Hip Surgeons Research Articles

Risk of Injury to the Neurovascular Structures in the Pararectus Approach Used in Acetabular Fractures: A Cadaver Study.

Complex acetabular fractures involving the quadrilateral plate may necessitate infrapectineal buttress plating, which can be performed through the pararectus approach. The aim of this cadaveric study was to identify the anatomical guide points to protect neurovascular structures at the risk of injury during the pararectus approach. Six fresh frozen cadavers (12 hemipelves) were dissected in this study. Location of the inferior epigastric artery (IEA), obturator nerve and corona mortis (CM) was measured using common anatomic landmarks, namely, anterior superior iliac spine, symphysis pubis (SP), and sacroiliac (SI) joint. In the superficial dissection of the abdominal wall, the mean distance between the IEA and anterior superior iliac spine was 106.7 ± 5.2 (range, 99.2-116.4) mm, and the mean distance between IEA and SP was 77.9 ± 3.5 (range, 70.6-82.2) mm. In deep dissection, the mean distance between the SI joint and the SP was 133.1 ± 5.7 (range, 126.0-142.0) mm. The mean distance between the SI joint and ON was 37.3 ± 2.8 (range, 31.0-41.0) mm. The CM was unable to be detected in 2 cadavers, 1 on the right and 1 on the left hemipelves. The mean distance between the CM and SP was 47.7 ± 3.9 (range, 43.0-55.0) mm. A pararectus approach is a useful approach which allows infrapectineal plating in the treatment of complex acetabular fractures; however, the preservation of critical neurovascular structures is essential during dissection. This study is helpful to identify the structures at risk according to commonly used anatomic landmarks. These data might be a necessary guideline for hip and trauma surgeons.

Fixation of the short global tissue-sparing hip stem.

Short, bone-conserving femoral components are increasingly used in total hip arthroplasty (THA). They are expected to allow tissue-conserving implantation and to render future revision surgery more straightforward but the long-term data on such components is limited. One such component is the global tissue-sparing (GTS) stem. Following the model for stepwise introduction of new orthopaedic implants, we evaluated early implant fixation and clinical outcome of this novel short-stem THA and compared it to that of a component with established good long-term clinical outcome. In total, 50 consecutive patients ≤ 70 years old with end-stage symptomatic osteo-arthritis were randomized to receive THA with the GTS stem or the conventional Taperloc stem using the anterior supine intermuscular approach by two experienced hip surgeons in two hospitals in the Netherlands. Primary outcome was implant migration. Patients were followed using routine clinical examination, patient reported outcome using Harris Hip Score (HHS), Hip Disability And Osteoarthritis Outcome Score (HOOS), EuroQol five-dimension questionnaire (EQ5D), and Roentgen Stereophotogrammetric Analysis (RSA) at three, six, 12, and 24 months. This study evaluated the two-year follow-up results. In addition to the initial migration pattern of distal migration (subsidence, Y-translation) and retroversion (Y-rotation) also exhibited by the Taperloc stem, the GTS stem showed an initial migration pattern of varization (X-translation combined with Z-rotation) and posterior translation (Z-translation). However, all components stabilized aside from one Taperloc stem which became loose secondary to malposition and was later revised. Clinical outcomes and complications were not statistically significantly different with the numbers available. A substantially different and more extensive initial migration pattern was seen for the GTS stem compared to the Taperloc stem. Although implant stabilization was achieved, excellent long-term survival similar to that of the Taperloc stem should not be inferred. Especially in the absence of clinically proven relevant improvement, widespread usage should be postponed until long-term safety has been established. Cite this article: Bone Joint J 2020;102-B(6):699-708.

Nonsteroidal Anti-Inflammatory Drugs in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society

Nonsteroidal Anti-Inflammatory Drugs in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society

The Efficacy and Safety of Nonsteroidal Anti-Inflammatory Drugs in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundNonsteroidal anti-inflammatory drugs (NSAIDs) have become widely used to manage perioperative pain following total joint arthroplasty (TJA). The purpose of our study is to evaluate the efficacy and safety of NSAIDs in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management. MethodsDatabases including MEDLINE, EMBASE, and the Cochrane Central Registry of Controlled Trials were searched for studies published prior to November 2018 on NSAIDs in TJA. Studies included after a systematic review evaluated through direct comparisons and/or meta-analysis, including qualitative and quantitative heterogeneity testing, to evaluate effectiveness and safety of NSAIDs. ResultsAfter critical appraisal of 2921 publications, 25 articles represented the best available evidence for inclusion in the analysis. Oral selective cyclooxygenase (COX)-2 and non-selective NSAIDs and intravenous ketorolac safely reduce postoperative pain and opioid consumption during the hospitalization for primary TJA. Administration of an oral selective COX-2 NSAID reduced postoperative opioid consumption after discharge from TKA. ConclusionStrong evidence supports the use of an oral selective COX-2 or non-selective NSAID and intravenous ketorolac as adjunctive medications to manage postoperative pain during the hospitalization for TJA. Although no safety concerns were observed, prescribers need to remain vigilant when prescribing NSAIDs.

The Efficacy and Safety of Acetaminophen in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundOral and intravenous (IV) acetaminophen has become widely used perioperatively as part of a multi-modal pain management protocol for primary total joint arthroplasty (TJA). The purpose of our study is to evaluate the efficacy and safety of acetaminophen in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management. MethodsWe searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for studies published prior to September 2019 on acetaminophen in primary TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of acetaminophen. ResultsIn total, 1287 publications were critically appraised yielding 17 publications representing the best available evidence for analysis. Oral and IV acetaminophen demonstrates the ability to safely reduce postoperative pain and opioid consumption during the inpatient hospital stay. No evidence was available to assess the efficacy and safety of oral acetaminophen after discharge. ConclusionModerate evidence supports the use of oral and IV acetaminophen as a non-opioid adjunct for pain management during the inpatient hospitalization. Strong evidence supports the safety of oral and IV acetaminophen when appropriately administered to patients undergoing primary TJA. Although there is lack of robust evidence for use of acetaminophen following discharge, it remains a low-cost and low-risk option as part of a multimodal pain regimen.

The Efficacy and Safety of Opioids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundOpioids are frequently used to treat pain after total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of opioids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management. MethodsThe MEDLINE, EMBASE, and Cochrane Central Register of controlled trials were searched for studies published before November 2018 on opioids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of opioids. ResultsPreoperative opioid use leads to increased opioid consumption and complications after TJA along with a higher risk of chronic opioid use and inferior patient-reported outcomes. Scheduled opioids administered preemptively, intraoperatively, or postoperatively reduce the need for additional opioids for breakthrough pain. Prescribing fewer opioid pills after discharge is associated with equivalent functional outcomes and decreased opioid consumption. Tramadol reduces postoperative opioid consumption but increases the risk of postoperative nausea, vomiting, dry mouth, and dizziness. ConclusionModerate evidence supports the use of opioids in TJA to reduce postoperative pain and opioid consumption. Opioids should be used cautiously as they may increase the risk of complications, such as respiratory depression and sedation, especially if combined with other central nervous system depressants or used in the elderly.

Opioids in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society

The American Association of Hip and Knee Surgeons, The American Academy of Orthopaedic Surgeons (AAOS), The Hip Society, The Knee Society, and The American Society of Regional Anesthesia and Pain Medicine worked together to develop evidence-based guidelines on the use of opioids in primary total joint arthroplasty (TJA). The purpose of these guidelines is to improve the treatment of orthopedic surgical patients and reduce practice variation by promoting a multidisciplinary evidence-based approach on the use of opioids following primary TJA.

Acetaminophen in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society

Acetaminophen in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society

Gabapentinoids in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society

Hip and knee arthroplasties are routine orthopedic procedures commonly associated with acute postoperative anemia, and in many cases require an allogeneic or autologous blood transfusion. Several techniques have been used to limit postoperative blood loss and risk of transfusion. Tranexamic acid (

The Efficacy and Safety of Gabapentinoids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundGabapentinoids are commonly used as an adjunct to traditional pain management strategies after total joint arthroplasty (TJA). The purpose of this study is to evaluate the efficacy and safety of gabapentinoids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management. MethodsThe MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched for studies published prior to November 2018 on gabapentinoids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of gabapentinoids. ResultsIn total, 384 publications were critically appraised to provide 13 high-quality studies regarded as the best available evidence for analysis. In the perioperative period prior to discharge, pregabalin reduces postoperative opioid consumption, but gabapentinoids do not reduce postoperative pain. After discharge, gabapentin does not reduce postoperative pain or opioid consumption, but pregabalin reduces both postoperative pain and opioid consumption. ConclusionModerate evidence supports the use of pregabalin in TJA to reduce postoperative pain and opioid consumption. Gabapentinoids should be used with caution, however, as they may lead to an increased risk of sedation and respiratory depression especially when combined with other central nervous system depressants such as opioids.

Classifications in Brief: The Dorr Classification of Femoral Bone.

Classifications in Brief: The Dorr Classification of Femoral Bone.

Trends in Leadership at Orthopedic Surgery Adult Reconstruction Fellowships

BackgroundFellowship directors (FDs) in adult reconstruction have a profound impact on current and future trainees within orthopedics. Our group sought to evaluate the shared characteristics among current adult reconstruction FDs to provide a framework for those aspiring to achieve this position and identify possible areas of improvement. MethodsFellowship programs were identified using the American Association of Hip and Knee Surgeons Directory. Data for each FD were gathered via electronic mail, telephone, curriculum vitae, and online searches. Demographic information collected included age, gender, ethnicity, residency/fellowship training, residency/fellowship graduation year, year hired by current institution, time since training completion until FD appointment, length in FD role, and Scopus H-index. ResultsInformation was gathered for 94 FDs. Of these, 100% were males; 80.6% were Caucasian, 12.90% were Asian American, 5.38% were Hispanic, and 1.08% were African American. The average age (52.6 years old), H-index (16.54), year of residency (2000) and fellowship (2001) graduation, and time since training until FD appointment (9.55 years) were analyzed. The top training programs to produce future FDs were Mayo Clinic (residency) and Harvard University (fellowship). ConclusionAdult reconstruction FDs are frequently distinguished by their level of research productivity and experience, but certainly more demographic diversity is needed within this cohort. Specific training programs may inherently have a vital role in the development of individuals for future leadership positions. These developments could be a result of unique features inherent to the training programs or because of a subset of applicants who pursue specific programs with aspirations of subsequent leadership opportunities.

Management of Recurrent Posterior Hip Dislocation in a Down Syndrome Patient with Dysplastic Hip Using Ganz Periacetabular Osteotomy: Follow Up After 4 Years

Recurrent hip dislocation in a Down Syndrome patient with dysplastic hip is a very challenging case to treat even for an expert orthopaedic hip surgeon. Least compliant patient and family, lowly educated with low socioeconomic status and the dysplastic hip forces limited option as a treatment. This is the first case world wide reporting 4 year follow up of dysplastic hip with Down Syndrome treated successfully with PAO technique.Methods:An eighteen years old female with history of Down Syndrome had multiple posterior hip dislocation episodes since 3 years prior. Several attempts of close reduction and hip spica applications were performed upon dislocation despite no successful retaining of reduction. Acetabular index of right hip were 550 and epiphyseal plate hasclosed. PatientwasperformedopenreductionusingSouthern-Mooreposteriorapproachand osteotomy of ischium, continued with capsulorrhaphy followed with Smith-Peterson anterior approach and osteotomy of superior ramus pubis and iliac bone. Then, derotation maneuver was performed under image intensifier to obtain adequate coveragefollowedwithbonegraftandfixationusing2cannulatedscrewandhipspica castapplication.Results:Within four years after surgery, the hip has never been dislocated again, patient could sit without pain and walk with full weight bearing although Harris Hip Score could not be performed due to Down Syndrome. Leg length discrepancy was negligible,fracture has fully united and acetabularin dex was300.Conclusions:Ganz periacetabular osteotomy, although a technically demanding surgery, is a preferable treatment in recurrent hip dislocation for Down Syndrome patient with good to excellent clinical and radiological ou tcome

The Removal of Total Hip and Total Knee Arthroplasty From the Inpatient-Only List Increases the Administrative Burden of Surgeons and Continues to Cause Confusion

BackgroundSeveral studies have shown that the removal of total knee arthroplasty (TKA) from the Centers for Medicare and Medicaid Services (CMS) inpatient-only (IPO) list has caused confusion among surgeons, hospitals, and patients. The purpose of this study is to determine whether similar confusion was present after CMS recently removed total hip arthroplasty (THA) from the IPO list. MethodsWe surveyed the American Association of Hip and Knee Surgeons membership via an online web-based questionnaire in February 2020. The 12-question form asked about practice type and the impact that having both THA and TKA removed from the IPO list has had on each surgeon’s practice. Responses were tabulated and descriptive statistics of each question reported. ResultsOf the 2847 American Association of Hip and Knee Surgeons members surveyed, 419 responded (14.7% response rate). Three hundred forty-one surgeons (81%) stated that changes to IPO status have increased their practice’s administrative burden. Fifty-four percent of surgeons reported that they have needed to obtain preauthorization or appeal a denial of preauthorization for an inpatient total joint arthroplasty at least monthly, while 257 surgeons (61%) have had patients contact their office regarding an unexpected copayment. Despite the commitment of CMS to waiving certain audits for 2 years, 43 respondents (10%) stated they had undergone an audit regarding a patient’s inpatient status. ConclusionThe removal of THA and TKA from the IPO list continues to be an administrative burden for arthroplasty surgeons and a source of confusion among patients. CMS should provide additional guidance to address surgeons’ concerns about preauthorization for inpatient stays, unexpected patient copayments, and CMS audits.

Residency Program Reputation Influences the American Association of Hip and Knee Surgeons Match Results

BackgroundNo data evaluate the impact that an applicant’s residency program reputation has on the outcome of the American Association of Hip and Knee Surgeons (AAHKS) fellowship match. This study sought to determine if an applicant’s residency program ranking was associated with where the applicant matched on their rank list. MethodsWe included all the US applicants from the “San Francisco Match” regarding AAHKS applicant data and match results from 2014 to 2018. Residency programs were divided into 5 tiers based on 2018 Doximity ranking of Orthopedic Residency Programs. Statistical analysis consisted of descriptive statistics, chi-squared tests, and analysis of variance. ResultsIn total, 656 applicants met inclusion criteria (620 males; 36 females). Tier 1 applicants applied to an average of 10 fewer programs than applicants from all other tiers. Eighteen percent of applicants from tier 1 residencies were offered interviews at 80%+ of their applied programs compared to 5% or less of the applicants from all other tiers. Applicants from top tier residencies matched at a significantly higher place on their rank list than other tiers (P < .05) and ranked into one of their first 2 choices 72% of the time. The mean fellowship rank position for tier 1 applicants was 5.96 compared to 7.04, 7.85, 7.78, and 8.10 for subsequent tiers, respectively (P < .05). ConclusionThe fellowship match process represents a high-stakes and expensive process. This study found that applicants from more prestigious residency programs apply to fewer programs, gain more interviews, and match higher on their rank list than applicants from other residency programs.

Survey of AAHKS International Members on the Impact of COVID-19 on Hip and Knee Arthroplasty Practices

BackgroundCoronavirus disease 2019 (COVID-19) pandemic poses an important risk to global health. MethodsThis study surveyed 370 international orthopedic surgeons affiliated with the American Association of Hip and Knee Surgeons to help identify the global impact of the COVID-19 pandemic on patient care. ResultsA total of 99 surgeons (27% of those surveyed) completed the questionnaire representing 32 different countries. Except for surgeons in Japan, all respondents noted that their practice had been affected to some degree and 70% of the surgeons have canceled elective procedures. More than a third of the surgeons have had to close their practices altogether and the remaining open practices were estimated to be sustainable for 7 weeks on average given their current situation. ConclusionThe COVID-19 pandemic has resulted in marked changes to the majority of international arthroplasty practices.

American Association of Hip and Knee Surgeons Advocacy Efforts in Response to the SARS-CoV-2 Pandemic

As soon as it became clear that our economy was going to be paralyzed by the SARS-CoV-2 pandemic, the American Association of Hip and Knee Surgeons leadership acted swiftly to ensure that our members were going to be eligible for the anticipated federal economic stimulus. The cessation of elective surgery, enacted in mid-March and necessary to stop the spread of the SARS-CoV-2 virus, would surely challenge the solvency of many of our members’ practices. Although our advocacy efforts discussed further have helped, clearly more relief is needed. Fortunately, our mitigation efforts have led to a “flattening of the curve” and discussions have begun on when, where, and how to safely start elective surgery again.

Management of Osteoarthritis of the Hip.

The American Academy of Orthopaedic Surgeons, in collaboration with the American Association of Hip and Knee Surgeons, the Hip Society, the American College of Radiology, the American Physical Therapy Association, the Limb-lengthening and Reconstruction Society, and the Pediatric Orthopaedic Society of North America, released Management of Osteoarthritis of the Hip: Evidence-Based Clinical Practice Guideline. The complete guideline is available on OrthoGuidelines (www.orthoguidelines.org). The guideline is intended to assist those taking care of patients with osteoarthritis of the hip in making decisions regarding the most appropriate treatment. A group of experts with knowledge of orthopaedic surgery, physical therapy, and musculoskeletal radiology developed 18 recommendations for nonoperative and operative treatment based on relevant literature. A companion article illustrates the use of these guidelines by discussing specific case examples and evidence-based treatments for osteoarthritis of the hip.

ASSOCIATION BETWEEN SADNESS AND SYMPTOM SEVERITY IN PEDIATRIC AND ADOLESCENT PATIENTS WITH HIP PAIN

Background: Patient-reported outcome measures (PROMs) are used by hip surgeons to assess treatment outcomes. Purpose: The purpose of this study was to evaluate patient-reported sadness and its association with perceived pain, symptoms, and clinical disease severity in patients with hip pain. Methods: A review of prospectively collected PROMs from patients presenting with hip pain was performed. PROMs were completed at baseline, one year, and two years post-treatment. Those who reported feeling ‘downhearted and blue’ sometimes, often, or always on a baseline SF-12 (SAD) were compared to those who did not (NOT SAD). A subset of patients diagnosed with femoroacetabular impingement (FAI) was analyzed to assess radiographic and intraoperative disease severity between the groups. Radiographic measures consisted of baseline alpha angle and lateral center edge angle. Intraoperative disease severity of the femoral head, labrum, acetabulum, and capsule was determined by an orthopaedic surgeon using a standardized 1-3 ranking system. A Mann-Whitney Test was used to compare groups. Results: Of 378 participants, the mean age was 15.3 (range 7-19) and 64.6% were female. Sixty-four participants (16.9%), of which 78.1% were female (p=0.013 compared to male) reported feeling SAD at baseline. SAD participants scored worse on the HOOS at baseline (55.8 vs. 66.1, p&lt;0.001), with significantly lower scores on every subscale (Table 1). Additionally, SAD participants demonstrated worse perceived outcomes one year post-treatment. While not significant, SAD participants also demonstrated a trend towards lower HOOS scores two years post-treatment (Table 1). Of 121 participants diagnosed with FAI (mean age 15.8; 72.7% female), SAD participants reported worse quality of life (29.1 vs. 44.5, p&lt;0.001), pain (52.2 vs. 60.1, p=0.049), physical function (59.7 vs. 68.8, p=0.028), and scored lower overall on the HOOS at baseline (53.8 vs. 62.0, p=0.023). However, SAD participants did not demonstrate worse radiographic or intraoperative disease severity (Table 2). One year post-treatment, SAD participants reported worse pain on the HOOS (68.0 vs. 87.6, p=0.033). There were no significant differences between the SAD and NOT SAD groups at two years post-treatment, but lower scores were noted (Table 1). Conclusion: The question of feeling ‘downhearted or blue,’ perhaps a symptom of underlying depression, may be associated with patient reported symptom severity at baseline and one year post-treatment. However, no differences were found in radiographic or intraoperative disease severity of hip impingement between the SAD and NOT SAD groups, indicating that symptoms of underlying depression may be a risk factor for poor treatment outcomes. [Table: see text][Table: see text]

Practical office ultrasound for the hip surgeon: current concepts

Ultrasound imaging allows for real-time dynamic visualisation of muscles, tendons, fascial planes and joints. This modality enhances the sensitivity of physical examination for the localisation of pathology and improves clinical diagnostic accuracy. Ultrasound improves the accuracy of targeted injections without the need for fluoroscopy. This modality is economically affordable, portable, and does not expose the patient or provider to radiation. A thorough understanding of the anatomy and biomechanics of the hip and a working knowledge of both intra-articular and extra-articular hip pathologies is essential to optimising the utility of this modality. Ultrasound-guided injections allow for real-time visualisation of both the needle and soft tissue or intra-articular target and are superior to unguided hip injections. Improved patient care can be achieved through the skilled use of ultrasound by a hip surgeon, radiologist or ultrasound technician with appropriate training.