Quantifying cup overhang after total hip arthroplasty: standardized measurement using reformatted computed tomography and association of overhang distance with iliopsoas impingement.

OBJECTIVES: Currently, there is no standardized measurement method for evaluating cup overhang (CO) in patients undergoing total hip arthroplasty (THA). We propose a novel, standardized method of measuring overhang distance in patients following primary total hip arthroplasty (THA) on computed tomography (CT) images after multiplanar reformation and compare it to a previously proposed measurement method on sagittal CT images. MATERIALS AND METHODS: This retrospective study included patients who underwent primary THA with an anterior approach. Patients with cup overhang (CO) and iliopsoas impingement (IPI) were identified by clinical and imaging data. Uncorrected overhang distance (ODu) was evaluated on orthogonal sagittal CT images while corrected overhang distance (ODc) was evaluated on reformatted sagittal CT images corrected for pelvic rotation and aligned with the plane of the cup face. RESULTS: Out of 220 patients with THA, 23 patients (10.4%) with CO and 16 patients (7.3%) with IPI were identified. CO was significantly associated to IPI (p < 0.001). The inter- and intrareader agreement was almost perfect for ODc (κ = 0.822, κ = 0.850), whereas it was fair and moderate for ODu (κ = 0.391, κ = 0.455), respectively. The discriminative ability of ODc was excellent (area under the curve (AUC) = 0.909 (95% confidence interval (CI) 0.784-1.000)) in the receiver operating characteristic analysis. Conversely, AUC for ODu was poor, measuring 0.677 (95% CI 0.433-0.921). CONCLUSION: We implemented a novel measurement method for CT images reformatted at the plane of the cup face to assess overhang distance in patients with CO following THA. CLINICAL RELEVANCE STATEMENT: While further validation is necessary, the proposed method is characterized by its high reproducibility and might be used to predict the occurrence of iliopsoas impingement in patients with cup overhang following total hip arthroplasty. KEY POINTS: • A novel, standardized method of measuring cup overhang distance in patients following primary total hip arthroplasty on CT images is proposed. • Cup overhang was associated to iliopsoas impingement. The proposed method was reproducible and showed excellent prediction of iliopsoas impingement in patients with cup overhang. • This method can be implemented in clinical practice when assessing CT images of patients with cup overhang for iliopsoas impingement.

Risks of major bleeding and venous thromboembolism in patients undergoing total hip or total knee arthroplasty using therapeutic dosages of DOACs.

About 1.5% of patients undergoing total hip (THA) or total knee arthroplasty (TKA) still develop postoperative venous thromboembolism (VTE), indicating that the current thromboprophylaxis strategy is not optimal. To evaluate the feasibility of therapeutic dosages of direct oral anticoagulants (DOACs) as thromboprophylaxis for high VTE risk patients, we determined the risks of major bleeding and VTE in patients who underwent THA/TKA and were treated with DOACs in therapeutic dosages for atrial fibrillation (AF). We conducted a registry-based cohort study from 2010 to 2018 in Denmark and included AF patients on therapeutic DOACs dose who underwent THA/TKA. AF patients were utilized as proxy since they have a life-long indication for therapeutic anticoagulant medication. The 49-days cumulative incidence (with death as competing risk) of major bleeding was assessed. The same was done for VTE at 49- and 90-days. 1,354 THA and TKA procedures were included. The 49-days cumulative incidence of major bleeding was 1.40% (95%Confidence Interval[CI] 0.88-2.14%). Most bleeding events occurred at the surgical site. The cumulative incidence of VTE at 49-days was 0.59% (95%CI 0.28-1.13%) and 0.74% (95%CI 0.38-1.32%) at 90-days. The incidence of major bleeding in THA/TKA patients on DOACs in therapeutic dosages was in line with previously reported incidences among THA/TKA patients on thromboprophylaxis dosages, while the incidence of VTE was relatively low. These data provide a solid basis for the design of randomized controlled trials to establish the safety and efficacy of therapeutic dosages of DOACs to prevent VTE in high-risk patients.

Photon-counting detector computed tomography for metal artifact reduction: a comparative study of different artifact reduction techniques in patients with orthopedic implants.

PURPOSE: Artifacts caused by metallic implants remain a challenge in computed tomography (CT). We investigated the impact of photon-counting detector computed tomography (PCD-CT) for artifact reduction in patients with orthopedic implants with respect to image quality and diagnostic confidence using different artifact reduction approaches. MATERIAL AND METHODS: In this prospective study, consecutive patients with orthopedic implants underwent PCD-CT imaging of the implant area. Four series were reconstructed for each patient (clinical standard reconstruction [PCD-CTStd], monoenergetic images at 140 keV [PCD-CT140keV], iterative metal artifact reduction (iMAR) corrected [PCD-CTiMAR], combination of iMAR and 140 keV monoenergetic [PCD-CT140keV+iMAR]). Subsequently, three radiologists evaluated the reconstructions in a random and blinded manner for image quality, artifact severity, anatomy delineation (adjacent and distant), and diagnostic confidence using a 5-point Likert scale (5 = excellent). In addition, the coefficient of variation [CV] and the relative quantitative artifact reduction potential were obtained as objective measures. RESULTS: We enrolled 39 patients with a mean age of 67.3 ± 13.2 years (51%; n = 20 male) and a mean BMI of 26.1 ± 4 kg/m2. All image quality measures and diagnostic confidence were significantly higher for the iMAR vs. non-iMAR reconstructions (all p < 0.001). No significant effect of the different artifact reduction approaches on CV was observed (p = 0.26). The quantitative analysis indicated the most effective artifact reduction for the iMAR reconstructions, which was higher than PCD-CT140keV (p < 0.001). CONCLUSION: PCD-CT allows for effective metal artifact reduction in patients with orthopedic implants, resulting in superior image quality and diagnostic confidence with the potential to improve patient management and clinical decision making.

Are social determinants of health associated with an increased length of hospitalization after revision total hip and knee arthroplasty? A comparison study of social deprivation indices.

INTRODUCTION: Length of stay (LOS) has been extensively assessed as a marker for healthcare utilization, functional outcomes, and cost of care for patients undergoing arthroplasty. The notable patient-to-patient variation in LOS following revision hip and knee total joint arthroplasty (TJA) suggests a potential opportunity to reduce preventable discharge delays. Previous studies investigated the impact of social determinants of health (SDoH) on orthopaedic conditions and outcomes using deprivation indices with inconsistent findings. The aim of the study is to compare the association of three publicly available national indices of social deprivation with prolonged LOS in revision TJA patients. MATERIALS AND METHODS: 1,047 consecutive patients who underwent a revision TJA were included in this retrospective study. Patient demographics, comorbidities, and behavioral characteristics were extracted. Area deprivation index (ADI), social deprivation index (SDI), and social vulnerability index (SVI) were recorded for each patient, following which univariate and multivariate logistic regression analyses were performed to determine the relationship between deprivation measures and prolonged LOS (greater than five days postoperatively). RESULTS: 193 patients had a prolonged LOS following surgery. Categorical ADI was significantly associated with prolonged LOS following surgery (OR = 2.14; 95% CI = 1.30-3.54; p = 0.003). No association with LOS was found using SDI and SVI. When accounting for other covariates, only ASA scores (ORrange=3.43-3.45; p < 0.001) and age (ORrange=1.00-1.03; prange=0.025-0.049) were independently associated with prolonged LOS. CONCLUSION: The varying relationship observed between the length of stay and socioeconomic markers in this study indicates that the selection of a deprivation index could significantly impact the outcomes when investigating the association between socioeconomic deprivation and clinical outcomes. These results suggest that ADI is a potential metric of social determinants of health that is applicable both clinically and in future policies related to hospital stays including bundled payment plan following revision TJA.

Construction of a Risk Prediction Model for Intraoperative Hypothermia in Patients Undergoing Lower Extremity Joint Replacement.

PURPOSE: To investigate the influencing factors of intraoperative hypothermia (IOH) in patients undergoing total joint arthroplasty (TJA) of the lower extremities, establish a risk prediction model, and test the effect of application. DESIGN: A prospective, observational study was conducted. METHODS: Patients who underwent total knee arthroplasty and total hip arthroplasty from June 2020 to December 2021 were prospectively analyzed. According to the occurrence of IOH, patients were divided into the IOH group (temperature less than 36 °C) and non-IOH group (temperature ≥36 °C). We collected demographic, anesthesia, and surgical data for both groups to identify risk factors for IOH and develop a predictive model. The model's goodness of fit was assessed using the Hosmer-Lemeshow test, and its predictive efficacy was evaluated using the receiver operating characteristic curve. FINDINGS: A total of 258 patients were included in this study, with 79 patients in the IOH group and 179 patients in the non-IOH group. Logistic regression analysis showed that American Society of Anesthesiologists' grade, blood loss, and duration of surgery were independent risk factors for IOH in lower extremity TJA patients. Hosmer-Lemeshow test P = .803, area under receiver operating characteristic curve was 0.846, Youden index was 0.490, sensitivity was 65.4%, specificity was 83.6%. In the external validation cohort, the application accuracy of the model was 83.3%. CONCLUSIONS: The prediction model established in this study is suitable for the risk assessment of IOH in TJA patients with good prediction effect, which can provide a tool for clinical medical staff to identify high-risk populations preoperatively.

Post-operative short-term clinical evaluation of direct lateral (Harding) approach in primary total hip replacement.

OBJECTIVE: To evaluate patients' functional outcomes after total hip arthroplasty through a direct lateral approach. METHODS: The prospective, observational, descriptive study was conducted at Al-Yarmouk Teaching Hospital, Baghdad, Iraq, from May 2019 to June 2020, and comprised patients aged 28-81 years having advanced osteoarthritis and avascular necrosis who underwent cementless total hip arthroplasty. The patients were followed up for 6 months. Outcome was assessed using the Harris hip score, Trendelenburg sign, post-operative hip dislocation, post-operative infection, and heterotopic ossifications. Data was analysed using Excel version 2019. RESULTS: Of the 30 patients, 14(47%) were males and 16(53%) were females. The overall mean age was 49.8±15.28 years. The mean pre-operative Harris hip score was 43.166±8.27, while it was 83.566±3.83 post-operatively (p<0.001). There was 1(3.33%) case of heterotopic ossification, 3(10%) had Trendelenburg sign. There was no case of postoperative hip dislocation or infection. CONCLUSIONS: The lateral hip approach was found to be associated with good post-operative hip stability and good post-operative functional outcome with low post-operative risk of infection.

Language-adaptive artificial intelligence: assessing CHATGPT'S answer to frequently asked questions on total hip arthroplasty questions.

ChatGPT is reported to be an acceptable tool to answer a majority of frequently asked patient questions. ChatGPT also converses in other languages including Urdu, which offers immense potential for the education of Pakistani patients. Therefore, this study evaluated ChatGPT's Urdu answers to the ten most frequently asked questions on Total Hip Arthroplasty, which were then rated by an expert. Out of 10 answers in English, 9 (90%) were satisfactory requiring minimal clarification and 1 (10%) was satisfactory requiring moderate clarification. In both Roman and Nastaliq script Urdu, 1 (10%) answer was satisfactory requiring moderate clarification, while 9 (90%) were unsatisfactory requiring substantial clarification. In conclusion, as opposed to ChatGPT English responses, Urdu responses were much less rigorous, generic, and lacked scientific rigor. We have a long way to go before Pakistani patients with limited English language skills could benefit from AI chatbots like ChatGPT.

Femoral anteversion change is associated with ischiofemoral impingement after total hip arthroplasty: a retrospective CT evaluation.

OBJECTIVES: We evaluated the relationship between femoral anteversion (FA), FA change, and ischiofemoral impingement (IFI) and the relationship between FA, femoral offset (FO), and greater trochanteric pain syndrome (GTPS) after total hip arthroplasty (THA). MATERIALS AND METHODS: In this retrospective study, two readers assessed FA and FO on CT images of 197 patients following primary THA with an anterior surgical approach between 2014 and 2021. FA change was calculated relative to preoperative CT, while FO change was calculated relative to preoperative radiographs and classified as decreased (≥-5 mm), increased (≥ + 5 mm), or restored (± 5 mm). Clinical and imaging data were analyzed for IFI and GTPS after surgery. Group differences were evaluated using Student's t-test, chi-square analysis, and receiver operating characteristic (ROC) analysis. RESULTS: The change in FA was 3.6 ± 3.3° to a postoperative FA of 22.5 ± 6.8°, while FO increased by 1.7 ± 3.5 mm to a postoperative FO of 42.9 ± 7.1 mm. FA and FA change were higher in patients with IFI (p ≤ 0.006), while no significant difference was observed for patients with and without GTPS (p ≥ 0.122). IFI was more common in females (p = 0.023). In the ROC analysis, an AUC of 0.859 was observed for FA change to predict IFI, whereas the AUC value was 0.726 for FA alone. No significant difference was found for FO change in patients with and without IFI or GTPS (p ≥ 0.187). CONCLUSION: Postoperative FA, FA change, and female sex were associated with IFI after anterior-approached THA. The change in FA was a better predictor of IFI than absolute postoperative FA alone. CLINICAL RELEVANCE STATEMENT: The findings of this study suggest that preservation of the preoperative femoral anteversion may reduce postoperative ischiofemoral impingement in patients undergoing total hip arthroplasty. KEY POINTS: • Higher postoperative femoral anteversion and anteversion change were associated with ischiofemoral impingement. • Femoral anteversion change was a better predictor of impingement than absolute postoperative anteversion. • No significant association was found between femoral offset and postoperative hip pain.

Risk Factors for Dislocation following Total Hip Arthroplasty in Developmental Dysplasia of the Hip: A Systematic Review and Meta-Analysis.

PURPOSE: This systematic review and meta-analysis aimed to identify risk factors of dislocation after total hip arthroplasty (THA) in patients with developmental dysplasia of the hip (DDH). METHODS: A systematic literature review was performed on 18th August 2022 using Medline, Embase, Scopus, Web of Science electronic databases, and a manual search. The study was conducted according to the PRISMA guidelines and registered with PROSPERO. Statistical analysis includes assessment of heterogeneity and data synthesis using RevMan 5.4. RESULTS: Review of five studies including 2865 patients and 116 dislocated hips found that lower body mass index (BMI) (SMD = 0.22, p = 0.04, I2 = 0%), Crowe classification type IV versus I, II, and III (OR = 2.70, p = 0.004, I2 = 51%), higher cup inclination (SMD = 0.39 p = 0.0007, I2 = 0%), femoral head size < 28 mm (OR = 5.07, p = 0.003, I2 = 71%), lateral surgical approach (OR = 1.96, p = 0.02, I2 = 0%), and postoperative infection (OR = 6.26, p < 0.0001, I2 = 0%) were significant risk factors. However, age, gender, cup anteversion, femoral osteotomy, vertical (V-COR) centre of rotation, intraoperative fracture, preoperative and postoperative leg length discrepancy (LLD) and previous hip surgery were not found to be significant risk factors. CONCLUSION: This study underscores importance of these risk factors in THA planning for DDH patients to reduce dislocation risk. Further research needed to understand mechanisms.

Spinopelvic alignment and low back pain after total hip arthroplasty: a scoping review.

OBJECTIVE: Spinopelvic alignment is increasingly considered as an essential factor for maintaining an energy-efficient posture in individuals with normal or pathological status. Although several previous studies have shown that changes in the sagittal spinopelvic alignment may occur in patients undergoing total hip arthroplasty (THA), no review of this area has been completed so far. Thus, the objective of this scoping review was to summarize the evidence investigating changes in spinopelvic alignment and low back pain (LBP) following THA. DATA SOURCES: We adhered to the established methodology for scoping reviews. Four electronic databases were systematically searched from inception-December 31, 2021. STUDY SELECTION: We selected prospective or retrospective observational or intervention studies that included patients with THA. DATA EXTRACTION: Data extraction and levels of evidence were independently performed using standardized checklists. DATA SYNTHESIS: A total of 45 papers were included in this scoping review, involving 5185 participants with THA. Pelvic tilt was the most common parameter measured in the eligible studies (n = 26). The results were not consistent across all studies; however, it was demonstrated that the distribution of pelvic tilt following THA had a range of 25° posterior to 20° anterior. Moreover, decreased sacral slope and lower pelvic incidence were associated with increased risk of dislocation in patients with THA. Lumbar spine scoliosis did not change significantly after THA in patients with bilateral hip osteoarthritis (5.50°(1.16°) vs. 3.73°(1.16°); P-value = 0.29). Finally, one study indicated that LBP improvement was not correlated with postoperative changes in spinopelvic alignment parameters. Several methodological issues were addressed in this study, including no sample size calculation and no type-I error adjustment for outcome multiplicity. CONCLUSIONS: Changes in spinopelvic alignment may occur after THA and may improve with time. Patients with a THA dislocation usually show abnormal spinopelvic alignment compared to patients without a THA dislocation. LBP usually improves markedly over time following THA.

Volume and Outcomes of Joint Arthroplasty.

BACKGROUND: Joint arthroplasties are among the most commonly performed elective surgeries in the United States. Surgical outcomes are known to improve with volume but it is unclear whether this has led to consolidation among elective surgeries. We examined trends in volumes per surgeon and hospital to assess whether the known volume-outcome relationship has led to consolidation in elective joint arthroplasty and to determine if there exist volume thresholds above which outcomes do not change. METHODS: Among Medicare beneficiaries who underwent either total knee or total hip arthroplasty from 2009 through 2015, we described volume trends and used mixed-effect models to relate annual surgeon and hospital volumes with 30-day complications or mortality. We tested for optimal volume cut points at both the hospital and surgeon level. RESULTS: Adjusted annual complication rates were inversely associated with volume for both procedures at both the surgeon level and hospital level, but there was minimal consolidation between 2009 and 2015. Complications no longer declined after volumes of each case exceeded 260 per year. The vast majority of cases (around 93% of hip and 88% of knee arthroplasties) were performed by surgeons operating at suboptimal volumes. CONCLUSION: More than 2 decades after the volume-outcome relationship was established for joint arthroplasty, many cases continue to be performed by low-volume surgeons, with far more cases performed by surgeons operating at suboptimal volumes. Further improvement could be expected through consolidation at both the hospital and surgeon level, with a target of at least 260 cases per surgeon annually for each operation. Payers seem best-equipped to drive consolidation.

Comparing ERAS-outpatient versus standard-inpatient hip and knee replacements: a mixed methods study exploring the experience of patients who underwent both.

BACKGROUND: Optimizing patients' total hip and knee arthroplasty (THA/TKA) experience is as crucial for providing high quality care as improving safety and clinical effectiveness. Yet, little evidence is available on patient experience in standard-inpatient and enhanced recovery after surgery (ERAS)-outpatient programs. Therefore, this study aimed to gain a more in-depth understanding of the patient experience of ERAS-outpatient programs in comparison to standard-inpatient programs. METHODS: We conducted a convergent mixed methods study of 48 consecutive patients who experienced both standard-inpatient and ERAS-outpatient THA/TKA contralaterally. A reflective thematic analysis was conducted based on data collected via a questionnaire. Bivariate correlations between the patient experience and patients' characteristics, clinical outcomes and care components satisfaction were performed. Then, the quantitative and qualitative data were integrated together. RESULTS: The theme Support makes the difference for better and for worse was identified by patients as crucial to their experience in both joint replacement programs. On the other hand, patients identified 3 themes distinguishing their ERAS-outpatient from their standard-inpatient experience: 1) Minimizing inconvenience, 2) Home sweet home and 3) Returning to normal function and activities. Potential optimization expressed by patients were to receive more preoperative information, additional postoperative rehabilitation sessions, and ensuring better coherence of care between hospital and home care teams. Weak to moderate positive and statistically significant correlations were found between patients' THA/TKA experience and satisfaction with pain management, hospital stay, postoperative recovery, home care, and overall results (rs = + [0.36-0.66], p-value < 0.01). CONCLUSION: Whatever the perioperative program, the key to improving patients' THA/TKA experience lies in improving support throughout the care episode. However, compared to standard-inpatient care, the ERAS-outpatient program improves patients' experience by providing dedicated support in postoperative care, reducing postoperative inconvenience, optimizing pain management, returning home sooner, and recovering and regaining function sooner. Patients' THA/TKA experience could further be enhanced by optimizing the information provided to the patient, the rehabilitation program and the coherence between care teams.

Effects of enhanced recovery after surgery practices on postoperative recovery and length of stay after unilateral primary total hip or knee arthroplasty in a private hospital.

INTRODUCTION: Enhanced recovery after surgery (ERAS) practices improve postoperative recovery and reduce postoperative length of stay (LOS) in patients undergoing primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). Our study investigated whether these promising results could be reproduced in a private hospital setting. METHODS: In total, 228 patients were included in the study cohort: the conventional group comprised 117 patients from 2012 to 2014, while the ERAS group comprised 111 patients from 2017 to 2018. All patients had undergone unilateral primary THA or TKA at a private hospital in Hong Kong. The outcome was postoperative LOS; factors affecting LOS were also investigated. RESULTS: No significant differences were found in any baseline parameters between the two groups of patients. The mean LOS was significantly shorter in the ERAS group than in the conventional group (3.28 ± 1.04 vs 5.16 ± 2.06 days, P<0.001). Moreover, a significantly greater proportion of patients could be discharged on or before postoperative day 3 in the ERAS group, compared with the conventional group (77.5% vs 13.7%, P<0.001). A significant difference in LOS was observed between general ward and private ward patients (3.06 ± 0.59 vs 3.66 ± 1.46 days, P=0.003). Sex, age, and nature of surgery (TKA vs THA) did not have significant effects on LOS. CONCLUSIONS: The ERAS practices yielded a significant improvement in postoperative LOS, compared to conventional practices, among patients who underwent unilateral primary THA or TKA in a private hospital.

Patient expectations and satisfaction 6 and 12 months following total hip and knee replacement.

PURPOSE: To assess (1) patient expectations before total hip (THR) and knee (TKR) replacement; (2) which expectations are met and unmet 6 and 12 months post-surgery; (3) the role of unmet expectations in satisfaction. METHODS: Questionnaires were mailed to consecutive patients following surgeon referral for primary THR or TKR. Patients listed their own expectations and also completed the Hospital for Special Surgery (HSS) Expectation Survey. We used content analysis to group expectations into themes. At 6 and 12 months post-surgery, patients were given a copy of their own list of individual expectations and reassessed each one as met or unmet. We also assessed fulfilled HSS expectations and satisfaction with surgery. RESULTS: The sample of 556 patients (49% THR, 57% female) had a mean age of 64 years (SD10). The five most frequent expectation themes were pain relief, mobility, walking, physical activities, and daily activities. Of these, physical activities had the lowest percentage met 12 months post-surgery. 95% (THR) and 87% (TKR) were satisfied/very satisfied with their surgery 12 months post-surgery. Very satisfied patients had a significantly greater percentage of met expectations (96% THR; 92% TKR) than dissatisfied patients (42% THR; 12% TKR). Although most expectations listed by patients were included in the HSS surveys, some were not, particularly for TKR. From 6 to 12 months, there was a significant increase in patient satisfaction for self-care, daily activities, and met expectations for THR and pain relief, self-care, daily activities, and recreational activities for TKR. CONCLUSIONS: Expectations should be explicitly addressed before surgery, including a discussion of realistic expectations, particularly for physical activities.

The diagnostic value of SPECT/CT in predicting the occurrence of osteonecrosis following femoral neck fracture: a prospective cohort study.

BACKGROUNDS: One of the most significant complications after a femoral neck fracture is osteonecrosis of the femoral head (ONFH). The concomitant use of single-photon emission computed tomography (SPECT) with computed tomography (CT) increases the sensitivity for detecting the anatomic location and severity of ONFH. In this study, we evaluated the diagnostic value of SPECT/CT for the occurrence of ONFH by quantifying the perfusion status of the femoral head. METHODS: A total of 30 patients who had multiple pinnings for femur neck fractures were included in this study. We classified the perfusion status into three groups: normal perfusion, decreased perfusion, and avascular groups, and compared the occurrence of femoral head necrosis between them. For quantitative analysis, we evaluated the uptake ratio of both femur heads (head-to-head uptake ratio). If the patient's contralateral hip was incomparable, we measured the uptake ratio from the superior dome of the ipsilateral acetabulum (head-to-acetabulum uptake ratio). RESULTS: Twenty-four patients out of 30 achieved bone union, whereas the others developed ONFH. When the population was divided into intact and defective perfusion groups on scintigraphy, the sensitivity, specificity, and accuracy of the test were 83.3, 75.0, and 76.7%, respectively. The mean head-to-head uptake ratio value with a 95% confidence interval (CI) was 1.10 (95% CI: 0.85-1.36). In the osteonecrosis group, the mean value of the head-to-head uptake ratio was 0.33 (95% CI: 0.28-0.38). In contrast, the ratio was 1.30 (95% CI: 1.03-1.57) in the non-osteonecrosis group, demonstrating a significant difference in the uptake ratio (P < 0.001). When the cutoff value of the uptake ratio was set to 0.5, both the sensitivity and specificity were 100%. There was also a significant difference in the head-to-acetabulum uptake ratio between the two groups (P <  0.001). CONCLUSIONS: SPECT/CT was useful in evaluating the perfusion status of the femoral head, showing high accuracy in predicting the occurrence of avascular necrosis. To demonstrate the reliability and validity of SPECT/CT, further prospective studies on a larger scale are warranted.

Rationale and design of the PaTIO study: PhysiotherApeutic Treat-to-target Intervention after Orthopaedic surgery.

BACKGROUND: Physiotherapy is a proven effective treatment strategy after total knee and hip arthroplasty (TKA/THA), however there is considerable practice variation regarding its timing, content and duration. This study aims to compare the (cost-) effectiveness of a standardized, treat-to-target postoperative physiotherapy strategy with usual postoperative care. METHODS: Using a cluster randomized study design, consecutive patients scheduled for a primary TKA/THA in 18 hospitals in the Netherlands will be assigned to the treat-to-target physio therapy strategy or usual postoperative care. With the treat-to-target strategy a standardized, individually tailored, exercise program is aimed at the attainment of specific functional milestones. Assessments are done at baseline, 6 weeks and 3, 6, 9 and 12 months follow up. The primary outcome will be the Knee injury / Hip disability and Osteoarthritis Outcome Score - Physical Function Short Form (KOOS-PS / HOOS-PS) at 3 months follow up. Secondary outcomes are the numeric rating scale for pain, the Oxford Knee and Hip Scores, performance-based test and the EuroQol 5D-5L for quality of life. Healthcare use, productivity and satisfaction with postoperative care are measured by means of questionnaires. In total, 624 patients will be needed of which 312 TKA and 312 THA patients. DISCUSSION: The study will provide evidence concerning the (cost-) effectiveness of the treat-to-target postoperative physiotherapy treatment compared to usual postoperative care. The results of this study will address an important evidence gap and will have a significant impact in daily practice of the physio therapist. TRIAL REGISTRATION: Registered in the Dutch Trial Registry on April 15, 2018. Registration number: NTR7129 .

[Effect of enhanced recovery after surgery for elderly patients with hemiarthroplasty for the treatment of femoral neck fracture].

Objective: To explore the clinical effect of enhanced recovery after surgery (ERAS) for the elderly patients with femoral neck fracture. Methods: A total of 92 elderly patients with femoral neck fracture who received hemiarthroplasty from July 2018 to December 2018 in Beijing Jishuitan Hospital were enrolled in this study. The average age of the participants was (75±6) years, including 31 males and 61 females, and 72(78.3%) of the patients complicated with comorbidity. According to the perioperative management method, the patients were divided into the observational group (47 cases with ERAS) and the control group (45 cases with normal management). The data related to operation, hospitalization, complication and nursing satisfaction were compared between the 2 groups. The visual analogue scale (VAS) was used for pain evaluation. The Harris scores for hip joint and EQ-5D index scores were applied to evaluate the clinical outcomes. The follow-up were performed periodically for 3 months. The measurement data in accordance with normal distribution and homogeneity of variance were compared with t test. Results: All the surgeries completed successfully and no patient died during perioperative period. Compared with the control group, the operation rate in 48 hours (χ(2)=17.781, P<0.01), bed days (Z=-4.987, P<0.01), and medical costs (Z=-4.315, P<0.01) favored that in the observational group. The incidence of complication and nursing satisfaction showed no significant difference between the two groups (31.1% vs 14.9%, 86.7% vs 95.7%, χ(2)=3.432, 1.380, both P>0.05). The perioperative VAS score was lower in the observational group. The Harris scores were higher in the observational group after 1 months (t=4.458, P<0.01), however the quality of life for 2 groups was similar at all time points (t=1.293, 1.227, both P>0.05). Conclusion: ERAS can improve hip function and reduce the hospital stays and medical costs for patients underwent HA operation.

[Risk factors of allogeneic red blood transfusion following enhanced recovery hip and knee arthroplasty].

Objective: To Explore the current status and risk factors of perioperative allogenic red blood cell transfusion following enhanced recovery hip and knee joint arthroplasty. Methods: Patients who have taken their primary unilateral total hip and knee arthroplasty (THA, TKA) or simultaneous primary THA were retrospectively included from January, 2019 to December, 2019 in West China Hospital. The baseline characteristics were compared between patients with allogeneic transfusion and those without. And logistic regression were used to analyze the risk factors of perioperative allogeneic red blood cell transfusion. Results: A total of 2 034 patients (2072 arthroplasties) were included, 705 males and 1 329 females, aged (60±24) years. Of all, 1 137 patients received primary THA (38 simultaneous THA), 897 patients received primary unilateral TKA. Eleven (0.54%) patients received allogeneic red blood cell transfusion, and the mean volume was (2.6±1.2) U. Deep venous thrombosis occurred in 2 patients (0.09%) undergoing primary TKA. The transfusion rate in primary THA patients was 0.79% (9/1 137), and 0.22% (2/897) in TKA. Lower preoperative hemoglobin level (P=0.041) and more hematological comorbidities (P=0.005) were detected in transfused patients. And logistic analysis further revealed that preoperative substandard hemoglobin level was the most important risk factor for transfusion (OR=5.663, P=0.018). Conclusions: Under the intervention of enhanced recovery after surgery concept and modern blood management strategies, the transfusion requirement has been significantly reduced following primary joint arthroplasty. Pre-operative hemoglobin level should be an important threshold for perioperative blood management.

[Diagnostic value of D-dimer for chronic periprosthetic infection after hip and knee joint replacement].

Objective: To investigate the diagnose value of D-dimer for chronic periprosthetic infection (PJI) after hip and knee arthroplasty. Methods: A retrospective analyze was conducted on 168 patients underwent revision arthroplasty and primary arthroplasty at the First Affiliated Hospital of Xinjiang Medical University from November 2017 to December 2018.There were 58 males and 110 females, aged(58.6±14.5)years.There were 48 cases of chronic PJI (21 cases of knee joint, 27 cases of hip joint), 57 cases of aseptic loosening (16 cases of knee joint, 41 cases of hip joint), and 63 cases of normal follow-up patients after hip (35 cases) or knee (28 cases) arthroplasty.The levels of D-dimer, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were collected.The levels of D-dimer in patients with chronic PJI of hip and knee joints were compared by Mann-Whitney U test.The diagnostic efficacy of D-dimer, ESR and CRP in chronic PJI of hip and knee joints was analyzed by receiver operator curve (ROC). Results: The D-dimer level was significantly higher in knee chronic PJI patients than hip chronic PJI patients(M (Q(R)) ) (1 040 (1 140.5) µg/L vs.435 (605) µg/L, Z=3.169, P=0.002) . ROC analysis showed that the optimum cutoff value of D-dimer in the diagnosis of chronic PJI was 370.5 µg/L, the sensitivity was 90.5%, the specificity was 84.1%; the optimum cutoff value of CRP was 9.3 mg/L, the sensitivity was 95.2%, the specificity was 90.9%, the optimum cutoff value of ESR was 33 mm/h, the sensitivity was 90.5%, and the specificity was 88.6%.The optimum cutoff value of D-dimer in the diagnosis of chronic PJI of hip joint is 294 µg/L, the sensitivity of diagnosis is 66.7%, the specificity is 77.6%; the optimum cutoff value of ESR is 45 mm/h, the sensitivity of diagnosis is 55.6% , the specificity is 97.4%; the optimum cutoff value of CRP is 8.1 mg/L, the sensitivity of diagnosis is 74.1%, the specificity is 84.2%. Conclusion: The value of D-dimer in the diagnosis of chronic PJI of knee joint is higher than that of hip joint, but the value of D-dimer in the diagnosis of chronic PJI is not better than ESR and CRP.

Perceived skills for sports performance after primary hip arthroplasty: a cross-sectional study.

PURPOSE: Recommendations arising from existing literature regarding restrictions and benefits of sporting activities after joint replacement surgery vary widely. As hip arthroplasty patients are becoming increasingly active, their expectations about post-operative function are constantly evolving. The aim of this study is to identify the perception of patients regarding their performance in sports activities after hip arthroplasty. METHODS: This cross-sectional study included all patients undergoing primary hip arthroplasty, for any diagnosis, between January 2009 and January 2016. By applying a telephone survey, practice of sports before surgery, resumption after surgery, level of performance, and causes of non-resumption of sports activities were assessed. RESULTS: Data of 531 patients were obtained. Of these, 13% were engaged in sports before surgery. The most frequently practiced sports were golf (27.5%) and tennis (22%). Of the 72 patients that practiced sports, only 44.4% (30 patients) returned to this activity after surgery. Nonetheless, 71% of these patients reported to have an equal or better athletic performance than before surgery. The main causes reported by patients not to return to sports were the fear of injury and recommendation of the surgeon. CONCLUSIONS: A significant number of patients return to sports after hip arthroplasty and most of them perceive a good athletic performance after surgery. These findings should enrich the pre-operative assessment of patient's expectations, particularly for those who wish to resume physical activity.