Total Hip Arthroplasty Cohort Research Articles

Increased risk for extended acetabular reconstruction in failed hip resurfacing as compared to failed total hip arthroplasty.

Hip resurfacing (HR) is intended to preserve the femoral bone stock during primary arthroplasty. On the other hand, little has been reported regarding the intraoperative need of bone reconstruction for extended acetabular defects during hip resurfacing revision. Thus, the aim of the presented study was to identify whether there is an increased need for acetabular bone reconstruction in HR revision surgery. We analyzed the data of 38 patients who underwent 39 conversions from a HR to a total hip arthroplasty (THA). Acetabular bone defects and the respective revision technique were compared against a temporary cohort of patients undergoing revision surgery of a conventional THA. In 29 HR patients revision required either autogenous or allogenous impaction bone grafting to adequately manage acetabular host bone degradation. In 10 cases additional implantation of a reinforcement device was necessary. Compared to the THA cohort revision of failed HR is associated with a significantly increased risk of higher grade bone defects (Paprosky classification) and extended acetabular reconstruction (p<0.05). This study provides evidence that revision of failed HR devices is associated with an increased risk for extensive acetabular defects. Furthermore, the preoperative radiographic assessment of HR devices often underestimates the intraoperative acetabular defect. Surgeons should be aware of this fact not to technically underestimate HR revision procedures.

The Total Joint Arthroplasty Cardiac Risk Index for Predicting Perioperative Myocardial Infarction and Cardiac Arrest After Primary Total Knee and Hip Arthroplasty

BackgroundCurrent indices fail to consistently predict risk for major adverse cardiac events after major total joint arthroplasty. MethodsAll primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) were identified from the National Surgical Quality Improvement Program data set. Based on prior analyses, age ≥80 years, history of hypertension, and history of cardiac disease were evaluated as predictors of myocardial infarction and cardiac arrest using stepwise multivariate logistic regression. A series of predictive scores were constructed and weighted to identify the influence of each variable on 30-day postoperative cardiac events, while comparing with the Revised Cardiac Risk Index (RCRI). ResultsAmong 85,129 patients, age ≥80 years, hypertension, and a history of cardiac disease were all statistically significant predictors of postoperative cardiac events (0.32%; n = 275) after TKA and THA (P ≤ .02). Equal weighting of all variables maintained the highest discriminative capacity in both THA and TKA cohorts. Adjusted models explained 75% and 71% of the variation in postoperative cardiac events for those with THA and TKA, respectively, without statistically significant lack of fit (P = .52; P = .23, respectively). Conversely, the RCRI was not a significant predictor of postoperative cardiac events after TKA (odds ratio, 3.36; 95% CI, 0.19, 58.04; P = .40), although it maintained a similar discriminative capacity after THA (76%). ConclusionThe current total joint arthroplasty Cardiac Risk Index score was the most economical in predicting postoperative cardiac complication after primary unilateral TKA and THA. The RCRI was not a significant predictor of perioperative cardiac events for TKA patients but performed similarly to the current model for THA.

Subchondral insufficiency fractures of the femoral head: associated imaging findings and predictors of clinical progression.

To characterize the morphology and imaging findings of femoral head subchondral insufficiency fractures (SIF), and to investigate clinical outcomes in relation to imaging findings. Fifty-one patients with hip/pelvis magnetic resonance (MR) images and typical SIF characteristics were identified and reviewed by two radiologists. Thirty-five patients had follow-up documentation allowing assessment of clinical outcome. Subgroup comparisons were performed using regression models adjusted for age and body mass index. SIF were frequently associated with cartilage loss (35/47, 74.5%), effusion (33/42, 78.6%), synovitis (29/44, 66%), and bone marrow oedema pattern (BMEP) (average cross-sectional area 885.7 ± 730.2mm(2)). Total hip arthroplasty (THA) was required in 16/35 patients, at an average of 6months post-MRI. Compared to the THA cohort, the non-THA group had significantly (p < 0.05) smaller overlying cartilage defect size (10mm vs. 29mm), smaller band length ratio and fracture diameters, and greater incidence of parallel fracture morphology (p < 0.05). Male gender and increased age were significantly associated with progression, p < 0.05. SIF were associated with synovitis, cartilage loss, effusion, and BMEP. Male gender and increased age had a significant association with progression to THA, as did band length ratio, fracture diameter, cartilage defect size, and fracture deformity/morphology. • Femoral head subchondral insufficiency fractures (SIF) frequently require total hip arthroplasty (THA). • SIF frequently coexist with synovitis, cartilage loss, and bone marrow oedema pattern. • SIF cartilage defect size, band length ratio, and fracture diameter/morphology can predict progression risk.

Can tranexamic acid change preoperative anemia management during total joint arthroplasty?

To investigate the postoperative transfusion and complication rates of anemic and nonanemic total joint arthroplasty patients given tranexamic acid (TXA). A cross-sectional prospective study was conducted of primary hip and knee arthroplasty cases performed from 11/2012 to 6/2014. Exclusion criteria included revision arthroplasty, bilateral arthroplasty, acute arthroplasty after fracture, and contraindication to TXA. Patients were screened prior to surgery, with anemia was defined as hemoglobin of less than 12 g/dL for females and of less than 13 g/dL for males. Patients were divided into four different groups, based on the type of arthroplasty (total hip or total knee) and hemoglobin status (anemic or nonanemic). Intraoperatively, all patients received 2 g of intravenous TXA during surgery. Postoperatively, allogeneic blood transfusion (ABT) was directed by both clinical symptoms and relative hemoglobin change. Complications were recorded within the first two weeks after surgery and included thromboembolism, infection, and wound breakdown. The differences in transfusion and complication rates, as well as the relative hemoglobin change, were compared between anemic and nonanemic groups. A total of 232 patients undergoing primary joint arthroplasty were included in the study. For the total hip arthroplasty cohort, 21% (18/84) of patients presented with preoperative anemia. Two patients in the anemic group and two patients in the nonanemic group needed ABTs; this was not significantly different (P = 0.20). One patient in the anemic group presented with a deep venous thromboembolism while no patients in the nonanemic group had an acute complication; this was not significantly different (P = 0.21). For nonanemic patients, the average change in hemoglobin was 2.73 ± 1.17 g/dL. For anemic patients, the average change in hemoglobin was 2.28 ± 0.96 g/dL. Between the two groups, the hemoglobin difference of 0.45 g/dL was not significant (P = 0.13). For the total knee arthroplasty cohort, 18% (26/148) of patients presented with preoperative anemia. No patients in either group required a blood transfusion or had an acute postoperative complication. For nonanemic patients, the average change in hemoglobin was 1.85 ± 0.79 g/dL. For anemic patients, the average change in hemoglobin was 1.09 ± 0.58 g/dL. Between the two groups, the hemoglobin difference of 0.76 g/dL was significant (P < 0.001). TXA administration results in low transfusion and complication rates and may be a useful adjunct for TJA patients with preoperative anemia.

Increasing obesity and comorbidity in patients undergoing primary total hip arthroplasty in the U.S.: a 13-year study of time trends.

BackgroundFew, if any data are available are available regarding the time-trends in characteristics of patients who have undergone primary THA. Our objective was to examine the time-trends in key demographic and clinical characteristics of patients undergoing primary total hip arthroplasty (THA).MethodsWe used the data from the Mayo Clinic Total Joint Registry from 1993–2005 to examine the time-trends in demographics (age, body mass index (BMI)), medical (Deyo-Charlson index) and psychological comorbidity (anxiety, depression) and underlying diagnosis of patients undergoing primary THA. Chi-square test and analysis for variance were used. Multivariable-adjusted logistic regression (age, sex, comorbidity-adjusted) compared 1993–95 to other study periods. Odds ratio (OR) and 95% confidence interval (CI) are presented.ResultsThe primary THA cohort consisted of 6,168 patients with 52% women. In unadjusted analyses, compared to 1993–95, significantly more patients (by >2-times for most) in 2002–05 had: BMI ≥ 40, 2.3% vs. 6.3%; depression, 4.1% vs. 9.8%; and anxiety, 3.4% vs. 5.7%; and significantly fewer had an underlying diagnosis of rheumatoid/inflammatory arthritis, 3.7% vs. 1.5% (p ≤ 0.01 for all). In multivariable-adjusted models, compared to 1993–95, significantly more patients in 2003–05 had (all p-values ≤ 0.01): BMI ≥ 40, OR, 2.79 (95% CI: 1.85, 4.22); Deyo-Charlson Index ≥ 3, 1.32 (1.07, 1.63); depression, 2.25 (1.66, 3.05); and anxiety, 1.71 (1.19, 2.15). Respectively, fewer patients had a diagnosis of RA/inflammatory arthritis: 0.28 (0.17, 0.46; p < 0.01). Over the 13-year study period, Deyo-Charlson index increased by 22% (0.9 to 1.1) and the mean age decreased by 0.7 years (65.0 to 64.3) (p < 0.01 for both).ConclusionsObesity, medical and psychological comorbidity increased and the underlying diagnosis of RA/inflammatory arthritis decreased rapidly in primary THA patients over 13-years. Our cohort characteristics are similar to previously described characteristics of national U.S. cohort, suggesting that these trends may be national rather than local trends. This is important information for policy makers to take into account for resource allocation. Studies of THA outcomes and utilization should take these rapidly changing patient characteristics into account.

Wear of highly crosslinked polyethylene acetabular components

Background and purpose — Wear rates of highly crosslinked polyethylene (XLPE) acetabular components have varied considerably between different published studies. This variation is in part due to the different techniques used to measure wear and to the errors inherent in measuring the relatively low amounts of wear in XLPE bearings. We undertook a scoping review of studies that have examined the in vivo wear of XLPE acetabular components using the most sensitive method available, radiostereometric analysis (RSA).Methods — A systematic search of the PubMed, Scopus, and Cochrane databases was performed to identify published studies in which RSA was used to measure wear of XLPE components in primary total hip arthroplasty (THA).Results — 18 publications examined 12 primary THA cohorts, comprising only 260 THAs at 2–10 years of follow-up. The mean or median proximal wear rate reported ranged from 0.00 to 0.06 mm/year. However, differences in the manner in which wear was determined made it difficult to compare some studies. Furthermore, differences in RSA methodology between studies, such as the use of supine or standing radiographs and the use of beaded or unbeaded reference segments, may limit future meta-analyses examining the effect of patient and implant variables on wear rates.Interpretation — This scoping review confirmed the low wear rates of XLPE in THA, as measured by RSA. We make recommendations to enhance the standardization of reporting of RSA wear results, which will facilitate early identification of poorly performing implants and enable a better understanding of the effects of surgical and patient factors on wear.

Radiographic Parameters Associated with Pain Following Total Hip and Surface Arthroplasty

Pain following total hip arthroplasty (THA) and surface arthroplasty (SRA) remains a significant source of patient dissatisfaction. Two hundred twenty-four SRA and 196 THA patients completed a pain drawing questionnaire and postoperative radiographic measurements of component positioning were performed. In the SRA cohort, 11 of 21 patients (52%) with acetabular uncoverage of ≥5mm versus 43 of 147 (29%) with acetabular uncoverage of ≤4.9mm reported groin pain (P=.03). In the THA cohort, an increased distal-third canal fill ratio and a lower canal calcar ratio trended towards a higher incidence of thigh pain (P=.10 and .06), while a decreased mid-third canal fill ratio was associated with increased severity of thigh pain (P=.04). This study identifies associations between radiographic findings and pain following THA and SRA.

Medical Comorbidity is Associated with Persistent Index Hip Pain after Total Hip Arthroplasty

To characterize whether medical comorbidity predicts persistent moderate-severe pain after total hip arthroplasty (THA). We analyzed the prospectively collected data from the Mayo Clinic Total Joint Registry for patients who underwent primary or revision THA between 1993 and 2005. Using multivariable-adjusted logistic regression analyses, we examined whether certain medical comorbidities were associated with persistent moderate-severe hip pain 2 or 5 years after primary or revision THA. Odds ratios (ORs), along with 95% confidence intervals (CIs) and P value, are presented. The primary THA cohort consisted of 5,707 THAs and 3,289 THAs at 2 and 5 years, and revision THA, 2,687 and 1,627 THAs, respectively. In multivariable-adjusted logistic regression models, in the primary THA cohort, renal disease was associated with lower odds of moderate-severe hip pain (OR 0.6; 95% CI 0.3, 1.0) at 2 years. None of the comorbidities were significantly associated at 5 years. In the revision THA cohort, heart disease was significantly associated with higher risk (OR 1.7; 95% CI 1.1, 2.6) at 2 years and connective tissue disease with lower risk (OR 0.5; 95% CI 0.3, 0.9) of moderate-severe hip pain at 5-year follow-up. This study identified new correlates of moderate-severe hip pain after primary or revision THA, a much-feared outcome of hip arthroplasty. Patients with these comorbidities should be informed regarding the risk of moderate-severe index hip pain, so that they can have a fully informed consent and realistic expectations.

SAT0335 Medical Comorbidity is Associated with Persistent Index Hip Pain after Primary THA

BackgroundPain is the #1 reason for patients with end-stage arthritis to undergo hip arthroplasty. More insights into factors that predict suboptimal pain outcomes after hip arthroplasty are needed to improve...

The outcomes of hip resurfacing compared to standard primary total hip arthroplasty in Men

BackgroundThe purpose of this study was to evaluate the clinical and radiographic outcomes of hip resurfacing patients and compare them to standard primary total hip arthroplasty procedures performed during the same period of time.MethodsOne hundred and fourteen consecutive men who had a mean age of 50 years (range, 20 to 85 years) and who had undergone 120 hip resurfacing arthroplasties between 2007 and 2009 were compared to 117 consecutive men (120 hips) who had undergone a standard total hip arthroplasty during the same time period. The mean follow-up was 42 months (range, 24 to 55 months) for both groups. Outcomes evaluated included implant survivorship, hip scores, activity levels, and complication rates.ResultsIn the resurfacing hip arthroplasty cohort, implant survivorship was 98% with two patients requiring a revision surgery one for femoral neck fracture and another for femoral head loosening. In comparison, implant survivorship was 99% in the standard total hip arthroplasty cohort, with 1 revision due to peri-prosthetic fracture which was successfully treated with a femoral component revision. In the resurfacing and standard hip arthroplasty cohorts, the mean post-operative Harris hip scores had improved to 96 and 94 points, respectively and were statistically similar. The resurfacing cohort had achieved a significantly higher mean post-operative University of California Activity Score (6.7 versus 5 points). There were no differences in the complication rates between the two cohorts.ConclusionWhen patients meet the appropriate selection criteria in the hands of experienced and high-volume arthroplasty surgeons, hip resurfacing provides excellent results at short- to mid-term follow-up.

Patient-level clinically meaningful improvements in activities of daily living and pain after total hip arthroplasty: data from a large US institutional registry

To characterize patient-level clinically meaningful improvements in pain and limitation of key activities of daily living (ADLs) after primary or revision total hip arthroplasty (THA). We analysed prospectively collected data from the Mayo Clinic Total Joint Registry to study clinically meaningful improvements in index hip pain severity and limitation in seven key ADLs (walking, climbing stairs, putting on shoes/socks, picking up objects, getting in/out of car, rising from a chair and sitting), from preoperative to 2- and 5-year post-THA. The primary THA cohort consisted of 6168 responders preoperatively, 5707 at 2 years and 3289 at 5 years postoperatively. The revision THA cohort consisted of 2063 responders preoperatively, 2682 at 2 years and 1627 at 5 years postoperatively. In the primary THA cohort, clinically meaningful pain reduction to mild or no hip pain at 2 years was reported by 94% with moderate and 91% with severe preoperative pain; respective proportions were 91% and 89% at 5-year follow-up. For revision THA, respective proportions were 84% and 77% at 2 years and 80% and 78% at 5 years. In the primary THA cohort, up to 4% with moderate and 17% with severe preoperative ADL limitation reported severe limitation in the respective activity 2 years post-primary THA; at 5 years, the respective proportions were up to 7% and 20%. Respective proportions for revision THA were up to 10% and 26% at 2 years and 13% and 30% at 5 years. These comprehensive data for patient-level clinically meaningful improvements in pain and seven key ADLs can help patients set realistic goals for improvement after THA.

Impact of alternative coding schemes on incidence rates of key complications after total hip arthroplasty: a risk-adjusted analysis of a national data set.

Administrative data are commonly used to examine orthopedic outcomes including total hip arthroplasty (THA), but little is known about how minor analytic decisions impact results. Our objective was to examine how the rates of 3 adverse outcomes (deep vein thrombosis [DVT], pulmonary embolism [PE], and hemorrhage) varied with subtle adjustments to our analytic method. We used Medicare Part A data to identify all beneficiaries who underwent primary or revision THA during 2007 to 2008. We used 2 published algorithms (Katz/Cram and Patient Safety Indicators [PSIs]) to identify cases of DVT, PE, and hemorrhage occurring at 3 different points in time; index admission; 30-day readmission; and index admission plus readmission. We used the kappa statistic to compare the agreement between methods. We examined variation in complication rates across hospitals using regression models that adjusted for differences in patient demographics and comorbidity. Among 202773 primary and 40973 revision THA patients, the agreement between the Katz/Cram and PSI methods was excellent for DVT and PE at all time points (kappa 0.95-1.0) but poor for hemorrhage (kappa 0.07-0.29). The incidence of DVT during the index admission among the primary THA cohort was 0.40% using the Katz/Cram method and 0.37% using the PSI method. The incidence of hemorrhage during the index admission among the primary THA cohort was 1.29% using the Katz/Cram method and 0.05% using the PSI method. We found significant variation in hospital rates of all 3 complications (DVT, PE, and hemorrhage). For example, the mean rate of hemorrhage at index admission or readmission for revision THA was 5.7% (standard deviation: 12.8%); we found 137 hospitals with hemorrhage rates of 25% or higher among their revision THA patients. We found important differences in the rates of THA complications depending upon the coding algorithms and time frame employed. Our results suggest that administrative data can be used to evaluate THA complications but that methodology should be carefully considered.

Cancer risk is not increased after conventional hip arthroplasty

Background and purpose Wear debris from conventional total hip arthroplasty (THA) induces chromosomal aberrations and DNA damage, which may promote cancerogenesis. A long latent period is required for solid tumors. We therefore re-analyzed a large THA cohort for cancer.Patients and methods We updated a cohort of 24,636 patients with primary osteoarthritis and metal-on-polyethylene THA who had been entered in the Finnish Arthroplasty Register between 1980 and 1995, and linked it to the Finnish Cancer Registry for cancer risk assessment up to 2005. The mean follow-up time was 13 years. The numbers of cancer cases observed were compared with expected rates based on incidence in the general population.Results The standardized incidence ratio (SIR) for the whole follow-up period was 0.95 (95% confidence interval (CI): 0.92–0.97). After 10 years of follow-up, the SIR was equal to that in the normal population (SIR = 0.98, 95% CI: 0.94–1.03). Incidence of lung cancer was low throughout the follow-up time and that of prostate cancer was slightly elevated. The incidence rates for all other forms of cancer did not deviate significantly from those in the normal population.Interpretation We found no increased cancer risk in patients with conventional THA after an average of 13 years and up to 25 years of follow-up.

Functional variants of the P2RX7 gene, aseptic osteolysis, and revision of the total hip arthroplasty: A preliminary study

Periprosthetic osteolysis (OL) is a major long-term complication of the total hip arthroplasty (THA), which can result in aseptic loosening and revision surgery. Purinergic receptor P2X, ligand-gated ion channel 7 (P2RX7) is an important regulator of inflammation and bone turnover. We were therefore interested in whether functional variants of the P2RX7 gene may be associated with OL and risk of THA failure. A total of 205 unrelated Czech patients with cementless-type THA were stratified according to the severity of acetabular OL and revision of THA. Four “loss-of-function” P2RX7 single nucleotide polymorphisms (SNPs), namely Glu496Ala, Ile568Asn, Arg307Gln, and null allele (rs35933842), were genotyped by polymerase chain reaction with sequence-specific primers (PCR-SSP). No significant association of P2RX7 variants with severity of OL was observed. The carriers of rare variants P2RX7 568Asn, 307Gln and null allele, all causing complete loss of P2RX7 function, tended to be overrepresented among patients with THA revision (9.6%) by comparison with those with unrevised functional prosthesis (2.1%, p = 0.09). Furthermore, the carriage of the P2RX7 307Gln allele was associated with greater cumulative hazard of THA revision ( p = 0.02). In this preliminary study, we could nominate but not clearly demonstrate rare P2RX7 loss-of-function variants being associated with THA failure. Investigation in large THA cohorts is therefore warranted.

No Difference in Gender-specific Hip Replacement Outcomes

Gender-specific total hip arthroplasty (THA) design has been recently debated with manufacturers launching gender-based designs. The purpose of this study was to investigate the survivorship and clinical outcomes of a large primary THA cohort specifically assessing differences between genders in clinical outcomes, implant survivorship, revisions as well as sizing and offset differences. We reviewed 3461 consecutive patients receiving 4114 primary THAs (1924 women, 1537 men) between 1980 and 2004 with a minimum of 2 years followup (mean, 11.33 +/- 6.5 years). A subset of patients with complete implant data was reviewed for sizing and offset differences. Preoperative, latest, and change in clinical outcome scores as well as Kaplan-Meier analysis were performed. Men had higher raw clinical outcome scores preoperatively and postoperatively. Differences in change of clinical outcome scores were found only in the WOMAC pain score in favor of the female cohort (39.4 versus 36.1). Survivorship and revision rate were not significantly different. Men used larger stems with greater stem lengths, neck offset, and neck lengths. Current implant systems were sufficiently versatile to address the different size and offset needs of male and female patients. These data suggest there is no apparent need for a gender-designed THA system. Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Long-Term Outcome of Surface Replacement With Comparison to an Age- and Time-Matched Primary Total Hip Arthroplasty Cohort

Surface replacement (SR) was introduced as a bone-conserving alternative to total hip arthroplasty (THA) 3 decades ago, then was abandoned due to polyethylene wear, stress shielding, and loosening. Improved bearing surfaces have renewed interest in SR. This study examined long-term SR outcome compared to an age- and time-matched THA cohort. Average age was 47 years at index procedure with 16 years follow-up (range, 5-28). Revision rates were 86% and 40% in SR and THA groups, respectively. However, at 20 years, with an end point of either intact SR or primary THA in the SR group, survivorship was 64% ± 6% versus 39% ± 7% unrevised in THA cohort. Contemporary and rapidly changing technology may result in longer-term SR success and improved THA longevity in young patients.

Orthopaedic Crossfire®—larger femoral heads: A triumph of hope over reason!: In the affirmative

The authors' wear studies of total hip arthroplasty cohorts have shown that less polyethylene wear and less deleterious effects of third body debris were found when smaller femoral head sizes were used. The authors' sliding-distance-coupled finite element model findings were corroborated by these clinical wear studies. Thus, with polyethylene on metal bearing surfaces, less wear should occur when smaller head sizes are used. Careful, precise component positioning is important to prevent dislocation. © 2003 Elsevier Inc. All rights reserved.

Choices and compromises in the use of small head sizes in total hip arthroplasty.

Observation cohort studies, a sliding-distance-coupled finite element model, and an expanded finite element model that simulates dislocation were used to evaluate the benefits and compromises associated with the use of smaller femoral heads in the total hip arthroplasty construct. Wear studies of total hip arthroplasty cohorts showed less polyethylene wear and less deleterious effects of third body debris when smaller femoral head sizes were used. The sliding-distance-coupled finite element model findings were corroborated by these clinical wear studies. The dislocation model predicted the increased propensity for dislocation when smaller modular head femoral components were used in the cohort studies. Impingement is not the only contributor to frank dislocation. The dislocation model explicitly defined the range of motion changes from impingement to dislocation, and the resisting moment changes between construct designs.