Candidates For Total Hip Arthroplasty Research Articles

The Impact of Bariatric Surgery on Postoperative Complications and Outcomes following Primary Total Hip Arthroplasty

AbstractThe prevalence of obesity is significantly increasing in the U.S. population and is associated with both increased incidence of total hip arthroplasty (THA) and potentially worsened postoperative outcomes. Current guidelines strongly encourage exercise-based weight loss in morbidly obese THA candidates to decrease patient risk profiles, but data on the impact of receiving bariatric surgery (BS) for weight loss prior to THA are limited and controversial. The purpose of this study was to clarify the impact of BS on postoperative complications and outcomes following THA. Using Current Procedural Terminology, International Classification of Diseases (ICD)-9, and ICD-10 codes, patients undergoing primary THA from 2010 to 2018 were retrospectively collected from PearlDiver's Mariner dataset. Patients were divided into three cohorts who underwent primary THA: nonmorbidly obese patients, morbidly obese patients, and morbidly obese patients who underwent THA within 2 years of BS. Patients were subsequently matched based on age, Charlson Comorbidity Index, gender, and tobacco use. The primary outcome of this study was the frequency of 90-day and 2-year postoperative complications following primary THA. Compared with morbidly obese non-BS patients, morbidly obese patients who underwent BS prior to receiving a primary THA were less likely to have blood transfusion (4.24 vs. 7.44%, p < 0.05), cellulitis (2.92 vs. 6.11%, p < 0.05), myocardial infarction (2.39 vs. 4.91%, p < 0.05), and deep venous thrombosis (1.06 vs. 3.05%, p < 0.05) at 90-day follow-up. The remaining 90-day postoperative outcomes were not found to be statistically different between cohorts. There were no significant differences in 2-year surgical complications between the morbidly obese non-BS cohort and morbidly obese BS cohort. In this study, we found that morbidly obese patients who underwent BS prior to THA had fewer 90-day medical complications and no significant differences in 2-year surgical complications compared with those who did not undergo BS prior to THA.

Should high-risk patients seek out care from high-volume surgeons?

Patients with a high comorbidity burden (HCB) can achieve similar improvements in quality of life compared with low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences total hip arthroplasty (THA) outcomes in HCB patients has not been investigated. This study aimed to compare complication rates and implant survivorship in HCB patients operated on by high-volume (HV) and non-HV THA surgeons. Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologists grade of III or IV, undergoing primary elective THA between January 2013 and December 2021, were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity-matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Between groups, 90-day readmissions and revisions were compared, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period. Years of experience were comparable between non-HV and HV surgeons (p = 0.733). The HV group had significantly shorter surgical times (p < 0.001) and shorter length of stay (p = 0.009) than the non-HV group. The HV group also had significantly fewer 90-day readmissions (p = 0.030), all-cause revisions (p = 0.023), and septic revisions (p = 0.020) compared with the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p = 0.023) and septic revision (p = 0.020) than the non-HV group. The HCB THA patients have fewer 90-day readmissions, all-cause revisions, and septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a HCB may benefit from referral to HV surgeons to reduce procedural risk and improve postoperative outcomes.

The Outcome of Total Hip Arthroplasty Without Subtrochanteric Shortening Osteotomy in Severe Developmental Dysplasia of the Hip

Background: Total hip arthroplasty (THA) is a surgical technique to correct developmental dysplasia of the hip (DDH). Various THA-based methods have been developed for managing end-stage osteoarthritis in patients with DDH Crowe type III or IV. Objectives: In this study, we evaluate the Harris hip score (HHS) before and after cementless THA without subtrochanteric shortening osteotomy (STO) in patients with DDH Crowe type III or IV who were candidates for THA, as well as complications and the need for revision surgery. Methods: This retrospective cohort study was conducted on patients with DDH Crowe type III and IV, who were candidates for cementless THA using the Watson Jones technique without shortening STO. The HHS was calculated and recorded in their medical files before surgery. Patients with missing or incomplete medical files, without written informed consent, with neurovascular diseases, immunosuppressive drug use, congenital bone and articular anomalies, low back pain radiating to the lower extremities, simultaneous fractures, a history of lower extremity fractures, or joint infections were excluded. The HHS was recalculated during outpatient follow-up. Neurovascular defects and the need for reoperation were also evaluated. All data were recorded and analyzed. Results: Thirty-two patients were enrolled with a mean ± SD age of 50.34 ± 15.45 years, most of whom were women (75%). The patients were followed for 2 to 7 years. Postoperative nerve defects were observed in only 1 (3.1%) patient. Hip reoperation was performed in 1 (3.1%) patient. The mean ± SD of HHS before surgery was 50.10 ± 12.48, which increased significantly to 77.99 ± 15.60 after surgery (P &lt; 0.001). Furthermore, the HHS was evaluated before and after the intervention for each gender, showing a significant increase in both. Conclusions: Cementless THA without shortening osteotomy can improve HHS in patients with DDH Crowe III and IV, providing satisfactory outcomes. Furthermore, complications, such as neurological defects and the need for reoperation, are minimal with this method.

Neuromonitoring in pre-post and intraoperative total hip replacement surgery in type 4 high-riding developmental dysplasia of the hip.

The choice approach to treating congenital dislocation of the hip joint is total hip replacement (THR). One of the severe but uncommon complications of THR is nerve damage. The most common nerve injury associated with total hip arthroplasty (THA) is sciatic nerve palsy, and the second typical nerve damage with THA is femoral nerve paralysis. In this prospective cohort study, 35 patients with type 4 high riding developmental dysplasia of the hip (DDH) who were candidates for THA were enrolled. The somatosensory evoked potential (SSEP), motor evoked potential (MEP), and electromyography (EMG) were measured pre-post and intraoperatively to check the status of the sciatic and femoral nerves. After collecting the mentioned information, the data was analyzed by SPSS V. 26 software. Out of 35 patients with DDH type 4 who were candidates for THR, nine patients showed a 50 percent decrease in SSEP amplitude, and six patients showed a 10 percent decrease in SSEP latency. One patient during and two patients after the surgery showed more than an 80 percent decrease in MEP amplitude. Meanwhile, 14 patients showed abnormal spikes during and two patients after surgery regarding EMG. All patients with disturbed neurophysiological findings reverted to normal in the further investigation during follow-up. No correlation was found between increasing limb shortness and these modalities. Using neuromonitoring techniques during Total Hip Arthroplasty (THA) can help identify potential early nerve damage, prevent post-surgical complications, and improve high-riding DDH patient outcomes.

Early- to mid-term outcome of a short, cementless, titanium, flat, tapered stem for primary total hip arthroplasty: an independent series.

This study aims to: (1) describe perioperative complications amongst patients who underwent primary total hip arthroplasty (THA) using a short cementless, titanium, flat, tapered stem; (2) estimate this stem's early- to mid-term survival; (3) identify factors associated with revision arthroplasty; and (4) describe femoral remodelling at minimum 6 years postoperatively. A retrospective review of consecutive patients who underwent THA using a Taperloc Microplasty stem (Zimmer-Biomet, Warsaw, Indiana, USA) with minimum 2-year follow-up was performed. Surgeries were performed by 1 of 6, non-designer, arthroplasty surgeons between 2014 and 2018. Outcomes included perioperative complications including revision arthroplasty, and survival. Cox analysis was used to analyse the effect of different factors on risk of revision arthroplasty. Radiographs with 6-year follow-up served to describe femoral remodelling. In 1205 patients, followed for 5.1 ± 1.4 years, the incidence of perioperative complication was 5.2% for which 29 patients (2.4%) required revision arthroplasty. The 5- and 7-year survival rates were 97.8% (95% CI, 96.9-98.5) and 97.0% (95% CI, 95.6-98.0), respectively. The only factor associated with revision arthroplasty was proximal femur morphology, as per Dorr classification (HR 1.24 [95%CI, 1.09-1.41]; p = 0.005). During radiographic assessment, 12% of patients showed ⩾25% of relative change in cortical thickness in Gruen zones 3 or 5. We observed calcar remodelling in 50% of radiographs while 10% showed presence of a pedestal sign. The 7-year survivorship of the Taperloc Microplasty stem is within National Institute for Health and Care Excellence (NICE) guidelines. Patients ⩽65 years with osteoarthritis and Dorr A/B femoral morphology may be ideal candidates for THA with this stem. Femoral remodelling is common and not associated with adverse outcome.

Predictive Factors for Length of Stay in Patients Undergoing Total Hip Arthroplasty: A Cross-Sectional Study.

Total hip arthroplasty (THA) is an effective surgery for patients with end-stage hip joint degenerative arthritis. This study aimed to determine peri-operative factors that impact the length of stay (LOS) and design a formula to predict LOS in patients undergoing THA. This cross-sectional study was performed from September 2019 to January 2020. For this study, all patients who underwent THA over a period of 12 years since 2005 were included in the study. Data about the LOS and several variables including demographic variables, surgery-related variables, transfusion, intensive care unit (ICU) admission, past drug history, comorbidities, and laboratory data, were gathered. Qualitative variables are presented as numbers (%), and quantitative variables are presented as mean Mann± standard deviation. Mann Whitney test , Kruskal-Wallis test, and Spearman's rank correlation test were also used. A total of 524 patients were included in the study; 12 were excluded .261 (51%) were female and 251(49%) male. The mean age was 56.13±17.04 years. In the univariate analysis, the day of admission, surgery indication, transfusion, diabetes mellitus, oral anti-diabetic drugs, American Society of Anesthesiology (ASA) score, preoperative hemoglobin (Hb) level, and type of prosthesis showed significant relation with LOS. Significant variables entered to zero truncated negative binomial regression. Among them, the day of admission, ASA score, preoperative Hb level, and type of prosthesis showed significant relation with LOS (P < 0.05) and were used for model design. Preoperative Hb level, ASA score, day of admission, and prosthesis type have an impact on LOS and can predict LOS in patients who are candidates for THA.

Total Hip Arthroplasty in the Nonparalytic Limb of Residual Poliomyelitis Patients: A Propensity Score Matched Study.

Poliomyelitis is a rare neuromuscular disease that can cause hip osteoarthritis on the contralateral side due to an abnormal mechanical weight-bearing state, making some residual poliomyelitis patients candidates for total hip arthroplasty (THA). The aim of this study was to investigate the clinical outcome of THA in the nonparalytic limbs of these patients compared with those of non-poliomyelitis patients. Patients treated between January 2007 and May 2021 were retrospectively identified in a single center arthroplasty database. Eight residual poliomyelitis cases that met the inclusion criteria were matched to non-poliomyelitis cases in a ratio of 1:2 based on age, sex, body mass index (BMI), age-adjusted Charlson comorbidity index (aCCI), surgeon, and operation date. The hip function, health-related quality of life, radiographic outcomes, and complications were analyzed with unpaired Student's t test, Mann-Whitney test, Fisher's exact test or analysis of covariance (ANCOVA). Survivorship analysis was determined using the Kaplan-Meier estimator analysis and Gehan-Breslow-Wilcoxon test. After a mean follow-up of about 5 years, patients with residual poliomyelitis had worse postoperative mobility outcomes(P < 0.05), but there was no difference in total modified Harris hip score (mHHS) or European quality of life-visual analogue scale (EQ-VAS) between the two groups (P > 0.05). There was no difference in radiographic outcomes or complications between the two groups, and patients had similar postoperative satisfaction (P > 0.05). No readmission or reoperation occurred in the poliomyelitis group (P > 0.05), but the postoperative limb length discrepancy (LLD) in the residual poliomyelitis group was greater than that in the control group (P < 0.05). Functional outcomes, health-related quality of life improvement were similarly significantly improved in the nonparalytic limb of residual poliomyelitis patients after THA compared with conventional osteoarthritis patients. However, the residual LLD and weak muscle strength of the affected side will still influence mobility, so residual poliomyelitis patients should be fully informed of this outcome before surgery.

Evaluating the contribution of fat infiltration in anterior gluteus minimus muscle to walking ability in female with unilateral hip osteoarthritis and candidates for total hip arthroplasty

BackgroundThe purpose of this study is to investigate the relationship between gait and fat infiltration in anterior and posterior gluteus minimus in the patients with hip osteoarthritis. MethodsNinety-one female patients who were diagnosed as the unilateral hip osteoarthritis, classified into Kellgren-Lawrence global scoring system grades 3 or 4, and candidate for total hip arthroplasty were retrospectively reviewed. The horizontally cross-sectional regions of interest for the gluteus medius and anterior and posterior gluteus minimus were manually circumscribed in a single transaxial computed tomography image and muscle density of those regions were obtained. The gait was assessed as the step and speed with the 10-Meter Walk Test. The multiple regression analysis was used to compare the step and speed with age, height, range of motion in flexion, the muscle density of anterior gluteus minimus in the affected side, and that of gluteus medius muscle in both affected and unaffected sides. FindingsMultiple regression analysis for step revealed that the muscle density of anterior gluteus minimus in the affected side and height were the independent predictors for step (R2 = 0.389, p < 0.001). That for speed identified the muscle density of anterior gluteus minimus in the affected side as the only factor determining speed (R2 = 0.287, p < 0.001). InterpretationThe fatty infiltration of anterior gluteus minimus muscle in affected side can be a predictor for the gait in in female with unilateral hip osteoarthritis and candidates for total hip arthroplasty.

Association of age and spinopelvic function in patients receiving a total hip arthroplasty

Restricted spinopelvic mobility received attention as a contributing factor for total hip arthroplasty (THA) instability. However, it is still unknown, how the spinopelvic function is influenced by age. In identifying the patients at highest risk for altered spinopelvic mechanics the study aimed to determine the association of age on the individual segments of the spinopelvic complex and global spinal sagittal alignment in patients undergoing THA. 197 patients were included in the prospective observational study conducting biplanar stereoradiography (EOS) in standing and sitting position pre-and postoperatively. Two independent investigators assessed C7-sagittal vertical axis (C7-SVA), cervical lordosis (CL), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), anterior plane pelvic tilt (APPT), and pelvic femoral angle (PFA). Key segments of the spinopelvic complex are defined as lumbar flexibility (∆ LL = LLstanding − LLsitting), pelvic mobility (∆ SS = SSstanding − SSsitting) and hip motion (∆ PFA = PFAstanding − PFAsitting). Pelvic mobility was further defined based on ∆ SS = SSstanding − SSsitting as stiff (∆ SS < 10°), normal (∆ SS ≥ 10°–30°) and hypermobile (∆ SS > 30°). The patient collective was classified into three groups: (1) < 60 years (n = 56), (2) ≥ 60–79 years (n = 112) and (3) ≥ 80 years (n = 29). Lumbar flexibility (∆ LL) was decreased with increasing age between all groups (36.1° vs. 23.1° vs. 17.2°/p1+2 < 0.000, p2+3 = 0.020, p1+3 < 0.000) postoperatively. Pelvic mobility (∆ SS) was decreased in the groups 2 and 3 compared to group 1 (21.0° and 17.9° vs. 27.8°/p1+2 < 0.000, p2+3 = 0.371, p1+3 = 0.001). Pelvic retroversion in standing position (APPT) was higher in group 2 and 3 compared to group 1 (1.9° and − 0.5° vs 6.9°/p1+2 < 0.000, p2+3 = 0.330, p1+3 < 0.000). Global sagittal spinal balance (C7-SVA) showed more imbalance in groups 2 and 3 compared to group 1 (60.4 mm and 71.2 mm vs. 34.5 mm/p1+2 < 0.000, p2+3 = 0.376, p1+3 < 0.000) postoperatively. The preoperative proportion of patients with stiff pelvic mobility in group 1 was distinctly lower than in group 3 (23.2% vs. 35.7%) and declined in group 1 to 1.8% compared to 20.7% in group 3 after THA. Changes after THA were reported for groups 1 and 2 representing spinopelvic complex key parameter lumbar flexibility (∆ LL), pelvic mobility (∆ SS) and hip motion (∆ PFA), but not for group 3. This is the first study to present age-adjusted normative values for spinopelvic mobility. The subgroups with increased age were identified as risk cohort for altered spinopelvic mechanics and enhanced sagittal spinal imbalance and limited capacity for improvement of mobility after THA. This valuable information serves to focus in the preoperative screening on the THA candidates with the highest risk for abnormal spinopelvic function.

Hip dysfunction-related urinary incontinence and total hip arthroplasty with the direct lateral approach.

There is a functional relationship between the hip joint and the pelvic floor muscles. In patients with secondary osteoarthritis of the hip, urinary incontinence is also seen. Research has shown that total hip arthroplasty (THA) surgery improves the symptoms of urinary incontinence. This prospective cross-sectional study without a control group was performed on THA candidates with urinary incontinence and secondary osteoarthritis with the aim of investigating the effect of THA with a direct lateral approach and subsequent routine physiotherapy on the symptoms of urinary incontinence. Sampling was performed using a simple method among those referred to orthopedic clinics in the private sector. Data were collected in all patients before and 3 months after THA using demographic, International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and hip range of motion record tables. The results are presented as mean with standard deviation. In this study, 16 men with a mean age of 76.75 years (±4.65) and 8 women with a mean age of 72.75 years (±7.32) participated. Before THA, stress urinary incontinence (54.16%) and urgency urinary incontinence (20.83%) had the highest frequency. However, after THA, the frequency of stress and urgency urinary incontinence decreased (16.66% and 8.33%, respectively). According to the results of the ICIQ, complete improvement of urinary incontinence symptoms was observed in up to 62.5% of the subjects. After THA, there was a significant difference between the mean total score obtained from the WOMAC questionnaire compared to before surgery. There was a significant improvement in the range of motion of the hip joint in all directions. THA and routine hip physiotherapy in patients with urinary incontinence and secondary hip osteoarthritis have a significant positive effect on improving symptoms of urinary incontinence and hip function. In addition, it significantly improves the ICIQ and WOMAC questionnaire scores.

Evaluation of health-related quality of life before and after total hip arthroplasty in the elderly in Iran: a prospective cohort study

BackgroundOwing to the direct impact of total hip arthroplasty (THA) on health-related quality of life (HRQOL) and the higher prevalence of THA in the elderly, this study aimed to compare HRQOL before, and after THA in the Iranian elderly.MethodsThe present prospective cohort study was performed on 161 THA candidates. Demographic data were extracted from records of patients. Before, 6, and 12 months after THA, a Short Form 36 health survey (SF-36) was used to assess HRQOL. Before THA, 6 and 12 months after THA, Physical (PCS), and mental component scores (MCS) were obtained from a hundred separately for each subscale of the questionnaire. The Paired t-test was used to compare HRQOL before and after THA.ResultsBoth 6 and 12 months after THA, HRQOL was significantly increased compared to previous THA (P = 0.001). In the first half-year after THA, vitality and emotional state were not different from pre-surgery. However, 12 months after THA, these two subscales also were significantly improved. Although, 6 months after THA, the PCS has dramatically gone up compared to the previous THA (P = 0.012), despite MCS was remained steady. Nonetheless, by comparison with the before surgery, 12 months after THA, MSC notably improved (P = 0.048).ConclusionHRQOL was appreciably improved by the THA in the elderly after 12 months. The improvement in HRQoL in the first 6 months after THA is related to the promotion in the physical aspect (PCS score), and in the second 6 months after THA is related to the promotion in the psychological aspect (MCS score).

Primary total hip arthroplasty in patients older than 90 years of age: a retrospective matched cohort study.

Advanced age is considered a major risk factor for postoperative complications in total hip arthroplasty (THA). Consequently, older patients undergoing THA may require more detailed pre-procedural examinations and more healthcare resources postoperatively than younger patients. The purpose of this study was to compare discharge parameters and complication rates of THA in patients ⩾90 years old to those <90 years old. A retrospective review of 14,824 THA patients from 2011 to 2021 at a high-volume, urban academic centre was conducted. Patients ⩾90 years old were propensity-matched to a control group of patients aged <90 years old. Patient demographics, surgical time, hospital length of stay (LOS), discharge disposition, and 90-day revision, readmission, and mortality rates were collected. Demographic differences and outcomes were assessed using chi-square and independent sample t-tests. After propensity matching, the average age in the younger cohort (YC, n = 54) was 75.81 ± 7.89, and 91.61 ± 1.73 for the older cohort (OC, n = 54). The OC had a longer LOS than the YC (mean 3.90 vs. 3.06 days; p = 0.031). Discharge disposition significantly differed (p = 0.007); older patients were more likely to be discharged to skilled nursing facilities (33.3% vs. 14.8%) or acute rehabilitation centres (14.8% vs. 3.7%) and less likely to be discharged to prior place of residence (home self-managed/home with services, 51.9% vs. 79.6%). There was no significant difference in surgical time (93.87 ± 29.75 vs. 96.09 ± 26.31 min; p = 0.682), 90-day revision rate (3.7% vs. 0%; p = 0.153), 90-day readmission rate (9.4% vs. 3.7%; p = 0.543), and 90-day mortality rate (1.9% vs. 1.9%; p = 1.000). Although THA patients over 90 years of age had a longer LOS and differing discharge disposition, these patients had similar complications compared to their younger counterparts. Thus, our study supports similar efficacy of THA in patients 90 years and older relative to younger THA candidates.

Effect of Coronal and Sagittal Spinal Malalignment on Spinopelvic Mobility in Patients Undergoing Total Hip Replacement: A Prospective Observational Study.

This was a prospective observational study. This investigation aimed (1) to determine the impact of sagittal spinal alignment with C7-sagittal vertical axis (SVA), pelvic incidence-lumbar lordosis (PI-LL) mismatch and Roussouly classification on individual segments of spinopelvic mobility represented by lumbar flexibility [∆lumbar lordosis (LL)], pelvic mobility [∆pelvic tilt (PT)], and hip motion [∆pelvic femoral angle (PFA)] and (2) to assess the influence of coronal spinal balance on the spinopelvic complex in patients undergoing total hip arthroplasty (THA) preoperatively and postoperatively. Restricted spinopelvic mobility gained attention as a contributing factor for THA instability. However, it remains unclear what influence the coronal and sagittal spinal alignment has on spinopelvic mobility. A total of 197 THA patients were included in the investigation conducting biplanar stereoradiography in standing and sitting position preoperatively and postoperatively. Two independent investigators assessed C7-SVA (≤50 mm balanced, >50 mm imbalanced), PI-LL (≤10 degrees balanced, >10 degrees imbalanced), refounded Roussouly classification, coronal spinal balance with C7-central sacral vertical line, LL, pelvic incidence (PI), PT, PFA. Individual segments of spinopelvic mobility based on the change from standing to sitting were defined as ∆LL, ∆PT, and ∆PFA. Unpaired t test or Welch t test for comparison between groups of 2 was applied. Analysis of variance and post hoc analysis according to Bonferroni or Games-Howell was used to determine differences between groups of >2. The Spearman rank correlation coefficient was used to determine the interrater reliability of the radiographic measurements. Significant differences were demonstrated for ∆LL (SVA balanced/imbalanced: 24.7 degrees/19.1 degrees, P =0.001; PI-LL balanced/imbalanced: 24.4 degrees/16.4 degrees, P <0.000), PT (SVA balanced/imbalanced: 12.5 degrees/15.2 degrees, P =0.029; PI-LL balanced/imbalanced: 10.8 degrees/20.5 degrees, P <0.000), PI (SVA balanced/imbalanced: 52.9 degrees/56.9 degrees, P =0.001; PI-LL balanced/imbalanced: 52.1 degrees/61.0 degrees, P <0.000), LL (SVA balanced/imbalanced: 54.8 degrees/47.8 degrees, P =0.029; PI-LL balanced/imbalanced: 55.3 degrees/42.6 degrees, P <0.000). The coronal spinal balance (central sacral vertical line) indicated no significant differences regarding spinopelvic mobility between positive, neutral, or negative balanced groups. Significant differences with decreased pelvic mobility (∆PT) and lumbar flexibility (∆LL) in low-grade PI types 1 and 2 compared with high-grade PI type 4 according to the Roussouly classification were observed. This is the first study to investigate spinal sagittal alignment using 3 different classifications in association to the spinopelvic complex in THA patients preoperatively and postoperatively. The significantly altered spinopelvic mechanics with decreased lumbar flexibility and increased pelvic retroversion in sagittal imbalanced patients clearly indicate the need for a separate consideration of the global spinal sagittal alignment. Our findings emphasize the importance of risk stratification for THA candidates in terms of sagittal imbalance attempting to mitigate the THA instability risk with accurate preoperative planning. Level III.

Spinopelvic mobility is influenced by pre-existing contralateral hip arthroplasty: a matched-pair analysis in patients undergoing hip replacement

BackgroundSpinopelvic mobility gained increased attention as a contributing factor for total hip arthroplasty (THA) instability. However, it is unknown how a pre-existing THA affects spinopelvic mobility. Therefore, a propensity-score-matched analysis of primary THA patients comparing the individual segments of spinopelvic mobility between patients with pre-existing THA and no-existing THA was conducted. Consequently, the study aimed to discuss (1) whether patients with a pre-existing THA have altered spinopelvic mobility compared to the control group and (2) if spinopelvic mobility changes after THA.MethodsA prospective observational study enrolled 197 elective primary THA patients, including N = 44 patients with a pre-existing unilateral THA. Using propensity-score matching adapted for age, sex, and BMI, N = 44 patients without a pre-existing THA were determined. The patients received stereoradiography in standing and relaxed sitting position pre- and postoperatively. Assessed parameters were lumbar lordosis (LL), pelvic tilt (PT), and pelvic femoral angle (PFA). Key parameters of the spinopelvic mobility were defined as lumbar flexibility (∆LL = LLstanding − LLsitting), pelvic mobility (∆PT = PTstanding − PTsitting) and hip motion (∆PFA = PFAstanding − PFAsitting). Pelvic mobility was classified as stiff (∆PT < 10°), normal (∆PT ≥ 10°–30°) and hypermobile (∆PT > 30°). The Wilcoxon rank sum test for dependent samples was used.ResultsPelvic mobility was significantly increased in the pre-existing THA group (∆PT 18.2° ± 10.7) compared to the control group (∆PT 7.7° ± 8.0; p < 0.001) preoperatively and postoperatively (pre-existing: 22.2° ± 9.3; control: 17.0° ± 9.2, p = 0.022). Lumbar flexibility was significantly increased in the pre-existing THA group (∆LL 21.6° ± 11.8) compared to the control group (∆LL 12.4° ± 7.8; p < 0.001) preoperatively and postoperatively (pre-existing: 25.7° ± 11.0; control: 19.0° ± 10.2; p = 0.011). The contribution of stiff pelvic mobility is distinctly smaller in the pre-existing THA group (25%) than in the control group (75%) preoperatively.ConclusionsPre-existing THA is associated with significantly enhanced pelvic mobility and lumbar flexibility. Accordingly, we identified the patients without a pre-existing THA as risk candidates with higher likelihood for pathological spinopelvic mobility. This information will assist arthroplasty surgeons in deciding which THA candidates require preoperative radiological screening for pathologic spinopelvic mobility.Level of evidenceLevel II prospective cohort study.

Weight Loss in Patients Waiting for Total Hip Arthroplasty: Fiber-Enriched High Carbohydrate Diet Improves Hip Function and Decreases Pain before Surgery.

The impact of obesity on clinical outcomes following joint replacement procedures is resounding. Therefore, multiple strategies to achieve a substantial weight loss before surgery are needed in obese patients. The aim of the study was to test the effect of a fiber-enriched high carbohydrate (FEHC) diet on the reduction in body weight and pain in elderly obese patients undergoing total hip arthroplasty (THA). Sixty-one candidates for THA were included in our study. Prior to the procedure, the participants have been randomly assigned to a 3-month diet intervention (FEHC diet or free diet). Anthropometric measures and food questionnaires were collected at the enrollment and after 3 months. The Oxford Hip Score (OHS), the Hip disability and Osteoarthritis Outcome Score (HOOS) and the Western Ontario McMaster Universities OA Index (WOMAC) were administered at baseline and before surgery. A statistically significant variation of weight was found in the FEHC diet group (−3.7 kg, −4.4–−2.5) compared to the control group (−0.2 kg; −1.4–1.7; p < 0.0001), as well as significant improvements in the OHS (p < 0.0001), the HOOS (p < 0.0001) and the WOMAC (p < 0.0001) questionnaires. According to the results of the study, the FEHC diet in obese patients undergoing THA might help weight loss and improve related anthropometric parameters as well as hip function and pain.

Efficacy of hydrated phospholipid polymer interfaces between all-polymer bearings for total hip arthroplasty.

Measurements of wear resistance and metal ion release are important for designing bearing couples or interfaces in total hip arthroplasty (THA). In this study, we investigated wear resistance and metal ion release of surface-modified metal-free all-polymer hip bearings, such as poly(ether-ether-ketone), (PEEK) on cross-linked polyethylene (PEEK-on-CLPE), with a hydrated gel-like surface layer, to propose an improved alternative to the conventional materials used to design THA bearings. The PEEK surface resulted in less metal ion release than the cobalt-chromium-molybdenum (Co-Cr-Mo) alloy surface owing to the lack of metal. The PEEK-on-CLPE bearing (6.33 mg/106 cycles) had lower wear (rate) than the bearing with Co-Cr-Mo alloy-on-CLPE (10.47 mg/106 cycles) under controlled laboratory conditions; the wear performance of the all-polymer hip bearings was further improved with hemi- or both-surface modified with a hydrated poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC) layer (3.74 and 3.06 mg/106 cycles, respectively). The PMPC-grafted interface of PEEK-on-CLPE will be especially suitable for THA candidates. This study is of key importance for the design of lifelong THA and a better understanding of the limitations resulting from using PEEK. Further studies are necessary to evaluate the possibility of using this material in artificial hips.

Effects of Sagittal Spinal Alignment on Postural Pelvic Mobility in Total Hip Arthroplasty Candidates

BackgroundRecent research has demonstrated that patients with reduced pelvic mobility from standing to sitting have higher rates of dislocation after total hip arthroplasty (THA). This study evaluates the effect of sagittal spinal deformity, defined by pelvic incidence–lumbar lordosis mismatch (PI-LL), on postural changes in pelvic tilt (PT). MethodsA multicenter database of 1100 preoperative THA patients was queried. Anterior-pelvic-plane tilt (APPt), spinopelvic tilt (SPT), and LL were measured from radiographs of patients in supine, standing, flexed-seated, and stepping-up postures; PI was measured from computed tomography. Patients were separated into 3 groups based on PI-LL (<−10°, −10° to 10°, >10°) and propensity-score matched by PI. Lumbar flatback-deformity was defined as PI-LL > 10°, hyperlordosis: PI-LL < −10°. SPT/APPt, including changes between each posture were compared across PI-LL groups using analysis of variance, with post-hoc Tukey tests. Pearson correlations were reported when testing associations between SPT/APPt change and PI-LL. ResultsAfter propensity-score matching, 288 patients were analyzed (mean 65 y; 49% F). SPT and APPt change differed across all PI-LL categories from standing to seated, supine, and stepping-up with less SPT/APPt recruitment among hyperlordotic vs flatback patients (all P < .001). Greater PI-LL correlated with greater SPT recruitment from standing to seated (R = 0.294), supine (R = 0.292), and stepping-up (R = 0.207) (all P < .001). Smaller LL changes from standing to seated were associated with greater SPT recruitment (R = 0.372, P < .001). ConclusionsPostural changes in SPT/APPt are associated with spinopelvic measures in THA candidates. Hyperlordotic patients tend to utilize their spines more compared with flatback patients who were more likely to recruit PT. Increased focus on patients with lumbar flatback and hyperlordosis may help in reducing prosthetic dislocation prevalence following THA.

Modifying Patient Expectations Can Enhance Total Hip Arthroplasty Postoperative Satisfaction

BackgroundA better understanding of patient expectations within the perioperative setting will enable clinicians to better tailor care to the needs of the total hip arthroplasty (THA) recipient. Such an approach will promote patient-centered decision-making and optimize recovery times while enhancing mandated hospital quality metrics. In the present study, we preoperatively and postoperatively surveyed THA candidates to elucidate the relationship between patient expectations and length of stay (LOS). MethodsThis is a multi-institutional prospective study among THA candidates. Patients were surveyed regarding discharge planning 1 week preoperatively and postoperatively to capture perioperative patient expectations and correlate with inpatient LOS. ResultsIn total, 93 THAs performed by 6 high-volume orthopedic surgeons at 2 medical centers. Our results demonstrated that patients of male gender and commercial insurance had significantly (P < .05) shorter LOS. Shorter LOS patients demonstrated significantly higher levels of LOS acceptance (“very comfortable” rate in same-day discharge: 75.0% and next-day discharge: 63.8%; 2 days: 40.7%; 3+ days: 42.9%; P < .05) and a higher likelihood to participate in SDD programs. Postoperatively, patients with a shorter LOS had more acceptance to their LOS, albeit not statistically significant (P = .20). ConclusionOur results suggest that guiding patient expectations within the perioperative setting is an essential component for successful and timely discharge after THA. Having clear and transparent discussion with the surgical team regarding the perioperative course can improve a THA candidate's understanding and buy-in with the postoperative plan, regardless of LOS. Finally, inpatient LOS does not appear to affect patient satisfaction. Level of EvidenceLevel II, prospective observational study.

Home Health Services Are Not Required for Select Total Hip Arthroplasty Candidates: Assessment and Supplementation With an Electronic Recovery Application

BackgroundAt our institution, all postoperative total hip arthroplasty (THA) candidates have received home health services (HHS), consisting of visiting nurses, physical and occupational therapists. However, with a more technologically inclined patient population, electronic patient rehabilitation applications (EPRAs) can be used to deliver perioperative care at the comfort of the patient's home. The aim of this study is to investigate the clinical utility and economic burden associated with digital rehabilitation applications in primary THA recipients. MethodsWe conducted a single-center, retrospective review of patients operated between November 2016 and November 2017. Before surgery, and at the discretion of the surgeon, patients were assigned to EPRA with HHS or EPRA alone. Patient baseline demographics, EPRA engagement, and validated patient-reported outcomes (PROs) were collected (Veterans Rand 12-Item Health Survey [VR-12] and Hip Disability and Osteoarthritis Outcome Score Junior) at baseline and 12 weeks. These PRO scores were correlated with cohort assignments to assess noninferiority of EPRA alone. ResultsIn total, 268 patients received either EPRA-HHS (n = 169) or EPRA (n = 99) alone. Patients receiving EPRA only were on average younger (60.8 vs 65.8; P < .0001), but otherwise similar to patients in the EPRA-HHS cohort. EPRA-only patients demonstrated no differences in VR-12 (P > .05) and Hip Disability and Osteoarthritis Outcome Score Junior (P > .05) when compared with EPRA-HHS. ConclusionThe integration of electronic rehabilitation tools is gaining acceptance within the orthopedic community. Our study demonstrated that EPRA alone was clinically noninferior while substantially less costly than EPRA-HHS.

Does Parkinson Disease Increase the Risk of Perioperative Complications After Total Hip Arthroplasty? A Nationwide Database Study

BackgroundParkinson disease (PD) is the second most common neurodegenerative disorder in the United States, affecting over 1 million people. As part of the disease process, PD can cause poor bone quality and other musculoskeletal problems that can affect a patient's quality of life. With advances in treatment, PD patients can be more active and may be candidates for total hip arthroplasty (THA). However, there is a paucity of literature on the outcomes of THA in PD patients. Therefore, the purpose of this study was to evaluate the perioperative outcomes of PD patients who underwent THA. Specifically, we assessed: (1) perioperative surgical and medical complications; (2) lengths of stay (LOSs); and (3) total hospital charges. MethodsUsing the Nationwide Inpatient Sample, patients who had PD and underwent THA between 2002 and 2013 were identified. With the use of propensity scores, PD patients were matched in a 1:3 ratio to patients without PD by the year of surgery, age, gender, race, Charlson/Deyo score, and insurance type. This yielded a total of 10,519 PD and 31,679 non-PD THA patients. Regression analyses were used to compare the risk of perioperative complications (any, surgical, medical), the percent differences in mean LOS, and the percent differences in total hospital charges. ResultsCompared with the matched cohort, PD patients had a 52% higher risk for any complication (odds ratio [OR] = 1.52; 95% confidence interval [CI], 1.37-1.69), a 30% higher risk for any surgical complication (OR = 1.30; 95% CI: 0.88-1.91), and a 54% higher risk for any medical complication (OR = 1.54; 95% CI, 1.38-1.71). Specifically, PD patients were more likely to have postoperative delirium (OR = 2.61; 95% CI: 1.77-3.85), altered mental status (OR = 3.01; 95% CI: 1.35-6.71), urinary tract infection (OR = 1.34; 95% CI: 1.09-1.76), and blood transfusion (OR = 1.62; 95% CI: 1.44-1.82). Also, PD patients had a mean LOS that was 8.57% longer (P < .0001), and mean total hospital charges that were 3.85% higher (P < .0001). ConclusionOrthopedic surgeons and neurologists should be involved in the preoperative counseling of PD patients regarding their potential increased risks associated with THA, which could help optimize their preoperative care. Furthermore, the risk of complications and higher costs could potentially lead to the development of different reimbursement methods in this population of patients.