Can Squeaking With Ceramic-On-Ceramic Hip Articulations In Total Hip Arthroplasty Be Avoided?

Squeaking is a recognized complication of total hip arthroplasty with ceramic on ceramic bearings but the etiology has not been well identified. We evaluated 183 hips in 148 patients who had undergone ceramic-on-ceramic noncemented total hip arthroplasties at one center between 1997–2007 by standardized telephone interviews and radiographic review. Audible squeaking was reported from 22 hips (12% of 183) of 19 patients. Prevalence of squeaking was associated with younger age; obesity; lateralized cup position; use of beta titanium alloy femoral components and shortened head length options; and higher reported activity level, greater pain, and decreased satisfaction at the time of the interview. Squeaking was described as having little personal significance by most patients. Squeaking might be preventable in part through medialization of the acetabular cup and avoidance of the use of shortened femoral necks.     

Can Total Hip Arthroplasty for Hip Fracture Be Safely Performed by Trainees? A Retrospective Cohort Study

BackgroundNo research is available comparing trainee and consultant outcomes for total hip arthroplasty (THA) for hip fracture. The aim of our study is to determine whether trainee-performed and consultant-performed THA produced equivalent radiological outcomes and complication rates for this patient cohort.MethodsWe performed a retrospective cohort study at our institution, with inclusion of patients who underwent a primary THA for hip fracture between March 30, 2017 and February 07, 2019. Relevant perioperative and outcome data were collected through electronic records. Radiological outcomes were assessed by 2 independent reviewers. Follow-up was performed until August 07, 2019.ResultsEighty-seven patients were included in the study. The mean length of follow-up was 13 months (range, 6-29). Forty-three patients underwent consultant-led operations and 44 underwent trainee-performed (ST3-ST8) operations under consultant supervision. There were no significant differences between the 2 groups regarding complication risk (no recorded dislocation, infection requiring reoperation, revision or 30-day mortality in either group). There were also no significant differences between trainees and consultants regarding the radiological outcomes of mean acetabular component inclination (37.2° vs 36.7°, respectively, P = .74); offset difference (+7.1 mm vs +7.2 mm, respectively, P = .91); leg length difference (+6.4 mm vs +5.7 mm, respectively, P = .56); and barrack grade for femoral cement mantle.ConclusionThis study suggests that radiological and safety outcomes for trainees performing THA for hip fracture with appropriate supervision are equivalent to consultant surgeons. However, given the low event rate of complications, a larger study is required to determine whether there is any statistically significant difference.     

What is the Role of Magnetic Resonance Imaging in the Evaluation of Total Hip Arthroplasty?

MRI has been shown to be an extremely effective instrument in the management of painful hip arthroplasty. Its superior soft tissue contrast and direct multiplanar acquisition compared to computerized tomography (CT) and radiographs allows for reproducible visualization of periacetabular osteolysis, demonstrating compression of neurovascular bundles by extracapsular synovial deposits. In addition, MRI can often elucidate etiology of neuropathy in the perioperative period and is further helpful in evaluating the soft tissue envelope, including the attachment of the hip abductors, short external rotators and iliopsoas tendon. A further advantage of MRI over CT is its lack of ionizing radiation. Most importantly, MRI can disclose intracapsular synovial deposits that precede osteoclastic resorption of bone.     

Does Preoperative Activity Level Affect Postoperative Outcomes Following Total Hip Arthroplasty?

BackgroundMany patients electing to undergo total hip arthroplasty (THA) value continuing active lifestyles when considering treatment options. Addressing these concerns requires evaluating the effect of preoperative activity level on patient-reported outcomes and improvement following THA.MethodsThree hundred thirty-five patients (368 hips) who underwent THA with a minimum 6-month (mean 533 ± 271 days) follow-up completed preoperative and postoperative University of California, Los Angeles (UCLA) activity score along with various patient-reported measures of function, pain, and mental state. Preoperative UCLA score divided patients into inactive, mild, and active groups. Analysis of covariance controlling for age, sex, body mass index, surgical approach, implant, bilateral cases, conversions, and follow-up time evaluated differences among groups for postoperative outcomes with subsequent Tukey-Kramer pairwise comparisons.ResultsMildly active patients (73:139 male:female) had better postoperative outcomes than inactive patients (40:70 male:female) for UCLA score, EuroQol Visual Analog Scale (EQVAS), Hip Outcome Score (HOS), 12-item Short-Form (SF-12) Physical, and Visual Analog Pain Scale (average/now/worst) (P values <0.001/<0.001/<0.001/<0.001/0.003/<0.001/<0.001). Active patients (32:14 male:female) had better postoperative outcomes than inactive patients for UCLA score, EQVAS, HOS, SF-12 Physical, and Visual Analog Pain Scale Worst (P values <0.001/0.024/0.001/0.001/0.017). No postoperative outcome differences existed between active and mild patients. Inactive patients displayed greater outcome improvements than mildly active patients for UCLA score, Harris Hip Score, and International Hip Outcome Tool (P values <0.001/<0.001/0.013) and active patients for UCLA score, EQVAS, HOS, International Hip Outcome Tool, and SF-12 Physical (P values <0.001/0.008/0.013/0.022/0.004).ConclusionsInactive patients achieve greater measure improvements following THA. Active patients achieve better absolute outcomes than inactive patients; however, increasing activity levels do not incrementally improve patient-reported outcome measures. Patients similarly improve pain and mental health regardless of activity level.     

Can Total Knee Arthroplasty Be Safely Performed Among Nonagenarians? An Evaluation of Morbidity and Mortality Within a Total Joint Replacement Registry

As the nonagenarian patient population continues to grow, more patients aged 90 and over will become candidates for total knee arthroplasty (TKA). This study evaluated the patient characteristics and incidence of postoperative morbidity and mortality of 216 nonagenarian TKA patients among 81,835 primary TKA patients followed by a total joint replacement registry. Nonagenarians had a greater number of comorbidities preoperatively, experienced a higher rate of deep vein thrombosis and 30 day mortality, and had a longer hospital length of stay. However, nonagenarians did not have an increased risk of infection nor pulmonary embolism and postoperative mortality was within expected rates for individuals 90 years and older. Higher readmission rates, however, highlight the benefits of close follow up during a prolonged postoperative period.     

Do Conversion Total Hip Arthroplasty Yield Comparable Results to Primary Total Hip Arthroplasty?

Background

The incidence of hip fractures is growing with the increasing elderly population. Typically, hip fractures are treated with open reduction internal fixation, hemiarthroplasty, or total hip arthroplasty (THA). Failed hip fracture fixation is often salvaged by conversion THA. The total number of conversion THA procedures is also supplemented by its use in treating different failed surgical hip treatments such as acetabular fracture fixation, Perthes disease, slipped capital femoral epiphysis, and developmental dysplasia of the hip. As the incidence of conversion THA rises, it is important to understand the perioperative characteristics of conversion THA. Some studies have demonstrated higher complication rates in conversion THAs than primary THAs, but research distinguishing the 2 groups is still limited.

Total Hip Arthroplasty in Patients With Previous Lumbar Fusion Surgery: Are There More Dislocations and Revisions?

Background

The purpose of this study was to determine whether the risk of dislocation and/or revision following THA is increased in patients with a history of prior lumbar fusion given the alterations in dynamic pelvic motion following LSF.

Does Pelvic Sagittal Inclination in the Supine and Standing Positions Change Over 10 Years of Follow-Up After Total Hip Arthroplasty?

Background

Functional anteversion and inclination of the cup change as the pelvic sagittal inclination (PSI) changes. The purposes of this study were to investigate the chronological changes of PSI during a 10-year follow-up period after total hip arthroplasty (THA) and to report the characteristics of patients who showed a greater than 10° change in the PSI from the supine to the standing position.

Have Venous Thromboembolism Rates Decreased in Total Hip and Knee Arthroplasty?

BackgroundVenous thromboembolism (VTE) is a major cause of morbidity, mortality, and healthcare costs in arthroplasty patients. In an effort to reduce VTEs, numerous strategies and guidelines have been implemented, but their impact remains unclear. The purpose of this study is to compare annual trends in 30-day VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), and all-cause mortality in (1) total hip arthroplasty (THA) and (2) total knee arthroplasty (TKA).MethodsThe American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database identified 363,530 patients who received a TKA or THA from 2008 to 2016. Bivariate analysis was performed to assess the association between the year in which surgery was performed and demographics and comorbidities. Bimodal multivariate logistic regression models for THA and TKA were developed for 2009-2016 using 2008 as a reference.ResultsOverall incidence of VTE, DVT, PE, and mortality for THA were 0.6%, 0.4%, 0.3%, and 0.2%, respectively. Based off of multivariate regression VTE, DVT, PE, and mortality rates have shown no significant (P > .05) change from 2008 to 2016 in THA patients. Overall incidence of VTE, DVT, PE, and mortality for TKA were 1.4%, 0.9%, 0.6%, and 0.1%, respectively. Multivariate regression revealed reductions when compared to 2008 for VTEs and DVTs from 2009 to 2016 (P < .05) for TKA patients. A significant reduction in PEs (P = .002) was discovered for 2016, while no significant change was observed in mortality (P > .05).ConclusionApproximately 1 in 71 patient undergoing TKA, and 1 in 167 undergoing THA developed a VTE within 30 days after surgery. Our study demonstrated that VTE incidence rates have decreased in TKA, while remaining stable in THA over the past 8 years. Further research to determine the optimal prophylaxis algorithm that would allow for a personalized, efficacious, and safe thromboprophylaxis regimen is needed.Level of EvidenceIII.     

Outcomes of Total Hip Arthroplasty After Acetabular Open Reduction and Internal Fixation in the Elderly—Acute vs Delayed Total Hip Arthroplasty

BackgroundOptimum management for the elderly acetabular fracture remains undefined. Open reduction and internal fixation (ORIF) in this population does not allow early weight-bearing and has an increased risk of failure. This study aimed to define outcomes of total hip arthroplasty (THA) in the setting of an acetabular fracture and compared delayed THA after acetabular ORIF (ORIF delayed THA) and acute fixation and THA (ORIF acute THA).MethodsAll acetabular fractures in patients older than 60 years who underwent ORIF between 2007 and 2018 were reviewed (n = 85). Of those, 14 underwent ORIF only initially and required subsequent THA (ORIF delayed THA). Twelve underwent an acute THA at the time of the ORIF (ORIF acute THA). The ORIF acute THA group was older (81 ± 7 vs 76 ± 8; P < .01) but had no other demographic- or injury-related differences compared with the ORIF delayed THA group. Outcome measures included operative time, length of stay, complications, radiographic assessments (component orientation, leg-length discrepancy, heterotopic ossification), and functional outcomes using the Oxford Hip Score (OHS).ResultsOperative time (P = .1) and length of stay (P = .5) for the initial surgical procedure (ORIF only or ORIF THA) were not different between groups. Four patients had a complication and required further surgeries; no difference was seen between groups. Radiographic assessments were similar between groups. The ORIF acute THA group had a significantly better OHS (40.1 ± 3.9) than the ORIF delayed THA group (33.6 ± 8.5) (P = .03).ConclusionIn elderly acetabulum fractures, ORIF acute THA compared favorably (a better OHS, single operation/hospital visit, equivalent complications) with ORIF delayed THA. We would thus recommend that in patients with risk factors for failure requiring delayed THA (eg, dome or roof impaction) that ORIF acute THA be strongly considered.     

Should Cannabinoids Be Added to Multimodal Pain Regimens After Total Hip and Knee Arthroplasty?

Background

This study investigated the effects of dronabinol on pain, nausea, and length of stay following total joint arthroplasty (TJA).

Is Outpatient Total Hip Arthroplasty Safe?

Background

Safety data for outpatient total hip arthroplasty (THA) remains scarce.

When Should Complete Blood Count Tests Be Performed in Primary Total Hip Arthroplasty Patients?

Background

Routine laboratory studies are often obtained following total hip arthroplasty (THA). Moreover, laboratory studies are often continued daily until the patient is discharged regardless of medical management. The purpose of this study was to investigate the use of routine complete blood count (CBC) tests following THA. Secondarily, the purpose was to identify patient factors associated with abnormal postoperative lab values.

Does Balancing a Total Hip Arthroplasty Require a New Paradigm? Functional 3-Dimensional Balancing in Total Hip Arthroplasty

BackgroundTraditional principles for successful outcomes in Total Hip Arthroplasty (THA) have relied largely on placing the socket in the native position and trying to restore static anatomical femoral parameters gauged on X-rays or intra-operative measurement. Stability is conventionally achieved by making appropriate changes during the time of trial reduction. Post-operative complications of dislocation and significant Limb Length Discrepancy (LLD) requiring foot wear modification represents opposite ends of the spectrum from a biomechanical perspective and these continue to be relatively high. A move towards giving more importance to functional dynamic parameters rather than static anatomical parameters and less reliance on stability testing at trial reduction is warranted.MethodsIntraoperative 3D functional balancing of THA without stability testing at trial reduction was practiced in all subjects undergoing THA in our unit from April 2014. To date 1019 patients have had their hips replaced with the same technique. They were followed up till April 2020 for post-operative complications of dislocation and significant LLD needing footwear modification. A secondary cohort of 114 patients from 1st January to December 31st 2017 within this primary group were analyzed clinically and radiologically to ascertain the implications of functional 3D balancing on X-ray parameters, clinical outcome scores (Harris Hip Score and Oxford Hip Score), ability to squat, and subtle subjective post-operative perception of limb lengthening (POPLL).ResultsIn the primary group of 1019 patients, there were only two dislocations and no patient needed footwear modification for LLD. In the detailed analysis of the secondary cohort of 114 patients, the correlation with restoration of static radiological parameters was inconsistent. 40 patients could not squat and 4 patients had subtle subjective post-operative perceived limb lengthening (POPLL). Measured outcomes such as HHS and OHS were improved in all patients with significant statistical significance (P < 0.001).ConclusionThis study underlines the fact that more importance must be given to functional dynamic parameters by 3D balancing of the THA and not on static anatomical X-rays parameters and stability testing during trial reduction. This represents a paradigm shift in the evolution of total hip arthroplasty.Level of EvidenceA Level II study. (Data collected from the ongoing prospective study) (http://www.spine.org/Documents/LevelsofEvidenceFinal.pdf).Supplementary InformationThe online version contains supplementary material available at 10.1007/s43465-021-00505-3.     

Are Oxford Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index Useful Predictors of Clinical Meaningful Improvement and Satisfaction After Total Hip Arthroplasty?

BackgroundUp to 15% of patients express dissatisfaction after total hip arthroplasty (THA). Preoperative patient-report outcome measures (PROMs) scores can potentially mitigate this by predicting postoperative satisfaction, identifying patients that will benefit most from surgery. The aim of this study was to (1) calculate the minimal clinically important difference (MCID) thresholds for Oxford Hip Score (OHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form-36 (SF-36) mental component summary (MCS) and physical component summary (PCS) scores and (2) identify the threshold values of these PROMs that could be used to predict patient satisfaction and expectation fulfilment.MethodsProspectively collected registry data of 1334 primary THA patients who returned for 2-year follow-up from 1998 to 2016 were reviewed. All patients were assessed preoperatively and postoperatively at 2 years using the OHS, WOMAC, and SF-36 PCS/MCS scores. The MCID for each PROMs was calculated, and the proportion of patients that attained MCID was recorded. The relationship between satisfaction, expectation fulfilment, and MCID attainment was analyzed using Spearman rank correlation. Optimal threshold scores for each PROM that predicted MCID attainment and satisfaction/expectation fulfilment at 2 years were calculated using receiver operating curve analysis.ResultsThe calculated MCID for OHS, WOMAC, SF-36 PCS, and SF-36 MCS were 5.2, 10.8, 6.7, and 6.2, respectively. A threshold value of 24.5 for the preoperative OHS was predictive of achieving WOMAC MCID at 2 years after THA (area under the curve 0.80, P < .001). 93.1% of patients were satisfied, and 95.5% had expectations fulfilled at 2 years. None of the PROMs were able to predict satisfaction.ConclusionOHS and WOMAC scores can be used to determine clinical meaningful improvement but are limited in their ability to predict patient satisfaction after THA.     

Preoperative Use of Aspirin in Total Knee Arthroplasty: Safe or Not?

ObjectiveTo compare the blood loss, transfusion rates and complications between the aspirin and non‐aspirin group in unilateral and bilateral total knee arthroplasties (TKAs) with a nested case–control design.MethodsThe present study retrospectively selected TKA cases from the Joint Arthroplasty Database at the Peking Union Medical College Hospital from January 2014 to December 2019 following strict inclusion and exclusion criteria, and divided them into the aspirin and non‐aspirin group based on the use of aspirin preoperatively. Bleeding was measured by blood loss, transfusion rate, drainage volume, hemoglobin (HGB) and hematocrit (HCT), while complications (cardiovascular events, venous thromboembolism events, cerebrovascular events and wound events) were compared between the groups. Student''s unpaired t‐test and Mann–Whitney U‐test were used to compare the differences of continuous variables between the two groups while chi‐square test and Fisher''s exact test were applied in categorical variables.ResultsA total of 560 patients with unilateral TKA and 285 patients with bilateral TKA were extracted. Among these, 280 patients used aspirin preoperatively. No other differences were found in demographic and surgical characteristics between the two groups except for the proportion of coronary artery diseases (P < 0.001). For primary outcomes, there was no significant higher blood loss and transfusion rate in the aspirin group, while the drainage of aspirin group was higher than the control group in bilateral TKAs (P = 0.043). The HGB and HCT of the aspirin group was significant lower in both unilateral and bilateral TKAs at POD5 (P < 0.05). For complications, there was a lower vascular related complication rate in aspirin group after unilateral TKAs (P = 0.040), but the wound event rate in aspirin group was higher than the control group (P = 0.049).ConclusionsPreoperative use of aspirin could prevent vascular related events during the perioperative period of TKA. However, it might also increase the risk of bleeding and wound complications.     

Is Total Hip Arthroplasty after Hip Arthrodesis as Good as Primary Arthroplasty?

Background  

Conversion of hip arthrodesis to a THA reportedly provides a reasonable solution, improving function, reducing back and knee pain, and slowing degeneration of neighboring joints associated with a hip fusion. Patients generally are satisfied with conversion despite the fact that range of mobility, muscle strength, leg-length discrepancy (LLD), persistence of limp, and need for assistive walking aids generally are worse than those for conventional primary THA.     

Is There a Role for Preoperative Iron Supplementation in Patients Preparing for a Total Hip or Total Knee Arthroplasty?

Background

Several treatment modalities exist for the treatment of perioperative anemia. We determined the effect of oral iron supplementation on preoperative anemia, and the use of blood-conserving interventions before total hip arthroplasty (THA) and total knee arthroplasty (TKA).