Incidence and Predictors of Subsidence Using Modular, Tapered, Fluted Titanium Femoral Stems in Aseptic Revision Total Hip Arthroplasty

BACKGROUND

Tapered, fluted titanium (TFT) femoral stems have become the gold standard in revision total hip arthroplasty (rTHA). However, there is a paucity of data on TFT stem subsidence rates following aseptic rTHA. Subsidence can lead to instability, mechanical failure, leg-length discrepancy, and may require revision surgery. This study evaluated the incidences and predictors of TFT subsidence in aseptic rTHA.

METHODS

A total of 102 TFT femoral stems of 4 designs were retrospectively reviewed. Stem subsidence was measured on digital radiographs taken immediately after surgery and at standard clinical follow-up. Patient characteristics, risk factors for subsidence, revision etiologies, and implant characteristics were recorded. Patient-reported outcome measures were also evaluated for a subset of cases.

RESULTS

Overall, 12% of stems subsided >1 cm, and subsidence was minimal (<3 mm) in ≥64% of cases. From immediate postoperative to 1-month radiographic follow-up, 79% of stems subsided a mean of 2.9 mm (range, 0.1 to 12 mm). Beyond 1 month, subsidence was minimal for ≥77% of cases. In multivariate analyses, women and less femoral implant canal fill were associated with greater subsidence (P ≤ .034). The TFT stem design was not associated with early subsidence (P = .816). There were no modular junction fractures. There were 2 fractures and 2 subsidence-related revisions for aseptic loosening that occurred postoperatively.

CONCLUSIONS

The amount of subsidence in TFT stems was low and was detectable in the early (less than 1 year) postoperative period. Maximizing TFT stem fill within the femoral canal appears to reduce the risk of subsidence without increasing femoral fracture rates and should be the goal with implantation of these devices.

LEVEL OF EVIDENCE

IV-Case Series, No Control Group.

Graft choice and techniques used in elbow ulnar collateral ligament reconstruction over the last 20 years: a systematic review and meta-analysis

BACKGROUND

Elbow medial ulnar collateral ligament (mUCL) injuries have become increasingly common, leading to a higher number of mUCL reconstructions (UCLR). Various techniques and graft choices have been reported. The purpose of this study was to evaluate the prevalence of each available graft choice, the surgical techniques most utilized, and the reported complications associated with each surgical method.

METHODS

A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysesguidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify all articles that included UCLR between January 2002 and October 2022. We included all studies that referenced UCLR graft choice, surgical technique, and/or ulnar nerve transposition. Studies were evaluated in a narrative fashion to assess demographics and report current trends in utilization and complications of UCLR as they pertain to graft choice and surgical techniques over the past 20 years. Where possible, we stratified based on graft and technique.

RESULTS

Forty-seven articles were included, reporting on 6671 elbows. The cohort was 98% male, had a weighted mean age of 21 years and follow-up of 53 months. There were 6146 UCLRs (92%) performed with an autograft and 152 (2.3%) that utilized an allograft, while 373 (5.6%) were from mixed cohorts of autograft and allograft. Palmaris longus autograft was the most utilized mUCL graft choice (64%). The most utilized surgical configuration was the figure-of-8 (68%). Specifically, the most common techniques were the modified Jobe technique (37%), followed by American Sports Medicine Institute (ASMI) (22%), and the docking (22%) technique. A concomitant ulnar nerve transposition was performed in 44% of all patients, with 1.9% of these patients experiencing persistent ulnar nerve symptoms after ulnar nerve transposition. Of the total cohort, 14% experienced postoperative ulnar neuritis with no prior preoperative ulnar nerve symptoms. Further, meta-analysis revealed a significantly greater revision rate with the use of allografts compared to autograft and mixed cohorts (2.6% vs. 1.8% and 1.9%, P = .003).

CONCLUSIONS

Most surgeons performed UCLR with palmaris autograft utilizing a figure-of-8 graft configuration, specifically with the modified Jobe technique. The overall rate of allograft use was 2.3%, much lower than expected. The revision rate for UCLR with allograft appears to be greater compared to UCLR with autograft, although this may be secondary to limited allograft literature.

Increased risk for early revision with quadriceps graft compared with patellar tendon graft in primary ACL reconstructions

PURPOSE

Bone patella-tendon bone (BPTB) and hamstring tendon (HT) autografts are the most used grafts in primary anterior cruciate ligament (ACL) reconstructions (ACLR) in Norway. Quadriceps tendon (QT) autograft has gained more popularity during the past years. The purpose of this study is to compare revision rates and patient-reported outcomes of primary QT with BPTB and HT autograft ACL reconstructions in Norway at 2-year follow-up. It was hypothesized that there would be no difference in 2-year revision rates between all three autografts.

METHODS

Data included primary ACLR without concomitant ligament surgeries, registered in the Norwegian Knee Ligament Register from 2004 through 2021. Revision rates at 2 years were calculated using Kaplan-Meier analysis. Hazard ratios (HR) for revision were estimated using multivariable Cox regression analysis with revision within 2 years as endpoint. Mean change in patient-reported outcome was recorded preoperatively and at 2 years through the Knee Injury and Osteoarthritis Outcome Score (KOOS) subcategories 'Sport' and 'Quality of Life' was measured for patients that were not revised and analysed with multiple linear regression.

RESULTS

A total of 24,790 primary ACLRs were identified, 10,924 with BPTB, 13,263 with HT and 603 with a QT graft. Patients in the QT group were younger (23.5 years), more of them were women (58.2%) and over 50% had surgery <3 months after injury. The QT group had the highest prevalence of meniscal injuries (61.9%). Revision estimates at 2-years were 3.6%, 2.5% and 1.2% for QT, HT and BPTB, respectively (p < 0.001). In a Cox regression analysis with QT as reference, BPTB had a lower risk of revision (HR 0.4, 95% Cl 0.2-0.7, p < 0.001). No significant difference was observed in the revision risk between QT and HT (HR 1.1, 95% Cl 0.7-1.8, n.s.). The two most common reported reasons for revision were: traumatic graft rupture and nontraumatic graft failure. There were no differences between the groups in change of KOOS in subcategories 'Sport' and 'Quality of Life' at 2-years follow-up.

CONCLUSION

The 2-year risk of revision after ACLR with QT was higher than BPTB and similar to HT. No difference was found between the groups in patient-reported outcomes. This study provides valuable insights for both surgeons and patients when making decisions about the choice of autografts in primary ACL reconstructions.

LEVEL OF EVIDENCE

Level II.

Increased Rates of Late Periprosthetic Fractures in Larger Hydroxyapatite-Coated Cementless Stems: Are Collared Stems a Better Alternative for Total Hip Arthroplasty?

BACKGROUND

Cementless hip stems are widely used for total hip arthroplasty (THA) and have demonstrated excellent survivorship. This study aimed to investigate the effects of stem size and calcar collars on rates of revision due to periprosthetic fracture.

METHODS

All primary THA procedures recorded by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from September 1999 to December 2021 for a diagnosis of osteoarthritis using a single cementless hip stem with modern bearings were included. The primary outcome measure was revision due to periprosthetic fracture. Stems were divided into 2 groups for comparison, large (size 14 to 20) and small-medium (6 to 13). A subanalysis was performed for collared stems. A total of 59,518 primary THA procedures were included.

RESULTS

The cumulative percent revision for periprosthetic fracture was significantly higher for large stems compared to small-medium stems (hazard ratio [HR] = 1.57 [95% confidence interval {CI} 1.18, 2.09] P = .002). Furthermore, collared stems had significantly lower revision rates due to late periprosthetic fracture compared to collarless variants (2 week + HR = 4.55 [95% CI 3.23, 6.42], P < .001). Large collarless stems were found to have greater revision rates due to fracture compared to small-medium collarless stems (HR = 1.55 [95% CI 1.13, 2.12] P = .006), but no difference was found between collared groups (HR = 1.37 [95% CI 0.68, 2.78] P = .382).

CONCLUSION

Large cementless hip stems have a higher rate of revision due to periprosthetic fracture compared to small-medium stems. Using a collared stem reduces the rate of periprosthetic fracture.

Influence of Surgeon Experience and Clinic Volume on Subjective Knee Function and Revision Rates in Primary ACL Reconstruction: A Study from the Swedish National Knee Ligament Registry

Background

Anterior cruciate ligament reconstruction (ACLR) performed by high-volume surgeons/clinics has been associated with increased graft individualization and decreased operating times, complication rates, and total costs.

Purpose

To investigate the influence of surgeon/clinic volume on subjective knee function and revision surgery rates at 2 years after primary ACLR.

Study Design

Cohort study; Level of evidence, 3.

Methods

Data from the Swedish National Knee Ligament Registry were used to study patients who underwent primary ACLR between 2008 and 2019. Surgeons/clinics were categorized based on a combination of total caseload volume (cutoff: 50 ACLRs/surgeon, 500 ACLRs/clinic) and annual volume (cutoff: 29 ACLRs/year/surgeon, 56 ACLRs/year/clinic). The thresholds of minimal important change (MIC), Patient Acceptable Symptom State (PASS), and treatment failure (TF) relative to the Knee injury and Osteoarthritis Outcome Score (KOOS) and KOOS4 (mean score of the KOOS Pain, Symptoms, Sports/Rec, and QoL subscales) were applied. Adjusted multivariable logistic regression was performed to assess variables influencing the MIC, PASS, or TF of the KOOS and KOOS4. Adjusted Cox regression analysis was conducted to determine the hazard ratio of subsequent ACLR.

Results

Of 35,371 patients, 16,317 had 2-year follow-up outcome data and were included. Patients who underwent primary ACLR by high-volume surgeons had significantly higher MIC and PASS rates and lower TF rates when compared with patients who underwent the procedure by low-volume surgeons: MICKOOS4: 70.6% vs 66.3%; PASSKOOS4: 46.0% versus 38.3%; and TFKOOS4: 8.7% versus 11.8% (all P < .02). Significantly decreased odds of achieving MICKOOS4 (OR, 0.74; 95% CI, 0.62-0.88) and PASSKOOS4 (OR, 0.71; 95% CI, 0.60-0.84) were found for ACLRs performed by low-volume surgeons. Clinic volume did not influence the odds of reaching MIC, PASS, or TF. Overall, 804 patients (2.3%) underwent subsequent ACLR at <2 years, with significantly higher revision rates among patients operated on at high-volume clinics (2.5% vs 1.7%; P < .001). However, in the adjusted Cox regression, surgeon/clinic volume had no influence on subsequent ACLR rates. High-volume surgeons/clinics had decreased time to surgery, operating time, perioperative complication rates, and use of thromboprophylaxis and nonroutine antibiotics (P < .001).

Conclusion

Patients who underwent primary ACLR by high-volume surgeons experienced increased improvement and satisfaction regarding subjective knee function. Factors other than surgical volume influenced subsequent surgery rates. Patients might benefit from undergoing primary ACLR by high-volume providers.

High Complication and Revision Rates in Anatomical Total Shoulder Arthroplasty with the Combination of Polyethylene and Cementless Convertible Metal-Backed Glenoid Components: A Retrospective Cohort Study

Background

Historically, Metal-Backed (MB) glenoid components in anatomical total Shoulder arthroplasty (aTSA) are prone to failure primarily due to loosening between the metal and bony surface. However, newer generations of MB glenoid components have performed well in reverse shoulder arthroplasty (RSA), with convertibility being considered to be the most significant benefit of MB components. Theoretically, MB components may be a viable option in "Rotator cuff at risk" cases. The aim of this study is to compare revisions versus revision-free survivorship and highlight problems associated with using convertible MB glenoid components in aTSA.

Methods

Between December 2015 and September 2018, aTSA was performed on 30 patients utilizing 32 implants with convertible MB glenoid (two patients were operated bilaterally). The first investigation was performed at a mean of 55.9 months (43-76) by search in the national registry for revisions with twelve cases. The second FU on all remaining patients without revisions was conducted at a mean of 54.9 months (46-71) through physical examination with fourteen patients (sixteen implants), with four patients missing. Demographic data, indications, complications, revisions, and re-operations were recorded for each patient.

Results

High rates of complications led to revisions or re-operation in aTSA in combination with MB (15/32). Seven problems were associated with polyethylene (PE), which included loosening, disengagement, or wear. Eight complications were not directly associated with the MB component. There was one with loosening on the metal-bone interface side. Conversion to RSA was possible in three cases, and secondary cuff failure was seen once. High infection rates (2/32) led to a different strategy for antibiotics and preoperative preparations.

Conclusion

MB glenoid components caused unacceptably high complication and revision rates in aTSA. PE wear, disengagement, or loosening were the main reasons for revisions. Therefore, procedures with MB glenoid components were abandoned in aTSA.

Level of Evidence

Level IV case series, treatment study.

Total Knee Arthroplasty in the Post-Traumatic Knee: Revision Risks and Functional Outcomes Compared to Osteoarthritic Knees. A Report of Primary Procedures From the Dutch Arthroplasty Register

BACKGROUND

Total knee arthroplasty (TKA) for post-traumatic arthritis (PTA) poses higher challenges and increased risks of complications compared to TKA for osteoarthritis (OA). This study aimed to compare implant survivorships, reasons for revision, and patient-reported outcome measures between OA and PTA as indications for TKA.

METHODS

We selected all primary TKAs for PTA or OA between 2007 and 2020 from the Dutch Arthroplasty Register (Landelijke Registratie Orthopedische Interventies). The study included 3,897 TKA procedures for PTA (median follow-up 4.6 years; interquartile range: 2.2, 7.3) and 255,259 procedures for OA (median follow-up 4.7 years; interquartile range 2.2, 7.6). A total of 10,480 revision procedures were performed across both groups (238 in PTA knees; 10,242 in OA knees). We analyzed the prevalence of preoperative comorbidities and postoperative complications, as well as the reasons for revision, and calculated the implant survival rates.

RESULTS

The survival revision rate in the OA group was significantly lower at both follow-up moments (5- and 10- years). The likelihood for revision was increased in TKA for PTA compared to TKA for OA (hazards ratio: 1.16 [95% confidence interval 1.02 to 1.33], P = .03). The most common reason for a revision was instability and arthrofibrosis in the PTA group compared to patellar pain for the OA group.

CONCLUSION

This study demonstrated an increased risk for revision for any reason in TKA for PTA compared to OA. Revision for instability and arthrofibrosis were more prevalent in the PTA group, while revision for patellar pain was less prevalent compared to TKA for OA.

Distal humeral hemiarthroplasty compared to total elbow replacement for distal humeral fractures: a registry analysis of 906 procedures

BACKGROUND

Total elbow replacement (TER) is an accepted treatment for complex intra-articular distal humerus fractures in elderly patients. Distal humeral hemiarthroplasty (HA) is also a potential surgical option for unreconstructable fractures and avoids the concerns regarding mechanical wear and functional restrictions associated with TER. In the current literature, there are limited data available to compare the revision rates of HA and TER for the treatment of fracture. We used data from a large national arthroplasty registry to compare the outcome of HA and TER undertaken for fracture/dislocation and to assess the impact of demographics and implant choice on revision rates.

METHODS

Data obtained from the Australian Orthopaedic Association National Joint Replacement Registry from May 2, 2005, to December 31, 2021, included all procedures for primary elbow replacement with primary diagnosis of fracture or dislocation. The analyses were performed using Kaplan-Meier estimates of survivorship and hazard ratios (HRs) from Cox proportional hazards models.

RESULTS

There were 293 primary HA and 631 primary TER procedures included. The cumulative percentage revision (CPR) rate at 9 years was 9.7% for HA (95% confidence interval [CI] 6.0, 15.7), and 11.9% (95% CI 8.5, 16.6) for TER. When adjusted for age and gender, there was a significantly higher risk of revision after 3 months for TER compared to HA (HR 2.47, 95% CI 1.22, 5.03, P = .012). There was no difference in the rate of revision for patients aged <55 years or ≥75 years when HA and TER procedures were compared. In primary TER procedures, loosening was the most common cause of revision (3.6% of primary TER procedures), and the most common type of revision in primary TER involved revision of the humeral component only (2.6% of TER procedures). TER has a higher rate of first revision for loosening compared to HA (HR 4.21, 95% CI 1.29, 13.73; P = .017). In HA procedures, instability (1.7%) was the most common cause for revision. The addition of an ulna component was the most common type of revision (2.4% of all HA procedures).

CONCLUSION

For the treatment of distal humerus fractures, HA had a lower revision rate than TER after 3 months when adjusted for age and gender. Age <55 or ≥75 years was not a risk factor for revision when HA was compared to TER. Loosening leading to revision is more prevalent in TER and increases with time. In HA, the most common type of revision involved addition of an ulna component with preservation of the humeral component.

Long-Term Outcomes and Revision Rates in Laryngeal Reinnervation

OBJECTIVES

Nonselective laryngeal reinnervation is an effective procedure to improve voice quality after unilateral vocal fold paralysis. Few studies have captured long-term outcome data, and the revision rate for this operation is currently unknown. The objective of this study is to describe the long-term outcomes and revision rates of unilateral, nonselective reinnervation in pediatric and adult patients.

METHODS

Patients who underwent laryngeal reinnervation from 2000 to 2022 with a single surgeon were identified for inclusion. Patients who underwent bilateral, super selective, deinnervation and reinnervation, and/or concurrent arytenoid adduction procedures were excluded. Outcome measures included maximum phonation time [MPT], voice handicap index score [VHI], patient-reported percent normal voice, revision procedures, and complications. Data were compiled and analyzed using paired t-tests, repeated measures analysis of covariance, and binary logistic regression analysis.

RESULTS

One hundred thirty-two patients underwent unilateral, nonselective ansa-recurrent laryngeal nerve [RLN] laryngeal reinnervation. Reinnervation significantly improved MPT and patient-reported percentage of normal voice and significantly decreased VHI. Eleven patients underwent revision procedures, corresponding to a revision rate of 8.3%. Additional procedures included medialization laryngoplasty [n = 3], medialization laryngoplasty with arytenoid adduction [n = 3] and injection augmentation greater than 1 year after reinnervation [n = 5]. The only factor associated with the need for additional surgery was time lapse from nerve injury to reinnervation. The overall complication rate was 6.8%; no patient required reintubation or tracheostomy.

CONCLUSION

Unilateral, nonselective laryngeal reinnervation can provide reliable improvement in vocal symptoms after recurrent laryngeal nerve injury. The revision rate after laryngeal reinnervation is favorable and comparable to framework surgery.

LEVEL OF EVIDENCE

Level IV Laryngoscope, 2024.

Medium-term results of inlay vs. onlay humeral components for reverse shoulder arthroplasty: a New Zealand Joint Registry study

BACKGROUND

The purpose of this study was to compare medium-term results of inlay and onlay humeral components in reverse shoulder arthroplasty (RSA). Specifically, we report differences in revision rate and functional outcomes between the 2 designs.

METHODS

The 3 most used inlay (in-RSA) and onlay (on-RSA) implants by volume from the New Zealand Joint Registry were included in the study. In-RSA was defined as having a humeral tray that recessed within the metaphyseal bone, whereas on-RSA was defined as having a humeral tray that rested on the epiphyseal osteotomy surface. The primary outcome was revision up to 8 years postsurgery. Secondary outcomes included the Oxford Shoulder Score (OSS), implant survival, and revision cause for in-RSA and on-RSA as well as individual prostheses.

RESULTS

There were 6707 patients (5736 in-RSA; 971 on-RSA) included in the study. For all causes, in-RSA demonstrated a lower revision rate compared to on-RSA (revision rate/100 component years: in-RSA 0.665, 95% confidence interval [CI] 0.569-0.768; on-RSA 1.010, 95% CI 0.673-1.415). However, the mean 6-month OSS was higher for the on-RSA group (mean difference 2.20, 95% CI 1.37-3.03; P < .001). However, this was not clinically significant. At 5 years, there were no statistically or clinically significant differences between the 2 groups with respect to the OSS.

CONCLUSION

The medium-term survival of in-RSA was higher than that of on-RSA. However, functional outcomes at 6 months were better for on-RSA compared to in-RSA. Further follow-up is required to understand the long-term survivorship and functional outcomes between these designs.

Primary reverse total shoulder arthroplasty for fractures requires more revisions than for degenerative conditions 1 year after surgery: an analysis from the Dutch Arthroplasty Register

BACKGROUND

Although reverse total shoulder arthroplasty (RTSA) is considered a viable treatment strategy for proximal humeral fractures, there is an ongoing discussion of how its revision rate compares with indications performed in the elective setting. First, this study evaluated whether RTSA for fractures conveyed a higher revision rate than RTSA for degenerative conditions (osteoarthritis, rotator cuff arthropathy, rotator cuff tear, or rheumatoid arthritis). Second, this study assessed whether there was a difference in patient-reported outcomes between these 2 groups following primary replacement. Finally, the results of conventional stem designs were compared with those of fracture-specific designs within the fracture group.

MATERIALS AND METHODS

This was a retrospective comparative cohort study with registry data from the Netherlands, generated prospectively between 2014 and 2020. Patients (aged ≥ 18 years) were included if they underwent primary RTSA for a fracture (<4 weeks after trauma), osteoarthritis, rotator cuff arthropathy, rotator cuff tear, or rheumatoid arthritis, with follow-up until first revision, death, or the end of the study period. The primary outcome was the revision rate. The secondary outcomes were the Oxford Shoulder Score, EuroQol 5 Dimensions (EQ-5D) score, numerical rating scale score (pain at rest and during activity), recommendation score, and scores assessing change in daily functioning and change in pain.

RESULTS

This study included 8753 patients in the degenerative condition group (mean age, 74.3 ± 7.2 years) and 2104 patients in the fracture group (mean age, 74.3 ± 7.8 years). RTSA performed for fractures showed an early steep decline in survivorship: Adjusted for time, age, sex, and arthroplasty brand, the revision risk after 1 year was significantly higher in these patients than in those with degenerative conditions (hazard ratio [HR], 2.50; 95% confidence interval, 1.66-3.77). Over time, the HR steadily decreased, with an HR of 0.98 at year 6. Apart from the recommendation score (which was slightly better within the fracture group), there were no clinically relevant differences in the patient-reported outcome measures after 12 months. Patients who received conventional stems (n = 1137) did not have a higher likelihood of undergoing a revision procedure than those who received fracture-specific stems (n = 675) (HR, 1.70; 95% confidence interval, 0.91-3.17).

CONCLUSION

Patients undergoing primary RTSA for fractures have a substantially higher likelihood of undergoing revision within the first year following the procedure than patients with degenerative conditions preoperatively. Although RTSA is regarded as a reliable and safe treatment option for fractures, surgeons should inform patients accordingly and incorporate this information in decision making when opting for head replacement surgery. There were no differences in patient-reported outcomes between the 2 groups and no differences in revision rates between conventional and fracture-specific stem designs.

Anatomic Total Shoulder Arthroplasty Versus Reverse Total Shoulder Arthroplasty in Patients Aged Over 70 Without a Full-Thickness Rotator Cuff Tear: A Systematic Review and Meta-Analysis

Introduction

This systematic review and meta-analysis compared the revision rates, complications, and outcomes in anatomic total shoulder arthroplasty (aTSA) and reverse TSA (rTSA) performed for primary glenohumeral osteoarthritis in patients aged over 70 years without a full-thickness rotator cuff tear.

Materials and Methods

We performed a systematic literature search identifying comparative studies meeting the above patient criteria and published from January 2010 to May 2022 from 3 databases: MEDLINE, EMBASE, and Cochrane Library. We performed the systematic review in accordance with PRISMA guidelines and the study was prospectively registered on PROSPERO.

Results

From the 1798 studies identified from the initial literature search, 4 met our inclusion criteria. Two thousand seven hundred thirty-one shoulder arthroplasties (1472 aTSA and 1259 rTSA) were evaluated with a minimum follow up of 2 years. A statistically significant lower revision rate was observed in rTSA compared to aTSA (odds ratio [OR] 0.50, 95% confidence interval [CI]: 0.30, 0.84, p < .05). No significant difference was noted between aTSA and rTSA in overall complication rate (OR 0.98, 95% CI 0.34, 2.86, p = .97) while aTSA displayed a statistically significant improved postoperative Constant-Murley score [aTSA: 80(75; 82), rTSA: 68(66; 76.5), p < .001].

Conclusion

Higher revision rates were identified following aTSA in our study population, although admittedly this is within retrospective studies. aTSA displayed equal functional results and postoperative complications compared to rTSA in patients over 70 without a full-thickness rotator cuff tear. Given these similar results a shoulder surgeon must carefully consider each patient individually prior to deciding the optimal form of arthroplasty to offer.

Shoulder joint arthroplasty in young patients: Analysis of 8742 patients from the Australian Orthopaedic Association National Joint Replacement Registry

Background

Shoulder replacement is a reliable treatment for the relief of pain and improvement of function in patients with glenohumeral arthritis, rotator cuff arthropathy, osteonecrosis and fracture. Limited data is available comparing revision rates for the different types of shoulder replacement when used in younger patients. This study aims to compare the survivorship of hemi resurfacing, stemmed hemiarthroplasty, total shoulder arthroplasty and reverse total shoulder arthroplasty in younger patients using data from a large national arthroplasty registry.

Methods

Data from the Australian Orthopaedic Association National Joint Replacement Registry was obtained for the period 16 April 2004-31 December 2018. The study population included all shoulder arthroplasty patients aged <65 years. These were stratified into two groups: <55 years and 55-64 years. A total of 8742 primary shoulder arthroplasty procedures were analysed (1936 procedures in the <55 years and 6806 in the 55-64 years age group).

Results

In the <55 years age group, there was no difference in revision rate for total shoulder arthroplasty versus reverse total shoulder arthroplasty at any time point. Reverse total shoulder arthroplasty had a lower revision rate after six months when compared to hemi resurfacing (HRA) (p = 0.031). Also, reverse total shoulder arthroplasty had a higher early rate of revision in the first 12 months compared to hemiarthroplasty (p = 0.018). However, from 2 years reverse total shoulder arthroplasty had a lower revision rate overall (p = 0.029).In the 55-64 years patient age group, reverse total shoulder arthroplasty had a lower earlier revision rate. This was statistically significant compared to hemi resurfacing (HRA) (p = 0.028), hemiarthroplasty (p = 0.049) and total shoulder arthroplasty (p < 0.001).

Conclusion

This study demonstrated that for patients aged <55 years there was no significant difference in the rate of revision when total shoulder arthroplasty and reverse total shoulder arthroplasty were compared. reverse total shoulder arthroplasty had a lower rate of revision when compared to hemi resurfacing and hemiarthroplasty after 2 years. reverse total shoulder arthroplasty had the lowest comparative revision rate in patients aged 55-64 years overall.

Dual-Modular Versus Single-Modular Stems for Primary Total Hip Arthroplasty: A Long-Term Survival Analysis

Background and Objectives: Increased revision rate of dual-modular (DM) femoral stems in primary total hip arthroplasty (THA) because of modular-neck breakage and adverse local tissue reactions (ALTRs) to additional junction damage products is well established and some designs have been recalled from the market. However, some long-term studies of specific DM stems did not confirm the inferiority of these stems compared to standard single-modular (SM) stems, and a head-to-head comparison THA is missing. The objectives of this multicentre study were to determine the survivorship and complication rates of a common DM stem design compared to a similar SM stem. Materials and Methods: In a time frame from January 2012 to November 2015, a cohort of 807 patients (882 hips) consecutively underwent primary cementless THAs at two orthopaedic centres. 377 hips were treated with a Zweimüller-type DM stem THA system and 505 hips with a similar SM stem THA system, both including a modern press-fit acetabulum. Kaplan-Meier survivorship and complication rates were compared between both groups in a median follow-up of 9.0 years (maximum, 9.9 years). Results: The 9-year survivorship of the DM stem THA system (92.6%, 95% CI 89.9-95.3) was significantly lower than that of the SM stem THA system (97.0%, 95% CI 95.2-98.8). There were no differences in revision rates for septic loosening, dislocation, and periprosthetic fractures between the two groups. One ceramic inlay and one Ti-alloy modular neck breakage occurred in the DM stem THA system group, but the main reason for revision in this group was aseptic loosening of components. Conclusions: The survivorship of the DM stem THA system was lower than the similar SM stem THA system in a comparable clinical environment with long-term follow-up. Our results confirmed that no rationale for stem modularity exists in primary THAs.

Mid- to long-term complications and outcome for morbidly obese patients after total knee arthroplasty: a systematic review and meta-analysis

Purpose

Due to substantial increase in obesity, the demand for total knee arthroplasty (TKA) in obese and morbidly obese patients is higher than ever. This review aims to investigate mid- to long-term complications, revision rates, and outcome for morbidly obese, compared with non-obese after TKA.

Methods

A systematic search was conducted in May 2021. Included studies reported revision rates for morbidly obese and non-obese with a mean follow-up of at least 2 years. Reported knee society score (KSS) has been used to compare the functional outcome. PRISMA protocol was followed, and PROSPERO registered (ID: CRD42021254119).

Results

From 12 studies that met the inclusion criteria, a total of 1031 cases of morbidly obese and 9797 cases of non-obese controls were included. The risk ratio for revision was 1.48 for the morbidly obese, compared with non-obese (95% CI: 0.98 to 2.24; P = 0.06). Regarding aseptic and septic revision, the risk ratio was 1.44 (95% CI: 0.64 to 3.25; P  = 0.37) and 2.22 (95% CI: 0.89 to 5.57; P  = 0.09), respectively. The morbidly obese scored lower in Objective Knee Society Score (OKSS) and Functional Knee Society Score (FKSS) both preoperatively and postoperatively, compared with the non-obese; however, the two groups improved equally in function scores OKSS (P= 0.967) and FKSS (P  = 0.834). Overall risk ratio for complications was 1.56 (95% CI: 0.98 to 2.48; P  = 0.06).

Conclusions

The gained benefit in functional outcome surpasses the increase in risk of revision and complications for the morbidly obese in TKA surgery.

Revision Rates After Total Ankle Replacement: A Comparison of Clinical Studies and Arthroplasty Registers

BACKGROUND

The aim of this study was to assess the outcome of total ankle replacement (TAR) regarding revision rates by comparing clinical studies of the last decade to data displayed in arthroplasty registers. The secondary aim was to evaluate whether dependent clinical studies show a superior outcome to independent publications. Additionally, revision rates of mobile bearing implants (MB-TARs) were compared to those of fixed bearing implants (FB-TARs).

METHODS

Clinical studies on TARs between 2010 and 2020 were systematically reviewed, with the endpoint being a revision for any reason. The parameter "revision rate per 100 observed component years (CYs)" was calculated for each publication. The pooled revision rate for clinical studies was compared to the data reported in arthroplasty registers. In a second step, revision rates were subdivided and analyzed for independent and dependent publications and for FB-TARs and MB-TARs.

RESULTS

A total of 43 publications met the inclusion criteria comprising 5806 TARs. A revision rate of 1.8 per 100 observed CYs was calculated, corresponding to a 7-year revision rate of 12.6%. The 3 arthroplasty registers included showed revision rates ranging from 8.2% to 12.3% after 7 years. No significant difference between dependent and independent publications nor between FB-TARs and MB-TARs was detected.

CONCLUSION

Revision rates of clinical studies and arthroplasty registers are comparable. Surgeons can compare their own revision rates with those from this study. Dependent studies do not seem to be biased, and no superiority for one bearing type can be described.

LEVEL OF EVIDENCE

Level III, systematic review of level III studies.

Complications and Revision Rates in Minimally Invasive Robotic-Guided Versus Fluoroscopic-Guided Spinal Fusions: The MIS ReFRESH Prospective Comparative Study

STUDY DESIGN

Prospective, multicenter, partially randomized.

OBJECTIVE

Assess rates of complications, revision surgery, and radiation between Mazor robotic-guidance (RG) and fluoro-guidance (FG).

SUMMARY OF BACKGROUND DATA

Minimally invasive surgery MIS ReFRESH is the first study designed to compare RG and FG techniques in adult minimally invasive surgery (MIS) lumbar fusions.

METHODS

Primary endpoints were analyzed at 1 year follow-up. Analysis of variables through Cox logistic regression and a Kaplan-Meier Survival Curve of surgical complications.

RESULTS

Nine sites enrolled 485 patients: 374 (RG arm) and 111 (FG arm). 93.2% of patients had more than 1 year f/u. There were no differences for sex, Charlson Comorbidity Index, diabetes, or tumor. Mean age of RG patients was 59.0 versus 62.5 for FG (P = 0.009) and body mass index (BMI) was 31.2 versus 28.1 (P< 0.001). Percentage of smokers was almost double in the RG (15.2% vs. 7.2%, P = 0.029). Surgical time was similar (skin-to-skin time/no. of screws) at 24.9 minutes RG and 22.9 FG (P = 0.550). Fluoroscopy during surgery/no. of screws was 15.5 seconds RG versus 35.4 seconds FG, (15 seconds average reduction). Fluoroscopy time during instrumentation/no. of screws was 3.6 seconds RG versus 17.8 seconds FG showing an 80% average reduction of fluoro time/screw in RG (P < 0.001). Within 1 year follow-up, there were 39 (10.4%) surgical complications RG versus 39 (35.1%) FG, and 8 (2.1%) revisions RG versus 7 (6.3%) FG. Cox regression analysis including age, sex, BMI, CCI, and no. of screws, demonstrated that the hazard ratio (HR) for complication was 5.8 times higher FG versus RG (95% CI: 3.5-9.6, P < 0.001). HR for revision surgery was 11.0 times higher FG versus RG cases (95% CI 2.9-41.2, P < 0.001).

CONCLUSION

Mazor robotic-guidance was found to have a 5.8 times lower risk of a surgical complication and 11.0 times lower risk for revision surgery. Surgical time was similar between groups and robotic-guidance reduced fluoro time per screw by 80% (approximately 1 min/case).Level of Evidence: 2.

Increased Revisions in Conversion Total Knee Arthroplasty After Periarticular Open Reduction Internal Fixation Compared With Primary Total Knee Arthroplasty: A Matched Cohort Analysis

BACKGROUND

Prior studies on conversion total knee arthroplasty (cTKA) have reported increased technical challenges and risk of complications compared with primary knee arthroplasty. The purpose of this study was to compare two-year postoperative complication/revision rates between patients undergoing cTKA after prior periarticular open reduction and internal fixation (ORIF) and those undergoing primary TKA.

METHODS

Patients who underwent cTKA after prior periarticular ORIF of the ipsilateral knee were identified in a national all-payer claims database from 2010 to 2018. This ORIF-cTKA cohort was propensity matched to participants undergoing primary TKA based on age, gender, Charlson comorbidity index, and obesity status. Univariate analysis was performed to analyze differences in two-year complication and revision rates.

RESULTS

After propensity matching, 823 patients were included in the ORIF-cTKA cohort and 1640 patients in the primary TKA cohort. No differences in demographics or comorbidities existed between cohorts. Relative to the primary TKA cohort, the ORIF-cTKA cohort had significantly higher incidences of all-cause revision (5.47% vs 2.47%, P = .001), periprosthetic joint infection (PJI; 4.74% vs 1.34%, P < .001), and intraoperative or postoperative periprosthetic fracture (1.58% vs 0.55%, P = .01) at two years postoperatively. There was also a nonsignificant trend toward increased rates of aseptic loosening (1.82% vs 0.91%, P = .052) in the ORIF-cTKA.

CONCLUSION

Relative to primary TKA, cTKA after periarticular ORIF is associated with significantly increased rates of all-cause revision, PJI, and periprosthetic fracture at two years postoperatively. Surgeons should counsel these patients about the increased risks of these postoperative complications and consider treating them as high risk for PJI in the perioperative period.

Long-Term Outcomes of 496 Anatomical Cementless Modular Femoral Stems: Eleven to Twenty Years of Follow-Up

BACKGROUND

The aim of the study is to assess the long-term outcomes of this specific stem (anatomical cementless modular stem ESOP), to review the survivorship, complication rate, and radiographic and clinical outcomes.

METHODS

Descriptive and analytical retrospective longitudinal observational study of patients was operated on total hip arthroplasty between 1998 and 2007. Four hundred ninety-six prostheses corresponding to 447 patients were reviewed, mean age was 65.8 years (standard deviation [SD] ±11.6 years), and median follow-up time was 13.4 years (range 1-20). The most used cups were cementless (75.8%). The most frequent friction pairs were metal-polyethylene (53.1%) and ceramic-polyethylene (24.2%). Main variables analyzed were stem survival, subsidence, coronal orientation, osteolysis, reintervention, and Oxford Hip Score.

RESULTS

From 496 implants, there were 22 lost to follow-up (4.4%). Stem revision was performed in 51 patients: 26 periprosthetic joint infections (2-stage revision), 16 periprosthetic fractures, and 8 one-stage revisions (6 real aseptic loosening with negative culture after revision). The stem survivorship at more than 15 years for any reason was 89.2% and for aseptic loosening 97.97%. No specific complications were found due to modularity. The mean subsidence and orientation was 2.06 mm (SD ±5.11 mm) and 0.41° varus (SD ±2.20°) respectively. Subsidence >5 mm or varus >5° was associated with a higher revision rate. Osteolysis was found in 110 patients (zone I = 79, VII = 57), associated with zirconium-polyethylene, without relationship to the stem revision rate or Oxford Hip Score.

CONCLUSION

To our knowledge, this study represents the largest series of this stem, revealing an excellent survival rate and long-term clinical outcomes similar to the best results of classical cementless stems published in the literature.

Intraoperative 3D imaging in intraarticular tibial plateau fractures - Does it help to improve the patients' outcomes?

BACKGROUND

In tibial plateau fractures (TPF) the restoration of an anatomical joint surface as well as an exact subchondral screw position for postoperative stability is crucial for the outcome. The aim of this study was to determine whether the additional use of an intraoperative 3D imaging intensifier (3D) might help to improve the outcome of complex TPF.

METHODS

We performed a retrospective case-control study of a level 1 trauma center. Patients with AO/OTA 41 B3 and C-TPF operated on using a 3D imaging intensifier between November 2015 and December 2018 (3D group) were included. The outcomes of this patients were compared to patients operated without 3D imaging between January 2005 to December 2014 (2D group). The comparison of the groups was performed by matched pair analysis. The functional outcome of both groups was measured by KOOS and Lysholm Score after a follow-up period of at least 12 months. Operation time, infections and postoperative revisions were registered.

RESULTS

In total, 18 patients were included in the 3D group (mean age: 51.0± 16.4 years; 12 females) and an equal number of matching partners from the 2D group (mean age: 50.3± 15.2 years; 11 females) were found (p=0.82; p=0.79). We found 9x B3, 2x C1, 1x C2, 6x C3 fractures according to AO/OTA for each group (p=1.00) with comparable ASA score (p=0.27). The mean operation time was 127.9± 45.9 min and 116.1± 45.7 min for the 3D and 2D group (p=0.28). The mean follow-up time was 20.9± 10.7 months for the 3D and 55.5± 34.7 months for the 2D group (p< 0.001). For the 3D group a mean Lysholm overall score of 67.4± 26.8 and KOOS overall score of 72.6± 23.5 could be assessed. In contrast, a mean Lysholm overall score of 62.0± 21.4 and KOOS overall score of 65.8± 21.6 could be measured in the 2D group (p=0.39; p=0.31). Thereby, functional outcome of the 3D group showed a significant higher KOOS Sport/Rec sub score of 54.7± 35.0 in comparison to the 2D group with 26.7± 31.6 (p= 0.01). Postoperative revisions had to be performed in 27.8% of cases in both groups (p=1.00). Due to the 3D imaging an intraoperative revision was performed in 33.3% (6/18).

CONCLUSION

In our study we could show that re-reduction of the fracture or implant re-positioning were performed in relevant numbers based on the 3D imaging. This was associated with a midterm clinical benefit in regard to better KOOS Sport/Rec scores.

TRIAL REGISTRATION

AZ 488 /20-ek.

Systematic review of primary total hip arthroplasty using titanium-titanium modular-neck prostheses: the true risk of revision

AIMS

Modular-neck femoral implants are used to enable more variability in femoral neck version, offset and length. It has been reported that these implants carry a higher rate of revision. The aim of this review was to assess the overall and cause-specific revision rate of titanium-titanium alloy modular-neck implants in primary total hip arthroplasty (THA).

METHODS

A systematic review was conducted following PRISMA guidelines and utilising multiple databases. All results were screened for eligibility. Studies published from 2000 onwards, using a current-generation, titanium-titanium, modular-neck implant were included. Overall and cause-specific revision rates were analysed, comparing to fixed-neck prostheses where applicable.

RESULTS

920 studies were screened. After applying exclusion criteria, 23 were assessed in full and 14 included. These consisted of 12 case series and 2 joint registry analyses. 21,841 patients underwent a modular-neck implant with a weighted mean follow-up of 5.7 years, mean age of 62.4 years, and average body mass index (BMI) of 28.4kg/m². The overall revision rate was 3.95% and 2.98% for modular and fixed-neck prostheses, respectively. For studies with >5 years follow-up the mean revision rate was 3.08%. There was no difference in cause-specific revision rates by implant design. Mean improvement in Harris Hip Score was 41.9.

CONCLUSIONS

At medium-term, revision rates for titanium-titanium primary modular-neck THA are acceptable. These prostheses are a sensible management option in patients with considerable anatomical hip deformity not amenable to correction with standard fixed-neck implants. Patients of male gender, high BMI and requiring prostheses with a larger neck, offset or head are at higher risk of implant failure.

Outcome of Debridement, Antibiotics, and Implant Retention With Modular Component Exchange in Acute Culture-Negative Periprosthetic Joint Infections

BACKGROUND

Modular component exchange and culture-directed antibiotic treatment is routinely employed for acute periprosthetic joint infection (PJI). However, as many as 7%-23% of PJIs have been reported to yield negative culture results. The efficacy of debridement, antibiotics, and implant retention (DAIR) with modular component exchange in the setting of acute culture negative PJI remains largely unknown. The aim of our study is to evaluate the outcomes of DAIR with modular component exchange in acute culture-positive and culture-negative PJI.

METHODS

A total of 149 consecutive patients with primary total joint replacements (90 total knee arthroplasties and 59 total hip arthroplasties) who underwent DAIR with modular component exchange for acute PJI with at least 3 years of follow-up were evaluated: (1) 46 culture-negative PJI patients and (2) 103 culture-positive PJI patients. Reinfection and aseptic revision rates along with complication rates were compared.

RESULTS

The reinfection rate for DAIR in acute culture-negative PJI was 13.0% compared to 19.4% in culture-positive PJI (P = .48). Mean survival time from reinfection between culture-negative (7.7 ± 0.4 years) and culture-positive (7.4 ± 0.3 years) PJI groups did not differ significantly (P = .40). Aseptic revision rates were 8.7% and 4.9% (P = .46), respectively, with loosening being the primary reason for implant failure in both cohorts.

CONCLUSIONS

Despite lack of an identifying organism to guide postoperative antibiotic therapy, DAIR with modular component exchange for acute culture-negative PJI was associated with similar reinfection rates compared to acute culture-positive PJI, suggesting that culture negativity may not be a contraindication to DAIR in patients with acute PJI.

Reverse total shoulder arthroplasty compared to stemmed hemiarthroplasty for proximal humeral fractures: a registry analysis of 5946 patients

BACKGROUND

There is an increasing trend toward the use of reverse total shoulder arthroplasty (RTSA) over stemmed hemiarthroplasty (HA) for the management of proximal humeral fractures. There are limited data available comparing the revision rates for RTSA and HA in the setting of a fracture. The aim of this study was to compare the revision rates for RTSA and HA when used for the treatment of a fracture and to analyze the effect of demographics and prosthesis fixation on these revision rates.

METHODS

Data obtained from the Australian Orthopaedic Association National Joint Replacement Registry from April 16, 2004, to December 31, 2017, included all procedures for primary diagnosis proximal humeral fracture. The analyses were performed using Kaplan-Meier estimates of survivorship and hazard ratios from Cox proportional hazards models.

RESULTS

Over the study period, there were 3049 (51%) RTSA and 2897 (49%) HA procedures. The cumulative percent revision rate at 9 years was lower for the RTSA than for the HA: 7.0% (95% confidence interval [CI], 4.8-10.1) compared with 11.7% (95% CI, 10.3-13.2). Between 0 and 6 months, the HA had a significantly lower revision rate than the RTSA (hazard ratio, 0.50; 95% CI, 0.34-0.72; P < .001). Between 6 month and 3 years, the HA had a significantly higher revision rate. For the RTSA, males have a significantly higher rate of revision compared with females. There is a higher rate of early revision due to instability in younger persons (55-64) and males. For both RTSA and HA, cemented prostheses have lower revision rates compared with cementless prostheses.

CONCLUSIONS

RTSA has a significantly lower revision rate compared with HA for the treatment of proximal humeral fractures in females. Younger patients (<65) and males are at risk of early revision secondary to instability. In these patient groups, either alternatives to RTSA or further attention to fixation of tuberosities and shoulder rehabilitation may be indicated.

Cemented vs. uncemented glenoid fixation in total shoulder arthroplasty for osteoarthritis: a New Zealand Joint Registry study

BACKGROUND

Total shoulder arthroplasty (TSA) is commonly performed for shoulder osteoarthritis (OA). Uncemented metal-backed (MB) glenoid components were introduced in an attempt to avoid glenoid loosening. New Zealand and Australian Joint Registry studies have shown significantly higher revision rates when uncemented MB glenoids are used. We used the New Zealand Joint Registry (NZJR) to compare all-cause revision rates and functional scores for TSA and investigated the trends of glenoid fixation used in New Zealand.

METHODS

The NZJR was accessed for all primary TSA undertaken for OA from January 2000 to December 2017. Patient demographics were collated. All-cause revision rates were reported as rate per 100 component-years. Analysis was repeated excluding the uncemented SMR L2 glenoid (LimaCorporate), as it was a potential confounder. Kaplan-Meier survival analysis was performed. Oxford Shoulder Scores at both 6 months and 5 years were analyzed.

RESULTS

A total of 2613 TSAs were performed for OA during the study period, representing 85.0% of all TSAs in New Zealand. Overall, 62.1% of the patients were female. In addition, 69.6% of glenoids were cemented and 30.4% uncemented. The most common uncemented MB glenoid was SMR 86.6% (LimaCorporate), and cemented was Global (DePuy) 49.8%. The revision rate for TSA with uncemented glenoids was significantly higher at 2.03 compared with cemented at 0.41 per 100 component-years (P < .001). Hazard ratio 5.0 for revision of uncemented glenoids. No significant difference was found in Oxford Scores at 6 months (39.7 vs. 40.3, P = .13) or 5 years (42.1 vs. 42.8, P = .22). The most common mode of failure was glenoid loosening in cemented glenoids (44.4%), and component failure in uncemented (34.8%). Revision for rotator cuff, deep infection, and instability were comparable between groups. When excluding SMR L2, uncemented MB glenoid all-cause revision rates remained significantly higher than cemented (1.42 vs. 0.41 per 100 component-years, P < .001). SMR L1 uncemented MB glenoids had a higher revision rate than the non-SMR uncemented glenoids (1.61 vs. 0.18 per 100 component-years, P = .009). Uncemented glenoid use peaked in New Zealand in 2011 at 46.7% of TSAs but declined to 20.1% in 2017.

CONCLUSIONS

In the NZJR, primary TSAs undertaken for OA have a significantly higher all-cause revision rate when the glenoid component is uncemented. Uncemented glenoids have a 5.0 times higher revision rate. Excluding SMR L2 glenoids from the analysis, the significantly higher revision rate remained for uncemented glenoids. These data reaffirm that uncemented MB glenoids are associated with higher revision rates.

Lower operating volume in shoulder arthroplasty is associated with increased revision rates in the early postoperative period: long-term analysis from the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

Improved short-term outcomes have been demonstrated with higher surgical volume in shoulder arthroplasty. There is however, little data regarding long-term outcomes.

METHOD

Revision data from the Australian Orthopaedic Association National Joint Replacement Registry from 2004-2017 was analyzed according to 3 selected surgeon volume thresholds: <10, 10-20, and >20 shoulder arthroplasty cases per surgeon, per year.

RESULTS

There was a significantly higher rate of revision for stemmed total shoulder arthroplasty (TSA) for osteoarthritis (OA) for the <10/yr compared with the >20/yr group for the first 1.5 years only (hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.08-1.71, P = .009). For reverse total shoulder arthroplasty (rTSA) performed for OA, there was a higher revision rate for the <10/yr compared with the >20/yr group for the first 3 months only (HR 2.58, 95% CI 1.67-3.97, P < .001). In rTSA for cuff arthropathy, there was a significantly higher rate of revision for the <10/yr compared with the >20/yr group throughout the follow-up period (HR 1.66, 95% CI 1.21-2.28, P = .001). There was no significant difference for the primary diagnosis of fracture.

CONCLUSION

Lower surgical volume was associated with higher all-cause revision rates in the early postoperative period in TSA and rTSA for OA and throughout the follow-up period in rTSA for cuff arthropathy. Despite increases in the volume of shoulder arthroplasties performed in recent years, more than 78% of surgeons undertake fewer than 10 procedures per year.

Patients With Modular-Neck Total Hip Arthroplasty: A Brief Five-Year Follow-Up Study

BACKGROUND

We have previously reported the early clinical results of a modular-neck stem identifying an early 2-year revision rate of 13% due to neck-stem corrosion. This report updates our findings to a midterm mean follow-up of 5 years.

METHODS

This is a consecutive retrospective review of 186 modular-neck hips in 175 patients with a mean follow-up period was 60.1 ± 22.9 months (range 24-100). We reviewed clinical findings, routine radiographs, detailed imaging (metal artifact reduction software-magnetic resonance imaging, ultrasound), and serum ion levels of cobalt and chromium. We performed a survival analysis with the endpoint defined as revision total hip arthroplasty due to neck-stem corrosion.

RESULTS

We revised 41 hips (22.0%) for neck-stem corrosion. Clinical symptoms (groin pain ± local swelling) were consistently present in those that came for revision. Mean serum cobalt ion levels increased as time passed in all patients. Detailed image findings showed that larger fluid collections and local soft tissue masses were seen predominately in symptomatic patients. However, 14% of patients who underwent revision did not have positive magnetic resonance imaging or ultrasound findings. The survival rate was 87% (95% confidence interval 81-92) at 3 years postoperatively and 72% (95% confidence interval 64-80) at 7 years postoperatively.

CONCLUSION

The revision rate for this modular-neck stem due to neck-stem corrosion at mid-term follow-up almost doubled in comparison to previous short-term results. It seems reasonable to consider clinical follow-up alone as symptoms, rather than blood testing for ion levels, seem to be the defining characteristic of failure.

Low Hospital Volume Increases Re-Revision Rate Following Aseptic Revision Total Knee Arthroplasty: An Analysis of 23,644 Cases

BACKGROUND

Along with rising numbers of primary total knee arthroplasty (TKA), the number of revision total knee arthroplasties (R-TKAs) has been increasing. R-TKA is a complex procedure requiring special instruments, implants, and surgical skills. Therefore it is likely that hospitals with more R-TKAs have more experience with this type of surgery and therefore fewer complications. The purpose of this study is to evaluate the relationship between hospital volume and re-revision rate following R-TKA.

METHODS

Using nationwide healthcare insurance data for inpatient hospital treatment, 23,644 aseptic R-TKAs in 21,573 patients treated between January 2013 and December 2017 were analyzed. Outcomes were 90-day mortality, 1-year re-revision rate, and in-house adverse events. The effect of hospital volumes on outcomes were analyzed by means of multivariate logistic regression. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

Hospital volume had a significant effect on 1-year re-revision rate (≤12 R-TKA/a: OR 1.44, CI 1.20-1.72; 13-24 R-TKA/a: OR 1.43, CI 1.20-1.71; 25-52 R-TKA/a: OR 1.13, CI 0.94-1.35; ≥53 R-TKA/a: reference). Ninety-day mortality and major in-house adverse events decreased with increasing volume per year, but after risk adjustment this was not statistically significant.

CONCLUSION

We found evidence of higher risk for re-revision surgery in hospitals with fewer than 25 R-TKA per year. It might contribute to improved patient care if complex elective procedures like R-TKA which require experience and a specific logistic background were performed in specialized centers.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Patient Characteristics Influence Revision Rate of Total Hip Arthroplasty: American Society of Anesthesiologists Score and Body Mass Index Were the Strongest Predictors for Short-Term Revision After Primary Total Hip Arthroplasty

BACKGROUND

Outcome and survival after primary total hip arthroplasty (THA) can be affected by patient characteristics. We examined the effect of case-mix on revision after primary THA using the Dutch Arthroplasty Register.

METHODS

Our cohort included all primary THAs (n = 218,214) performed in patients with osteoarthritis in the Netherlands between 2007 and 2018. Multivariable logistic regression analysis was used to calculate the difference in survivorship in patients with different patient characteristics (age, gender, American Society of Anesthesiologists [ASA] score, body mass index [BMI], Charnley score, smoking, and previous operations to the hip).

RESULTS

Case-mix factors associated with an increased risk for revision 1 year after THA were the following: a high ASA score (II and III-IV) (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1-2.0 and OR 3.0, 95% CI 1.7-5.3), a higher BMI (30-40 and >40) (OR 1.4, 95% CI 1.2-1.5 and OR 2.0, 95% CI 1.4-1.7), age ≥75 years (OR 1.5, 95% CI 1.1-2.0), and male gender (OR 1.3, 95% CI 1.2-1.4). A similar model for 3-year revision showed comparable results. High BMI (OR 1.9, 95% CI 1.3-2.9), a previous hip operation (OR 1.8, 95% CI 1.3-2.5), ASA III-IV (OR 1.2, 95% CI 1-1.6), and Charnley score C (OR 1.5, 95% CI 1.1-2.2) were associated with increased risk for revision. Main reasons for revision in obese and ASA II-IV patients were infection, dislocation, and periprosthetic fracture. Patients with femoral neck fracture and late post-traumatic pathology were more likely to be revised within 3 years, compared to osteoarthritis patients (OR 1.5, 95% CI 1.3-1.7 and OR 1.5, 95% CI 1.2-1.7).

CONCLUSION

The short-term risk for revision after primary THA is influenced by case-mix factors. ASA score and BMI (especially >40) were the strongest predictors for 1-year revision after primary THA. After 3 years, BMI and previous hip surgery were independent risk factors for revision. This will help surgeons to identify and counsel high-risk patients and take appropriate preventive measures.

Long-Term Outcomes of Ultra-Short Metaphyseal-Fitting Anatomic Cementless Femoral Stem in Total Hip Arthroplasty With Ceramic-on-Ceramic Articulation for Young Patients

BACKGROUND

The aim of this study is to assess the long-term outcomes of this specific stem in patients younger than 50 years old, with regard to clinical and radiographic outcomes, survivorship, and complication rate.

METHODS

Two hundred thirty-nine consecutive series of patients (324 hips) who were younger than 50 years old at the time of surgery were enrolled in the study. Osteonecrosis (50%) and dysplastic hip (34%) were most common diagnoses. Patients were informed to use crutches or walker for 4 weeks to protect the femoral component against rotational stress. The mean follow-up was 15.6 years (range 14-17).

RESULTS

At the latest follow-up, the mean Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index score, and University of California, Los Angeles activity score were 93 points, 13 points, and 7 points, respectively. Three patients (1.3%) had moderate thigh pain. All of the acetabular components and 321 (99%) femoral stems were solidly fixed at the time of the latest follow-up. Three stems (0.9%) were revised for aseptic loosening. Two hips (0.6%) had a dislocation and 2 hips (0.6%) had a periprosthetic fracture. Ceramic fracture or osteolysis was not found in any hip at the time of the final follow-up. Survival rate of the femoral component was 99.1% (95% confidence interval 94-100) and that of the acetabular component was 100% (95% confidence interval 94-100) at 15.6 years.

CONCLUSION

In this series, THA using an ultra-short metaphyseal-fitting anatomic cementless femoral stem provided excellent long-term clinical and radiographic results in patients younger than 50 years old. Furthermore, our initial theoretical concerns about early aseptic loosening due to the absence of distal stem fixation were not justified.

Low Hospital Volume Increases Revision Rate and Mortality Following Revision Total Hip Arthroplasty: An Analysis of 17,773 Cases

BACKGROUND

With the number of primary total hip arthroplasty (THA), the amount of revision THA (R-THA) increases. R-THA is a complex procedure requiring special instruments, implants, and surgical skills. Therefore it is likely that hospitals performing a higher number of R-THAs have more experience with this type of surgery and therefore fewer complications. The purpose of this study was to evaluate the relationship between hospital volume and risk of postoperative complications following R-THA.

METHODS

Using nationwide healthcare insurance data for inpatient hospital treatment, 17,773 aseptic R-THAs in 16,376 patients treated between January 2014 and December 2016 were included. Outcomes were 90-day mortality, 1-year revision procedures, and in-house adverse events. The effect of hospital volume on outcome was analyzed by means of multivariate logistic regression. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

Hospital volume had a significant effect on 90-day mortality (≤12 cases per year: OR 2.13, CI 1.53-2.96; 13-24: OR 1.79, CI 1.29-2.50; 25-52: OR 1.53, CI 1.11-2.10; ≥53: reference) and 1-year revision procedures (≤12: OR 1.26, CI 1.09-1.47; 13-24: OR 1.18, CI 1.02-1.37; 25-52: OR 1.03, CI 0.90-1.19; ≥53: reference). There was no significant effect on risk-adjusted major in-house adverse events.

CONCLUSION

We found evidence of higher risk for revision surgery and mortality in hospitals with fewer than 25 and 53 R-THA per year, respectively. To improve patient care, complex elective procedures like R-THA which require experience and a specific logistic background should be performed in specialized centers.

Cementless versus cemented glenoid components in conventional total shoulder joint arthroplasty: analysis from the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

Glenoid loosening is a common mode of failure after total shoulder arthroplasty (TSA). Newer cementless glenoid components have been introduced to promote biological fixation with the aim to decrease glenoid loosening. Limited data are available comparing revision rates between cemented and cementless glenoid fixation in TSA. The study aim was to compare the revision rates of cemented and cementless design glenoid components used in conventional TSA performed for the diagnosis of osteoarthritis. The secondary aim was to compare various subclasses of glenoid components.

METHODS

Data were obtained between April 16, 2004, and December 31, 2016, from the Australian Orthopaedic Association National Joint Replacement Registry. Within the study period, 10,805 primary conventional TSAs were identified. The analysis was undertaken for the diagnosis of osteoarthritis, which represented 95.8% of all conventional TSA procedures.

RESULTS

At 5 years, in patients with primary TSA procedures, those with cemented glenoids had a lower revision rate than those with cementless glenoids: 3.7% versus 17.9% (hazard ratio for entire period, 4.77). The most common revision diagnosis for primary conventional TSA with cementless glenoid fixation was rotator cuff insufficiency (4.4% for cementless vs 0.4% for cemented), instability and/or dislocation (3.8% for cementless vs 0.8% for cemented), and loosening and/or lysis (1.1% for cementless vs 1.1% for cemented).

CONCLUSIONS

Cementless glenoid components in conventional TSA had a significantly higher revision rate than cemented glenoid components. The loosening rates between cemented and cementless glenoid components were similar. Glenoid design and fixation are important considerations when selecting a prosthesis for TSA.

Early Functional, Radiological Outcomes and Satisfaction Rates of Total Ankle Arthroplasty in an Asian Population

BACKGROUND

Few studies have outlined the outcomes and complications in Asians undergoing total ankle arthroplasty. This study reports the functional, radiological outcomes and satisfaction rates in our Asian population.

METHODS

Patients who underwent primary total ankle arthroplasty from 2007 to 2013 were recruited. Outcomes evaluated were the AOFAS Ankle-Hindfoot Score (AHS), Visual Analogue Scale (VAS), and the Short Form 36 (SF-36)questionnaire. Outcome scores were collected prospectively up to 2 years. Patient satisfaction was evaluated on a 6-point scale based on North American Spine Society Low Back Pain Instrument and classified as satisfied or unsatisfied.

RESULTS

Forty-one patients underwent primary total ankle arthroplasty. All patients experienced improvements in AHS, VAS, and Mental Component Summary score of the SF-36 at both 6-month and 2-year postoperative interval. The mean AHS score improved from 35 ± 19 points preoperatively to 64 ± 24 at 6 months (P<.001) and 72 ± 26 at 24 months (P <.001). VAS scores improved from 7 ± 2 preoperatively to 3 ± 3 (P < .001) at 6 and 24 months. The Physical Component Summary (PCS) of the SF-36 has an established minimum clinically important difference (MCID) of 5. The mean improvement in PCS in our cohort met this MCID for the PCS; 63% and 71% of patients were satisfied with the procedure at 6 months and 2 years postoperatively, respectively. Revision rate in this series was 9.7%.

CONCLUSION

Total ankle arthroplasty has good patient satisfaction rates, with favorable early clinical outcome in Asian patients.

LEVELS OF EVIDENCE

Therapeutic, Level II.

Short-term and long-term revision rates after lumbar spine discectomy versus laminectomy: a population-based cohort study

BACKGROUND/OBJECTIVE

Degenerative diseases of the lumbar spine were managed with discectomy or laminectomy. This study aimed to compare these two surgical treatments in the postoperative revision rates.

DESIGN

A population-based cohort study from analysis of a healthcare database.

SETTING

Data were gathered from the Taiwan National Health Insurance Research Database (NHIRD).

PARTICIPANTS

We enrolled 16 048 patients (4450 women and 11 598 men) with a mean age of 40.34 years who underwent lumbar discectomy or laminectomy for the first time between 1 January 1997 and 31 December 2007. All patients were followed up for 5 years or until death.

RESULTS

Revision rate within 3 months of the index surgery was significantly higher in patients who underwent discectomy (2.75%) than in those who underwent laminectomy (1.18%; p<0.0001). This difference persisted over the first year following the index surgery (3.38% vs 2.57%). One year afterwards, the revision rates were similar between the discectomy (9.75%) and laminectomy (9.69%) groups. The final spinal fusion surgery rates were also similar between the groups (11.25% vs 12.08%).

CONCLUSION

The revision rate after lumbar discectomy was higher than that after laminectomy within 1 year of the index surgery. However, differences were not identified between patient groups for the two procedures with respect to long-term revision rates and the proportion of patients who required final spinal fusion surgery.

Minimally invasive posterior cervical foraminotomy with tubes to prevent undesired fusion: a long-term follow-up study

OBJECTIVE

The objective of this study was to compare anterior cervical discectomy and fusion (ACDF) and minimally invasive posterior cervical foraminotomy (MI-PCF) with tubes for the treatment of cervical radiculopathy in terms of the 1) overall revision proportion, 2) index and adjacent level revision rates, and 3) functional outcome scores.

METHODS

The authors retrospectively reviewed the records of consecutive patients who had undergone ACDF or MI-PCF at a single institution between 2009 and 2014. Patients treated for cervical radiculopathy without myelopathy and with a minimum 2-year follow-up were compared according to the procedure performed for their pathology. Primary outcome measures included the overall rate of revision with fusion and overall revision proportion as well as the rate of index and adjacent level revisions per year. Secondarily, self-reported outcome measures-Neck Disability Index (NDI) and visual analog scale (VAS) for arm (VASa) and neck (VASn) pain-at the preoperative and postoperative evaluations were analyzed. Standard binomial and categorical comparative analyses were performed.

RESULTS

Forty-nine consecutive patients were treated with MI-PCF, and 210 consecutive patients were treated with ACDF. The mean follow-up for the MI-PCF cohort was 42.9 ± 6.6 months (mean ± SD) and for the ACDF cohort was 44.9 ± 10.3 months. There was no difference in the overall revision proportion between the two cohorts (4 [8.2%] of 49 MI-PCF vs. 12 [5.7%] of 210 ACDF, p = 0.5137). There was no difference in the revision rate per level per year (3.1 vs. 1.7, respectively, p = 0.464). Moreover, there was no difference in the revision rate per level per year at the index level (1.8 vs. 0.7, respectively, p = 0.4657) or at an adjacent level (1.3 vs. 1.1, p = 0.9056). Neither was there a difference between the cohorts as regards the change from preoperative to final postoperative functional outcome scores (NDI, VASa, VASn).

CONCLUSIONS

Minimally invasive PCF for the treatment of cervical radiculopathy demonstrates rates of revision at the index and adjacent levels similar to those following ACDF. In order to confirm the positive efficacy and cost analysis findings in this study, future studies need to extend the follow-up and show that the rate of revision with fusion does not increase substantially over time.

Survival Rate of Short-Stem Hip Prostheses: A Comparative Analysis of Clinical Studies and National Arthroplasty Registers

BACKGROUND

The primary aim was to evaluate the outcome of short-stem hip prostheses in terms of overall revision rates. Data were taken from published literature and national arthroplasty registers. The second study aim was to evaluate a potentially superior outcome of dependent compared to independent clinical studies.

METHODS

All clinical studies on short-stem hip prostheses between 2006 and 2016 were reviewed and evaluated with a special interest on revision rates. Revision rate was calculated as "revision per 100 component years." Short stems were divided into femoral neck retaining (NR), neck sparing (NS), and neck harming (NH) prostheses. Published literature was further classified into dependent and independent studies, and data were compared to the Australian National Arthroplasty Register.

RESULTS

Fifty-two studies with 56 cohorts met the inclusion criteria and were therefore included in our study. All clinical studies showed a median revision rate of 4.8% after 10 years. NS and NH stems performed equally, whereas neck retaining prostheses were significantly inferior. Independent showed higher revision rates compared to dependent data without being statistically significant. The Australian register revealed a revision rate of 6.6% after one decade.

CONCLUSION

Similar low revision rates for NS and NH short-stem prostheses were found in the included data. Dependent studies seem not to be biased with regard to the longevity of short-stem hip replacement. Longer follow-up periods in clinical studies and more detailed information in arthroplasty registers would be desirable for future studies.

In-Hospital Morbidity and Postoperative Revisions After Direct Anterior vs Posterior Total Hip Arthroplasty

BACKGROUND

The direct anterior approach (DAA) offers the potential for less soft tissue insult, improved early recovery, and reduced dislocation rates. However, complications are associated with the DAA, particularly during the learning curve. We compare the DAA learning curve experience with the posterior approach regarding in-hospital complications and revision rate.

METHODS

We evaluated systemic and local in-hospital complications associated with primary unilateral cementless THAs from January 1, 2010 to December 31, 2012 in 4249 patients through a posterior approach and 289 patients through a DAA. All procedures were performed consecutively by high-volume surgeons who use a single approach in a nonselective manner. The DAA was performed by surgeon transitioning from the posterior approach, thus incorporating the learning curve. Demographics were comparable. Revision procedures were captured through a minimum 4-year follow-up. Analyses compared complication and revision rates.

RESULTS

The DAA group demonstrated shorter length of stay, procedure time, lower blood transfusion rate, and increased discharge to home rate. Local and major systemic in-hospital complications were rare and comparable between groups. The minor systemic complication rate was significantly greater for the posterior group (10.9% posterior vs 6.2% DAA, P < .05). Revision rate was significantly greater for the posterior group (2.7% posterior vs 0.7% DAA, P < .032). The incidence of revision for dislocation was 1.5% for the posterior approach vs 0.4% for the DAA.

CONCLUSION

There was an increased rate of in-hospital minor systemic complications and overall revision, predominantly due to instability, after THA by the posterior approach, in comparison with the DAA.

Highly Cross-Linked Polyethylene Reduces Osteolysis Incidence and Wear-Related Reoperation Rate in Cementless Total Hip Arthroplasty Compared With Conventional Polyethylene at a Mean 12-Year Follow-Up

BACKGROUND

A number of studies on total hip arthroplasty have compared highly cross-linked polyethylene (HXLPE) with conventional polyethylene (CPE) liners beyond 10 years. However, the impact of HXLPE on the wear-related reoperation rate is unclear. The purpose of this study was to evaluate the clinical advantage of using a single manufacturer's HXLPE in terms of reducing the reoperation rate.

METHODS

The study was a follow-up retrospective cohort study over a mean of 12 years that examined patients aged 45-70 years with cementless total hip arthroplasty using a 26-mm-diameter cobalt-chromium head. Sixty-seven patients (79 hips; HXLPE group = 41 hips, CPE group = 38 hips) were evaluated for a minimum 10-year follow-up. Kaplan-Meier survival analysis was performed, with wear-related reoperations and radiographic osteolysis serving as the end points. The polyethylene wear rate was also assessed.

RESULTS

The mean 12-year follow-up rates of survivorship that were evaluated using wear-related reoperations as the end point were 100% and 91.4% in the HXLPE and CPE groups, respectively (P = .007), and the mean 12-year follow-up rates of survivorship with osteolysis as the end point were 100% and 36.2%, respectively (P < .001). Compared with the CPE group, the HXLPE group presented a significantly reduced wear rate (HXLPE group, 0.035 mm/y; CPE group, 0.118 mm/y).

CONCLUSION

A unique strength of this study is that we assessed a single manufacturer's HXLPE while keeping most other implant parameters uniform. This study reveals the clinical advantage of using a single manufacturer's HXLPE in terms of a reduced wear-related reoperation rate at a mean 12-year follow-up.

Thirty-Year Experience With ACL Reconstruction Using Patellar Tendon: A Critical Evaluation of Revision and Reoperation

Background:

During the preoperative discussion prior to anterior cruciate ligament reconstruction (ACLR), patients are often interested in data regarding rates of revision reconstruction, reoperation, concomitant pathologic changes, and future contralateral ACL injury.

Purpose:

To analyze a single surgeon’s experience with primary and revision ACLR over a 30-year interval, focusing on incidence and risk factors for revision and reoperation.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients who underwent ACLR from 1986 to 2016 were identified from a prospectively maintained database. Covariates of interest included age, sex, time, and graft selection. Outcomes of interest included revision and reoperation rates.

Results:

A total of 2450 ACLRs (mean patient age, 29 years; 58% male) were reviewed. Among primary ACLRs performed (n = 2225), 68% entailed bone–patellar tendon–bone (BTB) autograft and 30% entailed BTB allograft. Patients undergoing ACLR with autograft and allograft had a mean age of 22 and 37 years, respectively. The rate of revision ACLR was 1.8% and 3.5% for primary and revision cases, respectively. An increased rate of revision was noted among females compared with males (2.6% vs 1.2%) and among allografts compared with autografts (2.7% vs 1.3%). Low-dose irradiation did not affect allograft revision rates. The nonrevision reoperation rate following primary ACLR was 12%. The nonrevision reoperation rate was lower among primary cases reconstructed with allograft than autograft (9% vs 13%). Seventeen percent of cases involved concomitant meniscal repair and, among these, 13% required revision meniscal surgery. The rate of contralateral ACLR was 5.3%

Conclusion:

This information is useful in the informed consent process, for perioperative decision making regarding graft choice, and for identifying patients who are at risk for injuring the uninvolved knee.

Does Computer Assisted Navigation Improve Functional Outcomes and Implant Survivability after Total Knee Arthroplasty?

The objective of this study was to determine whether computer assisted navigation in total knee arthroplasty (TKA) improves functional outcomes and implant survivability using data from a large national database. We analysed 9054 primary TKA procedures performed between 2006 and 2012 from the New Zealand National Joint Registry. Functional outcomes were assessed using Oxford Knee Questionnaires at six months and five years. On multivariate analysis, there was no significant difference in mean Oxford Knee Scores between the navigated and non-navigated groups at six months (39.0 vs 38.1, P=0.54) or five years (42.2 vs 42.0, P=0.76). At current follow-up, there was no difference in revision rates between navigated and non-navigated TKA (0.46 vs 0.43 revisions 100 component years, P=0.8).

Causes and rates of revision total knee arthroplasty: Local results from Isfahan, Iran

Background:

Knee replacement is one of the most frequently performed surgical procedures in the world. Local data on revision total knee arthroplasty (TKA) are limited. This study aims to assess the rates and causes of revision TKA in Kashani Hospital (Isfahan, Iran) from 2011 to 2013.

Materials and Methods:

We assessed all primary TKA and revision TKA procedures performed from 2011 to 2013 for the rate and causes of failures. Demographic data, duration from primary TKA to revision TKA and underlying diagnosis for primary TKA were also assessed.

Results:

Overall, 353 primary TKA procedures carried out in this period. The overall revisions following primary TKA in this period was 24 cases, indicating a revision burden of 6.8%. The most common cause of revision TKA was infection, which was in 16 cases (44.4%). Other causes included patellar complications, mechanical loosening of both tibia and femur, mechanical loosening of tibia, instability, and periprosthetic fracture. The main revision procedures were all component revision, tibial component revision, isolated tibial insert exchange and patellar tendon repair. The most common revision procedure was two stage all component revision, which was carried out in 13 subjects (36.1%).

Conclusion:

Local indications for revision TKA are mainly similar to those in other large centers. As compared with other centers, with considering the follow-up time, revision burden is relatively higher in this center.

Effect of glenoid cementation on total shoulder arthroplasty for degenerative arthritis of the shoulder: a review of the New Zealand National Joint Registry

BACKGROUND

Despite the lack of literature showing improved results compared with cemented designs, uncemented glenoid components are still commonly used in total shoulder arthroplasty (TSA). Most studies comparing cemented with uncemented glenoids involve small numbers or include patients with inflammatory arthritis.

METHODS

New Zealand National Joint Registry data was used to compare the outcomes of uncemented and cemented glenoids in TSA performed for degenerative arthritis. Measured variables were the revision rate and the Oxford Shoulder Score (OSS).

RESULTS

Data were retrieved on 1596 patients, with a mean follow-up 3.5 years (range 2-10.7 years), 1065 of whom had a cemented glenoid. There were no significant differences in any preoperative factors between the 2 groups. The revision rate for uncemented glenoids was 4.4 times higher than for cemented glenoids (1.92 vs. 0.44 revisions per 100 component-years, P < .001). Age <55 years was an independent risk factor for revision (P < .001). The most common reason for revision was rotator cuff wear (35.5%) in the uncemented glenoids and loosening (36.3%) in the cemented glenoids. The difference in the mean OSS between the 2 groups was less than 1 point at 6 months (P = .109) and at 5 years (P = .377).

CONCLUSION

Uncemented glenoids had a markedly higher revision rate. Patients aged <55 years have the highest revision rate regardless of glenoid fixation method. The higher revision rate in the uncemented glenoid group persisted when the effect of young age was corrected for. There was no clinically or statistically significant difference in the OSS results for clinical outcome between the two groups.

LEVEL OF EVIDENCE

Level III, retrospective cohort, treatment study.

Rates of revision and device failure in cochlear implant surgery: a 30-year experience

OBJECTIVES/HYPOTHESIS

To characterize revision cochlear implant surgery and quantify rates of revision and device failure.

STUDY DESIGN

Retrospective review of 235 cases of revision cochlear implant surgery performed at the Sydney Cochlear Implant Center over a period of 30 years, between January 1982 and June 2011.

METHODS

Patient demographics and characteristics of revision surgery were retrospectively extracted from a centralized database. Analyses of overall and cumulative rates were performed.

RESULTS

During the study period, 2,827 primary cochlear implantations were performed in 2,311 patients, with 201 primary implants in 191 patients of this cohort (109 children and 82 adults) undergoing 235 revision surgeries. The most common indication for revision surgery was device failure (57.8%), followed by migration/extrusion (23.4%), infection/wound complication (17.0%), and poor outcome/secondary pathology (6.4%). The majority of revision surgeries were reimplantations. Overall revision and device failure rates were 8.3% and 4.8%, respectively. The cumulative revision rate for primary implants at all ages increased linearly by 1% per year. The cumulative revision rate was significantly higher in children, and decreased with more recently performed implantations and with newer generations of implants.

CONCLUSIONS

The cumulative revision rate for primary implants suggests an ongoing linear relationship between the time of postprimary implantation and the need for revision surgery. We have formed an evidence base that characterizes the nature and frequency of revision surgery in a high-volume setting, allowing clinicians to effectively counsel prospective patients and clinics to understand the burden of revision surgery and device failure.

Total shoulder arthroplasty versus hemiarthroplasty for glenohumeral arthritis: A systematic review of the literature at long-term follow-up

Introduction:

The optimal surgical treatment of end-stage primary glenohumeral osteoarthritis remains controversial. The objective of this article is to systematically review the current available literature to formulate evidence-based guidelines for treatment of this pathology with an arthroplasty.

Materials and Methods:

A systematic literature search was performed to identify all articles from 1990 onward that presented data concerning treatment of glenohumeral arthritis with total shoulder arthroplasty (TSA) or head arthroplasty (HA) with a minimal follow-up of 7 years. The most relevant electronic databases were searched.

Results:

After applying the inclusion and exclusion criteria, we identified 18 studies (of the initial 832 hits). The search included a total of 1,958 patients (HA: 316 and TSA: 1,642) with 2,111 shoulders (HA: 328 + TSA: 1,783). The revision rate for any reason in the HA group (13%) was higher than in the TSA group (7%) (P < 0.001). There was a trend of a higher complication rate (of any kind) in the TSA group (12%) when compared with the HA group (8%) (P = 0.065). The weighted mean improvement in anteflexion, exorotation and abduction were respectively 33°, 15° and 31° in the HA group and were respectively 56°, 21° and 48° in the TSA group. Mean decrease in pain scores was 4.2 in the HA and 5.5 in the TSA group.

Conclusion:

Finally, we conclude that TSA results in less need for revision surgery, but has a trend to result in more complications. The conclusions of this review should be interpreted with caution as only Level IV studies could be included.

Level of Evidence:

IV.

Comparative pooled survival and revision rate of Austin-Moore hip arthroplasty in published literature and arthroplasty register data

The aim was to evaluate the pooled survival and revision rate of Austin-Moore hip arthroplasty (AMHA) in published literature and arthroplasty register data. A comprehensive literature analysis of clinical publications and register reports was conducted with the main endpoints revision surgery and revision rate. Sixteen relevant clinical studies have been found to significantly underestimate revision rates by a ratio of 2.15 compared to register data sets. The medium-term outcome of AMHA showed significantly worse outcomes than the use of other bipolar implants, or modular cervicocephalic prostheses and data of journal publications on revision rates deviate significantly from data of arthroplasty registers.

A Retrospective Review of Anterior Cruciate Ligament Reconstruction Using Patellar Tendon: 25 Years of Experience

Background:

The comparative data in the literature regarding rates of reoperation, revision ligament surgery, and contralateral surgery following anterior cruciate ligament reconstruction (ACLR) are variable and are often derived from studies with multiple surgeons, multiple centers, different surgical techniques, and a wide variety of graft choices.

Purpose:

To describe and analyze a single surgeon’s experience with ACLR using bone–patellar tendon–bone (BPTB) as the primary graft choice over a 25-year period.

Study Design:

Retrospective case series.

Methods:

All patients who underwent ACLR from 1986 to 2012 were identified from a prospectively maintained database. Traditional follow-up was only for patients who sought subsequent surgery with the index surgeon or presented with contralateral ACL injury. Covariates of interest included age, sex, time, and graft selection. Outcomes of interest included reoperation rates after primary/revision ACLR, rate of revision ACLR, success of meniscal repair with concomitant ACLR, and the proportion of patients undergoing contralateral surgery.

Results:

A total of 1981 patients (mean age, 29 years; 49% male) were identified. Of patients undergoing primary ACLR (n = 1809), 74% had BPTB autograft and 26% had a central third BPTB allograft. The mean age of patients undergoing autograft and allograft ACLR was 26 and 36 years, respectively (P < .05). Allograft tissue usage increased over time (P < .05). The rate of personal ACLR revision surgery was 1.7% (n = 30) for primary cases and 3.5% (n = 6) for revision cases. There were no significant differences in revision rates between primary autograft (1.6%) and allograft (2.0%) ACLR. With allograft use, the method of sterilization did not affect revision rates. The overall reoperation rate following primary ACLR was 10%; the 5-year reoperation rate was 7.7%. The reoperation rate was lower for primary cases reconstructed with allograft versus autograft (5% vs 12%) (P < .0001). Among primary ACLR cases, 332 patients (18%) underwent concomitant meniscal repair; 14% required revision meniscal surgery. The rate of contralateral ACLR was 6%.

Conclusion:

This information is useful for patients in the informed consent process, for perioperative decision making regarding graft choice, and for identifying patients who are at risk for injuring the uninvolved knee. The observed results in this series also emphasize that allograft ACLR can produce sustainable results with low complication rates in appropriately selected patients.