Background
Revision for prosthetic joint infection (PJI) has a major effect on patients’ health but it remains unclear if early PJI after primary THA is associated with a high mortality.
...Questions/Purposes
(1) Do patients with a revision for PJI within 1 year of primary THA have increased mortality compared with patients who do not undergo revision for any reason within 1 year of primary THA? (2) Do patients who undergo a revision for PJI within 1 year of primary THA have an increased mortality risk compared with patients who undergo an aseptic revision? (3) Are there particular bacteria among patients with PJI that are associated with an increased risk of death?
Methods
This population-based cohort study was based on the longitudinally maintained Danish Hip Arthroplasty Register on primary THA performed in Denmark from 2005 to 2014. Data from the Danish Hip Arthroplasty Register were linked to microbiology databases, the National Register of Patients, and the Civil Registration System to obtain data on microbiology, comorbidity, and vital status on all patients. Because reporting to the register is compulsory for all public and private hospitals in Denmark, the completeness of registration is 98% for primary THA and 92% for revisions (2016 annual report). The mortality risk for the patients who underwent revision for PJI within 1 year from implantation of primary THA was compared with (1) the mortality risk for patients who did not undergo revision for any reason within 1 year of primary THA; and (2) the mortality risk for patients who underwent an aseptic revision. A total of 68,504 primary THAs in 59,954 patients were identified, of those 445 primary THAs underwent revision for PJI, 1350 primary THAs underwent revision for other causes and the remaining 66,709 primary THAs did not undergo revision. Patients were followed from implantation of primary THA until death or 1 year of followup, or, in case of a revision, 1 year from the date of revision.
Results
Within 1 year of primary THA, 8% (95% CI, 6%–11%) of patients who underwent revision for PJI died. The adjusted relative mortality risk for patients with revision for PJI was 2.18 (95% CI, 1.54–3.08) compared with the patients who did not undergo revision for any cause (p < 0.001). The adjusted relative mortality risk for patients with revisions for PJI compared with patients with aseptic revision was 1.87 (95% CI, 1.11–3.15; p = 0.019). Patients with enterococci-infected THA had a 3.10 (95% CI, 1.66–5.81) higher mortality risk than patients infected with other bacteria (p < 0.001).
Conclusions
Revision for PJI within 1 year after primary THA induces an increased mortality risk during the first year after the revision surgery. This study should incentivize further studies on prevention of PJI and on risk to patients with the perspective to reduce mortality in patients who have had THA in general and for patients with PJI specifically.
Level of Evidence
Level III, therapeutic study.
Background and purpose - Socioeconomic inequality in health is recognized as an important public health issue. We examined whether socioeconomic status (SES) is associated with revision and mortality ...rates after total hip arthroplasty (THA) within 90 and 365 days.
Patients and methods - We obtained SES markers (cohabitation, education, income, and liquid assets) on 103,901 THA patients from Danish health registers (year 1995-2017). The outcomes were any revision (all revisions), specified revision (due to infection, fracture, or dislocation), and mortality. We used Cox regression analysis to estimate adjusted hazard ratio (aHR) of each outcome with 95% confidence interval (CI) for each SES marker.
Results - Within 90 days, the aHR for any revision was 1.3 (95% CI 1.1-1.4) for patients living alone vs. cohabiting. The aHR was 2.0 (CI 1.4-2.6) for low-income vs. high-income among patients < 65 years. The aHR was 1.2 (CI 0.9-1.7) for low liquid assets among patients > 65 years. Results were consistent for any revision within 365 days as well as for revisions due to infection, fracture, and dislocation. The aHR for mortality was 1.4 (CI 1.2-1.6) within 90 days and 1.3 (CI 1.2-1.5) within 365 days for patients living alone vs. cohabiting. Low education, low income, and low liquid assets were associated with increased mortality rate within both 90 and 365 days.
Interpretation - Our results suggest that living alone, low income, and low liquid assets were associated with increased revision and mortality up to 365 days after THA surgery. Optimizing medical conditions prior to surgery and implementing different post-THA support strategies with a focus on vulnerable patients may reduce complications associated with inequality.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
The Oxford Hip Score is used to evaluate the outcome after total hip arthroplasty. The Oxford Hip Score was developed more than 20 years ago with only some degree of patient involvement. We question ...if the Oxford Hip Score is still relevant for the present-day total hip artrhoplasty patients. We aimed to determine whether the Oxford Hip Score contains items that are relevant for present-day patients with osteoarthritis undergoing total hip arthroplasty, thus investigating the content validity. We identified 6 general items with 41 sub-items. The 6 general items were pain, walking, physical activities, functional abilities, quality of life and psychological health. We found that items in the Oxford Hip Score were all in some way relevant to the patients but that the Oxford Hip Score lacks several important items relevant for present-day total hip artrhoplasty patients, including several physical activities, functional abilities and certain aspects of quality of life and psychological health. We found that the Oxford Hip Score lacks important items for present-day patients in our population. Due to findings regarding several additional items that are not present in the Oxford Hip Score, particularly concerning physical activities and quality of life, we question the content validity of the Oxford Hip Score for a present-day population. Our findings indicate a need for a revision of the Oxford Hip Score.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background and purpose - In Denmark, all citizens are guaranteed free access to medical care, which should minimize socioeconomic status (SES) inequalities. We examined the association between SES ...and the utilization of total hip arthroplasty (THA) by age and over time.
Patients and methods - Data on education, income, liquid assets, and occupation on 104,055 THA cases and 520,275 population controls were obtained from Danish health registers. We used logistic regression to estimate adjusted odds ratios (aOR) for THA with 95% confidence intervals (CI).
Results - Risk (CI) of THA was higher for 45-55-year-olds with lowest vs. highest education (aOR 1.4 1.3-1.5), and for those with lowest vs. highest income (aOR 1.1 1.0-1.2). The association between education and income and higher risk of THA decreased with increasing age. The risk of THA was lower for persons with lowest vs. highest liquid assets in all age groups and time periods. The risk of THA was higher for persons with lowest education in 1995-2000 (aOR 1.2 1.1-1.3), but diminished in 2013-2017 (aOR 1.0 1.0-1.0). For those on lowest income there was a higher risk of THA in 1995-2000 (aOR 1.2 1.1-1.3), changing to lower risk in 2013-2017 (aOR 0.8 0.8-0.9).
Interpretation - In a society where all citizens are guaranteed free access to medical care, we observed a social inequality in regard to the risk of THA with a development over time and in relation to age in most of our SES markers, showing a need for more patient involvement by implementing more focused interventions targeted to the most vulnerable patient groups identified as currently living alone, on low income, and with a low level of liquid assets.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Background and purpose - The UCLA Activity Scale (UCLA) is a questionnaire assessing physical activity level from 1 (low) to 10 (high) in patients undergoing hip or knee arthroplasty (HA/KA). After ...translation and cultural adaptation, we evaluated the measurement properties of the Danish UCLA.
Patients and methods - After dual panel translation, cognitive interviews were performed among 55 HA/KA patients. An orthopedic surgeon and a physiotherapist estimated UCLA scores for 80 KA patients based on short interviews. Measurement properties were evaluated in 130 HA and 134 KA patients preoperatively and 1-year postoperatively.
Results - To suit Danish patients of today, several adaptations were required. Prior to interviews, 4 patients were excluded, and 11 misinterpreted the answer options. Examiners rated the remaining 65 patients (mean age 67 years) 0.2-1.6 UCLA levels lower than patients themselves. The 130 HA and 134 KA patients (mean age 71/68 years) changed from 4.3 (SD 1.9)/4.5 (1.8) preoperatively to 6.6 (1.8)/6.2 (1.0) at 1-year follow-up. 103 (79%) HA and 89 (66%) KA patients reported increased activity. Effect sizes were large (1.2/0.96). Knee patients reaching minimal important change (MIC, ≥ 8 Oxford Knee Score points) had higher 1-year UCLA scores than patients not reaching MIC.
Interpretation - Original scale development was undocumented. Content validity was questionable, and there was discrepancy between patient and examiner estimates. UCLA appears valuable for measuring change in self-reported physical activity on a group level. 4 out of 5 HA patients and 2 out of 3 KA patients were more physically active 1 year after joint replacement surgery.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Limited data exists on the implementation process and safety of discharge on the day of surgery after primary hip and knee arthroplasty in a multicenter setting. We report our study protocol on the ...investigation of the feasibility, safety, and socioeconomic aspects following discharge on day of surgery after hip and knee arthroplasty across 8 fast-track centers.
This is a study protocol for a prospective cohort study on discharge on day of surgery from the Center for Fast-track Hip and Knee Replacement. The collaboration includes 8 centers covering 40% of the primary hip and knee arthroplasty procedures undertaken in Denmark. All patients scheduled for surgery are screened for eligibility using well-defined inclusion and exclusion criteria. Eligible patients fulfilling discharge criteria will be discharged on day of surgery. We expect to screen 9,000 patients annually. Duration and outcome: Patients will be enrolled over a 3-year period from September 2022 and reporting of results will run continuously until December 2025. We shall report the proportion of eligible patients and patients discharged on day of surgery as well as limiting factors. Readmissions and complications within 30 days are recorded with real-time follow-up by research staff. Furthermore, patient-reported information on willingness to repeat discharge on day of surgery, contacts with the healthcare system, complications, and workability is registered 30 days postoperatively. EQ-5D, Oxford Knee Score, and Oxford Hip Score are completed preoperatively and after 3 months and 1 year. Finally, outcome data will be used in the development of a prediction model for successful discharge on the day of surgery.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Length of hospital stay after hip and knee arthroplasty is about 1 day in Denmark with few patients discharged on the day of surgery. Hence, a protocol for multicenter implementation of discharge on ...day of surgery has been instituted. We aimed to describe the implementation of outpatient hip and knee arthroplasty in a multicenter public healthcare setting.
We performed a prospective multicenter study from 7 public hospitals across Denmark. Patients were screened using well-defined in- and exclusion criteria and were discharged on day of surgery when fulfilling functional discharge criteria. The study period was from September 2022 to February 2023 with variable start of implementation. Data from the same centers in a 6-month period before the COVID pandemic from July 2019 to December 2019 was used for baseline control.
Of 2,756 primary hip and knee arthroplasties, 37% (95% confidence interval CI 35-39) were eligible (range 21-50% in centers) and 52% (range 24-62%) of these were discharged on day of surgery. 21% (CI 20-23) of all patients (eligible and non-eligible) were discharged on day of surgery with a range of 10-31% within centers. This was an additional 15% (CI 13-17, P < 0.001) compared with patients discharged in the control period (6% in 2019).
We found it possible to perform outpatient hip and knee replacement in 21% of patients in a public healthcare setting, probably to be increased with further center experience.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
The bearings with the best survivorship for young patients with total hip arthroplasty (THA) should be identified. We compared hazard ratios (HR) of revision of primary stemmed cementless THAs with ...metal-on-metal (MoM), ceramic-on-ceramic (CoC), and ceramic-on-highly-crosslinked-polyethylene (CoXLP) with that of metal-on-highly-crosslinked-polyethylene (MoXLP) bearings in patients aged 20-55 years with primary osteoarthritis or childhood hip disorders.
From the Nordic Arthroplasty Register Association dataset we included 1,813 MoM, 3,615 CoC, 5,947 CoXLP, and 10,219 MoXLP THA in patients operated on between 2005 and 2017 in a prospective cohort study. We used the Kaplan-Meier estimator for THA survivorship and Cox regression to estimate HR of revision adjusted for confounders (including 95% confidence intervals CI). MoXLP was used as reference. HRs were calculated during 3 intervals (0-2, 2-7, and 7-13 years) to meet the assumption of proportional hazards.
Median follow-up was 5 years for MoXLP, 10 years for MoM, 6 years for CoC, and 4 years for CoXLP. 13-year Kaplan-Meier survival estimates were 95% (CI 94-95) for MoXLP, 82% (CI 80-84) for MoM, 93% (CI 92-95) for CoC, and 93% (CI 92-94) for CoXLP bearings. MoM had higher 2-7 and 7-13 years' adjusted HRs of revision (3.6, CI 2.3-5.7 and 4.1, CI 1.7-10). MoXLP, CoC, and CoXLP had similar HRs in all 3 periods. The 7-13-year adjusted HRs of revision of CoC and CoXLP were statistically non-significantly higher.
In young patients, MoXLP for primary cementless THA had higher revision-free survival and lower HR for revision than MoM bearings. Longer follow-up is needed to compare MoXLP, CoC, and CoXLP.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
ObjectiveTo examine the risk factors for new chronic opioid use in elderly patients who underwent hip fracture surgery.DesignProspective population-based cohort study.Setting and participantsUsing ...Danish nationwide health registries, we identified all opioid non-user patients aged ≥65 years who had undergone hip fracture surgery from 2005 to 2016 and were alive within the first year following surgery.Main outcome measuresNew chronic opioid use defined by the dispensing of at least two prescription opioids within two of the last three quarters during the first year following surgery.ResultsWe identified 37 202 opioid non-user patients who underwent hip fracture surgery. Of these, 5497 (15%) developed new chronic opioid user within 1 year of surgery. Risk factors for new chronic opioid use were Body Mass Index (BMI) of <18.5 (adjusted OR (aOR) 1.22, 95% CI 1.09 to 1.36), BMI of 25.0–29.9 (aOR 1.12, 95% CI 1.04 to 1.21) and BMI of ≥30 (aOR 1.57, 95% CI 1.40 to 1.76) with BMI 18.6–24.9 as reference, a pertrochanteric/subtrochanteric fracture (aOR 1.27, 95% CI 1.20 to 1.34) with femoral neck fracture as reference, preoperative use (vs no-use) of non-steroidal anti-inflammatory drug (aOR 1.68, 95% CI 1.55 to 1.83), selective serotonin reuptake inhibitor (aOR 1.42, 95% CI 1.32 to 1.53), antidepressants (aOR 1.36, 95% CI 1.24 to 1.49), antipsychotics (aOR 1.21, 95% CI 1.07 to 1.35), corticosteroids (aOR 1.54, 95% CI 1.35 to 1.76), statins (aOR 1.09, 95% CI 1.02 to 1.18), antibiotics (aOR 1.32, 95% CI 1.22 to 1.42), antiosteoporosis drugs (aOR 1.33, 95% CI 1.19 to 1.49) and anticoagulatives (aOR 1.24, 95% CI 1.17 to 1.32). Presence of cardiovascular comorbidities, diabetes, gastrointestinal diseases, dementia, chronic obstructive pulmonary disease or renal diseases was further identified as a risk factor.ConclusionIn this large nationwide cohort study, we identified several risk factors associated with new chronic opioid use after hip fracture surgery among patients who were alive within the first year following surgery. Although not all factors are modifiable preoperative, this will allow clinicians to appropriately counsel patients preoperatively and tailor postoperative treatment.
Patients receiving a total hip arthroplasty (THA) are subsequently at an increased risk of cardiovascular disease (CVD). Further, socioeconomic status (SES) has an effect on CVD. We evaluated whether ...low SES is associated with a higher risk of readmission due to CVD after THA within 90 days in a setting with universal tax-supported healthcare.
We performed a nationwide population-based cohort study using Danish health registries from 1995 to 2017. Individual-based information on SES markers (cohabitation, education, income, and liquid assets) was obtained for all participants. The outcome was any hospital-treated CVD. The data was transformed using the pseudo-observation method to enable an estimation of the adjusted risk ratios (RRs) with 95% confidence intervals (CI) for each marker using generalized linear regression.
Among 103,286 THA patients, 452 were hospitalized with CVD within 90 days after surgery. Low SES seemed to be associated with a small increased risk of CVD, as the RRs for any CVD were 1.1 (95% CI 0.7-1.7) for patients living alone vs. cohabiting, 1.3 (CI 0.7- .3) for low education vs. high, 1.4 (CI 0.8-2.6) for low income vs. high, and 1.3 (CI 0.8-2.1) for low liquid assets vs. high.
Living alone, low education, low income, and low liquid assets seem to be associated with a small increased risk of readmission due to CVD 90 days after THA. Wide confidence intervals in risk should be considered when interpreting the study results.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
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