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Massardier E, Bauwens PH, Masson JB, Rongieras F, Bertani A. Survival and complications at a minimum 5years' follow-up of the modular Mark-2 Extreme™ cementless femoral stem: Does the reduced modularity resolve the mechanical issues of the Mark-I stem? Orthop Traumatol Surg Res 2023; 109:103613. [PMID: 37004733 DOI: 10.1016/j.otsr.2023.103613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 02/14/2023] [Accepted: 02/27/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION The Extreme™ modular stem was developed for implant revision with metaphyseal-diaphyseal defect. Due to the high breakage rate, a new "reduced modularity" design has been introduced, but without reported results. We therefore conducted a retrospective assessment of (1) overall stem survival, (2) functional results, (3) osseointegration, and (4) the rate of complications, and notably of mechanical failure. HYPOTHESIS Reduced modularity reduces the risk of revision surgery for mechanical failure. MATERIAL AND METHODS Forty-five prostheses were implanted between January 2007 and December 2010 in 42 patients with severe bone defect (Paprosky≥III) or periprosthetic shaft fracture. Mean age was 69.6years (range: 44-91years). Minimum follow-up was 5years, for a mean 115.4months (range: 60-156months). The main study endpoint was femoral stem survival, counting all-cause explantation as event. Functional assessment comprised subjective rating of satisfaction, Postel Merle d'Aubigné (PMA) and Harris Hip scores, and Forgotten Joint Score (FJS). Whether the revision assembly was carried out in situ, in the patient's hip, or outside, on the operating table, was not known in 2 cases; in the other 43, assembly was in situ in 15 cases (35%) and on the operating table in 28 (65%). RESULTS Five-year stem survival was 75.7% (95% CI: 61.9-89.5%), taking all causes of change together. Seventeen patients (45.9%) had complications, 13 (35.1%) requiring revision surgery, including 10 (27.0%) for stem replacement. Five patients (13.5%) had steam breakage at the junction between the metaphysis and the diaphyseal stem, 4 of which occurred within 2 years of implantation or of fixation of a periprosthetic fracture. Mean preoperative Harris score was 48.4 [IQR (25-75% interquartile range): 37-58] and PMA score 11.1 (IQR: 10-12), compared to respectively 74 (IQR: 67-89) and 13.6 (IQR: 12.5-16) at follow-up. Mean FJS at follow-up was 71.5 (IQR: 61-94.5). In the 15 in situ assemblies, there were 3 breakages (20%), compared to 2 (7.1%) in the 28 table assemblies (p=0.21). DISCUSSION The stem breakage rate was high despite the reduced modularity, which concentrated all stress on a single junction but without reducing the risk of mechanical failure. Surgical technique was faulty in some cases, with in situ assembly of the metaphysis after implanting the diaphyseal stem, which does not respect the manufacturer's recommendations. LEVEL OF EVIDENCE IV; retrospective study.
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Affiliation(s)
- Etienne Massardier
- Service de Chirurgie Orthopédique et Traumatologique Pavillon E, Hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, place d'Arsonval, 69008 Lyon, France.
| | - Paul-Henri Bauwens
- Service de Chirurgie Orthopédique et Traumatologique Pavillon E, Hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, place d'Arsonval, 69008 Lyon, France
| | - Jean-Baptiste Masson
- Service de Chirurgie Orthopédique et Traumatologique Pavillon E, Hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, place d'Arsonval, 69008 Lyon, France
| | - Frédéric Rongieras
- Service de Chirurgie Orthopédique et Traumatologique Pavillon E, Hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, place d'Arsonval, 69008 Lyon, France
| | - Antoine Bertani
- Service de Chirurgie Orthopédique et Traumatologique Pavillon E, Hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, place d'Arsonval, 69008 Lyon, France
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Jacquot L, Machenaud A, Bonnin MP, Chouteau J, Vidalain JP, Ramos-Pascual S, Saffarini M, Dubreuil S. Survival and Clinical Outcomes at 30 to 35 Years Following Primary Total Hip Arthroplasty With a Cementless Femoral Stem Fully Coated With Hydroxyapatite. J Arthroplasty 2022; 38:880-885. [PMID: 36496046 DOI: 10.1016/j.arth.2022.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/28/2022] [Accepted: 11/28/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The purpose of the present study was to update and report clinical outcomes and survival of primary total hip arthroplasty using a cementless double-tapered titanium fully hydroxyapatite-coated stem at a follow-up > 30 years. METHODS The outcomes of this series of 347 primary total hip arthroplasties were already published at a follow-up > 25 years, during which only 12 stems were revised. Since then, there were two additional stem revisions, bringing the total to 14 stem revisions (all of which also required cup revision). Patients still living with the original stem were assessed using the modified Harris Hip Score and patient satisfaction (very satisfied, satisfied, dissatisfied, and very dissatisfied). Revision incidence was calculated using the Kaplan-Meier (KM) method and Cumulative Incidence Function (CIF) at 35 years. RESULTS At a mean follow-up of 33 years (range, 31 to 35 years), 32 patients (34 hips) were still living with the original stem. Their mean modified Harris Hip Score was 86 points (range, 46 to 100) and all patients (100%) were very satisfied or satisfied with surgery. The revision incidence at 35 years considering (a) stem revision for any reason was 9.5% using KM and 4.5% using CIF; (b) stem revision for aseptic loosening was 3.1% using KM and 2.1% using CIF; and (c) reoperation or revision of any component for any reason was 45.3% using KM and 26.3% using CIF. CONCLUSION The present study has demonstrated excellent survival at 35 years for a cementless double-tapered titanium fully hydroxyapatite-coated stem. LEVEL OF EVIDENCE Level IV, Retrospective cohort study.
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Affiliation(s)
- Laurent Jacquot
- Artro Institute, Annecy Le Vieux, France; Clinique d'Argonay, Ramsay Santé, Annecy, France
| | - Alain Machenaud
- Artro Institute, Annecy Le Vieux, France; Clinique d'Argonay, Ramsay Santé, Annecy, France
| | - Michel P Bonnin
- Artro Institute, Annecy Le Vieux, France; Centre Orthopédique Santy, Hôpital Privé Jean Mermoz, Ramsay Santé, Lyon, France
| | - Julien Chouteau
- Artro Institute, Annecy Le Vieux, France; Clinique d'Argonay, Ramsay Santé, Annecy, France
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- ReSurg SA, Nyon, Switzerland
| | - Jean-Pierre Vidalain
- Artro Institute, Annecy Le Vieux, France; Clinique d'Argonay, Ramsay Santé, Annecy, France
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Thumser J, Cambon-Binder A, Even J, Babinet A, Anract P, Biau D. Sarcomas of the hand: A retrospective series of 26 cases. Orthop Traumatol Surg Res 2022; 108:102991. [PMID: 34144254 DOI: 10.1016/j.otsr.2021.102991] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 10/17/2020] [Accepted: 11/26/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Hand sarcomas frequently suffer from a delayed diagnosis, and the current guidelines for their management are often not followed. METHODS The objectives of our study were to determine: (1) the rate of inadequate initial treatments; (2) the rates of mortality, recurrence, and complementary excision in a cohort of patients with a sarcoma of the hand who were treated at our reference center between 2000 and 2015. RESULTS The series comprised 26 patients (mean age 40 years). Of the 20 patients not initially treated at a reference center, 17 had inadequate initial treatment. Of the six patients treated at our center, one had inadequate initial care. Significantly more patients had inadequate initial care outside a reference center (p=0.0045). The cumulative probabilities of recurrence or metastases at 5 years were 15% and 30%, respectively. Survival by cumulative incidence was 71% at 5 years and 56% at 10 years. CONCLUSIONS Sarcomas of the hand are a deadly pathology. All diagnostic uncertainty warrants referral of the patient to a reference center. LEVEL OF PROOF IV.
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Affiliation(s)
- Joannie Thumser
- Hôpital privé Armand-Brillard, 3-5, avenue Watteau, 94130 Nogent-sur-Marne, France.
| | - Adeline Cambon-Binder
- Sorbonne University, Orthopaedic and Trauma Department, Saint-Antoine Hospital, Paris, France
| | - Julien Even
- Clinique Internationale du Parc Monceau, Paris, France
| | - Antoine Babinet
- Paris-Descartes University, Orthopedic and Trauma Department, Cochin Hospital, Paris, France
| | - Philippe Anract
- Paris-Descartes University, Orthopedic and Trauma Department, Cochin Hospital, Paris, France
| | - David Biau
- Paris-Descartes University, Orthopedic and Trauma Department, Cochin Hospital, Paris, France
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Belgaïd V, Viste A, Fessy MH. Cementless hydroxyapatite-coated stem with dual mobility and posterior approach in over-80 year-old patients with osteoarthritis: Rates of dislocation and periprosthetic fracture at a mean 8 years' follow-up. Orthop Traumatol Surg Res 2022; 108:103196. [PMID: 34958972 DOI: 10.1016/j.otsr.2021.103196] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/31/2021] [Accepted: 02/03/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Straight cementless stems are common in primary total hip arthroplasty (THA) in the elderly, but controversial due to higher risk of loosening and periprosthetic fracture (PPF). Apart from registries, results for the Corail implant and dual mobility (DM) in over-80 years-old are not known, notably in case of systematic association to a DM cup. We therefore performed a retrospective analysis of Corail implants in patients aged≥80years at implantation for osteoarthritis of the hip, assessing 1) PPF rate and survival for cementless straight stems associated to DM cups, 2) complications, and dislocation in particular, and 3) clinical scores. HYPOTHESIS PPF and dislocation rates are low in THA with cementless straight stem associated to DM cup in patients aged≥80years. PATIENTS METHODS A retrospective study was conducted in our department for the period July 2007 to December 2012. Inclusion criteria were age≥80years, with primary THA for osteoarthritis. Exclusion criteria were revision procedure and femoral neck fracture. One hundred and twenty-eight consecutive THAs were included, in 120 patients, with a minimum 5years' follow-up. Clinical results were assessed on Harris Hip Score (HHS) and Oxford Hip Score (OHS). Data were collected for PPF or dislocation and other complications. RESULTS At a mean 8±1 years' follow-up (range, 5-10 years), 66 patients (55%, for 68 hips) were alive, 48 (40%, for 54 hips) had died, and 6 (5%, for 6 hips) were lost to follow-up. Median age at surgery was 83years (range, 80-93years). Mean OHS at last follow-up was 41±6 (range, 21-48) and HHS 83±14 (range, 23-100) with mean gain of 32 points (95% CI, [28-36]; p<0.001)). There were 2 cases (1.6%) of PPF, at 2 and 65months, and no dislocations or cases of aseptic loosening. There were 2 cases (1.6%) of intraoperative calcar fracture, treated by wire cerclage with immediate complete weight-bearing, without further complications. With death as a competing risk, cumulative 10-year incidence of femoral stem revision was 1.6% [95% CI: 0.4-6.5], and cumulative incidence of all-cause revision was 4.1% [95% CI: 1.7-9.7]. DISCUSSION In an over-80 year-old population, primary THA with straight cementless stem and 2nd generation dual mobility cup was an effective option with low risk of PPF or dislocation after a minimum 5-year of follow-up. LEVEL OF EVIDENCE IV; retrospective study.
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Affiliation(s)
- Vincent Belgaïd
- Service de chirurgie orthopédique et traumatologique, hospices Civils de Lyon, hôpital Lyon Sud, 165, Chemin du Grand Revoyet, 69495 Pierre Bénite Cedex, France
| | - Anthony Viste
- Service de chirurgie orthopédique et traumatologique, hospices Civils de Lyon, hôpital Lyon Sud, 165, Chemin du Grand Revoyet, 69495 Pierre Bénite Cedex, France; Univ de Lyon, Université Claude Bernard Lyon 1, Univ Gustave Eiffel, IFSTTAR, LBMC UMRT, 9406 Lyon, France.
| | - Michel-Henri Fessy
- Service de chirurgie orthopédique et traumatologique, hospices Civils de Lyon, hôpital Lyon Sud, 165, Chemin du Grand Revoyet, 69495 Pierre Bénite Cedex, France; Univ de Lyon, Université Claude Bernard Lyon 1, Univ Gustave Eiffel, IFSTTAR, LBMC UMRT, 9406 Lyon, France
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Lie SA, Fenstad AM, Lygre SHL, Kroken G, Dybvik E, Gjertsen JE, Hallan G, Dale H, Furnes O. Kaplan-Meier and Cox Regression Are Preferable for the Analysis of Time to Revision of Joint Arthroplasty: Thirty-One Years of Follow-up for Cemented and Uncemented THAs Inserted From 1987 to 2000 in the Norwegian Arthroplasty Register. JB JS Open Access 2022; 7:JBJSOA-D-21-00108. [PMID: 35224411 PMCID: PMC8865509 DOI: 10.2106/jbjs.oa.21.00108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Previous studies have suggested that the probability function of 1 minus the Kaplan-Meier survivorship overestimates revision rates of implants and that patient death should be included in estimates as a competing risk factor. The present study aims to demonstrate that this line of thinking is incorrect and is a misunderstanding of both the Kaplan-Meier method and competing risks. Methods: This study demonstrated the differences, misunderstandings, and interpretations of classical, competing-risk, and illness-death models with use of data from the Norwegian Arthroplasty Register for 15,734 cemented and 7,867 uncemented total hip arthroplasties (THAs) performed from 1987 to 2000, with fixation as the exposure variable. Results: The mean age was higher for patients who underwent cemented (72 years) versus uncemented THA (53 years); as such, a greater proportion of patients who underwent cemented THA had died during the time of the study (47% compared with 29%). The risk of revision at 20 years was 18% for cemented and 42% for uncemented THAs. The cumulative incidence function at 20 years was 11% for cemented and 36% for uncemented THAs. The prevalence of revision at 20 years was 6% for cemented and 31% for uncemented THAs. Conclusions: Adding death as a competing risk will always attenuate the probability of revision and does not correct for dependency between patient death and THA revision. Adjustment for age and sex almost eliminated differences in risk estimates between the different regression models. In the analysis of time until revision of joint replacements, classical survival analyses are appropriate and should be advocated. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Stein Atle Lie
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Dentistry, University of Bergen, Bergen, Norway
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Stein Håkon L Lygre
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
| | - Gard Kroken
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Eva Dybvik
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Jan-Erik Gjertsen
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Outcomes and survival of a modern dual mobility cup and uncemented collared stem in displaced femoral neck fractures at a minimum 5-year follow-up. Orthop Traumatol Surg Res 2022; 108:103164. [PMID: 34863956 DOI: 10.1016/j.otsr.2021.103164] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 09/02/2021] [Accepted: 09/27/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The choice of implant type for total hip replacement in the treatment of femoral neck fractures remains debated. Some authors advocate for the systematic use of cemented stems, while others do not use dual mobility first-line. We therefore conducted a retrospective study using a dual mobility cup (DMC) and an uncemented collared stem (UCS) in order to: (1) confirm the low dislocation rate in this indication, (2) assess other surgical complications, in particular periprosthetic fractures, (3) ensure that these benefits are maintained over time, at a minimum follow-up of 5 years and, (4) assess the rate of revision of the implants. HYPOTHESIS Our hypothesis was that the dual mobility dislocation rate for the treatment of femoral neck fractures was lower than for bipolar hemiarthroplasties or single mobility hip prostheses. PATIENTS AND METHODS A retrospective study of 244 femoral neck fractures (242 patients) treated with DMC and UCS was conducted, between 2013 and 2014. The mean age was 83±10 years (60-104). The occurrence of dislocation, periprosthetic fracture, infection of the surgical site, loosening, reoperation and revision were investigated. The HOOS Joint Replacement (JR) score was collected. The cumulative incidence with mortality was used as a competing risk. RESULTS The mean follow-up was 6 years±0.5 (5-7). At the last follow-up, 108 patients (50%) had died. Twenty-three patients (9.5%) were lost to follow-up. One case of symptomatic aseptic loosening of DMC was observed. The cumulative incidence of dislocations and periprosthetic fractures at 5 years were 2% (95% CI: 0.9-5.4) and 3% (95% CI: 1.2-6), respectively. The 5-year cumulative incidence of surgical site infections was 3.5% (95% CI: 1.8-7). The cumulative incidence of reoperations at 5 years was 7% (95% CI: 4.5-11). The causes of reoperation were periprosthetic fracture (n=6), infection (n=8), postoperative hematoma (n=2) and cup malposition (n=2). The cumulative incidence of a revision at 5 years was 2.7% (95% CI: 1.2-6). The cumulative incidence of a surgical complication from any cause at 5 years was 9% (95% CI: 6.7-14.8). The mean HOOS JR score was 79±5 (52-92). DISCUSSION The cumulative incidence of dislocation at 5 years is low and other surgical complications (including periprosthetic fractures) do not increase during this period for DMC associated with UCS, in femoral neck fractures. The use of this type of implant is reliable in the treatment of femoral neck fractures. LEVEL OF EVIDENCE IV; retrospective study without control group.
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Divecha HM, O'Neill TW, Lunt M, Board TN. The effect of uncemented acetabular liner geometry and lip size on the risk of revision for instability or loosening : a study on 202,511 primary hip arthroplasties from the National Joint Registry. Bone Joint J 2021; 103-B:1774-1782. [PMID: 34847718 DOI: 10.1302/0301-620x.103b12.bjj-2021-0471.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to determine if uncemented acetabular polyethylene (PE) liner geometry, and lip size, influenced the risk of revision for instability or loosening. METHODS A total of 202,511 primary total hip arthroplasties (THAs) with uncemented acetabular components were identified from the National Joint Registry (NJR) dataset between 2003 and 2017. The effect of liner geometry on the risk of revision for instability or loosening was investigated using competing risk regression analyses adjusting for age, sex, American Society of Anesthesiologists grade, indication, side, institution type, surgeon grade, surgical approach, head size, and polyethylene crosslinking. Stratified analyses by surgical approach were performed, including pairwise comparisons of liner geometries. RESULTS The distribution of liner geometries were neutral (39.4%; 79,822), 10° (34.5%; 69,894), 15° (21.6%; 43,722), offset reorientating (2.8%; 5705), offset neutral (0.9%; 1,767), and 20° (0.8%; 1,601). There were 690 (0.34%) revisions for instability. Compared to neutral liners, the adjusted subhazard ratios of revision for instability were: 10°, 0.64 (p < 0.001); 15°, 0.48 (p < 0.001); and offset reorientating, 1.6 (p = 0.010). No association was found with other geometries. 10° and 15° liners had a time-dependent lower risk of revision for instability within the first 1.2 years. In posterior approaches, 10° and 15° liners had a lower risk of revision for instability, with no significant difference between them. The protective effect of lipped over neutral liners was not observed in laterally approached THAs. There were 604 (0.3%) revisions for loosening, but no association between liner geometry and revision for loosening was found. CONCLUSION This registry-based study confirms a lower risk of revision for instability in posterior approach THAs with 10° or 15° lipped liners compared to neutral liners, but no significant difference between these lip sizes. A higher revision risk is seen with offset reorientating liners. The benefit of lipped geometries against revision for instability was not seen in laterally approached THAs. Liner geometry does not seem to influence the risk of revision for loosening. Cite this article: Bone Joint J 2021;103-B(12):1774-1782.
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Affiliation(s)
- Hiren M Divecha
- Centre for Hip Surgery, Wrightington Hospital, Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Terence W O'Neill
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal & Dermatological Sciences, University of Manchester, Manchester, UK.,Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK.,NIHR Manchester Biomedical Research Centre, Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Mark Lunt
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal & Dermatological Sciences, University of Manchester, Manchester, UK
| | - Tim N Board
- Centre for Hip Surgery, Wrightington Hospital, Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, UK
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Lacny S, Faris P, Bohm E, Woodhouse LJ, Robertsson O, Marshall DA. Competing Risks Methods Are Recommended for Estimating the Cumulative Incidence of Revision Arthroplasty for Health Care Planning Purposes. Orthopedics 2021; 44:e549-e555. [PMID: 34292813 DOI: 10.3928/01477447-20210618-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Cumulative incidence of revision provides a measure of the failure rate of joint replacements and can be used to project demand for revisions. The most commonly applied survival analysis method (Kaplan-Meier [KM]) does not account for competing risks (eg, death). The authors compared the cumulative incidence function (CIF), a competing risks method, with the KM method through application to population-based cohorts. They measured time to revision, death, or censoring for unilateral total hip arthroplasty (THA; n=12,496) and total knee arthroplasty (TKA; n=19,172) cohorts in administrative databases in Alberta and TKAs (n=80,177) in the Swedish Knee Arthroplasty Register. The authors compared relative differences between the KM and CIF. They fitted Cox, Fine and Gray, and Royston and Parmar regression models and compared coefficients, standard errors, and P values. On sensitivity analysis, the authors included staged bilateral operations. Kaplan-Meier estimates exceeded the CIF at each time point. The magnitude of overestimation increased with follow-up time and was greatest for the Swedish cohort. At 5 years, relative differences between KM and CIF estimates for the Alberta THA and TKA and Swedish TKA cohorts were 1.8%, 2.3%, and 3.8%, respectively. These differences increased to 3.1%, 5.8%, and 8.2%, respectively, at 9 years, reaching 39.1% at 20 years (Swedish cohort). On sensitivity analysis (including staged bilateral operations), the Fine and Gray subdistribution hazard ratio differed from the Cox and Royston and Parmar hazard ratios. When the frequency of competing risks is high, competing risks methods are recommended to obtain accurate cumulative incidence estimates for informing health care planning and decision making. [Orthopedics. 2021;44(4):e549-e555.].
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Testing the proportional hazards assumption in cox regression and dealing with possible non-proportionality in total joint arthroplasty research: methodological perspectives and review. BMC Musculoskelet Disord 2021; 22:489. [PMID: 34049528 PMCID: PMC8161573 DOI: 10.1186/s12891-021-04379-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 05/18/2021] [Indexed: 12/18/2022] Open
Abstract
Background Survival analysis and effect of covariates on survival time is a central research interest. Cox proportional hazards regression remains as a gold standard in the survival analysis. The Cox model relies on the assumption of proportional hazards (PH) across different covariates. PH assumptions should be assessed and handled if violated. Our aim was to investigate the reporting of the Cox regression model details and testing of the PH assumption in survival analysis in total joint arthroplasty (TJA) studies. Methods We conducted a review in the PubMed database on 28th August 2019. A total of 1154 studies were identified. The abstracts of these studies were screened for words “cox and “hazard*” and if either was found the abstract was read. The abstract had to fulfill the following criteria to be included in the full-text phase: topic was knee or hip TJA surgery; survival analysis was used, and hazard ratio reported. If all the presented criteria were met, the full-text version of the article was then read. The full-text was included if Cox method was used to analyze TJA survival. After accessing the full-texts 318 articles were included in final analysis. Results The PH assumption was mentioned in 114 of the included studies (36%). KM analysis was used in 281 (88%) studies and the KM curves were presented graphically in 243 of these (87%). In 110 (45%) studies, the KM survival curves crossed in at least one of the presented figures. The most common way to test the PH assumption was to inspect the log-minus-log plots (n = 59). The time-axis division method was the most used corrected model (n = 30) in cox analysis. Of the 318 included studies only 63 (20%) met the following criteria: PH assumption mentioned, PH assumption tested, testing method of the PH assumption named, the result of the testing mentioned, and the Cox regression model corrected, if required. Conclusions Reporting and testing of the PH assumption and dealing with non-proportionality in hip and knee TJA studies was limited. More awareness and education regarding the assumptions behind the used statistical models among researchers, reviewers and editors are needed to improve the quality of TJA research. This could be achieved by better collaboration with methodologists and statisticians and introducing more specific reporting guidelines for TJA studies. Neglecting obvious non-proportionality undermines the overall research efforts since causes of non-proportionality, such as possible underlying pathomechanisms, are not considered and discussed. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04379-2.
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Chatelet JC, Ait-Si-Selmi T, Machenaud A, Ramos-Pascual S, Fessy MH. Mid-Term Clinical and Radiographic Outcomes of a Long Cementless Monobloc Stem for Revision Total Hip Arthroplasty. J Arthroplasty 2021; 36:261-267. [PMID: 32819781 DOI: 10.1016/j.arth.2020.07.057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND For the past 2 decades, the authors have been using a long tapered cementless stem made of titanium and fully coated with hydroxyapatite for revision total hip arthroplasty. The purpose of this multicentric study is to assess clinical outcomes, radiographic outcomes, re-revision rates, and survival rates of this revision stem at a minimum 5-year follow-up. METHODS The records of a multicentric continuous series of 335 adults undergoing revision total hip arthroplasty using the Corail revision stem (DePuy, Leeds, UK) between 2000 and 2012 were retrospectively reviewed. The Harris Hip Score, Oxford Hip Score, and Engh score were recorded. Survival was assessed using the Kaplan-Meier method and cumulative incidence function. RESULTS Seventy-seven patients died with their revision stem in place, 47 could not be contacted, and 22 had stem re-revisions. This left a final cohort of 201 patients, aged 70 ± 12 years at revision surgery, with a body mass index of 26 ± 4. The Kaplan-Meier survival was 93.9% for re-revision of any component for any reason, 96.7% for re-revision of the stem for any reason, and 99.3% for re-revision of the stem for aseptic reasons. At last follow-up, the Harris Hip Score was 84.8 ± 13.1, the Oxford Hip Score was 21.0 ± 7.8, and the Engh score was 16.4 ± 6.7. CONCLUSION The long tapered cementless revision stem had excellent clinical and radiographic outcomes at a minimum follow-up of 5 years. The revision stem enabled restoration of bone stock in femurs with pre-revision bone defects, confirming that the hydroxyapatite coating promotes osseointegration, even in femurs with extensive bone loss. LEVEL OF EVIDENCE Level IV, retrospective cohort study.
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Affiliation(s)
- Jean-Christophe Chatelet
- Artro Institute, Lyon, France; Ramsay Santé, Centre de Chirurgie Orthopédique du Beaujolais, Arnas, France
| | - Tarik Ait-Si-Selmi
- Artro Institute, Lyon, France; Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
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- Artro Institute, Lyon, France
| | - Michel-Henri Fessy
- Artro Institute, Lyon, France; Department of Orthopaedic Surgery and Sports Medicine, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
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Pommepuy T, Putman S, May O, Miletic B, Ramos-Pascual S, Migaud H. Influence of Geometry and Extent of Coating on Survival of Cementless Distal-Locking Revision Stems at 7 to 18 Years. J Arthroplasty 2020; 35:3703-3709. [PMID: 32768257 DOI: 10.1016/j.arth.2020.06.090] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND We aimed to compare the long-term clinical outcomes, complications, and survival of 2 revision stems with different geometries, extents of coating, and distal-locking mechanisms. METHODS We retrospectively compared outcomes at a minimum of 7 years following revision THA using 2 proximally coated distal-locking stems: 98 Ultime first-generation (G1) and 116 Linea second-generation (G2) stems. Ten-year Kaplan-Meier survival was assessed considering stem re-revision for any reason and for aseptic reasons. At final follow-up, Harris Hip Score and Oxford Hip Score were collected, and any thigh pain or complications were noted. RESULTS Considering re-revision for any reason, survival was 69% for G1 stems and 91% for G2 stems. Considering re-revision for aseptic reasons, survival was 77% for G1 stems and 92% for G2 stems. Re-revisions were due to fracture of 6 G1 stems but no G2 stems. Complications that required reoperation without stem or cup removal occurred in 3 of the G1 stems and 1 of the G2 stems. Compared to the G1 stems, the G2 stems resulted in better Harris Hip Score (83 vs 71, P = .001), Oxford Hip Score (22 vs 27, P = .019), less thigh pain (4% vs 39%, P < .001), and fewer nonoperated complications (9% vs 15%). CONCLUSION The second-generation stem had significantly better survival and clinical outcomes than the first-generation stem. The differences in survival and clinical outcomes could be attributed to the larger coated surface of the G2 stem and to the fact that the G1 stem was originally intended as a temporary implant to be followed by de-escalation.
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Affiliation(s)
- Thomas Pommepuy
- Département Universitaire de Chirurgie Orthopédique et Traumatologique, Univ. Lille, CHU Lille, Lille, France; Service d'orthopédie C, Hôpital Roger Salengro, Centre Hospitalier Régional Universitaire de Lille, Lille, France; Clinique d'Arcachon, La Teste de Buch, France
| | - Sophie Putman
- Département Universitaire de Chirurgie Orthopédique et Traumatologique, Univ. Lille, CHU Lille, Lille, France; Service d'orthopédie C, Hôpital Roger Salengro, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Olivier May
- Département Universitaire de Chirurgie Orthopédique et Traumatologique, Univ. Lille, CHU Lille, Lille, France; Service d'orthopédie C, Hôpital Roger Salengro, Centre Hospitalier Régional Universitaire de Lille, Lille, France; Clinique Médipole-Garonne, Toulouse, France
| | - Bruno Miletic
- Département Universitaire de Chirurgie Orthopédique et Traumatologique, Univ. Lille, CHU Lille, Lille, France; Service d'orthopédie C, Hôpital Roger Salengro, Centre Hospitalier Régional Universitaire de Lille, Lille, France; Clinique la Louviere, Rue de la Louvière, Lille, France
| | | | - Henri Migaud
- Département Universitaire de Chirurgie Orthopédique et Traumatologique, Univ. Lille, CHU Lille, Lille, France; Service d'orthopédie C, Hôpital Roger Salengro, Centre Hospitalier Régional Universitaire de Lille, Lille, France
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What Is the Risk of THA Revision for ARMD in Patients with Non-metal-on-metal Bearings? A Study from the Australian National Joint Replacement Registry. Clin Orthop Relat Res 2020; 478:1244-1253. [PMID: 32345846 PMCID: PMC7319380 DOI: 10.1097/corr.0000000000001277] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are increasing reports of corrosion between the femoral head and trunnion in primary conventional THA, resulting in metal particulate release often termed trunnionosis. There may be heightened awareness of this condition because of severe soft-tissue reactions initially thought to be solely attributable to prostheses with a metal-on-metal (MoM) bearing surface. It is unclear what percentage of revisions for THA with non-MoM bearing surfaces can be attributed to trunnionosis and to what extent adverse reaction to metal debris (ARMD) seen with MoM bearings may also be seen with other bearing surfaces in THA. QUESTIONS/PURPOSES We analyzed data from a large national registry to ask: (1) What is the revision risk for the indication of ARMD in patients with conventional THA and modern non-MoM bearing surfaces such as metal or ceramic-on-cross-linked polyethylene (XLPE) or ceramic-on-ceramic? (2) What prosthesis factors are associated with an increased risk of such revision? (3) What is the relative revision risk for ARMD in THAs with large-head MoM bearings, small-head MoM bearings, and non-MoM modern bearing surfaces? METHODS The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) longitudinally maintains data on all primary and revision joint arthroplasties, with nearly 100% capture. The study population included all THAs using modern bearing surfaces (defined as metal or ceramic heads-on-XLPE and ceramic-on-ceramic bearing couples) revised because of ARMD between September 1999 and December 2018. Prostheses with modular necks were excluded. The cumulative percent revision (CPR) because of ARMD was determined. The study group consisted of 350,027 THAs with a modern bearing surface, 15,184 THAs with a large-head MoM bearing (≥ 36 mm), and 5474 THAs with a small head MoM bearing (≤ 32 mm). The patients in the group who received the modern bearing surfaces were slightly older than the patients in the groups who received the large- and small-head bearing surfaces, with a mean age 68 years (SD 12) versus a mean age 63 years (SD 12), and a mean age 62 years (SD 11), respectively. There was a higher proportion of women in the modern bearing surface group; 55% (193,312 of 350,027), compared with 43% (6497 of 15,184) in the large-head MoM group and 50% (2716 of 5474) in the small-head MoM group. The outcome measure was the CPR, which was defined using Kaplan-Meier estimates of survivorship to describe the time to the first revision for ARMD at 17 years. Hazard ratios (HR) from Cox proportional hazards models, adjusting for age and sex, were performed to compare the revision rates among groups. The registry defines a revision as a reoperation of a previous hip arthroplasty in which one or more of the prosthetic components is replaced or removed, or one or more components is added. RESULTS The CPR for ARMD for patients with a modern bearing surface at 17 years was 0.1% (95% confidence interval 0.0 to 0.1). After controlling for age and sex, we found that cobalt chrome heads, two specific prostheses (Accolade® I and M/L Taper), and head sizes ≥ 36 mm were associated with an increased risk of revision for ARMD. Metal-on-XLPE had a higher risk of revision for ARMD than ceramic-on-ceramic or ceramic-on-XLPE (HR 3.4 [95% CI 1.9 to 6.0]; p < 0.001). The Accolade 1 and the M/L Taper stems had a higher risk of revision than all other stems (HR, 8.3 [95% CI 4.7 to 14.7]; p < 0.001 and HR 14.4 [95% CI 6.0 to 34.6]; p < 0.001, respectively). Femoral stems with head sizes ≥ 36 mm had a higher rate of revision for ARMD than stems with head sizes ≤ 32 mm (HR 3.2 [95% CI 1.9 to 5.3]; p < 0.001).Large-head MoM bearings had a greater increase in revision for ARMD compared with modern bearing surfaces. The CPR for patients with a large-head MoM bearing at 17 years for ARMD was 15.5% (95% CI 14.5 to 16.6) and it was 0.1% for modern bearing surfaces (HR 340 [95% CI 264.2 to 438.0]; p < 0.001). Modern bearing surfaces likewise had a lower HR for revision for ARMD than did THAs with small-head MoM bearings, which had a 0.9% (95% CI 0.7 to 1.4) CPR compared with modern bearings from 0 to 9 years (HR 10.5 [95% CI 6.2 to 17.7]; p < 0.001). CONCLUSIONS The revision risk for ARMD with modern bearing surfaces in THA is low. The Accolade 1 and the M/L Taper stem have a higher risk of revision for ARMD and cobalt-chrome heads, and head sizes ≥ 36 mm have a higher rate of revision than ≤ 32 mm head sizes. ARMD is a rare failure mode for THA with non-MoM bearings, but in patients presenting with unexplained pain with no other obvious cause, this diagnosis should be considered and investigated further. LEVEL OF EVIDENCE Level III, therapeutic study.
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Fessy MH, Jacquot L, Rollier JC, Chouteau J, Ait-Si-Selmi T, Bothorel H, Chatelet JC. Midterm Clinical and Radiographic Outcomes of a Contemporary Monoblock Dual-Mobility Cup in Uncemented Total Hip Arthroplasty. J Arthroplasty 2019; 34:2983-2991. [PMID: 31444020 DOI: 10.1016/j.arth.2019.07.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/09/2019] [Accepted: 07/19/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The efficacy of contemporary monoblock dual-mobility (DM) cups to prevent dislocations in total hip arthroplasty (THA) is well reported, but there is little published data on their mid- to long-term outcomes. The authors aimed at reporting the 10-year survival of a contemporary DM cup as well as its clinical and radiographic outcomes. METHODS From a retrospective consecutive multicentric series of 516 patients (541 hips) that received uncemented THA between June 2007 and June 2010, 6 patients (6 hips) had cup and stem revisions, 5 patients (5 hips) had isolated stem revision, and 2 patients (2 hips) had isolated insert revision. A total of 103 patients (111 hips) died with their original implants, and 41 patients (42 hips) were lost to follow-up. This left 358 patients (375 hips) for clinical assessment at a median follow-up of 8.7 years (range, 6.8-10.5 years), including 279 patients (290 hips) with postoperative radiographs. Implant survival was calculated using the Kaplan-Meier method, and multivariable analyses were performed to determine whether clinical outcomes are associated with patient or surgical factors. RESULTS The 10-year survival considering revision for aseptic loosening as end point was 100% for the cup and 99.2% for the stem. No dislocations were observed, and radiographic assessment revealed 1 acetabular granuloma (0.3%), but no radiolucencies nor fractures. The Harris hip score improved from 49.6 ± 15.5 to 85.2 ± 14.5, and the postoperative Oxford hip score was 19.2 ± 7.6. Multivariable analyses revealed that improvement in Harris hip score increased with cup diameter (beta, 1.28; P = .039). CONCLUSION Our data confirmed satisfactory midterm outcomes of uncemented THA using a contemporary DM cup, with no dislocations nor cup revisions due to aseptic loosening. LEVEL OF EVIDENCE Level IV, retrospective cohort study.
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Affiliation(s)
- Michel-Henri Fessy
- Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Service de Chirurgie Orthopédique et Traumatologique, Pierre-Bénite Cedex, France; IFSTTAR, UMRT_9406, Laboratoire de Biomécanique et Mécanique des Chocs, Bron, France; Artro Group Institute, Lyon, France
| | - Laurent Jacquot
- Artro Group Institute, Lyon, France; Ramsay Générale de Santé, Department of Orthopaedic Surgery, Clinique d'Argonay, Annecy, France
| | - Jean-Charles Rollier
- Artro Group Institute, Lyon, France; Ramsay Générale de Santé, Department of Orthopaedic Surgery, Clinique d'Argonay, Annecy, France
| | - Julien Chouteau
- Artro Group Institute, Lyon, France; Ramsay Générale de Santé, Department of Orthopaedic Surgery, Clinique d'Argonay, Annecy, France
| | - Tarik Ait-Si-Selmi
- Artro Group Institute, Lyon, France; Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | | | - Jean-Christophe Chatelet
- Artro Group Institute, Lyon, France; Ramsay Générale de Santé, Centre de Chirurgie Orthopédique du Beaujolais, Arnas, France
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Are Hooded, Crosslinked Polyethylene Liners Associated with a Reduced Risk of Revision After THA? Clin Orthop Relat Res 2019; 477:1315-1321. [PMID: 31136427 PMCID: PMC6554106 DOI: 10.1097/corr.0000000000000710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hooded acetabular liners and head sizes ≥ 32 mm have both shown to have a beneficial effect on the revision rate for dislocation in THA. Experience with noncrosslinked polyethylene (nonXLPE) raised concerns regarding the risk of impingement damage, loosening, and osteolysis with hooded liners; however, the evidence for this in crosslinked polyethylene (XLPE) is inconclusive. The interaction between different femoral head sizes and hooded liners is not well understood, and it is unclear whether hooded XLPE liners have a beneficial effect on overall long-term survivorship. QUESTIONS/PURPOSES We analyzed a large national joint registry to ask: (1) Is the use of hooded XLPE liners associated with a reduced revision rate for dislocation compared with nonhooded liners? (2) Is there a difference in the revision rate for aseptic loosening/osteolysis? (3) Is head size associated with any difference in the revision rate between hooded and nonhooded liners? METHODS The Australian Orthopaedic Association National Joint Replacement Registry longitudinally maintains data on all primary and revision joint arthroplasties with nearly 100% capture. We analyzed all conventional primary THAs performed from registry inception in September 1999 until December 31, 2016 in patients with a diagnosis of osteoarthritis who had nonhooded or hooded XLPE bearings in a cementless acetabular shell. The study group included 192,659 THA procedures with XLPE liners, of which 67,904 were nonhooded and 124,755 were hooded. The mean age of patients receiving nonhooded liners was 70 years (range, 11-100 years); 44% were males. This was similar to the patients with hooded liners, who had a mean age of 70 years (range, 16-100 years); 45% were males. The main outcome measure was the cumulative percent revision at 15 years of the THA using Kaplan-Meier estimates of survivorship. We examined reasons for revision and and performed multivariable analysis to control for the confounding factors of three head size groups (< 32mm, 32mm, and > 32mm) and for the method of femoral fixation. RESULTS There was a higher revision rate for dislocation for patients with nonhooded liners at all times to 15 years (HR, 1.31; 95% CI, 1.17-1.47; p < 0.001). There was a higher revision rate for the diagnosis of aseptic loosening/osteolysis with patients with nonhooded liners compared with hooded liners (HR, 1.19; 95% CI, 1.05-1.34; p = 0.006). Head sizes of 32 mm or larger were independently associated with a lower comparative revision rate between hooded and nonhooded liners, but this was not apparent for head sizes smaller than 32 mm. It appeared that the main driver of the finding in larger heads was a reduced dislocation risk with hooded liners for 32 mm heads (HR, 1.50; 95% CI, 1.23-1.80; p < 0.001) and for heads larger than 32 mm (HR, 1.50; 95% CI, 1.20-1.89; p < 0.001). CONCLUSIONS Prior research has suggested that hooded acetabular liners may be associated with impingement, loosening, and osteolysis; however, in this large, registry-based report we found that XLPE hooded liners are not associated with an increased revision rate for aseptic loosening/osteolysis. Although there are many potential confounding variables in this registry analysis, if anything, surgeons using larger femoral heads and hooded liners likely did so in patients with a higher perceived dislocation risk. Patients with larger heads and XLPE hooded liners were, however, less likely to experience revision for dislocation. These liners therefore appear reasonable to use in primary THA at the surgeon's discretion. LEVEL OF EVIDENCE Level III, therapeutic study.
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Patellofemoral design enhancements reduce long-term complications of postero-stabilized total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2019; 27:1241-1250. [PMID: 30203198 DOI: 10.1007/s00167-018-5137-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 09/06/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE Few studies investigated whether trochlear and patellar design enhancements improve long-term outcomes of total knee arthroplasty (TKA). This study aimed to compare the long-term survival and complication rates of two consecutive generations of the same TKA system with identical tibiofemoral geometry, but different patellofemoral designs. METHODS The authors retrieved the records of 93 patients (104 knees) operated with the HLS II system and 116 patients (122 knees) operated with HLS Evolution system. Patients were evaluated preoperatively and at a minimum of 10 years noting all complications. Kaplan-Meier (KM) survival was compared for two endpoints: (1) revision of all components and (2) revision of any component. RESULTS From the HLS II series, the incidence of revision of all components was 6.4%, and of any component was 9.8%. From the HLS Evolution series, the incidence of revision of all components was 4.1%, and of any component was 5.1%. Comparing the survival at equivalent follow-up of 14 years, considering revision of all components, the HLS II had higher survival than the HLS Evolution (98.9% vs 95.9%), while considering revision of any component, the HLS II had lower survival than the HLS Evolution (93.0% vs 94.9%). The differences in survival of the two implants were not significant, neither at equivalent follow-up of 14 years (n.s.), nor at maximum follow-up of each cohort (n.s.). The complication rate was higher for the HLS II series compared to the HLS Evolution (28% vs 12%, p = 0.009), but patellofemoral complications were not more frequent (8% vs 6%, n.s.). CONCLUSIONS Though the differences in survival of the two implants were not significant, conflicting findings are observed due to partial revisions for patellar fractures (5 in the HLS II series and 1 in the HLS Evolution series) which could be related to patellofemoral design enhancements. This study highlights the importance of patello-femoral geometry, which is often overlooked in TKA. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
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Is a Cephalomedullary Nail Durable Treatment for Patients With Metastatic Peritrochanteric Disease? Clin Orthop Relat Res 2018; 476:2392-2401. [PMID: 30299285 PMCID: PMC6259881 DOI: 10.1097/corr.0000000000000523] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although cephalomedullary nail fixation is often used for metastatic peritrochanteric lesions of the femur, there is concern regarding the durability of the implant in comparison to endoprosthetic reconstruction. Previous studies have reported the proportion of patients who undergo reoperation for loss of stability, but the adequacy of the construct has not been critically evaluated in a competing risk analysis that incorporates death of the patient in the calculation. QUESTIONS/PURPOSES (1) What is the cumulative incidence of reoperation of cephalomedullary nails with death as a competing risk for metastatic lesions of the proximal femur? (2) What is the survival of patients with metastases to the proximal femur after cephalomedullary nailing? (3) What clinical factors are associated with implant stability in these patients? METHODS Between 1990 and 2009, 11 surgeons at one center treated 217 patients with cephalomedullary nails for metastatic proximal femoral lesions. This represented 40% (217 of 544) of the patients undergoing surgery for metastases in this location during the study period. In general, we used cephalomedullary nails when there was normal bone in the femoral head, no fracture in the neck, and a moderate-sized lesion; we favored bipolar hemiarthroplasty for femoral neck fractures and disease affecting the femoral head; finally, we used proximal femoral endoprosthetic replacement for large lesions with severe bone destruction. A retrospective study was conducted of 199 patients with cephalomedullary nails for peritrochanteric metastases from 1990 to 2009. Pathologic fracture, defined as a breach in cortex with a clear fracture line either with or without displacement, was present in 61 patients. The most common primary cancers were breast (42 of 199 patients [21%]), lung (37 of 199 patients [18%]), and renal cell (34 of 199 patients [17%]). A competing risk analysis was performed to describe the cumulative incidence of implant revision. Patient overall survival was assessed by Kaplan-Meier survivorship. A univariate analysis was performed to determine whether there was an association between revision surgery and various patient factors, including tumor histology, pathologic fracture, cementation, and radiation. RESULTS Loss of implant stability necessitating revision surgery occurred in 19 of 199 patients (10%). In a competing risk analysis with death of the patient as the competing event, the cumulative incidence of revision surgery was 5% (95% confidence interval [CI], 3%-9%) at 12 months and 9% (95% CI, 5%-13%) at 5 years. Using Kaplan-Meier analysis, the overall patient survival was 31% (95% CI, 25%-37%) at 12 months and 5% (95% CI, 3%-9%) at 60 months. Patients with lung cancer had the shortest overall survival of 11% (95% CI, 1%-21%) at 12 months, and patients with multiple myeloma had the longest overall survival of 71% (95% CI, 49%-94%) at 12 months (p < 0.001). Duration of patient survival beyond the median 7 months was the only factor associated with a greater likelihood of revision surgery. Factors not associated with revision included tumor histology, pathologic fracture, closed versus open nailing, cementation, gender, age, and postoperative radiation. CONCLUSIONS The competing risk analysis demonstrates a relatively low cumulative incidence of reoperation and suggests that cephalomedullary nailing is reasonable for patients with moderate-sized proximal femoral metastasis not affecting the femoral head. For the large majority of patients, the construct achieves the goal of stabilizing the femur for the duration of the patient's life. Longer patient survival was associated with greater risk of revision surgery, but no particular tumor histology was found to have a greater cumulative incidence of reoperation. Future work with a larger number of patients and stricter surgical indications may be needed to corroborate these findings. LEVEL OF EVIDENCE Level III, therapeutic study.
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Herry Y, Viste A, Bothorel H, Desmarchelier R, Fessy MH. Long-term survivorship of a monoblock long cementless stem in revision total hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2018; 43:2279-2284. [DOI: 10.1007/s00264-018-4186-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 09/24/2018] [Indexed: 01/23/2023]
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Mortensen JK, Johnsen SP, Andersen G. Prescription and predictors of post-stroke antidepressant treatment: A population-based study. Acta Neurol Scand 2018; 138:235-244. [PMID: 29691834 DOI: 10.1111/ane.12947] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2018] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Post-stroke depression and pathological crying are common and potentially serious complications after stroke and should be diagnosed and treated accordingly. Diagnosis and treatment probably rely on clinical experience and may pose certain challenges. We aimed to examine prescription and predictors of antidepressant treatment after ischemic stroke in a clinical setting. MATERIALS AND METHODS In this registry-based follow-up study, consecutive ischemic stroke patients were identified from the Danish Stroke Registry, holding information on antidepressant treatment during admission in Aarhus County from 2003 to 2010. Information on prescription after discharge was obtained from the Danish Prescription Database. Treatment initiation was analyzed using the cumulative incidence method including death as a competing risk. Multiple logistic regression was used to identify potential predictors of treatment. RESULTS Among 5070 consecutive first-ever ischemic stroke patients without prior antidepressant treatment, the cumulative incidence of antidepressant treatment and prescription over 6 months was 35.2% (95% CI: 33.8-36.6). Overall 16.5% (95% CI: 15.5-17.6) started treatment within 14 days corresponding to 48.1% (95% CI: 45.8-50.5) of all treated patients, and the most widely prescribed group of antidepressants was selective serotonin reuptake inhibitors (86%). Increasing stroke severity was associated with higher odds of initiating treatment. CONCLUSION Antidepressant treatment in this real-life clinical setting was common and initiated early, in almost half the treated patients within 14 days. Our results suggest that special focus should be given to the severe strokes as they may have a greater risk of requiring treatment.
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Affiliation(s)
- J. K. Mortensen
- Department of Neurology; Danish Stroke Centre; Aarhus University Hospital; Aarhus C Denmark
| | - S. P. Johnsen
- Department of Clinical Epidemiology; Aarhus University Hospital; Aarhus C Denmark
| | - G. Andersen
- Department of Neurology; Danish Stroke Centre; Aarhus University Hospital; Aarhus C Denmark
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Considerations for analysis of time-to-event outcomes subject to competing risks in veterinary clinical studies. J Vet Cardiol 2018; 20:143-153. [DOI: 10.1016/j.jvc.2018.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 02/28/2018] [Accepted: 03/15/2018] [Indexed: 12/19/2022]
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Abstract
Background and purpose - The use of competing risks models is widely advocated in the arthroplasty literature due to a perceived bias in comparison of simple Kaplan-Meier estimates. Proponents of competing risk models in the arthroplasty literature appear to be unaware of the subtle but important differences in interpretation of net and crude failure estimated by competing risk and Kaplan-Meier methods respectively. Methods - Using a simple simulation we illustrate the differences between competing risks and Kaplan-Meier methods. Results - Competing risk and Kaplan-Meier methods estimate different survival quantities, i.e., crude and net failure respectively. Estimates of crude failure estimated using competing risk methods will be less than net failure as estimated using Kaplan-Meier methods. Interpretation - Kaplan-Meier methods are appropriate for describing implant failure, whereas crude survival estimated using competing risk methods estimates the risk of surgical revision as it depends on both implant failure and mortality. Both competing risk models and Kaplan-Meier methods are useful in arthroplasty, and both provide unbiased estimates of crude and net failure in the absence of any confounding or selection respectively. Surgeons and researchers should carefully consider whether the use of competing risks is always justified. Lower estimates of failure from competing risk models may be misleading to surgeons who are attempting to select the best implants with the lowest failure rates for their patients.
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Affiliation(s)
- Adrian Sayers
- Musculoskeletal Research Unit, Bristol Medical School, Southmead Hospital, Bristol,Population Health Sciences, Bristol Medical School, Bristol,Correspondence:
| | - Jonathan T Evans
- Musculoskeletal Research Unit, Bristol Medical School, Southmead Hospital, Bristol
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Bristol Medical School, Southmead Hospital, Bristol,National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Bristol Medical School, Southmead Hospital, Bristol,National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, UK
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de Steiger R, Peng A, Lewis P, Graves S. What Is the Long-term Survival for Primary THA With Small-head Metal-on-metal Bearings? Clin Orthop Relat Res 2018; 476:1231-1237. [PMID: 29432270 PMCID: PMC6263567 DOI: 10.1007/s11999.0000000000000209] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Large-head metal-on-metal (MoM) bearing hip replacements have been shown to have a much higher rate of revision than other bearing surfaces. However, small-head (≤ 32 mm) MoM bearing surfaces have been in use for many years with several reports of satisfactory mid- to long-term survivorship. It is unclear whether the long-term survival of small-head MoM devices will continue to be satisfactory or whether the same concerns seen with the large-head MoM devices will ultimately become more prevalent. QUESTIONS/PURPOSES We analyzed a large national registry to ask: (1) What is the 15-year Kaplan-Meier survivorship of primary conventional THA using small-head (≤ 32 mm) MoM bearing surfaces compared with large-head MoM bearing surfaces in primary THA? (2) Is there an increased rate of revision for adverse reaction to metal debris (ARMD) in this group of patients over time? METHODS The Australian Orthopaedic Association National Joint Replacement Registry longitudinally maintains data on all primary and revision joint arthroplasties with nearly 100% capture. We analyzed all conventional primary THAs performed from Registry inception in September 1999 until December 31, 2015, in patients with a diagnosis of osteoarthritis and using MoM bearing surfaces ≤ 32 mm in diameter, defined as small-head MoM. The study group included 4838 primary THA with ≤ 32-mm MoM bearing surfaces. There were 2506 (51.8%) male patients and the median age of patients undergoing THA with a small-head MoM bearing surface was 64 years (range, 20-92 years of age). The outcome measure was the cumulative percent revision defined as the time to first revision using Kaplan-Meier estimates of survivorship at 15 years; reasons for revision and type of revision were also examined. We specifically investigated whether there was an increased risk of revision for ARMD in this MoM group compared with all other bearing surfaces. We compared these results with large-head MoM THAs (femoral head size > 32 mm). RESULTS The cumulative percent revision for small-head MoM designs at 15 years was 8.5% (95% confidence interval [CI], 7.3-9.9). The cumulative percent revision for large-head MoM at 14 years was 27.4% (95% CI, 24.8-30.2). Prostheses with a large-head MoM articulation have a higher rate of revision than small-head MoM bearing surfaces (hazard ratio after 6 years, 5.14; 95% CI, 4.1-6.5; p < 0.001). Over time, there was a gradual increase in the diagnosis of ARMD for small-head MoM and the cumulative incidence of revision for ARMD was 0.8% at 15 years. CONCLUSIONS Despite survival that is substantially greater than that of large-head MoM THAs, there has been a marked decrease in the use of small-head MoM designs in our registry. Although the reasons for this are likely multifactorial, the increasing incidence of revisions for ARMD among small-head MoM THAs is concerning. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Richard de Steiger
- R. de Steiger, Department of Surgery, Epworth Healthcare, University of Melbourne, Richmond, Victoria, Australia A. Peng, South Australian Health and Medical Research Institute, Adelaide, Australia P. Lewis, S. Graves, Australian Orthopaedic Association National Joint Replacement Registry, South Australian Health and Medical Research Institute, Adelaide, Australia This work was performed at the Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
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22
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Jacquot L, Bonnin MP, Machenaud A, Chouteau J, Saffarini M, Vidalain JP. Clinical and Radiographic Outcomes at 25-30 Years of a Hip Stem Fully Coated With Hydroxylapatite. J Arthroplasty 2018; 33:482-490. [PMID: 29066107 DOI: 10.1016/j.arth.2017.09.040] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/12/2017] [Accepted: 09/15/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Little is known about the survival of total hip arthroplasty implants with bioactive coatings beyond the first 20 years. The authors aimed to report survival of a tapered hip stem fully coated with hydroxylapatite (HA) at follow-up of 25-30 years. METHODS Of the original series of 320 patients (347 hips), 12 patients (12 hips) had stem and cup revisions, 54 patients (55 hips) had cup revisions, 17 patients (17 hips) had liner exchange. A total of 207 patients (225 hips) died with stems in place and 21 patients (24 hips) could not be reached. This left a cohort of 80 patients (86 hips) with their original stem for assessment. Survival was analyzed using the Kaplan-Meier (KM) method and cumulative incidence function (CIF). RESULTS Considering stem revision as endpoint, the revision risk calculated using the KM method was 6.3%, whereas using the CIF it was 3.7%. Considering any reoperation as endpoint, the revision risk calculated using the KM method was 41.2%, whereas using the CIF it was 25.9%. The Harris Hip Score for 77 patients (18 hips) was 81.6 ± 15.2. Standard x-rays were available for 52 hips (49 patients), and 10 (19.2%) showed radiolucencies <2 mm thick. CONCLUSION This study is the first to report outcomes of an HA-coated stem beyond 25 years. The survival of stem compares favorably with long-term survival of the Charnley cemented stem, and with shorter-term registry studies. The stem achieved its intended purpose of total osteointegration in the long-term, although the proximolateral region remains susceptible to radiolucencies.
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Affiliation(s)
- Laurent Jacquot
- Artro Institute, Annecy Le Vieux, France; Department of Orthopaedic Surgery, Clinique d'Argonay, Centre Le Périclès, Annecy, France
| | - Michel P Bonnin
- Artro Institute, Annecy Le Vieux, France; Ramsay Générale de Santé, Centre Orthopédique Santy, Hôpital PrivéJean Mermoz, Lyon, France
| | - Alain Machenaud
- Artro Institute, Annecy Le Vieux, France; Department of Orthopaedic Surgery, Clinique d'Argonay, Centre Le Périclès, Annecy, France
| | - Julien Chouteau
- Artro Institute, Annecy Le Vieux, France; Department of Orthopaedic Surgery, Clinique d'Argonay, Centre Le Périclès, Annecy, France
| | | | - Jean-Pierre Vidalain
- Artro Institute, Annecy Le Vieux, France; Department of Orthopaedic Surgery, Clinique d'Argonay, Centre Le Périclès, Annecy, France
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Late Reinfection May Recur More Than 5 Years After Reimplantation of THA and TKA: Analysis of Pathogen Factors. Clin Orthop Relat Res 2018; 476. [PMID: 29529667 PMCID: PMC6259703 DOI: 10.1007/s11999.0000000000000050] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Two-stage reimplantation has consistently yielded high rates of success for patients with chronic prosthetic joint infection, although results more than 5 years after reimplantation are not commonly reported. Numerous factors may contribute to the risk of reinfection, although these factors-as well as the at-risk period after reimplantation-are not well characterized. QUESTIONS/PURPOSES (1) What is the risk of reinfection after reimplantation for prosthetic joint infection at a minimum of 5 years? (2) Is the bacteriology of the index infection associated with late reinfection? (3) Is the presence of bacteria at the time of reimplantation associated with late reinfection? METHODS Between 1995 and 2010, we performed 97 two-stage revisions in 93 patients for prosthetic joint infection of the hip or knee, and all are included in this retrospective study. During that time, the indications for this procedure generally were (1) infections occurring more than 3 months after the index arthroplasty; and (2) more acute infections associated with prosthetic loosening or resistant organisms. One patient (1%) was lost to followup; all others have a minimum of 5 years of followup (mean, 11 years; range, 5-20 years) and all living patients have been seen within the last 2 years. Patients were considered free from infection if they did not have pain at rest or constitutional symptoms such as fever, chills, or malaise. The patients' bacteriology and resistance patterns of these organisms were observed with respect to recurrence of infection. Odds ratios and Fisher's exact test were performed to analyze the data. The incidence of reinfection was determined using cumulative incidence methods that considered death as a competing event. RESULTS Reinfection occurred in 12 of the 97 joints resulting in implant revision. The estimated 10-year cumulative incidence of infection was 14% (95% confidence interval [CI], 7%-23%) and incidence of infection from the same organism was 5% (95% CI, 1%-11%). Five occurred early or within 2 years and three were resistant pathogens (methicillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus epidermidis, or vancomycin-resistant Enterococcus). Seven late hematogenous infections occurred and all were > 4 years after reimplantation and involved nonresistant organisms. Three of the five (60%) early infections were caused by resistant bacteria, whereas all seven late infections were caused by different organisms or a combination of different organisms than were isolated in the original infection. The early reinfections were more often caused by resistant organisms, whereas late infections involved different organisms than were isolated in the original infection and none involved resistant organisms. With the numbers available, we found no difference between patients in whom bacteria were detected at the time of reimplantation and those in whom cultures were negative in terms of the risk of reinfection 5 years after reimplantation (18.6% [18 of 97] versus 81.4% [79 of 97], odds ratio 1.56 [95% CI, 0.38-6.44]; p = 0.54); however, with only 93 patients, we may have been underpowered to make this analysis. CONCLUSIONS In our study, resistant organisms were more often associated with early reinfection, whereas late failures were more commonly associated with new pathogens. We believe the most important finding in our study is that substantial risk of late infection remains even among patients who seemed free from infection 2 years after reimplantation for prosthetic joint infections of the hip or knee. This highlights the importance of educating our patients about the ongoing risk of prosthetic joint infection. LEVEL OF EVIDENCE Level III, therapeutic study.
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Dorth JA, Lee WR, Chino J, Abouassaly R, Ellis RJ, Myers ER. Cost-Effectiveness of Primary Radiation Therapy Versus Radical Prostatectomy for Intermediate- to High-Risk Prostate Cancer. Int J Radiat Oncol Biol Phys 2017; 100:383-390. [PMID: 29353655 DOI: 10.1016/j.ijrobp.2017.10.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 10/05/2017] [Accepted: 10/12/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE To compare, using a cost-effectiveness analysis, the quality-adjusted life expectancy (QALE) and cost between the 2 treatment options for intermediate- to high-risk prostate cancer: (1) radiation (RT) with androgen deprivation therapy (ADT) or (2) radical prostatectomy (RP) followed by adjuvant RT for patients with risk factors. METHODS AND MATERIALS Our Markov model allowed patients to transition between health states with yearly probabilities of developing cancer recurrence and/or toxicity. Probabilities were assigned according to favorable intermediate, unfavorable intermediate, or high-risk prostate cancer groups. The primary analysis examined outcomes for patients aged 65 years, whereas secondary analyses explored the effects of younger age, elevated baseline cardiovascular risk, and the use of salvage therapy. One-way and probabilistic sensitivity analyses were performed. RESULTS Across all primary and secondary analyses, and using a wide-range of assumptions, RT + ADT was the preferred treatment strategy for men with intermediate- to high-risk prostate cancer. The QALE was higher after RT + ADT by 0.5 to 1.14 quality-adjusted life years, compared with RP. Radiation plus ADT was cost-effective in all situations, falling beneath a threshold of $100,000 per quality-adjusted life year. Among all risk groups, a greater proportion of patients undergoing RP experienced single or multiple treatment toxicities. CONCLUSIONS Radiation plus ADT may result in improved QALE compared with RP for intermediate- to high-risk prostate cancer. Although biochemical failure is similar between treatment groups, there is a higher rate of developing multiple toxicities among patients treated with upfront RP.
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Affiliation(s)
- Jennifer A Dorth
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, Ohio.
| | - W Robert Lee
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Junzo Chino
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Robert Abouassaly
- Department of Urology, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, Ohio
| | - Rodney J Ellis
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, Ohio
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
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Cladière-Nassif V, Bourdet C, Audard V, Babinet A, Anract P, Biau D. Is it safe to preserve the deltoid when resecting the proximal humerus for a primary malignant bone tumour? A comparative study. Bone Joint J 2017; 99-B:1244-1249. [PMID: 28860407 DOI: 10.1302/0301-620x.99b9.2016-1317.r1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/18/2017] [Indexed: 11/05/2022]
Abstract
AIMS Resection of the proximal humerus for the primary malignant bone tumour sometimes requires en bloc resection of the deltoid. However, there is no information in the literature which helps a surgeon decide whether to preserve the deltoid or not. The aim of this study was to determine whether retaining the deltoid at the time of resection would increase the rate of local recurrence. We also sought to identify the variables that persuade expert surgeons to choose a deltoid sparing rather than deltoid resecting procedure. PATIENTS AND METHODS We reviewed 45 patients who had undergone resection of a primary malignant tumour of the proximal humerus. There were 29 in the deltoid sparing group and 16 in the deltoid resecting group. Imaging studies were reviewed to assess tumour extension and soft-tissue involvement. The presence of a fat rim separating the tumour from the deltoid on MRI was particularly noted. The cumulative probability of local recurrence was calculated in a competing risk scenario. RESULTS There was no significant difference (adjusted p = 0.89) in the cumulative probability of local recurrence between the deltoid sparing (7%, 95% confidence interval (CI) 1 to 20) and the deltoid resecting group (26%, 95% CI 8 to 50). Patients were more likely to be selected for a deltoid sparing procedure if they presented with a small tumour (p = 0.0064) with less bone involvement (p = 0.032) and a continuous fat rim on MRI (p = 0.002) and if the axillary nerve could be identified (p = 0.037). CONCLUSION A deltoid sparing procedure can provide good local control after resection of the proximal humerus for a primary malignant bone tumour. A smaller tumour, the presence of a continuous fat rim and the identification of the axillary nerve on pre-operative MRI will persuade surgeons to opt for a deltoid resecting procedure. Cite this article: Bone Joint J 2017;99-B:1244-9.
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Affiliation(s)
- V Cladière-Nassif
- Hôpital Cochin, 27 rue du Fabourg Saint Jacques, 75014 Paris, France
| | | | - V Audard
- Hôpital Cochin, 27 rue du Fabourg Saint Jacques, 75014 Paris, France
| | - A Babinet
- Hôpital Cochin, 27 rue du Fabourg Saint Jacques, 75014 Paris, France
| | - P Anract
- Hôpital Cochin, 27 rue du Fabourg Saint Jacques, 75014 Paris, France
| | - D Biau
- Hôpital Cochin, 27 rue du Fabourg Saint Jacques, 75014 Paris, France
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Haugan K, Johnsen LG, Basso T, Foss OA. Mortality and readmission following hip fracture surgery: a retrospective study comparing conventional and fast-track care. BMJ Open 2017; 7:e015574. [PMID: 28851773 PMCID: PMC5724094 DOI: 10.1136/bmjopen-2016-015574] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 06/08/2017] [Accepted: 07/26/2017] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To compare the efficacies of two pathways-conventional and fast-track care-in patients with hip fracture. DESIGN Retrospective single-centre study. SETTING University hospital in middle Norway. PARTICIPANTS 1820 patients aged ≥65 years with hip fracture (intracapsular, intertrochanteric or subtrochanteric). INTERVENTIONS 788 patients were treated according to conventional care from April 2008 to September 2011, and 1032 patients were treated according to fast-track care from October 2011 to December 2013. PRIMARY AND SECONDARY OUTCOME Primary: mortality and readmission to hospital, within 365 days follow-up. Secondary: length of stay. RESULTS We found no statistically significant differences in mortality and readmission rate between patients in the fast-track and conventional care models within 365 days after the initial hospital admission. The conventional care group had a higher, no statistical significant mortality HR of 1.10 (95% CI 0.91 to 1.31, p=0.326) without and 1.16 (95% CI 0.96 to 1.40, p=0.118) with covariate adjustment. Regarding the readmission, the conventional care group sub-HR was 1.02 (95% CI 0.88 to 1.18, p=0.822) without and 0.97 (95% CI 0.83 to 1.12, p=0.644) with adjusting for covariates. Length of stay and time to surgery was statistically significant shorter for patients who received fast-track care, a mean difference of 3.4 days and 6 hours, respectively. There was no statistically significant difference in sex, type of fracture, age or Charlson Comorbidity Index score at baseline between patients in the two pathways. CONCLUSIONS There was insufficient evidence to show an impact of fast-track care on mortality and readmission. Length of stay and time to surgery were decreased. TRIAL REGISTRATION NUMBER NCT00667914; results.
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Affiliation(s)
- Kristin Haugan
- Department of Orthopaedics, Orthopaedic Research Centre, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Lars G Johnsen
- Department of Orthopaedics, Orthopaedic Research Centre, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
| | - Trude Basso
- Department of Orthopaedics, Orthopaedic Research Centre, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Olav A Foss
- Department of Orthopaedics, Orthopaedic Research Centre, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Nakata E, Sugihara S, Osumi S, Yamashita N. Risk stratification for predicting symptomatic skeletal events (SSEs) in breast cancer patients with bone metastases. J Orthop Sci 2017; 22:743-748. [PMID: 28501434 DOI: 10.1016/j.jos.2017.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 03/16/2017] [Accepted: 03/26/2017] [Indexed: 02/09/2023]
Abstract
BACKGROUND Symptomatic skeletal events (SSEs) affect many patients with bone metastases from breast cancer. However, predictive models of SSEs in patients with bone metastases from breast cancer have not been established for clinical use. The purpose of this study is to examine risk factors for SSEs in those patients and by combining these risk factors patients are classified into several groups. With this risk-stratification model, we can identify patients at higher risk of SSEs and require close follow-up to maintain ADL. METHODS Participants included 189 female patients with bone metastases from breast cancer and treated in our institute between 2009 and 2012. To assess risk factors for the first SSEs, clinical data at the time of registration were assessed. To estimate the effects of covariates, we used cause-specific hazard modeling. RESULTS Multivariate analysis revealed that a high number of metastasized vertebral bodies (≥20) (p < 0.001) and elevated carcinoembryonic antigen (CEA) level (>5 ng/mL) (p = 0.003) were risk factors for SSEs. Patients were classified into four subgroups according to the combination of the number of vertebral metastases and CEA level: patients with CEA level > 5 ng/mL and ≥20 vertebral metastases; patients with CEA level ≤ 5 ng/mL and ≥20 vertebral metastases; patients with CEA level > 5 ng/mL and <20 vertebral metastases; and patients with CEA level ≤ 5 ng/mL and <20 vertebral metastases. Cumulative incidences of SSEs in these four subgroups at 6 months were 35.6%, 15.6%, 9.3%, and 3.7%, respectively. CONCLUSIONS Patients with elevated CEA level (>5 ng/mL) and extensive vertebral metastases (≥20) should be closely monitored in routine clinical care, to allow prevention of pathological fracture or paraplegia with the intervention of orthopedists or radiologists.
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Affiliation(s)
- Eiji Nakata
- Department of Orthopedic Surgery, Shikoku Cancer Center, Ko-160, Minamiumemoto-cho, Matsuyama 791-0280, Ehime, Japan.
| | - Shinsuke Sugihara
- Department of Orthopedic Surgery, Shikoku Cancer Center, Ko-160, Minamiumemoto-cho, Matsuyama 791-0280, Ehime, Japan.
| | - Shozo Osumi
- Department of Breast Oncology, Shikoku Cancer Center, Ko-160, Minamiumemoto-cho, Matsuyama 791-0280, Ehime, Japan.
| | - Natsumi Yamashita
- Clinical Research Center, Shikoku Cancer Center, Ko-160, Minamiumemoto-cho, Matsuyama 791-0280, Ehime, Japan.
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Johanson PE, Antonsson M, Shareghi B, Kärrholm J. Early Subsidence Predicts Failure of a Cemented Femoral Stem With Minor Design Changes. Clin Orthop Relat Res 2016; 474:2221-9. [PMID: 27188836 PMCID: PMC5014811 DOI: 10.1007/s11999-016-4884-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Radiostereometry (RSA) measurements of early micromotion can predict later failure in hip and knee prostheses. In hip implants, RSA has been particularly helpful in the evaluation of composite-beam stem designs. The Spectron EF Primary stem (Smith & Nephew, London, UK) has shown inferior performance compared with its predecessors in both clinical studies and registry reports. Early RSA studies have shown somewhat greater subsidence for the Spectron EF Primary stem compared with the earlier Spectron EF, but still within boundaries considered to be safe. QUESTIONS/PURPOSES Our primary research question was whether stem subsidence and rotation for this stem design measured with RSA at 2 years can predict later stem failure. A secondary question was whether high femoral stem offset and small stem sizes, both features specific to the Spectron EF Primary stem compared with its predecessors, are associated with stem failure rate. METHODS Two hundred forty-seven hips (209 patients with median age 63 years [range, 29-80 years], 65% female, and 77% primary osteoarthritis) with a valid RSA examination at 2 years were selected from four different RSA studies (totaling 279 hips in 236 patients) in our department. The studies were primarily aimed at evaluating cup fixation, bone cement, and polyethylene types. All study patients received a cemented Spectron EF Primary stem. The selected hips had complete followup until stem failure, death, or the end of the followup period. Stem failure was defined as revision of a loose femoral stem or radiological failure with significant osteolysis in Gruen zones 2 to 6. Cox regression analyses were performed to evaluate if stem subsidence and rotation after 2 years, adjusted for age, sex, stem size, standard/high stem offset, and conventional/highly crosslinked polyethylene, could predict later clinical aseptic failure of the stem. We identified 32 stem failures (27 revisions, five radiological failures) at 14 years median followup (range, 3-18 years). Ten-year stem survival was 94% (95% confidence interval [CI], 90%-96%). RESULTS Stem subsidence at 2 years (adjusted hazard ratio [HR], 6.0; 95% CI, 2.5-15; p < 0.001) and retrotorsion of the stem (adjusted HR, 1.7; 95% CI, 1.1-2.5; p = 0.018) were associated with later stem failure. Further risk factors were male sex (subsidence analysis HR, 6.9; p > 0.001), use of the two smallest stem sizes (HRsize 1, 8.0; p > 0.001, HRsize 2, 1 [reference], HRsize 3+, 0.06; p = 0.035), and the high offset option (HR, 3.1; p = 0.005). CONCLUSIONS Stem subsidence and retrotorsion at 2 years can predict later failure in the Spectron EF Primary stem, consistent with earlier findings on composite-beam cemented stems. Small stem size and high-offset stems comprise the main group of underperforming stems. We recommend that premarket small-scale RSA studies be performed after any design change to a THA femoral component, because even seemingly minor design changes may unexpectedly result in inferior performance. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Per-Erik Johanson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Sahlgrenska University Hospital/Sahlgrenska, 413 45, Gothenburg, Sweden.
| | - Martin Antonsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Bita Shareghi
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johan Kärrholm
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Clarke-Jenssen J, Wikerøy AKB, Røise O, Øvre SA, Madsen JE. Long-Term Survival of the Native Hip After a Minimally Displaced, Nonoperatively Treated Acetabular Fracture. J Bone Joint Surg Am 2016; 98:1392-9. [PMID: 27535442 DOI: 10.2106/jbjs.15.01154] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Few studies have evaluated the long-term results for nonoperatively treated acetabular fractures. The purpose of this study was to describe the long-term survival of the native acetabulum as well as the clinical and radiographic outcome for patients with nonoperatively treated acetabular fractures. METHODS All patients with acetabular fractures are prospectively registered in our acetabular fracture database and followed up at regular intervals for up to 20 years. We identified 236 patients (237 fractures) who had been treated nonoperatively between 1994 and 2004; 51 patients with incomplete data were excluded. For the survival analysis, 186 fractures with an average follow-up of 9 years (range, 1 to 20 years) were included. For the long-term clinical outcome, 104 patients with an average follow-up of 12.1 years (range, 9 to 20 years) were included. RESULTS The 10-year survival of the native hips was 94% (111 hips were at risk). Eighty-nine percent of the patients had a good or excellent Harris hip score, and 88% had a good or excellent Merle d'Aubigné and Postel score. The most important negative predictor for clinical outcome and survival of the hip was a fracture step-off of ≥2 mm measured in the obturator oblique radiograph. CONCLUSIONS Nonoperative treatment of minimally displaced acetabular fractures yields good to excellent long-term results. For patients with a questionable indication for fracture surgery, oblique radiographs (Judet views) are a helpful tool in the decision-making process, as a fracture step-off of ≥2 mm is a strong predictor for a poor clinical and radiographic result at 10 years. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- John Clarke-Jenssen
- Orthopaedic Department, Division of Surgery and Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | | | - Olav Røise
- Orthopaedic Department, Division of Surgery and Clinical Neuroscience, Oslo University Hospital, Oslo, Norway Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Stein Arne Øvre
- Orthopaedic Department, Division of Surgery and Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - Jan Erik Madsen
- Orthopaedic Department, Division of Surgery and Clinical Neuroscience, Oslo University Hospital, Oslo, Norway Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Pijls BG, Nelissen RGHH. The era of phased introduction of new implants. Bone Joint Res 2016; 5:215-7. [PMID: 27267796 PMCID: PMC4921053 DOI: 10.1302/2046-3758.56.2000653] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 04/16/2016] [Indexed: 01/28/2023] Open
Affiliation(s)
- B G Pijls
- Department of Orthopaedics, Leiden University Medical Center, The Netherlands
| | - R G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, The Netherlands
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31
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Lacny S, Bohm E, Hawker G, Powell J, Marshall DA. Assessing the comparability of hip arthroplasty registries in order to improve the recording and monitoring of outcome. Bone Joint J 2016; 98-B:442-51. [DOI: 10.1302/0301-620x.98b4.36501] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 10/15/2015] [Indexed: 11/05/2022]
Abstract
Aims We aimed to assess the comparability of data in joint replacement registries and identify ways of improving the comparisons between registries and the overall monitoring of joint replacement surgery. Materials and Methods We conducted a review of registries that are full members of the International Society of Arthroplasty Registries with publicly available annual reports in English. Of the six registries which were included, we compared the reporting of: mean age, definitions for revision and re-operation, reasons for revision, the approach to analysing revisions, and patient-reported outcome measures (PROMs) for primary and revision total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA). Results Outcomes were infrequently reported for HRA compared with THA and all hip arthroplasties. Revisions were consistently defined, though re-operation was defined by one registry. Implant survival was most commonly reported as the cumulative incidence of revision using Kaplan-Meier survival analysis. Three registries reported patient reported outcome measures. Conclusion More consistency in the reporting of outcomes for specific types of procedures is needed to improve the interpretation of joint registry data and accurately monitor safety trends. As collecting additional details of surgical and patient-reported outcomes becomes increasingly important, the experience of established registries will be valuable in establishing consistency among registries while maintaining the quality of data. Take home message: As the volume of joint replacements performed each year continues to increase, greater consistency in the reporting of surgical and patient-reported outcomes among joint replacement registries would improve the interpretation and comparability of these data to monitor outcomes accurately. Cite this article: Bone Joint J 2016;98-B:442–51.
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Affiliation(s)
- S. Lacny
- University of Calgary, Alberta Bone and
Joint Health Institute, 3280 Hospital Drive
NW, Calgary, Alberta T2N
4Z6, Canada
| | - E. Bohm
- University of Manitoba, 301-1155
Concordia Avenue, Winnipeg, Manitoba
R2K 2M9, Canada
| | - G. Hawker
- University of Toronto, 190
Elizabeth St., RFE, 3-805, Toronto, Ontario
M5G 2C4, Canada
| | - J. Powell
- University of Calgary, 0444
3134 Hospital Drive NW, Calgary, Alberta
T2N 4Z6, Canada
| | - D. A. Marshall
- University of Calgary, Alberta Bone and
Joint Health Institute, 3280 Hospital Drive
NW, Calgary, Alberta T2N
4Z6, Canada
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Abstract
BACKGROUND A patient who dies during the followup period of a study about total hip arthroplasty (THA) cannot subsequently undergo a revision. The presence of competing events (such as deaths, in a study on implant durability) violates an assumption of the commonly used Kaplan-Meier (KM) survivorship approach. In that setting, KM-based estimates of revision frequencies will be high relative to alternative approaches that account for competing events such as cumulative incidence methods. However, the degree to which this difference is clinically relevant, and the degree to which it affects different ages of patient cohorts, has been poorly characterized in orthopaedic clinical research. QUESTIONS/PURPOSES The purpose of this study was to compare KM with cumulative incidence survivorship estimators to evaluate the degree to which the competing event of death influences the reporting of implant survivorship at long-term followup after THA in patients both younger than and older than 50 years of age. METHODS We retrospectively reviewed 758 cemented THAs from a prospectively maintained single-surgeon registry, who were followed for a minimum of 20 years or until death. Revision rates were compared between those younger than or older than age 50 years using both KM and cumulative incidence methods. Patient survivorship was calculated using KM methods. A total of 21% (23 of 109) of the cohort who were younger than 50 years at the time of THA died during the 20-year followup period compared with 72% (467 of 649) who were older than 50 years at the time of surgery (p < 0.001). RESULTS In the cumulative incidence analysis, 19% of the younger than age 50 years cohort underwent a revision for aseptic causes within 20 years as compared with 5% in the older than age 50 years cohort (p < 0.001). The KM method overestimated the risk of revision (23% versus 8.3%, p < 0.001), which represents a 21% and 66% relative increase for the younger than/older than age 50 years groups, respectively. CONCLUSIONS The KM method overestimated the risk of revision compared with the cumulative incidence method, and the difference was particularly notable in the elderly cohort. Future long-term followup studies on elderly cohorts should report results using survivorship curves that take into account the competing risk of patient death. We observed a high attrition rate as a result of patient deaths, and this emphasizes a need for future studies to enroll younger patients to ensure adequate study numbers at final followup. LEVEL OF EVIDENCE Level III, therapeutic study.
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CORR Insights(®): Kaplan-Meier Survival Analysis Overestimates the Risk of Revision Arthroplasty: A Meta-analysis. Clin Orthop Relat Res 2015; 473:3443-5. [PMID: 25861791 PMCID: PMC4586219 DOI: 10.1007/s11999-015-4291-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 03/30/2015] [Indexed: 01/31/2023]
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Lacny S, Wilson T, Clement F, Roberts DJ, Faris PD, Ghali WA, Marshall DA. Kaplan-Meier Survival Analysis Overestimates the Risk of Revision Arthroplasty: A Meta-analysis. Clin Orthop Relat Res 2015; 473:3431-42. [PMID: 25804881 PMCID: PMC4586188 DOI: 10.1007/s11999-015-4235-8] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although Kaplan-Meier survival analysis is commonly used to estimate the cumulative incidence of revision after joint arthroplasty, it theoretically overestimates the risk of revision in the presence of competing risks (such as death). Because the magnitude of overestimation is not well documented, the potential associated impact on clinical and policy decision-making remains unknown. QUESTIONS/PURPOSES We performed a meta-analysis to answer the following questions: (1) To what extent does the Kaplan-Meier method overestimate the cumulative incidence of revision after joint replacement compared with alternative competing-risks methods? (2) Is the extent of overestimation influenced by followup time or rate of competing risks? METHODS We searched Ovid MEDLINE, EMBASE, BIOSIS Previews, and Web of Science (1946, 1980, 1980, and 1899, respectively, to October 26, 2013) and included article bibliographies for studies comparing estimated cumulative incidence of revision after hip or knee arthroplasty obtained using both Kaplan-Meier and competing-risks methods. We excluded conference abstracts, unpublished studies, or studies using simulated data sets. Two reviewers independently extracted data and evaluated the quality of reporting of the included studies. Among 1160 abstracts identified, six studies were included in our meta-analysis. The principal reason for the steep attrition (1160 to six) was that the initial search was for studies in any clinical area that compared the cumulative incidence estimated using the Kaplan-Meier versus competing-risks methods for any event (not just the cumulative incidence of hip or knee revision); we did this to minimize the likelihood of missing any relevant studies. We calculated risk ratios (RRs) comparing the cumulative incidence estimated using the Kaplan-Meier method with the competing-risks method for each study and used DerSimonian and Laird random effects models to pool these RRs. Heterogeneity was explored using stratified meta-analyses and metaregression. RESULTS The pooled cumulative incidence of revision after hip or knee arthroplasty obtained using the Kaplan-Meier method was 1.55 times higher (95% confidence interval, 1.43-1.68; p < 0.001) than that obtained using the competing-risks method. Longer followup times and higher proportions of competing risks were not associated with increases in the amount of overestimation of revision risk by the Kaplan-Meier method (all p > 0.10). This may be due to the small number of studies that met the inclusion criteria and conservative variance approximation. CONCLUSIONS The Kaplan-Meier method overestimates risk of revision after hip or knee arthroplasty in populations where competing risks (such as death) might preclude the occurrence of the event of interest (revision). Competing-risks methods should be used to more accurately estimate the cumulative incidence of revision when the goal is to plan healthcare services and resource allocation for revisions.
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Affiliation(s)
- Sarah Lacny
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Todd Wilson
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Fiona Clement
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Derek J Roberts
- Departments of Community Health Sciences and Surgery, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Peter D Faris
- Research Priorities and Implementation, Alberta Health Services, Foothills Medical Centre, 1403-29 Street NW, Calgary, AB, T2N 2T9, Canada
- Alberta Bone and Joint Health Institute, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - William A Ghali
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Deborah A Marshall
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- Health Research Innovation Centre, Room 3C56, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- McCaig Institute for Bone and Joint Health, Calgary, AB, Canada.
- Alberta Bone and Joint Health Institute, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
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Bartel AFP, Roukis TS. Total Ankle Replacement Survival Rates Based on Kaplan-Meier Survival Analysis of National Joint Registry Data. Clin Podiatr Med Surg 2015; 32:483-94. [PMID: 26407735 DOI: 10.1016/j.cpm.2015.06.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
National joint registry data provides unique information about primary total ankle replacement (TAR) survival. We sought to recreate survival curves among published national joint registry data sets using the Kaplan-Meier estimator. Overall, 5152 primary and 591 TAR revisions were included over a 2- to 13-year period with prosthesis survival for all national joint registries of 0.94 at 2-years, 0.87 at 5-years and 0.81 at 10-years. National joint registry datasets should strive for completion of data presentation including revision definitions, modes and time of failure, and patients lost to follow-up or death for complete accuracy of the Kaplan-Meier estimator.
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Affiliation(s)
- Annette F P Bartel
- Gundersen Medical Foundation, 1900 South Avenue, La Crosse, WI 54601, USA
| | - Thomas S Roukis
- Orthopaedic Center, Gundersen Health System, Mail Stop: CO2-006, 1900 South Avenue, La Crosse, WI 54601, USA.
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Barut N, Anract P, Babinet A, Biau D. Peri-prosthetic fractures around tumor endoprostheses: a retrospective analysis of eighteen cases. INTERNATIONAL ORTHOPAEDICS 2015. [PMID: 26216529 DOI: 10.1007/s00264-015-2915-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Tumour hip and knee endoprostheses have become the mainstay for reconstruction of patients with bone tumours. Fixation into host bone has improved over time. However, some patients present with a peri-prosthetic fracture over follow-up. The objective of this study was to analyse the mode of presentation and survival of implant after a peri-prosthetic fracture around a tumour endoprosthesis. METHODS Eighteen peri-prosthetic fractures (17 patients) were included. All patients were treated at a tertiary care center. There were 11 (65%) women; the median age at the time of fracture was 38 years old. All implants were cemented and all knee endoprostheses were fixed-hinge. Twelve (67%) fractures occurred after femoral resection and six (33%) fractures after proximal tibial resection. RESULTS There were three femoral neck fractures (UCS C), three femoral shaft type C fractures, two femoral shaft type B1, one tibial shaft type B2, three tibial shaft type C, three ankle fractures (UCS C) and three patella fractures (UCS F). Two fractures were treated conservatively and 16 were operated on. Only one patient had the implant revised. There were eight (44%) failures over follow-up; none of the conservative treatment failed. The cumulative probability of failure for any reason was 27% (8-52) and 55% (22-79) at five and ten years, respectively. CONCLUSIONS Peri-prosthetic fractures around massive endoprostheses are different from that of standard implants. There are more type C fractures; internal fixation is an attractive option at the time of presentation but the risk of revision over follow-up is high and patients should be informed accordingly.
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Affiliation(s)
- Nicolas Barut
- Hôpital Cochin, Assistance-Publique Hôpitaux de Paris, Service de Chirurgie Orthopédique, Paris, France,
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Wongworawat MD, Dobbs MB, Gebhardt MC, Gioe TJ, Leopold SS, Manner PA, Rimnac CM, Porcher R. Editorial: Estimating survivorship in the face of competing risks. Clin Orthop Relat Res 2015; 473:1173-6. [PMID: 25670658 PMCID: PMC4353504 DOI: 10.1007/s11999-015-4182-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 01/29/2015] [Indexed: 01/31/2023]
Affiliation(s)
- M. Daniel Wongworawat
- />Department of Orthopaedic Surgery, Loma Linda University School of Medicine, Loma Linda, CA USA
| | - Matthew B. Dobbs
- />Department of Orthopaedic Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO USA
| | - Mark C. Gebhardt
- />Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Terence J. Gioe
- />Minneapolis Veterans Affairs Medical Center, Minneapolis, MN USA
| | - Seth S. Leopold
- />Clinical Orthopaedics and Related Research, Philadelphia, PA 19103 USA
| | - Paul A. Manner
- />Department of Orthopaedics and Sports Medicine, University of Washington School of Medicine, Seattle, WA USA
| | | | - Raphaël Porcher
- />Center of Clinical Epidemiology, Hôpital Hôtel-Dieu, Paris, France
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Schuh R, Kaider A, Windhager R, Funovics PT. Does competing risk analysis give useful information about endoprosthetic survival in extremity osteosarcoma? Clin Orthop Relat Res 2015; 473:900-6. [PMID: 24867454 PMCID: PMC4317420 DOI: 10.1007/s11999-014-3703-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Conventional survival analysis for endoprosthetic complications does not consider competing events adequately. Patients who die of their disease are no longer at risk for complications; therefore, death as a competing event may alter survivorship estimates in the orthopaedic-oncological setting. QUESTIONS/PURPOSES This investigation aimed to compare (1) endoprosthetic survivorship after osteosarcoma by Kaplan-Meier analysis; and (2) by a competing risk model. METHODS Between 1981 and 2009, we performed 247 modular endoprostheses for patients with extremity osteosarcoma; 73 patients had a followup of less than 2 years but all patients were included in statistical analysis. No patients were lost to followup for reasons other than death. Revision-free endoprosthetic survival until soft tissue failure (Type 1), aseptic loosening (Type 2), structural failure (Type 3), infection (Type 4), and local tumor progression (Type 5) was estimated according to a Kaplan-Meier analysis and a competing risk model. Sixty-four patients died throughout followup; the 5- and 10-year overall survival and metastasis-free survival were 72% and 70% and 70% and 69%, respectively. One hundred twenty-two patients (49%) had complications. RESULTS Competing risk analysis consistently resulted in reduced estimates of the frequency of complications and reconstructive failures compared with Kaplan-Meier analysis. Cumulative risks for complication Types 1 to 5 at 10 years without/with death as a competing event revealed a risk of 19%/16% for Type 1, 26%/20% for Type 2, 51%/38% for Type 3, 23%/20% for Type 4, and 4%/3% for Type 5. CONCLUSIONS A competing risk model reveals considerably reduced risks for every complication compared with Kaplan-Meier analysis when death is included as a competing event. Because it more realistically represents the risks of complications, competing risk models should be used to arrive at risk estimates for purposes of counseling patients about those risks associated with modular endoprosthetic reconstruction. LEVEL OF EVIDENCE Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Reinhard Schuh
- />Department of Orthopaedics, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Alexandra Kaider
- />Section for Clinical Biometry, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- />Department of Orthopaedics, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Philipp T. Funovics
- />Department of Orthopaedics, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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Felden A, Vaz G, Kreps S, Anract P, Hamadouche M, Biau DJ. A cemented acetabular component with a reinforcement cross provides excellent medium-term fixation in total hip arthroplasty after pelvic irradiation. Bone Joint J 2015; 97-B:177-84. [DOI: 10.1302/0301-620x.97b2.34545] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Conventional cemented acetabular components are reported to have a high rate of failure when implanted into previously irradiated bone. We recommend the use of a cemented reconstruction with the addition of an acetabular reinforcement cross to improve fixation. We reviewed a cohort of 45 patients (49 hips) who had undergone irradiation of the pelvis and a cemented total hip arthroplasty (THA) with an acetabular reinforcement cross. All hips had received a minimum dose of 30 Gray (Gy) to treat a primary nearby tumour or metastasis. The median dose of radiation was 50 Gy (Q1 to Q3: 45 to 60; mean: 49.57, 32 to 72). The mean follow-up after THA was 51 months (17 to 137). The cumulative probability of revision of the acetabular component for a mechanical reason was 0% (0 to 0%) at 24 months, 2.9% (0.2 to 13.3%) at 60 months and 2.9% (0.2% to 13.3%) at 120 months, respectively. One hip was revised for mechanical failure and three for infection. Cemented acetabular components with a reinforcement cross provide good medium-term fixation after pelvic irradiation. These patients are at a higher risk of developing infection of their THA. Cite this article: Bone Joint J 2015;97-B:177–84.
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Affiliation(s)
- A. Felden
- Hôpital Cochin, 27
rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - G. Vaz
- Pavillon T de l'Hôpital Edouard Herriot, Hospices
Civils de Lyon, place d’Arsonval, 69003
Lyon, France
| | - S. Kreps
- Hôpital Européen Georges Pompidou, 20
Rue Leblanc, 75015 Paris, France
| | - P. Anract
- Hôpital Cochin, 27
rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - M. Hamadouche
- Hôpital Cochin, 27
rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - D. J. Biau
- Hôpital Cochin, 27
rue du Faubourg Saint-Jacques, 75014, Paris, France
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Pugh LR, Clarkson PW, Phillips AE, Biau DJ, Masri BA. Tumor endoprosthesis revision rates increase with peri-operative chemotherapy but are reduced with the use of cemented implant fixation. J Arthroplasty 2014; 29:1418-22. [PMID: 24612735 DOI: 10.1016/j.arth.2014.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 12/02/2013] [Accepted: 01/14/2014] [Indexed: 02/01/2023] Open
Abstract
Chemotherapy may reduce osseointegration of tumor endoprosthesis, while delaying chemotherapy may reduce survival. We studied the effects of chemotherapy and cemented fixation on tumor endoprosthesis survivorship with a retrospective analysis of 50 consecutive patients receiving lower limb salvage surgery. We compared rates of radiographic loosening/revision and effect of cement fixation between chemotherapy/no chemotherapy cohorts. Chemotherapy increased the total revision rate (HR = 3.8 [1-14], P = 0.033), but did not affect aseptic loosening. Cement fixation reduced revision for loosening (HR = 0.09 (0.008-0.98), P = 0.012) and showed less radiographic loosening (HR = 0.09 (0.02-0.51), P = 0.00066). Cement fixation had lower rates of revision for loosening and radiographic loosening regardless of whether chemotherapy was given. We conclude that for these implants, cement fixation provides superior results to uncemented fixation.
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Affiliation(s)
- Luke R Pugh
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| | - Paul W Clarkson
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| | - Amy E Phillips
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| | - David J Biau
- Department of Orthopaedic Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, 27 rue du Faubourg Saint Jacques, Paris, France
| | - Bassam A Masri
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
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Kraal T, van der Heide HJL, van Poppel BJ, Fiocco M, Nelissen RGHH, Doets HC. Long-term follow-up of mobile-bearing total ankle replacement in patients with inflammatory joint disease. Bone Joint J 2014; 95-B:1656-61. [PMID: 24293596 DOI: 10.1302/0301-620x.95b12.32146] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Little is known about the long-term outcome of mobile-bearing total ankle replacement (TAR) in the treatment of end-stage arthritis of the ankle, and in particular for patients with inflammatory joint disease. The aim of this study was to assess the minimum ten-year outcome of TAR in this group of patients. We prospectively followed 76 patients (93 TARs) who underwent surgery between 1988 and 1999. No patients were lost to follow-up. At latest follow-up at a mean of 14.8 years (10.7 to 22.8), 30 patients (39 TARs) had died and the original TAR remained in situ in 28 patients (31 TARs). The cumulative incidence of failure at 15 years was 20% (95% confidence interval (CI) 11 to 28). The mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score of the surviving patients at latest follow-up was 80.4 (95% CI 72 to 88). In total, 21 patients (23 TARs) underwent subsequent surgery: three implant exchanges, three bearing exchanges and 17 arthrodeses. Neither design of TAR described in this study, the LCS and the Buechel-Pappas, remains currently available. However, based both on this study and on other reports, we believe that TAR using current mobile-bearing designs for patients with end-stage arthritis of the ankle due to inflammatory joint disease remains justified.
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Affiliation(s)
- T Kraal
- Slotervaart Hospital, P.O. Box 90440, 1006 BK Amsterdam, the Netherlands
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Zeller V, Lhotellier L, Marmor S, Leclerc P, Krain A, Graff W, Ducroquet F, Biau D, Leonard P, Desplaces N, Mamoudy P. One-stage exchange arthroplasty for chronic periprosthetic hip infection: results of a large prospective cohort study. J Bone Joint Surg Am 2014; 96:e1. [PMID: 24382729 DOI: 10.2106/jbjs.l.01451] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Exchange arthroplasty of one or two stages is required for the treatment of chronic periprosthetic joint infections. Two-stage exchange is costly and has high morbidity with limited patient mobility between procedures. One-stage exchange has been promoted by several European teams as the preferred alternative. The aim of this study was to prospectively analyze the outcome of patients with a periprosthetic hip infection treated with one-stage exchange arthroplasty. METHODS We performed a prospective cohort study in a French referral center for osteoarticular infections including all periprosthetic hip infections treated with one-stage exchange arthroplasty from November 2002 to March 2010. Direct exchange was performed in chronic periprosthetic hip infection with no or minor bone loss and preoperative identification of a microorganism from joint fluid aspirate. No antibiotic-loaded bone cement was used. Antibiotic therapy was administered for twelve weeks: intravenously for four to six weeks, followed by an oral regimen for six to eight weeks. Follow-up was a minimum of two years. The following events were noted: relapse, new infection, joint revision for mechanical reasons, and periprosthetic hip infection-related and unrelated deaths. RESULTS One hundred and fifty-seven patients with periprosthetic hip infections with a median infection duration of 258 days (interquartile range, 120 to 551 days) prior to our index surgical procedure for infection were included. Periprosthetic hip infection occurred in ninety-nine cases of primary hip arthroplasty, twenty-seven cases of revision arthroplasty, and thirty-one cases in which the periprosthetic hip infection had been treated previously. A difficult-to-treat organism was isolated in fifty-nine cases (38%). After a median follow-up of 41.6 months (interquartile range, 28.1 to 66.9 months), two relapses, six new infections, nine revisions for mechanical reasons, two related deaths, and nineteen unrelated deaths occurred. CONCLUSIONS One-stage exchange arthroplasty is an effective surgical procedure in patients with periprosthetic hip infection who have good bone quality. Precise identification of the microorganism(s) and prolonged administration of appropriate intravenous antibiotic therapy are key factors for successful treatment.
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Affiliation(s)
- Valérie Zeller
- Service de Chirurgie Osseuse et Traumatologique, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France. E-mail address for V. Zeller:
| | - Luc Lhotellier
- Service de Chirurgie Osseuse et Traumatologique, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France. E-mail address for V. Zeller:
| | - Simon Marmor
- Service de Chirurgie Osseuse et Traumatologique, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France. E-mail address for V. Zeller:
| | - Philippe Leclerc
- Service de Chirurgie Osseuse et Traumatologique, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France. E-mail address for V. Zeller:
| | - Alysa Krain
- Service de Chirurgie Osseuse et Traumatologique, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France. E-mail address for V. Zeller:
| | - Wilfrid Graff
- Service de Chirurgie Osseuse et Traumatologique, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France. E-mail address for V. Zeller:
| | - Françoise Ducroquet
- Service de Chirurgie Osseuse et Traumatologique, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France. E-mail address for V. Zeller:
| | - David Biau
- Département de Biostatistique et Informatique Médicale, Hôpital Saint-Louis, 1, avenue Claude Vellefaux, AP-HP, Paris Université 7, 75475 Paris Cedex 10, France
| | - Philippe Leonard
- Service de Chirurgie Osseuse et Traumatologique, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France. E-mail address for V. Zeller:
| | - Nicole Desplaces
- Service de Chirurgie Osseuse et Traumatologique, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France. E-mail address for V. Zeller:
| | - Patrick Mamoudy
- Service de Chirurgie Osseuse et Traumatologique, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France. E-mail address for V. Zeller:
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How to deal with lost to follow-up in total knee arthroplasty : a new method based on the competing risks approach. INTERNATIONAL ORTHOPAEDICS 2013; 38:953-9. [PMID: 24305789 DOI: 10.1007/s00264-013-2193-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 11/05/2013] [Indexed: 11/12/2022]
Abstract
PURPOSE The aim of this study was to develop a more accurate method to deal with patients lost to follow-up based on the competing risks approach. METHODS A cohort of 112 patients who received 143 primary cemented total knee arthroplasties forms the basis for this study. Follow-up was up to 25 years. The new method for dealing with lost to follow-up accounts for competing events (i.e. death and failure of a prosthesis) using the cumulative incidence estimator and estimates time to event for patients lost to follow-up using national demographic registries. The results of this new method were compared with the worst case scenario estimated by Kaplan-Meier. RESULTS Six different situations were identified covering all possible situations in long-term follow-up for total knee arthroplasty. The new method--considering all patients lost to follow-up as revised--showed a twofold reduction in revision rate compared to the traditional worst case scenario using Kaplan-Meier. CONCLUSIONS Lost to follow-up should be prevented whenever possible, but this may be unavoidable for long-term follow-up studies. In situations where lost to follow-up does occur, the new proposed method offers an efficient and valid approach to deal with this problem.
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Azarjana K, Ozola A, Ruklisa D, Cema I, Rivosh A, Azaryan A, Pjanova D. Melanoma epidemiology, prognosis and trends in Latvia. J Eur Acad Dermatol Venereol 2012; 27:1352-9. [PMID: 23106225 DOI: 10.1111/jdv.12007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Melanoma incidence and mortality rates are increasing worldwide within the white population. Clinical and histological factors have been usually used for the prognosis and assessment of the risk for melanoma. OBJECTIVES The aim of the study was to describe the clinical and histopathological features of the cutaneous melanoma (CM) in the Latvian population, to test the association between melanoma features and patient survival, and to assess the time trends for melanoma incidence. METHODS We undertook a descriptive, retrospective analysis of archive data of 984 melanoma patients treated at the largest oncological hospital of Latvia, Riga East University Hospital Latvian Oncology Centre (LOC), between 1998 and 2008. Cox proportional hazards model was used to analyse patient survival and autoregressive models were applied to detect trends in melanoma incidence over time for various categories of melanoma. RESULTS The study showed a significant ascending trend in melanoma incidence in Latvia during the time period from 1998 to 2008 (ß = 1.83, 95% CI = 1.15-2.91, P = 0.011). Nodular melanoma was the most common tumour subtype with a frequency of 39.2%. Ulceration was present in 45.2% of melanomas. The mean Breslow thickness was 6.0 mm (6.8 mm) and no significant decline in median Breslow thickness was observed during the study period (P = 0.609). A better overall prognosis was detected for females in comparison with males (HR = 1.49; 95% CI = 1.22-1.81; P < 0.001). CONCLUSIONS There is a steady increase in melanoma incidence in Latvia with the majority of melanomas diagnosed at late stages with poor prognosis for survival.
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Affiliation(s)
- K Azarjana
- Department of Oral Pathology, Riga Stradins University, Riga, LatviaLatvian Biomedical Research and Study Centre, Riga, LatviaGenetics Institute, University College London, London, UKRiga East University Hospital Latvian Oncology Centre, Riga, LatviaFaculty of Computing, University of Latvia, Riga, LatviaFaculty of Life Sciences, University of Vienna, Vienna, Austria
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Gudnason A, Milbrink J, Hailer NP. Implant survival and outcome after rotating-hinge total knee revision arthroplasty: a minimum 6-year follow-up. Arch Orthop Trauma Surg 2011; 131:1601-7. [PMID: 21656196 DOI: 10.1007/s00402-011-1330-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Data on long-time survival and clinical function of rotating hinge knee prostheses used in revision total knee arthroplasty (TKA) are scarce. METHOD We evaluate the outcome of 42 revision TKA in 38 patients using the Endo-model rotating hinge total knee prosthesis after a minimum of 6 years, with 10-year implant survival as our primary outcome measure. Only revision TKAs performed due to aseptic loosening were included, and the Swedish Knee Arthroplasty Register was consulted in order to ensure that patients unavailable for clinical follow-up had not been revised elsewhere. Mean follow-up was after 8.8 (6-18) years, mean age at revision surgery was 72 (55-88) years, and most patients had severe medical comorbidities (n = 31). RESULTS At follow-up, four knees had been re-revised due to aseptic loosening, and five further knees underwent re-revision due to other reasons. With implant revision due to aseptic loosening as the endpoint, 10-year survival was 89.2%, and with implant revision due to any reason 10-year survival was 65.1%. 11 patients (13 knees) eligible for clinical follow-up were evaluated according to the Hospital for Special Surgery score (HSSS), the Knee Society scores (KSS), and by plain radiography. Mean HSSS was 67 (36-90), mean KSS-knee was 85 (73-96), and mean KSS-function was 29 (0-100). Radiography showed that no implant was in need of revision. CONCLUSION Our results indicate that revision arthroplasty of the knee with this rotating hinge prosthesis can be performed with satisfactory or good results in an elderly population with severe comorbidities.
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Affiliation(s)
- Asgeir Gudnason
- Department of Orthopaedics, Institute for Surgical Sciences, Uppsala University Hospital, 751 85 Uppsala, Sweden
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Weiss KR, Bhumbra R, Biau DJ, Griffin AM, Deheshi B, Wunder JS, Ferguson PC. Fixation of pathological humeral fractures by the cemented plate technique. ACTA ACUST UNITED AC 2011; 93:1093-7. [PMID: 21768635 DOI: 10.1302/0301-620x.93b8.26194] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pathological fractures of the humerus are associated with pain, morbidity, loss of function and a diminished quality of life. We report our experience of stabilising these fractures using polymethylmethacrylate and non-locking plates. We undertook a retrospective review over 20 years of patients treated at a tertiary musculoskeletal oncology centre. Those who had undergone surgery for an impending or completed pathological humeral fracture with a diagnosis of metastatic disease or myeloma were identified from our database. There were 63 patients (43 men, 20 women) in the series with a mean age of 63 years (39 to 87). All had undergone intralesional curettage of the tumour followed by fixation with intramedullary polymethylmethacrylate and plating. Complications occurred in 14 patients (22.2%) and seven (11.1%) required re-operation. At the latest follow-up, 47 patients (74.6%) were deceased and 16 (25.4%) were living with a mean follow-up of 75 months (1 to 184). A total of 54 (86%) patients had no or mild pain and 50 (80%) required no or minimal assistance with activities of daily living. Of the 16 living patients none had pain and all could perform activities of daily living without assistance. Intralesional resection of the tumour, filling of the cavity with cement, and plate stabilisation of the pathological fracture gives immediate rigidity and allows an early return of function without the need for bony union. The patient's local disease burden is reduced, which may alleviate tumour-related pain and slow the progression of the disease. The cemented-plate technique provides a reliable option for the treatment of pathological fractures of the humerus.
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Affiliation(s)
- K R Weiss
- Department of Orthopaedic Surgery, Division of Musculoskeletal Oncology, Shadyside Medical Center, 5200 Centre Avenue, Suite 415, Pittsburgh, Pennsylvania 15232, USA.
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Gillam MH, Salter A, Ryan P, Graves SE. Different competing risks models applied to data from the Australian Orthopaedic Association National Joint Replacement Registry. Acta Orthop 2011; 82:513-20. [PMID: 21895508 PMCID: PMC3242946 DOI: 10.3109/17453674.2011.618918] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
PURPOSE Here we describe some available statistical models and illustrate their use for analysis of arthroplasty registry data in the presence of the competing risk of death, when the influence of covariates on the revision rate may be different to the influence on the probability (that is, risk) of the occurrence of revision. PATIENTS AND METHODS Records of 12,525 patients aged 75-84 years who had received hemiarthroplasty for fractured neck of femur were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. The covariates whose effects we investigated were: age, sex, type of prosthesis, and type of fixation (cementless or cemented). Extensions of competing risk regression models were implemented, allowing the effects of some covariates to vary with time. RESULTS The revision rate was significantly higher for patients with unipolar than bipolar prostheses (HR = 1.38, 95% CI: 1.01-1.89) or with monoblock than bipolar prostheses (HR = 1.45, 95% CI: 1.08-1.94). It was significantly higher for the younger age group (75-79 years) than for the older one (80-84 years) (HR = 1.28, 95% CI: 1.05-1.56) and higher for males than for females (HR = 1.37, 95% CI: 1.09-1.71). The probability of revision, after correction for the competing risk of death, was only significantly higher for unipolar prostheses than for bipolar prostheses, and higher for the younger age group. The effect of fixation type varied with time; initially, there was a higher probability of revision for cementless prostheses than for cemented prostheses, which disappeared after approximately 1.5 years. INTERPRETATION When accounting for the competing risk of death, the covariates type of prosthesis and sex influenced the rate of revision differently to the probability of revision. We advocate the use of appropriate analysis tools in the presence of competing risks and when covariates have time-dependent effects.
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Affiliation(s)
| | - Amy Salter
- School of Population Health and Clinical Practice
| | | | - Stephen E Graves
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia
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Brunet O, Anract P, Bouabid S, Babinet A, Dumaine V, Toméno B, Biau D. Intercalary defects reconstruction of the femur and tibia after primary malignant bone tumour resection. A series of 13 cases. Orthop Traumatol Surg Res 2011; 97:512-9. [PMID: 21742565 DOI: 10.1016/j.otsr.2011.03.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 01/03/2011] [Accepted: 03/22/2011] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Performing intercalary segment reconstruction after malignant bone tumour resection results in both mechanical and biological challenges. Fixation must be solid enough to avoid short-term or mid-term mechanical failure. The use of an allograft or autograft must ensure long-term survival of the reconstruction. The goal of this study was to analyse the clinical and radiological outcomes of these reconstructions. PATIENTS AND METHODS Thirteen patients were operated on eight femurs and five tibias. The median age was 20 years old (range 14-50). The most common diagnosis was osteosarcoma. The median resection length was 15cm (Q1-Q3: 6-26). A plate was used for fixation in nine cases and an intramedullary locked nail in four cases. An isolated bone autograft was used in two cases, an isolated bone allograft in one case, a dual autograft-allograft composite in six cases, and vascularised fibula and allograft combination in four cases. RESULTS The cumulative probability of union was 46% (95% CI: 0-99%) at 1 year; at the final follow-up, union was achieved in 12 patients (92%). Because of non-unions, 13 iterative procedures were needed to obtain these results. A non-displaced fracture of a cuboid-shaped tibial graft occurred in one patient, which was treated conservatively. Three infections occurred. DISCUSSION The results of intercalary segmental defects reconstruction after bone tumour resection were good, both from an oncologic and radiological point-of-view. One or more iterative procedures are sometimes needed to finally obtain bone union. We prefer to use a free rectangular cuboidal tibial graft since reconstruction with a vascularised autograft is technically more difficult. The choice of fixation methods is still controversial and no approach was found to be superior. LEVEL OF EVIDENCE Level IV. Retrospective study.
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Affiliation(s)
- O Brunet
- Paris Descartes University, Cochin Hospital, Orthopaedic Surgery Department, 26, rue du faubourg Saint-Jacques, 75014 Paris, France.
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Pijls BG, Dekkers OM, Middeldorp S, Valstar ER, van der Heide HJL, Van der Linden-Van der Zwaag HMJ, Nelissen RGHH. AQUILA: assessment of quality in lower limb arthroplasty. An expert Delphi consensus for total knee and total hip arthroplasty. BMC Musculoskelet Disord 2011; 12:173. [PMID: 21781327 PMCID: PMC3155910 DOI: 10.1186/1471-2474-12-173] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Accepted: 07/22/2011] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND In the light of both the importance and large numbers of case series and cohort studies (observational studies) in orthopaedic literature, it is remarkable that there is currently no validated measurement tool to appraise their quality. A Delphi approach was used to develop a checklist for reporting quality, methodological quality and generalizability of case series and cohorts in total hip and total knee arthroplasty with a focus on aseptic loosening. METHODS A web-based Delphi was conducted consisting of two internal rounds and three external rounds in order to achieve expert consensus on items considered relevant for reporting quality, methodological quality and generalizability. RESULTS The internal rounds were used to construct a master list. The first external round was completed by 44 experts, 35 of them completed the second external round and 33 of them completed the third external round. Consensus was reached on an 8-item reporting quality checklist, a 6-item methodological checklist and a 22-item generalizability checklist. CONCLUSIONS Checklist for reporting quality, methodological quality and generalizability for case series and cohorts in total hip and total knee arthroplasty were successfully created through this Delphi. These checklists should improve the accuracy, completeness and quality of case series and cohorts regarding total hip and total knee arthroplasty.
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Affiliation(s)
- Bart G Pijls
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands, Albinusdreef 2, Room J-09-127; 2300 RC, Leiden, The Netherlands; P.O. Box 9600, Postzone J-11-S; 2300 RC Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Saskia Middeldorp
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Edward R Valstar
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands, Albinusdreef 2, Room J-09-127; 2300 RC, Leiden, The Netherlands; P.O. Box 9600, Postzone J-11-S; 2300 RC Leiden, The Netherlands
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, TU Delft, The Netherlands
| | - Huub JL van der Heide
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands, Albinusdreef 2, Room J-09-127; 2300 RC, Leiden, The Netherlands; P.O. Box 9600, Postzone J-11-S; 2300 RC Leiden, The Netherlands
| | - Henrica MJ Van der Linden-Van der Zwaag
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands, Albinusdreef 2, Room J-09-127; 2300 RC, Leiden, The Netherlands; P.O. Box 9600, Postzone J-11-S; 2300 RC Leiden, The Netherlands
| | - Rob GHH Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands, Albinusdreef 2, Room J-09-127; 2300 RC, Leiden, The Netherlands; P.O. Box 9600, Postzone J-11-S; 2300 RC Leiden, The Netherlands
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Ranstam J, Kärrholm J, Pulkkinen P, Mäkelä K, Espehaug B, Pedersen AB, Mehnert F, Furnes O. Statistical analysis of arthroplasty data. II. Guidelines. Acta Orthop 2011; 82:258-67. [PMID: 21619500 PMCID: PMC3235302 DOI: 10.3109/17453674.2011.588863] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
It is envisaged that guidelines for statistical analysis and presentation of results will improve the quality and value of research. The Nordic Arthroplasty Register Association (NARA) has therefore developed guidelines for the statistical analysis of arthroplasty register data. The guidelines are divided into two parts, one with an introduction and a discussion of the background to the guidelines (Ranstam et al. 2011a, see pages x-y in this issue), and this one with a more technical statistical discussion on how specific problems can be handled. This second part contains (1) recommendations for the interpretation of methods used to calculate survival, (2) recommendations on howto deal with bilateral observations, and (3) a discussion of problems and pitfalls associated with analysis of factors that influence survival or comparisons between outcomes extracted from different hospitals.
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Affiliation(s)
- Jonas Ranstam
- Swedish National Competence Center Musculoskeletal Disorders, Skåne University Hospital, Lund, The Swedish Knee Arthroplasty Register, and Lund University
| | - Johan Kärrholm
- The Swedish Hip Arthroplasty Register, Sahlgrenska University Hospital and Göteborg University, Göteborg, Sweden
| | - Pekka Pulkkinen
- The Finnish Arthroplasty Register and Department of Public Health, University of Helsinki
| | - Keijo Mäkelä
- The Finnish Arthroplasty Register and Turku University Central Hospital, Turku, Finland
| | - Birgitte Espehaug
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Alma Becic Pedersen
- The Danish Hip and Knee Arthroplasty Register, Department of Clinical Epidemiology, Competence Center North, Aarhus University Hospital, Aarhus, Denmark
| | - Frank Mehnert
- The Danish Hip and Knee Arthroplasty Register, Department of Clinical Epidemiology, Competence Center North, Aarhus University Hospital, Aarhus, Denmark
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