The choice of surgical approach for THA remains controversial. Some studies suggest that the direct anterior approach (DAA) leads to less muscle damage than the miniposterior approach (MPA), but ...there is little high-quality evidence indicating whether this accelerates recovery, or whether this approach-which may be technically more demanding-is associated with component malposition or more complications.
(1) Does the DAA result in faster return to activities of daily living than the MPA? (2) Does the DAA have superior patient-reported outcome measures than the MPA? (3) Does the DAA result in improved radiographic outcomes than the MPA? (4) Does the DAA have a higher risk of complications than the MPA?
Between March 1, 2013, and May 31, 2016, 116 patients undergoing primary unilateral THA were randomized to either the DAA or MPA; 15 patients withdrew after randomization, and one died 6 months after surgery from a stroke unrelated to the procedure. Recruitment stopped when 52 patients had been randomized into the DAA group and 49 in the MPA group (n = 101). After patient randomization, one high-volume surgeon performed all of the DAAs and three high-volume surgeons performed the MPA THAs. The groups did not differ in age (65 years; SD 11; range, 38-86 years), sex (52% women), or body mass index (mean 29 kg/m; SD 6 kg/m; range, 21-40 kg/m; all p > 0.40). Functional results included time to discontinue gait aids, discontinue all narcotics, and independence with various activities of daily living; accelerometer data evaluated activity level. Clinical and radiographic outcomes, Hip disability and Osteoarthritis Outcome Score, SF-12, and Harris hip scores to 1 year were also tabulated. The minimum followup was 365 days (mean ± SD, 627 ± 369 days).
There were slight differences in early functional recovery that favored the DAA versus the MPA: time to discontinue walker use (10 versus 15 days, p = 0.01) and time to discontinue all gait aids (17 versus 24 days, p = 0.04). There were no other differences in early functional milestones, although at 2 weeks after surgery, mean steps per day were 3897 (SD 2258; range, 737-11,010) for the DAA versus 2235 for the MPA (SD 1688; range, 27-7450; p < 0.01). There was no difference in activity monitoring at 1 year. There were no differences in patient-reported outcome scores between the groups. There was no difference in the radiographic parameters measured in the two groups, including leg length discrepancy, component position, or offset, and there was no subsidence observed in any hip. There was no difference in complications between the DAA and the MPA groups (8% four of 52 versus 10% five of 49; p = 0.33).
Both the DAA and MPA approaches provided excellent early recovery with a low risk of complications. Patients undergoing the DAA had a slightly faster recovery, as measured by milestones of function and quantified by activity monitor data, but no substantive differences were evident at 2 months. Because the DAA is the less studied approach, longer term (> 1 year) complications may yet accrue, will be important to quantify, and may offset early benefits.
Level I, therapeutic study.
How to Interpret Metal Ions in THA Taunton, Michael J.
The Journal of arthroplasty,
June 2020, 2020-06-00, 20200601, Letnik:
35, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Modern total hip arthroplasty has seen an unfortunate increase in proportional implant failures secondary to adverse local tissue reactions (ALTRs) secondary to wear of metal-on-metal (MoM) bearings ...and mechanically assisted crevice corrosion (MACC) related to corrosion at implant junctions and tapers. The purpose of this study is to describe the appropriate choice of metal ion testing and evaluation of those levels to identify failed total hip arthroplasty implants containing cobalt and chromium.
When presented with an arthroplasty of concern, the surgeon must determine what metal ion levels to obtain and then incorporate those levels into a treatment algorithm. Patients with painful hip arthroplasties are evaluated for chromium and cobalt by obtaining whole blood and synovial metal levels.
Synovial fluid cobalt had the highest correlation with ALTR compared with the other tests, with a threshold of 19.75 ng/ml, with a specificity of 89%, if the cobalt-to-chromium ratio is greater than 1.4 ng/ml in a metal on polyethylene hip, with a sensitivity of 95%.
The interpretation of whole blood metal ions is a key component of the algorithm in treating the symptomatic hip arthroplasty but is not to be used in a vacuum.
Background
Pelvic discontinuity is an increasingly common complication of THA. Treatments of this complex situation are varied, including cup-cage constructs, acetabular allografts with plating, ...pelvic distraction technique, and custom triflange acetabular components. It is unclear whether any of these offer substantial advantages.
Questions/purposes
We therefore determined (1) revision and overall survival rates, (2) discontinuity healing rate, and (3) Harris hip score (HHS) after treatment of pelvic discontinuity with a custom triflange acetabular component and (4) the cost of this reconstructive operation compared to other constructs.
Methods
We retrospectively reviewed 57 patients with pelvic discontinuity treated with revision THA using a custom triflange acetabular component. We reviewed operative reports, radiographs, and clinical data for clinical and radiographic results. We also performed a cost comparison with utilization of other techniques. Minimum followup was 24 months (average, 65 months; range, 24–215 months).
Results
Fifty-six of 57 (98%) were free of revision for aseptic loosening at latest followup. Fifty-four (95%) were free of revision of the triflange component for any reason. Thirty-seven (65%) were free of revision for any reason. Twenty-eight (49%) were free of revision for any reason and free of any component migration and had a healed discontinuity. Forty-six (81%) had a stable triflange component with a healed pelvic discontinuity. Average HHS was 74.8. The costs of the custom triflange implants and a Trabecular Metal
®
cup-cage construct were equivalent: $12,500 and $11,250, respectively.
Conclusions
In this group of patients with osteolytic pelvic discontinuity, triflange implants provided predictable mid-term fixation at a cost equivalent to other treatment methods.
Level of Evidence
Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Abstract Background The abuse of prescription opioids is an epidemic in the United States. Opioids are an effective, and often necessary, treatment of postoperative pain after Total Knee ...Arthroplasty. However, it is often difficult to know how much medication patients will need after discharge. The purpose of this study was to determine if patients discharged with greater quantities of opioids after Total Knee Arthroplasty (TKA) are less likely to titrate their use and more likely to request refills. Methods This is a retrospective review of 105 consecutive primary TKA performed at a single institution with at least 1 year of follow up. Exclusion criteria included bilateral TKA, preoperative opioid use, or reoperation within the first three months. Data collected included opioid refills, Knee Society Score (preoperative and follow up), and total and daily morphine equivalent dose (MED) prescribed. Results Patients were most commonly discharged on oxycodone (90%), Dilaudid (5%), and Vicodin (1%). In addition, 87% were prescribed tramadol. The median number of oxycodone (5 mg) and tramadol (50 mg) tablets prescribed was 80 (600 mg of oxycodone and 800 mg of tramadol). The average total prescribed MED was 1405 ± 616 mg (range, 273 to 3250). Refills occurred in 35% (34) of patients with 18% (19) being primary opioid refills and 16% (17) being tramadol refills. Two refills were needed in 4% (4) and three refills in 1% (1). Patients requiring refills did not differ in total prescribed MED (1521±624 vs 1349±609, p=0.1), daily prescribed MED (153±10 vs 155±7, p=0.8), or preoperative KSS (63±16 vs 60±13, p=0.3). Average follow up time was 2.4±0.5 years. At latest follow up only one patient remained on opioids (tramadol) for pain related to the operative knee. Conclusion The quantity of opioids prescribed after TKA varied widely, ranging from a total MED of 273 to 3250 mg. The refill rate did not differ between large prescriptions (≥1400 mg) and smaller prescriptions. Excessive opioid prescriptions should be avoided as they did not decrease the number of refills and pose the risk of divergence and subsequent abuse.
Dislocation is the most common reason for early revision following total hip arthroplasty (THA). More than 40 years ago, Lewinnek et al. proposed an acetabular "safe zone" to avoid dislocation. While ...novel at the time, their study was substantially limited according to modern standards. The purpose of this study was to determine optimal acetabular cup positioning during THA as well as the effect of surgical approach on the topography of the acetabular safe zone and the hazard of dislocation.
Primary THAs that had been performed at a single institution from 2000 to 2017 were reviewed. Acetabular inclination and anteversion were measured using an artificial intelligence neural network; they were validated with performance testing and comparison with blinded grading by 2 orthopaedic surgeons. Patient demographics and dislocation were noted during follow-up. Multivariable Cox proportional-hazards regression, including multidimensional analysis, was performed to define the 3D topography of the acetabular safe zone and its association with surgical approach.
We followed 9,907 THAs in 8,081 patients (4,166 women and 3,915 men; 64 ± 13 years of age) for a mean of 5 ± 3 years (range: 2 to 16); 316 hips (3%) sustained a dislocation during follow-up. The mean acetabular inclination was 44° ± 7° and the mean anteversion was 32° ± 9°. Patients who did not sustain a dislocation had a mean anteversion of 32° ± 9° (median, 32°), with the historic ideal anteversion of 15° observed to be only in the third percentile among non-dislocating THAs (p < 0.001). Multivariable modeling demonstrated the lowest dislocation hazards at an inclination of 37° and an anteversion of 27°, with an ideal modern safe zone of 27° to 47° of inclination and 18° to 38° of anteversion. Three-dimensional analysis demonstrated a similar safe-zone location but significantly different safe-zone topography among surgical approaches (p = 0.03) and sexes (p = 0.02).
Optimal acetabular positioning differs significantly from historic values, with increased anteversion providing decreased dislocation risk. Additionally, surgical approach and patient sex demonstrated clear effects on 3D safe-zone topography. Further study is needed to characterize the 3D interaction between acetabular positioning and spinopelvic as well as femoral-sided parameters.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Abstract This study sought to prospectively examine the clinical and radiographic differences between direct anterior (DA-THA) and mini-posterior approach total hip arthroplasty (MPA-THA). Fifty-four ...patients were prospectively randomized to either MPA or DA-THA. Patient recorded diaries were collected. Radiographs were reviewed. SF-36, WOMAC and HHS scores were tabulated. Time to ambulation without any assistive device favored DA-THA (22 vs. 28 days, P = 0.04). Three week SF mental scores favored MPA-THA (60.66 vs. 58.43, P = 0.01). In a randomized prospective trial, patients undergoing DA-THA voluntarily quit use of all walking aids on average 6 days earlier than patients with a MPA-THA. Little additional clinical or radiographic benefit was seen between the cohorts.
Dual-mobility (DM) components are increasingly used to prevent and treat dislocation after total hip arthroplasty (THA). Intraprosthetic dissociation (IPD) is a rare complication of DM that is ...believed to have decreased with contemporary implants. This study aimed to report incidence, treatment, and outcomes of contemporary DM IPD.
A total of 1,453 DM components were implanted at a single academic institution between January 2010 and December 2021: 695 in primary and 758 in revision THA. Of these, 49 presented with a dislocation of the large DM head and five presented with an IPD. At the time of closed reduction of the large DM dislocation, six additional IPDs occurred. The mean age was 64 years (SD 9.6), 54.5% were female (n = 6), and mean follow-up was 4.2 years (SD 1.8). Of the 11 IPDs, seven had a history of instability, five had abductor insufficiency, four had prior lumbar fusion, and two were conversions for failed fracture management.
The incidence of IPD was 0.76%. Of the 11 IPDs, ten were missed either at presentation or after attempted reduction. All ten patients with a missed IPD were discharged with a presumed reduction. The mean time from IPD to surgical treatment was three weeks (0 to 23). One patient died after IPD prior to revision. Of the ten remaining hips with IPD, the DM head was exchanged in two, four underwent acetabular revision with DM exchange, and four were revised to a constrained liner. Of these, five (50%) underwent reoperation at a mean 1.8 years (SD 0.73), including one additional acetabular revision. No patients who underwent initial acetabular revision for IPD treatment required subsequent reoperation.
The overall rate of IPD was low at 0.76%. It is essential to identify an IPD on radiographs as the majority were missed at presentation or after iatrogenic dissociation. Surgeons should consider acetabular revision for IPD to allow conversion to a larger DM head, and take care to remove impinging structures that may increase the risk of subsequent failure.
Abstract INTRODUCTION Metaphyseal fixation has promising early results in providing component stability and fixation in revision total knee arthroplasty (TKA). However, there are limited studies on ...mid-term results of metaphyseal sleeves. We analyzed complications, re-revisions, and survivorship free of revision for aseptic loosening of metaphyseal sleeves in revision TKA. METHODS Two hundred and eighty patients with 393 metaphyseal sleeves (144 femoral, 249 tibial) implanted during revision TKA from 2006 - 2014 were reviewed. Sleeves were most commonly cemented (55% femoral, 72% tibial). Mean follow-up was 3 years, mean age was 66 years, and mean BMI was 34 kg/m2 . Indications for revision TKA included: two-stage reimplantation for deep infection (37%), aseptic loosening of the tibia (14%), femur (12%), or both components (9%), and instability (14%). RESULTS There was a 12% rate of perioperative complications, most commonly intraoperative fracture (6.5%). Eight (2.5%) sleeves required removal: six (2%) during component resection for deep infection (all were well fixed at removal) as well as one (0.8%) femoral sleeve and one (0.8%) tibial sleeve for aseptic loosening. 5-year survivorship free of revision for aseptic loosening was 96% and 99.5% for femoral and tibial sleeves, respectively. Level of constraint, bone loss, sleeve and/or stem fixation, and revision indication did not significantly affect outcomes. CONCLUSION Metaphyseal sleeve fixation to enhance component stability during revision TKA has a 5-year survivorship free of revision for aseptic loosening of 96% and 99.5% in femoral and tibial sleeves, respectively. Both cemented and cementless sleeve fixation provides reliable durability at intermediate follow-up.
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