Trends in Incidence of Hip Fracture and Hip Replacement in Denmark, 1996 to 2018.

Importance: The past several decades have witnessed substantial changes in treatments that are particularly relevant for older patients. Objectives: To assess changes in national-level incidence rates of fracture- and musculoskeletal-related (ie, arthritis-related) hip replacement procedures for individuals aged 40 to 104 years over a 23-year period in Denmark. Design, Setting, and Participants: This cohort study used national Danish health registers to include the Danish population aged 40 to 104 years from January 1, 1996, to December 31, 2018. Data were analyzed from May 31, 2022, to February 14, 2024. Main Outcomes and Measures: Age- and period-specific incidence rates of hip fracture and hip replacement stratified on fracture-related vs arthritis-related indication. Results: From 1996 to 2018, a total of 3 664 979 individuals were followed up for a mean (SD) of 14.6 (7.7) years, resulting in a follow-up time of 53 517 861 person-years and 158 982 (first) hip fractures, of which 42 825 involved fracture-related hip replacement procedures. A further 104 422 individuals underwent arthritis-related hip replacement. During the first 2 decades of the 21st century, hip fracture rates declined by 35% to 40% for individuals aged 70 to 104 years, and the proportion of the population undergoing fracture-related hip replacement increased by 50% to 70%, with modest variation across those aged 75 to 99 years. Rates of arthritis-related hip replacements peaked for individuals aged 75 to 79 years, but with the largest relative rate increase (75%-100%) occurring for those aged 80 to 94 years, primarily from 2001 to 2015, whereafter it remained nearly unchanged. The decline in rates of arthritis-related hip replacement after 75 to 79 years of age was gradual and did not suggest an upper age limit for access to arthritis-related hip replacement. Conclusions and Relevance: The findings of this cohort study suggest that during the past several decades in Denmark, the incidence of hip fractures declined by 35% to 40% among patients aged 80 to 104 years, while the proportion receiving fracture-related hip replacement remained relatively constant after 75 years of age. During the first decades of the 21st century, arthritis-related hip replacement incidence increased by 50% to 100% among older patients and stabilized hereafter, with no apparent cutoff age for this type of procedure. These patterns indicate a positive overall trend with declining hip fracture incidence over the last decades in Denmark, and the observed hip replacement incidence suggests that age is currently not a major determining factor guiding this type of surgery.

[Considerable regional differences in patient injuries after primary hip and knee arthroplasty and between orthopedic departments depending on surgical volume]. / Regional skillnad i incidensen av skador efter ledprotesoperation.

Hip and knee arthroplasties are mostly successful procedures; however, patient injuries may occur and should be reported to Löf, the Swedish patient insurance. This study investigated the incidence of patient injuries after primary total hip and knee arthroplasty in the Swedish regions, differences in incidence depending on annual surgical volume, and types of approved injuries. Approved patient injuries were related to the total number of hip and knee arthroplasties registered in the Swedish Arthroplasty Register 2012-2021. The national incidence was 11.4 and 8.1 per 1,000 hip and knee arthroplasties respectively and varied in the regions from 30.4 to 4.9 and 15.4 to 5.4 per 1,000 hip and knee arthroplasties respectively. Orthopedic departments with higher annual volumes of performed arthroplasties had a lower proportion of patient injuries. Infection was the most common patient injury, followed by nerve lesions and mechanical complications. The differences may be due to underreporting and varying quality of care in the regions. A centralization of hip and knee arthroplasties may be beneficial.

Mini-Navigation Utilization in THA Results in Shorter Length of Stay, Increased Home Discharge, and Higher Physical Therapy Mobilization Scores Compared to THA Without Navigation.

BACKGROUND: As volume of total hip arthroplasty (THA) continues to increase, the utilization and availability of in-traoperative advanced technologies to arthroplasty surgeons continues to rise as well. Our primary goal was to determine whether the use of a mini navigation technology extended operative times and secondarily if it affected postoperative outcomes following elective THA. METHODS: A single-institution total joint arthroplasty da-tabase was utilized to identify adult patients who underwent elective THA from 2017 to 2019. Baseline demographic data along with surgical operative time, length of stay (LOS) and discharge disposition were collected. The Activity Measure for Post-Acute Care (AM-PAC) was used to determine physi-cal therapy progress. RESULTS: A total of 1,162 THAs were performed of which 69.1% (803) used navigation while 30.9% (359) did not. Baseline demographics including age, sex, body mass index (BMI), insurance, and smoking status were not statistically different between groups. The operative time was shorter in the navigation group compared to THA without navigation (115.1 vs. 118.9 min, p < 0.0001). Mean LOS was signifi-cantly shorter in the navigation THA group as compared to THA without navigation (2.1 vs. 2.6 days, p < 0.0001). Postoperative AM-PAC scores were higher in the navigation group on postoperative day 1 as compared to patients with-out navigation (18.87 vs. 17.52, p < 0.0001). Additionally, a greater percentage of patients were discharged directly home after THA with navigation as compared to THA without navigation (89.54% vs. 83.57%, p < 0.0001). CONCLUSION: Our study demonstrates that hip navigation technology in the setting of THA is associated with reduced operative times and higher AM-PAC mobilization scores. Hip mini navigation technology shortens operative times while improving early patient outcome scores in association with shorter LOS and greater home-based discharge.

Factors influencing patient selection of orthopaedic surgeons for total hip (THA) and total knee arthroplasty (TKA).

INTRODUCTION: The importance of identifying how patients choose their healthcare providers has grown with the prevalence of consumer-centric health insurance plans. There is currently a lack of studies exploring the factors associated with how patients select their hip and knee joint arthroplasty surgeons. The purpose of this study was to determine how patients find their arthroplasty providers and the relative importance of various arthroplasty surgeon characteristics. METHODS: An electronic mail survey was sent to 3522 patients who had visited our institution for an arthroplasty surgeon office visit between August 2022 and January 2023. The survey consisted of multiple-choice questions, which aimed to inquire about the patients' referral sources for their current arthroplasty surgeon. In addition, patients were requested to rate the significance of 22 surgeon-related factors, on a scale of 1 (Not Important At All) to 5 (Very Important), in choosing their arthroplasty surgeon. RESULTS: Of the 3522 patients that received the survey, 538 patients responded (15.3%). The most common referral sources were physician referral (50.2%), family/friend referral (27.7%), and self-guided research (24.5%). Of those that were referred by a physician, 54.4% of respondents were referred by another orthopaedic provider. Patients rated board certification (4.72 ± 0.65), in-network insurance status (4.66 ± 0.71), fellowship training (4.50 ± 0.81), bedside manner/personality (4.32 ± 0.86), and facility appearance (4.26 ± 0.81) as the five most important factors in picking an arthroplasty surgeon. Television (1.42 ± 0.83), print (1.50 ± 0.88), and online (1.58 ± 0.93) advertisements, along with social media presence (1.83 ± 1.08), and practice group size (2.97 ± 1.13) were rated as the five least important factors. CONCLUSION: Patients are most likely to select an arthroplasty surgeon based on referral from other physicians, namely orthopedic surgeons, in addition to board certification status, in-network insurance, and fellowship training. Overall, these findings highlight the importance of physician credentials and reputation within the orthopaedic community in order to attract and retain patients.

Urgent versus elective surgical disparities among American Indian and Alaska Native patients.

BACKGROUND: American Indian and Alaska Native (AIAN) health issues are understudied despite documentation of lower-than-average life expectancy. Urgent surgery is associated with higher rates of postsurgical complications and postoperative death. We assess whether American Indian and Alaska Native (AIAN) patients in Washington State are at greater risk of requiring urgent rather than elective surgery compared with non-Hispanic Whites (NHW). METHODS: We accessed data for the period 2009-2014 from the Washington State Comprehensive Hospital Abstract Reporting System (CHARS) database, which captures all statewide hospital admissions, to examine three common surgeries that are performed both urgently and electively: hip replacements, aortic valve replacements, and spinal fusions. We extracted patient race, age, insurance status, comorbidity, admission type, and procedures performed. We then constructed multivariable logistic regression models to identify factors associated with use of urgent surgical care. RESULTS: AIAN patients had lower mean age at surgery for all three surgeries compared with NHW patients. AIAN patients were at higher risk for urgent surgery for hip replacements (OR = 1.49, 95% CI 1.19-1.88), spinal fusions (OR = 1.39, 95% CI 1.04-1.87), and aortic valve replacements (OR = 2.06, 95% CI 1.12-3.80). CONCLUSION: AIAN patients were more likely to undergo urgent hip replacement, spinal fusion, and aortic valve replacement than NHW patients. AIAN patients underwent urgent surgery at younger ages. Medicaid insurance conferred higher risks for urgent surgery across all surgeries studied. Further research is warranted to more clearly identify the factors contributing to disparities among AIAN patients undergoing urgent surgery.

Site of Service Disparities Exist for Total Joint Arthroplasty.

BACKGROUND: The rate of outpatient total joint arthroplasty procedures, including those performed at ambulatory surgical centers (ASCs) and hospital outpatient departments, is increasing. The purpose of this study was to analyze if type of insurance is associated with site of service (in-patient vs outpatient) for total joint arthroplasty and adverse outcomes. MATERIALS AND METHODS: We identified patients undergoing unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), or total hip arthroplasty (THA) using Current Procedural Terminology codes in a national administrative claims database. Eligible patients were stratified by type of insurance (Medicaid, Medicare, private). The primary outcome was site of service. Secondary outcomes included general complications, procedural complications, and revision procedures. We evaluated the associations using adjusted multivariable logistic regression models. RESULTS: We identified 951,568 patients for analysis; 46,703 (4.9%) patients underwent UKA, 607,221 (63.8%) underwent TKA, and 297,644 (31.3%) underwent THA. Overall, 9.6% of procedures were outpatient. Patients with Medicaid were less likely than privately insured patients to receive outpatient UKA or THA (UKA: odds ratio [OR], 0.729 [95% CI, 0.640-0.829]; THA: OR, 0.625 [95% CI, 0.557-0.702]) but more likely than patients with Medicare to receive outpatient TKA or THA (TKA: OR, 1.391 [95% CI, 1.315-1.472]; THA: OR, 1.327 [95% CI, 1.166-1.506]). Patients with Medicaid were more likely to experience complications and revision procedures. CONCLUSION: Differences in site of service and complication rates following hip and knee arthroplasty exist based on type of insurance, suggesting a disparity in care. Further exploration of drivers of this disparity is warranted and can inform interventions (eg, progressive value-based payments) to support equity in orthopedic services. [Orthopedics. 2024;47(3):179-184.].

Examining racial disparities in utilization rate and perioperative outcomes following knee and hip arthroplasty.

BACKGROUND: Previous arthroplasty utilization research predominantly examined Black and White populations within the US. This is the first known study to examine utilization and complications in poorly studied minority racial groups such as Asians and Native Hawaiian/Pacific-Islanders (NHPI) as compared to Whites. RESULTS: Data from 3304 primary total hip and knee arthroplasty patients (2011 to 2019) were retrospectively collected, involving 1789 Asians (52.2%), 1164 Whites (34%) and 320 Native Hawaiians/Pacific Islanders (NHPI) (9.3%). The 2012 arthroplasty utilization rates for Asian, White, and NHPI increased by 32.5%, 11.2%, and 86.5%, respectively, by 2019. Compared to Asians, Whites more often underwent hip arthroplasty compared to knee arthroplasty (odds ratio (OR) 1.755; p < 0.001). Compared to Asians, Whites and NHPI more often received total knee compared to unicompartmental knee arthroplasty (White: OR 1.499; NHPI: OR 2.013; p < 0.001). White patients had longer hospitalizations (2.66 days) compared to Asians (2.19 days) (p = 0.005) following bilateral procedures. Medicare was the most common insurance for Asians (66.2%) and Whites (54.2%) while private insurance was most common for NHPI (49.4%). Compared to Asians, economic status was higher for Whites (White OR 0.695; p < 0.001) but lower for NHPI (OR 1.456; p < 0.001). After controlling for bilateral procedures, NHPI had a lower risk of transfusion compared to Asians (OR 0.478; p < 0.001) and Whites had increased risk of wound or systemic complications compared to Asians (OR 2.086; p = 0.045). CONCLUSIONS: Despite NHPI demonstrating a significantly poorer health profile and lower socioeconomic status, contrary to previous literature involving minority racial groups, no significant overall differences in arthroplasty utilization rates or perioperative complications could be demonstrated amongst the racial groups examined.

General anesthesia is not associated with dementia in older adults with osteoarthritis for hip/knee replacements, a national population-based nested case-control study.

BACKGROUND: Dementia is a prevalent neurological condition, yet the relationship between dementia and general anesthesia remains uncertain. The study aimed to explore the association between general anesthesia and dementia using a nationwide population-based database. METHODS: The study extracted data from Taiwan's national health insurance, which encompassed the records of one million insured residents. A total of 59,817 patients aged 65 years and above, diagnosed with osteoarthritis between 2002 and 2010, were included. Among these patients, 3277 individuals with an initial diagnosis of dementia between 2004 and 2013 were matched with non-dementia patients based on age, gender, and the date of osteoarthritis diagnosis. Following a 1:2 random matching, the case group included 2171 patients with dementia, while the control group consisted of 4342 patients without dementia. The data was analyzed using conditional and unconditional logistic regressions. RESULTS: No significant differences in the odds of dementia were found between individuals exposed to general and regional anesthesia during hip/knee replacement surgeries (OR = 1.11; 95%CI: 0.73-1.70), after adjusting for age, sex, and co-morbidities. Similarly, there were no significant differences in the odds of dementia based on different durations of anesthesia exposure (General: <2 h: OR = 0.91, 95%CI = 0.43-1.92; 2-4 h: OR = 1.21, 95%CI = 0.82-1.79; >4 h: OR = 0.39, 95%CI = 0.15-1.01; compared to no exposure. Regional: <2 h: OR = 1.18, 95%CI = 0.85-1.62; 2-4 h: OR = 0.9, 95%CI = 0.64-1.27; >4 h: OR = 0.55, 95%CI = 0.15-1.96; compared to no exposure). Likewise, no significant differences were observed in the odds of dementia based on the number of replacement surgeries (twice: OR = 0.74, 95%CI = 0.44-1.23, compared to once). CONCLUSION: Neither general anesthesia nor regional anesthesia in hip/knee surgery was associated with dementia. Different numbers and durations of anesthesia exposure showed no significant differences in the odds for dementia.

Prevalence of anemia and association with outcome in joint arthroplasty - is there a difference between primary and revision cases?

PURPOSE: Anemia has been shown to be a modifiable pre-operative, patient factor associated with outcome following arthroplasty. The aims of this retrospective study were to (1) ascertain the prevalence of preoperative anemia in patients undergoing primary and revision hip and knee arthroplasty at a tertiary referral center and (2) to test the association with outcome and whether it differs between primary and revision cases. METHODS: All hip and knee primary and revision arthroplasties performed at a Canadian academic, tertiary-care, arthroplasty center between 2012 and 2017 were included in this study. The study group consisted of 5944 patients, of which 5251 were primary Total Hip and Knee Arthroplasties or Hip Resurfacings and 693 were revision arthroplasties (65% hip revisions/35% knee revisions). Anemia was classified as per WHO definition (hemoglobin < 130 g/L for men and < 120 g/L for women). All anemic patients were grouped into mild, moderate or severe anemia. Length-of-stay, perioperative transfusion-rate, 90-day readmission, overall complication rate and reoperation rates were recorded. The effect of preoperative anemia and the effect of severity of the anemia was evaluated through multivariable regression analysis controlling for relevant covariates. RESULTS: Preoperatively, 15% (786/5251) of the primary patients and 47% (322/693) of the revision arthroplasty patients were anemic preoperatively. Anemic revision patients were 3.1 times more likely (95% CI: 1.47-6.33) to obtain blood transfusions during the hospital stay, compared to a 4.9 times higher risk in primary patients. The odds ratio to sustain any postoperative complication if anemic was 1.5 times higher (95% CI: 0.73-3.16) in revision patients and 1.7 in primary cases. In addition, the 90-day readmission rate among both groups was 1.6 times higher in anemic patients. Furthermore, anemic revision patients had a 5.3 days longer length of stay (95% CI: 2.63-7.91), compared to only 1 additional day in anemic primary patients (95% CI: 0.69-1.34). CONCLUSION: In this study cohort, the prevalence of anemia in patients awaiting revision arthroplasty was 3 times higher (46.6%) than in primary arthroplasty patients (18.7%). Preoperative anemia was associated with similarly, inferior outcomes in both groups. To reduce postoperative complications and the "burden" associated with anemia, these findings strongly recommend optimizing the preoperative hemoglobin in all arthroplasty patients. However, revision patients are affected more frequently, and particular attention must therefore be taken to this growing group in the future. LEVEL OF EVIDENCE: Level III.

Experiences with and perception of patient-reported outcome measurement in patients undergoing knee and hip replacement in Germany.

BACKGROUND: Patient-reported outcome measures - PROMs - have been developed to provide an assessment of patients' physical function, symptoms, and health-related quality of life. With patient-centered care becoming increasingly important, several national strategies have been initiated for PROM measurement. However, Germany is only at the beginning of this process. The objective of this study is to assess patients' experience with and perception of completing PROMs in patients undergoing knee and hip replacement in Germany. METHODS: This study used survey data from patients undergoing hip or knee replacement surgery in a hospital in Germany. Before surgery, patients completed a PROMs survey. After at least 6 months, patients were re-contacted to fill in a questionnaire about their experiences with and perception of the PROMs data collection. RESULTS: Most patients either agreed or totally agreed that the time to fill in the questionnaire was appropriate (89%), that the purpose of the PROMs collection was clear (85%), that the questionnaire's content applied to their appointment (73%), and that this systematic assessment was beneficial (81%). The corresponding proportions were 54% for feeling productive while waiting and 50% for feeling that the information in the questionnaire affected the patient-doctor interaction positively. Only few significant associations were found between patient characteristics and the favorability of patients' ratings. There were no significant differences between hip and knee replacement surgery patients regarding the favorability rating on any survey question. CONCLUSIONS: The results of this study suggest that PROMs collection in the context of hip and knee replacement surgery is practicable and partly also perceived beneficial by patients. Orthopedic procedures could serve as a starting point for broader use and routine PROMs collection in Germany.

Understanding the 30-day mortality burden after revision total hip arthroplasty.

BACKGROUND: Revision total hip arthroplasty (THA) is a challenging procedure that burdens the healthcare system. Despite being associated with worse outcomes relative to its primary counterpart, postoperative mortality after revision THA remains ill-defined. The present study aimed to (1) establish the overall 30-day mortality rate after revision THA and (2) explore the mortality rate stratified by age, comorbidity burden, and aseptic versus septic failure. METHODS: The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) database was retrospectively reviewed for all patients who underwent revision THA from 2011 to 2019. A total of 23,501 patients were identified and grouped into mortality (n = 161) and mortality-free (n = 23,340) cohorts. Patient demographics, comorbidities, and aseptic/septic failure were evaluated. RESULTS: The overall 30-day mortality was 0.69%. The mortality rate by age group (normalised per 1000 patients) was 0 (18-39 years [Y]), 0.67 (40-49 Y), 1.10 (50-59 Y), 2.58 (60-69 Y), 6.15 (70-79 Y) 19.32 (80-89 Y), and 58.22 (90+Y) (p < 0.001). The mortality rate by ASA classification (normalised per 1000 patients) was 0 (ASA I), 1.47 (ASA II), 6.94 (ASA III), 45.42 (ASA IV), and 200 (ASA V) (p < 0.001). The 30-day mortality rate for the septic and aseptic cohorts was 1.03% and 0.65%, respectively (p = 0.038). CCI scores (p < 0.001), diabetes (p < 0.001), systematic sepsis (p < 0.001), poor functional status (p < 0.001), BMI < 24.9 kg/m2 (p < 0.001), and dirty/infected wounds (p < 0.001) were all associated with increased mortality risk. CONCLUSIONS: 1 in 145 patients will suffer mortality during the 30 days after revision THA. PJI-related revision THA was associated with 1.5-fold increase in 30-day mortality rate compared to its aseptic counterpart. Certain patient determinants and baseline comorbidities, as measured by ASA and CCI scores, were associated with higher 30-day mortality rates. Therefore, it is imperative to identify such risk factors and implement perioperative patient optimisation pathways to mitigate the risk among vulnerable patients.

Shape of the association between preoperative hemoglobin level and postoperative outcomes in patients undergoing primary arthroplasty.

BACKGROUND: The shape of the association between preoperative hemoglobin level and outcomes after primary arthroplasty has not been adequately described. This study aimed to characterize the association between preoperative hemoglobin level and important outcomes after primary hip and knee arthroplasty and how this association is influenced by other key confounders. METHODS: Using de-identified, population-based health administrative data for Ontario housed at ICES, we identified all primary hip and knee arthroplasty procedures performed in Ontario between April 2007 and March 2017. Preoperative hemoglobin level, age, sex, Charlson Comorbidity Index score, American Society of Anesthesiologists score, preadmission living status, Hospital-patient One-year Mortality Risk (HOMR) score, and serum sodium and creatinine levels were extracted. All relevant postoperative outcomes that could be measured accurately were identified. We performed multivariable logistic regression and restricted cubic splines analyses. RESULTS: A total of 188 176 patients clustered within 532 surgeons were studied. The adjusted likelihood of transfusion increased notably and progressively when the preoperative hemoglobin level was below 135 g/L; duration of surgery, patient age and HOMR score amplified this association. Risk of postoperative admission to critical care showed a linear association with preoperative hemoglobin level. Risks of unplanned 30-day emergency department visit, 30-day readmission and 1-year all-cause mortality showed curvilinear associations with baseline hemoglobin level, with risks being notably greater as the level deviated from 137 g/L to 141 g/L. CONCLUSION: Preoperative hemoglobin levels, both high and low, were independently significantly associated with primary arthroplasty outcomes, and levels at which outcome risks started to increase exceeded threshold values commonly used to define "normal." Preoperative hemoglobin level should be considered in future bundled payment models that aim to account for case-mix when grading postarthroplasty outcomes.

Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons.

BACKGROUND: A survey was conducted at the 2021 Annual Meeting of the American Association of Hip and Knee Surgeons (AAHKS) to evaluate current practice management strategies among AAHKS members. METHODS: An application was used by AAHKS members to answer both multiple-choice and yes or no questions. Specific questions were asked regarding the impact of COVID-19 pandemic on practice patterns. RESULTS: There was a dramatic acceleration in same day total joint arthroplasty with 85% of AAHKS members performing same day total joint arthroplasty. More AAHKS members remain in private practice (46%) than other practice types, whereas fee for service (34%) and relative value units (26%) are the major form of compensation. At the present time, 93% of practices are experiencing staffing shortages, and these shortages are having an impact on surgical volume. CONCLUSION: This survey elucidates the current practice patterns of AAHKS members. The pandemic has had a significant impact on some aspects of practice activity. Future surveys need to monitor changes in practice patterns over time.

Costs of Joint Replacement in Osteoarthritis: A Study Using the National Joint Registry and Clinical Practice Research Datalink Data Sets.

OBJECTIVE: To estimate the costs of primary hip and knee replacement in individuals with osteoarthritis up to 2 years postsurgery, compare costs before and after the surgery, and identify predictors of hospital costs. METHODS: Patients age ≥18 years with primary planned hip or knee replacements and osteoarthritis in England between 2008 and 2016 were identified from the National Joint Registry and linked with Hospital Episode Statistics data containing inpatient episodes. Primary care data linked with hospital outpatient records were also used to identify patients age ≥18 years with primary hip or knee replacements between 2008 and 2016. All health care resource use was valued using 2016/2017 costs, and nonparametric censoring methods were used to estimate total 1-year and 2-year costs. RESULTS: We identified 854,866 individuals undergoing hip or knee replacement. The mean censor-adjusted 1-year hospitalization costs for hip and knee replacement were £7,827 (95% confidence interval [95% CI] 7,813, 7,842) and £7,805 (95% CI 7,790, 7,818), respectively. Complications and revisions were associated with up to a 3-fold increase in 1-year hospitalization costs. The censor-adjusted 2-year costs were £9,258 (95% CI 9,233, 9,280) and £9,452 (95% CI 9,430, 9,475) for hip and knee replacement, respectively. Adding primary and outpatient care, the mean total hip and knee replacement 2-year costs were £11,987 and £12,578, respectively. CONCLUSION: There are significant costs following joint replacement. Revisions and complications accounted for considerable costs and there is a significant incentive to identify best approaches to reduce these.

Female reproductive factors and risk of joint replacement arthroplasty of the knee and hip due to osteoarthritis in postmenopausal women: a nationwide cohort study of 1.13 million women.

OBJECTIVES: Previous studies of the relationships between female reproductive factors and osteoarthritis (OA) have shown conflicting results. In this study, we aimed to explore the relationships between reproductive factors and joint replacement arthroplasty of the knee (TKRA) and hip (THRA) in a large nationwide population-based cohort of postmenopausal Korean women. METHODS: We included 1,134,680 subjects who participated in national health examinations in 2009 in the study. The study outcomes were incident THRA or TKRA due to severe hip or knee OA. The relationships between reproductive factors and THRA or TKRA were evaluated using a multivariable-adjusted proportional hazards model. RESULTS: During a mean follow-up duration of 8.2 years, 1,610 incident THRA cases and 60,670 incident TKRA cases were observed. Later age at menarche, longer breastfeeding, HRT and OC use were associated with increased risk of TKRA for severe knee OA, while later age at menopause and longer reproductive span were associated with decreased risk. With regard to THRA for severe hip OA, later menarche, longer breastfeeding, HRT more than 5 years, and OC use more than 1 year were associated with higher risk. The associations between reproductive factors and severe OA were more pronounced in underweight and younger subjects. CONCLUSION: We found that shorter estrogen exposure was associated with higher risk of TKRA due to severe knee OA, and such associations were more pronounced in underweight and younger subjects. The association between shorter estrogen exposure and THRA was not robust.

Combination use of core decompression for osteonecrosis of the femoral head: A systematic review and meta-analysis using Forest and Funnel Plots.

OBJECTIVE: This study evaluated the efficacy and safety of CD combined with bone marrow stem cells in the treatment of femoral head necrosis by systematic review and meta-analysis. Methodology. PubMed, The Cochrane Library, Embase, CNKI, Google Scholar and MEDLINE, etc. databases were searched for clinical randomized controlled trials (RCTs) comparing core decompression combined with autologous bone marrow mesenchymal stem cells versus core decompression alone in the treatment of femoral head necrosis. The retrieval period is from the establishment of each database to May 20, 2021. After literature was extracted and literature quality was evaluated, meta-analysis was conducted by using RevMan5.3 software. RESULTS: A total of 420 osteonecrosis of the femoral head 452 patients' data were collected from all studies. Compared with the core decompression alone group, the CD combined with bone marrow stem cell showed marked reduction in the Visual analog scale (VAS), enhanced Harris hip score (HHS) at 12 months and 24 months, slowed down the progression of the disease, decreased the number of hips conversed to total hip arthroplasty (THA) in the future. CONCLUSION: Core decompression therapy is a very effective and safe treatment process used for ONFH. Moreover, CD combined autologous bone marrow stem cell transplantation can improve the survival rate of the necrotic head, reduce hip pain and delay the disease progression, the rate of THA postoperatively.

Ten-year survival of ceramic-on-ceramic total hip arthroplasty in patients younger than 60 years: a systematic review and meta-analysis.

BACKGROUND: Total hip arthroplasty (THA) with ceramic-on-ceramic (CoC) was created to minimise wear debris and aseptic loosening. A decade ago, a meta-analysis showed a 10-year survival rate of just 89%. Based on the excellent tribology of the current CoC, significant improvement of implant survivorship is expected. In patients younger than 60, we conducted a meta-analysis to assess 10-year survival and complications after using current primary CoC THA. MATERIALS AND METHODS: PubMed, Scopus, EMBASE, Virtual Health Library, and Cochrane Library were used to scan for published trials that met the inclusion criteria until January 2019. The qualified studies were subjected to a systematic review and proportional analysis, and the randomised controlled trials (RCTs) were included in a comparison meta-analysis. RESULTS: Thirteen studies were included 156 findings. The total number of hips was 2278. Nine studies were cohort, and four were RCTs between ceramic and polyethylene cups. The analysis revealed an average age of 44 years (range 24-54). The 10-year survival 96% (95% CI; 95.4-96.8%), aseptic loosening rate 0.516. (95% CI; 0.265-0.903), ceramic fracture rate 0.620 (95% CI; 0.34-1.034) and squeaking rate 2.687 (95% CI; 1.279-4.593). A comparison meta-analysis revealed the risk ratio (RR) for revision was 0.27 (95% CI; 0.15-0.47), and for aseptic loosening 0.15 (0.03-0.70) favouring CoC, while RR for component fracture was 1.62 (95% CI; 0.27-9.66) favouring the polyethylene. CONCLUSION: In patients under sixty, current CoC THAs are correlated with better 10-year outcomes than before and have high survivorship rates. LEVEL OF EVIDENCE: Level I.

Indirect impact of Covid-19 on hospital care pathways in Italy.

Earlier in 2020, seven Italian regions, which cover 62% of the Italian population, set up the Mimico-19 network to monitor the side effects of the restrictive measures against Covid-19 on volumes and quality of care. To this aim, we retrospectively analysed hospital discharges data, computing twelve indicators of volume and performance in three clinical areas: cardiology, oncology, and orthopaedics. Weekly indicators for the period January-July 2020 were compared with the corresponding average for 2018-2019; comparisons were performed within 3 sub-periods: pre-lockdown, lockdown, and post-lockdown. The weekly trend of hospitalisations for ST-segment elevation myocardial infarction (STEMI) showed a 40% reduction, but the proportion of STEMI patients with a primary PTCA did not significantly change from previous years. Malignant neoplasms surgery volumes differed substantially by site, with a limited reduction for lung cancer (< 20%) and greater declines (30-40%) for breast and prostate cancers. The percentage of timely surgery for femoral neck in the elderly remained constantly higher than the previous 2 years whereas hip and knee replacements fell dramatically. Hospitalisations have generally decreased, but the capacity of a timely and effective response in time-dependent pathways of care was not jeopardized throughout the period. General trends did not show important differences across regions, regardless of the different burden of Covid-19. Preventive and primary care services should adopt a pro-active approach, moving towards the identification of at-risk conditions that were neglected during the pandemic and timely addressing patients to the secondary care system.

Future of total hip arthroplasty with the Metha short stem in modern surgeries.

The aim of the study was to analyse the results of uncemented total hip replacement, using the Metha (metaphyseal) stem. A total of 158 patients (70 females and 88 males) were qualified to the study and submitted to total hip arthroplasty (183 procedures altogether), using the Metha stem. The mean age of the patients on the day of surgery was 51.7 years (the range from 17 to 69 years). The mean follow up period was 9.2 years (the range from 5 to 13.5 years). Preoperative assessments gave poor scores, according to the Merle d'Aubigne and Postel classification, modified by Charnley. The average improvement after surgery, according to the used scale, was 6.9 points. A very good outcome was recorded in 154 cases (84.2%), a good outcome was achieved in 20 cases (10.9%) and a poor outcome was confirmed in 9 cases, while no satisfactory case was observed. Poor outcomes were associated with implant loosening. Extraskeletal ossification was noted in 10 cases (5.5%). According to the Kaplan-Meier estimator, the 10-year survival was 93.2% and 97.3% for the whole implant and the stem alone, respectively. 1. Our follow-up period of more than 9 years on the average, indicates that Metha stems produce excellent clinical and functional results in operated young patients with advanced degenerative changes of the hip joint. 2. Assuming a proper qualification for the procedure, the absence of complications and a correct surgical technique, which is slightly more difficult, when compared to standard stem implantation, the risk of aseptic loosening is fairly negligible.

Association Between Same-Day Discharge Total Joint Arthroplasty and Risk of 90-Day Adverse Events in Patients with ASA Classification of ≥3.

BACKGROUND: Although safety in same-day discharge total joint arthroplasty (TJA) has been reported, findings are limited to healthier patients, specific surgeons, and/or specific institutions. Indications for same-day discharge TJA have expanded to include patients with multiple comorbidities; however, safety in this specific patient population remains unknown. Therefore, we sought to compare the risk of 90-day adverse events in higher-risk patients undergoing same-day discharge versus inpatient TJA. METHODS: The Kaiser Permanente Total Joint Replacement Registry was utilized to conduct a cohort study. All patients with an American Society of Anesthesiologists (ASA) classification of ≥3 who underwent primary elective TJA for osteoarthritis from 2017 through 2018 were identified. The risk of 90-day adverse events (i.e., emergency department visits, unplanned readmissions, complications, and mortality) was evaluated with use of propensity score-weighted Cox proportional hazard regression including noninferiority testing with a margin of 1.10. RESULTS: The cohort included a total of 5,250 patients who underwent total hip arthroplasty and 9,752 patients who underwent total knee arthroplasty, of whom 1,742 (33.2%) and 3,283 (33.7%) had same-day discharge, respectively. Same-day discharge hip arthroplasty was noninferior to an inpatient stay in terms of emergency department visits (hazard ratio [HR], 0.73; 1-sided HR 95% upper bound [UB], 0.84), readmissions (HR, 0.47; 95% UB, 0.61), and complications (HR, 0.63; 95% UB, 0.75); we did not have evidence of noninferiority for mortality (HR, 0.84; 95% UB, 1.97). Same-day discharge knee arthroplasty was noninferior to an inpatient stay in terms of emergency department visits (HR, 0.79; 95% UB, 0.87), readmission (HR, 0.80; 95% UB, 0.95), complications (HR, 0.72; 95% UB, 0.82), and mortality (HR, 0.53; 95% UB, 1.03). CONCLUSIONS: We found that same-day discharge TJA did not increase the risk of emergency department visits, unplanned readmissions, and complications compared with an inpatient stay for higher-risk patients, suggesting that it is possible to expand indications for same-day discharge TJA in the hospital setting while maintaining safety. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.