Total hip arthroplasty in sickle cell disease patients in a developing country.

BACKGROUND: Osteoarthritis secondary to osteonecrosis of the femoral head is a common presentation in patients with sickle cell disease. Functional limitations with or without deformities from these complications of sickle cell disease often require Total Hip Arthroplasty (THA) to improve outcome. AIM: The aim of this study was to evaluate the postoperative outcome of THA for secondary osteoarthritis from osteonecrosis of the head of the femur in patients with sickle cell disease. Methodology: A retrospective study of outcome of THA in sickle cell disease patients between January 2010 and December 2015 is presented. Primary outcome was measured using the rates of complications and the Harris Hip scores at 6 weeks, 12 weeks, 6 months, and yearly. RESULTS: A total of 68 THA in 56 patients with sickle cell disease was reviewed. The age range was 13-68 years, with a mean of 30.9 years. There were 15 males and 41 females (M: F ratio = 1:3). Approaches to the hip were direct lateral (64.3%), anterolateral (1.8%), and posterior (33.9%). 12 (21.4%) patients had bilateral total hip arthroplasty, and 44 (78.6%) had unilateral total hip arthroplasty. No patient required adductor tenotomy. Superficial surgical site infection was recorded in 7 (12.5%) patients. The postoperative functional outcome, measured by the Harris Hip score, was good or excellent in all patients, except 2 (2.9%) who required revision surgery following unacceptable results after primary hip arthroplasty. CONCLUSION: THA is a viable and effective treatment modality for sickle cell disease patients with osteonecrosis and secondary hip osteoarthritis. The choice of surgical approach does not affect the outcome.

How to evaluate the clinical outcome of joint-preserving treatment for osteonecrosis of the femoral head: development of a core outcome set.

BACKGROUND: This study aimed to develop a core outcome set (COS) for clinical trials of joint-preserving treatment for osteonecrosis of the femoral head (ONFH), that is, to define a minimal set of outcomes that should be reported in such trials. METHODS: A mixed research method was adopted in this study. First, clinical trials of hip preservation therapy were systematically researched and analyzed. Second, a three-round Delphi survey involving both doctors and patients was carried out to obtain the core outcome indicators. Round 1 was a modified Delphi questionnaire for doctors and patients to determine which outcomes are important to these stakeholders, round 2 determined what clinical evaluation core outcomes should be included for the joint-preserving treatment of ONFH, and round 3 determined how core outcomes should be measured. Finally, a consensus meeting was held to discuss and vote on the established COS. RESULTS: The results of the systematic review showed that 42 outcome indicators were classified according to common signs and symptoms, quality of life, long-term outcomes, radiological evaluation, blood biochemistry, and indexes of safety. The three rounds of Delphi surveys completed the selection of indicators for the COS and the determination of the corresponding measurements. A total of 73 orthopedic doctors and 103 patients participated in round 1, and the top 10 indicators selected were basically the same. In round 2, 32 experts identified the following indicators: pain, range of motion (ROM) of hip flexion, walking distance, and stable rating of X-ray images. In round 3, 35 experts defined the measurement of each indicator. Finally, the consensus meeting identified the four indicators aforementioned that constituted the COS. The scores for pain, ROM of hip flexion, and walking distance are from 0 to 10; 0 represents the best scores, while 10 represents the most serious impairment. The stable rating of X-ray images is determined by the morphology of the femoral head and the change in the density of the necrotic area. CONCLUSIONS: We established a COS for hip-preserving treatment of ONFH that includes four indicators: pain, ROM of hip flexion, walking distance, and stable rating of X-ray images.

Pain catastrophizing, anxiety, and depression in hip pathology.

AIMS: Psychological factors play a critical role in patient presentation, satisfaction, and outcomes. Pain catastrophizing, anxiety, and depression are important to consider, as they are associated with poorer outcomes and are potentially modifiable. The aim of this study was to assess the level of pain catastrophizing, anxiety, and depression in patients with a range of hip pathology and to evaluate their relationship with patient-reported psychosocial and functional outcome measures. PATIENTS AND METHODS: Patients presenting to a tertiary-centre specialist hip clinic were prospectively evaluated for outcomes of pain catastrophizing, anxiety, and depression. Validated assessments were undertaken such as: the Pain Catastrophizing Scale (PCS), the Hospital Anxiety Depression Scale (HADS), and the 12-Item Short-Form Health Survey (SF-12). Patient characteristics and demographics were also recorded. Multiple linear regression modelling, with adaptive least absolute shrinkage and selection operator (LASSO) variable selection, was used for analysis. RESULTS: A total of 328 patients were identified for inclusion, with diagnoses of hip dysplasia (DDH; n = 50), femoroacetabular impingement (FAI; n = 55), lateral trochanteric pain syndrome (LTP; n = 23), hip osteoarthrosis (OA; n = 184), and avascular necrosis of the hip (AVN; n = 16) with a mean age of 31.0 years (14 to 65), 38.5 years (18 to 64), 63.7 years (20 to 78), 63.5 years (18 to 91), and 39.4 years (18 to 71), respectively. The percentage of patients with abnormal levels of pain catastrophizing, anxiety, or depression was: 22.0%, 16.0%, and 12.0% for DDH, respectively; 9.1%, 10.9%, and 7.3% for FAI, respectively; 13.0%, 4.3%, and 4.3% for LTP, respectively; 21.7%, 11.4%, and 14.1% for OA, respectively; and 25.0%, 43.8%, and 6.3% for AVN, respectively. HADS Anxiety (HADSA) and Hip Disability Osteoarthritis Outcome Score Activities of Daily Living subscale (HOOS ADL) predicted the PCS total (adjusted R2 = 0.4599). Age, HADS Depression (HADSD), and PCS total predicted HADSA (adjusted R2 = 0.4985). Age, HADSA, patient's percentage of perceived function, PCS total, and HOOS Quality of Life subscale (HOOS QOL) predicted HADSD (adjusted R2 = 0.5802). CONCLUSION: Patients with hip pathology may exhibit significant pain catastrophizing, anxiety, and depression. Identifying these factors and understanding the impact of psychosocial function could help improve patient treatment outcomes. Perioperative multidisciplinary assessment may be a beneficial part of comprehensive orthopaedic hip care. Cite this article: Bone Joint J 2019;101-B:800-807.

Quality of life of patients with osteonecrosis of the femoral head: a multicentre study.

PURPOSE: Quality-of-life (QOL) assessments in patients with osteonecrosis of the femoral head (ONFH) have rarely been reported. This multicentre study aimed to elucidate the relationship between disease severity, including necrotic lesion type and radiological staging, and QOL, as well as between patients' characteristics and QOL. METHODS: Two hundred seventy-four patients with ONFH (108 females, 166 males; median age, 46 years) were asked to complete self-assessment QOL questionnaires including the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire, Oxford Hip Score, and SF-12v2. RESULTS: Patients with large necrotic lesion type or collapsed ONFH had low QOL scores. Among patients with non-collapsed lesions, patients with alcohol-associated ONFH had lower QOL scores than those with steroid-associated ONFH, those with bilateral ONFH had lower mental scores, and male patients had worse social condition scores. Among patients with collapsed lesions, middle-aged patients exhibited lower mental QOL, and a strong correlation was observed between social activity and mental health. CONCLUSION: Collapsed ONFH was associated with low QOL scores. Among patients with non-collapsed lesions, alcohol-associated ONFH, bilateral disease, and male sex were linked to low QOL scores.

Quality of Life in Pediatric Patients with Avascular Necrosis of the Femoral Head.

BACKGROUND: The aim of the present study was to evaluate health-related quality of life in pediatric patients with avascular necrosis of the femoral head. MATERIAL AND METHODS: A comparative study was conducted involving 32 children and adolescents in "ONFH Group" (subjects with a diagnosis of ONFH) and 44 in "Comparison Group" (asymptomatic children), both aged between 8 and 18. Clinical and sociodemographic data were obtained along with PedsQL 4.0 questionnaires to evaluate the quality of life in the age-ranges studied. RESULTS: The two groups were similar as regards sociodemographic characteristics. Comparison of the quality of life total scores demonstrated significant differences between the ONFH group and the comparison group (58.86±16.54 versus 82.08±9.51), and this also occurred in all the domains analyzed. The predictors that showed correlation with the quality of life were: presence of necrosis, age, time of diagnosis, radiographic classification, Charnley score, educational level, previous surgeries, and previous infections. CONCLUSION: Our data confirm the hypothesis that pediatric patients with ONFH demonstrate a lower quality of life than healthy children in all the domains evaluated, especially with regard to the physical aspect.

Pre-operative function, motivation and duration of symptoms predict sporting participation after total hip replacement.

There is little in the literature on the level of participation in sports which patients undertake after total hip replacement (THR). Our aims in this study were to determine first, the level of sporting activity, second, the predictive factors for returning to sporting activity, and third, the correlation between participation in sports and satisfaction after THR. We retrospectively identified 815 patients who had undergone THR between 1995 and 2005. All were asked to complete a self-administered questionnaire regarding their sporting activity. A total of 571 patients (71%) met the inclusion criteria and completed the evaluation. At a mean follow-up of 9.8 years (sd 2.9), 366 patients (64%) returned to sporting activity as defined by a University of California at Los Angeles (UCLA) score of > 5. The main reasons that patients had for refraining from sports were fear of dislocation (65; 31.6%), avoiding wear (52; 25.4%), and the recommendation of the surgeon (34; 16.6%). There was a significant relationship between higher post-operative participation in sport in those patients with a higher pre-operative Harris hip score (HHS) (p = 0.0074), motivation to participate in sporting activities (p = 0.00022) and a shorter duration of symptoms (p = 0.0034). Finally, there was a correlation between age (p = 0.00013), UCLA score (p = 0.012) and pre-operative HHS (p = 0.00091) and satisfaction. In conclusion, we found that most patients participate in sporting activity after THR, regardless of the advice of their surgeon, and that there is a correlation between the level of participation and pre-operative function, motivation, duration of symptoms and post-operative satisfaction.

Effect of depression on femoral head avascular necrosis from femoral neck fracture in patients younger than 60 years.

The purpose of this study was to determine the effect of depression on femoral head avascular necrosis (AVN) from femoral neck fracture in patients younger than 60 years and the relationship between depression and postoperative quality of life. The Beck Depression Inventory-II (BDI-II) was completed by 641 patients (352 men and 289 women; average age, 41.7±10.2 years; range, 20-60 years) postoperatively. Patients were divided into groups according to BDI-II score: a depressed group (BDI-II score of 14 or higher) and a nondepressed group (BDI-II score lower than 14). They were followed for an average of 28 months (range, 24-37 months). The postoperative diagnosis was confirmed by typical radiographs and single photon-emission computed tomography. Quality of life among patients was assessed using the Short Form-36 (SF-36) questionnaire. The overall incidences of depression and AVN were 30.6% (196 of 641) and 20.9% (134 of 641), respectively. Ninety-four (48.0%) patients in the depressed group and 40 (9.0%) patients in the nondepressed group ultimately developed AVN. Symptoms of depression significantly affected AVN. In addition, depression predicted patients' quality of life, as did sex, partner status, employment status, living alone, frequency of exercise, severity of fractures, and length of hospital stay. In a multiple linear regression model analyzing all of these variables, depression was the best independent predictor of quality of life. Depression in patients younger than 60 years with femoral neck fractures may increase postoperative femoral head AVN risk and greatly affect patients' quality of life.

Quality of sexual life after total hip arthroplasty in male patients with osteonecrosis of femoral head.

BACKGROUND: Patients with osteonecrosis of the femoral head (ONFH) have a severe impact on their health status, functionality and quality of life. Sexual life is an important component of the quality of life and is still a frequently neglected domain in patients with ONFH. The aims of the study were to evaluate the influence of the disease and the total hip arthroplasty (THA) surgery on quality of sexual life (QSL) in these patients. METHODS: A prospective, self-controlled study was done. 247 patients of ONFH who underwent unilateral or bilateral THA were asked to complete a standardized QSL questionnaire, and the score of QSL was evaluated preoperatively and at first year follow-up of post-THA operation. RESULTS: The mean age of the patient was 46.8 (range 25-60) years. 194 cases (78.5%, 276 hips) were alcohol-induced ONFH. There is significant decrease (p = 0.026) in sexual relationship impairment on the 0-8 scale from pre-THA (5.3 ± 0.7) to post-THA (2.3 ± 0.4). There is no significant difference for effect on sexual function (p = 0.14) between pre-THA (2.3 ± 0.4) and post-THA (1.8 ± 0.3). There is significant improvement (p = 0.018) in overall sexual satisfaction degree of patients on the 1-5 scale from pre-THA (2.7 ± 0.2) to post-THA (4.7 ± 0.6), but no significant increase for sexual partner. CONCLUSION: ONFH has impaired relationships with partner and overall sexual satisfaction degree of the male patients; THA has improved significantly relationships with partner and overall sexual satisfaction degree of the male patients, but no effect on sexual function of the patients and overall sexual satisfaction degree of sexual partner.

[Effects of Yougui recipe on the behavioral changes in rat of steroid-induced avascular necrosis of the femoral head].

OBJECTIVE: To explore the effect of Yougui Recipe, a kidney-supplementing and yang-activating formula which on the behavioral changes of rat of steroid-induced avascular necrosis of the femoral head (SANFH). METHODS: Thirty Wistar rats were involved and were randomly divided into the blank control group (group A), the model group (group B) and the Yougui Recipe group (group C). SANFH models were established by injection of colibacillus endotoxin and prednisolone intramuscularly. Group C was lavaged with Yougui Recipe (10 ml/kg), while group A and group B were lavaged with the same amount of saline. The behavior of catch force, independent activities, the tail suspension, field experiment and water cleans maze experiment were observed after 6 weeks. RESULTS: Compared with Yougui Recipe, rats in model group: catch force and independent activity decreases; the tail suspension activities was less time. In the desert field experiments, the total distance in 10 min movement reduced significantly. In the water maze experiment, incubation period of escape had a long time obviously, total distance of activities reduced. CONCLUSION: Yougui Recipe can relieve the ethologic change of rat model of steroid-induced avascular necrosis of the femoral head.

Pronounced risk of nontraumatic osteonecrosis of the femoral head among cigarette smokers who have never used oral corticosteroids: a multicenter case-control study in Japan.

BACKGROUND: Cigarette smoking has been linked to an increased risk of nontraumatic osteonecrosis of the femoral head (ONFH) in previous studies. However, the effect of smoking amount, duration and cessation, and interaction with corticosteroids remains unclear. The purpose of this study was to precisely evaluate the effects of smoking and the interaction with corticosteroid use. METHODS: This was a multicenter, matched case-control study in Japan. Cases were defined as patients who were newly diagnosed with ONFH at an initial visit or during the previous year if they were referred patients. For each case, matched controls were selected from patients without ONFH. The matching conditions were sex, age, and ethnicity. A logistic regression model was used to compute odds ratios (OR) and 95 % confidence intervals (95 % CI). RESULTS: We compared 72 cases with 244 matched controls. ORs were 3.89 (95 % CI 1.46-10.4) for current smokers, 3.89 (1.22-12.4) for smokers consuming more than 20 cigarettes per day, 4.26 (1.32-13.7) for smokers with 26 pack-years or more, and 3.11 (0.92-11.5) for smokers with a history of 29 years or more, with significant or marginally significant dose-response relationships. OR for current smokers was 10.3 among those who had never used corticosteroids and 1.56 among past or current corticosteroid users (P for interaction 0.010). CONCLUSIONS: Our results revealed that heavier cigarette smoking was associated with a higher risk of ONFH. The elevated risk from cigarette smoking was markedly pronounced among those who had never used oral corticosteroids.

Posttraumatic stress disorder in convalescent severe acute respiratory syndrome patients: a 4-year follow-up study.

OBJECTIVE: To measure the incidence and impact of posttraumatic stress disorder (PTSD) in a cohort of 70 subjects with severe acute respiratory syndrome (SARS). METHODS: Clinical assessments of PTSD were conducted at 2, 7, 10, 20 and 46 months after discharge from medical hospitalization for treatment of SARS. Diagnoses of PTSD were established by a trained psychiatrist using the Chinese Classification of Mental Disorders (CCMD-III) and Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria. To study the impact of PTSD, we used the Impact of Event Scale (IES), Zung Self-Rating Anxiety Scale (SAS), Zung Self-Rating Depression Scale (SDS), Symptom Checklist 90 (SCL-90), Short Form-36 (SF-36 Health Survey) and Social Disability Screening Schedule (SDSS). RESULTS: Of the 68 subjects who finished at least two follow-up interviews, 30 developed PTSD over the study period (44.1%). Scores on IES, SAS, SDS and SCL-90 (P<.0001) were higher, and functional impairment as measured by SF-36 (P<.0001) and SDSS was more severe (P=.0073) for subjects with PTSD. CONCLUSION: PTSD occurs in a significant percentage of subjects who recover from SARS, and the occurrence of PTSD predicts persistent psychological distress and diminished social functioning in the 4 years after SARS treatment.

The neglected femoral neck fracture in young adults: review of a challenging problem.

A neglected femoral neck fracture is one where there has been a delay of more than 30 days to seek medical help from the time of the original injury. Among the spectrum of femoral neck fractures, the neglected fracture in a young adult (age <60 years) is one of the most challenging to treat if femoral head salvage is attempted. The main complication is avascular necrosis (AVN) of the femoral head with most reported incidences being <15% (range 0% to 67%), which is similar to the complication rate with non-neglected femoral neck fractures. This review consolidates our current knowledge about the problem, discusses the various treatment options and compares the published long-term results. There are no clear guidelines for management of neglected femoral neck fractures, although multiple methods have been used with varying success. Bone grafting or internal fixation in isolation does not provide a satisfactory outcome. Osteotomy has given better outcomes (AVN 6% to 17%, non-union 0% to 15%), but mechanical changes at the femoral neck may lead to a persistent painful hip. Bone grafting with internal fixation has emerged as a reliable method with good long-term functional outcomes.

[Total hip arthroplasty without cement in children and adolescents: 17 cases]. / Arthroplastie totale de hanche sur mesure et sans ciment chez l'enfant et l'adolescent: à propos de 17 cas.

PURPOSE OF THE STUDY: Hip disease can produce major pain and functional disorders in children who should benefit from total hip arthroplasty. We report our experience with total hip prostheses implanted without cement in children. MATERIAL AND METHODS: We performed 17 total hip arthroplasties in 13 children who had various conditions, mainly chronic juvenile osteoarthritis and aseptic osteonecrosis secondary to sickle cell anemia. The acetabular inserts were not cemented. All the femoral stems were custom-made using computer-assisted preoperative planning based on standard x-rays and computed tomography findings. Outcome was assessed on the basis of patient satisfaction, pain, and function. Radiographically, we assessed stem implantation, stability and integration. Results were classed with the Harris score and also with the Steinbrocker classification in order to take into account the child's overall functional handicap. RESULTS: Mean follow-up was 36.4 months. There were three cases of superficial hematoma, one case of superficial sepsis and one acetabular loosening. All patients were satisfied. Unsatisfactory function, observed in 80% of the children preoperatively, was found in only 17% postoperatively. The Harris score improved from 23.8 preoperatively to 87.7 at last follow-up. There were no cases of stem loosening and integration was achieved in 85.3% of the cases proximally in the area with hydroxyapatite surfacing. DISCUSSION: The problem with these children is to determine when total hip arthroplasty should be proposed. We retain three important indications: uncontrollable chronic pain, normal school attendance impossible, no other possibility for conservative surgery. Several studies have reported only mediocre results with cemented stems. We opted for custom-made stems without cement for three reasons: preservation of bone stock, better adaptation to bone whose quality and morphology had been remodeled by the underlying condition and repeated osteotomies which also affect the gluteus medius, and finally, better chance of success for future revisions in these active young patients. CONCLUSION: The question on whether or not total hip arthroplasty should be performed early in these children to avoid osteotomies which could alter the longevity of a future prosthesis remains open. Custom-made stems inserted without cement have provided satisfactory results in our experience. To date, follow-up is too short to compare our results with those obtained by others using cemented stems.

Estudo da imagem corporal através do teste do desenho da figura humana em pacientes portadores de necrose asséptica da cabeça femoral / The use of the human figure drawing test in the analysis of the body image in patients with avascular necrosis of the femoral head

Os autores apresentam os resultados do estudo do desenho da imagem corporal de 66 indivíduos através do teste do desenho da figura humana enquanto teste projetivo. Foram analisados os resultados de 33 pacientes portadores de necrose asséptica da cabeça femoral em relaçäo a 33 indivíduos normais. Os itens do teste do desenho da figura humana com resultados significativos foram seis no grupo estudo, enquanto que no grupo controle somente um mostrou-se significativo. Os autores concluem que o teste do desenho da figura humana foi útil para avaliaçäo da auto-imagem em pacientes portadores de necrose asséptica da cabeça femoral

Behavioral sequelae of bracing versus surgery for Legg-Calvé-Perthes disease.

The Louisville Behavioral Checklist was administered to 23 white boys between the ages of 7 and 12 years who completed treatment for Perthes disease by bracing or surgery at the Florida Elks Children's Hospital. The groups were comparable, with 11 children in the surgery group and 12 in the bracing group. Results indicated statistically significant differences (p = 0.05) between the groups in three areas. Patients in the bracing group were more likely to demonstrate deficits in social, academic, and sexual behavior as compared with patients in the surgery group.