Ceramic-on-ceramic total hip arthroplasty: A new standard—Affirms

Highly cross-linked polyethylene has emerged as an improvement over conventional polyethylene in terms of wear characteristics and osteolysis in total hip replacement; however, decreased material properties could make it unsuitable for use in high-demand patients. Modern ceramic-on-ceramic bearings display extremely low wear and durability that make them an ideal bearing surface. Unfortunately, certain implant designs have been associated with squeaking, which has discouraged widespread use. Proper implant selection, orientation, and surgical technique can lead to optimal results with ceramic bearings, and substantial mid- to long-term data exists to support their use over other bearing surfaces in total hip replacement.     

Ceramic-on-ceramic total hip arthroplasty: A new standard—Opposes

This article reviews the performance characteristics of ceramic-on-ceramic as a bearing surface in total hip arthroplasty. Ceramic has superior wear properties but has yet to demonstrate decreased rate of revision compared to other bearings. There are no data to support ceramic-on-ceramic as a more cost-effective bearing surface. Conversely, it may be more costly to revise, and fracture of the latest generation ceramic heads may cause taper damage that necessitates stem removal in addition. A well-positioned ceramic-on-ceramic total hip is likely to perform well, but there is no evidence to support its use as a new standard for total hip arthroplasty.     

The “learning curve” of total hip arthroplasty

Total hip arthroplasty (THA) is one of the major breakthroughs in modern orthopedics this century. Since its introduction in the early 1960s by Sir J. Charnley, it has become the most common form of arthroplasty. The art of performing THA has developed to a large extent, yet with the inevitable price of a learning curve. The rates of early and late complications reported in the orthopedic literature have been decreasing gradually, along with improved short- and long-term results. We report the results of two similar series of THA performed with an interval of 15 to 20 years, which show that the improvement of the results that form the learning curve of THA at our institution is statistically significant.     

The reliability of modern alumina bearings in total hip arthroplasty—Update to a 2006 report

Ceramic components׳ clinical fractures in total hip arthroplasty (THA) are a rare but, nonetheless, serious complication. As a result of continued improvements in ceramic material quality, manufacturing methods, and implant design made over the last 30 years, the incidence of such failures has been drastically reduced. In this report, the frequency of these ceramic components׳ clinical failures in THA will be examined. In addition, some information regarding the contribution that can be made by the surgeon to enhance the reliability of ceramic components will also be presented. In order to get a broad view, the largest supplier of these components, CeramTec Medical Products (Plochingen, Germany), was contacted, and they agreed to share their most recent data. In the year 2000, the largest supplier of alumina–ceramic bearings for orthopedic applications (CeramTec GmbH, Plochingen, Germany) began a rigorous program of collecting clinical fracture data for all of its ceramic components. The clinical fracture data for the period of January 2000–June 2013 are reported here, with a review of the material properties, historical component fracture trends, and relative risk of fracture associated with alumina THA bearings. The data reported is divided into two separate groups. The first one is the incidence of clinical fracture of the Biolox^® forte material. This is their original material developed in the 1970s and is still available today and optimized over the years. The overall clinical fracture rate of these alumina components was 0.021%, or 21 in 100,000, during the January 2000–June 2013 time period. The second group is composed of components manufactured from their Alumina Matrix Composite, Biolox^® delta. The overall clinical fracture rate for these components is 0.0001% or 1 in 100,000. Almost 80% of these alumina bearing failures occurred within 36 months following surgery. Using the latest material and increasing femoral head diameter were associated with a substantially reduced risk of fracture. Alumina bearings used in modern THA implants are safe and reliable, with a very low risk of failure. Improvements in the materials, developments in the manufacturing, the introduction of the Alumina Matrix Composite, and the trend to utilize larger-diameter ball heads are likely to continue to reduce the concerns that have been in the mind of surgeons using ceramics in THA.     

The mini-anterior approach: Optimizes total hip arthroplasty outcome—Affirms

The direct anterior approach for total hip arthroplasty has gained popularity in recent years and evidence to support this method continues to grow. Through our own research, we have noted several advantages compared to the posterior approach. In our direct anterior approach patients, we have found earlier function recovery in the initial weeks after total hip arthroplasty. Fewer deficits to hip motion and strength occur with this approach. We are also able to obtain improved precision, accuracy, and reproducibility of acetabular cup placement. For these reasons, the direct anterior approach is our preferred method in performing total hip arthroplasty.     

Hybrid total hip arthroplasty: state-of-the-art in the new millennium?

Clinical results from the past 30 years have proven total hip arthroplasty (THA) to be an effective technique for treating arthritic and degenerative conditions of the hip. Though there is little question concerning the effectiveness THA in general, significant debate exists concerning the best technique for performing the procedure. Sir John Chamley's concept of low-friction arthroplasty (LFA), considered to be the gold standard for THA, employs a cemented fixation technique for both the femoral and acetabular components. Over time, the merits of cemented fixation have been called into question as significant percentages of LFA implants failed and required revision surgery. Hybrid total hip arthroplasty is a variation of LFA that employs cemented fixation of the femoral component with cementless fixation of the acetabular component. Intermediate-term clinical results of hybrid THA have shown it to be a promising technique, with revision rates of both the femoral and acetabular components superior to Chanley LFA studies at similar lengths of follow-up. Though these results are encouraging, long-term data from the hybrid THA studies are required before a conclusion can be made as to whether the hybrid method is in fact superior to the LFA technique for performing THA.     

Revision total hip arthroplasty exposure considerations: Which way in?

Revision total hip arthroplasty is becoming increasingly common. The surgical approach used to enter the hip can vary based on anatomy, surgical complexity, surgeon comfort, and experience. Traditionally, the posterior approach has been the most common surgical approach, with the direct lateral and anterior approaches used less frequently. Each approach has its advantages and disadvantages. The purpose of this article is to describe each of these approaches, including some of the clinical pearls, advantages, and disadvantages of each.     

The mini anterior approach: Optimizes total hip arthroplasty outcomes—Opposes

Much has been written and talked about in both the lay press as well as orthopaedic journals regarding the potential for enhanced recovery in anterior total hip arthroplasty. It is our feeling that the evidence regarding this claim is weak at best, and that the approach has a high complication rate in many surgeon’s hands. We propose the elements of leading to enhance recovery as it applies to all approaches to total hip arthroplasty and propose alternative means to achieve them.     

Barbed sutures in total hip and knee arthroplasty: what is the evidence? A meta-analysis

Introduction

Newer methods of wound closure such as bidirectional barbed sutures hold the potential to reduce closure time and thus overall operating room costs during total joint arthroplasty (TJA), including total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, it is unclear whether these sutures have similar clinical outcomes or whether they place the patient at risk of developing wound complications that may outweigh the time-saving benefits of these sutures.

Methods

A systematic review of the literature was performed to identify all level I trials that reported the use of barbed suture during TJA. We analyzed the efficacy, safety, major and minor complications, and overall cost related to barbed sutures.

Results

Four studies met our criteria, and included 588 patients who were randomized either to barbed suture closure (n?=?290 TJAs, 268 TKAs, and 22 THAs) or to a matched conventional suture cohort (n?=?298 TJAs, 279 TKAs, and 19 THA). In terms of time savings with wound closure, the barbed suture was 6.3 minutes faster than the conventional cohort (p?<?0.05). The odds for developing a minor complication were nearly identical (odds ratio [OR] 1.04, p?=?0.95) and for major complication was not significantly different (OR 2.94, p?=?0.27). The overall mean savings including both THA and TKA was USD 298 per case.

Conclusions

In randomized controlled trials, barbed sutures are consistently associated with shorter wound closure time, which also corresponds to cost savings, even when the higher cost of these sutures is taken into account. There was no significant difference in the odds of experiencing either minor or major complications between patients in whom barbed sutures versus standard sutures were used for wound closure. Current evidence supports continued use of these sutures.Level of Evidence: Level I

     

No clinical difference between large metal-on-metal total hip arthroplasty and 28-mm-head total hip arthroplasty?

Purpose  

We aimed to test the claim of greater range of motion (ROM) with large femoral head metal-on-metal total hip arthroplasty.     

Trochanteric non-union in revision total hip arthroplasty: does it matter?

The aims of this study were to assess whether trochanteric non-union is an important factor in revision total hip arthroplasty in terms of postoperative morbidity. We studied prospectively 97 consecutive patients undergoing revision total hip arthroplasty in the years 1992-1996. All operations were performed by one surgeon through a Charnley trans-trochanteric approach. The patients were followed-up over a period of 1-4 years and at 12 months postsurgery were assessed using a modified scoring system devised by D'Aubigne. Anatomical union of the greater trochanter was assessed by an anterior-posterior pelvic radiograph at 12 months to decide if the greater trochanter was united in the correct anatomical position. The trochanteric non-union rate was 18.5% (18 out of 97 patients). There was no significant difference between the patients in terms of pain, function and satisfaction scores at one year between those with trochanteric union and those without. This study suggests that trochanteric non-union post revision total hip arthroplasty is not a cause of increased morbidity.     

Femoral preparation in cemented total hip arthroplasty: reaming or broaching?

Surgical techniques continue to be refined to improve the results of primary cemented total hip arthroplasty. Although there has been much research in the areas of cementation and implant design, little work has specifically addressed how bone preparation can be optimized on the femoral side. On the basis of available scientific data, it appears that the broach-only system has several potential advantages over the traditional ream-and-broach technique. Broaching is usually faster, leaves behind more bone stock, and may improve both microinterlock and macrointerlock. Additionally, the excess bone resulting from broaching without reaming does not seem to compromise fixation at the bone-cement interface. Such differences may become even more important as the indications for cemented hip arthroplasty broaden to include increasingly younger and more active patients, because revision in these individuals is likely. In most cases, reaming is probably counterproductive, although it may be advantageous when used to open the femoral canal, to prevent varus stem orientation, and to manage sclerosis or deformity of bone due to a preexisting hip disorder or the presence of internal fixation devices. Regardless of which method is chosen, good bone surface cleansing and cement penetration remain paramount. More studies comparing reamed and nonreamed preparation are necessary to resolve this controversial issue definitively.     

Cemented total hip arthroplasty: still relevant in the new millennium?

Total hip arthroplasty can be performed successfully using cement or cementless technology. Cemented femoral stems can achieve enduring long-term suvivorship as long as meticulous surgical technique is utilized and patient selection is appropriate. Cemented acetabular components should only be utilized in patients with less than 10 years of remaining life expectancy. Critical risk factors for cemented total hip arthroplasty include atrophic osteoarthrtis on the acetabular side and unfavorable femoral geometry for the femoral stem such as "the stove-pipe" canal. Rapid polyethylene wear and osteolysis are rarely seen in contemporary cemented total hip arthroplasty performed with a smooth, tapered, collarless femoral stem with a highly polished head and a well-designed acetabular component.     

Which is more invasive—mini versus standard incisions in total hip arthroplasty?

In this study, interleukin-6 (IL-6), C-reactive protein (CRP), and haemoglobin levels were evaluated to compare the degree of surgical invasion between mini and standard incisions in total hip arthroplasty (THA). Sixty-two patients admitted for primary cementless THA were enrolled in this randomised study. The patients were allocated to have surgery through either a mini incision of <10 cm or a standard incision of 15 cm. In each group, inflammatory responses were evaluated by IL-6, CRP, and haemoglobin levels before operation and one day after operation. Significant differences were not found in IL-6, CRP, and haemoglobin levels between both groups. At six months after surgery, there were no significant differences in postoperative Harris hip scores or radiographic evaluations between both groups. In conclusion, a 5.0 cm difference in the skin incision to the hip joint seemed to have no influence on the degree of surgical invasion during THA.     

Morbid obesity in total hip arthroplasty: What does it mean?

Obesity affects 34% of the U.S. population, and the number of obese patients undergoing elective total hip arthroplasty (THA) is increasing each year. The objective of this study is to summarize the current scientific findings regarding the outcomes of THA in the morbidly obese (BMI > 40 kg/m²) patients. Specifically, our goal is to identify the incidence of complications and the influence on clinical and functional outcome measures in morbidly obese patients undergoing elective primary THA. A systematic review was performed identifying all of the studies from the PubMed, Medline, EBSCO and Cochrane Library databases that reported outcomes of primary THA in morbidly obese [body mass index (BMI) ≥ 40 kg/m²] patients. We identified 13 articles that met inclusion criteria for systematic review. These studies included 15,906 primary THAs in morbidly obese patients. Morbidly obese patients underwent THA at a significantly younger age compared to the non-morbidly obese cohort (63 years versus 70 years) comparator group. Eleven of the 13 studies reported complication rates in morbidly obese versus non-obese patient cohorts. Eight of the 11 studies reported increased complication rates in morbidly obese patients. Of the 13 studies, 9 had documented outcome scores in morbidly obese patients. All studies concluded that morbidly obese patients had the poorest overall preoperative and postoperative functional scores. Seven of the studies also documented the net gain in functional scores after THA between the morbidly obese and the non-morbidly obese groups. No difference was found between the groups. Morbidly obese patients undergo primary THA at a significantly younger age than non-obese patients. Furthermore, morbidly obese patients have a higher perioperative complication rate. Overall outcome measures are worse in the pre operative and the post operative phase in the short- and the medium-term follow-up time intervals. However, morbidly obese patients have similar functional gains as non-morbidly obese patients following THA.     

Does aprotinin reduce blood loss in total hip arthroplasty?

This prospective randomized study examined the effects of aprotinin during total hip arthroplasty (THA). Fifty patients who were enrolled in the study received aprotinin or normal saline. Mean intraoperative blood loss was reduced from 1496 mL in the control group to 1073 mL in the aprotinin group. The mean transfusion unit was 1.56 in the aprotinin group and 3.8 in the control group.     

Can pelvic tilting be ignored in total hip arthroplasty?

INTRODUCTION

The orientation of acetabular component is influenced by pelvic tilt, body position and individual variation in pelvic parameters. Most post-operative adverse events may be attributed to malposition of the component in the functional position. There is evidence that orientation of the pelvis changes from the supine to standing position. Authors report a case of recurrent dislocation after total hip arthroplasty due to excessive pelvic tilting.PRESENTATION OF CASE A 69-year old female with coxarthrosis had undergone total hip replacement with recurrent dislocation of the hip on bearing weight in spite of using constrained acetabular component.

DISCUSSION

Our case report substantiates the influence of pelvic tilt, incurred by a sagittal deformity of spine, on dynamic orientation of the acetabular cup which was positioned in accordance with the anatomic landmarks alone. If the reference is only bony architecture and dynamic positions of the pelvis are not taken into account, improper functional orientation of the acetabular cup can result in sitting and standing positions. These can induce instability even in anatomically appropriately oriented acetabular component.

CONCLUSION

The sagittal position of pelvis is a key factor in impingement and dislocation after total hip arthroplasty. Pelvic tilting affects the position of acetabular component in the sagittal plane of the body as compared with its anatomic position in the pelvis. We suggest a preoperative lateral view of spine-pelvis, in upright and supine position for evaluation of a corrective adaptation of the acetabular cup accordingly with pelvic balance.     

Primary total hip arthroplasty for acetabular fracture

Objective:To explore the operative indications and operative methods of primary total hip arthroplasty for acetabular fracture and to observe the clinical curative effect. Methods:We retrospectively summarized and analyzed the traumatic conditions, fracture types, complications, operative time, operative techniques, and short-term curative effect of 11 patients(10 males and 1 female, with a mean age of 42. 4 years) with acetabular fracture who underwent primary total hip arthroplasty. Results: The patients were followed up for 6-45 months (mean = 28 months). Their average Harris score of postoperative hip joint was 78. Conclusion:Under strict mastery of indications, patients with acetabular fracture may undergo primary total hip arthroplasty, but stable acetabular components should be made.     

Hip-spine relationship in total hip arthroplasty – Simplifying the concepts

Total hip arthroplasty (THA) has been described as the operation of the century. Despite significant advancement in the field of technology, hip instability remains second most common cause of revision hip surgery after infection. There is garning interest to identify role of hip-spine relationship in order to identify high-risk patients for instability after THA. Acetabular component position varies according to spinal alignment and mobility in order to decrease risk of impingement and instability. Preoperative work up includes standing pelvis anteroposterior radiograph and lateral spino-pelvic radiograph in standing and sitting position. The focus of this review is to develop an algorithm to address the spino-pelvic pathology and guide the treatment on the basis of sagittal movement of the spine-pelvis-hip complex and to minimise the rate of dislocation following THA.     

Calcar-guided short-stem total hip arthroplasty: Will it be the future standard? Review and perspectives

Short stems in total hip arthroplasty (THA) are becoming increasingly popular. In Germany, already 10.4% of all primary THAs are performed using a cementless short stem. The concept of modern, calcar-guided, short stems aims for an individualized reconstruction of the hip anatomy by following the calcar of the femoral neck, a bone- and soft-tissue-sparing implantation technique, and physiological loading. The stem design uses either metaphyseal fixation alone or additional diaphyseal anchoring, depending on the stem alignment and indication. These individualized anchorage types increase the potential indications for the safe use of a short stem. The design features may account for potential advantages of current short stem implants compared with earlier short-stem designs, particularly in cases of reduced bone quality or osteonecrosis of the femoral head and femoral neck fractures. The implantation technique, however, requires distinct knowledge regarding the characteristics of varus and valgus positioning, with the potential for clinical consequences. A learning curve for surgeons new to this technique must be taken into account. Cortical contact with the distal lateral cortex appears to be crucial to provide sufficient primary stability, and the use of intraoperative imaging to identify “undersizing” is highly recommended. Current results of several national registries indicate that calcar-guided short stems are among the most successful implants in terms of mid-term survivorship. However, long-term data remain scarce. This review introduces the characteristics of calcar-guided short-stem THA and summarizes the current evidence.