Posterior Total Hip Arthroplasty Research Articles

To Stage or Not to Stage? Comparison of Patient-Reported Outcomes, Complications, and Discharge Disposition After Staged and Simultaneous Bilateral Posterior Total Hip Arthroplasty

BackgroundPatients who have bilateral hip arthritis can be treated with bilateral total hip arthroplasty (bTHA) in either a staged or simultaneous fashion. The goal of this study was to determine whether staged and simultaneous posterior bTHA patients differ in regard to (1) patient-reported outcome measures, (2) 90-day complication rates, and (3) discharge dispositions and cumulative lengths of stay. MethodsPatients who (1) underwent simultaneous bTHA or staged bTHA (within 12 months) using the posterior approach, and (2) completed preoperative and 1-year postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement surveys were included in the study. A total of 266 patients (87 simultaneous bTHA and 179 staged bTHA) were included. Chart review was performed to collect patient-level variables, postoperative complications, discharge dispositions, and lengths of stay. ResultsStaged bTHA patients had higher Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement, Lower Extremity Activity Scale, and Veterans RAND 12-Item Health Survey physical component scores compared to simultaneous bTHA patients at 6 weeks after surgery (P = .019, .006, and .008, respectively), but these differences did not meet the minimal clinically important difference threshold for any questionnaire. Simultaneous bTHA was associated with higher rate of periprosthetic fractures (P = .034) and discharge to a location other than home (P < .001). ConclusionsThere were statistically significant, but likely not clinically meaningful differences in patient-reported outcomes for staged and simultaneous bTHA patients at 6 weeks after surgery. Surgeons should be aware of the higher periprosthetic fracture risk and greater likelihood of discharge to a rehabilitation facility associated with simultaneous bTHA. Further research should aim to understand which patients may benefit most from simultaneous bTHA.

Dislocation Following Anterior and Posterior Total Hip Arthroplasty in the Setting of Spinal Deformity and Stiffness: Evolving Trends Using a High-Risk Protocol at a Single Tertiary Center

BackgroundPatients who have spinal stiffness and deformity are at the highest risk for dislocation after total hip arthroplasty (THA). Previous reports of this cohort are limited to antero-lateral and postero-lateral (PL) approaches. We investigated the dislocation rate after direct anterior (DA) and PL approach THA with a contemporary high-risk protocol to optimize stability. MethodsWe investigated patients undergoing THA who had preoperative biplanar imaging from January-December 2019. Patients were identified using radiographic criteria of spinal-stiffness (<10-degree change in sacral slope from standing to seated) and deformity (flatback deformity with >10-degree difference in pelvic incidence and lumbar lordosis). There were 367 patients identified (181 DA, 186 PL). The primary outcome was dislocation rate at 2-years postoperatively. Risk-factors for dislocation were evaluated using logistic regressions (significance level of 0.05). ResultsThere were 6 (1.6%) dislocations in the entire cohort, with low dislocation rates for both DA (0.6%) and PL-THA (2.7%). We observed increased utilization of dual mobility with larger outer head bearings (>38 mm) with PL-THA (34.4 versus 5.0%, P < .01) and conversely increased utilization of 32-mm femoral-heads with DA-THA (39.4 versus 7.0%, P < .001). Surgical approach (PL) was not a significant risk-factor for dislocation (odds ratio: 5.03, P = .15). Patients who had a history of lumbar-fusion had 8-times higher odds for dislocation (OR: 8.20, P = .020). ConclusionsTo the best of our knowledge, this is the largest series to date evaluating DA and PL-THA in the hip-spine 2B-group. Our results demonstrate lower dislocation rate than expected with either surgical approach using a high-risk protocol.

Total Hip Arthroplasty in Patients with Bilateral Upper-Limb Amelia: A Report of 2 Cases.

We report two patients, a 43-year-old man and a 26-year-old woman, with bilateral absence of the upper extremity and severe hip osteoarthritis. The involved hip was the dominant extremity for both patients. Total hip arthroplasty (THA) was performed using a posterior approach with dual-mobility implants. Both patients report satisfactory outcomes including the ability to perform the significant range of motion required for daily activities such as toe-to-head motion. In patients with extreme range of motion requirements such as those affected with bilateral upper-limb amelia, a posterior THA with a dual-mobility implant may be safely and successfully performed to treat disabling hip osteoarthritis.

DIRECT ANTERIOR APPROACH OR POSTERIOR APPROACH TOTAL HIP ARTHROPLASTY: IS THERE A DIFFERENCE IN LONG-TERM REVISION RATES AND TEN-YEAR PATIENT-REPORTED OUTCOME MEASURES?

The Posterior and Lateral approaches are most commonly used for Total Hip Arthroplasty (THA) in the United Kingdom (UK). Fewer than 5% of UK surgeons routinely use the Direct Anterior Approach (DAA). DAA THA is increasing, particularly among surgeons who have learned the technique during overseas fellowships. Whether DAA offers long-term clinical benefit is unclear.We undertook a retrospective analysis of prospectively collected 10-year, multi-surgeon, multi-centre implant surveillance study data for matched cohorts of patients whose operations were undertaken by either the DAA or posterior approach. All operations were undertaken using uncemented femoral and acetabular components. The implants were different for the two surgical approaches. We report the pre-operative, and post operative six-month, two-year, five-year and 10-year Oxford Hip Score (OHS) and 10-year revision rates.125 patients underwent DAA THA; these patients were matched against those undergoing the posterior approach through propensity score matching for age, gender and body mass index. The 10-year revision rate for DAA THA was 3.2% (4/125) and 2.4% (3/125) for posterior THA. The difference in revision rate was not statistically significant. Both DAA and Posterior THA pre-operative OHS were comparable at 19.85 and 19.12 respectively. At the six-month time point, there was an OHS improvement of 20.89 points for DAA and 18.82 points for Posterior THA and this was statistically significant (P-Value &lt;0.001). At the two, five and 10-year time-points the OHS and OHS improvement from the pre-operative review were comparable. At the 10-year time point post-op the OHS for DAA THA was 42.63, 42.10 for posterior THA and the mean improvement from pre-op to 10-years post op was 22.78 and 22.98 respectively. There was no statistical difference when comparing the OHS or the OHS mean improvements at the two, five and 10-year point.Whilst there was greater improvement and statistical significance during the initial six month time period, as time went on there was no statistically significant difference between the outcome measures or revision rates for the two approaches.

Comparison of continuous transmuscular quadratus lumborum block and continuous psoas compartment block for posterior total hip arthroplasty: A randomised controlled trial.

Analgesia for hip surgery involves cutaneous anaesthesia at the site of the skin incision and the anterior hip capsule. This study aimed to compare continuous ultrasound (US)-guided transmuscular quadratus lumborum block (TQLB) with psoas compartment block (PCB) for analgesia in patients undergoing total hip arthroplasty (THA) under general anaesthesia (GA). This randomised, observer-blinded trial included 18-70-year-old American Society of Anesthesiologists physical status I-III patients undergoing THA under GA with either US-guided continuous TQLB or PCB. Primary objectives included a visual analogue scale (VAS; 0-100 mm) at rest and mobilisation at 6 h postoperatively (analysed by intention to treat and per protocol) using a non-inferiority margin of 20 mm. Secondary objectives included VAS at other time points, 24-h fentanyl consumption (analysed using the Wilcoxon rank-sum test), sensory dermatomes anaesthetised, motor weakness 30 min after block, and haemodynamic response to skin incision (analysed using the Chi-squared or Fisher's exact test). A P value less than 0.05 was considered statistically significant. VAS (0-100 mm) score at 6 h on rest was 25.34 ± 14.25 and 27.3 ± 9.6, mean difference (MD) was 1.9 [-3.3, 7.1] and at movement was 35.1 ± 23.0 and 38.6 ± 17.0, MD was 3.5 [-5.2, 12.2], in the PCB (n = 29) and QLB (n = 30) groups, respectively (i.e. less than the non-inferiority margin). However, VAS (rest) at 1, 12, and 24 h postoperatively and median (IQR) 24-h fentanyl consumption was significantly higher in the QLB group (1212.5 [300-2345] μg] when compared to the PCB group (635 [100-1645] μg; P = 0.0004). Though statistically, continuous QLB was non-inferior to continuous PCB for pain at rest and mobilisation at 6-hours postoperatively, a higher 24-hour perioperative fentanyl consumption and VAS show that QLB was clinically inferior to PCB.

Early Recovery Outcomes in Patients Undergoing Contemporary Posterior Approach Total Hip Arthroplasty: Each Week Shows Progress.

Background: Little is known about patients' postoperative week-by-week progress after undergoing posterior approach total hip arthroplasty (THA) with regard to pain, function, return to work, and driving. Purpose: We sought to evaluate a large cohort of patients undergoing posterior approach THA with modified posterior hip precautions to better understand the trajectory of recovery. Methods: Patients at a single institution undergoing primary posterior approach THA by fellowship-trained arthroplasty surgeons were prospectively enrolled. Patient functional status and early rehabilitation recovery milestones were evaluated preoperatively and each week postoperatively for 6 weeks. Results: Of 312 patients who responded to weekly questionnaires, there were varying response rates per question. At 1 week after surgery, 15% (39/256) of respondents had returned to work, increasing to 57% (129/225) at week 6. At 6 weeks, 77% of patients (174/225) had returned to driving; 25% (56/225) were taking pain medication (including prescription opioids or nonsteroidal anti-inflammatory drugs); and 15% (34/225) were using assistive devices (down from 91%, 78%, 56%, 35%, and 27% at weeks 1, 2, 3, 4, and 5, respectively). Average postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Lower Extremity Functional Scale scores were significantly higher than preoperative scores. Respondents reported significantly less pain at each week postoperatively than the previous week. Conclusion: These findings suggest that there may be an expected pathway for recovery after posterior THA using perioperative pain protocols, modified postoperative precautions, and physical therapy protocols to improve patient outcomes after THA, with most patients returning to normal at 4 weeks. Defining the expected recovery timeline may help surgeons in counseling patients preoperatively and guiding their recovery.

Acetabular Total Hip Arthroplasty Revision: A Summary of Operative Factors, Outcomes, and Comparison of Approaches

BackgroundRevision total hip arthroplasty (THA) presents a greater risk to patients than primary THA, and surgical approach may impact outcomes. This study aimed to summarize acetabular revisions at our institution and to compare outcomes between direct anterior and posterior revision THA. MethodsA series of 379 acetabular revision THAs performed from January 2010 through August 2022 was retrospectively reviewed. Preoperative, perioperative, and postoperative factors were summarized for all revisions and compared between direct anterior and posterior revision THA. ResultsThe average time to acetabular revision THA was 10 years (range, 0.04 to 44.1), with mechanical failure (36.7%) and metallosis (25.6%) being the most prevalent reasons for revision. No differences in age, body mass index, or sex were noted between groups. Anterior revision patients had a significantly shorter length of stay (2.2 versus 3.2 days, P = .003) and rate of discharge to a skilled nursing facility (7.5 versus 25.2%, P = .008). In the 90-day postoperative period, 9.2% of patients returned to the emergency department (n = 35) and twelve patients (3.2%) experienced a dislocation. There were 13.2% (n = 50) of patients having a rerevision during the follow-up period with a significant difference between anterior and posterior approaches (3.8 versus 14.7%, respectively, P = .049). ConclusionThis study provides some evidence that the anterior approach may be protective against skilled nursing facility discharge and rerevision and contributes to decreased lengths of stay. We recommend surgeons select the surgical approach for revision THA based on clinical preferences and patient factors.

Single-level Lumbar Fusion Versus Total Joint Arthroplasty: A Comparison of 1-year Outcomes.

Primary hip and knee arthroplasty represent two of the most successful orthopaedic surgical interventions in the past century. Similarly, lumbar fusion (LF) remains a valuable, evidence-based option to relieve pain and disability related to spinal degenerative conditions. This study evaluates the relative improvements in 1-year health-related quality of life (HRQOL) measures among patients undergoing primary single-level LF, primary total hip arthroplasty (THA), and primary total knee arthroplasty (TKA). Patients older than 18 years who underwent primary single-level posterior LF (posterolateral decompression and fusion with or without transforaminal lumbar interbody fusion, involving any single lumbar level), TKA, and THA at a single academic institution were retrospectively identified. Patient demographics and surgical characteristics were collected. HRQOL measures were collected preoperatively and at 1-year postoperative time point including Short-Form 12 Physical Component Score (PCS) and Mental Component Score (MCS) along with subspecialty-specific outcomes. A total of 2,563 patients were included (346 LF, 1,035 TKA, and 1,182 THA). Change in MCS-12 and PCS-12 after LF did not vary markedly by preoperative diagnosis. LF patients had a significantly lower preoperative MCS-12 (LF: 50.8, TKA: 53.9, THA: 52.9, P < 0.001), postoperative MCS-12 (LF: 52.5, TKA: 54.8, THA: 54.5, P < 0.001), postoperative PCS-12 (LF: 40.1, TKA: 44.0, THA: 43.9, P < 0.001), ΔPCS-12 (LF: 7.9, TKA: 10.8, THA: 11.9, P < 0.001), and PCS-12 recovery ratio (LF: 10.7%, TKA: 15.1%, THA 16.6%, P < 0.001) compared with TKA and THA patients. In regression analysis, both TKA and LF were found to be independently associated with a smaller ΔPCS-12 improvement (TKA: β = -1.36, P = 0.009; LF: β = -4.74, P < 0.001) compared with THA. TKA (β = -1.42, P = 0.003) was also independently associated with a smaller ΔMCS-12 improvement compared with THA. Patients undergoing single-level LF, TKA, and THA demonstrate notable improvements in HRQOL outcomes at 1 year postoperatively compared with preoperative baseline scores. The greatest improvements were found among THA patients, followed subsequently by TKA and LF patients. Both LF and TKA were independently associated with markedly less improvement in physical disability at 1 year postoperatively compared with THA. Retrospective Cohort Study.

Intraoperative Technology Use Improves Accuracy of Functional Safe Zone Targeting in Total Hip Arthroplasty.

Targets of acetabular inclination and anteversion have been suggested based on a patient's spinopelvic mobility. Current methods in total hip arthroplasty (THA) include manual instrumentation, computer-assisted navigation, and robotic-assisted surgery. This study aims to compare the accuracy of these 3 methods in targeting the functional safe zone. This is a prospective multicenter study including a series of 251 consecutive primary posterior THA patients from April 2019 to January 2021. Preoperative lateral standing and sitting spinopelvic radiographs were obtained. Each patient was classified using the Hip-Spine Classification. A functional safe zone plan was determined. Surgeons used their preferred method (manual instrumentation, computer-assisted, or robotic-assisted). Postoperative anteversion and inclination was measured and compared to the preoperative plan. Mean differences between preoperative and postoperative values were calculated. Welch's t-test was used to assess significant between-group differences with P < .05 considered significant. Of the 249 patients, there were 63 manual instrumentation, 68 computer-assisted navigation, and 118 robotic-assisted surgery. Robotic-assisted surgery (rTHA) was significantly more accurate in targeting anteversion (1±2) compared to manual instrumentation (mTHA; 7±6, P < .001) and computer-assisted navigation (cTHA; 6±6, P < .001). rTHA was also significantly more accurate in targeting inclination (1±1) compared to mTHA (8±7, P < .001) and cTHA (6±7, P < .001). Although cTHA had greater accuracy in targeting both inclination and anteversion compared to mTHA, these differences were not statistically significant. Robotic-assisted surgery was more accurate than both computer-assisted navigation and manual instrumentation in targeting the functional safe zone in primary THA. Further research is needed to evaluate the effect of improved accuracy on dislocation rates.

Does Total Hip Arthroplasty Affect Spinopelvic and Spinal Alignment?: A Prospective Observational Investigation.

A prospective observational study, level of evidence 3. The study with patients undergoing unilateral total hip arthroplasty (THA) aimed to evaluate the following hypotheses: (1) the spinal sagittal and coronal alignment alters due to THA, (2) the spinopelvic parameter changes after THA, (3) the spinopelvic alignment differs between sagittal balanced and imbalanced patients. Surgical correction of spinal sagittal misalignment affects the spinopelvic alignment and pelvic tilt. It is not yet known to what extent THA affects spinopelvic, spinal sagittal, and coronal alignment. A total of 153 patients undergoing THA were assessed with biplanar stereoradiography in standing position preoperatively and postoperatively. Two independent investigators examined C7-sagittal vertical axis (C7-SVA), pelvic incidence-lumbar lordosis (PI-LL) mismatch, lumbar lordosis (LL), C7-central sacral vertical line, pelvic oblique angle lumbosacral, intra-pelvic oblique angle, pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), anterior plane pelvic tilt (APPT), and pelvic femoral angle (PFA). An analysis of the sagittal misaligned subgroups of C7-SVA and PI-LL on the influence of the spinopelvic alignment was performed. A significant difference in spinopelvic parameters was detected in the preoperative to postoperative comparison (SS, PT, APPT, and PFA; P &lt;0.000) ( d =-0.394; d =0.609; d =-0.481; d =0.431). The coronal alignment and pelvic obliquity revealed no significant differences. The misaligned groups (C7-SVA; PI-LL) demonstrated significant increases in PI and PT and decreased in LL compared with the groups with normal sagittal alignment. Preoperatively, 66/153 (C7-SVA) and 46/153 (PI-LL) of the THA patients presented sagittal misalignment, respectively. The results suggest an effect of THA on sagittal spinal and spinopelvic alignment, with a significant reduction of PT postoperatively and no effect on coronal alignment. Particularly striking are the significant differences in the misaligned groups, which may be classified as risk population and potentially can contribute biomechanically to a higher risk of posterior impingement and anterior THA dislocation. The substantial proportion of sagittal misaligned patients in the THA collective illustrates the crucial need for interdisciplinary collaboration.

Patients Achieving 90°/45°/0° Intraoperative Stability Do Not Require Hip Precautions Following Posterior Approach Total Hip Arthroplasty: A Prospective Randomized Study

BackgroundHip precautions are traditionally employed after posterior total hip arthroplasty (THA). The primary purpose was to investigate the necessity of hip precautions after posterior approach THA. We hypothesized that eliminating precautions in patients that achieved appropriate intraoperative stability would not increase the dislocation rate. MethodsRandomized controlled trial of 346 consecutive eligible patients undergoing primary THA with a mean follow-up of 2.3 years (range 11 months to 3.7 years). Exclusion criteria: lumbar fusion, scoliosis, abductor insufficiency, inability to achieve intraoperative stability with combined 90° flexion and 45° internal rotation in 0° adduction. Fisher's exact test was used to compare dislocation rates between the hip precaution (HP) control group and no hip precaution (NP) study group. In addition, Mann–Whitney U test was used to compare differences in HOOS JR scores at 2, 6, 12 weeks between groups. ResultsThe dislocation rate was not increased in the NP (0/172: 0%) group compared to the HP group 4/174 (2.29%) (P = .418). All dislocations occurred in the precautions group, two of which required revision. There were no differences in mean HOOS Jr. scores at any 2, 6, or 12 weeks (P > .05 at all timepoints) (secondary outcome). ConclusionEliminating hip precautions in patients undergoing posterior approach THA that achieve 90°/45°/0° intraoperative stability does not increase the rate of dislocation. In fact, every dislocation occurred in patients receiving hip precautions. Short-term patient-reported outcome measures were not affected by hip precautions. Surgeons may discontinue the use of hip precautions as the standard of care in patients achieving 90°/45°/0° stability.

Stabilometric assessments of two rehabilitation protocols on postural parameters after posterior total hip arthroplasty: A prospective randomized comparative study

IntroductionAfter total hip arthroplasty (THA), patients continue to have muscular, functional and postural deficits. The literature seems to support the use of postoperative rehabilitation, especially self-directed programs. However, there is no set protocol for the management of postural disorders. Therefore, the purpose of this study was to compare postural parameters of a group of patients who underwent posterior THA followed by 2 different types of rehabilitation (stabilometric platform (SP) and home-based self-directed protocols) with a control group of operated patients who did not undergo rehabilitation and a control group of age-matched asymptomatic subjects. HypothesisWe hypothesized that rehabilitation would normalize the stabilometric parameters. Patients and MethodsA total of 67 subjects were enrolled in this study (mean age 67.85±1.22years) and divided into 4 groups. Forty-one of these subjects had undergone a posterior THA were randomly assigned between D10 and D21 to one of the following 3 groups: no rehabilitation control group (THACG=14), supervised rehabilitation with a stabilometric platform group (RSPG=16), and a self-directed home-based rehabilitation group (SDHRG=11). The 4th group was a control group made up of 26 age-matched asymptomatic nonoperated subjects (CG55-80). These rehabilitation protocols lasted 3weeks. At the end of the 3weeks, the groups performed the same stabilometric single leg and double leg stance tests (considering lower limb dominance) on an SP. ResultsNo significant differences were observed between groups in the bipedal stance, except between the CG55-80 and the THACG, where a higher energy expenditure was observed in the THACG during the static stance with eyes open (EO) and eyes closed (EC): increase in the path length (Plength) covered by the center of pressure (COP) (EO: p=01; EC: p=03) and the average velocity (Vavg) of the COP (EO: p=01; EC: p=03). These differences were not observed in the SDHRG and RSPG whether they were compared with one another or with both control groups. In the unipedal stance, subjects in the RSPG and SDHRG showed greater muscle activity in the anterior and posterior chains and hip abductors, and used less energy to maintain the stance than those in the CG55-80, regardless of lower limb dominance: decrease in the mediolateral range of COP displacement (Xrange) (hip abductor muscles) (p=02) and anteroposterior range of COP displacement (Yrange) (anterior and posterior chains) (p=3.49.10−3), 95% confidence ellipse area (Earea) of COP data (p=1.47.10−3), Plength (p=04) and Vavg (p=04). The RSPG had a smaller Earea than the SDHRG (p=04), demonstrating a better postural stability during the unipedal stance performed on the dominant operated leg. DiscussionOur results were consistent with the literature on the benefits of rehabilitation after THA, thus confirming our hypothesis that rehabilitation normalized stabilometric parameters between D31-D45, depending on the subjects. These results provide new information regarding rehabilitation techniques to be implemented postoperatively after a THA. A home-based self-directed rehabilitation program is just as effective as an SP program in managing postural disorders. Level of EvidenceII; randomized controlled trial with low statistical power.

Can robotic technology mitigate the learning curve of total hip arthroplasty?

AimsTraditionally, acetabular component insertion during total hip arthroplasty (THA) is visually assisted in the posterior approach and fluoroscopically assisted in the anterior approach. The present study examined the accuracy of a new surgeon during anterior (NSA) and posterior (NSP) THA using robotic arm-assisted technology compared to two experienced surgeons using traditional methods.MethodsProspectively collected data was reviewed for 120 patients at two institutions. Data were collected on the first 30 anterior approach and the first 30 posterior approach surgeries performed by a newly graduated arthroplasty surgeon (all using robotic arm-assisted technology) and was compared to standard THA by an experienced anterior (SSA) and posterior surgeon (SSP). Acetabular component inclination, version, and leg length were calculated postoperatively and differences calculated based on postoperative film measurement.ResultsDemographic data were similar between groups with the exception of BMI being lower in the NSA group (27.98 vs 25.2; p = 0.005). Operating time and total time in operating room (TTOR) was lower in the SSA (p < 0.001) and TTOR was higher in the NSP group (p = 0.014). Planned versus postoperative leg length discrepancy were similar among both anterior and posterior surgeries (p > 0.104). Planned versus postoperative abduction and anteversion were similar among the NSA and SSA (p > 0.425), whereas planned versus postoperative abduction and anteversion were lower in the NSP (p < 0.001). Outliers > 10 mm from planned leg length were present in one case of the SSP and NSP, with none in the anterior groups. There were no outliers > 10° in anterior or posterior for abduction in all surgeons. The SSP had six outliers > 10° in anteversion while the NSP had none (p = 0.004); the SSA had no outliers for anteversion while the NSA had one (p = 0.500).ConclusionRobotic arm-assisted technology allowed a newly trained surgeon to produce similarly accurate results and outcomes as experienced surgeons in anterior and posterior hip arthroplasty.Cite this article: Bone Jt Open 2021;2(6):365–370.

Comparison of postoperative effectiveness of less invasive short external rotator sparing approach versus standard posterior approach for total hip arthroplasty

BackgroundMost of the studies assessing the corrective posterior total hip arthroplasty (THA) mainly focused on the mini-incision approach. Studies exploring the short external rotator sparing approach are rare. Therefore, this study aimed to compare the effectiveness of standard posterior approach and short external rotator sparing approach.MethodsThis prospective observational study included 126 patients who underwent THA in June 2017–June 2018. Patients were assigned to standard (standard posterior approach) and corrective (short external rotator sparing approach) groups based on the surgical method. Surgical data were recorded postoperatively. Postoperative hip joint recovery was assessed using the times to ambulation and independent stair use, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Harris score, and Oxford hip score (OHS) at 2 and 8 postoperative weeks. The visual analog scale (VAS) was used for postoperative pain assessment.ResultsPostoperative changes of creatine kinase (CK), myoglobin, CRP, and prosthesis position were similar in both groups (P > 0.05). However, intraoperative blood loss (P < 0.001) and postoperative 6-h drainage volume (P = 0.03), hospital stay, blood transfusion rate, and times to ambulation and independent stair use were significantly reduced in the corrective group. Postoperatively, Oxford, and WOMAC scores significantly decreased in both groups. After surgery, the VAS score was more overtly decreased in the corrective group compared with the standard group.ConclusionsThis study concluded that the less invasive short external rotator sparing approach for THA caused less damage, reducing perioperative blood loss, shortening functional recovery time, maintaining prosthesis stability, and improving postoperative pain.

The Effect of Functional Pelvic Tilt on the Three-Dimensional Acetabular Cup Orientation in Total Hip Arthroplasty Dislocations

BackgroundAnterior and posterior pelvic tilt appears to play a role in total hip arthroplasty (THA) stability. When changing from the standing to the sitting position, the pelvis typically rotates posteriorly while the hips flex and this affects the femoro-acetabular positions. This case-control study compares changes in 3-D acetabular cup orientation during functional pelvic tilt between posterior THA dislocations vs stable THAs. MethodsStanding and sitting 3-D cup orientation was compared between fifteen posterior dislocations vs 233 prospectively followed stable THAs. 3-D cup orientation was calculated using previously validated trigonometric algorithms on biplanar radiographs. Those algorithms combine the angles in the three anatomical planes (coronal inclination, transverse version, and sagittal ante-inclination) in the standing position with the change in sagittal pelvic tilt from standing to sitting to calculate the 3-D orientation in the sitting position. ResultsThe standing cup orientation of the dislocated THAs was only characterized by a lower coronal inclination (P = .039). Compared with the controls, from standing to sitting, they showed less posterior pelvic tilt (P < .001). This led to a significant lower coronal inclination (P < .001) and sagittal ante-inclination (P < .001) in the sitting position but similar transverse version (P = .366). ConclusionsComparing posterior THA dislocations to stable THAs, there is a lower increase of all three orientation angles from standing to sitting. This leads to a decreased sitting coronal inclination and sagittal ante-inclination which may lead to an increased risk of impingement ensued by THA instability. By contrast, the transverse version was not significantly different in both positions. This confirms the importance of biplanar data on functional cup orientation. Level of EvidenceDiagnostic, Level III.

Utility of Intraoperative Fluoroscopic Positioning of Total Hip Arthroplasty Components Using a Posterior and Direct Anterior Approach.

Positioning of implant components for total hip arthroplasty (THA) is important for polyethylene liner wear, prosthesis joint stability, and range of motion. The introduction of fluoroscopy for the direct anterior approach has been shown to improve physician accuracy for component positioning. Few studies compare the use of intraoperative fluoroscopy for THA component positioning in posterior THA. The purpose of this project is to retrospectively evaluate the effect of intraoperative fluoroscopy on component positioning for THA using posterior and direct anterior approach (DAA). A retrospective review of postoperative weight-bearing X-ray films of THAs was performed over a 2-year period where a single fellowship-trained total joint surgeon introduced direct anterior approach into his practice while expanding the intraoperative use of fluoroscopy for all THA procedures, regardless of approach. Component position was evaluated through radiographic measurement of acetabular cup inclination (goal of 40 degrees), limb length discrepancy (goal of 0 mm), and femoral component offset difference (goal of 0 mm). Radiographic analysis was performed by two independent providers. Statistical analysis was performed using Student's t-tests. A total of 107 patients with an average age of 62 years were identified during the 2-year period surrounding the THA practice change, adding fluoroscopy to posterior and DAA THA. Three cohorts were identified: cohort A: 44 patients who underwent posterior THAs without the use of intraoperative fluoroscopy, cohort B: 35 patients who underwent direct anterior approach THAs with the use of intraoperative fluoroscopy, and cohort C: 18 patients who underwent posterior THAs with the use of intraoperative fluoroscopy. The use of intraoperative fluoroscopy for the posterior approach versus unguided posterior approach increased accuracy of both cup inclination (44 degrees vs 50 degrees, P < .05) and femoral offset (4 mm vs 7 mm, P < .05). A comparison of DAA with fluoroscopy versus posterior approach without fluoroscopy showed improvement in cup inclination (48 degrees vs 50 degrees, P < .05). Fluoroscopy with posterior approach versus fluoroscopy with DAA was found to have improved cup inclination (44 degrees vs 48 degrees, P < .05). Intraoperative use of fluoroscopy can improve component positioning for posterior THA.

Total Hip Arthroplasty in Patients Younger than 35 Is Effective Regardless of Surgical Approach

AbstractDespite the increasing frequency of younger patients undergoing total hip arthroplasty (THA), very few, if any, studies report on postoperative outcomes that specifically compare the two most commonly used approaches in this age group. The purpose of our study is to assess whether surgical approach affects postoperative outcomes in THA patients younger than 35 years. A retrospective analysis of 115 patients younger than 35 years that underwent primary unilateral THA between January 2013 and April 2018 was conducted. Patients were divided into two cohorts: (1) patients that underwent THA utilizing the anterior approach and (2) patients that underwent THA utilizing the posterior approach. Subanalysis controlling for surgical case complexity and use of robotic assistance was performed. Radiographic analysis included measurement of perioperative leg length discrepancies. Of the total 115 patients, 37 were in the anterior THA cohort, and 78 were in the posterior THA cohort. All baseline patient characteristics were similar among both cohorts. Patients in the anterior THA cohort had shorter mean operative times (95 vs. 121 minutes; p &lt; 0.01) and shorter mean hospital length of stay or LOS (1.9 vs. 2.8 days; p &lt; 0.01). Leg length discrepancies, dislocation, revision, and all-cause postoperative complication rates were similar between both cohorts. When excluding complex cases and use of robotic assistance (anterior n = 36, posterior n = 39), there was no difference in operative time, LOS, or postoperative outcomes. Our study suggests that surgically complex patients were more likely to undergo posterior rather than anterior THA. When controlling for surgical complexity and use of robotic assistance, no difference between approach with respect to operative time, hospital LOS, dislocation, revision, and all-cause postoperative surgical complication rates in THA recipients under 35 years of age was found. The results suggest that the anterior and posterior approaches can be equally effective for the majority of young THA patients.

Effect of subarachnoid anesthesia combined with propofol target-controlled infusion on blood loss and transfusion for posterior total hip arthroplasty in elderly patients.

Intravertebral and general anesthesia (GA) are two main anesthesia approaches but both have defects. This study was aimed to evaluate the effect of subarachnoid anesthesia combined with propofol target-controlled infusion (TCI) on blood loss and transfusion for total hip arthroplasty (THA) in elderly patients in comparison with combined spinal-epidural anesthesia (CSEA) or GA. Totally, 240 patients (aged ≥65 years, American Society of Anesthesiologists [ASA] I-III) scheduled for posterior THA were enrolled from September 1st, 2017 to March 1st, 2018. All cases were randomly divided into three groups to receive CSEA (group C, n = 80), GA (group G, n = 80), or subarachnoid anesthesia and propofol TCI (group T, n = 80), respectively. Primary outcomes measured were intra-operative blood loss, autologous and allogeneic blood transfusion, mean arterial pressure at different time points, length of stay in post-anesthesia care unit (PACU), length of hospital stay, and patient satisfaction degree. Furthermore, post-operative pain scores and complications were also observed. The difference of quantitative index between groups were analyzed by one-way analysis of variance, repeated measurement generalized linear model, Student-Newman-Keuls test or rank-sum test, while ratio index was analyzed by Chi-square test or Fisher exact test. Basic characteristics were comparable among the three groups. Intra-operative blood loss in group T (331.53 ± 64.33 mL) and group G (308.03 ± 64.90 mL) were significantly less than group C (455.40 ± 120.48 mL, F = 65.80, P < 0.001). Similarly, the autologous transfusion of group T (130.99 ± 30.36 mL) and group G (124.09 ± 24.34 mL) were also markedly less than group C (178.31 ± 48.68 mL, F = 52.99, P < 0.001). The allogenetic blood transfusion of group C (0 [0, 100.00]) was also significantly larger than group T (0) and group G (0) (Z = 2.47, P = 0.047). Except for the baseline, there were significant differences in mean arterial blood pressures before operation (F = 496.84, P < 0.001), 10-min after the beginning of operation (F = 351.43, P < 0.001), 30-min after the beginning of operation (F = 559.89, P < 0.001), 50-min after the beginning of operation (F = 374.74, P < 0.001), and at the end of operation (F = 26.14, P < 0.001) among the three groups. Length of stay in PACU of group T (9.41 ± 1.19 min) was comparable with group C (8.83 ± 1.26 min), and both were significantly shorter than group G (16.55 ± 3.10 min, F = 352.50, P < 0.001). There were no significant differences among the three groups in terms of length of hospitalization and post-operative visual analog scale scores. Patient satisfaction degree of group T (77/80) was significantly higher than group C (66/80, χ = 7.96, P = 0.004) and G (69/80, χ = 5.01, P = 0.025). One patient complained of post-dural puncture headache and two complained of low back pain in group C, while none in group T. Incidence of post-operative nausea and vomiting in group G (10/80) was significantly higher than group T (3/80, χ = 4.10, P = 0.043) and group C (2/80, χ = 5.76, P = 0.016). No deep vein thrombosis or delayed post-operative functional exercise was detected. Single subarachnoid anesthesia combined with propofol TCI seems to perform better than CSEA and GA for posterior THA in elderly patients, with less blood loss and peri-operative transfusion, higher patient satisfaction degree and fewer complications. chictr.org.cn: ChiCTR-IPR-17013461; http://www.chictr.org.cn/showproj.aspx?proj=23024.

The Influence of Lateral and Posterior Total Hip Arthroplasty Approaches on Muscle Activation and Joint Mechanics During Gait

BackgroundLateral and posterior total hip arthroplasty (THA) approaches disrupt muscle function, which could impact gait. The objectives of this study were to compare muscle activation and joint mechanics during gait, and isometric strength between participants after lateral and posterior THA approaches and healthy adults. MethodsParticipants 1 year post-THA from either lateral (n = 21) or posterior (n = 21) approaches, and healthy adults (n = 21) ambulated at self-selected speeds. Surface electromyography, optical motion capture, and force plates measured muscle activation and joint mechanics during gait. A dynamometer measured isometric torque. Gait characteristics and isometric torque were compared using analysis of variance and effect sizes (d). ResultsLateral THA group had higher gluteus medius amplitudes during gait compared to the healthy group (P < .01, d = −0.97). Posterior THA group had higher gluteus maximus amplitudes during loading response (P = .02, d = −0.94) and higher hamstring amplitudes during midstance (P = .02, d = 0.45-1.31) than the healthy group. Both THA groups had decreased hip flexion and adduction angle excursions during gait (d = 0.89-1.14), but increased medial rotation angle excursions (d = −1.06 to −0.91), compared to the healthy group. Lateral THA group had lower isometric hip abduction torque than the healthy group (P = .03, d = 0.74). There was no pelvic drop in the THA groups. ConclusionThere were few differences in gait and isometric torque between lateral and posterior THA groups. The elevated muscle activation amplitudes in the lateral and posterior THA groups compared to healthy adults were likely due to muscle weakness. Despite these findings, there was no evidence of pelvic drop.

Safely Implementing the Direct Anterior Total Hip Arthroplasty: A Methodological Approach to Minimizing the Learning Curve

Orthopaedic surgeons often cite concern for a learning curve as a barrier to adopting the direct anterior approach (DAA) for total hip arthroplasty (THA) while transitioning from other approaches. Studies both assessing and describing a practical approach and strategy to safely accomplish this transition, as well as the effect on clinical outcomes, are not well described. This prospective study compares a single surgeon's operative results and complications for the first consecutive 100 direct anterior THA to the last 100 consecutive posterior THA after 7 years in practice. The regimented and disciplined learning strategy used to implement the DAA is detailed in this study. The data were analyzed using univariate and multivariate regression models. Univariate analyses identified significant differences in sex, age, Asian race, and diagnostic cause for THA between the two cohorts. Multivariate analyses controlled for these differences and showed that relative to posterior THA, direct anterior THA cases were associated with 7-minute longer procedures (P = 0.002) and lengths of stay that were 0.7 days fewer (P = 0.013). No significant differences were present in the estimated blood loss, and importantly, no significant differences in death or surgical complication rates between cohorts. This study suggests that the DAA for THA can be safely implemented without the increased and adverse risk to the patient when a structured learning process is maintained and meticulously performed.