Objectives. The Kaplan-Meier estimation is widely used in orthopedics to
calculate the probability of revision surgery. Using data from a
long-term follow-up study, we aimed to assess the amount of bias
introduced by the Kaplan-Meier estimator in a competing risk setting. Methods. We describe both the Kaplan-Meier estimator and the competing
risk model, and explain why the competing risk model is a more appropriate
approach to estimate the probability of revision surgery when patients
die in a hip revision surgery cohort. In our study, a total of 62 acetabular
revisions were performed. After a mean of 25 years, no patients
were lost to follow-up, 13 patients had undergone revision surgery
and 33 patients died of causes unrelated to their hip. Results. The Kaplan-Meier estimator overestimates the probability of revision
surgery in our example by 3%, 11%, 28%, 32% and 60% at five, ten,
15, 20 and 25 years, respectively. As the cumulative incidence of
the competing event increases over time, as does the amount of
Extracapsular Hip Fractures (EHF's) are a significant health burden on healthcare services. Optimal treatment is controversial with conflicting evidence being reported. Currently treatment is undertaken with Intramedullary Nail (IMN) or Dynamic Hip Screw (DHS) constructs with a recent increase in IMN use (1). This study aims to conduct a systematic review of Randomised Control Trials published between 2020 and 2023 with particular focus on patient demographics and holistic patient outcomes. Using a unified search-protocol, RCT's published between 2020 and 2023 were collected from CENTRAL, PubMed, MEDLINE and EMBASE. Rayyan software screened duplicates. Using the CASP and Cochrane Risk of
The current evidence favors replacement for the treatment of displaced femoral neck fractures in the older patients. Controversies remain whether total hip replacement (THR), or hemiarthroplasty (HA) would result in better outcomes. The purpose of this study is to compare the outcomes, and the complications in patients who underwent THR or HA for displaced femoral neck fractures. There were 345 consecutive patients who had undergone either a THR or HA at a single institution. THR was done in 137, and HA was done in 208 patients, respectively. Standard peri-operative data were collected. The mean values for the data in the THR group are: age 69 years, ASA 2.7, OR time was 99 minutes, estimated blood loss 354 ml, and the length of stay 8 days. The mean values for the data in the HA group are: age 75 years, ASA 3.0, OR time 88 minutes, estimated blood loss 200 ml, and the length of stay 10 days. The overall complications were 8.8% (THR), and 9.1% (HA), respectively. The mortality rates for the patients were: at the 1-year (9.5% THR vs 16.3% HA), at the 3-year (15.3% THR vs 24.0% HA), and at the 5-year (19.7% THR vs 26.9% HA), respectively. Our data demonstrated similar peri-operative data and short-term complications between the two groups. There was a difference in the mortality rates between the two groups at all 3-time intervals following the surgery. This could be a reflection of the patient selection
Total hip arthroplasty has been constantly evolving with technological improvements to achieve the best survival rates. Although the new implants are under closer surveillance through processes such as Beyond Compliance, orthopaedic surgeons generally tend to look out for the latest implants with good short-term results and hope for better long-term results for these. We questioned whether such an assumption or
Patients undergoing total hip or knee arthroplasty (THA/TKA) are commonly associated with high pain scores and narcotic use. Duloxetine is effective in relieving chronic pain. The aim of this study was to evaluate the safety and efficacy of duloxetine for pain management following THA/TKA. Five major databases (PubMed, Embase, Scopus, Cochrane, and Web of Science) were searched for randomised controlled trials (RCTs) that compared duloxetine to placebo in patients that underwent THA/TKA. The primary outcome was pain reduction with rest and movement at short-term and long-term time intervals. Secondary outcomes were the use of analgesics, length of stay, and safety profile. The risk of
In 2022, approximately 60% of inserted cups and stems in Sweden utilized cemented fixation. Two predominant brands, Refobacin Bone Cement R and Palacos R+G, both incorporating gentamicin, were employed in over 90% of primary cemented Total Hip Arthroplasties (THAs) between 2012 and 2022. This study investigates whether the choice between these cement types affects the risk of revision. The five most frequently used cemented cups and the three most common stems were studied. Inclusion criteria encompassed hips with non-tumour diagnoses, operated through a direct lateral or posterior incision, featuring a 28–36 mm metal or ceramic head. Outcomes were assessed for cup revisions (n=55,457 Refobacin, 37,210 Palacos), stem revisions (n=51,732 Refobacin, 30,018 Palacos), and all-cemented THAs with either brand (n=45,265 Refobacin, 26,347 Palacos). Kaplan-Meier life tables and hazard ratios (HR) utilizing Cox regression were computed, adjusting for age, sex, diagnosis, implant type, femoral head size, and material. Over a 10-year period, the cumulative percent revision with Refobacin was consistently higher than Palacos in all three analyses (cups: Refobacin 2.4 (2.3–2.5), Palacos 2.1 (2.0–2.2); stems: Refobacin 2.6 (2.5–2.7), Palacos 2.1 (2,0–2,2); all-cemented: Refobacin 3.2 (2.9–3.5), Palacos 2.9 (2.6–3.2)). Both unadjusted and adjusted HR were 13–25% lower with Palacos. In the analysis of all-cemented THAs, the adjusted HR for Palacos was 0.85 (0.76–0.95). Separating revisions into infectious and non-infectious reasons revealed a lower risk of infectious revisions with Palacos in all three analyses (all-cemented: adjusted HR infection 0.66 (0.56–0.78); non-infectious 1.10 (0.94–1.28)). Hips cemented with Refobacin may face an increased risk of infection, potentially due to a smaller release of antibiotics into surrounding tissues. Unaccounted factors like different mixing systems or unknown
Over 8000 total hip arthroplasties (THA) in the UK were revised in 2019, half for aseptic loosening. It is believed that Artificial Intelligence (AI) could identify or predict failing THA and result in early recognition of poorly performing implants and reduce patient suffering. The aim of this study is to investigate whether Artificial Intelligence based machine learning (ML) / Deep Learning (DL) techniques can train an algorithm to identify and/or predict failing uncemented THA. Consent was sought from patients followed up in a single design, uncemented THA implant surveillance study (2010–2021). Oxford hip scores and radiographs were collected at yearly intervals. Radiographs were analysed by 3 observers for presence of markers of implant loosening/failure: periprosthetic lucency, cortical hypertrophy, and pedestal formation. DL using the RGB ResNet 18 model, with images entered chronologically, was trained according to revision status and radiographic features. Data augmentation and cross validation were used to increase the available training data, reduce
Implants in total hip replacement (THR) are associated with different clinical and cost-effectiveness profiles,. We estimate the costs and outcomes for NHS patients in the year after THR associated with implant bearing materials using linked routinely collected data. We linked NJR primary elective THR patients for osteoarthritis to HES and National PROMs. We estimated health care costs, health-related quality of life indices, and revision risks, in the year after primary and revision THRs overall. We used generalised linear models adjusting for patient and hospital characteristics and estimated 10-year cumulative probability of revision. We imputed utilities using chained equations for half the sample with missing PROMS. We linked 577,973 elective primary THRs and 11,812 subsequent revisions. One year after primary THR, patients with the cemented THRs using cobalt chrome or stainless steel head with HCLPE liner/cup cost the NHS, on average, £13,101 (95%CI £13,080,£13,122), had an average quality-of-life score of 0.788 (95%CI 0.787,0.788), and a 10-year revision probability of 1.9% (95%CI 1.6,2.3). Compared to the reference, patients receiving a cemented THR with delta ceramic head and HCLPE liner/cup, hybrid THR with delta ceramic head and HCLPE liner/cup, and hybrid THR with alumina head and HCLPE liner/cup had lower 1-year costs (-£572 \[95% CI -£775,-£385\], -£346 \[-£501,-£192\], -£371 \[-£574,-£168\] respectively), better quality of life (0.007 \[95% CI 0.003,0.011\], 0.013 \[0.010,0.016\], 0.009 \[0.005,0.013\] respectively), and lower 10-year revision probabilities (1.4% \[1.03,2.0\], 1.5 \[1.3,1.7\], 1.6%\[1.2,2.1\] respectively). Implant bearing materials are associated with varying mean costs and health outcomes after primary THR. Ours is the first study to derive costs and health outcomes from large, linked databases using multiple imputation methods to deal with
The aim of this study was to systemically review the evidence for the use of intra-operative cell salvage (ICS) among patients undergoing revision hip arthroplasty, and synthesis the available data to quantify any associated reduction in allogeneic blood transfusion. An electronic database search of MEDLINE (PubMed), EMBASE, Scopus and the Cochrane Library was completed from the date of inception to 9. th. February 2021, using a search strategy and protocol created in conjunction with the PRISMA statement. Inclusion criteria were (i) adult patients >18 years, (ii) ICS utilised in one study group, (iii) revision hip arthroplasty performed. Exclusion criteria were (i) pre-donation of red blood cells, (ii) mixed reporting without dedicated subgroup analysis for revision hip arthroplasty. Screening for eligibility, and quality assessment of included studies, was performed independently by two authors (TW and DH), and any disputes settled by third author (AK). Of the 187 records identified, 11 studies were included in the qualitative analysis, and 5 studies suitable for quantitative meta-analysis. Across the included studies there were 1856 participants, with a mean age of 63.86 years and a male: female ratio of 0.90. Quality assessment demonstrated low or medium risk of
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
Aims. Uncemented metal acetabular components show good osseointegration, but material stiffness causes stress shielding and retroacetabular bone loss. Cemented monoblock polyethylene components load more physiologically; however, the cement bone interface can suffer fibrous encapsulation and loosening. It was hypothesized that an uncemented titanium-sintered monoblock polyethylene component may offer the optimum combination of osseointegration and anatomical loading. Methods. A total of 38 patients were prospectively enrolled and received an uncemented monoblock polyethylene acetabular (pressfit) component. This single cohort was then retrospectively compared with previously reported randomized cohorts of cemented monoblock (cemented) and trabecular metal (trabecular) acetabular implants. The primary outcome measure was periprosthetic bone density using dual-energy x-ray absorptiometry over two years. Secondary outcomes included radiological and clinical analysis. Results. Although there were differences in the number of males and females in each group, no significant sex
Aims. It has been suggested that the direct anterior approach (DAA) should be used for total hip arthroplasty (THA) instead of the posterior approach (PA) for better early functional outcomes. We conducted a value-based analysis of the functional outcome and associated perioperative costs, to determine which surgical approach gives the better short-term outcomes and lower costs. Methods. This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and the Cochrane Handbook. Several online databases were searched. Non-stratified and stratified meta-analyses were conducted to test the confounding
Aims. A proximal femur fracture (PFF) is a common orthopaedic presentation, with an incidence of over 25,000 cases reported in the Australian and New Zealand Hip Fracture Registry (ANZHFR) in 2018. Hip fractures are known to have high mortality. The purpose of this study was to determine the utility of the Clinical Frailty Scale (CFS) in predicting 30-day and one-year mortality after a PFF in older patients. Methods. A retrospective review of all fragility hip fractures who met the inclusion/exclusion criteria of the ANZHFR between 2017 and 2018 was undertaken at a single large volume tertiary hospital. There were 509 patients included in the study with one-year follow-up obtained in 502 cases. The CFS was applied retrospectively to patients according to their documented pre-morbid function and patients were stratified into five groups according to their frailty score. The groups were compared using t-test, analysis of variance (ANOVA), and the chi-squared test. The discriminative ability of the CFS to predict mortality was then compared with American Society of Anaesthesiologists (ASA) classification and the patient’s chronological age. Results. A total of 38 patients were deceased at 30 days and 135 patients at one year. The 30-day mortality rate increased from 1.3% (CFS 1 to 3; 1/80) to 14.6% (CFS ≥ 7; 22/151), and the one-year mortality increased from 3.8% (CFS 1 to 3; 3/80) to 41.7% (CFS ≥ 7; 63/151). The CFS was demonstrated superior discriminative ability in predicting mortality after PFF (area under the curve (AUC) 0.699; 95% confidence interval (CI) 0.651 to 0.747) when compared with the ASA (AUC 0.634; 95% CI 0.576 to 0.691) and chronological age groups (AUC 0.585; 95% CI 0.523 to 0.648). Conclusion. The CFS demonstrated utility in predicting mortality after PFF fracture. The CFS can be easily performed by non-geriatricians and may help to reduce age related
Introduction. Quality measures play a substantial role in the Centers for Medicare and Medicaid Services' hospital payment and public reporting programs. The purpose of this study was to assess whether public measurement of total hip and knee arthroplasty risk-standardized readmission (RSRRs) and complication rates (RSCRs) was temporally associated with decreasing rates of adverse outcomes among Medicare beneficiaries. Methods. We evaluated annual trends in hospital-level risk-standardized complication and readmission rates in the fiscal years 2010–11 and 2016–17 for patients undergoing hospital-based inpatient hip/knee replacement procedures. We calculated hospital-level rates using the same measures and methodology used in public reporting. We examined annual trends in the distribution of hospital-level outcomes through density plots (similar to histograms). Results. Both rates of and variation in the complication and readmission outcomes declined steadily between 2010–11 and 2016–17. We noted a 33% relative reduction in hospital-level risk-standardized complication rates (RSCRs) and 25% relative reduction in hospital-level risk-standardized readmission rates (RSRRs). The interquartile range of RSCRs decreased by 18% (relative reduction) and of RSRRs decreased by 34% (relative reduction). Risk variable frequency in complication and readmission models did not systematically change over time, suggesting no evidence of widespread
Aims. Vancouver type B periprosthetic femoral fractures (PFF) are challenging complications after total hip arthroplasty (THA), and some treatment controversies remain. The objectives of this study were: to evaluate the short-to-mid-term clinical outcomes after treatment of Vancouver type B PFF and to compare postoperative outcome in subgroups according to classifications and treatments; to report the clinical outcomes after conservative treatment; and to identify risk factors for postoperative complications in Vancouver type B PFF. Methods. A total of 97 consecutive PPFs (49 males and 48 females) were included with a mean age of 66 years (standard deviation (SD) 14.9). Of these, 86 patients were treated with surgery and 11 were treated conservatively. All living patients had a minimum two-year follow-up. Patient demographics details, fracture healing, functional scores, and complications were assessed. Clinical outcomes between internal fixation and revisions in patients with or without a stable femoral component were compared. Conservatively treated PPFs were evaluated in terms of mortality and healing status. A logistic regression analysis was performed to identify risk factors for complications. Results. In surgically treated patients, all fractures united and nine complications were identified. The mean postoperative Visual Analogue Scale (VAS) for pain was 1.5 (SD 1.3), mean Parker Mobility Score (PMS) was 6.5 (SD 2.4), and mean Harris Hip Score (HHS) was 79.4 (SD 16.2). Among type B2 and type B3 fractures, patients treated with internal fixation had significantly lower PMS (p = 0.032) and required a longer time to heal (p = 0.012). In conservatively treated patients, one-year mortality rate was 36.4% (4/11), and two patients ultimately progressed to surgery. Young age (p = 0.039) was found to be the only risk factor for complications. Conclusion. The overall clinical outcome among Vancouver type B PFF was satisfactory. However, treatment with internal fixation in type B2 and B3 fractures had a significantly longer time to heal and lower mobility than revision cases. Conservative treatment was associated with high rates of early mortality and, in survivors, nonunion. This probably reflects our selection
Osteoarthritis of the hip is common and the mainstay of surgical treatment for end-stage disease is total hip replacement. There are few RCTs comparing long-term outcomes between prostheses; therefore, surgeons and patients are reliant on single-centre case-series and recently, analysis of joint registries, when making evidence-based implant choices. We conducted a systematic review, conforming to PRISMA, of Medline and Embase in September 2017. Single-centre case-series and papers analysing registries were included. Series looking at disease-specific cohorts (other than OA), under 15 years follow-up or lacking survival analyses were excluded. Resurfacings, revisions and complex-primaries were also excluded. 2750 abstracts were screened, resulting in 299 full-text articles. Following full review 124 articles were excluded and 21 series added from references, resulting in 150 analyses of individual prostheses/constructs and 12 papers from registries. We also analysed annual reports of registries. Registry data indicated cemented prostheses tended to better outcomes at late follow-ups, whereas case-series showed cementless prostheses tended to have better survival past 15 years with revision for any reason (of stem, cup or either component) as the end-point. The discrepancy between results from registry data and single-centre case series is stark, and whilst the reasons for these differences may be multifactorial, single-centre case-series included in this review often lacked sufficient power to provide precise estimates of survival. This is contrasted to data from registries, which tended to have far greater numbers from multiple centres, allowing results to be generalised to the population. The difference between these two modes of analysis suggests
Introduction. Instability remains a common complication following total hip arthroplasty (THA) and continues to account for the highest percentage of revisions in numerous registries. Many risk factors have been described, yet a patient-specific risk assessment tool remains elusive. The purpose of this study was to apply a machine learning algorithm to develop a patient-specific risk score capable of dynamic adjustment based on operative decisions. Methods. 22,086 THA performed between 1998–2018 were evaluated. 632 THA sustained a postoperative dislocation (2.9%). Patients were robustly characterized based on non-modifiable factors: demographics, THA indication, spinal disease, spine surgery, neurologic disease, connective tissue disease; and modifiable operative decisions: surgical approach, femoral head size, acetabular liner (standard/elevated/constrained/dual-mobility). Models were built with a binary outcome (event/no event) at 1-year and 5-year postoperatively. Inverse Probability Censoring Weighting accounted for censoring
Introduction. The proportion of arthroplasties performed in the ambulatory setting has increased substantially. However, concerns remain regarding whether same-day discharge may increase the risk of complications. The purpose of this study was to compare 90-day outcomes between inpatients and patients having surgery at an ambulatory surgery center (ASC). Methods. Among a single-surgeon cohort of 721 patients who underwent arthroplasty at a free-standing ASC, 611 (84.7%) were matched one-to-one to inpatients based on age, gender, American Society of Anesthesiologists (ASA) score, and Body Mass Index (110 patients could not be adequately matched). The cohort included 208 total hip arthroplasties (34.0%), 196 total knee arthroplasties (32.1%), 178 unicompartmental knee arthroplasties (29.1%), 25 hip resurfacings (4.1%), two revision hip arthroplasties (0.3%) and two revision knee arthroplasties (0.3%). Post-operative outcomes including readmissions, reoperations, unplanned clinic visits, emergency department visits, and complications were compared. Complications were classified as either major (i.e. death, periprosthetic joint infection, pulmonary embolism) or as minor (i.e. delayed wound healing, rashes, urinary retention). Results. The inpatient and outpatient groups were similar in all demographic variables, reflecting successful matching. The rates of any complications (4.1% outpatient vs. 5.1% inpatient, p=0.41), minor complications (2.6% vs. 3.4%; p=0.40), readmissions (1.6% vs. 2.0%; p= 0.67), reoperations (0.7% vs. 1.1%; p=0.36), and unplanned clinic visits (5.4% vs 6.7%; p=0.34) were all lower amongst the outpatient group but did not reach significance with the sample size studied. The rate of major complications was the same in both groups (1.6% for both; p=1.0) while patients who underwent surgery at an ASC had significantly fewer emergency department visits (1.0% vs. 3.1%; p=0.009). Conclusions. Arthroplasty performed in the ambulatory setting appears to be safe in properly selected patients. However, this finding may be partly due to selection
Objectives. The aim of this study was to use registry data to report and compare early patient outcomes following arthroscopic repair or debridement of the acetabular labrum. Methods. Data on adult patients who underwent arthroscopic labral debridement or repair between January 2012 and March 2019 was extracted from the UK Non-Arthroplasty Hip Registry dataset. Patients who underwent microfracture, osteophyte excision or a concurrent extra-articular procedure were excluded. Outcomes comprised EuroQol-5 Dimensions (EQ-5D) index and the International Hip Outcome Tool 12 (iHOT-12), preoperatively and at 6 and 12 months. Results. A total of 3,553 arthroscopies comprising 1,986 labral debridement (56%) and 1,567 labral repairs (44%) were identified. Both groups saw significant (p <0.0001) EQ-5D and iHOT-12 gain compared to pre-operative baseline scores at 6 months (iHOT-12: repair = +27.4 (95%CI 25.2 to 29.5), debridement = +24.8 (95%CI 22.7 to 26.9)) which was maintained at 12 months (repair = +28.3 (95%CI 26.0 to 30.6), debridement = +24.3 (95%CI 22.0 to 26.5)) with improvement being significantly greater in the repair group by 12 months (p = 0.016) including after modelling for patient and surgical factors. Overall, 64% of cases achieved the minimum clinically important difference (MCID) and 47% achieved substantial clinical benefit (SCB: repair = 51%, debridement = 43%, p = 0.005) at 12 months. Significant functional improvement was seen for both genders and in younger and older (>40 years) cohorts. Conclusion. Both labral repair and debridement techniques were successful in significantly improving 12-month outcomes following hip arthroscopy regardless of age or gender. Labral repair was associated with superior outcomes in comparison to debridement. Whilst patient selection is crucial, our findings support the repair of an injured labrum where possible. A multi-centre randomised controlled trial would be the most appropriate next step to overcome
Background. The purpose of this study was to report functional outcome scores following arthroscopic acetabular chondral procedures using the U.K. Non-Arthroplasty Hip Registry (NAHR). Methods. Data on adult patients who underwent hip arthroscopy between January 2012 and December 2018 was extracted from the NAHR. Patients who underwent femoral sided chondral procedures were excluded. Patients who underwent osteophyte excision or a concurrent extra-articular procedure were also excluded. Cases were then classified according to the acetabular chondral procedure performed – ‘chondroplasty’, ‘microfracture’ or ‘none’ (no chondral procedure recorded). Outcomes comprised EuroQol-5 Dimensions (EQ-5D) index and the International Hip Outcome Tool 12 (iHOT-12), preoperatively and at 6 and 12 months. Results. A total of 4,978 arthroscopies were identified (chondroplasty 26.4%, microfracture 5.4%, none 68.2%). Patients who underwent microfracture were significantly older (37.9y vs 37.3y) and of higher BMI (26.4 vs 25.8 kg/m2) than patients who underwent chondroplasty. Pre-operative, 6 and 12-month follow-up were available for 77%, 42% and 38% of cases respectively. This registry study found significant clinical improvement in all groups based on arthroscopic chondral procedure following hip arthroscopy. Patients who have microfracture seem to take longer to improve and have lower peak scores as compared with chondroplasty. All groups saw significant (p <0.0001) EQ-5D and iHOT-12 gain compared to pre-operative baseline scores at 6 months which was maintained at 12 months (12 month iHOT-12 gain: chondroplasty = +27.6 (95%CI 25.0 to 30.2), microfracture = +22.6 (95%CI 17.6 to 27.6), none = +25.4 (23.8 to 27.0)). There were no statistically significant between group differences in iHOT-12 gain. Comparing <40y vs >40y age groups, all saw significant improvements in baseline scores maintained up to 12 months however patients over 40y were slower to improve, particularly in microfracture with significantly poorer iHOT-12 gain at 6 months in comparison to patients under 40y but significance was lost by 12 months. Conclusion. Whilst patient selection is crucial (and we acknowledge selection