Introduction

The American Joint Replacement Registry (AJRR) was created to capture total hip (THA) and total knee arthroplasty (TKA) procedural data in order to conduct implant-specific survivorship analyses, produce risk-adjusted patient outcome data, and provide hospitals and surgeons with quality benchmarks. The purpose of this study is to compare early reports from the AJRR to other national registries to identify similarities and differences in surgeon practice and potential topics for future analysis.

Background: Fracture neck of the femur (NOF) is one of the indications for Total Hip Replacement (THR). However, the practice is not the same throughout the world. Aim: We compared the use of THR in the management of the fracture NOF using the annual reports of the National Joint Registries from various countries. Material and Methods: We used the latest available on line annual report of seven national arthroplasty registries to ascertain the rate of use of THR for fractures of the neck of the femur. The registries from Australia, Canada, Norway, Sweden, and the UK gave a detailed breakup of the indications for THR in their reports. Results: 11.9% of the all the THRs performed in Norway since 1987 were for NOFs. · 11.39% of all the THRs performed in Sweden since 1992 were for NOFs. 6.0% of the THRs performed in Canada in 2002–2003 were for NOFs. 2.9% of THRs performed in Australia since 1999 were for NOFs. 1.9% of the THRs performed in the UK in the period April – December 2003 were for NOFs. The registries from Finland and New Zealand had no detailed information on their websites regarding the indications for THA surgery. Discussion: In the Scandinavian countries, THR is performed for the management of a NOF 6 times more often than in the UK, and 4 times more often than in Australia. It is unlikely that the prevalence of patients with previous osteoarthritis of hip who sustain a NOF is higher in the Scandinavian countries than in the UK. Women in Sweden have a higher lifetime risk of hip fracture and live longer, so a procedure providing a good long term results would be beneficial. Provision of health care may also influence surgical management options. The long waiting lists for elective THR in the UK may explain the low number of THRs performed for NOFs

Aims. Loosening of components after total knee arthroplasty (TKA) can be associated with the development of radiolucent lines (RLLs). The aim of this study was to assess the rate of formation of RLLs in the cemented original design of the ATTUNE TKA and their relationship to loosening. Methods. A systematic search was undertaken using the Cochrane methodology in three online databases: MEDLINE, Embase, and CINAHL. Studies were screened against predetermined criteria, and data were extracted. Available National Joint Registries in the Network of Orthopaedic Registries of Europe were also screened. A random effects model meta-analysis was undertaken. Results. Of 263 studies, 12 were included with a total of 3,861 TKAs. Meta-analysis of ten studies showed high rates of overall tibial or femoral RLLs for the cemented original design of the ATTUNE TKA. The overall rate was 21.4% (95% confidence interval (CI) 12.7% to 33.7%) for all types of design but was higher for certain subgroups: 27.4% (95% CI 13.4% to 47.9%) for the cruciate-retaining type, and 29.9% (95% CI 15.6% to 49.6%) for the fixed-bearing type. Meta-analysis of five studies comparing the ATTUNE TKA with other implants showed a significantly higher risk of overall tibial or femoral RLLs (odds ratio (OR) 2.841 (95% CI 1.219 to 6.623); p = 0.016) for the ATTUNE. The rates of loosening or revision for loosening were lower, at 1.2% and 0.9% respectively, but the rates varied from 0% to 16.3%. The registry data did not report specifically on the original ATTUNE TKA or on revision due to loosening, but ‘all-cause’ five-year revision rates for the cemented ATTUNE varied from 2.6% to 5.9%. Conclusion. The original cemented ATTUNE TKA has high rates of RLLs, but their clinical significance is uncertain given the overall low associated rates of loosening and revision. However, in view of the high rates of RLLs and the variation in the rates of loosening and revision between studies and registries, close surveillance of patients who have undergone TKA with the original ATTUNE system is recommended. Cite this article: Bone Joint J 2023;105-B(6):610–621

Aim. National Joint Replacement Registries, which are important sources for periprosthetic joint infection (PJI) data, report an average PJI incidence ranging from 0.5 to 2.0%. Unfortunately, national registries including the Dutch Arthroplasty Register (LROI), are not specifically designed to register PJI. In the Netherlands, the LROI is a nationwide population-based registry with an overall completeness of more than 95%. 3. To ensure usability and reliability of PJI data from the LROI, it is important to evaluate the quality and completeness of these data. From 2013 onwards, eight hospitals in the South-East of the Netherlands, collected their PJI data in a detailed regional infection cohort (RIC), specifically designed for this purpose. This study aimed to determine the accuracy and completeness of PJI registration (hip and knee arthroplasty) in the LROI, by comparing the LROI with the RIC. Method. All patients registered with an acute PJI in the RIC between 2014–2018 were selected for the study and were matched with the LROI. According to the Workgroup of American Musculoskeletal Infections Society (MSIS), an acute PJI was defined as at least two phenotypically identical pathogens, isolated in cultures from at least two separate tissues, obtained from the affected peri-prosthetic tissue during the DAIR treatment (debridement, antibiotics, irrigation, and retention). Only PJI occurring within 90 days after primary hip or knee arthroplasty were included. The LROI data and completeness was based on the entered procedures and documented reason for revision infection, which was not specially based on the MSIS criteria. After checks on missing and incorrectly data, the completeness of registration in the LROI was calculated by comparing the number of registrations in the LROI with data from the RIC (gold standard). Results. Of the 639 primary total hip and knee arthroplasty with a suspected PJI registered in the RIC between 2014–2018, 352 cases met the definition of acute PJI. The overall incidence was 1%. When compared with the LROI, 164 of these cases were also registered in the LROI as PJI revision, resulting in a 53% underestimation of PJI for the LROI. Conclusions. LROI data on acute PJI shows a significant underestimation, which is comparable to scarce other literature sources. To ensure reliability and usability of national PJI data, a specifically part of the LROI has to be designed for registering PJI similar to the regional cohort

Preoperative planning for Total Hip Arthroplasty has been acknowledged as a vital step to facilitate a successful outcome. Templating ascertains the dimensions and positioning of the implants, minimizing both intraoperative and postoperative complications. The purpose of this study is to compare the accuracy of digital templating to acetate templating in the preoperative planning of Total Hip Arthroplasty. Preoperative planning was performed on 40 consecutive patients (mean age = 70.5 years), undergoing Total Hip Arthroplasty. Digital templating was performed by the Hip fellow 1, using Orthoview software (Jacksonville, FL, USA) and recorded the sizes of the cup and stem for each of the 40 patients. Subsequently, the same 40 patients were templated by Hip fellow 2, with X-rays done with a lead marker of known size by the side of the femur, using, acetate templating method. Templating results were compared to the actual sizes of the implants used, as noted in operative notes. Templating scores for the acetabular cup were 40% (16/40) with digital templating and 50% (20/40) with acetate templating. The templating scores for stem were 28% (11/40) with digital templating and 90% (36/40) with acetate templating. The differences between templating and actual implant sizes were plotted in Bland–Altman plot. Acetate templating proved to be statistically, significantly more accurate than digital templating (p value= 0.0083). Our results indicate that the traditional acetate method is solid and valid to use for preoperative planning. This method is accurate and offers a more affordable option for preoperative templating. Although the templated size is one, there is a tendency to increase cup size to use bigger heads, which is the recent National Joint Registries trend. We recommend that acetate templating should be used as the default option

Total knee arthroplasty (TKA) is a cost effective and extremely successful operation. As longevity increases, the demand for primary TKA will continue to rise. The success and survivorship of TKAs are dependent on the demographics of the patient, surgical technique and implant-related factors. . Currently the risk of failure of a TKA requiring revision surgery ten years post-operatively is 5%. . The most common indications for revision include aseptic loosening (29.8%), infection (14.8%), and pain (9.5%). Revision surgery poses considerable clinical burdens on patients and financial burdens on healthcare systems. . We present a current concepts review on the epidemiology of failed TKAs using data from worldwide National Joint Registries. Cite this article: Bone Joint J 2016;98-B(1 Suppl A):105–12

Objectives. Wear debris released from bearing surfaces has been shown to provoke negative immune responses in the recipient. Excessive wear has been linked to early failure of prostheses. Analysis using coordinate measuring machines (CMMs) can provide estimates of total volumetric material loss of explanted prostheses and can help to understand device failure. The accuracy of volumetric testing has been debated, with some investigators stating that only protocols involving hundreds of thousands of measurement points are sufficient. We looked to examine this assumption and to apply the findings to the clinical arena. . Methods. We examined the effects on the calculated material loss from a ceramic femoral head when different CMM scanning parameters were used. Calculated wear volumes were compared with gold standard gravimetric tests in a blinded study. . Results. Various scanning parameters including point pitch, maximum point to point distance, the number of scanning contours or the total number of points had no clinically relevant effect on volumetric wear calculations. Gravimetric testing showed that material loss can be calculated to provide clinically relevant degrees of accuracy. . Conclusions. Prosthetic surfaces can be analysed accurately and rapidly with currently available technologies. Given these results, we believe that routine analysis of explanted hip components would be a feasible and logical extension to National Joint Registries. Cite this article: Bone Joint Res 2014;3:60–8

Aims

Machine-learning (ML) prediction models in orthopaedic trauma hold great promise in assisting clinicians in various tasks, such as personalized risk stratification. However, an overview of current applications and critical appraisal to peer-reviewed guidelines is lacking. The objectives of this study are to 1) provide an overview of current ML prediction models in orthopaedic trauma; 2) evaluate the completeness of reporting following the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement; and 3) assess the risk of bias following the Prediction model Risk Of Bias Assessment Tool (PROBAST) tool.

Aims

To investigate the impact of consecutive perioperative care transitions on in-hospital recovery of patients who had primary total knee arthroplasty (TKA) over an 11-year period.

Aims

The aim of this study was to compare patient-reported outcomes (PROMs) following isolated anterior cruciate ligament reconstruction (ACLR), with those following ACLR and concomitant meniscal resection or repair.

Over the past 15 years metal on metal hip resurfacing (MOMHR) has seen a spectacular resurgence in utilization followed by near abandonment of the procedure. A select group of surgeons still offer the procedure to a select group of patients suggesting that there are benefits of MOMHR over total hip arthroplasty (THA). This is problematic for the following reasons:. 1). MOMHR does not lead to increased survivorship. The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the England and Wales National Joint Registry, from countries with high rates of utilization of MOMHR, both report significantly worse survivorship with MOMHR compared to all types of conventional THA. Risk factors for revision of resurfacing were older patients, females, smaller femoral head size, patients with developmental dysplasia, and certain implant designs. 2). MOMHR is associated with the generation of metal ions that can have devastating effects in some patients. Cobalt and chromium ions generated from MOMHR can result in adverse local tissues reactions around the hip, sometimes with catastrophic consequences, as well as neurological deficits, skin rashes, and cardiomyopathy. It is unclear as to which patients are at risk for the generation of high ion levels and less clear with respect to the host response to these ions. The discriminative and predictive values of ion testing are still being determined. MOMHR subsequently require careful follow-up with limited tools to assess risk and pending problems. 3). MOMHR is not less invasive. In order to deliver the femoral head for safe preparation and to access the acetabulum with the femoral head and neck in situ, significant dissection and retraction are required. The exposure issue is compounded as the procedure is most often performed in younger, larger males. Difficulty with exposure has been associated with an insult to the femoral head's blood supply that may lead to fracture and/or neck narrowing. 4). Preservation of the femoral canal with MOMHR does not improve outcomes of revision. The perceived advantage of preserved femoral head and neck implies that a conversion of a MOMHR to total hip should convey survivorship similar to primary THA. However, this is not the case as confirmed by data from the AOANJRR demonstrating worse survivorship of revised resurfacings when compared to a primary total hip arthroplasty. 5). MOMHR does not result in superior functional outcomes. Advocates for MOMHR often claim that the large femoral head and intact femoral neck in resurfacing results in a better functional outcome and therefore, a better quality of life and satisfaction when compared to a conventional THA. This, however, was not the case when gait speed, postural balance evaluations and functional tests were used in a randomised study of 48 patients, which failed to show an advantage of MOMHR over THA. In conclusion, it is relatively straightforward to oppose and argue against the use of hip resurfacings as they have worse outcomes in all National Joint Registries, produce metal ions with significant clinical consequences, are more invasive, are difficult to revise with subsequent inferior outcomes when compared to a conventional primary THA, and do not provide better function. These adverse features come with a premium price when compared to a conventional THA

At the New Zealand Shoulder and Elbow Society Meeting in 2005, it was decided to set up a national registry to look at the outcomes of rotator cuff repair in New Zealand. National Joint Registries have produced very powerful information on the performance of joint replacements, not just in the hands of the designer but for all surgeons. The patient numbers in these Registries have allowed powerful information to be derived which has had a significant impact on local practice. A nationwide registry on rotator cuff repair in New Zealand has the potential to provide similar powerful information. This is an area in which there has been rapid change over the last five years particularly with regard to surgical approach whether it be open, mini-open or arthroscopic and uncertainty remains as to what is best ‘best practice’. Surgeons are unwilling to invest time and effort into mastering sometimes difficult new procedures unless significant benefit can be demonstrated. Aspects addressed include anchors v. traditional drill holes in bone, anchor type, suture type and configuration, length of immobilisation, post-operative regime, effects of smoking and NSAIDs, on outcome and outcome versus size of tear. A pilot study is being undertaken to ensure the questionnaires are workable and the system will run smoothly. Early results of the pilot study will be presented

Background. The cemented mobile bearing metal backed low contact stress patellofemoral arthroplasty (LCS PFA) is a newer design belonging to the second generation of inlay type implant, based on the more successful knee arthroplasty model. The advantage is the patella can articulate with the trochlear implant as well as the femoral component of a total knee replacement (TKR). Patients. This series is a cohort of 21 patients who underwent 24 (3 bilateral) unicompartmental PFA replacements for isolated patellofemoral osteoarthritis. We have used the mobile bearing LCS PFA in all of them. There were 3 males and 18 females. Average age was 51(40-58) years. The Oxford Knee score was used to assess the results. Results. At the latest follow-up averaging 2.7 (0.5 to 4) years, 9 patients showed excellent improvement in their knee scores, 5 patients showed fair improvement and 7 patients very little. There were 9 revisions in 7 patients either due to mechanical problems or with persistent symptoms. We had 4 patients with mechanical complications who underwent revision and 4 patients had a conversion to TKR. The revision rate at 2 years was 33%. There were no infections or loosening of trochlear implants. Conclusion. The revision rate for this implant seems to be very high and mainly with the patellar implant (at the metal polyethylene interface). The Australian Orthopaedic association annual joint registry report 2008 reported a higher revision rate for the same implant at 5% from a pool of 1057 patients. The young active patient having a patellofemoral replacement may put extreme force on their patellar implant. We strongly advocate patellofemoral arthroplasties to be analysed separately from the unicompartmental knees in the National Joint Registries to highlight any persistent issues with this implant

The minimally invasive technique recommended by the designers in the implantation of the OXF UKA make for a demanding procedure: most recorded failures are of a technical nature and occur within the first 2-years of implantation. Also, data from the Swedish and NZ National Joint Registries (NJR) show clearly that revision rates and surgeon experience are inversely related. To present some technical points, using illustrative cases, where implantation has been associated with suboptimal outcome, or has lead to re-operation. To offer solutions for these potential problems. In 2004, data from the NZ NJR allowed analysis of all failures of OXF UKA leading to revision. The case notes and x-rays (where available) were studied (Hartnett et al, NZOA ASM, 2004). Clinical records of personal cases performed over 8 years up till July 2008 have also been studied and provide the illustrative cases. On the tibial side, mismatch between the length of the keel on the tibial component and the bony slot created for it can cause the tibial component to be too posteriorally-sited. Also, if too much cement is used, posterior protrusion of cement may be difficult to detect at operation. The combination of these two may cause symptoms postero-medially. Ways of preventing these problems are outlined. On the femoral side, NZJR records that aseptic loosening of the femoral component is a prominent cause of failure of OXF UKA. A number of techniques to improve cement intrusion can be implemented and are outlined. A case study of the only such encountered describes the possibility that the femoral intramedullary guide rod can inadvertently be driven into the femoral canal by knee motion during operation: this remained undetected until shown on the x-ray taken after operation. Simple modifications of technique can minimise the chance of suboptimal outcome after OXF UKA surgery

Aims

The Exeter V40 cemented polished tapered stem system has demonstrated excellent long-term outcomes. This paper presents a systematic review of the existing literature and reports on a large case series comparing implant fractures between the Exeter V40 series; 125 mm and conventional length stem systems.

Cementless knee arthroplasty has seen a recent resurgence in popularity due to conceptual advantages, including improved osseointegration providing biological fixation, increased surgical efficiency, and reduced systemic complications associated with cement impaction and wear from cement debris. Increasingly younger and higher demand patients are requiring knee arthroplasty, and as such, there is optimism cementless fixation may improve implant survivorship and functional outcomes.

Compared to cemented implants, the National Joint Registry (NJR) currently reports higher revision rates in cementless total knee arthroplasty (TKA), but lower in unicompartmental knee arthroplasty (UKA). However, recent studies are beginning to show excellent outcomes with cementless implants, particularly with UKA which has shown superior performance to cemented varieties. Cementless TKA has yet to show long-term benefit, and currently performs equivalently to cemented in short- to medium-term cohort studies. However, with novel concepts including 3D-printed coatings, robotic-assisted surgery, radiostereometric analysis, and kinematic or functional knee alignment principles, it is hoped they may help improve the outcomes of cementless TKA in the long-term. In addition, though cementless implant costs remain higher due to novel implant coatings, it is speculated cost-effectiveness can be achieved through greater surgical efficiency and potential reduction in revision costs. There is paucity of level one data on long-term outcomes between fixation methods and the cost-effectiveness of modern cementless knee arthroplasty.

This review explores recent literature on cementless knee arthroplasty, with regards to clinical outcomes, implant survivorship, complications, and cost-effectiveness; providing a concise update to assist clinicians on implant choice.

Cite this article: Bone Jt Open 2021;2(1):48–57.

Unicompartmental knee arthroplasty (UKA) has numerous advantages over total knee arthroplasty (TKA) and one disadvantage, the higher revision rate. The best way to minimize the revision rate is for surgeons to use UKA for at least 20% of their knee arthroplasties. To achieve this, they need to learn and apply the appropriate indications and techniques. This would decrease the revision rate and increase the number of UKAs which were implanted, which would save money and patients would benefit from improved outcomes over their lifetime.

Cite this article: Bone Joint J 2018;100-B:432–5.

Aims

Cementless unicompartmental knee arthroplasty (UKA) has advantages over cemented UKA, including improved fixation, but has a higher risk of tibial plateau fracture, particularly in Japanese patients. The aim of this multicentre study was to determine when cementless tibial components could safely be used in Japanese patients based on the size and shape of the tibia.