What’s New in Hip Replacement

Implant Design and Related Outcomes Dual Mobility In a recent study comparing dislocation mechanisms between dual-mobility, neutral, and constrained liners using a cadaveric model and a dual fluoroscopy system, Klemt et al. observed no increase in range of motion in the dual-mobility total hip arthroplasty (THA) construct when compared with a neutral THA construct, but did observe increased provocative anterior and posterior subluxation range of motion before dislocation1. The authors suggested that this may be the mechanism for previously observed lower dislocation rates. According to a 2 to 10-year postoperative follow-up study2, surgeons considering the use of some modular dual-mobility devices may want to include the potential for increased serum metal ion levels in their decision-making. Civinini et al. reported that 29.7% of patients had ion levels above the normal range. Polyethylene In a recent radiostereometric analysis study of wear rates of 2 different polyethylene liners and 2 sizes of cobalt-chromium femoral head3, Kjærgaard et al. reported on 94 patients at a 5-year follow-up and found very low wear rates for all implants and no difference in wear rates between vitamin E polyethylene liners and conventional cross-linked polyethylene liners for both 32-mm and 36-mm heads. Patient Factors in Relation to Outcomes Young Patients According to a study utilizing the New Zealand Joint Registry4, surgeons may need an additional metric with which to counsel young patients considering THA. Nugent et al. recommended using the lifetime risk of revision. Although they found an overall, 10-year implant survival rate of 93.6%, this survival rate was lowest in the youngest age group (46 to 50 years), who had an estimated lifetime risk of a revision surgical procedure of 27.6% compared with 1.1% in those who were 90 to 95 years of age at the time of the primary surgical procedure. Most young patients who present for the first time with early hip osteoarthritis will not require THA in the following 10 years, according to van Berkel et al.5. Following 588 participants at baseline and at 2, 5, 8, and 10 years, the authors observed that patients with early, symptomatic osteoarthritis progressed to THA in only 12% of cases. During the study, Kellgren and Lawrence scores worsened and the use of pain medication increased from 43% to 50% of participants. Despite this, all Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) subscales remained constant, on average, for patients who did not undergo arthroplasty. Race and Ethnicity Using the American College of Surgeons National Surgery Quality Improvement Program, Sheth et al. identified all African American patients in the database who underwent elective, primary THA between 2011 and 2017 (11,574 patients)6. Over the study period, the authors found an increase of 109% in THAs performed in this group as well as a reduction in the prevalence of osteonecrosis, anemia, and dyspnea. There were no changes in the rates of 30-day surgical complications, readmission, reoperations, and mortality. However, there was a decrease in the rate of postoperative medical complications, especially in the incidence of postoperative myocardial infarction. In another recent study of 1,041 African American patients undergoing THA and total knee arthroplasty (TKA), Chisari et al. reported that, when controlled for demographic characteristics and medical comorbidities, there were no differences in readmission or complication rates. However, African American patients had significantly lower preoperative Hip disability and Osteoarthritis Outcome Score (HOOS) and Knee disability and Osteoarthritis Outcome Score (KOOS) values at 33.5 points compared with Caucasian patients at 45.1 points (p < 0.001)7. Preoperative Opioid Usage In a recent study, Vakharia et al. identified 42,097 Medicare patients who underwent primary THA between 2005 and 2014 and produced 2 matched cohorts of patients with and without opioid use disorder8. The authors found that patients with opioid use disorder had a higher risk of developing periprosthetic joint infections (relative risk, 1.32) and having 90-day readmissions (relative risk, 1.23) and higher 90-day costs compared with controls. Prior Hip Arthroscopy Using the Swedish Hip Arthroplasty Registry, Lindman et al. compared 135 patients who had undergone failed ipsilateral hip arthroscopy and then underwent conversion to THA with 540 age-matched controls. The authors evaluated the patient-reported outcome measures obtained with the use of multiple questionnaires9. The mean interval between the arthroscopy and the THA was 27 months. The authors reported that, at the 1-year follow-up, there were no differences in hip pain or reported satisfaction between the 2 groups. Body Mass Index (BMI) Onggo et al. recently performed a meta-analysis and systematic review of 67 studies on the topic of obesity and THA outcomes that included 581,012 obese patients and 1,609,812 non-obese patients10. The authors found that obese patients had a higher risk of dislocations, reoperations, revisions, readmissions, all complications, deep infections, and superficial infections. In a subgroup analysis of morbidly obese patients (BMI ≥40 kg/m2), the risks of all of these parameters were even greater. In addition to a higher risk of complications, Katakam et al. found that obese class-III patients (BMI >40 kg/m2) also had a higher risk of no improvement in their postoperative physical function11. The authors reported that the class-III obese patients had a nearly threefold increased risk of not achieving the minimal clinically important difference on the HOOS-Physical Function Short Form (HOOS-PS) at the 1-year follow-up. Also, the authors suggested that their data may be used for setting patient expectations. Spinal Pathology Spinal pathology is increasingly understood as a risk factor for adverse events in the population undergoing THA. In a meta-analysis of 10 articles corresponding to 9 unique observational studies totaling 1,992,366 primary THAs, Wyatt et al. identified 32,945 cases of spinal fusion12. When comparing spinal fusion with no spinal fusion, the relative risk was 2.23 (95% confidence interval [CI], 1.81 to 2.74) for dislocation in 7 studies and 2.82 (95% CI, 1.37 to 5.80) for any complication in 3 studies. The identification of patients without a history of spinal fusion but with a clinically relevant stiff lumbar spine remains a challenge. In a Level-II, diagnostic study, Innmann et al. reported that patient screening can be accomplished through a combination of physical examination and a standing lateral radiographic image of the spinopelvic complex taken using a biplanar, low-radiation-dose imaging system13. After calculating what they referred to as a “hip user index” by quantifying the percentage of sagittal hip movement compared with the overall movement between the standing and deep-flexed positions, the authors reported a sensitivity of 90% and specificity of 71% for identifying a patient with little spinal contribution to sagittal motion when the standing pelvic tilt was found to be ≥19°. Previous Hip Surgical Procedures Douglas et al. compared matched retrospective cohorts of 25,081 patients who underwent primary THA with 8,339 patients who had undergone at least 1 hip surgical procedure prior to THA14. The authors found that the patients who underwent conversion THA had significantly higher rates of complications (periprosthetic joint infections, hip dislocations, mechanical complications, and need for a revision surgical procedure within 90 days), higher transfusion rates, higher 30-day readmission rates, and higher median cost of care at 90 days compared with the patients who underwent primary THA. Surgical Factors in Relation to Outcome Surgical Approach In a study of 30,098 patients who underwent THA between 2015 and 2018 in Ontario, Canada, Pincus et al. reported finding a small but significantly increased risk of major surgical complications among 2,993 propensity score-matched patients undergoing an anterior approach (61 patients [2%]) compared with 2,993 matched patients undergoing a posterior or lateral approach (29 patients [1%]); the absolute risk difference was 1.07% (95% CI, 0.46% to 1.69%), and the hazard ratio was 2.07 (95% CI, 1.48 to 2.88)15. In a similarly large study population, Charney et al. evaluated 38,399 THAs from the Kaiser Permanente’s Total Joint Replacement Registry for the impact of the surgical approach on rates of dislocation, revision for instability, revision for periprosthetic fracture, and revision for aseptic loosening16. The authors found a slightly lower risk of dislocation in the direct anterior approach group compared with the posterior approach group (hazard ratio, 0.39 [95% CI, 0.29 to 0.53]). However, there was a higher risk of revision for aseptic loosening in the direct anterior approach group compared with the posterior approach group (hazard ratio, 2.26 [95% CI, 1.35 to 3.79]). Implant Fixation Utilizing the Norwegian Arthroplasty Register, Dale et al. evaluated the modes of fixation in primary THA and the influence of age and sex with regard to reported lower survivorship for, but increased use of, cementless THA in some populations17. Utilizing data from 2005 to 2017, the authors found a considerably higher rate of revision due to fracture and dislocation in female patients 55 to 75 years of age undergoing THA with all-uncemented designs (relative risk, 1.3 [95% CI, 1.0 to 1.7]). This was higher still in female patients older than 75 years of age (relative risk, 1.8 [95% CI, 1.2 to 2.7]). The authors recommended against using uncemented stems in THA in these patients. Cement fixation was also endorsed by multiple investigators studying outcomes for displaced intracapsular hip fractures. In a prospective, double-blinded, randomized controlled trial (RCT), Clement et al. randomized 50 patients who were >60 years of age and had an intracapsular hip fracture to THA with either an uncemented design (n = 25) or a cemented design (n = 25)18. The study was terminated early after only one-quarter of the intended enrollment was reached because of the significantly higher rate of intraoperative complications (p = 0.004) in the uncemented group (8 patients). The authors endorsed the use of cemented components in these patients. In another publication, Nantha Kumar et al. performed a systematic review and meta-analysis of 2,819 hemiarthroplasties performed for intracapsular hip fractures19. They found no difference in the risk of mortality when comparing cemented and uncemented stems, but did find that uncemented implants had a substantially higher risk of periprosthetic fracture. With regard to surgeons selectively using uncemented stems in elderly women with good bones, in a recent study of 2,635 THAs20, Hopman et al. reported 18 revisions for early periprosthetic fracture in elderly female patients. These fractures were not correlated with BMI, osteoporosis, or Dorr classification. The authors estimated that the number needed to treat to avoid 1 revision, if assuming that the patients undergoing THA with no cement would have had no fractures with cement, was 48. Complications Surgeon Age as Risk Factor The goal of identifying complication risk factors has extended to the age of the surgeon. In a study of 122,043 THAs performed by 298 surgeons, Matar et al. found that middle-aged surgeons (45 to 55 years of age) had the lowest complication rate and younger surgeons had a higher risk of composite complications, revision, and infection21. Excluding older low-volume surgeons (who also had a higher composite risk of complications), older surgeons had complications similar to those of middle-aged surgeons. Dislocation The variable rate of dislocation in the literature may be due to the difficulty in identifying all of the dislocations that are occurring, according to Hermansen et al.22. Utilizing the Danish Hip Arthroplasty Register, the authors attempted to identify the true rate of a dislocation for patients undergoing THA for osteoarthritis using what the authors described as a comprehensive, nationwide review of patient files of patients who underwent THA performed between 2010 and 2014. They reported that their final tally was 50% higher than the results from using their registry alone and cautioned that better algorithms integrating medical records may be required to use registries to monitor dislocation. According to Huerfano et al., the dislocation rate, true or otherwise, does not seem to be influenced by the surgeon’s choice of approach. In their recent meta-analysis of 25 studies (5 RCTs and 20 non-RCTs) of 7,172 THAs23, the authors compared the posterolateral approach and the direct anterior approach and found no significant differences in dislocation rates between the approaches. Subgroup analyses indicated similar results with respect to posterior soft-tissue repair (p = 0.50) and the learning curve (p = 0.77). The authors concluded that the surgical approach had no influence on dislocation rate after THA. Adverse Local Tissue Reactions Kwon et al. reported on 89 consecutive patients managed for head-neck taper junction corrosion24. They found that the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) remained useful in excluding infection. The suggested cutoffs were 57 mm/hr for ESR, with 57% sensitivity and 94% specificity, and 35 mg/L for CRP, with 93% sensitivity and 76% specificity. The authors observed no significant differences in metal ion levels between the infected and uninfected groups. Even without infection, revision for adverse local tissue reaction in the hip can be challenging because of abductor insertion necrosis. Klemt et al. reported a decreased dislocation risk for these patients when managed with a dual-mobility implant25. In their cohort of 234 such patients, no dual-mobility implant had dislocated at a mean 4-year follow-up compared with 4.1% of patients treated with a constrained liner and 15.5% treated with a conventional articulation. Technology Virtual Clinic Visits El Ashmawy et al. provided some insight what of patients the on patients in a between 2017 and the authors the of and patient satisfaction with They found that, for the 1-year postoperative and follow-up only of patients required a Patient satisfaction rates were similarly with or very with this of Outcome et al. the and of the and Using the Hip Knee and as the authors found good in the in the joint population, they cautioned that may of postoperative THA THA patient is the by et al. in their study of consecutive THAs, 135 THAs, THAs, and THAs with They reported finding no clinically important differences in patient-reported outcome measures at 1 and 2 However, surgical time for the group was significantly (p < at than that for the group or the conventional group those who to intraoperative the surgical approach and the pelvic tilt may the of the et al. found that posterior pelvic tilt and an anterior surgical approach were significantly with postoperative in In a recent study, et al. learning for the of hip Using a the authors found that the was with the addition of a model was the They concluded that learning algorithms with patient-reported outcome measures and radiographic scores can in patients with hip and Spinal or THA et al. patients who underwent THA and identified patients who underwent THA before lumbar spinal fusion and patients who underwent THA after spinal The authors found that the patients who underwent THA first had an increased dislocation risk, higher rate of periprosthetic joint infection, surgical complications, revision, and postoperative opioid use compared with those who underwent THA after lumbar spinal et al. have that patients undergoing both THA and spinal fusion may from an Using a system, the authors 50 consecutive patients with spinal for or range of motion of The stiff spine was identified by standing and lateral spinopelvic patient model was the dislocations had a They reported of additional range of motion before for 1 of After THA Patient on to after THA remains In a study of et al. evaluated the of surgeons using a Over of surgeons were in of to after with regard to that was if the patient and recommended no at Opioid The topic of pain with remains of In a study of patients who underwent either THA or et al. evaluated the impact of postoperative The authors a between and of They found that of patients required postoperative between days to 90 and increase in the was with a increase in the the the between postoperative days and this increased to The authors recommended that to early opioid a reduction in after THA is not with a decrease in patient according to et Using an by et et al. reported a reduction in mean at with a mean of in the final from a of 298 (p < They no decrease in patient satisfaction In their of Hip and Knee et al. a postoperative of the risk of periprosthetic joint in patients identified as The study consecutive THAs and performed between 2011 and in patients were managed with an extended after were patients with extended had a significantly lower rate of periprosthetic joint than patients without extended difference in the rate was observed between patients who the extended and patients. In their recent systematic review of the use of to periprosthetic joint in THA and et al. the The authors identified 9 patients who and patients who did The authors found no for the They identified studies in which overall complications be compared and found no difference in overall complication risks with but that these studies were for differences in complications with use and The authors concluded that, without a large on points and in the of of not be used in primary THA and et al. the of in a systematic review and meta-analysis of 7 studies with THA and cases patients who and patients who did The authors reported no difference in the overall postoperative rates between the with and without before in primary THAs and and aseptic revision at 3 or in all studies in the subgroup and Surgeons for both spinal and may be in a recent study by et The authors if of spinal for THA and in the preoperative before the was and would have on They reported no adverse events when spinal before the and they and care were these In a meta-analysis of the use of and impact on complications, et al. identified 25 Although the authors found that use did and transfusion rates without an increase in complications, there was no significant difference in the use of or surgical for et al. use in the setting of using a randomized The authors found that intraoperative by and the of transfusion by for studies have to the of data for for The first study was a systematic review of the literature that included studies. In that study, et al. suggested that for patients after total joint arthroplasty is not to in The study was a systematic review and In that study, et al. suggested that taken as after THA and did not in in a significant from the of preoperative et al. a database from 2011 to identifying The authors found that preoperative and levels were with the of all adverse et al. evaluated patients with a preoperative of The authors found that patients with preoperative who underwent when compared with matched were at risk for early postoperative complications and had of increased risks of 30-day and 30-day was with major complications such as increased 1-year rates of periprosthetic joint infection, revision, dislocation, and fracture. In was significantly with an increased 90-day medical complication with the patients with lower compared with and higher compared with With regard to postoperative et al. performed a retrospective study of consecutive patients undergoing The authors to the of postoperative in an The authors identified of patients who medical that was to postoperative The observed were and and the rates for patients with postoperative and were to be after THA in the is estimated to cost in of In a recent systematic review and et al. to the outcomes with before and after randomized with patients, the authors reported that, compared with or no or minimal postoperative was not with physical at and preoperative with the group no between and physical at the and 1-year The authors suggested that preoperative may not be and recent have indicated that postoperative may only be needed in such as those with difficulty with of and those with The of a large number of recently studies to the that a higher of In addition to articles in this articles relevant to hip are to this review after the with a to in an in this Polyethylene wear with and metal femoral at a randomized controlled trial with radiostereometric Using radiostereometric 50 patients with osteoarthritis undergoing THA were randomized to have either a cobalt-chromium femoral or a femoral and were at the 5-year follow-up, both had very low wear rates and no differences in or outcomes were a time when THA implants have increasingly as a cost for and the age of patients undergoing THA has This has the potential to for implant and This study suggested that, at least in of wear rates, there was no in femoral another when the is with a cross-linked polyethylene This may be useful when after total hip a randomized controlled trial of in the postoperative In this randomized patients undergoing THA either a or a and were evaluated for pain and used the first as well as and at the first physical differences were between the 2 in of pain or In of patients the a to their In a that increasingly the cost with total joint performed in patients who are then on the of the surgical from the either to or to a setting with a a or a the decreased may have for this for the the of in any of the evaluated the in The that the be recommended for patients undergoing THA and may to be useful when patients considering this Hip The for in revision total hip a randomized Joint In this randomized were compared for and a of prior to prior to by at a combination of prior to and intraoperative and 3 totaling that a difference in reduction was clinically that all were There was only 1 overall and no differences were found between groups. Although the use of in the of patients undergoing THA has in and has a of in by The authors suggested that a range of may be in of and patient of cementless compared with cemented dual-mobility in elderly a randomized controlled study on patients with 2 follow-up. In this randomized trial of patients undergoing THA for et al. used to fixation in elderly patients. The authors found that cemented components at 3 and cementless implants in patients with low had not after 2 These data insight the history of cementless components in the elderly population and may be of use in implant in this with data on the increased periprosthetic femoral fracture risk in the elderly patient managed with a cementless this study may that a remains in for the THA performed with cemented

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