A comparison of patient-reported outcome measures (PROMs) between short and conventional stem hip replacements: a systematic review and meta-analysis

United States Experience With a Femoral Neck Retaining Total Hip Arthroplasty Stem: A Retrospective Study With Control Comparison From the Literature

BACKGROUND

Femoral neck retaining prostheses have gained popularity in Europe, but the United States has not seen the same trends occurring. Previous reports demonstrate high survivorship for these implants, but to our knowledge, there are no reports examining US data.

METHODS

After institutional review board approval, 824 primary total hip arthroplasties utilizing a femoral neck-retaining prosthesis were examined for femoral component survivorship rates. European studies were systematically reviewed to determine survivorship rates. The data were used to formulate a Kaplan-Meier survivorship curve and compare US data to that of the European studies.

RESULTS

European studies demonstrated survivorship rates for all causes of 97.7 and 99.0% for aseptic loosening at an average of 6 years (range, 4.5 to 10). The current study demonstrated an all-cause 94% Kaplan-Meier survivorship estimate at 5 years and when aseptic loosening only was considered, survivorship increased to 99.4% at 5 years and 98.4% at 11 years.

CONCLUSION

This femoral neck-retaining prosthesis demonstrated excellent survivorship that is comparable to the rates seen in European studies as well as the rates of standard and mid-stem prostheses in the United States.

Stable fixation of an ultra-short femoral neck-preserving hip prosthesis: a 5-year RSA, DXA, and clinical prospective outcome study of 48 patients

BACKGROUND AND PURPOSE

We previously showed promising primary stability and preservation of bone stock with the ultra-short neck-loading hip implant in total hip arthroplasty (THA). The aim of this study was to evaluate clinical outcome, implant stability, and bone mineral density (BMD).

METHODS

50 patients were treated with the ultra-short neck Primoris hip implant at baseline and 48 were available for evaluation at 5-year follow-up. 5 different patient-reported outcome measures (PROMs) including hip-specific scores, disease-specific and generic quality of life outcome measures, and an activity score were used. Furthermore, implant stability using radiostereometric analysis (RSA) and assessment of periprosthetic BMD using dual-energy X-ray absorptiometry (DXA) were applied.

RESULTS

By 1-year follow-up, all PROMs showed improvements and remained high at 5-year follow-up. After initial distal translation (subsidence) and negative rotation around the z-axis (varus tilt) the implant showed stable fixation at 5-year follow-up with no further migration beyond 12 months. In the regions of interest (ROI) 3 and 4, BMD remained stable. In ROI 2, further bone loss of 12% was found at 5-year follow-up.

CONCLUSION

Clinical outcome including PROMs was satisfying throughout the 5-year follow-up period. The hip implant remains stable with both bone preservation and loss 5 years after surgery.

No significant differences in 60-day postoperative complication rates between conventional and shortened stems

PURPOSE

To compare 60-day complication rates, radiographic outcomes, and clinical outcomes following primary THA with conventional versus shortened stems, in a large cohort study.

METHODS

The authors reviewed a consecutive series of 800 primary THAs, of which 781 met the inclusion/exclusion criteria: 395 received a conventional stem and 386 received a shortened stem. Intraoperative and postoperative complications were noted. Radiographic and clinical assessments were performed preoperatively and 60 days after surgery.

RESULTS

Compared to conventional stems, shortened stems had significantly less intraoperative complications (2.8% vs 0.3%, p = 0.006), but no significant differences in complications that did not require reoperation (1.0% vs 1.3%, p = 0.620), complications that required reoperation without stem revision (2.0% vs 1.0%, p = 0.384), and complications that required stem revision (0.5% vs 0.5%, p = 1.000). Four hips (two from each group) required stem revision and were thus excluded from 60-day assessment. There were no significant differences between groups in subsidence ≥ 3 mm (1.0% vs 0.5%, p = 0.686), alignment (90.3%vs 86.7%, p = 0.192), net change in offset (within 3 mm, 32.3% vs 30.5%, p = 0.097), and limb length discrepancy (3.0 ± 2.6 mm vs 2.9 ± 2.4 mm, p = 0.695). Compared to conventional stems, shortened stems had significantly better preoperative mHHS (56.5 ± 18.5 vs 64.5 ± 13.5, p < 0.001), and significantly lower net improvement in mHHS (29.9 ± 17.1 vs 24.4 ± 15.0, p < 0.001), but no significant differences in postoperative mHHS (87.3 ± 11.9 vs 89.4 ± 9.6, p = 0.109).

CONCLUSIONS

There were no significant differences between conventional and shortened stems in terms of postoperative complication rates, radiographic outcomes, and postoperative mHHS. However, patients implanted with shortened stems had less intraoperative complications, but lower net improvement in mHHS.

LEVEL OF EVIDENCE

Level IV, Retrospective comparative cohort study.

Can Arthroplasty Stem Influence Outcome: A Randomized Controlled Trial of Stem Length in Cemented Total Hip Arthroplasty

BACKGROUND

The primary aim was to assess whether a short (125 millimeter (mm)) stem offered an equivalent hip-specific function compared to the standard (150 mm) stem when used for cemented total hip arthroplasty. Secondary aims were to evaluate health-related quality of life, patient satisfaction, stem height and alignment, as well as radiographic loosenings and complications between the two stems.

METHODS

A prospective twin-center double-blind randomized control trial was conducted. During a 15-month period, 220 patients undergoing total hip arthroplasty were randomized to either a standard (n = 110) or a short (n = 110) stem. There were no significant (P ≥ .065) differences in preoperative variables between the groups. Functional outcomes and radiographic assessment were undertaken at a mean of 1 and 2 years.

RESULTS

There were no differences (P = .428) in hip-specific function according to the mean Oxford hip scores at 1 year (primary endpoint) or at 2 years (P = .622) between the groups. The short stem group had greater varus angulation (0.9 degrees, P = .003) when compared to the standard group and were more likely (odds ratio 2.42, P = .002) to have varus stem alignment beyond one standard deviation from the mean. There were no significant (P ≥ .083) differences in the forgotten joint scores, EuroQol-5-Dimension, EuroQol-visual analogue scale, short form 12, patient satisfaction, complications, stem height, or radiolucent zones at 1 or 2 years between the groups.

CONCLUSION

The cemented short stem used in this study had equivalent hip-specific function, health-related quality of life, and patient satisfaction when compared to the standard stem at mean 2 years post operation. However, the short stem was associated with a greater rate of varus malalignment, which may influence future implant survival.

Survival and radioclinical evaluation of the Optimys™ short stem at more than 6years' mean follow-up: A retrospective study of 108 cases

INTRODUCTION

The short stems developed in recent years offer an interesting alternative to standard long stems. The Optimys™ short stem has been widely studied, but not according to the National Institute for Health and Care Excellence (NICE) criteria. We therefore conducted a retrospective study of Optimys™ at a minimum 5years' follow-up, to assess: (1) survival on NICE criteria, (2) complications, (3) functional results, and (4) subsidence, restoration of offset and bone remodeling.

HYPOTHESIS

Optimys™ shows survival comparable to that of other non-cemented standard and short stems, with a<0.5% per year revision rate or<2.5% at 5years on NICE criteria.

MATERIAL AND METHODS

A single-center retrospective study included 108 Optimys™ stems at a mean 76.5months' follow-up (range: 60-112months). Clinical [Harris, Oxford-12 and forgotten hip (French version: SHO-12) scores] and radiologic data were collected pre- and postoperatively. Analysis focused on implant survival, complications, functional results and radiological results (restoration of offset, bone remodeling, subsidence and osseointegration) and risk factors for stem migration.

RESULTS

At a mean 76.5months' follow-up (range: 60-112months), Optimys™ survival was 97.7% (95% CI: 0.945-1). Oxford and Harris scores improved significantly: respectively, 16.1 vs. 44.7 [Δ=28.598; 95% CI: 27.410-29.785 (p<0.001)] and 45.3 vs. 95 [Δ=49.662; 95% CI: 47.442-51.882 (p<0.001)]. Mean forgotten hip score (SHO-12) at last follow-up was 82.7±19.6 (range: 35.4-100.0). There was 1 case of aseptic revision at 11months for femoral osseointegration defect. Mean subsidence was 1.64mm (range: 0-20.63mm); no predisposing factors could be identified. Femoral offset increased by a mean 2.41±4.53mm (range: -10.10 to 14.70mm).

CONCLUSION

The present study reports good survival for the Optimys™ stem, which meets NICE criteria. Radiologic and clinical results were encouraging, with a low rate of subsidence, comparable to other series, but with increased femoral offset.

LEVEL OF EVIDENCE

IV; retrospective cohort study.

Survivorship and Outcomes of Femoral Neck Preserving Stems in Primary Total Hip Arthroplasty

BACKGROUND

Short-stem femoral implants (SSFIs) promote the preservation of bone in the femoral neck, reduce soft tissue disruption, and facilitate minimally invasive surgical techniques. The purpose of this study was to report the revision rate, complication rate, patient satisfaction, patient-reported outcomes, and radiographic outcomes of patients who underwent total hip arthroplasty (THA) with the Alteon Neck Preserving Femoral Stem (ANPS).

METHODS

A prospectively maintained database was reviewed which analyzed 92 THAs between the years 2016 and 2018. Patient-reported outcomes, patient satisfaction, complication rates, and radiographic outcomes were assessed at 2-5 years postoperatively.

RESULTS

The final cohort consisted of 63 hips. Five patients (7.9%) underwent revision surgery and 2 (3.2%) had other complications not requiring revision. Survivorship when considering only the femoral component was 93.7% at an average of 41.4 months of follow-up. The average postoperative Oxford Hip Score (41.5 ± 8.3) and Harris Hip Score (77.9 ± 16.6) demonstrated significant improvement among our nonrevised patients, respectively (P < .001). Radiographs demonstrated spot welding in 56% of arthroplasties most commonly in Gruen Zones 2, 3, and 13 and that femur radiolucencies were visualized in 58% predominantly along the distal aspect of the stem. Radiographic femoral component subsidence was present in 9.7% of patients.

CONCLUSION

The ANPS may be less reliable than previously reported. Our cohort's revision rate was unacceptably high with 6.3% requiring revision surgery for femoral component loosening in less than 5 years. Surgeons should consider the challenges and prohibitive failure rate associated with SSFIs before routine usage in THA.

Continuous periprosthetic bone loss but preserved stability for a collum femoris-preserving stem: follow-up of a prospective cohort study of 21 patients with dualenergy X-ray absorptiometry and radiostereometric analysis with minimum 8 years of follow-up

Background and purpose - We previously described a decrease in bone mineral density (BMD) in the calcar region 2 years after insertion of the collum femoris-preserving (CFP) stem, but the implants were stable. Now we have examined the long-term changes in periprosthetic BMD and stability of the CFP stem. Patients and methods - We conducted a minimum 8-year follow-up of 21 patients from our original investigation. We examined periprosthetic BMD by dual-energy X-ray absorptiometry (DEXA) and implant stability by radiostereometric analysis (RSA). Results - Between 2 and 8 years 1 stem was revised due to aseptic loosening. Between 2 and 8 years we found a 14% (95% confidence interval [CI] 9-19) reduction in BMD in Gruen zone 6 and 17% (CI 6-28) in Gruen zone 7. From baseline the reduction in BMD was 30% (CI 23-36) in Gruen zone 6, 39% (CI 31-47) in Gruen zone 7, and 19% (CI 14-23) in Gruen zone 2. Between 2 and 8 years, RSA (n = 17) showed a mean translation along the stem axis of 0.02mm (CI -0.02 to 0.06) and a mean rotation around the stem axis of 0.08° (CI -0.26 to 0.41). From baseline mean subsidence was 0.07 mm (CI -0.16 to 0.03) and mean rotation around the stem axis was 0.23° (CI -0.23 to 0.68) at 8 years. Interpretation - There was continuous loss of proximomedial BMD at 8 years while the CFP stem remained stable. Proximal periprosthetic bone loss cannot be prevented by this stem.

Patient-reported results of simultaneous direct anterior approach and posterolateral approach total hip arthroplasties performed in the same patients

BACKGROUND

Several studies have compared clinical results of the direct anterior approach (DAA) and the posterolateral approach (PLA) in total hip arthroplasty (THA); however, the effect of the surgical approach on outcome of THA remains controversial. Most of these studies used two distinct groups of patients, and THAs were performed by different surgeons, using different designs of prosthesis. These confounding factors may limit the strength of the conclusions. The purpose of this prospective, simultaneous bilateral randomized study was to investigate whether patients would perceive the difference between the direct anterior approach (DAA) and the posterolateral approach (PLA) after THA.

MATERIALS AND METHODS

Among 20 patients scheduled to undergo same-day bilateral THA between October 2017 and August 2019, one hip was randomly assigned to DAA and the other to PLA. Patient-reported outcome measures [Hip disability and Osteoarthritis Outcome Score (HOOS), patients' hip pain on mobilization] and physician-assessed measures [Harris Hip Score (HHS), operative time, intraoperative blood loss, cup abduction, cup anteversion, stem orientation, and incidence of complications (intraoperative fracture, nerve damage, incisional problem, or postoperative dislocation)] were compared.

RESULTS

All patients were followed up for 12 months. Hip pain was significantly less with DAA-THA compared with PLA-THA at postoperative 1, 3, and 7 days (p < 0.05). There was no clinical difference between DAA-THA and PLA-THA in terms of the VAS, HOOS, or HSS at 6 weeks and 3, 6, and 12 months postoperatively (p > 0.05). DAA-THA had a longer operative time and shorter length of incision compared with PLA-THA. There was no statistical difference between DAA-THA and PLA-THA in terms of intraoperative blood loss, cup abduction, cup anteversion, stem orientation, and perioperative complications (p > 0.05).

CONCLUSIONS

This study demonstrates that DAA-THA and PLA-THA could provide comparable HHS and HOOS at all follow-ups. Compared with PLA-THA, DAA-THA is associated with less hip pain within postoperative 7 days and shorter incision length, but longer operative time.

LEVEL OF EVIDENCE

Level I, therapeutic study. Trial registration Chinese Clinical Trail Registry, ChiCTR1800019816. Registered 30 November 2018-retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=30863.

PROMIS Global-10 poorly correlates with legacy outcomes for patients undergoing hip arthroscopy

The Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 assesses generic-related quality of life, but has not been well studied in the orthopaedic literature. The purpose was to compare PROMIS Global-10 and legacy hip-specific patient-reported outcome measures (PROMs) in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). This study included patients who underwent primary hip arthroscopy with complete preoperative and 6-month post-operative follow-up. PROMIS Global-10 Physical (PROMIS-P) and Mental (PROMIS-M) components, as well as the modified Harris hip score (mHHS) and International Hip Outcome Tool-33 (iHOT-33) were assessed. PROM analysis included: post-operative changes, correlations, floor and ceiling effects and responsiveness. Final analysis included 112 patients. Average age and body mass index were 36.1±11.7 years and 24.8±3.9 kg/m², respectively. All 6-month PROMs, except PROMIS-M, were significantly improved compared to preoperative level (P<0.02). Preoperatively, PROMIS-P was poorly correlated with mHHS and iHOT-33 (r_s <0.4) whereas PROMIS-M was only poorly correlated with iHOT-33 (r_s <0.4, 95% CI of 0.02–0.37). Post-operatively, the iHOT-33 was poorly correlated with both PROMIS measures (r_s <0.4). The mHHS was fairly correlated with both PROMIS measures (r_s <0.6) post-operatively. The effect sizes for mHHS and iHOT-33 were high (d=1.2 and 1.40, respectively), whereas the effect sizes for PROMIS Global-10 were small (d<0.3). PROMIS Global-10 demonstrated lower effect sizes and poor to fair correlation with legacy hip-specific PROMs, and appears to have a limited role in the assessment of patients undergoing hip arthroscopy for FAIS. Therefore, the PROMIS Global-10 may have a limited role in assessing patients with FAIS.

Evaluation of the learning curve and initial outcomes with a short cervicometaphyseal fixation stem: A case series

INTRODUCTION

Total hip arthroplasty in young patients has evolved in recent decades, and the use of short stems in young adult patients has been gaining popularity. The restitution of the biomechanics of the hip is a primary requirement to determine the future success of total hip replacement, and even more so in young adults who present the particularity of having a high functional demand and a long life expectancy.

OBJECTIVE

The aim of this prospective study was to evaluate the learning curve and initial clinical-radiological outcomes of the Alteon Neck Preserving Stem™ (ANPS) (Exactech, Gainesville, FL, USA) with a minimum of 2 years follow up.

MATERIAL AND METHODS

We conducted a multicenter prospective study that analyzed 90 consecutive total hip replacements during 2014. We performed a clinical-radiological analysis measuring Harris Hip Score (HHS), subjective Rodes and Maudsley satisfaction evaluation, radiolucencies, components position, limb length discrepancy, heterotopic ossification, medical and surgical complications and learning curve.

RESULTS

During the first 30 cases, the intraoperative complication rate was 16%, while in the next 60 cases no intraoperative complications were reported. Thigh pain was reported in 3 cases (3.3%), being 2 moderates, and 1 severe. In 2 cases subsidences of 3 mm were detected in the first scheduled X-ray, both related to intraoperative fractures with no progression after 3 months. Mean HHS improved from 42.9 points (range 37-54 points) preoperatively to 93.2 on average (range, 87-96) at the end of the follow up (p < 0.01). Subjective evaluation was excellent in 75 (83.3%) cases and good in 15 patients (16.6%).

CONCLUSIONS

This short stem has good clinical radiological results in a short and medium term follow-up and in the hands of surgeons specializing in arthroplasty the learning curve is estimated to be less than 30 surgeries.

Total Joint Replacement of Ankle, Knee, and Hip: How Do Patients Perceive Their Operative Outcomes at 10 Years?

Background:

Patient-reported outcomes (PROMs) are an integral part of national joint registers in measuring outcomes of operative procedures and improving quality of care. There is lack of literature comparing outcomes of total ankle replacement (TAR) to total knee replacement (TKR) and total hip replacement (THR). The aim of this study was to compare PROMs between TAR, TKR, and THR patient groups at 1, 5, and 10 years.

Methods:

Prospective PROMs from patients who underwent a TAR, TKR, or THR procedure between 2003 and 2010 were studied. Patients were divided into 3 groups based on their index joint replacement (hip, knee, or ankle). Patient demographics (age, gender, body mass index), patient-reported outcome scores (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], 36-Item Short Form Health Survey [SF-36]) and patient satisfaction scores (4-point Likert scale) at follow-up were compared between the 3 groups.

Results:

Data was available on 1797 THR, 2475 TKR, and 146 TAR patients. TAR patients were younger and reported fewer number of comorbidities. All 3 groups improved significantly from preoperative to 10 years for WOMAC scores (P < .001). For SF-36 scores at 10 years, the THR group (32.2% follow-up) scored the highest for 3 domains (P = .031) when compared to the TKR group (29.1% follow-up). All 3 groups had similar outcomes for 5 of 8 domains; P < .05). For patient satisfaction, the THR group reported overall 95.1% satisfaction followed by 89.8% for the TKR group and 83.9% in the TAR group (42.4% follow-up).

Conclusion:

In this cohort with diminishing numbers over the decade of time the patients were followed up we found that patients are equally happy with functional and general health outcomes from total ankle replacement vs other major lower extremity joint replacement. TAR surgery should be considered as a viable treatment option in this patient group.

Level of Evidence:

Level III, retrospective case series.

The impact of reducing the femoral stem length in total hip arthroplasty during gait

AIM

The length of the femoral stem in total hip arthroplasty (THA) is a practical consideration to prevent gait impairment. The aim of this study was to determine if reducing the femoral stem length in THA would lead to impaired gait biomechanics.

METHODS

Patients uniformly with the same brand implant of differing lengths (100 mm vs 140-166 mm) were taken retrospectively from a prospective trial introducing a new short stem. Twelve patients without any other disorder to alter gait besides contralateral differing length stem THA were tested at differing gradients and speed on a validated instrumented treadmill measuring ground reaction forces. An anthropometrically similar group of healthy controls were analysed to compare.

RESULTS

With the same posterior surgical approach, the offset and length of both hips were reconstructed within 5 mm of each other with an identical mean head size of 36 mm. The short stem was the last procedure for all the hips with gait analysis occurring at a mean of 31 and 79 months postoperatively for the short and long stem THA, respectively. Gait analysis between limbs of both stem lengths demonstrated no statistical difference during any walking condition. In the 90 gait assessments with three loading variables, the short stem was the favoured side 51% of the time compared 49% for the long stem.

CONCLUSION

By testing a range of practical walking activities, no lower limb loading differences can be observed by reducing the femoral stem length. A shorter stem demonstrates equivalence in preference during gait when compared to a reputable conventional stem in total hip arthroplasty.