We continued a prospective longitudinal follow-up
study of 53 remaining patients who underwent open total meniscectomy
as adolescents and who at that time had no other intra-articular
pathology of the knee. Their clinical, radiological and patient-reported
outcomes are described at a mean follow-up of 40 years (33 to 50).
The cohort of patients who had undergone radiological evaluation
previously after 30 years were invited for clinical examination,
radiological evaluation and review using two patient-reported outcome
measures. A total of seven patients (13.2%) had already undergone total
knee replacement at the time of follow-up. A significant difference
was observed between the operated and non-operated knee in terms
of range of movement and osteoarthritis of the tibiofemoral joint,
indicating a greater than fourfold relative risk of osteoarthritis
at 40 years post-operatively. All patients were symptomatic as defined
by the Knee Injury and Osteoarthritis Outcome Score. This study represents the longest follow-up to date and it can
be concluded that meniscectomy leads to symptomatic osteoarthritis
of the knee later in life, with a resultant 132-fold increase in
the rate of total knee replacement in comparison to their geographical
and age-matched peers.
In this study we present our experience with
four generations of uncemented total knee arthroplasty (TKA) from Smith
&
Nephew: Tricon M, Tricon LS, Tricon II and Profix, focusing
on the failure rates correlating with each design change. Beginning
in 1984, 380 Tricon M, 435 Tricon LS, 305 Tricon 2 and 588 Profix
were implanted by the senior author. The rate of revision for loosening
was 1.1% for the Tricon M, 1.1% for the Tricon LS, 0.5% for the
Tricon 2 with a HA coated tibial component, and 1.3% for the Profix
TKA. No loosening of the femoral component was seen with the Tricon
M, Tricon LS or Tricon 2, with no loosening seen of the tibial component
with the Profix TKA. Regarding revision for wear, the incidence
was 13.1% for the Tricon M, 6.6% for the Tricon LS, 2.3% for the
Tricon 2, and 0% for the Profix. These results demonstrate that
improvements in the design of uncemented components, including increased
polyethylene thickness, improved polyethylene quality, and the introduction
of hydroxyapatite coating, has improved the outcomes of uncemented
TKA over time.
The aim of this prospective randomised study
was to compare the clinical and radiological results of a cemented
all-polyethylene Ultima acetabular component with those of a cementless
porous-coated acetabular component (PFC) following total hip replacement
(THR). A total of 287 patients received either a polyethylene acetabular
component (group A) or a cobalt–chromium porous-coated component
(group B) with an identical cemented femoral component and 28 mm
cobalt-chromium head, thus making it the largest study of its type.
Patients were evaluated radiologically and clinically using the
Harris hip score (HHS). Group A comprised 183 patients (73 male,
110 female) with a mean age of
71.3 years (55 to 89). Group B comprised 104 patients (48 male,
56 female) with a mean age of 69.8 years (56 to 89). A total of
16 patients (13 in Group A, three in Group B) did not have post-operative
data for analysis. The mean follow-up in group A was 7.52 years
(0.4 to 15.0) and in Group B 7.87 years (0.5 to 14.0). At final follow-up the mean HHS was similar between groups A
and B (74.5 (25 to 100) and 78.0 (37 to 100), respectively; p =
0.068). The total number of revisions for any cause was 28, 17 of
which were in group A and 11 in group B. The ten-year survivorship
was 86.8% (95% confidence interval (CI) 78.4 to 92.1) and 89.2%
(95% CI 78.3 to 94.8) for groups A and B, respectively (log-rank
p-value = 0.938). A total of 20 cemented and two cementless acetabular
components had evidence of acetabular radiolucencies or acetabular
component migration at last follow-up (p = 0.001). These results indicate that patients with a cemented all-polyethylene
and cementless porous-coated polyethylene lined acetabular component
have similar long-term clinical outcomes.
We determined the ten-year life expectancy of 5831 patients who had undergone 6653 elective primary total hip replacements at a regional orthopaedic centre between April 1993 and October 2004. Using hospital, general practitioner and the local health authority records, we recorded the dates of death for those who died following surgery. The mean age at operation was 67 years (13 to 96) with a male:female ratio of 2:3. Of 1154 patients with a ten-year follow-up 340 (29.5%) had died a mean of 5.6 years (0 to 10) after surgery. Using Kaplan-Meier curves, the ten-year survival was 89% in patients under 65 years at surgery, 75% in patients aged between 65 and 74 years, and 51% in patients over 75. The standardised mortality rates were considerably higher for patients under 45 years, 20% higher for those between 45 and 64 years, and steadily reduced in patients aged 65 and over. The survival of cemented hip replacement derived from the Swedish Hip Arthroplasty Register Annual Report 2004 exceeds the life expectancy of patients over the age of 60 in our area, suggesting that cemented hip replacement is the procedure of choice in this population.
Despite excellent results, the use of cemented
total hip replacement (THR) is declining. This retrospective cohort study
records survival time to revision following primary cemented THR
using the most common combination of components that accounted for
almost a quarter of all cemented THRs, exploring risk factors independently associated
with failure. All patients with osteoarthritis who had an Exeter
V40/Contemporary THR (Stryker) implanted before 31 December 2010
and recorded in the National Joint Registry for England and Wales
were included in the analysis. Cox’s proportional hazard models
were used to analyse the extent to which risk of revision was related
to patient, surgeon and implant covariates, with a significance
threshold of p <
0.01. A total of 34 721 THRs were included in
the study. The overall seven-year rate of revision for any reason
was 1.70% (99% confidence interval (CI) 1.28 to 2.12). In the final
adjusted model the risk of revision was significantly higher in
THRs with the Contemporary hooded component (hazard ratio (HR) 1.88,
p <
0.001) than with the flanged version, and in smaller head
sizes (<
28 mm) compared with 28 mm diameter heads (HR 1.50,
p = 0.005). The seven-year revision rate was 1.16% (99% CI 0.69
to 1.63) with a 28 mm diameter head and flanged component. The overall
risk of revision was independent of age, gender, American Society
of Anesthesiologists grade, body mass index, surgeon volume, surgical
approach, brand of cement/presence of antibiotic, femoral head material
(stainless steel/alumina) and stem taper size/offset. However, the
risk of revision for dislocation was significantly higher with a
‘plus’ offset head (HR 2.05, p = 0.003) and a hooded acetabular component
(HR 2.34, p <
0.001). In summary, we found that there were significant differences
in failure between different designs of acetabular component and
sizes of femoral head after adjustment for a range of covariates.
We report the general mortality rate after total
knee replacement and identify independent predictors of survival. We
studied 2428 patients: there were 1127 men (46%) and 1301 (54%)
women with a mean age of 69.3 years (28 to 94). Patients were allocated
a predicted life expectancy based on their age and gender. There were 223 deaths during the study period. This represented
an overall survivorship of 99% (95% confidence interval (CI) 98
to 99) at one year, 90% (95% CI 89 to 92) at five years, and 84%
(95% CI 82 to 86) at ten years. There was no difference in survival
by gender. A greater mortality rate was associated with increasing
age (p <
0.001), American Society of Anesthesiologists (ASA)
grade (p <
0.001), smoking (p <
0.001), body mass index (BMI)
<
20 kg/m2 (p <
0.001) and rheumatoid arthritis
(p <
0.001). Multivariate modelling confirmed the independent
effect of age, ASA grade, BMI, and rheumatoid disease on mortality.
Based on the predicted average mortality, 114 patients were predicted
to have died, whereas 217 actually died. This resulted in an overall
excess standardised mortality ratio of 1.90. Patient mortality after
TKR is predicted by their demographics: these could be used to assign
an individual mortality risk after surgery.
We compared the clinical and radiological outcomes
of two cementless femoral stems in the treatment of patients with
a Garden III or IV fracture of the femoral neck. A total of 70 patients At final follow-up there were no statistically significant differences
between the short anatomical and the conventional stems with regard
to the mean Harris hip score (85.7 (66 to 100) Our study demonstrated that despite the poor bone quality in
these elderly patients with a fracture of the femoral neck, osseo-integration
was obtained in all hips in both groups. However, the incidence
of thigh pain, pulmonary microemboli and peri-prosthetic fracture
was significantly higher in the conventional stem group than in
the short stem group.
Patients with osteoarthritis undergoing knee replacement have been reported to have an overall reduced mortality compared with that of the general population. This has been attributed to the selection of healthier patients for surgery. However, previous studies have had a maximum follow-up time of ten years. We have used information from the Swedish Knee Arthroplasty Register to study the mortality of a large national series of patients with total knee replacement for up to 28 years after surgery and compared their mortality with that of the normal population. In addition, for a subgroup of patients operated on between 1980 and 2002 we analysed their registered causes of death to determine if they differed from those expected. We found a reduced overall mortality during the first 12 post-operative years after which it increased and became significantly higher than that of the general population. Age-specific analysis indicated an inverse correlation between age and mortality, where the younger the patients were, the higher their mortality. The shift at 12 years was caused by a relative over-representation of younger patients with a longer follow-up. Analysis of specific causes of death showed a higher mortality for cardiovascular, gastrointestinal and urogenital diseases. The observation that early onset of osteoarthritis of the knee which has been treated by total knee replacement is linked to an increased mortality should be a reason for increased general awareness of health problems in these patients.
Our objective was to examine the rate of revision
and its predictive factors in patients undergoing total shoulder arthroplasty
(TSA). We used prospectively collected data from the Mayo Clinic
Total Joint Registry to examine five-, ten- and 20-year revision-free
survival following TSA and the predictive factors. We examined patient
characteristics (age, gender, body mass index, comorbidity), implant
fixation (cemented
Increased femoral head size may reduce dislocation rates following total hip replacement. The National Joint Registry for England and Wales has highlighted a statistically significant increase in the use of femoral heads ≥ 36 mm in diameter from 5% in 2005 to 26% in 2009, together with an increase in the use of the posterior approach. The aim of this study was to determine whether rates of dislocation have fallen over the same period. National data for England for 247 546 procedures were analysed in order to determine trends in the rate of dislocation at three, six, 12 and 18 months after operation during this time. The 18-month revision rates were also examined. Between 2005 and 2009 there were significant decreases in cumulative dislocations at three months (1.12% to 0.86%), six months (1.25% to 0.96%) and 12 months (1.42% to 1.11%) (all p <
0.001), and at 18 months (1.56% to 1.31%) for the period 2005 to 2008 (p <
0.001). The 18-month revision rates did not significantly change during the study period (1.26% to 1.39%, odds ratio 1.10 (95% confidence interval 0.98 to 1.24), p = 0.118). There was no evidence of changes in the coding of dislocations during this time. These data have revealed a significant reduction in dislocations associated with the use of large femoral head sizes, with no change in the 18-month revision rate.
In a systematic review, reports from national registers and clinical studies were identified and analysed with respect to revision rates after joint replacement, which were calculated as revisions per 100 observed component years. After primary hip replacement, a mean of 1.29 revisions per 100 observed component years was seen. The results after primary total knee replacement are 1.26 revisions per 100 observed component years, and 1.53 after medial unicompartmental replacement. After total ankle replacement a mean of 3.29 revisions per 100 observed component years was seen. The outcomes of total hip and knee replacement are almost identical. Revision rates of about 6% after five years and 12% after ten years are to be expected.
Antibiotic prophylaxis is routinely administered during joint replacement surgery and may predispose patients to
We describe the early results of a prospective study of 100 total ankle replacements (96 patients) at a single centre using the Mobility Total Ankle Replacement. At final review, six patients had died and five ankles (5%) had been revised, two by fusion and three by exchange of components. All remaining patients were reviewed at a minimum of three years. The mean follow-up was 43 months (4 to 63). The three-year survival was 97% (95% confidence interval (CI) 91 to 99). The four-year survival was 93.6% (95% CI 84.7 to 97.4). The portion of bony interface that was visible on plain radiograph was divided into 15 zones and a radiolucent line or osteolytic cavity was seen in one zone in 14 ankles. It was not seen in more than one zone. In five ankles it was >
10 mm in width. This study suggests that the early outcome of ankle replacement is comparable to that of other total joint replacements.
Recently the National Patient Safety Agency in the United Kingdom published a report entitled “Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur”. A total of 26 deaths had been reported to them when cement was used at hemiarthroplasty between October 2003 and October 2008. This paper considers the evidence for using cement fixation of a hemiarthroplasty in the treatment of hip fractures.
The cortical strains on the femoral neck and proximal femur were measured before and after implantation of a resurfacing femoral component in 13 femurs from human cadavers. These were loaded into a hip simulator for single-leg stance and stair-climbing. After resurfacing, the mean tensile strain increased by 15% (95% confidence interval (CI) 6 to 24, p = 0.003) on the lateral femoral neck and the mean compressive strain increased by 11% (95% CI 5 to 17, p = 0.002) on the medial femoral neck during stimulation of single-leg stance. On the proximal femur the deformation pattern remained similar to that of the unoperated femurs. The small increase of strains in the neck area alone would probably not be sufficient to cause fracture of the neck However, with patient-related and surgical factors these strain changes may contribute to the risk of early periprosthetic fracture.
We systematically reviewed the peer-reviewed literature to relate the survival of hybrid metal-on-metal hip resurfacing arthroplasty devices to a National Institute of Clinical Excellence (NICE) benchmark for choosing a primary total hip replacement, which is a survival rate of 90% at a follow-up of ten years. A total of 29 articles (10 621 resurfaced hips) met the inclusion criteria. The mean follow-up ranged from 0.6 to 10.5 years and the survival of the implant ranged from 84% to 100%. Of the 10 621 hips, 370 were revised (3.5%), with aseptic loosening as the most frequent mode of failure. None of the hip resurfacing arthroplasty implants used to date met the full ten-year NICE benchmark of survival. A total of 13 studies showed satisfactory survival compared with the three-year NICE benchmark.
Our aim in this pilot study was to evaluate the fixation of, the bone remodelling around, and the clinical outcome after surgery of a new, uncemented, fully hydroxyapatite-coated, collared and tapered femoral component, designed specifically for elderly patients with a fracture of the femoral neck. We enrolled 50 patients, of at least 70 years of age, with an acute displaced fracture of the femoral neck in this prospective single-series study. They received a total hip replacement using the new component and were followed up regularly for two years. Fixation was evaluated by radiostereometric analysis and bone remodelling by dual-energy x-ray absorptiometry. Hip function and the health-related quality of life were assessed using the Harris hip score and the EuroQol-5D. Up to six weeks post-operatively there was a mean subsidence of 0.2 mm (−2.1 to +0.5) and a retroversion of a mean of 1.2° (−8.2° to +1.5°). No component migrated after three months. The patients had a continuous loss of peri-prosthetic bone which amounted to a mean of 16% (−49% to +10%) at two years. The mean Harris hip score was 82 (51 to 100) after two years. The two-year results from this pilot study indicate that this new, uncemented femoral component can be used for elderly patients with osteoporotic fractures of the femoral neck.