Heterotopic ossification (HO) is known to be a common complication after total hip arthroplasty (THA). The minimal invasive (MIS) modified anterolateral approach has become popular in combination with a short stem. We analysed the incidence of HO following short-stem THA using this approach in combination with a postoperative administration of nonsteroidal anti-inflammatory drugs (NSAIDs).
Materials and methods
216 short stems were implanted in 162 patients. NSAIDs were administered for 2 weeks after surgery in 154 patients (95.1%). Standardised pre- and postoperative radiographic imaging was done at 2-year follow-up. HO was analysed according to the Brooker classification. Influence of age, gender, body mass index (BMI), and blood transfusion were analysed. Harris Hip Score (HHS) and visual analogue scale (VAS) of satisfaction were assessed. Operation time and blood-transfusion rate was documented. Short-term gastrointestinal side effects were recorded.
Results
The overall incidence of HO was 7.8% (16 cases). HO Brooker type 3 and 4 occurred in only 1 case (0.5%). No correlation with age, gender or BMI was revealed. HHS improved largely from 45.8 (SD 15.9) before surgery to 98.1 (SD 4.7) after a minimum of 2 years. At that point VAS satisfaction was 9.7 (SD 0.9). Mean operative time was 45.8 minutes (SD 18.7). 12 patients (7.4%) received at least 1 blood-transfusion. Gastrointestinal side effects occurred in 13 of 154 patients (8.4%).
Conclusions
The combination of short-stem THA, the MIS modified anterolateral approach and a postoperative application of NSAIDs resulted in the effective prevention of HO and excellent clinical results.
RegisD., SandriA., SambugaroE.Incidence of heterotopic ossification after surface and conventional total hip arthroplasty: a comparative study using anterolateral approach and indomethacin prophylaxis.Biomed Res Int.2013; 2013: 293528.
2.
AhrengartL., LindgrenU.Heterotopic bone after hip arthroplasty. Defining the patient at risk.Clin Orthop Relat Res.1993; (293): 153–159.
3.
BrookerA.F., BowermanJ.W., RobinsonR.A., RileyL.H.Jr.. Ectopic ossification following total hip replacement. Incidence and a method of classification.J Bone Joint Surg Am.1973; 55(8): 1629–1632.
4.
FurlongA.J., GiannoudisP.V., SmithR.M.Heterotopic ossification: a comparison between reamed and unreamed femoral nailing.Injury.1997; 28(1): 9–14.
5.
NilssonO.S., PerssonP.E.Heterotopic bone formation after joint replacement.Curr Opin Rheumatol.1999; 11(2): 127–131.
6.
WinklerS., CraiovanB., WagnerF., WeberM., GrifkaJ., RenkawitzT.Pathogenesis and prevention strategies of heterotopic ossification in total hip arthroplasty: a narrative literature review and results of a survey in Germany.Arch Orthop Trauma Surg.2015; 135(4): 481–489.
7.
EdwardsD.S., BarburS.A.R., BullA.M.J., StranksG.J.Posterior mini-incision total hip arthroplasty controls the extent of post-operative formation of heterotopic ossification.Eur J Orthop Surg Traumatol.2015; 25(6): 1051–1055.
8.
SneathR.J., BindiF.D., DaviesJ., ParnellE.J.The effect of pulsed irrigation on the incidence of heterotopic ossification after total hip arthroplasty.J Arthroplasty.2001; 16(5): 547–551.
9.
JiY., ChristophersonG.T., KlukM.W., AmraniO., JacksonW.M., NestiL.J.Heterotopic ossification following musculoskeletal trauma: modeling stem and progenitor cells in their microenvironment.Adv Exp Med Biol.2011; 720: 39–50.
10.
BoardT.N., KarvaA., BoardR.E., GambhirA.K., PorterM.L.The prophylaxis and treatment of heterotopic ossification following lower limb arthroplasty.J Bone Joint Surg Br.2007; 89(4): 434–440.
11.
JowseyJ., CoventryM.R.Heterotopic ossification: theoretical consideration possible etiological factors, and a clinical review of total hip arthroplasty patients exhibiting this phenomenon.Hip procs 5th Open Sci Meet Hip Soc St Louis.CV Mosby1997: 201–221.
12.
Fransen M, Neal B, Cameron ID, et al; HIPAID Collaborative Group.Determinants of heterotopic ossification after total hip replacement surgery.Hip Int.2009; 19(1): 41–46.
13.
BalB.S., LoweJ.A.E., e GietlerA., AletoT.J.Heterotopic ossification after 2-incision total hip arthroplasty.J Arthroplasty.2010; 25(4): 538–540.
14.
TippetsD.M., ZaryanovA.V., BurkeW.V.. Incidence of heterotopic ossification in direct anterior total hip arthroplasty: a retrospective radiographic review.J Arthroplasty.2014; 29(9): 1835–1838.
15.
HandelM., BrettschneiderJ., KöckF.X., AndersS., PerlickL., SellS.[Risk factors associated with heterotopic ossifications in primary total hip arthroplasty].Z Orthop Ihre Grenzgeb.2004; 142(5): 564–570.
16.
ToomA., HavikoT., RipsL.Heterotopic ossification after total hip arthroplasty.Int Orthop.2001; 24(6): 323–326.
17.
FransenM., NealB.Non-steroidal anti-inflammatory drugs for preventing heterotopic bone formation after hip arthroplasty.Cochrane Database Syst Rev.2004; CD001160(3): CD001160.
18.
XuB-G, XueD-T, WangX-H, YanS-G. [Selective COX-2 inhibitor versus nonselective COX-1 and COX-2 inhibitor in the prevention of heterotopic ossification after total hip arthroplasty: a meta-analysis of randomised trials].Zhongguo Gu Shang.2014; 27(7): 609–614. [Article in Chinese].
19.
BertinK.C., RöttingerH.Anterolateral mini-incision hip replacement surgery: a modified Watson-Jones approach.Clin Orthop Relat Res.2004; (429): 248–255.
20.
PfeilJ.Minimally invasive surgery in total hip arthroplasty.Springer; 2010.
21.
StehlíkJ., MusilD., HeldM., StárekM.[Minimally invasive total hip replacement-one-year results].Acta Chir Orthop Traumatol Cech.2008; 75(4): 262–270. [Article in Czech].
22.
KovacevicM.P., PfeilJ., KutznerK.P.Implantation of a new short stem in simultaneous bilateral hip arthroplasty – a prospective study on clinical and radiographic data of 54 consecutive patients.2014; 10: 456–461.
23.
Della ValleA.G., RuzoP.S., PavoneV., ToloE., MintzD.N., SalvatiE.A.Heterotopic ossification after total hip arthroplasty: a critical analysis of the Brooker classification and proposal of a simplified rating system.J Arthroplasty.2002; 17(7): 870–875.
24.
ZeckeyC., HildebrandF., FrinkM., KrettekC.Heterotopic ossifications following implant surgery—epidemiology, therapeutical approaches and current concepts.Semin Immunopathol.2011; 33(3): 273–286.
25.
Le DuffM.J., TakamuraK.B., AmstutzH.C.Incidence of heterotopic ossification and effects of various prophylactic methods after hip resurfacing.Bull NYU Hosp Jt Dis.2011; 69(Suppl 1): S36–S41.
26.
AnthonissenJ., OssendorfC., HockJ.L.. The role of muscular trauma in the development of heterotopic ossification after hip surgery: An animal-model study in rats.Injury.2016; 47(3): 613–616.
27.
MolliganJ., MitchellR., SchonL.. Influence of Bone and Muscle Injuries on the Osteogenic Potential of Muscle Progenitors: Contribution of Tissue Environment to Heterotopic Ossification.Stem Cells Transl Med.2016; 5(6): 745–753.
28.
GuoJ.J., TangN., YangH.L., QinL., LeungK.S.Impact of surgical approach on postoperative heterotopic ossification and avascular necrosis in femoral head fractures: a systematic review.Int Orthop.2010; 34(3): 319–322.
29.
MorreyB.F., AdamsR.A., CabanelaM.E.Comparison of heterotopic bone after anterolateral, transtrochanteric, and posterior approaches for total hip arthroplasty.Clin Orthop Relat Res.1984; (188): 160–167.
30.
BohlerN., HipmairG.The minimal invasive surgery anterior approach with supine patient positioning: a step-wise introduction of technique.Hip Int.2006; 16(Suppl 4): 48–53.
31.
MichelM.C., WitschgerP.MicroHip: a minimally invasive procedure for total hip replacement surgery using a modified Smith-Peterson approach.Ortop Traumatol Rehabil.2007; 9(1): 46–51.
32.
ChenD., BergerR.A.Outpatient minimally invasive total hip arthroplasty via a modified Watson-Jones approach: technique and results.Instr Course Lect.2013; 62: 229–236.
33.
WohlrabD., HagelA., HeinW.[Advantages of minimal invasive total hip replacement in the early phase of rehabilitation].Z Orthop Ihre Grenzgeb.2004; 142(6): 685–690.
RepantisT., BourasT., KorovessisP.Comparison of minimally invasive approach versus conventional anterolateral approach for total hip arthroplasty: a randomized controlled trial.Eur J Orthop Surg Traumatol.2015; 25(1): 111–116.
36.
PaiV.S.Heterotopic ossification in total hip arthroplasty. The influence of the approach.J Arthroplasty.1994; 9(2): 199–202.
