We compared the postoperative wound discharge rates and 3 months clinical results of three types of wound closure and dressing – 2-octylcyanoacrylate with Opstie (G+O), 2-octylcyanoacrylate with Tegaderm (G+T), and Opsite without 2-octylcyanoacrylate (O) in patients having primary total hip arthroplasty. We randomised 141 patients scheduled for primary total hip arthroplasty into 3 arms of this study- G+O, G+T, or O. The extent of wound discharge was recorded on a diagrammatic representation of the dressing in situ on paper and graded each day. Dressings were left in-situ provided the extent of wound discharge allowed for this. The patient was clinically reviewed at 3 months to assess their scar length, cosmesis, scar discomfort, and evidence of superficial or deep wound sepsis. A greater number of patients dressings remained dry on day 1 postoperatively in the two groups with 2-octylcyanoacrylate compared to the no glue group p=0.001. G+T group had a significantly lower proportion of patients with increased leakage of wounds on 2. nd. postoperative day p=0.044. At 3 months review, there was no statistical difference in the Hollander score or scar discomfort. In patients who have had primary total hip arthroplasty, usage of 2-octylcyanoacrylate for wound closure along with Tegaderm dressing reduces wound discharge. The same effect is not noted in glue with Opsite group. Whilst dressing changes required in the non-glue group compared from the two glue groups did not reach statistical significance, this may have clinical relevance for patients and nursing staff. No effect on postoperative length of stay, or wound complications was noted

When performing total hip replacements in patients with hip dysplasia, acetabular augmentation may be required to prevent early component failure. Preoperative radiographic templating may help estimate acetabularcomponent coverage but has not previously been shown to predict the need for augmentation. We developed a simple method to estimate the percentage of acetabular component coverage from pre-operative radiographs (True: False cup ratio). We aimed to evaluate whether this couldpredict the need foracetabular augmentation at primary total hip replacement for patients with dysplastic hips. We reviewed all patients with hip dysplasia who underwent a primary total hip replacement from 2005–2012. Classification of hip dysplasia (Crowe), centre edge angle (CEA), Sharp and Tonnis angles were determined on pre-operative radiographs for each patient. Templating was performed on anteroposteriorand lateral view hip radiographs to determine the likely percentage of acetabular component coverage using the True: False cup ratio. Patients requiring acetabular augmentation at time of primary total hip arthroplasty were noted. 128 cases were reviewed, 31 (24%) required acetabularaugmentation. Comparison between augmented and non-augmented cases revealed no difference in the mean CEA (p = 0.19), Sharp angles (p = 0.76) or Tonnis angles (p = 0.32). A lower True Cup: False Cup ratio was observed in the augmented groupcompared to the non-augmented group(median = 0.68 vs 0.88, p < 0.01). Preoperative templating can help predict which dysplastic hips are likely to require acetabular augmentation at primary total hip replacement

Restoration of anatomy is paramount in total hip arthroplasty (THA) to optimise function and stability. Leg-length discrepancy of ≥10mm is poorly tolerated and can be the subject of litigation. We routinely use a multimodal protocol to optimise soft tissue balancing which involves pre-operative templating, leg-length measurement supine and in the lateral position after positioning, and the use of an intra-operative leg-length measurement device to ensure optimisation of leg-length. We have analysed the results of our protocol in restoring leg-length in primary THA. Radiological leg-length was measured in a consecutive series of 50 patients who had THA for unilateral arthritis by an independent observer pre- and post-operatively using validated methods utilising radiological software. The measurements pre- and post-operative were compared. Patients with bilateral hip arthritis and poor imaging were excluded. Leg-length was successfully restored to within 5.0mm of the target leg-length in 84.0% of patients (mean +0.7mm (95% CI +0.2 to +1.1)). The other 14.0% of patients were restored to within 5.1–8.0mm (mean +2.2mm (95% CI −2.7 to +7.1)) and 2.0% of patients were restored to within 8.1–10.0mm. Leg length was accurately restored across the subset of patients within a narrow range of either side of the mean target leg length. Intra-operative measurement of leg length can be difficult but is vital in ensuring appropriate restoration of leg-length. We recommend a similar multimodal protocol to ensure restoration of leg-length within narrow limits to maximise function and patient satisfaction

Intraoperative fractures although rare are one of the complications known to occur while performing a total hip arthroplasty (THA). However, due to lower incidence rates there is currently a gap in this area of literature that systematically reviews this important issue of complications associated with THA.

Method: We looked into Electronic databases including PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), the archives of meetings of orthopaedic associations and the bibliographies of included articles and asked experts to identify prospective studies, published in any language that evaluated intra-operative fractures occurring during total hip arthroplasty from the year 1950-2020. The screening, data extraction and quality assessment were carried out by two researchers and if there was any discrepancy, a third reviewer was involved.

Fourteen studies were identified. The reported range of occurrence of fracture while performing hip replacement surgery was found to be 0.4-7.6%. Major risk factors identified were surgical approaches, Elderly age, less Metaphyseal-Diaphyseal Index score, change in resistance while insertion of the femur implants, inexperienced surgeons, uncemented femoral components, use of monoblock elliptical components, implantation of the acetabular components, patients with ankylosing spondylitis, female gender, uncemented stems in patients with abnormal proximal femoral anatomy and with cortices, different stem designs, heterogeneous fracture patterns and toothed design.

Intraoperative fractures during THA were managed with cerclage wire, femoral revision, intramedullary nail and cerclage wires, use of internal fixation plates and screws for management of intra operative femur and acetabular fractures.

The main reason for intraoperative fracture was found to be usage of cementless implants but planning and timely recognition of risk factors and evaluating them is important in management of intraoperative fractures. Adequate surgical site exposure is critical especially during dislocation of hip, reaming of acetabulum, impaction of implant and preparing the femoral canal for stem insertion. Eccentric and increased reaming of acetabulum to accommodate a larger cup is to be avoided, especially in females and elderly patients as the acetabulum is thinner. However, this area requires more research in order to obtain more evidence on effectiveness, safety and management of intraoperative fractures during THA.

Aim

This study aims to define the normal postoperative presepsin kinetics in patients undergoing primary cementless total hip replacement (THR).

Abstract

The thickness of the cement mantle surrounding total hip replacements has been used to predict the incidence of aseptic loosening. However little work has been done regarding the significance of the cement mantle distal to the tip of the femoral prosthesis. Results are reported of a radiographic audit study analyzing the thickness of the distal cement column in primary total hip replacement. In this study the thickness of cement distal to the tip of the femoral prosthesis was measured from 80 post-op AP radiographs taken over a period of 5 months using both the PACS system and plain film x-rays. The mean thickness was 2cm (max 8cm) (min −1.8cm) with a std dev of 1.7cm. This study demonstrated the wide variation in the thickness of the distal cement column achieved by surgeons. It also highlighted the fact that while 2–5mm is the generally accepted optimal cement mantle surrounding the femoral prosthesis, there is little guidance from the literature with regards the optimal thickness of the cement mantle distal to the tip of the femoral prosthesis. Further work requires to be undertaken to determine the optimal thickness of cement in this area, as well as changes in local surgical practice to ensure the optimal thickness of cement distally is consistently achieved. A re-audit of this work after alterations of surgical technique is desirable

Abstract

This was a retrospective study of registry data from a National Orthopaedic Hospital for all THRs with 10-year follow-up data. Inclusion criteria were all THRs with a minimum of 10-year follow-up data. All metal-on-metal (MoM) THRs and MoM resurfacings were excluded from the analysis due to the high rate of revision associated with these bearings. Univariate and multivariate analyses controlling for confounding variables were performed to compare outcomes. A total of 1,697 THRs were performed in 1,553 patients. The four significant predictors for revision were fixation type (p<0.01), surface bearing type (p<0.01), age (P<0.05) and head size (p<0.05). Gender, BMI and approach had no effect on revision rates. The lowest 10-year all-cause revision rates were seen in cemented THRs at 1.7%. Ceramic-on-poly bearings had the lowest revision rate at only 1.2%. Metal-on-poly bearings had a 1.7% revision rate. Ceramic on ceramic bearings had a 7.1% revision rate with 1 revision for squeak and 1 revision for ceramic head fracture. The causes for revision in order of decreasing frequency were as follows: Infection (n=13, 0.7%), dislocation (n=7, 0.4%), periprosthetic fracture (n=3, 0.2%) and aseptic loosening (n=2, 0.1%). There were 2 re-revisions at 10 years in total. The smaller 22.225mm head sizes had a significantly lower revision rate than other head sizes (p<0.05). Ceramic-on-poly bearings, cemented fixation and smaller head sizes perform better in the experience of this registry. However, with multivariate analysis, these differences were shown to be insignificant.

We undertook a retrospective cohort study to determine if body mass index (BMI) is an independent factor in determining patient outcome following total hip replacement (THR). Outcomes were determined using the Oxford Hip Score, a questionnaire designed to evaluate self-reported function and pain levels in people with hip pain. We looked at all THRs carried out on patients with a BMI of ≥30 over a 38 month period (220 operations) and compared these with 220 randomly selected THRs carried out on patients with a BMI of <30 within the same 38 month period. For each case we recorded patient BMI, P score and Oxford scores. We calculated the difference between pre-operative and one-year post-operative Oxford hip scores. We used Kendall's rank correlation to assess any potential correlation between BMI and functional change, and the Mann-Whitney U test to establish if functional change between the groups was statistically significant. Our study indicates that BMI is not an independent factor in determining relative subjective functional change following THR. Although it showed that patients with a BMI of ≥30 have worse function both before and after THR, there was no statistically significant difference between the two groups in terms of functional change. We therefore suggest that patients with a higher BMI be considered candidates for THR as they can expect the same degree of functional improvement. Given the trend for increasing numbers of obese patients in the population these findings could have a significant impact on the future of THR operations.

Background

The position of the hip-joint centre of rotation (HJC) within the pelvis is known to influence functional outcome of total hip replacement (THR). Superior, lateral and posterior relocations of the HJC from anatomical position have been shown to be associated with greater joint reaction forces and a higher incidence of aseptic loosening. In biomechanical models, the maximum force, moment-generating capacity and the range of motion of the major hip muscle groups have been shown to be sensitive to HJC displacement. This clinical study investigated the effect of HJC displacement and acetabular cup inclination angle on functional performance in patients undergoing primary THR.

It is known that excessive varus alignment of the femoral stem in total hip replacement (THR) creates a sub-optimal biomechanical environment which is associated with increased rates of revision surgery and component wear. Little is known regarding the effect of femoral stem alignment on patient functional outcome.

This study aimed to quantify self-reported outcomes and walking gait biomechanics in patients following primary and revision THA. The specific goals of this study were to investigate: (i) if primary and revision THA patients have comparable preoperative outcomes; and (2) if revision THA patients have worse postoperative outcomes than primary THA patients. Forty-three patients undergoing primary THA for osteoarthritis and 23 patients undergoing revision THA were recruited and followed longitudinally for their first 12 postoperative months. Reasons for revision were loosening (73%), dislocation (9%), and infection (18%). Patients completed the Hip dysfunction and Osteoarthritis Outcome Score (HOOS), and underwent gait analysis preoperatively, and at 3 and 12 months postoperatively. A 10 camera motion analysis system (V5 Vantage, Vicon, UK) recorded marker trajectories (100 Hz) during walking at self- selected speeds. A generic lower-body musculoskeletal model (Gait2392) was scaled using principal component analysis [1] and the inverse kinematics tool in Opensim 3.3 was used to compute joint angles for the lower limbs in the sagittal plane. Independent samples t-test were used to compare patient reported outcomes between the primary and revision groups at each timepoint. Statistical parametric mapping was used to compare gait patterns between the two groups at each timepoint. Preoperatively, patients undergoing primary THA reported significantly worse pain (p<0.001), symptoms (p<0.001), function (p<0.001), and quality of life (p=0.004). No differences were observed at 3 and 12 months postoperatively between patients who had received a primary or revision THA. The only observed difference in gait pattern was that patients with a revision THA had reduced hip extension at 3 months, but no differences were observed preoperatively and 12 months. Despite the suggestions in the literature that revision THA is bound to have worse outcomes compared to primary THA, we found no differences in in patient-reported outcomes and gait patterns at 12 months postoperatively. This suggests that it may be possible, in some circumstances, for patients following revision THA to achieve similar outcomes to their peers undergoing primary THA

Dislocation post THA confers a higher risk of re-dislocation (Kotwal et al, 2009). The dual mobility (DM) cup design (1974) was aimed at improving the stability by increasing the femoral head to neck ratio (Cuthbert et al., 2019) combining the ideas of low friction arthroplasty with increased jump distance associated with a big head arthroplasty. Understand the dislocation rates, rates of aseptic loosening, infection rate and revision rates between the 2 types of constructs to provide current and up-to date evidence. Medline, pubmed, embase and Cochrane databases were used based on PRISMA guidelines. RevMan software was used for the meta-analysis. Studies (English literature) which used DM construct with atleast 6 months follow-up used as intervention and non DM construct as control were included. 2 independent reviewers conducted the review with a third reviewer in case of difference in opinion regarding eligibility. Primary outcome was dislocation rate and secondary outcome was rate of revision. 564 articles identified out of which 44 articles were screened for full texts and eventually 4 systematic review articles found eligible for the study. Thus, study became a review of systematic reviews. From the 4 systematic reviews, another 35 studies were identified for data extraction and 13 papers were used for meta-analysis. Systematic reviews evaluated, projected an average follow up of 6-8 years with significantly lower dislocation rates for DM cups. The total number of patients undergoing DM cup primary THA were 30,559 with an average age 71 years while the control group consisted of 218,834 patients with an average age of 69 years. DM group had lower rate of dislocation (p < 0.00001), total lower rate of cup revision (p < 0.00001, higher incidence of fracture (p>0.05). DM THA is a viable alternative for conventional THA. The long-term results of DM cups in primary THA need to be further evaluated using high quality prospective studies and RCTs

Abstract. Introduction. Dislocation post THA confers a higher risk of re-dislocation (Kotwal et al, 2009). The dual mobility (DM) cup design (1974) was aimed at improving the stability by increasing the femoral head to neck ratio (Cuthbert et al., 2019) combining the ideas of low friction arthroplasty with increased jump distance associated with a big head arthroplasty. Aims. Understand the dislocation rates, rates of aseptic loosening, infection rate and revision rates between the 2 types of constructs to provide current and up-to date evidence. Methods. Medline, pubmed, embase and Cochrane databases were used based on PRISMA guidelines. RevMan software was used for the meta-analysis. Studies (English literature) which used DM construct with atleast 6 months follow-up used as intervention and non DM construct as control were included. 2 independent reviewers conducted the review with a third reviewer in case of difference in opinion regarding eligibility. Primary outcome was dislocation rate and secondary outcome was rate of revision. Results. 564 articles identified out of which 44 articles were screened for full texts and eventually 4 systematic review articles found eligible for the study. Thus, study became a review of systematic reviews. From the 4 systematic reviews, another 35 studies were identified for data extraction and 13 papers were used for meta-analysis. Systematic reviews evaluated, projected an average follow up of 6–8 years with significantly lower dislocation rates for DM cups. The total number of patients undergoing DM cup primary THA were 30,559 with an average age 71 years while the control group consisted of 218,834 patients with an average age of 69 years. DM group had lower rate of dislocation (p < 0.00001), total lower rate of cup revision (p < 0.00001, higher incidence of fracture (p>0.05). Conclusion. DM THA is a viable alternative for conventional THA. The long-term results of DM cups in primary THA need to be further evaluated using high quality prospective studies and RCTs. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Total joint replacement (TJR) was one of the most revolutionary breakthroughs in joint surgery. The majority studies had shown that most implants could last about 25 years, anyway, there is still variation in the longevity of implants. In US, for all the hip revisions from 2012 to 2017 in the United States, 12.0% of the patients were diagnosed as aseptic loosening. Variable studies have showed that any factor that could cause a systemic or partial bone loss, might be the risk of periprosthetic osteolysis and aseptic loosening. Breast cancer is the most frequent malignancy in women, more than 2.1 million women were newly diagnosed with breast cancer, 626,679 women with breast cancer died in 2018. It's been reported that the mean incidence of THA was 0.29% for medicare population with breast cancer in USA, of which the incidence was 3.46% in Norwegian. However, the effects of breast cancer chemotherapy and hormonotherapy, such as aromatase inhibitors (AI), significantly increased the risk of osteoporosis, and had been proved to become a great threat to hip implants survival. In this case, a 46-year-old female undertook chemotherapy and hormonotherapy of breast cancer 3 years after her primary THA, was diagnosed with aseptic loosening of the hip prosthesis. Her treatment was summarized and analyzed. Breast cancer chemotherapy and hormonotherapy might be a threat to the stability of THA prosthesis. More attention should be paid when a THA paitent occurred with breast cancer. More studies about the effect of breast cancer treatments on skeleton are required

Abstract. Objective. Short-stem total hip arthroplasty (THA) aims to preserve the proximal bone stock for future revisions, so that the first revision should resemble a primary intervention rather than a revision. This study aimed to compare the clinical and radiological outcomes in revision THA after failed short stem versus after failed conventional stem THA. Methods. This study included forty-five patients with revision THA divided into three groups (15 each); group A: revision after short stem, group B: revision after conventional cementless stem and group C revision after conventional cemented stem. The studied groups were compared regarding 31 variables including demographic data, details of the primary and revision procedures, postoperative radiological subsidence, hospital stay, time for full weight bearing (FWB), preoperative and postoperative clinical scores. Results. Early stem subsidence (40%) was the main indication of revision in group A compared to peri-prosthetic femoral fractures (PFFs) (73.3%) and aseptic loosening (53.3%) in group B and C respectively (P=0.021). The mean time to revision was significantly shorter in group A (15 months) compared to 95.33 and 189.40 months in group B and C respectively. (P=0.005). Sixty % (9 patients) in group A were revised in the first year. The mean operative time, blood loss, postoperative blood transfusion and hospital stay were significantly lower in group A compared to group B and C (P<0.001, <0.001, 0.002 and 0.001 respectively). Revisions in group A were performed using either short stems (13.3%) or conventional stems (86.7%) whilst 80% of patients needed long stems and 20% of patients needed conventional stems in group B and C (P<0.001). The mean postoperative Harris Hip Score (HHS) at the latest follow up was 87.07, 87.53 and 85.47 in group A, B and C respectively. All PFFS had excellent results according to Beal's and Tower's criteria; all fractures healed and the implants were stable. Conclusion. The most common cause of failure of short stems is early stem subsidence. Short stem THA has specific indications and patient selection is very crucial. Preoperative templating for short stems and a detailed analysis of the individual patient anatomy in anteroposterior and lateral views are mandatory to predict the correct implant size more accurately. The use of intraoperative imaging can verify the sizing, implant position, and sufficient contact with the lateral cortex. Revision of short stem THA resembled the primary THA. If a standard implant can be used in a surgical revision instead of a longer revision stem, this can be considered as an advantage for the hip arthroplasty treatment concept. However, this only applies if the longevity of the first treatment with a short stem is comparable with that of a standard stem. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction and Objective. A proper restoration of hip biomechanics is fundamental to achieve satisfactory outcomes after total hip arthroplasty (THA). A global hip offset (GO) postoperatively reduction of more than 5 mm was known to impair hip functionality after THA. This study aimed to verify the restoration of the GO radiographic parameter after primary THA by the use of a cementless femoral stem available in three different offset options without length changing. Materials and Methods. From a consecutive series of 201 patients (201 hips) underwent primary cementless THA in our centre with a minimum 3-year follow up, 80 patients (80 hips) were available for complete radiographic evaluation for GO and limb length (LL) and clinical evaluation with Harris hip score (HHS). All patients received the same femoral stem with three different offset options (option A with – 5 mm offset, option B and option C with + 5 mm offset, constant for each sizes) without changing stem length. Results. Mean GO significantly increased by + 3 mm (P < 0.05) and mean LL significantly decreased by + 5 mm (P < 0.05) after surgery, meaning that postoperatively the limb length of the operated side increased by + 5 mm. HHS significantly improved from 56.3 points preoperatively to 95.8 postoperatively (P < 0.001). Offset option A was used in 1 hip (1%), B in 59 hips (74%) and C in 20 hips (25%). Conclusions. The femur is lateralized with a mean of + 5mm after surgery than, the native anatomy, whatever type of stem was used. Thus, the use of this 3-offset options femoral stem is effective in restoring the native biomechanical hip parameters as GO, even if 2 offset options were considered sufficient to restore GO

Introduction. In total hip arthroplasty, a high radiographic inclination angle (RI) of the acetabular component has been linked to short- and long-term complications. There are several factors that lead to RI outliers including cup version, pelvic orientation and angle of the cup introducer relative to the floor. The primary aim of this study was to analyse what increases the risk of having a cup with an RI outside the target zone when controlling cup orientation with a digital inclinometer. Methods. In this prospective study, we included 200 consecutive patients undergoing uncemented primary THA in the lateral decubitus position using a posterior approach. Preoperatively, the surgeon determined the target intraoperative inclination (IOI. target. ). The intra-operative inclination of the cup (IOI. cup. ) was measured with the aid of a digital inclinometer after seating of the acetabular component. Anteroposterior pelvic radiographs were made to measure the RI of the acetabular component. The target zones were defined as 30°-45° and 35°-45° of RI. The operative inclination relative to the sagittal plane of the pelvis (OI. math. ) was calculated based on the radiographic inclination and anteversion angle. The difference between two outcome measures was expressed as Δ. Results. The mean RI was 37.9° SD 4.7, there were 12 cases with RI outside the 30°– 45° zone (6%) and 53 outliers (26.5%) with RI outside the 35°-45° zone. The mean absolute ΔIOI. cup. -IOI. target. was 1.2° SD 1.0. The absolute ΔIOI. cup. -IOI. target. was less than 1° in 108 patients (54%), less than 2° in 160 patients (80%), less than 3° in 186 patients (93%), and in 14 patients (7%) the difference was 3°-5°. The mean pelvic motion (ΔOI. math. -IOI. cup. ) was 8.8° SD 3.9 (95% CI 8.2° to 9.3°). The absolute deviation from the mean ΔOI. math. -IOI. cup. , which corresponds with the amount of pelvic motion, was significantly higher in RI outliers compared with non-outliers for both the 30°-45° and 35°-45° inclination zone (7.4° SD 3.3 vs 2.8° SD 2.1 and 4.7° SD 2.8 vs 2.5° SD 2.0 respectively) (p<0.0001). A linear regression analysis demonstrated a strong correlation between ΔOI. math. -IOI. cup. and the RI of the cup (r. 2. =0.70; P<0.0001). A multiple regression was run to predict ΔOI. math. -IOI. cup. from gender, BMI, side and hip circumference. These variables statistically significantly predicted ΔOI. math. -OIa. cup. , F(4, 195) = 19,435, p<0.0001, R2 = 0.285, but only side (p=0.04) and hip circumference (p<0.0001) added statistically significantly to the prediction. Discussion and Conclusion. When using a digital inclinometer 94% of cups had a RI within a 30°-45° zone and 73.5% of cups within a 35°-45° zone using a predefined IOI. target. based on the patient's hip circumference. The difference between the IOI. target. and the IOI. cup. of the acetabular component was less than 3° in 93% and less than 5° in all patients signifying that the surgeons were able to implant the cup close to their chosen intra-operative orientation. Deviation from the mean ΔOI. math. -IOI. cup. was significantly bigger in the RI outliers indicating that RI outliers were caused by more or less than deviation of the sagittal plane of the pelvis at time of cup impaction