Hemiarthroplasty for Hip Fractures: Posterior or Direct Lateral Approach? Advantages and Disadvantages.

BACKGROUND: Several approaches are used to access the hip joint; most common are the direct lateral and posterior. Little consensus exists on which to use when treating hip fractures. OBJECTIVES: To compare short-term complications, postoperative ambulation, and patient-reported outcome measures (PROMS) of direct lateral vs. posterior approaches in hemiarthroplasty for acute hip fractures. METHODS: We conducted a retrospective clinical trial with 260 patients who underwent bipolar hemiarthroplasty in the direct lateral or posterior approach (166 and 94, respectively) between January 2017 and December 2018. The clinical data included short-term complications: prosthetic dislocation, periprosthetic fractures, and infection. Postoperative ambulation was collected 6 weeks postoperatively; PROMS were collected for 173 patients at 2 years follow-up. RESULTS: There were six dislocations overall, average time to dislocation was 22 days postoperative (range 4-34). Five dislocations were after the posterior approach (5.3%) and one after direct lateral (0.6%) (P = 0.01). At 6 weeks follow-up, inability to walk was found in 16.9% of the direct lateral group and 6.4% of the posterior approach group (P = 0.02). In the posterior approach group, 76% could walk more than 20 meters; only half of the direct lateral group could (P = 0.0002). At 2 years follow-up, PROMS did not show a statistically significant difference between the groups. CONCLUSIONS: Posterior approach for hemiarthroplasty following femoral neck fractures allows superior ambulation to the direct lateral approach only for the short-term. However, no long-term clinical advantage was found. This short-term benefit does not justify the increased dislocation rate in the posterior approach.

Failure Rate and Early Complications of Thumb Carpometacarpal Joint Replacement-A Multicenter Retrospective Study of Two Modern Implant Designs.

Joint replacement arthroplasty for the treatment of thumb osteoarthritis is gaining popularity as recent studies have demonstrated better pinch and grip strength and faster rehabilitation. Our aim was to identify early complications in modern implant designs using a multicenter study. A total of 381 patients who underwent thumb carpometacarpal replacement surgery in six participating hospitals were enrolled. The complications included were fractures, dislocations, infections, tendon and nerve injuries, and complex regional pain syndrome. Major complications were defined as a failure to implant the prosthesis, revision surgery to remove the implant, and any other need for further surgical intervention. The secondary outcomes were any other complications treated non-surgically and the timing of the complications. Eleven procedures failed, and these patients were treated with trapeziectomies. Twelve other patients required repeat surgical interventions. Minor adverse events occurred in 25.4% of the cases, and transient irritation of the superficial radial nerve and De Quervain tendinopathy were the most prevalent complications. Although this cohort depicted the learning curves of multiple surgeons, our study demonstrated low short-term failure rates. An inability to achieve primary stability of the cup in the trapezium was the leading cause of failure. Dislocations and other major complications with modern implants were very few.

Treatment of Septic Arthritis of the Hip Joint Using Repeated Aspirations: When Should We Operate?

Background: The well-accepted treatment of septic arthritis of the hip joint (SAHJ) is surgical drainage of the joint, but repeated aspirations of the hip joint under sonography, have been used for over twenty years with significant success in some centers, including ours. In recent years, we identified some children who did not respond to aspirations and had to undergo arthrotomies. We were concerned that some children may have reached the operating room after a longer than ideal time. Objective: Identification of the characteristics of patients who did not respond to repeated aspirations and development of a treatment algorithm that expedites decision-making regarding the necessity of surgery. Methods: This is a single-center retrospective cohort analysis. All the patients diagnosed with SAHJ between 2007 and 2019 were identified. Patients who responded to repeated aspirations were compared to those who did not improve and required surgery. Demographic and clinical data and laboratory results were obtained from the patients' electronic medical records. Results: Forty-eight children (88.9%) were treated successfully with repeated aspirations and six children (11.1%) did not improve after aspirations and underwent hip arthrotomies. Five out of 48 children from the aspiration group (10.4%) and 4 out of 6 from the arthrotomy group (66.7%) had chronic comorbidities (p = 0.0051). The mean duration of fever over 38.5 degrees centigrade and the length of stay were higher in the arthrotomy group (p = 0.0040, p = 0.0301, respectively). When we examined the change in C-reactive protein (CRP) levels before and after the first aspiration (Delta CRP), we found a decrease in the aspiration group and an increase in the arthrotomy group (p = 0.0044). Conclusion: The new algorithm which we present allows an expeditious assessment of the patient's response to the repeated aspiration method and thus prevents unnecessary surgeries for the treatment of SAHJ. Patients with chronic comorbidities, prolonged fever, and an increase in CRP level following the first aspiration, are at risk of treatment failure and should be treated with an arthrotomy. Level of evidence for clinical articles: Level 4-cohort study.

Does hip morphology correlate with proximal femoral fracture type?

PURPOSE: To determine if boney morphology influences the anatomic location of hip fractures in elderly patients. METHODS: All patients with hip fractures between 2008 and 2012 who had hip radiographs taken prior to the fracture were reviewed. Fractures were classified as intracapsular or extracapsular and hip morphology was measured on the pre-fracture x-rays. Hip morphology was determined by alpha angle, lateral central edge angle, acetabular index, neck-shaft angle, hip axis length, femoral neck diameter, Tönnis classification for hip osteoarthritis (OA) and the presence of a crossover sign. RESULTS: 148 subjects (78.4% female, age 83.5 years) with proximal femur fractures were included. 44 patients (29.7%) had intracapsular fractures and 104 (70.3%) had extracapsular fractures. 48% of patients had previous hip fractures on the contralateral side and 74.6% had the same type of fracture bilaterally. The rates of bilateral intracapsular and extracapsular fractures were similar (33.7% vs. 40.9% respectively, p = 0.39). Extracapsular fractures had a statically significant higher neck-shaft angle, a shorter hip axis length, a narrower femoral neck diameter and a higher grade of Tönnis classification of OA (p = 0.04, 0.046, 0.03, 0.02 respectively). Acetabular coverage and the proximal femoral head-neck junction, which were evaluated by lateral centre-edge angle (LCEA), acetabular index and the presence of a crossover sign, did not correlate with fracture type. The alpha angle > 40° had a statistically significant higher likelihood for extracapsular fractures (p = 0.013). CONCLUSIONS: Acetabular coverage and proximal femoral head-neck junction morphology, were found to partially correlate with the location of hip fractures and do not fully elucidate fracture type susceptibility.

Does capsular closure influence patient-reported outcomes in hip arthroscopy for femoroacetabular impingement and labral tear?

Capsulotomy is necessary to facilitate instrument manoeuvrability within the joint capsule in many arthroscopic hip surgical procedures. In cases where a clear indication for capsular closure does not exist, surgeon's preference and experience often determines capsular management. The purpose of this study was to assess the influence of capsular closure on clinical outcome scores and satisfaction in patients who underwent hip arthroscopy surgery for femoroacetabular impingement (FAI) and labral tear. Data were prospectively collected and retrospectively analysed for hip arthroscopy surgeries with a minimum 2 years follow-up. Patients with developmental dysplasia of the hip, previous back or hip surgeries, and degenerative changes to this hip and secondary gains were excluded. Demographic data, intraoperative findings and patient-reported outcome scores were recorded, including the Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). A total of 29 and 35 patients were included in the non-closure and closure groups, respectively. The mean follow-up time was over 3 years for both groups. The mean pre-operative and post-operative HOS scores and MHHS scores did not significantly differ between groups (pre-operative HOS: 65.6 and 66.3, P = 0.898; post-operative HOS: 85.4 and 87.2, P = 0.718; pre-operative MHHS: 63.2 and 58.4, P = 0.223; post-operative MHHS: 85.7 and 88.7, P = 0.510). Overall patient satisfaction did not differ significantly between groups (non-closure 86.3%, closure group 88.6%; P = 0.672). Capsular closure did not significantly influence satisfaction or clinical outcome scores in patients who underwent arthroscopic hip surgery for FAI or labral tear.

Hip arthroscopy for intra-capsular benign tumors: a case series.

The purpose of this study is to demonstrate the assessment of intra-capsular femoral head and neck tumors, and to describe the arthroscopic surgical technique used to resect and fill the bone defects. Three cases of benign femoral head and neck lesions are presented. Two benign enchondromas and one benign osteochondroma were resected arthroscopically. Traction was used in one case. Modified Harris Hip Score improved in all three cases to scores of 95 or greater with an average improvement of 16 points with a minimum follow up of 15 months. Arthroscopic surgical resection of intra-capsular femoral hip lesions offers an effective alternative to open resection. This technique offered good outcomes in the limited cohort. We suggest that arthroscopic resection of intra-capsular femoral hip lesions be considered in relevant cases as an alternative to open resection.

Late clinical outcome of transient intraoperative systolic anterior motion post mitral valve repair.

OBJECTIVE: Systolic anterior motion (SAM) after mitral valve repair with significant mitral regurgitation requires immediate reintervention. Transient SAM immediately after repair is usually managed by hemodynamic maneuvers. We investigated the late clinical and echocardiographic significance of postoperative transient SAM. METHODS: Between 2004 and 2013, mitral valve repair was performed on 549 consecutive patients with degenerative mitral valve disease. Of the 45 patients (8.2%) identified with postrepair SAM, 5 needed immediate reintervention. Hemodynamic maneuvers, such as preload and afterload augmentation and rate control, effectively abolished SAM in 40 patients (SAM). They were followed and compared with the remaining 509 patients (non-SAM). RESULTS: Mean clinical follow-up was 54 ± 28 and 31 ± 26 months and was available in 100% and 95% (SAM and non-SAM) patients, respectively. One hospital death occurred in each group (P = .14). At follow-up, 2 patients (0.3%) showed significant SAM with left ventricular outflow tract obstruction, which resolved in 1 patient after beta-blocker therapy. SAM patients underwent exercise stress echocardiography: 1 patient showed left ventricular outflow tract obstruction that worsened after exercise. At 5 years, freedom from moderate or severe mitral regurgitation and New York Heart Association functional class III-IV was 85% versus 92% (P = .27) and 81% versus 92% (P = .15), and freedom from reoperation was 100% and 96% (P = .4), in SAM and non-SAM patients, respectively. CONCLUSIONS: Late postoperative exercise stress echocardiogram revealed low incidence of SAM in patients with immediate postrepair transient SAM. All other late clinical outcomes were similar to those of non-SAM repair patients. Conservative management of intraoperative transient SAM is both successful and reliable.