Acta Orthopaedica最新文献

Background and purpose:  The use of spinal implants has increased substantially. Their widespread use raises public health concerns. We aimed to study spinal surgery trends in Italy from 2001 to 2019 and present a mapping for ICD9-CM codes potentially related to spinal diagnoses and procedures.

Methods:  ICD9-CM codes of interest were selected and mapped to clinically meaningful spinal diagnostic categories and procedure classes. The Italian National Hospital Discharge Records database was then browsed according to these codes. Surgical volumes and trends were described. Population incidence rates (IR) were estimated and provided with 95% confidence intervals (CI). Variations in IRs were reported in terms of incidence rate ratio. The statistical significance of counts and IR time series trends was assessed by using the Cox-Stuart test.

Results:  1,560,969 spinal procedures were extracted from 209,818,966 admissions registered nationally. The annual number of spinal procedures increased significantly by 67%, from 58,369 in 2001 to 97,636 in 2019 (P < 0.002). 1,040,326 (67%) procedures did not include implants, while 590,643 (33%) used implants, 395,450 (25%) associated with fusions and 125,193 (8%) with non-fusions. Population IRs increased from 100.9 (CI 100.1-101.7) to 163.2 (CI 162.2-164.3) episodes per 100,000 inhabitants. Surgical volumes for non-implant-related procedures remained stable, while implant-related procedures increased significantly, by 420% over the 19 observed years (P = 0.002).

Conclusion: Spinal surgical procedures and their population incidence rates increased significantly. Fusions and other implant-related procedures increased substantially for most diagnostic categories. An ICD9-CM mapping for spinal diagnoses and procedures as a reproducible tool for further explorations was presented.

Background and purpose:  Discharge on day of surgery after hip or knee arthroplasty is increasing, but whether this leads to an increase in the overall number of post-discharge healthcare system contacts is unknown. We aimed to investigate whether day-case surgery leads to increased patient-reported healthcare system contacts compared with non-day-case surgery within the first 30 days postoperatively.

Methods:  We performed a prospective multicenter study at seven fast-track centers from September 2022 to August 2023. Candidates for primary total hip arthroplasty (THA), total knee arthroplasty (TKA), or unicompartmental knee arthroplasty (UKA) were evaluated for day-case eligibility using pre-defined criteria. Patients received a survey 30 days postoperatively regarding any healthcare system contacts related to surgery. Planned healthcare visits were excluded. We used day-case eligible patients not discharged on day of surgery (inpatients) as control group.

Results:  Of 2,278 day-case eligible patients, 2,073 (91%) completed the survey, including 1,146 day-case patients (55%) and 927 inpatients (45%). The overall rate of healthcare system contacts was 49% (95% confidence interval [CI] 45-51) in day-case patients compared with 52% (CI 49-56) in inpatients. Specific contacts included visits to a general practitioner (GP) or out-of-hours medical clinic (25% [CI 22-27] vs 32% [CI 29-35]), the emergency department (ED) (6% [CI 4-7] vs 7% [CI 5-8]), and outpatient clinics or wards (35% [CI 33-38] vs 35% [CI 32-38]). The most common reasons for all types of healthcare contacts were wound problems, prescription renewals, and pain management.

Conclusion:  Day-case hip and knee arthroplasties was not associated with increased healthcare system contacts within the first 30 days postoperatively.

Background and purpose:  Information on metastatic spine disease (MSD) based on nationwide data on trends and postoperative survival is limited but is needed to optimize treatment in this population. We aimed to assess the incidence of and survival rates after MSD surgery.

Methods:  This retrospective nationwide register-based study combined data from the Finnish Cancer Registry, Finnish Care Register for Health Care, and the Finnish Cause of Death Register from 1997 to 2020. Surgeries were identified using diagnosis and procedural codes, with primary spine pathologies excluded. Incidence rates were calculated per 100,000 inhabitants and adjusted for age and sex. Survival analysis was conducted using the Kaplan-Meier estimator.

Results:  1,845 patients underwent 1,992 surgeries, with a mean age of 65 years; 58% were men. The most common primary cancers were prostate cancer (15.1%), breast cancer (11.6%), and myeloma (10.6%). The incidence of MSD surgery increased by 87%, from 1.05 to 1.97 per 100,000 person-years. Surgery increased most among patients aged 70-79 years. Over the same period, the 6-month survival remained fairly stable. The overall survival probabilities were 57% (95% confidence interval [CI] 54-59) at 1 year, 44% (CI 42-46) at 2 years, 28% (CI 26-30) at 5 years, and 18% (CI 16-20) at 10 years. The 1-year survival was highest in patients with breast cancer at 75% (CI 69-81) and lowest in patients with kidney cancer at 45% (CI 38-53) and prostate cancer at 47% (CI 42-53).

Conclusion:  Finnish nationwide data showed an increase in MSD surgery between 1997 and 2020 with a stable postoperative survival of 57% (CI 48-69) to 76% (CI 66-89) at 6 months.

Background and purpose:  Return to work (RTW) following primary total hip arthroplasty (THA) is important for patients and society. We aimed to investigate the association between markers of socioeconomic status (SES) and RTW after primary THA, and whether the association is influenced by sex, age, and comorbidity.

Methods:  Using Danish population-based registries we included 9,431 patients aged 18 to 59 years, undergoing primary THA for osteoarthritis from 2008-2018. Exposure was individual-level data on SES markers (education, income, and cohabitation). Work status information before and after THA was obtained from the Danish Register for Evaluation of Marginalization. We computed cumulative incidence of RTW up to 24 months after THA. The association between SES and RTW was analyzed using Cox regression by hazard ratios with 95% confidence intervals (CI).

Results:  The median time to RTW was 54 days. Cumulative incidence of RTW was 86% by 6 months and 93% by 24 months. The adjusted hazard ratio for RTW was 1.9 (CI 1.8-2.0) for high vs low education, 2.2 (CI 2.1-2.3) for high vs low income, and 1.3 (CI 1.3-1.4) for cohabiting vs living alone. Associations were stronger in male than female patients for all SES markers.

Conclusion:  Most patients returned to work within 24 months, with the largest proportion within 6 months. Markers of low SES were associated with delayed RTW, highlighting the importance of enhanced focus on THA patients in socially vulnerable positions to reduce health and financial implications of delayed RTW.

Background and purpose:  We primarily aimed to report the results of ulnar shortening osteotomy (USO) in cases of ulna impaction syndrome (UIS), and secondarily to assess the influence of etiology, radiographic parameters, and comorbidities on the outcome.

Methods:  Patients with USO performed for UIS between 2014 and 2022 at our department were included in the study. Demographic, surgical, and postoperative data, including complications and revisions, were recorded retrospectively. An additional study-specific follow-up was performed in all available cases, including subjective outcome measures as Patient Related Wrist Evaluation (PRWE) and Quick Disability of the Arm Shoulder and Hand (Quick-DASH) scores, and standardized 90-90° wrist radiographs.

Results:  47 patients were treated with USO at mean age 45.8 years (standard deviation [SD] 16.7); 28 were female; median follow-up was 37 months (interquartile range [IQR] 22-57). Isolated USO was performed in 27 cases; the rest received a combination of procedures, e.g., wrist arthroscopy. USO-specific devices were used in all cases. Reoperations were performed in 12 cases, with implant removal in 11. Postoperative complications such as chronic regional pain syndrome or pseudoarthrosis were detected in 9 patients. 29 patients were additionally examined at median 36 months (IQR 22-49) follow-up. A median PRWE score of 7 (IQR 0-19) and a median Quick-DASH score of 4.5 (IQR 0-15.9) were reported. The subjective improvement was rated as very high by 24 patients. Radiographs showed a mean ulnar shortening of 2.9 mm (SD 1.1) and bone consolidation was achieved in all osteotomies at last follow-up. Relevant comorbidities weakly correlated with worse outcome scores (ρ = 0.41, 95% confidence interval [CI] -0.05 to 0.74 for PRWE and ρ = 0.40, CI -0.06 to 0.73 for Quick-DASH). No statistically significant difference could be detected in any other variables, including UIS etiology.

Conclusion:  We found that USO had good subjective results measure scores, but with relatively high complication and revision rates, including implant removal.

Background and purpose:  Guidelines for systemic antibiotic prophylaxis (SAP) in arthroplasty surgery vary worldwide from repeated doses to only 1 preoperatively. We aimed to investigate, primarily whether 4 doses reduced the risk of PJI compared with 1 to 3 doses, and secondarily if there was a difference between types of antibiotics.

Methods:  Patients reported to the Norwegian Arthroplasty Register and the Norwegian Hip Fracture Register with primary total knee (TKA), total (THA) or hemi- (HA) hip arthroplasty between 2005 and 2023 were included. Cases with 1 to 4 doses of cefalotin (half-life = 45 minutes), cefazolin (90 minutes), cefuroxime (70 minutes), cloxacillin (30 minutes), or clindamycin (180 minutes) were assessed. Primary outcome was 1-year risk of reoperation (adjusted hazard rate ratio; aHRR) for PJI and was estimated by Cox regression analyses. Secondary outcomes were reoperation for PJI and reoperation for any cause with follow-up of up to 19 years. Non-inferiority analyses and propensity score matching with subsequent Kaplan-Meier analyses were performed with a predetermined non-inferiority margin of 15% (aHRR = 1.15).

Results:  301,204 cases were included. Of these, 3,388 (1.1%) were reoperated on for PJI within 1 year. The 1-year incidence of reoperation for PJI was 98/9,760 (1.0%) for 1 dose of SAP, 109/10,956 (0.9%) for 2 doses, 178/18,948 (0.9 %) for 3 doses, and 3,003/261,540 (1.0%) for 4 doses. The 1-year risk (aHRR, 95% confidence interval [CI]) of reoperation for PJI was 1.0 (CI 0.8-1.2), 0.9 (CI 0.8-1.2), and 0.9 (CI 0.9-1.1) for 1, 2, and 3 doses, respectively, compared with 4 doses. The 1-year incidence of reoperation for PJI was 2,162/183,964 (1.2%) for cefalotin, 993/91,159 (1.1%) for cefazolin, 35/4,435 (0.8%) for cefuroxime, 85/9,022 (0.9%) for cloxacillin, and 113/12,624 (0.9%) for clindamycin. Compared with cefazolin, cloxacillin (1.2, CI 1.0-1.6) and cefalotin (1.4, CI 1.2-1.5) had a higher risk of reoperation for PJI, whereas cefuroxime (1.0, CI 0.7-1.4) and clindamycin (1.1, CI 0.9-1.3) had a similar risk.

Conclusion:  4 doses of SAP did not reduce the risk of PJI compared with 1 to 3 doses in primary arthroplasty as measured against PJI. Cefazolin, the 1st-generation cephalosporin with the longest half-life, showed the lowest risk of PJI.

Background and purpose: Some patients do not improve after total shoulder arthroplasty (TSA), indicating different recovery trajectories. We aimed to identify recovery trajectories after TSA based on the Oxford Shoulder Score (OSS). Second, we investigated whether recovery trajectories were associated with patient or procedure characteristics.

Methods:  We included primary anatomical and reversed TSAs (ATSAs/RTSAs) for osteoarthritis (OA) or cuff arthropathy/rupture with preoperative, 3-month, and/or 12-month postoperative OSS, registered between 2016 and 2022 in the Dutch Arthroplasty Register (n = 3,358). We used latent class growth modeling (LCGM) to identify recovery patterns, and multinomial logistic regression analyses to investigate associations between potential risk factors and class membership (odds ratio [OR], 95% confidence interval [CI]).

Results:  We identified 3 recovery patterns: "Fast responders" (59%), "Steady responders" (27%), and "Poor responders" (14%). Factors associated with "Steady responders" vs "Fast responders" were female vs male sex (OR 2.0, CI 1.5-2.7), ASA III-IV vs ASA I (OR 1.9, CI 1.2-3.1), Walch A1 vs B2 (OR 1.6, CI 1.1-2.5), and most vs medium socioeconomic deprivation (OR 1.4, CI 1.1-1.9). Factors associated with "Poor responders" vs "Fast responders" were ASA II vs ASA I (OR 2.0, CI 1.1-3.6), ASA III-IV vs ASA I (OR 3.0, CI 1.6-5.5), Walch A1 vs B2 (OR 2.1, CI 1.3-3.3), previous shoulder surgeries (OR 1.8, CI 1.3-2.4), most vs medium socioeconomic deprivation (OR 1.5, CI 1.2-2.0), RTSA for OA vs ATSA for OA (OR 1.8, CI 1.2-2.7), and RTSA for cuff arthropathy or rupture vs ATSA for OA (OR 2.3, CI 1.5-3.4).

Conclusion:  3 recovery trajectories were identified following TSA, which we labelled as "Fast responders," "Steady responders," and "Poor responders." "Steady responders" and "Poor responders" were more likely to have higher ASA scores, a Walch A1 vs B2 classification, and greater vs medium socioeconomic deprivation than "Fast responders." Moreover, "Steady responders" were more likely to be female, while "Poor responders" were more likely to have previous shoulder surgeries and RTSA for OA or for cuff arthropathy or rupture than "Fast responders."

Background and purpose:  Previous studies have shown large variation in the incidence of ankle fractures. Nationwide data covering longer periods is necessary to gain knowledge of the current trends. The aim of this study was to describe the trends in incidence, treatment, and mortality of ankle fracture during a 20-year period.

Methods:  Ankle fractures in patients ≥ 18 years old were identified in the Danish National Patient Register using the validated diagnosis and surgical procedure codes for ankle fractures. Incidence rates per 100,000 and incidence rate ratio (IRR) are reported with 95% confidence intervals (CI).

Results:  We identified 155,740 ankle fractures. The overall mean incidence rate during the period 1997-2018 was 164 (CI 163-165) per 100,000 person-years, being 154 (CI 152-155) for men and 203 (CI 202-205) for women. The incidence rate increased from 155 (CI 131-179) during 1997-2006 to 173 (CI 147-199) during 2007-2018, corresponding to an IRR of 1.12 (CI 1.10-1.12). This increase was primarily driven by an increase in women, with an IRR of 1.21 (CI 1.20-1.23) and for patients above 50 years, with an IRR of 1.22 (CI 1.08-1.10). The proportion of patients surgically treated increased from 21% in 1997-2006 to 25% in 2007-2018. The 1-year mortality risk was higher for patients above 65 years with an ankle fracture compared with the general population of the same age, with an IRR of 1.47 (CI 1.42-1.53).

Conclusion:  The incidence of ankle fracture increased from 1997 to 2018, primarily due to an increased incidence in women and in the elderly population. The proportion of surgically treated patients increased from 21% to 26%. Excess mortality after ankle fracture in patients above 65 years was observed.

Background and purpose:  Periprosthetic knee fractures (PPKFs) can be a serious complication after total knee arthroplasty (TKA). We aimed to compare patient-reported outcome (PRO) scores reported between 1 and 4 years after PPKF with a matched uncomplicated TKA control group.

Methods:  This nationwide cross-sectional matched cohort study included 372 TKA patients with a PPKF occurring from 2019 to 2022 and a control group of 878 uncomplicated TKA patients matched by age, time since TKA, and sex. The study population was derived from the Danish National Patient Register. The patients received questionnaires regarding knee function, quality of life, pain and satisfaction in 2023. The questionnaires included Oxford Knee Score (OKS), the Forgotten Joint Score (FJS), and the EQ-5D-5L Index.

Results:  The response rate was 48%. Mean OKS was 7 (confidence interval [CI] 5-9) points lower after a PPKF with a score of 30 (standard deviation [SD] 11) in the PPKF group vs 37 (SD 11) in the control group. The FJS was 13 (CI 7-19) points lower after a PPKF with a score of 50 (SD 30) in the PPKF group vs 63 (SD 30) in the control group. Mean EQ-5D-5L Index scores were 0.17 (CI 0.12-0.22) lower after a PPKF with a score of 0.68 (SD 0.25) in the PPKF group vs 0.85 (SD 0.25) in the control group. Additional analysis of patients who completed PROMs 1-2 years compared with 3-4 years after PPKF showed better PRO scores after 3-4 years with an OKS of 32 (SD 12) vs 27 (SD 12), FJS 55 (SD 32) vs 43 (SD 32), and EQ-5D-5L Index of 0.74 (SD 0.34) vs 0.60 (SD 0.34).

Conclusion:  Following PPKF, patients reported worse knee function, more pain, lower satisfaction, and poorer quality of life than those with uncomplicated TKAs.

Background and purpose:  Documentation of new-generation implants' short-term performance could reassure surgeons and patients about their use, while awaiting the long-term outcome. Our aim was to compare the performance of a newer total knee arthroplasty (TKA) system with its predecessor, measured by patient-reported knee function, pain, and complication rate.

Methods: We performed a multi-center, randomized, controlled trial (clinicaltrials.gov ID: NCT03073941). 314 patients with primary osteoarthritis were randomized to treatment with a Persona or NexGen cruciate-retaining TKA system and followed for 2 years. The primary outcome was measured with the patient-reported outcome (PRO) Oxford Knee Score (OKS) 2 years post-surgery. Secondary outcomes were the OKS-Activity and Participation questionnaire (OKS-APQ), Forgotten Joint Score (FJS), EQ-5D-3L, and number of complications during the study period. Responder analyses were performed using Patient Acceptable Symptom State (PASS) and Minimal Important Change (MIC) criteria.

Results:  Primary outcome was available from 289 patients (92%). We found no difference in adjusted mean OKS between the groups 2 years post-surgery (0.1, 95% confidence interval -1.4 to 1.7). We found no significant differences in adjusted mean of secondary PROs, PRO time-weighted averages, proportion of patients with PASS or MIC, or complications 2 years post-surgery.

Conclusion:  We found no difference in OKS 2 years post-surgery, or in any secondary variables analyzed including complications, between the 2 TKA systems. Short-term safety and performance of the Persona TKA was comparable to its predecessor.