This study evaluates the association between consultant and hospital volume and the risk of re-revision and 90-day mortality following first-time revision of primary hip replacement for aseptic loosening. We conducted a cohort study of first-time, single-stage revision hip replacements (RHR) performed for aseptic loosening and recorded in the National Joint Registry (NJR) data for England, Wales, Northern Ireland, and the Isle of Man between 2003 and 2019. Patient identifiers were used to link records to national mortality data, and to NJR data to identify subsequent re-revision procedures. Multivariable Cox proportional hazard models with restricted cubic splines were used to define associations between volume and outcome. Among 12,676 RHR there were 513 re-revisions within two years, and 95 deaths within 90 days of surgery. The risk of re-revision was highest for a consultant's first RHR (Hazard Ratio (HR) 1·58 (95%CI 1·16 to 2·15)) and remained significantly elevated for their first 26 cases (HR 1·26 (95%CI 1·00 to 1·58)). Annual consultant volumes of five/year were associated with an almost 30% greater risk of re-revision (HR 1·28 (95%CI 1·00 to 1·64)) and 80% greater risk of 90-day mortality (HR 1·81 (95%CI 1·02 to 3·21)) compared to volumes of 20/year. RHR performed at hospitals which had cumulatively undertaken fewer than 168 RHR were at up to 70% greater risk of re-revision (HR 1·70 (95% CI 1·12 to 2·60)), and those having undertaken fewer than 309 RHR were at up to three times greater risk of 90-day mortality (HR 3·06 (95% CI 1·19 to 7·86)). This study found a significantly higher risk of re-revision and early postoperative mortality following first-time single-stage RHR for aseptic loosening when performed by lower-volume consultants and at lower-volume institutions, supporting the move towards the centralisation of such cases towards higher-volume units and surgeons.
This study describes the variation in the annual volumes of revision hip arthroplasty (RHA) undertaken by consultant surgeons nationally, and the rate of accrual of RHA and corresponding primary hip arthroplasty (PHA) volume for new consultants entering practice. National Joint Registry (NJR) data for England, Wales, Northern Ireland, and the Isle of Man were received for 84,816 RHAs and 818,979 PHAs recorded between April 2011 and December 2019. RHA data comprised all revision procedures, including first-time revisions of PHA and any subsequent re-revisions recorded in public and private healthcare organizations. Annual procedure volumes undertaken by the responsible consultant surgeon in the 12 months prior to every index procedure were determined. We identified a cohort of ‘new’ HA consultants who commenced practice from 2012 and describe their rate of accrual of PHA and RHA experience.Aims
Methods
Approximately 15–20% of patients report chronic pain three months after total knee replacement (TKR). The STAR care pathway is a clinically important and cost-effective personalised intervention for patients with pain 3 months after TKR. The pathway comprises screening, assesment, onward referral for treatment and follow-up over one year. In a multicentre randomised controlled trial comparing the pathway with usual care, the pathway improved pain at 6 and 12 months. This study examined the longer-term clinical and cost-effectiveness of the STAR care pathway. STAR trial participants were followed-up at a median of 4 years post-randomisation. Co-primary outcomes were self-reported pain severity and interference in the replaced knee, assessed with the Brief Pain Inventory (BPI). Resource use from electronic hospital records was valued with UK reference costs.Abstract
Introduction
Methodology
To review the evidence and reach consensus on recommendations for follow-up after total hip and knee arthroplasty. A programme of work was conducted, including: a systematic review of the clinical and cost-effectiveness literature; analysis of routine national datasets to identify pre-, peri-, and postoperative predictors of mid-to-late term revision; prospective data analyses from 560 patients to understand how patients present for revision surgery; qualitative interviews with NHS managers and orthopaedic surgeons; and health economic modelling. Finally, a consensus meeting considered all the work and agreed the final recommendations and research areas.Aims
Methods
Several studies have reported that patients presenting during the evening or weekend have poorer quality healthcare. Our objective was to examine how timely surgery for patients with severe open tibial fracture varies by day and time of presentation and by type of hospital. This cohort study included patients with severe open tibial fractures from the Trauma Audit and Research Network (TARN). Provision of prompt surgery (debridement within 12 hours and soft-tissue coverage in 72 hours) was examined, using multivariate logistic regression to derive adjusted risk ratios (RRs). Time was categorized into three eight-hour intervals for each day of the week. The models were adjusted for treatment in a major trauma centre (MTC), sex, age, year of presentation, injury severity score, injury mechanism, and number of operations each patient received.Aims
Methods
Our main aim was to describe the trend in the comorbidities of patients undergoing elective total hip arthroplasties (THAs) and knee arthroplasties (KAs) between 1 January 2005 and 31 December 2018 in England. We combined data from the National Joint Registry (NJR) on primary elective hip and knee arthroplasties performed between 2005 and 2018 with pre-existing conditions recorded at the time of their primary operation from Hospital Episodes Statistics. We described the temporal trend in the number of comorbidities identified using the Charlson Comorbidity Index, and how this varied by age, sex, American Society of Anesthesiologists (ASA) grade, index of multiple deprivation, and type of KA.Aims
Methods
This study estimated trends in incidence of open fractures and the adherence to clinical standards for open fracture care in England. Longitudinal data collected by the Trauma Audit and Research Network were used to identify 38,347 patients with open fractures, and a subgroup of 12,170 with severe open fractures of the tibia, between 2008 and 2019 in England. Incidence rates per 100,000 person-years and 95% confidence intervals were calculated. Clinical care was compared with the British Orthopaedic Association Standards for Trauma and National Major Trauma Centre audit standards.Aims
Methods
Total hip replacement (THR) for end-stage osteoarthritis is a commonly performed cost-effective procedure, which provides patients with significant clinical improvement. Estimating the future demand for joint replacement is important to identify the healthcare resources needed. We estimated the number of primary THRs that will need to be performed up to the year 2060. We used data from The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man on the current volume of primary THR (n=94,936) performed in 2018. We projected future numbers of THR using a static estimated rate from 2018 applied to population growth forecast data from the UK Office for National Statistics up to 2060. By 2060, primary THR volume would increase from 2018 levels by an estimated 37.7% (n=130,766). For both males and females demand for surgery was also higher for patients aged 70 and over, with older patients having the biggest relative increase in volume over time: 70–79 years (144.6% males, 141.2% females); 80–89 years (212.4% males, 185.6% females); 90 years and older (448.0% males, 298.2% females). By 2060 demand for THR is estimated to increase by almost 40%. Demand will be greatest in older patients (70 years+), which will have significant implications for the health service that requires forward planning given morbidity and resource use is higher in this population. There is a backlog of current demand with cancellation of elective surgery due to seasonal flu pressures in 2017 and now Covid-19 in 2020. Orthopaedics already has the largest waiting list of any speciality. These issues will negatively impact the health services ability to deliver timely joint replacement to many patients for a number of years and require urgent planning.
This study explores the reported rate of surgical site infection (SSI) after hip fracture surgery in published studies concerning patients treated in the UK. Studies were included if they reported on SSI after any type of surgical treatment for hip fracture. Each study required a minimum of 30 days follow-up and 100 patients. Meta-analysis was undertaken using a random effects model. Heterogeneity was expressed using the I2 statistic. Risk of bias was assessed using a modified Newcastle-Ottawa Scale (NOS) system.Aims
Methods
Follow-up of arthroplasty varies widely across the UK. The aim of this NIHR-funded study was to employ a mixed-methods approach to examine the requirements for arthroplasty follow-up and produce evidence-based and consensus-based recommendations. It has been supported by BHS, BASK, BOA, ODEP and NJR. Four interconnected work packages have recently been completed: (1) a systematic literature review; (2a) analysis of routinely collected National Health Service data from four national data sets to understand when and which patients present for revision surgery; (2b) prospective data regarding how patients currently present for revision surgery; (3) economic modelling to simulate long-term costs and quality-adjusted life years associated with different follow-up care models and (4) a Delphi-consensus process, involving all stakeholders, to develop a policy document to guide appropriate follow-up care after primary hip and knee arthroplasty.
For ODEP10A∗ minimum implants, it is safe to disinvest in routine follow-up from 1 to 10 years post non-complex hip and knee replacement provided there is rapid access to orthopaedic review For ODEP10A∗ minimum implants in complex cases, or non-ODEP10A∗ minimum implants, periodic follow-up post hip and knee replacement may be required from 1 to 10 years At 10 years post hip and knee replacement, we recommend clinical, which may be virtual, and radiographic evaluation After 10 years post hip and knee replacement, frequency of further follow-up should be based on the 10-year assessment; ongoing rapid access to orthopaedic review is still required These recommendations apply to post primary hip and knee replacement follow-up The 10-year time point in these recommendations is based on a lack of robust evidence beyond ten years The term complex cases refer to individual patient and surgical factors that may increase the risk for replacement failure
Overarching statements
Few studies have compared aspirin with DOACs (direct oral anticoagulants = direct thrombin inhibitors and factor Xa inhibitors) for venous thromboembolism (VTE) prophylaxis following total hip and knee replacement (THR and TKR). We assessed the efficacy and safety of aspirin compared with DOACs for VTE prophylaxis following THR and TKR using the world's largest joint replacement registry. We studied the National Joint Registry linked to English hospital inpatient episodes for 218,650 THR and TKR patients. Patients receiving aspirin were matched separately to (1) direct thrombin inhibitors, and (2) factor Xa inhibitors using propensity scores. Outcomes assessed at 90 days included VTE, length of stay, and adverse events.Background
Methods
The aim of this study was to determine the polyethylene wear rate of Phase 3 Oxford Unicompartmental Knee Replacement bearings and to investigate the effects of resin type and manufacturing process. A total of 63 patients with at least ten years’ follow-up with three bearing types (1900 resin machined, 1050 resin machined, and 1050 resin moulded) were recruited. Patients underwent full weight-bearing model-based radiostereometric analysis to determine the bearing thickness. The linear wear rate was estimated from the change in thickness divided by the duration of implantation.Objectives
Methods
We compared implant and patient survival following intraoperative periprosthetic femoral fractures (IOPFFs) during primary total hip arthroplasty (THA) with matched controls. This retrospective cohort study compared 4831 hips with IOPFF and 48 154 propensity score matched primary THAs without IOPFF implanted between 2004 and 2016, which had been recorded on a national joint registry. Implant and patient survival rates were compared between groups using Cox regression.Aims
Patients and Methods
The aim of this study was to determine the long-term risk of undergoing knee arthroplasty in a cohort of patients with meniscal tears who had undergone arthroscopic partial meniscectomy (APM). A retrospective national cohort of patients with a history of isolated APM was identified over a 20-year period. Patients with prior surgery to the same knee were excluded. The primary outcome was knee arthroplasty. Hazard ratios (HRs) were adjusted by patient age, sex, year of APM, Charlson comorbidity index, regional deprivation, rurality, and ethnicity. Risk of arthroplasty in the index knee was compared with the patient’s contralateral knee (with Aims
Patients and Methods
Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control. We undertook an interrupted time series study with data from all patients aged more than 60 years with a hip fracture in England (2000 to 2018) using the Hospital Episode Statistics Admitted Patient Care (HES APC) data set linked to national death registrations. Difference-in-differences (DID) analysis incorporating equivalent data from the Scottish Morbidity Record was used to control for secular trends. The outcomes were 30-day and 365-day mortality, 30-day re-admission, time to operation, and acute length of stay.Aims
Materials and Methods
We investigated predictors of poor outcomes following metal-on-metal hip arthroplasty (MoMHA) revision surgery performed for adverse reactions to metal debris (ARMD), to help inform the revision threshold and type of reconstruction. A retrospective cohort study was performed involving 346 MoMHAs revised for histologically confirmed ARMD at two specialist centres (245=hip resurfacing, 101=total hip arthroplasty). Numerous preoperative (blood metal ions and imaging) and intraoperative (findings, and components removed/implanted) factors were used to predict poor outcomes. Poor outcomes were postoperative complications (including re-revisions), 90-day mortality, and poor Oxford Hip Scores (<27/48). Multivariable logistic regression models for predicting poor outcomes were developed using stepwise selection methods.Introduction
Patients and Methods
Smoking, a modifiable factor, may adversely affect post-operative outcomes. Healthcare providers are increasingly denying smokers access to total hip arthroplasty (THA) until they stop smoking. Evidence supporting this is unclear. We assessed the effect of smoking on outcomes following THA. We performed a retrospective observational study involving 60,812 THAs (12.4%=smokers, 31.2%=ex-smokers, 56.4%=non-smokers) from the Clinical Practice Research Datalink. Data were linked with Hospital Episode Statistics and the Office for National Statistics to identify outcomes. The effect of smoking on post-operative outcomes (complications, medications, revision, mortality, PROMs) was assessed using adjusted regression.Introduction
Patients and Methods
Total hip arthroplasty (THA) is indicated in independently mobile patients sustaining displaced intracapsular hip fractures. Studies presently suggest that the anterolateral approach is preferable to the posterior approach due to a perceived reduced risk of reoperations and dislocations. However, these observations come from small studies with short follow-up. We assessed whether surgical approach in THA performed for hip fractures effects outcomes. A retrospective observational study was performed using data collected prospectively by the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. All primary stemmed THAs implanted for hip fractures between 2003–2015 were eligible for inclusion (n=19,432). The two surgical approach groups (posterior versus anterolateral) were propensity-score matched for multiple potential patient and surgical confounding factors (n=14,536, with 7,268/group). Outcomes (implant survival, patient survival, intraoperative complications) were compared between the approach groups using regression analysis.Introduction
Patients and Methods
Intraoperative periprosthetic femoral fractures (IOPFF) lead to reduced implant survival. A deeper understanding of predictors enables surgeons to modify techniques and patient selection to reduce the risk of IOPFF. The aim of this study was to estimate predictors of IOPFF and each anatomical subtype (calcar crack, trochanteric fracture, femoral shaft fracture) during primary THA. This retrospective cohort study included 793823 primary THAs between 2004 and 2016. Relative risks for patient, surgical and implant factors are estimated for any IOPFF fracture and for all anatomical subtypes of IOPFF.Introduction
Methods
The aim of this study was to investigate the association between the type of operation used to treat a trochanteric fracture of the hip and 30-day mortality. Data on 82 990 patients from the National Hip Fracture Database were analyzed using generalized linear models with incremental case-mix adjustment for patient, non-surgical and surgical characteristics, and socioeconomic factors.Aims
Patients and Methods
Although we know that smoking damages health, we do not know impact of smoking on a patient's outcome following primary knee arthroplasty (KA). In the UK, clinical commissioning groups (CCGs) have the authority (& funds) to commission healthcare services for their communities. Over the past decade, an increasing number of CCGs are using smoking as a contraindication for patients with end-stage symptomatic knee arthritis being referred to a specialist for due consideration of KA without any clear evidence of the associated risks & benefits. The overall objective of this study is to compare clinical outcomes after knee arthroplasty surgery in smokers, ex-smokers & non-smokers. We obtained data from the UK Clinical Research Practice Datalink (CPRD) that contains information on over 11 million patients (7% of the UK population) registered at over 600 general practices. CPRD data was linked to Hospital Episode Statistics, hospital admissions & Patient Reported Outcome Measures (PROMs) data. We collected data on all KAs (n=64,071) performed over a 21-year period (1995 to 2016). Outcomes assessed included: local & systemic complications (at 6-months post-surgery): infections (wound, respiratory, urinary), heart attack, stroke & transient ischaemic attack, venous thromboembolism, hospital readmissions & GP visits (1-year), analgesic use (1-year), surgical revision (up to 20-years), mortality (90-days and 1-year), & 6-month change from pre-operative scores in Oxford Knee Score (OKS). Regression modelling is used to describe the association of smoking on outcomes, adjusting for confounding factors.Introduction
Methods
Unicompartmental knee arthroplasty (UKA) offers significant advantages over total knee arthroplasty (TKA) but is reported to have higher revision rates in joint registries. In both the New Zealand and the UK national registry the revision rate of cementless UKR is less than cementless. It is not clear whether this is because the cementless is better or because more experienced surgeons, who tend to get better results are using cementless. We aim to use registry data to compare cemented and cementless UKA outcomes, matching for surgical experience and other factors. We performed a retrospective observational study using National Joint Registry (NJR) data on 10,836 propensity matched Oxford UKAs (5418 cemented and 5418 cementless) between 2004 and 2015. Logistic regression was utilized to calculate propensity scores to match the cemented and cementless groups for multiple confounders using a one to one ratio. Standardised mean differences were used before and after matching to assess for any covariate imbalances. The outcomes studied were implant survival, reasons for revision and patient survival. The endpoint for implant survival was revision surgery (any component removal or exchange). Cumulative patient and implant survival rates were determined using the Kaplan-Meier method. Patients not undergoing revision or death were censored on the study end date. The study endpoints implant and patient survival were compared between cemented and cementless groups using Cox regression models with a robust variance estimator.Introduction
Methods
Pseudotumours have recently been reported in non-metal-on-metal total hip replacements (non-MoM THRs), however the magnitude and risk factors for this complication are unknown, as is the outcome of its treatment. 3340 primary THR undergoing revision for pseudotumour between 2008 and 2015 were identified in the National Joint Registry for England and Wales. 7.5% (n=249) of these pseudotumour revisions, had non-MoM bearing surfaces. The risk of revision for pseudotumour in non-MoM hips was 0.032% (249/789,397; 95% CI 0.028%–0.036%). The risk of pseudotumour revision was 2.35 times (95% CI 1.76–3.11) higher in ceramic-on-ceramic compared with hard-on-soft bearings, and 2.80 times (95% CI 1.74–4.36) higher in 36mm metal-on-polyethylene bearings compared to 28mm and 32mm metal-on-polyethylene bearings. The outcome of revision for pseudotumour non-MoM hips was studied in 185 hips. 13.5% (n=25) had re-revisions at a mean of 1.2 years (range 0.1–3.1 years). Infection (32%), dislocation/subluxation (24%), and aseptic loosening (24%) were the commonest indications for re-revision. The 4-year survival rate was 83.8% (95% CI=76.7%–88.9%). Multiple revision indications (Hazard Ratio (HR)=2.78; 95% CI=1.03–7.49) and incomplete revision procedures (HR=5.76; 95% CI=1.28–25.9) increased the risk of re-revision Although the overall risk of revision for pseudotumour in non-MoM THRs is low, the risk is increasing and is significantly higher in ceramic-on-ceramic and large head metal-on-polyethylene THR. These revisions have a high early failure rate.
The aim of this study was to determine whether the rates of revision
for metal-on-metal (MoM) total hip arthroplasties (THAs) with Pinnacle
components varied according to the year of the initial operation,
and compare these with the rates of revision for other designs of
MoM THA. Data from the National Joint Registry for England and Wales included
36 mm MoM THAs with Pinnacle acetabular components which were undertaken
between 2003 and 2012 with follow-up for at least five years (n
= 10 776) and a control group of other MoM THAs (n = 13 817). The
effect of the year of the primary operation on all-cause rates of revision
was assessed using Cox regression and interrupted time-series analysis.Aims
Patients and Methods
To determine the outcomes following revision surgery of metal-on-metal
hip arthroplasties (MoMHA) performed for adverse reactions to metal
debris (ARMD), and to identify factors predictive of re-revision. We performed a retrospective observational study using National
Joint Registry (NJR) data on 2535 MoMHAs undergoing revision surgery
for ARMD between 2008 and 2014. The outcomes studied following revision were
intra-operative complications, mortality and re-revision surgery.
Predictors of re-revision were identified using competing-risk regression
modelling.Aims
Patients and Methods
Few studies have assessed outcomes following non-metal-on-metal hip arthroplasty (non-MoMHA) revision surgery performed for adverse reactions to metal debris (ARMD). We assessed outcomes following non-MoMHA revision surgery performed for ARMD, and identified predictors of re-revision. We performed a retrospective observational study using data from the National Joint Registry for England and Wales. All non-MoMHAs undergoing revision surgery for ARMD between 2008 and 2014 were included (185 hips in 185 patients). Outcome measures following ARMD revision were intra-operative complications, mortality and re-revision surgery. Predictors of re-revision were identified using Cox regression.Objectives
Methods
Recent studies have demonstrated that implant-specific blood metal ion thresholds exist in unilateral and bilateral metal-on-metal (MoM) hip arthroplasty patients, with these thresholds being most effective for identifying patients at low-risk of adverse reactions to metal debris (ARMD). We investigated whether these new blood metal ion thresholds could effectively identify patients at risk of ARMD in an external cohort of MoM hip arthroplasty patients. We performed a validation study involving 803 MoM hip arthroplasties implanted in 710 patients at three European centres (323=unilateral Birmingham Hip Resurfacing (BHR); 93=bilateral BHR; 294=unilateral Corail-Pinnacle). All patients underwent whole blood metal ion sampling. Patients were divided into those with ARMD (revised for ARMD or ARMD on imaging; n=75), and those without ARMD (n=635). Previously devised implant-specific blood metal ion thresholds (cobalt=2.15μg/l for unilateral BHR; maximum cobalt or chromium=5.5μg/l for bilateral BHR; cobalt=3.57μg/l for unilateral Corail-Pinnacle) were applied to the validation cohort, with receiver operating characteristic curve analysis used to establish the discriminatory characteristics for each respective threshold. The area under the curve, sensitivity, specificity, positive predictive value and negative predictive value for distinguishing between patients with and without ARMD for each implant-specific threshold were respectively: unilateral BHR=89.4% (95% CI=82.8%-96.0%), 78.9%, 86.7%, 44.1%, 96.9%; bilateral BHR=89.2% (95% CI=81.3%-97.1%), 70.6%, 86.8%, 54.5%, 93.0%; unilateral Corail-Pinnacle=76.9% (95% CI=63.9%-90.0%), 65.0%, 85.4%, 24.5%, 97.1%. The 7μg/l UK MHRA threshold missed significantly more patients with ARMD compared with the implant-specific thresholds (4.9% vs. 2.8%; p=0.0003). This external multi-centre validation study has confirmed that MoM hip arthroplasty patients with blood metal ion levels below newly devised implant-specific thresholds have a low-risk of ARMD. Compared to implant-specific thresholds, the currently proposed fixed MHRA threshold missed more patients with ARMD. We recommend using implant-specific thresholds over fixed thresholds when managing MoM hip arthroplasty patients.
Recent studies have reported on non-metal-on-metal hip arthroplasty (non-MoMHA) patients requiring revision surgery for adverse reactions to metal debris (ARMD). Although the outcomes following revision surgery for ARMD in MoMHA patients are known to generally be poor, little evidence exists regarding outcomes following non-MoMHA revision surgery performed for ARMD. We determined the outcomes following non-MoMHA revision surgery performed for ARMD, and identified predictors of re-revision. We performed a retrospective observational study using data from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. All primary non-MoMHA patients who subsequently underwent revision surgery for ARMD between 2008–2014 were included (n=185). Outcome measures following ARMD revision were intraoperative complications, mortality, and re-revision surgery. Predictors of re-revision surgery were identified using Cox regression analysis. Intra-operative complications occurred in 6.0% (n=11) of ARMD revisions. The cumulative 4-year patient survival rate was 98.2% (95% CI=92.9–99.5%). Re-revision surgery was performed in 13.5% (n=25) of hips at a mean time of 1.2 years (range 0.1–3.1 years) following ARMD revision. Infection (32%), dislocation/subluxation (24%), and aseptic loosening (24%) were the commonest re-revision indications. The cumulative 4-year implant survival rate was 83.8% (95% CI=76.7%-88.9%). Significant predictors of re-revision were: multiple revision indications (Hazard Ratio (HR)=2.78; 95% CI=1.03–7.49; p=0.043), incomplete revision procedures (including modular component exchange only) (HR=5.76; 95% CI=1.28–25.9; p=0.022), and ceramic-on-polyethylene revision bearings (HR=3.08; 95% CI=1.01–9.36; p=0.047). Non-MoMHA patients undergoing ARMD revision have a high short-term risk of re-revision. Infection, dislocation/subluxation, and aseptic loosening were the commonest re-revision indications. Furthermore, important and potentially modifiable predictors of future re-revision were identified. Although the poor prognostic factors identified require validation in future studies, our findings may be used to counsel patients about the risks associated with ARMD revision surgery, and guide decisions about the reconstructive procedure.
Outcomes following metal-on-metal hip replacement (MoMHR) revision surgery for adverse reactions to metal debris (ARMD) have been poor, and inferior compared with non-ARMD revisions. Subsequently, surgeons and worldwide authorities widely recommended early revision for ARMD, with a lower surgical threshold adopted. However, the impact of early surgery for ARMD is unknown. We compared the rates of adverse outcomes following MoMHR revision surgery in matched ARMD and non-ARMD patients. We performed a retrospective observational study using data from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. All MoMHR patients subsequently undergoing revision surgery for any indication between August 2008 and August 2014 were eligible. ARMD and non-ARMD revisions were matched one-to-one for multiple potential confounding factors using propensity scores. Adverse outcomes following revision surgery (intra-operative complications, mortality, re-revision surgery) were compared between matched groups using regression analysis. In 2,576 matched MoMHR revisions (ARMD=1,288 and non-ARMD=1,288), intra-operative complications were similar between ARMD (2.4%) and non-ARMD (2.5%) revisions (odds ratio=0.97, 95% CI=0.59–1.60; p=0.899). All-cause mortality rates were lower following ARMD revision compared with non-ARMD revision (hazard ratio (HR)=0.43, 95% CI=0.22–0.86; p=0.018). All-cause re-revision rates were lower following ARMD revision compared with non-ARMD revision (HR=0.52, 95% CI=0.36–0.75; p<0.001). Compared with ARMD revision (5-years=94.3%), MoMHR revisions for infection (5-years=81.2%) and dislocation/subluxation (5-years=81.9%) had the lowest implant survival rates. Contrary to previous observations, MoMHRs revised for ARMD have approximately half the risk of re-revision and death compared to non-ARMD revisions. We suspect worldwide regulatory authorities have positively influenced outcomes following ARMD revision by widely recommending that surgeons exercise a lower revision threshold. Our findings suggest the threshold for ARMD revision surgery need not be lowered further. The high risk of failure following MoMHR revision for infection and dislocation is concerning.
To determine ten-year failure rates following 36 mm metal-on-metal
(MoM) Pinnacle total hip arthroplasty (THA), and identify predictors
of failure. We retrospectively assessed a single-centre cohort of 569 primary
36 mm MoM Pinnacle THAs (all Corail stems) followed up since 2012
according to Medicines and Healthcare Products Regulation Agency
recommendations. All-cause failure rates (all-cause revision, and
non-revised cross-sectional imaging failures) were calculated, with predictors
for failure identified using multivariable Cox regression.Aims
Patients and Methods
We recently published a paper comparing the incidence
of adverse outcomes after unicompartmental and total knee arthroplasty
(UKA and TKA). The conclusion of this study, which was in favour
of UKA, was dismissed as “biased” in a review in Cite this article:
The impact of pseudotumours associated with metal-on-metal hip resurfacings (MoMHRs) within the second decade is unknown. We investigated: (1) the incidence and risk factors for all-cause and pseudotumour revision following MoMHR at 15-years follow-up, and (2) whether risk factors were gender specific. This single-centre prospective cohort study included 1429 MoMHRs (1216 patients; 40% female) implanted between 1999–2009. All patients were contacted in 2010 and 2012 as per national recommendations. Patients with hip problems and/or suboptimal Oxford Hip Scores (<41/48) underwent cross-sectional imaging and blood metal ion sampling. Revisions were performed as indicated with diagnoses confirmed from operative and histopathological findings. Multi-variate Cox proportional hazard models assessed the association of predictor variables on time to all-cause and pseudotumour revision.Introduction
Patients and methods
Unicompartmental knee arthroplasty (UKA) has
advantages over total knee arthroplasty but national joint registries report
a significantly higher revision rate for UKA. As a result, most
surgeons are highly selective, offering UKA only to a small proportion
(up to 5%) of patients requiring arthroplasty of the knee, and consequently
performing few each year. However, surgeons with large UKA practices
have the lowest rates of revision. The overall size of the practice
is often beyond the surgeon’s control, therefore case volume may
only be increased by broadening the indications for surgery, and
offering UKA to a greater proportion of patients requiring arthroplasty
of the knee. The aim of this study was to determine the optimal UKA usage
(defined as the percentage of knee arthroplasty practice comprised
by UKA) to minimise the rate of revision in a sample of 41 986 records
from the for National Joint Registry for England and Wales (NJR). UKA usage has a complex, non-linear relationship with the rate
of revision. Acceptable results are achieved with the use of 20%
or more. Optimal results are achieved with usage between 40% and
60%. Surgeons with the lowest usage (up to 5%) have the highest
rates of revision. With optimal usage, using the most commonly used
implant, five-year survival is 96% (95% confidence interval (CI)
94.9 to 96.0), compared with 90% (95% CI 88.4 to 91.6) with low
usage (5%) previously considered ideal. The rate of revision of UKA is highest with low usage, implying
the use of narrow, and perhaps inappropriate, indications. The widespread
use of broad indications, using appropriate implants, would give
patients the advantages of UKA, without the high rate of revision. Cite this article:
Despite being one of the most common orthopaedic
operations, it is still not known how many arthroscopies of the knee
must be performed during training in order to develop the skills
required to become a Consultant. A total of 54 subjects were divided
into five groups according to clinical experience: Novices (n =
10), Junior trainees (n = 10), Registrars (n = 18), Fellows (n =
10) and Consultants (n = 6). After viewing an instructional presentation,
each subject performed a simple diagnostic arthroscopy of the knee
on a simulator with visualisation and probing of ten anatomical
landmarks. Performance was assessed using a validated global rating
scale (GRS). Comparisons were made against clinical experience measured
by the number of arthroscopies which had been undertaken, and ROC
curve analysis was used to determine the number of procedures needed
to perform at the level of the Consultants. There were marked differences between the groups. There was significant
improvement in performance with increasing experience (p <
0.05). ROC curve analysis identified that approximately 170 procedures
were required to achieve the level of skills of a Consultant. We suggest that this approach to identify what represents the
level of surgical skills of a Consultant should be used more widely
so that standards of training are maintained through the development
of an evidenced-based curriculum. Cite this article:
Whether to use total or unicompartmental knee
replacement (TKA/UKA) for end-stage knee osteoarthritis remains controversial.
Although UKA results in a faster recovery, lower rates of morbidity
and mortality and fewer complications, the long-term revision rate
is substantially higher than that for TKA. The effect of each intervention on
patient-reported outcome remains unclear. The aim of this study
was to determine whether six-month patient-reported outcome measures
(PROMs) are better in patients after TKA or UKA, using data from
a large national joint registry (NJR). We carried out a propensity score-matched cohort study which
compared six-month PROMs after TKA and UKA in patients enrolled
in the NJR for England and Wales, and the English national PROM
collection programme. A total of 3519 UKA patients were matched
to 10 557 TKAs. The mean six-month PROMs favoured UKA: the Oxford Knee Score
was 37.7 (95% confidence interval (CI) 37.4 to 38.0) for UKA and
36.1 (95% CI 35.9 to 36.3) for TKA; the mean EuroQol EQ-5D index
was 0.772 (95% CI 0.764 to 0.780) for UKA and 0.751 (95% CI 0.747
to 0.756) for TKA. UKA patients were more likely to achieve excellent
results (odds ratio (OR) 1.59, 95% CI 1.47 to 1.72, p <
0.001)
and to be highly satisfied (OR 1.27, 95% CI 1.17 to 1.39, p <
0.001), and
were less likely to report complications than those who had undergone
TKA. UKA gives better early patient-reported outcomes than TKA; these
differences are most marked for the very best outcomes. Complications
and readmission are more likely after TKA. Although the data presented
reflect the short-term outcome, they suggest that the high revision
rate for UKA may not be because of poorer clinical outcomes. These
factors should inform decision-making in patients eligible for either
procedure. Cite this article:
We explored the trends over time and the geographical
variation in the use of subacromial decompression and rotator cuff
repair in 152 local health areas (Primary Care Trusts) across England.
The diagnostic and procedure codes of patients undergoing certain
elective shoulder operations between 2000/2001 and 2009/2010 were extracted
from the Hospital Episode Statistics database. They were grouped
as 1) subacromial decompression only, 2) subacromial decompression
with rotator cuff repair, and 3) rotator cuff repair only. The number of patients undergoing subacromial decompression alone
rose by 746.4% from 2523 in 2000/2001 (5.2/100 000 (95% confidence
interval (CI) 5.0 to 5.4) to 21 355 in 2009/2010 (40.2/100 000 (95%
CI 39.7 to 40.8)). Operations for rotator cuff repair alone peaked
in 2008/2009 (4.7/100 000 (95% CI 4.5 to 4.8)) and declined considerably
in 2009/2010 (2.6/100 000 (95% CI 2.5 to 2.7)). Given the lack of evidence for the effectiveness of these operations
and the significant increase in the number of procedures being performed
in England and elsewhere, there is an urgent need for well-designed
clinical trials to determine evidence of clinical effectiveness. Cite this article: Bone Joint J 2014;96-B:70–4.
Although simulation studies have shown superior wear properties of metal-on-metal articulations, increased concern exists regarding the excess in-vivo wear of a small number of Metal-on-Metal-Hip-Resurfacing (MoMHRA) implants. Serum ion levels of Chromium (Cr) and Cobalt (Co) are surrogate markers of wear. Risk factors associated with increased wear include female gender, small components, dysplasia, cup orientation outside safe zone and femoral head downsize during surgery with an associated decrease in Head-Neck-Ratio (HNR). However, these factors are interlinked. This study aims to identify the factors that are most important for subsequent wear of MoMHRA, by performing a multivariate analysis. 206 patients (124M: 82F) with unilateral MoMHRA were included in this study. The average follow up was 3.3 years. All patients had Cr/Co levels measured at follow up. Inclination and anteversion of each cup were measured using EBRA. Cups were analysed as being within or outside the previously defined optimum-zone. HNR measurements were made from pre-operative (HNRpre) and post-operative (HNRpost) radiographs. The immediate changes in HNR (downsize/upsize of femoral head) as a result of the operation were expressed as: HNRprepost=HNRpost–HNRpre Multivariate linear regression modelling was used to explore the association between measures of ions with the following predictor variables (gender, age, diagnosis, femoral component size, orientation of the acetabular component, head/neck ratio and position of femoral stem). Analyses were carried out separately for each outcome (Cr and Co). Classification and Regression Tree (CART) models were fitted as a complimentary approach to regression modelling.INTRODUCTION
METHODS
The Oxford Knee Score (OKS) is a validated and widely used PROM that has been successfully used in assessing the outcome of knee arthroplasty (KA). It has been adopted as the nationally agreed outcome measure for this procedure and is now routinely collected. Increasingly, it is being used on an individual patient basis as a pre-operative measure of osteoarthritis and the need for joint replacement, despite not being validated for this use. The aim of this paper is to present evidence that challenges this new role for the OKS. We have analysed pre-operative and post-operative OKS data from 3 large cohorts all undergoing KA, totalling over 3000 patients. In addition we have correlated the OKS to patient satisfaction scores. We have validated our findings using data published from the UK NJR.Purpose
Method
We obtained information from the Elective Orthopaedic
Centre on 1523 patients with baseline and six-month Oxford hip scores
(OHS) after undergoing primary hip replacement (THR) and 1784 patients
with Oxford knee scores (OKS) for primary knee replacement (TKR)
who completed a six-month satisfaction questionnaire. Receiver operating characteristic curves identified an absolute
change in OHS of 14 points or more as the point that discriminates
best between patients’ satisfaction levels and an 11-point change
for the OKS. Satisfaction is highest (97.6%) in patients with an
absolute change in OHS of 14 points or more, compared with lower
levels of satisfaction (81.8%) below this threshold. Similarly,
an 11-point absolute change in OKS was associated with 95.4% satisfaction
compared with 76.5% below this threshold. For the six-month OHS
a score of 35 points or more distinguished patients with the highest
satisfaction level, and for the six-month OKS 30 points or more identified
the highest level of satisfaction. The thresholds varied according
to patients’ pre-operative score, where those with severe pre-operative
pain/function required a lower six-month score to achieve the highest
levels of satisfaction. Our data suggest that the choice of a six-month follow-up to
assess patient-reported outcomes of THR/TKR is acceptable. The thresholds
help to differentiate between patients with different levels of
satisfaction, but external validation will be required prior to
general implementation in clinical practice.
We obtained pre-operative and six-month post-operative
Oxford hip (OHS) and knee scores (OKS) for 1523 patients who underwent
total hip replacement and 1784 patients who underwent total knee
replacement. They all also completed a six-month satisfaction question. Scatter plots showed no relationship between pre-operative Oxford
scores and six-month satisfaction scores. Spearman’s rank correlation
coefficients were -0.04 (95% confidence interval (CI) -0.09 to 0.01)
between OHS and satisfaction and 0.04 (95% CI -0.01 to 0.08) between
OKS and satisfaction. A receiver operating characteristic (ROC) curve
analysis was used to identify a cut-off point for the pre-operative
OHS/OKS that identifies whether or not a patient is satisfied with
surgery. We obtained an area under the ROC curve of 0.51 (95% CI
0.45 to 0.56) for hip replacement and 0.56 (95% CI 0.51 to 0.60)
for knee replacement, indicating that pre-operative Oxford scores
have no predictive accuracy in distinguishing satisfied from dissatisfied
patients. In the NHS widespread attempts are being made to use patient-reported
outcome measures (PROMs) data for the purpose of prioritising patients
for surgery. Oxford hip and knee scores have no predictive accuracy
in relation to post-operative patient satisfaction. This evidence
does not support their current use in prioritising access to care.
This study investigates if there is a significant difference in this angle as measured on MRI between a study cohort with early AMG (partial thickness cartilage damage and intact ACL) and a comparator control cohort of patients (no cartilage damage and ACL rupture).
We have compared the outcome of hemiarthroplasty of the shoulder in three distinct diagnostic groups, using survival analysis as used by the United Kingdom national joint registers, patient-reported outcome measures (PROMs) as recommended by Darzi in the 2008 NHS review, and transition and satisfaction questions. A total of 72 hemiarthroplasties, 19 for primary osteoarthritis (OA) with an intact rotator cuff, 22 for OA with a torn rotator cuff, and 31 for rheumatoid arthritis (RA), were followed up for between three and eight years. All the patients survived, with no revisions or dislocations and no significant radiological evidence of loosening. The mean new Oxford shoulder score (minimum/worst 0, maximum/best 48) improved significantly for all groups (p <
0.001), in the OA group with an intact rotator cuff from 21.4 to 38.8 (effect size 2.9), in the OA group with a torn rotator cuff from 13.3 to 27.2 (effect size 2.1) and in the RA group from 13.7 to 28.0 (effect size 3.1). By this assessment, and for the survival analysis, there was no significant difference between the groups. However, when ratings using the patient satisfaction questions were analysed, eight (29.6%) of the RA group were ‘disappointed’, compared with one (9.1%) of the OA group with cuff intact and one (7.7%) of the OA group with cuff torn. All patients in the OA group with cuff torn indicated that they would undergo the operation again, compared to ten (90.9%) in the OA group with cuff intact and 20 (76.9%) in the RA group. The use of revision rates alone does not fully represent outcome after hemiarthroplasty of the shoulder. Data from PROMs provides more information about change in pain and the ability to undertake activities and perform tasks. The additional use of satisfaction ratings shows that both the rates of revision surgery and PROMs need careful interpretation in the context of patient expectations.
