Total Hip Arthroplasty Procedures Research Articles

Early Patient-Reported Outcome Measures Following Computer Navigated Total Hip Arthroplasty: A Study from the Australian Orthopaedic Association National Joint Replacement Registry.

Total hip arthroplasty (THA) is a well-established treatment for symptomatic hip osteoarthritis (OA). The use of computer navigation in THA aims to achieve the reconstruction of the joint more consistently and precisely. The aim of this study was to contrast patient-reported outcome measures (PROMs) for THA procedures with and without commercially available navigation technologies. Post-operative PROMs for primary THA procedures performed for OA between August 2018 and December 2022 and recorded in the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) were analyzed. Procedures using computer navigation were compared to those using conventional instrumentation. Baseline patient characteristics and surgeon volume were sub-analyzed. Multivariable regressions were used to compare postoperative PROMs. There were 13,400 THA procedures for OA with PROMs recorded and 749 with navigation. The mean (standard deviation) EuroQol-visual analog scales (EQ-VAS) scores for navigated cases were 67.3 (19.3) pre-operatively and 81.7 (15.0) post-operatively, compared with 66.0 (20.3) and 80.5 (15.8) for the non-navigated group. Oxford Hip scores (OHS) and patient-reported change were similar between groups. The change from pre- to postoperative EQ-VAS and OHS did not significantly differ between computer-navigated and non-navigated cases. After adjusting for patient and procedure factors, the use of computer navigation was associated with a higher rate of procedure satisfaction (rate ratio 1.03, 95% CI [confidence interval] 1.01 to 1.06, P = 0.02). While procedural satisfaction was marginally higher following navigated THA (P = 0.02), there were no statistically significant differences in the change in EQ-VAS or when comparing navigated with 'non-navigated' approaches for primary THAs. Based on the reviewed national registry data for PROMS, we were unable to demonstrate clinically relevant evidence to support claims of superiority of non-navigated or navigated primary THAs. Further work, including similar comparisons with longer-term follow-up, will be of value in elucidating if a true clinically relevant difference exists.

Utilization and Reimbursements of Primary Total Joint Arthroplasty in Ambulatory Surgical Centers: Analysis of Medicare Part A and B Databases

BackgroundRecent changes in Medicare reimbursement policies have facilitated the shift of primary total joint arthroplasty (TJA) volume to ambulatory surgical centers (ASC). The ASCs potentially provide a more cost-effective alternative to a hospital-setting TJA. This study investigated Medicare primary TJA utilization and reimbursement trends at ACSs compared to inpatient and outpatient settings between 2019 and 2022. MethodsMedicare Part A and B claims data from the Centers for Medicare & Medicaid Services (CMS) databases were analyzed. Primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures were identified using Current Procedural Terminology (CPT) codes, Diagnostic Related Group (DRG) codes, and Comprehensive Ambulatory Payment Classification (C-APC) codes based on respective settings. The ASC utilization data was extracted based on year. Billing data for ASCs, hospital outpatient departments (HOPD), and inpatient TJA were compared. Monetary values were adjusted to 2022 dollars using the Consumer Price Index (CPI). ResultsFrom 2019 to 2022, 1,665,237 primary TJA claims were billed (TKA 1,079,846 claims; THA 585,391 claims), with a 6.1% increase in total utilization. The volume of ASC TJAs increased by 327.1% (TKA 193.8% from 2020 to 2022; THA 61.1% from 2021 to 2022). In the same period, average reimbursement for ASC TJAs rose by 3.9% (TKA 3.4%; THA 1.3%) but showed an 8.1% decline after adjusting for inflation (TKA -8.4%; THA -6.2%). By 2022, ASCs accounted for 8.6% of the total TJAs with the lowest reimbursement per procedure (TKA $8,472.3; THA $8578.7). This shift to ASCs corresponded with $235 million saved compared to inpatient settings and $137 million saved compared to HOPDs per year. ConclusionOur study highlights a marked increase in TJA volume at ASCs, with the procedure costing significantly less than HODP or inpatient TJAs. The findings underscore the growing acceptance of these centers as viable, cost-effective alternatives to traditional hospital settings. However, with the declining value of ASC reimbursements, continued monitoring of reimbursement policy is necessary to ensure the sustainability of these cost-effective ASCs for TJAs.

Acute treatment of elderly patients with acetabular fractures by open reduction, internal fixation, and total hip arthroplasty: a 1-10-year follow-up of 48 patients.

Acetabular fractures in osteoporotic bone are associated with substantial joint impaction and comminution, previously shown to be prognostic for a poor result. A combined procedure of open reduction, internal fixation (ORIF), and total hip arthroplasty (THA) can be a good option, allowing for immediate weightbearing as tolerated. We report short- to medium-term outcome and complications of the results of patients treated with this combined procedure. 48 cases treated with ORIF and acute THA from 2000 to 2019 were identified from our local pelvic fracture registry, from which follow-up data was extracted. Descriptive statistics were used and Kaplan-Meier survival curves were calculated. Primary outcome was HHS at 1 year. Secondary outcomes were implant survival, complications requiring surgery, and mortality at 3 months. There were 37 men and 11 women treated in the study period. Mean age was 68 (37-87) years. 6 patients died within 3 months of surgery, leaving 42 cases available for follow-up. Mean follow-up (FU) was 2.8 (1-16) years. The most common mechanism of injury was fall from standing height (n = 36). Medical comorbidities were common. Mean Harris Hip Score (HHS) was 83 (51-100) at 1-year follow-up. There were 7 reoperations: 6 for postoperative infection and 1 closed reduction of implant dislocation. 38 had their implant intact at latest FU. At the latest FU, 28 patients were ambulatory without a walking aid. Our results indicate that ORIF and acute THA can be performed with good functional results in patients with unreconstructable displaced acetabular fractures, but with a significant risk of infection and revision.

Assessment of spinopelvic relationship among Turkish orthopedic surgeons in total joint replacement: a survey.

This study aims to investigate the preferences of orthopedics and traumatology specialists in evaluating the spinopelvic relationship in primary total hip arthroplasty (THA) in Türkiye. Members of the Turkish Orthopedics and Traumatology Association (n=2485) were invited to fill out the questionnaire. The survey was created using Google Forms and distributed to participants via WhatsApp and Gmail by sharing the link. A total of 205 orthopedic surgeons responded and completed the questionnaire. The survey included 13 questions about the duration of their experience, the number of THA and spinal instrumentation procedures they performed, the dislocation rates they encountered after surgery, and the radiological assessments they performed for the spinopelvic relationship. Sixty-three percent of the participants evaluated spinopelvic parameters in patients undergoing THA. Forty-seven percent of surgeons state that in their daily practice, they determine the angle of the acetabular component according to whether the spinal deformity is rigid, flexible, balanced, or unstable. While 88% of the participants stated the rate of encountering dislocation after primary THA as less than 2%, 12% of the participants stated it as more than 2%. It was observed that 40% of the surgeons with a prosthetic dislocation rate of more than 2% evaluated the spinopelvic relationship, while 67% of the surgeons with a dislocation rate of less than 2% evaluated the spinopelvic relationship. Approximately half of the orthopedic surgeons in Türkiye plan component placement in primary THA cases by considering the spinopelvic relationship. In order to increase awareness about the spinopelvic relationship, it would be beneficial to give more space to this subject in training programs and conferences. N/A.

The accuracy and efficiency of design and development of 3D printed integral anatomical acetabular prosthesis in total hip arthroplasty for Crowe type Ⅱ and Ⅲ developmental dysplasia of the hip

Objective: To compare the accuracy and efficiency between the model development method and the software development method, which design and develop 3D printed integral anatomical acetabular prosthesis to be used in total hip arthroplasty(THA) for patients with Crowe type Ⅱ and Ⅲ developmental dysplasia of the hip(DDH). Methods: Fifteen patients with end-stage hip osteoarthritis due to Crowe type Ⅱ and Ⅲ DDH who underwent THA in the Orthopedics Department of the First Affiliated Hospital of Bengbu Medical College between January 2015 and June 2023 were selected in this study retrospectively. There were 1 male (1 hip) and 14 females (17 hips) with a mean age of (55.1±9.1) years. There were 12 hips with Crowe type Ⅱ, 6 hips with Crowe type Ⅲ. The preoperative pelvis three-dimensional CT data in those patients were used to design integral anatomical acetabular prosthesis. The model development group used 3D printing technology to print life-size pelvis models. The acetabulum was reamed and the acetabulum cup was inserted into the socket according to conventional THA procedures. The bone defect above the acetabulum cup was filled with bone wax. The Mimics and 3-matic software were used to simulate the THA procedures, design and install the integrated anatomical acetabular prosthesis in the software development group. The operation time, the size of the acetabular cup, the volume and surface area of the acetabulum bone defect, the acetabular cup's inclination and anteversion, the horizontal distance and the vertical distance of hip rotation center were compared between the two methods. Results: The study in the two groups were all based on the data of 18 hips in the 15 patients. The horizontal and vertical distances of rotation center in the model development group and software development group was (32.08±1.80) mm, (32.17±2.40) mm and (14.36±1.53) mm, (15.11±1.45) mm, respectively (both P>0.05). The cup size in model development group was (48.56±1.15)mm, and it was (48.77±1.22) mm in the software group (P=0.160). The anteversion and inclination of the acetabular cup in the model and software groups were 23.79°±6.31°, 30.49°±11.03° and 15.17°±0.52°, 40.24°±0.58°, respectively (both P<0.01). The volume and surface area of the acetabulum bone defect in the model development group was (5.06±2.86) mm3 and (8.31±2.21) mm2, respectively, while it was (4.01±2.56)mm3 and (6.83±2.71) mm2, respectively, in the software development group (both P<0.05). The work time in the model development group was (24.43±0.68) h and (0.47±0.12) h in the software development group, respectively (P<0.001). Conclusion: Compared with the 3D printing model development method, the application of Mimics and 3-matic software to design and develop integrated anatomical acetabular prosthesis in total hip arthroplasty for Crowe type Ⅱ and Ⅲ DDH show advantages of convenience, high efficiency and more accuracy.

Trends in Hip Arthroplasty Cementation: Insights from an Italian Registry of 142,113 Patients

Introduction: The use of cementation in total hip arthroplasty (THA) has evolved over the years, with a notable shift toward cementless and hybrid techniques. The aim of this study is to evaluate data from an Italian registry on the type of fixation used in THA implants and their corresponding survival rates in a large patient cohort with long-term follow-up, and to compare these data with the most recent literature. Methods: From January 2000 to December 2020, a total of 137,256 primary THA procedures were performed, of which 10.4% were fixed with stem cementation. There were 4857 revision implants, of which 11.4% were implanted with stem cementation. Results: The trend showing a significant shift toward cementless fixation methods is particularly pronounced in younger patients, with cementless implants comprising 99.5% of procedures in patients under 40 years of age. As patient age increases, the use of cemented or hybrid fixation methods becomes more common. This trend aligns with existing literature, in which cementation is often preferred for elderly patients due to concerns about bone quality and the potential for better immediate fixation provided by cemented stems. At 10 years, the implant that showed the highest survival rate was the fully cemented implant, with a rate of 94.8%. This study also reports the causes of failure based on the different fixation techniques. Conclusions: The development of standardized guidelines that consider patient-specific factors such as age, bone quality, and comorbidities in the choice of fixation type could help reduce variability in practice and improve overall outcomes in hip arthroplasty.

Challenges and Long-Term Outcomes of Cementless Total Hip Arthroplasty in Patients Under 30: A 24-Year Follow-Up Study with a Minimum 8-Year Follow-Up, Focused on Developmental Dysplasia of the Hip.

Background: Total hip arthroplasty (THA) is a well-established and effective treatment for advanced osteoarthritis (OA) of the hip joint. While commonly performed in older patients, THA is increasingly used in younger individuals, especially in cases of secondary coxarthrosis. Technological advances have led to the development of specialized implants, which allow surgeons to address severe post-inflammatory or dysplastic deformities. Younger patients undergoing THA, often in their 20s or 30s, present higher functional expectations. Despite limited long-term studies, research indicates a higher rate of revision surgeries in this age group compared to older populations, making these procedures a unique challenge. Methods: This retrospective study analyzed 5263 primary total hip arthroplasties (THAs) performed at our center between May 1985 and December 2016. After excluding cemented and hybrid implants, as well as patients lost to follow-up or with other etiologies, 101 uncemented THA procedures in 92 patients aged 30 years or younger were included. The majority (64.4%) were due to dysplastic coxarthrosis (DDH), while avascular necrosis (26.7%) and juvenile rheumatoid arthritis (8.9%) accounted for the rest. The average patient age was 25.6 years, with a mean follow-up period of over 24 years. Surgical technique involved the anterolateral approach, with implants placed in the true acetabular region. Implants included Munich/Plasmacup, Mittelmeier, and P-M designs. Implant survival was estimated using the Kaplan-Meier estimator to determine the probability of implant longevity over the follow-up period. Outcomes were assessed using Merle d'Aubigné and Postel scores, modified by Charnley, alongside radiographic evaluations based on the Crowe, De Lee, and Gruen classifications. Results: Preoperatively radiological assessment of all hips was classified as grade IV according to the Kellgren-Lawrence scale. Over an average follow-up of 24 years, final outcomes using the modified Merle d'Aubigné and Postel (MAP) classification were excellent in 24%, good in 37%, satisfactory in 8%, and poor in 32% of cases. Results compared between DDH group and control group indicate significantly more poor results for the DDH group compared to the control group (p-value < 0.05). All poor outcomes were associated with prosthesis loosening, primarily involving P-M and Mittelmeier acetabular components. Complications included intraoperative fractures in five cases, peripheral nerve dysfunction in six cases, and heterotopic ossification in eight cases. Postoperative pain scores on the VAS scale improved from 6.8 to 1.7. The Kaplan-Meier estimator indicated 10-year survival rates of 85.2% for the entire prosthesis, with 69.8% survival at 15 years and 54.5% at 20 years. For each period the bio-functionality according to Kaplan-Meier estimator was in favor of the control group. Conclusions: Cementless THA in patients aged 30 or younger has demonstrated itself to be an efficacious treatment for hip osteoarthritis, yielding favorable bio-functional outcomes in both short- and long-term follow-up. Nevertheless, THA performed in the context of developmental dysplasia of the hip (DDH) carries a significantly elevated risk of postoperative complications, most notably aseptic loosening, which critically undermines implant survival rates. Given the young demographic and the anticipated prolonged functional lifespan of the prosthesis, there is an increased propensity for loosening over time, necessitating vigilant and sustained postoperative surveillance.

Validation of the 5-SNP score for the prediction of venous thromboembolism in a Danish fast-track cohort of 6,789 total hip and total knee arthroplasty patients

BackgroundVenous thromboembolism (VTE) is a serious complication following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Despite improvements with fast-track treatment protocols, still 0.5% of patients develop a VTE within 90-days postoperatively. Previously, the 5-SNP genetic risk scores (weighted and simplified), were developed to identify people at a high risk of VTE within the general population. ObjectivesWe aimed to assess whether the 5-SNP scores could be used to identify high-risk patients in a cohort of fast-track THA/TKA patients. Patients/MethodsA subset of patients from the Lundbeck Centre for Fast-track Hip and Knee Replacement Database, based on the availability of genetic information, was included. Within these patients, the 5-SNP scores were calculated and their discriminatory performance was determined by c-statistic. Furthermore, the 5-SNP scores were added to a simple logistic prediction model containing clinical predictors to assess the added predictive value. Results7,753 THA and TKA procedures (6,798 patients) were included in this study. The c-statistics for the weighted and simple 5-SNP score were 0.50 (95% confidence interval [CI] 0.39 – 0.61) and 0.48 (95%CI 0.38 – 0.58), respectively. For the model with clinical predictors, the c-statistic was 0.67 (95%CI 0.56 – 0.77). Addition of either of the 5-SNP scores did not improve discrimination in this model. ConclusionsThese findings do not support genetic risk profiling in fast-track THA/TKA patients to predict VTE. Hence, efforts should be directed at optimizing prediction models with clinical predictors.

Patient and Surgical Factors Associated With Long-Term Mortality Outcomes Up to Fifteen Years After Total Hip and Knee Arthroplasty: An Australian Orthopaedic Association National Joint Replacement Registry Study

BackgroundMortality rates following total hip arthroplasty (THA) and total knee arthroplasty (TKA) arthroplasty display distinct temporal patterns often attributed to patient selection bias, perioperative optimization, and comorbidities. Understanding these mortality patterns is essential for epidemiological and health economic longitudinal modeling. MethodsWe conducted a national registry-based cohort study in Australia using data from 1999 to 2022, examining primary and revision THA and TKA procedures for osteoarthritis. We assessed patient factors (age, sex, body mass index, and American Society of Anaesthesiologists score), and surgical factors (procedure, fixation, bearing surface, and implant volume) in relation to long-term mortality. Standardized mortality ratios were calculated by comparing observed and expected deaths based on national mortality rates. ResultsOur study included 540,181 THA and 880,036 TKA procedures. Temporal trends in mortality rates were observed, with a reduction in mortality rate observed up to seven years for both primary THA and primary TKA after the index procedure and an increased mortality rate observed thereafter. All patient factors were associated with differences in mortality rates, with younger (age range, 45 to 49 years) patients for primary TKA demonstrating the strongest association with mortality excess (15 years; standardized mortality ratios 2.02; 95% confidence interval 1.66 to 2.46). Revision procedures were associated with higher mortality rates compared to their respective primary procedures at all time points. ConclusionsOur study finds noncausal associations between patient and surgical factors and mortality up to fifteen years following THA and TKA for osteoarthritis in Australia. These findings are crucial for calibrating epidemiological and economic models and enhancing the precision of longitudinal outcome predictions for arthroplasty patients. While limitations exist, our study informs clinical practice, healthcare policies, and future research in arthroplasty surgery on a national scale, with potential relevance to similar populations worldwide. Level of EvidenceLevel III, therapeutic study.

Comparison of Implant Placement Accuracy Between Manual, Robot-Assisted, Computer-Navigated, Augmented Reality Navigated, Patient-Specific Instrumentation, and Accelerometer Navigated Total Hip Arthroplasty: A Systematic Review and Network Meta-Analysis.

Malpositioning of the acetabular cup during total hip arthroplasty (THA) can lead to complications. Robotic surgery and navigation techniques aim to address this issue, but there is limited evidence regarding which method can achieve better clinical outcomes. Therefore, this network meta-analysis (NMA) aimed to compare the efficacy of various navigation methods. This NMA of prospective randomized controlled trials compared robot-assisted systems (RAS), computer-assisted navigation systems (CAS), augmented reality-based portable navigation (AR), patient-specific instrumentation (PSI), portable accelerometer-based navigation (PN), and conventional methods (C) for THA procedures. We searched MEDLINE, EMBASE, Cochrane, Central Register of Controlled Trials, International Clinical Trials Platform Search Portal, and ClinicalTrials.gov. databases. The primary outcomes included revision surgery and postoperative clinical scores, and the secondary outcomes encompassed cup placement accuracy, acetabular cup placement outliers from the Lewinnek safe zone, surgical time, and complications. We used a Bayesian random-effects NMA, and confidence of evidence was assessed using confidence in NMA. We identified 45 studies including 2,122 patients. We did not find large differences in revision surgery, clinical outcome scores, cup inclination, or anteversion angle accuracy among the modalities. AR, CAS, and PSI exhibited a lower risk of outliers from safe zones than C. In addition, RAS and CAS had a longer surgical time than C. Robotic and navigation tools did not reduce the revision risk or enhance clinical outcomes. AR, CAS, PSI, and PN may decrease the risk of cup placement outliers in safe zones. However, the cup placement accuracy was equivalent, and the surgical time may be longer in RAS and CAS than in C. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Women undergoing primary total hip arthroplasty (THA) for hip fracture have lower in-hospital mortality compared to men

IntroductionWe evaluated the association of patient sex with in-patient mortality and discharge disposition after primary total hip arthroplasty (THA) for hip fracture in the U.S. MethodsUsing the 2016–2019 U.S. National Inpatient Sample (NIS), we calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) of the association of sex with post-procedural complications and in-hospital mortality after primary THA for hip fracture, adjusting for demographics, social determinants of health, medical comorbidity, hospital characteristics, and post-procedural complications. ResultsThere were 400,930 primary THA procedure hospitalizations for hip fracture in the 2016–2019 NIS data. In multivariable-adjusted analysis, compared to males, female sex was associated with lower in-hospital mortality following THA for hip fracture (aOR 0.65, 95 % CI 0.58 - 0.74; p < 0.001). Multivariable-adjusted analysis showed that female sex was associated with higher odds of discharge to a non-home destination after a THA for hip fracture (aOR 1.14, 95 % CI 1.07 - 1.22; p < 0.001). ConclusionsFemale sex was associated with lower in-hospital mortality after a THA for hip fracture. Further insights into the protective mechanisms that mediate this lower mortality in women undergoing a THA for hip fracture are needed to achieve better outcomes for men in the future.

Leg length discrepancy risk differs between fit-and-fill and taper wedge stems across Dorr types.

The comparison between the cementless taper wedge stem and fit-and-fill stem in total hip arthroplasty (THA) for various proximal femoral morphological types has not been thoroughly assessed. This study aimed to compare the risk of leg length discrepancy (LLD) ≥ 10mm between these two stem types in Dorr type A, B, and C femurs. From April 2015 through April 2021, we analyzed 1178 unilateral primary cementless THA procedures. We categorized all procedures into three groups: Dorr type A (N = 220, 18.7%), B (N = 875, 74.3%), and C (N = 83, 7.0%). Within each Dorr type, we compared the incidence and risk of postoperative LLD ≥ 10mm between the two stem types. The factors considered in the multivariate regression analyses included stem type, age, sex, body mass index, diagnosis, canal flare index, femoral cortical index and stem alignment. The taper wedge stem group had a higher overall incidence of LLD ≥ 10mm (12.8% vs. 7.4%, P = 0.012) and in Dorr type A femurs (22.2% vs. 7.6%, P = 0.014), compared with the fit-and-fill stem group. In multivariate analysis, the taper wedge stem exhibited an increased risk of LLD ≥ 10mm only in Dorr type A femurs (aOR: 3.449, 95% CI: 1.325-8.794). The incidence and risk of LLD ≥ 10mm were not different between the two stems in Dorr type B and C femurs. The taper wedge stem demonstrated an elevated risk of LLD ≥ 10mm in Dorr type A femurs compared with the fit-and-fill stem, necessitating meticulous preoperative templating and intraoperative femoral canal preparation.

Incidence of Ceramic Component Fractures in Total Hip Arthroplasty Using Contemporary Ceramic-On-Ceramic Bearings: A Retrospective Study Spanning Two Decades From Two Tertiary Referral Hospitals

IntroductionCeramic-on-ceramic (CoC) bearings have been widely used in total hip arthroplasty (THA) due to their excellent wear properties. However, ceramic component fractures remain a concern. This study aimed to report the incidence of third- and fourth-generation ceramic component fracture and identify factors that might influence this complication. MethodsA total of 9,280 hips that underwent THA with third- and fourth-generation CoC bearings at two tertiary institutions between 1997 and 2023 were retrospectively reviewed, and the incidence and associated factors of CoC bearing fracture were determined. We performed a Kaplan–Meier survival analysis to assess implant survivorship. Logistic regression was applied to evaluate the influence of implant size and patient-specific factors on the risk of revision. ResultsOut of the 9,280 THA procedures, there were 33 (0.36%) revisions for CoC bearing fracture. Specifically, revisions for fracture were performed for zero out of 6,654 fourth-generation CoC heads, 26 (0.990%) of 2,626 third-generation CoC heads, two (0.030%) of 6,654 fourth-generation CoC liners, and five (0.190%) of 2,626 third-generation CoC liners. All ceramic head fractures occurred in a 28 mm head. Younger age was related to both ceramic head and liner fracture. ConclusionsTo our knowledge, this is the largest two-center retrospective study on CoC bearing fractures to date. The risk of revision for fracture of CoC bearings is low, as previously reported. Our data were comparable to recent evidence suggesting that the latest generation of ceramic components can significantly decrease the incidence of head fracture but not liner fracture. Factors such as younger age and men may be associated with an increased risk of ceramic component fractures. Level of evidenceIII, therapeutic.

Unveiling the dynamics of intraoperative contamination in total hip arthroplasty: the discrepancy between particulate and microbial contamination in surgical site infection risk

BackgroundSurgical site infection (SSI) is a major problem following total hip arthroplasty (THA). This study investigated the impact of a standard intraoperative routine where the surgical team wears full-body exhaust suits (space suits) within a laminar airflow (LAF)-ventilated operating room (OR) on environmental contamination. Our primary objective was to identify potential modifiable intraoperative factors that could be better controlled to minimize SSI risk.MethodsWe implemented an approach involving simultaneous and continuous air sampling throughout actual primary cementless THA procedures. This method concurrently monitored both airborne particle and microbial contamination levels from the time the patient entered the OR for surgery until extubation.ResultsAirborne particulate and microbial contamination significantly increased during the first and second patient repositionings (postural changes) when the surgical team was not wearing space suits. However, their concentration exhibited inconsistent changes during the core surgical procedures, between incision and suturing, when the surgeons wore space suits. The microbial biosensor detected zero median microbes from draping to suturing. In contrast, the particle counter indicated a significant level of airborne particles during head resection and cup press-fitting, suggesting these procedures might generate more non-viable particles.ConclusionsThis study identified a significant portion of airborne particles during the core surgical procedures as non-viable, suggesting that monitoring solely for particle counts might not suffice to estimate SSI risk. Our findings strongly support the use of space suits for surgeons to minimize intraoperative microbial contamination within LAF-ventilated ORs. Therefore, minimizing unnecessary traffic and movement of unsterile personnel is crucial. Additionally, since our data suggest increased contamination during patient repositioning, effectively controlling contamination during the first postural change plays a key role in maintaining low microbial contamination levels throughout the surgery. The use of sterile gowns during this initial maneuver might further reduce SSIs. Further research is warranted to investigate the impact of sterile attire on SSIs.

Intraoperative estimation of natural femoral anteversion from proximal femoral osseous orientation during total hip arthroplasty

BackgroundThe purpose of this study was to elucidate the relationship between the orientation of the osseous structure of the proximal femur encountered during total hip arthroplasty (THA) and preoperative femoral anteversion (FA).MethodsThree-dimensional models were constructed using full-length lower extremity computed tomography images from a total of 80 participants. Femoral neck cutting was performed at heights of 5, 10, and 15 mm relative to the lesser trochanter. Following neck cutting, the angles formed by the anterior outer cortex and posterior outer cortex with the posterior condylar line (PCL) were defined as the anterior cortical angle (ACA) and posterior cortical angle (PCA), respectively. Univariate linear regression analysis was conducted using the remaining measurements with FA as the dependent variable.ResultsThe mean age of the participants was 60.98 ± 10.82 years (males, 60.50 ± 11.36 years; females, 61.45 ± 10.37 years) (p = 0.697). All cortical angles and FA were larger in women compared to those in men. When comparing measurements by age groups, no statistically significant differences were observed. Univariate linear regression analysis with FA as the dependent variable showed statistical significance for all cortical angles. The adjusted R2 values were 0.711 (ACA5), 0.677 (ACA10), 0.572 (ACA15), 0.493 (PCA5), 0.574 (PCA10), and 0.446 (PCA15).ConclusionNatural FA can be inferred from the anterior cortical angle (ACA) from femoral neck cutting plane observed during the THA procedure without preoperative images.Trial registrationRetrospectively registered.

Estimated Carbon Savings from Changing Surgical Trends in Primary Elective Total Hip Arthroplasty in England: A Retrospective Observational Study.

The National Health Service (NHS) in England has set a target to be net zero for carbon emissions by 2045. The aim of this study was to investigate how changes in key aspects of clinical practice over the last 8 years have contributed towards reducing the per-patient carbon footprint of elective total hip arthroplasty (THA). This was a retrospective analysis of administrative data. Data were extracted from the Hospital Episode Statistics database for all adult (≥ 17 years), primary, elective THA procedures conducted in England from 1 April, 2014 to 31 March, 2022. The estimated carbon footprint for key elements of the surgical pathway were calculated based on data from Greener NHS and the Sustainable Healthcare Coalition. Data were available for 537,441 THA procedures conducted during the study period. The per-patient carbon footprint associated with the primary THA (index) procedure fell by around 25% from 2014/15 to 2021/22. Length of stay was by far the largest contributor to this decline, falling from 169.1 kgCO2e to 117.6 kgCO2e per patient from 2014/15 to 2021/22. Absolute declines in the carbon footprint associated with emergency readmissions, revisions and outpatient attendances were more modest. If all patients in all years had the 2021/22 average carbon footprint, then carbon equivalent to powering 19,976 UK homes for 1year would have been saved. Improving per-patient efficiency of surgery is likely to contribute towards meeting the NHS's net-zero target whilst also helping to improve patient outcomes, reduce costs and cut waiting lists.

Pathway to Excellence: One Institution's Experience Obtaining the Joint Commission's Advanced Total Hip and Total Knee Replacement Certification.

As the prevalence of total hip and total knee arthroplasty procedures increase over the next decades, hospitals seek opportunities to improve quality outcomes while simultaneously limiting costs and mitigating risks of complications. The Joint Commission's Advanced Total Hip and Total Knee Replacement (THKR) certification is one of the highest quality standard certification programs in the nation and is the only one that collaborates with the American Academy of Orthopedic Surgeons. To obtain THKR certification, several requirements based on evidence-based clinical practice guidelines must be met. The process is described from initial identification of stakeholders to ongoing efforts to retain certification. Joint Commission THKR certification was awarded after rigorous review and on-site visit. Compliance with advanced care standards from the time of orthopedic consultation through postsurgical follow-up was reviewed. Joint Commission THKR certification provides supporting evidence of the institutions journey in processes toward delivering high quality clinical care. A multidisciplinary team with ongoing collaboration is necessary to obtain and retain certification.

Should we be concerned when the anterior approach to the hip goes accidentally medial? A retrospective study

BackgroundThe direct anterior approach is increasingly used for primary total hip arthroplasty (THA) due to its minimally invasive nature and rapid recovery time. Difficulties in identifying the correct intermuscular interval can arise during the procedure, sometimes resulting in excessive medial exposure. This study aimed to evaluate demographics and risk factors, outcomes, and potential complications in those THA patients in which a medialized approach was performed.MethodsWe retrospectively reviewed cases of anterior THA to identify cases where the surgical approach to the hip was more medial than the standard interval. Demographic data, operative time, blood loss, intraoperative and postoperative complications, radiographic findings were collected and compared with a control group of 50 THA performed using the standard anterior intermuscular interval.ResultsIn a series of 1,450 anterior total hip arthroplasty (THA) procedures performed between January 2018 and December 2021, with an average follow-up of 33 ± 22.3 months, six patients (0.4%) had a medialized surgical interval. In one case the superficial layer was medial to the sartorious muscle while in the other five cases, the interval was lateral to the sartorius superficially, and medial to the rectus femoris deeply. Four out of 6 patients (66.6%) showed neuropraxia affecting the femoral nerve, and 3 out of 6 (50%) had involvement of the lateral femoral cutaneous nerve. In 6 out of 6 patients (100%), surgery was performed during the learning curve of DAA. No patients in the control group developed femoral nerve neuropraxia, and 2 out of 50 patients (4%) showed involvement of the lateral femoral cutaneous nerve.Discussion and conclusionThe anterior approach can rarely result in excessive medial exposure to the hip joint, especially during the learning curve. In our study cohort, an increased rate of neurological complications and reduced outcomes were observed, thereby rendering this event of particular clinical significance. To avoid unconventional intermuscular intervals, patient positioning and correct identification of the muscle bellies by recognizing the orientation of the muscle fibers are useful, together with the identification and ligation of the circumflex vessels, to ensure the identification of the correct intermuscular interval.

New Comprehensive Score for Predicting Difficulties in Revision Total Hip Arthroplasty

BackgroundRevision total hip arthroplasty (THA) can be complex, and assessing possible difficulties is important to predict the operative time. No simple score for predicting difficulties has been assessed prospectively. We therefore developed an original score for the pre-operative evaluation of extraction and reconstruction difficulties. The objectives of this prospective study were to (1) assess correlations between score values and operative time, (2) determine whether the score predicted the need for revision implants and/or filling material, (3) determine whether the score predicted intra-operative and post-operative complications, and (4) evaluate the inter-observer and intra-observer reproducibility of the score. HypothesisThe score is reproducible and correlates well with the operative time, thereby allowing prediction of this parameter before surgery. Material and methodsA prospective study of 103 revision THA procedures performed between March 2018 and August 2023 was conducted. The primary outcome was operative time and the secondary outcomes were use of a revision implant, use of filling material, and intra-operative and post-operative complications. The score was determined by four observers to allow evaluation of inter-observer agreement. Intra-observer agreement was assessed by having one of the observers determine the score a second time after inclusion of the last patient. The score has a maximum value of 20 and allows classification of the procedure as very difficult, difficult, and moderately difficult. ResultsMean operative time correlated with the score value: 136.0 ± 33.9 min in the very difficult group, 102.0 ± 34.8 min in the difficult group, and 75.4 ± 65.5 min in the moderately difficult group (p = 0.0002). The score predicted the use of a reinforcement ring (40 procedures: 12/17 [70%], 11/25 [44%], and 17/61 [28%] in the very difficult, difficult, and moderately difficult groups, respectively; p = 0.01) and of a long stem (20 procedures: 8/17 [47%], 7/25 [28%], and 5/61 [8%] patients in the very difficult, difficult, and moderately difficult groups, respectively; p < 0.001). The score did not predict the use of filling material (42 procedures: 10/17 [59%], 9/25 [36%], and 23/61 [37%] in the very difficult, difficult, and moderately difficult groups, respectively; p = 0.250). The score predicted both intra-operative complications (5/17 [29%], 4/25 [16%], and 4/61 [6%] procedures in the very difficult, difficult, and moderately difficult groups, respectively; p = 0.028) and post-operative complications (4/17 [23%], 0/25 [0%], and 6/61 [9%] in the very difficult, difficult, and moderately difficult groups, respectively; p = 0.15). Inter-observer agreement was strong according to Landis-Koch criteria, with kappa values ranging from 0.70 to 0.79 [0.57–0.90]. The kappa value for intra-observer agreement was 0.74 [0.63–0.85]. DiscussionThis score predicts surgical difficulties by adding criteria to bone destruction, in contrast to widely used classifications for revision THA. Moreover, the score is reproducible and predicts the operative time, thus potentially playing an important role during pre-operative planning. Level of evidenceIV; prospective observational non-comparative study

Preoperative SSRI use increases perioperative transfusion need in patients undergoing surgical procedures on the hip joint.

Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for psychiatric conditions. Previous studies have shown that SSRIs can increase bleeding risk by affecting platelet aggregation. However, their impact on perioperative outcomes in hip surgery remains uncertain. This case-control study examines the link between preoperative SSRI use and perioperative transfusion requirements in hip surgery patients. Data from the M161Ortho dataset of Pearl Diver patient records database were utilized. Patients who underwent hip joint surgery between 2010 and 2022 and had documented preoperative SSRI use within one month prior to surgery were included. Patients with coagulopathy disorders or coagulopathy medication use were excluded. Perioperative transfusion need was defined as receiving red blood cell or whole blood transfusions on the same date or within 10 days following the surgery. A total of 75,374 patients with preoperative SSRI use were matched with an equal number of non-SSRI users. Preoperative SSRI use was associated with an increased risk of requiring perioperative transfusion (5.7% vs. 5.1%, P < 0.001). Subgroup analysis demonstrated increased transfusion risk in patients undergoing pinning (2.6% vs. 1.8%, P = 0.02), open reduction with internal fixation (ORIF) (8.9% vs. 8.2%, P = 0.007), and total hip arthroplasty (THA) (3.8% vs. 3.4%, P < 0.001), but no significant difference was observed in patients undergoing hemiarthroplasty. Clinicians should be aware of the potential risk of increased perioperative transfusion requirements in hip surgery patients using SSRIs, especially during pinning, ORIF, and THA procedures. It is essential to consider this when managing patients on SSRIs before hip surgery.