Outcome Of THA Research Articles

Open reduction internal fixation versus hemiarthroplasty versus total hip arthroplasty in the elderly: a review of the National Surgical Quality Improvement Program database

BackgroundTotal hip arthroplasty (THA), hemiarthroplasty (HA), and open reduction internal fixation (ORIF) are treatment options for femoral neck fractures. However, the optimal surgical treatment remains unclear. The present study aimed to describe the 30-d postoperative outcomes of THA, HA, and ORIF among patients aged ≥65 y with femoral neck fractures within a national surgical database. Materials and methodsA retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program for January 2005 through December 2009 was conducted. We included patients aged ≥65 y who had undergone THA, HA, or ORIF for femoral neck fractures. We collected information on patient demographics, comorbidities, risk factors, and complication rates. A logistic regression model was used to assess the variation in overall morbidity and mortality after surgery. ResultsOverall, 3423 patients met the inclusion criteria: 674 underwent ORIF, 428 HA, and 2321 THA. Most patients were white (83.6%, n = 2862), female (64.4%, n = 2204), and >70 y old (78.4%, n = 2682). On adjusted multivariate analysis, no differences were found in the 30-d mortality rates among the ORIF, HA, and THA groups. Patients who underwent ORIF (odds ratio 0.51, 95% confidence interval 0.27–0.94) and HA (odds ratio 0.43, 95% confidence interval 0.22–0.84) had a lower likelihood of developing respiratory complications compared with those who underwent THA. ConclusionsNo differences were found in the 30-d mortality rates among the ORIF, HA, and THA groups. ORIF and HA resulted in a lower likelihood of developing respiratory complications than THA.

Subsidence of a cementless femoral component influenced by body weight and body mass index

This trial was designed to evaluate the impact of physical characteristics such as body mass index, body weight and height on distal stem migration of a cementless femoral component, as the influence of obesity on the outcome of THA is still debated in literature and conflicting results have been found. In this retrospective cohort study, migration patterns for 102 implants were analysed using the Einzel-Bild-Roentgen-Analyse (EBRA-FCA, femoral component analysis). In all cases the Vision 2000 stem was implanted and combined with the Duraloc acetabular component (DePuy, Warsaw, Indiana). The mean follow-up was 93 months. EBRA-FCA evaluations revealed a mean subsidence of 1.38 mm after two years, 2.06 mm after five and 2.24 mm after seven years. Five stems loosened aseptically. Correlation between increased migration over the whole period and aseptic loosening was highly significant (p < 0.001). Surgical technique had a significant influence on migration and stem stability (p = 0.002) but physical patient characteristics such as body weight over 75 kg and height over 165 cm also significantly influenced stem subsidence towards progressive migration (p = 0.001, p < 0.001). However, a high BMI did not trigger progressive stem migration (p = 0.87). Being of the male gender raised the odds for increased migration (p = 0.03). Physical characteristics such as body weight and height showed significant influence on migration patterns of this cementless femoral component. The operating surgeon should be aware that body weight above 75 kg and height over 165 cm may trigger increased stem migration and the surgeon should aim to fit these prostheses as tightly as possible. However this study demonstrates that a high BMI does not trigger progressive stem migration. Further investigations are needed to confirm our findings.

Cemented total hip arthroplasty with subtrochanteric femoral shortening transverse osteotomy for severely dislocated hips: outcome with a 3- to 10-year follow-up period

BackgroundTotal hip arthroplasty (THA) for the treatment of severe dislocation of the hip is a technically demanding procedure. In most previous reports, techniques and clinical outcomes using cementless prostheses are widely reported, but there have been few reports on the technique and outcomes using cemented prostheses. The purpose of this study was to evaluate the outcomes of a cemented THA with a simultaneous subtrochanteric femoral shortening transverse osteotomy in patients with Crowe type III or IV developmental dysplasia of the hip. MethodsWe retrospectively reviewed 15 hips in 11 patients who underwent cemented THA with subtrochanteric femoral shortening transverse osteotomy and with placement of the acetabular component at the level of the anatomic hip center. Patients were evaluated preoperatively and postoperatively with the Merle d'Aubigne and Postel hip score. Radiographic examination was performed to evaluate the level of the femoral osteotomy site, of the radiographic leg lengthening, and of bone union. ResultsThe clinical evaluation by the Merle d'Aubigne and Postel hip score was improved from 8.1 ± 2.5 preoperatively to 15.1 ± 1.3 at the time of final follow-up. Radiographic evidence of bone union at the osteotomy site appeared at more than 6 months after operation. Moreover, there were 3 (20%) nonunions that needed reoperation. No acetabular and femoral components exhibited radiological loosening at the time of final follow-up. In addition, one delayed union causing thigh pain was treated with low-intensity pulsed ultrasound that accelerated bone formation. ConclusionOur results in this study indicate that we should prevent instability at the transverse osteotomy site and an adequate intercalary cortical bone graft is needed to prevent nonunion in cemented THA combined with a subtrochanteric femoral shortening transverse osteotomy. We should apply this procedure with caution in patients, especially those who show less potential bone formation activity.

Short-term outcome of hybrid THA using HA-coating cup and polish-tapered stem

Short-term outcome of hybrid THA using HA-coating cup and polish-tapered stem

Letter to the Editor: The Functional Outcome of Hip Resurfacing and Large-head THA is the Same

Dr. Lavigne and his coauthors [2] performed a PRCT to address a question that needs to be answered urgently: can resurfacing provide superior function over conventional hip replacement for active patients that might make the reported higher risk of reoperation worthwhile? However, their power calculation was based on the premise that anything less than a 12% increase in normal walking speed would not be significant on the grounds that an earlier study had found such a difference between patients who had hip resurfacing and those with an arthritic hip [3]. This position is obtuse. The difference between the comfortable walking speeds of fit men in their 30s and 70s is only 0.13 m/second or less than 10% [1]. In fast walking, as measured by Lavigne et al. [2], which might be considered a surrogate for top speed, the patients who had hip resurfacing walked 0.9 m/second, or 5% faster than the patients who had total hip replacements, however the study was not powered to detect this difference. Others have noted that patients who had hip resurfacing have higher UCLA scores than patients who had hip replacements [4], suggesting that at higher levels of activity, the presence of a normal femoral neck and head might confer some advantage. This costly and well-conducted trial has contributed a detailed methodology to the literature. However, by setting a bar of 12% superiority, the authors appear determined to avoid finding a 10% significance, a level that medical interventions use across many specialities. Even a 5% performance improvement in any sport would constitute overwhelming superiority. Such a type II error should be acknowledged in a trial which genuinely is seeking to establish superiority of an intervention.

Letters to the editors

Dear Editors: In our experience and also according to the others,2, 3 aseptic loosening in THA can be caused by heterogeneous factors and especially the premature failure should be analyzed with maximum attention. Here, median time to failure was 42 months (1–120 months), therefore particularly in the patients with shorter time to failure an alternative explanation for failure should be sought. In this line surgical inexperience, low-grade sepsis, and inconvenient implant seem to be more plausible cause of the failure than the role for IL-6 pathway influence on osteoclasts as suggested by the authors. The study group consisted of 57 Caucasian patients with failed both the cups and stems in eleven of them, failed stems in 22 and cups in 24 of them, respectively. Such mismatch precludes obtaining valid conclusions on the association between genetic predisposition and outcome. Importantly, in addition to the above-mentioned criticism, there is also concern about the different mechanisms of failure at the site of cups and stems. Also differences in the cemented and cementless implants/interfaces or polyethylene origin/ manufacturing could play a role in the mechanism of aseptic loosening.4 In addition, several studies reported increased risk to premature failure in relation to the particular design of the prosthesis.5 As a result, one cannot make significant conclusions without adjusting for other risk factors potentially playing a role in THA failure. Despite the extensive statistics used in this study we doubt that the approach to the data analysis is adequate. The study population comprised only patients operated for aseptic loosening within first 10 years after THA. However, survivorship analysis related to the GNAS1 genotypes would benefit from the usage of a systematic THA cohort which could better control for other relevant factors and competitive risks. Alternatively, appropriate control group comprising patients with the same THA that did not fail within the critical time period would provide base for the case-control study design.6 Having realized any such study design, the authors could consider the observed differences to be significant and possibly causal. In fact, the authors are aware that the presented data are limited by the size of their study population. Nevertheless, it should be further noted that the key observation from the study (association of GNAS1 T393C SNP with time to aseptic loosening in males) is based just on the 20 THA patients among whom only four were GNAS1 TT homozygotes. Such number of cases should be considered quite far from the optimum number for the analyses of genetic components of complex diseases and/or their complications.7 Regardless the GNAS1 genotype, the authors reported apparent difference in THA survival between male and female THA patients. Because this finding may also be relevant for observed “contradictory” impact of GNAS1 SNP on aseptic loosening in males and females, we missed any discussion of other possible causes of THA outcome being dependent on gender. The authors' work was supported in part by the Internal Grant Agency, Czech Ministry of Health (grant NR-9490-3).

Effect of Prior Salter or Chiari Osteotomy on THA with Developmental Hip Dysplasia

Controversy exists regarding the outcome of THA after prior pelvic osteotomy. We conducted a retrospective chart and radiographic review to obtain outcome measures for perioperative complications, acetabular and femoral component revisions, Harris hip score, and survivorship and compared these outcomes for patients presenting with developmental dysplasia of the hip treated surgically using THA with and without prior pelvic osteotomy. We performed 103 primary THAs in 87 patients with osteoarthritis secondary to developmental dysplasia of the hip with a minimum 3-year followup. Previous pelvic osteotomy was performed in 52 hips (Salter, 40; Chiari, nine; Salter and Chiari, three), and 51 hips had no previous surgery (control group). The pelvic osteotomy group did not have higher rates of femoral or acetabular intraoperative fracture or dislocation compared with the control group. The overall revision rate was 28.8% in the pelvic osteotomy group compared with 19.6% in the control group. The revision rate for aseptic loosening was 23.1% in the pelvic osteotomy group compared with 17.6% in the control group. Harris hip scores (range, 20-87) were not compromised, and overall survivorship rates 8 years postoperatively were not different at any time between the pelvic osteotomy (83.3%) and control (88.4%) groups. Prior pelvic osteotomy did not lead to a higher perioperative complication rate, higher revision rate, compromised Harris hip score, or shortened survivorship in eventual THA in developmental dysplasia of the hip. Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

In Brief: Crowe’s Classification: Arthroplasty in Developmental Dysplasia of the Hip

In Brief: Crowe’s Classification: Arthroplasty in Developmental Dysplasia of the Hip

A stature-specific concept for uncemented, primary total hip arthroplasty

Background and purpose Variations in hip anatomy limit the femoral canal fit of standard uncemented hip stems. In addition, there are still issues with leg length discrepancy and offset reconstruction, potentially resulting in impingement, dislocation, and wear. Modular stems with different shapes for femoral canal fit and multiple neck options may improve the outcome and reduce complications.Patients and methods 173 patients (190 hips) received an uncemented THA with 1 of 2 different stem shapes for canal fit and a modular neck for stature-specific hip reconstruction. Median follow-up time was 9 (7–13) years. During the follow-up period, 20 patients died (22 hips) and 12 patients (13 hips) were lost to follow-up. 155 hips were available for evaluation, including clinical and radiological outcome.Results 1 stem was revised for a periprosthetic fracture following trauma; 10 cups and 2 modular necks were revised (1 for breakage and 1 during cup revision). At 10 years, stem survival was 100%, modular neck survival was 99% (CI: 95–100), and cup survival was 94% (CI: 87–97). No leg length discrepancies were measured in 96% of cases. Offset with anatomic lateralization was achieved in 98%. Median Harris hip score was 94 (47–100) and median Merle d'Aubigné score was 16 (10–18). Relevant radiolucent lines and osteolysis were not found.Interpretation The uncemented modular neck, dual-stem system used in this series allows accurate reconstruction of the joint by adapting the implant to the needs of the patient. This may improve the outcome of primary THA, which is supported by the results of this medium-term follow-up evaluation.

A non-invasive acoustic and vibration analysis technique for evaluation of hip joint conditions

The performance evaluation of THA outcome is difficult and surgeons often use invasive methods to investigate effectiveness. A non-invasive acoustic and vibration analysis technique has recently been developed for more-in-depth evaluation of in vivo hip conditions. Gait kinematics, corresponding vibration and sound measurement of five THA subjects were analyzed post-operatively using video-fluoroscopy, sound and accelerometer measurements while walking on a treadmill. The sound sensor and a pair of tri-axial accelerometers, externally attached to the pelvic and femoral bone prominences, detected frequencies that are propagated through the femoral head and acetabular cup interactions. A data acquisition system was used to amplify the signal and filter out noise generated by undesired frequencies. In vivo kinematics and femoral head sliding quantified using video fluoroscopy were correlated to the sound and acceleration measurements. Distinct variations between the different subjects were identified. A correlation of sound and acceleration impulses with separation has been achieved. Although, in vivo sounds are quite variable in nature and all correlated well with the visual images. This is the first study to document and correlate visual and audible effects of THA under in-vivo conditions. This study has shown that the development of the acoustic and vibration technique provides a practical method and generates new possibilities for a better understanding of THA performance.

Is the Long-term Outcome of Cemented THA Jeopardized by Patients Being Overweight?

Although the effect of being overweight on the long- and short-term outcome of THA remains unclear, the majority of orthopaedic surgeons believe being overweight negatively influences the longevity of a hip implant. We asked whether complications and long-term survival of cemented THA differed in overweight patients (body mass index [BMI] > 25 kg/m2) and obese patients (BMI > 30 kg/m2) compared with normal-weight patients (BMI < 25 kg/m2). We retrospectively analyzed 411 consecutive patients (489 THAs) treated with cemented THA between 1974 and 1993. Except for cardiovascular comorbidity, we observed no differences in demographics among these weight groups. We found no differences in the number of intraoperative or postoperative complications. The survival rates for the three BMI groups were similar. The 10-year survival for any revision was 94.9% (95% confidence interval, 91.6%-98.2%), 90.4% (95% confidence interval, 85.6%-95.2%), and 91% (95% confidence interval, 81.2%-100%) for normal-weight, overweight, and obese patients, respectively. Cox regression analysis showed BMI and weight had no major influence on survival rates. The differences in mean Harris hip score at final followup were 4.8 between normal-weight and overweight patients and 7.1 between normal-weight and obese patients. Being overweight and obesity had no influence on perioperative complication rates in this cohort and did not negatively influence the long-term survival of cemented THA.

Increased Surgical Volume Is Associated with Lower THA Dislocation Rates

The presumed correlation between an increasing volume of health care procedures and an improvement in outcomes is sometimes referred to as the practice-makes-perfect effect. Growing interest in outcomes-based research has led to numerous papers examining this relationship for various surgical procedures, including total hip arthroplasty. The results of these studies have important implications for consumers, providers, and healthcare financers. Accordingly, we review the literature to date examining surgeon and hospital volume effects on hip arthroplasty outcomes, with a specific focus on the effects of volume on dislocation. A systemic review of the literature demonstrates a substantial positive association between surgical volumes and improvement in most THA outcomes, including dislocation; that is, increasing surgical volume is associated with lower dislocation rates. This correlation appears to be stronger and is more clearly established for surgeon volumes than it is for hospital volumes.

PRESIDENTIAL GUEST ADDRESS: The Swedish Hip Registry

The Swedish Hip Register was initiated in 1979. The mission of the register is to improve the outcome of THA. The hypothesis is that feedback of data stimulates participating clinics to reflect and improve. In addition to revision surgery, patient-based outcome measures and radiographic results are included to improve sensitivity. All patients who have a total hip arthroplasty answer a questionnaire preoperatively and again after 1, 6, and 10 years postoperatively. The questionnaire includes the Charnley classification, EQ-5D and visual analog scales concerning pain and overall satisfaction and is used by 31 of 81 units. Average costs for the procedure ($11,000) are obtained from a national database. The mean gain in the EQ-5D index after 1 year for 3900 patients was 0.37, giving a low cost of $3000 per quality adjusted life year. Patient satisfaction and pain amelioration generally was high. The national average 7-year survival (revision as endpoint), has improved from 93.5% (+/- 0.15) to 95.8 (+/- 0.15) between the two periods 1979 to 1991 and 1992 to 2003. National implant registers define the epidemiology of primary and revision surgery. In conjunction with individual subjective patient data and radiography they contribute to development of evidence-based THA surgery.

The Outcomes of Small-Incision Total Hip Arthroplasty Using Modifications of Existing Surgical Approaches

Total hip arthroplasty has evolved over the past few decades. Minimally invasive hip arthroplasty has been introduced to the orthopedic community, and it has stirred controversy with respect to the purported benefits over the conventional approaches. Studies done by the pioneers or by exprienced surgeons demonstrate that minimally invasive techniques can improve the immediate outcomes of total hip arthroplasty. Less blood loss, shorter hospitalization, and faster return to normal life are potential benefits of any minimally invasive surgery. However, the majority of those studies implement changes in the intraoperative and postoperative protcols that may independently affect the outcome of THA. The literature lacks proper prospective studies that compare conventional and minimally invasive total hip arthroplasty and the effect of different rehabilitation protocols on the outcome. Also, the results of different approaches for minimally invasive hip arthroplasty remain to be studied. The purpose of this report is to review the results of reported short-term outcomes and complications of small-incision total hip replacements performed with several modifications of existing surgical approaches.

Total Hip Arthroplasty After Failed Transtrochanteric Rotational Osteotomy for Avascular Necrosis of the Femoral Head

We compared the clinical and radiographic outcome of 15 hips converted to total hip arthroplasty after failed transtrochanteric rotational osteotomy (THA after TRO) for avascular necrosis of the femoral head (ANFH) with that of a matched control group of 16 hips with primary THA for ANFH. The operating time in THA after TRO was significantly longer than that in primary THA. Perioperative blood loss in THA after TRO was significantly more than that in primary THA. Postoperative complications were observed in 4 hips of THA after TRO. The Harris Hip Score, the stability of implants, and survival rates did not significantly differ in both groups. We conclude that TRO did not influence the outcome of secondary THA at short- and middle-term follow-up.

Primary Total Hip Arthroplasty After Acetabular Fracture*†

In most cases, when THA is performed after an acetabular fracture, it is done to manage secondary degenerative change or, possibly, osteonecrosis of the femoral head. Secondary complicating factors may be encountered during the THA. After initial nonsurgical treatment of an acetabular fracture, an occult or frank acetabular nonunion and malunion are not uncommon and may extend to the residual pelvic ring. After surgical treatment, intrusive hardware, heterotopic bone, dense scar tissue, ischemic muscle or bone, and occult infection are additional hazards that may be encountered. When acute sciatic nerve palsy, whether induced traumatically or iatrogenically, accompanies the initial acetabular injury, the palsy is likely to be exacerbated during a subsequent THA. A careful clinical and radiographic evaluation is needed, along with the formulation of a detailed surgical strategy. The need for specialized arthroplasty instruments, fixation devices, and autograft or, occasionally, allograft has to be identified. When heterotopic bone is evident, an extensile approach may be needed to allow adequate exposure for its complete removal. After a bone defect and/or a nonunion with displacement has been characterized, one or more strategies for obliteration of the defect are considered; these include the use of impaction grafting, a structural graft, a cup inserted with multiple screws, mesh, or a suitable ring or other fixation device. Evaluation of results has shown that, overall, the late outcome of THA after acetabular fracture is inferior to that of arthroplasty performed because of degenerative arthritis. Although open reduction and internal fixation of an acute acetabular fracture was previously hypothesized as an effective way to improve the anticipated late outcome of THA by the elimination of a large fracture gap or the prevention of a potential nonunion, current observations do not support that hypothesis. An initial open reduction may compromise the outcome of a subsequent THA by compromising the blood supply of the acetabulum and by initiating the formation of scar tissue, heterotopic bone, or an occult or frank infection. For a highly selected group of especially severe acetabular fractures, particularly those in elderly patients, THA appears to be a promising therapeutic alternative.

The direct lateral approach to the hip.

A direct lateral approach to the hip is described which allows adequate access for orientation of the implant, for the insertion ofthe cement and for the correction ofdiscrepancy in leg length. An anatomical observation was made that the gluteus medius muscle is inserted into the greater trochanter by a tendon and that the axis of the shaft of the femur lies anterior to the main bulk of the muscle which was left