Patient satisfaction and total hip arthroplasty: a review

Robotic-assistance did not reduce complications in total hip arthroplasty

Aims & objectives

Robotic-assisted total hip arthroplasty (rTHA) is an increasingly common method of joint arthroplasty used to improve surgical accuracy and reduce human error. Despite not having compelling clinical data on long-term complications or outcomes to justify additional time costs, its rate of use is increasing. In this study we compare the longitudinal rates of complications between patients undergoing conventional total hip arthroplasty (cTHA) and rTHA.

Materials & methods

Data from the TriNetX Research Network identified subjects with at least 5 years of patient follow up data through electronic health records. The first cohort were patients undergoing cTHA, and the second cohort included patients undergoing rTHA. Propensity score matching of known factors that can affect clinical outcomes at 1:1 ratio was performed to reduce confounding variables. Records with conditions unrelated to primary THA such as pathological fracture or revision arthroplasty were excluded. Rates of complication in five outcomes were observed at 1, 3 and 5 years: prosthetic joint infection, dislocation, revision, loosening, and periprosthetic fracture.

Results

The database contained 95,085 THA patients. Analysis was performed with 2241 patients in each matched cohort. At 5 years, there was no difference in all-cause complications between the cTHA cohort and rTHA cohort [OR (95 % CI), 1.073 (0.772-1.491)]. Also, no differences were noted in rates of revision [OR (95 % CI), 1.1.604(0.726, 3.543)] or dislocation [OR (95 % CI), 1.775(0.976, 3.228)].

Conclusion

Despite evidence for improved surgical accuracy and reduced errors, robotic assistance did not reduce the rate of complications over a 5-year period after total hip arthroplasty.

The Patient Acceptable Symptom State (PASS) has Little Utility Before Total Hip or Knee Arthroplasty

BACKGROUND

A better understanding of patient's a preoperative symptom state may assist in a more holistic evaluation of patients pursuing total joint arthroplasty (TJA). This study aimed to determine factors associated with preoperative Patient Acceptable Symptom State (PASS) scores in TJA patients and to determine the predictive ability of patient-reported outcome measures (PROMs) for achieving PASS preoperatively.

METHODS

All patients undergoing primary, elective TJA between January and October 2021 at a single institution and who had completed a preoperative PASS, preoperative Patient-Reported Outcome Measurement Information System (PROMIS) questionnaires, and joint-specific PROMs were eligible for inclusion. Descriptive statistics and independent samples t-tests were utilized. Receiver operating characteristic curves and area under the curve analyses were created to determine threshold values for PROMs representing PASS achievement.

RESULTS

A total of 287 total hip arthroplasty (THA) patients and 378 total knee arthroplasty (TKA) patients completed PASS preoperatively, with 12.9% of THA patients and 29.6% of TKA patients reporting acceptable symptom states. The PASS responses were associated with PROMIS Physical Function (PROMIS-PF) (P < 0.001) but not Hip Dysfunction and Osteoarthritis Score, Joint Replacement (P = 0.073) scores in THA. The PASS responses were similarly associated with PROMIS-PF (P < 0.010) as well as Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (P = 0.030) scores in TKA. The Hip Dysfunction and Osteoarthritis Score, Joint Replacement and PROMIS-PF threshold values of 55.6 and 40, respectively, only weakly predicted preoperative PASS achievement in THA. The Knee Injury and Osteoarthritis Outcome Score, Joint Replacement and PROMIS-PF threshold values of 52.5 and 39, respectively, only weakly predicted preoperative PASS achievement in TKA.

CONCLUSIONS

In patients undergoing THA or TKA, 12.9 and 29.6% of patients were satisfied with their symptoms before surgery, respectively. None of the threshold values for the assessed PROMs strongly predict PASS achievement. Given that not all patients indicated for TJA reported unacceptable health states, these findings question the validity of the PASS questionnaire preoperatively.

Relationship between stem-bone contact patterns and clinical outcomes of taper-wedged stem designed to fit the bone morphology of the Japanese

INTRODUCTION

Taper-wedged stems have a stable fit and favorable clinical results. However, detailed studies on stem-bone contact patterns and clinical outcomes specific to Japanese patients are limited. This study aimed to describe stem-bone contact patterns and assess clinical outcomes in Japanese patients undergoing primary total hip arthroplasty (THA) with taper-wedged stems designed to fit the bone morphology of the Japanese population.

METHODS

We retrospectively reviewed 125 Japanese patients who underwent THA via a direct anterior approach using taper-wedged stems designed to fit the bone morphology of the Japanese population. Relationships between stem-bone contact patterns and clinical and radiographic outcomes were examined. Preoperative radiographs were evaluated to assess femoral morphology. Postoperative radiographs were evaluated to determine stem-bone contact patterns and the canal filling ratio. We divided the patients into proximal and distal fitting groups according to the stem-bone contact pattern. Osseointegration was assessed on the last follow-up radiograph using the Engh and O-SS scores.

RESULTS

The mean follow-up period was 5.1 years. Proximal femoral stem-bone contact was achieved in 90.4% of the cases. Both groups had good clinical and radiographic outcomes. Except for differences in preoperative bone morphology, there were no differences in demographics or clinical outcomes between the groups. The distal fitting type was more common in cases with champagne flute morphology. No aseptic loosening or revision was observed, and good osseointegration was obtained in either group.

CONCLUSION

THA with taper-wedged stems designed to fit the bone morphology of Japanese patients achieved favorable stem-bone contact patterns and acceptable short- to mid-term clinical and radiographic outcomes. Population-specific implant designs tailored to Japanese bone morphology may improve surgical outcomes and implant longevity.

Patient Personality Influences Early Overall Satisfaction Following Primary Total Hip and Knee Arthroplasty

BACKGROUND

Up to 20% of patients report dissatisfaction following primary total joint arthroplasty (TJA). Patient characteristics, surgical techniques, and clinical outcomes do not fully explain dissatisfaction. Dispositional personality traits are related to health behaviors and outcomes. We evaluated the relationship between patient personality and early overall satisfaction after TJA.

METHODS

Elective unilateral primary TJAs (n = 377) were prospectively enrolled. The sample consisted of 61% women, with an average age and body mass index of 67 years (range, 31 to 89) and 35 (range, 15 to 62), respectively. A validated personality assessment was administered preoperatively. Satisfaction was measured at a mean of 4.8 (range, 2.5 to 6.4) months postoperatively, as were other covariates, including whether expectations for pain and functional improvement were met, joint health scores, mental and physical health, and health literacy. Patient sex, race, age, body mass index, American Society of Anesthesiologists Physical Status classification, surgeon, procedure type, and complications within 90 days of surgery also served as covariates. Variables significantly related to being satisfied with TJA were analyzed using binary logistic regression.

RESULTS

Patient-reported satisfaction was 80% for improvement in recreational activities, 86% for improvement in the ability to perform housework and yardwork, and 93% for pain relief and the overall result of surgery. In multivariable analyses, each unit increase in the personality trait open-mindedness increased overall and pain relief satisfaction by 3.87 and 2.65 times, respectively (P ≤ 0.012), as did each unit increase in expectations being met (2.33 and 5.87 times, respectively, P ≤ 0.001). The area under the receiver operating characteristic curve statistics indicated that accounting for open-mindedness enhanced the classification of satisfied and not satisfied patients beyond accounting for whether expectations were met.

CONCLUSIONS

Patient personality influences early patient-reported satisfaction after TJA, warranting careful consideration when using this metric to assess surgical effectiveness and reimbursement.

Evaluation of the sexual satisfaction quality of female patients and their sexual partners after total hip arthroplasty surgery

OBJECTIVES

This study aims to identify the effects of total hip arthroplasty (THA) on sexual activity and performance in sexually active female patients with hip arthritis and their partners in the early period, focusing on mobility and pain.

PATIENTS AND METHODS

Between January 2014 and December 2020, a total of 60 female patients (mean age: 49.4±4.2 years; range, 30 to 60 years) who were sexually active and underwent THA in our clinic were retrospectively analyzed. The New Sexual Satisfaction Scale (NSSS) and Visual Analog Scale (VAS) for satisfaction were used in sexual functional evaluation. The NSSS and VAS scores at three, six, and 12 months postoperatively were compared. The relationship between sexual functions, demographic data, and duration was analyzed.

RESULTS

The NSSS levels of the cases were 11.5% at three months, 46.2% at the sixth month, and 81.7% at 12 months after surgery. The increase in joint range of motion, which correlated with NSSS, was 21.4% at three months, 62.5% at six months, and 68.4% at 12 months. The NSSS results did not significantly differ among patients with varying demographics (p>0.05). While 21% of the patients had average NSSS during preoperative period, this increased to 61.5% after surgery. The VAS scores before and after THA were 4 and 6, respectively. Significant relations between both self-centered and spouse/partner-centered NSSS of the patients and patients' ease in sexual intercourse (p=0.011 and p=0.002, respectively) and sexual quality (p=0.000 for both) were found after one-year follow-up. Multivariate analysis revealed that patients' ease in sexual intercourse and sexual quality significantly affected self-centered (p=0.047 and p=0.000, respectively) and spouse/partner-centered (p=0.006 and p=0.000, respectively) NSSS of the patients.

CONCLUSION

After THA surgery, sexual activity of female patients gradually increases at three, six, and 12 months in the early period due to decreased pain and increased mobility. In addition, the sexual satisfaction quality of both patients and their sexual partners increases significantly.

Management of post-arthroplasty pain: a narrative review of emerging interventional treatments

Total joint arthroplasties are one of the most common orthopedic procedures with over 1 million total hip and knee arthroplasties performed annually. While the majority of patients experience favorable long-term outcomes, a significant number of patients continue to report persistent pain more than 3 months post-arthroplasty that is unresponsive to conservative treatment. Although current treatment options may seem limited, there are a variety of innovative procedures for the management of post-arthroplasty pain with the overall goal of reducing pain and restoring function. In this review, we outline the work-up for persistent post-arthroplasty pain and provide a review of the literature on interventional treatment modalities consisting of intra-articular steroids, radiofrequency ablation, and neuromodulation for the management of chronic post-arthroplasty pain in the hip, knee, ankle, and shoulder.

Does Replicating Native Hip Biomechanics Improve Patient-Reported Outcome Measures After Total Hip Arthroplasty?

BACKGROUND

Enabling technology, such as computer navigation and robotics, provides more precise implant position, which allows surgeons the ability for personalized alignment in total hip arthroplasty (THA). To date, THA implant position studies have focused on dislocation rates, rather than on patient-reported outcome measures (PROMs). This study evaluated the impact of the THA component position on clinically significant differences in PROMs.

METHODS

A total of 1,682 consecutive primary THAs were retrospectively reviewed. Acetabular and femoral component position as well as femoral offset and leg-length discrepancy (LLD) were measured on all preoperative and postoperative radiographs. Modern PROM scores were evaluated. Minimal clinically important difference (MCID), substantial clinical benefit, and patient-acceptable symptom state values were assessed for applicable PROMs. Univariate and multivariate statistical analyses were performed with P < 0.05 as significant. The mean clinical follow-up was 21.9 months (range, one to 128).

RESULTS

In multivariate analysis, the acetabular component position closer to the native hip center of rotation was associated with a greater probability of achieving the Hip disability and Osteoarthritis Outcome Score for Joint Replacement MCID, substantial clinical benefit, and patient-acceptable symptom state thresholds (P ≤ 0.008). An increase in postoperative femoral offset was associated with achieving the MCID for the University of California Los Angeles activity level and patients being 'very satisfied or satisfied' (P ≤ 0.004). The mean postoperative LLD was 3.8 mm (range, 24.5 mm short to 36.6 mm long); however, postoperative LLD was not a predictor of PROMs (P ≥ 0.167) with statistical power ≥ 87%.

CONCLUSIONS

Study results demonstrated that replicating the native center of rotation and optimizing femoral offset was associated with clinically relevant improvements in PROMs. Interestingly, in this large cohort, leg length inequality was not associated with PROMs. Further research is warranted on THA component position, including spino-pelvic parameters and PROMs.

LEVEL OF EVIDENCE

III.

Temporal Patterns and Treatment Associations in Complications Following Hip Arthroplasty

Background and Objectives: Hip arthroplasty is commonly performed to enhance mobility and quality of life in patients with severe joint degeneration. However, post-surgery complications such as infections, dislocations, and mechanical failures remain prevalent and vary over time. This study examines the relationship between time intervals post-surgery and the occurrence of complications and explores the associations between specific treatment modalities and complications. It also investigates temporal patterns of infectious and mechanical complications to inform more effective post-surgery care. Materials and Methods: A retrospective cohort study was conducted on hip arthroplasty patients to analyze the occurrence and distribution of complications across medium-term (1-5 years) and long-term (≥6 years) intervals. Treatment modalities, including joint debridement, lavage, antibiotics, and mechanical interventions, were analyzed for their association with complications. Chi-Square tests were used, with significance set at p < 0.05. Results: A significant association was found between time intervals and complications (χ2 = 58.149, df = 19, p < 0.001). Infections were more prevalent in the medium-term, while mechanical complications such as dislocation, implant loosening, and periprosthetic fractures were more common in the long-term. Antibiotics were strongly linked to infectious complications (χ2 = 279.000, p < 0.001), and mechanical treatments were associated with fractures and dislocations. Conclusions: The study confirms that the timing of complications post-surgery plays a critical role in their occurrence. Specific complications become more prevalent at different intervals, emphasizing the need for tailored treatment strategies. Antibiotics for infections and mechanical interventions for fractures and dislocations should be adjusted based on timing. These findings highlight the importance of time-specific post-surgery care and suggest areas for further research on long-term strategies and risk factors.

The Choice of Hip Arthroplasty: HRA or THA? Revealed by Meta-Analysis

BACKGROUND

Total hip arthroplasty (THA) is the gold standard for end-stage hip arthrosis, while hip resurfacing arthroplasty (HRA) is considered a more bone-conserving alternative. This meta-analysis aimed to compare the safety and clinical efficacy of HRA and THA.

METHODS

The databases of PubMed, EMBASE, Cochrane Library, and CNKI were searched for RCTs comparing HRA and THA in treating hip arthrosis from database initiation to April 2024. Inclusion and exclusion criteria were defined, and data extraction, quality evaluation, and risk bias assessment were performed. A meta-analysis was conducted using appropriate RevManv5.4 and Stata v14.0 software.

RESULTS

Twenty RCTs from six countries were included. HRA had a similar revision rate, function scores (WOMAC, HSS, OHS, UCLA activity score, EQ-D, EQ-5D VAS), and blood levels of cobalt and chromium compared to THA. HRA had fewer complications and less blood loss but required more operating time.

CONCLUSIONS

HRA is a safe and effective alternative to THA, with similar revision and functional outcomes, less blood loss, and is particularly suitable for young male patients with a demand for high-level activities.

Does Preoperative Bisphosphonate Use Impact the Risk of Periprosthetic Fracture Following Total Hip Arthroplasty?

BACKGROUND

Bisphosphonate (BP) use is not uncommon among total hip arthroplasty (THA) candidates. While the impact of BP therapy post-THA has been investigated, there is a paucity of literature discussing the impact of BP therapy pre-THA. Using a national dataset, we aimed to study the association between preoperative BP use and surgical outcomes in primary THA recipients.

METHODS

This retrospective cohort study used a commercial claims and Medicare Supplemental database to identify adults aged ≥ 18 years who had an index nonfracture-related primary THA from 2016 to 2020. The use of BP was defined as ≥ 6 months of BP therapy in the year prior to THA. Outcomes were 90-day all-cause readmission, 90-day readmission related to periprosthetic fracture (PPF), 90-day and 1-year all-cause revision, 1-year PPF-related revision, and 1-year diagnosis of PPF. In a 1:5 propensity score-matched analysis, each THA patient who had preoperative BP use was matched to five THA patients who did not have preoperative BP use. Logistic regression models were fitted; we report odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Of 91,907 THA patients, 1,018 (1.1%) used BP preoperatively. In the propensity score-matched cohort (1,018 preoperative BP users and 5,090 controls), preoperative BP use was significantly associated with increased odds of 90-day all-cause revision surgery (OR 1.67; 95% CI 1.10 to 2.53; P = 0.02), 1-year PPF-related revision (OR 2.23; 95% CI 1.21 to 4.10; P = 0.01), and 1-year PPF diagnosis (OR 1.88; 95% CI 1.10 to 3.20; P = 0.02). There were no statistically significant associations between preoperative BP use and the other outcomes in the matched cohort.

CONCLUSIONS

These findings suggest that preoperative BP use is associated with an increased risk of revision surgery and PPF in both the short and long term. This information can help in preoperative planning and patient counseling, potentially leading to improved surgical outcomes and reduced complication rates.

A nurse-led approach to enhancing foot and ankle tissue repair: A study using fibroblast growth factor and skin flap technique

INTRODUCTION

Foot and ankle soft tissue defects with exposed bone pose significant challenges in wound healing and patient satisfaction OBJECTIVE: The study aims to assess the impact of nursing care quality and patient satisfaction on optimizing outcomes for complex foot and ankles injuries, focusing on the timing of rh-FGF administration after reconstructive surgery METHODS: This study included eighteen patients (15 males and 3 females) with traumatic foot and ankle soft tissue defects and exposed bone wounds, treated between January 2021 and December 2022. Patients were randomly assigned to three groups, underwent reconstructive surgery, and received rh-bFGF at varying times postoperatively. Key outcomes included wound healing time, hospital stay duration, satisfaction with nursing care scale, American Orthopedic Foot and Ankle Society (AOFAS) score, and Visual Analogue Scale for pain. All patients were followed for at least three months RESULTS: The study population had an average age of 41.1 years, with a range from 16 to 74 years. Findings indicated an average hospital stay of 17 days and a corresponding wound healing time of 17 days. At three months post-operation, the average American Orthopedic Foot and Ankle Society (AOFAS) score was 88. A notable 88.9 % of patients expressed satisfaction with the attentiveness of nursing staff and the privacy afforded to them. Furthermore, 84.3 % rated the nurses' competence positively, and 83.3 % appreciated the support provided to family and friends, along with personalized care and nurses' expertise in patient management. The results demonstrated a consistent trend of improvement in all assessed outcomes across the three treatment groups. Patients in Group 1, who received rh-bFGF one day after surgery, demonstrated the most favorable outcomes. This was followed by Group 3, which received rh-bFGF until ischemic changes were noted. In contrast, Group 2, which received rh-bFGF once inflammatory granulation had subsided, exhibited the least improvement CONCLUSION: The results of this study highlight the crucial role of timing in the administration of rh-bFGF for optimizing soft tissue repair in patients with foot and ankle defects. Timely application of rh-bFGF post-surgery is essential for achieving favorable patient outcomes, improving patient satisfaction with nursing care, and facilitating faster recovery.

The Association of Jumbo Femoral Heads and Acetabular Cup Position on Patient Outcomes After Modern Posterior Approach Total Hip Arthroplasty

BACKGROUND

Use of jumbo femoral heads (≥ 40 mm) in total hip arthroplasty decreases postoperative dislocation; however, may leave patients more susceptible to groin pain. Limited data exist for the effect of jumbo femoral heads and acetabular cup position on modern patient-reported outcome measures (PROMs). This study evaluated the effect of jumbo femoral heads and acetabular cup position on PROMs after primary total hip arthroplasty.

METHODS

A total of 328 consecutive primary THAs of a single implant system with various femoral head sizes (36% ≥ 40 mm) were retrospectively reviewed. Acetabular cup inclination and anteversion were radiographically measured. Demographics, comorbidities, and implant sizes were documented. Prospectively collected University of California Los Angeles Activity Level, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR), and satisfaction were evaluated. The mean follow-up was 1.2 years (range, one to five). A P-value of 0.05 was considered statistically significant.

RESULTS

Femoral head size was not associated with University of California Los AngelesActivity Level scores at any time point (P ≥ 0.209). Independent of patient sex, the mean HOOS JR score was significantly higher in the ≥ 40 mm femoral head group compared to the < 40 mm head group at 4 months although not reaching a clinically significant threshold (mean difference 4.4, 95% CI [confidence interval]: 0.5 to 8.3, P = 0.027); however, mean scores at the latest follow-up were not different (P = 0.956). The HOOS JR scores ≥ 90 and being "very satisfied or satisfied" were associated with a wide range and several combinations of acetabular cup inclination and anteversion. A total of 88.9% of patients reported being "very satisfied or satisfied" at the latest follow-up.

CONCLUSIONS

Patients achieved comparable PROMs regardless of femoral head size, suggesting large femoral heads may not leave patients susceptible to groin pain in addition to reducing the risk of postoperative dislocation. Excellent patient outcomes correlated with wide ranges of acetabular cup positions.

LEVEL OF EVIDENCE

III.

Discharge Disposition after Total Hip Arthroplasty: A 10-Year Analysis of Trends and Predictors of Nonhome Discharge (2011-2021)

BACKGROUND

Total hip arthroplasty (THA) practices are evolving under the influence of the current value-based healthcare system and bundled payment models. This study aimed to (1) evaluate national trends in discharge disposition and postoperative outcomes after THA, (2) compare discharge cohorts on episode-of-care parameters, and (3) determine predictors of nonhome discharge from 2011 to 2021.

METHODS

The National Surgical Quality Improvement Program database was queried for THA data from 2011 to 2021. A total of 328,380 patients undergoing THA were identified between 2011 and 2021. Of these patients, 276,710 were discharged home and 51,670 were discharged to nonhome locations. Trends of annual discharge disposition, healthcare utilization parameters, and proxies for postoperative complications were reported. A multivariable logistic regression analysis was conducted to identify potential risk factors for nonhome discharge.

RESULTS

The percentage of patients who were discharged to home increased from 70.20% in 2011 to 92.42% in 2021. In those discharged to home, 30-day readmission rates, 30-day major complication rates, length of stay, any wound complications, and need for transfusion all decreased within the past decade. The percentage of patients who were discharged to nonhome locations decreased from 29.80% in 2011 to 7.58% in 2021. In this group, major complication rates within 30 days, length of stay, and need for mechanical ventilation increased from 2011 to 2021. Greater age, female sex, body mass index of <18.5, race, smoking, higher comorbidity burden, and functional status were associated with greater odds ratios of nonhome discharge.

CONCLUSION

Home discharge after THA has increased substantially over the past decade, with more than 90% of patients now being discharged home. However, a small subset of higher-risk patients still requires nonhome discharge and experience worse outcomes. Focused efforts based on known discharge risk factors may allow implementing perioperative optimization strategies to further improve outcomes in this population.

Low-grade systemic inflammation, but not neuroinflammation, is associated with 12-month postoperative outcome after total hip arthroplasty in patients with painful osteoarthritis

Aims

Better prediction of outcome after total hip arthroplasty (THA) is warranted. Systemic inflammation and central neuroinflammation are possibly involved in progression of osteoarthritis and pain. We explored whether inflammatory biomarkers in blood and cerebrospinal fluid (CSF) were associated with clinical outcome, and baseline pain or disability, 12 months after THA.

Methods

A total of 50 patients from the Danish Pain Research Biobank (DANPAIN-Biobank) between January and June 2018 were included. Postoperative outcome was assessed as change in Oxford Hip Score (OHS) from baseline to 12 months after THA, pain was assessed on a numerical rating scale, and disability using the Pain Disability Index. Multiple regression models for each clinical outcome were included for biomarkers in blood and CSF, respectively, including age, sex, BMI, and Kellgren-Lawrence score.

Results

Change in OHS was associated with blood concentrations of tumour necrosis factor (TNF), interleukin-8 (IL-8), interleukin-6 receptor (IL-6R), glycoprotein 130 (gp130), and IL-1β (R2 = 0.28, p = 0.006), but not with CSF biomarkers. Baseline pain was associated with blood concentrations of lymphotoxin alpha (LTα), TNFR1, TNFR2, and IL-6R (R2 = 0.37, p < 0.001) and CSF concentrations of TNFR1, TNFR2, IL-6, IL-6R, and IL-1Ra (R2 = 0.40, p = 0.001). Baseline disability was associated with blood concentrations of TNF, LTα, IL-8, IL-6, and IL-1α (R2 = 0.53, p < 0.001) and CSF concentrations of gp130, TNF, and IL-1β (R2 = 0.26, p = 0.002). Thus, preoperative systemic low-grade inflammation predicted 12-month postoperative outcome after THA, and was associated with preoperative pain and disability.

Conclusion

This study highlights the importance of systemic inflammation in osteoarthritis, and presents a possible path for better patient selection for THA in the future. Preoperative central neuroinflammation was associated with preoperative pain and disability, but not change in OHS after THA.

Wear, Material Transfer, and Electrocautery Damage Are Ubiquitous on CoCrMo Femoral Knee Retrievals

Despite high total knee arthroplasty (TKA) survivorship after 10 years (92%-99%), a gap persists where patient satisfaction lags clinical success. Additionally, while cobalt chrome molybdenum (CoCrMo) use decreases in primary total hip arthroplasty, the alloy continues to be widely used in TKA femoral components. In vivo, CoCrMo degradation may be associated with adverse local tissue reactions (ALTR) and compared with the hip, the damage mechanisms that may release metal in the knee and the potential biological effects remain poorly understood. In this study, we characterized the damage on 50 retrieved CoCrMo femoral knee implants paired with 19 titanium alloy and 31 CoCrMo tibial baseplates. We asked (1) what damage modes can release CoCrMo debris in vivo from femoral components and (2) how frequently does the damage occur? First, we developed a semiquantitative scoring system for abrasive wear. Then, we characterized damage modes on CoCrMo femoral implants using digital optical microscopy (DOM), scanning electron microscopy (SEM), and energy dispersive X-ray spectroscopy (EDS). We found that wear, electrocautery damage, and Ti-6Al-4V material transfer were ubiquitous. Of the 50 CoCrMo femoral implants we investigated, we documented wear on 100% (n = 50/50), electrocautery damage on 98% (n = 49/50), and Ti-6Al-4V material transfer to the posterior condyles on 95% (n = 18/19). Our results suggest that these damage modes may be more prevalent than previously thought and may act as metal release mechanisms in vivo.

Translation of a Dutch Version of the Total Shoulder Arthroplasty Postoperative Satisfaction Questionnaire

To our knowledge, no Dutch questionnaires exist to administer patient satisfaction after total shoulder arthroplasty. The goal of this study is to develop a Dutch translation of the satisfaction questionnaire used by Swarup et al. (2017)1, into Dutch. This ensures the suitability for clinical application an application in research in all Dutch-speaking regions worldwide. A forward-backward translation approach was used. The clarity of the pre-final version was tested on 8-35 post-operative total shoulder arthroplasty patients. The responses of the patients were studied at one single time point. The Dutch translation of the satisfaction questionnaire proposed by Swarup et al. (2017)1 was considered clear to more than 80% of patients, which was set as norm value where the questionnaire can be assumed clear and understable. The Dutch translation of the postoperative satisfaction questionnaire by Swarup et al. (2017)1 met the 80% clarity criterion and can be considered clear. This study provides a base for future research assessing the psychometric properties of this questionnaire.

No difference in early functional outcome between the direct anterior approach and posterior approach in patients following total hip arthroplasty

BACKGROUND

Objective and subjective outcomes in the direct anterior approach (DAA) and posterior approach (PA) in total hip arthroplasty (THA) were assessed in this study, using the Oxford Hip Score (OHS) as primary outcome. Pain, 3 objective performance-based tests, surgical time, blood loss and length of stay were assessed as secondary outcomes.

METHODS

Patients with primary end-stage osteoarthritis were prospectively enrolled by shared decision making for the DAA (32 patients) or PA (26 patients). Baseline data were collected preoperatively and outcomes postoperatively at 2-, 6-, 9- and 12-month follow-up.

RESULTS

There is no significant difference (p < 0.05) between the DAA and PA on primary outcome (OHS). There was a main effect of time which indicated an increase of OHS over time independent of group (p < 0.01).

CONCLUSIONS

In the current study, no significant differences in postoperative functional outcome were found between DAA and PA in all follow-up moments.

Defining patient satisfaction after reverse total shoulder arthroplasty: a systematic review

BACKGROUND

The prevalence of reverse total shoulder arthroplasty (rTSA) has grown rapidly. As indications for the procedure expand, the proportion of patients who have satisfactory outcomes after rTSA has not been well defined. This systematic literature review explores overall patient satisfaction after rTSA and defines patient satisfaction based on indication for surgery.

METHODS

A literature search was performed for studies describing patient satisfaction after rTSA in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Papers were included if they investigated patient satisfaction after rTSA at a minimum of 2-year follow-up. Data were collected on patient demographics, including age, gender, and body mass index. Follow-up duration, indication for surgery, and patient reported outcome measures relating to patient satisfaction were also recorded.

RESULTS

There were a total of 5234 patients and 5288 shoulders from the 45 included studies. The overall study population was 61.2% female and the average age was 71.1 years (range 23-99). Satisfaction results were recorded at final follow-up, with average follow-up of 49.1 months (range 24-228). Overall patient satisfaction ranged from 77.7% to 87.8%, depending on patient satisfaction patient reported outcome measures. When stratified by diagnosis, patients with a diagnosis of glenohumeral osteoarthritis (GHOA) rated better satisfaction on all metrics when compared to patients with a diagnosis of cuff tear arthropathy or massive rotator cuff tear.

CONCLUSION

This systematic review demonstrated that patients who undergo rTSA for either GHOA, cuff tear arthropathy, or massive rotator cuff tear are generally satisfied with their procedure, with the rate of satisfaction highest in GHOA. Focusing on patient satisfaction may provide the best overall assessment of health care quality in a very understandable and tangible form. Overall satisfaction rate is valuable information for patient education and can be utilized as part of effective surgical counseling.

Decreased Instability in High-Risk (Hip-Spine 2B) Patients After Modifications of Surgical Planning and Technique

BACKGROUND

Patients undergoing primary total hip arthroplasty (THA) who have spinal deformity and a stiff spine are the highest-risk group for instability. Despite the increasing use of dual-mobility cups and large femoral heads, dislocation remains a major complication after THA. Preoperative planning becomes a critical aspect of ensuring precise component positioning within a safe zone. The purpose of this study was to investigate dislocation rates over a 9-year period.

METHODS

A retrospective review of 4,731 THAs performed by 3 orthopaedic surgeons between January 2014 and March 2023 was performed. Spinopelvic measurements were conducted to determine the hip-spine classification group for each patient. Only patients classified as 2B (pelvic incidence-lumbar lordosis > 10° and Δsacral slope < 10°) were eligible. Both absolute and relative dislocation frequencies were then analyzed using time-series analysis techniques and Fisher's exact tests.

RESULTS

A total of 281 hip-spine 2B patients undergoing primary THA were eligible for analysis (57% women; mean age, range: 66 years, 23 to 87; mean body mass index, range: 28, 16 to 45). The overall dislocation rate was 4.3%. Use of femoral head sizes ≥ 40 mm increased from 4% in 2014 to 2019 to 37% in 2020 to 2023 (P < .001), while the use of dual-mobility cups decreased from 100% in 2014 to 2019 to 37% in 2020 to 2023 (P < .001). Acetabular component planning was changed from the supine plane to the standing plane in February 2020. Those changes in surgical practice were notably correlated with a significant decrease in dislocation rates from 6.8% in 2014 to 2019 to 1.5% in 2020 to 2023 (P = .03).

CONCLUSIONS

Our study demonstrates that the introduction of advanced preoperative THA planning to the standing plane, coupled with precise intraoperative technology for implant placement, can significantly reduce the risk of instability in high-risk THA patients. Notably, we observed a significant decrease in dislocation rates, which aligned with the shift in surgical practice.

LEVEL OF EVIDENCE

IV.

Mid-Term Migration Pattern of a Cemented Collared Anatomical Stem-A Retrospective Study Using EBRA-FCA

Background: Aseptic loosening is one of the leading causes of stem revision. Einzel Bild Röntgen Analyse-Femoral Component Analysis allows for the detection of distal stem migration, which is used as a predictive factor for implant longevity. This study aims to demonstrate the migration behavior of a cemented collared anatomical stem. Methods: This study retrospectively examined all patients who received a cemented Lubinus SP II stem (Waldemar Link, Hamburg, Germany) between 2003 and 2019. We used the EBRA-FCA software (University of Innsbruck, Austria) to determine the migration patterns and thoroughly examined the patients' medical histories. In addition, the potential influence of femoral configuration and BMI on the migration behavior was assessed. Results: This study included 61 patients (48 females and 13 males) with a total of 61 stems that met our inclusion criteria. The mean age at surgery was 76 years (ranging from 30 to 93 years). According to EBRA-FCA migration analysis, a median subsidence of 0.7 mm was observed at 24 months and at the final follow-up (median 78 months). Distal stem migration was significantly higher at the 6-month time point in patients with Dorr type A femurs compared to Dorr type B femurs (p = 0.016). Body mass index (BMI) had no significant effect on stem migration. Conclusions: The measured subsidence of the Lubinus SP 2 stem using EBRA-FCA was below established thresholds, indicating excellent long-term outcomes. Although there was significantly increased subsidence in Dorr type A femurs during the initial 6 months, thereafter, no statistically significant difference was observed compared to Dorr type B femurs.

Patient Demographic Factors Affect Response Rates to Patient-Reported Outcome Measures for Total Hip Arthroplasty Patients

BACKGROUND

The Hip Disability and Osteoarthritis Outcome Score (HOOS JR) is a widely used patient-reported outcome measures questionnaire for total hip arthroplasty (THA). However, not all patients choose to complete HOOS JR, and thus, a subset of the THA population may be underrepresented. This study aims to investigate the association between patient demographic factors and HOOS JR response rates.

METHODS

This was a retrospective cohort study of adult, English-speaking patients who underwent primary THA by a fellowship-trained arthroplasty surgeon between 2017 and 2023 at a single, high-volume academic institution. The HOOS JR completion status-complete or incomplete-was recorded for each patient within 90 days of surgery. Standard statistical analyses were performed to assess completion against multiple patient demographic factors.

RESULTS

Of the 2,908 total patients, 2,112 (72.6%) had complete and 796 (27.4%) had incomplete HOOS JR questionnaires. Multivariate analysis yielded statistical significance (P < .05) for the distribution of patient age, race, insurance, marital status, and income quartile with respect to questionnaire completion. Patient sex or religion did not affect response rates. Failure to complete HOOS JR (all P < .001) was associated with patients aged 18 to 39 (59.8%), who identified as Black (36.4%) or "other" race (39.6%), were never married (38%), and were in the lower half income quartiles (43.9%, 35.9%) when compared to the overall incomplete rate.

CONCLUSIONS

Multiple patient demographic factors may affect the HOOS JR response rate. Overall, our analyses suggest that older patients who identify as White and are of higher socioeconomic status are more likely to participate in the questionnaire. Efforts should focus on capturing patient groups less likely to participate to elucidate more generalizable trends in arthroplasty outcomes.

Comparative Study of Alternative Methods for Measuring Leg Length Discrepancy after Robot-Assisted Total Hip Arthroplasty

BACKGROUND

Our study addresses the lack of consensus on measuring leg length discrepancy (LLD) after total hip arthroplasty (THA). We will assess the inter-observer variability and correlation between the five most commonly used LLD methods and investigate the use of trigonometric principles in overcoming the limitations of current techniques.

METHODS

LLD was measured on postoperative AP pelvic radiographs using five conventional methods. CT images created a 3D computer model of the pelvis and femur. The resulting models were projected onto a 2D, used to measure LLD by the five methods. The measurements were evaluated via Taguchi analysis, a statistical method identifying the process's most influential factors. The approach was used to assess the new trigonometric method.

RESULTS

Conventional methods demonstrated poor correlation. Methods referenced to the centers of the femoral heads were insensitive to LLD originating outside the acetabular cup. Methods referencing either the inter-ischial line or the inter-obturator foramina to the lesser trochanter were sensitive to acetabular and femoral components. Trigonometry-based measurements showed a higher correlation.

CONCLUSIONS

Our results underscore clinicians' need to specify the methods used to assess LLD. Applying trigonometric principles was shown to be accurate and reliable, but it was contingent on proper radiographic alignment.

Total Hip Arthroplasty Combined with Proximal Femoral Reconstruction Effectively Treats Severe Hip Deformities: A Novel Osteotomy Technique

OBJECTIVE

Total hip arthroplasty (THA) combined with proximal femoral reconstruction is a novel osteotomy technique developed to address severe hip deformities. There is a paucity of robust clinical and radiological evidence regarding the outcomes of this novel osteotomy technique. This study aimed to evaluate the clinical and radiological outcomes of THA combined with proximal femoral reconstruction during the early follow-up.

METHODS

This is a retrospective case series of 63 hips who underwent THA combined with proximal femoral reconstruction at a single institution between January 2020 and July 2023. The mean age of patients was 39.6 ± 12.6 years. The mean follow-up was 25.6 ± 3.8 months. Surgical characteristics and perioperative variables were evaluated to assess the efficacy of this technique. Harris hip score (HHS) was utilized to evaluate hip function. Leg length discrepancy (LLD) was evaluated in X-ray. The incidence of major adverse events including deep vein thrombosis (DVT), osteolysis, nonunion of the osteotomy, intraoperative femoral fracture, and infection was also evaluated. Paired-samples t-test was used to compare preoperative and postoperative HHS and LLD.

RESULTS

The mean operative time was 125.1 min. The mean size of the acetabular components used was 45.2 mm, and the stem size was 7.5. The primary friction interface was ceramic-on-ceramic, accounting for 92.1% of cases. The average length of hospital stay was 8.5 days. The mean cost of treatment was 46,296.0 Yuan. There was a significant improvement in postoperative HHS (p < 0.001) and LLD (p < 0.001) compared to preoperative values. The incidence of deep venous thrombosis was 4.8%; osteolysis rates for the cup and stem were 4.8% and 6.4%, respectively. The non-union and dislocation rates were 1.6% and 3.2%, respectively. There was no incidence of postoperative infection.

CONCLUSION

The novel osteotomy surgical procedure yields reliable and impressive clinical and radiological outcomes, with minimal complications. We advocate for its use in complex primary THA cases involving severe proximal femoral deformities.

Knowledge, attitudes, and practices of orthopedic operating room personnel regarding the use of pneumatic tourniquets

INTRODUCTION

Pneumatic tourniquets (PTs) play a crucial role in hemostasis during orthopedic surgery. This study aimed to investigate the current knowledge, attitudes, and practices (KAP) of orthopedic operating room personnel concerning the use of PTs.

METHODS

This cross-sectional study was conducted from Jul. 2023 to Aug. 2023. An online questionnaire was used to collect demographic information and KAP score data of the orthopedic operating room personnel from Hangzhou Regional Hospitals.

RESULTS

A total of 336 participants included orthopedic physicians (37.8%), orthopedic nurses (31.5%), anesthesiologists (8.9%), operating room nurses (19.9%) and medical students (1.8%). The median knowledge score was 28.5 (24, 32), with a maximum score of 38; the median attitude score was 31 (28, 35), of a maximum of 35; the median practice score was 41 (36, 44), of a maximum of 45. Correlation analysis showed links between knowledge and attitude (r = 0.388, p<0.001), knowledge and practice (r = 0.401, p<0.001), and attitude and practice (r = 0.485, p<0.001). Multivariate logistic regression analysis confirmed that female gender (OR = 0.294, 95% CI: 0.167-0.520; p<0.001), working in a specialized hospital (OR = 0.420, 95% CI: 0.219-0.803; p = 0.009), and occupation as a surgical anesthesiologist (OR = 3.358, 95% CI: 1.466-7.694; p = 0.004) were associated with better knowledge scores. A higher educational degree (OR = 0.237, 95% CI: 0.093-0.608; p = 0.003) was associated with better practice scores. No previous training was associated with lower knowledge (OR = 0.312, 95% CI: 0.187-0.520; p<0.001) and practice (OR = 0.325, 95% CI: 0.203-0.521; p<0.001) scores.

CONCLUSION

Orthopedic personnel in this study had acceptable knowledge, attitude, and practice concerning the use of PTs; additional training and guidance might enhance proficiency.

What Are the Diagnosis-Specific Thresholds of Minimal Clinically Important Difference and Patient Acceptable Symptom State in Hip Disability and Osteoarthritis Outcome Score After Primary Total Hip Arthroplasty?

BACKGROUND

This study aimed to determine the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) thresholds for Hip Disability and Osteoarthritis Outcome Score (HOOS) pain, physical short form (PS), and joint replacement (JR) 1 year after primary total hip arthroplasty stratified by preoperative diagnosis of osteoarthritis (OA) versus non-OA.

METHODS

A prospective institutional cohort of 5,887 patients who underwent primary total hip arthroplasty (January 2016 to December 2018) was included. There were 4,184 patients (77.0%) who completed a one-year follow-up. Demographics, comorbidities, and baseline and one-year HOOS pain, PS, and JR scores were recorded. Patients were stratified by preoperative diagnosis: OA or non-OA. Minimal detectable change (MDC) and MCIDs were estimated using a distribution-based approach. The PASS values were estimated using an anchor-based approach, which corresponded to a response to a satisfaction question at one year post surgery.

RESULTS

The MCID thresholds were slightly higher in the non-OA cohort versus OA patients. (HOOS-Pain: OA: 8.35 versus non-OA: 8.85 points; HOOS-PS: OA: 9.47 versus non-OA: 9.90 points; and HOOS-JR: OA: 7.76 versus non-OA: 8.46 points). Similarly, all MDC thresholds were consistently higher in the non-OA cohort compared to OA patients. The OA cohort exhibited similar or higher PASS thresholds compared to the non-OA cohort for HOOS-Pain (OA: ≥80.6 versus non-OA: ≥77.5 points), HOOS-PS (OA: ≥83.6 versus non-OA: ≥83.6 points), and HOOS-JR (OA: ≥76.8 versus non-OA: ≥73.5 points). A similar percentage of patients achieved MCID and PASS thresholds regardless of preoperative diagnosis.

CONCLUSIONS

While MCID and MDC thresholds for all HOOS subdomains were slightly higher among non-OA than OA patients, PASS thresholds for HOOS pain and JR were slightly higher in the OA group. The absolute magnitude of the difference in these thresholds may not be sufficient to cause major clinical differences. However, these subtle differences may have a significant impact when used as indicators of operative success in a population setting.

Predicting Recovery Following Total Hip and Knee Arthroplasty Using a Clustering Algorithm

Background

Recovery following total joint arthroplasty is patient-specific, yet groups of patients tend to fall into certain similar patterns of recovery. The purpose of this study was to identify and characterize recovery patterns following total hip arthroplasty (THA) and total knee arthroplasty (TKA) using patient-reported outcomes that represent distinct health domains. We hypothesized that recovery patterns could be defined and predicted using preoperative data.

Methods

Adult patients were recruited from a large, urban academic center. To model postoperative responses to THA and TKA across domains such as physical health, mental health, and joint-specific measures, we employed a longitudinal clustering algorithm that incorporates each of these health domains. The clustering algorithm from multiple health domains allows the ability to define distinct recovery trajectories, which could then be predicted from preoperative and perioperative factors using a multinomial regression.

Results

Four hundred forty-one of 1134 patients undergoing THA and 346 of 921 undergoing TKA met eligibility criteria and were used to define distinct patterns of recovery. The clustering algorithm was optimized for 3 distinct patterns of recovery that were observed in THA and TKA patients. Patients recovering from THA were divided into 3 groups: standard responders (50.8%), late mental responders (13.2%), and substandard responders (36.1%). Multivariable, multinomial regression suggested that these 3 groups had defined characteristics. Late mental responders tended to be obese (P = .05) and use more opioids (P = .01). Substandard responders had a larger number of comorbidities (P = .02) and used more opioids (P = .001). Patients recovering from TKA were divided among standard responders (55.8%), poor mental responders (24%), and poor physical responders (20.2%). Poor mental responders were more likely to be female (P = .04) and American Society of Anesthesiologists class III/IV (P = .004). Poor physical responders were more likely to be female (P = .03), younger (P = .04), American Society of Anesthesiologists III/IV (P = .04), use more opioids (P = .02), and be discharged to a nursing facility (P = .001). The THA and TKA models demonstrated areas under the curve of 0.67 and 0.72.

Conclusions

This multidomain, longitudinal clustering analysis defines 3 distinct patterns in the recovery of THA and TKA patients, with most patients in both cohorts experiencing robust improvement, while others had equally well defined yet less optimal recovery trajectories that were either delayed in recovery or failed to achieve a desired outcome. Patients in the delayed recovery and poor outcome groups were slightly different between THA and TKA. These groups of patients with similar recovery patterns were defined by patient characteristics that include potentially modifiable comorbid factors. This research suggests that there are multiple defined recovery trajectories after THA and TKA, which provides a new perspective on THA and TKA recovery.

Level of Evidence

III.

Diagnosis-Specific Thresholds of the Minimal Clinically Important Difference and Patient Acceptable Symptom State for KOOS After Total Knee Arthroplasty

UPDATE

This article was updated on May 1, 2024 because of a previous error, which was discovered after the preliminary version of the article was posted online. The byline that had read "Ahmed K. Emara, MD 1 *, Ignacio Pasqualini, MD 1 *, Alison K. Klika, MS 1 , Melissa N. Orr, BS 1 , Pedro J. Rullán, MD 1 , Nicolas S. Piuzzi, MD 1 , and the Cleveland Clinic Arthroplasty Group†" now reads "Ahmed K. Emara, MD 1 *, Ignacio Pasqualini, MD 1 *, Yuxuan Jin, MS 1 , Alison K. Klika, MS 1 , Melissa N. Orr, BS 1 , Pedro J. Rullán, MD 1 , Nicolas S. Piuzzi, MD 1 , and the Cleveland Clinic Arthroplasty Group†".

BACKGROUND

Literature-reported minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds for patient-reported outcome measures demonstrate marked variability. The purpose of this study was to determine the minimal detectable change (MDC), MCID, and PASS thresholds for the Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subdomain, Physical Function Short Form (PS), and Joint Replacement (JR) among patients with osteoarthritis (OA) who underwent primary total knee arthroplasty (TKA).

METHODS

A prospective cohort of 6,778 patients who underwent primary TKA was analyzed. Overall, 1-year follow-up was completed by 5,316 patients for the KOOS Pain, 5,018 patients for the KOOS PS, and 4,033 patients for the KOOS JR. A total of 5,186 patients had an OA diagnosis; this group had an average age of 67.0 years and was 59.9% female and 80.4% White. Diagnosis-specific MDCs and MCIDs were estimated with use of a distribution-based approach. PASS values were estimated with use of an anchor-based approach, which corresponded to a response to a satisfaction question at 1 year postoperatively.

RESULTS

The MCID thresholds for the OA group were 7.9 for the KOOS Pain, 8.0 for the KOOS PS, and 6.7 for the KOOS JR. A high percentage of patients achieved the MCID threshold for each outcome measure (KOOS Pain, 95%; KOOS PS, 88%; and KOOS JR, 94%). The MDC 80% to 95% confidence intervals ranged from 9.1 to 14.0 for the KOOS Pain, 9.2 to 14.1 for the KOOS PS, and 7.7 to 11.8 for the KOOS JR. The PASS thresholds for the OA group were 77.7 for the KOOS Pain (achieved by 73% of patients), 70.3 for the KOOS PS (achieved by 68% of patients), and 70.7 for the KOOS JR (achieved by 70% of patients).

CONCLUSIONS

The present study provided useful MCID, MDC, and PASS thresholds for the KOOS Pain, PS, and JR for patients with OA. The diagnosis-specific metrics established herein can serve as benchmarks for clinically meaningful postoperative improvement. Future research and quality assessments should utilize these OA-specific thresholds when evaluating outcomes following TKA. Doing so will enable more accurate determinations of operative success and improvements in patient-centered care.

LEVEL OF EVIDENCE

Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Satisfaction rates, function, and return to activity following young adult total hip arthroplasty

Aims

Young adults undergoing total hip arthroplasty (THA) largely have different indications for surgery, preoperative function, and postoperative goals compared to a standard patient group. The aim of our study was to describe young adult THA preoperative function and quality of life, and to assess postoperative satisfaction and compare this with functional outcome measures.

Methods

A retrospective cohort analysis of young adults (aged < 50 years) undergoing THA between May 2018 and May 2023 in a single tertiary centre was undertaken. Median follow-up was 31 months (12 to 61). Oxford Hip Score (OHS) and focus group-designed questionnaires were distributed. Searches identified 244 cases in 225 patients. Those aged aged under 30 years represented 22.7% of the cohort. Developmental dysplasia of the hip (50; 45.5%) and Perthes' disease (15; 13.6%) were the commonest indications for THA.

Results

Preoperatively, of 110 patients, 19 (17.2%) were unable to work before THA, 57 (52%) required opioid analgesia, 51 (46.4%) were reliant upon walking aids, and 70 (63.6%) had sexual activity limited by their pathology. One patient required revision due to instability. Mean OHS was 39 (9 to 48). There was a significant difference between the OHS of cases where THA met expectation, compared with the OHS when it did not (satisfied: 86 (78.2%), OHS: 41.2 (36.1%) vs non-satisfied: 24 (21%), OHS: 31.6; p ≤ 0.001). Only one of the 83 patients (75.5%) who returned to premorbid levels of activity did so after 12 months.

Conclusion

Satisfaction rates of THA in young adults is high, albeit lower than commonly quoted figures. Young adults awaiting THA have poor function with high requirements for mobility aids, analgesia, and difficulties in working and undertaking leisure activities. The OHS provided a useful insight into patient function and was predictive of satisfaction rates, although it did not address the specific demands of young adults undertaking THA. Function at one year postoperatively is a good indication of overall outcomes.

Use of a fluoroscopy-based robotic-assisted total hip arthroplasty system produced greater improvements in patient-reported outcomes at one year compared to manual, fluoroscopic-assisted technique

INTRODUCTION

The adoption of new technology should be supported by improvements in patient-reported outcomes (PROMs). The purpose of this study was to assess the one-year PROMs of patients who underwent total hip arthroplasty (THA) using a novel, fluoroscopy-based, robotic-assisted (RA-THA) system when compared to a manual, fluoroscopic-assisted technique (mTHA).

MATERIALS AND METHODS

A review of 91 consecutive mTHA and 85 consecutive RA-THA via a direct anterior approach was conducted. All cases were performed by the same surgeon at the same institution, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Outcomes included one-year Veterans RAND-12 (VR-12) Physical/Mental, Hip Disability and Osteoarthritis Outcome (HOOS) Pain/Physical Function/Joint Replacement, and University of California Los Angeles (UCLA) Activity scores, as well as the difference between pre-operative and one-year post-operative PROMs.

RESULTS

Patients in the RA-THA cohort had lower pre-operative HOOS-JR scores compared to patients in the mTHA cohort (37.0 vs. 43.1; p = 0.031). Cohorts experienced similar one-year post-operative VR-12, HOOS, and UCLA Activity scores. Patients in the RA-THA cohort experienced greater improvements across all pre- and post-operative HOOS scores compared to patients in the mTHA cohort: Pain (+ 54.7 vs. +42.1; p = 0.009), Physical Function (-41.6 vs. -28.7; p = 0.007), and Joint Replacement (+ 46.6 vs. +33.0; p = 0.002). These differences exceeded minimum clinically important difference (MCID).

CONCLUSIONS

Both manual and robotic cohorts experienced benefit from THA at one-year post-operative. Importantly, the use of a novel, fluoroscopy-based robotic assistance system for primary THA resulted in greater improvements in PROMs at one-year relative to manual technique.

Factors Influencing Patient Satisfaction with Total Joint Replacement Surgery

Background

Replacement arthroplasty surgery is a surgical procedure that is needed to restore the activity of a joint. Patient satisfaction regarding arthroplasty surgery is influenced by post-operative complication rate, ability to afford care, and quality of interaction. In this study, we assessed patients' postoperative complications, mobility, and pain management as proxies for their overall satisfaction with total joint replacement (TJR).

Methods

An anonymous web-based survey was conducted for patients who had undergone any total joint replacement surgery in the US. Respondents were adults living in the United States.

Results

180 individuals met the inclusion criteria and responded to the survey. Age, education, gender, and race were fitted against the patient satisfaction level with the surgeon. While education [P=0.4720], gender [P=0.5097 ], and race [P=0.8183] were not significant, age in years [P=0.02340] was predictive of overall satisfaction levels [R2=0.0213]. When controlling for BMI, infection [P=0.0164], nerve damage [P=0.0250], delayed healing [P=0.0024], hematoma [P=0.0497], were more likely to occur in participants who have had a knee replacement, as compared to shoulder and hip replacement surgery. When controlling for mobility before surgery vs. mobility after surgery [P=0.0114], patients who selected the highest level of mobility before surgery were likely to select the highest level of mobility after surgery. Medicaid, Medicare, private insurance, employer-based insurance, and no insurance were fitted against the patient's self-reported difficulty in paying for their treatment/care. Although employer-based insurance [P=0.0790] was not significant in predicting difficulty in paying for the surgery, patients with Medicaid [P=0.0280], Medicare [P=0.0200], or private insurance [P=0.0343] did.

Conclusion

In this cohort, older patients were associated with having improved satisfaction with the surgeon who performed their joint replacement. Complications were higher in patients who underwent a knee arthroplasty compared to a shoulder or hip arthroplasty.

Predicting Functional Outcomes of Total Hip Arthroplasty Using Machine Learning: A Systematic Review

The aim of this review was to assess the reliability of machine learning (ML) techniques to predict the functional outcome of total hip arthroplasty. The literature search was performed up to October 2023, using MEDLINE/PubMed, Embase, Web of Science, and NIH Clinical Trials. Level I to IV evidence was included. Seven studies were identified that included 44,121 patients. The time to follow-up varied from 3 months to more than 2 years. Each study employed one to six ML techniques. The best-performing models were for health-related quality of life (HRQoL) outcomes, with an area under the curve (AUC) of more than 84%. In contrast, predicting the outcome of hip-specific measures was less reliable, with an AUC of between 71% to 87%. Random forest and neural networks were generally the best-performing models. Three studies compared the reliability of ML with traditional regression analysis: one found in favour of ML, one was not clear and stated regression closely followed the best-performing ML model, and one showed a similar AUC for HRQoL outcomes but did show a greater reliability for ML to predict a clinically significant change in the hip-specific function. ML offers acceptable-to-excellent discrimination of predicting functional outcomes and may have a marginal advantage over traditional regression analysis, especially in relation to hip-specific hip functional outcomes.

Does Body Mass Index (BMI) Affect the Reconstruction of Biomechanical Parameters in Patients Undergoing Total Hip Replacement (THR) through the Direct Anterior Approach (DAA)?

OBJECTIVE

Direct anterior approach total hip replacement (DAA-THR) is gaining increased interest due to its tissue-sparing nature and rapid recovery. Obesity has been shown to be a significant parameter influencing cup positioning in DAA-THR. It was the intention of this retrospective study to examine how obesity would influence the restoration of native hip biomechanical parameters during DAA-THR.

MATERIALS AND METHODS

A total of 74 patients from a high-volume university orthopedic center after unilateral DAA-THA were included. Patients were retrospectively allocated to a study group (BMI > 30 kg/m2) and a control group (BMI < 30 kg/m2). Furthermore, propensity-score matching for baseline parameters was performed, leaving 30 patients in each group. Biomechanical parameters of the hip (i.e., femoral offset (FO), abductor lever arm (ABL), acetabular offset (AO), center of rotation (COR), stem alignment (SA), body weight lever arm (BWL), cup inclination (CI), and leg length discrepancy (LLD) were evaluated on standardized plain radiographs, and parameters were compared to the native contralateral hip.

RESULTS

Mean BMI in the study group was 35.07 ± 5.13 kg/m2 and 25.43 ± 2.64 kg/m2 in the control group. There was a significant decrease of the ABL only in the study cohort (p = 0.01). CI and SA did not differ between both cohorts. FO was slightly increased compared to the native hip in both groups. There was a marginally higher but non-significant proportion of improper FO restoration in the study group (19 vs. 16 patients, p = 0.60).

CONCLUSIONS

Obesity, as quantified by BMI, only has a limited impact on the adequate reconstruction of native biomechanical parameters of the hip during DAA-THR. ABL was the only parameter to be significantly decreased in the overweight patients after DAA-THR. Therefore, special care should be taken on proper acetabular reaming and consequent seating of the cup in the obese patient to avoid excessive lateral positioning.

Joint awareness among total hip arthroplasty patients operated through anterior approach versus posterior approach: a systematic review and meta-analysis

PURPOSE

The aim of this systematic review and meta-analysis was to compare joint awareness in patients who underwent total hip arthroplasty (THA) via the anterior approach (AA) versus the posterior approach (PA). The hypothesis was that patients who underwent THA via AA would have better forgetfulness of the artificial joint.

METHODS

A comprehensive search of major literature databases and bibliographic details was conducted to identify studies evaluating the forgotten joint score (FJS-12) in total hip arthroplasty (THA) patients operated through the anterior approach (AA) and posterior approach (PA). Out of 234 studies identified, seven studies met the inclusion criteria for review. The Newcastle-Ottawa Scale was used to evaluate the quality of evidence and the risk of bias in the included studies. The FJS-12 was evaluated at three months, one year, and beyond 2 years.

RESULTS

The mean FJS-12 at > 2 years was 82.03 in the AA group and 80.32 in the PA group. The forest plot analysis (n = 819 patients) revealed no significant difference in FJS-12 score between these two approaches (MD 2.13, 95% CI [- 1.17, 5.42], p = 0.21; I2 = 60%). However, the joint awareness was significantly lesser in the AA group at 3 months (MD 12.56, 95% CI [9.58, 15.54], p < 0.00001, I2 = 0%) and 1 year (MD 9.55, 95% CI [7.85, 11.24], p < 0.0001, I2 = 0%).

CONCLUSIONS

After analyzing the available literature, it was found that THA patients operated through the AA approach have significantly lower joint awareness than those operated through the PA approach in the first year of surgery. However, there is no significant difference in joint awareness between these two approaches after 2 years.

LEVEL OF EVIDENCE

III.

Evaluation of Neuropathic Pain after Total Knee Arthroplasty: Do Yellow Flags Matter?

Up to 20% of total knee arthroplasty (TKA) patients continue to experience chronic postsurgical pain. Various factors have been identified as potential contributors, including so-called "yellow flags", encompassing symptoms of depression, anxiety, and catastrophizing, which were examined in this study to assess their predictive value concerning functional outcomes after TKA.

METHODS

Fifty TKA patients were categorized into high-risk and low-risk groups based on clinical assessment, demographic data, medication, and patient-reported outcome measures (DN4, SF-36, WOMAC, NRS, Fibromyalgia Survey Questionnaire, Pain Catastrophizing Scale, and Hospital Anxiety and Depression Scale). Postoperative outcomes within six months after TKA were then compared.

RESULTS

Both groups exhibited significant (p < 0.001) improvements in all WOMAC and NRS subscales, as well as in the physical function, role physical, pain, and energy/fatigue subdomains of the SF-36 after six months, while the high-risk group showed lower WOMAC scores regarding stiffness (19.0 ± 18.3 vs. 27.2 ± 20.7, p < 0.001) and pain (13.5 ± 13.3 vs. 15.1 ± 16.3, p = 0.029). The high-risk group showed significantly worse preoperative DN4 scores (1.8 ± 1.3 vs. 3.0 ± 1.1, p = 0.002) than the low-risk group, which persisted for one day (2.3 ± 1.2 vs. 3.5 ± 1.5, p = 0.005) and six weeks (2.2 ± 1.9 vs. 3.6 ± 2.3, p = 0.041) postoperatively.

CONCLUSIONS

Our results indicate that pre-existing yellow flags contribute to a more challenging early postoperative phase, underscoring the importance of considering individual patient characteristics and psychological factors to optimize TKA outcomes.

Editorial: factors influencing the outcome of total hip and knee arthroplasty

BACKGROUND

Total hip and knee arthroplasty for end stage arthritis are among the most cost-effective interventions available in all of medicine. Success of hip and knee arthroplasties is not universal and approximately one in ten patients are not satisfied with their arthroplasty and 10 to 34% of patients have an unfavourable long term pain outcome. The aim of this edition of Arthroplasty was to identify factors associated with: (1) poor joint specific outcome, (2) poor health related quality of life outcome and (3) dissatisfaction following total hip and knee arthroplasty.

METHODS

The scope was deliberately broad to identify factors (known and unknown) that influence outcome of total hip and knee arthroplasty, and of 40 submissions, eight were selected for this special edition after peer review.

RESULTS

Many of the included studies reported subjective patient reported outcome measures as their key outcomes but other objective measures such as muscle mass, timed Up-and-Go test, kneeling ability and postoperative pain are also featured. Some studies involved a focus on early rehabilitation after surgery (ERAS) principles and how to optimise pre-rehabilitation and reduce length of hospital stay readmission and reoperation. The effect of metal allergy and drain usage on outcomes is also explored. A variety of methodologies have been used including one randomised control trial, some machine learning and three systematic reviews investigating the effect of metal allergy on outcomes, associations with postoperative pain and the effect of patella resurfacing.

CONCLUSION

This special edition has advanced our knowledge of factors influencing to the outcome of hip and knee arthroplasty but has also identified several areas of research that need to be addressed to improve the outcomes of our patients.

Head, acetabular liner composition, and rate of revision and wear in total hip arthroplasty: a Bayesian network meta-analysis

Total hip arthroplasty (THA) is a common procedure for patients suffering from hip pain e.g. from osteoarthritis, osteonecrosis, or hip fractures. The satisfaction of patients undergoing THA is influenced by the choice of implant type and material, with one key factor being the selection of the appropriate material combination for the bearing surface. In this Bayesian network meta-analysis, we investigated the impact of material combinations for the bearing surface on the longevity of hip implants. The wear penetration rate per year and the total wear penetration in the liner resulting from different material combinations, as well as the survival rate at last follow-up, were examined. We analyzed a total of 663,038 THAs, with 55% of patients being women. Mean patient age was 59.0 ± 8.1 years and mean BMI 27.6 ± 2.6 kg/m2. The combination of an aluminium oxide (Al2O3) head and an Al2O3 liner demonstrated the lowest wear penetration at last follow-up and the lowest rate of wear penetration per year. Additionally, the combination of a crosslinked polyethylene (XLPE) liner and a zircon oxide (ZrO2) head demonstrated the lowest rate of revision at last follow-up. These findings underscore the importance of careful material selection for hip implant bearing surfaces to optimize their longevity and patient satisfaction after THA.

Patient-Reported Outcomes Following Revision Total Hip Arthroplasty Demonstrate Less Improvement and Significantly Higher Rates of Worsening Compared to Primaries

BACKGROUND

Patient-reported outcome measures (PROMs) provide the patient's perspective following total hip arthroplasty (THA), although differences between primary THA (pTHA) and revision THA (rTHA) remain unclear. Thus, we compared the Minimal Clinically Important Difference for Improvement (MCID-I) and Worsening (MCID-W) in pTHA and rTHA patients.

METHODS

Data from 2,159 patients (1,995 pTHAs/164 rTHAs) who had completed Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form (HOOS-PS), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, or PROMIS Global-Physical questionnaires were analyzed. The PROMs and MCID-I/MCID-W rates were compared using statistical tests and multivariate logistic regressions.

RESULTS

Compared to the pTHA group, the rTHA group had lower rates of improvement and higher rates of worsening for almost all PROMs, including HOOS-PS (MCID-I: 54 versus 84%, P < .001; MCID-W: 24 versus 4.4%, P < .001), PF10a (MCID-I: 44 versus 73%, P < .001; MCID-W: 22 versus 5.9%, P < .001), PROMIS Global-Mental (MCID-W: 42 versus 28%, P < .001), and PROMIS Global-Physical (MCID-I: 41 versus 68%, P < .001; MCID-W: 26 versus 11%, P < .001). Odds ratios supported rates of worsening following revision for the HOOS-PS (Odds Ratio (OR): 8.25, 95% Confidence Interval (CI): 5.62 to 12.4, P < .001), PF10a (OR: 8.34, 95% CI: 5.63 to 12.6, P < .001), PROMIS Global-Mental (OR: 2.16, 95% CI: 1.41 to 3.34, P < .001), and PROMIS Global-Physical (OR: 3.69, 95% CI: 2.46 to 5.62, P < .001).

CONCLUSION

Patients reported higher rates of worsening and lower rates of improvement following rTHA than pTHA, with significantly less score improvement and lower postoperative scores for all PROMs after revision. Most patients reported improvements following pTHA, with few worsening postoperatively.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Net Promoter Score: a prospective, single-centre observational study assessing if a single question determined treatment success after primary or revision hip arthroplasty

BACKGROUND

Our study aimed to identify the relationship between treatment outcome assessed by patient-reported outcomes (PROMs) and satisfaction measured by calculation of the Net Promoter Score (NPS), which identifies promoters, following total hip arthroplasty (THA). The aim was to evaluate this association separately in primary and revision THA and to determine thresholds based on PROMs that identify detractors of the surgical procedure or the centre.

METHODS

A total of 1,243 patients who underwent primary or revision THA at our hospital were asked to complete questionnaires of the Oxford Hip Score (OHS), Euroquol-5D (EQ-5D) and information on pain intensity preoperatively, three and 12 months after surgery. Postoperatively, the patients were additionally asked about their satisfaction with the procedure and the hospital by using three different NPS questions. The association between PROMs and NPS was evaluated based on group comparisons of primary or revision THA and receiver operating characteristics analysis (ROC) to determine threshold values.

RESULTS

At 12 months the NPS of all three questions were invariably linked to treatment outcome in patients after primary THA and patients with a single revision. In these two treatment groups, promoters always showed significantly better PROM scores than detractors. The NPS score was always higher in the primary group in comparison to the single revision group, e.g. 66.4% would undergo the procedure again in the first group, while only 33.0% would opt for this in the latter group. The high thresholds for the PROMs at 12 months, that were calculated by ROC analysis to identify promoter/detractors, indicate that patients` satisfaction required very good joint function and pain relief. However, the NPS was not a suitable tool to identify patients who need further care in an early phase after surgery.

CONCLUSIONS

With NPS already a single question or a single parameter provides the desired information regarding patient satisfaction and also treatment success.

TRIAL REGISTRATION

The study was approved by the Ethics Committee at the Medical Faculty of the University Rostock: "Ethikkommission an der Medizinischen Fakultät der Universität Rostock", Address: St.-Georg Str. 108 18055 Rostock, Germany, reference number: A2015-0055.

Similar Patient Satisfaction and Quality of Life Improvement Achieved with TKA and THA According to the Goodman Scale: A Comparative Study

Background: Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are effective treatments for severe knee and hip osteoarthritis. Historically, TKA has been associated with lower satisfaction than THA, but recent advances in knee surgery have led to lower dissatisfaction rates. This study aimed to compare the satisfaction and self-reported improvement in the quality of life of two cohorts of patients who underwent TKA and THA, respectively. Methods: This observational study compared two previously published cohorts of patients who underwent THA and TKA in a single university center. The Goodman scale was used to assess satisfaction and self-perception of improved quality of life after TKA and THA at a minimum one-year follow-up. Propensity score matching was used to balance age, gender, and follow-up between groups. Significance was set at 0.05. Results: The study included a total of 105 THAs and 131 TKAs. Both groups had high levels of satisfaction with pain relief, ability to do house/yard work, and overall satisfaction, with above 90% satisfaction rates. Regarding improvement in quality of life, both groups had 86% of patients reporting improvement as "much better." After propensity score matching, no significant difference was found between THA and TKA for any of the comparisons made using the Goodman scale. Conclusions: The study showed that both TKA and THA resulted in high levels of satisfaction and improvement in quality of life. There was no significant difference in satisfaction rates between TKA and THA, contrary to the historical trend of lower satisfaction rates for TKA.

What Factors Identified in Initial Osteoarthritis Management Are Associated With Poor Patient-reported Outcomes After THA? A Register-based Study

BACKGROUND

Some patients report long-term pain or no improvement in health-related quality of life (HRQoL) or are dissatisfied after THA. However, factors associated with these poorer patient-reported outcomes after surgery are inconsistent and have typically been studied in the late phase of hip osteoarthritis (OA) among patients already eligible for surgery. Earlier identification of risk factors would provide time to address modifiable factors, helping to improve patients' pain, HRQoL, and satisfaction after surgery and reduce the burden on orthopaedic clinics by referring patients who are better prepared for surgery.

QUESTIONS/PURPOSES

We analyzed data from patients with hip OA referred to a first-line OA intervention program in primary healthcare at a stage when they had not been referred for THA, and asked: (1) What percentage of patients who proceed to THA report lack of improvement in pain, lack of improvement in HRQoL as measured by the EQ-5D, or are not satisfied with surgery 1 year after THA? (2) What associations exist between baseline factors at referral to this first-line OA intervention program and these poorer patient-reported outcomes 1 year after THA?

METHODS

We included 3411 patients with hip OA (mean age 67 ± 9 years, 63% [2160 of 3411] women) who had been referred for first-line OA interventions between 2008 and 2015 and subsequently underwent THA for OA. All patients were initially identified through the Swedish Osteoarthritis Register, which follows and evaluates patients in a standardized national first-line OA intervention program. Then, we identified those who were also registered in the Swedish Arthroplasty Register with a THA during the study period. We included only those with complete patient-reported outcome measures for pain, HRQoL, and satisfaction preoperatively and 1-year postoperatively, representing 78% (3411 of 4368) of patients, who had the same baseline characteristics as nonrespondents. Multiple logistic regression was used to assess the associations between 14 baseline factors and the aforementioned patient-reported outcomes of pain, HRQoL, and satisfaction 1 year after THA, adjusted for all included factors.

RESULTS

Five percent (156 of 3411) of the study population lacked improvement in pain, 11% (385 of 3411) reported no improvement in HRQoL, and 10% (339 of 3411) reported they were not satisfied with surgery 1 year after THA. Charnley Class C (multiple-joint OA or another condition that affects the ability to walk) was associated with all outcomes: lack of improvement in pain (OR 1.84 [95% CI 1.24 to 2.71]; p = 0.002), lack of improvement in HRQoL (OR 1.83 [95% CI 1.42 to 2.36]; p < 0.001), and not being satisfied (OR 1.40 [95% CI 1.07 to 1.82]; p = 0.01). Older age was associated with a lack of improvement in pain (OR per year 1.03 [95% CI 1.01 to 1.05]; p = 0.02), lack of improvement in HRQoL (OR per year 1.04 [95% CI 1.03 to 1.06]; p < 0.001), and not being satisfied (OR per year 1.03 [95% CI 1.01 to 1.05]; p < 0.001). Depression was associated with a lack of improvement in pain (OR 1.54 [95% CI 1.00 to 2.35]; p = 0.050) and with not being satisfied (OR 1.50 [95% CI 1.11 to 2.04]; p = 0.01) but not with a lack of improvement in HRQoL (OR 1.04 [95% CI 0.76 to 1.43]; p = 0.79). Having four or more comorbidities was associated with a lack of improvement in HRQoL (OR 2.08 [95% CI 1.39 to 3.10]; p < 0.001) but not with a lack of improvement in pain and not being satisfied.

CONCLUSION

The results of this study showed that older age, Charley Class C, and depression in patients with first-line OA interventions were risk factors associated with poorer outcomes regarding pain, HRQoL, and satisfaction after THA. Screening patients with hip OA for depression early in the disease course would provide increased time to optimize treatments and may contribute to better patient-reported pain, HRQoL, and satisfaction after future THA. Further research should focus on identifying the optimal time for surgery in patients with depression, as well as what targeted interventions for depression can improve outcome of surgery in these patients.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The Direct Anterior Approach (DAA) as a Standard Approach for Total Hip Arthroplasty (THA) in Coxa Profunda and Protrusio Acetabuli? A Radiographic Analysis of 188 Cases

INTRODUCTION

The direct anterior approach (DAA) represents a well-recognized soft tissue sparing technique for primary total hip arthroplasty (THA). The feasibility and suitability of the DAA in cases of complex acetabular deformities, namely coxa profunda (CP) and protrusio acetabuli (PA), remain to be determined.

METHODS

A total of 188 cases of CP (100 cases) and PA (88 cases) hips undergoing primary THA via the DAA were retrospectively analyzed. Surgical and radiographic parameters were evaluated and potential complications were assessed. Finally, successful implantation was defined if surgical and radiographic parameters were well within established values of non-complex primary THA.

RESULTS

In 159 hips, the medial border of the acetabular component was transferred laterally to the ilioischial line, corresponding to a fully treated acetabular protrusion. In 23 (12.23%) cases, mild, and in 5 (2.66%) cases, moderate residual acetabular protrusion remained after THA. Postoperatively, 11.40% (PA group) and 9.00% (CP group) had a leg length discrepancy (LLD) greater than 10 mm. The mean operative time was significantly less than 60 min. A linear relationship between the BMI and operative time was observed, with an additional 0.9 min of operative time per BMI unit. Overall, complications were rare and did not differ between the two groups.

CONCLUSION

The results of this study suggest that the DAA is a suitable approach for primary THA in patients with coxa profunda and acetabular protrusion if performed by experienced surgeons familiar with the DAA. Obese patients with acetabular protrusion may pose a significant limitation to the DAA and caution should be advised in cases of obesity.

Hip precautions after posterior-approach total hip arthroplasty among patients with primary hip osteoarthritis do not influence early recovery: a systematic review and meta-analysis of randomized and non-randomized studies with 8,835 patients

BACKGROUND AND PURPOSE

Hip precautions are routinely prescribed to patients with osteoarthritis to decrease dislocation rates after total hip arthroplasty (THA) using a posterior approach. However, recommendations have been based on very low certainty of evidence. We updated the evidence on the influence of hip precautions on early recovery following THA by this systematic review.

MATERIALS AND METHODS

We performed systematic searches for randomized controlled trials (RCT) and non-randomized (NRS) studies in MEDLINE, Embase, PEDro, and CINAHL published from 2016 to July 2022. 2 reviewers independently included studies comparing postoperative precautions with minimal or no precautions, extracted data, and assessed the risk of bias. Random effects meta-analyses were used to synthesize the results. The certainty of the evidence was rated by the Grading of Recommendations Assessment and Evaluation approach. The critical outcome was the risk of hip dislocations within 3 months of surgery. Other outcomes were long-term risk of dislocation and reoperation, self-reported and performance-based assessment of function, quality of life, pain, and time to return to work.

RESULTS

4 RCTs and 5 NRSs, including 8,835 participants, were included. There may be no or negligible difference in early hip dislocations (RCTs: risk ratio [RR] 1.8, 95% confidence interval [CI] 0.6-5.2; NRS: RR 0.9, CI 0.3-2.5). Certainty in the evidence was low for RCTs and very low for NRSs. Finally, precautions may reduce the performance-based assessment of function slightly, but the evidence was very uncertain. For all other outcomes, no differences were found (moderate to very low certainty evidence).

CONCLUSION

The current evidence does not support routinely prescribing hip precautions post-surgically for patients undergoing THA to prevent hip dislocations. However, the results might change with high-quality studies.

Patient-rated satisfaction and improvement following hip and knee replacements: Development of prediction models

RATIONALE

Effective preoperative assessments of determinants of health status and function may improve postoperative outcomes.

AIMS AND OBJECTIVES

We developed risk scores of preoperative patient factors and patient-reported outcome measures (PROMs) as predictors of patient-rated satisfaction and improvement following hip and knee replacements.

PATIENTS AND METHODS

Prospectively collected National Health Service and independent sector patient data (n = 30,457), including patients' self-reported demographics, comorbidities, PROMs (Oxford Hip/Knee score (OHS/OKS) and European Quality of Life (EQ5D index and health-scale), were analysed. Outcomes were defined as patient-reported satisfaction and improvement following surgery at 7-month follow-up. Univariable and multivariable-adjusted logistic regressions were undertaken to build prediction models; model discrimination was evaluated with the concordance index (c-index) and nomograms were developed to allow the estimation of probabilities.

RESULTS

Of the 14,651 subjects with responses for satisfaction following hip replacements 564 (3.8%) reported dissatisfaction, and 1433 (9.2%) of the 15,560 following knee replacement reported dissatisfaction. A total of 14,662 had responses for perceived improvement following hip replacement (lack of improvement in 391; 2.7%) and 15,588 following knee replacement (lack of improvements in 1092; 7.0%). Patients reporting poor outcomes had worse preoperative PROMs. Several factors, including age, gender, patient comorbidities and EQ5D, were included in the final prediction models: C-indices of these models were 0.613 and 0.618 for dissatisfaction and lack of improvement, respectively, for hip replacement and 0.614 and 0.598, respectively, for knee replacement.

CONCLUSIONS

Using easily accessible preoperative patient factors, including PROMs, we developed models which may help predict dissatisfaction and lack of improvement following hip and knee replacements and facilitate risk stratification and decision-making processes.

[Physiological reactions in the interface between cementless implants and bone]

BACKGROUND

Surgical treatment of patients with osteoarthritis of the hip and persisting symptoms under conservative therapy has become increasingly important against the background of an aging population.

OBJECTIVES

What are the physiological reactions in the interface between cementless implants and bone?

METHODS

The literature is reviewed, expert opinions and animal models are analyzed and discussed.

RESULTS

Surface coating of implants with hydroxyapatite or titanium can have positive effects on osteointegration. Additional local application of mediators might be beneficial for osteointegration in the future.

CONCLUSION

Early peri-implant bone healing directly after implantation and late remodeling of the bone-implant interface are essential for secondary implant stability.

The Effect of Surgeon and Hospital Volume on Total Hip Arthroplasty Patient-Reported Outcome Measures: An American Joint Replacement Registry Study

BACKGROUND

Some studies have shown lower morbidity and mortality rates with increased surgeon and hospital volumes after total hip arthroplasty (THA). This study sought to determine the relationship between surgeon and hospital volumes and patient-reported outcome measures after THA using American Joint Replacement Registry data.

METHODS

Using American Joint Replacement Registry data from 2012 to 2020, 4,447 primary, elective THAs with both preoperative and 1-year postoperative Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) scores were analyzed. This study was powered to detect the minimum clinically important difference (MCID). The main exposure variables were median annual surgeon and hospital volumes. Tertiles were formed based on the median annual number of THAs conducted: low-volume (1 to 42), medium-volume (42 to 96), and high-volume (≥96) surgeons and low-volume (1 to 201), medium-volume (201 to 392), and high-volume (≥392) hospitals. Mean preoperative and 1-year postoperative HOOS-JR scores were compared.

RESULTS

Preoperative HOOS-JR scores were significantly higher at high-volume hospitals than low-volume and medium-volume hospitals (49.66 ± 15.19 vs. 47.68 ± 15.09 and 48.34 ± 15.22, P < 0.001), although these differences were less than the MCID. At the 1-year follow-up, no difference was noted with no resultant MCID. Preoperative and 1-year HOOS-JR scores did not markedly vary with surgeon volume. In multivariate regression, low-volume and medium-volume surgeons and hospitals had similar odds of MCID achievement in HOOS-JR scores compared with high-volume surgeons and hospitals, respectively.

CONCLUSION

Using the HOOS-JR score as a validated patient-reported outcome measure, higher surgeon or hospital THA volume did not correlate with higher postoperative HOOS-JR scores or greater chances of MCID achievement in HOOS-JR scores compared with medium and lower volume surgeons and hospitals.

Large Femoral Heads and Select Dual-Mobility Bearings Are Associated With Reduced Instability in Contemporary Posterior Approach Total Hip Arthroplasty

BACKGROUND

Postoperative dislocation is considered the main drawback of posterior approach total hip arthroplasty (THA). Thinner highly cross-linked polyethylene and dual-mobility bearings allow maximizing femoral head diameter per a given cup size. This study evaluated dislocation rates as large femoral head bearings were introduced into a practice over an 11-year period.

METHODS

A total of 1,511 consecutive primary THAs were retrospectively reviewed. Demographics, implant sizes, femoral head-acetabular cup ratio, and dislocation status were collected from the electronic medical record. Data were evaluated using time series analysis techniques as larger femoral heads, thinner polyethylene liners, and dual-mobility bearings were introduced. The cohort was 57% women with mean age and body mass index of 62 years (range, 13 to 93) and 31 kg/m² (range, 13 to 54), respectively.

RESULTS

The overall dislocation rate was 0.98%. Use of femoral head sizes ≥ 40 millimeters increased from 4% in the years 2010 to 2016 to 51% in the years 2017 to 2021, correlating with a 50% reduction in dislocation rate from 1.4% to 0.7% (P = .279). Also, no dislocations occurred in patients who had dual-mobility bearings or ≥ 40-millimeter femoral heads (P = .007). Twelve of 14 dislocations occurred in cases with head-cup ratio < 0.7 (P = .013). Thirteen of 14 dislocations were in women (P = .005).

CONCLUSION

Maximizing the femoral head diameter per given cup size correlated with a decrease in dislocation rate in modern posterior approach THA. Furthermore, these results suggest that dual-mobility articulations should be reserved for high-risk patients or patients in whom a 40-millimeter femoral head is not possible.

LEVEL OF EVIDENCE

IV-consecutive case series; no control group.

Patellar Component Design Does Not Impact Clinical Outcomes in Primary Total Knee Arthroplasty

BACKGROUND

Round or oval implants are used in patellar resurfacing during total knee arthroplasty (TKA). However, whether component geometry affects clinical outcomes is unclear. This study aimed to determine if one implant shape conferred superior outcomes to the other.

METHODS

A retrospective review of primary TKA cases performed from 2016 to 2020 was conducted at an urban, tertiary academic center. Four hundred consecutive, primary TKAs were included in these analyses. Cases were included if a surgeon used the round design then oval design for fifty consecutive cases. Baseline demographic data and radiographic measurements were assessed. Surgical data, reasons for revision, and patient-reported outcome measures were analyzed. Independent samples t-test and chi-square tests were used to compare means and proportions. There were no demographic differences between the cohorts.

RESULTS

Postoperative patellar tilt was statistically different between the cohorts. Sixteen patients required revision surgery; however, revision rates did not differ between the cohorts. Of the 9 rounds, 1 button was revised for infection. Of the 7 ovals, 1 button was revised for infection and 1 for loosening. Veterans RAND 12 Physical Component Score at 3 months postoperatively was higher for the round cohort, but no differences were observed at 1 year.

CONCLUSION

While radiographic patellar tilt was significantly different between the cohorts, there was no clinical correlation in outcomes at 3 months or 1 year postoperatively. Longer-term follow-up studies are needed to evaluate the implications of patellar component design on outcomes and function. Nevertheless, the current study affirms that both designs are clinically equivalent which should be used to guide clinical decision-making.

LEVEL III EVIDENCE

Retrospective Cohort.

The Relationship Between Perioperative Care Quality and Postoperative Comfort Level in Patients With Hip Replacement Surgery

PURPOSE

To examine the relationship between perioperative care quality and postoperative comfort level of patients undergoing hip replacement surgery.

DESIGN

This is a descriptive study.

METHODS

This study was conducted with 90 patients between February and September 2021 in a training and research hospital in Turkey. Data were collected from Information Form, the Good Perioperative Nursing Care Scale (for Patients) (GPNCS), and the Post Hip Replacement Comfort Scale (PHRCS).

FINDINGS

The mean age of the patients was 65.58 ± 15.10 years. The mean total scores of the patients in GPNCS and PHRCS were 134.61 ± 16.29 and 3.58 ± 0.40, respectively. In the correlation analysis, a statistically significant and positive weak relationship was determined between GPNCS and PHRCS, and as the quality of care during the surgery increases, the postoperative comfort levels increase (r = 0.253, P < .05).

CONCLUSIONS

Ensuring the comfort of patients during the surgery as well as in the pre-, intra- and postoperative period is necessary and important for the quality of care. In addition, since the quality of the care during surgery is effective on the postoperative comfort levels of the patients, quality nursing care is required pre-, intra-, and postoperative periods.

Perioperative management of leg-length discrepancy in total hip arthroplasty: a review

Leg-length discrepancy (LLD) presents a significant management challenge to orthopedic surgeons and remains a leading cause of patient dissatisfaction and litigation after total hip arthroplasty (THA). Over or under-lengthening of the operative extremity has been shown to have inferior outcomes, such as dislocation, exacerbation of back pain and sciatica, and general dissatisfaction postoperatively. The management of LLD in the setting of THA is multifactorial, and must be taken into consideration in the pre-operative, intra-operative, and post-operative settings. In our review, we aim to summarize the best available practices and techniques for minimizing LLD through each of these phases of care. Pre-operatively, we provide an overview of the appropriate radiographic studies to be obtained and their interpretation, as well as considerations to be made when templating. Intra-operatively, we discuss several techniques for the assessment of limb length in real time, and post-operatively, we discuss both operative and non-operative management of LLD. By providing a summary of the best available practices and strategies for mitigating the impact of a perceived LLD in the setting of THA, we hope to maximize the potential for an excellent surgical and clinical outcome.

Factors associated with persistent postsurgical pain after total knee or hip joint replacement: a systematic review and meta-analysis

Studies have identified demographic, clinical, psychosocial, and perioperative variables associated with persistent pain after a variety of surgeries. This study aimed to perform a systematic review and meta-analysis of factors associated with persistent pain after total knee replacement (TKR) and total hip replacement (THR) surgeries. To meet the inclusion criteria, studies were required to assess variables before or at the time of surgery, include a persistent postsurgical pain (PPSP) outcome measure at least 2 months after a TKR or THR surgery, and include a statistical analysis of the effect of the risk factor(s) on the outcome measure. Outcomes from studies implementing univariate and multivariable statistical models were analyzed separately. Where possible, data from univariate analyses on the same factors were combined in a meta-analysis. Eighty-one studies involving 171,354 patients were included in the review. Because of the heterogeneity of assessment methods, only 44% of the studies allowed meaningful meta-analysis. In meta-analyses, state anxiety (but not trait anxiety) scores and higher depression scores on the Beck Depression Inventory were associated with an increased risk of PPSP after TKR. In the qualitative summary of multivariable analyses, higher preoperative pain scores were associated with PPSP after TKR or THR. This review systematically assessed factors associated with an increased risk of PPSP after TKR and THR and highlights current knowledge gaps that can be addressed by future research.