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The Bone & Joint Journal Feb 2018Periprosthetic joint infection (PJI) is a serious complication of total hip arthroplasty (THA). Different bearing surface materials have different surface properties and... (Meta-Analysis)
Meta-Analysis Review
AIMS
Periprosthetic joint infection (PJI) is a serious complication of total hip arthroplasty (THA). Different bearing surface materials have different surface properties and it has been suggested that the choice of bearing surface may influence the risk of PJI after THA. The objective of this meta-analysis was to compare the rate of PJI between metal-on-polyethylene (MoP), ceramic-on-polyethylene (CoP), and ceramic-on-ceramic (CoC) bearings.
PATIENTS AND METHODS
Electronic databases (Medline, Embase, Cochrane library, Web of Science, and Cumulative Index of Nursing and Allied Health Literature) were searched for comparative randomized and observational studies that reported the incidence of PJI for different bearing surfaces. Two investigators independently reviewed studies for eligibility, evaluated risk of bias, and performed data extraction. Meta-analysis was performed using the Mantel-Haenzel method and random-effects model in accordance with methods of the Cochrane group.
RESULTS
Our search strategy revealed 2272 studies, of which 17 met the inclusion criteria and were analyzed. These comprised 11 randomized controlled trials and six observational studies. The overall quality of included studies was high but the observational studies were at high risk of bias due to inadequate adjustment for confounding factors. The overall cumulative incidence of PJI across all studies was 0.78% (1514/193 378). For each bearing combination, the overall incidence was as follows: MoP 0.85% (1353/158 430); CoP 0.38% (67/17 489); and CoC 0.53% (94/17 459). The meta-analysis showed no significant difference between the three bearing combinations in terms of risk of PJI.
CONCLUSION
On the basis of the clinical studies available, there is no evidence that bearing choice influences the risk of PJI. Future research, including basic science studies and large, adequately controlled registry studies, may be helpful in determining whether implant materials play a role in determining the risk of PJI following arthroplasty surgery. Cite this article: 2018;100-B:134-42.
Topics: Arthroplasty, Replacement, Hip; Ceramics; Hip Prosthesis; Humans; Incidence; Metals; Polyethylene; Prosthesis Design; Prosthesis-Related Infections; Risk Factors; Surface Properties
PubMed: 29437054
DOI: 10.1302/0301-620X.100B2.BJJ-2017-0575.R1 -
Anesthesiology Aug 2010A systematic search was conducted to determine the characteristics of perioperative anemia, its association with clinical outcomes, and the effects of patient blood... (Review)
Review
A systematic search was conducted to determine the characteristics of perioperative anemia, its association with clinical outcomes, and the effects of patient blood management interventions on these outcomes in patients undergoing major orthopedic surgery. In patients undergoing total hip or knee arthroplasty and hip fracture surgery, preoperative anemia was highly prevalent, ranging from 24 +/- 9% to 44 +/- 9%, respectively. Postoperative anemia was even more prevalent (51% and 87 +/- 10%, respectively). Perioperative anemia was associated with a blood transfusion rate of 45 +/- 25% and 44 +/- 15%, postoperative infections, poorer physical functioning and recovery, and increased length of hospital stay and mortality. Treatment of preoperative anemia with iron, with or without erythropoietin, and perioperative cell salvage decreased the need for blood transfusion and may contribute to improved patient outcomes. High-impact prospective studies are necessary to confirm these findings and establish firm clinical guidelines.
Topics: Anemia; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Blood Transfusion; Disease Management; Humans; Postoperative Complications
PubMed: 20613475
DOI: 10.1097/ALN.0b013e3181e08e97 -
Orthopaedic Surgery May 2021The diagnostic potential of D-dimer and fibrinogen to detect periprosthetic joint infection (PJI) of the hip and knee is not well-understood. The aim of this study was... (Meta-Analysis)
Meta-Analysis
The diagnostic potential of D-dimer and fibrinogen to detect periprosthetic joint infection (PJI) of the hip and knee is not well-understood. The aim of this study was to determine whether D-Dimer and fibrinogen can be used as effective biomarkers to screen PJI. A systematic review of the literature indexed in Web of Science, PubMed, Cochrane Library, Embase, and Google Scholar databases was performed. All studies using D-dimer levels in serum or plasma, or fibrinogen levels in plasma, for the diagnosis of PJI were included. Meta-analysis estimates, including sensitivity, specificity, diagnostic odds ratios (DOR), and the area under the summary receiver operating characteristic curve (AUSROC), were calculated using a random-effects model, and used to assess the diagnostic accuracy of these biomarkers. A total of nine studies were analyzed, and their quality was considered to be acceptable. D-dimer gave a limited diagnostic value if serum and plasma combined: sensitivity (0.77, 95% confidence interval [CI] [0.63 to 0.87]), specificity (0.67, 95% CI [0.54 to 0.78]), DOR (6.81, 95% CI [2.67 to 17.37]), and AUSROC (0.78, 95% CI [0.74 to 0.82]). Plasma D-dimer levels were associated with less satisfactory sensitivity (0.65, 95% CI 0.57 to 0.71), specificity (0.58, 95% CI 0.50 to 0.66), DOR (2.52, 95% CI 1.64 to 3.90), and AUSROC (0.65, 95% CI 0.61 to 0.69). Serum D-dimer levels showed higher corresponding values of 0.89 (95% CI 0.79 to 0.94), 0.76 (95% CI 0.55 to 0.89), 24.24 (95% CI 10.07 to 58.32), and 0.91 (95% CI 0.88 to 0.93). Plasma fibrinogen showed acceptable corresponding values of 0.79 (95% CI 0.70 to 0.85), 0.73 (95% CI 0.57 to 0.85), 10.14 (95% CI 6.16 to 16.70), and 0.83 (95% CI 0.79 to 0.86). Serum D-dimer may be an effective marker for the diagnosis of PJI in hip and knee arthroplasty patients, and it may show higher diagnostic potential than plasma fibrinogen. Plasma D-dimer may have limited diagnostic potential.
Topics: Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Biomarkers; Fibrin Fibrinogen Degradation Products; Fibrinogen; Humans; Prosthesis-Related Infections
PubMed: 33682337
DOI: 10.1111/os.12969 -
Health Technology Assessment... Jan 2015Total hip replacement (THR) involves the replacement of a damaged hip joint with an artificial hip prosthesis. Resurfacing arthroplasty (RS) involves replacement of the... (Review)
Review
Total hip replacement and surface replacement for the treatment of pain and disability resulting from end-stage arthritis of the hip (review of technology appraisal guidance 2 and 44): systematic review and economic evaluation.
BACKGROUND
Total hip replacement (THR) involves the replacement of a damaged hip joint with an artificial hip prosthesis. Resurfacing arthroplasty (RS) involves replacement of the joint surface of the femoral head with a metal surface covering.
OBJECTIVES
To undertake clinical effectiveness and cost-effectiveness analysis of different types of THR and RS for the treatment of pain and disability in people with end-stage arthritis of the hip, in particular to compare the clinical effectiveness and cost-effectiveness of (1) different types of primary THR and RS for people in whom both procedures are suitable and (2) different types of primary THR for people who are not suitable for hip RS.
DATA SOURCES
Electronic databases including MEDLINE, EMBASE, The Cochrane Library, Current Controlled Trials and UK Clinical Research Network (UKCRN) Portfolio Database were searched in December 2012, with searches limited to publications from 2008 and sample sizes of ≥ 100 participants. Reference lists and websites of manufacturers and professional organisations were also screened.
REVIEW METHODS
Systematic reviews of the literature were undertaken to appraise the clinical effectiveness and cost-effectiveness of different types of THR and RS for people with end-stage arthritis of the hip. Included randomised controlled trials (RCTs) and systematic reviews were data extracted and risk of bias and methodological quality were independently assessed by two reviewers using the Cochrane Collaboration risk of bias tool and the Assessment of Multiple Systematic Reviews (AMSTAR) tool. A Markov multistate model was developed for the economic evaluation of the technologies. Sensitivity analyses stratified by sex and controlled for age were carried out to assess the robustness of the results.
RESULTS
A total of 2469 records were screened of which 37 were included, representing 16 RCTs and eight systematic reviews. The mean post-THR Harris Hip Score measured at different follow-up times (from 6 months to 10 years) did not differ between THR groups, including between cross-linked polyethylene and traditional polyethylene cup liners (pooled mean difference 2.29, 95% confidence interval -0.88 to 5.45). Five systematic reviews reported evidence on different types of THR (cemented vs. cementless cup fixation and implant articulation materials) but these reviews were inconclusive. Eleven cost-effectiveness studies were included; four provided relevant cost and utility data for the model. Thirty registry studies were included, with no studies reporting better implant survival for RS than for all types of THR. For all analyses, mean costs for RS were higher than those for THR and mean quality-adjusted life-years (QALYs) were lower. The incremental cost-effectiveness ratio for RS was dominated by THR, that is, THR was cheaper and more effective than RS (for a lifetime horizon in the base-case analysis, the incremental cost of RS was £11,284 and the incremental QALYs were -0.0879). For all age and sex groups RS remained clearly dominated by THR. Cost-effectiveness acceptability curves showed that, for all patients, THR was almost 100% cost-effective at any willingness-to-pay level. There were age and sex differences in the populations with different types of THR and variations in revision rates (from 1.6% to 3.5% at 9 years). For the base-case analysis, for all age and sex groups and a lifetime horizon, mean costs for category E (cemented components with a polyethylene-on-ceramic articulation) were slightly lower and mean QALYs for category E were slightly higher than those for all other THR categories in both deterministic and probabilistic analyses. Hence, category E dominated the other four categories. Sensitivity analysis using an age- and sex-adjusted log-normal model demonstrated that, over a lifetime horizon and at a willingness-to-pay threshold of £20,000 per QALY, categories A and E were equally likely (50%) to be cost-effective.
LIMITATIONS
A large proportion of the included studies were inconclusive because of poor reporting, missing data, inconsistent results and/or great uncertainty in the treatment effect estimates. This warrants cautious interpretation of the findings. The evidence on complications was scarce, which may be because of the absence or rarity of these events or because of under-reporting. The poor reporting meant that it was not possible to explore contextual factors that might have influenced study results and also reduced the applicability of the findings to routine clinical practice in the UK. The scope of the review was limited to evidence published in English in 2008 or later, which could be interpreted as a weakness; however, systematic reviews would provide summary evidence for studies published before 2008.
CONCLUSIONS
Compared with THR, revision rates for RS were higher, mean costs for RS were higher and mean QALYs gained were lower; RS was dominated by THR. Similar results were obtained in the deterministic and probabilistic analyses and for all age and sex groups THR was almost 100% cost-effective at any willingness-to-pay level. Revision rates for all types of THR were low. Category A THR (cemented components with a polyethylene-on-metal articulation) was more cost-effective for older age groups. However, across all age-sex groups combined, the mean cost for category E THR (cemented components with a polyethylene-on-ceramic articulation) was slightly lower and the mean QALYs gained were slightly higher. Category E therefore dominated the other four categories. Certain types of THR appeared to confer some benefit, including larger femoral head sizes, use of a cemented cup, use of a cross-linked polyethylene cup liner and a ceramic-on-ceramic as opposed to a metal-on-polyethylene articulation. Further RCTs with long-term follow-up are needed.
STUDY REGISTRATION
This study is registered as PROSPERO CRD42013003924.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
Topics: Age Factors; Arthroplasty, Replacement, Hip; Cost-Benefit Analysis; Humans; Models, Economic; Osteoarthritis, Hip; Pain Management; Quality-Adjusted Life Years; Randomized Controlled Trials as Topic; Sex Factors; Technology Assessment, Biomedical
PubMed: 25634033
DOI: 10.3310/hta19100 -
Acta Orthopaedica 2015Few studies have addressed the association between early migration of femoral stems and late aseptic revision in total hip arthroplasty. We performed a meta-regression... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND PURPOSE
Few studies have addressed the association between early migration of femoral stems and late aseptic revision in total hip arthroplasty. We performed a meta-regression analysis on 2 parallel systematic reviews and meta-analyses to determine the association between early migration and late aseptic revision of femoral stems.
PATIENTS AND METHODS
Of the 2 reviews, one covered early migration data obtained from radiostereometric analysis (RSA) studies and the other covered long-term aseptic revision rates obtained from survival studies with endpoint revision for aseptic loosening. Stems were stratified according to the design concept: cemented shape-closed, cemented force-closed, and uncemented. A weighted regression model was used to assess the association between early migration and late aseptic revision, and to correct for confounders. Thresholds for acceptable and unacceptable migration were determined in accordance with the national joint registries (≤ 5% revision at 10 years) and the NICE criteria (≤ 10% revision at 10 years).
RESULTS
24 studies (731 stems) were included in the RSA review and 56 studies (20,599 stems) were included in the survival analysis review. Combining both reviews for the 3 design concepts showed that for every 0.1-mm increase in 2-year subsidence, as measured with RSA, there was a 4% increase in revision rate for the shape-closed stem designs. This association remained after correction for age, sex, diagnosis, hospital type, continent, and study quality. The threshold for acceptable migration of shape-closed designs was defined at 0.15 mm; stems subsiding less than 0.15 mm in 2 years had revision rates of less than 5% at 10 years, while stems exceeding 0.15 mm subsidence had revision rates of more than 5%.
INTERPRETATION
There was a clinically relevant association between early subsidence of shape-closed femoral stems and late revision for aseptic loosening. This association can be used to assess the safety of shape-closed stem designs. The published research is not sufficient to allow us to make any conclusions regarding such an association for the force-closed and uncemented stems.
Topics: Arthroplasty, Replacement, Hip; Hip Prosthesis; Humans; Prosthesis Design; Prosthesis Failure; Radiostereometric Analysis; Reoperation; Risk Factors; Treatment Outcome
PubMed: 25909455
DOI: 10.3109/17453674.2015.1043832 -
Medicina (Kaunas, Lithuania) Mar 2023Sarcopenia is a progressive and generalized skeletal muscle disorder associated with poor outcomes and complications, including falls, fractures, physical disability,... (Review)
Review
Sarcopenia is a progressive and generalized skeletal muscle disorder associated with poor outcomes and complications, including falls, fractures, physical disability, and death. The aim of this review is to assess the possible influence of sarcopenia on outcomes of sarcopenia in patients who underwent knee or hip replacement. A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Medline, EMBASE, Scopus, CINAHL, and CENTRAL bibliographic databases were searched. General study characteristics extracted were: primary author and country, year of publication, type of study, level of evidence (LOE), sample size, mean age, gender, follow-up, type of surgery, diagnosis, and outcomes. At the final screening, five articles met the selection criteria and were included in the review. Sarcopenia influences the Barthel Index (BI), which is significantly lower compared to patients without sarcopenia, which indicates that the patient is subjected to a worsening of this condition that can influence their normal life since they will become dependent on someone else. No difference in mortality rate was found was found between the studies. This systematic review addressed the possible role of sarcopenia in patients undergoing joint replacement surgery. Despite the lack of high-quality literature on this topic, a general trend in considering sarcopenia as a negative factor for quality of life in joint replacement patients was reported. However, the lack of significant results means it is not possible to report useful conclusions.
Topics: Humans; Sarcopenia; Quality of Life; Arthroplasty, Replacement, Knee; Arthroplasty, Replacement, Hip; Fractures, Bone
PubMed: 36984525
DOI: 10.3390/medicina59030524 -
Chinese Medical Journal Aug 2016Periprosthetic joint infection (PJI) is the main cause of failure following total joint arthroplasty. Until now, the diagnosis of PJI is still confronted with technical... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Periprosthetic joint infection (PJI) is the main cause of failure following total joint arthroplasty. Until now, the diagnosis of PJI is still confronted with technical limitations, and the question of whether synovial fluid biomarker, C-reactive protein (CRP), can provide high value in the diagnosis of PJI remains unanswered and, therefore, was the aim of the study.
METHODS
First, we conducted a systematic review on CRP in the diagnosis of PJI by searching online databases using keywords such as "periprosthetic joint infection", "synovial fluid", and "C-reactive protein". Eligible studies providing sufficient data to construct 2 × 2 contingency tables were then selected based on the list of criteria and the quality of included studies was assessed subsequently. Finally, the reported sensitivity, specificity, diagnostic odds ratio (DOR), summary receiver operating characteristic (SROC) curve, and the area under the SROC (AUSROC) were pooled together and used to evaluate overall diagnostic performance.
RESULTS
Seven studies were included in our review, six of which comprising a total of 456 participants were further investigated in our meta-analysis. The pooled sensitivity, specificity, and DOR were 0.92 (95% confidence interval [CI]: 0.86-0.96), 0.90 (95% CI: 0.87-0.93), and 101.40 (95% CI: 48.07-213.93), respectively. The AUSROC was 0.9663 (standard error, 0.0113).
CONCLUSIONS
Synovial fluid CRP is a good biomarker for the diagnosis of PJI with high sensitivity and specificity.
Topics: Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Biomarkers; C-Reactive Protein; Female; Humans; Male; Prosthesis-Related Infections; Synovial Fluid
PubMed: 27503025
DOI: 10.4103/0366-6999.187857 -
European Journal of Orthopaedic Surgery... Oct 2023Extended trochanteric osteotomy (ETO) has proved to be an effective technique in complicated stem removal in femoral aseptic loosening or periprosthetic fracture. Debate... (Review)
Review
BACKGROUND
Extended trochanteric osteotomy (ETO) has proved to be an effective technique in complicated stem removal in femoral aseptic loosening or periprosthetic fracture. Debate remains about its safety in periprosthetic joint infection (PJI). The primary aim of this study is to analyze the ETO reinfection and union rate in two-stage hip revision.
MATERIAL AND METHODS
A systematic literature review was performed regarding all studies reporting ETO outcomes in the two-stage revision for hip PJI up to October 2022, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. A literature search was conducted in the following databases: MEDLINE/EMBASE, Scopus, Web of Science, and Cochrane. Quality assessment of the articles was performed using the Methodological Index for Non-Randomized Studies. This systematic review was registered in the International Prospective Registry of Systematic Reviews. Patient demographic, clinical, and surgical data were collected.
RESULTS
This systematic review included and analyzed nine clinical studies with a total of 382 ETO PJI hips in two-stage revision. The overall ETO reinfection rate was 8.9% (34 hips), consistent with the reinfection rate after two-stage revision in patients without ETO. The overall ETO union rate was 94.8% (347 hips), comparable to the ETO union rate in non-septic patients. Compared between a group of patients with ETO PJI and a group of patients with non-PJI ETO, there were no significant differences in postoperative complications, both septic and aseptic, and for postoperative HHS.
CONCLUSION
ETO proved to be a safe and effective procedure in PJI revisions. It may be a viable option in challenging femoral stem removal during the two-stage hip revision in PJI.
LEVEL OF EVIDENCE
IV.
Topics: Humans; Arthroplasty, Replacement, Hip; Reinfection; Retrospective Studies; Reoperation; Osteotomy; Arthritis, Infectious; Prosthesis-Related Infections
PubMed: 36849679
DOI: 10.1007/s00590-023-03497-y -
The Bone & Joint Journal Nov 2015Vascular injuries during total hip arthroplasty (THA) are rare but when they occur, have serious consequences. These have traditionally been managed with open... (Review)
Review
Vascular injuries during total hip arthroplasty (THA) are rare but when they occur, have serious consequences. These have traditionally been managed with open exploration and repair, but more recently there has been a trend towards percutaneous endovascular management. We performed a systematic review of the literature to assess if this change in trend has led to an improvement in the overall reported rates of morbidity and mortality during the last 22 years in comparison with the reviews of the literature published previously. We found a total of 61 articles describing 138 vascular injuries in 124 patients. Injuries because of a laceration were the most prevalent (n = 51, 44%) and the most common presenting feature, when recorded, was bleeding (n = 41, 53.3%). Delay in diagnosis was associated with the type of vascular lesion (p < 0.001) and the clinical presentation (p = 0.002). Open exploration and repair was the most common form of management, however percutaneous endovascular intervention was used in one third of the injuries and more constantly during the last 13 years. The main overall reported complications included death (n = 9, 7.3%), amputation (n = 2, 1.6%), and persistent ischaemia (n = 9, 7.3%). When compared with previous reviews there was a similar rate of mortality but lower rates of amputation and permanent disability, especially in patients managed by endovascular strategies.
Topics: Amputation, Surgical; Arthroplasty, Replacement, Hip; Delayed Diagnosis; Endovascular Procedures; Humans; Vascular System Injuries
PubMed: 26530643
DOI: 10.1302/0301-620X.97B11.35241 -
BMC Musculoskeletal Disorders Dec 2021Deep periprosthetic infection after total hip arthroplasty (THA) is a serious and challenging complication for the orthopedic surgeon. Muscular flaps may represent a... (Review)
Review
BACKGROUND
Deep periprosthetic infection after total hip arthroplasty (THA) is a serious and challenging complication for the orthopedic surgeon. Muscular flaps may represent a valid management option for the treatment of this condition. We present a systematic literature review about the use of muscular flaps for the treatment of hip prosthetic joint infection.
METHODS
The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seventy-seven articles, out of 279 titles, were considered eligible for the full-text analysis. Finally 15 studies that met inclusion criteria were included in this review.
RESULTS
Overall, 210 patients (49% males, 48.6% females and 2.4% not reported) suffering from THA infection treated with muscular flaps were collected. The mean age was 69.6 years. Mean follow-up, reported in all studies, was 3.3 years. The results presented by the different authors, highlight the effectiveness of muscular flaps for the treatment of periprosthetic infection, in terms of function, limb salvage, prevention of the recurrences, cost-effectiveness, and quality of life postoperatively.
CONCLUSIONS
Muscle flaps provide an excellent management option for patients with persistent infection after total hip arthroplasty.
Topics: Aged; Arthritis, Infectious; Arthroplasty, Replacement, Hip; Female; Hip Joint; Hip Prosthesis; Humans; Male; Muscle, Skeletal; Persistent Infection; Quality of Life; Surgical Flaps
PubMed: 34949162
DOI: 10.1186/s12891-021-04945-8