Hip
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Royal National Orthopaedic Hospital NHS Trust, Stanmore, United Kingdom
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Royal National Orthopaedic Hospital NHS Trust, Stanmore, United Kingdom
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Institute of Orthopaedics and Musculoskeletal Science, University College London, United Kingdom
Cleveland Clinic London, United Kingdom
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CT is the principal imaging modality used for the pre-operative 3D planning and assessment of total hip arthroplasty (THA).
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The image quality offered by CT has a radiation penalty to the patient. Higher than necessary radiation exposure is of particular concern when imaging young patients and women of childbearing age, due to the greater risk of radiation-induced cancer in this group.
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A harmonised low-dose CT protocol is needed, evidenced by the huge variability in the 17 protocols reviewed. The majority of the protocols were incomplete, leading to uncertainty among radiographers when performing the scans.
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Only three protocols (20%) were optimised for both ‘field of view’ and image acquisition parameters. 10 protocols (60%) were optimised for ‘field of view’ only. These protocols included imaging of the relevant landmarks in the bony pelvis in addition to the knees – the reference for femoral anteversion.
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CT parameters, including the scanner kilovoltage (kV), milliamperage–time product (mAs) and slice thickness, must be optimised with a ‘field of view’ that includes the relevant bony landmarks. The recommended kV and mAs values were very wide ranging from 100 to 150 and from 100 to 250, respectively.
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The large variability that exists amongst the CT protocols illustrates the need for a more consistent low-dose CT protocol for the planning of THA. This must provide an optimal balance between image quality and radiation dose to the patient.
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Current CT scanners do not allow for measurements of functional pelvic orientation and additional upright imaging modalities are needed to augment them.
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Department of Occupational Therapy, Shu-Zen Junior College of Medicine and Management, Kaohsiung City, Taiwan
Department of Biomedical Engineering, I-Shou University, Kaohsiung City, Taiwan
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Department of Pharmacy, School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
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Purpose
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Comminuted fractures with poor bone quality in the elderly are associated with poor outcomes. An alternative to open reduction and internal fixation (ORIF) alone, primary or acute total hip arthroplasty (aTHA), allows early mobilization with full weight bearing. In this study, we aim to analyze whether treatment of aTHA with/withtout ORIF (limited ORIF) vs ORIF alone yields better intra-operative results, functional outcomes, and less complications.
Methods
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PubMed, Cochrane, Embase, and Scopus databases were searched in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Random-effects model and 95% confidence intervals were used. The outcomes of interest were surgery time, blood loss, length of hospital stay, Harris hip score (HHS), 36-Item Short Form Survey (SF-36), complication rate, surgical site infection rate, heterotopic ossification rate, reoperation rate, and mortality rate.
Results
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Ten observational studies with a total of 642 patients (415 ORIF alone and 227 aTHA with/without ORIF) were included in the systematic review. Compared to ORIF alone, aTHA with limited ORIF provided higher HHS (P = 0.029), better physical function (P = 0.008), better physical component summary (P = 0.001), better mental component summary (P = 0.043) in postoperative 1-year SF-36, lesser complication rate (P = 0.001), and lesser reoperation rate (P = 0.000), but however greater bodily pain (P = 0.001) in acetabular fractured elderlies.
Conclusions
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Acute THA with limited ORIF is favorable alternative to ORIF technique alone. It provided better HHS, physical, and mental component summary in SF-36 and yielded lower complication and reoperation rate compare to ORIF alone.
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Purpose
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This is a systematic review and meta(regression) analysis to assess the performance of custom triflange acetabular components (CTAC) in total hip arthroplasty (THA) revision surgery. Implant-related complications, failure rate, functional outcomes and implant and surgical technique-related predictors for outcome were assessed.
Methods
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This systematic review was performed according to PRISMA guidelines and registered with PROSPERO (2020 CRD42020209700). PubMed, Embase, Web of Science, COCHRANE Library and Emcare were searched. Studies on Paprosky type 3A and 3B or AAOS type 3 and 4 acetabular defects with a minimum follow-up of 12 months and cohorts > 10 patients were included.
Results
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Thirty-three studies were eligible for inclusion (n = 1235 hips, 1218 patients). The methodological quality of the studies was moderate (AQUILA: 7.4/11 points). Considerable heterogeneity was observed in terms of complications, re-operations and implant failure reporting. The total incidence of implant-related complications was 24%. The incidence of re-operation for any reason was 15%, and the implant failure rate was 12% at a mean of 46.9 months and the post-operative Harris Hip Score improved by a mean of 40 points. Several predictors for outcome were found, such as implant generation, follow-up length and study start date.
Conclusions
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The use of CTAC in revision THA has satisfactory complication and implant failure rates. The CTAC technique improves post-operative clinical outcomes and the meta-regression analysis showed that there is a clear association between improvements in the CTAC performance and the evolvement of this technique over time.
Division of Orthopaedics and Trauma Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
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Faculty of Medicine, University of Berne, Berne, Switzerland
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Since the middle of the 20th century, total hip arthroplasty has become a very successful treatment for all end-stage diseases of the hip joint. Charnley solved with his low frictional torque arthroplasty the problem of wear and friction with the introduction of a new bearing couple and the reduction of the head size, which set the prerequisite for the further development of stem design.
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This narrative review presents the major developments of regular straight stems in hip arthroplasty. It does not only provide an overview of the history but also assembles the generally scarce documentation available regarding the rationale of developments and illustrates often-unsuspected links.
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Charnley's success is based on successfully solving the issue of fixation of the prosthetic components to the bone, using bone cement made of polymethyl-methacrylate. In the field of cemented anchorage of the stem, two principles showing good long-term revision rates emerged over the years: the force-closed and the shape-closed principles.
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The non-cemented anchorage bases on prosthesis models ensure enough primary stability for osteointegration of the implant to occur. For bone to grow onto the surface, not only sufficient primary stability is required but also a suitable surface structure together with a biocompatible prosthetic material is also necessary.
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Anticoagulation use is common in elderly patients presenting with hip fractures and has been shown to delay time to surgery (TTS). Delays in operative treatment have been associated with worse outcomes in hip fracture patients. Direct oral anticoagulants (DOACs) comprise a steadily increasing proportion of all oral anticoagulation. Currently, no clear guidelines exist for perioperative management of hip fracture patients taking DOACs.
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DOAC use is associated with increased TTS, with delays frequently greater than 48 h from hospital presentation. Increased mortality has not been widely demonstrated in DOAC patients, despite increased TTS. Timing of surgery was not found to be associated with increased risk of transfusion or bleeding.
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Early surgery appears to be safe in patients taking DOACs presenting with a hip fracture, but is not currently widely accepted due to factors such as site-specific anesthesiologic protocols that periodically delay surgery. Direct oral anticoagulant use should not routinely delay surgical treatment in hip fracture patients.
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Surgical strategies to limit blood loss should be considered and include efficient surgical fixation, topical application of hemostatic agents, and the use of intra-operative cell salvage.
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Anesthesiologic strategies have utility in minimizing risk and a collaborative effort to minimize blood loss should be undertaken by the surgeon and anesthesiologist. Anesthesia team interventions include considerations regarding positioning, regional anesthesia, permissive hypotension, avoidance of hypothermia, judicious administration of blood products, and the use of systemic hemostatic agents.
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Purpose
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Intra-articular injection is a well-established and increasingly used treatment for the patient with mild-to-moderate hip osteoarthritis. The objectives of this literature review and meta-analysis are to evaluate the effect of prior intra-articular injections on the risk of periprosthetic joint infection (PJI) in patients undergoing total hip arthroplasty (THA) and to try to identify which is the minimum waiting time between hip injection and replacement in order to reduce the risk of infection.
Methods
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The database of PubMed, Embase, Google Scholar and Cochrane Library was systematically and independently searched, according to Preferred Reporting Items for Systematic Reviews and Meta–Analyses (PRISMA) guidelines. To assess the potential risk of bias and the applicability of the evidence found in the primary studies to the review, the Newcastle–Ottawa scale (NOS) was used. The statistical analysis was performed by using the software ’R’ version 4.2.2.
Results
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The pooling of data revealed an increased risk of PJI in the injection group that was statistically significative (P = 0.0427). In the attempt to identify a ’safe time interval’ between the injection and the elective surgery, we conducted a further subgroup analysis: in the subgroup 0–3 months, we noted an increased risk of PJI after injection.
Conclusions
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Intra-articular injection is a procedure that may increase the risk of developing periprosthetic infection. This risk is higher if the injection is performed less than 3 months before hip replacement.
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This review summarizes the sclerotic zone's pathophysiology, characterization, formation process, and impact on femoral head necrosis.
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The sclerotic zone is a reaction interface formed during the repair of femoral head necrosis.
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Compared with normal bone tissue, the mechanical properties of the sclerotic zone are significantly enhanced.
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Many factors influence the formation of the sclerotic zone, including mechanics, bone metabolism, angiogenesis, and other biological processes.
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The sclerotic zone plays an essential role in preventing the collapse of the femoral head and can predict the risk of the collapse of the femoral head.
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Regulating the formation of the sclerotic zone of the femoral head has become a direction worthy of study in treating femoral head necrosis.
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Care and Public Health Research Institute (CAPHRI) Maastricht University, Maastricht, the Netherlands
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Care and Public Health Research Institute (CAPHRI) Maastricht University, Maastricht, the Netherlands
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Care and Public Health Research Institute (CAPHRI) Maastricht University, Maastricht, the Netherlands
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Background
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Total hip arthroplasty is a reliable option to treat osteoarthritis. It reduces pain, increases quality of life, and restores function. The direct anterior approach (DAA), posterior approach (PA), and straight lateral approach (SLA) are mostly used. This systematic review evaluates current literature about costs and cost-effectiveness of DAA, PA, and SLA.
Methods
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A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic search, registered in the PROSPERO database (registration number: CRD42021237427), was conducted of databases PubMed, CINAHL, EMBASE, Cochrane, Clinical Trials, Current Controlled Trials, ClinicalTrials.gov, NHS Centre for Review and Dissemination, Econlit, and Web of Science. Eligible studies were randomized controlled trials (RCTs) or comparative cohort studies reporting or comparing costs or cost-effectiveness of either approach as the primary outcome. The risk of bias (RoB) was assessed. For comparison, all costs were converted to American Dollars (reference year 2016).
Results
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Six systematic review studies were included. RoB ranged from low to high, the level of evidence ranged from 2 to 4, and methodological quality was moderate. Costs ranged from $5313.85 to $15 859.00 (direct) and $1921.00 to $6364.30 (indirect) in DAA. From $5158.46 to $12 344.47 (direct) to $2265.70 to $5566.01 (indirect) for PA and from $3265.62 to $8501.81 (direct) and $2280.16 (indirect) for SLA. Due to heterogeneity of included costs, they were not directly comparable. Solid data about cost-effectiveness cannot be presented.
Conclusions
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Due to limited and heterogenous evidence about costs and cost-effectiveness, the effect of these in surgical approach is unknown. Further well-powered research to make undisputed conclusions is needed.
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There is no universal safe zone for cup orientation. Patients with spinal arthrodesis or a degenerative lumbar spine are at increased risk of dislocation.
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The relative contributions of the hip (femur and acetabulum) and of the spine (lumbar spine) in body motion must be considered together. The pelvis links the two and influences both acetabular orientation (i.e. hip flexion/extension) and sagittal balance/lumbar lordosis (i.e. spine flexion/extension).
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Examination of the spino-pelvic motion can be done through clinical examination and standard radiographs or stereographic imaging. A single, lateral, standing spinopelvic radiograph would be able to providemost relevant information required for screening and pre-operative planning.
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A significant variability in static and dynamic spinopelvic characteristics exists amongst healthy volunteers without known spinal or hip pathology.
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The stiff, arthritic, hip leads to greater changes in pelvic tilt (changes are almost doubled), with associated obligatory change in lumbar lordosis to maintain upright posture (lumbar lordosis is reduced to counterbalance for the reduction in sacral slope). Following total hip arthroplasty and restoration of hip flexion, spinopelvic characteristics tend to change/normalize (to age-matched healthy volunteers).
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The static spinopelvic parameters that are directly associated with increased risk of dislocation are lumbo-pelvic mismatch (pelvic incidence – lumbar lordosis angle >10°), high pelvic tilt (>19°), and low sacral slope when standing. A high combined sagittal index (CSI) when standing (>245°) is associated with increased risk of anterior instability, whilst low CSI when standing (<205°) is associated with increased risk of posterior instability.
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Aiming to achieve an optimum CSI when standing within 205–245° (with narrower target for those with spinal disease) whilst ensuring the coronal targets of cup orientation targets are achieved (inclination/version of 40/20 ±10°) is our preferred method.
Division of Orthopaedic Surgery and Musculoskeletal Trauma Care, Surgery Department, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
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Division of Orthopaedic Surgery and Musculoskeletal Trauma Care, Surgery Department, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
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Division of Orthopaedic Surgery and Musculoskeletal Trauma Care, Surgery Department, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
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Offsets in the frontal plane are important for hip function.
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Research on total hip arthroplasty (THA) surgery agrees that increasing femoral offset up to 5 mm could improve functional outcome measures.
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The literature indicates that global offset is a key parameter that physicians should restore within 5 mm during surgery and avoid decreasing.
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Substantiated findings on acetabular offset are lacking despite its recognized importance, and the medialization approach must be assessed in light of its shortcomings.
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Future research, possibly through improved measurement, unified definitions, patient-specific surgical planning, and technology-enhanced surgical control, with specific focus on acetabular offset, is needed to better understand its impact on THA outcomes.
