The efficacy of pre-operative preparation with intravenous iron and/or erythropoietin in anaemic patients undergoing orthopaedic surgery: An observational study.

BACKGROUND: Pre-operative anaemia and transfusion are common among patients undergoing elective orthopaedic surgery. Application of 'patient blood management' might be the most effective way to reduce both anaemia and transfusion. Pre-operative administration of iron and/or erythropoietin (EPO) is one of the cornerstones of the first pillar of patient blood management, but in a daily clinical setting, efficacy and long-term safety of this measure have not been analysed thoroughly to date. OBJECTIVE: To investigate the influence of pre-operative preparation (PREP) of patients with iron and/or EPO on peri-operative transfusion needs and long-term survival. DESIGN: Single-centre, retrospective study. SETTING: Anaesthesia department, University hospital. INTERVENTIONS: Pre-operative preparation with iron and/or EPO versus no preparation. METHODS: After approval of our local ethics committee, data of 5518 patients who received total hip or total knee replacement between 2008 and 2014 were included. Patients receiving iron and/or EPO were included in the PREP group, whereas patients without iron and/or EPO were included in the no preparation group. From the full data set, a bias-reduced subset of 662 patients was obtained by means of propensity score-matching to compare peri-operative red blood cell utilisation and long-term survival of patients between groups. RESULTS: Patients in the PREP group needed a lower number of units of red blood cells than patients in the no preparation group (0.2 ±â€Š0.8 vs. 0.5 ±â€Š1.3, P < 0.001), had a lower transfusion rate (12 vs. 24%, P < 0.05) and had a similar haemoglobin concentration (10.7 ±â€Š1.3 vs. 10.6 ±â€Š1.1 g dl, not significant) at discharge. No differences in long-term survival were observed between the two study groups. CONCLUSION: PREP of patients with iron and/or EPO in orthopaedic patients can be considered highly effective in terms of transfusion reduction, without influencing long-term survival.

No bias for developer publications and no difference between first-generation trochlear-resurfacing versus trochlear-cutting implants in 15,306 cases of patellofemoral joint arthroplasty.

PURPOSE AND HYPOTHESIS: The study aim was to assess the outcome of patellofemoral arthroplasty (PFA), paying particular interest to 'revisions for any reason'. The hypothesis was that there is a superior outcome of PFA reported in dependent clinical studies in contrast to independent clinical literature and that there is a superior outcome of 'trochlear-cutting' PFA in comparison with 'first-generation trochlear-resurfacing' implants. METHODS: Studies on PFA from its market introduction in 1955 onwards were systematically reviewed. The revision rate, which was calculated as 'revisions per 100 component years (CY)', was evaluated in 45 studies published in indexed, peer-reviewed international scientific journals. In addition, 'first-generation trochlear-resurfacing' and 'trochlear-cutting' implants as well as dependent and independent clinical literature were analysed. Furthermore, the data of three arthroplasty registers were analysed. RESULTS: A total of 15,306 PFA were included consisting of 2266 cases in worldwide literature data and of 13,040 cases in register data. 2.22 revisions per 100 CY were observed in worldwide literature data, which corresponds to a revision rate of 22.2% after 10 years. Revision rates between 18.9 and 27% after 10 years were shown by the included three national joint registers. In the group analyses no significant differences were detected. CONCLUSIONS: This meta-analysis did not reveal significant differences in the comparison between developer over independent publications and between 'first-generation-resurfacing' over 'trochlear-cutting' implants. In conclusion the data of developer publications do not seem to be biased. 'Trochlear-cutting' devices of PFA had slightly superior outcomes, but that benefit was not statistically significant. Nevertheless, we would recommend 'trochlear-cutting' devices for further use in PFA. LEVEL OF EVIDENCE: Meta-analysis of Level IV case series.

Sidus Stem-Free Shoulder System for primary osteoarthritis: short-term results of a multicenter study.

BACKGROUND: The aim of this prospective multicenter study was to evaluate clinical and radiologic results of a new metaphyseal anchored system. This system features a different anchor geometry that potentially leads to better bony integration and less loosening. METHODS: From November 2012 until December 2015, 148 patients (151 shoulders) were treated with the Sidus Stem-Free Shoulder System at 9 centers in Europe. The main indication was primary osteoarthritis (80.1%). This analysis only includes patients diagnosed with primary osteoarthritis (n = 121). A clinical evaluation was performed using the Constant-Murley score, Subjective Shoulder Value, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, and range of motion. Radiologic assessment was based on the occurrence of radiolucent lines and signs of implant migration, osteolysis, loosening, and heterotopic ossification. RESULTS: We evaluated 105 patients after a follow-up period of 2 years. There were 53 women and 52 men. The average age was 64 years. Total shoulder arthroplasty was performed in 73 cases and hemiarthroplasty in 32. The Constant-Murley score improved from 26 points preoperatively to 70 points at 2 years' follow-up (P < .001). The Subjective Shoulder Value increased from 34% to 84% (P < .001), and the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form increased from 34 points to 86 points (P < .001). Radiologically, neither migration nor loosening was found. However, radiolucent lines of 2 mm or greater could be detected around the glenoid in 2 cases, but none of them have had clinical relevance yet. The overall complication rate was 6.7%, and the revision rate was 0%. CONCLUSION: Patients with the Sidus Stem-Free Shoulder System achieve good clinical and radiologic short-term results that are comparable with the results of other stem-free shoulder implants.

Revision surgery after total joint arthroplasty: a complication-based analysis using worldwide arthroplasty registers.

The authors performed a complication-based analysis of total knee (TKA), total hip (THA), and total ankle arthroplasty (TAA) using worldwide arthroplasty registers. We extracted data with respect to reason for revision surgery and pooled causes. The most common causes for revisions in THA were aseptic loosening (55.2%), dislocation (11.8 %), septic loosening (7.5%), periprosthetic fractures (6%), and others. The most common causes in TKA were aseptic loosening (29.8%), septic loosening (14.8%), pain (9.5%), wear (8.2%), and others. The most common causes in TAA were aseptic loosening (38%), technical errors (15%), pain (12%), septic loosening (9.8%), and others. Revisions in TKA and THA differ with respect to type of complication. However, in case of TAA, higher rates of technically related complications are reported.

Outcome after total ankle arthroplasty-results and findings from worldwide arthroplasty registers.

PURPOSE: The data currently available concerning total ankle arthroplasty (TAA) does not allow valid conclusions in several clinically relevant areas. Total ankle arthroplasty imposes special requirements on the methodology of data collection, evaluation, publication and the assessment of register data. METHODS: We undertook a structured and descriptive analysis of all outcome data available from high-quality national arthroplasty registers worldwide. Register data from Sweden, Finland, Norway, New Zealand and Australia were included in the analysis. RESULTS: There are marked differences between Europe and Oceania with respect to indications. All data sets show revision rates of approximately 10 % at five years, of which about 40 % of cases are for aseptic loosening. Inlay fractures are relatively common, which indicates potential for the improvement of implants. The documentation of intraoperative surgical errors leading to revision surgery varies significantly among registers. A relevant number of complications are treated without an implant component being exchanged and therefore not covered by a register. CONCLUSIONS: The results of TAA are promising, but the revision rate is higher than for total hip or knee arthroplasty. TAA outcome measurement by means of registers has several specific requirements necessitating additional documentation beyond the basic data set. For methodological reasons the evaluation of results is more complex than for hip or knee arthroplasty. It will therefore be essential to standardise data collection and evaluation and develop a methodology addressing the specific needs of TAA.

Organisation, data evaluation, interpretation and effect of arthroplasty register data on the outcome in terms of revision rate in total hip arthroplasty.

Originally developed in Scandinavia, national arthroplasty registers have spread worldwide during the last decade. The value of registers for quality improvement in arthroplasty has frequently been documented. However, for the development of a successful register a few key points should be taken into account. Uncontrolled loss of patients from the registry area should be avoided. Registers should form an integral part of a country's medical system. To realise the potential for improvement, it is crucial that physicians deal with the results in detail. Thus it is absolutely essential to involve the specialty societies in the interpretation and dissemination of results. With respect to revision rates, register data are usually more valid than meta-analyses of clinical studies. For every physician the most valuable data are those coming from a register in his own country; the development of national arthroplasty registers should therefore be continued.

Fracture, nonunion and postoperative infection risk in the smoking orthopaedic patient: a systematic review and meta-analysis.

This systematic review and meta-analysis aimed to analyse negative effects of smoking in orthopaedic and trauma patients.A PubMed search was carried out for studies published until July 2020 regarding effects of smoking on fracture risk, nonunion, infection after orthopaedic surgery, and persisting nonunion after scaphoid nonunion surgery. Random effects models calculated for outcome parameters, and relative risks (RR) with 95% confidence intervals are provided. No adjustments for covariates were made. Heterogeneity was assessed with Higgins' I2, publication bias with Harbord's p (Hp), sensitivity analysis performed on funnel plots and quality of studies was analysed using the Newcastle-Ottawa Scale.Of 3362 retrieved entries, 69 were included in the final analysis. Unadjusted RR for smokers to develop vertebral (six studies, seven entries; RR: 1.61; p = 0.008; I2 = 89.4%), hip (11 studies, 15 entries; RR: 1.28; p = 0.007; I2 = 84.1%), and other fractures (eight studies, 10 entries; RR: 1.75; p = 0.019; I2 = 89.3%) was significantly higher. Postoperative infection risk was generally higher for smokers (21 studies; RR: 2.20; p < 0.001; I2 = 58.9%), and remained upon subgroup analysis for elective spinal (two studies; RR: 4.38; p < 0.001; I2 = 0.0%) and fracture surgery (19 studies; RR: 2.10; p < 0.001; I2 = 58.5%). Nonunion risk after orthopaedic (eight studies; RR: 2.15; p < 0.001; I2 = 35.9%) and fracture surgery (11 studies; RR: 1.85; p < 0.001; I2 = 39.9%) was significantly higher for smokers, as was persisting nonunion risk after surgery for scaphoid nonunion (five studies; RR: 3.52; p < 0.001; I2 = 0.0%). Sensitivity analysis for each model reduced heterogeneity whilst maintaining significance (all I2 < 20.0%).Smoking has a deleterious impact on fracture incidence, and (subsequent) development of nonunions and postoperative infections. Cite this article: EFORT Open Rev 2021;6:1006-1019. DOI: 10.1302/2058-5241.6.210058.

Serum leptin is correlated to high turnover in osteoporosis.

OBJECTIVE: Clinical data have suggested that obesity protects against osteoporosis. Leptin, mainly secreted by white adipose tissue, might be involved by mediating an effect on bone metabolism. This study was conducted to investigate a possible relationship of leptin and bone turn-over in postmenopausal women with osteoporosis. METHODS: We measured bone mineral density (BMD), serum leptin levels and markers of bone metabolism, including osteocalcin and cross-laps in 44 patients with osteoporosis. The main group consisted of 32 postmenopausal women. RESULTS: Mean serum leptin was 13.1 microg/L and showed no statistically significant difference to the levels measured in a collective of normal persons adjusted for age and BMI. When related to serum cross-laps as markers of bone resorption, a positive correlation (p<0.05) was observed, whereas no correlation with osteocalcin could be seen. CONCLUSIONS: A dual control of bone formation by leptin is assumed: This involves local mechanisms acting on osteoblasts and a central inhibitory effect on bone metabolism via a hypothalamic relay. Our data indicate that the net effect of circulating leptin may cause bone loss and is significantly related to high-turnover serum bone markers, at least in postmenopausal women with osteoporosis.

30-Years of experience with the cementless implanted Alloclassic CSF screw cup total hip arthroplasty system - An ultra-long-term follow-up.

OBJECTIVE: The aim of this study was to evaluate our long-term results with the Alloclassic CSF screw cup total hip arthroplasty system. This is the first study to provide a 30-year follow-up, based upon our 30-year follow up study on the Alloclassic stem system. METHODS: We reviewed 178 Alloclassic CSF screw cup systems, implanted in 171 patients from 1986 to 1987. The Zweymüller stem family was used in all cases. 136 patients had died over the last 30 years, so twenty-nine out of 35 patients being still alive, with a mean follow-up of 29,46 years (SD 0,48), were contacted by telephone and evaluated radiologically and clinically. Our loss-to-follow up was 17,14%. The mean age at follow-up was 83,01 years (72,4-95,2; SD 6,86). RESULTS: If the endpoint is defined as the removal of the cup for aseptic loosening (3 cases), the overall survival rate is 98,31%. If the endpoint is revision for any reason (27 cases), the survival rate is 84,83%. Eleven patients needed an exchange of head and liner. The mean time from implantation until change of head and liner was 21,44 years (SD 5,92). CONCLUSION: After 30 years of monitoring we can state that the evaluated system is very reliable in primary and secondary THA.

30-years of experience with the cementless implanted Alloclassic total hip arthroplasty system-An ultra-long-term follow-up.

OBJECTIVE: The aim of this study was to evaluate our long-term results with the Zweymüller hochgezogen and SL total hip arthroplasty system. This is the first study to provide a 30-year follow-up. METHODS: We reviewed 186 Alloclassic stem systems (Zweymüller hochgezogen (112) and SL (74), implanted in 179 patients from 1986 to 1987.Two different types of cementless acetabular components were used.143 patients had died over the last 30 years, so thirty out of 36 patients being still alive, with a mean follow-up of 29,48 years (SD 0,51), were contacted by telephone and evaluated radiologically and clinically. Our loss-to-follow up was 16,7%. The mean age at follow-up was 83,57 years (72,4-95,2; SD 6,77). RESULTS: If the endpoint is defined as the removal of the stem for aseptic loosening (3 cases), the overall survival rate is 98,38%. If the endpoint is revision for any reason (27 cases), the survival rate is 85,48%. Eleven patients needed an exchange of head and liner. The mean time from implantation until change of head and liner was 21,44 years (SD 5,92).Most of the radiolucent lines and osteolytic zones were found in the proximal Gruen-zones 1 and 7 (69,7 and 21,2%). CONCLUSION: After 30 years of monitoring we can state that the evaluated system is very reliable in primary and secondary THA.

Osteolysis in total hip arthroplasty after head and inlay revision surgery.

Wear debris seems to be the most likely reason for osteolysis in THA. The aim was to show the influence of head and acetabular liner revision surgery on osteolytic zones around the femoral component. Can head and inlay revision surgery reduce the size of the osteolytic zones around the femoral component? Which patients could benefit? 47 patients (51 hips), who had undergone THA head and inlay revision surgery between 1999 and 2011, were reviewed. The mean lifetime for the prosthesis was 15.1 years (8-26, standard deviation 4.5) and the mean follow-up for head and inlay was 39.2 months (12-113, standard deviation 30). The heads used in revision surgery were made of metal (26) and ceramics (25). In 36 cases a ultra-high-molecular-weight polyethylene inlay was taken, in 15 cases a regular PE-inlay. We compared the pre-surgical and follow-up anterior-posterior X-rays. The mean size of radiolucent areas before revision surgery was 147 sq.mm (5-389 sq.mm, standard deviation 115). Thirty-nine months (12-113) after surgery, their mean size was 145 sq.mm (7-604 sq.mm, standard deviation 124). Radiolucent zones exceeding 100 sq.mm could be reduced by an average of 28% in 18 out of 29 cases. The results showed an improvement in 29 out of 51 cases and a stop of progress in one case. According to the findings there may be a benefit for patients with big radiolucent areas.

Patients with arthritis undergoing surgery: how should we manage tumour necrosis factor blocking agents perioperatively?-A systematic literature review.

We systematically reviewed the literature on the infectious risk in patients treated with tumour necrosis factor blocking agents (TNF-BA) undergoing surgery: we searched the Medline (PubMed) and the online archive from the Annual European Congress of Rheumatology and the Annual Scientific Meeting of the American College of Rheumatology. Of total 1259 reports, 14 were finally analysed. With one exception all were retrospective. Four of 6 studies compared patients on TNF-BA with those not receiving TNF-BA, and found an increased risk of infection with the use of TNF-BA. None of the other studies which compared continued with discontinued treatment at surgery found an increased risk of infection, when the medication was continued perioperatively. In conclusion, while in theory there is an increased risk of infections when TNF-BA are administered perioperatively, the available literature does not necessarily support this. It rather appears that patients receiving TNF-BA are a priori at a higher risk of postoperative infections. Scheduling surgery at the end of the drug interval and adding one "safety" week prior to surgery should be an acceptable plan in daily clinical practice.

Impact of implant developers on published outcome and reproducibility of cohort-based clinical studies in arthroplasty.

BACKGROUND: The reproducibility of the results of cohort-based clinical studies of arthroplasty procedures by the average orthopaedic surgeon is a major issue involving the quality of the scientific literature. We compared the results of a comprehensive literature analysis with data from national arthroplasty registries to examine the influence of arthroplasty implant inventors on the outcomes published in peer-reviewed journals. METHODS: A structured review of the literature published in MEDLINE-listed journals was performed. A comparison of the average revision rates in the identified studies (adjusted for the number of arthroplasty cases and the duration of follow-up) with the registry data was then conducted. RESULTS: Seventeen of the analyzed arthroplasty implants were developed in the United States. Studies by the developers of these implants often had a substantial influence on the published outcome. For approximately 50% of the implant systems analyzed, the average revision rate derived by combining all published studies showed a statistically significant and clinically relevant deviation from the revision rate derived from the arthroplasty registry data, which reflected the outcome in the average patient. For the majority of implants for which the revision rate calculated from the published clinical studies was very low compared with the rate calculated from the registry data, the developing institution accounted for 39% to 100% of the published outcome data for the implant. In contrast, the published results were usually reproducible in clinical practice if <25% of the published data were reported by the developers. Three of the nine arthroplasty implants developed in Europe showed a significant and clinically relevant difference between the revision rate derived from only the studies published by the developers and the rate calculated from the registry data. However, because of the considerably greater amount of data from independent studies that was typically available for the European implants than for the American implants, studies by the developer that deviated significantly from the registry data could usually also be identified as outliers by a meta-analysis of all published studies. A high proportion of the published data involving three of the European implants was reported by the inventors, but comparison with the registry data revealed that the average published revision rates for two of these three implants were reproducible in clinical practice. CONCLUSIONS: The published results of the clinical studies involving many of the arthroplasty implants, especially implants developed in the United States, were highly influenced by reports from the center that developed the implant. This often had a substantial effect on the reproducibility of the outcome data. There appeared to be relevant differences between the medical research systems in Europe and the United States that also affected the reproducibility and applicability of the results for the average surgeon. Registry data can contribute substantial added value to an informed discussion of arthroplasty outcomes.

Long-term results of the cementless ALLOCLASSIC hip arthroplasty system using a 28-mm ceramic head: with a retrospective comparison to a 32-mm head.

One hundred twenty-four total hip arthroplasties in 119 patients, all performed with the cementless ALLOCLASSIC hip arthroplasty system (SL stem and CSF cup; Centerpulse, Winterthur, Switzerland), were analyzed retrospectively. In all hips, a 28-mm head and an ultrahigh-molecular-weight polyethylene inlay were used. Of the 124 hips, 81 could be investigated clinically and radiologically after an average of 150.6 months (range, 133-169 months). Twenty-six patients (26 hips) died in the interim. One of these patients had septic cup loosening. Seventeen hips (16 patients) were not available for follow-up because of health reasons (12 hips in 11 patients), lack of cooperation (3 hips in 3 patients), or loss to follow-up (2 hips in 2 patients). Of the 124 total hip arthroplasties, 4 cups were removed (2 aseptic and 2 septic loosening). No stem had to be removed. If aseptic loosening is defined as the end point, the survival rate is 98.4% (95% confidence interval, 93.8%-99.6%) for the cup and 100% for the stem after 157 months. If revision for any reason is defined as the end point, the survival rate is 95.6% (95% confidence interval, 90.1%-98.3%). Before operation, the average Harris Hip Score was 36.4 points (21-46). At time of follow-up, the average Harris Hip Score was 89.7 points (54-100). Radiolucent lines and osteolyses were found only seldom (mostly in the proximal stem zones).

Reconstruction of severe acetabular bone-deficiency: the Burch-Schneider antiprotrusio cage in primary and revision total hip arthroplasty.

Ninety Burch-Schneider antiprotrusio cages in 87 patients implanted in primary and revision total hip arthroplasty were analyzed. Sixty-seven hips (64 patients) could be examined clinically and radiologically after an average of 50.3 months (minimum 23.6, maximum 131.0 months). Twenty patients (20 hips) died in interim and 3 patients (3 hips) were not available for follow-up. Of the 90 Burch-Schneider antiprotrusio cages, 4 had to be removed and 8 further cages were considered definitely loose. The survival rate is 93.4% (95% confidence interval, 74.3%-96.7%) after 131 months if the endpoint "cage explantation" is used. The average Harris Hip Score was improved from 28.2 preoperatively to 73.5 points at the time of follow-up. Radiolucent lines were often found in the Charnley/DeLee's zones II and III. In contrast, osteolyses were seldom seen.

Long-term results with the cementless Alloclassic brand hip arthroplasty system.

The first 100 Alloclassic (Centerpulse, Winterthur, Switzerland) hip prostheses implanted at Allgemeines Krankenhaus Linz were examined in this study. All cases involved primary total hip arthroplasty. Of these 100, 75 could be followed up clinically and radiologically. All living patients were contacted by telephone. The follow-up period was at least 10 years. If the endpoint is defined as removal of the prosthesis due to aseptic loosening, the survival rate was 96.9% for the cup and 100% for the stem after 132 months. The average Harris Hip Score was 85.4 points. Radiolucent lines and osteolyses were found primarily in the proximal zones of the stem.