Unilateral Total Hip Arthroplasty Research Articles

A Prospective Randomized Controlled Trial Assessing the Impact of Preoperative Combined with Postoperative Progressive Resistance Training on Muscle Strength, Gait, Balance and Function in Patients Undergoing Total Hip Arthroplasty.

The aim of this study is to investigate the effects of a preoperative combined with postoperative moderate-intensity progressive resistance training (PRT) of the operative side in patients with hip osteoarthritis (HOA) who are undergoing total hip arthroplasty (THA). The study seeks to evaluate the impact of this combined intervention on muscle strength, gait, balance, and hip joint function in a controlled, measurable, and objective manner. Additionally, the study aims to compare the outcomes of this combined intervention with those of preoperative or postoperative muscle strength training conducted in isolation. A total of 90 patients with HOA scheduled for unilateral primary THA were randomly assigned to three groups: Pre group (preoperative PRT), Post group (postoperative PRT), and Pre& Post group (preoperative combined with postoperative PRT) focusing on hip flexion, extension, adduction, and abduction of operated side. Muscle strength, gait parameters, balance, and hip function were assessed at specific time points during a 12-month follow-up period. All three groups showed significant improvements in muscle strength, with the Pre& Post group demonstrating the most pronounced and sustained gains. Gait velocity and cadence were significantly improved in the Pre& Post group at 1-month and 3-month postoperative follow-ups compared to the other groups. Similarly, the Pre& Post group exhibited superior balance performance at 3-month and 12-month postoperative follow-ups. The Harris Hip Score also showed better outcomes in the Pre& Post group at all follow-up intervals. Preoperative combined with postoperative moderate-intensity PRT in HOA patients undergoing THA led to superior improvements in muscle strength, gait, balance, and hip joint function compared to preoperative or postoperative PRT alone. This intervention shows significant promise in optimizing postoperative rehabilitation and enhancing patient outcomes following THA.

Effects of a Modified Long-Acting Cocktail on Analgesia and Enhanced Recovery After Total Hip Arthroplasty: A Double-Blinded Randomized Clinical Trial

BackgroundWe compared the efficacy and safety of a modified cocktail for postoperative analgesia and early functional rehabilitation in patients undergoing total hip arthroplasty (THA). MethodsA prospective, double-blind randomized controlled trial was conducted with 200 patients who underwent unilateral primary THA at our hospital. Magnesium sulfate and sodium bicarbonate were added to a traditional cocktail of ropivacaine, epinephrine, and dexamethasone. Primary outcome measures were visual analogue scale (VAS) pain scores at various intervals after surgery; morphine consumption for rescue analgesia after surgery; and time to first rescue analgesia. Secondary outcomes were hip function after surgery, daily walking distance, and quadriceps muscle strength. The third index was the incidence of postoperative adverse reactions. ResultsMorphine consumption was significantly lower in the modified cocktail group than in the control group in the first 24 hours after surgery (6.2 ± 6.0 versus 14.2 ± 6.4 mg, P < 0.001), as was total morphine consumption (10.0 ± 8.6 versus 19.2 ± 10.1 mg, P < 0.001). The duration of the first rescue analgesia was significantly prolonged (23.7 ± 10.3 versus 11.9 ± 5.8 mg, P < 0.001). Morphine consumption was also significantly reduced in the magnesium sulfate and sodium bicarbonate groups over a 24-hour period compared with that in the control group (9.4 ± 6.5 versus 14.2 ± 6.4 mg, P < 0.001, 9.6 ± 6.4 versus 14.2 ± 6.4 mg, P < 0.001). The modified cocktail group had significantly lower resting VAS pain scores than the control group at 6, 12, and 24 hours after surgery (P = 0.036, P = 0.010, and P = 0.017, respectively). The VAS pain scores during movement at 6 and 12 hours after surgery were also significantly lower than those in the control group (P = 0.045, P < 0.001, respectively). The modified cocktail, magnesium sulfate, and sodium bicarbonate groups showed better hip range of motion (P < 0.001, P = 0.013, P = 0.046, respectively) and longer walking distance (P < 0.001, P = 0.014, P = 0.019, respectively) on the first postoperative day, and levels of inflammatory markers were significantly reduced. The incidence of postoperative adverse reactions was similar among the four groups. ConclusionThe modified cocktail with a new adjuvant can prolong the duration of postoperative analgesia, reduce the dosage of rescue analgesics, and accelerate early postoperative functional recovery in patients undergoing THA.

The learning curve of a novel seven-axis robot-assisted total hip arthroplasty system: a randomized controlled trial

BacgroundThe aim of this study was to assess the learning curve of a novel seven-axis robot-assisted total hip arthroplasty (RaTHA) system.MethodsA total of 59 patients who underwent unilateral total hip arthroplasty at our institution from June 2022 to September 2022 were prospectively included in the study. In this randomized controlled clinical trial, robot-assisted THA (RaTHA) and Conventional THA (CoTHA) were performed using cumulative sum (CUSUM) analysis to evaluate the learning curve of the RaTHA system. The demographic data, preopera1tive clinical data, duration of operation, postoperative Harris Hip Score (HHS), postoperative Western Ontario and McMaster Universities Arthritis Index (WOMAC) score, and duration of operation between the learning stage and the proficiency stage of the RaTHA group were compared between the two groups.ResultsThe average duration of operation of the RaTHA group was increased by 34.73 min compared with the CoTHA group (104.26 ± 19.33 vs. 69.53 ± 18.38 min, p < 0.01). The learning curve of the RaTHA system can be divided into learning stage and proficiency stage, and the former consists of the first 13 cases by CUSUM analysis. In the RaTHA group, the duration of operation decreased by 29.75 min in the proficiency stage compared to the learning stage (121.12 ± 12.84 vs.91.37 ± 12.92, p < 0.01).ConclusionsThis study demonstrated that the surgical team required a learning curve of 13 cases to become proficient using the RaTHA system. The duration of operation, total blood loss, and drainage gradually shortened (decreased) with the learning curve stage, and the differences were statistically significant.Trial registrationNumber: ChiCTR2200061630, Date: 29/06/2022.

Nanotechnology for Pain Management.

Introduction: In the context of the current opioid crisis, non-pharmacologic approaches to pain management have been considered important alternatives to the use of opioids or analgesics. Advancements in nano and quantum technology have led to the development of several nanotransporters, including nanoparticles, micelles, quantum dots, liposomes, nanofibers, and nano-scaffolds. These modes of nanotransporters have led to the development of new drug formulations. In pain medicine, new liposome formulations led to the development of DepoFoam™ introduced by Pacira Pharmaceutical, Inc. (Parsippany, NJ, USA). This formulation is the base of DepoDur™, which comprises a combination of liposomes and extended-release morphine, and Exparel™, which comprises a combination of liposomes and extended-release bupivacaine. In 2021, Heron Therapeutics (San Diego, CA, USA) created Zynrelef™, a mixture of bupivacaine and meloxicam. Advancements in nanotechnology have led to the development of devices/patches containing millions of nanocapacitors. Data suggest that these nanotechnology-based devices/patches reduce acute and chronic pain. Methods: Google and PubMed searches were conducted to identify studies, case reports, and reviews of medical nanotechnology applications with a special focus on acute and chronic pain. This search was based on the use of keywords like nanotechnology, nano and quantum technology, nanoparticles, micelles, quantum dots, liposomes, nanofibers, nano-scaffolds, acute and chronic pain, and analgesics. This review focuses on the role of nanotechnology in acute and chronic pain. Results: (1) Nanotechnology-based transporters. DepoDur™, administered epidurally in 15, 20, or 25 mg single doses, has been demonstrated to produce significant analgesia lasting up to 48 h. Exparel™ is infiltrated at the surgical site at the recommended dose of 106 mg for bunionectomy, 266 mg for hemorrhoidectomy, 133 mg for shoulder surgery, and 266 mg for total knee arthroplasty (TKA). Exparel™ is also approved for peripheral nerve blocks, including interscalene, sciatic at the popliteal fossa, and adductor canal blocks. The injection of Exparel™ is usually preceded by an injection of plain bupivacaine to initiate analgesia before bupivacaine is released in enough quantity from the depofoarm to be pharmacodynamically effective. Finally, Zynrelef™ is applied at the surgical site during closure. It was initially approved for open inguinal hernia, abdominal surgery requiring a small-to-medium incision, foot surgery, and TKA. (2) Nanotechnology-based devices/patches. Two studies support the use of nanocapacitor-based devices/patches for the management of acute and chronic pain. A randomized study conducted on patients undergoing unilateral primary total knee (TKA) and total hip arthroplasty (THA) provided insight into the potential value of nanocapacitor-based technology for the control of postoperative acute pain. The results were based on 2 studies, one observational and one randomized. The observational study was conducted in 128 patients experiencing chronic pain for at least one year. This study suggested that compared to baseline, the application of a nanocapacitor-based Kailo™ pain relief patch on the pain site for 30 days led to a time-dependent decrease in pain and analgesic use and an increase in well-being. The randomized study compared the effects of standard of care treatment to those of the same standard of care approach plus the use of two nanocapacitor-based device/patches (NeuroCuple™ device) placed in the recovery room and kept in place for three days. The study demonstrated that the use of the two NeuroCuple™ devices was associated with a 41% reduction in pain at rest and a 52% decrease in the number of opioid refills requested by patients over the first 30 days after discharge from the hospital. Discussion: For the management of pain, the use of nano-based technology has led to the development of nano transporters, especially focus on the use of liposome and nanocapacitors. The use of liposome led to the development of DepoDur™, bupivacaine Exparel™ and a mixture of bupivacaine and meloxicam (Zynrelef™) and more recently lidocaine liposome formulation. In these cases, the technology is used to prolong the duration of action of drugs included in the preparation. Another indication of nanotechnology is the development of nanocapacitor device or patches. Although, data obtained with the use of nanocapacitors are still limited, evidence suggests that the use of nanocapacitors devices/patches may be interesting for the treatment of both acute and chronic pain, since the studies conducted with the NeuroCuple™ device and the based Kailo™ pain relief patch were not placebo-controlled, it is clear that additional placebo studies are required to confirm these preliminary results. Therefore, the development of a placebo devices/patches is necessary. Conclusions: Increasing evidence supports the concept that nanotechnology may represent a valuable tool as a drug transporter including liposomes and as a nanocapacitor-based device/patch to reduce or even eliminate the use of opioids in surgical patients. However, more studies are required to confirm this concept, especially with the use of nanotechnology incorporated in devices/patches.

Correlation between femoral offset, rotation center and leg length discrepancy after total hip arthroplasty based on digital analysis

CT scans combined with Mimics software were used to measure femoral offset (FO), rotation center height (RCH) and lower leg length discrepancy (LLD) following total hip arthroplasty (THA), and the relationship between FO, RCH and LLD after THA is discussed. Retrospective analysis was performed on 40 patients with unilateral THA who met standard cases from October 2020 to June 2022. There were 21 males and 19 females, 18 patients on the left side and 22 patients on the right side, aged range from 30 to 81 years old, with an average age of (58.90 ±14.13) years old, BMI ranged from 17.3 to 31.5 kg·m-2 with an average of (25.3±3.4) kg·m-2. There were 30 cases of femoral head necrosis (Ficat type Ⅳ), 2 cases of hip osteoarthritis (Tönnis type Ⅲ), 2 cases of developmental hip dislocation combined with end-stage osteoarthritis (Crowe type Ⅲ), and 6 cases of femoral neck fracture (Garden type Ⅳ). Three-dimensional CT reconstruction of pelvis was taken preoperative and postoperative, and three-dimensional reconstruction model was established after processing by Mimics software. FO, RCH and LLD were measured on the model. The criteria for FO reconstruction were as follows:postoperative bilateral FO difference less than 5 mm;the standard for equal length of both lower limbs was as follows:postoperative LLD difference less than 5 mm. Bilateral FO difference was positively correlated with LLD (r=0.744, P<0.001). Chi-square test was performed between the FO reconstructed group and the non-reconstructed eccentricity group:The results showed that the isometric ratio of lower limbs in the FO reconstructed group was significantly higher than that in the FO reconstructed group (χ2=6.320, P=0.012). The bilateral RCH difference was significantly negatively correlated with LLD(r=-0.877, P<0.001). There is a linear relationship between bilateral FO difference and bilateral RCH difference and postoperative LLD, and the linear regression equation is satisfied:postoperative LLD=0.038x-0.099y+0.257(x:postoperative bilateral FO difference, y:postoperative bilateral RCH difference; Unit:cm), F=77.993, R2=0.808, P=0.009. After THA, LLD increased with the increase of FO and decreased with the increase of RCH. The effect of lower limb isometric length can be obtained more easily by reconstruction of FO. There is a linear relationship between the bilateral FO difference and the bilateral RCH difference after THA and LLD, and the regression equation can provide a theoretical reference for judging LLD.

Effect of transcutaneous electrical acupoint stimulation on postoperative urinary function in elderly patients undergoing total hip arthroplasty.

To observe the effect of transcutaneous electrical acupoint stimulation (TEAS) on postoperative urinary function in elderly patients undergoing total hip arthroplasty (THA). One hundred and eighty elderly patients undergoing unilateral THA without indwelling urinary catheters were randomly assigned to a TEAS group (90 cases, 3 cases dropped out, 4 cases were eliminated) and a sham TEAS group (90 cases, 1 case dropped out, 4 cases were eliminated). Both groups received fascia iliac block and subarachnoid block anesthesia under ultrasound guidance. The patients in the TEAS group were treated with TEAS at Zhongji (CV 3), Guanyuan (CV 4), and bilateral Huiyang (BL 35), Ciliao (BL 32) 30 minutes before anesthesia initiation, with dissperse-dense wave, frequency of 2 Hz/100 Hz, until 30 minutes after surgery. The patients in the sham TEAS group underwent the same procedure with the device applied at the same acupoints but without electrical stimulation. The incidence of postoperative urinary retention (POUR), time to first void, voiding threshold, urinary adenosine triphosphate (ATP) level, postoperative abnormal voiding status (bladder residual volume, re-catheterization rate, nocturia occurrence), and postoperative incidence of urinary tract infection (UTI) and prosthetic joint infection (PJI) were observed in both groups. The incidence of POUR in the TEAS group was lower than that in the sham TEAS group (P<0.05); the time to first void in the TEAS group was shorter than that in the sham TEAS group (P<0.05); the voiding threshold in the TEAS group was lower than that in the sham TEAS group (P<0.05); the urinary ATP level in the TEAS group was higher than that in the sham TEAS group (P<0.05); the bladder residual volume in the TEAS group was lower than that in the sham TEAS group (P<0.05); the nocturia occurrence in the TEAS group was lower than that in the sham TEAS group (P<0.05). However, there was no statistically significant difference in re-catheterization rate, incidence of UTI, and incidence of PJI between the two groups (P>0.05). TEAS could effectively reduce the occurrence of postoperative urinary retention and improve the postoperative urinary function in elderly patients undergoing THA, which might be related with increasing the urinary ATP level.

Ten Year Experience with Same Day Discharge Outpatient Total Hip Arthroplasty: Patient Demographics Changed, But Safe Outcomes Were Maintained

IntroductionThis study aimed to characterize changes in patient demographics and outcomes for same-day discharge (SDD) total hip arthroplasty (THA) over a 10-year period at a single orthopaedic specialty hospital. MethodsA consecutive series of 1,654 patients between 2013 and 2022 who underwent unilateral THA and were discharged on the same calendar day were retrospectively reviewed. Patient demographics, including age, sex, body mass index (BMI), age-adjusted Charlson Comorbidity Index (ACCI), and American Society of Anaesthesiologists (ASA), were collected. Readmissions, complications, and unplanned visits were recorded for 90 days postoperatively. In order to compare the demographics of patients over time, patients were divided into three groups: Time Group A (2013 to 2016), Time Group B (2017 to 2019), and Time Group C (2020 to 2022). ResultsThe mean age, BMI, ASA score, and CCI increased significantly across each time group. Age increased from 57 years (range, 23 to 77) to 60 years (range, 20 to 87). The BMI increased from 28.1 (range, 18 to 41) to 29.4 (range, 18 to 47). The percentage of patients aged > 70 years almost doubled over time, as did the percentage of patients who had a BMI > 35. Overall complications increased from 3.44 to 6.82%, reflective of the changing health status of patients. Readmissions increased from 0.57 to 1.70% over time. Despite this, there were no readmissions for any patient within the first 24 hours of surgery. ConclusionOur study has three important findings. We identified a worsening patient demographic over time with an increasing percentage of patients of advanced age and higher BMI, ASA, and ACCI. Also, there was also an increase in readmissions, complications, and unplanned visits. In addition, despite this worsening patient demographic, there were no readmissions within 24 hours and a low rate of readmissions or unplanned visits within the first 48 hours across all time periods, suggesting that SDD-THA continues to be safe in properly selected patients.

A Novel Approach for Correcting Limb Length Discrepancy in Total Hip Arthroplasty.

This study aimed to evaluate the accuracy of the suture technique, along with the utilization of a spirit-level devicewhich is an instrument designed to indicate whether a surface is horizontal or vertical, in comparison to the conventional supraacetabular pin method and caliper measurement for correcting leg length discrepancy (LLD) during total hip arthroplasty (THA). Materialsand methods: Consecutive patients who underwent unilateral primary THA between January 2021 and March 2023 were included in the study. The exclusion criteria were severe flexion and adduction contracture that could affect the accuracy of measurements, a history of lower extremity surgery, the presence of lower extremity deformity, and the absence of postoperative full-length radiographs. Patients were allocated into two groups based on the technique employed for correcting LLD during THA. Group 1 (n=62) consisted of patients evaluated using the suture technique with a spirit-level device, while group 2 (n=75) comprised patients who underwent the supraacetabular pin method with caliper measurement. The distance between the inter-teardrop line and the tip of the lesser trochanter was measured for both hips to assess LLD. The mean preoperative LLD was similar between groups, which was 11.6 ± 9.1 mm in group 1 and 9.5 ± 9.8 mm in group 2 (p=0.191). Postoperatively, group 1 had a significantly lower LLD compared to group 2 (p<0.001). According to the results obtained from this study, the use of a suture technique in conjunction with a spirit-level device to achieve a consistent leg position is an effective method for correcting LLD during THA.

Subsequent total joint arthroplasty: Are we learning from the first stage?

With the increasing incidence of total joint arthroplasty (TJA), there is a desire to reduce peri-operative complications and resource utilization. As degenerative conditions progress in multiple joints, many patients undergo multiple procedures. To determine if both physicians and patients learn from the patient's initial arthroplasty, resulting in improved outcomes following the second procedure. The institutional database was retrospectively queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients with only unilateral THA or TKA, and patients undergoing same-day bilateral TJA, were excluded. Patient demographics, comorbidities, and implant sizes were collected at the time of each procedure and patients were stratified by first vs second surgery. Outcome metrics evaluated included operative time, length of stay (LOS), disposition, 90-d readmissions and emergency department (ED) visits. A total of 642 patients, including 364 undergoing staged bilateral TKA and 278 undergoing bilateral THA, were analyzed. There was no significant difference in demographics or comorbidities between the first and second procedure, which were separated by a mean of 285 d. For THA and TKA, LOS was significantly less for the second surgery, with 66% of patients having a shorter hospitalization (P < 0.001). THA patients had significantly decreased operative time only when the same sized implant was utilized (P = 0.025). The vast majority (93.3%) of patients were discharged to the same type of location following their second surgery. However, when a change in disposition was present from the first surgery, patients were significantly more likely to be discharged to home after the second procedure (P = 0.033). There was no difference between procedures for post-operative readmissions (P = 0.438) or ED visits (P = 0.915). After gaining valuable experience recovering from the initial surgery, a patient's perioperative outcomes are improved for their second TJA. This may be the result of increased confidence and decreased anxiety, and it supports the theory that enhanced patient education pre-operatively may improve outcomes. For the surgical team, the second procedure of a staged THA is more efficient, although this finding did not hold for TKA.

Anatomical cup implantation assisted with dynamic 3D planning improves functional outcomes in primary total hip arthroplasty: A retrospective study.

Anatomical cup implantation is a promising approach in primary total hip arthroplasty (THA) and improves functional outcomes. We aimed to evaluate the cup position and functional outcomes in primary THA with preoperative dynamic 3D planning. We retrospectively reviewed 54 hips in 48 patients who underwent primary THA with anatomical cup implantation (mean follow-up time: 52months). Cup positions were evaluated based on patient-specific morphology, the acetabular fossa and the combined anteversion test. Functional outcomes were assessed after THA. The paired-sample t-test was performed for surgical and contralateral native hips among 42 patients who underwent unilateral THA. Two hips suffered intraoperative trochanteric fracture, but no hip dislocations occurred. No patients reported groin or thigh pain, and all patients were capable of deep squatting and one-leg standing. The mean Harris hip score, WOMAC score, and physical SF-36 score were 94.46 ± 6.16, 10.41 ± 3.62, and 95.19 ± 8.74, respectively. Except for acetabular offset, THA restored biomechanics to those of contralateral native hip, including cup anteversion, abduction, femoral offset and acetabular height (P> 0.05). This study provided evidence for the application of anatomical cup implantation assisted with dynamic 3D planning in primary THA, which restored morphology and improved functional outcomes.

Image quality and metal artifact reduction in total hip arthroplasty CT: deep learning-based algorithm versus virtual monoenergetic imaging and orthopedic metal artifact reduction

BackgroundTo compare image quality, metal artifacts, and diagnostic confidence of conventional computed tomography (CT) images of unilateral total hip arthroplasty patients (THA) with deep learning-based metal artifact reduction (DL-MAR) to conventional CT and 130-keV monoenergetic images with and without orthopedic metal artifact reduction (O-MAR).MethodsConventional CT and 130-keV monoenergetic images with and without O-MAR and DL-MAR images of 28 unilateral THA patients were reconstructed. Image quality, metal artifacts, and diagnostic confidence in bone, pelvic organs, and soft tissue adjacent to the prosthesis were jointly scored by two experienced musculoskeletal radiologists. Contrast-to-noise ratios (CNR) between bladder and fat and muscle and fat were measured. Wilcoxon signed-rank tests with Holm-Bonferroni correction were used.ResultsSignificantly higher image quality, higher diagnostic confidence, and less severe metal artifacts were observed on DL-MAR and images with O-MAR compared to images without O-MAR (p < 0.001 for all comparisons). Higher image quality, higher diagnostic confidence for bone and soft tissue adjacent to the prosthesis, and less severe metal artifacts were observed on DL-MAR when compared to conventional images and 130-keV monoenergetic images with O-MAR (p ≤ 0.014). CNRs were higher for DL-MAR and images with O-MAR compared to images without O-MAR (p < 0.001). Higher CNRs were observed on DL-MAR images compared to conventional images and 130-keV monoenergetic images with O-MAR (p ≤ 0.010).ConclusionsDL-MAR showed higher image quality, diagnostic confidence, and superior metal artifact reduction compared to conventional CT images and 130-keV monoenergetic images with and without O-MAR in unilateral THA patients.Relevance statementDL-MAR resulted into improved image quality, stronger reduction of metal artifacts, and improved diagnostic confidence compared to conventional and virtual monoenergetic images with and without metal artifact reduction, bringing DL-based metal artifact reduction closer to clinical application.Key points• Metal artifacts introduced by total hip arthroplasty hamper radiologic assessment on CT.• A deep-learning algorithm (DL-MAR) was compared to dual-layer CT images with O-MAR.• DL-MAR showed best image quality and diagnostic confidence.• Highest contrast-to-noise ratios were observed on the DL-MAR images.Graphical

Insurance Status Predicts Periprosthetic Joint Infection after Total Hip Arthroplasty

AbstractPeriprosthetic joint infection (PJI) is one of the most severe complications following total hip arthroplasty (THA), and identifying factors associated with PJI is vital for preoperative risk stratification. The aim of this study was to compare risk of PJI after THA across insurance payers using a statewide health data registry. A retrospective review was conducted querying the New York Statewide Planning and Research Cooperative System for all patients undergoing elective unilateral primary THA using International Classification of Diseases (ICD)-9 and ICD-10 procedure codes. Patients were stratified into groups based on their insurance provider as private payer, Medicare, Medicaid, or worker's compensation. Demographics, hospital clinical data, complications, PJI rates, and mortality rates were collected. PJI rates were significantly different between groups at both 3 (p &lt; 0.001) and 12 months (p &lt; 0.001) postoperatively, highest at both time points in the Medicaid group (3 months: 1.3%; 12 months: 1.8%). Log-rank test demonstrated increased cumulative PJI rates in the worker's compensation and Medicaid groups up to 108 months postoperatively (p &lt; 0.001). Multivariate Cox proportional hazard regression, adjusted for demographics, found that Medicaid insurance was associated with 1.4 times increased risk for PJI relative to Medicare (hazard ratio:1.39; 95% confidence interval [1.19, 1.62]; p &lt; 0.001). These results suggest patients undergoing THA covered by Medicaid are at increased risk for PJI compared with patients covered by other insurance payers. Surgeons should recognize this patient population is at an increased risk for PJI, and compensation policies for treating patients covered by Medicaid should reflect the increased complication rate associated with this population.

Change of joint line convergence angle and other coronal alignments after total hip arthroplasty

BackgroundThe purpose of this study was to determine the unloading effect of total hip arthroplasty (THA) on the ipsilateral knee joint through the joint line convergence angle (JLCA) change and determine the changes in other coronal radiographic parameters after THA, and evaluate the sensitivity of JLCA. Patients and methodsWe retrospectively assessed 70 patients who underwent unilateral THA. Hip parameters such as neck shaft angle (NSA), neck length, and femoral offset and coronal alignment parameters of the lower extremity such as hip–knee–ankle angle (HKA), femur length, mechanical lateral distal femoral angle (mLDFA), JLCA, medial proximal tibial angle (MPTA), lateral distal tibial angle (LDTA), and plafond talus angle (PTA) were measured in the operative and non-operative sides. We compared all hip and coronal alignment parameters between before and 1 year after THA, and the amount of standardized changes (Δ) between all hip and coronal alignment parameters on the operative side, respectively. ResultsAll mean hip and coronal alignment parameters on the operative side changed significantly 1-year after THA; however, those on the non-operative side did not. On the operative side, mean JLCA and PTA changed in the direction of closing the joint lateral space, from 1.81° and 0.47° to 1.22° and 0.11°, respectively (p<0.001 and 0.046, respectively). Mean NSA, HKA, and mLDFA changed in the valgus direction, from 129.39°, 2.62°, and 86.69° to 133.54°, 1.53°, and 85.91°, respectively (p<0.001). Mean femoral offset, neck length, and femur length increased from 36.45mm, 47.83mm, and 429.20mm to 39.85mm, 55.06mm, and 436.33mm, respectively (p<0.001). Mean MPTA and LDTA increased from 85.43° and 87.50° to 86.73° and 90.38, respectively (p<0.001). JLCA was more vulnerable to change than HKA, femur length, mLDFA, MPTA, and PTA (p<0.05). DiscussionJLCA change on the operative side was more sensitive than changes of other coronal alignments after THA. According to the cohort, THA might have an unloading effect on the medial compartment of the knee joint. Level of evidenceIV; retrospective case-control and cohort studies.

Routine pretransfusion testing before primary total hip or knee arthroplasty are an expensive and wasteful routine. Systematic review and meta-analysis.

The excessive routine ordering of pretransfusion tests (blood typing, screening, and cross-matching) for surgical cases incurs significant unnecessary costs and places an undue burden on transfusion services. This study aims to systematically review the literature regarding the necessity of routine pretransfusion tests before total hip arthroplasty (THA) or total knee arthroplasty (TKA) and summarize their outcomes. A systematic review and meta-analysis were performed. The study's characteristics, the prevalence of over-ordering pretransfusion tests, transfusion rates, and potential cost savings to the healthcare system were analyzed. The study included 17,667 patients. Pooled results revealed a 96.3% over-ordering pretransfusion test rate (95% CI: 0.92-1.00; p < 0.001) among patients undergoing primary THA or TKA. The pooled prevalence of hospital transfusion rate was 3.6%. Notably, there were statistically significant differences in preoperative hemoglobin (Hb) levels between patients not requiring transfusion (Hb = 13.9g/dl; 95% CI 12.59-15.20; p < 0.001) and those needing transfusion (Hb = 11.9g/dl; 95% CI 10.69-13.01; p < 0.001) (p = 0.03). The per-patient total cost savings ranged from 28.63 to 191.27 dollars. Our study suggests that routine pre-transfusion testing for all patients undergoing primary THA or TKA may be unnecessary. We propose limiting pretransfusion test orders to patients with preoperative hemoglobin levels below 12g/dl in unilateral primary TKA or THA. This targeted approach can result in significant cost savings for healthcare systems and transfusion services by reducing the over-ordering of pretransfusion tests in these surgical procedures.

Does Your Patient Need to Lose Weight? Weight Change Before and After Total Hip Arthroplasty Does Not Affect Health Care Utilization and Achievement of the Minimal Clinically Important Difference

BackgroundDespite the potential negative impact of preoperative obesity on total hip arthroplasty (THA) outcomes, the association between preoperative and postoperative weight change and outcomes is much less understood. Therefore, this study aimed to determine the impact of preoperative and postoperative weight change and preoperative body mass index (BMI) on health care utilization, satisfaction, and achievement of minimal clinically important difference (MCID) for Hip Disability and Osteoarthritis Outcome Score Physical Function Short-Form (HOOS PS) and HOOS Pain. MethodsPatients who underwent primary elective unilateral THA between January 2016 and December 2019 were included (N = 2,868). Multivariable logistic regression assessed the association between BMI and preoperative and postoperative weight change on outcomes while controlling for demographic characteristics. ResultsThere was no association between preoperative weight change and prolonged length of stay (> 3 days), 90-day readmission, nonhome discharge, patient dissatisfaction at 1 year, or achievement of HOOS Pain or HOOS PS MCID. Postoperative weight loss was an independent risk factor for patient dissatisfaction at 1 year but was not associated with achievement of either HOOS Pain or HOOS PS MCID at 1-year postoperative. Preoperative obesity classes I to III were independent risk factors for nonhome discharge. Nevertheless, preoperative obesity class I and class II were associated with an increased probability of reaching HOOS Pain MCID. Preoperative BMI was not associated with an increased risk of patient dissatisfaction. ConclusionsPreoperative weight change does not appear to influence health care utilization, satisfaction, or achievement of MCID in pain and function following THA. Postoperative weight loss may play a role as a risk factor for dissatisfaction following THA. Additionally, patients who had a higher baseline BMI may be more likely to see improvement in pain following THA. Therefore, when counseling obese patients for THA, surgeons must balance the risk of perioperative complications with the expectation of greater improvements in pain.

The prevalence of bilateral and ipsilateral radiographic osteoarthritis is high in White, Asian and Native Hawaiian/Pacific Islanders presenting for unilateral knee or hip arthroplasty.

It is estimated that one-third of patients presenting with unilateral joint pain have contralateral osteoarthritis (OA) at first presentation. Most studies have primarily examined White patient cohorts. The purpose of this study was to determine the prevalence of contralateral joint OA for patients presenting for unilateral total knee (TKA), unicompartmental knee (UKA) or total hip arthroplasty (THA) among Asian, Native Hawaiian/Pacific Islander and White patients. Bilateral radiographic reports at initial presentation of 2,312 subjects who underwent unilateral arthroplasties (332 UKAs, 933 TKAs and 1,047 THAs) were reviewed. The presence of contralateral OA was recorded and compared by racial group and type of arthroplasty performed. Parametric statistical analyses were performed to determine differences between groups. Multivariable analyses were completed for each arthroplasty group to determine the influence on the presence of contralateral OA, presented as odds ratios and 95% confidence intervals. Contralateral joint OA was present in 86.7%, 90.4% and 70.4% of UKA, TKA and THA patients, respectively. Concurrent hip OA was present in 41.6% and 59.5% of UKA and TKA patients. No racial differences in the prevalence of contralateral knee OA were found for knee arthroplasty patients. White patients (74.6%) had a greater prevalence of contralateral hip OA compared to Asians (66.5%, p = 0.037) amongst THA recipients. Increased age and body mass index were significantly associated with the presence of contralateral knee OA. Increased age, being male and being White were significant contributors for the presence of contralateral hip OA. The prevalence of contralateral joint OA and concurrent hip OA is high in all three racial groups. Due to the extensive prevalence of contralateral and concurrent knee and hip OA, bilateral radiographic evaluation should be considered for all patients presenting with unilateral hip or knee pain due to OA.

The Financial Burden of Patient Comorbidities on Total Hip Arthroplasties—A Matched Cohort Analysis of High Comorbidity Burden and Non–High Comorbidity Burden Patients

BackgroundThe impact of increased patient comorbidities on the cost-effectiveness of total hip arthroplasty (THAs) is lacking. This study aimed to compare revenue, costs, and short-term (90 days) surgical outcomes between patients who have and do not have a high comorbidity burden (HCB). MethodsWe retrospectively reviewed 14,949 patients who underwent an elective, unilateral THA between 2012 and 2021. Patients were stratified into HCB (Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiology scores of 3 or 4) and non-HCB groups, and were further 1:1 propensity matched based on baseline characteristics. Perioperative data, revenue, costs, and contribution margins (CMs) of the inpatient episode were compared between groups. Also, 90-day readmissions and revisions were compared between groups. Of the 11,717 patients who had available financial data (n = 1,017 HCB, n = 10,700 non-HCB), 1,914 patients were included in the final matched analyses (957 per group). ResultsTotal (P < .001) and direct (P < .001) costs were significantly higher for HCB patients. Comparable revenue between cohorts (P = .083) resulted in a significantly decreased CM in the HCB patient group (P < .001). The HCB patients were less likely to be discharged home (P < .001) and had significantly higher 90-day readmission rates (P = .049). ConclusionsIncreased THA costs for HCB patients were not matched by increased revenue, resulting in decreased CM. Higher rates of nonhome discharge and readmissions in the HCB population add to the additional financial burden. Adjustments to the current reimbursement models should better account for the increased financial burden of HCB patients undergoing THA and ensure access to care for all patient populations. Level of evidenceIII.

Predictive Factors of Pain and Functional Outcome 5 Years Following Total Hip Arthroplasty: A Prospective Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement Cohort Study

BackgroundPrevious reports have identified a number of potential predictors of pain and function after total hip arthroplasty (THA). However, the results of these studies were conflicting, and most had a short follow-up after THA. The purpose of this study was to identify factors predictive of pain and function 5 years after THA. MethodsA multicenter cohort of 7,934 primary unilateral THA patients was prospectively enrolled in the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement consortium. Demographic data, comorbidities, and patient-reported outcome measures were collected preoperatively and postoperatively at 5 years, including the Hip Disability and OSteoarthritis Outcome Score (HOOS) pain and activities of daily living (ADL) scores. Multivariate logistic regression models with 95% confidence interval were used to identify independent predictors of pain and function at 5 years. ResultsThe patient dissatisfaction percentage was 8.2% at 5 years after THA. The multivariate regression identified the following predictive factors for the HOOS pain score at 5 years: age, educational level, insurance, smoking, race, Charlson Comorbidity Index, back pain severity, number of other lower extremity painful joints, the Knee Injury and Osteoarthritis Outcome Score pain severity of the ipsilateral knee, preoperative Short-Form Health Survey 36-item (SF-36) mental component summary score, and HOOS pain scores. The multivariate regression identified the following predictor factors for HOOS ADL score at 5 years: body mass index, insurance, smoking, race, back pain severity, number of other lower extremity painful joints, Knee Injury and Osteoarthritis Outcome Score pain severity of ipsilateral knee, preop HOOS ADL, and preoperative SF-36 mental component summary score and SF-36 physical component summary score. ConclusionsOverall, 8.2% of patients were dissatisfied 5 years after primary THA. We have identified a number of factors that predict less improvement in pain and function 5 years after THA. These potentially modifiable factors can be targeted with preoperative patient optimization programs to improve patient outcomes and satisfaction after primary THA. Knowledge of these factors that predict less improvement in pain and function can assist the surgeon and patient during shared decision-making, and in setting appropriate patient expectations preoperatively.

No Impact of Contact Between the Medial Collar of a Hydroxyapatite-Coated Triple-Tapered Stem and the Femoral Neck on Periprosthetic Bone Mineral Density

BackgroundHydroxyapatite-coated, triple-tapered, shorter-length stems with a medial collar have been reported with good results for a few years. We investigated whether contact between the medial collar and femoral neck affects clinical outcomes and changes in bone mineral density (BMD) in patients who have this type of stem in their total hip arthroplasty construct. MethodsThis was a retrospective, single-center study involving 62 patients scheduled for unilateral total hip arthroplasty using a hydroxyapatite-coated, triple-tapered, shorter-length stem who were followed for at least 1 year postoperatively. All patients had a Dorr type B femoral canal shape. Contact between the medial collar and the femoral neck was evaluated by computed tomography at the third postoperative month, and patients were classified into 2 groups. Postoperative clinical outcomes were investigated by the Western Ontario and McMaster Universities Arthritis Index and the Japanese Orthopaedic Association scores; radiological evaluation included stem fixation, spot welds and cortical hypertrophy, postoperative 3-dimensional stem alignment, and periprosthetic BMD changes. ResultsThere were 51 patients in the Contact + group (collar and neck contact) and 11 in the Contact-group (no contact). There were no differences between the 2 groups in the improvement of Western Ontario and McMaster Universities Arthritis Index and Japanese Orthopaedic Association scores, stem fixation, occurrence of cortical hypertrophy, or 3-dimensional stem alignment. Radiolucent lines were present in zones 3, 4, and 5 in 6 patients (12%) in the Contact + group only, who had no statistical difference between the 2 groups. Bone mineral density (BMD) decreased most in zone 7 in both groups, with no difference between the 2 groups. ConclusionsThe presence or absence of contact between the medial collar and femoral neck did not affect postoperative BMD changes or radiological or clinical results. Level of EvidenceTherapeutic Level III.

Leg length discrepancy should be assessed based on the whole length of the lower limb in patients with osteoarthritis secondary to developmental dysplasia of the hip.

This study aimed to investigate the incidence of ≥ 5 mm asymmetry in lower and whole leg lengths (LLs) in patients with unilateral osteoarthritis (OA) secondary to developmental dysplasia of the hip (DDH-OA) and primary hip osteoarthritis (PHOA), and the relationship between lower and whole LL asymmetries and femoral length asymmetry. In total, 116 patients who underwent unilateral total hip arthroplasty were included in this study. Of these, 93 had DDH-OA and 23 had PHOA. Patients with DDH-OA were categorized into three groups: Crowe grade I, II/III, and IV. Anatomical femoral length, femoral length greater trochanter (GT), femoral length lesser trochanter (LT), tibial length, foot height, lower LL, and whole LL were evaluated using preoperative CT data of the whole leg in the supine position. Asymmetry was evaluated in the Crowe I, II/III, IV, and PHOA groups. The incidences of whole and lower LL asymmetries were 40%, 62.5%, 66.7%, and 26.1%, and 21.7%, 20.8%, 55.6%, and 8.7% in the Crowe I, II/III, and IV, and PHOA groups, respectively. The incidence of tibial length asymmetry was significantly higher in the Crowe IV group (44.4%) than that in the PHOA group (4.4%). In all, 50% of patients with DDH-OA with femoral length GT and LT asymmetries had lower LL asymmetry, and 75% had whole LL asymmetry. The incidences of lower and whole LL asymmetries were 20% and 42.9%, respectively, even in the absence of femoral length GT and LT asymmetries. Overall, 43% of patients with unilateral DDH-OA without femoral length asymmetry had whole LL asymmetry of ≥ 5 mm. Thus, both the femur length and whole LL should be measured to accurately assess LL discrepancy in patients with unilateral DDH-OA.