Promoting cemented fixation of the femoral stem in elderly female hip arthroplasty patients and elderly hip fracture patients: a retrospective cohort study from the Norwegian Arthroplasty Register and the Norwegian Hip Fracture Register.

BACKGROUND AND PURPOSE: Uncemented stems increase the risk of revision in elderly patients. In 2018, we initiated a national quality improvement project aiming to increase the proportion of cemented stems in elderly female total hip arthroplasty (THA) and hip fracture hemiarthroplasty (HA) patients. We aimed to evaluate the association of this project on the frequency of cemented stems and the risk of secondary procedures in the targeted population. METHODS: 10,815 THAs in female patients ≥ 75 years in the Norwegian Arthroplasty Register and 19,017 HAs in hip fracture patients ≥ 70 years in the Norwegian Hip Fracture Register performed in 2015-2017 and 2019-2021 at all Norwegian hospitals were included in this retrospective cohort study. The quality improvement project was implemented at 19 hospitals (8,443 patients). 1-year revision risk (THAs) and reoperation risk (HAs) were calculated for uncemented and cemented stems by Kaplan-Meier and Cox adjusted hazard rate ratios (aHRRs) with all-cause revision/reoperation as main endpoint. RESULTS: The use of cemented stem fixation in the targeted population increased from 26% to 80% for THAs and from 27% to 91% for HAs. For THAs, the 1-year revision rate decreased from 3.7% in 2015-2017 to 2.1% in 2019-2021 (aHRR 0.7, 95% confidence interval [CI] 0.5-0.9) at the intervention hospitals. For HAs, the reoperation rate decreased from 5.9% in 2015-2017 to 3.3% in 2019-2021 (aHRR 0.6, CI 0.4-0.8) at the intervention hospitals. CONCLUSION: The quality improvement project resulted in a significant increase in the proportion of cemented stems and reduced risk of secondary procedures for both THAs and HAs.

The Clinical Presentation of Endometriosis and Its Association to Current Surgical Staging.

(1) Despite its high prevalence, the diagnostic delay of endometriosis is still estimated to be about 7 years. The objective of the present study is to understand the symptomatology of endometriosis in patients across various countries and to assess whether the severity of symptoms correlates with the diagnosed stage of disease. (2) An international online survey collected self-reported responses from 2964 participants from 59 countries. Finalization of the questionnaire and its distribution was achieved by cooperation with various organizations and centers around the globe. (3) Chronic pain presentation remarkably increased between Stage 1 and 2 (16.2% and 32.2%, respectively). The prevalence of pain only around and during menstruation was negatively correlated to the stage, presenting with 15.4% and 6.9% in Stages 1 and 4, respectively. Atypical presentation of pain was most commonly reported in stage 4 (11.4%). Pain related solely to triggering factors was the most uncommon presentation of pain (3.2%). (4) Characteristics of pain and quality of life tend to differ depending on the reported stage of the endometriosis. Further research may allow a better stage estimation and identification of patients with alarming symptomatic presentation indicative of a progressive stage, even those that are not yet laparoscopically diagnosed.

COVID-19 pandemic and the consequential effect on patients with endometriosis.

STUDY QUESTION: What was the effect of the coronavirus disease 2019 (COVID-19) pandemic on healthcare and quality of life in those suffering from endometriosis? SUMMARY ANSWER: Our study reveals a clear correlation between the deterioration of the reported physical and mental state and impaired medical care for patients suffering from endometriosis during the COVID-19 pandemic. WHAT IS KNOWN ALREADY: The quality of life of patients suffering from endometriosis is compromised in a variety of aspects. In response to the ongoing COVID-19 pandemic, self-isolation practices aimed at curbing the spread of COVID-19 have severely complicated the availability of proper medical care worldwide. STUDY DESIGN SIZE DURATION: The study involved a cross-sectional international self-reported online survey. Responses were accepted between November 2020 and January 2021. The survey was prepared by the Department of Obstetrics and Gynaecology in a medical university setting. The survey contained 17 questions and was placed online. Cooperation with different endometriosis organizations around the world enabled distribution of the survey through their social media platforms. PARTICIPANTS/MATERIALS SETTING METHODS: The study participants (n = 3024 replies) originated from 59 countries. The questionnaire was created after a literature review and is partially based on the validated quality of life questionnaires, adjusted to the study question. The survey was then translated to 15 other languages following World Health Organization recommendations as closely as possible. Chi-square tests for independence were carried out for the analysis of the two variables: suspension of health services, and the patients mental and physical well-being. MAIN RESULTS AND THE ROLE OF CHANCE: Out of 3024 participants from 59 countries who submitted the questionnaire between November 2020 and January 2021, 2964 (98.01%) provided information that enabled a full analysis. For the 1174 participants who had their medical appointments cancelled, 43.7% (n = 513) reported that their symptoms had been aggravated, and 49.3% (n = 579) reported that their mental state had worsened.In comparison, of the 1180 participants who kept their appointments, only 29.4% (n = 347) stated that their symptoms had been aggravated, and 27.5% (n = 325) stated their mental health had worsened. The results showed that there was a significant link between the reported deterioration of mental and physical wellbeing and impaired medical care (cancellation) (P ≪ 0.001). A total of 610 participants did not have medical appointments scheduled, and these participants followed a similar pattern as the participants who kept their appointments, with 29.0% (n = 177) reporting aggravation of symptoms and 28.2% (n = 172) reporting that their mental state had worsened. LIMITATIONS REASONS FOR CAUTION: Cultural differences among international participants are to be expected and this may have affected how participants from different countries interpreted and answered the questionnaire. Translating the questionnaire into 15 different languages, even though incorporating backwards translation, could possibly lead to different interpretations of given questions, simply based on different wording in the languages. The majority of respondents (around 90%) were from Europe and South America and therefore the findings may not be generalizable to other locations. WIDER IMPLICATIONS OF THE FINDINGS: Further research is needed to assess the true impact and long-term consequences of the COVID-19 pandemic for patients living with endometriosis. STUDY FUNDING/COMPETING INTERESTS: This study received no funding and the authors declare they have no relevant conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.

Kaplan-Meier and Cox Regression Are Preferable for the Analysis of Time to Revision of Joint Arthroplasty: Thirty-One Years of Follow-up for Cemented and Uncemented THAs Inserted From 1987 to 2000 in the Norwegian Arthroplasty Register.

BACKGROUND: Previous studies have suggested that the probability function of 1 minus the Kaplan-Meier survivorship overestimates revision rates of implants and that patient death should be included in estimates as a competing risk factor. The present study aims to demonstrate that this line of thinking is incorrect and is a misunderstanding of both the Kaplan-Meier method and competing risks. METHODS: This study demonstrated the differences, misunderstandings, and interpretations of classical, competing-risk, and illness-death models with use of data from the Norwegian Arthroplasty Register for 15,734 cemented and 7,867 uncemented total hip arthroplasties (THAs) performed from 1987 to 2000, with fixation as the exposure variable. RESULTS: The mean age was higher for patients who underwent cemented (72 years) versus uncemented THA (53 years); as such, a greater proportion of patients who underwent cemented THA had died during the time of the study (47% compared with 29%). The risk of revision at 20 years was 18% for cemented and 42% for uncemented THAs. The cumulative incidence function at 20 years was 11% for cemented and 36% for uncemented THAs. The prevalence of revision at 20 years was 6% for cemented and 31% for uncemented THAs. CONCLUSIONS: Adding death as a competing risk will always attenuate the probability of revision and does not correct for dependency between patient death and THA revision. Adjustment for age and sex almost eliminated differences in risk estimates between the different regression models. In the analysis of time until revision of joint replacements, classical survival analyses are appropriate and should be advocated. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk of total hip arthroplasty after elite sport: linking 3304 former world-class athletes with the Norwegian Arthroplasty Register.

OBJECTIVES: At present, there is no cure for osteoarthritis (OA), but severe hip joint degeneration can require total hip arthroplasty (THA). The literature on OA after elite sport is limited. We hypothesise that elite athletic activity increases the risk of receiving a THA later in life. METHODS: We linked a cohort of former Norwegian world-class athletes (1402 females and 1902 males, active 1936-2006) to the Norwegian Arthroplasty Register (THA performed 1987-2020). We used standardised incidence ratio (SIR), one-minus Kaplan-Meier and relative Cox regression (relative HR, RHR), with 95% CIs, and funnel plots at age 75, to assess THA risk for different sport disciplines, joint impact categories of sport disciplines and sex. The risk of THA for the corresponding general Norwegian population was used as reference. RESULTS: We found an overall increased risk for THA for the former elite athletes (SIR 2.11, 95% CI 1.82 to 2.40) at age 75 years, compared with the general population. THA risk at age 75 years was 11.6% for female athletes and 8.3% for male athletes. SIR was 1.90 (95% CI 1.49 to 2.31) for female and 2.28 (95% CI 1.87 to 2.70) for male athletes. Among males, high joint impact sport disciplines were associated with increased risk compared with low-impact sport disciplines (RHR 1.81, 95% CI 1.06 to 3.08, p=0.029). CONCLUSION: Having been an elite athlete was associated with a doubling of THA risk compared with the general population for both sexes. High joint impact sport disciplines were associated with subsequent THA for male athletes.

Personalized estimation of one-year mortality risk after elective hip or knee arthroplasty for osteoarthritis.

AIMS: To develop and validate patient-centred algorithms that estimate individual risk of death over the first year after elective joint arthroplasty surgery for osteoarthritis. METHODS: A total of 763,213 hip and knee joint arthroplasty episodes recorded in the National Joint Registry for England and Wales (NJR) and 105,407 episodes from the Norwegian Arthroplasty Register were used to model individual mortality risk over the first year after surgery using flexible parametric survival regression. RESULTS: The one-year mortality rates in the NJR were 10.8 and 8.9 per 1,000 patient-years after hip and knee arthroplasty, respectively. The Norwegian mortality rates were 9.1 and 6.0 per 1,000 patient-years, respectively. The strongest predictors of death in the final models were age, sex, body mass index, and American Society of Anesthesiologists grade. Exposure variables related to the intervention, with the exception of knee arthroplasty type, did not add discrimination over patient factors alone. Discrimination was good in both cohorts, with c-indices above 0.76 for the hip and above 0.70 for the knee. Time-dependent Brier scores indicated appropriate estimation of the mortality rate (≤ 0.01, all models). CONCLUSION: Simple demographic and clinical information may be used to calculate an individualized estimation for one-year mortality risk after hip or knee arthroplasty (https://jointcalc.shef.ac.uk). These models may be used to provide patients with an estimate of the risk of mortality after joint arthroplasty. Cite this article: Bone Joint Res 2020;9(11):808-820.