Acta Orthopaedica最新文献

Background and purpose:  National joint arthroplasty registries are the gold standard for monitoring long-term acetabular implant survivorship. Sensitive radiographic surveillance (SRS) has been recommended as a complementary surveillance approach, but no study has investigated whether implants introduced with no sensitive radiographic surveillance (NSRS) are associated with higher revision rates. Therefore, we investigated whether acetabular implants with NSRS are associated with higher revision rates than those with SRS.

Methods:  Acetabular implants with SRS were defined as those with published evidence of stability measurements assessed using either radiostereometric analysis or "Ein Bild Röntgen Analyse." Evidence of SRS of acetabular implant designs was sourced from 2 literature reviews. A mixed-effects model was used to pool and compare the revision rate of acetabular implants with SRS and NSRS at 5 and 10 years from 5 arthroplasty registries.

Results:  There were 29 unique acetabular implant designs with SRS and 86 designs with NSRS that had matching 5- and 10-year revision rates. At 5 years, there was a mean difference of 0.8% (95% confidence interval [CI] 0.5-1.1) in mean all-cause revision rates favoring implants with SRS. Mean all-cause revision rates at 10 years for acetabular implants with SRS and NSRS were 5.2% (CI 4.9-5.5) and 7.4% (CI 7.0-7.9) respectively, with a mean difference of 1.8% (CI 1.2-2.3) favoring implants with SRS.

Conclusion:  Acetabular implants with NSRS were associated with 1.8% higher pooled revision rates than those with SRS at 10 years, which represents a relative increase in acetabular revision burden of approximately 36%.

Background and purpose: Tibial periprosthetic fractures (PPF), periprosthetic joint infections (PJI), and bearing dislocations (BD) are among the most common short-term complications in medial unicompartmental knee arthroplasty (mUKA). We aim to assess whether patients with these complications have patient-reported outcome measures (PROMs) that differ from patients with primary mUKA, primary total knee arthroplasty (TKA), or after revision TKA .

Methods: This observational study included 74 mUKA patients reoperated for PPF (n = 22), PJI (n = 15), or BD (n =3 7) between January 2018 and January 2023. Comparator groups included 1,940 primary mUKA, 3,485 primary TKA, and 350 reoperated TKA patients. The primary endpoint was Oxford Knee Score (OKS) at 12 months. Missing data was imputed, and multilevel Tobit regression was used to analyze differences in PROMs.

Results: At 12 months, reoperated mUKAs had lower PROM scores than primary mUKAs (OKS difference -3.3, 95% confidence interval [CI] -5.0 to -1.5) and TKAs (OKS difference -2.7, CI -4.4 to -0.9) but higher than reoperated TKAs (OKS difference: 3.0, CI 1.1 to 5.0). PPF mUKAs had 12-month scores resembling reoperated TKAs (OKS difference -0.7, CI -3.9 to 2.5). PJI mUKAs and BD mUKAs had 12-month scores resembling primary mUKAs (PJI: OKS difference -2.4, CI -6.2 to 1.5, BD: OKS difference -2.2, CI -4.7 to 0.2) and primary TKAs (PJI: OKS difference -1.7, CI -5.6 to 2.1, BD: OKS-difference -1.6, CI -4.1 to 0.8).

Conclusion: Patients reoperated for PJI and BD achieved outcomes comparable to primary mUKAs and TKAs, while PPF resulted in scores lower than primary mUKAs and TKAs, comparable to reoperated TKAs.

Background and purpose:  The use of a tourniquet in knee replacement surgery is debated. Given the conflicting evidence, we aimed to compare the risk of revision after total knee replacements (TKR) with or without the use of tourniquet.

Methods:  In this register based observational study, we included the 5 most common cemented primary TKR models due to osteoarthritis reported to the Swedish Arthroplasty Register 2010-2024 and followed them until December 31, 2024. The first revision for implant loosening was the primary outcome. We estimated the cumulative revision rate (CRR) with 95% confidence interval (CI) using the 1-Kaplan-Meier method. We examined the use of a tourniquet regarding the risk of revision using multiple Cox regression analysis to calculate the hazard ratio (HR) with CI and adjusted for potential confounding factors.

Results:  Of the 149,616 TKRs included, 65,570 (44%) were with tourniquet and 84,046 (56%) without tourniquet. The CRR was similar at all time-points for all causes and infection; however, CRR started to increase at 6-7 years for implant loosening with use of a tourniquet. In the Cox regression analysis, the use of a. tourniquet was associated with an increased risk of revision for implant loosening after 5 years (HR 1.56, CI 1.06-2.30). There was no difference in revision for all causes (HR 1.07, CI 0.99-1.15) or infection (HR 1.08, CI 0.97-1.21).

Conclusion:  The use of a tourniquet was associated with an increased risk of revision for implant loosening after 5 years, while no association was found for all-cause revision or infection. Our results do not support the use of a tourniquet in TKR as a strategy to reduce the risk of revision, either due to all causes, implant loosening, or infection.

Background and purpose:  Patellofemoral joint replacements (PFR) and total knee replacements (TKR) are surgical treatment options for patellofemoral joint osteoarthritis. We aimed to compare patient-reported outcome measures (PROMs) for these procedures, and revision thresholds for PFR.

Methods:  Data from the National Joint Registry (2009-2021) was linked with the Hospital Episodes Statistics (HES) database. Data was then merged with the PROMs dataset and adjusted using inverse proportional treatment weighting methods. Primary PROMS were Oxford Knee Score (OKS) and EQ5D-3L at the 6-18-month mark with a minimal clinically important difference of 5 for OKS. Secondary outcome measures included threshold to revision, defined as the cut-off score at which an arthroplasty was revised. Differences in patient characteristics between those classed as best and worst outcomes were compared and regression analyses examined the influence of factors such as age, provider type (public or private healthcare), and comorbidities on PROMs with results stratified by sex.

Results:  340,449 matched records were analyzed (1,085 PFR, 339,364 TKR). The median postoperative OKS was 35 (PFR) and 38 (TKR), with a difference of -2.4. Patients with the best PFR outcomes were older (62.0 vs 57.2 years, P = 0.01). The median 6-month EQ5D-3L was 0.77 (PFR) and 0.80 (TKR). PFR had a higher revision hazard ratio (3.4, 95% confidence interval 2.7-4.4, P = 0.01), indicating a lower threshold for revision.

Conclusion:  Up to 18 months, in terms of OKS and EQ5D-3L, there was no significant difference between the 2 procedures. PFR had a lower threshold for revision compared with TKR. Future research should incorporate more objective measures, such as activity level, where objective differences might be identified.

Background and purpose:  While complication rates for primary pelvic and acetabular fracture surgeries are well documented, limited data exists on complications following osteosynthesis implant removals. We aimed to evaluate the complication rates of pelvic implant removals with respect to the surgical approach, type of implant, and indication for removal.

Methods:  This retrospective, consecutive case series included all patients undergoing pelvic implant removal between January 2013 and December 2023 using Kocher-Langenbeck, modified Stoppa (AIP), or ilioinguinal approaches for the removal. Isolated minimally invasive, percutaneous implant removals were excluded.

Results:  154 implant removals in 141 patients were analyzed. Overall complication rate was 34% (n = 53). Most common complications were intraoperative bleeding requiring transfusion (n = 17; 11%), postoperative anemia requiring transfusion (n = 12; 7.8%), and vascular injuries (n = 9; 5.8%). The ilioinguinal approach showed a higher complication rate (19/37; 51%) than the Kocher-Langenbeck (21/68; 31%) or the Stoppa/AIP approach (13/49; 27%). Removal of implants from the anterior pelvic ring and acetabulum (22/45; 49%) also had a higher complication risk than from the posterior pelvic ring and acetabulum (20/67; 30%) or of symphyseal plates (11/42; 26%). Removal due to infection also showed a particularly high complication rate (25/57; 44%) compared with aseptic indications, e.g., interfering material or removal for THA.

Conclusion:  Pelvic implant removals, especially from the anterior pelvic ring or acetabulum, using the ilioinguinal approach, and in case of infection, are associated with a particularly high complication risk. These findings can support clinical decision-making and informing patients on the potential risks of hardware removals.

Background and purpose:  Adding antioxidant to highly cross-linked polyethylene (XLPE) is proposed to improve oxidation resistance and decrease wear in total hip replacements (THR), but long-term performance is unknown. We aimed to compare the revision rates of THR using cementless acetabular components where the insert was made of either XLPE with antioxidant (AOXLPE) or XLPE, using data from a large national registry.

Methods:  The population was THR from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) in the 10-year period 2014-2023 with modular cementless acetabular components and ceramic or metal femoral heads used for osteoarthritis. We compared primary THR using XLPE with antioxidant (AOXLPE) acetabular inserts with XLPE acetabular inserts. The outcome measured was all-cause revision. Cumulative percentage revision (CPR) was calculated using the Kaplan-Meier method, and comparisons made using Cox proportional hazards models.

Results:  There were 198,073 THRs, of which 35,309 had AOXLPE inserts. There were 769 and 4,327 revisions with AOXLPE and XLPE inserts, respectively. While there was no early difference, the AOXLPE group had a lower revision rate after 3 years (HR 0.64, 95% confidence interval [CI] 0.48-0.84). When adjusted for multiple factors the AOXLPE group still had a lower revision rate after 3 years (HR 0.63, CI 0.47-0.83). Revisions for loosening, wear-related causes, and fracture were proportionately lower in the AOXLPE group, but no difference was found with revisions for dislocation/instability or infection.

Conclusion:  While there was no early difference, THR with AOXLPE acetabular inserts had a lower revision rate after 3 years than XLPE. This suggests a possible clinical benefit using AOXLPE but the difference may, in part, be related to the associated femoral or acetabular components.

Background and purpose:  Management of pediatric distal forearm fractures ranges from no or simple immobilization to surgical fixation. Treatment decisions depend on age and fracture severity, but practices vary widely across countries. As surgical intervention has increased internationally, we aimed to investigate national trends in incidence and treatment of pediatric distal forearm fractures in Denmark from 1999-2018 Methods: We conducted a population-based register study of children aged 0-15 with distal forearm fractures (S525 + S526) registered in the Danish National Patient Registry from 1999-2018. Treatments within 1 week of injury were grouped into: non-surgical (no immobilization, soft bandage or cast immobilization), closed reduction and immobilization, and surgical fixation. Procedure codes included closed reduction, open reduction, K-wires, or other fixations such as external fixation, nail, plate, or screws.

Results:  There were 175,083 fractures over the 20 years, yielding a mean incidence of 829/100,000/year in children aged 0-15 years. The highest incidences were 1,494/100,000 among 11-year-old girls and 1,720/100,000 among 13-year-old boys. The primary treatment in all age groups was non-surgical treatment, though decreasing from 92% in 1999 to 89% in 2018. The proportion of closed reduction declined from 7% to 2%, while K-wire fixation increased from 1% to 8%. When stratified by age groups, the same trend was seen in all but the 0-3-year-olds.

Conclusion:  The overall incidence remained stable during the study period. Non-surgical treatment remained predominant, whereas closed reductions decreased in favor of more K-wire fixations.

Background and purpose:  Migration is an early sign of loosening. We investigated the migration and stability of the cemented Persona Partial Knee (PPK, Zimmer Biomet, Warsaw, IN, USA), for both the femoral and tibial component, and evaluated the clinical results at 5 years' follow-up.

Methods:  In this prospective cohort study, primary cemented PPKs were implanted. Migration of the tibial and femoral component at 5 years postoperatively was calculated using model-based radiostereometric analysis (mRSA) in terms of translations and rotations. To evaluate the clinical results, a clinical examination was performed using the Knee Society Score (KSS), and PROMs (NRS pain, KOOS-PS, OKS, EQ-5D) were registered.

Results:  26 patients were included. At 5 years postoperatively, we found low migration of both the tibial and femoral component, namely a translation of < 0.21 mm and rotation of < 0.75° in all directions for both components. Compared with 2 years' follow-up, the tibial components showed an increased total translation and total rotation at 5 years. The femoral components showed stable migration compared with 2 years' follow-up. The KSS decreased between 2 and 5 years, while the PROMs remained stable between 2 and 5 years' follow-up.

Conclusion:  The PPK showed low migration of both the tibial and femoral components at 5 years' follow-up. The femoral component was stable between 2 and 5 years, while the tibial component still migrated.

Background and purpose:  Total hip arthroplasty (THA) in young patients is rare but increasingly performed. We aimed to analyze implant survivorship and risk factors for revision in patients aged 30 years or less after THA based on the German Arthroplasty Registry (EPRD).

Methods:  Kaplan-Meier survival analysis and Cox proportional hazard models were used to analyze the EPRD dataset from 2013 to 2023 for factors associated with increased risk of revision. The primary outcome was first revision operation.

Results:  1,622 primary THAs in 1,452 patients were analyzed. The mean age was 26 years (range 11-30), 908 (56%) of whom were male. The most frequent diagnosis was secondary osteoarthritis (1,146, 72%), followed by osteonecrosis (357, 22%), and hip dysplasia (53, 3.2%). Of all THAs, 1,601 (99%) were uncemented, and 1,574 (97%) received ceramic heads. The average follow-up period was 3.7 years (range 0-10.6). 47 hips were revised with a cumulative revision rate (CRR) at 8 years of 4.6% (95% confidence interval [CI] 2.8-7.3). The most frequent revision cause was infection in 11 cases (0.7%). Increased revision risk was associated with pediatric hip disease for those with prior surgery for Perthes, HR 4.3 (CI 1.9-9.6), pelvic osteotomy HR 2.8 (CI 1.1-7.5), and a primary diagnosis of hip dysplasia, HR 3.4 (CI 1.3-8.5).

Conclusion:  Uncemented THA in young patients demonstrated a revision rate of 4.6% (CI 2.8-7.3), which we believe is a satisfactory mid-term survival. Patients with pediatric hip disease present the highest risk of revision.