Plasma soluble fms-like tyrosine kinase-1, placental growth factor, and vascular endothelial growth factor system gene variants as predictors of survival in heart failure.

AIMS: Soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF), components of the vascular endothelial growth factor (VEGF) system, play key roles in angiogenesis. Reports of elevated plasma levels of sFlt-1 and PlGF in coronary heart disease and heart failure (HF) led us to investigate their utility, and VEGF system gene single nucleotide polymorphisms (SNPs), as prognostic biomarkers in HF. METHODS AND RESULTS: ELISA assays for sFlt-1, PlGF and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were performed on baseline plasma samples from the PEOPLE cohort (n = 890), a study of outcomes among patients after an episode of acute decompensated HF. Eight SNPs potentially associated with sFlt-1 or PlGF levels were genotyped. sFlt-1 and PlGF were assayed in 201 subjects from the Canterbury Healthy Volunteers Study (CHVS) matched to PEOPLE participants. All-cause death was the major endpoint for clinical outcome considered. In PEOPLE participants, mean plasma levels for both sFlt-1 (125 ± 2.01 pg/ml) and PlGF (17.5 ± 0.21 pg/ml) were higher (both p < 0.044) than in the CHVS cohort (81.2 ± 1.31 pg/ml and 15.5 ± 0.32 pg/ml, respectively). sFlt-1 was higher in HF with reduced ejection fraction compared to HF with preserved ejection fraction (p = 0.005). The PGF gene SNP rs2268616 was univariately associated with death (p = 0.016), and was also associated with PlGF levels, as was rs2268614 genotype. Cox proportional hazards modelling (n = 695, 246 deaths) showed plasma sFlt-1, but not PlGF, predicted survival (hazard ratio 6.44, 95% confidence interval 2.57-16.1; p < 0.001) in PEOPLE, independent of age, NT-proBNP, ischaemic aetiology, diabetic status and beta-blocker therapy. CONCLUSIONS: Plasma sFlt-1 concentrations have potential as an independent predictor of survival and may be complementary to established prognostic biomarkers in HF.

Clinical and functional outcomes of TKA after HTO or UKA: a New Zealand Joint Registry Study.

INTRODUCTION: Surgical options for patients with unicompartmental knee osteoarthritis include high tibial osteotomy (HTO) or unicompartmental knee arthroplasty (UKA). When managing younger patients with a higher chance of further surgery, the outcome of any subsequent conversion to total knee arthroplasty (TKA) also needs to be considered. The aim of this study was to compare implant survivorship and patient-reported outcomes for patients undergoing TKA after previous HTO or UKA, with comparisons for age, gender and comorbidities. METHODS: Revision risk and 6-month Oxford Knee Scores (OKS) from the New Zealand Joint Registry were compared for patients who underwent TKA after HTO (HTO-TKA; n = 1556) or UKA (UKA-TKA; n = 965) between 1999 and 2019, with a comparison group of primary TKA (n = 110,948). Mean follow-up was 8.2 years. RESULTS: Adjusted revision risk was similar for HTO-TKA and UKA-TKA groups (hazard ratio (HR) 1.04, p = 0.84); and risk for both groups were higher than primary TKA (HTO-TKA HR 1.45, p = 0.002; UKA-TKA HR 1.51, p = 0.01). Overall adjusted mean OKS at 6 months for HTO-TKA (36.2) was similar to primary TKA (36.8, p = 0.23); and both were higher than UKA-TKA (34.2, p < 0.001). For the youngest patient group (< 55 years), revision rates of UKA-TKA were two-fold higher than HTO-TKA (2.8 vs. 1.3 per 100 component yrs, p < 0.03). HTO-TKA had better OKS (37.5 vs. 34.1, p < 0.0001) for males. Mean OKS for UKA-TKA was lower than HTO-TKA for patients with ASA 1-2 (35.6 vs. 37.5, p < 0.01). CONCLUSION: The findings from this study suggest that revision rate following TKA after HTO and UKA are similar. However, TKA after HTO have superior functional outcomes compared with TKA after UKA and are comparable to functional outcomes post primary TKA. The results support the use of HTO for young, male and less co-morbid patients.

Reverse total shoulder arthroplasty for acute proximal humeral fracture has comparable 10-year outcomes to elective indications: results from the New Zealand Joint Registry.

HYPOTHESIS AND BACKGROUND: Recently, the indication of reverse total shoulder arthroplasty (RTSA) has expanded beyond rotator cuff arthropathy to include treatment of complex acute proximal humeral fracture (PHF). Limited previous studies have compared the long-term clinical and functional outcomes of patients undergoing RTSA for PHF vs. elective indications for degenerative conditions. The purpose of this study was to compare implant survivorship, reasons for revision and functional outcomes in patients undergoing RTSA for acute PHF with those undergoing elective RTSA in a population-based cohort study. METHODS: Prospectively collected data from the New Zealand Joint Registry from 1999 to 2021 and identified 6862 patients who underwent RTSA. Patients were categorized by preoperative indication, including PHF (10.8%), rotator cuff arthropathy (RCA) (44.5%), osteoarthritis (OA) (34.1%), rheumatoid arthritis (RA) (5.5%), and old traumatic sequelae (5.1%). Revision-free implant survival and functional outcomes (Oxford Shoulder Scores [OSSs] at the 6-month, 5-year, and 10-year follow-ups) were adjusted by age, sex, American Society of Anesthesiologists class, and surgeon experience and compared. RESULTS: Revision-free implant survival at 10 years for RTSA for PHF was 97.3%, compared with 96.1%, 93.7%, 92.8%, and 91.3% for OA, RCA, RA and traumatic sequelae, respectively. When compared with RTSA for PHF, the adjusted risk of revision was significantly higher for traumatic sequelae (hazard ratio = 2.3, P = .023) but not for other elective indications. The most common reason for revision in the PHF group was dislocation or instability (42.9%), which was similar to the OA (47.6%) and traumatic sequelae (33.3%) groups. At 6 months post-surgery, OSSs were significantly lower for the PHF group compared with the RCA, OA, and RA groups (31.1 vs. 35.6, 37.7, and 36.5, respectively, P < .001), and similar to traumatic sequelae (31.7, P = .431). At 5 years, OSSs were only significantly lower for PHF compared with OA (37.4 vs. 41.0, P < .001) and there was no difference between the PHF and other groups. At 10 years, there were no significant differences between groups. CONCLUSIONS: RTSA for PHF demonstrated reliable long-term survivorship and functional outcomes compared with elective indications. Despite lower functional outcomes in the early postoperative period for the PHF group, implant survivorship was similar in patients undergoing RTSA for the primary indication of acute PHF compared with RCA, OA, and RA and superior compared to the primary indication of traumatic sequelae.

Is MRI screening for bone marrow oedema useful in predicting lumbar bone stress injuries in adult male professional cricketers? A New Zealand pilot study.

OBJECTIVES: The aims were to (1) prospectively observe the incidence of bone marrow oedema in asymptomatic adult male domestic professional cricketers during a season and evaluate its relationship to the development of lumbar bone stress injury and (2) further understand the practicalities of implementing a Magnetic Resonance Imaging-based screening program to prevent lumbar bone stress injury in New Zealand cricket. DESIGN: Prospective observational cohort. METHODS: Adult male pace bowlers received 6-weekly pre-planned Magnetic Resonance Imaging scans over a single season to determine the presence and intensity of bone marrow oedema in the posterior vertebral arches of the lumbar spine. The participants bowling volume and back pain levels were monitored prospectively. RESULTS: 22 participants (mean age 25.3 years (range 20-32 years)) completed all 4 scans. Ten participants had a prior history of lumbar bone stress injury. Ten participants (45 %, 95 % confidence interval 24-68 %) had bone marrow oedema evident on at least one scan, with 9 (41 %) participants recording a bone marrow oedema intensity ≥ 2 and 5 (23 %) participants demonstrated an intensity ≥ 3. During the study one participant was diagnosed with a lumbar bone stress reaction. No participants developed a lumbar bone stress fracture. CONCLUSIONS: Due to the lower incidence of lumbar bone stress injuries in adult bowlers coupled with uncertainty over appropriate threshold values for bone marrow oedema intensity, implementation of a resource intense screening program aimed at identifying adult domestic cricketers at risk of developing a lumbar bone stress injury is not currently supported.

Descriptive Epidemiology of Pediatric Inflammatory Bowel Disease in Oceania: A Systematic Review and Meta-Analysis.

OBJECTIVES: Pediatric inflammatory bowel diseases (IBDs) are chronic, idiopathic illnesses of the digestive tract, which can impact adversely on children's quality of life and burden health systems. International studies have shown these diseases are increasing. The aim was to describe pediatric IBD epidemiology across Oceania by conducting a systematic review and meta-analysis of incidence and prevalence. METHODS: Medline, EMBASE and Web of Science databases were searched in October 2022 for studies reporting rates of IBD, Crohn disease (CD), or ulcerative colitis (UC) in children (≤19 years). Several data collection methodologies were included and pooled estimates of incidence and prevalence were calculated using a random effects model with I2 measures of heterogeneity. RESULTS: Nineteen articles provided 15 incidence and 7 prevalence studies. Fourteen studies were from Australia, 8 studies from New Zealand, and no studies were found from the Pacific Islands. Study dates ranged from 1950 to 2020 with 11 studies using population-based designs. Pooled estimates for annual incidence were IBD 4.1 (3.4-4.8, I2 = 98.7), CD 2.3 (1.9-2.7, I2 = 98.6), and UC 0.9 (0.6-1.1, I2 = 96.8) per 100,000 person-years. Prevalence rates were IBD 36.0 (23.5-48.5, I2 = 98.4), CD 23.2 (6.6-39.8, I2 = 97.8), and UC 7.6 (2.7-12.5, I2 = 99.6) per 100,000 persons. CONCLUSIONS: Pediatric IBD is prevalent in Oceania with high incidence rates, particularly for CD. Low rates of IBD were observed in indigenous Australian, Maori, and New Zealand Pacific children and there were no studies from the Pacific Islands highlighting this as an area in need of further research.

The Strongest Oxford Knee Score Predictors of Subsequent Revision are "Overall Pain," "Limping When Walking," and "Knee Giving Way".

BACKGROUND: The Oxford Knee Score (OKS) is used to measure knee arthroplasty outcomes; however, it is unclear which questions are more relevant. Our aims were to (1) identify which OKS question(s) were the strongest predictors of subsequent revision and (2) compare the predictive ability of the "pain" and "function" domains. METHODS: All primary total knee arthroplasties (TKAs) and unicompartmental knee arthroplasties (UKAs) in the New Zealand Joint Registry between 1999 and 2019 with an OKS at 6 months (TKA n = 27,708; UKA n = 8,415), 5 years (TKA n = 11,519; UKA n = 3,365) or 10 years (TKA n = 6,311; UKA n = 1,744) were included. Prediction models were assessed using logistic regressions and receiver operating characteristic analyses. RESULTS: A reduced model with 3 questions ("overall pain," "limping when walking," "knee giving way") showed better diagnostic ability than full OKS for predicting UKA revision at 6 months (area under the curve [AUC]: 0.80 versus 0.78; P < .01) and 5 years (0.81 versus 0.77; P = .02), and comparable diagnostic ability for predicting TKA revision at all time points (6 months, 0.77 versus 0.76; 5 years, 0.78 versus 0.75; 10 years, 0.76 versus 0.73; all not significant), and UKA revision at 10 years (0.80 versus 0.77; not significant). The pain domain had better diagnostic ability for predicting subsequent revision for both procedures at 5 and 10 years. CONCLUSION: Questions on "overall pain", "limping when walking", and "knee giving way" were the strongest predictors of subsequent revision. Attention to low scores from these questions during follow-up may allow for prompt identification of patients most at risk of revision.

Short-term outcomes following 159 stemmed pyrolytic carbon shoulder hemiarthroplasties and how they compare with conventional hemiarthroplasties and total shoulder arthroplasties in patients younger than 60 years with osteoarthritis: results from the New Zealand National Joint Registry.

BACKGROUND: Despite the increasing use of pyrolytic carbon (pyrocarbon) hemiarthroplasty (PyCHA), clinical data reporting on its outcomes remain scarce. To date, no studies have compared the outcomes of stemmed PyCHA vs. conventional hemiarthroplasty (HA) and anatomic total shoulder arthroplasty (aTSA) in young patients. The primary aim of this study was to report on the outcomes of the first 159 stemmed PyCHAs performed in New Zealand. The secondary aim was to compare the outcomes of stemmed PyCHA vs. HA and aTSA in patients aged <60 years with osteoarthritis. We hypothesized that stemmed PyCHA would be associated with a low revision rate. We further hypothesized that in young patients, PyCHA would be associated with a lower revision rate and superior functional outcomes compared with HA and aTSA. METHODS: Data from the New Zealand National Joint Registry were used to identify patients who underwent PyCHA, HA, and aTSA between January 2000 and July 2022. The total number of revisions in the PyCHA group was determined, and the indications for surgery, reasons for revision, and types of revision were recorded. In patients aged <60 years, a matched-cohort analysis was performed comparing functional outcomes using the Oxford Shoulder Score (OSS). The revision rate of PyCHA was compared with that of HA and aTSA, calculated as revisions per 100 component-years. RESULTS: In total, 159 cases of stemmed PyCHA were performed and 5 cases underwent revision, resulting in an implant retention rate of 97%. Among patients aged <60 years with shoulder osteoarthritis, 48 underwent PyCHA compared with 150 who underwent HA and 550 who underwent aTSA. Patients treated with aTSA had a superior OSS compared with PyCHA and HA patients. The difference in the OSS between the aTSA and PyCHA groups exceeded the minimal clinically important difference of 4.3. There was no difference in revision rates between the groups. CONCLUSIONS: This study represents the largest cohort of patients treated with PyCHA and is the first to compare stemmed PyCHA with HA and aTSA in young patients. In the short term, PyCHA appear to be a promising implant with an excellent implant retention rate. In patients aged <60 years, the revision rate is comparable between PyCHA and aTSA. However, aTSA remains the implant of choice to optimize early postoperative function. Further studies are required to elucidate the long-term outcomes of PyCHA, particularly how they compare with those of HA and aTSA in young patients.

Associations of the Oxford Knee Score and knee arthroplasty revision at long-term follow-up.

BACKGROUND: Self-reported outcome measures are increasingly being collected for healthcare evaluation therefore it is prudent to understand their associations with patient outcomes. Our aims were to investigate: (1) if Oxford Knee Score (OKS) is associated with impending revision at long-term (5 and 10 years) follow-up, and (2) if decreased OKS at subsequent follow-ups is associated with higher risk of revision. PATIENTS AND METHODS: All total knee (TKAs) and unicompartmental knee arthroplasties (UKAs) between 1999 and 2019 in the New Zealand Joint Registry with an OKS at 6 months (TKA n = 27 708, UKA n = 8415), 5 years (TKA n = 11 519, UKA n = 3365) or 10 years (TKA n = 6311, UKA n = 1744) were included. Logistic regression determined associations of the OKS with revision within 2 years of each score. Change in OKS between timepoints were compared with revision risk. RESULTS: For every one-unit increase in OKS, the odds of TKA and UKA revision decreased by 10% and 11% at 6 months, 10% and 12% at 5 years and 9% and 5% at 10 years. For both procedures a decrease of seven or more OKS points from previous follow-up was associated with higher risk of revision (5 years: TKA 4.7% versus 0.5%, UKA 8.7% versus 0.9%; 10 years: TKA 4.4% versus 0.7%, UKA 11.3% versus 1.5%; all P < 0.01). CONCLUSION: The OKS had a strong negative association with risk of impending TKA and UKA revision from early to long-term (10+ years) follow-up. A decrease of seven or more points when compared with the previous follow-up was also associated with higher revision risk.

The Impact of Disease Activity on Sexual and Erectile Dysfunction in Patients With Inflammatory Bowel Disease.

BACKGROUND: Increased disease activity may be a risk factor for sexual dysfunction (SD) in patients with inflammatory bowel disease (IBD). This study investigated associations between objective measures of disease activity and sexual function. METHODS: Adults with IBD undergoing ileocolonoscopy were prospectively recruited. Demographic, sexual function (Female Sexual Function Index and International Index of Erectile Function), disease activity (endoscopic, biomarker, and symptoms), psychological symptoms, and quality-of-life data were collected. Rates of SD and erectile dysfunction (ED) were compared between patients with active and inactive inflammation and symptoms using the Fisher's exact test. Logistic regression examined associations between SD and ED, and disease characteristics and psychological symptoms. RESULTS: A total of 159 participants were included, 97 had Crohn's disease and 85 were women. SD was reported in 36 of 59 and 13 of 59 sexually active women and men, respectively and ED in 22 of 59 sexually active men. Rates of SD and ED were similar between individuals with active and inactive IBD based on endoscopic indices (P > .05) and biomarkers (P > .05). Women with active IBD symptoms experienced significantly higher rates of SD (P < .05), but men did not (P > .05). Multivariable logistic regression identified that symptoms of severe depression (odds ratio, 5.77; 95% confidence interval, 1.59-20.94) were associated with SD in women, and severe anxiety (odds ratio, 15.62; 95% confidence interval, 1.74-140.23) was associated with ED in men. CONCLUSIONS: Objective measures of disease activity are not associated with SD or ED in patients with IBD. Clinicians should consider concomitant psychological symptoms contributing to the sexual health of patients with IBD.

Faecal Myeloperoxidase as a Biomarker of Endoscopic Activity in Inflammatory Bowel Disease.

BACKGROUND AND AIMS: Inflammatory bowel disease [IBD], consisting of Crohn's disease [CD] and ulcerative colitis [UC], is a relapsing-remitting illness. Treat-to-target IBD management strategies require monitoring of gastrointestinal inflammation. This study aimed to investigate faecal myeloperoxidase [fMPO], a neutrophil granule enzyme, as a biomarker of IBD activity. METHODS: Prospectively recruited participants with IBD, undergoing ileocolonoscopy for disease assessment, provided biological samples and completed symptom questionnaires prior to endoscopy. fMPO, C-reactive protein [CRP], and faecal calprotectin [fCal] were compared with validated endoscopic indices [simple endoscopic score for CD and UC endoscopic index of severity]. Receiver operating characteristic [ROC] curves assessed the performance of fMPO, CRP, and fCal in predicting endoscopic disease activity. Baseline biomarkers were used to predict a composite endpoint of complicated disease at 12 months [need for escalation of biologic/immunomodulator due to relapse, steroid use, IBD-related hospitalisation, and surgery]. RESULTS: A total of 172 participants were recruited [91 female, 100 with CD]. fMPO was significantly correlated with endoscopic activity in both CD [r = 0.53, p < 0.01] and UC [r = 0.63, p < 0.01], and with fCal in all patients with IBD [r = 0.82, p < 0.01]. fMPO was effective in predicting moderate-to-severely active CD [AUROC 0.86, p < 0.01] and UC [AUROC 0.92, p < 0.01]. Individuals with a baseline fMPO > 26 µg/g were significantly more likely to reach the composite outcome at 12 months (hazard ratio [HR] 3.71, 95% confidence interval [CI] 2.07-6.64, p < 0.01). CONCLUSIONS: Faecal myeloperoxidase is an accurate biomarker of endoscopic activity in IBD and predicted a more complicated IBD course during follow-up.

The disease severity index for inflammatory bowel disease is associated with psychological symptoms and quality of life, and predicts a more complicated disease course.

BACKGROUND: The Disease Severity Index (DSI) is a novel tool to predict disease severity in inflammatory bowel disease (IBD). However, its ability to predict disease complications and the presence of psychosocial comorbidity is unclear. AIMS: To assess prospectively associations between the DSI and psychological symptoms, quality-of-life (QoL) and disease outcomes in an IBD cohort. METHODS: Patients with IBD undergoing ileocolonoscopy were followed prospectively for 12 months. DSI, psychological symptoms (perceived stress (PSS-10), depression (PHQ-9), anxiety (GAD-7)) and QoL (IBDQ-32) scores were assessed at baseline. Logistic regression identified variables predicting a complicated IBD course at 12 months (composite outcome of need for escalation of biological/immunomodulator for disease relapse, recurrent corticosteroid use, IBD-related hospitalisation and surgery). Receiver operating characteristics (ROC) analysis identified optimal DSI thresholds predicting a complicated disease course and multivariable logistic regression assessed the risk of reaching this outcome. RESULTS: One hundred and seventy-two patients were recruited (100 Crohn's disease, 91 female). Median DSI was 21 (IQR 11-32) and 97 patients had endoscopically active disease at baseline. The DSI was significantly higher in patients with symptoms of moderate-severe stress (PSS-10 > 14, p < 0.01), depression (PHQ-9 ≥ 10, p < 0.01), anxiety (GAD-7 ≥ 10, p < 0.05) and impaired quality-of-life (IBDQ-32 < 168, p < 0.01). Only the baseline DSI (OR 1.05, p < 0.01) and endoscopically active disease (OR 6.12, p < 0.01) were associated with a complicated IBD course. A DSI > 23 was strongly predictive of a complicated IBD course (OR 8.31, p < 0.001). CONCLUSIONS: The DSI is associated with psychological distress, impaired QoL and predicts a more complicated disease course in patients with IBD.

How do 3D-printed primary uncemented acetabular components compare with established uncemented acetabular cups? The experience of the New Zealand National Joint Registry.

BACKGROUND: 3D-printed or additive manufactured acetabular implants are an exciting new technology being used in hip surgery with increasing frequency especially in complex acetabular reconstructions. However, the performance of acetabular components produced by this method for primary THR is unknown. METHODS: 41,272 uncemented cups in primary THR for OA were identified in the NZJR for the purposed of this study. There were 39,080 uncemented cups in the control group (15,798 Pinnacle cups, 12,724 Trident cups and 10,558 RM Pressfit cups) compared to 2192 3D-printed uncemented implants (1397 Delta TT cups, 640 Ti Por and 155 Polymax cups). All-cause revision rates and reasons for revision were examined. Kaplan-Meier survival analysis was performed. RESULTS: 3D-printed cups were inserted into younger, fitter patients with a higher mean BMI compared to those in the control group (p < 0.001). The overall all-cause revision rate for 3D-printed cups was not significantly different to the controls: 0.77/100 cys (95% CI 0.59-1) compared to 0.55/100 cys (95% CI 0.52-0.58) in the control group (p = 0.058, Hazards ratio 1.29, 95% CI 0.992-1.678). There was no difference in aseptic cup loosening or deep infection rates between either group or indeed individual implant designs. CONCLUSIONS: 3D-printed uncemented cups provide reliable survivorship and clinical results in primary THR comparable to established designs manufactured by traditional means. The theoretical concerns of increased rates of fatigue failure or deep infection are unsubstantiated.

Vascular endothelial growth factor-A promoter polymorphisms, circulating VEGF-A and survival in acute coronary syndromes.

BACKGROUND: Development of a competent collateral circulation in established coronary artery disease is cardio-protective. The vascular endothelial growth factor (VEGF) system plays a key role in this process. We investigated the prognostic performance of circulating VEGF-A and three genetic variants in the VEGFA gene in a clinical coronary cohort. METHODS AND RESULTS: The Coronary Disease Cohort Study (CDCS) recruited 2,140 patients, with a diagnosis of acute coronary syndrome (ACS), after admission to Christchurch or Auckland City Hospitals between July 2002 and January 2009. We present data for 1927 patients from the cohort genotyped for three SNPs in the VEGF-A gene, rs699947 (C-2578A), rs2010963 (C405G) and rs3025039 (C936T). Plasma VEGF-A concentrations were assayed in a subgroup (n = 550) of CDCS patients (geometric mean 36.6 [34.7-38.5] pg/ml). VEGF-A levels correlated with patient heart rate at baseline (p = 0.034). None of rs699947, rs3025039, nor rs2010963 genotypes were significantly associated with VEGF-A levels, but rs3025039 genotype was positively associated with collateral vessels perfusion according to the Rentrop classification (p = 0.01) and baseline natriuretic peptide levels (p<0.05). Survival in the CDCS cohort was independently associated with baseline VEGF-A levels and (in males) with rs699947 genotype. CONCLUSIONS: This study is strongly suggestive that VEGF-A levels have value as a prognostic biomarker in coronary heart disease patients and SNPs in VEGF-A deserve further investigation as prognostic markers and indicators of angiogenic potential influencing the formation of collateral circulation.

Quality of life preferences in colorectal cancer patients aged 80 and over.

BACKGROUND: Management of patients with colorectal cancer (CRC) is about not only survival, but also quality of life (QoL). What patients want is important but is not well researched or understood for elderly patients where it is very relevant. This study aimed to measure and compare what patients with CRC aged 80 and over and surgeons consider important in terms of survivorship after surgery for CRC. METHODS: Patients aged 80 and over who were having surgery for CRC were recruited and interviewed using closed and open questions about their expectations of surgery and various QoL dimensions. These were assessed preoperatively and 3 months post-operatively. Surgeons ranked the same QoL dimensions of patients by questionnaire. RESULTS: Nineteen patients (median age 87.5, range 80-95, eight males and 11 females) were recruited. Patients rated items relating to health, mobility and independence (n = 23) as top three items most often followed by people outside self (n = 13). Surgeons underestimated importance in 17 domains with the biggest discrepancy being in 'avoiding a stoma' (4.11 versus 2.3, P < 0.01). CONCLUSION: With patients over 80 years having surgery for CRC, there is a lack of concordance between what surgeons think is important and what patients think is important. Despite this, CRC patients aged 80 and older are almost always satisfied with the outcome of surgery. Surgeons should ensure that they understand patients' expectations and that they are aligned with likely outcomes of surgery.

Influence of serum inflammatory cytokines on cytochrome P450 drug metabolising activity during breast cancer chemotherapy: a patient feasibility study.

Individual response to chemotherapy in patients with breast cancer is variable. Obesity and exercise are associated with better and worse outcomes, respectively, and it is known that both impact the systemic cytokine milieu. Cytochrome P450 (CYP) enzymes are responsible for the metabolism of many chemotherapy agents, and CYP enzyme activity has been shown to be modified by inflammatory cytokines in vitro and in vivo. Cytokine-associated changes in CYP metabolism may alter chemotherapy exposure, potentially affecting treatment response and patient survival. Therefore, better understanding of these biological relationships is required. This exploratory single arm open label trial investigated changes in in vivo CYP activity in twelve women treated for stage II or III breast cancer, and demonstrated for the first time the feasibility and safety of utilising the Inje phenotyping cocktail to measure CYP activity in cancer patients receiving chemotherapy. Relative CYP activity varied between participants, particularly for CYP2C9 and CYP2D6, and changes in serum concentrations of the inflammatory cytokine monocyte chemoattractant protein 1 inversely correlated to CYP3A4 activity during chemotherapy. Future use of phenotyping cocktails in a clinical oncology setting may help guide drug dosing and improve chemotherapy outcomes.Clinical Trial Registration: Trial was retrospectively registered to the Australia New Zealand Clinical Trial Registry (ANZCTR). ACTRN12620000832976, 21 Aug 2020, https://www.anzctr.org.au/ACTRN12620000832976.aspx .

Does surgical approach affect early outcomes following primary total hip replacement in obese patients?

AIM: The aim of this study was to assess whether obese patients undergoing primary total hip replacement (THR) via a posterior approach had superior revision rates and Oxford Hip Scores (OHS) compared to those via a lateral approach. PATIENTS AND METHODS: This is a retrospective cohort study using prospective data from the New Zealand Joint Registry applying STROBE and RECORD guidelines. Patients undergoing THR since 2010 were stratified by body mass index (BMI) into obese (BMI 30-39 kg/m2), and morbidly obese (BMI ⩾40 kg/m2) groups. All-cause revision rates, and 6-month OHS post-surgery were compared between groups. Multivariate analysis was performed. RESULTS: 12,109 unilateral THRs in obese patients were identified. The mean follow-up was 2.8 years (range 0.01-6.95 years). Univariate analysis in the BMI ⩾ 40 group showed the posterior approach had a significantly lower all-cause revision rate (0.99/100 observed component years (ocys); 95% CI, 0.65-1.44/100 ocys) than the lateral approach (1.71/100 ocys (95% CI, 0.98-2.77/100 ocys), p < 0.05). There was no significant difference in dislocation rates between the surgical approaches. OHS was statistically higher in the posterior approach group in BMI 30-39 patients (p < 0.001) but not clinically significant. Multivariate analysis showed femoral head size significantly influenced all-cause revision rates and mitigated against the increased risk associated with the surgical approach. CONCLUSION: The choice of surgical approach in obese patients conveys no advantage in overall revision rates in the short-term. Choosing an appropriate size of femoral head may be of greater importance than choice of surgical approach for obese patients in primary THR.

Cemented vs. uncemented glenoid fixation in total shoulder arthroplasty for osteoarthritis: a New Zealand Joint Registry study.

BACKGROUND: Total shoulder arthroplasty (TSA) is commonly performed for shoulder osteoarthritis (OA). Uncemented metal-backed (MB) glenoid components were introduced in an attempt to avoid glenoid loosening. New Zealand and Australian Joint Registry studies have shown significantly higher revision rates when uncemented MB glenoids are used. We used the New Zealand Joint Registry (NZJR) to compare all-cause revision rates and functional scores for TSA and investigated the trends of glenoid fixation used in New Zealand. METHODS: The NZJR was accessed for all primary TSA undertaken for OA from January 2000 to December 2017. Patient demographics were collated. All-cause revision rates were reported as rate per 100 component-years. Analysis was repeated excluding the uncemented SMR L2 glenoid (LimaCorporate), as it was a potential confounder. Kaplan-Meier survival analysis was performed. Oxford Shoulder Scores at both 6 months and 5 years were analyzed. RESULTS: A total of 2613 TSAs were performed for OA during the study period, representing 85.0% of all TSAs in New Zealand. Overall, 62.1% of the patients were female. In addition, 69.6% of glenoids were cemented and 30.4% uncemented. The most common uncemented MB glenoid was SMR 86.6% (LimaCorporate), and cemented was Global (DePuy) 49.8%. The revision rate for TSA with uncemented glenoids was significantly higher at 2.03 compared with cemented at 0.41 per 100 component-years (P < .001). Hazard ratio 5.0 for revision of uncemented glenoids. No significant difference was found in Oxford Scores at 6 months (39.7 vs. 40.3, P = .13) or 5 years (42.1 vs. 42.8, P = .22). The most common mode of failure was glenoid loosening in cemented glenoids (44.4%), and component failure in uncemented (34.8%). Revision for rotator cuff, deep infection, and instability were comparable between groups. When excluding SMR L2, uncemented MB glenoid all-cause revision rates remained significantly higher than cemented (1.42 vs. 0.41 per 100 component-years, P < .001). SMR L1 uncemented MB glenoids had a higher revision rate than the non-SMR uncemented glenoids (1.61 vs. 0.18 per 100 component-years, P = .009). Uncemented glenoid use peaked in New Zealand in 2011 at 46.7% of TSAs but declined to 20.1% in 2017. CONCLUSIONS: In the NZJR, primary TSAs undertaken for OA have a significantly higher all-cause revision rate when the glenoid component is uncemented. Uncemented glenoids have a 5.0 times higher revision rate. Excluding SMR L2 glenoids from the analysis, the significantly higher revision rate remained for uncemented glenoids. These data reaffirm that uncemented MB glenoids are associated with higher revision rates.

Surgical site infection rate is higher following hip and knee arthroplasty when cefazolin is underdosed.

PURPOSE: While many guidelines recommend higher doses of cefazolin for patients with higher body weights, there are scant outcome data showing the benefit of higher doses. Surgical site infection (SSI) rates by dose of cefazolin used for surgical prophylaxis after hip or knee arthroplasty were analyzed. METHODS: Analysis of patient data entered into New Zealand's national, prospective, surveillance and quality improvement SSI Improvement Programme database for the period July 2013 through December 2017 was conducted. The US Centers for Disease Control and Prevention's National Healthcare Safety Network SSI definitions were used, and patients were followed for 90 days after surgery. Underdosing was defined as use of 1 g of cefazolin in patients weighing 80 kg or more or a cefazolin dose of <3 g in those weighing 120 kg or more. RESULTS: There were 38,288 procedures where cefazolin was used for prophylaxis; patient body weight was known for all these procedures. Of the 1,840 patients who received 1 g of cefazolin, 676 (37%) weighed 80 kg or more. Of the 2,011 patients weighing 120 kg or more, 1,464 (73%) were underdosed. After multivariable analysis, male gender, higher total surgical risk scores, performance of revision and hip arthroplasties, and cefazolin underdosing were associated with higher SSI rates. For the 2,106 underdosed patients, the odds ratio for SSI was 2.19 (95% confidence interval, 1.61-2.99; P < 0.0001). The number of higher-weight patients needed to treat to prevent 1 SSI was 83, with an estimated cost of 35 kg/m2 or >40 kg/m2) remains unanswered.

Are Lipped Polyethylene Liners Associated with Increased Revision Rates in Patients with Uncemented Acetabular Components? An Observational Cohort Study.

BACKGROUND: Recurrent dislocation after THA remains a serious complication that carries with it a high risk of revision surgery. Previous studies have shown reduced dislocation rates with the use of lipped polyethylene (PE) liners in modular uncemented acetabular components, but there may be increased wear because of impingement, which may lead to aseptic loosening in the longer term; whether the aggregate benefit of lipped PE liners outweighs the risks associated with their use remains controversial. QUESTIONS/PURPOSES: We used data from the New Zealand Joint Registry to (1) compare Kaplan-Meier survival rates, (2) rates of revisions for dislocation between neutral and lipped PE liners, and (3) revision rates for aseptic loosening for the four most commonly used modular uncemented cups. METHODS: We used data from the New Zealand Joint Registry (NZJR) to identify 31,247 primary THAs using the four most commonly used uncemented modular acetabular implants from January 1, 1999 to December 31, 2018. The lipped liner group comprised 49% males (9924 of 20,240) compared with 42% (4669 of 11,007) in the neutral group (p < 0.001); 96% (19,382 of 20,240) of patients in the liner group had OA versus 95% (10,450 of 11,007) in the neutral group (p < 0.001). There was no difference in other patient characteristics such as age (mean 66.9 years), BMI (mean 29 ± 6 kg/m) and American Society of Anesthesiologists grade. The mean follow-up was 5.1 years (SD 3.9) and longest follow-up 19.3 years. The NZJR has more than 96% capture rate and data entry is a mandatory requirement of members of the New Zealand Orthopaedic Association. Kaplan-Meier survival rates were compared between 20,240 lipped and 11,007 neutral PE liners. Highly cross-linked polyethylene was used in 99% of lipped liner cups and 85% of neutral liner cups. Associated hazard ratios were calculated using a Cox regression analysis with a Kaplan-Meier revision-free estimates plot. RESULTS: The Kaplan-Meier survival at 10 years for lipped PE liners was 96% (95% confidence interval 95.4 to 96.2) and for neutral liners 95% (95% CI 94.7 to 95.9). After controlling for age, gender approach, femoral head size, and the use of image guidance, the all-cause revision risk was greater for neutral PE liners than that for lipped PE liners (HR 1.17 [95% CI 1.06 to 1.36]; p = 0.032). There was a higher risk of revision for dislocation in those with neutral PE liners than in those with lipped liners (HR 1.84 [95% CI 1.41 to 2.41]; p < 0.001) but no difference in the revision rate for aseptic acetabular component loosening (HR 0.85 [95% CI 0.52 to 1.38]; p = 0.511). CONCLUSIONS: The use of a lipped PE liner is not associated with a higher rate of aseptic loosening in patients who undergo primary THA compared with a neutral PE liner. Lipped PE liners are associated with lower rates of dislocation and lower all-cause revision rates without any increased association with revision rates for wear and aseptic loosening. LEVEL OF EVIDENCE: Level III, therapeutic study.

Does the femoral offset affect replacements? The results from a National Joint Registry.

BACKGROUND: Femoral component offset influences the torque forces exerted on a femoral stem and may therefore adversely affect femoral component survival. This study investigated the influence of femoral component offset on revision rates for primary total hip replacements (THR) registered on the New Zealand Joint Registry (NZJR). METHODS: There were 106,139 primary THRs registered, resulting in 4960 revisions for any cause. There were 46,242 THRs performed using the five commonest femoral components listed on the NZJR. A total of 41,100 were done for primary osteoarthritis of which 40,548 had all the offset information available for analysis. We defined low offset as < 42 mm, standard as 42-48 mm and high offset as > 48 mm offset and examined revision rates according to the reasons for revision. We performed survival analyses for both cemented and uncemented femoral components grouped by the different offsets. RESULTS: The all-cause revision rate was 0.54/100 component years (cys). Stems with < 42 mm offset had a revision rate of 0.58/100 cys (mean 0.58; 95% confidence interval (CI) 0.53-0.63), 42-48 mm offset 0.47 (95% CI 0.43-0.52) and > 48 mm offset 0.67 (95% CI 0.57-0.79). There was no significant difference in all-cause revision rates between varying stem offsets in uncemented stems adjusting for age and gender. In cemented stems both high and low offset stems were more likely to be revised. Uncemented stems of all offsets were more likely to undergo revision for femoral fracture. CONCLUSIONS: Femoral component offset affects the overall all-cause revision rate of the most commonly used cemented stem, but not uncemented stem designs. In cemented stems offset influences the rate of revision for loosening and periprosthetic fractures.