Sex and Biology: Broader Impacts Beyond the Binary.

What are the implications of misunderstanding sex as a binary, and why is it essential for scientists to incorporate a more expansive view of biological sex in our teaching and research? This roundtable will include many of our symposium speakers, including biologists and intersex advocates, to discuss these topics and visibilize the link between ongoing reification of dyadic sex within scientific communities and the social, political, and medical oppression faced by queer, transgender, and especially intersex communities. As with the symposium as a whole, this conversation is designed to bring together empirical research and implementation of equity, inclusion, and justice principles, which are often siloed into separate rooms and conversations at academic conferences. Given the local and national attacks on the rights of intersex individuals and access to medical care and bodily autonomy, this interdisciplinary discussion is both timely and urgent.

A small number of surgeons outside the control-limit: an observational study based on 9,482 cases and 208 surgeons performing primary total hip arthroplasties in western Sweden.

Background and purpose - Feedback programs relating to surgeon levels have been introduced in some orthopedic quality registers around the globe. The aim of an established surgeon feedback program is to help surgeons understand their practice and enable an analysis of their own results. There is no surgeon feedback program in Sweden in the orthopedic quality registers and there is a fear that a feedback system might pinpoint surgeons as poor performers, partly due to patient case mix. As a step prior to the introduction of a future possible feedback program in Sweden, we assessed the variation in the occurrence of adverse events (AE) within 90 days and reoperations within 2 years between surgeons in western Sweden and explored the number of surgeons outside the control-limit following primary total hip arthroplasties (THAs).Patients and methods - Patient data, surgical data, and information on the surgeons, relating to surgeries performed in 2011-2016, were retrieved from 9 publicly funded hospitals in western Sweden. Data from medical hospital records, the Swedish Hip Arthroplasty Register (SHAR) and a regional patient register located in western Sweden were linked to a database. Funnel plots with control-limits based on upper 95% and 99.8% confidence intervals (CI) were used to illustrate the variation between surgeons in terms of the outcome and to explore the number of surgeons outside the control-limit. Both observed and standardized proportions are explored. The definition of surgeons outside the control-limit in the study is a surgeon above the upper 95% CI.Results - The study comprised 9,482 primary THAs due to osteoarthritis performed by 208 surgeons, where 91% of the included primary THAs were performed by orthopedic specialists and 9% by trainees. The mean overall annual volume for all surgeons was 27. The observed overall mean rate for AEs within 90 days for all surgeons was 6.2% (5.8-6.7) and for reoperations within 2 years 1.8% (1.7-2.2). The proportion of surgeons outside the 95% CI was low for both AEs (0-5%) and reoperations within 2 years (0-1%) in 2011-2016. The corresponding numbers were even lower for AEs (0-3%) but similar for reoperations (0-1%) after standardization for differences in case mix. In a sub-analysis when the number of surgeries performed was restricted to more than 10 primary THAs annually to being evaluated, almost half or more of all the surgeons were excluded from the annual analysis. The result of this restriction was that all surgeons outside the control-limit disappeared after standardization for both AEs and reoperations for all the years investigated. Considering the complete period of 6 years, less than 1% (1 high-volume surgeon for AEs and 2 high-volume surgeons for reoperations) after risk adjustments were outside the 95% CI, and no surgeons were outside the 99.8% CI.Interpretation - In a Swedish setting, the variation in surgeon performance, as measured by AEs within 90 days and reoperations within 2 years following primary THA, was small and 3% or less of the surgeons were outside the 95% CI for the investigated years after adjustments for case mix. The risk for an individual surgeon to be regarded as having poor performance when creating surgeon-specific feedback in the SHAR is very low when volume and patient risk factors are considered.

Surgical treatment of Vancouver type B periprosthetic femoral fractures: patient characteristics and outcomes of 1381 fractures treated in Sweden between 2001 and 2011.

AIMS: We investigated patient characteristics and outcomes of Vancouver type B periprosthetic fractures treated with femoral component revision and/or osteosynthesis. PATIENTS AND METHODS: The study utilized data from the Swedish Hip Arthroplasty Register (SHAR) and information from patient records. We included all primary total hip arthroplasties (THAs) performed in Sweden since 1979, and undergoing further surgery due to Vancouver type B periprosthetic femoral fracture between 2001 and 2011. The primary outcome measure was any further reoperation between 2001 and 2013. Cross-referencing with the National Patient Register was performed in two stages, in order to identify all surgical procedures not recorded on the SHAR. RESULTS: Out of 1381 Vancouver type B fractures that fulfilled the inclusion criteria, 257 underwent further reoperation by the end of 2013. Interprosthetic and Type B1 fractures had a higher risk for reoperation. For B1 fractures, the rate of reoperation did not differ (p = 0.322) after use of conventional (26%) or locking plate osteosynthesis (19%). No significant differences were observed between cemented, cementless monoblock, and cementless modular revision components for the treatment of type B2 and B3 fractures. CONCLUSION: In this country-specific study, the choice of locking or conventional plates for the treatment of type B1, and cemented or cementless femoral components fixation for B2 and B3 fractures, had no significant influence on risk for reoperation. Interprosthetic fractures adversely affected the outcome of treatment of type B fractures. Differences in the patient characteristics of the compared groups were observed. Cite this article: Bone Joint J 2019;101-B:1447-1458.

Lower reoperation rate with locking plates compared with conventional plates in Vancouver type C periprosthetic femoral fractures: A register study of 639 cases in Sweden.

AIM: To investigate demographics and outcomes of Vancouver type C periprosthetic femoral fractures (PPFF) treated with open reduction and internal fixation. METHODS: Patient data were obtained from medical charts of cases reported to the Swedish Hip Arthroplasty Register and/or from the National Patient Register. Vancouver type C fractures undergoing surgery between 2001 and 2011, in patients who had received their primary THR between 1979 and 2011, were included. Any further reoperation performed between 2001 and 2013 and related to the PPFF constituted the primary outcome. RESULTS: A total of 632 patients with 639 Vancouver type C fractures were identified. The majority of the patients were women (84%) and they had a fracture distal to a cemented stem (95%). The mean age at the time of fracture was 72 years. Treatment was performed with a locking plate (363 cases), a conventional plate (184 cases), an intramedullary nail (62 cases), or with double plating (30 cases). The overall reoperation rate was 17%, and mortality within one year of the operation was 16%. Locking plates had a significantly lower reoperation rate than conventional plates (p<0.001) and intramedullary nailing (p = 0.005). Interprosthetic femoral fractures did not have a statistically different outcome compared with non-IPFFs. CONCLUSIONS: The lowest reoperation rate was observed using locking plates in Vancouver type C fractures when compared with conventional plates or intramedullary nailing. The presence of an ipsilateral knee prosthesis did not influence the outcome of the surgical treatment.

High annual surgeon volume reduces the risk of adverse events following primary total hip arthroplasty: a registry-based study of 12,100 cases in Western Sweden.

Background and purpose - Most earlier publications investigating whether annual surgeon volume is associated with lower levels of adverse events (AE), reoperations, and mortality are based on patient cohorts from North America. There is also a lack of adjustment for important confounders in these studies. Therefore, we investigated whether higher annual surgeon volume is associated with a lower risk of adverse events and mortality within 90 days following primary total hip arthroplasty (THA). Patients and methods - We collected information on primary total hip arthroplasties (THA) performed between 2007 and 2016 from 10 hospitals in Western Sweden. These data were linked with the Swedish Hip Arthroplasty Register and a regional patient register. We used logistic regression (simple and multiple) adjusted for age, sex, comorbidities, BMI, fiation technique, diagnosis, surgical approach, time in practice as orthopedic specialist and annual volume. Annual surgeon volume was calculated as the number of primary THAs the operating surgeon had performed 365 days prior to the index THA. Results - 12,100 primary THAs, performed due to both primary and secondary osteoarthritis by 268 different surgeons, were identified. The median annual surgeon volume was 23 primary THAs (range 0-82) 365 days prior to the THA of interest and the mean risk of AE within 90 days was 7%. If the annual volume increased by 10 primary THAs in the simple logistic regression the risk of AE decreased by 10% and in the adjusted multiple regression the corresponding number was 8%. The mortality rate in the study was low (0.2%) and we could not find any association between 90-day mortality and annual surgeon volume. Interpretation - High annual surgical activity is associated with a reduced risk of adverse events within 90 days. Based on these findings healthcare providers should consider planning for increased surgeon volume.

The design of the cemented stem influences the risk of Vancouver type B fractures, but not of type C: an analysis of 82,837 Lubinus SPII and Exeter Polished stems.

Background and purpose - In total hip replacements, stem design may affect the occurrence of periprosthetic femoral fracture. We studied risk factors for fractures around and distal to the 2 most used cemented femoral stems in Sweden. Patients and methods - This is a register study including all standard primary Lubinus SPII and Exeter Polished stems operated in Sweden between 2001 and 2009. The outcome was any kind of reoperation due to fracture around (Vancouver type B) or distal to the stem (Vancouver type C), with use of age, sex, diagnosis at primary THR, and year of index operation as covariates in a Cox regression analysis. A separate analysis of the primary osteoarthritis patient group was done in order to evaluate eventual influence of the surgical approach (lateral versus posterior) on the risk for Vancouver type B fractures. Results - The Exeter stem had a 10-times (95% CI 7-13) higher risk for type B fractures, compared with the Lubinus, while no statistically significant difference was noticed for type C fractures. The elderly, and patients with hip fracture or idiopathic femoral head necrosis, had a higher risk for both fracture types. Inflammatory arthritis was a risk factor only for type C fractures. Type B fractures were more common in men, and type C in women. A lateral approach was associated with decreased risk for Type B fracture. Interpretation - Stem design influenced the risk for type B, but not for type C fracture. The influence of surgical approach on the risk for periprosthetic femoral fracture should be studied further.

Incidence and demographics of 1751 surgically treated periprosthetic femoral fractures around a primary hip prosthesis.

INTRODUCTION: Periprosthetic femoral fractures (PPFF), treated surgically, have been recorded in the Swedish Hip Arthroplasty Register (SHAR) since 1979. It is postulated that fractures treated with other methods other than stem revision have a lower registration rate, which may lead to incomplete registry data and thus, inaccurate information. We collected all PPFFs surgically treated in Sweden between 2001 and 2011 with the purpose of studying the annual incidence, demographics and distribution of fracture types with regard to type of fixation. METHODS: Data was linked between the SHAR and the National Patient Register (NPR) in order to detect even those PPFFs not reported to the SHAR. Fractures were classified according to the Vancouver classification system, based on information collected from the medical charts. This procedure was validated with observer variation analysis compared to fracture classification based on radiographs. In total 1751 first-time PPFFs around primary conventional stems were included. RESULTS: The incidence of PPFF increased from about 1.0 per 1000 primary THRs to 1.4. Vancouver type C fractures (37% of all fractures) were more common than previously reported, and more common in cemented than in uncemented stems. The 3 most common stem designs involved were Exeter polished, Lubinus SPII, and Charnley (66.3% of all stems), partly reflecting their occurrence in the Swedish THR population. DISCUSSION: The incidence of PPFFs has increased in Sweden during the period 2001 to 2011. The improved reporting of type C fractures, after data-linking, revealed an almost 4 times higher incidence compared to previous register studies in Sweden.

Does surgeon experience affect patient-reported outcomes 1 year after primary total hip arthroplasty?

Background and purpose - Several studies have reported on the influence of various factors on patient-reported outcomes (PROs) after total hip arthroplasty (THA), but very few have focused on the experience of the surgeon. We investigated any association between surgeons' experience and PROs 1 year after primary THA. Patients and methods - Patient characteristics and surgical data at 10 hospitals in western Sweden were linked with PROs (EQ-5D-3L, Satisfaction Visual Analogue Scale (VAS), Pain VAS). These data were retrieved from the Swedish Hip Arthroplasty Register (SHAR). The surgeon's level of experience was divided into 4 subgroups related to experience: < 8 years, 8-15 years, and >15 years of clinical practice after specialist certificate. If no specialist certificate was obtained the surgery was classified as a trainee surgery. Surgeons with >15 years' experience as an orthopedic specialist were used as reference group in the analyses. Results - 8,158 primary THAs due to osteoarthritis were identified. We identified the surgeons' level of experience in 8,116 THAs. Data from SHAR on pre- and postoperative PROs and satisfaction at 1 year were available for 6,713 THAs. We observed a statistically significant difference among the 4 groups of surgeons regarding mean patient age, ASA classification, Charnley classification, diagnosis, and fixation technique. At 1-year follow-up, there were no statistically significant differences in Pain VAS, EQ-5D index, or EQ VAS among the subgroups of orthopedic specialists. Patients operated on by orthopedic trainees reported less satisfaction with the result of the surgery compared with the reference group. Interpretation - These findings indicate that patients can expect similar health improvements, pain reduction, and satisfaction 1 year after a primary THA operation irrespective of years in practice after specialty certification as an orthopedic surgeon.

Epidemiology of periprosthetic femur fracture around a total hip arthroplasty.

Periprosthetic femoral fractures can be classified as intraoperative and postoperative fractures. The intraoperative fractures mostly occur during the insertion of the femoral stem. Depending on the fixation method used, differences in the incidence of intraoperative fractures have been reported. An increase of intraoperative fractures is reported with the introduction of uncemented stems and this is often a consequence of the effort to obtain a sufficient press-fit to gain initial stem stability. In revision surgery an even higher incidence has been reported, ranging between 3.6% and 20.9% when cemented or uncemented prostheses are used, respectively. This review article reports on the prevalence of periprosthetic femoral fractures around a total hip replacement.

Three hundred and twenty-one periprosthetic femoral fractures.

BACKGROUND: The purpose of this study was to determine the demographics, incidence, and results of treatment of periprosthetic fractures in a nationwide observational study. METHODS: In the years 1999 and 2000, 321 periprosthetic fractures were reported to the Swedish National Hip Arthroplasty Register. All of the associated hospital records were collected. At the time of follow-up, the Harris hip score, a health-related quality-of-life measure (the EuroQol-5D [EQ-5D] index), and patient satisfaction were used as outcome measurements. A radiologist performed the radiographic evaluation. RESULTS: Ninety-one patients, with a mean age of 73.8 years, sustained a fracture after one or several revision procedures, and 230 patients, with a mean age of 77.9 years, sustained a fracture after a primary total hip replacement. Minor trauma, including a fall to the floor, and a spontaneous fracture were the main etiologies for the injuries. A high number of patients had a loose stem at the time of the fracture (66% in the primary replacement group and 51% in the revision group). Eighty-eight percent of the fractures were classified as Vancouver type B; however, there was difficulty with preoperative categorization of the fractures radiographically. There was a high failure rate resulting in a low short to mid-term prosthetic survival rate. The sixty-six-month survival rate for the entire fracture group, with reoperation as the end point, was 74.8% +/- 5.0%. One factor associated with fracture risk was implant design. CONCLUSIONS: On the basis of these findings, we believe that high-risk patients should have routine radiographic follow-up. Such a routine could identify a loose implant and make intervention possible before a fracture occurred. Furthermore, we recommend an exploration of the joint to test the stability of the implant in patients with a Vancouver type-B fracture in which the stability of the stem is uncertain.

Periprosthetic femoral fractures classification and demographics of 1049 periprosthetic femoral fractures from the Swedish National Hip Arthroplasty Register.

Postoperative femoral periprosthetic fracture is an uncommon complication of total hip arthroplasty surgery, but several centers worldwide have recently reported an increase in total numbers of such fractures. This severe complication is costly for society and results in high morbidity. Our analysis of 1049 periprosthetic fractures occurring in Sweden between 1979 and 2000 and recorded in the Swedish National Hip Arthroplasty Register focuses on patient- and implant-related factors, fracture classification, and fracture frequency. These were our 3 major findings: (1) a majority of the patients who sustained a late periprosthetic femoral fracture had a loose stem. (2) Implant-related factors are significantly associated with occurrence of a periprosthetic fracture. (3) Since the 1980s in Sweden, treatment results for periprosthetic fractures have been poor, with low long-term survivorship and a high frequency of complications. We have initiated further studies of this important problem.