Resuming elective hip and knee arthroplasty after the first phase of the SARS-CoV-2 pandemic: the European Hip Society and European Knee Associates recommendations.

PURPOSE: The Covid-19 pandemic has disrupted health care systems all over the world. Elective surgical procedures have been postponed and/or cancelled. Consensus is, therefore, required related to the factors that need to be in place before elective surgery, including hip and knee replacement surgery, which is restarted. Entirely new pathways and protocols need to be worked out. METHODS: A panel of experts from the European Hip Society and European Knee Association have agreed to a consensus statement on how to reintroduce elective arthroplasty surgery safely. The recommendations are based on the best available evidence and have been validated in a separate survey. RESULTS: The guidelines are based on five themes: modification and/or reorganisation of hospital wards. Restrictions on orthopaedic wards and in operation suite(s). Additional disinfection of the environment. The role of ultra-clean operation theatres. Personal protective equipment enhancement. CONCLUSION: Apart from the following national and local guidance, protocols need to be put in place in the patient pathway for primary arthroplasty to allow for a safe return.

Recommendations for resuming elective hip and knee arthroplasty in the setting of the SARS-CoV-2 pandemic: the European Hip Society and European Knee Associates Survey of Members.

PURPOSE: The COVID-19 pandemic has disrupted the health care system around the entire globe. A consensus is needed about resuming total hip and knee procedures. The European Hip Society (EHS) and the European Knee Association (EKA) formed a panel of experts that have produced a consensus statement on how the safe re-introduction of elective hip and knee arthroplasty should be undertaken. METHODS: A prospective online survey was done among members of EHS and EKA. The survey consisted of 27 questions. It includes basic information on demographics and details the participant's agreement with each recommendation. The participant could choose among three options (agree, disagree, abstain). Recommendations focussed on pre-operative, peri-operative, and post-operative handling of patients and precautions. RESULTS: A total of 681 arthroplasty surgeons participated in the survey, with 479 fully completing the survey. The participants were from 44 countries and 6 continents. Apart from adhering to National and Local Guidelines, the recommendations concerned how to make elective arthroplasty safe for patients and staff. CONCLUSION: The survey has shown good-to-excellent agreement of the participants with regards to the statements made in the recommendations for the safe return to elective arthroplasty following the first wave of the COVID-19 pandemic.

Disruption of joint arthroplasty services in Europe during the COVID-19 pandemic: an online survey within the European Hip Society (EHS) and the European Knee Associates (EKA).

PURPOSE: The aim of the present study was to evaluate the impact of the coronavirus (COVID-19) pandemic on joint arthroplasty service in Europe by conducting an online survey of arthroplasty surgeons. METHODS: The survey was conducted in the European Hip Society (EHS) and the European Knee Associates (EKA). The survey consisted of 20 questions (single, multiple choice, ranked). Four topics were addressed: (1) origin and surgical experience of the participant (four questions); (2) potential disruption of arthroplasty surgeries (12 questions); (3) influence of the COVID-19 pandemic on the particular arthroplasty surgeon (four questions); (4) a matrix provided 14 different arthroplasty surgeries and the participant was asked to state whether dedicated surgery was stopped, delayed or cancelled. RESULTS: Two-hundred and seventy-two surgeons (217 EHS, 55 EKA) from 40 different countries participated. Of the respondents, 25.7% stated that all surgeries were cancelled in their departments, while 68.4% responded that elective inpatient procedures were no longer being performed. With regard to the specific surgical procedures, nearly all primary TJA were cancelled (92.6%) as well as aseptic revisions (94.7%). In most hospitals, periprosthetic fractures (87.2%), hip arthroplasty for femoral neck fractures and septic revisions for acute infections (75.8%) were still being performed. CONCLUSION: During the current 2020 COVID-19 pandemic, we are experiencing a near-total shutdown of TJA. A massive cutback was observed for primary TJA and revision TJA, even in massively failed TJA with collapse, dislocation, component failure or imminent dislocation. Only life-threatening pathologies like periprosthetic fractures and acute septic TJA are currently undergoing surgical treatment. LEVEL OF EVIDENCE: V.

A predictive radiological analysis of short stems versus both shortened and long stems in primary hip replacement: A case-control study of 100 cases of Metha versus ABG II and Omnifit HA at 2-8years' follow-up.

INTRODUCTION: Short hip stems, intended to conserve bone stock and ensure a more physiological distribution of stress in the femur under loading, are meeting with renewed interest. Radiologic semiology is not known exactly, particularly in relation to conventional implants; we therefore conducted a case-control study of 3 types of implant differing only in stem length: short, shortened or long. The aim was: (1) to compare radiographic aspects, (2) to attempt to systematize medium-term radiologic status for the 3 types, and (3) to assess the impact of radiographic aspect on loosening and revision rates. HYPOTHESIS: The short Metha stem is better adapted to the recipient bone than longer stems, without sacrificing stability. MATERIAL AND METHODS: A prospective series comprising the first 100 selected cases of hip replacement using the short Metha stem was compared to two other series of 100 "long" (Omnifit HA) and 100 "shortened" (ABG II) stems at comparable follow-up: 4.05±1.44years (range: 2-8years) for Metha, 4.48±0.97years (range: 2-8years) for Omnifit, and 4.75±2.07years (range: 2-8years) for ABG II. Selection criteria in this initial phase were very strict: young age and/or high activity level, with good bone stock and femoral morphology suited to fitting a Metha stem (no "stovepipe" or "champagne-flute" femurs), for which 12.8% of primary hip replacements were selected. Matching was performed by sampling on criteria of age, gender, body-mass index and etiology. Radiographic parameters were compared between the short stem group and the two control groups and classified according to Engh-Massin score (10 points for fixation and 17 for stability). RESULTS: The short Metha stem provided excellent fixation scores: 7.65/10, versus 7.16 (P=0.003) and 5.92 (P=0.0001) for ABG II and Omnifit, respectively. Likewise, stability was scored 14.23/17 for Metha, vs. 14.51 (NS) and 11.83 (P=0.0001) respectively, and the total score was higher for Metha (21.88/27) than ABG II (21.67; P=0.03) or, more particularly, Omnifit (17.83; P=0.0001). The Metha stem was never associated with thigh pain or periprosthetic fracture. 8-year survival was 100%, without significant difference with respect to ABG II (100%; NS) or Omnifit (98.8%; 95% CI: 0.964-1; NS). DISCUSSION: The apparent radiologic superiority of the short Metha stem requires long-term confirmation in non-selected series. Meanwhile, Metha can be asserted to have demonstrated optimal compromise between lasting bone anchorage and respect of bone physiology under loading at medium term. LEVEL OF EVIDENCE: III, case-control study.

Cost-effectiveness model comparing dual-mobility to fixed-bearing designs for total hip replacement in France.

BACKGROUND: Instability is among the main causes of total hip arthroplasty (THA) failure. In clinical studies, THA with a dual-mobility cup (THA-DM) decreased the risk of instability after primary THA compared to THA with a fixed-bearing design (THA-FB). However, whether THA-DM is more cost-effective than THA-FB has not been established using Markov modelling with determination of the incremental cost-effectiveness ratio (ICER). The objectives of this work were to: (1) measure the efficiency of these two options, (2) use the nationwide hospital electronic database (PMSI) to estimate direct costs of dislocations and revisions for instability, and (3) conduct deterministic and probabilistic sensitivity analyses to estimate potential mean annual cost-savings in France. HYPOTHESIS: We hypothesised that primary THA-DM was cost-saving compared to primary THA-FB. MATERIAL AND METHODS: In the database, we identified 80,405 patients who had THA in 2009 and we collected their outcomes over 4 years (2009-2012). Cost-effectiveness was assessed based on the costs of resources used for all consequences of prosthetic dislocation and paid for by the statutory health insurance system or other sources. RESULTS: THA-DM was associated with a relative risk of dislocation of 0.4 versus THA-FB. This risk difference translated into 3283 fewer dislocations per 100,000 patients with THA-DM. The corresponding cost-savings for the 140,000 primary THA procedures done in France annually was 39.62 million Euros. A relative risk of 0.2 would yield annual cost-savings of 56.28 million Euros. In the probabilistic sensitivity analysis, THA-DM was the less costly option under all hypotheses, with potential maximum cost-savings of more than 100 million Euros per year in France. DISCUSSION: This comparative cost-effectiveness analysis suggests that THA-DM may induce substantial cost-savings compared to THA-FB. This possibility should be assessed by long-term clinical studies of new-generation DM prostheses.

Outcomes and prognostic factors in revision hip arthroplasty for severe intra-pelvic cup protrusion: 246 cases.

BACKGROUND: The outcome of revision total hip arthroplasty (THA) for intra-pelvic cup protrusion is unclear. Hence, we conducted a large retrospective study to clarify the surgical strategy (hip lever arm and cup mechanical fixation) and the outcomes of reconstruction for severe intra-pelvic cup protrusion. HYPOTHESIS: We hypothesized that restoration of the anatomic hip centre in such acetabular revisions decreased the risk of recurrent loosening. MATERIAL AND METHODS: The study included 246 THA procedures (in 220 patients), with a follow-up of 5.2 ± 4.9 years (1-24.2) after the index surgery. Bone loss was estimated using the SOFCOT classification (grade III or IV in 80% of cases) and the Paprosky classification (IIIA or IIIB in 58% of cases). Quality of the reconstruction was assessed on X-rays according to the correction of the protrusion and position of the hip centre of rotation. RESULTS: After a clinical follow-up of at least 5 years, with a mean of 9.9 ± 4.1 years (5-24 years), the mean Postel-Merle d'Aubigné score was 14.2 ± 3.1 and the mean Harris Hip Score was 78.0 ± 18.7. Cup protrusion was partially or completely corrected in every case and cup position was normal in 27 (11%) cases. The centre of rotation was within 10mm of the physiological position in 158 (64.2%) cases, acceptable in 77 (31.3%) cases, ascended in 9 (3.7%) cases, and worsened in 1 (0.4%) case. Revision for cup or cup and femoral failures was required in 24 (9.8%) cases. Cumulative survival rates with cup loosening as the endpoint were 88.5% after 5 years, 79.9% after 10 years, and 63.9% at last follow-up at 13.6 years. DISCUSSION: Our hypothesis that restoration of anatomic hip centre decreased the risk of recurrent loosening was not verified: success or failure in restoring the normal centre of rotation did not correlate significantly with final cup status. Recurrent aseptic loosening was the cause of failure in 9.8% of cases. Ensuring long-term effective mechanical stability had a greater impact on global outcomes than restoring an ideal centre of rotation.

Is unicompartmental-to-unicompartmental revision knee arthroplasty a reliable option? Case-control study.

BACKGROUND: In selected patients with failed unicompartmental knee arthroplasty (UKA), revision UKA is a reliable option and may even provide lower morbidity rates and better functional outcomes compared to revision total knee arthroplasty. MATERIAL AND METHODS: In a multicentre retrospective study of 425 knees requiring revision surgery after UKA, 36 knees were managed with revision UKA. RESULTS: Of the 36 knees, 3 (8.33%) required iterative revision surgery, for aseptic loosening. After a mean follow-up of 8.3 years, the mean IKS knee and function scores were high (93.81/100 and 90.77/100, respectively). DISCUSSION: In carefully selected patients, UKA-to-UKA revision performed according to a rigorous operative technique deserves a role in the surgical strategy for failed UKA. LEVEL OF EVIDENCE: III, multicentre retrospective case-control study.

Clinical results, radiological findings and survival of a proximally hydroxyapatite-coated hip ABG II stem at a minimum of ten years' follow-up: results of a consecutive multicentre study of 1148 hips in 1053 patients.

We report a multicentre prospective consecutive study assessing the long-term outcome of the proximally hydroxyapatite (HA)-coated ABG II monobloc femoral component in a series of 1148 hips in 1053 patients with a mean age at surgery of 64.77 years (22 to 80) at a mean follow-up of 10.84 years (10 to 15.25). At latest follow-up, the mean total Harris hip score was 94.7 points (sd; 6.87; 49 to 100), and the mean Merle d'Aubigné-Postel score was 17.6 points (sd 1.12; 7 to 18). The mean total Engh radiological score score was 21.54 (sd 5.77; 3.5 to 27), with 95.81% of 'confirmed ingrowth', according to Engh's classification. With aseptic loosening or pain as endpoints, three AGB II stems (0.26%) failed, giving a 99.7% survival rate (se 0.002; 95% confidence interval (CI) 0.994 to 1) at 14 years' follow-up. The survival of patients ≤ 50 years of age (99.0% (se 0.011; 95% CI 0.969 to 1)) did not differ significantly from those of patients aged > 50 years (99.8% (se 0.002; 95% CI 0.994 to 1)). This study confirmed the excellent long-term results currently achieved with the ABG II proximally HA-coated monobloc stem. Cite this article: Bone Joint J 2013;95-B:1610-16.

Unicompartmental knee arthroplasty modes of failure: wear is not the main reason for failure: a multicentre study of 418 failed knees.

BACKGROUND: This study originated from a symposium held by the French Hip and Knee Society (Société française de la hanche et du genou [SFHG]) and was carried out to better assess the distribution of causes of unicompartmental knee arthroplasty (UKA) failures, as well as cause-specific delay to onset. HYPOTHESIS: Our working hypothesis was that most failures were traceable to wear occurring over a period of many years. MATERIALS AND METHODS: A multicentre retrospective study (25 centres) was conducted in 418 failed UKAs performed between 1978 and 2009. We determined the prevalence and time to onset of the main reasons for revision surgery based upon available preoperative findings. Additional intraoperative findings were analysed. The results were compared to those of nation wide registries to evaluate the representativeness of our study population. RESULTS: Times to revision surgery were short: 19% of revisions occurred within the first year and 48.5% within the first 5 years. Loosening was the main reason for failure (45%), followed by osteoarthritis progression (15%) and, finally, by wear (12%). Other reasons were technical problems in 11.5% of cases, unexplained pain in 5.5%, and failure of the supporting bone in 3.6%. The infection rate was 1.9%. Our results were consistent with those of Swedish and Australian registries. DISCUSSION: Our hypothesis was not confirmed. The short time to failure in most cases suggests a major role for surgical technique issues. Morbidity related to the implant per se may be seen as moderate and not greater than with total knee prostheses. The good agreement between our data and those of nationwide registries indicates that our population was representative. A finer analysis is needed, indicating that the establishment of a French registry would be of interest.

Cross-cultural adaptations of the Oxford-12 HIP score to the French speaking population.

BACKGROUND: An objective measurement of surgical procedures outcomes is inherent to professional practices quality control; this especially applies in orthopaedics to joint replacement outcomes. A self-administered questionnaire offers an attractive alternative to surgeon's judgement but is infrequently used in France for these purposes. The British questionnaire, the 12-item Oxford Hip Score (OHS) was selected for this study because of its ease of use. HYPOTHESIS: The objective of this study was to validate the French translation of the self-assessment 12-item Oxford Hip Score and compare its results with those of the reference functional scores: the Harris Hip Score (HHS) and the Postel-Merle d'Aubigné (PMA) score. MATERIALS AND METHODS: Based on a clinical series of 242 patients who were candidates for total hip arthroplasty, the French translation of this questionnaire was validated. Its coherence was also validated by comparing the preoperative data with the data obtained from the two other reference clinical scores. RESULTS: The translation was validated using the forward-backward translation procedure from French to English, with correction of all differences or mistranslations after systematized comparison with the original questionnaire in English. The mean overall OHS score was 43.8 points (range, 22-60 points) with similarly good distribution of the overall value of the three scores compared. The correlation was excellent between the OHS and the HHS, but an identical correlation between the OHS and the PMA was only obtained for the association of the pain and function parameters, after excluding the mobility criterion, relatively over-represented in the PMA score. DISCUSSION AND CONCLUSION: Subjective questionnaires that contribute a personal appreciation of the results of arthroplasty by the patient can easily be applied on a large scale. This study made a translated and validated version of an internationally recognized, reliable self-assessment score available to French orthopaedic surgeons. The results obtained encourage us to use this questionnaire as a complement to the classical evaluation scores and methods.

Uncemented stems in hip replacement--hydroxyapatite or plain porous: does it matter? Based on a prospective study of HA Omnifit stems at 15-years minimum follow-up.

For many years, acrylic cement has been regarded as the unique available means for a long term and secure fixation of components in hip arthroplasty. A new generation of uncemented implants coated in hydroxyapatite (HA) has arisen since the mid-1980s, aiming to provide a 'biological interface' between metal and surrounding bone, and thus the hydroxyapatite interface was defined some years ago as a distinct entity from both cemented and 'plain porous' fixation. Based upon our 20-year experience with the HA Omnifit stem, this paper aims to discuss the efficiency of hydroxyapatite as a means of fixation for femoral components in hip arthroplasty, then examine whether the addition of a calcium phosphate layer induces any adverse effects, and finally make comparisons between HA-coated versus porous hip stems reported in the literature. With respect to fixation of femoral components in hip arthroplasty we report excellent results from the partially coated HA Omnifit stem in our series, with 99.20% of survival rate at 17-year follow-up, these results being consistent and similar to other HA series in the literature. HA 'uncemented' fixation can therefore be considered reliable and efficient. Furthermore, two decades of hydroxyapatite coatings have resulted in the identification of no major adverse effects. In fact calcium phosphate ions participate in the physiological turn-over of bone remodelling, and the HA coating is replaced by new bone formation without any fibrous tissue layer. Since HA particles are biodegradable and do not produce any inflammatory reaction in the surrounding bone, fears of osteolysis or third body wear due to HA debris have not been confirmed. Finally, comparison between HA versus plain porous femoral components through the literature has demonstrated better results with HA than porous alone both in terms of the quantity and quality of bone remodelling, and the potential migration and subsidence of the stem.

Hydroxyapatite-coated total knee replacement: clinical experience at 10 to 15 years.

This study describes 146 primary total knee replacements, either fully or partially coated with hydroxyapatite of which 74 knees in 68 patients were available for clinical and radiological assessment at a mean of 11.2 years (10 to 15). The global failure rate was 1.37% and survival rate with mechanical failure as the end-point was 98.14%. Radiological assessment indicated intimate contact between bone and the hydroxyapatite coating. Over time the hydroxyapatite coating appears to encourage filling of interface gaps remaining after surgery. Our results compare favourably with those of series describing cemented or porous-coated knee replacements, and suggest that fixation with hydroxyapatite is a reliable option in primary total knee replacement.

[Hinge prosthesis of the knee. Apropos of 185 cases]. / Les prothèses à charnière du genou. A propos de 185 cas.

On hundred and ninety-five hinge prostheses have been inserted between 1970 and 1981, most of them of the G.U.E.P.A.R. type. One hundred and forty-three were followed up. The etiology of five per-operative deaths is discussed. It is concluded that this dramatic event was related to gas embolism. Precautions necessary to avoid such accidents are described particularly at the time of release of the tourniquet. There were 11 cases of sepsis, eight loosenings and four post-operative fractures of the femur or tibia. The functional results were found to be satisfactory but better with the G.U.E.P.A.R. type than with the Shiers prosthesis. Most of the post-operative pain originated from the patella; this aspect of the pain should be able to be avoided by systematic use of patellar resurfacing. The authors conclude that a hinge prosthesis should be used only in cases of severe deformity, of severe instability or in cases of failure of resurfacing procedures.

Pouteau-Colles fracture: double-closed "basket-like" pinning according to Kapandji. Apropos of a homogeneous series of 70 cases.

First described by Kapandji, the double closed "basket-like" pinning is a new and quite attractive treatment of the Colles' fracture. With or without XR TV, following closed reduction the epiphysis is fixed steady with two Kirschner wires, sliding along its lateral and its posterior aspects, entering the radius at the fracture site and transfixing the bone cortex above. Plaster cast is unnecessary, and wrist reeducation begins on the first day post-op. Technical "know-how" is specified, and seventy-two patients followed up. Present findings indicate that the complication rate is very low, excellent and good results are 83%. Rehabilitation is quicker, socio-economically gratifying. We believe that the method significantly improves the conservative treatment of Colles' fracture and decide to use it extensively from now on.