Aim. Prosthetic joint infection (PJI) is a serious complication following total hip arthroplasty (THA) entailing increased mortality, decreased quality of life, and high healthcare costs. In 2009 a nationwide, multidisciplinary infection control program was launched in Sweden, PRISS, which aimed to reduce the PJI burden by 50%. The primary aim was to investigate whether the PRISS project reduced PJI incidence after primary THA; the secondary aim was to evaluate other possible benefits of PRISS, such as shorter time to diagnosis. Method. We obtained data on patients undergoing primary THA in Sweden (n = 45,723 patients, 49,946 THAs), 2012–2014. Using personal identity numbers, this cohort was matched with the Swedish Prescribed Drug Registry. Medical records of patients with ≥4 weeks antibiotic consumption were reviewed to verify PJI diagnosis (n = 2240, 2569 THAs). Results. The cumulative incidence of PJI following the PRISS project was 1.2% [95% CI 1.1–1.3] as compared to 0.9% [95% CI 0.8–1.0] before. Cox regression models for the PJI incidence post PRISS indicates there were no statistical significance difference versus pre PRISS (HR 1.1 [95% CI 0.9–1.3]. There were similar time to PJI diagnosis after the PRISS project 24 vs 23 days (p=0.5). Conclusions. Despite the comprehensive nationwide PRISS project, Swedish PJI incidence was higher after the project and time to diagnosis remained unchanged. Factors contributing to PJI, such as increasing obesity, higher ASA class, and more fractures as indications, explain the PJI increase among primary THA patients

The optimal method of tibial fixation when using a hamstring tendon autograft in anterior cruciate ligament (ACL) reconstruction is unclear. This study aimed to compare the risk of revision ACL reconstruction between suspensory and interference devices on the tibial side. Prospective data on primary ACL reconstructions recorded in the New Zealand ACL Registry between April 2014 and December 2019 were analyzed. Only patients with a hamstring tendon autograft fixed with a suspensory device on the femoral side were included. The rate of revision ACL reconstruction was compared between suspensory and interference devices on the tibial side. Univariate Chi-Square test and multivariate Cox regression was performed to compute hazard ratios (HR) and 95% confidence intervals (CI) with adjustment for age, gender, time-to-surgery, activity at the time of injury, number of graft strands and graft diameter. 6145 cases were analyzed, of which 59.6% were fixed with a suspensory device on the tibial side (n = 3662), 17.6% fixed with an interference screw with a sheath (n = 1079) and 22.8% fixed with an interference screw without a sheath (n = 1404). When compared to suspensory devices (revision rate = 3.4%), a higher risk of revision was observed when using an interference screw with a sheath (revision rate = 6.2%, adjusted HR = 2.05, 95% CI 1.20 – 3.52, p = 0.009) and without a sheath (revision rate = 4.6%, adjusted HR = 1.81, 95% CI 1.02 – 3.23, p = 0.044). The number of graft strands and a graft diameter of ≥8 mm did not influence the risk of revision. When reconstructing the ACL with a hamstring tendon autograft, the use of an interference screw, with or without a sheath, on the tibial side has a higher risk of revision when compared to a suspensory device

Several different algorithms attempt to estimate life expectancy for patients with metastatic spine disease. The Skeletal Oncology Research Group (SORG) has recently developed a nomogram to estimate survival of patients with metastatic spine disease. Whilst the use of the SORG nomogram has been validated in the international context, there has been no study to date that validates the use of the SORG nomogram in New Zealand. This study aimed to validate the use of the SORG nomogram in Aotearoa New Zealand. We collected data on 100 patients who presented to Waikato Hospital with a diagnosis of spinal metastatic disease. The SORG nomogram gave survival probabilities for each patient at each time point. Receiver Operating Characteristic (ROC) Area Under Curve (AUC) analysis was performed to assess the predictive accuracy of the SORG score. A calibration curve was also performed, and Brier scores calculated. A multivariate Cox regression analysis was performed. The SORG score was correlated with 30 day (AUC = 0.72) and 90-day mortality (AUC = 0.71). The correlation between the SORG score and 90-day mortality was weaker (AUC = 0.69). Using this method, the nomogram was correct for 79 (79%) patients at 30-days, 59 patients (59%) at 90-days, and 42 patients (42%) at 365-days. Calibration curves demonstrated poor forecasting of the SORG nomogram at 30 (Brier score = 0.65) and 365 days (Brier score = 0.33). The calibration curve demonstrated borderline forecasting of the SORG nomogram at 90 days (Brier score = 0.28). Several components of the SORG nomogram were not found to be correlated with mortality. In this New Zealand cohort the SORG nomogram demonstrated only acceptable discrimination at best in predicting life 30-, 90- or 356-day mortality in patients with metastatic spinal disease

Meniscal repairs are commonly performed during anterior cruciate ligament (ACL) reconstruction. This study aimed to identify the risk factors for meniscal repair failure following concurrent primary ACL reconstruction. Primary ACL reconstructions with a concurrent repair of a meniscal tear recorded in the New Zealand ACL Registry between April 2014 and December 2018 were analyzed. Meniscal repair failure was defined as a patient who underwent subsequent meniscectomy, and was identified after cross-referencing data from the ACL Registry with the national database of the Accident Compensation Corporation (ACC). Multivariate Cox regression was performed to produce hazard ratios (HR) with 95% confidence intervals (CI) to identify the patient and surgical risk factors for meniscal repair failure. 2041 meniscal repairs were analyzed (medial = 1235 and lateral = 806). The overall failure rate was 9.4% (n = 192). Failure occurred in 11.1% of medial (137/1235) and 6.8% of lateral (55/806) meniscal repairs. The risk of medial failure was higher with hamstring tendon autografts (adjusted HR = 2.00, 95% CI 1.23 – 3.26, p = 0.006) and in patients with cartilage injury in the medial compartment (adjusted HR = 1.56, 95% CI 1.09 – 2.23, p = 0.015). The risk of lateral failure was higher when the procedure was performed by a surgeon with an annual case volume of less than 30 ACL reconstructions (adjusted HR = 1.92, 95% CI 1.10 – 3.33, p = 0.021). Age, gender, time from injury-to-surgery and femoral tunnel drilling technique did not influence the risk of meniscal repair failure. When repairing a meniscal tear during ACL reconstruction, the use of a hamstring tendon autograft or the presence of cartilage injury in the medial compartment increases the risk of medial meniscal repair failure. Lower surgeon case volume increases the risk of lateral meniscal repair failure

Aim. Two types of national registers surveil infections after primary total hip arthroplasty (THA) in Norway: The National surveillance system for surgical site infections (NOIS) that surveil all primary THAs 30 days postoperatively for surgical site infections (SSI), and the Norwegian Arthroplasty Register (NAR) that follow all THAs until any surgical reoperation/revision or the death of the patient. Since these registers report on the same THAs we assessed correspondence between and time trends for the two registers in period 2013 to 2022. All reported THAs were included. Method. The THAs were matched on a group level according to sex, age and ASA-class. In addition to descriptive statistics, adjusted Cox regression analyses were performed with adjustment for sex, age group (<45, 45-54, 55-64, 65-74, 75-84, >85 years) and ASA-class (1, 2, 3, 4 and missing). Changes in annual incidence and adjusted hazard rate (aHR) was calculated. Endpoints in the NOIS were 30-Days SSI and 30-Days reoperation for SSI. Endpoints in the NAR were 30-Days and 1-Year reoperation for periprosthetic joint infection (PJI). Results. The NOIS had registered 87,923 THAs with 1,393 (1.58%) SSIs and 765 (0.87%) reoperations for SSI within 30 postoperatively. The NAR had registered 91,194 THAs with 725 (0.80%) reoperations for infection after 30 days, and 1,019 (1.21%) reoperations for infections after one year. The distribution of sex, age and ASA-class was near identical in the two registers. There was a mean annual reduction in risk of both SSI (aHR 0.92 (95% CI 0.90-0.93)) and reoperation for SSI (0.95(0.92-0.97)) and PJI (30-Days: 0.96 (0.94-0.99), 1-Year: 0.95-0.99)) over the period 2013-2022. Conclusions. The NOIS and the NAR have excellent completeness and the registrations in both registers may be considered representative for the Norwegian population. Not all SSI are reoperated. The incidence and risk of SSI (NOIS) and reoperation for PJI (NAR) is declining and may reflect a true reduction in incidence of PJI after primary THA

The optimal timing of when to perform manipulation under anesthesia (MUA) for stiffness following total knee arthroplasty (TKA) is unclear. This study aimed to identify the risk factors for MUA following primary TKA and whether performing an “early” MUA within 3 months results in a greater improvement in range of motion. Primary TKAs performed between January 2013 and December 2018 at three tertiary New Zealand hospitals were reviewed. International Classification of Diseases discharge coding was used to identify patients who underwent an MUA. Multivariate Cox regression was performed to identify patient and surgical risk factors for MUA. Pre- and post-MUA knee flexion angles were identified through manual review of operation notes. Multivariate linear regression was performed to compare the mean flexion angles pre- and post-MUA, as well as the mean gain in flexion, between patients undergoing “early” (<3 months) versus “late” MUA (>3 months). 7386 primary TKAs were analyzed in which 131 underwent subsequent MUA (1.8%). Patients aged <65 years were two times more likely to undergo MUA compared to patients aged ≥65 years (2.5% versus 1.3%, adjusted hazard ratio = 2.1, p<0.001). Gender, body mass index, patient comorbidities or a history of cancer were not associated with the risk of MUA. There was no difference in the final post-MUA flexion angle between patients who underwent early versus late MUA (104.7 versus 104.1 degrees, p = 0.819). However, patients who underwent early MUA had poorer pre-MUA flexion (72.3 versus 79.6 degrees, p = 0.012), and subsequently had a greater overall gain in flexion compared to patients who underwent late MUA (mean gain 33.1 versus 24.3 degrees, p<0.001). Younger age was the only patient risk factor for MUA. A greater overall gain in flexion was achieved in patients who underwent early MUA within 3 months

Arthrofibrosis is a less common complication following anterior cruciate ligament (ACL) reconstruction and there are concerns that undergoing early surgery may be associated with arthrofibrosis. The aim of this study was to identify the patient and surgical risk factors for arthrofibrosis following primary ACL reconstruction. Primary ACL reconstructions prospectively recorded in the New Zealand ACL Registry between April 2014 and December 2019 were analyzed. The Accident Compensation Corporation (ACC) database was used to identify patients who underwent a subsequent reoperation with review of operation notes to identify those who had a reoperation for “arthrofibrosis” or “stiffness”. Univariate Chi-Square test and multivariate Cox regression analysis was performed. Hazard ratios (HR) with 95% confidence intervals (CI) were computed to identify the risk factors for arthrofibrosis. 9617 primary ACL reconstructions were analyzed, of which 215 patients underwent a subsequent reoperation for arthrofibrosis (2.2%). A higher risk of arthrofibrosis was observed in female patients (adjusted HR = 1.67, 95% CI 1.22 – 2.27, p = 0.001), patients with a history of previous knee surgery (adjusted HR = 1.97, 95% CI 1.11 – 3.50, p = 0.021) and when a transtibial femoral tunnel drilling technique was used (adjusted HR = 1.55, 95% CI 1.06 – 2.28, p = 0.024). Patients who underwent early ACL reconstruction within 6 weeks of their injury did not have a higher risk of arthrofibrosis when compared to patients who underwent surgery more than 6 weeks after their injury (3.5% versus 2.1%, adjusted HR = 1.56, 95% CI 0.97 – 2.50, p = 0.07). Age, graft type and concomitant meniscal injury did not influence the rate of arthrofibrosis. Female sex, a history of previous knee surgery and a transtibial femoral tunnel drilling technique are risk factors for arthrofibrosis following primary ACL reconstruction

Aim. Rifampicin as a biofilm-active antibiotic drug has a significant role in the treatment of periprosthetic joint infection (PJI). However, rifampicin resistance is an increasing threat to PJI treatment. This study aimed to evaluate the prevalence of rifampicin resistant staphylococci over time and its association with infection-free survival after PJI in a single centre in Sweden. Methods. We included 238 PJIs in 238 patients who had undergone PJI revision surgery from 2001 to 2020 on whom the causative bacteria were staphylococci, and the agent was tested for rifampicin resistance. Data regarding agents, rifampicin resistance, treatment and outcome was obtained. Kaplan-Meier survival analysis and a Cox regression model with adjustment for age, sex, localisation (hip or knee) and type of prosthesis (primary or revision) were used to calculate infection-free survival rates and adjusted risk ratios (HRs) of the risk of treatment failure. Treatment failure was defined as any reoperation or suppression treatment with antibiotics due to prolonged infection. Results. Among the included 238 PJIs, 40 rifampicin-resistant staphylococci [93% Coagulase Negative Staphylococci (CoNS)] and 29 treatment failures were identified. The proportion of rifampicin resistant agents decreased from 25% in 2010–2015 to 12% in 2016–2020. The 2-year infection-free survival rates were 79.0% (95% CI 0.66–0.92) for the rifampicin resistant and 90% (95% CI 0.86–0.94) for the rifampicin sensitive group. Patients with PJI caused by rifampicin resistant bacteria had a significantly higher risk of treatment failure than those caused by sensitive bacteria (HR 2.5; 95% CI 1.0–6.2). Conclusions. The incidence of PJI caused by rifampicin resistant staphylococci decreased in Uppsala, Sweden over the past 20 years. PJI caused by rifampicin-resistant staphylococci has a two-fold risk for treatment failure compared to PJI caused by rifampicin-sensitive staphylococci, which stresses the importance of retaining rifampicin resistance low. Additionally, the increased risk of treatment failure when PJI is caused by a rifampicin-resistant bacteria warrants consideration of a more conservative treatment strategy

Background and purpose. Previous publications have reported an increased but levelling out risk of revision for infection after total hip arthroplasty (THA) in Norway. We assessed the changes in risk of major (cup and/or stem, 1- or 2-stage) and minor revisions (debridement, exchange of modular parts, antibiotics and implant retention (DAIR)) for infection after primary THAs reported to the Norwegian Arthroplasty Register (NAR) over the period 2005-2022. Patients and methods. Primary THAs reported to the NAR from 2005 to 2022 were included. Time was stratified into time periods (2005-2009, 2010-2018, 2019-2022) based on a previous publication. Cox regression analyses, adjusted for sex, age and ASA-classification, with the first revision for infection were performed. Results. 140,338 primary THAs met the inclusion criteria. 1.3% (1,785) were revised for infection during the study period. 0.5% (638) had major revisions, whereas 0.8% (1,147) had DAIRs for infection. The risk of revision for infection was 1.2 (95%CI 1.1-1.4) for 2010-2018 and 1.0 (0.8-1.1) for 2019-2022 compared to 2005-2009. Compared to 2010-2018, the risk of revision for infection was 0.8 (0.7-0.9) for 2019-2022. The risk of DAIR for infection was 1.5 (1.3-1.9) for 2010-2018 and 1.2 (1.0-1.4) for 2019-2022 compared to 2005-2009. Compared to 2010-2018, the risk of DAIR for infection was 0.8 (0.7-0.9) for 2019-2022. The risk of major revision for infection was 0.8 (0.7-1.0) for 2010-2018 and 0.8 (0.6-1.0) for 2019-2022 compared to 2005-2009. Interpretation. The overall risk of revision for infection after THA, in Norway, has decreased in the period 2019-2022. The risk for DAIR initially increased in the period 2005-2009, levelled out 2010-2018 before starting to decrease in 2019-2022. The risk of major revision for infection was reduced in the period 2005-2009 before levelling out. This shows changes in revision strategies, but may also reflect a true decrease in periprosthetic joint infection

Aim. Previous publications have suggested that the incidence of revisions due to infection after THA is increasing. We performed updated time-trend analyses of risk and timing of revision due to infection after primary THAs in the Nordic countries during the period 2004–2018. Methods. 569,463 primary THAs reported to the Nordic Arthroplasty Register Association from 2004 through 2018 were studied. We estimated adjusted hazard ratios (aHR) with 95% confidence interval by Cox regression with the first revision due to infection after primary THA as endpoint. The risk of revision was investigated. In addition, we explored changes in the time span from primary THA to revision due to infection. Results. 5,653 (1.0%) were revised due to infection. The risk of revision due to infection increased through the study period. Compared to the period 2004–2008, the aHRs were 1.4 (95%CI 1.3–1.5) for 2009–2013, and 1.9 (1.7–2.0) for 2014–2018. We found an increased risk in all four Nordic countries. Compared to 2004–2008, the aHR due to infection 0–30 days after THA was 2.5 (2.1–2.9) for 2009–2013 and 3.4 (3.0–3.9) for 2013–2018. The aHR of revision due to infection 31–90 days after THA was 1.5 (1.3–1.9) for 2009–2013 and 2.5 (2.1–3.0) for 2013–2018, compared to 2004–2008. Beyond 91 days after THA, the risk of revision due to infection was stable over the whole study period. Interpretation. The risk of revision due to deep infection after THA nearly doubled throughout the period 2004–2018. This increase was mainly due to an increased risk of early revisions. The cause for these changes may be multifactorial (patient selection, diagnostics, revision strategy, completeness of reporting, etc.), are not possible to disclose in the present study, and warrants further research

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

Aim. To describe the management of PJI due to S. aureus in CRIOAcs in 2019 and to particularly focus on the evaluation of the efficacy of DAIR regarding control of infection and risk factors for failure up to 12 months. Method. Thirteen CRIOAcs were selected to participate to the study. Data concerning the management of all the PJI in the year 2019 were retrospectively collected and registered in eCRFs. Inclusion criteria were: ≥ 18 years old patients with S. aureus ± other bacteria (in per surgical procedure sample); knee or hip PJI and with clinical signs of infection. Patients treated with bacteriophages were excluded. All eligible patients were notified by an information letter. Patients treated by the DAIR procedure were selected, and rate of control of infection (no inflammatory local signs or no new surgical procedure or no S. aureus in case of puncture) was analyzed using Kaplan Meier method and risk factors for failure at 12 months were assessed using Cox regression model. Results. A total of 978 PJI were managed in the 9 CRIOAcs, including 238 hip and knee PJI due to S. aureus and 79 to S. aureus plus another bacteria. Among all of them, 154 were managed with DAIR, and 100 fulfilled inclusion criteria, notifying no opposition to their data collection. The median age was 73.0 years; 57% were male, the median Charlson score was 4.0; 66% had hip PJI. A total of 45 failure were observed during the period studied. At 12 months, the control rate was 58. 7% [36.5–75.4], 49.3% [34.3–62.7] in in early and late PJI respectively according to Tsukuyama classification and 49.6% [30.5–66.1], 54.1% [37.7 – 68.0] in early and delayed/late PJI respectively according to Zimmerli classification, 56.6% [39.5–70.5] in case of mobile part exchange, 53.4% [35.3–68.5] for MRSA PJI and 63.4% [50.5–73. 8] in patients treated with rifampicin. No rifampicin intake was the only significative risk factor for failure in univariate analysis (HR=0.31 (0.17–0.57), p=0.0002), and remained significant after adjustment on Charlson score (aHR=0.34 (0.18–0.64), p=0.0008). Conclusions. The DAIR procedure is frequently performed in patients with acute and late PJI, and is associated with a high rate of failure, especially for patients who cannot receive rifampin. There is a strong rational to assess the use of bacteriophages during the DAIR, as bacteriophages have antibiofilm activity in vitro, and could improve the efficacy of the DAIR to control the disease

The Oxford mobile bearing knee prosthesis (Zimmer Biomet Inc, Warsaw, Ind) is considered a good treatment option for isolated medial compartment knee arthrosis. From February 2001 until August 2016, 1719 primary Oxford medial unicompartmental knee replacement procedures were completed at our center by a group of seven surgeons. We undertook this study to examine the long-term survivorship of the Oxford unicompartmental knee replacement looking at survivorship and reasons for failure. A retrospective consecutive case series review was completed, and all revisions and re-operations were identified. Conversion to total knee replacement (TKA) was considered a failure. Kaplan-Meier survival analysis was used to calculate the 15-year survivorship of the group overall. We specifically looked at age, gender, BMI and surgeon caseload in addition to the reasons for failure. A statistical analysis was performed and differences in survivorship were compared for the variables listed. A logistic cox regression was performed to explore predictors of revision. Overall 15-year survivorship was 89.9%. Female survivorship of 88.1% was statistically worse than the male group at 91.8% (p=0.018). Younger patients (75yrs of age (p= 0.036). There was a large range in surgical case load by individual surgeons (range 17–570 knees). There were no statistically significant differences in age, BMI, or gender when comparing the individual surgeon groups. There was a large range in 15-year survivorship between individual surgeons (range 78.3% – 95%). Overall the most common reason for revision was due to wear of the unreplaced portion of the knee (lateral and/or patella-femoral joint) followed by aseptic loosening, polyethylene dislocation, infection or persistent pain. The 15-year survivorship results of the Oxford medial unicompartmental knee replacement at our center compares favourably to other published series and large registry data series. We found a reduction in survivorship in female patients and younger patients (< 5 5yrs). There were also significant differences in survivorship based on the individual surgeon. A more selective patient approach yielded the best long-term survivorship and equivalent to that of total knee replacement. We therefore suggest using a more selective approach when choosing patients for a medial unicompartmental knee replacement with the Oxford mobile bearing prosthesis in order to enhance long-term survivorship

The management of primary malignant bone tumors with metastatic disease at presentation remains a challenge. While surgical resection has been shown to improve overall survival among patients with non-metastatic malignant bone tumors, current evidence regarding the utility of surgery in improving overall survival in metastatic patients remains limited. The 2004–2016 National Cancer Database (NCDB) was queried using International Classification of Diseases 3rd Edition (ICD-O-3) topographical codes to identify patients with primary malignant bone tumors of the extremities (C40.0-C40.3, C40.8 and C40.9) and/or pelvis (C41.4). Patients with malignant bone tumors of the axial skeleton (head/skull, trunk and spinal column) were excluded, as these cases are not routinely encountered and/or managed by orthopaedic oncologists. Histological codes were used to categorize the tumors into the following groups - osteosarcomas, chondrosarcomas, and Ewing sarcomas. Patients who were classified as stage I, II or III, based on American Joint Commission of Cancer (AJCC) guidelines, were excluded. Only patients with metastatic disease at presentation were included in the final study sample. The study sample was divided into two distinct groups – those who underwent surgical resection of the primary tumors vs. those who did not receive any surgery of the primary tumor. Kaplan-Meier survival analysis was used to report unadjusted 5-year overall survival rates between patients who underwent surgical resection of the primary tumor, compared to those who did not. Multi-variate Cox regression analyses were used to assess whether undergoing surgical resection of the primary tumor was associated with improved overall survival, after controlling for differences in baseline demographics, tumor characteristics (grade, location, histological type and tumor size), and treatment patterns (underwent metastatectomy of distal and/or regional sites, positive vs. negative surgical margins, use of radiation therapy and/or chemotherapy). Additional sensitivity analyses, stratified by histologic type for osteosarcomas, chondrosarcomas and Ewing sarcomas, were used to assess prognostic factors for overall survival. A total of 2,288 primary malignant bone tumors (1,121 osteosarcomas, 345 chondrosarcomas, and 822 Ewing sarcomas) with metastatic disease at presentation were included – out of which 1,066 (46.0%) underwent a surgical resection of the primary site. Overall 5-year survival rates, on unadjusted Kaplan-Meier log-rank analysis, were significantly better for individuals who underwent surgical resection vs. those who did not receive any surgery (31.7% vs. 17.3%; p<0.001). After controlling for differences in baseline demographics, tumor characteristics and treatment patterns, undergoing surgical resection of primary site was associated with a reduced overall mortality (HR 0.42 [95% CI 0.36–0.49]; p<0.001). Undergoing metastectomy (HR 0.92 [95% CI 0.81–1.05]; p=0.235) was not associated with a significant improvement in overall survival. On stratified analysis, radiation therapy was associated with improved overall survival for Ewing Sarcoma (HR 0.71 [95% CI 0.57–0.88]; p=0.002), but not for osteosarcoma (HR 1.14 [95% CI 0.91–1.43]; p=0.643) or chondrosarcoma (HR 1.08 [95 % CI 0.78–1.50]; p=0.643). Chemotherapy was associated with improved overall survival for osteosarcoma (HR 0.50 [95% CI 0.39–0.64]; p<0.001) and chondrosarcoma (HR 0.62 [95% CI 0.45–0.85]; p=0.003), but not Ewing sarcoma (HR 0.79 [95% CI 0.46–1.35]; p=0.385). Surgical resection of the primary site significantly improves overall survival for primary malignant bone tumors with metastatic disease at presentation. Physicians should strongly consider surgical resection of the primary tumor, with adjunct systemic and/or radiation therapy (dependent on tumor histology), in patients presenting with metastatic disease at presentation

Aim. The aim of this study was to assess the influence of the true operating room (OR) ventilation on the risk of revision due to infection after primary total hip arthroplasty (THA) reported to the Norwegian Arthroplasty Register (NAR). Method. 40 orthopedic units were included during the period 2005 – 2015. The Unidirectional airflow (UDAF) systems were subdivided into small-area, low-volume, vertical UDAF (lvUDAF) (volume flow rate (VFR) (m. 3. /hour) <=10,000 and diffuser array size (DAS) (m. 2. ) <=10); large-area, high-volume, vertical UDAF (hvUDAF) (VFR >=10,000 and DAS >=10) and Horizontal UDAF (H-UDAF). The systems were compared to conventional, turbulent ventilation (CV) systems. The association between revision due to infection and OR ventilation was assessed using Cox regression models, with adjustments for sex, age, indication for surgery, ASA-classification, method of fixation, modularity of the components, duration of surgery, in addition to year of primary THA. All included THAs received systemic, antibiotic prophylaxis. Results. 51,292 primary THAs were eligible for assessment. 575 (1.1%) of these THAs had been revised due to infection. Compared to CV, there was similar risk of revision due to infection after THA performed in ORs with lvUDAF (RR=0.9, 95 % CI: 0.7–1.1) and with H-UDAF (RR=1.3, 95 % CI: 0.9–1.8). The risk of revision due to infection after THA performed in ORs with large-area hvUDAF-systems was lower (RR=0.8, 95% CI: 0.6–0.9, p=0.01) compared to CV. Conclusions. This study indicates that large-area, high-volume, vertical UDAF systems may be superior to conventional ventilation systems as a prophylactic measure against THA infection. This emphasizes the importance of assessing the big diversity of different ventilation systems when studying effect measures

We present 346 consecutive revision procedures for aseptic loosening with acetabular impaction bone grafting (AIBG) and a cemented polyethylene cup. Defects were contained with mesh alone. Mean follow up of 6.6 years, range 8 days-13 years. The Oxford Hip (OHS) and Harris Hip (HHS) scores were collected prospectively. Radiological definition of cup failure was either > 5mm displacement, or > 5° rotation. Cox regression analysis was performed on ten separate patient and surgical factors to determine their significance on survivorship. Kaplan Meier survivorship at 10 years (42 cases remaining at risk) for aseptic loosening was 87% (95% confidence Interval (CI): 81.6 to 92.2) and 85.6% (95% CI: 80.3 to 90.9) for all revisions. These results are comparable to other reported series utilising AIBG. However, there were 88 cases (25%) that exceeded the radiological migration parameters, but their functional scores were not significantly different to the non-migrators: OHS p=0.273, HHS p=0.16. The latest post-operative mean OHS was 33 (SD 10.66). Female gender (p=0.039), increasing graft thickness (p=0.006) and the use of mesh (p=0.037) were significant risk factors for revision, but differing techniques in graft preparation, including artificial graft expanders (p=0.73), had no significant effect when analysed using Cox regression

Background. Periprosthetic joint infection (PJI) after knee arthroplasty surgery remains a serious complication. Yet, there is no international consensus on the surgical treatment of PJI. The purpose was to assess the prosthesis survival rates, risk of re-revision, and mortality rate following the different surgical strategies (1-stage or 2-stage implant revision, and irrigation and debridement (IAD) with implant retention) used to treat PJI. Methods. The study was based on 653 total knee arthroplasties (TKAs) revised due to PJI in the period 1994 to 2016. Kaplan-Meier (KM) and multiple Cox regression analyses were performed to assess the survival rate of these revisions and the risk of re-revisions. We also studied the mortality rates at 90 days and 1 year after revision for PJI. Results. Of the 653 revision TKAs; 329, 81, and 243 revisions were performed with IAD, 1-stage, and 2-stage revision procedures, respectively. During the follow-up period, 19%, 12.3% and 11.5% of the IAD, 1-stage, and 2-stage revision cases were re-revised due to PJI, respectively. With any reasons of re-revision as end-point the 5 year KM survival of the index revision procedure was 76%, 82%, and 84% after IAD, 1-stage, and 2-stage revision, respectively. Similarly, the 5-year KM survival with a re-revision for infection as end-point was 79%, 88%, and 87% after IAD, 1-stage, and 2-stage revision, respectively. There were no statistically significant differences between 1-stage and 2-stage revision for re-revision of any reasons (RR=1.6; 95% CI: 0.8–3.1) nor did we find a difference for re-revision due to deep infection (RR=1.4; 95% CI: 0.6–3.1) as end-point. In an age-stratified analysis, however, the risk of re-revision for any causes was 4 times increased after 1-stage revision compared to 2-stage revision in patients over 70 years of age (RR=4.2, 95% CI: 1.3–13.7) but the risk was similar for deep infection as end-point. Age had no statistically significant effect on the risk of re-revision for knees revised with the IAD procedure. The 90-days and 1-year mortality rate after revision for PJI were 2.1% and 3.6% after IAD, 1.2% and 1.2% after 1-stage revision, and 0.4% and 1.6% after 2-stage revision and there were no statistically significant differences in mortality rate according to revision procedure. Conclusion. IAD had good results compared to earlier published studies. Despite that 1-stage revisions had a 4 times higher risk for re-revision compared to 2-stage revisions in older patients, the overall outcomes after 1-stage and 2-stage revision were similar

Aim. The aim of this study was to validate the information on operating room ventilation reported to the Norwegian Arthroplasty Register (NAR) and to assess the influence of this ventilation on the risk of revision due to infection after primary total hip arthroplasty (THA). Method. Current and previous ventilation systems were evaluated together with the hospitals head engineer in 40 orthopaedic hospitals. The ventilation system of each operating room was assessed and confirmed as either conventional ventilation, vertical laminar airflow (LAF) or horizontal LAF. We then identified cases of first revision due to deep infection after primary THA and the type of ventilation system reported to the NAR in the period 1987–2014. The association between revision due to infection and operating room ventilation was estimated by relative risks (RR) in a Cox regression model. Results. 103370 primary THAs and 971 (0.9%) first revisions due to deep infection were reported. 51% of the primary THAs were performed in a room with vertical LAF, 44% in a room with conventional ventilation and 5% in a room with horizontal LAF. There was a mean misreporting rate of approximately 12%. There was similar risk of revision due to infection after THA performed in operating rooms with vertical laminar air flow compared to conventional ventilation (RR=0.95, 95 % CI: 0.8–1.1) and an increased risk of revision due to infection after THA performed in horizontal LAF conditions compared to conventionally ventilated conditions (RR=1.3, 95 % CI: 1.0–1.7). Conclusions. Surgeons are not fully aware of what kind of ventilation there is in the operating room. This study may indicate that vertical LAF is not superior to conventional ventilation concerning reduction of THA infection, and therefore does not justify any increased installation costs. Also, horizontal LAF systems appear to be inferior to other ventilation systems

Introduction. Previous registry studies of ceramic-on-polyethylene (C-PE) and ceramic-on-ceramic (COC) have focused on revision outcomes following primary surgery. Less is known about the effect of ceramic bearings on infection, dislocation, and mortality as outcomes following primary total hip arthroplasty (THA) for the Medicare population. We asked (1) does the use of C-PE bearings influence outcomes following THA as compared with metal-on-polyethylene (M-PE); and (2) does the use of COC bearings influence outcomes following THA as compared with M-PE?. Methods. A total of 315,784 elderly Medicare patients (65+) who underwent primary THA between 2005 and 2014 with known bearing types were identified from the Medicare 100% inpatient sample administrative database. Outcomes of interest included relative risk of 90-day readmission, infection, dislocation, revision, or mortality at any time point after primary surgery. Propensity scores were developed to adjust for selection bias in the choice of bearing type at index primary surgery. Cox regression incorporating propensity score stratification (10 levels) was then used to evaluate the impact of bearing surface selection on outcomes, after adjusting for patient-, hospital-, and surgeon-related factors. Results. For primary THA patients treated with C-PE bearings and COC bearings, there was significantly reduced risk of infection relative to M-PE bearings (C-PE Hazard Ratio, HR: 0.86, p=0.001; COC Hazard Ratio, HR: 0.74, p=0.01). For the C-PE cohort, we also observed reduced risk of 90-day readmission (HR: 0.94, p<0.001); dislocation (HR: 0.81, p<0.001); and mortality (HR: 0.92, p<0.001). There was no significant difference in risk of revision for either the C-PE or COC bearing cohorts when compared with M-PE. For the COC cohort, there was no significant difference in readmission, dislocation, or mortality risk. Conclusions. The results indicate that, after adjusting for selection bias and various confounding patient-, surgeon-, and hospital-related factors, Medicare patients treated with primary THA with ceramic bearings exhibit lower risk of infection than those treated with M-PE bearings. In addition, C-PE bearings were associated with lower risk of dislocation and mortality. As in previous registry studies, we found that ceramic bearings have similar revision risk as M-PE bearings in primary THA at between 8 and 9 years of follow-up. The findings of this study support further research into the long-term association between ceramic bearings in primary THA and clinical outcomes

The aim of this study was to validate the information on operating room ventilation reported to the Norwegian Arthroplasty Register (NAR). We then wanted to assess the influence of operating room ventilation on the rate of revision due to infection after primary THA performed in operating rooms with conventional ventilation, “greenhouse”–ventilation and Laminar Airflow ventilation (LAF). We identified cases of THA revisions due to deep infection and the type of ventilation system reported to the NAR from the primary THA. We included 5 orthopaedic units reporting 17947 primary THAs and 136 (0.8%) revisions due to infection during the 28 year inclusion period from 1987 to 2014. The hospitals were visited and the current and previous ventilation systems were evaluated together with the hospitals head engineer, and the factual ventilation on the specific operating rooms was thereby assessed. The association between revision due to infection and operating room ventilation was estimated by calculating relative risks (RR) in a Cox regression model. 73% of the primary THAs were performed in a room with LAF, in contrast to the reported 80 % of LAF. There was similar risk of revision due to infection after THA performed in operating rooms with laminar air flow compared to conventional ventilation (RR=0.7, 95 % CI: 0.2–2.3) and after THA performed in operating rooms with “greenhouse”-ventilation compared to conventional ventilation (RR=1.2, 0.1–11). Surgeons are not fully aware of what kind of ventilation there is in the operating room. This study may indicate that, concerning reduction in incidence of THA infection, LAF does not justify the substantial installation cost. The numbers in the present study are too small to conclude strongly. Therefore, the study will be expanded to include all hospitals reporting to the NAR