UNASSIGNED: The aim of this study was to evaluate the development of the worldwide survival rate of primary total hip arthroplasty (THA). The hypothesis was that survival improved over the last decade in worldwide arthroplasty registers.
UNASSIGNED: THA registers were screened in 2022 and compared between different countries with respect to the number of primary implantations per inhabitant, age, fixation type, and survival rate, and compared to similar data from 2009. The data from these reports were analyzed in terms of number, age distribution, and procedure type of primary THAs. Survival curves and a comparative analysis with respect to the development over time were calculated.
UNASSIGNED: We identified nine hip arthroplasty registers that contained sufficient data to be included. A large variation was found in the annual number of primary THA implantations per inhabitant, with more than the factor 4 for all age groups across regions. The procedure type varied strongly as well, e.g. in Sweden, 50% were cemented THAs, whereas in Emilia-Romagna (Italy), 96% of THAs were implanted cementless. We found an improved survival rate of 5%, with 90% of survival after 15 years in the cohorts from 2021 compared to 85% in the cohorts from 2009.
UNASSIGNED: The present study revealed a significant improvement in the survival of THA in worldwide arthroplasty registers within different countries and regions over the period of one decade. We believe that it is safe to state that the success of THA is still rising with respect to this main outcome.

BACKGROUND: The purpose of the study was to gain insight into how clinically relevant improvement in patient-reported outcome measure scores after total hip arthroplasty (THA) and total knee arthroplasty (TKA) may be underestimated or overestimated, we compared patient-reported outcome measure respondents and nonrespondents on their adverse event rates and assessed whether adverse event occurrence was associated with clinically relevant patient-reported outcome measure improvement from those without adverse events.
METHODS: All primary THAs and TKAs performed in 19 Dutch hospitals between January 2017 and December 2019 were included. The hip disability and osteoarthritis outcome score-physical function short form (HOOS-PS) and knee injury and osteoarthritis outcome score-physical function short form (KOOS-PS) were used to assess the physical function after THA and TKA, respectively. Adverse events included 1-year revision, 30-day readmission, 30-day complications, and long (ie, >75th percentile) length of stay. A clinically relevant improvement was defined as at least a 10-point decrease in HOOS-PS and 9 points in KOOS-PS scores. Associations between adverse events and clinically relevant HOOS-PS and KOOS-PS improvement were assessed using binary logistic regression models adjusted for patient characteristics and clustering of patients within hospitals.
RESULTS: There were 20,338 THA and 18,082 TKA procedures included. Adverse events occurred more frequently in HOOS-PS and KOOS-PS nonrespondents than in respondents. The THA patients experiencing revision, complications, or long length of stay were less likely to experience clinically relevant HOOS-PS improvements (odds ratios of 0.11 [0.06 to 0.20], 0.44 [0.30 to 0.63], and 0.66 [0.50 to 0.88], respectively). The TKA patients experiencing revision or long length of stay were less likely to experience clinically relevant KOOS-PS improvements (odds ratios of 0.26 [0.12 to 0.55] and 0.63 [0.50 to 0.80], respectively).
CONCLUSIONS: Clinically relevant HOOS-PS and KOOS-PS improvements are likely overestimated, as nonrespondents had higher adverse event rates which were associated with lower likelihood to achieve clinically relevant HOOS-PS and KOOS-PS improvements.

BACKGROUND: Hip and knee implants can either be fixed without cement, press-fit, or with bone cement. Real-world data from arthroplasty registers, as well as studies provide a broad database for the discussion of cemented versus uncemented arthroplasty procedures.
OBJECTIVE: What does current evidence from international arthroplasty registries and meta-analyses recommend regarding cemented or cementless fixation of hip and knee implants?
METHODS: A recommendation is generated by means of direct data comparison from the arthroplasty registries of eight countries (USA, Germany, Australia, UK, Sweden, Norway, New Zealand, Netherlands), the comparison of 22 review studies and meta-analyses based on registry data, as well as an evaluation of recommendations of healthcare systems from different nations. For this purpose, reviews and meta-analyses were selected where the results were statistically significant, as were the annual reports of the arthroplasty registries that were current at the time of writing.
RESULTS: For knee arthroplasties, long survival time as well as lower risk of revision can be achieved with the support of cemented fixation with antibiotic-loaded bone cement. In patients aged 70 years and older, cemented fixation of hip stem implants significantly reduces risk of intraoperative or postoperative periprosthetic fracture (quadruple). This applies both to elective total hip arthroplasties and to hemiarthroplasty after femoral neck fractures. Antibiotic-loaded bone cement significantly (p = 0.041) reduces the risk of periprosthetic infection, especially in patients with femoral neck fractures.
CONCLUSIONS: Total knee replacement with antibiotic-loaded bone cement is well established internationally and is evidence-based. Registry data and meta-analyses recommend cemented fixation of the hip stem in older patients. In Germany, USA and Australia these evidence-based recommendations still must be transferred to daily practice.
UNASSIGNED: HINTERGRUND: Hüft- und Knieimplantate können entweder zementfrei, press-fit oder mit Knochenzement befestigt werden. Reale Daten aus Endoprothesenregistern sowie Studien bieten eine breite Datenbasis für die Diskussion zwischen zementierten und unzementierten Endoprothesen. ZIEL: Was empfehlen die aktuellen Erkenntnisse aus internationalen Endoprothesenregistern und Metaanalysen zur zementierten oder zementfreien Fixierung von Hüft- und Knieimplantaten?
METHODS: Mittels direktem Datenvergleich aus den Endoprothesenregistern von acht Ländern (USA, Deutschland, Australien, Großbritannien, Schweden, Norwegen, Neuseeland, Niederlande), dem Vergleich von 22 Übersichtsarbeiten und Metaanalysen auf der Basis von Registerdaten sowie einer Auswertung von Empfehlungen von Gesundheitssystemen aus verschiedenen Nationen wird eine Empfehlung generiert. Hierfür wurden Übersichtsarbeiten und Metaanalysen ausgewählt, deren Ergebnisse statistisch signifikant waren, sowie die Jahresberichte der zum Zeitpunkt der Erstellung der Studie aktuellen Endoprothesenregister.
UNASSIGNED: Bei Knieendoprothesen können durch die zementierte Fixierung mit antibiotikahaltigem Knochenzement eine lange Überlebenszeit und ein geringeres Revisionsrisiko erreicht werden. Bei Patienten im Alter von 70 Jahren und älter reduziert die zementierte Fixierung von Hüftschaftimplantaten das Risiko einer intra- oder postoperativen periprothetischen Fraktur signifikant (um das Vierfache). Dies gilt sowohl für elektive Hüfttotalendoprothesen als auch für Hemiarthroplastiken nach Schenkelhalsfrakturen. Antibiotikabelasteter Knochenzement reduziert das Risiko einer periprothetischen Infektion signifikant (p = 0,041), insbesondere bei Patienten mit Schenkelhalsfrakturen.
UNASSIGNED: Die Knietotalendoprothese mit antibiotikahaltigem Knochenzement ist international gut etabliert und evidenzbasiert. Registerdaten und Metaanalysen empfehlen die zementierte Fixierung des Hüftschaftes bei älteren Patienten. In Deutschland, USA und Australien müssen diese evidenzbasierten Empfehlungen noch in die tägliche Praxis übertragen werden.

OBJECTIVE: The primary aim was to assess whether preoperative health-related quality of life (HRQoL) was associated with postoperative mortality following total hip arthroplasty (THA) and knee arthroplasty (KA). Secondary aims were to assess whether patient demographics/comorbidities and/or joint-specific function were associated with postoperative mortality.
METHODS: Patients undergoing THA (n = 717) and KA (n = 742) during a one-year period were identified retrospectively from an arthroplasty register. Patient demographics, comorbidities, Oxford score, and EuroQol five-dimension (EQ-5D) were recorded preoperatively. Patients were followed up for a minimum of seven years and their mortality status was obtained. Cox regression analysis was used to adjust for confounding.
RESULTS: During the study period, 111 patients (15.5%) undergoing THA and 135 patients (18.2%) undergoing KA had died at a mean follow-up of 7.5 years (7 to 8). When adjusting for confounding, the preoperative EQ-5D was associated with postoperative mortality, and for each 0.1 difference in the utility there was an associated change in mortality risk of 6.7% (p = 0.048) after THA, and 6.8% (p = 0.047) after KA. Comorbidities of connective tissue disease (p ≤ 0.026) and diabetes (p ≤ 0.028) were associated with mortality after THA, whereas MI (p ≤ 0.041), diabetes (p ≤ 0.009), and pain in other joints (p ≤ 0.050) were associated with mortality following KA. The preoperative Oxford score was associated with mortality, and for each one-point change in the score there was an associated change in mortality risk of 2.7% (p = 0.025) after THA and 4.3% (p = 0.003) after KA.
CONCLUSIONS: Worse preoperative HRQoL and joint specific function were associated with an increased risk of postoperative mortality. Both HRQoL and joint-specific function decline with longer waiting times to surgery for THA and KA and therefore may result in an increased postoperative mortality risk than would have been expected if surgery had been undertaken earlier.Cite this article: Bone Jt Open 2022;3(12):933-940.

OBJECTIVE: Patients with femoral neck fractures (FNFs) treated with total hip arthroplasty (THA) have an almost ten-fold increased risk of dislocation compared to patients undergoing elective THA. The surgical approach influences the risk of dislocation. To date, the influence of differing head sizes and dual-mobility components (DMCs) on the risk of dislocation has not been well studied.
METHODS: In an observational cohort study on 8,031 FNF patients with THA between January 2005 and December 2014, Swedish Arthroplasty Register data were linked with the National Patient Register, recording the total dislocation rates at one year and revision rates at three years after surgery. The cumulative incidence of events was estimated using the Kaplan-Meier method. Cox multivariable regression models were fitted to calculate adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for the risk of dislocation, revision, or mortality, stratified by surgical approach.
RESULTS: The cumulative dislocation rate at one year was 8.3% (95% CI 7.3 to 9.3) for patients operated on using the posterior approach and 2.7% (95% CI 2.2 to 3.2) when using the direct lateral approach. In the posterior approach group, use of DMC was associated with reduced adjusted risk of dislocation compared to 32 mm heads (HR 0.21 (95% CI 0.07 to 0.68); p = 0.009). This risk was increased with head sizes < 32 mm (HR 1.47 (95% CI 1.10 to 1.98); p = 0.010). Neither DMC nor different head sizes influenced the risk of revision following the posterior approach. Neither articulation was associated with a statistically significantly reduced adjusted risk of dislocation in patients where the direct lateral approach was performed, although this risk was estimated to be HR 0.14 (95% CI 0.02 to 1.02; p = 0.053) after the use of DMC. DMC inserted through a direct lateral approach was associated with a reduced risk of revision for any reason versus THA with 32 mm heads (HR 0.36 (95% CI 0.13 to 0.99); p = 0.047).
CONCLUSIONS: When using a posterior approach for THA in FNF patients, DMC reduces the risk of dislocation, while a non-significant risk reduction is seen for DMC after use of the direct lateral approach. The direct lateral approach is protective against dislocation and is also associated with a lower rate of revision at three years, compared to the posterior approach. Cite this article: Bone Joint J 2022;104-B(7):844-851.

BACKGROUND: The aim of this study was to compare the use of mobile-bearing, fixed-bearing, posterior-stabilized (PS) and medial pivot design to describe epidemiological differences and subsequent outcomes.
METHODS: A systematic literature search was performed using the NORE website to identify the relevant arthroplasty registers. Inclusion criteria were the following: (1) reports had to be publicly available, (2) reports had to be written in German or English language, (3) differentiation between mobile- and fixed-bearing, posterior-stabilized, and if possible, medial pivot designs had to be possible from the present reports, and (4) data had to be reported for at least three consecutive years and the latest report had to be from the year 2020 to retrieve recent data.
RESULTS: Six registries (England and Wales, Australia, Norway, New Zealand, Germany, Switzerland) offered sufficient data according to the inclusion criteria. In all countries, the dominant type of bearing used for total knee arthroplasty (TKA) was fixed-bearing, with percentages ranging from 60.8% to 84.1% in 2018, 63.6% to 85.7% in 2019 and 66.2% to 87.4% in 2020. A large variation was observed concerning mobile-bearing design, which showed a range from 2.8% to 39.2% in 2018, 2.6% to 36.4% in 2019 and 2.9% to 33.8% in 2020. Some variation was found regarding the use of PS TKA, as its percentage frequency ranged from 9.7% to 29.2% in 2018, 9.8% to 29.4% in 2019 and 10.1% to 28.5% in 2020. Medial pivot design had a share of 9.1% in 2018, 8.6% in 2019 and 8.4% in 2020 in Australia, while it only accounted for 1.4% in 2018, 2.1% in 2019 and 2.5% in 2020 in Germany.
CONCLUSIONS: The comparison of arthroplasty registers from England and Wales, Australia, Norway, New Zealand, Germany and Switzerland revealed large differences regarding the application of posterior-stabilized designs, but also common ground considering the overwhelming use of fixed-bearing inserts, which, when inserted correctly, eradicate the potential complication of bearing dislocation. Arthroplasty registers offer a real-world clinical perspective with the aim to improve quality and patient safety.

OBJECTIVE: The aim of this study was to report the incidence of implant-related complications, further operations, and their influence on the outcome in a series of patients who underwent primary reverse total shoulder arthroplasty (RTSA).
METHODS: The prospectively collected clinical and radiological data of 797 patients who underwent 854 primary RTSAs between January 2005 and August 2018 were analyzed. The hypothesis was that the presence of complications would adversely affect the outcome. Further procedures were defined as all necessary operations, including reoperations without change of components, and partial or total revisions. The clinical outcome was evaluated using the absolute and relative Constant Scores (aCS, rCS), the Subjective Shoulder Value (SSV) scores, range of motion, and pain.
RESULTS: The overall surgical site complication rate was 22% (188 complications) in 152 patients (156 RTSAs; 18%) at a mean follow-up of 46 months (0 to 169). The most common complications were acromial fracture (in 44 patients, 45 RTSAs; 5.3%), glenoid loosening (in 37 patients, 37 RTSAs; 4.3%), instability (in 23 patients, 23 RTSAs; 2.7%), humeral fracture or loosening of the humeral component (in 21 patients, 21 RTSAs; 2.5%), and periprosthetic infection (in 14 patients, 14 RTSAs; 1.6%). Further surgery was undertaken in 79 patients (82 RTSAs) requiring a total of 135 procedures (41% revision rate). The most common indications for further surgery were glenoid-related complications (in 23 patients, 23 RTSAs; 2.7%), instability (in 15 patients, 15 RTSAs; 1.8%), acromial fractures (in 11 patients, 11 RTSAs; 1.3%), pain and severe scarring (in 13 patients, 13 RTSAs; 1.5%), and infection (in 8 patients, 8 RTSAs; 0.9%). Patients who had a complication had significantly worse mean rCS scores (57% (SD 24%) vs 81% (SD 16%)) and SSV scores (53% (SD 27%) vs 80% (SD 20%)) compared with those without a complication. If revision surgery was necessary, the outcome was even further compromised (mean rCS score: 51% (SD 23%) vs 63% (SD 23%); SSV score: 4% (SD 25%) vs 61% (SD 27%).
CONCLUSIONS: Although the indications for, and use of, a RTSA are increasing, it remains a demanding surgical procedure. We found that about one in five patients had a complication and one in ten required further surgery. Both adversely affected the outcome. Cite this article: Bone Joint J 2022;104-B(3):401-407.

BACKGROUND: Acromial and scapular spine fractures (ASFs) are known complications following implantation of reverse total shoulder arthroplasty (RTSA). The entity of acromial stress reaction (ASR) without fracture has recently been described. The purpose of this study was to analyze the incidence, radiographic predictors, treatment options, healing rates, and clinical outcomes of ASF and ASR compared with a control group.
METHODS: A total of 854 primary RTSAs were implanted between 2005 and 2018 in a single shoulder unit of a tertiary referral hospital and retrospectively reviewed for the incidence of ASF and ASR. ASR was defined as pain at the acromion or scapular spine after fracture exclusion on computed tomography scans. The ASF group was matched to a control group. Preoperative and postoperative radiographs were analyzed for radiographic predictors of ASF or ASR. The impact of ASF and ASR, operative vs. nonoperative treatment, and fracture union on clinical outcomes (Constant-Murley score [CS], Subjective Shoulder Value [SSV], and range of motion) with a minimum follow-up period of 2 years was analyzed.
RESULTS: A total of 46 ASFs (5.4%) in 44 patients and 44 ASRs (5.2%) in 43 patients were detected at a mean of 16 ± 24 months and 20 ± 23 months postoperatively, respectively. Predictive radiographic factors were an increased critical shoulder angle and lateralization shoulder angle. The overall union rate was 55% (22 of 40) but was significantly higher following operative treatment (9 of 11, 82%) compared with nonoperative treatment (13 of 29, 45%). Patients with ASF or ASR demonstrated inferior clinical outcomes (CS, 44 ± 21 and 48 ± 18; SSV, 52% ± 25% and 57% ± 27%) compared with the control group (CS, 66 ± 14; SSV, 82% ± 22%) independent of bony union or treatment at a mean of 59 ± 33 months (ASF) and 61 ± 38 months (ASR).
CONCLUSIONS: ASF and ASR are frequent complications following RTSA implantation with similar poor clinical outcome measures. The healing rate was shown to be much higher with a surgical approach. Nevertheless, fracture consolidation does not result in better clinical outcomes compared with nonunion.

BACKGROUND: Improved short-term outcomes have been demonstrated with higher surgical volume in shoulder arthroplasty. There is however, little data regarding long-term outcomes.
METHODS: Revision data from the Australian Orthopaedic Association National Joint Replacement Registry from 2004-2017 was analyzed according to 3 selected surgeon volume thresholds: <10, 10-20, and >20 shoulder arthroplasty cases per surgeon, per year.
RESULTS: There was a significantly higher rate of revision for stemmed total shoulder arthroplasty (TSA) for osteoarthritis (OA) for the <10/yr compared with the >20/yr group for the first 1.5 years only (hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.08-1.71, P = .009). For reverse total shoulder arthroplasty (rTSA) performed for OA, there was a higher revision rate for the <10/yr compared with the >20/yr group for the first 3 months only (HR 2.58, 95% CI 1.67-3.97, P < .001). In rTSA for cuff arthropathy, there was a significantly higher rate of revision for the <10/yr compared with the >20/yr group throughout the follow-up period (HR 1.66, 95% CI 1.21-2.28, P = .001). There was no significant difference for the primary diagnosis of fracture.
CONCLUSIONS: Lower surgical volume was associated with higher all-cause revision rates in the early postoperative period in TSA and rTSA for OA and throughout the follow-up period in rTSA for cuff arthropathy. Despite increases in the volume of shoulder arthroplasties performed in recent years, more than 78% of surgeons undertake fewer than 10 procedures per year.

OBJECTIVE: Our aim was to assess the outcome with respect to cumulative revision rates of unicompartmental knee arthroplasty (UKA) by comparing published literature and arthroplasty registry data. Our hypothesis was that there is a superior outcome of UKA described in dependent clinical studies compared to independent studies or arthroplasty registers.
METHODS: A systematic review of all clinical studies on UKA in the past decade was conducted with the main endpoint revision rate. Revision rate was calculated as \"revision per 100 component years (CY)\". The respective data were analysed with regard to a potential difference of the percentage of performed revision surgeries as described in dependent and independent clinical studies. Clinical data were further compared to arthroplasty registers in a systematic search algorithm.
RESULTS: In total, 48 study cohorts fulfilled our inclusion criteria and revealed 1.11 revisions per 100 CY. This corresponds to a revision rate of 11.1% after 10 years. No deviations with regard to revision rates for UKA among dependent and independent clinical literature were detected. Data from four arthroplasty registers showed lower survival rates after 10 years compared to published literature without being significant.
CONCLUSIONS: The outcomes of UKA in dependent and independent clinical studies do not differ significantly and are in line with arthroplasty register datasets. We cannot confirm biased results and the authors recommend the use of UKAs in properly selected patients by experts in their field.