Total hip arthroplasty using large-diameter metal-on-metal articulation in patients with neuromuscular weakness

Total Hip Arthroplasty in Patients With Neurological Conditions: A Systematic Review

Background

As operative techniques and implant design have evolved over time, total hip arthroplasty (THA) is increasingly being carried out for patients with neurological impairment. This patient group places unique surgical challenges to the arthroplasty surgeon, which may include contractures, instability, and altered muscular tone. The purpose of this systematic review is to report the patient outcomes, complications, and implant survival following THA for patients with neurological conditions affecting the hip. Thus, we aim to support orthopaedic surgeon decision-making when considering and planning THA for these patients.

Methods

A systematic review was performed as per Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using the PubMed/Medline OVID, Cochrane, and Embase databases. All studies reporting the outcomes of THA in the neurological population which met defined inclusion criteria were included.

Results

From an initial screen of 1820 studies, 45 studies with a total of 36,251 THAs were included in the final selection. All 45 studies reported complication rates, with controls included in 16 for comparison. High complication rates were observed following THA in the neurologically impaired population, most notably dislocation with observed rates up to 10.6%. An improvement was noted in all 36 studies (1811 THAs) which reported upon patient-reported outcomes.

Conclusions

THA may be beneficial in the selected patients with neurological conditions, to reduce pain and improve function. There is an increased risk of complications which require careful consideration when planning the operation and open discussion with prospective patients and caregivers before proceeding with surgery.

Cemented versus uncemented hemiarthroplasty for femoral neck fractures in patients with neuromuscular diseases: a minimum of 2 years' follow-up study

BACKGROUND

The aim of this study was to compare the outcomes of cemented and uncemented hemiarthroplasty for femoral neck fractures in patients with neuromuscular disease.

METHODS

We reviewed 156 patients with neuromuscular disease who underwent hemiarthroplasty between June 2015 and December 2019. Patients were divided into cemented group (n = 105) and uncemented group (n = 51), with a minimum follow-up of 2 years. Factors including preoperative features, duration of surgery, intraoperative blood loss, complications, pain, Harris hip scores (HHS), and quality of life were compared across groups, and Kaplan-Meier curves were used to estimate survival.

RESULTS

In the uncemented group, the mean duration of surgery was 16.0 min. shorter (p = 0.001) and the mean intraoperative blood loss was 71.1 mL less (p = 0.01). Visual analog scales (VAS), HHS, and European Quality of Life-5 Dimensions (EQ-5D) scores were not different between the groups. Despite a few potential trends, we did not observe a difference in complications such as periprosthetic fractures and dislocations. The rates of mortality were similar between groups (p=0.821).

CONCLUSIONS

Both arthroplasties may be used with good medium-term results in the treatment of femoral neck fractures in patients with neuromuscular diseases.

Clinical outcomes in elective total hip arthroplasty in Parkinson's disease: a systematic review of the literature

Parkinson’s disease (PD) poses a significant challenge for the arthroplasty surgeon, owing to excessive muscle tone, higher fracture risk and poor bone quality. Several studies have reported high mortality, early failure and perioperative complications associated with hip fracture surgery in PD; however, no higher-level evidence exists regarding elective hip arthroplasty.

The aim of our study was to perform a systematic review to evaluate the evidence basis and clinical outcomes pertaining to patients with underlying Parkinson’s disease undergoing elective total hip arthroplasty (THA).

We searched MEDLINE, EMBASE and The Cochrane Central Register of Controlled Trials to identify studies evaluating the safety and clinical outcomes of THA in patients suffering from Parkinson’s. Our review conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Ten studies encompassing 49,730 patients were included in our systematic review. Qualitative synthesis demonstrated comparable results between PD patients and controls with respect to one-year mortality and surgical site infections. PD patients experienced more medical complications, had a longer hospital stay and worse long-term implant survival. Some studies also reported a higher rate of dislocation, periprosthetic fractures and aseptic loosening.

Decisions about the optimal articulation, the utilization of cemented components, dual-mobility cups or constrained liners were not uniform among included studies.

THA in patients with Parkinson’s disease can offer significant functional gains and pain relief. Surgical considerations pertain to the approach and ways to address instability, whereas emphasis should be placed on appropriate counselling and exploring whether potential improvement of life quality outweighs the risks.

Cite this article: EFORT Open Rev 2020;5:856-865. DOI: 10.1302/2058-5241.5.200034

Heterotopic Ossification following Total Elbow Arthroplasty in a Patient with Parkinson's Disease: Case Report and Literature Review

Introduction. Heterotopic ossification (HO) usually develops following surgery or trauma. Risk factors for HO following elbow fractures include delay to surgery (>7 days), floating fractures, and elbow subluxation. Systemic risk factors for HO include male sex; concurrent cranial, neurological, or abdominal injury; high-energy trauma; previous development of HO; and contralateral fracture. To date, no studies have reported on Parkinson's disease (PD) as a risk factor for the development of HO. Case Presentation. A 68-year-old female with PD (treated with levodopa-carbidopa) sustained a right closed (OTA type A3) distal humerus fracture and was treated with a total elbow arthroplasty. Postoperatively, development of significant near-ankylosing HO was observed and contributed to significant restriction of elbow motion with activities of daily living. After HO maturation, the osseous growth was excised, and the area irradiated. The patient regained excellent elbow motion with no recurrence of HO. Discussion. A literature review revealed six cases of HO development in PD patients following arthroplasty. Patients with PD have higher serum concentrations of interleukins (IL) and tumor necrosis factor- (TNF-) α. These factors stimulate BMP-2 production which may promote osteogenesis. Levodopa-carbidopa may also influence HO through stimulation of growth hormone and IGF-1. Conclusion. Parkinsonism may promote heterotopic bone growth through the release of osteoinductive factors. HO development may also be mediated by levodopa-carbidopa therapy. Future research should highlight the link between HO and PD and identify if prophylaxis is warranted in PD patients undergoing arthroplasty.

Matched Cohort Analysis of Total Hip Arthroplasty in Patients With and Without Parkinson's Disease: Complications, Mortality, Length of Stay, and Hospital Charges

BACKGROUND

Increased complication rate has been reported in Parkinson's disease (PD) patients following total hip arthroplasty (THA). However, this has not previously been studied on a national scale. The purpose of this study was to determine whether PD patients had increased cost, complication, mortality, and length of stay following THA using a national database.

METHODS

The Healthcare Cost and Utilization Project Nationwide Inpatient Sample was evaluated for the years 2000-2014. PD patients were matched 1:3 with non-PD control patients for age, gender, Charlson Comorbidity Index, and year of admission using a propensity score matching procedure. Univariable and multivariable logistic regression were used to determine the relationship between PD and surgical outcomes in the matched cohort.

RESULTS

794,689 THAs were performed from 2000-2014. 4003 patients (0.50%) had comorbid Parkinson's disease. Before matching, arthroplasty patients with PD were significantly older (P < .001), more frequently male (P < .001), and had greater Charlson Comorbidity Index (P < .001). In the matched cohort, PD was associated with increased length of stay (3.1 vs 2.7 days, P < .001), total hospital charges ($49,061 vs $45,571, P < .001), and in-hospital complication rate (14.6% vs 11.7%, P < .001). There was no difference in-hospital mortality (0.50% vs 0.47%, P = .781).

CONCLUSIONS

Matched cohort analysis demonstrated increases in complication rate, length, and cost of hospitalization for THA in patients with PD. However, in-hospital mortality rate in PD patients was not increased. Of note, the elevation in per-episode cost ($3490) may be of concern when considering PD patients for surgery within the evolving "bundled payment" model of care.

LEVEL OF EVIDENCE

Prognostic- Level III.

Inhospital Complications of Patients With Neuromuscular Disorders Undergoing Total Joint Arthroplasty

INTRODUCTION

Orthopaedic surgeons are wary of patients with neuromuscular (NM) diseases as a result of perceived poor outcomes and lack of data regarding complication risks. We determined the prevalence of patients with NM disease undergoing total joint arthroplasty (TJA) and characterized its relationship with in-hospital complications, prolonged length of stay, and total charges.

METHODS

Data from the Nationwide Inpatient Sample from 2005 to 2014 was used for this retrospective cohort study to identify 8,028,435 discharges with total joint arthroplasty. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify 91,420 patients who had discharge diagnoses for any of the NM disorders of interest: Parkinson disease, multiple sclerosis, cerebral palsy, cerebrovascular disease resulting in lower extremity paralysis, myotonic dystrophy, myasthenia gravis, myositis (dermatomyositis, polymyositis, and inclusion-body myositis), spinal muscular atrophy type III, poliomyelitis, spinal cord injury, and amyotrophic lateral sclerosis. Logistic regression was used to estimate the association between NM disease and perioperative outcomes, including inpatient adverse events, length of stay, mortality, and hospital charges adjusted for demographic, hospital, and clinical characteristics.

RESULTS

NM patients undergoing TJA had increased odds of total surgical complications (odds ratio [OR] = 1.21; 95% confidence interval [CI], 1.17 to 1.25; P < 0.0001), medical complications (OR = 1.41; 95% CI, 1.36 to 1.46; P < 0.0001), and overall complications (OR = 1.32; 95% CI, 1.28 to 1.36; P < 0.0001) compared with non-NM patients. Specifically, NM patients had increased odds of prosthetic complications (OR = 1.09; 95% CI, 0.84 to 1.42; P = 0.003), wound dehiscence (OR = 5.00; 95% CI, 1.57 to 15.94; P = 0.0002), acute postoperative anemia (OR = 1.20; 95% CI, 1.16 to 1.24; P < 0.0001), altered mental status (OR = 2.59; 95% CI, 2.24 to 2.99; P < 0.0001), urinary tract infection (OR = 1.45; 95% CI, 1.34 to 1.56; P < 0.0001), and deep vein thrombosis (OR = 1.27; 95% CI, 1.02 to 1.58; P = 0.021). No difference of in-hospital mortality was observed (P = 0.155).

DISCUSSION

Because more patients with NM disease become candidates of TJA, a team of neurologists, anesthesiologists, therapists, and orthopaedic surgeon is required to anticipate, prevent, and manage potential complications identified in this study.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Incidence of perioperative complications in total hip and knee arthroplasty in patients with Parkinson disease

INTRODUCTION

The aim of this study is to evaluate the difference in perioperative complication rate in total hip, bipolar hemiarthroplasties and total knee arthroplasty in patients with Parkinson disease in trauma and elective surgery in our Musculoskeletal Center during a period of 10 years.

MATERIAL AND METHOD

Between 2006 and 2016, 45 bipolar hemiarthroplasties in trauma surgery, 15 total knee and 19 total hip arthroplasties in patients with Parkinson's disease were performed. We divided the patients in two groups. Group I included trauma cases (45) and group II elective surgery cases (34). Complications were documented and divided into local minor and major complications and general minor and major complications. Fisher's exact test was used for statistical evaluation.

RESULTS

In both groups, there was one local major complication (p > 0.05): In group I, there was one case of loosening of a K-wire which was removed operatively. In group II, there was one severe intraarticular bleeding requiring puncture of the hematoma. In group I, there were 38 general complications; in group II, there were 17 general complications. There was no statistical difference in complication rate (p > 0.05).

CONCLUSION

Total hip arthroplasty, bipolar hemiarthroplasties and knee arthroplasty in patients with Parkinson disease is possible in elective and trauma surgery. Complication rate is higher in comparison with patients not suffering from Parkinson disease, but there is no difference in complication rate in elective and trauma surgery. Nevertheless, early perioperative neurological consultation in patients with Parkinson disease is recommended to minimize complications and improve early outcomes after arthroplasty.

Total Hip Arthroplasty in Patients With Parkinson Disease: Improved Outcomes With Dual Mobility Implants and Cementless Fixation

BACKGROUND

Parkinson disease (PD) results in severe limitation in ambulation caused by abnormality of gait and posture. The rate of complications, including fractures and dislocation after total hip arthroplasty (THA), can be higher among these patients. The goal of this study was to investigate the long-term outcomes of primary and revision THAs with cementless dual mobility implants.

METHODS

This retrospective study examines 59 PD patients who had surgery between 2002 and 2012. All the primary cases were performed for osteoarthritis and all patients received cementless acetabular implants with dual mobility bearing surface. The femoral stem was cemented in 4 patients who underwent revision surgery. The mean follow-up time was 8.3 years (4-14 years).

RESULTS

Good to excellent pain relief was achieved in 53 of 57 patients at the 2-year follow-up and in 40 of 47 patients at their latest follow-up. The most common medical complication was cognitive impairment (12 of 57 patients). One patient sustained an intraprosthetic hip dislocation 9 years after surgery, which required revision. Four patients sustained periprosthetic femoral fractures with well-fixed stem, requiring open reduction and internal fixation. The disability had increased in 68% of the patients in the latest follow-up visit.

DISCUSSION

Our study shows that elective primary or revision THA using cementless implants with dual mobility bearing surface in patients with PD provides satisfactory long-term outcomes, although many of these patients may see a general worsening of their activities over time due to PD.

Total hip arthroplasty in patients with neuromuscular imbalance

Patients with neuromuscular imbalance who require total hip arthroplasty (THA) present particular technical problems due to altered anatomy, abnormal bone stock, muscular imbalance and problems of rehabilitation. In this systematic review, we studied articles dealing with THA in patients with neuromuscular imbalance, published before April 2017. We recorded the demographics of the patients and the type of neuromuscular pathology, the indication for surgery, surgical approach, concomitant soft-tissue releases, the type of implant and bearing, pain and functional outcome as well as complications and survival. Recent advances in THA technology allow for successful outcomes in these patients. Our review suggests excellent benefits for pain relief and good functional outcome might be expected with a modest risk of complication. Cite this article: Bone Joint J 2018;100-B(1 Supple A):17-21.

Total hip arthroplasty via the direct anterior approach with a dual mobility cup for displaced femoral neck fracture in patients with a high risk of dislocation

Introduction: Although total hip arthroplasty (THA) is superior to bipolar hemiarthroplasty (BHA) for displaced femoral neck fracture in terms of hip pain, function and reoperation rate, THA has a higher rate of dislocation. The direct anterior approach (DAA) and a dual mobility cup (DMC) are associated with lower rates of dislocation. The aim of this study was to investigate the outcomes of THA compared with BHA, and in those patients who had a THA we investigated those with a DMC (DMC-THA) and compared them with those had a single conventional cup (Single cup-THA).

Materials: A total of 89 patients living independently were included between 2009 and 2015. We assessed patient characteristics, peri- and post-operative outcomes, walking ability and one-year mortality. Adjusted odds ratios (Adjusted ORs) were estimated for decrease of walking ability and one-year mortality using a logistic regression model with adjustment for potential confounders such as age, neuromuscular diseases with weakness, duration of surgery, perioperative blood loss and preoperative walking ability.

Results: BHA (20 patients) versus THA (69 patients): There was no significant difference in the walking ability in either group. Multivariable logistic regression analysis demonstrated a significant association with one-year mortality in both groups [THA Adjusted ORs 0.088 (95% CI 0.0007–0.69); p = 0.020]. Single cup-THA (36 patients) versus DMC-THA (33 patients): The DMC-THA group had significantly greater age and more patients with neuromuscular diseases with weakness compared with the Single cup-THA group. Multivariable logistic regression analysis demonstrated no significant difference in the decrease of walking ability and in the one-year mortality between the groups. There were no post operative dislocations in any group.

Discussion: THA via the DAA is one of the best treatments for displaced femoral neck fracture with a low risk of dislocation. THA via the DAA with a DMC is a safe and effective treatment for the patients with a high risk of dislocation.

The Outcomes of Total Hip Replacement in Patients with Parkinson's Disease: Comparison of the Elective and Hip Fracture Groups

INTRODUCTION

The aim of the study was to compare the clinical outcomes following elective and traumatic total hip arthroplasty in Parkinson's disease patients.

MATERIALS AND METHODS

Ten patients with osteoarthritis comprise the elective group (mean age at operation 74 years; mean follow-up 82 months). Thirteen patients with femoral fracture comprise the hip fracture group (mean age 76 years; mean follow-up 54 months). All patients were followed up at 6 and 36 months postoperatively and at the time of the latest follow-up.

RESULTS

Despite the significant improvement in Merle d'Aubigné-Postel and pain scores, disability related to Parkinson's disease increased during the follow-up. Whereas more than 1/3 of hip fracture patients and all elective patients walked independently at 36 months after total hip arthroplasty, 43% of living patients from both groups were able to walk independently at the time of the latest follow-up. The medical complications were seen mainly in patients with hip fracture.

CONCLUSIONS

Excellent pain relief with preserved walking ability without support of another person and acceptable complication profile was observed in Parkinson's disease patients at 36 months after elective total hip arthroplasty. This procedure may be indicated in Parkinson's disease patients after careful and individualized planning.

Is There a Benefit to Head Size Greater Than 36 mm in Total Hip Arthroplasty?

This study compares the rate of dislocation and revision for instability between 36-mm and anatomic femoral heads (large diameter metal-on-metal THA, dual-mobility bearings, and hip resurfacing arthroplasty) in patients at high risk for dislocation. A total of 501 high-risk patients, over a 10-year period, were identified (282 36-mm THA, 24 dual-mobility bearings, 83 metal-on-metal arthroplasty, and 112 hip resurfacing arthroplasty). There were 13 dislocations in the 36-mm group compared to 1 in the anatomic group (4.6% vs 0.5%; P = .005). Four patients dislocated more than once in the 36-mm group (1.4% vs 0%; P = .04), and 2 patients in the 36-mm group required a revision for instability (0.7% vs 0%; P = .11). These results suggest that anatomic head sizes significantly lower the risk of dislocation in high-risk patients.

Large-diameter metal-on-metal total hip arthroplasty: dislocation infrequent but survivorship poor

BACKGROUND

Use of large-diameter metal-on-metal (MoM) articulations in THA increased, at least in part, because of the possibility of achieving improved joint stability and excellent wear characteristics in vitro. However, there have been subsequent concerning reports with adverse reactions to metal debris (ARMD), pseudotumors, and systemic complications related to metal ions.

QUESTIONS/PURPOSES

The purpose of this study was to determine at a minimum of 2 years' followup (1) the proportion of patients who experienced a dislocation; (2) the short-term survivorship obtained with these implants; (3) the causes of failure and the proportion of patients who developed ARMD; and (4) whether there were any identifiable risk factors for revision.

METHODS

We reviewed the results of 1235 patients who underwent 1440 large-diameter MoM primary THAs at our institution using two acetabular devices from a single manufacturer with minimum 2-year followup. Large-diameter MoM devices were used in 48% (1695 of 3567) of primary THAs during the study period. We generally used these implants in younger, more active, higher-demand patients, in patients considered at higher risk of instability, and in patients with adequate bone stock to achieve stable fixation without use of screws. Clinical records and radiographs were reviewed to determine the incidence and etiology of revision. Patients whose hips were revised were compared with those not revised to identify risk factors; Kaplan-Meier survivorship analysis was performed as was multivariate analysis to account for potential confounding variables when evaluating risk factors. Minimum followup was 2 years (average, 7 years; range, 2-12 years); complete followup was available in 85% of hips (1440 of 1695).

RESULTS

Dislocation occurred in one hip overall (<1%; one of 1440). Kaplan-Meier analysis revealed survival free of component revision was 87% at 12 years (95% confidence interval, 84%-90%). The two most common indications for revision were ARMD (48%; 47 of 108 hips revised) and loosening or failure of ingrowth (31%; 34 of 108). Risk factors for component revision were younger age at surgery (relative risk [RR] 0.98 per each increased year; p=0.02), higher cup angle of inclination (RR 1.03 per each increased degree; p=0.04), and female sex (RR 1.67; p=0.03).

CONCLUSIONS

Large-diameter MoM THAs are associated with a very low dislocation rate, but failure secondary to ARMD and loosening or lack of ingrowth occur frequently. Patients with MoM THA should be encouraged to return for clinical and radiographic followup, and clinicians should maintain a low threshold to perform a systematic evaluation. Early diagnosis and appropriate treatment are recommended to prevent the damaging effects of advanced ARMD.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

A new automated way to measure polyethylene wear in THA using a high resolution CT scanner: method and analysis

As the most advantageous total hip arthroplasty (THA) operation is the first, timely replacement of only the liner is socially and economically important because the utilization of THA is increasing as younger and more active patients are receiving implants and they are living longer. Automatic algorithms were developed to infer liner wear by estimating the separation between the acetabular cup and femoral component head given a computed tomography (CT) volume. Two series of CT volumes of a hip phantom were acquired with the femoral component head placed at 14 different positions relative to the acetabular cup. The mean and standard deviation (SD) of the diameter of the acetabular cup and femoral component head, in addition to the range of error in the expected wear values and the repeatability of all the measurements, were calculated. The algorithms resulted in a mean (± SD) for the diameter of the acetabular cup of 54.21 (± 0.011) mm and for the femoral component head of 22.09 (± 0.02) mm. The wear error was ± 0.1 mm and the repeatability was 0.077 mm. This approach is applicable clinically as it utilizes readily available computed tomography imaging systems and requires only five minutes of human interaction.