Fernando Comba

No need for routine closed suction drainage in elective arthroplasty of the hip A prospective randomized trial in 104 operations

BACKGROUND The purpose of this study was to determine the utility of closed suction drainage (CSD) in elective total hip arthroplasty (THA). PATIENTS AND METHODS We randomized 104 elective, consecutive THAs to receive drainage (53) or no drainage (51). 60 arthroplasties were cemented and 44 hybrid. RESULTS In the drainage group, 2 hematomas and 2 superficial wound infections occurred; there were no wound complications in the undrained group (p = 0.04). Patients receiving drainage had a greater reduction in hematocrit (10.4 vs 7.4) (p = 0.03), and longer hospital stay (5.1 days vs 4.7) (p = 0.01). At the 3-month follow-up, we found no deep wound infections in either group. INTERPRETATION We no longer use CSD in elective, primary, routine THA.

Combining C-reactive Protein and Interleukin-6 May Be Useful to Detect Periprosthetic Hip Infection

BackgroundThe sensitivity and specificity to detect periprosthetic infection of the different methods have been questioned, and no single laboratory test accurately detects infection before revision arthroplasty.Questions/purposesWe asked whether preoperative C-reactive protein (CRP) and interleukin-6 (IL-6) could lead to similar sensitivity, specificity, and predictive values as our previous results obtained with intraoperative frozen section (FS) in revision total hip arthroplasty (THA).MethodsWe prospectively followed 69 patients who had undergone revision THA for failure of a primary THA. The definitive diagnosis of an infection was determined on the basis of positive histopathologic evidence of infection or growth of bacteria on culture.ResultsEleven of the 69 hips were infected. The combination of an elevated CRP and IL-6 was correlated with deep infection in all the cases and showed a sensitivity of 0.57 (0.13–1.00), a specificity of 1.00 (0.99–1.00), a positive predictive value of 1.00 (0.87–1.00), and a negative predictive value of 0.94 (0.87–1.00). FS showed a sensitivity of 0.81 (0.54–1.00), a specificity of 0.98 (0.94–1.00), a positive predictive value of 0.90 (0.66–1.00), and a negative predictive value of 0.96 (0.91–1.00). Combining CRP and IL-6 provided similar sensitivity, specificity, and positive predictive values as the FSs.ConclusionsOur data suggest the combination of CRP and IL-6 would be a useful serologic tool to complement others when diagnosing periprosthetic infection.Level of EvidenceLevel I, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Squeaking in a Delta Ceramic-on-Ceramic Uncemented Total Hip Arthroplasty

Squeaking is one of the main concerns related to the use of ceramic-on-ceramic total hip arthroplasty. Although it has received much recent publicity, most of the previous reports on this complication have been related to the use of the second generation of alumina ceramics combined with a cup having an elevated metal rim to protect the ceramic liner from neck impingement. We report a patient with a third-generation Biolox Delta (CeramTec AG, Plochingen, Germany) ceramic-on-ceramic uncemented total hip arthroplasty without an elevated metal rim in the cup who presented with a squeaking hip at 23 months postoperative. Although this complication was mainly related to a specific design in the literature, this case demonstrates that newer generation of ceramics can also present squeaking.

Primary Total Hip Arthroplasty With Fourth-Generation Ceramic-on-Ceramic: Analysis of Complications in 939 Consecutive Cases Followed for 2-10 Years

BACKGROUND Delta ceramics may be the bearing of choice for younger and active patients due to its improved toughness and wear characteristics, provided there is no risk of fracture. However, ceramic fracture is the most serious complication related to this type of bearing. Although millions of Delta ceramics have been implanted worldwide, short to midterm results have been scarcely reported in the literature. The purpose of this study was to report the complication rate at short to midterm follow-up associated with the bearing surface used in a series of primary total hip arthroplasties with Delta ceramic-on-ceramic bearings performed in a single institution. METHODS A total of 939 cases (880 patients) undergoing primary total hip arthroplasty with fourth-generation Delta ceramic-on-ceramic bearings were retrospectively reviewed. They were followed for an average of 5.3 years (2-10 years). RESULTS One hip experienced a liner fracture, 2 cups presented early loosening due to friction between the acetabular screw and the backside of the liner, one femoral ball head had a fracture; one case of squeaking was reported, which is impending revision. Considering revision or impending revision in relationship with the bearing surface as the end point, the mean survival rate was 99.3% (confidence interval 95%, 98.3%-99.7%) at 2-10 years. CONCLUSION This study showed a low rate of ceramic fracture compared with others; however, it was much higher than the complication rate presented by the manufacturers. The complications observed were directly related to technical errors that surgeons should avoid when using this type of surface.

Favourable mid-term results of the VerSys CT polished cemented femoral stem for total hip arthroplasty.

We evaluated the mid-term clinical and radiographical performance of a cohort of patients who underwent primary total hip replacement with a modern, forged cobalt–chrome, polished cemented femoral stem with proximal and distal centralisation. Sixty-seven patients with 73 hybrid total hip replacements were followed up clinically and radiographically for an average of 6.1 years (4–8.5). No patient was lost. No hips required revision, and all stems are radiographically well-fixed. Four hips developed localised osteolysis: one at the site of a proximal periprosthetic fracture, another at the level of a lateral femoral window of a previous core decompression, the third at the mid third of the femoral component, and the fourth on the greater trochanter, associated with accelerated polyethylene wear. This modern polished stem yielded excellent, predictable clinical and radiographic results at an intermediate follow-up.RésuméNous évaluons à moyen terme un groupe de patients après arthroplastie totale primaire de la hanche avec une tige cimentée, en chrome cobalt poli, a centralisation proximale et distale. Soixante sept patients avec 73 prothèses hybrides étaient suivis cliniquement et radiologiquement pendant une durée moyenne de 6,1 ans (4–8,5), sans perdu de vue. Aucune hanche n’avait eu de révision chirurgicale, et toutes les tiges étaient radiologiquement bien fixées. Quatre hanches avaient, une ostéolyse localisée : au niveau d’une fracture péri-prothétique proximale, au niveau de la fenêtre corticale d’un précédent forage, à hauteur du tiers moyen de la tige et au niveau du grand trochanter associé à une usure précoce du PE. Cette tige fémorale donne un excellent résultat à moyen terme.

Hip arthroscopy in osteoarthritis: a systematic review of the literature.

Background Hip arthroscopy treatment in patients with osteoarthritis is controversial. Hypothesis/Purpose To systematically review the clinical outcome of patients with hip osteoarthritis (OA) treated with arthroscopy and what proportion of these patients subsequently underwent total hip arthroplasty (THA). Study design Systematic review. Methods PubMed, Cochrane library and LILACS were searched from January 1990 through December 2013 for eligible studies. The methodological quality of the collected data (applied to each study) was performed with a modified version of the Coleman methodology score (mCMS). Results 11 studies were included in this review. Most of the studies included reported clinical improvements. The overall conversion rate to THA ranged from 9.5% to 50%. Mean time between arthroscopy and THA was 13.5 months. Conclusions The quality of studies is low. We have found inconclusive evidence to make categorical indications for hip arthroscopy in the treatment of OA, although we have found that there is some postoperative clinical outcome improvement of pain and function in a short-term evaluation. Increasingly worse outcomes were seen as the severity of OA increased.

The Agreement and Repeatability of Computer-Based Wear Measurement of Total Hip Arthroplasties

We assessed the agreement and repeatability of a software package for wear measurement in 19 total hip arthroplasties followed up for 4 to 8 years. Three observers with different levels of expertise (a hip surgeon [O1], a fellow [O2], and a medical student who is a research assistant of the laboratory in which the software was developed [O3]) determined the 2-dimensional wear and wear direction with the Hip Suite software (University of Chicago, Chicago, Ill). For intraobserver and interobserver comparisons, we used intraclass correlation coefficient (ICC) and repeatability. The intraobserver ICC for wear and wear direction was 0.83 and 0.78 for O1, 0.54 and 0.48 for O2, and 0.81 and 0.89 for 03. The interobserver ICCs were 0.43 (range, 0.07-0.87) for wear and 0.8 (range, 0.71-0.86) for wear direction. Computerized wear measurements have substantial intraobserver and interobserver variability, especially when performed by surgeons without extensive experience in the use of the software, a finding which questions its precision and validity.

THA conversion rate comparing decompression alone, with autologous bone graft or stem cells in osteonecrosis

Introduction: Core decompression (CD) with or without the addition of autologous bone graft (CDBG) is currently the most widely accepted treatment for hip osteonecrosis in stages of pre-collapse. The use of bone marrow mesenchymal stem cells (CDSC) is emerging as a promising biological alternative. We sought to determine the total hip arthroplasty (THA) conversion rate for patients treated with CD, CDBG or CDSC. Material and methods: Between 1996 and 2012, 97 cases were evaluated in 72 patients: 47 CD cases, 34 CDGB cases and 16 CDSC cases. The mean age was 39 (20-63) years, 25 bilateral, 19 female and 53 male, 14 Ficat 1 and 83 Ficat 2. Bilateral cases with asymmetric stage and equal treatment were excluded. Results: Conversion rate to THA was 44% for the CD group (21/47) at an average of 77 (24-324) months; 50% for the CDBG group (17/34) at an average of 34 (24-240) months and 50% for the CDSC group (8/16) at an average of 48 (24-72) months (p = 0.619). Log Rank test for survivorship analysis was not significant (p = 0.2011). Immunodeficiency or corticosteroid treatment history was associated with 16/47 of the CD group, 7/34 in the CDBG group and 1/16 in the CDSC group. Trauma was associated with 2/47 of the CD group, 5/34 of the CDBG group and none of the CDSC group. Hazard ratio considering risk factors was not significant (p = 0.252). Conclusions: In these series of cases including patients with pre-collapse osteonecrosis, we observed non-significant results regarding rate of conversion to THA with CD, CDBG or CDSC at an average of 5.5 years.

Fracture of the C-Stem cemented femoral component in revision hip surgery using bone impaction grafting technique: report of 9 cases.

We present a series of 9 fractures of a C-Stem femoral component (6 long stems and 3 conventional stems) that had been implanted with the use of impaction bone grafting (IBG). The length of the long fractured stems was 240 mm in 4 cases and 200 mm in 2. The patients presented had an average BMI of 26.5 and an average of 2.7 previous hip surgeries (range 2-5 surgeries) before the stem fracture. A total of 5 cases presented with a metal mesh fracture in addition to the fractured stem. Bending of the stems or stem defects was not observed in any case. Typical fracture waves consistent with fatigue failure were clearly visible on all the cut surfaces, starting anterolaterally and propagating to the medial side. Although fatigue fracture of a modern cemented tapered polished femoral stem is a rare event, stress due to the absence of proximal femoral bone support could be sufficient to put this stem at a higher risk for fatigue fracture in non-obese patients.

Skin staples versus intradermal wound closure following primary hip arthroplasty: a prospective, randomised trial including 231 cases.

Intradermal wound closure is controversial in primary total hip arthroplasty. Randomised, controlled trials in wound closure following a total hip arthroplasty (THA) are scarce. Our hypothesis was that skin staples closure would be related to a similar complication rate and operative time as intradermal closure with polypropylene. From September 2011 to May 2012, 231 THAs in 219 patients with an average age of 62 years old (range: 21-91) were performed. No differences were observed in both groups according to sex, age, BMI and comorbidities (p = 0,82). Cases were divided into 3 groups according to medical factors that influence wound healing: group 1 (no medical history, 70.5%), group 2 (diabetes, tobacco smokers, obesity, corticosteroids, rheumatoid disease, 25%) and group 3 (organ transplantation, neoplastic patients or 2 or factors of group 2, 4.5%). Once randomised using a computer-generated method, all patients remained within the group to which they were allocated to wound closure with skin staples (Leukosan® SkinStapler PTW-35, BSN, Germany) that were used in 112 THAs in 105 patients (48%), or continuous 3.0 intradermal non-absorbable polypropylene suture (Prolene™ 0, Ethicon Inc. Somerville, New Jersey, USA) in 119 THAs in 115 patients (52%). A 3.8% wound complication rate was observed in this series, with a 2.1% complication rate for the group that was closed with skin staples and a 1.7% rate for the group with intradermal suture (p = 0.7). All the complications were treated conservatively except for one acute deep infection (0.4%) that was successfully treated with debridement, component retention and intravenous antibiotics. There were no differences in both groups related to operative time or wound length. In these series of primary elective THAs, skin staples were associated with a similar complication rate to an intradermal closure technique.