Porous Metal Augments Have Comparable Outcomes to Other Constructs for Severe Acetabular Bone Loss at a Mean Follow-up of 6.6-Years.

INTRODUCTION: Acetabular reconstruction options in the setting of severe bone loss remain limited, with few comparative studies published to date. The purpose of this study was to compare the outcomes of revision total hip arthroplasty (THA) for severe bone loss using porous metal augments to cup-cage and triflange prostheses. METHODS: We reviewed a consecutive series of 180 patients who had Paprosky 3A or 3B acetabular defects and underwent revision THA. Patients treated with porous augments (n = 141) were compared with those who received cup-cages or triflange constructs (n = 39). Failure of the acetabular construct was defined as undergoing acetabular revision surgery or radiographic evidence of loosening. RESULTS: There was no difference in acetabular component survivorship in patients undergoing revision THA with porous augments or a cage or triflange prosthesis (92.2 versus 87.2%, P = 0.470) at a mean follow-up of 6.6 ± 3.4 years. Overall survivorship free from any revision surgery was comparable between the two groups (78.7 versus 79.5%, P = 0.720). There was also no difference in dislocation (5.7 versus 10.3%, P = 0.309) or periprosthetic joint infection rates (7.8 versus 10.3%, P = 0.623). In a subgroup analysis of patients who had pelvic discontinuity (n = 47), survivorship free from any revision surgery was comparable between the two groups (79.5 versus 72.2%, P = 0.543). CONCLUSION: Porous metal augments in the setting of severe acetabular bone loss demonstrated excellent survivorship at intermediate-term (mean 6.6-year) follow-up, even in cases of pelvic discontinuity, with comparable outcomes to cup-cages and triflanges. Instability and infection remain major causes of failure in this patient population, and long-term follow-up is needed.

Do joint-preserving hip procedures compromise subsequent total hip arthroplasty? A meta-analysis of complications, functional outcome and survivorship.

BACKGROUND: Joint-preserving hip operations can help relieve pain and delay the need for long-term joint arthroplasty. Previous research has not identified procedures that can compromise outcomes following total hip arthroplasty (THA). This meta-analysis aims to evaluate the effect of joint-preserving hip operations on outcomes following subsequent THA. METHODS: MEDLINE, EMBASE and Scopus databases were searched from the date of inception until February 2024. All studies comparing outcomes following THA in individuals with (PS) and without prior surgery (NPS) of the femur or pelvis were included. Data on operative time, blood loss, intra- and post-operative complications, functional outcomes, and implant survivorship were extracted. RESULTS: 16 studies, comprising 2576 patients were included (PS = 939, NPS = 1637). The PS group was associated with significantly longer operative time [MD: 8.1, 95% CI: 4.6-11.6], significantly greater blood loss [MD: 167.8, 95% CI: 135.6-200.0], and a higher risk of intra-operative peri-prosthetic fracture [RR: 1.9, 95% CI: 1.2-3.0], specifically, with prior femoral osteotomy. There were no differences in terms of risks of dislocation [RR: 1.8, 95% CI: 1.0-3.2], implant loosening [RR: 1.0, 95% CI: 0.7-1.5], or revision surgery [RR: 1.3, 95% CI: 1.0-1.7] between the two groups. The PS group was associated with significantly poorer improvements in functional outcome [MD: -5.6, 95% CI: -7.6-(-3.5)], specifically, with prior acetabular osteotomy. Implant survivorship in the two groups was comparable after one year [HR: 1.9, 95% CI: 0.6-6.2] but significantly inferior in the PS group after five years [HR: 2.5, 95% CI: 1.4-4.7], specifically, with prior femoral osteotomy. CONCLUSION: Joint-preserving hip operations are associated with greater intra-operative challenges and complications. In subsequent joint arthroplasty, prior acetabular procedures affect functional outcomes while prior femoral procedures influence implant survivorship. Hip pain due to the morphological sequelae of pediatric hip pathology can be debilitating at a young age. Surgical decision-making at that time needs to consider the survivorship of a THA implanted at that young age against the consequences of hip preservation surgery on further THA.

Factors that influence surgical decision-making for geriatric displaced femoral neck fractures: Bullet Health Analysis (BHA) I : Worldwide Orthopaedic Research Collaboration: Leveraging Big Data (WORLD) I.

PURPOSE: The management of geriatric femoral neck fractures, which includes options like hemiarthroplasty (HA), total hip arthroplasty (THA), and fixation, exhibits regional and healthcare setting variations. However, there is a lack of information on global variations in practice patterns and surgical decision factors for this injury. METHODS: Survey data were collected from April 2020 to June 2023 via Orthobullets Case Studies, a global clinical case collaboration platform hosted on a prominent orthopedic educational website. Collaboratively developed standardized polls, based on the best available evidence and a comprehensive, peer-reviewed, evidence-based item list, were used to capture surgeons' treatment preferences worldwide. Subsequent analyses explored preferences within subspecialties and practice settings. Multivariable regression analysis identified associations between subspecialty, practice type, the likelihood of choosing THA, and the preferred femoral fixation method. RESULTS: Our study encompassed 2595 respondents from 76 countries. Notably, 51.5% of participants (n = 1328; 51.5%, 95% CI 49.6-53.4%) leaned towards THA and 44.9% for HA, while 3.6% favoured surgical fixation. Respondents affiliated with academic institutions and large non-university-affiliated hospitals were 1.74 times more likely to favour THA, and arthroplasty specialists exhibited a 1.77-fold preference for THA. There was a 19-fold variation for cemented femoral fixation between the United Kingdom (UK) and USA with the UK favouring cemented fixation. CONCLUSION: Our study reveals a significant shift towards THA preference for managing geriatric femoral neck fractures, influenced by subspecialty and practice settings. We also observed a pronounced predominance of cement fixation in specific geographic locations. These findings highlight the evolving fracture management landscape, emphasizing the need for standardization and comprehensive understanding across diverse healthcare settings.

Risk Factors for Periprosthetic Femoral Fractures after Cementless Total Hip Arthroplasty.

BACKGROUND: The present study aimed to identify the risk factors of periprosthetic femoral fracture (PFF) after cementless total hip arthroplasty (THA) and rank them based on importance. METHODS: The age, sex, body mass index (BMI), osteoporosis, canal flare index (CFI), canal bone ratio (CBR), canal calcar ratio (CCR), stem design, and stem canal fill ratio (P1, P2, P3, and P4) of the proximal femoral medullary cavity of 111 THA patients who had PFF and 388 who did not have PFF were analyzed. Independent-samples student t-tests were used for continuous variables, and Chi-square tests were used for categorical variables. The importance rankings of influencing factors were assessed using a random forest algorithm. Dimensionally reduced variables were then incorporated into a binary logistic regression model to determine the PFF-related risk factors. RESULTS: The mean age, BMI, CBR, CCR, and incidence of osteoporosis were higher in cases of PFF (all P < 0.001), while the mean CFI, P1, P2, P3, and P4 were lower in cases of PFF (P < 0.001, P = 0.033, P = 0.008, P < 0.001, and P < 0.001, respectively). Additionally, the stem design was also statistically associated with PFF (P < 0.001). Multivariate logistic regression revealed that advanced age, higher BMI, osteoporosis, stem design, lower CFI, higher CBR, higher CCR, lower P1, lower P2, lower P3, and lower P4 were the risk factors of PFF (P < 0.001, P < 0.001, P < 0.001, P < 0.001, P < 0.001, P = 0.010, P < 0.001, P = 0.002, P < 0.001, P < 0.001, and P = 0.007, respectively). The ranked importance of the risk factors for PFF was P3, CFI, osteoporosis, CBR, age, P4, P1, stem design, CCR, BMI, and P2. CONCLUSION: Lower P3, lower CFI, osteoporosis, higher CBR, advanced age, lower P4, lower P1, stem design, higher CCR, higher BMI, and lower P2 increased the risk of PFF.

Decreasing Hip Offset in Total Hip Arthroplasty Results in Decreased Physical Function Scores.

INTRODUCTION: Acetabular and femoral offset play an important role in total hip arthroplasty (THA) for postoperative stability and biomechanical function. However, it is unknown whether offset impacts patient-reported outcomes (PRO). This study evaluated patients undergoing direct anterior (DA) THA with the hypothesis that patients who have a decrease in hip offset post-operatively would have lower physical function scores and higher pain interference. METHODS: There were 499 patients who underwent DA THA at a single tertiary academic institution who were retrospectively evaluated. Pre- and post-operative hip offset was measured by two reviewers using the Sundsvall method on standing anteroposterior (AP) pelvis radiographs. Post-operative changes in hip offset were categorized as increased (> 5 mm), matched (within 5 mm of the pre-operative offset measurement), or decreased (> 5 mm). Post-operative PROs with a minimum 1-year follow-up were recorded. A one-way analysis of variance (ANOVA) was utilized to compare post-operative pain and PROs between groups. RESULTS: Patients who had decreased offset had the lowest mean post-operative physical function scores at 39.4 (8.0), followed by the increased offset group at 42.2 (10.4) and the matched offset group at 42.8 (9.8) (P < 0.01). There were significant differences in post-operative physical function scores between matched offset (42.8) and decreased offset (39.4) groups (P < 0.01), as well as between increased offset (42.2) and decreased offset (39.4) groups (P = 0.04). There was no difference between matched and increased offset cohorts. CONCLUSION: Our data suggests that reducing hip offset may result in worse physical function scores compared to those who have matched or increased hip offset. This should be considered intraoperatively, and efforts should be made to avoid reduced offset even in the presence of hip stability.

An in-depth analysis of young adults with osteonecrosis secondary to developmental dysplasia of the hip who underwent total hip arthroplasty.

BACKGROUND: Patients with osteonecrosis of the femoral head secondary to DDH frequently require total hip arthroplasty (THA), but it is not well understood which factors necessitate this requirement. We determined the incidence of THA in patients who have osteonecrosis secondary to DDH and factors associated with need for THA. METHODS: We included patients who received closed or open reductions between 1995 and 2005 with subsequent development of osteonecrosis. We determined osteonecrosis according to Bucholz and Ogden; osteoarthritis severity (Kellgren-Lawrence), subluxation (Shenton's line); neck-shaft angle; and acetabular dysplasia (centre-edge and Sharp angles). We also recorded the number of operations of the hip in childhood and reviewed case notes of patients who received THA to describe clinical findings prior to THA. We assessed the association between radiographic variables and the need for THA using univariate logistic regression. RESULTS: Of 140 patients (169 hips), 22 patients received 24 THA (14%) at a mean age of 21.3 ± 3.7 years. Associated with the need for THA were grade III osteonecrosis (OR 4.25; 95% CI 1.70-10.77; p = 0.0019), grade IV osteoarthritis (21.8; 7.55-68.11; p < 0.0001) and subluxation (8.22; 2.91-29.53; p = 0.0003). All patients who required THA reported at least 2 of: severe pain including at night, stiffness, and reduced mobility. Acetabular dysplasia and number of previous operations were not associated with the need for THA. CONCLUSIONS: We identified a 14% incidence of THA by age 34 years in patients with osteonecrosis secondary to DDH. Grade III osteonecrosis (global involvement femoral head and neck) was strongly associated with THA, emphasising the importance to avoid osteonecrosis when treating DDH.

Does Artificial Intelligence Outperform Humans Using Fluoroscopic-Assisted Computer Navigation for Total Hip Arthroplasty?

Background: Successful total hip arthroplasty (THA) relies on the correct implant position. THA accuracy can be improved with the use of intraoperative fluoroscopic-assisted computer navigation. Artificial intelligence (AI) software may enhance fluoroscopic navigation; however, the accuracy of the AI compared to human-controlled software in assessing acetabular component position and leg length discrepancy (LLD) has not been studied. Methods: We analyzed 420 consecutive primary THAs performed by a single surgeon using fluoroscopic-assisted computer navigation software. The first cohort of 211 patients required inputs from a human technician (manual), while the second cohort of 209 patients used an automated version of the software controlled by AI. The intraoperative acetabular component placement (inclination and anteversion) and LLD were recorded and compared to the 2-week postoperative standing anterior-posterior pelvis radiograph. Results: Ninety-four percent (199/211) of cups in the manual cohort and 95% (198/209) of cups in the AI cohort were within the Lewinnek "safe-zone" (P = 1.0). In the manual cohort, 69% (146/211) of THAs had a final LLD within ±2 mm of the intraoperatively navigated LLD (ie, ΔLLD ≤2 mm). In the AI cohort, 66% (137/209) of THAs had a final LLD within ±2 mm of the intraoperatively navigated LLD (P = .47). Ninety-nine percent (209/211) of hips in the manual cohort and 98% (205/209) of hips in the AI cohort had a final LLD within ±5 mm of the intraoperatively navigated LLD (P = .45). Conclusions: Both AI and human-controlled versions of the same navigation platform were similarly accurate for navigating cup position within the Lewinnek "safe zone" and LLD accuracy.

Patients' needs and experiences of telerehabilitation after total hip and knee arthroplasty: A qualitative systematic review and meta-synthesis.

Background: The number of patients undergoing joint replacement procedures is continuously increasing. Tele-equipment is progressively being employed for postrehabilitation of total hip and knee replacements. Gaining a comprehensive understanding of the experiences and requirements of patients undergoing total hip and knee arthroplasty who participate in telerehabilitation can contribute to the enhancement of telerehabilitation programs and the overall rehabilitation and care provided to this specific population. Objective: To explore the needs and experiences of total hip and knee arthroplasty patients with telerehabilitation. Design: Systematic review and qualitative synthesis. Methods: Electronic databases PubMed, Web of Science, The Cochrane Library, Embase, CINAHL, Scopus, ProQuest, CNKI, Wanfang Data, VIP, and SinoMed were systematically searched for information on the needs and experiences of telerehabilitation for patients with total hip arthroplasty and total knee arthroplasty in qualitative studies. The search period was from the creation of the database to March 2024. Literature quality was assessed using the 2016 edition of the Australian Joanna Briggs Institute Centre for Evidence-Based Health Care Quality Assessment Criteria for Qualitative Research. A pooled integration approach was used to integrate the findings inductively. Results: A total of 11 studies were included and 4 themes were identified: the desire to communicate and the need to acquire knowledge; accessible, high-quality rehabilitation services; positive psychological experiences; the dilemmas of participating in telerehabilitation. Conclusions: This study's findings emphasize that the practical needs and challenges of total hip and knee arthroplasty patients' participation in telerehabilitation should be continuously focused on, and the advantages of telerehabilitation should be continuously strengthened to guarantee the continuity of patients' postoperative rehabilitation and to promote their postoperative recovery.

Long-term outcomes of converting fused hips to total hip arthroplasty are satisfactory: a systematic review and meta-analysis.

Background: Although conversion arthroplasty of fused hips can relieve pain and provide patient satisfaction, long-term outcomes of total hip arthroplasty (THA) after hip fusion remain a subject of debate. This meta-analysis aimed to assess the effectiveness of THA for fused hips over a long period with concerns over potential complications. Methods: A systematic search of five databases from 2000 until 2023 identified English studies evaluating THA for fused hips with at least 100 months of follow-up. Meta-analyses were conducted using random-effect models via the comprehensive meta-analysis software. Sensitivity analysis, in-depth meta-regression, Egger's test, and the trim-and-fill method were performed appropriately. Results: The meta-analysis assessed 790 patients and 889 hips with a mean follow-up of 11 years. At the final follow-up, the mean Harris Hip Score (HHS) and leg length discrepancy (LLD) improved by 34.755 and 2.3 cm from the baseline, respectively. Regarding survival of hip fusion conversion to THA, most studies (88.8%) reported a 5-year implant survival rate of at least 90%, and the 15-year and 20-year implant survival rates, ranged between 80-90% and 70-90%, respectively. Subjective dissatisfaction with the conversion of hip fusion to THA was only 5.3%. Composite rates of revision, instability, and aseptic loosening were 13.6%, 3.8%, and 8.8%, respectively. Conclusions: Conversion of fused hips to THA results in favourable long-term outcomes regarding HHS, LLD, survival rates, and subjective satisfaction, leading to improved quality of life in properly selected patients. However, the presence of complications should be considered when evaluating the overall success of the procedure.

Statin use in total joint arthroplasty: a systematic review.

Introduction: There has been increased interest in the use of Statins in total hip and knee arthroplasty (THA and TKA) patients to improve outcomes and reduce postoperative complications. This study was performed to systematically review the evidence on Statin use in total joint arthroplasty, specifically its benefits and complications. Methods: Adhering to the PRISMA guidelines, a systematic review of PubMed, Embase, Scopus, Web of Science, and the Cochrane database was performed to find studies reporting on the effects of Statin use on outcomes of THA and TKA. Two authors independently selected relevant papers to include. Results: A total of 18 papers were included in the final analysis. Most were retrospective studies, with heterogeneous patient selection and outcome measures. The evidence on the risks and benefits of Statin use on outcomes of total joint arthroplasty was very limited and heterogeneous. Studies were focusing on perioperative cardiac outcomes, clinical outcomes and complications, renal, pulmonary, and gastrointestinal outcomes. Due to the heterogeneity of reported data, a formal meta-analysis was not possible. Conclusions: There is some evidence in the literature suggesting that perioperative use of Statins, especially in Statin-naïve patients, may reduce cardiac (e.g. atrial fibrillation) and noncardiac (e.g. delirium) complications, while not increasing the risk of muscle or liver toxicity. The authors also found low levels of evidence that Statin use may reduce the long-term risk for revision surgery and osteolysis.

Stem anteversion is not affected by proximal femur geometry in robotic-assisted total hip arthroplasty.

BACKGROUND: In the present study, the surgeon aimed to align the stem at 5° to 25° in anteversion. The robotic technology was used to measure stem anteversion with respect to proximal femur anteversion at different levels down the femur. METHODS: A total of 102 consecutive patients underwent robotic-arm-assisted total hip arthroplasty (RTHA). 3D CT-based preoperative planning was performed to determine femoral neck version (FNV), posterior cortex anteversion (PCA), anterior cortex anteversion (ACA), and femoral metaphyseal axis anteversion (MAA) at 3 different levels: D (10 mm above lesser trochanter), E (the midpoint of the planned neck resection line) and F (head-neck junction). The robotic system was used to define and measure stem anteversion during surgery. RESULTS: Mean FNV was 6.6° (SD: 8.8°) and the mean MAA was consistently significantly higher than FNV, growing progressively from proximal to distal. Mean SV was 16.4° (SD: 4.7°). There was no statistically significant difference (P = 0.16) between SV and MAA at the most distal measured level. In 96.1% cases, the stem was positioned inside the 5°-25° anteversion range. CONCLUSIONS: Femoral anteversion progressively increased from neck to proximal metaphysis. Aligning the stem close to femoral anteversion 10 mm above the lesser trochanter often led to the desired component anteversion.

The Accuracy of Cup Placement in Total Hip Arthroplasty (THA) Using an Augmented Reality-Based Navigation System.

Background AR HIP Navigation System® (AR-navi; Zimmer-Biomet, Warsaw, IN) is a portable navigation system employing augmented reality via a smartphone app, which was developed in Japan. We retrospectively analyzed the accuracy of cup placement in total hip arthroplasty (THA) using AR-navi, to investigate whether obesity is associated with an absolute value error in cup placement angle. Methods We retrospectively analyzed 45 hips in 43 patients who underwent THA using AR-navi (AR-navi group) and compared them with 45 hips in 45 patients who underwent THA using alignment rods (conventional group). Results The mean absolute error of cup placement (AR-navi group vs. conventional group) was found to be 2.60° (±2.11) in radiographic inclination (RI) for the AR-navi group and 4.61° (±3.28) for the conventional group, which indicates significant difference in the AR-navi group compared to that in the conventional group (p = 0.0036). The mean absolute error of radiographic anteversion (RA) was 3.57° (±3.36) for the AR-navi group and 3.87° (±2.97) for the conventional group (p = 0.4732). The mean absolute error of RI was 2.36° (±2.24) in the obese group and 3.16° (±2.03) in the nonobese group, and the mean absolute error of RA was 4.08° (±4.51) and 3.16° (±2.05) in the obese and nonobese groups, respectively. Conclusions Cup placement accuracy for THA using AR-navi was 2.60 ± 2.11° for RI and 3.87 ± 2.97° for RA. Compared to THA using the conventional method, the RI installation error was significantly improved with AR Navi. There was no significant difference in the mean absolute error of RI and RA among the obese and nonobese groups.

Five-Year Survivorship of Total Hip Arthroplasty With a Proximally Coated, Medially Collared, Triple-Tapered Femoral Stem: A Retrospective, Multicenter Registry Review.

Background The anterior approach for total hip arthroplasty (THA) has gained popularity in recent years. Some surgeons have been hesitant to adopt the approach due to concerns over increased complications such as intraoperative fracture, stem loosening, and stem revision. This study aims to evaluate the all-cause revision rate and survivorship of a collared, triple-tapered stem that was designed specifically for use with the anterior approach in THA to enhance outcomes and reduce adverse events. Methodology A retrospective outcomes review was conducted to assess survivorship and clinical outcomes for a specific proximally coated, medially collared triple-tapered (MCTT) femoral stem. Results In a cohort of 5,264 hips, Kaplan-Meier survivorship estimates (95% confidence interval [CI]; N with further follow-up), with survivorship defined as no revision of any component for any reason at five years after the index procedure, were 98.9% (97.8%-99.4%; 43) under the clinical assumption and 99.6% (99.4%-99.7%; 894) under the registry assumption. With survivorship defined as stem revision for any reason, survivorship estimates at five years postoperatively were 99.6% (99.3%-99.8%; 43) under the clinical assumption and 99.8% (99.7%-99.9%; 894) under the registry assumption. The mean follow-up time was 94.52 days (standard deviation [SD] 2.24, range 90.03-96.02). At five years postoperatively, the mean Harris Hip Score was 95.19, and the mean Hip Disability and Osteoarthritis Outcome Score Junior (HOOS JR) score was 98.66. Conclusions Our evaluation demonstrates excellent construct and stem survivorship and very low complication rates at midterm postoperative follow-up.

Outcomes of Hybrid Total Hip Arthroplasty for Subchondral Insufficiency Fracture of the Femoral Head.

Background: The purpose of this study was to evaluate functional outcomes, radiologic results, and complications after hybrid total hip arthroplasty (THA) in patients with subchondral insufficiency fractures (SIFs) of the femoral head. Methods: From June 2009 to December 2020, among 985 patients who underwent hybrid THA at our hospital, 19 patients diagnosed with SIF through a retrospective chart review were included. Those under 50 years of age, with radiographic findings of osteonecrosis on the contralateral side of surgery, a history of organ transplantation, and alcohol abuse, were excluded. Functional evaluation was performed using a modified Harris Hip Score (HHS). After surgery, inclination and anteversion of the acetabular cup and version of the femoral system were measured using postoperative x-ray. The outpatient follow-up was performed at 6 weeks, 3 months, 9 months, and 12 months after surgery and every year thereafter. Complications including dislocation, implant loosening, stem subsidence, and periprosthetic infection were observed on follow-up radiographs. Results: The average follow-up time was 29.3 ± 9.1 months (range, 24-64 months) with no loss to follow-up. The mean modified HHS was 83.4 ± 9.6 (range, 65-100) at the last outpatient clinic follow-up. The average inclination of the acetabular cup was 41.9° ± 3.4° (range, 37°-48°), and the anteversion was 27.5° ± 6.7° (range, 18°-39°). The version of the femoral stem was 19° ± 5.7° (range, 12°-29°). There was no case of intraoperative fracture. There were no cases of dislocation, loosening of the cup, subsidence of the femoral stem, intraoperative or periprosthetic fracture, or periprosthetic infection on the follow-up radiographs. Conclusions: In our study, hybrid THA showed favorable outcomes in patients diagnosed with SIF, and there were no further special considerations as for THA performed due to other diseases or fractures.

Total Hip Arthroplasty Outcomes before or after Renal Transplant: A Retrospective Large Cohort Analysis.

Background: While it is known that patients with end-stage renal disease (ESRD) are at an increased risk of complications following total hip arthroplasty (THA), there is a gap in the literature in comparing patients with ESRD to patients who undergo renal transplant (RT) before or after THA. This study is to address this gap by analyzing outcomes of THA in ESRD patients, RT patients, and RT candidates. Methods: Using the PearlDiver Mariner database, ESRD patients, RT patients, and RT candidates undergoing primary THA were identified and compared. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to 2 years. Ninety-day emergency department (ED) visits and inpatient readmission were also documented. Results: A total of 7,868 patients were included: 5,092 had ESRD, 2,520 had RT before THA, and 256 were candidates for RT. Compared to patients with ESRD, RT patients demonstrated lower rates of medical complications such as pneumonia (3.61% vs. 5.99%, p = 0.039) and transfusion (4.60% vs. 7.66%, p < 0.001). Additionally, RT patients displayed decreased rates of surgical complications, including wound complications (2.70% vs. 4.22%, p = 0.001), periprosthetic joint infection (PJI) at 1 year (2.30% vs. 4.81%, p < 0.001) and 2 years (2.58% vs. 5.42%, p < 0.001), and aseptic loosening at 2 years (0.79% vs. 1.43%, p = 0.006). Similarly, when compared to RT candidates, RT patients demonstrated a lower incidence of postoperative complications, including 1-year PJI (2.30% vs. 5.08%, p = 0.013), 2-year PJI (2.58% vs. 5.08%, p = 0.028), 1-year aseptic loosening (0.56% vs. 2.73%, p < 0.001), and 2-year aseptic loosening (0.79% vs. 2.73%, p = 0.005). RT patients also had lower rates of ED visits and hospital readmissions. Conclusions: Compared to ESRD patients and RT candidates, patients with RT have a significantly lower likelihood of medical complications, PJI, aseptic hardware loosening, ED visits, and hospital readmission. Patients with ESRD on the RT waiting list should delay THA until after RT surgery. For those not eligible for RT, it is vital to take extra precautions to reduce the risk of complications.

The Avantage ® dual mobility cup in primary total hip arthroplasty: A registry study.

Background: Avantage Cup has been widely used in dual mobility implants. However, in Swedish Registry, the outcome of the Avantage Cup is reported with higher implants revision compared to control. The aim of our study was to verify if the same results are present in the Registry of Prosthetic Orthopedic Implants (RIPO) of Emilia Romagna (ER, Italy), as the Avantage cup was the most implanted dual mobility cup for a long follow-up reported in this Registry (2000-2012). Furthermore, we assessed the survival rate of the implant over the time. Methods: We included all patients that underwent a primary THA using the Avantage cup during the period 2000-2020 in RIPO Registry. The survivorship of the primary THA implants was calculated and plotted according to Kaplan-Meier method. Results: 886 Avantage cups were included in the analysis. During the observational period 44 hips were revised. The most common reasons for revision were: periprosthetic fractures (PPF) (n = 7, 0.8 %), deep infection (n = 7, 0.8 %), and cup aseptic loosening (n = 13, 1.5 %).The survival rate of the implant was 96.8 % (95.3-97.8) at 5 years, 95.7 at 10 years (94.0-97.0) and 92.1 at 15 years (88.5-94.6). Conclusion: In conclusion, this study has demonstrated that the Avantage cup in primary hip arthroplasty implanted with a "friendly" femoral stem granted satisfactory long-term survival. Therefore, in the Swedish Registry, the cause of the poor results presented for Avantage Cup could be the thick, rough neck stem of the widely used Lubinus stem.

Tranexamic acid may benefit patients with preexisting thromboembolic risk undergoing total joint arthroplasty: a systematic review and meta-analysis.

Purpose: This study sought to determine if the use of tranexamic acid (TXA) in preexisting thromboembolic risk patients undergoing total joint arthroplasty (TJA) was linked to an increased risk of death or postoperative complications. Methods: We conducted a comprehensive search for studies up to May 2023 in PubMed, Web of Science, EMBASE, and the Cochrane Library. We included randomized clinical trials, cohort studies, and case-control studies examining the use of TXA during TJA surgeries on high-risk patients. The Cochrane Risk of Bias instrument was used to gauge the excellence of RCTs, while the MINORS index was implemented to evaluate cohort studies. We used mean difference (MD) and relative risk (RR) as effect size indices for continuous and binary data, respectively, along with 95% CIs. Results: Our comprehensive study, incorporating data from 11 diverse studies involving 812 993 patients, conducted a meta-analysis demonstrating significant positive outcomes associated with TXA administration. The findings revealed substantial reductions in critical parameters, including overall blood loss (MD = -237.33; 95% CI (-425.44, -49.23)), transfusion rates (RR = 0.45; 95% CI (0.34, 0.60)), and 90-day unplanned readmission rates (RR = 0.86; 95% CI (0.76, 0.97)). Moreover, TXA administration exhibited a protective effect against adverse events, showing decreased risks of pulmonary embolism (RR = 0.73; 95% CI (0.61, 0.87)), myocardial infarction (RR = 0.47; 95% CI (0.40-0.56)), and stroke (RR = 0.73; 95% CI (0.59-0.90)). Importantly, no increased risk was observed for mortality (RR = 0.53; 95% CI (0.24, 1.13)), deep vein thrombosis (RR = 0.69; 95% CI (0.44, 1.09)), or any of the evaluated complications associated with TXA use. Conclusion: The results of this study indicate that the use of TXA in TJA patients with preexisting thromboembolic risk does not exacerbate complications, including reducing mortality, deep vein thrombosis, and pulmonary embolism. Existing evidence strongly supports the potential benefits of TXA in TJA patients with thromboembolic risk, including lowering blood loss, transfusion, and readmission rates.

Effect of Corticosteroid Use on the Occurrence and Progression of Osteonecrosis of the Femoral Head: A nationwide Nested Case-Control Study.

BACKGROUND: Although it is very well known that corticosteroids cause osteonecrosis of the femoral head (ONFH), it is unclear as to which patients develop ONFH. Additionally, there are no studies on the association between corticosteroid use and femoral head collapse in ONFH patients. We aimed to investigate the association between corticosteroid use and the risk of ONFH among the general population and what factors affect ONFH occurrence. Additionally, we aimed to demonstrate which factors affect femoral head collapse and total hip arthroplasty (THA) after ONFH occurrence. METHODS: A nationwide, nested case-control study was conducted with data from the National Health Insurance Service Physical Health Examination Cohort (2002 to 2019) in the Republic of Korea. We defined ONFH (N = 3,500) using diagnosis and treatment codes. Patients who had ONFH were matched 1:5 to form a control group based on the variables of birth year, sex, and follow-up duration. Additionally, in patients who have ONFH, we looked for risk factors for progression to THA. RESULTS: Compared with the control group, ONFH patients had a low household income and had more diabetes, hypertension, dyslipidemia, and heavy alcohol use (drinking more than 3 to 7 drinks per week). Systemic corticosteroid use (≥ 1,800 mg) was significantly associated with an increased risk of ONFH incidence. However, lipid profiles, corticosteroid prescription, and cumulative doses of corticosteroid did not affect the progression to THA. CONCLUSION: The ONFH risk increased rapidly when cumulative prednisolone use was ≥ 1,800 mg. However, oral or high-dose intravenous corticosteroid use and cumulative dose did not affect the prognosis of ONFH. Since the occurrence and prognosis of ONFH are complex and multifactorial processes, further study is needed.

The John Charnley Award: The Impact of Human Leukocyte Antigen (HLA) Genotype on Bacterial Infection Rates and Successful Eradication in Total Hip Arthroplasty.

BACKGROUND: Genetics plays an important role in several medical domains, however, the influence of human leukocyte antigen (HLA) genotype on the development of periprosthetic joint infection (PJI) in total hip arthroplasty (THA) remains unknown. The primary aim of this study was to determine if HLA genotype is associated with the development of bacterial PJI in THA. Secondarily, we evaluated the association between HLA genotype and PJI treatment success. METHODS: A retrospective, matched, case-control study was performed using prospectively collected data from a single institution. A total of 49 patients who underwent primary THA were included, with a mean follow-up of 8.5 years (range, 4.2 to 12.9). The 23 cases (PJI) and 26 controls (no PJI) were matched for age, sex, follow-up, body mass index (BMI), primary diagnosis, and comorbidities (P > 0.05). High-resolution genetic analysis targeting 11 separate HLA loci was performed in all patients using serum samples. The HLA gene frequencies and carriage rates were determined and compared between cohorts. A subgroup analysis of PJI treatment success (18) and failure (5) was performed. Statistical significance was set at P = 0.10 for genetic analysis and at 0.05 for all other analyses. RESULTS: There were four HLA alleles that were significantly associated with the development of PJI. The 3 at-risk alleles included HLA-C*06:02 (OR [odds ratio] 5.25, 95% CI [confidence interval] 0.96 to 28.6, P = 0.064), HLA-DQA1*04:01 (P = 0.096), and HLA-DQB1*04:02 (P = 0.096). The single protective allele was HLA-C*03:04 (OR 0.12, 95% CI 0.01 to 1.10, P = 0.052). There were no specific HLA alleles that were associated with treatment success or failure. CONCLUSION: This study suggests that there are at-risk and protective HLA alleles associated with the development of PJI in THA. To our knowledge, this is the first study to demonstrate an association between patient HLA genotype and the development of PJI. A larger study of the subject matter is necessary and warranted.

How Has the Total Hip Arthroplasty Patient Population Changed? A Ten-Year Analysis of Total Hip Arthroplasty Patients from 2013 to 2022: A Retrospective, Single-Center Study.

INTRODUCTION: Over the past decades, utilization of total hip arthroplasty (THA) has steadily increased. Understanding the demographic trends of THA patients can assist in projecting access to care. This study sought to assess the temporal trends in THA patient baseline characteristics and socioeconomic factors. METHODS: We retrospectively analyzed 16,296 patients who underwent primary elective THA from January 1st, 2013 to December 31st, 2022. Demographic data, including age, sex, race, body mass index (BMI), Charlson Comorbidity Index (CCI), insurance, and socioeconomic status (SES), as determined by median income by patients' zip code, were collected. The trends of these data were analyzed using the Mann-Kendall test. RESULTS: Over the past decade at our institution, patient age (2013: 62.1 years to 2022: 65.1 years, P = 0.001), BMI (2013: 29.0 to 2022: 29.5, P = 0.020), and mean CCI (2013: 2.4 to 2022: 3.1, P = 0.001) increased. The proportion of Medicare patients increased from 48.4% in 2013 to 54.9% in 2022 (P = 0.001). The proportion of African American patients among the THA population increased from 11.3% in 2013 13.0% in 2022 (P = 0.012). Over this period, 90-day readmission and 1-year revision rates did not significantly change (2013: 4.8 and 3.0% to 2022: 3.4 and 1.4%, P = 0.107 and P = 0.136, respectively). The proportion of operations using robotic devices also significantly increased (2013: 0% to 2022: 19.1%; P < 0.001). CONCLUSION: In the past decade, the average age, BMI, and comorbidity burden of THA patients have significantly increased, suggesting improved access to care for these populations. Similarly, there have been improvements in access to care for African American patients. Along with these changes in patient demographics, we found no change in 90-day readmission or 1-year revision rates. Continued characterization of the THA patient population is vital to understanding this demographic shift and educating future strategies and improvements in patient care.