Surgical treatment of hip osteoarthritis: update in total hip arthroplasty

Total hip replacement is one of the most successful procedures in orthopaedic surgery. There are two different technologies for implant fixation in total hip replacement: cemented and cementless, both can be combined, which is called Hybrid arthroplasty. Long term implant stability results in long term function. The most important factor that limits longevity of well-fixed implants is the wear of the articular surfaces. Wear of the polyethylene from the acetabulum generates particles that access the implant bone or the implant-cement-bone interface. This produces an inflammatory reaction, osteolysis and implant loosening. Polyethylene of higher resistance to wear and prosthetic articulations without polyethylene (hard on hard bearings), have been introduced to improve wear particle generation. Minimally invasive surgical techniques minimize surgical trauma to sort tissue around the hip joint, facilitating a better and more rapid recovery.     

Revision total knee arthroplasty in patients with osteoarthritis

Total knee replacement (TKR) is a technically demanding surgical procedure, which is becoming more reliable and durable than total hip replacements. The authors describe the mechanisms of failure, the clinical evaluation of the painful TKR, the surgical planning techniques, and the overall results of revision TKR to date.     

Relevant change in radiological progression in patients with hip osteoarthritis. I. Determination using predictive validity for total hip arthroplasty

OBJECTIVE: To determine a cut-off point above which a change in joint space width (JSW) could be considered as relevant in patients with hip osteoarthritis (OA) on the basis of predicted need for subsequent total hip arthroplasty (THA). METHODS: A multicentre, prospective, longitudinal, 5-yr follow-up study was performed. A pelvic radiograph was obtained at entry and after 1 and 2 yr. For each film, the narrowest JSW was measured using a 0.1 mm graduated magnifying glass. The absolute and relative differences between baseline and 1 and 2 yr of follow-up were calculated. We determined the cut-off points above which an absolute or relative decrease in JSW between baseline and 1 and 2 yr of follow-up could be considered relevant on the basis of the predicted need for THA during the remaining years of the study. The need for THA was categorized as 'yes' or 'no'. Thereafter, for each observed change in JSW (0.1 per 0.1 mm or 1% per 1%), the sensitivity and specificity for subsequent THA were calculated. The choice of cut-off was based on maximal sensitivity and specificity, using the graphic representation of correct classification probabilities. In this way it was possible to obtain the best measured JSW threshold with maximal true positive and minimal false positive results. RESULTS: A total of 423 and 385 patients met the criteria for analysis using the decrease in JSW between baseline and 1 and 2 yr respectively. The best cut-off points were absolute decreases in JSW of 0.2 and 0.4 mm and relative decreases in JSW of 15 and 20% after 1 and 2 yr respectively, with corresponding ranges of sensitivity and specificity of 68-75 and 67-78%. CONCLUSION: This work determined the cut-off above which a change in JSW could be considered clinically relevant in patients with hip OA, on the basis of predicted subsequent need for THA. For validation, similar studies should be conducted in other countries with different health-care systems.     

Piroxicam and naproxen in patients with osteoarthritis of the hip waiting for total hip replacement

Summary Two-hundred and fifty-two patients waiting for a total hip replacement for degenerative hip disease were randomized to two groups of nonsteroidal anti-inflammatory medication using piroxicam, 20 mg per day, and naproxen, 750 mg per day, after exclusion for severe dyspepsia or peptic ulcer, asthma, idiosyncracy, dissent, age below 50 years, Harris hip score above 50, or significant contralateral disease. A significant improvement in the pain and daily activity parameters was obtained in both groups. The effect was better in the piroxicam group one month after the commencement of the treatment, and equal in the groups later during the observation period of 2–5 months. We conclude that continuous medication is beneficial in patients with severe osteoarthritis scheduled for operation. However, the side effects of the medication have to be carefully considered and followed up.     

S-ROM型THA治疗成人发育性髋关节结构不良继发骨关节炎

目的对S-ROM型全髋关节置换术(THA)治疗成人发育性髋关节结构不良(DDH)继发骨关节炎(OA)的近期疗效进行评价。方法对成人DDH继发OA的12例(15髋)患者进行S-ROM型THA。对Crowe型和型患者应用小直径髋臼假体和小号细直柄股骨假体。结果12例均一期愈合,除3例Crowe型患者出现暂时性腓总神经麻痹(2~4个月后恢复)、2例脱位外,余均顺利康复。Harris评分由术前的40.18分恢复到术后的85.34分。结论DDH患者存在骨性和肌性结构异常,手术难度较大;S-ROM型假体适合对DDH的治疗,近期疗效显著。     

The impact of body mass index on later total hip arthroplasty for primary osteoarthritis: a cohort study in 1.2 million persons

OBJECTIVE: To investigate the effects of body mass index (BMI), height, and age on the risk of later total hip arthroplasty for primary osteoarthritis (OA). METHODS: We matched screening data on body height and weight from 1,152,006 persons ages 18-67 years who attended a compulsory screening for tuberculosis in 1963-1975 with data from the Norwegian Arthroplasty Register for the years 1987-2003. We identified 28,425 total hip replacements because of primary OA. RESULTS: We found dose-response associations between both height and BMI and later hip arthroplasty. The relative risk (RR) among men with a BMI > or = 32 kg/m2 versus a BMI of 20.5-21.9 kg/m2 was 3.4 (95% confidence interval [95% CI] 2.9-4.0). The corresponding RR in women was 2.3 (95% CI 2.1-2.4). There was a decreasing trend in the RR with an increasing age at screening. Among men, the RR for an increase of 5 kg/m2 in the BMI was 2.1 (95% CI 1.7-2.5) when measured at age <25 years and 1.5 (95% CI 1.3-1.7) when measured at ages 55-59 years. Among women, the corresponding RR values were 1.7 (95% CI 1.5-1.9) and 1.1 (95% CI 1.1-1.2). CONCLUSION: There was a strong dose-response association between BMI and later total arthroplasty for OA of the hip. Being overweight entailed the highest RR among young participants, and the participants who were overweight at a young age maintained an excess RR for arthroplasty throughout the followup period.     

Satisfactory cross cultural equivalence of the Dutch WOMAC in patients with hip osteoarthritis waiting for arthroplasty

BACKGROUND: Cross cultural validity is of vital importance for international comparisons. OBJECTIVE: To investigate the validity of international Dutch-English comparisons when using the Dutch translation of the Western Ontario and McMaster Universities osteoarthritis index (WOMAC). PATIENTS AND METHODS: The dimensionality, reliability, construct validity, and cross cultural equivalence of the Dutch WOMAC in Dutch and Canadian patients waiting for primary total hip arthroplasty was investigated. Unidimensionality and cross cultural equivalence was quantified by principal component and Rasch analysis. Intratest reliability was quantified with Cronbach's alpha, and test-retest reliability with the intraclass correlation coefficient. Construct validity was quantified by correlating sum scores of the Dutch WOMAC, Arthritis Impact Measurement Scales (Dutch AIMS2), Health Assessment Questionnaire (Dutch HAQ), and Harris Hip Score (Dutch HHS). RESULTS: The WOMAC was completed by 180 Dutch and 244 English speaking Canadian patients. Unidimensionality of the Dutch WOMAC was confirmed by principal component and Rasch analysis (good fit for 20/22 items). The intratest reliability of the Dutch WOMAC for pain and physical functioning was 0.88 and 0.96, whereas the test-retest reliability was 0.77 and 0.92, respectively. Dutch WOMAC pain sum score correlated 0.69 with Dutch HAQ pain, and 0.39 with Dutch HHS pain. Dutch WOMAC physical functioning sum score correlated 0.46 with Dutch AIMS2 mobility, 0.62 with Dutch AIMS2 walking and bending, 0.67 with Dutch HAQ disability, and 0.49 with Dutch HHS function. Differential item functioning (DIF) was shown for 6/22 Dutch items. CONCLUSIONS: The Dutch WOMAC permits valid international Dutch-English comparisons after correction for DIF.     

Bilateral synchronous total hip arthroplasty for end-stage arthropathy in hemophilia A patients: A retrospective study

Total hip arthroplasty (THA) has been an effective tool of advanced hemophiliac hip arthritis. There are only limited data of bilateral synchronous THA for end-stage arthropathy in hemophilia A patients.The aim of this retrospective study was to analyze clinical outcome and complication rate of bilateral THA for hemophilia A patients with end-stage arthropathy of hip and review the operative strategy.From August 2012 to July 2016, 48 hips of 24 patients with hemophilia A patients underwent THA by a single experienced chief orthopedic surgeon. Clinical and radiological evaluations were included of operation time, blood loss, the quantity of blood transfusion, clotting factor consumption, duration of hospitalization, modified Harris hip score, complication rate, and radiographic assessment.All the 24 patients successfully completed the operation, followed up for 5 to 8 years, and the mean time was 6.5 years. The average operation time was 140 minutes (range, 120–180 minutes). The average total blood loss was 225 mL (range, 150–400 mL). The mean red blood cell transfusion amount was 2.4 U (range, 0–6 U). the mean hospitalization time was 24 days (range, 16–46 days). The mean amount of clotting factor VIII used in the perioperative period for management of hemophilia A was 30,600 U (range, 18,000–52,000 U). Average modified Harris hip score increased from 46.6 (range 28–70) points preoperatively to 90.2 (range 75–98) points at final follow-up, complications were few.With excellent operative techniques and hematological management, bilateral synchronous THA for end-stage arthropathy in hemophilia A patients can provide satisfactory outcomes.     

Coronal tibiofemoral subluxation in patients with osteoarthritis was corrected after total knee arthroplasty

The objective of this study was to investigate the effect of preoperative coronal tibiofemoral subluxation (CTFS) on postoperative mechanical alignment in patients undergoing total knee arthroplasty (TKA) for primary knee osteoarthritis (OA) and to investigate whether TKA can correct preoperative CTFS. We hypothesized that TKA would correct CTFS in patients with knee OA. A retrospective analysis of 102 patients with knee OA who underwent TKA was performed. The preoperative and postoperative CTFS and mechanical alignment were measured and compared. At the same time, the baseline values of CTFS and mechanical alignment in “normal” patients were measured and compared with those in the operation group. Eighty patients were eventually enrolled in the study. Mechanical alignment was corrected from 7.3 ± 5.2°, preoperatively, to 1.6 ± 2.3° postoperatively, while the tibiofemoral subluxation was corrected from 5.3 ± 2.6 mm, preoperatively, to 2.3 ± 2.7 mm postoperatively. There was no significant correlation between preoperative CTFS and gender (r = 0.03), BMI (r = −0.09), age (r = 0.05), or preoperative mechanical alignment (r = 0.09). In addition, there was no correlation between the degree of correction of CTFS and the degree of correction of overall mechanical alignment (r = 0.14). The difference between the value for CTFS in the “normal” patients and the preoperative value for arthritis cohorts were statistically significant (P = .004). However, no significant difference was appreciated between the value for CTFS in the “normal” patients and the postoperative value for TKA cohorts (P = .25). Preoperative CTFS does not affect postoperative mechanical alignment. Excellent TKA can correct preoperative CTFS in OA patients to reduce prosthesis wear and improve postoperative patient satisfaction.     

Comparison of femoral sagittal axis between navigated total knee arthroplasty and conventional total knee arthroplasty in patients with knee osteoarthritis

To compare femoral sagittal axis between navigated total knee arthroplasty (TKA) and conventional TKA.A total of 136 cases were assigned to group 1 (navigated TKA) and 77 cases were assigned to group 2 (conventional TKA). Specifically, this study targeted patients with degenerative osteoarthritis. Only patients with primary TKA were analyzed. Hip knee ankle angle and lateral femoral bowing were measured using preoperative scanogram. Anterior femoral bowing was measured using preoperative femoral lateral X rays. The presence of anterior femoral notching and the insertion angle of the femoral implant with respect to the anatomical sagittal plane of the distal femur were checked using postoperative lateral knee X rays. Student t-test was used to compare the difference in the position of the sagittal plane of the femoral implant between the navigated TKA group and the conventional TKA group.When comparing the 2 groups, the sagittal axis of the femoral implant was more extended than the anatomical sagittal plane axis of the distal femur in group 1 than in group 2 (P = .01). There was a significant negative correlation between the value of anterior femoral bowing and the degree of flexion to the sagittal plane of the femoral implant in group 1 (correlation coefficient: –0.40, P = .01). The occurrence of anterior femoral notching was significantly higher in group 1 than in group 2.During navigated TKA, imageless navigation does not consider the anatomical variation of the femoral shaft. Therefore, surgeons should take into consideration that when performing navigated TKA, a femoral implant could be inserted more extended for the anatomical sagittal axis of the distal femur than for the conventional TKA. Also, surgeon should know that the degree of extension insertion of the femoral implant increases as femoral anterior bowing increases.     

A case of ochronotic arthropathy treated with total hip arthroplasty

We report a case of ochronotic arthropathy treated with total hip arthroplasty. The articular cartilage of the patient's femoral head and synovium displayed black pigmentation. Microscopically, the articular cartilage revealed reddish-brown pigmentation (particularly in deep cartilage), necrotic chondrocytes, and slight black pigmentation in the cytoplasm of chondrocytes. Electron microscopy revealed electron-dense material deposited predominantly along and between collagen fibers.     

A case of ochronotic arthropathy treated with total hip arthroplasty

Abstract

We report a case of ochronotic arthropathy treated with total hip arthroplasty. The articular cartilage of the patient's femoral head and synovium displayed black pigmentation. Microscopically, the articular cartilage revealed reddish-brown pigmentation (particularly in deep cartilage), necrotic chondrocytes, and slight black pigmentation in the cytoplasm of chondrocytes. Electron microscopy revealed electron-dense material deposited predominantly along and between collagen fibers.     

Quantitative measurement of joint space narrowing progression in hip osteoarthritis: a longitudinal retrospective study of patients treated by total hip arthroplasty

OBJECTIVES: To evaluate the rate of progression of radiological joint space narrowing (JSN) in patients operated on for hip osteoarthritis (OA) and to determine its predictive factors. METHODS: Study design: retrospective longitudinal trial of 61 patients who underwent total hip arthroplasty (THA) for hip OA (69 operated hips). Mean follow-up 81.2 +/- 9.9 months. Collected data: (1) standing frontal radiographs of the pelvis from diagnosis to surgery (246 films) for morphological evaluation and quantitative measurement of joint space width (JSW) (computerized reading of digitized X-rays); (2) demographic data (sex, age, body mass index, smoking status, professional and sporting activities, family history of OA); (3) clinical data (age at onset- diagnosis and THA, drug consumption, time from diagnosis to permanent disability, OA at other joints, previous THA of the contralateral hip). Statistics: multivariate analysis. RESULTS: The yearly mean narrowing (YMN) of MeanJSW was 0.43 +/- 0.43 mm/yr (median 0.29, range 0.03- 2.55). YMN correlated inversely with joint space width at operation and follow-up duration, and was increased in atrophic OA (r = 0.71). The time between diagnosis and THA correlated with JSW at diagnosis, and was inversely correlated with age at onset and YMN. It was longer in patients with hypertrophic OA (r = 0.69). CONCLUSION: Rapid progression of JSN, older age and absence of osteophytes appear to be the main factors leading to THA.      

Quadriceps muscle wasting persists 5 months after total hip arthroplasty for osteoarthritis of the hip: a pilot study

Aims: To determine whether additional muscle fibre wasting of the ipsilateral vastus lateralis muscle occurs in the early postoperative period after total hip arthroplasty for osteoarthritis of the hip and whether there is an improvement in preoperative measures of quadriceps muscle thickness, strength, pain and function over a 5‐month postoperative period. Methods: Twelve patients had ipsilateral needle quadriceps biopsy for muscle morphology and bilateral quadriceps muscle thickness ultrasound preoperatively, 5 days and 4 weeks postoperatively and a further muscle thickness measurement at 5 months. Seven additional patients and five age‐matched control subjects had bilateral quadriceps muscle ultrasound thickness preoperatively, 6 weeks and 5 months postoperatively, with assessment of quadriceps muscle dynamometry, pain scores and Timed Up and Go (TUG) test. Results: Preoperatively, all 19 patients demonstrated significant atrophy of the ipsilateral compared with the contralateral quadriceps muscle (P = 1.8 × 10^–7) on muscle ultrasound, which persisted at 5 months follow up (P = 0.009). Muscle morphology preoperatively showed type 2A and 2B muscle fibre atrophy on needle muscle biopsy, with further atrophy of all three fibre types (P = 0.029) at 5 days postoperatively associated with a fibre type shift from type 1 to 2A fibres (P = 0.0011) at 1 month. There was improvement in hip pain postoperatively and a significant improvement in the TUG test (P = 0.007). However, there was no improvement in muscle strength on dynamometry. Conclusions: There is significant ipsilateral quadriceps atrophy and weakness with 2A and 2B fibre atrophy preoperatively in patients with osteoarthritis of the hip with exacerbation and further atrophy of all three fibre types 5 days postoperatively. Postoperative follow up showed that the reduction in ipsilateral quadriceps muscle thickness persisted at 5 months despite physical rehabilitation. Patients did note significant improvement in pain postoperatively and improvement on functional assessment with the TUG test. Other therapeutic strategies may have to be developed to reverse disuse muscle atrophy. (Intern Med J 2001; 31: 7–14)     

A tool for measuring functional outcomes after total hip arthroplasty

Purpose. To describe a functional milestone scale (FMS) for measuring functional progression following total hip arthroplasty and to demonstrate that this scale meets accepted standards of scale construction. Methods. Inter-observer reliability of the scale was determined for 30 patients using a kappa coefficient of concordance (k) for ordinal data, representing 221 pairs of observations. There were 79, 54, 44, and 44 pairs of observations for transfer, walker, crutch, and stair ambulation, respectively. Results. The k coefficient ranged from 0.82 to 0.91. Agreement between therapists was almost perfect according to the criteria of Feinstein. Conclusions. The FMS exhibits substantial inter-observer reliability and moderate to substantial validity. We have demonstrated its clinical applications as well as showing it to be a useful management and research tool.     

Cost-effectiveness of total joint arthroplasty in osteoarthritis

Although total joint replacement (TJR) is a major advance in the treatment of patients with osteoarthritis, its cost-effectiveness has been questioned. We report the results of a study of the costs and benefits of TJR in consecutive osteoarthritis patients, 6 months after the surgery. Health status was measured by the Index of Well-Being. Costs of services for arthritis were determined by interview and billing records. Six months after TJR, significant improvements were seen in global health and in functional status. The average cost of care for the 6 months prior to TJR was $933. The average cost during the 6 months beginning with the TJR was $22,730 per patient--due almost entirely to costs of surgery. In general, the surgery did not change work status, probably because the mean age of the patients was 66.4 years. There were large effectiveness/cost differentials (the larger the effectiveness/cost differential, the higher the degree of cost-effectiveness [CE]). At 6 months, for all patients, the CE was associated with initial health status. The highest CE was observed in 10 patients who initially had the poorest health. TJR is more cost-effective for patients with the most to gain and less effective for those with better preoperative health status.     

Current risk factors for asymptomatic venous thromboembolism in patients undergoing total hip arthroplasty

Abstract

Objective: A history of venous thromboembolism (VTE) is a risk factor for newly formed VTE after total hip arthroplasty (THA). However, its morbidity and association with postoperative VTE are not clear and, therefore, were investigated in this study.

Methods: Four-hundred and nineteen patients scheduled for primary THA were included. We preoperatively identified any VTE factors such as obesity, age, and history of VTE by interviewing and duplex ultrasonography for all patients, and the patients were assigned into ‘high-’ or ‘low-risk’ groups, that were the indication whether chemoprophylaxis was administered after surgery. Postoperative VTE was also examined on the day 7 by enhanced computed tomography (CT) for all patients.

Results: Preoperative VTE were detected in 48 patients (11.4%), and postoperative VTE were found in 44 (10.5%). Linear and multivariate logistic regression analysis revealed osteonecrosis and preoperative VTE were the independent factors associated with postoperative VTE (Odds ratio (OR) 1.0 e-7 and 5.00, respectively). In the survey of each risk group, only preoperative VTE was recognized as a risk factor for high-risk group, and longer operation time for low-risk group.

Conclusion: The present study confirmed high frequency of preoperative VTE which was still the strongest risk factor for postoperative asymptomatic VTE