analysis showed the bone-stem contact full at 2 levels of taper. The double-tapered prosthetic stem can therefore be usefully employed both in primary and in revision surgeries.

Do Mortality and Complication Rates Differ Between Periprosthetic and Native Hip Fractures?

BACKGROUND

Epidemiological estimates indicate a rising incidence of periprosthetic hip fractures. While native hip fractures are known to be a highly morbid condition, a significant body of research has led to improved outcomes and decreased complications following these injuries. Comparatively, little research has evaluated the relative morbidity and mortality of periprosthetic hip fractures. The purpose of this study was to compare the morbidity and mortality of periprosthetic vs native hip fractures.

METHODS

Using the National Surgical Quality Improvement Program (NSQIP) database, 523 periprosthetic hip fractures were matched to native hip fractures using propensity scores. The 30-day rates of complications were compared using McNemar's test. A multivariate regression was then used to determine independent risk factors for mortality following periprosthetic fracture.

RESULTS

Mortality was similar between groups (periprosthetic: 2.7% vs native: 3.4%; P = .49). Periprosthetic fractures exhibited a greater rate of overall (63.1% vs 38.6%; P < .001) and minor complications (59.1% vs 34.4%; P < .001). There was an increased rate of return to the operating room (7.8% vs 3.1%; P < .001) and blood transfusion in the periprosthetic group (54.9% vs 30.2%; P = .001). Age greater than 85 (odds ratio 9.21) and dependent functional status (odds ratio 5.38) were both independent risk factors for mortality following periprosthetic fracture.

CONCLUSIONS

While native hip fractures are known to be highly morbid, our findings suggest that periprosthetic hip fractures have a similar mortality with significantly higher short-term morbidity. Future research is warranted to better understand risk factors and prevention strategies for complications in this subset of patients.

Gout arthropathy following hip arthroplasty: a need for routine aspiration microscopy? A review of the literature and case report

This article presents the case of a patient with pain associated with a total hip replacement. Following aspiration microscopy, a diagnosis of gout in a total hip replacement was made. Successful treatment was instituted with medical management in the presence of coexisting aseptic loosening. Gout in a total hip replacement is an exceptionally rare diagnosis. The gold standard for diagnosis is not urate level but crystal identification in the synovial fluid. The authors would therefore recommend that as part of a thorough workup for painful prosthetic joint requiring revision, a present or past history of gout is sought and a fluid aspirate should be examined not only for infection but also under polarized light for crystal arthropathy.