Global Trends in Patellar Resurfacing From 2004 to 2022.

BACKGROUND: International rates of patellar resurfacing in primary total knee arthroplasty (TKA) are highly variable. This study sought to determine how trends in patellar resurfacing rates have changed between 2004 and 2022. In addition, we investigated how modern rates of revision have varied between resurfaced and unresurfaced patellae in primary TKA among national joint registries. METHODS: Data between 2004 and 2022 was obtained either from the publicly available joint registry annual reports, a literature review, or via direct correspondence with registry personnel in Sweden, New Zealand, Australia, the United States, Norway, the United Kingdom, the Netherlands, Switzerland, Canada, and India. Only English language national joint registries or data via direct correspondence with registry administrators were utilized. Additionally, the 10-year cumulative risk of revision TKA with and without patellar resurfacing was pulled from those registries that had this data available. RESULTS: There were persistent differences in the rates of patellar resurfacing among countries. Australia documented a 40% increase in patellar resurfacing rates, while other countries demonstrated modest or little change in resurfacing rates. This may indicate that surgeons are making the decision to resurface based on national TKA revision rates. The average rates of patellar resurfacing in primary TKA ranged from 4% in Sweden to 94% in the United States. Canada, the United States, Australia, and Switzerland documented a lower risk of revision when the patella was resurfaced, while Sweden, conversely, showed a higher risk of revision with resurfacing. CONCLUSIONS: Rates of patellar resurfacing in primary TKA were highly variable among countries, as were rates of change over time. It appears that the optimal patellar resurfacing strategy may depend mostly on unique patient factors and surgeon expertise. Future studies should attempt to elucidate the individual patient characteristics that contribute to increased risks of revision or anterior knee pain to determine who will most benefit from patellar resurfacing in primary TKA.

Primary Total Knee Arthroplasty in Hemophilia and Allied Disorders: Revision Rates and Their Causes.

When patients with hemophilia and allied disorders (von Willebrand disease and other congenital bleeding disorders) do not receive adequate primary hematologic prophylaxis from infancy, their joints will suffer knee joint degeneration; when such joint degeneration becomes very advanced (painful and disabling) despite previous conservative treatment, the only way to alleviate the problem will be to implant a primary total knee arthroplasty (TKA). The literature has shown that twenty years after implantation, 71% of primary TKAs are still functional; on the other hand, 18% have to be revised as a consequence of periprosthetic joint infection (PJI). The main causes of revision total knee arthroplasty are PJI and aseptic loosening (39% each).

No Difference in Revision Rates or Patient-Reported Outcome Measures Between Surgical Approaches for Total Hip Arthroplasty Performed for Femoral Neck Fracture: An Analysis of 5,025 Primary Total Hip Arthroplasties From the New Zealand Joint Registry.

BACKGROUND: Total hip arthroplasty (THA) for femoral neck fracture (FNF) can be performed through different surgical approaches. This study compared the revision rates and patient-reported outcome measures by surgical approach. METHODS: Data from the New Zealand Joint Registry were analyzed for patients undergoing primary THA for FNF from January 2000 to December 2021. A total of 5,025 THAs were performed for FNF; the lateral approach was used in 2,499 (49.7%), the posterior in 2,255 (44.9%), and the anterior in 271 (4.3%). The primary outcome measure was the all-cause revision rate. Secondary outcome measures included revision rates for: dislocation, aseptic femoral component loosening, periprosthetic fracture, and infection. Oxford Hip Scores (OHS) were also collected. Age, sex, body mass index, American Society of Anesthesiologists score, femoral head size, dual mobility use, femoral fixation, and surgeon experience were assessed as potential confounding variables. RESULTS: There was no difference in the revision rates between lateral and posterior (P = .156), lateral and anterior (P = .680), or posterior and anterior (P = .714) approaches. There was no difference in the reasons for revision between the lateral and posterior approaches or 6-month OHS (P = .712). There was insufficient data to compare the anterior approach. CONCLUSIONS: There is no difference in the overall revision rates, reasons for revision, or OHS between the lateral and posterior surgical approaches for THA performed for FNF. Insufficient data on the anterior approach is available for an accurate comparison. LEVEL OF EVIDENCE: Level III.

Risk of revision total knee arthroplasty for patients with prior bariatric surgery or class III obesity.

BACKGROUND: Bariatric surgery (BS) is indicated for select class III obesity patients undergoing total knee arthroplasty (TKA) to reduce obesity-related complications. This study assessed the effect of BS on TKA revision rates compared to the general population and class III obesity patients without a history of BS. METHODS: A national database identified patients who had primary TKA. They were divided into two groups: those with BS prior to TKA and those without. Patients without BS formed two control groups, a matched general population, and a matched class III obese cohort. The BS group was matched with controls based on age, Charlson Comorbidity Index (CCI), gender, and diabetes mellitus. Revision rates were analyzed using Kaplan-Meier survival analysis and hazard ratios (HR), calculated using Cox proportional hazard modeling. RESULTS: 14,292 BS patients were compared to 57,006 matched general population controls, and 19,504 BS patients were compared to 77,846 matched class III obesity control patients. BS patients had a higher risk of 5-year all-cause revision (HR: 1.13; P = 0.014) and revision due to periprosthetic fracture (HR: 1.39; P < 0.001) compared to the general population. Compared to class III obesity controls, BS patients had a lower risk of 5-year revision due to prosthetic joint infection (HR: 0.77; P = 0.001), with no difference in all-cause revision (P = 0.362). CONCLUSION: BS does not reduce all-cause TKA revision risk compared to the general or matched class III obesity population. However, it lowers the risk of revision due to prosthetic joint infection when compared to patients with class III obesity. LEVEL OF EVIDENCE: IV.

No Difference in Revision Rates up to 10 years Following Total Hip Arthroplasty in Patients Who Had Prior Bariatric Surgery When Compared to Patients Who Had Class III Obesity: A Propensity Matched Analysis.

BACKGROUND: There is no clear research showcasing bariatric surgery's (BS's) impact on long-term surgical complications following total hip arthroplasty (THA). Therefore, this study compared the 10-year cumulative incidence and risk of revision following THA in patients who underwent BS when compared to the general population and class III obesity patients who did not undergo BS. METHODS: Patients who underwent elective THA from 2010 to 2021 were identified using an all-payer claims database. Patients who underwent BS prior to THA were separately matched to a control of the general population and those who had class III obesity (body mass index ≥40) by age, sex, Charlson Comorbidity Index, and diabetes using a 1:4 ratio. Kaplan-Meier analyses generated 10-year cumulative incidence rates, and a Cox proportional hazard ratio (HR) model generated HRs and 95% confidence intervals (CIs). RESULTS: When compared to the general control, patients who have a history of BS had an elevated 10-year risk of all-cause revision (HR 1.31, 95% CI: 1.16 to 1.47, P < .001), prosthetic joint infection (HR: 1.62, CI: 1.30 to 2.04; P < .001), mechanical loosening (HR: 1.20, CI: 1.01 to 1.44; P = .040), and dislocation/instability (HR: 1.35, CI: 1.09 to 1.68; P = .007). There was no difference in the 10-year risk of all-cause revision or other indications for revision in the BS cohort compared to the matched class III obesity cohort (P = .142). CONCLUSIONS: Those who underwent BS before THA had comparable 10-year revision rates when compared to those who had class III obesity and higher rates compared to the general population. This suggests BS may not reduce the 10-year surgical risks associated with obesity when compared to a class III obese surgical population.

A comparison of revision rates for stemmed and stemless primary anatomic shoulder arthroplasty with all-polyethylene glenoid components: analysis from the Australian Orthopaedic Association National Joint Replacement Registry.

BACKGROUND: We compared the rate of all-cause revision of 2 classes of primary anatomic shoulder arthroplasty, stemmed (stTSA) and stemless (slTSA), undertaken with cemented all-polyethylene glenoid components. METHODS: A large national arthroplasty registry identified 2 cohort groups for comparison, stTSA and l undertaken for all diagnoses between January 1, 2011, and December 31, 2021. A subanalysis from January 1, 2017, allowed capturing of additional patient demographics including American Society of Anesthesiologists score, body mass index, and glenoid morphology. The cumulative percent revision (CPR) was determined using Kaplan-Meier estimates of survivorship and hazard ratios (HR) from Cox proportional hazard models adjusted for age and gender. RESULTS: Of the 7995 stTSA procedures, the CPR at 9 years was 5.6% (95% confidence interval [CI]: 5.0, 6.4), and for 3156 slTSA procedures, the CPR was 4.4% (95% CI: 3.6, 5.5). There was no significant difference in the rate of revision between the study groups (HR = 0.76 [95% CI: 0.51, 1.14], P = .189, adjusted for age, gender, humeral head size, humeral fixation, bearing surface, glenoid design, and mean surgeon volume [MSV]). There was an increased rate of revision for stTSA and slTSA undertaken with humeral head sizes <44 mm (stTSA <44 mm vs. 44-50 mm, HR = 1.56 [CI: 1.18, 2.08], P = .001; slTSA <44 mm vs. 44-50 mm, HR = 2.08 [CI: 1.32, 3.33], P = .001). MSV as a continuous predictor was not a revision risk to stTSA vs. slTSA, but categorically, a low MSV (<10 stTSA + slTSA cases per annum) was associated with a higher revision rate for stTSA (10-20 cases/yr vs. <10 cases/yr, HR = 0.72 [CI: 0.55, 0.95], P = .019) but was not in slTSA. Revision rates were increased for stTSA with non-crosslinked polyethylene (XLPE) glenoids vs. XPLE after 2 years (HR = 2.20 [CI: 1.57, 3.08], P < .001) but did not significantly differ for slTSA. Metal/XPLE (humeral/glenoid) bearing surface of stTSA rate of revision was not different from each combination of slTSA bearing surface. Instability/dislocation was a revision risk for slTSA vs. stTSA (HR = 1.93 [CI: 1.28, 2.91], P = .001), but from 2017, neither of American Society of Anesthesiologists score, body mass index, and glenoid morphology changed the rate of revision. CONCLUSIONS: Revision rates of stTSA and slTSA did not significantly differ and were associated with humeral head size but not patient characteristics. Surgeon inexperience of anatomic shoulder arthroplasty and non-XLPE glenoids were risk factors for stTSA revision but not slTSA. The metal/XLPE stTSA rate of revision was not found to differ significantly from slTSA regardless of polyethylene or humeral head bearing type. Revision for instability/dislocation was more common for slTSA.

Single center evaluation of outcomes of modular dual mobility liners during revision total hip arthroplasty: A five-year follow-up.

Introduction: Revision total hip arthroplasty (rTHA) is at increased risk for postoperative instability when compared to primary cases, which has been mitigated to some extent with the introduction of dual mobility (DM) reconstructions. These constructs were designed to lower dislocation rates and to improve impingement-free range of motion. As a follow-up to our prior institutional study, we expanded on a cohort of DM reconstructions compared to non-DM constructs. We examined a modular dual mobility system in rTHA to measure loosening of the acetabular component, as well as revision and dislocation rates in comparison to an historical cohort of single articulation prostheses.Materials/Methods: This retrospective cohort study from a single center included 254 patients who underwent rTHA with a dual mobility liner by three fellowship-trained surgeons between January 1, 2014 and December 1, 2019. This was a follow-up to an historical cohort of revisions performed with a single articulation prosthesis (n = 120) from the same surgeons performed between January 1, 2011 and December 23, 2013. The inclusion criteria included consecutively performed rTHAs that had a minimum follow-up of 2 years. We excluded patients who had femoral revisions and head/liner revisions only. The average follow-up in the dual mobility cohort and the single articulation cohort was 5 years (range, 2-10 years) and 2.5 years (range, 1.5-4.3 years), respectively. The primary outcomes were dislocation, aseptic loosening, and re-revision rates. Secondary outcomes were radiographic analyses of cup migration and osteolysis. Results: There were 4 out of 256 (1.6%) dislocations from the dual mobility cohort compared to 7 out of 120 (5.8%), P < 0.001 from the single articulation cohort. The rates of aseptic loosening were 3.2% (8 out of 254) and 4.2% (5 out of 120), P = 0.124, respectively, between the cohorts. The re-revision rate was 5.9% for the DM liners and 8.3% in the control cohort, P = 0.38. Radiographic analyses revealed no cup migration and osteolysis in any of the patients that had no dislocations. Conclusion: The dual mobility articulations in rTHA demonstrated improved results in terms of lower dislocations rates when compared to a single articulation prostheses. Our center uses these articulations for revisions and surgeons should consider the use of these bearings when performing rTHA.

Cementless Compared to Cemented Total Knee Arthroplasty is Associated With More Revisions Within 1 Year of Index Surgery.

Background: Cementless total knee arthroplasties (TKAs) have gained renewed interest due to improved implant designs and lower rates of revision than its cemented counterparts. The purpose of this study was to compare revision rates between cemented vs cementless TKAs within 1 year of primary arthroplasty. Methods: This was a retrospective review from the PearlDiver Patient Record Database. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients who had undergone cemented and cementless TKAs and subsequent surgical revisions. An unadjusted univariate analysis of patient demographics, Charlson Comorbidity Index score, and surgical revisions at 90 days and 1 year after TKA was performed using chi-squared testing. Multivariate logistic regression analyses were subsequently performed for 1-year surgical complications requiring revision. Results: Of 324,508 patients, 312,988 (96.45%) underwent cemented TKAs, and 11,520 (3.55%) underwent cementless TKAs. Patients undergoing cementless TKA tended to be younger than patients undergoing cemented TKA (63.67 ± 9.15 cementless vs 66.22 ± 8.85 cemented, P < .001). Univariate chi-squared testing showed that cementless patients were more likely to require 1-component femoral or tibial revision at 90 days and 1 year, irrigation and debridement at 90 days and 1 year, and arthroscopy with lysis of adhesions at 1 year only. Similar findings were observed for these 3 revision procedures at 1 year after correcting for age, gender, and Charlson Comorbidity Index score using multivariate logistic regression analysis as cementless TKA patients had higher odds ratios for each of the revisions. Conclusions: Small but significant differences were found in surgical revisions among cementless TKAs when compared to cemented TKAs within 1 year of the index procedure.

Postoperative outcomes of total elbow replacement in haemophilic elbow arthropathy: A systematic review.

INTRODUCTION: Total elbow replacement (TER) is a surgical treatment option for haemophilic elbow arthropathy. AIM: To review the outcomes of TER in haemophilic elbow arthropathy. The primary outcome measures were perioperative blood loss, postoperative complications, revision rates and length of hospital stay (LOS). Secondary outcomes were elbow range of motion (ROM), functional outcome scores and the visual analogue pain scale (VAS). MATERIALS AND METHODS: PubMed, Medline, Embase and the Cochrane register were searched conforming to the PRISMA guidelines. Only studies with a minimum postoperative follow-up of 1 year were included. Quality appraisal was performed utilizing the MINORS criteria. RESULTS: One hundred and thirty-eight articles were identified. Following article screening, only seven studies met the inclusion criteria. A total of 51 TERs in 38 patients were performed, with the Coonrad-Morrey prosthesis utilized in 51% of cases. The pooled postoperative complication and revision rates were 49% and 29%, respectively. Surgery-related postoperative mortality was 3.9%. The mean preoperative Mayo elbow performance score (MEPS) was 43 ± 20 whereas the mean postoperative MEPS was 89 ± 6. Mean preoperative VAS was 7.2 ± 1.9 while the mean postoperative VAS was 2.0 ± 1.4. Mean preoperative and postoperative elbow flexion arcs were 54 ± 15 and 91 ± 10 degrees, respectively. Mean preoperative and postoperative forearm rotation arcs were 86 ± 40 and 135 ± 19 degrees, respectively. CONCLUSION: TER for haemophilic elbow arthropathy provides good to excellent improvements in pain and elbow ROM postoperatively. However, the overall complication and revision rates are relatively high, when compared to TER performed for other indications.

Are Short Stems Associated With Higher Fracture Rates and Early Revision Rates in Primary Total Hip Arthroplasty? A Noninferiority Analysis.

BACKGROUND: This study aimed to determine if "short" femoral stems were noninferior to (at least as good as) standard-length stems in regards to 90-day periprosthetic fracture and 1-year revision rates. METHODS: Using the MARCQI implant registry, a retrospective study of statewide data was carried out on 64,084 total hip arthroplasties (THAs) between 2012 and 2017. We noticed an increase in the use of "short" uncemented femoral hip stems during THA. Chi-square tests were used to test homogeneity of categorical variables. The covariates included in the analyses were identified using modern epidemiological methods. A Type I probability of 0.05 was used as the level of statistical significance. Inverse probability of treatment weighting (IPTW) was used to mitigate confounding variables. RESULTS: One hundred and seven stems were implanted by surgeons in the state of Michigan. They were classified according to the Khanuja Classification System as Type 2A (trapezoidal, double-tapered calcar loading, n = 3,281), Type 3 (calcar loading with lateral flare, n = 1,898), and Type 4 (shortened, tapered, conventional, n = 19,580), and were compared to standard-length, type 5, stems (n = 33,322) in regards to the 2 outcomes (periprosthetic fractures and 1-year revision rates). Overall, 1-year revision and the 90-day fracture rates were 1.3% (791/57,853) and 1.1% (631/57,968), respectively. Noninferiority was established for all short stems at the clinical threshold of an odds ratio (OR) of 1.5 with P-values <0.05 for 90-day fractures. In regards to 1-year revision rates, noninferiority was also established for Type 3 and 4 stems (P < .05). CONCLUSION: The increased use of "short stems" in Michigan did not lead to increased 1-year revision or 90-day fracture rates.

Revision surgery following minimally invasive decompression for lumbar spinal stenosis with and without stable degenerative spondylolisthesis: a 5- to 15-year reoperation survival analysis.

OBJECTIVE: Minimally invasive decompression (MID) is an effective procedure for lumbar spinal stenosis (LSS). Long-term follow-up data on reoperation rates are lacking. The objective of this retrospective cohort study was to evaluate reoperation rates in patients with LSS who underwent MID, stratified for degenerative lumbar spondylolisthesis (DLS), with a follow-up between 5 and 15 years. METHODS: All consecutive patients with LSS who underwent MID between 2002 and 2011 were included. All patients had neurogenic claudication from central and/or lateral recess stenosis, without or with up to 25% of slippage (grade I spondylolisthesis), and no obvious dynamic instability on imaging (increase in spondylolisthesis by ≥ 5 mm demonstrated on supine-to-standing or flexion-extension imaging). Reoperation rates defined as any operation on the same or adjacent level were assessed. Revision decompression alone was considered if the aforementioned clinical and radiographic criteria were met; otherwise, patients underwent a minimally invasive posterior fusion. RESULTS: A total of 246 patients (mean age 66 years) were included. Preoperative spondylolisthesis was present in 56.9%. The mean follow-up period was 8.2 years (range 5.0-14.9 years). The reoperation rates in patients with and without spondylolisthesis were 15.7% and 15.1%, respectively; fusion was required in 7.1% and 7.5%, with no significant difference (redecompression only, p = 0.954; fusion, p = 0.546). For decompression only, the mean times to reoperation were 3.9 years (95% CI 1.8-6.0 years) for patients with DLS and 2.8 years (95% CI 1.3-4.2 years) for patients without DLS; for fusion, the mean times to reoperation were 3.1 years (95% CI 1.0-5.3 years) and 3.1 years (95% CI 1.1-5.1 years), respectively. CONCLUSIONS: In highly selected patients with stable DLS and leg-dominant pain from central or lateral recess stenosis, the long-term reoperation rate is similar between DLS and non-DLS patients undergoing MIS decompression.

Outcome of revised metal-on-metal hip arthroplasties: a Dutch arthroplasty register study.

BACKGROUND: Preliminary results of metal-on-metal (MoM) hip arthroplasty were satisfactory, but since 2004 data showed high failure rates. National joint replacement registries are multi-centre databases comprised of thousands of subjects and implants which allow for identifying variables predictive of implant failure. The aim of the current study was to estimate re-revision rates after revision of a primary MoM hip arthroplasty in the Dutch Arthroplasty Register (LROI) and to assess potential predictor variables of re-revision of these MoM hip arthroplasties. METHODS: Eligible procedures were those with a revision for any reason except infection, after an initial primary surgery with a hip resurfacing (HRA) or large-head MoM (LH-MoM) total hip arthroplasty (THA). The probability of re-revision for both types of MoM hip arthroplasty over time was estimated using the cumulative incidence function taking mortality as a competing risk into account. A proportional sub-distribution hazards regression model was used to assess potential predictor variables of re-revision of these MoM hip arthroplasties. RESULTS: A total of 3476 records of revised implants were included, of which 873 (25.2%) were MoM implants. Over the course of follow-up, 101 (11.5%) MoM implants were re-revised. During follow-up 36 (4.3%) patients who received a MoM-implant at primary arthroplasty and a revision afterwards had died. The regression model showed that for primary MoM implants a MoM articulation after revision (HR 2.48; 95% CI 1.53-4.03, p < 0.001), femoral-only revisions (HR 3.20; 95% CI 2.06-4.99, p < 0.001) and periprosthetic fractures (HR 1.98; 95% CI 1.03-3.82, p = 0.042) as reason for the first revision were statistically significant risk factors for re-revision. CONCLUSION: Both types of large-head MoM hip arthroplasties have shown high revision and re-revision rates; risk factors were identified. The outcome of this study can be helpful in managing expectations of patients and orthopaedic surgeons.

The effect of polyethylene thickness on revision rates of contemporary cruciate retaining knee replacements. A registry analysis.

BACKGROUND: An attribute that may influence knee replacement survivorship is tibial polyethylene (PE) insert thickness. Previous studies have suggested thin polyethylene made from ultra-high molecular weight polyethylene (UHMWPE) leads to higher rates of revision surgery. This study aimed to determine if modern polyethylene thickness is associated with altered survivorship of primary total knee arthroplasty (TKA) procedures. METHODS: A retrospective analysis of data from Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) was done on well performing total knee arthroplasty prostheses used in Australia from 1999-2018. Six of the best performing minimally stabilized prostheses were examined and categorized into three PE thickness subgroups: A (≤10 mm), B (11-14 mm) and C (≥15 mm). There were 185,539 TKA procedures, of which 64.3% (n = 119,382) were ≤ 10 mm, 33.5% (n = 62,173) 11-14 mm, and 2.2% (n = 3984) ≥ 15 mm. Differences in revision rates were analysed for all causes, including loosening, wear, and instability. RESULTS: At 14 years, respective cumulative point revision (CPR) was A: 4.8, B: 4.2 and C: 6.0. The thickest polyethylene group (≥15 mm) had a higher rate of revision for any reason compared to both 11-14 mm and ≤ 10 mm groups. When non-XLPE was analysed the ≤ 10 mm group had higher rates of revision compared to the 11-14 mm group, but this difference was not seen with XLPE. CONCLUSION: Higher rates of revision were seen overall in the thicker PE group (≥15 mm). This group also had higher rates of revision for loosening, instability, and infection. The use of a thicker insert may be a sign of surgical complexity, but is associated with increased revision.

Cervical spine degenerative disease is an independent risk factor for increased revision rate following total knee arthroplasty.

INTRODUCTION: The relationship between cervical degenerative pathology and total knee arthroplasty (TKA) revision rates is not well understood. The aim of the study was to determine whether cervical spine degenerative diseases have a role in complications following TKA within 2 years. METHODS: Data were collected from the Humana insurance database using the PearlDiver Patient Records Database from 2007-2017. Patients who had a primary TKA were identified using Current Procedural Terminology (CPT) code 27,447, and patients with degenerative cervical disease were identified using CPT and International Classification of Diseases (ICD) codes. Data on patients' demographics, comorbidities and postoperative complications were recorded and analyzed with univariate and multivariate analysis with significance set at p < 0.05. A Kaplan-Meier analysis was conducted to estimate the 1- and 2-year rates of survival free from revision. RESULTS: A total of 81,873 patients were included in this study. Following multivariate analysis, cervical spine degenerative disease patients were at increased risk of all-cause revision surgery following 1 year (OR: 1.342 95% CI: 1.149-1.569; p < 0.001) and 2 year (OR: 1.338; 95% CI: 1.184-1.512; p < 0.001). At 2 years, patients with cervical spine degenerative disease had a survival rate of 97.7%, while the survival rate was 99.2% among the non-cervical degenerative cohort. CONCLUSIONS: Based on these results, patients with cervical spine degenerative pathology should be counseled that their spinal pathology may impair outcomes following TKA.

Patients Receiving a Primary Unicompartmental Knee Replacement Have a Higher Risk of Revision but a Lower Risk of Mortality Than Predicted Had They Received a Total Knee Replacement: Data From the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man.

BACKGROUND: To determine unicompartmental (UKR) and total knee replacement (TKR) revision rates, compare UKR revision rates with what they would have been had they received TKR instead, and assess subsequent re-revision and 90-day mortality rates. METHODS: Using National Joint Registry data, we estimated UKR and TKR revision and mortality rates. Flexible parametric survival modeling (FPM) was used to model failure in TKR and make estimates for UKR. Kaplan-Meier estimates were used to compare cumulative re-revision for revised UKRs and TKRs. RESULTS: Ten-year UKR revision rates were 2.5 times higher than expected from TKR, equivalent to 70 excess revisions/1000 cases within 10 years (5861 excess revisions in this cohort). Revision rates were 2.5 times higher for the highest quartile volume UKR surgeons compared to the same quartile for TKR and 3.9 times higher for the lowest quartiles respectively. Re-revision rates of revised TKRs (10 years = 17.5%, 95% confidence interval [CI] 16.4-18.7) were similar to revised UKRs (15.2%, 95% CI 13.4-17.1) and higher than revision rates following primary TKR (3.3%, 95% CI 3.1-3.5). Ninety-day mortality rates were lower after UKR compared with TKR (0.08% vs 0.33%) and lower than predicted had UKR patients received a TKR (0.18%), equivalent to 1 fewer death per 1000 cases. CONCLUSION: UKR revision rates were substantially higher than TKR even when demographics and caseload differences were accounted for; however, fewer deaths occur after UKR. This should be considered when forming treatment guidelines and commissioning services. Re-revision rates were similar between revised UKRs and TKRs, but considerably higher than for primary TKR, therefore UKR cannot be considered an intermediate procedure.

Cost-effectiveness analysis of Coblation versus mechanical shaver debridement in patients following knee chondroplasty.

BACKGROUND: To compare costs and outcomes following knee chondroplasty with Coblation versus mechanical shaver debridement (MSD) in patients with grade III articular cartilage lesions of the knee. METHODS: A decision-analytic model was developed to compare costs and outcomes of the two methods from a US payer perspective. We used published clinical data from a single-center randomized clinical trial (RCT) designed to compare outcomes between Coblation and MSD in patients with grade III articular cartilage lesions of the medial femoral condyle. Following primary knee chondroplasty, patients experienced either treatment success (no additional surgery required) or required a revision over the 4 year follow-up period. Costs associated with the initial chondroplasty, physical therapy sessions through the 6 week postoperative period, and revision rates at 4 years post-surgery were estimated using 2018 US Medicare Physician Fee Schedule. Sensitivity analyses including a 10 year time horizon and threshold analyses were performed to test the robustness of the model. RESULTS: The estimated total cost per patient was $4614 and $7886 for Coblation and MSD, respectively, resulting in cost-savings of $3272 in favor of Coblation, making it a dominant strategy because of lower costs and improved clinical outcomes. Threshold analysis showed that Coblation remained dominant even when revision rates were assumed to increase from the base case rate of 14-66%. Sensitivity analyses showed that cost-saving results were insensitive to variations in revision rates, number of physical therapy sessions and the time horizon used. CONCLUSION: Coblation chondroplasty is a cost-saving procedure compared with MSD in the treatment of patients with grade III articular cartilage lesions of the knee.

The effect of implant size difference on patient outcomes and failure after bilateral simultaneous total knee arthroplasty.

BACKGROUND: Proper sizing of femoral and tibial components has been associated with long-term outcomes and survivorship in simultaneous bilateral total knee arthroplasty (SBTKA) and may be a reason for differences in outcomes between knees. The aim of this study compares post-operative outcomes and revision rates in patients undergoing SBTKA with different component sizes. METHODS: A retrospective review was conducted at a single academic institution identifying patients who underwent SBTKA from 2011 to 2019. Inclusion criteria included: primary osteoarthritis, similar pre-operative deformity, and same implant manufacturer. The primary outcome compares pre- and post-op (delta, Δ) Knee Society Score-Knee Score (KSS-KS) and range of motion (ROM) between knees. Secondary outcome measures were all-cause revisions rates, including manipulations under anesthesia and arthroscopy with or without lysis of adhesions. RESULTS: 149 patients were identified who met the inclusion criteria: 128 patients had femoral size difference (FSD) of 0, 138 patients had tibial size difference (TSD) of 0, 21 patients with FSD of 1, and 11 patients with TSD of 1. There was no difference in ΔKSS-KS or ΔROM in patients for any FSD or TSD. Revisions for aseptic loosening were greater for TSD 1 compared to TSD 0 (p < 0.001). No other differences in cause of revision were identified. CONCLUSION: A TSD of 1 may be associated with increased revision rates for aseptic loosening in both smaller and larger sized implants. Surgeons may achieve optimal patient outcomes in SBTKA with proper sized implants through increased awareness of component asymmetry and repeat intraoperative evaluation when asymmetrical measurements occur.

Effect of Functional Endoscopic Sinus Surgery on Outcomes in Chronic Rhinosinusitis​.

PURPOSE OF REVIEW: Chronic rhinosinusitis (CRS) has a significant negative impact on quality of life (QoL). Surgical treatment of CRS is indicated when medical therapy fails to achieve adequate symptom control. This review summarizes the latest information on the outcomes after endoscopic sinus surgery (ESS) with relation to QoL, revision rates, olfaction, absenteeism, asthma control, use of systemic medications, quality of sleep and complications. We also provide an update regarding the factors that can impact outcomes. RECENT FINDINGS: CRS has classically been divided into two phenotypes depending on the presence or absence of nasal polyps. However, this is an oversimplification as many factors impact disease burden and outcome after treatment. It has been demonstrated that in many cases, ESS fails to meet the expectations of the patients. Evidence based patient counselling is key to help surgeons guide their patients in the best possible way to make well-informed decisions. Repeatedly it has been demonstrated that ESS improves QoL, improves olfaction, leads to better asthma control and less use of systemic antibiotics. However, various patient characteristics including phenotype, disease burden, comorbidities, age, gender and surgical technique can influence the outcome after ESSIt is of paramount importance to include a follow-up period when discussing revision rates. Based on available data, the genuine revision rate is probably 15-20% after five to ten years of follow-up. The revision rate is also affected by various factors and comorbidities.

Revision of unicompartmental knee arthroplasty using the in situ referencing technique.

OBJECTIVE: Revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) with the in situ referencing technique aiming to preserve as much ligament function and epi-metaphyseal bone stock as possible. INDICATIONS: Aseptic loosening, progression of osteoarthritis, periprosthetic fracture, periprosthetic infection, arthrofibrosis, polyethylene wear, malalignment, instability, femoro-tibial impingement. CONTRAINDICATIONS: Unexplained pain, localized or systemic active infection (anywhere). SURGICAL TECHNIQUE: Referencing for the tibia and the femur cuts is performed prior to implant removal. The tibial cutting jig and the initial tibial resection level is set in a way that the sawblade just fits under the tibial implant. In case too much bone needs to be removed to achieve flush implant sitting on both the medial and lateral tibia, a step cut needs to be performed to build up the medial defect with an augment. Prior to femoral component removal, rotational alignment is determined and intramedullary referencing for the distal femur osteotomy is performed. Level of constraint and additional tibial stem fixation is chosen according to the amount of bone resected and according to ligament stability. POSTOPERATIVE MANAGEMENT: Sterile dressings and elastic compression bandaging. No limitation of active/passive range of motion. Full weight-bearing or partial weight-bearing for 2 weeks postoperatively in the presence of bone or soft tissue defects. RESULTS: Between 2008 and 2019, 84 patients underwent revision of unicompartmental knee arthroplasty. The mean follow-up was 64 months (range 3-132 months). Implant survival after revision of UKA to TKA was 92% (95% CI = 82-97%) at 5 years of follow-up and 86% (95% CI = 69-93%) at 10 years of follow-up. The mean Oxford knee score was 20.1 (6-39, SD ± 6.5) preoperatively and 30.2 (3-48, SD ± 11.3) postoperatively. The mean visual analogue scale was 6.9 (range 1-10, SD ± 1.8) preoperatively and 3.9 (range 0-9, SD ± 2.6) postoperatively.

Patient-Reported Outcome Measures of Total Knee Arthroplasties for Post-Traumatic Arthritis versus Osteoarthritis: A Short-Term (5- to 10-year) Retrospective Matched Cohort Study.

BACKGROUND: The objective of the study was to compare the patient-reported outcome measures (PROM) of patients with post-traumatic arthritis (PTA) versus patients with osteoarthritis (OA) undergoing total knee arthroplasty (TKA) and compare the rates of revision among these two groups. METHODS: Using a prospectively held institutional registry, we retrospectively reviewed patients ≥60 years of age who underwent unilateral TKA between May 2007 and February 2012. Patients with previous or concomitant diagnosis of inflammatory arthropathy or an initial open fracture were excluded. PTA patients were matched 1:5 with OA patients undergoing TKA. Validated PROMs were recorded at baseline before index TKA and the last follow-up. Reason and time to revision surgery was reported, and survivorship was compared using Kaplan-Meier curves. RESULTS: Seventy-five PTA patients were matched to 375 OA patients. There was no difference between these groups with respect to age (67.7 ± 5.6 vs 67.8 ± 5.5 years; P = .876), body mass index (28.6 ± 5.4 vs 28.7 ± 5.3 kg/m2; P = .948), sex (65.3% vs 65.3% females; P = .999), Charlson Comorbidity Index (21.3% vs 21.3% Index 1-2, P = .999), and time to follow-up (93.0 ± 13.4 vs 88.2 ± 13.7 months; P = .999). No statistically significant difference was found in PROMs at baseline and the last follow-up (P > .05), the rate or time to revision surgery between the two groups (P-value = .635; log-rank test). CONCLUSION: Unlike previous studies, TKA for PTA does not pose lower PROMs or higher revision rates when compared to TKA for OA. These results could help provide surgeons with a frame of reference in terms of expectations for patients with PTA undergoing TKA.