HIP International最新文献

Background: Safe surgical dislocation has revolutionised hip preservation surgery by allowing complete access to the proximal femur while minimising the risk of avascular necrosis. However, despite meticulous technique, intraoperative injury to the superior retinacular vessels (SRV), the primary blood supply to the femoral head, can still occur, potentially compromising outcomes.

Purpose: To identify, classify, and analyse intraoperative patterns and mechanisms of SRV injury during surgical hip dislocation procedures performed for complex hip deformities.

Methods: A prospective analysis of all cases with intraoperative lateral retinacular damage during hip preservation surgeries through surgical dislocation between 2005 and 2024 was performed. Patient demographics, preoperative diagnoses, intraoperative findings, and patterns of SRV damage were documented. Standard safe surgical dislocation with trochanteric flip osteotomy was performed in all cases, with vascular assessment using arterial Dopplers and intraosseous femoral head drilling.

Results: 14 patients (mean age 14 years; 7 males, 7 females) were included. Preoperative diagnoses included Perthes disease, stable and unstable slipped capital femoral epiphysis (SCFE), healed SCFE, chondrolysis, and pseudo-rheumatoid dysplasia. Patterns of SRV injury included stripping of the lateral retinaculum during internal rotation in 3 cases, spontaneous avulsion in unstable slips and dysplastic hips, ischemia following distal neck osteotomies, and iatrogenic avulsion following combined flap elevation and circumferential cam osteoplasty. Pre-existing vascular compromise was common in unstable and healed slips. Careful surgical technique, controlled reduction, and intraoperative vascular monitoring minimised further SRV damage.

Conclusions: This study represents the largest reported intraoperative series of SRV injuries during surgical hip dislocation. Internal rotation during reduction, osteotomy near the physeal scar, and extensive cam osteoplasty were major contributors to SRV injury. Awareness of vulnerable steps, meticulous surgical technique, and intraoperative assessment of femoral head perfusion are essential to preserve the femoral head's vascular integrity during complex hip preservation procedures.

Introduction: This study evaluated the accuracy of cup placement by the robotic arm-assisted system (Mako) in obese patients with developmental dysplasia of the hip (DDH).

Methods: This retrospective single-centre study included 923 consecutive hips with primary robotic arm-assisted total hip arthroplasty (THA). After propensity score-matching, 80 hips with DDH each were selected for the obese group and non-obese group. Postoperative cup orientation and positioning were assessed by superimposition of a 3-dimensional cup template, using postoperative computed tomography images with pelvic coordinates matching the preoperative planning.

Results: The absolute error of cup inclination and anteversion was comparable between the obese and non-obese groups (1.2 ± 1.0° vs. 1.2 ± 1.0° and 1.4 ± 1.0° vs. 1.6 ± 1.2°, respectively). The absolute error of the transverse, sagittal, and longitudinal axes between the obese and non-obese groups were 1.0 ± 0.9 mm vs. 1.4 ± 1.0 mm, 1.5 ± 1.0 mm vs. 1.3 ± 1.8 mm, and 1.4 ± 1.2 mm vs. 1.3 ± 0.9 mm (p = 0.02, p = 0.89, and p = 0.12, respectively). There was no significant difference in cup orientation or positioning in the obese group, regardless of body mass index.

Conclusions: Robotic arm-assisted THA enables accurate cup placement even in obese patients with DDH.

Background: With the increased rates of revision total hip (rTHA) and total knee arthroplasty (rTKA), the financial burden of these procedures is at risk of straining the healthcare system. Our study sought to create a model to evaluate the cost-effectiveness of rTKA and rTHA performed by high-volume (HV) and low-volume (LV) surgeons.

Methods: The database of rTKA and rTHA from April 2018 to March 2021 at our academic institution was retrospectively reviewed. Surgeons above the 90^th percentile in annual volume were classified as HV surgeons and the remainder were classified as LV surgeons. Previously published cost estimates were utilised for operative time, hospital length of stay (LOS), discharge disposition, 90-day readmission, and 1-year re-revision.

Results: A total of 442 rTKA were performed by 30 surgeons and 420 rTHA were performed by 32 surgeons. 3 surgeons were HV in each group with HV surgeons performing 213 (48.2%) rTKA and 215 (51.2%) rTHA in the study period. LV surgeons had longer operative times for both rTKA (167.1 vs. 145.8 minutes; p < 0.001) and rTHA (172.5 vs. 151.2 minutes; p < 0.001). Both groups had equivalent discharge disposition, 90-day readmission, and 1-year re-revision. HV surgeons had lower estimated mean costs for rTHA ($22,027.81 vs. $24,617.39) and rTKA ($20,343.23 vs. $18,554.67).

Conclusions: HV surgeons have a lower estimated mean cost for both rTHA and rTKA. Healthcare systems may benefit from having rTHA and rTKA procedures performed by HV surgeons who are able to perform these revision procedures for a lower cost without negatively impacting patient outcomes.

Background: The anterior femoral cortical window is an attractive alternative to the extended trochanteric osteotomy when removing femoral cement in revision hip arthroplasty. CT-based additive manufacturing technology has now permitted the creation of patient-specific instrumented (PSI) jigs to facilitate this. The jig simplifies creation of the window, potentiating medullary exposure through an optimally-sized window and therefore cement removal. Between 2006 and 2021 this technique was used in 22 cases at a regional hospital in New Zealand (mean age 74; range 44 to 89 years). 16 cases were for aseptic loosening and 6 for infection. We describe the technique and our case series. Bone incorporation for the cortical window was assessed in all cases using CT imaging. Oxford scores were obtained at a minimum of 6 months after revision surgery. Of the 6 septic cases 5 went onto successful stage-2 procedures, the other to a Girdlestone procedure.

Results: The mean rectangular shaped window size was 8 × 1.5 cm and in each case, this provided adequate intramedullary access. On average at minimum 5 months post-surgery, 84% bone incorporation of the cortical window occurred on CT (40-100%). The functional outcome Oxford hip score was 37 (range 22-48) for 10 cases. There were 2 cases with femoral component subsidence which then stabilised.

Conclusions: This technique description and retrospective case series has shown the effectiveness of removing a distal femoral cement mantle in revision hip arthroplasty using an anterior femoral cortical window, recently optimised using a PSI jig. This technique is a straightforward alternative to a trochanteric osteotomy. Reliable bony integration of the cortical window occurred and functional outcomes were comparable with the mean score for revision hip procedures reported in the New Zealand Joint Registry.

Introduction: Prior studies have shown human immunodeficiency virus (HIV) may be a risk factor for early revision following THA, but little data exists looking at long-term implant survivorship. Therefore, the purpose of this study was to compare the 10-year cumulative incidence rate for revision following THA in patients with and without HIV.

Methods: A retrospective cohort analysis of patients with HIV undergoing elective THA was conducted using a national database. Patients were stratified into asymptomatic HIV (AHIV) and acquired immune deficiency syndrome (AIDS) cohorts. These patients were propensity-score matched to a group of elective THA patients without HIV based on age, gender, and Charlson Comorbidity Index (CCI) at a 1:2 ratio. Kaplan-Meier and Cox Proportional Hazards Regression Analyses were used to assess cumulative incidence and risk of revisions within 10-years of the index procedure.

Results: In total, 678 patients were at-risk at the 10-year mark. There were no differences in 10-year risk of revision THA, amongst patients with HIV when compared to matched and unmatched controls (p > 0.05 for all). Patients with HIV did have an increased risk of periprosthetic joint infection (PJI) following THA when compared to the unmatched control (p = 0.001).

Discussion: Surgeons and patients can be reassured of comparable 10-year revision rates in patients with and without HIV. However, as these patients are at increased risk for PJI and PPF, especially those with AIDS, when compared to the general population, surgeons should consider PJI prophylactic modalities in this patient population.

Purpose: The aim of the present study was to assess outcomes of using the push-through total femoral prothesis (PTTF) for revision total hip replacement with extreme bone loss.

Methods: 10 consecutive patients who received PTTF between 2012 and 2018 for revision hip arthroplasty were included in the study. Primary functional outcomes were assessed using Harris Hip Score (HHS), Toronto Extremity Salvage Score (TESS) and Musculoskeletal Tumor Society (MSTS) scores. Range of motion, complications, and ambulatory status were also recorded to assess secondary outcomes.

Results: 2 of 10 patients underwent surgery with PTTF for both knee and hip arthroplasty revision. The mean time between index surgery and PTTF was 15 years (3-32 yrs). Acetabular components were revised in 6 of 10 patients during PTTF application. After a mean follow-up of 5.9 years, hip dislocations occurred in 3 patients. All of the dislocated hips were ones with retained conventional non-constrained acetabular bearings. Patient satisfaction was high (MSTS: 67%, HHS: 61.2%, TESS 64.6%) despite high re-operation rate (40%) and minor postoperative problems.

Conclusions: PTTF should be considered for hip and knee arthroplasty revision procedures in patients with an extreme bone defect. Consistent usage of constrained liners should be considered to avoid hip dislocation, which was our main problem following the procedure.

Introduction: Bone loss represents a formidable challenge in hip revision surgery. Recent advances in revision implants and the use of new materials have diminished the need for cup-cages in addressing severe acetabular bone loss, which, however, may still be indicated in certain situations. The objectives of this study are to assess survival, functional outcomes, and reasons for the failure of managing severe acetabular bone loss with titanium cages and cemented cup.

Methods: 57 patients treated with an acetabular cage and cemented cup for acetabular revision between January 2014 and July 2018 were retrospectively evaluated. Inclusion criteria comprised cup loosening with bone loss greater than IIB according to Paprosky classification, and a follow-up of at least 60 months.

Results: The average age at the time of surgery was 74.8 years (SD 10.7). The acetabular bone defect according to the Paprosky classification was: type II C in 10 patients (21.7%), type III A in 21 patients (45.7%) and type III B in 15 patients (32.6%). Pelvic discontinuity was present in 35 cases (76.1%). The average follow-up during the final assessment was 78.3 months (SD 14.9). The reoperation rate was 13% (6 patients) and the complications rate was 17.4%. The survivorship of the implant was 87% at final follow-up.At the final follow-up average HHS was 89.4 ± 13.4, average WOMAC 15.7 ± 17.2, average HOOS 81.3 ± 19 and average FJS-12 83.7 ± 17.2. At the final follow-up, 32 patients (80%) showed excellent or good outcomes (HHS >80).

Conclusions: In the presence of severe bone defects, acetabular reconstruction using titanium acetabular cages and cemented UHMWPE cups remains a valid treatment option. Specifically, this acetabular reconstruction system should be favoured for elderly or low-demand patients, with the possibility of using it safely even in patients with pelvic discontinuity.

Introduction: Surgeons allocate an indication(s) for revision surgery on NJR Minimum Data Set forms in the immediate perioperative period, when results from intraoperative histology and microbiology samples are not available. We evaluated to what extent the postoperative diagnostics obtained for patients undergoing metal-on-metal hip arthroplasty (MoMHA) revision surgery align with the indication for revision listed in the NJR.

Methods: NJR data for MoMHA revision patients (2004-2015) at a single centre were linked to hospital records of microbiology and histology testing for prosthetic joint infection (PJI) and adverse reaction to metal debris (ARMD). The Musculoskeletal Infection Society and Mirra classifications were used as "gold standards' to classify PJI and ARMD respectively and to assess the diagnostic accuracy of the clinician selected revision indication recorded on MDS forms.

Results: Of 301 cases, 5.6% (n = 17) and 3.7% (n = 11) were revised for PJI and ARMD respectively. In a further 6.6% (n = 20, PJI) and 15.6% (n = 47, ARMD) the indication for revision selected at the time of surgery did not corroborate with the test results from intraoperative samples. Diagnostic accuracy analysis revealed sensitivity and specificity of indication for surgery at the time of revision for PJI of 35.5% (95% CI, 19.2-54.6) and 97.8% (CI, 54.6-95.2) respectively, and for ARMD of 7.41% (CI, 2.06-17.9) and 97.2% (CI, 94.3-98.9) respectively.

Conclusions: We observed that the results of histology and microbiology analyses of intraoperative samples may provide evidence to support alternative diagnoses in 20% of cases. This indicates a need for a change in the work-up of these cases to allow a more accurate prediction of the indication for revision. Alternatively, if there was evidence of a difference in outcome for patients where the indication may be changed when such data becomes available, the feasibility of a facility to add additional information from samples taken intraoperatively when it becomes available should be explored.

Background: Whether postoperative posterior pelvic tilt progression is an independent risk factor for cup revision after total hip arthroplasty (THA) with a conventional polyethylene (PE) liner is unclear. This long-term follow-up study assessed the association between posterior pelvic tilt and cup revision after THA using the porous-coated anatomic (PCA) total hip system.

Methods: This retrospective cohort study included 94 patients who underwent THA using the PCA total hip system and participated in postoperative follow-up for a mean of 25 years. The Japanese Orthopaedic Association (JOA) hip score was the clinical outcome, and prosthetic alignment and the change in pelvic tilt were measured as radiological outcomes. Prosthetic survival rates for revision as the endpoint were evaluated, and risk factors for cup revision were identified using a multivariate logistic regression analysis.

Results: The JOA hip score improved significantly (p < 0.001) after THA (before THA: 41 ± 6.3 points; after THA: 86 ± 8.9 points). The postoperative posterior pelvic tilt progressed 3.6 ± 3.2°. Survival rates of the cup and stem at 27 years postoperatively were 60.8% and 87.5%, respectively (p < 0.001). The main reason for revision (81% of all revisions) was aseptic loosening. Postoperative posterior pelvic tilt progression was an independent risk factor for cup revision (odds ratio, 1.53; 95% confidence interval, 1.06-2.20; p = 0.022).

Conclusions: When the PCA total hip system was used, the stem exhibited good longevity during a mean follow-up period of 25 years; however, the cup was vulnerable because of aseptic loosening. Postoperative posterior pelvic tilt progression was an independent risk factor for cup revision.

Background: Total hip arthroplasty is one of the most successful and cost-effective interventions for improving quality of life. Dislocation is a well-recognised complication with a significant health and economic burden. The aim of this study was to establish the current management practices for patients presenting with a prosthetic hip dislocation. This was measured through the primary outcome of definitive management, either in the form of revision surgery or the consideration for this through a referral pathway. The secondary outcome measured the number of dislocations per patient resulting in consideration for definitive management.

Methods: Between January and July 2019, 186 patients who sustained a prosthetic hip dislocation were identified from 13 separate institutions. Data were retrospectively collected including patient demographics, co-morbidities, details of the arthroplasty, number of dislocations, and management, both in the acute setting and after discharge.

Results: 149 patients who sustained 200 dislocations were included. The median (interquartile range) interval between primary total hip arthroplasty and first dislocation was 6 (0-13) years. An urgent reduction was achieved either in the emergency department or operating theatre in 3 (1.5%) and 188 (94%) cases, respectively, and 2 (1%) underwent urgent revision. Only 55 patients (36.9%) received definitive management, either in the form of revision surgery or consideration for this. The number of dislocations was the only independent predictor of definitive management (p = 0.001, odds ratio [OR] 1.332; 95% confidence intervals 1.130-1.570).

Conclusions: There is a lack of consensus regarding the definitive management of patients with prosthetic hip dislocation. Our study highlights the need for a standardised pathway for the management of this complication. We aim to expand this study to a national level to propose a data-driven management algorithm for prosthetic hip dislocations.