Age, activity, and native femoral offset are associated with articular noise in ceramic on ceramic total hip arthroplasty (THA) with custom stems.

PURPOSE: To report the prevalence of articular noise following total hip arthroplasty (THA) with custom stems and ceramic-on-ceramic (CoC) bearings, to determine the risk factors for articular noise, and the effect of articular noise on quality of life (QoL). METHODS: A consecutive series of uncemented primary THAs using custom stems implanted between 01/02/ 2014-01/04/2017 were evaluated. The cohort comprised 479 patients (529 hips, 301 males and 228 females), aged 55.9 ± 11.6 with a BMI of 25.8 ± 4.3 kg/m2. Postoperative assessment included Oxford hip score (OHS), forgotten joint score (FJS), and a dedicated questionnaire on articular noise. Descriptive statistics were used to summarise the data. Regression analyses were performed to study factors associated with presence of noise. RESULTS: At a minimum follow-up of five years, 431 patients (476 hips) were available for postoperative assessment. OHS was 45.3 ± 6.1, FJS was 83.6 ± 24.7, and 69 patients (71 hips, 15%) reported articular noise. The impact of noise on QoL was 1.4 ± 2.1. Multivariable analyses confirmed that the presence of articular noise was associated with younger age (OR,0.95; 95%CI,0.93-0.97; p < 0.001), smaller native femoral offset (OR, 0.95; 95%CI,0.90-1.00;p = 0.034), as well as intense (OR, 3.15; 95%CI, 1.15-9.79; p = 0.033) and very intense physical activity (OR, 4.71; 95%CI, 1.52-16.15; p = 0.009). CONCLUSION: The prevalence of articular noise following primary THA with custom stems and CoC bearings was 15%, but the impact of noise on QoL was minimal for most patients. Younger, highly active patients should be advised of an increased likelihood of noise from CoC THA, particularly if they have low native femoral offset on preoperative imaging.

Excellent Clinical Outcomes and Return to Dance of 6 Active, Professional Ballet Dancers Aged Younger Than 40 Years at Total Hip Arthroplasty Through Direct Anterior Approach With a Custom Stem: A Case Report.

OBJECTIVE: To report clinical outcomes and return to dance after total hip arthroplasty (THA) by direct anterior approach (DAA) using custom stems in young, active, professional ballet dancers. DESIGN: Case report. SETTING: Tertiary. PATIENTS: Six active, professional ballet dancers younger than 40 years who intended to resume ballet after THA. INTERVENTIONS: Primary THA by muscle-sparing DAA using custom stems. MAIN OUTCOME MEASURES: Return to dance, Oxford hip score (OHS), forgotten joint score (FJS), and satisfaction with surgery and pain using numeric rating scale (NRS). CTs were acquired 2 days after surgery to assess implant position. Descriptive statistics were used. RESULTS: The cohort comprised 4 women and 2 men aged 15 to 39 years. At 2.5 to 5.1 years of follow-up, all patients returned to professional ballet dance. Time to return to dance was 3 to 4 months for 3 patients and 12 to 14 months for 3 patients. Clinical scores were excellent, except for FJS in 1 patient who had considerable pain at her spine and ipsilateral foot. All patients were satisfied with surgery (NRS = 10). There were no complications, reoperations, or revisions. CTs confirmed that stems and cups were correctly positioned. CONCLUSIONS: All 6 young, active, professional ballet dancers who underwent THA by muscle-sparing DAA using custom stems returned to professional ballet dance and were completely satisfied with surgery. At >2 years of follow-up, 5 patients had excellent clinical outcomes and reported their dancing level to be as expected or better, whereas 1 patient had a lower FJS and was unable to return to her expected dance level.

Little or No Differences in Hip Morphology Between Professional Dancers and Controls: A Systematic Review.

OBJECTIVE: To systematically evaluate and synthesize the literature on bony hip morphology of professional dancers, as measured by 2D or 3D imaging techniques. DATA SOURCES: A literature search was performed on November 20, 2020, using MEDLINE, Embase, and Cochrane. Clinical studies were eligible if they reported on hip morphology of professional dancers. Two independent reviewers screened titles, abstracts, and full-texts to determine eligibility; performed data extraction; and assessed the quality of eligible studies according to the Joanna Briggs Institute (JBI) checklist. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. MAIN RESULTS: The search returned 1384 records; 449 were duplicates, 923 were excluded after title/abstract/full-text screening, and 12 were eligible, reporting on 447 individuals (352 professional dancers and 95 controls). The JBI checklist indicated that 11 studies scored ≥4 points. For professional dancers, lateral center edge angle was 22.4 to 30.8 degrees, acetabular version was 6.7 to 13.5 degrees, neck-shaft angle was 132.5 to 139.5 degrees, and femoral version was 4.7 to 14.4 degrees. Statistically significant differences between dancers and controls were found in some of the studies for acetabular version, neck-shaft angle, and femoral version, although only femoral version showed clinically relevant differences. CONCLUSIONS: The bony hip morphology of professional dancers is similar to that of other athletes and age-matched controls, which is in contrast to the authors' clinical experience. We presume that the abnormal morphology we have seen at the clinic is only present in symptomatic dancers who require total hip arthroplasty (THA) and is not a general characteristic of all dancers. Further studies should compare the hip morphology of dancers undergoing THA with matched nondancers.

Ceramic-on-ceramic THA Implants in Patients Younger Than 20 Years.

BACKGROUND: Poor survival of THA implants in very young patients has been attributed to use of cemented implants, wear of conventional polyethylene, and the presence of morphologic deformities in the proximal femur or in the acetabulum. Few studies have reported the long-term results of ceramic-on-ceramic implants in THAs in patients younger than 20 years. QUESTION/PURPOSES: We determined: (1) the proportion of patients who experienced complications related to the ceramic bearing (squeaking, fracture); (2) the survivorship free from loosening and free from revision for any reason; (3) whether patients with osteonecrosis had inferior survivorship compared with patients whose surgical indication was all other diagnoses including sequelae of pediatric hip disorders (developmental dysplasia of the hip, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis); and (4) clinical function. METHODS: Between 1979 and 2013, we performed 113 primary THAs in 91 patients younger than 20 years at the time of surgery. Of those, 105 THAs (83 patients) were done with ceramic-on-ceramic bearings (91% of the 91 patients); during that period, a ceramic-on-ceramic bearing couple was indicated in all patients younger than 20 years. In eight patients (eight hips), a cemented polyethylene cup was implanted because the diameter of the acetabulum was smaller than the smallest available ceramic cup (46 mm), or because adequate fixation of a ceramic press-fit cup could not be achieved despite careful reaming of the acetabulum. The most common diagnosis indicating THA was avascular necrosis of the femoral head (56.2%; 59 hips). Thirty-five patients (40 hips) had undergone previous operations before the replacement. Three patients (4%; four hips) died from unrelated causes, nine patients (11%; 13 hips) were lost to followup, and four patients (five hips) had a followup greater than 8.5 years but have not been seen in the last 5 years. Patients were assessed clinically (using the Merle d'Aubigne-Postel score, Hip disability and Osteoarthritis Outcome score (HOOS), and the SF-12(®) Health Survey, and radiographically for signs of radiolucencies, subsidence, or osteolysis on plain films. The mean followup was 8.8 ± 6.1 years (range, 2-34.4 years). RESULTS: Five patients experienced transient noise generation, defined as a snap in four patients and squeaking in one. Seventeen hips underwent revision surgery-16 for aseptic loosening and one for septic loosening. The implant survival rate at 10 years with aseptic loosening as the endpoint was 90.3% (95% CI, 82.4%-98.9%). No hip had acetabular or femoral osteolysis. Survivorship in patients with osteonecrosis did not differ from survivorship in patients with other diagnoses. The Merle d'Aubigne-Postel score increased from 10.1 ± 4.0 to 17.6 ± 1.1 (p < 0.01); the mean HOOS score was 79.3 ± 13.8 (range, 50.6-100); the mean SF-12(®) physical and mental component scores were 48.1 ± 7.9 (range, 21.4-57.6), and 47.4 ± 12.2 (range, 24.5-99.4), respectively. CONCLUSIONS: We found that patient-reported outcomes scores improved in most patients undergoing THA in this very young study group. Underlying diagnosis did not affect long-term survivorship. However, the revision-free survival rate at 10 years is lower than published estimates in older patients, and with 11% of patients lost to followup, our estimates may represent a best-case scenario. Therefore, we believe THA should be performed as a last resort in this population. LEVEL OF EVIDENCE: Level IV, therapeutic study.

High Rates of Satisfaction and Return to Dance in Current or Former Professional Ballet Dancers After Total Hip Arthroplasty With a Muscle-Sparing Direct Anterior Approach Using Custom Femoral Stems.

Background: Professional ballet dancers have high expectations after total hip arthroplasty (THA), particularly if they intend to resume dancing as performers or teachers. Purpose: To report clinical outcomes and return to dance after THA with a muscle-sparing direct anterior approach using a custom femoral stem in a cohort of current or former professional ballet dancers. Study Design: Case series; Level of evidence, 4. Methods: Twenty-three patients (26 hips) were included, that identified as current or former professional ballet dancers, from a consecutive series of 1699 hips that underwent primary THA by 1 of 2 surgeons. Both surgeons routinely implanted custom femoral stems using a muscle-sparing direct anterior approach in active and/or high-demand patients. All patients completed a questionnaire postoperatively that assessed dance capabilities, the visual analog scale (VAS) for hip pain (0-10), the VAS for satisfaction with surgery (0-10), the Oxford Hip Score (OHS), and the Forgotten Joint Score (FJS). Results: The initial cohort comprised 19 women and 4 men, with a mean age of 50.5 ± 14.9 years and a mean 38.0 ± 14.4 years of dance experience. One patient underwent revision THA for a leg-length discrepancy, leaving 22 patients (25 hips) with a mean follow-up of 3.4 ± 1.4 years. The mean VAS satisfaction score was 9.8 ± 0.6, and the mean VAS pain score was 0.5 ± 1.0. The postoperative OHS and FJS were 46 ± 2 and 92 ± 15, respectively. Overall, 16 patients resumed ballet at 5.1 ± 3.9 months, 3 resumed other types of dance, and 3 did not resume any type of dance. None of the 6 patients who did not resume ballet indicated pain in the operated hip as the reason for stopping. Conclusion: In current or former professional ballet dancers, THA by a muscle-sparing direct anterior approach using a custom femoral stem yielded excellent clinical outcomes at a minimum of 2 years, with the highest satisfaction score of 10 points reported for 88% of hips and 72% of hips being totally pain free. Furthermore, 73% of patients resumed ballet, and 86% resumed dance in general.

Sexual activity resumption after total hip arthroplasty: A satisfaction survey in 101 patients.

BACKGROUND: We are not aware of studies conducted in France to assess information provided by surgeons about the impact of total hip arthroplasty (THA) on sexual activity or sexual activity resumption after THA. The objectives of this study in a cohort of patients seen after THA were to evaluate: (1) the time to sexual activity resumption, (2) whether sexual activity resumption was discussed with the surgeon and whether the patients wanted information on this point, and (3) the modalities and experience of sexual activity resumption according to demographic features. HYPOTHESIS: Age and sex influence the timing and modalities of sexual activity resumption after THA. METHODS: We conducted a single-centre prospective cohort study in consecutive patients who received follow-up for 6months after THA. Each patient completed an anonymised questionnaire on preoperative sexual activity, modalities of postoperative sexual activity resumption, information delivered by the surgeon, and expectations regarding the delivered information. The patients also specified their age and sex on the questionnaire. RESULTS: Of 101 included patients, 49 were still sexually active before surgery. Of these 49 patients, 35 (71.4%) reported no difference in the frequency of sexual activity before and after THA. Only 4 (8.2%) patients did not resume sexual activity during follow-up. Older age was associated with a lower demand for information [odds ratio, 0.95; 95% confidence interval: 0.91-0.99 (p=0.01)]. Compared to the females, the males more often recovered similar sexual activity to that before surgery regarding frequency [18/20 vs. 17/29 (p=0.02)] and quality of sexual positions [15/20 vs. 9/29 (p=0.003)]. Males resumed sexual activity on average during the first 3weeks [10/20 (p=0.02)], compared to after 6weeks for most females [13/29 (p=0.03)]. Age was not associated with the time to sexual activity resumption [ρ=0.0868; 95% confidence interval: -0.205 to 0.365 (p=0.56)]. DISCUSSION: Among patients who were sexually active before surgery, 71.4% reported having resumed the same frequency of sexual activity 6months after surgery. The main difficulty in both males and females was fear of prosthetic hip dislocation, which was related in part to insufficient preoperative information. Males resumed sexual activity earlier than did females. In patients who were sexually active before surgery, age was not associated with the resumption of sexual activity after surgery. LEVEL OF EVIDENCE: IV, prospective study with no control group.

Two-incisions direct anterior approach for THR: Surgical technique and early outcome.

PURPOSE: In recent times the direct anterior approach for total hip replacement has gained considerable interest among orthopaedic surgeons because of the relative muscle-sparing nature than other surgical approaches. However, critics believe that this approach is associated with steep learning curve and high complication rates, mainly attributed to a more limited exposure to the femur. In order to make femoral access easier and implantation of acetabulum in anatomic plane, we designed a "two incisions anterior approach technique" for total hip replacement. The aim of the present study is to determine safety of this technique with respect to perioperative complications as well as early clinical outcome. METHODS: A retrospective review is carried out on a consecutive series of patients who underwent primary total hip replacement by the single surgeon through the two incisions direct anterior approach from 01/2014 to 11/2014. We analysed peri-operative complications and clinical outcome at two years' follow-up. RESULTS: We observed 01(0.9%) intra-operative complication; calcar fracture and 01(0.9%) anterior dislocation in first post-operative week. All patients reported improvement of their symptoms. The mean modified oxford hip score was significantly better from 25(11-37), preoperatively to 46.97(33-48) at mean latest follow-up. The mean modified Merle d'Aubigné-Postel score improved to 16.84(12-18) from 9.25 (4-14) preoperatively. CONCLUSION: The described surgical technique is simple and reproducible technique for easier exposure of femur and insertion of acetabulum in anatomic plane for total hip replacement through direct anterior approach. Easier and better femoral access helps to place implant in anatomical position as well as reduces the risk of femoral fracture associated with inadequate femoral exposure. The added advantage of this technique is, risks of injury to lateral femoral cutaneous nerve can be minimised by careful dissection and isolation of the nerve.

ASSIST applicability scoring of surgical trials. an investigator-reported assessment tool.

CONTEXT: We aimed to develop a new tool for assessing and depicting the applicability of the results of surgical randomized controlled trials (RCTs) from the trial investigators' perspective. METHODS: We identified all items related to applicability by a systematic methodological review, and then a sample of surgeons used these items in a web-based survey to evaluate the applicability of their own trial results. For each applicability item, participants had to indicate on a numerical scale that was simplified as a three-item scale: 1) items essential to consider, 2) items requiring attention, and 3) items inconsequential to the applicability of the results of their own RCT to clinical practice. For the final tool, we selected only items that were rated as being essential or requiring attention for at least 25% of the trials evaluated. We propose a specific process to construct the tool and to depict applicability in a graph. We identified all investigators of published and registered ongoing RCTs assessing surgery and invited them to participate in the web-based survey. RESULTS: 148 surgeons assessed applicability for their own trial and participated in the process of item selection. The final tool contains 22 items (4 dedicated to patients, 5 to centers, 5 to surgeons and 8 to the intervention). We proposed a straightforward process of constructing the graphical tool: 1) a multidisciplinary team of investigators or other care providers participating in the trial could independently assess each item, 2) a consensus method could be used, and 3) the investigators could depict their assessment of the applicability of the trial results in 4 graphs related to patients, centers, surgeons and the intervention. CONCLUSIONS: This investigator-reported assessment tool could help readers define under what conditions they could reasonably apply the results of a surgical RCT to their clinical practice.