Three out of four working-age patients have fulfilled expectations towards paid employment six months after total hip or knee arthroplasty: a multicentre cohort study.

To investigate factors associated with fulfilment of expectations towards paid employment after total hip/knee arthroplasty (THA/TKA). Cohort study including preoperatively employed patients aged 18-64 scheduled for THA/TKA. Expectations were collected preoperatively, and 6 and 12 months postoperatively with the paid employment item of the Hospital-for-Special-Surgery Expectations Surveys (back-to-normal = 1; large improvement = 2; moderate improvement = 3; slight improvement = 4; not applicable = 5). Patients scoring not applicable were excluded. Fulfilment was calculated by subtracting preoperative from postoperative scores (< 0: unfulfilled; ≥ 0: fulfilled). Multivariable logistic regression analyses were conducted separately for THA/TKA at 6 and 12 months postoperatively. Six months postoperatively, 75% of THA patients (n = 237/n = 316) and 72% of TKA patients (n = 211/n = 294) had fulfilled expectations. Older age (TKA:OR 1.08, 95% CI 1.01-1.15) and better postoperative physical functioning (THA:OR 1.10, 95% CI 1.06-1.14; TKA:OR 1.03, 95% CI 1.01-1.06) increased the likelihood of fulfilment. Physical work tasks (THA:OR 0.12, 95% CI 0.03-0.44), preoperative sick leave (TKA:OR 0.33, 95% CI 0.17-0.65), and difficulties at work (THA:OR 0.10, 95% CI 0.03-0.35; TKA:OR 0.41, 95% CI 0.17-0.98) decreased the likelihood of fulfilment. Twelve months postoperatively similar risk factors were found. Three out of four working-age THA/TKA patients had fulfilled expectations towards paid employment at 6 months postoperatively. Preoperative factors associated with fulfilment were older age, mental work tasks, no sick leave, postoperative factors were better physical functioning, and no perceived difficulties at work.

Reduction in use of MRI and arthroscopy among patients with degenerative knee disease in independent treatment centers versus general hospitals: a time series analysis.

The use of MRI and arthroscopy are considered low-value care in most patients with degenerative knee disease. To reduce these modalities, there have been multiple efforts to increase awareness. Reductions have been shown for general hospitals (GH), but it is unclear whether this may be partly explained by a shift of patients receiving these modalities in independent treatment centers (ITCs). The aims of this study were to assess (i) whether the trend in use of MRI and arthroscopy in patients with degenerative knee disease differs between ITCs and GH, and (ii) whether the Dutch efforts to raise awareness on these recommendations were associated with a change in the trend for both types of providers. All patients insured by a Dutch healthcare insurer aged ≥50 years with a degenerative knee disease who were treated in a GH or ITC between July 2014 and December 2019 were included. Linear regression was used with the quarterly percentage of patients receiving an MRI or knee arthroscopy weighted by center volume, as the primary outcome. Interrupted time-series analysis was used to evaluate the effect of the Dutch efforts to raise awareness. A total of 14 702 patients included were treated in 90 GHs (n = 13 303, 90.5%) and 29 ITCs (n = 1399, 9.5%). Across the study period, ITCs on an average had a 16% higher MRI use (P < .001) and 9% higher arthroscopy use (P = .003). MRI use did not change in both provider types, but arthroscopy use significantly decreased and became stronger in ITCs (P = .01). The Dutch efforts to increase awareness did not significantly influence either MRI or arthroscopy use in ITCs (P = .55 and P = .84) and GHs (P = .13 and P = .70). MRI and arthroscopy uses were higher in ITCs than GHs. MRI use did not change significantly among patients ≥ 50 years with degenerative knee disease in both provider types between 2014 and 2019. MRI- and arthroscopy use decreased with ITCs on average having higher rates for both modalities, but also showing a stronger decrease in arthroscopy use. The Dutch efforts to increase awareness did not accelerate the already declining trend in the Netherlands.

Knee kinematics are not different between asymmetrical and symmetrical tibial baseplates in total knee arthroplasty: A fluoroscopic analysis of step-up and lunge motions.

PURPOSE: This clinical fluoroscopy study investigated knee kinematics of two different cemented fixed-bearing, posterior-stabilised (PS) total knee arthroplasty (TKA) designs: an asymmetric tibial component including an asymmetric insert designed to optimise personalised balance and fit and its precursor symmetrical design with symmetric insert. METHODS: A consecutive series of patients (16 TKAs from each treatment group) participating in a randomised controlled trial comparing TKA migration was included. The exclusion criterion was the use of walking aids. Flat-panel fluoroscopic recordings of step-up and lunge motions were acquired 1-year postoperatively. Medial and lateral contact points (CPs) were determined to calculate CP displacement, femoral axial rotation and pivot position. Using linear mixed-effects modelling techniques, kinematics between TKA designs were compared. RESULTS: During knee extension between 20° flexion and full extension, the CPs moved anteriorly combined with a small internal femoral rotation (a screw-home mechanism). Whereas CP movement was reversed: femoral rollback, external femoral rotation while flexing the knee between full extension and 20° knee flexion, At larger flexion angles, femoral axial rotation (FAR) occurred around a lateral pivot point both during step-up and lunge. The symmetric design had a 2.3° larger range of FAR compared to the asymmetric design during lunge (p = 0.02). All other kinematics were comparable. CONCLUSION: Despite the differences in design, this study showed that the asymmetric and symmetric PS TKA designs had mostly comparable knee kinematics during step-up and lunge motions. It is therefore expected that the functionality of the successor TKA design is similar to that of its precursor design. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Linking Patient-Reported Outcome Measure Scores to Adverse Event Data to Gain Insight into Overestimation of Postoperative Patient-Reported Outcome Measure Improvement After Total Hip Arthroplasty and Total Knee Arthroplasty Due to Selective Nonresponse.

BACKGROUND: The purpose of the study was to gain insight into how clinically relevant improvement in patient-reported outcome measure scores after total hip arthroplasty (THA) and total knee arthroplasty (TKA) may be underestimated or overestimated, we compared patient-reported outcome measure respondents and nonrespondents on their adverse event rates and assessed whether adverse event occurrence was associated with clinically relevant patient-reported outcome measure improvement from those without adverse events. METHODS: All primary THAs and TKAs performed in 19 Dutch hospitals between January 2017 and December 2019 were included. The hip disability and osteoarthritis outcome score-physical function short form (HOOS-PS) and knee injury and osteoarthritis outcome score-physical function short form (KOOS-PS) were used to assess the physical function after THA and TKA, respectively. Adverse events included 1-year revision, 30-day readmission, 30-day complications, and long (ie, >75th percentile) length of stay. A clinically relevant improvement was defined as at least a 10-point decrease in HOOS-PS and 9 points in KOOS-PS scores. Associations between adverse events and clinically relevant HOOS-PS and KOOS-PS improvement were assessed using binary logistic regression models adjusted for patient characteristics and clustering of patients within hospitals. RESULTS: There were 20,338 THA and 18,082 TKA procedures included. Adverse events occurred more frequently in HOOS-PS and KOOS-PS nonrespondents than in respondents. The THA patients experiencing revision, complications, or long length of stay were less likely to experience clinically relevant HOOS-PS improvements (odds ratios of 0.11 [0.06 to 0.20], 0.44 [0.30 to 0.63], and 0.66 [0.50 to 0.88], respectively). The TKA patients experiencing revision or long length of stay were less likely to experience clinically relevant KOOS-PS improvements (odds ratios of 0.26 [0.12 to 0.55] and 0.63 [0.50 to 0.80], respectively). CONCLUSIONS: Clinically relevant HOOS-PS and KOOS-PS improvements are likely overestimated, as nonrespondents had higher adverse event rates which were associated with lower likelihood to achieve clinically relevant HOOS-PS and KOOS-PS improvements.

Multiple Joint Arthroplasty in Hip and Knee Osteoarthritis Patients: A National Longitudinal Cohort Study.

BACKGROUND: Many patients suffer from osteoarthritis (OA) in multiple joints, possibly resulting in multiple joint arthroplasties (MJAs). Primarily, we determined the cumulative incidence (Cin) of MJA in hip and knee joints up to 10 years. Secondly, we calculated the mean time between the first and subsequent joint arthroplasty, and evaluated the different MJA trajectories. Lastly, we compared patient characteristics and outcomes (functionality and pain) after surgery between MJA patients and single hip arthroplasty or knee arthroplasty (HA and KA) patients. METHODS: Primary index (first) HA or KA for OA were extracted from the Dutch Arthroplasty Register. The 1, 2, 5, and 10-year Cin (including competing risk death) of MJA, mean time intervals, and MJA-trajectories were calculated and stratified for primary index HA or KA. Sex, preoperative age, and body mass index were compared using ordinal logistic regression. Outcomes, measured preoperatively, 3, 6, and 12 months postoperatively (function: Hip Disability or Knee Injury and OA Outcome Score; Pain: Numerical Rating Scale), were compared using linear regression. RESULTS: A total of 140,406 HA-patients and 140,268 KA-patients were included. One, 2, 5, and 10-year Cin for a second arthroplasty were respectively 8.9% [95% confidence interval (CI): 8.7 to 9.0], 14.3% [95% CI: 14.1 to 14.5], 24.0% [95% CI: 23.7 to 24.2], and 32.7% [95% CI: 32.2 to 33.1] after index HA, and 9.5% [95% CI: 9.4 to 9.7], 16.0% [95% CI: 15.9 to 16.2], 26.4% [95% CI: 26.1 to 26.6], and 35.8% [95% CI: 35.4 to 36.3] after index KA. The 10-year Cin for > 2 arthroplasties were small in both the index HA and KA groups. Time-intervals from first to second, third, and fourth arthroplasty were 26 [95% CI: 26.1 to 26.7], 47 [95% CI: 46.4 to 48.4], and 58 [95% CI: 55.4 to 61.1] months after index HA, and 26 [95% CI: 25.9 to 26.3], 52 [95% CI: 50.8 to 52.7], and 61 [95% CI: 58.3 to 63.4] months after index KA. There were 83% of the second arthroplasties placed in the contralateral cognate joint (ie, knee or hip). Differences in postoperative functionality and pain between MJAs and single HAs and KAs were small. CONCLUSIONS: The 10-year Cin showed that about one-third of patients received a second arthroplasty after approximately 2 years, with the majority in the contralateral cognate joint. Few patients received > 2 arthroplasties within 10 years. Being a women, having a higher body mass index, and being younger increased the odds of MJA. Postoperative outcomes were slightly negatively affected by MJA.

Pediatric hip disorders are not associated with an increased 10-year revision risk after total hip arthroplasty under the age of 55: results from the Dutch Arthroplasty Register.

BACKGROUND AND PURPOSE:  Developmental dysplasia (DDH) and Legg-Calvé-Perthes disease (LCPD) are common indications for total hip arthroplasty (THA) at a young age, and may be associated with increased revision risk. We aimed to investigate the 10-year cumulative aseptic cup revision and overall revision risk of THA, and investigated whether these are increased compared with THA for primary osteoarthritis (OA) in patients below 55 years. METHODS:  All THAs (2007-2019) in patients under the age of 55 for the indications OA, DDH, and LCPD were extracted from the Dutch Arthroplasty register. The 10-year cumulative incidences of aseptic cup failure and overall revision were assessed for the 3 groups, with death as a competing risk. Cox regression analysis was used. RESULTS:  24,263 THAs were identified: 20,645 (85%) for OA, 3,032 (13%) for DDH, and 586 (2%) for LCPD. The 10-year cumulative revision risk for aseptic cup failure was 3.4% (95% confidence interval [CI] 3.0-3.8) for OA, 3.4% (CI 2.4-3.4) for DDH, and 1.7% (CI 0.2-3.1) for LCPD. The 10-year cumulative overall revision risk was 6.0% (CI 5.6-6.5) for OA, 6.0% (CI 4.9-7.2) for DDH, and 5.1% (2.7-7.5) for LCPD. The multivariable Cox regression analysis for aseptic cup failure yielded hazard ratios of 0.7 (0.5-1.2) for DDH, and 0.8 (0.3-2.1) for LCPD compared with OA. No statistically significant differences for overall revision were found. CONCLUSION:  THA performed for DDH or LCDP in patients under the age of 55 was not associated with a statistically significant increased risk of aseptic cup revision or overall revision, compared with THA performed for primary OA in the same age group.

Influence of marker-selection method in radiostereometric analysis of total knee arthroplasty on tibial baseplate migration patterns: a secondary analysis of a randomized controlled trial with 5-year follow-up.

BACKGROUND AND PURPOSE: Different marker-selection methods are applied to represent implant and tibial segments in radiostereometric analysis (RSA) studies of total knee arthroplasty (TKA). Either a consistent set of markers throughout subsequent RSA examinations ("consistent-marker method") is used or all available markers at each follow-up ("all-marker method"). The aim of this secondary analysis was to compare marker-selection methods on individual and group level TKA migration results. METHODS: Data from a randomized RSA study with 72 patients was included. Tibial baseplate migration was evaluated at 3 months, 1, 2, and 5 years postoperatively with both marker-selection methods. Additionally, migration was calculated using 5 fictive points, either plotted based on the consistent set of markers or all available markers. RESULTS: Migration could be calculated with both marker-selection methods for 248 examinations. The same prosthesis and bone markers (n = 136), different prosthesis markers (n = 71), different bone markers (n = 21), or different prosthesis and bone markers (n = 20) were used. The mean difference in maximum total point motion (MTPM) between all examinations was 0.02 mm, 95% confidence interval -0.26 to 0.31 mm. 5 implants were classified as continuously migrating with the consistent-marker method versus 6 implants (same 5 plus one additional implant) with the all-marker method. Using fictive points, fewer implants were classified as continuously migrating in both marker-selection methods. Differences between TKA groups in mean MTPM were comparable with both marker-selection methods, also when fictive points were used. CONCLUSION: Estimated group differences in mean MTPM were similar between marker-selection methods, but individual migration results differed. The latter has implications when classifying implants for estimated risk of future loosening.

CGR-CUSUM: a continuous time generalized rapid response cumulative sum chart.

Rapidly detecting problems in the quality of care is of utmost importance for the well-being of patients. Without proper inspection schemes, such problems can go undetected for years. Cumulative sum (CUSUM) charts have proven to be useful for quality control, yet available methodology for survival outcomes is limited. The few available continuous time inspection charts usually require the researcher to specify an expected increase in the failure rate in advance, thereby requiring prior knowledge about the problem at hand. Misspecifying parameters can lead to false positive alerts and large detection delays. To solve this problem, we take a more general approach to derive the new Continuous time Generalized Rapid response CUSUM (CGR-CUSUM) chart. We find an expression for the approximate average run length (average time to detection) and illustrate the possible gain in detection speed by using the CGR-CUSUM over other commonly used monitoring schemes on a real-life data set from the Dutch Arthroplasty Register as well as in simulation studies. Besides the inspection of medical procedures, the CGR-CUSUM can also be used for other real-time inspection schemes such as industrial production lines and quality control of services.

Allelic expression imbalance in articular cartilage and subchondral bone refined genome-wide association signals in osteoarthritis.

OBJECTIVES: To present an unbiased approach to identify positional transcript single nucleotide polymorphisms (SNPs) of osteoarthritis (OA) risk loci by allelic expression imbalance (AEI) analyses using RNA sequencing of articular cartilage and subchondral bone from OA patients. METHODS: RNA sequencing from 65 articular cartilage and 24 subchondral bone from OA patients was used for AEI analysis. AEI was determined for all genes present in the 100 regions reported by the genome-wide association studies (GWAS) catalog that were also expressed in cartilage or bone. The count fraction of the alternative allele (φ) was calculated for each heterozygous individual with the risk SNP or with the SNP in linkage disequilibrium (LD) with it (r2 > 0.6). Furthermore, a meta-analysis was performed to generate a meta-φ (null hypothesis median φ = 0.49) and P-value for each SNP. RESULTS: We identified 30 transcript SNPs (28 in cartilage and two in subchondral bone) subject to AEI in 29 genes. Notably, 10 transcript SNPs were located in genes not previously reported in the GWAS catalog, including two long intergenic non-coding RNAs (lincRNAs), MALAT1 (meta-φ = 0.54, FDR = 1.7×10-4) and ILF3-DT (meta-φ = 0.6, FDR = 1.75×10-5). Moreover, 12 drugs were interacting with seven genes displaying AEI, of which seven drugs have been already approved. CONCLUSIONS: By prioritizing proxy transcript SNPs that mark AEI in cartilage and/or subchondral bone at loci harbouring GWAS signals, we present an unbiased approach to identify the most likely functional OA risk-SNP and gene. We identified 10 new potential OA risk genes ready for further translation towards underlying biological mechanisms.

Identification and functional characterization of imbalanced osteoarthritis-associated fibronectin splice variants.

OBJECTIVE: To identify FN1 transcripts associated with OA pathophysiology and investigate the downstream effects of modulating FN1 expression and relative transcript ratio. METHODS: FN1 transcriptomic data was obtained from our previously assessed RNA-seq dataset of lesioned and preserved OA cartilage samples from the Research osteoArthritis Articular Cartilage (RAAK) study. Differential transcript expression analysis was performed on all 27 FN1 transcripts annotated in the Ensembl database. Human primary chondrocytes were transduced with lentiviral particles containing short hairpin RNA (shRNA) targeting full-length FN1 transcripts or non-targeting shRNA. Subsequently, matrix deposition was induced in our 3D in vitro neo-cartilage model. Effects of changes in the FN1 transcript ratio on sulphated glycosaminoglycan (sGAG) deposition were investigated by Alcian blue staining and dimethylmethylene blue assay. Moreover, gene expression levels of 17 cartilage-relevant markers were determined by reverse transcription quantitative polymerase chain reaction. RESULTS: We identified 16 FN1 transcripts differentially expressed between lesioned and preserved cartilage. FN1-208, encoding migration-stimulating factor, was the most significantly differentially expressed protein coding transcript. Downregulation of full-length FN1 and a concomitant increased FN1-208 ratio resulted in decreased sGAG deposition as well as decreased ACAN and COL2A1 and increased ADAMTS-5, ITGB1 and ITGB5 gene expression levels. CONCLUSION: We show that full-length FN1 downregulation and concomitant relative FN1-208 upregulation was unbeneficial for deposition of cartilage matrix, likely due to decreased availability of the classical RGD (Arg-Gly-Asp) integrin-binding site of fibronectin.

Enhanced in vivo and ex vivo thrombin generation after lower-leg trauma, but not after knee arthroscopy.

BACKGROUND: There is room for improvement of prevention of venous thromboembolism (VTE) after lower-leg cast application or knee arthroscopy. Information about the mechanism of clot formation in these patients may be useful to identify new prophylaxis targets. We aimed to study the effect of 1) lower-leg injury and 2) knee arthroscopy on thrombin generation. METHODS: A cross-sectional study was conducted using plasma samples of POT-(K)CAST trials to measure ex vivo thrombin generation (Calibrated Automated Thrombography [CAT]) and plasma levels of prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin (TAT), fibrinopeptide A (FPA). Plasma was obtained shortly after lower-leg trauma or before and after (< 4 h) knee arthroscopy. Participants were randomly selected from those who did not develop VTE. For aim 1, samples of 88 patients with lower-leg injury were compared with 89 control samples (i.e., preoperative samples of arthroscopy patients). Linear regression was used to obtain mean differences (or ratios if ln-retransformed because of skewedness) adjusted for age, sex, body mass index, comorbidities. For aim 2, pre- and postoperative samples of 85 arthroscopy patients were compared, for which mean changes were obtained. RESULTS: In patients with lower-leg injury (aim 1), endogenous thrombin potential, thrombin peak, velocity index, FPA and TAT were increased as compared with controls. In arthroscopy patients (aim 2), pre- and postoperative levels were similar for all parameters. CONCLUSION: Lower-leg trauma increases thrombin generation both ex vivo and in vivo, in contrast to knee arthroscopy. This may imply that the pathogenesis of VTE is different in both situations.

Out-of-hospital opioid prescriptions after knee and hip arthroplasty: prescribers and the first prescribed opioid.

BACKGROUND: We determined the first prescribed opioid and the prescribers of opioids after knee and hip arthroplasty (KA/HA) between 2013 and 2018 in the Netherlands. We also evaluated whether the first prescribed opioid dose was associated with the total dispensed dose and long-term opioid use in the first postoperative year. METHODS: The Dutch Foundation for Pharmaceutical Statistics was linked to the Dutch Arthroplasty Register. Stratified for KA/HA, the first out-of-hospital opioid within 30 days of operation was quantified as median morphine milligram equivalent (MME). Opioid prescribers were orthopaedic surgeons, general practitioners, rheumatologists, anaesthesiologists, and other physicians. Long-term use was defined as ≥1 opioid prescription for >90 postoperative days. We used linear and logistic regression analyses adjusted for confounders. RESULTS: Seventy percent of 46 106 KAs and 51% of the 42 893 HAs were prescribed ≥1 opioid. Oxycodone increased as first prescribed opioid (from 44% to 85%) whereas tramadol decreased (64-11%), but their dosage remained stable (stronger opioids were preferred by prescribers). An increase in the first prescription of 1% MME resulted in a 0.43%/0.37% increase in total MME (KA/HA, respectively). A 100 MME increase in dose of the first dispensed opioid had a small effect on long-term use (prevalence: 25% KA, 20% HA) (odds ratio=1.02/1.01 for KA/HA, respectively). Orthopaedic surgeons increasingly prescribed the first prescription between 2013 and 2018 (44-69%). General practitioners mostly prescribed consecutive prescriptions (>50%). CONCLUSION: Oxycodone increased as first out-of-hospital prescription between 2013 and 2018. The dose of the first prescribed opioid was associated with the total dose and a small increased risk of prolonged use. First prescriptions were mostly written by orthopaedic surgeons and consecutive prescriptions by general practitioners.

Sex differences in perceived expectations of the outcome of total hip and knee arthroplasties and their fulfillment: an observational cohort study.

The influence of sex on preoperative expectations and their fulfillment following total hip and knee arthroplasty (THA/TKA) remains unexplored. We investigated differences between men and women in perceived preoperative expectations on the outcome of THA/TKA and their fulfillment 1 year postoperatively. We performed a cohort study. Expectations were collected preoperatively and 1 year postoperatively using the Hospital for Special Surgery Hip/Knee Replacement Expectations Surveys (HSS-HRES/KRES; not applicable = 0, applicable: back to normal = 1, much = 2/moderate = 3/slight improvement = 4). Fulfillment of expectations was calculated by subtracting preoperative from postoperative scores (score < 0:unfulfilled; score ≥ 0:fulfilled). We included patients with "applicable" expectations. Chi-square and ordinal regression were used to compare expectations and fulfillment regarding sex. 2333 THA (62% women) and 2398 TKA (65% women) patients were included. 77% of THA and 76% of TKA patients completed the HSS-HRES/HSS-KRES both preoperatively and 1 year postoperatively. Men more often perceived items as "applicable", with differences in 9/20 (HSS-HRES) and 9/19 (HSS-KRES) preoperative items and, respectively, 12/20 (HSS-HRES) and 10/19 (HSS-KRES) postoperative items. The largest differences (> 10%) were found in sexual activity and working ability. 16/20 (HSS-HRES) and 14/19 (HSS-KRES) items showed an increased probability of having higher preoperative expectations of ≥ 10%, in favor of men. In all items, 60% of the respondents indicated that their expectation was fulfilled. Differences were observed in 16/20 (HSS-HRES) and 6/19 (HSS-KRES) items in favor of men. Sex differences were present in expectations and fulfillment, with higher applicability of items, preoperative expectations and fulfillment in men, especially on items related to functional activities.Trial registration: Trial-ID NTR3348.

What Changes Have Occurred in Opioid Prescriptions and the Prescribers of Opioids Before TKA and THA? A Large National Registry Study.

BACKGROUND: Opioid use before TKA or THA is linked to a higher risk of revision surgery and less functional improvement. In Western countries, the frequency of preoperative opioid use has varied, and robust information on temporal changes in opioid prescriptions over time (in the months before surgery as well as annual changes) and among prescribers is necessary to pinpoint opportunities to improve on low-value care patterns, and when they are recognized, to target physician populations for intervention strategies. QUESTIONS/PURPOSES: (1) What proportion of patients undergoing arthroplasties receive an opioid prescription in the year before TKA or THA, and what were the preoperative opioid prescription rates over time between 2013 and 2018? (2) Does the preoperative prescription rate vary between 12 and 10 months and between 3 and 1 months in the year before TKA or THA, and did it change between 2013 and 2018? (3) Which medical professionals were the main prescribers of preoperative opioids 1 year before TKA or THA? METHODS: This was a large-database study drawn from longitudinally maintained national registry sources in the Netherlands. The Dutch Foundation for Pharmaceutical Statistics was linked to the Dutch Arthroplasty Register from 2013 to 2018. TKAs and THAs performed because of osteoarthritis in patients older than 18 years, which were also uniquely linked by age, gender, patient postcode, and low-molecular weight heparin use, were eligible. Between 2013 and 2018, 146,052 TKAs were performed: 96% (139,998) of the TKAs were performed for osteoarthritis in patients older than 18 years; of them, 56% (78,282) were excluded because of our linkage criteria. Some of the linked arthroplasties could not be linked to a community pharmacy, which was necessary to follow patients over time, leaving 28% (40,989) of the initial TKAs as our study population. Between 2013 and 2018, 174,116 THAs were performed: 86% (150,574) were performed for osteoarthritis in patients older than 18 years, one arthroplasty was excluded because of an outlier opioid dose, and a further 57% (85,724 of 150,574) were excluded because of our linkage criteria. Some of the linked arthroplasties could not be linked to a community pharmacy, leaving 28% (42,689 of 150,574) of THAs, which were performed between 2013 and 2018. For both TKA and THA, the mean age before surgery was 68 years, and roughly 60% of the population were women. We calculated the proportion of patients undergoing arthroplasties who had at least one opioid prescription in the year before arthroplasty and compared data from 2013 to 2018. Opioid prescription rates are given as defined daily dosages and morphine milligram equivalents (MMEs) per arthroplasty. Opioid prescriptions were assessed by preoperative quarter and by operation year. Possible changes over time in opioid exposure were investigated using linear regression, adjusted for age and gender, in which the month of operation since January 2013 was used as the determinant and MME as the outcome. This was done for all opioids combined and per opioid type. Possible changes in opioid prescription rates in the year before arthroplasty were assessed by comparing the time period of 1 to 3 months before surgery with the other quarters. Additionally, preoperative prescriptions per operation year were assessed per prescriber category: general practitioners, orthopaedic surgeons, rheumatologists, and others. All analyses were stratified by TKA or THA. RESULTS: The proportion of patients undergoing arthroplasties who had an opioid prescription before TKA increased from 25% (1079 of 4298) in 2013 to 28% (2097 of 7460) in 2018 (difference 3% [95% CI 1.35% to 4.65%]; p < 0.001), and before THA increased from 25% (1111 to 4451) to 30% (2323 to 7625) (difference 5% [95% CI 3.8% to 7.2%]; p < 0.001). The mean preoperative opioid prescription rate increased over time between 2013 and 2018 for both TKA and THA. For TKA, an adjusted monthly increase of 3.96 MME was observed (95% CI 1.8 to 6.1 MME; p < 0.001). For THA, the monthly increase was 3.8 MME (95% CI 1.5 to 6.0; p = 0.001. For both TKA and THA, there was a monthly increase in the preoperative oxycodone rate (3.8 MME [95% CI 2.5 to 5.1]; p < 0.001 and 3.6 [95% CI 2.6 to 4.7]; p < 0.001, respectively). For TKA, but not for THA, there was a monthly decrease in tramadol prescriptions (-0.6 MME [95% CI -1.0 to -0.2]; p = 0.006). Regarding the opioids prescribed in the year before surgery, there was a mean increase of 48 MME (95% CI 39.3 to 56.7 MME; p < 0.001) for TKA between 10 and 12 months and the last 3 months before surgery. For THA, this increase was 121 MME (95% CI 110 to 131 MME; p < 0.001). Regarding possible differences between 2013 and 2018, we only found differences in the period 10 to 12 months before TKA (mean difference 61 MME [95% CI 19.2 to 103.3]; p = 0.004) and the period 7 to 9 months before TKA (mean difference 66 MME [95% CI 22.0 to 110.9]; p = 0.003). For THA, there was an increase in the MMEs prescribed between 2013 and 2018 for all four quarters, with mean differences ranging from 43.9 to 55.4 MME (p < 0.05). The average proportion of preoperative opioid prescriptions prescribed by general practitioners ranged between 82% and 86% (41,037 of 49,855 for TKA and 49,137 of 57,289 for THA), between 4% and 6% (2924 of 49,855 for TKA and 2461 of 57,289 for THA), by orthopaedic surgeons, 1% by rheumatologists (409 of 49,855 for TKA and 370 of 57,289 for THA), and between 9% and 11% by other physicians (5485 of 49,855 for TKA and 5321 of 57,289 for THA). Prescriptions by orthopaedic surgeons increased over time, from 3% to 7% for THA (difference 4% [95% CI 3.6 to 4.9]) and 4% to 10% for TKA (difference 6% [95% CI 5% to 7%]; p < 0.001). CONCLUSION: Between 2013 and 2018, preoperative opioid prescriptions increased in the Netherlands, mainly because of a shift to more oxycodone prescriptions. We also observed an increase in opioid prescriptions in the year before surgery. Although general practitioners were the main prescribers of preoperative oxycodone, prescriptions by orthopaedic surgeons also increased during the study period. Orthopaedic surgeons should address opioid use and its associated negative effects in preoperative consultations. More intradisciplinary collaboration seems important to limit the prescribing of preoperative opioids. Additionally, research is necessary to assess whether opioid cessation before surgery reduces the risk of adverse outcomes. LEVEL OF EVIDENCE: Level III, therapeutic study.

The relationship between publication of high-quality evidence and changes in the volume and trend of subacromial decompression surgery for patients with subacromial pain syndrome in hospitals across Australia, Europe and the United States: a controlled interrupted time series analysis.

AIMS: To evaluate the extent to which publication of high-quality randomised controlled trials(RCTs) in 2018 was associated with a change in volume or trend of subacromial decompression(SAD) surgery in patients with subacromial pain syndrome(SAPS) treated in hospitals across various countries. METHODS: Routinely collected administrative data of the Global Health Data@work collaborative were used to identify SAPS patients who underwent SAD surgery in six hospitals from five countries (Australia, Belgium, Netherlands, United Kingdom, United States) between 01/2016 and 02/2020. Following a controlled interrupted time series design, segmented Poisson regression was used to compare trends in monthly SAD surgeries before(01/2016-01/2018) and after(02/2018-02/2020) publication of the RCTs. The control group consisted of musculoskeletal patients undergoing other procedures. RESULTS: A total of 3.046 SAD surgeries were performed among SAPS patients treated in five hospitals; one hospital did not perform any SAD surgeries. Overall, publication of trial results was associated with a significant reduction in the trend to use SAD surgery of 2% per month (Incidence rate ratio (IRR) 0.984[0.971-0.998]; P = 0.021), but with large variation between hospitals. No changes in the control group were observed. However, publication of trial results was also associated with a 2% monthly increased trend (IRR 1.019[1.004-1.034]; P = 0.014) towards other procedures performed in SAPS patients. CONCLUSION: Publication of RCT results was associated with a significantly decreased trend in SAD surgery for SAPS patients, although large variation between participating hospitals existed and a possible shift in coding practices cannot be ruled out. This highlights the complexities of implementing recommendations to change routine clinical practice even if based on high-quality evidence.

The reliability of revision rates following primary shoulder arthroplasty as a quality indicator to rank hospital performance: a national registry analysis including 13,104 shoulders and 87 hospitals.

BACKGROUND: To assess the extent of between-hospital variation in revision following primary shoulder arthroplasty (SA), both overall and for specific revision indications to guide quality improvement initiatives, and to assess whether revision rates are suitable as quality indicators to reliably rank hospital performance. METHODS: All primary SAs performed between 2014 and 2018 were included from the Dutch Arthroplasty Register to examine 1-year revision and all primary SAs performed between 2014 and 2016 for 1- and 3-year revisions. For each hospital, the observed number (O) of revisions was compared with that expected (E) based on case-mix and depicted in funnel plots with 95% control limits to identify outlier hospitals. The rankability (ie, the reliability of ranking hospitals) was calculated as the percentage of total hospital variation due to true between-hospital differences rather than chance and categorized as low (<50%), moderate (50%-75%), and high (>75%). RESULTS: A total of 13,104 primary SAs (87 hospitals) in 2014-2018 were included, of which 7213 were performed between 2014 and 2016. Considerable between-hospital variation was found in 1-year revision in 2014-2016 (median 1.6%, interquartile range 0.0%-3.1%), identifying 3 outlier hospitals having overall significantly more revisions than expected (O/E range 1.9-2.3) and for specific indications (cuff pathology and infection). Results for 2014-2018 were similar. For 3-year revision, 3 outlier hospitals were identified (O/E range 1.7-3.3). Rankabilities for all outcomes were low. CONCLUSIONS: Considerable between-hospital variation was observed for 1- and 3-year revision rates following primary SA, where outlier hospitals could be identified based on large differences in revision for specific indications to direct quality improvement initiatives. However, rankabilities were low, meaning that much of the other (smaller) variation in performance could not be detected, rendering revisions unsuitable to rank hospital performances following primary SA.

Treatment of neurogenic scapular winging: a systematic review on outcomes after nonsurgical management and tendon transfer surgery.

BACKGROUND: Scapular winging is a rare condition of the shoulder girdle that presents challenging treatment decisions for clinicians. To inform clinical practice, clinicians need guidance on what the best treatment decision is for their patients, and such recommendations should be based on the total evidence available. Therefore, the purpose of this review was to systematically review the evidence regarding nonsurgical management and tendon transfer surgery of patients with neurologic scapular winging due to serratus anterior (SA) or trapezius (TP) palsy. METHODS: PubMed, Embase, Web of Science, Cochrane Library, Emcare, and Academic Search Premier were searched up to April 5, 2022, for studies reporting on clinical outcomes after nonsurgical management and tendon transfer surgery of scapular winging due to weakness of the SA or TP muscle. The Integrated quality Criteria for Review Of Multiple Study (ICROMS) tool was used to classify the quality of the studies. Primary outcomes were the fraction of patients with spontaneous recovery after nonsurgical management and improvement in shoulder function, pain scores, and shoulder scores after tendon transfer surgery. Data were pooled if data on the same outcome were available for at least 3 studies, using random-effects meta-analysis. RESULTS: Twenty-three (10 moderate-quality [MQ] and 13 low-quality) studies were included. Six studies (3 MQ; 234 shoulders) reported on outcomes after nonsurgical management of SA palsy, whereas 12 (6 MQ; 221 shoulders) and 6 studies (1 MQ; 80 shoulders) evaluated the outcomes of tendon transfer for SA or TP palsy (1 study addressed both). Spontaneous recovery of scapular winging with nonsurgical management varied between 21% and 78% across studies after a median follow-up of 72 months. For surgical management of SA palsy, pooling data in a meta-analysis showed that patients on average improved by 47° (95% confidence interval [CI]: 34-61, P ≤ .001) in active forward flexion, had lower visual analog scale scores for pain (mean difference [MD]: -3.0, 95% CI: -4.9 to -1.0, P = .003), and had substantial improvements in American Shoulder and Elbow Surgeons (MD: 24, 95% CI: 9-39, P = .002) and Constant scores (MD: 45, 95% CI: 39-51, P ≤ .001). Patients with TP palsy on average improved by 36° (95% CI: 21-51, P ≤ .001) in active forward flexion after tendon transfer. Statistical pooling was not possible for other outcome measures as insufficient data were available. CONCLUSION: A substantial part of nonsurgically managed patients with scapular winging seem to have persistent complaints, which should be part of the information provided to patients. Data pooling demonstrated significant improvements in shoulder function, pain scores, and shoulder scores after tendon transfer surgery, but higher quality evidence is needed to allow for more robust recommendations and guide clinical decision-making on when to perform such functional surgery.

Association Between Surface Modifications for Biologic Fixation and Aseptic Loosening of Uncemented Total Knee Arthroplasties.

BACKGROUND: Various surface modifications are used in uncemented total knee arthroplasties (TKAs) to enhance bony ingrowth and longevity of implants. This study aimed to identify which surface modifications are used, whether they are associated with different revision rates for aseptic loosening, and which are underperforming compared to cemented implants. METHODS: Data on all cemented and uncemented TKAs used between 2007 and 2021 were obtained from the Dutch Arthroplasty Register. Uncemented TKAs were divided into groups based on their surface modifications. Revision rates for aseptic loosening and major revisions were compared between groups. Kaplan-Meier, Competing-Risk, Log-rank tests, and Cox regression analyses were used. In total, 235,500 cemented and 10,749 uncemented primary TKAs were included. The different uncemented TKA groups included the following: 1,140 porous-hydroxyapatite (HA); 8,450 Porous-uncoated; 702 Grit-blasted-uncoated; and 172 Grit-blasted-Titanium-nitride (TiN) implants. RESULTS: The 10-year revision rates for aseptic loosening and major revision of the cemented TKAs were 1.3 and 3.1%, and for uncemented TKAs 0.2 and 2.3% (porous-HA), 1.3 and 2.9% (porous-uncoated), 2.8 and 4.0% (grit-blasted-uncoated), and 7.9% and 17.4% (grit-blasted-TiN), respectively. Both type of revision rates varied significantly between the uncemented groups (log-rank tests, P < .001, P < .001). All grit-blasted implants had a significantly higher risk of aseptic loosening (P < .01), and porous-uncoated implants had a significantly lower risk of aseptic loosening than cemented implants (P = .03) after 10 years. CONCLUSION: There were 4 main uncemented surface modifications identified, with different revision rates for aseptic loosening. Implants with porous-HA and porous-uncoated had the best revision rates, at least equal to cemented TKAs. Grit-blasted implants with and without TiN underperformed, possibly due to the interaction of other factors.

Challenges in developing national orthopedic health research agendas in the Netherlands: process overview and recommendations.

Growing demand for clinical research to improve evidence-based medicine in daily medical practice led to healthcare evaluation, which assesses the effectiveness of the existing care. The first step is identifying and prioritizing the most important evidence uncertainties. A health research agenda (HRA) can be valuable and helps determine funding and resource allocation, aiding researchers and policymakers to design successful research programs and implement the results in daily medical practice. We provide an overview of the development process of the first 2 HRAs within orthopedic surgery in the Netherlands and the following research process. In addition, we developed a checklist with recommendations for the future development of an HRA. This perspective guides the development of highquality and widely supported nationwide HRAs, including preparatory actions. This improves the uptake of evidence uncertainties in a successful research program and disseminates evidence-based literature in daily medical practice to improve patient care.

Change in CT-measured acetabular bone density following total hip arthroplasty: a systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Assessing peri-acetabular bone quality is valuable for optimizing the outcomes of primary total hip arthroplasty (THA) as preservation of good quality bone stock likely affects implant stability. The aim of this study was to perform a meta-analysis of peri-acetabular bone mineral density (BMD) changes over time measured using quantitative computer tomography (CT) and, second, to investigate the influence of age, sex, and fixation on the change in BMD over time. METHODS: A systematic search of Embase, Scopus, Web of Science, and PubMed databases identified 19 studies that measured BMD using CT following THA. The regions of interest (ROI), reporting of BMD results, and scan protocols were extracted. A meta-analysis of BMD was performed on 12 studies that reported measurements immediately postoperatively and at follow-up. RESULTS: The meta-analysis determined that periacetabular BMD around both cemented and uncemented components decreases over time. The amount of BMD loss increased relative to proximity of the acetabular component. There was a greater decrease in cortical BMD over time in females and cancellous BMD for young patients of any sex. CONCLUSION: Peri-acetabular BMD decreases at different rates relative to its proximity to the acetabular component. Cancellous BMD decreases more in young patients and cortical bone decreases more in females. Standardized reporting parameters and suggested ROI to measure peri-acetabular BMD are proposed, to enable comparison between implant and patient variables in the future.