Obesity is a risk factor for atrial fibrillation. Whether weight reduction and cardiometabolic risk factor management can reduce the burden of atrial fibrillation is not known.
To determine the ...effect of weight reduction and management of cardiometabolic risk factors on atrial fibrillation burden and cardiac structure.
Single-center, partially blinded, randomized controlled study conducted between June 2010 and December 2011 in Adelaide, Australia, among overweight and obese ambulatory patients (N = 150) with symptomatic atrial fibrillation. Patients underwent a median of 15 months of follow-up.
Patients were randomized to weight management (intervention) or general lifestyle advice (control). Both groups underwent intensive management of cardiometabolic risk factors.
The primary outcomes were Atrial Fibrillation Severity Scale scores: symptom burden and symptom severity. Scores were measured every 3 months from baseline to 15 months. Secondary outcomes performed at baseline and 12 months were total atrial fibrillation episodes and cumulative duration measured by 7-day Holter, echocardiographic left atrial area, and interventricular septal thickness.
Of 248 patients screened, 150 were randomized (75 per group) and underwent follow-up. The intervention group showed a significantly greater reduction, compared with the control group, in weight (14.3 and 3.6 kg, respectively; P < .001) and in atrial fibrillation symptom burden scores (11.8 and 2.6 points, P < .001), symptom severity scores (8.4 and 1.7 points, P < .001), number of episodes (2.5 and no change, P = .01), and cumulative duration (692-minute decline and 419-minute increase, P = .002). Additionally, there was a reduction in interventricular septal thickness in the intervention and control groups (1.1 and 0.6 mm, P = .02) and left atrial area (3.5 and 1.9 cm2, P = .02).
In this study, weight reduction with intensive risk factor management resulted in a reduction in atrial fibrillation symptom burden and severity and in beneficial cardiac remodeling. These findings support therapy directed at weight and risk factors in the management of atrial fibrillation.
anzctr.org.au Identifier: ACTRN12610000497000.
Instability after total knee arthroplasty is a common but poorly understood complication.
Data from a large national registry was used to study patient and prosthesis characteristics of 2605 total ...knee arthroplasty revisions for instability. The cumulative percent revision was calculated using Kaplan-Meier estimates, and Cox proportional models used to compare revision rates. The rate of further revision was analyzed with regard to prostheses used in the first revision.
Instability increased from 6% of all first revision procedures in 2003 to 13% in 2019. The revision risk was lower for minimally stabilized prostheses, males, and patients aged ≥65 years. Polyethylene insert exchange was used for 55% of revision procedures, using a thicker insert in 93% and a change in insert conformity in 24% of cruciate-retaining knees. The increase in either thickness or conformity had no effect on the rate of further revision. After a revision for instability, 24% had a second revision by 14 years. Recurrent instability accounted for 32% of further revisions. A lower second revision rate was seen after revision of both femoral and tibial components, and where constrained components were used.
Revision for instability is increasing. Revising both femoral and tibial components led to a lower rate of second revision compared to a change in insert alone. Recurrent instability was common.
Joint arthroplasty registries traditionally report survivorship outcomes mainly on primary joint arthroplasty. The outcome of first revision procedures is less commonly reported, because large ...numbers of primary procedures are required to analyze a sufficient number of first revision procedures. Additionally, adequate linkage of primary procedures to revisions and mortality is required. When undertaking revision hip surgery, it is important for surgeons to understand the outcomes of these procedures to better inform patients.
Using data from a large national joint registry, we asked: (1) What is the overall rate of revision of the first aseptic revision procedure for a primary THA? (2) Does the rate of revision of the first revision vary by the diagnosis for the first revision? (3) What is the mortality after the first revision, and does it vary by the reason for first revision?
The Australian Orthopaedic Association National Joint Replacement Registry longitudinally maintains data on all primary and revision joint arthroplasties, with nearly 100% capture. The analyses for this study were performed on primary THA procedures in patients with a diagnosis of osteoarthritis up to December 31, 2020, who had undergone subsequent revision. We excluded all primary THAs involving metal-on-metal and ceramic-on-metal bearing surfaces and prostheses with exchangeable necks because these designs may have particular issues associated with revisions, such as extensive soft tissue destruction, that are not seen with conventional bearings, making a comparative analysis of the first revision involving these bearing surfaces more complicated. Metal-on-metal bearing surfaces have not been used in Australia since 2017. We identified 17,046 first revision procedures from the above study population and after exclusions, included 13,713 first revision procedures in the analyses. The mean age at the first revision was 71 ± 11 years, and 55% (7496 of 13,713) of the patients were women. The median (IQR) time from the primary procedure to the first revision was 3 years (0.3 to 7.3), ranging from 0.8 years for the diagnosis of dislocation and instability to 10 years for osteolysis. There was some variation depending on the reason for the first revision. For example, patients undergoing revision for fracture were slightly older (mean age 76 ± 11 years) and patients undergoing revision for dislocation were more likely to be women (61% 2213 of 3620). The registry has endeavored to standardize the sequence of revisions and uses a numerical approach to describe revision procedures. The first revision is the revision of a primary procedure, the second revision is the revision of the first revision, and so on. We therefore described the outcome of the first revision as the cumulative percent second revision. The outcome measure was the cumulative percent revision, which was defined using Kaplan-Meier estimates of survivorship to describe the time to the second revision. Hazard ratios from Cox proportional hazards models, adjusting for age and gender, were performed to compare the revision rates among groups. When possible, the cumulative percent second revision at the longest follow-up timepoint was determined with the available data, and when there were insufficient numbers, we used appropriate earlier time periods.
The cumulative percent second revision at 18 years was 26% (95% confidence interval CI 24% to 28%). When comparing the outcome of the first revision by reason, prosthesis dislocation or instability had the highest rate of second revision compared with the other reasons for first revision. Dual-mobility prostheses had a lower rate of second revision for dislocation or instability than head sizes 32 mm or smaller and when compared to constrained prostheses after 3 months. There was no difference between dual-mobility prostheses and head sizes larger than 32 mm. There were no differences in the rate of second revision when first revisions for loosening, periprosthetic fracture, and osteolysis were compared. If cemented femoral fixation was performed at the time of the first revision, there was a higher cumulative percent second revision for loosening than cementless fixation from 6 months to 6 years, and after this time, there was no difference. The overall mortality after a first revision of primary conventional THA was 1% at 30 days, 2% at 90 days, 5% at 1 year, and 40% at 10 years. A first revision for periprosthetic fracture had the highest mortality at all timepoints compared with other reasons for the first revision.
Larger head sizes and dual-mobility cups may help reduce further revisions for dislocation, and the use of cementless stems for a first revision for loosening seems advantageous. Surgeons may counsel patients about the higher risk of death after first revision procedures, particularly if the first revision is performed for periprosthetic fracture.Level of Evidence Level III, therapeutic study.
Vitamin B12 deficiency is prevalent in many countries of origin of refugees. Using a threshold of 5% above which a prevalence of low Vitamin B12 is indicative of a population health problem, we ...hypothesised that Vitamin B12 deficiency exceeds this threshold among newly-arrived refugees resettling in Australia, and is higher among women due to their increased risk of food insecurity. This paper reports Vitamin B12 levels in a large cohort of newly arrived refugees in five Australian states and territories.
In a cross-sectional descriptive study, we collected Vitamin B12, folate and haematological indices on all refugees (n = 916; response rate 94% of eligible population) who had been in Australia for less than one year, and attended one of the collaborating health services between July 2010 and July 2011.
16.5% of participants had Vitamin B12 deficiency (<150 pmol/L). One-third of participants from Iran and Bhutan, and one-quarter of participants from Afghanistan had Vitamin B12 deficiency. Contrary to our hypothesis, low Vitamin B12 levels were more prevalent in males than females. A higher prevalence of low Vitamin B12 was also reported in older age groups in some countries. The sensitivity of macrocytosis in detecting Vitamin B12 deficiency was only 4.6%.
Vitamin B12 deficiency is an important population health issue in newly-arrived refugees from many countries. All newly-arrived refugees should be tested for Vitamin B12 deficiency. Ongoing research should investigate causes, treatment, and ways to mitigate food insecurity, and the contribution of such measures to enhancing the health of the refugee communities.
Loss of glenoid fixation is a key factor affecting the survivorship of primary total shoulder arthroplasty (TSA). It is not known whether the lower revision rates associated with crosslinked ...polyethylene (XLPE) compared with those of non-XLPE identified in hip and knee arthroplasty apply to shoulder arthroplasty.
We used data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) to compare the revision rates of primary stemmed anatomic TSA using XLPE to procedures using non-XLPE. In patients receiving a primary stemmed anatomic TSA for osteoarthritis, we asked: (1) Does the rate of revision or reason for revision vary between XLPE and non-XLPE all-polyethylene glenoid components? (2) Is there any difference in the revision rate when XLPE is compared with non-XLPE across varying head sizes? (3) Is there any difference in survival among prosthesis combinations with all-polyethylene glenoid components when they are used with XLPE compared with non-XLPE?
Data were extracted from the AOANJRR from April 16, 2004, to December 31, 2020. The AOANJRR collects data on more than 97% of joint replacements performed in Australia. The study population included all primary, stemmed, anatomic TSA procedures performed for osteoarthritis using all-polyethylene glenoid components. Procedures were grouped into XLPE and non-XLPE bearing surfaces for comparison. Of the 10,102 primary stemmed anatomic TSAs in the analysis, 39% (3942 of 10,102) used XLPE and 61% (6160 of 10,102) used non-XLPE. There were no differences in age, gender, or follow-up between groups. Revision rates were determined using Kaplan-Meier estimates of survivorship to describe the time to the first revision, with censoring at the time of death or closure of the database at the time of analysis. Revision was defined as removal, replacement, or addition of any component of a joint replacement. The unadjusted cumulative percent revision after the primary arthroplasty (with 95% confidence intervals CIs) was calculated and compared using Cox proportional hazard models adjusted for age, gender, fixation, and surgeon volume. Further analyses were performed stratifying according to humeral head size, and a prosthesis-specific analysis adjusted for age and gender was also performed. This analysis was restricted to prosthesis combinations that were used at least 150 times, accounted for at least four revisions, had XLPE and non-XLPE options available, and had a minimum of 3 years of follow-up.
Non - XLPE had a higher risk of revision than XLPE after 1.5 years (HR 2.3 95% CI 1.6 to 3.1; p < 0.001). The cumulative percent revision at 12 years was 5% (95% CI 4% to 6%) for XLPE and 9% (95% CI 8% to 10%) for non-XLPE. There was no difference in the rate of revision for head sizes smaller than 44 mm. Non-XLPE had a higher rate of revision than XLPE for head sizes 44 to 50 mm after 2 years (HR 2.3 95% CI 1.5 to 3.6; p < 0.001) and for heads larger than 50 mm for the entire period (HR 2.2 95% CI 1.4 to 3.6; p < 0.001). Two prosthesis combinations fulfilled the inclusion criteria for the prosthesis-specific analysis. One had a higher risk of revision when used with non-XLPE compared with XLPE after 1.5 years (HR 3.7 95% CI 2.2 to 6.3; p < 0.001). For the second prosthesis combination, no difference was found in the rate of revision between the two groups.
These AOANJRR data demonstrate that noncrosslinked, all-polyethylene glenoid components have a higher revision rate compared with crosslinked, all-polyethylene glenoid components when used in stemmed anatomic TSA for osteoarthritis. As polyethylene type is likely an important determinant of revision risk, crosslinked polyethylene should be used when available, particularly for head sizes larger than 44 mm. Further studies will need to be undertaken after larger numbers of shoulder arthroplasties have been performed to determine whether this reduction in revision risk associated with XLPE bears true for all TSA designs.
Level III, therapeutic study.
Background
Obesity is a known risk factor for the development of hip osteoarthritis. The aim of this study was to investigate whether obesity is associated with the risk of undergoing total hip ...replacement (THR) in Australia.
Methods
A cohort study was conducted comparing data from the Australian Bureau of Statistics and the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from 2017 to 2018. Body mass index (BMI) data for patients undergoing primary total hip replacement and resurfacing for osteoarthritis were obtained from the AOANJRR. The distribution of THR patients by BMI category was compared to the general population, in age and sex sub‐groups.
Results
During the study period, 32 495 primary THR were performed for osteoarthritis in Australia. Compared to the general population, there was a higher prevalence of Class I, II and III obesity in patients undergoing THR in both sexes aged 35–74 years. Class III obese females and males aged 55–64 years were 2.9 and 1.7 times more likely to undergo THR, respectively (P < 0.001). Class III obese females and males underwent THR on average 5.7 and 7.0 years younger than their normal weight counterparts, respectively.
Conclusion
Obese Australians are at increased risk of undergoing THR, and at a younger age.
Obese Australians are at increased risk of undergoing total hip replacement, and at a younger age. These findings have significant implications for future healthcare planning and education.
Patients who have kidney failure are at higher risk of requiring total hip arthroplasty (THA) and are at higher risk of complications. This study compared the rate of revision surgery and mortality ...following THA between patients who have kidney failure receiving long term dialysis or who had a kidney transplant and those who did not have kidney failure.
A data linkage study was performed using data from 2 national registries: a registry of dialysis and kidney transplant patients and a registry of THA procedures. Both registries had coverage of almost all procedures or treatments in Australia. Data from September 1999 to December 2016 were used. Mortality and revision surgery were compared between patients receiving dialysis, those who had a functioning kidney transplant, and patients who did not have kidney failure using Cox and Fine-Gray (competing risk) regression models. A total of 383,478 primary THA procedures were identified as people receiving dialysis (n = 490), who had a functioning kidney transplant (n = 459), or who did not have kidney failure (n = 382,529).
There was no significant difference in the overall rate of revision surgery between the groups (dialysis versus no kidney failure HR = 1.20; 95% CI 0.76, 1.88, transplant versus no kidney failure (hazard ratio) HR = 1.01; 95% (confidence interval) CI 0.66, 1.53). The risk for death after surgery was significantly higher in the dialysis group compared to both the functioning transplant group (HR = 3.44; 95%CI 1.58, 7.5), and in those without kidney failure (HR = 4.13; 95%CI 3.25, 5.25).
The rate of mortality after THA in patients on dialysis is higher than in patients who have a functioning transplant or those who do not have kidney failure, but there is no early excess mortality to suggest a difference in this metric due to the surgery.
The aim of this study was to examine the incidence of overweight and obesity in patients undergoing primary total shoulder arthroplasty (TSA) for osteoarthritis (OA) in Australia compared to the ...incidence of obesity in the general population.
A 2017/18 cohort consisting of 2997 patients from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) who underwent TSA were compared with matched controls from the Australian Bureau of Statistics (ABS) National Health Survey from the same time period. The 2 groups were analyzed according to body mass index (BMI) category, sex, and age.
According to the 2017/18 National Health Survey, 35.6% of Australian adults were overweight and 31.3% were obese. Of the primary TSA cases performed, 34.9% were overweight and 50.1% were obese. The relative risk of requiring TSA for OA increased with increasing BMI category. Class III obese females, aged 55-64, were 8.6 times more likely to receive a TSA compared to their normal weight counterparts. Males in the same age and BMI category were 2.5 times more likely. Class III obese patients underwent TSA 4 years (female) and 6 years (male) younger than their normal weight counterparts.
Obesity significantly increases the risk of requiring TSA. The association appears to be particularly strong for younger females.
Background
Total hip replacement (THR) and total knee replacement (TKR) are cost‐effective interventions to reduce pain and disability associated with osteoarthritis, however there is no clear ...guidelines available to determine appropriate patient selection and the timing of surgery. This prospective cohort study aimed to evaluate the hospital‐ and surgeon‐level variation in the severity of patient‐reported symptoms prior to THR and TKR.
Methods
Patients undergoing primary THR (n = 4330) or TKR (n = 7054) for osteoarthritis who participated in a national registry‐led Patient Reported Outcome Measures (PROMs) pilot program were included in the analysis. Pre‐operative Oxford Hip Score (OHS) and Oxford Knee Score (OKS) (range 0–48; representing worst to best hip/knee pain and function) data were examined for variation between private and public hospitals and between surgeons using linear mixed models.
Results
Pre‐operative mean OHS was significantly higher (better) in patients whose surgery was performed in a private hospital compared to public hospitals; 21.39 versus 18.11 (mean difference 3.27, 95% CI 1.75, 4.79). For OKS, the difference between private hospital and public hospital scores was dependent on BMI and gender. Most of the variation in pre‐operative OHS and OKS was not at the individual hospital‐ or surgeon‐level, which explained only a negligible proportion of the model variance (⟨5%) for THR and TKR.
Conclusion
Apart from a difference between private and public hospitals, there was little between‐hospital or between‐surgeon symptom variation in joint‐specific pain and function prior to THR or TKR. The findings suggest consistency in the surgical thresholds for patients being offered hip and knee joint replacement procedures.
This study evaluated the hospital‐ and surgeon‐level variation in the severity of patient‐reported symptoms prior to total hip and total knee replacement surgery and found only negligible between‐surgeon variation in symptom severity, but significant differences between public and private hospital settings. These data indicate that surgeons are applying consistent surgical thresholds to hip and knee joint replacement patients. Threshold differences between public and private hospitals may reflect under‐ or over‐treatment and differences in access to care in these settings.
Abstract Background Dislocation is a leading cause of revision after primary total hip arthroplasty (THA). While more common in the first few years post procedure, dislocation can occur at any time. ...This study investigated the difference in late dislocation in ceramic on ceramic bearings compared to metal on polyethylene and ceramic on polyethylene bearings in THA. Methods Data was used from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the cumulative percent revision (CPR) for dislocation was estimated using the Kaplan-Meier method for the different bearing surfaces. There were 192,275 THA included in the study with 101,915 metal on cross linked polyethylene (MoXLPE), 30,256 ceramic on cross linked polyethylene (CoXLPE), and 60,104 ceramic on ceramic (CoC). Results The CPR for dislocation at 13 years for MoXLPE, CoXLPE and CoC groups was 1.2 (95% CI 1.1- 1.3), 1.0 (95% CI 0.7- 1.4) and 0.9 (95% CI 0.8-1.1) respectively. There was an increased risk of revision for dislocation for MoXLPE compared to CoXLPE and CoC. When stratified for head size there was no difference in the risk of revision for dislocation between MoXLPE, CoXLPE and CoC in the 28mm and 32mm head sizes. With head sizes 36mm, MoXLPE had a higher rate of dislocation compared to other materials. Conclusion Bearing surface has little impact on revision for dislocation.
PDF
