Effect of single versus multiple prophylactic antibiotic doses on prosthetic joint infections following primary total hip arthroplasty in patients with osteoarthritis at public and private hospitals in Denmark: protocol for a nationwide cross-over, cluster randomised, non-inferiority trial [The Pro-Hip-Quality Trial]

INTRODUCTION

A feared complication after total hip arthroplasty (THA) is prosthetic joint infection (PJI), associated with high morbidity and mortality. Prophylactic antibiotics can reduce the risk of PJI. However, there is no consensus on the dosages and current recommendations are based on a low evidence level. The objective is to compare the effect of a single versus multiple doses of prophylactic antibiotics administered within 24 hours on PJI.

METHODS AND ANALYSIS

The study is designed as a cross-over, cluster randomised, non-inferiority trial. All clinical centres use both antibiotic practices (1 year of each intervention). All Danish orthopaedic surgery departments will be involved: Based on quality databases, 2-year cohorts of approximately 20 000 primary THAs conducted at 39 public and private hospitals, will be included.

INCLUSION CRITERIA

age ≥18 years, all indications for THA except patients operated due to acute or sequelae from proximal femoral or pelvic fractures or bone tumour or metastasis. The primary outcome is PJI within 90 days after primary THA. Secondary outcomes include (1) serious adverse events, (2) potential PJI, (3) length of hospitalisation stay, (4) cardiovascular events, (5) hospital-treated infections, (6) community-based antibiotic use, (7) opioid use and (8) use of acetaminophen and non-steroidal anti-inflammatory drugs. All outcome measures will be extracted from national databases. Analyses will be based on the intention-to-treat population. Non-inferiority will be shown if the upper limit of the two-sided 95% CI for the OR is less than 1.32 for the single dose as compared with multiple doses. The results will establish best practice on antibiotic prophylaxis dosages in the future.

ETHICS AND DISSEMINATION

This study has been approved by Committees on Health Research Ethics for The Capital Region of Denmark (21069108) and The Danish Medicines Agency (2021091723). All results will be presented in peer-reviewed medical journals and international conferences.

TRIAL REGISTRATION NUMBER

NCT05530551.

Fast-track revision knee arthroplasty

BACKGROUND

Limited data exist on fast-track protocols in relation to revision knee arthroplasty. Hence, the aim of this study was to report length of stay (LOS), risk of LOS > 5 days and readmission ≤ 90 days after revision knee arthroplasty in centers with a well-established fast-track protocol in both primary and revision surgery.

METHODS

An observational cohort study from the Centre for Fast-track Hip and Knee Replacement and the Danish Knee Arthroplasty Register. We included elective aseptic major component revision knee arthroplasties consecutively from 6 dedicated fast-track centers from 2010 to 2018.

RESULTS

1439 revision knee arthroplasties were analyzed, including 900 total revisions, 171 large partial revisions (revision of either femoral or tibia component) and 368 revisions of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA). Mean age was 65 years (SD 10.9) and 66% were females. Mean LOS was 3.7 days (SD 3.9) in the study period, but decreased to 2.4 days (SD 1.3) in 2018. Risk factors for LOS > 5 days was ≥ 1 previous revision, use of walking aid, BMI > 35, ages < 50, 70-79 and ≥ 80 years, whereas revision of UKA to TKA and large partial revision were negatively associated. The 90-day readmission and mortality risk was 9.1% and 0.5%. Cardiac disease and use of walking aid were associated with increased risk of readmission ≤ 90 days.

CONCLUSION

Elective aseptic major component revision knee arthroplasty using similar fast-track protocols as in primary TKA is safe with short and decreasing LOS.

Preoperative BMD does not influence femoral stem subsidence of uncemented THA when the femoral T-score is > -2.5

Background and purpose - It is believed that in uncemented primary total hip arthroplasty (THA) the anchorage of the stem is dependent on the level of bone mineral density (BMD) of the femoral bone. This is one of the reasons for the widely accepted agreement that a cemented solution should be selected for people with osteoporosis or age > 75 years. We evaluated whether preoperative BMD of the femur bone is related to femoral stem migration in uncemented THA.Patients and methods - We enrolled 62 patients (mean age 64 years (range 49-74), 34 males) scheduled for an uncemented THA. Before surgery we undertook DEXA scans of the proximal femur including calculation of the T- and Z-scores for the femoral neck. Evaluation of stem migration by radiostereometric analysis (RSA) was performed with 24 months of follow-up. In 56 patients both preoperative DEXA data and RSA data were available with 24 months of follow-up.Results - None of the patients had a T-score below -2.5. We found no statistically significant relationship between preoperative BMD and femoral stem subsidence after 3 or 24 months. When comparing the average femoral stem subsidence between 2 groups with T-score > -1 and T-score ≤ -1, respectively, we found no statistically significant difference after either 3 or 24 months when measured with RSA.Interpretation - In a cohort of people ≤ 75 years of age and with local femur T-score > -2.5 we found no relationship between preoperative BMD and postoperative femoral stem subsidence of a cementless THA.

Migration of the uncemented Echo Bi-Metric and Bi-Metric THA stems: a randomized controlled RSA study involving 62 patients with 24-month follow-up

Background and purpose - Despite the good results after total hip arthroplasty (THA), new implants are continuously being developed to improve durability. The Echo Bi-Metric (EBM) THA stem is the successor to the Bi-Metric (BM) THA stem. The EBM stem includes many of the features of the BM stem, but minor changes in the design might improve the clinical performance. We compared the migration behavior with radiostereometric analysis (RSA) of the EBM stem and the BM stem at 24 months and evaluated the clinical outcome. Patients and methods - We randomized 62 patients with osteoarthritis (mean age 64 years, female/male 28/34) scheduled for an uncemented THA to receive either an EBM or a BM THA stem. We performed RSA within 1 week after surgery and at 3, 6, 12, and 24 months. The clinical outcome was evaluated using Harris Hip Score (HHS) and Oxford Hip Score (OHS). Results - At 24 months, we found no statistically significant differences in migration between the two implants. During the first 3 months both the EBM and the BM stems showed visible subsidence (2.5 mm and 2.2 mm respectively), and retroversion (2.5° and 2.2° respectively), but after 3 months this stabilized. The expected increase in HHS and OHS was similar between the groups. Interpretation - The EBM stem showed a migration at 24 months not different from the BM stem, and both stems display satisfying clinical results.

Observational study of a new modular femoral revision system

BACKGROUND

The uncemented Arcos^TM Modular Femoral Revision System (ARCOS) is a new comprehensive, press-fit revision design. The modular design offers a wide range of possible combinations to accommodate different variations of anatomy and bone stock. The ARCOS is made by a proximal body and a distal stem. As probably the only ones worldwide we predominantly use a combination of body and stem which supports proximal fixation and load, since this mimics the concept of the primary total hip arthroplasty with proximal weight-bearing, leading to bone stock preservation and no stress shielding or thigh pain.

AIM

To evaluate the early results after femoral revision in a consecutive series of patients undergoing surgery over 3 years.

METHODS

We included 116 patients in the study. They were operated in the period August 2011 to December 2014 and we got a clinical mean observation time of 4 (0.5-6) years. Clinical and radiographical follow-up included present function of the hip assessed by Harris Hip Score, Oxford Hip Score, and EQ5D (measure of health outcome). Of the 116 patients, 17 died in the interim and were consequently included only in the implant survivorship analysis; 46 patients attended the follow-up control.

RESULTS

In total 6 (5%) hips were re-revised due to infection (n = 3), fracture (n = 2) or subsidence (n = 1). No patient was re-revised due to aseptic loosening. The 1-, 2- and 5-year probability of implant survival (95%CI) were 97% (93%-100%), 97% (93%-100%) and 96% (92%-99%), respectively. In this cohort 95 patients received a combination of a proximal broach and a distal curved and slotted stem (BS), aiming for proximal fixation and load bearing; 21 patients received a different combination. When comparing these two groups the BS-group had a 5-year implant survival probability (95%CI) of 97% (93%-100%) compared with the group of other combinations with a 5-year implant survival probability (95%CI) of 90% (78%-100%) (P = 0.3). Our regression analysis showed that periprosthetic fracture as an indication for the ARCOS operation was the only significant negative outcome predictor. The mean Harris Hip Score result (100 points being best) was 83 (range 5-98). The mean Oxford Hip Score result (48 points being best) was 40 (range 19-48).

CONCLUSION

The early results of the ARCOS are promising compared with similar studies. We encourage the use of the BS combination whenever the bone stock proximally is adequate.

Incidence and Risk Factors for Stroke in Fast-Track Hip and Knee Arthroplasty-A Clinical Registry Study of 24,862 Procedures

BACKGROUND

Postoperative stroke is a severe complication with a reported 30-day incidence of 0.4%-0.6% after total hip (THA) and knee arthroplasty (TKA). However, most data are based on diagnostic codes and with limited details on perioperative care, including the use of fast-track protocols. We investigated the incidence of and preoperative and postoperative factors for stroke after fast-track THA/TKA.

METHODS

We used an observational study design of elective fast-track THA/TKA patients with prospective collection of comorbidity and complete 90-day follow-up. Medical records were evaluated for events potentially disposing to stroke. Identification of relevant preoperative risk factors was done by multivariable logistic regression. Incidence of stroke was compared with a Danish background population.

RESULTS

Of 24,862 procedures with a median length of stay of 2 (interquartile range, 2-3) days, we found 27 (0.11%; 95% confidence interval [CI], 0.08%-0.16%) and 43 strokes (0.17%, 95% CI, 0.13%-0.23%) ≤30 and ≤90 days after surgery, respectively. Preoperative risk factors for stroke ≤30 days were age ≥ 85 years (odds ratio [OR], 4.3; 95% CI, 1.1-16.3) and anticoagulant treatment (OR, 3.1; 95% CI, 1.2-7.9). Preoperative anemia was near significant (OR, 2.1; 95% CI, 0.98-4.6, P = .055). Eight strokes ≤30 days were preceded by a cardiovascular event within the second postoperative day. Incidence of stroke after postoperative day 30 was similar to a Danish background population.

CONCLUSION

Risk of postoperative stroke in fast-track THA and TKA was low but may be further reduced with increased focus on avoiding perioperative cardiovascular events and in patients with preoperative anticoagulants or anemia.

Incidence and related factors for intraoperative failed spinal anaesthesia for lower limb arthroplasty

BACKGROUND

Spinal anaesthesia is the preferred choice for total hip- and knee arthroplasty (THA/TKA), due to the claimed superior outcome profile, relative simple technique and without the need for advanced airway support. However, choosing and informing about spinal anaesthesia should also include the risk for intraoperative failed spinal anaesthesia with associated pain, discomfort and suboptimal settings for airway management. Small-scale studies suggest incidences from 1 to 17%; however, no multi-institutional large data exists on failed spinal incidence and related factors during THA/TKA, hindering evidence-based information and potential anaesthesia stratification.

METHODS

In a sub-analysis, data from a prospective study on spinal anaesthesia for THA/TKA were examined for incidence of intraoperative conversion to general anaesthesia. Potential perioperative factors (age, gender, American Society of Anaesthesiologist (ASA) score, height, weight, BMI, procedure, bupivacaine dosage and duration of time from spinal administration until end of surgery) were analysed with logistic regression for relation to failed spinal anaesthesia.

RESULTS

In all, 1451 patients were included for analysis, whereof 57 (3.9%) had failed spinal anaesthesia. Spinal failure patients were significantly younger (61 vs. 67 years, P = 0.003), and operation time longer in the failed spinal group vs no-failure, respectively (133 vs. 89 min, P < 0.001). No significant differences were found with regard to bupivacaine volume, gender, ASA-score, height, weight, BMI or THA vs. TKA.

CONCLUSION

Failed spinal anaesthesia for THA and TKA is a relatively frequent occurrence and identification of risk patients is not feasible. These results should be considered when choosing anaesthesia and included in the information to patients.

Cementless One-Stage Revision in Chronic Periprosthetic Hip Joint Infection. Ninety-One Percent Infection Free Survival in 56 Patients at Minimum 2-Year Follow-Up

BACKGROUND

Cementless 1-stage revision in chronic periprosthetic hip joint infections is limited evaluated. The purpose of this study was to evaluate a specific treatment protocol in this patient group.

METHODS

The study was performed as a multicenter, proof-of-concept, observational study with prospective data collection. Patients were treated with a cementless 1-stage revision according to the CORIHA protocol between 2009 and 2014. Fifty-six patients, McPherson type III-A/B-1/2, were enrolled with a mean follow-up time from the CORIHA procedure of 4 years (minimum of 2 years). The primary outcome was re-revision performed due to infection and was evaluated by competing risk analysis, with death and aseptic revision as competing events. All-cause mortality was evaluated by Kaplan-Meier survival analysis. Oxford Hip Score (OHS) was used as disease-specific patient-reported outcome measure.

RESULTS

The cumulative incidence of re-revision due to infection was 8.9% (confidence interval [CI] 3.2%-18.1%). The 1-year and 5-year survival incidence was 96% (CI 86%-99%) and 89% (CI 75%-95%). OHS at baseline was 19.9 (CI 17.3-22.6) and at 24-month follow-up 35.1 (CI 31.7-38.5). The mean change in OHS from baseline to 24-month follow-up was 11.8 points (CI 7.3; 16.3). Three patients had aseptic revision performed: two suffered periprosthetic fractures and one had stem subsidence. Failure analysis of the 5 reinfections did not detect a clear pattern as to the cause of failure.

CONCLUSION

We found that cementless 1-stage revision in chronic periprosthetic hip joint infections has low reinfection rates in selected patients and may be applicable as a first-line treatment.

Increased risk of intraoperative and early postoperative periprosthetic femoral fracture with uncemented stems

Background and purpose - The use of uncemented fixation in total hip arthroplasty (THA) is increasing. Registry studies have indicated an increased risk of revision of uncemented implants due to early periprosthetic femoral fracture. In this paper, we describe the incidence and predisposing factors for intraoperative and early postoperative (≤ 90 days) periprosthetic femoral fractures after cemented and uncemented THA. Patients and methods - This was a prospective observational study in 8 Danish high-volume centers from February 2010 to November 2013. We used the 90-day follow-up from the Danish National Patient Registry and patient records. We obtained intraoperative information from the Danish Hip Arthroplasty Registry and from surgical notes. Results - Of 7,169 primary consecutive THAs, 5,482 (77%) were performed using uncemented femoral components. The total incidence of periprosthetic femoral fractures ≤ 90 days postoperatively was 2.1% (n = 150). 70 fractures were detected intraoperatively (46 required osteosynthesis). 51 postoperatively detected fractures occurred without trauma (42 of which were reoperated) and 29 were postoperative fall-related fractures (27 of which were reoperated). 134 fractures (2.4%) were found in uncemented femoral components and 16 (0.9%) were found in cemented femoral components (p < 0.001). Uncemented femoral stem (relative risk (RR) = 4.1, 95% CI: 2.3-7.2), medically treated osteoporosis (RR =2.8, CI: 1.6-4.8), female sex (RR =1.6, CI: 1.1-2.2), and age (RR =1.4 per 10 years, CI: 1.2-1.6) were associated with increased risk of periprosthetic femoral fracture when analyzed using multivariable regression analysis. Interpretation - Uncemented femoral components were associated with an increased risk of early periprosthetic femoral fractures, especially in elderly, female, and osteoporotic patients.

A Pilot Study of the Effects of Vivostat Patient-derived Fibrin Sealant in Reducing Blood Loss in Primary Hip Arthroplasty

A pilot study evaluated the effectiveness of Vivostat patient-derived fibrin sealant in reducing blood loss in patients who underwent primary hip arthroplasty. Eighty adult patients undergoing elective surgery were randomized to receive either Vivostat sealant or control (no additional hemostatic treatment). Patients allocated Vivostat sealant donated 120 mL of blood, which was then processed perioperatively to produce a fibrin sealant that was applied to the bleeding wound surfaces just before closure. Transfusion requirements, blood loss during surgery, drain volumes, and daily hematocrit and hemoglobin levels were measured. Hospitalization times, adverse events, and postoperative wound complications were also monitored. Blood loss during surgery and wound drainage volume was lower in the Vivostat group than in the control group, although the differences were not significantly different. Transfusion requirements (median, 270 mL of packed red blood cells) and hospitalization times (both median 7 days) were the same for both groups. No adverse events related to the use of Vivostat occurred. There were indications of a possible reduction in the incidence of postoperative wound oozing (15% vs 25%) and hematomas (6% vs 11%) with the use of Vivostat compared with the control group, although differences were not statistically significant. In conclusion, in this pilot study, use of Vivostat patient-derived fibrin in hip arthroplasty was not associated with a significant reduction in blood loss. Further studies, with larger numbers of patients, may be warranted to investigate a possible benefit of Vivostat in reducing postoperative wound complications.

Renal function after elective total hip replacement

Background and purpose - Acute kidney injury (AKI) is associated with increased short-term and long-term mortality in intensive care populations and in several surgical specialties, but there are very few data concerning orthopedic populations. We have studied the incidence of AKI and the prevalence of chronic kidney disease (CKD) in an elective population of orthopedic patients undergoing primary total hip replacement, hypothesizing that chronic kidney disease predisposes to AKI. Patients and methods - This was a single-center, population-based, retrospective, registry-based cohort study involving all primary elective total hip replacements performed from January 2003 through December 2012. Patient demographics and creatinine values were registered. We evaluated the presence of CKD and AKI according to the international guidelines for kidney disease (KDIGO Acute Kidney Injury Workgroup 2013 ). Results - 3,416 patients were included (2,064 females (60%)). AKI (according to KDIGO criteria) was seen in 75 patients (2.2%, 95% CI: 1.7-2.7) in the course of primary total hip replacement. Of these, 26 had pre-existing CKD of class 3-5. Pre-existing CKD of class 3-5, indicating moderately to severely reduced kidney function, was seen in 374 individuals (11%). Interpretation - Development of acute kidney injury appears to be a substantial problem compared to other complications related to elective total hip arthroplasty, i.e. luxation and infection. Patients with pre-existing chronic kidney disease may be especially vulnerable. The clinical impact of acute kidney injury in an elective orthopedic population remains to be elucidated.

Postoperative anemia and early functional outcomes after fast-track hip arthroplasty: a prospective cohort study

BACKGROUND

Postoperative anemia is prevalent in fast-track hip arthroplasty (THA) where patients are mobilized and discharged early, but whether anemia impairs functional recovery after discharge has not been adequately evaluated previously. This study aimed to evaluate whether postoperative anemia influenced recovery of mobility and quality of life (Qol) during the first 2 weeks after discharge from THA.

STUDY DESIGN AND METHODS

This was a prospective observational study in 122 THA patients more than 65 years of age. Mobility and Qol were assessed pre- and postoperatively by the 6-minute walk test (6MWT; primary outcome), the timed up-and-go test, and the FACT-anemia subscale. Twenty-four-hour mobility at home was assessed by activity monitoring on Days 1 to 6 after discharge. Hemoglobin (Hb) at discharge (HbD) and the Hb decrease from preoperatively (ΔHb) were compared to mobility and Qol the first 2 weeks after discharge using bivariate and multivariate linear regression.

RESULTS

Mean (±SD) HbD and ΔHb values were 11.1 (±1.4) and 2.8 (±1.2) g/dL and correlated weakly to 6MWT 2 weeks after discharge (r = 0.23 and r = -0.20 respectively; p < 0.05) but HbD levels were not correlated to other mobility or Qol measures. After adjustment for preoperative patient-related factors, HbD explained 6% (95% confidence interval, 0%-9%; p < 0.05) of the variation in 6MWT recovery.

CONCLUSION

Despite a weak, but significant, correlation between postoperative Hb and the recovery of 6MWT, all other mobility and Qol measures were not influenced by postoperative Hb. Thus, moderate postoperative anemia has limited impact on early postdischarge functional recovery after fast-track THA.

Nurse-led telephone follow-up after total knee arthroplasty--content and the patients' views

AIM AND OBJECTIVES

To generate information on how telephone follow-up consultations, structured by nursing status according to the VIPS-model, functioned after total knee arthroplasty. The objectives were to unfold the content of the telephone follow-ups according to the structure for nursing status and to explore the patients' views of the telephone follow-ups.

BACKGROUND

The length of stay in hospital following total knee arthroplasty has fallen markedly, and patients now have to be responsible for their recovery from a very early stage. After discharge, patients may experience a variety of health problems. A clinical trial was conducted to evaluate the effect of telephone follow-up, and information on how the telephone follow-ups functioned is relevant for implementation into clinical practice.

DESIGN

A qualitative design was used.

METHOD

One hundred and four case reports from telephone follow-up consultations and individual interviews with 10 patients formed the data material. Content analysis was used for the analysis.

RESULTS

The content of the telephone follow-ups included dialogues relating to all key subjects for nursing status except 'culture/spirituality'. The structured Telephone follow-up was valued by total knee arthroplasties patients as representing a holistic approach and providing adequate information, counselling and support after discharge to home. Three categories were identified with regard to the patients' views: 'A means for reflection and provision of adequate information and counselling', 'Supportive' and 'Not the only resource for support and counselling'.

CONCLUSION

Nursing status according to the VIPS model is a comprehensive structure to identify the need for counselling, information and support after total knee arthroplasty. The structured telephone follow-ups were valued for representing a holistic approach and providing adequate information, counselling and support after discharge to home. Conducting telephone follow-up with a holistic approach demands specialised and broad nursing experience.

RELEVANCE TO CLINICAL PRACTICE

Postdischarge follow-up is important.

Re-admissions, re-operations and length of stay in hospital after aseptic revision knee replacement in Denmark: a two-year nationwide study

We present detailed information about early morbidity after aseptic revision knee replacement from a nationwide study. All aseptic revision knee replacements undertaken between 1st October 2009 and 30th September 2011 were analysed using the Danish National Patient Registry with additional information from the Danish Knee Arthroplasty Registry. The 1218 revisions involving 1165 patients were subdivided into total revisions, large partial revisions, partial revisions and revisions of unicondylar replacements (UKR revisions). The mean age was 65.0 years (27 to 94) and the median length of hospital stay was four days (interquartile range: 3 to 5), with a 90 days re-admission rate of 9.9%, re-operation rate of 3.5% and mortality rate of 0.2%. The age ranges of 51 to 55 years (p = 0.018), 76 to 80 years (p < 0.001) and ≥ 81 years (p < 0.001) were related to an increased risk of re-admission. The age ranges of 76 to 80 years (p = 0.018) and the large partial revision subgroup (p = 0.073) were related to an increased risk of re-operation. The ages from 76 to 80 years (p < 0.001), age ≥ 81 years (p < 0.001) and surgical time > 120 min (p < 0.001) were related to increased length of hospital stay, whereas the use of a tourniquet (p = 0.008) and surgery in a low volume centre (p = 0.013) were related to shorter length of stay. In conclusion, we found a similar incidence of early post-operative morbidity after aseptic knee revisions as has been reported after primary procedures. This suggests that a length of hospital stay ≤ four days and discharge home at that time is safe following aseptic knee revision surgery in Denmark.

Hip dislocations after 2,734 elective unilateral fast-track total hip arthroplasties: incidence, circumstances and predisposing factors

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To investigate the incidence of hip dislocation 90 days after total hip arthroplasty in relation to time after surgery, mechanism of dislocation and predisposing factors.

METHODS

Prospective data on preoperative patient characteristics from six Danish arthroplasty departments with similar fast-track approaches were cross-referenced with the Danish National Patient Registry for complete 90-day follow-up on readmissions, including emergency-room contacts. Complete patient files and postoperative radiographs were reviewed in case of dislocations. Unadjusted comparisons were made using t test/Chi-square analyses, while evaluation of risk factors potentially predisposing to dislocations was done using uni- and multivariate regression analysis.

RESULTS

A total of 2,734 consecutive unselected procedures were available for analysis, of which 65 (2.4 %) had dislocations. Of these, eight were during index admission and five were treated and discharged from the emergency room. Mechanisms of dislocation were most often movement while supine or sitting for the first 30 days and due to squatting/bending from day 31 to 90. The 65 patients with dislocations had suboptimal cup placement in 34 (52.3 %), and a femoral head size of <36 mm in 20 (30.8 %) cases. Predisposing factors of dislocation were age ≥75 [OR:1.96 (1.18-3.38)], pharmacologically treated psychiatric disease [OR:2.37 (1.29-4.36)] and department of surgery [OR:2.27 (1.31-3.40)] but not hospital stay of <4 days. Departments with recommendations for activity restrictions had fewer dislocations than a department without restrictions.

CONCLUSIONS

Patients ≥75 years and with pharmacologically treated psychiatric disease may be at increased risk of dislocations after fast-track total hip arthroplasty. Further studies including detailed information on patient and prosthesis characteristics, and activity restrictions are needed to reduce the risk of dislocation.

Early morbidity after aseptic revision hip arthroplasty in Denmark

Data on early morbidity and complications after revision total hip replacement (THR) are limited. The aim of this nationwide study was to describe and quantify early morbidity after aseptic revision THR and relate the morbidity to the extent of the revision surgical procedure. We analysed all aseptic revision THRs from 1st October 2009 to 30th September 2011 using the Danish National Patient Registry, with additional information from the Danish Hip Arthroplasty Registry. There were 1553 procedures (1490 patients) performed in 40 centres and we divided them into total revisions, acetabular component revisions, femoral stem revisions and partial revisions. The mean age of the patients was 70.4 years (25 to 98) and the median hospital stay was five days (interquartile range 3 to 7). Within 90 days of surgery, the readmission rate was 18.3%, mortality rate 1.4%, re-operation rate 6.1%, dislocation rate 7.0% and infection rate 3.0%. There were no differences in these outcomes between high- and low-volume centres. Of all readmissions, 255 (63.9%) were due to ‘surgical’ complications versus 144 (36.1%) ‘medical’ complications. Importantly, we found no differences in early morbidity across the surgical subgroups, despite major differences in the extent and complexity of operations. However, dislocations and the resulting morbidity represent the major challenge for improvement in aseptic revision THR.

Cite this article: Bone Joint J 2014; 96-B:1464–71.

Telephone follow-up by nurse following total knee arthroplasty - protocol for a randomized clinical trial (NCT 01771315)

BACKGROUND

Due to shorter hospitalization, patients have to take responsibility for their rehabilitation period at a very early stage. The objective of this trial is to study the effects of two treatment schemes following total knee arthroplasty: conventional treatment following discharge from hospital and early follow-up by telephone consultations in addition to conventional treatment following discharge from hospital. The ultimate aim is to increase the effectiveness of the treatment by improving patients' health status, promote self-efficacy, and reduce the number of acute visits to the orthopaedic outpatient clinic during the rehabilitation period.

METHOD/DESIGN

The design is a randomized un-blinded parallel group clinical trial conducted at the Department of Orthopaedic Surgery, Gentofte Hospital, the Capital Region of Denmark. In total, 116 patients will be allocated by an external randomization program to 2 groups: an intervention group following usual treatment after discharge supplemented by a nurse managed structured follow-up consultation conducted by telephone 4 and 14 days after discharge from hospital and a control group following treatment as usual. The consultations are structured by key subjects relevant to assess the health status according to the VIPS-model (the Swedish acronym for the concepts Well-being, Integrity, Prevention and Safety). The content of the consultations can vary according to the patients´ individual situations and needs. All consultations are conducted by the researcher responsible for the trial. The effect is measured 1, 3, 6 and 12 months post-surgery. The primary outcome is self-reported physical function measured by The Western Ontario and McMaster Universities Arthritis Index. Secondary outcomes are self-reported health-related quality of life, general self-efficacy and the number of acute visits to the orthopaedic outpatient clinic.

DISCUSSION

The result of this trial is expected to provide new knowledge to support the development of targeted and effective follow-up after total knee arthroplasty in order to improve the patients´ health-related knowledge and skills of being able to take actively part in their illness and improve their health status.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01771315.

Increased risk for early periprosthetic fractures after uncemented total hip replacement

INTRODUCTION

The purpose of this study was to describe a new type of proximal periprosthetic fracture occurring within the first six weeks after total hip arthroplasty and to analyse possible causes of a rising incidence.

MATERIAL AND METHODS

Patient files and radiographs from 2,408 uncemented hip replacements were analysed and patients with a periprosthetic split fracture reaching from the calcar to the medial femoral shaft below the lesser trochanter were included.

RESULTS

A total of 28 fractures in 2,408 uncemented primary hip replacements were included. Almost all fractures were seen in women. No correlation with diagnosis, age, body mass index, operation time, operative technique or implant position could be demonstrated, but a possible correlation with post-operative mobilisation and pain treatment was observed. Trainees had more fractures than experienced surgeons (non-significant).

CONCLUSION

We conclude that the increasing use of uncemented hip replacements implies an increasing risk of perioperative femoral fracture. The cause of the fractures remains unclear, but is probably multifactorial.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Care principles at four fast-track arthroplasty departments in Denmark

INTRODUCTION

The goal of this study was to describe the logistic and clinical set-up at four Danish arthroplasty departments offering fast-track surgery.

MATERIAL AND METHODS

Based on the National Patient Registry's information on patients who have undergone total hip and knee arthroplasty, four departments were chosen for evaluation in accordance with the following inclusion criteria: documented fast-track surgery with written care plans, a surgical volume of > 450 arthroplasties and short length of stay (LOS) (< 5 days).

RESULTS

The mean LOS ranged from 2.8 to 3.9 days. Logistic features included homogeneous entities, regular staff, high level of continuity, preoperative information including intended LOS, admission on the day of surgery and functional discharge criteria. The clinical features were both intraoperative (spinal anaesthesia, local infiltration analgesia, plans for fluid therapy, small standard incisions, no drains, compression bandages and cooling) and postoperative (deep venous thrombosis prophylaxis starting 6-8 hours postoperatively, multimodal opioid-sparing analgesia, early mobilisation and discharge when functional criteria were met) facilitating early rehabilitation and discharge.

CONCLUSION

The logistic set-up at the four departments was almost identical. The basic care prerequisites to pooling the patients from these four departments were in place. Future studies will include outcomes as well as safety aspects of this set-up.

The cementless AGC 2000 knee prosthesis: 20-year results in a consecutive series

One hundred and fourteen AGC 2000 porous-coated cementless total knee arthroplasties were performed in 102 patients between 1984 and 1986. We report their 20-year results with patient assessment, Hospital for Special Surgery knee score, weight-bearing radiographs done under fluoroscopic control and survivorship analyses. All patients could be accounted for. With prosthesis revision as a failure criterion, the cumulative survival rate of all prosthetic components at 20 years was 84.4%. The fall in success rate was primarily due to early tibial and late patellar component failure. The cumulative survival rate of the tibial component was 97.2% and that of the femoral component was 100% at 20 years.

Femoral revision with impaction allografting and an uncemented femoral component

A technique for uncemented revision of the femoral component which combines impaction allografting and the use of a long-stemmed proximally coated titanium prostheses (Bimetric, Biomet Inc.) is described. The results after a mean follow-up of 112 months are reported. From 1991 to 1995 femoral component revision for aseptic loosening was performed on 100 hips. In 14 cases (14%) an intraoperative fracture occurred and 7 patients (7%) had other postoperative complications. Seventeen patients (17%) required further revision, 10 because of aseptic loosening. Of 50 surviving patients with retained implants 88% had no pain, 10% had slight pain and only 2% had severe pain. Thirty-eight patients had radiographic signs of remodelling of the graft and/or cortical repair. In cases with a successful outcome, the results have been encouraging in relation to clinical performance, regeneration of bone and implant survival.

[Polyphalangism--a rare anomaly]

Polyphalangism/hyperphalangism is a very rare autosomal dominant anomaly. Polyphalangism is characterized by an extra phalanx between two other phalanges. The abnormality is distinguished from polydactyly in that there are more phalanges in a finger but no more than five fingers to a hand. Polyphalangism can be part of various syndromes, but isolated polyphalangism is very rarely seen. We report the first case of polyphalangism/hyperphalangism in the Danish literature.

[Randomized comparison of CAM walker and light-weight plaster cast in the treatment of first-time Achilles tendon rupture]

INTRODUCTION

The aim of this study was to compare a CAM walker to a traditional cast. We expected the CAM walker to be comparable.

MATERIAL AND METHODS

Fifty patients with a first time rupture of the Achilles tendon were randomised to either a cast or a CAM walker. Both groups were immobilised for eight weeks. All patients were examined four and 12 months after the injury.

RESULTS

We found five reruptures in 29 patients treated with a cast (17%). No reruptures occurred in 21 patients treated with a CAM walker. The difference was not statistically significant (p = 0.066). There was no difference in age, sex, patient satisfaction, dominant/non dominant leg, muscle strength, or range of motion.

DISCUSSION

The CAM walker is a useful alternative to a cast, with few complications and lower costs. Owing to the risk of type two error (44%), it is possible that we could have found a significant difference in the number of reruptures if the number of patients had been larger.

Cementless porous-coated total knee arthroplasty: 10-year results in a consecutive series

We report the results of 114 AGC 2000 porous-coated, cementless total knee arthroplasties (TKA) performed consecutively in 102 patients during the period 1984-1986. After 10 years, 58 TKAs in 52 patients were evaluated with patient assessment, Hospital for Special Surgery knee score, weight-bearing radiographs done under fluoroscopic control, and survivorship analysis. All dropouts within the first 9 years were patients dying with a functioning TKA except 1 revision secondary to a supracondylar fracture after 8.5 years. Of the patients, 53 (92%) were satisfied or very satisfied with their TKA, and 55 (95%) of the knees were rated good or excellent. There was no pain in 53 knees, and the median knee flexion was 110 degrees. Six radiolucencies >1 mm were found beneath parts of the tibial component, and 5 radiolucencies were seen beneath the femoral component. None had progressed compared with the 5-year follow-up, and in all cases trabeculae could be seen reaching the prosthetic component. No migrations had occurred since the 5-year follow-up. No obvious joint space reduction was seen. Osteolysis presenting as an isolated cyst was found in 1 knee in the lateral tibial condyle and was not progressive. Two tibial components had been revised because of aseptic loosening and 1 because of septic loosening, all within the first 3 years. No femoral or patellar components were revised. The cumulative prosthesis survival rate after 10 to 11 years was 97%. When pain and radiographic loosening also were considered, the success rate was 87%. Cementless insertion of a nonmodular, porous-coated TKA resulted in a long-term durable bone-prosthesis interface. The flat-on-flat articulation did not result in catastrophic polyethylene wear or osteolysis within the first 10 years.

The hemispherical Harris-Galante acetabular cup, inserted without cement. The results of an eight to eleven-year follow-up of one hundred and sixty-eight hips

We studied the results for 168 available hips from a series of 324 consecutive primary total hip arthroplasties that had been performed with insertion of a Harris-Galante-I acetabular component without cement. The acetabulum had been reamed in a so-called line-to-line manner, and the cup had been fixed with one to four screws. A femoral component with a modular alumina-ceramic head had been inserted with cement in all hips. The median duration of follow-up was 112 months (range, 101 to 131 months). Of the original 324 hips, 109 could not be included in the clinical and radiographic follow-up because the patients had died and thirty could not be included because the patients were not available for examination. Seventeen hips had had a revision of the acetabular cup: five, because of infection; five, because of dislocation; three, because of aseptic loosening; and four, because of technical failure. This left 168 hips for clinical and radiographic follow-up; of these, fifteen had had a revision of the femoral component only. Of the remaining 153 hips, which had not had a revision, 147 (96 percent) were considered by the patient to have a satisfactory, good, or excellent result. One hip was found to have a loose cup on radiographic evaluation and was therefore considered to have failed, but the clinical function was good. We concluded that, with an overall rate of aseptic loosening of 1 percent (four of 324) after an intermediate (ten-year) duration of follow-up, use of this cup has good results.

[Non-cemented acetabular cup in hip arthroplasty. Prosthesis survival and clinical results after 1-8 years]

This is a retrospective clinical evaluation of 1028 primary hip arthroplasties performed with the non-cemented Harris-Galante I acetabulaer cup. Hospital records regarding all hips operated from July 1985 through March 1992 were evaluated after a median of 48 (12-93) months. Furthermore, questionnaires were sent out to all patients still alive in order to establish the actual function of the hips. At time of evaluation, 43 of the 1028 primary acetabular cups (4.2%) had been or were due to be revised. (20 because of one or more episodes of dislocation or displacement of the cup, 10 due to deep infection, eight following aseptic loosening of the cup, two because of implant failure and three due to other reasons). Four hundred and twenty-six hips were without pain, 274 had only mild or slight pain, whereas 84 experienced moderate or worse pain. We conclude, that the results after non-cemented hemispheric acetabular arthroplasties in this study are satisfying with a low rate of aseptic loosening.

[Increasing incidence of clubfoot in the county of Frederiksborg]

The incidence of congenital clubfoot in Frederiksborg County, Denmark, was studied over a period of 16 years (1979-1994). Altogether 60, 186 live infants were born, and of these 72 had a congenital clubfoot. Twenty-five children (35%) had bilateral clubfoot and 54 (75%) were boys. The overall incidence was 1.20 per thousand children. The incidence increased significantly during the observation period and was 2.41 per thousand in 1994. We cannot explain the rise in incidence.

Evaluation of 100 Müller curved-stem and 276 Müller long-stem total hip arthroplasties after 10 to 15 years of follow-up

This study evaluates 376 total hip arthroplasties performed between 1978 and 1983 using 276 Müller long-stem and 100 Müller curved-stem prostheses. Demographic and clinical data were obtained from patient records. All patients still alive who did not undergo revision arthroplasty were sent a detailed questionnaire. Results indicated that long-term survival of the femoral component of the arthroplasty was significantly better when the Müller long-stem was used. Furthermore, there was no difference in the clinical out-come between patients who underwent revision and those who did not. To eliminate demographic differences between the two groups, 77 patients from each group were paired. There was no difference in clinical results of the hips between the paired groups, and long-term survival of the Müller long-stem was still significantly better using Kaplan-Meier analysis.

Survival of autotransfused red cells. 51Cr studies in 10 knee arthroplasty patients

We determined the long-term survival of red blood cells collected postoperatively from the surgical drains, filtered and autotransfused with the Constavac Blood Conservation System. 10 patients with knee arthrosis were treated with cementless total knee arthroplasty and postoperatively connected to the autotransfusion system. Shed blood was collected for 6 hours postoperatively and then reinfused. Before reinfusion, a fraction of the blood shed was radiolabeled with chromium-51 (51Cr). For a postoperative minimum period of 40 days the activity of 51Cr was measured in frequent venous blood samples. The time from 100% to 50% activity of the isotope (T50Cr) was 21 days, equal to that reported for banked autologous blood.

Late disassembly of modular acetabular components. A report of two cases

We report two cases of late disassembly of modular acetabular components, 4 and 5 years after implantation. One was revised immediately after the disassembly and one after 4 months, the latter demonstrating excessive wear of metal and polyethylene. Radiographs showing eccentric displacement of the femoral head in the cup associated with a dark, curved shadow representing the displaced polyethylene insert identify this type of implant failure.

Older's classification of Colles' fractures. Good intraobserver and interobserver reproducibility in 185 cases

To evaluate the reliability of the Older classification, 4 observers classified 185 distal radius fractures twice with 1 month's interval. Both the intraobserver agreement and the interobserver agreement were high, with kappa values of 0.75 (0.69-0.79) and 0.69 (0.60-0.77), respectively. The agreement was especially high for type 1 and type 4 fractures. Older's method of classifying distal radius fractures can thus be recommended for clinical use.

Displaced distal radius fractures. A comparative study of early results following external fixation, functional bracing in supination, or dorsal plaster immobilization

A comparison of the radiographical and functional results after displaced distal radius fractures in 41 patients treated by external fixation (EF), 36 patients treated by functional bracing in supination (FUSU), and 49 patients treated by dorsal plaster immobilization (DPI) was performed. The rate of initial complications after EF was 53%, compared with 22% after FUSU and 14% after DPI. The radiographical result after EF was significantly better than after nonoperative treatment, but the functional result after 3 and 6 months demonstrated no significant difference between the three series. Consequently, EF and FUSU do not restore wrist function faster than conventional plaster treatment (DPI), but EF improves the radiographical result, though the rate of complications is higher.

Displaced diaphyseal forearm fractures in children: classification and evaluation of the early radiographic prognosis

In a retrospective study of 70 children with 73 diaphyseal forearm fractures, we measured the radiographic angulation and sideways displacement initially, after reduction, at 1 week and at union. Statistical analysis was performed with a multivariate log linear regression model to evaluate the correlation between variables. We showed that the initial displacement of the fracture and the age of the patient had only a minor influence on the position at union. We constructed a classification system using the measurements initially, after reduction, and at 1 week and showed that the prognostic value of the classification system could be improved during the period of treatment. We recommend that all displaced diaphyseal forearm fractures in children should be radiographed after 1 week and after 2 weeks.

External fixation or a cast for Colles' fracture

Function and radiographic position were evaluated 2.5 years after a displaced distal radial fracture had been reduced and treated by external fixation in 40 patients as compared with immobilization in a below-the-elbow cast in 91 patients. Wrist function was better after external fixation associated with less residual displacement. The frequency of arthrosis was the same in both series. The rate of complications after external fixation was higher than after immobilization in a plaster cast, notably sensory disturbances in the thumb. This complication can probably be eliminated by modifying the surgical technique.

Osteoarthritis after Colles' fracture

Fifty-six patients with displaced Colles' fractures were examined 7 years after fracture. Slight radiographic changes of osteoarthritis were seen in 17 cases, moderate changes in 7 cases, and severe arthrosis in 1 case. At follow up, the occurrence of osteoarthritis was not related to radial shortening or residual dorsal angulation; it did show, however, a high correlation to the initial displacement of the fracture and the age of the patient. Radiographic osteoarthritis also influenced the function of the wrist, especially in the older patients.

Total hip replacement in patients aged 80 years and older

Total hip replacement was performed in 27 patients aged 80 years and older. In the early postoperative period, medical complications occurred in 13 patients and arthroplasty-related complications in 5 patients. At the time of the follow-up, after an average of 31 months, there was one case of acetabular cup loosening, which was revised. Twenty of 22 patients were free from pain at rest, and the social function of the patients had remained almost unchanged.

Function after distal radius fracture

Follow-up of 154 patients 3.5 years after a distal radius fracture treated by reduction and immobilization in plaster demonstrated that the initial displacement influenced their function. The classification of Older et al. (1965) was prognostic for the outcome. Residual deformity had the greatest influence on the function. The most frequent late problem was instability and tenderness in the distal radioulnar joint.

Displaced supracondylar fractures of the humerus in children

From 1972 to 1981, 60 children with severely displaced supracondylar fractures were treated with closed reduction and vertical osseous traction with a screw in the olecranon. None of the patients had complications (infection or neurovascular damage) due to the treatment, but eight patients had loss of reduction and required second reduction. The average hospitalization time was 2.6 weeks, and all fractures had united within four weeks. A follow-up study of 56 patients was performed an average of 78 months after the injury. All patients had an excellent (75%) or good (25%) end result. Vertical osseous traction is easy to apply and carries few risks of complications. The method is recommended, provided longer hospitalization time is acceptable or permissible.

Early displacement of distal radius fracture

In a retrospective series of 269 patients with distal radius fracture, initially undisplaced fractures (Older Type 1) had a good radiographical prognosis, whereas the more comminuted fractures showed increasing shortening until union, averaging 8 mm. Secondary displacement most often occurred during the first 2 weeks of immobilization, indicating that the radiographical control should be performed at that time. Reduction and fixation with plaster of the severely displaced Type 3 and 4 fractures never led to a satisfying radiographical end-result. Therefore, alternative methods of fixation should be considered in these fractures.