Primary Total Hip Replacement Patients Research Articles

Reducing Blood Transfusions in Primary Total Hip Replacement Patients: Effectiveness of Near-patient Testing and a Dedicated Preoperative Anemia Clinic.

Objective Preoperative anemia in orthopedic patients is associated with higher allogeneic blood transfusion rates and poorer outcomes. Up to 25% of the patients listed for major orthopedic surgery have some degree of anemia. Good perioperative patient blood management is essential to reduce the sequelae of anemia and the need for transfusions. We assessed the efficacy of rapid near-patient testing in conjunction with a dedicated preoperative anemia clinic for screening and treating primary total hip replacement (THR) patients for anemia. Methods A comparison of overall allogeneic blood transfusion rates was made for patients undergoing primary total hip replacement before and after the implementation of near-patient testing and of a dedicated preoperative anemia clinic over 1 year. A comparison was also performed between anemic patients who were referred to the clinic with those who were not referred. Preoperative hemoglobin levels, allogeneic blood transfusion rates and clinic treatment for 1,095 patients were reviewed. Results There was a significant decrease in transfusion rates in patients undergoing primary THR from 10.0 to 6.2% ( p < 0.05; χ2 test) after the implementation of near-patient testing and of a dedicated preoperative anemia clinic pathway. The allogeneic blood transfusion rate for anemic patients who were treated in the clinic was 6.7% compared with 26.9% for patients who were anemic preoperatively but were not treated in the clinic ( p < 0.05; Fisher exact test). On average, treatment in the pathway increased the hemoglobin of the patients by 20 g/L, from 104 g/L to 124 g/L ( p < 0.001). Conclusions Near-patient testing, in conjunction with a dedicated preoperative anemia clinic, reduces perioperative allogenic blood transfusion requirements for patients undergoing primary THR by providing rapid identification and effective treatment of preoperative anemia.

Can the minimal clinically important difference be determined in a French-speaking population with primary hip replacement using one PROM item and the Anchor strategy?

BackgroundThe impact of surgery on the patient is classically assessed on pre- and post-treatment scores. However, it is increasingly recommended to rank these results according to the minimal clinically important difference (MCID), using either the data distribution method or the anchor method, latter consisting in an extra question specifically targeting the patient's improvement. MCIDs vary between populations and, to the best of our knowledge; there have been no investigations in France regarding this in the context of total hip replacement (THR). Therefore, we conducted a prospective study in a population with THR to determine: 1) whether MCID scores in France were comparable to those reported in the data from the international literature; 2) whether a general item taken from a different score could serve as an anchor; and 3) whether an item from the actual questionnaire itself could serve as an anchor. HypothesisWhen pre- and post-treatment scores are available, an item from the questionnaire itself can serve as an anchor for MCID. Material and methodsIn a prospective observational study, 123 primary THR patients (69 male, 54 female), out of 150 initially included, completed the 5 domains of the HOOS hip disability and osteoarthritis outcome score and the Oxford-12 questionnaire, preoperatively and at 6–12 months. The MCID was calculated via the distribution-based and the anchor-based methods. Two Oxford items (questions 1 and 2) and 2 HOOS items (questions S1 and Q4) were used as anchors, as well as a supplementary question on improvement and the Forgotten Joint Score (FJS). ResultsAt a mean 10.12±1.2 months’ follow-up [range, 6.5–11.9 months], the Oxford-12 score increased from 19±8 [3–35] to 40±10 [8–48] (p<0.001), all HOOS components demonstrated improvement, and the FJS at the final follow-up was 71±29 [0–100]. The general items (Oxford question 1 and HOOS question Q4) were more discriminating than the joint-specific items (Oxford question 2 and HOOS question S1). Based on results from the 3 anchors (improvement rated 1 to 5, Oxford question 1 and HOOS question Q4), 3 to 5 patients showed deterioration, 5 to 6 were unchanged, 30 to 40 were slightly improved, and 73 to 80 were improved by THR. The mean MCID on both distribution and anchor methods was 9 [5.5–12] for Oxford-12, 20 [12–27] for HOOS symptoms, 26 [10–36] for HOOS pain, 22 [11.5–28] for HOOS function, 26 [13–34] for HOOS sport and 22 [14–28] for HOOS quality of life. DiscussionThe MCID for the Oxford-12 and HOOS scores in a French population was comparable to data from the past literature. Using a score item as an anchor to define improvement is possible, but only if a general item is used. Level of evidenceIV; prospective study without control group. Clinical Trials registrationNCT04057651.

THE EFFECT OF TRANEXAMIC ACID IN PRIMARY TOTALHIP ARTHROPLASTY

Back ground: In this Randomized Controlled Trials clinical study, we report results of the effect of tranexamic acid intravenous administration and local injection on transfusion rate and perioperative blood loss in primary total hip replacement.Aim of the Study: The aim of this study is to evaluate the effect of tranexamic acid intravenous administration and local injection on transfusion rate and perioperative blood loss in primary total hip replacementPatients and methods: The study will include 30 patients in each of the 2 groups.Group (1) Including 30 cases (control group).Group (2) Including 30 cases managed by I.V and local TXA injection. We compare between both group as regard transfusion rate and perioperative blood loss.Results: Patients in the TXA group had significantly higher postoperative hemoglobin (10.34 vs 9.78 g/dl, P<0.102), lower hemoglobin changes (1.88 vs 2.52 g/dl, p < 0.001). higher postoperative hematocrit (34.37 vs 31.46 L/L, P<0.009), lower hematocrit changes (6.17 vs 7.36 L/L, p < 0.001), lower total blood loss (906 vs 1208 ml, P<0.001), lower transfusion rate (6.7 %vs 26.7%, P<0.038), no statistically significant difference between 2 groups regarding demographic data (weight and sex), There was no difference among the 2 groups regarding to the rates of deep vein thrombosis. No patients had thromboembolic complications.Conclusion: In the present study, I. Vcombined with topical administration of TXA significantly reduced postoperative blood loss in patients having a primary unilateral THA. The calculated blood loss was 25% lower in patients who were managed with TXA as compared with the placebo, with a mean difference of approximately 300 ml. Patients in the TXA group had significantly higher postoperative hemoglobin than placebo patient higher postoperative hematocrit lower transfusion rate decreased about 20 %.

Determining the risk of acute kidney injury in patients who underwent total joint replacement: A retrospective study

ObjectivesTotal joint replacement (TJR) is a commonly performed procedure worldwide, and postoperative acute kidney injury (AKI) is one of the complications that determine the overall prognosis in various surgical settings. We aimed to identify the risk of AKI after TJR (primary and revision) and determine the factors associated with postoperative AKI. MethodsWe performed a retrospective study of 1068 patients (>18 years) who underwent TJR between 2014 and 2019 at a tertiary medical center. Patients’ demographic, clinical, and laboratory data were reviewed. ResultsA total of 1068 patients were included in this study [mean age, 60.5 ± 13 years; 260 men (24.3%); 808 women (75.7%)]. A total of 962 patients (90.1%) underwent primary joint replacement (PJR) and 106 underwent joint revision (9.9%). Sixty-six patients (6.2%) had postoperative AKI. Primary total hip replacement patients had a lower risk of AKI than patients with other types of TJR (3.0%; p = 0.024). The factors associated with AKI (adjusting for known confounders) included male gender [adjusted odds ratio (AOR): 1.751; 95% confidence interval (CI): 1.01–3.03; p = 0.046], diabetes mellitus (DM) [AOR: 2.806; 95% CI: 1.687–5.023; p ≤ 0.001], hypertension (HTN) [AOR: 1.751; 95% CI: 1.159–3.442; p = 0.013], and the use of vancomycin as a prophylactic antibiotic [AOR: 1.691; 95% CI: 1.1–2.913; p = 0.050]. Chronic kidney disease (CKD) [AOR: 1.00; 95% CI: 0.432–2.27; p = 0.981] was not found to be a significant risk factor. ConclusionIn this study, the risk of preoperative AKI in patients who underwent TJR was 6.2%. Male gender, preoperative comorbidities such as DM and HTN, and preoperative use of vancomycin were associated with increased risk of postoperative AKI.

A feasibility randomised controlled trial to evaluate the effectiveness of a novel neuromuscular electro-stimulation device in preventing the formation of oedema following total hip replacement surgery

AimThe aim of this feasibility study was to investigate the potential role of a novel neuromuscular electrical stimulation (NMES) device in preventing the formation of oedema following total hip replacement (THR). MethodsSuccessive primary THR patients were recruited into a randomised controlled trial. Participants were randomised to wear either the NMES device or compression stockings continually from post-surgery until discharge.The main outcome measure was presence of lower limb oedema, assessed by taking measurements of the circumference of the ankle, knee and thigh on the operated leg and non-operated leg, pre-operatively, post-operatively, at two days post-operatively and every day until discharge. Secondary objectives were to compare adverse events, the presence of asymptomatic and symptomatic deep vein thrombosis (DVT) and device tolerability between groups. ResultsData from 40 participants were analysed (NMES (n = 20), compression stockings (n = 20)). The NMES group had significantly less oedema and the device was found to be tolerable and safe. ConclusionThe results of this study suggest that the NMES is a safe and well tolerated alternative to compression stockings, which should be considered by clinicians seeking the additional benefit of reducing post-operative oedema. In addition the NMES device should be considered as part of a DVT prophylaxis.

Evidence that osteocyte perilacunar remodelling contributes to polyethylene wear particle induced osteolysis

Periprosthetic osteolysis (PO) leading to aseptic loosening, is the most common cause of failure of total hip replacement (THR) in the mid- to long-term. Polyethylene (PE) particulates from the wear of prosthesis liners are bioactive and are implicated in the initiation and or progression of osteolysis. Evidence exists that cells of the osteoblast/osteocyte lineage are affected by PE particles and contribute to the catabolic response by promoting osteoclastic bone resorption. In this study, we hypothesised that osteocytes contribute directly to PO by removing bone from their perilacunar matrix. Osteocyte responses to ultra-high molecular weight PE (UHMWPE) particles were examined in vitro in human primary osteocyte-like cultures, in vivo in the mouse calvarial osteolysis model, and in the acetabulum of patients undergoing revision total hip replacement (THR) surgery for PO. Osteocytes exposed to UHMWPE particles showed upregulated expression of catabolic markers, MMP-13, carbonic anhydrase 2 (CA2), cathepsin K (CTSK) and tartrate resistant acid phosphatase (TRAP), with no effect on cell viability, as assessed by Caspase 3 activity. Consistent with this catabolic activity causing perilacunar bone loss, histological analysis of calvarial sections from mice exposed to UHMWPE revealed a significant (p<0.001) increase in osteocyte lacunar area (Lac.Ar) compared to sham-operated animals. Furthermore, acetabular biopsies from patients with PO also showed significantly (p<0.001) increased osteocyte lacunar size in trabecular bone adjacent to PE particles, compared with osteocyte lacunar size in bone from primary THR patients. Together, these findings suggest a previously unrecognised action of UHMWPE wear particles on osteocytes, which directly results in a loss of osteocyte perilacunar bone. This action may exacerbate the indirect pro-osteoclastic action of UHMWPE-affected osteocytes, previously shown to contribute to aseptic loosening of orthopaedic implants. Statement of SignificanceThis study addresses the clinical problem of periprosthetic osteolysis, bone loss in response to polyethylene wear particles derived from materials used in orthopaedic implants. Periprosthetic osteolysis has been thought to be due largely to wear particles stimulating the activity of bone resorbing osteoclasts. However, in this study we demonstrate for the first time that polyethylene particles stimulate another type of bone loss, mediated by the direct activity of bone mineral embedded osteocytes, termed osteocytic osteolysis or osteocyte perilacunar remodelling. This study provides new mechanistic insight into wear-particle mediated bone loss and represents a new paradigm for the way in which bone cells, namely osteocytes, the key controlling cell type in bone, react to biomaterials.

Bone Mineral Density and Fracture Risk Assessment to Optimize Prosthesis Selection in Total Hip Replacement.

The variability in patient outcome and propensity for surgical complications in total hip replacement (THR) necessitates the development of a comprehensive, quantitative methodology for prescribing the optimal type of prosthetic stem: cemented or cementless. The objective of the research presented herein was to describe a novel approach to this problem as a first step towards creating a patient-specific, presurgical application for determining the optimal prosthesis procedure. Finite element analysis (FEA) and bone mineral density (BMD) calculations were performed with ten voluntary primary THR patients to estimate the status of their operative femurs before surgery. A compilation model of the press-fitting procedure was generated to define a fracture risk index (FRI) from incurred forces on the periprosthetic femoral head. Comparing these values to patient age, sex, and gender elicited a high degree of variability between patients grouped by implant procedure, reinforcing the notion that age and gender alone are poor indicators for prescribing prosthesis type. Additionally, correlating FRI and BMD measurements indicated that at least two of the ten patients may have received nonideal implants. This investigation highlights the utility of our model as a foundation for presurgical software applications to assist orthopedic surgeons with selecting THR prostheses.

The effect of a collar and surface finish on cemented femoral stems: a prospective randomised trial of four stem designs

The optimal design for a cemented femoral stem remains a matter of debate. Over time, the shape, surface finish and collar have all been modified in various ways. A clear consensus has not yet emerged regarding the relative merits of even the most basic design features of the stem. We undertook a prospective randomised trial comparing surface finish and the effect of a collar on cemented femoral component subsidence, survivorship and clinical function. One hundred and sixty three primary total hip replacement patients were recruited prospectively and randomised to one of four groups to receive a cemented femoral stem with either a matt or polished finish, and with or without a collar. At two years, although there was a trend for increased subsidence in the matt collarless group, this was not statistically significant (p = 0.18). At a mean of 10.1 years follow-up, WOMAC scores for the surviving implants were good, (Range of means 89-93) without significant differences. Using revision or radiographic loosening as the endpoint, survivorship of the entire cohort was 93 % at 11 yrs, (CI 87-97 %). There were no significant differences in survivorship between the two groups with polished stems or the two groups with matt stems. A comparison of the two collarless stems demonstrated a statistically significant difference in survivorship between polished (100 %) and matt (88 %) finishes (p = 0.02). In the presence of a collar, surface finish did not significantly affect survivorship or function. Between the two collarless groups a polished surface conferred an improved survivorship.

The influence of social deprivation on bone donation: a 10 year retrospective study

An audit identifying all surgical bone donors over a 10 year period was conducted. Postcodes were used to link data from the index of multiple deprivation (IMD) 2007 to give each donor a deprivation score. An audit from 2000 to 2010 of primary total hip replacement (THR) patients was also conducted, and similarly a deprivation score was identified for each patient. IMD scores are split into quintiles. A high IMD score indicates a high degree of social deprivation. Conversely low IMD scores indicate a more affluent community. The mean IMD 2007 score was 13.36 (95% CI 13.12-13.60). The national mean IMD score is 21.7 (CI 21.52-21.88). The difference is significant (p < 0.0001). The mean IMD 2007 score of primary THR patients identified in the arthroplasty database was 19.19 (CI 19.00-19.38). The difference between the mean arthroplasty score and the mean score of donors is significant (p < 0.0001). The donation rate increases as social deprivation decreases from quintile to quintile in both: the older patients (CI 1.08-1.14; p < 0.0001) and the general population (CI 1.20-1.25; p < 0.0001). Bone donors are substantially less deprived than their donor pool of THR patients. Donor rates are consistently lower in quintiles which are more deprived.

Peptic ulcer disease and heart disease are associated with periprosthetic fractures after total hip replacement

Background and purpose There have been no published studies assessing the possible association of medical comorbidities with periprosthetic fracture risk. We therefore assessed whether medical comorbidity is associated with risk of periprosthetic fractures after total hip replacement (THR).Material and methods We used prospectively collected data from 1989–2008 in the Mayo Clinic Total Joint Registry for 2 cohorts: primary THR and revision THR. The main variables of interest were Deyo-Charlson comorbidities at the time of surgery. Outcome of interest was p ostoperative periprosthetic fracture at postoperative day 1 onwards. MultivariableCox regression models were additionally adjusted for age, sex, body mass index, American Society of Anesthesiology (ASA) class, and operative diagnosis.Results We identified 14,065 primary THRs and 6,281 revision THRs with mean follow-up times of 6.3 and 5.6 years, respectively. There were 305 postoperative periprosthetic fractures in the primary THR cohort and 330 in the revision THR cohort. In patients who underwent primary THR, 2 comorbidities were associated with higher risk of periprosthetic fracture: peptic ulcer disease with adjusted hazard ratio of 1.5 (95% CI: 1.1–2.2) and heart disease with adjusted hazard ratio of 1.7 (CI: 1.2–2.4). In patients with revision THR, peptic ulcer disease was associated with a higher adjusted risk of periprosthetic fracture, 1.6 (CI: 1.1–2.3).Interpretation Peptic ulcer disease and heart disease in primary THR patients and peptic ulcer disease in revision THR patients were associated with higher postoperative periprosthetic fracture risk. Further studies are needed to understand whether disease severity or specific medications used for treatment, or both, are responsible for this association. This may allow identification of modifiable factors.

Determinants of discharge destination following elective total hip replacement

To identify the factors associated with discharge to an inpatient rehabilitation facility versus discharge directly to home after elective total hip replacement (THR). Data were obtained from a medical record review and a cross-sectional survey of a population-based cohort of patients who received elective primary or revision THR in 1995. Postoperative functional status was measured as the ability to walk independently prior to discharge. A multivariate regression model was developed with discharge to an inpatient rehabilitation facility versus directly to home as the dependent variable. The model adjusted for demographic characteristics, socioeconomic features, and several preoperative and postoperative clinical factors. We included 1,276 patients age 65-94 years in the analysis. Of these, 58% were discharged from the acute care hospital to a rehabilitation facility. The cohort had mean age of 73 years; 96% were white; 62% were female; 32% were living alone; 38% had an annual income less than $20,000; and 78% were unable to walk independently in the hospital before discharge. For primary THR patients, multivariate analysis showed a significant association between being discharged to a rehabilitation facility and being unable to walk at discharge, older age, obesity, and living alone. For revision THR patients, multivariate analysis also showed a significant association between being discharged to a rehabilitation facility and being unable to walk at discharge. In a large population-based sample, postoperative functional status, age, obesity, and social support all influenced the discharge destination following elective THR.