Statistical analysis of total hip arthroplasty at rural hospital in Maharashtra under MJPJAY: a prospective study

Background:Studies have reported that patients with human immunodeficiency virus (HIV) have a high incidence of osteonecrosis of the femoral head (ONFH). Total hip arthroplasty (THA) is an effective management of ONFH. However, little data exist regarding the use of THA for the HIV patients with ONFH in China. This study reviewed the outcomes of HIV-positive patients who underwent THA for ONFH, compared with HIV-negative individuals.Methods:The patients who underwent THA for ONFH from September 2012 to September 2014 in Beijing Ditan Hospital, Capital Medical University were retrospectively studied. Twenty-eight HIV-positive patients and 35 HIV-negative patients underwent 48 THAs and 45 THAs with cementless components, respectively. Medical records and follow-up data were reviewed. Harris Hip Score (HHS) was applied to evaluate the pain and function of the hips before and after THA. Complications such as wound healing, surgical site infection, deep venous thrombosis, pulmonary embolism, sepsis, mortality, and complications from the prosthesis were reviewed. The operation time, blood loss, and hospital stay were compared between the two groups.Results:The mean follow-up period was 19.5 ± 5.8 months (ranging from 6 to 30 months). The mean age of the HIV-positive patients with osteonecrosis at the time of surgery was 35 years old, which was significantly lower than that of the HIV-negative group (42 years old) (P < 0.05). The HIV-positive patients underwent surgery a mean of 2.5 years after their original symptoms, which was significantly shorter than the HIV-negatives’ (mean 4 years) (P < 0.05). Among HIV-positive patients, the prevalence of being male and rate of bilateral procedures were significantly higher than those in the HIV-negative group (P < 0.05). The operation time in HIV-positive patients was significantly longer than that in HIV-negative patients (P < 0.05). There were no significant differences in blood loss or hospital stay between the two groups (P > 0.05). The HHSs of two groups significantly improved after THAs (P < 0.05), without significant difference between two groups. No wound complication, sepsis, mortality, prosthesis complication, and occupational exposure occurred, except for two cases of heterotopic ossification and one case of humeral head necrosis.Conclusions:ONFH is more likely to occur bilaterally in younger HIV-positive males. The development of osteonecrosis seems faster in HIV-positive patients than in HIV-negative patients. This should be cautionary for asymptomatic HIV-positive patients with low viral RNA level and in the primary HIV stage. Despite longer operation times in the HIV-positive patients than in the HIV-negative patients, THA is still a safe and efficient approach to treat ONFH in HIV-positive patients. The incidence of complications is much lower than previously reported. However, the long-term follow-up is needed.

BACKGROUND: Nowadays total hip arthroplasty (THA) is the method of choice for the treatment of late stages osteonecrosis of the femoral head (OFH) and osteoarthritis (OA) of the hip joint. OBJECTIVE: To evaluate the efficacy and complication pattern of THA in late stages of OFH and OA. MATERIALS AND METHODS: The study included 74 patients who underwent primary THA for OA stages IIIIV (Kellgren and Lawrence classification) and for OFH stages IIIIV (ARCO classification). Group 1 included 34 patients with OFH stages IIIIV, and group 2 40 patients with OA stages IIIIV. The groups were comparable by gender and age. All patients underwent implantation of endoprosthesis components using press-fit fixation with a metalpolyethylene articulation. Treatment results were assessed with regard to the incidence of complications and functional results at 3, 6 months, 1 and 3 years after THA. RESULTS: In our study, the survival rate of components after THA within 3 years after implantation was 100%. No cases of periprosthetic fracture, periprosthetic infection, and aseptic instability of endoprosthesis components were observed in both groups. The surface inflammation of the postoperative wound was detected in 1 (2.9%) patient in the OFH group and in 1 (2.5%) patient in OA group. Dislocation of the endoprosthesis occurred in 1 patient with OFH; there were no such findings in the OA group. The frequency of peri-implant osteolysis was twice lower (2.5%) in patients with OA compared to OFH group (5.8%). There were no statistically significant differences in the functional results dynamics before and after surgery between the groups (Harris score). The average Harris scale score in patients with OFH was 63 and reached 94 after 3 years; in OA group 58 and 94, respectively. CONCLUSION: THA is an alternative method in the treatment of severe hip arthroplasty. Endoprosthetics using a cementless endoprosthesis with a metalpolyethylene articulation demonstrated high efficacy as well as a low number of complications among patients with OFH and OA. We found no significant difference in THA results in terms of survival, postoperative complications, and functional outcome in patients with OFH and OA. Longer postoperative follow-up is advisable, which may allow us to establish some differences in treatment outcomes.

To investigate the clinical outcome for the treatment of osteonecrosis of the femoral head (ONFH) in advanced stage by a short-stem prosthesis preserving femoral neck in total hip arthroplasty (THA). From June 2008 to December 2009, 9 hips in 8 patients with advanced stage of ONFH were treated by a short-stem preserving femoral neck in THA. The mean age was 24.1 years (range: 20 - 36). There were 3 patients (3 hips) with alcohol-induced ONFH and 5 patients (6 hips) with steroid-induced ONFH. According to the classification of Association Research Circulation Osseous (ARCO), 7 hips were in stage III-C and 2 hips in stage IV respectively. The clinical outcomes were evaluated according to the Harris evaluation score and radiographic analysis. All patients were followed up for a mean duration of 18.1 months (range: 12 - 30). The mean Harris hip score improved from preoperative (42.8 ± 8.6) points to (92.8 ± 6.1) points at the time of final follow-up. The outcomes were excellent in 7 hips and better in 2 hips. Neither osteolysis of mortar and femur nor loose component was found from radiological films. The pain of all hips disappeared and no complications occurred. The short-term clinical outcome is satisfactory for treating young patients with advanced stage of ONFH by a short-stem prosthesis preserving femoral neck in THA.

Editorial Comment

The purpose of this review was to identify and describe what is known regarding the clinical presentation and the various methods of management of osteonecrosis of the femoral head (ONFH) following coronavirus disease 2019 (COVID-19), based on current literature. COVID-19 results from infection with the Severe Acute Respiratory Syndrome Corona Virus2. A large number of infected patients manifest multi-systemic pathologies for several weeks to months following recovery. This condition is now identified as postacute COVID-19 syndrome (PACS). COVID-19 could result in ONFH either directly due to endothelial dysfunction and a hypercoagulable state, or secondary to corticosteroid medications used during its management, as a manifestation of PACS. Despite a fairly widespread awareness of this condition, there is a scarcity of literature regarding its clinical presentation and management. A literature search was conducted using the following electronic databases: PubMed/Medline, Embase, and Scopus. The following search terms were used: “covid (AND) osteonecrosis” and “covid (AND) avascular (AND) necrosis.” The preliminary search results were screened to identify relevant literature. Data pertaining to the clinical presentation and management of post-COVID-19 ONFH were retrieved from these studies, and tabulated and presented systematically. Post-COVID-19 ONFH has been reported in a wide range of age groups, with unilateral or bilateral hip involvement. A greater proportion of reported cases were associated with: the male gender, high body mass index, severe COVID-19 infection, and corticosteroid consumption. The onset of symptoms, commonly pain and difficulty in walking, has been reported to vary from a few days to a few years following the detection of COVID-19. Most studies reported patient presentation with stage-2 or stage-3 ONFH. Conservative management of this condition with bisphosphonates has shown promising preliminary results. Among surgical management options, core decompression and total hip arthroplasty have been described. Long-term outcomes of patients managed with various treatment modalities are currently not available. Future observational studies could confirm the findings in this review, and lay the foundation for high-quality systematic reviews. The information presented herein can aid in the drafting of appropriate screening and surveillance protocols for COVID-19 patients.

Osteonecrosis of the femoral head (ONFH) typically affects relatively young, active patients and frequently follows an unrelenting course resulting in considerable loss of function. In human immunodeficiency virus-infected patients, ONFH is a growing problem. Etiology, pathogenesis, and treatment of ONFH in these patients remain controversial. We analyzed retrospectively patients with ONFH in a series of 815 patients followed in our AIDS reference center. Six patients out of the 815 were affected by ONFH (0.74%). The sex ratio was 1. Two of the six patients (33.3%) had no evidence of risk factor, whereas four patients (66.6%) had risk factors. One patient had three cumulated risk factors which were corticosteroids, chemotherapy, and radiotherapy. For this patient, the onset time for ONFH was shorter (36 months). It is difficult to attribute the effect to any single class of antiretroviral agents because combination therapy is standard of care, and a change in therapies is common. All classes of antiretroviral drugs have been used: protease inhibitors (mean use duration of 15.2 months before the ONFH onset), non-nucleoside reverse transcriptase inhibitors (12 months), and nucleoside reverse transcriptase inhibitors (40.5 months). ONFH was bilateral in four cases (66.6%) and unilateral in two cases (33.3%). One patient had other osteonecrosis location (both shoulders). ONFH was classified on plain radiography stage IV in five patients and stage III in one patient. All patients received initial medical treatment. It consisted of painkillers and non-weight bearing of the hip. All were finally operated on by total hip arthroplasty (THA). The average interval between ONFH diagnosis and the first THA was 10.3 months for the six patients. A controlateral THA was performed for three patients after a mean interval of 23.3 months after ONFH diagnosis. Of the nine implanted prostheses, four were cemented, four were cementless, and one was resurfacing prosthesis.

To evaluate the value of cementless hip arthroplasty in the treatment of posttraumatic and atraumatic osteonecrosis (ON) of the femoral head. The study was conducted at the Department of Orthopedics and Traumatology, Military Medical Academy, between January 1st, 1999 and December 31st, 2003. Twenty-five patients with 27 implanted endoprostheses, and the diagnosis of osteonecrosis of the femoral head, and radiographically confirmed Arlet-Ficat stage III and IV were evaluated retrospectively. The results were evaluated according to Harris Hip Score (HHS). The research included 10 patients with traumatically induced osteonecrosis and 15 patients (17 endoprothesis) with osteonecrosis of the femoral head. The mean age of the patients in the group with posttraumatic osteonecrosis of the femoral head was 41 (19-62) years, and in the group of the patients with atraumatic osteonecrosis of the femoral head it was 40.2 (21-53) years. Complications included one case with postoperative luxation, and one case with iatrogenic sciatic nerve palsy. The average Harris Hip Scores in the group of posttraumatic osteonecrosis were 31 points preoperatively and 86 points postoperatively. In the group of osteonecrosis of atraumatic etiology, the average Harris Hip Score was 28 points preoperatively, and 77 points postoperatively. Postoperative Harris Hip Scores were compared with the Student's t-test and the results showed no statistically significant difference (p = 0,125). Our study did not find any significant difference between the results of posttraumatic and atraumatic osteonecrosis of the femoral head treated with cementless endoprosthesis.

Comparison of Results of Total Hip Arthroplasty in Patients Under 50 Years Who Had Osteonecrosis of the Femoral Head or Osteoarthritis: A Propensity-Matched Cohort Study From the Geneva Arthroplasty Registry With a Mean 12-Year Follow-Up.

Osteonecrosis of the femoral head (ONFH) is commonly detected in young patients and most surgeons tend to delay total hip arthroplasty (THA) until the end stage of the disease. We hypothesised that post-operative range of motion (ROM) of the hip as well as baseline ROM at the time of surgery decreases with the disease progression. The purpose of this study was to determine whether patients, who were operated at an advanced stage, have pre- and post-operative hip ROM similar to ROM of patients, who were operated at earlier stages. Eight hundred and fifty patients (850 hips) treated with THA for ONFH were classified according to pre-operative stages of Association Research Circulation Osseous (ARCO). Fifty-six patients were operated at stage 2, 458 at stage 3, and 336 at stage 4. Pre-operative and oneyear post-operative ROM was compared among the stages. Pre-operative sum of hip ROM decreased with the progression of ARCO stage (P < 0.001) and correlated with the post-operative sum of hip ROM (correlation coefficient 0.661). Although hip ROM improved after THA in all stages, post-operative ROM in patients with lower pre-operative ROM did not improve to the same level as in those with a higher pre-operative ROM (P < 0.001). The progression of ONFH negatively affected post-operative hip ROM as well as baseline hip ROM at the time of THA. Surgeons should consider a delay of THA negatively affects the hip ROM after the arthroplasty, when they determine the treatment modality for ONFH patients.

BackgroundStudies have reported that osteonecrosis of the femoral head (ONFH) is more prevalent in patients with human immunodeficiency virus (HIV). Total hip arthroplasty (THA) is considered reasonable management of ONFH. However, only scarce data exist on the outcomes of THA for HIV-infected patients in South Korea. The purpose of this study was to evaluate the midterm results of HIV-positive patients who underwent THA for ONFH.MethodsWe performed a retrospective review of HIV-infected patients with ONFH who underwent THA in our institution from 2005 to 2021. Twenty-two hips in 15 patients underwent THAs with cementless implants. The clinical and radiographic evaluation was performed at each follow-up, and any complication was recorded.ResultsThe mean follow-up period was 5.2 years (range, 1.0–16.0 years). The mean age of the HIV infected patients with osteonecrosis at the time of surgery was 44.7 ± 11.6 years. ONFH occurred 9.8 ± 3.7 years after the initial diagnosis of HIV infection. The average modified Harris hip score improved from 58.3 ± 14.8 to 95.2 ± 11.3 at the latest follow-up. Surgical complications such as infection, nerve injury, or dislocation were not present. The radiographic evidence of stable fixation by bone ingrowth without migration was seen in all implants.ConclusionsOur data suggest that THA is a safe and valid option of treatment for ONFH in well-controlled HIV-infected patients in Korea. Further large-scale nationwide studies are warranted.

Effect of Corticosteroid Use on the Occurrence and Progression of Osteonecrosis of the Femoral Head: A Nationwide Nested Case-Control Study

Osteonecrosis of the femoral head (ONFH) is caused when circulation within the femoral head is disrupted. Etiology of this disease is characterized by either traumatic events or atraumatic risk factors, such as chronic alcohol consumption or glucocorticoid use. ONFH commonly presents as pain in the groin, gluteus muscles, and/or knee with reductions in internal rotation range of motion of the hip. ONFH pathology can be confirmed with radiographic or advanced imaging and characterized by stage, size and location of the lesion. Treatment for ONFH consists of conservative and therapeutic methods as well as surgical intervention. Historically, ONFH has been treated using total hip arthroplasty (THA), but with increasing incidence in a younger, active population, measures to preserve the native hip joint have been explored. Recent advancements in hip arthroscopy and arthroscopy-assisted core decompression have led to improved outcomes, reduced pain and higher hip survival rate for early onset ONFH compared with more invasive approaches such as THA. Biologic treatments combined with arthroscopic core decompression have also shown improved outcomes and quality of life in few reports, suggesting a potential role for biologic adjuncts. The current study provides a comprehensive review and update on the literature surrounding arthroscopy-assisted core decompression for patients with ONFH.

Purpose: The appropriate surgical procedure for Stage 3 osteonecrosis of the femoral head (ONFH) remains controversial. This study aimed to evaluate and compare postoperative quality of life (QOL) in patients who underwent total hip arthroplasty (THA) and bipolar hemiarthroplasty (BHA) for ONFH based on comprehensive and disease-specific scales using patient-directed questionnaires. Methods: We included 54 of 66 patients who underwent artificial joint replacement for ONFH more than 1 year ago at our hospital between April 2013 and September 2020. THA was performed for ONFH Stage 4 and BHA for Stage 3 or below. The mean postoperative observation period in the THA and BHA groups was 3.9 and 3.7 years, respectively. The Short-Form 6-Dimension measure was used to calculate utility values. Results: No significant differences in questionnaire results regarding disease-specific or comprehensive measures were observed after arthroplasty for ONFH between the THA and BHA groups. The utility values were 0.60 and 0.58 in the THA and BHA groups, respectively. Conclusion: The postoperative QOL was similar between patients who underwent THA for Stage 4 ONFH and BHA for Stage 3 ONFH. Therefore, THA or BHA can be performed on patients with ONFH after considering age, stage classification, and previous medical conditions.

The rate of failure of primary total hip arthroplasty in patients with osteonecrosis of the femoral head is higher than that in patients with osteoarthritis. The purpose of this prospective study was to document the clinical and radiographic results of arthroplasty with so-called third-generation cementing and the results of second-generation cementless total hip arthroplasty in ninety-eight consecutive patients with osteonecrosis of the femoral head. Fifty patients who had had simultaneous bilateral total hip arthroplasty with a cemented stem in one hip and a cementless stem in the other and forty-eight patients who had had a unilateral total hip arthroplasty with a cementless stem were included in the study. A cementless acetabular component was used in all hips. The presumed cause of the osteonecrosis was ethanol abuse in fifty-seven patients, unknown in twenty-seven, fracture of the femoral neck in nine, and steroid use in five. There were eighty men and eighteen women. The mean age at the time of the arthroplasty was 47.3 years (range, twenty-six to fifty-eight years). Clinical and radiographic evaluations were performed preoperatively; at six weeks; at three, six, and twelve months; and yearly thereafter. The average duration of follow-up was 9.3 years. The average Harris hip scores in the group treated with unilateral arthroplasty (97 points) and the group treated with bilateral arthroplasty (94 points) were similar at the time of final follow-up. They were also similar between the group treated with cement (mean, 96 points) and that treated without cement (95 points). No component had aseptic loosening in either group. In one hip, a cemented femoral stem (2%) and a cementless cup were revised because of infection. Two cementless stems (2%) were revised because of fracture of the proximal part of the femur with loosening of the stem. Annual wear of the polyethylene liner averaged 0.22 mm in the group treated with cement (a zirconia head) and 0.14 mm in the group treated without cement (a cobalt-chromium head). The prevalence of osteolysis in zones 1 and 7 of the femur was 16% in the group treated with cement and 24% in the group treated without cement. Advancements in surgical technique and better designs have greatly improved the long-term survival of cemented and cementless implants in young patients with osteonecrosis of the femoral head. Although there was no aseptic loosening of the components, a high rate of linear wear of the polyethylene liner and a high rate of osteolysis in these high-risk young patients remain challenging problems.

Total hip arthroplasty (THA) is a definitive option for end-stage osteonecrosis of the femoral head (ONFH). Historically, higher revision rates were observed in this population compared to THA for osteoarthritis (OA). This study provides a comprehensive evaluation of postoperative medical and surgical complications comparing THA in ONFH and OA at 90 days, 1 year, and 2 years after surgery. The PearlDiver database identified 45,002 OA and 8,429 ONFH patients who underwent THA. Mechanical complications (prosthetic loosening and osteolysis, implant failure), dislocation, renal and respiratory complications were significantly increased in the ONFH group within 2 years after THA. Pulmonary embolism rates where increased in younger ONFH patients within 2 years after THA. This data helps clinicians in the postoperative risk assessment of patients with ONFH.