Over the past year, there have been many changes in hip arthroplasty. Some of the new information further solidifies practices such as the use of tranexamic acid for blood conservation and the detection of infection through alpha defensins, and other studies have enhanced our knowledge of surgical approaches and the modes of failure of implants. Compared with the past, the biggest changes have not been in surgical materials or techniques but in how surgeons will practice in the future with respect to outcomes.
Factors That May Alter Outcomes Following Total Hip Replacement
Total hip arthroplasty is increasingly being utilized in younger, more active patients with long life expectancies. Researchers have conducted studies using different bearing couples in the hopes of improving the longevity of implants. In one report, the authors conducted a Level-I study to determine if there was a short-term to intermediate-term survivorship difference among common total hip arthroplasty bearings used in patients younger than 65 years of age1. This report described the survivorship of ceramic on ceramic, ceramic on highly cross-linked polyethylene, and metal on highly cross-linked polyethylene. Direct-comparison meta-analysis found no differences among the bearing surfaces in terms of the risk of revision. Network meta-analysis likewise found no differences in survivorship across the three implant types, suggesting that, at least in the short term, any of the bearing combinations functioned well in younger patients. Another randomized controlled trial compared the results of ceramic-on-ceramic bearing with those of ceramic-on-polyethylene bearings2. At the 10-year follow-up, there were no group differences (p > 0.48) in both the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) and the SF-12 (RAND 12-Item Health Survey). There were no failures or loss of fixation related to bearing surfaces or wear in either group. Comparing ceramic-on-ceramic bearings with ceramic-on-polyethylene bearings, there were few short-term differences in function or wear. These studies did not show the relative costs of each of these bearing couples, and, given the similarities in short-term performance and current cost constraints, the least costly combination might be a better overall choice. Only longer-term studies will establish the superiority of these bearing combinations.
Highly cross-linked polyethylene infused with vitamin E (E-poly; Biomet) was developed to increase oxidative resistance without affecting mechanical properties. A Level-I therapeutic study compared early-term femoral-head penetration of an E-poly liner with that of a heat-treated polyethylene liner (ArComXL; Biomet) using radiostereometric analysis3. In comparing both forms of polyethylene, Shareghi et al. concluded that there were no significant differences observed in femoral-head penetration rates between E-poly and ArComXL, and the theoretical advantages of E-poly remained to be confirmed.
Modularity was progressively introduced to total hip arthroplasty to provide the surgeon with intraoperative options of neck length, offset, and version to optimize hip mechanics and stability. This has come at the price of increased risk of fretting and corrosion of the modular interfaces. In a retrieval study of metal-on-polyethylene bearings, Triantafyllopoulos et al. evaluated the effects of head size, duration of implantation, alloy compositions, and location on the severity of fretting and corrosion on the surfaces of head tapers and stem trunnions4. The authors concluded that fretting and corrosion are regular occurrences in metal-on-polyethylene total hip replacements, but neither damage type was related to femoral-head size. Conversely, taper design, duration of implantation, and alloy combination affected the severity of both fretting and corrosion. In another retrieval study of metal-on-polyethylene prostheses, the effects of femoral-head length on fretting and corrosion of head-neck tapers were evaluated5. Head length was observed to affect fretting (p = 0.03), with increased neck length and greater offset being associated with the extent of corrosion. Finally, Kocagoz et al. quantified the volumetric material loss from the head bore and stem cone tapers of a matched cohort of ceramic and metal heads retrieved during revision surgical procedures6. There was less material lost in the ceramic heads, and the authors concluded that ceramic femoral heads may be an effective means by which to reduce metal release caused by taper fretting and corrosion at the head bore-stem interface in total hip replacements.
Modularity at the neck-stem junction has also resulted in even greater amounts of corrosion and fretting. One prospective study of 216 total hip arthroplasties showed a 37% revision rate at a mean follow-up of 19.3 months7. The cause for revision in 73 of these 80 hips was an adverse local tissue reaction. All of the patients had an increase in their serum cobalt levels, with a mean of 8.6 ng/mL. Corrosion was more prominent at the neck-stem junction compared with the head-neck junction.
Complications of Total Hip Replacement
Recent studies have described some of the factors associated with dislocation, including surgical approach, bearing material, constraint, and the acetabular safe zone. In a report based on the Kaiser Permanente Registry, the anterolateral approach and direct anterior approach had a lower risk of dislocation relative to the posterior approach8. Another study using the New Zealand Joint Registry found that bearing surface had little association with dislocation after the first year of the surgical procedure9. A prospective evaluation compared two cohorts that differed only by type of bearing, including a modern dual mobility bearing (mobile bearing) and a fixed bearing. Using instability as the end point, 100% of the mobile-bearing cohort had no dislocation compared with 94.8% of the fixed-bearing cohort10.
With regard to choices in surgical approach, the single major factor in minimizing the risk of dislocation is the appropriate positioning of the implants, and this is dependent on surgical experience and the surgeon’s comfort in performing the approach. With all other factors being equal and the increased use of ≥32-mm diameter heads, the long-term risks of dislocation are generally comparable regardless of approach.
Transfusion and Blood Management
The routine use of tranexamic acid in hip replacement has been very effective in minimizing the need for blood transfusions following hip replacement. Adding to previous studies, a randomized, double-blind, controlled study using topical tranexamic acid administration demonstrated postoperative transfusion rates for patients who underwent total hip replacement decreasing from 22% to 6%11.
There have been lingering concerns that tranexamic acid should not be administered intravenously in patients with a history of thrombotic events, including cardiac disease, stents, deep venous thrombosis, or other related issues. A retrospective review was performed for more than 13,000 cases, in which tranexamic acid was administered to all patients regardless of thrombosis history. The major findings of this retrospective cohort study showed that the odds of postoperative venous thromboembolism and 30-day mortality were unchanged with intravenous tranexamic acid administration12. On the basis of this study, there appears to be no contraindication for intravenous tranexamic acid in patients with a history of venous thromboembolism.
In one study, Bedair et al. suggested that the use of recombinant erythropoietin might be beneficial in decreasing the need for postoperative transfusions13. Although the use of erythropoietin reduced the need for postoperative transfusion for high-risk patients undergoing hip or knee arthroplasty, its administration was not considered cost-effective. It is likely that this medication may continue to be used in a small percentage of patients who are undergoing total hip replacement and are considered at high risk for postoperative anemia.
The routine use of suction drains following total hip replacement is generally not warranted and has been shown to actually increase the need for postoperative blood transfusions14,15. Both cell savers and reinfusible drains have not been cost-effective or reliable in decreasing the need for postoperative transfusions.
Venous Thromboembolic Disease
New reports continue to be published demonstrating very low rates of deep venous thrombosis after total hip replacement. Notably, aspirin and mechanical prophylaxis continue to perform favorably and are commonly used in preference to low molecular-weight heparins. In the first of two reports by Nam et al., a risk stratification protocol divided patients into routine and high-risk patients who underwent total hip replacement16. The routine group received a mobile compression device and aspirin, and the high-risk group received warfarin. The cumulative rate of venous thromboembolism was 0.5% for both groups at 6 weeks. The routine group had a lower rate of major bleeding (0.5% compared with 2.0%, p = 0.006). In their larger study of both total hip arthroplasty and total knee arthroplasty primary and revision cases (>3,000 patients), similar findings were achieved when aspirin was compared with other means of prophylaxis17. These findings suggest that aspirin is as effective as Coumadin (warfarin) or low-molecular-weight heparin, with less cost and no requirements for monitoring. Newer ongoing studies may support the use of 81-mg enteric-coated aspirin twice daily as being as effective as a full dose (325 mg) taken twice daily.
Minimizing the risk of infection has been attempted through the preoperative use of chlorhexidine wipes and washing along with the assessment and treatment of nasal colonization with Staphylococcus species18. However, some studies have raised questions about the effectiveness of these approaches19,20. One report suggested that decolonization with povidone-iodine might be as effective as treatment with antibiotics such as mupirocin, with significantly less cost21. A prospective randomized trial of >1,000 patients showed a 22% Staphylococcus aureus colonization rate and a 0.8% rate with methicillin-resistant Staphylococcus aureus (MRSA)20. Although periprosthetic joint infection was higher in the Staphylococcus carriers, this was not significant. In contrast to many preceding studies, in another study, Ponce et al. could not demonstrate a clear benefit to their screening or decolonizing protocol22.
Many orthopaedic surgeons performing total hip arthroplasty wear body exhaust suits. In a systematic review23, the older, negative-pressure, Charnley-type body exhaust suits were compared with the current, positive-pressure, surgical helmet systems. Other authors reported that the older, negative-pressure suits provided less air and wound contamination compared with current positive-pressure designs, and they concluded that the older designs were superior to the current systems24.
Traditionally, the evaluation of potential periprosthetic joint infection has included serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Further confirmatory diagnosis of periprosthetic joint infection also relied on positive culture results of the joint fluid or implant. One study demonstrated that the sensitivity of preoperative aspiration was only 13% and the specificity was 98%. In the same patients, serum CRP sensitivity was 95% and the specificity was 20%25. These findings demonstrate the challenges in diagnosing deep periprosthetic infections.
The Musculoskeletal Infection Society (MSIS) criteria defining periprosthetic joint infection have gained acceptance and have impacted the diagnosis and treatment of periprosthetic joint infection. Synovial fluid biomarkers increasingly are being studied as more accurate diagnostic tools. Sixteen biomarkers were tested for diagnostic performance in 29 periprosthetic joint infection cases and 66 aseptic cases, and five of these demonstrated 100% sensitivity and specificity. The five biomarkers are not commonly used but may represent the future of periprosthetic joint infection diagnosis. They include alpha-defensin 1-3, neutrophil elastase 2, bactericidal/permeability-increasing protein (bpi), and neutrophil gelatinase-associated proteins26,27.
Another biomarker, interleukin-6 (IL-6), was reported in 16 of 55 patients with positive cultures at the time of staged reimplantation for deep infection. An IL-6 level of ≥13 pg/mL had a positive predictive value of 91%, but an IL-6 level of ≤8 pg/mL had a negative predictive value of 92%28. Hoell et al. believed that IL-6 was a reasonable marker for identifying persistent infection after the first stage of revision joint arthroplasty and before attempting reimplantation.
The use of chronic suppression with oral antibiotics after periprosthetic joint infection is an area of special interest. For all cases in one study, the 5-year infection-free prosthetic survival rate was 68% in the suppression group and 41% in the non-suppression group. The authors concluded that chronic suppression with oral antibiotics increased the infection-free prosthetic survival rate following surgical treatment for periprosthetic joint infection29. This means of treatment remains an alternative for patients who are unable to undergo multiple complex procedures with removal of implants and the use of antibiotic spacers.
Revision Total Hip Replacement
The use of modular tapered fluted stems has become the mainstay of treatment for most femoral revision cases30,31. After their initial introduction, some of these designs were associated with a risk of fracture at the modular junction, a high-stress area. Improvements in metallurgy and design have served to decrease this risk. Houdek et al. reported on the use of this type of stem in staged treatment for total hip replacement cases with previous infections and with a minimum follow-up of 5 years. At that time interval, they reported stem survivorship of 87% and a reinfection rate of 16%32.
Several new reports on the technical aspects of hip replacement surgical procedures have been published.
Two long-term follow-up reports on liners cemented into a retained acetabular shell revealed a high postoperative dislocation rate (16% and 28%). A re-revision surgical procedure was required in a substantial percentage of patients in both studies (16% and 31%)33,34. It should be noted that a cemented liner may necessitate a smaller femoral head with a decreased jump distance. Although not uncommonly used as a salvage procedure, this high rate of dislocation and failure may have surgeons reconsider this as a viable option in revision surgical procedures.
Surgeon-Specific and Institutional Factors in Reducing Risk
In their study, Bronson et al. suggested that an important factor in reducing risk to patients may be dependent on surgeons and their institutions. For individual surgeons, both surgical volume and experience have been shown to improve outcomes, and the same is true for hospitals. However, any surgeon and any institution can offer a patient a joint replacement regardless of these two factors, with the majority of joint replacements being done by surgeons who perform fewer than four such procedures a month. Bronson et al. asked whether all surgeons or hospitals should be offering these procedures and whether regional centers of specialized care, known as centers of excellence, should be created that focus on specific procedures35.
Patient-Related Factors That Affect Outcomes
Many studies have shown that obesity is a major risk factor for increasing surgical time and the risk of complications following a surgical procedure36-47. One report summarized the surgical risks in obese patients, and the authors concluded that elevated body mass index (BMI) increased the risk of postoperative complications following total joint arthroplasty37.
Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, one study evaluated more than 13,000 patients who were stratified into five groups based on body mass index (BMI) and were matched for sex, age, surgical procedure type, and American Society of Anesthesiologists (ASA) class48. This demonstrated an association between elevated BMI and overall complications (p < 0.001), medical complications (p = 0.005), and surgical complications (p < 0.001), including superficial (p = 0.019) and deep wound infection (p = 0.040), return to the operating room (p = 0.016), and time from the operating room to discharge (p = 0.003)48,49.
One study has questioned the efficacy and validity of the NSQIP score in predicting postoperative complications49. Therefore, other means of risk stratification are needed, with such methodologies needing to be easy to use and accurate in their predictive accuracy. To date, no one means of risk stratification has been shown to be either most accurate or most predictive, and further studies need to be performed in the area of preoperative risk assessment. Several reports have also demonstrated that the risk of complications using the anterior approach is higher in obese patients50,51.
The unanswered question in working with the obese patient population is how to best counsel and to help morbidly obese individuals who otherwise would benefit from a hip replacement. Compliance with weight loss programs can be difficult, especially in a population that is otherwise sedentary and is unable to exercise because of pain from the arthritic joint. In one study, McLawhorn et al. suggested that bariatric surgical procedures for morbidly obese patients were a cost-effective option in improving outcomes following total joint surgical procedures42. In another study, Perry and MacDonald suggested that obese patients should not be denied surgical procedures on the basis of weight alone because the improvements in lifestyle were comparable and were possibly superior to those of normal-weight patients45. Despite commonly heard patient statements that they were unable to lose weight because of their arthritic pain, most patients did not actually have any substantial weight loss following a joint replacement surgical procedure52. Overall, the majority of studies suggest that obesity is a modifiable risk factor that should be addressed prior to the surgical procedure if the risk of complications is to be minimized.
Opioid usage, especially on a chronic basis, has been associated with increased incidence of complications following total joint replacement53,54. Furthermore, outcomes in these patients are worse, including increases in the length of stay, the need for mechanical ventilation, and even death55. Therefore, as with any other high-risk population associated with worse outcomes, surgeons may be faced with the ethical dilemma of operating on these patients knowing that they and their institutions may incur additional expenses or penalties, or of possibly choosing to withhold the surgical procedure to avoid unnecessary complications and negative outcomes.
Smokers, and even former smokers, have a higher risk of complications following total hip arthroplasty. As expected, smokers had a higher risk of wound complications and deep infections compared with non-smokers. Both current and former smokers also had a higher risk of complications compared with the non-smoking cohort56. In fact, smoking was associated with a higher risk of surgical site infection compared with even excessive alcohol consumption57. In the current absence of risk stratification for hip replacements, patients who are current smokers should be counseled about the relative risks of undergoing a joint replacement while still smoking. Smoking as a practice is clearly associated with an increased risk of infection and therefore may represent a relative contraindication for joint replacement surgical procedures.
Other Patient-Dependent Risk Factors
Psychiatric illness, specifically depression, has been associated with poor outcomes. Dave et al. found that patients with greater levels of self-reported pain, pain catastrophizing, and depression prior to the surgical procedure also had a greater incidence of persistent pain and functional limitation following joint replacement surgical procedures. These authors also found a modest correlation between patient-reported pain and successful surgical outcomes and suggested that further evaluation for depression prior to a surgical procedure might benefit outcomes58.
Patient-Reported Outcomes, Joint Registries, and Bundled Payments
The American Academy of Orthopaedic Surgeons (AAOS) and the American Association of Hip and Knee Surgeons (AAHKS) have taken an active role in working with the Centers for Medicare & Medicaid Services (CMS) with regard to the current proposals for instituting bundled payments for joint replacement during 2016. The overall goals of this approach are to improve outcomes while decreasing costs, including length of stay, discharge to inpatient facilities, and cost per episode of care59-62. One study has shown that this integrative approach has been successful in accomplishing all of these goals, at least within a large hospital academic setting63. Part of the reimbursement for total hip arthroplasty will include adjustments for patient-reported outcome measures, along with deductions for poor outcomes, including infections, readmissions for all causes, and death following the surgical procedure.
Although alternative payment methods such as bundled payments may decrease the overall cost per episode of care, surgeons have raised important concerns. A payment model based on risk stratification is crucial if surgeons are expected to continue offering patients the opportunity to eliminate pain and to improve mobility without the associated financial penalties62.
Many changes have occurred over the past year in total hip replacement. Rather than the prior focus on new implants or materials, there has been growing emphasis on decreasing costs while improving outcomes, with more attention being placed on the patient experience.
In the preparation of this manuscript, we reviewed nearly 600 peer-reviewed studies on hip replacement that were published within the last year alone. Of these, very few were considered true Level-I studies, with the majority being retrospective Level-IV reports. Many of these studies lacked adequate controls, and others made claims that were either overstated or not clearly supported by the data. If surgeons are to make changes in their practices on the basis of the published literature, it is crucial that such studies are appropriately designed prior to implementation and that they include appropriate control groups.
The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in the Update, six other articles with a higher Level of Evidence grade were identified that were relevant to hip replacement. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help guide your further reading, in an evidence-based fashion, in this subspecialty area.
Evidence-Based Articles Related to Hip Replacement
Bechtel CP, Gebhart JJ, Tatro JM, Kiss-Toth E, Wilkinson JM, Greenfield EM. Particle-induced osteolysis is mediated by TIRAP/Mal in vitro and in vivo: dependence on adherent pathogen-associated molecular patterns. J Bone Joint Surg Am. 2016 Feb 17;98(4):285-94.
Aseptic loosening of joint replacements is felt to result in part from the biologic responses to particulate wear debris. One of the main molecular mechanisms in this process has been through the presence of pathogen-associated molecular patterns, formerly referred to as endotoxins. An example of a pathogen-associated molecular pattern is bacterial lipopolysaccharide. The presence of persistent and adherent pathogen-associated molecular patterns on particulate wear debris has been shown to elicit a more vigorous biologic response and osteolysis compared with cleaned particles. Conversely, it has also been shown that cleaning of particles is effective in reducing this biologic response. Currently, all orthopaedic implants undergo a passivation step in nitric acid, and this is also effective in removing residual pathogen-associated molecular patterns.
In previous studies, the authors showed that there are genetic polymorphisms in the receptors for pathogen-associated molecular patterns that can alter the biologic responses to these stimuli. In this study, macrophages that did not express the pathogen-associated molecular pattern receptor called TIRAP/Mal (toll/interleukin-1 receptor domain-containing adapter protein/MyD88 adapter-like) had significantly diminished gene expression and secretion of inflammatory proteins such as IL-1β, tumor necrosis factor alpha (TNF-α), and IL-6, and this was also seen as decreased osteolysis with in vivo experiments.
On the basis of this information, this study demonstrated the potentially critical role of pathogen-associated molecular patterns in the mechanisms by which particulate wear debris can result in implant loosening. Furthermore, the authors have also shown that genetics of the individual with regard to specific receptors may play an important role in predisposing patients to an increased biologic response to wear debris that could lead to early implant loosening.
Goodman SM, Menon I, Christos PJ, Smethurst R, Bykerk VP. Management of perioperative tumour necrosis factor α inhibitors in rheumatoid arthritis patients undergoing arthroplasty: a systematic review and meta-analysis. Rheumatology (Oxford). 2016 Mar;55(3):573-82. Epub 2015 Oct 7.
Surgeons performing hip replacement on patients with rheumatoid arthritis are faced with unique challenges. Bone quality may be impaired, with thinner cortices and weaker overall strength. Smaller implants may be required, and soft-tissue balancing may also be difficult. Finally, wound-healing problems and risks of infection are higher in this population. TNF-α inhibitors are becoming more widely utilized in the treatment of rheumatoid arthritis and have been extremely effective in diminishing the deformities and pain of rheumatoid arthritis. Surgeons contemplating surgical procedures on patients taking these medications are faced with the decision to either stop these medications well in advance of the surgical procedure or to allow a potential flare-up of rheumatoid arthritis symptoms if the medications are discontinued. This study reviewed the literature on this subject and showed the odds ratio of patients who were and were not taking these medications prior to the surgical procedure developing a deep infection. In a meta-analysis, the authors concluded that patients who were taking a TNF-α inhibitor had an increased risk of perioperative infection, with an odds ratio of 2.47. They did caution that other factors such as smoking, diabetes, corticosteroid use, or higher disease activity might also play a role in developing infection and suggested that well-controlled randomized studies would be valuable in determining the exact effect of TNF-α inhibitors in the development of surgical site infections following hip replacement.
Harper CM, Dong Y, Thornhill TS, Wright J, Ready J, Brick GW, Dyer G. Can therapy dogs improve pain and satisfaction after total joint arthroplasty? A randomized controlled trial. Clin Orthop Relat Res. 2015 Jan;473(1):372-9. Epub 2014 Sep 9.
The use of animals to augment traditional medical therapies has been well established. The authors of this study evaluated the role of therapy dogs in an orthopaedic population following total hip and total knee replacements. Specifically, they evaluated the effects of therapy dogs on visual analog scale pain scores as well as on the patients’ self-reported satisfaction with their hospital experience with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Using a cohort of >70 randomized patients, the authors found that patients who had therapy dogs had a final visual analog scale score that was 2.4 points lower than those in the control group. The patients who had therapy dogs also reported higher top-box scores for nursing communication and pain management, and an overall hospital rating of 9.6 compared with 8.6. These findings were not only significant, but the differences were likely also to be clinically important as well. Therefore, the authors suggested that the use of therapy dogs might improve the patient experience following joint replacement surgical procedures.
Højer Karlsen AP, Geisler A, Petersen PL, Mathiesen O, Dahl JB. Postoperative pain treatment after total hip arthroplasty: a systematic review. Pain. 2015 Jan;156(1):8-30.
There are many options for the management of pain following total hip arthroplasty, but no consensus on a standardized protocol or guidelines from the AAOS. This review investigated nearly 60 randomized studies and included opiate consumption, pain scores, adverse events, and length of hospital stay. In their review, the authors concluded that many studies had a high risk of bias, substantial differences in assessment tools and criteria for pain, irregular reporting of adverse events, considerable differences in supplemental analgesic consumption, and basic analgesic regimens, all of which, taken together, made the results difficult to interpret. Nonsteroidal anti-inflammatory drugs and lumbar plexus block were demonstrated to provide reductions in postoperative pain scores. Intrathecal opioids increased pruritus, and lumbar plexus block reduced nausea and pruritus. The review demonstrated that some analgesic interventions may have the capacity to reduce mean opioid requirements and/or mean pain intensity compared with controls, but the available randomized placebo-controlled trials do not allow a designation of a “best proven intervention” for total hip arthroplasty.
Papakostidis C, Tosounidis TH, Jones E, Giannoudis PV. The role of “cell therapy” in osteonecrosis of the femoral head. A systematic review of the literature and meta-analysis of 7 studies. Acta Orthop. 2016 Feb;87(1):72-8. Epub 2015 Jul 29.
Compared with osteoarthritis, osteonecrosis of the femoral head is a less common problem leading to hip replacement. However, many of these patients are younger or have substantial comorbidities including alcohol abuse, chronic corticosteroid usage, underlying solid or blood malignancies, or diseases such as sickle cell. Although most studies suggest that hip replacement in this population is successful, the long-term results are generally worse than those for patients with a diagnosis of osteoarthritis. The authors conducted a literature review and investigated whether implantation of autologous bone marrow aspirate, containing high concentrations of pluripotent mesenchymal stem cells, into the core decompression track would improve the clinical and radiographic results compared with the classical method of core decompression alone. The primary outcomes of interest were structural failure (collapse) of the femoral head and conversion to total hip replacement. Their review showed that injection of autologous stem cells was superior to core decompression by a factor of 5. They suggested that the injection of aspirated bone marrow cells would be a useful adjunct to core decompression in delaying the need for hip replacement in patients with osteonecrosis of the femoral head.
Van der Weegen W, Kornuijt A, Das D. Do lifestyle restrictions and precautions prevent dislocation after total hip arthroplasty? A systematic review and meta-analysis of the literature. Clin Rehabil. 2016 Apr;30(4):329-39. Epub 2015 Mar 31.
Precautions and limitations following hip replacement have been a fundamental aspect of postoperative care, especially when using the posterior approach. The anterolateral approach had the desirable effect of lower dislocation rates, but at the cost of potentially weakened abductor muscles and a painless limp. The anterior approach has recently gained popularity and has the potential advantages of a lower dislocation rate in the early postoperative period and more rapid recovery following a surgical procedure. This approach frequently requires the use of expensive and dedicated tables and fluoroscopy, and it perhaps has a higher incidence of fractures and perforations of the femur. Most surgeons would agree that there was an extensive learning curve in becoming comfortable with this approach.
This study reviewed >100 other studies that included >1,000 patients who underwent hip replacement with a posterior or an anterolateral approach. The authors compared the dislocation rate between patients who were and were not given restrictions in motion or activity following the procedure. Both groups were comparable in numbers and demographic characteristics.
The authors’ review showed that the rates of dislocation in the group given restrictions and those in the unrestricted group were comparable. More importantly, the unrestricted group had a more rapid return to activities. The authors concluded that a more liberal approach toward lifestyle restrictions actually improved the rate of recovery and function, without increasing the risk of dislocation.
With the use of larger head sizes in bearing couples, the overall rate of dislocation has decreased and is roughly comparable regardless of surgical approach, and surgeons are now able to get good results using a variety of techniques that allow them to achieve the best results possible. If validated by further clinical investigations, the findings in this study may alter the use of traditional restrictions in activity and positioning following total hip replacement and may result in improved recovery and activity without an increase in the risk of dislocation.
Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.
Disclosure: Two authors of this work (J.T.N. and S.J.I.) received a stipend from JBJS for writing this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work.
1. Wyles CC, Jimenez-Almonte JH, Murad MH, Norambuena-Morales GA, Cabanela ME, Sierra RJ, Trousdale RT. There are no differences in short- to mid-term survivorship among total hip-bearing surface options: a network meta-analysis. Clin Orthop Relat Res. 2015 ;473(6):2031–41. Epub 2014 Dec 17.
2. Beaupre LA, Al-Houkail A, Johnston DW. A randomized trial comparing ceramic-on-ceramic bearing vs ceramic-on-crossfire-polyethylene bearing surfaces in total hip arthroplasty. J Arthroplasty. 2016 ;31(6):1240–5. Epub 2015 Dec 7.
3. Shareghi B, Johanson PE, Kärrholm J. Femoral head penetration of vitamin E-infused highly cross-linked polyethylene liners: a randomized radiostereometric study of seventy hips followed for two years. J Bone Joint Surg Am. 2015 ;97(16):1366–71.
4. Triantafyllopoulos GK, Elpers ME, Burket JC, Esposito CI, Padgett DE, Wright TM. Otto Aufranc Award: Large heads do not increase damage at the head-neck taper of metal-on-polyethylene total hip arthroplasties. Clin Orthop Relat Res. 2016 ;474(2):330–8.
5. Del Balso C, Teeter MG, Tan SC, Lanting BA, Howard JL. Taperosis: Does head length affect fretting and corrosion in total hip arthroplasty? Bone Joint J. 2015 ;97-B(7):911–6.
6. Kocagoz SB, Underwood RJ, MacDonald DW, Gilbert JL, Kurtz SM. Ceramic heads decrease metal release caused by head-taper fretting and corrosion. Clin Orthop Relat Res. 2016 ;474(4):985–94. Epub 2016 Feb 4.
7. Nawabi DH, Do HT, Ruel A, Lurie B, Elpers ME, Wright T, Potter HG, Westrich GH. Comprehensive analysis of a recalled modular total hip system and recommendations for management. J Bone Joint Surg Am. 2016 ;98(1):40–7.
8. Sheth D, Cafri G, Inacio MC, Paxton EW, Namba RS. Anterior and anterolateral approaches for THA are associated with lower dislocation risk without higher revision risk. Clin Orthop Relat Res. 2015 ;473(11):3401–8.
9. Pitto RP, Garland M, Sedel L. Are ceramic-on-ceramic bearings in total hip arthroplasty associated with reduced revision risk for late dislocation? Clin Orthop Relat Res. 2015 ;473(12):3790–5.
10. Epinette JA. Clinical outcomes, survivorship and adverse events with mobile-bearings versus fixed-bearings in hip arthroplasty-a prospective comparative cohort study of 143 ADM versus 130 Trident cups at 2 to 6-year follow-up. J Arthroplasty. 2015 ;30(2):241–8. Epub 2014 Oct 2.
11. Yue C, Kang P, Yang P, Xie J, Pei F. Topical application of tranexamic acid in primary total hip arthroplasty: a randomized double-blind controlled trial. J Arthroplasty. 2014 ;29(12):2452–6. Epub 2014 Mar 29.
12. Duncan CM, Gillette BP, Jacob AK, Sierra RJ, Sanchez-Sotelo J, Smith HM. Venous thromboembolism and mortality associated with tranexamic acid use during total hip and knee arthroplasty. J Arthroplasty. 2015 ;30(2):272–6. Epub 2014 Sep 6.
13. Bedair H, Yang J, Dwyer MK, McCarthy JC. Preoperative erythropoietin alpha reduces postoperative transfusions in THA and TKA but may not be cost-effective. Clin Orthop Relat Res. 2015 ;473(2):590–6.
14. Springer BD, Odum SM, Fehring TK. What is the benefit of tranexamic acid vs reinfusion drains in total joint arthroplasty? J Arthroplasty. 2016 ;31(1):76–80. Epub 2015 Aug 18.
15. van Bodegom-Vos L, Voorn VM, So-Osman C, Vliet Vlieland TP, Dahan A, Koopman-van Gemert AW, Vehmeijer SB, Nelissen RG, Marang-van de Mheen PJ. Cell salvage in hip and knee arthroplasty: a meta-analysis of randomized controlled trials. J Bone Joint Surg Am. 2015 ;97(12):1012–21.
16. Nam D, Nunley RM, Johnson SR, Keeney JA, Clohisy JC, Barrack RL. Thromboembolism prophylaxis in hip arthroplasty: routine and high risk patients. J Arthroplasty. 2015 ;30(12):2299–303. Epub 2015 Jul 2.
17. Nam D, Nunley RM, Johnson SR, Keeney JA, Clohisy JC, Barrack RL. The effectiveness of a risk stratification protocol for thromboembolism prophylaxis after hip and knee arthroplasty. J Arthroplasty. 2016 ;31(6):1299–306. Epub 2015 Dec 17.
18. Weiser MC, Moucha CS. The current state of screening and decolonization for the prevention of Staphylococcus aureus surgical site infection after total hip and knee arthroplasty. J Bone Joint Surg Am. 2015 ;97(17):1449–58.
19. Baratz MD, Hallmark R, Odum SM, Springer BD. Twenty percent of patients may remain colonized with methicillin-resistant Staphylococcus aureus despite a decolonization protocol in patients undergoing elective total joint arthroplasty. Clin Orthop Relat Res. 2015 ;473(7):2283–90.
20. Sousa RJ, Barreira PM, Leite PT, Santos AC, Ramos MH, Olivera AF. Preoperative Staphylococcus aureus screening/decolonization protocol before total joint arthroplasty-results of a small prospective randomized trial. J Arthroplasty. 2016 ;31(1):234–9. Epub 2015 Aug 14.
21. Torres EG, Lindmair-Snell JM, Langan JW, Burnikel BG. Is preoperative nasal povidone-iodine as efficient and cost-effective as standard methicillin-resistant Staphylococcus aureus screening protocol in total joint arthroplasty? J Arthroplasty. 2016 ;31(1):215–8. Epub 2015 Sep 26.
22. Ponce B, Raines BT, Reed RD, Vick C, Richman J, Hawn M. Surgical site infection after arthroplasty: comparative effectiveness of prophylactic antibiotics: do surgical care improvement project guidelines need to be updated? J Bone Joint Surg Am. 2015 ;96(12):970–77. [Epub ahead of print].
23. Young SW, Zhu M, Shirley OC, Wu Q, Spangehl MJ. Do ‘surgical helmet systems or ‘body exhaust suits’ affect contamination and deep infection rates in arthroplasty? A systematic review. J Arthroplasty. 2016 ;31(1):225–33. Epub 2015 Aug 1.
24. Hanselman AE, Montague MD, Murphy TR, Dietz MJ. Contamination relative to the activation timing of filtered-exhaust helmets. J Arthroplasty. 2016 ;31(4):776–80. Epub 2015 Nov 10.
25. Janz V, Bartek B, Wassilew GI, Stuhlert M, Perka CF, Winkler T. Validation of synovial aspiration in Girdlestone hips for detection of infection persistence in patients undergoing 2-stage revision total hip arthroplasty. J Arthroplasty. 2016 ;31(3):684–7. Epub 2015 Oct 9.
26. Deirmengian C, Kardos K, Kilmartin P, Cameron A, Schiller K, Parvizi J. Diagnosing periprosthetic joint infection: has the era of the biomarker arrived? Clin Orthop Relat Res. 2014 ;472(11):3254–62.
27. Deirmengian C, Kardos K, Kilmartin P, Gulati S, Citrano P, Booth RE Jr. The alpha-defensin test for periprosthetic joint infection responds to a wide spectrum of organisms. Clin Orthop Relat Res. 2015 ;473(7):2229–35.
28. Hoell S, Borgers L, Gosheger G, Dieckmann R, Schulz D, Gerss J, Hardes J. Interleukin-6 in two-stage revision arthroplasty: what is the threshold value to exclude persistent infection before re-implanatation? Bone Joint J. 2015 ;97-B(1):71–5.
29. Siqueira MB, Saleh A, Klika AK, O’Rourke C, Schmitt S, Hiquera CA, Barsoum WK. Chronic suppression of periprosthetic joint infections with oral antibiotics increases infection-free survivorship. J Bone Joint Surg Am. 2015 ;97(15):1220–32.
30. Konan S, Garbuz DS, Masri BA, Duncan CP. Modular tapered titanium stems in revision arthroplasty of the hip: the risk and causes of stem fracture. Bone Joint J. 2016 ;98-B(1 Suppl A):50–3.
31. McLaughlin JR, Lee KR. Total hip arthroplasty with an uncemented tapered femoral component in patients younger than 50 years of age: a minimum 20-year follow-up study. J Arthroplasty. 2016 ;31(6):1275–8. Epub 2015 Dec 20.
32. Houdek MT, Perry KI, Wyles CC, Berry DJ, Sierra RJ, Trousdale RT. Use of a modular tapered fluted femoral component in revision total hip arthroplasty following resection of a previously infected total hip: minimum 5-year follow-up. J Arthroplasty. 2015 ;30(3):435–8. Epub 2014 Sep 6.
33. Rivkin G, Kandel L, Qutteineh B, Liebergall M, Mattan Y. Long term results of liner polyethylene cementation technique in revision for peri-acetabular osteolysis. J Arthroplasty. 2015 ;30(6):1041–3. Epub 2015 Jan 30.
34. Tan TL, Le Duff MJ, Ebramzadeh E, Bhaurla SK, Amstutz HC. Long-term outcomes of liner cementation into a stable retained shell: a concise follow-up of a previous report. J Bone Joint Surg Am. 2015 ;97(11):920–4.
35. Bronson WH, Lindsay D, Lajam C, Iorio R, Caplan A, Bosco J. Ethics of provider risk factor modification in total joint arthroplasty. J Bone Joint Surg Am. 2015 ;97(19):1635–9.
36. Adhikary SD, Liu WM, Memtsoudis SG, Davis CM 3rd, Liu J. Body mass index more than 45 kg/m(2) as a cutoff point is associated with dramatically increased postoperative complications in total knee arthroplasty and total hip arthroplasty. J Arthroplasty. 2016 ;31(4):749–53. Epub 2015 Nov 10.
37. Alvi HM, Mednick RE, Krishnan V, Kwasny MJ, Beal MD, Manning DW. The effect of BMI on 30 day outcomes following total joint arthroplasty. J Arthroplasty. 2015 ;30(7):1113–7. Epub 2015 Feb 7.
38. Cornell CN. CORR Insights®: morbid obesity: increased risk of failure after aseptic revision TKA. Clin Orthop Relat Res. 2015 ;473(8):2628–9. Epub 2015 Apr 21.
39. Foster SA, Hambright DS, Antoci V, Greene ME, Malchau H, Kwon YM. Effects of obesity on health related quality of life following total hip arthroplasty. J Arthroplasty. 2015 ;30(9):1551–4. Epub 2015 Mar 31.
40. Gholson JJ, Shah AS, Gao Y, Noiseux NO. Morbid obesity and congestive heart failure increase operative time and room time in total hip arthroplasty. J Arthroplasty. 2016 ;31(4):771–5. Epub 2015 Nov 10.
41. Issa K, Harwin SF, Malkani AL, Bonutti PM, Scillia A, Mont MA. Bariatric orthopaedics: total hip arthroplasty in super-obese patients (those with a BMI of ≥50 kg/m2). J Bone Joint Surg Am. 2016 ;98(3):180–5.
42. McLawhorn AS, Southren D, Wang YC, Marx RG, Dodwell ER. Cost-effectiveness of bariatric surgery prior to total knee arthroplasty in the morbidly obese: a computer model-based evaluation. J Bone Joint Surg Am. 2016 ;98(2):e6.
43. Lau EC, Son MS, Mossad D, Toossi N, Johanson NA, Gonzalez MH, Meller MM. The validity of administrative BMI data in total joint arthroplasty. J Arthroplasty. 2015 ;30(10):1683–7. Epub 2015 May 5.
44. O’Toole P, Maltenfort MG, Chen AF, Parvizi J. Projected increase in periprosthetic joint infections secondary to rise in diabetes and obesity. J Arthroplasty. 2016 ;31(1):7–10. Epub 2015 Jul 21.
45. Perry KI, MacDonald SJ. The obese patient: a problem of larger consequence. Bone Joint J. 2016 ;98-B(1)(Suppl A):3–5.
46. Robinson RP. What will we do now with the super-obese patient undergoing total hip arthroplasty? Commentary on an article by Kimona Issa, MD, et al.: “Bariatric orthopaedics: total hip arthroplasty in super-obese patients (those with a BMI of ≥50 kg/m2)”. J Bone Joint Surg Am. 2016 ;98(3):e12.
47. Ward DT, Metz LN, Horst PK, Kim HT, Kuo AC. Complications of morbid obesity in total joint arthroplasty: risk stratification based on BMI. J Arthroplasty. 2015 ;30(9 Suppl):42–6. Epub 2015 Jun 3.
48. Pugely AJ, Martin CT, Gao Y, Schweizer ML, Callaghan JJ. The incidence of and risk factors for 30-day surgical site infections following primary and revision total joint arthroplasty. J Arthroplasty. 2015 ;30(9 Suppl):47–50. Epub 2015 Jun 3.
49. Edelstein AI, Kwasny MJ, Suleiman LI, Khakhkhar RH, Moore MA, Beal MD, Manning DW. Can the American College of Surgeons risk calculator predict 30-day complications after knee and hip arthroplasty? J Arthroplasty. 2015 ;30(9 Suppl):5–10. Epub 2015 May 27.
50. Russo MW, Macdonell JR, Paulus MC, Keller JM, Zawadsky MW. Increased complications in obese patients undergoing direct anterior total hip arthroplasty. J Arthroplasty. 2015 ;30(8):1384–7. Epub 2015 Mar 17.
51. Watts CD, Houdek MT, Wagner ER, Sculco PK, Chalmers BP, Taunton MJ. High risk of wound complications following direct anterior total hip arthroplasty in obese patients. J Arthroplasty. 2015 ;30(12):2296–8. Epub 2015 Jun 12.
52. Ast MP, Abdel MP, Lee YY, Lyman S, Ruel AV, Westrich GH. Weight changes after total hip or knee arthroplasty: prevalence, predictors, and effects on outcomes. J Bone Joint Surg Am. 2015 ;97(11):911–9.
53. Best MJ, Buller LT, Klika AK, Barsoum WK. Outcomes following primary total hip or knee arthroplasty in substance misusers. J Arthroplasty. 2015 ;30(7):1137–41. Epub 2015 Feb 7.
54. Menendez ME, Ring D, Bateman BT. Preoperative opioid misuse is associated with increased morbidity and mortality after elective orthopaedic surgery. Clin Orthop Relat Res. 2015 ;473(7):2402–12. Epub 2015 Feb 19.
55. Post ZD. CORR Insights(®): preoperative opioid misuse is associated with increased morbidity and mortality after elective orthopaedic surgery. Clin Orthop Relat Res. 2015 ;473(7):2413–4. Epub 2015 Mar 10.
56. Duchman KR, Gao Y, Pugely AJ, Martin CT, Noiseux NO, Callaghan JJ. The effect of smoking on short-term complications following total hip and knee arthroplasty. J Bone Joint Surg Am. 2015 ;97(13):1049–58.
57. Maradit Kremers H, Kremers WK, Berry DJ, Lewallen DG. Social and behavioral factors in total knee and hip arthroplasty. J Arthroplasty. 2015 ;30(10):1852–4. Epub 2015 May 5.
58. Dave AJ, Selzer F, Losina E, Klara KM, Collins JE, Usiskin I, Band P, Dalury DF, Iorio R, Kindsfater K, Katz JN. Is there an association between whole-body pain with osteoarthritis-related knee pain, pain catastrophizing, and mental health? Clin Orthop Relat Res. 2015 ;473(12):3894–902. Epub 2015 Oct 6.
59. Froemke CC, Wang L, DeHart ML, Williamson RK, Ko LM, Duwelius PJ. Standardizing care and improving quality under a bundled payment initiative for total joint arthroplasty. J Arthroplasty. 2015 ;30(10):1676–82. Epub 2015 May 5.
60. Iorio R. The future is here: bundled payments and International Statistical Classification of Diseases, 10th Revision. J Arthroplasty. 2016 ;31(5):931. Epub 2016 Mar 2.
61. Iorio R, Clair AJ, Inneh IA, Slover JD, Bosco JA, Zuckerman JD. Early results of Medicare’s Bundled Payment Initiative for a 90-day total joint arthroplasty episode of care. J Arthroplasty. 2016 ;31(2):343–50. Epub 2015 Sep 9.
62. Kamath AF, Courtney PM, Bozic KJ, Mehta S, Parsley BS, Froimson MI. Bundled payment in total joint care: survey of AAHKS membership attitudes and experience with alternative payment models. J Arthroplasty. 2015 ;30(12):2045–56. Epub 2015 May 29.
63. Bolz NJ, Iorio R. Bundled payments: our experience at an academic medical center. J Arthroplasty. 2016 ;31(5):932–5. Epub 2016 Mar 2.