Total Hip Arthroplasty With Subtrochanteric Shortening Osteotomy in Patients With High Hip Dislocation Secondary to Childhood Septic Arthritis: A Matched Comparative Study With Crowe IV Developmental Dysplasia

BackgroundTotal hip arthroplasty (THA) with subtrochanteric shortening osteotomy (SSO) is performed to manage hips with high dislocations. We compared outcomes of THA with SSO in patients with high hip dislocation resulting from childhood septic arthritis and Crowe IV developmental dysplasia of the hip (DDH).MethodsWe reviewed 60 THAs with SSO performed between May 1996 and December 2013. Thirty-one cases were classified as sequelae of childhood infection and 29 as DDH. Twenty-five hips were selected for each group after the propensity score was matched with preoperative demographics and leg length discrepancy (LLD). Clinical scores, complication and reoperation rates, radiographic results, and survivorships were compared. The mean duration of follow-up was 12.3 (range 5-22) years.ResultsThe average correction in LLD was 2.5 cm for childhood infection and 3.6 cm for DDH (P = .002). The infection group received more transfusions (mean 3.3 vs 2.0 units, P = .002), required more time for union of osteotomy site (mean 6.8 vs 5.2 months, P = .042), and reported lower Harris Hip Score (mean 85.1 vs 91.3, P = .017). Reoperations were performed in 11 (44%) previously infected hips and 3 (12%) DDHs (P = .012). Kaplan-Meier survivorship with an endpoint of revision for any reason was lower in the infection group (83.6%) than in the DDH group (100%) at 10 years (log rank, P = .040).ConclusionTHA with SSO in high hip dislocation secondary to childhood septic arthritis demonstrated less favorable clinical outcomes with increased risks of complication, compared with those performed in Crowe IV DDH with similar degree of chronic dislocation.     

Long-Term Results of Total Hip Arthroplasty in Young Patients With Osteonecrosis After Allogeneic Bone Marrow Transplantation for Hematological Disease: A Multicenter,Propensity-Matched Cohort Study With a Mean 11-Year Follow-Up

BackgroundThe number of young patients with hematological disease requiring total hip arthroplasty (THA) is expected to increase. We aimed to investigate the long-term THA outcomes in patients with osteonecrosis of the femoral head (ONFH) following allogeneic bone marrow transplantation (BMT) for hematological disease.MethodsAll patients who underwent THA for osteonecrosis after BMT from 1997 to 2012 were identified at 2 institutions. Using propensity scores, 75 THAs in 45 patients were matched for age, gender, body mass index, American Society of Anesthesiologists score, and year of surgery with 75 THAs in 58 patients with idiopathic ONFH without a history of hematological disease (1:1 ratio). The mean age at surgery was 36.7 years and 52% were men. Clinical and radiographic evaluations were performed and clinical scores were obtained at last follow-up. Kaplan-Meier analyses were used to compare survivorship.ResultsAt a mean follow-up of 10.6 ± 3.5 years, clinical, radiographic, and survivorship outcomes, and the Harris hip scores were similar between both groups. The 13-year survivorship for all-cause revision was 93.4% for the BMT group and 95% for the control group (P = .928). No significant differences were observed between groups in the rates of reoperation (4% vs 5.3%, P = 1.000), 90-day readmission (all 5.3%), or overall mortality (4.4% vs 1.7%, P = .681). No hips had periprosthetic joint infection or septic loosening in either group. Osteolysis occurred in none of the BMT patients and in 2 hips (2.7%) of the control patients (P = .497).ConclusionThis large cohort multicenter survey at 11-year follow-up shows that contemporary cementless THA in young hematological disease patients after allogeneic BMT is not associated with a higher risk for surgical complications, revision, reoperation, readmission, and mortality compared to a matched cohort of idiopathic ONFH.     

Midterm Outcomes and Frequency of Osteolysis of Total Hip Arthroplasty Using Cementless Modular Stem for Asian Patients

BackgroundModular stems are useful for total hip arthroplasty (THA) in anatomically difficult dysplasia. Here, we present mean 6.8-year outcomes of cementless primary THA using S-ROM-A (modified modular stem for Asian patients) femoral prosthesis in anatomically difficult cases.MethodsCharts of 373 patients (461 hips) undergoing THA (mean age, 58 years) were reviewed for clinical evaluation of modified Merle d’Aubigné-Postel score and Kaplan-Meier survivorship with revision for any reason as the end point. For radiographic analysis, 331 patients (412 hips) followed up for ≥5 years were included. Bearing couples were metal-on-metal (n = 145), metal-on-polyethylene (n = 120), and ceramic-on-polyethylene (n = 147). Radiography and multiplanar computed tomography were performed.ResultsNo postoperative dislocation or deep infection occurred. Mean modified Merle d’Aubigné-Postel score improved significantly (10.9 points preoperatively, 16.7 points at last follow-up; P < .001). Cumulative 5- and 10-year stem survival rates were 100% and 84%, respectively (95% confidence interval, 75%-93%). All stems were classified as bone ingrown fixation. Osteolysis occurred in metal-on-metal (42.8%) and metal-on-polyethylene (15.8%) groups. Mean time to osteolysis was ~3 years, with no significant difference between 3 groups (P = .264). In logistic regression, lower cup inclination angle was significantly associated with osteolysis (odds ratio, 0.914; 95% confidence interval, 0.84-0.99; P = .029).ConclusionS-ROM-A femoral prosthesis achieved excellent midterm fixation, and the modular system was useful in primary THA with severe deformity. Bearing couples are potentially associated with adverse reactions to metal debris. S-ROM-A with ceramic-on-polyethylene bearing couples may be an option for anatomically difficult THA.     

Intra-Articular Hyaluronic Acid Injections Less Than 6 Months Before Total Hip Arthroplasty: Is It Safe? A Retrospective Cohort Study in 565 Patients

BackgroundIntra-articular hyaluronic acid (IAHA) can be injected into an osteoarthritic hip joint to reduce pain and to improve functionality. Several studies report IAHA to be safe, with minor adverse effects that normally disappear spontaneously within a week. However, intra-articular corticosteroids prior to total hip arthroplasty (THA) have been associated with increased infection rates. This association has never been investigated for IAHA and THA. We aimed to assess the influence of IAHA on the outcome of THA, with an emphasis on periprosthetic joint infection (PJI).MethodsAt a mean follow-up of 52 months (±18), we compared complication rates, including superficial and deep PJIs, of THA in patients who received an IAHA injection ≤6 months prior to surgery (injection group) with that of patients undergoing THA without any previous injection in the ipsilateral hip (control group). One hundred thirteen patients (118 hips) could be retrospectively included in the injection group, and 452 patients (495 hips) in the control group.ResultsNo differences in baseline characteristics nor risk factors for PJI between the 2 groups were found. The clinical outcomes in terms of VAS pain scores (1.4 vs 1.7 points, P = .11), modified Harris Hip Scores (77 vs 75 points, P = .09), and Hip disability and Osteoarthritis Outcome Scores (79 vs 76 points, P = .24) did not differ between the injection group and the control group. Also, complications in terms of persistent wound leakage (0% vs 1.2%, P = .60), thromboembolic events (0% vs 0.6%, P = 1.00), periprosthetic fractures (1.7% vs 1.2%, P = .65), and dislocations (0% vs 0.4%, P = 1.00) did not differ. However, in the injection group there was a higher rate of PJIs (4% vs 0%, P < .001) and postoperative wound infections (9% vs 3%, P = .01), compared to the control group.ConclusionOur findings suggest that IAHA performed 6 months or less prior to THA may pose a risk for increased rates of PJI. We recommend refraining from performing THA within 6 months after IAHA administration.     

Periacetabular osteolysis is the problem in contemporary total hip arthroplasty in young patients

We retrospectively reviewed 474 patients (492 hips) with a contemporary cemented total hip arthroplasty (THA) (mean age, 38.9 years) and 504 patients (532 hips) with a cementless THA (mean age, 39.3 years). Patients were evaluated clinically and radiographically. The mean follow-up was similar (14.5 vs 14.8 years) in both groups. The mean postoperative Harris hip scores (93.6 vs 94.7 points), the mean Western Ontario and McMaster Universities Osteoarthritis Index scores (12 vs 13 points), and the mean University of California, Los Angeles activity scores (6.9 vs 7.1 points) were similar between the 2 groups. Incidence of acetabular osteolysis (16% vs 20%) and femoral osteolysis (8% vs 9%) was similar between the 2 groups. Survivorship of cup (86% vs 82%) and stem (98% vs 98.5%) was similar between the 2 groups. Periacetabular osteolysis constitutes the major challenge in modern THAs in young patients.     

Total Hip Arthroplasty in Patients With Osteogenesis Imperfecta

BackgroundOsteogenesis imperfecta (OI) comprises a spectrum of disorders that result in bone fragility. This presents unique challenges when performing total joint arthroplasty in patients with OI. The purpose of this study is to determine the survivorship and clinical outcomes of total hip arthroplasty (THA) in patients with OI.MethodsWe retrospectively reviewed our institution’s total joint registry from 1969 to 2018 for all primary THAs in patients with a history of OI. There were 11 patients (13 hips) with a mean follow-up of 13 years (range 6-20). Survivorship free of component revision was determined using Kaplan-Meier analysis. Patient-reported clinical outcomes were assessed using Harris Hip Scores.ResultsAt final follow-up, the status of the implant was known in all 13 hips. One patient (1 hip) was deceased. Four hips (31%) underwent revision surgery at a mean of 9 years (range 5-17). Survivorship free of component revision was 52% at 20 years. Mean Harris Hip Scores at final follow-up were fair (75, 47-97), but significantly improved compared to available preoperative scores (P = .0015). No intraoperative complications occurred during the 13 primary THAs.ConclusionTHA in patients with OI is associated with high revision rates and low survivorship at long-term follow-up. Although this is a very challenging patient population, THA provided these patients with improved functional outcomes. To the authors’ knowledge, this is the largest series of primary THA in patients with OI reported in the literature and therefore provides surgeons with important data regarding the expected outcomes following THA in this unique patient population.Level of EvidenceLevel IV.     

The Effects of Rasp Oversize on the Clinical and Radiographic Outcomes of Total Hip Arthroplasty With a Collared Satin-Finished Composite Beam Cemented Stem

BackgroundThis study aimed to compare the clinical and radiographic outcomes of using two different oversized rasps in total hip arthroplasty (THA) with a composite beam cemented stem (DCM-J).MethodsA consecutive series of 105 hips underwent hybrid THA using the DCM-J stem between 2006 and 2010. Among the patients with a minimum 10-year follow-up, a 1.5-mm oversized rasp was used in 38 hips (group S), whereas a 0.5-mm oversized rasp was used in 36 hips (group M). The Japanese Orthopedic Association hip score and radiographic findings were evaluated, including cement mantle thickness, stress shielding, and cortical hypertrophy.ResultsThe Japanese Orthopedic Association hip score was significantly improved postoperatively with 100% of the implant survival rate in both groups when septic loosening was excluded. Radiographic assessment performed immediately postoperatively revealed that the cement mantle thickness was significantly larger in group M than group S in Gruen zone 1 but did not differ between groups in zones 2-7. Stress shielding was significantly more frequent in group M than group S at 2 years (P = .011), 5 years (P = .012), and ≥10 years postoperatively (P = .038). Cortical hypertrophy appeared in a time-dependent manner; however, the prevalence did not significantly differ between groups at final follow-up at a mean of 11.7 years (range 10-14 years) postoperatively.ConclusionsThe DCM-J stem achieved good clinical results in both groups. Stress shielding was significantly more frequent in THA using the 0.5-mm rasp than the 1.5-mm rasp, indicating that sufficient cement mantle room should be prepared for the cemented stem.     

What are the Outcomes After Primary Total Hip and Knee Arthroplasty in Patients With Prior Cerebrovascular Accidents?

BackgroundFor patients who have a history of cerebrovascular accident (CVA) with neurological sequelae undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), we sought to determine mortality rate, implant survivorship, complications, and clinical outcomes.MethodsOur total joint registry identified CVA sequelae patients undergoing primary THA (n = 42 with 25 on affected hip) and TKA (n = 56 with 34 on affected knee). Patients were 1:2 matched based upon age, sex, body mass index, and surgical year to a non-CVA cohort. Mortality and implant survivorship were evaluated via Kaplan-Meier methods. Clinical outcomes were assessed via Harris Hip scores or Knee Society scores . Mean follow-up was 5 years (range, 2-12).ResultsFor CVA sequelae and non-CVA patients, respectively, the 5-year patient survivorship was 69 versus 89% after THA (HR = 2.5; P = .006) and 56 versus 90% after TKA (HR = 2.4, P = .003). No significant difference was noted between groups in implant survivorship free from any reoperation after THA (P > .2) and TKA (P > .6). Postoperative CVA occurred at an equal rate in CVA sequelae and non-CVA patients after TKA (1.8%); none after THA in either group. The magnitude of change in Harris Hip scores (P = .7) and Knee Society scores (P = .7) were similar for CVA sequelae and non-CVA patients.ConclusionComplications, including the risk of postoperative CVA, implant survivorship, and outcome score improvement are similar for CVA sequelae and non-CVA patients. A 2.5-fold increased risk of death at a mean of 5 years after primary THA or TKA exist for CVA sequelae patients.     

Total Hip Arthroplasty in Patients With Osteopetrosis

BackgroundOsteopetrosis is an inherited bone disease associated with high risk of osteoarthritis and fracture non-union, which can lead to total hip arthroplasty (THA). Bone quality and morphology are altered in these patients, and there are limited data on results of THA in these patients. The goals of this study were to describe implant survivorship, clinical outcomes, radiographic results, and complications in patients with osteopetrosis undergoing primary THA.MethodsWe identified 7 patients (9 hips) with osteopetrosis who underwent primary THA between 1970 and 2017 utilizing our total joint registry. The mean age at index THA was 48 years and included two males and five females. The mean follow-up was 8 years.ResultsThe 10-year survivorship free from any revision or implant removal was 89%, with 1 revision and 1 resection arthroplasty secondary to periprosthetic femoral fractures. The 10-year survivorship free from any reoperation was 42%, with 4 additional reoperations (2 ORIFs for periprosthetic femoral fractures, 1 sciatic nerve palsy lysis of adhesions, 1 hematoma evacuation). Harris hip scores significantly increased at 5 years (P = .04). Five hips had an intraoperative acetabular fracture, and 1 had an intraoperative femur fracture. All postoperative femoral fractures occurred in patients with intramedullary diameter less than 5 mm at a level 10 cm distal to the lesser trochanter.ConclusionPrimary THA in patients with osteopetrosis is associated with good 10-year implant survivorship (89%), but a very high reoperation (58%) and periprosthetic femoral fracture rate (44%). Femoral fractures appear associated with smaller intramedullary diameters.     

Long-Term Outcomes of Cementing Highly Cross-Linked Polyethylene Liners Into Well-Fixed Acetabular Shells in Revision Total Hip Arthroplasty

BackgroundCementing a new liner into a secure, well-positioned metallic shell can be a less-invasive strategy in revision total hip arthroplasty (THA). This study aimed to report the mean 14-year outcomes of cementing highly cross-linked polyethylene (XLPE) liners into well-fixed acetabular shells in revision THAs.MethodsThis study reviewed a single-surgeon series of cementing XLPE liners into well-fixed acetabular components. Of the 52 hips (51 patients) evaluated, 48 hips (47 patients) that satisfied a minimum follow-up of 10 years were included. The Harris Hip score was used for clinical evaluation. Final hip radiographs were used to determine the extent of acetabular osteolysis and stability of the components. The mean age at index operation was 53 years (range, 32 to 72). The mean follow-up duration was 14 years (range, 10 to 18).ResultsThe mean Harris Hip score improved from 58 points (range, 23-81) preoperatively to 91 points (range, 45-100) at the final evaluation (P < .001). A total of 3 acetabular rerevisions were performed, all for aseptic loosening of the outer shell. One postoperative dislocation occurred, but it was successfully treated with a closed reduction. Final radiographs showed a significant reduction in acetabular osteolysis (P < .001). Implant survivorship free from any rerevision was 93.3% (95% confidence interval, 85.9-100%) at 14 years.ConclusionCementing an XLPE liner into a well-fixed acetabular shell in revision THA demonstrated excellent clinical and radiographic outcomes at a mean of 14 years postoperatively. This technique could be a safe and durable option in the absence of XLPE liners compatible with preimplanted shells.     

Outcomes of free vascularized fibular graft for post-traumatic osteonecrosis of the femoral head

IntroductionOsteonecrosis of the femoral head (ONFH) can occur after traumatic injuries of the hip. Surgical treatment with total hip arthroplasty (THA) may not produce lifelong viability in younger patients. Free vascularized fibular graft (FVFG) has become a reliable method to delay or even avoid THA in this patient population by aiming to correct loss of viable bone through vascularized autologous bone transfer. The purpose of this study was to evaluate the longevity and outcomes of FVFG for traumatic hip injuries resulting in ONFH.MethodsWe performed a retrospective review of our institutional database of patients who had undergone FVFG from 1980-2006 for post-traumatic ONFH and had a minimum follow-up of 5 years. Data collected included demographics, pre-operative Urbaniak ONFH staging, Harris Hip scores (HHS), SF-12 scores, and conversion to THA.ResultsSeventy-two hips in 68 patients met inclusion criteria. Mean follow-up was 11.6 years (range 5.1–33.2 years). Etiology included femoral neck fracture in 36 patients (61%), hip dislocation in 7 (12%), trauma without fracture or dislocation in 11 (19%), and femoral neck nonunion in 5 (8%). The most common stage at presentation was stage IV (48 patients). Graft survival at final follow-up (mean 10.9 years) was 64%, with mean time to conversion to THA of 8.4 years in those that did not survive (36%). There was no difference between THA conversion rates in hips with pre-collapse (Stage I and II) versus impending or post-collapse (Stage III or IV) lesions (p = 0.227). In hips with surviving grafts at final follow-up, mean HHS improved from 56.7 to 77.3 (SD 24.57, range 69–93), a mean improvement of 20.6 (p < 0.001).ConclusionsOur study reveals improvement in HHS in surviving FVFG and an acceptable overall THA conversion rate at mid to long term follow-up in Urbaniak stage I through IV hips. FVFG remains a viable option for treatment in younger patients with pre- and post-collapse (stage IV) ONFH lesions secondary to hip trauma.     

Target Price Adjustment for Hip Fractures Is Not Sufficient in the Bundled Payments for Care Improvement Initiative

BackgroundUnder the Bundled Payments for Care Improvement (BPCI) initiative, the Centers for Medicare and Medicaid Services (CMS) adjusts the target price for total hip arthroplasty (THA) based upon the historical proportion of fracture cases. Concerns exist that hospitals that care for hip fracture patients may be penalized in BPCI. The purpose of this study is to compare the episode-of-care (EOC) costs of hip fracture patients to elective THA patients.MethodsWe reviewed a consecutive series of 4096 THA patients from 2015 to 2018. Patients were grouped into elective THA (n = 3686), fracture THA (n = 176), and hemiarthroplasty (n = 274). Using CMS claims data, we compared EOC costs, postacute care costs, and performance against the target price between the groups. To control for confounding variables, we performed a multivariate analysis to identify the effect of hip fracture diagnosis on costs.ResultsElective THA patients had lower EOC ($18,200 vs $42,605 vs $38,371; P < .001) and postacute care costs ($4477 vs $28,093 vs $23,217; P < .001) than both hemiarthroplasty and THA for fracture. Patients undergoing arthroplasty for fracture lost an average of $23,122 (vs $1648 profit for elective THA; P < .001) with 91% of cases exceeding the target price (vs 20% for elective THA; P < .001). In multivariate analysis, patients undergoing arthroplasty for fracture had higher EOC costs by $19,492 (P < .001).ConclusionPatients undergoing arthroplasty for fracture cost over twice as much as elective THA patients. CMS should change their methodology or exclude fracture patients from BPCI, particularly during the COVID-19 pandemic.     

Is Robotic-Assisted Technology Still Accurate in Total Hip Arthroplasty for Fibrous-Fused Hips?

BackgroundTotal hip arthroplasty (THA) for fibrous-fused hips is technically demanding. This study aimed to evaluate the precision and accuracy, as well as the rate of conversion of robotic-assisted THA in such difficult patients.MethodsWe retrospectively analyzed 67 patients (84 hips) who underwent THA with fibrous-fused hips between August 2018 and June 2021 at our institution. Demographics, acetabular cup positioning, leg-length discrepancies, and postoperative Harris hip scores were recorded for all patients. Thirty-six patients (44 hips) who underwent robotic-assisted THA and 31 patients (40 hips) who underwent manual THA were enrolled in this study.ResultsThe robot accurately executed the preoperative plan, and there were no statistically significant differences between the preoperative planned anteversion, inclination, and postoperative measurements. In the robotic group, the percentage of acetabular cups in the safe zone was significantly higher than in the manual group (87.2 versus 55%, respectively, P = .042). The rate of conversion to manual THA for various reasons in the robotic-assisted THA group was 11.4% (5/44). Compared with manual THA, the mean increase in operative time for conversion from robotic-assisted to manual THA was 24 min (P < .001).ConclusionIn patients who have fibrous-fused hips, preoperative planning can be accurately executed by robotic-assisted technology. Compared with manual THA, robotic-assisted THA had a remarkable advantage in improving the frequency of achieving cup positioning within the target zone. Overall, robotic-assisted technology was helpful in such difficult cases, and the approximately 11.4% of cases converted to manual THA are reminders that surgeons should be thoroughly prepared preoperatively.     

Hip Resurfacing: A Single Surgeon U.S. Series With Minimum Ten-Year Follow-up

BackgroundMetal-on-metal hip resurfacing is an alternative to total hip arthroplasty (THA). The aim of this study was to determine implant survivorship, analyze patient-reported outcomes measures and to determine patient satisfaction for patients who underwent metal-on-metal hip resurfacing at a large US academic institution by a single surgeon with a minimum of 10-year follow-up.MethodsPatients who underwent hip resurfacing from September 2006 through November 2009 were included. Patient demographics and variables were collected from a prospectively maintained institutional database and patients completed an additional questionnaire with patient-reported outcomes measures.ResultsA total of 350 patients (389 hips) out of 371 (433 hips) with a minimum 10-year follow-up were successfully contacted (94.3% follow-up). Mean age was 53 years, 258 were male (73%). 377 out of 389 hips (96.9%) did not require additional surgery. Gender was significantly related to implant survivorship (males 99.0%, females 90.9%; P < .001). 330 patients (369 hips, 94.8%) were satisfied with their surgery. Males had higher proportion of satisfaction scores (P = .02) and higher modified Harris Hip Score (odds ratio = 2.63 (1.39, 4.98), P = .003). Median modified Harris Hip Score score for non-revised hips was 84.0 [80.0; 86.0] versus those requiring revision, 81.5 [74.0; 83.0], (P = .009).ConclusionAt a minimum 10-year follow-up, hip resurfacing, using an implant with a good track record, demonstrates 99.0% survivorship in male patients with an average age of 52 years. We believe that the continued use of metal-on-metal hip resurfacing arthroplasty in this population is justified by both positive patient reported outcomes and survivorship.     

Curved Intertrochanteric Varus Osteotomy vs Total Hip Arthroplasty for Osteonecrosis of the Femoral Head in Patients Under 50 Years Old

BackgroundGiven recent advances in total hip arthroplasty (THA), curved intertrochanteric varus osteotomy (CVO) is not indicated as a treatment for osteonecrosis of the femoral head (ONFH), unless indicated to maintain long-term hip function and achieve patient satisfaction. We aimed to compare the clinical outcomes of CVO with those of THA for treatment of ONFH in young adults <50 years old.MethodsThis comparative study included 105 ONFH patients: 59 patients (65 hips) who underwent CVO and 46 patients (56 hips) who underwent THA. Assessment tools included the Harris hip score (HHS), patient-reported outcomes of the Short Form-36, Oxford hip score, Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire, and University of California, Los Angeles score, together with complication and survival rates.ResultsPreoperative HHS was significantly higher in the CVO group than in the THA group (P < .01). At the last follow-up, no between-group differences were noted in HHS, all domains of Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire scores, Oxford hip score, and Short Form-36. University of California, Los Angeles scores and complication rates were comparable: 3% for the CVO and 7% for the THA group. The 10-year survival rate with surgery for any reason as the end point was comparable, at 91.8% for the CVO and 97.7% for the THA group.ConclusionFunctional outcomes, survival rate, and sporting activities for patients <50 years old undergoing CVO or THA for ONFH were comparable after a mean follow-up period of 10 years. Strict indications for CVO can help maintain hip function and patient satisfaction equivalent to that for THA, in the long term.     

A Modified Modular Stem in Primary Total Hip Arthroplasty for Developmental Dysplasia of the Hip: Average 11-year Follow-Up in Cases With Previously Reported 3-year Clinical Results

BackgroundModular stems require careful follow-up, especially after any design modification. This study investigated the mid- to long-term outcomes of total hip arthroplasty in patients with developmental dysplasia of the hip using the S-ROM-A stem, a modified S-ROM stem for Asians.MethodsWe previously reported short-term outcomes for all 220 dysplastic hips that underwent primary total hip arthroplasty with the S-ROM-A stem. Here, we followed the clinical and radiological outcomes of 201 of the 220 hips (91%) for a mean 11.4 years postoperatively. We also performed multivariate analysis to determine whether large anteversion angle adjustment was associated with increased osteolysis.ResultsThe cumulative survival rate of the stem at 168 months postoperatively was 97.4%. Two hips underwent revision surgery, including 1 due to neck trunnionosis. Characteristic distal stem fracture occurred in 3 hips (1.5%). Most partial radiolucent lines observed around the sleeve early postoperatively disappeared by 7 years, postoperatively. Mild osteolysis occurred relatively frequently (20%), but a multivariate model adjusted for polyethylene type showed no significant association between the occurrence of osteolysis and anteversion adjustment of the modular stem (stem anteversion decreased ≤?20°, P = .829; stem anteversion increased ≥+20°, P = .619).ConclusionPartial radiolucent lines early postoperatively do not affect long-term outcomes. The clinical benefits of actively adjusting the stem anteversion angle outweigh the mechanical risks. Mild osteolysis, stem fracture, and trunnionosis were relatively frequent complications. Analysis with longer follow-up and more cases are necessary to clearly determine if these complications are associated with the design modification.     

Comparison of Modular Conventional and High-Flexion Posterior-Stabilized Total Knee Arthroplasties in the Same Patients at a Mean Follow-Up of 15 Years

BackgroundAs previous studies are limited to short-term clinical data on conventional and high-flexion total knee arthroplasties (TKAs), long-term clinical data on these TKAs remain unclear. Therefore, we evaluated long-term functional outcome, range of knee motion, revision rate, implant survival, and the prevalence of osteolysis after conventional and high-flexion TKAs in the same patients.MethodsThe authors evaluated a cohort of 1206 patients with a mean age of 65.3 ± 7 years (range: 22-70) who underwent bilateral simultaneous sequential TKAs. One knee received a conventional TKA and the other received a high-flexion TKA. The mean duration of follow-up was 15.6 years (range: 14-17).ResultsNo significant differences were found between the 2 groups at the latest follow-up with respect to Knee Society score (93 vs 92 points, P = .765), pain score (45 vs 44 points, P = .641), range of knee motion (125° vs 126°, P = .712), and radiographic and computed tomography scan results. Furthermore, no significant revision rate differences were found between the 2 groups (1.3% for conventional TKA vs 1.6% for high-flexion TKA; P = .137). There was no osteolysis recorded in either group. The rate of survivorship free of implant revision or aseptic loosening was 98.7% (95% CI = 91-100) for conventional TKA and 98.4% (95% CI = 91-100) for high-flexion TKA at 17 years.ConclusionAt the latest follow-up, we were not able to demonstrate any significant difference between conventional and high-flexion TKAs with respect to functional outcome scores, range of knee motion, revision rate, implant survival, and prevalence of osteolysis.     

Articular Noise After THA Using Delta CoC Bearings Has Little Impact on Quality of Life

BackgroundTo report clinical outcomes and survival at a minimum of 10 years of a consecutive series of uncemented total hip arthroplasty (THA) with fourth-generation ceramic-on-ceramic (CoC) bearings and determine the incidence of articular noises, their risk factors, and impact on quality of life (QoL).MethodsFrom a series of 456 CoC THAs, there were 25 revisions, 38 deceased, and 36 lost to follow-up. The remaining 357 hips were assessed at 11.1 ± 0.7 years (range, 10-14) using the Forgotten Joint Score, Oxford Hip Score, and a questionnaire on articular noises. Kaplan-Meier survival was calculated, and multivariable analysis was performed to determine associations between articular noise and patient/surgical factors.ResultsThe 10-year survival was 96.3% for the cup, 96.5% for the stem, and 94.2% for all components. The Forgotten Joint Score was 79 ± 26 (range, 0-100), and Oxford Hip Score was 16 ± 7 (range, 12-60). The mean impact of articular noises on QoL was 1.8 ± 2.9 (range, 0-9): considered negligible in 60 hips (16%), moderate in 27 hips (7%), and severe in only 13 hips (4%). Multivariable analyses revealed that the incidence of articular noise decreased with age (odds ratio [OR], 0.94; P = .001), body mass index (OR, 0.85; P = .001), and in hips implanted with 32-mm (vs 36 mm) heads (OR, 0.18; P = .030).ConclusionOf 100 hips (28%) that reported some articular noises 10 years after CoC THA, the impact of articular noises on QoL was negligible for most patients. Although larger heads can improve mobility and reduce risks of dislocations, surgeons must be aware that increasing head size could also increase risks of articular noises, notably in young and active patients.     

Multi-centre study of cement-in-cement and in-cement femoral revision total hip arthroplasty using polished,stainless steel stems

BackgroundExposure of the acetabular component during revision total hip arthroplasty is often difficult and stems are often difficult to remove. Polished and tapered cemented stems are easily removed and can be easily reconstructed by either cement-in-cement or in-cement technique. This study was a retrospective review of the medium-term outcomes of revision total hip arthroplasty conducted with the Exeter stem fixed by cement-in-cement or in-cement method in four institutions.MethodsThis study included hips (n = 103) reconstructed by cement-in-cement or in-cement technique on the femoral side during revision total hip arthroplasty in four institutions between 2003 and 2015. The mean age at surgery was 71.1 years (range, 43–86 years), and the mean follow-up period was 5.6 years (range, 0–13 years).ResultsRevision arthroplasty was required for acetabular component complications in 69 hips, for dislocation in 25, for infection in eight, and for stem fracture in one hip. Re-revision was required in 10 hips for: infection (n = 6), acetabular component complications (n = 3), and dislocation (n = 1). No radiographic loosening, cement fractures, or osteolysis of the femoral components were observed. Ten-year survival rate was 99% with the endpoint of femoral revision surgery, and 100% with the endpoint of femoral aseptic loosening.ConclusionsThe medium-term outcomes of revision total hip arthroplasty on the femoral side conducted using the cement-in-cement or in-cement technique were favourable, with no cases of aseptic loosening. As long as the bone-cement interface remains robust, there is no need to remove all the cement, and the cement-in-cement or in-cement technique should be used for reconstruction.     

Prior Pelvic Osteotomy Affects the Outcome of Subsequent Total Hip Arthroplasty

BackgroundAlthough pelvic osteotomy (PO) is an important surgical procedure that can alleviate symptoms and potentially slow progression of osteoarthritis in patients with development dysplasia of the hip, some patients eventually require conversion to total hip arthroplasty (THA). This study aimed to determine the outcome of conversion THA in patients with prior PO.MethodsForty nine patients with a history of prior PO who underwent conversion THA at a single institution were matched at a 1:3 ratio based on the date of surgery, age, gender, and body mass index with 147 developmental dysplasia of the hip patients who underwent primary THA without prior PO. A retrospective chart review was performed to compare outcomes at a minimum follow-up of 2 years.ResultsPatients with prior PO required more supplemental screw fixation for the acetabular component (59.2% vs 38.1%, P = .016), more autologous bone grafting (24.5% vs 11.6%, P = .048), had a longer mean operative time (106.0 vs 79.8 minutes, P < .001), and greater estimated blood loss (350.0 vs 206.8 mL, P = .015). Patients with prior PO had smaller cup version angle (26.0° vs 29.0°, P = .012) and greater discrepancy in the limb length (10.3 vs 7.26 mm, P = .041). Eight hips (16.3%) with prior PO and 6 (4.1%) without osteotomy required reoperation (P = .008). There was no difference in outcome scores at the latest follow-up.Conclusion: THA after prior PO is technically demanding, leading to longer operative times, greater blood loss, and variation in implant placement. Although functional outcomes are similar, THA after a prior PO is more likely to require reoperation.ConclusionTHA after prior PO is technically demanding, leading to longer operative times, greater blood loss, and variation in implant placement. Although functional outcomes are similar, THA after a prior PO is more likely to require reoperation.