Acetabular Cup Revision Combined With Tensor Facia Lata Reconstruction for Management of Massive Abductor Avulsion After Failed Total Hip Arthroplasty

We report on 17 patients with massive abductor avulsions after total hip arthroplasty (THA) treated with medialization of the acetabular component and tensor fascia lata (TFL) reconstruction. All patients had severe limp, positive Trendelenburg sign, and avulsion of the abductor insertion confirmed on MRI. Mean age was 69 years (range, 50–83 years), and mean follow-up period was 36 months (range, 18–78 months). After surgery, 9 patients had no limp (47%), 8 patients had a mild limp, and abductor power improved from mean 2.5/5 to mean 3.8 (P < 0.0001). At latest follow-up, the Harris Hip Score was excellent in 6 hips (37%), good in 7 (43%) hips, and fair or poor in 3 (23%). Two patients with mild limp were not satisfied with their procedure.     

Large Diameter Metal on Metal Articulations. Comparison of Total Hip Arthroplasty and Hip Resurfacing Arthroplasty

The use of large diameter metal bearing total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA) increased in popularity in the last decade. More recent literature has highlighted the effect of head size in patient outcomes. Data was obtained from the Australian Orthopaedic Association National Joint Replacement Registry (AOA-NJRR) to evaluate the Birmingham (MoM) bearing surface when used with THA and HRA. There is no difference in the overall rate of revision between the THA and HRA but head size has a significant effect on revision rate. The data show that small diameter metal bearings in HRA (below 50 mm) have a higher rate of revision than large diameter metal bearings in HRA (equal to and above 50 mm) (P < .001). Conversely the large diameter metal bearings in THA have a higher rate of revision than the small diameter metal bearings in THA (P = .027). The revision rate for large diameter HRA compared to small diameter THA is not significantly different P = .670. We recommend caution when choosing either a large diameter (≥ 50 mm) metal on metal THA or small diameter (< 50 mm) HRA.     

Iliopsoas Impingement After Direct Anterior Approach Total Hip Arthroplasty: Epidemiology,Risk Factors,and Treatment Options

BackgroundThe objective of this study is to evaluate the incidence, natural history, response to treatment, and risk factors for anterior iliopsoas impingement (AIPI) after direct anterior approach (DAA) total hip arthroplasty (THA).MethodsBetween January 1, 2009 and January 4, 2014, 600 patients (655 hips) who underwent primary DAA THA were retrospectively reviewed. AIPI incidence was calculated. Natural history and response to a stepwise treatment approach was assessed. Radiographic anterior acetabular component overhang was measured. Asymptomatic controls were used to identify risk factors for the development of AIPI.ResultsIn total, 518 patients (559 hips) met the inclusion criteria. The incidence of AIPI was 32/559 (5.7%). Symptom resolution occurred in 22/32 (68.8%) patients at final follow-up. Nonoperative management was successful in 15/32 (46.9%) patients. Operative intervention resulted in symptom resolution in 5/8 (62.5%) patients. On univariate analysis, female gender (odds ratio [OR] 2.79), acetabular component to native femoral head diameter ratio above 1.1 (OR 3.85), and any measurable overhang (OR 7.07) significantly raised the risk of AIPI, while increasing native femoral head diameter was protective for AIPI (OR 0.83).ConclusionAIPI is a cause of groin pain after DAA THA, which often improves with conservative measures. Significant predisposing factors for AIPI include female gender, small native femoral head diameter, increased acetabular component to femoral head diameter ratio, and most notably, any measurable acetabular component overhang.Level of EvidenceLevel III, retrospective cohort study.     

Periacetabular Bone Mineral Density Changes After Resurfacing Hip Arthroplasty Versus Conventional Total Hip Arthroplasty. A Randomized Controlled DEXA Study

A randomized controlled trial was performed to evaluate acetabular bone mineral density (BMD) changes after hip resurfacing (RHA) versus an established conventional total hip arthroplasty (THA). A total of 71 patients were allocated randomly to receive either an RHA press-fit cobalt–chromium cup (n = 38) or a THA with a threaded titanium cup and polyethylene-metal-inlay insert (n = 33). The BMD in five separate periacetabular regions of interest (ROI) was prospectively quantified preoperative until 24 months. We conclude that, in contrast to our hypothesis, periacetabular BMD was better preserved after RHA than after placement of a conventional THA. Long term follow-up studies are necessary to see whether this benefit in bone preservation sustains over longer time periods and whether it is turned into clinical benefits at future revision surgery.     

Total Hip Arthroplasty after Acetabular Fracture: Incidence of Complications,Reoperation Rates and Functional Outcomes: Evidence Today

The outcome of THA following acetabular fracture was analyzed on 654 patients with a systematic review approach. An uncemented acetabular and femoral component was used in 80.1% and 59.8% of the cases respectively. The median Harris hip score was 88 points. In the early THA group, Kaplan–Meier survivorship analysis with any loosening, osteolysis or revision as the end point revealed that the 10-year cup survival was 81% whereas in the late THA group was 76% (P = 0.287). The 10-year survival was 95% for the early stems and 85% for the late ones (P = 0.001). Due to their complexity these fractures should be managed in highly specializing units where the expertise of arthroplasty and trauma reconstruction is available.     

Comparison of Acetabular Shell Position Using Patient Specific Instruments vs. Standard Surgical Instruments: A Randomized Clinical Trial

Total hip arthroplasty (THA) survivorship relies largely upon appropriate acetabular cup placement. The purpose of this prospective randomized controlled trial was to determine whether the use of a preoperative 3D planning software in combination with patient specific instrumentation (PSI) results in improved cup placement compared with traditional techniques. Thirty-six THA patients were randomized into standard (STD) or PSI technique. Standard approach was completed using traditional techniques, while PSI cases were planned and customized surgical instruments were manufactured. Postoperative CT scans were used to compare planned to actual results. Differences found between planned and actual anteversion were − 0.2° ± 6.9° (PSI) and − 6.9° ± 8.9° (STD) (P = 0.018). Use of 3D preoperative planning along with PSIs resulted in significantly greater anteversion accuracy than traditional planning and instrumentation.     

Intra-Articular Bupivacaine Reduces Postoperative Pain and Meperidine Use After Total Hip Arthroplasty: A Randomized,Double-Blind Study

One hundred patients receiving unilateral total hip arthroplasty (THA) were randomized to receive an intra-articular injection of 300 mg bupivacaine or normal saline after completion of surgery. Pain scores of the bupivacaine group were significantly lower than those of the control group the first 12 hours postoperatively (all, P < 0.001). A significantly lower dose of meperidine was used in the study group than in the control group the first 24 hours postoperatively (median, 25 vs. 45 mg, P < 0.001). Nineteen patients in the study group required meperidine the first day after surgery, as compared to 45 patients in the control group. We conclude that intra-articular injection of bupivacaine after THA reduces pain and meperidine use in the first 12 hours after surgery.     

Factors Influencing Revision Risk Following 15 740 Single-Brand Hybrid Hip Arthroplasties : A Cohort Study From a National Joint Registry

This retrospective cohort study of a National Joint Registry data examines survival time to revision following the commonest brand of primary hybrid THA, exploring risk factors independently associated with failure. Overall 5-year revision was 1.56%. In the final adjusted model, revision risk was significantly higher with standard polyethylene (PE) liners (metal-on-PE: hazard ratio [HR] = 2.52, P = 0.005, ceramic-on-PE: HR = 2.99, P = 0.025) when compared to metal-on-highly-cross-linked (XL) PE. Risk of revision with ceramic-on-ceramic bearings was borderline significant (HR = 1.86, P = 0.061). A significant interaction between age and acetabular shell type (solid or multi-hole) was found (P = 0.022), suggesting that solid shells performed significantly better in younger patients. In summary, we found that there were significant differences in implant failure between different bearing surfaces and shell types after adjusting for a range of covariates.     

Similar Improvement in Gait Parameters Following Direct Anterior & Posterior Approach Total Hip Arthroplasty

We compared gait parameters prior to, at 6 months and 1 year following total hip arthroplasty (THA) performed via direct anterior approach (DAA) and posterior approach (PA) by a single surgeon in 22 patients. A gait analysis system involving reflective markers, infrared cameras and a multicomponent force plate was utilized. Postoperatively, the study cohort demonstrated improvement in flexion/extension range of motion (ROM) (P = 0.001), peak flexion (P = 0.005) and extension (P = 0.002) moments with no differences between groups. Internal/external ROM improved significantly in the DAA group (P = 0.04) with no change in the PA group. THA performed via DAA and PA offers similar improvement in gait parameters with the exception of internal/external ROM which might be related to the release and repair of external rotators during PA THA.     

Early Outcome Comparison Between the Direct Anterior Approach and the Mini-Incision Posterior Approach for Primary Total Hip Arthroplasty: 150 Consecutive Cases

This study evaluated early postoperative results of 150 consecutive primary total hip arthroplasties performed by a single surgeon; 50 from mini-incision posterior approach, 50 during the learning curve for the direct anterior approach, and 50 subsequent cases when the approach was routine. The anterior approach groups had significantly reduced hospital length of stays (2.9 and 2.7 days versus 3.9 days for the posterior group; P < 0.0001) and discharge to home versus rehab was more likely (80% and 84% in anterior groups, 56% in posterior group; P = 0.0028). In the anterior groups, there was significantly less use of assistive devices and narcotics at 6 weeks, and pain was significantly lower. Primary total hip arthroplasty using the anterior approach allows for superior recovery in a matched cohort of patients.     

Effect of Price Capitation on Implant Selection for Primary Total Hip and Knee Arthroplasty

While price capitation strategies may help to control total hip (THA) and knee arthroplasty (TKA) implant costs, its effect on premium implant selection is unclear. Primary THA and TKA cases 6 months before and after capitated pricing implementation were retrospectively identified. After exclusions, 716 THA and 981 TKA from a large academic hospital and 2 midsize private practice community hospitals were reviewed. Academic hospital surgeons increased premium THA implant usage (66.5% to 70.6%; P = 0.28), while community surgeons selected fewer premium implants (36.4%) compared to academic surgeons, with no practice change (P = 0.95). Conversely, premium TKA implant usage significantly increased (73.4% to 89.4%; P < 0.001) for academic surgeons. Community surgeons used premium TKA implants at greater rates in both periods, with all cases having ≥ 1 premium criterion.     

Acetabular Total Hip Arthroplasty Revision: A Summary of Operative Factors,Outcomes, and Comparison of Approaches

BackgroundRevision total hip arthroplasty (THA) presents a greater risk to patients than primary THA, and surgical approach may impact outcomes. This study aimed to summarize acetabular revisions at our institution and to compare outcomes between direct anterior and posterior revision THA.MethodsA series of 379 acetabular revision THAs performed from January 2010 through August 2022 was retrospectively reviewed. Preoperative, perioperative, and postoperative factors were summarized for all revisions and compared between direct anterior and posterior revision THA.ResultsThe average time to acetabular revision THA was 10 years (range, 0.04 to 44.1), with mechanical failure (36.7%) and metallosis (25.6%) being the most prevalent reasons for revision. No differences in age, body mass index, or sex were noted between groups. Anterior revision patients had a significantly shorter length of stay (2.2 versus 3.2 days, P = .003) and rate of discharge to a skilled nursing facility (7.5 versus 25.2%, P = .008). In the 90-day postoperative period, 9.2% of patients returned to the emergency department (n = 35) and twelve patients (3.2%) experienced a dislocation. There were 13.2% (n = 50) of patients having a rerevision during the follow-up period with a significant difference between anterior and posterior approaches (3.8 versus 14.7%, respectively, P = .049).ConclusionThis study provides some evidence that the anterior approach may be protective against skilled nursing facility discharge and rerevision and contributes to decreased lengths of stay. We recommend surgeons select the surgical approach for revision THA based on clinical preferences and patient factors.     

Plain Radiographs Fail to Reflect Femoral Offset in Total Hip Arthroplasty

Successful biomechanical reconstruction is a major goal in total hip arthroplasty (THA). We measured leg length (LL), global (GO) and femoral offset (FO) change on anteroposterior pelvis radiographs and on three-dimensional computed-tomography (3D-CT) with fiducial landmarks after cementless THA on 18 hips of cadaveric specimens. Measurements on radiographs were performed twice by four examiners and showed high interobserver (mean CCC ≥ 0.79) and intraobserver agreements (mean ICC ≥ 0.88). Mean differences between radiographic and 3D-CT measurements were 1.0 (SD 2.0) mm for LL, 0.6 (SD 3.6) mm for GO and 1.4 (SD 5.2) mm for FO. 1% of radiographic LL-, 15% of GO- and 35% of FO measurements were outside a tolerance limit of 5 mm. Radiographs seem acceptable for measuring LL/GO change but fail to reflect FO change in THA.     

Activity,Sleep and Cognition After Fast-Track Hip or Knee Arthroplasty

Optimized perioperative care after total hip and knee arthroplasty (THA/TKA) has decreased length of stay (LOS) but data on activity, sleep and cognition after discharge are limited. We included 20 patients ≥ 60 years undergoing THA/TKA, monitoring them for 3 days preoperatively and 9 days postoperatively with actigraphs for sleep and activity assessment. Pain scores were recorded daily. Cognition was evaluated by 2 cognitive tests. Results showed a mean age was 70.5 years and mean LOS was 2.6 days. Actigraphs showed increased daytime sleep and decreased motor activity postoperatively. Early postoperatively cognitive decline and increased pain returned to preoperative levels by postoperative day (POD) 5–9. Despite the small sample size the study illustrated that post-discharge activity is decreased and daytime sleep is increased after fast-track THA/TKA, while cognition and pain return to preoperative levels by POD 9. Objective assessment of these recovery parameters may be valuable in future interventional studies to enhance recovery after THA/TKA.     

Relative Head Size Increase Using an Anatomic Dual Mobility Hip Prosthesis Compared to Traditional Hip Arthroplasty: Impact on Hip Stability

Smaller head sizes and head/cup ratios make cups smaller than 50 mm and larger than 58 mm, more prone to dislocation. Using computer modeling, we compared average head sizes and posterior horizontal dislocation distance (PHDD) in two 78-patient matched cohorts. Cup sizes were small (≤ 50 mm) or large (≥ 58 mm). The control cohort had conventional fixed bearing prostheses, while the experimental cohort had anatomical dual mobility (ADM) hip prostheses. ADM cups have larger average head sizes and PHDD than traditional fixed bearing prostheses by 11.5 mm and 80% for cups ≤ 50 mm, and 16.3 mm and 90% for cups ≥ 58 mm. Larger head sizes and increased head/cup ratio may allow the ADM prosthesis to reduce the incidence of dislocation.     

A Simple Method Using a PACS to Minimize Leg Length Discrepancy in Primary THA : A Method to Minimize Leg Length Discrepancy

We determined whether a PACS-based method (head-lesser trochanter distance [HLD]) better equalized leg length discrepancy (LLD) after primary THA than a conventional method. We retrospectively reviewed 312 patients (379 hips) with osteonecrosis or primary osteoarthritis who underwent primary cementless THA: 198 patients (240 hips) underwent THA using the HLD method, while the conventional group consisted of 114 patients (139 hips) in whom we measured with the method of McGee and Scott. We then compared the LLDs in the two groups. We observed no difference in the mean postoperative LLD. A higher percentage of patients in the HLD group had an LLD less than 6 mm: 81% vs 68% hips, respectively. HLD method decreases the possibility of an LLD over 6 mm after THA.     

Is Cup Positioning Challenged in Hips Previously Treated With Periacetabular Osteotomy?

After periacetabular osteotomy (PAO), some patients develop osteoarthritis with need of a total hip arthroplasty (THA). We evaluated the outcome of THA following PAO and explored factors associated with inferior cup position and increased polyethylene wear. Follow-up were performed 4 to 10 years after THA in 34 patients (38 hips) with previous PAO. Computer analysis evaluated cup position and wear rates. No patient had dislocations or revision surgery. Median scores were: Harris hip 96, Oxford hip 38 and WOMAC 78. Mean cup anteversion and abduction angles were 22^o (range 7°–43°) and 45° (range 28°–65°). Outliers of cup abduction were associated with persisting dysplasia (CE < 25°). THA after PAO can produce excellent clinical results. Persisting acetabular dysplasia following PAO may lead surgeons to place the acetabular component in excessive cup abduction, and this tendency should be recognized at the time of the PAO.     

Changes in Bone Mineral Density of the Acetabulum and Proximal Femur After Total Hip Resurfacing Arthroplasty

Our aim was to investigate the changes in bone mineral density (BMD) of acetabulum and proximal femur after total hip resurfacing arthroplasty. A comparative study was carried out on 51 hips in 48 patients. Group A consisted of 25 patients (26 hips) who had undergone total hip resurfacing and group B consisted of 23 patients (25 hips) who had had large-diameter metal-on-metal total hip arthroplasty (THA). BMDs around the acetabulum and proximal femur were measured using dual-energy x-ray absorptiometry (DEXA) at 2 weeks, 6 months, 1 year and annually thereafter during the 3 years after surgery. At final follow-up, the acetabular net mean BMD decreased by 11% in group A and 10% in group B with no differences between two groups (P = .35). For the femoral side, in Gruen zone 1, the mean BMD increased by 4% in group A, whereas it decreased by 11% in group B (P = .029). In Gruen zone 7, the mean BMD increased by 8% at the final follow-up in group A, whereas it decreased by 13% in group B (P = .02). In both groups the mean BMD increased by 3% in Gruen zones 3, 4, 5, and 6. Stress-related bone loss of the acetabulum was comparable for MOM THA and resurfacing devices, but proximal femoral bone density increased in the resurfacing group and decreased in the THA group.     

Impact of Dexamethasone on Length of Stay and Early Pain Control in Direct Anterior Approach Total Hip Arthroplasty With Neuraxial Anesthesia

BackgroundDexamethasone has been shown to reduce postoperative pain and opioid consumption for total joint arthroplasty patients; however, its impact on patients who received neuraxial anesthesia (NA) is not well described. We examined the impact of perioperative dexamethasone on outcomes for patients undergoing direct anterior approach total hip arthroplasty (THA) under NA.MethodsA retrospective review was conducted for 376 THA patients from a single institution. Univariate analysis was used to compare postoperative outcomes for 164 THA patients receiving dexamethasone compared to 212 who did not receive dexamethasone.ResultsNo differences in age, gender, body mass index, or American Society of Anesthesiologists (ASA) Score were observed between the groups. Patients receiving perioperative dexamethasone reported statistically significantly lower postanesthesia care unit (PACU) pain numeric rating scale (Dexamethasone 1.6 vs No dexamethasone 2.3, P = .014) and received lower PACU morphine milligram equivalents (MME) (Dexamethasone 8.57 vs No dexamethasone 11.44, P < .001). Patients receiving dexamethasone had significantly shorter LOS (Dexamethasone 29.40 vs No dexamethasone 35.26 hrs., P < .001).ConclusionPerioperative dexamethasone is associated with decreased postoperative pain and narcotic consumption, and shorter length of stay for patients undergoing primary direct anterior approach THA with NA.     

Spinal Factors Influencing Change in Pelvic Sagittal Inclination From Supine Position to Standing Position in Patients Before Total Hip Arthroplasty

In some atypical patients, pelvic sagittal inclination (PSI) changes posteriorly by > 10° from supine to standing position before total hip arthroplasty (THA). Several studies have suggested PSI in standing position is related to lumbar degeneration. The purpose of this study was to investigate spinal factors influencing changes in PSI from supine to standing position before THA. Participants comprised 163 consecutive patients who had undergone THA. Presence of compression fractures, presence of lumbar spondylolisthesis, thoracic kyphosis angle, lumbar lordosis angle, S1 anterior tilt angle and T4 plumb line position were investigated as spinal factors. Presence of compression fractures, age, presence of lumbar spondylolisthesis and small S1 anterior tilt angle were independently associated with posterior change in PSI from supine to standing position in patients before THA.