Bone cement implantation syndrome in hip arthroplasty: Frequency, severity and prevention.

INTRODUCTION: Cemented femoral implants incur a serious risk of potentially fatal accidents in case of bone cement implantation syndrome (BCIS). As French data are sparse regarding this issue, Orthorisq, the official accreditation body for orthopedic surgeons, conducted an inter-professional survey: 1) to assess the frequency of BCIS, 2) to analyze risk factors related to the patient and to professional practices, and 3) to set out guidelines to reduce frequency and/or severity. HYPOTHESIS: French data on BCIS are underestimated and need updating to ease communication between colleagues. MATERIAL AND METHOD: In 2019, Orthorisq ran a survey of its members' practices and a "mirror" survey of anesthesiologists. In the decade from 2009 to 2018, the 775 respondent orthopedic surgeons, both occasional and systematic "cementers", reported their experience with a declared annual rate of 80,112 arthroplasties, including 63,799 (79.6%) in scheduled surgery. Some of the survey questions concerned cementing technique. With the help of the French College of Anesthesia and Intensive Care Medicine, 305 anesthesiologists responded to the mirror survey. RESULTS: The 776 orthopedic surgeons reported 1896 cementing accidents with 387 deaths during the study decade. Accidents were 6-fold more frequent in traumatology than in scheduled orthopedic surgery (0.71% versus 0.12%) and, more importantly, were more serious: mortality was 10-fold higher (0.17% versus 0.017% [p<0.001]). Certain "tricks and tips" intended to improve cementing quality, such as a dedicated system and especially a plug, significantly increased the risk of BCIS (p<0.001). Over the same period, the 305 anesthesiologists had been involved in 490 cementing accidents; 88 (29%) had been faced by at least 1 death, most often in emergency settings (60/28). While 753 surgeons (96%) reported warning the anesthetists and 571 (74%) waited for agreement before cementing, only 109 (36%) and 124 (41%) anesthetists reported being systematically alerted to cementing and implant reduction, respectively. The rate of serious accidents was 0.19% and mortality was 0.05%, for a cumulative probability of 0.24% per year. Extrapolated to the data of the ATIH Technical Agency of Hospitalization Information and subtracting arthroplasties by "never-cementers", these figures indicate 311 accidents with 65 deaths in femoral BCIS for 2018. DISCUSSION: In scheduled surgery, BCIS was exceptional, but the rate in traumatology was much higher. Certain techniques intended to improve femoral cementing quality actually increased the risk of BCIS; in high-risk patients, especially in traumatology, non-cemented femoral implants or else a 1st-generation cementing technique should therefore be preferred. Prevention of BCIS and/or reduction of severity require identification of at-risk patients and good communication between surgeons and anesthesiologists, especially at the various steps of the checklist. LEVEL OF EVIDENCE: IV; case series.

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.

Intra- and extra-articular planes of reference for use in total hip arthroplasty: a preliminary study.

PURPOSE: Acetabular component malalignment in total hip arthroplasty can lead to potential complications such as dislocation, component impingement and excessive wear. Computer-assisted orthopaedic surgery systems generally use the anterior pelvic plane (APP). Our aim was to investigate the reliability of anatomical landmarks accessible during surgery and to define new potential planes of reference. METHODS: Three types of palpations were performed: virtual, on dry bones and on two cadaveric specimens. Four landmarks were selected, the reproducibility of their positioning ranging from 0.9 to 2.3 mm. We then defined five planes and tested them during palpations on two cadaveric specimens. RESULTS: Two planes produced a mean orientation error of 5.0° [standard deviation (SD 3.3°)] and 5.6° (SD 2.7°). CONCLUSIONS: Even if further studies are needed to test the reliability of such planes on a larger scale in vivo during surgery, these results demonstrated the feasibility of defining a new plane of reference as an alternative to the APP.

Modified Exeter technique in revision hip surgery: does distal fixation of the stem affect allograft transformation?

Promising results have made the Exeter technique a valuable alternative in hip replacement revision. However, even with this technique, subsidence remains a difficult problem because it may lead to additional revision if it is not mild and self-limited. We propose a technical modification that achieves primary stability by cementing the distal portion of the stem directly to the host bone. We conducted a prospective study on 45 hips. After an average of 46 (range, 18-72) months of follow-up monitoring, no hips required or underwent revision for aseptic loosening of the prosthesis. Four stems subsided <5 mm. In each case, distal cementation was only fair, so implant strength was decreased. Allograft transformation occurred in 36 hips and was associated with host bone remodeling in 11. This technical modification appears to be reliable, as satisfactory distal cementation was achieved in 41 hips (91%), and the modification did not interfere with allograft transformation.