We report patient-reported outcomes and complications
associated with contemporary periacetabular osteotomy (PAO) surgery
in treating symptomatic acetabular dysplasia and compare these outcomes
with total hip arthroplasty (THA) in patients with similar demographic
details. Two consecutive cohorts included patients between aged
18 to 40 years who had undergone either PAO (100 hips; 24 male,
76 female) or THA (55 hips; 18 male, 37 female). At a mean follow-up
of 5.9 years (2 to 13), there was significant improvement in the
modified Harris hip pain (p <
0.001, PAO and p <
0.001, THA),
function (p <
0.001, PAO and p = 0.001, THA), and total scores
(p <
0.001, PAO and p <
0.001, THA) within each cohort. There
were no significant differences in the clinical outcome scores between
the groups. Complication rates were low and similar in each cohort
(p = 0.68). Similar to THA, contemporary PAO surgery is a clinically
effective procedure that improves function and activity levels,
provides pain relief and is associated with an acceptable complication
rate. Cite this article:
The early failure and revision of bimodular primary
total hip arthroplasty prostheses requires the identification of the
risk factors for material loss and wear at the taper junctions through
taper wear analysis. Deviations in taper geometries between revised
and pristine modular neck tapers were determined using high resolution
tactile measurements. A new algorithm was developed and validated
to allow the quantitative analysis of material loss, complementing
the standard visual inspection currently used. The algorithm was applied to a sample of 27 retrievals ( Cite this article:
The ‘jumbo’ acetabular component is now commonly
used in acetabular revision surgery where there is extensive bone
loss. It offers high surface contact, permits weight bearing over
a large area of the pelvis, the need for bone grafting is reduced
and it is usually possible to restore centre of rotation of the
hip. Disadvantages of its use include a technique in which bone
structure may not be restored, a risk of excessive posterior bone
loss during reaming, an obligation to employ screw fixation, limited
bone ingrowth with late failure and high hip centre, leading to increased
risk of dislocation. Contraindications include unaddressed pelvic
dissociation, inability to implant the component with a rim fit,
and an inability to achieve screw fixation. Use in acetabulae with
<
50% bone stock has also been questioned. Published results
have been encouraging in the first decade, with late failures predominantly because
of polyethylene wear and aseptic loosening. Dislocation is the most
common complication of jumbo acetabular revisions, with an incidence
of approximately 10%, and often mandates revision. Based on published results,
a hemispherical component with an enhanced porous coating, highly
cross-linked polyethylene, and a large femoral head appears to represent
the optimum tribology for jumbo acetabular revisions. Cite this article:
The August 2015 Hip &
Pelvis Roundup360 looks at: The well-fixed acetabular revision; Predicting complications in revision arthroplasty; Is infection associated with fixation?; Front or back? An enduring question in hip surgery; Muscle-sparing approaches?; Gabapentin as a post-operative analgesic adjunct; An Indian take on AVN of the hip; Weight loss and arthroplasty
Ceramic-on-metal (CoM) is a relatively new bearing
combination for total hip arthroplasty (THA) with few reported outcomes.
A total of 287 CoM THAs were carried out in 271 patients (mean age
55.6 years (20 to 77), 150 THAs in female patients, 137 in male)
under the care of a single surgeon between October 2007 and October
2009. With the issues surrounding metal-on-metal bearings the decision
was taken to review these patients between March and November 2011,
at a mean follow-up of 34 months (23 to 45) and to record pain,
outcome scores, radiological analysis and blood ion levels. The
mean Oxford Hip Score was 19.2 (12 to 53), 254 patients with 268
hips (95%) had mild/very mild/no pain, the mean angle of inclination
of the acetabular component was 44.8o (28o to
63o), 82 stems (29%) had evidence of radiolucent lines
of >
1 mm in at least one Gruen zone and the median levels of cobalt
and chromium ions in the blood were 0.83 μg/L (0.24 μg/L to 27.56 μg/L)
and 0.78 μg/L (0.21 μg/L to 8.84 μg/L), respectively. The five-year
survival rate is 96.9% (95% confidence interval 94.7% to 99%). Due to the presence of radiolucent lines and the higher than
expected levels of metal ions in the blood, we would not recommend
the use of CoM THA without further long-term follow-up. We plan
to monitor all these patients regularly. Cite this article:
The aim of this cadaver study was to identify
the change in position of the sciatic nerve during arthroplasty
using the posterior surgical approach to the hip. We investigated
the position of the nerve during this procedure by dissecting 11
formalin-treated cadavers (22 hips: 12 male, ten female). The distance
between the sciatic nerve and the femoral neck was measured before
and after dislocation of the hip, and in positions used during the
preparation of the femur. The nerve moves closer to the femoral
neck when the hip is flexed to >
30° and internally rotated to 90° (90°
IR). The mean distance between the nerve and femoral neck was 43.1
mm (standard deviation ( This study demonstrates that the sciatic nerve becomes closer
to the operative field during hip arthroplasty using the posterior
approach with progressive flexion of the hip. Cite this article:
We evaluated the outcome of treatment of nonunion
of an intracapsular fracture of the femoral neck in young patients
using two cannulated screws and a vascularised bone graft. A total
of 32 patients (15 women and 17 men, with a mean age of 36.5 years;
20 to 50) with failed internal fixation of an intracapsular fracture
were included in the study. Following removal of the primary fixation,
two cannulated compression screws were inserted with a vascularised
iliac crest bone graft based on the ascending branch of the lateral
femoral circumflex artery. At a mean follow-up of 6.8 years (4 to 10), union was achieved
in 27 hips (84%). A total of five patients with a mean age of 40.5
years (35 to 50) had a persistent nonunion and underwent total hip
arthroplasty as also did two patients whose fracture united but
who developed osteonecrosis of the femoral head two years post-operatively. Statistical
analysis showed that younger patients achieved earlier and more
reliable union (p <
0.001). The functional outcome, as assessed
by the Harris Hip score, was better in patients aged <
45 years
compared with those aged >
45 years (p <
0.001). These findings suggest that further fixation using two cannulated
compression screws and a vascularised iliac crest bone graft is
an effective salvage treatment in patients aged <
45 years, in
whom osteosynthesis of a displaced intracapsular fractures of the
femoral neck has failed. Cite this article:
A total of 56 male patients with a displaced
intracapsular fracture of the hip and a mean age of 81 years (62
to 94), were randomised to be treated with either a cemented hemiarthroplasty
(the Exeter Trauma Stem) or reduction and internal fixation using
the Targon Femoral Plate. All surviving patients were reviewed one
year after the injury, at which time restoration of function and
pain in the hip was assessed. There was no statistically significant
difference in mortality between the two groups (7/26; 26.9% for
hemiarthroplasty These results indicate that cemented hemiarthroplasty gives better
results than internal fixation in elderly men with a displaced intracapsular
fracture of the hip. Cite this article:
Tranexamic acid (TXA), an inhibitor of fibrinolysis,
reduces blood loss after total knee arthroplasty. However, its effect
on minimally invasive total hip arthroplasty (THA) is not clear.
We performed a prospective, randomised double-blind study to evaluate
the effect of two intravenous injections of TXA on blood loss in
patients undergoing minimally invasive THA. In total, 60 patients (35 women and 25 men with a mean age of
58.1 years; 17 to 84) who underwent unilateral minimally invasive
uncemented THA were randomly divided into the study group (30 patients,
20 women and ten men with a mean age of 56.5 years; 17 to 79) that
received two intravenous injections 1 g of TXA pre- and post-operatively
(TXA group), and a placebo group (30 patients, 15 women and 15 men
with a mean age of 59.5 years; 23 to 84). We compared the peri-operative
blood loss of the two groups. Actual blood loss was calculated from
the maximum reduction in the level of haemoglobin. All patients
were followed clinically for the presence of venous thromboembolism. The TXA group had a lower mean intra-operative blood loss of
441 ml (150 to 800) This prospective, randomised controlled study showed that a regimen
of two intravenous injections of 1 g TXA is effective for blood
conservation after minimally invasive THA. Cite this article:
Tribocorrosion at the head–neck taper interface
– so-called ‘taperosis’ – may be a source of metal ions and particulate
debris in metal-on-polyethylene total hip arthroplasty (THA). We examined the effect of femoral head length on fretting and
corrosion in retrieved head–neck tapers Head length was observed to affect fretting (p = 0.03), with
28 mm + 8 mm femoral heads showing greater total fretting scores
than all other head lengths. The central zone of the femoral head
bore taper was subject to increased fretting damage (p = 0.01),
regardless of head length or stem offset. High-offset femoral stems
were associated with greater total fretting of the bore taper (p
= 0.04). Increased fretting damage is seen with longer head lengths and
high-offset femoral stems, and occurs within a central concentric
zone of the femoral head bore taper. Further investigation is required
to determine the effect of increased head size, and variations in
head–neck taper design. Cite this article:
We report the kinematic and early clinical results
of a patient- and observer-blinded randomised controlled trial in which
CT scans were used to compare potential impingement-free range of
movement (ROM) and acetabular component cover between patients treated
with either the navigated ‘femur-first’ total hip arthroplasty (THA) method
(n = 66; male/female 29/37, mean age 62.5 years; 50 to 74) or conventional
THA (n = 69; male/female 35/34, mean age 62.9 years; 50 to 75).
The Hip Osteoarthritis Outcome Score, the Harris hip score, the
Euro-Qol-5D and the Mancuso THA patient expectations score were
assessed at six weeks, six months and one year after surgery. A
total of 48 of the patients (84%) in the navigated ‘femur-first’
group and 43 (65%) in the conventional group reached all the desirable
potential ROM boundaries without prosthetic impingement for activities
of daily living (ADL) in flexion, extension, abduction, adduction
and rotation (p = 0.016). Acetabular component cover and surface
contact with the host bone were >
87% in both groups. There was
a significant difference between the navigated and the conventional
groups’ Harris hip scores six weeks after surgery (p = 0.010). There
were no significant differences with respect to any clinical outcome
at six months and one year of follow-up. The navigated ‘femur-first’
technique improves the potential ROM for ADL without prosthetic
impingement, although there was no observed clinical difference
between the two treatment groups. Cite this article:
There is no single standardised method of measuring
the orientation of the acetabular component on plain radiographs
after total hip arthroplasty. We assessed the reliability and accuracy
of three methods of assessing anteversion of the acetabular component
for 551 THAs using the PolyWare software and the methods of Liaw
et al, and of Woo and Morrey. All measurements of the three methods
had excellent intra- and inter-observer reliability. The values
of the PolyWare software, which determines version of the acetabular
component by edge detection were regarded as the reference standard.
Although the PolyWare software and the method of Liaw et al were similarly
precise, the method of Woo and Morrey was significantly less accurate
(p <
0.001). The method of Liaw et al seemed to be more accurate
than that of Woo and Morrey when compared with the measurements
using the PolyWare software. If the qualified lateral radiograph
was selected, anteversion measured using the method of Woo and Morrey
was considered to be relatively reliable. Cite this article:
We present the results of 62 consecutive acetabular
revisions using impaction bone grafting and a cemented polyethylene
acetabular component in 58 patients (13 men and 45 women) after
a mean follow-up of 27 years (25 to 30). All patients were prospectively
followed. The mean age at revision was 59.2 years (23 to 82). We performed Kaplan–Meier (KM) analysis and also a Competing
Risk (CR) analysis because with long-term follow-up, the presence
of a competing event (i.e. death) prevents the occurrence of the
endpoint of re-revision. A total of 48 patients (52 hips) had died or had been re-revised
at final review in March 2011. None of the deaths were related to
the surgery. The mean Harris hip score of the ten surviving hips
in ten patients was 76 points (45 to 99). The KM survivorship at 25 years for the endpoint ‘re-revision
for any reason’ was 58.0% (95% confidence interval (CI) 38 to 73)
and for ‘re-revision for aseptic loosening’ 72.1% (95% CI 51 to
85). With the CR analysis we calculated the KM analysis overestimates
the failure rate with respectively 74% and 93% for these endpoints.
The current study shows that acetabular impaction bone grafting
revisions provide good clinical results at over 25 years. Cite this article:
We report the clinical and radiographic outcomes
of 208 consecutive femoral revision arthroplasties performed in 202
patients (119 women, 83 men) between March 1991 and December 2007
using the X-change Femoral Revision System, fresh-frozen morcellised
allograft and a cemented polished Exeter stem. All patients were
followed prospectively. The mean age of the patients at revision
was 65 years (30 to 86). At final review in December 2013 a total
of 130 patients with 135 reconstructions (64.9%) were alive and
had a non re-revised femoral component after a mean follow-up of
10.6 years (4.7 to 20.9). One patient was lost to follow-up at six
years, and their data were included up to this point.
Re-operation for any reason was performed in 33 hips (15.9%), in
13 of which the femoral component was re-revised (6.3%). The mean
pre-operative Harris hip score was 52 (19 to 95) (n = 73) and improved
to 80 (22 to 100) (n = 161) by the last follow-up. Kaplan–Meier
survival with femoral re-revision for any reason as the endpoint
was 94.9% (95% confidence intervals (CI) 90.2 to 97.4) at ten years;
with femoral re-revision for aseptic loosening as the endpoint it was
99.4% (95% CI 95.7 to 99.9); with femoral re-operation for any reason
as the endpoint it was 84.5% (95% CI 78.3 to 89.1); and with subsidence ≥ 5
mm it was 87.3% (95% CI 80.5 to 91.8). Femoral revision with the
use of impaction allograft bone grafting and a cemented polished
stem results in a satisfying survival rate at a mean of ten years’ follow-up. Cite this article:
There is little evidence on the cost effectiveness
of different brands of hip prostheses. We compared lifetime cost effectiveness
of frequently used brands within types of prosthesis including cemented
(Exeter V40 Contemporary, Exeter V40 Duration and Exeter V40 Elite
Plus Ogee), cementless (Corail Pinnacle, Accolade Trident, and Taperloc Exceed)
and hybrid (Exeter V40 Trilogy, Exeter V40 Trident, and CPT Trilogy).
We used data from three linked English national databases to estimate
the lifetime risk of revision, quality-adjusted life years (QALYs)
and cost. For women with osteoarthritis aged 70 years, the Exeter V40 Elite
Plus Ogee had the lowest risk of revision (5.9% revision risk, 9.0
QALYs) and the CPT Trilogy had the highest QALYs (10.9% revision
risk, 9.3 QALYs). Compared with the Corail Pinnacle (9.3% revision
risk, 9.22 QALYs), the most commonly used brand, and assuming a
willingness-to-pay of £20 000 per QALY gain, the CPT Trilogy is
most cost effective, with an incremental net monetary benefit of £876.
Differences in cost effectiveness between the hybrid CPT Trilogy
and Exeter V40 Trident and the cementless Corail Pinnacle and Taperloc
Exceed were small, and a cautious interpretation is required, given
the limitations of the available information. However, it is unlikely that cemented brands are among the most
cost effective. Similar patterns of results were observed for men
and other ages. The gain in quality of life after total hip arthroplasty,
rather than the risk of revision, was the main driver of cost effectiveness. Cite this article:
The repair of chondral lesions associated with
femoroacetabular impingement requires specific treatment in addition
to that of the impingement. In this single-centre retrospective
analysis of a consecutive series of patients we compared treatment
with microfracture (MFx) with a technique of enhanced microfracture
autologous matrix-induced chondrogenesis (AMIC). Acetabular grade III and IV chondral lesions measuring between
2 cm2 and 8 cm2 in 147 patients were treated
by MFx in 77 and AMIC in 70. The outcome was assessed using the
modified Harris hip score at six months and one, two, three, four
and five years post-operatively. The outcome in both groups was
significantly improved at six months and one year post-operatively.
During the subsequent four years the outcome in the MFx group slowly deteriorated,
whereas that in the AMIC group remained stable. Six patients in
the MFx group subsequently required total hip arthroplasty, compared
with none in the AMIC group We conclude that the short-term clinical outcome improves in
patients with acetabular chondral damage following both MFx and
AMIC. However, the AMIC group had better and more durable improvement,
particularly in patients with large (≥ 4 cm2) lesions. Cite this article:
A total of 31 patients, (20 women, 11 men; mean
age 62.5 years old; 23 to 81), who underwent conversion of a Girdlestone
resection-arthroplasty (RA) to a total hip replacement (THR) were
compared with 93 patients, (60 women, 33 men; mean age 63.4 years
old; 20 to 89), who had revision THR surgery for aseptic loosening
in a retrospective matched case-control study. Age, gender and the
extent of the pre-operative bone defect were similar in all patients.
Mean follow-up was 9.3 years (5 to 18). Pre-operative function and range of movement were better in the
control group (p = 0.01 and 0.003, respectively) and pre-operative
leg length discrepancy (LLD) was greater in the RA group (p <
0.001). The post-operative clinical outcome was similar in both
groups except for mean post-operative LLD, which was greater in
the study group (p = 0.003). There was a significant interaction
effect for LLD in the study group (p <
0.001). A two-way analysis
of variance showed that clinical outcome depended on patient age
(patients older than 70 years old had worse pre-operative pain,
p = 0.017) or bone defect (patients with a large acetabular bone
defect had higher LLD, p = 0.006, worse post-operative function
p = 0.009 and range of movement, p = 0.005), irrespective of the
group. Despite major acetabular and femoral bone defects requiring complex
surgical reconstruction techniques, THR after RA shows a clinical
outcome similar to those obtained in aseptic revision surgery for
hips with similar sized bone defects. Cite this article:
Tranexamic acid (TXA) has been used to reduce
blood loss during total hip arthroplasty (THA), but its use could increase
the risk of venous thromboembolic disease (VTE). Several studies
have reported that TXA does not increase the prevalence of deep
vein thrombosis (DVT), but most of those used routine chemical thromboprophylaxis,
thereby masking the potential increased risk of TXA on VTE. We wished
to ascertain whether TXA increases the prevalence of VTE in patients
undergoing THA without routine chemical thromboprophylaxis. We carried
out a retrospective case-control study in 254 patients who underwent
a primary THA, 127 of whom received TXA (1 g given pre-operatively)
and a control group of 127 who did not. All patients had mechanical
but no chemical thomboprophylaxis. Each patient was examined for
DVT by bilateral ultrasonography pre-operatively and on post-operative
days 1 and 7. TXA was found to statistically significantly increase
the incidence of total DVT on post-operative day 7 compared with
the control group (24 (18.9%) and 12 (9.4%), respectively; p <
0.05) but most cases of DVT were isolated distal DVT, with the exception
of one patient with proximal DVT in each group. One patient in the control
group developed a non-fatal symptomatic pulmonary embolism (PE).
The use of TXA did not appear to affect the prevalence of either
proximal DVT or PE. Cite this article: