Mapping existing hip and knee replacement registries in Europe

An alternative ex vivo method to evaluate the osseointegration of Ti-6Al-4V alloy also combined with collagen

Due to the increasing number of orthopedic implantation surgery and advancements in biomaterial manufacturing, chemistry and topography, there is an increasing need of reliable and rapid methods for the preclinical investigation of osseointegration and bone ingrowth. Implant surface composition and topography increase osteogenicity, osteoinductivity, osteoconductivity and osseointegration of a prosthesis. Among the biomaterials used to manufacture an orthopedic prosthesis, titanium alloy (Ti-6Al-4V) is the most used. Type I collagen (COLL I) induces cell function, adhesion, differentiation and bone extracellular matrix component secretion and it is reported to improve osseointegration if immobilized on the alloy surface. The aim of the present study was to evaluate the feasibility of an alternative ex vivo model, developed by culturing rabbit cortical bone segments with Ti-6Al-4V alloy cylinders (Ti-POR), fabricated through the process of electron beam melting (EBM), to evaluate osseointegration. In addition, a comparison was made with Ti-POR coated with COLL I (Ti-POR-COLL) to evaluate osseointegration in terms of bone-to-implant contact (BIC) and new bone formation (nBAr/TAr) at 30, 60 and 90 d of culture. After 30 and 60 d of culture, BIC and nBAr/TAr resulted significantly higher in Ti-POR-COLL implants than in Ti-POR. No differences have been found at 90 d of culture. With the developed model it was possible to distinguish the biomaterial properties and behavior. This study defined and confirmed for the first time the validity of the alternative ex vivo method to evaluate osseointegration and that COLL I improves osseointegration and bone growth of Ti-6Al-4V fabricated through EBM.

Imaging Analysis of Prosthesis Angle after Hip Replacement with Direct Anterior Approach in Lateral Position

The use of lateral DAA-THA for the treatment of end-stage hip disorders has good recent clinical efficacy, does not require special surgical beds and traction equipment, uses traditional surgical instruments, reduces the requirements for surgical beds and surgical instruments, enters through the nerve and muscle anatomical gap without cutting any muscle or nerve tissue, is minimally invasive, and has good surgical maneuverability, low bleeding, low postoperative pain, short hospitalization time, and rapid recovery. It is a safe and effective minimally invasive procedure because of its light weight, short hospital stay, and rapid recovery. In this paper, we used imaging to observe the angle of the posterior prosthesis. And the results showed that hip arthroplasty using the direct anterior approach improved hip mobility in early stages compared with other approaches and reduced pain. The direct anterior approach and length between total hip arthroplasty using direct lateral and posterior lateral approach and partial data (surgical time, blood loss, etc.) were significantly worse than those using direct forward approach. In addition, the direct anterior approach to total hip arthroplasty is subject to a learning curve and requires at least 33 cases of experience to achieve a lower complication rate.

The Effect of Resistance Training on the Function after Hip Replacement: A Meta-analysis of Randomized Controlled Trials

INTRODUCTION

The efficacy of resistance training for hip replacement remains controversial. We conducted a systematic review and meta-analysis to explore the influence of resistance training on functional recovery for hip replacement.

METHODS

We searched PubMed, EMbase, Web of Science, EBSCO, and Cochrane Library databases through April 2018 for randomized controlled trials (RCTs) assessing the effect of resistance training on hip replacement.

RESULTS

Five RCTs involving 251 patients are included in the meta-analysis. Overall, compared with the control group for post-hip replacement patients, resistance training can significantly improve hip-related quality of life (standard mean difference [SMD] = 0.35; 95% CI = 0.02 to 0.68; p = 0.04), symptoms (SMD = 0.41; 95% CI = 0.08 to 0.74; p = 0.02), sports and recreation (SMD = 0.41; 95% CI = 0.08 to 0.75; p = 0.01), and reduce pain scores (SMD = 0.41; 95% CI = 0.08 to 0.74; p = 0.02), but has no remarkable impact on activities of daily living function (SMD = 0.48; 95% CI = 0 to 0.96; p = 0.05), sit to stand (SMD = 0.17; 95% CI = - 0.25 to 0.59; p = 0.44), stair climb performance (SMD = 0.06; 95% CI = - 0.36 to 0.48; p = 0.77), and leg extension power (SMD = 0.42; 95% CI = - 0.17 to 1.01; p = 0.17).

CONCLUSIONS

Resistance training is associated with significantly improved hip-related quality of life, symptoms, and sports and recreation, and decreased pain scores in post-hip replacement patients.

Three-dimensional pre-operative planning of primary hip arthroplasty: a systematic literature review

Three-dimensional (3D) pre-operative planning in total hip arthroplasty (THA) is being recognized as a useful tool in planning elective surgery, and as crucial to define the optimal component size, position and orientation. The aim of this study was to systematically review the existing literature for the use of 3D pre-operative planning in primary THA.A systematic literature search was performed using keywords, through PubMed, Scopus and Google Scholar, to retrieve all publications documenting the use of 3D planning in primary THA. We focussed on (1) the accuracy of implant sizing, restoration of hip biomechanics and component orientation; (2) the benefits and barriers of this tool; and (3) current gaps in literature and clinical practice.Clinical studies have highlighted the accuracy of 3D pre-operative planning in predicting the optimal component size and orientation in primary THAs. Component size planning accuracy ranged between 34-100% and 41-100% for the stem and cup respectively. The absolute, average difference between planned and achieved values of leg length, offset, centre of rotation, stem version, cup version, inclination and abduction were 1 mm, 1 mm, 2 mm, 4°, 7°, 0.5° and 4° respectively.Benefits include 3D representation of the human anatomy for precise sizing and surgical execution. Barriers include increased radiation dose, learning curve and cost. Long-term evidence investigating this technology is limited.Emphasis should be placed on understanding the health economics of an optimized implant inventory as well as long-term clinical outcomes. Cite this article: EFORT Open Rev 2020;5:845-855. DOI: 10.1302/2058-5241.5.200046.

Computerized registry as a potential tool for surveillance and management of complex bone and joint infections in France: French registry of complex bone and joint infections

Aims

The French registry for complex bone and joint infections (C-BJIs) was created in 2012 in order to facilitate a homogeneous management of patients presented for multidisciplinary advice in referral centres for C-BJI, to monitor their activity and to produce epidemiological data. We aimed here to present the genesis and characteristics of this national registry and provide the analysis of its data quality.

Methods

A centralized online secured database gathering the electronic case report forms (eCRFs) was filled for every patient presented in multidisciplinary meetings (MM) among the 24 French referral centres. Metrics of this registry were described between 2012 and 2016. Data quality was assessed by comparing essential items from the registry with a controlled dataset extracted from medical charts of a random sample of patients from each centre. Internal completeness and consistency were calculated.

Results

Between 2012 and 2016, 30,607 presentations in MM were recorded corresponding to 17,748 individual patients (mean age 62.1 years (SD 18.4); 10,961 (61.8%) males). BJI was considered as complex for 63% of cases (n = 19,355), and 13,376 (44%) had prosthetic joint infections (PJIs). The controlled dataset, available for 19 centres, included 283 patients. Global consistency and completeness were estimated at 88.2% and 88.9%, respectively, considering missing items in the eCRFs as negative results.

Conclusion

This national registry is one of the largest prospective databases on BJI and its acceptable data quality parameters allow further use for epidemiological purposes.Cite this article: Bone Joint Res 2020;9(9):635-644.

Disruption of joint arthroplasty services in Europe during the COVID-19 pandemic: an online survey within the European Hip Society (EHS) and the European Knee Associates (EKA)

PURPOSE

The aim of the present study was to evaluate the impact of the coronavirus (COVID-19) pandemic on joint arthroplasty service in Europe by conducting an online survey of arthroplasty surgeons.

METHODS

The survey was conducted in the European Hip Society (EHS) and the European Knee Associates (EKA). The survey consisted of 20 questions (single, multiple choice, ranked). Four topics were addressed: (1) origin and surgical experience of the participant (four questions); (2) potential disruption of arthroplasty surgeries (12 questions); (3) influence of the COVID-19 pandemic on the particular arthroplasty surgeon (four questions); (4) a matrix provided 14 different arthroplasty surgeries and the participant was asked to state whether dedicated surgery was stopped, delayed or cancelled.

RESULTS

Two-hundred and seventy-two surgeons (217 EHS, 55 EKA) from 40 different countries participated. Of the respondents, 25.7% stated that all surgeries were cancelled in their departments, while 68.4% responded that elective inpatient procedures were no longer being performed. With regard to the specific surgical procedures, nearly all primary TJA were cancelled (92.6%) as well as aseptic revisions (94.7%). In most hospitals, periprosthetic fractures (87.2%), hip arthroplasty for femoral neck fractures and septic revisions for acute infections (75.8%) were still being performed.

CONCLUSION

During the current 2020 COVID-19 pandemic, we are experiencing a near-total shutdown of TJA. A massive cutback was observed for primary TJA and revision TJA, even in massively failed TJA with collapse, dislocation, component failure or imminent dislocation. Only life-threatening pathologies like periprosthetic fractures and acute septic TJA are currently undergoing surgical treatment.

LEVEL OF EVIDENCE

V.

Global Perspectives on Arthroplasty of Hip and Knee Joints

There is a broad variation of implantation rates, indications, and types of prostheses used for hip and knee joint replacement procedures among different countries. The establishment of national joint registers has improved knowledge and quality of data related to joint implantation. Comparing reports of different national registries is crucial to determine potential variations in practices among surgeons and arthroplasty centers and to identify topics for future analysis. In this report, data from these registries in addition to manufacturer reports were used to evaluate procedure volumes and implants utilization trends of primary and revision total hip and knee replacement around the world.

Survival Rate and Application Number of Total Hip Arthroplasty in Patients With Femoral Neck Fracture: An Analysis of Clinical Studies and National Arthroplasty Registers

BACKGROUND

Total hip arthroplasty (THA) is an increasingly popular treatment option for fractured neck of femur (NOF). The primary aim of this study is to systematically review all literature on primary THA and hemiarthroplasty (HA) after fractured NOF to calculate an overall revision rate. Furthermore, we wanted to compare primary THA implantations after fractured NOF between different countries in terms of THA number per inhabitant.

METHODS

All clinical studies on THA and HA for femoral neck fractures between 1999 and 2019 were reviewed and evaluated with a special interest on revision rate. Revision rate was calculated as "revision per 100 component years." THA registers were compared between different countries with respect to the number of primary implantations per inhabitant.

RESULTS

THA studies showed a mean revision rate of 11.8% after 10 years, which was lower than a 24.6% 10-year revision rate for HA. We identified 8 arthroplasty registers that revealed an annual average incidence of THA for fractured NOF of 9.7 per 100,000 inhabitants.

CONCLUSION

This study showed that patients with THA were less likely to be revised at 10 years compared to HA. We found similar annual numbers of THAs for fractured NOF per inhabitant across countries. The results of this analysis can be used to rank present and future national THA numbers within an international context.

Medical Devices: Definition, Classification, and Regulatory Implications

We propose the following definition of a medical device: "A contrivance designed and manufactured for use in healthcare, and not solely medicinal or nutritional." Current regulatory classifications of medical devices are complex and designed primarily for regulators. We propose a simpler classification, based on (1) the site of application of the device, (2) the time scale of its use, and (3) whether it has an external power source. The regulation of medical devices is less well developed than the regulation of medicinal products, which it could follow more closely. In particular, devices that incorporate medicines should be required to meet the same regulatory standards as medicinal products. This would remove the anomaly that some delivery systems that incorporate medicines are classified as devices while other similar systems that deliver the same medicines are classified as medicinal products. Some improvements might also result from more widespread use of registries, such as those used for prosthetic joint replacements. Registries would allow both a prospective examination of the performance of high-risk devices and a retrospective analysis when signals from other sources of information suggest problems. Those who apply for a marketing authorization for a new device should have to assure regulators of its quality of manufacture, safety, and efficacy before licensing. Even the most straightforward device should be shown to be useable in practice. Trials on patients, or at least simulations of use in the real world, should be practicable for most devices.

Medical Devices: Classification and Analysis of Faults Leading to Harms

INTRODUCTION

Harms from medical devices are important, but have been much less well studied than adverse drug reactions. Information provided to device users is of variable quality.

OBJECTIVE

Our aim was to define "medical device fault" and "adverse effect of a medical device"; to establish whether medical device faults arise in design, manufacture, or use; and to consider ways of mitigating the adverse effects of medical devices.

METHODS

We analysed 100 consecutive faults reported by the US Food and Drug Administration (FDA) and 50 faults reported by the UK Medicines and Healthcare products Regulatory Agency (MHRA), and classified faults according to the point at which they occurred.

RESULTS

Nearly 70% of reported faults related to devices that entered the body. Over 70% arose at the design stage, a quarter of the faults were associated with manufacture, and less than 5% were primarily caused by faulty use.

CONCLUSION

We defined a medical device fault as an unintended failure in the design, manufacture, or use of a medical device that leads to, or has the potential to lead to, harm to the patient, and an adverse effect of a medical device as an unintended and appreciably harmful effect, caused by a medical device, which demonstrates a hazard of the device and may warrant preventive measures, or a change in the mode of use, or withdrawal of the device. Most faults that generate warnings arise from problems at the design stage, some arise at the manufacturing stage, and a few in usage. Careful assessment of the design of safety-critical devices in the light of previous problems may help to prevent repetition of errors. It would be helpful if, in addition to user manuals, manufacturers were required to produce Summaries of Device Characteristics (SDCs, "labels") that contained a systematically presented set of information about a product.

Changing Device Regulations in the European Union: Impact on Research, Innovation and Clinical Practice

BACKGROUND

Up until 2017, medical devices were placed on the European Union's (EU) single market in accordance with either Medical Device Directive 93/42/EEC for general medical devices or Medical Device Directive 90/385/EEC for active implantable devices. However, some devices that complied with these directives still failed catastrophically. In the orthopaedic device field, these failures were most pronounced in metal-on-metal hip devices causing severe patient morbidity with increased need for revision surgery which had unpredictable outcomes. Subsequently, the newly introduced Medical Device Regulations 2017/745 are aimed at addressing patient safety based on previous experience and thorough device assessment prior to and post-release on the EU single market; to accommodate for this they are substantially different (and more stringent). This poses a greater challenge for manufacturers and regulatory bodies in terms of time and resources.

METHODS

A review of the EU directives and published literature was undertaken. This review provides the rationale behind this change and its potential impact on research, industry, and clinical practice.

DISCUSSION

The change in legal requirements for the medical devices to be put on the EU single market ultimately leads to increased patient safety, which is supported by clinical professionals. The new requirements for data transparency, post-market surveillance, and implant information availability increase the chance of catastrophic failure prevention. However, the exact method of implementation remains uncertain, and some essential rules on the data requirements for compliance have not yet been published by the EU. These limitations may limit the availability of products on the market including withdrawal of existing devices and a decrease in new medical device innovation. It is speculated that lack of new technologies within the medical device area can dramatically affect patient safety itself by not allowing potentially safer materials and methods on the EU single market, as the focus for the manufacturer becomes existing devices.

Complication Rates in Total Knee Arthroplasty Performed for Osteoarthritis and Post-Traumatic Arthritis: A Comparison Study

BACKGROUND

The number of total knee arthroplasty (TKA) procedures performed in the United States has been increasing. Increased complication rates have been demonstrated in patients with post-traumatic arthritis (PTA) undergoing TKA. However, there remains limited data directly comparing outcomes of TKA performed for osteoarthritis (OA) and PTA.

METHODS

The National Inpatient Sample was utilized to identify patients undergoing elective TKA between 2006 and 2015 for OA and PTA. The prevalence of preoperative comorbidities and the incidence of postoperative complications including superficial wound infection, deep joint infection, acute deep venous thrombosis, and pulmonary embolus were analyzed.

RESULTS

Between 2006 and 2015, the National Inpatient Sample database accounted for 1,301,394 patients diagnosed with either PTA (14,206) or OA (1,287,188) undergoing TKA. The incidence of superficial wound infection, deep joint infection, and acute deep venous thrombosis was found to occur at a higher rate in patients with a diagnosis of PTA compared to OA. The incidence of pulmonary embolus was not found to be statistically different between the 2 groups. Patients with PTA had a higher prevalence of drug and alcohol abuse, psychosis, and liver disease, whereas patients with OA had a higher prevalence of obesity, diabetes, heart disease, and lung disease.

CONCLUSION

This study demonstrates an increased risk of complications in patients undergoing TKA for PTA compared to OA. Surgeons can use this information to help aid in counseling patients preoperatively. Furthermore, these data provide objective evidence that could have implications with regards to establishing bundled payment reimbursement in this patient population.

Regional differences between the US, Scandinavia, and South Korea in patient demographics and patient-reported outcomes for primary total knee arthroplasty

INTRODUCTION

Differences in total knee arthroplasty (TKA) patient demographics and clinical outcomes may exist between international regions, yet research is limited. The aim of this study was, therefore, to compare TKA patient demographics and patient-reported outcome measure (PROM) scores between the US, Scandinavia, and South Korea.

MATERIALS AND METHODS

A total of 398 TKA patients from three regions were assessed: 169 in Scandinavia (3 centers), 129 in the US (3 centers), and 100 patients in South Korea (2 centers). Regional variation in patient demographics was assessed using Kruskal-Wallis H tests. Regional variation in PROM scores from preoperative, 1-, 3- and 5-year visits was assessed using piecewise linear mixed effect models. The PROMs analyzed were a numerical rating scale for satisfaction and the Knee Osteoarthritis Outcome Score.

RESULTS

South Korean patients were the oldest (p < 0.001) and had the highest Charnley class (p < 0.001); US patients had the highest BMI (p < 0.001); Scandinavian patients had the lowest preoperative KL grade (p < 0.001). Scandinavian patients were associated with better preoperative and worse postoperative PROM scores. Scandinavian patients were also associated with moderately lower levels of satisfaction. These differences were lessened but remained significant after controlling for relevant demographic and surgical factors.

CONCLUSIONS

Regional differences were found in TKA patient demographics and PROMs between the US, Scandinavia, and South Korea. The regional differences in patient demographics support the need for more research and clear guidelines related to TKA appropriateness criteria. The better preoperative and worse postoperative Scandinavian PROM scores may have been related to their less severe KL grade but might also reflect cultural differences in how patients reflect on their health state when answering PROMs. Clinicians should be aware of these international differences in PROM scores when interpreting studies conducted in different international regions. Future studies should investigate TKA variation between more international regions and assess intraregional variation.

LEVEL OF EVIDENCE

Level III.

Acetabular defects in revision hip arthroplasty: a therapy-oriented classification

INTRODUCTION

The treatment of severe acetabular bone loss remains a difficult challenge. No classification system is available that combines intuitive use, structured design and offers a therapeutic recommendation according to the current literature and modern state of the art treatment options. The goal of this study is to introduce an intuitive, reproducible and reliable guideline for the evaluation and treatment of acetabular defects.

METHODS

The proposed Acetabular Defect Classification (ADC) is based on the integrity of the acetabular rim and supporting structures. It consists of 4 main types of defects ascending in severity and subdivisions narrowing down-defect location. Type 1 presents an intact acetabular rim, type 2 includes a noncontained defect of the acetabular rim ≤ 10 mm, in type 3 the rim defect exceeds 10 mm and type 4 includes different kinds of pelvic discontinuity. A collective of 207 preoperative radiographs were graded according to ADC and correlated with intraoperative findings. Additionally, a randomized sample of 80 patients was graded according to ADC by 5 observers to account for inter- and intra-rater reliability.

RESULTS

We evaluated the agreement of preoperative, radiographic grading and intraoperative findings presenting with a k value of 0.74. Interobserver agreement presented with a k value of 0.62 and intraobserver at a k value of 0.78.

CONCLUSION

The ADC offers an intuitive, reliable and reproducible classification system. It guides the surgeon pre- and intraoperatively through a complex field of practice.

The influence of the infusion of ephedrine and phenylephrine on the hemodynamic stability after subarachnoid anesthesia in senior adults - a controlled randomized trial

Background

We studied the influence of ephedrine or phenylephrine infusion administered immediately after spinal anesthesia (SA) on hemodynamics in elderly orthopedic patients.

Methods

A prospective, randomized, double-blind, placebo-controlled study.

After a subarachnoid injection of 15 mg of levobupivacaine, the participants received an infusion of either ephedrine 20 mg (E group), phenylephrine 250 mcg (P group) or saline (C group) within 30 min. We measured blood pressure, cardiac index (CI) and heart rate (HR) from 15 min before to 30 min after SA.

Results

Seventy patients were included in the final analysis. At the end of measurements, mean arterial pressure (MAP) decreased significantly after SA in comparison to the baseline value in the C group but was maintained in the P and E group, with no significant differences between the groups. CI decreased after SA in the C group, was maintained in the P group, and increased significantly in the E group with significant differences between the C and E group (p = 0.049) also between the P and E (p = 0.01) group at the end of measurements. HR decreased significantly after SA in the C and P group but was maintained in the E group, with significant differences between the P and E group (p = 0.033) at the end of measurements.

Conclusions

Hemodynamic changes after SA in elderly orthopedic patients can be prevented by an immediate infusion of phenylephrine or ephedrine. In addition to maintaining blood pressure, the ephedrine infusion also maintains HR and increases CI after SA.

Trial registration

ISRCTN registry with registration number ISRCTN44377602, retrospectively registered on 15 June 2017.

Trends in Total Hip Arthroplasty in Germany from 2007 to 2016: What Has Changed and Where Are We Now?

BACKGROUND

The number of total hip arthroplasties (THA) is rising in many industrialized nations. At the same time, the evidence regarding different types of prostheses and fixation techniques is constantly evolving. Therefore, this study aimed to analyze changes in THA by these advancements during the last decade.

METHODS

A retrospective analysis of data provided by the Federal Statistical Office of Germany from 2007 to 2016 was conducted using codes from the German procedure classification system and associated International Statistical Classification of Diseases and Related Health Problems codes. THA procedures were evaluated according to diagnoses, sex, and age of patients, along with the distribution of different prosthesis types. Additionally, changes in these parameters over time were analyzed.

RESULTS

From 2007 to 2016 a total of 2 157 041 primary THA procedures were performed in Germany, with an increase of 14.4% over this period. Overall, cementless standard THA (STHA) was used most frequently (50.0%), followed by hybrid variants (18.8%), hemiarthroplasties (15.9%), cemented standard THA (cSTHA; 9.2%), cementless short-stem THA (ssTHA; 4.8%), and hip resurfacing (HR; 0.9%) techniques. During the study period, the number of cSTHA and HR decreased significantly, whereas the use of STHA and ssTHA rose substantially, with a significantly higher application of these procedures in the elderly population. While osteoarthritis of the hip joint was the main indication for THA, several procedure-specific differences were identified.

CONCLUSION

The present data clearly demonstrate an increase in the use of cementless fixation for THA in Germany during the last decade and document a rise in ssTHA in recent years with, in contrast, the use of HR decreasing to a minimum.

Preoperative valgus deformity has twice the risk of failure as compared to varus deformity after total knee arthroplasty

PURPOSE

The aim of this study was to assess whether preoperative valgus or varus deformity affected survivorship after total knee arthroplasty (TKA) and to quantify the risk factors for implant failure in a registry-based population.

METHODS

The Emilia-Romagna Registry of Prosthetic Orthopedic Implants was examined regarding TKAs performed on patients with a preoperative diagnosis of valgus or varus deformity. Demographics, implant characteristic and survivorships were investigated and compared. A total of 2327 TKA procedures performed from 2000 to 2016 were included in the study. Six hundred and forty primary TKAs with a diagnosis of valgus deformity were evaluated with a median follow-up of 3.3 years; 1687 primary TKAs with a diagnosis of varus deformity were evaluated with a median follow-up of 2.5 years.

RESULTS

Bi-compartmental, cemented posterior stabilised fixed-bearing implants were preferred. For both diagnoses, the implant survivorship rate was greater than 98% in the first year. However, the survival curve of the TKAs implanted for valgus deformity showed a greater slope in the first 3 years as compared to the survival curve of those implanted for varus deformity. Valgus deformity had a 2.1-fold higher risk for revision as compared with varus deformity. Infection was a major cause of implant failure in TKAs for varus deformity, 9/24 (37.5%), while its incidence was lower for valgus deformity, 1/21 (4.8%).

CONCLUSIONS

Preoperative valgus alignment showed a twofold risk of failure as compared to varus alignment after TKA. This should be considered in daily practice, and surgeons are called on to pay more attention when performing TKAs on such patients. Prospective randomised controlled trials are, therefore, necessary to better understand the role of preoperative coronal knee deformity in implant failure.

LEVEL OF EVIDENCE

Prognostic study, level III.

Patient-reported outcome measures (PROMs) after elective hip, knee and shoulder arthroplasty: protocol for a prospective cohort study

Background

The number of hip, knee and shoulder arthroplasties continues to rise worldwide. The Organization for Economic Cooperation and Development has launched an initiative (called PaRIS Initiative) for the systematic collection of Patient Reported Outcome Measures (PROMs) in patients undergoing elective hip and knee arthroplasty. The Rizzoli Orthopedic Institute (IOR) was selected as a pilot center for the launch of the Initiative in Italy given that IOR hosts the Registry of Orthopedic Prosthetic Implants (RIPO), a region-wide registry which collects joint implant data from all the hospitals in the Emilia-Romagna Region. In this specific geographic area information related to PROMs after joint replacement is unknown. This paper describes the protocol of a study (PaRIS-IOR) that aims to implement the collection of a set of PROMs within an existing implant registry in Italy. The study will also investigate the temporal trend of PROMs in relation to the type of prosthesis and the type of surgical intervention.

Methods

The PaRIS-IOR study is a prospective, single site, cohort study that consists of the administration of PROMs questionnaires to patients on the list for elective arthroplasty. The questionnaires will be administered to the study population within 30 days before surgery, and then at 6 and 12 months following surgery. The study population will consist of consecutive adult patients undergoing either hip, knee or shoulder arthroplasty. The collected data will be linked with those routinely collected by the RIPO in order to assess the temporal trend of PROMs in relation to the type of prosthesis and the type of surgical intervention.

Discussion

The PaRIS-IOR study could have important implications in targeting the factors influencing functional outcomes and quality of life reported by patients after hip, knee and shoulder arthroplasty, and will also represent the first systematic collection of PROMs related to arthroplasty in Italy.

Trial registration

Protocol version (1.0) and trial registration data are available on the platform www.clinicaltrial.gov with the identifier NCT03790267, first posted on December 31, 2018.

ASA class is associated with early revision and reoperation after total hip arthroplasty: an analysis of the Geneva and Swedish Hip Arthroplasty Registries

Background and purpose - Data from several joint replacement registries suggest that the rate of early revision surgery after primary total hip arthroplasty (THA) is increasing. The ASA class, now widely recorded in arthroplasty registries, may predict early revision. We investigated the influence of ASA class on the risk of revision and other reoperation within 3 months and within 5 years of primary THA. Patients and methods - We used data from the Geneva and Swedish Hip Arthroplasty Registries, on primary elective THAs performed in 1996-2016 and 2008-2016, respectively. 5,319 and 122,241 THAs were included, respectively. Outcomes were all-cause revision and other reoperations evaluated using Kaplan-Meier survival and Cox regression analyses. Results - Within 3 months after surgery, higher ASA class was associated with greater risk of revision and other reoperation. 3-month cumulative incidences of revision by ASA class I, II, and III-IV respectively, were 0.6%, 0.7%, and 2.3% in Geneva and 0.5%, 0.8%, and 1.6% in Sweden. 3-month cumulative incidences of other reoperation were 0.4%, 0.7%, and 0.9% in Geneva and 0.2%, 0.4%, and 0.7% in Sweden. Adjusted hazard ratios (ASA III-IV vs. I) for revision within 3 months were 2.7 (95% CI 1.2-5.9) in Geneva and 3.3 (CI 2.6-4.0) in Sweden. Interpretation - Assessment of ASA class of patients prior to THA will facilitate risk stratification. Targeted risk-reduction strategies may be appropriate during the very early postoperative period for patients identified as at higher risk. Systematically recording ASA class in arthroplasty registries will permit risk adjustment and facilitate comparison of revision rates internationally.

Will registries slow down or accelerate innovation?

The increasing use of regional and national registries of surgical implants has raised concerns that the cost and consequences of these initiatives will adversely influence innovation. The opposite appears to be true, with no evidence of a reduction in overall innovation and an association of increased innovation in countries with more evaluation using registries.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180065

Research methodology and practical issues relating to the conduct of a medical device registry

BACKGROUND

The postmarket research goal is to assess "generalizability" or "external validity" to see if the early results of clinical trials with investigational devices are reproducible in everyday practice in the real world and the longer term. Registries have an important but ambivalent role in achieving this goal.

METHODS

Although registries are common, in practice they follow the regulatory processes that appear designed primarily for pharmaceutical clinical trials and confirmatory studies. We review the literature to assess different definitions and the role of registries in the hierarchy of scientific evidence. We analyze common characteristics affecting registry design, implementation, and governance as well as safety reporting and off-label use while describing the experience of setting up an international, prospective registry for an endovascular device used to treat abdominal aortic aneurysms.

RESULTS

Key areas in which to distinguish registries from trials are as follows: eligibility, setting (patients and institutions), device configurations and iterations, the use of design and quality "spaces," a focus on systematic quality checks (rather than source data monitoring), open-ended follow-up, flexibility in the definition of end points and sample sizes, data sharing, and publishing commitments.

CONCLUSION

Both clinical trials and registries are essential and complementary research methods and the strengths and weaknesses of each need to be recognized. The specific characteristics of registry research deserve to be acknowledged and safeguarded in the regulations governing clinical investigations with medical devices.

Feasibility of identifying important changes in care management resulting from cardiovascular magnetic resonance (CMR) using hospital episode data in patients who activate the primary percutaneous coronary intervention (PPCI) pathway

BACKGROUND

We determined whether it is feasible to identify important changes in care management resulting from cardiovascular magnetic resonance (CMR) in patients who activate the primary percutaneous coronary intervention (PPCI) pathway from hospital episode data, in order to construct a composite primary outcome (hypothesised to reduce the risk of major adverse cardiac-related events, MACE) to compare patients exposed to CMR or not.

METHODS

We used Hospital Episode Statistics (HES) and Patient Episode Database for Wales (PEDW) to identify clinical events that reflected important changes in management in the year following the index admission in five subgroups of patients who activated the PPCI pathway recruited as part of a feasibility cohort study (n = 1655 with HES/PEDW data). For all subgroups, we identified frequency of events and time to the first event for each change in management.

RESULTS

We identified all clinical events (new diagnoses, additional diagnostic tests and procedures) except for medication prescriptions. Diagnostic tests were underestimated because most are carried out in outpatient clinics and outpatient datasets had missing procedure codes for 74% of patients (some tests done in hospital may also not be recorded). We successfully tabulated frequencies of events and distributions of times to first event for most changes in management by CMR status and in CMR / non CMR centres.

CONCLUSIONS

It is feasible to identify changes in care management between patients who have / do not have CMR within relevant patient subgroups. Further work to derive a weighting algorithm is required before attempting to combine the events in a composite endpoint.

Symptoms of osteoarthritis influence mental and physical health differently before and after joint replacement surgery: A prospective study

Background

Patient-reported outcomes are increasingly used in evaluations of joint replacement surgery, but it is unclear if symptoms of osteoarthritis (i.e., pain and dysfunction) influence health perceptions similarly before and after surgery.

Methods

In this prospective study based on a hospital-based arthroplasty registry, patients with primary total hip or knee arthroplasty (THA, N = 990, and TKA, N = 907) completed the WOMAC Pain and Function scales, and the SF12 Physical and Mental Component Scores (PCS and MCS), before surgery and one year later. Associations between WOMAC and SF12 scales were examined using mixed linear regression models.

Results

All patient-reported outcomes improved following total joint arthroplasty, but the associations between symptom scales and global health perceptions were altered. Mental health scores at a given level of pain or function were lower after surgery than before, by about 4–5 points, a clinically meaningful and statistically significant difference. In contrast, the associations between WOMAC scales and the PCS remained stable. These findings were observed in both cohorts of patients.

Conclusions

After total joint arthroplasty, mental health scores were lower than would have been expected given the symptomatic improvement. This suggests that relationships between patient-reported outcomes are context-dependent, and that care should be exerted when interpreting changes in patient-reported outcomes over time.