Acta Orthopaedica最新文献

Background and purpose:  The new Tri-Lock bone -preserving stem with a collarless proximal-coated tapered-wedge design was compared with a classic well-proven collarless proximal-coated long and round-tapered design. Our primary aim was to compare femoral stem fixation (subsidence) of the Tri-Lock stem with the classic Summit stem, and secondarily to compare the change in periprosthetic bone mineral density (BMD) and PROMS between stem groups.

Methods:  In a patient-blinded randomized controlled trial, 52 patients at mean age 60 (SD 6) received cementless Tri-Lock (n = 26) or Summit (n = 26) femoral stems with a cementless Pinnacle cup, a cross-linked polyethylene liner, and a CoCr head. Patients were followed for 5 years with radiostereometric analysis (RSA), dual-energy X-ray absorptiometry (DXA), and patient-reported outcome measures (PROMs). We measured mean (CI) values of migration and periprosthetic bone mineral density and calculated between group differences.

Results:  At 2-year follow-up, the mean difference in subsidence was 0.14 mm (95% confidence interval [CI] -0.27 to 0.56) and below the chosen minimal clinically important difference of 0.6 mm. At 5-year follow-up, for the Tri-Lock and Summit stems, the mean subsidence was 0.38 (CI 0.04-0.72) and 0.24 (CI 0.09-0.57), and the mean retroversion was 1.68° (CI 0.80-2.55) and 1.53° (CI 0.68-2.37), respectively. There was initial periprosthetic BMD loss for both stems. At 5-year follow-up, the mean metaphyseal bone loss was minimal for the Tri-Lock stem (zone 1: -2.8% vs -11.5%) while the Summit stem preserved the medial diaphyseal bone better (zone 6: -7.1% vs -13.6%). At the medial stem tip, BMD was increased with the Summit stem (zone 5: +3.4% vs -1.5%). At 5-year follow-up, median EQ5D was 1 in both groups and median Oxford Hip Score was 47 (Tri-Lock) and 45 (Summit) with no statistical significant differences between groups.

Conclusion: The Tri-Lock and the Summit stems displayed similar migration until mid-term follow-up. At 3 months both stems had lost metaphyseal periprosthetic bone mineral density (BMD). During the following years, the new design regained more metaphyseal BMD. Contrarily, the long and round-tapered stem design regained or even increased diaphyseal BMD. PROM scores improved beyond the reference level for both groups.

Background and purpose:  Long-term opioid therapy (LTOT) has frequently been reported in patients undergoing total hip or knee arthroplasty (THA or KA). However, there is no clear recommendation on the definition. We aimed to evaluate the sensitivity of the estimated risk of LTOT and association with mortality after THA and KA to the selection among 14 different candidate LTOT definitions.

Methods:  Using data from the nationwide Danish registries, we included patients with osteoarthritis undergoing primary THA during 2016-2019 (n = 28,957) or KA during 2014-2020 (n = 51,239). We obtained individual-level information on opioid prescriptions from any pharmacy 1 year before and 1 year after surgery. 14 common LTOT definitions were selected from the literature. The primary outcome was the variation in the 1-year crude risk of LTOT corresponding to variation in LTOT definition. Analysis was done overall and stratified by sex, age, prior opioid use, and year of surgery. The secondary outcome was the 4-year mortality among patients meeting each LTOT definition.

Results:  The 1-year risk of LTOT varied from 1.2% (95% confidence interval [CI] 1.1-1.3) to 20.1% (CI 19.6-20.5) for THA and 0.2% (CI 0.1-0.2) to 29.6% (CI 29.2-30.0) for KA patients depending on definition. For THA or KA, women had a higher risk of LTOT than men for all definitions, thus, LTOT varies from 0.2% (CI 0.1-0.2) to 32.9% (CI 32.3-33.4) for women and from 0.1% (CI 0.1-0.2) to 24.9% (24.4-25.5) for men. With increasing age risks of LTOT were steady or slightly decreasing. There was a decrease in the risk of LTOT from 2016 to 2019 for all definitions. 4-year mortality in patients meeting LTOT definitions varied from 9.8% (CI 8.9-10.7) to 16.3% (CI 13.2-20.1) for THA and 6.9% (CI 6.4-7.4) to 10.5% (CI 8.5-12.9) for KA patients.

Conclusion:  The estimation of the risk of LTOT after THA or KA and association with mortality is strongly dependent on the definition of LTOT used by researchers. This highlights the limitation on the comparability of opioid studies assessing risk and prognosis in these patients.

Background and purpose:  Patellofemoral arthroplasty (PFA) is a rare surgical procedure for isolated patellofemoral osteoarthritis (PFOA). This study compares patient demographics, long-term survival rates, revision risks, and causes of revision in PFA with total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA).

Methods: Data from the Norwegian Arthroplasty Register (NAR) (1994-2022) included 725 PFA, 102,135 TKA, and 14,315 UKA procedures. We used Kaplan-Meier (KM) analysis to calculate implant survival at 2, 5, 10, and 15 years and Cox regression adjusted for confounders to assess revision risks. Revision causes were analyzed for procedures after 2005.

Results:  PFA patients were more often female (72%) than TKA (62%) and UKA (51%) patients and had a lower mean age (54.3 for PFA, 69.0 for TKA, and 65.6 for UKA). At 10 years, KM survival was 85% (95% confidence interval [CI] 80.6-88.2) for PFA, 94% (CI 93.8-94.2) for TKA, and 84% (CI 83.6-85.1) for UKA. Among patients < 60 years, KM survival at 10 years was 84% (CI 79.4-88.1) for PFA, 90% (CI 89.3-90.4) for TKA, and 79% (CI 77.1-80.3) for UKA. In patients < 60 years with < 10 years' follow-up, the adjusted hazard ratios (HR) for revision were 0.9 for TKA and 1.7 for UKA compared with PFA. Adjusted HR for > 10 years' follow-up showed lower revision risks for TKA with 0.3 and no significant difference for UKA (HR 0.9). Progression of OA was the leading cause of revision in PFA (49%).

Conclusion:  PFA was predominantly performed in younger female patients. In patients < 60 years, PFA showed similar 10-year survival to TKA but inferior survival after 15 years. Revision rates for PFA are comparable to UKA but inferior to TKA.

Background and purpose:  There are still strong beliefs in medicine concerning things that bring "bad luck." It is unclear whether a suspicious component size or surgery date is related to "bad luck" in orthopedic surgery. We aimed to examine: (i) if a potentially unlucky femoral stem size 13 in total hip arthroplasty (THA), and (ii) if a possible unlucky surgery date, Friday 13th, in THA and total knee arthroplasty (TKA) have a higher revision rate.

Methods:  We analyzed 611,050 THAs and TKAs, performed in the past 13 years using Dutch Arthroplasty Register data. The revision rate of uncemented femoral stem size 13 (Corail and Taperloc) in THA was compared with all other stem sizes of the same type. Furthermore, the revision rate of THA and TKA implanted on Friday 13th was compared with all other days and with other Fridays. Both were performed using competing risk analyses with death as competing risk and cause-specific multivariable Cox proportional hazard regression analyses.

Results:  The use of an uncemented Corail or Taperloc femoral stem size 13 in THA was associated with a lower revision rate (3.0%, 95% confidence interval [CI] 2.3-4.0) compared with the revision rate of other femoral stem sizes (3.5%, CI 3.3-3.8) (hazard ratio [HR] 0.76, CI 0.65-0.87). TKA procedures on Friday 13th were not associated with increased revision rate (5.2%, CI 4.1-6.7) compared with procedures on other days (6.0%, CI 5.9-6.2) or on other Fridays (5.8%, CI 5.4-6.2) (HR 1.03, CI 0.80-1.32 and HR 1.01, CI 0.79-1.30, respectively). For THA, procedures on Friday 13th were associated with a higher revision rate (5.1%, CI 3.9-6.6) compared with procedures on other days (4.6%, CI 4.5-4.8) (HR 1.32, CI 1.04-1.67) but not compared with procedures on other Fridays (4.8%, CI 4.4-5.1) (HR 1.24, CI 0.97-1.58).

Conclusion:  Based on national arthroplasty registry data, femoral stem size 13 in THA was associated with a lower revision rate. TKA procedures on Friday 13th were not associated with increased revision rate; however, in THA there seems to be an increased risk of revision in THA procedures performed on Friday 13th compared with other days, but not when compared with other Fridays.

Background and purpose:  The optimal duration of antibiotic prophylaxis for reducing serious adverse events (SAEs) after total hip arthroplasty (THA) is unclear. We aimed to assess the comparative effectiveness of different strategies of antibiotic prophylaxis in preventing SAEs after THA.

Methods:  We searched Medline, Embase, CENTRAL, and the Clinical Trial Registration Database for randomized controlled trials evaluating antibiotic prophylaxis in patients undergoing primary THA. Two authors independently screened, extracted data, and assessed the risk of bias. We defined SAEs as prosthetic joint infections, other serious infections, major cardiovascular events, venous thromboembolisms, or mortality. The primary summary measures were odds ratios (ORs) with 95% confidence intervals (CI). The evidence was assessed using the confidence in network meta-analysis (CINeMA) framework.

Results:  Of 6,131 identified citations, 10 trials of 2-group comparisons were included, involving 9,106 patients. Duration of antibiotics was grouped as follows: placebo (3), a single dose (3), multiple doses ≤ 24 hours (6), multiple doses (> 1 day) (6), and bone cement with antibiotics (2). Compared with placebo, point estimates suggest lower odds of SAEs after THA for most antibiotic strategies, except multiple doses > 1 day. Multiple doses showed no clear evidence of superiority to single dose: OR (multiple doses ≤ 24 hours) = 0.87 (CI 0.20-3.73; very low) or over more days (> 1 day) OR = 0.40 (CI 0.07-2.42; very low) nor were multiple doses > 1 day superior to multiple doses ≤ 24 hours, OR = 0.46 (0.11-1.90; very low).

Conclusion:  Relative to placebo, point estimates suggested that most antibiotic prophylaxis regimens may reduce SAEs after THA, with no clear evidence of added benefit from multiple doses. These findings should be interpreted with caution due to the lack of precision and the corresponding very low certainty of evidence for some comparisons.

Femoral neck fractures (FNFs) are associated with loss of function in all ages and excess mortality. The societal costs are high. Treatment needs to be tailored based on fracture type, functional demand, and physiological age of the patient. Internal fixation is often preferred for undisplaced FNFs and for displaced FNFs in young patients. Anatomical reduction is essential, but slight valgus is accepted. For a majority of those with displaced FNFs, a cemented hemiarthroplasty is the best alternative. This educational article suggests a treatment algorithm for FNFs and describes the evidence base for the recommended surgical techniques. Basicervical fractures, stress and pathological fractures are not included in this review.

Background and purpose:  Revision total hip arthroplasty (rTHA) is a complex procedure that may benefit from centralization. We examined the association between annual hospital volume of rTHA and re-revision risk and mortality.

Methods:  We included all rTHAs between 2007 and 2022 in general hospitals, registered in the Dutch Arthroplasty Register (LROI; n = 12,515). Hospitals were categorized into low (< 25 rTHA/year) or high volume (≥ 25 rTHA/year). Competing-risk analyses and Cox proportional hazard regression analyses were performed to assess implant re-revision and Kaplan-Meier survival analysis for mortality. Results were stratified into septic (permanent Girdlestone, 1-stage, and 2-stage revisions) and aseptic first revisions.

Results:  1-stage septic revisions showed a higher risk of re-revision in high-volume hospitals (hazard ratio [HR] 1.6, 95% confidence interval [CI] 1.1-2.4). We found no difference in re-revision risk after DAIR (HR 1.1, CI 0.9-1.3). 2-stage septic revisions were more often performed in high-volume hospitals (5% vs 2%). There was no statistical difference in re-revision rates between hospitals after revision for aseptic loosening (HR 1.1, CI 0.9-1.4), dislocation (HR 1.1, CI 0.9-1.4), and periprosthetic fractures (HR 1.1, CI 0.8-1.5). Mortality showed no differences between groups, neither for septic nor aseptic revisions.

Conclusion:  There was no difference between high-volume hospitals and low-volume hospitals regarding risk for re-revision after aseptic loosening, dislocation and periprosthetic fracture, and septic DAIR and mortality. In high-volume hospitals, 1-stage septic revisions was associated with a significantly higher re-revision risk. 2-stage revisions are more frequent in high-volume hospitals, indicating more complex pathology.

Background and purpose:  There is no clear evidence on whether migration or wear is the best predictor for later acetabular cup loosening. We aimed to investigate whether early wear or migration, measured via radiostereometric analysis (RSA), predicts later cup loosening. We also compared long-term aseptic loosening rates between conventional (CPE) and highly crosslinked polyethylene (XLPE) cups.

Methods:  Data was drawn from a randomized controlled trial (RCT) (ClinicalTrials.Gov NCT00698672) of 150 patients receiving cemented total hip arthroplasties (THAs), with 10-year RSA follow-up. 5 groups were assessed based on implant combinations (Charnley or Spectron EF stems with CPE or XLPE cups and CoCr or Oxinium heads). Migration and wear up to 2 years were evaluated against 18-year cup survival using receiver operating characteristic (ROC) curves.

Results: 19 cups (17 CPE, 2 XLPE) were loose at final follow-up. The area under the ROC curve (AUC) was 0.56 (95% confidence interval [CI] 0.40-0.73) for early migration and 0.85 (CI 0.77-0.94) for early polyethylene (PE) wear, with a difference of 0.29 (CI 0.09-0.49). Hazard ratio for loosening was 0.88 (CI 0.20-3.89) for early migration > 0.2 mm and 19.4 (CI 2.55-147) for early wear > 0.2 mm. At 18 years, survival free of aseptic loosening was 65% (CI 48-77) for CPE and 96% (CI 85-99) for XLPE cups, with a 9-fold higher risk of loosening for CPE.

Conclusion:  Early polyethylene wear, not migration, predicted long-term cup loosening. XLPE showed superior long-term performance over CPE with less wear, cup loosening, and revision.

Background and purpose:  Return to work is an important objective and measure of treatment success in the working-age population. Many patient-related factors have been shown to be associated with failure to resume working postoperatively. The aim of this longitudinal database study was to determine return to work rates in a 24-month follow-up after lumbar fusion. We also evaluated whether return to work was affected by the physical demand of work or the preoperative dominance of leg or back pain.

Methods:  348 consecutive patients available to the workforce underwent lumbar fusion. Return to work at 12 and 24 months was evaluated by patient questionnaires. Patients rated the physical demand of work into 3 categories: light, moderately demanding, or demanding. The surgeon identified the predominant symptom preoperatively, dividing patients into back and leg pain groups.

Results:  Return to work was 69% (95% confidence interval [CI] 64-73) and 76% (CI 71-81), at 12- and 24-month follow-ups, respectively. Patients in physically demanding work were less likely to resume working than patients in light work (63% vs 86% at 24 months, respectively). The predominant symptom did not affect return to work.

Conclusion:  In patients of working age, three-quarters of lumbar spine fusion patients returned to work within 2 years of surgery. Work absenteeism was higher in physically demanding occupations and only 60% of the patients with predominant leg pain returned to their physically heavy occupation in the first year following lumbar fusion.

Background and purpose:  Data on distal radius fractures (DRFs) with concomitant metaphyseal distal ulna fractures is limited. We aimed to determine whether a combined DRF and distal ulna fracture (DRUF) predicts a worse patient-reported outcome, measured by the Disabilities of the Arm, Shoulder, and Hand (DASH) score, 1 year after injury.

Methods:  This prospective registry-based cohort study included 5,536 adult patients with a DRF between 2003 and 2018. The 1-year DASH scores were recorded. All DRUFs were identified. Multivariable binary logistic regression assessed whether the presence of a distal ulna fracture predicted a 1-year DASH score > 35, indicating severe upper-extremity symptoms.

Results:  259 of 5,536 patients (4.7%) had a DRUF. Their mean age was 73 years (SD 15), and 86% were women. The median 1-year DASH score was higher in the combined fracture group compared with those with a DRF only (23, interquartile range [IQR] 5-45] vs 9, IQR 2-27, P < 0.001). A DRUF increased the odds of a 1-year DASH > 35 by 97% (OR 1.97, 95% confidence interval [CI] 1.40-2.75, P < 0.001). Surgical fixation of the DRF in DRUF patients was associated with lower odds of a worse outcome (OR 0.44, CI 0.23-0.85, P = 0.02). Distal ulna fracture fixation did not affect 1-year DASH (P = 0.7).

Conclusion:  The odds of having a DASH > 35, indicating severe symptoms, almost doubled at 1 year in patients with a DRUF compared with those with a DRF only.