Cementless total hip arthroplasty for patients previously treated with femoral osteotomy for hip dysplasia: the incidence of periprosthetic fracture

Total hip arthroplasty after failed transtrochanteric rotational osteotomy for osteonecrosis of the femoral head: analysis of three-dimensional morphological features

BACKGROUND

In total hip arthroplasty (THA) after failed transtrochanteric rotational osteotomy (TRO) for osteonecrosis of the femoral head (ONFH), deformity of the proximal femur has been reported to affect stem placement. The aims of this study were to evaluate the morphological changes in the proximal femur, muscle atrophy, and soft tissue thickening in THA after TRO and the clinical outcomes.

METHODS

The TRO group included 17 patients (18 hips) who underwent THA after failed TRO. The control group included 21 patients (28 hips) who underwent primary THA for ONFH. To evaluate the deformity of the proximal femur before THA, we measured the anteroposterior and mediolateral diameters of the femur on computed tomographic slices 5 mm proximal to the lesser trochanter. To evaluate muscle atrophy and soft tissue thickening, we measured the thicknesses of the psoas major, iliac, and gluteus medius muscles and the anterior capsule of the hip joint.

RESULTS

The ratio of the anteroposterior to mediolateral diameters of the proximal femur was significantly greater in the TRO group (p < 0.01). The thicknesses of the muscles did not differ between the two groups, whereas the anterior capsule was significantly thicker in the TRO group (p < 0.05). Varus or valgus stem alignment (> 3°) was frequent in the TRO group (p < 0.01).

CONCLUSIONS

The round shape of the proximal femur was deformed after TRO compared with primary THA for ONFH, which may have caused malposition of the stem. In addition, we should pay attention to anterior protrusion of the proximal femur and thickening of the anterior capsule.

Short-term results of total hip arthroplasty using a tapered cone stem for patients with previous femoral osteotomy

PURPOSE

In total hip arthroplasty (THA) for patients with previous femoral osteotomy, we hypothesized that a tapered cone stem may be an option due to the altered morphology of the proximal femur. The purpose of this study was to assess the short-term results of THA after femoral osteotomy using a tapered cone stem, and to identify issues that require further attention.

METHODS

Twenty-two hips in 21 consecutive patients who underwent THA after femoral osteotomy using a Wagner Cone tapered cone stem were retrospectively reviewed, with a mean follow-up period of 34.4 (range, 24-50) months. Clinical information was obtained from medical records. On preoperative radiographs, the Dorr type was classified based on the anteroposterior cortical index. On postoperative radiographs, the degree of stem subsidence and the stem location with the highest canal fill ratio were assessed.

RESULTS

The mean Harris hip score significantly improved from 55.2 at baseline to 84.8 at final follow-up. Radiologically, stem subsidence (>3 mm) was observed in seven hips, and it stabilized within 1 year after THA in all cases. In five of seven hips with stem subsidence, the highest postoperative canal fill ratio was observed in the distal third of the stem. The proportions of males and Dorr type A were significantly higher among hips with stem subsidence than among those without. During the follow-up period, no hips showed implant loosening or required revision surgery.

CONCLUSIONS

The occurrence of stem subsidence should be noted when using Wagner Cone stems for Dorr type A femurs after femoral osteotomy.

Modular stem in total hip arthroplasty for patients with trochanter valgus deformity: surgical technique and case series

Background

Trochanter valgus deformity (TVD) is a rare condition of total hip arthroplasty (THA). Femoral osteotomy could be required in correcting the deformity to implant femoral stem in severe TVD. In this study, we described one unpublished technique of reverse sleeve of S-ROM to get through the complex situation. This study aimed to summarize and evaluate its technical challenges, safety and effectiveness.

Methods

From January 2006 to December 2014, we enrolled patients whose sleeves were implanted towards the great trochanter in THA with TVD. Their demographics, perioperative and postoperative information were recorded. To explore its indication, we measured and analyzed the ratio of greater trochanter/lesser trochanter (G/L ratio) and trochanter valgus angle (TVA).

Results

Twelve patients (1 male and 11 female, average age 42.30 ± 10.23) had mean follow-up of 6 years. Among them, only two patients had intraoperative femoral fracture. The survivorship of femoral prosthesis was 100%. The Harris hip score (HHS) increased from preoperative 34.31 ± 14.43 to postoperative 84.12 ± 11.33. All patients’ G/L ratio were larger than 1.50.

Conclusions

The reverse sleeve of S-ROM was a reliable method for the patients with severe TVD, which brought satisfying clinical outcomes in mid-term follow-up.

The effect of previous pelvic or proximal femoral osteotomy on the outcomes of total hip arthroplasty in patients with dysplastic coxarthrosis

OBJECTIVE

This study aimed to evaluate whether a history of a pelvic osteotomy or proximal femoral osteotomy compromises the outcomes of total hip arthroplasty in patients with dysplastic coxarthrosis.

METHODS

The results of total hip arthroplasty in 240 hips of 172 patients without previous pelvic osteotomy or proximal femoral osteotomy were compared to 118 hips of 88 patients with a previous pelvic osteotomy or proximal femoral osteotomy (osteotomy group). Technical difficulties and rates of complications during surgery, operative time, estimated blood loss, rates of postoperative complications, and pre- and postoperative Harris Hip Scores and visual analog scale pain scores were compared between the two groups.

RESULTS

In the osteotomy, the rate of complications was higher and the operative time was longer. The estimated blood loss was also higher, and the latest follow-up Harris Hip Scores and visual analog scale pain scores were worse in this group. Total hip arthroplasty was more demanding and the revision rate was higher in the osteotomy group (six vs four revisions).

CONCLUSION

Our data showed that a previous history of pelvic osteotomy or proximal femoral osteotomy compromised the clinical outcomes of subsequent total hip arthroplasty and is related to an increased rate of complications, prolonged operative time, and increased amount of blood loss.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

Adult Idiopathic Bilateral Coxa Vara with Hip Osteoarthritis Treated with Bilateral Proximal Femur Osteotomy: A Case Report

CASE

We reported a case of a 25-year-old woman with idiopathic bilateral coxa vara who had initial presentation of hip osteoarthritis. She was later treated with bilateral subtrochanteric valgus osteotomy. A good functional outcome was recorded without nonunion or deformity recurrence. The arthritis of the hips also decelerated.

CONCLUSIONS

Coxa vara first diagnosed in adulthood was relatively uncommon, and the cause in this present case was uncertain. Subtrochanteric valgus osteotomy seemed to be a suitable treatment for this case.

What Is the Impact of a Previous Femoral Osteotomy on THA? A Systematic Review

BACKGROUND

Femoral osteotomies have been widely used to treat a wide range of developmental and degenerative hip diseases. For this purpose, different types of proximal femur osteotomies were developed: at the neck as well as at the trochanteric, intertrochanteric, or subtrochanteric levels. Few studies have evaluated the impact of a previous femoral osteotomy on a THA; thus, whether and how a previous femoral osteotomy affects the outcome of THA remains controversial.

QUESTIONS/PURPOSES

In this systematic review, we asked: (1) What are the most common complications after THA in patients who have undergone femoral osteotomy, and how frequently do those complications occur? (2) What is the survival of THA after previous femoral osteotomy? (3) Is the timing of hardware removal associated with THA complications and survivorship?

METHODS

A systematic review was carried out on PubMed, the Cochrane Systematic Reviews Database, Scopus, and Embase databases with the following keywords: "THA", "total hip arthroplasty", and "total hip replacement" combined with at least one of "femoral osteotomy" or "intertrochanteric osteotomy" to achieve the maximum sensitivity of the search strategy. Identified studies were included if they met the following criteria: (1) reported data on THAs performed after femoral osteotomy; (2) recorded THA followup; (3) patients who underwent THA after femoral osteotomy constituted either the experimental group or a control group; (4) described the surgical and clinical complications and survivorship of the THA. The database search retrieved 383 studies, on which we performed a primary evaluation. After removing duplicates and completing a full-text evaluation for the inclusion criteria, 15 studies (seven historically controlled, eight case series) were included in the final review. Specific information was retrieved from each study included in the final analysis. The quality of each study was evaluated with the Methodological Index for Non-randomized Studies (MINORS) questionnaire. The mean MINORS score for the historically controlled studies was 14 of 24 (range, 10-17), whereas for the case series, it was 8.1 of 16 (range, 5-10).

RESULTS

The proportion of patients who experienced intraoperative complications during THA ranged from 0% to 17%. The most common intraoperative complication was femoral fracture; other intraoperative complications were difficulties in hardware removal and nerve palsy; 15 studies reported on complications. The survivorship of THA after femoral osteotomy in the 13 studies that answered this question ranged from 43.7% to 100% in studies that had a range of followup from 2 to 20 years. The timing of hardware removal was described in five studies, three of which detailed more complications with hardware removal at the time of THA.

CONCLUSIONS

This systematic review demonstrated that THA after femoral osteotomy is technically more demanding and may carry a higher risk of complications than one might expect after straightforward THA. Staged hardware removal may reduce the higher risk of intraoperative fracture and infection, but there is no clear evidence in support of this contention. Although survivorship of THA after femoral osteotomy was generally high, the studies that evaluated it were generally retrospective case series, with substantial biases, including selection bias and transfer bias (loss to followup), and so it is possible that survivorship of THA in the setting of prior femoral osteotomy may be lower than reported.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Dual offset metaphyseal-filling stems in primary total hip arthroplasty in dysplastic hips after a minimum follow-up of ten years

PURPOSE

The aim of this study was to assess the long-term performance of tapered one-third proximally coated stems in dysplastic hips.

METHODS

This study included 135 dysplasia patients (150 hips) who underwent a total hip arthroplasty and had a minimum follow-up of ten years. Single design tapered stems were used in all patients. There were 112 women (83%) and 23 men (17%) with a mean age of 45 years (23 to 72) at the time of surgery. The mean follow-up was 14.7 years (10 to 16.8). For clinical evaluation, the Harris Hip Score and Merle D'Aubigne scale were used pre-operatively and at the final follow-up. Implant survival was calculated using Kaplan-Meier survivorship analysis, with failure defined as a component revision for any reason.

RESULTS

Overall, one stem was revised for a deep infection. There were no other femoral stem revisions secondary to loosening, wear, periprosthetic fracture, or instability. Radiographic evaluation showed excellent stem osteointegration in all cases. Kaplan-Meier survivorship, with stem revision for any reason as the end point, was 98% at 14 years (95% confidence interval 92.5 to 99.8).

CONCLUSION

This study demonstrates that a dual offset tapered stem achieved excellent survivorship and stability, as well as good clinical outcome scores with minimal thigh pain and stress shielding in patients with arthritis and developmental dysplasia of the hip; a dual offset tapered stem may be a suitable option for primary total hip arthroplasty in this group.

Total hip arthroplasty with a monoblock conical stem and subtrochanteric transverse shortening osteotomy in Crowe type IV dysplastic hips

PURPOSE

This series assessed the clinical and radiographic outcomes of total hip arthroplasty (THA) with femoral shortening osteotomy for the management of patients with Crowe type IV hip dysplasia.

METHODS

Only patients with Crowe type IV hip dysplasia who underwent primary THA combined with a subtrochanteric transverse osteotomy with an uncemented monoblock conical stem were included. The clinical and radiographic evaluations were performed before and immediately after surgery, and at last follow-up. The hip function was assessed with the Harris Hip Score (HHS).

RESULTS

Seventy-four patients (102 hips) with a mean age of 53.9 (range, 20-83) were evaluated at an average follow-up of 11.3 years (range, 5-25). Stem revision occurred in two (1.9%) cases, with a survivorship of 95.9% (95%IC, 91.9-99.9%) at ten years. The average HHS increased from 44 (range, 15-78) pre-operatively to 90.3 (range, 62-100) at last follow-up (p < 0.001). Osteotomy site non-union and early dislocation were observed in 3.9 and 3.8%, respectively. No cases of nerve palsy were reported.

CONCLUSIONS

THA with a monoblock conical stem associated with subtrochanteric transverse osteotomy provides good long-term survival, clinical and radiographic results. It may be considered an effective management of patients with Crowe IV hip dysplasia.

Clinical Results and Prognostic Factors for Outcomes of Valgus Femoral Osteotomy Combined with Chiari Pelvic Osteotomy for Osteoarthritis of the Hip

Background

Surgeons have long debated whether advanced or end-stage osteoarthritis of the hip in young patients should be treated with total hip arthroplasty or osteotomy. We reviewed the intermediate-term clinical results of valgus femoral osteotomy combined with Chiari pelvic osteotomy (VCO) for advanced or end-stage osteoarthritis associated with severe acetabular dysplasia of the hip in young patients and analyzed prognostic factors related to conversion to total hip arthroplasty.

Methods

The study group included 54 hips in 50 patients (5 men and 45 women; average age at the time of surgery, 45.6 years). The minimum and average durations of follow-up were 10 and 17.6 years, respectively. The Japanese Orthopaedic Association hip score (JOA score) was used for clinical evaluation. The probability of survival of the VCO from the time of the operation until the end point of conversion to total hip arthroplasty was calculated with use of the Kaplan-Meier method. We defined prognostic factors of outcome (conversion to total hip arthroplasty) with the Cox proportional hazards model.

Results

The mean total JOA score increased from 53.0 points preoperatively to 77.1 points at 1 year postoperatively, 81.6 points at 5 years, and 76.8 points at 10 years. The survival rates were 83.3%, 59.7%, and 46.9% at 10, 15, and 20 years, respectively. On univariate and multivariate analyses, patients with a low degree of acetabular roof obliquity had better postoperative results.

Conclusions

VCO is a surgical approach that preserves joint function in young patients with advanced or end-stage osteoarthritis associated with severe acetabular dysplasia of the hip. The postoperative prognosis of VCO was improved in patients with a low degree of acetabular roof obliquity.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Perioperative Periprosthetic Fractures Associated With Primary Total Hip Arthroplasty

BACKGROUND

Periprosthetic fracture (PPF) is a rare but devastating complication of primary total hip arthroplasty (THA). While PPF is associated with increased morbidity and mortality, early revision rate, and poor patient outcome, there is a paucity of data on patient and hospital-dependent risk factors. Using a large administrative database, we investigated epidemiology and the risk factors associated with perioperative PPF after primary THA.

METHODS

We performed a retrospective review of the National Inpatient Sample records from 2006 to 2011 and identified 1062 PPFs of 1,187,969 patients using International Classification of Diseases, Ninth Revision code for PPF (996.44). We then analyzed sociodemographic characteristics, comorbidities, and hospital characteristics of our study population.

RESULTS

The overall incidence of PPF in National Inpatient Sample database was 0.089% (8.9 per 10,000 THAs). Patient-dependent risk factors were: female (odds ratio [OR] 1.93, 95% confidence interval [CI] 1.67-2.22), low household income (OR 1.4, 95% CI 1.18-1.65), Medicaid (OR 1.89, 95% CI 1.39-2.57), and uninsured (OR 2.74, 95% CI 1.63-4.61). Patients with malnutrition and hemiparesis/hemiplegia were associated 10-fold and 6-fold risk of PPF. Nonteaching hospitals (OR 1.15, 95% CI 1.01-1.32), hospitals in northeast (OR 1.29, 95% CI 1.04-1.59), and rural hospitals (OR 1.27, 95% CI 1.06-1.53) had higher incidence of PPF.

CONCLUSION

Our study demonstrates that the incidence of PPF was low in our study population, and greater awareness is needed when performing primary THAs in patients with risk factors identified in our study to prevent PPF.

Clinical results of arthroscopic surgery in patients over 50 years of age-what viability does it have as a joint preservative surgery?

BACKGROUND

To identify whether hip arthroscopy is a suitable option for treating hip pain in elderly patients and investigate the clinical outcomes of hip arthroscopic surgery for labrum tear and/or osteoarthritis in patients over 50 years of age.

METHODS

Between August 2009 and May 2014, a series of 23 patients (6 men and 17 women) with a mean age of 59 years underwent arthroscopy. We retrospectively examined the clinical records, radiographs, and outcome questionnaires from all patients. The mean follow-up period was 28 months.

RESULTS

The mean Japan Orthopedic Association hip score after surgery improved by a statistically significant amount. Eight patients (34.8%) were noted to have a progression of osteoarthritis (OA) diagnosed by radiograph, and one underwent THA after 13 months following arthroscopic surgery. The patients in which OA progression was noted were identified as having radiographical OA preoperatively and acetabular cartilage damage in the arthroscopic findings.

CONCLUSIONS

Arthroscopic surgery performed in selected patients over 50 years of age might be beneficial if classified as Tönnis grade 0 preoperatively and/or classified as Outerbridge grade II in the arthroscopic findings.