Comparison of Effectiveness and Safety of Oxycodone Hydrochloride and Fentanyl for Post-operative Pain Following Total Hip Arthroplasty: A Randomized Triple-Blind Trial.

Background: Total hip replacement (THR) is frequently associated with intense post-surgical pain. Effective pain management is of crucial importance to improving patient's condition and increasing his/her satisfaction in the post-operative time. Objectives: This study aimed to compare the analgesic effect and safety of oxycodone and fentanyl after THR. Methods: Seventy-two cases scheduled for elective THR were included in this randomized, triple-blind trial. The patients were equally randomized into 2 groups: Fentanyl group (50 ug of fentanyl) and oxycodone group (oxycodone 4 mg). Drugs were received 20 min prior to the end of the operation. Results: Post-operative visual analog scale (VAS) measurements at rest and movement at the post-anesthesia care unit (PACU) and in the ward, 2 h, 4 h, and 8 h post-operatively exhibited a significantly reduced value in the oxycodone group compared to the fentanyl group (P-value < 0.05). Time to first rescue for analgesia was delayed significantly in the oxycodone compared to the fentanyl group (P-value < 0.001). Fentanyl consumption (ug) in the 1st post-operative 12 h, 24 h, and 48 h decreased significantly in the oxycodone group compared to the fentanyl group (P-value < 0.001). Post-operative nausea, vomiting, headache, and pruritus were matched between the 2 groups (P > 0.05). Conclusions: A bolus dose of 4 mg of oxycodone provided superior analgesic efficacy than 50 ug fentanyl as evidenced by significantly lower pain score, delayed onset to first request for analgesia, and the smaller amount of fentanyl consumption at 12, 24, and 48 h post-total hip arthroplasty compared to fentanyl. The incidence of adverse events was comparable between the 2 groups.

Accuracy of cup placement compared with preoperative surgeon targets in primary total hip arthroplasty using standard instrumentation and techniques: a global, multicenter study.

BACKGROUND: Acetabular cup positioning in total hip arthroplasty (THA) is closely related to outcomes. The literature has suggested cup parameters defined by the Lewinnek safe zone; however, the validity of such measures is in question. Several studies have raised concerns about the benefits of using the Lewinnek safe zone as a predictor of success. In this study we elected to use prospective surgeon targets as the basis for comparison to see how successful surgeons are positioning their cup using standard instruments and techniques. METHODS: A prospective, global, multicenter study was conducted. Cup positioning success was defined as a composite endpoint. Both cup inclination and version needed to be within 10° of the surgeon target to be considered a success. Radiographic analysis was conducted by a third-party reviewer. RESULTS: In 170 subjects, inclination, target versus actual, was 44.8° [standard deviation (SD 0.9°)] and 43.1° (SD 7.6°), respectively (p = 0.0029). Inclination was considered successful in 84.1% of cases. Mean version, target versus actual, was 19.4° (SD 3.9°) and 27.2° (SD 5.6°), respectively (p < 0.0001). Version was considered successful in 63.4% of cases, and combined position (inclination and version) was considered successful in 53.1%. CONCLUSION: This study shows that with traditional methods of placing the cup intraoperatively, surgeons are only accurate 53.1% of the time compared with a predicted preoperative plan. This study suggests that the inconsistency in cup positioning based on the surgeon's planned target is potentially another important variable to consider while using a mechanical guide or in freehand techniques for cup placement in THA. TRIAL REGISTRATION: This study is registered on ClinicalTrials.gov, NCT03189303.

Mechanisms and Preventative Strategies for Persistent Pain following Knee and Hip Joint Replacement Surgery: A Narrative Review.

Chronic postsurgical pain (CPSP) following total knee arthroplasty (TKA) and total hip arthroplasty (THA) is a prevalent complication of joint replacement surgery which has the potential to decrease patient satisfaction, increase financial burden, and lead to long-term disability. The identification of risk factors for CPSP following TKA and THA is challenging but essential for targeted preventative therapy. Recent meta-analyses and individual studies highlight associations between elevated state anxiety, depression scores, preoperative pain, diabetes, sleep disturbances, and various other factors with an increased risk of CPSP, with differences observed in prevalence between TKA and THA. While the etiology of CPSP is not fully understood, several factors such as chronic inflammation and preoperative central sensitization have been identified. Other potential mechanisms include genetic factors (e.g., catechol-O-methyltransferase (COMT) and potassium inwardly rectifying channel subfamily J member 6 (KCNJ6) genes), lipid markers, and psychological risk factors (anxiety and depression). With regards to therapeutics and prevention, multimodal pharmacological analgesia, emphasizing nonopioid analgesics like acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs), has gained prominence over epidural analgesia. Nerve blocks and local infiltrative anesthesia have shown mixed results in preventing CPSP. Ketamine, an N-methyl-D-aspartate (NMDA)-receptor antagonist, exhibits antihyperalgesic properties, but its efficacy in reducing CPSP is inconclusive. Lidocaine, an amide-type local anesthetic, shows tentative positive effects on CPSP. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) have mixed results, while gabapentinoids, like gabapentin and pregabalin, present hopeful data but require further research, especially in the context of TKA and THA, to justify their use for CPSP prevention.

Bone mineral density changes around the stem correlate with stress changes after total hip arthroplasty: A study using thermoelastic stress analysis.

Purpose: Thermoelastic stress analysis (TSA) was used to evaluate stress changes over the entire surface of a specimen. This study aimed to assess the relationship between femoral stress distribution, analysed using TSA and changes in bone mineral density (BMD) after total hip arthroplasty (THA). Methods: Stress changes in the simulated bone before and after taper-wedge stem insertion were measured using the TSA. Stress changes were compared with BMD changes around the stem 1 year after surgery in a THA patient (58 hips) with the same taper-wedge stem. Subsequently, we compared the correlation between stress changes and BMD changes. Results: TSA revealed significant stress changes before and after stem insertion, with prominent alterations in the proximal medial region. The BMD changes at 1 year post-THA exhibited a 15%-25% decrease in the proximal zones, while Zones 2-6 showed a -6% to 3% change. Notably, a strong positive correlation (0.886) was found between the stress change rate and BMD change rate. Conclusions: This study demonstrated a high correlation between femoral stress distribution assessed using TSA and subsequent BMD changes after THA. The TSA method offers the potential to predict stress distribution and BMD alterations postsurgery, aiding in implant development and clinical assessment. Combining TSA with finite element analysis could provide even more detailed insights into stress distribution. Level of Evidence: Case series (with or without comparison).

Total Hip Arthroplasty in Dyggve-Melchior-Clausen Syndrome: Literature Review and Case Report.

Dyggve-Melchior-Clausen (DMC) disease is a rare spondyloepiphyseal autosomal recessive disorder characterized by skeletal dysplasia and intellectual disability. Hip arthritis, often secondary to hip dysplasia, presents at an early age. Current literature suggests that osteotomies do not benefit DMC syndrome-associated hip disease but reports of total hip arthroplasty in these patients are lacking. We present a case of bilateral hip replacement in a 31-year-old patient with DMC syndrome. After planning the operation with the use of computed tomography, we chose to use a small-dimension porous cup along with an appropriately sized version control stem in order to address the unique acetabular and femoral deformities. In conclusion, we consider total hip replacement in DMC syndrome to be safe and effective in addressing a challenging hip pathology.

Identification of Surgeon Outliers to Improve Cost Efficiency: A Novel Use of the Centers for Medicare and Medicaid Quality Payment Program.

BACKGROUND: Bundled payment programs for total joint arthroplasty (TJA) have become popular among both private and public payers. Because these programs provide surgeons with financial incentives to decrease costs through reconciliation payments, there is an advantage to identifying and emulating cost-efficient surgeons. The objective of this study was to utilize the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) in combination with institutional data to identify cost-efficient surgeons within our region and, subsequently, identify cost-saving practice patterns. METHODS: Data was obtained from the CMS QPP for total knee (TKA) and total hip (THA) surgeons within a large metropolitan area from January 2019 to December 2021. A simple linear regression determined the relationship between surgical volume and cost-efficiency. Internal practice financial data determined whether patients of identified surgeons differed with respect to x-ray visits, physical therapy visits, out-of-pocket payments to the practice, and whether surgery was done in hospital or surgical center settings. RESULTS: There were four TKA and three THA surgeons who were cost-efficiency outliers within our area. Outliers and non-outlier surgeons had patients who had similar BMI, ASA, and age-adjusted CCI scores. Patients of these surgeons had fewer x-ray visits for both TKA and THA (1.06 versus 1.11, P < 0.001; 0.94 versus 1.15, P < 0.001) and lower out-of-pocket costs ($86.10 versus $135.46, P < 0.001; $116.10 versus $177.40, P < 0.001). If all surgeons performing > 30 CMS cases annually within our practice achieved similar cost-efficiency, the savings to CMS would be $17.2 million for TKA alone ($75,802,705 versus $93,028,477). CONCLUSION: The CMS QPP can be used to identify surgeons who perform cost-efficient surgeries. Practice patterns that result in cost savings can be emulated to decrease the cost curve, resulting in reconciliation payments to surgeons and institutions and cost savings to CMS.

Orthopedic Challenges in Avascular Necrosis Management: A Case Report of Surgical Complications and Multidisciplinary Care.

A 52-year-old woman, with a multifaceted medical background encompassing spinal cord injury, pneumonia, and recurrent hospitalizations, presents with enduring left hip and leg discomfort ultimately diagnosed as avascular necrosis (AVN). She previously underwent intraosseous direct anterior arthroplasty (DAA) of the left hip during the removal of orthopedic artifacts. Despite enduring hypertension, severe trochanter dislocation, and prosthesis fracture, she recovered and required additional surgery to address the dislocation and fracture. This case underscores the challenges in diagnosing and treating AVN, emphasizing the importance of meticulous postoperative care and a multidisciplinary approach. Challenges highlighted by AVN include delayed diagnosis, intricate surgical procedures, and the potential need for further interventions due to hardware complications and infection as seen in this patient.

Mid-Term Outcomes of a Short Modular Neck-Preserving Cementless Hip Stem: A Retrospective Study With a 6-Year Minimum Follow-Up.

Background: The neck-preserving cementless short stem represents a valid therapeutic option for total hip replacement in high-functional-demand patients, but few studies are available about the use of modularity in the last-generation short stem. The aim of the study was to evaluate the mid-term survival of a specific implant design that combines partial collum short hip stem with neck modularity; assessing the functional status was the second endpoint. Methods: A retrospective single-center cohort study was conducted on 75 patients aged 35 to 80 years, with a minimum 6-year follow-up. Patients with neurological/rheumatic pathologies and previous hip surgeries were excluded. All the patients underwent total hip replacement with a short modular neck-preserving cementless hip stem. Clinical outcomes, complications, revisions, and the Western Ontario and McMaster Universities Osteoarthritis Index, Harris hip score, and Short Form 12-Item Health Survey (SF-12) questionnaires were evaluated. The results were compared with healthy population's data extracted from the literature, stratified by age. Results: The Kaplan-Meier analysis revealed a 10-year implant survival rate of 96.7%, coupled with a revision rate of 1.3%. Results showed a Harris hip score and physical SF-12 significantly lower and a mental SF-12 higher when compared to healthy population. No statistically significant differences emerged when comparing groups based on neck modularity. Conclusions: The short modular neck-preserving cementless hip stem emerged as a reasonable choice for patients with elevated functional demands, ensuring good clinical outcomes while preserving bone integrity. The use of a modular neck in short stems didn't show any mechanical problems in the mid-term.

Acetabular Distraction: Promising 5-Year Outcomes for the Treatment of Chronic Pelvic Discontinuity.

BACKGROUND: Severe acetabular bone loss encountered during revision total hip arthroplasty (THA) poses a clinical challenge. In cases involving pelvic discontinuity, where the ilium is separated superiorly from the inferior ischiopubic segment through the acetabulum, acetabular distraction may be used to restore the biomechanics of the hemipelvis. This technique allows for correct sizing of the acetabulum, and the subsequent peripheral distraction and medial compression at the discontinuity provide initial mechanical stability and biological fixation as bone ingrowth occurs. Accordingly, this study aimed to assess long-term 5-year outcomes following acetabular distraction across two institutions. METHODS: We retrospectively identified all patients who underwent revision THA in which the acetabular distraction technique was performed for the treatment of chronic pelvic discontinuity between 2002 and 2018. Demographic, operative, and clinical post-operative data were collected. Clinical endpoints included post-operative radiographic outcomes, complications requiring additional surgery, and re-operation for all causes. Only patients who had a minimum 5-year follow-up were included in this study. RESULTS: A total of 15 patients (Paprosky IIC: one patient, 6.7%; Paprosky IIIA: five patients, 33.3%; Paprosky IIIB: nine patients, 60%) who had a mean follow-up time of 9 years (range, 5.1 to 13.5) were analyzed. Porous tantalum augments were used in 11 (73.3%) cases to primarily address posterior-superior defects (100%). There were four (26.7%) patients that required re-operation, only two of which were for indications related to the acetabular construct, leading to an overall survivorship of 86.7%. Both patients had a prior revision THA before the implementation of the distraction technique. Evidence of bridging callus formation was reported radiographically for 14 (93.3%) patients at the time of the last clinical follow-up. CONCLUSION: For patients who have chronic pelvic discontinuity, acetabular distraction shows promising long-term outcomes. Even so, larger multicenter studies are needed to better support the efficacy of this technique.

Total Hip Arthroplasty Versus Education and Exercise: A Propensity-Matched Analysis of 266 Patients Who Have Hip Osteoarthritis.

BACKGROUND: Total hip arthroplasty (THA) for osteoarthritis (OA) is a major health system cost. Education and exercise (Edu+Ex) programs may reduce the number of THAs needed, but supporting data is limited. This study aimed to estimate the treatment effect of THA versus Edu+Ex on pain, function, and quality of life outcomes 3- and 12-months after treatment initiation for hip OA. METHODS: Patients who had hip OA who underwent THA or an Edu+Ex program were included in this propensity-matched study. In 778 patients (Edu+Ex n = 303; THA n = 475), propensity scores were based on pre-treatment characteristics, and patients were matched on a 1:1 ratio. Between-group treatment effects (pain, function, and quality of life) were estimated as the mean difference in change from pre-treatment to 3- and 12-month follow-up using linear mixed models. RESULTS: The matched sample consisted of 266 patients (Edu+Ex n = 133; THA n = 133) that were balanced on all pre-treatment characteristics except opioid use. At 12-month follow-up, THA resulted in significantly greater improvements in pain (mean difference [MD] 35.4; 95% CI [confidence interval] 31.4 to 39.4), function (MD 30.5; 95% CI 26.3 to 34.7), and quality of life (MD 33.6; 95% CI 28.8 to 38.4). Between 17 and 30% of patients receiving Edu+Ex experienced a surgical threshold for clinically meaningful improvement in outcomes, compared to 84 and 90% of THA patients. CONCLUSIONS: A THA provides greater improvements in pain, function, and quality of life. A significant proportion of Edu+Ex patients had clinically meaningful improvements, suggesting Edu+Ex may result in THA deferral in some patients, but confirmatory trials are needed.

Comparison of Early Post-operative Step and Stair Counts with the Direct Anterior Approach versus the Posterior Approach for Total Hip Arthroplasty.

INTRODUCTION: The purpose of this study was to evaluate the impact of direct anterior (DAA) or posterior (PA) approaches on step and stair counts after total hip arthroplasty (THA) using a remotely monitored mobile application with a smartwatch while controlling for baseline characteristics. METHODS: This is a secondary data analysis from a prospective cohort study of patients utilizing a smartphone-based care management platform. The primary outcomes were step and stair counts and changes from baseline through one year. Step and stair counts were available for 1,501 and 847 patients, respectively. Longitudinal regression models were created to control for baseline characteristics. RESULTS: Patients in the DAA group had significantly lower BMI (P = 0.049) and comorbidities (P = 0.028), but there were no significant differences in age (P = 0.225) or sex (P = 0.315). The DAA patients had a higher average and improvement from baseline in step count at two and three weeks post-operatively after controlling for patient characteristics (P = 0.028 and P = 0.044, respectively). The average stair counts were higher for DAA patients at one month post-operatively (P = 0.035), but this difference was not significant after controlling for patient demographics. Average stair ascending speeds and changes from baseline were not different between DAA and PA patients. Descending stair speed was higher at two weeks post-operatively for DAA patients, but was no longer higher after controlling for baseline demographics. DISCUSSION: After controlling for baseline characteristics, DAA patients demonstrate earlier improvement in step count than PA patients after THA. However, patient selection and surgeon training may continue to influence outcomes through a surgical approach.

Effects of Intrathecal Morphine Administration in Patients Undergoing Primary Total Hip Arthroplasty Under Spinal Anesthesia With Quadratus Lumborum Block for Postoperative Analgesia.

Introduction Quadratus lumborum (QL) block has previously been shown to provide improved analgesia in patients undergoing primary total hip arthroplasty (THA) under spinal anesthesia when compared to spinal anesthesia alone. Additionally, recent studies have shown the addition of intrathecal morphine (ITM) to provide superior postoperative analgesia in patients undergoing various surgical interventions including total knee arthroplasty under spinal anesthesia with peripheral nerve blockade. At this time, however, there has not been a study evaluating the effects of intrathecal morphine in patients undergoing THA under spinal anesthesia with QL block. This study aims to assess if the addition of intrathecal morphine can provide adequate or even superior postoperative analgesia in patients undergoing primary THA. Methods This retrospective study included 26 patients in the spinal/QL block/intrathecal morphine (SA+QLB+ITM) group, 31 patients in the spinal/QL block group (SA+QLB), and 28 patients in the spinal only (SA or control) group. Twenty-six patients undergoing primary THA under a combination of spinal anesthesia and peripheral nerve blockade (quadratus lumborum block) were given a dose of 100 mcg of intrathecal morphine. Various parameters were evaluated including Post-Anesthesia Care Unit (PACU) and 24-hour visual analog scale (VAS) scores, time to first opioid use, 24- and 48-hour total opioid use as oral morphine equivalents (OME), 24-hour ambulation distance, and time from block placement to hospital discharge. The results were analyzed and compared to patients undergoing primary THA under spinal anesthesia with QL block (no intrathecal morphine) and compared to a control group of patients undergoing primary THA under spinal anesthesia only. Results The study analysis included 26 patients in the SA+QLB+ITM group, 31 patients in the SA+QLB group, and 28 patients in the SA (control) group. When compared with the control group, the SA+QLB+ITM had lower 24-hour total opioid usage (mean difference 20.80 OME, CI 6.454 to 35.15, p-value 0.0025), longer time to 1st opioid use (mean difference -20.51 hours later, p-value .0052), lower 24-hr VAS (difference 2.421, p-value 0.0012, CI 0.8559 to 3.987), and faster time to discharge (16.00 hr earlier, p-value 0.0459). When compared to the SA+QLB group, the SA+QLB+ITM group only showed a statistically significant difference in faster time to discharge (19.46 hr earlier, p-value 0.0068). However, while there was no statistically significant difference in time to 1st opioid use between the control and SA+QLB group, the difference did become significant when comparing the control to the SA+QLB+ITM group (mean difference -20.51 hours later (p-value .0052). There was no significant difference in either of the three groups in ambulation distance at 24 hours, PACU VAS, or 48-hour total opioid use. Conclusion Our study concludes that the addition of 100 mcg ITM for total hip arthroplasty under spinal anesthesia improved postoperative analgesia compared to the control group. Also, the ITM group did better with respect to delay in first opioid use and decreased hospital stay compared to the control and block-only groups. Our study warrants no more concerns of PONV, pruritus, or respiratory depression with this dose of ITM and requires standard postoperative care.

Medium- to long-term clinical efficacy of total hip arthroplasty with structural bone grafting for dysplasia of the hip.

BACKGROUND: Patients with dysplasia of the hip (DDH) have different degrees of bone defects above and outside the acetabulum, and anatomically reconstructing the acetabular centre of rotation is difficult in primary total hip arthroplasty (THA). METHODS: From April 2012 to December 2022, 64 patients (64 hips) with DDH treated with THA with structural bone graft in the superolateral acetabulum were selected. The Oxford hip score(OHS), Barthel index (BI), leg length discrepancy, Wibegr central edge-angle(CE), gluteus medius muscle strength, vertical and horizontal distance of the hip rotation center, coverage rate of the bone graft and complications were used to evaluate the clinical effectiveness of the patients. RESULTS: All patients were followed up for an average of 7.3±1.9 years. The OHS improved significantly after the operation (P<0.001). The postoperative BI was significantly greater than that before operation (P<0.001). The postoperative leg length discrepancy was significantly lower than that before the operation (P<0.001). Postoperative bedside photography revealed that the height and horizontal distance to the hip rotation center were significantly lower after surgery than before surgery (P<0.001). The postoperative CE was significantly greater than that before surgery (P<0.001). No acetabular component loosening or bone graft resorption was found during the postoperative imaging examination. CONCLUSIONS: The use of biological acetabular cup combined with structural bone graft in the superolateral acetabulum in THA for DDH can obtain satisfactory medium and long-term clinical and radiological results.

Intraoperative live measurement of femoral head size for acetabular cup sizing: simple, accurate, and green!

PURPOSE: Templating is the first step in achieving a successful total hip arthroplasty. We hypothesize that native head size is highly correlated with implanted cup size. Therefore, the purpose of this study is to look for a correlation between sizes of the intra-operative measurement of the femoral head and the implanted cup. METHODS: This is a monocentric observational study conducted from December 2018 till January 2023. All patients admitted for a primary total hip arthroplasty were included and retrospectively reviewed. Intra-operative femoral head measurement, radiographic femoral head diameter, templated (planned) cup size, and definitive implanted cup size were recorded. RESULTS: The sample included 154 patients (85 female and 69 males) with a mean age of 66.2 ± 10.4 years. There were 157 THA cases; 82 on the right side and 75 on the left side. The native head size and acetate template on digital radiographs were the most significantly positively correlated with cup size (P < 0.0001) while the radiological head size was significantly negatively correlated with cup size (P = 0.009). The implanted cup was on average 2 ± 2 mm bigger than the native head size measured intra-operatively. CONCLUSION: The native femoral head diameter measured intra-operatively is a simple and reliable tool to help the surgeons choose the proper size of the acetabular cup, preventing complications during surgery hence optimizing results post operatively. This technique would contribute to a more ecofriendly orthopaedic reconstructive surgery.

Projected volume of primary total joint arthroplasty in the USA from 2019 to 2060.

INTRODUCTION: The global incidence of total joint arthroplasty (TJA) has consistently risen over time, and while various forecasts differ in magnitude, future projections suggest a continued increase in these procedures. Differences in future United States projections may arise from the modeling method selected, the nature of the national arthroplasty registry employed, or the representativeness of the specific hospital discharge records utilized. In addition, many models have not accounted for ambulatory surgery as well as all payer types. Therefore, to attempt to make a more accurate model, we utilized a national representative sample that included outpatient arthroplasties and all insurance types to predict the volumes of primary TJA in the USA from 2019 to 2060. METHODS: A national, all-payer database was queried. All patients who underwent primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) from January 1, 2010, to December 31, 2019, were identified using international classification of disease Ninth Revision (9) and Tenth Revision (10) codes and current procedure terminology codes. Absolute frequencies and incidence rates were calculated per 100,000 for both THA and TKA procedures, with 95% confidence intervals. Mean growth in absolute frequency and incidence rates were calculated for each procedure from 2010 to 2014, and 2010 to 2019, with 95% confidence intervals (CI). RESULTS: The overall increase in THA and TKA procedures are expected to grow + 10 and + 36%, respectively, using linear regressions and + 9 and + 37%, respectively. The most positive mean growth in procedure frequency occurred from 2010 to 2014 for THA (+ 24, 95% Confidence Interval (CI): + 21, + 27) and 2010-2019 for TKA (+ 11%, 95% CI: + 9, + 14). There positive trend patterns in incidence rate growth for both procedures, with similar 2010-2019 incidence rates + 6%) for THA (+ 3%, 95% CI: + 0, + 6%) and TKA (+ 3%, 95% CI: + 1%, + 6%). CONCLUSION: Utilizing a nationally representative database, we demonstrated that TJA procedures would continue with an increased growth pattern to 2060, though slightly decreased from the surge from 2014 to 2019. While this finding applies to the representativeness of the population at hand, the inclusion of outpatient arthroplasty and all payer types validates an approach that has not been undertaken in previous projection studies.

Is there a role of calprotectin testing in the diagnosis of surgical site infections after total hip and knee arthroplasty? A preliminary study.

BACKGROUND: Recent studies have revealed the usefulness of synovial calprotectin (CLP) in diagnosing chronic periprosthetic joint infections (PJIs). However, there is still a lack of evidence to support the use of serum CLP in the diagnosis of early PJIs and surgical site infections (SSIs) after total joint arthroplasties (TJAs). OBJECTIVES: The primary aim of this study is to investigate the standard kinetics of CLP concentrations in the blood during the very early postoperative period after non-complicated total hip arthroplasty (THA) and total knee arthroplasty (TKA). The secondary aim was to perform a preliminary comparison of CLP concentrations between non-infected patients and patients with recognized SSIs. MATERIAL AND METHODS: A total of 64 consecutive patients who underwent primary THA and TKA were included in this prospective research. Sixty patients (30 THA and 30 TKA) were scheduled to determine the standard shape of the blood CLP curve and the expected concentrations during the first 5 postoperative days after non-complicated TJAs. In 4 additonal patients, early SSI was confirmed, and they were included in a separate SSI subgroup. RESULTS: Calprotectin demonstrated a linear increase during the first 5 postoperative days. Statistically significant differences in CLP concentrations between non-infected cases and SSIs were not observed. The preoperative median results with interquartile range (Q1-Q3) were 0.52 (0.39-0.64) mg/dL and 0.5 (0.47-0.52) mg/dL (p = 0.77), while post operation they were as follows: on postoperative day 1: 0.88 (0.53-1.3) mg/dL and 0.86 (0.62-1.1) mg/dL (p = 0.84), on postoperative day 3: 1.77 (1.29-2.08) mg/dL and 1.85 (1.70-1.95) mg/dL (p = 0.72), and on postoperative day 5: 2.32 (1.79-2.67) mg/dL and 2.56 (2.25-2.83) mg/dL (p = 0.55), respectively. CONCLUSION: Serial CLP measurements during the early postoperative period revealed a linear (statistically significant) increase in concentration to postoperative day 5 without an evident point of decrease. A significant difference in median values and the course of curve patterns between the non-complicated and SSI groups was not observed.

Ipsilateral pubic ramus fracture during total hip arthroplasty is not rare: does it matter?

INTRODUCTION: Periprosthetic fractures in total hip arthroplasty (THA) have been well described and studied. However, there is a lack of reports on ipsilateral pubic ramus fractures during THA due to the rare occurrence of such fractures and ambiguity of symptoms. With the use of postoperative computed tomography (CT) examinations, we have identified that asymptomatic ipsilateral pubic ramus fractures occur frequently during THA. This study aims to evaluate the incidence, location, clinical outcomes, and risk factors of ipsilateral pubic ramus fractures during THA. METHODS: From May 2022 to March 2023, a single surgeon performed 203 THAs in 183 patients at a single institution. All patients underwent postoperative CT scans three days after THA. The patients with ipsilateral pubic ramus fractures were followed up for a minimum of six months. Basic demographics, osteoporosis, general conditions of the operations, and outcomes of THA were investigated in all patients. RESULTS: Twenty-two cases (10.8%) of ipsilateral pubic ramus fractures were identified on postoperative CT scans. All fractures were located near the origin of the superior or inferior pubic ramus. Five fractures were detected on simple postoperative radiographs. The fractures did not cause any further complications at a minimum of six-month postoperative follow-up. Univariate and multivariate analyses did not identify any risk factors associated with these fractures. CONCLUSIONS: Although the incidence of ipsilateral pubic ramus fractures during THA is high, treatment is not required as they do not cause any significant clinical symptoms or affect the prognosis of THA. However, the possibility of occurrence of these fractures must be explained to the patients before surgery.

Coxa valga and antetorta configuration leads to underestimation of the femoral component size: a matched case-control study of patients undergoing cementless total hip arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) is the gold standard procedure for patients with end-stage osteoarthritis after failed conservative therapy. Digital templating is commonly employed in preoperative preparation for THA and contributes positively to its outcome. However, the impact of coxa valga and antetorta (CVA) configurations on stem size prediction accuracy remains not reported. Previous studies demonstrated that the size of the lesser trochanter (LT) can be used to determine femoral anteversion on pelvis radiographs. This study investigates the accuracy of preoperative digital templating in predicting stem size in patients with CVA undergoing cementless THA. METHODS: Preoperative radiographs of 620 patients undergoing cementless THA were retrospectively investigated. Radiographs were standardized with patients standing and the leg internally rotated by 15°. A CVA group was established including patients with a CCD angle greater than 140° and a lesser trochanter (LT) size of at least 10 mm for men and 8 mm for women. For the control group, radiographs with a CCD angle ranging from 125-135° and LT size 3-10 mm for men and 3-8 mm for women were selected. Preoperative templating was performed using mediCAD. To reduce confounding factors, case-control matching was carried out for BMI and body height. RESULTS: After case-control matching, a total of thirty-one matches were analyzed. Stem size was underestimated in 74% (23/31) in the CVA and 13% (4/31) in the control group (p < 0.001). Moreover, patients with CVA were more likely to be underestimated by two sizes compared to controls (p < 0.004). In contrast, the exact stem size was predicted more frequently in the control group (p < 0.001). CONCLUSION: Stem size in patients with a CVA configuration are at high risk of being underestimated when using digital templating. These findings can be valuable for guiding in intraoperative decisions and lowering the risk of complications associated with an undersized femoral component.

Hip-Spine and Knee-Spine Syndrome: Is Low Back Pain Improved After Total Hip and Knee Arthroplasty?

INTRODUCTION: Hip and knee osteoarthritis (OA) and low back pain (LBP) are prevalent diseases that can negatively impact daily activities. The concurrent existence of lumbar spine disorders with hip or knee issues forms two syndromes: hip-spine syndrome (HSS) and knee-spine syndrome (KSS). The primary objective of this study is to evaluate the relationship between hip and knee OA and LBP, as well as the changes to LBP after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The secondary objective is to identify the cause of LBP among patients with hip and knee OA. MATERIAL AND METHODS: The group of hip OA patients treated with THA consisted of 34 individuals, and the group of knee OA patients treated with TKA consisted of 45 individuals. In these two groups of patients, the LBP was assessed using the visual analog scale score preoperatively and four and 12 months postoperatively. To determine the cause of LBP, we compared preoperative and postoperative (12-month) pelvic obliquity and hip or knee pain in patients with and without preoperative LBP. RESULTS: For hip OA-THA, more than half (55.88%) of patients suffering from hip OA also experienced moderate to severe LBP. Improvement in LBP was noticed in 79% of these patients at both four and 12 months post-THA, with levels dropping from 6.84 to 2.58 and then 2.53, respectively. Moreover, improvements in hip pain and pelvic obliquity were observed in patient groups both with and without preoperative LBP following THA. This suggests that there's no obvious correlation between LBP and these parameters. For knee OA-TKA, most (62.22%) patients with knee OA experienced moderate to very severe LBP. In 50% of these patients, LBP showed improvement at four and 12 months post-TKA (6.39 → 4.79 → 4.04). Additionally, in both groups with and without preoperative LBP, knee pain and pelvic obliquity were improved after TKA, suggesting no clear association between LBP and these parameters. CONCLUSIONS: HSS and KSS were frequently observed in patients. A significant improvement in LBP was seen after THA or TKA, suggesting that total arthroplasty should be prioritized before spinal surgery. Furthermore, there is not a definitive link between LBP, joint pain, and pelvic obliquity.

Is There a Learning Curve for the 5-Year Implant Survival Rate of Total Hip Arthroplasty Using the Direct Anterior Approach with a Traction Table? - A Prospective Cohort Study.

BACKGROUND: The direct anterior approach (DAA) for total hip arthroplasty (THA) is attracting attention as a minimally invasive surgery, but the learning curve to master this approach is a concern, and its effect on long-term results is unknown. The purpose of this prospective cohort study was to clarify how the learning curve affects the five-year results of DAA THA with a traction table. METHODS: Of 402 THA cases using DAA with a mobile traction table and fluoroscopy, 249 cases composed of the first 50 cases for each surgeon were assessed during a learning curve, and 153 cases were evaluated after more than 50 cases of experience. RESULTS: The five-year-implant survival rate was 99.2% both during and after the learning curve. The two-year complication rate in the learning curve group was 8.9 versus 5.9%, which was not statistically significant. The two-to-five-year complication rates also did not differ between cohorts (0 versus 0.7%). Both groups demonstrated decreased complication rates when comparing two-year complications to the two-to-five-year complications. Clinical scores significantly improved by two years and were maintained at five years in both groups. The cup-safe zone success rates were 96.4% during the learning curve and 98.7% after the learning curve. The stem-safe zone success rates were 97.2% during the learning curve and 96.1% after the learning curve. Surgical time was approximately 20 minutes shorter after the first 50 cases than during the learning curve (70.8 versus 90.6 minutes, P = 0.001). Intraoperative blood loss was significantly less after the learning curve than during the learning curve. CONCLUSION: This study implicates that the learning curve affects perioperative results such as surgical time and intraoperative blood loss, but has little effect on short-term results up to two years after surgery and no effect on mid-term results from two to five years after surgery.