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The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: closed (30 June 2021) | Viewed by 38376

Special Issue Editor

Prof. Dr. Boris Michael Holzapfel

E-Mail Website
Guest Editor
Department of Orthopaedics and Traumatology, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
Interests: hip & knee arthroplasty; musculoskeletal oncology; tissue engineering & regenerative medicine
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

The past decades have witnessed tremendous efforts to increase the quality of care of patients suffering from congenital or acquired hip disorders. The modern concept of femoro-acetabular impingement and our steadily growing understanding of the mechanisms that lead to instability of the hip joint have created new therapeutic pathways, the real potential of which we are just beginning to recognize. Hip arthroscopy and joint preservation techniques such as the Bernese periacetabular osteotomy have become the standard of care for patients with prearthritic deformities and nowadays some of these reconstructive techniques can even be performed via minimally-invasive approaches. Recent advances in Tissue Engineering & Regenerative Medicine (TE&RM) have triggered a paradigm shift in therapeutic decision making away from methods to replace damaged articular and periarticular structures with inert implants to more biological solutions that focus on regeneration of tissue defects with smart biomaterials or cell-based platforms. Nevertheless, hip replacement still remains the mainstay of therapy for advanced osteoarthritis. Although total hip arthroplasty is referred to as one of the most successful and effective surgical procedures of our times, it still offers room for improvements. Implantation techniques, “enhanced recovery after surgery” (ERAS) - protocols and implant materials are constantly being developed further, and nowadays, the use soft tissue sparing approaches such as the direct anterior approach is steadily increasing for both primary and revision hip replacement.  

The present Special Issue aims to present an overview about cutting-edge developments in adult hip surgery: From Regeneration and Reconstruction to Replacement and Revision.

Prof. Dr. Boris Michael Holzapfel
Guest Editor

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Keywords

  • Hip Surgery
  • Joint Reconstruction
  • Regenerative Medicine
  • Pelvic Osteotomy
  • Hip Replacement
  • Developmental Dysplasia
  • Direct Anterior Approach (DAA)
  • Revision Arthroplasty
  • Enhanced Recovery after Surgery (ERAS)

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Published Papers (15 papers)

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Research

8 pages, 418 KiB  
Article
Open Hip Abductor Repair Hitting the Sack-Abductor Tendon Repair Significantly Improves Sleep Quality
by Alexander Zimmerer, Luis Navas, Dominic Pfeil and Matthias Hauschild
J. Clin. Med. 2021, 10(21), 5164; https://doi.org/10.3390/jcm10215164 - 4 Nov 2021
Cited by 2 | Viewed by 2006
Abstract
Purpose: To (1) describe the prevalence of abnormal sleep quality in patients with hip abductor tears (HAT), to (2) determine whether sleep quality improves after open HAT repair, and to (3) to report clinical short-term outcomes in patients undergoing open HAT repair. Methods: [...] Read more.
Purpose: To (1) describe the prevalence of abnormal sleep quality in patients with hip abductor tears (HAT), to (2) determine whether sleep quality improves after open HAT repair, and to (3) to report clinical short-term outcomes in patients undergoing open HAT repair. Methods: The data of 28 patients (29 hips) who underwant open HAT repair were prospectively analyzed at midterm follow-up. The Pittsburgh Sleep Quality Index (PSQI), modified Harris Hip Score (mHHS), the University of California, Los Angeles activity scale (UCLA), and Visual Analog Scale (VAS) for pain were determined via questionnaire. Paired t-tests were applied to compare preoperative and post-operative Patient-reported Outcome Measures (PROMs). Logistic regression was performed to determine the association between PSQI improvement achievement and demographic variables (laterality, sex, age, body-mass-index (BMI), and preoperative mHHS). The minimal clinically important difference (MCID) was calculated for the mHHS. Results: A total of 28 patients were included. Four patients (14.3%) suffered post-operative complications after open HAT repair. The predominance of patients was female (77.4%), with a mean age of 60 ± 13 years. The average follow-up was 30.35 ± 16.62 months. Preoperatively, 27 (96.4%) patients experienced poor sleep quality (PSQI > 5); at follow-up, 7 (25%) patients experienced poor sleep quality. Univariate logistical regression analysis demonstrated no significant association between preoperative demographic data and achieving postoperative PSQI < 5. The MCID of mHHS was calculated to be 12.5. Overall, 90% of patients achieved MCID for mHHS. Conclusion: Preoperative sleep quality was impaired in 96.4% of HAT patients (PSQI > 5). However, these patients showed an improvement in sleep disturbances after open HAT repair in the early postoperative period. Ninety percent of patients showed significant improvements in mHHS and achieved the corresponding MCID. Level of Evidence: Case series; Level IV. Full article
(This article belongs to the Special Issue The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision)
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10 pages, 893 KiB  
Article
Sports Activity and Patient-Related Outcomes after Cementless Total Hip Arthroplasty in Patients Younger than 40 Years
by Luis Navas, Jasmin Faller, Sebastian Schmidt, Marcus Streit, Matthias Hauschild and Alexander Zimmerer
J. Clin. Med. 2021, 10(20), 4644; https://doi.org/10.3390/jcm10204644 - 10 Oct 2021
Cited by 5 | Viewed by 2363
Abstract
Background: The management of degenerative hip diseases in young patients remains a challenge. Despite the improvement of hip-preserving procedures, total hip arthroplasty (THA) may be required in some instances. In addition, young patients undergoing THA have high expectations concerning their postoperative level of [...] Read more.
Background: The management of degenerative hip diseases in young patients remains a challenge. Despite the improvement of hip-preserving procedures, total hip arthroplasty (THA) may be required in some instances. In addition, young patients undergoing THA have high expectations concerning their postoperative level of activity. Purpose: (1) to define the sports activity level and the return to sports after THA, (2) to describe the modification or initiation of new sports disciplines, and (3) to report the clinically meaningful outcomes after THA in patients younger than 40 years. Methods: A total of 36 patients (40 hips) were prospectively analyzed at a midterm follow-up of 3.9 years. The modified Harris Hip Score (mHHS); the Visual Analog Scale (VAS) for pain; the University of California, Los Angeles (UCLA) activity scale; and sports and recreational activity levels were assessed via questionnaire. The minimal clinically important difference (MCID) was determined by calculating half of the standard deviation, and the substantial clinical benefit (SCB) as well as patient acceptable symptomatic state (PASS), were calculated by the anchor method for the mHHS. Results: At the final follow-up, there was a significant improvement in mHHS (34.1 to 92.6; p < 0.0001), UCLA (3.2 to 7.6; p < 0.0001), and VAS for pain (8 to 1; p < 0.0001). More patients were active in sports at follow-up than before surgery (44% to 92%, p < 0.0001). In addition, the duration and frequency of sports activities showed a significant increase (p < 0.0001). The MCID, SCB and PASS for mHHS were 89% and 58%, respectively. No revision surgery had to be performed. Conclusion: This study showed that a large proportion of patients under 40 years of age who underwent THA increased their physical activity. Eighty-six percent of the patients were highly active, with a UCLA score ≥ 7. Furthermore, the reported MCID, SCB, and PASS for mHHS were achieved by more than 80% of patients. Full article
(This article belongs to the Special Issue The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision)
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14 pages, 10933 KiB  
Article
The Expression Levels of Toll-like Receptors after Metallic Particle and Ion Exposition in the Synovium of a Murine Model
by Xiangyun Cheng, Volkmar Jansson, Jan Philippe Kretzer, Rainer Bader, Sandra Utzschneider and Alexander C. Paulus
J. Clin. Med. 2021, 10(16), 3489; https://doi.org/10.3390/jcm10163489 - 7 Aug 2021
Cited by 1 | Viewed by 1946
Abstract
To date, the exact role of specific Toll-like receptors (TLRs) in regulating immune reactivity to metallic byproducts of orthopedic implants has not been fully clarified. In light of the situation, our objective in this investigation was to assess the expression levels of surface [...] Read more.
To date, the exact role of specific Toll-like receptors (TLRs) in regulating immune reactivity to metallic byproducts of orthopedic implants has not been fully clarified. In light of the situation, our objective in this investigation was to assess the expression levels of surface TLRs after metallic particle and ion exposure in an established animal model. Ten female BALB/c mice in each group received intra-articular injections of phosphate buffer (PBS) (control), metallic particles (MP), and metallic ions (MI), respectively. Seven days later, immunohistochemical staining was undertaken in the synovial layer of the murine knee joints using anti-TLR 1, 2, 4, 5, and 6 polyclonal antibodies. In addition to increased cellular infiltrates and a hyperplastic synovial membrane, the MP group showed significantly elevated TLR expression compared to the control group and had higher TLR 1-, 4-, and 6-positive cells than the MI group (p < 0.0167). TLR 4- and TLR 6-positive cells were significantly augmented for the MI group compared to the control group (p < 0.0167). Additionally, greenish corrosion particles found in the necrotic tissue suggested that metallic particles might release a certain level of locally toxic metallic ions in vivo. Full article
(This article belongs to the Special Issue The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision)
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Graphical abstract

10 pages, 957 KiB  
Article
Superior Functional Outcome and Comparable Health-Related Quality of Life after Enhanced Recovery vs. Conventional THA: A Retrospective Matched Pair Analysis
by Franziska Leiss, Melanie Schindler, Julia Sabrina Götz, Günther Maderbacher, Matthias Meyer, Jan Reinhard, Florian Zeman, Joachim Grifka and Felix Greimel
J. Clin. Med. 2021, 10(14), 3096; https://doi.org/10.3390/jcm10143096 - 14 Jul 2021
Cited by 10 | Viewed by 2094
Abstract
Background: The concept of enhanced recovery after total hip arthroplasty is gaining worldwide interest, as it shortens the length of hospital stay without an increase of complications. The aim of the study was to investigate the functional outcome and health-related quality of life [...] Read more.
Background: The concept of enhanced recovery after total hip arthroplasty is gaining worldwide interest, as it shortens the length of hospital stay without an increase of complications. The aim of the study was to investigate the functional outcome and health-related quality of life 12 months after cementless total hip arthroplasty with the use of an enhanced recovery concept in comparison to a conventional rehabilitation. Material and Methods: 320 patients were retrospectively analyzed who underwent primary cementless total hip arthroplasty (THA). A total of 123 of the patients received an enhanced recovery program (ERAS) and 197 patients a conventional rehabilitation (Non-ERAS). Twelve months postoperatively, a clinical examination was performed regarding satisfaction, function and pain. Results were evaluated using WOMAC, EQ-5D-5L and EQ-VAS. A 1:1 matching was performed to correct for confounding variables, regarding age, sex and ASA score. Finally, 122 patients (n = 61, in each group) were analyzed and compared. Results: Patients showed a significant improvement of WOMAC total score, subscale pain, subscale stiffness and subscale function from preoperative to the follow up after 12 months in both groups, with significantly superior results for the WOMAC total score for the ERAS group (p = 0.042). EQ-5D and EQ-5D VAS showed a significant improvement from preoperative to 12 months postoperative (p < 0.001) for both groups, while no difference regarding the group-comparison was shown. Conclusion: Health-related quality of life and functional outcome increased to excellent values after total hip arthroplasty with the use of an enhanced recovery concept and a conventional rehabilitation, with a superior WOMAC total score for ERAS and a tendency to better results for health-related quality of life for patients with ERAS within the follow up after 12 months. Full article
(This article belongs to the Special Issue The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision)
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10 pages, 1027 KiB  
Article
Influence of Anxiety/Depression, Age, Gender and ASA on 1-Year Follow-Up Outcomes Following Total Hip and Knee Arthroplasty in 5447 Patients
by Julia Sabrina Götz, Achim Benditz, Jan Reinhard, Melanie Schindler, Florian Zeman, Joachim Grifka, Felix Greimel and Franziska Leiss
J. Clin. Med. 2021, 10(14), 3095; https://doi.org/10.3390/jcm10143095 - 13 Jul 2021
Cited by 18 | Viewed by 2151
Abstract
Introduction: There are many factors influencing the outcome after total joint arthroplasty (TJA). In particular, patient-related factors such as age, gender, ASA (American Society of Anesthesiologists), or preoperative anxiety/depression have become increasingly important. The aim of this study was to examine the association [...] Read more.
Introduction: There are many factors influencing the outcome after total joint arthroplasty (TJA). In particular, patient-related factors such as age, gender, ASA (American Society of Anesthesiologists), or preoperative anxiety/depression have become increasingly important. The aim of this study was to examine the association of these parameters with 1-year postoperative outcomes after total knee and total hip arthroplasty (TKA, THA). Methods: A retrospective cohort of 5447 TJA patients was evaluated by pre- and postoperative analysis of EQ-5D, EQ-VAS and WOMAC Score. Furthermore, major focus was put on the association between age, gender, ASA, preoperative anxiety/depression and outcome parameters. Results: 53.3% (2903/5447) of all patients were identified with anxiety/depression at time of surgery. In the analysis, patients without anxiety/depression showed statistically significantly (p < 0.05) better EQ-5D, EQ-VAS and WOMAC scores. In addition, patients with ASA 2 or 3 and age over 70 years showed statistically significantly (p < 0.01) worse EQ-5D and WOMAC scores. Gender did not influence the postoperative EQ-5D and WOMAC results, but men had significantly better EQ-VAS scores than women in this study. Conclusion: Preoperative anxiety/depression symptoms show worse clinical outcomes 1 year postoperatively after TJA. Other outcome-influencing factors are higher age and ASA 2 or 3. In the future, such patients should be identified, and as far as applicable, a treatment of anxiety/depression or comorbidities should be implemented preoperatively of the surgical procedure to improve clinical outcomes. Full article
(This article belongs to the Special Issue The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision)
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7 pages, 4838 KiB  
Article
Developmental Hip Dysplasia Treated with Cementless Total Hip Arthroplasty Using a Straight Stem and a Threaded Cup—A Concise Follow-Up, At a Mean of Twenty-Three Years
by Viktor Janz, Christian Hipfl, Felix Düppers, Carsten F. Perka and Georgi I. Wassilew
J. Clin. Med. 2021, 10(9), 1912; https://doi.org/10.3390/jcm10091912 - 28 Apr 2021
Cited by 9 | Viewed by 1823
Abstract
We previously reported the 9-year follow-up results of 121 cementless total hip arthroplasties (THAs) from 1990 to 1994 in 93 patients with developmental dysplasia of the hip (DDH). The present study reports the updated long-term results after a mean follow-up of 23 years. [...] Read more.
We previously reported the 9-year follow-up results of 121 cementless total hip arthroplasties (THAs) from 1990 to 1994 in 93 patients with developmental dysplasia of the hip (DDH). The present study reports the updated long-term results after a mean follow-up of 23 years. Fifty-seven patients (72 hips) were alive and available for follow-up. Since our previous report, nine THAs had been revised. The cumulative implant survivorship of any component was 87% (95% CI, 78–92%). The cumulative probability of not having aseptic cup loosening was 87% (95% CI, 77–93%) and there was no revision surgery for aseptic stem loosening. In three hips (5%), an exchange of the ball and liner due to polyethylene wear was performed after a mean of 12 years. This study demonstrates that cementless THA for DDH with restoration of the hip joint center provides excellent long-term durability. Full article
(This article belongs to the Special Issue The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision)
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9 pages, 1080 KiB  
Article
Midterm Survivorship of an Uncemented Hydroxyapatite-Coated Titanium Femoral Component and Clinically Meaningful Outcomes in Patients Older Than 75 Years
by Alexander Zimmerer, Luis Navas, Stefan Kinkel, Stefan Weiss, Matthias Hauschild and Marcus Streit
J. Clin. Med. 2021, 10(5), 1019; https://doi.org/10.3390/jcm10051019 - 2 Mar 2021
Cited by 6 | Viewed by 1936
Abstract
Purpose: It remains controversial whether cementless femoral components are safe in elderly patients. The aim of this study was (1) to determine the stem survival rate in patients >75 years of age who were treated with an uncemented femoral component and (2) to [...] Read more.
Purpose: It remains controversial whether cementless femoral components are safe in elderly patients. The aim of this study was (1) to determine the stem survival rate in patients >75 years of age who were treated with an uncemented femoral component and (2) to report clinically significant results on a mid-term follow-up. Methods: 107 total hip arthroplasties (THA) were retrospectively evaluated in 97 patients over 75 years of age (mean age 78 years, range 75–87) treated with an uncemented femoral stem. The minimum follow-up was five years (mean 6.4 years, range 5–8). Stem survival rates, clinically meaningful outcomes, and incidence of complications were evaluated. Results: Kaplan-Meier survival analysis, with the endpoint revision for any reason, showed a 6.4-year survival rate of 98% (95% CI, 95–99%; 63 hips at risk). The survival rates were comparable for male and female patients (log-rank test, p = 0.58). The modified Harris Hip Score (mHHS) improved from 42.2 (12 to 85) points to 81.1 (22 to 97) points (p < 0.0001). Mid-term minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) were 25, 84, and 70, respectively. Conclusion: An uncemented stem is a viable option in patients over 75 years with good clinical outcomes and survivorship. Periprosthetic fractures were not a relevant failure mechanism with the stem used. Full article
(This article belongs to the Special Issue The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision)
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11 pages, 613 KiB  
Article
Excellent Functional Outcome and Quality of Life after Primary Cementless Total Hip Arthroplasty (THA) Using an Enhanced Recovery Setup
by Franziska Leiss, Julia Sabrina Götz, Günther Maderbacher, Matthias Meyer, Jan Reinhard, Florian Zeman, Joachim Grifka and Felix Greimel
J. Clin. Med. 2021, 10(4), 621; https://doi.org/10.3390/jcm10040621 - 6 Feb 2021
Cited by 20 | Viewed by 2996
Abstract
Background: Total hip arthroplasty combined with the concept of enhanced recovery is of continued worldwide interest, as it is reported to improve early functional outcome and treatment quality without increasing complications. The aim of the study was to investigate functional outcome and quality [...] Read more.
Background: Total hip arthroplasty combined with the concept of enhanced recovery is of continued worldwide interest, as it is reported to improve early functional outcome and treatment quality without increasing complications. The aim of the study was to investigate functional outcome and quality of life 4 weeks and 12 months after cementless total hip arthroplasty in combination with an enhanced recovery concept. Methods: A total of 109 patients underwent primary cementless Total Hip Arthroplasty (THA) in an enhanced recovery concept and were retrospectively analyzed. After 4 weeks and 12 months, clinical examination was analyzed regarding function, pain and satisfaction; results were evaluated using Harris Hip score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EQ-5D-5L, EQ-VAS and subjective patient-related outcome measures (PROMs). Preoperatively, HADS (Hospital Anxiety and Depression Scale) was collected. A correlation analysis of age, American Society of Anesthesiologists (ASA), HADS and comorbidities (diabetes mellitus, art. hypertension, cardiovascular disease) with WOMAC, Harris Hip score (HHS) and EQ-5D was performed. Results: Patients showed a significant improvement in Harris Hip score 4 weeks and 12 months postoperatively (p < 0.001). WOMAC total score, subscale pain, subscale stiffness and subscale function improved significantly from preoperative to 12 months postoperative (p < 0.001). EQ-5D showed a significant improvement preoperative to postoperative (p < 0.001). The influence of anxiety or depression (HADS-A or HADS-D) on functional outcome could not be determined. There was a high patient satisfaction postoperatively, and almost 100% of patients would choose enhanced recovery surgery again. Conclusion: Cementless THA with the concept of enhanced recovery improves early clinical function and quality of life. PROMs showed a continuous improvement over a follow-up of 12 months after surgery. PROMs can help patients and surgeons to modify expectations and improve patient satisfaction. Full article
(This article belongs to the Special Issue The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision)
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9 pages, 2006 KiB  
Article
A New Rectus and Sartorius Sparing Approach for Periacetabular Osteotomy in Patients with Developmental Dysplasia of the Hip
by Jannis Löchel, Viktor Janz, Carsten Perka, Andre Hofer, Alexander Zimmerer and Georgi I. Wassilew
J. Clin. Med. 2021, 10(4), 601; https://doi.org/10.3390/jcm10040601 - 5 Feb 2021
Cited by 8 | Viewed by 2760
Abstract
Background: periacetabular osteotomy (PAO) is known as the gold standard surgical treatment in young adults with symptomatic hip dysplasia. With the aim of reducing soft tissue trauma, we developed a new rectus and sartorius sparing (RASS) approach. We hypothesized that this new PAO [...] Read more.
Background: periacetabular osteotomy (PAO) is known as the gold standard surgical treatment in young adults with symptomatic hip dysplasia. With the aim of reducing soft tissue trauma, we developed a new rectus and sartorius sparing (RASS) approach. We hypothesized that this new PAO technique was equal regarding acetabular reorientation, complication rate, and short-term clinical outcome parameters, compared to our conventional, rectus sparing (RS) approach. Patients and Methods: we retrospectively assessed all PAO procedures performed by a single surgeon between 2016 and 2019 (n = 239 hips in 217 patients). The cases in which the new RASS technique were used (n = 48) were compared to the RS cases for acetabular orientation parameters, surgical time, perioperative reduction of hemoglobin level, and length of hospital stay (LOHS). Inclusion criteria were a lateral center-edge angle (LCEA) <25° and osteoarthritis Tönnis grade ≤1. Patients with acetabular retroversion or additional femoral osteotomy were excluded. Results: the mean patient age at the time of surgery was 29 years (14 to 50, SD ± 8.5). Females accounted for 79.5% in this series. The mean preoperative LCEA were 16° (7 to 24°, SD ± 4.4) and 15° (0 to 23°, SD ± 6) in the RASS and the RS group, respectively (p = 0.96). The mean preoperative acetabular index (AI) angles were 14° (2 to 25°, SD ± 4) and 14° (7 to 29°, SD ± 4.3), respectively (p = 0.67). The mean postoperative LCEA were significantly improved to 31° (25 to 37°, SD ± 3.5, p < 0.001) and 30.2° (20 to 38°, SD ± 4, p < 0.001), respectively. The mean postoperative AI angles improved to 2.8° (−3 to 13°, SD ± 3.3, p < 0.001) and 3° (−2 to 15°, SD ± 3.3, p < 0.001), respectively. There were no significant differences between the RASS and the RS group for surgical time, perioperative reduction in hemoglobin level, and LOHS. No blood transfusions were necessary perioperatively in either group. No major perioperative complication occurred in either group. We observed one surgical site infection (SSI) requiring superficial debridement in the RS group. Conclusion: the RASS approach for PAO showed to be a safe procedure with equivalent acetabular reorientation and equivalent clinical outcome parameters compared to the RS approach. Additionally, patients have fewer postoperative restrictions in mobilization with the RASS approach. Full article
(This article belongs to the Special Issue The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision)
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7 pages, 285 KiB  
Article
Transversus abdominis Plane Block for Improved Early Postoperative Pain Management after Periacetabular Osteotomy: A Randomized Clinical Trial
by Jannis Löchel, Viktor Janz, Vincent Justus Leopold, Michael Krämer and Georgi I. Wassilew
J. Clin. Med. 2021, 10(3), 394; https://doi.org/10.3390/jcm10030394 - 21 Jan 2021
Cited by 11 | Viewed by 2336
Abstract
Background: Patients undergoing periacetabular osteotomy (PAO) may experience significant postoperative pain due to the extensive approach and multiple osteotomies. The aim of this study was to assess the efficacy of the transversus abdominis plane (TAP) block on reducing opioid consumption and improving [...] Read more.
Background: Patients undergoing periacetabular osteotomy (PAO) may experience significant postoperative pain due to the extensive approach and multiple osteotomies. The aim of this study was to assess the efficacy of the transversus abdominis plane (TAP) block on reducing opioid consumption and improving clinical outcome in PAO patients. Patients and Methods: We conducted a two-group randomized-controlled trial in 42 consecutive patients undergoing a PAO for symptomatic developmental dysplasia of the hip (DDH). The study group received an ultrasound-guided TAP block with 20 mL of 0.75% ropivacaine prior to surgery. The control group did not receive a TAP block. All patients received a multimodal analgesia with nonsteroidal anti-inflammatory drugs (NSAID) (etoricoxib and metamizole) and an intravenous patient-controlled analgesia (PCA) with piritramide (1.5 mg bolus, 10 min lockout-time). The primary endpoint was opioid consumption within 48 h after surgery. Secondary endpoints were pain scores, assessment of postoperative nausea and vomiting (PONV), measurement of the quality of recovery using patient-reported outcome measure and length of hospital stay. Forty-one patients (n = 21 TAP block group, n = 20 control group) completed the study, per protocol. One patient was lost to follow-up. Thirty-three were women (88.5%) and eight men (19.5%). The mean age at the time of surgery was 28 years (18–43, SD ± 7.4). All TAP blocks were performed by an experienced senior anaesthesiologist and all operations were performed by a single, high volume surgeon. Results: The opioid consumption in the TAP block group was significantly lower compared to the control group at 6 (3 mg ± 2.8 vs. 10.8 mg ± 5.6, p < 0.0001), 24 (18.4 ± 16.2 vs. 30.8 ± 16.4, p = 0.01) and 48 h (29.1 mg ± 30.7 vs. 54.7 ± 29.6, p = 0.04) after surgery. Pain scores were significantly reduced in the TAP block group at 24 h after surgery. There were no other differences in secondary outcome parameters. No perioperative complication occurred in either group. Conclusion: Ultrasound-guided TAP block significantly reduces the perioperative opioid consumption in patients undergoing PAO. Full article
(This article belongs to the Special Issue The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision)
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9 pages, 9797 KiB  
Article
Femoral Revision Total Hip Arthroplasty Performed through the Interval of the Direct Anterior Approach
by Martin Thaler, Dietmar Dammerer, Michael Ban, Hermann Leitner, Ismail Khosravi and Michael Nogler
J. Clin. Med. 2021, 10(2), 337; https://doi.org/10.3390/jcm10020337 - 18 Jan 2021
Cited by 8 | Viewed by 2944
Abstract
Background: we report the clinical outcomes for femoral revision total hip replacement (THR) using the Direct Anterior Approach (DAA) interval. Methods: 149 patients (165 hips) with a mean age of 68.9 years (range, 33.2–91.0 years) and a mean follow-up of 4.2 years (1.1–8.9 [...] Read more.
Background: we report the clinical outcomes for femoral revision total hip replacement (THR) using the Direct Anterior Approach (DAA) interval. Methods: 149 patients (165 hips) with a mean age of 68.9 years (range, 33.2–91.0 years) and a mean follow-up of 4.2 years (1.1–8.9 years) were included. The indication for revision surgery was aseptic stem loosening in 131 (79.4%) hips, periprosthetic fracture in 29 (17.6%) hips, revision for stem malalignment in one (0.6%) hip, and prosthetic failure in four (2.4%) hips. Results: an endofemoral approach was used for 156 hips, and a Wagner transfemoral osteotomy was used for nine hips. An additional cup revision was done in 52 hips (uncemented cup: n = 29; cemented cup: n = 21; acetabular cage: n = 2). The overall complication rate was 14.5% (24 complications). Ten patients (10 hips) were revised (8 cups, 2 liners, 2 stems) with an average time to revision of 6 months (range, 3–23 months). The median preoperative Western Ontario McMasters Osteoarthritis Score (WOMAC) score was 52.5 (Inter Quartile Range (IQR): 33.3), which improved to 27.2 (IQR: 30) postoperatively (p < 0.01). Conclusion: use of the DAA achieved similar results when compared with other surgical approaches in terms of clinical outcomes and complications, including dislocation rate. These results suggest that femoral revision using the DAA interval can be a safe and reliable procedure. Full article
(This article belongs to the Special Issue The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision)
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9 pages, 2115 KiB  
Article
Inferior Outcome after Unstable Trochanteric Fracture Patterns Compared to Stable Fractures in the Elderly
by Johannes Gleich, Carl Neuerburg, Christoph Linhart, Alexander Martin Keppler, Daniel Pfeufer, Christian Kammerlander, Wolfgang Böcker and Christian Ehrnthaller
J. Clin. Med. 2021, 10(2), 171; https://doi.org/10.3390/jcm10020171 - 6 Jan 2021
Cited by 6 | Viewed by 2743
Abstract
Background: Various risk factors affecting outcome of elderly patients after proximal femur fracture have been identified. The present study aims to evaluate the impact of the fracture pattern in trochanteric fractures on postoperative mobility and complications. Methods: Ninety-two patients with a mean age [...] Read more.
Background: Various risk factors affecting outcome of elderly patients after proximal femur fracture have been identified. The present study aims to evaluate the impact of the fracture pattern in trochanteric fractures on postoperative mobility and complications. Methods: Ninety-two patients with a mean age of 84 years were included. According to the revised AO/OTA classification, fractures were divided into stable (AO 31A1) and unstable (AO 31A2/3) patterns. A follow-up examination was performed 12 months after cephalomedullary fixation to assess outcome parameters for mobility/activities of daily living (Parker Mobility Score (PMS)/Barthel Index (BI)) and complications (increase in requirement of care, hospital readmission, mortality rate). Results: At follow-up, patients with unstable trochanteric fracture patterns presented with lower PMS and BI compared to stable fractures (p < 0.05). Further, higher requirement of care and higher readmission rates compared to stable patterns were observed. Conclusion: Unstable trochanteric fractures presented inferior outcome compared to simple fracture patterns. This might be explained by the increasing surgical trauma in unstable fractures as well as by the mechanical impact of the lesser trochanter, which provides medial femoral support and is of functional relevance. Subsequent studies should assess if treatment strategies adapted to the specific fracture pattern (refixation of lesser trochanter) influence outcome in unstable trochanteric fractures. Full article
(This article belongs to the Special Issue The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision)
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16 pages, 3196 KiB  
Article
Impact of Tranexamic Acid on Chondrocytes and Osteogenically Differentiated Human Mesenchymal Stromal Cells (hMSCs) In Vitro
by Mike Wagenbrenner, Tizian Heinz, Konstantin Horas, Axel Jakuscheit, Joerg Arnholdt, Susanne Mayer-Wagner, Maximilian Rudert, Boris M. Holzapfel and Manuel Weißenberger
J. Clin. Med. 2020, 9(12), 3880; https://doi.org/10.3390/jcm9123880 - 29 Nov 2020
Cited by 5 | Viewed by 2200
Abstract
The topical application of tranexamic acid (TXA) helps to prevent post-operative blood loss in total joint replacements. Despite these findings, the effects on articular and periarticular tissues remain unclear. Therefore, this in vitro study examined the effects of varying exposure times and concentrations [...] Read more.
The topical application of tranexamic acid (TXA) helps to prevent post-operative blood loss in total joint replacements. Despite these findings, the effects on articular and periarticular tissues remain unclear. Therefore, this in vitro study examined the effects of varying exposure times and concentrations of TXA on proliferation rates, gene expression and differentiation capacity of chondrocytes and human mesenchymal stromal cells (hMSCs), which underwent osteogenic differentiation. Chondrocytes and hMSCs were isolated and multiplied in monolayer cell cultures. Osteogenic differentiation of hMSCs was induced for 21 days using a differentiation medium containing specific growth factors. Cell proliferation was analyzed using ATP assays. Effects of TXA on cell morphology were examined via light microscopy and histological staining, while expression levels of tissue-specific genes were measured using semiquantitative RT-PCR. After treatment with 50 mg/mL of TXA, a decrease in cell proliferation rates was observed. Furthermore, treatment with concentrations of 20 mg/mL of TXA for at least 48 h led to a visible detachment of chondrocytes. TXA treatment with 50 mg/mL for at least 24 h led to a decrease in the expression of specific marker genes in chondrocytes and osteogenically differentiated hMSCs. No significant effects were observed for concentrations beyond 20 mg/mL of TXA combined with exposure times of less than 24 h. This might therefore represent a safe limit for topical application in vivo. Further research regarding in vivo conditions and effects on hMSC functionality are necessary to fully determine the effects of TXA on articular and periarticular tissues. Full article
(This article belongs to the Special Issue The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision)
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13 pages, 5475 KiB  
Article
Revision Arthroplasty Through the Direct Anterior Approach Using an Asymmetric Acetabular Component
by Peter Michael Prodinger, Igor Lazic, Konstantin Horas, Rainer Burgkart, Rüdiger von Eisenhart-Rothe, Manuel Weissenberger, Maximilian Rudert and Boris Michael Holzapfel
J. Clin. Med. 2020, 9(9), 3031; https://doi.org/10.3390/jcm9093031 - 21 Sep 2020
Cited by 7 | Viewed by 3112
Abstract
Despite increasing numbers of primary hip arthroplasties performed through the direct anterior approach (DAA), there is a lack of literature on DAA revision arthroplasty. The present study was performed in order to evaluate outcomes and revision rates after revision through the DAA using [...] Read more.
Despite increasing numbers of primary hip arthroplasties performed through the direct anterior approach (DAA), there is a lack of literature on DAA revision arthroplasty. The present study was performed in order to evaluate outcomes and revision rates after revision through the DAA using an asymmetric acetabular component with optional intra- and extramedullary fixation. In a retrospective cohort study, we analyzed prospectively collected data of 57 patients (61 hips, 43 female, 18 male) who underwent aseptic acetabular component revision through the DAA with the abovementioned implant system between January 2015 and December 2017. The mean follow-up was 40 months (12–56). Survival rates were estimated using the Kaplan–Meier method. All complications were documented and functional outcomes were assessed pre- and postoperatively. Kaplan–Meier analysis revealed an estimated five-year implant survival of 97% (confidence interval CI 87–99%). The estimated five-year survival with revision for any cause was 93% (CI 83–98%). The overall revision rate was 6.6% (n = 4). Two patients had to undergo revision due to periprosthetic infection (3.3%). In one patient, the acetabular component was revised due to aseptic loosening four months postoperatively. Another patient suffered from postoperative iliopsoas impingement and was treated successfully by arthroscopic iliopsoas tenotomy. Two (3.3%) of the revised hips dislocated postoperatively. The mean Harris Hip Score improved from 35 (2–66) preoperatively to 86 (38–100) postoperatively (p < 0.001). The hip joint’s anatomical center of rotation was restored at a high degree of accuracy. Our findings demonstrate that acetabular revision arthroplasty through the DAA using an asymmetric acetabular component with optional intra- and extramedullary fixation is safe and practicable, resulting in good radiographic and clinical midterm results. Full article
(This article belongs to the Special Issue The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision)
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13 pages, 594 KiB  
Article
The Association between High Body Mass Index and Early Clinical Outcomes in Patients with Proximal Femur Fractures
by Michael Müller, Alexander Gutwerk, Frederik Greve, Lisa Völker, Michael Zyskowski, Chlodwig Kirchhoff, Peter Biberthaler, Dominik Pförringer and Karl Braun
J. Clin. Med. 2020, 9(7), 2076; https://doi.org/10.3390/jcm9072076 - 2 Jul 2020
Cited by 15 | Viewed by 3182
Abstract
Background: Fractures of the proximal femur constitute daily work in orthopedic trauma surgery. With the continuous increase of obesity in the general population, surgeons face several known technical challenges. The aim of this study was to investigate the association of high body mass [...] Read more.
Background: Fractures of the proximal femur constitute daily work in orthopedic trauma surgery. With the continuous increase of obesity in the general population, surgeons face several known technical challenges. The aim of this study was to investigate the association of high body mass index (BMI) in patients with proximal femur fractures with intra- and postoperative adverse events, as well as with functional outcomes after successful surgery. Methods: In this retrospective, single-center cohort study, 950 patients who sustained a fracture of the proximal femur (femoral neck fracture or trochanteric fracture) and underwent surgical treatment at our level I trauma center between 2003 and 2015 were included. Patient-specific data were obtained in regard to demographics, comorbidities, and fracture morphology. In-hospital postoperative complications (i.e., need for revision surgery, wound site infection, pneumonia, urinary tract infection, necessary transfusion, and deep-vein thrombosis) were analyzed, along with the length of hospitalization and overall mortality rate. Functional outcome was assessed using the Barthel index and the patient’s ability to walk on crutches. Mortality rate and need for revision surgery were assessed over a two-year time period. Any adverse event was correlated to one of the four WHO’s BMI groups. Results: The cohort included 80 (8.4%) underweight patients, 570 (60.0%) normal weight patients, 241 (25.4%) overweight patients, and 59 (6.2%) obese patients. We found more femoral neck fractures (506, or 53%) than trochanteric fractures (444, or 47%). In bivariate analysis, no significant difference was found in regard to overall mortality or postoperative complications. Hospitalization time (LOS) differed between the underweight (12.3 ± 4.8 days), normal (13.6 ± 7.8 days), overweight (14.2 ± 11.7 days), and obese patients (16.0 ± 9.7 days) (p = 0.040). Operation time increased stepwise with increasing BMI: underweight = 85.3 ± 42.9 min; normal weight = 90.2 ± 38.2 min; overweight = 99.9 ± 39.9 min; obese = 117.2 ± 61.5 min (p < 0.001). No significant difference was found by analyzing functional outcomes. However, patients with intermediate BMI levels (18.5–30 kg/m2) tended to achieve the best results, as represented by a higher Barthel index score and the patient’s ability to walk on crutches. Conclusion: Increased BMI in patients with proximal femur fractures is associated with both longer operation time and length of hospitalization (LOS). Postoperative mobilization and functional outcomes appear to follow a reversed J-curve distribution (with overweight patients showing the best functional results), whereas both obese and underweight patients have associated poorer function. Full article
(This article belongs to the Special Issue The 4 R’s of Modern Adult Hip Surgery: From Regeneration and Reconstruction to Replacement and Revision)
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