Aim. The current recommendation in Norway is to use four doses of a first-generation cephalosporin (cefazolin or cephalotin) as systemic antibiotic prophylaxis (SAP) the day of surgery in primary joint arthroplasty. Due to shortage of supply, scientific development, changed courses of treatment and improved antibiotic stewardship, this recommendation has been disputed. We therefore wanted to assess if one dose of SAP was non-inferior to four doses in preventing periprosthetic joint infection (PJI) in primary joint arthroplasty. Method. We included patients with primary hip- and knee arthroplasties from the Norwegian Arthroplasty Register and the Norwegian Hip Fracture Register for the period 2005-2023. We included the most used SAPs (cephalotin, cefazolin, cefuroxime, cloxacillin and clindamycin), administered as the only SAP in 1-4 doses, starting preoperatively. Risk of revision (Hazard rate ratio; HRR) for PJI was estimated by Cox regression analyses with adjustment for sex, age, ASA class, duration of surgery, reason for- and type of arthroplasty, and year of primary arthroplasty. The outcome was 1-year reoperation or revision for PJI. Non-inferiority margins were calculated for 1, 2 and 3 doses versus reference of 4 doses of SAP at the day of surgery, against a predetermined limit of 15% increased risk of PJI. Results. In total 274,188 primary arthroplasties (total hip 133,985, hemi hip 51,442, and total knee 88,761) were included. Of these primary arthroplasties, 2,996 (1.1%) had subsequent revisions for PJI during the first postoperative year. One dose of SAP was given in 9,603 arthroplasties, two doses in 10,068, three doses in 18,351, and four doses in 236,166 arthroplasties. With the recommended four doses as reference, the HRR (95% CI) for 1-year revision for infection was 0.9 (0.7-1.1) for one dose, 1.0 (0.8-1.2) for two doses, and 0.9 (0.8-1.1) for three doses. The corresponding adjusted 1-year revision incidences for PJI was 0.9 (0.7-1.1), 1.0 (0.8-1.2), 0.9 (0. 8-1.1) and 1.0 (1.0-1.1) for one, two, three and four doses respectively, and less than four doses was found to be non-inferior. Conclusions. One preoperative dose of SAP in primary joint arthroplasty surgery seems to be non-inferior to the current recommendation of four doses of a first-generation cephalosporin as PJI-prophylaxis. This finding may simplify the course of treatment for arthroplasty patients, save costs, and improve antibiotic stewardship

Aims

This study aims to evaluate the impact of metabolic syndrome in the setting of obesity on in-hospital outcomes and resource use after total joint replacement (TJR).

The August 2024 Knee Roundup³⁶⁰ looks at: Calcification’s role in knee osteoarthritis: implications for surgical decision-making; Lower complication rates and shorter lengths of hospital stay with technology-assisted total knee arthroplasty; Revision surgery: the hidden burden on surgeons; Are preoperative weight loss interventions worthwhile?; Total knee arthroplasty with or without prior bariatric surgery: a systematic review and meta-analysis; Aspirin triumphs in knee arthroplasty: a decade of evidence; Efficacy of DAIR in unicompartmental knee arthroplasty: a glimpse from Oxford.

Aims

To examine whether natural language processing (NLP) using a clinically based large language model (LLM) could be used to predict patient selection for total hip or total knee arthroplasty (THA/TKA) from routinely available free-text radiology reports.

Aims

Metal and ceramic humeral head bearing surfaces are available choices in anatomical shoulder arthroplasties. Wear studies have shown superior performance of ceramic heads, however comparison of clinical outcomes according to bearing surface in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) is limited. This study aimed to compare the rates of revision and reoperation following metal and ceramic humeral head TSA and HA using data from the National Joint Registry (NJR), which collects data from England, Wales, Northern Ireland, Isle of Man and the States of Guernsey.

Aims

Our primary aim was to assess reoperation-free survival at one year after the index injury in patients aged ≥ 75 years treated with internal fixation (IF) or arthroplasty for undisplaced femoral neck fractures (uFNFs). Secondary outcomes were reoperations and mortality analyzed separately.

Aims

Total femoral arthroplasty (TFA) is a rare procedure used in cases of significant femoral bone loss, commonly from cancer, infection, and trauma. Low patient numbers have resulted in limited published work on long-term outcomes, and even less regarding TFA undertaken for non-oncological indications. The aim of this study was to evaluate the long-term clinical outcomes of all TFAs in our unit.

Unicompartmental knee arthroplasty (UKA) is associated with a higher risk of revision compared with total knee arthroplasty (TKA). The outcomes of knee arthroplasty are typically presented as implant survival or incidence of revision after a set number of years, which can be difficult for patients and clinicians to conceptualise. We aimed to calculate the ‘lifetime risk’ of revision for UKA as a more relatable estimate of risk projection over a patient's remaining lifetime, and make comparisons to TKA. All primary UKAS performed from 1999 to 2019 (n=13,481) captured by the New Zealand Joint Registry (NZJR) were included. The lifetime risk of revision was calculated and stratified by age, gender and American Society of Anesthesiologists (ASA) status. The lifetime risk of revision for UKA was highest in the youngest patients (46-50 years; 40.4%) and lowest in the oldest patients (86-90 years; 3.7%). Lifetime risk of revision was higher for females (range 4.3%-43.4% cf. males 2.9%-37.4%) and patients with higher ASA status (ASA 3-4 range 8.8%-41.2% cf. ASA 1 1.8%-29.8%), regardless of age. The lifetime risk of UKA was two-fold higher than TKA (ranging from 3.7%-40.4% UKA, 1.6%-22.4% TKA) across all age groups. Increased risk of revision in the younger patients was associated with aseptic loosening in both males and females, and pain in females. Periprosthetic joint infections (PJI) accounted for 4% of all UKA revisions, in contrast to 27% for TKA; risk of PJI was higher for males than females for both procedures. The lifetime risk of revision is a more meaningful measure of arthroplasty outcomes and can aid with patient counselling prior to UKA. Findings from this study show the increased lifetime risk of UKA revision for younger patients, females and those with higher ASA status

Aims. The metabolic equivalent of task (MET) score examines patient performance in relation to energy expenditure before and after knee arthroplasty. This study assesses its use in a knee arthroplasty population in comparison with the widely used Oxford Knee Score (OKS) and EuroQol five-dimension index (EQ-5D), which are reported to be limited by ceiling effects. Methods. A total of 116 patients with OKS, EQ-5D, and MET scores before, and at least six months following, unilateral primary knee arthroplasty were identified from a database. Procedures were performed by a single surgeon between 2014 and 2019 consecutively. Scores were analyzed for normality, skewness, kurtosis, and the presence of ceiling/floor effects. Concurrent validity between the MET score, OKS, and EQ-5D was assessed using Spearman’s rank. Results. Postoperatively the OKS and EQ-5D demonstrated negative skews in distribution, with high kurtosis at six months and one year. The OKS demonstrated a ceiling effect at one year (15.7%) postoperatively. The EQ-5D demonstrated a ceiling effect at six months (30.2%) and one year (39.8%) postoperatively. The MET score did not demonstrate a skewed distribution or ceiling effect either at six months or one year postoperatively. Weak-moderate correlations were noted between the MET score and conventional scores at six months and one year postoperatively. Conclusion. In contrast to the OKS and EQ-5D, the MET score was normally distributed postoperatively with no ceiling effect. It is worth consideration as an arthroplasty outcome measure, particularly for patients with high expectations. Cite this article: Bone Jt Open 2023;4(3):129–137

Source of the study: University of Auckland, Auckland, New Zealand and University of Otago, Christchurch, New Zealand. Outcomes following knee arthroplasty are typically defined as implant survivorship at defined timepoints, or revision incidence over time. These estimates are difficult to conceptualise, and lack context for younger patients with more remaining years of life. We therefore aimed to determine a ‘lifetime’ risk of revision as a more useful metric for total (TKA) and unicompartmental knee arthroplasty (UKA). The New Zealand Joint Registry was used to identify 96,497 primary TKAs and 13,481 primary UKAs performed between 1999 and 2019. Patient mortality and revision incidence were also extracted. Estimates of lifetime risk were calculated using an actuarial lifetable method. The estimates were stratified by age and gender. Reasons for revision were categorised using previously published standardised definitions. The lifetime risk of UKA revision was two-fold higher than TKA across all age groups (range 3.7-40.4% UKA, 1.6-22.4% TKA). Revision risk was higher for males with TKA (range 3.4%-25.2% males, 1.1%-20% females), but higher for females with UKA (range 4.3%-43.4% vs. 2.9%-37.4% for males). Revision due to infections were higher for TKA (1.5% males, 0.7% females) compared with UKA (0.4% males, 0.1% females). The increased risk in younger UKA patients was associated with higher incidence of aseptic loosening (UKA 2%, TKA 1%) and ‘unexplained pain’ (UKA 2%, TKA 0.2%). The risk for UKA was two-fold higher than TKA, and this was partially explained by a higher proportion of revisions due to ‘unexplained pain’. For TKA, males had higher risk of revision, in contrast to UKA where females had higher risk; this gender difference was associated with higher incidence of infections with TKA. Younger age, gender and higher ASA status were also associated with increased lifetime risk of UKA revision. Lifetime risk of revision can provide a meaningful measure of arthroplasty outcomes to aid patient counselling

Aims

The primary aim was to assess whether preoperative health-related quality of life (HRQoL) was associated with postoperative mortality following total hip arthroplasty (THA) and knee arthroplasty (KA). Secondary aims were to assess whether patient demographics/comorbidities and/or joint-specific function were associated with postoperative mortality.

Aims. Unicompartmental knee arthroplasty (UKA) has a higher risk of revision than total knee arthroplasty (TKA), particularly for younger patients. The outcome of knee arthroplasty is typically defined as implant survival or revision incidence after a defined number of years. This can be difficult for patients to conceptualize. We aimed to calculate the ‘lifetime risk’ of revision for UKA as a more meaningful estimate of risk projection over a patient’s remaining lifetime, and to compare this to TKA. Methods. Incidence of revision and mortality for all primary UKAs performed from 1999 to 2019 (n = 13,481) was obtained from the New Zealand Joint Registry (NZJR). Lifetime risk of revision was calculated for patients and stratified by age, sex, and American Society of Anesthesiologists (ASA) grade. Results. The lifetime risk of revision was highest in the youngest age group (46 to 50 years; 40.4%) and decreased sequentially to the oldest (86 to 90 years; 3.7%). Across all age groups, lifetime risk of revision was higher for females (ranging from 4.3% to 43.4% vs males 2.9% to 37.4%) and patients with a higher ASA grade (ASA 3 to 4, ranging from 8.8% to 41.2% vs ASA 1 1.8% to 29.8%). The lifetime risk of revision for UKA was double that of TKA across all age groups (ranging from 3.7% to 40.4% for UKA, and 1.6% to 22.4% for TKA). The higher risk of revision in younger patients was associated with aseptic loosening in both sexes and pain in females. Periprosthetic joint infection (PJI) accounted for 4% of all UKA revisions, in contrast with 27% for TKA; the risk of PJI was higher for males than females for both procedures. Conclusion. Lifetime risk of revision may be a more meaningful measure of arthroplasty outcomes than implant survival at defined time periods. This study highlights the higher lifetime risk of UKA revision for younger patients, females, and those with a higher ASA grade, which can aid with patient counselling prior to UKA. Cite this article: Bone Joint J 2022;104-B(6):672–679

Aims

This study aimed to describe the use of revision knee arthroplasty in Australia and examine changes in lifetime risk over a decade.

Aims. Debridement, antibiotics, and implant retention (DAIR) is a widely accepted form of surgical treatment for patients with an early periprosthetic joint infection (PJI) after primary arthroplasty. The outcome of DAIR after revision arthroplasty, however, has not been reported. The aim of this study was to report the success rate of DAIR after revision arthroplasty with a follow-up of two years. Methods. This retrospective study, conducted at the Sint Maartenskliniek, Nijmegen, the Netherlands, included 88 patients who underwent DAIR within 90 days of revision total hip or total knee arthroplasty between 2012 and 2019. Details of the surgical procedures and PJI were collected. Univariate analysis and a subgroup analysis of the culture-positive group were performed. Kaplan-Meier survivorship curves were constructed. Results. The overall success rate of DAIR, with respect to the retention of components and the cure of infection, was 68% after two years. DAIR performed with an interval of > 30 days after the index revision procedure (odds ratio (OR) 0.24 (95% confidence interval (CI) 0.08 to 0.72); p = 0.008), a repeated DAIR within 90 days (OR 0.37 (95% CI 0.14 to 0.97); p = 0.040), and the use of an immunosuppressive agent (OR 0.13 (95% CI 0.02 to 0.67); p = 0.012) were associated with a significantly reduced success rate. In the culture-positive group, a mismatch between the antibiotic treatment and the susceptibility of the organism was associated with a significantly lower success rate (OR 0.13 (95% CI 0.03 to 0.62); p = 0.007). Conclusion. DAIR is an acceptable form of surgical treatment for patients with a suspected early PJI after revision arthroplasty of the hip or knee. DAIRs performed after a prolonged interval, multiple DAIRs, and antibiotic mismatches were significantly associated with an increased risk of failure. Optimization of the host immune response and the prevention of antibiotic mismatch are modifiable factors that may improve the outcome. The high rate of mismatches was an important finding, underlining the need for a review of the local microbiological data, which might improve the outcome. Cite this article: Bone Joint J 2022;104-B(4):464–471

Aims

The aim of this study was to identify the minimal clinically important difference (MCID), minimal important change (MIC), minimal detectable change (MDC), and patient-acceptable symptom state (PASS) in the Forgotten Joint Score (FJS) according to patient satisfaction six months following total hip arthroplasty (THA) in a UK population.

Aims

While preoperative bloodwork is routinely ordered, its value in determining which patients are at risk of postoperative readmission following total knee arthroplasty (TKA) and total hip arthroplasty (THA) is unclear. The objective of this study was to determine which routinely ordered preoperative blood markers have the strongest association with acute hospital readmission for patients undergoing elective TKA and THA.

Aims

It has been shown that the preoperative modification of risk factors associated with obesity may reduce complications after total knee arthroplasty (TKA). However, the optimal method of doing so remains unclear. The aim of this study was to investigate whether a preoperative Risk Stratification Tool (RST) devised in our institution could reduce unexpected intensive care unit (ICU) transfers and 90-day emergency department (ED) visits, readmissions, and reoperations after TKA in obese patients.

Aims

The aim of this study was to measure the effect of hospital case volume on the survival of revision total knee arthroplasty (RTKA).