Mid-term outcomes of the R3™ delta ceramic acetabular system in total hip arthroplasty.

BACKGROUND: Whilst bony fixation of hip replacement has stable solutions, there remains controversy over which bearing best optimizes longevity and function. Ceramic-on-ceramic (CoC) bearing combinations are associated with lower risk of revision due to aseptic loosening and dislocation. Evidence for long-term functional outcomes of modern, 4th generation CoC bearings is limited. The aim of this study was to analyze outcomes and complications of the R3™ Acetabular System (Smith & Nephew, Inc., Cordova, TN, USA) in combination with BIOLOX® Delta ceramic femoral head in patients undergoing primary total hip arthroplasty (THA). METHODS: Between June 2009 and May 2011, 175 patients (178 hips) were enrolled into a prospective, study at 6 sites in Europe and prospectively followed-up at 3 months and 1, 3, 5, and 7 years postoperative. RESULTS: Total WOMAC score improved from 63 (range, 22-91) preoperative to 8 (range, 0-8) at 1-year follow-up and remained unchanged at 7-year follow-up. Modified Harris hip score improved from 45 (range, 10-87) preoperative to 83 (range, 25-100) at 3 months, 91 (range, 42-100) at 1 year, and 92 (range, 46, 100) at 7 years. UCLA Activity Rating Scale score improved from 3.3 (range, 1-8) preoperative to 6.2 (range, 2-8) at 1 year; it marginally declined to 5.8 (range, 3-8) at 7-year follow-up. There were 4 trochanteric fractures and 5 patients died of unrelated reasons. Three hips were revised (2 periprosthetic fractures and 1 subluxation). The 7-year cumulative survival rate was 98.3%. CONCLUSION: Clinical and functional improvements of THA with CoC bearing are maintained at 7 years postoperative. TRIAL REGISTRATION: ClinicalTrials.Gov, NCT03566082 , Registered 10 January 2018-retrospectively registered.

Large head ceramic-on-ceramic bearing in primary total hip arthroplasty: average 3-year follow-up of a multicentre study.

BACKGROUND: Surgeons are increasingly using larger femoral head sizes in total hip arthroplasty (THA) to improve stability and reduce the rate of dislocation, 1 of the leading causes of revision surgery. Large ceramic head sizes up to 48 mm can now be used with monoblock acetabular components. National registries have shown promising results at short-term with large diameter ceramic-on-ceramic THA, with very low revision rates.This study reports on the average 3-year follow up of a press-fit monoblock large diameter acetabular shell with a pre-assembled ceramic liner, with emphasis on the radiographic outcome, complications related to the implantation of the cup, and the patient's clinical outcome. METHODS: 170 hips in 169 patients were reviewed at an average 38 ± 5.8 months following surgery. RESULTS: The radiographic review revealed no acetabular cup loosening, no osteolysis and no cup migration. 1 acetabular cup was revised for malposition. The patient clinical outcome and the satisfaction rate were excellent. At 3 years, 7.1% of patients complained of groin pain and 3.5% spontaneously reported hip joint generated noise. 1 patient sustained a non-recurrent traumatic hip dislocation 2 years post surgery. CONCLUSIONS: New technology should be introduced cautiously on the market. This is especially true for the large diameter ceramic monoblock acetabular component used in this study since it involves a new acetabular component design. At short term, we have not identified new modes of failure with this implant. Longer follow-up is still needed to assess the safety of large ceramic bearing in THA.

Measuring patient empowerment - A systematic review.

OBJECTIVE: The purpose of this systematic review was to identify generic instruments measuring patient empowerment and related concepts and analyse the main content and psychometric properties of these instruments. METHODS: A systematic search was conducted using empowerment and related concepts (enablement, activation, engagement, perceived control) as search terms. The main content of the instruments was analysed by classifying the subscales and items of the elements of empowerment into patient's capacities, patient's knowledge, patient's behaviour and support by others. Psychometric properties were analysed with the criteria of Terwee and colleagues (2007). RESULTS: Thirteen instruments were identified; and out of them, five instruments covered all the four elements used to define of empowerment. Psychometric properties were variable; none of the instruments contained all the evaluated psychometric properties. CONCLUSION: There are generic instruments measuring empowerment and its related concepts. The instruments were heterogeneous in structure and psychometric properties. Empowerment is more wide-ranging and multidimensional than its related concepts. PRACTICE IMPLICATIONS: This review provides knowledge for healthcare professionals and researchers who want to support or evaluate patients' empowerment. With a generic instrument, it is possible to obtain comparable information from diverse patient groups. Further testing of psychometric properties of each instrument is recommended.

Effectiveness of conservative treatment for patellofemoral pain syndrome: A systematic review and meta-analysis.

OBJECTIVE: To evaluate the evidence regarding the effectiveness of conservative treatment in reducing patellofemoral pain. DATA SOURCES: CENTRAL, MEDLINE, CINAHL, and PEDro databases. STUDY SELECTION: Adults with patellofemoral pain, randomized controlled trials only, any conservative treatment compared with placebo, sham, other conservative treatment, or no treatment. Two independent reviewers. DATA EXTRACTION: Data were extracted from the full-text of the articles, based on Cochrane Collaboration recommendations. The outcome of interest was the difference between groups regarding change in pain severity. DATA SYNTHESIS: The majority of studies were underpowered. More than 80% of the 37 trials did not show a clinically significant benefit. Clinically significant effects of different sizes were found for 7 trials (6 studies out of 7 had short follow-ups). These effects were found for: (i) pulsed electromagnetic fields combined with home exercise -33.0 (95% CI -45.2 to -20.8); (ii) hip muscle strengthening -65.0 (95% CI -87.7 to -48.3) and -32.0 (-37.0 to -27.0); (iii) weight-bearing exercise -40.0 (95% CI -49.4 to -30.6); (iv) neuromuscular facilitation combined with aerobic exercise and stretching -60.1 (95% CI -66.9 to -54.5); (v) postural stabilization -24.4 (95% CI -33.5 to -15.3); and (vi) patellar bracing -31.6 (95% CI -35.2 to -28.0). CONCLUSION: There is no evidence that a single treat-ment modality works for all patients with patellofemoral pain. There is limited evidence that some treatment modalities may be beneficial for some subgroups of patients with patellofemoral pain.

Survival of uncemented cups from a single manufacturer implanted from 1985 to 2013: Finnish Arthroplasty Register data.

INTRODUCTION: Total hip arthroplasty (THA) with uncemented implants has been a relatively common procedure in Finland during the recent decades. The most common brand of uncemented implants was chosen for further analysis to study the survivorship of this uncemented cup design in comparison to cemented references. PATIENTS, MATERIALS AND METHODS: Since 1980, The Finnish Arthroplasty Register has collected information on THAs on a national level. This study was based on information of THAs recorded in the Finnish Arthroplasty Register from 1985 to 2013. If patient had undergone bilateral THA, only the first one was included. Altogether, 49,289 THAs were included. RESULTS: The overall 10-year implant survivorship of uncemented implants was 84.3% (95% CI 83.5-85.0%) and of cemented implants 90.6% (90.2-90.0%). The 10-year survival of the contemporary uncemented implants was 90.8% (94.0-95.5%) and 88.5% (84.2-91.7%). The most recently introduced uncemented cup designs had good survivorship rates at 5 years; 10-year survival data are not yet available. CONCLUSIONS: We found that modern uncemented cup designs may provide good long-term survivorship rates comparable with the gold standard of cemented cups. However, polyethylene wear, liner problems and periosthetic osteolysis may still occur, also with modern uncemented acetabular components.

Poor 10-year survivorship of hip resurfacing arthroplasty.

Background and purpose - In a previous registry report, short-term implant survival of hip resurfacing arthroplasty (HRA) in Finland was found to be comparable to that of total hip arthroplasty (THA). Since then, it has become evident that adverse reactions to metal debris (ARMDs) may also be associated with HRA, not only with large-diameter head metal-on-metal THA. The aim of the study was to assess medium- to long-term survivorship of HRA based on the Finnish Arthroplasty Register (FAR). Patients and methods - 5,068 HRAs performed during the period 2001-2013 in Finland were included. Kaplan-Meier survival analysis was used to calculate survival probabilities and their 95% confidence intervals (CIs). Cox multiple regression, with adjustment for age, sex, diagnosis, femoral head size, and hospital volume was used to analyze implant survival of HRA devices with revision for any reason as endpoint. The reference group consisted of 6,485 uncemented Vision/Bimetric and ABG II THAs performed in Finland over the same time period. Results - The 8-year survival, with any revision as an endpoint, was 93% (CI: 92-94) for Birmingham Hip Resurfacing (BHR), 86% (CI: 78-94) for Corin, 91% (CI: 89-94) for ReCap, 92% (CI: 89-96) for Durom, and was 72% (CI: 69-76) for the Articular Surface Replacement (ASR). The 10-year survival, with any revision as an endpoint, for reference THAs was 92% (CI: 91-92) and for all HRAs it was 86% (CI: 84-87%). Female HRA patients had about twice the revision risk of male patients. ASR had an inferior outcome: the revision risk was 4-fold higher than for BHR, the reference implant. Interpretation - The 10-year implant survival of HRAs is 86% in Finland. According to new recommendations from NICE (The National Institute for Health and Care Excellence), an HRA/THA should have a revision rate of 5% or less at 10 years. None of the HRAs studied achieved this goal.

Lower extremity musculoskeletal disorders in nurses: A narrative literature review.

AIMS: The aim of the narrative review was to describe and analyze lower extremity musculoskeletal disorders (MSDs) in nurses and to identify factors associated with these disorders. The ultimate goal was to promote lower extremity health in nurses by recognizing factors that could improve their well-being at work. METHODS: A systematic search on the Medline, CINAHL, and PsychInfo databases was conducted, producing altogether 945 citations, of which 35 were selected for this review. The studies were analyzed by content analysis. RESULTS: Nurses have different MSDs in their lower extremities, with which the knee, foot, and ankle being most commonly affected. These problems are often correlated, and problems in the ankle can first appear as knee problems. CONCLUSIONS: Musculoskeletal disorders in lower extremities and their resulting disability are common within the nursing workforce worldwide, representing a major cause of sick leave absence and often leading to long-term absence.

Is there more than one approach to evaluating the variability of surgeons' performance?

INTRODUCTION: To demonstrate that the variability found to be significant between surgeons' performances within a small group does not necessarily mean that this significance applies to the entire field of that specific type of surgery. It is common for inferences and recommendations for an entire field to be based on the variability within a small group of surgeons. The variability between groups usually remains unknown. METHODS: An analysis of variance was used to assess the statistical significance of the variability among surgeons' performances of a specific type of surgery within the studied sample. The intraclass correlation coefficient was used to investigate how large a segment of this variability can be explained by a surgeon-related factor for the entire surgeon population of a specific field. The topic was illustrated using data obtained from a group of seven surgeons who operated on the penetrating rotator cuff tears of 742 patients. RESULTS: There were statistically significant differences between seven surgeons in the improvement of pain and the range of shoulder joint motion. However, only a small (≤2%) and statistically non-significant part of this variability could be explained by a difference between surgeons when the results were interpolated across the entire population of shoulder surgeons. DISCUSSION AND CONCLUSION: Variability in performance within a group of surgeons performing a specific type of surgery cannot be generalized to include the performance of all surgeons doing the same type of surgery without additional statistical analyses.

Adverse reaction to metal debris after Birmingham hip resurfacing arthroplasty.

BACKGROUND AND PURPOSE: Concern has emerged about local soft-tissue reactions after hip resurfacing arthroplasty (HRA). The Birmingham Hip Resurfacing (BHR) was the most commonly used HRA device at our institution. We assessed the prevalence and risk factors for adverse reaction to metal debris (ARMD) with this device. PATIENTS AND METHODS: From 2003 to 2011, BHR was the most commonly used HRA device at our institution, with 249 implantations. We included 32 patients (24 of them men) who were operated with a BHR HRA during the period April 2004 to March 2007 (42 hips; 31 in men). The mean age of the patients was 59 (26-77) years. These patients underwent magnetic resonance imaging (MRI), serum metal ion measurements, the Oxford hip score questionnaire, and physical examination. The prevalence of ARMD was recorded, and risk factors for ARMD were assessed using logistic regression models. The mean follow-up time was 6.7 (2.4-8.8) years. RESULTS: 6 patients had a definite ARMD (involving 9 of the 42 hips). 8 other patients (8 hips) had a probable ARMD. Thus, there was definite or probable ARMD in 17 of the 42 hips. 4 of 42 hips were revised for ARMD. Gender, bilateral metal-on-metal hip replacement and head size were not factors associated with ARMD. INTERPRETATION: We found that HRA with the Birmingham Hip Resurfacing may be more dangerous than previously believed. We advise systematic follow-up of these patients using metal ion levels, MRI/ultrasound, and patient-reported outcome measures.

The effect of tear size on the treatment outcome of operatively treated rotator cuff tears.

PURPOSE: The aim of this study was to evaluate the relationship between the tear size and the short-term clinical outcome of rotator cuff reconstruction. The hypothesis was that the size of the rotator cuff tear has a direct negative correlation with post-operative clinical outcome. METHODS: Five hundred and seventy-six consecutive shoulders with a primarily arthroscopically treated full-thickness rotator cuff tear were followed up. Rotator cuff tear size (anteroposterior dimension) was measured intraoperatively with an arthroscopic measuring probe. The Constant score was used as an outcome measure and was measured pre-operatively and 1-year post-operatively. RESULTS: Five hundred and sixty-nine patients (99 %) were available for 1-year follow-up. The mean age of patients was 59.6 (SD 9.6) years. There were 225 (40 %) female and 344 (60 %) male patients. The mean size of the rotator cuff tear was 25 mm (SD 18). The mean pre- and post-operative Constant score was 52.3 (SD 17.4) and 74.2 (SD 15.5), respectively (p < 0.0001). The intraoperatively detected tear size correlated significantly with the pre-operative Constant score (r = -0.20, p < 0.0001). Furthermore, there was even stronger and significant correlation between the tear size and the final post-operative Constant score (r = -0.36, p < 0.0001). The correlation was similar between the genders, but the Constant scores were significantly lower in women (p < 0.0001). The lowest scores were detected in tears with infraspinatus tendon involvement. CONCLUSIONS: The size of the rotator cuff tear linearly correlates with the Constant scores both pre- and post-operatively. The outcome of rotator cuff reconstruction is strongly related to the intraoperatively detected tear size. LEVEL OF EVIDENCE: Retrospective comparative register study, Level III.

Conservative treatment or surgery for shoulder impingement: systematic review and meta-analysis.

OBJECTIVE: To investigate the evidence on effectiveness of surgery for shoulder impingement compared with conservative treatment. DATA SOURCES: Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL and Science Citation Index databases were searched in March 2013 unrestricted by date or language. STUDY SELECTION: Controlled randomized (RCT) or quasi-randomized clinical trials comparing surgery and conservative treatment of shoulder impingement were included. DATA EXTRACTION: The methodological quality of each included trial was assessed according to the Cochrane Collaboration's domain-based evaluation framework. DATA SYNTHESIS: Of seven included RCTs, risk of systematic bias was considered to be low for two, high for four, and unclear for one RCT. The random-effect meta-analysis was conducted on four RCTs involving 347 subjects (173 surgically treated cases and 174 controls). There was no significant difference in changes in pain intensity between surgically and conservatively treated subjects (Hedges's g = 0.01 in favor of conservative treatment, 95% CI -0.27 to 0.30). CONCLUSION: Based on the review of seven RCTs, the evidence on effectiveness of surgical or conservative treatment of shoulder impingement was found to be limited. There was, however, moderate evidence that surgical treatment is not more effective than active exercises on reducing pain intensity caused by shoulder impingement. Implications for Rehabilitation Based on the review of seven RCTs, the evidence on effectiveness of surgical or conservative treatment of shoulder impingement was found to be limited. There was moderate evidence that surgical treatment is not more effective than active exercises on reducing pain intensity caused by shoulder impingement. Because of surgery's higher costs and susceptibility for complications compared with costs and risks of conservative treatment, conservative treatment can be recommended as a first choice of treatment of shoulder impingement in first or second grade.

Three metal-on-metal hip replacement devices from the same manufacturer--a short- to mid-term survival.

The aim of this retrospective study was to evaluate short- to mid-term results of three different metal-on-metal hip devices from the same manufacturer. A total of 329 hip operations were performed in a single academic unit between 2004 and 2010 using either Birmingham hip resurfacing or Synergy--Birmingham and Synergy--R3 total hip arthroplasty. The overall survival rate at the end of the follow-up time for Birmingham hip resurfacing was 88%, for Synergy--Birmingham total hip arthroplasty 95%, and for Synergy--R3 total hip arthroplasty 81% (p = 0.036). Five revision operations were performed due to adverse reaction to metal debris. Head sizes > 50 mm had lower revision rates compared to smaller ones. Synergy--R3 had a poor survival already at short-term. The mid-term survival of Birmingham hip resurfacing arthroplasty was inferior compared to previous studies.

Cancer incidence and cause-specific mortality in patients with metal-on-metal hip replacements in Finland.

BACKGROUND AND PURPOSE: Metal-on-metal hip implants have been widely used, especially in the USA, Australia, England and Wales, and Finland. We assessed risk of death and updated data on the risk of cancer related to metal-on-metal hip replacements. PATIENTS AND METHODS: A cohort of 10,728 metal-on-metal hip replacement patients and a reference cohort of 18,235 conventional total hip replacement patients were extracted from the Finnish Arthroplasty Register for the years 2001-2010. Data on incident cancer cases and causes of death until 2011 were obtained from the Finnish Cancer Registry and Statistics Finland. The relative risk of cancer and death were expressed as standardized incidence ratio (SIR) and standardized mortality ratio (SMR). SIR/SIR ratios and SMR/SMR ratios, and Poisson regression were used to compare the cancer risk and the risk of death between cohorts. RESULTS: The overall risk of cancer in the metal-on-metal cohort was not higher than that in the non-metal-on-metal cohort (RR = 0.91, 95% CI: 0.82-1.02). The risk of soft-tissue sarcoma and basalioma in the metal-on-metal cohort was higher than in the non-metal-on-metal cohort (SIR/SIR ratio = 2.6, CI: 1.02-6.4 for soft-tissue sarcoma; SIR/SIR ratio = 1.3, CI: 1.1-1.5 for basalioma). The overall risk of death in the metal-on-metal cohort was less than that in the non-metal-on-metal cohort (RR = 0.78, CI: 0.69-0.88). INTERPRETATION: The overall risk of cancer or risk of death because of cancer is not increased after metal-on-metal hip replacement. The well-patient effect and selection bias contribute substantially to the findings concerning mortality. Arthrocobaltism does not increase mortality in patients with metal-on-metal hip implants in the short term. However, metal-on-metal hip implants should not be considered safe until data with longer follow-up time are available.

Adverse reaction to metal debris after ReCap-M2A-Magnum large-diameter-head metal-on-metal total hip arthroplasty.

BACKGROUND AND PURPOSE: The clinical findings of adverse reaction to metal debris (ARMD) following large-diameter-head metal-on-metal total hip arthroplasty (LDH MoM THA) may include periarticular fluid collections, soft tissue masses, and gluteal muscle necrosis. The ReCap-M2a-Magnum LDH MoM THA was the most commonly used hip device at our institution from 2005 to 2012. We assessed the prevalence of and risk factors for ARMD with this device. METHODS: 74 patients (80 hips) had a ReCap-M2a-Magnum LDH MoM THA during the period August 2005 to December 2006. These patients were studied with hip MRI, serum chromium and cobalt ion measurements, the Oxford hip score questionnaire, and by clinical examination. The prevalence of ARMD was recorded and risk factors for ARMD were assessed using logistic regression models. The mean follow-up time was 6.0 (5.5-6.7) years. RESULTS: A revision operation due to ARMD was needed by 3 of 74 patients (3 of 80 hips). 8 additional patients (8 hips) had definite ARMD, but revision was not performed. 29 patients (32 hips) were considered to have a probable or possible ARMD. Altogether, 43 of 80 hips had a definite, probable, or possible ARMD and 34 patients (37 hips) were considered not to have ARMD. In 46 of 78 hips, MRI revealed a soft tissue mass or a collection of fluid (of any size). The symptoms clicking in the hip, local hip swelling, and a feeling of subluxation were associated with ARMD. INTERPRETATION: ARMD is common after ReCap-M2a-Magnum total hip arthroplasty, and we discourage the use of this device. Asymptomatic patients with a small fluid collection on MRI may not need instant revision surgery but must be followed up closely.