Systematic review and meta-analysis on SuperPATH approach versus conventional approaches for hip arthroplasty.

AIM: The SuperPATH approach has been in practice for almost a decade. There is no systematic review to date comparing the novel SuperPATH approach with conventional approaches. Therefore, it is important to conduct an up-to-date review to evaluate the benefits and drawbacks of the SuperPATH approach in comparison to widely accepted traditional approaches.Our primary aim was to compare the newer SuperPATH approach with the traditional approaches to the hip in terms of functional outcome and radiological parameters. We also aimed to identify any potential complications of the SuperPATH approach as it is a new surgical technique lacking any published sytematic reviews. MATERIALS AND METHODS: The review was conducted in accordance with the steps detailed in the Cochrane Handbook for Systematic reviews of intervention and will be reported bearing in mind the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PICO terms were independently searched in multiple databases. Studies that compared SuperPATH with traditional approaches were included in the analysis. RESULTS: 7 studies including a total of 730 patients were available for final analysis. 3 studies were randomised control trials, 2 were prospective cohort studies and 2 were non-randomised case control studies.Patients in the SuperPATH group were discharged earlier (2 days difference in weighted mean). The operative time was 5 minutes longer (84.46 vs. 78.99) and there was a marginal decrease in blood loss (38 ml lesser) in the SuperPATH approach. VAS Score and HHS at the end of 1 year was comparable in both study groups. Cup abduction angle and anteversion angles were acceptable and comparable in both groups. CONCLUSIONS: The SuperPATH approach shows minimal improvement in length of hospital stay and blood loss with no significant improvement in pain or functional outcome score. There are no major complications reported and the radiological parameters are comparable.

The impact of frailty on patient-reported outcomes following hip and knee arthroplasty.

AIM: to determine the impact of frailty on patient-reported outcomes following hip and knee arthroplasty. METHODS: we used linked primary and secondary care electronic health records. Frailty was assessed using the electronic frailty index (categorised: fit, mild, moderate, severe frailty). We determined the association between frailty category and post-operative Oxford hip/knee score (OHS/OKS) using Tobit regression. We calculated the proportion of patients in each frailty category who achieved the minimally important change (MIC) in OHS (≥8 points) and OKS (≥7 points) and the proportion who reported a successful outcome (hip/knee problems either 'much better' or 'a little better' following surgery). RESULTS: About 42,512 people who had a hip arthroplasty and 49,208 who had a knee arthroplasty contributed data. In a Tobit model adjusted for pre-operative OHS/OKS, age, sex and quintile of index of multiple deprivation, increasing frailty was associated with decreasing post-operative OHS and OKS, respectively, ß-coefficient (95% CI) in severely frail versus fit, -6.97 (-7.44, -6.49) and - 5.88 (-6.28, -5.47). The proportion of people who achieved the MIC in OHS and OKS, respectively, decreased from 92 and 86% among fit individuals to 84 and 78% among those with severe frailty. Patient-reported success following hip and knee arthroplasty, respectively, decreased from 97 and 93% among fit individuals to 90 and 83% among those with severe frailty. CONCLUSION: frailty adversely impacts on patient-reported outcomes following hip and knee arthroplasty. However, even among those with severe frailty, the large majority achieved the MIC in OHS/OKS and reported a successful outcome.

The impact of frailty on short-term mortality following primary total hip and knee arthroplasty due to osteoarthritis.

BACKGROUND: We determined the association between frailty and short-term mortality following total hip and knee arthroplasty (THA/TKA) for osteoarthritis and also the impact of THA/TKA on short-term mortality compared with a control population. METHODS: Frailty was assessed using a frailty index (categorised: fit, mild, moderate, severe frailty). The association between frailty and short-term mortality following THA/TKA was assessed using Cox regression. Mortality following THA/TKA was also compared with a control population with osteoarthritis but no previous THA/TKA, matched on year of birth, sex and quintile of index of multiple deprivation. RESULTS: A total of 103,563 cases who had a THA, 125,367 who had a TKA and matched controls contributed. Among those who had surgery, mortality increased with increasing frailty; adjusted hazard ratio (HR) (95% CI) at 30 days in severely frail versus fit: following THA, 2.85 (1.84, 4.39) and following TKA, 2.14 (1.29, 3.53). The predicted probability of 30-day mortality following THA/TKA varied by age, sex and frailty: following THA, from 0.05% among fit women aged 60-64 years to 6.55% among men with severe frailty aged ≥90 years. All-cause 30-day mortality was increased in fit cases following THA and TKA, respectively, versus fit controls (adjusted HR (95% CI), 1.60 (1.15, 2.21) and 2.98 (1.81, 4.89)), though not among cases with mild, moderate or severe frailty versus controls in the same frailty category. CONCLUSION: Short-term mortality increased with increasing frailty following THA/TKA. Comparison of mortality among cases and controls may be affected by a 'healthy surgery' selection effect.

Study to Assess the Rate of Adverse Reaction to Metal Debris in Hip Resurfacing at a Minimum 13-year Follow-up.

BACKGROUND: Hip Resurfacing (HR), although reducing in popularity, is still used in the younger male population. Excellent medium-term results have been published; however, the use of metal on metal has reduced with increased awareness of adverse reactions to metal debris (ARMD). ARMD has been shown to often be clinically "silent" following large Head MoM total hip replacement (THR). The purpose of our study was to report the incidence of ARMD following HR with a minimum follow-up of 13 years. METHODS: We performed a retrospective study of a consecutive series of patients who underwent HR between January 1, 2000 and August 1, 2005. All patients were entered into our hospital MoM hip replacement surveillance program database. Patients were reviewed yearly for symptoms and blood ion levels. Patients had Magnetic Resonance (MR) imaging to assess for ARMD. RESULTS: A total of 102 patients with 123 hip replacements were included in the study. Eight hips in 7 patients were revised: two for fracture, one for avascular necrosis, and five for ARMD. A best-case scenario of 109 (93.2%) resurfacings were surviving at 13 years. With regard to the radiological analysis, 34% were found to have ARMD on MR. CONCLUSION: While the implant survivorship in our series is acceptable, we found a high incidence of ARMD. Surgeons and patients with or considering a HR should be aware of the risk of ARMD developing. This allows an informed choice as to the best implant for their personal requirement and informs of the potential modes of failure and need for long-term screening.

Is the use of antibiotic-loaded bone cement associated with a lower risk of revision after primary total hip arthroplasty?

AIMS: The aim of this study was to investigate whether the use of antibiotic-loaded bone cement influenced the risk of revision surgery after primary total hip arthroplasty (THA) for osteoarthritis. METHODS: The study involved data collected by the National Joint Registry (NJR) for England and Wales, Northern Ireland and the Isle of Man between 1 September 2005 and 31 August 2017. Cox proportional hazards were used to investigate the association between use of antibiotic-loaded bone cement and the risk of revision due to prosthetic joint infection (PJI), with adjustments made for the year of the initial procedure, age at the time of surgery, sex, American Society of Anesthesiologists (ASA) grade, head size, and body mass index (BMI). We looked also at the association between use of antibiotic-loaded bone cement and the risk of revision due to aseptic loosening or osteolysis. RESULTS: The cohort included 418,857 THAs of whom 397,896 had received antibiotic-loaded bone cement and 20,961 plain cement. After adjusting for putative confounding factors, the risk of revision for PJI was lower in those in whom antibiotic-loaded bone cement was used (hazard ration (HR) 0.79; 95% confidence interval (CI) 0.64 to 0.98). There was also a protective effect on the risk of revision due to aseptic loosening or osteolysis, in the period of > 4.1 years after primary THA, HR 0.57, 95% CI 0.45, 0.72. CONCLUSION: Within the limits of registry analysis, this study showed an association between the use of antibiotic-loaded bone cement and lower rates of revision due to PJI. The findings support the continued use of antibiotic-loaded bone cement in cemented THA. Cite this article: Bone Joint J 2020;102-B(8):997-1002.

The evolution of the trunnion.

Implant modularity has recently come under increasing scrutiny due to concerns regarding wear, corrosion and potential adverse reactions to metal debris. This review outlines the evolution and development of the femoral stem trunnion and relates this to contemporary issues now encountered.Despite different manufacturers producing what appear to be similar trunnion designs, there is still a lack of standardisation, with small but significant design variations. Wear and corrosion is certainly not a new phenomenon, but recent changes in design and the use of larger metal head sizes has potentially made the problem more prevalent. These issues along with steps to avoid these problems are discussed.

Osteochondral lesion of the hip treated with partial femoral head resurfacing. Case report and six-year follow-up.

INTRODUCTION: This case describes a case of an osteochondral lesion in the femoral head and its treatment by partial resurfacing of the femoral head using the HemiCAP (Contoured Articular Prosthetic) hip resurfacing system. CASE HISTORY: A 19-year-old patient who complained of 15 months of worsening left hip pain. X-rays and MR scan revealed a large osteochondral lesion. SURGERY: A Ganz approach to the hip in the lateral position was used. The osteochondral lesion was identified, lying superiorly and centrally on the head, in the weight bearing zone. The osteochondral fragment was removed and HemiCAP prosthesis applied. OUTCOME: At six-year follow-up the patient remains pain free clinically. And radiographic follow-up shows no evidence of loosening. CONCLUSION: There are multiple methods of treatment described in the literature for osteochondral lesions; but treatments for defects of the femoral head are few. We conclude that partial hip resurfacing using the HemiCAP prosthesis is an effective treatment for osteochondral defects of the femoral head.

Bone allograft in the U.K.: perceptions and realities.

Bone allografts are widely used in the U.K. in joint revision surgery. Despite this widespread usage, there remain concerns among the surgical community regarding the safety of allografts, in terms of the risk of transmission of infection, together with a persistent misconception that allografts are in limited availability. In this paper we discuss the precautions taken to ensure that allografts are safe, and review the residual risks. We also demonstrate that the availability of allograft in the U.K., both actual and potential, greatly exceeds the current clinical demand.

Acetabular revision surgery with the uncemented oblong BOFOR Cup--early to midterm results.

INTRODUCTION: Failure of acetabular components frequently leads to bone loss with extensive elongated defects in the surrounding bone. In these cases the use of an oblong cup has been described as an option for acetabular reconstruction. We report the longest follow up results obtained with this implant to date. MATERIALS AND METHODS: A prospective study was conducted to evaluate the results of the BOFOR oblong revision cup. Between 2001 and 2006, 15 acetabular revisions were performed for aseptic loosening of the acetabular cup. The acetabular defects were classified as type 2A to 3A, according to Paprosky's criteria. No allografts were used in any of the cases. The mean follow-up was 90 months (range 60-120 months). RESULTS: Clinical assessment at follow-up showed a significantly improved mean Harris Hip Score from 39 points preoperatively to 84 points postoperatively and a mean Oxford Hip Score from 55 points preoperatively to 22 points postoperatively. Only one case underwent re-revision due to aseptic loosening in a patient with severe ankylosing spondylitis. There were no cases of dislocation or infection. One patient had a sciatic nerve neurapraxia. After an average follow up of 7.5 years, 93% of the investigated implants remained in-situ without further revision. CONCLUSION: This study shows that the BOFOR cup provided good clinical results and showed satisfactory stability at early to midterm follow-up.

Medical management of osteonecrosis of the hip: a review.

Osteonecrosis or avascular necrosis (AVN) of the hip is a progressive disease mainly affecting adults in their third, fourth or fifth decade of life. Studies into the natural history of the disease suggest that femoral head collapse occurs within 2-3 yrs with associated degenerative changes and at that stage arthroplasty is the most reliable treatment option. Therefore prevention of femoral head collapse is highly desirable in this young patient group. In early stage disease, before femoral head collapse (Ficat and Arlet stage 1-3) core decompression of the femoral head is currently the most widely used procedure to try to relieve intraosseous pressure in the femoral head and restore blood supply.Greater understanding of the pathogenesis of osteonecrosis has led to research into non-surgical management of early stages of the disease, including pharmacological and biophysical treatments.There may be a reduction in symptoms and evidence of prevention of disease progression following some non-surgical treatments. Further studies are needed, including trials comparing medical management with surgical intervention.

Functional and radiological evaluation of a simple intra operative technique to avoid limb length discrepancy in total hip arthroplasty.

We aimed to assess the radiological and functional outcome of total hip arthroplasty performed using a simple technique for intra-operative leg length assessment. The comparative group was made up of patients receiving total hip arthroplasty prior to introduction of the technique. Fifty patients were studied in each group. The pre- and 3 month post-operative leg length difference (LLD) was measured radiologically along with pre- and 12 months post-operative Oxford hip scores (OHS) and University of California Los Angeles (UCLA) activity scores.There were no statistically significant differences in pre-operative parameters between the two groups. The mean LLD in the new technique group was 0.46 mm which was significantly less than in the control group (p< 0.001). Post operative OHS values were worse when shortening or lengthening was >5 mm in both groups. UCLA activity scores were significantly better in the new technique group than in the control group (p< 0.001). The overall radiological and functional outcome of the patients was better in the new technique group.Functional outcome is related to small differences in leg length and our simple new technique can be used to control leg length intraoperatively.

Clinical experience of revision of metal on metal hip arthroplasty for aseptic lymphocyte dominated vasculitis associated lesions (ALVAL).

There has been growing concern regarding the systemic and local effects of metal ions released from metal-on-metal hip resurfacings and total hip replacements, including the development of aseptic lymphocyte dominated vasculitis associated lesions (ALVAL). We describe our experience of treating 13 patients with failed metal on metal bearing hip prostheses secondary to this condition. Hip revision occurred at mean of 45 months following primary surgery. Groin pain was present in all patients. Other common features included large bursal swelling and mechanical symptoms. 3 patients developed their symptoms immediately postoperatively. The mean time to presentation was 21 months. Radiographic abnormalities noted included 3 patients with cup loosening and 2 patients with neck thinning. The mean cup inclination was 52 degrees. Surgical findings included bursal swellings and creamy brown fluid. Osteolysis was rarely seen. 12 revisions were achieved with primary implants and all patients had immediate symptomatic improvement. One patient was left with a pseudoarthrosis due to extensive soft tissue destruction. Diagnosis of ALVAL was confirmed histologically. The diagnosis of ALVAL should be considered in patients with unexplained pain from a metal on metal bearing hip arthroplasty. Surgical findings are typical and symptoms tend to resolve reliably following conversion to an alternative bearing surface.

Processed versus fresh frozen bone for impaction bone grafting in revision hip arthroplasty.

BACKGROUND: Impaction grafting is a technique to restore bone loss both in the femur and the acetabulum during revision hip arthroplasty surgery. Initially impaction grafting was undertaken using fresh frozen femoral head allografts that were milled to create morselized bone pieces that could be impacted to create a neo-cancellous bone bed prior to cementation of the new implant. Results of medium and long term outcome studies have shown variable results using this technique. Currently both processed and non-processed allograft bone are used and the purpose of this review was to analyse the evidence for both. OBJECTIVES: To determine the clinical effectiveness of processed (freeze dried or irradiated) bone in comparison to fresh frozen (unprocessed) bone. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1985 to 2008), EMBASE (1985 to 2008), CINAHL(1985 to 2008) and the National Research Register. Additional sources were also searched. Handsearching of relevant journals and conference abstracts was also undertaken. Searches were complete to 31 August 2008. SELECTION CRITERIA: Randomised controlled trials that compared different types of bone for impaction grafting. DATA COLLECTION AND ANALYSIS: Three hundred and sixty references were identified from the searches. Following detailed eligibility screening, three hundred and fifty nine references did not meet the eligibility criteria. Further details are required about one trial in order to determine it's eligibility. MAIN RESULTS: No trials were identified that met the criteria for inclusion in the review. AUTHORS' CONCLUSIONS: Good quality randomised controlled trials are required in this area so that a surgeon's choice of bone graft can be informed by evidence rather than personal preference.

Cemented total hip arthroplasty in a patient with alpha-mannosidosis: a case report.

Mannosidosis is an extremely rare genetic disease occurring due to deficiency of the lysosomal enzyme, alpha-mannosidase. Patients with this disorder often suffer from musculoskeletal abnormalities and muscular weakness leading to joint destruction and severe morbidity along with other major systems involvement. We present here such a case of a 27-year-old male that highlights the challenges in management of hip joint destruction secondary to Mannosidosis.

Post-operative anxiety and depression levels in orthopaedic surgery: a study of 56 patients undergoing hip or knee arthroplasty.

OBJECTIVE: To investigate the presence and rates of anxiety and depression in postsurgical patients. METHODS: The Hospital Anxiety and Depression Scale was used to measure anxiety and depression levels. Patients completed the questionnaire on the day prior to surgery, then on each post-operative day up to and including their day of discharge. Statistical analysis using logistic regression was performed to determine whether any variables were risk factors for developing anxiety or depression. Fifty-six patients undergoing lower limb arthroplasty agreed to take part. RESULTS: Post-operatively 17 patients became anxious prior to discharge. No variables were significant predictors of anxiety. Post-operatively 28 subjects (50%) became depressed at some point prior to discharge. Females were more likely to become depressed than males odds ratio (OR) = 3.48 [95% confidence interval (CI) 1.01-11.88]. Those who had had a previous lower limb arthroplasty were more likely to develop post-operative depression, OR = 3.92 (95% CI 1.05-14.6). Site of operation was not found to be significant, OR = 0.67 (95% CI 0.20-2.22). Age and anaesthetic method were not predictive of depression. The mean time point for development of depression was 2.43 days (SD = 1.40 days) and the time of deepest depression was 2.93 days (SD = 1.72 days). The mean length of depression was 1.93 days (SD = 1.21 days). The mean length of stay for depressed patients was 5 days (SD = 1.72), compared with 4 days for the non-depressed patients (SD = 1.62 days). CONCLUSION: The results suggest that post-operative depression does occur in orthopaedic surgery. The prevalence may be higher than that reported in other surgical specialities. These findings emphasize the need for evaluation of patients' psychiatric state post-operatively.

Knee injuries in restrained car drivers in German road traffic accidents.

BACKGROUND: The purpose of this study was to estimate the prevalence of knee injuries in real world car crashes in Germany. Restrained car drivers (RCD) were included in a medical and technical analysis to create a basis for preventive measures. METHODS: Technical and medical data were collected at the scene, shortly after the crash. Two time periods (group A, 1985-1993; group B, 1995-2003) were compared focusing on knee injuries [abbreviated injury scale (AISKnee)]. Technical analysis included type of collision, impact angle, and relative velocity. Medical analysis included injury pattern and severity (AIS, maximum AIS). RESULTS: About 5,972 RCD were included in this study from a total of 22,804 victims involved in 16,563 crashes. In total, severe injuries (AISKnee 2/3) occurred in 1.2% (82 patients) of all RCD. The knee injury prevalence significantly decreased over time (group A vs. B, p < 0.0001). A so-called dashboard injury was registered in 5.8% (n = 5). CONCLUSIONS: The overall prevalence for knee injuries in RCD involved in road traffic accidents was low and decreased over time. Higher loads were necessary to cause ligamentous injuries of the knee than fractures in the knee region. Because direct impact caused most of the injuries, modifications of the interior and exterior design should reduce the incidence of these injuries. A dashboard injury was very rare.

Navigated lower limb axis measurements: Influence of mechanical weight-bearing simulation.

Successful outcomes following high tibial osteotomy (HTO) require precise realignment of the mechanical axis of the lower extremity. The inability to accurately assess the weight-bearing axis intraoperatively may account for inappropriate degrees of correction with the osteotomy. We tested the hypothesis that axial loading of the limb affects alignment during an HTO procedure. A custom mechanical load apparatus was developed to simulate weight-bearing conditions intraoperatively. Fixation to the trunk was achieved by supraacetabular pins and an external fixation device, which allowed the pelvis to be rigidly fixed relative to the apparatus while axial load was applied to the foot. Ten fresh cadavers were used for testing. The baseline mechanical axis was determined by a navigation system. HTO was then performed, and varying degrees of valgus correction were obtained and stabilized. For each correction, one quarter, one half, or full body weight was applied axially to the foot, and the axis deviation was measured. Subsequently, the MCL was sequentially released to determine the effect of ligament incompetence. Prior to osteotomy, load application did not produce significant axis deviations. Following osteotomy, the mechanical axis deviation shifted significantly in all trials, increasing as load magnitude and degree of correction increased. With complete sectioning of the MCL, a further significant shift in the axis occurred. Deviations of mechanical axis occur on weight bearing in lower limbs following HTO. These shifts must be considered and possibly quantified to achieve the desired axis correction and maximize the chance at a successful long term outcome.

The effect of irrigation fluid temperature on core body temperature in arthroscopic shoulder surgery.

INTRODUCTION: The purpose of this study was to investigate the relationship between irrigation fluid temperature and core body temperature in patients undergoing arthroscopic shoulder surgery. MATERIALS AND METHODS: Twenty-four consecutive patients undergoing arthroscopic subacromial decompression were allocated to receive irrigation fluid at either room temperature (22 degrees C) or warmed to 36 degrees C. There were no statistically significant differences between the two groups in any of the preoperative parameters. Core temperature was monitored throughout surgery. The maximum drop in core temperature for each patient was calculated. RESULTS: The mean maximum drop in the room temperature group was 1.67 degrees C (95% CI 1.33-1.97) and 0.33 degrees C (95% CI 0.17-0.49) in the warmed fluid group (P < 0.001). Further to this the drop in core temperature in the room temperature group was maintained throughout surgery whereas normothermia resumed by 30 min in the warmed fluid group. CONCLUSION: We thus conclude that core temperature may be influenced by irrigation fluid temperature and recommend that fluid be warmed to 36 degrees C.

Anatomic variations in the long head of biceps: contribution to shoulder dysfunction.

The long head of the biceps (LHB) is a subject of interest to shoulder surgeons and physiotherapist alike. Since the advent of shoulder arthroscopy, knowledge of and interest in the LHB has increased. We discuss the current knowledge on anatomic variants of the LHB. Several cadaveric studies have refined the standard textbook description of the LHB origin, showing that it originates from the superior glenoid labrum and the supraglenoid tubercle. These studies have provided important information for the assessment of the LHB, guiding the treatment of lesions such as superior labral anterior posterior (SLAP) tears. Described variants to the anterosuperior glenoid labrum should be noted, from the superior sublabral recess to the Buford complex. Congenital absence of the LHB should be appreciated. Only 4 previous cases have been reported. We have experience in treating 3 further cases. Further information on the function of the LHB has been gleaned from electomyographic, cadaveric, and clinical studies. These have shown that it has a role in stabilizing the humeral head. It has been stated that it may have a proprioceptive function. Classification systems for symptomatic LHB lesions and congenital absence of the LHB tendon are proposed. The management of LHB lesions is also discussed.