The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 93, Issue 20

Specialty Update | October 19, 2011

What's New in Total Hip Arthroplasty

Michael H. Huo, MD¹; Guillaume D. Dumont, MD¹; Justin R. Knight, MD¹; Michael A. Mont, MD¹

¹ Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390. E-mail address for M.H. Huo: michael.huo@utsouthwestern.edu

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Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.

J Bone Joint Surg Am, 2011 Oct 19;93(20):1944-1950. doi: 10.2106/JBJS.K.00656

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Extract

We have elected to follow the same methodology used in the past eleven years for the writing of this review. Data were extracted from reports published in The Journal of Bone and Joint Surgery, The Journal of Arthroplasty, and Clinical Orthopaedics and Related Research. The time period for data inclusion was from April 2010 to April 2011. We included data presented on total hip arthroplasty at the major meetings, including the 2010 Hip Society Fall Meeting, the 2010 Annual Meeting of the American Association of Hip and Knee Surgeons (AAHKS), the 2011 Hip Society Open Meeting, and the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS).

Figures in this Article

Introduction

We have organized the review into four sections: (1) metal-on-metal articulation, (2) clinical outcome of total hip arthroplasty, (3) complications, and (4) practice management.

Metal-on-Metal Articulation

There have been numerous publications and abstracts over the past several years on the potential deleterious effects of metal-on-metal bearing couplings. The British Orthopaedic Association and the British Hip Society issued a Device Alert with regard to the use of metal-on-metal bearing couplings in 2010¹. The United States Food and Drug Administration (U.S. FDA) issued its version of the guidelines recently (in February 2011). Great attention has been focused on this subject, particularly with the recall of an acetabular component with a metal bearing surface, the ASR XL design (DePuy, Warsaw, Indiana), in August 2010.

Recommendations for Evaluation of Pain After Hip Arthroplasty with Metal-on-Metal Articulation

Recommendations from the British device alert guidelines¹ include (1) yearly clinical and radiographic evaluation; (2) serum metal ion analysis and use of advanced imaging such as magnetic resonance imaging (MRI), computerized tomography (CT), or ultrasound for symptomatic patients; and (3) repeat testing in three months if the cobalt or chromium level exceeds seven parts per million. Similar guidelines have been recommended by the U.S. FDA, AAOS, AAHKS, and The Hip Society^2-4.

Clinical Outcome of Hip Resurfacing and Total Hip Arthroplasty with Metal-on-Metal Articulation

McGrory et al.⁵ conducted a systematic review of modern hip resurfacing arthroplasties. They found a 1.4 to 3.6-fold greater revision rate after hip resurfacing arthroplasties than after standard total hip arthroplasties. There are numerous limitations in such comparisons, such as differences among the patients in terms of demographic characteristics and activity levels. The authors reported that increased surgical experience resulted in fewer revisions. van der Weegen et al.⁶ reviewed 433 reports on hip resurfacing. They selected twenty-nine studies involving 10,621 hip resurfacing arthroplasties for the final analysis. The revision rate was 3.5%, with femoral neck fracture being the most frequent cause for revision. Bozic et al.⁷ analyzed the claims data for Medicare recipients from 2005 to 2007 and found that 47,047 patients underwent total hip arthroplasty. Three types of bearing couples were used: metal-on-metal, metal-on-polyethylene, and ceramic-on-ceramic. A metal-on-metal bearing was used in 35% of younger Medicare patients (age, sixty-five to sixty-nine years), and this rate decreased to 28% in older patients (age, more than eighty years). The only difference was a greater risk of infection in patients with a metal-on-metal bearing as compared with a ceramic-on-ceramic bearing. After adjustment for all of the variables, patients with a metal-on-metal bearing did not have a greater risk of any complication, including revision.

Several reports focused on the long-term (ten-year) results of hip resurfacing. Amstutz et al.⁸ reported a ten-year survival rate of 88.6% in a study of 100 consecutive hips (eighty-nine patients). There were no failures in the hips with a femoral component size of >46 mm. The authors also did not observe femoral head cystic or necrotic defects of >1 cm in these patients with larger components. Treacy et al.⁹ reported a ten-year survival rate of 95.5% in a study of 144 consecutive hips. The survival rate was higher for male patients (98%) with larger components in comparison with female patients or those with smaller-size components.

Higher failure rates have been reported in association with monoblock designs. A possible cause is that monoblock designs are less than a full hemisphere (180°) in order to reduce impingement risks. This design feature reduces contact with the host acetabular bone and potentially reduces fixation stability. In addition, the clearance between the cup and the femoral head component is greater with monoblock cups to prevent catching because the cups have been shown to deform >100 μm in loaded conditions. Cup deformation may lead to increased torsional force. Grimes¹⁰ found excessive deformation, leading to decreased operational clearance. This was proposed to lead to increased friction, greater torque, and decreased contact area with early failure in twelve retrieved cups.

Mechanism of Failure of Metal-on-Metal Implants

Suboptimal component position has been correlated with increased levels of serum metal ions, adverse localized tissue reactions, and increased failure of metal-on-metal bearings. Hart et al.¹¹ analyzed 138 retrieved implants and reported a correlation between the cup abduction angle and the wear rate (p = 0.001). There also was a correlation between edge-loading and the wear rate (p < 0.0001). However, there was no correlation between head size and the wear rate. The same researchers¹² did not find a correlation between the cup anteversion position (either alone or in combination with femoral anteversion) and the wear rate with use of three-dimensional CT evaluation. Tiberi et al.¹³ reported on the intermediate-term outcome of 585 consecutive hip arthroplasties with metal-on-metal bearings (469 resurfacing arthroplasties and 116 total hip arthroplasties) that had been performed by a single surgeon. The mean duration of follow-up was five years (range, two to eleven years). The revision rate was high (2.7%) in association with the recalled ASR XL design. The important finding was that adverse local-tissue reactions were associated with edge wear and subluxation due to increased combined cup and femoral anteversion of >40°. The effect of excessive anteversion was independent of the cup abduction angle. Other significant factors associated with adverse tissue reaction were hip resurfacing, female sex, and small component size.

Metal ions and wear debris have long been known to be associated with inflammatory markers in patients with failed hip arthroplasties. Ball et al.¹⁴ reported a fifteenfold increase in inflammatory cytokines interleukin-6 (IL-6), IL-8, and IL-10 in the synovial fluid of ten patients with adverse reactions to a metal-on-metal bearing as compared with the fluid from three patients who had polyethylene-induced periarticular osteolysis. Garbuz et al.¹⁵ reported the metal ion levels and the prevalence of pseudotumor detected with ultrasonography in three groups of patients (all asymptomatic): (1) patients managed with large femoral head metal-on-metal total hip replacements (n = 29), (2) patients managed with hip resurfacing (n = 21), and (3) patients managed with standard metal-on-polyethylene total hip replacements (n = 23). Group 1 (metal-on-metal total hip replacements) had the highest serum metal ion levels. The ratio of pseudotumor among the groups was 8:3:1, respectively. However, there was no conclusive correlation between metal ion levels and the prevalence of pseudotumor. Stulberg et al.¹⁶ evaluated the metal ion levels in 173 patients (192 hips) at a minimum of five years after surgery and found higher ion levels in association with smaller femoral head size and bilateral hip arthroplasty but not component position. These different data may be due to different implant designs and the ion measurement methods used. Ebramzadeh et al.¹⁷ reported on 308 retrieved hip resurfacing implants. Metal wear was low in patients with metal allergy but was actually higher in those with no metal allergy.

Adverse local-tissue reaction and osteolysis were reported by several groups at the 2011 Annual Meeting of the AAOS. Barnett et al.¹⁸ reported high rates of cup revision (2.8%) and overall reoperation (5.2%) in a series of 1797 total hip arthroplasties performed with a metal-on-metal bearing. The mean duration of follow-up was thirty-one months. Eleven revisions were attributed to adverse tissue reaction to metal debris. Barrett et al.¹⁹ reported only a 0.56% prevalence of adverse soft-tissue reaction in a study of 1055 total hip arthroplasties performed with use of a modular cup with a metal-on-metal articulation. Langton et al.²⁰ studied 4226 patients who had undergone hip resurfacing with three different devices. Fifty-eight revisions were performed because of adverse soft-tissue reaction. This mechanism of failure was 9.8% for one of the three devices and 1% to 1.5% for the other two. Huber et al.²¹ analyzed the tissues from nine hips with a metal-on-metal articulation in a postmortem retrieval study. The implants were well functioning at the time of death. The average wear measurement was <4 μm/yr. Histological analysis demonstrated evidence of metallosis in all hips and demonstrated local lymphocytic infiltration in eight hips. Energy-dispersive x-ray analysis demonstrated the presence of cobalt and chromium in all hips. Traces of corrosion product were found in three hips. In three of six hips, osteolysis was not detected on radiographs. These data demonstrated that similar findings in response to a metal-on-metal articulation were present in hips with well-functioning total hip replacements as in those with failed total hip replacements.

Groin pain is not infrequent following any hip arthroplasty. Bartelt et al.²² specifically evaluated the prevalence of groin pain reported by patients with different bearing couplings following total hip arthroplasty. Groin pain occurred after 7% of the conventional metal-on-polyethylene total hip arthroplasties, 15% of the metal-on-metal total hip arthroplasties, and 18% of the hip resurfacing procedures. The authors were unable to identify any specific reasons. However, they postulated that impingement, activity level, and higher expectations were the explanations. Femoral neck narrowing is observed in >10% of patients with hip resurfacing. Grammatopoulos et al.²³ found femoral neck narrowing to be associated with increased wear in 214 patients after a mean duration of follow-up of 4.3 years. The authors recommended additional workup and close monitoring for patients with progressive femoral neck narrowing after two years or with narrowing >10% of the femoral neck diameter.

Clinical Outcome of Total Hip Arthroplasty

Epidemiology

Bozic²⁴ presented the most current data on total hip arthroplasty implant utilization in the United States. Of the 444,600 hip arthroplasties that were performed in 2009, 60% were primary total hip arthroplasties, 13% were revision total hip arthroplasties, 24% were hemiarthroplasties, and 4% were hip resurfacings. The total implant sales were $2.54 billion, representing a 4.7% increase from 2008. Eighty-six percent of the primary total hip arthroplasties were done with use of cementless fixation, 10% were done with use of hybrid fixation, <1% were done with reverse hybrid or cement fixation, and 3% were done with use of resurfacing implants. With respect to the bearing surfaces, 49% were metal on highly cross-linked polyethylene, 21% were metal on metal, 19% were ceramic on highly cross-linked polyethylene, 4% were ceramic on ceramic, and 4% were either metal or ceramic on conventional polyethylene. The femoral head size was >36 mm in 23% of the procedures, 36 mm in 35%, 32 mm in 22%, and <32 mm in 20%. When compared with the utilization data from 2000, there was a twofold increase in cementless femoral stems (81% compared with 40%).

Numerous policy initiatives focusing on quality improvement have been instituted. Bozic et al.²⁵ analyzed data on 182,146 consecutive patients who underwent primary total hip arthroplasty (33%) and total knee arthroplasty (67%) under the care of 3421 surgeons in 312 hospitals over a two-year period. Fifty-nine percent of the operations were funded by Medicare. Eighty-nine percent were performed in urban communities. Antibiotic prophylaxis was not utilized in 5% of procedures, whereas it was continued beyond twenty-four hours in 27%. Prophylaxis against venous thromboembolism was not started in the first forty-eight hours in 14% of the patients. Full compliance with all of the process measures was reported in only 58% of the cases. The mean length of stay was 3.9 days. Forty-seven percent of the patients were discharged to an inpatient facility. The thirty-day mortality rate was 0.1%, and the readmission rate was 4%. The rates of surgical complications and reoperations were both 3%. After adjustment for multivariate analysis, higher surgeon volume was associated with better outcomes and a lower rate of complications. This was also true for higher hospital volume. The most important finding was that maximizing adherence to evidence-based processes or care resulted in improved clinical outcomes and shorter length of hospital stay, an effect that was independent of hospital or surgeon volume.

Lu et al.²⁶ specifically analyzed whether a physician-owned specialty hospital was a driver for increases in total joint arthroplasty volume in the Medicare population. They identified twenty-four locations that experienced the entry of a new physician-owned specialty hospital from 1991 to 2005. Two different control markets were matched to the first group: (1) a new arthroplasty program in a general hospital, and (2) markets without a new arthroplasty program. All three groups demonstrated growth, and the difference was not significant (p > 0.05). The overall utilization rate was higher both before and after the introduction of a physician-owned specialty hospital in those markets, in comparison with the baseline and growth utilization rates in the other two market groups. Multiple factors are involved in the increased utilization of total joint arthroplasty. The data from this study suggested that physician ownership of hospital programs is not a factor.

Revision Surgery

There have been numerous data on the epidemiology and outcome of revision total joint arthroplasty. Ong et al.²⁷ analyzed the 5% Medicare claims database from 1997 to 2006. Thirty-five thousand seven hundred and forty-six patients underwent primary total hip arthroplasty. Of these, 1205 underwent an initial revision. The five-year survival rate was 95.9% for primary total hip arthroplasty and 81.0% for revision total hip arthroplasty. Patients undergoing revision total hip arthroplasty were fivefold more likely to require further revision in comparison with patients undergoing an index primary total hip arthroplasty (risk ratio [RR] = 4.89, p < 0.001). Younger age and higher Charlson index score were identified as significant predictors for the failure of primary total hip arthroplasty but not revision total hip arthroplasty. Jafari et al.²⁸ reported a failure rate of 18.7% among 1366 revision total hip arthroplasties. Infection was the most common failure mechanism, accounting for nearly one-third (30.2%) of the revisions.

Complex revision arthroplasties remain challenging. Babis et al.²⁹ reported the mean twelve-year follow-up results of seventy-two revisions performed with use of an allograft-prosthetic composite (APC). Repeat revision was necessary in nineteen hips after a mean duration of follow-up of 3.7 years, with one-fourth of the revisions being performed because of infection. The survival rate was only 69% at ten years. Predictors of failure included Paprosky type-IV bone deficiency (p = 0.02), more than two prior revisions (p = 0.05), and the length of the allograft (p = 0.005). Distal stem fixation is the most commonly utilized surgical technique in femoral revisions. Weiss et al.³⁰ presented data on ninety revisions that had been performed with use of a modular tapered stem design; the minimum duration of follow-up was five years (mean, six years). Eighty percent of the femora were classified as having Paprosky type-3A or greater bone deficiency. The mean Harris hip score was 72. The five-year survival rate for the femoral stem was 98%. The most common complication was dislocation (19%). The average femoral stem subsidence was 2.7 mm, with 15% of the stems demonstrating subsidence of >5 mm. Lakstein et al.³¹ reported six femoral stem fractures among 165 patients who received a modular design. All fractures occurred at the body-stem taper junction. All stems that fractured had insufficient medial bone support. Evidence of wear and fatigue was found in all of the taper junctions between the upper and lower parts of the stem. Risk factors included excessive body weight, implant undersizing, and insufficient medial bone support.

Outcome in Patients with Associated Conditions

Many patients who are managed with total hip arthroplasty have associated spinal disease or back symptoms. Parvizi et al.³² administered a detailed questionnaire to 344 patients before and at standard intervals after hip arthroplasty. Back pain was reported by 49.4% of the patients before total hip arthroplasty. The back pain resolved in 66.4% of these patients after surgery. Of the 34% of patients who did not have resolution of back pain, 10.5% had no detectable spinal abnormality. Patients with residual back pain had lower Harris hip scores (p = 0.01) and lower Short Form-36 (SF-36) physical (p = 0.02) and mental (p = 0.01) scores. Of importance, 10% of patients without preoperative back pain had back pain after total hip arthroplasty. Symptoms resolved spontaneously in half of the patients with back pain prior to total hip arthroplasty, and spinal pathology was found in the other half with additional workup. Radiating pain distal to the knee was significantly greater in patients with known spinal abnormality (p = 0.0001). These data are important for the surgeon to use when counseling patients with associated spinal abnormality or symptoms prior to undergoing total hip arthroplasty.

Kim³³ used the Nationwide Inpatient Sample (NIS) to assess the hospital resource utilization in a study of patients with morbid obesity who were managed with total hip arthroplasty and total knee arthroplasty. In 2006, 2.9% of the total hip arthroplasties and 4.2% of the total knee arthroplasties were performed in morbidly obese patients. After adjustment for all of the variables, obese patients required more resource utilization for total hip arthroplasty (9% more resources, $1432 per case) and total knee arthroplasty (7% more resources, $1025 per case). The limitations of this study included (1) the use of an administrative database rather than prospective data collection, (2) the lack of a specific reason to explain the greater resource utilization, and (3) the lack of clinical outcome data.

Higuera et al.³⁴ analyzed predictors of adverse outcome in a study of 502 geriatric patients (age, more than sixty-five years) who underwent 550 total hip arthroplasties and total knee arthroplasties from January 2008 to September 2008 in a large regional health system. Sixty-two percent of the patients were women, and 38% were men. The mean age was 73.5 years. The majority of patients had either spinal (72%) or epidural (12%) anesthesia. The overall complication rate was 64%. The rate of readmission within ninety days was 5.8%, with 62% of the readmissions being due to a complication related to the operation. Of these eighteen patients who required readmission, sixteen (89%) needed another surgical procedure. The ninety-day mortality rate was 1%. Age was not a factor for length of stay, disposition, readmission, or reoperation. However, there was a 40% increased risk of complications for each additional decade of life. Heart failure (RR = 2.93) and coronary artery disease (RR = 4.31) were the only medical comorbidities associated with greater complications. Two surgical variables had an association with complications: (1) bilateral versus unilateral arthroplasty (with bilateral arthroplasty being associated with greater complications), and (2) the type of anesthesia (with epidural anesthesia being associated with greater complications). However, these factors were only relevant to total knee arthroplasty, not total hip arthroplasty. The clinical utility of these data is to counsel the patients and to optimize their risk profile before surgery.

Complications

SooHoo et al.³⁵ reviewed the discharge data for 138,399 patients who were managed with primary total hip arthroplasty in California from 1995 to 2005. They specifically evaluated the complications during the first ninety days. The overall complication rate was 3.81%. The most frequent complication was dislocation (1.39%). The mortality rate was 0.68%, the infection rate was 0.70%, and the venous thromboembolism rate was 0.64%. The complication rate was lower in high-volume hospitals (those rated in the top 20% by case volume). Patient-related factors that were associated with an increased risk of complications included an increased Charlson comorbidity score, diabetes, rheumatoid arthritis, advanced age, male sex, and black race.

Infection

Deep periprosthetic joint infection remains the most complex and costly complication. There is no one specific test that offers great specificity and sensitivity for the diagnosis of infection. False-negative and false-positive culture results have been reported in >10% of joint fluid aspirates. Parvizi et al.³⁶ retrospectively analyzed 323 revision total hip replacements for implant loosening. They found that the C-reactive protein (CRP) was elevated in greater frequency (48% compared with 27%; p = 0.03), and to a higher value (2.1 compared with 1.2 mg/dL; p = 0.01), in patients with confirmed infection as compared with those without infection. There was no difference between the groups in terms of the erythrocyte sedimentation rate (ESR). Berbari et al.³⁷ performed a meta-analysis of the accuracy of serology markers for periprosthetic joint infections. They included thirty publications from an initial cohort of 327 papers. These studies included 3909 revision total hip arthroplasties (51%) and total knee arthroplasties (49%). They found the highest correlation with periprosthetic infection to be interleukin-6 (odds ratio [OR] = 315), followed by CRP (OR = 13), although only a few studies involved interleukin-6. They recommended more rigorous prospective studies to more accurately determine what would be the most efficacious preoperative protocol to detect infection in patients undergoing revision arthroplasty. On the basis of these two recent studies, CRP determination should be included in the workup of all patients who are scheduled for revision arthroplasty, and perhaps additional studies should be performed for those with an abnormal CRP.

A two-stage implant-exchange protocol remains the most efficacious clinical approach for the treatment of periprosthetic infection. Azzam et al.³⁸ reported a success rate of only 44% in association with debridement, irrigation, and retention of implants in a study of 104 patients with infection following total hip and total knee arthroplasties. The mean duration of follow-up was 5.7 years. The predictors of failure included staphylococcal infection, a high American Society of Anesthesiologists (ASA) class, and gross pus in the joint. Oussedik et al.³⁹ reported a 4% reinfection rate in a study of fifty consecutive infections following total hip arthroplasty that were treated by a single surgeon with use of a standardized protocol. The mean duration of follow-up was 6.8 years. Eleven of the infections were treated with single-stage implant exchange. There was no reinfection in the single-stage group. Moreover, patients in the single-stage group reported better Harris hip scores (p = 0.0003) and visual analog scores for satisfaction (p = 0.001) as compared with those in the two-stage group. Single-stage surgery was avoided in patients with resistant organisms, mixed-flora infections, or gram-negative infections. These data further reflect that the treatment protocol must be individualized to optimize infection eradication and functional outcome.

Poorer outcomes have been reported following periprosthetic infections with methicillin-resistant organisms (methicillin-resistant Staphylococcus aureus [MRSA] and methicillin-resistant Staphylococcus epidermidis [MRSE]). Leung et al.⁴⁰ reviewed the outcomes of fifty MRSA or MRSE infections around total hip implants that were treated with a two-stage protocol involving the insertion of articulating antibiotic-impregnated spacers between the first and second stages. The failure rate was 21%. Of the eight patients with recurrent infection, two (25%) were successfully managed with an additional two-stage protocol. The other six patients required resection arthroplasty. Lower WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), Oxford-12, and UCLA (University of California at Los Angeles) activity scores were reported for the twenty-seven patients who had successful index treatment as compared with a comparable population of patients who had an infection with sensitive organisms. Patients with methicillin-resistant infections should be counseled with regard to the complexity and the less predictable success even with use of the “gold-standard” protocols. The economic impact is also greater with MRSA infections. Parvizi et al.⁴¹ reported that the mean cost of treating MRSA infection was $107,264, compared with a mean cost of $68,053 for the treatment of infections with sensitive organisms.

Many different clinical strategies have been proposed to reduce periprosthetic joint infections. Johnson et al.⁴² recommended using chlorhexidine wash at home before total hip arthroplasty in a study of 1134 patients. Only 157 patients (13.8%) complied with the protocol. However, there was no infection in this group. The infection rate was 1.6% in the noncompliant group. Hooper et al.⁴³ reviewed the records of >51,000 patients in the New Zealand Joint Registry with a specific focus on the utilization of a laminar flow room and body-exhaust suits. Thirty-six percent of the procedures were done in laminar flow rooms, and 24% involved the use of body-exhaust suits. The overall infection rate in the first six months was very low (forty-six cases; prevalence, 0.09%). The infection rate was actually higher in cases involving the use of laminar flow rooms or body-exhaust suits. Those patients possibly were at higher risk for infection, which led to the utilization of these clean-air strategies.

Venous Thromboembolism

Venous thromboembolism (VTE) is a serious complication. It is targeted as one of the outcomes that the government and insurance payers use as a performance measure of hospitals as well as surgeons. Pedersen et al.⁴⁴ analyzed data in the Danish total hip arthroplasty registry from 1995 to 2006. Ninety-three percent of the 67,469 patients received pharmacological prophylaxis with use of a low-molecular-weight heparin, and the other 7% received either the synthetic pentasaccharide or combination therapy. The rate of readmission because of VTE was 1.02% at a median of twenty-two days following surgery. The prevalence of symptomatic deep-vein thrombosis (DVT) was 0.7%, and the prevalence of nonfatal pulmonary embolism (PE) was 0.3%. The rate of mortality due to all causes was 1.0%, and the rate of mortality due to VTE was 0.05%. Increased risk was found with previous VTE (RR = 8.09), higher Charlson comorbidity index (RR = 1.45), and cardiovascular disease (RR = 1.40). These data should serve as a foundation on which to compare other epidemiology data in large patient cohorts and to compare the efficacy of newer antithrombotic agents.

Blood Conservation

Blood conservation in patients undergoing total hip arthroplasty has been targeted by organizations focused on performance and outcome measures. Many different options have been demonstrated to reduce allogeneic blood transfusion during and after surgery. Barsoum et al.⁴⁵ conducted a prospective, randomized study on the use of a bipolar sealer during surgery. One hundred and forty patients undergoing primary total hip arthroplasty were randomized either to the use of this particular sealer or to standard Bovie electrocautery during surgery. There was no difference in the mean number of units of blood transfusion between the groups (0.38 compared with 0.44; p = 0.72). Identical proportions of patients in each group (21%) required blood transfusion (p = 0.90). There were no differences between the groups in terms of intraoperative blood loss, hemoglobin level, pain score, pain medication usage, length of hospital stay, or short-term Harris hip score. This technology might be of greater value in special patient populations such as patients undergoing revision surgery, patients with coagulopathy, and Jehovah's Witness patients.

Tranexamic acid is a synthetic fibrinolytic agent that is used to reduce blood loss following total joint arthroplasty. Ralley et al.⁴⁶ reviewed the transfusion needs for 234 patients undergoing total hip arthroplasty and total knee arthroplasty over a three-month period in 2007 and compared the data with those for 259 patients undergoing the same surgical procedures over a three-month period in 2008. The only difference between the groups was the utilization of a single-bolus intravenous dose of 20 mg/kg of tranexamic acid in the second group. There was a reduction of the transfusion rate from 13.5% to 3.6% in the patients managed with total hip arthroplasty and from 13.1% to 2.0% in those managed with total knee arthroplasty. There was no difference in terms of complications. Economic analysis demonstrated an estimated saving of $65,000 (Canadian) in blood conservation in a population of 1000 total joint arthroplasties.

Practice Management

Patient Satisfaction

Most surgeons perceive nearly 100% satisfaction in patients managed with total hip arthroplasty. Anakwe et al.⁴⁷ conducted a prospective study of 907 patients from 2003 to 2008 at a single center with use of patient-reported outcome measures and found that 7% of the patients were dissatisfied one year after surgery. Univariate analysis demonstrated depression on the SF-12 mental score and symptomatic arthritis of another joint to be significant predictors of dissatisfaction. However, only associated symptomatic arthritis was a predictor of dissatisfaction on multivariate analysis. Predictors of satisfaction were pain relief (p < 0.001), increased activity (p < 0.001), and meeting patient expectations (p < 0.001).

Pain Management

Pain management is critical for patient satisfaction and optimization of outcome. A common focus of various proposed clinical protocols is the reduction of opioid consumption. Post et al.⁴⁸ conducted a prospective, randomized trial of 116 patients. One group received patient-controlled analgesia with use of fentanyl for twenty-four hours followed by oral narcotics. The other group received scheduled administration of multimodal analgesia including acetaminophen, celecoxib, and pregabalin. The non-narcotic group demonstrated lower pain scores in the first twenty-four hour period (p < 0.001), less opioid consumption (p = 0.001), less nausea (p = 0.005), less pruritus (p = 0.005), less dizziness (p = 0.003), and less constipation (p = 0.001). However, there was no measurable difference between the two groups in terms of overall patient satisfaction. Busch et al.⁴⁹ prospectively enrolled sixty-four patients undergoing primary total hip arthroplasty. Half were randomized to a periarticular injection protocol including ropivacaine, ketorolac, epinephrine, and morphine. All patients received identical pain-management protocol after surgery: patient-controlled analgesia, oral opioids, and acetaminophen. Patients in the injection group used less patient-controlled analgesia at the six-hour (p = 0.0023) and twenty-four-hour (p = 0.0093) intervals. They also reported lower visual analog scale (VAS) pain scores in the post-anesthesia care unit (p = 0.0019). However, there was no difference between groups in terms of pain scores at rest. There was no difference in terms of wound complications or length of hospital stay. Multimodal medications along with local wound injection appear to be safe and efficacious for reducing the opioid consumption in patients undergoing total joint arthroplasty.

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Topics

hip replacement arthroplasty ; prosthetic joint infection ; hip bearing surface, metal-on-metal

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Michael H. Huo, Guillaume D. Dumont, Justin R. Knight, Michael A. Mont; What's New in Total Hip Arthroplasty. The Journal of Bone & Joint Surgery. 2011 Oct;93(20):1944-1950.

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