This tip comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.
It is well-established that total hip arthroplasty (THA) improves quality of life, but how about longevity itself? Cnudde et al.1 attempted to identify associations between THA and lower mortality rates, acknowledging that such rates may also be influenced by diagnostic, patient-related, socioeconomic, and surgical factors.
Using data from the Swedish Hip Arthroplasty Register, the authors identified 131,808 patients who underwent THA between January 1, 1999 and December 31, 2012. Among those patients, 21,755 died by the end of follow-up. Relative survival among the THA patients was compared with age- and sex-matched survival data from the entire Swedish population.
Patients undergoing elective THA had a slightly improved survival rate compared with the general population for approximately 10 years after surgery, but by 12 years, there was no survival-rate difference between patients undergoing THA and the general population (r = 1.01; 95% CI, 0.99-1.02; p = 0.13).
After controlling for other relevant factors and using primary osteoarthritis as the reference diagnosis, the authors found that patients undergoing THA for osteonecrosis of the femoral head, inflammatory arthritis, and secondary osteoarthritis had poorer relative survival.
In addition, married patients and those with higher levels of education fared better. The authors could not pinpoint the reasons for the increase in relative survival among THA patients, but these findings suggest that the explanation is most likely multifactorial.
- Do Patients Live Longer After THA and Is the Relative Survival Diagnosis-specific?Cnudde P, Rolfson O, Timperley AJ, Garland A, Kärrholm J, Garellick G, Nemes S. Clin Orthop Relat Res. 2018 Feb 28. doi: 10.1007/s11999.0000000000000097. [Epub ahead of print]
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Control of Bone Growth by Epiphyseal Stapling: A Preliminary Report
W P Blount and G R Clarke: JBJS, 1949 July; 31 (3): 464
This 14-page, amply illustrated article was the oldest paper selected by Kavanagh et al. in their 2013 JBJS bibliometric analysis of the 100 classic papers of pediatric orthopaedics. Blount and Clarke proved definitively that long-bone growth could be arrested by appropriately timed epiphyseal stapling and that growth would resume after staple removal. Their work spared many children with linear or angular leg deformities—often a result of polio—from the risk of more invasive operative methods.
Epidemiology of Revision Total Hip Arthroplasty in the US
K J Bozic, S M Kurtz, E Lau, K Ong, T P Vail, D J Berry: JBJS, 2009 January; 91 (1): 128
Fast forwarding 60 years from the Blount and Clarke study, we arrive at this epidemiological analysis of >51,000 revision hip replacements. The findings from this 2009 Level II prognostic study provided information that has guided THA research, implant design, and clinical decision-making throughout the past decade.
Every surgical approach to total hip arthroplasty (THA)—posterior, anterior, or lateral and conventional or minimally invasive—has adherents and critics. Despite scores of published studies comparing these different approaches, no single best practice has yet emerged.
On Monday, February 12, 2018 at 6:30 PM EST, JBJS will present a complimentary* webinar that addresses this ongoing debate with recent evidence about five different surgical approaches to THA. Moderated by James Waddell, MD, former President of the Canadian Orthopaedic Association, the webinar will springboard off two JBJS articles:
- Knut Erik Mjaaland, MD will discuss a registry study that found no significant 5-year outcome differences among four different approaches: two minimally invasive (anterior and anterolateral), and two conventional (posterior and direct lateral).
- R. Michael Meneghini, MD will explain why his group concluded that the direct anterior approach may confer a greater risk of early femoral component failure due to aseptic loosening, compared with the direct lateral or posterior approaches.
After the authors’ presentations, Anthony Unger, MD and Tad Mabry, MD will add clinical perspectives to the current state of this important research. During the last 15 minutes of the webinar, panelists will answer questions from the audience.
Space is limited, so Register Now.
* This webinar is complimentary for those who attend the event live and will continue to be available for 24 hours following its conclusion.
The relationship between chronic kidney disease (CKD) and acute kidney injury (AKI) is circular: surgical patients with preexisting CKD are at increased risk of AKI, and even mild or transient AKI is associated with future development of CKD.
In the November 1, 2017 JBJS, Gharaibeh et al. report findings from a retrospective cohort study with a nested case-control analysis that assessed the rate and risk factors associated with AKI after total hip arthroplasty (THA).
From a total of 10,323 THAs analyzed, AKI developed postoperatively in only 114 cases (1.1%). A multivariate analysis of the entire cohort identified four preoperative comorbidities that increased the risk of AKI by 2- to 4-fold: CKD, heart failure, diabetes, and hypertension. In addition to those risk factors, an analysis of the case-control cohort found that increasing BMI and perioperative blood transfusions were also associated with a higher risk of AKI.
Using data from the entire cohort, the authors developed an AKI risk calculator focused on presurgical variables (see graph). Based on that model, which will require independent validation, a 65-year-old man with either CKD or heart failure would have a 2% risk of AKI; the risk would increase to 4% if that patient had CKD and hypertension and to 16.1% in the presence of CKD, hypertension, and heart failure.
The anticipated increase in demand for joint replacements could lead to US surgeons performing approximately 572,000 THAs during the year 2030. A certain (and possibly increasing) proportion of those future procedures will occur in patients who have hypertension, diabetes, heart failure, and/or chronic kidney disease. The findings from Gharaibeh et al., especially the yet-to-be-validated AKI risk score, could help hip surgeons better counsel patients and identify those who might benefit from heightened postsurgical monitoring of kidney function.
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, James T. Ninomiya, MD, MS, lead author of the September 20, 2017 Specialty Update on Hip Replacement, selected the five most clinically compelling findings from among the more than 50 studies covered in the Specialty Update.
Obesity and THA Outcomes
–Obesity is a well-established risk factor for perioperative THA complications. A prospective registry-based study found that reoperation and implant revision or removal rates increased with increasing BMI. More specifically, increasing BMI was associated with increased rates of early hip dislocation and deep periprosthetic infection.
–Two studies 1, 2 demonstrated that patients who have intra-articular injections within 3 months prior to THA experienced nearly double the risk of periprosthetic infection in the first postoperative year, compared with those in noninjection control groups.
Surgical Approaches to THA
–A study of >2,100 patients revealed that, despite claims to the contrary, there were no differences in dislocation rates between those who underwent THA using the direct anterior approach and a propensity-score matched cohort who underwent THA using a posterior approach.3
–What is the optimal temperature for an orthopaedic operating room? Anecdotes are often used to justify keeping operating rooms at uncomfortably high temperatures, which leads to discomfort and fatigue for members of the surgical team. A comprehensive literature review led authors to suggest that preoperative patient warming, intraoperative patient warming with forced-air devices, and keeping OR temperature at ≤19° C is the ideal combination for comfort while still maximizing patient safety and outcomes.
Return to Driving
–Following joint replacement, patients often ask when it will be safe to return to driving. A meta-analysis of 19 studies concluded that the mean time for return to baseline reaction time for braking was 2 weeks following a right-sided hip replacement and 4 weeks following a right-sided knee replacement.4 The authors stressed, however, that return-to-driving recommendations should be individualized for each patient.
- Schairer WW, Nwachukwu BU, Mayman DJ, Lyman S, Jerabek SA. Preoperative hip injections increase the rate of periprosthetic infection after total hip arthroplasty. J Arthroplasty. 2016 ;31(9)(Suppl):166–169.e1. Epub 2016 Apr 22.
- Werner BC, Cancienne JM, Browne JA. The timing of total hip arthroplasty after intraarticular hip injection affects postoperative infection risk. J Arthroplasty. 2016 ;31(4):820–3. Epub 2015 Sep 1.
- Maratt JD, Gagnier JJ, Butler PD, Hallstrom BR, Urquhart AG, Roberts KC. No difference in dislocation seen in anterior vs posterior approach total hip arthroplasty. J Arthroplasty. 2016 ;31(9)(Suppl):127–30. Epub 2016 Mar 15.
- van der Velden CA, Tolk JJ, Janssen RPA, Reijman M. When is it safe to resume driving after total hip and total knee arthroplasty? A meta-analysis of literature on post-operative brake reaction times. Bone Joint J. 2017 ;99-B(5):566–76.
The debate regarding minimally invasive/minimal incision total hip arthroplasty (THA) has been simmering for a decade and a half. When assessing the impact of adult reconstruction procedures, patients and treating physicians alike are most interested in longer-term results. Improved return of function in the first 3 to 6 weeks is of some value to all patients—and perhaps of great value to younger patients—and that has been one of the purported advantages of the “minimalist” approach. But it is the long-term results that really matter.
In the October 18, 2017 issue of The Journal, Stevenson et al. provide 10-year results from a 2005 randomized trial of small-incision posterior hip arthroplasty, and they confirm it adds no clinical, radiographic, or implant-survivorship benefit when compared with a standard posterior approach. An extra caveat here is that these procedures, originally done in 2003-2004, were undertaken by a highly experienced surgeon who had performed >300 minimal-incision THAs. In the hands of surgeons with less experience, smaller incisions may result in suboptimal component positioning and other complications, a point emphasized by Stevenson et al. and by Daniel Berry in his JBJS editorial accompanying the original study.
This long-term data is of great value to patients and surgeons alike. It is my hope that such high-quality evidence will temper the claims used in marketing materials that hype minimally invasive approaches, to which hip surgeons are routinely subjected.
Marc Swiontkowski, MD
The May 17, 2017 edition of The Journal of Bone & Joint Surgery features a registry-based study by Mjaaland et al. comparing implant-survival/revision outcomes in total hip arthroplasty (THA) among four different surgical approaches:
- Minimally Invasive (MI) Anterior (n=2017)
- MI Anterolateral (n=2087)
- Conventional Posterior (n=5961)
- Conventional Direct Lateral (n=11,795)
Although the authors analyzed a whopping 21,860 THAs from 2008 to 2013, the findings are limited by the fact that all of those procedures used an uncemented stem.
Overall, the revision rates and risk of revision with the MI approaches were similar to those of the conventional approaches. There was a higher risk of revision due to infection in THAs that used the direct lateral approach than in THAs using the other three approaches. “To our knowledge,” the authors write, “this finding has not been previously described in the literature, and we do not have an explanation for it.” The authors also found a reduced risk of revision due to dislocation in THAs that used the MI anterior, MI anterolateral, and direct lateral approaches, relative to those using the posterior approach.
While the authors found all-cause risk of revision to be similar among all four approaches, they note that the follow-up in the study was relatively short (mean of 4.3 years) and that “additional studies are needed to determine whether there are long-term differences in implant survival.”
An estimated 40% of total costs from a total hip arthroplasty (THA) episode are accrued from post-discharge services. With that in mind, Austin et al. embarked on a randomized controlled trial comparing outcomes among two groups of primary THA patients: those who followed a 10-week self-directed home exercise regimen (n=54) and those who received a combination of in-home and outpatient physical therapy (PT) for 10 weeks (n=54). The results were published in the April 19, 2017 edition of The Journal of Bone & Joint Surgery.
At 1 month and 6 to 12 months after surgery, patients in both groups showed significant preoperative-to-postoperative improvements in function as measured by all administered instruments (Harris Hip Score, WOMAC Index, and SF-36 Physical Health Survey). However, there was no difference in any of the measured functional outcomes between the two groups.
In addition, a total of 30 patients (28%) crossed over between groups: 20 (37%) from the formal physical therapy group and 10 (19%) from the home exercise group. The 10 patients who crossed over from home exercise to formal PT were not meeting progress goals; they tended to be older and had worse preoperative function than those in that cohort who did not cross over.
So, while this study provides evidence that unsupervised home exercise can be as effective as a structured rehabilitation program for most patients, the authors say the following patient characteristics might be indications for a referral to formal PT:
- Older age
- Poorer preoperative function
- Severe preoperative gait imbalance
- Postoperative neurological complications
- Expectations for quick return to high-level activity
An estimated 7 million people living in the US have undergone a total joint arthroplasty (TJA), and the demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA) will almost certainly increase during the next 15 years. But how many people can expect to have an additional TJA after having a first one?
That’s the question Sanders et al. address in their historical cohort study, published in the March 1, 2017 edition of The Journal of Bone & Joint Surgery. They followed more than 4,000 patients who underwent either THA or TKA between 1969 and 2008 to assess the likelihood of those patients undergoing a subsequent, non-revision TJA.
Here’s what they found:
- Twenty years after an initial THA, the likelihood of a contralateral hip replacement was 29%.
- Ten years after an initial THA, the likelihood of a contralateral knee replacement was 6%, and the likelihood of an ipsilateral knee replacement was 2% at 20 years.
- Twenty years after an initial TKA, the likelihood of a contralateral knee replacement was 45%.
- After an initial TKA, the likelihood of a contralateral hip replacement was 3% at 20 years, and the likelihood of an ipsilateral hip replacement was 2% at 20 years.
In those undergoing an initial THA, younger age was a significant predictor of contralateral hip replacement, and in those undergoing an initial TKA, older age was a predictor of ipsilateral or contralateral hip replacement.
The authors conclude that “patients undergoing [THA] or [TKA] can be informed of a 30% to 45% chance of a surgical procedure in a contralateral cognate joint and about a 5% chance of a surgical procedure in noncognate joints within 20 years of initial arthroplasty.” They caution, however, that these findings may not be generalizable to populations with more racial or socioeconomic diversity than the predominantly Caucasian population they studied.