Time to Achieve the Minimal Clinically Important Difference in Primary Total Hip Arthroplasty: Comparison of Anterior and Posterior Surgical Approaches

Time to Minimal Clinically Important Difference in Patients Undergoing Conversion Total Hip Arthroplasty After Femoral Neck Fracture: A Propensity Score Matched Study

BACKGROUND

Conversion total hip arthroplasty (cTHA) is commonly used for patients with persistent osteoarthritis or failed fixation following femoral neck fracture (FNF). There are limited data comparing patient-reported outcomes between patients undergoing cTHA after FNF and primary THA (pTHA) patients. This study aimed to compare the time to reach the minimal clinically important difference for improvement (MCID) for the Hip Disability and Osteoarthritis Outcomes Score-Physical Function Short Form, Patient-Reported Outcomes Measurement Information System (PROMIS) Global Physical, and PROMIS Physical Function short form 10a (PF-10a).

METHODS

Patients undergoing cTHA for FNF between 2016 and 2022 were identified from an institutional database and propensity score matched 1:4 to pTHA patients by age, sex, body mass index, and Charlson Comorbidity Index. Demographic and MCID achievement rates were compared. To assess the time to achieve MCID, survival curves with and without interval censoring were used.

RESULTS

A total of 258 THAs (52 FNF cTHA and 206 pTHA) were analyzed. All FNFs were managed surgically. The rate of achieving MCID was similar between the FNF cTHA and pTHA cohorts for all three PROMs. For PROMIS PF-10a, FNF cTHA had a markedly longer median time to MCID at 9.8 months (95% confidence interval [CI], 6.5 to 12.1) compared with 4.2 months (95% CI, 3.3 to 6.0) for pTHA (P < 0.001). Interval censoring revealed that FNF cTHA achieved MCID for PROMIS PF-10a between 5.07 and 5.34 months, whereas pTHA achieved MCID between 1.37 and 1.37 months (P < 0.001).

CONCLUSION

The time to achieve MCID was markedly slower for FNF cTHA patients compared with pTHA patients. This delay in achieving MCID should be factored into shared decision-making discussions to enhance preoperative expectation management and patient education. Future research is needed to identify modifiable factors that could improve recovery outcomes for FNF cTHA patients.

Does Robotic Assistance Increase the Likelihood of Achieving the Minimal Clinically Important Improvement Following Total Hip Arthroplasty? Findings From a Propensity Score Matched Analysis of 1,364 Procedures

BACKGROUND

Robotic-assisted total hip arthroplasty (rTHA) is associated with improved component positioning compared to manual THA (mTHA). However, its impact on achieving the minimal clinically important difference (MCID) in patient-reported outcomes remains unclear. This study compared rates of MCID for improvement (MCID-I), MCID for worsening (MCID-W), and complication rates between rTHA and mTHA.

METHODS

We performed a retrospective analysis of 341 rTHAs, matched 1:3 by propensity score to 1,023 mTHAs based on age, sex, body mass index, and Charlson Comorbidity Index. All THAs were performed between 2016 and 2022. Patient-reported outcomes included Patient-Reported Outcomes Measurement Information System (PROMIS) global physical, PROMIS global mental, PROMIS physical function short form 10a, and the Hip Disability and Osteoarthritis Outcome Score-physical function short form. We compared the rates of MCID-I and MCID-W between rTHA and mTHA at one year postoperatively, as well as 90-day complication rates and 2-year revision-free survival.

RESULTS

For Hip Disability and Osteoarthritis Outcome Score-physical function short form, MCID-I rates were similar between mTHA and rTHA (85.3 versus 80.3%; P = 0.063), as were MCID-W rates (5.2 versus 7.6%; P = 0.16). Rates of MCID-I and MCID-W for PROMIS global physical, PROMIS global mental, and PROMIS physical function short form 10a were also comparable between the groups (all P > 0.05). Additionally, no significant differences were found in 90-day readmission rates (mTHA: 8.3 versus rTHA: 8.5%; P = 0.67) or 2-year revision-free survival (98.5% for both groups; P = 0.99).

CONCLUSIONS

Robotic-assisted THA and mTHA have similar rates of clinically important improvements, complications and revision-free survival. Both approaches demonstrate excellent outcomes at one year. Further research should investigate long-term differences between rTHA and mTHA.

Conversion Total Hip Arthroplasty Results in Delayed Patient Improvement Timelines Compared to Primary Total Hip Arthroplasty: Findings From a Propensity-Score Matched Analysis of Time to Achieve Minimal Clinically Important Difference in 698 Procedures

BACKGROUND

Previous studies have shown that conversion total hip arthroplasty (cTHA) is associated with worse clinical outcomes, increased complications, and higher costs than primary total hip arthroplasty (pTHA). An underinvestigated factor that may vary between cTHA and pTHA is patient postoperative clinical improvement timelines. This study compared the median time to achieve minimal clinically important difference (MCID) between cTHA and pTHA patients.

METHODS

We conducted a retrospective analysis comparing 175 cTHA and 523 propensity score-matched pTHA patients. Patient-reported outcomes were evaluated using preoperative and postoperative scores of Patient-Reported Outcomes Measurement Information System (PROMIS) Global Physical, PROMIS Physical Function-10a, and Hip disability and Osteoarthritis Outcome Score Physical Function Shortform. Time to achieve MCID was assessed using survival curves with and without interval-censoring, and statistical comparisons were performed using log-rank and weighted log-rank tests.

RESULTS

Using interval censoring to more precisely determine the exact time to achieve MCID, cTHA patients had a statistically delayed time to MCID for the PROMIS Physical Function-10a (3.03 to 3.04 versus 1.63 to 1.63; P = 0.011) and PROMIS Global Physical (0.73 to 0.74 versus 0.67 to 0.67; P = 0.049) as compared to pTHA patients. Time to MCID for the Hip disability and Osteoarthritis Outcome Score Physical Function Shortform was similar between cohorts (1.43 to 1.44 versus 1.33 to 1.34; P = 0.40).

CONCLUSIONS

Patients undergoing cTHA may have delayed improvement timelines as compared to pTHA. This finding is possibly related to the increased medical and surgical complexity of cTHA. Conversion total hip arthroplasty remains a safe and effective treatment choice to improve patient hip pain and function in many settings. Yet arthroplasty surgeons can counsel cTHA patients that it may take approximately 3 months for the median patient to experience clinically relevant improvement. The same improvement timeline may be experienced by the median pTHA patient in only 1.6 months.

Intrawound vancomycin powder for prevention of surgical site infections in primary joint arthroplasty: an umbrella review of systematic reviews and meta-analyses

OBJECTIVES

The aim of this umbrella review is to explore the effect of intrawound vancomycin on the incidence of infection and wound complications in patients undergoing primary joint arthroplasty.

METHODS

Two authors conducted a systematic search of PubMed, EMBASE, Medline, and the Cochrane Central Register of Controlled Trials from inception to 15 October 2023. All systematic reviews and meta-analyses examining the effect of intrawound vancomycin on the incidence of infection and wound complications in primary joint arthroplasty were included. Two authors independently screened and extracted the data from the studies, evaluated the methodological quality of the included studies using the Assessment of Multiple Systematic Reviews scale, and assessed the publication bias and small-sample effects.

RESULTS

Our umbrella review includes a total of five systematic reviews, comprising 16 retrospective studies. The pooled results indicate that intrawound vancomycin significantly reduces overall infection rates [odds ratio (OR): 0.41; 95% confidence interval (CI): 0.30-0.54, P < 0.001], superficial infections (OR: 0.51; 95% CI: 0.26-0.97, P = 0.04), and periprosthetic joint infection rates (OR: 0.38; 95% CI: 0.28-0.52, P < 0.001) among patients undergoing primary joint arthroplasty. However, vancomycin did not increase the risk of aseptic wound complications (OR: 1.34; 95% CI: 0.88-2.04, P = 0.17) and prolong wound healing (OR: 1.40; 95% CI: 0.87-2.26, P = 0.17).

CONCLUSIONS

Based on the available research, our umbrella review demonstrates that intrawound vancomycin significantly reduces infection rates in primary joint arthroplasty, including periprosthetic joint and superficial infections, without increasing wound complications. However, given the inclusion of studies with varying quality, these findings should be interpreted with caution. Further high-quality studies are needed to better confirm its long-term safety, cost-effectiveness, and overall clinical utility.

Primary Total Hip Arthroplasty Achieves Minimal Clinically Important Difference Faster than Revision Total Hip Arthroplasty

BACKGROUND

Despite the prevalence of total hip arthroplasty (THA) as a treatment for hip-related conditions, there is limited research directly comparing the patient-reported outcome measures between primary and revision total hip arthroplasty (rTHA). This study compared the time to achieve minimal clinically important difference (MCID) between primary and rTHA.

METHODS

We conducted a retrospective analysis comparing 6,671 THAs (6,070 primary and 601 all-cause rTHAs) performed between 2016 and 2022. Patient-reported outcomes were evaluated using preoperative and postoperative scores of Patient-Reported Outcomes Measurement Information System (PROMIS) Global Physical, PROMIS Physical Function Short Form 10a (PF-10a), and Hip Injury and Osteoarthritis Outcome Score - Physical Function Short Form (HOOS-PS). The time to achieve MCID was assessed using survival curves with and without interval-censoring, and statistical comparisons were performed using log-rank and weighted log-rank tests.

RESULTS

Comparing the time to achieve MCID without interval-censoring, primary total hip arthroplasty (pTHA) demonstrated significantly faster median times than rTHA for PROMIS Global Physical (3.3 versus 3.9 months, P < 0.001), PROMIS PF-10a (3.6 versus 6.2 months, P < 0.001), and HOOS-PS (3.1 versus 4.0 months, P < 0.001). Similarly, when using interval-censoring, pTHA continued to achieve MCID significantly faster than rTHA for PROMIS Global Physical (0.23 to 0.24 versus 0.50 to 0.51 months, P < 0.001), PROMIS PF-10a (1.43 to 1.44 versus 3.03 to 3.04 months, P < 0.001), and HOOS-PS (0.87 to 0.87 versus 1.20 to 1.21 months, P < 0.001).

CONCLUSIONS

Across all patient-reported outcome measures, pTHA achieved MCID significantly faster than rTHA, irrespective of interval-censoring. These findings underscore the importance of setting realistic postoperative recovery expectations during perioperative patient counseling. Future studies should investigate the factors influencing time to achieve MCID and explore how to enhance rTHA techniques and perioperative management for improved patient outcomes.

LEVEL OF EVIDENCE

III.

Recovery Time and Success: A Comparative Study of Robotic and Manual Total Hip Arthroplasty Outcomes

BACKGROUND

Despite the growing utilization of robotic-assisted total hip arthroplasty (rTHA), major debate remains regarding its comparative effectiveness in achieving optimal patient outcomes compared to manual total hip arthroplasty (mTHA). This study aimed to compare both the rate and time to achieve minimal clinically important difference (MCID) between rTHA and mTHA.

METHODS

We conducted a retrospective analysis comparing 341 rTHAs with a 1:3 propensity score-matched cohort of 1,023 mTHAs performed from 2016 to 2022. Propensity scores were generated based on age, sex, body mass index, and Charlson comorbidity index. Patient-reported outcomes were evaluated using preoperative and postoperative scores of Patient-Reported Outcomes Measurement Information System (PROMIS) Global Physical, PROMIS Physical Function-10a (PF-10a), and Hip disability and Osteoarthritis Outcome Score - Physical Function Shortform (HOOS-PS). The time to achieve MCID was assessed using survival curves with and without interval censoring, and statistical comparisons were performed using log-rank and weighted log-rank tests.

RESULTS

Manual total hip arthroplasty demonstrated a significantly higher rate of achieving MCID for PROMIS Global Physical (84.1 versus 79.8%, P = 0.003) and HOOS-PS (60.0 versus 44.9%, P < 0.001), while rates for PROMIS PF-10a were similar (58.6 versus 56.0%, P = 0.085). In the interval-censored analysis, rTHA achieved MCID for HOOS-PS significantly faster than mTHA (0.67 versus 1.0 months, P < 0.001). However, no significant differences were found for PROMIS Global Physical (0.24 versus 0.70 months, P = 0.18) and PROMIS PF-10a (1.60 versus 3.03 months, P = 0.73) when compared to mTHA.

CONCLUSIONS

We conducted a propensity score-matched analysis of rTHA and mTHA, accounting for baseline characteristics, but not factors such as case difficulty and anatomic complexity. We found that rTHA achieved MCID faster, while mTHA had a higher overall proportion of MCID achievement. Robotic-assisted surgery may expedite initial recovery, while manual techniques may lead to better long-term outcomes.