Aims. Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within two years of
Aims. This study describes the variation in the annual volumes of revision hip arthroplasty (RHA) undertaken by consultant surgeons nationally, and the rate of accrual of RHA and corresponding
Given the prolonged waits for hip arthroplasty seen across the U.K. it is important that we optimise priority systems to account for potential disparities in patient circumstances and impact. We set out to achieve this through a two-stage approach. This included a Delphi-study of patient and surgeon preferences to determine what should be considered when determining patient priority, followed by a Discrete Choice Experiment (DCE) to decide relative weighting of included attributes. The study was conducted according to the published protocol ([. https://boneandjoint.org.uk/article/10.1302/2633-1462.310.BJO-2022-0071. ](. https://boneandjoint.org.uk/article/10.1302/2633-1462.310.BJO-2022-0071. )). The Delphi study was performed online over 3 rounds with anonymous ranking and feedback. Included factors were voted as either Consensus in, Consensus out, or No Consensus• following an established scoring criterion. A final consensus meeting determined the prioritisation factors (and their levels) to be included in the DCE. The DCE was then conducted using an online platform, with surgeons performing 18 choice sets regarding which merited greater priority between two hypothetical patients. Results were collated and analysed using multinomial logit regression analysis (MNL). For the Delphi study there were 43 responses in the first round, with a subsequent 91% participation rate. Final consensus inclusion was achieved for Pain; Mobility/Function; Activities of Daily Living; Inability to Work/Care; Length of Time Waited; Radiological Severity and Mental Wellbeing. 70 individuals subsequently contributed to the DCE, with radiological severity being the most significant factor (Coefficient 2.27 \[SD 0.31\], p<0.001), followed by pain (Coefficient 1.08 \[SD 0.13\], p<0.001) and time waited (Coefficient for 1-month additional wait 0.12 \[SD 0.02\], p<0.001). The calculated trade-off in waiting time for a 1-level change in pain (e.g., moderate to severe pain) was 9.14 months. These results present a new method of determining comparative priority for those on
Hyponatraemia is a potentially preventable post-operative complication following hip arthroplasty. There is a paucity of literature reporting its incidence and guidelines for prevention - unlike AKI which has been prioritised to great success. Hyponatraemia is now rife in elective orthopaedics causing multiple symptoms that delay ambulation and increase the length of hospital stay. We aim to assess the incidence of hyponatraemia and AKI as a benchmark following elective primary total hip arthroplasty (THA), as well as identify patients most at risk in a high volume arthroplasty centre. Between April 2018 and September 2018 all primary THA surgeries performed in one hospital were retrospectively reviewed. Pre-operative and 1 day post operative bloods were analysed. Patients included had normal pre-operative sodium. A total of 221 patients underwent THA. The mean age was 73.6 and ASA 2.1. No patients had a recorded AKI, however 42% of patients had a new post operative hyponatraemia. Of the hyponatraemia cases, 75% were mild, 18% were moderate, and 7% were severe. There was correlation between increased age and increased severity of hyponatraemia. The mean age of patients with mild hyponatraemia was 72.1, moderate was 77.7, and severe was 78.8. An association between ASA and severity of hyponatraemia was noted. In patients who had an ASA of 4 and hyponatraemia, 66% were moderate or severe, ASA 3 was 25%, ASA 2 was 24% and ASA 1 was 0%. The patients who had severe hyponatraemia received on average 3.5L fluid input perioperatively. Rates of post op hyponatraemia are significantly higher than AKI in primary THA. Severity of hyponatraemia increases with age and ASA. Due to its negative outcomes on recovery the high levels of hyponatraemia are worrying. We have identified which patient cohorts are more at risk and recommend more care should be taken in their perioperative fluid balance. It may be beneficial to consider successful AKI prevention and management campaigns and apply them to the prevention of hyponatraemia following hip arthroplasty.
We determined the association between frailty and 30-day mortality following total hip arthroplasty (THA) and the impact of THA on 30-day mortality compared to a control population. We used primary care data (Clinical Practice Research Datalink), linked secondary care data (Hospital Episode Statistics) and Office for National Statistics mortality data. Frailty was assessed using a validated frailty index based on coded data in the primary care record and categorised as fit, mild, moderate, and severe frailty. The association between frailty and 30-day mortality following THA due to osteoarthritis was assessed using Cox regression, adjusted for year of birth, sex, quintile of index of multiple deprivation and year of surgery. Mortality following THA was also compared to a control population who had osteoarthritis but no previous THA, matched on year of birth, sex, and quintile of index of multiple deprivation. 103,563 cases who had a THA and their matched controls contributed data. Among those who had THA, compared to fit participants, 30-day mortality increased with increasing frailty; adjusted hazard ratio (HR) (95% CI) among mild frailty, 0.87 (0.66, 1.15); moderate frailty 1.73 (1.26, 2.38); and severe frailty, 2.85 (1.84, 4.39). Compared to fit controls who did not have surgery, 30-day mortality was higher among fit people who had THA, adjusted HR 1.60 (1.15, 2.21). There was, however, no statistically significant difference in 30-day mortality among cases with mild, moderate and severe frailty compared to controls in the same frailty category. Among people who had THA, 30-day mortality increased with increasing frailty. While 30-day mortality was increased among fit individuals who had THA compared to fit controls who did not have surgery, there did not appear to be increased mortality among individuals with mild, moderate or severe frailty compared to controls in the same frailty category. A healthy surgery (selection) effect may have impacted on the comparison of mortality among cases and controls.
Inpatient rehabilitation services following joint replacement have been estimated to cost over $3 billion/ yr. A shift in reimbursement strategies to bundle payments with the goal of decreasing cost and improving quality has given discharge disposition after joint replacement a front row seat. Our objectives were (1) to establish a correlation between the accuracy of current tools utilized to predict discharge location and (2) compare preoperative and postoperative patient oriented outcomes (POO's) according to discharge disposition. 188 consecutive total hip arthroplasty (THA) surgeries performed by a single surgeon were prospectively studied. Pre-intervention assessment of the probable and preferred discharge disposition was performed using one of 5 tools (1) experienced surgical coordinator evaluation (2) Risk Assessment and Prediction Tool (RAPT); (3) Charlson Score; (4) ASA Score; and (5) Patient Self-Reported Health Status. Demographic characteristics, Visual Analogue Scale, QWB-7, SF-36, WOMAC, clinical scores were recorded before and after surgery. Correlation between final discharge disposition (home vs rehab) and its predictors was performed. Preoperative and postoperative outcomes were compared, p<0.05 was considered significant.Introduction
Methods
We report a retrospective review of the incidence of venous thromboembolism in 463 consecutive patients who underwent primary total hip arthroplasty (487 procedures). Treatment included both total hip replacement and hip resurfacing, and the patients were managed without anticoagulants. The thromboprophylaxis regimen included an antiplatelet agent, generally aspirin, hypotensive epidural anaesthesia, elastic compression stockings and early mobilisation. In 258 of these procedures (244 patients) performed in 2005 (cohort A) mechanical compression devices were not used, whereas in 229 (219 patients) performed during 2006 (cohort B) bilateral intermittent pneumatic calf compression was used. All operations were performed through a posterior mini-incision approach. Patients who required anticoagulation for pre-existing medical problems and those undergoing revision arthroplasty were excluded. Doppler ultrasonographic screening for deep-vein thrombosis was performed in all patients between the fourth and sixth post-operative days. All patients were reviewed at a follow-up clinic six to ten weeks after the operation. In addition, reponse to a questionnaire was obtained at the end of 12 weeks post-operatively. No symptomatic calf or above-knee deep-vein thrombosis or pulmonary embolism occurred. In 25 patients in cohort A (10.2%) and in ten patients in cohort B (4.6%) asymptomatic calf deep-vein thromboses were detected ultrasonographically. This difference was statistically significant (p = 0.03). The regimen followed by cohort B offers the prospect of a low incidence of venous thromboembolism without subjecting patients to the higher risk of bleeding associated with anticoagulant use.
Deaths due to overdose involving opioids have nearly quadrupled in USA in the last 20 years. Several published studies have shown that preoperative opioid use independently predicts perioperative complications in total joint arthroplasty. Our objectives were to (1) assess preoperative opioid consumption in patients undergoing total hip arthroplasty (THA) and (2) to determine how preoperative opioid use affects patient oriented outcomes (POO's) and hip scores before and after THA. 54 primary THA by a single surgeon were reviewed. A new patient questionnaire was administered to document preoperative opioid consumption (type, dosage and length of use); preoperatively and postoperatively POO's measurements [visual analog scale (VAS), QWB-7, SF-36, and WOMAC] and hip scores were recorded. Patients were stratified into two groups: (1) Opioid Users and (2) Non-Opioid Users. Oral morphine equivalents (OME) were calculated for opioid using patients using standard methodology.Introduction
Methods
Prosthetic joint infections (PJI) are a devastating consequence in total hip arthroplasties (THA) with both significant morbidity and sometimes mortality, posing a significant health economic burden. Studies, both clinical and in-vitro have suggested possible reduction in PJI with the use of ceramic bearings. We have investigated the relationship of ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoP) or metal-on-polyethylene (MoP) bearing surface in affecting outcome of revision surgery after primary THA using data collected from National Joint Registry for England and Wales, Northern Ireland and the Isle of Man between 2002 and 2016. We used a competing risk regression model to investigate predictors of each revision outcome, such as infection, dislocation, aseptic revision and all cause revisions. The results were adjusted for age, gender, ASA grade, BMI, indication for surgery, intraoperative complications and implant data. We identified 456,457 THA (228,786 MoP, 128,403 CoC and 99,268 CoP). In a multivariable model, the adjusted risk of revision for PJI was lower with CoC (OR-0.748, p<0.001) and CoP (OR-0.775, p<0.001) when compared to MoP bearing. Additionally there was also a significant reduction in the risk of all cause revision for CoC (OR-0.918, p=0.002) and CoP (0.806, p<0.001), bearings as compared with MoP. The protective effect of ceramic bearing was predominantly seen after two years of implantation with a significant (p<0.0001) reduction of revision for PJI in both CoC (by 42.8%) and CoP (by 41.3%) group. Similarly significant effect was seen for aseptic revision beyond two years and overall all cause revision rate beyond two years reduced by 21.6% for CoC and 27.1% for CoP (p<0.001). Within the limits of registry analysis, this study has demonstrated an association between the use of ceramic bearing and lower rates of revision for all cause revisions especially infection and aseptic loosening. This finding supports the use of ceramic bearings in THA.
We studied the safety and efficacy of multimodal thromboprophylaxis (MMP) in patients with a history of venous thromboembolism (VTE) undergoing total hip arthroplasty (THA). MMP includes discontinuation of procoagulant medications, VTE risk stratification, regional anesthesia, an intravenous bolus of unfractionated heparin before femoral work, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient's risk. From 2004 to 2018, 257 patients (mean age: 67 years; range: 26–95) with a history of VTE underwent 277 primary, elective THAs procedures (128 right, 100 left, 9 single-stage bilateral, 20 staged bilateral) by two orthopaedic surgeons at a single institution. The patients had a history deep vein thrombosis (DVT) 186 (67%), pulmonary embolism (PE) 43 (15.5%), or both 48 (17.5%). Chemoprophylaxis included aspirin (38 patients) and anticoagulation (239 patients; Coumadin: 182, low-molecular-weight heparin: 3, clopidogrel: 1, rivaroxaban: 3, and a combination: 50). Forty eight patients (17.3%) had a vena cava filter at the time of surgery. Patients were followed for 120 days to detect complications, and for a year to detect mortality.Introduction
Material and methods
Primary total hip arthroplasty (THA) is one of the most effective ways of improving quality of life (QoL). We have compared the improvement in QoL in 62 patients who had a cemented revision of a THA with that of 62 primary replacements. One year after operation the median QoL score had been significantly improved in both groups; from 0.870 to 0.990 in the primary group (p <
0.0001) and from 0.870 to 0.980 in the revised group (p <
0.0001). There was no significant difference in the improvement in scores between the groups (p = 0.29). When reviewed after four years there was no difference in the pain score for either group (p = 0.89), but that for function had deteriorated significantly. This was associated with revision surgery (p = 0.018) and a low preoperative QoL score (p = 0.004). We conclude that both primary and revision operations give a significant improvement in the QoL but function after revision may be less durable than after a primary arthroplasty.
Porous tantalum is a highly osteoinductive biomaterial, initially introduced in orthopedics in 1997, with a subsequent rapid evolution of orthopedic applications. The use of porous tantalum for the acetabular component in primary total hip arthroplasty (THA) has demonstrated excellent short-term and mid-term results. However, long term data are scarce. The purpose of this prospective study is to report the long-term clinical and radiological outcome following use of an uncemented porous tantalum acetabular component in primary THA with a minimum follow-up of 17.5 years, in a previously studied cohort of patients. We prospectively followed 128 consecutive primary THAs in 140 patients, between November 1997 and June 1999. A press-fit porous tantalum monoblock acetabular component was used in all cases. The presence of initial gaps in the polar region, as sign of incomplete seating of the monoblock cup, was assessed on the immediate postoperative radiographs. All patients were followed clinically and radiographically at 6, 12, and 24 weeks and 12 months and then at 2, 5, 8, 10, and 19 years, for a mean of 18.1 years (range 17.5 – 19 years). Periacetabular dome gap filling, acetabular cup migration and polyethylene wear were assessed by the EBRA digital measurement system, until 2 years postoperatively. Mean age of patients at the time of operation was 60.4 years old (range 24 – 72). Harris hip score, Oxford Hip Score and range of motion (ROM) were dramatically improved in all cases (p < 0.001). In the initial postoperative radiographs, periacetabular dome gaps were observed in the 15% of cases, and were progressively filled within 6 months. In 2 years postoperatively, the mean component migration, as shown in EBRA study, was 0.67 mm. At last follow-up, all cups were radiographically stable with no evidence of migration, gross polyethylene wear, progressive radiolucencies, osteolytic lesions or acetabular fractures. The survivorship with re-operation for any reason as end point was 92.8%, whereas the survivorship for aseptic loosening as an end point was 100%. Upon visual inspection, two removed acetabular components due to recurrent dislocation and infection, respectively, showed extensive bone osseointegration. In our primary THA series, the porous tantalum monoblock cup demonstrated excellent clinical and radiographic outcomes with no failures because of aseptic loosening at a mean follow-up of 18.1 years. Porous tantalum acetabular components showed excellent initial stability, produced less wear debris and revealed a great potential for bone ingrowth. Due to its unique osteoinductive properties and elliptical shape, porous tantalum monoblock cups have demonstrated superior short and long-term survivorship compared to other press fit prostheses in the market.
Peri-prosthetic femoral fracture after total hip replacement (THR) is associated with a poor outcome and high mortality. However, little is known about its long-term incidence after uncemented THR. We retrospectively reviewed a consecutive series of 326 patients (354 hips) who had received a CLS Spotorno replacement with an uncemented, straight, collarless tapered titanium stem between January 1985 and December 1989. The mean follow-up was 17 years (15 to 20). The occurrence of peri-prosthetic femoral fracture during follow-up was noted. Kaplan-Meier survival analysis was used to estimate the cumulative incidence of fracture. At the last follow-up, 86 patients (89 hips) had died and eight patients (eight hips) had been lost to follow-up. A total of 14 fractures in 14 patients had occurred. In ten hips, the femoral component had to be revised and in four the fracture was treated by open reduction and internal fixation. The cumulative incidence of peri-prosthetic femoral fracture was 1.6% (95% confidence interval 0.7 to 3.8) at ten years and 4.5% (95% confidence interval 2.6 to 8.0) at 17 years after the primary THR. There was no association between the occurrence of fracture and gender or age at the time of the primary replacement. Our findings indicate that peri-prosthetic femoral fracture is a significant mode of failure in the long term after the insertion of an uncemented CLS Spotorno stem. Revision rates for this fracture rise in the second decade. Further research is required to investigate the risk factors involved in the occurrence of late peri-prosthetic femoral fracture after the implantation of any uncemented stem, and to assess possible methods of prevention.
The hip-shelf procedure is less often indicated since the introduction of peri-acetabular osteotomy (PAO). Although this procedure does not modify pelvic shape, its influence on subsequent total hip arthroplasty (THA) is not known. We performed a case-control study comparing THA after hip-shelf surgery and THA in dysplastic hips to determine: 1) its influence on THA survival, 2) technical issues and complications related to the former procedure. We performed a retrospective case-control study comparing 61 THA cases done after hip-shelf versus 63 THA in case-matched dysplastic hips (control group). The control group was matched according to sex, age, BMI, ASA and Charnley score, and bearing type. We compared survival and function (Harris, Oxford-12), complications at surgery, rate of bone graft at cup insertion, and post-operative complications. The 13-year survival rates for any reason did not differ: 89% ± 3.2% in THA after hip shelf versus 83% ± 4.5% in the controls (p = 0.56). Functional scores were better in the control group (Harris 90 ± 10, Oxford 41/48) than in the hip-shelf group (Harris 84.7 ± 14.7, Oxford 39/48) (p = 0.01 and p = 0.04). Operative time, bleeding and rate of acetabular bone grafting (1.6 hip-shelf versus 9.5 control) were not different (p > 0.05). Postoperative complication rates did not differ: one transient fibular nerve palsy and two dislocations (3.2%) in the hip-shelf group versus four dislocations in the control group (6.3%). The hip-shelf procedure does not compromise the results of a subsequent THA in dysplastic hips. This procedure is simple and may keep its indications versus PAO in severely subluxed hips or in case of severe femoral head deformity.
We compared the risks of re-revision and mortality between two-stage and single-stage revision surgeries among patients with infected
The rising prevalence of osteoarthritis, associated with an ageing population, is expected to deliver increasing demand across Scotland for arthroplasty services in the future. Understanding the scale of potential change to operative workflow is essential to ensure adequate provision of services and prevent prolonged waiting times that can cause patient harm. This future service demand for primary and revision hip arthroplasty across Scotland, and the rest of the U.K., is hitherto unknown. We set out to provide projections of future primary & revision hip arthroplasty out to 2038 utilising historical trend data (2008–2018) from the Scottish Arthroplasty Project. All analyses were performed using the Holt's exponential smoothing projection method with the forecast package in R statistics. Results were adjusted for projected future population estimates provided by National Records of Scotland. Independent age & sex group predictions were also performed. All results are presented per 100,000 population at-risk per year (/100k/year). The predicted rise of
Ceramic bearing fracture is a rare complication following implantation using modern day ceramic bearing materials. Revision bearing options in such cases is debated, with the choice between ceramic-on-ceramic and ceramic-on-polyethylene bearings. Revision to a hard on soft bearing raises concerns about potential catastrophic wear secondary to a third-body reaction caused by the fractured ceramic particles. Data was collected retrospectively from the NJR, electronic patient records, revision database and picture archiving and communication system. Templating software was used to determine linear wear between first post-operative radiograph and the latest available follow up. Univariate analysis was used to examine patient demographics and the wear rates for revision of ceramic bearing fractures to ceramic on polyethylene components. The intra and inter-rater reliability of wear measurements was calculated. There were twelve patients identified as meeting the inclusion criteria. The average age at revision was 62 years (54–72). There were 6 liner and 6 head fractures revised to delta ceramic heads and cross-linked polyethylene acetabular components. The most frequently used head size was 32mm. At mean follow up of 3.8 years (0.5 6.1 years), median 4.4 years, linear wear rate was calculated at 0.08± 0.06 mm/year. Both intra-rater and inter-rater reliability was excellent with ICC scores of 0.99 at all timepoints. Revision to ceramic on polyethylene (CoP) bearings following ceramic fracture does not cause early catastrophic wear at early follow up. It appears safe to use this hard on soft bearing combination, given that wear rates are comparable to what is expected in a
Objectives. We used the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) to investigate the risk of revision due to prosthetic joint infection (PJI) for patients undergoing primary and revision hip arthroplasty, the changes in risk over time, and the overall burden created by PJI. Methods. We analysed revision total hip arthroplasties (THAs) performed due to a diagnosis of PJI and the linked index procedures recorded in the NJR between 2003 and 2014. The cohort analysed consisted of 623 253 index
The growth of life expectancy during the last decades has led to an increment in age-related conditions such as hip arthritis and fractures. On the other hand, these elderly patients will present a higher incidence of mental diseases which, in some studies, have been associated with inferior results. This study aims to evaluate the differences in early complication rates between patients with cognitive impairment compared with those without this condition following total hip replacement for osteoarthritis or fracture in the context of contemporary perioperative care protocols. We conducted a retrospective cohort study where cognitively-impaired patients who required
There is paucity of reliable data examining the treatment pathway for hip replacements over the life of the patient in terms of risk of revision and re-revisions. We did a retrospective observational registry-based study of the National Joint Registry, using data on hip replacements from all participating hospitals in England and Wales, UK. We included data on all first revisions, with an identifiable primary procedure, with osteoarthritis as the sole indication for the original primary procedure. Kaplan-Meier estimates were used to determine the cumulative probability of revision and subsequent re-revision after