Utilization rates of hip arthroplasty in OECD countries

Trends in arthroplasty in Japan by a complete survey, 2014-2017

BACKGROUND

Precise knowledge of the prevalence and trends of arthroplasty can facilitate the design of medical plans for efficient treatments. The National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) Open Data Japan provides statistics about the annual number of arthroplasties (knee, hip, shoulder, finger, elbow, and foot/ankle) through health insurance claim numbers for these surgeries. The purpose of this study was to document the annual arthroplasty numbers between 2014 and 2017 in Japan and to analyze their four-year trends, gender differences, age distributions, and regional differences as revealed by the complete survey.

METHODS

Numbers of arthroplasty surgeries were extracted from the NDB Open Data Japan for 2014-2017. For "knee", "hip", "shoulder", "finger", "elbow", and "foot/ankle" arthroplasties, we showed the annual arthroplasty numbers, annual arthroplasty numbers by age group, annual arthroplasty numbers in individual prefectures, and annual arthroplasty numbers per 100,000 population in individual prefectures.

RESULTS

The annual arthroplasty numbers in 2017 were 146,189 for all joints, 82,304 for knees, 59,029 for hips, 2454 for shoulders, 1551 for fingers, 536 for elbows, and 291 for feet/ankles. For the four years up to 2017, the rate of alteration in the number of arthroplasties was +14% for total arthroplasties, +9% for knees, +21% for hip joints, +97% for shoulders, + 8% for fingers, -10% for elbows, and +25% for feet/ankles. The proportion of females was 70-90% and the peak age was between the late 60s and late 70s for all joints. Variations in arthroplasty numbers per population by prefecture appeared to be small for knees and hips and large for other joints.

CONCLUSIONS

We revealed the annual total number of arthroplasties for each joint in Japan using the NDB Open Data Japan for the first time.

Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature

BACKGROUND

Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery.

METHODS

A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations.

RESULTS

Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92).

CONCLUSIONS

Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes.

RECOMMENDATION

PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

My hip journey: A qualitative study of patients' experiences of an eHealth program for patient preparation and recovery from hip replacement surgery

AIM AND OBJECTIVE

To explore patient experiences, perceived benefits and suggestions of an eHealth program for pre- and post-operative education for total hip arthroplasty.

BACKGROUND

eHealth programs for surgical patients can facilitate the delivery of information, provide individualised rehabilitation plans and enable communication with health professionals to promote overall patient recovery.

DESIGN

A qualitative descriptive study was conducted following the COREQ guidelines. A convenience sample of nine patients who had total hip arthroplasty and used the My Hip Journey eHealth program were recruited and participated in individual semi-structured telephone interviews. Interviews were audio recorded, transcribed verbatim and analysed using inductive thematic analysis.

RESULTS

The participant group were aged between 53 and 70 years. The results are described in three overarching themes and sub-themes: (1) Supported surgical journey-how the My Hip Journey eHealth program supported them in their preparation and recovery from their surgery, and how the program provided information and encouraged engagement; (2) Motivated recovery-how patients found the program motivational, facilitated their self-management and enabled communication with the healthcare team if they had any concern; and (3) Functionality-how the program related to ease of use, its interactivity with the patient and suggestions for future use.

CONCLUSIONS

The patients reported that using the eHealth program for pre- and post-operative education was helpful to their overall surgical experience and recovery. It was found to engage patients in their care, enabled self-management, encouraged communication with health professionals and motivated them with their recovery. These findings identify the potential for eHealth programs to support patients in the preparation and post-operative stages, and in their post-discharge self-care for other surgical and orthopaedic journeys.

RELEVANCE TO CLINICAL PRACTICE

Patient experiences of eHealth education can inform nurses of the benefits of eHealth and the development of future eHealth education programs.

Use of dual mobility cups for total hip arthroplasty in sub-Saharan Africa: interest and perspectives

INTRODUCTION

Hip arthroplasty and revision surgery are growing exponentially in OECD countries. In developing countries, it is an infrequent intervention and its practice is limited. It is exposed to a higher rate of infectious and mechanical failures than in developed countries. The aim of the actual study is to provide a review of the literature on total hip arthroplasty series in sub-Saharan Africa followed by an overview of the interest and perspectives of the use of dual mobility (DM) cups.

MATERIALS AND METHODS

Scopus, EMBASE, Medline, PubMed, and Safoonline databases were searched including papers published at any date. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. All papers from South Africa were excluded.

RESULTS

We identified 22 series of total hip arthroplasty in 14 SSA countries. The practice of total hip arthroplasty is not very widespread. The cups used are mostly conventional implants, and complications (mechanical and infectious) are frequent.

DISCUSSION

The interest for the use of dual mobility cups in sub-Saharan Africa can be summarized in two points: mechanical and socio-economical. Dual mobility cups provide more mechanical stability and a reduction in the overall cost of treatment by reducing the rate of complications. These prospects will make it possible to evaluate this medical device in the long term in a hostile environment conductive to complications.

CONCLUSION

The use of dual mobility deserves to be developed in African settings.

Surgical cup placement affects the heating up of total joint hip replacements

The long-term success of highly effective total hip arthroplasty (THA) is mainly restricted by aseptic loosening, which is widely associated with friction between the head and cup liner. However, knowledge of the in vivo joint friction and resulting temperature increase is limited. Employing a novel combination of in vivo and in silico technologies, we analyzed the hypothesis that the intraoperatively defined implant orientation defines the individual joint roofing, friction and its associated temperature increase. A total of 38,000 in vivo activity trials from a special group of 10 subjects with instrumented THA implants with an identical material combination were analyzed and showed a significant link between implant orientation, joint kinematics, joint roofing and friction-induced temperature increase but surprisingly not with acting joint contact force magnitude. This combined in vivo and in silico analysis revealed that cup placement in relation to the stem is key to the in vivo joint friction and heating-up of THA. Thus, intraoperative placement, and not only articulating materials, should be the focus of further improvements, especially for young and more active patients.

The Update on Instruments Used for Evaluation of Comorbidities in Total Hip Arthroplasty

INTRODUCTION

It is a well-established fact that concomitant diseases can affect the outcome of total hip arthroplasty (THA). Therefore, careful preoperative assessment of a patient's comorbidity burden is a necessity, and it should be a part of routine screening as THA is associated with a significant number of complications. To measure the multimorbidity, dedicated clinical tools are used.

METHODS

The article is a systematic review of instruments used to evaluate comorbidities in THA studies. To create a list of available instruments for assessing patient's comorbidities, the search of medical databases (PubMed, Web of Science, Embase) for indices with proven impact on revision risk, adverse events, mortality, or patient's physical functioning was performed by two independent researchers.

RESULTS

The initial search led to identifying 564 articles from which 26 were included in this review. The measurement tools used were: The Charlson Comorbidity Index (18/26), Society of Anesthesiology classification (10/26), Elixhauser Comorbidity Method (6/26), and modified Frailty Index (5/26). The following outcomes were measured: quality of life and physical function (8/26), complications (10/26), mortality (8/26), length of stay (6/26), readmission (5/26), reoperation (2/26), satisfaction (2/26), blood transfusion (2/26), surgery delay or cancelation (1/26), cost of care (1/26), risk of falls (1/26), and use of painkillers (1/26). Further research resulted in a comprehensive list of eleven indices suitable for use in THA outcomes studies.

CONCLUSION

The comorbidity assessment tools used in THA studies present a high heterogeneity level, and there is no particular system that has been uniformly adopted. This review can serve as a help and an essential guide for researchers in the field.

Analysis of AM Parameters on Surface Roughness Obtained in PLA Parts Printed with FFF Technology

Fused filament fabrication (FFF) 3D printing technology allows very complex parts to be obtained at a relatively low cost and in reduced manufacturing times. In the present work, the effect of main 3D printing parameters on roughness obtained in curved surfaces is addressed. Polylactic acid (PLA) hemispherical cups were printed with a shape similar to that of the acetabular part of the hip prostheses. Different experiments were performed according to a factorial design of experiments, with nozzle diameter, temperature, layer height, print speed and extrusion multiplier as variables. Different roughness parameters were measured—Ra, Rz, Rku, Rsk—both on the outer surface and on the inner surface of the parts. Arithmetical mean roughness value Ra and greatest height of the roughness profile Rz are usually employed to compare the surface finish among different manufacturing processes. However, they do not provide information about the shape of the roughness profile. For this purpose, in the present work kurtosis Rku and skewness Rsk were used. If the height distribution in a roughness profile follows a normal law, the Rku parameter will take a value of 3. If the profile distribution is symmetrical, the Rsk parameter will take a value of 0. Adaptive neural fuzzy inference system (ANFIS) models were obtained for each response. Such models are often employed to model different manufacturing processes, but their use has not yet been extended to 3D printing processes. All roughness parameters studied depended mainly on layer height, followed by nozzle diameter. In the present work, as a general trend, Rsk was close to but lower than 0, while Rku was slightly lower than 3. This corresponds to slightly higher valleys than peaks, with a rounded height distribution to some degree.

In vivo loading on the hip joint in patients with total hip replacement performing gymnastics and aerobics exercises

A further increase in the number of total hip arthroplasty (THA) is predicted, in particular the number of young THA patients has raised and with it their demands. There is no standardized evidence-based rehabilitation program and no reliable guidelines for sports activities after THA. Stretching and strengthening gymnastics are routinely performed in rehabilitation and aerobics as a sport after THA. The aim of the investigation was to determine the in vivo force and moments acting on the hip prosthesis during gymnastics and aerobic exercises to provide a source for evidence-based recommendations. Hip joint loads were measured in six patients with instrumented hip implants. The resulting force F_Res, bending moment M_Bend at the neck and torsional moment M_Tors at the stem were examined during seven strengthening (with two different resistance bands) and four stretching gymnastic exercises and seven aerobic exercises with and without an aerobic step board compared to the loads during the reference activity walking. The stretching and strengthening gymnastics exercises and the aerobic exercises with and without a board demonstrated in their median peak force and moments mostly lower or similar values compared to walking. Significantly increased loads were recorded for the flexor stretching exercise in monopod stand (F_res and M_Bend), the strengthening abduction exercise on the chair (M_Tors) and the strengthening flexion exercise with the stronger resistance band (M_Tors). We also found a significant increase in median peak values in aerobic exercises with a board for the "Basic Step" (ipsilateral started F_res and M_Tors; contralateral started M_Tors), "Kickstep ipsilateral started" (F_res and M_Tors) and "Over the Top contralateral started" (F_res). The in vivo loads in THA patients during frequently performed stretching, strengthening and aerobic exercises were demonstrated for the first time. It was proved that stretching gymnastic exercises are safe in terms of resulting force, bending and torque moments for THA patients, although an external assistance for stabilization may be considered. Strengthening gymnastics exercises are reliable in terms of F_res, M_Bend and M_Tors, but, based on our data, we recommend to adhere to the communicated specific postoperative restrictions and select the resistance bands with lower tension. Aerobic exercises without an aerobic board can be considered as reliable activity in terms of force and moments for THA patients. Aerobic exercises with a board are not recommended for the early postoperative period and in our opinion need to be adapted to the individual muscular and coordinative resources.

Endurance testing and finite element simulation of a modified hip stem for integration of an energy harvesting system

Instrumented implants are a promising approach to further improve the clinical outcome of total hip arthroplasties. For the integrated sensors or active functions, an electrical power supply is required. Energy harvesting concepts can provide autonomous power with unlimited lifetime and are independent from external equipment. However, those systems occupy space within the mechanically loaded total hip replacement and can decrease the life span due to fatigue failure in the altered implant. We previously presented a piezoelectric energy harvesting system for an energy-autonomous instrumented total hip stem that notably changes the original implant geometry. The aim of this study was to investigate the remaining structural fatigue failure strength of the metallic femoral implant component in a worst-case scenario. Therefore, the modified hip stem was tested under load conditions based on ISO 7206-4:2010. The required five million cycles were completed twice by all samples (n = 3). Additionally applied cycles with incrementally increased load levels up to 4.7 kN did not induce implant failure. In total, 18 million cycles were endured, outperforming the requirements of the ISO standard. Supplementary finite element analysis was conducted to determine stress distribution within the implant. A high stress concentration was found in the region of modification. The stress level showed an increase compared to the previously evaluated physiological loading situation and was close to the fatigue data from the literature. The stress concentration factor compared to the original geometry amounted to 2.56. The assessed stress level in accordance with the experimental fatigue testing can serve as a maximum reference value for further implant design modifications and optimisations.

Influential literatures in periprosthetic infection following joint arthroplasty: A bibliometric review

The objective of this bibliometric literature review was to identify and analyze the most frequently cited manuscripts on the topic of periprosthetic joint infection. Periprosthetic infection following joint arthroplasty is a complication leading to rising rates of mortality and increasing economic strain. No prior study has evaluated the most impactful literature on the topic of periprosthetic joint infection (“PJI”) in total hip and knee arthroplasty. Knowledge and appreciation of the most influential publications on this topic can guide and inspire future research endeavors. Using the Clarivate Analytics Web of Science database, the 50 most cited articles related to periprosthetic infection following joint arthroplasty were identified. Numerous metrics including citation frequency, year of publication, country of origin, level-of-evidence (LOE), article type, and contributing authors/institutions were recorded. The seven most cited articles (per year) during the past 10 years were also identified. The years of publications of the articles included in the final analysis ranged from 1969 to 2014. “Current concepts: Prosthetic-joint infections” by Zimmerli et al. was the most frequently cited article. Level of Evidence (“LOE”) of 2 and 3 were the most common. Clinical outcomes was the most common article type. Mayo Clinic and Thomas Jefferson University produced the most publications. Hanssen and Parvisi were the most productive authors. 2000–2009 ( n = 25) was the most prolific decade in terms of number of publications. Using citation analysis as an indication of influence, the most influential articles on periprosthetic joint infection were highlighted. Analysis of the most recognized publication on PJI provides an enhanced understanding of the diagnosis, treatment, and future research of PJI. Future studies may combine the search results of multiple databases including Scopus, Web of Science and PubMed to rectify any discrepancies in citation data and to capture additional literature on PJI.

Cost-effectiveness analyses comparing cemented, cementless, hybrid and reverse hybrid fixation in total hip arthroplasty: a systematic overview and critical appraisal of the current evidence

Background: This study aims to present an overview and critical appraisal of all previous studies comparing costs and outcomes of the different modes of fixation in total hip arthroplasty (THA). A secondary aim is to provide conclusions regarding the most cost-effective mode of implant fixation per gender and age-specific population in THA, based on high quality studies.Methods: A systematic search was conducted to identify cost-effectiveness analyses (CEAs) comparing different modes of implant fixation in THA. Analysis of results was done with solely CEAs that had a high methodological quality.Results: A total of 12 relevant studies were identified and presented, of which 5 were considered to have the methodological rigor for inclusion in the analysis of results. These studies found that either cemented or hybrid fixation was the most cost-effective implant fixation mode for most age- and gender-specific subgroups.Conclusion: Currently available well performed CEAs generally support the use of cemented and hybrid fixation for all age-groups relevant for THA and both genders. However, these findings were mainly based on a single database and depended on assumptions made in the studies' methodology. Issues discussed in this paper have to be considered and future work is needed.

Complications, readmission and reoperation rates in one-stage bilateral versus unilateral total hip arthroplasty: a high-volume single center case-control study

The study aimed to assess the safety of one-stage bilateral total hip arthroplasty (THA) compared with unilateral THA. In this retrospective observational case–control study were included patients undergoing unilateral (group 1) and one-stage bilateral (group 2) THA in a high-volume center. The groups were matched for gender, age at surgery, and pre-operative American Society of Anesthesiology score. The following variables were assessed: local and systemic complications, postoperative anemia, 30-day and 1-year readmission and reoperation rates, length of hospital stay, and ambulation time. Group 1 reported a significantly higher rate of local and systemic complications compared with group 2 (5.4% versus 3.9% and 29.6% versus 4.7%, respectively). Postoperative anemia was significantly lower in group 1 compared with group 2 (8.1% versus 30%). There was no significant difference in terms of 30-day and 1-year readmission rates between the two groups. The average length of hospital stay was 5.1 ± 2.3 days in group 1, and 5.3 ± 1.9 days in group 2 (p = 0.78). Ambulation time was significantly lower for group 1 (day 0.9 ± 0.9 in group 1, and day 1 ± 0.8 in group 2, p = 0.03). In a high-volume center, one-stage bilateral THA is a safe procedure compared with unilateral THA in terms of postoperative local and systemic complications, 30-day readmission and 1-year reoperation rates, and length of hospital stay.

Minimal clinically important differences in randomised clinical trials on pain management after total hip and knee arthroplasty: a systematic review

BACKGROUND

Sample size determination is essential for reliable hypothesis testing in clinical trials and should rely on adequate sample size calculations with alpha, beta, variance, and an effect size being the minimal clinically important difference (MCID). This facilitates interpretation of the clinical relevance of statistically significant results. No gold standard for MCIDs exists in postoperative pain research.

METHODS

We searched Cochrane Central Register of Controlled Trials, MEDLINE, and Embase for English language articles on randomised trials investigating analgesic interventions after total hip or knee arthroplasty. Primary outcomes were the reported MCIDs for pain score and cumulated rescue opioid consumption. Secondary outcomes included reported sample size calculations and propensity to report statistical significance without reaching MCID. Trend analyses were conducted using statistical process control.

RESULTS

We included 570 trials. Median MCID for 0-24 h opioid consumption was 10 mg i.v. morphine equivalents for absolute reductions (interquartile range [IQR]: 6.8-14.5) and relative 40% (IQR: 30-50%). Median MCIDs for pain scores were absolute 15 mm at rest (IQR: 10-20) and 18 mm during movement (IQR: 10-20) on a 0-100 mm VAS and relative 30% (IQR: 20-30%). No trends were demonstrated for MCIDs. Adequate sample size calculations were reported in 34% of trials. In 46% of trials with statistically significant primary outcomes, the differences did not reach the predetermined MCID.

CONCLUSIONS

We provide clinician-perceived MCID estimates for rescue opioid consumption and pain scores that can be used for sample size calculations until reliable evidence-based patient-rated MCIDs emerge. Nearly half of the trials with significant findings did not reach the predetermined MCID.

Comparing an eHealth Program (My Hip Journey) With Standard Care for Total Hip Arthroplasty: Randomized Controlled Trial

Background

The role of eHealth programs to support patients through surgical pathways, including total hip arthroplasty (THA), is rapidly growing and offers the potential to improve patient engagement, self-care, and outcomes.

Objective

The aim of this study is to compare the effects of an eHealth program (intervention) versus standard care for pre- and postoperative education on patient outcomes for primary THA.

Methods

A prospective parallel randomized controlled trial with two arms (standard care and standard care plus access to the eHealth education program) was conducted. Participants included those who underwent THA. Outcome measures were collected preadmission, at 6 weeks, and at 3 and 6 months after surgery. The primary outcome was the Hip Dysfunction and Osteoarthritis Outcome Score. Secondary outcomes were a 5-level 5-dimension quality of life measure and the self-efficacy for managing chronic disease scale. Demographic and clinical characteristics were also collected. A satisfaction survey was completed by all participants 6 weeks after surgery, and those in the intervention arm completed an additional survey specific to the eHealth program.

Results

A total of 99 patients were recruited: 50 in the eHealth program (intervention) and 49 in standard care (control). Clinical improvements were demonstrated in both groups across all time points. Per-protocol analysis demonstrated no differences between the groups for all outcome measures across all time points. Participants in the eHealth program reported that the program was accessible, that they felt comfortable using it, and that the information was helpful.

Conclusions

This study demonstrated that the eHealth program, in addition to standard care, had no additional benefit to THA recovery compared with standard care alone. The study found that the eHealth program was highly valued by participants, and it supported the preoperative preparation, recovery, and postoperative rehabilitation of participants.

Trial Registration

Australian New Zealand Clinical Trial Registry ACTRN12617001433392; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373657

Short-stem total hip arthroplasty is not associated with an earlier return to work compared to a straight-stem design

Return to work (RTW) has been specifically identified as a high priority in patients undergoing total hip arthroplasty (THA). This investigation sought to assess the effect of the stem design on patients' RTW. Secondly, the study aimed to identify risk factors that lead to a delayed RTW. Questionnaires inquiring about RTW, employment history, educational level, type of work, physical demands and joint awareness were administered by post. Further data were collected from patients' hospital records. 176 patients who underwent THA using a short-stem and 97 patients using a straight-stem design were compared. The median return to work time was 10 weeks [IQR 7-14 weeks], with no significant difference between the two groups (short stems vs. straight stems; 10 [IQR 7-14] vs. 11 [7.5-13.5] weeks; p = 0.693). In the multivariate linear regression analysis, self-employment vs. employee (p = 0.001), dimension of preoperative workload (p = 0.001), preoperative sick leave (p < 0.001), and hospital length of stay (LOS) (p < 0.001) independently affected the period until work was resumed. The Forgotten-Joint-Score-12 showed no significant difference between the two groups. The data show that the majority of THA patients can expect to resume work and stem design has no impact on RTW. Employees with preoperative sick leave, prolonged hospital LOS and low workload are at higher risk for a delayed RTW.

Towards an effective sensing technology to monitor micro-scale interface loosening of bioelectronic implants

Instrumented implants are being developed with a radically innovative design to significantly reduce revision surgeries. Although bone replacements are among the most prevalent surgeries performed worldwide, implant failure rate usually surpasses 10%. High sophisticated multifunctional bioelectronic implants are being researched to incorporate cosurface capacitive architectures with ability to deliver personalized electric stimuli to peri-implant target tissues. However, the ability of these architectures to detect bone-implant interface states has never been explored. Moreover, although more than forty technologies were already proposed to detect implant loosening, none is able to ensure effective monitoring of the bone-implant debonding, mainly during the early stages of loosening. This work shows, for the first time, that cosurface capacitive sensors are a promising technology to provide an effective monitoring of bone-implant interfaces during the daily living of patients. Indeed, in vitro experimental tests and simulation with computational models highlight that both striped and circular capacitive architectures are able to detect micro-scale and macro-scale interface bonding, debonding or loosening, mainly when bonding is weakening or loosening is occurring. The proposed cosurface technologies hold potential to implement highly effective and personalized sensing systems such that the performance of multifunctional bioelectronic implants can be strongly improved. Findings were reported open a new research line on sensing technologies for bioelectronic implants, which may conduct to great impacts in the coming years.

Total Hip Arthroplasty Revision Surgery: Impact of Morbidity on Perioperative Outcomes

BACKGROUND

Primary and revision total hip arthroplasty (THA) is increasingly performed in patients with high comorbidity burden. Its predominantly negative effects on outcomes are well understood in primary THA; however, the effects of morbidity on revision THA are unknown. Since revision procedures account for about 10% of the total surgical volume, we set out to investigate the effects of physical health status on perioperative outcomes in this setting.

METHODS

We queried our prospectively collected institutional database for patients who underwent revision THA at our institution (Orthopedic University Hospital Friedrichsheim, Frankfurt) between 2007 and 2011. Patients were classified according to American Society of Anesthesiologists (ASA) category and number of comorbidities. Subsequently, their impact on perioperative parameters was analyzed.

RESULTS

Our database revealed 294 cases of revision THA during the study period. Patients preoperatively classified as ASA 3 and 4 showed significantly higher rates of intraoperative and postoperative complications, transfusions, prolonged intensive care unit (ICU) stay, and total length of stay (LOS) compared to patients classified as ASA 1 and 2. Similarly, patients with >3 comorbidities presented with significantly elevated postoperative complications, ICU stay, and LOS. Particularly, preoperative cardiac diseases were associated with increased blood loss, transfusions, duration of surgery, postoperative complications, ICU stay, LOS, and re-revisions.

CONCLUSION

Poor physical health condition is associated with negative perioperative outcomes in revision THA. Especially cardiac comorbidities are linked to unfavorable outcomes, which have important implications for assessment of perioperative risk.

Preoperative Risk Prediction Models for Short-Term Revision and Death After Total Hip Arthroplasty: Data from the Finnish Arthroplasty Register

Because of the increasing number of total hip arthroplasties (THAs), even a small proportion of complications after the operation can lead to substantial individual difficulties and health-care costs. The aim of this study was to develop simple-to-use risk prediction models to assess the risk of the most common reasons for implant failure to facilitate clinical decision-making and to ensure long-term survival of primary THAs.

Wear of hip prostheses increases serum IGFBP-1 levels in patients with aseptic loosening

The biological mechanisms involved in aseptic loosening include inflammation-associated and bone resorption-associated processes. Coordinated cellular actions result in biochemical imbalances with devastating consequences for the joint. Given that this condition is not known for showing systemic signs, we investigated whether circulating levels of inflammation-related proteins are altered in patients with aseptic loosening. Our study included 37 patients who underwent revision surgery due to hip osteolysis and aseptic loosening and 31 patients who underwent primary total hip arthroplasty. Using antibody arrays, we evaluated the serum levels of 320 proteins in four patients from each group. The results showed differences in insulin-like growth factor-binding protein 1 (IGFBP-1) concentrations, which we then quantified using enzyme-linked immunosorbent assay tests in all study patients. The results confirmed that serum IGFBP-1 concentrations were higher in the revision surgery patients than in the hip arthroplasty patients. In vitro studies showed that exposure of human osteoblasts to titanium particles induced an IGFBP-1 release that further increased when exposure to particles was performed in media conditioned by human M1 macrophages. These findings suggest that elevated serum IGFBP-1 levels in patients with aseptic loosening can arise from increased local IGFBP-1 production in the inflammatory environment of the periprosthetic bed.

Accuracy of cup placement in total hip arthroplasty by means of a mechanical positioning device: a comprehensive cadaveric 3d analysis of 16 specimens

INTRODUCTION

We tested whether a mechanical device (such as Hipsecure) to pinpoint the anterior pelvic plane (APP) as a guide can improve acetabular cup placement. To assess accuracy we asked: (1) is the APP an effective guide to position acetabular cup placement within acceptable ° of divergence from the optimal 40° inclination and 15° anteversion; (2) could a mechanical device increase the number of acetabular cup placements within Lewinnek's safe zone (i.e. inclination 30° to 50°; anteversion 5° to 25°)?

METHODS

16 cadaveric specimens were used to assess the 3D surgical success of using a mechanical device APP to guide acetabular cup placement along the APP. We used the Hipsecure mechanical device to implant acetabular cups at 40° inclination and 15° anteversion. Subequently, all cadaveric specimens with implants were scanned with a CT and 3D models were created of the pelvis and acetabular cups to assess the outcome in terms of Lewinnek's safe zones.

RESULTS

The mean inclination of the 16 implants was 40.6° (95% CI, 37.7-43.4) and the mean anteversion angle was 13.4° (95% CI, 10.7-16.1). All 16 cup placements were within Lewinnek's safe zone for inclination (between 30° and 50°) and all but 2 were within Lewinnek's safe zone for anteversion (between 5° and 25°).

CONCLUSION

In cadaveric specimens, the use of a mechanical device and the APP as a guide for acetabular cup placement resulted in good positioning with respect to both of Lewinnek's safe zones.

The robustness of prostate radiotherapy for patients with hip prosthesis

The aim of this study was to investigate prostate radiotherapy techniques for the patients with hip prosthesis in 4 different field setups. Volumetric Modulated Arc Therapy (VMAT) technique was used in 4 different cases: (1) using full VMAT arcs (VMAT_F); (2) same arcs as in case 1 but with avoidance sectors (VMAT_ASEC); (3) as case 2 but with the addition of a lateral static field through the prosthesis (VMAT_ASEC+STAT); (4) as in case 1 but with an automated structure avoidance option to avoid irradiation through the prosthesis (VMAT_ASTR). Fifteen previously treated prostate patients were retrospectively selected to this study. Treatment plans were created for all patients using all 4 techniques. The potential prosthesis misalignment in the treatment setup was modeled by moving the prosthesis 0.5, 1.0, and 1.5 cm ventrally and dorsally and recalculating the plans in each case. For VMAT_ASEC, the dose parameters for organs at risk were the highest and the dose coverage of the target volume was the poorest when compared to the other techniques. For VMAT_ASEC+STAT, the movement of the prosthesis changed the target dose distribution the most. VMAT_F and VMAT_ASTR fulfilled the planning criteria the best, even when the prosthesis was misaligned. VMAT_F radiated through the prosthesis more than VMAT_ASTR and increased the dose near the prosthesis surface when compared to VMAT_ASTR. VMAT_ASTR and VMAT_F were the most robust techniques for the patients with the hip prosthesis considering plan quality and the effect of positioning errors. The increased prosthesis surface dose with VMAT_F and possible dose calculation uncertainties favors the use of VMAT_ASTR.

Functional and radiological outcomes after treatment with custom-made acetabular components in patients with Paprosky type 3 acetabular defects: short-term results

BACKGROUND

Severe acetabular defects require special treatment with either impaction bone grafting, metal augmented cups or cup-cage constructs. Even these options are often not adequate, especially in hips with Paprosky type 3 defects with loss of anterior and posterior columns. This study investigates the clinical and radiological outcomes of custom-made acetabular components (© Materialise NV, Leuven, Belgium) for Paprosky type 3 defects.

METHODS

Sixteen patients were eligible for this trial, nine of whom agreed to be included. All of them completed one year of follow-up. The Harris hip score and the Oxford hip score were used to compare pre- and postoperative functional outcomes. Radiological follow-up comprised anteversion and inclination of the implanted cup and offset measurements in both hips (femoral, medial, ischial offset and center of rotation). Statistical analyses were performed with IBM SPSS Statistics.

RESULTS

The mean follow-up time of the nine patients was 12.2 months (range: 10-18). The Oxford hip score and Harris hip score improved from 19.8 and 50.1 to 29.4 and 68.8, respectively (p = 0.009 and 0.01). There were complications in three cases (33.3%), which led to one re-revision (11.1%). Radiologic follow-up showed restoration of the height of the center of rotation and of the global offset. Significant difference was detected in the femoral offset.

CONCLUSIONS

The functional and radiological outcomes are promising. However, long-term outcomes still need to be examined.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Patients with hip fracture and total hip arthroplasty surgery differ in anthropometric, but not cardiovascular screening abnormalities

Background

With the rising number of hip surgeries, simple and cost-effective tools for surgery risk assessment are warranted. The analysis of heart rate variability (HRV) may not only provide critical insights into the general frailty of patients with hip surgery, but also allow for better differentiation of health profiles in different hip surgery groups. Using HRV analysis, the present study compared cardiovascular as well as anthropometric parameters between patients with hip surgery, the hip fracture surgery group (HFS) and the total hip arthroplasty group (THA), and a control group.

Methods

71 participants (56.3% women), aged 60–85 years, took part, divided into three groups—patients after hip surgery (21 HFS and 30 THA patients) and a control group (20 participants). Electrocardiogram was recorded at baseline and after the application of a physical stressor (grip strength). A 3 (group) × 2 (time) repeated measures ANOVA, and a chi square test were carried out to test for group differences.

Results

Higher weight (p = .002), body mass index (p = .001), and systolic blood pressure (p = .034) were found in THA patients compared to HFS patients. Lower calf circumference (p = .009) and diastolic blood pressure (p = .048) were observed for the HFS group compared to the control group. For cardiovascular parameters, significant differences emerged between the HFS group and the control group in HR (p = .005), SDNN (p = .034) and SD2 (p = .012). No significant differences in cardiovascular parameters were observed between the two hip surgery groups: neither at baseline nor during stressor recovery.

Conclusions

While HRV seems to differentiate well between HFS patients and controls, more research with larger samples is needed to scrutinize similaritites and differences in cardiovascular profiles between HFS and THA patients.

The variation of arthroplasty procedures in the OECD Countries: analysis of possible influencing factors by linear regression

Total hip and knee replacements (THR, TKR) are among the most common surgeries but incidence rates vary between OECD countries. Previous studies suggested economic factors to be most influential but did not take into account health care system related factors. Hence we analysed the possible influence of healthcare system related factors on the operation rate. We used OECD data for 27 countries and calculated Age-Standardized Incidence Rates (ASIR). In order to determine possible explanatory variables on the ASIRs we performed a stepwise blockwise linear regression. The ASIR of hip and knee replacement varies widely. We identified statistically significant determinants which influence the ASIR of THR in a positive manner: incidence and length of stay of coxarthrosis, ASIR of knee replacement, health expenditures, number of nurses and an etatistic social insurance. Diabetes prevalence, gross domestic product and number of doctor consultations, however, have a negative influence on the ASIR. TKR rate is positively influenced by health expenditures and incidence rate of gonarthrosis, negatively by the number of primary practitioners. We observed strong geographic disparities in the frequency of THR and THR that cannot be explained by age structure of the countries. Economic factors seem to play a secondary role while healthcare related factors have a greater influence.

Incidence of postoperative complications and non- periprosthetic fractures after total hip arthroplasty: A more than 10-year follow-up retrospective cohort study

OBJECTIVE

Postoperative complications and non-periprosthetic fractures (NPPFs), which was defined as a fracture existing non- periprosthetic implant, after total hip arthroplasty (THA) have a negative effect on the patients' ability to perform activities of daily living. Thus, investigating these incidences of patients after THA will be valuable as it lead to a more strategic physical therapy interventions and advanced research to prevent these problems. The purpose of this study was to investigate the incidence of postoperative complications related to implants and NPPFs in patients after THA, a more than 10-year follow-up.

METHODS

This is a retrospective cohort study. A total 892 patients with hip osteoarthritis who underwent primary THA were analyzed (age at surgery was 45-79 years; 805 women; the average follow-up period was 12.4-year). The postoperative complications related to implants and NPPFs were calculated using data from their medical records.

RESULTS

The postoperative complications occurred in 37 patients, and NPPFs occurred in 72 patients, who were significantly older, and hip and knee OA diagnosis, compared to patients without NPPFs ( p <.05). The most common cause of NPPFs was minor trauma. In patients aged ≧ 65 years, significantly more NPPFs occurred during the first year after surgery( p <.05).

CONCLUSION

More than 10-year after THA, the incidence of NPPFs was higher than that of postoperative complications related to implants. Older patients who had hip and knee OA were a significantly higher risk of developing NPPFs due to falls within the first year after surgery.

The role of superior capsular approach (SuperPATH) in the treatment of femoral neck fractures with hemiarthroplasty implantation: our experience and review of literature

BACKGROUND AND AIM OF THE WORK

since 2003, a series of so called 'micro-posterior' approaches have been developed in the orthopaedic surgery to perform total hip replacement. These techniques present several theoretical advantages compared to the classic postero-lateral approach: reduction in blood loss, post-operative pain, and length of stay but also improving functional outcomes. In our hypothesis these goals could also be obtained in patients with femoral neck fractures, especially in the elderly with several comorbidities.

METHODS

In our series we performed 50 consecutive cemented hemiarthroplasties through SuperPATH approach. At the latest follow-up (FU) 41 patients were included in the study. Clinical and radiological evaluation was performed before the surgery and at the latest FU using VAS score, Harris Hip Score (HHS) and conventional AP and LL X-rays.

RESULTS

We didn't report any intra-operative complication (i.e. periprosthetic fractures, vasculo-nervous injuries or dislocations) or any case with a dysmetria greater than 1 cm. Mean blood transfusion units were 0.8 during surgery (0 - 4) and 1,6 after surgery (0-4). We reported a mean length of stay of 9.7 days (range 7-15) mainly due to our patients' high comorbidity rate. At the last one-year FU no cases of dislocation, infection and clinical or radiographical signs of prosthetic loosening were recorded. All our patients returned to the same activity level before femoral fracture occurred, according to HHS.

CONCLUSION

The SuperPATH is a real minimally invasive approach with a low rate of intra- and post-operative complications. It is related to a reduced dislocation rate and potentially to a reduced infection rate compared to the conventional surgical approaches, allowing, furthermore, a faster functional recovery. According to our experience the advantages of this type of approach can be obtained in the trauma field too.

Differences in patient characteristics and external validity of randomized clinical trials on pain management following total hip and knee arthroplasty: a systematic review

Background

The external validity of randomized controlled trials (RCTs) is critical for the relevance of trial results in a clinical setting. We aimed to assess the external validity of RCTs investigating postoperative pain treatment after total hip and knee arthroplasty (THA and TKA) by comparing patient characteristics in these trials with a clinical cohort. Further, we assessed the use of exclusion criteria of the included RCTs.

Methods

We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials for relevant RCTs up to June 2019. Data on patient characteristics from this research population were compared with an unselected clinical cohort from the Danish Hip and Knee Arthroplasty Registries in the period 2005–2019. Trends in patient characteristics and the use of exclusion criteria were assessed with control charts.

Results

In total, 550 RCTs with 48 962 participants were included in the research cohort. The clinical cohort included 101 439 THA patients and 90 505 TKA patients. Patient characteristics (age, body mass index (BMI), American Society of Anesthesiologists (ASA) score and sex distribution) in the research cohort resembled those of the clinical cohort. Age, BMI and ASA scores did not change over time in the research cohort. In the clinical cohort, age increased among both THA and TKA patients, and BMI and ASA scores increased among TKA patients. Most commonly used exclusion criteria in the RCTs were high ASA score (62%), older age (45%), obesity (32%) and chronic opioid use (41%). Exclusion of chronic opioid users and individuals with obesity increased over time.

Conclusion

Patient characteristics in research trials investigating postoperative pain management after THA and TKA currently resemble those of a clinical cohort. However, individuals in the clinical cohort are getting older, and TKA patients more obese with increasing ASA scores. Concomitantly, RCTs increase the tendency to exclude patients with older age, obesity, chronic pain and/or opioid use. This trending discrepancy can hinder the generalizability of future research results, and therefore increased focus on pragmatic trials resembling real-world conditions are needed.

PROSPERO registration number

CRD42019125691

Cost Analysis of Dual-Mobility Constructs in Revision Total Hip Arthroplasty: A European Payer Perspective

Dual-mobility constructs have been shown to significantly and substantially decrease dislocations after revision total hip arthroplasty (THA). The authors have previously shown that dual-mobility (DM) constructs are cost-effective given their ability to decrease dislocations and re-revision for dislocation. The goal was to report the costs of DM and large femoral head (LFH) constructs in revision THAs from a European health care payer perspective. A Markov model was constructed to analyze the costs incurred by payers in the United Kingdom, Germany, Italy, and Spain over 3 years in revision THAs with DM or LFH constructs. Model states and probabilities were derived from prospectively collected registry data in 302 patients who underwent revision THA with a DM or 40-mm LFH construct and were then mapped to corresponding procedural reimbursement codes and tariffs for each country. Costs were weighted average national payments for reintervention procedures performed in the 3 years following revision THA. Probabilistic sensitivity analysis examined the effect of combined uncertainty across all model parameters. During a 3-year period following revision THA, reintervention rates were 9% for DM constructs and 19% for LFH constructs (P=.01). Comparing DM and LFH constructs, cumulative incremental costs over 3-years' follow-up were £428 vs £1447 in the United Kingdom, euro 451 vs euro 1272 in Germany, euro 540 vs euro 1425 in Italy, and euro 523 vs euro 1562 in Spain, respectively. At mid-term follow-up, DM constructs used in revision THAs were associated with a significantly lower risk of reintervention, which translated to lower health care payer costs compared with LFH constructs among European health care payers. [Orthopedics. 2020;43(4):250-255.].

Strain shielding for cemented hip implants

BACKGROUND

Long-term survival of hip implants is of increasing relevance due to the rising life expectancy. The biomechanical effect of strain shielding as a result of implant insertion may lead to bone resorption, thus increasing risk for implant loosening and periprosthetic fractures. Patient-specific quantification of strain shielding could assist orthopedic surgeons in choosing the biomechanically most appropriate prosthesis.

METHODS

Validated quantitative CT-based finite element models of five femurs in intact and implanted states were considered to propose a systematic algorithm for strain shielding quantification. Three different strain measures were investigated and the most appropriate measure for strain shielding quantification is recommended. It is used to demonstrate a practical femur-specific implant selection among three common designs.

FINDINGS

Strain shielding measures demonstrated similar trends in all Gruen zones except zone 1, where the volumetric strain measure differed from von-Mises and maximum principal strains. The volumetric strain measure is in better agreement with clinical bone resorption records. It is also consistent with the biological mechanism of bone remodeling so it is recommended for strain shielding quantification. Applying the strain shielding algorithm on three different implants for a specific femur suggests that the collared design is preferable. Such quantitative biomechanical input is valuable for practical patient specific implant selection.

INTERPRETATION

Volumetric strain should be considered for strain shielding examination. The presented methodology may potentially enable patient-specific pre-operative strain shielding evaluation so to minimize strain shielding. It should be further used in a longitudinal study so to correlate between strain shielding predictions and clinical bone resorption.

Projections of Primary TKA and THA in Germany From 2016 Through 2040

BACKGROUND

Future projections for both TKA and THA in the United States and other countries forecast a further increase of already high numbers of joint replacements. The consensus is that in industrialized countries, this increase is driven by demographic changes with more elderly people being less willing to accept activity limitations. Unlike the United States, Germany and many other countries face a population decline driven by low fertility rates, longer life expectancy, and immigration rates that cannot compensate for population aging. Many developing countries are likely to follow that example in the short or medium term amid global aging. Due to growing healthcare expenditures in a declining and aging population with a smaller available work force, reliable predictions of procedure volume by age groups are requisite for health and fiscal policy makers to maintain high standards in arthroplasty for the future population.Questions/purposes (1) By how much is the usage of primary TKA and THA in Germany expected to increase from 2016 through 2040? (2) How is arthroplasty usage in Germany expected to vary as a function of patient age during this time span?

METHODS

The annual number of primary TKAs and THAs were calculated based on population projections and estimates of future healthcare expenditures as a percent of the gross domestic product (GDP) in Germany. For this purpose, a Poisson regression analysis using age, gender, state, healthcare expenditure, and calendar year as covariates was performed. The dependent variable was the historical number of primary TKAs and THAs performed as compiled by the German federal office of statistics for the years 2005 through 2016.

RESULTS

Through 2040, the incidence rate for both TKA and THA will continue to increase annually. For TKA, the incidence rate is expected to increase from 245 TKAs per 100,000 inhabitants to 379 (297-484) (55%, 95% CI 21 to 98). The incidence rate of THAs is anticipated to increase from 338 to 437 (357-535) per 100,000 inhabitants (29% [95% CI 6 to 58]) between 2016 and 2040. The total number of TKAs is expected to increase by 45% (95% CI 14 to 8), from 168,772 procedures in 2016 to 244,714 (95% CI 191,920 to 312,551) in 2040. During the same period, the number of primary THAs is expected to increase by 23% (95% CI 0 to 50), from 229,726 to 282,034 (95% CI 230,473 to 345,228). Through 2040, the greatest increase in TKAs is predicted to occur in patients aged 40 to 69 years (40- to 49-year-old patients: 269% (95% CI 179 to 390); 50- to 59-year-old patients: 94% (95% CI 48 to 141); 60- to 69-year-old patients: 43% (95% CI 13 to 82). The largest increase in THAs is expected in the elderly (80- to 89-year-old patients (71% [95% CI 40 to 110]).

CONCLUSIONS

Although the total number of TKAs and THAs is projected to increase in Germany between now and 2040, the increase will be smaller than that previously forecast for the United States, due in large part to the German population decreasing over that time, while the American population increases. Much of the projected increase in Germany will be from the use of TKA in younger patients and from the use of THA in elderly patients. Knowledge of these trends may help planning by surgeons, hospitals, stakeholders, and policy makers in countries similar to Germany, where high incidence rates of arthroplasty, aging populations, and overall decreasing populations are present.

LEVEL OF EVIDENCE

Level III, economic and decision analysis.

Multi-disciplinary Rehabilitation Outcome Checklist: Italian validation of an instrument for risk of discharge in patients with total hip and/or knee replacement

Object:

This article describes the translation and cultural adaptation of the Multi-disciplinary Rehabilitation Outcome Checklist Scale in Italian and reports the procedures to test their validity and reliability.

Methods:

The forward and backward translation was conducted by specialized and certified translators, independently from each other. The scale was then reviewed by a group of 20 experts. The process of cultural adaptation and validation took place on a cohort of patients who performed a joint replacement of hip and/or knee surgery in two hospitals of Rome.

Results:

The culturally adapted scale was administered to 114 patients. It results that the interoperator reliability is equal to intraclass correlation coefficient (ICC) = 0.977 for hip and ICC = 0.97 for knee. The construct validity and the responsiveness are statistically significant.

Conclusion:

It is a scale capable of assessing the patient in a comprehensive and multidisciplinary manner at the time of hospital discharge, useful for dismissing the patient in the most appropriate timing and with the best clinical and functional conditions.

The use of digitally collected patient-reported outcome measures for newly operated patients with total knee and hip replacements to improve post-treatment recovery: study protocol for a randomized controlled trial

Background

The number of total knee replacements (TKRs) and total hip replacements (THRs) has been increasing noticeably in high-income countries, such as Germany. In particular, the number of revisions is expected to rise because of higher life expectancy and procedures performed on younger patients, impacting the budgets of health-care systems. Quality transparency is the basis of holistic patient pathway optimization. Nevertheless, a nation-wide cross-sectoral assessment of quality from a patient perspective does not yet exist. Several studies have shown that the use of patient-reported outcome measures (PROMs) is effective for measuring quality and monitoring post-treatment recovery. For the first time in Germany, we test whether early detection of critical recovery paths using PROMs after TKR/THR improves the quality of care in a cost-effective way and can be recommended for implementation into standard care.

Methods/design

The study is a two-arm multi-center patient-level randomized controlled trial. Patients from nine hospitals are included in the study. Patient-centered questionnaires are employed to regularly measure digitized PROMs of TKR/THR patients from the time of hospital admission until 12 months post-discharge. An expert consortium has defined PROM alert thresholds at 1, 3, and 6 months to signal critical recovery paths after TKR/THR. An algorithm alerts study assistants if patients are not recovering in line with expected recovery paths. The study assistants contact patients and their physicians to investigate and, if needed, adjust the post-treatment protocol. When sickness funds’ claims data are added, the cost-effectiveness of the intervention can be analyzed.

Discussion

The study is expected to deliver an important contribution to test PROMs as an intervention tool and examine the determinants of high-quality endoprosthetic care. Depending on a positive and cost-effective impact, the goal is to transfer the study design into standard care. During the trial design phase, several insights have been discovered, and there were opportunities for efficient digital monitoring limited by existing legacy care models. Digitalization in hospital processes and the implementation of digital tools still represent challenges for hospital personnel and patients. Furthermore, data privacy regulations and the separation between the in- and outpatient sector are roadblocks to effectively monitor and assess quality along the full patient pathway.

Trial registration

German Clinical Trials Register: DRKS00019916. Registered November 26, 2019 – retrospectively registered.

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.

Smart Product Design Process through the Implementation of a Fuzzy Kano-AHP-DEMATEL-QFD Approach

Product design has become a critical process for the healthcare technology industry, given the ever-changing demands, vague customer requirements, and interrelations among design criteria. This paper proposed a novel integration of fuzzy Kano, Analytic Hierarchy Process (AHP), Decision Making Trial and Evaluation Laboratory (DEMATEL), and Quality Function Deployment (QFD) to translate customer needs into product characteristics and prioritize design alternatives considering interdependence and vagueness. First, the customer requirements were established. Second, the fuzzy KANO was applied to calculate the impact of each requirement, often vague, on customer satisfaction. Third, design alternatives were defined, while the requirements’ weights were calculated using AHP. DEMATEL was later implemented for evaluating the interdependence among alternatives. Finally, QFD was employed to select the best design. A hip replacement surgery aid device for elderly people was used for validation. In this case, collateral issues were the most important requirement, while code change was the best-ranked design.

Enhanced recovery following hip and knee arthroplasty: a systematic review of cost-effectiveness evidence

OBJECTIVES

To assess cost-effectiveness of enhanced recovery pathways following total hip and knee arthroplasties. Secondary objectives were to report on quality of studies and identify research gaps for future work.

DESIGN

Systematic review of cost-utility analyses.

DATA SOURCES

Ovid MEDLINE, Embase, the National Health Service Economic Evaluations Database and EconLit, January 2000 to August 2019.

ELIGIBILITY CRITERIA

English-language peer-reviewed cost-utility analyses of enhanced recovery pathways, or components of one, compared with usual care, in patients having total hip or knee arthroplasties for osteoarthritis.

DATA EXTRACTION AND SYNTHESIS

Data extracted by three reviewers with disagreements resolved by a fourth. Study quality assessed using the Consensus on Health Economic Criteria list, the International Society for Pharmacoeconomics and Outcomes Research and Assessment of the Validation Status of Health-Economic decision models tools; for trial-based studies the Cochrane Collaboration's tool to assess risk of bias. No quantitative synthesis was undertaken.

RESULTS

We identified 17 studies: five trial-based and 12 model-based studies. Two analyses evaluated entire enhanced recovery pathways and reported them to be cost-effective compared with usual care. Ten pathway components were more effective and cost-saving compared with usual care, three were cost-effective, and two were not cost-effective. We had concerns around risk of bias for all included studies, particularly regarding the short time horizon of the trials and lack of reporting of model validation.

CONCLUSIONS

Consistent results supported enhanced recovery pathways as a whole, prophylactic systemic antibiotics, antibiotic-impregnated cement and conventional ventilation for infection prevention. No other interventions were subject of more than one study. We found ample scope for future cost-effectiveness studies, particularly analyses of entire recovery pathways and comparison of incremental changes within pathways. A key limitation is that standard practices have changed over the period covered by the included studies.

PROSPERO REGISTRATION NUMBER

CRD42017059473.

Altering the Course of Technologies to Monitor Loosening States of Endoprosthetic Implants

Musculoskeletal disorders are becoming an ever-growing societal burden and, as a result, millions of bone replacements surgeries are performed per year worldwide. Despite total joint replacements being recognized among the most successful surgeries of the last century, implant failure rates exceeding 10% are still reported. These numbers highlight the necessity of technologies to provide an accurate monitoring of the bone–implant interface state. This study provides a detailed review of the most relevant methodologies and technologies already proposed to monitor the loosening states of endoprosthetic implants, as well as their performance and experimental validation. A total of forty-two papers describing both intracorporeal and extracorporeal technologies for cemented or cementless fixation were thoroughly analyzed. Thirty-eight technologies were identified, which are categorized into five methodologies: vibrometric, acoustic, bioelectric impedance, magnetic induction, and strain. Research efforts were mainly focused on vibrometric and acoustic technologies. Differently, approaches based on bioelectric impedance, magnetic induction and strain have been less explored. Although most technologies are noninvasive and are able to monitor different loosening stages of endoprosthetic implants, they are not able to provide effective monitoring during daily living of patients.

Race, Discharge Disposition, and Readmissions After Elective Hip Replacement: Analysis of a Large Regional Dataset

Purpose: Total hip arthroplasty (THA) is one of the fastest growing procedures. There is increasing evidence that social determinants of health influence health care utilization and outcomes after THA, including postoperative care. We sought to examine how race impacts discharge destination after elective THA, and we assessed the impact of discharge destination on 90-day readmission to an acute care hospital. Methods: We conducted a retrospective study using data from the Pennsylvania Health Care Cost Containment Council Database. We included patients of African American (AA) or white race undergoing THA, discharge disposition (inpatient rehabilitation facility [IRF], skilled nursing facility [SNF], home health care (HHC), home), and 90-day readmission rates. Results: Our study included 93,493 primary elective THAs. Compared with whites, AAs were more likely to be discharged to an IRF or SNF or HHC than home after THA. In all age groups, discharge to an IRF, SNF, or HHC for postop care/rehab was associated with higher odds of 90-day readmission as compared with home. Conclusion: AA race was associated with higher odds of discharge to an institution (IRF/SNF) or HHC for post-THA care. Disposition to these were associated with significantly higher risk of 90-day readmission to acute care hospital compared with home.

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.

Geographical and ethnic differences of osteoarthritis-associated hip and knee replacement surgeries in New Zealand: a population-based cross-sectional study

OBJECTIVES

To (1) explore the regional and ethnic differences in rates of publicly funded osteoarthritis-associated hip and knee replacement surgeries and (2) investigate the mortality after surgery.

DESIGN

Population-based, retrospective, cross-sectional study.

SETTING

General population in New Zealand.

PARTICIPANTS

Patients with osteoarthritis who underwent publicly funded primary hip and knee replacement surgeries in 2005-2017. Patients aged 14-99 years were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

Age-standardised rate, standardised mortality ratio (SMR) and 30 days, 90 days and 1 year mortality.

RESULTS

We identified 53 439 primary hip replacements and 50 072 primary knee replacements with a diagnosis of osteoarthritis. The number and age-standardised rates of hip and knee replacements increased over time. Māori had the highest age-standardised rate of hip replacements, followed by European/others and Pacific, and Asian had the lowest rate. Pacific had the highest age-standardised rate of knee replacements, followed by Māori and European/others, and Asian had the lowest rate. The Northern Health Network had the lowest rate of hip surgeries, and the Southern Health Network had the lowest rate of knee surgeries. The SMRs of patients undergoing hip and knee replacements were lower than the general population: 0.92 (95% CI 0.89 to 0.95) for hip and 0.79 (95% CI 0.76 to 0.82) for knee. The SMRs were decreasing over time. The patterns of 30 days, 90 days and 1 year mortality were similar to the SMR.

CONCLUSIONS

The numbers of publicly funded osteoarthritis-associated primary hip and knee replacements are steadily increasing. Māori people had the highest age-standardised rate of hip replacements and Pacific people had the highest rate of knee replacements. The Northern Health Network had the lowest rate of hip surgeries, and the Southern Health Network had the lowest rate of knee surgeries. Compared with the general population, patients who had hip and knee replacements have a better life expectancy.

Relationship between exposure to the natural environment and recovery from hip or knee arthroplasty: a New Zealand retrospective cohort study

OBJECTIVES

Determine whether patients who live in greener and more walkable neighbourhoods live longer, and take fewer opioids, following hip or knee arthroplasty.

DESIGN

Retrospective cohort study.

SETTING

Residential environment following surgery at one of 54 New Zealand hospitals.

PARTICIPANTS

All people who received a total hip or knee arthroplasty at a publicly-funded hospital in New Zealand in 2006 and 2007 (7449 hip arthroplasties and 6558 knee arthroplasties).

PRIMARY AND SECONDARY OUTCOME MEASURE

Time to all-cause mortality and number of postsurgical opioid prescriptions.

RESULTS

Patients who lived in greener neighbourhoods, as measured by the Normalised Difference Vegetation Index, lived longer following hip or knee arthroplasty (standardised OR: 0.95, 95% CI 0.92 to 0.99). However, when we estimated separate hip-arthroplasty-only and knee-arthroplasty-only models, greenness was only significantly associated with greater longevity following hip arthroplasty. Similarly, patients who lived in greener neighbourhoods took fewer opioids in the 12 months following hip or knee arthroplasty (standardised OR: 0.97, 95% CI 0.95 to 0.99), but in separate hip-arthroplasty-only and knee-arthroplasty-only models, greenness was only significantly associated with lower opioid use following hip arthroplasty. Walkability was not significantly associated with postsurgical opioid use or postsurgical longevity. All ORs were adjusted for sex, ethnicity, age, presurgical chronic health conditions, presurgical opioid use, social deprivation and length of hospital stay.

CONCLUSIONS

Consistent with the literature on enhanced-recovery programme, people who lived in greener neighbourhoods took fewer opioids, and lived longer, following hip arthroplasty. Improving access to the natural environment may therefore be an effective component of postsurgical recovery programme.

Cost-analysis of inpatient and outpatient parenteral antimicrobial therapy in orthopaedics: A systematic literature review

BACKGROUND

Increasing numbers of total joint arthroplasties and consecutive revision surgery are associated with the risk of periprosthetic joint infections (PPJI). Treatment of PPJI is complex and associated with immense socio-economic burden. One treatment aspect is parenteral antiinfective therapy, which usually requires an inpatient setting [Inpatient parenteral antibiotic therapy (IPAT)]. An alternative is outpatient parenteral treatment [Outpatient parenteral antibiotic therapy (OPAT)]. To conduct a health economic cost-benefit analysis of OPAT, a detailed cost analysis of IPAT and OPAT is required. So far, there is a lack of knowledge on the health economic effects of IPAT and OPAT for PPJI.

AIM

To review an economic comparison of IPAT and OPAT.

METHODS

A systematic literature review was performed through Medline following the PRISMA guidelines.

RESULTS

Of 619 identified studies, 174 included information of interest and 21 studies were included for quantitative analysis of OPAT and IPAT costs. Except for one study, all showed relevant cost savings for OPAT compared to IPAT. Costs for IPAT were between 1.10 to 17.34 times higher than those for OPAT.

CONCLUSION

There are only few reports on OPAT for PPJI. Detailed analyses to support economic or clinical guidelines are therefore limited. There is good clinical evidence supporting economic benefits of OPAT, but more high quality studies are needed for PPJI.

Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis

BACKGROUND

Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes.

METHODS

The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations.

RESULTS

The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87.

CONCLUSIONS

Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation.

RECOMMENDATION

neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty.

TRIAL REGISTRY NUMBER

PROSPERO CRD42018099935.

Systematic review of the clinical effectiveness for long-term follow-up of total hip arthroplasty

Objectives: Total hip arthroplasty (THA) is highly successful but national registries indicate that average age has lowered and that younger patients are at higher risk of revision. Long-term follow-up of THA was historically recommended to identify aseptically failing THA, minimising the risks associated with extensive changes, but follow-up services are now in decline. A systematic review was conducted to search for evidence of the clinical or cost-effectiveness of hip arthroplasty surveillance. Methods: The study was registered with PROSPERO International Prospective Register of Systematic Reviews and conducted according to PRISMA guidelines; databases included MEDLINE and Embase, and all studies were quality assessed. Original studies (2005 to 2017) reporting follow-up of adults with THA in situ >5 years were included. Researchers extracted quantitative and qualitative data from each study. Results: For eligibility, 4,137 studies were screened: 114 studies were included in the final analysis, representing 22 countries worldwide. Data extracted included study endpoint, patient detail, loss to follow-up, revisions, scores and radiographic analysis. Six themes were derived from inductive content analysis of text: support for long-term follow-up, subgroups requiring follow-up, effect of materials/techniques on THA survival, effect of design, indicators for revision, review process. Main findings-follow-up was specifically recommended to monitor change (eg asymptomatic loosening), when outcomes of joint construct are unknown, and for specific patient subgroups. Outcome scores alone are not enough, and radiographic review should be included. Conclusion: There were no studies directly evaluating the clinical effectiveness of the long-term follow-up of THA but expert opinions from a range of international authors advocated its use for defined subgroups to provide patient-centred care. In the absence of higher level evidence, these opinions, in conjunction with emerging outputs from the national joint registries, should be used to inform services for long-term follow-up of THA.

Early Results From the American Joint Replacement Registry: A Comparison With Other National Registries

BACKGROUND

The American Joint Replacement Registry (AJRR) was created to capture knee and hip arthroplasty data in the United States. The purpose of this study was to compare early reports from the AJRR to other national registries to identify topics for future analysis.

METHODS

Hip and knee arthroplasty data were extracted from the AJRR, Australia, New Zealand, United Kingdom, Norway, and Sweden from 2014 to 2016. Hip arthroplasty data including femoral and acetabular fixation, bearing surface, head size, dual-mobility bearings, resurfacing, and revision burden were compared. Knee arthroplasty data including polyethylene type, unicondylar arthroplasty, mobile bearings, cruciate-retaining implants, patella resurfacing, and revision burden were compared. Registry characteristics and patient demographics were reported using descriptive statistics.

RESULTS

In 2016, the AJRR captured 28% of arthroplasty procedures performed in the United States compared with 95%-98.3% among other registries. Cementless femoral fixation was 96.7% in the AJRR compared with 21.8%-63.4%. Ceramic and 36-mm heads were most common in AJRR; all other registries reported that metal and 32-mm heads were most popular. Dual-mobility articulations were used in 8% of primary and 28% of revision total hip arthroplasty procedures in the AJRR. The AJRR reported a unicondylar knee arthroplasty rate of 3.2% compared with 5.1%-13.3% in other registries, but the highest rates of posterior-stabilized total knee arthroplasties (48.5% compared to 8.2%-28.7%) and patella resurfacing (93.9% compared to 2.4%-51.6%).

CONCLUSION

Several differences in hip and knee arthroplasty practices exist between the United States and other countries. Future studies should focus on understanding why differences in practice trends exist and assess outcomes associated with these practices.

LEVEL OF EVIDENCE

Level III, retrospective.

Orthopedic Surgery in Rheumatoid Arthritis: Results from the Spanish National Registry of Hospitalized Patients over 17 Years

OBJECTIVE

To analyze the trend of orthopedic surgery (OS) rates on patients with rheumatoid arthritis (RA).

METHODS

Retrospective observational study based on information provided by the Spanish National System of Hospital Data Surveillance. All hospitalizations of patients with RA for orthopedic surgery [total hip arthroplasty (THA), total knee arthroplasty (TKA), arthrodesis, and upper limb arthroplasty (ULA)] during 1999-2015 were analyzed. The age-adjusted rate was calculated. Generalized linear models were used for trend analysis.

RESULTS

There were 21,088 OS in patients over 20 years of age (77.9% women). OS rate adjusted by age was 754.63/100,000 RA patients/year (women 707.4, men 861.1). Neither an increasing nor a decreasing trend was noted for the total OS. However, trend and age interacted, so in the age ranges 20-40 years and 40-60 years, an annual reduction of 2.69% and 2.97%, respectively, was noted. In the age ranges over 80 years and 60-80 years, we noted an annual increase of 5.40% and 1.09%, respectively. The average age at time of OS increased 5.5 years during the period analyzed. For specific surgeries, a global annual reduction was noted in rates for arthrodesis. In THA, there was an annual reduction in patients under 80 years. In TKA and ULA, there was an annual reduction in patients under 60 years.

CONCLUSION

Although the overall OS rate has not changed, there is a decrease in the rate of arthrodesis at all ages, THA in patients under 80 years of age, as well as TKA and ULA in patients under 60 years of age.

Trends in hospitalisation rates for inflammatory bowel disease in western versus newly industrialised countries: a population-based study of countries in the Organisation for Economic Co-operation and Development

BACKGROUND

Hospitalisation rates for inflammatory bowel disease (IBD) vary across the world. We aimed to investigate temporal patterns of hospitalisation for IBD in member countries of the Organisation for Economic Co-operation and Development (OECD).

METHODS

From the OECD database, we assessed IBD-related hospitalisation rates (expressed as annual rates per 100 000 inhabitants) for 34 countries from 1990 to 2016. We calculated mean hospitalisation rates for the period 2010-15 and used joinpoint regression models to calculate average annual percentage changes with 95% CIs.

FINDINGS

Mean hospitalisation rates for IBD from 2010 to 2015 were highest in North America (eg, 33·9 per 100 000 in the USA), Europe (eg, 72·9 per 100 000 in Austria), and Oceania (eg, 31·5 per 100 000 in Australia). Hospitalisation rates for IBD were stabilising or decreasing over time in many countries in these regions but increasing in others. Countries in Asia and Latin America and the Caribbean had the lowest IBD-related hospitalisation rates but the greatest increases in rates over time. For example, Turkey had an annual hospitalisation rate of 10·8 per 100 000 inhabitants and an average annual percentage change of 10·4% (95% CI 5·2-15·9). Similarly, Chile had an annual hospitalisation rate of 9·0 per 100 000 inhabitants and an average annual percentage change of 5·9% (4·9-7·0).

INTERPRETATION

Hospitalisation rates for IBD are high in western countries but are typically stabilising or decreasing, whereas rates in many newly industrialised countries are rapidly increasing, which reflects the known increase in IBD prevalence in these countries. Potential explanations for these trends include changes in the epidemiology of IBD, health-care delivery, and infrastructure in these countries, as well as overall country-specific patterns in hospitalisations and differences between countries in data collection methods.

FUNDING

None.

In vitro and in vivo investigations of a-C/a-C:Ti nanomultilayer coated Ti6Al4V alloy as artificial femoral head

Hydrogen-free a-C/a-C:Ti nanomultilayer (a-C NM) films were deposited on medical Ti6Al4V by the magnetron sputtering technique under bias-graded voltage. Cell tests and implantations were performed for the a-C NM films coated Ti6Al4V with the uncoated Ti6Al4V as the control. The canine total hip arthroplasty (THA) surgeries were conducted for 12 dogs using the coated femoral heads, with the CoCr heads as the control. Results of cell tests showed that the coated Ti6Al4V had no cytotoxicity, and there was no statistical difference of the cell attachment rates between the coated and uncoated sample (P = 0.091). No significant difference of the tissue response around the coated and uncoated implants were observed after the intramuscular (P = 0.679) and intraosseous implantations (P = 0.122). After two years of successful canine THA, the polyethylene wear particles isolated from periprosthetic soft tissue showed similar sizes, shapes and counts in the two groups (all of the P values >0.05). The retrieved femoral heads showed slightly change of the surface roughness, but no statistical differences between groups (P = 0.696). However, the systemic metal ion analysis indicated that the content of Co and Cr ions released in the coated group (Co: 0.71 ± 0.06 μg/L, Cr: 0.52 ± 0.05 μg/L) were significant lower than that in the control (Co: 1.98 ± 0.16 μg/L, Cr: 1.17 ± 0.19 μg/L) (both P < 0.005). Histological analysis of the periprosthetic tissue in CoCr group showed a severer histiocyte response than that in the coated group (P = 0.029). The head-taper interfaces showed galvanic corrosion attack in the CoCr group, but not in the coated Ti6Al4V group. Therefore, the a-C NM films coated Ti6Al4V exhibited good biocompatibility as an implant material. Compared with the CoCr, the coated Ti6Al4V femoral head could provide comparable in vivo wear properties, release less harmful metal ions and reduce the inflammatory response in periprosthetic tissue, which may help to prolong the longevity of prostheses.

The Effect of Total Hip Arthroplasty on Sports and Work Participation: A Systematic Review and Meta-Analysis

Background

Total hip arthroplasty (THA) is a successful procedure to treat end-stage hip osteoarthritis. The procedure is increasingly performed in adults of working age, who often wish to return to sports (RTS) and return to work (RTW). However, a systematic overview of the evidence on RTS and RTW after THA is lacking.

Objectives

Our aim was to systematically review (1) the extent to which patients RTS and RTW after THA, including (2) the time to RTS and RTW.

Methods

We searched MEDLINE and Embase from inception until October 2017. Two authors screened and extracted the data, including study information, patient demographics, rehabilitation protocols and pre- and postoperative sports and work participation. Methodological quality was assessed using the Newcastle–Ottawa scale. Data on pre- and postoperative sports and work participation were pooled using descriptive statistics.

Results

A total of 37 studies were included, of which seven were prospective studies and 30 were retrospective studies. Methodological quality was high in 11 studies, moderate in 16 studies, and low in ten studies. RTS was reported in 14 studies. Mean RTS was 104% to the pre-surgery level and 82% to the pre-symptomatic sports level. Time to RTS varied from 16 to 28 weeks. RTW was reported in 23 studies; the mean was 69%. Time to RTW varied from 1 to 17 weeks.

Conclusion

A great majority of patients RTS and RTW after THA within a timeframe of 28 and 17 weeks, respectively. For the increasingly younger THA population, this is valuable information that can be used in the preoperative shared decision-making process.

Electronic supplementary material

The online version of this article (10.1007/s40279-018-0924-2) contains supplementary material, which is available to authorized users.

Cementless metaphyseal reverse shoulder arthroplasty: our preliminary experience

Reverse shoulder arthroplasty (rTSA) is a largely used procedure with a wide variety of indications. The incidence of this surgery is increased in recent years and the literature expects similar trend for the future. Metaphyseal stem rTSA seems to be a promising solution considering major objectives the preservation of humeral bone stock and ease of revision. In our study we analyzed 19 patients treated with cementless metaphyseal stem rTSA for osteoarthritis (group A) and acute fractures (group B). In group A (7 patients) the average Constant score improved from 21,57 (16-29) to 56,85 (38-72), the average SST improved from 2,29 (1-4) to 9,43 (8-12) and the mean VAS score improved from 14,29 to 4,86. In group B (12 patients) the mean Constant-Murlay score at last follow up was 42,17; the average SST was 7 and average pain score was 8,92. Overall active range-of-motion (ROM) improved significantly. Surgical considerations, clinical (analyzing Constant score and Simple Shoulder Test) and radiological short-term outcomes are encouraging, with low rate of complications. Long term follow-up studies are necessary to confirm our findings and the potential benefits related to these implants. (www.actabiomedica.it)