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

BackgroundThere has been an increase in hip arthroscopy (HA) over the last decade. After HA, some patients may ultimately require a total hip arthroplasty (THA). However, there is a scarcity of research investigating the outcomes in patients undergoing THA with a history of ipsilateral HA.MethodsThe PearlDiver research program (www.pearldiverinc.com) was queried to capture all patients undergoing THA between 2015 and 2020. Propensity matching was performed to match patients undergoing THA with and without a history of ipsilateral THA. Rates of 30-day medical complications, 1-year surgical complications, and THA revision were compared using multivariate logistic regression. Kaplan-Meier analysis was conducted to estimate survival probabilities of each of the groups with patients undergoing THA .ResultsAfter propensity matching, cohorts of 1940 patients undergoing THA without prior HA and 1940 patients undergoing a THA with prior HA were isolated for analysis. The mean time from HA to THA was 1127 days (standard deviation 858). Patients with a history of ipsilateral HA had an increased risk for dislocation (odds ratio [OR] 1.56, P = .03) and overall decreased implant survival within 4 years of undergoing THA (OR 1.53; P = .05). Furthermore, our data demonstrate the timing of previous HA to be associated with the risk of complications, as illustrated by the increased risk for dislocation (OR 1.75, P = .03), aseptic loosening (OR 2.18, P = .03), and revision surgery at 2 (OR 1.92, P = .02) and 4 years (OR 2.05, P = .01) in patients undergoing THA within 1 year of HA compared twitho patients undergoing THA more than 1 year after HA or with no previous history of HA.ConclusionPatients undergoing THA after HA are at an increased risk for surgical complications, as well as the need for revision surgery.     

Morbid Obesity Is a Significant Risk of Failure Following Revision Total Hip Arthroplasty

Background

Although it has been shown that morbidly obese patients experience good outcomes following primary total hip arthroplasty (THA), it is unclear whether this also applies to revision surgery. The purpose of this study was to examine the effect of a high body mass index (BMI) on the outcome of revision THA.

Super Obesity Is an Independent Risk Factor for Complications After Primary Total Hip Arthroplasty

Background

Recent studies have reported higher postoperative complication rates in obese and morbidly obese patients undergoing total hip arthroplasty (THA). Less data are available regarding super-obese (body mass index [BMI] >50 kg/m²) patients. This study aims to quantify the risk of complications after THA in super-obese patients on a national scale and to put these risks in context by comparing them to patients of other BMI classes as well as those undergoing revision THA.

Complications After Revision Total Hip Arthroplasty in the Medicare Population

Background

The purpose of this study was to identify the incidence and types of complications after revision total hip arthroplasty (THA) within the first year, and determine the relative risk factors for these complications and of re-revision.

Patient-Reported Outcomes After Revision of Metal-on-Metal Total Bearings in Total Hip Arthroplasty

Background

Failure of metal-on-metal (MOM) total hip arthroplasty (THA) bearings is often accompanied by an aggressive local reaction associated with destruction of bone, muscle, and other soft tissues around the hip. Little is known about whether patient-reported physical and mental function following revision THA in MOM patients is compromised by this soft tissue damage, and whether revision of MOM THA is comparable with revision of hard-on-soft bearings such as metal-on-polyethylene (MOP).

Independent Risk Factors for Transfusion in Contemporary Revision Total Hip Arthroplasty

BackgroundThe incidence of transfusion in contemporary revision total hip arthroplasty (THA) remains high despite recent advances in blood management, including the use of tranexamic acid. The purpose of this prospective investigation was to determine independent risk factors for transfusion in revision THA.MethodsSix centers prospectively collected data on 175 revision THAs. A multivariable logistic analysis was performed to determine independent risk factors for transfusion. Revisions were categorized into subgroups for analysis, including femur-only, acetabulum-only, both-component, explantation with spacer, and second-stage reimplantation. Patients undergoing an isolated modular exchange were excluded.ResultsTwenty-nine patients required at least one unit of blood (16.6%). In the logistic model, significant risk factors for transfusion were lower preoperative hemoglobin, higher preoperative international normalized ratio (INR), and longer operative time (P < .01, P = .04, P = .05, respectively). For each preoperative 1g/dL decrease in hemoglobin, the chance of transfusion increased by 79%. For each 0.1-unit increase in the preoperative INR, transfusion chance increased by 158%. For each additional operative hour, the chance of transfusion increased by 74%. There were no differences in transfusion rates among categories of revision hip surgery (P = .23). No differences in demographic or surgical variables were found between revision types.ConclusionDespite the use of tranexamic acid, transfusions are commonly required in revision THA. Preoperative hemoglobin and INR optimization are recommended when medically feasible. Efforts should also be made to decrease operative time when technically possible.     

Risk of Prosthetic Joint Infection Increases Following Early Aseptic Revision Surgery of Total Hip and Knee Arthroplasty

BackgroundIt is important to identify risk factors for periprosthetic joint infection (PJI) following total joint arthroplasty in order to mitigate the substantial social and economic burden. The objective of this study is to evaluate early aseptic revision surgery as a potential risk factor for PJI following total hip (THA) and total knee arthroplasty (TKA).MethodsPatients who underwent primary THA or TKA with early aseptic revision were identified in 2 national insurance databases. Control groups of patients who did not undergo revision were identified and matched 10:1 to study patients. Rates of PJI at 1 and 2 years postoperatively following revision surgery were calculated and compared to controls using a logistic regression analysis.ResultsIn total, 328 Medicare and 222 Humana patients undergoing aseptic revision THA within 1 year of index THA were found to have significantly increased risk of PJI at 1 year (5.49% vs 0.91%, odds ratio [OR] 5.61, P < .001 for Medicare; 7.21% vs 0.68%, OR 11.34, P < .001 for Humana) and 2 years (5.79% vs 1.10%, OR 4.79, P < .001 for Medicare; 8.11% vs 1.04%, OR 9.05, P < .001 for Humana). Similarly for TKA, 190 Medicare and 226 Humana patients who underwent aseptic revision TKA within 1 year were found to have significantly higher rates of PJI at 1 year (6.48% vs 1.16%, OR 7.69, P < .001 for Medicare; 6.19% vs 1.28%, OR 4.89, P < .001 for Humana) and 2 years (8.42% vs 1.58%, OR 6.57, P < .001 for Medicare; 7.08% vs 1.50%, OR 4.50, P < .001 for Humana).ConclusionEarly aseptic revision surgery following THA and TKA is associated with significantly increased risks of subsequent PJI within 2 years.     

Acute Delayed Infection: Increased Risk in Failed Metal on Metal Total Hip Arthroplasty

Adverse local tissue reactions occurring in metal-on-metal total hip arthroplasty (MoM THA) could potentially lead to secondary failure modes such as dislocation or infection. The authors report a series of 124 patients treated with MoM hip arthroplasty between 2006 and 2010 with a minimum follow-up of 3 years. Eight hips presented with acute delayed or late periprosthetic joint infection (PJI) (defined as an infection occurring after 3 months in an otherwise well functioning implant). The rate of infection observed was higher than expected, almost 4 times higher (5.6%) compared to previous historical cohorts from our institution (1.3%). This high risk of infection in patients with DePuy ASR implants requires further study but we theorize that the increased prevalence of infection could be due to a combination of particulate debris, molecular (rather than particulate) effects of Co and Cr ions on soft tissues, and/or products of corrosion that may change the local environment predisposing to infection.     

Underweight Patients are at Increased Risk for Complications following Total Hip Arthroplasty

BackgroundGiven the prevalence of obesity in the United States, much of the adult reconstruction literature focuses on the effects of obesity and morbid obesity. However, there is little published data on the effect of being underweight on postoperative outcomes. This study aimed to examine the risk of low body mass index (BMI) on complications after total hip arthroplasty (THA).MethodsA large national database was queried between 2010 and 2020 to identify patients who had THAs. Using International Classification of Disease codes, patients were grouped into the following BMI categories: morbid obesity (BMI>40), obesity (BMI 30 to 40), normal BMI (BMI 20 to 30), and underweight (BMI<20). There were 58,151 patients identified, including 2,484 (4.27%) underweight patients, 34,710 (59.69%) obese patients, and 20,957 (36.04%) morbidly obese patients. Control groups were created for each study group, matching for age, sex, and a comorbidity index. Complications that occurred within 1 year postoperatively were isolated. Subanalyses were performed to compare complications between underweight and obese patients. Statistical analyses were performed using Pearson Chi-squares.ResultsCompared to their matched control group, underweight patients showed increased odds of THA revision (Odds Ratio (OR) = 1.32, P = .04), sepsis (OR = 1.51, P = .01), and periprosthetic fractures (OR = 1.63, P = .01). When directly comparing underweight and obese patients (BMI 30 and above), underweight patients had higher odds of aseptic loosening (OR = 1.62, P = .03), sepsis (OR = 1.34, P = .03), dislocation (OR = 1.84, P < .001), and periprosthetic fracture (OR = 1.46, P = .01).ConclusionMorbidly obese patients experience the highest odds of complications, although underweight patients also had elevated odds for several complications. Underweight patients are an under-recognized and understudied high risk arthroplasty cohort and further research is needed.     

Repeat 2-Stage Revision for Recurrent Infection of Total Hip Arthroplasty

Eleven patients who developed reinfection after 2-stage revision for infected total hip arthroplasty (THA) were treated with a repeat 2-stage rerevision. Of the 11 rerevisions, 4 were successful, with no recurrent infection at mean follow-up of 44 months. Reinfection occurred in 7 patients of whom 6 involved either a significantly compromised host or poor local wound status. Clinical symptoms of infection were controlled in 4 of the 7 reinfected cases with antibiotic therapy in 2, irrigation and debridement in 1, and a third 2-stage revision THA in 1. Repeat 2-stage treatment of infected THA is associated with a high failure rate. However, successful results can be achieved particularly if the host is not immunocompromised and healthy soft tissue coverage is present.     

Prior Hip Arthroscopy Increases Risk for Perioperative Total Hip Arthroplasty Complications: A Matched-Controlled Study

BackgroundArthroscopic hip surgery is becoming increasingly popular for the treatment of femoroacetabular impingement and labral tears. Reports of outcomes of hip arthroscopy converted to total hip arthroplasty (THA) have been limited by small sample sizes. The purpose of this study was to investigate the impact of prior hip arthroscopy on THA complications.MethodsWe queried our institutional database from January 2005 and December 2017 and identified 95 hip arthroscopy conversion THAs. A control cohort of 95 primary THA patients was matched by age, gender, and American Society of Anesthesiologists score. Patients were excluded if they had undergone open surgery on the ipsilateral hip. Intraoperative complications, estimated blood loss, operative time, postoperative complications, and need for revision were analyzed. Two separate analyses were performed. The first being intraoperative and immediate postoperative complications through 90-day follow-up and a second separate subanalysis of long-term outcomes on patients with minimum 2-year follow-up.ResultsAverage time from hip arthroscopy to THA was 29 months (range 2-153). Compared with primary THA controls, conversion patients had longer OR times (122 vs 103 minutes, P = .003). Conversion patients had a higher risk of any intraoperative complication (P = .043) and any postoperative complication (P = .007), with a higher rate of wound complications seen in conversion patients. There was not an increased risk of transfusion (P = .360), infection (P = 1.000), or periprosthetic fracture between groups (P = .150). When comparing THA approaches independent of primary or conversion surgery, there was no difference in intraoperative or postoperative complications (P = .500 and P = .790, respectively).ConclusionConversion of prior hip arthroscopy to THA, compared with primary THA, resulted in increased surgical times and increased intraoperative and postoperative complications. Patients should be counseled about the potential increased risks associated with conversion THA after prior hip arthroscopy.     

Obesity Increases the Risk of Postoperative Complications and Revision Rates Following Primary Total Hip Arthroplasty: An Analysis of 131,576 Total Hip Arthroplasty Cases

Background

The aim of our study is to evaluate the association of body mass index (BMI) and the risk of postoperative complications, mortality, and revision rates following primary total hip arthroplasty given other potentially confounding patient characteristics in a large cohort study.

Ceramic Insert Dislodgment After Revision Ceramic-on-Ceramic Total Hip Arthroplasty

We present a case of early ceramic insert dislodgment in a young patient with revision uncemented ceramic-on-ceramic total hip arthroplasty. The presentation may be subtle and the dislodgment may go unnoticed. This incidence draws our attention to the need for careful intraoperative confirmation of the insert position and frequent serial radiographic monitoring. The case also draws speculation of possible design flaws in the locking mechanism predisposing for the insert dislodgment.     

Risk Factors and Costs Associated With Clostridium difficile Colitis in Patients With Prosthetic Joint Infection Undergoing Revision Total Hip Arthroplasty

Background

With the increased demand for primary total hip arthroplasty (THA) and corresponding rise in revision procedures, it is imperative to understand the factors contributing to the development of Clostridium difficile colitis. We aimed to provide a detailed analysis of: (1) the incidence of; (2) the demographics, lengths of stay, and total costs for; and (3) the risk factors and mortality associated with the development of C. difficile colitis after revision THA.

Two-Stage Revision Total Hip Arthroplasty With a Specific Articulating Antibiotic Spacer Design: Reliable Periprosthetic Joint Infection Eradication and Functional Improvement

Background

Two-stage revision utilizing spacers loaded with high-dose antibiotic cement prior to reimplantation remains the gold standard for treatment of periprosthetic joint infections (PJI) in total hip arthroplasty (THA) in North America, but there is a paucity of data on mid-term outcomes. We sought to analyze the survivorship free of infection, clinical outcomes, and complications of a specific articulating spacer utilized during 2-stage revision.

Prevention of Dislocation After Total Hip Arthroplasty

Background

Prevention of dislocation after primary total hip arthroplasty (THA) begins with patient preoperative assessment and planning.

Low Hospital Volume Increases Revision Rate and Mortality Following Revision Total Hip Arthroplasty: An Analysis of 17,773 Cases

BackgroundWith the number of primary total hip arthroplasty (THA), the amount of revision THA (R-THA) increases. R-THA is a complex procedure requiring special instruments, implants, and surgical skills. Therefore it is likely that hospitals performing a higher number of R-THAs have more experience with this type of surgery and therefore fewer complications. The purpose of this study was to evaluate the relationship between hospital volume and risk of postoperative complications following R-THA.MethodsUsing nationwide healthcare insurance data for inpatient hospital treatment, 17,773 aseptic R-THAs in 16,376 patients treated between January 2014 and December 2016 were included. Outcomes were 90-day mortality, 1-year revision procedures, and in-house adverse events. The effect of hospital volume on outcome was analyzed by means of multivariate logistic regression. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.ResultsHospital volume had a significant effect on 90-day mortality (≤12 cases per year: OR 2.13, CI 1.53-2.96; 13-24: OR 1.79, CI 1.29-2.50; 25-52: OR 1.53, CI 1.11-2.10; ≥53: reference) and 1-year revision procedures (≤12: OR 1.26, CI 1.09-1.47; 13-24: OR 1.18, CI 1.02-1.37; 25-52: OR 1.03, CI 0.90-1.19; ≥53: reference). There was no significant effect on risk-adjusted major in-house adverse events.ConclusionWe found evidence of higher risk for revision surgery and mortality in hospitals with fewer than 25 and 53 R-THA per year, respectively. To improve patient care, complex elective procedures like R-THA which require experience and a specific logistic background should be performed in specialized centers.     

Obesity Is Independently Associated With Early Aseptic Loosening in Primary Total Hip Arthroplasty

Background

Obesity affects millions of patients in the United States and is associated with several complications after total hip arthroplasty (THA). The effect of obesity on the rate and mode of primary THA failure remains poorly understood, especially given other potentially confounding patient characteristics. We hypothesized that, among patients with a failed primary THA, obesity is independently associated with aseptic loosening and a higher rate of early revision.

Causes of Revision in Young Patients Undergoing Total Hip Arthroplasty

BackgroundThe purpose of this study was to identify reasons for revision of total hip arthroplasty (THA) in patients who underwent primary THA at or before the age of 35 years. We hypothesized that the reasons for revision in younger patients would be different from the general older population of patients undergoing THA because of the differences in diagnoses, complexity of deformities, and differences in activity level.MethodsData for 108 hips in 82 patients who underwent primary THA at our institution before the age of 35 years from 1982-2007 and subsequently underwent revision THA were reviewed. Operative reports and clinic notes were reviewed to determine baseline characteristics, reason for revision, timing of revision, and components revised.ResultsThe mean age at index surgery was 25.4 years, and mean time from index to revision surgery was 10.1 years. The most common preoperative diagnoses included avascular necrosis, juvenile idiopathic arthritis, developmental dysplasia of the hip, and posttraumatic arthritis. The most common reasons for revision were acetabular loosening (30.1%), femoral loosening (23.7%), and polyethylene wear (24.7%). 8.3% of patients underwent primary THA with highly cross-linked polyethylene, while the remainder of the patients underwent THA when conventional polyethylene was used. There was no statistically significant association between which component(s) were revised and initial fixation (ie cemented or uncemented prosthesis) (P = .26).ConclusionCauses of revision in this population appear to differ from the general THA population. In young patients, acetabular loosening, femur loosening, and polyethylene wear were the most common causes of revision. Instability and infection were less common compared with literature reports of causes of revision in older patients. Findings in this study may be useful in counseling young patients undergoing THA, though results were likely influenced by the use of conventional rather than highly cross-linked polyethylene in this cohort.     

Two-Stage Revision Total Hip Arthroplasty Without Spacer Placement: A Viable Option to Manage Infection in Patients With Severe Bone Loss or Abductor Deficiency

BackgroundHigh rates of spacer-related complications in two-stage exchange total hip arthroplasty (THA) have been reported. Patients with advanced bone defects and abductor deficiency may benefit from a nonspacer two-stage revision. This study reports on the clinical course of a contemporary two-stage exchange for periprosthetic hip infection without spacer insertion.MethodsWe reviewed 141 infected THAs with extensive bone loss or abductor damage who underwent two-stage exchange without spacer placement. The mean duration from resection arthroplasty to reimplantation was 9 weeks (2-29). Clinical outcomes included interim revision, reinfection, and aseptic revision rates. Restoration of leg-length and offset was assessed radiographically. Modified Harris hip scores were calculated. Mean follow-up was 5 years (3-7). Treatment success was defined using the modified Delphi consensus criteria.ResultsThirty-four patients (24%) had treatment failure, including 13 reinfections, 16 interim redebridements for persistent infection, 2 antibiotic suppressive therapies, and 3 prosthetic joint infection–related deaths. Aseptic rerevision after reimplantation was necessary in 14 patients (10%). Dislocation accounted for most aseptic complications, with 20 dislocations occurring in 15 patients (11%). Leg-length and offset were restored to preoperative measures. Mean modified Harris hip scores significantly improved from 35 points to 67 points.ConclusionA nonspacer two-stage exchange is a viable option for managing chronically infected THA with severe bone loss or abductor deficiency, showing comparable rates of interim revision and recurrence of infection. Cementless reimplantation demonstrates good midterm survivorship with comparable functional outcomes and leg-length restoration. However, dislocation continues to be a major concern.