Computer navigation for total knee arthroplasty has improved alignment compared with that resulting from non-navigated total knee arthroplasty. This study analyzed data from the Australian ...Orthopaedic Association National Joint Replacement Registry to examine the effect of computer navigation on the rate of revision of primary total knee arthroplasty.
The cumulative percent revision following all non-navigated and navigated primary total knee arthroplasties performed in Australia from January 1, 2003, to December 31, 2012, was assessed. In addition, the type of and reason for revision as well as the effect of age, surgeon volume, and use of cement for the prosthesis were examined. Kaplan-Meier estimates of survivorship were used to describe the time to first revision. Hazard ratios (HRs) from Cox proportional hazards models, with adjustment for age and sex, were used to compare revision rates.
Computer navigation was used in 44,573 (14.1% of all) primary total knee arthroplasties, and the rate of its use increased from 2.4% in 2003 to 22.8% in 2012. Overall, the cumulative percent revision following non-navigated total knee arthroplasty at nine years was 5.2% (95% confidence interval CI = 5.1 to 5.4) compared with 4.6% (95% CI = 4.2 to 5.1) for computer-navigated total knee arthroplasty (HR = 1.05 95% CI = 0.98 to 1.12, p = 0.15). There was a significant difference in the rate of revision following non-navigated total knee arthroplasty compared with that following navigated total knee arthroplasty for younger patients (HR = 1.13 95% CI = 1.03 to 1.25, p = 0.011). Patients less than sixty-five years of age who had undergone non-navigated total knee arthroplasty had a cumulative percent revision of 7.8% (95% CI = 7.5 to 8.2) at nine years compared with 6.3% (95% CI = 5.5 to 7.3) for those who had undergone navigated total knee arthroplasty. Computer navigation led to a significant reduction in the rate of revision due to loosening/lysis (HR = 1.38 95% CI = 1.13 to 1.67, p = 0.001), which is the most common reason for revision of total knee arthroplasty.
Computer navigation reduced the overall rate of revision and the rate revision for loosening/lysis following total knee arthroplasty in patients less than sixty-five years of age.
There is ongoing debate concerning the best method of femoral fixation in older patients receiving primary THA. Clinical studies have shown high survivorship for cemented and cementless femoral ...stems. Arthroplasty registry studies, however, have universally shown that cementless stems are associated with a higher rate of revision in this patient population. It is unclear if the difference in revision rate is a reflection of the range of implants being used for these procedures rather than the mode of fixation.
(1) Is the risk of revision higher in patients older than 75 years of age who receive one of the three cementless stems with the highest overall survivorship in the registry than in those of that age who received one of the three best-performing cemented stems? If so, is there a difference in risk of early revision versus late revision, defined as revision within 1 month after index surgery? (2) Are there any diagnoses (such as osteoarthritis OA or femoral neck hip fracture) in which the three best-performing cementless stems had better survivorship than one of the three best-performing cementless stems? (3) Do these findings change when evaluated by patient sex?
The Australian Orthopaedic Association National Joint Replacement Registry data were used to identify the best three cemented and the best three cementless femoral stems. The criteria for selection were the lowest 10-year revision rate and use in > 1000 procedures in this age group of patients regardless of primary diagnosis. The outcome measure was time to first revision using Kaplan-Meier estimates of survivorship. Comparisons were made for THAs done for any reason and then specifically for OA and femoral neck fracture separately.
Overall, the cumulative percent revision in the first 3 months postoperatively was lower among those treated with one of the three best-performing cemented stems than those treated with one of the three best-performing cementless stems (hazard ratio HR for best three cementless versus best three cemented = 3.47 95% confidence interval {CI}, 1.60-7.53, p = 0.001). Early revision was 9.14 times more common in the best three cementless stems than in the best three cemented stems (95% CI, 5.54-15.06, p = 0.001). Likewise, among patients with OA and femoral neck fracture, the cumulative percent revision was consistently higher at 1 month postoperatively among those treated with one of the three best-performing cementless stems than those treated with one of the three best-performing cementless stems (OA: HR for best three cementless versus best three cemented = 8.82 95% CI, 5.08-15.31, p < 0.001; hip fracture: HR for best 3 cementless versus best three cemented = 27.78 95% CI, 1.39-143.3, p < 0.001). Overall, the cumulative percent revision was lower in the three best cemented stem group than the three best cementless stem group for both males and females at 1 month postoperatively (male: HR = 0.42 95% CI, 0.20-0.92, p = 0.030; female: HR = 0.06 95% CI, 0.03-0.10, p < 0.001) and for females at 3 months postoperatively (HR = 0.15 95% CI, 0.06-0.33, p < 0.001), after which there was no difference.
Cementless femoral stem fixation in patients 75 years or older is associated with a higher early rate of revision, even when only the best-performing prostheses used in patients in this age group were compared. Based on this review of registry data, it would seem important to ensure the proper training of contemporary cementing techniques for the next generation of arthroplasty surgeons so they are able to use this option when required. However, the absence of a difference in the two groups undergoing THA after 3 months suggests that there can be a role for cementless implants in selected cases, depending on the surgeon's expertise and the quality and shape of the proximal femoral bone.
Level III, therapeutic study.
Abstract Background Opioids are commonly used for the management of preoperative and postoperative pain among patients undergoing total knee arthroplasty (TKA). There is limited literature on the ...chronic use of opioids pre-TKA and post-TKA. The aim of this study was to characterize the use of opioids in TKA patients before and after surgery and identify risk factors of chronic opioid use. Methods Opioid use among 15,020 patients undergoing TKA (01/01/2001-31/12/2012) was examined. Generalized estimating equations assessed change in total oral morphine equivalents pre-TKA and post-TKA, and logistic regression estimated risk factors of chronic opioid use. Results Of the total sample, 7782 (52.0%) patients had at least 1 opioid (38.6% pre-TKA and 34.4% post-TKA). The most commonly prescribed opioids were oxycodone, codeine + acetaminophen, and tramadol. Pre-TKA, 720 (4.8%) patients were chronic opioid users, of which 241 (33.5%) stopped being chronic users after surgery and 479 (66.5%) continued but had a 16% reduction (incidence rate ratio = 0.84; 95% confidence interval, 0.78-0.90) in total oral morphine equivalents. Of the 5077 (33.8%) occasional opioid user pre-TKA, 2407 (47.4%) stopped after surgery. Compared to nonopioid users, chronic users were younger, were female, had more comorbidity, and had longer hospital stays. Older age was associated with ceasing chronic opioid use post-TKA. Conclusion There was a reduction in opioid use following TKA. Almost 50% of occasional users and more than 30% of chronic users pre-TKA ceased opioids postoperatively. There was a reduction in use for those chronic users who continued to take opioids postsurgery.
Studies have identified increased cancer risk among patients undergoing total hip arthroplasty (THA) compared to the general population. However, evidence of all-cause and site-specific cancer risk ...associated with different bearing surfaces has varied, with previous studies having short latency periods with respect to use of modern Metal-on-Metal (MoM) bearings. Using the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) linked to Australasian Association of Cancer Registries data, our aim was to evaluate risk of all-cause and site-specific cancer according to bearing surfaces in patients undergoing THA for osteoarthritis and whether risk increased with MoM bearings.
Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated by comparing number of observed cancer cases to expected number based on incidence rate in the Australian population. All-cause and site-specific cancer rates were calculated for all conventional stemmed THA (csTHA) and resurfacing THA (rsTHA) procedures performed for osteoarthritis. Cox proportional hazards models were used to compare cancer rates for MoM, ceramic-on-ceramic (CoC) and resurfacing procedures with a comparison group comprising metal-on-polyethylene (MoP) or ceramic-on-polyethylene (CoP) procedures.
There were 156,516 patients with csTHA procedures and 11,321 with rsTHA procedures for osteoarthritis performed between 1999 and 2012. Incidence of all-cause cancer was significantly higher for csTHA (SIR 1.24, 95% CI 1.22-1.26) and rsTHA (SIR 1.74, 95% CI 1.39-2.04) compared to the Australian population. For csTHA, there was no significant difference in all-site cancer rates for MoM (Hazard Ratio (HR) 1.01, 95%CI 0.96-1.07) or CoC (HR 0.98, 95%CI 0.94-1.02) compared to MoP and CoP bearings. Significantly increased risk of melanoma, non-Hodgkins lymphoma, myeloma, leukaemia, prostate, colon, bladder and kidney cancer was found for csTHA and, prostate cancer, melanoma for rsTHA procedures when compared to the Australian population, although risk was not significantly different across bearing surfaces.
csTHA and rsTHA procedures were associated with increased cancer incidence compared to the Australian population. However, no excess risk was observed for MoM or CoC procedures compared to other bearing surfaces.
Abstract Although deep surgical site infection (SSI) is a major complication of primary total hip arthroplasty (THA), there are conflicting data regarding the incidence of deep SSI, and no ...comprehensive evaluation of the associated risk factors has been undertaken. We performed a systematic review of the literature; undertaking computer-aided searches of electronic databases, assessment of methodological quality, and a best-evidence synthesis. The incidence of SSI ranged from 0.2% before discharge to 1.1% for the period up to and including 5 years post surgery. Greater severity of a pre-existing illness and a longer duration of surgery were found to be independent risk factors for deep SSI. There is a need for high-quality, prospective studies to further identify modifiable risk factors for deep SSI after THA.
Background Patient-reported outcome measures (PROMs) are commonly used to evaluate surgical outcome in patients undergoing joint replacement surgery, however routine collection from the target ...population is often incomplete. Representative samples are required to allow inference from the sample to the population. Although higher capture rates are desired, the extent to which this improves the representativeness of the sample is not known. We aimed to measure the representativeness of data collected using an electronic PROMs capture system with or without telephone call follow up, and any differences in PROMS reporting between electronic and telephone call follow up. Methods Data from a pilot PROMs program within a large national joint replacement registry were examined. Telephone call follow up was used for people that failed to respond electronically. Data were collected pre-operatively and at 6 months post-operatively. Responding groups (either electronic only or electronic plus telephone call follow up) were compared to non-responders based on patient characteristics (joint replaced, bilaterality, age, sex, American Society of Anesthesiologist (ASA) score and Body Mass Index (BMI)) using chi squared test or ANOVA, and PROMs for the two responder groups were compared using generalised linear models adjusted for age and sex. The analysis was restricted to those undergoing primary elective hip, knee or shoulder replacement for osteoarthritis. Results Pre-operatively, 73.2% of patients responded electronically and telephone follow-up of non-responders increased this to 91.4%. Pre-operatively, patients responding electronically, compared to all others, were on average younger, more likely to be female, and healthier (lower ASA score). Similar differences were found when telephone follow up was included in the responding group. There were little (if any) differences in the post-operative comparisons, where electronic responders were on average one year younger and were more likely to have a lower ASA score compared to those not responding electronically, but there was no significant difference in sex or BMI. PROMs were similar between those reporting electronically and those reporting by telephone. Conclusion Patients undergoing total joint replacement who provide direct electronic PROMs data are younger, healthier and more likely to be female than non-responders, but these differences are small, particularly for post-operative data collection. The addition of telephone call follow up to electronic contact does not provide a more representative sample. Electronic-only follow up of patients undergoing joint replacement provides a satisfactory representation of the population invited to participate.
ObjectivesTo determine chronic opioid use pre-THA (total hip arthroplasty) and post-THA, and risk factors for persistent or new chronic opioid use post-THA.DesignRetrospective cohort ...study.SettingAustralian Government Department of Veterans' Affairs health claims database.Participants9525 patients who had an elective unilateral THA between 1/01/2001 and 12/31/2012.Primary outcome measureChronic opioid use. Defined as 90 days of continuous opioid use or 120 days of non-continuous use.ResultsPre-THA, 6.2% (n=593) of patients were chronic users, while 5.2% (n=492) were post-THA. Among the 492 postoperative chronic users, 302 (61%) were chronic users pre-THA and post-THA and 190 (39%) became new chronic users after surgery. Risk factors for persistent chronic use were younger age (OR=0.96, 95% CI 0.93 to 0.99/1-year increment), back pain (OR=1.99, 95% CI 1.20 to 3.23), diabetes (OR=3.52, 95% CI 1.05 to 11.8), hypnotics use (OR=2.52, 95% CI 1.48 to 4.30) and higher pre-THA opioid exposure (compared with opioid use for 94–157 days, 157–224 days (OR=3.75, 95% CI 2.28 to 6.18), 225+ days (OR=5.18, 95% CI 2.92 to 9.19). Risk factors for new chronic opioid use post-THA were being a woman (OR=1.40, 95% CI 1.00 to 1.96), back pain (OR=3.90, 95% CI 2.85 to 5.33), depression (OR=1.70, 95% CI 1.20 to 2.41), gastric acid disease (OR=1.62, 95% CI 1.16 to 2.25), migraine (OR=5.11, 95% CI 1.08 to 24.18), liver disease (OR=4.33, 95% CI 1.08 to 17.35), weight loss (OR=2.60, 95% CI 1.06 to 6.39), dementia (OR=2.19, 95% CI 1.04 to 4.61), hyperlipidaemia (OR=1.38, 95% CI 1.00 to 1.91), hypnotics (OR=1.56, 95% CI 1.13 to 2.16) and antineuropathic pain medication use (OR=3.11, 95% CI 2.05 to 4.72).ConclusionsPatients undergoing THA are exposed to opioids for long periods of time, putting them at high risk of harm related to opioid use. We identified groups at risk of chronic opioid use, including younger patients and women, as well as modifiable risk factors of chronic opioid use, including level of opioid exposure presurgery and hypnotic use. These indicators of chronic opioid use can be used by clinicians to target patient groups for suitable pain management interventions.
Long-term implant survivorship in THA and TKA involves a combination of factors related to the patient, the implants used, and the decision-making and technical performance of the surgeon. It is ...unclear which of these factors is the most important in reducing the proportion of revision surgery.
We used data from a large national registry to ask: In patients receiving primary THA and TKA for a diagnosis of osteoarthritis, do (1) the reasons for revision and (2) patient factors, the implants used, and the surgeon or surgical factors differ between surgeons performing THA and TKA who have a lower revision rate compared with all other surgeons?
Data were analyzed for all THA and TKA procedures performed for a diagnosis of osteoarthritis from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from September 1, 1999, when collection began, to December 31, 2018. The AOANJRR obtains data on more than 98% of joint arthroplasties performed in Australia. The 5-year cumulative percent revision (CPR) was identified for all THAs and TKAs performed for a diagnosis of osteoarthritis with 95% confidence intervals (overall CPR); the 5-year CPR with 95% CIs for each surgeon was calculated for THA and TKA separately. For surgeons to be included in the analysis, they had to have performed at least 50 procedures and have a 5-year CPR. The 5-year CPR with 95% CIs for each THA and TKA surgeon was compared with the overall CPR. Two groups were defined: low revision rate surgeons (the upper confidence level for a given surgeon at 5 years is less than 3.84% for THA and 4.32% for TKA), and all other surgeons (any surgeon whose CPR was higher than those thresholds). The thresholds were determined by setting a cutoff at 20% above the upper confidence level for that class. The approach we used to define a low revision rate surgeon was similar to that used by the AOANJRR for determining the better-performing prostheses and is recommended by the International Prosthesis Benchmarking Working Group. By defining the groups in this way, a significant difference between these two groups is created. Determining a reason for this difference is the purpose of presenting the proportions of different factors within each group. The study group for THA included 116 low revision rate surgeons, who performed 88,392 procedures (1619 revised, 10-year CPR 2.7% 95% CI 2.6% to 2.9%) and 433 other surgeons, who performed 170,094 procedures (6911 revised, 10-year CPR 5.9% 95% CI 5.7% to 6.0%). The study group for TKA consisted of 144 low revision rate surgeons, who performed 159,961 procedures (2722 revised, 10-year CPR 2.6% 95% CI 2.5% to 2.8%) and 534 other surgeons, who performed 287,232 procedures (12,617 revised, 10-year CPR 6.4% 95% CI 6.3% to 6.6%). These groups were defined a priori by their rate of revision, and the purpose of this study was to explore potential reasons for this observed difference.
For THA, the difference in overall revision rate between low revision rate surgeons and other surgeons was driven mainly by fewer revisions for dislocation, followed by component loosening and fracture in patients treated by low revision rate surgeons. For TKA, the difference in overall revision rate between low revision rate surgeons and other surgeons was driven mainly by fewer revisions for aseptic loosening, followed by instability and patellofemoral complications in patients treated by low revision rate surgeons. Patient-related factors were generally similar between low revision rate surgeons and other surgeons for both THA and TKA. Regarding THA, there were differences in implant factors, with low revision rate surgeons using fewer types of implants that have been identified as having a higher-than-anticipated rate of revision within the AOANJRR. Low revision rate surgeons used a higher proportion of hybrid fixation, although cementless fixation remained the most common choice. For surgeon factors, low revision rate surgeons were more likely to perform more than 100 THA procedures per year, while other surgeons were more likely to perform fewer than 50 THA procedures per year. In general, the groups of surgeons (low revision rate surgeons and other surgeons) differed less in terms of years of surgical experience than they did in terms of the number of cases they performed each year, although low revision rate surgeons, on average, had more years of experience and performed more cases per year. Regarding TKA, there were more differences in implant factors than with THA, with low revision rate surgeons more frequently performing patellar resurfacing, using an AOANJRR-identified best-performing prosthesis combination (with the lowest rates of revision), using fewer implants that have been identified as having a higher-than-anticipated rate of revision within the AOANJRR, using highly crosslinked polyethylene, and using a higher proportion of cemented fixation compared with other surgeons. For surgeon factors, low revision rate surgeons were more likely to perform more than 100 TKA procedures per year, whereas all other surgeons were more likely to perform fewer than 50 procedures per year. Again, generally, the groups of surgeons (low revision rate surgeons and other surgeons) differed less in terms of years of surgical experience than they did in terms of the number of cases they performed annually, although low revision rate surgeons, on average, had more years of experience and performed more cases per year.
THAs and TKAs performed by surgeons with the lowest revision rates in Australia show reductions in all of the leading causes of revision for both THA and TKA, in particular, causes of revision related to the technical performance of these procedures. Patient factors were similar between low revision rate surgeons and all other surgeons for both THA and TKA. Low revision rate THA surgeons were more likely to use cement fixation selectively. Low revision rate TKA surgeons were more likely to use patella resurfacing, crosslinked polyethylene, and cemented fixation. Low revision rate THA and TKA surgeons were more likely to use an AOANJRR-identified best-performing prosthesis combination and to use fewer implants identified by the AOANJRR as having a higher-than-anticipated revision rate. To reduce the rate of revision THA and TKA, surgeons should consider addressing modifiable factors related to implant selection. Future research should identify surgeon factors beyond annual case volume that are important to improving implant survivorship.
Level III, therapeutic study.
Background
The incidence of joint arthroplasty is increasing worldwide. International estimates of future demand for joint arthroplasty have used models that propose either an exponential future ...increase, despite obvious system constraints, or static increases, which do not account for past trends. Country-specific projection estimates that address limitations of past projections are necessary. In Australia, a high-income country with the 7th highest incidence of TKA and 15th highest incidence of THA of the Organization for Economic Cooperation and Development (OECD) countries, the volume of TKAs and THAs increased 198% between 1994 and 2014.
Questions/purpose
To determine the projected incidence and volume of primary TKAs and THAs from 2014 to 2046 in the Australian population older than 40 years.
Methods
Australian State and Territory Health Department data were used to identify TKAs and THAs performed between 1994 and 1995 and 2013 and 2014. The Australian Bureau of Statistics was the source of the population estimates for the same periods and population-projected estimates until 2046. The incidence rate (IR), 95% CI, and prediction interval (PI) of TKAs and THAs per 100,000 Australian citizens older than 40 years were calculated. Future IRs were estimated using a logistic model, and volume was calculated from projected IR and population. The logistic growth model assumes the existence of an upper limit of the TKA and THA incidences and a growth rate directly related to this incidence. At the beginning, when the observed incidence is much lower than the asymptote, the increase is exponential, but it decreases as it approaches the upper limit.
Results
A 66% increase in the IR of primary THAs between 2013 and 2046 is projected for Australia (2013: IR = 307 per 100,000, 95% CI, 262-329 per 100,000 compared with 2046: IR= 510 per 100,000, 95% PI, 98-567 per 100,000), which translates to a 219% increase in the volume during this period. For TKAs the IR is expected to increase by 26% by 2046 (IR = 575 per 100,000; 95% PI, 402-717 per 100,000) compared with 2013 (IR = 437 per 100,000; 95% CI, 397-479 per 100,000) and the volume to increase by 142%.
Conclusion
A large increase in the volume of arthroplasties is expected using a conservative projection model that accounts for past surgical trends and future population changes in Australia. These findings have international implications, as they show that using country- specific, conservative projection approaches, a substantial increase in the number of these procedures is expected. This increase in joint arthroplasty volume will require appropriate workforce planning, resource allocation, and budget planning so that demand can be met.
Level of Evidence
Level II, economic and decision analysis.
Background and purpose - The increase in shoulder arthroplasty may lead to a burden of revision surgery. This study compared the rate of (2nd) revision following aseptic 1st revision shoulder ...arthroplasty, considering the type of primary, and the class and type of the revision.
Patients and methods - All aseptic 1st revisions of primary total reverse shoulder arthroplasty (rTSA group) and of primary total stemmed and stemless total shoulder arthroplasty (non-rTSA group) procedures reported to our national registry between April 2004 to December 2018 were included. The rate of 2nd revision was determined using Kaplan-Meier estimates and comparisons were made using Cox proportional hazards models.
Results - There was an increased risk of 2nd revision in the 1st month only for the rTSA group (n = 700) compared with the non-rTSA group (n = 991); hazard ratio (HR) = 4.8 (95% CI 2.2-9). The cumulative percentage of 2nd revisions (CPR) was 24% in the rTSA group and 20% in the non-rTSA group at 8 years. There was an increased risk of 2nd revision for the type (cup vs. head) HR = 2.2 (CI 1.2-4.2), but not class of revision for the rTSA group. Minor (> 3 months) vs. major class revision, and humeral revision vs. all other revision types were second revision risk factors for the non-rTSA group.
Interpretation - The CPR of revision shoulder arthroplasty was > 20% at 8 years and was influenced by the type of primary, the class, and the type of revision. The most common reasons for 2nd revision were instability/dislocation, loosening, and infection.
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