The bikini incision anterior cemented total hip arthroplasty: Assessment of radiological and clinical outcomes - A mid-term review.

INTRODUCTION: There has been an increased interest in minimally invasive direct anterior approach total hip arthroplasty (THA) to provide greater patient satisfaction, improve pain relief, and reduce the duration of hospitalisation. A direct anterior approach hybrid cemented THA, utilising a bikini line incision, can be technically challenging. We aimed to undertake radiological analysis of femoral stem cementation, clinical outcomes, and component survivorship. METHODS: Over a 5-year period, 215 primary elective bikini anterior THA conducted by a single surgeon were included. All procedures were performed using a cemented collarless polished stem. The operation was performed on a standard operating table. Patients undergoing posterior approach, revision procedures, and fractured neck of femurs were excluded. Post-operative radiographs were analysed for femoral cementation quality using the Barrack grading system. Harris hip scores (HHS) were determined at 6 weeks, 12 weeks, annually thereafter and the difference in HHS was noted. RESULTS: In total, 215 anterior bikini THA (R = 101, L = 114) were performed in 199 patients (M = 89, F = 110) with a mean age of 77 and mean follow up of 2.9 years (range = 0.5-5). Radiographic analysis of femoral cementation showed 189 femoral stems (88%) were either Barrack A or B cementation grade, suggesting optimal cementation. Lucency in the cement-bone interface occurred mainly in Gruen Zone 1 (43%) and Zone 13(46.9%). At the most recent follow-up (mean 2.9 years), component survivorship was at 99.54% (stem). Significant improvement was noted in Harris hip scores at final follow-up (from 54 preoperatively to 92.7 at 2.9 years postoperatively). CONCLUSION: Our results suggest that a bikini incision direct anterior approach for total hip arthroplasty can be safely employed to perform cemented femoral stems on a standard operating table.

Minimizing complications in bikini incision direct anterior approach total hip arthroplasty: A single surgeon series of 865 cases.

PURPOSE: The purpose of this study was to report all complications during the first consecutive 865 cases of bikini incision direct anterior approach (DAA) total hip arthroplasty (THA) performed by a single surgeon. The secondary aims of the study are to report our clinical outcomes and implant survivorship. We discuss our surgical technique to minimize complication rates during the procedure. METHODS: We undertook a retrospective analysis of our complications, clinical outcomes and implant survivorship of 865 DAA THA's over a period of 6 years (mean = 3.9yrs from 0.9 to 6.8 years). RESULTS: The complication rates identified in this study were low. Medium term survival at minimum 2-year survival and revision as the end point, was 99.53% and 99.84% for the stem and acetabular components respectively. Womac score improved from 49 (range 40-58) preoperatively to 3.5(range 0-8.8) and similarly, HHS scores improved from 53(range 40-56) to 92.5(range 63-100) at final follow-up (mean = 3.9 yrs) when compared to preoperative scores. CONCLUSIONS: These results suggest that bikini incision DAA technique can be safely utilised to perform THA.

Limited penetration of cobalt and chromium ions into the cerebrospinal fluid following metal on metal arthroplasty: a cross-sectional analysis.

Background: The purpose of this study was to determine the concentration of cobalt (Co) and chromium (Cr) ions in synovial fluid, blood plasma and cerebrospinal fluid (CSF) of patients with metal-on-metal (MoM) implants, and to assess the relationship between implant history and patient characteristics with ion concentrations in CSF.Methods: An observational, non-randomised cross-sectional study was conducted with patients presenting to a single surgeon for treatment of degenerative conditions of the hip and knee. Blood and fluid samples were collected intraoperatively and analysed for proteins and trace elements.Results: Overall, the presence of an implant was associated with significantly higher Co and Cr concentrations in plasma (controls 5-115 nmol/L Co, 5-232 nmol/L Cr; well-functioning implant recipients 5-469 nmol/L Co, 5-608 nmol/L Cr; hip revisions 6-546 nmol/L Co, 5-573 nmol/L Cr), and for Cr concentrations in CSF (controls 5-24 nmol/L; well-functioning implant recipients 6-36 nmol/L, hip revisions 7-32 nmol/L). In absolute terms, <1% of the levels observed in the joint fluid and <15% of plasma metals appeared in the CSF. Multivariable regression models suggested different transfer mechanisms of Co and Cr to the CSF, with the presence of an implant not associated with ion levels.Conclusion: The presence of MoM implants is associated with significantly higher plasma levels of Co and Cr but not CSF levels, and the CSF/plasma ratio appears to be influenced by the plasma concentration in a nonlinear fashion. Co and Cr may be transferred to the CSF by different mechanisms, and their concentrations appears dependent on other factors yet to be identified. Although higher levels of plasma ions are associated with above average CSF metal concentrations, the thresholds for neurotoxicity remain unclear and require further study.

When do patients drive after minimally invasive anterior hip replacements? A single surgeon experience of 212 hip arthroplasties.

INTRODUCTION: Patients desire to return to normal activities soon after hip arthroplasty, with driving often being an integral component. We aimed to determine when patients resumed driving following a minimally invasive anterior bikini hip replacement and when they returned to work. METHODOLOGY: All consecutive patients undergoing elective primary bikini hip replacements between January 2017 and April 2018 were included in the study. Patients who did not drive were excluded. A detailed questionnaire was sent to patients 3-6 weeks after surgery to record their driving status. Fifty patients were randomly selected to assess flexion at the hip, knee and ankle joints while seated in the driver's seat of their own vehicle. RESULTS: Altogether 212 anterior bikini total hip replacements (L = 102, R = 108 and 1 bilateral one stage) were performed in 198 patients (F = 129 and M = 69) with a mean age of 69 years. A total of 76% patients returned to driving within the first 3 weeks after surgery, of which 25 (14%) resumed driving within the first post-operative week, 71 (39%) in the second week and 42 (23%) in the third week. Among them, 98.4% stated they were confident when they first started driving and 90.66% stated they were more comfortable driving after surgery than before. Employed patients returned to work within 1-79 days (mean = 24 days). CONCLUSION: Surgeons may allow patients to resume driving within 1 week after anterior hip replacement and return to work within 3 weeks if they are medically fit and deemed safe.

One-stage bilateral anterior bikini total hip replacement - experience of two cases.

Bilateral hip arthrosis is commonly seen and two-staged bilateral Total Hip Arthroplasty (THA) is a preferred choice of treatment due to the fear of complications associated with one-stage bilateral procedures. However, many studies now indicate that the treatment option should be patient specific. We report two cases of one-stage bilateral anterior THA. First, a 54-year-old male operated over a year ago and second a 59-year-old female operated 6 weeks ago. Both presented with a long history of bilateral grade IV hip arthritis causing them severe pain, compromised gait and disturbed sleep. Post-surgery, they were mobilized within few hours after surgery as part of our enhanced recovery programme. There was a drastic increase in their Harris Hip Scores from 34.5 in case 1 and 19.2 in case 2 to 100 for both hips in both patients. They reported excellent recovery, regained normal gait pattern, returned quickly to their routine lifestyle and felt it was an economical option. We conclude that one-stage bilateral bikini anterior THA is a preferred surgical option for patients with bilateral hip arthritis that are medically fit.

Accuracy of bone resection in total knee arthroplasty using CT assisted-3D printed patient specific cutting guides.

INTRODUCTION: We conducted this study to determine if the pre-surgical patient specific instrumented planning based on Computed Tomography (CT) scans can accurately predict each of the femoral and tibial resections performed through 3D printed cutting guides. The technique helps in optimization of component positioning determined by accurate bone resection and hence overall alignment thereby reducing errors. METHODS: Prophecy evolution medial pivot patient specific instrumented knee replacement systems were used for end stage arthrosis in all consecutive cases over a period of 20 months by a single surgeon. All resections (4 femoral and 2 tibial) were measured using a vernier callipers intraoperatively. These respective measurements were then compared with the preoperative CT predicted bone resection surgical plan to determine margins of errors that were categorized into 7 groups (0 mm to ≥2.6 mm). RESULTS: A total of 3618 measurements (averaged to 1206) were performed in 201 knees (105 right and 96 left) in 188 patients (112 females and 76 males) with an average age of 67.72 years (44 to 90 years) and average BMI of 32.3 (25.1 to 42.3). 94% of all collected resection readings were below the error margin of ≤1.5 mm of which 90% showed resection error of ≤1 mm. Mean error of different resections were ≤0.60 mm (P ≤ 0.0001). In 24% of measurements there were no errors or deviations from the templated resection (0.0 mm). CONCLUSION: The 3D printed cutting blocks with slots for jigs accurately predict bone resections in patient specific instrumentation total knee arthroplasty which would directly affect component positioning.

One-stage Exchange Arthroplasty for Periprosthetic Hip and Knee Joint Infections.

BACKGROUND: Periprosthetic joint infection (PJI) is a devastating complication of joint replacement surgery. In an aging population of the developed world, the increasing numbers of hip and knee replacements will inevitably lead to increasing incidence of PJI, carrying with (it) significant patient morbidity and cost to the health care system. Two-stage exchange arthroplasty is currently the gold standard but it is associated with multiple operations, prolonged hospitalization and impaired functionality. One-stage exchange arthroplasty is similar to the two-stage procedure but the interval between removal of the prosthesis and reimplantation of a new one is only a few minutes. It has the theoretical benefits of a single anesthetic, shorter hospitalization, less cost and improved function. METHODS: We reviewed the current literature regarding the outcomes of one-stage exchange arthroplasties focusing on re-infection rates and functional outcomes. RESULTS: Current themes around the one-stage exchange procedure include the indications for the procedure, definition of re-infection, surgical techniques used to provide fixation and differences in approach for hip and knee replacements. CONCLUSION: The current literature on one-stage exchange procedure is promising, with comparable results to two-stage revisions for hips and knees in selected patients. However, there is a great need for a large multi-centred randomized control trial, focusing on re-infection rates and functional scores postoperatively, to provide concrete guidelines in managing this complex condition.

Do Nonsteroidal Anti-Inflammatory Drugs Cause Endoprosthetic Loosening? Mid- to Long-Term Follow-Up of 100 Total Hip Arthroplasties after Local NSAID Infiltration.

We evaluated the effect of local infiltration of NSAIDs on prosthetic fixation at mid- to long-term follow-up of total hip arthroplasties. Intra-articular local NSAID (ketorolac) was injected into hip joints and surrounding tissues intraoperatively and postoperatively as a part of multimodal pain management protocol. Clinical and radiographic evaluation was performed for any evidence of component loosening or failure and clinical outcomes in 100 total hip joint arthroplasties with a mean follow-up of 7.3 years (4.9 to 11 yrs). Radiographic analysis at the most recent follow-up showed no evidence of loosening, subsidence, or migration and no evidence of impending failure. Clinical outcomes showed improved Harris hip scores. Intra-articular NSAID used in the intraoperative/postoperative period in hip arthroplasty showed no evidence of prosthetic loosening at mid- to long-term follow-up.

Peri-operative interventions producing better functional outcomes and enhanced recovery following total hip and knee arthroplasty: an evidence-based review.

The increasing numbers of patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA), combined with the rapidly growing repertoire of surgical techniques and interventions available have put considerable pressure on surgeons and other healthcare professionals to produce excellent results with early functional recovery and short hospital stays. The current economic climate and the restricted healthcare budgets further necessitate brief hospitalization while minimizing costs.Clinical pathways and protocols introduced to achieve these goals include a variety of peri-operative interventions to fulfill patient expectations and achieve the desired outcomes.In this review, we present an evidence-based summary of common interventions available to achieve enhanced recovery, reduce hospital stay, and improve functional outcomes following THA and TKA. It covers pre-operative patient education and nutrition, pre-emptive analgesia, neuromuscular electrical stimulation, pulsed electromagnetic fields, peri-operative rehabilitation, modern wound dressings, standard surgical techniques, minimally invasive surgery, and fast-track arthroplasty units.

Hip resurfacing in an 88-year-old patient? Highlighting selection criteria for hip resurfacings in patients older than 65 years.

The success of hip resurfacings in the older population is still to be determined, although it has been an attractive option in the much younger patients with arthrosis of the hip. We present a 95-year-old active, independent patient who underwent a Birmingham hip resurfacing at 88 years of age. More than 7 years after surgery, the original components are still in situ, and the patient is pain-free with a very active lifestyle at the age of 95 years. Hip resurfacings are not without risks, and we highlight the evolution of strict selection criteria for patients older than 65 years who may be suitable candidates for hip resurfacing arthroplasty.