The value of national arthroplasty registry data in 2023.

The importance of registries has been brought into focus by recent UK national reports focusing on implant (Cumberlege) and surgeon (Paterson) performance. National arthroplasty registries provide real-time, real-world information about implant, hospital, and surgeon performance and allow case identification in the event of product recall or adverse surgical outcomes. They are a valuable resource for research and service improvement given the volume of data recorded and the longitunidal nature of data collection. This review discusses the current value of registry data as it relates to both clinical practice and research.

First-time revision knee arthroplasty using a hinged prosthesis : temporal trends, indications, and risk factors associated with re-revision using data from the National Joint Registry for 3,855 patients.

AIMS: The aim of this study was to identify variables associated with time to revision, demographic details associated with revision indication, and type of prosthesis employed, and to describe the survival of hinge knee arthroplasty (HKA) when used for first-time knee revision surgery and factors that were associated with re-revision. METHODS: Patient demographic details, BMI, American Society of Anesthesiologists (ASA) grade, indication for revision, surgical approach, surgeon grade, implant type (fixed and rotating), time of revision from primary implantation, and re-revision if undertaken were obtained from the National Joint Registry data for England, Wales, Northern Ireland, and the Isle of Man over an 18-year period (2003 to 2021). RESULTS: There were 3,855 patient episodes analyzed with a median age of 73 years (interquartile range (IQR) 66 to 80), and the majority were female (n = 2,480, 64.3%). The median time to revision from primary knee arthroplasty was 1,219 days (IQR 579 to 2,422). Younger age (p < 0.001), decreasing ASA grade (p < 0.001), and indications for revision of sepsis (p < 0.001), unexplained pain (p < 0.001), non-polyethylene wear (p < 0.001), and malalignment (p < 0.001) were all associated with an earlier time to revision from primary implantation. The median follow-up was 4.56 years (range 0.00 to 17.52), during which there were 410 re-revisions. The overall unadjusted probability of re-revision for all revision HKAs at one, five, and ten years after surgery were 2.7% (95% confidence interval (CI) 2.2 to 3.3), 10.7% (95% CI 9.6 to 11.9), and 16.2% (95% CI 14.5 to 17.9), respectively. Male sex (p < 0.001), younger age (p < 0.001), revision for septic indications (p < 0.001) or implant fracture (p = 0.010), a fixed hinge (p < 0.001), or surgery performed by a non-consultant grade (p = 0.023) were independently associated with an increased risk of re-revision. CONCLUSION: There were several factors associated with time to first revision. The re-revision rate was 16.2% at ten years; however, the risk factors associated with an increased risk of re-revision could be used to counsel patients regarding their outcome.Cite this article: Bone Joint J 2023;105-B(1):47-55.

The impact of COVID-19 on mortality after hip fracture : a population cohort study from England.

AIMS: Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England. METHODS: We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1 February 2019 and 31 October 2020 in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England's SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models. RESULTS: Analysis of 102,900 hip fractures (42,630 occurring during the pandemic) revealed that among those with COVID-19 infection at presentation (n = 1,120) there was a doubling of 90-day mortality; hazard ratio (HR) 2.09 (95% confidence interval (CI) 1.89 to 2.31), while the HR for infections arising between eight and 30 days after presentation (n = 1,644) the figure was greater at 2.51 (95% CI 2.31 to 2.73). Malnutrition (1.45 (95% CI 1.19 to 1.77)) and nonoperative treatment (2.94 (95% CI 2.18 to 3.95)) were the only modifiable risk factors for death in COVID-19-positive patients. Patients who had tested positive for COVID-19 more than two weeks prior to hip fracture initially had better survival compared to those who contracted COVID-19 around the time of their hip fracture; however, survival rapidly declined and by 365 days the combination of hip fracture and COVID-19 infection was associated with a 50% mortality rate. Between 1 January and 30 June 2020, 1,273 (99.7% CI 1,077 to 1,465) excess deaths occurred within 90 days of hip fracture, representing an excess mortality of 23% (99.7% CI 20% to 26%), with most deaths occurring within 30 days. CONCLUSION: COVID-19 infection more than doubles the rate of early hip fracture mortality. Those contracting infection between 8 and 30 days after initial presentation are at even higher mortality risk, signalling the potential for targeted interventions during this period to improve survival.Cite this article: Bone Joint J 2022;104-B(10):1156-1167.

Temporal trends of primary hinge knee arthroplasty and risk factors associated with revision: National Joint Registry data from 2003 to 2018 for 4921 patients.

BACKGROUND: The aim was to describe temporal changes and associated changes in patient demographics and surgical variables, revision rate and factors associated with revision of primary hinge knee arthroplasty (HKA) in the UK. METHODS: National Joint Registry data for England, Wales, Northern Ireland and Isle of Mann was used to examine the temporal trends in patient demographics, surgical factors and indications for primary HKA usage over a 16-year (2003 to 2018) period and associated risk factors for revision. RESULTS: There were 4921 patient episodes with a median follow up of 5.5 (range 0 to 16.3) years. The median age was 75years and the majority were female (72.9%). There was a tenfold increase in the use of HKA (p < 0.001), with an increased relative usage in female patients (p = 0.010), but no significant changes in age (p = 0.484) or BMI (p = 0.781). There were 227 revisions performed at a median of 695days. The overall unadjusted probabilities of revision at 1, 5 and 10 years were 1.5% (95% confidence intervals (CI) 1.1to1.8), 4.4% (95%CI 3.7 to 5.0) and 6.4% (95%CI 5.5 to 7.3), respectively. Cox proportional hazard analysis demonstrated younger age (p < 0.01), male sex (hazard ratio (HR) 1.43, p < 0.01), morbid obesity (HR 2.31, p = 0.022) or previous trauma as the indication (HR 1.48, p = 0.025) were associated with an increased risk of revision. CONCLUSION: There was an increase in the use of HKA with increased uptake among female patients. The revision rate was a 6.4% at 10 years, however, younger age, male sex, morbid obesity or previous trauma were associated with an increased risk of revision. LEVEL OF EVIDENCE: III Retrospective study.

Simultaneous or Staged Bilateral Total Hip Arthroplasty? An Analysis of Complications in 14,460 Patients Using National Data.

BACKGROUND: Simultaneous bilateral total hip arthroplasty (SimBTHA) is often performed in younger, fitter patients with bilateral hip disease. If patients are deemed not suitable for SimBTHA due to concurrent comorbidity, it may be more appropriate to perform staged bilateral total hip arthroplasties (StBTHAs) 3-6 months apart to minimize complications and morbidity. Complication rates following hip arthroplasty are low and large national datasets are helpful for assessing these rare events. We aimed at comparing SimBTHA vs StBTHA in order to determine any differences in morbidity and mortality. METHODS: Hospital Episode Statistics data for all patients who underwent bilateral THAs in the English National Health Service between April 2005 and July 2014 were obtained. Patients were grouped into SimBTHAs (same day) or staged, with the second THA occurring between 3 and 6 months after the first. Medical and surgical complications were compared and total length of stay was assessed. RESULTS: A total of 2507 underwent SimBTHAs and 9915 had StBTHAs. SimBTHA patients were significantly younger (60.6 vs 65.5 years, P < .001) and more likely to be male, but had similar Charlson comorbidity scores. Compared to StBTHAs, patients undergoing SimBTHAs had a greater risk of pulmonary embolism, myocardial infarction, renal failure, chest infection, and inhospital death. Patients undergoing SimBTHAs had a significantly shorter overall hospital stay (8.9 vs 10.4 days). Patients undergoing SimBTHA at high-volume units had a lower average Charlson score and subsequent complication rate than low-volume units. CONCLUSION: These findings highlight the greater risks of SimBTHA in patients with Charlson score greater than 0 performed at lower-volume centers in England.

Conventional Versus Highly Cross-Linked Polyethylene in Primary Total Knee Replacement: A Comparison of Revision Rates Using Data from the National Joint Registry for England, Wales, and Northern Ireland.

BACKGROUND: There is evidence to support the use of highly cross-linked polyethylene (HXLPE) in patients undergoing total hip arthroplasty. However, the benefits for those undergoing total knee arthroplasty are uncertain, with conflicting reports based on previous cohort analyses. The purpose of the present study was to compare the revision rates following primary total knee arthroplasty with use of HXLPE as compared with conventional polyethylene (CPE) using data from the National Joint Registry (NJR) for England, Wales and Northern Ireland. METHODS: We performed a retrospective analysis of primary total knee arthroplasties recorded in the NJR from 2003 to 2014. Cobalt-chromium (CoCr)-CPE and CoCr-HXLPE bearing surfaces were compared using all-cause revision, aseptic revision, and septic revision as end points. Survival analyses were conducted using rates per 100 years observed, Kaplan-Meier survival estimates, and Cox regression hazard ratios (HRs) adjusted for age, sex, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), lead surgeon grade, and implant constraint. Secondary analyses compared the most commonly used HXLPEs (Zimmer Prolong, DePuy XLK, and Stryker X3) against CPE for the 3 most common total knee arthroplasty systems (NexGen, PFC Sigma, and Triathlon). RESULTS: In the present study of 550,658 total knee arthroplasties, the unadjusted aseptic revision rates were significantly lower following procedures performed with CPE (n = 513,744) as compared with those performed with HXLPE total knee replacements (n = 36,914) (0.29 [95% confidence interval (CI), 0.28 to 0.30] compared to 0.38 [95% CI, 0.35 to 0.42], p < 0.01). The 10-year HR associated with CPE was 0.4 (95% CI, 0.1 to 0.8, p = 0.03). There were no significant differences between the adjusted revision rates of HXPLE compared with CPE in individual analyses of the most common total knee arthroplasty systems. However, for the subset of patients who were both <60 years of age and had a BMI of >35 kg/m, the "second-generation" Stryker X3 HXLPE demonstrated significantly better survival than its respective CPE, with CPE having an HR of 2.6 (95% CI, 1.2 to 5.9) (p = 0.02). CONCLUSIONS: Alternative bearings are marketed as having improved wear properties over traditional CoCr-CPE. This registry-based analysis demonstrated no overall survival benefit of HXLPE after a maximum duration of follow-up of 12 years. Because of their increased cost, the routine use of HXLPE bearings may not be justified. However, they may have a role in specific "higher demand" groups such as patients <60 years of age and/or those with a BMI of >35 kg/m. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete list of levels of evidence.

Staphylococcal resistance profiles in deep infection following primary hip and knee arthroplasty: a study using the NJR dataset.

INTRODUCTION: This study aimed to (1) report the rates of resistance against a variety of antibiotics for pure Staphylococcal infections, and (2) examine the impact of ALBC use at primary surgery has on resistance patterns for patients undergoing first-time revision of primary hip and knee arthroplasty for indication of infection. MATERIALS AND METHODS: Data from the National Joint Registry database for England and Wales were linked to microbiology data held by Public Health England to identify a consecutive series of 258 primary hip and knee arthroplasties performed between April 2003 and January 2014 that went on to have a revision for Staphylococcal deep periprosthetic infection. Multivariate binary logistic regression was used to study predictors of microorganism resistance to a range of antimicrobials. RESULTS: After adjusting for patient and surgical factors, multivariate analysis showed the use of gentamicin-loaded bone cement at the primary surgery was associated with a significant increase in the risk of Staphylococcal gentamicin resistance (odds ratio 8.341, 95% CI 2.297-30.292, p = 0.001) and methicillin resistance (odds ratio 3.870, 95% CI 1.319-11.359, p = 0.014) at revision for infection. CONCLUSIONS: Clinicians must anticipate the possibility of antibiotic resistance to ALBC utilised at primary surgery.

VASO (Vitamin D and Arthroplasty Surgery Outcomes) study - supplementation of vitamin D deficiency to improve outcomes after total hip or knee replacement: study protocol for a randomised controlled feasibility trial.

BACKGROUND: Vitamin D deficiency has been linked to poor outcomes after total hip replacement (THR) or total knee replacement (TKR), including lower patient-reported outcome measures (PROMs), peri-prosthetic infection and longer hospital stay. We present a randomised feasibility trial protocol designed to prospectively investigate the influence of vitamin D testing, and subsequent supplementation for deficiency, prior to THR/TKR. METHODS/DESIGN: One hundred adult patients undergoing primary THR/TKR for osteoarthritis at two NHS hospital trusts in North East England will be recruited. Exclusion criteria include lack of mental capacity, revision surgery, participants already taking vitamin D/calcium supplements, or a known contraindication to vitamin D treatment. Participants will be ineligible for the trial if they have an estimated glomerular filtration rate < 30 ml/minute. We will measure patients' vitamin D levels at baseline, and those identified as deficient (vitamin D < 50 nmol/L) will be randomised to receive either vitamin D supplementation or no supplementation prior to, and for 6 months following, surgery. Patients with a normal vitamin D level (≥50 nmol/L) will receive no supplementation. Vitamin D levels will be rechecked on the day of surgery and again at 6 months. Patients will also complete a lifestyle questionnaire, as well as the Oxford hip or knee and EQ-5D-3 L PROM questionnaires, at baseline and at 6 months following surgery. The aims are to determine the feasibility of the methodology and to gather data to inform the conduct of a future, larger trial to investigate if supplementation with vitamin D, in those who are deficient, prior to THR/TKR improves outcomes as measured by PROM scores. DISCUSSION: Previous reports have measured vitamin D levels and correlated this to outcome, but we can find no randomised trial in which researchers investigated the effect of supplementation. The aim of this trial is to determine if vitamin D deficiency is a modifiable risk factor for poor outcome after THR/TKR. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN14533082 . Registered on 3 April 2017.

Intraoperative complications during revision shoulder arthroplasty: a study using the National Joint Registry dataset.

BACKGROUND: The surgical options for revision shoulder arthroplasty and the number of procedures performed are increasing. However, little is known about the risk factors for intraoperative complications associated with this complex surgery. METHODS: The National Joint Registry (NJR) is a surgeon reported database recording information on major joint replacements including revision shoulder arthroplasty. Using multivariable binary logistic regression modelling, we analyzed 1445 revision shoulder arthroplasties reported to the NJR between April 2012 and 2015. RESULTS: The risk of developing a complication during revision surgery was greater than primary arthroplasty (5% versus 2.5%). An intraoperative fracture was the most common complication occurring in 50 (3.5%) cases. Nerve injuries were recorded for two (0.1%) patients and vascular injuries for one (0.1%) patient. The incidence of intraoperative fractures was higher in females than males (relative risk = 3.25; p = 0.005). Periprosthetic fracture as an indication for revision carried the highest risk for any complication (relative risk = 3.00, p = 0.06). CONCLUSIONS: This is the largest registry study to date investigating the incidence and risk factors for intraoperative complications during revision shoulder arthroplasty. Females have over three times the risk of intraoperative fractures compared to males. This study will help inform surgeons to accurately counsel patients.

Length of stay and its impact upon functional outcomes following lower limb arthroplasty.

PURPOSE: The aim was to investigate the interplay between patient characteristics and (1) length of hospital stay and (2) one-year patient-reported outcome following total knee and hip arthroplasty. METHODS: Event (survival) analysis and structural equation modelling were performed for 1001 patients undergoing knee (n = 566) and hip (n = 435) arthroplasty in a single institution. RESULTS: Age, body mass index and co-morbidities were independent predictors of length of stay in both event analysis and structural equation modelling. These patient characteristics and type of arthroplasty had both small direct and indirect effects on patient-reported outcome measures at one year. Length of stay had a small effect (<2 %) in SF-36 scores at one year. CONCLUSION: Predictors that influence length of stay also impact on one-year post-operative outcome and therefore should be taken into account during patient selection and discharge planning. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.

Analysis of causative microorganism in 248 primary hip arthroplasties revised for infection: a study using the NJR dataset.

INTRODUCTION: This study aimed to describe the epidemiology of the causative organism in a series of primary hip arthroplasties revised for a diagnosis of periprosthetic joint infection (PJI) in England and Wales. METHODS: Patient data from the National Joint Registry (NJR) was linked to microbiology data held by Public Health England (PHE) which identified a series of 248 primary hip arthroplasties revised for PJI between 2003 and 2014. Definitive cultures, isolated at time of revision surgery, were available for all cases. Total hip arthroplasty (n = 239, 96%) and hip resurfacing (n = 5, 2%) were the most commonly performed primary procedures. A two-stage revision was the most common operative management (n = 174, 70%). RESULTS: 202 (81%) cases were infected with a single genus microorganism and the most commonly implicated genus was Staphylococcus species (70% of all single genus infections). Staphylococcus species were also the most commonly identified microorganism in mixed genus infections (74% of patient's cultures). There was a significant difference in microorganism distribution when comparing uncemented vs cement implant fixation, with a higher incidence of Gram-negative infection observed in the uncemented group (p = 0.048, Chi-square). CONCLUSIONS: Both prophylactic and therapeutic antibiotic regimes should be focused on targeting Staphylococci.

Does pre-operative sampling predict intra-operative cultures and antibiotic sensitivities in knee replacements revised for infection?: a study using the NJR dataset.

PURPOSE: This study examined a cohort of primary knee arthroplasties revised for peri-prosthetic infection to (1) determine whether the microorganisms isolated by sampling (up to 6 months pre-operatively) are representative of the microorganisms encountered at the time of knee revision, (2) determine whether the antibiotic sensitivity profiles of matching organisms correlate and (3) determine whether the proportion of organism and antibiotic sensitivity matches is influenced by the type of infection, timing of sample collection and the type of microorganism isolated. METHODS: From the National Joint Registry database for England and Wales, a consecutive series of primary knee arthroplasties performed between 2003 and 2014 that went on to have a revision for peri-prosthetic infection were identified. Each case was then linked to a national microbiology database held by Public Health England. Following data linkage, intra-operative and pre-operative cultures were identified and compared in a group of 75 patients. RESULTS: Pre-operative genus matched intra-operative genus in 56 of 75 cases (75 %). Of those 56, the corresponding antimicrobial sensitivities matched in 37 (66 % of cases). Overall, 37 of 75 cases (49 %) matched for both microorganism and antimicrobial sensitivity. The proportion of matches was highest in the pure Staphylococcal genus infections (genus match 88 %, sensitivity match 62 %, genus and sensitivity match 55 %) and lowest in those patients with mixed organism infections (genus match 29 %, sensitivity match 14 %). CONCLUSION: Pre-operative joint sampling obtained by either aspiration or tissue biopsy is advocated in cases where peri-prosthetic infection is suspected and provides the only means of determining infecting organism prior to revision. Overall, only half of all pre-operative cultures matched completely the findings of intra-operative samples in terms of both the microorganism(s) encountered and their corresponding antimicrobial sensitivity profile. Clinicians should be vigilant regarding the possibility of the patient acquiring further microorganisms or the development of new antibiotic resistance by the time of revision, especially in historic pre-operative cultures. Broad spectrum antibiotic therapies should therefore be employed until final microorganisms and antimicrobial sensitivities are confirmed from intra-operative samples. LEVEL OF EVIDENCE: IV.

Implant Optimisation for Primary Hip Replacement in Patients over 60 Years with Osteoarthritis: A Cohort Study of Clinical Outcomes and Implant Costs Using Data from England and Wales.

BACKGROUND: Hip replacement is one of the most commonly performed surgical procedures worldwide; hundreds of implant configurations provide options for femoral head size, joint surface material and fixation method with dramatically varying costs. Robust comparative evidence to inform the choice of implant is needed. This retrospective cohort study uses linked national databases from England and Wales to determine the optimal type of replacement for patients over 60 years undergoing hip replacement for osteoarthritis. METHODS AND FINDINGS: Implants included were the commonest brand from each of the four types of replacement (cemented, cementless, hybrid and resurfacing); the reference prosthesis was the cemented hip procedure. Patient reported outcome scores (PROMs), costs and risk of repeat (revision) surgery were examined. Multivariable analyses included analysis of covariance to assess improvement in PROMs (Oxford hip score, OHS, and EQ5D index) (9159 linked episodes) and competing risks modelling of implant survival (79,775 procedures). Cost of implants and ancillary equipment were obtained from National Health Service procurement data. RESULTS: EQ5D score improvements (at 6 months) were similar for all hip replacement types. In females, revision risk was significantly higher in cementless hip prostheses (hazard ratio, HR = 2.22, p<0.001), when compared to the reference hip. Although improvement in OHS was statistically higher (22.1 versus 20.5, p<0.001) for cementless implants, this small difference is unlikely to be clinically important. In males, revision risk was significantly higher in cementless (HR = 1.95, p = 0.003) and resurfacing implants, HR = 3.46, p<0.001), with no differences in OHS. Material costs were lowest with the reference implant (cemented, range £1103 to £1524) and highest with cementless implants (£1928 to £4285). Limitations include the design of the study, which is intrinsically vulnerable to omitted variables, a paucity of long-term implant survival data (reflecting the duration of data collection), the possibility of revision under-reporting, response bias within PROMs data, and issues associated with current outcome scoring systems, which may not accurately reflect level of improvement in some patients. CONCLUSIONS: Cement fixation, using a polyethylene cup and a standard sized head offers good outcomes, with the lowest risks and at the lowest costs. The most commonly used cementless and resurfacing implants were associated with higher risk of revision and were more costly, while perceptions of improved function and longevity were unsupported.

No functional benefit of larger femoral heads and alternative bearings at 6 months following primary hip replacement.

BACKGROUND AND PURPOSE: There has been a recent trend towards the use of greater femoral head sizes in an attempt to improve function and enhance stability after primary hip replacement. This has been associated with the use of alternative bearings, theoretically to reduce wear and improve implant longevity. METHODS: We examined the influence of these variables on patient-reported outcome measures (PROMs) for a consecutive series of primary hip replacements using National Joint Registry (NJR) and PROMs-linked data. To minimize the confounding influence of implant design factors, the single most commonly used brand in England and Wales (DePuy Corail Pinnacle) was examined. Improvement in patient hip-specific outcomes (Oxford hip score, OHS), general health outcomes (Euroqol, EQ-5D), and rates of self-reported complications (bleeding, wound problems, re-admission, and reoperation) were compared for different head sizes (28-mm, 32-mm, and 36-mm) and bearings (metal-on-polyethylene (MoP), ceramic-on-polyethylene (CoP), and ceramic-on-ceramic (CoC)), adjusting for differences in case mix. RESULTS: At a mean follow-up of 7 months, improvements in OHS and EQ5D index were similar for 28-mm and 36-mm heads. A 32-mm head was associated with poorer function (OHS: 20, 99% CI: 19-21, p = 0.002; EQ5D index: 0.39, 99% CI: 0.36-0.42, p = 0.004), although these small differences may not be of clinical importance. There were no statistically significant benefits of either CoP or CoC bearings compared to a MoP bearing. Complication rates were similar within comparisons of head sizes or bearings. INTERPRETATION: In this short-term study, we did not find any functional benefits of larger head sizes or alternative bearings, after adjusting for other influences. We question their use in routine primary hip replacement given the lack of evidence of improved long-term survival in the literature.

The impact of body mass index on patient reported outcome measures (PROMs) and complications following primary hip arthroplasty.

Influence of BMI upon patient outcomes and complications following THA was examined across a national cohort of patients. Outcomes were compared by BMI groups (19.0-29.9kg/m(2) [reference], 30.0-34.9kg/m(2) [obese class I], 35.0kg/m(2)+ [obese class II/III]), adjusted for case-mix differences. Obese class I patients had a significantly smaller improvement in OHS (18.9 versus 20.5, P<0.001) and a greater risk of wound complications (odds ratio [OR]=1.57, P=0.006). For obese class II/III patients, there were significantly smaller improvements in OHS and EQ-5D index (P<0.001), and greater risk of wound complications (P=0.006), readmission (P=0.001) and reoperation (P=0.003). Large improvements in patient outcomes were seen irrespective of BMI, although improvements were marginally smaller and complication rates higher in obese patients.

Evolution of the hip fracture population: time to consider the future? A retrospective observational analysis.

OBJECTIVE: To examine how the population with fractured neck of femur has changed over the last decade and determine whether they have evolved to become a more physically and socially dependent cohort. DESIGN: Retrospective cohort study of prospectively collected Standardised Audit of Hip Fractures of Europe data entered on to an institutional hip fracture registry. PARTICIPANTS: 10 044 consecutive hip fracture admissions (2000-2012). SETTING: A major trauma centre in the UK. RESULTS: There was a generalised increase in the number of admissions between 2000 (n=740) and 2012 (n=810). This increase was non-linear and best described by a quadratic curve. Assuming no change in the prevalence of hip fracture over the next 20 years, our hospital is projected to treat 871 cases in 2020 and 925 in 2030. This represents an approximate year-on-year increase of just over 1%. There was an increase in the proportion of male admissions over the study period (2000: 174 of 740 admissions (23.5%); 2012: 249 of 810 admissions (30.7%)). This mirrored national census changes within the geographical area during the same period. During the study period there were significant increases in the numbers of patients admitted from their own home, the proportion of patients requiring assistance to mobilise, and the proportion of patients requiring help with basic activities of daily living (all p<0.001). There was also a twofold to fourfold increase in the proportion of patients admitted with a diagnosis of cardiovascular disease, renal disease, diabetes and polypharmacy (use of >4 prescribed medications; all p<0.001). CONCLUSIONS: The expanding hip fracture population has increasingly complex medical, social and rehabilitation care needs. This needs to be recognised so that appropriate healthcare strategies and service planning can be implemented. This epidemiological analysis allows projections of future service need in terms of patient numbers and dependency.

Early PROMs following total knee arthroplasty--functional outcome dependent on patella resurfacing.

Patella resurfacing during primary total knee arthroplasty (TKA) remains controversial. Variation in published results for patella resurfacing may potentially be explained by differences in design between TKA brands. We interrogated NJR-PROMs data to ascertain whether there is an early functional benefit to resurfacing the patella, both overall and for each of the five most popular primary knee designs through use of the Oxford Knee Score. A total of 8103 resurfaced TKAs and 15,290 nonresurfaced TKAs were studied. There was a large variation in the proportion of knees undergoing patella resurfacing by brand (Nexgen=16% versus Triathlon=52%). Patellar resurfacing did not significantly influence the magnitude of improvement in overall knee function or anterior knee-specific function irrespective of TKA brand or for cruciate retaining versus sacrificing designs.

Factors influencing revision risk following 15 740 single-brand hybrid hip arthroplasties: a cohort study from a National Joint Registry.

This retrospective cohort study of a National Joint Registry data examines survival time to revision following the commonest brand of primary hybrid THA, exploring risk factors independently associated with failure. Overall 5-year revision was 1.56%. In the final adjusted model, revision risk was significantly higher with standard polyethylene (PE) liners (metal-on-PE: hazard ratio [HR]=2.52, P=0.005, ceramic-on-PE: HR=2.99, P=0.025) when compared to metal-on-highly-cross-linked (XL) PE. Risk of revision with ceramic-on-ceramic bearings was borderline significant (HR=1.86, P=0.061). A significant interaction between age and acetabular shell type (solid or multi-hole) was found (P=0.022), suggesting that solid shells performed significantly better in younger patients. In summary, we found that there were significant differences in implant failure between different bearing surfaces and shell types after adjusting for a range of covariates.

Revision for unexplained pain following unicompartmental and total knee replacement.

BACKGROUND: Unicompartmental knee arthroplasty has been associated with consistently worse implant survival rates than total knee arthroplasty in worldwide arthroplasty registers. The rate of revision and the proportion of revisions performed for unexplained knee pain after either a unicompartmental or total knee arthroplasty were studied to assess if there is evidence to support the hypothesis that the numbers of revisions performed for unexplained knee pain differ between these two implant types. METHODS: Using data from the National Joint Registry (NJR) of England and Wales, we identified 402,714 primary knee arthroplasties (366,965 total knee arthroplasties and 35,749 unicompartmental knee arthroplasties) that were consecutively entered from April 2003 to December 2010. The status of all implants was assessed as of December 2010, at which time 6075 implants (4503 total knee implants and 1572 unicompartmental knee implants) had been revised at a maximum of eight years. Survival analysis and Cox regression analysis with adjustment of differences in age, sex, American Society of Anesthesiologists (ASA) grade, and indication for arthroplasty were performed with use of the end points of revision for any reason, revision for unexplained pain, and revision for other reasons. RESULTS: Revision for unexplained pain was more common after unicompartmental knee arthroplasty than after total knee arthroplasty (representing 23% of revisions as compared with 9% of revisions; p < 0.001). The five-year rate of revision for unexplained pain was 1.6% for the unicompartmental knee arthroplasty group and 0.2% for the total knee arthroplasty group. With use of Cox regression, the hazard ratio (HR) for unicompartmental knee arthroplasty relative to total knee arthroplasty with the end points of revision for any reason, revision for unexplained pain, and revision for all other reasons were 2.82 (95% confidence interval [CI], 2.66 to 2.99; p < 0.001), 6.76 (95% CI, 5.84 to 7.83; p < 0.001), and 2.39 (95% CI, 2.24 to 2.56; p < 0.001), respectively. The mean time from primary implantation to revision was similar for both implant types. CONCLUSIONS: While more unicompartmental knee implants than total knee implants were revised for unexplained pain, when these revisions for unexplained pain were discounted, unicompartmental knee arthroplasty still had a significantly greater risk of revision from other reasons than did total knee arthroplasty. The revision rate in isolation may not be a reliable way to compare different implant designs and should instead be considered in the context of the reason for failure.