Excellent survival of two anatomically adapted hydroxyapatite coated cementless Total Hip Arthroplasties. A mean follow-up of 11.3 years.

There are many different types of cementless anatomically adapted Total Hip Arthroplasties (THAs) on the market, the Anatomic Benoist Gerard (ABG) I and II are such types of cementless THAs. In this retrospective single-centre study we evaluated the overall survival with revision for any reason and aseptic loosening as endpoint at more than 11 years follow-up. Between 2000 and 2004, 244 cementless THAs were performed in 230 patients in a primary care hospital. At a mean of 11.3 years follow-up (range 9.8 - 12.8 years) clinical examination, plain radiography and Patient Reported Outcome Measures (PROMs) were obtained and analysed. The PROMs consisted of the Oxford Hip Score (OHS) and the Western Ontario and McMaster University Index (WOMAC). At a mean of 11.3 years follow-up 32 patients (13.1%) had died of unrelated causes. Of the remaining cohort all 198 patients (212 THAs) have been reached for evaluation. There were no patients considered as lost to follow-up. At a mean of 11.3 years 11 patients (11 THAs) have had a revision of either the femoral implant or acetabular component resulting in an overall survival of 95.5%. There was no statistically significant difference (p=0.564) in survival between the ABG I and II THAs. Radiographic there were no changes between the ABG I and II last follow up. The ABG II performed statistically significant better in PROMs. We concluded that both anatomically adapted hydroxyapatite coated cementless THAs show excellent survival at more than 11 years follow-up.

Advanced osteoarthritis of the hip as reason for extensive asymmetric leg edema: a rare case report and review of the literature.

An enlarged iliopectineal bursa (IB) can cause pressure on iliofemoral veins. Clinical presentation can manifest as asymmetrical lower extremity edema. This case report demonstrates extensive asymmetrical leg edema caused by femoral vein compression based on iliopectineal bursitis (IB-itis) associated with advanced osteoarthritis (OA) of the left hip joint with an outline of relevant current literature. A female patient presented with left hip pain and edema in the leg. X-ray showed severe OA of the left hip. Computed Tomography (CT) concluded a cystic abnormality at the left iliopsoas muscle associated with the joint consistent with IB-itis, associated with a degenerative left hip joint. Hybrid total hip replacement was performed. At three-month follow-up her left leg showed no longer signs of extensive edema and she walked without the use of walking aids. IB-itis is mostly associated with rheumatoid arthritis (RA). There are no reports which only describe OA as cause of IB-itis. Extensive asymmetrical leg edema can be caused by venous compression of the femoral vein by an IB-itis. If the latter is the consequence of advanced hip OA, a total hip replacement can yield excellent clinical outcomes both functionally and with regard to the edema.

No differences in mid-term survival and clinical outcome between CT- and MRI-based patient-specific instrumentation for total knee arthroplasty, a randomized controlled trial.

PURPOSE: The purpose of this prospective randomized controlled trial was to compare the clinical outcome and the survival rate of total knee arthroplasty between CT- and MRI-based patient-specific instrumentation 5 years after initial surgery. METHODS: At a mean follow-up of 5.8 years (SD 0.3), 98 patients (64% women, loss to follow-up 28%) were included in this analysis. To assess the differences in clinical outcome, patients fulfilled PROMs preoperatively and at each follow-up moment. At final follow-up, the Forgotten Joint Score was adjusted. RESULTS: At final follow-up, no new patients underwent revision surgery in both groups. Regarding the clinical outcome, no statistically significant difference between the groups was found. The Forgotten Joint Score was only performed at final follow-up and showed no significant difference between both groups. CONCLUSION: At mid-term follow-up, survival rates between CT- and MRI-based patient-specific instrumentation did not show a significant difference. Regarding clinical outcome, only the EQ-5D-VAS (p < 0.040) showed a statistically significant difference over time, in favor of the MRI-group. LEVEL OF EVIDENCE: Level I.

Safety and efficacy of outpatient hip and knee arthroplasty: a systematic review with meta-analysis.

INTRODUCTION: This systematic review aimed to assess the safety and efficacy of outpatient joint arthroplasty (OJA) pathways compared to inpatient pathways. MATERIALS AND METHODS: An electronic literature search was conducted to identify eligible studies. Studies comparing OJA with inpatient pathways-following hip and/or (partial) knee arthroplasty-were included. Included studies were assigned-based on OJA definition-to one of the following two groups: (1) outpatient surgery (OS); outpatient defined as discharge on the same day as surgery; and (2) semi-outpatient surgery (SOS); outpatient defined as discharge within 24 h after surgery with or without an overnight stay. Methodological quality was assessed. Outcomes included (serious) adverse events ((S)AEs), readmissions, successful same-day discharge rates, patient-reported outcome measures (PROMs) and costs. Meta-analyses and subgroup analyses by type of arthroplasty were performed when deemed appropriate. RESULTS: A total of 41 studies (OS = 26, SOS = 15) met the inclusion criteria. One RCT and 40 observational studies were included, with an overall risk-of-bias of moderate to high. Forty studies were included in the meta-analysis. Outpatients (both OS and SOS) were younger and had a lower BMI and ASA class compared to inpatients. Overall, no significant differences between outpatients and inpatients were found for overall complications and readmission rates, and improvement in PROMs. By type of arthroplasty, only THAs in OS pathways were associated with fewer AEs [OR = 0.55 (0.41-0.74)] compared to inpatient pathways. 92% of OS patients were discharged on the day of surgery. OJA resulted in an average cost reduction of $6.797,02. CONCLUSION: OJA pathways are as safe and effective as inpatient pathways in selected populations, with a potential reduction of costs. Considerable risk of bias in the majority of studies emphasizes the need for further research.

A short-term radiological and clinical comparison between the bi-cruciate and cruciate retaining total knee arthroplasty A retrospective case controlled study.

PURPOSE: The aim of this study was to provide a short term comparison in radiological and clinical outcome between Bi-Cruciate Retaining (BCR)- and Cruciate Retaining (CR) Total Knee Arthroplasty (TKA). METHODS: The cohort consists of 122 patients undergoing a TKA with PSI, equally distributed over the BCR- and CR-TKA group. Perioperative conditions were observed and radiological images were analysed pre-, 6-weeks, and 1-year postoperative to quantify alignment differences between BCR- and CR-TKA. Preoperatively predicted templates were compared with the implanted size to determine predictive value. In addition mean range of motion and revision rates were determined in both groups. RESULTS: No significant difference was observed in amount of outliers in component alignment between BCR- and CR-TKA. Outliers of the Hip-Knee-Ankle-Axis (HKA-axis) occurred significantly more frequent (P = 0.009) in the BCR-group (37.7%) compared to CR-TKA (18.0%). No clinically relevant differences regarding the predictive sizing of implant components was obtained. No significant differences were observed in revision rates (P = 1.000) and ROM (p = 0.425) between the BCR-groep and CR-group at 2-years FU. CONCLUSION: This study illustrates that although the HKA-axis was not fully restored, bi-cruciate retaining surgical technique for BCR-TKA is safe and effective with comparable radiological and clinical outcome as CR TKA. Randomized controlled trials with longer follow up on the HKA-axis alignment and clinical parameters are needed to confirm the presented results and should focus on possible cut off values concerning leg axis in order to define in what patients a BCR-TKA can safely be used. LEVEL OF EVIDENCE IV: Retrospective Case Controlled Study.

CR-lipped bearing is an adequate functional solution to patients with perioperative excessive laxity in cruciate retaining total knee arthroplasty.

BACKGROUND: The cruciate retaining lipped (CR-lipped) bearing is designed to provide more anterior-posterior (AP) stability and could be employed to resolve excessive intraoperative laxity during the cruciate retaining TKA (CR-TKA). The aim of the study was to determine whether the CR-lipped bearing in CR-TKAs with a perioperative excessive laxity allows equivalent functional results as compared to the standard CR articulation. METHODS: A cohort of 111 TKAs with CR-lipped bearings was matched to a cohort of conventional CR bearings regarding age and sex. The CR-lipped bearing was used in patients with excessive knee AP laxity and the regular CR bearing was used in patients without excessive AP laxity during TKA. Various PROMs (WOMAC, KSS, SF-36) were assessed preoperatively and at 5-years postoperative in combination with revision rate and Range of Motion (ROM). RESULTS: PROMs did not differ significantly between both groups 5-years postoperatively. Mean ROM (flexion) 5-years postoperatively was not significantly different. The implant survivorship was 100% for both cohorts with revision for any reason as end point. CONCLUSION: Based on these results, the CR-lipped bearing is a safe and effective solution for mild interoperatively assessed PCL laxity during CR-TKA without loss of function or decreased survivorship at 5 years. Peroperative conversion to a PS-TKA in order to obtain satisfactory functional scores might therefore not be necessary when mild PCL laxity is observed during surgery. Further research should focus on verifying this approach and longer follow-up is needed to generate data on long term survivorship. LEVEL OF EVIDENCE: Level IV therapeutic, retrospective, cohort study.

Cemented versus uncemented hemiarthroplasty of the hip in patients with a femoral neck fracture: a comparison of two modern stem design implants.

PURPOSE: We wished to compare the outcome of two types of cemented and uncemented modern stem design implants after hemiarthroplasty, with both an Orthopaedic Data Evaluation Panel rating of 10A. METHODS: This retrospective study compares data obtained from two centres, with a total study population of 655 (n = 393 cemented, n = 262 uncemented). Patients were matched at baseline for gender, age, surgery side, American Society of Anesthesiologists score, body mass index and pre-operative haemoglobin level. Outcome measurements were prosthesis-related complications, pre- and post-operative, with reoperation rate and mortality and other complications after 1 year, surgery time, blood loss and immobility at discharge. RESULTS: There were no significant differences in mortality after 1 year, total other complications, immobility at the time of discharge and total prosthesis-related complications between both groups. Significantly more periprosthetic fractures and post-operative infections were seen in the uncemented group with significantly more reoperations compared to the cemented group. Significant differences were seen in cardiovascular complications, blood loss and surgery time in favour of the uncemented group. CONCLUSIONS: In consequence of the significant higher prosthesis-related complications (e.g. infections, periprosthetic fractures and reoperations) in the uncemented group in this study, we recommend cemented hemiarthroplasty in patients with a femoral neck fracture. LEVEL OF EVIDENCE: Level III, Case Controlled Study.

A radiological analysis of the difference between MRI- and CT-based patient-specific matched guides for total knee arthroplasty from the same manufacturer: a randomised controlled trial.

AIMS: This prospective randomised controlled trial was designed to evaluate the outcome of both the MRI- and CT-based patient-specific matched guides (PSG) from the same manufacturer. PATIENTS AND METHODS: A total of 137 knees in 137 patients (50 men, 87 women) were included, 67 in the MRI- and 70 in the CT-based PSG group. Their mean age was 68.4 years (47.0 to 88.9). Outcome was expressed as the biomechanical limb alignment (centre hip-knee-ankle: HKA-axis) achieved post-operatively, the position of the individual components within 3° of the pre-operatively planned alignment, correct planned implant size and operative data (e.g. operating time and blood loss). RESULTS: The patient demographics (e.g. age, body mass index), correct planned implant size and operative data were not significantly different between the two groups. The proportion of outliers in the coronal and sagittal plane ranged from 0% to 21% in both groups. Only the number of outliers for the posterior slope of the tibial component showed a significant difference (p = 0.004) with more outliers in the CT group (n = 9, 13%) than in the MRI group (0%). CONCLUSION: The post-operative HKA-axis was comparable in the MRI- and CT-based PSGs, but there were significantly more outliers for the posterior slope in the CT-based PSGs. TAKE HOME MESSAGE: Alignment with MRI-based PSG is at least as good as, if not better, than that of the CT-based PSG, and is the preferred imaging modality when performing TKA with use of PSG. Cite this article: Bone Joint J 2016;98-B:786-92.

Accuracy of CT-based patient-specific guides for total knee arthroplasty in patients with post-traumatic osteoarthritis.

Published clinical trials who studied the accuracy of patient-specific guides (PSG) for total knee arthroplasty exclude patients with articular deformity of the knee joint. We prospectively analysed a series of 30 patients with post-traumatic osteoarthritis of the knee joint with use of PSG. At 1 year post-operative, the achieved biomechanical (HKA) axis and varus/valgus of the femur and tibia components were measured on anterior-posterior (AP) long-standing weight-bearing radiographs. Flexion/extension of the femoral and AP slope of the tibia component was measured on standard lateral radiographs. Percentages >3° deviation of the pre-operative planned HKA axis and individual implant components were considered as outliers. Approved and used implant size, median blood loss (ml) and operation time (min) were obtained from the operation records. Pre- and 1-year post-operative patient-reported outcome measures (PROMs) were performed. Eighty-three per cent of the patients had a HKA axis restored <3° of the pre-operative planned alignment. Varus/valgus outliers were 0.0 and 6.7 % for the femoral and tibial components, respectively. Percentages of outliers of flexion/extension were 36.7 % for the femoral component and 10.0 % for the AP slope of the tibial component. Median blood loss was 300 ml (50-700), while operation time was 67 min (44-144). In 20 % of all cases, the approved implant size was changed into one size smaller. One-year post-operative PROMs improved significantly. We conclude that the accuracy of CT-based PSG is not impaired in patients with post-traumatic osteoarthritis and this modality can restore biomechanical limb alignment.

Femoral revision with impaction bone grafting and a cemented polished tapered stem.

OBJECTIVE: Biological repair of femoral bone loss using bone impaction grafting. Reconstruction of the centre of rotation of the hip using a cemented stem, the size and offset of which are at the discretion of the surgeon. INDICATIONS: Femoral implant loosening with bone loss. CONTRAINDICATIONS: Infection, neurological disorders, noncompliant patient. SURGICAL TECHNIQUE: Extraction of the loose femoral implant, cortical reconstruction using meshes if required, impaction bone grafting with special instruments, cement fixation of a polished tapered stem. POSTOPERATIVE MANAGEMENT: Individualized period of bed rest and limited weight bearing. RESULTS: Impaction bone grafting and a cemented polished stem were used to perform 33 femoral reconstructions. After a mean follow-up of 15 years, no femoral reconstruction had to be revised. One unrecognized intraoperative fracture healed after nonsurgical treatment, three postoperative femoral fractures healed after plate fixation with the stem left in situ. The average Harris Hip Score improved from 49 prior to surgery to 85 points thereafter. Kaplan-Meier analysis with femoral revision for any reason as the end point showed a survival rate of 100 %.

High rate of failure of impaction grafting in large acetabular defects.

We reviewed the results of 71 revisions of the acetabular component in total hip replacement, using impaction of bone allograft. The mean follow-up was 7.2 years (1.6 to 9.7). All patients were assessed according to the American Academy of Orthopedic Surgeons (AAOS) classification of bone loss, the amount of bone graft required, thickness of the graft layer, signs of graft incorporation and use of augmentation. A total of 20 acetabular components required re-revision for aseptic loosening, giving an overall survival of 72% (95% CI, 54.4 to 80.5). Of these failures, 14 (70%) had an AAOS type III or IV bone defect. In the failed group, poor radiological and histological graft incorporation was seen. These results suggest that impaction allografting in acetabular revision with severe bone defects may have poorer results than have previously been reported.

A bioresorbable molding mesh for impaction grafting revision hip surgery.

Impacted morselized allografts are used to treat bone loss in revision surgery. This technique depends on adequate mechanical support of the graft. Metal support devices function well, but there are disadvantages associated with the use of steel meshes. In this cadaveric, surgical simulation model we investigated the surgical and mechanical suitability of a bioresorbable molding mesh for use in impaction grafting revision surgery. Surgical feasibility was assessed, and mechanical deformation of the mesh during the surgical procedure and postoperative cyclic loading of the specimens were measured with strain gauges. All meshes were surgically usable. The exterior surface deformation of the meshes during the surgical procedure and postoperative mechanical loading did not exceed 4500 microm/m, although the meshes were not damaged in a four-point bending test in which deformations higher than 19,000 microm/m were reached. Therefore, results of this study suggest that this type of bioresorbable mesh seems to have sufficient initial mechanical properties to warrant additional preclinical in vivo study.

Tricalcium-phosphate and hydroxyapatite bone-graft extender for use in impaction grafting revision surgery. An in vitro study on human femora.

Impacted morsellised allografts have been used successfully to address the problem of poor bone stock in revision surgery. However, there are concerns about the transmission of pathogens, the high cost and the shortage of supply of donor bone. Bone-graft extenders, such as tricalcium phosphate (TCP) and hydroxyapatite (HA), have been developed to minimise the use of donor bone. In a human cadaver model we have evaluated the surgical and mechanical feasibility of a TCP/HA bone-graft extender during impaction grafting revision surgery. A TCP/HA allograft mix increased the risk of producing a fissure in the femur during the impaction procedure, but provided a higher initial mechanical stability when compared with bone graft alone. The implications of the use of this type of graft extender in impaction grafting revision surgery are discussed.

Implant wear and osteolysis with a hydroxylapatite-coated screw cup.

Radiographs of 72 uncemented hip implants with a mean follow-up of 6.5 years were analysed to measure wear of the implant. The wear rate was measured using the modified technique of Livermore and was found to be 0.13 mm per year (CI 95% 0.080-0.18). There was no statistical correlation between wear and age, gender and cup angle, but there was a correlation between wear and the number and size of cysts. This has not been previously published. In view of the risk of loosening and of a dramatic increase in the rate of wear when the femoral head articulates with the metal backing, it is important to plan revision of these cups in good time and to ensure regular radiographic surveillance of these patients.

Revision knee arthroplasty using impaction grafting and primary implants.

A technique is described for revision knee arthroplasty with impaction grafting of cancellous bone grafts to treat bone loss and the use of primary implants. Specially designed impaction instruments were used. Bone loss was classified according to the Anderson Orthopaedic Research Institute classification. Four-year follow-up of 11 knees in 9 patients showed good clinical and radiographic results.