Comprehensive Guidance for the Prevention of Periprosthetic Joint Infection After Total Joint Arthroplasty and Pitfalls in the Prevention.

Total joint arthroplasty (TJA) is a surgical procedure, in which parts of damaged joints are removed and replaced with a prosthesis. The main indication of TJA is osteoarthritis, and the volume of TJA is rising annually along with the increase of aged population. Hip and knee are the most common joints, in which TJAs are performed. The TJA prosthesis is composed of metal, plastic, or ceramic device. Even though TJA is the most successful treatment for end-stage osteoarthritis, it is associated with various complications, and periprosthetic joint infection (PJI) is the most serious complication after TJA. With the increasing volume of TJAs, there is a simultaneous rise in the incidence of PJI. Contamination of the surgical wound and the adherence of bacteria to the surface of prosthetic component represent the initial step in the pathogenesis of PJI. The main sources of the contamination are 1) patient's own flora, 2) droplets in the operation room air, and 3) surgical gloves and instruments. Even though modern techniques have markedly reduced the degree of contamination, TJAs cannot be done in completely germ-free conditions and some degree of contamination is inevitable in all surgical procedures. However, not all contamination leads to PJI. It develops when the burden of contamination exceeds the immune threshold or the colony forming units (CFUs) and various factors contribute to a decrease in the CFU level. Surgeons should be aware of the germ burden/CFU concept and should monitor sources of contamination to maintain the germ burden below the CFU to prevent PJI.

Comparison between osteonecrosis of the humeral and femoral heads - epidemiological analysis of the surgical trend using the nationwide claims database of the republic of Korea.

BACKGROUNDS: The humeral head is the second most common site of osteonecrosis, after the femoral head. However, compared to osteonecrosis of the femoral head (ONFH), epidemiological information on osteonecrosis of the humeral head (ONHH) is scarce. We hypothesised that different biomechanical properties of the shoulder from the hip joint might present different epidemiological characteristics of ONHH from those of the ONFH. To evaluate epidemiological differences, we compared trends in the surgical treatment of ONHH and ONFH using the nationwide medical claims database of the Republic of Korea (ROK). METHODS: We analysed epidemiological data from the Health Insurance Review and Assessment (HIRA) database of the ROK between 2008 and 2018. HIRA database contains almost all medical information in an anonymised form, including demographics, diagnoses, and types of surgical procedures, generated through healthcare practices in ROK. The annual incidence rates of ONHH and ONFH were calculated based on the total number of the general population. Demographics, annual incidence, and the proportion of post-traumatic osteonecrosis and surgical procedures were compared according to the anatomical site and the affected year. RESULTS: The total number of patients treated for ONHH and ONFH during the study period was 1,028 and 66,260, respectively. Although the incidence of ONHH increased, it is a relatively rare disease compared to ONFH. ONHH occurred more frequently in females, while ONFH occurred predominantly in male patients (p < 0.001). Surgical treatment for ONHH was most frequently performed in older patients (63.7%), whereas middle-aged patients had the largest proportion of ONFH (48.9%, p < 0.001). The proportion of post-traumatic osteonecrosis was significantly higher in the ONHH (5.1%) than in the ONFH (1.9%, p < 0.001). Arthroplasty was performed more frequently in the ONHH (96.0%) than in the ONFH (92.9%, p < 0.001). CONCLUSION: Despite the anatomical similarities between the hip and shoulder joints, the different biomechanical properties, such as weight-bearing functions, might cause epidemiological differences between ONHH and ONFH.

The Korean hip fracture registry study.

BACKGROUND: The purpose of the Korean Hip Fracture Registry (KHFR) Study is to establish a nationwide, hospital-based prospective cohort study of adults with hip fracture to explore the incidence and risk factors of second osteoporotic fractures for a Fracture Liaison Service (FLS) model. METHODS: The KHFR, a prospective multicenter longitudinal study, was launched in 2014. Sixteen centers recruited participants who were treated for hip fracture. The inclusion criteria were patients, who were treated for proximal femur fracture due to low-energy trauma and aged 50 or more at the time of injury. Until 2018, 5,841 patients were enrolled in this study. Follow-up surveys were conducted annually to determine occurrence of second osteoporotic fracture, and 4,803 participants completed at least one follow-up survey. DISCUSSION: KHFR is a unique resource of individual level on osteoporotic hip fracture with radiological, medical, and laboratory information including DXA (dual energy x-ray absorptiometry), bone turnover marker, body composition, and hand grip strength for future analyses for FLS model. Modifiable factors for mortality after hip surgery is planned to be identified with nutritional assessment and multi-disciplinary interventions from hospitalization to follow-ups. The proportions of femoral neck, intertrochanteric, and subtrochanteric fractures were 517 (42.0%), 730 (53.6%), and 60 (4.4%), respectively, from 2014 to 2016, which was similar in other studies. Radiologic definition of atypical subtrochanteric fracture was adopted and 17 (1.2%) fractures among 1,361 proximal femoral fractures were identified. Internal fixation showed higher reoperation rate compared to arthroplasty in unstable intertrochanteric fractures (6.1% vs. 2.4%, p = 0.046) with no significant difference in mortality. The KHFR plans to identify outcomes and risk factors associated with second fracture by conducting a 10-year cohort study, with a follow-up every year, using 5,841 baseline participants. TRIAL REGISTRATION: Present study was registered on Internet-based Clinical Research and Trial management system (iCReaT) as multicenter prospective observational cohort study (Project number: C160022, Date of registration: 22th, Apr, 2016).

Anterior and Lateral Femoroacetabular Excursion Angles Are Helpful for Assessing Femoroacetabular Impingement Syndrome: A Cross-Sectional Cohort Study.

PURPOSE: To develop a radiographic measurement to evaluate the femoroacetabular space using 3-dimensional (3D) hip models in asymptomatic hips, and to evaluate the reliability and validity of the femoroacetabular excursion angle (FAEA) in symptomatic patients. METHODS: From January 2020 to December 2020, we recruited patients with healthy hips to establish 3D models. Through the simulation of 14 activities of daily living (ADLs), anterior and lateral impingement-free FAEAs were measured. Another cross-sectional cohort was formed from consecutive symptomatic subjects with impingement signs during the same period. In the validation cohort, anterior and lateral FAEAs were assessed on modified Dunn's and anteroposterior views of the hip, respectively. We evaluated the reliability and clinical implications of the FAEAs. RESULTS: In the discovery cohort (n = 33), hips with collisions tended to have smaller computed tomography-based FAEAs than collision-free hips, although alpha and lateral center-edge (CE) angles were comparable. Additionally, hips with a lower quartile of FAEAs had a significantly higher number of ADLs with collisions. In the validation cohort (n = 411), the FAEA measurement was highly reliable (kappa statistics >0.95 for both interobserver and intraobserver reliabilities). The femoroacetabular impingement syndrome (FAIS) group (n = 165) showed significantly smaller anterior and lateral FAEAs than the non-FAIS group (all P < .001, Cramer V = .420). The optimal cut-off values for anterior and lateral FAEAs were 32.6° and 48.9°, respectively. In univariate regression, anterior (odds ratio [OR] = 0.91; 95% confidence interval [CI] = 0.89-0.94) and lateral (OR = 0.91; 95% CI = 0.89-0.93) FAEAs were significantly associated with FAIS. Moreover, in multivariate regression adjusted for alpha and lateral CE angles, anterior FAEA remained a significant predictor (OR = 0.96; 95% CI = 0.93-0.99), and small FAEA was an independent risk factor for FAIS (OR = 1.99; 95% CI = 1.06-3.71) for any small FAEA (OR = 2.88; 95% CI = 1.32-6.31) for both small FAEAs. CONCLUSION: The FAEA is a valid measurement for FAIS with high reliability. Small FAEA was an independent risk factor for FAIS in the multivariate regression model, even after adjusting for alpha and lateral CE angles. LEVEL OF EVIDENCE: Level III, diagnostic study.

Effect of Total Hip Arthroplasty on Ipsilateral Lower Limb Alignment and Knee Joint Space Width: Minimum 5-Year Follow-up.

BACKGROUND: This study aimed to 1) assess the effect of total hip arthroplasty (THA) on coronal limb alignment, namely, the hip-knee-ankle angle (HKA), 2) identify factors that determine changes in the HKA, and 3) determine whether alignment changes influence the knee joint space width. METHODS: We retrospectively evaluated 266 limbs of patients who underwent THA. Three types of prostheses with neck shaft angles (NSAs) of 132°, 135°, and 138° were used. Several radiographic parameters were measured in the preoperative and final radiographs (at least 5 years after THA). A paired t-test was used to confirm the effect of THA on HKA change. Multiple regression analysis was performed to identify radiographic parameters related to HKA changes following THA and changes in knee joint space width. Subgroup analyses were performed to reveal the effect of NSA change on the HKA change, and the proportion of total knee arthroplasty usage and changes in radiographic parameters between maintained joint space and narrowed joint space groups were compared. RESULTS: The preoperative mean HKA was 1.4° varus and increased to 2.7° varus after THA. This change was related to changes in the NSA, lateral distal femoral angle, and femoral bowing angle. In particular, in the group with a decrease in NSA of > 5°, the preoperative mean HKA was largely changed from 1.4° varus to 4.6° varus after THA. The prostheses with NSA of 132° and 135° also led to greater varus HKA changes than those with an NSA of 138°. Narrowing of the medial knee joint space was related to changes in the varus direction of the HKA, decrease in NSA, increase in femoral offset. CONCLUSION: A large reduction in NSA can lead to considerable varus limb alignment after THA, which can have adverse effects on the medial compartment of the ipsilateral knee.

A 10- to 12-year follow-up study of delta ceramic-on-ceramic total hip arthroplasty.

BACKGROUND: We previously reported five-to-seven-year results of total hip arthroplasty (THA) with the use of delta ceramic-on-ceramic (CoC) bearing. We conducted an extension study with a CT scan at a minimum of 10 years after surgery. METHODS: From March 2009 to March 2011, 273 patients (310 hips) received cementless THA with delta CoC bearing, porous-coated cup and hydroxyapatite-coated stem. In this extended study, 252 patients (144 men and 108 women) (288 hips) with a mean age of 49.7 years (16-83) at surgery were followed for a mean of 10.4 years (10-12) with CT scans in 133 hips (46.2%, 133/288). Clinical and radiographic evaluations were made at each follow-up and Kaplan-Meier survival analysis was performed with revision and reoperation as endpoints. RESULTS: There were no more ceramic fractures. Compared to mid-term results, the incidence of squeaking and RLLs increased to 3.1% (9/288) and 19.4% (56/288), respectively. The RLL progressed to focal osteolysis in 3 hips (5.4%, 3/56). No hip had detectable wear or prosthetic loosening. Two hips were reoperated due to periprosthetic joint infection and periprosthetic femoral fracture in each. The survivorship decreased to 98.3% (96.7-99.9%) at 12 years. CONCLUSION: During the extended follow-up, no additional ceramic fracture occurred, and the incidence of squeak increased by 0.7%. The long-term survivorship of Delta CoC THA was encouraging. However, focal osteolysis occurred around the hydroxyapatite-coated stem in 1% (3/288). LEVEL OF EVIDENCE: II (Prospective cohort study).

Sarcopenia: an unsolved problem after hip fracture.

INTRODUCTION: Sarcopenia, loss of muscle mass and strength, leads to functional dependence and disability. To date, no study reported the postoperative change of sarcopenia prevalence after hip fractures. Thus, we assessed postoperative changes in the prevalence of osteoporosis and sarcopenia in hip fracture patients. MATERIALS AND METHODS: Among 1159 patients, who underwent surgery for low-energy hip fractures between May 2012 and December 2019, 224 patients (38 men and 186 women with a mean age of 76.8 ± 8.7 years) were studied with preoperative and follow-up dual-energy X-ray absorptiometry (DXA). Bone mineral density (BMD) and skeletal muscle mass were measured on DXA scans. The postoperative changes in the prevalence of osteoporosis and that of the sarcopenia were evaluated as well as Koval grade of the hip fracture patients. RESULTS: While there was no significant change in BMD, SMI significantly decreased postoperatively. Mean decrease of the SMI was 0.53 kg/m2 in men and 0.38 kg/m2 in women. Prevalence of sarcopenia increased from 63 to 89% (p = 0.014) in men and from 45 to 57% (p = 0.006) in women. Lower BMI (Odds ratio (OR) 0.85 (95% confidence interval (CI) 0.76-0.96), p = 0.008) and prior sarcopenia (OR 14.47 (95% CI 5.29-35.39), p < 0.001) were the risk factors for the decrease of SMI after hip fracture. CONCLUSIONS: After hip fracture, osteoporosis seemed to be well managed and the prevalence of osteoporosis did not increase. However, SMI decreased and the prevalence of sarcopenia increased. More active measures are warranted to prevent sarcopenia in elderly hip fracture patients.

High Risk of Neck-liner Impingement and Notching Observed with Thick Femoral Neck Implants in Ceramic-on-ceramic THA.

BACKGROUND: Recently, impingement between the femoral stem and ceramic liner, which appears as a notch in the stem neck on radiographs, has emerged as a new complication. However, the proportion of impingement, potential risk factors, and related complications are poorly elucidated. QUESTION/PURPOSES: In patients who underwent ceramic-on-ceramic (CoC) THA and had at least 10 years of follow-up, we asked: (1) What proportion had radiographic evidence of stem neck-ceramic liner impingement (notching of the stem), and what implant design, implantation factors, or complications such as ceramic fracture or metallosis are associated with impingement? (2) How common are the complications of noise and ceramic fracture? (3) What are the radiologic changes (including fixation of femoral and acetabular components, osteolysis, and heterotopic ossification) and clinical outcomes as determined by the modified Harris hip score (mHHS) for this cohort? (4) What is the survivorship with implant revision as the endpoint and with reoperation for any reason as the endpoint after CoC THA using a thick-neck stem design? METHODS: Between May 2003 and April 2010, 643 patients underwent primary THA at a tertiary referral hospital. After excluding patients with metal-on-polyethylene and with ceramic-on-polyethylene implants, 621 patients were considered eligible for this study. All patients received the same hemispherical titanium cup, a standard-length tapered titanium stem, and a CoC bearing. Of those, 19% (115) were lost to follow-up before 10 years, and 8% (50) were excluded because they died before the minimum follow-up duration of 10 years, leaving 73% (456) for analysis. Patients had a mean age of 50 ± 14 years and were followed for a median (range) of 13 years (10 to 17). The mean cup abduction was 38° ± 5°, and the mean cup anteversion was 26° ± 7°. To determine the proportion of patients with the neck-liner impingement, we analyzed the plain radiographs of every patient during follow-up to detect notches around the stem. The detection of stem neck notches on the radiographs was reliable (intraobserver reliability: κ = 0.963; p < 0.001 and interobserver reliability: κ = 0.975; p < 0.001). To evaluate factors related to notching, we compared the possible confounding factors including gender, age, BMI, implant position, neck length, and head diameter. Complications such as ceramic fracture, noise, dislocation, and periprosthetic joint infection were recorded. Noise was evaluated via interview and with the Hip Noise Assessment Questionnaire, which assessed the noise qualitatively. For clinical outcome, we assessed the mHHS, which includes pain and function scales (0 [worst] to 100 [best]), every visit. Tilting of at least 4° or migration of at least 4 mm was the criteria for cup loosening; subsidence more than 3 mm, any change in position, or a continuous radiolucent line greater than 2 mm was the criteria for stem loosening. To evaluate osteolysis, we performed CT scans in 57% (262 of 456) of patients. Kaplan-Meier survivorship analysis was performed using the endpoints of survivorship free from implant revision and survivorship free from reoperation for any cause. RESULTS: The proportion of stem neck notching was 11% (49 of 456). There were no differences in cup abduction and anteversion between hips with notches and those without notches. Notched hips were more likely to have 28-mm than 32-mm heads (90% [44 of 49] versus 70% [285 of 407]; odds ratio 3.77 [95% CI 1.46 to 9.73]; p = 0.004). None of the 49 notched hips had a ceramic head or liner fracture or evidence of metallosis. A ceramic head fracture was reported in 2% (9 of 456); all fractures occurred in 28-mm short neck heads. A ceramic liner fracture occurred in 0.2% (1 of 456), and noise was noted in 6% (27 of 456). Acetabular osteolysis developed in 2% (7 of 456). The mHHS was 91 ± 12 points at the final follow-up. The survivorship free from implant revision was 97% (95% CI 96% to 99%), and the survivorship free from reoperation for any cause was 96% (95% CI 95% to 98%) at 13 years. CONCLUSION: The proportion of stems with neck-ceramic liner impingement and ceramic component fracture were unacceptably high after the use of a thick-neck stem design, especially when a 28-mm head was used. We have discontinued the use of this stem design and we recommend that such stems should not be used when CoC bearings are used. As these findings might be generalized to other bearing couples, further studies focused on polyethylene liner wear and local metallosis due to thick stem neck are warranted. LEVEL OF EVIDENCE: Level III, therapeutic study.

Do Cementless Short Tapered Stems Reduce the Incidence of Thigh Pain After Hip Arthroplasty? Systematic Review and Meta-Analysis.

BACKGROUND: The purpose of this study was to determine whether short tapered stems reduce the rate of thigh pain through a systematic review and meta-analysis of comparative studies between short tapered stems and standard-length tapered stems. METHODS: We conducted a meta-analysis of comparative studies: 1) retrospective studies and 2) randomized controlled trials (RCTs), on 2 stem designs: short tapered stem versus standard-length tapered stem. Studies were selected by means of the following criteria: 1) study design: retrospective comparative studies, prospective comparative studies, RCTs; 2) study population: patients with total hip arthroplasty or hemiarthroplasty for hip disease or hip fracture; 3) intervention: short tapered stem and standard tapered stem; and 4) outcomes; thigh pain, other clinical results. RESULTS: Among the 250 articles that were identified at the initial search, 6 studies, 4 RCTs and 2 retrospective comparative studies, were included in this meta-analysis. In the analysis of retrospective studies, the short tapered stem reduced the risk of thigh pain compared to the standard tapered stem (risk ratio [RR] = 0.13; 95% confidence interval [CI], 0.02-0.09; Z = -2.07; P = 0.039). However, in the analysis of RCTs, the incidence of thigh pain was similar between the two stem designs (RR = 1.21; 95% CI, 0.76-1.93; Z = 0.82; P = 0.410). Overall meta-analysis including all studies showed that the short tapered stem did not reduce the incidence of thigh pain compared to the standard-length tapered stem (RR = 0.91; 95% CI, 0.59-1.40; Z = -0.44, P = 0.663). CONCLUSIONS: We did not find a significant difference in the incidence of thigh pain between short tapered stem and standard tapered stem in hip arthroplasty. TRIAL REGISTRATION: PROSPERO Identifier: CRD42021231240.

Effectiveness of Online Video Instruction on Time to Start Ambulation and Duration of Hospital Stay, Satisfaction and Functional Recovery in Patients Undergoing Total Hip Arthroplasty.

BACKGROUND: At the end of 2014, we implemented an online video to inform patients of the entire process from admission to rehabilitation after total hip arthroplasty (THA). In this study, we investigated the effectiveness of online video instruction in THA patients. METHODS: Electronic medical records of 184 patients undergoing THA in 2014 (pre-video group) and 182 patients in 2015 (post-video group) were reviewed. We compared 1) the time to start wheelchair ambulation, 2) walker or crutch ambulation, 3) the length of hospital stay, 4) postoperative satisfaction using visual analogue scale (0-10 points), and 5) modified Harris Hip Score (mHHS) at postoperative 6 weeks. RESULTS: In the post-video group, the time to start wheelchair ambulation (1.8 ± 0.6 vs. 2.4 ± 3.2 days, P = 0.021) and walker/crutch ambulation were faster (2.9 ± 1.2 vs. 3.8 ± 1.0 days, P = 0.016), and the hospital stay was shorter (8.2 ± 4.7 vs. 9.9 ± 7.8 days, P = 0.001) compared to the pre-video group. The visual analogue scale for satisfaction (7.84 ± 1.62 vs. 7.68 ± 1.85 points) and mHHS (89.59 ± 9.47 vs. 89.58 ± 8.59) were similar. CONCLUSION: Online video instruction is an effective tool to expedite ambulation and reduce the hospital stay without compromising the clinical outcome and postoperative complications after THA.

Operational Definition Identifying Osteoporotic Vertebral Fractures in the Claims Database.

BACKGROUND: We analyzed the International Classification of Diseases, 10th edition (ICD-10) diagnostic codes, procedure codes, and radiographic image codes for vertebral fracture (VF) used in the database of Health Insurance Review and Assessment Service (HIRA) of Korea to establish a validated operational definition for identifying patients with osteoporotic VF in claims data. METHODS: We developed three operational definitions for detecting VFs using 9 diagnostic codes, 5 procedure codes and 4 imaging codes. Medical records and radiographs of 2,819 patients, who had primary and subordinated codes of VF between January 2016 and December 2016 at two institutions, were reviewed to detect true vertebral fractures. We evaluated the sensitivity and positive predictive value (PPV) of the operational definition in detecting true osteoporotic VF and obtained the receiver operating characteristic (ROC) curve. RESULTS: Among the 2,819 patients who had primary or secondary diagnosis codes for VF, 995 patients satisfied at least one of the criteria for the operational definition of osteoporotic VF. Of these patients, 594 were judged as having true fractures based on medical records and radiographic examinations. The sensitivity and PPV were 62.5 (95% confidence interval [CI], 59.4-65.6) and 59.7(95% CI, 56.6-62.8) respectively. In the receiver operating characteristic analysis, area under the curve (AUC) was 0.706 (95% CI, 0.688-0.724). CONCLUSION: Our findings demonstrate the validity of our operational definitions to identify VFs more accurately using claims data. This algorithm to identify VF is likely to be useful in future studies for diagnosing osteoporotic VF.

Long-Term Wear-Related Complications of Cross-Linked Versus Conventional Polyethylene After Total Hip Arthroplasty: A Meta-Analysis.

BACKGROUND: Highly cross-linked polyethylene (HXLPE) liners have been developed to address the wear-related problems associated with conventional polyethylene (CPE) such as osteolysis or aseptic loosening in total hip arthroplasty (THA). In this systematic meta-analysis, we compared the long-term efficacy in preventing radiological osteolysis and revision surgery between HXLPE and CPE. METHODS: We included 14 studies that compared HXLPE and CPE reporting the incidence of wear-related complications with a minimum follow-up of 10 years. We investigated 5 wear-related complications: osteolysis, excessive wear, linear wear rate, revision surgery due to wear, and progress of osteolysis/aseptic loosening. We conducted a pair-wise meta-analysis to estimate odds ratio (OR) and a proportional meta-analysis to estimate the incidence of each complication. RESULTS: Among 1,175 THAs, 220 osteolysis and 78 wear-related revisions were detected. The use of HXLPE reduced the risk of overall osteolysis (OR 0.30; P = .001), excessive wear (OR 0.10; P < .001), linear wear rate (weighted mean difference 0.09; P < .001), the risk of overall wear-related revisions (OR 0.06; P < .001), and revisions due to aseptic loosening (OR 0.23; P = .015). As per the proportional meta-analysis, the pooled prevalence of osteolysis, excessive wear, and the overall wear-related revision rate were 14%, 8%, and 3% in HXLPE and 25%, 33%, and 20% in CPE, respectively. CONCLUSION: The current evidence shows that HXLPE dramatically reduced the rate of osteolysis and wear-related revision surgery. However, as polyethylene wear and osteolysis still lead to revision surgery, ongoing clinical and retrieval studies are required to analyze long-term outcomes.

The 2021 Association Research Circulation Osseous Classification for Early-Stage Osteonecrosis of the Femoral Head to Computed Tomography-Based Study.

BACKGROUND: The Association Research Circulation Osseous developed a novel classification for early-stage (precollapse) osteonecrosis of the femoral head (ONFH). We hypothesized that the novel classification is more reliable and valid when compared to previous 3 classifications: Steinberg, modified Kerboul, and Japanese Investigation Committee classifications. METHODS: In the novel classification, necrotic lesions were classified into 3 types: type 1 is a small lesion, where the lateral necrotic margin is medial to the femoral head apex; type 2 is a medium-sized lesion, with the lateral necrotic margin being between the femoral head apex and the lateral acetabular edge; and type 3 is a large lesion, which extends outside the lateral acetabular edge. In a derivation cohort of 40 early-stage osteonecrotic hips based on computed tomography imaging, reliabilities were evaluated using kappa coefficients, and validities to predict future femoral head collapse by chi-squared tests and receiver operating characteristic curve analyses. The predictability for future collapse was also evaluated in a validation cohort of 104 early-stage ONFH. RESULTS: In the derivation cohort, interobserver reliability (k = 0.545) and intraobserver agreement (63%-100%) of the novel method were higher than the other 3 classifications. The novel classification system was best able to predict future collapse (P < .05) and had the best discrimination between non-progressors and progressors in both the derivation cohort (area under the curve = 0.692 [0.522-0.863], P < .05) and the validation cohort (area under the curve = 0.742 [0.644-0.841], P = 2.46 × 10-5). CONCLUSION: This novel classification is a highly reliable and valid method of those examined. Association Research Circulation Osseous recommends using this method as a unified classification for early-stage ONFH. LEVEL OF EVIDENCE: Level III, diagnostic study.

Distribution and outliers of anteversion of short-length cementless stem.

INTRODUCTION: Inadequate stem version might lead to impingement and instability after cementless total hip arthroplasty (THA). We evaluated (1) the distribution of short-stem anteversion, (2) the proportion of stems with an anteversion less than 5° or larger than 25°, (3) combined cup and stem anteversion, and (4) dislocation rate. MATERIALS AND METHODS: We evaluated the native femoral anteversion and stem anteversion in 340 patients (340 THAs): 144 men and 196 women. Their mean age was 56.2 (22-87) years and mean body mass index was 25.1 (15.2-40.7) kg/m2. The femoral neck anteversion was measured on pre-operative CT scan and the stem anteversion was obtained during the operation. The safe zone of the stem anteversion was defined as 5 to 25°. RESULTS: The femoral neck anteversion ranged from -15 to 61° (mean, 15.0°; SD, ±10.6°). The stem anteversion ranged -7 to 50° (mean, 15.7°; SD, ±9.5°). It was optimal (5-25°) in 71.2% (242/340), insufficient (<5°) in 13.3% (45/340), and excessive (>25°) in 15.6% (53/340). The stem anteversion had a medium correlation with the femoral neck anteversion (correlation coefficient = 0.449). The combined anteversion was 42.0° (range, 35.2-52.3°; SD, ±2.8°). During two to four year follow-up, no hip dislocated. CONCLUSIONS: Short-length stem had a great variability in the anteversion and considerable portion (28.9%, 98/340) of stems had an anteversion outside the safe zone. Surgeons should be aware of this variability of stem anteversion to compensate for abnormal stem anteversion, which might lead to impingement and instability after THA.

Risk factors for subsequent vertebral fractures following a previous hip fracture.

INTRODUCTION: The purpose of our study was to evaluate the incidence and to identify risk factors of subsequent vertebral fractures after hip fractures, and to determine whether the subsequent vertebral fracture increases the mortality rate of elderly hip fracture patients. MATERIALS AND METHODS: From January 2009 to July 2016, 1,554 patients were diagnosed as having a hip fracture and were treated surgically at our institution. Among them, 1121 patients age > 50 years at the time of injury and were followed up for 1 year or longer after the hip fracture surgery. In these patients, radiographs of the hip and spine were taken at each follow-up. We reviewed medical records and radiographs of these patients. Among the 1121 patients, 107 patients (9.5%) had subsequent vertebral fractures after the hip fracture during entire follow-up periods. RESULTS: In multivariable analysis, previous history of vertebral fracture [odds ratio (OR), 2.62; p < 0.001], medication possession rate (MPR) of osteoporosis treatment < 80% (OR, 1.92; p = 0.014), and a lower lumbar bone mineral density (BMD) (OR, 2.58; p = 0.001) appeared as risk factors for subsequent vertebral fractures. CONCLUSION: However, the subsequent vertebral fractures did not affect the mortality after the hip fractures. Age ≥ 70 years [hazard ration (HR) 2.70; p = .039], body mass index < 18.5 kg/m2 (HR, 2.57; p =0 .048), and Charlson comorbidity index ≥ 2 (HR, 2.04; p =0.036) were risk factors of the death. Timely management is warranted to prevent subsequent vertebral fractures in hip fracture patients with risk factors.

How does the multidimensional frailty score compare with grip strength for predicting outcomes after hip fracture surgery in older patients? A retrospective cohort study.

BACKGROUND: Frailty and low handgrip strength (HGS) are associated with adverse outcomes after hip fracture (HF) surgery. We aimed to compare the predictive role of frailty and HGS for adverse outcome in HF patients. METHODS: We included older patients (age ≥ 65 years) who underwent HF surgery to compare the predictive role of HGS and hip-multidimensional frailty score (Hip-MFS) for postoperative complications and mortality. The Hip-MFS was calculated based on comprehensive geriatric assessment (CGA), and HGS was measured with a hand dynamometer. The primary outcome was a composite of postoperative complications (e.g., pneumonia, urinary tract infection, delirium, acute pulmonary thromboembolism, and unplanned intensive care unit admission). The secondary outcomes were 6-month mortality and mortality at the end of follow-up. RESULTS: The median observation time was 620.5 days (interquartile range: 367.0-784.8 days). Among the 242 patients (mean age: 81.5 ± 6.7 years, 73.1% women), 106 (43.8%) experienced postoperative complications. The 6-month mortality and mortality at the end of follow-up were 7.4% (n = 18) and 20.7% (n = 50), respectively. The Hip-MFS (odds ratio [OR], 1.250; 95% confidence interval [CI], 1.092-1.432) and HGS (OR, 1.147; 95% CI, 1.082-1.215) could predict postoperative complications. The Hip-MFS could predict both 6-month mortality (hazard ratio [HR], 1.403; 95% CI, 1.027-1.917) and mortality at the end of follow-up (HR, 1.493; 95% CI, 1.249-1.769) after adjustment, while HGS was only associated with mortality at the end of follow-up (HR, 1.080; 95% CI, 1.024-1.139). For mortality at the end of follow-up, predictive models with the Hip-MFS were superior to those with HGS in the time-dependent receiver-operating curve analysis after adjustment (p = 0.017). Furthermore, the addition of Hip-MFS or HGS to the American Society of Anesthesiologists (ASA) classification improved its prognostic ability. CONCLUSIONS: Both the Hip-MFS and HGS could predict postoperative complications and improve prognostic utility when combined with the ASA classification. The Hip-MFS was a stronger predictor of mortality than HGS after HF surgery. HGS could be a useful pre-screening tool to identify patients at a high risk of postoperative complications and those who may benefit from further CGA.

No Clinically Important Differences in Thigh Pain or Bone Loss Between Short Stems and Conventional-length Stems in THA: A Randomized Clinical Trial.

BACKGROUND: Short-length stems were developed to reduce bone loss of the proximal femur and potentially decrease the incidence of thigh pain after cementless THA. However, it remains unknown whether short stems indeed reduce bone loss or the frequency of thigh pain. QUESTIONS/PURPOSES: Is there a difference between short- and standard-length stems in terms of: (1) the frequency or severity of thigh pain, (2) modified Harris hip scores, (3) implant loosening, or (4) bone mineral density as measured by dual-energy x-ray absorptiometry? METHODS: Between March 2013 and January 2014, three surgeons performed 205 primary THAs. To be eligible, patients needed to be at least 20 years of age, have not undergone previous history of hip surgery, and have no metabolic bone disease. A total of 100 patients were randomized to receive THA either with a short stem (n = 56) or with a standard-length stem (n = 44). Both stems were proximally coated, tapered, cementless stems. Compared with standard stems, short stems typically were 30- to 35-mm shorter. A total of 73% (41 of 56) and 77% (34 of 44) of those groups, respectively, were accounted for at a minimum of 5 years and were analyzed. The presence of thigh pain during activity was evaluated using a 10-point VAS, and the modified Harris hip score was calculated by research assistants who were blinded to the treatment groups. Plain radiographs were taken at 6 weeks, 6 months, and 12 months postoperatively, and every 1 year thereafter; loosening was defined as subsidence > 3 mm or a position change > 3° on serial radiographs. Radiological assessment was performed by two researchers who did not participate in the surgery and follow-up evaluations. Bone mineral density of the proximal femur was measured using dual-energy x-ray absorptiometry at 4 days, 1 year, 2 years, and 5 years postoperatively. The primary endpoint of our study was the incidence of thigh pain during 5-year follow-up. Our study was powered at 80% to detect a 10% difference in the proportion of patients reporting thigh pain at the level of 0.05. RESULTS: With the numbers available, we found no difference between the groups in the proportion of patients with thigh pain; 16% (9 of 56) of patients in the short-stem group and 14% (6 of 44) of patients in the standard-stem group experienced thigh pain during the follow-up period (p = 0.79). In all patients, the pain was mild or moderate (VAS score of 4 or 6 points). Among the 15 available patients who reported thigh pain, there was no difference between the implant groups in mean severity of thigh pain (4.3 ± 0.8 versus 4.2 ± 0.7; p = 0.78). There were no between-group differences in the short versus standard-length stem groups in terms of mean modified Harris hip score by 5 years after surgery (89 ± 13 versus 95 ± 7 points; p = 0.06). No implant was loose and no hip underwent revision in either group. Patients in the short-stem group showed a slightly smaller decrease in bone mineral density in Gruen Zones 2, 3, and 5 than those in the standard-stem group did; the magnitude of the difference seems unlikely to be clinically important. CONCLUSION: We found no clinically important differences (and few differences overall) between short and standard-length THA stems 5 years after surgery in a randomized trial. Consequently, we recommend that clinicians use standard-length stems in general practice because standard-length stems have a much longer published track record in other studies, and short stems can expose patients to the uncertainty associated with novelty, without any apparent offsetting benefit. LEVEL OF EVIDENCE: Level I, therapeutic study.

Burden and future projection of revision Total hip Arthroplasty in South Korea.

BACKGROUND: The annual number of hip arthroplasties is increasing combined with the aging population worldwide. In accordance with the increasing number of primary hip arthroplasties, the number of revision total hip arthroplasties (THAs) is expected to increase. The incidence and burden of revision THAs in the United States and have been reported by registry studies. To identify potential differences according to ethnics and regional practice, it is important to obtain data from East Asia. Nevertheless, there has been a lack of studies on the burden and future projection of revision THA based on a large-scale database in East Asia. The purpose of this study was to evaluate annual incidence and burden of revision THAs and to project the future burden in South Korea. METHODS: We identified primary THAs, primary hemiarthroplasties (HAs) and revision THAs, which were performed from 2010 to 2018, using database of Health Insurance and Review and Assessment (HIRA); nation-wide medical claim system of South Korea. The annual incidence rates (per 100,000) of primary THA, primary HA and revision THA, and the annual burden of revision THA; the number of revision THAs divided by the sum of primary hip arthroplasties and revision THAs, were calculated. The future burden of revision THAs were projected through 2030 using generalized linear model with Quasi-poisson regression. RESULTS: During the 9-year period, the annual incidences of primary THA, primary HA and revision THA increased by 47, 29 and 3%, respectively, while the revision burden decreased from 0.13 to 0.10. Compared to 2018, the annual incidences of primary THA, HA, and revision THA were projected to increase by 7.2, 2.3 and 1.1% per year, respectively, whereas the burden of revision THA was projected to decrease to 0.07 in 2030. CONCLUSION: Trends of revision THA in South Korea were similar with those of national registry studies from the United States. The annual incidence of revision THA has steadily increased, whereas its burden has decreased. Findings of our study could be used for epidemiological comparison between Western countries and East Asia as well as for the establishment of medical policies of revision THA in East Asian countries.

Comparison of Mortality, Length of Hospital Stay and Transfusion between Hemiarthroplasty and Total Hip Arthroplasty in Octo- and Nonagenarian Patients with Femoral Neck Fracture: a Nationwide Study in Korea.

BACKGROUND: The purpose of this study was to compare the mortality rate between patients undergoing hemiarthroplasty (HA) and those undergoing total hip arthroplasty (THA) in two age groups: patients aged 65-79 years (non-octogenerian) and patients aged ≥ 80 years (octogenarian). METHODS: We identified elderly (aged ≥ 65 years) femoral neck fracture patients who underwent primary THA or HA from January 1, 2005 to December 31, 2015 in South Korea using the Health Insurance and Review and Assessment database; the nationwide medical claim system of South Korea. We separately compared the mortality rate between the HA group and THA group in two age groups. A generalized estimating equation model with Poisson distribution and logarithmic link function was used to calculate the adjusted risk ratio (aRR) of death according to the type of surgery. RESULTS: The 3,015 HA patients and 213 THA patients in younger elderly group, and 2,989 HA patients and 96 THA patients in older elderly group were included. In the younger elderly group, the mortality rates were similar between the two groups. In older elderly group, the aRR of death in the THA group compared to the HA group was 2.16 (95% confidence interval [CI], 1.20-3.87; P = 0.010) within the in-hospital period, 3.57 (95% CI, 2.00-6.40; P < 0.001) within 30-days, and 1.96 (95% CI, 1.21-3.18; P = 0.006) within 60-days. CONCLUSIONS: In patients older than 80 years, THA was associated with higher postoperative mortality compared to HA. We recommend the use of HA rather than THA in these patients.

Effect of Dementia on Postoperative Mortality in Elderly Patients with Hip Fracture.

BACKGROUND: The aim of this study was to assess the prevalence of dementia as an underlying disease in elderly patients with hip fracture, to investigate the effect of dementia on postoperative mortality after surgery of hip fracture, and to analyze the differences in postoperative mortalities according to the severity of dementia through subgroup analysis. METHODS: This study selected 2,346 elderly patients who were diagnosed with unilateral intertrochanteric or femoral neck fractures who underwent surgery between January 2004 and December 2018. The patients were classified into the non-dementia group (2,196 patients) and dementia group (150 patients; no-medication [66 patients] and medication [84 patients] subgroups). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the groups. A univariate regression test was performed using age, sex, diagnosis, surgery type, and Charlson's comorbidity index (CCI), as these variables had P values of < 0.10. Multivariate regression analysis was performed to identify independent risk factors associated with mortality. RESULTS: The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were 1.8%, 3.8%, 5.6%, 8.9%, and 13.6%, respectively, in the non-dementia group, and 2%, 7.3%, 14%, 19.3%, and 24%, respectively, in the dementia group (P = 0.748, P = 0.048, P < 0.001, P < 0.001, and P = 0.001). The factors that affected the 1-year mortality were age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.08; P < 0.001), sex (OR, 2.68; 95% CI, 2.07-3.47; P < 0.001), CCI (OR, 1.34; 95% CI, 1.23-1.47; P < 0.001), and dementia (OR, 1.70; 95% CI, 1.46-1.08; P = 0.016). In subgroup analysis, severity of dementia influenced the 6-month mortality (OR, 1.41; 95% CI, 1.70-2.01; P = 0.018), and 1-year mortality (OR, 1.30; 95% CI, 1.17-1.90; P = 0.027). CONCLUSION: In elderly hip fracture patients, the comparison between patients with and without dementia revealed that dementia was an independent risk factor for mortality at a minimum of 1 year of follow-up, and the severity of dementia in hip fracture patients was a risk factor for mortality within 6 months and 1 year, postoperatively.