Valid and reliable techniques for assessing performance
are essential to surgical education, especially with the emergence
of competency-based frameworks. Despite this, there is a paucity
of adequate tools for the evaluation of skills required during joint
replacement surgery. In this scoping review, we examine current
methods for assessing surgeons’ competency in joint replacement
procedures in both simulated and clinical environments. The ability
of many of the tools currently in use to make valid, reliable and
comprehensive assessments of performance is unclear. Furthermore,
many simulation-based assessments have been criticised for a lack
of transferability to the clinical setting. It is imperative that
more effective methods of assessment are developed and implemented
in order to improve our ability to evaluate the performance of skills
relating to total joint replacement. This will enable educators
to provide formative feedback to learners throughout the training
process to ensure that they have attained core competencies upon
completion of their training. This should help ensure positive patient
outcomes as the surgical trainees enter independent practice. Cite this article:
The Single Assessment Numerical Evalution (SANE) score is a pragmatic alternative to longer patient-reported outcome measures (PROMs). The purpose of this study was to investigate the concurrent validity of the SANE and hip-specific PROMs in a generalized population of patients with hip pain at a single timepoint upon initial visit with an orthopaedic surgeon who is a hip preservation specialist. We hypothesized that SANE would have a strong correlation with the 12-question International Hip Outcome Tool (iHOT)-12, the Hip Outcome Score (HOS), and the Hip disability and Osteoarthritis Outcome Score (HOOS), providing evidence for concurrent validity of the SANE and hip-specific outcome measures in patients with hip pain. This study was a cross-sectional retrospective database analysis at a single timepoint. Data were collected from 2,782 patients at initial evaluation with a hip preservation specialist using the iHOT-12, HOS, HOOS, and SANE. Outcome scores were retrospectively analyzed using Pearson correlation coefficients.Aims
Methods
Spasticity used to be considered a contraindication for total hip replacement (THR) procedures. Due to the development of implants as well as surgical skills, THR became an option for the treatment of painful dislocation of the hip joint in patients with spastic plegia. The aim of this study was an evaluation of mid-term results of THR in spastic CP adolescent patients with painful hips with hip joint subluxation or dislocation. In 2014–2022, 18 pts (19 hips) with CP aged 16 to 20 years underwent THR in our department. The mean follow-up was 4 years (range: 1 – 9 years). Results were evaluated using the Gross Motor Function Scale, VAS scale in accordance with the Ashworth scale, types of implants used (dual mobility cup and not dual mobility cup), and radiological assessment (Crowe scale). Complications have been thoroughly analyzed. In 10 pts there has been an improvement in the GMFSC scale average from 1 to 2 points observed after the surgery. All pts have improved in the VAS scale average of 8 points (from 10 to 7). According to the Crowe scale repositioning of preoperative dislocation to primary acetabulum was achieved in all cases. Complications occurred in 4 cases: dislocations of 2 THR with dual mobility cup and 2 THR with non-dual mobility cup requiring revision surgery with good final result. No statistical significance was noted according to the type of cup (Mann-Whitney U Test). The most important risk factor for complications is severe spasticity. We believe, that CP pts with painful hips should be treated using THR. We didn't observe any significant differences between the types of implants. These findings may serve as a basis for the prediction of outcomes of THR treatment in this specific group of pts. Level of evidence: Case-control or retrospective comparative study-Level III
Rotational acetabular osteotomy (RAO), one of periacetabular osteotomies, is an effective joint-preserving surgical treatment for developmental dysplasia of the hip. Since 2013, we have been using a CT-based navigation for RAO to perform safe and accurate osteotomy. CT-based navigation allows precise osteotomy during surgery but cannot track the bony fragment after osteotomy. Thus, it is an issue to achieve successful reorientation in accordance with preoperative planning. In this presentation, we introduce a new method to achieve reorientation and evaluate its accuracy. Thirty joints in which CT-based navigated RAO was performed were included in this study. For the first 20 joints, reorientation was confirmed by tracing the lateral aspect of rotated fragment with navigation and checked if it matched with the preoperative planning. For the latter 10 joints, a new method was adopted. Four fiducial points were made on lateral side of the acetabulum in the preoperative 3-dimensional model and intraoperatively, rotation of the osteotomized bone was performed so that the 4 fiducial points match the preoperative plan. To assess the accuracy of position of rotated fragment in each group, preoperative planning and postoperative CT were compared. A total of 24 radial reformat images of postoperative CT were obtained at a half-hour interval following the clockface system around the acetabulum. In every radial image, femoral head coverage of actual postop- and planned were measured to evaluate the accuracy of acetabular fragment repositioning. The 4-fiducial method significantly reduced the reorientation error. Especially in the 12:00 to 1:00 position of the acetabulum, there were significantly fewer errors (p<0.01) and fewer cases with under-correction of the lateral acetabular coverage. With the new method with 4 reference fiducials, reorientation of the acetabulum could be obtained as planned with lesser errors.
Femoral stem design affects periprosthetic bone mineral density (BMD), which may impact long term survival of cementless implants in total hip arthroplasty (THA). The aim of this study was to examine proximal femoral BMD in three morphologically different uncemented femoral stems designs to investigate whether one particular design resulted in improved preservation of BMD. 119 patients were randomized to receive either a proximally coated dual taper wedge stem, a proximally coated anatomic stem or a fully coated collarless triple tapered stem. Dual energy x-ray absorptiometry scans (Lunar iDXA, GE Healthcare, Madison, WI) assessed BMD across the seven Gruen zones pre-operatively, and post-operatively at 6-weeks, 1-year, and 2-years comparing the unoperated contralateral femur as a control. BMD increased in zones one (2.5%), two (17.1%), three (13.0%), five (10%) and six (17.9%) for all stems. Greater preservation of BMD was measured on the lateral cortex (zone 2) for both the dual taper wedge and anatomic stems (p = 0.019). The dual taper wedge stem also demonstrated preservation of BMD in the medial calcar (zone 7) whilst the anatomic and triple taper stem declined in this region, however this was not statistically significant (p = 0.059). BMD decreased on average by 2.1% in the mid-diaphysis region, distal to the stem tip (zone 4) for all implants. All stems performed equivalently at final follow-up in all patient reported outcome measures. Implant design was shown to impact BMD changes. All stems preserved bone at the metaphyseal level in early follow-up, which theoretically indicates favorable implant fixation. There was no significant stress shielding observed, however longer follow-up is required to elucidate the impact of this finding on implant survivorship.
Noise induced hearing loss (NIHL) is a common cause of preventable deafness in adults and exposure to loud noise at work is a significant risk factor for its development. In order to protect the hearing of workers in the U.K., the Health and Safety Executive (HSE), on behalf of the Department for Work and Pensions, established the Control of Noise at Work Regulations (2005). The objectives of this study were to define the levels of noise exposure for the surgeon, assistant, scrub nurse and anaesthetist during total hip and knee arthroplasty surgery. In addition, we sought to determine whether the noise exposure during these procedures reaches or exceeds the action values set out by the U.K. Noise at Work Regulations (2005). To our knowledge no real-time assessment of personal noise exposure has been performed simultaneously on multiple members of the theatre team during arthroplasty surgery. Individual noise exposure during arthroplasty hip and knee surgery was recorded using a personal noise dosemeter system model 22 (DM22) (Pulsar instruments, Filey, U.K.). Recordings were taken real-time during five separate theatre sessions. Each theatre session included two arthroplasty procedures and lasted approximately 4hrs. Personal noise exposure was expressed in terms of peak sound pressure and an average noise exposure over an 8-hour time-period to reflect the noise experienced by the ear over a working day. In all three sessions involving total hip replacement surgery the peak sound pressure, for the operating surgeon, exceeded the exposure action values set out by the U.K. Noise at Work Regulations. Theatre sessions involving total knee replacement surgery did not exceed any exposure action values. The peak sound pressures experienced during total hip replacement surgery are too high and mandate that the surgeon should be provided with appropriate hearing protection. In addition, if the upper exposure action value is routinely exceeded then the theatre should be designated a hearing protection zone.
We designed a study to evaluate whether (1) there were differences in PROMs between different reasons for revision THA at baseline, (2) there was a different interaction effect for revision THA for all PROMs, and (3) complication and re-revision rates differ between reason for revision THA. Prospective cohort of 647 patients undergoing rTHA, with a minimum of 2 years FU. The reason for revision were classified as infection, aseptic loosening, dislocation, structural failure and painful THA with uncommon causes. PROMs (EQ-5D score, Oxford hip score (OHS), VAS pain, complication and failure rates were compared between different groups. Patients with different reason for revision had improvement of PROMs’ over time. Preoperatively, patients revised due to infection and aseptic loosening had poorer OHS and EQ-5D than patients with other reason for revision. Pain scores at baseline were highest in patients revised due to dislocation. Infection and aseptic loosening groups also showed a significant interaction effect over time in both OHS and EQ-5D. No PROMs significant differences between groups were observed 2 years postoperatively. Overall complications, and re-revision rates were 35.4 and 9.7% respectively. The reason for revision THA did not associate with clinical outcomes. Good outcomes were reached regardless of the reason for revision, as patients with the poorest pre-operative scores had the best improvement in PROMs over time. Complication and re-operation rates were relatively high, in line with previous reports, but did not differ between different reasons for revision THA.
Orthopaedic surgeons are exposed to high levels of noise when performing common surgical procedures. Noise induced hearing loss (NIHL) has been demonstrated amongst senior orthopaedic staff. The objective of this study was to investigate the prevalence of hearing loss amongst arthroplasty surgeons compared to non-surgical clinicians and explore the factors associated with hearing loss. A cross-sectional prevalence study. Arthroplasty surgeons and non-surgical clinicians were recruited from orthopaedic and medical conferences. All participants were given a paper questionnaire including demographic details, hearing history and Tinnitus and Hearing Survey (THS). All participants were screened for hearing loss in a quiet room using the HearCheck Screener™ (Siemens, UK). Logistic regression was used to identify factors associated with hearing loss. All statistical models were adjusted for age, gender, smoking status and personal noise exposure. A power calculation estimated a sample size of 100 participants.Background
Methods
While previously underappreciated, factors related to the spine contribute substantially to the risk of dislocation following total hip arthroplasty (THA). These factors must be taken into consideration during preoperative planning for revision THA due to recurrent instability. We developed a protocol to assess the functional position of the spine, the significance of these findings, and how to address different pathologies at the time of revision THA. Prospectively collected data on 111 patients undergoing revision THA for recurrent instability from January 2014 to January 2017 at two institutions were included (protocol group) and matched 1:1 to 111 revisions specifically performed for instability not using this protocol (control group). Mean follow-up was 2.8 years. Protocol patients underwent standardized preoperative imaging including supine and standing anteroposterior (AP) pelvis and lateral radiographs. Each case was scored according to the Hip-Spine Classification in Revision THA.Aims
Patients and Methods
The purpose of this study was to evaluate the long term changes in bone mineral density (BMD) following implantation of a low-modulus composite femoral component designed to closely match the stiffness of the proximal femur and minimize stress shielding. Specifically, we asked: 1) How does BMD in the proximal femur change with time and with Gruen zone location; 2) Does BMD in the proximal femur stabilize after two years of implantation? We retrospectively reviewed a subgroup of sixteen patients who had preoperative and postoperative DEXA scans in an FDA multi-center prospective trial of this composite stem. Five of these sixteen patients returned for long-term DEXA scans at a mean 22.0 years post-op (range 21.2–22.6 years). BMD in the 7 Gruen zones at final follow-up was compared to immediate post-operative and 2-year follow-up values. Percentage change was calculated and change in BMD was plotted against time from immediate post-operative measurements to each subsequent follow-up.Introduction
Methods
There is still little information on the histological characteristics of the acetabular bone tissue after failure of the primary prosthetic component. The purpose of this study is to characterize the viability and quality of the acetabular bone tissue in patients undergoing acetabular revision for aseptic loosening of uncemented components. 19 patients were enrolled: 14 hip revisions and 5 primary total hip arthroplasty. Overall bone quality was significantly worse in the study group due reduced viability, overturn of lamellar structures, reduced amount of intramedullary hematopoietic component in respect to the controls; this could result in poor ability of the host bone to interact with the implanted components.
Porous surfaces developed over the past decades have been shown to promote tissue ingrowth. Hydroxyapatite (HA) coatings have been added to these porous coatings in an attempt to further augment bone ingrowth. The development of additive manufacturing techniques has allowed for precision in building these complex porous structures. The effect of supplemental HA coatings on these new surfaces is unclear. The purpose of this study is to evaluate the biological fixation of a novel 3D printed porous implant in a canine model. In addition, we evaluated the effect of different HA coatings on this 3D printed implant. A canine transcortical model was used to evaluate the performance of three different laser rapid manufacturing (LRM) Ti6Al4V cylindrical implants (5.2 mm diameter, 10mm length): LRM with precipitated hydroxyapatite (P-HA), LRM with plasma sprayed hydroxyapatite (PS-HA), and a hydroxyapatite-free control (No-HA). The implants were 50–60% porous with a mean pore size of 450 μm and have a random interconnected architecture with irregular pore sizes and shapes that are designed based on the structure of cancellous bone. A lateral approach to the femoral diaphysis was used to prepare 5 mm unicortical, perpendicular drill holes in 12 canines. One of each implant type was press-fit into each femur. The femora were harvested at both 4 and 12 weeks post implantation, radiographed and prepared for either mechanical push-out testing to assess the shear strength of the bone-implant interface (left femora, N=6) or for histological processing (right femora, N=6). An un-paired Student's t-test was used to compare statistical significance between the 4 and 12-week results, as well as differences due to implant type; p<0.05 was considered significant.Introduction
Methods
Patients with rheumatoid arthritis (RA) have a higher risk of surgical site infection (PJI) than patients with osteoarthritis (OA). Disease modifying therapy is in widespread use in RA patients, and biologic medications may increase Staphylococcus aureus colonization rates. Because S. aureus colonization likely increases risk of surgical infection, perioperative assessments and therapies to decrease the risk of invasive S.aureus infections may be warranted. The objective of this study was to determine if there was a difference in S. aureus carriage among patients with RA, OA, and RA on biologics (RA+B). An a priori power analysis determined 123 participants per group were needed to detect a relative difference of 20% among groups with 80% power. After IRB approval, patients were screened; included patients met American College of Rheumatology classification criteria. Patients were approached between April 2017 and May 2018 and asked to perform a nasal swab while on site using the Center for Disease Control's swabbing protocol; questionnaires pertaining to their current health status were collected. Swabs were inoculated onto ChromAgar/ChromID MRSA plates for detection of S. aureus. Mann-Whitney U and Chi-square tests were used to evaluate baseline differences between groups. Logistic regression evaluated the associations between groups and S. aureus carriage. All statistical analyses were performed using SAS Software version 9.3 (SAS Institute, Cary, NC); statistical significance was defined as p<0.05.Introduction
Methods
Given the increasing number of total hip arthroplasty
procedures being performed annually, it is imperative that orthopaedic
surgeons understand factors responsible for instability. In order
to treat this potentially complex problem, we recommend correctly
classifying the type of instability present based on component position, abductor
function, impingement, and polyethylene wear. Correct classification
allows the treating surgeon to choose the appropriate revision option
that ultimately will allow for the best potential outcome. Cite this article:
The development of an algorithm that provides accurate individualised estimates of revision risk could help patients make informed surgical treatment choices. This requires building a survival model based on fixed and modifiable risk factors that predict outcome at the individual level. Here we compare different survival models for predicting prosthesis survivorship after hip replacement for osteoarthritis using data from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR). In this comparative study we implemented parametric and flexible parametric (FP) methods and random survival forests (RSF). The overall performance of the parametric models was compared using Akaike information criterion (AIC). The preferred parametric model and the RSF algorithm were further compared in terms of the Brier score, concordance index and calibration via repeated five-fold cross-validation.Introduction
Methods
Ceramic heads are used in hip revision surgery to mitigate corrosion concerns. Manufacturers recommend using a pristine titanium sleeve in conjunction with a well-fixed metal stem to prevent early failure of the ceramic head. However, the influence of impact force, head size, and sleeve offset on pull-off strength and seating displacement of a revision head assembly is not fully understood. Therefore, the purpose of this study was to investigate the pull-off strength and displacement of commercially available revision ceramic heads and titanium taper sleeve offsets (BIOLOX OPTION, CeramTec GmbH, Plochingen, Germany) while covering a range of clinically relevant impaction forces. Two head sizes (28 mm, n = 12 and 36 mm, n = 12) and two taper adapter sleeve offsets (small, n = 12 and extra-large, n = 12) were tested in this study. A dynamic impaction rig was constructed to seat the head, sleeve, and stem assembly (Fig. 1). Consistent impaction forces were achieved by dropping a hammer fixed to a lever arm from a pre-determined height onto a standard impactor instrumented with a piezoelectric force sensor (PCB Piezotronics Inc.). Axially applied forces of 2 kN and 6 kN were used to cover a range of typical impaction forces. Three non-contact differential variable reluctance transducers (LORD Sensing Systems) were used to track the displacement of the head relative to the stem. Subsequently, samples were transferred to a servo hydraulic testing machine, and a pull-off test was carried out per ISO 7206–10 to measure the disassembly force.Introduction
Methods
The primary purpose of the current study was to evaluate and compare the wear properties of vitamin E-doped, highly-crosslinked PE (VEPE) and one formulation of moderately cross-linked and mechanically-annealed ultra-high molecular weight PE (ModXLPE) in patients five years after primary THA. We also sought to understand whether polyethylene wear is associated with radiographic evidence of bone resorption or with deterioration in patient-reported outcome measures (PROMs). A total of 221 patients from four international centers were recruited into a prospective RSA and clinical outcomes study. Seventy percent (76%) of patients received VEPE (vs. ModXLPE) liners, and 36% received ceramic (vs. metal) femoral heads. PROMs and radiographs were collected preoperatively and at one, two, and five years postoperatively. In addition, RSA radiographs were collected to measure PE wear. We observed similar bedding in through the one-year interval and wear through the two-year interval between the two liner types. However, there was significantly more femoral head penetration in the ModXLPE cohort compared to the VEPE cohort at the five-year follow-up (p<0.001). The only variables independently predictive of increased wear were ModXLPE (vs VEPE) liner type (β=0.22, p=0.010) and metal (vs. ceramic) femoral head type (β=0.21, p=0.013). There was no association between increased wear and radiolucency development (p=0.866) or PROMs. No patients were found to have evidence of osteolysis. At five-years postoperatively, patients treated with VEPE (vs. ModXLPE) and ceramic (vs. metal) femoral heads demonstrated decreased wear. At the longest follow-up (five years postoperatively), the wear rates for both liner groups were very low and have not led to any osteolysis or implant failures via aseptic loosening.
Vitamin E-diffused, highly crosslinked polyethylene (VEPE) and porous titanium-coated (PTC) shells were introduced in total hip arthroplasty (THA) to reduce the risk of aseptic loosening. The purpose of this study was: 1) to compare the wear properties of VEPE to moderately crosslinked polyethylene; 2) to assess the stability of PTC shells; and 3) to report their clinical outcomes at seven years. A total of 89 patients were enrolled into a prospective study. All patients received a PTC shell and were randomized to receive a VEPE liner (n = 44) or a moderately crosslinked polyethylene (ModXLPE) liner (n = 45). Radiostereometric analysis (RSA) was used to measure polyethylene wear and component migration. Differences in wear were assessed while adjusting for body mass index, activity level, acetabular inclination, anteversion, and head size. Plain radiographs were assessed for radiolucency and patient-reported outcome measures (PROMs) were administered at each follow-up.Aims
Patients and Methods
Osteolysis secondary to ultra-high molecular weight polyethylene (UHMWPE) wear is a leading cause of late-term implant failure via aseptic loosening in patients treated with total hip arthroplasty (THA). Radiation crosslinking of UHMWPE has been shown to decrease wear. However, the resulting polymer (crosslinked-PE) has a high free radical content. Two different methods that have been used to reduce the remaining free radicals are mechanical annealing and chemical stabilization using Vitamin E, a free radical scavenger. The primary purpose of the current study was to evaluate and compare the wear properties of vitamin E-doped crosslinked-PE (VEPE) and one formulation of mechanically annealed crosslinked-PE using radiostereometric analysis (RSA) in patients five years after primary THA. We also sought to understand the association between polyethylene wear and patient-reported outcome measures (PROMs). Three-hundred and five patients from six international centers were enrolled. Seventy-six percent were treated with highly-crosslinked (95 kGy) VEPE liners, and the rest received moderately-crosslinked (50 kGy) (ModXL), mechanically annealed liners. Data was collected prospectively at one-, two-, and five-year intervals. At the 5-year follow-up, proximal femoral head penetration into the VEPE liners (median = 0.05mm (range, −0.03–1.20)) was significantly lower than the penetration into the ModXL liners (median = 0.15mm (range, −0.22–1.04)) (p<0.001). In the VEPE cohort the median proximal penetration did not increase from one- to five-year follow-up (p=0.209). In contrast, there was a significant increase in femoral head penetration for the ModXL group (p<0.001) during that same time. Multivariable regression showed that the only variable predictive of increased wear was ModXL liner type (B=0.12, p<0.001). There were no differences in PROMs between the liner groups, and there was no correlation between polyethylene wear and PROMs for the cohort as a whole. The current study is the largest analysis of polyethylene wear at five-year follow-up using the RSA technique. We observed similar bedding in through the two-year interval between the two liner types, however, there was significantly more wear in the ModXL cohort at five-years. Currently, the wear rates for both liner groups are below the osteolysis threshold and have not led to any implant failures via aseptic loosening. Continued follow-up will provide a better understanding of the association between wear rate and clinical outcomes.
Since January 1993 we have carried out MR arthrography on 23 patients with clinical symptoms and signs of abnormality of the acetabular labrum. Most of the patients were young adults. Such symptoms are known precursors of osteoarthritis, and therefore early and accurate evaluation is required. We assessed the value of MR arthrography of the hip as a minimally-invasive diagnostic technique, in a prospective study and compared the findings with those at subsequent operations. All the patients complained of groin pain; 22 had a positive acetabular impingement test and 15 had radiological evidence of hip dysplasia. In 21 of the patients, MR arthrography suggested either degeneration or a tear of the labrum or both. These findings were confirmed at operation in 18 patients, but there was no abnormality of the labrum in the other three. In two of the patients, MR arthrography erroneously suggested an intact labrum. Both MR arthrography and intraoperative inspection located lesions of the superior labrum most often, and these appeared slightly larger on arthrography than at operation. We consider that MR arthrography is a promising diagnostic technique for the evaluation of abnormalities of the acetabular labrum.
