Trends in Revision Hip Arthroplasty for Prosthetic Joint Infection: A Single-Center Study of 423 Hips at a High-Volume Center Between 2008 and 2021.

BACKGROUND: Prosthetic joint infection (PJI) is one of the most devastating complications after total hip arthroplasty (THA), and comorbidities increase the risk. We examined whether there was a temporal change in the demographics, especially regarding comorbidities, of patients who have PJIs and were treated over a 13-year study period at a high-volume academic joint arthroplasty center. In addition, the surgical methods used and the microbiology of the PJIs were assessed. METHODS: Revisions (n = 423, 418 patients) due to PJI of the hip performed at our institution between 2008 and September 2021 were identified. All included PJIs fulfilled the 2013 International Consensus Meeting diagnostic criteria. The surgeries were categorized into one of the following categories: debridement, antibiotics, and implant retention, 1-stage revision, and 2-stage revision. Infections were classified as early, acute hematogenous, and chronic infections. RESULTS: There was no change in the median age of the patients, but the proportion of ASA-class 4 patients increased from 10.5% to 20%. The incidence of early infections increased from 0.11 per 100 primary THAs in 2008 to 1.09 in 2021. The incidence of 1-stage revisions increased the most, rising from 0.10 per 100 primary THAs in 2010 to 0.91 per 100 primary THAs in 2021. Furthermore, the proportion of infections caused by Staphylococcus aureus increased from 26.3% in 2008 to 2009 to 40% in 2020 to 2021. CONCLUSION: The comorbidity burden of PJI patients increased during the study period. This increase may present a treatment challenge, as comorbidities are known to have a negative effect on PJI treatment outcomes.

Congenital anomalies in the offspring of women with total hip replacement: a nationwide register study in Finland.

BACKGROUND: Few previous studies have analysed the possible teratogenic effect of maternal total hip replacement (THR) on congenital anomalies. The aim of this study was to estimate the risk of major congenital anomalies in the offspring of women with THR. Furthermore, we compared the risks based on type of implant (metal-on-metal [MoM]/non-MoM). METHODS: The study population for this register-based cohort study was gathered from six Finnish national registers. All fertile-aged females who underwent THR from 1980 to 2007 and three reference females for each THR patient without THR were selected. THR operation day was the start of the follow-up for both groups. Information on pregnancies, induced abortions (IA) and congenital anomalies was gathered for the years 1987-2007 and the proportions of congenital anomalies were compared. RESULTS: In the THR group, 2429 women had 256 pregnancies, 205 (80.1%) deliveries and 51 (19.9%) IAs. In the reference group, 7276 women had 1670 pregnancies, 1443 (86.4%) deliveries and 236 (13.6%) IAs. There was no difference in the incidence of major anomalies between the THR (3.5%, n = 9) and the reference group (3.6%, n = 60), p = 0.91. In the THR group, there was no difference in the risk of major anomalies between the patients with a MoM-THR (10.5%, 2/19) and those with a non-MoM (2.9%, 7/241) (OR 3.93, 95% confidence interval 0.76-20.2; p = 0.13). CONCLUSIONS: Reassuringly, maternal THR does not appear to increase the risk of major congenital anomalies or pregnancies ending due to suspected foetal anomalies. Studies with larger study populations are needed to further assess the risk of anomalies in the offspring of women having MoM-THR.

No effect of delivery on total hip replacement survival: a nationwide register study in Finland.

Background and purpose - Previous small studies have suggested that delivery does not adversely affect the survivorship of total hip replacement (THR). We investigated whether delivery after primary THR affects hip implant survivorship in a large population-based study sample Patients and methods - In this register-based nationwide cohort study, all women aged 15-45 who underwent primary THR in Finland from 1987 to 2007 were included from the Finnish Arthroplasty Register. Data on deliveries were obtained from the medical birth register. After primary THR, 111 women (133 THRs) delivered and formed the delivery group. In the reference group, 1,878 women (2,343 THRs) had no deliveries. We used Kaplan-Meier analysis with 95% confidence intervals (CI) to study implant survivorship at 6 and 13 years, and Cox multiple regression to assess survival and hazard ratios (HRs), with revision for any reason as an endpoint with adjustment for age, rheumatoid arthritis, and stem and cup fixation. Results - 51 (38%) revisions were recorded in the delivery group and 645 (28%) revisions in the reference group. The 6-year implant survivorship was 91% (CI 85-96) in the delivery group and 88% (CI 87-90) in the reference group. The 13-year survival rates were 50% (CI 39-62) and 61% (CI 59-64). The adjusted HR for revision after delivery was 0.7 (CI 0.4-1.2) in ≤ 6.8 years' follow-up and 1.1 (CI 0.8-1.6) in > 6.8 years' follow-up. Interpretation - Based on the findings in this nationwide study of hip replacement in fertile-aged women, delivery does not seem to decrease THR implant survivorship; women should not be afraid of or avoid becoming pregnant after THR.

Pregnancy outcome in women after total hip replacement: A population-based study.

OBJECTIVE: Only a few small studies have been published on pregnancies after total hip replacement (THR), and they have reported no adverse pregnancy outcomes after THR. The aim of our study was to evaluate whether maternal THR affects pregnancy outcomes on a population-based level. STUDY DESIGN: Data for this nationwide register-based cohort study have been collected from four national registries in Finland from 1980 to 2007. All females who had undergone THR during that period formed the patient group, and three controls for each patient without THR were selected. Patient group comprised 2429 women, 719 (29.6%) of whom had 1190 pregnancies ending in singleton deliveries. Of those births, 986 were before THR and 204 after THR. The control group comprised 7276 women, 2805 (38.6%) of whom had 5112 pregnancies ending in singleton deliveries, 3695 occurred before the index date (time point when THR took place within the patient group) and 1417 after. Logistic regression model was used to analyze univariable and adjusted odds ratios (aOR) for adverse neonatal outcomes after maternal THR compared with controls. Data were adjusted using the following variables: maternal age, smoking, rheumatoid arthritis. RESULTS: Stillbirth was more common in the patient group compared with control group 4 (2.0%) vs 8 (0.6%) p = 0.02. Moreover, neonates in the patient group were more likely to be born preterm (aOR 3.58, p=<0.001), small for gestational age (aOR 2.83, p = 0.006) and low birthweight (aOR 4.79, p=<0.001), compared to control group. Trial of labor more likely ended in emergency cesarean section in the patient group than in the control group 39 (28.9%) vs 150 (11.6%), p=<0.001. Adverse pregnancy outcome was more common after THR also when compared to pregnancies before THR. CONCLUSIONS: Neonates born after maternal total hip replacement have an increased risk of stillbirth, small for gestational age, low birthweight and preterm birth. Trial of labor is more likely to end in emergency cesarean section.

Lower birth rate in patients with total hip replacement.

Background and purpose - There have been few studies on the effect of THR on pregnancy or delivery, and they have mainly been based on small and regional data. We evaluated the birth rate nationwide in patients of fertile age with THR. Patients and methods - This nationwide population-based cohort study was based on registry data on 5,863 Finnish THR patients who had undergone a THR between 1985 and 2006, and who were aged 15-45 years (females) or 15-50 years (males) at the time of THR. The matched reference cohort consisted of 17,575 sex- and age-matched individuals (3 for each patient) who were alive and resident in Finland at the time of the patient's THR. Birth rate and Cox hazard ratios (HRs) with 95% CI for live births were calculated. Results - The birth rate after THR was approximately 20-60% lower in the male and female patient groups than in the reference individuals. The probability of having a live birth after THR was lower in female patients than in reference individuals, in all but the oldest age group (40-45 years). The same phenomenon was seen in male patients in all but the youngest age group (15-19 years). Adjustment for potential confounders increased the probability of THR patients having a live birth compared to reference individuals, but the birth rate was still clearly reduced (in men, adjusted HR =0.80, 95% CI: 0.69-0.92; in women, adjusted HR =0.56, 95% CI: 0.46-0.68). Interpretation - THR has a substantial effect on the birth rate of offspring, in both women and men. THR patients had a lower birth rate and probability of having a child after surgery, even after taking possible confounders into account.

Total knee arthroplasty with an uncemented trabecular metal tibial component: a registry-based analysis.

Previous poor results have kept the appeal of uncemented total knee arthroplasties (TKAs) minimal. We analyzed the mid-term survivorship and reasons for failures of a contemporary uncemented porous tantalum monoblock tibial component nation-wide. During the study period (2003-2010), such tibial components were used in 1143 primary TKAs recorded in the Finnish Arthroplasty Registry. Seven-year survivorship of these TKAs was 100% (95% CI 99-100) with revision for aseptic loosening of the tibial component, and 97% (95% CI 96-98) with revision for any reason as the respective end points. The most common reasons for revisions were instability and prosthetic joint infections. In conclusion, TKAs using an uncemented porous tantalum monoblock tibial component showed excellent mid-term survivorship in a population-based setting.

A review of national shoulder and elbow joint replacement registries.

BACKGROUND: The aim was to review the funding, organization, data handling, outcome measurements, and findings from existing national shoulder and elbow joint replacement registries; to consider the possibility of pooling data between registries; and to consider wether a pan european registry might be feasible. MATERIALS AND METHODS: Web sites, annual reports, and publications from ongoing national registries were searched using Google, PubMed, and links from other registries. Representatives from each registry were contacted. RESULTS: Between 1994 and 2004, 6 shoulder registries and 5 elbow registries were established, and by the end of 2009, the shoulder registries included between 2498 and 7113 replacements and the elbow registries between 267 and 1457 replacements. The registries were initiated by orthopedic societies and funded by the government or by levies on implant manufacturers. In some countries, data reporting and patient consent are required. Completeness is assessed by comparing data with the national health authority. All registries use implant survival as the primary outcome. Some registries use patient-reported outcomes as a secondary outcome. CONCLUSIONS: A registry offers many advantages; however, adequate long-term funding and completeness remain a challenge. It is unlikely that large-scale international registries can be implemented, but more countries should be encouraged to establish registries and, by adopting compatible processes, data could be pooled between national registries, adding considerably to their power and usefulness.

Reconstruction of the trapeziometacarpal joint in inflammatory joint disease using interposition of autologous tendon or poly-L-D-lactic acid implants: a prospective clinical trial.

Interposition arthroplasty with bioreplaceable poly-L-D-lactic acid (PLDLA) implants has yielded promising results in reconstruction of rheumatoid hands. In this prospective clinical study we compared the PLDLA implant arthroplasty (n = 17) with that of tendon interposition (n = 12) for destruction of the trapeziometacarpal joint in arthritic patients. There was no significant difference between the two groups preoperatively. At one-year follow-up, the mean pain and function scores were 5 and 13 in the PLDLA group, and 19 and 43 in the tendon interposition group, respectively. At one-year follow-up the visual analogue scale (VAS) for function of the PLDLA group differed significantly from that of the tendon interposition group (p = 0.03). This difference was not found at three months postoperatively, and disappeared again at two-year follow-up. Otherwise, no significant difference was found between the groups in the pain or function scores, functional tests, or range of movement. Bioreplaceable interposition arthroplasty works at least as well as tendon interposition. The operation is easier.

Reliability of the hip-to-ankle radiograph in determining the knee and implant alignment after total knee arthroplasty.

Hip-to-ankle radiographs have been used to evaluate lower limb alignment before and after total knee arthroplasty. However, earlier studies have inappropriately used correlation to assess the reproducibility of the radiographs. We determined the reliability of the hip-to-ankle radiograph using the Bland-Altman analysis. Two consecutive hip-to-ankle radiographs were obtained in 52 patients (52 knees) after total knee arthroplasty. There was an excellent agreement between mechanical axis angles, tibiofemoral angles, and femoral and tibial component alignment in the two radiographs. There was also an excellent agreement between all intra and interobserver analyses. The hip-to-ankle radiograph appears to be a reliable and reproducible means for determining the alignment of the knee in the coronal plane after total knee arthroplasty. In routine follow-up, the short anteroposterior knee radiograph may provide sufficient information. However, only the hip-to-ankle radiograph provides accurate information on the weightbearing mechanical axis in patients with suspected lower limb malalignment.

Early results of 827 trabecular metal revision shells in acetabular revision.

We evaluated the survival of 827 acetabular revisions with Trabecular Metal Revision Shell using data from a nationwide arthroplasty register. The mean age of the patients was 69.1 years. The 3-year overall survivorship was 92% (95% confidence interval, 88-95), which coincides with earlier reports. Revision rate for aseptic loosening was only 2%. The most common reason for revision was dislocation of the prosthesis with or without malposition of the socket (60%). Age was found to have significant effect on cup survivorship: each additional year in age decreased the risk of revision by 2.4% (95 % confidence interval, 0.1-4.7; P = .044). We found no differences in survival rates between aseptic and septic revisions. Furthermore, sex, diagnosis, and hospital volume did not affect the survival.

Increasing incidence of hip arthroplasty for primary osteoarthritis in 30- to 59-year-old patients.

BACKGROUND AND PURPOSE: The use of hip arthroplasties is evidently increasing, but there are few published data on the incidence in young patients. METHODS: We used data on total and resurfacing hip arthroplasties (THAs and RHAs) from the Finnish Arthroplasty Register and population data from Statistics Finland to analyze the incidences of THA and RHA in patients aged 30-59 years in Finland, for the period 1980 through 2007. RESULTS: The combined incidences of THAs and RHAs among 30- to 59-year-old inhabitants increased from 9.5 per 10(5) inhabitants in 1980 to 61 per 10(5) inhabitants in 2007. Initially, the incidence of THA was higher in women than men, but since the mid-90s the incidences were similar. The incidence increased in all age groups studied (30-39, 40-49, and 50-59 years) but the increase was 6-fold and 36-fold higher in the latter two groups than in the first. The incidence of THA was constant; the increased incidence of overall hip arthroplasty was due to the increasing number of RHAs performed. INTERPRETATION: We have found a steady increase in the incidence of hip arthroplasty in patients with primary hip osteoarthritis in Finland, with an accelerating trend in the past decade, due to an increase in the incidence of RHA. As the incidence of hip osteoarthritis has not increased, the indications for hip arthroplasty appear to have become broader.

Comparison of bioreplaceable interposition arthroplasty with metatarsal head resection of the rheumatoid forefoot.

BACKGROUND: Interposition arthroplasty with bioreplaceable poly-L/D-lactic acid (PLDLA) implants has been studied in Finland with promising results in reconstruction of the rheumatoid hand. We evaluated this material in a series of patients with rheumatoid forefoot deformities. MATERIALS AND METHODS: Thirty-five patients were randomized to either PLDLA metatarsophalangeal joint interposition arthroplasty group (16 patients) or to conventional metatarsal head resection group (19 patients). RESULTS: At 3 months after surgery, the function VAS was significantly better in the control group (p = 0.003). The difference disappeared by 12 months. Otherwise, comparison between the two groups did not reveal any statistically significant differences in the AOFAS scores or the pain VAS at 3 or 12 months. CONCLUSION: Early results after PLDLA interposition arthroplasty of metatarsophalangeal joints were not as promising as previously reported with rheumatoid metacarpophalangeal reconstruction.

Total ankle replacement: a population-based study of 515 cases from the Finnish Arthroplasty Register.

BACKGROUND AND PURPOSE: Although total ankle replacement (TAR) is a recognized procedure for treatment of the painful arthritic ankle, the best choice of implant and the long-term results are still unknown. We evaluated the survival of two TAR designs and factors associated with survival using data from the nationwide arthroplasty registry in Finland. METHODS: 573 primary TARs were performed during the period 1982-2006 because of rheumatic, arthritic, or posttraumatic ankle degeneration. We selected contemporary TAR designs that were each used in more than 40 operations, including the S.T.A.R. (n = 217) and AES (n = 298), to assess their respective survival rates. The mean age of the patients was 55 (17-86) years and 63% of operations were performed in women. Kaplan-Meier analysis and the Cox regression model were used for survival analysis. The effects of age, sex, diagnosis, and hospital volume were also studied. RESULTS: The annual incidence of TAR was 1.5 per 10(5) inhabitants. The 5-year overall survivorship for the whole TAR cohort was 83% (95% CI: 81-86), which agrees with earlier reports. The most frequent reasons for revision were aseptic loosening of one or both of the prosthesis components (39%) and instability (39%). We found no difference in survival rate between the S.T.A.R. and AES designs. Furthermore, age, sex, diagnosis, and hospital volume (< 10 and > 100 replacements in each of 17 hospitals) did not affect the TAR survival. INTERPRETATION: Based on our findings, we cannot conclude that any prosthesis was superior to any other. A high number of technical errors in primary TARs suggests that this low-volume field of implant arthroplasty should be centralized to fewer units.

Total elbow arthroplasty in rheumatoid arthritis: a population-based study from the Finnish Arthroplasty Register.

BACKGROUND AND PURPOSE: Although total elbow arthroplasty (TEA) is a recognized procedure for the treatment of the painful arthritic elbow, the choice of implant is still obscure. We evaluated the survival of different TEA designs and factors associated with survival using data from a nationwide arthroplasty register. METHODS: 1,457 primary TEAs for rheumatoid elbow destruction were performed during 1982 to 2006 in one hospital specialized in the treatment of rheumatoid arthritis (n = 776) and in 19 other hospitals (n = 681). The mean age of the patients was 59 years and 87% of the TEAs were performed in women. We selected different contemporary TEA designs, each used in more than 40 operations including the Souter-Strathclyde (n = 912), i.B.P./Kudo (n = 218), Coonrad-Morrey (n = 164), and NESimplavit/Norway (n = 63) to assess their individual survival rates. Kaplan-Meier analysis and the Cox regression model were used for survival analysis. RESULTS: The most frequent reason for revision was aseptic loosening (47%). We found no differences in survival rates between different TEA designs. We did, however, find a 1.5-fold (95% CI: 1.1-2.1) elevated risk of revision in unspecialized hospitals as compared to the one hospital specialized in treatment of rheumatoid arthritis. In the Souter-Strathclyde subgroup, there was a reduced risk of revision (RR 0.6, p = 0.001) in TEAs implanted over 1994-2006 as compared to those implanted earlier (1982-1993). The 10-year survivorship for the whole TEA cohort was 83% (95% CI: 81-86), which agrees with earlier reports. INTERPRETATION: The influence of implant choice on the survival of TEA is minor compared to hip and knee arthroplasties. Inferior survival rates of the TEAs performed in the unspecialized hospitals demonstrates the importance of proper indications, surgical technique, and postoperative follow-up, and endorses the need for centralization of these operations at specialized units.

Similar results with 21 Kudo and 21 Souter-Strathclyde total elbow arthroplasties in patients with rheumatoid arthritis.

INTRODUCTION: The results of different prostheses used for total elbow arthroplasty (TEA) in rheumatoid arthritis (RA) have been reported in only a few studies. Small differences in survival or function between implants have been reported. We retrospectively evaluated the results of 42 Souter-Strathclyde and Kudo TEAs. MATERIALS AND METHODS: Between 1988 and 1994, 21 consecutive patients with RA and severe elbow destruction underwent a Souter-Strathclyde TEA. Between 1994 and 1998, another group comprising 21 consecutive patients with RA with severe elbow destruction underwent a Kudo TEA. RESULTS: There were six revisions for the groups combined, including four aseptic loosenings, one fracture and one liner wear and metallosis. The 5-year survival for the Souter-Strathclyde and the Kudo were 85% (95% CI 69-100) and 95% (95% CI 85-100), respectively. The difference between the groups was not statistically significant as tested by the Cox regression analysis. The majority of the patients were free of pain at follow-up. More than half of the patients were able to perform only light housekeeping tasks and a considerable proportion even had difficulties in maintaining personal hygiene. The elbow range of motion improved only slightly after the operation. CONCLUSION: Both the Souter-Strathclyde and the Kudo TEAs provide good pain relief in the arthritic elbow leading to high patient satisfaction despite the residual disabilities. Only small differences in the results between the Souter-Strathclyde and the Kudo TEAs were found. More than half of the patients were able to perform only light housekeeping tasks and a considerable proportion even had difficulties in maintaining personal hygiene. The elbow range of motion improved only slightly after the operation.

Outcome after temporary physeal stapling for knee valgus deformity in children with JIA.

INTRODUCTION: Majority of children with secondary knee valgus deformity due to juvenile idiopathic arthritis (JIA) are affected by the polyarthritic disease subtype. Progressive rheumatoid knee destruction in patients with JIA and valgus deformity may necessitate total knee replacement (TKR) at a young age. Temporary physeal arrest is a safe and effective method for correction of knee valgus malalignment prior to closure of the epiphyseal growth plates even during active arthritis. RESULTS: Most of the angular correction achieved in the stapled knees (n = 103) in the present cohort remained the same through the long-term follow-up though in some patients the deformity did recur. The advantages of angular correction prior to possible future TKR include easier soft tissue balancing, diminished bony deformity and less deranged collateral ligaments reducing the need for expensive custom and constrained implants. CONCLUSION: However, the effect of the correction on postponing the early need for TKR is limited.