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MSK Lab, Imperial College London, UK
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Multimodal protocols for pain control, blood loss management and thromboprophylaxis have been shown to benefit patients by being more effective and as safe (fewer iatrogenic complications) as conventional protocols.
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Proper patient selection and education, multimodal protocols and a well-defined clinical pathway are all key for successful day-case arthroplasty.
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By potentially being more effective, cheaper than and as safe as inpatient arthroplasty, day-case arthroplasty might be beneficial for patients and healthcare systems.
Cite this article: EFORT Open Rev 2018;3:130-135. DOI: 10.1302/2058-5241.3.170031
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Conventional techniques for hip and knee arthroplasty have led to good long-term clinical outcomes, but complications remain despite better surgical precision and improvements in implant design and quality.
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Technological improvements and a better understanding of joint kinematics have facilitated the progression to ‘personalized’ implant positioning (kinematic alignment) for total hip (THA) and knee (TKA) arthroplasty, the true value of which remains to be determined.
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By achieving a true knee resurfacing, the kinematic alignment (KA) technique for TKA aims at aligning the components with the physiological kinematic axes of the knee and restoring the constitutional tibio-femoral joint line frontal and axial orientation and soft-tissue laxity.
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The KA technique for THA aims at restoring the native ‘combined femoro-acetabular anteversion’ and the hip’s centre of rotation, and occasionally adjusting the cup position and design based on the assessment of the individual spine-hip relation.
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The key element for optimal prosthetic joint kinematics (hip or knee) is to reproduce the femoral anatomy.
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The transverse acetabular ligament (TAL) is the reference landmark to adjust the cup position.
Cite this article: EFORT Open Rev 2018;3:98-105. DOI: 10.1302/2058-5241.3.170022
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Total hip arthroplasty (THA) surgery has shown dramatic changes in terms of increased number of procedures and of technical development in recent years. It has been described as “the operation of the 20th century” for the excellent results, the high satisfaction of the patients and the improvement of the quality of life.
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A lot of variations have been introduced over the last few decades in THA especially in terms of indications (both in younger and older patients), techniques and devices (approaches, tissue preservation, biomaterials and industrial finishing), per-operative management (blood loss and pain control) and post-operative protocols (the so called “fast track” surgery). Looking at all these advances the emerging question is: have all of them been justified both in terms of improvement of the results for the patients and of the cost/benefit ratio from an economical point of view?
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The purpose of this paper is to critically analyse the advantages and the disadvantages of the theoretically proposed “advances in hip arthroplasty” and attempt to understand which are justified of such “advances” nowadays, based on the international and the European perspective with a focus on the author’s personal clinical experience.
Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.170008. Originally published online at www.efortopenreviews.org
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‘Fast-track’ surgery was introduced more than 20 years ago and may be defined as a co-ordinated peri-operative approach aimed at reducing surgical stress and facilitating post-operative recovery.
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The fast-track programmes have now been introduced into total hip arthroplasty (THA) surgery with reduction in post-operative length of stay, shorter convalescence and rapid functional recovery without increased morbidity and mortality. This has been achieved by focusing on a multidisciplinary collaboration and establishing ‘fast-track’ units, with a well-defined organisational set-up tailored to deliver an accelerated peri-operative course of fast-track surgical THA procedures.
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Fast-track THA surgery now works extremely well in the standard THA patient. However, all patients are different and fine-tuning of the multiple areas in fast-track pathways to get patients with special needs or high co-morbidity burden through a safe and effective fast-track THA pathway is important.
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In this narrative review, the principles of fast-track THA surgery are presented together with the present status of implementation and perspectives for further improvements.
Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160060. Originally published online at www.efortopenreviews.org
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Performing sports after total hip arthroplasty (THA) may be associated with a risk of
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Trauma (fracture and dislocation)
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Shorter implant survival
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There is no proof that trauma occurs more often than in healthy individuals, but sequelae may be more severe.
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Shorter implant survival due to repetitive high contact forces is a fact, due to increased wear. The 15 year survival in highly active patients seems to be around 80%.
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Surgeons can address the needs of active patients by using bearings with low wear rates, and femoral heads up to 36 mm in diameter.
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The data provided in this review may help to fully inform active patients of the risks. The patient has to balance the pros and cons of sports after THA and to decide the best way for themselves.
Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160059. Originally published online at www.efortopenreviews.org
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Hip arthroscopy is an evolving surgical technique that has recently increased in popularity.
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Although femoroacetabular impingement was an important launch pad for this technique, extra-articular pathology has been described through hip endoscopy.
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Good clinical results in the medium term will allow improvements in this technique and increase its indications.
Cite this article: EFORT Open Rev 2017;2:58-65. DOI: 10.1302/2058-5241.2.150041
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Avascular necrosis (AVN) of the femoral head (FH) causes 5% to 12% of total hip arthroplasties (THA). It especially affects active male adults between the third and fifth decades of life. The exact worldwide incidence is unknown. There are only few data related to each country, but most of it relates to the United States.
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Non-surgical management has a very limited role in the treatment of AVN of the FH and only in its earliest stages. Core decompression (CD) of the hip is the most common procedure used to treat the early stages of AVN of the FH. Recently, surgeons have considered combining CD with autologous bone-marrow cells, demineralised bone matrix or bone morphogenetic proteins or methods of angiogenic potential to enhance bone repair in the FH.
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Manuscripts were deemed eligible for our review if they evaluated treatment of early stage AVN of the FH with biotechnology implanted via CD. After application of eligibility criteria, we selected 19 reports for final analysis.
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The principal results showed that only by correctly mastering the therapeutic principles and adopting proper methods specifically oriented to different stages can the best therapeutic effect be achieved. Combining CD with biotechnology could result in a novel long-lasting hip- preserving treatment option.
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Furthermore, more refined clinical studies are needed to establish the effectiveness of biotechnology treatments in AVN of the FH.
Cite this article: EFORT Open Rev 2017;2:41-50. DOI: 10.1302/2058-5241.2.150006
IRCCS Galeazzi Orthopedic Institute, Milan, Italy
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IRCCS Galeazzi Orthopedic Institute, Milan, Italy
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Acetabular bone loss is a relevant concern for surgeons dealing with a failed total hip arthroplasty.
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Since the femoral head is no longer available, allografts represent the first choice for most reconstructive solutions, either as a structural buttress or impacted bone chips.
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Even though fresh-frozen bone is firmly recommended for structural grafts, freeze-dried and/or irradiated bone may be used alternatively for impaction grafting. Indeed, there are some papers on freeze-dried or irradiated bone impaction grafting, but their number is limited, as is the number of cases.
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Xenografts do not represent a viable option based on the poor available evidence but bioactive bioceramics such as hydroxyapatite and biphasic calcium phosphates are suitable bone graft extenders or even substitutes for acetabular impaction grafting.
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Bone-marrow-derived mesenchymal stem cells and demineralised bone matrix seem to act as reliable bone graft enhancers, i.e. adjuvant therapies able to improve the biological performance of standard bone grafts or substitutes. Among these therapies, platelet-rich plasma and bone morphogenetic proteins need to be investigated further before any recommendations can be made.
Cite this article: EFORT Open Rev 2016;1:431-439. DOI:10.1302/2058-5241.160025
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Large-head metal-on-metal (MoM) bearings were re-popularised in the late 1990s with the introduction of modern hip resurfacing (HR), followed closely by large metal head total hip arthroplasty (THA). A worldwide increase in the use of MoM hip arthroplasty subsequently saw a sharp decline, due to serious complications.
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MoM was rapidly adopted in the early 2000s until medical device alerts were issued by government regulatory agencies and national and international organisations, leading to post-marketing surveillance and discontinuation of these implants.
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Guidelines for MoM hip implant follow-up differ considerably between regulatory authorities worldwide; this can in part be attributed to missing or conflicting evidence.
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The authors consider that the use of large-head MoM THA should be discontinued. MoM HR should be approached with caution and, when considered, should be used only in patients who meet all of the recommended selection criteria, which limits its indications considerably.
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The phased introduction of new prostheses should be mandatory in future. Close monitoring of outcomes and long-term follow-up is also necessary for the introduction of new prostheses.
Cite this article: van Lingen CP, Zagra LM, Ettema HB, Verheyen CC. Sequelae of large-head metal-on-metal hip arthroplasties: current status and future prospects. EFORT Open Rev 2016;1:345-353. DOI: 10.1302/2058-5241.1.160014.
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Total hip arthroplasty (THA) is a common procedure for primary osteoarthritis, but increasing numbers are also being performed for other pathologies such as secondary arthritis, inflammatory arthropathies and trauma. Estimates suggest that around 8.5 million people in the UK are affected by joint pain secondary to arthritis and a rising ageing population has resulted in an increase in THA operations of around 4% per year over the last six years.
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Multiple studies have shown that THA provides improved quality of life scores, but there remains the burden of complications which account for 15% of £1bn NHS liability payouts. DaPalma et al analysed the financial impact of complications following THA and found the additional cost of a dislocation within six weeks of surgery is 342% of the primary cost.
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Following primary THA, complications may occur as a result of incorrect component positioning of the femoral stem, the acetabular cup or both. It is known that acetabular malposition may lead to increased rates of dislocation, impingement, edge-loading, polyethylene wear, pelvic osteolysis and prosthesis failure.
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Acetabular component positioning has been described as the single most important factor in dictating risk of dislocation following THA. Furthermore, instability and dislocation after primary THA is the most common single reason for revision surgery accounting for 22.5% of all revisions and 33% of acetabular revisions.
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We outline the currently available methods of acetabular navigation comparing freehand techniques with computer and robotic-assisted navigation of the acetabular component.
Cite this article: Davenport D, Kavarthapu V. Computer navigation of the acetabular component in total hip arthroplasty: a narrative review. EFORT Open Rev 2016;1:279-285. DOI: 10.1302/2058-5241.1.000050.
