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 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.     

Ceramic-on-ceramic bearings in total hip arthroplasty: “The future is now”

Total hip arthroplasty (THA) currently provides durable long-term outcomes, but osteolysis secondary to polyethylene wear debris remains a cause of aseptic loosening and revision. Ceramic-on-ceramic bearings surfaces have a long history of successful clinical use. Reported limitations of ceramic bearings are fracture and squeaking, but their incidence has been reduced through the evolution of fourth-generation ceramic compounds and a greater understanding of the role of component positioning, edge loading and resultant noise generation. The optimum bearing surface is one with very low wear rates, a low coefficient of friction, scratch resistance and is biologically inert. It is also one that can safely accommodate larger femoral head sizes to minimize dislocation rates without damaging the taper junction. Such a material already exists with modern ceramics, making them the ideal bearing material for total hip arthroplasty. “The future is now”.     

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.     

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.     

Dual mobility: A choice for primary total hip arthroplasty?

Dual-mobility sockets were introduced in the United States in 2010. The smaller inside diameter head offered the potential advantage of lower wear and the larger outside diameter head offered the potential advantage of improved stability. Initially, indications were advocated for patients with increased instability risk. However, with larger diameter metal-on-metal articulations falling out of favor, the indications for dual-mobility components are expanding. The author has used this design in over 400 primary THAs with only one dislocation. One loose cup was revised. Dislocation of the smaller femoral head from the larger polyethylene head remains a theoretical risk with DM designs.     

Obesity in total hip arthroplasty—does it really matter?: A meta-analysis

Background and purpose

Discussion persists as to whether obesity negatively influences the outcome of hip arthroplasty. We performed a meta-analysis with the primary research question of whether obesity has a negative effect on short- and long-term outcome of total hip arthroplasty.

Methods

We searched the literature and included studies comparing the outcome of hip arthroplasty in different weight groups. The methodology of the studies included was scored according to the Cochrane guidelines. We extracted and pooled the data. For continuous data, we calculated a weighted mean difference and for dichotomous variables we calculated a weighted odds ratio (OR). Heterogeneity was calculated using I₂ statistics.

Results

15 studies were eligible for data extraction. In obese patients, dislocation of the hip (OR = 0.54, 95% CI: 0.38–0.75) (10 studies, n = 8,634), aseptic loosening (OR = 0.64, CI: 0.43–0.96) (6 studies, n = 5,137), infection (OR = 0.3, CI: 0.19–0.49) (10 studies, n = 7,500), and venous thromboembolism (OR = 0.56, CI: 0.32–0.98) (7 studies, n = 3,716) occurred more often. Concerning septic loosening and intraoperative fractures, no statistically significant differences were found, possibly due to low power. Subjective outcome measurements did not allow pooling because of high heterogeneity (I₂ = 68%).

Interpretation

Obesity appears to have a negative influence on the outcome of total hip replacement.Obesity has reached epidemic proportions in the USA, and the rest of the well-developed world is expected to follow. Since obesity is a well-documented risk factor for the development of osteoarthritis (Sturmer et al. 2000, Flugsrud et al. 2006), an increased need for joint arthroplasty in obese people can be expected. Surgery on obese patients can lead to longer duration of the operative procedures themselves, with higher complication rates and longer hospital stays, and some authors have even suggested refusal of elective surgery in obese patients (Fehring et al. 2007).A controversy that has flared up during the last decennium is whether obesity might also influence the functional results and survival of total hip arthroplasty (THA), with studies showing either different or similar outcome compared to normal-weight patients. For both outcomes, different explanations have been postulated. McClung et al. (2000), for example, found that a higher BMI was associated with lower activity, resulting in less polyethylene wear in these patients, since wear is a function of use and not time. On the other hand, higher forces acting on the prosthesis in obese patients may lead to early loosening.Generally, a person with a BMI between 25 and 30 is categorized as overweight, and someone with a BMI of greater than 30 is obese. In this meta-analysis, we evaluated the results of all published trials comparing outcome and survival of primary THA between different BMI groups (BMI of < 30 and of > 30). Our main research question was whether obesity has a negative effect on the short- and long-term outcome of total hip arthroplasty.     

Dual-mobility components obviate the need for constrained components in revision total hip arthroplasty–Affirms

Dual-mobility hip components provide an additional articular surface, with the goals of improving range of motion and overall stability. In many European centers, these components are used for primary total hip arthroplasty. However, their greatest utility may be to prevent and treat recurrent dislocation after revision total hip arthroplasty. Several retrospective series have shown satisfactory results for this indication at medium-term follow-up. There are important concerns with these components, including intraprosthetic dislocation and polyethylene wear causing chronic dislocation, but these are rare phenomena. At present, dual-mobility components are the preferred solution to manage recurrent dislocation in revision surgery.     

Chronic total hip arthroplasty instability—Causes and cures

Chronic instability following total hip arthroplasty (THA) is a complex problem and is the most common reason for revision THA. Understanding the etiology of instability is paramount to choosing the appropriate treatment. In general, component malposition should always be addressed. Abductor deficiency, being seen more often with metal on metal THA failures, is a difficult problem to address that typically requires the use of a constrained liner. The use of dual mobility articulations have recently become popular and have demonstrated good early results for preventing re-revision in patients at high risk for instability.     

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.     

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.     

Glenohumeral osteoarthritis in young patients: Stemless total shoulder arthroplasty trumps resurfacing arthroplasty–Affirms

In the past 2 decades, advancements have been made in procedures for preserving and restoring the function of the proximal humerus when treating glenohumeral (GH) osteoarthritis. This review addresses two surgical options for GH osteoarthritis in the young patient, stemless total shoulder arthroplasty and resurfacing arthroplasty. These procedures preserve bone stock, have low complication rates, ease future revision if indicated, and report equal if not superior results compared with stemmed implant options. Comparative studies especially of long-term clinical outcomes of humeral resurfacing and stemless implants are still needed to make an informed treatment decision, especially in the young patient.     

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.     

Proximal cement fixation in total hip arthroplasty—first results with a new stem design

Stem loosening and stress-shielding are problems encountered in cemented hip arthroplasty. Could proximal stem fixation by partial cementing solve the problem? More physiological transmission of forces with only proximal cement fixation seems to be possible with this recent development (Z-stem, Option 3000, Mathys Orthopaedics, Bettlach, Switzerland). In a prospective clinical trial, this new implant was used for total hip arthroplasty in human patients. One hundred and thirty-three (133) total hip replacements in 123 patients were performed between April 1996 and January 2003. All of them were followed up regularly; 53 were analysed with the EBRA-FCA method (Einzel Bild Röntgen Analyse—femoral component analysis), whereas the rest were analysed using conventional follow-up X-rays. Eighty-six (86) patients with 95 hips could be examined in August 2004 to obtain mid-term results. At this stage, the mean follow-up time was 61 months (5.08 years), with a maximum of 100 months (8.33 years). Up to October 2004, nine cases needed a revision. The clinical data collected reported an average Harris Hip Score of 89.3 (good). The EBRA-FCA analysis reported a mean subsidence of less than 1.5 mm after the first two years, under the EBRA threshold of predicted loosening. At the latest follow-up (at an average of 61 months), there was an average stable subsidence of 2.4 mm in general. Eight (8) patients presented with subsidence of more than 5 mm. The results of the new implant seem to be encouraging. Finally, comparing our results to other fixation concepts will require longer follow-up periods.     

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.     

Head—neck modularity for total hip arthroplasty: Is It Necessary?

Although modular head—neck combinations for femoral components are convenient and useful, theoretical concerns make them less attractive. In a consecutive series of 100 primary cementless total hip arthroplasties, the neck length chosen for the broach trial reduction was compared with the final neck length chosen after the actual femoral component had been impacted. In 19%, the neck length was changed after insertion of the femoral component. As a result, leg-length inequality or wastage of these femoral components would have resulted. For cementless femoral components, the ability to adjust neck length after component impaction remains important.     

Displaced intracapsular hip fractures: hemiarthroplasty or total arthroplasty?

The role of total hip arthroplasty for the treatment of displaced intracapsular fractures of the proximal femur in active patients is controversial. Some authors have shown that such patients, when treated with a bipolar or unipolar hemiarthroplasty, are at increased risk of having acetabular erosion develop that might require later revision to a total hip replacement. In fact, the results of some authors were not substantially different from those reported for elective total hip arthroplasty and were better than results reported for hemiarthroplasty. However, other authors have strongly recommended avoiding total hip replacement in active elderly patients without preexisting acetabular disease (osteoarthritis, rheumatoid arthritis, Paget's disease). Although the current belief is that there is a place for primary total hip arthroplasty after intracapsular hip fracture, and that this procedure should be reserved for patients with preexisting symptomatic acetabular disease, in a preliminary prospective comparative study of 46 active patients without preexisting acetabular disease, the current author found better results with cemented Charnley's total hip arthroplasty than with cemented Thompson's hemiarthroplasty. Long-term outcome and more detailed indications for total hip replacement as the primary treatment for intracapsular displaced fractures of the proximal femur are topics for additional study.