Hip resurfacing arthroplasty complicated by mismatched implant components

EFORT recommendations for off-label use, mix & match and mismatch in hip and knee arthroplasty

Off-label use is frequently practiced in primary and revision arthroplasty, as there may be indications for the application of implants for purposes outside the one the manufacturers intended.

Under certain circumstances, patients may benefit from selective application of mix & match. This can refer to primary hip arthroplasty (if evidence suggests that the combination of devices from different manufacturers has superior results) and revision hip or knee arthroplasty (when the exchange of one component only is necessary and the invasiveness of surgery can be reduced).

Within the EFORT ‘Implant and Patient Safety Initiative’, evidence- and consensus-based recommendations have been developed for the safe application of off-label use and mix & match in primary as well as revision hip and knee arthroplasty.

Prior to the application of a medical device for hip or knee arthroplasty off-label and within a mix & match situation, surgeons should balance the risks and benefits to the patient, obtain informed consent, and document the decision process appropriately.

Nevertheless, it is crucial for surgeons to only combine implants that are compatible. Mismatch of components, where their sizes or connections do not fit, may have catastrophic effects and is a surgical mistake.

Surgeons must be fully aware of the features of the components that they use in off-label indications or during mix & match applications, must be appropriately trained and must audit their results.

Considering the frequent practice of off-label and mix & match as well as the potential medico-legal issues, further research is necessary to obtain more data about the appropriate indications and outcomes for those procedures.

Cite this article: EFORT Open Rev 2021;6:982-1005. DOI: 10.1302/2058-5241.6.210080

Mismatch 'never events' in hip and knee arthroplasty: a cohort and intervention study

AIMS

The aim of this study was to give estimates of the incidence of component incompatibility in hip and knee arthroplasty and to test the effect of an online, real-time compatibility check.

MATERIALS AND METHODS

Intraoperative barcode registration of arthroplasty implants was introduced in Denmark in 2013. We developed a compatibility database and, from May 2017, real-time compatibility checking was implemented and became part of the registration. We defined four classes of component incompatibility: A-I, A-II, B-I, and B-II, depending on an assessment of the level of risk to the patient (A/B), and on whether incompatibility was knowingly accepted (I/II).

RESULTS

A total of 26 524 arthroplasties were analyzed. From 12 307 procedures that were undertaken before implementation of the compatibility check, 21 class A incompatibilities were identified (real- or high-risk combinations; 0.17%; 95% confidence interval (CI) 0.11 to 0.26). From 5692 hip and 6615 knee procedures prior to implementation of the compatibility check, we found rates of class A-I incompatibility (real- or high-risk combinations unknowingly inserted) of 0.14% (95% CI 0.06 to 0.28) and 0.17% (95% CI 0.08 to 0.30), respectively. From 14 217 procedures after the introduction of compatibility checking (7187 hips and 7030 knees), eight class A incompatibilities (0.06%; 95% CI 0.02 to 0.11) were identified. This difference was statistically significant (p = 0.008).

CONCLUSION

Our data presents validated estimates of the baseline incidence of incompatibility events for hip and knee arthroplasty procedures and shows that a significant reduction in class A incompatibility events is possible using a web-based recording system. Cite this article: Bone Joint J 2019;101-B:960-969.

Can We Avoid Implant-selection Errors in Total Joint Arthroplasty?

BACKGROUND

Implant selection in the operating room is a manual process. This manual process combined with complex compatibility rules and inconsistent implant labeling may lead to implant-selection errors. These might be reduced using an automated process; however, little is known about the efficacy of available automated error-reduction systems in the operating room.

QUESTIONS/PURPOSES

(1) How often do implant-selection errors occur at a high-volume institution? (2) What types of implant-selection errors are most common?

METHODS

We retrospectively evaluated our implant log database of 22,847 primary THAs and TKAs to identify selection errors. There were 10,689 THAs and 12,167 TKAs included during the study period from 2012 to 2017; there were no exclusions and we had no missing data in this study. The system provided an output of errors identified, and these errors were then manually confirmed by reviewing implant logs for each case found in the medical records. Only those errors that were identified by the system were manually confirmed. During this time period all errors for all procedures were captured and presented as a proportion. Errors identified by the software were manually confirmed. We then categorized each mismatch to further delineate the nature of these events.

RESULTS

One hundred sixty-nine errors were identified by the software system just before implantation, representing 0.74 of the 22,847 procedures performed. In 15 procedures, the wrong side was selected. Twenty-five procedures had a femoral head selected that did not match the acetabular liner. In one procedure, the femoral head taper differed from the femoral stem taper. There were 46 procedures in which there was a size mismatch between the acetabular shell and the liner. The most common error in TKA that occurred in 46 procedures was a mismatch between the tibia polyethylene insert and the tibial tray. There were 13 procedures in which the tibial insert was not matched to the femoral component according to the manufacturer's guidelines. Selection errors were identified before implantation in all procedures.

CONCLUSIONS

Despite an automated verification process, 0.74% of the arthroplasties performed had an implant-selection error that was identified by the software verification. The prevalence of incorrect/mismatched hip and knee prostheses is unknown but almost certainly underreported. Future studies should investigate the prevalence of these errors in a multicenter evaluation with varying volumes across the involved sites. Based on our results, institutions and management should consider an automated verification process rather than a manual process to help decrease implant-selection errors in the operating room.

LEVEL OF EVIDENCE

Level IV, therapeutic study.