Total hip arthroplasty by direct anterior approach in the lateral position for the treatment of ankylosed hips

Prediction and Risk Factors of Lower Extremity Deep Vein Thrombosis after Total Joint Arthroplasty

This study was to retrospectively analyze the incidence of deep vein thrombosis (DVT) in patients undergoing total joint arthroplasty (TJA) and analyze the risk factors for DVT. 113 patients with TJA were divided into the DVT group (n = 11) and the non-DVT group (n = 102) according to the postoperative ultrasound diagnosis, and the incidence of DVT after TJA was calculated. Logistic regression was used to analyze the correlation between DVT and patients' age, medical history, surgical factors, blood indexes to identify the risk factors of DVT after TJA. Receiver operator characteristic (ROC) curve was constructed to evaluate the diagnostic accuracy of risk factors for DVT. According to the results of ultrasound examination, DVT occurred in 11 of 113 patients after TJA, and the incidence rate of DVT was 9.73%. Univariate analysis showed that the levels of age, diabetes mellitus, operation time, intraoperative blood loss, intraoperative blood transfusion, antithrombin-Ⅲ (AT-Ⅲ), plasma protein C (PC), soluble platelet endothelial cell adhesion molecules-1 (SPECAM-1) and tissue-type plasminogen activator (t-PA) in the DVT group were significantly different from those in the non-DVT group (P < 0.05). Multivariate analysis showed that combined diabetes, decreased PC and t-PA were risk factors for DVT (P < 0.05). ROC analysis showed that PC combined with t-PA had the highest diagnostic accuracy for DVT. Patients with diabetes mellitus are at high risk for DVT after TJA, the increase of D-dimer, the decrease of PC and t-PA after 24 h of TJA is the the risk factors for DVT occurrence.

Factors predisposing to limited flexion after total hip arthroplasty for the treatment of axial spondyloarthritis

Hip involvement is a common condition in about one-third of patients with axial spondyloarthritis (axSpA). We assessed the incidence of possible factors that predispose patients to limited flexion after total hip arthroplasty (THA) for the treatment of axSpA. We retrospectively reviewed 516 patients with axSpA (759 hips) who underwent THA. Baseline patient demographics and clinical, laboratory, and surgery-related parameters were retrospectively collected. The preoperative and latest follow-up Harris hip score (HHS) and hip flexion ability were compared. After documenting the degree of postoperative hip flexion at the latest follow-up visit, we classified hips into good flexion group (> 90°) and poor flexion group (≤ 90°). The differences of baseline parameters between good flexion and poor flexion group were examined. Then those baseline parameters with P < 0.1 in intergroup comparisons were further included into the multivariate logistic models. The median duration of follow-up was 118.5 months (range, 25.0-269.1 months). The median HHS increased from 36.0 (25.0, 44.0) before surgery to 85.0 (77.0, 92.0) at the latest follow-up visit (P < 0.001). At the latest follow-up visit, 406 hips (53.5%) had hip flexion > 90°. The patients who were somewhat dissatisfied represented 147 hips (19.4%), and those who were very dissatisfied represented 46 hips (6.1%). The primary cause of dissatisfaction was limited range of motion (ROM) (323 hips, 80.1%). The multivariate logistic regression model revealed that the significant variables for postoperative poor hip flexion were the younger age of disease onset (OR = 0.967; P = 0.024), psoriasis (PSO) (OR = 2.071; P = 0.007), elevated C-reactive protein (CRP) (OR = 1.031; P < 0.001), and the lack of direct anterior approach (DAA) (OR = 0.372; P = 0.015). Although THA reconstruction for axSpA patients with end-stage hip involvement achieved encouraging clinical outcomes, it was prone to a restriction of hip flexion, which is closely associated with patient satisfaction. The younger age of disease onset, PSO, elevated CRP and the lack of DAA were significantly associated with limited postoperative hip flexion. Key Points • The restriction of hip flexion after THA reconstruction for axSpA patients is closely associated with patient satisfaction. • The younger age of disease onset, PSO, elevated CRP and the lack of DAA were significantly associated with limited postoperative hip flexion.

A Femoral Neck Osteotomy for the Patients with Ankylosing Spondylitis and Thoracolumbar Kyphosis Combined with Hip Flexion Contracture

OBJECTIVE

The surgical treatment of patients with ankylosing spondylitis and severe thoracolumbar kyphosis combined with hip flexion contracture is very difficult for all the surgeons. The femoral neck osteotomy (FNO) is the first step to break the ice. The evaluation of a new modified FNO method is very important to improve the curative effect.

METHODS

Five male patients with nine bone-fused hips who underwent the new femoral neck osteotomy were included from October 2021 to March 2022. The FNO was designed that the saw blade was manipulated from the lateral femoral neck base to the inferior part of the femoral head, keeping Pauwels' angle less than 30° on the coronal plane. On the transverse plane, the angle between the saw blade and the coronal plane was more than 15°. On the sagittal plane, the saw blade cut through the femoral neck. They accepted pedicle subtraction osteotomy (PSO) after FNO according to the patient' recovery. Then, 2 weeks later, the patients underwent total hip arthroplasty (THA). The visual analogue scale (VAS), Harris hip score (HHS) and passive hip flexion-extension range of motion (ROM) were used to evaluate hip function. The data were analyzed by paired t-test.

RESULTS

The average operation time and blood loss of FNO, the average interval between FNO and THA were collected. The average angle of the trunk and lower limb (ATL) was 36.33° ± 16.36° pre-FNO, 82.89° ± 13.51° post-FNO and 175.22° ± 3.42° post-THA. The average VAS scores were 0 pre-FNO, 5 ± 1.58 post-FNO and 2.6 ± 0.55 post-THA. The average HHS was 43.56 ± 1.59 preoperatively and 83.89 ± 2.21 postoperatively. The average hip extension ROM was 23.89° ± 12.69° pre-FNO, -22.67° ± 14.18° post-FNO and - 3.33° ± 2.50 post-THA°. The average hip flexion ROM was 23.89° ± 12.69° pre-FNO, 35.56° ± 12.11° post-FNO and 104.44° ± 5.27° post-THA. The differences among them were significant (p < 0.05). Only one hip (11.11%) displaced completely after FNO.

CONCLUSION

A new modified FNO was developed, which can provide osteotomy with a certain degree of stability and greater ease for performing PSO and THA.

[Effectiveness analysis of MAKO robotic-arm assisted total hip arthroplasty via direct anterior approach for bony fused hips]

Objective

To investigate the effectiveness of MAKO robotic-arm assisted total hip arthroplasty (THA) via direct anterior approach (DAA) for bony fused hips in ankylosing spondylitis (AS).

Methods

Between June 2021 and January 2022, MAKO robotic-arm assisted THA via DAA was applied to treat 10 cases (12 hips) of AS with bony fused hips. There were 7 males and 3 females; the age ranged from 30 to 71 years, with an average age of 42.4 years. The duration of AS was 12-35 years, with an average of 21.4 years. The preoperative hip was ankylosed in flexion in 3 cases, with a flexion angle of 20°, 30°, 35°, respectively; 9 cases were ankylosed in extension. The operation time and complications were recorded; the visual analogue scale (VAS) score, Harris score, and Oxford hip scale (OHS) score before and after operation, and postoperative range of motion (flexion, extension, internal rotation, external rotation, adduction, and abduction) were used to evaluate the recovery of joint function; according to the postoperative anteroposterior X-ray film and CT scan of both hip joints, the abduction angle, anteversion angle, the difference between bilateral combined off-set and the lower limb length discrepancy were measured.

Results

The operation time ranged from 80 to 190 minutes (mean, 134.6 minutes). All 10 patients were followed up 5-11 months (mean, 7.4 months). There was no serious adverse events such as incision infection, deep vein thrombosis of lower extremities, hip redislocation, aseptic loosening of the prosthesis, or death. At 5 months after operation, the acetabular prosthesis angle of abduction was 37°-45° (mean, 40.3°), anteversion angle was 9°-20° (mean, 15.8°). The difference between bilateral combined off-set was 0-10 mm (mean, 4.3 mm); the lower limb length discrepancy was 0-12 mm (mean, 3.5 mm). At last follow-up, the average range of motion of the hip joint was 89.2° in flexion (range, 80°-100°), 1.7° in extension (range, -5°-10°), 7.1° in internal rotation (range, 0°-15°), 20.4° in external rotation (range, 10°-30°), 7.9° in adduction (range, 0°-20°), and 16.5° in abduction (range, 10°-25°). At last follow-up, the VAS score, Harris score, and OHS score significantly improved when compared with those before operation ( P<0.05).

Conclusion

The MAKO robotic-arm assisted THA via DAA can achieve satisfactory results in the treatment of AS with bony fused hip, which has the advantages of accurate prosthesis installation, soft tissue release, and less trauma during operation.

Conversion of a Fused or Ankylosed Hip to Total Hip Arthroplasty: Is the Direct Anterior Approach in the Lateral Decubitus Position an Ideal Solution?

Background

Total hip arthroplasty (THA) using the direct anterior approach (DAA) is becoming increasingly popular due to its potential benefits over the posterolateral approach (PLA). However, few studies have compared the efficacies of these two surgical approaches in hip fusion treatment. This study compared early clinical direct anterior and posterolateral THA outcomes in hip fusion treatment.

Methods

Here, 127 hips (65 DAA, 62 PLA) were retrospectively evaluated. Early postoperative functional outcomes of DAA and PLA groups were assessed using Harris score and Oxford Hip Score (OHS) and standard anteroposterior hip radiographs. Surgical characteristics, perioperative results, and complications within 6 months postoperatively were recorded.

Results

Though baseline values were similar, Harris and OHS scores were better in the DAA group than in the PLA group at 1 and 3 months postoperatively. The average cup anteversion angle was significantly greater in the DAA group than in the PLA group (12.7° vs. 11.1°). More hips undergoing DAA were successfully orientated in both inclination and anteversion angles (46 vs. 32). Early postoperative hip function predictors were preoperative fused hip position, surgical approach, and range of motion. DAA was associated with reduced postoperative blood loss and shorter hospital stays. Furthermore, 14 vs. 8 complications occurred in the DAA vs. PLA group. Lateral femoral cutaneous nerve injuries were observed in eight hips (12.3%) of the DAA group.

Conclusion

For fused or ankylosed hips, THA using DAA in the lateral decubitus position may result in excellent prosthesis positioning and faster postoperative recovery throughout early follow-up vs. PLA.

Total hip arthroplasty in fused hips with spine stiffness in ankylosing spondylitis

Ankylosing spondylitis (AS) is characterized by involvement of the spine and hip joints with progressive stiffness and loss of function. Functional impairment is significant, with spine and hip involvement, and is predominantly seen in the younger age group. Total hip arthroplasty (THA) for fused hips with stiff spines in AS results in considerable improvement of mobility and function. Spine stiffness associated with AS needs evaluation before THA. Preoperative assessment with lateral spine radiographs shows loss of lumbar lordosis. Spinopelvic mobility is reduced with change in sacral slope from sitting to standing less than 10 degrees conforming to the stiff pattern. Care should be taken to reduce acetabular component anteversion at THA in these fused hips, as the posterior pelvic tilt would increase the risk of posterior impingement and anterior dislocation. Fused hips require femoral neck osteotomy, true acetabular floor identification and restoration of the hip center with horizontal and vertical offset to achieve a good functional outcome. Cementless and cemented fixation have shown comparable long-term results with the choice dependent on bone stock at THA. Risks at THA in AS include intraoperative fractures, dislocation, heterotopic ossification, among others. There is significant improvement of functional scores and quality of life following THA in these deserving young individuals with fused hips and spine stiffness.

Preoperative ultrasound to map the three-dimensional anatomical distribution of the lateral femoral cutaneous nerve in direct anterior approach for total hip arthroplasty

Background

The postoperative complaints of hypoesthesia or a burning sensation due to lateral femoral cutaneous nerve (LFCN) injury in patients are not yet solved. The present study aimed to identify the three-dimensional (3D) distribution of LFCN using preoperative ultrasound and evaluate the rate of injury in direct anterior approach for total hip arthroplasty.

Methods

A total of 59 patients (28 males and 31 females, age 69.0 ± 4.6 years, BMI 24.7 ± 3.0 kg/m²) were randomly allocated to the ultrasound group and 58 patients (28 males and 30 females, age 68.5 ± 4.5 years, BMI 24.8 ± 2.8 kg/m²) were in the control group. Surgeons received the data of 3D distribution of LFCN only in the ultrasound group before surgery with respect to the direction, the depth on the skin, and the length to tensor fasciae latae (TFL). The anatomical characteristics of LFCN in the surgical region were summarized. At 1 and 3 months of post surgery, the rate of LFCN injury and abnormal sensitive area was evaluated in both groups.

Results

There was a significant consistency in gender, age and BMI of these two groups (P > 0.05). Based on the data from the ultrasound group, over 90% of patients had one or two branches of LFCN. LFCN always courses in the fascia layer, the depth ranged from 6.8 ± 2.6 (3.0–12.0) mm to 11.1 ± 3.4 (4.0–17.0) mm and depended on the thickness of the subcutaneous fat, and length was 3.3 ± 4.6 (− 5.0–10.0) mm at proximal part and − 2.7 ± 4.7 (− 10.0–8.0) at distal end to the medial edge of TFL. Both the rate of LFCN injury and abnormal sensory area in the ultrasound group was significantly lower than those in the control group (3.4% vs. 25.9%, P = 0.001, at 1 month; 3.4% vs. 22.4%, P = 0.005, at 3 months).

Conclusions

LFCN mostly courses along the medial border of TFL in the fascia layer. The 3D distribution of LFCN using preoperative ultrasound mapping could help the surgeons to evaluate the risk of injury preoperatively and decrease the rate of injury during the operation. However, some branch injuries, especially for the fan type LFCN, could not be avoided.

Cementless total hip arthroplasty for three different degrees of hip involved secondary to ankylosing spondylitis: an analysis of 195 hips

Background

Hip involved secondary to ankylosis spondylitis (AS) had a huge influence on hip function. Cementless total hip arthroplasty (THA) can improve hip function. However, no previous study compared the outcomes of THA for AS patients with three different degrees of hip involvement.

Methods

The 195 hips were retrospectively analyzed and divided into non-ankylosed group (group A, 94 hips), fibrous ankylosed group (group B, 49 hips), and bony ankylosed group (group C, 52 hips). postoperative range of motion (ROM), harris hip scores (HHS), the short-form 12 health survey (SF-12), length of stay (LOS), cost, radiological assessments, and complications were compared.

Results

The follow-up time was (79.4 ± 29.5) months for group A, (80.6 ± 28.9) months for group B, and (79.1 ± 28.9) months for group C (P = 0.966). Group A had the best postoperative hip ROM (P < 0.001), while group A and B can realize better HHS than group C (P < 0.001). The three groups had similar SF-12 postoperatively. For group A, LOS and cost for unilateral procedure were the least than that for group B and C (P = 0.003 and P = 0.001). Similar radiological assessments were achieved for three groups. 1 hip in group A encountered delay union of wound. 1 hip in group C encountered delay union of wound and dislocation and another patient encountered femoral fracture intraoperatively. 12 hips (12.8%) in group A, 6 hips (12.2%) in group B, and 6 hips (11.5%) in group C encountered asymptomatic heterotopic ossification (P = 0.977).

Conclusion

For AS patients with hip involvement, THA can improve hip ROM and function. THA for the non-ankylosed hip can realize the better hip function and postoperative ROM than ankylosed hip.

Direct anterior versus posterolateral approaches for clinical outcomes after total hip arthroplasty: a systematic review and meta-analysis

OBJECTIVE

The main objective of our study was to compare the intraoperative and postoperative outcomes of direct anterior approach (DAA) with posterolateral approaches (PLA).

METHODS

We searched Cochrane library, Web of Science, and PubMed for literatures comparing DAA with PLA. On the basis of inclusion and exclusion criteria, relevant literatures were selected. Two members independently screened qualified literatures, evaluated the literature quality, and extracted data information.

RESULTS

Eighteen randomized controlled trials (RCTs) and non-RCTs totaling 34,873 patients (DAA = 9636, PLA = 25237) were contained in this systematic review and meta-analysis. The results showed that DAA were reduced in terms of length of hospital stay (weighted mean difference (WMD) = -0.43, 95% confidence interval (CI) -0.78 to -0.09, P = 0.01), LLD (WMD = -2.00, 95% CI -2.75 to -1.25, P < 0.00001), PE/DVT (WMD = 0.36, 95% CI 0.15 to 0.85, P = 0.02), dislocation (WMD = 0.42, 95% CI 0.30 to 0.59, P < 0.00001) and visual analog scale (VAS) (WMD = -0.57, 95% CI -0.91 to -0.23, P = 0.0009) compared with PLA; however, DAA compared with the PLA was increasing in terms of operative time (WMD = 14.81, 95% CI 7.18 to 22.44, P = 0.0001), intraoperative blood loss (WMD = 105.13, 95% CI 25.35 to 184.90, P = 0.01), fracture (WMD = 1.46, 95% CI 1.00 to 2.11, P = 0.05), and Harris hip score (HHS) (WMD = 1.19, 95% CI 0.77 to 1.61, P < 0.00001).

CONCLUSIONS

DAA was preferable effectiveness to PLA in early pain relief and functional recovery; however, PLA has a shorter operation time, intraoperative less blood loss and fracture.

TRIAL REGISTRATION

Registration ID, CRD42020151208.