Prevention of early complications following total hip replacement

Risk factors for peri-megaprosthetic joint infections in tumor surgery: A systematic review

BACKGROUND

Peri-megaprosthetic joint infections (PJI) in tumor surgery are complex and challenging complications that significantly impact the outcomes of the patients. The occurrence of PJI poses a substantial threat to the success of these operations. This review aims to identify and summarize the risk factors associated with PJI in tumor surgery with megaprosthetic reconstruction as well as to determine the overall risk of PJI in limb salvage surgery.

METHODS

A thorough examination of published literature, scrutinizing the incidence of PJI in tumor prostheses after limb salvage surgery was done. Research studies that documented the incidence of PJI in tumor patients who underwent limb salvage surgery, and explored the risk factors associated with the occurrence of PJI were deemed eligible.

RESULTS

A total of 15 studies were included in the analysis and underwent comprehensive examination. After the exploration of key parameters, several significant risk factors for PJI concerning the type of implant coating, surgical site characteristics, patient demographics, and procedural factors were recorded.

DISCUSSION

The findings underscore the need for a nuanced approach in managing tumor patients undergoing limb salvage surgery and megaprosthetic reconstruction, with emphasis on individualized risk assessments and individualized preventive strategies.

Two-Dimensional Versus Three-Dimensional Preoperative Planning In Total Hip Arthroplasty

BACKGROUND

Pre-operative planning in total hip arthroplasty (THA), involves utilizing radiographs or advanced imaging modalities, including computerized tomography (CT) scans, for precise prediction of implant sizing and positioning. This study aimed to compare Three-Dimensional (3D) versus Two-Dimensional (2D) pre-operative planning in primary THA with respect to key surgical metrics, including restoration of the horizontal and vertical Center of Rotation (COR), combined offset, and leg length.

METHODS

This study included 60 patients undergoing primary THA for symptomatic hip osteoarthritis, randomly allocated to either robotic-arm-assisted or conventional THA. Digital 2D templating and 3D planning using the robotic software were performed for all patients. All measurements to evaluate the accuracy of templating methods were conducted on the pre-operative CT scanogram, using the contralateral hip as a reference. Sensitivity analyses explored differences between 2D and 3D planning in patients who had supero-lateral or medial osteoarthritis patterns.

RESULTS

Compared to 2D templating, 3D templating was associated with less medialization of the horizontal COR (-1.2 versus -0.2 mm, P = 0.002) and more accurate restoration of the vertical COR (1.63 versus 0.3 mm, P < 0.001) with respect to the contralateral side. Furthermore, 3D templating was superior for planned restoration of leg length (+0.23 versus -0.74 mm, P = 0.019). Sensitivity analyses demonstrated that in patients who had medial osteoarthritis, 3D planning resulted in less medialization of horizontal COR and less offset reduction. Conversely, in patients who had supero-lateral osteoarthritis, there was less lateralization of horizontal COR and less offset increase using 3D planning. Additionally, 3D planning showed superior reproducibility for stem, acetabular cup sizes, and neck angle, while 2D planning often led to smaller stem and cup sizes.

CONCLUSION

Our findings indicated higher accuracy in the planned restoration of native joint mechanics using 3D planning. Additionally, this study highlights distinct variances between the two planning methods across different osteoarthritis pattern subtypes, offering valuable insights for clinicians employing 2D planning.

A prospective randomized controlled trial comparing CT-based planning with conventional total hip arthroplasty versus robotic arm-assisted total hip arthroplasty

Aims

Achieving accurate implant positioning and restoring native hip biomechanics are key surgeon-controlled technical objectives in total hip arthroplasty (THA). The primary objective of this study was to compare the reproducibility of the planned preoperative centre of hip rotation (COR) in patients undergoing robotic arm-assisted THA versus conventional THA.

Methods

This prospective randomized controlled trial (RCT) included 60 patients with symptomatic hip osteoarthritis undergoing conventional THA (CO THA) versus robotic arm-assisted THA (RO THA). Patients in both arms underwent pre- and postoperative CT scans, and a patient-specific plan was created using the robotic software. The COR, combined offset, acetabular orientation, and leg length discrepancy were measured on the pre- and postoperative CT scanogram at six weeks following surgery.

Results

There were no significant differences for any of the baseline characteristics including spinopelvic mobility. The absolute error for achieving the planned horizontal COR was median 1.4 mm (interquartile range (IQR) 0.87 to 3.42) in RO THA versus 4.3 mm (IQR 3 to 6.8; p < 0.001); vertical COR mean 0.91 mm (SD 0.73) in RO THA versus 2.3 mm (SD 1.3; p < 0.001); and combined offset median 2 mm (IQR 0.97 to 5.45) in RO THA versus 3.9 mm (IQR 2 to 7.9; p = 0.019). Improved accuracy was observed with RO THA in achieving the desired acetabular component positioning (root mean square error for anteversion and inclination was 2.6 and 1.3 vs 8.9 and 5.3, repectively) and leg length (mean 0.6 mm vs 1.4 mm; p < 0.001). Patient-reported outcome measures were comparable between the two groups at baseline and one year. Participants in the RO THA group needed fewer physiotherapy sessions postoperatively (median six (IQR 4.5 to 8) vs eight (IQR 6 to 11; p = 0.005).

Conclusion

This RCT suggested that robotic-arm assistance in THA was associated with improved accuracy in restoring the native COR, better preservation of the combined offset, leg length correction, and superior accuracy in achieving the desired acetabular component positioning. Further evaluation through long-term and registry data is necessary to assess whether these findings translate into improved implant survival and functional outcomes.

Associated Factors of Functional Ability in Older Persons Undergoing Hip Surgery Immediately Post-Hospital Discharge: A Prospective Study

BACKGROUND

hip fractures commonly have an impact on older adults' health. Surgical treatment aims to reduce pain and promote functional ability. However, developing adverse health outcomes or complications post-hip surgery may impede older patients' recovery to return to functional ability as pre-fracture. We aimed to examine the association of personal factors and adverse health outcomes during hospitalization and post-hospital discharge on the functional ability of older people undergoing hip surgery.

METHODS

a total of 120 older people with hip fractures who were scheduled for surgery at three tertiary hospitals and met the inclusion criteria were recruited for this study. Data were obtained at admission, before discharge, and during the two-week postoperative follow-up using the Demographic, Hip Dysfunction and Osteoarthritis Outcome Score, Joint Replacement, the Confusion Assessment Method (CAM) Thai version, and Health Outcome Questionnaires. Descriptive statistics and multiple logistic regression analyses were performed to analyze the data.

RESULTS

most participants were female, with a mean age of 78.10 years (range = 60-93; SD = 8.37). The most common adverse health outcome during hospitalization was urinary tract infection, followed by delirium, pneumonia, deep vein thrombosis, and surgical site infection. At two weeks immediately post-hospital discharge, 16 participants experienced unpleasant events, including delirium, urinary tract infection, surgical site infection, and pneumonia. The significant predictors of poor functional ability at two weeks immediately post-hospital discharge were old age (OR = 1.114, p = 0.001), subtrochanteric fracture (OR = 13.48, p = 0.008), and type of surgery (OR = 4.105, p = 0.049).

An Analysis of the Preoperative Factors, Spinopelvic Mobility and Sagittal Spinal Alignment in Pre-THA Patients

Hip arthroplasty is a very effective medical procedure. The optimal positioning of the components and the functioning of the endoprosthesis are influenced, among other things, by the mobility and balance of the spine. The aim of the study was to analyze the factors influencing the mobility of the lumbar-pelvic-iliac complex (spinopelvic mobility) together with the assessment of sagittal spinal alignment in patients prior to THA (total hip arthroplasty). Patients who underwent hip replacement surgery due to advanced osteoarthritis of the hip were enrolled in the study (n = 103). The sociodemographic characteristics, BMI, radiological advancement of the degenerative disease, quality of life, and range of joint mobility were completed using a proprietary questionnaire, the EQ-5D-5L questionnaire, and a clinical examination. X-ray images were analyzed: AP of the pelvis standing up, lateral of the spine standing and sitting. Key parameters were measured as ∆SS-change in sacrum angle value when changing from standing to sitting position and pelvic incidence (PI)-lumbar lordosis (LL) mismatch-sagittal lumbar pelvic balance measured in standing position. The patients were assigned to the appropriate groups according to the Hip-Spine Classification: normal group: 1A (n = 65; 63.1%), abnormal groups: 1B (n = 17; 16.5%), 2A (n = 16; 15.5%), 2B (n = 5; 4.9%). A correlation was shown between the abnormal groups and the individual components of PROMs in the scope of the self-service and normal activities categories (EQ-5D and EQ-VAS). However, the strength of the relationship turned out to be moderate, and the remaining components of the survey were statistically insignificant. The remaining factors analyzed, i.e., age, BMI, the range of hip motion, the presence of contracture in the joint in a clinical examination, and the radiological advancement of osteoarthritis on the Tonnis scale, do not predict abnormal relationships between the spine and the pelvis in our patients waiting for THA. Therefore, further investigations are needed to evaluate the correlation between preoperative factors and the lumbar-pelvic-iliac complex in patients prior to planned hip arthroplasty.

Accuracy of Leg Length and Hip Offset Measurements Using a Fluoroscopic Grid During Anterior Approach Total Hip Arthroplasty

Background

Minimizing leg length (LLD) and hip offset (OD) discrepancies is critical for tissue tension and implant longevity in total hip arthroplasty (THA). The direct anterior approach (DAA) helps surgeons recreate these values under fluoroscopy. Several methods to accomplish this have been described, with no consensus on which is superior. This study evaluated the ability to minimize LLD and OD using a surgeon-controlled, adjustable fluoroscopic grid. We hypothesized that this tool would recreate parameters to within 10 mm of the contralateral side.

Methods

One hundred eleven primary THAs performed with an adjustable radiopaque grid to equalize leg length and hip offset were retrospectively reviewed. These values were measured on postoperative radiographs and compared to the contralateral hip. Patients were excluded if they had inadequate imaging, revision arthroplasty, preexisting deformities, or underwent approaches other than DAA.

Results

Mean age was 59.1 ± 11.1 years, 63.1% of patients were female, and average body mass index was 27.8 ± 7.0. Mean LLD was 3.7 ± 3.0 mm, while mean OD was 4.6 ± 3.6 mm. 95.5% of hips showed LLD < 10 mm, while 93.7% of hips had OD < 10 mm. Furthermore, 76.6% of hips had LLD < 5 mm, while 62.2% of hips had OD < 5 mm.

Conclusions

The described technique restored limb length and hip offset during DAA THA. This technique yields consistent results and offers an inexpensive alternative to costly digital software and more cumbersome fixed grid systems.

Functional Component Positioning in Total Hip Arthroplasty and the Role of Robotic-Arm Assistance in Addressing Spinopelvic Pathology

Hip, spine, and pelvis function as a unified kinetic chain. Any spinal pathology, results in compensatory changes in the other components to accommodate for the reduced spinopelvic motion. The complex relationship between spinopelvic mobility and component positioning in total hip arthroplasty presents a challenge in achieving functional implant positioning. Patients with spinal pathology, especially those with stiff spines and little change in sacral slope, are at high instability risk. In this challenging subgroup, robotic-arm assistance enables the execution of a patient specific plan, avoiding impingement and maximizing range of motion; especially utilizing virtual range of motion to dynamically assess impingement.

Functional implant positioning in total hip arthroplasty and the role of robotic-arm assistance

INTRODUCTION

Accurate implant positioning, tailored to the phenotype and unique biomechanics of each patient is the single most important objective in achieving stability in THA and maximise range of motion. The spine-pelvis-hip construct functions as a single unit adapting to postural changes. It is widely accepted in the literature that no universaltarget exists and variations in spinopelvic mobility mandate adjustments to the surgical plan; thus bringing to the fore the concept of personalised, functional component positioning.

METHODS

This manuscript aims to outline the challenges posed by spinopelvic imbalance and present a reproducible, stepwise approach to achieve functional-component positioning. We also present the one-year functional outcomes and Patient Reported Outcome Measures of a prospective cohort operated with this technique.

RESULTS AND CONCLUSION

Robotic-arm assisted Total Hip Arthroplasty has facilitated enhanced planning based on the patient's phenotype and evidence suggests it results in more reproducible and accurate implant positioning. Preservation of offset, avoiding leg-length discrepancy, accurate restoration of the centre of rotation and accomplishing the combinedversion target are very important parameters in Total Hip Arthroplasty that affect post-operative implant longevity, patient satisfaction and clinical outcomes.

Is aspirin still relevant as a single pharmacological agent for venous thromboembolism prophylaxis post hip and knee arthroplasty surgery: A retrospective review

Introduction: Aspirin is widely used for the prevention of venous thromboembolism (VTE) after total hip arthroplasty (THA) and total knee arthroplasty (TKA). It is well-established that the bleeding and wound complication risk for aspirin is low or equivalent to the other anticoagulant agents, but there is still ongoing controversy regarding the efficacy of aspirin for VTE prophylaxis. The current HSE (2012) guideline suggests 72 h of enoxaparin and 4 weeks of Aspirin therapy. But is this practice still relevant with more recent guidelines, NICE (2021) and SIGN (2014) suggesting that Aspirin is not recommended as a single pharmacological agent for VTE prophylaxis. Method: A Retrospective review was performed of a single centre, between January 2016 and May 2021 assessing for symptomatic VTE post-THA and TKA. All the patients received enoxaparin and aspirin as per the HSE guidelines. Using NIMIS we assessed which patients received a workup for potential symptomatic VTE and who had a confirmed VTE within 3 months post-surgery. The secondary outcome was mortality within 3 months post-surgery. Results: A total of 1178 patients (721 undergoing THR and 457 undergoing TKR) were included in the study. The number of patients who received a workup for potential symptomatic VTE was 124 of 1178 (10.53%). VTE occurred in 13 of 721 patients (1.80%) of the THR patients and 1 of 457 (0.22%) of the TKR patients, and a total of 14 of 1178 patients (1.19%). Of these 7 (0.59%) patients developed a DVT and 7 (0.59%) a PE. No patients suffered a fatal pulmonary embolism within 90 days of index surgery nor any other cause of mortality. Conclusion: Aspirin is not only still relevant but can be considered as one of the most optimal pharmacological agents in preventing VTE after THA and TKA.