Hip fracture is a common injury in the elderly. Recent studies in orthopaedic access have demonstrated inequities affecting Māori. This study aimed to compare the demographic differences between Māori and NZ Europeans with hip fractures, identify any deficiencies in initial, surgical and post op care and in outcomes. All cases in New Zealand from 2018–2020 were included. Key outcomes included time to theatre from admission, change in walking status, residential status and survival at 120 days post fracture. Univariate analysis compared differences in demographics, surgical and management factors between ethnicities. Key outcome comparisons were conducted using multivariate analysis to assess whether ethnicity was an independent risk factor for outcomes.Aims
Methods
The New Zealand Joint Registry (NZJR) was established in 1999. However, ethnicity data was not recorded by prioritisation in line with Ministry of Health (MoH) recommendations. Recently, cross-referencing with MoH updated ethnicity data for all 326,150 entries in the NZJR database. The objective of this national level, population study was to identify any ethnic disparities in access and outcome for Māori for primary total hip (THA) and knee arthroplasty (TKA) for Osteoarthritis. The utilisation rate for THA and TKAs were calculated for the Māori and NZ European population from all data in the NZJR and Census data in 2001, 2006, 2013 and 2018. Utilisation rate was reported separately for four age groups (<55, 55-64, 65-74, >75) over four time periods (1999-2004, 2005-2009, 2010-2014, 2015-2020). Revision rate, 6 months and 5-year Oxford scores were adjusted for age, sex and BMI, then compared between groups. In every age group and at all but one time point, significant under-utilisation of TKA was observed in Māori. For THAs, Māori had similar utilisation rates in the <55 and 55-64 age groups, but significantly lower utilisation rates in all other age groups. When adjusted for age, sex and BMI, no significant differences in revision rates were observed between Māori and NZ Europeans for THAs (HR 0.939, P 0.417) or TKAs (HR 1.129, P 0.149). Adjusted 6 months and 5-year Oxford scores were significantly higher in NZ Europeans, however, the maximum difference was less than 3 points and is unlikely to be clinically significant. Despite the same risk of being diagnosed with osteoarthritis, Māori are less likely to undergo THA and TKA. There are no clinically significant differences in outcomes post arthroplasty between Māori and NZ Europeans. Further research is required to investigate causes for lower utilisation in Māori.
Multiple joint registries have reported better implant survival for patients aged >75 years undergoing total hip arthroplasty (THA) with cemented implant combinations when compared to hybrid or uncemented implant combinations. However, there is considerable variation within these broad implant categories, and it has therefore been suggested that specific implant combinations should be compared. We analysed the most common contemporary uncemented (Corail/Pinnacle), hybrid (Exeter V40/Trident) and cemented (Exeter V40/Exeter X3) implant combinations in the New Zealand Joint Registry (NZJR) for patients aged >75 years. All THAs performed using the selected implants in the NZJR for patients aged >75 years between 1999 and 2018 were included. Demographic data, implant type, and outcome data including implant survival, reason for revision, and post-operative Oxford Hip Scores were obtained from the NZJR, and detailed survival analyses were performed. Primary outcome was revision for any reason. Reason for revision, including femoral or acetabular failure, and time to revision were recorded. 5427 THAs were included. There were 1105 implantations in the uncemented implant combination group, 3040 in the hybrid implant combination group and 1282 in the cemented implant combination group. Patient reported outcomes were comparable across all groups. Revision rates were comparable between the cemented implant combination (0.31 revisions/100 component years) and the hybrid implant combination (0.40 revisions/100 component years) but were statistically significantly higher in the uncemented implant combination (0.80/100 component years). Femoral-sided revisions were significantly greater in the uncemented implant combination group. The cemented implant and hybrid implant combinations provide equivalent survival and functional outcomes in patients aged over 75 years. Caution is advised if considering use of the uncemented implant combination in this age group, predominantly due to a higher risk of femoral sided revisions. The authors recommend comparison of individual implants rather than broad categories of implants.
Femoral neck fractures following arthroscopic osteochondroplasty of the femoral head-neck junction for femoroacetabular impingement have been observed in our practice and anecdotally reported in the literature. The aim of the present study was to assess the rate of fracture, identify risk factors, and determine the impact on short-term patient outcome. Our prospectively recorded database of 431 consecutive hip ar-throscopies was retrospectively analyzed to identify patients who had suffered a postoperative femoral neck fracture. Seven cases were found and comprised the study group (SG). For evaluation of potential risk factors, the SG was compared with all 376 cases that had undergone femoral osteochondroplasty (OG) for age, gender, height, weight and BMI. Additionally, the bony correction in the SG was measured on conventional radiographs as well on either an MRI or CT scan and compared with a reference group (RG). Clinical outcomes were determined from analysis of preoperative and postoperative WOMAC scores and compared between SG and RG. 1.9% (7 males) sustained a fracture after minor trauma that occurred at an average of 4.4 weeks postoperatively. The SG had a significantly higher mean age (p=0.01) when compared with the OG. The postoperative alpha angles were significantly (p=0.006) lower on radial reformations scans in the SG then in the RG. The resection depth ratios measured in the SG were significantly higher on both x-rays (p=0.022) and scans (p=0.013). Using receiver-operating characteristic (ROC) curves cut-off values for age and resection depth ratio on standard x-rays were found to be 44 years and 18%, respectively. After a mean follow-up 20 months there was a significant lower WOMAC (p=0.030) in the SG and no gain pre to postoperatively. Male gender, older age (>44 years) and depth of bony resection (>18% head radius) were found to be independent risk factors for fracture. Femoral neck fracture has a negative impact on patient's short-term outcome. We are now more conservative with the post operative rehabilitation protocol for at risk patients.
The risk that hip preserving surgery may negatively influence the performance and outcome of subsequent total hip replacement (THR) remains a concern. The aim of this study was to identify any negative impact of previous hip arthroscopy on THR. Out of 1271 consecutive patients who underwent primary THR between 2005 and 2009, eighteen had previously undergone ipsilateral hip arthroscopy. This study group (STG) was compared with two control groups (CG: same approach, identical implants; MCG: paired group matched for age, BMI and Charnley categories). Operative time, blood loss, evidence of heterotopic bone and implant loosening at follow-up were compared between the SG and the MCG. Follow-up WOMAC were compared between the three groups. Blood loss was not found to be significantly different between the SG and MCG. The operative time was significantly less (p>0.001) in the SG. There was no significant difference in follow-up WOMAC between the groups. No implant related complications were noted on follow-up radiographs. Two minor complications were documented for the SG and three for the MCG. We have found no evidence that previous hip arthroscopy negatively influences the performance or short-term outcome of THR.
