What’s New in Hip Surgery

The trend of high-quality publications exploring the orthopaedic management of hip pathology has continued since the last iteration of this Guest Editorial. Common themes of this update include preoperative and perioperative management in total hip arthroplasty (THA), perioperative pain control, and emerging technologies. It is imperative that today’s hip surgeon remain knowledgeable about these rapidly expanding topics. Preoperative Considerations in THA Punnoose et al. published the results of a systematic review and meta-analysis involving 48 trials (3,570 patients) comparing prehabilitation with standard preoperative care in adults undergoing orthopaedic procedures1. Pain, muscle strength, function, health-related quality of life, and disease-specific and/or joint-specific outcomes were assessed for THA (among other orthopaedic procedures). In the preoperative setting, there was moderate-certainty evidence favoring prehabilitation in THA over standard care for the outcomes of hip abductor strength and health-related quality of life. In addition, there was low-certainty evidence favoring prehabilitation over standard care for the outcomes of pain and function. At 3 and 12 months postoperatively, there was low-certainty evidence favoring prehabilitation over standard care in THA, with a smaller benefit for patients undergoing THA compared with total knee arthroplasty (TKA). Similarly, in a recent article, Adebero et al. analyzed 28 trials to assess the effectiveness of prehabilitation on outcomes following THA2. Pain, health-related quality of life, strength, range of motion, and function were all significantly improved in patients receiving prehabilitation prior to TKA. In contrast, the trials addressing THA were limited and contradictory. Evidently, prehabilitation may have some role in improving the preoperative status of patients who will undergo THA, whereas the postoperative benefits are less substantial. Prehabilitation may be more useful in patients who undergo TKA than in those who undergo THA based on current evidence, with a potential, but limited, benefit in THA. Perioperative Management Postoperative drainage after hip and knee replacement can be problematic for patients and surgeons. In their secondary analysis of their Australian Orthopaedic Association National Joint Replacement Registry-based study, Sidhu et al.3 examined whether enoxaparin compared with aspirin was associated with increased postoperative wound drainage. In the cluster-randomized, crossover, noninferiority, nested registry trial (CRISTAL4), 31 institutions across Australia examined the prevalence of deep vein thrombosis in patients. Sidhu et al. took the results from 2 of the high-volume centers participating in this trial and examined them for wound complications. The included patients received 100-mg aspirin or 40-mg enoxaparin daily for 35 days after hip replacement and for 14 days after knee replacement. They found that overall persistent wound drainage did not differ (p = 0.40) between groups: 8% for the aspirin group and 9% for the enoxaparin group (odds ratio [OR], 1.2). However, in those patients who underwent a subcuticular closure, persistent wound drainage was observed in 7.7% of patients taking enoxaparin and 2.4% of patients taking aspirin (OR, 3.6; p = 0.009). This difference was not observed in those patients who underwent skin staple closure, and there was no difference in reoperations. The authors did advise caution when interpreting these results given the small sample size and the presence of effect modification by the thromboprophylaxis agent and type of wound closure, which prevented full model analysis. Intraoperative hemostasis remains a topic of discussion. Tranexamic acid (TXA) is widely adopted as a perioperative agent utilized to decrease perioperative blood loss in major orthopaedic operations. In a Cochrane Review, Gibbs et al. aimed to determine which of the commonly utilized perioperative agents (intravenous or oral TXA and recombinant factor VIIa) used in blood loss prevention were effective at reducing bleeding in patients requiring definitive fixation for hip, pelvic, and long-bone fractures5. The authors found that intravenous administration of TXA compared with placebo may reduce the risk of requiring allogenic blood products for 30 days postoperatively (risk ratio [RR], 0.48 [95% confidence interval (CI), 0.34 to 0.69]; 6 randomized controlled trials [RCTs], 457 participants), but with a low degree of certainty due to statistical imprecision. Additionally, the authors were uncertain if topical TXA compared with placebo resulted in fewer transfusions or less all-cause mortality, and they could not analyze factor VIIa because of a lack of evidence. The risk assessment tools for the development of deep vein thrombosis and pulmonary embolism are of particular use to the arthroplasty community. The Caprini score is a commonly used tool to predict the risk of the subsequent development of deep vein thrombosis or pulmonary embolism after a surgical intervention. Arthroplasties themselves automatically result in a patient score that is a minimum of 5 on this scale, and, as such, the effectiveness of this scale as a predictive tool in this population has been questioned. Qiao et al. aimed to answer this question via their study of 7 years of data on venous thromboembolism6. In their study, the authors included 3,807 patients who had undergone preoperative and postoperative ultrasonography on postoperative days 3 to 5, making it the largest study to date. The authors found a strong correlation between a greater Caprini score and venous thromboembolism (r = −0.775; p = 0.003); however, they noted that the receiver operating characteristic (ROC) curve had a poor area under the curve (AUC) of 0.619, confirming that the Caprini score is not prognostic. They determined that a Caprini score of ≥8.5 suggested a high risk of venous thromboembolism and recommended appropriate prophylaxis for high-risk patients. However, it is worth noting that the Youden index associated with their chosen cutoff was 0.175, which indicates only a modest level of effectiveness for a diagnostic test. In addition, 92.4% of the deep vein thromboses were located below the knee and were “muscular,” which has debatable clinical importance. The authors confirmed a strong correlation; however, the precise cutoff value for an increased regimen of thromboprophylaxis in the population undergoing arthroplasty remains debated. As the lower-extremity ultrasound scan was performed on postoperative days 3 to 5 and not beyond, deep vein thrombotic events occurring after this would have been missed, which limited the interpretation of the results. Perioperative Pain Control Nerve Blockade There have been numerous high-quality studies recently published on pain control in the perioperative period. Bravo et al. conducted an RCT comparing a pericapsular nerve group block with periarticular anesthetic infiltration after spinal anesthesia7 and found no difference in terms of the quadriceps motor blockade at any time point postoperatively. This was unexpected and was thought to be due to the questionable power of the study to adequately detect the difference and the multifactorial nature of quadriceps weakness in the postoperative period. The periarticular anesthetic infiltration resulted in lower static pain scores at all time intervals postoperatively (range of visual analog scale [VAS] difference, 0 to 2), in addition to lower dynamic pain scores (with adduction) at 3 and 6 hours (VAS difference, 2). There were no differences in opioid requirements in the postoperative period. The authors concluded that the increased success of the periarticular anesthetic infiltration block was due to its coverage of the posterior tissues, which was deficient in the pericapsular nerve group block. Alternatively, some researchers are considering quadratus lumborum blockage as a pain control strategy. Takeda et al.8 compared quadratus lumborum blockage with femoral nerve blockage in their RCT and found no significant difference in cumulative morphine consumption (p = 0.72) or intraoperative morphine consumption (p = 0.26). The authors could not show a clear superiority of quadratus lumborum blockage over femoral nerve blockage with respect to postoperative strength or fall risk. There was a debate in a subsequent letter to the editor regarding concerns over the sample size for that study9. In their RCT, Umeh et al.10 examined quadratus lumborum blockage compared with periarticular anesthetic infiltration in the population undergoing hip arthroscopy but did not find any differences in postoperative opioid consumption (p > 0.05) or a difference in postoperative quadriceps weakness (p = 0.2). As the baseline pain after THA tends to be low and variable, the concern regarding the above studies is that they would be underpowered to detect minor differences in analgesic effect. Oral Pain Medication Oral analgesia to decrease opioid consumption after joint replacement is an attractive adjuvant. Duloxetine has been classified as a selective serotonin and norepinephrine reuptake inhibitor (SSNRI) and has been previously investigated for its action after joint replacement. Azimi et al.11 investigated its postoperative role in their systematic review and meta-analysis of the current high-level evidence. After including 9 Level-I RCTs, the authors determined a significant and moderate decrease in oral morphine milligram equivalents and a lower overall pain level at several time points; however, they called into question the clinical importance of the latter, given that the reduction did not meet the minimal clinically important difference. There was also significant heterogeneity in the results, creating a low certainty of evidence. The authors concluded that the use of duloxetine may reduce the intensity of pain; however, they also concluded that “the current evidence does not support routine use for the sole purpose of reducing post-operative pain” and that its potential opioid-sparing effects must be weighed against the side effects. Meanwhile, in their RCT, Shen et al.12 assessed the impact of TXA on opioid use by comparing oral administration with intravenous administration. The authors enrolled 161 patients and assessed pain in the first 3 days via a VAS score and postoperative tramadol consumption. They also measured C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and interleukin-6 (IL-6) daily for the first 3 days, as inflammatory markers. They found that topical TXA appeared to yield a lower VAS score, as well as lower CRP, ESR, and IL-6 measurements. The results should be interpreted with caution, however, as the differences in the VAS score, CRP, ESR, and IL-6 were minimal, which questions their clinical importance. In addition, preoperative levels were not measured, and spinal anesthesia compared with general anesthesia did not appear to be controlled for. It is plausible that topical TXA may reduce hematoma formation, which, in turn, may decrease postoperative pain and may reduce inflammatory markers; however, more research is required to answer this interesting question. Hip Fracture Management Displaced Femoral Neck Fracture In a recent study by Lynch Wong et al., the rates of postoperative periprosthetic femoral fractures after THA with cemented polished taper-slip stems (0.9%) were higher than with cementless stems (0.7%)13. Of note in this study, patients with a polished femoral were 5 more to have a for postoperative periprosthetic femoral compared with patients with a cementless The concerns postoperative periprosthetic femoral fractures with these stems are and should be in in registry as by THA reduction and fixation may the of In a recent systematic review and meta-analysis of and femoral et al. a and hip for and The rate was for by a dynamic hip There was no difference in rate between and THA. This analysis did not between and femoral fractures and, as such, more research is However, these results support the use of arthroplasty for all femoral of Femoral Neck Fracture to the on management of femoral et al. on their results comparing fixation and for the management of and femoral The hip score (p = and the (p = were significantly in the compared with also had a higher rate of compared with p = and compared with p = for femoral fractures had with to blood loss and Perioperative in Hip Fracture Management Perioperative is in the hip recent systematic have on this area of clinical for this patient et al. the evidence from Cochrane and other systematic of randomized or trials to assess the perioperative that may to blood rates of and for blood in patients with a hip This Cochrane included results from involving The 2 of were TXA and TXA It was determined that given or the of patients requiring by The risk of TXA administration was assessed and was found to be minimal to with to deep vein thrombosis pulmonary embolism 9 or on 2 studies with there was to be to no difference in outcomes when was in the perioperative period. 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