Assessment of Medical and Social Risk Factors Before Arthroplasty in Argentina: A Poll of Argentinian Hip and Knee Association (ACARO) Members.

BACKGROUND: Assessment of risk factors is crucial for lowering complication rates and costs of hip and knee arthroplasty. The objective of this study was to assess if members of the Argentinian Hip and Knee Association (ACARO) are influenced by such risk factors when planning surgery. METHODS: In 2022, a survey was distributed as an electronically based questionnaire to 370 members of the ACARO. A descriptive analysis was performed on 166 proper answers (44.9%). RESULTS: There were 68% of the respondents who were specialists in joint arthroplasty and 32% practiced general orthopedics. A large number had large volumes at private hospitals without service/residents and 48.2% had been in practice for more than 15 years. Of the responding surgeons, 99% routinely performed a preoperative reversible risk factors evaluation that considered diabetes, malnutrition, weight, and smoking, and 95% canceled/postponed the surgery for abnormalities. Malnutrition was important for 79% of the polled with blood albumin being used by 69.3%. Fall risk assessment was performed by 60.2% of the surgeons. Only 44% of the surgeons felt free to choose the implant for the arthroplasty, possibly because 69.9% work for a capitated system. Important delays for surgery were reported by 63.9 and 84.3% had waiting lists. 74.7% of the polled noted physical or psychological deterioration during such delays. CONCLUSION: Socioeconomic factors firmly impact on the accessibility to arthroplasty in Argentina. Despite these barriers, the qualitative analysis of this poll let us demonstrate greater awareness of preoperative risk factors, especially diabetes as the most reported comorbidity.

Do nonagenarians have more complications and unplanned readmissions than octogenarians following primary THA? A retrospective cohort study.

INTRODUCTION: The performance of total hip arthroplasty in elderly patients, especially nonagenarians, is challenging due to higher patient frailty and medical comorbidities. We compared 90-day postoperative complications and unplanned readmissions between nonagenarians and octogenarians undergoing elective THA. METHODS: One hundred and eleven patients undergoing elective, unilateral THA were retrospectively analyzed. Forty-four patients were nonagenarians (Group A), and 67 patients were octogenarians (Group B). Demographic data included age, gender, body mass index (BMI), ASA score and Charlson Comorbidity Index (CCI). Frailty was defined according to the Rockwood Frailty Index. All patients underwent a thorough preoperative assessment through a specific institutional clinical pathway created for this matter. Postoperative adverse events were grouped into major or minor. A regression model was used to evaluate independent risk factors for the development of complications. RESULTS: There were no differences in the ASA score (65.9% vs. 53.7% ASA III-IV), prevalence of frailty (1% vs. 9%) and comorbidities between both groups (p > .05). The CCI was higher in nonagenarians (p = 0.007). Nonagenarians had more in-hospital complications, although most were minor (p = 0.002), none of which resulted in mortality. Ninety-day unplanned readmissions were similar between groups, with 4 (9.1%) and 6 (9%) in groups A and B, respectively (p = 1). Although age was a factor associated with the development of postoperative complications in the univariate regression model (OR 3.81, 95% CI 1.31 to 11.11, p = 0.014), it lost significance after performing the multivariate analysis (OR 2.48, 95% CI 0.78 to 7.90, p = 0.125). CONCLUSION: The age of 90 years old was not a barrier to perform elective THA safely. Nonagenarians had higher in-hospital minor complications when compared to the younger cohort. However, age over 90 years was not an independent risk factor for unplanned readmissions or mortality. Multimodal protocols of perioperative care are paramount for improving outcomes after THA in very old patients.

Feasibility of total hip arthroplasty in cerebral palsy patients: a systematic review on clinical outcomes and complications.

PURPOSE: Total hip arthroplasty (THA) is a successful treatment for hip osteoarthritis secondary to hip dysplasia. However, the reported rate of complications following THA in the settings of neuromuscular diseases is high. This systematic review aimed to analyze the indications, functional outcomes and surgical failures of primary THA in cerebral palsy (CP) patients. METHODS: MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews were searched, and all clinical studies focusing on THA in patients with CP from inception through March 2020 were included. The methodological quality was assessed with Guo et al.'s quality appraisal checklist for case series and case-control studies, while cohort and prospective studies were evaluated with a modified version of the Downs and Black's quality assessment checklist. RESULTS: The initial search returned 69 studies out of which 15, including 2732 THAs, met the inclusion criteria. The most frequent indication for THA was dislocated painful hip for which previous non-operative treatment had failed. Complications presented in 10 to 45% of cases. The most frequently reported complication was dislocation (1-20%), followed by component loosening (0.74-20%). Aseptic component loosening was the most frequent cause of revision surgery, followed by dislocation and periprosthetic fracture. Mean implant survival at ten years was 84% (range 81-86%). CONCLUSION: The available literature suggests that although THA is a beneficial procedure in CP patients, it has a higher rate of complications and worse implant survival than the general population.

Preliminary outcomes of the cementless UNITED hip system for primary total hip arthroplasty at a minimum 2-year follow-up.

INTRODUCTION: This study aimed to report the initial results of the cementless UNITED hip system in primary total hip arthroplasty (THA) with a minimum follow-up of 2 years. METHODS: We retrospectively studied a consecutive series of 203 cementless THAs in 180 patients operated between 2015-2017. We included 89 female and 91 male patients with a mean age of 67 (28 to 89) years. The mean follow-up was 40 (29 to 62) months. Clinical outcome scores and radiographs were measured. Survival was calculated defining failure as the need for any further femoral or acetabular revision, irrespective of the reason. RESULTS: No femoral component loosening was detected. One patient had a Vancouver-B1 intraoperative periprosthetic femoral fracture treated with implant retention and cerclage wires. Two acetabular components were revised for aseptic loosening. Three patients suffered an acute infection treated with debridement, antibiotics, and implant retention. The mean Merle d'Aubigné et Postel scores improved from 13 (4 to 16) points preoperatively to 17 (12 to 18) points at the latest follow-up (p < 0.001). At a mean time of 40 months of follow-up, the survival was 99% and 100% for the acetabular and the femoral components, respectively. CONCLUSION: This cementless design showed excellent preliminary outcomes in terms of fixation and patient satisfaction, comparable to that of other well-known similar systems.

A Repeat Dose of Perioperative Dexamethasone Can Effectively Reduce Pain, Opioid Requirement, Time to Ambulation, and In-Hospital Stay After Total Hip Arthroplasty: A Prospective Randomized Controlled Trial.

BACKGROUND: The ideal dose of intravenous glucocorticoids to control pain in total hip arthroplasty (THA) remains unclear. This randomized controlled trial compared postoperative pain and tramadol requirement in patients undergoing unilateral primary THA who received one versus two perioperative doses of dexamethasone. METHODS: Patients consented to undergo blinded, simple randomization to either one (at anesthetic induction [1D-group]: 54 patients) or two (with an additional dose 8 hours after surgery [2D-group]: 61 patients) perioperative doses of 8-mg intravenous dexamethasone. Pain was evaluated with visual analog scale at 8, 16, and 24 hours postoperatively and with tramadol requirement. The secondary outcomes included postoperative nausea and vomiting, time to ambulation, and length of stay. RESULTS: Age (mean, 66 ± 13 years), body mass index (mean, 29 ± 5), gender (60% female), and history of diabetes were similar between groups (P >.05). Pain was higher at 16 (4 [interquartile range {IQR} 3-5] vs 2 [IQR 1-3]; P <.001) and 24 (2.5 [IQR 2-3] vs 1 [IQR 0-1] P <.001) hours postoperatively in the 1D-group patients. 1D-group patients had significantly more tramadol consumption (50 [IQR 50-100] vs 0 [IQR 0-50]; P = .01), as well as postoperative nausea and vomiting (18 [33.3%] vs 5 [8.2%]; P = .001). Fifty-five (90%) patients in the 2D-group and 32 (59%) in the 1D-group ambulated on postoperative day 0 (P = .0002). Fifty-eight (95%) patients in the 2D-group and 37 (68%) in the 1D-group were discharged on postoperative day 1 (P = .0002). CONCLUSION: An additional dose of dexamethasone at 8 hours postoperatively significantly reduced pain, tramadol consumption, time to ambulation, and length of stay after primary THA.

Unaddressed arterial injuries in revision total hip arthroplasty: mortality outcomes of a low-prevalence complication.

PURPOSE: Peri-operative major arterial haemorrhage after revision total hip arthroplasty (RTHA) is an odd but limb- and life-threatening complication. In this retrospective analysis, we sought to determine the prevalence of such injuries requiring selective catheter embolization or bypass after RTHA and to evaluate the associated mortality rate. METHODS: Between 1995 and 2016, 2524 RTHAs were performed at a high-volume centre (1031 one-stage revisions, 1370 two-stage revisions and 123 resection arthroplasties). Throughout this period, nine patients presented with signs of persistent bleeding unaddressed during index surgery (9/2524; 0.35%), causing haemodynamic instability. All patients underwent angiographic exploration within the first 24 post-operative hours. Angiography evidenced four cases of bleeding pseudoaneurysms (three of them related to the common femoral artery and one to the medial circumflex femoral artery) and five cases of direct lacerations (one case in the inferior epigastric artery, one in the hypogastric artery, one in the external iliac artery, one in the popliteal artery and another in the superior gluteal artery). RESULTS: Six cases underwent selective percutaneous angiographic embolization with gelatin microspheres, obtaining immediate haemodynamic stabilization; whereas three cases required a further bypass surgery with synthetic graft. Of the former group, four patients had an uneventful evolution, while two died at a mean of 49 days after surgery due to multi-organ failure (MOF). Two cases of the bypass group died because of MOF at a mean of 22 days. Overall mortality rate was 44%. CONCLUSIONS: The overall risk of arterial injury associated with RTHA was low. However, recognition of such a complication is imperative since it was associated with a high mortality rate.

Prolonged social lockdown during COVID-19 pandemic and hip fracture epidemiology.

PURPOSE: To analyse the impact of prolonged mandatory lockdown due to COVID-19 on hip fracture epidemiology. METHODS: Retrospective case-control study of 160 hip fractures operated upon between December 2019 and May 2020. Based on the date of declaration of national lockdown, the cohort was separated into two groups: 'pre-COVID time' (PCT), including 86 patients, and 'COVID time' (CT), consisting of 74 patients. All CT patients tested negative for SARS-CoV-2. Patients were stratified based on demographic characteristics. Outcome measures were 30-day complications, readmissions and mortality. A logistic regression model was run to evaluate factors associated with mortality. RESULTS: Age, female/male ratio, body mass index and American Society of Anaesthesia score were similar between both groups (p > 0.05). CT patients had a higher percentage of Charlson ≥ 5 and Rockwood Frailty Index ≥ 5 scores (p < 0.05) as well as lower UCLA and Instrumental Activities of Daily Living scores (p < 0.05). This translated into a higher hemiarthroplasty/total hip arthroplasty ratio during CT (p = 0.04). Thromboembolic disease was higher during CT (p = 0.02). Readmissions (all negative for SARS-CoV-2) were similar between both groups (p = 0.34). Eight (10.8%) casualties were detected in the CT group, whereas no deaths were seen in the control group. Logistic regression showed that frailer (p = 0.006, OR 10.46, 95%CI 8.95-16.1), less active (p = 0.018, OR 2.45, 95%CI 1.45-2.72) and those with a thromboembolic event (p = 0.005, OR 30, 95%CI 11-42) had a higher risk of mortality. CONCLUSION: Despite testing negative for SARS-CoV-2, CT patients were less active and frailer than PCT patients, depicting an epidemiological shift that was associated with higher mortality rate.

Impaction Bone Grafting or Uncemented Modular Stems for the Treatment of Type B3 Periprosthetic Femoral Fractures? A Complication Rate Analysis.

BACKGROUND: Because the gold standard for the treatment of Vancouver type-B3 periprosthetic femoral fractures (PFFs) is yet to be defined, we sought to analyze the complication rate between the impaction bone grafting (IBG) technique with a cemented stem and reconstruction with an uncemented distally-fixed modular stem (DFMS). METHODS: We retrospectively studied 54 B3 PFFs operated between 2000 and 2016, comparing the complication rate of 33 patients treated with the IBG technique (group A) with 21 patients treated with a DFMS (group B). Median follow-up of groups A and B were 75 months (interquartile range [IQR], 36-111 months) and 55 months (IQR, 32-73 months), respectively (P = .008). Median age of groups A and B were 78 years (IQR, 74-83 years) and 81 years (IQR, 74-86 years), respectively (P = .30). Median grade of Endo-Klink femoral bone defect was 3 (IQR, 3-3) for both groups (P = .11). We performed a multiple regression analysis to determine risk factors for complications including the following variables: age, initial diagnosis, and surgical technique. RESULTS: As for infection outcomes, 2-stage revision surgery was more frequent in group A than in group B (4 vs 0, P = .003). Group A presented more implant failures than group B (5 vs 1, P = .195). We found 4 dislocations in group B and 2 in group A (P = .192). Multiple regression analysis showed a significant association between surgical technique and complication rate (P = .01). The IBG technique presented an odds risk for complications of 4.77 (P = .016; IQR, 1.33-17.21). CONCLUSION: Femoral reconstruction with the IBG technique evidenced an ostensibly higher complication rate than that of DFMS for the treatment of B3 PFF.

Aggressive granulomatosis of the hip: a forgotten mode of aseptic failure.

PURPOSE: It has been acknowledged that implant wear correlates with the risk for periprosthetic osteolysis, being aggressive granulomatosis the worst expression of bone resorption. We sought to determine the clinical, radiological, and histological features of aggressive granulomatosis after primary total hip arthroplasty (THA). METHODS: We included nine cases with aggressive granulomatosis of the hip around cemented stems. Indications for revision THA consisted of progressive signs of extensive bone resorption or implant loosening. Mean follow-up since revision THA was 143 months (SD ± 59.4). We analysed clinical outcomes, component loosening and gross as well as histological characteristics of the granulomatous lesions. RESULTS: Overall mean time between primary THA and revision surgery was 81 months (SD ± 20.8). All of the cases evidenced multiple ovoid tumour-like lesions around the stem with extensive bone loss. Only one case reported thigh pain before revision surgery, with radiological evidence of stem loosening; the remaining cases were asymptomatic with well-fixed implants. Gross anatomy findings revealed metallosis in the femoral canal and inside the cystic lesions. Pathology analysis showed monocyte-macrophage-dominated adverse foreign-body-type tissue reaction with fibroblastic reactive zones and granulomatous inflammation. CONCLUSIONS: We found a prevalence of 1% of this aseptic mode of implant failure. Since most of the retrieved stems were not loose, we did not find any alarming clinical symptoms anticipating implant failure. In this scenario, surgeons should be aware of the rapidly progressive nature of this entity and propose a revision THA in a timely fashion.

Re-admissions treble the risk of late mortality after primary total hip arthroplasty.

BACKGROUND: Following a total hip arthroplasty (THA), early hospital re-admission rates of 3-11% are considered as 'acceptable' in terms of medical care cost policies. Surprisingly, the impact of re-admissions on mortality has not been priorly portrayed. Therefore, we sought to determine the mortality rate after 90-day re-admissions following a THA in a series of patients from a captive medical care program. PATIENTS AND METHODS: We prospectively analysed 90-day readmissions of 815 unilateral, elective THA patients operated upon between 2010 and 2014 whose medical care was the one offered by our institution. We stratified our sample into readmitted and non-readmitted cohorts. Through a Cox proportional hazards model, we compared demographic characteristics, clinical comorbidities, surgical outcomes and laboratory values between both groups in order to determine association with early and late mortality. RESULTS: We found 37 (4.53%) re-admissions at a median time of 40.44 days (IQR 17.46-60.69). Factors associated with re-admission were hospital stay (p = 0.00); surgical time (p = 0.01); chronic renal insufficiency (p = 0.03); ASA class 4 (p = 0.00); morbid obesity (p = 0.006); diabetes (p = 0.04) and a high Charlson index (p = 0.00). Overall mortality rate of the series was 3.31% (27/815). Median time to mortality was 455.5 days (IQR 297.58-1170.65). One-third (11/37) of the re-admitted patients died, being sepsis non-related to the THA the most common cause of death. After adjusting for confounders, 90-day re-admissions remained associated with mortality with an adjusted HR of 3.14 (CI95% 1.05-9.36, p = 0.04). CONCLUSIONS: Unplanned re-admissions were an independent risk factor for future mortality, increasing three times the risk of mortality.

Primary Total Hip Arthroplasty With Fourth-Generation Ceramic-on-Ceramic: Analysis of Complications in 939 Consecutive Cases Followed for 2-10 Years.

BACKGROUND: Delta ceramics may be the bearing of choice for younger and active patients due to its improved toughness and wear characteristics, provided there is no risk of fracture. However, ceramic fracture is the most serious complication related to this type of bearing. Although millions of Delta ceramics have been implanted worldwide, short to midterm results have been scarcely reported in the literature. The purpose of this study was to report the complication rate at short to midterm follow-up associated with the bearing surface used in a series of primary total hip arthroplasties with Delta ceramic-on-ceramic bearings performed in a single institution. METHODS: A total of 939 cases (880 patients) undergoing primary total hip arthroplasty with fourth-generation Delta ceramic-on-ceramic bearings were retrospectively reviewed. They were followed for an average of 5.3 years (2-10 years). RESULTS: One hip experienced a liner fracture, 2 cups presented early loosening due to friction between the acetabular screw and the backside of the liner, one femoral ball head had a fracture; one case of squeaking was reported, which is impending revision. Considering revision or impending revision in relationship with the bearing surface as the end point, the mean survival rate was 99.3% (confidence interval 95%, 98.3%-99.7%) at 2-10 years. CONCLUSION: This study showed a low rate of ceramic fracture compared with others; however, it was much higher than the complication rate presented by the manufacturers. The complications observed were directly related to technical errors that surgeons should avoid when using this type of surface.

Intraoperative synovial C-reactive protein is as useful as frozen section to detect periprosthetic hip infection.

BACKGROUND: Synovial quantification of C-reactive protein (SCRP) has been recently published with high sensitivity and specificity in the diagnosis of periprosthetic joint infection. However, to our knowledge, no studies have compared the use of this test with intraoperative frozen section, which is considered by many to be the best intraoperative test now available. QUESTIONS/PURPOSES: We asked whether intraoperative SCRP could lead to comparable sensitivity, specificity, and predictive values as intraoperative frozen section in revision total hip arthroplasty. METHODS: A prospective study was performed including 76 patients who underwent hip revision for any cause. SCRP quantification (using 9.5 mg/L as denoting infection) and the analysis of frozen section of intraoperative samples (five or more polymorphonuclear leukocytes under high magnification in 10 fields) were performed in all the patients. The definitive diagnosis of an infection was determined according to the Musculoskeletal Infection Society (MSIS). In this group, 30% of the patients were diagnosed with infection using the MSIS criteria (23 of 76 patients). RESULTS: With the numbers available, there were no differences between SCRP and frozen section in terms of their ability to diagnose infection. The sensitivity of SCRP was 90% (95% confidence interval [CI], 70.8%-98.6%), the specificity was 94% (95% CI, 84.5%-98.7%), the positive predictive value was 87% (95% CI, 66.3%-97%), and the negative predictive value was 96% (95% CI, 87%-99.4%); the sensitivity, specificity, positive predictive value, and negative predictive value were the same using frozen sections to diagnose infection. The positive likelihood ratio was 16.36 (95% CI, 5.4-49.5), indicating a low probability of an individual without the condition having a positive test, and the negative likelihood ratio was 0.10 (95% CI, 0.03-0.36), indicating low probability of an individual without the condition having a negative test. CONCLUSIONS: We found that quantitative SCRP had similar diagnostic value as intraoperative frozen section with comparable sensitivity, specificity, and predictive value in a group of patients undergoing revision total hip arthroplasty. In our institution, SCRP is easier to obtain, less expensive, and less dependent on the technique of obtaining and interpreting a frozen section. If our findings are confirmed by other groups, we suggest that quantitative SCRP be considered as a viable alternative to frozen section. LEVEL OF EVIDENCE: Level I, diagnostic study.

Medium-term outcomes of conventional versus short uncemented femoral stems for primary total hip arthroplasty in patients younger than 55 years.

BACKGROUND: Short stems are designed with a bone preservation philosophy in mind. This study aims to compare the outcomes/complications and survival of a collarless fully hydroxyapatite (HA)-coated conventional tapered stem and a HA-coated partial neck-retaining uncemented short stem in patients ⩽55 years old at medium-term follow-up. METHODS: We retrospectively studied 247 uncemented THAs operated between 2010 and 2014, comparing 146 patients treated with the fully HA-coated collarless stem (Group A) with 101 patients treated with a partial neck preserving, HA-coated short stem (Group B). 87 and 62 males were in groups A and B, respectively (p = 0.11). The mean age of the series was 46 years (17-55) (p =0.16). The mean follow-up of groups A and B were 9.9 (7-12) years and 9.7 (7-12) years, respectively (p =0.21). RESULTS: Mean Harris Hip Score improved from 55 to 92 in group A (p <0.001) and from 54 to 95 in group B (p <0.001), without differences between groups. Mean femoral neck length preservation in groups A and B was 13.6 (0-28) mm and 26 (11-38) mm, respectively (p =0.001). 13 (8.9%) and 1 (1%) patients in groups A and B presented postoperative complications, respectively (p =0.008). The conventional stem group had more aseptic loosening (Group A 3.4% vs. Group B 0%, p =0.06) along with more Symptomatic radiolucent lines (Group A 3.4% vs. Group B 0%, p =0.06). CONCLUSIONS: Both conventional and short stems showed excellent implant survival rates and functional outcomes at a mean follow-up of 9.8 years. However, complications and radiolucent lines were more frequent with a collarless conventional-length stem. Bone preservation of the femoral neck and diaphysis may be preferred in active young patients.

Late Periprosthetic Femoral Stress Fracture Associated with Extra-articular Deformity in a Patient with Fibrous Dysplasia: A Case Report.

CASE: In the setting of a total hip arthroplasty performed in a patient with a proximal femoral deformity, atraumatic periprosthetic femoral stress fracture may arise as a complication. We report a rare case of a late periprosthetic femoral stress fracture around a cemented stem in a patient with a history of fibrous dysplasia of the proximal femur. After a 10-year uneventful period, the patient complained about a subtle, subacute pain in his left thigh induced by exercise but not with daily axial load. Diagnosis of a nondisplaced, incomplete (i.e., only compromising the lateral femoral cortex) periprosthetic femoral stress fracture was made with plain radiographs, blood work, and bone scintigraphy. Surgical treatment consisted of a minimally invasive plate osteosynthesis bridging the femoral deformity plus percutaneous osteoperiosteal decortication. At 5-year follow-up, the patient was asymptomatic with full return to physical activity, with radiographs evidencing callus formation. CONCLUSION: Stress fractures around well-fixed femoral stems, while infrequent, should be addressed in patients with a history of severe proximal femur deformity experiencing atraumatic thigh pain.

Anterior Center-Edge Angle Is Less Reliable Than Anterior Wall Index to Predict Anterior Coverage of the Femoral Head.

BACKGROUND: No consensus is available regarding which radiographic measurement most accurately correlates with anterior coverage of the femoral head. PURPOSE: (1) To determine the correlation between 2 measurements of anterior wall coverage: total anterior coverage (TAC) calculated from radiographs and equatorial anterior acetabular sector angle (eAASA) calculated from computed tomography (CT) scans; (2) to define the correlation between anterior center-edge angle (ACEA) and anterior wall index (AWI) with TAC and eAASA; and (3) to investigate what other radiographic metrics may help predict anterior coverage. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: The authors retrospectively reviewed 77 hips (48 patients) for which radiographs and CT scans were obtained for reasons other than hip-related pain. Mean age of the population was 62 ± 22 years; 48 (62%) hips were from female patients. Two observers measured lateral center-edge angle (LCEA), AWI, Tönnis angle, ACEA, CT-based pelvic tilt, and CT-based acetabular version, with all Bland-Altman plots within 95% agreement. Correlation between intermethod measurements was estimated with a Pearson coefficient. Linear regression was used to test the ability of baseline radiographic measurements to predict both TAC and eAASA. RESULTS: Pearson coefficients were r = 0.164 (ACEA vs TAC; P = .155), r = 0.170 (ACEA vs eAASA; P = .140), r = 0.58 (AWI vs TAC; P = .0001), and r = 0.693 (AWI vs eAASA; P < .0001). Multiple linear regression model 1 showed that AWI (ß = 17.8; 95% CI, 5.7 to 29.9; P = .004), CT acetabular version (ß = -0.45; 95% CI, -0.71 to -0.22; P = .001), and LCEA (ß = 0.33; 95% CI, 0.19 to 0.47; P = .001) were useful to predict TAC. Multiple linear regression model 2 revealed that AWI (ß = 25; 95% CI, 15.67 to 34.4; P = .001), CT acetabular version (ß = -0.48; 95% CI, -0.67 to -0.29; P = .001), CT pelvic tilt (ß = 0.26; 95% CI, 0.12 to 0.4; P = .001), and LCEA (ß = 0.21; 95% CI, 0.1 to 0.3; P = .001) accurately predicted eAASA. Model-based estimates and 95% CIs using 2000 bootstrap samples from the original data were 6.16 to 28.6 for AWI in model 1 and 15.1 to 34.26 for AWI in model 2. CONCLUSION: There was a moderate to strong correlation between AWI and both TAC and eAASA, whereas ACEA correlated weakly with the former measurements, thus not being useful to quantify anterior acetabular coverage. Other variables such as LCEA, acetabular version, and pelvic tilt may also help predict anterior coverage in asymptomatic hips.

Successful hip revision surgery following refracture of a modern femoral stem using a cortical window osteotomy technique: A case report and review of literature.

BACKGROUND: The ExeterTM Universal cemented femoral component is widely used for total hip replacement surgery. Although there have been few reports of femoral component fracture, removal of a broken femoral stem can be a challenging procedure. CASE SUMMARY: A 54-year-old man with a Dorr A femur sustained a refracture of a primary ExeterTM stem, two years after receiving a revision using a cement-within-cement technique (CWC) through an extended trochanteric osteotomy (ETO). The technical problems related to the CWC technique and the ETO played a major role in the stem fatigue refracture. We performed revision surgery and removed the distal cement using a cortical femoral window technique, followed by re-implantation with an uncemented, modular, distally-fixed uncemented stem. The patient experienced an uneventful postoperative recovery. CONCLUSION: Re-fracture of a modern femoral ExeterTM stem is a rare event, but technical complications related to revision surgery can lead to this outcome. The cortical window osteotomy technique can facilitate the removal of a broken stem and cement, allowing for prosthetic re-implantation under direct vision and avoiding ETO-related complications.

High failure rate with the GAP II ring and impacted allograft bone in severe acetabular defects.

BACKGROUND: Reconstruction rings and bone allografts have been proposed to manage severe acetabular bone loss. However, a high early failure rate of the Graft Augmentation Prosthesis (GAP) II reinforcement ring (Stryker Orthopaedics, Mahwah, NJ, USA) has been reported in one small series. QUESTIONS/PURPOSES: We therefore determined (1) the survival of this device in combination with impacted morselized allograft bone in patients with severe defects and (2) the complication rate. METHODS: We retrospectively reviewed 24 patients (21 aseptic and three septic) with severe acetabular bone loss (10 hips with Type III defects and 14 with Type IV defects according to the American Academy of Orthopaedic Surgeons classification). We determined function and numbers of failures. The minimum followup was 24 months (mean, 34 months; range, 24-72 months). RESULTS: At latest followup, the reconstruction had failed in nine of the 24 patients: six with aseptic loosening, three with infection. The average postoperative Merle d'Aubigné-Postel score of the patients whose reconstructions had not failed was 16.6 points; at latest followup, these patients had radiographic evidence of incorporation and consolidation of bone allografts. Seven of the nine patients whose reconstructions had failed underwent reoperation. Fatigue fracture of the ring at the plate-cup union occurred in five patients at an average of 45 months postoperatively. All patients with failed reconstructions who underwent reoperation were treated with Trabecular Metal(™) (Zimmer Inc, Warsaw, IN, USA) cups and were functioning well at latest followup. CONCLUSIONS: We observed a high rate (37%) of early catastrophic failures of the GAP II reconstruction ring, particularly in patients with Type IV defects. Due to this high failure rate, we have abandoned its use. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Squeaking in a Delta ceramic-on-ceramic uncemented total hip arthroplasty.

Squeaking is one of the main concerns related to the use of ceramic-on-ceramic total hip arthroplasty. Although it has received much recent publicity, most of the previous reports on this complication have been related to the use of the second generation of alumina ceramics combined with a cup having an elevated metal rim to protect the ceramic liner from neck impingement. We report a patient with a third-generation Biolox Delta (CeramTec AG, Plochingen, Germany) ceramic-on-ceramic uncemented total hip arthroplasty without an elevated metal rim in the cup who presented with a squeaking hip at 23 months postoperative. Although this complication was mainly related to a specific design in the literature, this case demonstrates that newer generation of ceramics can also present squeaking.

Impaction Bone Grafting for Severe Femoral Bone Loss: Surgical Technique in Revision Total Hip Arthroplasty.

Revision total hip arthroplasty in the setting of extensive femoral bone loss poses a considerable challenge to the adult reconstructive surgeon. When the proximal femoral bone stock is deficient or absent, there are few options for reconstruction. In such cases, treatment options include distal cementless fixation (either modular or nonmodular), impaction bone grafting (IBG), a megaprosthesis, or even an allograft-prosthesis composite. Each of these procedures has advantages and disadvantages related to bone preservation, surgical timing, and complexity (depending on the learning curve). For its capacity of restoring bone stock, we have been utilizing the IBG technique at our center since August 1987. The aim of the present article was to describe a step-by-step femoral IBG procedure for severe proximal femoral circumferential bone loss, highlighting its current indications and contraindications. Description: The specific steps to perform this procedure include (1) preoperative planning; (2) positioning of the patient and surgical approach; (3) cautious removal of the previous components; (4) preparation of the bone graft; (5) implantation of the appropriate IBG revision system, restoring bone loss from distal to proximal and utilizing metal mesh as needed; (6) implantation of the new stem, bypassing the defect; and (7) aftercare with protected weight-bearing in order to avoid subsidence of the stem and periprosthetic fracture. Alternatives: There are several alternatives to the IBG technique in the setting of revision total hip arthroplasty with extensive femoral bone loss. These alternatives include distal cementless fixation (either modular or nonmodular), a megaprosthesis, or an allograft-prosthesis composite. Rationale: The rationale for use of the IBG technique is restoration of bone stock. Although this issue may be irrelevant in low-demand elderly patients, we believe it is of the utmost importance among young (i.e., <60 years old) and active patients. This technique is versatile enough to be utilized in different scenarios such as periprosthetic fracture, periprosthetic joint infection (2-stage protocols), and aseptic loosening. Expected Outcomes: We have reported favorable clinical and radiographic outcomes for the treatment of both aseptic and septic femoral component loosening. In all cases, we utilized vancomycin-supplemented impacted cancellous allograft without evidence of secondary effects with regard to bone incorporation, nephrotoxicity, or allergic reactions. Although it was initially contraindicated, we further extended the indication for this reconstruction alternative to cases of circumferential proximal bone loss with non-neoplastic bone defects of ≤15 cm, utilizing encompassing metal mesh and a bypassing long stem. Recently, we reported on poorer outcomes following IBG compared with the use of uncemented modular stems for the treatment of type B3 periprosthetic femoral fractures, with a significantly higher rate of infection and implant breakage for the former treatment. Nowadays, we advocate the use of this technique in young, active patients (i.e., <60 years old) with a femoral bone defect Paprosky grade IIIB or IV, in which reconstitution of bone stock is crucial to avoid an eventual implant failure in the long term. Important Tips: This technique requires an experienced team. This procedure should be avoided in the presence of active periprosthetic joint infection.The gluteus maximus tendon should be detached to avoid tensioning the sciatic nerve and to decrease the chance of periprosthetic femoral fracture.Massive bone loss can jeopardize correct implant orientation and restoration of biomechanics. In this scenario, surgeons might consider the intercondylar axis as a guide for femoral version.Try to avoid (if possible) trochanteric or extended trochanteric osteotomy because proximal bone stock is necessary to contain the bone grafts. In some cases, such as those in which the removal of the stem is difficult, especially with certain uncemented stem designs, an extended trochanteric osteotomy must be performed. Whether or not a cemented stem is removed, it is mandatory to remove all remaining cement in the femoral canal.Preoperative templating is a necessity to reconstruct leg length. Accurately determining the length of the mesh is the most important step to avoid shortening or overlengthening of the lower extremity.Approximately 10 cm of circumferential metal mesh should be fixed with 3 to 5 double cerclage metal wires to the remaining bone. The new femoral stem should bypass extend beyond the mesh for approximately 5 cm. If the stem does not bypass the mesh, there is an increased risk of postoperative fracture.In order to decrease the risk of intraoperative femoral fracture, the distal aspect of the femur should be secured with cerclage wires, and the proximal aspect of the femur should also be protected with cerclage wires over the mesh. As in any other complex femoral revision procedure, torsional forces in the supracondylar zone should be avoided, especially during trial or stem reduction maneuvers.Always utilize a bone graft mixed with antibiotic powder.Retrograde cementation must be done with cement that is in a more liquid state than in primary total hip arthroplasty. Acronyms & Abbreviations: PO = postoperativePMMA = polymethyl methacrylateIV = intravenousLMWH = low molecular weight heparinDVT/EP = deep vein thrombosis and extended prophylaxis.

Adverse Local Tissue Reaction Associated With Ceramic-On-Metal Bearing Surface in Primary Total Hip Arthroplasty: Report of Two Cases.

Total hip arthroplasty (THA) is one of the most common and successful surgical procedures worldwide. At the same time, it is constantly evolving, and as a consequence, advances in implant technology have led to significant improvements in the different materials of the acetabular and femoral components. The selection of bearing surfaces and their tribology are critical to achieving a successful outcome. Pseudotumors are important, and usually misdiagnosed, complications associated with hard bearing surfaces such as metal-on-metal couples. They belong to a group of reactions called adverse local tissue reaction, which can occur in the vicinity of any THA. We present 2 cases of adverse local tissue reaction associated with the use of ceramic-on-metal bearings surfaces in 2 primary THAs that were treated with modular component exchange during single-stage revision surgery. Level of Evidence: IV.