Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial

BACKGROUND

Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications.

METHODS

HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896).

FINDINGS

Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4-9) in the accelerated-surgery group and 24 h (10-42) in the standard-care group (p<0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (-1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (-2 to 4; p=0·71).

INTERPRETATION

Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care.

FUNDING

Canadian Institutes of Health Research.

Review of successful litigation against english health trusts in the treatment of adults with orthopaedic pathology: clinical governance lessons learned

BACKGROUND

Reviewing litigation brought against health institutions is a clinical governance issue and can help to prevent further cases. While large-scale databases are rare, the British National Health Service Litigation Authority deals with claims brought against all public health trusts in England.

METHODS

We reviewed all 2312 successful cases pertaining to adult orthopaedic claims between 2000 and 2006 in an effort to establish trends of litigation and highlight specific areas of concern such that orthopaedic health care could be potentially improved. A total of 1473 entries had sufficient detail to be considered in our study.

RESULTS

There were 4,847,841 elective and trauma-related orthopaedic procedures performed between 2000 and 2006 in the United Kingdom. Compared with the number of cases performed, the frequency of successful litigation is relatively low but financially costly to the National Health Service. From 2000 to 2006, a total of more than US$321,695,072 was paid in adult orthopaedic surgery-related settlements. The most common reason for successful litigation was due to the presence and sequelae of infection (123 cases). In the remaining cases, successful litigation appeared to be related to two common themes: the consent process and the mismanagement of orthopaedic conditions, particularly fractures, cauda equina syndrome, and compartment syndrome.

CONCLUSIONS

These findings highlight the fact that education and vigilance remain important components of orthopaedic training as many of the cases of successful litigation had a preventable cause.

Standardised consent forms on the website of the British Orthopaedic Association

The British Orthopaedic Association has endorsed a website, www.orthoconsent.com, allowing surgeons free access to a bank of pre-written consent forms. These are designed to improve the level of information received by the patient and lessen the risk of successful litigation against surgeons and Health Trusts.

Ten-year follow-up study of three alternative bearing surfaces used in total hip arthroplasty in young patients

Aims

We present the ten-year data of a cohort of patients, aged between 18 and 65 years (mean age 52.7 years; 19 to 64), who underwent total hip arthroplasty. Patients were randomised to be treated with a cobalt-chrome (CoCr) femoral head with an ultra-high molecular weight polyethylene (UHMWPE), highly cross-linked polyethylene (XLPE) or ceramic-on-ceramic (CoC) bearing surface.

Patients and Methods

A total of 102 hips (91 patients) were randomised into the three groups. At ten years, 97 hips were available for radiological and functional follow-up. Two hips (two patients) had been revised (one with deep infection and one for periprosthetic fracture) and three were lost to follow-up. Radiological analysis was performed using a validated digital assessment programme to give linear, directional and volumetric wear of the two polyethylene groups.

Results

There was a significantly reduced rate of steady-state linear wear with XLPE (0.07 mm/yr) compared with UHMWPE (0.37 mm/yr) (p = 0.001). Volumetric wear was also significantly reduced in the XLPE group (29.29 mm3/yr) compared with the UHMWPE group (100.75mm3/yr) (p = 0.0001). There were six patients with UHMWPE who had non-progressive osteolysis and none in the XLPE group. All three bearing groups had significant improvements in 12-item short form health survey scores, Western Ontario and McMaster Universities Osteoarthritis Index score and Harris Hip Score. However, the improvement in HSS was significantly less in the UHMWPE group (p = 0.0188) than in the other two groups. At ten years, the rates of volumetric and linear wear in the XLPE group remain low and predominantly below the estimated threshold for osteolysis (1 mm/yr). The rate of linear wear in the XLPE group was three times less than in the UHMWPE group at five-year follow-up and five times less at ten years. The rate of volumetric wear was also three times less in the XLPE group at ten years.

Conclusion

While CoC also performs well, XLPE at ten years remains a safe and excellent bearing option in young patients, with low rates of wear and no evidence of osteolysis. Cite this article: Bone Joint J 2017;99-B:1590–5.

Temporal Trends and Predictors of Thirty-Day Readmissions and Emergency Department Visits Following Total Knee Arthroplasty in Ontario Between 2003 and 2016

BACKGROUND

Total knee arthroplasty (TKA) is the second most common surgery performed in Canada. Understanding and improving quality metrics associated with such high-volume procedures is of utmost importance to maximize value within the healthcare system, which is a balance between cost and quality. Although rates and predictors of hospital readmission and emergency department (ED) visits following TKA have previously been described in privatized healthcare settings, few studies have evaluated trends in length of stay (LOS), hospital readmissions, and ED visits following TKA in a universal single-payer system.

METHODS

Using data from a provincially held and validated registry, the Institute for Clinical and Evaluative Sciences, we undertook a review of all 205,152 TKAs performed in the province of Ontario, Canada, between 2003 and 2016. We determined temporal trends in utilization, LOS, readmissions, and ED visits and evaluated patient and provider predictors of hospital readmissions and ED visits using multivariate logistic regression modeling. We also grouped and described the most common reasons for readmission and ED visits based on the available International Classification of Diseases, Ninth Revision and Tenth Revision coding information.

RESULTS

LOS decreased significantly over the study period (P < .0001), from a median of 5 days (10th percentile 3 days, 90th percentile 8 days) in 2003 to a median of 3 days (10th percentile 2 days, 90th percentile 4 days) in 2016. All-cause 30-day readmissions did not change significantly over the study period, but the rate of ED visits increased significantly over time. Predictors of 30-day readmission following TKA included older age, male gender, lower income quartile, not having a postoperative visit with a primary care physician (PCP), increased comorbidities, longer LOS, urgent or revision surgery, admission to a teaching hospital, and discharge to an inpatient rehabilitation facility. Variables that predicted increased odds of an ED visit included older age, male gender, lower income quartile, not having a postop visit with a PCP, increasing comorbidities, year of surgery, longer LOS, and revision surgery. Admission to a teaching hospital and discharge to an inpatient rehabilitation facility showed a trend toward increased odds of an ED visit.

CONCLUSIONS

We identified a significant increase in ED visits following TKA in Ontario between 2003 and 2016, with no corresponding increase in hospital readmissions despite a significant temporal trend toward shorter LOS. Predictors of ED visits and readmissions were similar, including male gender, lower income, higher comorbidities, and lacking a PCP visit postoperatively. Increased rates of ED visits following TKA in Ontario represent a quality problem, as they are associated with increased cost to the public healthcare system without any substantial benefit. Interventions aimed at redirecting patients from the ED for minor postoperative concerns should be investigated, as this is likely to improve care by reducing costs, improving efficiency, and enhancing patient experience.

Outcomes of an integrated community-based nurse-led cardiovascular disease prevention programme

Background

National guidance for England recommends that cardiovascular disease (CVD) should be managed as a family of diseases in the community. Here, we describe the results of such an approach.

Methods

Patients with established CVD or who were at high multifactorial risk (HRI) underwent a 12-week community-based nurse-led prevention programme (MyAction) that included lifestyle and risk factor management, prescription of medication and weekly exercise and education sessions.

Results

Over a 6-year period, 3232 patients attended an initial assessment; 63% were male, and 48% belonged to black and minority ethnic groups. 56% attended an end-of-programme assessment, and 33% attended a one year assessment. By the end of the programme, there was a significant reduction in smoking prevalence but only in HRI (−3.7%, p<0.001). Mediterranean diet score increased in both CVD (+1.2, p<0.001) and HRI (+1.5; p<0.001), as did fitness levels (CVD +0.8 estimated Mets maximum, p<0.001, HRI +0.9 estimated Mets maximum, p<0.001) and the proportions achieving their physical activity targets (CVD +40%, p<0.001, HRI +37%, p<0.001). There were significant increases in proportions achieving their blood pressure (CVD +15.4%, p<0.001, HRI +25%, p<0.001 and low-density lipoprotein cholesterol targets (CVD +6%, p=0.004, HRI +23%, p<0.001). Statins and antihypertensive medications significantly increased in HRI. Significant improvements in depression scores and quality-of-life measures were also seen. The majority of improvements were maintained at 1 year.

Conclusion

These results demonstrate that an integrated vascular prevention programme is feasible in practice and reduces cardiovascular risk in patients with established CVD and in those at high multifactorial risk.

Highly Porous Titanium Acetabular Components in Primary and Revision Total Hip Arthroplasty: A Systematic Review

BACKGROUND

A number of papers have been published reporting on the clinical performance of highly porous coated titanium acetabular cups in primary and revision total hip arthroplasty (THA). However, no systematic review of the literature has been published to date.

METHODS

The US National Library of Medicine (PubMed/MEDLINE), Embase, and the Cochrane Database of Systematic Reviews were queried for publications utilizing the following keywords: "tritanium" OR "highly-porous" AND "titanium" OR "acetabular" AND "trabecular" AND "titanium".

RESULTS

Overall, 16 studies were included in this review (11,366 cases; 60% females, 2-7 years mean follow-up). The overall survival rate of highly porous titanium acetabular components in primary cases was 99.3% (10,811 of 10,886 cases), whereas the rate of aseptic loosening was 0.1%. The overall survival rate of the highly porous titanium acetabular components in revision THA cases was 93.5% (449 of 480 cases), whereas the rate of aseptic loosening was 2.1%.

CONCLUSION

There was moderate quality evidence to show that the use of highly porous titanium acetabular components in primary and revision THA cases is associated with satisfactory clinical outcomes in the short- and medium-term, without showing any evidence of cup migration or radiolucency. Taking into consideration that there is no evidence yet regarding the long-term survivorship of these components, we feel that further research of higher quality is required to generate more evidence-based conclusions regarding the longevity of highly porous titanium acetabular implants compared with conventional titanium counterparts.

Converting hip and knee arthroplasty cases to same-day surgery due to COVID-19

AIMS

In 2020, the COVID-19 pandemic meant that proceeding with elective surgery was restricted to minimize exposure on wards. In order to maintain throughput of elective cases, our hospital (St Michaels Hospital, Toronto, Canada) was forced to convert as many cases as possible to same-day procedures rather than overnight admission. In this retrospective analysis, we review the cases performed as same-day arthroplasty surgeries compared to the same period in the previous 12 months.

METHODS

We conducted a retrospective analysis of patients undergoing total hip and knee arthroplasties over a three-month period between October and December in 2019, and again in 2020, in the middle of the COVID-19 pandemic. Patient demographics, number of outpatient primary arthroplasty cases, length of stay for admissions, 30-day readmission, and complications were collated.

RESULTS

In total, 428 patient charts were reviewed for October to December of 2019 (n = 195) and 2020 (n = 233). Of those, total hip arthroplasties (THAs) comprised 60% and 58.8% for 2019 and 2020, respectively. Demographic data was comparable with no statistical difference for age, sex, contralateral joint arthroplasty, or BMI. American Society of Anesthesiologists grade I was more highly prevalent in the 2020 cohort (5.1-times increase; n = 13 vs n = 1). Degenerative disc disease and fibromyalgia were less significantly prevalent in the 2020 cohort. There was a significant increase in same day discharges for non-direct anterior approach THAs (two-times increase) and total knee arthroplasty (ten-times increase), with a reciprocal decrease in next day discharges. There were significantly fewer reported superficial wound infections in 2020 (5.6% vs 1.7%) and no significant differences in readmissions or emergency department visits (3.1% vs 3.0%).

CONCLUSION

The COVID-19 pandemic meant that hospitals and patients were hopeful to minimize the exposure to the wards, and minimize strain on the already taxed inpatient beds. With few positives during the COVID-19 crisis, the pandemic was the catalyst to speed up the outpatient arthroplasty programme that has resulted in our institution being more efficient, and with no increase in readmissions or early complications. Cite this article: Bone Jt Open 2021;2(7):545-551.

Intramedullary Nailing Versus Plate Fixation for the Treatment Displaced Midshaft Clavicular Fractures: A Systematic Review and Meta-Analysis

The two commonly performed surgical techniques used to repair displaced midshaft clavicle fractures are plate fixation or intramedullary nailing; however, despite recent evidence, the optimal method to treat such fractures remains a continued topic of debate. A meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate long term function, complications, and operative duration in adult patients receiving intramedullary nailing in comparison to plating. Seven RCTs and three quasi-randomized trials were included. No significant difference was found in long-term function between the two groups (MD: −0.66, 95% CI: −2.03 to 0.71, I² = 62%, p = 0.34). Patients who received plating had a 2.19 times increased risk of treatment failure, but this failed to reach significance (95% CI: 0.93 to 5.15, I² = 0%, p = 0.07). The risk of non-operative complications was 2.11 times higher in patients who received plating and this reached statistical significance (95% CI: 1.38 to 3.23, I² = 53%, p = 0.0006). Finally, plating significantly prolonged operative duration by 20.16 minutes (95% CI: 16.87 to 23.44, I² = 56%, p < 0.00001). Our results suggest that intramedullary nailing and plating provide equivalent long-term functional outcomes; however, plating may lead to a higher risk of treatment failure and non-operative complications.

Complications of closing wedge high tibial osteotomies for unicompartmental osteoarthritis of the knee

We systematically reviewed the published literature on the complications of closing wedge high tibial osteotomy for the treatment of unicompartmental osteoarthritis of the knee. Publications were identified using the Cochrane Library, MEDLINE, EMBASE and CINAHL databases up to February 2012. We assessed randomised (RCTs), controlled group clinical (CCTs) trials, case series in publications associated with closing wedge osteotomy of the tibia in patients with osteoarthritis of the knee and finally a Cochrane review. Many of these trials included comparative studies (opening wedge versus closing wedge) and there was heterogeneity in the studies that prevented pooling of the results.

A 3 year minimum follow up of Endoprosthetic replacement for distal femoral fractures - An alternative treatment option

INTRODUCTION

Although the use of an endoprosthesis for distal femoral fractures remains a valid treatment option the widespread use is in its infancy.

METHODOLOGY

In this retrospective case series, we review cases of distal femoral fracture treated with endoprosthetic replacement (EPR). The outcomes we assessed were the time to start mobilising, the time to discharge, morbidity and mortality as well as an Oxford knee score to assess pain and function and also the early survivorship. 6 of the 11 from the cohort had existing Total Knee Replacements (TKRs) in situ.

RESULTS

There were 11 knees in our cohort with a mean age of 81.5 years (range 52-102 years). The median time to follow up was 3.5 years (range 1.6 to 5.5 years). The median times to theatre was 3 days and to discharge was 16 days. Oxford functional and pain scores were 32/48.

DISCUSSION

In the appropriate patient and fracture pattern, Endoprosthetic knee replacement is an excellent option in the treatment of distal femoral fractures whether associated with an existing TKR or not. The implant is more costly than traditional open reduction and internal fixation, but the earlier return to full mobility post-operatively may save on hospital/care home stay and free up hospital space and minimise complications.

A cost-effectiveness assessment of dual-mobility bearings in revision hip arthroplasty

Aims

The rate of dislocation when traditional single bearing implants are used in revision total hip arthroplasty (THA) has been reported to be between 8% and 10%. The use of dual mobility bearings can reduce this risk to between 0.5% and 2%. Dual mobility bearings are more expensive, and it is not clear if the additional clinical benefits constitute value for money for the payers. We aimed to estimate the cost-effectiveness of dual mobility compared with single bearings for patients undergoing revision THA.

Methods

We developed a Markov model to estimate the expected cost and benefits of dual mobility compared with single bearing implants in patients undergoing revision THA. The rates of revision and further revision were calculated from the National Joint Registry of England and Wales, while rates of transition from one health state to another were estimated from the literature, and the data were stratified by sex and age. Implant and healthcare costs were estimated from local procurement prices and national tariffs. Quality-adjusted life-years (QALYs) were calculated using published utility estimates for patients undergoing THA.

Results

At a minimum five-year follow-up, the use of dual mobility was cost-effective with an estimated incremental cost-effectiveness ratio (ICER) of between £3,006 and £18,745/QALY for patients aged < 55 years and between 64 and 75 years, respectively. For those aged > 75 years dual mobility was only cost-effective if the timeline was beyond seven years. The use of dual mobility bearings was cost-saving for patients aged < 75 years and cost-effective for those aged > 75 years if the time horizon was beyond ten years.

Conclusion

The use of dual mobility bearings is cost-effective compared with single bearings in patients undergoing revision THA. The younger the patient is, the more likely it is that a dual mobility bearing can be more cost-effective and even cost-saving. The results are affected by the time horizon and cost of bearings for those aged > 75 years. For patients aged > 75 years, the surgeon must decide whether the use of a dual mobility bearing is a viable economic and clinical option.

Cite this article: Bone Joint J 2020;102-B(9):1128–1135.

601 metal-on-metal total hip replacements with 36 mm heads a 5 minimum year follow up: Levels of ARMD remain low despite a comprehensive screening program

BACKGROUND

We conducted a retrospective study to assess the clinical outcome, failure rate, and reason for failure of a large consecutive series of 36 mm MoM Corail/Pinnacle total hip replacements (THRs).

METHODS

Between 2006 and 2011, 601 consecutive 36 mm MoM THRs were performed (585 patients). Patients were followed according to the UK Medicines and Healthcare Products Regulatory Agency (MHRA) guidelines. All patients were accounted for and 469 patients (78%) were clinically and radiographically assessed. 328 females and 141 males with a median age of 73 (range 36-94 years) and a median follow up of 7.2 years (range 5.2-9.7 years) were followed. Clinical data included blood cobalt and chromium, Oxford Hip Score (OHS), plain radiograph, ultrasound of hip and intra-operative findings in those patients who had revision surgery.

RESULTS

56 patients died of causes unrelated to their hip replacement. The mean survivorship of the implant was 92.8% (range 91.6-94%, 95% CI) at a median time to follow up of 84 months (62-113 months). The functional outcome was good with a median OHS of 38 out of 48 (23-44). The dislocation rate was 0.99%, with all these 6 cases requiring revision. 476 patients had blood tests. 100 patients (21%) had elevated levels of either cobalt above MHRA guidelines of 7 parts per billion (120 and 135 nmol/L respectively for cobalt and chromium). Cobalt was elevated independently of chromium in 75% of the cases (but never vice versa). The mean cup inclination angle was 42°. Each incremental stem size increase resulted in a decrease in cobalt by 11 nmol/L. The most common reason for revision was adverse reaction to metal debris (ARMD) (12 cases).

CONCLUSION

This paper is the largest and longest follow up of 36 mm MoM THRs. Using the MHRA guidelines for follow up, the revision rates of this cohort has remained low compared to other studies, but unacceptably higher than that of other bearing surfaces.

LEVEL OF EVIDENCE

III.

Wear Rates of XLPE Nearly 50% Lower Than Previously Thought After Adjusting for Initial Creep: An RCT Comparing 4 Bearing Combinations

Background

The ideal bearing combination for total hip arthroplasty (THA) remains debatable. Highly cross-linked polyethylene (XLPE) is widely used, but long-term wear rates are not fully known, nor is how much the initial "creep," if any, affects overall wear. Additionally, the use of oxidized zirconium (OxZir) is purported to lower polyethylene wear rates, but this has not been proven. We present the 10-year data of a cohort of patients who underwent THA. Patients were prospectively randomized to 1 of 4 bearing combinations: a conventional ultra-high molecular weight polyethylene (UHMWPE) or XLPE acetabular liner coupled with either a cobalt-chromium (CoCr) or OxZir femoral head. The aims of the study were to (1) assess the extent to which creep affected overall wear rates and (2) assess wear rates between OxZir and CoCr with polyethylene.

Methods

A total of 92 hips (92 patients) between the ages of 22 and 65 years (mean, 52.2 ± 9.3 years) were randomized to 4 groups. At 10 years, 70 (76%) of the hips were available for analysis; patients who had undergone revision, had died, or were lost to follow-up were excluded from final analysis. Radiographic analysis was performed using a validated digital assessment program to determine linear, volumetric, and directional wear of the polyethylene for all 4 bearing couples. Radiographic assessments were performed immediately postoperatively, at 6 and 12 weeks, and then annually for a minimum of 10 years.

Results

XLPE had significantly lower wear rates than UHMWPE. Once creep was eliminated, annual and overall wear rates were nearly 50% lower than have been previously reported. This was proportionally more important in the XLPE group than in the UHMWPE group. There was a nonsignificant trend toward a lower wear rate with OxZir heads.

Conclusions

Creep plays a notably more important role than first thought. Once creep was eliminated, the overall wear rate was even lower than previously assumed. This has important implications for the overall survivorship of hip arthroplasty implants.

Level of Evidence

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Anemia at Presentation Predicts Acute Mortality and Need for Readmission Following Geriatric Hip Fracture

There is a paucity of research regarding the relationship between anemia and postoperative morbidity and mortality among geriatric patients presenting with hip fracture. The objective of this study was to determine the effect of anemia at presentation on 30-day morbidity and mortality among geriatric patients with hip fracture.

The manufacture of generic replicas of implants for arthroplasty of the hip and knee

Joint replacement of the hip and knee remain very satisfactory operations. They are, however, expensive. The actual manufacturing of the implant represents only 30% of the final cost, while sales and marketing represent 40%. Recently, the patents on many well established and successful implants have expired. Companies have started producing and distributing implants that purport to replicate existing implants with good long-term results.

The aims of this paper are to assess the legality, the monitoring and cost saving implications of such generic implants. We also assess how this might affect the traditional orthopaedic implant companies.

Cite this article: Bone Joint J 2016;98-B:892–900.

Patient-Reported Outcome Measures of Total Knee Arthroplasties for Post-Traumatic Arthritis versus Osteoarthritis: A Short-Term (5- to 10-year) Retrospective Matched Cohort Study

BACKGROUND

The objective of the study was to compare the patient-reported outcome measures (PROM) of patients with post-traumatic arthritis (PTA) versus patients with osteoarthritis (OA) undergoing total knee arthroplasty (TKA) and compare the rates of revision among these two groups.

METHODS

Using a prospectively held institutional registry, we retrospectively reviewed patients ≥60 years of age who underwent unilateral TKA between May 2007 and February 2012. Patients with previous or concomitant diagnosis of inflammatory arthropathy or an initial open fracture were excluded. PTA patients were matched 1:5 with OA patients undergoing TKA. Validated PROMs were recorded at baseline before index TKA and the last follow-up. Reason and time to revision surgery was reported, and survivorship was compared using Kaplan-Meier curves.

RESULTS

Seventy-five PTA patients were matched to 375 OA patients. There was no difference between these groups with respect to age (67.7 ± 5.6 vs 67.8 ± 5.5 years; P = .876), body mass index (28.6 ± 5.4 vs 28.7 ± 5.3 kg/m²; P = .948), sex (65.3% vs 65.3% females; P = .999), Charlson Comorbidity Index (21.3% vs 21.3% Index 1-2, P = .999), and time to follow-up (93.0 ± 13.4 vs 88.2 ± 13.7 months; P = .999). No statistically significant difference was found in PROMs at baseline and the last follow-up (P > .05), the rate or time to revision surgery between the two groups (P-value = .635; log-rank test).

CONCLUSION

Unlike previous studies, TKA for PTA does not pose lower PROMs or higher revision rates when compared to TKA for OA. These results could help provide surgeons with a frame of reference in terms of expectations for patients with PTA undergoing TKA.

The association of preoperative blood markers with postoperative readmissions following arthroplasty

AIMS

While preoperative bloodwork is routinely ordered, its value in determining which patients are at risk of postoperative readmission following total knee arthroplasty (TKA) and total hip arthroplasty (THA) is unclear. The objective of this study was to determine which routinely ordered preoperative blood markers have the strongest association with acute hospital readmission for patients undergoing elective TKA and THA.

METHODS

Two population-based retrospective cohorts were assembled for all adult primary elective TKA (n = 137,969) and THA (n = 78,532) patients between 2011 to 2018 across 678 North American hospitals using the American College of Surgeons National Quality Improvement Programme (ACS-NSQIP) registry. Six routinely ordered preoperative blood markers - albumin, haematocrit, platelet count, white blood cell count (WBC), estimated glomerular filtration rate (eGFR), and sodium level - were queried. The association between preoperative blood marker values and all-cause readmission within 30 days of surgery was compared using univariable analysis and multivariable logistic regression adjusted for relevant patient and treatment factors.

RESULTS

The mean TKA age was 66.6 years (SD 9.6) with 62% being females (n = 85,163/137,969), while in the THA cohort the mean age was 64.7 years (SD 11.4) with 54% being female (n = 42,637/78,532). In both cohorts, preoperative hypoalbuminemia (< 35 g/l) was associated with a 1.5- and 1.8-times increased odds of 30-day readmission following TKA and THA, respectively. In TKA patients, decreased eGFR demonstrated the strongest association with acute readmission with a standardized odds ratio of 0.75 per two standard deviations increase (p < 0.0001).

CONCLUSION

In this population level cohort analysis of arthroplasty patients, low albumin demonstrated the strongest association with acute readmission in comparison to five other commonly ordered preoperative blood markers. Identification and optimization of preoperative hypoalbuminemia could help healthcare providers recognize and address at-risk patients undergoing TKA and THA. This is the most comprehensive and rigorous examination of the association between preoperative blood markers and readmission for TKA and THA patients to date. Cite this article: Bone Jt Open 2021;2(6):388-396.

Survival analysis and functional outcome of the Oxford unicompartmental knee replacement up to 11 years follow up at a District General Hospital

BACKGROUND

There have been several large originator studies reporting excellent results with this prosthesis but far fewer large independent studies. We present, to our knowledge, the largest independent series documenting excellent survivorship rates and good functional outcomes at a mean follow up of 5.5 years post implantation of the Oxford unicompartmental knee replacement.

METHODS

Our prospective study looks at the survivorship and the functional outcome of 364 Oxford UKRs performed in a district general hospital at a mean follow up of 5.5 years (range 5-11 years). Post operatively knees were assessed in a research clinic using the Oxford knees score (as well as the American Knee Society Score and the Hospital for Special Surgery Score). Maximal flexion was also measured.

RESULTS

There were 26 revisions of 364 knees giving a survivorship, with revision as the end point, of 93% at a mean of 5.5 years post op (range 5-11 years). We achieved an Oxford score of 37.5, a mean AKSS of 161 (divided as American knee functional score 75.75/American knee objective score 85.4 (excellent)). The mean HSS score was 84.5. We achieved 'Excellent' Oxford knee scores in 137 knees (48%), 'Good' in 75 (26%), 'Moderate' in 51 (17%) and 'Poor' in only 27 (9%) of knees. Mean improvement in functional scores were: Oxford score (14.4), AKSS (71) and HSS (26.3). Mean maximal flexion was 123° range (110-140).

CONCLUSIONS

We have confirmed that good medium to long-term function and survival can be obtained following Oxford medial knee replacement for treating anteromedial osteoarthritis, in our large independent series.

Exeter Universal cemented femoral component

AIMS

We present the results, in terms of survival, clinical outcome, and radiological appearance at 20 years, in a cohort of 225 cemented Exeter Universal femoral components (Stryker, Newbury, UK) implanted in 207 patients, at a district general hospital.

METHODS

All patients in this study had a total hip arthroplasty (THA) using an Exeter Universal femoral component with a cemented (n = 215) or cementless (n = 10) acetabular component. Clinical and radiological data were collected prospectively at one year, five years, and every five years thereafter. Patients lost to radiological and clinical follow-up (five) were cross-referenced with National Joint Registry (NJR) data and general practitioner (GP) records to assess whether they had undergone revision for any reason.

RESULTS

During this period of study 144 patients (157 hips) died (69.78%). Two patients were lost to follow-up, leaving 61 patients (66 hips) available for review (29.33%). Of the 225 hips, three underwent revision for femoral failure with osteolysis. One underwent femoral component revision for treatment of a periprosthetic fracture. Eight underwent revision of the acetabular component only for loosening. Two hips had both components revised, when components were found to be loose at time of revision for acetabular loosening, though no radiological femoral osteolysis. Two patients underwent revision for infection. Using femoral loosening as an endpoint, the survival of the Exeter Universal femoral component was 98.7% (n = 220, 95% confidence interval (CI) 96.1% to 100%) at 20 to 22 years. Survival with an endpoint of revision for any reason was 92.6% (n = 209, 95% CI 89.4 to 95.55), with a 'worst-case scenario' (considering two patients lost to follow-up to have failed), the overall survival rate was 91.7% (n = 207, 95% CI 87.8 to 95.9) at 20 to 22 years.

CONCLUSION

Our results confirm excellent long-term results for the cemented Exeter Universal femoral componentimplanted outside of the originating centre. Cite this article: Bone Joint J 2020;102-B(10):1319-1323.

Assessment of the equivalence of a generic to a branded femoral stem

Aims

The aim of this study was to compare the design of the generic OptiStem XTR femoral stem with the established Exeter femoral stem.

Materials and Methods

We obtained five boxed, as manufactured, implants of both designs at random (ten in total). Two examiners were blinded to the implant design and independently measured the mass, volume, trunnion surface topography, trunnion roughness, trunnion cone angle, Caput-Collum-Diaphyseal (CCD) angle, femoral offset, stem length, neck length, and the width and roughness of the polished stem shaft using peer-reviewed methods. We then compared the stems using these parameters.

Results

We found that the OptiStems were lighter (p < 0.001), had a rougher trunnion surface (p < 0.001) with a greater spacing and depth of the machined threads (p < 0.001), had greater trunnion cone angles (p = 0.007), and a smaller radius at the top of the trunnion (p = 0.007). There was no difference in stem volume (p = 0.643), CCD angle (p = 0.788), offset (p = 0.993), neck length (p = 0.344), stem length (p = 0.808), shaft width (p = 0.058 to 0.720) or roughness of the polished surface (p = 0.536).

Conclusion

This preliminary investigation found that whilst there were similarities between the two designs, the generic OptiStem is different to the branded Exeter design.

Cite this article: Bone Joint J 2017;99-B:310–16.

Is Oxidized Zirconium Femoral Head Superior to Other Bearing Types in Total Hip Arthroplasty? A Systematic Review and Meta-Analysis

BACKGROUND

Oxidized zirconium (OxZi) is a relatively new type of material that combines the strength of a metal with the surface/wears properties of a ceramic. Our aim was to investigate whether OxZi femoral heads lead to lower polyethylene wear, higher survival rate, and better clinical outcomes than the other bearing types in patients treated with total hip arthroplasty (THA).

METHODS

Two reviewers independently conducted a systematic search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses using the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews. These databases were queried with the terms: a. "oxidized" AND "zirconium" AND "total" AND "hip" AND "arthroplasty"; b. "oxinium" AND "total" AND "hip" AND "arthroplasty". The primary outcome measures were the survival rate of the bearing surfaces as well as the polyethylene wear.

RESULTS

The vast majority (85.7%) of the studies, which reported the mean polyethylene wear rate, showed that there was not any significant difference between OxZi and cobalt-chrome (CoCr) femoral heads (rate ratio: 0.836; 95% confidence interval: 0.362-1.928; P = .674). All studies comparing the survival rate of OxZi and CoCr femoral heads illustrated almost excellent survivorship with both implants.

CONCLUSION

OxZi femoral heads did not lead to lower polyethylene wear rate or higher survival rate, when compared with CoCr femoral heads in patients treated with THA. On the basis of these results and taking into account the higher cost of these implants, we would not recommend the routine use of OxZi femoral heads in primary THAs.

LEVEL OF EVIDENCE

Systematic review and meta-analysis of therapeutic studies I-III.

A Large-Scale Fifteen-Year Minimum Survivorship of a Cementless Triple Tapered Femoral Stem

BACKGROUND

This study reports the long-term outcomes of a metaphyseal fit-and-fill cementless femoral component in total hip arthroplasty (THA) with a follow-up of 15-19 years.

METHODS

We conducted a retrospective review of 376 consecutive THAs (345 patients), using a triple tapered stem performed between 2000 and 2003 with a view to assessing survivorship and radiological and functional outcomes. Images were assessed for initial alignment, terminal osteolysis, or subsidence, while clinical outcomes were assessed using the St Michael's Hip Score.

RESULTS

Forty-five (11.9%) hips were lost to follow-up, 20 (5.31%) had died before our 15-year cutoff follow-up, and 4 (1.06%) had declined follow-up early on, leaving 307 hips (81.64%, 276 patients) available for both clinical and radiological follow-up at a minimum of 15 years (range 15-19). The mean age at the time of operation was 49.6 years (range 19-71) and the cohort included 131 (42.67%) male and 145 (47.23%) female patients. Seven stems (2.28%) were revised: 4 due to periprosthetic fractures, 2 for periprosthetic joint infection, and 1 for adverse reaction to metal debris at the trunnion. The St Michael's Hip Score improved from 14.2 (range 9-23) preoperatively to 22.3 (range 13 to 25) at the last documented follow-up (P = .000). Kaplan-Meier survivorship with stem revision for any reason as the end point was 97.70%. Worst-case scenario Kaplan-Meier survivorship, where all lost to follow-up are considered as failures, was 85.3%. No stem was revised for aseptic loosening.

CONCLUSION

This triple tapered stem in THA shows excellent survivorship beyond a minimum of 15 years.

Access to hip arthroplasty and rates of complications in different socioeconomic groups : a review of 111,000 patients in a universal healthcare system

AIMS

Total hip arthroplasty (THA) is one of the most successful surgical procedures. The objectives of this study were to define whether there is a correlation between socioeconomic status (SES) and surgical complications after elective primary unilateral THA, and investigate whether access to elective THA differs within SES groups.

METHODS

We conducted a retrospective, population-based cohort study involving 202 hospitals in Ontario, Canada, over a 17-year period. Patients were divided into income quintiles based on postal codes as a proxy for personal economic status. Multivariable logistic regression models were then used to primarily assess the relationship between SES and surgical complications within one year of index THA.

RESULTS

Of 111,359 patients who underwent elective primary THA, those in the lower SES groups had statistically significantly more comorbidities and statistically significantly more postoperative complications. While there was no increase in readmission rates within 90 days, there was a statistically significant difference in the primary and secondary outcomes including all revisions due (with a subset of deep wound infection and dislocation). Results showed that those in the higher SES groups had proportionally more cases performed than those in lower groups. Compared to the highest SES quintile, the lower groups had 61% of the number of hip arthroplasties performed.

CONCLUSION

Patients in lower socioeconomic groups have more comorbidities, fewer absolute number of cases performed, have their procedures performed in lower-volume centres, and ultimately have higher rates of complications. This lack of access and higher rates of complications is a "double hit" to those in lower SES groups, and indicates that we should be concentrating efforts to improve access to surgeons and hospitals where arthroplasty is routinely performed in high numbers. Even in a universal healthcare system where there are no penalties for complications such as readmission, there seems to be an inequality in the access to THA. Cite this article: Bone Joint J 2022;104-B(5):589-597.