Time trends in case-mix and risk of revision following hip and knee arthroplasty in public and private hospitals: a cross-sectional analysis based on 476,312 procedures from the Dutch Arthroplasty Register.

BACKGROUND AND PURPOSE: This study aims to assess time trends in case-mix and to evaluate the risk of revision and causes following primary THA, TKA, and UKA in private and public hospitals in the Netherlands. METHODS: We retrospectively analyzed 476,312 primary arthroplasties (public: n = 413,560 and private n = 62,752) implanted between 2014 and 2023 using Dutch Arthroplasty Register data. We explored patient demographics, procedure details, trends over time, and revisions per hospital type. Adjusted revision risk was calculated for comparable subgroups (ASA I/II, age ≤ 75, BMI ≤ 30, osteoarthritis diagnosis, and moderate-high socioeconomic status (SES). RESULTS: The volume of THAs and TKAs in private hospitals increased from 4% and 9% in 2014, to 18% and 21% in 2022. Patients in private hospitals were younger, had lower ASA classification, lower BMI, and higher SES compared with public hospital patients. In private hospitals, age and ASA II proportion increased over time. Multivariable Cox regression demonstrated a lower revision risk for primary THA (HR 0.7, CI 0.7-0.8), TKA (HR 0.8, CI 0.7-0.9), and UKA (HR 0.8, CI 0.7-0.9) in private hospitals. After initial arthroplasty in private hospitals, 49% of THA and 37% of TKA revisions were performed in public hospitals. CONCLUSION: Patients in private hospitals were younger, had lower ASA classification, lower BMI, and higher SES com-pared with public hospital patients. The number of arthroplasties increased in private hospitals, with a lower revision risk compared with public hospitals.

Low revision rate throughout the adoption of the direct superior approach in primary total hip arthroplasty: an analysis based on 1551 total hip arthroplasties from the Dutch Arthroplasty Register.

BACKGROUND: Recently, surgeons introduced a minimally invasive modification on the classic posterolateral approach (PLA) in total hip arthroplasty (THA): the direct superior approach (DSA). We investigated the association between surgeon's experience and the risk of early revision of the DSA in primary THA, using data from the Dutch Arthroplasty Register (LROI). METHODS: We retrieved all primary THAs performed using the DSA in 4 hospitals between 2016 and 2022 (n = 1551). Procedures were sorted in 5 groups using the date of operation and number of previous procedures per surgeon: 1-25; 26-50; 51-75; 76-100; >100. Subsequently, data from different surgeons were pooled together and the risk of revision was calculated via a multilevel time-to-event analysis. RESULTS: The overall revision rate was 1.5% after a mean follow-up of 2 years. Patients from the 1-25 group had comparable risks of revision compared to patients in the >100 group (hazard ratio [HR] 1.0 [CI, 0.3-3.2]). The risk for patients in groups 26-50, 51-75 and 75-100 was also not statistically different from the >100 group (resp. HR 1.5 [CI, 0.5-5.0], 1.8 [CI, 0.5-6.4] and 0.5 [CI, 0.1-4.0]). Main reasons of revision were dislocation (0.5%) and infection (0.4%). CONCLUSIONS: We did not identify an association between the surgeon's experience and the early risk of revision for the DSA in primary THA in the Netherlands. The DSA seems safe in the early adoption phases with a low risk of revision due to dislocation and revision for all other causes.

Machine Learning Did Not Outperform Conventional Competing Risk Modeling to Predict Revision Arthroplasty.

BACKGROUND: Estimating the risk of revision after arthroplasty could inform patient and surgeon decision-making. However, there is a lack of well-performing prediction models assisting in this task, which may be due to current conventional modeling approaches such as traditional survivorship estimators (such as Kaplan-Meier) or competing risk estimators. Recent advances in machine learning survival analysis might improve decision support tools in this setting. Therefore, this study aimed to assess the performance of machine learning compared with that of conventional modeling to predict revision after arthroplasty. QUESTION/PURPOSE: Does machine learning perform better than traditional regression models for estimating the risk of revision for patients undergoing hip or knee arthroplasty? METHODS: Eleven datasets from published studies from the Dutch Arthroplasty Register reporting on factors associated with revision or survival after partial or total knee and hip arthroplasty between 2018 and 2022 were included in our study. The 11 datasets were observational registry studies, with a sample size ranging from 3038 to 218,214 procedures. We developed a set of time-to-event models for each dataset, leading to 11 comparisons. A set of predictors (factors associated with revision surgery) was identified based on the variables that were selected in the included studies. We assessed the predictive performance of two state-of-the-art statistical time-to-event models for 1-, 2-, and 3-year follow-up: a Fine and Gray model (which models the cumulative incidence of revision) and a cause-specific Cox model (which models the hazard of revision). These were compared with a machine-learning approach (a random survival forest model, which is a decision tree-based machine-learning algorithm for time-to-event analysis). Performance was assessed according to discriminative ability (time-dependent area under the receiver operating curve), calibration (slope and intercept), and overall prediction error (scaled Brier score). Discrimination, known as the area under the receiver operating characteristic curve, measures the model's ability to distinguish patients who achieved the outcomes from those who did not and ranges from 0.5 to 1.0, with 1.0 indicating the highest discrimination score and 0.50 the lowest. Calibration plots the predicted versus the observed probabilities; a perfect plot has an intercept of 0 and a slope of 1. The Brier score calculates a composite of discrimination and calibration, with 0 indicating perfect prediction and 1 the poorest. A scaled version of the Brier score, 1 - (model Brier score/null model Brier score), can be interpreted as the amount of overall prediction error. RESULTS: Using machine learning survivorship analysis, we found no differences between the competing risks estimator and traditional regression models for patients undergoing arthroplasty in terms of discriminative ability (patients who received a revision compared with those who did not). We found no consistent differences between the validated performance (time-dependent area under the receiver operating characteristic curve) of different modeling approaches because these values ranged between -0.04 and 0.03 across the 11 datasets (the time-dependent area under the receiver operating characteristic curve of the models across 11 datasets ranged between 0.52 to 0.68). In addition, the calibration metrics and scaled Brier scores produced comparable estimates, showing no advantage of machine learning over traditional regression models. CONCLUSION: Machine learning did not outperform traditional regression models. CLINICAL RELEVANCE: Neither machine learning modeling nor traditional regression methods were sufficiently accurate in order to offer prognostic information when predicting revision arthroplasty. The benefit of these modeling approaches may be limited in this context.

The Direct Superior Approach in Total Hip Arthroplasty: A Systematic Review.

BACKGROUND: Evolution of the surgical approach for total hip arthroplasty (THA) has led to the development of the minimally invasive direct superior approach (DSA). It is hypothesized that the DSA reduces postoperative pain and hospital length of stay (LOS). We aimed to provide an overview of current evidence on clinical, functional, and radiological outcomes with respect to risk of revision, complications, pain scores, physical function, operative time, LOS, blood loss, radiological outcomes, and learning curve. METHODS: A comprehensive search of Medline, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar, reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search extension guidelines, was conducted to identify studies evaluating clinical, functional, and radiological outcomes of the DSA. Quality assessment was performed using the Cochrane Risk of Bias tool and Newcastle-Ottawa Scale. The review protocol was prospectively registered in the International Prospective Registry of Systematic Reviews. RESULTS: Seventeen studies were included, generally of moderate quality. Qualitative synthesis evidenced accurate implant positioning, short LOS, and a short learning curve. Conflicting findings were reported for postoperative complications compared with conventional approaches. Better functional outcomes were seen in the early postoperative period than the posterolateral approach (PLA). Outcomes such as blood loss and operative time exhibited conflicting results and considerable heterogeneity. CONCLUSION: Based on moderate-certainty evidence, it is uncertain if the DSA provides short-term advantages over conventional approaches such as PLA. There is limited evidence on long-term outcomes post-THA using the DSA. Further studies and ongoing registry monitoring is crucial for continuous evaluation of its long-term outcomes. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Femoral Neck Design Does Not Impact Revision Risk After Primary Total Hip Arthroplasty Using a Dual Mobility Cup.

Background: The use of dual mobility (DM) cups has increased quickly. It is hypothesized that femoral neck taper geometry may be involved in the risk of prosthetic impingement and DM cup revision. We aim to (1) explore the reasons for revision of DM cups or head/liners and (2) explore whether certain femoral neck characteristics are associated with a higher risk of revision of DM cups. Methods: Primary total hip arthroplasties with a DM cup registered in the Dutch Arthroplasty Register between 2007 and 2021 were identified (n = 7603). Competing risk survival analyses were performed, with acetabular component and head/liner revision as the primary endpoint. Reasons for revision were categorized in cup-/liner-related revisions (dislocation, liner wear, acetabular loosening). Femoral neck characteristics were studied to assess whether there is an association between femoral neck design and the risk of DM cup/liner revision. Multivariable Cox proportional hazard analyses were performed. Results: The 5- and 10-year crude cumulative incidence of DM cup or head/liner revision for dislocation, wear, and acetabular loosening was 0.5% (CI 0.4-0.8) and 1.9% (CI 1.3-2.8), respectively. After adjusting for confounders, we found no association between the examined femoral neck characteristics (alloy used, neck geometry, CCD angle, and surface roughness) and the risk for revision for dislocation, wear, and acetabular loosening. Conclusions: The risk of DM cup or head/liner revision for dislocation, wear, and acetabular loosening was low. We found no evidence that there is an association between femoral neck design and the risk of cup or head/liner revision.

No clinically relevant difference in patient-reported outcomes between the direct superior approach and the posterolateral or anterior approach for primary total hip arthroplasty: analysis of 37,976 primary hip arthroplasties in the Dutch Arthroplasty Registry.

BACKGROUND AND PURPOSE: The direct superior approach (DSA) is a modification of the posterolateral approach (PLA) for total hip arthroplasty (THA). Patient-reported outcome measures (PROMs) of the DSA have not been investigated previously using nationwide data. Our aim was to assess PROMs after THA using the DSA compared with the PLA and, secondarily, with the anterior approach (DAA). PATIENTS AND METHODS: In this population-based cohort study we included 37,976 primary THAs performed between 2014 and 2020 (PLA: n = 22,616; DAA: n = 15,017; DSA: n = 343) using Dutch Arthroplasty Registry data. PROMs (NRS pain, EQ-5D, HOOS-PS, and OHS) were measured preoperatively, and at 3 and 12 months postoperatively. Repeated measurements were analyzed using mixed-effects models, adjusted for confounders, to investigate the association between surgical approach and PROMs over time. RESULTS: From baseline to 3 and 12 months, improvements for NRS pain scores, EQ-5D, and OHS were comparable for the DSA compared with the PLA or DAA. No difference was found in HOOS-PS improvement 3 months postoperatively between DSA and PLA (-0.2, 95% confidence interval [CI] -2.4 to 1.9) and between DSA and DAA (-1.7, CI -3.9 to 0.5). At 12 months postoperatively, patients in the DSA group had improved -2.8 points (CI -4.9 to -0.6) more in HOOS-PS compared with the DAA, but not with the PLA group (-1.0, CI -3.2 to 1.1). CONCLUSION: Our study showed no clinically meaningful differences between the DSA and either PLA or DAA.

Effects of faba bean, blue lupin and rapeseed meal supplementation on amino acid metabolism of dairy cows fed grass silage-based diets.

Information about the amino acid (AA) supply of locally produced protein supplements to dairy cow metabolism is needed to design sustainable diets for milk production. In this dairy cow experiment, grass silage and cereal-based diets supplemented with isonitrogenous amounts of rapeseed meal (RSM), faba beans (FB) and blue lupin seeds (BL) were compared with a control diet (CON) without protein supplementation. The diets were arranged as a 4 × 4 Latin Square using periods of 21 days, and four rumen-cannulated Nordic Red dairy cows were used in the experiment. The intake of all AAs increased in response to protein supplementation and was for many individual AAs higher when RSM rather than the grain legumes FB and BL were fed. The total AA flow at the omasal canal was 3 026, 3 371, 3 373 and 3 045 g/day for cows fed CON, RSM, FB and BL, respectively, but only RSM resulted in higher milk protein output. This may be explained by the higher provision of essential AA for milk protein synthesis when RSM was fed. The cows fed FB showed some positive features such as a tendency for greater omasal flow of branched-chain AA compared with BL. Overall, low plasma methionine and/or glucose concentrations in all treatments suggest that their supply was possibly limiting further production responses under the dietary conditions of the current study. It seems that the benefits of grain legume supplementation are limited when high-quality grass silage and cereal-based diets are used as the basal diet, but higher responses in amino acid supply and subsequent production responses can be expected when RSM is used.

Similar revision rate after cemented and cementless femoral revisions for periprosthetic femoral fractures in total hip arthroplasty: analysis of 1,879 revision hip arthroplasties in the Dutch Arthroplasty Register.

BACKGROUND AND PURPOSE: Periprosthetic femoral fracture (PPF) after total hip arthroplasty (THA) is a serious complication, as it often is followed by functional deficits and morbidity. There is no consensus regarding the optimal stem fixation method and whether additional cup replacement is beneficial. The aim of our study was to perform a direct comparison of reasons and risk of re-revision between cemented and uncemented revision THAs following PPF using registry data. PATIENTS AND METHODS: 1,879 patients registered in the Dutch Arthroplasty Registry (LROI) who underwent a first-time revision for PPF between 2007 and 2021 (cemented stem: n = 555; uncemented stem: n = 1,324) were included. Competing risk survival analysis and multivariable Cox proportional hazard analyses were performed. RESULTS: 5- and 10-year crude cumulative incidence of re-revision following revision for PPF was similar between cemented (resp. 13%, 95% CI 10-16 and 18%, CI 13-24) and uncemented (resp. 11%, CI 10-13 and 13%, CI 11-16) revisions. Multivariable Cox regression analysis, adjusting for potential confounders, showed a similar risk of revision for uncemented and cemented revision stems. Finally, we found no difference in risk of re-revision between a total revision (HR 1.2, 0.6-2.1) compared with a stem revision. CONCLUSION: We found no difference in the risk of re-revision between cemented and uncemented revision stems after revision for PPF.

Revision risk by using the direct superior approach (DSA) for total hip arthroplasty compared with postero-lateral approach: early nationwide results from the Dutch Arthroplasty Register (LROI).

BACKGROUND AND PURPOSE: The direct superior approach (DSA) is a modification of the classic posterolateral approach (PLA) for total hip arthroplasty (THA), in which the iliotibial band and short external rotators are spared. The revision rate of the DSA has not been investigated previously using arthroplasty registry data. We examined the reasons and risk of revision of the DSA, compared with the direct anterior approach (DAA) and PLA. PATIENTS AND METHODS: In this population-based cohort study we included 175,543 primary THAs performed between 2014 and 2020 (PLA, n = 117,576; DAA, n = 56,626; DSA, n = 1,341). Competing risk survival analysis and multivariable Cox proportional hazard analyses, adjusted for potential confounders, were performed. RESULTS: After 3 years, crude revision rates due to any reason were 2.1% (95% confidence interval [CI] 1.3-3.3) for DSA, and 2.9% (CI 2.8-3.0) for PLA. Crude dislocation revision rates were 0.3% (CI 0.1-0.8) for DSA, versus 1.0% (CI 0.9-1.0) for PLA. Dislocation revision rate for DSA did not differ from DAA (0.3% [CI 0.2-0.3]). Multivariable Cox regression analysis demonstrated no overall difference in revision rates for the DSA (HR 0.6 [CI 0.4-1.09) compared with the PLA. Lower risk of revision due to dislocation was found in patients operated on through the DSA (HR 0.3 [0.1-0.9]) compared with the PLA. CONCLUSION: Early nationwide results suggest that the DSA for total hip arthroplasty seems to show a tendency towards a lower risk of revision for dislocation but no overall reduced revision risk compared with the PLA.

The learning curve of the direct anterior approach is 100 cases: an analysis based on 15,875 total hip arthroplasties in the Dutch Arthroplasty Register.

BACKGROUND AND PURPOSE: In the last decade, the direct anterior approach (DAA) for total hip arthroplasty (THA) has become more popular in the Netherlands. Therefore, we investigated the learning curve and survival rate of the DAA in primary THA, using data from the Dutch Arthroplasty Register (LROI). PATIENTS AND METHODS: We identified all patients who received a primary THA using the DAA in several high-volume centers in the Netherlands between 2007 and 2019 (n = 15,903). Procedures were ordered per surgeon, using date of operation. Using the procedure number, operations were divided into 6 groups based on the number of previous procedures per surgeon (first 25, 26-50, 51-100, 101-150, 151-200, > 200). Data from different surgeons in different hospitals was pooled together. Revision rates were calculated using a multilevel time-to-event analysis. RESULTS: Patients operated on in group 1-25 (hazard ratio [HR] 1.6; 95% CI 1.1-2.4) and 26-50 (HR 1.6; CI 1.1-2.5) had a higher risk for revision compared with patients operated on in group > 200 THAs. Between 50 and 100 procedures the revision risk was increased (HR 1.3; CI 0.9-1.9), albeit not statistically significant. From 100 procedures onwards the HR for revision was respectively 1.0 (CI 0.6-1.6) and 0.8 (CI 0.5-1.4) for patients in operation groups 101-150 and 151-200. Main reasons for revision were loosening of the stem (29%), periprosthetic infection (19%), and dislocation (16%). INTERPRETATION: We found a 64% increased risk of revision for patients undergoing THA using the DAA for the first 50 cases per surgeon. Between 50 and 100 cases, this risk was 30% increased, but not statistically significant. From 100 cases onwards, a steady state had been reached in revision rate. The learning curve for DAA therefore is around 100 cases.

Effects of faba bean, blue lupin and rapeseed meal supplementation on nitrogen digestion and utilization of dairy cows fed grass silage-based diets.

There is increasing interest in using locally produced protein supplements in dairy cow feeding. The objective of this experiment was to compare rapeseed meal (RSM), faba beans (FBs) and blue lupin seeds (BL) at isonitrogenous amounts as supplements of grass silage and cereal based diets. A control diet (CON) without protein supplement was included in the experiment. Four lactating Nordic Red cows were used in a 4 × 4 Latin Square design with four 21 d periods. The milk production increased with protein supplementation but when expressed as energy corrected milk, the response disappeared due to substantially higher milk fat concentration with CON compared to protein supplemented diets. Milk protein output increased by 8.5, 4.4 and 2.7% when RSM, FB and BL were compared to CON. The main changes in rumen fermentation were the higher propionate and lower butyrate proportion of total rumen volatile fatty acids when the protein supplemented diets were compared to CON. Protein supplementation also clearly increased the ruminal ammonia N concentration. Protein supplementation improved diet organic matter and NDF digestibility but efficiency of microbial protein synthesis per kg organic matter truly digested was not affected. Flow of microbial N was greater when FB compared to BL was fed. All protein supplements decreased the efficiency of nitrogen use in milk production. The marginal efficiency (amount of additional feed protein captured in milk protein) was 0.110, 0.062 and 0.045 for RSM, FB and BL, respectively. The current study supports the evidence that RSM is a good protein supplement for dairy cows, and this effect was at least partly mediated by the lower rumen degradability of RSM protein compared to FB and BL. The relatively small production responses to protein supplementation with simultaneous decrease in nitrogen use efficiency in milk production suggest that economic and environmental consequences of protein feeding need to be carefully considered.

Which patients improve most after total hip arthroplasty? Influence of patient characteristics on patient-reported outcome measures of 22,357 total hip arthroplasties in the Dutch Arthroplasty Register.

BACKGROUND: Patient-reported outcome measures (PROMs) after total hip arthroplasty (THA), can be influenced by patient characteristics (case-mix factors). We used the Dutch Arthroplasty Register (LROI) to determine the effect of case-mix on improvement of PROMs after primary THA. METHODS: We included all primary THAs (n = 22,357) performed in the Netherlands between 2014 and 2018. The Hip disability and Osteoarthritis Outcome Score Physical function short form (HOOS-PS), Oxford Hip Score (OHS), EQ-5D index score and thermometer, and Numeric Rating Scales (NRS) measuring pain during activities and at rest, were recorded. The difference between preoperative and 3- and 12-month postoperative scores was calculated (delta-PROM) and used as primary outcome variable. Multivariable linear regression was used to examine the association between patient characteristics (age, sex, ASA score, body mass index (BMI), Charnley class, smoking, and previous operations to the affected hip) and PROMs. Cohens' d was used to measure effect size. RESULTS: Postoperative improvement (delta-PROM) on HOOS-PS, OHS, EQ-5D, and pain relief were significantly higher in patients <60 years, in patients with female gender, a high ASA score (III-IV), a BMI >30 kg/m2, and patients without a previous operation to the hip. Cohen's d indicated clinically small differences (0.2). CONCLUSIONS: Patients benefiting most in terms of postoperative improvement of self-reported physical functioning, pain relief and quality of life after primary THA were young, female, with a high ASA or BMI score, and without previous operations to the hip.

Grass silage pulp as a dietary component for high-yielding dairy cows.

Green biorefineries provide novel opportunities to use the green biomass efficiently and utilize the ecosystem services provided by grasslands more widely. The effects of the inclusion of fractionated grass silage solid fraction (pulp) on feed intake, rumen fermentation, diet digestion and milk production in dairy cows were investigated. Pulp was separated from grass silage using a screw press simulating a green biorefinery. Partial removal of liquid from forage increased DM concentration from 220 to 432 g/kg and NDF from 589 to 709 g/kg DM while CP decreased from 144 to 107 g/kg DM. A feeding trial using an incomplete changeover design with 24 Nordic Red cows and two 3-week periods was conducted. The pulp replaced grass silage in the diet at 0 (P0), 25 (P25) and 50 (P50) percentage of total forage, which was fed ad libitum with 13 kg of concentrate for all treatments. The forage DM intake was highest on P25 (14.1 kg/day) while P0 and P50 did not differ from each other (13.2 and 13.0 kg/day, respectively). There were no differences between the treatments in rumen pH or ammonia N, but the proportion of acetate increased with increasing pulp inclusion. The digestibility was measured using acid insoluble ash and indigestible NDF (iNDF) as internal markers. Neither of the markers detected differences in NDF digestibility, but according to iNDF, apparent total tract organic matter digestibility decreased with increasing pulp inclusion. The cows maintained milk production at P25, but it showed some decline at P50 (energy-corrected milk at P0 and P25 was 39.8 kg/day while for P50, it was 38.5 kg/day, P = 0.056) and the milk protein yield significantly declined with higher pulp inclusion. Simultaneously, the nitrogen use efficiency in milk production increased. It seems that the fibrous grass-based fraction from a biorefinery process has potential to be used as a feed for ruminants.

Metabolisable energy of grass and red clover silages fed to sheep at maintenance level.

This study investigated the effect of forage type (grass or red clover) and harvesting time (primary growth or regrowth) of silage on energy and N utilisation by sheep fed at maintenance level. Specifically, the assumption of constant loss of energy of digestible organic matter from energy losses in urine and CH4 applied in evaluation of silage metabolisable energy (ME) was investigated. Urinary excretion of high-energy phenolic compounds related to solubilisation of lignin was assumed to affect urinary energy (UE) losses from sheep fed highly digestible grass silage (GS). A total of 25 primary growth and regrowth silages of timothy (Phleum pratense) and meadow fescue (Festuca pratensis) grass mixtures and red clover (Trifolium pratense) samples collected in digestibility trials with sheep, including faecal and urine samples, were used for energy and N determinations. Urinary concentration of monophenolic compounds and CH4 emissions in vitro were also analysed. Daily faecal N output, CH4 yield (MJ/kg DM intake), proportion of CH4 energy in digestible energy (DE) and proportion of UE in DE were greater (P ≤ 0.03) in sheep fed red clover silage (RCS) than GS. Furthermore, less (P = 0.01) energy was lost as UE of DE in sheep fed primary growth GS compared with the other treatments. The relationship between UE and silage N intake or urinary N output for both silage types (i.e. grass v. red clover) was strong, but the fit of the regressions was better for GS than RCS. The CH4/DE ratio decreased (P < 0.05) and the UE/DE ratio increased (P < 0.05) with increasing organic matter digestibility in RCS. These relationships were not significant (P < 0.05) for the GS diets. The regression coefficient was higher (P < 0.05) for GS than RCS when regressing ME concentration on digestible organic matter. The results of this study imply that ME/DE ratio is not constant across first-cut GS of different maturities. The ME production response may be smaller from highly digestible first-cut GS but could not be clearly related to urinary excretion of monophenols derived from solubilisation of lignin. Furthermore, energy lost in urine was not clearly defined for RCS and was much more predictable for GS from silage N concentration.

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.

Review: Alternative and novel feeds for ruminants: nutritive value, product quality and environmental aspects.

Ruminant-based food production faces currently multiple challenges such as environmental emissions, climate change and accelerating food-feed-fuel competition for arable land. Therefore, more sustainable feed production is needed together with the exploitation of novel resources. In addition to numerous food industry (milling, sugar, starch, alcohol or plant oil) side streams already in use, new ones such as vegetable and fruit residues are explored, but their conservation is challenging and production often seasonal. In the temperate zones, lipid-rich camelina (Camelina sativa) expeller as an example of oilseed by-products has potential to enrich ruminant milk and meat fat with bioactive trans-11 18:1 and cis-9,trans-11 18:2 fatty acids and mitigate methane emissions. Regardless of the lower methionine content of alternative grain legume protein relative to soya bean meal (Glycine max), the lactation performance or the growth of ruminants fed faba beans (Vicia faba), peas (Pisum sativum) and lupins (Lupinus sp.) are comparable. Wood is the most abundant carbohydrate worldwide, but agroforestry approaches in ruminant nutrition are not common in the temperate areas. Untreated wood is poorly utilised by ruminants because of linkages between cellulose and lignin, but the utilisability can be improved by various processing methods. In the tropics, the leaves of fodder trees and shrubs (e.g. cassava (Manihot esculenta), Leucaena sp., Flemingia sp.) are good protein supplements for ruminants. A food-feed production system integrates the leaves and the by-products of on-farm food production to grass production in ruminant feeding. It can improve animal performance sustainably at smallholder farms. For larger-scale animal production, detoxified jatropha (Jatropha sp.) meal is a noteworthy alternative protein source. Globally, the advantages of single-cell protein (bacteria, yeast, fungi, microalgae) and aquatic biomass (seaweed, duckweed) over land crops are the independence of production from arable land and weather. The chemical composition of these feeds varies widely depending on the species and growth conditions. Microalgae have shown good potential both as lipid (e.g. Schizochytrium sp.) and protein supplements (e.g. Spirulina platensis) for ruminants. To conclude, various novel or underexploited feeds have potential to replace or supplement the traditional crops in ruminant rations. In the short-term, N-fixing grain legumes, oilseeds such as camelina and increased use of food and/or fuel industry by-products have the greatest potential to replace or supplement the traditional crops especially in the temperate zones. In the long-term, microalgae and duckweed of high-yield potential as well as wood industry by-products may become economically competitive feed options worldwide.

Similar Superior Patient-Reported Outcome Measures for Anterior and Posterolateral Approaches After Total Hip Arthroplasty: Postoperative Patient-Reported Outcome Measure Improvement After 3 months in 12,774 Primary Total Hip Arthroplasties Using the Anterior, Anterolateral, Straight Lateral, or Posterolateral Approach.

BACKGROUND: Patient-reported outcome measures (PROMs) are used to evaluate the outcome of total hip arthroplasty (THA). We determined the effect of surgical approach on PROMs after primary THA. METHODS: All primary THAs, with registered preoperative and 3 months postoperative PROMs were selected from the Dutch Arthroplasty Register. Based on surgical approach, 4 groups were discerned: (direct) anterior, anterolateral, direct lateral, and posterolateral approaches. The following PROMs were recorded: Hip disability and Osteoarthritis Outcome Score Physical function Short form (HOOS-PS); Oxford Hip Score; EQ-5D index score; EQ-5D thermometer; and Numeric Rating Scale measuring pain, both active and in rest. The difference between preoperative and postoperative scores was calculated (delta-PROM) and used as primary outcome measure. Multivariable linear regression analysis was performed for comparisons. Cohen's d was calculated as measure of effect size. RESULTS: All examined 4 approaches resulted in a significant increase of PROMs after primary THA in the Netherlands (n = 12,274). The anterior and posterolateral approaches were associated with significantly more improvement in HOOS-PS scores compared with the anterolateral and direct lateral approaches. Furthermore, the posterolateral and anterior approaches showed greater improvement on Numeric Rating Scale pain scores compared with the anterolateral approach. No relevant differences in delta-PROM were seen between the anterior and posterolateral surgical approaches. CONCLUSION: Anterior and posterolateral surgical approaches showed more improvement in self-reported physical functioning (HOOS-PS) compared with anterolateral and direct lateral approaches in patients receiving a primary THA. However, clinical differences were only small.

The effect of bearing type on the outcome of total hip arthroplasty.

Background and purpose - Alternative bearing surfaces such as ceramics and highly crosslinked polyethylene (HXLPE) were developed in order to further improve implant performance of total hip arthroplasties (THAs). Whether these alternative bearing surfaces result in increased longevity is subject to debate. Patients and methods - Using the Dutch Arthroplasty Register (LROI), we identified all patients with a primary, non-metal-on-metal THA implanted in the Netherlands in the period 2007-2016 (n = 209,912). Cumulative incidence of revision was calculated to determine differences in survivorship of THAs according to bearing type: metal-on-polyethylene (MoPE), metal-on-HXLPE (MoHXLPE), ceramic-on-polyethylene (CoPE), ceramic-on-HXLPE (CoHXLPE), ceramic-on-ceramic (CoC), and oxidized-zirconium-on-(HXL)polyethylene (Ox(HXL)PE). Multivariable Cox proportional hazard regression ratios (HRs) were used for comparisons. Results - After adjustment for confounders, CoHXLPE, CoC, and Ox(HXL)PE resulted in a statistically significantly lower risk of revision compared with MoPE after 9 years follow-up (HR =0.8-0.9 respectively, compared with HR =1.0). For small (22-28 mm) femoral head THAs, lower revision rates were found for CoPE and CoHXLPE (HR =0.9). In the 36 mm femoral head subgroup, CoC-bearing THAs had a lower HR compared with MoHXLPE (HR =0.7 versus 1.0). Crude revision rates in young patients (< 60 years) for CoHXLPE, CoC, and Ox(HXL)PE (HR =0.7) were lower than MoPE (HR =1.0). However, after adjustment for case mix and confounders these differences were not statistically significant. Interpretation - We found a mid-term lower risk of revision for CoHXLPE, CoC, and Ox(HXL)PE bearings compared with traditional MoPE-bearing surfaces.