Outcomes of surgical management of total HIP replacement in patients aged 65 years and older: cemented versus cementless femoral components and lateral or anterolateral versus posterior anatomical approach

Cemented versus Cementless Femoral Fixation for Elective Primary Total Hip Arthroplasty: A Nationwide Analysis of Short-Term Complication and Readmission Rates

Cementless fixation during total hip arthroplasty (THA) is the predominant mode of fixation utilized for both acetabular and femoral components during elective primary THAs performed in the United States. This study aims to compare early complication and readmission rates between primary THA patients receiving cemented versus cementless femoral fixation. The 2016-2017 National Readmissions Database was queried to identify patients undergoing elective primary THA. Postoperative complication and readmission rates at 30, 90, and 180 days were compared between cemented and cementless cohorts. Univariate analysis was conducted to compare differences between cohorts. Multivariate analysis was performed to account for confounding variables. Of 447,902 patients, 35,226 (7.9%) received cemented femoral fixation, while 412,676 (92.1%) did not. The cemented group was older (70.0 vs. 64.8, p < 0.001), more female (65.0% vs. 54.3%, p < 0.001), and more comorbid (CCI 3.65 vs. 3.22, p < 0.001) compared to the cementless group. On univariate analysis, the cemented cohort had decreased odds of periprosthetic fracture at 30 days postoperatively (OR: 0.556, 95%-CI 0.424-0.729, p < 0.0001), but higher odds of hip dislocation, periprosthetic joint infection, aseptic loosening, wound dehiscence, readmission, medical complications, and death at all timepoints. On multivariate analysis, the cemented fixation cohort demonstrated reduced odds of periprosthetic fracture at all postoperative timepoints: 30 (OR: 0.350, 95%-CI 0.233-0.506, p < 0.0001), 90 (OR: 0.544, 95%-CI 0.400-0.725, p < 0.0001), and 180 days (OR: 0.573, 95%-CI 0.396-0.803, p = 0.002). Cemented femoral fixation was associated with significantly fewer short-term periprosthetic fractures, but more unplanned readmissions, deaths, and postoperative complications compared to cementless femoral fixation in patients undergoing elective THA.

A Systematic Review and Meta-Analysis of Non-database Comparative Studies on Cemented Versus Uncemented Femoral Stems in Primary Elective Total Hip Arthroplasty

BACKGROUND

Cemented and uncemented femoral stems have shown excellent survivorship and outcomes in primary total hip arthroplasty (THA). Cementless stems have become increasingly common in the United States; however, multiple large database studies have suggested that elderly patients may have fewer complications with a cemented stem. As conclusions from large databases may be limited due to variations in data collection, this study investigated femoral stem survivorship and complication rates based on cement status in non-database studies.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized to identify articles for inclusion up until June 2021. Included articles directly compared outcomes and complications between patients undergoing primary THA without femoral stem cementing to those with cementing. Studies were excluded if they utilized large databases or consisted of patients with a preoperative diagnosis of trauma.

RESULTS

Of the 1700 studies, 309 were selected for abstract review and nineteen for full-text review. A total of seven studies were selected. Meta-analyses indicated substantial heterogeneity between studies. There were no differences in revision rates (cementless: 5.53% vs. cemented 8.91%, P = .543), infection rates (cementless: 0.60% vs. cemented: 0.90%, P = .692), or periprosthetic fracture rates (cementless: 0.52% vs. cemented: 0.51%, P = .973) between groups.

CONCLUSION

There is scarce literature comparing outcomes and complications between cemented and cementless femoral stems in primary elective THA without utilizing a database methodology. In our study, there were no differences in complications detected on meta-analyses. Given previous findings in database studies, additional high-quality cohort studies are required to determine if selected patients may benefit from a cemented femoral stem.

Fraturas intracapsulares do colo femoral no idoso

Currently, intracapsular femoral neck fracture (IFNF) is still a great challenge for orthopedists. In spite of the progress that has been made, a high mortality rate persists in the first year, especially in Brazil, where there is no awareness that such fractures in elderly patients should be treated as a medical emergency. The present article seeks to provide an update on the preoperative, surgical, and postoperative approaches.

Total hip replacement: A meta-analysis to evaluate survival of cemented, cementless and hybrid implants

AIM

To determine whether cemented, cementless, or hybrid implant was superior to the other in terms of survival rate.

METHODS

Systematic searches across MEDLINE, CINAHL, and Cochrane that compared cemented, cementless and hybrid total hip replacement (THR) were performed. Two independent reviewers evaluated the risk ratios of revision due to any cause, aseptic loosening, infection, and dislocation rate of each implants with a pre-determined form. The risk ratios were pooled separately for clinical trials, cohorts and registers before pooled altogether using fixed-effect model. Meta-regressions were performed to identify the source of heterogeneity. Funnel plots were analyzed.

RESULTS

Twenty-seven studies comprising 5 clinical trials, 9 cohorts, and 13 registers fulfilled the research criteria and analyzed. Compared to cementless THR, cemented THR have pooled RR of 0.47 (95%CI: 0.45-0.48), 0.9 (0.84-0.95), 1.29 (1.06-1.57) and 0.69 (0.6-0.79) for revision due to any reason, revision due to aseptic loosening, revision due to infection, and dislocation respectively. Compared to hybrid THR, the pooled RRs of cemented THR were 0.82 (0.76-0.89), 2.65 (1.14-6.17), 0.98 (0.7-1.38), and 0.67 (0.57-0.79) respectively. Compared to hybrid THR, cementless THR had RRs of 0.7 (0.65-0.75), 0.85 (0.49-1.5), 1.47 (0.93-2.34) and 1.13 (0.98-1.3).

CONCLUSION

Despite the limitations in this study, there was some tendency that cemented fixation was still superior than other types of fixation in terms of implant survival.

Anterior and Anterolateral Approaches for THA Are Associated With Lower Dislocation Risk Without Higher Revision Risk

BACKGROUND

Lack of consensus continues regarding the benefit of anteriorly based surgical approaches for primary total hip arthroplasty (THA). The purpose of this study was to evaluate the risk of aseptic revision, septic revision, and dislocations for various approaches used in primary THAs from a community-based healthcare organization.

QUESTIONS/PURPOSES

(1) What is the incidence of aseptic revision, septic revision, and dislocation for primary THA in a large community-based healthcare organization? (2) Does the risk of aseptic revision, septic revision, and dislocation vary by THA surgical approach?

METHODS

The Kaiser Permanente Total Joint Replacement Registry was used to identify primary THAs performed between April 1, 2001 and December 31, 2011. Endpoints were septic revisions, aseptic revisions, and dislocations. The exposure of interest was surgical approach (posterior, anterolateral, direct lateral, direct anterior). Patient, implant, surgeon, and hospital factors were evaluated as possible confounders. Survival analysis was performed with marginal multivariate Cox models. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. A total of 42,438 primary THAs were available for analysis of revision outcomes and 22,237 for dislocation. Median followup was 3 years (interquartile range, 1-5 years). The registry's voluntary participation is 95%. The most commonly used approach was posterior (75%, N = 31,747) followed by anterolateral (10%, N = 4226), direct anterior (4%, N = 1851), and direct lateral (2%, N = 667).

RESULTS

During the study period 785 hips (2%) were revised for aseptic reasons, 213 (0.5%) for septic reasons, and 276 (1%) experienced a dislocation. The revision rate per 100 years of observation was 0.54 for aseptic revisions, 0.15 for septic revisions, and 0.58 for dislocations. There were no differences in adjusted risk of revision (either septic or aseptic) across the different THA approaches. However, the anterolateral approach (adjusted HR, 0.29; 95% CI, 0.13-0.63, p = 0.002) and direct anterior approach (adjusted HR, 0.44; 95% CI, 0.22-0.87, p = 0.017) had a lower risk of dislocation relative to the posterior approach. There were no differences in any of the outcomes when comparing the direct anterior approach with the anterolateral approach.

CONCLUSIONS

Anterior and anterolateral surgical approaches had the advantage of a lower risk of dislocation without increasing the risk of early revision.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Outcome of custom-made IMP femoral components of total hip arthroplasty: a follow-up of 15 to 22 years

A total of 1659 primary THAs using a cemented custom-made intra-operative manufactured prosthesis (IMP)-stem were studied. The end point for survival was defined as revision of the stem for any reason. Revision arthroplasty was performed in 49 cases. The IMP-stems had a revision free 20-year survival rate of 95.5%. Revisions were performed mainly because of aseptic loosening. There were no drawbacks like increased infection risk due to the prolonged surgical time needed for the intra-operative production of the stem. These data provide evidence that the cemented IMP-stem is able to provide good long-term results.

Safety and efficacy of non-cemented femoral fixation in patients 75 years of age and older

The aim of this study was to assess peri-operative complications, safety and efficacy of non-cemented femoral fixation in total hip arthroplasty (THA) as compared to cemented femoral fixation in the elderly population. Fifty-two matched pair analysis of patients with 75 years of age and older (104 patients), who underwent primary THA from June 1997 to December 2004, was performed based on age, sex, BMI, and Charnley classification. Mean age was 81 years (75-101) and the average follow up was 3.1 ± 2.9 years (1.2-6.4). There was no difference in peri-operative cardiopulmonary complications, pulmonary failures, deep venous thrombosis, pulmonary embolus, length of stay, or discharge deposition between the two groups. Non-cemented fixation is safe and effective in patients older than 75 years of age.

Influence of surgical approach on postoperative femoral bone remodelling after cementless total hip arthroplasty

We retrospectively evaluated the femoral periprosthetic bone mineral density (BMD) in a consecutive series of patients who had undergone total hip arthroplasty (THA) with a straight, double tapered cementless stem using a muscle-sparing anterolateral (group A) and the transgluteal (group B) surgical approach. Dual-energy x-ray absorptiometry (DXA) measurements were performed in the first postoperative week (t1), and after 3 (t2), 6 (t3) and 12 months (t4) using an identical protocol. Patients were clinically and radiographically evaluated at final follow-up (t4). A complete set of four consecutive DXA measurements was obtained for 16 hips in group A and 26 hips in group B. In patients in whom the transgluteal approach was used (Group B), we observed a significantly greater decline in overall periprosthetic BMD (netavg) and in BMD in the periprosthetic regions of interest (ROI) 1, 4, 5 and 6 between t1 and t4. At clinical and radiographic evaluation at t4, no differences between the groups were detected. Femoral periprosthetic BMD is affected by the selected surgical approach in the first postoperative year. This might be attributed to altered femoral loading as a result of differences in intraoperative damage to the abductor muscles.

Understanding recovery: changes in the relationships of the International Classification of Functioning (ICF) components over time

The International Classification of Functioning, Disability and Health framework describes human functioning through body structure and function, activity and participation in the context of a person's social and physical environment. This work tested the temporal relationships of these components. Our hypotheses were: 1) there would be associations among physical impairment, activity limitations and participation restrictions within time; 2) prior status of a component would be associated with future status; 3) prior status of one component would influence status of a second component (e.g. prior activity limitations would be associated with current participation restrictions); and, 4) the magnitude of the within time relationships of the components would vary over time. Participants from Canada with primary hip or knee joint replacement (n = 931), an intervention with predictable improvement in pain and disability, completed standardized outcome measures pre-surgery and five times in the first year post-surgery. These included physical impairment (pain), activity limitations and participation restrictions. ICF component relationships were evaluated cross-sectionally and longitudinally using path analysis adjusting for age, sex, BMI, hip vs. knee, low back pain and mood. All component scores improved significantly over time. The path coefficients supported the hypotheses in that both within and across time, physical impairment was associated with activity limitation and activity limitation was associated with participation restriction; prior status and change in a component were associated with current status in another component; and, the magnitude of the path coefficients varied over time with stronger associations among components to three months post surgery than later in recovery with the exception of the association between impairment and participation restrictions which was of similar magnitude at all times. This work enhances understanding of the complexities of the ICF component relationships in evaluating disability over time. Further longitudinal studies including evaluation of contextual factors are required.

Predictors of length of hospital stay after total hip replacement

PURPOSE

To identify variables affecting length of hospital stay after total hip replacement (THR) while controlling for potential confounders.

METHODS

Records of 199 consecutive elective unilateral THRs were reviewed. Clinical and demographic data including age, gender, body mass index, comorbidities, surgical factors (surgical approach, type of prosthesis, use of cement, operating time), anaesthetic factors (type of anaesthesia, ASA physical status), and length of hospital stay were recorded.

RESULTS

64% of patients left hospital within 12 days, 28% within 3 weeks, and 8% after 3 weeks. The median length of hospital stay was longer in women than men (11.5 vs. 9 days, p=0.009), in patients aged >65 years than those younger (13 vs. 9 days, p<0.0001), and in those with American Society of Anesthesiologists (ASA) grades 3 and 4 than grades 1 or 2 (14 vs. 9 days, p<0.0001). A greater proportion of women than men (45% vs. 27%, p=0.007), patients aged >65 years than those younger (61% vs. 37% or 24%, p<0.0001), and those with ASA grades 3 and 4 than grades 1 and 2 (68% vs. 25%, p<0.0001) stayed 12 days or longer. In the multiple regression analysis, the predictors for prolonged hospital stay (12 days or more) were patient age >65 years (p<0.003), female gender (p<0.05), and ASA grades 3 and 4 (p<0.0001). Of the 72 patients with prolonged stay, 7% had no, 26% had one, 42% had 2, and 25% had all 3 predictors.

CONCLUSION

Prolonged hospital stay after THR is largely predetermined by case mix. Our study helps to identify individuals who need longer rehabilitation and more care.

The trajectory of recovery and the inter-relationships of symptoms, activity and participation in the first year following total hip and knee replacement

OBJECTIVE

Primary total hip (THR) and knee (TKR) replacement outcomes typically include pain and function with a single time of follow-up post-surgery. This research evaluated the trajectory of recovery and inter-relationships within and across time of physical impairments (PI) (e.g., symptoms), activity limitations (AL), and social participation restrictions (PR) in the year following THR and TKR for osteoarthritis.

DESIGN

Participants (hip: n=437; knee: 494) completed measures pre-surgery and at 2 weeks, 1, 3, 6 and 12 months post-surgery. These included PI (Hip Disability and Osteoarthritis Outcome Score (HOOS)/Knee Injury and Osteoarthritis Outcome Score (KOOS) symptoms and Chronic Pain Grade); AL (HOOS/KOOS activities of daily living and sports/leisure activities); and, PR (Late Life Disability and the Calderdale community mobility). Repeated measures analysis of variance (RANOVA) was used to evaluate the trajectory of recovery of outcomes and the inter-relationships of PI, AL and PR were evaluated using path analysis. All analyses were adjusted for age, sex, obesity, THR/TKR, low back pain and mood.

RESULTS

THR: age 31-86 years with 55% female; TKR: age 35-88 years with 65% female. Significant improvements in outcomes were observed over time. However, improvements were lagged over time with earlier improvements in PI and AL and later improvements in PR. Within and across time, PI was associated with AL and AL was associated with PR. The magnitude of these inter-relationships varied over time.

CONCLUSION

Given the lagged inter-relationship of PI, AL and PR, the provision and timing of interventions targeting all constructs are critical to maximizing outcome. Current care pathways focusing on short-term follow-up with limited attention to social and community participation should be re-evaluated.

Objective functional assessment of total hip arthroplasty following two common surgical approaches: the posterior and direct lateral approaches

Despite the high number of total hip arthroplasty (THA) procedures performed each year, there is no common consensus on the best surgical approach. Gait is known to improve following THA although it does not return to what is typically quantified as normal, and surgical approach is believed to be a contributing factor. The current study evaluates postoperative hip function and provides an objective assessment following two common surgical approaches: the McFarland-Osborne direct lateral and the southern posterior. Faced with the common problem of providing an objective comparison from the wealth of data collected using motion analysis techniques, the current study investigates the application of an objective classification tool to provide information on the effectiveness of each surgery and to differentiate between the characteristics of hip function following the two approaches. Seven inputs for the classifier were determined through statistical analysis of the biomechanical data. The posterior approach group exhibited greater characteristics of non-pathological gait and displayed a greater range of functional ability as compared with the lateral approach cohort. The classification tool has proved to be successful in characterizing non-pathological and THA function but was insufficient in distinguishing between the two surgical cohorts.

Cemented and cementless total hip replacement. Critical analysis and comparison of clinical and radiological results of 182 cases operated in Al Razi Hospital, Kuwait

OBJECTIVE

In this study we present the results of a series of cemented Exeter and cementless Zweymuller implants.

SUBJECT AND METHODS

Eighty-seven cemented and 95 cementless hip replacements for different hip pathologies were followed for an average period of 36 months for cementless and 60 months for cemented cases. Clinical results were calculated using the Merle d'Aubigne score. The orientation of the prosthetic components and the fixation of the cup and stem were analyzed. The clinical and radiological results were compared using statistical methods.

RESULTS

In the average period of 36 months in cementless and 60 months in cemented hip replacements the clinical results improved significantly when compared with the preoperative score (p < 0.05). Sixty-seven cemented acetabular cups (77.1%) were in the desired position (30-50 degrees ) and 20 cemented cups (22.9%) were outside this range. Seventy-six cups (80%) were in the desired degree of abduction and 19 (20%) were outside this range. All cups except 1 were anteverted or neutral. Of the femoral stems, 173 were in the neutral position, 5 in the valgus and 4 in the varus position. Cemented cups were more commonly loose and cemented and cementless stems did equally well. No significant differences in rate of complications were found.

CONCLUSION

Cementless acetabular implants had better clinical results and a lower loosening rate at 3 years of follow-up compared to cemented implants at 5 years of follow-up. The cemented femoral implants were equally stable compared to the cementless ones.

Cementless hemiarthroplasty for femoral neck fractures in elderly patients

OBJECTIVES

The use of cement is associated with increased morbidity and mortality rate in elderly patients, hence cementless hemiarthroplasty is suggested. We evaluated the results of cementless hemiarthroplasty for femoral neck fractures in elderly patients with high-risk clinical problems.

MATERIALS AND METHODS

Forty-eight patients (29 females, 19 males) with a mean age of 88 years (range: 78 to 102 years). having femoral neck fractures were treated with the use of cementless hemiarthroplasty. Porous-coated femoral stems were used in 30 patients (62%) and modular type femoral revision stems in 18 patients (38%). Bipolar femoral heads were used in all patients. Radiological follow-up after operation was done at the one, three, six months and annually.

RESULTS

The mean follow-up period was 4.2 years (range: 18 months to eight years). None of the patients died during hospitalization. Medical complications occurred in six patients (12%) within the follow-up period and four patients (8%) died within this period. Only two hips were converted to total hip arthroplasty due to acetabular erosion. Femoral revision was planned for one patient with a subsidence of > 3 mm. None of the patients had acetabular protrusion or heterotopic ossification. The mean Harris-hip score was 84 (range: 52 to 92). Dislocation occurred in one patient (2%).

CONCLUSION

Cementless hemiarthroplasty is a suitable method of treatment for femoral neck fractures in elderly patients with high-risk clinical problems especially of a cardiopulmonary nature. This method decreases the risk of hypotension and fat embolism associated with cemented hemiarthroplasty.

Comparison of cemented and uncemented fixation in total hip replacement: a meta-analysis

BACKGROUND

The choice of optimal implant fixation in total hip replacement (THR)--fixation with or without cement--has been the subject of much debate.

METHODS

We performed a systematic review and meta-analysis of the published literature comparing cemented and uncemented fixation in THR.

RESULTS

No advantage was found for either procedure when failure was defined as either: (A) revision of either or both components, or (B) revision of a specific component. No difference was seen between estimates from registry and single-center studies, or between randomized and non-randomized studies. Subgroup analysis of type A studies showed superior survival with cemented fixation in studies including patients of all ages as compared to those that only studied patients 55 years of age or younger. Among type B studies, cemented titanium stems and threaded cups were associated with poor survival. An association was found between difference in survival and year of publication, with uncemented fixation showing relative superiority over time.

INTERPRETATION

While the recent literature suggests that the performance of uncemented implants is improving, cemented fixation continues to outperform uncemented fixation in large subsets of study populations. Our findings summarize the best available evidence qualitatively and quantitatively and provide important information for future research.

Clinical outcome of total hip arthroplasty using the normalized and proportionalized femoral stem with a minimum 20-year follow-up

Currently, there are several femoral stem designs available for use, but few have an extended track record. We have previously reported on 10- and 15-year outcome studies of total hip arthroplasty (THA) using a cemented normalized and proportionalized femoral stem from a single surgeon series. This is a follow-up study reporting the minimum 20-year outcome of this femoral stem design. The study began with THA performed in a consecutive series of 184 patients; stem fixation was achieved using first-generation cementing techniques. The overall early complication rate was 10%. There were 23 patients (31 hips) who had been followed-up for a minimum 20-year period (average 21.3 years). Mean d'Aubigne and Postel scores improved from 5.9 to 11.3; mean Harris hip scores improved from 43.8 to 92.8. Kaplan-Meier survivorship was 93% at 20 years (95% confidence interval); there were no stem failures. The use of a cemented normalized and proportionalized femoral stem in primary THA provides satisfactory long-term clinical and radiological outcomes in patients.

Evaluation of an accelerated aging medium for acrylic bone cement based on analysis of nanoindentation measurements on laboratory-prepared and retrieved specimens

The thrust of the study was a critical evaluation of the efficacy of a medium (30% v/v H(2)O(2), at 60 degrees C) that has been suggested in a literature report as being suitable for simulating the oxidative aging process, seen in vivo, in the acrylic bone cement mantles of total hip and knee joint replacements. For this purpose, quasi-static and dynamic nanoindentation measurements were used to obtain material properties--elastic modulus, E; hardness, H; and the variation of the storage and loss moduli with the frequency of the applied indenting force--of PalacosR acrylic bone cement specimens after various periods of immersion (7, 14, 21, and 28 days) in the aging solution, and of specimens prepared from cement mantles retrieved from cemented total hip joint replacements after various times in vivo (0.92-21 years). Also, best-fit relationships were obtained between E and time in the H(2)O(2) solution (t), H and t, E and in vivo time (T), and H and T. This body of results points to the possibility that the aging solution is effective, although the evidence is not conclusive.

Influence of the activator in an acrylic bone cement on an array of cement properties

In all but one of the acrylic bone cement brands used in cemented arthroplasties, N,N-dimethyl-4-toluidine (DMPT) serves as the activator of the polymerization reaction. However, many concerns have been raised about this activator, all related to its toxicity. Thus, various workers have assessed a number of alternative activators, with two examples being N,N-dimethylamino-4-benzyl laurate (DMAL) and N,N-dimethylamino-4-benzyl oleate (DMAO). The results of limited characterization of cements that contain DMAL or DMAO have been reported in the literature. The present work is a comprehensive comparison of cements that contain one of these three activators, in which the values of a large array of their properties were determined. These properties range from the setting time and maximum exotherm temperature of the curing cement to the variation of the loss elastic modulus of the cured cement with frequency of the applied indenting force in dynamic nanoindentation tests. The present results, taken in conjunction with those presented in previous reports by the present authors and co-workers on other properties of these cements, indicate that both DMAL and DMPT are suitable alternatives to DMPT.

Posterior versus lateral surgical approach for total hip arthroplasty in adults with osteoarthritis

BACKGROUND

Osteoarthritis (OA) of the hip is a progressive condition that has no cure and often requires a total hip arthroplasty (THA). The principal methods for THA are the posterior and direct lateral approaches. The posterior approach is considered to be easy to perform, however, increased rates of dislocation have been reported. The direct lateral approach facilitates cup positioning which may decrease rates of hip dislocation and diminishes the risk of injury to the sciatic nerve. However, there is an increased risk of limp. Dislocation of a hip prosthesis is a clinically important complication after THA, in terms of morbidity implications and costs.

OBJECTIVES

To determine the risks of prosthesis dislocation, postoperative Trendelenburg gait and sciatic nerve palsy after a posterior approach, compared to a direct lateral approach, for adult patients undergoing THA for primary OA and to update the previous review made in 2003.

SEARCH STRATEGY

MEDLINE, EMBASE, CINAHL and Cochrane databases were searched and updated, from the previous search of 2002, to Oct 13, 2005. No language restrictions were applied.

SELECTION CRITERIA

Published trials comparing posterior and direct lateral surgical approaches to THA in participants 18 years and older with a diagnosis of primary hip OA.

DATA COLLECTION AND ANALYSIS

Retrieved articles were assessed independently by the two reviewers for their methodological quality.

MAIN RESULTS

Four prospective cohort studies involving 241 participants met the inclusion criteria. The primary outcome, dislocation, was reported in two studies. No significant difference between posterior and direct lateral surgical approach was found [1/77 (1.3%) versus 3/72 (4.2%); relative risk (RR) 0.35; 95% confidence intervals (CI) 0.04 to 3.22]. The presence of postoperative Trendelenburg gait was not significantly different between these surgical approaches. The risk of nerve palsy or injury (all nerves taken together) was significantly higher among the direct lateral approaches [1/43 (2%) versus 10/49 (20%); RR 0.16, 95% CI 0.03 to 0.83]. However, there were no significant differences when comparing this risk nerve by nerve for both approaches, in particular for the sciatic nerve. Of the other outcomes considered only the average range of internal rotation in extension of the hip was significantly higher (weighted mean difference 16 degrees, 95% CI 8 to 23) in the posterior approach group (mean 35 degrees , standard deviation 13 degrees ) compared to the direct lateral approach (mean 19 degrees , standard deviation 13 degrees ).

AUTHORS' CONCLUSIONS

The quality and quantity of information extracted from the trials performed to date are insufficient to make any firm conclusion on the optimum choice of surgical approach in adult patients undergoing primary THA for OA.

Cemented or uncemented femoral component in primary total hip replacement? A review from a clinical and radiological perspective

Controversy exists regarding the optimal method of fixation for primary total hip replacement, particularly the femoral component. We performed a systematic literature review to explore whether cemented total hip replacement can achieve better clinical and radiological outcomes. A total of 29 publications were selected using computer-aided and manual searches. A qualitative comparison of results in clinical and radiological changes was then conducted. Most of the literature showed that better short-term clinical and functional outcomes could be obtained from cemented femoral fixation than from uncemented femoral fixation. Results were less clear for the mid-term clinical outcome, though in general, cemented fixation still appeared to show a superior clinical outcome. Radiographic differences are variable and do not seem to correlate with clinical findings. For the short- and mid-term, cemented femoral component is recommended. However, a long-term randomised trial combined with a large cohort study or registry is needed.

Surgical approach influences periprosthetic femoral bone density

Our hypothesis was that the bone mineral density of the proximal femur is altered significantly by surgical approach. The change in long-term periprosthetic bone mineral density in relation to the alteration of the musculature after the anterolateral (Group A) and transgluteal approaches (Group B) has been compared. There were 35 hips (30 patients) in Group A and 47 hips (37 patients) in Group B. No significant differences were seen between groups with respect to age, gender, diaphyseal bone mineral density distribution, or average stem size in a Wilcoxon-Mann-Whitney test. Measurement of bone mineral density in femoral Gruen zones revealed a significant bone loss in Group B compared with Group A in the multivariate analysis, which was confirmed by univariate post hoc tests in Zones I, II, VI, and VII (multiple significance according to Bonferroni-Holm's procedure). The functional outcome, however, showed no significant differences between the two groups postoperatively. A potential reason for the bone mineral density shift might have been a redistribution of the musculoskeletal loading across the hip after a transgluteal, compared with an anterolateral, surgical approach. A difference in the muscular damage caused by the two surgical approaches seems to have a significant influence on the long-term bone loss.

Cementless double-tapered total hip arthroplasty in patients 75 years of age and older

Concerns exist with cementless total hip arthroplasty (THA) femoral fixation in the elderly patient population. This study reviews the outcomes of a tapered cementless femoral component in elderly patients 75 years of age and older. Forty-seven patients (49 hips) older than 74 years of age (average age, 79 years) underwent primary cementless THA with a double-tapered stem between 1996 and 2000. Radiographs and clinical data were reviewed. At a mean follow-up of 5 years, the mean postoperative Harris Hip Score was 84, with 87% having no or minimal pain; none had severe thigh pain. Two cases of stem subsidence and no progressive radiolucencies were seen. One well-fixed stem was revised for unexplained pain (2%). Survival with aseptic loosening as an end-point was 100%. Overall implant survival was 98% at an average of 5 years. No perioperative deaths or significant orthopedic complications were identified. Advanced age is not a contraindication for tapered cementless THA.

Primary total hip arthroplasty using a modular proximally coated prosthesis in patients older than 70: two to eight year results

Patients older than 70 years who underwent primary total hip arthroplasty using a modular proximally porous-coated femoral stem with an ingrowth hemispherical acetabular component were evaluated. This included 135 hips in 122 patients, with an average 5-year follow-up period. This study included 96 patients (107 hips) still living; 26 patients (28 hips) patients had died, and 8 patients were lost to follow up. In this study, 93% of patients had little or no pain, and 95% were extremely or very satisfied with the operation. Mean Harris Hip score was 83, with a Short Form-36 (SF-36) physical component and mental component summary score of 41 and 51, respectively. Osteolysis surrounding the femur was seen in 8 hips (7%) and around the acetabulum in 6 hips (5%). No components were loose or required revision.