Marcus Bankes

Systematic review of total hip arthroplasty in patients under 30 years old

We performed a systematic review to assess whether joint replacement in this very young patient group provides significant functional improvement and whether these procedures are associated with good implant survivorship. The studies included presented the results of 450 THA procedures. All patients showed an improvement in functional score and symptom relief. Unce-mented stems showed good integration with no signs of loosening. Cemented implants showed high rates of loosening. This study shows that THA in the very young patient can provide good functional improvement and relief of symptoms and that the more modern uncemented implant designs used with hard-on-hard bearings can be associated with improved implant survival. Long-term studies are necessary to confirm the superiority and improved survivorship of these newer implants.

Functional outcomes of total hip arthroplasty in patients aged 30 years or less: a systematic review and meta-analysis

Introduction Young adult hip surgery is a growing subspecialty. Increasingly total hip arthroplasty (THA) is offered to patients aged 30 or less suffering from end-stage hip arthropathy from a variety of congenital, developmental and acquired conditions. There is a paucity of evidence to advise such patients and surgeons alike on the functional outcomes of THA in this age group, as individual studies tend to include small cohorts. Methods A systematic review and meta-analysis was performed to assess whether THA in patients aged 30 years or less provides significant functional improvement. The primary outcome measure was change in Harris Hip Score. Secondary outcome measures were implant survivorship and the effect of fixation type and bearing surface. Results The results of 743 primary THA procedures were included. Weighted mean patient age was 22.7 years. Harris Hip Score improved by a weighted mean difference of 42.17 points out of 100 (95% confidence interval, 36.48-47.86 points, p<0.001) after THA at a weighted mean follow-up of 8.4 years. Pooled revision rate was 5.0% for the same time period. Conclusions This is the largest review to date of THA in patients aged 30 or less. The results show significant functional improvement measured by Harris Hip Score. The revision rate of 5% at 8.4 years is comparable to the general THA population. This contrasts high revision rates reported in older reviews of the literature, suggesting adoption of improved techniques and implants in the more recent literature.

Cementless total hip replacements in sickle cell disease

Background Sickle cell disease (SCD) affects around 80,000 people in the USA and 12,000 in the UK. Up to 40% of patients will get osteonecrosis of the femoral head. Cemented acetabular components yield poor results with the rate of osteolysis ranging from 13.5 to 46%. We report on a consecutive cohort of patients with SCD who underwent uncemented THA with ceramic-on-ceramic (CoC) bearings. Methods Since 2002 52 primary THAs were carried out in 40 patients. The average age was 36.1 years (17-54). 48 cases had exchange blood transfusion preoperatively and 3 had top-up transfusions. An S-ROM was used in 47 hips a Solutions stem in 4 hips and an AML in 1. It was necessary to drill the femur during 12 hips. There were 5 intra-operative peri-prosthetic fractures. 2 dislocations were observed. 2 superficial infections were detected. Results All components have in-grown. There have been no cases of radiographic osteolysis, migration or loosening of the hip with average 5-year (2-10.1) follow-up. Conclusions The combination of a multidisciplinary team approach and uncemented implants, with ceramic-on-ceramic bearings used, has made THA in patients with SCD a safe and reliable procedure in our hospital.

A pain in the backside: a case report of coxa saltans occurring at the proximal hamstring origin

Coxa saltans occurring at the proximal hamstring origin has been rarely reported in the literature. It is better known as occurring at the iliotibial band or the iliopsoas tendon. We report a case of coxa saltans due to subluxation of the origin of the long head of biceps femoris tendon at the ischial tuberosity. This was successfully treated using a mini-open surgical technique. Six weeks postoperatively, the snapping and the associated pain were abolished and the patient was able to resume their participation in athletic activities.

Erythropoietin provides a useful strategy for treating preoperative anemia in planned elective orthopedic surgery: an analysis of benefit in routine practice.

There is strong evidence that preoperative anemia that is not corrected can result in increased mortality and morbidity, particularly in patients who have cardiovascular disease. Major orthopedic surgery such as hip and knee replacement can require transfusion of significant quantities of allogeneic red blood cells (RBCs). This is problematic for several reasons. First, there is evidence that clinical outcome is prejudiced by blood transfusion. Infection risk is increased not only directly by contaminated blood products, but also by the indirect immunosuppressive effect of transfusion. Allergic reactions and incompatibility are further risks associated with blood transfusion. Second, health economics disfavor blood transfusion on the grounds of reduced supply of blood components and high costs of blood preservation. Recent progress in the development of a blood-based assay for prion infection by variant Creutzfeldt-Jakob disease (vCJD) may reduce infection risk, but correspondingly may further reduce the availability of RBCs for transfusion. There is therefore a pressing need to develop and evaluate alternative strategies for correcting preoperative anemia in patients who require major orthopedic surgery. In this regard, recombinant human erythropoietin (EPO) is a promising “blood-saving technique.” Our institution’s existing Healthcare Trust protocol evaluates patients individually for transfusion, rather than designating a formal hemoglobin (Hb) threshold. Blood management strategies are well established within our Trust, including preoperative screening and intraoperative and postoperative cell salvage. We developed a protocol to further reduce exposure to allogeneic blood transfusion by utilizing EPO in adult patients before elective major orthopedic surgery and thereby evaluate our ability to utilize EPO therapy in standard preoperative care, that is, outside the formal setting of a research study. EPO therapy was considered for patients with moderate anemia (Hb level, 10-13 g/dL) scheduled for planned primary total hip replacement (THR) or revision THR or total knee replacement (TKR). Data were also collected from one patient who received EPO regimens on two occasions before right acetabular revision procedure; in this case, EPO was utilized because of the patient’s religious objections to a blood transfusion. We excluded patients with clinically relevant diseases according to the discretion of the investigator. Importantly, we also excluded patients with trauma from our study. This protocol was for patients with physiologic or chronic anemia due to underlying disease such as renal impairment, diabetes, and chronic inflammation. Patients were assessed for Hb, ferritin, vitamin B12, and folate levels 21 days before surgery and weekly thereafter. Intravenous (IV) iron sucrose 200 mg was prescribed and administered concurrently with EPO for all patients who had ferritin levels of less than 100 ng/mL while oral iron (ferrous sulfate 200 mg bd until surgery) was prescribed for patients who had ferritin levels of more than 100 ng/mL to prevent EPO-associated iron deficiency. Patients with Hb levels of 10 to 13 g/dL were administered EPO in the form of epoetin beta 40,000 units (60,000 units if weight >90 kg) subcutaneously weekly. Two patients were included, at the clinical discretion of the investigator, who had initial Hb levels of 9.8 and 9.9 g/dL, respectively. The protocol encouraged weekly EPO from 21 days before surgery unless the Hb level was more than 14 g/dL. EPO was not administered on the day of surgery except in two patients who joined the study 14 days before surgery. All patients received postoperative thromboprophylaxis with enoxaparin 40 mg subcutaneously as per Healthcare Trust policy. We identified 30 episodes of care for 29 patients with a mean age of 73.4 years (range, 48-88 years) and pre-EPO mean Hb level of 11.3 g/dL. Twenty-two episodes of care achieved three EPO injections at weekly intervals, and eight episodes of care achieved only two EPO injections either because of practical barriers preventing attendance at clinic or because they were referred too late in the pathway to achieve three injections. All patients received IV iron sucrose except for one patient who had a ferritin level of more than 100 ng/mL and therefore received oral iron. The mean Hb level of all patient episodes on the day of surgery was 12.9 g/dL. For male patients, the post-EPO mean Hb level was 12.7 g/dL and 60% (n = 5) had Hb levels within the normal range according to World Health Organization criteria. For female patients, the post-EPO mean Hb level was 12.9 g/dL and 88% (n = 25) had Hb levels within normal range. Surgery without blood transfusion was performed in 90% (27 of 30) of episodes of care. Of the remaining three episodes, surgery was deferred because of cardiac history and the patient’s religious beliefs in two cases, respectively. Blood transfusion was required in only one episode of care, due to severe perioperative hemorrhage unrelated to treatment. Thus of 28 operations only one required a transfusion, which was for an unexpected complication. In addition, there were no instances of venous thromboembolism among the 30 episodes of care. A recent audit in our institution has established that blood transfusion is currently performed in a significant proportion of patients who undergo elective orthopedic surgery. This audit of 980 patients over 1 year identified that patients were transfused blood as follows: 37% of

Experience and outcome data of the British non-arthroplasty hip registry:

Introduction: The non-arthroplasty hip registry (NAHR) is a United Kingdom national register that monitors the efficacy of hip preservation surgery. We aim to highlight early experiences of incorporating the NAHR into our practice at a tertiary centre. Methods: Between December 2013 and February 2015, 381 patients were identified on the NAHR database that had undergone non-arthroplasty hip surgery. Patient-related outcome measures EuroQuol 5D-5L (EQ-5D) and the International Hip Outcome Tool 12 (iHOT-12) were recorded at baseline and 6 months. Results: The 289 arthroscopic surgeries showed a statistical significant difference (p<0.05) in iHOT-12 for both males (45.21-65.07) and females (34.57 to 55.53), and in EQ-5D for both males (0.59-0.75) and females (0.56-0.65). The 92 open procedures showed a statistical significant difference (p<0.05) in both iHOT-12 (31.71-62.42) and EQ-5D (0.54-0.68). Conclusions: Overall our results from the NAHR indicate hip preservation surgery is effective at relieving pain and improving quality of life in the short term.

An approach to hip pain in a young adult

### What you need to know Hip pain in young adults is not normal and can be severe and disabling, affecting work, parenting, and leisure activities.12 The causes of hip pain in young adults (aged 16-50) tend to receive less attention than those in children (including Perthes’ disease, slipped capital femoral epiphysis, and septic arthritis) and in older patients (usually osteoarthritis). Imaging studies might not reveal an underlying problem, even where the patient’s symptoms are a consequence of clinically significant pathology. Research has improved understanding of the causes of hip pain in young adults, including femoroacetabular impingement syndrome (FAI) and dysplasia of the hip, and has identified new treatments, although evidence is still limited.34 Importantly, both FAI and hip dysplasia are treatable causes of hip pain in young adults.456 This Practice Pointer aims to help the non-specialist evaluate young adults presenting with hip pain, and provides an update on common young adult hip pathologies. Hip problems in young adults can be considered as problems within the joint itself …

Three-dimensional assessment of impingement risk in geometrically parameterised hips compared with clinical measures

Abstract Abnormal bony morphology is a factor implicated in hip joint soft tissue damage and an increased lifetime risk of osteoarthritis. Standard 2‐dimensional radiographic measurements for diagnosis of hip deformities, such as cam deformities on the femoral neck, do not capture the full joint geometry and are not indicative of symptomatic damage. In this study, a 3‐dimensional geometric parameterisation system was developed to capture key variations in the femur and acetabulum of subjects with clinically diagnosed cam deformity. The parameterisation was performed for computed tomography scans of 20 patients (10 female and 10 male). Novel quantitative measures of cam deformity were taken and used to assess differences in morphological deformities between males and females. The parametric surfaces matched the more detailed, segmented hip bone geometry with low fitting error. The quantitative severity measures captured both the size and the position of cams and distinguished between cam and control femurs. The precision of the measures was sufficient to identify differences between subjects that could not be seen with the sole use of 2‐dimensional imaging. In particular, cams were found to be more superiorly located in males than in females. As well as providing a means to distinguish between subjects more clearly, the new geometric hip parameterisation facilitates the flexible and rapid generation of a range of realistic hip geometries including cams. When combined with material property models, these stratified cam shapes can be used for further assessment of the effect of the geometric variation under impingement conditions.

The Critical Role of Registries in Documenting the Outcomes of Hip Preservation Surgery

In the UK, a Non Arthroplasty Hip Register (NAHR) was launched in 2012 to allow data collection for patients with hip conditions other than arthroplasty or fracture (e.g. iliopsoas impingement, SUFE, Perthes etc.). The NAHR can track the outcome of conservative or surgical treatment. The surgeon can choose to enter as many scores and procedures as he/she wishes over any time interval. The NAHR plots the results over time and displays them graphically. For patients with FAI, pre-operative scores (including EQ5-D, and iHOT-12) are collected automatically by the Registry. Only one pathway can be opened for each hip for an individual. If a surgeon tries to register a patient where a pathway has already been started he/she will be prompted to contact the previous surgeon through the Registry and allowed to add to the data pathway for that patient. By collecting longitudinal outcomes in this way, it will be possible to answer key questions concerning the natural history of, and the effect of surgical treatment on, hip pathologies.

Clinical Diagnosis in Hip Disease

Hip disease in the sporting young adult patient has traditionally been difficult to accurately diagnose. It is not uncommon for patients to have been given more than one diagnosis and several modalities of treatment before the true pathology is found. A systematic approach including history, examination and specialist investigations will give the highest possible chance of accurate diagnosis. However, our knowledge of hip pathology and its causative factors is still evolving and therefore the standard hip examination learnt during early medical training should now be replaced with a more thorough set of questions and clinical tests suited for active young adults.