Faculty Bibliography

AIM: To determine whether there is a functional difference between patients who actively follow-up in the office (OFU) and those who are non-compliant with office follow-up visits (NFU). METHODS: We reviewed a consecutive group of 588 patients, who had undergone total joint arthroplasty (TJA), for compliance and functional outcomes at one to two years post-operatively. All patients were given verbal instructions by the primary surgeon to return at one year for routine follow-up visits. Patients that were compliant with the instructions at one year were placed in the OFU cohort, while those who were non-compliant were placed in the NFU cohort. Survey mailings and telephone interviews were utilized to obtain complete follow-up for the cohort. A chi(2) test and an unpaired t test were used for comparison of baseline characteristics. Analysis of covariance was used to compare the mean clinical outcomes after controlling for confounding variables. RESULTS: Complete follow-up data was collected on 554 of the 588 total patients (93%), with 75.5% of patients assigned to the OFU cohort and 24.5% assigned to the NFU cohort. We found significant differences between the cohorts with the OFU group having a higher mean age (P = 0.026) and a greater proportion of females (P = 0.041). No significant differences were found in either the SF12 or WOMAC scores at baseline or at 12 mo postoperative. CONCLUSION: Patients who are compliant to routine follow-up visits at one to two years post-operation do not experience better patient reported outcomes than those that are non-compliant. Additionally, after TJA, older women are more likely to be compliant in following surgeon instructions with regard to follow-up office care.

PURPOSE: There are limited studies examining the long-term survivorship for the current generation of metal-on-metal hip resurfacing (MOMHR) implants in the young male population, and fewer studies have been published on prospectively collected outcomes data for total hip resurfacing in the USA. The purpose of this study was to demonstrate the efficacy of MOMHR in comparison with total hip arthroplasty (THA) using validated outcome measures, survivorship and complication rates. METHODS: The study prospectively followed 136 implants in 123 male patients <65 years, all with a primary diagnosis of osteoarthritis and similar comorbidities as determined by the American Society of Anesthesiologists (ASA) score. A single-surgeon cohort of 89 MOMHRs was compared with a similar cohort of 47 THAs. Outcomes were prospectively assessed with the Short-Form Health Survey of 12 questions (SF-12) and Western Ontario and McMaster Universities (WOMAC) questionnaires pre- and postoperatively at yearly intervals. Minimum follow-up was two years, and average follow-up was 3.9 years. RESULTS: Diagnosis, body mass index (BMI), American Association of Anesthesiologists (ASA) and pre-operative pain and function scores were not significantly different between groups. There was no difference in SF-12 scores postoperatively. At one and two years postoperatively, the MOMHR group had better WOMAC scores than the THA group, but no difference was seen at three to five years postoperatively. There were no revisions in either group over the study period. CONCLUSIONS: This study demonstrated good results for hip resurfacing in men <65 years five years postoperatively and similar function to THA patients.

BACKGROUND: Intertrochanteric hip fractures are a major source of morbidity and financial burden, accounting for 7% of osteoporotic fractures and costing nearly $6 billion annually in the United States. Traditionally, "stable" fracture patterns have been treated with an extramedullary sliding hip screw whereas "unstable" patterns have been treated with the more expensive intramedullary nail. The purpose of this study was to identify parameters to guide cost-effective implant choices with use of decision-analysis techniques to model these common clinical scenarios. METHODS: An expected-value decision-analysis model was constructed to estimate the total costs and health utility based on the choice of a sliding hip screw or an intramedullary nail for fixation of an intertrochanteric hip fracture. Values for critical parameters, such as fixation failure rate, were derived from the literature. Three scenarios were evaluated: (1) a clearly stable fracture (AO type 31-A1), (2) a clearly unstable fracture (A3), or (3) a fracture with questionable stability (A2). Sensitivity analysis was performed to test the validity of the model. RESULTS: The fixation failure rate and implant cost were the most important factors in determining implant choice. When the incremental cost for the intramedullary nail was set at the median value ($1200), intramedullary nailing had an incremental cost-effectiveness ratio of $50,000/quality-adjusted life year when the incremental failure rate of sliding hip screws was 1.9%. When the incremental failure rate of sliding hip screws was >5.0%, intramedullary nails dominated with lower cost and better health outcomes. The sliding hip screw was always more cost-effective for A1 fractures, and the intramedullary nail always dominated for A3 fractures. As for A2 fractures, the sliding hip screw was cost-effective in 70% of the cases, although this was highly sensitive to the failure rate. CONCLUSIONS: Sliding hip screw fixation is likely more cost-effective for stable intertrochanteric fractures (A1) or those with questionable stability (A2), whereas intramedullary nail fixation is more cost-effective for reverse obliquity fractures (A3). These conclusions are highly sensitive to the fixation failure rate, which was the major influence on the model results.

Computer navigation in total knee arthroplasty (TKA) is intended to produce more reliable results, but its impact on functional outcomes has not been firmly demonstrated. Literature searches were performed for Level I randomized trials that compared TKA using imageless computer navigation to those performed with conventional instruments. Radiographic and functional outcomes were extracted and statistically analyzed. TKA performed with computer navigation was more likely to be within 3 degrees of ideal mechanical alignment (87.1% vs. 73.7%, P < .01). Navigated TKAs had a higher increase in Knee Society Score at 3-month follow-up (68.5 vs. 58.1, P = .03) and at 12-32 month follow-up (53.1 vs. 45.8, P < .01). Computer navigation in TKA provides more accurate alignment and superior functional outcomes at short-term follow-up.

Lesser-trochanter-to-center-of-femoral-head-distance (LTCHD) is commonly used in hip reconstruction. Demographic and radiographic variables were analyzed to predict the LTCHD and femoral head size (FHS). Two hundred twenty six patients after hip arthroplasty and 136 patients after hip hemiarthroplasty (HA) were retrospectively reviewed. Five variables significantly affected the LTCHD and four affected the FHS. For LTCHD, it was relative neck length (RNL), gender, height, race, age and weight. For FHS it was gender, height, age and race. The average predicted LTCHD was within 2.86 mm, and the FHS was 1.63 +/- 1.10mm of the intra-operative measurements. By using our regression formulas the LTCHD and FHS can be calculated preoperatively to help improve precision in leg length and offset reconstruction.

Cephalomedullary devices (CMN) have become an increasingly popular for treatment of intertrochanteric hip fractures compared to sliding hip screw and side plate (SHS) devices. Failed fixation is often treated with conversion total hip arthroplasty (THA). We performed a multi-institutional study in which 60 patients with SHS devices and 31 patients with CMN devices were converted to THA. Harris Hip Score improved from 41.6 preoperatively to 83.6 at final follow-up in the SHS group and from 41.6 to 78.6 in the CMN group, with no significant difference between the groups (P=0.23). However, the complication rate in converted CMN patients was significantly higher at 41.9% compared with 11.7% (P=0.001) in converted SHS patients. Prior fixation with CMN may be associated with significantly higher complication rates during conversion.

AIM: To track the short-term neck narrowing changes in Birmingham metal-on-metal hip resurfacing (MOMHR) patients. METHODS: Since 2001, the Center for Hip and Knee Replacement started a registry to prospectively collect data on hip and knee replacement patients. From June 2006 to October 2008, 139 MOMHR were performed at our center by two participate surgeons using Birmingham MOMHR prosthesis (Smith Nephew, United States). It is standard of care for patients to obtain low, anteriorposterior (LAP) pelvis radiographs immediately after MOMHR procedure and then at 3 mo, 1 year and 2 year follow up office visits. Inclusion criteria for the present study included patients who came back for follow up office visit at above mentioned time points and got LAP radiographs. Exclusion criteria include patients who missed more than two follow up time points and those with poor-quality X-rays. Two orthopaedic residency trained research fellows reviewed the X-rays independently at 4 time points, i.e., immediate after surgery, 3 mo, 1 year and 2 year. Neck-to-prosthesis ratio (NPR) was used as main outcome measure. Twenty cases were used as subjects to identify the reliability between two observers. An intraclass correlation coefficient at 0.8 was considered as satisfied. A paired t-test was used to evaluate the significant difference between different time points with P < 0.05 considered to be statistically significant. RESULTS: The mean NPRs were 0.852 +/- 0.056, 0.839 +/- 0.052, 0.835 +/- 0.051, 0.83 +/- 0.04 immediately, 3 mo, 1 year and 2 years post-operatively respectively. At 3 mo, NPR was significantly different from immediate postoperative X-ray (P < 0.001). There was no difference between 3 mo and 1 year (P = 0.14) and 2 years (P = 0.53). Femoral neck narrowing (FNN) exceeding 10% of the diameter of the neck was observed in only 4 patients (5.6%) at two years follow up. None of these patients developed a femoral neck fracture (FNF). CONCLUSION: Femoral neck narrowing after MOMHR occurred as early as 3 mo postoperatively, and stabilized thereafter. Excessive FNN was not common in patients within the first two years of surgery and was not correlated with risk of FNF.

The effects of altering patients' femoral offset (FO) during total hip arthroplasty on postoperative pain and function have not been well described. This study compared clinical outcomes as assessed by the Short Form 12 Health Survey and Western Ontario and McMaster University Osteoarthritis Index between patients who had their FOs restored to varying degrees (compared to the contralateral normal hip [CL]). We retrospectively measured postoperative FOs on standard anteroposterior pelvis radiographs and compared to the CL. Patients were categorized into one of 3 groups: decreased offset (< -5 mm compared to CL), normal offset (between -5 and +5 mm), and increased offset (> +5 mm). The decreased offset group exhibited Western Ontario and McMaster University Osteoarthritis Index Physical Function scores that were less than those of the normal offset and increased offset groups (72.03, 82.23, and 79.51, respectively [P = .019]). In conclusion, reducing a patients' native FO led to inferior functional outcome scores.

This article quantifies pain differences in the immediate postoperative period between patients undergoing total hip arthroplasty (THA) and metal-on-metal hip resurfacing (MoMHR). Patients less than 65 years old indicated for either a primary MoMHR or THA were screened for consent. A total of 51 patients completed the study. Controlling for confounding factors, patients having MoMHR experienced significantly less pain at 24 hours than patients having THA. The MoMHR cohort experienced a significantly shorter length of stay than the THA cohort. MoMHR shows a significantly lower pain level at 24 hours than THA and a significantly earlier discharge.