The Hospital Frailty Risk Score (HFRS) is a validated geriatric comorbidity measure derived from routinely collected administrative data. The purpose of this study is to evaluate the utility of the ...HFRS as a predictor for postoperative adverse events after primary total hip (THA) and knee (TKA) arthroplasty.
In a retrospective analysis of 8250 patients who had undergone THA or TKA between 2011 and 2019, the HFRS was calculated for each patient. Reoperation rates, readmission rates, complication rates, and transfusion rates were compared between patients with low and intermediate or high frailty risk. Multivariate logistic regression models were used to assess the relationship between the HFRS and postoperative adverse events.
Patients with intermediate or high frailty risk showed a higher rate of reoperation (10.6% vs 4.1%, P < .001), readmission (9.6% vs 4.3%, P < .001), surgical complications (9.1% vs 1.8%, P < .001), internal complications (7.3% vs 1.1%, P < .001), other complications (24.4% vs 2.0%, P < .001), Clavien-Dindo grade IV complications (4.1% vs 1.5%, P < .001), and transfusion (10.4% vs 1.3%, P < .001). Multivariate logistic regression analyses revealed a high HFRS as independent risk factor for reoperation (odds ratio OR = 2.1; 95% confidence interval CI, 1.46-3.09; P < .001), readmission (OR = 1.78; 95% CI, 1.21-2.61; P = .003), internal complications (OR = 3.72; 95% CI, 2.28-6.08; P < .001), surgical complications (OR = 3.74; 95% CI, 2.41-5.82; P < .001), and other complications (OR = 9.00; 95% CI, 6.58-12.32; P < .001).
The HFRS predicts adverse events after THA and TKA. As it derives from routinely collected data, the HFRS enables hospitals to identify at-risk patients without extra effort or expense.
Level III–retrospective cohort study.
Persistent pain around the greater trochanter is a common complication after total hip arthroplasty. Restoration of biomechanics such as leg length, femoral und acetabular offset is crucial in THA. ...The purpose of this study was to evaluate postoperative differences of these parameters after THA and to analyze their association to greater trochanteric pain syndrome. Furthermore, we aimed to evaluate the clinical relevance of trochanteric pain syndrome compared to patient reported outcome measures. 3D-CT scans of 90 patients were analyzed after minimalinvasive total hip arthroplasty and leg length, femoral and acetabular offset differences were measured. Clinical evaluation was performed three years after THA regarding the presence of trochanteric pain syndrome and using outcome measures. Furthermore, the patients' expectation were evaluated. Patients with trochanteric pain syndrome showed a higher absolute discrepancy of combined leg length, femoral and acetabular offset restoration compared to the non-operated contralateral side with 11.8 ± 6.0 mm than patients without symptoms in the trochanteric region with 7.8 ± 5.3 mm (p = 0.01). Patients with an absolute deviation of the combined parameters of more than 5 mm complained more frequently about trochanteric symptoms (29.2%, 19/65) than patients with a biomechanical restoration within 5 mm compared to the non-affected contralateral side (8.0%, 2/25, p = 0.03). Clinical outcome measured three years after THA was significantly lower in patients with trochanteric symptoms than without trochanteric pain (p < 0.03). Similarly, fulfillment of patient expectations as measured by THR-Survey was lower in the patients with trochanteric pain (p < 0.005). An exact combined restoration of leg length, acetabular and femoral offset reduces significantly postoperative trochanteric pain syndrome and improves the clinical outcome of the patients.
Total hip and knee replacements are frequently performed curative treatment options in end-stage arthritis. In this study, we analyzed clinical outcome, complications, and predictors of outcome in ...modern joint replacement.
In a retrospective analysis of over 2000 primary total hip and knee replacements from our institutional joint registry, responder rates for positive outcome as defined by the OMERACT-OARSI criteria, postoperative complication rates, and patient-reported outcome measures (EQ-5D, WOMAC) within the first year were compared between hip and knee replacements. Furthermore, preoperative risk factors associated with nonresponder rate were evaluated.
Positive responder rate was higher for hip replacements with 92.8% (1145/1234) than for knee replacements with 86.1% (839/975, P < .001). Infection rates were lower (P = .04), whereas intraoperative fracture occurred more frequently (P = .001) in hip than in knee replacements. Patient-reported outcome measures 1 year after surgery were higher in hip than in knee replacements with EQ-5D (0.88 ± 0.17 to 0.81 ± 0.19, P < .001) and WOMAC (84.58 ± 16.73 to 74.31 ± 18.94, P < .001). Besides the type of joint replacement (hazard ratio HR 2.0, P < .001), high preoperative outcome measures (HR 7.4, P < .001) and male gender (HR 1.4, P = .05) were independent risk factors of nonresponders after joint replacement.
Both total hip and knee replacements are safe procedures with low complication rates. Still, postoperative outcome is higher in hip than in knee arthroplasty. High preoperative clinical scores are a risk factor for poor clinical improvement following total joint replacement and can be used in counseling patients in the office.
Revisions after total joint replacement increase constantly. In the current study, we analyzed clinical outcome, complication rates, and cost-effectiveness of revision arthroplasty. In a ...retrospective analysis of 162 revision hip and knee arthroplasties from our institutional joint registry responder rate, patient-reported outcome measures (EQ-5D, WOMAC), complication rates, and patient-individual charges in relation to reimbursement were compared with a matched control group of primary total joint replacements. Positive responder rate one year postoperatively was lower for revision arthroplasties with 72.9% than for primary arthroplasties with 90.1% (OR=0.30, 95%CI=0.18–0.59, p=0.001). Correspondingly, improvement in patient-reported outcome measures one year after surgery was lower in revision than in primary joint arthroplasty with EQ-5D 0.19±0.25 to 0.30±0.24 (p<0.001) and WOMAC 24.3±30.3 to 41.2±21.3 (p<0.001). Infection rate was higher in revision (6.8%) compared to primary replacements (0%, p=0.001). Mean charges in revision arthroplasty were 76.0% higher than in matched primary joint replacements (7110.8±2249.4$ to 4041.1±975.7$, p<0.001), whereas reimbursement was only 23.6% higher (9243.3±2258.4$ in revision and 7477.9±703.1$ in primary arthroplasty, p<0.001). Revision arthroplasty is associated with lower outcome and higher infection rate compared to primary replacements. The high financial expense of revision arthroplasty is only partly covered by a higher reimbursement.
Kinematic alignment is an alternative approach to mechanical alignment. Kinematic alignment can restore the joint line to its prearthritic condition, and its advocates have suggested it may be ...associated with other benefits. But this alignment approach often results in tibial components that are placed in varus and femoral components that are placed in valgus alignment, which may result in an increased risk of component loosening because of wear. Like malaligned implant components, kinematically aligned knee implants could increase wear in vivo, but we lack comparative data about wear behavior between these approaches.
(1) Do the different alignment approaches (kinematic, mechanical, and purposefully malaligned components) result in different wear rates in a wear simulator? (2) Do the different alignment approaches lead to different worn areas on the polyethylene inserts in a wear simulator? (3) Do the different alignment approaches result in different joint kinematics in a wear simulator?
Mechanical alignment was simulated in a force-controlled manner with a virtual ligament structure according to the International Organization for Standardization (ISO 14243-1) using a knee wear simulator. To simulate kinematic alignment, flexion-extension motion, internal-external torque, and the joint line were tilted by 4°, using a novel mechanical setup, without changing the force axis. The setup includes bearings with inclinations of 4° so that the joint axis of 4° is determined. To verify the angle of 4°, a digital spirit level was used. To simulate malalignment, we tilted the implant and, therefore, the joint axis by 4° using a wedge with an angle of 4° without tilting the torque axes of the simulator. This leads to a purposefully malaligned tibial varus and femoral valgus of 4°. For each condition, three cruciate-retaining knee implants were tested for 3.0 x 10 6 cycles, and one additional implant was used as soak control. Gravimetric wear analyses were performed every 0.5 x 10 6 cycles to determine the linear wear rate of each group by linear regression. The wear area was measured after 3.0 x 10 6 cycles by outlining the worn areas on the polyethylene inserts, then photographing the inserts and determining the worn areas using imaging software. The joint kinematics (AP translation and internal-external rotation) were recorded by the knee simulator software and analyzed during each of the six simulation intervals.
Comparing the wear rates of the different groups, no difference could be found between the mechanical alignment and the kinematic alignment (3.8 ± 0.5 mg/million cycles versus 4.1 ± 0.2 mg/million cycles; p > 0.99). However, there was a lower wear rate in the malaligned group (2.7 ± 0.2 mg/million cycles) than in the other two groups (p < 0.01). When comparing the total wear areas of the polyethylene inserts among the three different alignment groups, the lowest worn area could be found for the malaligned group (716 ± 19 mm 2 ; p ≤ 0.003), but there was no difference between kinematic alignment and mechanical alignment (823 ± 19 mm 2 versus 825 ± 26 mm 2 ; p > 0.99). Comparing the AP translation, no difference was found between the mechanical alignment, the kinematic alignment, and the malalignment group (6.6 ± 0.1 mm versus 6.9 ± 0.2 mm versus 6.8 ± 0.3 mm; p = 0.06). In addition, the internal-external rotation between mechanical alignment, kinematic alignment, and malalignment also revealed no difference (9.9° ± 0.4° versus 10.2° ± 0.1° versus 10.1° ± 0.6°; p = 0.44).
In the current wear simulation study, the wear rates of mechanical alignment and kinematic alignment of 4° were in a comparable range.
The results suggest that kinematic alignment with up to 4° of component inclination may give the surgeon confidence that the reconstruction will have good wear-related performance when using a modern cruciate-retaining implant. The malaligned group had the lowest wear rate, which may be a function of the smaller worn area on the inserts compared with the other two alignment groups. This smaller articulation area between the femoral condyles and polyethylene insert could increase the risk of delamination of malaligned components over longer test durations and during high-load activities. For that reason, and because malalignment can cause nonwear-related revisions, malalignment should be avoided. Further in vitro and clinical studies must prove whether the wear simulation of different alignments can predict the wear behavior in vivo.
Mesenchymal stromal cells (MSCs) that are promising for cartilage tissue engineering secrete high amounts of prostaglandin E2 (PGE2), an immunoactive mediator involved in endochondral bone ...development. This study aimed to identify drivers of PGE2 and its role in the inadvertent MSC misdifferentiation into hypertrophic chondrocytes. PGE2 release, which rose in the first three weeks of MSC chondrogenesis, was jointly stimulated by endogenous BMP, WNT, and hedgehog activity that supported the exogenous stimulation by TGF-β1 and insulin to overcome the PGE2 inhibition by dexamethasone. Experiments with PGE2 treatment or the inhibitor celecoxib or specific receptor antagonists demonstrated that PGE2, although driven by prohypertrophic signals, exerted broad autocrine antihypertrophic effects. This chondroprotective effect makes PGE2 not only a promising option for future combinatorial approaches to direct MSC tissue engineering approaches into chondral instead of endochondral development but could potentially have implications for the use of COX-2-selective inhibitors in osteoarthritis pain management.
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•MSCs increase secretion of the osteoarthritis regulator PGE2 during chondrogenesis.•Endogenous BMP/WNT/HH signals join exogenous TGFβ/insulin to stimulate PGE2 release.•PGE2 is an autocrine negative feedback regulator of chondrocyte hypertrophy.•COX-2-selective osteoarthritis medication could compromise chondroprotection by PGE2.
Wear and corrosion at modular neck tapers in THA can lead to major clinical implications such as periprosthetic osteolysis, adverse local tissue reactions, or implant failure. The material ...degradation processes at the taper interface are complex and involve fretting corrosion, third-body abrasion, as well as electrochemical and crevice corrosion. One phenomenon in this context is imprinting of the head taper, where the initially smooth surface develops a topography that reflects the rougher neck taper profile. The formation mechanism of this specific phenomenon, and its relation to other observed damage features, is unclear. An analysis of retrieved implants may offer some insights into this process.
(1) Is imprinting related to time in situ of the implants and to the taper damage modes of corrosion and fretting? (2) Are implant design parameters like neck taper profile, stem material, or head seating associated with the formation of imprinting? (3) Is imprinting created by an impression of the neck taper profile or can a different mechanistic explanation for imprinting be derived?
Thirty-one THAs with cobalt-chromium-molybdenum-alloy (CoCrMo) heads retrieved between 2013 and 2019 at revision surgery from an institutional registry were investigated. Inclusion criteria were: 12/14 tapers, a head size of 36 mm or smaller, time in situ more than 1 year, and intact nonmodular stems without sleeve adaptors. After grouping the residual THAs according to stem type, stem material, and manufacturer, all groups of three or more were included. Of the resulting subset of 31 retrievals, nine THAs exhibited a still assembled head-neck taper connection. The median (range) time in situ was 5 years (1 to 23). Two stem materials (21 titanium-alloy and 10 stainless steel), three kinds of bearing couples (11 metal-on-metal, 13 metal-on-polyethylene, and seven dual-mobility heads), and two different neck taper profiles (six wavy profile and 25 fluted profile) were present in the collection. Four THAs exhibited signs of eccentric head seating. The 31 investigated THAs represented 21% of the retrieved THAs with a CoCrMo alloy head during the specified period.At the head tapers, the damage modes of corrosion, fretting, and imprinting were semiquantitatively rated on a scale between 0 (no corrosion/fretting/imprinting) and 3 (severe corrosion/fretting/imprinting). Corrosion and fretting were assessed applying the Goldberg score, with the modification that the scale started at 0 and not at 1. Imprinting was assessed with a custom scoring system. Rating was done individually at the proximal and distal head taper half and summed to one total damage score for each retrieval and damage mode. Correlations between the damage modes and time in situ and between the damage modes among each other, were assessed using the Spearman rank order correlation coefficient (ρ). Associations between imprinting and implant design parameters were investigated by comparing the total imprinting score distributions with the Mann-Whitney U-test. Metallographically prepared cross-sections of assembled head-neck taper connections were examined by optical microscopy and disassembled head and neck taper surfaces were assessed by scanning electron microscopy (SEM).
The imprinting damage score increased with time in-situ (ρ = 0.72; p < 0.001) and the corrosion damage score (ρ = 0.63; p < 0.001) but not with the fretting damage score (ρ = 0.35; p = 0.05). There was no difference in total imprinting score comparing neck taper profiles or stem materials, with the numbers available. Eccentric head seating had elevated total imprinting score (median 6 interquartile range 0) compared with centric seating (median 1 2; p = 0.001). Light optical investigations showed that imprinting can be present on the head taper surfaces even if the depth of abraded material exceeds the neck taper profile height. SEM investigations showed bands of pitting corrosion in the imprinted grooves.
The microscopic investigations suggest that imprinting is not an independent phenomenon but a process that accompanies the continuous material degradation of the head taper surface because of circular damage on the passive layer induced by grooved neck tapers.
Material loss from head-neck taper connections involving CoCrMo alloy heads is a source of metal ions and could potentially be reduced if hip stems with smooth neck tapers were used. Surgeons should pay attention to the exact centric seating of the femoral head onto the stem taper during joining of the parts.
Offset restoration in total hip arthroplasty (THA) is associated with postoperative range of motion (ROM) and gait kinematics. We aimed to research into the impact of high offset (HO) and standard ...stems on postoperative ROM. 121 patients received cementless THA through a minimally-invasive anterolateral approach. A 360° hip ROM analysis software calculated impingement-free hip movement based on postoperative 3D-CTs compared to ROM values necessary for activities of daily living (ADL). The same model was then run a second time after changing the stem geometry between standard and HO configuration with the implants in the same position. HO stems showed higher ROM for all directions between 4.6 and 8.9° (p < 0.001) compared with standard stems but with high interindividual variability. In the subgroup with HO stems for intraoperative offset restoration, the increase in ROM was even higher for all ROM directions with values between 6.1 and 14.4° (p < 0.001) compared to offset underrestoration with standard stems. Avoiding offset underrestoration resulted in a higher amount of patients of over 20% for each ROM direction that fulfilled the criteria for ADL (p < 0.001). In contrast, in patients with standard stems for offset restoration ROM did increase but not clinically relevant by offset overcorrection for all directions between 3.1 and 6.1° (p < 0.001). Offset overcorrection by replacing standard with HO stems improved ROM for ADL in a low number of patients below 10% (p > 0.03). Patient-individual restoration of offset is crucial for free ROM in THA. Both over and underrestoration of offset should be avoided.
Background and purpose - Improving health care and demographic change have resulted in a steady increase in geriatric patients undergoing total hip (THA) and knee (TKA) arthroplasty. Postoperative ...delirium (POD) is a frequent and severe complication after major surgery. Therefore, we analyzed the impact of POD on outcome after THA and TKA.
Patients and methods - In a consecutive series of 10,140 patients who had undergone elective THA or TKA between 2011 and 2020, rates of reoperation within 90 days, readmission within 90 days, complications, and responder rate as defined by the OMERACT-OARSI criteria were compared between patients with and without POD. Multivariable logistic regression models were used to assess the relationship between POD and other postoperative complications.
Results - Patients with POD showed higher rates of reoperation (12% vs. 5%), readmission (15% vs. 5%), surgical complications (7% vs. 2%), non-surgical complications (8% vs. 4%), Clavien-Dindo IV° complications (10% vs. 2%) and transfusion (14% vs. 2%). POD led to lower responder rate (76% vs. 87%) 1 year after total joint replacement. All previous comparisons statistically significant. Multivariable logistic regression analyses revealed POD as an independent risk factor for reoperation (OR = 2; CI 1-3), readmission (OR = 2; CI 2-4) and Clavien-Dindo IV° complications (OR = 3; CI 2-5).
Interpretation - POD is a serious problem in elective joint replacement. Affected patients suffer more complications and show poor patient-reported outcome 1 year postoperatively. Systematic prevention strategies and standardized therapy protocols are mandatory to avoid burden to patients and healthcare providers.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
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