Impact of Nordic Arthroplasty Register Association (NARA) collaboration on demographics, methods and revision rates in knee arthroplasty: a register-based study from NARA 2000-2017.

BACKGROUND AND PURPOSE: We have previously observed differences in treatment and outcome of knee arthroplasties in the Nordic countries. To evaluate the impact of Nordic collaboration in the last 15 years we aimed to compare patient demographics, methods, and revision rates in primary knee arthroplasties among the 4 Nordic countries. PATIENTS AND METHODS: We included 535,051 primary knee arthroplasties reported 2000-2017 from the Nordic Arthroplasty Register Association (NARA) database. Kaplan-Meier analysis (KM) and restricted mean survival time (RMST) analysis were used to evaluate the cumulative revision rate (CRR) and RMST estimates with 95% confidence intervals (CI) and to compare countries in relation to risk of revision for any reason. RESULTS: After 2010, the increase in incidence of knee arthroplasty plateaued in Sweden and Denmark but continued to increase in Finland and Norway. In 2017 the incidence was highest in Finland with 226 per 105 person-years, while it was less than 150 per 105 in the 3 other Nordic countries. In total knee arthroplasties performed for osteoarthritis (OA), overall CRR at 15 years for revision due to any reason was higher in Denmark (CRR 9.6%, 95% CI 9.2-10), Norway (CRR 9.1%, CI 8.7-9.5), and Finland (CRR 7.0%, CI 6.8-7.3) compared with Sweden (CRR 6.6%, CI 6.4-6.8). There were differences among the countries in use of implant brand and type, fixation, patellar component, and use of unicompartmental knee arthroplasty. INTERPRETATION: We evinced a slowing growth of incidence of knee arthroplasties in the Nordic countries after 2010 with Finland having the highest incidence. We also noted substantial differences among the 4 Nordic countries, with Sweden having a lower risk of revision than the other countries. No impact of NARA could be demonstrated and CRR did not improve over time.

Non-surgical and surgical treatments for rotator cuff disease: a pragmatic randomised clinical trial with 2-year follow-up after initial rehabilitation.

BACKGROUND: Rotator cuff disease (RCD) causes prolonged shoulder pain and disability in adults. RCD is a continuum ranging from tendinopathy to full-thickness tendon tear. Recent studies have shown that subacromial decompression and non-surgical treatments provide equivalent results in RCD without a full-thickness tendon lesion. However, the importance of surgery for full-thickness tendon tears remains unclear. METHODS: In a pragmatic, randomised, controlled trial, 417 patients with subacromial pain underwent 3-month initial rehabilitation and MRI arthrography (MRA) for the diagnosis of RCD. Of these, 190 shoulders remained symptomatic and were randomised to non-surgical or surgical treatments. The primary outcomes were the mean changes in the Visual Analogue Scale for pain and the Constant Murley Score for shoulder function at the 2-year follow-up. RESULTS: At the 2-year follow-up, both non-surgical and surgical treatments for RCD reduced pain and improved shoulder function. The scores differed between groups by 4 (95% CI -3 to 10, p=0.25) for pain and 3.4 (95% CI -0.4 to 7.1, p=0.077) for function. Among patients with full-thickness ruptures, the reduction in pain (13, 95% CI 5 to 22, p=0.002) and improvement in function (7.0, 95% CI 1.8 to 12.2, p=0.008) favoured surgery. CONCLUSIONS: Non-surgical and surgical treatments for RCD provided equivalent improvements in pain and function. Therefore, we recommend non-surgical treatment as the primary choice for patients with RCD. However, surgery yielded superior improvement in pain and function for full-thickness rotator cuff rupture. Therefore, rotator cuff repair may be suggested after failed non-surgical treatment. TRIAL REGISTRATION DETAILS: ClinicalTrials.gov, NCT00695981 and NCT00637013.

Association between fixation type and revision risk in total knee arthroplasty patients aged 65 years and older: a cohort study of 265,877 patients from the Nordic Arthroplasty Register Association 2000-2016.

Background and purpose - The population of the Nordic countries is aging and the number of elderly patients undergoing total knee arthroplasty (TKA) is also expected to increase. Reliable fixation methods are essential to avoid revisions. We compared the survival of different TKA fixation concepts with cemented fixation as the gold standard.Patients and methods - We used data from the Nordic Arthroplasty Register Association (NARA) database of 265,877 unconstrained TKAs performed for patients aged ≥ 65 years with primary knee osteoarthritis between 2000 and 2016. Kaplan-Meier (KM) survival analysis with 95% confidence intervals (CI) and the Cox multiple-regression model were used to compare the revision risk of the fixation methods.Results - Cemented fixation was used in 243,166 cases, uncemented in 8,000, hybrid (uncemented femur with cemented tibia) in 14,248, and inverse hybrid (cemented femur with uncemented tibia) fixation in 463 cases. The 10-year KM survivorship (95% CI) of cemented TKAs was 96% (96 - 97), uncemented 94% (94 - 95), hybrid 96% (96 - 96), and inverse hybrid 96% (94 - 99), respectively. Uncemented TKA was associated with increased risk of revision compared with the cemented TKA; the adjusted hazard ratio was 1.3 (95% CI 1.1 - 1.4).Interpretation - Cemented, hybrid, and inverse hybrid TKAs showed 10-year survival rates exceeding 95%. Uncemented fixation was associated with an increased risk of revision in comparison with cemented fixation. As both hybrid and inverse hybrid fixation were used in only a limited number of TKAs, indicating possibility of selection bias in their favor, cemented TKA still remains the gold standard, as it works reliably in the hands of many.

Solitary juvenile xanthogranuloma in the spine pretreated with neoadjuvant denosumab therapy followed by surgical resection in a 5-year-old child: case report and literature review.

PURPOSE: We present a case report that describes neoadjuvant denosumab therapy initiated in a child with a solitary giant cell-rich juvenile xanthogranuloma tumor involving the spine, and review the current literature. METHODS: A giant cell-rich histiocytic lesion involving the 11th thoracic vertebral body was identified in a healthy 5-year-old girl with persistent back and pelvic pain for several months. Imaging examinations and an open biopsy were performed to obtain a definite pathologic diagnosis. As the tumor appeared to be aggressive in nature, we administered adjuvant therapy with denosumab preoperatively and then performed a total spondylectomy. RESULTS: Histopathology confirmed that the tumor was juvenile xanthogranuloma. No tumor metastases or recurrence were detected at the 3-year follow-up, and the patient was asymptomatic. CONCLUSIONS: In giant cell-rich tumors, denosumab is occasionally used as neoadjuvant or adjuvant therapy, especially for tumors in difficult locations or with substantial soft tissue extensions. Rare adverse events in children include skin infections and disruption of calcium homeostasis. Surgical treatment is aimed at removing the tumor and relieving the symptomatic spinal cord compression. Use of denosumab as neoadjuvant therapy for juvenile xanthogranuloma involving the spine has not been reported previously.

Reoperation Rates Following Instrumented Lumbar Spine Fusion.

STUDY DESIGN: A prospective cohort study. OBJECTIVE: This study evaluated the cumulative reoperation rate and indications for reoperation following instrumented lumbar spine fusion (LSF). SUMMARY OF BACKGROUND DATA: LSF reduces disability and improves health-related quality of life for patients with several spinal disorders. The rate of instrumented LSF has drastically increased over the last few decades. The increased incidence of LSF, however, has led to increased reoperation rates. METHODS: The data are based on the prospective LSF database of Tampere University Hospital that includes all elective indications for LSF surgery. A total of 433 consecutive patients (64% women, mean age 62 years) who underwent LSF in Tampere University Hospital between 2008 and 2011 were evaluated and indications for reoperations were rechecked from patient records and radiographs. The most common diagnosis for the primary surgery was degenerative spondylolisthesis and the mean follow-up time was 3.9 years. The cumulative incidence of reoperations and the "time to event" survival rate was calculated by Kaplan-Meier analysis. RESULTS: By the end of 2013, 81 patients had undergone at least one reoperation. The cumulative reoperation rate at 2 years was 12.5% (95% confidence interval: 95% CI: 9.7-16.0) and at 4 years was 19.3% (95% CI: 15.6-23.8). The most common pathology leading to reoperation was adjacent segment pathology with a cumulative reoperation rate of 8.7% (95% CI: 6.1-12.5) at 4 years. The corresponding rates for early and late instrumentation failure were 4.4% (95% CI: 2.7-7.0) and 2.9% (95% CI: 1.9-7.1), respectively, and for acute complications, 2.5% (95% CI: 1.4-4.5). CONCLUSION: Although previous studies reported that early results of spinal fusion are promising, one in five patients required reoperation within 4 years after surgery. Patients and surgeons should be aware of the reoperation rates when planning fusion surgery. LEVEL OF EVIDENCE: 4.