Acta Orthopaedica最新文献

Purpose: The primary aim of our study was to identify the absolute incidence and implant survival of multiply revised knee arthroplasties based on nationwide register data. The secondary aim was to determine the change in the absolute incidence and implant survival of multiply revised knee arthroplasties Methods: We performed a retrospective observational study of primary knee arthroplasties using several nationwide Danish registers. All primary knee arthroplasties performed in Denmark from 1998 to 2021 were identified. From these primary arthroplasties, revision procedures were identified. Kaplan-Meier plots were used in survival analysis to estimate the likelihood of implant survival.

Results: 161,384 primary knee arthroplasties and their revisions performed between 1998 and 2021 were identified; of 13,786 (8.5%) revisions there were 10,638 1st revisions, 2,148 2nd revisions, 624 3rd revisions, 223 4th revisions, and 153 procedures that had been revised more than 4 times. The 10-year revision-free survival of primary arthroplasties was 92.3% (95% confidence interval [CI] 92.2-92.5). First-time revisions had a 10-year revision-free survival of 75.9% (CI 74.9-76.9). The 10-year survival of second- and third-time revisions was 65.1% (CI 62.6-67.6) and 57.8% (CI 53.4-62.5), respectively. The 10-year implant survival probabilities of primary knee arthroplasties were 91.4% in 1998-2009 and 93.3% in 2010-2021 (difference 2.2%). The 10-year implant survival probabilities of 1st revisions were 77% in 1998-2009 and 75% in 2010-2021 (difference -2.4%).

Conclusion: We found that 0.3% of all primary knee arthroplasties resulted in 3 or more revisions. The implant survival decreased for each consecutive revision, with almost half of the 3rd revisions being re-revised within 10 years. The 10-survival of the primary implant was higher in 2010-2021, and the 10-year survival of the 1st revision was higher in 1998-2009.

Background and purpose: Younger recipients of total hip arthroplasty (THA) highly prioritize returning to preoperative levels of physical activity (PA). Surgeons have tended to give cautious advice concerning high-impact sports participation, but there have been few long-term studies. The purpose of our study was to investigate the risk of revision arthroplasty in relation to postoperative PA levels.

Methods: Patients registered in the Geneva Arthroplasty Register (GAR) who had elective THA when they were aged < 65 years were studied. Postoperative PA was collected prospectively 5-yearly using the UCLA activity scale. Cox proportional hazards models were used to estimate associations between PA and risk of revision THA.

Results: Amongst 1,370 eligible subjects, median age at THA 58 years (interquartile range 51-61), UCLA scores were available for 973 (71%). During follow-up over 15 years, there were 79 revisions, giving a cumulative risk of 7.4% (95% confidence interval [CI] 5.8-9.4). After adjusting for covariates, we found an increased risk of revision for each unit increase in postoperative PA (HR 1.2, CI 1.1-1.4), and among people performing the most intensive PA (HR 2.7, CI 1.3-5.6) compared with those who were inactive.

Conclusion: The overall risk of revision was small but intensive and moderate PA may be associated with an increased risk of revision.

Background and purpose: Several studies from the United States report an increased risk of prolonged opioid use after shoulder replacement. We aimed to determine the incidence and risk factors of prolonged opioid use after elective shoulder replacement in a nationwide Danish population.

Methods: All primary elective shoulder arthroplasties reported to the Danish Shoulder Arthroplasty Registry (DSR) from 2004 to 2020 were screened for eligibility. Data on potential risk factors was retrieved from the DSR and the National Danish Patient Registry while data on medication was retrieved from the Danish National Health Service Prescription Database. Prolonged opioid use was defined as 1 or more dispensed prescriptions on and 90 days after date of surgery (Q1) and subsequently 1 or more dispensed prescriptions 91-180 days after surgery (Q2). Preoperative opioid use was defined as 1 or more dispensed prescriptions 90 days before surgery. Logistic regression models were used to estimate risk factors for prolonged opioid use.

Results: We included 5,660 patients. Postoperatively 1,584 (28%) patients were dispensed 1 or more prescriptions in Q1 and Q2 and were classified as prolonged opioid users. Among the 2,037 preoperative opioid users and the 3,623 non-opioid users, 1,201 (59%) and 383 (11%) respectively were classified as prolonged users. Preoperative opioid use, female sex, alcohol abuse, previous surgery, high Charlson Comorbidity index, and preoperative use of either antidepressants, antipsychotics, or benzodiazepines were associated with increased risk of prolonged opioid use.

Conclusion: The incidence of prolonged opioid use was 28%. Preoperative use of opioids was the strongest risk factor for prolonged opioid use, but several other risk factors were identified for prolonged opioid use.

Background and purpose: It is still debatable which is the least invasive approach to the hip joint in arthroplasty for a femoral neck fracture (FNF). We compared the traditional direct lateral approach (DLA) with the direct anterior approach (DAA) regarding creatine kinase (CK), C-reactive protein (CRP), and hemoglobin (Hb).

Methods: In a randomized controlled trial, 130 elderly patients with dislocated FNFs treated with total hip arthroplasty (THA) were included. CK, CRP, and Hb were measured preoperatively and on postoperative days 1 to 4 and were compared between the DAA and DLA groups using repeated measures mixed-effect models.

Results: The CK level was significantly higher on the 1st postoperative day in the DLA group, 597 U/L (95% confidence interval [CI] 529-666) vs 461 U/L (CI 389-532), estimated mean difference (MD) 136 U/L (CI 38-235). The CRP levels were significantly higher on postoperative days 3 and 4 in the DLA group, 207 mg/L (CI 189-226) vs 161 mg/L (CI 143-180), estimated MD 46 mg/L (CI 19-72) and 162 mg/L (CI 144-181) vs 121 (CI 102-140), estimated MD 41 mg/L (CI 15-68). Blood loss, expressed as difference in Hb, did not differ between the groups.

Conclusion: In an elderly population with FNFs, we found that the DAA, compared with the DLA, results in less CK and CRP increase, but no change in Hb.

Background and purpose: Arthroplasty surgeons traditionally assess cup orientation after total hip arthroplasty (THA) on supine radiographs. Contemporary hip-spine analyses provide information on standing, functional cup orientation. This study aims to (i) characterize cup orientations when supine and standing; (ii) determine orientation differences between postures; and (iii) identify factors associated with magnitude of orientation differences.

Methods: This is a 2-center, multi-surgeon, prospective, consecutive cohort study. 419 primary THAs were included (57% women; mean age: 64 years, standard deviation [SD] 11). All patients underwent supine and standing antero-posterior pelvic and lateral spinopelvic radiographs. Cup orientation and spinopelvic parameters were measured. Target cup orientation was defined as inclination/anteversion of 40°/20° ± 10°. A change in orientation (Δinclination/Δanteversion) between postures > 5° was defined as clinically significant. Variability was defined as 2 x SD.

Results: Inclination increased from 40° (supine) to 42° (standing) corresponding to a Δinclination of 2° (95% confidence interval [CI] 2-3). Anteversion increased from 25° (supine) to 30° (standing) corresponding to a Δanteversion of 5° (CI 5-6). When supine, 69% (CI 65-74) of THAs were within target, but only 44% (CI 39-49) were within target when standing, resulting in a further 26% (CI 21-30) being out of target when standing. From supine to standing, a clinically significant change in anteversion (> 5°) was seen in 47% (CI 42-52) of cases. Δanteversion was higher in women than in men (6°, CI 5-7 vs 5°, CI 4-5) corresponding to a difference of 1° (CI 1-2), which was dependent on tilt change, standing cup anteversion, age, and standing pelvic tilt.

Conclusion: Cup inclination and version increase upon standing but significant variability exists due to patient factors.

Background and purpose: Dislocation is a severe complication following total hip arthroplasty (THA). Hip precautions have been recommended in the initial postoperative period but evidence supporting this practice is limited. We therefore conducted a population-based study to evaluate the association between discontinuing recommending postoperative hip precautions and the risk of early dislocation.

Methods: This is a cohort study with data from the Danish Hip Arthroplasty Register and the Danish National Patient Register. We included patients who underwent primary THA for osteoarthritis in 2004-2019 in public hospitals in the Capital Region of Denmark. The cohort was divided into the hip precautions group, comprising patients operated on between 2004 and 2009, and the no-precautions group operated on between 2014 and 2019. The primary outcome was the difference in the absolute risk of dislocation within 3 months post-surgery. The secondary outcome assessed the same risk within 2 years. We evaluated the difference in absolute risk using absolute risk regression (ARR).

Results: The cumulative incidence of dislocation within 3 months was 2.9% (confidence interval [CI] 2.5-3.3) in the hip precautions group and 3.5% (CI 3.1-3.9) in the no-precautions group. The risk of dislocation was higher in the no-precautions group but failed to reach statistical significance in the crude (ARR 1.2, CI 0.9-1.6) and multivariate model (ARR 1.4, CI 0.9-2.2).

Conclusion: We found a higher but statistically insignificant increase in the risk of early dislocation in the no-precautions group. The lack of significance in the association may be explained by the increased use of 36-mm femoral heads after the guideline revision.

Background and purpose: The primary aim of this systematic review and meta-analysis was to evaluate the success rate of 3 different epiphysiodesis techniques with implant usage for the treatment of leg-length discrepancy (LLD) in the pediatric population. The secondary aim was to address effectiveness (final LLD) and the reported complications of staples, tension-band plates (TBP), and percutaneous epiphysiodesis screws (PETS).

Methods: In this systematic review we searched MEDLINE (PubMed), Embase, Cochrane Library, Web of Science and Scopus for studies on skeletally immature patients with LLD treated with epiphysiodesis with an implant. The extracted outcome categories were effectiveness of epiphysiodesis (LLD measurements pre-/postoperatively, successful/unsuccessful) and complications that were graded on severity.

Results: 44 studies (2,184 patients) were included. 455 underwent epiphysiodesis with PETS, 578 patients with TBP, and 1,048 with staples. Successful epiphysiodesis was reported in 76% (95% confidence interval [CI] 61-89) with PETS (9 studies), 67% (CI 54-79) with TBP (10 studies), and 51% (CI 28-65) with Blount staples (8 studies). From pooled analysis, the severe complications rate was 7% for PETS, 17% for TBP, and 16% for Blount staples. Angular deformity was reported in 4% after PETS, 10% after TBP, and 17% after Blount staples.

Conclusion: Our results showed that epiphysiodesis with PETS implants was the most successful technique. PETS had a higher success rate, fewer severe complications, and a lower proportion with angular deformity.

Background and purpose: The aim of our study was to investigate change in modifiable risk factors following preoperative optimization and whether risk of superficial surgical site infection (SSI) after total joint arthroplasty (TJA) could be reduced.

Methods: This is a prospective study of implementation of a preoperative optimization pathway for patients waiting for primary TJA. Information regarding the intervention arm was collected from January 2019 to January 2021, first at decision for operation and then at preoperative assessment 1 week prior to operation. The control arm was included between August 2018 and September 2020 after receiving conventional preoperative preparation and information gathered at preoperative assessment. Follow up occurred 6 weeks postoperatively for both groups. The primary outcome was postoperative superficial SSI.

Results: The optimization effort resulted in improvement of weight, anemia, HbA1c, vitamin D, and patient engagement. At preoperative assessment the baseline characteristics of the 2 groups were similar except that the intervention group had substantially more comorbidities. Regarding superficial SSI, association was found with BMI ≥ 30 and HbA1c ≥ 42 mmol/mol in the control group but not in the intervention group. When corrected for differences in ASA classification (reflecting comorbidities), age, and sex, being in the intervention group was associated with lower odds of occurrence of superficial SSI compared with the control group (OR 0.64, 95% confidence interval 0.42-0.97).

Conclusion: We showed that preoperative optimization in a structured cooperation between hospital and primary care was associated with a reduced risk of superficial SSI.

Background and purpose: The aim of our study was to assess the regional variations in Achilles tendon rupture incidence and treatment methods in Finland during the period 1997-2019.

Methods: The Finnish National Hospital Discharge Register (NHDR) and the Finnish Register of Primary Health Care Visits (PHCR) were searched to identify all adult patients diagnosed with Achilles tendon rupture during our study period. The population-based annual incidence and incidences of surgically and non-surgically treated Achilles tendon ruptures were calculated for each hospital district.

Results: Achilles tendon rupture incidence increased from 17.3 per 105 person-years in 1997 to 32.3 per 105 in 2019. The mean incidence of Achilles tendon ruptures ranged from 26.4 per 105 (North Savo) to 37.2 per 105 (Central Ostrobothnia). The incidence of Achilles tendon ruptures increased in all areas. The proportion of non-surgical treatment of Achilles tendon ruptures ranged in 1997 from 7% (Vaasa) to 67% (Åland) and in 2019 from 73% (Southwest Finland) to 100% (East Savo, Kainuu, Länsi-Pohja, Åland). During the study period, a shift towards non-surgical treatment was evident in all hospital districts.

Conclusion: Regional variations in Achilles tendon rupture incidence exist in Finland; however, the incidence increased in all areas during the follow-up period. More Achilles tendon rupture patients are currently being treated non-surgically throughout the country.

Background and purpose: Dislocations continue to be a serious complication after primary total hip arthroplasty (THA). Our primary aim was to report the "true" incidence of dislocations in Denmark and secondarily to validate a previously developed algorithm designed to identify THA dislocations in the updated version of the Danish National Patient Register (DNPR), based on data from the Danish Hip Arthroplasty Register (DHR).

Methods: We included 5,415 primary THAs from the DHR performed from July 1 to December 31, 2019. Version 3 of the DNPR was launched in February 2019, and a combination of data from the DNPR and a comprehensive national review of 1,762 hospital contacts enabled us to identify every dislocation occurring during the 1st year after THA to determine the "true" 1-year incidence of dislocation. The results were presented as proportions with 95% confidence intervals (CI), and validation was performed by calculating sensitivity and predictive values.

Results: The "true" 1-year incidence of dislocation was 2.8% (CI 2.4-3.3). Of these, 37% suffered recurrent dislocations during the follow-up period. Between-hospital variation ranged from 0.0% to 9.6%. The algorithm demonstrated a sensitivity close to 95%, while maintaining a positive predictive value of above 94%.

Conclusion: The "true" 1-year incidence of dislocation of 2.8% is comparable to earlier findings, and large variation among hospitals continues to be evident. We have proven the algorithm to be valid in the latest DNPR (version 3), enabling it to be employed as a new quality indicator in future annual DHR reports.