Background
Despite widespread use of ceramic-on-ceramic (CoC) in total hip arthroplasty (THA) during the past 10 years, little is known about why revisions are performed in hips with this bearing or ...the time elapsed before revision.
Questions/purposes
The purposes of this study were: (1) Do the reasons for first revision differ between CoC bearings and other bearing couples? (2) Does the time to revision differ between CoC and other bearing couples? (3) Are there unique reasons for revisions of CoC bearings?
Methods
All members of the Société Française de Chirurgie Orthopédique et Traumatologique (SoFCOT) who performed ≥ 30 revisions per year were invited to participate in this multicenter, prospective, observational study. Our data represent 12% of the revision procedures performed in France. A total of 2107 first revisions of THA (from January 2010 to December 2011) were done in 2107 patients (1201 females 57% and 906 males 43%; median age, 73 years; age range, 17–104 years) at the time of surgery after a median of 11 years (range, 0 day–42 years) after the primary THA. There were 238 of 2107 (11%) CoC, 148 of 2107 (7%) metal-on-metal (MoM), and 1721 of 2017 (82%) metal-on-polyethylene (MoP) bearings.
Results
The reasons for reoperation differed according to the bearing component: (1) for the MoP reference bearing (odds ratio OR; 95% confidence interval), cup loosening occurred in 698 of 1721 hips (41%), periprosthetic fracture in 220 of 1721 hips (13%), and osteolysis in 213 of 1721 hips (12%); (2) for CoC, cup loosening occurred in 41 of 238 hips (17%) (OR, 0.31 0.22–0.43; p < 0.001), infection in 39 of 238 hips (16%) (OR, 1.63 1.12–2.37; p = 0.01), and dislocation in 23 of 238 hips (10%) (OR, 0.9 0.57–1.42; p = 0.9); (3) for MoM, cup loosening occurred in 28 of 148 hips (19%) (OR, 0.34 0.22–0.52; p < 0.001), adverse reaction to metallic debris in 26 of 148 hips (18%) (OR, 18.12 9.84–33.4; p < 0.001), and infection in 16 of 148 hips (11%) (OR, 1 0.59–1.73; p = 0.9). In comparison with MoP, osteolysis was rarely the reason for revision in CoC (four of 238 hips 2%; OR, 0.12 0.05–0.33; p < 0.001), but this bearing was frequently revised because of iliopsoas irritation (18 of 238 hips 8%; OR, 4.9 2.7–9; p < 0.001). The time elapsed before revision differed between bearings: median of 3 years (range, 3 days to 28 years) for CoC and 4 years (range, 14 days to 37 years) for MoM versus a median 13 years (range, 0 day to 42 years) for MoP (p < 0.001). Thirty-seven of the 238 revisions (16%) were directly related to ceramic use (ceramic breakage n = 23, squeaking n = 6, impingement n = 7, incorrect ceramic insert insertion n = 1). No factors were identified that contributed to breakage of the 12 bulk ceramic components (eight heads, four inserts, four of 12 Delta ceramic). No factors were associated with squeaking, iliopsoas irritation, or impingement, but component orientation was not assessed.
Conclusions
The reasons and time to first revision differed between CoC and other bearings. CoC THAs are revised earlier and are sensitive to mechanical problems such as impingement, squeaking, and ceramic rupture that did not disappear with introduction of Delta ceramics and large-diameter (≥ 36 mm) bearings. CoC was rarely revised for osteolysis, but a high rate of iliopsoas irritation requires further investigation.
Level of Evidence
Level III, therapeutic study.
Lateral wedge augmentation trochleoplasty (LWAT) was the earliest described trochleoplasty technique but was gradually replaced by other methods for the treatment of patello-femoral instability with ...trochlear dysplasia. Data on the outcomes of this procedure in adults are limited. We therefore performed a retrospective study in patients managed by LWAT to assess (1) clinical (recurrent instability and functional scores), (2) and radiological (patello-femoral osteoarthritis) outcomes.
LWAT is associated with a low long-term rate of recurrent patello-femoral dislocation and with no risk of progression to severe patello-femoral osteoarthritis.
Between 1988 and 1995, LWAT was performed on 66 knees in 58 patients to treat patello-femoral instability with trochlear dysplasia. Among them, 17 knees in 13 patients were re-evaluated 16 then 25 years after surgery and were included in the study. At both time points, the following were recorded: stability, pain, the Lille patello-femoral function score, and changes in radiographic and computed tomography findings. In addition to LWAT, Insall's realignment vastus medialis advancement was performed in 4 cases, sartorius muscle transposition in 9 cases, and anterior tibial tubercle osteotomy in 10 cases.
No episodes of patello-femoral dislocation were recorded during the 25-year follow-up. The mean Lille patello-femoral function score (0 worst to 100 highest) was 90±15 (range, 48–99) after 16 years and 86±23 (range, 33–94) after 25 years. After 16 years, 8/17 knees had evidence of patello-femoral osteoarthritis, which was Iwano stage 1 in 7 cases and Iwano stage 2 in 1 case. Patello-femoral osteoarthritis was noted in 12 of 13 knees after 25 years but was mild (Iwano stage 1 or 2) in 8 cases. After 25 years, arthroplasty had been performed for 4 of the 17 knees, with 2 cases each of patello-femoral arthroplasty and total knee arthroplasty.
LWAT is a reliable procedure that provides sustained protection against patello-femoral dislocation and good functional scores when used to treat patello-femoral instability due to trochlear dysplasia. Our results do not support claims that LWAT may be associated with high rates of severe osteoarthritis even after more than 20 years.
IV, retrospective observational study with no control group.
Abstract Prophylactic anticoagulation is recommended up to 35 days after total hip replacement (THR). Although several studies have assessed the incidence of thrombotic events or bleeding events ...after THR, the corresponding measures of association have never been studied concomitantly. Here, we evaluated the duration of the elevated risks (relative to the baseline risk) of both venous thromboembolic events and bleeding events after THR for coxarthrosis among middle-aged patients. This was a population-based, cross-over cohort study of data extracted from the French national inpatient database between 2007 and 2013. We included middle-aged patients (aged 45 to 69) having undergone THR for coxarthrosis. We compared the numbers of pulmonary embolisms (PEs) (respectively upper gastrointestinal bleedings (UGIBs)) following the THR with the numbers occurring during three unexposed periods one year later. This enabled us to estimate the odds ratio (OR) 95% confidence interval (CI) for each of six successive 35-day intervals. The study included 108,099 patients. The ORs for PE were respectively 12.4(95%CI, 8.6–17.8) (absolute difference rate per 100,000 (ADR/100,000) = 130) and 5.0(95%CI, 3.4–7.4) (ADR/100,000 = 52) for the first two 35-day intervals, and the risk was close to 1 thereafter. The risk of UGIB fell quickly, with an OR of 6.5(95%CI, 4.6–9.1) (ADR/100,000 = 83) and 0.8(95%CI, 0.4–1.6) for the first two 35-day intervals, respectively. The majority of UGIBs occurred during the inpatient stay for THR. Among middle-aged patients, the risk of a PE remains elevated beyond 35 days after THR for coxarthrosis, whereas the risk of a UGIB remains elevated for the first 35 days only.
Patellar complications are a source of poor total knee arthroplasty (TKA) outcomes that can require re-operation or prosthetic revision. Complications can occur with or without patellar resurfacing. ...The objective of this work is to answer six questions. (1) Have risk factors been identified, and can they help to prevent patellar complications? Patellar complications are associated with valgus, obesity, lateral retinacular release, and a thin patella. Selecting a prosthetic trochlea that will ensure proper patellar tracking is important. Resurfacing is an option if patellar thickness is greater than 12mm. (2) What is the best management of patellar fracture? The answer depends on two factors: (a) is the extensor apparatus disrupted? and (b) is the patellar implant loose? When either factor is present, revision surgery is needed (extensor apparatus reconstruction, prosthetic implant removal). When neither factor is present, non-operative treatment is the rule. (3) What is the best management of patellar instability? Rotational malalignment should be sought. In the event of femoral and/or tibial rotational malalignment, revision surgery should be considered. If not performed, options consist of medial patello-femoral ligament reconstruction and/or medialization tibial tuberosity osteotomy. (4) What is the best management of patellar clunk syndrome? When physiotherapy fails, arthroscopic resection can be considered. Recurrence can be treated by open resection, despite the higher risk of complications with this method. (5) What is the best management of anterior knee pain? The patient should be evaluated for causes amenable to treatment (fracture, instability, clunk, osteonecrosis, bony impingement on the prosthetic trochlea). If patellar resurfacing was performed, loosening should be considered. Otherwise, secondary resurfacing is appropriate only after convincingly ruling out other causes of pain. A painstaking evaluation is mandatory before repeat surgery for anterior knee pain: surgery is not in order in the 10% to 15% of cases that have no identifiable explanation. (6) What can be done to treat patellar defects? Available options include re-implantation (with bone grafting, cement, a biconvex implant, or a metallic frame), bone grafting without re-implantation, patellar reconstruction, patellectomy (best avoided due to the resulting loss of strength), osteotomy, and extensor apparatus allograft reconstruction.
V, expert opinion.
In revision total hip arthroplasty (THA), the advent of porous custom-made triflange acetabular implants with 3D scan planning offers a new perspective to improve implantation accuracy and anatomical ...restoration of the center of rotation (COR). This issue was investigated using CT-scan as the measurement tool, but in limited series (±10 cases) and without investigating the factors that may influence errors in positioning. Therefore we performed a retrospective study aiming to: (1) assess the placement accuracy of such implants with respect to the preoperative planning, (2) examine whether the volume of bone to be resected in order to apply the implant had an impact on this accuracy, (3) assess if errors in position at surgery had any influence on function, complications and survival.INTRODUCTIONIn revision total hip arthroplasty (THA), the advent of porous custom-made triflange acetabular implants with 3D scan planning offers a new perspective to improve implantation accuracy and anatomical restoration of the center of rotation (COR). This issue was investigated using CT-scan as the measurement tool, but in limited series (±10 cases) and without investigating the factors that may influence errors in positioning. Therefore we performed a retrospective study aiming to: (1) assess the placement accuracy of such implants with respect to the preoperative planning, (2) examine whether the volume of bone to be resected in order to apply the implant had an impact on this accuracy, (3) assess if errors in position at surgery had any influence on function, complications and survival.Preoperative planning could be accurately reproduced when implanting porous custom-made acetabular implants, and that accuracy would decrease in proportion to the volume of bone to be resected METHOD: Twenty patients undergoing THA revision with porous custom-made acetabular implants were included in this single-center retrospective study. Mean follow-up was 17.9 months ± 9.4 2-45.1. Preoperative planning was performed using 3D scanographic modeling. A post-operative CT scan was performed to assess implantation accuracy in terms of orientation and COR restitution. Demographic data, Oxford scores, complications and survival were recorded.HYPOTHESISPreoperative planning could be accurately reproduced when implanting porous custom-made acetabular implants, and that accuracy would decrease in proportion to the volume of bone to be resected METHOD: Twenty patients undergoing THA revision with porous custom-made acetabular implants were included in this single-center retrospective study. Mean follow-up was 17.9 months ± 9.4 2-45.1. Preoperative planning was performed using 3D scanographic modeling. A post-operative CT scan was performed to assess implantation accuracy in terms of orientation and COR restitution. Demographic data, Oxford scores, complications and survival were recorded.Mean deviation from the preoperative planning in inclination, anteversion and rotation were 4.3 ° ± 2.5, 6.1 ° ± 4.7, and 7 ° ± 4.6, respectively. Restoration of the COR showed a mean deviation of 2.1 ± 1.3 mm anteroposteriorly, 2.5 ± 2 mm mediolaterally and 2.2 ± 1.3 mm proximodistally. In total, 45% (9/20) of implants were positioned with perfect restoration of orientation (±10 °) and COR (±5 mm). The mean planned bone resection was 8.1 ± 4.9 cm3, with placement accuracy and COR restitution decreasing significantly when the volume of bone to be resected exceeded 2.7 cm3. One dislocation was found (5%, 1/20). Survival at last follow-up was 100%, the mean Oxford score at follow-up was 31.7 ± 7.9 16-52, without being influenced by errors in position or COR restitution.RESULTSMean deviation from the preoperative planning in inclination, anteversion and rotation were 4.3 ° ± 2.5, 6.1 ° ± 4.7, and 7 ° ± 4.6, respectively. Restoration of the COR showed a mean deviation of 2.1 ± 1.3 mm anteroposteriorly, 2.5 ± 2 mm mediolaterally and 2.2 ± 1.3 mm proximodistally. In total, 45% (9/20) of implants were positioned with perfect restoration of orientation (±10 °) and COR (±5 mm). The mean planned bone resection was 8.1 ± 4.9 cm3, with placement accuracy and COR restitution decreasing significantly when the volume of bone to be resected exceeded 2.7 cm3. One dislocation was found (5%, 1/20). Survival at last follow-up was 100%, the mean Oxford score at follow-up was 31.7 ± 7.9 16-52, without being influenced by errors in position or COR restitution.In total 45% of the implants restored an orientation and a COR as planned, particularly when the volume of bone to be resected is less than 2.7 cm3. Although these are complex cases with large amounts of bone loss, 3D manufacturing could give us hope of greater precision. The link between better precision and low bone resection volume could be an area to develop with the manufacturer in order to improve results.CONCLUSIONIn total 45% of the implants restored an orientation and a COR as planned, particularly when the volume of bone to be resected is less than 2.7 cm3. Although these are complex cases with large amounts of bone loss, 3D manufacturing could give us hope of greater precision. The link between better precision and low bone resection volume could be an area to develop with the manufacturer in order to improve results.III; diagnostic using CT in transversal retrospective study.LEVEL OF EVIDENCEIII; diagnostic using CT in transversal retrospective study.
Patellofemoral instability may occur in a young population as a result of injury during sporting activities. This review focuses on return to sport after one episode of dislocation treated no ...operatively and as well after surgery for chronic patellofemoral instability. With or without surgery, only two-thirds of patients return to sports at the same level as prior to injury. A high-quality rehabilitation programme using specific exercises is the key for a safe return to sporting activities. To achieve this goal, recovery of muscle strength and dynamic stability of the lower limbs is crucial. The focus should be directed to strengthen the quadriceps muscle and pelvic stabilizers, as well as lateral trunk muscle training. Patient education and regularly performed home exercises are other key factors that can lead to a successful return to sports. The criteria for a safe return to sports include the absence of pain, no effusion, a complete range of motion, almost symmetrical strength, and excellent dynamic stability.
Level of evidence
IV.
Bone defects during acetabular revision of total hip arthroplasty raise a problem of primary fixation and of durable reconstruction. Bone graft with direct cemented fixation or in a reinforcement ...cage was long considered to be the gold standard; however, failures were reported after 10 years’ follow-up, especially in segmental defect of the roof or pelvic discontinuity. In such cases, metallic materials were proposed, to ensure primary fixation by a roughness effect with added screws, and especially to avoid failure due to bone resorption in the medium term. We report a systematic literature analysis, addressing the following questions: (1) What materials are available and can be used with dual mobility (DM) designs? Apart from Trabecular Metal™ (TM), in which a DM cup can be cemented for sizes≥56mm, 4 other porous metals are available (Tritanium™, Trabecular Titanium™, Conceloc™, Regenerex™ and Gription™) although only the first 3 can be associated to DM. (2) Can the cost of these materials be estimated and compared to allograft with reinforcement cage? Considering simply the cost of the implant itself, compared to reconstruction by graft+cage+cemented cup (€2100), TM incurs an extra cost of €534, but with €1434 not covered by the French healthcare insurance. The cost of custom implants (apart from hemi-pelvis) ranges between €4200 and €8500, with only €4749 cover. (3) Do metallic materials ensure better survival than allograft+cage, according to severity of bone loss? Metallic reconstruction is claimed (with a low level of evidence) to reduce the risk of iterative loosening, but with a higher rate of dislocation, probably due to the lack of DM in many series. (4) What are the advantages and drawbacks of modular and custom metallic reconstructions? Modular reconstructions do not require 3D preoperative planning, but incur the risks of complications inherent to modularity. Custom implants can deal with more extensive defects, but require 5 to 8 weeks’ production and are difficult to implant for the larger ones and/or when revision is limited to the acetabulum. (5) In what indications are these materials irreplaceable? Prior failure of allograft+cage in Paprosky type III defect with or without pelvic discontinuity shows the greatest benefit from metallic reconstruction, conditional on certain technical tricks. Only reconstructions using TM have more than 10 years’ follow-up; other materials will need close monitoring. Failures in allograft with reinforcement cages occurred after about 10 years, and TM will need longer follow-up to prove its effectiveness. The high risk of dislocation should enable DM to be used, especially for small-diameter metallic reconstructions.
The number of total knee arthroplasty (TKA) revisions is expected to increase 601% in the United States between 2005 and 2030. This type of information is not available in France, and the last ...national study on this topic was done in 2000. This led us to perform a comparative study to determine if 1) the frequency of TKA revisions has increased and 2) the reasons for reoperation have changed relative to data gathered in 2000 at a single hospital in France.
The frequency of TKA revision has increased between the two studies, performed 15 years apart.
In this retrospective observational single-center study (January 2013 to December 2016), all patients with a TKA who were reoperated with or without any component change were included. This cohort was compared to our historical cohort defined in 2000 of 68 TKA reoperations between January 1991 and January 1998. The reasons for revision were determined by consulting computerized patient records to find the disease history, clinical examinations, imaging findings, laboratory tests and the surgery report. Cases due to periprosthetic fractures, infection and skin-related complications were excluded in order to be consistent with the indications of the historical cohort.
Between 2013 and 2016, 349 TKA revisions were performed, and 255 met the inclusion criteria. Note that the historical cohort had 68 cases. The mean time elapsed between the primary TKA and revision procedure was 5.3 years 34 days to 31 years. Eight reasons for reoperation were identified. Aseptic loosening (85 cases (33.3%)), stiffness (70 cases (27.5%)), tibiofemoral laxity (39 cases (15.3%)) and patellar complications (34 cases (13.3%)) were the four most common reasons for reoperation.
The frequency has changed over time: relative to 2000, the annual frequency increased by a factor of 6.5. The reasons have also changed over time: there was an increase in revisions for aseptic loosening (33.3% vs. 23.5%), stiffness (27.5% vs. 20.6%) and knee joint laxity (15.3% vs. 10.3%). Conversely, there was a reduction in revisions for patellar complications (13.3% vs. 26.5%), unexplained pain (0.4% vs. 8.8%) and patellar clunk syndrome (1.2% vs. 4.4%).
The number of TKA revisions has increased by a factor of 6.5, with aseptic loosening still being the most common reason. The number of revisions performed for stiffness and knee joint laxity have increased. Fewer revisions are being done for unexplained pain because surgeons are now better able to determine the cause of TKA-related pain. There were fewer patella-related complications because of technical progress. The data generated from our single-center study are consistent with current published data.
II, comparative study.
The impact of surgery on the patient is classically assessed on pre- and post-treatment scores. However, it is increasingly recommended to rank these results according to the minimal clinically ...important difference (MCID), using either the data distribution method or the anchor method, latter consisting in an extra question specifically targeting the patient's improvement. MCIDs vary between populations and, to the best of our knowledge; there have been no investigations in France regarding this in the context of total hip replacement (THR). Therefore, we conducted a prospective study in a population with THR to determine: 1) whether MCID scores in France were comparable to those reported in the data from the international literature; 2) whether a general item taken from a different score could serve as an anchor; and 3) whether an item from the actual questionnaire itself could serve as an anchor.
When pre- and post-treatment scores are available, an item from the questionnaire itself can serve as an anchor for MCID.
In a prospective observational study, 123 primary THR patients (69 male, 54 female), out of 150 initially included, completed the 5 domains of the HOOS hip disability and osteoarthritis outcome score and the Oxford-12 questionnaire, preoperatively and at 6–12 months. The MCID was calculated via the distribution-based and the anchor-based methods. Two Oxford items (questions 1 and 2) and 2 HOOS items (questions S1 and Q4) were used as anchors, as well as a supplementary question on improvement and the Forgotten Joint Score (FJS).
At a mean 10.12±1.2 months’ follow-up range, 6.5–11.9 months, the Oxford-12 score increased from 19±8 3–35 to 40±10 8–48 (p<0.001), all HOOS components demonstrated improvement, and the FJS at the final follow-up was 71±29 0–100. The general items (Oxford question 1 and HOOS question Q4) were more discriminating than the joint-specific items (Oxford question 2 and HOOS question S1). Based on results from the 3 anchors (improvement rated 1 to 5, Oxford question 1 and HOOS question Q4), 3 to 5 patients showed deterioration, 5 to 6 were unchanged, 30 to 40 were slightly improved, and 73 to 80 were improved by THR. The mean MCID on both distribution and anchor methods was 9 5.5–12 for Oxford-12, 20 12–27 for HOOS symptoms, 26 10–36 for HOOS pain, 22 11.5–28 for HOOS function, 26 13–34 for HOOS sport and 22 14–28 for HOOS quality of life.
The MCID for the Oxford-12 and HOOS scores in a French population was comparable to data from the past literature. Using a score item as an anchor to define improvement is possible, but only if a general item is used.
IV; prospective study without control group.
NCT04057651.
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