Acetabular cup position differs in spinopelvic mobility types: a prospective observational study of primary total hip arthroplasty patients

Introduction: Spinopelvic mobility was identified as a contributing factor for total hip arthroplasty (THA) instability. The influence of spinopelvic function on acetabular cup positioning has not yet been sufficiently investigated in a prospective setting. Therefore, our study aimed (1) to assess cup inclination and anteversion in standing and sitting based on spinopelvic mobility, (2) to identify correlations between cup position and spinopelvic function, (3) and to determine the influence of the individual spinal segments, spinal sagittal balance, and spinopelvic characteristics on the mobility groups. Materials and methods: A prospective study assessing 197 THA patients was conducted with stereoradiography in standing and sitting position postoperatively. Two independent investigators determined cup anteversion and inclination, C7-Sagittal vertical axis, cervical lordosis (CL), thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope, pelvic tilt (PT), anteinclination (AI), and pelvic femoral angle (PFA). Spinopelvic mobility is defined based on increment PT = PTstanding - PTsitting as increment PT = 10-30 degrees normal, and increment PT > 30 degrees hypermobile. Pearson coefficient represented correlations between the cup position and spinopelvic parameters. Results: Significant differences were demonstrated for cup anteversion (stiff/hypermobile 29.3 degrees/40.1 degrees; p < 0.000) and inclination (stiff/hypermobile 43.5 degrees/60.2 degrees; p < 0.000) in sitting, but not in standing position. increment (standing/sitting) of the cup anteversion (stiff/neutral/hypermobile 5.8 degrees/12.4 degrees/19.9 degrees; p < 0.000) and inclination (stiff/neutral/hypermobile 2.3 degrees/11.2 degrees/18.8 degrees; p < 0.000) revealed significant differences between the mobility groups. The acetabular cup position in sitting, was correlated with lumbar flexibility ( increment LL) and spinopelvic mobility. Significant differences were detected between the mobility types and acetabular orientation (AI sit:stiff/hypermobile 47.6 degrees/65.4 degrees; p < 0.000) and hip motion ( increment PFA:stiff/hypermobile 65.8 degrees/37.3 degrees; p < 0.000). Assessment of the spinal segments highlighted the role of lumbar flexibility ( increment LL:stiff/hypermobile 9.9 degrees/36.2 degrees; p < 0.000) in the spinopelvic complex. Conclusion: The significantly different acetabular cup positions in sitting and in the increment between standing and sitting and the significantly altered spinopelvic characteristics in terms of stiff and hypermobile spinopelvic mobility underlined the consideration for preoperative functional radiological assessment. Identifying the patients with altered spinopelvic mechanics due to a standardized screening algorithm is necessary to provide safe acetabular cup positioning. The proximal spinal segments appeared not to be involved in the spinopelvic function

Total hip arthroplasty for destructive septic arthritis of the hip using a two-stage protocol without spacer placement

Introduction: The optimal treatment of patients with a degenerative joint disease secondary to an active or chronic septic arthritis of the hip is unclear. The aim of the present study was to report on our experience with two-stage total hip arthroplasty (THA) using a contemporary treatment protocol without spacer insertion. Materials and methods: Our prospective institutional database was used to identify all patients with degenerative septic arthritis treated with a non-spacer two-stage protocol between 2011 and 2017. Clinical outcomes included interim revision, periprosthetic infection (PJI) and aseptic revision rates. Restoration of leg-length and offset were assessed radiographically. Modified Harris hip score (mHHS) were obtained. Treatment success was defined using the modified Delphi consensus criteria. Mean follow-up was 62 months (13-110). Results: A total of 33 patients with a mean age of 60 years (13-85) were included. 55% of the cohort was male and average Charlson Comorbidity Index (CCI) was 3.7 (0-12). 21 patients (64%) had an active/acute infection and 12 patients (36%) were treated for chronic/quiescent septic arthritis. Overall, 11 patients (33%) had treatment failure, including 5 patients who failed to undergo THA, 2 interim re-debridement for persistent infection, and 4 patients who developed PJI after an average of 7 months (0.3-13) following THA. The most common identified pathogen was Staphylococcus aureus (42.4%). No aseptic revision was recorded following THA. Leg-length and offset were successfully restored. Mean mHHS improved from 35.2 points to 73.4 points. Conclusion: Two-stage THA without spacer placement is a viable treatment option for destructive septic arthritis of the hip, demonstrating comparable rates of infection control and functional outcome. However, definitive resection arthroplasty is not uncommon in these often critically ill patients

Is a preoperative pathogen detection a prerequisite before undergoing one-stage exchange for prosthetic joint infection of the hip?

BACKGROUND A preoperative pathogen detection is considered a prerequisite before undergoing one-stage exchange for prosthetic joint infection (PJI) according to most guidelines. This study compares patients with and without preoperative pathogen detection undergoing one-stage exchange for PJI of the hip. The authors put up the hypothesis that a preoperative pathogen detection is no prerequisite in selected cases undergoing one-stage exchange. METHODS 30 consecutive patients with PJI of the hip, treated with one-stage exchange, between 2011 and 2021, were retrospectively included. Mean age was 70 years and mean follow-up 2.1 ± 1.8 years. PJI was defined according to the European Bone and Joint Infection Society. One-stage exchange was performed in (1) chronic PJI longer than 4 weeks, (2) well-retained bone condition, (3) absence of multiple prior revisions for PJI (≤ 2) with absence of difficult-to-treat pathogens in the past, and (4) necessity/preference for early mobility due to comorbidities/age. RESULTS One-stage exchange was performed in 20 patients with and in 10 without a preoperative pathogen detection. Age (71 years, 68 years, p = 0.519), sex (50% and 30% males, p = 0.440), American Society of Anesthesiologists Score (2.2, 2.4, p = 0.502), and Charlson Comorbidity Index (3, 4, p = 0.530) did not differ among the two groups. No significant differences were noted concerning preoperative CRP (15 mg/l, 43 mg/l, p = 0.228), synovial cell count (15.990/nl, 5.308/nl, p = 0.887), radiological signs of loosening (55%, 50%, p = 0.999), and intraoperative histopathology. Except a higher rate of coagulase-negative staphylococci (70%, 20%, p = 0.019) in patients with a preoperative pathogen detection, no significant differences in pathogen spectrum were identified among groups. Revision for PJI recurrence was performed in one patient with an initial preoperative pathogen detection (3.3%). Additional revisions were performed for dislocation in two and postoperative hematoma in one patient. Revision rate for both septic and aseptic causes (p = 0.999), stay in hospital (16 and 15 days, p = 0.373) and modified Harris Hip Score (60, 71, p = 0.350) did not differ between groups. CONCLUSION Patients with and without a preoperative pathogen detection did not show significant differences concerning baseline characteristics, clinical and functional outcomes at 2 years. An absent preoperative pathogen detection is no absolute contraindication for one-stage exchange in chronic PJI, if involving good bone quality and absence of multiple prior revisions

Periacetabular Osteotomy and Postoperative Pregnancy—Is There an Influence on the Mode of Birth?

As a surgical treatment option in symptomatic developmental dysplasia of the hip, periacetabular osteotomy (PAO) is often performed in female patients of childbearing age. Yet, to date, little is known about the procedure's influence on postoperative pregnancies and the mode of delivery. Our study's aim therefore was to investigate patient and physician decision making in women after PAO. We invited all patients who had undergone PAO in our institution from January 2015 to June 2017 to participate in a paper-based survey. Of these, we included all female patients and performed a retrospective chart review as well as analysis of pre- and postoperative radiological imaging. A total of 87 patients were included, 20 of whom gave birth to 26 children after PAO. The mean overall follow-up was 5.3 +/- 0.8 years. Four (20.0%) patients reported that their obstetrician was concerned due to their history of PAO. The mean time before the first child's birth was 2.9 +/- 1.3 years. Eleven (55.0%) patients underwent cesarean section for the first delivery after PAO, three of whom reported their history of PAO as the reason for this type of delivery. Patients with a history of PAO have a higher risk of delivering a child by cesarean section compared with the general population, in which the rate of cesarean section is reported to be 29.7%. As cesarean sections are associated with increased morbidity and mortality compared with vaginal deliveries, evidence-based recommendations for pregnancies after pelvic osteotomy are needed

Extended Trochanteric Osteotomy with Intermediate Resection Arthroplasty Is Safe for Use in Two-Stage Revision Total Hip Arthroplasty for Infection

Background: This study sought to compare the results of two-stage revision total hip arthroplasty (THA) for periprosthetic infection (PJI) in patients with and without the use of an extended trochanteric osteotomy (ETO) for removal of a well-fixed femoral stem or cement. Methods: Thirty-two patients who had undergone an ETO as part of a two-stage revision without spacer placement were matched 1:2 with a cohort of sixty-four patients of the same sex and age who had stem removal without any osteotomy. Clinical outcomes including interim revision, reinfection and aseptic failure rates were evaluated. Modified Harris hip scores (mHHS) were calculated. Minimum follow-up was two years. Results: Patients undergoing ETO had a significantly lower rate of interim re-debridement compared to non-ETO patients (0% vs. 14.1%, p = 0.026). Reinfection following reimplantation was similar in both groups (12.5% in ETO patients vs. 9.4% in non-ETO patients, p = 0.365). Revision for aseptic reason was necessary in 12.5% in the ETO group and 14.1% in the non-ETO group (p = 0.833). Periprosthetic femoral fractures were seen in three patients (3.1%), of which all occurred in non-ETO patients. Dislocation was the most common complication, which was equally distributed in both groups (12.5%). The mean mHHS was 37.7 in the ETO group and 37.3 in the non-ETO group, and these scores improved significantly in both groups following reimplantation (p < 0.01). Conclusion: ETO without the use of spacer is a safe and effective method to manage patients with well-fixed femoral stems and for thorough cement removal in two-stage revision THA for PJI. While it might reduce the rate of repeated debridement in the interim period, the use of ETO appears to lead to similar reinfection rates following reimplantation

Functional Assessment and Patient-Related Outcomes after Gluteus Maximus Flap Transfer in Patients with Severe Hip Abductor Deficiency

(1) Background: Degeneration of the hip abductor mechanism, a well-known cause of functional limitation, is difficult to treat and is associated with a reduced health-related quality of life (HRQOL). The gluteus maximus muscle flap is a treatment option to support a severely degenerative modified gluteus medius muscle. Although several reports exist on the clinical outcome, there remains a gap in the literature regarding HRQOL in conjunction with functional results. (2) Methods: The present study consists of 18 patients with a mean age of 64 (53‒79) years, operatively treated with a gluteus maximus flap due to chronic gluteal deficiency. Fifteen (83%) of these patients presented a history of total hip arthroplasty or revision arthroplasty. Pre and postoperative pain, Trendelenburg sign, internal rotation lag sign, trochanteric pain syndrome, the Harris Hip Score (HHS), and abduction strength after Janda (0‒5) were evaluated. Postoperative patient satisfaction and health-related quality of life, according to the Short Form 36 (SF-36), were used as patient-reported outcome measurements (PROMs). Postoperative MRI scans were performed in 13 cases (72%). (3) Results: Local pain decreased from NRS 6.1 (0-10) to 4.9 (0-8) and 44% presented with a negative Trendelenburg sign postoperatively. The overall HHS results (p = 0.42) and muscular abduction strength (p = 0.32) increased without significance. The postoperative HRQOL reached 46.8 points (31.3-62.6) for the mental component score and 37.1 points (26.9-54.7) for the physical component score. The physical component results presented a high level of positive correlation with HHS scores postoperatively (R = 0.88, p < 0.001). Moreover, 72% reported that they would undergo the operative treatment again. The MRI overall showed no significant further loss of muscle volume and no further degeneration of muscular tissue. (4) Conclusions: Along with fair functional results, the patients treated with a gluteus maximus flap transfer presented satisfying long-term PROMs. Given this condition, the gluteus maximus muscle flap transfer is a viable option for selected patients with chronic gluteal deficiency

Does obesity affect acetabular cup position, spinopelvic function and sagittal spinal alignment? A prospective investigation with standing and sitting assessment of primary hip arthroplasty patients

Background: Total hip arthroplasty (THA) instability is influenced by acetabular component positioning, spinopelvic function and sagittal spinal alignment. Obesity is considered as a risk factor of THA instability, but the causal relationship remains unknown. This study aimed to investigate the influence of BMI on (1) spinopelvic function (lumbar flexibility, pelvic mobility and hip motion), (2) sagittal spinal alignment pre- and postoperatively and (3) acetabular cup position postoperatively in primary THA patients in a prospective setting. Methods: One hundred ninety patients receiving primary total hip arthroplasty were enrolled in a prospective cohort study and retrospectively analysed. All patients received stereoradiography (EOS) in standing and relaxed sitting position pre-and postoperatively. C7-sagittal vertical axis (C7-SVA), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), anterior plane pelvic tilt (APPT), and pelvic femoral angle (PFA) were assessed. Key parameters of the spinopelvic function were defined as lumbar flexibility ( increment LL = LLstanding - LLsitting), pelvic mobility ( increment PT = PTstanding - PTsitting) and hip motion ( increment PFA = PFA(standing) - PFA(sitting)). Pelvic mobility was further defined based on increment PT as stiff, normal and hypermobile ( increment PT 30 degrees). The patients were stratified to BMI according to WHO definition: normal BMI >= 18.5-24.9 kg/m(2) (n = 68), overweight >= 25.0-29.9 kg/m(2) (n = 81) and obese >= 30-39.9 kg/m(2) (n = 41). Post-hoc analysis according to Hochberg's GT2 was applied to determine differences between BMI groups. Results: Standing cup inclination was significant higher in the obese group compared to the normal BMI group (45.3 degrees vs. 40.1 degrees; p = 0.015) whereas standing cup anteversion was significantly decreased (22.0 degrees vs. 25.3 degrees; p = 0.011). There were no significant differences for spinopelvic function key parameter lumbar flexibility ( increment LL), pelvic mobility ( increment PT) and hip motion ( increment PFA) in relation to BMI stratified groups. The obese group demonstrated significant enhanced pelvic retroversion compared to the normal BMI group (APPT - 1.8 degrees vs. 2.4 degrees; p = 0.028). The preoperative proportion of stiff pelvic mobility was decreased in the obese group (12.2%) compared to normal (25.0%) and overweight (27.2%) groups. Spinal sagittal alignment in C7-SVA and PI-LL mismatch demonstrated significantly greater imbalance in the obese group compared to the normal BMI group (68.6 mm vs. 42.6 mm, p = 0.002 and 7.7 degrees vs. 1.2 degrees, p = 0.032, respectively) The proportion of patients with imbalanced C7-SVA was higher in the obese (58.5%) than in the normal BMI group (44.1%). Conclusions: The significantly increased spinal sagittal imbalance with altered pelvic mechanics is a potential cause for the reported increased risk of THA dislocations in obese patients. Consequently, the increased spinal sagittal imbalance in combination with normal pelvic mobility need to be taken into account when performing THA in obese patients

Management of Chronically Infected Total Knee Arthroplasty With Severe Bone Loss Using Static Spacers With Intramedullary Rods

Fragestellung: Der zweizeitige Prothesenwechsel mit Verwendung eines temporären, antibiotikahaltigen Spacers gilt als Goldstandard für die Behandlung der chronisch infizierten Knietotalendoprothese (KTEP). Bei Vorliegen großer Knochendefekte haben sich statische Spacer mit intramedullärer Verankerung bewährt. Ziel dieser Studie war es, die bakterielle Besiedelung der diaphysär verankerten Spacerstangen zu analysieren sowie das infektfreie Überleben, Komplikationen und Risikofaktoren für ein Therapieversagen zu bestimmen. Material und Methoden: 97 Patienten, welche bei infizierter KTEP mit ausgeprägtem Knochendefekt einen zweizeitigen Wechsel erhielten, wurden eingeschlossen. In allen Fällen wurden nach Prothesenausbau und radikalem Débridement, Stahlstangen eines AO- Fixateurs in beide Markräume eingeführt, auf Gelenkniveau konnektiert und der Gelenkraum mit antibiotikahaltigem Knochenzement ausgefüllt. Die mittlere Verweildauer des Spacers betrug 9 Wochen (6-24). Die Spacerstangen wurden mittels Sonikation analysiert. Das Therapieversagen wurde nach dem modifizierten Delphi-Konsensus definiert. Das mittlere Follow-up betrug 41 Monate (27–56). Ergebnisse: Bei allen Patienten konnte ein stabiles Kniegelenk ohne mechanische Komplikationen im Intervall erzielt werden. In nur zwei Fällen (2%) konnten auf den Spacerstangen Erreger nachgewiesen werden und keiner dieser Patienten erlitt eine Reinfektion. Insgesamt benötigten 9 Patienten (9%) einen Spacerwechsel, 3 Patienten (3%) hatten eine Reinfektion mit dem gleichen Erreger, 9 Patienten (9%) mit einem neuen Erreger und ein Patient (1%) verstarb frühpostoperativ nach KTEP-Reimplantation. Folglich trat bei 22 von 97 Patienten (23%) ein Therapieversagen auf. Patienten mit schlechterem Host- und Lokalstatus hatten ein signifikant höheres Risiko für eine Reinfektion (p=0.04 und p=0.03). Es waren keine Amputationen notwendig und alle Patienten hatten zum letzten Follow-up eine KTEP implantiert, wobei 2 Patienten eine antibiotische Langzeit-Suppression erhielten. Schlussfolgerung: Die Verwendung von statischen Spacern mit intramedullärer Verankerung stellen ein sicheres Verfahren dar, mit welchem das Kniegelenk ohne mechanische Komplikationen im Intervall belastet werden kann. Die meisten Reinfektionen wurden durch neue Erreger verursacht und Immun- und Weichteilstatus scheinen den Therapieerfolg maßgeblich zu beeinflussen.Background: Two-stage revision with static antibiotic spacers is the preferred treatment for chronically infected total knee arthroplasty (TKA) associated with severe bone loss. Intramedullary rods to reinforce static spacers have been described. On those, however, bacterial colonization may occur and hamper infection control. This study reports the microbiological findings on the spacer rods and the treatment outcome among these patients. Methods: We reviewed 97 infected TKA with extensive bone loss treated with antibiotic-loaded cement spacers reinforced with intramedullary rods. Mean interim period with the spacer in situ was 9 weeks (range: 6-24 weeks). Intraoperative cultures and sonicated spacer rods were analyzed. Mean follow-up after TKA reimplantation was 41 months (range: 27-56 months). Treatment success was defined using the modified Delphi consensus criteria. Results: In all patients, a stable knee joint with no mechanical failures in the interim period was achieved. Sonication cultures of the removed spacer rods were positive in only 2 cases (2%), and none of them failed. Overall, twenty-two patients (23%) had treatment failure, including 3 reinfections caused by the same organism, 9 reinfections caused by a different organism, 9 patients required interim spacer exchange, and 1 patient died in the early postoperative course after TKA reimplantation. Host and limb status was significantly worse in patients who sustained reinfection. At the latest follow-up, all patients had a TKA in place, and 2 patients received chronic antibiotic suppression. Conclusion: Two-stage revision with the use of intramedullary rods is a safe treatment for chronically infected TKA with severe bone loss eliminating mechanical complications in the interim period. Most reinfections grew different organisms compared with initial infection. Compromised hosts and extremities may be subjected to chronic antibiotic suppression

Total hip arthroplasty for destructive septic arthritis of the hip using a two-stage protocol without spacer placement

Introduction!#!The optimal treatment of patients with a degenerative joint disease secondary to an active or chronic septic arthritis of the hip is unclear. The aim of the present study was to report on our experience with two-stage total hip arthroplasty (THA) using a contemporary treatment protocol without spacer insertion.!##!Materials and methods!#!Our prospective institutional database was used to identify all patients with degenerative septic arthritis treated with a non-spacer two-stage protocol between 2011 and 2017. Clinical outcomes included interim revision, periprosthetic infection (PJI) and aseptic revision rates. Restoration of leg-length and offset were assessed radiographically. Modified Harris hip score (mHHS) were obtained. Treatment success was defined using the modified Delphi consensus criteria. Mean follow-up was 62 months (13-110).!##!Results!#!A total of 33 patients with a mean age of 60 years (13-85) were included. 55% of the cohort was male and average Charlson Comorbidity Index (CCI) was 3.7 (0-12). 21 patients (64%) had an active/acute infection and 12 patients (36%) were treated for chronic/quiescent septic arthritis. Overall, 11 patients (33%) had treatment failure, including 5 patients who failed to undergo THA, 2 interim re-debridement for persistent infection, and 4 patients who developed PJI after an average of 7 months (0.3-13) following THA. The most common identified pathogen was Staphylococcus aureus (42.4%). No aseptic revision was recorded following THA. Leg-length and offset were successfully restored. Mean mHHS improved from 35.2 points to 73.4 points.!##!Conclusion!#!Two-stage THA without spacer placement is a viable treatment option for destructive septic arthritis of the hip, demonstrating comparable rates of infection control and functional outcome. However, definitive resection arthroplasty is not uncommon in these often critically ill patients