Hydroxyapatite-Coated Femoral Stems in Primary Total Hip Arthroplasty: An Updated Meta-Analysis.

BACKGROUND: Most primary total hip arthroplasties (THAs) performed in the United States utilize cementless fixation with porous or hydroxyapatite (HA) coating. A previous meta-analysis comparing HA-coated versus non-HA-coated stems in primary THA published in 2013 found no significant difference between the 2. However, an updated analysis of the current literature is needed to assess the potential benefit of HA-coated stems in primary THA. METHODS: Various libraries were searched through May 2022 according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Studies included were randomized controlled trials comparing HA-coated femoral stems to non-HA-coated stems in primary THA. Outcomes included Harris Hip Score (HHS), endosteal bone formation, radiolucent lines, linear wear rate, revision for aseptic loosening, thigh pain, and heterotopic ossification. RESULTS: There were significantly fewer revisions for aseptic loosening (P = .004) and decreased postoperative thigh pain (P = .03) for patients who have with HA-coated stems. There was no significant difference in HHS (P = .20), endosteal bone formation (P = .96), radiolucent lines (P = .75), linear wear rate (P = .41), or heterotopic ossification (P = .71) between HA-coated and non-HA-coated stems. CONCLUSION: We found that HA-coated femoral stems in primary THA led to significantly fewer stem revisions for aseptic loosening and less postoperative thigh pain compared to non-HA-coated stems. These findings suggest HA-coated femoral stems should be preferred over non-HA-coated femoral stems in primary THA.

Biomedical Research Infographics and Visual Abstracts Increase Social Media Attention and Article Citation.

Biomedical research Infographics, a short-form neologism for "information graphics," illustrate medical educational information in an engaging manner by enhancing concise text with figures, tables, and data visualizations in the form of charts and graphs. Visual Abstracts present a graphic summary of the information contained in a medical research abstract. In addition to improving retention, both Infographics and Visual Abstracts allow for dissemination of medical information on social media and increase the breadth of medical journal readership. In addition, these new methods of scientific communication increase citation rates, as well as social media attention as determined by Altmetrics (alternative metrics).

Comparative Analysis of Contemporary Fixed Tibial Inserts: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials.

Background: Multiple options are available for the tibial insert in total knee arthroplasty (TKA). A systematic review (SR) and network meta-analysis (NMA) to compare available randomized controlled trials (RCTs) could assist with decision making. We aim to show that designs with increased conformity may improve function and satisfaction without an increase in complications though posterior stabilized (PS) inserts will likely have more flexion. Methods: A search of MEDLINE, EMBASE, and the Cochrane Library was performed. Studies were limited to RCTs evaluating cruciate retaining (CR), PS, anterior stabilized (AS), medial pivot (MP), bicruciate retaining (BR), and bicruciate stabilizing (BCS) inserts. Mean differences (MD) were used for patient reported outcome measures (PROMs) and odds ratios (OR) for reoperation rates and MUA. A systematic review was performed for satisfaction. Results: 27 trials were identified. The NMA showed no difference from a statistical or clinical standpoint for PROMs evaluated. There was a statistical difference for increased flexion for PS knees (3 degrees p 0.04). There were no differences in the MUA or reoperation rates. There was insufficient information to determine if a specific insert improved satisfaction. Discussion: The results of this NMA show no statistical or clinical difference in PROMs. There was higher flexion for PS knees though the amount was not clinically significant. There was insufficient data for conclusions on patient satisfaction. Therefore, the surgeon should evaluate the clinical situation to determine the best insert rather than choose and insert based on functional scores, patient satisfaction, or complication rates.

Closed Incision Negative Pressure Wound Therapy for Elective Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Persistent wound drainage after total joint arthroplasty (TJA) increases the risk of surgical site infections (SSIs). Closed incision negative pressure wound therapy (ciNPWT) decreases infections in traumatic wounds, but evidence for its use after elective TJA is limited. The purpose of this meta-analysis of level I studies is to determine the effect of ciNPWT on risk of SSI and wound complications following TJA. METHODS: MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched for randomized controlled trials comparing ciNPWT vs standard dressings after total hip (THA) and total knee arthroplasty (TKA). Studies exclusively involving THA for femoral neck fractures were excluded. Risk of SSI and noninfectious wound complications (blisters, seroma, hematoma, persistent drainage, dehiscence, and wound edge necrosis) following TJA were analyzed. RESULTS: SSI risk was lower with ciNPWT compared to standard dressings (3.4% vs 7%; relative risk [RR] 0.48, P = .007), specifically in revision THA and TKA (4.1% vs 10.5%; RR 0.41, P = .03). ciNPWT increased the noninfectious complication risk after primary TKA (RR 4.71, P < .0001), especially causing wound blistering (RR 12.66, P < .0001). ciNPWT decreased hospital length of stay by 0.73 days (P = .04) and reoperation rate (RR 0.28, P = .01). CONCLUSION: ciNPWT decreases SSI risk compared to standard dressings after revision TJA, but not primary TJA. ciNPWT is associated with >12-fold increased risk of wound blistering after primary TKA. ciNPWT plays a role in revision TJA management, but additional randomized controlled trials with uniform wound assessment methods must be performed to sufficiently power findings and draw conclusions on the use of ciNPWT after primary TJA.

Implantable Subacromial Balloon Spacers in Patients With Massive Irreparable Rotator Cuff Tears: A Systematic Review of Clinical, Biomechanical, and Financial Implications.

PURPOSE: To determine the clinical, biomechanical, and financial impact of the use of subacromial balloon spacers in the surgical management of massive, irreparable rotator cuff tears (RCTs). METHODS: All studies assessing the use of implantable subacromial balloon spacers for management of massive, irreparable RCTs were systematically searched. Risk of bias was assessed using Methodological Index for Non-Randomized Studies criteria. Data extraction and analysis was performed for pain and function scores, shoulder range of motion (ROM), glenohumeral contact pressure and vertical migration of humeral head, and cost. Subjective synthesis was performed with forest plots when outcomes were reported in 3 or more studies. RESULTS: In total, 19 studies met inclusion criteria for analysis; 337 patients (mean age 68 years) had 343 subacromial balloon spacer implantations. Throughout a mean follow-up of 33 months, there was significant improvement in the Total Constant Score (preoperative: 22.5-41.8; postoperative: 51.4-72.3), Oxford Shoulder Score (preoperative: 21.3-26; postoperative: 34.39-48.2), American Shoulder and Elbow Surgeons score (preoperative: 24.5-59.1; postoperative: 72.5-85.7), and shoulder ROM parameters. Subacromial balloon spacer placement resisted superior humeral head migration (range of preoperative to postoperative difference: 2.8-6.2 mm) and decreased peak subacromial pressure during shoulder ROM. CONCLUSIONS: Existing literature of subacromial balloon spacers has a high risk of bias, lack of appropriate control, and low levels of evidence. A qualitative synthesis indicates that subacromial balloon spacer implantation in patients with massive irreparable RCTs is cost-effective and leads to improved function (Total Constant Score and Oxford Shoulder Score) and ROM. In cadaveric studies, subacromial balloon spacers resist superior humeral head migration and reduce subacromial pressure. The theoretical risk of biodegradation of the balloon spacer has not been substantiated in study of up to 5-years follow-up, and the risk of complications from this procedure appears to be minimal. LEVEL OF EVIDENCE: IV; Systematic review of level III-IV studies.

Editorial Commentary: Published Sham Trials in Orthopaedic Surgery Are Flawed and Potentially Unethical-A Wolf in Sheep's Clothing.

Sham controlled randomized controlled trials attempt to isolate the beneficial health effects of orthopaedic surgery from benefits due to patients' belief in surgery. The physiological effects of sham surgery, genetic variations that influence responsiveness to placebo, cultural, and geographic influences confound results of these trials. There is a need for high methodological standard for sham-controlled trials as there is potential for direct patient harm and indirect harm from misinformation generated from poorly conducted studies. Confounding factors that affect the reliability of published sham trails expose patients to the potential harm from sham surgery without adequate methodological rigor which could be unethical.

Automatic Characterization of Pelvic and Sacral Measures from 200 Subjects.

BACKGROUND: An understanding of pelvic and acetabular morphology and orientation is required for accurate surgical reconstruction of the hip and spine, as well for component placement in a total hip arthroplasty. Our objectives were to develop an automated system for measuring pelvic and sacral orientations utilizing computed tomographic (CT) scans and to characterize these measures across 200 asymptomatic subjects. METHODS: An automated feature recognition algorithm was created to identify acetabular and pelvic orientation across 200 scans generated for non-musculoskeletal conditions. Three-dimensional models were generated from CT data to serve as inputs to the algorithm. Acetabular orientation was defined by comparing a plane fit to the acetabular rim with the anterior pelvic plane. Pelvic inclination, pelvic tilt, and sacral slope were defined as the angles between landmarks identified across the pelvis: pubic tubercles, acetabular center, left and right anterior superior iliac spines, and sacral plate. RESULTS: The mean sacral slope was 36.49°, the mean pelvic tilt was 15.60°, and the mean pelvic incidence was 52.05°. The mean sacropubic angle was 32.48° and the mean pelvic-Lewinnek angle was 8.93°. Significant differences between male and female subjects were observed in the sacral slope (mean difference, 4.72°; p < 0.05), pelvic tilt α (mean difference, 4.17°; p < 0.05), pelvic tilt γ (mean difference, 3.06°; p < 0.05), and the pelvic-Lewinnek angle (mean difference, 1.76°; p < 0.05). The comparison of acetabular orientation measures with those in a prior study of the same cohort yielded intraclass correlation coefficients (ICCs) all above 0.97. The validation of sacral orientation via manual measurement also yielded ICC values all at or above 0.97. CONCLUSIONS: Our algorithm showed a high degree of consistency in acetabular orientation measures with respect to a prior study of the same cohort. The measures of pelvic orientation were found to be accurate and reliable when compared with manual measurements of the same data set. All measurements of pelvic orientation were consistent with the means reported in the literature. CLINICAL RELEVANCE: An accurate and reproducible, automated technique for determining pelvic and acetabular orientation provides a way to characterize these measures as an aid in clinical diagnosis and preoperative planning.

Editorial Commentary: Hip Arthroscopy for Femoroacetabular Impingement in Systemic Inflammatory Disease: Pirates Gold in Uncharted Waters.

Hip pain in patients with systemic inflammatory diseases may arise from synovitis, cartilage degeneration or bony abnormalities like femoroacetabular impingement or acetabular dysplasia. With advances in early diagnosis and medical management of the autoimmune response, these often-young patients may benefit from correction of underlying bony abnormalities like femoroacetabular impingement. Short-term improvement in patients' pain and function can be achieved with hip arthroscopic treatment. However, the long-term efficacy of hip arthroscopy in systemic inflammatory disease needs further research. Careful selection of patients with nondysplastic hips without significant cartilage degradation, correction of underlying bony abnormalities, collaboration with rheumatologist, and use of evidence-based perioperative management of anti-rheumatic drugs are keys to success.

Digital Orthopaedics: A Glimpse Into the Future in the Midst of a Pandemic.

BACKGROUND: The response to COVID-19 catalyzed the adoption and integration of digital health tools into the health care delivery model for musculoskeletal patients. The change, suspension, or relaxation of Medicare and federal guidelines enabled the rapid implementation of these technologies. The expansion of payment models for virtual care facilitated its rapid adoption. The authors aim to provide several examples of digital health solutions utilized to manage orthopedic patients during the pandemic and discuss what features of these technologies are likely to continue to provide value to patients and clinicians following its resolution. CONCLUSION: The widespread adoption of new technologies enabling providers to care for patients remotely has the potential to permanently change the expectations of all stakeholders about the way care is provided in orthopedics. The new era of Digital Orthopaedics will see a gradual and nondisruptive integration of technologies that support the patient's journey through the successful management of their musculoskeletal disease.

Editorial Commentary: Myth Buster-Is Femoral Retroversion a Contraindication to Hip Arthroscopy in Femoroacetabular Impingement?

Hip arthroscopy can effectively address cam and pincer impingement by reshaping bone prominences or bone edges. However, hip arthroscopy cannot be used to correct severe bone torsion abnormalities such as acetabular or femoral retroversion. As a result, some surgeons contraindicate hip arthroscopy in patients with femoral retroversion absent correction of the torsion abnormalities. However, recent research has suggested that hip arthroscopy absent osteotomy, with a focus on labral preservation and thorough correction of underlying cam and pincer bony abnormalities, achieves positive outcomes. Still, although femoral retroversion should not be considered a contraindication for hip arthroscopy, patients should be carefully counseled about residual symptoms.

Editorial Commentary: Low-Dose Hip Computed Tomography Sharpens the Saw for Hip Preservation: Can It Cut the Tree?

Computed tomography scans provide excellent visualization of complex hip deformities and assist in the diagnosis and surgical planning of hip preservation surgery. The dose of harmful ionizing radiation can be reduced while preserving reasonable image quality. Low-dose hip computed tomography can be used successfully for preoperative planning. Readers should consider strategies to reduce the radiation dose from computed tomography scans and consider magnetic resonance imaging arthrograms for assessment of cartilage and labral status before hip preservation surgery.

Editorial Commentary: Hip Arthroscopy-The Tissue-Friendly Evolution.

The field of hip arthroscopy is saturated with low-level studies. A systematic review of these low-level studies provides low-level evidence favoring tissue-friendly restorative techniques such as labral repair and capsular repair over nonrestorative techniques such as labral debridement and capsulotomy. Iatrogenic complications such as nerve injuries and heterotopic ossification remain the most common complications of hip arthroscopy. This indicates that there is a further scope in improving the safety of hip arthroscopy. There is a need for innovative, well-designed benchtop and high-level clinical studies for rapid advancement in hip arthroscopy techniques.

Automated femoral version estimation without the distal femur.

Femoral version impacts the long-term functioning of the femoroacetabular joint. Accurate measurements of version are thus required for success in total hip arthroplasties and hip reconstructive surgeries. These are impossible to obtain without visualization of the distal femur, which is often unavailable preoperatively as the majority of imaging scans are isolated to the pelvis and proximal femur. We developed an automated algorithm for identifying the major landmarks of the femur. These landmarks were then used to identify proximal axes and create a statistical shape model of the proximal femur across 144 asymptomatic femora. With six proximal axes selected, and 200 parameters (distances and angles between points) from the shape model measured, the best-fitting linear correlation was found. The difference between true version and version predicted by this model was 0.00 ± 5.13° with a maximum overestimation and underestimation of 11.80 and 15.35°, respectively. The mean absolute difference was 4.14°. This model and its prediction of femoral version are a substantial improvement over pre-operative 2D or intra-operative visual estimation measures. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:3161-3168, 2018.

Acetabular Dysplasia in Middle-Aged Patients: Periacetabular Osteotomy or Total Hip Arthroplasty?

BACKGROUND: Treatment of middle-aged patients with acetabular dysplasia is challenging because of mild osteoarthritis, long life span, high activity level, and sports participation. Both periacetabular osteotomy (PAO) and total hip arthroplasty (THA) provide pain relief, improve function, and can last over 2 decades. We compare the 2 procedures for functional outcome (including sports participation), pain relief, and morbidity. METHODS: We compared patients in the 30-50 years age group with symptomatic acetabular dysplasia who underwent PAO (n = 14) or THA (n = 14) with minimum 4-year follow-up. We compared postoperative activity (modified Harris Hip Score, high activity arthroplasty score, and modified Merle d'Aubigné-Postel Score) and sports participation (Tegner and University of California Los Angeles activity scores) in the 2 groups. Morbidity was compared by durations of postoperative pain >4/10, narcotic use, use of gait aids, and time to return to normal activities. RESULTS: Sports participation and function scores improved after surgery in both groups without significant intergroup difference at minimum 4-year follow-up. Patients with PAO had longer duration of postoperative pain (P = .01) and used gait aids longer (P = .04) than patients with THA. There were 3 minor reoperations in the PAO group and none in the THA group. CONCLUSIONS: PAO and THA both produce comparable improvement in sports participation and function. PAO was associated with longer durations of pain and use of gait aids. These findings may be important in the decision-making process in middle-aged patients with symptomatic acetabular dysplasia.

Revision TKA for Flexion Instability Improves Patient Reported Outcomes.

UNLABELLED: Instability is a major cause of early revision of total knee arthroplasty (TKA), of which flexion instability is a major subset. We analyzed radiologically evident corrections, patient reported outcome and complications associated with revision TKA for flexion instability in a retrospective cohort of 37 patients with minimum one year follow up. Following revision surgery, there was a significant increase in mean posterior condylar offset ratio and a significant decrease in tibial slope while the level of joint line was not significantly altered. Patient reported version of knee society score showed significant improvement with surgery and 26 of 37 patient reported perceptible improvement on a 7-point Likert scale. LEVEL OF EVIDENCE: Level IV, Case series. See the Guidelines for Authors for a complete description of levels of evidence.

Save the torn labrum in hips with borderline acetabular coverage.

BACKGROUND: Hip arthroscopy for labral tears improves short-term function, but reoperations occur in 5% to 47% of patients. The effect of borderline acetabular coverage on reoperation rate has been debated. Labral repair rather than débridement has been proposed to improve function, but the effect on reoperation rate is unclear. QUESTIONS/PURPOSES: We determined whether (1) borderline compared to adequate acetabular coverage increased reoperations and (2) labral repair compared to débridement reduced reoperations. METHODS: We retrospectively reviewed 106 patients (mean age, 39 years) who underwent hip arthroscopy for labral tears. Based on radiographs, we classified patients into those with borderline (n = 50) or adequate (n = 56) acetabular coverage. We further divided each group into those with labral débridement or repair: borderline acetabular coverage, n = 25 and 25, respectively; adequate acetabular coverage, n = 39 and 17, respectively. We assessed reoperations in borderline versus adequate acetabular coverage and labral débridement versus repair, modified Harris hip scores (mHHSs), and survival. Minimum followup was 12 months (mean, 33 months; range, 12-65 months). RESULTS: Twenty-three of 106 patients had reoperations. Reoperation rate was higher with borderline than with adequate acetabular coverage. Reoperation rate was lower with labral repair than with débridement. Survival to reoperation was similar in the four subgroups although there was a tendency for early reoperation in patients with borderline acetabular coverage with débridement. Improvement in mean mHHS was comparable in the four subgroups. CONCLUSIONS: We found borderline acetabular coverage increased reoperation rates. Labral repair reduced the likelihood of reoperation, especially in hips with borderline acetabular coverage. Hip arthroscopy for labral tears was associated with high reoperation rates in hips with borderline acetabular coverage. LEVEL OF EVIDENCE: Level IV, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

Is there a preferred articulating spacer technique for infected knee arthroplasty? A preliminary study.

BACKGROUND: Periprosthetic infection in TKA is a devastating and challenging problem for both patients and surgeons. Two-stage exchange arthroplasty with an interval antibiotic spacer reportedly has the highest infection control rate. Studies comparing static spacers with articulating spacers have reported varying ROM after reimplant, which could be due to differences in articulating spacer technique. QUESTIONS/PURPOSES: We therefore determined whether one of three articulating spacer techniques was superior in terms of (1) infection control, (2) final ROM, and (3) cost. PATIENTS AND METHODS: We retrospectively reviewed 53 patients with infected TKAs who had two-stage exchange arthroplasty with one of three techniques with articulating spacers: autoclaving an original component (n = 15), a new femoral component (n = 16), and a silicone mold component (n = 22). We compared infection control, ROM, and cost. Minimum followup was 12 months (mean, 39 months; range, 12-105 months). RESULTS: We found no difference in infection control among the three techniques. Infection control was achieved in 13 of 15 (86.7%) autoclaved original component spacers at mean 73 months (range, 37-105 months), 15 of 16 (93.8%) new femoral component spacers at mean 19 months (range, 12-32 months), and 20 of 22 (90.9%) silicone mold component spacers at mean 32 months (range, 14-56 months). Mean final flexion was 95.7°, 98.3°, and 93.8°, respectively. Direct costs for all implants, molds, cement, and antibiotics were $932, $3589, and $3945, respectively. CONCLUSIONS: We found comparable infection control and ROM for the three techniques. Direct cost was least for the autoclaved original component technique.

Diagnosis and management of infected total knee arthroplasty.

Infection following total knee arthroplasty can be difficult to diagnose and treat. Diagnosis is multifactorial and relies on the clinical picture, radiographs, bone scans, serologic tests, synovial fluid examination, intra-operative culture and histology. Newer techniques including ultrasonication and molecular diagnostic studies are playing an expanded role. Two-stage exchange arthroplasty with antibiotic cement and 4-6 weeks of intravenous antibiotic treatment remains the most successful intervention for infection eradication. There is no consensus on the optimum type of interval antibiotic cement spacer. There is a limited role for irrigation and debridement, direct one-stage exchange, chronic antibiotic suppression and salvage procedures like arthrodesis and amputation. We examine the literature on each of the diagnostic modalities and treatment options in brief and explain their current significance.

The Chitranjan Ranawat Award: fate of two-stage reimplantation after failed irrigation and débridement for periprosthetic knee infection.

BACKGROUND: Irrigation and débridement is an attractive low morbidity solution for acute periprosthetic knee infection. However, the failure rate in the literature is high, averaging 68% (range, 61%-82%). Patients who fail subsequently undergo two-stage reimplantation after a prolonged period of illness. This leads to higher surgical risk and further delays in rehabilitation and may contribute to failure of subsequent revision surgery. QUESTIONS/PURPOSES: We determined the rerevision rate due to infection after two-stage reimplantation performed for failed irrigation and débridement of infected TKA. METHODS: We performed a multicenter retrospective review of periprosthetic knee infections treated with a two-stage procedure from 1994 to 2008. Selection criteria for the study included initial treatment with irrigation and débridement and subsequent two-stage revision surgery. Failure of two-stage revision was defined as the need for any additional surgery due to infection. RESULTS: Of the 83 knees that had undergone previous irrigation and débridement, 28 (34%) failed subsequent two-stage revision and required reoperation for persistent infection. CONCLUSIONS: The failure rate in this series of two-stage revisions for periprosthetic knee infection in patients treated with previous irrigation and débridement is considerably higher than previously reported failure rates of two-stage revision. Factors affecting the failure rate may include host quality, thoroughness of débridement, and organism virulence. Patients and surgeons must understand that irrigation and débridement, while initially attractive, may lead to high failure rates of subsequent two-stage reimplantation. LEVEL OF EVIDENCE: Level III, therapeutic study. See the guidelines online for a complete description of level of evidence.