The importance of registries has been brought into focus by recent UK national reports focusing on implant (Cumberlege) and surgeon (Paterson) performance. National arthroplasty registries provide ...real-time, real-world information about implant, hospital, and surgeon performance and allow case identification in the event of product recall or adverse surgical outcomes. They are a valuable resource for research and service improvement given the volume of data recorded and the longitunidal nature of data collection. This review discusses the current value of registry data as it relates to both clinical practice and research.
Abstract Influence of BMI upon patient outcomes and complications following THA was examined across a national cohort of patients. Outcomes were compared by BMI groups (19.0–29.9 kg/m2 reference, ...30.0–34.9 kg/m2 obese class I, 35.0 kg/m2 + obese class II/III), adjusted for case-mix differences. Obese class I patients had a significantly smaller improvement in OHS (18.9 versus 20.5, P < 0.001) and a greater risk of wound complications (odds ratio OR = 1.57, P = 0.006). For obese class II/III patients, there were significantly smaller improvements in OHS and EQ-5D index ( P < 0.001), and greater risk of wound complications ( P = 0.006), readmission ( P = 0.001) and reoperation ( P = 0.003). Large improvements in patient outcomes were seen irrespective of BMI, although improvements were marginally smaller and complication rates higher in obese patients.
BACKGROUND:There is evidence to support the use of highly cross-linked polyethylene (HXLPE) in patients undergoing total hip arthroplasty. However, the benefits for those undergoing total knee ...arthroplasty are uncertain, with conflicting reports based on previous cohort analyses. The purpose of the present study was to compare the revision rates following primary total knee arthroplasty with use of HXLPE as compared with conventional polyethylene (CPE) using data from the National Joint Registry (NJR) for England, Wales and Northern Ireland.
METHODS:We performed a retrospective analysis of primary total knee arthroplasties recorded in the NJR from 2003 to 2014. Cobalt-chromium (CoCr)-CPE and CoCr-HXLPE bearing surfaces were compared using all-cause revision, aseptic revision, and septic revision as end points. Survival analyses were conducted using rates per 100 years observed, Kaplan-Meier survival estimates, and Cox regression hazard ratios (HRs) adjusted for age, sex, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), lead surgeon grade, and implant constraint. Secondary analyses compared the most commonly used HXLPEs (Zimmer Prolong, DePuy XLK, and Stryker X3) against CPE for the 3 most common total knee arthroplasty systems (NexGen, PFC Sigma, and Triathlon).
RESULTS:In the present study of 550,658 total knee arthroplasties, the unadjusted aseptic revision rates were significantly lower following procedures performed with CPE (n = 513,744) as compared with those performed with HXLPE total knee replacements (n = 36,914) (0.29 95% confidence interval (CI), 0.28 to 0.30 compared to 0.38 95% CI, 0.35 to 0.42, p < 0.01). The 10-year HR associated with CPE was 0.4 (95% CI, 0.1 to 0.8, p = 0.03). There were no significant differences between the adjusted revision rates of HXPLE compared with CPE in individual analyses of the most common total knee arthroplasty systems. However, for the subset of patients who were both <60 years of age and had a BMI of >35 kg/m, the “second-generation” Stryker X3 HXLPE demonstrated significantly better survival than its respective CPE, with CPE having an HR of 2.6 (95% CI, 1.2 to 5.9) (p = 0.02).
CONCLUSIONS:Alternative bearings are marketed as having improved wear properties over traditional CoCr-CPE. This registry-based analysis demonstrated no overall survival benefit of HXLPE after a maximum duration of follow-up of 12 years. Because of their increased cost, the routine use of HXLPE bearings may not be justified. However, they may have a role in specific “higher demand” groups such as patients <60 years of age and/or those with a BMI of >35 kg/m.
LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete list of levels of evidence.
Abstract Unlike the English National Joint Registry (NJR) for arthroplasty, no surgeon driven national database currently exists for ligament surgery in England. Therefore information on outcome and ...adverse events following anterior cruciate ligament (ACL) surgery is limited to case series. This restricts the ability to make formal recommendations upon surgical care. Prospectively collected data, which is routinely collected on every NHS patient admitted to hospital in England, was analysed to determine national rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary thromboembolism (PTE) rate, 30-day wound infection and readmission rates following primary ACL reconstruction between March 2008 and February 2010 (13,941 operations, annual incidence 13.5 per 100,000 English population). 90-day DVT and PTE rates were 0.30% (42) and 0.18% (25) respectively. There were no in-hospital deaths. 0.75% (104) of the consecutive patient cohort had a wound complication recorded. 0.25% (35) underwent a further procedure to wash out the infected knee joint and 1.36% (190) were readmitted to an orthopaedic ward within 30 days. This is the first national comprehensive study of the incidence of significant complications following ACL surgery in England. This should allow meaningful interpretation of future baseline data supporting the development of a national ligament registry.
Prosthetic joint infection (PJI) is a devastating complication. Studies have suggested reduction in PJI with the use of ceramic bearings.
Adult patients who underwent total hip arthroplasty (THA) ...using an uncemented acetabular component with ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoP), or metal-on-polyethylene (MoP) bearing surfaces between 2002 and 2016 were extracted from the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man. A competing risk regression model to investigate predictors of each revision outcome was used. Time-to-event was determined by duration of implantation since primary surgery with competing risks being death or revision. The results were adjusted for age, gender, American Association of Anaesthesiologists grade, body mass index, surgical indication, intraoperative complications, and implant data.
In total, 456,457 THAs (228,786 MoP, 128,403 CoC, and 99,268 CoP) were identified. Multivariable modeling showed that the risk of revision for PJI was significantly lower with CoC (risk ratio 0.748, P < .001) and CoP (risk ratio 0.775, P < .001) compared to MoP. Significant reduction in risk of aseptic and all-cause revision was also seen. The significant protective effect of ceramic bearing was predominantly seen 2 years after implantation. Aseptic revision beyond 2 years reduced by 18.1% and 24.8% for CoC and CoP (P < .001), respectively. All-cause revision rate beyond 2 years reduced by 21.6% for CoC and 27.1% for CoP (P < .001)
This study demonstrates an association between the use of ceramic as part of the bearing, with lower rates of revision for all causes, revision for infection, and revision for aseptic causes, supporting ceramic bearings in THA.
Background Data on venous thromboembolic (VTE) events after different types of shoulder surgery have not previously been available in large numbers in the United Kingdom. We aimed to determine ...baseline postoperative complication rates with reference to national thromboembolic prophylaxis guidelines. Methods Diagnostic and operative codes are routinely collected on every patient admitted to the hospital in the English NHS. Data for a 42-month period were analyzed for planned shoulder surgery (total replacement, hemiarthroplasty, or arthroscopy) and proximal humeral fracture surgery (internal fixation or replacement). In addition, complications during the two 6-month periods before and after the implementation of national thromboprophylaxis guidelines were compared. Rates of symptomatic deep venous thrombosis, pulmonary embolism, and mortality within 90 days were extracted. Results For total shoulder replacement (4,061 patients), deep venous thrombosis, pulmonary embolism, and mortality rates were 0%, 0.20%, and 0.22%, respectively. For arthroscopic procedures (65,302 patients), the rates were less than 0.01%, 0.01%, and 0.03%, respectively. For proximal humeral fracture surgery (internal fixation or replacement, 4,696 patients), the rates were 0.19%, 0.40%, and 3.02%, respectively. There was no significant difference in the VTE event or mortality rates before and after the introduction of the 2007 National Institute for Health and Clinical Excellence guidelines after arthroscopy or proximal humeral fracture surgery. A statistically significant decrease in total shoulder replacement–related mortality was found, from 0.72% (5 patients) to 0%. Discussion VTE disease is not a significant problem after shoulder surgery, and thromboprophylaxis may not be required, even in high-risk patients. National thromboprophylaxis guidelines did not affect VTE event rates.
Hip replacement is one of the most commonly performed surgical procedures worldwide; hundreds of implant configurations provide options for femoral head size, joint surface material and fixation ...method with dramatically varying costs. Robust comparative evidence to inform the choice of implant is needed. This retrospective cohort study uses linked national databases from England and Wales to determine the optimal type of replacement for patients over 60 years undergoing hip replacement for osteoarthritis.
Implants included were the commonest brand from each of the four types of replacement (cemented, cementless, hybrid and resurfacing); the reference prosthesis was the cemented hip procedure. Patient reported outcome scores (PROMs), costs and risk of repeat (revision) surgery were examined. Multivariable analyses included analysis of covariance to assess improvement in PROMs (Oxford hip score, OHS, and EQ5D index) (9159 linked episodes) and competing risks modelling of implant survival (79,775 procedures). Cost of implants and ancillary equipment were obtained from National Health Service procurement data.
EQ5D score improvements (at 6 months) were similar for all hip replacement types. In females, revision risk was significantly higher in cementless hip prostheses (hazard ratio, HR = 2.22, p<0.001), when compared to the reference hip. Although improvement in OHS was statistically higher (22.1 versus 20.5, p<0.001) for cementless implants, this small difference is unlikely to be clinically important. In males, revision risk was significantly higher in cementless (HR = 1.95, p = 0.003) and resurfacing implants, HR = 3.46, p<0.001), with no differences in OHS. Material costs were lowest with the reference implant (cemented, range £1103 to £1524) and highest with cementless implants (£1928 to £4285). Limitations include the design of the study, which is intrinsically vulnerable to omitted variables, a paucity of long-term implant survival data (reflecting the duration of data collection), the possibility of revision under-reporting, response bias within PROMs data, and issues associated with current outcome scoring systems, which may not accurately reflect level of improvement in some patients.
Cement fixation, using a polyethylene cup and a standard sized head offers good outcomes, with the lowest risks and at the lowest costs. The most commonly used cementless and resurfacing implants were associated with higher risk of revision and were more costly, while perceptions of improved function and longevity were unsupported.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Simultaneous bilateral total hip arthroplasty (SimBTHA) is often performed in younger, fitter patients with bilateral hip disease. If patients are deemed not suitable for SimBTHA due to concurrent ...comorbidity, it may be more appropriate to perform staged bilateral total hip arthroplasties (StBTHAs) 3-6 months apart to minimize complications and morbidity. Complication rates following hip arthroplasty are low and large national datasets are helpful for assessing these rare events. We aimed at comparing SimBTHA vs StBTHA in order to determine any differences in morbidity and mortality.
Hospital Episode Statistics data for all patients who underwent bilateral THAs in the English National Health Service between April 2005 and July 2014 were obtained. Patients were grouped into SimBTHAs (same day) or staged, with the second THA occurring between 3 and 6 months after the first. Medical and surgical complications were compared and total length of stay was assessed.
A total of 2507 underwent SimBTHAs and 9915 had StBTHAs. SimBTHA patients were significantly younger (60.6 vs 65.5 years, P < .001) and more likely to be male, but had similar Charlson comorbidity scores. Compared to StBTHAs, patients undergoing SimBTHAs had a greater risk of pulmonary embolism, myocardial infarction, renal failure, chest infection, and inhospital death. Patients undergoing SimBTHAs had a significantly shorter overall hospital stay (8.9 vs 10.4 days). Patients undergoing SimBTHA at high-volume units had a lower average Charlson score and subsequent complication rate than low-volume units.
These findings highlight the greater risks of SimBTHA in patients with Charlson score greater than 0 performed at lower-volume centers in England.
Abstract The posterior and lateral approaches to primary hip arthroplasty were compared using national data from England and Wales. Specific component combinations of the most commonly used cemented ...and cementless implant brands were analysed separately. There was no significant difference between the approaches for all-cause revision risk (cemented: P = 0.726, cementless: P = 0.295) and revision for dislocation ( P = 0.176, P = 0.695) at 12 months following 37,593 procedures, after adjusting for patient and surgical variables. Analysis of 3881 linked episodes found the posterior approach was associated with significantly higher improvement in function (Oxford Hip Score: 20.8 versus 18.9, P < 0.001 (cemented procedures); 21.7 versus 20.2, P = 0.008 (cementless), EQ5D index: 0.416 versus 0.383, P = 0.003; 0.431 versus 0.384, P = 0.003). The posterior approach may offer a functional benefit (albeit small clinically), without increased revision risk.
Purpose:
Several controversies in the optimal treatment of femoral neck fractures persist, together with large variations in clinical practice.
Methods:
A narrative literature review covering 4 ...current controversies in the surgical management of femoral neck fractures (total hip arthroplasty (THA) versus hemiarthroplasty (HA), cemented versus uncemented HA, internal fixation versus arthroplasty, operative versus non-operative) was performed. Available literature was balanced against annual trends in the management of femoral neck fractures from the public domain of several national registries (Sweden, Norway, The Netherlands, Australia and New Zealand).
Results:
For most controversies, the literature provides stronger evidence than is reflected by variations encountered in daily practice. Implementation of clinical evidence tends to lag behind and important differences exist between countries.
Conclusions:
Trends of clinical practice from national registries indicate that implementation of available clinical evidence needs to be improved.
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