Treatment Of Hip Research Articles

Clinical impact of microbiological results in two-stage revision arthroplasty with spacer exchange.

Patients who require a spacer exchange as part of a two-stage procedure for the treatment of periprosthetic hip and knee joint infections (PJI) have high failure rates. Little is known about the clinical impact of microbiological results and changes in the microbiological spectrum and resistance pattern in these patients. Between 01/2011 and 12/2019, 312 patients underwent a total of 327 two-stage revision arthroplasties at our institution. A spacer exchange was required in 52/312 (16.7%) patients (27 knee/25 hip). Microbiological results, antibiotic resistance patterns, patient's host factors as well as re-revision and re-infection rates at a median follow-up of 47.8months (range 12.2-116.7months) were analyzed. A propensity score (PS)-matched analysis of patients who underwent spacer exchange and patients treated with standard two-stage procedure was performed. We found a high number of microbiological spectrum changes in patients with multiple culture positive procedures between explantations and spacer exchanges (10/12 [83.3%]), spacer exchanges and reimplantations (3/4 [75%]) as well as between reimplantations and subsequent re-revision surgeries (5/6 [83.3%]). In 9/52 (17.3%) patients, same microorganisms were detected repeatedly in two different procedures. We observed changes in the antibiotic resistance patterns in 6/9 (66.7%) of these patients. High re-infection rates were found in patients with culture positive reimplantations (10/12 [83.3%]), and low re-infection rates were found in patients with culture negative reimplantations (2/40 [5%]; p < 0.001). Between patients with and without spacer exchange, no differences were found in the re-revision rates (13/52 [25%] with vs. 13/52 [25%] without; p = 1.00) as well as re-infection rates (12/52 [23.1%] with vs. 8/52 [15.4%] without; p = 0.32). Changes in microbiological spectrum and antibiotic resistance patterns between stages are common in patients who require a spacer exchange. If eradication of the microorganism at reimplantation can be accomplished, comparable re-revision rates to standard two-stage procedures can be achieved.

Managing Borderline Dysplasia: It Can Take More Than Just a Periacetabular Osteotomy: Commentary on an article by Jeffrey J. Nepple, MD, et al.: "Outcomes of Periacetabular Osteotomy for Borderline Acetabular Dysplasia".

Commentary Nepple et al. report the outcomes of a single experienced surgeon treating patients with borderline hip dysplasia from 2010 to 2020. The article correctly points out that a majority of clinical reports of outcomes of treatment for patients with borderline hip dysplasia used arthroscopy without periacetabular osteotomy (PAO)1. This article represents an important contribution documenting the outcomes of treatment correcting structural causes of instability with or without arthroscopy. A previous series of PAOs, including cases from the senior author, used different criteria (lateral center-edge angle [LCEA] of 15° to 25°) to define mild dysplasia2, and those outcomes are not directly comparable with those in the current article, in which an LCEA of 18° to 25° was used to describe borderline dysplasia. The results in the current article demonstrate clinical success in 148 of 156 hips in patients undergoing primary surgery. The article provides important data on radiographic parameters for correction of acetabular dysplasia. The article does not provide a detailed analysis of preoperative femoral neck morphology or femoral torsion. However, several points regarding this clinical series of patients with borderline hip dysplasia are instructive. The authors point out that “A comprehensive assessment of the hip … is critical to informing an accurate diagnosis. Currently, there remain no clear clinical guidelines to differentiate between fundamental mechanical diagnoses (impingement compared with instability) and definitively guide treatment selection.” In other words, the clinical assessment of the patient presentation plays an important role in discriminating between the underlying pathologic mechanisms of impingement or instability. In the entire cohort of 186 hips in 178 patients, only 21 hips underwent an isolated PAO. The majority of treated hips required addition of a concomitant hip arthroscopy to the PAO as treatment for labral or articular cartilage pathology (130 of 186 hips). Similarly, 120 hips required a femoral osteoplasty to treat impingement at the time of the PAO. These 2 important observations emphasize the importance of clinicians and learners who are interested in treating patients with this type of hip pathology gaining experience in evaluating patients with instability as well as patients with impingement. The ability to differentiate instability from impingement depends in part on clinical exposure to the presentation of these types of hip pathology. Of note, neither the evaluation nor treatment of the young adult hip is addressed in the latest iteration of the Accreditation Council for Graduate Medical Education (ACGME) Orthopaedic Surgery Milestones3. This study does not provide an assessment with a control group with similar labral and intra-articular pathology treated without arthroscopy. Therefore, it is unclear whether hip arthroscopy with labral refixation and chondral interventions as performed in this cohort would be required to achieve similar outcomes. A previous study indicated that not treating femoroacetabular impingement at the time of the PAO was associated with poorer long-term outcomes4. However, the reported data in the current study indicate that hip arthroscopy at the time of the PAO has not adversely impacted results. Nepple et al. also point out the adverse impact that a previous unsuccessful hip arthroscopy has on the outcomes in patients with borderline hip dysplasia. The majority of these previous arthroscopies were not performed by the senior author. It is not clear whether these patients had concomitant impingement with borderline dysplasia and developed instability after arthroscopy, or they had clinical instability that had been misdiagnosed as impingement initially. There are many reports detailing successful treatment of femoroacetabular impingement arthroscopically in the setting of borderline dysplasia1. However, clearly a hip arthroscopy that leaves the patient with symptomatic hip instability has an adverse impact on outcome after structural correction with PAO. Finally, the diversity of treatments required to provide successful outcomes in the cohort of patients studied by Nepple et al. provides some evidence for the need for personalized medicine in the care of young patients with hip pathology. As with all such clinical series, the reported results are a benchmark for all clinicians to aspire toward. The results in this article represent the work of an experienced surgeon selectively managing multiple aspects of hip pathology to optimize outcomes in this defined cohort of patients.

Intra- and interobserver variability of novel magnetic resonance imaging parameters for hip screening and treatment outcomes at age 5years.

The outcome measure of neonatal hip screening is usually the radiographic acetabular index. To assess the feasibility of magnetic resonance imaging (MRI) without sedation and compare the utility of outcome parameters measured from MRI images. The invitation for MRI scanning at 5years of age was incorporated into follow-up for babies who had more than one ultrasound examination during treatment or surveillance. Diagnostic images were obtained in 132 of 134 children. The mean osseous acetabular index (standard deviation [SD]) was 16.6 (3.3) degrees for the right hip and 17.8 (3.2) for the left; the values for the cartilaginous acetabular index were 3.1 (3) and 3.4 (3.2). The mean downslope of a tangent to the lateral bony acetabular roof was 10.4 (4.5) and 9.0 (4.3) with respect to Hilgenreiner's line and that of a line drawn through the apex to the margin of the acetabulum was 3.7 (4.6) and 3.9 (4.7). Intra- and interobserver variation was greater for measures specific to the lateral acetabular roof than for ossific and cartilaginous indices. There was significant negative correlation between the downslope of the tangent to the lateral roof index and the age at onset of treatment on both sides, but no significant correlation for ossific or cartilaginous acetabular indices or apex-marginal index. MRI without sedation at 5years of age is feasible as an outcome measure for hip screening programmes. Parameters specific to the lateral acetabulum may better reflect acetabular sufficiency, despite having greater observer variation than cartilaginous and ossific acetabular indices.

A Sonography-based Decision Model for Use in Treatment of Developmental Dysplasia of the Hip

The objective of this study was to delineate a model for management of developmental dysplasia of the hip (DDH) treatment that incorporates hip ultrasound with objective/predicative parameters at key decision-making times. Hip sonograms of 74 infants (59 females, 15 males; 141 hips) with DDH were retrospectively reviewed. Hip sonographic score (HSS; ranges 0-10) was developed to reflect hip status based on sonographic position, stability, and morphology. Analysis on different management groups (i.e., no treatment, successful treatment, and failed treatment) showed that the trend of HSS is helpful in predicting course of the disease and determining effectiveness of treatment. A model for the management of DDH that utilizes an HSS and frequency schedule for hip sonography that is aligned with times of critical treatment decisions is proposed. This model illustrates how hip sonography can bring added value when timed to guide critical treatment decisions. (Journal of Surgical Orthopaedic Advances 32(1):047-054, 2023).

An interesting case of external type of coxa saltans treated by z plasty of iliotibial band-a case report

&lt;p&gt;Coxa saltans commonly known as snapping hip is a nagging illness which can physically and mentally hinder patients life.&lt;strong&gt; &lt;/strong&gt;A snapping hip (coxa saltans) secondary to a tight iliotibial band rarely needs surgical release since most cases respond well to conservative management. The purpose of this study is to present the surgical results of refractory external-type snapping hip by Z-plasty of the iliotibial band. We present a case report of 47-year-old lady who was diagnosed to have snapping hip of external type who was treated with Brignall and stainsby technique of Z plasty. The surgical results of Z-plasty are excellent and predictable. Careful examination is necessary to rule out other causes. Z-plasty is recommended as an effective surgical treatment of the refractory snapping hip.&lt;/p&gt;

Effects of Hot Isostatic Pressing on the Properties of Laser-Powder Bed Fusion Fabricated Water Atomized 25Cr7Ni Stainless Steel

25Cr7Ni stainless steel (super duplex stainless steels) exhibits a duplex microstructure of ferrite and austenite, resulting in an excellent combination of high strength and corrosion resistance. However, Laser-Powder Bed Fusion fabrication of a water-atomized 25Cr7Ni stainless steel of novel chemical composition resulted in a purely ferritic microstructure and over 5% porosity. The current study investigated the effects of two hot isostatic pressing parameters on the physical, mechanical, and corrosion properties as well as microstructures of water-atomized 25Cr7Ni stainless steel of novel composition fabricated by L-PBF for the first time in the literature. The corrosion behaviour was studied using linear sweep voltammetry in a 3.5% NaCl solution. The Hot Isostatic Pressing-treated sample achieved over 98% densification with a corresponding reduction in porosity to less than 0.1% and about 3~4% in annihilation of dislocation density. A duplex microstructure of ferrite 60% and austenite 40%was observed in the X-Ray Diffraction and etched metallography of the HIP-treated samples from a purely ferritic microstructure prior to the HIP treatment. With the evolution of austenite phase, the HIP-treated samples recorded a decrease in Ultimate Tensile Strength, yield strength, and hardness in comparison with as-printed samples. The variation in the morphology of the evolved austenite grains in the HIP-treated samples was observed to have a significant effect on the elongation. With a reduction in porosity and the evolution of the austenite phase, the HIP-treated samples showed a higher corrosion resistance in comparison with the as-printed samples.

On the Impact of an Integrated HIP Treatment on the Very High Cycle Fatigue Life of Ni-Based SX Superalloys

On the Impact of an Integrated HIP Treatment on the Very High Cycle Fatigue Life of Ni-Based SX Superalloys

Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT

Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT

Outcomes after arthroscopic treatment of external snapping hip

Outcomes after arthroscopic treatment of external snapping hip

Bedside hip aspiration results in decrease in total general anesthesia time in pediatric patients: A multicenter study.

The purpose of this study is to compare pediatric hip aspiration in the operating room under general anesthesia or via bedside aspiration under moderate sedation and delineate the anesthetic time required. A database query conducted at two academic institutions identified all patients under the age of 17 who underwent hip aspiration between 2000 and 2017. At one institution, aspiration was performed in the operating room under general anesthesia. Patients were kept anesthetized until cell count was complete. At the second institution, aspiration was performed in the emergency room at bedside under sedation. The medical record was reviewed for demographic data, hip aspiration results, diagnoses, treatment, and anesthesia time. A total of 233 patients (233 hips) with a mean age of 7.2 years were identified. Seventy-five patients underwent aspiration in the operating room, and 158 patients underwent bedside aspiration. Patients with a negative aspiration averaged 87 min under anesthesia when performed in the operating room and 29 min under sedation when performed at bedside. Patients with a negative aspiration performed in the operating room after 5 pm averaged 99 min under anesthesia, and 73 min under anesthesia when performed between 7 am and 5 pm (p < 0.01). Seventy-eight (49%) patients who underwent bedside aspiration did not require operative intervention and therefore avoided general anesthesia. Pediatric hip aspiration performed in the operating room results in prolonged anesthesia times while synovial fluid is transported and processed. Anesthesia times are significantly longer after 5 pm. Bedside aspiration resulted in significantly less anesthesia exposure, with half of patients undergoing bedside aspiration avoiding general anesthesia altogether. Level III.

Reimplantation after Periprosthetic Joint Infection: The Role of Microbiology.

Periprosthetic joint infection (PJI) is among the most feared orthopedic complications. Critical questions are whether the infection is completely resolved before reimplantation and what the clinical significance of positive culture is at reimplantation. The aim of this study was to determine whether a correlation exits between culture results at reimplantation after spacer insertion for hip and knee PJI and treatment failure rate. The data of 84 patients who underwent two-stage exchange arthroplasty for hip or knee PJI were reviewed and the results of intraoperative culture at reimplantation were analyzed quantitatively and qualitatively. Correlations were sought between these patterns and treatment outcome. Our data indicate no evidence for a correlation between positive culture at reimplantation and greater risk of treatment failure. Nonetheless, we noted a higher, albeit statistically not significant rate of treatment failure in patients with at least two samples testing positive. The role of microbiology at reimplantation remains unclear, but a positive culture might signal increased risk for subsequent implant failure. Further studies are needed to elucidate the implications of this finding.

Globular surface layer in electron beam powder-bed fusion Ti-6Al-4V after standard powder removal blasting and hot isostatic pressing

A globular α recrystallization has been discovered at the surface of net shape electron beam powder-bed fusion (PBF-EB) Ti-6Al-4V alloy parts. This recrystallization is the result of powder recovery blasting followed by hot isostatic pressing treatment (HIP), which mimics the thermomechanical treatment necessary to achieve globularization in wrought Ti-6Al-4V. The thickness of the globular surface α is variable depending on the blasting intensity as well as the presence of surface protrusions that block the line-of-sight of the blasting media. The globular layer contains a 0001 orientation relationship parallel to the blasting direction, plus a low intragranular orientation deviation, when compared to the bulk. The results indicate that this globular α at the surface may be present for all net-shape Ti-6Al-4V components that have been manufactured via PBF-EB and subjected to a HIP treatment. Tunable fatigue and wear performance may be possible through controlled blasting parameters and globular surface layer thickness.

Transfusion Rates in the Operative Treatment of Prosthetic Hip and Knee Infection.

Surgery for prosthetic joint infection (PJI) can often lead to significant blood loss, necessitating allogeneic blood transfusion (ABT). The use of ABT is associated with higher rates of morbidity and death in revision total joint arthroplasty, particularly in the treatment of PJI. We compared ABT rates by procedure type among patients treated for PJI. We retrospectively reviewed 143 operative cases of hip and knee PJI performed at our institution between 2016 and 2018. Procedures were categorized as irrigation and debridement (I&D) with modular component exchange (modular component exchange), explantation with I&D and placement of an antibiotic spacer (explantation), I&D with antibiotic spacer exchange (spacer exchange), or antibiotic spacer removal and prosthetic reimplantation (reimplantation). Rates of ABT and the number of units transfused were assessed. Factors associated with ABT were assessed with a multilevel mixed-effects regression model. Of the cases, 77 (54%) required ABT. The highest rates of ABT occurred during explantation (74%) and spacer exchange (72%), followed by reimplantation (36%) and modular component exchange (33%). A lower preoperative hemoglobin level was associated with higher odds of ABT. Explantation, reimplantation, and spacer exchange were associated with greater odds of ABT. Antibiotic spacer exchange and explantation were associated with greater odds of multiple-unit transfusion. Rates of ABT remain high in the surgical treatment of PJI. Antibiotic spacer exchange and explantation procedures had high rates of multiple-unit transfusions, and additional units of blood should be made available. Preoperative anemia should be treated when possible, and further refinement of blood management protocols for prosthetic joint infection is necessary. [Orthopedics. 2022;45(6):353-359.].

Comparison of treatment outcomes of stable and unstable developmental dysplasia of the hip with the Tübingen splint.

BackgroundThe Tübingen splint was initially developed for the treatment of stable developmental hip dysplasia (DDH). Later on, some authors expanded its include for the treatment of unstable DDH, but there remain some controversies in the literature. This study aims to compare the outcome between stable and unstable DDH treated with a Tübingen splint.MethodsEpidemiological data and ultrasonographic data of all infants diagnosed with DDH and initially treated with a Tübingen splint at our institution between May 2017 and February 2020 were assessed retrospectively. We divided the population into stable and unstable hips using the Graf classification. Age at treatment initiation, duration of treatment, complications, and radiological outcome between 12 and 24 months were investigated.ResultsWe included a total of 45 patients (57 hips) affected by DDH treated with the Tübingen splint. Treatment has been successful in 93% of stable hips and only 40% of unstable hips. Radiological outcome at 1-year follow-up significantly correlated with initial Graf classification (p < 0.001).ConclusionThe Tübingen splint is a safe and effective treatment for stable hips, nevertheless, for unstable hips, closed reduction, and spica cast remains the gold standard.

Automated quantification of cartilage quality for hip treatment decision support

PurposePreservation surgery can halt the progress of joint degradation, preserving the life of the hip; however, outcome depends on the existing cartilage quality. Biochemical analysis of the hip cartilage utilizing MRI sequences such as delayed gadolinium-enhanced MRI of cartilage (dGEMRIC), in addition to morphological analysis, can be used to detect early signs of cartilage degradation. However, a complete, accurate 3D analysis of the cartilage regions and layers is currently not possible due to a lack of diagnostic tools.MethodsA system for the efficient automatic parametrization of the 3D hip cartilage was developed. 2D U-nets were trained on manually annotated dual-flip angle (DFA) dGEMRIC for femoral head localization and cartilage segmentation. A fully automated cartilage sectioning pipeline for analysis of central and peripheral regions, femoral-acetabular layers, and a variable number of section slices, was developed along with functionality for the automatic calculation of dGEMRIC index, thickness, surface area, and volume.ResultsThe trained networks locate the femoral head and segment the cartilage with a Dice similarity coefficient of 88 ± 3 and 83 ± 4% on DFA and magnetization-prepared 2 rapid gradient-echo (MP2RAGE) dGEMRIC, respectively. A completely automatic cartilage analysis was performed in 18s, and no significant difference for average dGEMRIC index, volume, surface area, and thickness calculated on manual and automatic segmentation was observed.ConclusionAn application for the 3D analysis of hip cartilage was developed for the automated detection of subtle morphological and biochemical signs of cartilage degradation in prognostic studies and clinical diagnosis. The segmentation network achieved a 4-time increase in processing speed without loss of segmentation accuracy on both normal and deformed anatomy, enabling accurate parametrization. Retraining of the networks with the promising MP2RAGE protocol would enable analysis without the need for B1 inhomogeneity correction in the future.

Precipitation, transformation, and coarsening of carbides in a high-carbon Ni-based superalloy during selective laser melting and hot isostatic pressing processes

Carbides are vital phases in determining the mechanical properties of solid solution nickel-based superalloys. The precipitation, transformation, and coarsening of carbides in a high-carbon Ni-based superalloy during selective laser melting and the HIP process were investigated using scanning electron microscopy, transmission electron microscopy, X-ray diffraction, and thermodynamic modeling . A high carbon content (0.2 wt%) resulted in complicated M x C y -type carbides enriched in W and Cr due to the uneven segregation of Cr and W in the as-built GH3230G. The complicated carbides were transformed into M 6 C-type carbides, and coarsening of carbides occurred after HIP treatment. Thermodynamic calculation results explained the precipitation and coarsening of carbides. In addition, larger carbide particles with a size of 1.1 µm were always distributed along the epitaxial grain boundaries, while smaller carbide particles at a scale of 0.3 µm were apt to form at the subgrain boundaries. The cross-section micrographs below the fractures showed that some microvoids were always initiated at coarse carbide/matrix interfaces, which induced intergranular fracture at elevated temperatures. This work can be extended to elucidate carbide formation, transformation, and evolution for additively manufactured superalloys and predict their impact on the mechanical properties of this kind of alloy. • A modified GH3230 alloy with a high carbon content of 0.2 wt% was successfully fabricated by SLM. • Precipitation and coarsening of carbides in a high-carbide superalloy during the SLM and HIP processes are investigated. • Complicated carbides precipitated during the SLM process because of the segregation of Cr, W, and C. • Purifying and coarsening of carbide precipitates occurred during the HIP process due to W migrationand Cr desegregation.

Massive “risotto bursitis” of the great trochanter bursa after proximal femoral varus osteotomy with 5,0 LCP- a case report

The “risotto phenomenon” is a rare pathologic finding, mostly seen as a nonspecific response to chronic inflammation around the shoulder joint- subacromial and subdeltoid bursitis, rheumatoid arthritis, sero-negative inflammatory arthritis, septic arthritis and tuberculous arthritis. A few scientific reports associate rice body formation with the use of different type of osteosynthesis, bony anchors and bioabsorbable sutures. They are usually an incidental asymptomatic finding, requiring no specific treatment, but could be symptomatic demanding surgical excision. We present the clinical case of a 17-year- old female patient with a “risotto bursitis” of the great trochanter bursa, documented during planned surgical removal of a locking compression plate after proximal femoral varus osteotomy for bilateral developmental dysplasia of the hip treatment.

60% Reduction of reoperations and complications for elderly patients with hip fracture through the implementation of a six-item improvement programme

IntroductionHip fractures are common, serious and costly fractures in the elderly population. Several guidelines seeking to ensure best practice have been introduced. Although our institution complied with national guidelines for...

20-year hip survivorship and patient-reported outcome measures after transpositional osteotomy of the acetabulum for dysplastic hips.

Although periacetabular osteotomies are widely used for the treatment of symptomatic dysplastic hips, long-term surgical outcomes and patient-reported outcome measures (PROMs) are still unclear. Accordingly, we assessed hip survival and PROMs at 20 years after transpositional osteotomy of the acetabulum (TOA). A total of 172 hips in 159 patients who underwent TOA were followed up at a mean of 21.02 years (16.6 to 24.6) postoperatively. Kaplan-Meier analysis was used to assess survivorship with an endpoint of total hip arthroplasty (THA). PROMs included the visual analogue scale (VAS) Satisfaction, VAS Pain, Oxford Hip Score (OHS), and Forgotten Joint Score-12 (FJS-12). Thresholds for favourable outcomes for OHS (≥ 42) and FJS-12 (≥ 51) were obtained using the receiver operating characteristic curve with VAS Satisfaction ≥ 50 and VAS Pain < 20 as anchors. THA was performed on 37 hips (21.5%) by the latest follow-up. Kaplan-Meier analysis indicated that the hip survival rate at 20 years was 79.7% (95% confidence interval (CI) 73.7 to 86.3). Multivariate analysis showed that preoperative Tönnis grade significantly influenced hip survival. Tönnis grades 0, 1, and 2 were associated with 20-year survival rates of 93.3% (95% CI 84.8 to 100), 86.7% (95% CI 79.8 to 94.3), and 54.8% (95% CI 41.5 to 72.3), respectively. More than 60% of the patients exhibited favourable PROMs. An advanced Tönnis grade at the latest follow-up and a higher BMI were both significantly associated with unfavourable OHS, but not with other PROMs. This study demonstrated the durability of TOA for hips with Tönnis grades 0 to 1 at 20 years. While the presence of advanced osteoarthritis and higher BMI was associated with lower hip functions (OHS), it was not necessarily associated with worse patient satisfaction and joint awareness. Cite this article: Bone Joint J2022;104-B(7):767-774.

Antifungal-Loaded Acrylic Bone Cement in the Treatment of Periprosthetic Hip and Knee Joint Infections: A Review.

Little is known about the clinical use of antifungal-loaded acrylic bone cement in the treatment of periprosthetic hip and knee joint infections (PJIs). Hence, we performed a literature search using PubMed/MEDLINE from inception until December 2021. Search terms were “cement” in combination with 13 antifungal agents. A total of 10 published reports were identified, which described 11 patients and 12 joints in which antifungal-loaded cement was employed. All studies were case reports or case series, and no randomized controlled trials were identified. In 6 of 11 patients, predisposing comorbidities regarding the emergence of a fungal PJI were present. The majority of the studies reported on infections caused by Candida species. In six cases (seven joints), the cement was solely impregnated with an antifungal, but no antibiotic agent (amphotericin B, voriconazole, and fluconazole). In the other five joints, the cement was impregnated with both antibiotic(s) and antifungals. Great discrepancies were seen regarding the exact loading dose. Four studies investigated the local elution of antifungal agents in the early postoperative period and observed a local release of antifungals in vivo. We conclude that there is a paucity of data pertaining to the clinical use of antifungal-loaded bone cement, and no studies have assessed the clinical efficacy of such procedures. Future studies are urgently required to evaluate this use of antifungals in PJI.