Permissive Weight Bearing in Patients With Surgically Treated Periprosthetic Femoral Fractures Around Total Hip Arthroplasty: A Scoping Review.

Periprosthetic femoral fractures (PPFF) around total hip arthroplasty (THA) are one of the leading causes of hip revision. High mortality rates are observed after revision in case of PPFF around THA. To modify risk factors, early postoperative mobilization is necessary. Permissive weight bearing (PWB) is designed to optimize clinical recovery in aftercare. This study aimed to perform a scoping review to summarize the current available evidence on postoperative weight bearing in late PPFF around THA and the implementation of PWB in aftercare. A systematic search was performed on the Cochrane Library, Web of Science, Ovid MEDLINE, EMBASE, and CINAHL databases on January 26th, 2023. Articles were screened in two stages by two independent reviewers. Studies describing adult patients with a history of primary THA who were surgically treated for late PPFF and mentioning prescribed postoperative weight-bearing protocols with relevant outcome measures were included. Seven studies were included, reporting data on 22 patients (age range 47-97 years, BMI range 19-32 kg/m2, ASA classification range 2-3). No studies used PWB in aftercare. The non-weight-bearing group showed no complications. The restricted weight-bearing group had one death and one implant failure. The full weight-bearing group experienced one deep infection and one plate removal because of impingement. The main finding was that, after an extensive systematic search, no articles could be included focusing on PWB in patients with a late PPFF after THA. Addressing this gap in the literature is essential to advancing the understanding of postoperative weight-bearing protocols and PWB for late PPFF around THA.

Survival rates of anatomically shaped and tapered slip cemented femoral implants: an analysis of 76,281 femoral implants of the Dutch arthroplasty register (LROI).

INTRODUCTION: In cemented total hip arthroplasty (THA) various shapes and geometries of femoral implants are in use. Collarless, polished, and tapered (CPT) implants, and anatomically shaped (AS) implants are most commonly used. Due to their different design features, this might lead to different survival outcomes. In this register-based study, overall implant survival and short-term complications of CPT and AS cemented implants were evaluated. METHODS: Data of the Dutch Arthroplasty Register (LROI) were used. Cemented femoral implants, which could be classified as CPT or AS were included in this study. Implants were excluded when no classification could be made or if implanted <100 times. Survival analyses were performed using Kaplan-Meier survival analysis and multivariable Cox-proportional hazard analysis. RESULTS: 76,281 cemented THAs were included. At a mean of 5.1 years follow-up (SD 3.1, range 0-12 years), the overall survival of the AS implants was higher compared with the CPT implants, with a survival, of 99.2% and 99.0% respectively (log-rank; p < 0.001). Multivariable regression analysis revealed a higher rate for revision because of loosening of the AS implants (HR 2; CI, 1.4-3.1). AS implants had a lower rate for periprosthetic fractures compared with the CPT implants (HR 0.13; CI, 0.07-0.23). CONCLUSIONS: Both designs show excellent overall survival rates at short-term follow-up. There is a higher overall survival of AS implants when compared with CPT implants. Revision for implant loosening, however, was statistically significantly higher in AS implants when compared with the CPT implants.

The humeral suspension technique: a novel operation for deltoid paralysis.

Isolated deltoid paralysis is a rare pathology that can occur after axillary nerve injury due to shoulder trauma or infection. This condition leads to loss of deltoid function that can cause glenohumeral instability and inferior subluxation, resulting in rotator cuff muscle fatigue and pain. To establish dynamic glenohumeral stability, a novel technique was invented. Humeral suspension is achieved using a double button implant with non-resorbable high strength cords between the acromion and humeral head. This novel technique was used in two patients with isolated deltoid paralysis due to axillary nerve injury. The results indicate that the humeral suspension technique is a method that supports centralizing the humeral head and simultaneously dynamically stabilizes the glenohumeral joint. This approach yielded high patient satisfaction and reduced pain. Glenohumeral alignment was improved and remained intact 5 years postoperative. The humeral suspension technique is a promising surgical method for subluxated glenohumeral joint instability due to isolated deltoid paralysis.

Impact of enhanced recovery pathways on safety and efficacy of hip and knee arthroplasty: A systematic review and meta-analysis.

BACKGROUND: Over the past decades, clinical pathways (CPs) for hip and knee arthroplasty have been strongly and continuously evolved based on scientific evidence and innovation. AIM: The present systematic review, including meta-analysis, aimed to compare the safety and efficacy of enhanced recovery pathways (ERP) with regular pathways for patients with hip and/or knee arthroplasty. METHODS: A literature search in healthcare databases (Embase, PubMed, Cochrane Library, CINAHL, and Web of Science) was conducted from inception up to June 2018. Relevant randomized controlled trials as well as observational studies comparing ERP, based on novel evidence, with regular or standard pathways, prescribing care as usual for hip and/or knee arthroplasty, were included. The effect of both CPs was assessed for (serious) adverse events [(S)AEs], readmission rate, length of hospital stay (LoS), clinician-derived clinical outcomes, patient reported outcome measures (PROMs), and financial benefits. If possible, a meta-analysis was performed. In case of considerable heterogeneity among studies, a qualitative analysis was performed. RESULTS: Forty studies were eligible for data extraction, 34 in meta-analysis and 40 in qualitative analysis. The total sample size consisted of more than 2 million patients undergoing hip or knee arthroplasty, with a mean age of 66 years and with 60% of females. The methodological quality of the included studies ranged from average to good. The ERP had lower (S)AEs [relative risk (RR): 0.9, 95% confidence interval (CI): 0.8-1] and readmission rates (RR: 0.8, 95%CI: 0.7-1), and reduced LoS [median days 6.5 (0.3-9.5)], and showed similar or improved outcomes for functional recovery and PROMs compared to regular pathways. The analyses for readmission presented a statistically significant difference in the enhanced recovery pathway in favor of knee arthroplasties (P = 0.01). ERP were reported to be cost effective, and the cost reduction varied largely between studies (€109 and $20573). The overall outcomes of all studies reported using Grading of Recommendation, Assessment, Development and Evaluation, presented moderate or high quality of evidence. CONCLUSION: This study showed that implementation of ERP resulted in improved clinical and patient related outcomes compared to regular pathways in hip and knee arthroplasty, with a potential reduction of costs.

Disappointing long-term outcome of THA with carbon-fiber-reinforced poly-ether-ether-ketone (CFR-PEEK) as acetabular insert liner: a prospective study with a mean follow-up of 14.3 years.

INTRODUCTION: Insert liner wear of the acetabular component is one of the predictive values for survival of total hip arthroplasties (THAs). This prospective single-centre study was designed to evaluate the follow-up of carbon-fiber-reinforced poly-ether-ether-ketone (CFR-PEEK) insert liner used as bearing in cementless THAs. METHODS: 29 healthy patients with an indication for cementless THA were selected for a CFR-PEEK insert liner and followed over time. All patients received a cementless THA with a CFR-PEEK insert liner used as bearing. At different follow-up moments patients were routinely examined and were analysed using the Oxford Hip Score (OHS), the modified Merle d'Aubigne-Postel (MAP) score, and radiologically. At the follow up moments the plain radiographics where assessed for loosening, cyst formations and wear of the CFR-PEEK liners. RESULTS: At a mean of 14.3 years follow-up 4 revisions of the acetabular component were performed, resulting in a survival rate of 86.5% (CI 95%, 72.4-96.6). A statistically significant difference in OHS and MAP scores between pre- and postoperative follow-up moments was observed. The acetabular components of the remaining patients showed no radiological abnormalities at 14.3 years follow-up. The overall CFR-PEEK wear was low, with a mean of 0.81 (0.2-1.4) mm wear at 14.3 years follow-up. CONCLUSIONS: In this series we found an aseptic loosening with unclear reasons in 4 well-positioned acetabular components, hence we do not recommend routine use of CFR-PEEK insert liners as bearing in cementless THAs. All the remaining THAs and acetabular components were in situ without abnormalities at 14.3 years follow-up.

Comparable clinical and radiographical outcomes between second and third generation of gamma nails.

The aim of the study is to compare the overall complication rate and in particular lag screw cut-out between the Trochanteric Gamma Nail and the Gamma 3 Nail. A total of 294 implants (Trochanteric Gamma Nail= 132 and Gamma 3 Nail=163) in 291 patients were analysed. All clinical data was obtained from the patients medical records. Subsequently radiographs were evaluated for fracture type according to the AO classification and lag screw position by determining the tip-apex distance, the Parker's ratio and the neck- shaft-angle. No significant differences in complication rates were found. The Parker's ratio was associated with lag screw cut-out : patients with medial cut-out had more a posteriorly placement (n=9, 3.1%), while patients with cranial cut-out had a more cranial placement of the lag screw (n=10, 3.4%). The tip-apex-distance and neck-shaft-angle were not associated with cut-out. The complication rate of the Gamma 3 Nail does not differ from the Trochanteric Gamma Nail. A lag screw positioning central or slightly inferior on the anteroposterior view and central on the lateral view is recommended.

Metal ion concentrations after metal-on-metal hip arthroplasty are not correlated with habitual physical activity levels.

INTRODUCTION: Metal-on-metal (MoM) hip arthroplasties have shown high clinical failure rates with many patients at risk for a revision and under surveillance for high metal ion concentrations. Implant wear releasing such ions is assumed to be a function of use, i.e. the patient's physical activity. This study aimed to assess whether habitual physical activity levels of MoM patients are correlated with metal ion concentrations and are higher in patients with high (at risk) than in patients with low (safe) metal ion concentrations. METHODS: A cohort study was conducted of patients with any type of MoM hip prosthesis. Metal ion concentrations were determined using ICP-MS. Habitual physical activity of subjects was measured in daily living using an acceleration-based activity monitor. Outcome consisted of quantitative and qualitative activity parameters. RESULTS: In total, 62 patients were included. Mean age at surgery was 60.8 ± 9.3 years and follow-up was 6.3 ± 1.4 years. Cobalt concentrations were highly elevated overall (112.4 ± 137.9 nmol/L) and significantly more in bilateral (184.8 ± 106.5 nmol/L) than in unilateral cases (87.8 ± 139.4 nmol/L). No correlations were found between physical activity parameters and metal ion concentrations. Subgroup analysis of patients with low versus high cobalt concentration showed no significant differences in habitual physical activity. DISCUSSION: No correlation was found between physical activity levels and metal ion concentrations. Implant use by normal habitual activities of daily living seems not to influence metal ion concentrations.

Patient specific guides for total knee arthroplasty are ready for primetime.

AIM: To present the radiological results of total knee arthroplasty (TKA) with use of patient specific matched guides (PSG) from different manufacturer in patients suffering from severe osteoarthritis of the knee joint. METHODS: This study describes the results of 57 knees operated with 4 different PSG systems and a group operated with conventional instrumentation (n = 60) by a single surgeon. The PSG systems were compared with each other and subdivided into cut- and pin PSG. The biomechanical axis [hip-knee-ankle angle (HKA)], varus/valgus of the femur [frontal femoral component (FFC)] and tibia (frontal tibial component) component, flexion/extension of the femur [flexion/extension of the femur component (LFC)] and posterior slope of the tibia [lateral tibial component (LTC)] component were evaluated on long-leg standing and lateral X-rays. A percentage of > 3(°) deviation was seen as an outlier. RESULTS: The inter class correlation coefficient (ICC) revealed that radiographic measurements between both assessors were reliable (ICC > 0.8). Fisher exact test was used to test differences of proportions. The percentage of outliers of the HKA-axis was comparable between both the PSG and conventional groups (12.28% vs 18.33%, P < 0.424) and the cut- and pin PSG groups (14.3% vs 10.3%, P < 1.00). The percentage of outliers of the FFC (0% vs 18.33%, P < 0.000), LFC (15.78% vs 58.33%, P < 0.000) and LTC (15.78% vs 41.67%, P < 0.033) were significant different in favour of the PSG group. There were no significant differences regarding the outliers between the individual PSG systems and the PSG group subdivided into cut- and pin PSG. CONCLUSION: PSG for TKA show significant less outliers compared to the conventional technique. These single surgeon results suggest that PSG are ready for primetime.