Increased early complications after total hip arthroplasty compared with hemiarthroplasty in older adults with a femoral neck fracture.

Aims: The aim of this study was to compare the early postoperative mortality and morbidity in older patients with a fracture of the femoral neck, between those who underwent total hip arthroplasty (THA) and those who underwent hemiarthroplasty. Methods: This nationwide, retrospective cohort study used data from the Japanese Diagnosis Procedure Combination database. We included older patients (aged ≥ 60 years) who underwent THA or hemiarthroplasty after a femoral neck fracture, between July 2010 and March 2022. A total of 165,123 patients were included. The THA group was younger (mean age 72.6 (SD 8.0) vs 80.7 years (SD 8.1)) and had fewer comorbidities than the hemiarthroplasty group. Patients with dementia or malignancy were excluded because they seldom undergo THA. The primary outcome measures were mortality and complications while in hospital, and secondary outcomes were readmission and reoperation within one and two years after discharge, and the costs of hospitalization. We conducted an instrumental variable analysis (IVA) using differential distance as a variable. Results: The IVA analysis showed that the THA group had a significantly higher rate of complications while in hospital (risk difference 6.3% (95% CI 2.0 to 10.6); p = 0.004) than the hemiarthroplasty group, but there was no significant difference in the rate of mortality while in hospital (risk difference 0.3% (95% CI -1.7 to 2.2); p = 0.774). There was no significant difference in the rate of readmission (within one year: risk difference 1.3% (95% CI -1.9 to 4.5); p = 0.443; within two years: risk difference 0.1% (95% CI -3.2 to 3.4); p = 0.950) and reoperation (within one year: risk difference 0.3% (95% CI -0.6 to 1.1); p = 0.557; within two years: risk difference 0.1% (95% CI -0.4 to 0.7); p = 0.632) after discharge. The costs of hospitalization were significantly higher in the THA group than in the hemiarthroplasty group (difference $2,634 (95% CI $2,496 to $2,772); p < 0.001). Conclusion: Among older patients undergoing surgery for a femoral neck fracture, the risk of early complications was higher after THA than after hemiarthroplasty. Our findings should aid in clinical decision-making in these patients.

Outcomes after hip fracture surgery in patients receiving non-steroidal anti-inflammatory drugs alone, acetaminophen alone, or both.

Aims: The use of multimodal non-opioid analgesia in hip fractures, specifically acetaminophen combined with non-steroidal anti-inflammatory drugs (NSAIDs), has been increasing. However, the effectiveness and safety of this approach remain unclear. This study aimed to compare postoperative outcomes among patients with hip fractures who preoperatively received either acetaminophen combined with NSAIDs, NSAIDs alone, or acetaminophen alone. Methods: This nationwide retrospective cohort study used data from the Diagnosis Procedure Combination database. We included patients aged ≥ 18 years who underwent surgery for hip fractures and received acetaminophen combined with NSAIDs (combination group), NSAIDs alone (NSAIDs group), or acetaminophen alone (acetaminophen group) preoperatively, between April 2010 and March 2022. Primary outcomes were in-hospital mortality and complications. Secondary outcomes were opioid use postoperatively; readmission within 90 days, one year, and two years; and total hospitalization costs. We used propensity score overlap weighting models, with the acetaminophen group as the reference group. Results: We identified 93,018 eligible patients, including 13,068 in the combination group, 29,203 in the NSAIDs group, and 50,474 in the acetaminophen group. Propensity score overlap weighting successfully balanced patient characteristics among the three groups, with no significant difference in in-hospital mortality rates observed among the groups (combination group risk difference 0.0% (95% CI -0.5 to 0.4%); NSAIDs group risk difference -0.2% (95% CI -0.5 to 0.2%)). However, the combination group exhibited a significantly lower risk of in-hospital complications than the acetaminophen group (risk difference -1.9% (95% CI -3.2 to -0.6%)) as well as a significantly lower risk of deep vein thrombosis (risk difference -1.4% (95% CI -2.2 to -0.7%)). Furthermore, total hospitalization costs were higher in the NSAIDs group than in the acetaminophen group (difference USD $438 (95% CI 249 to 630); p < 0.001). No significant differences in other secondary outcomes were observed among the three groups. Conclusion: The combination of acetaminophen with NSAIDs appears to be safe and advantageous in terms of reducing in-hospital complications.

Anti-osteoporotic drug efficacy for periprosthetic bone loss after total hip arthroplasty: A systematic review and network meta-analysis.

BACKGROUND: Periprosthetic bone loss following total hip arthroplasty (THA) threatens prosthesis stability. This systematic review and network meta-analysis aimed to compare the efficacy of anti-osteoporotic drugs for measures of hip function according to functional outcomes, periprosthetic femoral bone mineral density loss in each Gruen zone, and revision surgery after THA. METHODS: The systematic search of six literature databases was conducted in December 2021 in accordance with PRISMA guidelines. Adult participants who underwent primary THA were included. A random-effects network meta-analysis was performed within a frequentist framework, and the confidence in the evidence for each outcome was evaluated using the CINeMA tool, which assessed the credibility of results from the network meta-analysis. We included 22 randomized controlled trials (1243 participants) comparing the efficacy and safety of bisphosphonates (including etidronate, clodronate, alendronate, risedronate, pamidronate, and zoledronate), denosumab, selective estrogen receptor modulator, teriparatide, calcium + vitamin D, calcium, and vitamin D. We defined the period for revision surgery as the final follow-up period. RESULTS: Raloxifene, bisphosphonate, calcium + vitamin D, and denosumab for prosthetic hip function might have minimal differences when compared with placebos. The magnitude of the anti-osteoporotic drug effect on periprosthetic femoral bone loss varied across different Gruen zones. Bisphosphonate, denosumab, teriparatide might be more effective than placebo in Gruen zone 1 at 12 months after THA. Additionally, bisphosphonate might be more effective than placebo in Gruen zones 2, 5, 6, and 7 at 12 months after THA. Denosumab was efficacious in preventing bone loss in Gruen zones 6 and 7 at 12 months after THA. Teriparatide was likely to be efficacious in preventing bone loss in Gruen zone 7 at 12 months after THA. Raloxifene was slightly efficacious in preventing bone loss in Gruen zones 2 and 3 at 12 months after THA. Calcium was slightly efficacious in preventing bone loss in Gruen zone 5 at 12 months after THA. None of the studies reported revision surgery. CONCLUSIONS: Bisphosphonate and denosumab may be effective anti-osteoporotic drugs for preventing periprosthetic proximal femoral bone loss due to stress shielding after THA, particularly in cementless proximal fixation stems, which are the most commonly used prostheses worldwide.

Relationship between the Accuracy of the Acetabular Cup Angle and BMI in Posterolateral Total Hip Arthroplasty with CT-Based Navigation.

Background and Objectives: Precise acetabular cup placement is essential for successful total hip arthroplasty (THA). In obese patients, its accuracy is often difficult to achieve because of the thickness of the soft tissues. This study aimed to determine the relationship between the accuracy of acetabular cup angle and body mass index (BMI) in posterolateral THA using the computed tomography-based navigation (CT-navi) system. Materials and Methods: We retrospectively reviewed 145 consecutive primary THAs using the CT-navi system between January 2015 and January 2018. All surgeries were performed using cementless cups employing the posterolateral approach with the patient in the decubitus position. We compared the radiographic inclination and anteversion obtained intraoperatively from the CT-navi with those measured by postoperative CT using three-dimensional templating software. We evaluated the relationship between the extent of errors and correlation with BMI. Results: In non-overweight patients (BMI < 25, 88 hips), the mean navigation errors for inclination were 2.8 ± 2.2° and for anteversion were 2.6 ± 2.3°. Meanwhile, in overweight patients (BMI ≥ 25, 57 hips), the mean navigation errors were 2.6 ± 2.4° for inclination and 2.4 ± 2.4° for anteversion. We found no significant difference between overweight and non-overweight patients in both inclination and anteversion. There was no correlation between the extent of errors and BMI. Conclusions: In posterolateral THA, CT-navi can aid the precise placement of the acetabular cup irrespective of a patient's BMI.

Comparison between cup implantations during total hip arthroplasty with or without a history of rotational acetabular osteotomy.

INTRODUCTION: Total hip arthroplasty (THA) after rotational acetabular osteotomy (RAO) is technically demanding because of the characteristic acetabular morphology after RAO. The present study aimed to investigate the differences in the three-dimensional cup position between THA after RAO and primary THA. MATERIALS AND METHODS: We analysed the pre-operative and post-operative computed tomography (CT) data of 120 patients (20 patients after RAO and 100 patients without a history of RAO) who underwent THA between January 2017 and June 2018. We evaluated radiographic parameters, including acetabular anteversion, antero-posterior distance at the level of the femoral head centre, the presence of anterior acetabular osteophyte and/or rotated fragment during RAO from the CT data. Additionally, operative data and clinical scores were also evaluated. RESULTS: Although we found no significant differences in any clinical parameters, there were significant differences in radiographic parameters and operative data. The morphology of the acetabulum was significantly retroverted, and the antero-posterior distance was longer in patients after RAO, compared to the implanted cup. Additionally, longer operative time was necessary for such patients. These results reflect the atypical acetabular morphology after RAO, and emphasize that care should be taken to avoid anterior bony impingement and post-operative dislocation. CONCLUSION: For cup implantation during THA after RAO, surgeons should acknowledge the atypical morphology of the acetabulum and not be misled by its visual shape.

Severe osteolysis and periprosthetic femoral fracture 45 years after acrylic hemiarthroplasty of the hip: a case report.

BACKGROUND: Hip arthroplasty using acrylic prosthesis was once conducted; however, it has now been abandoned because of early breakages and wear of material. Therefore, complications or revision surgeries due to the use of acrylic prostheses are becoming rare. CASE PRESENTATION: A 76-year-old woman presented with a sudden onset of severe pain in her left femur while walking. Radiographs revealed severe osteolysis and periprosthetic femoral fracture 45 years after the initial hemiarthroplasty using an acrylic prosthesis. We performed a Girdlestone resection arthroplasty by removing the prosthesis and fixing the fracture site using an intramedullary nail and metal plate. The patient was pain-free in her hip and leg 2 years and 9 months after the surgery. Although she walked with a cane or crutches, no postoperative complications were observed. CONCLUSIONS: The combined use of an intramedullary nail and plate fixation with resection arthroplasty could offer acceptable results for patients with severe osteolysis and periprosthetic fracture after femoral head replacement using an acrylic prosthesis. Our report seems relevant because it not only reminds us of the significant steps made in the development of modern total hip arthroplasty; it also highlights one of the surgical options for severe osteolysis and periprosthetic fracture of the hip.

Fracture of ossified Achilles tendons: A review of cases.

Fracture of an ossification of the Achilles tendon (OAT) is a rare entity, and its etiology, pathology, and treatment remain unclear. We reviewed and scrutinized 18 cases (16 articles) of the fracture of an OAT. The most common etiologies of the ossifications include previous surgery and trauma. The fractures often occur without any trigger or with minimal trigger. The long, > 5 cm, ossification in the body of the Achilles tendon may have a higher risk of fracture. The OAT itself is often asymptomatic; however, its fracture causes severe local pain, swelling, and weakness of plantar flexion, which forces patients to undergo aggressive treatments. Regarding the treatments of the fractures, nonoperative treatment by immobilizing ankle joint could be an option for elderly patients. However, because it often cannot produce satisfactory results in younger patients, surgical treatment is typically recommended. Excision of the fractured mass and repairing the tendon is applicable if the remnant is enough. If there is a defect after the excision, reconstruction with autologous grafts or adjacent tendon transfer is performed. Gastrocnemius fascia turndown flap, hamstring tendon and tensor fascia lata are used as autologous grafts, whereas peroneus brevis and flexor hallucis longus tendons are used for the tendon transfer. If the fracture of an OAT is treated properly, the functional result will be satisfactory.

Characteristics of three-dimensional acetabular morphology of patients with excellent outcome after rotational acetabular osteotomy over 20 years.

BACKGROUND: Rotational acetabular osteotomy (RAO) is a type of pelvic osteotomy performed to improve the acetabular bony coverage against the femoral head for patients with acetabular dysplasia. The acetabular bony coverage is ideally evaluated three-dimensionally; however, there is a paucity of published data regarding three-dimensional morphology in patients with long-term excellent outcome after RAO. The present study investigated the characteristics of three-dimensional acetabular morphology with long-term excellent outcome after RAO in comparison to patients with normal hip joints and those converted to total hip arthroplasty (THA) after RAO because of osteoarthritis (OA) progression. METHODS: Anteroposterior plain radiograph and computed tomography data of 57 hip joints (17 joints with excellent outcome 20 years or more after RAO, 16 normal joints, and 20 joints converted to THA after RAO) were analyzed. The two-dimensional lateral center-edge (CE) angle from plain radiographs and acetabular anteversion, anterior acetabular sector angle, and posterior sector angle from computed tomography (CT) images were calculated. RESULTS: Compared with patients converted to THA, all parameters in patients with long-term excellent outcome after RAO were similar to those in patients with normal hip joints, particularly in the three-dimensional analyses. The anterior bony coverage was excessive, whereas the posterior bony coverage was deficient in patients converted to THA after RAO. Anterior bony impingement and posterior instability may be the cause of OA progression after RAO. CONCLUSION: Caution must be taken to avoid rotating the separated fragment excessively to the anterior direction during RAO to prevent OA progression and achieve long-term excellent outcome.

Midterm results of revision total hip arthroplasty for migrated bipolar hemiarthroplasty in patients with hip osteoarthritis using cementless cup with the rim-fit technique.

PURPOSE: The results of reamed bipolar hemiarthroplasty (BHA) in patients with hip osteoarthritis (OA) are reported to be unfavorable. Acetabular reaming for sufficient bony coverage caused bipolar head migration into the superomedial direction, and most patients required revision surgeries. Several methods are applicable to treat decreased bone stock. This study aimed to investigate the midterm results of revision surgeries using the cementless cup with the rim-fit technique. METHODS: Between 1996 and 2014, acetabular revision surgeries using the cementless cup with the rim-fit technique were performed in 86 hips (74 patients). We evaluated radiographic outcomes, including positional change of the rotation center of the artificial femoral head, presence of implant loosening, and filling of the initial gap. We also evaluated clinical outcomes, including the Harris hip score (HHS), and postoperative complications. RESULTS: The average positional changes from BHA to prerevision surgeries were 8.0 mm superiorly and 4.1 mm medially. The average changes from prerevision to postrevision surgeries were 3.7 mm inferiorly and 2.4 mm laterally. No implant loosening was found in all cases; the initial gap between the acetabular host bone and the acetabular cup was filled in 53 (93%) among 57 hips. The average HHS improved from 65.9 before revision surgeries to 83.8 in the latest follow-up. Dislocation and postoperative periprosthetic fracture occurred in two and five hips, respectively; no cases required rerevision surgeries. CONCLUSION: There were favorable midterm results of the revision total hip arthroplasty for migrated BHA in patients with hip OA using cementless cup with the rim-fit technique.

Total Hip Arthroplasty in a Patient with Oto-Spondylo-Megaepiphyseal Dysplasia Planned by Three-Dimensional Motion Analyses and Full-Scale Three-Dimensional Plaster Model of Bones.

We present the case of a 28-year-old woman with oto-spondylo-megaepiphyseal dysplasia, which is a rare skeletal disorder, who underwent bilateral total hip arthroplasty. Full-scale three-dimensional plaster model of the acetabulum and the femur provided us with a feasible preoperative plan. Pre- and postoperative three-dimensional motion analyses proved a significant improvement in her ambulation and confirmed the efficacy of total hip arthroplasty. In conclusion, full-scale three-dimensional plaster models of the bone and three-dimensional motion analyses were useful for total hip arthroplasty in patients with skeletal dysplasia.

Evaluation of the three-dimensional bony coverage before and after rotational acetabular osteotomy.

PURPOSE: Rotational acetabular osteotomy is a type of pelvic osteotomy that involves rotation of the acetabular bone to improve the bony coverage of the femoral head for patients with acetabular dysplasia. Favourable post-operative long-term outcomes have been reported in previous studies. However, there is a paucity of published data regarding three-dimensional bony coverage. The present study investigated the three-dimensional bony coverage of the acetabulum covering the femoral head in hips before and after rotational acetabular osteotomy and in normal hips. METHODS: The computed tomography data of 40 hip joints (12 joints before and after rotational acetabular osteotomy; 16 normal joints) were analyzed. The three-dimensional bony coverage of each joint was evaluated using original software. RESULTS: The post-operative bony coverage improved significantly compared with pre-operative values. In particular, the anterolateral aspect of the acetabulum tended to be dysplastic in patients with acetabular dysplasia compared to those with normal hip joints. However, greater bony coverage at the anterolateral aspect was obtained after rotational acetabular osteotomy. Meanwhile, the results of the present study may indicate that the bony coverage in the anterior aspect may be excessive. CONCLUSION: Three-dimensional analysis indicated that rotational acetabular osteotomy achieved favorable bony coverage. Further investigations are necessary to determine the ideal bony coverage after rotational acetabular osteotomy.

Clinical and Radiographic Outcomes of Total Hip Arthroplasty With a Specific Liner in Small Asian Patients: Influence of Patient-Related, Implant-Related, and Surgical Factors on Femoral Head Penetration.

BACKGROUND: We evaluated the clinical and radiographic outcomes, including femoral head penetration, of total hip arthroplasty performed using a specific polyethylene (PE) liner in small Asian patients at 10 years after the index surgery. In addition, we investigated whether femoral head penetration was affected by patient-related, implant-related, and surgical factors. METHODS: Between August 2002 and June 2005, for cementless primary total hip arthroplasty, we used acetabular PE liners that were manufactured from GUR 1050 resin, machined from isostatic compression-molded bar stock, and sterilized with a gamma ray irradiation in argon gas. We assessed 82 hips in 78 patients who received these liners. RESULTS: The mean Harris hip score improved from 41.0 preoperatively to 84.5 at 10 years postoperatively. Periprosthetic osteolysis was observed in 7 hips (9.8%). No acetabular component migration was detected, and no revision surgery was performed 10 years postoperatively. The mean steady-state wear rate was 0.031 mm/y, which was lower than the wear rate for other conventional PE liners of the previous studies. Among the patient-related, implant-related, and surgical factors, sex was significantly associated with the mean steady-state wear rate, with a higher rate in male patients than in female patients. CONCLUSION: PE acetabular liners used in small Asian patients show similar clinical outcomes and reduced wear compared with those of other liners. In addition, sex is significantly associated with the mean steady-state wear rate, and the steady-state wear rate is higher in male patients than in female patients.

A Patient-Specific Instrument for Femoral Stem Placement During Total Hip Arthroplasty.

To ensure that the femoral stem is placed in the proper position during total hip arthroplasty, the authors developed a patient-specific instrument. A total of 10 total hip arthroplasties were performed with the assistance of the patient-specific instrument during this study. The mean accuracy of stem tilt, varus/valgus, and anteversion was 2.1°±4.1°, 1.0°±0.7°, and 4.7°±1.2°, respectively. No complications were observed and no reoperations were required for any of the patients who underwent surgery included in this study. The results support the feasibility of this patient-specific instrument for use during stem placement in total hip arthroplasty. [Orthopedics. 2017; 40(2):e374-e377.].

Clinical and radiographic outcomes of total hip replacement with poly(2-methacryloyloxyethyl phosphorylcholine)-grafted highly cross-linked polyethylene liners: three-year results of a prospective consecutive series.

OBJECTIVES: This study aimed to evaluate the clinical safety and wear-resistance of the novel highly cross-linked polyethylene (HXLPE) acetabular liner with surface grafting of poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC) at 3 years after total hip replacement (THR). METHODS: Eighty consecutive patients underwent cementless THR using a 26-mm diameter cobalt-chromium-molybdenum alloy femoral head and a PMPC-grafted HXLPE liner for the bearing couplings. We evaluated the clinical and radiographic outcomes of 76 patients at 3 years after the index surgery. RESULTS: The clinical results at 3 years were equivalent to a Harris hip score of 95.6 points. No adverse events were associated with the implanted PMPC-grafted HXLPE liner, and no periprosthetic osteolysis was detected. The mean femoral head penetration rate was 0.002 mm/year, representing marked reduction compared with other HXLPE liners. CONCLUSIONS: A PMPC-grafted HXLPE liner is a safe option in THR and probably reduces the generation of wear particles.

Epimerization in peptide thioester condensation.

Peptide segment couplings are now widely utilized in protein chemical synthesis. One of the key structures for the strategy is the peptide thioester. Peptide thioester condensation, in which a C-terminal peptide thioester is selectively activated by silver ions then condensed with an amino component, is a powerful tool. But the amino acid adjacent to the thioester is at risk of epimerization. During the preparation of peptide thioesters by the Boc solid-phase method, no substantial epimerization of the C-terminal amino acid was detected. Epimerization was, however, observed during a thioester-thiol exchange reaction and segment condensation in DMSO in the presence of a base. In contrast, thioester-thiol exchange reactions in aqueous solutions gave no epimerization. The epimerization during segment condensation was significantly suppressed with a less polar solvent that is applicable to segments in thioester peptide condensation. These results were applied to a longer peptide thioester condensation. The epimer content of the coupling product of 89 residues was reduced from 27% to 6% in a condensation between segments of 45 and 44 residues for the thioester and the amino component, respectively.