Total hip replacement among sickle cell patients in a low-income country-Yemen

PURPOSE

Sickle cell patients presented with progressive hip pain and limitation of daily activities, as evidenced by low preoperative hip scores and failed conservative therapy. Management of femoral head avascular necrosis (AVN) using total hip replacement (THR) in sickle cell disease (SCD) is widespread in developed countries, but it is still in its initiation stage in developing countries. The outcome of using cementless THR among SCD patients is still unknown with lack of published studies from regional countries. This study aimed to evaluate the outcome of using cementless primary THR among patients with sickle cell disease with end-stage hip avascular necrosis in Yemen.

METHODS

Thirty cementless primary total hip arthroplasty (THA) were performed for AVN of the femoral head in 27 sickle cell patients, at Al.-Thawra Modern General Hospital-Sana'a, Yemen, from January 2018 to December 2022.

RESULTS

The mean age of the patients was 27 ± five years (ranged 18-37 years) with a male to female ratio was 3:1. Steinberg staging for hip AVN was stage IV, one patient (3%); stage VI, thirteen patients (45%); and stage V, sixteen patients (51%). THR was on right side 14 (52%), left side 10 (37%), and bilateral 3 (11%). The implant used was ceramic on polyethylene acetabular liner. All patients showed improvement in Harris hip score from preoperative mean hip score was 25 ± 8 points to postoperative mean hip score was 88 ± 6 points at the last follow-up. Mean of the length of stay in hospital was 12.7 ± eight days (ranged from 4 to 32 days); the mean operating time was 107 ± 23 min. Three cases had superficial wound infection; four patients had five intraoperative fractures; two cases had pulmonary complications; one case had abdominal crisis. All patients had postoperative leg length discrepancy less than 2 cm. None had deep infection, nerve injury, wound hematoma, aseptic loosing, dislocation, DVT, heterotopic ossification, or death.

CONCLUSION

THR in SCD has a good outcome using cementless THA with a low rate of complication in Yemen, a developing country.

Long-term outcomes of total hip arthroplasty in patients with developmental dysplasia of the hip: a minimum 21-year follow-up

PURPOSE

Early osteoarthritis (OA) due to developmental dysplasia of the hip (DDH) is a known indication for total hip arthroplasty (THA). Though screening tools and joint-preserving procedures have been established successfully, there still is a relevant number of patients suffering DDH. Due to the lack of long-term outcome studies, we like to close this gap and present the results of a highly specialized center.

METHODS

The study included 126 patients, who were treated in our institution with primary THA for DDH between January 1997 and December 2000. At the time of final follow-up, at a mean of 23 years postoperatively, 110 patients (121 hips) were clinically evaluated using the Harris-Hip Score. In addition, complication and surgical revision rates were assessed. We collected surgery-related data like implant choice and special surgical features such as autologous acetabular reconstruction or femoral osteotomies. Additionally, the severity of preoperative DDH was measured radiographically according to Crowe classification.

RESULTS

There were 91 female (83%) and 19 male (17%) patients with an average age of 51 ± 9.5 years (range 21-65) included. Mean follow-up was 23 ± 1.3 years (21-25), with a minimum of 21 years being necessary for inclusion. Using revision for any indication as primary endpoint, the Kaplan-Meier survivorship was 98.3% at 10 years and 81.8% at final follow-up. The overall revision rate was 18% (22 cases), which were split up as follows: 20 (17%) implant failures (loosened or broken components), one (1%) periprosthetic infection and one (1%) periprosthetic fracture. Regarding complications, we observed nine (7%) dislocations and one case (1%) with severe heterotopic ossification that required surgical excision. The mean Harris-Hip score at latest follow-up was 78 ± 14 points (32-95).

CONCLUSIONS

Though implants and surgical techniques have improved over time, our results suggest THA in patients suffering DDH to be seriously challenging with relatively high overall complications in long-term observation and fair clinical outcome after 21 years postoperatively. There is evidence that prior osteotomy might be associated with a higher revision rate.

Which patient-specific parameters correlate with operation time for total hip arthroplasty? - A retrospective analysis of the direct anterior approach

PURPOSE

The current study aims to identify patient-specific factors that correlate with operation time for total hip arthroplasty (THA) performed via the direct anterior approach (DAA).

METHODS

In this retrospective study, patient-specific factors were tabulated from the charts and measured from preoperative templating radiographs. These factors were correlated with operation time by bivariate analysis. Significant factors were used for stepwise multiple regression analysis.

RESULTS

Nine hundred-sixty procedures were included. BMI (R = 0.283), the distance from the superior iliac spine to the greater trochanter (DAA Plane) (R = - 0.154), patients age (R = 0.152) and the abdominal fat flap (R = 0.134) showed the strongest correlations (p < 0.005) with operation time. The multiple regression model including BMI, Kellgren and Lawrence Score, Age, DAA Plane and the Canal to Calcar ratio had the best predictive accuracy (corrected R2 = 0.122).

CONCLUSIONS

Patient-specific factors that make the entry into the femur difficult correlate significantly with operation time of THA via the DAA.

Differences in femoral component subsidence rate after THA using an uncemented collarless femoral stem: full weight-bearing with an enhanced recovery rehabilitation versus partial weight-bearing

BACKGROUND

Femoral component subsidence is a known risk factor for early failure of total hip arthroplasty (THA) using cementless stems. The aim of the study was to compare an enhanced recovery concept with early full weight-bearing rehabilitation and partial weight-bearing on stem subsidence. In addition, the influence of patient-related and anatomical risk factors on subsidence shall be assessed.

METHODS

One hundred and fourteen patients underwent primary cementless THA and were retrospectively analyzed. Sixty-three patients had an enhanced recovery rehabilitation with early full weight-bearing and 51 patients had rehabilitation with partial weight-bearing (20 kg) for 6 weeks. Postoperative subsidence was analyzed on standing pelvic anterior-posterior radiographs after 4 weeks and 1 year. Subsidence was measured in mm. Anatomical and prosthetic risk factors (stem size, canal flare index, canal fill ratio as well as BMI and demographic data) were correlated.

RESULTS

Femoral stem subsidence rate was significantly higher for the group with an enhanced recovery concept compared to the group with partial weight-bearing at the first radiological follow up after 4 weeks [2.54 mm (SD ± 1.86) vs. 1.55 mm (SD ± 1.80)] and the second radiological follow up after 1 year [3.43 mm (SD ± 2.24) vs. 1.94 (SD ± 2.16)] (p < 0.001, respectively). Stem angulation > 3° had a significant influence on subsidence. Canal flare index and canal fill ratio showed no significant correlation with subsidence as well as BMI and age.

CONCLUSION

In the present study, cementless stem subsidence was significantly higher in the group with enhanced recovery rehabilitation compared to partial weight-bearing. Small absolute values and differences were demonstrated and therefore possibly below clinical relevance. Anatomical radiological parameters and anthropometric data did not appear to be risk factors for stem subsidence.

Midterm Survivorship of an Uncemented Hydroxyapatite-Coated Titanium Femoral Component and Clinically Meaningful Outcomes in Patients Older Than 75 Years

Purpose: It remains controversial whether cementless femoral components are safe in elderly patients. The aim of this study was (1) to determine the stem survival rate in patients >75 years of age who were treated with an uncemented femoral component and (2) to report clinically significant results on a mid-term follow-up. Methods: 107 total hip arthroplasties (THA) were retrospectively evaluated in 97 patients over 75 years of age (mean age 78 years, range 75–87) treated with an uncemented femoral stem. The minimum follow-up was five years (mean 6.4 years, range 5–8). Stem survival rates, clinically meaningful outcomes, and incidence of complications were evaluated. Results: Kaplan-Meier survival analysis, with the endpoint revision for any reason, showed a 6.4-year survival rate of 98% (95% CI, 95–99%; 63 hips at risk). The survival rates were comparable for male and female patients (log-rank test, p = 0.58). The modified Harris Hip Score (mHHS) improved from 42.2 (12 to 85) points to 81.1 (22 to 97) points (p < 0.0001). Mid-term minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) were 25, 84, and 70, respectively. Conclusion: An uncemented stem is a viable option in patients over 75 years with good clinical outcomes and survivorship. Periprosthetic fractures were not a relevant failure mechanism with the stem used.

Absence of instabilities and intra-prosthetic dislocations at 7 to 11 years following THA using a fourth-generation cementless dual mobility acetabular cup

PURPOSE

Dual-mobility (DM) cups are increasingly used in total hip arthroplasty (THA) but there lacks literature on their long-term results. We aimed to investigate outcomes of a fourth-generation cementless DM acetabular cup at 7-11 years.

METHODS

We retrospectively evaluated 240 consecutive hips that received cementless THA using the same dual mobility cup (Novae Sunfit TH) and femoral stem (Corail). Patients were recalled at ≥7 years to collect Oxford hip scores (OHS), Harris hip scores (HHS), and inspect for radiolucent lines and granulomas. Multi-variable analyses were performed to determine whether HHS or OHS were associated with pre- or intra-operative variables.

RESULTS

At 8.4 ± 0.8 years (range, 7-11), 6 hips were revised (2.5%), 54 deceased (22.5%), and 14 could not be reached (5.8%). Four revisions (2 cup+stem, 2 liners only) were due to sepsis (1.7%), one (cup and stem) for trauma (0.4%), and one (stem) due to aseptic loosening (0.4%). For the remaining 166 hips, HHS was 83.6 ± 13.2 and OHS was 20.3 ± 6.7. Multi-variable analysis confirmed that HHS (β = - 0.38; p = 0.039) and OHS (β = 0.36; p < 0.001) worsened with age, and that OHS was worse for Charnley C patients (β = 3.17; p = 0.009). Neither granulomas nor radiolucenies were observed around any cups, but radiolucenies were seen around 25 stems (20.3%).

CONCLUSIONS

This fourth-generation DM cup demonstrated satisfactory outcomes at 7-11 years, with no instabilities or cup revisions due to aseptic loosening. Better OHS was observed for younger patients and those presenting higher Charnley grade.

LEVEL OF EVIDENCE

Level IV, retrospective case study.

Femoral stem subsidence in cementless total hip arthroplasty: a retrospective single-centre study

PURPOSE AND HYPOTHESIS

Subsidence is a known reason for early failure of total hip arthroplasty (THA). In particular, cementless THA might be vulnerable to migration. The present study analysed femoral stem subsidence after primary cementless THA. Prosthetic and anatomical risk factors for early femoral stem subsidence were evaluated.

METHODS

Two hundred thirty-one consecutive patients who underwent primary cementless THA in a single centre were retrospectively analysed. Post-operative results were evaluated in consideration of prosthetic and anatomical properties in correlation with subsidence on standing pelvic anteroposterior radiographs. Stem type and design, demographic data, BMI, canal flare index (CFI) and canal fill ratio (CFR) were evaluated.

RESULTS

The subsidence rate was significantly higher in collarless femoral stems [3.1 mm (SD 2.8 mm) vs. 1.9 mm (SD 1.5 mm); p = 0.013] while the anatomical type of the proximal femur as described by the canal flare index did not influenced subsidence (p = 0.050). Also, the canal fill ratio showed no significant correlation with subsidence at any level.

CONCLUSIONS

In the present study, stem subsidence was significantly higher in the collarless group compared to collared stems. No anatomical parameter (CFI and CFR) could be identified as risk factor for subsidence. Neither age nor BMI influenced subsidence in this cohort. Still, subgroup analysis indicated a sex-dependent role of BMI. Prospective studies of large cohorts should address the problem of subsidence in the future.

LEVEL OF EVIDENCE

Retrospective therapeutic study, Level IV.

Effect of stem alignment on long-term outcomes of total hip arthroplasty with cementless Bi-Metric femoral components

We investigated the effects of varus-valgus alignment on the long-term outcomes after cementless total hip arthroplasty (THA) using a porous coated version of Bi-Metric^® femoral stems. The Kaplan-Meier survival analysis was performed in 71 hips. The survival rate with femoral revision for aseptic loosening as the end point was 100% at 17 years. Nevertheless, the initial stem alignment was more valgus in patients with the Engh grade III-IV stress shielding than patients with the Engh grade I-II. Our results suggest that valgus misalignment of cementless Bi-Metric stem might be a potential risk factor for the progression of stress shielding.

Cementless total hip arthroplasty with medial wall osteotomy for the sequelae of septic arthritis of the hip

Background

We performed a retrospective study to evaluate the results of acetabular circumferential medial wall osteotomy, a procedure designed to provide secure fixation of a cementless hemispherical acetabular cup for the sequelae of septic arthritis of the hip.

Methods

We assessed 38 total hip arthroplasties (THAs) with circumferential acetabular medial wall osteotomies performed on patients with sequelae of septic arthritis of the hip between 1993 and 2000, who were followed up for ≥ 3 years. The average follow-up period was 8.3 years (range, 3 to 12 years). The indication for this technique was poor acetabular cup coverage of ≤ 70% on preoperative templating. In all cases, cementless hemispherical acetabular cups were fixed to the true acetabulum. Additional procedures included soft tissue release in 16 hips and femoral derotational and shortening osteotomies in 12 hips. We evaluated both clinical and radiological results.

Results

The Harris hip scores improved from 57 points preoperatively to 91 points postoperatively. Radiological analysis revealed no aseptic loosening or radiolucent lines around the acetabular cup. Stable bony fixation of the acetabular cup in the true acetabulum was seen in all cases. Acetabular osteolysis was demonstrated in 12 hips. Revision surgery was performed in 6 hips, but there were no complications related to acetabular circumferential medial wall osteotomy.

Conclusions

Circumferential acetabular medial wall osteotomy can provide appropriate positioning and sufficient coverage of the acetabular cup and thus preserve the medial wall thickness in cementless THA without the need for additional bone grafting for the sequelae of septic arthritis of the hip.