What’s New in Hip Replacement

Primary total hip arthroplasty (THA) procedures continue to increase. On the basis of data from 2000 to 2014, the frequency of THA in the U.S. is projected to grow to 635,000 procedures per year by 20301. The majority of implants from these procedures are expected to last >20 years. A study of 94,292 total hip replacements from the Finnish Arthroplasty Registry noted a survivorship of 58% at 25 years2. THA complications (especially periprosthetic joint infection [PJI] and dislocation), as well as perioperative management to optimize short stays and outpatient THA while minimizing perioperative complications, continue to draw heavy attention. Implant Design and Related Outcomes In a study evaluating 2016 data from the American Joint Replacement Registry (AJRR) compared with other national registries, the authors found that cementless stem fixation combined with the use of ceramic and 36-mm heads was the current preference in the U.S., while other registries indicated that cemented implants and metal and 32-mm heads were most commonly used3. Cemented Versus Cementless Implants There is evidence that cemented implants outperform cementless counterparts in elderly patients when early complication rates are compared. On the basis of the recent Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) annual report, Tanzer et al. reported that, among patients >75 years of age who underwent THA, those treated with the best-performing cementless femoral stems had more early revisions (<30 days postoperatively) compared with those treated with the best-performing cemented implants4. These early revisions were mainly attributable to the risk of revision for fracture or loosening. This difference disappeared after 90 days following surgery4. Bearing Surfaces Metal-on-Polyethylene (MoP) Studies show better long-term survival with a metal-on-highly-cross-linked-polyethylene (HXLPE) articulation compared with metal-on-conventional, non-cross-linked polyethylene (CPE) in younger patients5-7. In a retrospective review of 101 hips in 84 patients ≤50 years of age, with a duration of follow-up of 15 to 20 years, cobalt-chromium (CoCr)-on-CPE showed a high rate of wear-related revision (13 of 101, 12.9%)5. In contrast, the authors of another report noted excellent 15-year survivorship and functional outcome with no wear-related revision in a cohort of 82 patients (89 hips) ≤50 years of age with CoCr-on-HXLPE6. An observational study from the AOANJRR showed that hips in which XLPE was used (199,131 procedures) had a significantly lower revision rate at 16 years following THA for osteoarthritis compared with hips in which CPE was used (41,171 procedures), regardless of the head material7. Ceramic-on-Ceramic (CoC) or Ceramic-on-Polyethylene (CoP) Clicking or squeaking continues to be present in a small percentage of patients who undergo THA with CoC components. In 1 report, audible noise was present in 6.4% of hips (48 of 749) following THA with use of fourth-generation alumina CoC bearings, although no patient underwent revision for clicking or squeaking8. The selection of CoP recently surpassed MoP as the most popular bearing surface used in THA in the U.S.9. Metal-on-Metal (MoM) A study from Korea demonstrated an acceptable rate of aseptic loosening (cup, 10.5%; stem, 6.1%) in a cohort of 114 hips treated with THA using 28-mm MoM components; the average follow-up was 20 years (range, 17 to 23 years)10. Nonetheless, the use of an MoM articulation continues to decline secondary to persistent concerns for metal debris-induced adverse local tissue reactions. Surface Treatment The authors of a prospective multicenter study reported that, at the 5-year follow-up, titanium alloy (Ti6Al4V) acetabular shells with a porous titanium coating (PTC) had a higher percentage of gaps/radiolucency compared with plasma-sprayed (PS) acetabular shells from the same manufacturer (23% versus 5%). Patients in the PTC group had more patient-reported pain, although none underwent revision for loosening11. Short Versus Standard Stems In a randomized double-blinded study, persistent mid-thigh pain was much more prevalent among patients with a short Collum Femoris Preserving (CFP) stem (LINK) (19%) compared with a full-profile wedge-tapered Alloclassic Zweymüller stem (Zimmer) (7%) at medium-term follow-up. Both cohorts, however, had a high percentage of varus malalignment (14% and 16%, respectively), and the results may not be generalizable to other cementless designs12. The association between periprosthetic femoral fracture and length/geometry of cementless implants was also studied. In a cohort study of 5,090 consecutive, direct-anterior primary THAs performed at a single institution, the incidence of periprosthetic fracture using femoral components with 4 variations in length and geometry was evaluated13. All stems were of a single-taper wedge design from the same manufacturer, with 1 of 4 configurations: full-length, standard profile; full-length, reduced distal profile; short-length, standard profile; and short-length, reduced distal profile. There was a trend toward a higher risk of periprosthetic fracture in the short-length-with-standard-profile group13. It is unclear whether the same trend would hold using other surgical approaches. Head Size In a study using data from the Nordic Arthroplasty Register Association database and including 186,231 patients who underwent MoP THA with use of a 28, 32, or 36-mm head, the authors found that the risk of dislocation was reduced with the use of 32 versus 28-mm heads, although the overall revision risk remained similar. Surprisingly, transitioning from 32 to 36-mm heads was associated with a higher risk of revision for all causes, including the risk of dislocation14. It appeared that 32-mm heads would be the optimal choice for MoP THA. Dual-Mobility Constructs Modular dual-mobility constructs employ a CoCr articular surface liner that locks into an outer shell of titanium. A systematic review of mid-term studies of dual-mobility constructs supports their efficacy in reducing the incidence of dislocation after both primary and revision THA15. The wear rate for contemporary dual-mobility constructs using an HXLPE design showed substantially larger magnitudes of initial head penetration and wear than those reported for HXLPE in fixed-bearing couples (twice the rate)16. It approaches a steady state after 2 years, making it comparable with traditional fixed bearings; future studies should address the long-term outcomes16. A propensity score-matched study showed that patients with a dual-mobility construct had a lower risk of revision due to dislocation, although there was no difference in the overall risk of revision between the dual-mobility construct group and the MoP/CoP group. The authors speculated that selection bias may have been present, as the dual-mobility construct group also showed a higher risk of revision due to infection17. Patient Factors in Relation to Outcomes Medical Comorbidities Dialysis dependence was demonstrated to be an independent risk factor for 30-day adverse events, intensive care unit (ICU) care, longer length of stay, and rehabilitation needs in patients undergoing total joint arthroplasty (TJA)18. Patients with hepatitis C who received interferon or direct antiviral agents prior to THA appeared to have fewer postoperative complications, especially PJI19. Dorr Type In a matched comparative study, a higher incidence of femoral stem-related complications (mainly periprosthetic femoral fractures) was observed when using double-tapered wedge stems in Dorr type-A compared with type-B femora20. A study correlating proximal femoral morphology and leg length after THA showed that patients with a Dorr type-A femur and a high femoral cortical index (FCI, defined as the ratio of cortical width minus endosteal width to the cortical width at a level 100 mm below the tip of the lesser trochanter on an anteroposterior radiograph of the hip) were at increased risk of leg lengthening while patients with a Dorr type-C femur and a low FCI had an increased probability of shortening21. Body Mass Index (BMI) Several studies showed a higher risk of complications (up to 3 times) among THA patients classified as morbidly obese compared with normal controls22-24. In particular, researchers in the U.K. reported on, to our knowledge, the largest longitudinal cohort study to date analyzing the influence of BMI on THA outcomes (>410,000 patients)25. Patients who were morbidly obese (BMI of 40 to 60 kg/m2) had the highest probability of revision at 10 years (twice that of the underweight group), while 90-day mortality was significantly higher for the underweight group compared with those with normal BMI. Milder obesity (BMI of 25 to 40 kg/m2) seemed to have a protective effect against mortality25. In another study, patients classified as super obese (BMI of ≥45 kg/m2) had a greater risk of reoperation and readmission and greater 90-day costs compared with the nonobese cohort, but they had comparable quality-of-life improvements26. Patients classified as morbidly obese who underwent bariatric surgery prior to TJA showed a reduced comorbidity burden at the time of TJA, with reduced post-TJA complications; however, the risk of revision was not reduced27. While obesity seems to be a major negative predictor of adverse outcomes, some argue that THA is still cost-effective for morbidly obese and super obese groups and recommend against a cutoff threshold to avoid unnecessary loss of health-care access28. Preoperative Opioid Use Opioid use within 3 months preceding THA was an independent predictor of early revision, while obesity and anxiety/depression were also shown to predict early failure of treatment29. Significantly higher 30-day readmission and revision rates were observed among THA/TKA (total knee arthroplasty) patients with a history of long-term preoperative opioid use30. In another study, patients who used opioids preoperatively tended to have significantly lower patient-reported outcome scores and longer hospital stays, and were more likely to be discharged to a rehabilitation facility31. Tobacco Use In a recent study, smokers had a significantly higher risk of deep infection and reoperation after revision THA compared with nonsmokers, and the risk was higher than for primary THA32. The authors of a systematic review and meta-analysis found that former tobacco users had a significantly lower risk of wound complications and PJI compared with current smokers. Smoking cessation counseling prior to total joint arthroplasty is strongly advocated33. A history of smoking was also recently tied to increased risk of nerve injury in patients undergoing THA34. Surgical Approach The optimal surgical approach in primary THA remains controversial. A systematic review and meta-analysis of prospective studies showed less pain and better reported function through 90 days postoperatively for the direct anterior approach compared with the posterior approach35. However, when comparing early revision rates (<5 years from index primary surgery), the direct anterior approach was associated with a significantly higher rate of early revision due to femoral loosening compared with the posterior approach, while the posterior approach demonstrated a higher incidence of early revision due to instability36. A Dutch joint-registry study showed small improvements in the 3-month postoperative patient-reported outcome measure (PROM) for the direct anterior and posterolateral approaches compared with the direct lateral and anterolateral approaches37. Regardless of the different approaches, there are minimal differences in gait mechanics at early or late follow-up38. The long-term prognosis of lateral femoral cutaneous nerve (LFCN) neuropathy was also investigated. One study found that approximately 11% of patients had persistent LFCN neuropathic symptoms even at 6 to 8 years after direct anterior THA, and the most common presentation was numbness (37%). This, however, did not affect hip functional scores39. Complications There is substantial variation in reported THA complication rates among national databases and joint registries. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) tends to show the lowest rate of complications40. Medical Complications A study of 10-year Hospital Episode Statistics data from the U.K. including 540,623 THAs showed that postoperative medical complications decreased year-after-year despite a steady rise in the average Charlson Comorbidity Index score. The only 2 exceptions were lower respiratory tract infection and renal failure, which continued to rise41. Venous Thromboembolism (VTE) and Anticoagulation A systematic review found that industry-funded studies assessing thromboprophylaxis reported fewer patients with pulmonary embolism (PE), major bleeding, and mortality compared with nonfunded studies42. A cross-sectional study in 5 countries found that the rate of in-hospital VTE after hip arthroplasty was 0.16% in Canada, 1.41% in France, 0.84% in New Zealand, 0.66% in the U.S. (California), and 0.37% in Switzerland, while the benchmark was 0.58%. French data showed a higher rate, potentially because of the systematic use of ultrasound, which could result in the over-detection of deep venous thrombosis (DVT) but not PE43. A retrospective analysis of the NSQIP data set from 2008 to 2016 demonstrated that the risk of DVT was not associated with obesity in patients undergoing THA. The risk of PE, however, was found to be elevated in THA patients whose BMI was ≥35 kg/m2. The authors concluded that, since current pharmacologic anticoagulation regimens can reduce the DVT rate but have not been demonstrated to affect the rate of PE or death, the data do not support increased DVT anticoagulation in THA patients who are obese but without other VTE risk factors44. Dislocation Spinopelvic pathology dominated the literature on THA dislocation, with important research focused on spine-pelvis-hip radiographs in the sagittal plane and the related functional safe zone45-52. It has been proposed that the spinopelvic relationship be categorized according to 4 groups, as at the preoperative normal normal normal normal should be to the for may using a dual-mobility construct with of to the functional plane on than anteroposterior A was recently proposed on the basis of anteroposterior anteroposterior and and lateral spinopelvic The a of and a risk sagittal as a and as a to use in revision THA. This was in a group of patients who underwent revision hip for for patients who were using the function were compared with a matched group of patients who were not using the The dislocation rate was among patients who had the compared with for those who did Patients undergoing THA with a history of had a increased risk of dislocation compared with those who had 5 years after study found that to the as well as of increased the risk of dislocation in primary there was no increased perioperative of dislocation in patients undergoing following an THA, 1 study demonstrated that had a elevated risk of dislocation per compared with those without risk per PJI The and on PJI in patients undergoing and 5-year of PJI following THA were found to be and however, there was no decline in the risk of PJI PJI is the mortality rate was noted to be and 5-year the of A PJI on recently a for hip and knee PJI and the and PJI in PJI of a for in both preoperative and One recent study found that there is no difference in as defined by the between patients and those a major of PJI PJI to the risk for PJI following A surgical a revision and were the most A association between postoperative tract infection and PJI after THA or was in a retrospective cohort study of patients years association was found between postoperative and continues the of versus revision for In a recent study, the authors reported an survival rate at a of 2 years of follow-up when using cementless revision in the of patients with periprosthetic hip joint In another study, of revisions had an in the between 2 concerns the for the of between the of a for postoperative have been including an age of years, of and of an of risk related to postoperative are and should be the percentage probability of periprosthetic femoral fracture using cementless stems was demonstrated to be only at 10 years, increased to at years after primary another study the incidence of periprosthetic femoral fracture in stems found that the incidence of periprosthetic femoral fracture continued to after the and the incidence of aseptic loosening in the A study using data from the national found that the annual incidence of periprosthetic femoral fracture in primary THAs increased from of to of the of to In the report, type-C 4 more than and they were more commonly in cemented The incidence of with MoP is and an average of 5 years to metal the ratio have been shown to be higher in MoP (range, or compared with MoM (range, to study a level of and a ratio of to be a cutoff threshold for important MoP The of and to decline by and 3 months after in the femoral nerve was observed in 17 of patients who underwent the direct anterior approach in THA when were against the anterior of the although was The authors of another recent study of the anterior in a safe to the to avoid In a recent retrospective cohort study using the A data was found to be associated with significantly lower rates of dislocation and aseptic revision of the acetabular following primary The authors when their results because of by In a double-blinded study in the U.K. that patients undergoing THA or the use of with an and to show a in the rate of surgical infection and The has a rise in the incidence of both outpatient and THA, according to a recent comparative and have been for or to be while also patient supports a trend toward better postoperative outcomes when hip is performed by While the majority of primary THAs are performed at are the majority of these A more relationship was by a New data set of of the was associated with a 2 to in the risk of complications, and revision to while hospital was associated with a in complications and a 4 to in The opioid has has more in recent years. opioid after joint surgery show that to of patients continue opioid use even at 1 year have been to reduce opioid without of A study indicated that fewer compared with 90 was associated with a in opioid and decreased opioid without pain scores and patient-reported In a retrospective review of patients who underwent THA and reported a history of those reported and including respiratory and In study, no patient with a who was an adverse It was also found that, for the patients with a who were or no differences could be found in the rate of Use is an of the THA to reduce loss and the risk of by including the American Association of and Surgeons and the American of Orthopaedic Surgeons state that no of or time of have been shown to A recent randomized study did that postoperative of reduced loss compared with a single preoperative The of 1 preoperative of 2 by 3 postoperative of of loss in Smoking A study from the demonstrated that level of 8 within 1 of TJA could significantly rates of smokers It also to of patients who reported as continued smoking and as more than after surgery among those who and A from demonstrated that the of could to for among patients undergoing THA, by a in postoperative pain scores of was also in reducing opioid and The of use in patients with undergoing THA or was recently in a retrospective study of 2 of patients in the group and in the patients who received were not found to have a significantly higher infection rate than to the that PJI is an study have been with the of with a a mainly a using significantly the length of of patients undergoing THA by 1 evidence that the postoperative of and following THA in patients with a normal preoperative level is the should be by risk and Preoperative and of and 4 have been as below which should postoperative and It has been that the use of the in for THA including of patients with THA with a had significantly higher than those without a and among the THA with a was greater for those The of The a of recently studies related to the that received a higher of In to in 4 other with a higher of to hip are to review after the standard with a to in an in and risk of or after total hip a cohort study from national Joint This to the knowledge, the largest study using the databases to address the association between perioperative and postoperative 30-day PE, and from all among patients who underwent THA. A total of patients were the study from to among received perioperative and did use was not found to significantly the risk of PE, or The authors were to the of using on patients with and other in of on outcomes after primary and revision total hip at the a cohort study patients who underwent primary or revision THA from through A using 32 found in the medical including 17 and of was used to the study as index of of to and of to in-hospital complications, differences were found only for wound complications and the and with patients had a significantly higher risk of mortality ratio of dislocation, wound and reoperation within 90 days and 1 year after primary THA. The authors did not a association of with aseptic periprosthetic or prior bariatric surgery outcomes following total joint arthroplasty in the morbidly A This meta-analysis studies from to with a total of patients who underwent THA or underwent bariatric surgery prior to TJA and the patients with obesity as the group. The study found that bariatric surgery prior to TJA was associated with reduced of medical complications, length of stay, and The of wound infection or and the long-term of dislocation, periprosthetic and revision were not the THA and bariatric surgery was associated with a in the risk of PJI after but not after THA. of of and on in the after total hip the randomized The and in is a study the and of 4 regimens or after THA. The was 1 surgery and 6 for for a total of 4 of the on the postoperative and patients were in the The authors found that significantly reduced compared with in the after The surgical approach versus for the study cohort was not which have the postoperative for

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