Hip
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Total hip arthroplasty (THA) is a remarkably successful operation that has grown rapidly its utilization.
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Early modern THA constructs as developed by Sir John Charnley featured cemented femoral stems and acetabular components. The technique of cementing components for THA has evolved over time.
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Modern acetabular preparation requires exposure of the subchondral bone with appropriate cement penetration into the trabecular bone, whereas femoral preparation requires cleaning of the canal, cement restrictor placement, retrograde filling, and pressurization of the cement.
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When used appropriately, these techniques result in excellent long-term survivorship of implants and are also widely considered to be the ideal method of fixation for hip fractures.
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The purpose of this article to review the history, properties, techniques, and outcomes of bone cement utilization in THA.
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Hip joints with bearings composed of cobalt–chromium alloy (metal-on-metal bearings) have been one of the most widely used implants in joint replacement arthroplasty. Unfortunately, these implants can contribute to a complication called aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL), a type IV metal hypersensitivity response around the joint.
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Consistent with such bearings, increased metal debris can be found in the surrounding fluids and in remote tissues and organs, due to wear and corrosion. It is hypothesized that metal ions released from the prosthesis (including Co2+) can potentially form haptens with proteins such as serum albumin in synovial fluid that in turn elicit ALVAL.
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Generally, elevated cobalt and chromium levels in synovial fluids may indicate implant failure. However, such measurements cannot be used as a reliable tool to predict the onset of ALVAL. To detect ALVAL, some diagnostic tests, questionnaires and imaging techniques have been used clinically with some success, but a standardized approach is lacking.
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At present, guidelines for implant usage and patient management are ambiguous and inconsistent across health care authorities. To reduce and better manage the development of ALVAL, further research into the precise molecular mechanism(s) by which ALVAL develops is urgently needed.
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Identification of diagnostic and prognostic biomarkers for ALVAL is required, as are more standardized guidelines for surgery and patient management.
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Bone morphology has been increasingly recognized as a significant variable in the evaluation of non-arthritic hip pain in young adults.
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Increased availability and use of multidetector CT in this patient population has contributed to better characterization of the osseous structures compared to traditional radiographs.
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Femoral and acetabular version, sites of impingement, acetabular coverage, femoral head–neck morphology, and other structural abnormalities are increasingly identified with the use of CT scan.
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In this review, a standard CT imaging technique and protocol is discussed, along with a systematic approach for evaluating pelvic CT imaging in patients with non-arthritic hip pain.
Universidad de La Laguna, Tenerife, Spain
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Universidad de La Laguna, Tenerife, Spain
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Universidad de La Laguna, Tenerife, Spain
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Universidad de La Laguna, Tenerife, Spain
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There is currently a debate on whether all Vancouver B2 periprosthetic hip fractures should be revised.
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The aim of our work was to establish a decision-making algorithm that helps to decide whether open reduction and internal fixation (ORIF) or revision arthroplasty (RA) should be performed in these patients.
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Relative indications in favour of ORIF are low-medium functional demand (Parker mobility score (PMS) <5), high anaesthetic risk (American Society of Anesthesiologists score (ASA) ≥ 3), many comorbidities (Charlson Comorbidity Index (CCI) ≥ 5), 1 zone fractured (VB2.1), anatomical reconstruction possible, and no prior loosening (hip pain).
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Relative indications in favour of RA are high functional demand (PMS ≥6), low anaesthetic risk (ASA< 3), few comorbidities (CCI<5), fracture ≥ 2 zones (VB2.2), comminuted fractures, and prior loosening (hip pain).
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In cemented stems, those fractures with fully intact cement–bone interface, no stem subsidence into the cementraliser, cement mantle anatomically reducible, and some partial stem-cement attachment can be safely treated with ORIF.
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Background and purpose
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Diagnostics and treatment of developmental dysplasia of the hip (DDH) are highly variable in clinical practice. To obtain more uniform and evidence-based treatment pathways, we developed the ‘Dutch guideline for DDH in children < 1 year’. This study describes recommendations for unstable and decentered hips.
Materials and methods
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The Appraisal of Guidelines for Research and Evaluation criteria (AGREE II) were applied. A systematic literature review was performed for six predefined guideline questions. Recommendations were developed, based on literature findings, as well as harms/benefits, patient/parent preferences, and costs (GRADE).
Results
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The systematic literature search resulted in 843 articles and 11 were included. Final guideline recommendations are (i) Pavlik harness is the preferred first step in the treatment of (sub) luxated hips; (ii) follow-up with ultrasound at 3–4 and 6–8 weeks; (iii) if no centered and stable hip after 6–8 weeks is present, closed reduction is indicated; (iv) if reduction is restricted by limited hip abduction, adductor tenotomy is indicated; (v) in case of open reduction, the anterior, anterolateral, or medial approach is advised, with the choice based on surgical preference and experience; (vi) after reduction (closed/open), a spica cast is advised for 12 weeks, followed by an abduction device in case of residual dysplasia.
Interpretation
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This study presents recommendations on the treatment of decentered DDH, based on the available literature and expert consensus, as Part 2 of the first official and national evidence-based ‘Guideline for DDH in children < 1 year’. Part 1 describes the guideline sections on centered DDH in a separate article.
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Acetabular component orientation and position are important factors in the short- and long-term outcomes of total hip arthroplasty.
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Different definitions of inclination and anteversion are used in the orthopaedic literature and surgeons should be aware of these differences and understand their relationships.
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There is no universal safe zone.
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Preoperative planning should be used to determine the optimum position and orientation of the cup and assess spinopelvic characteristics to adjust cup orientation accordingly.
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A peripheral reaming technique leads to a more accurate restoration of the centre of rotation with less variability compared with a standard reaming technique.
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Several intraoperative landmarks can be used to control the version of the cup, the most commonly used and studied is the transverse acetabular ligament.
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The use of an inclinometer reduces the variability associated with the use of freehand or mechanical alignment guides.
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The smaller the head fragment, the more likely it is located at the bottom and in front of the femoral head, which then determines the most suitable approach.
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A CT scan is essential after reduction and before resumption of weight-bearing to verify the size and congruence of the fragments and whether there are foreign bodies and/or a fracture of the posterior wall.
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Classifications should include the size of the fragment and whether or not there is an associated fracture of the acetabulum or femoral neck (historical ‘Pipkin’, modernised ‘Chiron’).
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In an emergency, the dislocation should be rectified, without completing the fracture (sciatic nerve palsy should be diagnosed before reduction). A hip prosthesis may be indicated (age or associated cervical fracture).
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Delayed orthopaedic treatment is sufficient if congruence is good. A displaced fragment can be resected (foreign bodies and ¼ head), reduced and osteosynthesised (⅓ and ½ head), and a posterior wall fracture reduced and osteosynthesised. Small fragments can be resected under arthroscopy. The approach is medial (Luddloff, Ferguson, Chiron) to remove or osteosynthesise ⅓ or ¼ fragments; posterior for ½ head or a fractured posterior wall.
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The results remain quite good in case of resection or an adequately reduced fragment. Long-term osteoarthritis is common (32%) but well tolerated with a low rate of prosthetisation. Avascular necrosis remains a possible complication (8.2%). Sciatic nerve palsy (4% of fracture dislocations) is more common for dislocations associated with posterior wall fractures.
Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK
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With an ever-ageing population, the incidence of hip fractures is increasing worldwide. Increasing age is not just associated with increasing fractures but also increasing comorbidities and polypharmacy.
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Consequently, a large proportion of patients requiring hip fracture surgery (HFS) are also prescribed antiplatelet and anti-coagulant medication. There remains a clinical conundrum with regards to how such medications should affect surgery, namely with regards to anaesthetic options, timing of surgery, stopping and starting the medication as well as the need for reversal agents.
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Herein, we present the up-to-date evidence on HFS management in patients taking blood-thinning agents and provide a summary of recommendations based on the existing literature.
IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
Fondazione Livio Sciutto Onlus, Campus Savona – Università degli Studi di Genova, Savona, Italy
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Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
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Fondazione Livio Sciutto Onlus, Campus Savona – Università degli Studi di Genova, Savona, Italy
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The study investigated the existing guidelines on the quality and frequency of the follow-up visits after total hip replacement surgery and assessed the level of evidence of these recommendations.
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The review process was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Additional works were retrieved by direct investigation of the available guidelines of the most important orthopedic societies and regulatory agencies.
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The current systematic review of the literature resulted in zero original papers, four guidelines for routine follow-up and three guidelines for special cases. Concerning the quality of evidence behind them, these guidelines were not evidence based but drafted from expert consensus.
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The most important finding of this review is the large variation of recommendations in the follow-up schedule after total hip arthroplasty and the lack of evidence-based indications. Indeed, all the above-reported guidelines are the result of a consensus among experts in the field (level of recommendation class D ‘very low’) and not based on clinical studies.
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School of Health Professions Education (SHE), Maastricht University, Maastricht, the Netherlands
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School of Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
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Prosthetic hip-associated cobalt toxicity (PHACT) is caused by elevated blood cobalt concentrations after hip arthroplasty.
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The aim of this study is to determine which symptoms are reported most frequently and in what type of bearing. We also try to determine the blood level of cobalt concentrations associated with toxicological symptoms.
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A systematic review was conducted on the 10th of July according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A methodological quality assessment (risk of bias (RoB)) was performed. Primary outcomes were the reported symptoms of cobalt toxicity and the level of cobalt concentrations in blood. These levels were associated with toxicological symptoms. A total of 7645 references were found of which 67 relevant reports describing 79 patients.
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The two most used bearings in which PHACT was described were metal-on-metal (MoM) bearings (38 cases) and revised (fractured) ceramic-on-ceramic (CoC) bearings where the former ceramic head was replaced by a metal head (32 cases).
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Of all reported symptoms, most were seen in the neurological system, of which 24% were in the sensory system and 19.3% were in central/peripheral system, followed by the cardiovascular (22.1%) system.
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The mean cobalt concentration for MoM-bearings was 123.7 ± 96.8 ppb and 1078.2 ± 1267.5 ppb for the revised fractured CoC-bearings.
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We recommend not to use a metal-based articulation in the revision of a fractured CoC bearing and suggest close follow-up with yearly blood cobalt concentration controls in patients with a MoM bearing or a revised fractured CoC bearing.
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Level of Evidence: Level V, systematic review
