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AIMS: Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years due to proposed benefits, including a lower risk of dislocation and improved early functional recovery. This study investigates the dislocation rate in a non-selective, consecutive cohort undergoing THA via the DAA without any exclusion or bias in patient selection based on habitus, deformity, age, sex, or fixation method. METHODS: We retrospectively reviewed all patients undergoing THA via the DAA between 2011 and 2017 at our institution. Primary outcome was dislocation at minimum two-year follow-up. Patients were stratified by demographic details and risk factors for dislocation, and an in-depth analysis of dislocations was performed. RESULTS: A total of 2,831 hips in 2,205 patients were included. Mean age was 64.9 years (24 to 96), mean BMI was 29.2 kg/m2 (15.1 to 53.8), and 1,595 patients (56.3%) were female. There were 11 dislocations within one year (0.38%) and 13 total dislocations at terminal follow-up (0.46%). Five dislocations required revision. The dislocation rate for surgeons who had completed their learning curve was 0.15% compared to 1.14% in those who had not. The cumulative periprosthetic infection and fracture rates were 0.53% and 0.67%, respectively. CONCLUSION: In a non-selective, consecutive cohort of patients undergoing THA via the DAA, the risk of dislocation is low, even among patients with risk factors for instability. Our data further suggest that the DAA can be safely used in all hip arthroplasty patients without an increased risk of wound complications, fracture, infection, or revision. The inclusion of seven surgeons increases the generalizability of these results. Cite this article: Bone Joint J 2021;103-B(7 Supple B):38-45.

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Total knee arthroplasty (TKA) is associated with an increased need for blood transfusions and thus an increase in risks associated with blood transfusion such as transfusion reactions, infections, fluid overload, and altered mental status. Tranexamic acid (TXA) is an antifibrinolytic medication that can reduce perioperative blood loss in TKA. However, the best method of delivery has not been defined although topical intra-articular TXA (IA-TXA) may have a theoretical advantage as it is applied directly when and where it is needed to control bleeding. Blinded and nonblinded randomized controlled trials and case-controlled trials published since 2010 were found using database searches. Data were extracted and analyzed with the goal of discovering through meta-analysis if IA-TXA reduces blood loss, blood transfusions, and without increasing adverse events, especially thromboembolic events, compared with placebo. Blood loss from suction drains and calculated total blood loss were significantly lower in the IA-TXA group. The frequency of blood transfusion and the number of units of blood transfused were significantly lower in the IA-TXA group. The risk of adverse events was not increased for IA-TXA versus placebo. Topical IA-TXA in primary, unilateral TKA successfully reduces blood loss and the frequency of blood transfusions. In addition, it does not appear to increase the risk of thromboembolic adverse events. There is need for further research to determine the optimal dosage and the preferred delivery system of IA-TXA in TKA.

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Previous meta-analyses established that tranexamic acid confers benefits when used during total hip arthroplasty (THA). However, 2 of these meta-analyses included a variety of routes of administration of tranexamic acid in THA (topical, intravenous, oral, and intra-articular), another meta-analysis included a variety of antifibrinolytic drugs (not restricted to a single drug), and the final meta-analysis included nonrandomized controlled trials. This meta-analysis focused on a single medication, tranexamic acid, administered in a specific way, intravenously in patients undergoing primary THA, using data reported only in randomized controlled studies. Outcomes were restricted to blood loss, allogeneic transfusion rates, and complications. Other outcomes, such as return to function or clinical scores, could not be evaluated because of lack of consistent reporting. To better understand the effects of intravenous tranexamic acid in THA on clinical outcomes, such as recovery, return to function, and patient-reported outcome measures, it would be helpful to have more controlled trials examining these measures in a standardized manner. Intravenous tranexamic acid was beneficial for blood loss intraoperatively, blood loss through drains, and total blood loss during hospitalization, in addition to reducing allogeneic transfusion rates. No difference between intravenous tranexamic acid and placebo was found for most complications, except deep venous thrombosis, which showed favorable results with placebo. [Orthopedics.2016; 39(5):e883-e892.].

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BACKGROUND: There is now a clear trend with increased usage of cementless femoral stems for all ages and most patients. As the number of total hip arthroplasties (THAs) performed annually continues to increase with expanding indications for THA and demands for improved quality of life, so will the prevalence of THA in the elderly and aging populations. This is worrisome as the risk of complications with cementless femoral stems increases in elderly patients and those with poor bone quality. The purpose of this study is to analyze the available data from comparative studies to determine whether cementless femoral stems are overused and whether cemented stems warrant increased consideration. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searches were performed to find original studies comparing cementless and cemented femoral stems; large population registry studies and reports were also included. RESULTS: This systematic review documents that older patients with cementless fixation increase the risk of revision, there is no clear fixation advantage in midaged patients, and younger patients fare better with cementless fixation. Complications after THA create burdens on the health care system and on patients. CONCLUSIONS: Using evidence-based data should be better guidance in selecting the most reliable implants for THA. Although cementless femoral fixation for THA has evolved to the "new standard," it has not been proven to be the "gold standard" for all patients.

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Peri-operative tranexamic acid (TXA) significantly reduces the need for allogeneic blood transfusion in total hip arthroplasty (THA) and thus hospital costs are reduced. Before employing TXA in primary THA at our institution, facility costs were $286.90/THA for blood transfusion and required 0.45 man-hours/THA (transfusion rate 19.87%). After incorporating TXA, the cost for intravenous application was $123.38/THA for blood transfusion and TXA medication and 0.07 man-hours/THA (transfusion rate 4.39%) and the cost for topical application was $132.41/THA for blood transfusion and TXA and 0.14 man-hours/THA (transfusion rate 12.86%). TXA has the potential to reduce the facility cost per THA and the man-hours/THA from blood transfusions.

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Tranexamic acid (TXA) has proven to be very advantageous to the total knee arthroplasty (TKA) population. With TXA, the need for allogeneic blood transfusion is reduced and thus hospital costs are reduced. In our hospital system, before TXA was used, facility cost was an estimated $84.90/TKA for blood transfusion and required 0.13 man-hours/TKA (transfusion rate 6.5%); after incorporating intravenous TXA, cost was $82.59/TKA for blood transfusion and TXA medication and 0.007 man-hours/TKA (transfusion rate 0.3%). There were no transfusions when TXA was applied topically, and the facility cost was $39.14/TKA and no employee hours consumed. Topical TXA has the potential to significantly reduce blood transfusions and decrease hospital man-hours/TKA as well as achieve larger cost saving.

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BACKGROUND: Mobile bearings have been compared with fixed bearings used in TKA. However, rotating platforms, a specific type of mobile bearing, have not been compared with fixed-bearings using meta-analysis. QUESTIONS/PURPOSES: We asked whether the performance of a rotating-platform bearing is superior to, comparable to, or worse than a fixed bearing. Four areas were investigated: clinical performance, component alignment, adverse event rates, and revision rates. METHODS: Searches of Medline, EMBASE, Google Scholar, and the Cochrane databases, combined with reference lists from published meta-analyses and systematic reviews of mobile-bearing versus fixed-bearing prostheses used in TKAs, provided 17 nonlanguage-restricted studies consisting of 1910 TKAs (966 rotating platform versus 944 fixed bearing). Random-effect modeling was used for all meta-analyses, thereby mitigating possible effects of heterogeneity among studies. All meta-analyses were examined for publication bias using funnel plots; publication bias was not detected for any meta-analysis. RESULTS: There were no statistically or clinically significant differences in clinical performance (clinical scores, ROM, and radiographic evaluation), component alignment, revision rates, or adverse event rates except for tibial component alignment in the AP plane, which favored TKA with fixed-bearings (p = 0.020; standardized mean difference, 0.229; 95% CI, 0.035-0.422), but the effect size was small enough that it was not considered clinically important. CONCLUSIONS: Based on our findings, which agree substantially with those of prior systematic reviews of TKAs with mobile-bearing versus fixed-bearing prostheses, there is no compelling case for either rotating-platform or fixed-bearing implant design in terms of clinical performance, component alignment, adverse event frequencies, or survivorship. This dataset, which was limited to a maximum 6 years followup, is insufficient to address questions related to wear or late revisions. We therefore suggest that implant choice should be made on the basis of other factors, perhaps including cost or surgeon experience.

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Computer-aided navigation in total knee arthroplasty (TKA) promises improved alignment, performance, and survivorship. Previous meta-analyses demonstrated that navigation yields better component alignment; however, they did not discuss other indicators of performance. This meta-analysis compares navigated (NAV) and conventional (CONV) TKAs and includes clinical outcomes and adverse events. Forty-seven studies (22 randomized trials) of varying methodological quality involving 7,151 TKAs created the sample population. Statistical analyses included analysis of variance of weighted means and random effects modeling. As seen in previous meta-analyses, NAV is favored over CONV TKA. Analysis of surgical characteristics found that length of surgery and tourniquet times were lower for CONV, but not significant. Meta-analysis found that tourniquet times favored CONV but not a strong relationship for length of surgery. Analysis of individual adverse events did not reveal any significant differences. However, when examining adverse events in their totality, the NAV experienced significantly fewer complications. TKA performed with imageless navigation improves component alignment, provides for lower blood loss, improves clinical outcomes as measured by Knee Society and WOMAC scores, and has fewer total adverse events. Published data are insufficient to determine any correlations between component alignment and outcomes.

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The purpose of this review is to examine the validity of positive claims regarding the direct anterior approach (DAA) with a fracture table for total hip arthroplasty. Recent literature regarding the DAA was searched and specific claims investigated including improved early outcomes, speed of recovery, component placement, dislocation rates, and complication rates. Recent literature is positive regarding the effects of total hip arthroplasty with the anterior approach. While the data is not definitive at present, patients receiving the anterior approach for total hip arthroplasty tend to recover more quickly and have improved early outcomes. Component placement with the anterior approach is more often in the "safe zone" than with other approaches. Dislocation rates tend to be less than 1% with the anterior approach. Complication rates vary widely in the published literature. A possible explanation is that the variance is due to surgeon and institutional experience with the anterior approach procedure. Concerns remain regarding the "learning curve" for both surgeons and institutions. In conclusion, it is not a matter of should this approach be used, but how should it be implemented.

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BACKGROUND: The literature comparing limited incision and standard incision THAs is confusing regarding whether limited incision THA improves short-term recovery without compromising long-term durability and survival. Further, previously published meta-analyses cannot conclude that limited incision THA is better. With new data, we seek to discover if the answers now exist. PURPOSE: We used meta-analysis to compare surgical and hospitalization data, clinical outcomes, and complication rates, and thus (1) confirm whether limited incision THA is at least comparable to standard incision THA; and (2) determine whether limited incision THA is an improvement over standard incision THA. METHODS: The PubMed database was searched using the terms "minimally", "invasive", and "total hip". Inclusion was limited to studies directly comparing limited incision with standard incision THA and reporting effect sizes. RESULTS: We identified 418 articles. Of these 11 provided background information and 30 provided data (3548 THAs) for the systematic review. Limited incision THA was better than standard incision THA in four measures: length of hospitalization (6 versus 7 days), VAS pain at discharge (2 versus 4), blood loss (421 mL versus 494 mL), and the Harris hip score at 3 months postoperation (90 versus 84). There were no outcomes for which standard incision was better. There was no major difference in the rate of complications. CONCLUSIONS: Short-term recovery favors limited incision over standard incision THA. The lack of consistent reporting for surgical outcomes, clinical outcomes, and complications continues to create difficulties when comparing limited and standard incision THAs.

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Advocates for navigated (NAV) total hip arthroplasty (THA) emphasize the potential for improved component placement. We reviewed published literature to investigate the claim of increased precision of acetabular component placement in navigated THA compared to conventional (N-NAV) THA. Major medical and publishers' databases were searched, making no restrictions for study type, yet restricting results to English-language sources. Nine studies of varying methodological quality involving 1479 THA with a mean age of 59.10 years were included. There was no statistically significant difference in mean acetabular component abduction and anteversion angles between the NAV and N-NAV groups. There was a statistically significant difference in the incidence of acetabular component placement in the "safe zone," with NAV having significantly more "safe placements" than N-NAV, regardless of the chosen safe zone. In addition, NAV had significantly fewer dislocations than N-NAV. These outcomes demonstrate the possible patient benefit from navigation and resulting tighter control of component position.

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Improper acetabular component orientation negatively affects the outcome of total hip arthroplasty through increasing dislocation rates, component impingement, bearing surface wear, and the number of revision surgeries. Leg length, hip biomechanics, pelvic osteolysis, and acetabular component migration are also affected by malposition. With conventional techniques, numerous variables, such as patient size, deformity and/or position, and decreased visualization, contribute to inter- and intrasurgeon acetabular component variability during surgery regardless of surgeon experience and practice volume. New acetabular component implantation techniques, such as patient-specific morphology, that incorporate anatomic landmarks may provide more accurate and individualized target zones. These techniques, coupled with the use of quantitative technology such as computer-aided navigation, may improve the precision of acetabular component placement.

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The published clinical and radiographic outcomes data for primary cementless low-contact stress (LCS) total knee arthroplasty (TKA) were examined. The majority of patients (92.6%) were pain free or had only mild pain, and excellent or good knee scores (99.1%) at follow-up. Patella difficulties and significant radiolucent lines were rare, occurring in less than 1% of patients. The average range of motion (ROM) for patients without a history of previous knee surgeries was 112.1 degrees. Previous knee procedures had a negative impact on ROM. Overall, primary cementless LCS TKA achieves excellent clinical nd radiographic results.

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The influence of femoral component surface finish was investigated by comparing 2 finishes, precoat and satin finish, for 1 cemented total hip arthroplasty (THA) system using 1 acetabular cup design. All surgeries were performed by a single surgeon in 2 consecutive series. Minimum 2-year follow-up outcomes (36 precoat, 25 satin) were compared using Harris Hip Scores, radiographs, and survivorships. The precoat population experienced significantly more radiographic and debonding failures than the satin-finish population, and significantly more pain (P <.05). Comparing failures and nonfailures within the precoat population disclosed neither significant preoperative nor significant cement-grade differences. Because of failure performance of the precoat surface finish, this surgeon no longer implants these components.

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