Acta Orthopaedica最新文献

Background and purpose:  There is ongoing debate over whether results from randomized trials assigning patients to surgery or first-line treatment can be generalized to clinical practice. Therefore, we aimed to compare patients with hip osteoarthritis accepting enrollment in the Progressive Resistance Training versus Total Hip Arthroplasty (PROHIP) trial in Denmark with those declining (enrolled in an observational cohort [non-PROHIP]).

Methods:  We used a cross-sectional study design to compare demographics and patient-reported outcomes among patients eligible for enrollment in the PROHIP trial. We used the standardized difference (StdDiff), the absolute difference with 95% confidence interval (CI), and the propensity (odds ratio [OR]) of accepting participation in the PROHIP trial to assess imbalances between groups. We pre-specified that StdDiff values < 0.2 indicated a negligible difference, whereas values ≥ 0.8 indicated incomparability.

Results: 402 patients were included, with 109 in the PROHIP trial and 293 in the non-PROHIP cohort. Patients enrolled in the PROHIP trial had a mean (standard deviation [SD]) Oxford Hip Score at baseline of 25.1 (SD 5.9) compared with 22.6 (SD 6.9) in the non-PROHIP cohort (between-group difference, 2.5 points [CI 1.1-4.0], StdDiff 0.4, OR 1.06 [CI 1.02-1.10]). This pattern was consistent across almost all secondary patient-reported outcomes applied in the PROHIP trial. For most demographic variables, there were negligible between-group differences at baseline.

Conclusion:  We found minimal imbalances in some baseline demographic variables and most patient-reported outcomes, with those who accepted enrollment in the PROHIP trial having more favorable outcomes at recruitment than those who declined. However, most differences were not clinically important.

Background and purpose:  Traditional surgery for arthritis of the distal radioulnar joint (DRUJ), which typically involves resecting the ulnar head, is being increasingly challenged by newer techniques, such as prosthetic ulnar head replacement. The aim of our prospective cohort study was to investigate the clinical and patient-reported functional results, up to 2 years postoperatively, among patients with DRUJ arthritis treated with ulnar head replacement or resection.

Methods:  40 patients were included and underwent either ulnar head replacement (n = 22) or ulnar head resections (n = 18), due to DRUJ pathology between 2015 and 2020. Patients were followed up at 3, 6, 12, and 24 months postoperatively by the means of Patient-Rated Wrist Evaluation (PRWE) (primary outcome), and Disability of the Arm, Shoulder and Hand (DASH) questionnaires, pain, range of forearm rotation, and grip strength (secondary outcomes). Postoperative complications were recorded. 19 and 16 patients, respectively, responded at the 24-months follow-up. Female sex and inflammatory arthritis were more common in the resection group. General linear regression analyses adjusting for diagnosis and baseline PRWE score were performed for our primary outcome.

Results:  The median and interquartile range (IQR) improvement in PRWE from baseline to 24 months was 69 (IQR 49-87) to 27 (IQR 6-48) in the replacement group and 60 (IQR 50-86) to 23 (IQR 5-44) in the resection group, indicating that both groups improved from baseline. There were no differences in unadjusted estimates at any time point. The adjusted means in PRWE at 24 months were 35 and 26 points in the replacement and resection groups, respectively, corresponding to a statistically insignificant mean difference of 8.6 (95% confidence interval -11.7 to 28.2). We found no statistically significant group differences in any of the secondary outcomes at any time point. Postoperative complications affected 6 patients with ulnar head replacement, whereas none were reported for patients with ulnar head resection.

Conclusion:  We found that the outcome after ulnar head replacement is not superior to ulnar head resection in the short term.

Background and purpose:  The Oral Versus Intravenous Antibiotics (OVIVA) trial demonstrated that oral antibiotic therapy was noninferior to intravenous antibiotic therapy when used during the initial 6 weeks in the treatment of bone and joint infections (BJIs). We aimed to evaluate clinical outcomes, antibiotic treatment details, and complication rates following the implementation of the OVIVA protocol.

Methods:  All patients treated for BJIs between September 2019 and September 2020 at the specialized orthopedic infection unit of Herlev Hospital were eligible for inclusion. This study included data on patient demographics, antibiotic regimens, type of infection, microbiology, length of stay, adverse drug reactions, and definite treatment failure at 1 year.

Results:  A cohort of 129 patients was included. After a median of 7 days of intravenous therapy, 127 patients underwent an early switch to oral antibiotics. The most frequently used class of oral antibiotics was penicillins (68%). Adverse drug reactions, mostly gastrointestinal, occurred in 36% of all patients. Definite treatment failure at 1 year was 13% with oral antibiotics.

Conclusion:  We found a comparably low failure rate of 13% among patients who were able to transition to oral antibiotics when applying the treatment protocol from the OVIVA study.

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.