Total Hip Replacement Patients Research Articles

Meaningful Text: Total Hip Replacement Patients’ Lived Experience of a Nursing Care Plan Written in Lay Language

Background: Person-centred care involves respecting patients’ experiences, preferences, and needs, as well as sharing information with them and involving them in care planning. Scant research has been conducted on how it influences patients to have direct access to their care planning when it has been established through the use of standardised care plans or pathways. In the orthopaedic ward in which this study was conducted, a standardised nursing care plan for total hip replacement patients (THR), which was originally written in professional language, was rewritten in lay language and used as peri-operative teaching material for this patient group. Study Aim: To explore the meaning THR patients ascribe to the lived experience of reading and retaining their standardised nursing care plan in lay language during their hospital stay. Methods: The data collection and analysis followed a method adapted by the Vancouver School of Doing Phenomenology. Data were collected through 12 in-depth interviews with six THR patients. Results: The main finding was that the participants acquired knowledge from the text of the care plan that was understandable and meaningful, as evidenced by the empowering impact it had on them. This impact included improved psychological wellbeing, more open communication, and the provision of a tool to keep track of care. Some revisions of the care plan were recommended. Conclusion: The study suggests that a patient version of standardised care plans can act as an important educational tool for THR patients that can empower them to manage their health situations.

Effects of COVID-19 Quarantine on patients affect of hip osteoarthritis in list for joint replacement

Background: The emergency caused by COVID-19 Pandemia has resulted in a complete suspension and consequent delay of common planned surgery such total hip replacement in patients affect by osteoarthritis. At the same time, the issue of the quarantine imposed changes to the normal lifestyle of these patients. The purpose of our study is to evaluate how the presence of these two factors affect the quality of live of patients living in the Italian red zone. Methods: From outpatient pre-operative assessment we collect data about: demographic data, WOMAC score, NRS (Numeric rating scale 0-10), PCS SF12 and MCS SF12 score. Selected patients were therefore contacted by telephone call and re-assess using the same score. In addition, patients were asked if they intended to undergo the planned surgery again despite the current emergency. Results: 14 patient have been recruited for the study. Male/female ration was 10/4, mean age was 70 years. Pre operative outpatient assessment mean WOMAC score was 44,86 (SD ± 8,52) , mean NRS was 8,07 (SD ± 1,33), PCS SF12 was 30,33 (SD ± 5,0) and MCS SF12 was 40,95 (SD ± 3,51). At re-evalutation the mean WOMAC score was 32,86 (SD ± 17,88) , mean NRS was 5,79 (SD ± 3,66), PCS SF12 was 39,9 (SD ± 3,70) and MCS SF12 was 50,14 (SD ± 6,86). Conclusion: The exceptionale pandemic from Covid-19 has profoundly changed our lifestyle, impacting normal daily activities but also on regular surgical activity in patients affected by osteoarthritis. Our study suggested that the lifestyle changes imposed by the situation led to an improvement of clinical score. This shows how an exceptional event can affect many aspects of daily life.

Periacetabular osteotomy with concomitant hip arthroscopy: A case series with 24 months minimum follow-up.

To describe patient-reported outcomes, radiological results, and revision to total hip replacement in patients with hip dysplasia that underwent periacetabular osteotomy as isolated treatment or concomitant with hip arthroscopy. Case series study. Between 2014 and 2017, patients were included if they complained of hip pain and had a lateral center-edge angle ≤ of 20°. Exclusion criteria included an in-maturate skeleton, age of 40 or older, previous hip surgery, concomitant connective tissue related disease, and Tönnis osteoarthritis grade ≥ 1. All patients were studied before surgery with an anteroposterior pelvis radiograph, false-profile radiograph, and magnetic resonance imaging. Magnetic resonance imaging was used to assess intraarticular lesions, and if a labral or chondral injury was found, concomitant hip arthroscopy was performed. The non-parametric median test for paired data was used to compare radiological measures (anterior and lateral center-edge angle, Tönnis angle, and extrusion index) after and before surgery. Survival analysis was performed using revision to total hip arthroplasty as a failure. Kaplan Meier curve was estimated. The data were processed using Stata. A total of 15 consecutive patients were included; 14 (93%) were female patients. The median follow-up was 3.5 years (range, 2 to 8 years). The median age was 20 (range 13 to 32). Lateral center-edge angle, Tönnis angle, and extrusion index correction achieved statistical significance. Seven patients (47%) underwent concomitant hip arthroscopy; three of them (47%) were bilateral (10 hips). The labrum was repaired in six cases (60%). Three patients (15%) required revision with hip arthroplasty, and no hip arthroscopy-related complications are reported in this series. To perform a hip arthroscopy concomitant with periacetabular osteotomy did not affect the acetabular correction. Nowadays, due to a lack of conclusive evidence, a case by case decision seems more appropriate to design a comprehensive treatment.

Profile and Trends in Comorbidity for Patients Undergoing Hip and Knee Arthroplasty Using the Rx-Risk Measure with Pharmaceutical Dispensing Records

IntroductionPatient comobidity at time of primary joint replacement (JR) impacts on outcomes including revision and mortality. Understanding changes in comorbidity profiles is important when assessing change in outcomes over time. Most arthroplasty registries have limited comorbidity information due to their minimum dataset. One approach to obtaining additional comorbidity data is linking registry data with national administrative data. Objectives and ApproachObjectives were to quantify pre-operative comorbidity profile of patients undergoing primary total hip replacement (THR) and total knee replacement (TKR) for osteoarthritis. Also, to examine temporal trends in individual comorbidities for THR and TKR patients. National pharmaceutical dispensing data were linked with THR and TKR arthroplasty patients. Medication dispensing histories in 12-months preceding JR (2003-2017) for 237,333 THR and 394,965 TKR patients, were mapped to 47 comorbidity classes using the Rx-Risk-V measure - a pharmacy-based measure of comorbidity. Comorbidity scores were calculated by summing comorbidity categories for individual patients. Trends in comorbidity scores/categories were described, with comorbidity information presented by PBS beneficiary category (concessional/general), stratified by age (<65/≥65 years). ResultsMedian (interquartile range) comorbidity scores were higher in concessional patients ≥65y, THR:5(3-6), TKR:5(3-7); <65y,TKR:5(3-6) but not THR:4(2-6). Comparative scores for general patients (both ages) were THR:4(2-6) and TKR:3(2-5). Trends in median comorbidity scores were consistent across study period, THR:4- 5(concessional)/2-3(general) and TKR:4-5(concessional)/4(general). Commonly identified comorbidities in younger concessional THR patients were pain, measured by opioid use (62.4%), inflammation/pain, measured by use of non-steroidal anti-inflammatories (62.2%), GORD (36.2%) and hypertension (36.1%). Individual comorbidities remained generally stable over time. However, increased patient proportions were seen in THR concessionals <65y for opioid pain (59.1%-71.1%), depression (24.5-42.5%), whilst inflammation/pain (82.1-56.1%) and antiplatelet use (≥65y:23.5-9.2%) declined. Conclusion / Implicationsn THR or TKR patients no appreciable change in comorbidity score or comorbidity profile occurred over time. This suggests that improving JR outcomes over time are unlikely due solely to variation in patient comorbidity profiles.

What are the inpatient and day case costs following primary total hip replacement of patients treated for prosthetic joint infection: a matched cohort study using linked data from the National Joint Registry and Hospital Episode Statistics

BackgroundProsthetic joint infection (PJI) following total hip replacement (THR) surgery is a serious complication that negatively impacts patients’ lives and is financially burdensome for healthcare providers. As the number of THRs increases, so does this financial burden. This research estimates the economic burden with respect to inpatient and day case hospital admissions for patients receiving revision surgery for PJI following primary THR.MethodsIn this matched cohort study, the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) was used to identify patients. Patients revised for PJI with a one- or two-stage revision following THR and patients not revised for PJI were matched on several characteristics using exact and radius matching. Hospital inpatient and day case healthcare records from the English Hospital Episode Statistics database were obtained for 5 years following the identified patient’s primary THR. UK national unit costs were applied to hospital admissions and the 5-year total cost was estimated. A two-part model (Probit and generalised linear model) was employed to estimate the incremental difference in costs between those revised and not revised for PJI.ResultsBetween 2006 and 2009, 1914 revisions for PJI were identified in the NJR. The matching resulted in 422 patients revised for PJI and 1923 matches not revised for PJI who were included in the analysis. The average cost of inpatient and day case admissions in the 5 years following primary THR was approximately £42,000 for patients revised for PJI and £8000 for patients not revised for PJI. The difference in costs over the 5 years was £33,452 (95% CI £30,828 to £36,077; p < 0.00).ConclusionsIn the 5 years following primary THR, patients who develop PJI and have revision surgery cost approximately £33,000 (over 5-fold) more than patients not revised for PJI based on their hospital inpatient and day case admissions alone. The total burden of PJI is likely to be much higher when also considering outpatient, primary and community care costs. This highlights the need to find both ways to reduce the incidence of PJI following THR and cost-effective treatment strategies if PJI occurs.

Why Do People Undergo THR and What Do They Expect to Gain-A Comparison of the Views of Patients and Health Care Professionals.

Little concerted effort has been made to understand why individuals undergo total hip replacement (THR) surgery and their rehabilitation goals. Similarly, insight of views and perspective of health care professionals’ (HCPs) regarding surgery and what objective measures help them with decision-making is lacking. This patient and public involvement report aimed to explore both patients’ and HCPs’ perspectives of THR surgery. Twenty patients, 10 pre-THR, 10 post-THR, 9 physiotherapists, and 6 surgeons took part. Results suggest a consensus among patients and HCPs on pain reduction being the main reason for undergoing THR. The inability to carry out simple daily activities such as dog walking and sleep deprivation had a significant effect on patients’ mental and physical well-being. This article is the first to explore the views of THR patients and HCPs on reasons behind THR surgery amalgamated into a single report. As walking is important, wearable activity monitors are suggested as a possible motivator to enhance patient compliance to self-care rehabilitation and increase quality of life. A future research project on the use of such wearable activity monitors in enhancing mobility post-THR is therefore planned.

A prospective study on cancer risk after total hip replacements for 41,402 patients linked to the Cancer registry of Norway

BackgroundConcerns have been raised that implants used in total hip replacements (THR) could lead to increased cancer risk. Several different materials, metals and fixation techniques are used in joint prostheses and different types of articulation can cause an increased invasion of particles or ions into the human body.MethodsPatients with THR registered in the Norwegian Arthroplasty Register during 1987–2009 were linked to the Cancer registry of Norway. Patients with THR due to osteoarthritis, under the age of 75 at time of surgery, were included. Standardized incidence ratios (SIR) were applied to compare cancer risk for THR patients to the general population. Types of THR were divided into cemented (both components), uncemented (both components), and hybrid (cemented femoral and uncemented acetabular components). To account for selection mechanisms, time dependent covariates were applied in Cox-regression, adjusting for cancer risk the first 10 years after surgery. The analyses were adjusted for age, gender and if the patient had additional THR-surgery in the same or the opposite hip. The study follows the STROBE guidelines.ResultsComparing patients with THR to the general population in Norway we found no differences in cancer risk. The overall SIR for the THR-patients after 10 years follow-up was 1.02 (95% CI: 0.97–1.07). For cemented THR, the SIR after 10 years follow-up was 0.99 (95% CI: 0.94–1.05), for uncemented, 1.16 (95% CI: 1.02–1.30), and for hybrid 1.12 (95% CI: 0.91–1.33). Adjusted Cox analyses showed that patients with uncemented THRs had an elevated risk for cancer (hazard ratio: HR = 1.24, 95% CI: 1.05–1.46, p = 0.009) when compared to patients with cemented THRs after 10 years follow-up. Stratified by gender the increased risk was only present for men. The risk for patients with hybrid THRs was not significantly increased (HR = 1.07, 95% CI: 0.85–1.35, p = 0.55) compared to patients with cemented THRs.ConclusionsTHR patients had no increased risk for cancer compared to the general population. We found, however, that receiving an uncemented THR was associated with a small increased risk for cancer compared to cemented THR in males, but that this may be prone to unmeasured confounding.

Developing thresholds for intervention recommendation and treatment success after orthopedic surgery

Abstract Background Patient reported outcome measures (PROMs) are increasingly used to monitor recovery paths and the outcome of orthopedic procedures. One of the focus areas is endoprosthetic joint care. Unfavorable post-surgery PROM scores might indicate adverse recovery paths. As of now, an adequate definition of thresholds for recommending an adaptation of therapy does not exist. The same is true for thresholds defining treatment success. Methods To address this research gap, minimal clinical improvement differences and patient acceptable symptom states are estimated using anchor-based methods. Moreover, to better capture the variance in patients' recovery paths, we calculate thresholds for subgroups of patients exhibiting similar pre-operative PROM scores. For this purpose, we use patient data from two German hospitals, covering roughly 6,000 total hip and knee replacement patients treated between 2016 and 2018. Patients answered standard PROM (WOMAC, EQ-5D) and tailored patient satisfaction questionnaires prior to surgery as well as three and twelve months after surgery. Results Whereas we found similar threshold values for total hip and knee replacement patients at the 12 months mark, threshold values after 3 months are systematically better for hip patients than for knee patients. Moreover, we find that thresholds depend on pre-surgery PROM scores. Patients with low pre-surgery scores recover slower, patients in mid-quartiles show large score improvements, and patients in the highest quartile show only mild improvements. Conclusions The study shows that when defining thresholds, it should not only be discriminated by indication but also by patient's pre-surgery condition. This pre-surgery condition can best be described by pre-surgery PROM scores. Further, to implement thresholds into standard care, policy makers need to collaborate with public sickness funds and hospitals to refine thresholds based on nation-wide data. Key messages An adequate definition of PROM score thresholds is necessary to be able to evaluate intervention recommendations and treatment success after surgery. So far, existing research is limited. Recovery paths and therefore PROM score thresholds differ between indications and are dependent on patients’ pre-surgery condition, best described by pre-surgery PROM scores.

Influence of a Preadmission Procedure-Specific Consent Document on Patient Recall of Informed Consent at 4 Weeks After Total Hip Replacement: A Randomized Controlled Trial.

Consent is a legal and ethical requirement for undertaking surgical procedures; however, the literature suggests that there continues to be poor recall among patients of the surgical risks discussed during the consent process. The aim of this study was to evaluate whether the addition of a preadmission procedure-specific consent document would improve patient recall of surgical risks at 4 weeks after total hip replacement in patients consented with a procedure-specific consent form. A prospective randomized controlled trial allocated seventy adult patients who were undergoing a primary total hip replacement to either receive (intervention group) or not receive (control group) a preadmission procedure-specific consent document. All patients were also consented with a procedure-specific consent form on the morning of surgery and were contacted 4 weeks later to assess recall of surgical risks. There was a very poor recall rate seen in both the intervention group (16%) and the control group (13%), with no statistically significant difference between them (P = 0.49). A large number (30%) of patients could not recall a single risk. A subgroup analysis excluding these "consent nonresponders" did show a significantly increased recall rate in the intervention group (24.5% versus 18.25%, P = 0.02). Patient recall of potential complications of total hip replacement was poor despite the intervention. Although not effective overall, the use of a preadmission procedure-specific consent document did improve recall of potential complications of surgery in a subset of patients. The phenomenon of consent nonresponders is worth exploring in future research.

Assessment and reliability of the World Health Organisation quality of life (WHO QOL-BREF) questionnaire in total hip replacement patients

BackgroundSeveral functional scoring tools are available to evaluate the outcomes of total hip replacements (THRs) for diseased or damaged hips. Majority of these scores were devised in western countries and their cross-cultural compatibilities are rarely demonstrated. The World Health Organisation quality of life (WHO QOL-BREF) questionnaire with 4 domains, is one of the best known multilingual instruments for such assessment. Its reliability has never been demonstrated for THRs and the present study was conceptualised for the same. MethodsTHRs done over 6 years were followed up retrospectively. Revision THRs and hemiarthroplasties were excluded. All the cases were done by a single senior arthroplasty surgeon. Clinical examination was done and questionnaires for WHO QOL-BREF and Harris Hip scores were given to the patients. ResultsThe number of patients included in the study was 96 with 115 operated hips. The average age of these patients was 41.40 years ranging from 17 to 80 years. There was strong male preponderance in our series of patients with 90 THRs. The mean score of domain 1 was 70.8 (SD 21.6), domain 2: 72.4 (SD 18.8), domain 3: 74.7 (SD 16.8) and domain 4: 75.4 (SD 14.8); showed significant functional improvement post THR in domain 2 (P = 0.0001), domain 3 (P = 0.0010) and domain 4(P = 0.0001), when compared to scores of general healthy population. Similarly, the scores were significantly improved in all domains as compared to cohorts of post-operative acetabular and hip fractures. The score was found to be a reliable tool with Cronbach’s alpha of 0.912 and strong correlation was present with the standard Harris hip scores (p = 0.000). ConclusionWHO QOL-BREF is a potent tool to assess the quality of life in patients undergoing THRs. It can be used as a single index of measurement and it is simple, reproducible and reliable.

Predictive ability of the American Society of Anaesthesiologists physical status classification\xa0system on health-related quality of life of patients after total hip replacement: comparisons across eight EQ-5D-3L value sets

BackgroundAmerican Society of Anaesthesiologists (ASA) physical status classification system and its association with postoperative outcomes has been studied in different diseases. However, there is a paucity of studies on the relationship between ASA class and postoperative health-related quality of life (HRQoL) outcomes following total hip replacement (THR).The aim of this study was to assess the discriminative abilities of EQ-5D-3L value sets from Sweden, Germany, Denmark and the United Kingdom in relation to ASA classes and these value sets’ abilities to show the predictive performance of ASA classes on HRQoL among THR patients in Sweden.MethodsA longitudinal study was conducted using data of patients in the Swedish Hip Arthroplasty Register who underwent THR between 2008 and 2016. We included 69,290 pre- and 1-year postoperative records and 21,305 6-year postoperative records. The study examined three experience-based EQ-5D-3L value sets (the Swedish VAS and TTO and the German VAS) and five hypothetical value sets (TTO from Germany and VAS and TTO value sets from Denmark and the UK each). Using linear models, the abilities of the value sets to discriminate among ASA classes and to show the predictive performance of ASA classes on HRQoL score were assessed.ResultsAll value sets differentiated among ASA classes and showed the predictive effect of ASA classes on HRQoL. ASA classes were found to predict HRQoL consistently for all value sets investigated, with small variations in prediction error among the models.ConclusionASA classes of patients undergoing THR predicted HRQoL scores significantly and consistently, indicating their importance in tailoring care for patients.

Quantitative ultrahigh-molecular-weight polyethylene wear in total elbow retrievals

The purpose of this study was to evaluate ultrahigh-molecular-weight polyethylene (UHMWPE) wear and damage from retrieved total elbow arthroplasty components and compare invivo wear with wear produced invitro. Explanted total elbow components were collected at revision surgery. UHMWPE damage was characterized visually, whereas penetration and wear were quantified using micro-computed tomography and gas pycnometry. Volumetric wear rates were compared with historical hip data, and wear data were compared with reported invitro wear test data. Humeral bushing damage primarily occurred in the form of burnishing, scratching, and pitting at the articular face in the region of contact with the ulnar component. Wear of the ulnar bushings was concentrated on the edge of the component at the point of contact with the axis pin. Pitting and embedded debris were dominant damage modes, in addition to burnishing and delamination. Backside wear was negligible. The median linear penetration rates of the lateral, medial, and ulnar bushings were 0.14 mm/yr (range, 0.01-0.78 mm/yr), 0.12mm/yr (range, 0.03-0.55 mm/yr), and 0.11 mm/yr (range, 0.01-0.69 mm/yr), respectively. The volumetric wear rates of the lateral, medial, and ulnar bushings were 5.5 mm3/yr (range, 0.7-37.2 mm3/yr), 5.9 mm3/yr (range, 0.6-25.5 mm3/yr), and 5.5 mm3/yr (range, 1.2-51.2 mm3/yr), respectively. The observed wear rates were similar to those reported in well-functioning total hip replacement patients with conventional UHMWPE bearings. We found limitations in reported invitro testing resulting in wear that was not consistent with our retrieval data. We recommend further investigation to clinically validate invitro simulation to provide appropriate loading protocols for elbow wear simulation.

2231-PUB: Perioperative Glucose Control Protocol: Hip and Knee Arthroplasty

Diabetes and stress hyperglycemia is associated with surgical site infections and other complications. Glucose control may be a modifiable risk factor. Our hospital and healthcare system did not have a standardized protocol for perioperative glucose management. There was variability in pre-surgery diabetes medication adjustments, no proactive glucose monitoring, no glucose control metrics and variable approaches to peri-operative glucose management. We, therefore, initiated a pilot quality improvement project. The population selected were total hip and knee replacement patients as diabetes (∼25%) is a common co-morbidity and there was a signal that diabetes (40% of cases) was associated with deep surgical site infections. The project was an opportunity to implement a population health approach to peri-operative and inpatient glucose management; decrease practice variability and foster a multi-disciplinary team approach. We standardized the recommended adjustments of diabetes medications prior to surgery (e.g., basal insulin decreased 20% the day before surgery); established a uniform A1c threshold of 8% (changed to 7.5%) to postpone surgery and started routine glucose monitoring on the day of surgery in all joint surgery cases. We implemented a standardized correction insulin protocol to be used by anesthesiology and encouraged the use of basal-meal-correction insulin, rather than sliding scale insulin, after surgery, in suitable patients by the hospitalists. The quality project showed a dramatic decrease in hypoglycemia on the day of surgery (∼95% decrease), significantly increased A1c monitoring (3 fold), detected unrecognized diabetes (13%), prediabetes (37%) and stress hyperglycemia and increased the use of correction insulin. Although suggestive, the small sample size and short intervention duration (6 months) were insufficient to detect a significant drop in infection rates. This project is in sustain phase and expanding to other high risk surgeries and can be a model for the entire system. Disclosure A. Pick: None. J.D. Baralli: None. H. Sandhu: None. R. Khorzad: None.

Repeated cobalt and chromium ion measurements in patients with bilateral large-diameter head metal-on-metal ReCap-M2A-Magnum total hip replacement

Background and purpose — Whole-blood (WB) chromium (Cr) and cobalt (Co) measurements are vital in the follow-up of metal-on-metal total hip replacement (MoM THR) patients. We examined whether there is a substantial change in repeated WB, Co, and Cr levels in patients with bilateral ReCap-M2A-Magnum THR. We also specified the number of patients exceeding the safe upper limit (SUL) of WB Co and Cr in the repeated measurement.Patients and methods — We identified 141 patients with bilateral ReCap-M2A-Magnum THR operated in our institution. 61 patients had repeated WB metal ion measurements with bilateral MoM implants still in situ in the second measurement. The mean time elapsing from the first measurement (initial measurement) to the second (control measurement) was 1.9 years (SD = 0.6, range 0.2–3.5). We used earlier established SUL levels for bilateral implants by Van Der Straeten et al. (2013).Results — The median (range) Co and Cr values decreased in the repeated measurement from 2.7 (0.6–25) to 2.1 (0.5–21) and 2.6 (0.8–14) to 2.1 (0.5–18) respectively. In 13% of the patients Co levels exceeded the SUL in the initial measurement and the proportion remained constant, at 13%, in the repeated measurement. In 5% of the patients, Cr levels were above SUL in the initial measurement and an equal 5% in the control measurement.Interpretation — Repeated WB metal ion levels did not increase in patients with bilateral ReCap-M2A-Magnum THR with a mean 1.9-year measurement interval. Long-term development of WB metal ion levels is still unclear in these patients.

Neck of femur fracture: who gets a total hip replacement? A review of 230 eligible patients.

To investigate patient-specific factors that predict Total Hip Replacement (THR) in patients with fracture neck of femur (NOF), fulfilling the National Institute of Health and Care Excellence (NICE) criteria. Hip fracture database from a district general hospital and university hospital was retrospectively reviewed to identify patients fulfilling NICE criteria for THR after fracture NOF. Patient demographics, Nottingham Hip Fracture score (NHFS), complications, re-operations, revision, 30days and one-year mortality was obtained from patient-records. Independent predictors correlating with the outcome of surgery were identified. A logistic regression analysis was used to predict the type of surgery in these patients. A total of 230 (114 WMH and 116 MH) were identified; 133 (57.8 per-cent) received hip hemiarthroplasty (HA), and 97 (42.2 per-cent) received THR. Patients receiving THR (mean 73.5years, 95% CI 72-74.8) were significantly younger in comparison to patients receiving HA (mean 81.7years, 95% CI 80.5-82.8). A negative correlation is noted between NHFS and type of surgery (Pearson's correlation - 0.537, p < 0.01), implying higher NHFS decreased the likelihood of receiving THR. Regression analysis showed NHFS (p-0.001) and walking ability (p-0.001) as significant predictors for the type of surgery (Nagelkerke R2-0.472). A log-rank test showed higher estimated survival time in patients with THR in comparison to HA (p-value 0.002). NHFS and walking ability can be used as an adjunct to the NICE criteria for selecting patients for THR after fracture NOF. Carefully selected patients treated with THR survive longer and have a better outcome in comparison to HA.

Hip resurfacing generates a more physiological gait than total hip replacement: A case-control study

BackgroundRestoration of the constitutional joint anatomy after hip replacement favours physiological peri-articular soft-tissue tension and kinematics, and is likely to be functionally beneficial. Hip resurfacing (HR) and conventional total hip replacement (THR) are two different options for replacing degenerated hips, and are likely to result in different anatomical reconstruction. We initiated this study to investigate the differences in gait performance between these two prosthetic options, and aimed to answer the following questions: (1) does HR result in better restoration of the frontal hip anatomical parameters, (2) and generate a more physiological gait compared to THR? (3) Does the quality of the anatomical restoration after THR influence gait performance? HypothesesOur hypothesis was that a better anatomical restoration using HR versus THR would produce more physiological (symmetric) gait. MethodsWe retrospectively reviewed 52 patients who had unilateral primary osteoarthritis successfully treated by replacement (40 THRs and 12 HRs). Hip anatomical parameters were measured on standing pelvic radiographs on both the prosthetic and the contralateral healthy hips. Patients undertook gait assessment under both normal and stress conditions at a mean follow-up of 14 months (7 to 16 months). Gait performances were compared between HR and THR, and the relationship between gait performances and quality of frontal anatomical restoration (estimated on radiograph) were assessed. ResultsCompared to the native contralateral side, the HR procedure tended to decrease all independent anatomical radiographic parameters with the exception of the vertical centre of rotation offset, whilst the THR procedure tended to increase them; the difference between HR and THR was only statistically significant for femoral offset and global horizontal offset (increased after THR while reduced after HR). Only 50% of THR and 25% of HR procedures closely anatomically (±15%) recreated both global horizontal offset and global vertical offset. Under normal conditions (normal walking speed and flat ramp), the gait was fairly symmetric for both the HR and the THR patients with a symmetry index of 0.62% and 3.14% respectively. At high walking speed (stress conditions), the symmetry index degraded for both groups, but the gait remained more symmetric in the HR group (2.09%), compared to the THR group (5.74%); nevertheless, the difference remained not statistically significant (p=0.159). We were unable to detect any significant relationship between gait performances and radiographically measured hip frontal anatomical parameters. Discussion/conclusionsHR procedure is more consistent than conventional THR in generating a more physiological gait under stress conditions. Radiographic estimation of the quality of the frontal anatomical hip restoration is of poor value to predict gait performances of THR patients. Level of evidenceIII – retrospective case-control study with prospective data collection.

The results of a stepwise implementation of a fast-track program in total hip and knee replacement patients

BackgroundSeveral reports have shown that enhanced recovery or fast-track (FT) regime introduction in patients undergoing total knee replacement (TKR) and total hip replacement (THR) results in significant reduction in length of stay (LOS) with no associated increase of complications or readmission rate. Despite that, FT programs for arthroplasty have has not been uniformly recognized or accepted by many orthopaedic surgeons and there is still no consensus on the best implementation process. The aim of this study was to report the results of a stepwise implementation of a FT regime in TKR and THR patients in a general orthopaedic department. Material and methodsThis was a retrospective study of prospectively collected data (from 2014 to 2017) concerning all consecutive unselected patients who underwent TKR or THR on Monday morning. At stage 1 the rehabilitation and physiotherapy component was changed, at stage 2 and 3 a patient's blood management program and a pain management program were prospectively recorded (i.e. respectively Patients’ demographics, ASA classification, Charlson index, LOS, blood loss, transfusion rate, complications and 30 – day readmissions). ResultsFour hundred and thirty four patients underwent either TKR (n: 302) or THR (n:132) and were included in this study. A gradual reduction of mean LOS was found in THR patients from 5.7 days to 3.0 days and in TKR patients from 5.6 days to 3.4 days. Furthermore, no significant difference was found in complications or regarding the 30-day readmission rate at the different stages of implementation of the different FT components (i.e. at the final stage 96.7% of THR and 86.7% of TKR patients were discharged to home by the fourth post-operative day). ConclusionThe stepwise implementation of a FT program in an unelected population of THR and TKR patients was effective and safe, reducing the post-surgical recovery time and patients’ LOS with no major complications and no increase of 30-day re-admissions.

A three year prospective study of functional and clinical outcomes of total hip replacement at a tertiary care hospital

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Hip joint is a crucial joint in the body whose function is essential for normal daily activities. Osteoarthritis of the hip cripples the daily functional capacity and total hip arthroplasty is considered to relieve the pain and increase the quality of life among these patients. The objective of present study was to assess the clinical and functional outcome in total hip replacement patients in terms of early joint function and stability of the hip joint and also to assess complications of procedures.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A three-year prospective study was conducted on 58 cases that fulfilled the inclusion criteria. Ethical approval and consent were obtained for the study. Standard clinical and laboratory evaluation was performed on all the cases and the data was noted in Microsoft excel sheet and analyzed. Modified Harris hip scoring was done pre operatively and postoperatively and follow-up was done at discharge, 4&lt;sup&gt;th&lt;/sup&gt; week, 6 months and one year.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Surgery was performed on 58 cases with age range 34-73 years and a mean of 43.58 years. Avascular necrosis was the main indication (55.2%). Maximum patient follow-up was 38 weeks. The mean preoperative score was 41.04 with minimum score being 10 and maximum being 76, postoperative score was 99.63 with minimum 64 and maximum was 109. Statistical significance was observed between preoperative and postoperative scores with regard to the parameters of pain, gait, functional activity and range of motion. Anterior thigh pain was the common postoperative complaint (15.5%).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; In conclusion, total hip replacement gives good clinical and functional outcomes. However, the outcomes are influenced by multiple factors which include indication for surgery, age of the cases, and type of prosthesis, operative technique and post-operative follow up.&lt;/p&gt;&lt;p class="abstract"&gt; &lt;/p&gt;

Congenital anomalies in the offspring of women with total hip replacement: a nationwide register study in Finland.

Few previous studies have analysed the possible teratogenic effect of maternal total hip replacement (THR) on congenital anomalies. The aim of this study was to estimate the risk of major congenital anomalies in the offspring of women with THR. Furthermore, we compared the risks based on type of implant (metal-on-metal [MoM]/non-MoM). The study population for this register-based cohort study was gathered from six Finnish national registers. All fertile-aged females who underwent THR from 1980 to 2007 and three reference females for each THR patient without THR were selected. THR operation day was the start of the follow-up for both groups. Information on pregnancies, induced abortions (IA) and congenital anomalies was gathered for the years 1987-2007 and the proportions of congenital anomalies were compared. In the THR group, 2429 women had 256 pregnancies, 205 (80.1%) deliveries and 51 (19.9%) IAs. In the reference group, 7276 women had 1670 pregnancies, 1443 (86.4%) deliveries and 236 (13.6%) IAs. There was no difference in the incidence of major anomalies between the THR (3.5%, n = 9) and the reference group (3.6%, n = 60), p = 0.91. In the THR group, there was no difference in the risk of major anomalies between the patients with a MoM-THR (10.5%, 2/19) and those with a non-MoM (2.9%, 7/241) (OR 3.93, 95% confidence interval 0.76-20.2; p = 0.13). Reassuringly, maternal THR does not appear to increase the risk of major congenital anomalies or pregnancies ending due to suspected foetal anomalies. Studies with larger study populations are needed to further assess the risk of anomalies in the offspring of women having MoM-THR.

Evaluation of hip precautions following total hip replacement: a before and after study

Purpose To evaluate the effect of hip precautions following total hip replacement (THR) by comparing outcomes of patients who received hip precautions with those who did not. Methods Before (phase 1) and after (phase 2) study with two consecutive cohorts of patients. In phase 1, patients were strictly educated about hip precautions. In phase 2, patients were not advised about precautions but encouraged to move as able. The primary outcome was the Oxford Hip Score (measuring pain and function) at three months. Secondary outcomes included Oxford Hip Score, activities of daily living (ADLs) (Nottingham Extended Activities of Daily Living), sleep (Pittsburgh Sleep Quality Index), mood (Hospital Anxiety and Depression Scale), and quality of life (QoL) (EQ-5 D). Results A total 237 participants successfully underwent THR surgery, 118 participants in phase 1 and 119 in phase 2. At three months postoperatively, participants had significantly equivalent Oxford Hip Scores (MD= −0.82, 95% CI: −2.64 to 1.00). No significant differences between the groups were observed at six weeks and three months postoperatively for secondary outcomes. Conclusions Patients recovered at a similar rate regardless of whether they received hip precautions or not, with no increase in complications observed. The findings lend evidence to support decision-making around the removal of precautions. Implications for rehabilitation The use of no hip precautions resulted in no additional benefit following primary total hip replacement surgery in terms of functional recovery. Patients who were not prescribed precautions had significantly less pain and greater function during the first week after surgery. Total hip replacement patients had similar outcomes at six weeks and three months postoperatively regardless of whether they received hip precautions or not. The study provides evidence to suggest that hip precautions may not be needed routinely following elective primary total hip replacement.