Is Parkinson's Disease Associated with Increased Mortality, Poorer Outcomes Scores, and Revision Risk After THA? Findings from the Swedish Hip Arthroplasty Register.

BACKGROUND: Neurological conditions such as Parkinson's disease are commonly accepted as a risk factor for an increased likelihood of undergoing revision surgery or death after THA. However, the available evidence for an association between Parkinson's disease and serious complications or poorer patient-reported outcomes after THA is limited and contradictory. QUESTIONS/PURPOSES: (1) Do patients with a preoperative diagnosis of Parkinson's disease have an increased risk of death after elective THA compared with a matched control group of patients? (2) After matching for patient- and surgery-related factors, do revision rates differ between the patients with Parkinson's disease and the matched control group? (3) Are there any differences in patient-reported outcome measures for patients with Parkinson's disease compared with the matched control group? METHODS: Data were derived from a merged database with information from the Swedish Hip Arthroplasty Register and administrative health databases. We identified all patients with Parkinson's disease who underwent THA for primary osteoarthritis between January 1, 1999 and December 31, 2012 (n = 490 after exclusion criteria applied). A control group was generated through exact one-to-one matching for age, sex, Charlson comorbidity index, surgical approach, and fixation method. Risk of death and revision were compared between the groups using Kaplan-Meier and log-rank testing. Patient-reported outcome measures (PROMs), routinely recorded as EQ-5D, EQ VAS, and pain VAS, were measured at the preoperative visit and at 1-year postoperatively; mean absolute values for PROM scores and change in scores over time were compared between the two groups. RESULTS: The risk of death did not differ at 90 days (control group risk = 0.61%; 95% CI = 0.00-1.3; Parkinson's disease group risk = 0.62%; 95% CI = 0.00-1.31; p = 0.998) or 1 year (control group = 2.11%; 95% CI = 0.81-3.39; Parkinson's disease group = 2.56%, 95% CI = 1.12-3.97; p = 0.670). At 9 years, the risk of death was increased for patients with Parkinson's disease (control group = 28.05%; 95% CI = 22.29-33.38; Parkinson's disease group = 54.35%; 95% CI = 46.72-60.88; p < 0.001). The risk of revision did not differ at 90 days (control group = 0.41%; 95% CI = 0.00-0.98; Parkinson's disease group = 1.03%; 95% CI = 0.13-1.92; p = 0.256). At 1 year, the risk of revision was higher for patients with Parkinson's disease (control group = 0.41%; 95% CI = 0.00-0.98; Parkinson's disease group = 2.10%; 95% CIs = 0.80-3.38; p = 0.021). This difference was more pronounced at 9 years (control group = 1.75%; 95% CI = 0.11-3.36; Parkinson's disease group = 5.44%; 95% CI = 2.89-7.91; p = 0.001) when using the Kaplan-Meier method. There was no difference between the control and Parkinson's disease groups for level of pain relief at 1 year postoperatively (mean reduction in pain VAS score for control group = 48.85, SD = 20.46; Parkinson's disease group = 47.18, SD = 23.96; p = 0.510). Mean change in scores for quality of life and overall health from preoperative measures to 1 year postoperatively were smaller for patients in the Parkinson's disease group compared with controls (mean change in EQ-5D scores for control group = 0.42, SD = 0.32; Parkinson's disease group = 0.30, SD = 0.37; p 0.003; mean change in EQ VAS scores for control group = 20.94, SD = 23.63; Parkinson's disease = 15.04, SD = 23.00; p = 0.027). CONCLUSIONS: Parkinson's disease is associated with an increased revision risk but not with short-term mortality rates relevant to assessing risk versus benefit before undergoing THR. The traditional reluctance to perform THR in patients with Parkinson's disease may be too conservative given that the higher long-term risk of death is more likely due to the progressive neurological disorder and not THR itself, and patients with Parkinson's disease report comparable outcomes to controls. Further research on outcomes in THR for patients with other neurological conditions is needed to better address the broader assumptions underlying this traditional teaching.Level of Evidence Level III, therapeutic study.

High annual surgeon volume reduces the risk of adverse events following primary total hip arthroplasty: a registry-based study of 12,100 cases in Western Sweden.

Background and purpose - Most earlier publications investigating whether annual surgeon volume is associated with lower levels of adverse events (AE), reoperations, and mortality are based on patient cohorts from North America. There is also a lack of adjustment for important confounders in these studies. Therefore, we investigated whether higher annual surgeon volume is associated with a lower risk of adverse events and mortality within 90 days following primary total hip arthroplasty (THA). Patients and methods - We collected information on primary total hip arthroplasties (THA) performed between 2007 and 2016 from 10 hospitals in Western Sweden. These data were linked with the Swedish Hip Arthroplasty Register and a regional patient register. We used logistic regression (simple and multiple) adjusted for age, sex, comorbidities, BMI, fiation technique, diagnosis, surgical approach, time in practice as orthopedic specialist and annual volume. Annual surgeon volume was calculated as the number of primary THAs the operating surgeon had performed 365 days prior to the index THA. Results - 12,100 primary THAs, performed due to both primary and secondary osteoarthritis by 268 different surgeons, were identified. The median annual surgeon volume was 23 primary THAs (range 0-82) 365 days prior to the THA of interest and the mean risk of AE within 90 days was 7%. If the annual volume increased by 10 primary THAs in the simple logistic regression the risk of AE decreased by 10% and in the adjusted multiple regression the corresponding number was 8%. The mortality rate in the study was low (0.2%) and we could not find any association between 90-day mortality and annual surgeon volume. Interpretation - High annual surgical activity is associated with a reduced risk of adverse events within 90 days. Based on these findings healthcare providers should consider planning for increased surgeon volume.

Association between patient survival following reoperation after total hip replacement and the reason for reoperation: an analysis of 9,926 patients in the Swedish Hip Arthroplasty Register.

Background and purpose - The association between long-term patient survival and elective primary total hip replacement (THR) has been described extensively. The long-term survival following reoperation of THR is less well understood. We investigated the relative survival of patients undergoing reoperation following elective THR and explored an association between the indication for the reoperation and relative survival. Patients and methods - In this observational cohort study we selected the patients who received an elective primary THR and subsequent reoperations during 1999-2017 as recorded in the Swedish Hip Arthroplasty Register. The selected cohort was followed until the end of the study period, censoring or death. The indications for 1st- and eventual 2nd-time reoperations were analyzed and the relative survival ratio of the observed survival and the expected survival was determined. Results - There were 9,926 1st-time reoperations and of these 2,558 underwent further reoperations. At 5 years after the latest reoperation, relative survival following 1st-time reoperations was 0.94% (95% CI 0.93-0.96) and 0.90% (CI 0.87-0.92) following 2nd-time reoperations. At 5 years patients with a 1st-time reoperation for aseptic loosening had higher survival than expected; however, reoperations performed for periprosthetic fracture, dislocation, and infection had lower survival. Interpretation - The relative survival following 1st- and 2nd-time reoperations in elective THR patients differs by reason for reoperation. The impact of reoperation on life expectancy is more obvious for infection/dislocation and periprosthetic fracture.

Do Patients Live Longer After THA and Is the Relative Survival Diagnosis-specific?

BACKGROUND: Hip replacements are successful in restoring mobility, reducing pain, and improving quality of life. However, the association between THA and the potential for increased life expectancy (as expressed by mortality rate) is less clear, and any such association could well be influenced by diagnosis and patient-related, socioeconomic, and surgical factors, which have not been well studied. QUESTIONS/PURPOSES: (1) After controlling for birth year and sex, are Swedish patients who underwent THA likely to survive longer than individuals in the general population? (2) After controlling for relevant patient-related, socioeconomic/demographic factors and surgical factors, does relative survival differ across the various diagnoses for which THAs were performed in Sweden? METHODS: Data from the Swedish Hip Arthroplasty Register, linked to administrative health databases, were used for this study. We identified 131,808 patients who underwent THA between January 1, 1999, and December 31, 2012. Of these, 21,755 had died by the end of followup. Patient- and surgery-specific data in combination with socioeconomic data were available for analysis. We compared patient survival (relative survival) with age- and sex-matched survival data in the entire Swedish population according to Statistics Sweden. We used multivariable modeling proceeded with a Cox proportional hazards model in transformed time. RESULTS: Patients undergoing elective THA had a slightly improved survival rate compared with the general population for approximately 10 years after surgery. At 1 year after surgery, the survival in patients undergoing THA was 1% better than the expected survival (r = 1.01; 95% confidence interval [CI], 1.01-1.02; p < 0.001); at 5 years, this increased to 3% (r = 1.03; 95% CI, 1.03-1.03; p < 0.001); at 10 years, the difference was 2% (r = 1.02; 95% CI, 1.02-1.03; p < 0.001); and by 12 years, there was no difference between patients undergoing THA and the general population (r = 1.01; 95% CI, 0.99-1.02; p = 0.13). Using the diagnosis of primary osteoarthritis as a reference, hip arthroplasties performed for sequelae of childhood hip diseases had a similar survival rate (hazard ratio [HR], 1.02; 95% CI, 0.88-1.18; p = 0.77). Patients undergoing surgery for osteonecrosis of the femoral head (HR, 1.69; 95% CI, 1.60-1.79; p < 0.001), inflammatory arthritis (HR, 1.49; 95% CI, 1.38-1.61; p < 0.001), and secondary osteoarthritis (HR, 2.46; 95% CI, 2.03-2.99; p < 0.001) all had poorer relative survival. Comorbidities and the Elixhauser comorbidity index had a negative association with relative survival. Level of achieved education (middle level of education: HR, 0.90, 95% CI, 0.87-0.93, p < 0.001; high level: 0.76, 95% CI, 0.73-0.80, p < 0.001) and marital status (single status: HR, 1.33; 95% CI, 1.28-1.38; p < 0.001) were also negatively associated with survival. CONCLUSIONS: Whereas it has been known that in most patients, THA improves quality of life, this study demonstrates that it also is associated with a slightly increased life expectancy that lasts for approximately 10 years after surgery, especially among patients whose diagnosis was primary osteoarthritis. This adds further proof of a health-economic value for this surgical intervention. The reasons for the increase in relative survival are unknown but are probably multifactorial. LEVEL OF EVIDENCE: Level III, therapeutic study.

Relative survival following hemi-and total hip arthroplasty for hip fractures in Sweden.

BACKGROUND: Hip fractures are a common problem in the ageing population. Hip arthroplasty is the common treatment option for displaced intracapsular neck of femur fractures. Even though hip replacements are successful in restoring mobility, reducing pain and diminishing loss of health-related quality of life, the potential impact of a hip fracture on life expectancy as well as the postoperative mortality need consideration. The purpose of this study was to describe the mid-term relative survival rate for a cohort of Swedish patients whom underwent total- or hemiarthroplasty surgery following hip fracture. We also explored whether the survival rate is prosthesis-type specific and influenced by comorbidities, sex, socioeconomic and surgical factors. METHODS: Using prospectively collected information of the Swedish Hip Arthroplasty Register-linked database we identified 43,891 patients operated between 2005 and 2012. Patient- and surgery-specific data in combination with socio-economic data were available for this analysis. We studied relative survival rate and used multivariable modelling with Cox Proportional Hazards Model in Transformed Time. RESULTS: Compared to the Swedish general population the baseline excess hazard was very high in the first half year after the operation, thereafter the excess hazard decreased but remained non-negligible through the 8 years' follow-up period. The mortality rate of males was higher compared to women. Higher Elixhauser comorbidity index (ECI) was associated with worsening survival. However, patients who had ECI = 0 had higher mortality than patients with ECI =1 the first 420 days post fracture. Patients with a hemiarthroplasty had a worse survival than patients with a total hip arthroplasty. Of the hospital types considered university hospitals had lower survival rate. Younger patients had a greater loss of expected life span than patients who suffer hip fracture in their more advanced ages. CONCLUSIONS: Swedish hip fracture patients who undergo arthroplasty surgery had a high excess hazard of dying in the first half year following surgery, and this excess hazard never subsided to negligible levels at least up to 8 years after surgery. Interestingly having no prior record of illnesses worsened the initial mortality. Men living alone had the highest long-term excess mortality.

Risk of further surgery on the same or opposite side and mortality after primary total hip arthroplasty: A multi-state analysis of 133,654 patients from the Swedish Hip Arthroplasty Register.

Background and purpose - The hip-related timeline of patients following a total hip arthroplasty (THA) can vary. Ideally patients will live their life without need for further surgery; however, some will undergo replacement on the contralateral hip and/or reoperations. We analyzed the probability of mortality and further hip-related surgery on the same or contralateral hip. Patients and methods - We performed a multi-state survival analysis on a prospectively followed cohort of 133,654 Swedish patients undergoing an elective THA between 1999 and 2012. The study used longitudinally collected information from the Swedish Hip Arthroplasty Register and administrative databases. The analysis considered the patients' sex, age, prosthesis type, surgical approach, diagnosis, comorbidities, education, and civil status. Results - During the study period patients were twice as likely to have their contralateral hip replaced than to die. However, with passing time, probabilities converged and for a patient who only had 1 non-revised THA at 10 years, there was an equal chance of receiving a second THA and dying (24%). It was 8 times more likely that the second hip would become operated with a primary THA than that the first hip would be revised. Multivariable regression analysis reinforced the influence of age at operation, sex, diagnosis, comorbidity, and socioeconomic status influencing state transition. Interpretation - Multi-state analysis can provide a comprehensive model of further states and transition probabilities after an elective THA. Information regarding the lifetime risk for bilateral surgery, revision, and death can be of value when discussing the future possible outcomes with patients, in healthcare planning, and for the healthcare economy.

Use of dual-mobility cup in revision hip arthroplasty reduces the risk for further dislocation: analysis of seven hundred and ninety one first-time revisions performed due to dislocation, reported to the Swedish Hip Arthroplasty Register.

PURPOSE: Dislocation after total hip arthroplasty (THA) is a common reason for revision. The last decade fostered a significant increase in the use of dual-mobility cups (DMCs). Here we report our study on the short-term survival rate of a cemented DMC reported to the Swedish Hip Arthroplasty Register (SHAR) compared with other cemented designs used in first-time revision due to dislocation. METHODS: During 2005-2015, 984 first-time revisions for dislocation were reported to SHAR. In 436 of these cases a cemented dual articular cup was used. During the same time period, 355 revisions performed with a standard cemented cup (femoral head size 28-36 mm) were reported to the SHAR. Patients receiving a DMC were slightly older (75 years, p = 0.005). Re-revision for all reasons was used as primary endpoint. We also anlaysed risk for re-revision of the acetabular component and re-revision due to dislocation. Kaplan-Meier implant survival and a Cox regression analyses adjusted for age and gender were performed. RESULTS: Implant survival at 4 years for all reasons (91% ± 3.7% vs 86% ± 4.1%, p = 0.02), and especially for re-operation because of dislocation, favours the DMC group (96% ± 3.0% vs 92% ± 3.3%, p = 0.001). DISCUSSION: Our findings indicate that use of a cemented DMC reduces the short- to mid-term risk of a second revision in first-time revisions compared with classic cup designs. Longer follow-up is needed to establish any long-term clinical advantages when DMCs are used in revisions performed due to dislocation.

Comorbidity does not predict long-term mortality after total hip arthroplasty.

Background and purpose - In-hospital death following total hip arthroplasty (THA) is related to comorbidity. The long-term effect of comorbidity on all-cause mortality is, however, unknown for this group of patients and it was investigated in this study. Patients and methods - We used data from the Swedish Hip Arthroplasty Register, linked to the National Patient Register from the National Board of Health and Welfare, for patients operated on with THA in 1999-2012. We identified 120,836 THAs that could be included in the study. We evaluated the predictive power of the Charlson and Elixhauser comorbidity indices on mortality, using concordance indices calculated after 5, 8, and 14 years after THA. Results - All comorbidity indices performed poorly as predictors, in fact worse than a base model with age and sex only. Elixhauser was, however, the least bad choice and it predicted mortality with concordance indices 0.59, 0.58, and 0.56 for 5, 8, and 14 years after THA. Interpretation - Comorbidity indices are poor predictors of long-term mortality after THA.

Linking Swedish health data registers to establish a research database and a shared decision-making tool in hip replacement.

BACKGROUND: Sweden offers a unique opportunity to researchers to construct comprehensive databases that encompass a wide variety of healthcare related data. Statistics Sweden and the National Board of Health and Welfare collect individual level data for all Swedish residents that ranges from medical diagnoses to socioeconomic information. In addition to the information collected by governmental agencies the medical profession has initiated nationwide Quality Registers that collect data on specific diagnoses and interventions. The Quality Registers analyze activity within healthcare institutions, with the aims of improving clinical care and fostering clinical research. MAIN BODY: The Swedish Hip Arthroplasty Register (SHAR) has been collecting data since 1979. Joint replacement in general and hip replacement in particular is considered a success story with low mortality and complication rate. It is credited to the pioneering work of the SHAR that the revision rate following hip replacement surgery in Sweden is amongst the lowest in the world. This has been accomplished by the diligent follow-up of patients with feedback of outcomes to the providers of the healthcare along with post market surveillance of individual implant performance. During its existence SHAR has experienced a constant organic growth. One major development was the introduction of the Patient Reported Outcome Measures program, giving a voice to the patients in healthcare performance evaluation. The next aim for SHAR is to integrate patients' wishes and expectations with the surgeons' expertise in the form of a Shared Decision-Making (SDM) instrument. The first step in building such an instrument is to assemble the necessary data. This involves linking the SHARs database with the two aforementioned governmental agencies. The linkage is done by the 10-digit personal identity number assigned at birth (or immigration) for every Swedish resident. The anonymized data is stored on encrypted serves and can only be accessed after double identification. CONCLUSION: This data will serve as starting point for several research projects and clinical improvement work.

The True Dislocation Incidence following Elective Total Hip Replacement in Sweden: How Does It Relate to the Revision Rate?

(1) Background: The true dislocation incidence following THA is difficult to ascertain in population-based cohorts. In this study, we explored the cumulative dislocation incidence (CDI), the relationship between the incidence of dislocation and revision surgery, patient- and surgery-related factors in patients dislocating once or multiple times, and differences between patients being revised for dislocation or not. (2) Methods: We designed an observational longitudinal cohort study linking registers. All patients with a full dataset who underwent an elective unilateral THA between 1999 and 2014 were included. The CDI and the time from the index THA to the first dislocation or to revision were estimated using the Kaplan-Meier (KM) method, giving cumulative dislocation and revision incidences at different time points. (3) Results: 136,810 patients undergoing elective unilateral THA were available for the analysis. The 30-day CDI was estimated at 0.9% (0.9-1.0). The revision rate for dislocation throughout the study period remained much lower. A total of 51.2% (CI 49.6-52.8) suffered a further dislocation within 1 year. Only 10.9% of the patients with a dislocation within the first year postoperatively underwent a revision for dislocation. (4) Discussion: The CDI after elective THA was expectedly considerably higher than the revision incidence. Further studies investigating differences between single and multiple dislocators and the criteria by which patients are offered revision surgery following dislocation are urgently needed.

Severe metallosis owing to intraprosthetic dislocation in a failed dual-mobility cup primary total hip arthroplasty.

We report a case of extensive metallosis owing to an intraprosthetic dislocation of a dual-mobility cup after a primary total hip arthroplasty. A 70-year-old man was referred to us from another center with a painful right hip 3 years after the arthroplasty. Initial investigations were suspicious of osteolysis secondary to metallosis with the characteristic "bubble sign" visualized on plain radiographs. At the revision procedure, widespread black staining of soft tissues and bone was noted. The polyethylene liner had dislodged leading to erosion of the metal socket by the prosthetic head. Histopathology examination of periprosthetic tissue confirmed metallosis. To our knowledge, this is the first reported case of severe metallosis owing to a known complication of dual-mobility sockets.

The association of surgical approach and bearing size and type with dislocation in total hip arthroplasty for acute hip fracture.

AIMS: Patients with femoral neck fractures (FNFs) treated with total hip arthroplasty (THA) have an almost ten-fold increased risk of dislocation compared to patients undergoing elective THA. The surgical approach influences the risk of dislocation. To date, the influence of differing head sizes and dual-mobility components (DMCs) on the risk of dislocation has not been well studied. METHODS: In an observational cohort study on 8,031 FNF patients with THA between January 2005 and December 2014, Swedish Arthroplasty Register data were linked with the National Patient Register, recording the total dislocation rates at one year and revision rates at three years after surgery. The cumulative incidence of events was estimated using the Kaplan-Meier method. Cox multivariable regression models were fitted to calculate adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for the risk of dislocation, revision, or mortality, stratified by surgical approach. RESULTS: The cumulative dislocation rate at one year was 8.3% (95% CI 7.3 to 9.3) for patients operated on using the posterior approach and 2.7% (95% CI 2.2 to 3.2) when using the direct lateral approach. In the posterior approach group, use of DMC was associated with reduced adjusted risk of dislocation compared to 32 mm heads (HR 0.21 (95% CI 0.07 to 0.68); p = 0.009). This risk was increased with head sizes < 32 mm (HR 1.47 (95% CI 1.10 to 1.98); p = 0.010). Neither DMC nor different head sizes influenced the risk of revision following the posterior approach. Neither articulation was associated with a statistically significantly reduced adjusted risk of dislocation in patients where the direct lateral approach was performed, although this risk was estimated to be HR 0.14 (95% CI 0.02 to 1.02; p = 0.053) after the use of DMC. DMC inserted through a direct lateral approach was associated with a reduced risk of revision for any reason versus THA with 32 mm heads (HR 0.36 (95% CI 0.13 to 0.99); p = 0.047). CONCLUSION: When using a posterior approach for THA in FNF patients, DMC reduces the risk of dislocation, while a non-significant risk reduction is seen for DMC after use of the direct lateral approach. The direct lateral approach is protective against dislocation and is also associated with a lower rate of revision at three years, compared to the posterior approach. Cite this article: Bone Joint J 2022;104-B(7):844-851.

Total, hemi, or dual-mobility arthroplasty for the treatment of femoral neck fractures in patients with neurological disease : analysis of 9,638 patients from the Swedish Hip Arthroplasty Register.

AIMS: The aim of this study was to investigate the potentially increased risk of dislocation in patients with neurological disease who sustain a femoral neck fracture, as it is unclear whether they should undergo total hip arthroplasty (THA) or hemiarthroplasty (HA). A secondary aim was to investgate whether dual-mobility components confer a reduced risk of dislocation in these patients. METHODS: We undertook a longitudinal cohort study linking the Swedish Hip Arthroplasty Register with the National Patient Register, including patients with a neurological disease presenting with a femoral neck fracture and treated with HA, a conventional THA (cTHA) with femoral head size of ≤ 32 mm, or a dual-mobility component THA (DMC-THA) between 2005 and 2014. The dislocation rate at one- and three-year revision, reoperation, and mortality rates were recorded. Cox multivariate regression models were fitted to calculate adjusted hazard ratios (HRs). RESULTS: A total of 9,638 patients with a neurological disease who also underwent unilateral arthroplasty for a femoral neck fracture were included in the study. The one-year dislocation rate was 3.7% after HA, 8.8% after cTHA < 32 mm), 5.9% after cTHA (= 32 mm), and 2.7% after DMC-THA. A higher risk of dislocation was associated with cTHA (< 32 mm) compared with HA (HR 1.90 (95% confidence interval (CI) 1.26 to 2.86); p = 0.002). There was no difference in the risk of dislocation with DMC-THA (HR 0.68 (95% CI 0.26 to 1.84); p = 0.451) or cTHA (= 32 mm) (HR 1.54 (95% CI 0.94 to 2.51); p = 0.083). There were no differences in the rate of reoperation and revision-free survival between the different types of prosthesis and sizes of femoral head. CONCLUSION: Patients with a neurological disease who sustain a femoral neck fracture have similar rates of dislocation after undergoing HA or DMC-THA. Most patients with a neurological disease are not eligible for THA and should thus undergo HA, whereas those eligible for THA could benefit from a DMC-THA. Cite this article: Bone Joint J 2022;104-B(1):134-141.

Hip arthroplasty for acute hip fracture in patients with neurological disorders: A report Of 9,702 cases from the Swedish arthroplasty register.

INTRODUCTION: The purpose of this study was to investigate neurological disorder as a risk factor for dislocation following arthroplasty for acute hip fractures. We also analysed medical and surgical adverse events (AE), readmission, reoperation, revision, and mortality as secondary outcomes. METHODS: A longitudinal cohort study using prospectively collected and aggregated data from the Swedish Hip Arthroplasty Register (SHAR) and the Swedish national patient register. All patients presenting with an acute hip fracture and treated with an arthroplasty in the period from 2005 to 2014 from the SHAR were identified. Patients in receipt of bilateral arthroplasties were excluded. Patients with a relevant pre-existing and diagnosed neurological disorder, as defined by ICD-10 codes, were identified (n = 9,702). All other cases (n = 29,411) were available for logistic regression propensity score matching. Patients were 1:1 matched on age, sex, Charlson comorbidity index, total versus hemiarthroplasty, head size, surgical approach, and year of surgery. Dislocations, adverse events, readmission, reoperation, revision, and mortality were studied using Kaplan-Meier analysis and Cox regression. RESULTS: The risk of dislocations was higher for patients with neurological disorder (HR=1.19, CI 1.03- 1.39, p<0.05). Neurological disorder was associated with increased risk of encountering an adverse event (p<0.001 at 90-days); these patients were at higher risk of dying (HR=1.51, CI 1.47-1.56, p<0.001) however they were less likely to be readmitted (HR=0.73, CI 0.70- 0.76, p<0.001). No excess risks of reoperation (HR=1.02, CI 0.90-1.17; p = 0.73) or revision (HR=1.00, CI 0.86-1.17; p = 0.99) were identified in the study group. DISCUSSION: Compared to matched controls, individuals with a preoperatively identified neurological diagnosis had higher rates of mortality, dislocations, and adverse events, but this cohort was not at increased risk of reoperation or revision. This study highlights an area of focus for future research to improve the long-term outcomes in patients with neurological disease undergoing arthroplasty for an acute hip fracture.

Does Medial Overhang of the Greater Trochanter Influence Femoral Stem Position During Cemented Hip Arthroplasty? A Retrospective Radiological Review.

Purpose We investigate the effect that variation in the anatomy of the greater trochanter (GT), in particular the medial overhang, can have on femoral stem alignment in total hip arthroplasty (THA). Methods Pre- and post-operative anteroposterior pelvic radiographs of 576 consecutive patients undergoing THA were retrospectively analysed. Medial overhang of the GT relative to the lateral femur diaphysis was measured. The femoral morphology was classified according to Dorr classification. The alignment of the femoral stem axes on post-operative radiographs was recorded. Results Following exclusions, 500 THAs performed by six surgeons all using the same cemented polish tapered stems were analysed: 320 THAs were performed via the posterior-lateral approach and 180 via the direct-lateral approach. Mean stem varus was 0.53° (range: -7 to 7°). Mean medial overhang was 21 mm (range: 8-43 mm). An overhang of <20 mm had a mean varus of -0.1°, an overhang of 20-30 mm had a mean varus of 0.8° and an overhang of >30 mm had a mean varus of 2.33°. Those with an overhang of <20 mm had a 2% chance of significant varus (≥4°), increasing to 9.5% for 20-30 mm and 44.4% for >30 mm. One-way analysis of variance comparison of these groups returned a p-value of <0.0001. Dorr type A femora had a mean varus of 0.52°, Dorr B had a mean varus of 0.54° and Dorr C had a mean varus of 0.46°. The posterior-lateral approach had a mean varus of 1.05° (range: -7 to 7°) compared to -0.40° (range: -5 to 5°) for direct-lateral approach. The t-test comparing approach was p < 0.0001. Discussion The extent of medial overhang of the GT can adversely affect the final stem position in THA, resulting in a statistically significant increase in mean stem varus. There is a linear relationship between stem position and GT overhang, with an increased chance of significant varus malposition (44.4% with >30 mm of overhang). Conclusions Scrutiny of pre-operative radiographs to determine high-risk patients is important, and we propose a classification system of GT anatomy to aid assessment.

Extended trochanteric osteotomy: improving the access and reducing the risk in revision THA.

This review article presents a comprehensive literature review regarding extended trochanteric osteotomy (ETO).The history, rationale, biomechanical considerations as well as indications are discussed.The outcomes and complications as reported in the literature are presented, discussed and compared with our own practice.Based on the available evidence, we present our preferred technique for performing ETO, its fixation, as well as post-operative rehabilitation.The ETO aids implant removal and enhanced access. Reported union rate of ETO is high. The complications related to ETO are much less frequent than in cases when accidental intra-operative femoral fracture occurred that required fixation.Based on the literature and our own experience we recommend ETO as a useful adjunct in the arsenal of the revision hip specialist. Cite this article: EFORT Open Rev 2020;5:104-112. DOI: 10.1302/2058-5241.5.190005.

Head size in primary total hip arthroplasty.

The use of larger femoral head size in total hip arthroplasty (THA) has increased during the past decade; 32 mm and 36 mm are the most commonly used femoral head sizes, as reported by several arthroplasty registries.The use of large femoral heads seems to be a trade-off between increased stability and decreased THA survivorship.We reviewed the literature, mainly focussing on the past 5 years, identifying benefits and complications associated with the trend of using larger femoral heads in THA.We found that there is no benefit in hip range of movement or hip function when head sizes > 36 mm are used.The risk of revision due to dislocation is lower for 36 mm or larger bearings compared with 28 mm or smaller and probably even with 32 mm.Volumetric wear and frictional torque are increased in bearings bigger than 32 mm compared with 32 mm or smaller in metal-on-cross-linked polyethylene (MoXLPE) THA, but not in ceramic-on-XLPE (CoXLPE).Long-term THA survivorship is improved for 32 mm MoXLPE bearings compared with both larger and smaller ones.We recommend a 32 mm femoral head if MoXLPE bearings are used. In hips operated on with larger bearings the use of ceramic heads on XLPE appears to be safer. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170061.

Trends in hip replacements between 1999 and 2012 in Sweden.

National Registers document changes in the circumstance, practice, and outcome of surgery with the passage of time. In the context of total hip replacement (THR), registers can help elucidate the relevant factors that affect the clinical outcome. We evaluated the evolution of factors related to patient, surgical procedure, socio-economy, and various outcome parameters after merging databases of the Swedish Hip Arthroplasty Register, Statistics Sweden and the National Board of Health and Welfare. Data on 193,253 THRs (164,113 patients) operated between 1999 and 2012 were merged. We studied the evolution of surgical volume, patient demographics, socio-economic factors, surgical factors, length-of-stay, mortality rate, adverse events, re-operation and revision rates, and Patient Reported Outcome Measures (PROMs). Throughout this time period the majority of patients were operated on with a diagnosis of primary osteoarthritis. Comorbidity indices increased each year observed. The share of all-cemented implants has dropped from 92% to 68%. More than 88% of the bearings were metal-on-polyethylene. Length-of-stay decreased by 50%. There was a reduction in 30- and 90-day mortality. Re-operation and revision rates at 2 years are decreasing. The post-operative PROMs improved despite the observation of worse pre-operative pain scores getting over time. The demographics of patients receiving a THR, their comorbidities, and their primary diagnosis are changing. Notwithstanding these changes, outcomes like mortality, re-operations, revisions, and PROMs have improved. The practice of hip arthroplasty has evolved, even in a country such as Sweden that is considered to be conservative with regard taking on new surgical practices. © 2017 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 36:432-442, 2018.

Is Preoperative Patient-Reported Health Status Associated with Mortality after Total Hip Replacement?

The influence of comorbidities and worse physical status on mortality following total hip replacement (THR) leads to the idea that patient-reported health status may also be a predictor of mortality. The aim of this study was to investigate the relationship between patient-reported health status before THR and the risk of dying up to 5 years post-operatively. For these analyses, we used register data on 42,862 THR patients with primary hip osteoarthritis operated between 2008 and 2012. The relative survival ratio was calculated by dividing the observed survival in the patient group by age- and sex-adjusted expected survival of the general population. Pre-operative responses to the five EQ-5D-3L (EuroQol Group) dimensions along with age, sex, education status, year of surgery, and hospital type were used as independent variables. Results shown that, as a group, THR patients had a better survival than the general population. Broken down by the five EQ-5D-3L dimensions we observed differentiated survival patters. For all dimensions, those reporting extreme problems had higher mortality than those reporting moderate or no problems. In conclusion, worse health status according to the EQ-5-3L before THR is associated with higher mortality up to five years after surgery. EQ-5D-3L responses may be useful in a multifactorial individualized risk assessment before THR.

Midterm results following uncemented, modular, fully porous coated stem used in revision total hip arthroplasty: Comparison of two stem systems.

BACKGROUND: Aim of this study was to evaluate stem subsidence and survivorship of implant following implantation of Revitan (Zimmer) and MP (Waldemar Link) stems. METHODS: Retrospective case series with clinical and radiological follow-up of 1-10 years. RESULTS: 47 Revitan and 57 MP stems were analyzed. In 12 cases there was subsidence of the stem present. Two Revitan stems and one MP stem were revised as a result of subsidence. Failure rate was 4.3% for Revitan, 1.8% for MP stem and difference was not statistically significant. CONCLUSION: There is no significant difference in subsidence or survivorship between Revitan and MP stems.