ObjectiveTo compare the effects of piriformis muscle release versus preservation in total hip arthroplasty (THA) via supercapsular percutaneously-assisted total hip (SuperPATH) approach on muscle injury. MethodsForty-nine patients undergoing initial THA via SuperPATH approach between June 2022 and June 2023 were randomly divided into two groups, with 24 patients in trial group and 25 patients in control group. The trial group received piriformis muscle release intraoperatively, whereas the control group underwent muscle preservation. There was no significant difference in baseline data such as gender, age, body mass index, disease type, American Society of Anesthesiologists (ASA) grading, and preoperative muscle infiltration, muscle atrophy, muscle injury serological indicators, Harris score, etc. (P>0.05). The incision length, operation time, intraoperative blood loss, total blood loss, hospital stay, preoperative and postoperative 1-day muscle injury serological indicators [including creatine kinase (CK) and lactic dehydrogenase (LDH)], and incidence of complications between two groups were recorded. Harris score was used to evaluate the recovery of hip joint function. MRI was used to evaluate the extent of hip muscle injuries (gluteus minimus, gluteus medius, piriformis, obturator internus, quadratus femoris), including tendon integrity, degree of muscle fat infiltration, and degree of muscle atrophy preoperative and 1 year postoperatively. ResultsThe operation time, intraoperative blood loss, and total blood loss in the trial group were significantly shorter than those in the control group (P<0.05). There was no significant difference in the incision length and length of hospital stay between the two groups (P>0.05). Both groups showed a significant increase in serum CK and LDH levels on postoperative day 1 compared to preoperative levels (P<0.05), but there was no significant difference between the two groups (P>0.05). All patients were followed up, the follow-up time for the trial group and the control group was (14.8±2.8) and (15.1±3.0) months, respectively, with no significant difference (t=−0.400, P=0.691). Incisions healed by first intention in both groups, with 1 case in the trial group and 2 cases in the control group experiencing venous thrombosis in the calf muscle space. There was no complication such as deep vein thrombosis, pulmonary embolism, hip dislocation, prosthesis loosening, or periprosthetic infection in the lower limbs. There was no significant difference in the incidence of complications between the two groups (P>0.05). At 1 year after operation, both groups of patients showed a significant increase in Harris scores compared to preoperative levels (P<0.05), but there was no significant difference between the two groups (P>0.05). Compared with preoperative results, both groups showed significant fat infiltration in the piriformis and obturator muscles at 1 year after operation (P<0.05), while there was no significant fat infiltration in the gluteus minimus, gluteus medius, and quadratus femoris muscles (P>0.05). At 1 year after operation, except for the higher incidence of piriformis muscle fat infiltration in the control group compared to the trial group (P<0.05), there was no significant difference in the incidence of other muscle infiltrations between the two groups (P>0.05). At 1 year after operation, both groups of piriformis and obturator muscles showed significant muscle atrophy compared to preoperative levels (P<0.05). The gluteus minimus and gluteus medius showed mild atrophy compared to preoperative levels, while the maximum transverse diameter of the quadriceps muscle slightly increased, but the differences were not significant (P>0.05). There was no significant difference in the maximum cross-sectional diameter or cross-sectional area changes of each muscle between the two groups (P>0.05). At 1 year after operation, the continuity of the gluteus medius and quadratus femoris muscles in both groups was intact. Both groups had some patients with incomplete continuity of the piriformis muscle, obturator internus, and gluteus minimus, but the difference was not significant (P>0.05). ConclusionThe SuperPATH approach THA may cause injury to the piriformis, gluteus minimus, and obturator internus. The piriformis muscle release does not increase muscle injury, but it can shorten the operation time and reduce bleeding.
【Abstract】 Objective To evaluate the flexibil ity of the treatment of osteoarthritis secondary to acetabular dysplasiaby total hip arthroplasty (THA) , in which the acetabular component is placed in the true acetabulum and femoral osteotomy is not performed. Methods From January 1999 to December 2005, 35 THA procedures were performed in 32 patients with 35 hips, including 6 males with 7 hips and 26 females with 28 hips, with the average age of 53 years (ranging from 28 years to 72 years). On the basis of Crowe classification, type I included 10 patients with 11 hips, type II included 14 patients with 15 hips, type III included 5 patients with 6 hips, and type IV included 3 patients with 3 hips. All patients experienced severe pain and dysfunction. In 19 cases, the leg length discrepancy was from 3 cm to 6 cm. The Harris score was 41.49 ± 10.13 before the operation. In all procedures, the soft tissue was released entirely and the acetabular component was placed in the true acetabulum, but femoral osteotomy was not performed. Results The average operation time of unilateral THA was 50 minutes. All patients were given transfusion from 2 U to 4 U. All incisions healed at the first stage. After the operation, the leg was lengthened 2-6 cm, and the two legs were equally long. The follow-up lasted for 12 to 60 months. The Harris score was 84.71 ± 9.34 after the operation, showing statistically significant differece (P lt; 0.05). According to cl inical outcomes and X-ray films, no dislocation, femoral fracture, femoral or sciatic nerve palsy was detected. Conclusion It is effective to use THA procedures for osteoarthritis secondary to acetabular dysplasia. If the soft tissue is released entirely, the leg will be lengthened 4-6 cm without nerve palsy.
Objective Using the mono-energy reconstruction images and X-ray films to investigate whether the ABG Ⅱ short-stem could improve the filling ratio, stability, and alignment in the Dorr type C femur, compared with the Corail long-stem. MethodsAmong patients who were with Dorr type C femurs and treated with total hip arthroplasty between January 2006 and March 2012, 20 patients with a Corail long-stem (Corail group) and 20 patients with an ABG Ⅱ short-stem (ABG Ⅱ group) were randomly selected. The differences in gender, age, body mass index, and preoperative diagnoses between the two groups were not significant (P>0.05). The ABG Ⅱ group was with a mean follow-up of 142 months (range, 102-156 months), and the Corail group was with a mean follow-up of 107 months (range, 91-127 months). There was no significant difference in the Harris score and subjective satisfaction score between the two groups at last follow-up (P>0.05). At last follow-up, dual-energy CT scans with mono-energy image reconstruction were used to calculate the prosthetic filling ratio and to measure the alignment of the prosthesis in the coronal and sagittal positions. Stability assessment was performed based on X-ray films, and the subsidence distance was measured using EBRA-FCA software. ResultsX-ray film observation showed that the prostheses in the two groups were stable and no signs of loosening was found. The incidence of pedestal sign was significantly lower in the ABGⅡ group than in the Corail group (P<0.05), and the incidence of heterotopic ossification was significantly higher in the ABGⅡ group than in the Corail group (P<0.05). The subsidence distance of femoral stem in ABG Ⅱ group was significantly greater than that in Corail group (P<0.05), and the subsidence speed of femoral stem in ABG Ⅱ group was also greater than that in Corail group, but the difference was not significant (P>0.05). The overall prosthesis filling ratio was significantly higher in the ABG Ⅱ group than in the Corail group (P<0.05), while the coronal filling ratio at the lesser trochanter, 2 cm below the lesser trochanter, and 7 cm below the lesser trochanter were not significant (P>0.05). The results of prosthesis alignment showed that there was no significant difference in the sagittal alignment error value and the incidence of coronal and sagittal alignment error >3° between the two groups (P>0.05), while the coronal alignment error value in the ABG Ⅱ group was significantly greater than that in the Corail group (P<0.05). Conclusion Although the ABG Ⅱ short-stem avoids the distal-proximal mismatch of the Corail long-stem in the Dorr type C femur and thus achieves a higher filling ratio, it does not appear to achieve better alignment or stability.
ObjectiveTo review the perioperative blood management (PBM) of total knee arthroplasty (TKA) and total hip arthroplasty (THA).MethodsRecent researches on PBM for TKA and THA were comprehensively read and summarized. Then the advantages and disadvantages of various measures together with the clinical experience of West China Hospital of Sichuan University were evaluated from three aspects, including optimizing hematopoiesis, reducing blood loss and blood transfusion, which could provide a basis for clinical selection.ResultsThere are many PBM methods in TKA and THA, among which the optimization of hematopoiesis mainly includes the application of perioperative iron and erythropoietin. Measures to reduce bleeding include the use of tourniquet, intraoperative controlled hypotension, and perioperative antifibrinolytic agents. Autologous blood transfusion includes preoperative autologous blood donation, hemodilution and cell salvage. Allogeneic blood transfusion is the ultimate treatment for anemia. The application of erythropoietin combined with iron therapy for blood mobilization before surgery together with intraoperative controlled hypotension for bleeding control and the multiple use of tranexamic acid can achieve satisfactory clinical results.ConclusionIn the perioperative period of TKA and THA, single or multiple use of different blood management measures should be considered carefully according to the physical and economic conditions of patients individually, so as to reduce the blood loss and allogeneic blood transfusion optimally, and finally accelerate the recovery of patients.
Objective To systematically evaluate the difference in leg length discrepancy (LLD) between robot-assisted total hip arthroplasty (THA) and traditional THA. Methods The Cochrane Library, PubMed, Web of Science, EMbase, CNKI, Wanfang, VIP, and CBM databases were searched by computer to collect cohort studies of robot-assisted and traditional THAs from inception to August 11th, 2021. Two researchers independently screened the literature, extracted the data, and evaluated the risk of bias of the included studies. Meta-analysis was performed using RevMan 5.3 software. ResultsA total of 10 high-quality cohort studies were included. The results of Meta-analysis showed that compared with traditional THA, LLD after robot-assisted THA was smaller [MD=−1.64, 95%CI (−2.25, −1.04), P<0.001], Harris scores at 3 and 12 months after operation were higher [MD=1.50, 95%CI (0.44, 2.57), P=0.006; MD=7.60, 95%CI (2.51, 12.68), P=0.003]. However, the operative time was longer [MD=8.36, 95%CI (4.56, 12.17), P<0.000 1], and the postoperative acetabular anteversion angle was larger [MD=1.91, 95%CI (1.43, 2.40), P<0.001]. There was no significant difference in Harris score at 6 months, amnesia index (Forgotten joint score, FJS), postoperative acetabular abduction angle, and incidence of complication between the two groups (P>0.05). Conclusion Robot-assisted THA is superior to traditional THA in postoperative LLD.
Objective To investigate clinical significanceand surgical protocols about the balance of the lower limb lengths in the total hip arthroplasty. Methods Forty-eight patients undergoing the unilateral primary total hip arthroplasty from March 2000 to October 2004 were retrospectively studied. In 12 hips, the prostheses were of the cement type; in 36 hips, of the mixture type. Thirty patients with an equal limb length had a fractured femoral neck, 10 patients had a shortened (1.0-2.0 cm) limb, 6 patients had a shortened (2.0-4.0 cm)limb, and 2 patients had a shortened (4.0-6.0 cm) limb. Based on the clinical measurement and radiographic examination, the surgical protocols were designed, the hip prosthesis type was chosen, and the neck length of the femoral prosthesis and the position of osteotomy were estimated. By the wearing of the acetabula properly, the best rotation point was found out during the operation. The cut plane of the femoral neck was adjusted according to the results of the radiographic and other examinations. The neck length was readjusted after the insertion of the prosthesis so as to achieve an intended limblength equalization. Results All the patients were followed up for 3-42 months.According to the Harris scoring system, clinical results were excellent in 30 patients, good in 12, fair in4, and poor in 2. Of the 30 patients with an equal limb before operation, 5 were lengthened 1.0-2.0 cm in their lower limbs, and 1 lengthened 2.5 cm postoperatively. Of the 18 patients with shortened limbs before operation, 10 returned to the same lengths in their lower limbs, 6 were lengthened 1.0-2.0 cm in their lower limbs, but 2 with seriously-shortened lower limbs for congenital dysplasia of the hipjoint were still shortened 2.0-3.0 cm in the limb length after operation. The Harris hip scores revealed an average of 92.3 points in the patients with an equal limb length, and 88.6 points in the patients with shortened limbs. 〖WTHZ〗Conclusion Many factors, such as surgical protocols, prosthesis type designs, and the management techniques during the operation, can affect the limb length after operation. As the limb length discrepancy will make the patients feel disappointed, the clinical measurements are very important before operation. Application of the comprehensive appraisal methods during the operation, use of the soft tissuebalance method, and skills for obtaining an equal limb length during the total hip arthroplasty are also important for improving the surgical result further.
To compare the cl inical effect of total hi p arthroplasty (THA) using posterolateral conventional or minimally invasive incision. Methods From January 2007 to November 2007, 38 patients (41 hi ps) were treated with minimally invasive THA (mini-incision group), and 15 patients (15 hi ps) underwent conventional THA (conventional incision group). Mini-incision group: 23 males (25 hi ps) and 15 females (16 hi ps) aged (53.2 ± 15.5) years old; body mass index (BMI) was 23.4 ± 3.3; there were 20 cases (20 hips) of femoral neck fracture, 2 cases (2 hips) of primary osteoarthritis, 14 cases (16 hips) of stage III or IV aseptic necrosis of the femoral head, 2 cases (3 hips) of ankylosing spondyl itis involving hip joint; Harris hip score was 47.7 ± 5.5 and the course of disease was (4.5 ± 4.3) years. Conventional incision group: 7 males (7 hips) and 8 females (8 hips) aged (54.8 ± 10.8) years old; BMI was 26.1 ± 5.1; there were 8 cases (8 hips) of femoralneck fracture, 1 case (1 hip) of primary osteoarthritis, 5 cases (5 hips) of stage III or IV aseptic necrosis of the femoral head, 1 case (1 hip) of ankylosing spondyl itis involving hip joint; Harris hip score was 51.2 ± 4.3 and the course of disease was (3.8 ± 3.7) years. There were no statistically significant differences between two groups in the general information (P gt; 0.05). Results There were statistical differences between two groups in terms of incision length, perioperative blood loss, drainage volume and blood transfusion volume (P lt; 0.05), and no statistical differences were evident in operative time, abduction angle and the anteversion angle of acetabular cup (P gt; 0.05). All incisions healed by first intention and no early postoperative compl ications occurred. Two groups were followed for 12-22 months (average 18.3 months). All patients walked without the crutch at 2-3 months after operation. The Harris score of the mini-incision group and the conventional incision group 6 months after operation was 88.6 ± 3.6 and 85.8 ± 3.3, respectively, indicating there was no significant difference between two groups (P gt; 0.05), but there was significant difference between before and after operation (P lt; 0.05). Conclusion Compared with conventional THA, the minimaly incisive using posteroplateral approach THA has the merits of mini invasion, sl ight hemorrage, short hospital stay, minor compl ication, convenient management of femoral head and accurate prosthesis location. However, strict attention should be paid to operative indications.
ObjectiveTo evaluate the accuracy of using smartphone to measure the angle of acetabular component in total hip arthroplasty (THA). MethodsBetween June 2012 and September 2015, the acetabular abduction and anteversion angles were measured in 50 patients undergoing THA. There were 24 males and 26 females, aged 37 to 83 years (mean, 71 years). The left hip was involved in 22 cases and the right hip in 28 cases. Of 50 patients, 34 suffered from fracture of the femoral neck, and 16 suffered from avascular necrosis of the femoral head. Acetabular dysplasia was excluded in all cases. A smartphone was used to measure the acetabular abduction and anteversion angles during operation; standard Picture Archiving and Communication Systems (PACS) was used to measured the acetabular abduction and anteversion angles on the X-ray film at 1 week after operation. It was defined as positive that the component angle values by PACS measurement were greater than those by the smartphone measurement, whereas as negative. The two measurement methods were compared, and intra-observer variability was assessed by analyzing the intraclass correlation coefficient (ICC), the Mann-Whitney U-test was used to analyze difference. ResultsThe ICC was 0.84 in the acetabular component angles by smartphone and PACS measurement methods. The acetabular component abduction angle was (44.02±1.33)° and the anteversion angle was (17.62±2.20)° by smartphone measurement. The acetabular component abduction angle was (44.74±4.05)° and the anteversion angle was (17.22±5.57)° by PACS measurement. There was no significant difference between two measurement methods (Z=-1.977, P=0.482; Z=-0.368, P=0.713). The acetabular component angle was in the safe zone in 44 cases; and the acetabular component anteversion angle was beyond safe range of 1 to 5°, and the abduction angle was beyond safe range of 1 to 3° in 6 cases. Intra-measurement variability was -21 to +10° for the anteversion angle and -10 to + 9° for the abduction angle, indicating that the acetabular component anteversion angle by smartphone measurement was greater than that by the PACS measurement, and the abduction angle was less than that by PACS measurement. ConclusionSmartphone is a convenient tool to measure the acetabular component angle in THA.
Objective To review research advances of revision surgery after primary total hip arthroplasty (THA) for patients with Crowe type Ⅳ developmental dysplasia of the hip (DDH). Methods The recent literature on revision surgery after primary THA in patients with Crowe type Ⅳ DDH was reviewed. The reasons for revision surgery were analyzed and the difficulties of revision surgery, the management methods, and the related prosthesis choices were summarized. Results Patients with Crowe type Ⅳ DDH have small anteroposterior diameter of the acetabulum, large variation in acetabular and femoral anteversion angles, severe soft tissue contractures, which make both THA and revision surgery more difficult. There are many reasons for patients undergoing revision surgery after primary THA, mainly due to aseptic loosening of the prosthesis. Therefore, it is necessary to restore anatomical structures in primary THA, as much as possible and reduce the generation of wear particles to avoid postoperative loosening of the prosthesis. Due to the anatomical characteristics of Crowe type Ⅳ DDH, the patients have acetabular and femoral bone defects, and the repair and reconstruction of bone defects become the key to revision surgery. The acetabular side is usually reconstructed with the appropriate acetabular cup or combined metal block, Cage, or custom component depending on the extent of the bone defect, while the femoral side is preferred to the S-ROM prosthesis. In addition, the prosthetic interface should be ceramic-ceramic or ceramic-highly cross-linked polyethylene wherever possible. Conclusion The reasons leading to revision surgery after primary THA in patients with Crowe type Ⅳ DDH and the surgical difficulties have been clarified, and a large number of clinical studies have proposed corresponding revision modalities based on which good early- and mid-term outcomes have been obtained, but further follow-up is needed to clarify the long-term outcomes. With technological advances and the development of new materials, personalized prostheses for these patients are expected to become a reality.
ObjectiveTo explore the clinical outcomes of acetabular revision using a metal reconstruction cage. MethodsBetween October 2006 and October 2013, 16 patients (16 hips) underwent acetabular revision with a metal reconstruction cage. There were 4 males and 12 females, with the mean age of 62.7 years (range, 49-78 years). The time from total hip arthroplasty to revision was 3-15 years (mean, 8.2 years). The causes for revision were aseptic acetabular loosening in 15 cases, and femoral periprosthetic fracture (Vancouver type B3) in 1 case. According to the American Academy of Orthopaedic Surgeons (AAOS) classification, there were 12 cases of type III and 4 cases of type IV; according to the Paprosky classification, there were 12 cases of type IIIA and 4 cases of type IIIB. Harris score was used for hip function evaluation, and visual analogue scale (VAS) for pain in the thigh. X-ray films were taken for imaging evaluation. ResultsHealing of incision by first intention was obtained in all patients. Deep venous thrombosis occurred in 1 patient, and was cured after anticoagulation therapy. No complications of infection, neurovascular injury, and prosthetic dislocation were found. Sixteen patients were followed up 6.8 years on average (range, 2-9 years). The Harris score was significantly increased from preoperative 42.44±4.66 to 91.88±3.28 at last follow-up (t=–106.30, P=0.00). Two patients had mild pain in the thigh, but pain disappeared at 1 year after operation. At immediate after operation, the abduction angle was 37-54° (mean, 42.9°). The distance between acetabular rotation centre and teardrop line was (33.67±12.19) mm for preoperative value and was (20.67±9.63) mm for postoperative value, showing significant difference (t=–9.60, P=0.00). The distance between acetabular rotation centre and lateral teardrop was (34.98±12.30) mm for preoperative value and was (40.04±6.61) mm for postoperative value, showing significant difference (t=–3.15, P=0.00). X-ray film results showed bony fusion at the osteotomy sites at 4 to 12 months after operation. No continuous radiolucent line, prosthetic dislocation, or osteolysis was found, and bony ingrowth was observed in all patients. No patient received re-revision due to prosthetic loosening. ConclusionThe metal reconstruction cage for acetabular revision can achieve good effectiveness for patients with serious bone defect.