Proponents of the direct anterior approach (DAA) for hip arthroplasty (THA) claim lower postoperative pain compared to the posterolateral approach (PA); however, whether that theoretical advantage results in lower opioid consumption is unclear. We sought to investigate the relationship between the DAA and PA on total 90-day predicted opioid consumption in a large cohort.

Retrospective analysis identified 2,304 DAA and 6,288 PA primary THAs in patients >18 years old from February 2019 to April 2022. Ninety-day postoperative total morphine milligram equivalent (MME); in-hospital administration, discharge prescriptions, and refills within 90 days were compared between DAA and PA cohorts. Nearest-neighbor matching was performed controlling for age, sex, BMI, ASA, and periarticular injection to evaluate opioid consumption patterns for DAA and PA. Quantile regression was employed to predict the median (50th percentile) MME prescribed by surgical approach.

After matching, DAA and PA demonstrated similar median total 90-day prescribed MME (p = 0.008). After adjusting for patient and surgical factors, quantile regression predicted a similar median total 90-day prescribed MME for DAA and PA (243.5 versus 242.7; p = 0.78). While approach did not demonstrate a significant relationship for predicted 90-day MME, other factors including age, sex, BMI, length of stay, peripheral anesthesia, periarticular injection, and white or Caucasian race demonstrated a significant relationship with predicted 90-day MME (p <0.0001).

While we identified several risk factors for increased in-hospital and 90-day post-operative opioid consumption, a comparison between DAA and PA did not demonstrate significantly different opioid prescribing patterns.

Introduction

We studied the safety and efficacy of multimodal thromboprophylaxis (MMP) in patients with a history of venous thromboembolism (VTE) undergoing total hip arthroplasty (THA). MMP includes discontinuation of procoagulant medications, VTE risk stratification, regional anesthesia, an intravenous bolus of unfractionated heparin before femoral work, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient's risk.

Purpose: To determine mortality and morbidity for bilateral total knee replacment compared to unilateral knee replacement and revision total knee replacement using the National National Hospital Discharge Survey to include large numbers of patients and look at outcomes.

Method: We analyzed nationally representative data to elucidate the demographics, comorbidities, hospital stay, in-hospital complications and mortality of patients undergoing BTKA and compared them with those of patients undergoing UTKA and revision TKA (RTKA). Data in the National Hospital Discharge Survey on hospital discharges with procedure codes for BTKA, UTKA and RTKA between 1990 and 2004 was analyzed. The demographics, comorbidities, in-hospital stay, complications and mortality were studied. We identified 4,169,489 discharges (153,259 BTKAs; 3,677,161 UTKAs; and 339,069 RTKAs).

Results: Patients undergoing BTKA were younger (1.5 years) and had a lower prevalence of comorbidities for hypertension (vs. UTKA), diabetes, lung disease, and coronary artery disease (vs. UTKA and RTKA). The length of hospitalization was 5.8 days for BTKA, 5.28 for UTKA, and 5.41 for RTKA. Despite similar length of hospitalization, the prevalence of procedure related complications was higher for BTKA (14.17%+/−0.76 (SE)) than for UTKA (9.01%+/−0.17) and RTKA (9.84%+/−0.57). In hospital mortality was highest for BTKA patients (BTKA: 0.47%+/−0.15%; UTKA: 0.30%+/−0.03; RTKA: 0.27%+/−0.09).

Conclusion: Despite younger age and lower comorbidity burden, patients undergoing BTKA had an approximately 1.6 times higher rate of procedure related complications and mortality compared to those undergoing UTKA. Outcomes for RTKA patients for most variables were similar to those for UTKA. In a multivariate analysis, BTKA, advanced age and male gender were independent risk factors for complications and mortality following TKA surgery.

Particles generated at the non articulating surface (backside) of modular acetabular components have been implicated in the development of periprosthetic osteolysis after total hip arthroplasty. Several design changes have been introduced in modern uncemented acetabular cups in an attempt to reduce backside wear, including the use of so called “non-modular cups”. We compared the backside wear of retrieved cementless non-modular cups, with modular cups of first and second generation designs.

Nine retrieved non-modular cups (Implex) were match paired for time in situ, patient age and weight, with 9 retrieved Trilogy cups, 9 Harris-Galante 1, and 9 Harris-Galante 2. The average time in situ was 2.5 years (1 to 7). The backside was divided in quadrants and each rated utilizing a score with a value from 0 (absence of wear) to 3 (severe backside wear) for a total ranging from 0 to 12. The score was validated for intra and inter observer reproducibility.

Among 36 quadrants in the HG1 group there were 3 rated 1, 23 rated 2, and 10 rated 3. In the HG2 group, there was 1 quadrant rated 0, 16 rated 1, 14 rated 2, and 5 rated 3. In the Trilogy group, there were 6 quadrants rated 0, 27 rated 1, and 3 rated 2. In the Implex group, there were 15 quadrants rated 0, 21 rated 1. The average total backside wear score and 95%CI were 8.4 (7.6–9.3); 7.3 (5.5–9.1); 3.7 (3.2–4.1); and 2.3 (1.3–3.4) respectively. The HG1 and HG2 groups demonstrated similar backside wear scores (p=0.3). The HG1 and HG2 designs demonstrated significantly more backside wear than the Trilogy and Implex (p< 0.01). The differences between the Trilogy and the Implex were not significant in this cohort.

A comparison of the “in vivo” backside wear of first generation and modern acetabular cups has not been published to date. Despite the limitations imposed by the small sample studied, the presence of multiple screw holes in the HG retrievals, and sub-optimal matching for sex, height, and varied indication for revision, we detected significant reduction in the backside wear of modern modular and non-modular acetabular cups when compared to first generation modular designs.

First generation uncemented modular cups reproduciblyfixed to bone but they were associated with unacceptable rates of pelvicosteolysis and mechanical failure. Consequently, second generation cups weredeveloped with shells having a limited number of holes or no holes, and improved conformity and locking mechanisms with the liner. The purpose of this study is to report the clinical and radiographic results of a second generation acetabular component for primary total hip arthroplasty.

297 patients who underwent 335 consecutive primary total hip arthroplasties by a single surgeon with the Trilogy modular acetabular component were followed clinically with the Hospital for Special Surgery Hip Scoring System and radiographs, for 4 to 7 years. All cups were implanted with a press-fit technique.

This second generation acetabular cup design achieved predictable fixation and was associated with a low prevalence of revision for loosening and low prevalence of osteolysis at an intermediate follow up.

The role of surface finish on the survivorship of cemented stems is controversial. The purpose of this study is to prospectively evaluate the mid-term clinical and radiographic performance of a cohort of patients who underwent total hip replacement with two identical cemented femoral stems differing only in surface finish (VerSys, Zimmer, Warsaw, IN).

64 total hip replacements with a rough stem (Ra: 70–100 micro inches) and 138 total hip replacements with a satin finish stem (Ra: 20–25 micro inches) were followed clinically and radio graphically for 4 to 7 years. All surgeries were performed by one surgeon, during a period of 1 year, utilizing the same surgical approach and technique, ace tabular cup, cement type and cementing technique. The groups had similar demographics, diagnosis, preoperative clinical score, cement mantle quality, alignment, and length of follow up.

The preoperative and postoperative Hospital for Special Surgery Hip Score at last follow up of the patients with a successful operation was not significantly different among the two groups. Five hips in the rough group and none in the satin group developed aseptic loosening and required revision (p=0.0009). The femoral bone-cement interface revealed progressive radiolucent lines or osteolysis in 8 out of 64 rough stems and in 3 out of 138 satin stems (p=0.01). There were progressive radiolucenciesor osteolysis in 44 out of possible 448 Gruen zones in the rough surface group and in 8 out of possible 966 Gruen zones in the satin finish group(p< 0.001).

A rough, textured stem is more likely to fail at intermediate follow-up than a satin surface stem. We recommend that the surface of cemented stems should be satin or polished, with a Ra of less than 20 micro inches.