Trends in Total Hip Arthroplasty in Germany from 2007 to 2016: What Has Changed and Where Are We Now?

Impact of tranexamic acid use in total hip replacement patients: A systematic review and meta-analysis

Purpose

Tranexamic acid (TXA) dose in the context of primary complete hip replacements (THA) is still a hot debate about the best way to administer TXA. The need to select the most efficient and secure TXA dosing regimen, taking into account elements like perioperative bleeding, postoperative complications, and patient outcomes, has been emphasized by numerous studies. Improving clinical procedures and the general efficacy and safety of employing TXA in THA surgeries requires addressing this ongoing debate.

Methods

For this systematic review, We looked at the safety and efficacy of administering TXA intravenously (iTXA) and topically (tTXA) during THA. A thorough search turned up ten randomized controlled trials with 1295 individuals. Parameters evaluated included blood loss, Hb level on the day following surgery, transfusion rates, and drainage volume.

Results

Strategies had comparable impacts on deep vein thrombosis occurrences and wound complications. iTXA produced considerably less intraoperative blood loss (WMD = -12.687), concealed blood loss (WMD = 14.276), and the greatest hemoglobin drop (WMD = -0.400) when compared to tTXA.

Conclusion

Both administration techniques were secure and efficient in primary THA, although iTXA showed superior results in lowering blood loss and Hb decline.

Cemented Calcar-Guided Short-Stem Prostheses in Geriatric Patients: Short-Term Results from a Prospective Observational Study

Both cementless and cemented stems have exhibited favorable long-term outcomes in total hip arthroplasty. Nonetheless, in elderly patients, cemented hips offer an advantage due to their reduced risk of periprosthetic fractures. This study aimed to assess the initial outcomes of 28 patients who underwent unilateral cemented total hip arthroplasty utilizing a calcar-guided A2 stem (ARTIQO GmbH, Lüdinghausen, Germany). Various types of antibiotic-loaded bone cement were employed. During follow-up, we recorded demographic data and comorbidities and employed standardized clinical assessment tools, including the Harris Hip Score. Radiographic assessments included preoperative, postoperative, and follow-up imaging to evaluate subsidence, osteolysis, and bone resorption. The results indicated that among the 28 patients, 5 withdrew consent and 2 patients passed away from unrelated causes. Additionally, one prosthesis was explanted due to the undersizing of the cement stopper, which resulted in an inadequate cement mantle. As a result, 20 patients underwent a 1-year follow-up, revealing noteworthy enhancements in clinical scores, with no instances of radiolucent lines or osteolysis. No infections were detected. In summary, our short-term experience with this particular cemented short-stem design yielded promising results, exhibiting excellent functional outcomes, no aseptic loosening attributable to the stem, and no infections. Further clinical studies and registry data are essential to corroborate these findings.

What features of stem increase the risk of intraoperative femoral fracture during cementless primary hip arthroplasty?

INTRODUCTION

Cementless fixation has become increasingly popular in hip arthroplasty due to its shorter operation time, easier technique, biologic fixation, and avoidance of bone cement implantation syndrome compared to cemented fixation. However, intraoperative periprosthetic femoral fracture (IOPFx) is a disconcerting complication during cementless hip arthroplasty. Our purpose was to identify the features of cementless stem that increase the risk of IOPFx during primary hip arthroplasty.

MATERIALS AND METHODS

We retrospectively reviewed all 4806 hip arthroplasties that was performed in a single institution from May 2003 to December 2020. Age at the index arthroplasty, sex, body mass index, physical status, ambulatory function, side of the operation, operational history, cause of the index arthroplasty, type of arthroplasty, surgical approach, surgeon, implant information, and events during the operation were investigated. The shoulder geometry and length of stem were also reviewed. The event of interest was narrowed down to IOPFx among various records of intraoperative events.

RESULTS

We found IOPFx of 2.6% among all the hips operated with cementless stem. In the multivariable analysis, female (OR = 1.52), childhood hip disease (OR = 2.30), stove-pipe femur (OR = 2.43), combined approach (OR = 2.60), and standard length of stem (OR = 1.59) were found to be significant risk factors of IOPFx.

CONCLUSIONS

In conclusion, a stem with a standard length is significantly associated with risk of IOPFx compared to a shortened stem. These findings highlight the importance of careful consideration in terms of the risk of IOPFx when standard length cementless stem is chosen.

[Customized partial pelvis replacement: three-dimensional planning and management concepts]

The planning and implantation of a customized partial pelvis replacement places high demands on both the surgeon and the entire team (engineer, assistants, surgical team). Thanks to careful preoperative planning and meticulous perioperative execution, customized partial pelvic replacement represents a complex but reliable procedure for defect reconstruction even with highly complex acetabular bone defects or after multiple previous surgeries.

Cemented versus Cementless Total Hip Arthroplasty for Femoral Head Osteonecrosis: A Study Based on National Claim Data in South Korea

INTRODUCTION

The purpose of this study was to compare the rates of revision, periprosthetic joint infection (PJI), and periprosthetic fracture (PPF) between patients with osteonecrosis of the femoral head (ONFH) undergoing noncemented total hip arthroplasty (THA) and cemented THA using a national claim data in South Korea.

METHODS

We identified patients who received THA for ONFH from January 2007 to December 2018 using ICD diagnosis codes and procedural codes. Patients were categorized into two groups according to the fixation method: with or without cement. The survivorship of THA was calculated using the following end points: revision of both the cup and stem, revision of the single component, any type of revision, PJI, and PPF.

RESULTS

A total of 40,606 patients: 3,738 patients (9.2%) with cement and 36,868 patients (90.7%) without cement, received THA for ONFH. The mean age of the noncemented fixation group (56.2 ± 13.2 years) was significantly lower than that of the cemented fixation group (57.0 ± 15.7 years, P = 0.003). The risk of revision and PJI was notably higher in cemented THA (hazard ratio: 1.44 [1.21 to 1.72] and 1.66 [1.36 to 2.04], respectively). Noncemented THA had a higher 12-year survivorship compared with cemented THA with any revision and PJI as the end point.

DISCUSSION

Noncemented fixation had better survivorship than cemented fixation in patients with ONFH.

The impact of femoral bone quality on cementless total hip pre-operative templating

INTRODUCTION

Accurate templating is an integral part of pre-operative planning for total hip arthroplasty (THA). Templating of cementless implant accuracy has been average. The aim of this study was to assess the impact of Dorr femoral classification on the accuracy of pre-operative digital templating.

PATIENTS AND METHODS

This was a retrospective study of cementless THA pre-operative planning using one implant design. A total of 210 primary THA were reviewed. A total of 102 cementless THAs matched the exclusion and inclusion criteria, using one implant combination, were analyzed by an orthopaedic resident and a fellowship trained arthroplasty surgeon. Each x-ray was evaluated and assigned a femoral Dorr classification. Accuracy of templating was determined by comparing the templated size with the actual implant size both for the femoral and acetabular components.

RESULT

Out of the 102 cases, exact templating size was achieved in 35.3% for the acetabulum, 25.5% for the femur, and only in 9.8% for both components. Reasonable templating, ± one of the actual size, was achieved in 78.4% for the acetabulum, 74.5% for the femur, and 60.8% for both components. Use of Dorr femoral type classification did not result in better templating accuracy.

CONCLUSION

Pre-operative hip cementless templating using digital x-rays with double marker method do not improve accuracy compared to other methods available for templating. Accounting for bone quality using the Dorr femoral classification did not improve accuracy.

Fracture of a titanium femoral neck after revision total hip arthroplasty

We report a case of a fractured titanium alloy (Ti6Al4V) femoral stem 2 years after revision (debridement, antibiotics and implant retention due to periprosthetic joint infection) total hip arthroplasty (THA). Material analysis revealed a superficial abnormality on the upper neck surface caused by local melting with electrocautery probably acting as a stress amplifier. This lesion presumably was the trigger of a fatigue fracture with typical features on the fracture surface. Electrocautery should therefore be avoided in case of revision THA or used with utmost care to avoid contact with the femoral stem.

Does Additive Pressurized Carbon Dioxide Lavage Improve Cement Penetration and Bond Strength in Cemented Arthroplasty?

The modern cementing technique in cemented arthroplasty is a highly standardized and, therefore, safe procedure. Nevertheless, aseptic loosening is still the main reason for revision after cemented total knee or cemented total hip arthroplasty. To investigate whether an additional carbon dioxide lavage after a high-pressure pulsatile saline lavage has a positive effect on the bone-cement interface or cement penetration, we set up a standardized laboratory experiment with 28 human femoral heads. After a standardized cleaning procedure, the test implants were cemented onto the cancellous bone. Subsequently, the maximum failure load of the bone-cement interface was determined using a material testing machine to pull off the implant, and the cement penetration was determined using computed tomography. Neither the maximum failure load nor cement penetration into the cancellous bone revealed significant differences between the groups. In conclusion, according to our experiments, the additive use of the carbon dioxide lavage after the high-pressure pulsatile lavage has no additional benefit for the cleaning of the cancellous bone and, therefore, cannot be recommended without restrictions.

In vivo analysis of hip joint loading on Nordic walking novices

Objective

To evaluate the influence of Nordic walking (NW) on hip joint loads in order to determine whether it can be safely performed during postoperative physiotherapy in patients after orthopeadic surgery of the hip.

Methods

Internal hip joint loads were directly measured in vivo in 6 patients using instrumented hip prostheses during NW and ordinary walking (OW). All patients received training in two different NW techniques (double-poling and the diagonal technique) by a certified NW instructor. Measurements were conducted on a treadmill at a speed of 4 km/h on level ground, at 10% inclination and at 10% slope as well as on a level lawn at a self chosen comfortable speed. Resultant contact force (F_res), bending moment (M_bend) and torsional torque (M_tors) were compared between NW and OW as well as between both NW techniques.

Results

Joint loads showed a double peak pattern during all setups. Neither NW technique significantly influenced hip joint loads at the time of the first load peak during contralateral toe-off (CTO), which was also the absolute load peak, in comparison to OW. Compared to OW, double-poling significantly reduced F_res and M_bend at the time of the second load peak during the contralateral heel strike (CHS) on level ground both on the treadmill (− 6% and − 7%, respectively) and on the lawn (− 7% and − 9%). At 10% inclination, the diagonal technique increased F_res and M_bend at CHS (by + 6% and + 7%), but did not increase the absolute load peak at CTO.

Conclusion

Joint loads during NW are comparable to those of OW. Therefore, NW can be considered a low-impact activity and seems to be safe for patients that are allowed full weight bearing, e.g. during postoperative rehabilitation after THA.

Can hip resurfacing be safely revised with short-stem total hip arthroplasty? A case series of six patients

BACKGROUND

The usage of short stems in primary total hip arthroplasty (THA) has constantly gained popularity over the last decade, however, to date, short stems are not eligible to be used as revision implants. The aim of this study was to retrospectively evaluate the outcome of revision surgery of failed hip resurfacing arthroplasty (HRA) using short-stem THA.

METHODS

In a single center, retrospective analysis, 6 consecutive patients who were treated with a calcar-guided short stem after failure of HRA were evaluated. The mean follow-up was 3.25 years (SD 0.45). Patient reported outcome measurements (PROMs) were recorded using the Harris hip score (HHS) and The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The health status was evaluated by the EQ-5D-5L score. Pain and satisfaction were obtained using the visual analogue scale (VAS). Radiographic analysis was performed by evaluating osteolysis, stress shielding, alignement and signs of aseptic loosening. Complications were documented.

RESULTS

At last follow-up, clinical outcome was excellent (HHS ≥ 90) in 5 patients and good (HHS = 87) in 1 patient. The mean WOMAC score was 5.73% (SD 3.66%). The mean EQ-5D-5L index was 0.914 (SD 0.07). Pain and satisfaction on VAS was 1.83 (SD 5.18) and 8.67 (SD 0.94), respectively. Radiologically, no signs of subsidence, aseptic loosening, stress shielding and fracture were obvious. No major complications occurred. To date, no further revision surgery was needed.

CONCLUSIONS

The outcomes of the present case series propose that HRA can be safely revised using short-stem THA in a selected patient group. Clinical and radiological results are encouraging. Based on the present data, short stems may be considered as a revision implant for failed HRA for experienced surgeons.

Bone cement implantation syndrome in cemented hip hemiarthroplasty-a persistent risk

Background

Every year, ~ 210,000 initial implantations of hip endoprostheses are carried out in Germany alone. The “bone cement implantation syndrome” (BCIS) is considered a severe peri- and early-postoperative complication when implanting cemented prostheses. The origin of the BCIS and its impact on the clinical outcome are still uncertain. This study investigates the clinical progression after BCIS cases in patients with cemented hemiarthroplasty. Risk factors for the occurrence of BCIS are evaluated.

Material and methods

Clinical data of all patients with a proximal femur fracture and which received a cemented hemiarthroplasty within a period of 9.5 years have been collected. BCIS (+) patients and BCIS (−) patients were compared with respect to their demographics and clinical outcome. Risk factors for the development of BCIS were identified.

Results

A total of 208 patients could be included with complete data sets. The mean age was 81.1 ± 10.0 years. Overall, 37% of the patients showed symptoms of BCIS. In comparison to BCIS (−) patients there was a significantly higher rate of cardiovascular complications (27.3% vs. 13.7%, p = 0.016) and a higher in-hospital mortality rate (15.6% vs. 4.6%, p = 0.006) in BCIS (+) patients. Age, absence of a femoral borehole and ASA status were identified as statistically significant risk factors of BCIS.

Conclusion

BCIS is frequently observed and in some cases severe complication. The therapy is exclusively symptomatic; identifying preventional measures might reduce the occurrence of BCIS.

Evaluation of intra- and interobserver reliability in the assessment of the 'critical trochanter angle'

Background

The recently described ‘critical trochanter angle’ (CTA) is a novel parameter in the preoperative risk assessment of stem malalignment in total hip arthroplasty. As its reproducibility needs to be evaluated, the given study aims to investigate intra- and interobserver reliability. It is hypothesized that both analyses justify the clinical use of the CTA.

Methods

A total of 100 pelvic radiographs obtained prior to total hip arthroplasty were retrospectively reviewed by four observers with different levels of clinical experience. The CTA was measured twice by each observer at different occasions in the previously described technique. Intra- and interobserver reliability was evaluated using intraclass correlation coefficients (ICC) with confidence intervals (CI) and the Bland–Altman approach.

Results

The mean CTA in both measuring sequences was 20.58° and 20.78°. The observers’ means ranged from 17.76° to 25.23°. Intraobserver reliability showed a mean difference of less than 0.5° for all four observers (95% limit of agreement: − 7.70–6.70). Intraobserver ICCs ranged from 0.92 to 0.99 (CI 0.88–0.99). For interobserver variation analysis, ICCs of 0.83 (CI 0.67–0.90) and 0.85 (CI 0.68–0.92) were calculated.

Conclusion

Analyses concerning intra- and interobserver reliability in the assessment of the CTA showed ‘very good’ and ‘good’ results, respectively. In view of these findings, the use of the CTA as an additional preoperative parameter to assess the risk of intraoperative stem malalignment seems to be justified.

What the Surgeon Can Do to Reduce the Risk of Trunnionosis in Hip Arthroplasty: Recommendations from the Literature

Trunnionosis, defined as wear and corrosion at the head–neck taper connection, is a cause of failure in hip arthroplasty. Trunnionosis is linked to a synergistic combination of factors related to the prosthesis, the patient, and the surgeon. This review presents analytical models that allow for the quantification of the impact of these factors, with the aim of providing practical recommendations to help surgeons minimize the occurrence of this failure mode. A tighter fit reduces micromotion and, consequently, fretting of the taper connection. The paramount parameters controlling the fixation force are the coefficient of friction and the impaction force. The influence of the head diameter, as well as of the diameter and angle of the taper, is comparatively small, but varus alignment of the taper and heads with longer necks are unfavourable under physiologic loads. The trunnion should be rinsed, cleaned, and dried carefully, while avoiding any contamination of the bore—the female counterpart within the head—prior to assembly. Biological debris, and even residual water, might critically reduce the fixation of the taper connection between the head and the neck. The impaction force applied to the components should correspond to at least two strong blows with a 500 g hammer, striking the head with an ad hoc impactor aligned with the axis of the taper. These strong blows should correspond to a minimum impaction force of 4000 N.