Cadera/Hip: Paciencia si se lesiona un nervio tras la PTC

Long-term prognosis of nerve palsy after total hip arthroplasty: results of two-year-follow-ups and long-term results after a mean time of 8 years

B Zappe, P M Glauser, M Majewski, H R Stöckli, P E Ochsner
Archives of Orthopaedic and Trauma Surgery 2014, 134 (10):1477-82

INTRODUCTION: Nerve damage is a rare but serious complication after THA. There exist only little data about the outcome of these patients particularly regarding the long-term results later than 2 years postoperatively. Aim of this study is to answer the following questions: Is the recovery to be expected for light nerve lesions different from the severe ones? Is there a possibility of nerve recovery more than 2 years after THA? Is the potential of nerve recovery depending on the affected nerve?

MATERIALS AND METHODS: This study investigates 2,255 primary THA as well as revision surgeries performed from 1988 to 2003 relating to iatrogenic nerve lesion. We classified the nerve lesion according to the core muscle strength in severe (M0-M2) and light (M3-M4) nerve damage and differentiated between femoral, sciatic and superior gluteal nerve, according to the electromyography.

RESULTS: We found 34 cases of iatrogenic nerve damage representing an incidence of 1.5 %. 17 of 34 (50 %) patients showed a complete recovery after 2 years. Out of the remaining 17 patients, six out of seven patients with a final examination after a median time of 93 months achieved further improvement. The different nerves showed no significant different potential of recovery.

CONCLUSIONS: In contrast to the literature, an improvement beyond the limit of 2 years is probable and independent of the nerve affected.

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Pronóstico tardío de la parálisis nerviosa  tras prótesis total de cadera: resultados a los dos y  ocho años de seguimiento

INTRODUCCIÓN: La lesión nerviosa tras una prótesis total de cadera (PTC) es una complicación rara pero grave. Existen pocos datos sobre los resultados en estos pacientes, especialmente los de más de dos años. El objeto del estudio presente es responder a las siguientes preguntas: ¿La recuperación esperada en casos de lesión nerviosa leve es distinta en casos de lesión grave?¿Existe la posibilidad de recuperación nerviosa después de dos años de la PTC? ¿Depende la posibilidad de recuperación nerviosa del nervio afectado?

MATERIAL Y MÉTODOS: En el estudio se investigaron 2.255 PTC primarias y de revisión realizadas entre 1988 y 2003 relacionadas con una lesión iatrogénica del nervio. Hemos clasificado la lesión del nervio según la puntuación de la fuerza muscular en grave (M0-M2) y leve (M3-M4) y hemos diferenciado entre los nervios femoral, ciático y glúteo superior según el electromiograma.

RESULTADOS: Hemos encontrado 34 casos de lesión iatrogénica del nervio que supone una incidencia del 1.5%. 17 de 34 pacientes (50%) presentaban una recuperación completa a los 2 años. De entre los restantes 17 pacientes, seis de los siete que se examinaron tras un tiempo medio de 93 meses mejoraban aún más. Los distintos nervios no mostraban posibilidades  de recuperación significativamente distintas. 

CONCLUSIONES: En contraste con lo recogido en la bibliografía, es probable una mejoría después de 2 años de evolución que es independiente del nervio afectado

Cadera / Hip: cada milímetro cuenta

Restoration of the Hip Center During THA Performed for Protrusio Acetabuli Is Associated With Better Implant Survival
Yaser M. K. Baghdadi MD, A. Noelle Larson MD, Rafael J. Sierra MD
Clin Orthop Relat Res (2013) 471:3251–3259
DOI 10.1007/s11999-013-3072-x

Abstract

Background
Acetabular protrusio is an uncommon finding in hip arthritis. Several reconstructive approaches have been used; however the best approach remains undefined. Questions/purposes Our purposes in this study were to (1) describe the THA survivorship for protrusio as a function of the acetabular component, (2) evaluate survi- vorship of the cup as a function of restoration of radiographic hip mechanics and offset, and (3) report the long-term clinical results.

Methods
One hundred twenty-seven patients (162 hips) undergoing primary THA with acetabular protrusio were retrospectively reviewed. The mean age of the patients at surgery was 66 ± 13 years, and the mean followup was 10 ± 6 years (range, 2–25 years).The cup fixation was uncemented in 107 (83 with bone graft) and cemented in 55 hips (14 with bone graft). Preoperative and postoperative radiographs were reviewed for restoration of hip mechanics and offset.

Results
The THA survival from aseptic cup revision at 15 years was 89% (95% CI, 75%–96%) for uncemented compared with 85% (95% CI, 68%–94%) for cemented cups. The risk of aseptic cup revision significantly increased by 24% (hazards ratio, 1.24; 95% CI, 1.02–1.5) for every 1 mm medial or lateral distance away from the native hip center of rotation to the prosthetic head center. Harris hip scores were improved by mean of 27 ± 20 points (n = 123) with a higher postoperative score for uncemented bone grafted compared with solely cemented cups (81 ± 16 versus 71 ± 20 points).

Conclusions
Restoring hip center of rotation using an uncemented cup with or without bone graft was associated with increased durability in our series. There was a 24% increase in the risk of aseptic cup revision for every 1 mm medial or lateral distance away from the native hip center to the prosthetic head center.

Level of Evidence
Level III, therapeutic study

Cadera / Hip: Menos complicaciones en la PTC bajo anestesia regional

Effects of regional versus general anesthesia on outcomes after total hip arthroplasty: a retrospective propensity-matched cohort study.

Helwani MA, Avidan MS, Ben Abdallah A, Kaiser DJ, Clohisy JC, Hall BL, Kaiser HA

J Bone Joint Surg Am. 2015 Feb 4;97(3):186-93

doi: 10.2106/JBJS.N.00612.

Abstract

BACKGROUND: 

Many orthopaedic surgical procedures can be performed with either regional or general anesthesia. We hypothesized that total hip arthroplasty with regional anesthesia is associated with less postoperative morbidity and mortality than total hip arthroplasty with general anesthesia.

METHODS: 

This retrospective propensity-matched cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database included patients who had undergone total hip arthroplasty from 2007 through 2011. After matching, logistic regression was used to determine the association between the type of anesthesia and deep surgical site infections, hospital length of stay, thirty-day mortality, and cardiovascular and pulmonary complications.

RESULTS: 

Of 12,929 surgical procedures, 5103 (39.5%) were performed with regional anesthesia. The adjusted odds for deep surgical site infections were significantly lower in the regional anesthesia group than in the general anesthesia group (odds ratio [OR] = 0.38; 95% confidence interval [CI] = 0.20 to 0.72; p < 0.01). The hospital length of stay (geometric mean) was decreased by 5% (95% CI = 3% to 7%; p < 0.001) with regional anesthesia, which translates to 0.17 day for each total hip arthroplasty. Regional anesthesia was also associated with a 27% decrease in the odds of prolonged hospitalization (OR = 0.73; 95% CI = 0.68 to 0.89; p < 0.001). The mortality rate was not significantly lower with regional anesthesia (OR = 0.78; 95% CI = 0.43 to 1.42; p > 0.05). The adjusted odds for cardiovascular complications (OR = 0.61; 95% CI = 0.44 to 0.85) and respiratory complications (OR = 0.51; 95% CI = 0.33 to 0.81) were all lower in the regional anesthesia group.

CONCLUSIONS: 

Compared with general anesthesia, regional anesthesia for total hip arthroplasty was associated with a reduction in deep surgical site infection rates, hospital length of stay, and rates of postoperative cardiovascular and pulmonary complications. These findings could have an important medical and economic impact on health-care practice

LEVEL OF EVIDENCE: Therapeutic Level III

Cadera/Hip/Hüfte/Hanche: No sirve la puntuación WOMAC

Can the pre-operative Western Ontario and McMaster score predict patient satisfaction following total hip arthroplasty? 

Rogers, B. A., Alolabi, B., Carrothers, A. D., Kreder, H. J., Jenkinson, R. J.

Bone Joint J 2015;97-B:150–3.

In this study we evaluated whether pre-operative Western Ontario and McMaster Universities (WOMAC) osteoarthritis scores can predict satisfaction following total hip arthroplasty (THA).

Prospective data for a cohort of patients undergoing THA from two large academic centres were collected, and pre-operative and one-year post-operative WOMAC scores and a 25-point satisfaction questionnaire were obtained for 446 patients. Satisfaction scores were dichotomised into either improvement or deterioration. Scatter plots and Spearman’s rank correlation coefficient were used to describe the association between pre-operative WOMAC and one-year post-operative WOMAC scores and patient satisfaction. Satisfaction was compared using receiver operating characteristic (ROC) analysis against pre-operative, post-operative and WOMAC scores.

We found no relationship between pre-operative WOMAC scores and one-year post-operative WOMAC or satisfaction scores, with Spearman’s rank correlation coefficients of 0.16 and –0.05, respectively. The ROC analysis showed areas under the curve (AUC) of 0.54 (pre-operative WOMAC), 0.67 (post-operative WOMAC) and 0.43 ( WOMAC), respectively, for an improvement in satisfaction.

We conclude that the pre-operative WOMAC score does not predict the post-operative WOMAC score or patient satisfaction after THA, and that WOMAC scores can therefore not be used to prioritise patient care.

 

Cadera/Hip/Hüfte/Hanche: Más cabezonas pero más estables

Dislocation Rates Following Primary Total Hip Arthroplasty Have Plateaued in the Medicare Population
Akshay Goel, Edmund Lau, Kevin L. Ong, Daniel J. Berry, Arthur L. Malkani
The Journal of Arthroplasty
Accepted: November 18, 2014;
DOI: http://dx.doi.org/10.1016/j.arth.2014.11.012

Abstract

Dislocation remains one of the most frequent complications following total hip replacement. Numerous risk factors predisposing patients to dislocation have been identified. Larger diameter femoral heads (32 mm or larger) came into common use in the mid 2000’s have been shown to improve hip stability. The purpose of this study was to determine if the use of larger femoral head diameters, in combination with recent practice including enhanced soft tissue choices and various operative exposure choices has led to any further decline in dislocation rates following primary total hip arthroplasty. The study included 51,901 patients undergoing primary THA identified from 5% Medicare Part B (physician/carrier) claims between January 1, 1997 and December 31, 2011. Dislocation rate at 6 months following THA was 2.84% over the study period (1997–2011). From 2005–2011, dislocation rates following primary THA have plateaued in the United States at approximately 2%. This suggests that the full benefits using large femoral head sizes now realized. For further improvement in dislocation rates, a greater emphasis will be required on patient selection, surgical technique and component alignment.

Cadera/Hip/Hüfte/Hanche: A conducir mucho antes que antes

When is it Safe for Patients to Drive after Right Total Hip Arthroplasty?
Victor H. Hernandez, Alvin Ong, Fabio Orozco, Anne M. Madden, Zachary
The Journal of Arthroplasty
Online: November 25, 2014
DOI: http://dx.doi.org/10.1016/j.arth.2014.11.015

Abstract

Old studies recommend 6 weeks post-op before patients can return to driving safely. This is a prospective study assessing brake reaction time (BRT) after THA. 38 patients underwent a pre-op, 2, 4 and 6 weeks post op BRT test. General Linear Repeated Measurement was used. The mean pre-op reaction time was 0.635+/-0.160 sec SD and 2-week was 0.576+/-0.137 sec SD(p = 0.029); 33 patients (87 %) were able to reach their baseline time by 2 weeks. The remaining five patients (13%) reached their baseline at the 4-week post-op. No differences were found with respect to age, gender, and the use of assistive devices. With new techniques in THA, most of patients return to normal times within the 2-week.

Cadera/Hip/Hüfte/Hanche: Crece la resistencia de algunos estafilococos

Increasing Resistance of Coagulase-Negative Staphylococci in Total Hip Arthroplasty Infections: 278 THA-Revisions due to Infection Reported to the Norwegian Arthroplasty Register from 1993 to 2007
Olav Lutro, Håkon Langvatn, Håvard Dale, Johannes Cornelis Schrama, Geir Hallan, Birgitte Espehaug, Haakon Sjursen, Lars B Engesæter
Adv Orthop. 2014;2014:580359. doi: 10.1155/2014/580359. Epub 2014 Oct 9.

We investigated bacterial findings from intraoperative tissue samples taken during revision due to infection after total hip arthroplasty (THA). The aim was to investigate whether the susceptibility patterns changed during the period from 1993 through 2007.

Reported revisions due to infection in the Norwegian Arthroplasty Register (NAR) were identified, and 10 representative hospitals in Norway were visited. All relevant information on patients reported to the NAR for a revision due to infection, including bacteriological findings, was collected from the medical records.

A total of 278 revision surgeries with bacterial growth in more than 2 samples were identified and included. Differences between three 5-year time periods were tested by the chi-square test for linear trend. The most frequent isolates were coagulase-negative staphylococci (CoNS) (41%, 113/278) and Staphylococcus aureus (19%, 53/278). The proportion of CoNS resistant to the methicillin-group increased from 57% (16/28) in the first period, 1993-1997, to 84% (52/62) in the last period, 2003-2007 (P = 0.003). There was also significant increase in resistance for CoNS to cotrimoxazole, quinolones, clindamycin, and macrolides. All S. aureus isolates were sensitive to both the methicillin-group and the aminoglycosides. For the other bacteria identified no changes in susceptibility patterns were found.

Cadera/Hip/Hüfte/Hanche: tendencias colocando prótesis de cadera

Trends in total hip arthroplasty implant utilization in the United States

Lehil MSBozic KJ

J Arthroplasty 2014 Oct; 29(10):1915-8

Abstract

Total hip arthroplasty (THA) implant usage has evolved as experience has been gained with newer implant designs. The purpose of this study was to characterize trends in THA implant usage between 2001 and 2012. The Orthopedic Research Network, which includes 174 hospitals and ~105,000 THA, was used to evaluate trends in fixation, bearings, acetabular cup and liner, and femoral head usage. 

In 2012, 93% of THAs were cementless; 56% of THA bearings were metal-HXLPE; and 35% were ceramic-HXLPE. 99% of acetabular cups were modular. 61% of femoral heads were metal, 39% were ceramic, 51% were 36mm, and 28% were 32mm. V

THA implant usage trends favor cementless fixation, metal-on-polyethylene or ceramic-on-polyethylene bearings, modular acetabular cups, and large diameter femoral heads.

Cadera/Hip/Hüfte/Hanche: hay que centrarse en la persona

Person-centred care compared with standardized care for patients undergoing total hip arthroplasty: a quasi-experimental study
Lars-Eric Olsson, Jón Karlsson, Urban Berg, Johan Kärrholm, Elisabeth Hansson
Journal of Orthopaedic Surgery and Research 2014 October 9, 9 (1): 95

Background
A common approach to decrease length of stay has been to standardize patient care, for example, by implementing clinical care pathways or creating fast-track organizations. In a recent national report, it was found that Sweden's healthcare system often fails to anticipate and respond to patients as individuals with particular needs, values and preferences. We compared a standardized care approach to one of person-centred care for patients undergoing total hip replacement surgery.

Methods
A control group (n =138) was consecutively recruited between 20th September 2010 and 1st March 2011 and an intervention group (n =128) between 12th December 2011 and 12th November 2012, both scheduled for total hip replacement. The primary outcome measures were length of stay and physical function at both discharge and 3 months later.

Results
The mean length of stay in the control group was 7 days (SD 5.0) compared to 5.3 days in the intervention group (SD 2.2). Physical functional performance, as assessed using activities of daily living, was similar at baseline for both groups. At discharge, 84% in the control group had regained activities of daily living level A vs. 72% in the intervention group. At 3 months after surgery, 88% in the control group had regained their independence vs. 92.5% in the person-centred care group.

Conclusions
Focusing attention on patients as people and including them as partners in healthcare decision-making can result in shorter length of stay. The present study shows that the patients should be the focus and they should be involved as partners.

Cadera/Hip/Hüfte/Hanche: El hundimiento del vástago femoral tiene un tope

Loosely implanted cementless stems may become rotationally stable after loading.
Kannan A1, Owen JR, Wayne JS, Jiranek WA.
Clin Orthop Relat Res. 2014 Jul;472(7):2231-6

Abstract

BACKGROUND:
Experimental studies have suggested that initial micromotion of cementless components may lead to failure of osteointegration. Roentgen stereophotogrammetric analyses have shown durable implant fixation can be achieved long-term even when initial instability exists, as evidenced by subsidence. However improved implant stability as a result of subsidence, before osteointegration, has not been shown biomechanically.

QUESTIONS/PURPOSES:
We asked whether insertionally loose cementless tapered femoral stems show (1) less rotational stability (more toggle); (2) more subsidence; and (3) reduced ability to resist torsion (lower initial construct stiffness), lower torque at failure, and greater rotation to failure in comparison to well-fixed cementless tapered femoral stems.

METHODS:
Ten matched pairs of cadaveric femurs were implanted with well-fixed and loose cementless tapered stems. The loose stem construct was obtained by appropriately broaching the femur but afterwards inserting a stem one size smaller than that broached. Femoral stem rotational stability of implanted femurs was tested by measuring the angular rotation (ie, toggle) required to produce a torque of 2 N-m at 0 N, 250 N, and 500 N vertical load in 25° adduction simulating single-legged stance. Subsidence was measured as vertical movement during the toggle tests. Then at 500 N initial vertical load, femoral stems were externally rotated to failure. The construct stiffness between 5 and 40 N-m was determined to assess ability to resist torsion. The torque and rotation to failure were recorded to compare failure characteristics. Groups were compared using mixed model ANOVA followed by Tukey-Kramer post hoc pairwise comparison for toggle and subsidence tests and by Student's paired t-tests for stiffness, torque at failure, and rotation to failure tests.

RESULTS:
Loose tapered cementless stems were less stable (ie, more toggle) than well-fixed at 0 N of load (p < 0.0001), but no difference was detectable in toggle between loose and well-fixed stems at 250 N (p = 0.7019) and 500 N (p = 0.9970). Loose tapered cementless stems showed significant subsidence at 250 N (p < 0.0001) and 500 N (p < 0.0001), which was not found in the well-fixed stems at 250 N (p = 0.8813) and 500 N (p = 0.1621). Torsional stiffness was lower for loose stems as compared with well-fixed stems (p = 0.0033). No difference in torque at failure (p = 0.7568) or rotation to failure (p = 0.2629) was detected between loose and well-fixed stems.

CONCLUSIONS:
In this study, we observed that insertionally loose cementless stems have the ability to subside and become rotationally stable with loading. They did not exhibit a lower torque or rotation to failure in comparison to well-fixed stems when under simulated single-legged stance.

Cadera/Hip/Hüfte/Hanche: Qué le espera el paciente joven tras una prótesis total de cadera

Mid-to long-term results of revision total hip replacement in patients aged 50 years or younger 
Lee, P. T. H., Lakstein, D. L., Lozano, B., Safir, O., Backstein, J., Gross, A. E.
Bone Joint J 2014;96-B:1047–51.

Revision total hip replacement (THR) for young patients is challenging because of technical complexity and the potential need for subsequent further revisions.

We have assessed the survivorship, functional outcome and complications of this procedure in patients aged < 50 years through a large longitudinal series with consistent treatment algorithms.
Of 132 consecutive patients (181 hips) who underwent revision THR, 102 patients (151 hips) with a mean age of 43 years (22 to 50) were reviewed at a mean follow-up of 11 years (2 to 26) post-operatively. We attempted to restore bone stock with allograft where indicated.

Using further revision for any reason as an end point, the survival of the acetabular component was 71% (sd 4) and 54% (sd 7) at ten- and 20 years. The survival of the femoral component was 80% (sd 4) and 62% (sd 6) at ten- and 20 years. Complications included 11 dislocations (6.1%), ten periprosthetic fractures (5.5%), two deep infections (1.1%), four sciatic nerve palsies (2.2%; three resolved without intervention, one improved after exploration and freeing from adhesions) and one vascular injury (0.6%). The mean modified Harris Hip Score was 41 (10 to 82) pre-operatively, 77 (39 to 93) one year post-operatively and 77 (38 to 93) at the latest review.

This overall perspective on the mid- to long-term results is valuable when advising young patients on the prospects of revision surgery at the time of primary replacement.

Cadera / Hip / Hüfte: Más inflamación y dolor en pacientes obesos tras PTC

Association of Obesity With Inflammation and Pain After Total Hip Arthroplasty

Roja Motaghedi, James J. Bae, Stavros G. Memtsoudis, David H. Kim, Jonathan C. Beathe, Leonardo Paroli, Jacques T. YaDeau, Michael A. Gordon, Daniel B. Maalouf, Yi Lin

Clinical Orthopaedics and Related Research®

May 2014, Volume 472, Issue 5, pp 1442-1448

Abstract

Background

The prevalence of obesity is increasing, and obesity often leads to degenerative joint disease requiring total hip arthroplasty (THA). Obesity is a proinflammatory state associated with an increase in chronic, low-grade inflammatory response. As such, it may augment the postoperative inflammatory response, which has been associated with postoperative pain and complications.

Questions/purposes

We determined whether severity of obesity was associated with (1) severity of inflammatory response, as measured by the in vivo circulating levels of cytokines and ex vivo functional reactivity of mononuclear blood cells, and (2) severity of pain, as measured by verbal pain scores and analgesic consumption, in the first 24 hours after THA.

Methods

We studied 60 patients (20 normal weight, 20 overweight, 20 obese) undergoing elective primary unilateral THA in this prospective cross-sectional study. Blood samples were collected for C-reactive protein and cytokine levels, including IL-1β, IL-2, IL-6, IL-8, and tumor necrosis factor α (TNF-α), from patients before and 24 hours after surgery. Cytokine response of whole blood was evaluated ex vivo with or without two standard activators, phorbol-12-myristate-13-acetate and lipopolysaccharide, using standardized blood sample from patients at 24 hours. These standard immune activators are implicated in the inflammatory response to gram-negative infection, translocation of microbial products, pathophysiology of septic shock syndrome in human, and tumor promotion. Pain response was gauged using verbal pain scores (on a 0- to 10-point scale, where 0 = no pain and 10 = worst pain) at rest and with activity at 24 hours after surgery and analgesic consumption of volume of epidural analgesic solution for the first 24 hours after surgery.

Results

No correlation was found between BMI and postoperative spontaneous circulating cytokine levels. However, after activation of blood leukocytes with lipopolysaccharide, there was a significant positive correlation between the BMI and IL-1β, IL-6, and TNF-α levels (r = 0.26–0.32; p = 0.03, p = 0.03, and p = 0.01, respectively), suggesting priming of the innate immune system in obesity and potential for excessive postoperative inflammatory response. Obesity was not associated with increased pain or analgesic consumption in the first 24 hours after surgery

Conclusions

Obesity is associated with a proinflammatory state after THA as demonstrated by enhanced cytokine reactivity. Larger studies exploring the specific impact of obesity and inflammation on surgical outcomes, including pain, are warranted.

Level of Evidence

Level II, therapeutic study

Cadera/Hip/Hüfte: para los peques PTC no cementada cerámica/cerámica

The results of uncemented total hip replacement in children with juvenile idiopathic arthritis at ten years.

Daurka JS, Malik AK, Robin DA, Witt JD.

J Bone Joint Surg Br. 2012 Dec;94(12):1618-24

Abstract

The inherent challenges of total hip replacement (THR) in children include the choice of implant for the often atypical anatomical morphology, its fixation to an immature growing skeleton and the bearing surface employed to achieve a successful long-term result. 

We report the medium-term results of 52 consecutive uncemented THRs undertaken in 35 paediatric patients with juvenile idiopathic arthritis.

The mean age at the time of surgery was 14.4 years (10 to 16). The median follow-up was 10.5 years (6 to 15). 

During the study period 13 THRs underwent revision surgery. With revision as an endpoint, subgroup analysis revealed 100% survival of the 23 ceramic-on-ceramic THRs and 55% (16 of 29) of the metal- or ceramic-on-polyethylene. This resulted in 94% (95% CI 77.8 to 98.4) survivorship of the femoral component and 62% (95% CI 41.0 to 78.0) of the acetabular component. 

Revision of the acetabular component for wear and osteolysis were the most common reasons for failure accounting for 11 of the 13 revisions. The success seen in patients with a ceramic-on-ceramic articulation seems to indicate that this implant strategy has the potential to make a major difference to the long-term outcome in this difficult group of patients.

Cadera / Hip: peores resultados postartroscopia en caso de choque femoroacetabular con espacio articular reducido

The Effect of Joint Space on Midterm Outcomes After Arthroscopic Hip Surgery for Femoroacetabular Impingement.

Skendzel JG, et al. Show all Am J Sports Med. 2014 Mar 7

Abstract

BACKGROUND: Excellent short-term results have been reported after hip arthroscopic surgery to address femoroacetabular impingement (FAI).

Purpose/ HYPOTHESIS: The purpose of this study was to determine if patients with narrow joint spaces had inferior outcomes at a postoperative minimum of 5 years and if they had a higher conversion rate to total hip arthroplasty (THA). The hypothesis was that patients with ≤2-mm joint spaces would report inferior outcomes and that patients with >2-mm joint spaces would have improved survivorship (no conversion to THA). 

STUDY DESIGN: Cohort study; Level of evidence, 3. 

METHODS: Between March 2005 and January 2008, prospectively collected data were analyzed for patients older than 18 years of age undergoing hip arthroscopic surgery for FAI. Radiographic measurements of joint space were collected, and hips were grouped as having preserved (>2 mm) or limited (≤2 mm) joint space. Outcome measures included the Western Ontario and McMaster Universities Arthritis Index (WOMAC), modified Harris Hip Score (MHHS), Hip Outcome Score (HOS) for activities of daily living and sports, and Short Form-12 (SF-12). 

RESULTS: There were 559 patients included, 466 (83%) of whom were contacted. Fifty-four patients with limited joint spaces (86%) converted to THA, while only 63 patients with preserved joint spaces (16%) converted to THA. The mean survival time for patients with preserved joint spaces was 88 months (95% CI, 85-91 months), and the mean survival time for patients with limited joint spaces was 40.0 months (95% CI, 33.7-46.3 months) (P = .0001). Complete follow-up outcome data were available on 323 patients, none of whom had THA, with a mean follow-up of 73 months. The mean postoperative HOS for activities of daily living and sports were significantly better in patients with preserved joint spaces (82 vs 62 [P = .012] and 77 vs 47 [P = .003], respectively) compared with those with limited joint spaces at a mean of 73 months postoperatively (range, 60-97 months). 

CONCLUSION: Hip arthroscopic surgery for FAI resulted in significantly better outcomes and activity levels at minimum 5-year follow-up in patients with preserved joint spaces. Hips with limited joint spaces converted to THA earlier than did those with preserved joint spaces.

Cadera / Hip: ¿PTC en ancianos y obesos?

Total hip replacement: unique challenge in the obese and geriatric populations

McDonald, John E; Huo, Michael 

Current Opinion in Orthopaedics:

January 2008 - Volume 19 - Issue 1 - p 33–36

Abstract

Purpose of review: Total hip replacement is one of the safest and most clinically efficacious operations in orthopedic surgery. It has been extended to more and more patient populations over the past four decades. The purpose of this review is to present the contemporary data of total hip replacement in two unique patient populations: obese patients and geriatric patients older than 75 years of age.

Recent findings: There are unique clinical challenges in these patients. In addition, the clinical outcome and complications are different from more routine total hip replacement populations.

Summary: The recent research has shown that total hip replacement in the obese and elderly populations can be successful, and should not be denied solely based on these two criteria. There is a need for more research to investigate postoperative instability in the obese patient population, and perioperative mental confusion and cognitive function deterioration in the elderly patient population.

Cadera / Hip: El vástago no cementado recubierto de hidroxiapatita: patrón de referencia

Hip reconstruction: Edited by Michael H. Huo

Uncemented hydroxyapatite-coated stems for primary total hip arthroplasty

Markel, David C; Gheraibeh, Petra J

Current Opinion in Orthopaedics:

January 2008 - Volume 19 - Issue 1 - p 16–20

Abstract

Purpose of review: The review is intended to describe the most recent evidence surrounding the use of hydroxyapatite-coated uncemented femoral stems.

Recent findings: Until recently, the research on hydroxyapatite-coated femoral stems has been limited to retrospective and prospective studies with short-term follow-up. Recently, several authors have published 10–15-year follow-up data that are very promising. Hydroxyapatite is a good adjunct for fostering bony ingrowth and ongrowth of femoral components. This in turn results in less pain, faster onset of implant stability, and a lower incidence of aseptic loosening.

Summary: A proximally coated press-fit femoral component augmented with a hydroxyapatite coating provides predictable outcome and may be favored as a state of the art or gold standard for primary hip arthroplasty.

Cadera / Hip: PTC de recubrimiento sólo en casos seleccionados

Total hip resurfacing: a viable alternative to total hip arthroplasty for the young active hip patient in the United States?

Macaulay, William

Current Opinion in Orthopaedics:

January 2008 - Volume 19 - Issue 1 - p 2–5

Abstract

Purpose of review: Metal-on-metal hip resurfacing was approved by the Food and Drug Administration in the United States in May 2006. The present review provides a succinct overview of metal-on-metal hip resurfacing for the reader who may wonder whether this procedure currently has a role in the treatment of hip disease in the young active American adult.

Recent findings: Recent studies reviewed herein focus on the issues of head viability, biomechanics, metal ions and bone preservation. Also, although late mid-term and long-term outcomes data are lacking, published short-term to mid-term survivorship is highlighted.

Summary: Metal-on-metal hip resurfacing is an interesting improvement/modification of traditional hip resurfacing systems that has fallen out of widespread use due to unacceptably high rates of failure. Despite the fervor demonstrated by aggressive patients searching for a more bone-preserving alternative to total hip arthroplasty, metal-on-metal hip resurfacing should be reserved for appropriately selected patients and should be performed only by skilled/high-volume/properly trained hip surgeons. It is incumbent upon surgeons and implant manufacturers to monitor early complications and to closely track and report outcomes over the mid-term and longer term to assure patient safety now and into the future.

Cadera / Hip: ¿Dolor por el vástago femoral? A lo mejor el vástago compuesto

Composite femoral stem for total hip arthroplasty

Glassman, Andrew H

Current Opinion in Orthopaedics. 19(1):6-10, January 2008.

Abstract

Purpose of review: 

Excessive femoral component stiffness contributes to stress shielding and thigh pain. A more flexible stem that provides enduring biologic fixation, reduces stress shielding, and minimizes thigh pain would therefore be of significant clinical benefit.

Recent findings: 

Recent findings indicate success in attaining these goals using the Epoch composite stem (Zimmer, Warsaw, Indiana, USA). Mechanical testing demonstrates reduced stiffness without compromise of strength and fatigue properties. Canine and human radiographs and postmortem retrievals show reliable and extensive bone ingrowth. Prospective trials indicate outstanding clinical results. Plain film and dual-energy X-ray absorptiometry studies, including series of bilateral total hip arthroplasty with an Epoch on one side and an alternative design on the other, show reduced stress shielding with the Epoch.

Summary: 

The favorable results observed with the Epoch stem have significant clinical implications. Larger, stiffer solid metal stems, even if made of titanium alloy, are associated with higher incidences of stress shielding and thigh pain. The use of a composite femoral stem may circumvent these problems.

 

Rodilla y cadera /Joint: perder peso antes de la artroplastia

The Impact of Pre-Operative Weight Loss on Incidence of Surgical Site Infection and Readmission Rates After Total Joint Arthroplasty

Maria C.S. Inacio, PhD, Donna Kritz-Silverstein, PhD, Rema Raman, PhD, Caroline A. Macera, PhD, Jeanne F. Nichols, PhD, Richard A. Shaffer, PhD, Donald C. Fithian, MD

J Arthroplasty Volume 29, Issue 3 , Pages 458-464.e1, March 2014

Published online 09 September 2013.

Abstract 

This study characterized a cohort of obese total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients (1/1/2008–12/31/2010) and evaluated whether a clinically significant amount of pre-operative weight loss (5% decrease in body weight) is associated with a decreased risk of surgical site infections (SSI) and readmissions post-surgery. 10,718 TKAs and 4066 THAs were identified. During the one year pre-TKA 7.6% of patients gained weight, 12.4% lost weight, and 79.9% remained the same. In the one year pre-THA, 6.3% of patients gained weight, 18.0% lost weight, and 75.7% remained the same. In TKAs and THAs, after adjusting for covariates, the risk of SSI and readmission was not significantly different in the patients who gained or lost weight pre-operatively compared to those who remained the same.