HIP International

Advice given to patients on driving resumption after total hip arthroplasty (THA) is inconsistent. Due to a lack of clear guidelines, surgeons’ recommendations range between 4–8 weeks after surgery to resume driving. Delays in driving return can have detrimental social and economic impact. However, it is important to ensure patients only resume driving once safe. This study presents a systematic review and meta-analysis of driving simulation studies after THA to establish when patients can safely return to driving postoperatively.

A systematic review and meta-analysis using PRISMA guidelines was undertaken. Titles and abstracts were screened for inclusion, data was extracted, and studies assessed for bias risk. Review Manager, was used for statistical analysis. Values for brake reaction time (BRT) were included for meta-analysis.

14 articles met the inclusion criteria. Of these, 7 measured BRT and were included in the meta-analysis. Pooled means of both right and left THA showed BRT around or above preoperative baseline at 1 week, 2 weeks and 3 weeks, and below baseline at 6 weeks, 12 weeks, 32 weeks and 52 weeks. Of these, the pooled means at 6, 32, and 52 weeks were significant (p < 0.05).

Studies not meeting meta-analysis inclusion criteria were included in a qualitative analysis, examining self-reported postoperative driving return times which ranged from 6 days to over a year or in rare cases, never. Majority of patients (n = 960) self-reported driving return within approximately 6 weeks (pooling of mean values 32.9 days).

The mean return to driving time recommended in the literature was 4.5 weeks. Based upon BRT meta-analysis, a return to baseline braking performance was noted at 6 weeks postoperatively. However, driving is a complex skill, and patient recommendation should be individualised based on factors such as vehicle transmission type, THA technique, surgical side, medication and comorbidities.

Although the Pinnacle Acetabular Hip System (DePuy Synthes) has demonstrated excellent survivorship results since it was first introduced in 2003, there have been a growing number of cases indicating that Pinnacle liners may be subject to a higher-than-expected rate of early dissociation failure. Between 2006 and 2020, our Centre received 212 retrieved Pinnacle liners from Western Australian hospitals. Of these, 26 were removed due to liner dissociation.

To better understand the frequency and cause of this complication we assessed all retrieved Pinnacle acetabular components for type, damage modes and patient demographics. The leverage force required to dissociate Pinnacle liners was also measured and compared with another commonly used acetabular system, the Trident (Stryker Orthopaedics).

The estimated minimum incidence of liner dissociation from our data was 0.35%. Characterisation of dissociated Pinnacle cases (n = 26) revealed 73% were female with an average age of 59 compared to all retrieved Pinnacle cases (n = 212) where 58% were female with an average age of 66. Retrieval analysis indicated plastic deformation of the liner into an ovoid shape, signs of impingement on the rim postero-superiorly and shearing of the liner’s anti-rotation tabs was common. Mechanical testing indicated that the dissociation strength of Pinnacle cups decreases at approximately 6.6 N/year in situ (p = 0.01).

The survival rate of Pinnacle acetabular cups is exceptional with only 5% revised at 10 years. However, surgeons should be aware of the clinical symptoms and high-risk demographics when assessing patients with polyethylene Pinnacle liners.

In the United States, over 1,000,000 total joint arthroplasty (TJA) surgeries are performed annually and has been forecasted that this number will exceed 4,000,000 by the year 2030. Many different types of dressing exist for use in TJA surgery, and it is unclear if any of the newer, hydrofibre dressings are superior to traditional dressings at reducing rates of infections or improving wound healing. Thus, the aim of this systematic review and meta-analysis was to assess the impact of hydrofiber dressings on reducing complications.

A systematic review and meta-analysis was performed using the online databases MEDLINE and the Cochrane Library. Randomized controlled trials (RCTs) comparing hydrofibre dressings to a standard dressing were included. Summary measures are reported as odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs). Our primary outcome was prosthetic joint infection (PJI). Secondary outcomes included blisters, dressing changes and wound irritation.

5 RCTs were included. Hydrofibre dressing had no observable effect on PJI or wound irritation (OR 0.53; 95% CI, 0.14–1.98; p = 0.35). Hydrofibre dressings reduced the rate of blisters (OR 0.36; 95% CI, 0.14–0.90; p = 0.03) and number of dressing changes (MD -1.89; 95% CI, -2.68 to -1.11).

In conclusion, evidence suggests hydrofibre dressings have no observable effect on PJI and wound irritation. Evidence for reduction in blisters and number of dressings is modest given wide CIs and biased trial methodologies. Use of hydrofibre dressings should be considered inconclusive for mitigating major complications in light of current best evidence.

Hip resurfacing remains a valid option in young male patients. The creation of the optimum cement mantle aids fixation of the femoral component. If the cement mantle is too thick the prosthesis can remain proud leading to early failure or if it penetrates too far into the femoral head, it may cause osteonecrosis.

18 of 96 femoral heads collected from patients undergoing total hip arthroplasty were matched for their surface porosity. They were randomly allocated into 2 different cementing groups. Group 1 had the traditional bolus of cement technique, while group 2 had a modified cementing technique (swirl) where the inside of the femoral component was lined with an even layer of low viscosity cement.

The traditional bolus technique had significantly greater cement mantle thickness in 3 of 4 zones of penetration (p = 0.002), greater and larger air bubble formation (6 of 9 in bolus technique vs. 1 in 9 in swirl technique, p = 0.05) and more incomplete cement mantles compared with the swirl technique. There was no relationship to femoral head porosity.

The swirl technique should be used to cement the femoral component in hip resurfacing. Long-term clinical studies would conform if this translates into increased survivorship of the femoral component.

Approximately half of dislocating total hip arthroplasties (THAs) demonstrate acetabular component position within traditional safe zones. It is unclear if postoperative functional acetabular position can be reliably improved by considering preoperative pelvic tilt. We investigated whether standing cup position targets could be more accurately achieved by considering preoperative standing pelvic tilt in addition to bone landmarks when planning for robot-assisted THA.

We reviewed 146 THAs performed by a single surgeon using computed tomography-based 3-dimensional planning and robotic technology to guide acetabular reaming and component insertion. Planning for 73 consecutive cases started at 40° of inclination and 22° of anteversion relative to the supine functional plane and was adjusted to better match native hip anatomy. Planning for the next 73 cases was modified to consider standing pelvic position based on standing preoperative radiographs. We compared groups to determine the rate when cups were placed outside our standing targets of 15–30° anteversion and 35–50° inclination.

Cup position proved to be reliable in both groups, with 83% of cups in the anatomic planning cohort and 90% of cups in the functional planning cohort achieving standing targets for both anteversion and inclination (p = 0.227). Variances were lower in the functional planning group: 9.4° versus 15.8° of inclination (p = 0.079) and 18.3° versus 26.1° of anteversion (p = 0.352). The range of functional positions was narrower in the functional planning group: 35.7–47.5° versus 31.8–54.9° of inclination and 16.7–35.0° versus 10.1–35.9° of anteversion.

Our results suggest enhanced planning that considers pelvic tilt, when coupled to a precision tool to achieve the plan, can reliably achieve target standing component positions. Considering preoperative functional pelvic position may improve postoperative functional acetabular component placement in THA, but the clinical benefit of this has yet to be confirmed.

The outcomes of constrained liners (CLs) in total hip arthroplasty (THA) remain inconclusive. We evaluated the mid-term performance of CLs in a consecutive series of high-risk dislocation patients undergoing primary or revision THA performed by a single surgeon. The survival, dislocation rate, complications, and functional patients’ scores were assessed. Surgical tips to enhance outcomes were reviewed.

45 patients who received the Trident Tripolar CL between 2010 to 2019 were retrospectively evaluated from Arthroplasty Registry Thessaloniki. There were 17 primary and 28 revision THAs. The primary indications for using CL were severe abductor insufficiency or comorbidities, increasing the dislocation risk in primary, and recurrent dislocation or abductor insufficiency in revision THAs. The mean patient’s age was 68.5 (±14.5) years, and the mean follow-up 3.81 (±1.66) years.

There were 2 dislocations and 1 deep infection in the revision group. For any reason, the cumulative 6-year survival rate was 93.3%, 100% for primary, and 89.3% for revision THAs. The mean overall CL survival was 76.3 months for any reason (95% CI, 68.1–84.5) and 80.5 months for dislocation (95% CI, 75.8–85.2). The mean postoperative functional scores were significantly improved (p < 0.001) at the latest follow-up.

CLs can provide hip stability and durable fixation in selected low-demand patients with high-risk for dislocation after primary and revision THA at mid-term follow-up. Careful patient selection and the refined surgical technique aiming at the neutral liner position and considering the high CLs’ offset relative to stem-neck impingement are necessary to maximise outcomes.

Femoral head osteonecrosis (FHON) is a well-recognised complication in patients with human immunodeficiency virus (HIV) infection. Total hip arthroplasty (THA) is a reliable solution to FHON and has provided functional improvement and pain relief in these patients. Higher complication rates, in particular infections, have been reported in the series of THAs done in the HIV-positive patients. The purpose of this study was to evaluate the complication rate of THA for FHON in HIV-positive patients managed with the highly active antiretroviral therapy (HAART) protocols.

A retrospective review was performed of HIV-positive patients with FHON who underwent THAs over a 10-year period at a single institution.

A total of 56 THAs (44 patients) met the inclusion criteria. The mean age at the time of THAs was 47 (range 34–60) years. Of the 44 patients, 39 (88.6%) were males. The mean follow-up was 6.6 (range 2.0–11.3) years. The overall complication rate was 12.5%, with 2 (3.6%) cases of deep periprosthetic infections.

HIV-positive patients with FHON undergoing THAs do have a considerable complication rate (12.5%). The deep periprosthetic infection rate (3.6%) in these patients, however, has decreased with contemporary disease modification protocols.

There are ongoing debates on the effects of surgical approach on outcome after total hip arthroplasty (THA). It was hypothesised that with the anterolateral approach, trauma to the abductor arm can occur and related detrimental effects can diminish the postoperative outcomes. In this first randomised controlled trial in the literature on this subject, isokinetic performance and patient-reported functional outcomes were evaluated in patients undergoing THA with a posterior approach (PA) and an anterolateral approach (ALA).

A total of 48 patients scheduled to undergo THA were randomised to ALA or PA groups. The patients were evaluated preoperatively and at 6 and 12 months postoperatively, with flexion, extension and abduction strength measurements and the Harris Hip Score (HHS). The physiatrist performing isokinetic tests and the patients were blinded to the study groups.

Both groups were similar in respect of age, body mass index (BMI), gender and preoperative isokinetic performance and HHS. Both groups demonstrated similar isokinetic performance (p < 0.05) and there was no difference in HHS (p < 0.05) at the 6- and 12-months follow-up evaluations.

Although there is concern about potential abductor muscle damaging during ALA, the results of this randomised controlled study demonstrated that ALA can produce similar isokinetic performance and functional outcome to PA at 6 and 12 months, despite the close proximity to the abductor arm.

ClinicalTrials.gov NCT04640740 (retrospectively registered).

Adding hydroxyapatite to a stem to enhance ingrowth is a matter of debate, even less is known about the long-term effect on stability by adding hydroxyapatite (HA). Continuous migration in the first 2–5 years is an indicator of failed osteointegration or pending failure, enhancing the risk of loosening within 10 years after initial surgery. We performed a double-blinded randomised RSA trial with 5-year follow-up, to compare and analyse migration characteristics of the hydroxyapatite uncoated (HA−) and hydroxyapatite coated (HA+) Zweymuller-type hip stem.

In this single-centre prospective randomised controlled trial 51 patients were randomised to receive either a HA− or a HA+ Zweymuller-type hip stem during total hip replacement. After 5 years, 35 patients were still eligible for follow-up evaluation. The migration pattern was measured by use of radio stereometric analysis (RSA) images up to 2 years to evaluate short-term migration, additionally RSA images were obtained 5 years postoperatively to assess late-term and continuous migration. Furthermore, the improvement of clinical outcome was analysed by HSS and HOOS ADL and pain subscales preoperative and after 5 years.

After initial settling of the implant, no significant migration occurred up to 5 years post-surgery for HA+ as well as HA− prostheses. Continuous migration within the 2–5 years’ time interval was not observed for both HA+ nor the HA− group in all directions (p < 0.05). No significant difference between both groups was observed (p < 0.10). In both groups the HHS and HOOS improved significantly at 5 years compared to baseline for both groups. Improvement was not altered by the hydroxyapatite coating. No significant difference between both groups was observed (p > 0.58).

Addition of a hydroxyapatite coating did not influence the migration 5 years postoperatively for the Zweymuller-type hip stem.

Clinical Trial Protocol number: NL 23524.048.08

Periacetabular reconstruction after resection of primary bone tumour is a very demanding procedure. They are frequently associated with scarce functional results and a high rate of complications. We report a series of patients with periacetabular resections for primary bone tumours and reconstruction with a porous tantalum (PT) acetabular cup (AC).

27 patients (median age 30 years) were included, being affected by primary bone tumours of the pelvis and treated with peri-acetabular resection and reconstruction with a PT AC. The diagnoses were 13 osteosarcomas, 7 chondrosarcomas and 7 Ewing sarcomas. Function was assessed with the Harris Hip Score and complications were classified according to Zeifang.

The median follow-up was 70 months. 1 patient required removal of the PT AC because of implant associated infection 55 months after surgery. There was 1 hip dislocation and no case of aseptic loosening. At final follow-up, the median HHS was 81 points (range 48–92).

The used PT AC had good medium-term survival rates and good functional results. This technique is a viable reconstructive option after resections of periacetabular primary bone sarcomas.

To evaluate the long-term clinical outcomes of 2 cemented ultra-high molecular weight polyethylene (UHMWPE) acetabular components, with the main difference between the 2 components being their method of sterilisation.

Data was collected prospectively on 352 consecutive total hip replacements, performed between March 2000 and July 2004, at a single centre. A posterior approach was used with a cemented C-Stem femoral component (DePuy, Warsaw, IN, USA) in all cases and either the Ogee (DePuy, Warsaw, IN, USA) or the Opera (Smith & Nephew, Memphis, TN, USA) acetabular implant. Patients were reviewed clinically and radiologically with a median 12-year follow-up (6–16 years).

The risk of experiencing loosening was 90% lower for the Gamma irradiated implant (GII) group compared to the ethylene oxide sterilised implant (EOSI) group, which was statistically significant (p = 0.003), (HR 0.10; 95% CI, 0.02–0.45). The incidence of cup revision was also lower in the GII group (p = 0.029), but after adjustment for age, gender and BMI was not statistically significant (p = 0.104). 15-year survivorship with failure/loosening as an endpoint was 70.1% for the EOS implant and 92.9% for the GII (OR 4.99; CI 95%, 1.75–14.2) and with revision as an endpoint was 81.4% for the EOSI and 92.9% for the GII (OR 2.60; CI 95%, 0.87–7.75)

We report increased rates of loosening, revision and failure for the EOSI compared to the GII at long-term follow-up. This may have been attributable to the different sterilisation methods used.

Hip capsular management after hip arthroscopy remains a topic of debate. Most available current literature is of poor quality and are retrospective or cohort studies. As of today, no clear consensus exists on capsular management after hip arthroscopy.

To evaluate the effect of routine capsular closure versus unrepaired capsulotomy after interportal capsulotomy measured with NRS pain and the Copenhagen Hip and Groin Outcome Score (HAGOS).

All eligible patients with femoroacetabular impingement who opt for hip arthroscopy (n = 116) were randomly assigned to one of both treatment groups and were operated by a single surgeon. Postoperative pain was measured with the NRS score weekly the first 12 weeks after surgery. The HAGOS questionnaire was measured at 12 and 52 weeks postoperatively.

Baseline characteristics and operation details were comparable between treatment groups. Regarding the NRS pain no significant difference was found between groups at any point the first 12 weeks after surgery (p = 0.67). Both groups significantly improved after surgery (p < 0.001). After 3 months follow-up there were no differences between groups for the HAGOS questionnaire except for the domain sport (p = 0.02) in favour of the control group. After 12 months follow-up there were no differences between both treatment groups on all HAGOS domains (p > 0.05).

The results of this randomised controlled trial show highest possible evidence that there is no reason for routinely capsular closure after interportal capsulotomy at the end of hip arthroscopy.

This trial was registered at the CCMO Dutch Trial Register: NL55669.048.15.

Bony morphology is central to the pathomechanism of femoroacetabular impingement syndrome (FAIS), however isolated radiographic measures poorly predict symptom onset and severity. More comprehensive morphology measurement considered together with patient factors may better predict symptom presentation. This study aimed to determine the morphological parameter(s) and patient factor(s) associated with symptom age of onset and severity in FAIS.

99 participants (age 32.9 ± 10.5 years; body mass index (BMI 24.3 ± 3.1 kg/m²; 42% females) diagnosed with FAIS received standardised plain radiographs and magnetic resonance scans. Alpha angle in four radial planes (superior to anterior), acetabular version (AV), femoral torsion, lateral centre-edge, anterior centre-edge (ACEA) and femoral neck-shaft angles were measured. Age of symptom onset (age at presentation minus duration of symptoms), international Hip Outcome Tool-33 (iHOT-33) and modified UCLA activity scores were recorded. Backward stepwise regression assessed morphological parameters and patient factors (age, sex, BMI, symptom duration, annual income, private/public healthcare system accessed) to determine variables independently associated with onset age and iHOT-33 score.

Earlier symptom onset was associated with larger superoanterior alpha angle (p = 0.007), smaller AV (p = 0.023), lower BMI (p = 0.010) and public healthcare system access (p = 0.041) (r² = 0.320). Worse iHOT-33 score was associated with smaller ACEA (p = 0.034), female sex (p = 0.040), worse modified UCLA activity score (p = 0.010) and public healthcare system access (p < 0.001) (r² = 0.340).

Age of symptom onset was chiefly predicted by femoral and acetabular bony morphology measures, whereas symptom severity predominantly by patient factors. Factors measured explained a small amount of variance in the data; additional unmeasured factors may be more influential.

(1) To compare the pre- and postoperative driving performance in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS); (2) to examine the differences in driving performance between patients with versus without capsular repair.

Patients who underwent arthroscopic hip surgery for FAIS were included. Driving performance of participating patients was collected using a driving simulator preoperatively and at 2 weeks, 4–6 weeks and 8–12 weeks postoperatively. Data collected included demographics, surgery laterality, intraoperative procedures, left and right turn reaction time, total turn reaction time, gas off time (GOF), and break reaction time (BRT). Repeated measures analysis of variance (ANOVA) was used for statistical analysis.

21 subjects (9 males, 12 females) with a mean age of 30 ± 9 years were included and 57.1% of the subjects had right-sided surgery. There was no difference between the mean preoperative and the 2-week postoperative left (0.72 seconds and 0.75 seconds, respectively) right (0.77 seconds and 0.75 seconds, respectively), and total (0.74 seconds and 0.75 seconds, respectively) turn reaction times as well as GOF (0.62 seconds and 0.60 seconds, respectively) and BRT (0.92 seconds and 0.93 seconds, respectively), indicating that the patients’ driving performance returned to the preoperative level as early as 2 weeks following hip arthroscopy for FAIS. There was no significant difference amongst any of the driving variables between patients who underwent capsular repair (50%) and those who did not. There was no significant difference amongst any of the driving variable s between patients who underwent left versus right hip arthroscopy.

Patients’ driving performance returns to the preoperative level as early as 2 weeks after hip arthroscopy for FAIS. Surgery laterality nor capsular repair make any significant difference in the time for driving abilities to return to baseline. The impact of intraoperative procedures performed, and the analgesic medications used postoperatively on the driving ability of patients undergoing hip arthroscopy warrants further investigation in larger patient populations.

To explore the value of MRI upon diagnosis of ischiofemoral impingement syndrome (IFI) and to recognise deformation or oedema of the quadratus femoris muscle. MRI applied to measure the ischial femoral space (IFS), the average width of quadratus femoral space (QFS), and the ischial intertuberal diameter.

A retrospective analysis was carried out of 213 hip joints MRI images of 58 cases diagnosed with IFI and 61 cases of normal subjects. IFS, QFS and ischial intertuberal diameter were measured by axial T1WI sequence. The morphological and signal changes of the quadratus femoris muscle were observed through proton density weighted image fat suppression sequence (PDWI-FS).

The widths of IFS and QFS in the normal group were larger than those in the case group, while the ischial intertuberal diameter was significantly smaller (p < 0.05). Pearson correlation analysis revealed that there was a positive correlation (r = 0.824) between IFS and QFS in all hip joints and a negative correlation between the ischial intertuberal diameter and the widths of IFS and QFS (r = −0.213, −0.222, p < 0.05) respectively. As the grade of oedema in quadratus femoris muscle increased, the corresponding IFS gradually decreased. The corresponding IFS width of grade 0 oedema of the quadratus femoris muscle oedema was significantly higher than that of grade 1, grade 2 and grade 3. The receiver operating characteristic curve (ROC) of the subjects was applied to determine the diagnostic boundary value of the IFS and QFS in IFI patients, which was 1.98 cm and 1.05 cm respectively. The area under the curve (AUC) was 0.948 and 0.953 respectively.

MRI examination could provide a reliable basis for the diagnosis of ischiofemoral impingement syndrome. The narrowing of IFS and QFS with deformation and oedema in the quadratus femoris muscle may be the features of manifestation of IFI.

Periprosthetic femoral fractures (PPF) are a devastating complication after total hip arthroplasty (THA). Both trauma and adult reconstruction surgeons or combined teams treat these fractures following management algorithms. The aim of this study is to investigate the current treatment of PPF by members of the European Hip Society (EHS).

An online survey of the members of the European Hip Society (EHS) was conducted. 20 cases of periprosthetic fracture were presented and surgeons were asked to answer questions regarding classification, treatment and postoperative treatment protocol.

A total of 132 (130 male; 2 female) EHS members responded. Mean years in surgical practice was 18.8 (min. 1 year; max. 50 years). The preferred surgical method was combined open reduction and internal fixation (ORIF) (30.3%) for AG fractures, ORIF with cables (30.4%) for AL fractures, combined ORIF (cable and plate) for B1 fractures (49.2%), stem revision with cables for B2 fractures (73.1%), stem revision with cables for B3 (55.9%) fractures and combined ORIF (cable and plate: 55.5%) for C fractures. Surprisingly, 10.8% suggested various stem revision techniques for B1 and 17.4% for C fractures. Strong variations were observed regarding postoperative weight-bearing protocol.

A strong consensus was found for the choice of conservative or surgical treatment of the different PPF types according to the Vancouver Classification. Various stem revision techniques were the preferred surgical techniques for Vancouver B2 (91.2%) and B3 (88.6%) fractures. However, for postoperative weight-bearing, when the ORIF technique was used, a significant variation of protocols was found.