The relevance of biomaterials to the prevention and treatment of osteoporosis.

Total hip arthroplasty (THA) is a very satisfactory surgical procedure for end-stage hip disorders.Implant modifications, such as large femoral heads to improve stability, porous metals to enhance fixation and alternative bearings to improve wear, have been introduced over the last decade in order to decrease the rate of early and late failures.There is a changing pattern of THA failure modes.The relationship between failure modes and patient-related factors, and the time and type of revision are important for understanding and preventing short and late failure of implants.The early adoption of innovations in either technique or implant design may lead to an increased risk of early failure. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170068.

Total hip arthroplasty: Survival and modes of failure

Objective To compare the survival of different implant combinations for primary total hip replacement (THR). Design Systematic review and network meta-analysis. Data sources Medline, Embase, The Cochrane Library, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and the EU Clinical Trials Register. Review methods Published randomised controlled trials comparing different implant combinations. Implant combinations were defined by bearing surface materials (metal-on-polyethylene, ceramic-on-polyethylene, ceramic-on-ceramic, or metal-on-metal), head size (large ≥36 mm or small Results 77 studies were included in the systematic review, and 15 studies (3177 hips) in the network meta-analysis for revision. There was no evidence that the risk of revision surgery was reduced by other implant combinations compared with the reference implant combination. Although estimates are imprecise, metal-on-metal, small head, cemented implants (hazard ratio 4.4, 95% credible interval 1.6 to 16.6) and resurfacing (12.1, 2.1 to 120.3) increase the risk of revision at 0-2 years after primary THR compared with the reference implant combination. Similar results were observed for the 2-10 years period. 31 studies (2888 patients) were included in the analysis of Harris hip score. No implant combination had a better score than the reference implant combination. Conclusions Newer implant combinations were not found to be better than the reference implant combination (metal-on-polyethylene (not highly cross linked), small head, cemented) in terms of risk of revision surgery or Harris hip score. Metal-on-metal, small head, cemented implants and resurfacing increased the risk of revision surgery compared with the reference implant combination. The results were consistent with observational evidence and were replicated in sensitivity analysis but were limited by poor reporting across studies. Systematic review registration PROSPERO CRD42015019435.

https://www.bmj.com/content/bmj/359/bmj.j4651.full.pdf

Choice of implant combinations in total hip replacement: systematic review and network meta-analysis

Association between fixation technique and revision risk in total hip arthroplasty patients younger than 55 years of age. Results from the Nordic Arthroplasty Register Association.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/jor.23184

Acrylic bone cement in total joint arthroplasty: A review

The optimal method of fixation for primary total hip replacements (THR), particularly fixation with or without the use of cement is still controversial. In a systematic review and metaanalysis of all randomized controlled trials comparing cemented versus uncemented THRS available in the published literature, we found that there is no significant difference between cemented and uncemented THRs in terms of implant survival as measured by the revision rate. Better short-term clinical outcome, particularly an improved pain score can be obtained with cemented fixation. However, the results are unclear for the long-term clinical and functional outcome between the two groups. No difference was evident in the mortality and the post operative complication rate. On the other hand, the radiographic findings were variable and do not seem to correlate with clinical findings as differences in the surgical technique and prosthesis design might be associated with the incidence of osteolysis. We concluded in our review that cemented THR is similar if not superior to uncemented THR, and provides better short term clinical outcomes. Further research, improved methodology and longer follow up are necessary to better define specific subgroups of patients in whom the relative benefits of cemented and uncemented implant fixation can be clearly demonstrated.

Cemented versus uncemented fixation in total hip replacement: a systematic review and meta-analysis of randomized controlled trials

Introduction. The Royal College of Surgeons in England published guidelines in 2008 outlining the information that should be documented at each surgery. St. James's Hospital uses a standard operation sheet for all surgical procedures and these were examined to assess documentation standards. Objectives. To retrospectively audit the hand written orthopaedic operative notes according to established guidelines. Methods. A total of 63 operation notes over seven months were audited in terms of date and time of surgery, surgeon, procedure, elective or emergency indication, operative diagnosis, incision details, signature, closure details, tourniquet time, postop instructions, complications, prosthesis, and serial numbers. Results. A consultant performed 71.4% of procedures; however, 85.7% of the operative notes were written by the registrar. The date and time of surgery, name of surgeon, procedure name, and signature were documented in all cases. The operative diagnosis and postoperative instructions were frequently not documented in the designated location. Incision details were included in 81.7% and prosthesis details in only 30% while the tourniquet time was not documented in any. Conclusion. Completion and documentation of operative procedures were excellent in some areas; improvement is needed in documenting tourniquet time, prosthesis and incision details, and the location of operative diagnosis and postoperative instructions.

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Audit of Orthopaedic Surgical Documentation.

Concomitant ipsilateral femoral neck and shaft fractures are uncommon, occurring in 1-9% of femoral shaft fractures. While this injury typically occurs in young patients following high-energy trauma, little consensus has been established regarding the optimal fixation approach. A multitude of treatment strategies exist, with limited evidence as to which is more favorable. The aim of this study was to appraise current evidence, comparing management with either one single or separate devices for both fractures. A systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 1992 and 2018 comparing the rate of postoperative nonunion, malunion, delayed union, avascular necrosis, infection or reoperation between at least one method of single device fixation and one method of separate device fixation were included. Six non-randomized cohort studies assessing 173 patients were suitable for inclusion, each comparing single device cephalomedullary nail fixation of both fractures with a combination of devices. All patients presented following high-energy trauma, at a median age of 32 years. While low complication rate and favorable outcomes were found across both groups, no significant difference could be inferred between either treatment strategy. This injury continues to occur in the traditionally described patient group, and results in acceptable postoperative outcomes. A paucity of randomized studies limits the ability to recommend a single or separate device treatment approach, and as such prospective, randomized trials with adequately powered sample sizes are required to definitively compare surgical management strategies in this rare but complex injury.

Single versus separate implant fixation for concomitant ipsilateral femoral neck and shaft fractures: A systematic review.

Introduction Hip fractures are a significant cause of morbidity and mortality in the elderly and are also associated with increased healthcare costs. A second contralateral hip fracture can lead to even more complications and healthcare costs. A significant proportion of the Irish hip fracture population does not receive a bone health assessment or falls specialist assessment to reduce the risk of future falls and fractures. This study aimed to analyze the incidence of a non-simultaneous contralateral hip fracture in an Irish population. Methods We retrospectively analyzed 1,344 patients presenting to our institution with a hip fracture from January 2007 to June 2019. Patients aged ≥ 60 years old presenting with a neck of femur or pertrochanteric fracture were included in our study. We excluded patients who had sub-trochanteric and femoral shaft fractures, high energy fractures, and pathological fractures. We also excluded patients less than 60 years old, as fractures in these younger patients may not be purely related to osteoporosis. Results A total of 1,099 hip fractures meeting the inclusion criteria were treated at our unit during the designated time period. A total of 102 (9.3%) patients experienced a second hip fracture. The mean age at first presentation in our institution was 78.5 years old, with a mean time between first and second hip fractures of 37.2 months. Conclusions Patients presenting with a second hip fracture may represent 9.3% of the Irish hip fracture population. We hope that this study will help inform on the rate of second hip fractures in an Irish population and help advocate for improved resources and implementation of secondary prevention strategies.

Incidence of Non-Simultaneous Contralateral Second Hip Fractures: A Single-Center Irish Study.

Introduction

Hip fractures are increasingly prevalent and can result in substantial morbidity, mortality, and cost. Despite the existence of enhanced management strategies, prolonged hip fracture admissions persist. This study’s objective was to ascertain characteristics associated with a prolonged length of stay (LOS) and quantify return to baseline once discharged.

Methods

A retrospective audit of hip fractures over a four-year period was conducted, identifying patients with a LOS over 100 days. Demographics, comorbidities, pre- and post-admission function, and status were assessed. Patients sustaining inpatient hip fractures were excluded to negate the effect of initial admission on LOS.

Results

Seven hundred and eleven hip fractures were treated, of which 48 (6.8%) were suitable for inclusion. The patients' median age and LOS was 83.5 years and 153 days, respectively. Preoperative American Society of Anesthesiologists - Physical Status (ASA-PS) Grades II and III predominated at 41.7% and 39.6%, respectively. Eighteen of patients had a diagnosis of dementia before admission, increasing to 29 on discharge (P = 0.0026). One patient was in long-term care prior to admission, rising to 30 on discharge (P < 0.0001), with only 25.6% returning to pre-admission residential status (P < 0.0001). Nineteen patients were mobilising unaided prior to admission, decreasing to only two following discharge, with a mere 37.1% returning to their pre-admission mobility baseline (P < 0.0001).

Discussion

Hip fracture patients with multiple comorbidities or a diagnosis of dementia were most likely to have a prolonged LOS which, in turn, impacted upon return to baseline mobility, cognitive status, and independence. Early identification and management of this cohort may help reduce the potential disease burden and economic effects that a prolonged LOS creates.

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Prasad Ellanti

Papers

Cemented versus uncemented fixation in total hip replacement: a systematic review and meta-analysis of randomized controlled trials

Audit of Orthopaedic Surgical Documentation.

Single versus separate implant fixation for concomitant ipsilateral femoral neck and shaft fractures: A systematic review.

Incidence of Non-Simultaneous Contralateral Second Hip Fractures: A Single-Center Irish Study.

Predisposing Factors and Outcomes After Prolonged Admission Following Hip Fracture