We used the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) to investigate the risk of revision due to prosthetic joint infection (PJI) for patients undergoing primary and revision hip arthroplasty, the changes in risk over time, and the overall burden created by PJI. We analysed revision total hip arthroplasties (THAs) performed due to a diagnosis of PJI and the linked index procedures recorded in the NJR between 2003 and 2014. The cohort analysed consisted of 623 253 index primary hip arthroplasties, 63 222 index revision hip arthroplasties and 7585 revision THAs performed due to a diagnosis of PJI. The prevalence, cumulative incidence functions and the burden of PJI (total procedures) were calculated. Overall linear trends were investigated with log-linear regression.Objectives
Methods
Introduction. The Centers for Medicare and Medicaid Services (CMS) removed total knee arthroplasty (TKA) from inpatient-only status in 2018. Our goal was to measure the adoption of outpatient TKAs, the impact on re-treatment rates, and the economic implications for hospitals. Methods. We utilized 100% national Medicare Part A fee-for-service (FFS) patient-level claims data for 2017–2018. We excluded DRG 469 TKAs since they are unlikely to be outpatient candidates, which left 257,107 primary TKAs in 2017 and 264,393 in 2018. We examined the
This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days. We analyzed data from 26,393 patients with trochanteric AO/OTA A1 and A2 fractures treated with IMNs (n = 9,095) or SHSs (n = 17,298) in the Norwegian Hip Fracture Register (January 2008 to December 2020). Exclusions were made for patients aged < 60 years, pathological fractures, pre-2008 operations, contralateral hip fractures, fractures other than trochanteric A1/A2, and treatments other than IMNs or SHSs. Kaplan-Meier and Cox regression analyses adjusted for type of fracture, age, sex, cognitive impairment, American Society of Anesthesiologists (ASA) grade, and time period were conducted, along with calculations for number needed to harm (NNH).Aims
Methods
Our primary aim was to establish the proportion of female orthopaedic consultants who perform arthroplasty via cases submitted to the National Joint Registry (NJR), which covers England, Wales, Northern Ireland, the Isle of Man, and Guernsey. Secondary aims included comparing time since specialist registration, private practice participation, and number of hospitals worked in between male and female surgeons. Publicly available data from the NJR was extracted on the types of arthroplasty performed by each surgeon, and the number of procedures of each type undertaken. Each surgeon was cross-referenced with the General Medical Council (GMC) website, using GMC number to extract surgeon demographic data. These included sex, region of practice, and dates of full and specialist registration.Aims
Methods
This study aimed to investigate the estimated change in primary and revision arthroplasty rate in the Netherlands and Denmark for hips, knees, and shoulders during the COVID-19 pandemic in 2020 (COVID-period). Additional points of focus included the comparison of patient characteristics and hospital type (2019 vs COVID-period), and the estimated loss of quality-adjusted life years (QALYs) and impact on waiting lists. All hip, knee, and shoulder arthroplasties (2014 to 2020) from the Dutch Arthroplasty Register, and hip and knee arthroplasties from the Danish Hip and Knee Arthroplasty Registries, were included. The expected number of arthroplasties per month in 2020 was estimated using Poisson regression, taking into account changes in age and sex distribution of the general Dutch/Danish population over time, calculating observed/expected (O/E) ratios. Country-specific proportions of patient characteristics and hospital type were calculated per indication category (osteoarthritis/other elective/acute). Waiting list outcomes including QALYs were estimated by modelling virtual waiting lists including 0%, 5% and 10% extra capacity.Aims
Methods
Early large treatment effects can arise in small studies, which lessen as more data accumulate. This study aimed to retrospectively examine whether early treatment effects occurred for two multicentre orthopaedic randomized controlled trials (RCTs) and explore biases related to this. Included RCTs were ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation), a two-arm study of surgery versus non-surgical treatment for proximal humerus fractures, and UK FROST (United Kingdom Frozen Shoulder Trial), a three-arm study of two surgical and one non-surgical treatment for frozen shoulder. To determine whether early treatment effects were present, the primary outcome of Oxford Shoulder Score (OSS) was compared on forest plots for: the chief investigator’s (CI) site to the remaining sites, the first five sites opened to the other sites, and patients grouped in quintiles by randomization date. Potential for bias was assessed by comparing mean age and proportion of patients with indicators of poor outcome between included and excluded/non-consenting participants.Aims
Methods
Prosthetic joint infection (PJI) is an uncommon but serious complication of hip and knee replacement. We investigated the rates of revision surgery for the treatment of PJI following primary and revision hip and knee replacement, explored
The aim of this study was to conduct a cross-sectional, observational cohort study of patients presenting for revision of a total hip, or total or unicompartmental knee arthroplasty, to understand current routes to revision surgery and explore differences in symptoms, healthcare use, reason for revision, and the revision surgery (surgical time, components, length of stay) between patients having regular follow-up and those without. Data were collected from participants and medical records for the 12 months prior to revision. Patients with previous revision, metal-on-metal articulations, or hip hemiarthroplasty were excluded. Participants were retrospectively classified as ‘Planned’ or ‘Unplanned’ revision. Multilevel regression and propensity score matching were used to compare the two groups.Aims
Methods
To identify the prevalence of neuropathic pain after lower limb fracture surgery, assess associations with pain severity, quality of life and disability, and determine baseline predictors of chronic neuropathic pain at three and at six months post-injury. Secondary analysis of a UK multicentre randomized controlled trial (Wound Healing in Surgery for Trauma; WHiST) dataset including adults aged 16 years or over following surgery for lower limb major trauma. The trial recruited 1,547 participants from 24 trauma centres. Neuropathic pain was measured at three and six months using the Doleur Neuropathique Questionnaire (DN4); 701 participants provided a DN4 score at three months and 781 at six months. Overall, 933 participants provided DN4 for at least one time point. Physical disability (Disability Rating Index (DRI) 0 to 100) and health-related quality-of-life (EuroQol five-dimension five-level; EQ-5D-5L) were measured. Candidate predictors of neuropathic pain included sex, age, BMI, injury mechanism, concurrent injury, diabetes, smoking, alcohol, analgaesia use pre-injury, index surgery location, fixation type, Injury Severity Score, open injury, and wound care.Aims
Methods
The primary aim of this study was to compare the postoperative systemic inflammatory response in conventional jig-based total knee arthroplasty (conventional TKA) versus robotic-arm assisted total knee arthroplasty (robotic TKA). Secondary aims were to compare the macroscopic soft tissue injury, femoral and tibial bone trauma, localized thermal response, and the accuracy of component positioning between the two treatment groups. This prospective randomized controlled trial included 30 patients with osteoarthritis of the knee undergoing conventional TKA versus robotic TKA. Predefined serum markers of inflammation and localized knee temperature were collected preoperatively and postoperatively at six hours, day 1, day 2, day 7, and day 28 following TKA. Blinded observers used the Macroscopic Soft Tissue Injury (MASTI) classification system to grade intraoperative periarticular soft tissue injury and bone trauma. Plain radiographs were used to assess the accuracy of achieving the planned postioning of the components in both groups.Aims
Methods
The aims of this study were to determine the rates of surgical complications, reoperations, and readmissions following herniated lumbar disc surgery, and to investigate the impact of sociodemographic factors and comorbidity on the rate of such unfavourable events. This was a longitudinal observation study. Data from herniated lumbar disc operations were retrieved from a large medical database using a combination of procedure and diagnosis codes from all public hospitals in Norway from 1999 to 2013. The impact of age, gender, geographical affiliation, education, civil status, income, and comorbidity on unfavourable events were analyzed by logistic regression.Aims
Patients and Methods
Introduction. A new interest for Metal-on-Metal (MoM) has risen worldwide. In Finland using of 28mm MoM bearings during the last years has gone up rapidly. MOM bearings in THAs are used more and more in Finland for young patients. We present short-term results of 136 MoM THAs. Patients and methods. In our Department both 28 mmMetasul- (Sulzer) ja M2a (Biomet) systems have been used. Metasul Pressfit cementless monoblock cup has titanium net on poly cup with cobolt-chrome bearing and the stem used was cementless CLS. M2a system was performed using cementless Biomet Bimetric-stem and cemented Stanmore poly cup with cobolt-chrome bearing. This series consists of 129 consecutive patients and 136 hips operated on in our department during years 2000–2002. Results. Mean age was 53yrs (20–73), BMI 27,0 (16,4–42,9). Indication was primary athrosis in 87, rheumatoid arthritis in 15, avascular femoral head necrosis in 12, dys-placia with secondary OA in 9, and other in 13. Hardinge approach was used 59 and posterior approach 77 times. Metasul was used 85 and M2a 51 times. Mean follow-up time was 20 months. Pre/postoperative HHS was 54 (23–97)/94(48–100). Leg length discrepancy 1–2,5 cm was noticed in 19 patients. 4 luxations occurred during the follow-up period. No thromboembolic or neurological complications occurred. In 5 operations peroperative fracture of trochanter major was noticed and fixed and in addition to that fissure of the femur was noticed in 5 cases; no signs of loosening was noticed in these. 2 cups had signs of loosening in all 3 zones, 11 cups in 2, and 19 in one zone. One femoral component had signs of loosening in all 7 zones, 2 in 2 zones, and 5 in one zone. Discussion. Good MoM results from 1970s encouraged us to start again to use MoM THAs in our department. At the same
We assessed the age-related differences in the
use of total shoulder arthroplasty (TSA) and outcomes, and associated
time-trends using the United States Nationwide Inpatient Sample
(NIS) between 1998 and 2010. Age was categorised as <
50, 50
to 64, 65 to 79 and ≥ 80 years. Time-trends in the use of TSA were
compared using logistic regression or the Cochran Armitage test. The overall use of TSA increased from 2.96/100 000 in 1998 to
12.68/100 000 in 2010. Significantly lower rates were noted between
2009 and 2010, compared with between 1998 and 2000, for: mortality,
0.1% The rates of use of TSA/100 000 by age groups, <
50, 50 to
64, 65 to 79 and ≥ 80 years were: 0.32, 4.62, 17.82 and 12.56, respectively
in 1998 (p <
0.001); and 0.65, 17.49, 75.27 and 49.05, respectively
in 2010 (p <
0.001) with an increasing age-related difference
over time (p <
0.001). Across the age categories, there were
significant differences in the proportion: discharged to an inpatient
facility, 3.2% In a nationally representative sample, we noted a time-related
increase in the use of TSA and increasing age-related differences
in outcomes indicating a changing epidemiology of the use of TSA.
Age-related differences in outcomes suggest that attention should
focus on groups with the worst outcomes. Cite this article:
Treatment by TKR of severe deformities : fixed varus or valgus knee, or flexion contracture, sometimes combined (valgus and flexed knee as for example in rheumatoid arthritis) is frequently a difficult challenge. Seldom a flessum, recurvatum or malrotation have also to be managed. These deformations, articular, extra-articular or combined can be observed in knee arthritis associated with malalignement, malunion of diaphysis, malunion of lower part of the femur or upper tibia after fracture or osteotomy, chronic juvenile arthritis or rheumatoid arthritis, Paget’s or post-rachitism disease. In 60′ and 70′ the most difficult cases have been frequently treated by hinge prosthesis with a high percentage of infection and loosening; many of the other cases treated with customary prosthesis had a poor follow-up because instability, luxation, patellar problems, pain or recurrence of the deformity. Now to obtain the best prosthesis survival rate , the well trained orthopaedic surgeon has to make a good radiographical and clinical examination and the a good planification with the good choices:. - necessity or not to perform, as a first stage, an osteotomy of femur or tibia to correct a mal-union or a deformity in frontal, sagittal or horizontal plane. - type of prosthesis ( constrained or not, PCL sparing or sacrificing, mobile bearing ),. - medial or lateral approach, and then Keblish procedure or not; tibial tubercle osteotomy or quadricepsplasty in stiff knees;. - sequence and level of tibial and femoral cuts; always perpendicular, for us, to the mechanical axis ,. - different steps of release of lateral, or medial and sometimes posterior ligamenteous and capsular elements, with many controversies for lateral compartment (iliotibial band, collateral lateral ligament, popliteus, posterolateral capsule, biceps tendon ). - necessity of medial ligament advancement or thightening when distension in severe valgus knee,. - repair of bone loss by cement, or more usually by bone graft or metal wedge. ARTICULAR OR PARA ARTICULAR DEFORMITIES. 1) FIXED VARUS KNEE. Treatment of this deformation is usually not so difficult. In case of postero-stabilized prosthesis implantation, after removal of medial condylar and tibial plateau osteophytes resection of PCL and release of semi-membranosus tendon and postero- medial capsule are performed. Pes anserinus and collateral medial ligament release creating a subperiosteal elevation of the medial envelope is sometimes needed for good soft tissue balance; in such case a constrained plateau can be useful. It is also possible to try PCL sparing but a good tightening of PCL is difficult and reconstruction by bone graft, metal wedge or cement or medial tibial plateau is in most cases necessary to protect tibial insertions of PCL. 2) FIXED VALGUS KNEE. We prefer the Keblish approach to have a direct look on the tightened formations (iliotibial band, lateral collateral ligament, popliteus. We agree with the Krackow’s classification of valgus knee in 3 groups. For group 1. , according to Whiteside it is possible to spare the PCL in the majority of cases if we accept to use a bone graft or a metal wedge on the lateral femoral condyle or/and tibial plateau taking the medial compartment as a reference.This choice of arthroplasty with PCL retention maintains the right level of the knee joint and offers often a best stability than postero-stabilized prosthesis does; PCL well tightened is a “third ligament” giving frontal stability as proved in traumatology. In fact many surgeons prefer to use postero-stabilized arthroplasty to avoid difficulties in PCL managing, and they release in different controversed steps the lateral elements. If there is instability they implant a more constrained tibial insert than usually. As communicated by Burdin it is also possible to prevent instability by performing a sagittal osteotomy of the lateral condyle around the insertions of popliteus and collateral ligament, and screw it after obtaining a good balance of the knee with the displacement of the osteotomized bone downward and/or posteriorly. For group 2. , which is caracterized by medial collateral ligament instability, it is safer to treat these knees with a postero-stabilized more or less constrained prosthesis than using a PCL sparing one and advancement of the medial ligament. For group 3. , severe overcorrection in valgus after lateral closed osteotomy for tibia varus realizes an upper tibial malunion. Prosthesis implantation is difficult: difficulties of soft tissue balance, conflict between upper tibial lateral cortex and tibial metalback stem, and bad coverage or overlapping of the tibial metalback, unless using a twisted stem. Different options can be choosen:. postero-stabilized prosthesis needs a release of lateral side; the tibial cut perpendicular to mechanical axis resecting bone to the bottom of the lateral defect takes off a too big amount of bone on the medial tibial plateau to have a safe support for metal back. If bone graft of lateral plateau is done to avoid this fact a constrained insert is potentially necessary. implantation of a PCL sparing prosthesis with also release of lateral soft tissue, and reconstruction of medial tibial plateau and eventually condylar bone loss. For stability of the knee PCL acts as a collateral ligament. correction of the deformity by a new tibial osteotomy and after its consolidation implantation of the prosthesis some months later. tibial osteotomy and prosthesis can be performed during the same operation, using a long tibial stem, cemented or not to stabilize the osteotomy site. 3) FLEXION CONTRACTURE. Correction of the deformity can be difficult when flexion is more than 30 or 40 degrees; PCL is not always an obstacle for correction. Sometimes initialy anterior bony deformity of the upper tibia has to be resected , especially in rheumatoid arthritis. After regular cut of the distal femur and removing of posterior osteophytes and loose bodies, elevation of posterior capsule from the distal femur is less dangerous than transverse incision of its middle part. If needed proximal attachements of gastrocnemius can also be stripped from the femur. Then if knee extension is not possible with trial component the tightened PCL has to be sacrified, or released or lengthened for some surgeons wanting to spare it. Finally a choice between lengthening of hamstrings and pes anserinus or a new cut of distal femur is necessary with use in some cases of a more constrained tibial plateau. For good tracking of patella lateral retinacular release is also mandatory. 4) FLESSUM, RECURVATUM, MALROTATION. Small flessum or recurvatum in metaphyseal area can be managed with the femoral anterior and posterior distal femoral cuts or tibial cut with sometimes incidence on prosthesis choice and biomechanical consequences. Malrotation around 15 degrees can also be corrected by implants positioning, and perhaps a little more than 15° using a mobile bearing prosthesis. EXTRA ARTICULAR OR COMBINED DEFORMITIES. In this type of deformity it can be necessary to perform in the same or in two separate operations its correction by a diaphyseal osteotomy preferably at the site of the deformity. It is mandatory to have a good fixation of the bone to allow a quick and strong rehabilitation of the knee after prosthesis implantation. Plating, nailing or stabilization by the stem of prosthesis can be used. At the present
We examined the risk of thrombotic and major
bleeding events in patients undergoing total hip and knee replacement
(THR and TKR) treated with thromboprophylaxis, using nationwide
population-based databases. We identified 83 756 primary procedures
performed between 1997 and 2011. The outcomes were symptomatic venous thromboembolism
(VTE), myocardial infarction (MI), stroke, death and major bleeding
requiring hospitalisation within 90 days of surgery. A total of 1114 (1.3%) and 483 (0.6%) patients experienced VTE
and bleeding, respectively. The annual risk of VTE varied between
0.9% and 1.6%, and of bleeding between 0.4% and 0.8%. The risk of
VTE and bleeding was unchanged over a 15-year period. A total of
0.7% of patients died within 90 days, with a decrease from 1% in
1997 to 0.6% in 2011 (p <
0.001). A high level of comorbidity
and general anaesthesia were strong risk factors for both VTE and
bleeding, with no difference between THR and TKR patients. The risk
of both MI and stroke was 0.5%, which remained unchanged during
the study period. In this cohort study of patients undergoing THR and TKR patients
in routine clinical practice, approximately 3% experienced VTE,
MI, stroke or bleeding. These risks did not decline during the 15-year
study period, but the risk of dying fell substantially. Cite this article:
We report serum metal ion level data in patients with unilateral and bilateral hip resurfacing over a ten-year period. In these patients there is an increase in both cobalt and chromium levels above the accepted reference ranges during the first 18 months after operation. Metal ion levels remain elevated, but decline slowly for up to five years. However, the levels then appear to start rising again in some patients up to the ten-year mark. There was no significant difference in cobalt or chromium levels between men and women. These findings appear to differ from much of the current literature. The clinical significance of a raised metal ion level remains under investigation.
The results of hip and knee replacement surgery
are generally regarded as positive for patients. Nonetheless, they are
both major operations and have recognised complications. We present
a review of relevant claims made to the National Health Service
Litigation Authority. Between 1995 and 2010 there were 1004 claims
to a value of £41.5 million following hip replacement surgery and
523 claims to a value of £21 million for knee replacement. The most common
complaint after hip surgery was related to residual neurological
deficit, whereas after knee replacement it was related to infection.
Vascular complications resulted in the highest costs per case in
each group. Although there has been a large increase in the number of operations
performed, there has not been a corresponding relative increase
in litigation. The reasons for litigation have remained largely
unchanged over time after hip replacement. In the case of knee replacement,
although there has been a reduction in claims for infection, there
has been an increase in claims for technical errors. There has also
been a rise in claims for non-specified dissatisfaction. This information
is of value to surgeons and can be used to minimise the potential
mismatch between patient expectation, informed consent and outcome. Cite this article:
Perthes’ disease is an osteonecrosis of the juvenile
hip, the aetiology of which is unknown. A number of comorbid associations
have been suggested that may offer insights into aetiology, yet
the strength and validity of these are unclear. This study explored
such associations through a case control study using the United
Kingdom General Practice Research database. Associations investigated
were those previously suggested within the literature. Perthes’ disease has a significant association with congenital
genitourinary and inguinal anomalies, suggesting that intra-uterine
factors may be critical to causation. Other comorbid associations
may offer insight to support or refute theories of pathogenesis.