Short to Midterm Follow-Up of Periprosthetic Bone Mineral Density after Total Hip Arthroplasty with the Ribbed Anatomic Stem

Total Hip Arthroplasty in Patients with Hip Osteoporosis: A Narrative Review

Osteoporosis and osteopenia can affect patients undergoing arthroplasty of the hip, which is typically recommended for patients with severe osteoarthritis or elderly patients with a femoral neck fracture. Preoperative screening for this type of bone loss could be helpful to patients and prevent poor outcomes due to the rate of underdiagnosis of osteoporosis, which can reach 73% in patients undergoing hip arthroplasty. Complications associated with low bone mineral density include periprosthetic fractures as well as an increased revision rate. Although the benefit of antiresorptive medications postoperatively has been demonstrated, when administered preoperatively, worse outcomes were reported compared to its non-usage. Surgical management is as important as pre-medication. According to general recommendations, cemented implants provide greater benefit in osteoporotic patients. However, when using cementless implants, ribbed stems, straight tapered stems, stems with medial calcar contact, and titanium-composed stems can be used to prevent periprosthetic loss of bone mineral density; however, they should not be placed in a varus position. These stems can also be coated with zoledronate and other products.

When the Total Hip Replacement Fails: A Review on the Stress-Shielding Effect

Total hip arthroplasty is one of the most common and successful orthopedic surgeries. Sometimes, periprosthetic osteolysis occurs associated with the stress-shielding effect: it results in the reduction of bone density, where the femur is not correctly loaded, and in the formation of denser bone, where stresses are confined. This paper illustrates the stress shielding effect as a cause of the failing replacement of the hip joint. An extensive literature survey has been accomplished to describe the phenomenon and identify solutions. The latter refer to the design criteria and the choice of innovative materials/treatments for prosthetic device production. Experimental studies and numerical simulations have been reviewed. The paper includes an introduction to explain the scope; a section illustrating the causes of the stress shielding effect; a section focusing on recent attempts to redefine prosthetic device design criteria, current strategies to improve the osteointegration process, and a number of innovative biomaterials; functionally graded materials are presented in a dedicated section: they allow customizing prosthesis features with respect to the host bone. Conclusions recommend an integrated approach for the production of new prosthetic devices: the “engineering community” has to support the “medical community” to assure an effective translation of research results into clinical practice.

Health technology assessment through Six Sigma Methodology to assess cemented and uncemented protheses in total hip arthroplasty

The purpose of this study is to use Health Technology Assessment (HTA) through the Six Sigma (SS) and DMAIC (Define, Measure, Analyse, Improve, Control) problem-solving strategies for comparing cemented and uncemented prostheses in terms of the costs incurred for Total hip arthroplasty (THA) and the length of hospital stay (LOS). Multinomial logistic regression analysis for modelling the data was also performed. Quantitative parameters extracted from gait analysis, electromyography and computed tomography images were used to compare the approaches, but the analysis did not show statistical significance. The variables regarding costs were studied with the Mann-Whitney and Kruskal-Wallis tests. No statistically significant difference between cemented and uncemented prosthesis for the total cost of LOS was found, but the cost of the surgeon had an influence on the overall expenses, affecting the cemented prosthetic approach. The material costs of surgery for the uncemented prosthesis and the cost of theatre of surgery for the cemented prosthesis were the most influential. Multinomial logistic regression identified the Vastus Lateralis variable as statistically significant. The overall accuracy of the model is 93.0%. The use of SS and DMAIC cycle as tools of HTA proved that the cemented and uncemented approaches for THA have similar costs and LOSy.

Bone mineral density, osteopenia, osteoporosis, and fracture risk in patients with atopic dermatitis: a systematic review and meta-analysis

BACKGROUND

The relationship between atopic dermatitis (AD) and abnormal bone metabolism remains unclear. We performed a systematic review and meta-analysis to determine whether patients with AD were associated with increased risks of low bone mineral density (BMD), osteopenia, osteoporosis, and related fractures.

METHODS

We searched PubMed, Embase, and the Cochrane Library through December 2019 to identify studies that investigated the association between AD and abnormal bone metabolism (including BMD, osteopenia, osteoporosis, and related fractures). The predefined primary outcome was related fractures; secondary outcomes included osteoporosis, osteopenia, and BMD. We calculated the summary odds ratios (ORs) and 95% confidence intervals (CIs) using a random-effects model.

RESULTS

Ten studies were included in this systematic review. In children and adolescents, four studies investigated the association between AD and BMD; three studies indicated that children and adolescents with AD were associated with an increased risk of low BMD; one study found similar BMD between AD and control groups. In adults, three studies assessed the risk of fracture and were included in the meta-analysis, comprising 562,405 AD patients among 3,171,268 participants. Adults with AD were associated with an increased risk of fracture (OR 1.13; 95% CI, 1.05-1.22; P=0.001). Three studies investigated the association between AD and osteoporosis, which suggested that patients with AD were associated with an increased risk of osteoporosis (OR 1.95; 95% CI, 1.18-3.23; P=0.009). Further, patients with AD were associated with increased risks of osteopenia (OR 1.90; 95% CI, 1.51-2.38; P<0.001) and low BMD at the femur and spine.

CONCLUSIONS

Patients with AD were associated with increased risks of low BMD, osteopenia, osteoporosis, and related fractures. Both clinical studies and basic research are needed to clarify the mechanisms of association between AD and abnormal bone metabolism.

Perioperative patient-specific factors-based nomograms predict short-term periprosthetic bone loss after total hip arthroplasty

BACKGROUND

Although medical intervention of periprosthetic bone loss in the immediate postoperative period was recommended, not all the patients experienced periprosthetic bone loss after total hip arthroplasty (THA). Prediction tools that enrolled all potential risk factors to calculate an individualized prediction of postoperative periprosthetic bone loss were strongly needed for clinical decision-making.

METHODS

Data of the patients who underwent primary unilateral cementless THA between April 2015 and October 2017 in our center were retrospectively collected. Candidate variables included demographic data and bone mineral density (BMD) in spine, hip, and periprosthetic regions that measured 1 week after THA. Outcomes of interest included the risk of postoperative periprosthetic bone loss in Gruen zone 1, 7, and total zones in the 1st postoperative year. Nomograms were presented based on multiple logistic regressions via R language. One thousand Bootstraps were used for internal validation.

RESULTS

Five hundred sixty-three patients met the inclusion criteria were enrolled, and the final analysis was performed in 427 patients (195 male and 232 female) after the exclusion. The mean BMD of Gruen zone 1, 7, and total were decreased by 4.1%, 6.4%, and 1.7% at the 1st year after THA, respectively. 61.1% of the patients (261/427) experienced bone loss in Gruen zone 1 at the 1st postoperative year, while there were 58.1% (248/427) in Gruen zone 7 and 63.0% (269/427) in Gruen zone total. Bias-corrected C-index for risk of postoperative bone loss in Gruen zone 1, 7, and total zones in the 1st postoperative year were 0.700, 0.785, and 0.696, respectively. The most highly influential factors for the postoperative periprosthetic bone loss were primary diagnosis and BMD in the corresponding Gruen zones at the baseline.

CONCLUSIONS

To the best of our knowledge, our study represented the first time to use the nomograms in estimating the risk of postoperative periprosthetic bone loss with adequate predictive discrimination and calibration. Those predictive models would help surgeons to identify high-risk patients who may benefit from anti-bone-resorptive treatment in the early postoperative period effectively. It is also beneficial for patients, as they can choose the treatment options based on a reasonable expectation following surgery.

Comparison of Bone Remodeling Between Collum Femoris-Preserving Stems and Ribbed Stems in 1-Stage Bilateral Total Hip Arthroplasty

BACKGROUND This study examined a cohort of patients who underwent bilateral THAs. CFP prostheses and ribbed prostheses were each used on both sides. We assessed the midterm clinical, radiological, and bone remodeling outcomes around prosthesis of these patients. MATERIAL AND METHODS From January 2009 to January 2013, 53 patients were enrolled in our study. We clinically evaluated all patients by recording Harris hip and Oxford hip scores. Some radiological indicators of the femoral prosthesis position were measured. Periprosthetic bone remodeling was assessed via bone mineral density (BMD) measurements. RESULTS The mean preoperative HHS of the CFP group and ribbed group were no significantly different (P=0.570). The neck-shaft angle in the ribbed group was significantly greater than in the CFP group (P<0.001). The CFP group had a greater offset (P<0.001). There was no significant difference in leg-length discrepancy (P=0.727) or Engh score between the 2 groups at the last follow-up (P=0.858). The preoperative BMD was increased at the last follow-up in Gruen zones 3 and 5 (P<0.05) and decreased in Gruen zones 1 and 7 (P<0.05) on the CFP side. BMD was increased in Gruen zone 4 (P=0.007) on the ribbed side. Pearson correlations and rate of complications were not significantly different. CONCLUSIONS Both the CFP and ribbed stem significantly improved the preoperative HHSs and OHSs. The bone remodeling of the CFP stem was more concentrated in the middle and distal regions of the prosthesis, while that of the ribbed stem was more concentrated in the proximal portion of the prosthesis.

Femoral Stress Changes after Total Hip Arthroplasty with the Ribbed Prosthesis: A Finite Element Analysis

Background

A total hip reconstruction is related to the stress distribution throughout the prosthesis, cement, and femur. Researches on reducing the stress in all components to minimize the risk of failure are of great significance. The objective of our study was to determine the biomechanical variation in overall femoral stress and periprosthetic femoral stress distribution after implantation with the Ribbed anatomic prosthesis.

Methods

Three-dimensional finite element models of intact femur and Ribbed prosthesis were developed according to the morphology, while the hip joint loading and the strength of related muscles were applied in the models. The overall stress changes of the intact femur before and after the implantation were analyzed, and the periprosthetic stress distribution especially in the proximal region of the femur was quantified.

Results

As a result, the overall stress pattern of the femur did not change after the implantation compared with the intact femur. The region of peak stress value was located in the middle and lower segments of the full length femur, but the stress value level decreased. The final prosthesis resulted in a significant decrease in the equivalent stress level of the periprosthetic bone tissue, and the most severe area appeared at the endmost posterior quadrant. The stress shielding ratio of the Ribbed prosthesis was 71.6%. The stress value level gradually increased towards the distal part of the prosthesis and recovered to physiological level at the end of the prosthesis.

Conclusions

The Ribbed prosthesis can cause significant stress shielding effect in the proximal femur. These results may help optimize prosthetic design to reduce stress shielding effect and improve clinical outcomes.