Hip
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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.
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Pigmented villonodular synovitis (PVNS) is a rare disease that can affect any joint, bursa or tendon sheath.
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The hip is less frequently affected than the knee, and hence is less discussed in scientific journals.
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PVNS of the hip mainly occurs in young adults, requiring early diagnosis and adequate treatment to obtain good results.
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There is no consensus on the management of PVNS of the hip in current literature.
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We will discuss the options for surgical intervention in hip PVNS using a literature review of clinical, biological, etiological, histological and radiographic aspects of the disease.
Cite this article: Steinmetz S, Rougemont A-L, Peter R. Pigmented villonodular synovitis of the hip. EFORT Open Rev 2016;1:260-266. DOI: 10.1302/2058-5241.1.000021.
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Dislocation remains a common cause of failure after total hip arthroplasty. The limitations of existing approaches to address instability have led to the development of powerfull options: constrained liners, dual mobility and large heads. These implant-related options have proven to be very efficient, but have raised concerns.
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With constrained liners, restricted range of motion (ROM) is responsible for impingement leading to high likelihood of failure, depending on the design, with various failure modes.
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Improvements of the bearing materials have addressed some of the concerns about increased volumetric wear of conventional polyethylene and offer an option to reduce instability: large diameter heads have the advantage of increased ROM before impingement, increased head-neck ratio, and jump distance. Highly cross-linked polyethylene helps address the risk for increased wear, and also large heads provide improved stability without the risk of mechanical failures observed with constrained liners. However, the increase of the head size remains limited as reducing the thickness of the liner may lead to fractures. In addition, the jump distance decreases as the cup abduction increases.
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The dual mobility concept simultaneously attempts to address head-neck ratio, constraint, and jump distance. Despite the need for longer follow-up, concerns raised about potential increased wear and intra-prosthetic dislocation with first generation implants have been addressed with modern designs.
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With a dramatic increase of the head-neck ratio whilst reducing the risk of mechanical failure or excessive wear, dual mobility THA outperforms large diameter heads and constrained liners at 10 years follow-up. For these reasons, dual mobility continues to gain interest worldwide and is becoming the most popular option to manage instability.
Cite this article: Guyen O. Constrained liners, dual mobility or large diameter heads to avoid dislocation in THA. EFORT Open Rev 2016;1:197-204. DOI: 10.1302/2058-5241.1.000054.
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Navigation in primary total hip arthroplasty has a history of over 20 years. During this process, imageless computer navigation can be particularly helpful in optimally restoring the hip’s biomechanics. This involves the accurate placement of the acetabular component with the determination of the anteversion and abduction, whereby the navigated femur-first technique also allows for a calculation of the combined anteversion. Additional critical parameters such as the reconstruction of the rotation centre, as well as the femoral and acetabular offset, can also be optimally adjusted. Last but not least, an intra-operative evaluation and equalisation of the leg length is possible.
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Nonetheless, the disadvantages of this surgical technique in terms of the high costs in the acquisition and preservation of the necessary devices, as well as the longer operation time, must be taken into account. However, economic aspects are not the only thing preventing widespread use of the navigation technique. Determining the plane of reference (APP) for the optimal orientation of the implants is based on palpation of the bony landmarks – and this is influenced by the thickness of the soft tissue layer. Furthermore, the experience of the surgeon constitutes a variable that influences the accuracy of navigation.
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In summary, hip navigation certainly offers an interesting technique for the optimisation of total hip arthroplasty with reconstruction of proper biomechanics. At the same time, there is currently a lack of high-quality randomised controlled long-term trials that evaluate the clinical advantage for the patients, together with cost utility and survival rates.
Cite this article: Renner L, Janz V, Perka C, Wassilew GI. What do we get from navigation in primary THA? EFORT Open Rev 2016;1:205-210. 10.1302/2058-5241.1.000034.
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Based on the exceptional tribological behaviour and on the relatively low biological activity of ceramic particles, Ceramic-on-Ceramic (CoC) total hip arthroplasty (THA) presents significant advantages
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CoC bearings decrease wear and osteolysis, the cumulative long-term risk of dislocation, muscle atrophy, and head-neck taper corrosion.
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However, there are still concerns regarding the best technique for implantation of ceramic hips to avoid fracture, squeaking, and revision of ceramic hips with fracture of a component.
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We recommend that surgeons weigh the potential advantages and disadvantages of current CoC THA in comparison with other bearing surfaces when considering young very active patients who are candidates for THA.
Cite this article: Hernigou P, Roubineau F, Bouthors C, Flouzat-Lachaniette C-H. What every surgeon should know about Ceramic-on-Ceramic bearings in young patients. EFORT Open Rev 2016;1:107-111. DOI: 10.1302/2058-5241.1.000027.
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One of the most common causes for revision surgery following total hip arthroplasty (THA) is dislocation.
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Dislocation is associated with a considerable amount of suffering and risks for the patient, and extra costs for the health care system.
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Compared with degenerative arthritis, the dislocation rate is doubled for avascular necrosis and multiplied by three times for congenital dislocation, four for fracture, five for nonunion, malunion or a failed hip arthroplasty, and eleven times after surgery for prosthetic instability.
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In analysing instability the cause may be assessed as 1) locally caused within the hip with explanatory radiographic findings, 2) locally caused without explanatory radiographic findings or 3) non-locally caused, i.e. non-compliant patient, neuromuscular or cognitive disorders.
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Revision strategies for instability are typically directed to correct the underlying aetiology, but also to strive for an upsizing of the head and liner.
Cite this article: Ullmark G. The unstable total hip arthroplasty. EFORT Open Rev 2016;1:83-88. DOI: 10.1302/2058-5241.1.000022.
