Incidence of silent venous thromboembolism after total hip arthroplasty: A comparison of rivaroxaban and enoxaparin.

PROPOSE: Total hip arthroplasty (THA) is associated with a significant risk of venous thromboembolism (VTE). Different thromboprophylaxis strategies have been used to prevent VTE. The primary aim of this study was to report the incidence of VTE and compare the efficacy and safety of rivaroxaban to enoxaparin. The secondary outcome was to report the incidence of silent deep venous thrombosis (DVT) using computed tomography venography. METHODS: One hundred sixty patients who underwent THA were enrolled in a prospective study. Patients were randomized into two groups as follows: those who received rivaroxaban 10 mg oral daily (group RXE) and those who received enoxaparin 40 IU/day subcutaneously for 14 days (group ENO). RESULTS: Both groups were matched for age, sex, comorbidities, special habits and preoperative laboratory investigations. The overall incidence of DVT was 5% (n = 8), which included four patients clinically diagnosed as having DVT and four with silent DVT. All the DVT cases occurred in veins below the knee and in the group RXE; none of the cases occurred in group ENO (p = 0.04). The incidence of DVT was significantly higher in patients with high body mass indexes (p < 0.001), older age (p = 0.024) and medical comorbidities (p = 0.14). No mortality, pulmonary embolism, stroke, wound infection or major bleeding occurred in either group. CONCLUSIONS: Among the patients who underwent hip arthroplasty, rivaroxaban prophylaxis was found to be associated with lower efficacy and similar safety outcomes as compared with enoxaparin anticoagulants.

One-Year Mortality Rates Following Fracture of the Femoral Neck Treated With Hip Arthroplasty in an Aging Saudi Population: A Trauma Center Experience.

INTRODUCTION: Femoral neck fracture is a common problem in elderly patients, and it is managed with either total hip arthroplasty or hemiarthroplasty with very good outcomes. However, the reported 1-year mortality rate is as high as 33%. MATERIAL AND METHODS: This study was a retrospective cohort study. The electronic patient records were searched for all physiologically old patients with displaced femoral neck fractures that were managed with either hemiarthroplasty or total hip arthroplasty. The primary aim of this study was to estimate morbidity and mortality rates at 30 days and 1 year. The secondary outcome was to determine major complications and factors influencing mortality. RESULTS: From January 2017 to December 2018, a total of 99 patients were included in the study. Of those, 57 were female patients. The mortality rate was 15.2%. The significant predictors of death included the age at the time of surgery, readmission within 30 days of initial admission, acute renal impairment, and the need for preoperative medical intervention. Patients treated with total hip arthroplasty had lower mortality rates than those treated with hemiarthroplasty (P = .017). DISCUSSION: To the best of our knowledge, this is the first study conducted in Saudi Arabia to report detailed perioperative-related complications and outcomes following neck of femur fractures. The results of our study confirm the persistently high morbidity and mortality associated with this patient group. CONCLUSION: Efforts should be aimed at optimizing preoperative medical management, which is vital to ensure early identification of medically unfit patients.

Results of single stage exchange arthroplasty with retention of well fixed cement-less femoral component in management of infected total hip arthroplasty.

AIM: To investigate success of one stage exchange with retention of fixed acetabular cup. METHODS: Fifteen patients treated by single stage acetabular component exchange with retention of well-fixed femoral component in infected total hip arthroplasty (THA) were retrospectively reviewed. Inclusion criteria were patients with painful chronic infected total hip. The patient had radiologically well fixed femoral components, absence of major soft tissue or bone defect compromising, and infecting organism was not poly or virulent micro-organism. The organisms were identified preoperatively in 14 patients (93.3%), coagulase negative Staphylococcus was the infecting organism in 8 patients (53.3%). RESULTS: Mean age of the patients at surgery was 58.93 (± 10.67) years. Mean follow-up was 102.8 mo (36-217 mo, SD 56.4). Fourteen patients had no recurrence of the infection; one hip (6.7%) was revised for management of infection. Statistical analysis using Kaplan Meier curve showed 93.3% survival rate. One failure in our series; the infection recurred after 14 mo, the patient was treated successfully with surgical intervention by irrigation, and debridement and liner exchange. Two complications: The first patient had recurrent hip dislocation 12 years following the definitive procedure, which was managed by revision THA with abductor reconstruction and constrained acetabular liner; the second complication was aseptic loosening of the acetabular component 2 years following the definitive procedure. CONCLUSION: Successful in management of infected THA when following criteria are met; well-fixed stem, no draining sinuses, non-immune compromised patients, and infection with sensitive organisms.

Outcome of Revision Total Hip Arthroplasty in Management of Failed Metal-on-Metal Hip Arthroplasty.

BACKGROUND: This is a retrospective review of the functional outcomes and complications of revision total hip arthroplasty (THA) of failed metal-on-metal (MoM) hip arthroplasty. METHODS: A total of 20 revision THAs were performed in 19 patients. Of them, 2 cases were failed hip resurfacing, and 18 cases were failed (MoM) THA. The mean age at revision (THA) was 59.35 years (standard deviation [SD] 9.83). RESULTS: The mean follow-up was 45 months (SD 13.98). The indications of revision were aseptic loosening of acetabular component without adverse local tissue reaction (ALTR; 10 hips), aseptic loosening of the acetabular and femoral components without ALTR (1 hip), painful hip associated with ALTR (6 hips), iliopsoas impingement associated with a large-diameter femoral head or malpositioned acetabular component (3 hips). The acetabular components were revised in 18 hips using Trabecular Metal Modular cups. The femoral components were revised in 3 hips. A constrained acetabular liner was used in 5 hips. The Harris hip score significantly improved from 48.4 (SD 12.98) to 83.25 (SD 10.08). There were 2 complications (1 foot drop and 1 superficial infection) and 1 failure (recurrent dislocation) that required revision to a constrained liner. CONCLUSION: Early results of revision THA of failed MoM hip arthroplasty showed improvement in pain and functional outcome. No case of failed bone ingrowth was noted with the use of Trabecular Metal Modular cups. Extensive soft tissue and abductor muscles dysfunctions were common. A constrained acetabular component with repair of the hip abductors might be beneficial.

Closed suction drainage has no benefits in revision total hip arthroplasty: a randomized controlled trial.

PURPOSE: Several studies have failed to show significant benefits of closed suction drainage (CSD) in routine primary total hip arthroplasty (THA). However, blood loss, haematoma formation and wound complications are generally much greater in revision THA as compared to primary THA. The purpose of this study was to determine if CSD is beneficial for revision THA patients. METHODS: We conducted a prospective, randomized, controlled trial at our institution between July 2013 and July 2014. Eighty-eight patients undergoing revision THA were enrolled and randomly assigned to receive a CSD (n = 44) or to not receive a CSD (n = 44). All first-stage revision surgeries for infection were excluded. Primary outcomes were haemoglobin loss and number of patients transfused. Secondary outcomes included functional outcome evaluated with Harris hip score (HHS), pain evaluated with visual analogue scale (VAS), and length of hospital stay. RESULTS: There were significantly more patients in the CSD group that required blood transfusions (20/44 as compared to 11/44, p = 0.04). Patients in the no CSD group were discharged earlier than patients in the CSD group (4.3 days as compared to 5.4 days, p = 0.002). No statistical significant difference was found in the HHS or pain VAS between the groups. CONCLUSIONS: This study did not demonstrate any benefit with the use of CSD for revision THA with regard to wound related complications, infection or early functional outcome. Post-operative blood loss, transfusion rate, and length of hospital stay may be higher with CSD.

Distal Femoral Arthroplasty for Management of Periprosthetic Supracondylar Fractures of the Femur.

BACKROUND: The incidence of periprosthetic supracondylar femoral fractures is 0.3% to 2.5% after primary total knee arthroplasty. METHODS: We performed a retrospective review 17 patients managed by distal femoral arthroplasty for periprosthetic supracondylar femoral fracture. RESULTS: Mean age was 76 years (SD, 12.58). Mean follow-up was 33.9 months (SD, 10.57). Mean final range of motion was 2° of fixed flexion (SD, 5.3) and flexion of 90.2° (SD, 20.8). Mean final follow-up Knee Society Score was 67.15 (SD, 19.7). Mean Short Form-12 physical component was 36.57 (SD, 11.2), and mean Short Form-12 mental component was 42.64 (SD, 12.09). Four complications (4 patients) were managed successfully without revision of the prosthesis. Two failures (2 patients) required prosthesis revision: patellar maltracking with knee dislocation, and periprosthetric femoral fracture. CONCLUSION: Distal femoral arthroplasty is a successful procedure. Complication rates are not insignificant, which is expected with the complexity of this clinical scenario.

Promising Mid-term Results With a Cup-cage Construct for Large Acetabular Defects and Pelvic Discontinuity.

BACKGROUND: Restoring normal anatomy and achieving stable fixation of the acetabular component can be especially challenging when the surgeon must deal with severe acetabular defects and/or pelvic discontinuity. The cup-cage (CC) construct, where an ilioischial cage is cemented within a biologically fixed porous metal cup, has emerged as an excellent option to treat such challenges. QUESTIONS/PURPOSES: We sought to determine (1) mid-term Kaplan-Meier survival; (2) clinical outcomes based on Merle d'Aubigné-Postel scores; (3) radiological outcomes based primarily on construct migration; and (4) the complication rate for a series of 67 CC procedures performed at our institution. METHODS: All hip revision procedures between January 2003 and March 2012 where a CC was used (with the exception of tumor cases or acute fracture; four total cases) that had a minimum 2-year followup and that had been seen within the last 2 years were included in this retrospective review. Acetabular bone loss and presence of pelvic discontinuity were assessed according to the Gross classification. Sixty-seven CC procedures with an average followup of 74 months (range, 24-135 months; SD, 34.3) months were identified; 26 of 67 (39%) were Gross Type IV and 41 of 67 (61%) were Gross Type V (pelvic discontinuity). Postoperative clinical and radiological evaluation was done annually. Merle d'Aubigné-Postel scores were recorded and all radiographs were compared with the 6-week postoperative radiographs to evaluate for radiographic loosening or migration. Failure was defined as revision surgery for any cause, including infection. RESULTS: The 5-year Kaplan-Meier survival rate with revision for any cause representing failure was 93% (95% confidence interval [CI], 83.1-97.4), and the 10-year survival rate was 85% (95% CI, 67.2-93.8). The Merle d'Aubigné-Postel score improved significantly from a mean of 6 preoperatively to 13 postoperatively (p < 0.001). Four CC had nonprogressive radiological migration of the ischial flange and they remain stable. CONCLUSIONS: We believe that the CC construct is a suitable choice to treat chronic pelvic discontinuity; it also remains a reliable option for the treatment of severe acetabular bone defects if stable fixation cannot be obtained through the use of a trabecular metal cup with or without augments. LEVEL OF EVIDENCE: Level IV, therapeutic study.

The focally constrained liner is a reasonable option for revision of unstable total hip arthroplasty.

PURPOSE: Revision surgery for a patient with previous recurrent dislocations or abductor muscle dysfunction has been considered to be a complication-prone procedure regardless of the type of constrained implant used. We investigated the survivorship of a focally constrained acetabular liner used for revision total hip arthroplasty in patients with abductor insufficiency or previous recurrent dislocations. METHODS: We retrospectively reviewed 98 patients in whom a focally constrained acetabular liner was used to treat abductor insufficiency or previous recurrent dislocations. The mean age was 69.4 years (37-92) and 64 of these were females. Previously, the patients had undergone a mean of two (1-5) revisions. The mean follow-up was 38 (12-66) months. Kaplan-Meier survival curves were calculated and Log-rank test was used to test the difference in survivorship between patients with abductor insufficiency and previous dislocations. RESULTS: Sixteen patients needed a further re-revision for any cause. Thus, the revision-free survivorship was 84.3 % at five years. Five patients suffered a dislocation with a mean of five months post-operatively and were managed with repeat revision. Five patients failed at the implant-host bone interface. Three of these failures occurred after cementing the constrained liner into a pre-existing shell. CONCLUSIONS: The focally constrained liner provided a reasonable option for revision total hip arthroplasty in patients with hip instability. Failures were observed in patients with acetabular osteolysis but seemingly well-fixed component and unrecognized impingement.

Vancouver type B2 and B3 periprosthetic fractures treated with revision total hip arthroplasty.

PURPOSE: Periprosthetic fractures are the fourth most common cause for hip revision and a devastating complication. Our purpose is to report results and quality of life following revision THA for Vancouver B2 and B3 fractures. METHODS: This was a retrospective review from January 2000 to November 2012 to identify all revision THA performed for Vancouver types B2 and B3 that had a minimum follow-up of two years. Routine post-operative and radiographic evaluation to assess patient survival, implant failure, complications and quality of life was involved. Statistical analysis was made with the Kaplan-Meier survival curve with 95 % confidence interval and the log rank (Mantel-Cox) test. RESULTS: A total of 76 fractures were included, with an average follow-up 74.4 months. Mean age at the revision surgery was 75.7 years (range, 41-97 years; SD, 12.4). Sixty-six cases were classified as Vancouver B2 and treated with distal fixation stem. Ten cases were Vancouver B3 and a proximal femoral allograft technique was used. The overall five-year Kaplan-Meier survival rate for the patients was 77.9 % (95 % CI, 67.4-88.4), and the ten-year rate was 65.1 % (95 % CI, 51.4-78.8). Five-year Kaplan-Meier survival rate for the implants was 89.6 % (95 % CI, 82.2-97); we presented seven failures. The mean SF-12 mental was 55.1 (range, 31-68; SD, 8.1) and the physical was 37.4 (range, 16-55; SD, 9.4). CONCLUSION: Mortality rate after periprosthetic fractures is high as compared to other hip surgeries; our Kaplan-Meier analysis showed that it tends to plateau after five years. In our series the failure rate was low and occurred early in the post-operative period.

Patients report improvement in quality of life and satisfaction after hip resurfacing arthroplasty.

BACKGROUND: A number of reconstructive procedures are available for the management of hip osteoarthritis. Hip resurfacing arthroplasty is now an accepted procedure, with implant survivorship comparable to THA at up to 10 years' followup in certain series. Most reports focus on implant survivorship, surgeon-derived results, or complications. Fewer data pertain to patient-reported results, including validated measures of quality of life (QoL) and satisfaction and baseline measures from which to determine magnitude of improvement. Validated patient-reported results are essential to guide patients and surgeons in the current era of informed and shared decision making. QUESTIONS/PURPOSES: We determined whether patients reported improvement in disease-specific, joint-specific, and generic QoL after hip resurfacing arthroplasty; whether patients were satisfied with the results of the procedure; and latest activity level and return to sport. METHODS: We retrospectively reviewed 127 patients (100 men, 27 women) who underwent 143 hip resurfacing procedures between 2002 and 2006. Mean patient age was 52 years. Patients completed the WOMAC, Oxford Hip Score, and SF-12 at baseline and again at minimum 2-year followup (mean, 2.5 years; range, 2-6 years). At latest followup, patients completed a validated satisfaction questionnaire and UCLA activity score. RESULTS: All QoL scores improved (normalized to a 0-100 scale, where 100 = best health state). WOMAC improved from 46 to 95, Oxford Hip Score from 42 to 95, SF-12 (physical) from 34 to 54, and SF-12 (mental) from 46 to 56. Patient satisfaction score was 96. UCLA activity score was 8. CONCLUSIONS: The majority of patients reported improvement in QoL, were very satisfied with their outcome, and returned to a high level of activity after hip resurfacing arthroplasty. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Total hip arthroplasty in steroid-induced osteonecrosis: early functional and radiological outcomes.

BACKGROUND: The proportion of total hip arhtoplasties (THAs) associated with corticosteroid use is uncertain, and the mechanisms of corticosteroid-induced osteonecrosis remain unknown. We sought to evaluate the clinical and radiographic outcomes, complications and satisfaction with THA among patients with corticosteroid-induced osteonecrosis. METHODS: We retrospectively assessed functional outcome at a minimum 1-year follow-up using the Western Ontario and MacMaster Universities Arthritis Index (WOMAC); Oxford Hip Score; Short Form (SF)-12; University of California, Los Angeles (UCLA) Activity; and patient satisfaction scores. RESULTS: We included 31 patients (35 hips). The average follow-up was 20 (range 12- 55) months, and the average age at surgery was 47 (range 19-78) years. At follow-up, patients showed significant improvement in all 4 components of the WOMAC (means: function 84, stiffness 75, pain 86, global 84), Oxford-12 (mean 83) and SF-12 (means: mental 40 and physical 48) scores. However, there was no significant improvement in the UCLA Activity scores. Mean patient satisfaction scores were good for pain relief (86), function (80), recreation (77.5) and overall results of surgery (86). Radiographic review at follow-up showed that all components were well fixed with no evidence of loosening. The complication rate was high (17%), with 6 complications in 5 patients (6 of 35 hips). Four patients (4 of 35 hips; 11%) required reoperations. CONCLUSION: Total hip arthroplasty in patients with corticosteroid-induced osteonecrosis of the femoral head is successful in reducing pain and improving function; however, the rate of complications and reoperation is high.

Clinical outcomes of primary total joint arthroplasty among nonagenarian patients.

A retrospective cohort study and a comparative literature review were undertaken to determine outcomes and survival/mortality rates among nonagenarian patients who underwent total joint arthroplasty (TJA). Thirty-nine patients who underwent TJA (14 hips, 25 knees) aged 90+ years were identified from a database of 9817 primary TJA cases performed at one hospital between 1998 and 2010. Findings were compared to synthesized data from relevant published literature review (LR). The mean age was 91.3 (±1.4) years, 79.5% were rated by the American Society of Anesthetists as 3+. Medical complication rate was 25.6% vs 36.2% for LR cases (P = .219). Perioperative death rate was 2.6% vs 2.1% among LR cases (P = 1.000). At 3.8-year follow-up, mortality rate was 59% (LR, 58.2%; 5.1 years), with a mean age of 95.2 (±3.5) years at death (LR, 96.3 ± 3.4). Excellent clinical outcomes were achieved. Primary TJA remains a viable and effective procedure in nonagenarian patients.

Preoperative knee stiffness and total knee arthroplasty outcomes.

A retrospective case-control study was conducted to evaluate 1-year total knee arthroplasty (TKA) outcomes among preoperative stiff knees, range of motion (ROM) 80° or less, compared with nonstiff preoperative knees, ROM 100° or greater. A total of 134 stiff knee cases were compared with a matched cohort of 134 non-stiff knee controls. Knee Society Score and Oxford Knee Score change scores from baseline to 1 year were similar between the groups. Stiff knees experienced a significantly greater mean improvement in ROM from baseline to 1 year (30.8° ± 18.8°) as compared with nonstiff knees (1.1° ± 12.8°) (P < .0001). Although ultimate ROM of a TKA can be restricted secondary to preoperative stiffness, improvements in outcomes and ROM are not affected. We conclude that progression of stiffness should not in and of itself lead to earlier intervention of TKA in most cases.

Randomized controlled trial of radiographic and patient-assessed outcomes following fixed versus rotating platform total knee arthroplasty.

This prospectively blinded randomized controlled study evaluated the difference in the functional and radiological outcomes in patients who received a press-fit condylar Sigma cemented cruciate-substituting total knee arthroplasty with either a rotating platform (RP) or a fixed bearing (FB). There were 51 joints in 49 patients: 24 joints in the RP group (mean follow-up, 43 months) and 27 joints in the FB group (mean follow-up, 40 months). At baseline, there was no significant difference in age, body mass index, preoperative diagnosis, Charnley class, range of motion, clinical and functional scores, between the RP and FB groups. At mid-term follow up both the RP and FB give equivalent results, but patients with the RP tended to have a higher activity level score.