Identifying Critical Evidence Gaps in Wound Closure and Incision Management After Total Knee Arthroplasty: Delphi Panel Insights.

INTRODUCTION: In orthopaedic surgery, particularly total knee arthroplasty (TKA), the management of surgical wounds is critical for optimal wound healing and successful patient outcomes. Despite advances in surgical techniques, challenges persist in effectively managing surgical wounds to prevent complications and infections. This study aimed to identify and address the critical evidence gaps in wound management in TKA, including preoperative optimization, intraoperative options, and for the avoidance of postoperative complications. These are important issues surrounding wound management, which is essential for improving patient recovery and the overall success of the surgery. METHODS: Utilizing the Delphi method, this study brought together 20 experienced orthopaedic surgeons from Europe and North America. Conducted from April to September 2023, the process involved three stages: an initial electronic survey, a virtual meeting, and a concluding electronic survey. The panel reviewed and reached a consensus on 26 specific statements about wound management in TKA based on a comprehensive literature review. During these three stages and after further panel review, an alternative goal of the Delphi panel was to also identify critical evidence gaps in the current understanding of wound management practices for TKA. RESULTS: While the panel reached consensus on various wound management practices, they highlighted several major evidence gaps. Also, there was general consensus on issues such as wound closure methods including the use of mesh-adhesive dressings, skin glue, staples, sutures (including barbed sutures),and negative-pressure wound therapy (NPWT). However, it was deemed necessary that further evidence needs to be generated to address the cost-effectiveness of each and develop best practices for promoting patient outcomes. The identification of these gaps points to areas requiring more in-depth research and improvements to enhance wound care in TKA. DISCUSSION: The identification of these major evidence gaps underscores the need for targeted research in wound management surrounding TKA. Addressing these evidence gaps is crucial for the future development of more effective, efficient, and patient-friendly wound care strategies. Future research should prioritize these areas, focusing on comparative effectiveness studies and further developing clear guidelines for the use of emerging technologies. Bridging these gaps has the potential to improve patient outcomes, reduce complications, and elevate the overall success rate of TKA surgeries.

Which factors are associated with a successful outcome following total hip arthroplasty in patients with early radiographic osteoarthritis?

BACKGROUND: It is unclear which factors are associated with a successful total hip arthroplasty (THA) in patients with early radiographic osteoarthritis (OA). METHODS: 70 patients with early OA (Kellgren and Lawrence [KL] grades 0-2) who underwent THA were compared with 200 patients with advanced OA (KL grades 3-4). Outcomes were Oxford Hip Scores (OHS), EQ-5D and EQ-VAS scores; compared preoperatively with 1 year postoperatively. We investigated which clinical and radiographic (plain x-ray, CT, MRI) features predicted successful THA (postoperative OHS ⩾42). RESULTS: The early OA group were significantly younger (61 vs. 66 years; [p = 0.0035). There were no significant differences in BMI, ASA grade or gender. After adjusting for confounders, the advanced OA group had a significantly greater percentage of possible change (PoPC) in OHS (75.8% vs. 50.4%; p < 0.0001) and improvement in EQ-5D (0.151 vs. 0.002; p < 0.0001). There were no significant differences in complication, revision or readmission rates. In the early OA group, 16/70 (22.9%) patients had a 'successful' THA. Patients who had a 'successful' THA were significantly more likely to have subchondral cysts on CT/MRI (91.7% vs. 57.7%; p = 0.0362). The presence of cysts on CT/MRI was associated with a significantly greater PoPC in OHS (61.6% vs. 38.2%; p = 0.0353). The combination of cysts and joint space width <1 mm was associated with a PoPC of 68%. CONCLUSIONS: THA in patients with early OA (KL grades 0-2) on plain radiographs should be indicated with caution. We advocate preoperative cross-sectional imaging in these patients. In the absence of cysts on CT/MRI, a THA seems unlikely to provide a satisfactory outcome.

International Delphi Study on Wound Closure and Incision Management in Joint Arthroplasty Part 2: Total Hip Arthroplasty.

BACKGROUND: This modified Delphi study aimed to develop a consensus on optimal wound closure and incision management strategies for total hip arthroplasty (THA). Given the critical nature of wound care and incision management in influencing patient outcomes, this study sought to synthesize evidence-based best practices for wound care in THA procedures. METHODS: An international panel of 20 orthopedic surgeons from Europe, Canada, and the United States evaluated a targeted literature review of 18 statements (14 specific to THA and 4 related to both THA and total knee arthroplasty). There were 3 rounds of anonymous voting per topic using a modified 5-point Likert scale with a predetermined consensus threshold of ≥ 75% agreement necessary for a statement to be accepted. RESULTS: After 3 rounds of voting, consensus was achieved for all 18 statements. Notable recommendations for THA wound management included (1) the use of barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); (2) the use of subcuticular sutures over skin staples (lower risk of superficial infections and higher patient preferences, but longer closing times); (3) the use of mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); (4) for at-risk patients, the use of negative pressure wound therapy over other dressings (lower wound complications and reoperations, as well as fewer dressing changes); and (5) the use of triclosan-coated sutures (lower risk of surgical site infection) over standard sutures. CONCLUSIONS: Through a structured modified Delphi approach, a panel of 20 orthopedic surgeons reached consensus on all 18 statements pertaining to wound closure and incision management in THA. This study provides a foundational framework for establishing evidence-based best practices, aiming to reduce variability in patient outcomes and to enhance the overall quality of care in THA procedures.

International Delphi Study on Wound Closure and Dressing Management in Joint Arthroplasty: Part 1: Total Knee Arthroplasty.

BACKGROUND: The purpose of this modified Delphi study was to obtain consensus on wound closure and dressing management in total knee arthroplasty (TKA). METHODS: The Delphi panel included 20 orthopaedic surgeons from Europe and North America. There were 26 statements identified using a targeted literature review. Consensus was developed for the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of ≥ 75% was required for consensus. RESULTS: All 26 statements achieved consensus after three rounds of anonymous voting. Wound closure-related interventions that were recommended for use in TKA included: 1) closing in semi-flexion versus extension (superior range of motion); 2) using aspirin for venous thromboembolism prophylaxis over other agents (reduces wound complications); 3) barbed sutures over non-barbed sutures (lower wound complications, better cosmetic appearances, shorter closing times, and overall cost savings); 4) mesh-adhesives over other skin closure methods (lower wound complications, higher patient satisfaction scores, lower rates of readmission); 5) silver-impregnated dressings over standard dressings (lower wound complications, decreased infections, fewer dressing changes); 6) in high-risk patients, negative pressure wound therapy over other dressings (lower wound complications, decreased reoperations, fewer dressing changes); and 7) using triclosan-coated over non-antimicrobial-coated sutures (lower risks of surgical site infection). CONCLUSIONS: Using a modified Delphi approach, the panel achieved consensus on 26 statements pertaining to wound closure and dressing management in TKA. This study forms the basis for identifying critical evidence supported by clinical practice for wound management to help reduce variability, advance standardization, and ultimately improve outcomes during TKA. The results presented here can serve as the foundation for knowledge, education, and improved clinical outcomes for surgeons performing TKAs.

Revision of double-tapered, titanium, fully hydroxyapatite-coated femoral stems: ease of extraction and subsequent reconstruction.

BACKGROUND: Fully hydroxyapatite coated, double-tapered, titanium stems are the most commonly used uncemented implants in the UK with survivorship reported at 96.3% at 23 years however there is no literature on the consequences of revision. We aimed to explore the reasons for failure, ease of stem extraction, extent of bone loss and complexity of the subsequent reconstruction. METHODS: Between December 2012 and March 2019, 104 cases requiring removal of the Corail® stem (DePuy Synthes, Warsaw, IN, USA) were identified from the National Joint Registry (NJR) and our local revision database. Indication for revision, surgical/reconstruction technique, complications and follow-up data were reviewed. RESULTS: The common reasons for revision were aseptic loosening 45.2%, infection 23.5%, instability 4.8% and peri-prosthetic fracture 12.5%. Removal of the implant without extended trochanteric osteotomy (ETO) was achieved in 94.2% of cases. Of those revised for aseptic loosening 23% were proximal, 38% were proximal/mid stem and 38% all zones. Significant bone loss is not a common feature of the failure of this stem with 95% graded as a Paprosky grade 2 or less. In terms of reconstruction, 69.2% were revised to a primary cemented stem. CONCLUSIONS: In the majority of cases revision can be achieved without an ETO and reconstruction possible using a primary stem as significant bone loss is not a common feature of failure of this stem design. We conclude that this stem is safe to use in younger patients who may outlast any type of primary implant and would inevitably face revision in their lifetime.

Do patients with well-functioning total hip arthroplasty achieve typical sagittal plane hip kinematics? A proof of concept study.

BACKGROUND: Total hip arthroplasty (THA) patients have been shown to not achieve normal sagittal plane hip kinematics. However, previous studies have only conducted group level analysis and as such lack the sensitivity to highlight whether individual patients do achieve normal hip kinematics. As such this study looked to determine whether some patients with well-functioning THA achieve typical sagittal plane hip kinematics. METHODS: Sagittal plane hip kinematics were collected on 11 well-functioning THA patients (Oxford Hip Score = 46 ± 3) and 10 asymptomatic controls using a 3-dimensional motion analysis system during self-paced walking. High-functioning THA patients were identified as those who displayed sagittal plane hip kinematics that were within the variance of the control group on average, and low-functioning patients as those who did not. RESULTS: 5 THA patients were identified as high-functioning, displaying hip kinematics within the variance of the control group. High-functioning THA patients displayed peak hip flexion and extension values more closely aligned to asymptomatic control group than low-functioning patients. However, hip range of motion was comparable between high- and low-functioning total hip arthroplasty patients and reduced compared to controls. CONCLUSION: The presence of high-functioning THA patients who display comparable sagittal plane hip kinematics to controls suggests these patients do achieve normative function and challenges the conclusions of previous group level analysis. Understanding why some patients achieve better function post-operatively will aid pre- and post-operative practices to maximise functional recovery.

A comparison of mortality rates following revision hip arthroplasty for periprosthetic fracture, infection or aseptic loosening.

BACKGROUND: Mortality following revision hip surgery for periprosthetic fracture (PPF) is comparable to neck of femur fractures. Our institution provides a regional "PPF Service". The aim of this study was to determine the time to surgery and mortality rate for PPF, compared to revision for infection or aseptic loosening. METHODS: Revision arthroplasty procedures performed for PPF, infection or aseptic loosening between January 2014 and December 2015 were identified. Comparisons were made between the 3 groups for baseline demographics, admission to higher-level care, length of stay, complications and mortality. RESULTS: There were 37 PPF, 71 infected and 221 aseptic revisions. PPF had a higher proportion of females (65% vs. 39% in infection and 53% in aseptic; p = 0.031) and grade 3 and 4 ASA patients (p = 0.006). Median time to surgery for PPF was 8 days (95% CI, 6-16). Single-stage procedures were performed in 84% of PPF, 42% of infections and 99% of aseptic revisions (p < 0.001). 19% of PPF revisions required HDU admission, 1% in the aseptic group and none in the infection group. Median length of stay was significantly different (PPF 10; infection 14; aseptic 8 days (p < 0.001). The 1-year mortality rate for PPF was 0%, 2.8% for infection and 0.9% in the aseptic group (p = 0.342). CONCLUSIONS: Despite the PPF group having higher ASA grades and more HDU admissions, our 1-year mortality rate was 0% and not significantly different to infection or aseptic loosening. Our low complication and 1-year mortality rate is encouraging and supports the safety of a regional "Periprosthetic Fracture Service".

Treatment patterns and clinical and economic burden of hip dislocation following primary total hip arthroplasty in England.

AIMS: The aim of this study was to estimate the clinical and economic burden of dislocation following primary total hip arthroplasty (THA) in England. METHODS: This retrospective evaluation used data from the UK Clinical Practice Research Datalink database. Patients were eligible if they underwent a primary THA (index date) and had medical records available 90 days pre-index and 180 days post-index. Bilateral THAs were excluded. Healthcare costs and resource use were evaluated over two years. Changes (pre- vs post-THA) in generic quality of life (QoL) and joint-specific disability were evaluated. Propensity score matching controlled for baseline differences between patients with and without THA dislocation. RESULTS: Among 13,044 patients (mean age 69.2 years (SD 11.4), 60.9% female), 191 (1.5%) had THA dislocation. Two-year median direct medical costs were £15,333 (interquartile range (IQR) 14,437 to 16,156) higher for patients with THA dislocation. Patients underwent revision surgery after a mean of 1.5 dislocations (1 to 5). Two-year costs increased to £54,088 (IQR 34,126 to 59,117) for patients with multiple closed reductions and a revision procedure. On average, patients with dislocation had greater healthcare resource use and less improvement in EuroQol five-dimension index (mean 0.24 (SD 0.35) vs 0.44 (SD 0.35); p < 0.001) and visual analogue scale (0.95 vs 8.85; p = 0.038) scores, and Oxford Hip Scores (12.93 vs 21.19; p < 0.001). CONCLUSION: The cost, resource use, and QoL burden of THA dislocation in England are substantial. Further research is required to understand optimal timing of revision after dislocation, with regard to cost-effectiveness and impact on QoL. Cite this article: Bone Joint J 2022;104-B(7):811-819.

Development of the Revision Hip Complexity Classification using a modified Delphi technique.

AIMS: The aim of this modified Delphi process was to create a structured Revision Hip Complexity Classification (RHCC) which can be used as a tool to help direct multidisciplinary team (MDT) discussions of complex cases in local or regional revision networks. METHODS: The RHCC was developed with the help of a steering group and an invitation through the British Hip Society (BHS) to members to apply, forming an expert panel of 35. We ran a mixed-method modified Delphi process (three rounds of questionnaires and one virtual meeting). Round 1 consisted of identifying the factors that govern the decision-making and complexities, with weighting given to factors considered most important by experts. Participants were asked to identify classification systems where relevant. Rounds 2 and 3 focused on grouping each factor into H1, H2, or H3, creating a hierarchy of complexity. This was followed by a virtual meeting in an attempt to achieve consensus on the factors which had not achieved consensus in preceding rounds. RESULTS: The expert group achieved strong consensus in 32 out of 36 factors following the Delphi process. The RHCC used the existing Paprosky (acetabulum and femur), Unified Classification System, and American Society of Anesthesiologists (ASA) classification systems. Patients with ASA grade III/IV are recognized with a qualifier of an asterisk added to the final classification. The classification has good intraobserver and interobserver reliability with Kappa values of 0.88 to 0.92 and 0.77 to 0.85, respectively. CONCLUSION: The RHCC has been developed through a modified Delphi technique. RHCC will provide a framework to allow discussion of complex cases as part of a local or regional hip revision MDT. We believe that adoption of the RHCC will provide a comprehensive and reproducible method to describe each patient's case with regard to surgical complexity, in addition to medical comorbidities that may influence their management. Cite this article: Bone Jt Open 2022;3(5):423-431.

The effect of uncemented acetabular liner geometry and lip size on the risk of revision for instability or loosening : a study on 202,511 primary hip arthroplasties from the National Joint Registry.

AIMS: The aim of this study was to determine if uncemented acetabular polyethylene (PE) liner geometry, and lip size, influenced the risk of revision for instability or loosening. METHODS: A total of 202,511 primary total hip arthroplasties (THAs) with uncemented acetabular components were identified from the National Joint Registry (NJR) dataset between 2003 and 2017. The effect of liner geometry on the risk of revision for instability or loosening was investigated using competing risk regression analyses adjusting for age, sex, American Society of Anesthesiologists grade, indication, side, institution type, surgeon grade, surgical approach, head size, and polyethylene crosslinking. Stratified analyses by surgical approach were performed, including pairwise comparisons of liner geometries. RESULTS: The distribution of liner geometries were neutral (39.4%; 79,822), 10° (34.5%; 69,894), 15° (21.6%; 43,722), offset reorientating (2.8%; 5705), offset neutral (0.9%; 1,767), and 20° (0.8%; 1,601). There were 690 (0.34%) revisions for instability. Compared to neutral liners, the adjusted subhazard ratios of revision for instability were: 10°, 0.64 (p < 0.001); 15°, 0.48 (p < 0.001); and offset reorientating, 1.6 (p = 0.010). No association was found with other geometries. 10° and 15° liners had a time-dependent lower risk of revision for instability within the first 1.2 years. In posterior approaches, 10° and 15° liners had a lower risk of revision for instability, with no significant difference between them. The protective effect of lipped over neutral liners was not observed in laterally approached THAs. There were 604 (0.3%) revisions for loosening, but no association between liner geometry and revision for loosening was found. CONCLUSION: This registry-based study confirms a lower risk of revision for instability in posterior approach THAs with 10° or 15° lipped liners compared to neutral liners, but no significant difference between these lip sizes. A higher revision risk is seen with offset reorientating liners. The benefit of lipped geometries against revision for instability was not seen in laterally approached THAs. Liner geometry does not seem to influence the risk of revision for loosening. Cite this article: Bone Joint J 2021;103-B(12):1774-1782.

The effect of cemented acetabular component geometry on the risk of revision for instability or loosening : a study of 224,874 primary hip arthroplasties from the National Joint Registry.

AIMS: To determine if primary cemented acetabular component geometry (long posterior wall (LPW), hooded, or offset reorientating) influences the risk of revision total hip arthroplasty (THA) for instability or loosening. METHODS: The National Joint Registry (NJR) dataset was analyzed for primary THAs performed between 2003 and 2017. A cohort of 224,874 cemented acetabular components were included. The effect of acetabular component geometry on the risk of revision for instability or for loosening was investigated using log-binomial regression adjusting for age, sex, American Society of Anesthesiologists grade, indication, side, institution type, operating surgeon grade, surgical approach, polyethylene crosslinking, and prosthetic head size. A competing risk survival analysis was performed with the competing risks being revision for other indications or death. RESULTS: The distribution of acetabular component geometries was: LPW 81.2%; hooded 18.7%; and offset reorientating 0.1%. There were 3,313 (1.5%) revision THAs performed, of which 815 (0.4%) were for instability and 838 (0.4%) were for loosening. Compared to the LPW group, the adjusted subhazard ratio of revision for instability in the hooded group was 2.31 (p < 0.001) and 4.12 (p = 0.047) in the offset reorientating group. Likewise, the subhazard ratio of revision for loosening was 2.65 (p < 0.001) in the hooded group and 13.61 (p < 0.001) in the offset reorientating group. A time-varying subhazard ratio of revision for instability (hooded vs LPW) was found, being greatest within the first three months. CONCLUSION: This registry-based study confirms a significantly higher risk of revision after cemented THA for instability and for loosening when a hooded or offset reorientating acetabular component is used, compared to a LPW component. Further research is required to clarify if certain patients benefit from the use of hooded or offset reorientating components, but we recommend caution when using such components in routine clinical practice. Cite this article: Bone Joint J 2021;103-B(11):1669-1677.

Pathogenic variants in GNPTAB and GNPTG encoding distinct subunits of GlcNAc-1-phosphotransferase differentially impact bone resorption in patients with mucolipidosis type II and III.

PURPOSE: Pathogenic variants in GNPTAB and GNPTG, encoding different subunits of GlcNAc-1-phosphotransferase, cause mucolipidosis (ML) II, MLIII alpha/beta, and MLIII gamma. This study aimed to investigate the cellular and molecular bases underlying skeletal abnormalities in patients with MLII and MLIII. METHODS: We analyzed bone biopsies from patients with MLIII alpha/beta or MLIII gamma by undecalcified histology and histomorphometry. The skeletal status of Gnptgko and Gnptab-deficient mice was determined and complemented by biochemical analysis of primary Gnptgko bone cells. The clinical relevance of the mouse data was underscored by systematic urinary collagen crosslinks quantification in patients with MLII, MLIII alpha/beta, and MLIII gamma. RESULTS: The analysis of iliac crest biopsies revealed that bone remodeling is impaired in patients with GNPTAB-associated MLIII alpha/beta but not with GNPTG-associated MLIII gamma. Opposed to Gnptab-deficient mice, skeletal remodeling is not affected in Gnptgko mice. Most importantly, patients with variants in GNPTAB but not in GNPTG exhibited increased bone resorption. CONCLUSION: The gene-specific impact on bone remodeling in human individuals and in mice proposes distinct molecular functions of the GlcNAc-1-phosphotransferase subunits in bone cells. We therefore appeal for the necessity to classify MLIII based on genetic in addition to clinical criteria to ensure appropriate therapy.

Role of preoperative magnetic resonance imaging in patients with quiescent septic arthritis undergoing primary total hip arthroplasty.

AIM: to evaluate the role of preoperative magnetic resonance imaging (MRI) in assessing patients with a history of quiescent hip septic arthritis undergoing total hip arthroplasty. MATERIALS AND METHODS: retrospective consecutive study of patients with previous history of septic arthritis who underwent MRI scans of their hips prior to primary hip arthroplasty surgery and who also had minimum 2 years follow up postoperatively. Detailed radiographic examinations were obtained, demographic and microbiological data collected. The primary outcome measure was whether a preoperative MRI scan had influenced the surgical decision-making and planning. Rate of recurrence of infection and complications was also collected at final follow up. RESULTS: sixteen patients with quiescent hip septic arthritis were included. There were 4 males and 12 females with average age at time of primary hip arthroplasty 51.7 years (range 22-75). Five patients had childhood septic arthritis with no documented microbiology data. Eleven patients had adult onset septic arthritis. In patients with childhood septic arthritis the MRI findings were similar to those with degenerative joint disease and had no added value to the routine surgical work up. MRIs of patients with adult onset septic arthritis showed persistent findings of effusion, marrow oedema and soft tissue oedema and had no added value to the surgical planning. All but one underwent single stage total hip arthroplasty. At final follow up, with average 4.6 years (range 2-8), none had a recurrence of infection. CONCLUSION: In our experience, preoperative MRI scans did not influence the surgical decision making and are not recommended for routine practice in the surgical work up of quiescent septic arthritis prior to total hip arthroplasty.

Cortical strut allografts in salvage revision arthroplasty: Surgical technique and clinical outcomes.

BACKGROUND: The aim of this study was to present our clinical outcomes and surgical technique in strut allografts preparation using staggered holes to enhance osteointegration and demineralised bone matrix (DBM) as an adjunct to cortical strut allografts in salvage revision arthroplasty patients. METHODS: Retrospective consecutive series of patients who required strut allograft femoral reconstructions with minimum 2 years follow up between 2012 and 2018. Frozen washed irradiated, cortical struts were used and prepared adding 2 mm staggered drill holes along the length of the strut and applying DBM paste on the graft-host interface. Outcome measures included radiographic strut union, graft resorption, infection and complications. RESULTS: 15 patients included; 3 males and 12 females with median age 72 years (range 60-93). All had significant bony defects (Paprosky III/IV in 12 cases including 3 cases of periprosthetic hip fractures and further 3 cases of periprosthetic knee fractures around revision hinged implants). At final follow up, median 3.8 years (range 2.7-7.2), 14/15 (93.3%) struts had united at a median 6 months (range 5-8), complete incorporation with cortical round-off was seen at median 12 months (range 8-48) in 12/15 (80%) struts, 2/15 (13.3%) show radiographic evidence of proximal minimal graft resorptions although the remainder of the strut had integrated and were asymptomatic. There were no cases of infection. CONCLUSIONS: Use of strut allografts helps to reconstruct bone defects, restore bone stock, and provide stable fixation for complex patterns of periprosthetic fractures around hip/knee implants and salvage revision cases with 93.3% union rate at median 6 months.

Canal occlusion in cemented primary total hip replacement: autologous compacted bone block compared to a commercially available gelatine plug.

AIMS: To evaluate the stability of 2 canal occlusion systems; an autologous, compacted bone block and the biodegradable C-plug. We also sought to investigate any relationship between stability of the systems and the quality of cementation. A retrospective radiographic comparative review was conducted. METHODS: A total of 203 consecutive patients were analysed, 89 received an autologous bone block and 114 had C-plugs. There was no significant differences between the groups in terms of age, sex and primary diagnosis. The mean cement tail length in the bone block group (6.42 mm; range 0-31) was significantly shorter than in the C-plug group (17.11 mm; range 0-65.7). RESULTS: The proportion of patients with good quality of cementation (Barrack grade A) was significantly higher in the bone block group (80.6%) as compared to the C-plug group (56%) (p < 0.001). There was a negative correlation between the length of the cement tail and the Barrack grade, indicating that a short cement tail is associated with better quality cementation. CONCLUSIONS: We have shown that improved cement penetration and shorter cement tails can be achieved with the cheapest of all options for canal occlusion, an autologous compacted bone block and hence recommend this technique.

Is Preoperative Identification of the Infecting Organism Essential Before Single-Stage Revision Hip Arthroplasty for Periprosthetic Infection?

BACKGROUND: It is commonly stated that identification of the infecting organism is a prerequisite to single-stage revision arthroplasty of the hip for deep infection. We have performed single-stage revision in a series of patients where the organism was not identified preoperatively. The aim of this study is to investigate whether the rate of infection eradication following single-stage revision was affected by preoperative knowledge of the infecting organism. METHODS: We identified all patients who had undergone a single-stage revision for a deep infection at our hospital between 2006 and 2015. One hundred five patients were assigned into 2 groups based upon whether the infecting organism had been identified preoperatively (group A = 28) or not (group B = 77). RESULTS: The reinfection rates were 3.6% in group A and 9.1% for group B (P = .679). Re-revision rates were 7.1% and 9.1%, respectively (P = 1.00). Overall, the implant survival rate at 6 years was 87.9% (95% confidence interval, 97.4-78.4). In group B, preoperative aspiration was performed in 36.4% (28/77) of cases. Staphylococci species were the predominant causative organisms, with gram-negative involvement in 19.0% (20/105) of cases. CONCLUSION: The rate of infection eradication and overall survivorship with single-stage revision was similar in our series to that reported in the literature. While desirable, we did not find identification of the infecting organism before surgery influenced the outcome. Given the functional and economic benefits of single-stage revision, we suggest that failure to identify an organism is not an absolute contraindication to this approach.

Overview of Randomized Controlled Trials in Primary Total Hip Arthroplasty (34,020 Patients): What Have We Learnt?

AIM: To provide an overview of randomized controlled trials (RCTs) in primary total hip arthroplasty summarizing the available high-quality evidence. MATERIALS AND METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA), we searched the Cochrane Central Register of Controlled Trials (2020, Issue 1), Ovid MEDLINE, and Embase. We excluded nonrandomized trials, trials on neck of femur fractures or revision surgery, systematic reviews, and meta-analyses. Trials that met our inclusion criteria were assessed using a binary outcome measure of whether they reported statistically significant findings. These were then classified according to the intervention groups (surgical approach, fixation, and component design use, among others). RESULTS: Three hundred twelve RCTs met the inclusion criteria and were included. The total number of patients in those 312 RCTs was 34,020. Sixty-one RCTs (19.5%) reported significant differences between the intervention and the control groups. The trials were grouped into surgical approach 72, fixation 7, cement 16, femoral stem 46, head sizes 5, cup design 18, polyethylene 25, bearing surfaces 30, metal-on-metal 30, resurfacing 20, navigation 15, robotics 3, surgical technique 12, and closure/drains/postoperative care 13 RCTs. DISCUSSION: The evidence reviewed indicates that for the vast majority of patients, a standard conventional total hip arthroplasty with a surgical approach familiar to the surgeon using standard well-established components and highly cross-linked polyethylene leads to satisfactory clinical outcomes. This evidence also offers arthroplasty surgeons the flexibility to use the standard and cost-effective techniques and achieve comparable outcomes.

Survivorship and Radiological Analysis of a Monoblock, Hydroxyapatite-Coated Titanium Stem in Revision Hip Arthroplasty.

BACKGROUND: We evaluated the survivorship, incidence of complications, radiological subsidence, proximal stress shielding, and patient-reported outcomes of a conservative, monoblock, hydroxyapatite-coated femoral stem. METHODS: This retrospective cohort study reports on 254 revision hip arthroplasties between January 2006 and June 2016. The mean age of patients was 71 years. The mean length of follow-up was 62 months (range 12-152). RESULTS: There were 13 stem re-revisions: infection (4), periprosthetic fracture (4), aseptic stem loosening (3), stem fracture (1), and extended trochanteric osteotomy nonunion (1). Kaplan-Meier aseptic stem survivorship was 97.33% (confidence interval 94-100) at 6 years. There were 29 intraoperative fractures. There were 6 cases of subsidence greater than 10 mm; however, none required revision. Ninety-six percent of cases showed no proximal stress shielding. Thigh pain was reported in 3% of cases. CONCLUSION: This study confirms that this stem provides good survivorship at 6 years, acceptable complication rates, adequate proximal bone loading, low incidences of thigh pain, and reliable clinical performance in revision hip arthroplasty. KEY MESSAGE: A monoblock, fully hydroxyapatite-coated titanium stem is reliable in revision arthroplasty with mild-moderate femur deficiencies.

Preoperative pain catastrophisation may predict worse patient-reported outcomes after primary hip arthroplasty: A pilot study.

AIM: to investigate the relationship between pain catastrophising and patient-reported clinical outcomes following primary total hip arthroplasty. MATERIALS AND METHODS: prospective consecutive study of 103 patients who completed preoperative Pain Catastrophisation Score (PCS), preoperative and 12-month postoperative Oxford Hip Score (OHS). Correlation analysis was carried out between the improvement in OHS (mean difference between pre- and postoperative scores) and the mean preoperative PCS score using the Pearson's r rank test. Multiple linear regression was then performed using the postoperative OHS as the outcome variable against a number of predictor variables. RESULTS: there were 37 males and 66 females with average age of 60.5 years (range 22-84). Mean preoperative PCS score was 16.3 (±13.6; range 0-49). Mean preoperative OHS was 16.5 (±3.5) which had improved at 12-months postoperatively to a mean 38.1 (±11.1). The difference was statistically significant (P < 0.0001). Preoperative PCS scores were correlated with the OHS improvement at 12-months which revealed a weak negative correlation Pearson's correlation coefficient r = - 0.248 (P = 0.0114). Preoperative PCS score, predictor variable, had statistically significant relationship with the postoperative OHS (P = 0.0207). The regression coefficient for the PCS was -0.25, therefore for each unit increase in the preoperative PCS score there was a 0.25 unit decrease in the postoperative OHS score. CONCLUSION: pain catastrophising appear to predict poorer postoperative patient-reported outcome measures. Further research is needed to evaluate the value of early identification of high-risk patients and the role of preoperative involvement of pain specialists and its effects on postoperative outcomes.