Total hip arthroplasty in high riding Dysplastic cases in older age (more than 60 years)

Introduction:
Total hip arthroplasty in dysplastic hips is a challenging operation itselt. If is done in older age (more than 60 years ) it has more difficulties and complications. Ilium (acetabulum) was unloaded for many years so there is no firm and good bone stuck for cup insertion.On the other hand, adaptive mecha-nisems for gait and balance are not fully functional so hip scores may not rise as you predict in these cases. Also, neurovascular bundle are not flexible so they are prone to injury.

Materials and methods:
From 2010 to 2019, every cases of total hip arthroplasty in high ride cases (crowe 3 and 4) more than 60 years old were studied. Early and late cup failure, harris hip score and neurovascular complications were considered.

Results:
18 cases of THA in DDH crowe 3 or 4 older than 60 years old were studied. 4 cases of early cup failure were recorded. 2 cases penetrate into pelvis and 2 cases of early mechanical failure were seen. Gait problem and limping persists in all f them. 3 vascular injury( 2 thrombosis and 1 arerial rupture) were seen.

Discussion:
There are approximately 30% major complication in these cases. Patient education and preoperative pre-diction of complications are mandatory.

Post-operative dislocation following Total Hip Arthroplasty in patients with neck of femur fractures is a great concern (2-10%). Dual mobility cups have been suggested to address this complication. Our study sets out to compare the dislocation rates between 2 types of dual mobility total hip arthroplasty (DM THA) in patients with neck of femur fractures in our institution from August 2017 to September 2020. 2 types of DM THA were used during this period; Zimmer Biomet G7 DM acetabular system (Group 1) and Novae SERF system (Group 2). 90 patients used DM THA for neck of femur fractures between August 2017 to September 2020. The mean patients' age was 70.67 (Range: 46-89 years old). 66 patients are female and 24 male. 37 patients had the G7 system and 1 (2.7%) sustained a posterior dislocation. 53 patients had the SERF system and 1 (1.9%) sustained a posterior dislocation. Both dislocations occured following mechanical falls. The P value on Fisher’s exact is 1.0. The mean Charlson Comorbidity index for the 90 patients was 3.52 (Group 1=3.49:Group 2=3.55). Group 1 did not have any other complications. Group 2 had 1 (1.9%) patient present with infection of prosthesis. The mean follow up time for the patients was 12 months 16.5 days (ranging between 15 to 1156 days). This study revealed that the use of DM THA in patients with neck of femur fractures reduced the risk of post-operative dislocation. Both G7/NOVAE SERF acetabular system are equally effective and have a low risk of dislocation

Background
Debate encompasses the use of Vitamin E Poly Ethylene or conventional Poly Ethylene liner in primary hip arthroplasty. Does Inclusion of vitamin E in PE give adequate protection from oxidation and maintains lower rates of wear.

Patients and methods:
We performed this study following both the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement (PRISMA) and the Cochrane Handbook for systematic reviews and meta-analysis. studies were included from any region , written in any language. We included only the randomised control trials comparing the femoral head penetration between Vitamin-E diffused highly cross-linked polyethylene(VEPE) liner and conventional liners in primary total hip arthroplasty.
Results:
We included ten studies in this meta-analysis. We conducted them using Review Manager V.5.0. We computed the risk ratio to measure the treatment effect, considering the heterogeneity. We used Random-effect models. VEPE had insignificant marginal advantages for FHP within 3 months post operative. Additionally, VEPE showed significant less FHP after two and five years. After one year it showed significant less FHP with the VEPE group versus the UHMWPE cohort and a non-significant difference between the VEPE and XLPE group.
Conclusions: In terms of FHP, this metanalysis shows less FHP for the VEPE compared with the conventional PE. Longer follow-up period is required to evaluate whether the oxidation protection gained by vitamin E, results in lower wear rates , less osteolysis and aseptic loosening in comparison with the conventional PE in the long term.

Calcar osteotomy in revision Total hip arthroplasty instead Extended trochanteric osteotomy, Which one is better?



Introduction:
In revision total hip arthroplasty there may be need to remove cement in cemented stems or remove well fixed stems in un cemented cases. Classically, it is extended trochanteric osteotomy that can help the surgeon. But, calcar osteotomy can be used instead of ETO to remove implants. It has the advantage of preserving continuity of abductors to greater trochanter and diaphysis of femur.

Materials and methods:
From 2005 to 2019 every cases of revision arthroplasty which need stem removal (cemented or cement less) were studied in our hospital. One group is done by classic extended greater trochanteric osteotomy and the other group by calcar osteotomy. Abductor function ,greater trochanter migration and harris hip score were compared.

Results:
There was no greater trochanter upward migration in calcar osteotomy cases and also force of abductors were much more than ETO cases. On the other hand, there were better harris hip scores in calcar osteotomy cases. Non union of greater trochanter and abductor dysfunction were major disadvantages in ETO cases.

Discussion:
For stem revision (cemented orcementless) calcar osteotomy is recommended instead of extended trochanteric osteotomy. It has better results and less complications.

Background: Total hip arthroplasty has been the mainstay treatment for improving the quality of life in patients with primary degenerative and osteonecrotic hip disease. The objective of this study is to assess the impact of patients’ quality of life and hip function by comparing overall intermediate clinical outcomes between direct anterior and mini-posterior approaches for total hip arthroplasty.

Methods: Retrospective cohort study, 60 patients (24 females and 6 males from MPA; 16 females and 14 males for DAA). Operative time, length of admission, duration of parenteral analgesics, duration until ambulation and complications were compared. Modified Harris Hip Score (mHHS) pre-and post-operatively, Forgotten Joint Score-12 (FJS-12) post-operatively was assessed through follow-up/telemedicine.

Results: The mean age for mini-posterior and direct anterior approaches were 62.97 years old and 59.53 years old respectively. Pre-operative mHHS were not statistically different. Operative time and blood loss were not statistically different. Length of admission, duration of analgesia use, leg length discrepancy, and mHHS between the two approaches were not statistically different. FJS-12 for the DAA group was statistically higher. Duration until ambulation was statistically higher in the MPA group. 6.67% of the patients had Lateral femoral cutaneous nerve injury from the DAA group.

Conclusion: Direct anterior approach and mini-posterior approach for primary THA produces good to excellent clinical outcomes post-operatively. Achievement of a better quality of life as measured by lack of awareness on the operated hip remarkably increased by performing THA via the DAA.

Background: Patient-reported outcomes measures (PROMs) helps to ensure the patients ‘voice’ is present and to ensure therapeutic management remains patient centered. Neither implant survival data nor data on PROMs, prove conclusive as a single parameter in the identification of a superior method of implant fixation. The aim of the study was to evaluate and compare PROMs following cemented and uncemented total hip arthroplasty (THA) in Indian population using Oxford hip scoring system (OHSS). Methods: A retrospective comparative study was conducted on 74 Indian patients who underwent THA with 37 patients in each cemented and uncemented THA group between December 2012 to December 2017. The minimum follow-up period was 36 months following surgery. Post-operative OHSS were collected from each group and compared. Results: There was statistically no significant difference (p value 0.177) in postoperative OHS in cemented [37.03(SD +/- 3.329)] as compared to uncemented THA [38.08(SD +/- 3.328)]. Statistically no significant difference (p value = 0.225) in the pain score of OHSS in cemented [14.70(SD +/- 1.824)] as compared to uncemented THA [15.22(SD +/- 1.782)]. Statistically no significant difference (p value = 0.232) in functional score of OHS in cemented [22.32(SD +/- 1.842)] as compared to uncemented THA group [22.86(SD +/- 2.016)]. Conclusion: There is no significant difference in the PROMs, pain and functional status in uncemented as compared to cemented THA using OHSS. Gender, comorbid conditions and postoperative complications had no significant difference in OHS between two groups. Key words: SD – standard deviation.

The purposes of this study were to determine the incidence, annual trend, and perioperative outcomes of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total hip arthroplasty (THA) for osteoarthritis and to determine associated risk factors. The diagnosis of infection was determined based on the criteria outlined by the CDC.
 We performed a retrospective population-based cohort study using prospectively collected patient-level data. We used the Mann-Kendall Trend Test to detect monotonic trends in deep SSI rates over time. Adjusted outcomes of interest were day readmission and mortality. We performed multiple logistic regression analysis to determine the effect of different surgical and patient factors on the risk of developing a deep SSI within 90-days of surgery. A total of 22,685 patients were included. 46 patients had a confirmed deep SSI within 90-days of surgery. The annual infection rate decreased over the 7 years of our study period (p = 0.026). Developing an infection was associated with increase odds ratios for 30-day (p<0.001), 60-day (p<0.001), and 90-day (p<0.001) readmission but was not associated with mortality at any time point. The risk factors associated with an infection were elevated BMI (OR, 3.42 [95% CI 1.75-7.20]; p<0.001), chronic renal disease (OR, 3.52 [95% CI 1.17-8.59]; p=0.011), cardiac illness (OR, 2.47 [1.30-4.69]; p=0.005) and hospital volume (OR, 1.02 [1.01-1.03]; p=0.003). Using prospectively collected data with a robust methodological process, several risk factors were identified. This work establishes a reliable baseline infection rate for early-onset deep SSI after THA for osteoarthritis.

Introduction: Past studies have not explored the relationship between iron deficiency anemia (IDA) and postoperative outcomes after primary total hip arthroplasty (THA) surgery. The purpose of this study is to compare the 2-year minimum follow-up postoperative outcomes in THA patients with and without IDA. Methods: Data from the New York State’s Statewide Planning and Research Cooperative System database from 2009 to 2013 was retrospectively analyzed to isolate primary THA patients. 60,168 THA patients were then grouped into two cohorts based on IDA status with 1:1 propensity score matching based on age, gender, and obesity status (n=984 each, 1968 total). Patient demographics, hospital variables, and postoperative outcomes (surgical complications, medical complications, readmissions, revision of THA, reoperations, mortality during hospitalization) were compared. To evaluate the association of IDA with postoperative outcomes after THA surgery, logistic regression analysis with covariates (age, gender, and obesity status) was performed. Results: IDA patients were found to have longer hospital stays (5.1 days vs. 3.9 days; p<0.001) and increased total surgical charges ($52,911 vs. $48,981; p=0.006). IDA patients also had increased rates of surgical complications (wound complications, transfusions of blood) and medical complications (acute renal failure) but decreased rates of revisions of THA (all, p>0.05). Conclusion: This retrospective study found that in 2-year minimum follow-up THA patients, IDA was found to be a significant predictor of increased rates of postoperative medical and surgical complications. These results may be beneficial for orthopaedic surgeons when discussing benefits and risks associated with THA surgery with their patients.

Introduction: The goal of this systematic review is to analyze studies regarding fluoroscopy-assisted THA to determine average fluoroscopy time and radiation exposure dose. Methods: PubMed was queried for studies pertaining to intraoperative THA fluoroscopy. Studies that did not include fluoroscopy time or radiation exposure were excluded, as well as commentaries, editorials, and case reports. The average fluoroscopy time and radiation exposure dose were computed. Results: 106 papers were initially collected. 11 studies remained considering the exclusion criteria. Patients undergoing fluoroscopy-guided THA had an average fluoroscopy time of 21.4 (95% CI 16.6 – 26.1) seconds and underwent an average radiation dose of 1.8 x 10-3 (95% CI 7.4 x 10-4 – 2.9 x 10-3) Gy. Of the 3 studies with available data, 2 reported an overall radiation exposure to the surgeon, which was averaged to 7.7 x 10-5 (95% CI 1.4 x 10-5 – 1.4 x 10-4) Gy. Jinnai et al. reported radiation exposure to 3 different regions of the surgeon: the thyroid (1.1 x 10-5 Gy), sternal notch (2.1 x 10-7 Gy), and eyes (5.6 x 10-6 Gy). This value is well below minimum radiation values (as stated by the CDC) needed to cause adverse patient effects: symptoms of acute radiation syndrome may begin after radiation doses of at least 0.7 Gy and cutaneous radiation injury may present after exposure to radiation doses of at least 2 Gy. Conclusion: Our review demonstrates that fluoroscopy-guided THA is a safe procedure. Patients and surgical staff are exposed to negligible radiation doses.

The aim of this study was to compare the accuracy in correction of leg length discrepancy (LLD) and restoring femoral offset in patients undergoing total hip arthroplasty (THA) with preoperative digital templating versus without. Secondary objectives were the accuracy of implant sizes(templated versus actual), cup inclination and the femoral neck cut.

This retrospective cohort study comared 56 patients who underwent arthroplasty surgery with pre-operative digital templating and 50 patients without templating over 1 year.

The templated and non-templated cohorts were matched for variables including age (mean = 71.8 years vs 70.9 years, pre op LLD (– 4.9mm) vs – 5.2mm and pre op offset 41.2 vs 43.7.

Preoperative digital templating resulted in correction of LLD to <5mm in 76.8% of cases, 5-10mm in 21.4% and >10mm in 1 case only (1.8%). The non-templated cohort had a LLD <5mm in 50% of cases, 5-10mm in 28% and >10mm in 22%. Chi square testing demonstrated this to be statistically significant (p = 0.002).

The mean pre-operative offset in templated group was 40mm and 46mm postoperatively . The non-templated cohort had a mean pre-operative offset off 42 and 36mm post-operatively. Independent t testing revealed statistical significance at a p value of 0.05.

Preoperative digital templating leads to an increased likelihood of restoring LLD to <5mm and a significantly increased likelihood of preventing lengthening > 10mm.

Templating significantly increases the chance of restoring femoral offset to match the native hip and a negative (decreased) offset is seen in the non-templated group of patients.