Reduction In Revision Rates Research Articles

THE INFLUENCE OF BEARING SURFACE ON PERIPROSTHETIC JOINT INFECTION IN TOTAL HIP ARTHROPLASTY

BackgroundIncreasing evidence suggests a link between the bearing surface used in total hip arthroplasty (THA) and the occurrence of infection. It is postulated that polyethylene has immunomodulatory effects and may influence bacterial function and survival, thereby impacting the development of periprosthetic joint infection (PJI). This study aimed to investigate the association between polyethylene type and revision surgery for PJI in THA using data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). We hypothesized that the use of XLPE would demonstrate a statistically significant reduction in revision rates due to PJI compared to N-XLPE.MethodsData from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) spanning September 1, 1999, to December 31, 2021, were used to compare the infection revision rates between THA using N-XLPE and XLPE. We calculated the Cumulative Percentage Revision rate (CPR) and Hazard Ratio (HR) while controlling for factors like age, sex, body mass index (BMI), American Society of Anesthesiologists’ (ASA) grade, and head size.ResultsFrom the total 361,083 primary THAs, 26,827 used N-XLPE and 334,256 used XLPE. Excluding data from the first 6 months post-surgery, 220 revisions occurred in the N-XLPE group and 1,055 in the XLPE group for PJI. The HR for infection revision was significantly higher in N-XLPE compared to XLPE, at 1.64 (95% CI, 1.41–1.90, p<0.001).ConclusionsThis analysis provides evidence of an association between N-XLPE and revision for infection in THA. We suspect that polyethylene wear particles contribute to the susceptibility of THA to PJI, resulting in a significantly higher risk of revision for infection in N-XLPE hips compared to those with XLPE.Level of EvidenceTherapeutic Level III.

Can Technology Assistance be Cost Effective in TKA? A Simulation-Based Analysis of a Risk-prioritized, Practice-specific Framework.

Can Technology Assistance be Cost Effective in TKA? A Simulation-Based Analysis of a Risk-prioritized, Practice-specific Framework.

Can a Reduction in Revision Rates Make Robotic Total Knee Arthroplasty Cost Neutral With Manual Total Knee Arthroplasty at Ten-Year Follow-Up? An Episode Cost Analysis

BackgroundAdvocates of robotic total knee arthroplasty (RTKA) suggest that its greater cost may be recaptured through a reduction in revision rates. We sought to determine what reduction in revision TKA would be required for RTKA to become cost neutral with manual TKA (MTKA). MethodsEpisode costs were determined for 2392 RTKAs and 2392 MTKAs. Mean total cost of revision TKA in our health system was identified. Episode cost difference of the RTKA and MTKA cohorts was divided by the mean cost of revision TKA to estimate the reduction in revisions required to make RTKA cost neutral with MTKA. The National Joint Registry was consulted to determine the cumulative revision rate for the implant used in this study. ResultsEpisode cost for the RTKA cohort was $5.7M greater than MTKA. Mean acute stay cost for revision TKA was $20,972, but post-acute costs were not available. If post-acute costs for revision TKA are conservatively estimated at 50% of episode cost (ie, episode cost = $41,944), 131 revision TKAs would need to be prevented in the RTKA cohort to make it cost neutral with MTKA. The National Joint Registry cumulative revision rate for this implant is 3.37% at 10 years, thus only 81 revisions would be expected per cohort. ConclusionOur data suggest that it is not possible for RTKA to achieve cost parity with MTKA through a reduction in revision rate alone. Future price reductions may make the cost comparison more favorable. In addition, demonstration of improved patient outcomes would undeniably add value to RTKA and change the analysis.

How Large a Study Is Needed to Detect TKA Revision Rate Reductions Attributable to Robotic or Navigated Technologies? A Simulation-based Power Analysis.

How Large a Study Is Needed to Detect TKA Revision Rate Reductions Attributable to Robotic or Navigated Technologies? A Simulation-based Power Analysis.

Reduction in complication and revision rates for robotic-guided short-segment lumbar fusion surgery: results of a prospective, multi-center study.

Studies evaluating robotic guidance in lumbar fusion are limited primarily to evaluation of screw accuracy and perioperative complications. This is the first study to evaluate granular differences in short and long-term complication and revision rate profiles between robotic (RG) fluoroscopic (FG) guidance for minimally invasive short-segment lumbar fusions. A retrospective analysis of a prospective, multi-center database was performed. Complications were subdivided into surgical (further subcategorized into adjacent segment disease, new-onset back pain, radiculopathy, motor-deficit, hardware failure, pseudoarthrosis), wound, and medical complications. Complication and revision rates were compared between RG and FG groups cumulatively at 30, 90days, and 1 year. 374 RG and 111 FG procedures were performed. RG was associated with an 86.25, 83.20, and 69.42% cumulative reduction in complication rate at 30, 90days, and 1 year, respectively, compared to FG (p < 0.001). At all follow-up points, new-onset radiculopathy and medical complications were most prevalent in both groups. The greatest reductions in complication rates were seen for new-onset back pain (88.13%; p = 0.001) and wound complications (95.05%; p < 0.001) at 30days, new-onset motor deficits (90.11%; p = 0.004) and wound complications (85.16%; p < 0.001) at 90days, and new-onset motor deficits (85.16%; p = 0.002), wound (85.16%; p < 0.001), and medical complications (75.72%; p < 0.001) at 1 year. RG was associated with a 92.58% (p = 0.002) reduction in revision rate at 90days and a 66.08% (p = 0.026) reduction at 1 year. RG was associated with significant reductions in postoperative complication rates at all follow-up time points and significant reductions in revision rates at 90days and 1 year.

Implications of Applying New Technology in Cosmetic and Reconstructive Facial Plastic Surgery.

The field of facial plastic and reconstructive surgery is privy to a myriad of technological advancements. As innovation in areas such as imaging, computer applications, and biomaterials progresses at breakneck speed, the potential for clinical application is endless. This review of recent progress in the implementation of new technologies in facial plastic surgery highlights some of the most innovative and impactful developments in the past few years of literature. Patient-specific surgical modeling has become the gold standard for oncologic and posttraumatic reconstructive surgery, with demonstrated improvements in operative times, restoration of anatomical structure, and patient satisfaction. Similarly, reductions in revision rates with improvements in learner technical proficiency have been noted with the use of patient-specific models in free flap reconstruction. In the cosmetic realm, simulation-based rhinoplasty implants have drastically reduced operative times while concurrently raising patient postoperative ratings of cosmetic appearance. Intraoperative imaging has also seen recent expansion in its adoption driven largely by reports of eradication of postoperative imaging and secondary-often complicated-revision reconstructions. A burgeoning area likely to deliver many advances in years to come is the integration of bioprinting into reconstructive surgery. Although yet to clearly make the translational leap, the implications of easily generatable induced pluripotent stem cells in replacing autologous, cadaveric, or synthetic tissues in surgical reconstruction are remarkable.

Threshold for Computer- and Robot-Assisted Knee and Hip Replacements in the English National Health Service.

To estimate threshold prices for computer- and robot-assisted knee and hip replacement. A lifetime cohort Markov model provided the framework for analysis. Linked primary care and inpatient hospital records informed estimates of outcomes under current practice. Outcomes were estimated under a range of hypothetical relative improvements in quality of life if unrevised and in revision risk after computer or robot-assisted surgery. Threshold prices, a price at which the net health benefit from funding the intervention would be zero, for these improvements were estimated for a cost-effectiveness threshold of £20 000 per additional quality-adjusted life-year (QALY) gained. For average patient profiles under current knee and hip replacement practice, lifetime QALYs were 10.3 (9.9 to 10.7) and 11.0 (10.6 to 11.4), with costs of £6060 (£5947 to £6203) and £6506 (£6335 to £6710) for knee and hip replacement, respectively. A combined 50% relative reduction in risk of revision and 5% improvement in postoperative quality of life if unrevised would, for example, result in QALYs increasing to 10.9 (10.4 to 11.3) and 11.6 (11.2 to 12.0), and costs falling to £5880 (£5816 to £5956) and £6258 (£6149 to £6376) after knee and hip replacement, respectively. These particular improvements would have an associated threshold price of £11 182 (£10 691 to £11 721) for knee replacement and £12 134 (£11 616 to £12 701) for hip replacement. The 50% reduction in revision rate alone would have associated threshold prices of £1094 (£788 to £1488) and £1347 (£961 to £1842), and the 5% improvement in quality of life alone would have associated threshold prices of £9911 (£9476 to £10 296) and £10 578 (£10 171 to £10 982). At current prices, computer- and robot-assisted knee and hip replacement will likely need to lead to improvements in patient-reported outcomes in addition to any reduction in the risk revision.

Systematic review of the outcome of cemented versus uncemented total hip arthroplasty following pelvic irradiation.

The objective of this study is to evaluate the outcomes of total hip arthroplasty (THA) in patients with radiation-related changes to the bone, and specifically whether there is a difference in outcomes between cemented and uncemented acetabular components. A database search was performed to identify available studies reporting adults undergoing THA who have previously had pelvic irradiation. Data were extracted and analysed with respect to the use of cemented versus uncemented acetabular components. Statistical analysis was performed using the Chi-square test for independence. Theall-cause revision ratewas 24% in the cemented THA group (27/111), compared with 15% of uncemented THAs (22/143) (p = 0.073). Revision for acetabular aseptic loosening occurred in 16%of cases (18/111) in the cemented group and 10% (15/143) in the uncemented group (p = 0.178). Acetabular aseptic loosening was reported in 24% of cemented THAs (27/111) and 14% of uncemented THAs (20/143), which was statistically significant (p = 0.035). Not all of these went on to have revisionTHA. TheIncidence of prosthetic joint infection was similar in both groups. Overall outcomes appear to be better for uncemented THAs in post-radiotherapy patients, with a significantly lower rate of aseptic loosening and an appreciable (but not statistically significant) reduction in revision rate. The best outcomes seem to be associated with the use of acetabular reinforcement across both cemented and uncemented groups, but further work is needed to evaluate this.

Why hip implants fail: Patient, surgeon, or device?

In the joint registry era, outcomes of arthroplasty procedures are frequently attributed to the device. It is important to recognize the roles of the patient and the surgeon. Based on registry data, the four leading causes of hip arthroplasty revision are loosening/lysis, instability, infection, and periprosthetic fracture. The patient and/or the surgeon plays a greater role than the device in revision for instability, infection, and periprosthetic fracture. Variables related to the patient and the surgeon can also contribute to loosening/lysis. A greater reduction in revision rates will come through improvements in surgical care than from improvements in prosthetic joints.

CORR Insights ®: Metal-on-conventional total hip arthroplasty bearing surfaces have a higher risk of revision than metal-on-highly crosslinked polyethylene: results from a US registry.

H ighly crosslinked polyethylene (XLPE) has essentially supplanted conventional polyethylene for use in total hip arthroplasty (THA) during the past decade. There now exists good evidence to demonstrate a clear reduction in femoral head penetration (and presumably polyethylene wear) and periprosthetic osteolysis associated with the use XLPE compared to conventional polyethylene in THA [2, 3]. While the annual reports of Australian Orthopaedic Association National Joint Replacement Registry continue to show the clinical benefits of XLPE (demonstrating a reduction in revision rates) [1], other investigators have not demonstrated a clear reduction in revision rates with the use of XLPE at mid-term followup [4]. The current study by Paxton and colleagues attempts to demonstrate the clinical benefits resulting from the use of XLPE compared to conventional polyethylene through the analysis of a large US-based patient database. Their findings demonstrate that, for two specific implant designs, the revision rate was significantly decreased for XLPE compared to the use of conventional polyethylene. Therefore, this work essentially confirms the experience reported by the Australian Orthopaedic Association National Joint Replacement Registry during the past decade. While important work, this study is limited by the observational nature of the study, inherent to all registry or database analysis, and only provides information about two specific hip designs (both of which having been replaced by more recent designs by their respective manufacturers). Furthermore, analysis of this type does not provide any radiological, functional or patient-derived outcomes This CORR Insights is a commentary on the article ‘‘Metal-on-conventional Total Hip Arthroplasty Bearing Surfaces Have a Higher Risk of Revision Than Metal-on-highly Crosslinked Polyethylene: Results From a US Registry’’ by Paxton and colleagues available at: DOI: 10.1007/s11999-014-4105-9 The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or the Association of Bone and Joint Surgeons. This CORR Insights comment refers to the article available at DOI: 10.1007/s11999-0144105-9

Hormone replacement therapy and mid-term implant survival following knee or hip arthroplasty for osteoarthritis: a population-based cohort study

Osteolysis and subsequent prosthesis loosening is the most common cause for revision following total knee arthroplasty (TKA) or total hip arthroplasty (THA). Hormone replacement therapy (HRT) could reduce osteolysis through its antiresorptive effects. We studied whether HRT use is associated with reduced revision rates in a community-based cohort of women undergoing TKA or THA for osteoarthritis. Female participants in the General Practice Research Database undergoing a primary TKA or THA from 1986 to 2006 were included. We excluded patients aged <40 years at the date of primary, and those with a history of previous hip fracture or rheumatoid arthritis. Women with at least 6 months of HRT were identified as HRT users. We further explored the associations among HRT use of ≥12 months, adherence (medication possession ratio) and cumulative use and revision risk. Cox models were fitted to model implant survival in years. Propensity score matching was used to control for confounding. We matched 2700 HRT users to 8100 non-users, observed for a median (IQR) of 3.3 (1.5-6.1) years after TKA/THA. HR for HRT ≥6 months was 0.62 (95% CI 0.41 to 0.94), whereas HR for ≥12 months was 0.48 (0.29 to 0.78). Higher adherence and therapy duration were associated with further reductions in revision rates. Preoperative HRT appeared unrelated to implant survival. HRT use is associated with an almost 40% reduction in revision rates after a TKA/THA. These findings require replication in external cohorts and experimental studies.

How to deal with lost to follow-up in total knee arthroplasty

The aim of this study was to develop a more accurate method to deal with patients lost to follow-up based on the competing risks approach. A cohort of 112 patients who received 143 primary cemented total knee arthroplasties forms the basis for this study. Follow-up was up to 25 years. The new method for dealing with lost to follow-up accounts for competing events (i.e. death and failure of a prosthesis) using the cumulative incidence estimator and estimates time to event for patients lost to follow-up using national demographic registries. The results of this new method were compared with the worst case scenario estimated by Kaplan-Meier. Six different situations were identified covering all possible situations in long-term follow-up for total knee arthroplasty. The new method--considering all patients lost to follow-up as revised--showed a twofold reduction in revision rate compared to the traditional worst case scenario using Kaplan-Meier. Lost to follow-up should be prevented whenever possible, but this may be unavoidable for long-term follow-up studies. In situations where lost to follow-up does occur, the new proposed method offers an efficient and valid approach to deal with this problem.

Long‐Term Revision Rate due to Infection in Hydrophilic‐Coated Inflatable Penile Prostheses: 11‐Year Follow‐up

Penile implant surgery continues to be an important option for men with erectile dysfunction. Advancements in technology of implants have contributed to improved survival from mechanical breakdown. Prosthesis infection remains a serious adverse event. For the last 8 years, the Titan implant (Coloplast Corporation, Minneapolis, MN, USA) has been available with an infection-retardant polyvinylpyrrolidone coating. To compare the infection rates between coated three-piece inflatable penile prostheses (IPPs) with the previous non-coated model. Infection-related revisions reported in the physician-generated, manufacturer-tabulated patient information forms (PIFs). PIFs reported into the voluntary, post-market registry of Coloplast Corporation from July 14, 2000 to September 30, 2011 were retrospectively reviewed. Infection-related revisions entered into the product evaluation database for coated and non-coated IPPs were compared. Data were analyzed using Pearson's chi-squared test. The database included 36,391 PIFs related to primary IPP implantation. At 11 years of follow-up, 4.6% (7,031) of non-coated IPPs were removed or replaced due to infections, whereas 1.4% (29,360) of hydrophilic-coated implants reported replacements due to device infections. The hydrophilic coating of the IPP components makes the device slippery and prevents bacterial attachment. The hydrophilic coating allows rapid absorption of antibiotics in an aqueous solution and allows these water-soluble antibiotics to elute off the device into the implant spaces. Unfortunately, information pertaining to what agents were used in the studies patients was not tabulated. The rate of revision due to device infection was reduced 69.56% in patients with hydrophilic-coated IPPs (P<0.001). To the best of our knowledge, this is the longest post-marketing registry report related to IPP infections. At 8 years of follow-up, the hydrophilic-coated IPPs demonstrated a significant reduction in revision rates due to infection when compared with the 11-year follow-up of non-coated implants. Since there was no information or uniformity of antibiotics used in the soaking solution, it is uncertain which antibiotic selection provided the best results. In vitro testing against known infectious agents may further benefit IPP patients by reducing the prosthesis infection rate.

Latent class cluster analysis shows four distinct subtypes of knee OA: data from the osteoarthritis initiative

s / Osteoarthritis and Cartilage 20 (2012) S54–S296 S177 Therefore, we assessed whether HRT use is associated with reduced implant failure rates in a community-based cohort. Methods: Study population: Female participants in the General Practice Research Database undergoing a TKA or THA from 1986 to 2006 were included. Revision surgery was identified using READ codes. In order to identify arthroplasties indicated for osteoarthritis, we excluded patients aged 80%) adherence were identified as HRT users. Three sensitivity analyses were carried out, where we explored the association between HRT use for 12 months, HRT adherence and cumulative use, and time to failure. We used time varying Cox Models to account for the immortal time till met definition of HRT use. Statistical analysis: Time-varying Cox models were used to estimate hazard ratios (HR) for HRT users versus non-users matched by propensity score to minimize for confounding by indication. Potential confounders were: age, gender, body mass index, joint replaced (hip/knee), year of surgery, OA indication, fracture history, anti-osteoporosis medication use, oral glucocorticoids, smoking, alcohol intake, multiple deprivation index, UK region, co-morbid conditions, and use of drugs which can affect bone metabolism. Results: Of 24,733 eligible women included, 3,644 met the definition of HRT user and the remaining 21,089 were non-users. From the propensitymatching, 2,700 HRT users and 3 comparable controls (8,100women)were selected. The median (interquartile range) follow-up was 3.3 (1.5-6.1) years after surgery. Despite matching, HRT users were more likely to be taking drugs with increase fracture risk. A total of 168 (1.56%) participants underwent revision surgery during the period of followup. The cumulative failure rate was significantly lower in HRT users than non-users (27(1.00%) vs 141(1.74%, p1⁄40.007)). HRT use for 6 months was associated with a lower risk of revision (HR 0.61 (0.41 to 0.93)) [Figure]. Both higher adherence (p1⁄40.007) and longer therapy duration (p1⁄40.008) led to further reductions in revision rates. [Table]. Sensitivity analyses: effect of adherence and cumulative use of HRT on implant surv

USE OF COST-EFFECTIVENESS ANALYSIS TO EVALUATE NEW TECHNOLOGIES IN ORTHOPAEDICS

Background: Alternative bearing surfaces offer the potential to reduce wear and improve implant longevity following total hip arthroplasty. However, these technologies are associated with higher costs, the potential for unintended consequences, and uncertain benefits in terms of long-term survival of the implants. The purpose of this study was to evaluate the cost-effectiveness of the use of alternative bearings in total hip arthroplasty. Methods: A decision-analysis model was constructed to estimate the cost-effectiveness of the use of alternative bearings for patients undergoing total hip arthroplasty. Model inputs, including costs, clinical outcome probabilities, and health utility values, were derived from a review of the literature. Sensitivity analyses were performed to evaluate the impact of patient age at the time of surgery, implant costs, and reductions in revision rates on the cost-effectiveness of alternate bearing surfaces. Results: In a population of fifty-year-old patients, use of an alternative bearing with an incremental cost of $2000 would be cost-saving over the individual's lifetime if it were associated with at least a 19% reduction in the twenty-year implant failure rate when compared with the failure rate for a conventional bearing. In a population of patients over the age of sixty-three years, the same implant would be associated with higher lifetime costs than would a conventional bearing, regardless of the presumed reduction in the revision rate. Conversely, an alternative bearing that adds only $500 to the cost of a conventional total hip arthroplasty could be cost-saving in a population of patients over the age of sixty-five years, even if it were associated with only a modest reduction in the revision rate. In a population of patients over the age of seventy-five years, no alternative bearing would be associated with lifetime cost-savings, regardless of the cost or the presumed reduction in the revision rate. Conclusions: The cost-effectiveness of alternative bearings is highly dependent on the age of the patient at the time of surgery, the cost of the implant, and the associated reduction in the probability of revision relative to that associated with conventional bearings. Our findings provide a quantitative rationale for requiring greater evidence of effectiveness in reducing the probability of implant failure when more costly alternative bearings are being considered, particularly for older patients. Level of Evidence: Decision analysis, Level I. See Instructions to Authors for a complete description of levels of evidence.

Use of Cost-Effectiveness Analysis to Evaluate New Technologies in Orthopaedics: The Case of Alternative Bearing Surfaces in Total Hip Arthroplasty

Alternative bearing surfaces offer the potential to reduce wear and improve implant longevity following total hip arthroplasty. However, these technologies are associated with higher costs, the potential for unintended consequences, and uncertain benefits in terms of long-term survival of the implants. The purpose of this study was to evaluate the cost-effectiveness of the use of alternative bearings in total hip arthroplasty. A decision-analysis model was constructed to estimate the cost-effectiveness of the use of alternative bearings for patients undergoing total hip arthroplasty. Model inputs, including costs, clinical outcome probabilities, and health utility values, were derived from a review of the literature. Sensitivity analyses were performed to evaluate the impact of patient age at the time of surgery, implant costs, and reductions in revision rates on the cost-effectiveness of alternate bearing surfaces. In a population of fifty-year-old patients, use of an alternative bearing with an incremental cost of 2000 dollars would be cost-saving over the individual's lifetime if it were associated with at least a 19% reduction in the twenty-year implant failure rate when compared with the failure rate for a conventional bearing. In a population of patients over the age of sixty-three years, the same implant would be associated with higher lifetime costs than would a conventional bearing, regardless of the presumed reduction in the revision rate. Conversely, an alternative bearing that adds only 500 dollars to the cost of a conventional total hip arthroplasty could be cost-saving in a population of patients over the age of sixty-five years, even if it were associated with only a modest reduction in the revision rate. In a population of patients over the age of seventy-five years, no alternative bearing would be associated with lifetime cost-savings, regardless of the cost or the presumed reduction in the revision rate. The cost-effectiveness of alternative bearings is highly dependent on the age of the patient at the time of surgery, the cost of the implant, and the associated reduction in the probability of revision relative to that associated with conventional bearings. Our findings provide a quantitative rationale for requiring greater evidence of effectiveness in reducing the probability of implant failure when more costly alternative bearings are being considered, particularly for older patients.