Primary Total Hip Arthroplasty Procedures Research Articles

Trends in Gender Diversity Among Total Hip Arthroplasty Surgeons.

A pronounced gender imbalance is evident among orthopaedic surgeons. In the field of arthroplasty, there exists a dearth of comprehensive data regarding gender representation. This study aimed to analyze the gender diversity, or lack thereof, within the field of total hip arthroplasty (THA). In addition, this study used literature review to identify possible reasons for the gender disparity among THA surgeons and identify the best next steps to promote gender equity within orthopaedics. A retrospective analysis was conducted using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set to quantify orthopaedic surgeons who performed primary THA procedures from 2013 to 2020. To assess trends in the number of hip surgeons by sex and the evolving female-to-male ratio, two-sided correlated Mann-Kendall tests were conducted. Overall, 3,853 to 4,550 surgeons billed for primary THA annually. Of this number, an average of 1.7% was female. The mean number of services billed for by male surgeons was 31.62 ± 24.78 per year and by female surgeons was 26.43 ± 19.49 per year. Trend analysis of female-to-male ratio demonstrated an increasing trend of statistical significance (P = 0.009). The average number of procedures by female surgeons annually remained stable throughout the study, whereas there was a steady increase in that for male surgeons. Results showed a notable and sustained upward trajectory from 2013 to 2020 in the number of female surgeons billing for THA along with the female-to-male ratio. However, female surgeons constitute a mere 2% of surgeons engaging in primary THA billing. Furthermore, the annual average number of THAs conducted by female surgeons exhibited constancy, whereas there was a gradual increase in the median number of annual procedures performed by their male counterparts. Future studies should aim to identify and resolve specific barriers prohibiting female medical students from pursuing and obtaining a career as an orthopaedic THA surgeon. Retrospective analysis using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set.

Oral Postoperative Antibiotic Prophylaxis for Outpatient Total Hip and Knee Arthroplasty: Describing Current Practices

BackgroundDespite an increase in outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA), large-scale data are lacking on current practice for antibiotic prophylaxis prescribing. We aimed to describe current oral antibiotic prophylaxis practices nationally for outpatient THA and TKA. MethodsThis nationwide retrospective cohort study included primary outpatient THA or TKA procedures in patients aged 18 to 64 years from 2018 to 2021 using a national claims database. Oral antibiotic prescriptions filled perioperatively (defined as 5 days before to 3 days after surgery) were extracted; these were categorized and assumed to represent postoperative prophylaxis. Multivariable logistic regression measured associations between patient and surgery characteristics and perioperative oral antibiotic prophylaxis. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) are reported. ResultsOral antibiotic prescriptions were filled in 16.5% of 73,015 outpatient THA and TKA (18.4% of 24,857 THAs, 15.5% of 48,158 TKAs) procedures. Prescriptions were most often for cephalosporins (74.3%), with cephalexin (52.8%), and cefadroxil (19.1%) being the most common. Non-cephalosporin antibiotics prescribed were mainly clindamycin (6.8%), sulfamethoxazole-trimethoprim (6.7%), and doxycycline (6.2%). The odds of receiving oral antibiotic prophylaxis were higher for THA compared to TKA (OR 1.13, 95% CI 1.09 to 1.18, P < .001) and in the presence of obesity, diabetes, and autoimmune conditions (OR 1.08 to 1.13, P < .001 to .01). Ambulatory surgery center procedures also had significantly increased odds of prophylaxis compared to hospital-based outpatient surgeries (OR 2.62, 95% CI 2.51 to 2.73, P < .001). Additionally, regional and time-based variations were noted. ConclusionsPerioperative oral antibiotic prophylaxis prescriptions were filled in only 16.5% of outpatient THA and TKA cases, with variation in the type of antibiotic prescribed. The receipt of any prophylaxis and specific medications was associated with demographic, clinical, and procedure-related characteristics. Follow-up research will evaluate associations with infection risk reduction.

Major complications after total hip arthroplasty with the direct anterior approach at a high-volume Ontario tertiary care centre.

The rate of major surgical complications for high-volume orthopedic surgeons using the direct anterior approach (DAA) in Ontario, Canada, is not known. The purpose of this study was to investigate the rate of major surgical complications after total hip arthroplasty (THA) using DAA performed by experienced orthopedic surgeons at a high-volume tertiary care centre in Ontario. We conducted a retrospective cohort review of primary THA through DAA performed by 2 experienced fellowship-trained surgeons at an academic hospital in London, Ontario, between Jan. 1, 2012, and May 1, 2019. We excluded the first 100 cases to allow for surgeon learning curves. We recorded major surgical complications (intraoperative events, postoperative periprosthetic fractures, dislocation requiring closed or open reduction, implant failure [aseptic loosening or subsidence], early (< 6 wk) deep wound infection requiring irrigation and débridement, late (≥ 6 wk) deep wound infection requiring irrigation and débridement, and wound complications [wound dehiscence, stitch abscess, erythema, hematoma or seroma]) within 1 year of THA. A total of 875 primary DAA THA procedures were included. The rates of surgical complications were 0.9% for intraoperative events, 1.5% for postoperative periprosthetic fractures, 0.8% for implant failure, 0.7% for early deep wound infection, 0.1% for late deep wound infection and 3.2% for wound complications; there were no cases of dislocation. The rate of revision for implant failure within 1 year was 0.1%. Male sex was associated with a greater risk of implant failure (p = 0.01), and having a higher body mass index was associated with both increased rates of infection (p < 0.01) and having a wound complication (p < 0.01). Intraoperative events, postoperative periprosthetic fractures, implant failure, deep wound infection and wound complications accounted for the major surgical complications within 1 year of THA through DAA. The low revision rate suggests that DAA is a safe approach for THA.

Increased Rates of Late Periprosthetic Fractures in Larger Hydroxyapatite-Coated Cementless Stems: Are Collared Stems a Better Alternative for Total Hip Arthroplasty?

BackgroundCementless hip stems are widely used for total hip arthroplasty (THA) and have demonstrated excellent survivorship. This study aimed to investigate the effects of stem size and calcar collars on rates of revision due to periprosthetic fracture. MethodsAll primary THA procedures recorded by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from September 1999 to December 2021 for a diagnosis of osteoarthritis using a single cementless hip stem with modern bearings were included. The primary outcome measure was revision due to periprosthetic fracture. Stems were divided into 2 groups for comparison, large (size 14 to 20) and small-medium (6 to 13). A subanalysis was performed for collared stems. A total of 59,518 primary THA procedures were included. ResultsThe cumulative percent revision for periprosthetic fracture was significantly higher for large stems compared to small-medium stems (hazard ratio [HR] = 1.57 [95% confidence interval {CI} 1.18, 2.09] P = .002). Furthermore, collared stems had significantly lower revision rates due to late periprosthetic fracture compared to collarless variants (2 week + HR = 4.55 [95% CI 3.23, 6.42], P < .001). Large collarless stems were found to have greater revision rates due to fracture compared to small-medium collarless stems (HR = 1.55 [95% CI 1.13, 2.12] P = .006), but no difference was found between collared groups (HR = 1.37 [95% CI 0.68, 2.78] P = .382). ConclusionLarge cementless hip stems have a higher rate of revision due to periprosthetic fracture compared to small-medium stems. Using a collared stem reduces the rate of periprosthetic fracture.

MANAGING THE COST OF ADVANCING TECHNOLOGIES

Advances in total hip and knee replacement technologies have heretofore been largely driven by corporate marketing hype with each seeming advancement accompanied by a cost increase often out in front of peer-reviewed reports documenting their efficacy or not.As example, consider the growing use of ceramic femoral heads in primary total hip arthroplasty (THA). The question to consider is “Can an upcharge of $350 for a ceramic femoral head in primary THA be justified?” The answer to this question lies in an appreciation of whether the technology modifies the potential for costly revision arthroplasty procedures.Peer-Reviewed Laboratory &amp; Clinical Review - According to the 2022 Australian National Joint Replacement Registry, the four leading causes of primary THA failure requiring revision are: 1.) infection, 2.) dislocation/instability, 3.) periprosthetic fracture and 4.) loosening, which constitute 87.5% of the reported reasons for revision.Focusing on these failure modes, hip simulator findings report that ceramic femoral heads dramatically reduce wear debris generation, decreasing the potential for osteolytic response leading to loosening. Further, ceramic materials enable the utilization of larger head sizes, avoiding the potential for dislocation. The overall mid- to long-term survival rate reported in the peer-reviewed, clinical literature for these bearings has exceeded 95% with virtually no osteolysis.Also, could bearing surface choice influence periprosthetic joint infection (PJI)? A study on a total of more than 10,500 primary THA procedures reported a confirmed PJI incidence of 2.4% for cobalt-chrome and 1.6% for ceramic femoral heads, suggesting that the employ of a ceramic bearing surface may also play a role in decreasing the potential for infection.Review of the clinical data available for ceramic bearings justifies that it is better to “pay me now than to pay orders of magnitude later”, if in fact a revision THA can be avoided, significantly reducing the overall financial burden to the healthcare system.

How Sterile Are Our Operating Rooms? A Comparison of Air Quality During Primary TKA and THA

Introduction: Airborne Biologic Particles (ABPs) are a potential risk factor for infection following total joint arthroplasty. Factors such as temperature and humidity may affect the number of ABPs which can increase the risk of infection. Comparisons of ABP count between Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) have yet to be made. Our study examines the differences in ABP count between primary THA and TKA procedures. Methods: We analyzed all primary TJA procedures done within the same OR at an academic institution from April 2019 to June 2020. All procedures between the dates of March 15, 2020 – May 4, 2020 were excluded to avoid COVID-related confounding. Intraoperative measurements of temperature, humidity, and ABP count per minute were recorded. A report containing surgical data from the same time was generated using the institution’s Electronic Health Records (EHR) system and cross-referenced to the intraoperative measurements using procedure start and end times. ABP was calculated as an average ABP count per minute. Descriptive statistics were used to evaluate differences in variables of interest. P-values were calculated using t-test for continuous variables and chi square for categorical values. Results: A total of 168 cases were included in the study, comprised of 98 (58.3%) primary THA and 70 (41.7%) primary TKA. No significant differences in room temperature or particle counts across all particle sizes were found between THA and TKA groups. Similarly, time spent in the room was not significantly different between THA and TKA. The only variable that was significantly different between the two groups was average relative humidity, with higher humidity in the THA group (46.9% + 7.56 vs 44.4% + 8.02, p=0.008). Conclusion: There were no significant differences in temperature or particle count between primary THA and primary TKA procedures, suggesting OR air quality was similar between the two procedure types. Further investigation including additional variables such as OR size, airflow patterns, and different procedure types should be performed to better characterize the role of ABPs in air quality and infection risk.

Selective Use of Dual-Mobility Did Not Significantly Reduce 90-Day Readmissions or Reoperations After Total Hip Arthroplasty

BackgroundSelective use of dual mobility (DM) implants in total hip arthroplasty (THA) patients at high dislocation risk has been proposed. However, evidence-based utilization thresholds have not been defined. We explored whether surgeon-specific rates of DM utilization correlate with rates of readmission and reoperation for dislocation. MethodsWe retrospectively reviewed 14,818 primary THA procedures performed at a single institution between 2011 and 2021, including 14,310 fixed-bearing (FB) and 508 DM implant constructs. Outcomes including 90-day readmissions and reoperations were compared between patients who had FB and DM implants. Cases were then stratified into 3 groups based on the attending surgeon’s rate of DM utilization (≤ 1, 1 to 10, or > 10%) and outcomes were compared. ResultsThere were no differences in 90-day outcomes between FB and DM implant groups. Surgeon frequency of DM utilization ranged from 0% to 43%. There were 48 surgeons (73%) who used DM in ≤ 1% of cases, 11 (17%) in 1% to 10% of cases, and 7 (10%) in > 10% of cases. The 90-day rates of readmission (7.3% versus 7.6% versus 7.2%, P = .7) and reoperation (3.4% versus 3.9% versus 3.8%, P = .3), as well as readmission for instability (0.5% versus 0.6% versus 0.8%, P = .2) and reoperation for instability (0.5% versus 0.5% versus 0.8%, P = .6), did not statistically differ between cohorts. ConclusionSelective DM utilization did not reduce 90-day readmissions or reoperations following primary THA. Other dislocation-mitigation strategies (ie, surgical approach, computer navigation, robotic assistance, and large diameter FBs) may have masked any benefits of selective DM use.

Bone remodeling and cortical thinning distal to the femoral stem: a retrospective review.

There is a paucity of information on the bone remodeling that occurs distal to the femoral stem following total hip arthroplasty as most previous studies have focused on proximal changes. In this study, we report the cortical thinning that occur distal to the femoral stem after primary total hip arthroplasty. A retrospective review was performed at one institution over a 5-year period. 156 primary total hip arthroplasty procedures were included. The Cortical Thickness Index (CTI) was measured on both operative and non-operative hips at 1cm, 3cm and 5cm below the prosthetic stem tip on anteroposterior radiographic images pre-operatively as well as at 6months, 12months and 24months post-operatively. The difference in average CTI was measured using paired t-tests. There were statistically significant decreases in CTI distal to the femoral stem at 12months and 24months (-1.3% and -2.8%, respectively). Greater losses were seen in female patients, patients older than 75, and patients with BMI less than 35 at 6months postoperative. There were no differences in CTI at any time point on the non-operative side. The current study demonstrates that patients undergo bone loss as measured by CTI distal to the stem in the first 2years following total hip arthroplasty. Comparison to the contralateral non-operative side confirms that this change is greater than expected for the natural aging process. A greater understanding of these changes will help optimize post-operative management and direct future innovations in implant design.

Acetabular Component Removal Systems

As primary total hip arthroplasty procedures continue to rise, acetabular revision surgery will be in increasing demand. Treatment of acetabular component failure and associated bone defects depends on patient characteristics, the degree and location of bone loss, the ability of the columns to support biologic fixation, and the presence of pelvic discontinuity. In revision total hip arthroplasty, technological advances have been made to address limitations of acetabular cup removal while preserving host bone stock. The goal of acetabular revision reconstruction should be to obtain stable fixation and restore the hip center. The various acetabular cup removal systems are discussed.

EARLY PROMS FOLLOWING TOTAL HIP ARTHROPLASTY WITH AND WITHOUT COMPUTER NAVIGATION SYSTEM: A STUDY FROM THE AUSTRALIAN NATIONAL JOINT REPLACEMENT REGISTRY

Total hip arthroplasty (THA) is an effective treatment for symptomatic hip osteoarthritis (OA). While computer-navigation technologies in total knee arthroplasty show survivorship advantages and are widely used, comparable applications within THA show far lower utilisation. Using national registry data, this study compared patient reported outcome measures (PROMs) in patients who underwent THA with and without computer navigation.Data from Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) PROMs program included all primary THA procedures performed for OA up to 31 December 2020. Procedures using the Intellijoint HIP® navigation system were identified and compared to procedures using other computer navigation systems or conventional instrumentation only. Changes in PROM scores between pre-operative and 6-month post-operative time points were analysed using multiple regression model, adjusting for pre-operative score, patient age, gender, ASA score, BMI, surgical approach, and hospital type.There were 65 primary THA procedures that used the Intellijoint HIP® system, 90 procedures used other types of computer navigation, and the remaining 5,284 primary THA procedures used conventional instrumentation. The estimated mean changes in the EuroQol visual analogue scale (EQ VAS) score and Oxford Hip score did not differ significantly when Intellijoint® was compared to conventional instruments (estimated differences of 2.4, 95% CI [-1.7, 6.5], p = 0.245, and −0.5, 95% CI [-2.5, 1.4], p = 0.592, respectively). The proportion of patients who were satisfied with their procedure was also similar when Intellijoint® was compared to conventional instruments (rate ratio 1.06, 95% CI [0.97, 1.16], p = 0.227).The preliminary data demonstrate no significant difference in PROMs when comparing the Intellijoint HIP® THA navigation system with both other navigation systems and conventional instrumentation for primary THAs performed for OA. Level of evidence: III (National registry analysis)

EARLY REVISION RATES OF TOTAL HIP ARTHROPLASTY USING INTELLIJOINT HIP® COMPUTER NAVIGATION SYSTEM: A STUDY FROM THE AUSTRALIAN NATIONAL JOINT REPLACEMENT REGISTRY OF 1,911 PROCEDURES

Total hip arthroplasty (THA) is an effective treatment for symptomatic hip osteoarthritis (OA). Computer-navigation technologies in total knee arthroplasty show evidence-supported survivorship advantages and are used widely. The aim of this study was to determine the revision outcome of hip commercially available navigation technologies.Data from the Australian Orthopaedic Association National Joint Replacement Registry from January 2016 to December 2020 included all primary THA procedures performed for osteoarthritis (OA). Procedures using the Intellijoint HIP® navigation were identified and compared to procedures inserted using ‘other’ computer navigation systems and to all non-navigated procedures. The cumulative percent revision (CPR) was compared between the three groups using Kaplan-Meier estimates of survivorship and hazard ratios (HR) from Cox proportional hazards models, adjusted for age and gender. A prosthesis specific analysis was also performed.There were 1911 procedures that used the Intellijoint® system, 4081 used ‘other’ computer navigation, and 160,661 were non-navigated. The all-cause 2-year CPR rate for the Intellijoint HIP® system was 1.8% (95% CI 1.2, 2.6), compared to 2.2% (95% CI 1.8, 2.8) for other navigated and 2.2% (95% CI 2.1, 2.3) for non-navigated cases. A prosthesis specific analysis identified the Paragon/Acetabular Shell THAs combined with the Intellijoint HIP® system as having a higher (3.4%) rate of revision than non-navigated THAs (HR = 2.00 (1.01, 4.00), p=0.048).When this outlier combination was excluded, the Intellijoint® system group demonstrated a two-year CPR of 1.3%. There was no statistical difference in the CPR between the three groups before or after excluding Paragon/Acetabular Shell system.The preliminary data presented demonstrate no statistical difference in all cause revision rates when comparing the Intellijoint HIP® THA navigation system with ‘other’ navigation systems and ‘non-navigated’ approaches for primary THAs performed for OA. The current sample size remains too small to permit meaningful subgroup statistical comparisons.

Hip Arthroplasty Outcomes in the Presence of Kidney Failure: A National Data Linkage Study

BackgroundPatients who have kidney failure are at higher risk of requiring total hip arthroplasty (THA) and are at higher risk of complications. This study compared the rate of revision surgery and mortality following THA between patients who have kidney failure receiving long term dialysis or who had a kidney transplant and those who did not have kidney failure. MethodsA data linkage study was performed using data from 2 national registries: a registry of dialysis and kidney transplant patients and a registry of THA procedures. Both registries had coverage of almost all procedures or treatments in Australia. Data from September 1999 to December 2016 were used. Mortality and revision surgery were compared between patients receiving dialysis, those who had a functioning kidney transplant, and patients who did not have kidney failure using Cox and Fine-Gray (competing risk) regression models. A total of 383,478 primary THA procedures were identified as people receiving dialysis (n = 490), who had a functioning kidney transplant (n = 459), or who did not have kidney failure (n = 382,529). ResultsThere was no significant difference in the overall rate of revision surgery between the groups (dialysis versus no kidney failure HR = 1.20; 95% CI 0.76, 1.88, transplant versus no kidney failure (hazard ratio) HR = 1.01; 95% (confidence interval) CI 0.66, 1.53). The risk for death after surgery was significantly higher in the dialysis group compared to both the functioning transplant group (HR = 3.44; 95%CI 1.58, 7.5), and in those without kidney failure (HR = 4.13; 95%CI 3.25, 5.25). ConclusionThe rate of mortality after THA in patients on dialysis is higher than in patients who have a functioning transplant or those who do not have kidney failure, but there is no early excess mortality to suggest a difference in this metric due to the surgery.

Operative room time comparison between general and spinal anesthesia in total hip arthroplasty: an institutional study.

A relatively high expense with any procedure is total operative time; two components being the time spent anesthetizing the patient and time spent transferring the patient out of the operating room (OR). Both times can be affected by the anesthetic method used. This study compares different operative time intervals for both spinal anesthesia (SA) and general anesthesia (GA), in patients undergoing a primary total hip arthroplasty (THA), to identify the most appropriate and cost-effective anesthetic method. A retrospective chart review was performed at a single institution for primary total hip arthroplasty procedures performed in the year 2019. Primary THAs without complications performed by three orthopedic surgeons were selected. Anesthesia records for 200 patients were used to compare perioperative time intervals; 100 consecutive patients that received SA and 100 consecutive patients that received GA. The time spent transferring the patient out of the operating room was 8min for GA and 5min for SA (p < 0.001). Total operative time for GA was 90min and 87min for SA (p = 0.3330). Total pre-operative time averaged 26min in SA compared to 25min in GA (p = 0.5874). Non-operative total time (all time components of patient interaction excluding surgery start to surgery finish) was significantly shorter in SA with an average of 52 compared to 56 in GA (p = 0.0151). Time to transfer patient out of the OR and total non-operative time was significantly shorter in patients who received spinal anesthesia. These results and the complications of both general and spinal anesthesia should be taken into consideration when anesthetizing patients undergoing primary THA. III.

Revision Total Hip Arthroplasty with a Modular Fluted Tapered Stem for a Periprosthetic Femoral Fracture.

As the number of primary total hip arthroplasty procedures performed each year continues to rise, so too do the number of complications, including periprosthetic femoral fracture1-9. Vancouver B2 and B3 periprosthetic femoral fractures are difficult to treat because they require the surgeon to simultaneously manage a femoral fracture and gain new implant fixation. Fluted tapered stems have advanced the treatment of periprosthetic femoral fractures by providing immediate axial and rotational implant fixation distal to the fracture10-18. Modular fluted tapered stems provide the added practical advantage of allowing length and anteversion adjustment after implantation of the distal fixation portion of the stem. In this technique, a modified extended trochanteric osteotomy incorporating the fracture is utilized to gain access to the loose femoral implant and femoral diaphyseal canal. The femoral diaphyseal canal is then sequentially reamed in 1-mm increments. A fluted tapered stem with the appropriate length, diameter, and axial and rotational stability is inserted into the canal. A proximal body is then chosen that establishes the appropriate leg length, femoral offset, and version. The final proximal body is engaged into the fluted tapered stem. Finally, the fracture is fixed around the implant with a combination of cables or wires. Historically, implants such as extensively porous coated stems were utilized to treat Vancouver B2 or B3 periprosthetic femoral fractures. Unfortunately, these implants were associated with high rates of failure and revision7,9. The introduction of a fluted tapered stem provided a more reliable implant that achieves immediate axial and rotational stability. In addition, utilizing a fluted tapered stem allowed for a more soft-tissue-preserving approach to these complex injuries, in turn allowing the fracture to be reduced around the implant proximally with cerclage cables and or wires. Modular fluted tapered stems provide the additional advantage of allowing the surgeon to modify leg length, offset, and femoral version, independently of the fluted tapered stem. As a result of these unique advantages, these stems were introduced several years ago for the treatment of Vancouver B2 or B3 periprosthetic femoral fractures. Contemporary series have demonstrated that the use of a modular fluted tapered stem leads to improved implant survivorship and clinical outcomes with lower complication rates for Vancouver B2 and B3 periprosthetic femoral fractures1,10-12,14-19. Template both the fluted tapered stem and proximal body preoperatively. The proximal body should be templated at the ideal hip center of rotation that appropriately restores leg lengths and offset. Template the fluted tapered stem so that it provides appropriate isthmic fit and bypasses the most distal extent of the fracture by at least 2 cortical diameters.Utilize a modified extended trochanteric osteotomy for your exposure in order to facilitate visualization of the fracture and to provide direct access to the femoral canal.Place a prophylactic cable prior to preparing the femur for the implant in order to help prevent iatrogenic fracture.Place a trial stem and obtain intraoperative anteroposterior and lateral radiographs in order to assess the position of the implants and the risk of anterior cortical perforation.When placing the final implants, be sure the fluted tapered stem has both axial and rotational stability.Reduce and fix the fracture after the final implants are placed and the hip is reduced. AP = anteroposteriorMFT = modular fluted tapered (stem)ETO = extended trochanteric osteotomyTHA = total hip arthroplastyCT = computed tomographyPJI = periprosthetic joint infection.

Role of Operating Room Size on Air Quality in Primary Total Hip Arthroplasty

BackgroundAirborne biologic particles (ABPs) can be measured intraoperatively to evaluate operating room (OR) sterility. Our study examines the role of OR size on air quality and ABP count in primary total hip arthroplasty (THA). MethodsWe analyzed primary THA procedures done within 2 ORs measuring 278 ft2 and 501 ft2 at a single academic institution from April 2019 to June 2020. Temperature, humidity, and ABP count per minute were recorded with a particle counter intraoperatively and cross-referenced with surgical data from the electronic health records using procedure start and end times. Descriptive statistics were used to evaluate differences in variables. P-values were calculated using t-test and chi-squared test. ResultsA total of 116 primary THA cases were included: 18 (15.5%) in the “small” OR and 98 (84.5%) in the “large” OR. Between-group comparisons revealed significant differences in temperature (small OR: 20.3 ± 1.23 C versus large OR: 19.1 ± 0.85 C, P < .0001) and relative humidity (small OR: 41.1 ± 7.24 versus large OR: 46.9 ± 7.56, P < .001). Significant percent decreases in ABP rates for particles measuring 2.5 um (−125.0%, P = .0032), 5.0 um (−245.0%, P = .00078), and 10.0 um (−413.9%, P = .0021) were found in the large OR. Average time spent in the OR was significantly longer in the large OR (174 ± 33 minutes) compared to the small OR (151 ± 14 minutes) (P = .00083). ConclusionTemperature and humidity differences and significantly lower ABP counts were found in the large compared to the small OR despite longer average time spent in the large OR, suggesting the filtration system encounters less particle burden in larger rooms. Further research is needed to determine the impact this may have on infection rates.

Early Revision Rates of Total Hip Arthroplasty Using the Intellijoint HIP Computer Navigation System: A Study From the Australian National Joint Replacement Registry of 1911 Procedures.

Total hip arthroplasty (THA) is an effective treatment for symptomatic hip osteoarthritis. The aim of this study was to determine the revision outcome of commercially available navigation technologies. Data from the Australian Orthopaedic Association National Joint Replacement Registry from January 2016 to December 2020 included all primary THA procedures performed for osteoarthritis. Procedures using the Intellijoint HIP navigation system were identified and compared to procedures using "other" computer navigation systems and to nonnavigated procedures. The cumulative percent revision (CPR) was compared between the 3 groups using Kaplan-Meier estimates of survivorship and hazard ratios from Cox proportional hazards models, adjusted for age and gender. There were 1911 procedures that used the Intellijoint system, 4081 used "other" computer navigation systems, and 160,661 were nonnavigated procedures. The all-cause 2-year CPR rate for the Intellijoint system was 1.8% (95% confidence interval [CI], 1.2-2.6), compared to 2.2% (95% CI, 1.8-2.8) for other navigated cases and 2.2% (95% CI, 2.1-2.3) for nonnavigated cases. A prosthesis analysis identified the Paragon/Acetabular Shell THAs combined with the Intellijoint system to have a higher (3.4%) rate of revision than nonnavigated THAs (hazard ratio= 2.00 [95% CI, 1.01-4.00], P= .048). When this combination was excluded, the Intellijoint group demonstrated a 2-year CPR of 1.3%. There was no statistical difference in the CPR between the 3 groups before or after excluding the Paragon/Acetabular Shell system. The preliminary data presented demonstrate no statistical difference in all-cause revision rates when comparing the Intellijoint system with "other" navigation systems and "nonnavigated" approaches for primary THAs. III (National registry analysis).

Total Hip Arthroplasty via direct anterior approach for osteonecrosis; comparison with primary hip osteoarthritis in a mid term follow up

BackgroundTo determine the mid-term outcomes of conventional cementless Total Hip Arthroplasty (THA) in patients with avascular necrosis (AVN) of the femoral head and compare to patients with primary hip osteoarthritis (OA). MethodA total of 330 consecutive primary THA procedures (AVN and OA) performed between 2010 and 2013 by a single surgeon and in a single center using the direct anterior approach (DAA) were included. Assessments including SF-36, WOMAC, and Harris Hip Scores (HHS) were retrieved from patients before the surgery and at the latest follow-up. Clinical and functional outcomes were compared between the AVN and OA groups. ResultsA total of 294 consecutive THA (AVN = 107, OA = 187) with 104.4 ± 6.2 months follow-up were analyzed, which AVN patients were significantly younger (32.0 vs. 59.6 y/o). Corticosteroid 34 (31.8%), idiopathic AVN 31 (29.0%) and use of unapproved weight gain supplements (UWGS) 23 (21.5%) were the main reasons for AVN. Despite that preoperative scores were comparable (P > 0.05), the HHS, SF-36, and WOMAC scores are significantly higher in the AVN group after THA surgery (P < 0.05). Moreover, flexion and abduction ROM were significantly higher in the AVN group (P < 0.05). Regarding each complication, no significant difference was observed between groups. In the whole sample, there were 5 (1.7%) revisions due to loosening of acetabular components, all the OA group (P > 0.05). ConclusionConventional cementless THA with highly cross-linked polyethylene provides satisfactory mid-term results in patients with AVN with a low rate of postoperative complications. Compared to primary OA patients, this group reaches superior postoperative scores.

Preoperative planning of primary total hip arthroplasty using conventional radiographs

Objective: The aim of this study was to present an analog method for preoperative planning of primary total hip arthroplasty procedures based on component measurements by overlaying the transparency of the prosthesis on preoperative radiographs and checking the accuracy, both for predicting the size of the acetabular and femoral components to be used and to restore offset and correct dysmetria if any. Methodology: From May 2019 to June 2022, 18 primary total hip arthroplasties were performed and were analyzed in 18 patients at the Post graduate Department of Orthopaedics GMC Srinagar. Measurements on femoral and acetabular components obtained by planning were compared to those used in surgery. Displacements measured through preoperative planning was compared with planning measured on postoperative radiographs. Dysmetria was assessed before and after surgery. Results: accuracy of 68.5% (p

Intraoperative Acoustics: Auditory Cues in Hip Reconstructive Surgery.

Orthopaedic surgeons rely on visual and tactile cues to guide performance in the operating room (OR). However, there is very little data on how sound changes during orthopaedic procedures and how surgeons incorporate audio feedback to guide performance. This study attempts to define meaningful changes in sound during vital aspects of total hip arthroplasty (THA) within the spectrum of human hearing. 84 audio recordings were obtained during primary elective THA procedures during sawing of the femoral neck, reaming of the acetabulum, acetabular cup impaction, polyethylene liner impaction, femoral broaching, planning of the femoral calcar and press-fit of a porous-coated stem in 14 patients. We graphed changes in frequency intensity across the human spectrum of hearing and sampled frequencies showing differences over time for statistically meaningful changes. Sawing of the femoral neck, polyethylene impaction, and stem insertion showed significant temporal increases in overall sound intensity. Calcar planing showed a significant decrease in sound intensity. Moreover, spectrographic analysis showed that, for each of the critical tasks in THA, there were characteristic frequencies that showed maximal changes in loudness. These changes were above the 1 dB change in intensity required for detection by the human ear. Our results clearly demonstrate reproducible sound changes during total hip arthroplasty that are detectable by the human ear. Surgeons can incorporate sound as a valuable source of feedback while performing total hip arthroplasty to guide optimal performance in the OR. These findings can be extrapolated to other orthopaedic procedures that produce characteristic changes in sound. Moreover, it emphasizes the importance of limiting ambient noise in the OR that might make sound changes hard to distinguish.

Frank Stinchfield Award: Does Bariatric Surgery Prior to Primary Total Hip Arthroplasty Really Improve Outcomes?

Optimal management of morbid obesity before total hip arthroplasty (THA) remains debated. Recently, bariatric procedures have become more common with advancements in surgical techniques. We hypothesized that bariatric surgery prior to primary THA would mitigate acute postoperative complications and improve implant survivorship. A retrospective review from 1995 to 2020 identified 88 primary THA procedures in 71 unique patients who previously underwent bariatric surgery (73% Roux-en-Y). This cohort was matched 1:1:1 for age, gender, surgical year, American Society of Anesthesiologists score, and Charlson Comorbidity Index to cohorts of patients with body mass index (BMI) <40 kg/m2 and BMI ≥40 kg/m2. Revisions, reoperations, and acute complications were compared. Subgroup analysis then evaluated historical (pre-2012) relative to contemporary (2012 and after) bariatric procedures. Revision rates for bariatric patients were higher relative to controls with low (hazard ratio [HR] 19, P < .01) and high BMI (HR 8, P < .01). Reoperation rates showed a similar increase for bariatric patients when compared to low (HR 9, P < .01) and high BMI (HR 4, P= .01) patients. Moreover, bariatric patients had an increased dislocation risk compared to the low (HR 7, P= .03) and high BMI (HR 17, P < .01) patients. Contemporary bariatric techniques had similar complications, revisions, and reoperations relative to historical procedures. Morbidly obese patients undergoing THA have increased risks of certain complications, but it is unclear if bariatric surgery improves this risk. This study found that patients undergoing bariatric surgery have worse implant survivorship and higher dislocation rates compared to patients with naturally low and high BMIs. Further investigation into the post-bariatric metabolic state is warranted. Prognostic Level IV.