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Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin, IrelandDepartment of Trauma & Orthopaedics, Galway University Hospital, Galway, IrelandDepartment of Trauma & Orthopaedics, Royal College of Surgeons Ireland, Dublin, Ireland
Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin, IrelandDepartment of Trauma & Orthopaedics, Royal College of Surgeons Ireland, Dublin, IrelandRothman Orthopedic Institute, Thomas Jefferson University Hospital, PA, USA
Department of Trauma & Orthopaedics, Galway University Hospital, Galway, IrelandDepartment of Trauma & Orthopaedics, Royal College of Surgeons Ireland, Dublin, Ireland
Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin, IrelandDepartment of Trauma & Orthopaedics, St James Hospital, Dublin, IrelandSchool of Medicine, University College Dublin, Dublin, Ireland
Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin, IrelandDepartment of Trauma & Orthopaedics, Royal College of Surgeons Ireland, Dublin, IrelandSchool of Medicine, University College Dublin, Dublin, Ireland
As operative techniques and implant design have evolved over time, total hip arthroplasty (THA) is increasingly being carried out for patients with neurological impairment. This patient group places unique surgical challenges to the arthroplasty surgeon, which may include contractures, instability, and altered muscular tone. The purpose of this systematic review is to report the patient outcomes, complications, and implant survival following THA for patients with neurological conditions affecting the hip. Thus, we aim to support orthopaedic surgeon decision-making when considering and planning THA for these patients.
Methods
A systematic review was performed as per Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using the PubMed/Medline OVID, Cochrane, and Embase databases. All studies reporting the outcomes of THA in the neurological population which met defined inclusion criteria were included.
Results
From an initial screen of 1820 studies, 45 studies with a total of 36,251 THAs were included in the final selection. All 45 studies reported complication rates, with controls included in 16 for comparison. High complication rates were observed following THA in the neurologically impaired population, most notably dislocation with observed rates up to 10.6%. An improvement was noted in all 36 studies (1811 THAs) which reported upon patient-reported outcomes.
Conclusions
THA may be beneficial in selected patients with neurological conditions, to reduce pain and improve function. There is an increased risk of complications which require careful consideration when planning the operation and open discussion with prospective patients and caregivers before proceeding with surgery.
]. Dislocation and aseptic loosening concerns led to a historical reluctance from surgeons to perform THA for patients with neurological conditions, with many proceeding towards salvage procedures in the primary instance such as arthrodesis or resection arthroplasty [
] with a greater understanding of the biomechanical environment surrounding prosthetic hips, which has naturally extended to the neurological population [
Matched cohort analysis of total hip arthroplasty in patients with and without Parkinson's disease: complications, mortality, length of stay, and hospital charges.
National joint registry for England, Wales, and northern Ireland. Good outcome of total hip replacement in patients with cerebral palsy: a comparison of 389 patients and 425,813 controls from the national joint registry for England and Wales.
]. Such interventions have become increasingly more common over the past 10 years, and as such, the available literature has greatly expanded. The aim of this systematic review is to build upon the previous work of Queally et al and report on the complete literature relating to THA for patients affected by neurological conditions [
]. This review will serve as a guide for orthopaedic surgeons planning THAs in the neurologically impaired population and to enable an informed discussion with patients and their caregivers regarding potential complications and anticipated outcomes.
Material and methods
Search strategy and eligibility
In February 2022, a systematic review of the literature was performed by 2 independent reviewers (C.S.O.D. and A.J.H.) with respect to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.
]. The PubMed/Medline OVID, Cochrane, and Embase databases were screened from their inception to February 2, 2022, inclusively. The search strategy was adapted from the study by Queally et al. [
], with predetermined search terms utilized for each of the aforementioned databases, including THA Population, Neurological Impairment, and Outcome (see attached in Appendix).
Following the removal of duplicate studies, both independent reviewers manually screened the titles and abstracts of the returned studies while applying our predetermined exclusion criteria, with the senior authors (B.J.O.D. and J.M.Q.) acting as arbitrators in cases of discrepancy of opinion. Following the removal of excluded studies, both independent reviewers applied the predetermined inclusion criteria to the remaining studies to evaluate all potential studies for definitive inclusion. Thereafter, the reference lists of all included studies were screened for further studies that potentially may meet the inclusion criteria.
Inclusion criteria encompassed (1) studies reporting the outcomes of THA in patients with neurological conditions, (2) studies published in English language, and (3) published in a peer review journal with full text available. Exclusion criteria included (1) case reports, (2) review articles, (3) abstract-only studies, and (4) cadaveric or biomechanical studies.
Outcomes of interest
The results from each study were tabulated following a quality assessment using the GRADE tool (Grading of Recommendation, Assessment, Development and Evaluation) [
A predesigned data-collection template was then collated including (1) study population, including neurological condition, study type, follow-up period, patient demographics; (2) implants utilized and surgical technique; (3) patient-reported outcomes; (4) complications; and (5) arthroplasty revision rate.
Descriptive statistics were performed using Stata software version 16.1 (StataCorp, College Station, TX). A Meta-analysis of the included studies was not performed due to the significant heterogeneity in study location, patient age, disease severity, implant type, surgical technique, and reporting of outcomes.
Results
There were 1820 studies collated in the initial database search, which was subsequently reduced to 1514 following duplicate removal. Following abstract screening, 108 full-text articles were assessed, leaving 45 studies, with 36,251 patients, included in the final review. Of the 45 studies, 36 reported functional outcomes of 1811 patients, using various rating scales, and all 45 reported complications. The PRISMA flow chart with reasons for exclusion is illustrated in Figure 1.
Figure 1PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flowchart.
Parkinson’s disease (PD) is a progressive neurodegenerative disorder characterized by elevated tone and classical motor symptoms such as bradykinesia, rigidity, rest tremor, as well as both postural and gait impairment, in addition to cognitive effects such as memory impairment which may complicate rehabilitation [
]. Between 2000 and 2014, the incidence of THAs performed for patients with PD increased from 946 to 1655 within the United States Nationwide Inpatient Sample (NIS) [
Matched cohort analysis of total hip arthroplasty in patients with and without Parkinson's disease: complications, mortality, length of stay, and hospital charges.
Focusing on the primary admission and immediate perioperative period, 2 studies using the United States NIS and carried out by Kleiner et al. and Newman et al. [
Matched cohort analysis of total hip arthroplasty in patients with and without Parkinson's disease: complications, mortality, length of stay, and hospital charges.
] observed an increased length of stay for PD patients compared to control. Medical complications were common in the PD cohort and included delirium and respiratory and urinary tract infections, replicating the experiences of PD patients undergoing nonorthopedic surgeries, thus highlighting the need for medical optimization and multidisciplinary care [
Eight studies with a total of 1296 THAs reported medium-term follow-up of over 2 years. These were primarily elective primary THAs (949 THAs), with several revision (58 THAs) and trauma (26 THAs) cases also classified. The mean age was 72.6 years, with a range of disability levels included from Hoehn and Yahr Classification stage I and II to severely affected grade IV and V patients [
]. This followed through to higher revision rates due to recurrent dislocation in Joint Registry–based studies by Wojtowicz et al. in Sweden and Jamsen et al. in Finland, for their cohorts of 495 and 297 PD THAs compared to matched control [
Is Parkinson's disease associated with increased mortality, poorer outcomes scores, and revision risk after THA? Findings from the Swedish hip arthroplasty register.
]. With respect to surgical indication, the dislocation rates in the trauma and revision THA group of the study by Weber et al., 12.2%, were higher than those in the elective group which experienced no dislocations [
]. Periprosthetic infection rates were over 2 times greater within the PD group in each of the 3 studies by Wojtowicz et al., Shah et al., and Rondon et al., which included matched control patients without neurological conditions [
Is Parkinson's disease associated with increased mortality, poorer outcomes scores, and revision risk after THA? Findings from the Swedish hip arthroplasty register.
Is Parkinson's disease associated with increased mortality, poorer outcomes scores, and revision risk after THA? Findings from the Swedish hip arthroplasty register.
]. Notwithstanding the higher complication and implant revision rates experienced by the PD group, an improvement in functional activity and pain was reported in each of the studies postoperatively. A point of note made by Weber et al. was that beyond an initial improvement in function at 1 year postoperatively, longer term outcomes were often limited by PD disease progression, as shown by a parallel deterioration in Hoehn and Yahr disease scores [
Cerebral palsy describes a group of permanent disorders of movement and posture attributable to nonprogressive disturbances that occurred in the developing brain [
Within the primary admission period, Moon et al. using the US NIS database reported a longer length of stay and increased risk of perioperative medical complications despite a younger mean age at the time of surgery in their cohort of 2062 Cerebral Palsy (CP) patients matched 10:1 to a non-CP control group [
]. Over the first 90 days, Moore et al. in their study of 864 CP patients matched 4:1, from the US Mariner patients records database, found a statistically significant increased odds ratio of medical complications such as urinary (odds ratio [OR] 2.42, 95% confidence interval 1.25-4.58) or respiratory tract infection (OR 3.77, 95% confidence interval 1.64-8.56) and periprosthetic fracture (OR 2.55, 95% confidence interval 1.42-4.46) [
Reviewing the England and Wales Joint Registry data from 389 CP patients undergoing THA, King et al. reported cumulative revision rates of 2.6% and 6.4% at 1 year and 5 years, respectively [
National joint registry for England, Wales, and northern Ireland. Good outcome of total hip replacement in patients with cerebral palsy: a comparison of 389 patients and 425,813 controls from the national joint registry for England and Wales.
]. Hybrid implants had the lowest 5-year revision rate of 1.2%, with uncemented (7.1%) and resurfacing (11.5%) implants faring less favorably. For comparison, the unmatched control cumulative revision rate was 0.79% at 1 year and 2.9% at 5 years. Among seven other retrospective studies, at varying lengths of follow-up, revision rates ranged from 0% to 27%. These studies with a combined 189 patients at mean 94 months of follow-up, reported 20 dislocations (10.6%), 11 cases of aseptic loosening (5.8%), 6 infections (3.2%), and 6 periprosthetic fractures (3.2%) [
The use of a dual-mobility concept in total hip arthroplasty patients with spastic disorders: no dislocations in a series of ten cases at midterm follow-up.
]. While there was considerable heterogeneity across the studies with regard to severity of CP symptoms, functional improvements were noted in multiple studies, including cases of both mild and severe impairment [
Multiple sclerosis (MS) is a chronic inflammatory autoimmune condition primarily affecting the central nervous system via demyelination of the axonal sheaths, which disrupts transmission [
Newman et al. found that during the primary admission, the rate of perioperative and surgical complications was higher for MS patients than for the control, based on an US NIS Inpatient Sample of 5899 MS patients who underwent THA [
]. There was also an increased average length of hospital stay and likelihood of requiring admittance to step-down care facilities before returning home from hospital in the MS cohort.
Among those studies that reported THA complications individually, the 2018 retrospective review of Newman et al. with 41 THAs in the Cleveland Clinic observed dislocation, infection, and aseptic loosening at higher rates than those in control [
]. With regard to implant revision rates, Quinlan et al. estimated the rate at 2 years to be 4.23% from their analysis of US Medicare analytical files [
Newman et al. also reported variable functional outcome scores depending upon MS phenotype, with a higher mean Hip Disability and Osteoarthritis Outcome Score Joint Replacement score of 95 in the primary progressive subtype, as opposed to 70 in the secondary progressive group [
]. MS patients demonstrated lower modified Harris Hip Score and Hip Disability and Osteoarthritis Outcome Score Joint Replacement hip function scores than control despite receiving increased physiotherapy care although this may be partly reflective of progression of their disease during the period of this study as demonstrated by worsening of mMSIS scores. Results from the included MS THA studies are displayed in [
Poliomyelitis is an infectious viral disease caused by the polio enterovirus, in which loss and degradation of anterior horn cells in the lower motor neuron system leads to varying degrees of muscle wasting, hyporeflexia, and flaccid paralysis [
] may lead to subluxation and abnormal loading throughout hip development during childhood, with resultant bony dysplasia and painful degenerative hip arthritis [
]. They found an improvement in functional outcomes both in a polio-affected and unaffected limb. Their component revision rate at 6-year follow-up was 5.1%, with osteolysis (10.2%) and dislocation (5.1%) being the most commonly encountered complications. A further 8 retrospective case series with a total of 78 THAs also reported improved functional outcomes through a variety of scoring systems, [
Charcot or neuropathic arthropathy occurs in patients with reduced sensory and nociceptive feedback in a joint susceptible to repetitive microtrauma, leading to progressive joint destruction and deformity [
The largest of these was from Chalmers et al. in 2018 who described a case series of 12 THAs in 11 patients, with a range of underlying medical conditions, including Charcot-Marie-Tooth disease and diabetes mellitus [
]. They reported considerable improvements in pain and function, which correlated with a mean rise in HHS at 5-year follow-up, notwithstanding a high rate of complications, as seen in Figure 6.
Figure 6Total hip arthroplasty in Charcot joint results.
Further studies reported experiences with THA in the setting of an assortment of other neurological conditions, such as stroke, traumatic brain injury, spinal cord injury, brain tumors, and spondylotic neuropathy. A number of these studies grouped multiple underlying conditions together. Although these studies did not differentiate results by the underlying condition, the functional results were positive in each case.
The outcomes of THA on the affected hemiplegic limb following stroke were investigated by Henawy and Badie through a retrospective review of 24 patients in both the trauma and elective settings between 2013 and 2015 [
]. Following stroke, patients may experience upper motor neuron signs such as spasticity in the affected limb, posing similar challenges to that of CP, both intraoperatively and in the rehabilitation period. Excellent functional improvements were reported following arthroplasty, and they quantified this using the Harris and Merle d’Aubigne Hip Scores [
]. Studies by Wang et al., Ryu et al., Abdelazim and Michael, Alosh et al., and Park et al. also included patients with a history of stroke among their neurological THA groups, [
Often, arthroplasty surgeons operate on a limited number of patients with neurological conditions. A British joint registry–based study of 389 THAs for CP patients by King et al. found that only 23% of surgeons performed more than 1 THA procedure on a CP patient during the study period of 2003-2012 [
National joint registry for England, Wales, and northern Ireland. Good outcome of total hip replacement in patients with cerebral palsy: a comparison of 389 patients and 425,813 controls from the national joint registry for England and Wales.
High annual surgeon volume reduces the risk of adverse events following primary total hip arthroplasty: a registry-based study of 12,100 cases in Western Sweden.
]. A study of nearly 38,000 Canadian patients found that surgeons who performed <35 THAs a year had a dislocation rate of 1.9% vs 1.3% for surgeons with greater volumes [
]. While patient and caregiver preference may favor a local hospital with accessible follow-up, it is worth considering that arthroplasty procedures in patients with neurological conditions should ideally be performed by specialists with sufficient case volume. In addition, given the increased perioperative care needs as detailed in the following section, centers with well-integrated multidisciplinary teams are preferable. This can create a virtuous circle of specialty knowledge, surgeon's and theatre staff's familiarity with novel components, and multidisciplinary expertise.
Perioperative care
Advance THA planning allows for medical optimization, surgical planning with possible lead in time for implant delivery, as well as patient and caregiver education. Multidisciplinary input from health-care professionals is crucial. Many patients with neurological conditions, such as PD, MS, and CP, receive regular disease-modifying medication. A perioperative neurological assessment can help optimize their regimen to minimize spasticity and tremor. Patients with spasticity may also benefit from botulinum toxin injection prior to THA [
]. Postoperatively, patients are at increased risk of medical complications such as delirium, respiratory tract infections, falls, and periprosthetic fractures, alongside an increased length of stay, [
Matched cohort analysis of total hip arthroplasty in patients with and without Parkinson's disease: complications, mortality, length of stay, and hospital charges.
]. CT scanning may also be required if surgeons plan to use image-based navigation or robotic systems, which may be helpful in aiding accurate implant positioning in particularly challenging cases [
The accuracy of the computed tomography-based navigation system in total hip arthroplasty is comparable with crowe type IV and crowe type I dysplasia: a case-control study.
Physiotherapists can develop an individualized prehabilitation program tailored to the patient’s capabilities. Advance occupational therapy assessment can anticipate assistive supports or ambulatory devices and address potential barriers to discharge from hospital, particularly for patients who experience concomitant upper-extremity spasticity and deformity [
]. Preoperative patient education regarding muscle rehabilitation and hip movement restrictions has also been shown in other arthroplasty settings to reduce the risk of dislocations [
The most common complication observed in our review was dislocation, and reducing its risk is a major focus of operative planning in patients with neurological conditions. Other complications such as infection were also observed at an increased rate within the neurological population, and standard measures to mitigate them, such as medical optimization, antibiotic prophylaxis, operating environment, and meticulous asepsis, are advised [
An uncemented prosthesis were favored in 69% of studies throughout our review. In those patients with particularly high risk of dislocation, such as severe Gross Motor Function Classification System level V CP, advanced PD, and poliomyelitis, implant designs such as dual-mobility (DM) implants and acetabular liners, with additional levels of constraint, were utilized. DM implants have a broad application in high-risk revision surgeries and are increasing in popularity. Neurological conditions in which DM implants have been used successfully over the last 10 years include PD, [
The use of a dual-mobility concept in total hip arthroplasty patients with spastic disorders: no dislocations in a series of ten cases at midterm follow-up.
]. The modular design of DM cups also allows for screw placement for additional cup fixation in cases of significant bone loss, which has been reported as a challenge when performing THA for patients with neurological conditions [
]. Lazennec et al. utilized DM components in their study of 63 PD THA cases, of whom 33% were undergoing revision arthroplasty and reported a single dislocation episode (1.6%) at a mean 8.3 years of follow-up [
]. Dislocation events observed in the setting of DM constructs cite the use of smaller outer polyethylene insert diameter (<38 mm), which corresponds to a smaller inner head size and cup malposition [
]. Morin et al. also reported a low dislocation rate of 2.5% in their group of 40 high Gross Motor Function Classification System grade 5 cerebral palsy THAs; however, this event was associated with an intraprosthetic dissociation requiring operative revision [
]. Intraprosthetic dissociation requiring operative reduction was also reported by Ryu et al. in their study of 35 patients affected by neurological conditions [
]. Such liners may be beneficial in reducing dislocation by containing the femoral head beyond its equator, thus preventing the head from dislocating out of socket. However, concerns arise regarding the significant reduction in primary arc range when constrained liners are utilized, which may paradoxically increase the risk of instability, and there is a high failure rate with poor initial placement, through liner dissociation, component loosening, and recurrent dislocations [
]. A simpler measure, widely adopted throughout the reviewed studies, is to use femoral heads with a larger diameter of greater than 36 mm, which increases the head-neck ratio, while also increasing the primary arc range prior to an impingement event, which could result in a dislocation [
There is no clear consensus regarding the optimal surgical approach, and thus, further research in this area would be of benefit. Of the included studies that detailed their surgical approach, the posterior approach was favored most in 14 of the 25 studies, highlighting the necessity to achieve a robust soft-tissue repair to minimize dislocation risk [
]. Achieving a robust envelop is difficult due to the degree of soft-tissue laxity in common neurological conditions, and for this reason, surgeons made use of additional combined anteversion and extended postoperative restrictions such as abduction braces and knee immobilizers, while hip spica casts were prevalent in the past [
There are a number of limitations regarding the findings of this review. Bias may have been introduced in the reporting of complications by virtue of the retrospective nature of included studies which are heterogenic by nature. Our initial search found a number of studies from the same institution with overlapping patient groups, whereby the series of the largest cohort was selected for inclusion. The statistical analysis for subgroups was limited due to discrepancies in reporting of results among the included studies.
Conclusions
THA reliably improves symptoms of painful hip arthritis for patients with neurological conditions affecting the hip. It is important for surgeons, patients, and caregivers to be aware of the increased risk of associated complications, most notably dislocation with specific risk data presented herein, before proceeding with surgery. As a technically challenging operation, it should be undertaken by experienced arthroplasty surgeons allowing for familiarity with novel techniques and implants, with sufficient multidisciplinary support to meet their perioperative care requirements.
Conflicts of interest
The authors declare there are no conflicts of interest.
For full disclosure statements refer to https://doi.org/10.1016/j.artd.2022.11.001.
“Total hip arthroplasty” OR THA OR “total hip replacement” OR THR OR “arthroplasty, replacement, Hip”[Mesh]
#2 Neurological Population
“cerebral palsy” OR “spina bifida” OR myelomeningocele OR poliomyelitis OR “Parkinson disease” OR “multiple sclerosis” OR stroke OR CVA OR “acquired brain injury” OR Charcot OR “neuropathic arthropathy” OR “neuromuscular disease” OR “spinal injury” OR “paralytic hip” OR “Cerebral Palsy”[Mesh] OR “Spinal Dysraphism”[Mesh] OR “Meningomyelocele”[Mesh] OR “poliomyelitis”[Mesh] OR “Parkinson Disease”[Mesh] OR “Multiple Sclerosis”[Mesh] OR “Stroke”[Mesh] OR “Brain Injuries”[Mesh] OR “Arthropathy, Neurogenic”[Mesh] OR “Neuromuscular Diseases”[Mesh] OR “Spinal Injuries”[Mesh]
#3 Outcome
outcome OR “clinical outcome” OR “patient outcome” OR revision OR mortality OR death OR infection OR complication OR dislocation OR “patient reported outcome measure” OR PROM OR “Treatment Outcome”[Mesh] OR “Patient Reported Outcome Measures”[Mesh] OR “Reoperation”[Mesh] OR “Mortality”[Mesh] OR “Death”[Mesh] OR “Infections”[Mesh] OR “Intraoperative Complications”[Mesh] OR “Postoperative Complications”[Mesh] OR “Joint Dislocations”[Mesh]
“Total hip arthroplasty” OR THA OR “total hip replacement” OR THR OR MeSH descriptor: [Arthroplasty, replacement, hip] explode all trees
#2 Neurological Population
“cerebral palsy” OR “spina bifida” OR myelomeningocele OR poliomyelitis OR “Parkinson disease” OR “multiple sclerosis” OR stroke OR CVA OR “acquired brain injury” OR Charcot OR “neuropathic arthropathy” OR “neuromuscular disease” OR “spinal injury” OR “paralytic hip” OR MeSH descriptor: [Cerebral Palsy] explode all trees OR MeSH descriptor: [Spinal Dysraphism] explode all trees OR MeSH descriptor: [Meningomyelocele] explode all trees OR MeSH descriptor: [Poliomyelitis] explode all trees OR MeSH descriptor: [Parkinson Disease] explode all trees OR MeSH descriptor: [Multiple Sclerosis] explode all trees OR MeSH descriptor: [Stroke] explode all trees OR MeSH descriptor: [Arthropathy, Neurogenic] explode all trees OR MeSH descriptor: [Neuromuscular Disease] explode all trees OR MeSH descriptor: [Spinal Injuries] explode all trees
#3 Outcome
outcome OR “clinical outcome” OR “patient outcome” OR revision OR mortality OR death OR infection OR complication OR dislocation OR “patient reported outcome measure” OR PROM OR MeSH descriptor: [Patient Outcome Assessment] explode all trees OR MeSH descriptor: [Reoperation] explode all trees OR MeSH descriptor: [Mortality] explode all trees OR MeSH descriptor: [Death] explode all trees OR MeSH descriptor: [Infections] explode all trees OR MeSH descriptor: [Intraoperative Complications] explode all trees OR MeSH descriptor: [Postoperative Complications] explode all trees OR MeSH descriptor: [Hip Dislocation] explode all trees
“Total hip arthroplasty” OR THA OR “total hip replacement” OR THR OR ′total hip replacement'/exp
#2 Neurological Population
“cerebral palsy” OR “spina bifida” OR myelomeningocele OR poliomyelitis OR “Parkinson disease” OR “multiple sclerosis” OR stroke OR CVA OR “acquired brain injury” OR Charcot OR “neuropathic arthropathy” OR “neuromuscular disease” OR “spinal injury” OR “paralytic hip” OR ′cerebral palsy'/exp OR ′spinal dysraphism'/exp OR 'meningomyelocele'/exp OR 'poliomyelitis'/exp OR ′Parkinson disease'/exp OR ′multiple sclerosis'/exp OR ′cerebrovascular accident'/exp OR ′acquired brain injury'/exp OR ′neuropathic joint disease'/exp OR ′neuromuscular disease'/exp OR ′spine injury'/exp
#3 Outcome
outcome OR “clinical outcome” OR “patient outcome” OR revision OR mortality OR death OR infection OR complication OR dislocation OR “patient reported outcome measure” OR PROM OR ′treatment outcome'/exp OR ′clinical outcome'/exp OR ′revision arthroplasty'/exp OR 'mortality'/exp OR 'death'/exp OR 'infection'/exp OR ′postoperative complication'/exp OR ′perioperative complication'/exp OR ′hip dislocation'/exp
Matched cohort analysis of total hip arthroplasty in patients with and without Parkinson's disease: complications, mortality, length of stay, and hospital charges.
National joint registry for England, Wales, and northern Ireland. Good outcome of total hip replacement in patients with cerebral palsy: a comparison of 389 patients and 425,813 controls from the national joint registry for England and Wales.
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.
Is Parkinson's disease associated with increased mortality, poorer outcomes scores, and revision risk after THA? Findings from the Swedish hip arthroplasty register.
The use of a dual-mobility concept in total hip arthroplasty patients with spastic disorders: no dislocations in a series of ten cases at midterm follow-up.
High annual surgeon volume reduces the risk of adverse events following primary total hip arthroplasty: a registry-based study of 12,100 cases in Western Sweden.
The accuracy of the computed tomography-based navigation system in total hip arthroplasty is comparable with crowe type IV and crowe type I dysplasia: a case-control study.
All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Conor O’Driscoll, Andrew Hughes, and Martin Davey. The first draft of the manuscript was written by Conor O’Driscoll, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
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