Low implantation volume, comorbidities, male sex and implantation of constrained TKA identified as risk factors for septic revision in knee arthroplasty: A register-based study from the German Arthroplasty Registry.

PURPOSE: Periprosthetic joint infection (PJI) is a major cause of revision surgery after total knee arthroplasty (TKA) and unicondylar knee arthroplasty (UKA). Patient- and hospital-related risk factors need to be assessed to prevent PJI. This study identifies influential factors and differences in infection rates between different implant types. METHODS: Data were obtained from the German Arthroplasty Registry. Septic revisions were calculated using Kaplan-Meier estimates with septic revision surgery as the primary endpoint. Patients with constrained and unconstrained TKA or UKA were analysed using Holm's multiple log-rank test and Cox's proportional hazards ratio. The 300,998 cases of knee arthroplasty analysed included 254,144 (84.4%) unconstrained TKA, 9993 (3.3%) constrained TKA and 36,861 (12.3%) UKA with a maximum follow-up of 7 years. RESULTS: At 1 year, the PJI rate was 0.5% for UKA and 2.8% for TKA, whereas at 7 years, the PJI rate was 4.5% for UKA and 0.9% for TKA (p < 0.0001). The PJI rate significantly increased for constrained TKA compared to unconstrained TKA (p < 0.0001). The PJI rate was 2.0% for constrained TKA and 0.8% for unconstrained TKA at 1 year and 3.1% and 1.4% at 7 years. Implantation of a constrained TKA (hazard ratio [HR] = 2.55), male sex (HR = 1.84), increased Elixhauser score (HR = 1.18-1.56) and implant volume of less than 25 UKA per year (HR = 2.15) were identified as risk factors for revision surgery; an Elixhauser score of 0 (HR = 0.80) was found to be a preventive factor. CONCLUSIONS: Reduced implant volume and constrained knee arthroplasty are associated with a higher risk of PJI. Comorbidities (elevated Elixhauser score), male sex and low UKA implant volume have been identified as risk factors for PJI. Patients who meet these criteria require specific measures to prevent infection. Further research is required on the potential impact of prevention and risk factor modification. LEVEL OF EVIDENCE: Level III.

Unicondylar knee arthroplasty demonstrating a significant increased risk for aseptic revisions compared to unconstrained and constrained total knee arthroplasty: An analysis of aseptic revisions after unicondylar and primary total knee arthroplasty of the German Arthroplasty Registry.

PURPOSE: Due to ageing population, the implantation rate of total knee arthroplasties (TKAs) is continuously growing. Aseptic revisions in primary knee arthroplasty are a major cause of revision. The aim of the following study was to determinate the incidence and reasons of aseptic revisions in constrained and unconstrained TKA, as well as in unicondylar knee arthroplasties (UKAs). METHODS: Data collection was performed using the German Arthroplasty Registry. Reasons for aseptic revisions were calculated. Incidence and comparison of aseptic revisions were analysed using Kaplan-Meier estimates. A multiple χ2 test with Holm's method was used to detect group differences in ligament ruptures. RESULTS: Overall, 300,998 cases of knee arthroplasty with 254,144 (84.4%) unconstrained TKA, 9993 (3.3%) constrained TKA and 36,861 (12.3%) UKA were analysed. Aseptic revision rate in UKA was significantly increased compared to unconstrained and constrained TKA (p < 0.0001). In constrained TKA, a 2.0% revision rate for aseptic reasons were reported after 1 year, while in unconstrained TKA 1.1% and in UKA, 2.7% of revisions were identified. After 7 years in constrained TKA 3.3%, in unconstrained TKA 2.8%, and in UKA 7.8% sustained aseptic revision. Ligament instability was the leading cause of aseptic revision accounting for 13.7% in unconstrained TKA. In constrained TKA, 2.8% resulted in a revision due to ligament instability. In the UKA, the most frequent cause of revisions was tibial loosening, accounting for 14.6% of cases, while progression of osteoarthritis accounted for 7.9% of revisions. Ligament instability was observed in 14.1% of males compared to 15.9% of females in unconstrained TKA and in 4.6% in both genders in UKA. CONCLUSION: In patients with UKA, aseptic revision rates are significantly higher compared to unconstrained and constrained TKA. Ligament instability was the leading cause of aseptic revision in unconstrained TKA. In UKA, the most frequent cause of revisions was tibial loosening, while progression of osteoarthritis was the second most frequent cause of revisions. Comparable levels of ligament instability were observed in both sexes. LEVEL OF EVIDENCE: Level III, cohort study.

Aseptic midterm survival rates between different cemented tibial stem designs in hinged total knee arthroplasty: a 6-year evaluation from the German Arthroplasty Registry.

INTRODUCTION: The rate of revision TKA and thus the use of hinged implants (HI) steadily rises. Aseptic loosening lies on the top of the failure patterns. However, no evidence exists until now based on national scale high-caseloads that analyzes the impact of cemented HI stem-design on aseptic survival rates. METHODS: Data on aseptic HI-revisions with full-cemented tibia-stems were conducted from the German Arthroplasty Registry. Cases were divided in primary HI (PHI) and HI used in revision operations (RHI). Endpoint was a new revision following either a PHI or an RHI. The impact of stem conicity (conical vs. cylindrical), diameter (≤ 13 mm vs. > 13 mm), length (≤ 90 mm vs. > 90 mm) and offset on the 6-Year-Cumulative-Aseptic-Revision-Rate (6Y-CARR) was estimated via Kaplan-Meier curve and compared between groups via Log-Rank-Tests. RESULTS: 3953 PHI and 2032 RHI fulfilled inclusion-criteria. Stem conicity had no impact on 6Y-CARR (p = 0.08 and p = 0.8). Diameter > 13 mm hat an impact on PHI (p = 0.05) with lower 6Y-CARR but not on RHI (p = 0.2). Length > 90 mm showed significantly worst 6Y-CARR in PHI (p = 0.0001) but not in RHI (p = 0.3). Offset-stems showed significantly better 6Y-CARR in PHI (p = 0.04), but not in RHI (p = 0.7). CONCLUSION: There was no significant impact of the cemented tibia-stem conicity on 6Y-CARR, neither in PHI nor in RHI. The effect of length, diameter and offset on the 6Y-CARR observed in the PHI, was not detectable in the more complex RHI-cases reflecting its limited clinical relevance by itself in more multifactorial backgrounds. Therefore, results must be interpreted with caution due to considerable system-effects and different utilization-scenarios.

High revision rates and mortality after distal femoral replacement for periprosthetic distal femoral fractures: analysis from the German Arthroplasty Registry (EPRD).

PURPOSE: This study was initiated to analyze the outcome after distal femoral replacement (DFR) for periprosthetic distal femoral fractures (PDFF). METHODS: Data from the German Arthroplasty Registry (EPRD) were analyzed. A total of 626 patients could be identified with a DFR for PDFF. Mean age was 78.8 years, and 84.2% were female. Revisions and mortality were analyzed and compared with patient groups with a similar procedure (revision total knee arthroplasty) or similar general condition (fracture total hip arthroplasty, hip hemiarthroplasty). Matched-pair-analyses were performed. RESULTS: Within one year after surgery, 13.2% of the patients had died and further 9.4% were revised. Within four years, 32.7% had died and 19.7% were revised. Revisions were nearly twice as high as in the comparison groups. Periprosthetic infection (PJI) was the most frequent cause for revision, resulting in a PJI rate of 12.8%, which was lower in the comparison groups. Mortality after DFR was as similar high as after fracture hip arthroplasty. CONCLUSION: PDFF are a serious injury, and the necessary surgical treatment has a high risk of complications. Every third patient after DFR for PDFF had died and every fifth patient needed revision within 4 years after surgery. Efforts should be undertaken to provide optimal treatment to these high-risk patients to reduce unfavorable outcomes. LEVEL OF EVIDENCE: III. REGISTRATION OF CLINICAL TRIALS: As this is a registry-derived study of data of the German Arthroplasty Registry (EPRD), no registration was performed.

Aseptic revisions and pulmonary embolism after surgical treatment of femoral neck fractures with cemented and cementless hemiarthroplasty in Germany: an analysis from the German Arthroplasty Registry (EPRD).

BACKGROUND: Femoral neck fractures (FNF) are among the most common fractures in Germany and are often treated by hemiarthroplasty (HA). The aim of this study was to compare the occurrence of aseptic revisions after cemented and uncemented HA for the treatment of FNF. Secondly, the rate of pulmonary embolism was investigated. METHODS: Data collection for this study was performed using the German Arthroplasty Registry (EPRD). HAs after FNF were divided into subgroups stratified by stem fixation (cemented vs uncemented) and paired according to age, sex, BMI, and the Elixhauser score using Mahalanobis distance matching. RESULTS: Examination of 18,180 matched cases showed a significantly increased rate of aseptic revisions in uncemented HA (p < 0.0001). After 1 month 2.5% of HAs with uncemented stems required an aseptic revision, while 1.5% were reported in cemented HA. After 1 and 3 years' follow-up 3.9% and 4.5% of uncemented HA and 2.2% and 2.5% of cemented HA needed aseptic revision surgery. In particular, the proportion of periprosthetic fractures was increased in cementless implanted HA (p < 0.0001). During in-patient stays, pulmonary emboli occurred more frequently after cemented HA [0.81% vs 0.53% in cementless HA (OR: 1.53; p = 0.057)]. CONCLUSION: For uncemented hemiarthroplasties a statistically significantly increased rate of aseptic revisions and periprosthetic fractures was evident within a time period of 5 years after implantation. During the in-hospital stay, patients with cemented HA experienced an increased rate of pulmonary embolism, but without statistically significant results. Based on the present results, with knowledge of prevention measurements and correct cementation technique, cemented HA should be preferred when using HA in the treatment of femoral neck fractures. TRAIL REGISTRATION: The study design of the German Arthroplasty Registry was approved by the University of Kiel (ID: D 473/11). LEVEL OF EVIDENCE: Level III, Prognostic.

Comparison of mortality rate and septic and aseptic revisions in total hip arthroplasties for osteoarthritis and femoral neck fracture: an analysis of the German Arthroplasty Registry.

BACKGROUND: Indications for total hip arthroplasties (THA) differ from primary osteoarthritis (OA), which allows elective surgery through femoral neck fractures (FNF), which require timely surgical care. The aim of this investigation was to compare mortality and revisions in THA for primary OA and FNF. METHODS: Data collection for this study was performed using the German Arthroplasty Registry (EPRD) with analysis THA for the treatment of FNF and OA. Cases were matched 1:1 according to age, sex, body mass index (BMI), cementation, and the Elixhauser score using Mahalanobis distance matching. RESULTS: Overall 43,436 cases of THA for the treatment of OA and FNF were analyzed in this study. Mortality was significantly increased in FNF, with 12.6% after 1 year and 36.5% after 5 years compared with 3.0% and 18.7% in OA, respectively (p < 0.0001). The proportion for septic and aseptic revisions was significantly increased in FNF (p < 0.0001). Main causes for an aseptic failure were mechanical complications (OA: 1.1%; FNF: 2.4%; p < 0.0001) and periprosthetic fractures (OA: 0.2%; FNF: 0.4%; p = 0.021). As influencing factors for male patients with septic failure (p < 0.002), increased BMI and Elixhauser comorbidity score and diagnosis of fracture (all p < 0.0001) were identified. For aseptic revision surgeries, BMI, Elixhauser score, and FNF were influencing factors (p < 0.0001), while all cemented and hybrid cemented THA were associated with a risk reduction for aseptic failure within 90 days after surgery (p < 0.0001). CONCLUSION: In femoral neck fractures treated with THA, a significant higher mortality, as well as septic and aseptic failure rate, was demonstrated compared with prosthesis for the therapy of osteoarthritis. Increased Elixhauser comorbidity score and BMI are the main influencing factors for development of septic or aseptic failure and can represent a potential approach for prevention measures. LEVEL OF EVIDENCE: Level III, Prognostic.

Ceramic Coating in Cemented Primary Total Knee Arthroplasty is Not Associated With Decreased Risk of Revision due to Early Prosthetic Joint Infection.

BACKGROUND: Prosthetic joint infection (PJI) is one of the most frequent and devastating causes of short-term revision total knee arthroplasty (TKA). In vitro evidence suggests ceramic surfaces demonstrate resistance to biofilm, but the clinical effect of bearing surface modifications on the risk of PJI remains unclear. This premier registry-based study examines the influence of ceramic bearing surface coatings on the outcome in cemented primary TKA. METHODS: In total, 117,660 cemented primary TKAs in patients with primary osteoarthritis recorded in the German arthroplasty registry since 2012 were followed up for a maximum of 3 years. The primary endpoint was risk of revision for PJI on ceramic coated and uncoated cobalt-chromium-molybdenum femoral components. Propensity score matching for age, gender, obesity, diabetes mellitus, depression and Elixhauser comorbidity index, and substratification on common design twins with and without coating was performed. RESULTS: In total, 4637 TKAs (85.1% female) with a ceramic-coated femoral component were identified, 42 had been revised for PJI and 122 for other reasons at 3 years. No survival advantage due to the risk of revision for PJI could be determined for ceramic-coated components. Revision for all other reasons demonstrated a significant higher rate for TKAs with ceramic-coated components. However, the results of this were confounded by a strong prevalence (20.7% vs 0.3%) of metal sensitivity in the ceramic-coated group. CONCLUSION: No evidence of reduced risk for PJI due to ceramic-coated implants in cemented primary TKA was found. Further analysis for revision reasons other than PJI is required.

Short versus conventional stem in cementless total hip arthroplasty : An evidence-based approach with registry data of mid-term survival.

BACKGROUND: Short-stemmed total hip arthroplasty (THA) is well established and gaining popularity in Germany. The perception that short stems may predispose to primary instability in the femur has resulted in a more thorough follow-up of younger patient cohorts than the typical uncemented THA population. To address this issue, an evidence-based approach is presented for a retrospective mid-term survival analysis of a large registry-based cohort in primary cementless THA comparing short stems with a matched group of conventional stems. MATERIAL AND METHODS: Propensity score matching (PSM, see Infobox 1) was used on 131,580 primary cementless THAs fulfilling the inclusion criteria performed between November 2012 and September 2019 and the cumulative probability of revision (CPR) of short and conventional stems for any reason, for reasons excluding prosthetic joint infection (PJI), and due to PJI were compared. RESULTS: After PSM at 1:1 balanced groups of 17,526 short stems and of 17,526 conventional stems were achieved demonstrating no significant difference for CPR for any reason and for reasons excluding PJI. Matched CPR for any reason was 2.9% (95% confidence interval, CI, 2.4-3.5%) 5 years after primary THA in the short stem and 3.1% (95% CI 2.7-3.4%) in the conventional stem group. The CPR excluding PJI was 2.2% (95% CI 1.7-2.7%) vs. 2.1% (95% CI 1.8-2.4%). In contrast, the incidence of PJI was statistically significant lower for short stems. CONCLUSION: For the considered period, there was no statistically significant survival difference in uncemented THA between comparison groups but a lower incidence for PJI in short-stem THA. Further analyses of registry data are required to rule out range of indications and late mechanical failure of short stems.

[Influence of institutional experience on results in hip and knee total arthroplasty : An analysis from the German arthroplasty registry (EPRD)]. / Einfluss der institutionellen Erfahrung auf die Ergebnisse in Hüft- und Knietotalendoprothetik : Eine Analyse aus dem Endoprothesenregister Deutschland (EPRD).

BACKGROUND: The German Arthroplasty Registry, EPRD, has the ability to examine early factors influencing the probability of failure of total hip arthroplasty (THA) and knee arthroplasty (TKA). The study analyses the influence of the overall experience of a hospital, as well as the change in supplier on the revision rate. MATERIALS AND METHODS: A total of 164,903 cementless THA and 155,577 cemented TKA were in follow-up from 656 hospitals from 2012 to 2019. The number of arthroplasties performed per hospital per year was used as a surrogate parameter for institutional experience. This number was subdivided into 250, 251-500 and more than 500 for hip and knee per year and the overall revision rate was analysed. Additionally, the effects of the change of a major supplier of implant systems to a hospital were analysed. At least 70% of the documented implant components for each calendar quarter were used in that hospital to define the company as a major supplier. RESULTS: The overall revision rate for THA was 3.9% for hospitals with up to 250 arthroplasties per year, 3.3% for hospitals with 251-500 arthroplasties per year and 2.9% for hospitals performing over 500 surgeries per year (p < 0.0001). The revision rate for TKA was also significantly different between the three groups with 3.4, 3.3 and 2.7% (p < 0.0001). Changing the supplier of implant systems also showed a significant increase of the revision rate (p < 0.0001 for THA, p = 0.02 for TKA). CONCLUSION: The institutional experience significantly influences short-term results in terms of the revision rate of hip and knee arthroplasty. Changing the implant system even in an experienced hospital has a major impact on the early revision rate and, therefore, needs careful transition.

A new universal, standardized implant database for product identification: a unique tool for arthroplasty registries.

INTRODUCTION: Every joint registry aims to improve patient care by identifying implants that have an inferior performance. For this reason, each registry records the implant name that has been used in the individual patient. In most registries, a paper-based approach has been utilized for this purpose. However, in addition to being time-consuming, this approach does not account for the fact that failure patterns are not necessarily implant specific but can be associated with design features that are used in a number of implants. Therefore, we aimed to develop and evaluate an implant product library that allows both time saving barcode scanning on site in the hospital for the registration of the implant components and a detailed description of implant specifications. MATERIALS AND METHODS: A task force consisting of representatives of the German Arthroplasty Registry, industry, and computer specialists agreed on a solution that allows barcode scanning of implant components and that also uses a detailed standardized classification describing arthroplasty components. The manufacturers classified all their components that are sold in Germany according to this classification. The implant database was analyzed regarding the completeness of components by algorithms and real-time data. RESULTS: The implant library could be set up successfully. At this point, the implant database includes more than 38,000 items, of which all were classified by the manufacturers according to the predefined scheme. Using patient data from the German Arthroplasty Registry, several errors in the database were detected, all of which were corrected by the respective implant manufacturers. CONCLUSIONS: The implant library that was developed for the German Arthroplasty Registry allows not only on-site barcode scanning for the registration of the implant components but also its classification tree allows a sophisticated analysis regarding implant characteristics, regardless of brand or manufacturer. The database is maintained by the implant manufacturers, thereby allowing registries to focus their resources on other areas of research. The database might represent a possible global model, which might encourage harmonization between joint replacement registries enabling comparisons between joint replacement registries.

[High revision rates and mortality after treatment of periprosthetic distal femur fractures with a distal femur replacement : An analysis from the EPRD]. / Hohe Revisionsraten und Mortalität nach Versorgung periprothetischer distaler Femurfrakturen mit einem distalen Femurersatz : Eine Analyse aus dem EPRD.

BACKGROUND: Periprosthetic distal femoral fractures (PDFF) are challenging injuries, as mostly geriatric patients with serious comorbidities are affected. Revision to a distal femoral replacement (DFR) is often the best option in very distal fractures, poor bone stock and/or loose total knee replacement. Data on outcome after these surgeries is limited. OBJECTIVES: This study was initiated to analyze the outcome after distal femoral replacement for periprosthetic distal femoral fractures. MATERIALS AND METHODS: Data of the German Arthroplasty Registry (EPRD) were analyzed. From a total of 43,945 revision knee replacement surgeries in the registry, 629 patients could be identified with a PDFF in which a DFR was used for revision. The mean age was 79.1 years, and 84.1% were female. Revisions and mortality were analyzed and compared with patient groups with a similar procedure (revision total knee arthroplasty) or similar general condition (fracture hip replacement). To make the groups more comparable, matched-pair-analyses were performed that included age, gender, BMI and comorbidities as matching parameters. RESULTS: Within 1 year after surgery 17.1% of the patients died and 10.4% were revised. Within 4 years 35.5% died and 22.3% were revised. Revision rates were lower in elective knee revisions (1 year 6.0%, 4 years 16.8%). Periprosthetic joint infection (PJI) accounted for 50% of all revisions, resulting a PJI rate of 7.3%. Mortality after DFR was similarly high as after fracture hip arthroplasty. CONCLUSION: After DFR for PDFF every third patient died, and every fifth patient needed revision within 4 years after surgery, which demonstrates the severity of this injury. Efforts should be undertaken to provide optimal treatment to these high-risk patients to reduce unfavorable outcomes. Surgeries should be well prepared and performed as early as possible in hospitals with adequate experience.

Influence of the type of stem and its fixation on revision and immediate postoperative mortality in elective total hip arthroplasty.

Aims: Despite higher rates of revision after total hip arthroplasty (THA) being reported for uncemented stems in patients aged > 75 years, they are frequently used in this age group. Increased mortality after cemented fixation is often used as a justification, but recent data do not confirm this association. The aim of this study was to investigate the influence of the design of the stem and the type of fixation on the rate of revision and immediate postoperative mortality, focusing on the age and sex of the patients. Methods: A total of 333,144 patients with primary osteoarthritis (OA) of the hip who underwent elective THA between November 2012 and September 2022, using uncemented acetabular components without reconstruction shells, from the German arthroplasty registry were included in the study. The revision rates three years postoperatively for four types of stem (uncemented, uncemented with collar, uncemented short, and cemented) were compared within four age groups: < 60 years (Young), between 61 and 70 years (Mid-I), between 71 and 80 years (Mid-II), and aged > 80 years (Old). A noninferiority analysis was performed on the most frequently used designs of stem. Results: The design of the stem was found to have no significant influence on the rate of revision for either sex in the Young group. Uncemented collared stems had a significantly lower rate of revision compared with the other types of stem for females in the Mid-I group. There was a significantly higher rate of revision for uncemented stems in females in the Mid-II group compared with all other types of stem, while in males the rate for uncemented stems was only significantly higher than the rate for cemented stems. Cemented stems had a significantly lower revision rate compared with uncemented and short stems for both sexes in the Old cohort, as did females with collared stems. The rate of immediate postoperative mortality was similar for all types of stem in the Old age group, as were the American Society of Anesthesiologists grades. Conclusion: In patients aged > 80 years, uncemented and short stems had significantly higher revision rates compared with cemented and collared stems, especially in females. The design of the stem and type of fixation have to be analyzed in more detail than only considering cemented and uncemented fixation, in order to further improve the success of THA.

[Aseptic revisions and pulmonary embolism after surgical treatment of femoral neck fractures with cemented and cementless hemiarthroplasty in Germany : An analysis from the Germany Arthroplasty Registry (EPRD)]. / Aseptische Revisionen und Lungenembolien nach operativer Behandlung von Schenkelhalsfrakturen mittels zementierten und zementfreien Hemiprothesen in Deutschland : Eine Analyse aus dem Endoprothesenregister Deutschland (EPRD).

BACKGROUND: Femoral neck fractures (FNF) are among the most common fractures in Germany and are often treated by hemiarthroplasty (HA). The aim of this study was to compare the occurrence of aseptic revisions after cemented and uncemented HA for the treatment of FNF. Secondly, the rate of pulmonary embolism was investigated. METHODS: Data collection for this study was performed using the German Arthroplasty Registry (EPRD). HAs after FNF were divided into subgroups stratified by stem fixation (cemented vs uncemented) and paired according to age, sex, BMI, and the Elixhauser score using Mahalanobis distance matching. RESULTS: Examination of 18,180 matched cases showed a significantly increased rate of aseptic revisions in uncemented HA (p < 0.0001). After 1 month 2.5% of HAs with uncemented stems required an aseptic revision, whereas 1.5% were reported in cemented HA. After 1 and 3 years' follow-up 3.9% and 4.5% of uncemented HA and 2.2% and 2.5% of cemented HA needed aseptic revision surgery. In particular, the proportion of periprosthetic fractures was increased in cementless implanted HA (p < 0.0001). During in-patient stays, pulmonary emboli occurred more frequently after cemented HA (0.81% vs 0.53% in cementless HA [OR: 1.53; p = 0.057]). CONCLUSION: For uncemented hemiarthroplasties a statistically significantly increased rate of aseptic revisions and periprosthetic fractures was evident within a time period of 5 years after implantation. During the in-hospital stay, patients with cemented HA experienced an increased rate of pulmonary embolism compared with patients with cementless HA, but this difference was not statistically significant. Based on the present results, with knowledge of prevention measures and the correct cementation technique, the use of cemented HA should be preferred in the treatment of femoral neck fractures.

[Standard and special liner in primary hip arthroplasty : Current study and survey results from the German Arthroplasty Registry (EPRD)]. / Standard- und Spezialinlays in primärer Hüftendoprothetik : Aktuelle Studien- und Umfrageergebnisse aus dem Endoprothesenregister Deutschland (EPRD).

BACKGROUND: Instability constitutes the main reason for revision hip arthroplasties. Modified polyethylene liners are designed to improve the stability of a hip replacement. In July 2022 The Bone & Joint Journal published a study with data of the German Arthroplasty Registry (EPRD). The study investigated mechanical failure of standard and modified liner designs in primary, cementless total hip arthroplasty. Following the study, the EPRD conducted a survey of German clinics to research the utilization of lipped liners in primary total hip replacement. METHODS: The liner study included 151,096 primary, elective, cementless total hip arthroplasties. Data from November 2012 to November 2020 were obtained from the EPRD. Standard polyethylene liners were compared with lipped, angulated, offset and angulated/offset inlays. Cumulative incidences for endpoint revision due to mechanical complication were calculated with a competing risk analysis. The influence of other variables was investigated with a multivariate Cox regression. In the following online survey, 237 out of 789 hospitals completed a form. RESULTS AND CONCLUSION: In our analysis, only offset liners were, compared to standard liners, associated with a reduced risk of mechanical failure in a short to medium follow up. However, the resultant joint reaction force is increased with offset liners due to the lateralization of the hip center of rotation. Thus, the long-term performance of offset liners needs to be observed. Our survey indicated that lipped liners were implanted more often if the posterior approach was used. Moreover, lipped liners were mostly positioned with the elevated rim in the biomechanically less optimal posterior-superior quadrant. To improve stability it is suggested to position the elevated rim in the posterior-inferior quadrant.

Infection after intracapsular femoral neck fracture - does antibiotic-loaded bone cement reduce infection risk after hemiarthroplasty and total hip arthroplasty?

Aims: The aim of this investigation was to compare risk of infection in both cemented and uncemented hemiarthroplasty (HA) as well as in total hip arthroplasty (THA) following femoral neck fracture. Methods: Data collection was performed using the German Arthroplasty Registry (EPRD). In HA and THA following femoral neck fracture, fixation method was divided into cemented and uncemented prostheses and paired according to age, sex, BMI, and the Elixhauser Comorbidity Index using Mahalanobis distance matching. Results: Overall in 13,612 cases of intracapsular femoral neck fracture, 9,110 (66.9%) HAs and 4,502 (33.1%) THAs were analyzed. Infection rate in HA was significantly reduced in cases with use of antibiotic-loaded cement compared with uncemented fixated prosthesis (p = 0.013). In patients with THA no statistical difference between cemented and uncemented prosthesis was registered, however after one year 2.4% of infections were detected in uncemented and 2.1% in cemented THA. In the subpopulation of HA after one year, 1.9% of infections were registered in cemented and 2.8% in uncemented HA. BMI (p = 0.001) and Elixhauser Comorbidity Index (p < 0.003) were identified as risk factors of periprosthetic joint infection (PJI), while in THA cemented prosthesis also demonstrated an increased risk within the first 30 days (hazard ratio (HR) = 2.73; p = 0.010). Conclusion: The rate of infection after intracapsular femoral neck fracture was statistically significantly reduced in patients treated by antibiotic-loaded cemented HA. Particularly for patients with multiple risk factors for the development of a PJI, the usage of antibiotic-loaded bone cement seems to be a reasonable procedure for prevention of infection.

Is Elective Total Hip Arthroplasty Safe in Nonagenarians?: An Arthroplasty Registry Analysis.

BACKGROUND: An increasing number of elderly patients are becoming candidates for elective total hip arthroplasty (THA). Conflicting results exist with regard to the safety of THA in nonagenarians. The aims of this study were to evaluate postoperative mortality and morbidity after THA in nonagenarians and underlying risk factors. We hypothesized that nonagenarians undergoing elective THA would show higher morbidity than younger patients and higher mortality than nonagenarians in the general population. METHODS: This was an observational cohort study using data from the German Arthroplasty Registry (Endoprothesenregister Deutschland [EPRD]). Of 323,129 THAs, 263,967 (including 1,859 performed on nonagenarians) were eligible. The mean follow-up (and standard deviation) was 1,070 ± 641 days (range, 0 to 3,060 days). The exclusion criteria were age of <60 years at admission and nonelective THAs or hemiarthroplasties. The cohort was divided into 4 age groups: (1) 60 to 69 years, (2) 70 to 79 years, (3) 80 to 89 years, and (4) ≥90 years. Comorbidities representing independent risk factors for postoperative complications and mortality were identified via a logistic regression model. Mortality rates were compared with those from the general population with data from the Federal Statistical Office. The end points of interest were postoperative major complications, minor complications, and mortality. RESULTS: Among the greatest risk factors for major and minor complications and mortality were congestive heart failure, pulmonary circulation disorders, insulin-dependent diabetes, renal failure, coagulopathy, and fluid and electrolyte disorders. Compared with younger groups, the risks of major and minor complications and mortality were significantly higher in nonagenarians. Mortality increased when major complications occurred. After 1 year, the survival rate in patients without a major complication was 94.4% compared with 79.8% in patients with a major complication. The mortality rates of nonagenarians in the study population were lower than those in the corresponding age group of the general population. The 1-year mortality rates at 90 years of age were 10.5% for men and 6.4% for women within the study group compared with 18.5% for men and 14.7% for women among the general population. CONCLUSIONS: Comorbidities favor the occurrence of complications after elective THA in nonagenarians and thus increase postoperative morbidity. In the case of complications, mortality is also increased. The fact that mortality is still lower than within the general population shows that this aspect can be controlled by careful patient selection and adequate preparation. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

The Prophylactic Effect of Single vs. Dual Antibiotic-Loaded Bone Cement against Periprosthetic Joint Infection Following Hip Arthroplasty for Femoral Neck Fracture: An Analysis of the German Arthroplasty Registry.

BACKGROUND: Antibiotic-loaded bone cement in arthroplasties is currently experiencing increased usage. Therefore, single and double antibiotic-loaded bone cements are commercially available and used in orthopedic surgery. The aim of this investigation was to compare the clinical use of single compared to dual antibiotic-loaded bone cement for implant fixation after femoral neck fracture. Further infection rates were to be compared in (partial) arthroplasty for the treatment of femoral neck fracture for both treatment options. METHODS: On the basis of the German Arthroplasty Registry (EPRD), all cases of femoral neck fracture treated with hemiarthroplasty (HA), or total hip arthroplasty (THA) with single and dual antibiotic-loaded bone cement, were included into the data analysis. The infection risk was compared using Kaplan-Meier estimates. RESULTS: In total, 26,845 cases (HA 76.3%-THA: 23.7%) with femoral neck fracture were included. Within recent years, an increasing usage of dual antibiotic-loaded cement in Germany, with a current proportion of 7.30% in arthroplasty procedures for femoral neck fracture treatment, has been observed. In patients treated with HA, the proportion of dual antibiotic-loaded cement was 7.86%, while in those treated with THA, 5.46% of all prostheses were fixated with a two antibiotic component cement. For all arthroplasty procedures using single antibiotic-loaded bone cement after six months 1.8%, after one year 1.9%, and after five years 2.3%, of the cases failed due to periprosthetic joint infection (PJI), while in the same time period, in cases with dual antibiotic-loaded bone cement 1.5%, 1.5% and 1.5% suffered from infection (p = 0.34). A infection rate of 1.1% after HA with dual antibiotic-loaded bone cement was reported, compared to a 2.1% infection rate whilst using single antibiotic-loaded bone cement after five years (p = 0.098). The number required for treatment when using HA was 91. CONCLUSIONS: The use of dual antibiotic-loaded bone cement is increasingly used in arthroplasty procedures after femoral neck fractures. It demonstrates a reduction of PJI after HA and seems, therefore, to be a useful method for the prevention of infection, especially in patients with increased risk factors for PJI.

Modified acetabular component liner designs are not superior to standard liners at reducing the risk of revision : an analysis of 151,096 cementless total hip arthroplasties from the German Arthroplasty Registry.

AIMS: Registry studies on modified acetabular polyethylene (PE) liner designs are limited. We investigated the influence of standard and modified PE acetabular liner designs on the revision rate for mechanical complications in primary cementless total hip arthroplasty (THA). METHODS: We analyzed 151,096 primary cementless THAs from the German Arthroplasty Registry (EPRD) between November 2012 and November 2020. Cumulative incidence of revision for mechanical complications for standard and four modified PE liners (lipped, offset, angulated/offset, and angulated) was determined using competing risk analysis at one and seven years. Confounders were investigated with a Cox proportional-hazards model. RESULTS: Median follow-up was 868 days (interquartile range 418 to 1,364). The offset liner design reduced the risk of revision (hazard ratio (HR) 0.68 (95% confidence interval (CI) 0.50 to 0.92)), while the angulated/offset liner increased the risk of revision for mechanical failure (HR 1.81 (95% CI 1.38 to 2.36)). The cumulative incidence of revision was lowest for the offset liner at one and seven years (1.0% (95% CI 0.7 to 1.3) and 1.8% (95% CI 1.0 to 3.0)). No difference was found between standard, lipped, and angulated liner designs. Higher age at index primary THA and an Elixhauser Comorbidity Index greater than 0 increased the revision risk in the first year after surgery. Implantation of a higher proportion of a single design of liner in a hospital reduced revision risk slightly but significantly (p = 0.001). CONCLUSION: The use of standard acetabular component liners remains a good choice in primary uncemented THA, as most modified liner designs were not associated with a reduced risk of revision for mechanical failure. Offset liner designs were found to be beneficial and angulated/offset liner designs were associated with higher risks of revision. Cite this article: Bone Joint J 2022;104-B(7):801-810.

Factors influencing periprosthetic femoral fracture risk.

AIMS: Periprosthetic femoral fractures (PPF) are a serious complication of total hip arthroplasty (THA) and are becoming an increasingly common indication for revision arthroplasty with the ageing population. This study aimed to identify potential risk factors for PPF based on an analysis of registry data. METHODS: Cases recorded with PPF as the primary indication for revision arthroplasty in the German Arthroplasty Registry (Endoprothesenregister Deutschland (EPRD)), as well as those classified as having a PPF according to the International Classification of Diseases (ICD) codes in patients' insurance records were identified from the complete datasets of 249,639 registered primary hip arthroplasties in the EPRD and included in the analysis. RESULTS: The incidence of PPFs was higher (24.6%; 1,483) than reported in EPRD annual reports listing PPF as the main reason for revision (10.9%; 654). The majority of fractures occurred intraoperatively and were directly related to the implantation process. Patients who were elderly, female, or had comorbidities were at higher risk of PPFs (p < 0.001). German hospitals with a surgical volume of < 300 primary procedures per year had a higher rate of PPFs (p < 0.001). The use of cemented and collared prostheses had a lower fracture risk PPF compared to uncemented and collarless components, respectively (both p < 0.001). Collared prostheses reduced the risk of PPF irrespective of the fixation method and hospital's surgical volume. CONCLUSION: The high proportion of intraoperative fractures emphasises the need to improve surgeon training and surgical technique. Registry data should be interpreted with caution because of potential differences in coding standards between institutions. Cite this article: Bone Joint J 2021;103-B(4):650-658.