Degenerative Hip Disease Research Articles

Prior Lumbar Spinal Arthrodesis Increases Risk of Prosthetic-Related Complication in Total Hip Arthroplasty

BackgroundDegenerative hip disorders often coexist with degenerative changes of the lumbar spine. Limited data on this patient population suggest inferior functional improvement and pain relief after surgical management. The purpose of this study is to compare the rates of prosthetic-related complication after primary total hip arthroplasty (THA) in patients with and without prior lumbar spine arthrodesis (SA). MethodsMedicare patients (n = 811,601) undergoing primary THA were identified and grouped by length of prior SA (no fusion, 1-2 levels fused [S-SAHA], and ≥3 levels fused [L-SAHA]). ResultsCompared with controls, patients with prior SA had significantly higher rates of complications including dislocation (control: 2.36%; S-SAHA: 4.26%; and L-SAHA: 7.51%), revision (control: 3.43%, S-SAHA: 5.55%, and L-SAHA: 7.77%), loosening (control: 1.33%, S-SAHA: 2.10%, and L-SAHA: 3.04%), and any prosthetic-related complication (control: 7.33%, S-SAHA: 11.15% [relative risk: 1.52], and L-SAHA: 14.16% [relative risk: 1.93]) within 24 months (P < .001). ConclusionThe interplay of coexisting degenerative hip and spine disease deserves further attention of both arthroplasty and spine surgeons.

Conversion of a failed hip resurfacing arthroplasty to total hip arthroplasty: pearls and pitfalls.

Surface replacement arthroplasty (SRA) remains a viable alternative to total hip arthroplasty (THA) in appropriately selected, active adults with degenerative hip disease. However, orthopedic surgeons are facing a number of scenarios where revision of one or both components of an SRA is indicated. Indications for revision vary and impact the potential outcomes of conversion of a SRA to THA. While clinical outcomes are generally favorable, a growing body of data illustrates patients who undergo conversion of a SRA to THA to be at increased risk of requiring a repeat revision surgery and experiencing functional outcomes inferior to that of a primary THA. The results of patients undergoing conversion of a SRA to THA highlight the need for careful patient selection, thorough preoperative counseling, and technical precision when performing a SRA. Furthermore, a systematic approach to the failed SRA is necessary to ensure optimal clinical results.

Morphological and Functional Hip Long-Term Results after Exstrophy Repair.

Introduction Abnormalities of the bony pelvis in exstrophy-epispadias complex (EEC) and their possible relation to hip disease are well described. However, there is a lack of information about long-term orthopedic consequences and hip function in patients with EEC. Therefore, we investigated clinical and radiological results in an EEC patient cohort after long-term follow-up. Patients and Methods We conducted a cross-sectional study using standardized radiography, clinical investigation, and the Harris hip score. Seventeen postpuberty consecutive unselected EEC patients (3 female, 14 male; mean age 18.2 years) that presented to our clinic due to urological procedures or routine check-up from 2010 to 2011 were included. All had undergone symphysis approximation with a traction bandage without osteotomy in early childhood. Radiological analysis was conducted offline by two independent investigators. Results Radiological analysis showed a mean pubic diastasis of 5.1 cm (range 2.8-8.5 cm). Borderline hip dysplasia was present in four patients, one of them having had co-occurring developmental hip dysplasia in previous history. No severe dysplasia, subluxation, or luxation of the hip was found; however, one patient showed early hip arthrosis. Clinical examination revealed no relevant restriction of range of motion, although rotation and abduction were slightly altered in five patients. None of the EEC patients complained about pain or restriction in sports or daily activities. Harris hip score was perfect for all but one study participants. Conclusion Despite EEC-specific hip morphology, long-term hip function is not impaired in patients after symphyseal approximation without osteotomy in the newborn period. The symphysis diastasis after this procedure is comparable to available postosteotomy data. The large majority of EEC patients did not show dysplastic or degenerative hip disease. Functional hip score results confirmed reasonable age-related hip function in nearly all examined patients. However, postnatal ultrasound hip screening is recommended to prevent and adequately treat potential co-occurring developmental hip dysplasia.

Down Syndrome Increases the Risk of Short-Term Complications After Total Hip Arthroplasty

BackgroundDown syndrome is the most common chromosomal abnormality and is associated with degenerative hip disease. Because of the recent increase in life expectancy for patients with this syndrome, orthopaedic surgeons are likely to see an increasing number of these patients who are candidates for total hip arthroplasty (THA). MethodsUsing Nationwide Inpatient Sample (NIS) data from 1998 to 2010, we compared the short-term adverse outcomes of THA among 241 patients with Down syndrome and a matched 723-patient cohort. Specifically, we assessed: (1) incidence of THA; (2) perioperative medical and surgical complications during the primary hospitalization; (3) length of stay; and (4) hospital charges. ResultsThe annual mean number of patients with Down syndrome undergoing THA was 19. Compared to matched controls, Down syndrome patients had an increased risk of perioperative (OR, 4.33; P<.001), medical (OR, 4.59; P<.001) and surgical (OR, 3.51; P<.001) complications during the primary hospitalization. Down syndrome patients had significantly higher incidence rates of pneumonia (P=.001), urinary tract infection (P<.001), and wound hemorrhage (P=.027). The mean lengths of stay for Down syndrome patients were 26% longer (P<.001), but there were no differences in hospital charges (P=.599). ConclusionDuring the initial evaluation and pre-operative consultation for a patient with Down syndrome who is a candidate for THA, orthopaedic surgeons should educate the patient, family and their clinical decision makers about the increased risk of medical complications (pneumonia and urinary tract infections), surgical complications (wound hemorrhage), and lengths of stay compared to the general population.

Quality of life after total hip arthroplasty according to the indication

The aim of this work is to determine the quality of life after rehabilitation for total hip arthroplasty (THA) in our Moroccan context, and according to the indication of THA. This is a prospective study from January 2013 to June 2014 on THA (including 7 bilateral) indicated by severe inflammatory or degenerative hip diseases, and sent to the Physical Medicine and Rehabilitation Ibn Rushd Hospital in Casablanca for functional rehabilitation. The quality of life of our patients was assessed by the Western Ontario and McMaster scale Universities Arthritis Index (WOMAC). 30 women and 15 men, mean age 47.5 years (20–75 years). 30 THA for severe inflammatory hip disease (including 5 bilateral), 22 PTH (including 2 bilateral) for degenerative hip disease. The mean VAS pain decreased from 60/100 to 12/100. The quality of life of the patients was improved in all cases. We compared the results according to the indication, degenerative hip disease versus inflammatory. The disappearance of pain after joint replacement surgery was similar in both groups. Functional status and quality of life of patients with inflammatory diseases, especially rheumatoid was altered. In our cases, the indications justifying the prosthesis were characterized by the predominance of inflammatory hip disease; this is explained by the systematic recruitment of such patients for postoperative rehabilitation in physical medicine and rehabilitation in this context. Improving the quality of life confirms the good results expected after total hip replacement despite some socio-cultural adaptations needed, especially for religious practice. The difference in quality of life as a function of the indication can be explained by the presence of another particular joint damage in inflammatory diseases.

The Direct Anterior Approach for 1-Stage Bilateral Total Hip Arthroplasty: Early Outcome Analysis of a Single-Surgeon Case Series

BackgroundOne-stage bilateral total hip arthroplasty (B-THA) is rarely performed despite a 20% incidence of bilateral degenerative hip disease requiring surgical intervention. MethodsWe retrospectively evaluated functional outcomes in 22 consecutive patients undergoing B-THA with a matched cohort undergoing unilateral THA by the same surgeon using the direct anterior approach. ResultsAlthough there was a significant difference in blood loss (P < .01) and surgical time (P < .001), there was no difference in length of hospital stay (P = .09), number of discharges to a rehabilitation facility (P = .22), or postoperative Harris Hip scores (P = .75). ConclusionsAdvances in blood loss and pain management protocols in association with the direct anterior approach should renew interest in the efficacy of 1-stage B-THA.

The effect of education for daily physical activity level recovery of osteoarthritis patients after total knee arthroplasty. A prospective randomized controlled clinical trial using accelerometry

The effect of education for daily physical activity level recovery of osteoarthritis patients after total knee arthroplasty. A prospective randomized controlled clinical trial using accelerometry

Developmental dysplasia of the hip: What has changed in the last 20 years?

Developmental dysplasia of the hip (DDH) describes the spectrum of structural abnormalities that involve the growing hip. Early diagnosis and treatment is critical to provide the best possible functional outcome. Persistence of hip dysplasia into adolescence and adulthood may result in abnormal gait, decreased strength and increased rate of degenerative hip and knee joint disease. Despite efforts to recognize and treat all cases of DDH soon after birth, diagnosis is delayed in some children, and outcomes deteriorate with increasing delay of presentation. Different screening programs for DDH were implicated. The suspicion is raised based on a physical examination soon after birth. Radiography and ultrasonography are used to confirm the diagnosis. The role of other imaging modalities, such as magnetic resonance imaging, is still undetermined; however, extensive research is underway on this subject. Treatment depends on the age of the patient and the reducibility of the hip joint. At an early age and up to 6 mo, the main treatment is an abduction brace like the Pavlik harness. If this fails, closed reduction and spica casting is usually done. After the age of 18 mo, treatment usually consists of open reduction and hip reconstruction surgery. Various treatment protocols have been proposed. We summarize the current practice for detection and treatment of DDH, emphasizing updates in screening and treatment during the last two decades.

Total Hip Arthroplasty versus Hip Resurfacing: Evidence Based Review and Current Indications

Total hip arthroplasty (THA) is the gold standard in the treatment of degenerative hip disease, especially in the older patient. Concerns regarding the higher levels of failure of traditional implants in younger, more active patients have led to a search for alternative arthroplasty techniques. Hip resurfacing (HR) is one of these alternatives. When compared with THA, HR has some theoretical advantages that stem from preservation of the patient’s normal proximal femoral anatomy and the use of a large diameter metal on metal bearing. This has the potential to more accurately replicate physiological hip function, reduce the risk of dislocation and allow higher levels of activity with minimal wear of the articulating surface. In addition, the preservation of proximal femoral bone stock offers the potential for easier revision options as would inevitably be required in younger patients. In order to be considered a suitable alternative, HR would need to demonstrate improvements or at least equivalence in functional outcomes and survivorship along with evidence of successful preservation of bone stock leading to good outcomes from future revision surgery. Whilst the recent expansion of data both in the orthopaedic literature and the mainstream media concerning the potentially devastating problems from large metal-on-metal (MoM) bearings in some settings carries some salient lessons for both the development, marketing and uptake of new orthopaedic implants, it should be put in the context of the resurfacing literature as a whole. In this review we aim to review the current evidence base for HR compared with THA and examine the current indications for the procedure.

Analysis of Factors Influencing Return to Work after Total Hip Arthroplasty

BACKGROUND. Patients who undergo total hip arthroplasty (THA) find it difficult to return to work. OBJECTIVES. Analysis of factors influencing return to work after THA. Assessment of patients' quality of life and its impact on their attitude to work. MATERIAL AND METHODS. We studied patients operated on for degenerative hip disease at the Department of Orthopaedic Surgery of Medical Centre of Postgraduate Education in Otwock between 2007 and 2012. The total number of the patients was 400; however, we chose only those patients who were younger than 65 and still in employment. The study population consisted of 54 of these patients. The mean patient age was 55.89 (±7.424). There were 29 men (57.3%) and 25 women (46.3%). RESULTS. 32 patients (59.3%) returned to work. There was a statistically significant difference regarding the attitude to work and return to work. An overwhelming majority of the patients who returned to work--31 out of 32 (96.6%)--liked their jobs. The 12 patients (22.22%) who did not return to work declared their intention to apply for a disability pension. The patients who returned to work assessed their physical health as better than the patients who did not return to work. CONCLUSIONS. 1. 40.7% of patients after THA did not return to preoperative employment. The reasons for not returning were not medical, because elimination of pain and an increased range of motion made return to work possible. 2. The perception of the quality of physical and psychological health among patients with THA who returned to work was significantly better than among those who did not return.

Short-term results of total hip replacement due to acetabular fractures

This study aims to evaluate short-term results of total hip replacement performed for post-traumatic osteoarthritis and/or femoral head necrosis caused by acetabular fractures. We performed 39 arthroplasties due to acetabular fractures on 25 male and 14 female patients during the course of a five-year period. The mean age of the patients was 45 years (range 25 to 73 years) at the time of surgery. Cemented cup was implanted in 29 patients and uncemented cup in 10 patients. Bone replacement was indicated in eight patients for different degrees of acetabular deformities. Implantation of an acetabular socket was indicated in six patients. The evaluation was based on the Harris hip score (HHS). The mean HHS score was 42 prior to arthroplasty and 81 after arthroplasty. Repeated surgery was required for infection in two patients. Dislocation of the prosthesis occurred in three patients, deep venous thrombosis in one patient and the lesion of the sciatic nerve in one patient after surgery. Our study results suggest that the selection of the cup type depends on the condition and bone deformity secondary to acetabular fracture. Surgical interventions are technically more difficult, and take longer with a high rate of the postoperative complications and prolonged rehabilitation period, compared to arthroplasties for degenerative hip diseases.

Retrospective Evaluation of Femoral Osteoplasty And Labral Debridement in Cam-Type Femoroacetabular Impingement Patients—An Average Followup of 5 Years (SS-38)

Femoroacetabular impingement (FAI) has been increasingly recognized as a source of primary hip pathology and has been associated with early onset degenerative hip disease. Cam-type impingement can create shear stress at the acetabular rim, causing chondral delamination and articular-sided labral degeneration. The purpose of this study is to evaluate the clinical outcomes of arthroscopic treatment of cam-type femoroacetabular impingement. Ninety-four consecutive patients (100 hips) with cam impingement underwent arthroscopic femoral neck osteoplasty and labral debridement. Eighty-two hips (82%) were contacted and available for followup at a mean of 60 months (range, 40-74). Patients were assessed with preoperative and postoperative physical examination, nonarthritic hip score (NAHS), Western Ontario and McMasters Universities (WOMAC) score, and radiographs to assess the Tonnis Grade for osteoarthritis and alpha-angle. Postoperative evaluation included pain score assessment with a visual analog scale and satisfaction assessment. Eighty-two hips were contacted for followup evaluation. There were 54 patients who had not undergone additional surgeries. Six patients required revision hip arthroscopies. Twenty-two patients underwent hip arthroplasty, summing up to an overall revision rate of 28%. Of the patients who had not undergone revision surgeries, the mean NAHS rose from 48.9 to 78 and the WOMAC increased from 66.8 to 77. Patient satisfaction was 70 percent. Twenty-five of the 54 hips were available for clinical evaluation. Presence of internal rotation impingement sign decreased from 92.6 to 37.5 percent. Repeat radiograph showed improved alpha angles from 76.8 to 61.6 degrees. Of the patients with pre-existing osteoarthritis (Tonnis Grade 2-3), 84.6% went on to require hip arthroplasty. Of the patients with minimal to no pre-existing osteoarthritis (Tonnis Grade 0-1), 16.4% went on to require hip arthroplasty. Arthroscopic femoral neck resection in patients with cam-type FAI results in improved clinical outcomes, decreased physical symptoms, and a high patient satisfaction at a mean followup of 5 years. In the subset of patients with pre-existing osteoarthritis, there is high risk of needing an arthroplasty procedure within 5 years.

Arthroplastie de hanche et sport

Recreational sports activities are compatible with a total hip arthroplasty but the question becomes more problematic with many impact sports, which in general are not recommended. In 2012, two types of hip arthroplasty can be proposed for patients with degenerative hip disease: a conventional prosthesis with a femoral stem or a hip resurfacing procedure, which does not affect the femoral canal. Hip resurfacing is proposed for young and/or active patients who want to resume their activities without restriction. Based on data in the literature, conventional prostheses would not enable patients to resume all sports; only those sports with a low contact component would be acceptable. Conversely, the rate of resumed sports activities in high contact sports appears to be quite high after hip resurfacing, much more so than with conventional prostheses. Practice of high-impact (and/or high intensity) sports thus appears to be compatible with hip resurfacing although no long-term study has analyzed the consequences of this activity on wear and/or aseptic loosening.

The classification of degenerative hip disease

It is probable that both genetic and environmental factors play some part in the aetiology of most cases of degenerative hip disease. Geneticists have identified some single gene disorders of the hip, but have had difficulty in identifying the genetics of many of the common causes of degenerative hip disease. The heterogeneity of the phenotypes studied is part of the problem. A detailed classification of phenotypes is proposed. This study is based on careful documentation of 2003 consecutive total hip replacements performed by a single surgeon between 1972 and 2000. The concept that developmental problems may initiate degenerative hip disease is supported. The influences of gender, age and body mass index are outlined. Biomechanical explanations for some of the radiological appearances encountered are suggested. The body weight lever, which is larger than the abductor lever, causes the abductor power to be more important than body weight. The possibility that a deficiency in joint lubrication is a cause of degenerative hip disease is discussed. Identifying the phenotypes may help geneticists to identify genes responsible for degenerative hip disease, and eventually lead to a definitive classification.

Destructive discovertebral degenerative disease of the lumbar spine

The uncommon variant of degenerative hip joint disease, termed rapidly progressive osteoarthritis, and highlighted by severe joint space loss and osteochondral disintegration, is well established. We present a similar unusual subset in the lumbar spine termed destructive discovertebral degenerative disease (DDDD) with radiological features of vertebral malalignment, severe disc resorption, and "bone sand" formation secondary to vertebral fragmentation. Co-existing metabolic bone disease is likely to promote the development of DDDD of the lumbar spine, which presents with back pain and sciatica due to nerve root compression by the "bone sand" in the epidural space. MRI and CT play a complimentary role in making the diagnosis.

Outcomes of total hip replacement in patients with slipped capital femoral epiphysis

Total hip replacement has been advocated for the treatment of degenerative hip diseases secondary to slipped capital femoral epiphysis; nonetheless, outcomes of this procedure have not been well established. We reviewed the outcomes of modern total hip replacements in patients who suffered from slipped capital femoral epiphysis. A retrospective study was carried out on 32 total hip replacements performed on 28 patients who suffered from slipped capital femoral epiphysis from August 1994 to January 2007. The average age at the time of surgery was 45years. Clinical evaluation was performed using the Harris Hip Score, radiographic assessment measuring cup and stem orientation, the extent of osteolysis around the implant, and leg length discrepancy. The average follow-up was 98months (range 25-204months). Two total hip replacements failed, one for stem aseptic loosening and the other for modular neck failure. The cumulative survival rate at 9years was 92.8%. If the end point was revision for implant loosening, the survival rate improved to 96.8% at 9years. The only complication recorded was an intraoperative fracture of the lesser trochanter immediately treated with cerclage wire. At the latest follow-up, the Harris Hip Score averaged 86 (range 70-97). Leg length discrepancies greater than 1cm were present in 18 cases before surgery, and in only 6 cases after surgery. We recommend total hip replacement for patients who suffer from slipped capital femoral epiphysis because of the satisfactory survival, low complication rate, and the possibility of restoring leg length.

Acetabular Liner Revision Using an Anterolateral Approach

Total hip arthroplasty (THA) is recognized as a successful treatment for degenerative hip joint disease. An epidemiological study using the National Hospital Discharge Survey in the United States reported that the number of primary THAs increased from 119,000 in 1990 to 193,000 in 2002. According to nationwide inpatient sample data, the demand for primary THA was estimated to increase from 208,600 in 2005 to 572,000 (174%) in 2030 in the United States. The number of revision THAs in the United States has subsequently increased and is projected to increase from 40,800 in 2005 to 96,700 in 2030. Because revision THAs have a higher incidence of dislocation than primary THAs, preserving the soft tissue, including the gluteus medius muscle, is more necessary at revision THA. However, to our knowledge, few studies have reported soft tissue damage at revision THA. An anterolateral modified Watson-Jones approach, which is between the hip abductor and the tensor fascia lata, preserves the abductor muscles.This article describes 2 cases in which acetabular liner revision was performed through an anterolateral modified Watson-Jones approach. The anterolateral approach provided an excellent surgical field at acetabular liner revision, with no major complications, and has the possibility of being a useful for acetabular liner revision.

Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies?

Whilst patients undergoing total knee replacements generally have good relief of their symptoms, up to 20% complain of persisting pain. Revision rates have therefore been rising, particularly so for unexplained pain. We reviewed the causes of painful total knee replacements including extrinsic causes. Forty-five consecutive patients referred to our department with painful total knee replacement were reviewed with our standard protocol, including history and examination, inflammatory markers and radiological studies including radiographs of the hip and knee and computed tomography scan of the knee joint. Of the 45 patients, 15 patients had degenerative hip and lumbar spine disease which resolved after injections of the relevant joints. Nine patients had unexplained pain. Patients may still be undergoing knee arthroplasty for degenerative lumbar spine and hip osteoarthritis. We suggest heightened awareness at pre- and post-operative assessment and thorough history and examination with the use of diagnostic injections to identify the cause of pain if there is doubt.

Radiographic Risk Factors for Labral Lesions in Femoroacetabular Impingement

Tears of the acetabular labrum can lead to pain, disability, and osteoarthritis. Several pathomechanisms have been proposed, including femoroacetabular impingement (FAI). Labral tears have been reported to occur in the presence of even subtle deformities of the acetabulum and femoral head-neck junction. We analyzed the association of the extent of bony deformity and presence and extent of labral lesions in hips with FAI. Radiographs of 123 hips in 116 patients receiving surgical treatment for FAI were analyzed and correlated to the presence and extent of labral lesions. Radiographic parameters of the acetabulum included acetabular index of the weightbearing zone, center-edge angle, inclination of the acetabulum, lateral head extrusion index, and retroversion. On the femoral side, neck-shaft angle, asphericity of the femoral head, superior and anterior alpha angle, offset, and offset ratio were measured. Osteoarthritis was graded according to Tönnis and Kellgren and Lawrence. Labral lesions were graded according to the modified Beck classification. A correlation between labral lesions and age, gender, affected side, type of impingement, and presence and extent of chondromalacia also was tested. No correlation was found between presence or extent of labral lesions and any radiographic parameter tested, except osteoarthritis classification. The severity of labral lesions correlated to the severity of acetabular chondromalacia as well as patient age (Beck Grade 0 versus Grade 1, Beck Grade 0 versus Grades 1 and 2). In the presence of impingement-inducing deformity, the extent of deformation is not associated with the incidence of labral lesions. Labral lesions are associated with early degenerative hip disease in FAI. Level I, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Arthroscopic Grafting of Chondral Defects and Subchondral Cysts of the Acetabulum

We present a novel arthroscopic-assisted technique to graft chondral defects and subchondral cysts of the acetabular socket using a synthetic osteochondral plug. Four patients with groin pain, solitary cysts in the roof of the acetabulum and radiographic evidence of early osteoarthritis were treated. A bone tunnel was prepared from the region of the iliac crest to the acetabular articular surface. A synthetic osteochondral plug was inserted in an ante-grade fashion and positioned flush with the lunate articular cartilage. The minimum follow-up from surgery was 8 months (mean 10 months, range 8 to 11 months). There were no peri-operative complications related to the procedure. All patients reported an improvement in symptoms and function at the latest follow-up. One of the patients underwent a re-look arthroscopy at 5 months for persistent dull groin and buttock pain. Capsular adhesions of the labrum were identified and released. The mean non-arthritic hip score improved from 53.8 (range 43.8 to 70) pre-operatively to 84.6 (range 78.8 to 87.5) at 6 months. Computed tomography and magnetic resonance imaging at 6 months confirmed the stability of the osteochondral plugs and on-going healing. This procedure offers an arthroscopic means to treat patients with solitary acetabular cysts and may prove effective for chondral grafting of denuded acetabular areas in early to moderate degenerative hip disease.