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Background and Purpose:  We aimed to determine sex differences for periprosthetic joint infections after primary arthroplasty of the hip, knee, ankle, and shoulder in osteoarthritis patients in an international perspective., Methods:  This is a multinational combined arthroplasty registry study. Each arthroplasty registry performed Cox-regression analysis of their data and reported the crude and adjusted hazard ratios (HR) with an a priori designed data form. A random-effects model was used to pool these HRs to estimate an overall HR with 95% confidence interval (CI). Adjustment was undertaken for patient age, BMI, ASA grade, type of fixation, and type of implant. 9 arthroplasty registries participated. Patients who received primary total joint arthroplasty for primary osteoarthritis were considered: 2,134,313 hip arthroplasties, 2,658,237 knee arthroplasties, 57,889 shoulder arthroplasties, and 8,445 ankle arthroplasties. We calculated hazard ratios (HR) for the overall risk of complete revision due to infection for each implant type and follow-up., Results: The pooled HR for revision due to infection for men compared with women at 1-year follow-up was 1.60 (95% confidence interval [CI] 1.42-1.80) for hip arthroplasties; 2.06 (CI 1.90-2.46) for knee arthroplasties; 4.51 (CI 2.99-6.80) for shoulder arthroplasties; and 0.87 (CI 0.46-1.62) for ankle arthroplasties. These results remained consistent over time and were identified in both unadjusted and adjusted models., Conclusion:  Men have a higher risk of revision due to infection than women after primary hip, knee, and shoulder arthroplasty. No evidence of difference was found for ankle arthroplasty. These elevated relative risks persist in the fully adjusted investigations and over the 10-year postoperative period studied.

Background: Many factors, including some related to the patient, implant selection, and the surgeon's skill and expertise, likely contribute to the risk of THA revision. However, surgeon factors have not been extensively analyzed in national joint replacement registries, and there is limited insight into their potential as a confounding variable for revision outcomes; for example, if surgeons with higher revision rates choose more successful prostheses, would this alone reduce their revision rate?, Questions/purposes: This study used Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) data for patients receiving primary THA for a diagnosis of osteoarthritis to answer the following questions: (1) Will the difference in revision rates among surgeons change or disappear when only procedures performed with the best prostheses or prostheses that have been identified as having higher revision rates are considered? (2) Is the benefit associated with using the best-performing prostheses different among surgeons with different revision rates? (3) Do the reasons for revision differ between surgeons with higher rates of revision compared with surgeons with lower rates of revision?, Methods: All primary THA procedures performed and recorded in the AOANJRR for osteoarthritis from September 1, 1999, to December 31, 2022, were considered for inclusion. Each THA prosthesis used was categorized per the AOANJRR as superior-performing, middle-performing, or identified as having a higher rate of revision by the AOANJRR benchmarking process. Surgeons who had performed at least 50 procedures and had a recorded 2-year cumulative percent revision (CPR) were included. After applying these restrictions, the study consisted of 302,066 procedures performed by 476 known surgeons. For the primary outcome measure of all-cause revision, we examined the variation in all-cause revision rates across individual surgeons when different classes of devices were used to assess whether differences between surgeons persisted when accounting for prosthesis selection. For the purposes of descriptively comparing reasons for revision between surgeons with higher-than-average or lower-than-average risk of revision, surgeons were classified into quartiles and outcomes compared when these surgeons used the same class of prosthesis., Results: The difference in rates of revision among surgeons remained even after accounting for the effects of the prosthesis used. For any given surgeon, identified prostheses were associated with higher revision rates compared with both superior-performing prostheses (HR 1.73 [95% CI 1.57 to 1.92]; p < 0.01) and medium-performing prostheses (HR 1.31 [95% CI 1.20 to 1.43]; p < 0.01). All surgeons demonstrated a lower revision rate when using a superior-performing prosthesis, but the difference was greatest for surgeons with the highest rates of revision. Surgeons with the lowest rates of revision had a 19-year CPR of 3.9% (95% CI 3.0% to 5.0%) when using a superior-performing prosthesis compared with 5.4% (95% CI 4.0% to 7.3%) for procedures in which an identified prosthesis was used. Surgeons with the highest rates of revision had a 19-year CPR of 10.9% (95% CI 8.6% to 13.8%) when using a superior-performing prosthesis, and this increased to 20.4% (95% CI 18.0% to 23.1%) for procedures in which an identified prosthesis was used. The reasons for revision differ between surgeons, with causes of revision likely preventable and not related to the prosthesis choice being apparent for surgeons with high revision rates., Conclusion: The choice of implant and the surgeon performing the index procedure both affected the risk of revision as well as the reasons for revision. Surgeons could improve the survivorship of the arthroplasties they perform by choosing implants identified by registries as having lower revision rates. Acceptance of the fact that surgeons have different revision rates is needed, and detailed analysis is required to explain why surgeons with high revision rates have increased rates of likely preventable revisions, and outside of prosthesis choice, how revision rates can be lowered. The influence of training, fellowship completion, ongoing education, patient selection, indications for surgery, and factors underlying prosthesis decision-making should be assessed. The surgeon performing THA is an important confounder that should be considered in future registry analyses., Level of Evidence: Level III, therapeutic study., Competing Interests: 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., (Copyright © 2024 by the Association of Bone and Joint Surgeons.)

Background: Anterior approach total hip arthroplasty (THA) decreases the rate of dislocation but increases femoral-sided complications in the way of periprosthetic fractures and component loosening. A cemented prosthesis may reduce femoral-sided complications and improve the risk:benefit profile of anterior approach THA., Methods: Data from the Australian National Joint Replacement Registry were analysed for patients undergoing primary THA via the anterior or posterior approach using a cemented polished femoral stem from January 2015 to December 2021. The primary outcome measure was the cumulative percent revision (CPR) for all causes and CPR for femoral component loosening and fracture. The CPR for the primary outcome measures were compared between the anterior and posterior approach and adjusted for age, sex, ASA score, BMI and femoral head size., Results: The study included 60,739 THAs with cemented stems (10,742 anterior, 49,997 posterior). The rate of revision of the anterior versus the posterior approach did not significantly differ (HR 0.87 (95% CI, 0.74-1.03), p  = 0.100). Anterior approach THA had a significantly higher rate of revision for femoral component loosening (HR 5.06 [95% CI, 3.08-8.30], p  < 0.001); and a decreased rate of revision for infection (HR 0.59 [95% CI, 0.43-0.81], p  = 0.001) and dislocation/instability (HR 0-3 months 0.48 [95% CI, 0.27-0.83], p  = 0.008; HR >3 months 0.30 [95% CI, 0.15-0.61], p  < 0.001). There was no difference in the rate of revision surgery for fracture between the 2 approaches (HR 1.01 [95% CI, 0.71-1.43]), p  = 0.975)., Conclusions: There is no significant difference in overall revision rates with cemented femoral fixation performed with an anterior or posterior approach. Cemented fixation performed with the anterior approach partly mitigates femoral complications with no difference in the revision rate for fracture but an increased rate of femoral component loosening., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The aim of this study was to examine the incidence of overweight and obesity in patients undergoing primary total shoulder arthroplasty (TSA) for osteoarthritis (OA) in Australia compared to the incidence of obesity in the general population., Materials and Methods: A 2017/18 cohort consisting of 2997 patients from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) who underwent TSA were compared with matched controls from the Australian Bureau of Statistics (ABS) National Health Survey from the same time period. The 2 groups were analyzed according to body mass index (BMI) category, sex, and age., Results: According to the 2017/18 National Health Survey, 35.6% of Australian adults were overweight and 31.3% were obese. Of the primary TSA cases performed, 34.9% were overweight and 50.1% were obese. The relative risk of requiring TSA for OA increased with increasing BMI category. Class III obese females, aged 55-64, were 8.6 times more likely to receive a TSA compared to their normal weight counterparts. Males in the same age and BMI category were 2.5 times more likely. Class III obese patients underwent TSA 4 years (female) and 6 years (male) younger than their normal weight counterparts., Conclusion: Obesity significantly increases the risk of requiring TSA. The association appears to be particularly strong for younger females., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Patients who have kidney failure are at higher risk of requiring total hip arthroplasty (THA) and are at higher risk of complications. This study compared the rate of revision surgery and mortality following THA between patients who have kidney failure receiving long term dialysis or who had a kidney transplant and those who did not have kidney failure., Methods: A data linkage study was performed using data from 2 national registries: a registry of dialysis and kidney transplant patients and a registry of THA procedures. Both registries had coverage of almost all procedures or treatments in Australia. Data from September 1999 to December 2016 were used. Mortality and revision surgery were compared between patients receiving dialysis, those who had a functioning kidney transplant, and patients who did not have kidney failure using Cox and Fine-Gray (competing risk) regression models. A total of 383,478 primary THA procedures were identified as people receiving dialysis (n = 490), who had a functioning kidney transplant (n = 459), or who did not have kidney failure (n = 382,529)., Results: There was no significant difference in the overall rate of revision surgery between the groups (dialysis versus no kidney failure HR = 1.20; 95% CI 0.76, 1.88, transplant versus no kidney failure (hazard ratio) HR = 1.01; 95% (confidence interval) CI 0.66, 1.53). The risk for death after surgery was significantly higher in the dialysis group compared to both the functioning transplant group (HR = 3.44; 95%CI 1.58, 7.5), and in those without kidney failure (HR = 4.13; 95%CI 3.25, 5.25)., Conclusion: The rate of mortality after THA in patients on dialysis is higher than in patients who have a functioning transplant or those who do not have kidney failure, but there is no early excess mortality to suggest a difference in this metric due to the surgery., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Obesity is a known risk factor for the development of hip osteoarthritis. The aim of this study was to investigate whether obesity is associated with the risk of undergoing total hip replacement (THR) in Australia., Methods: A cohort study was conducted comparing data from the Australian Bureau of Statistics and the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from 2017 to 2018. Body mass index (BMI) data for patients undergoing primary total hip replacement and resurfacing for osteoarthritis were obtained from the AOANJRR. The distribution of THR patients by BMI category was compared to the general population, in age and sex sub-groups., Results: During the study period, 32 495 primary THR were performed for osteoarthritis in Australia. Compared to the general population, there was a higher prevalence of Class I, II and III obesity in patients undergoing THR in both sexes aged 35-74 years. Class III obese females and males aged 55-64 years were 2.9 and 1.7 times more likely to undergo THR, respectively (P < 0.001). Class III obese females and males underwent THR on average 5.7 and 7.0 years younger than their normal weight counterparts, respectively., Conclusion: Obese Australians are at increased risk of undergoing THR, and at a younger age., (© 2023 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Importance: Ischemic heart disease remains the leading cause of mortality following hip and knee arthroplasty. Due to its antiplatelet and cardioprotective properties, aspirin has been proposed as an agent that could reduce mortality when used as venous thromboembolism (VTE) prophylaxis following these procedures., Objective: To compare aspirin with enoxaparin in reducing 90-day mortality for patients undergoing hip or knee arthroplasty procedures., Design, Setting, and Participants: This study was a planned secondary analysis of the CRISTAL cluster randomized, crossover, registry-nested trial performed across 31 participating hospitals in Australia between April 20, 2019, and December 18, 2020. The aim of the CRISTAL trial was to determine whether aspirin was noninferior to enoxaparin in preventing symptomatic VTE following hip or knee arthroplasty. The primary study restricted the analysis to patients undergoing total hip or knee arthroplasty for a diagnosis of osteoarthritis only. This study includes all adult patients (aged ≥18 years) undergoing any hip or knee arthroplasty procedure at participating sites during the course of the trial. Data were analyzed from June 1 to September 6, 2021., Interventions: Hospitals were randomized to administer all patients oral aspirin (100 mg daily) or subcutaneous enoxaparin (40 mg daily) for 35 days after hip arthroplasty and 14 days after knee arthroplasty procedures., Main Outcomes and Measures: The primary outcome was mortality within 90 days. The between-group difference in mortality was estimated using cluster summary methods., Results: A total of 23 458 patients from 31 hospitals were included, with 14 156 patients allocated to aspirin (median [IQR] age, 69 [62-77] years; 7984 [56.4%] female) and 9302 patients allocated to enoxaparin (median [IQR] age, 70 [62-77] years; 5277 [56.7%] female). The mortality rate within 90 days of surgery was 1.67% in the aspirin group and 1.53% in the enoxaparin group (estimated difference, 0.04%; 95% CI, -0.05%-0.42%). For the subgroup of 21 148 patients with a nonfracture diagnosis, the mortality rate was 0.49% in the aspirin group and 0.41% in the enoxaparin group (estimated difference, 0.05%; 95% CI, -0.67% to 0.76%)., Conclusions and Relevance: In this secondary analysis of a cluster randomized trial comparing aspirin with enoxaparin following hip or knee arthroplasty, there was no significant between-group difference in mortality within 90 days when either drug was used for VTE prophylaxis., Trial Registration: http://anzctr.org.au Identifier: ACTRN12618001879257.

Background: The objective is to determine whether body mass index is associated with patient-reported expectations and well-being before primary total hip or total knee arthroplasty, and patient-reported outcomes 6 months after surgery., Methods: Data were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Outcome measures included pre-operative expectations for post-operative mobility, joint pain and health, pre- and post-operative EQ-5D-5L, EQ-VAS, Oxford Hip/Knee Scores and joint pain scales, and post-operative perceived change and perceived satisfaction. Associations with BMI were assessed using chi-square tests, analysis of variance and Linear Mixed Models equations., Results: Data were available for 12 816 primary THA patients and 20 253 primary TKA patients. Pre-operatively, patients in higher BMI categories were significantly more likely to expect ongoing problems with mobility, more joint pain and poorer health following surgery (P<0.01 for all analyses). For arthroplasty patients, higher BMI was associated with poorer pre-operative and post-operative scores for all measures. BMI was positively associated with improvements in EQ-5D, OHS/KS and joint pain. While between-group differences were statistically significant, many were small in magnitude. There was no association between BMI and patient-perceived change or satisfaction after arthroplasty., Conclusion: Patients undergoing THA/TKA, higher BMI was associated with lower pre-operative expectations, poorer well-being before surgery, and worse scores after surgery. Patients who were obese demonstrated comparable satisfaction with their operated joint, compared with non-obese patients. BMI was associated with greater pre- to post-operative improvements in outcome scores for EQ-5D, VAS knee, OHS/OKS and joint pain but these differences may not be clinically important., (© 2023 Royal Australasian College of Surgeons.)

Purpose: Infection is a major complication following joint replacement (JR) surgery. However, little data exist regarding antibiotic utilisation following primary JR and how use changes with subsequent revision surgery. This study aimed to examine variation in antibiotic utilisation rates before and after hip replacement surgery in those revised for infection, revised for other reasons and those without revision., Methods: This retrospective cohort analysis used linked data from the Australian Orthopaedic Association National Joint Replacement Registry and Australian Government Pharmaceutical Benefits Scheme. Patients were included if undergoing total hip replacement (THR) for osteoarthritis in private hospitals between 2002 and 2017. Three groups were examined: primary THR with no subsequent revision (n = 102 577), primary THR with a subsequent revision for reasons other than periprosthetic joint infection (PJI) (n = 3156) and primary THR with a subsequent revision for PJI (n = 520). Monthly antibiotic utilisation rates and prevalence rate ratios (PRRs) with 95% confidence intervals (CIs) were calculated in the 2 years pre- and post-THR., Results: Prior to primary THR antibiotic utilisation was 9%-10%. After primary THR, antibiotic utilisation rates were higher among patients revised for PJI (PRR 1.69, 95% CI 1.60-1.79) compared to non-revised patients, while the utilisation rate was lower in patients revised for reasons other than infection (PRR 0.96, 95% CI 0.93-0.98). For those revised for infection, antibiotic utilisation post-revision surgery was two times higher than those revised for other reasons (PRR 2.16, 95% CI 2.08-2.23). Utilisation of injectable antibiotics including, vancomycin, flucloxacillin and cephazolin was higher in those revised for PJI patients 0-2 weeks following surgery but not in those revised for other reasons compared to the non-revised group., Conclusions: Ongoing antibiotic utilisation after primary surgery may be an early signal of problems with the THR and should be a prompt for primary care physicians to refer patients to specialists for further appropriate investigations and management., (© 2022 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons Ltd.)

Objectives: Studies have identified increased cancer risk among patients undergoing total hip arthroplasty (THA) compared to the general population. However, evidence of all-cause and site-specific cancer risk associated with different bearing surfaces has varied, with previous studies having short latency periods with respect to use of modern Metal-on-Metal (MoM) bearings. Using the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) linked to Australasian Association of Cancer Registries data, our aim was to evaluate risk of all-cause and site-specific cancer according to bearing surfaces in patients undergoing THA for osteoarthritis and whether risk increased with MoM bearings., Methods: Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated by comparing number of observed cancer cases to expected number based on incidence rate in the Australian population. All-cause and site-specific cancer rates were calculated for all conventional stemmed THA (csTHA) and resurfacing THA (rsTHA) procedures performed for osteoarthritis. Cox proportional hazards models were used to compare cancer rates for MoM, ceramic-on-ceramic (CoC) and resurfacing procedures with a comparison group comprising metal-on-polyethylene (MoP) or ceramic-on-polyethylene (CoP) procedures., Results: There were 156,516 patients with csTHA procedures and 11,321 with rsTHA procedures for osteoarthritis performed between 1999 and 2012. Incidence of all-cause cancer was significantly higher for csTHA (SIR 1.24, 95% CI 1.22-1.26) and rsTHA (SIR 1.74, 95% CI 1.39-2.04) compared to the Australian population. For csTHA, there was no significant difference in all-site cancer rates for MoM (Hazard Ratio (HR) 1.01, 95%CI 0.96-1.07) or CoC (HR 0.98, 95%CI 0.94-1.02) compared to MoP and CoP bearings. Significantly increased risk of melanoma, non-Hodgkins lymphoma, myeloma, leukaemia, prostate, colon, bladder and kidney cancer was found for csTHA and, prostate cancer, melanoma for rsTHA procedures when compared to the Australian population, although risk was not significantly different across bearing surfaces., Conclusions: csTHA and rsTHA procedures were associated with increased cancer incidence compared to the Australian population. However, no excess risk was observed for MoM or CoC procedures compared to other bearing surfaces., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Pratt et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The ability to identify which patients are at a greater risk of early revision knee arthroplasty has important practical and resource implications. Many international arthroplasty registries administer patient-reported outcome measures (PROMs) to provide a holistic assessment of pain, function, and quality of life. However, few PROM scores have been evaluated as potential indicators of early revision knee arthroplasty, and earlier studies have largely focused on knee-specific measures., Questions/purposes: This national registry-based study asked: (1) Which 6-month postoperative knee-specific and generic PROM scores are associated with early revision knee arthroplasty (defined as revision surgery performed 6 to 24 months after the primary procedure)? (2) Is a clinically important improvement in PROM scores (based on thresholds for the minimal important change) after primary knee arthroplasty associated with a lower risk of early revision?, Methods: Preoperative and 6-month postoperative PROM scores for patients undergoing primary knee arthroplasty were sourced from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and Arthroplasty Clinical Outcomes Registry National. Between January 2013 and December 2020, PROM data were available for 19,402 primary total knee arthroplasties; these data were linked to AOANJRR data on revision knee arthroplasty. Of these, 3448 procedures were excluded because they did not have 6-month PROM data, they had not reached the 6-month postoperative point, they had died before 24 months, or they had received revision knee arthroplasty before the 6-month PROMs assessment. After these exclusions, data were analyzed for 15,954 primary knee arthroplasties. Associations between knee-specific (knee pain, Oxford Knee Score, and 12-item Knee injury and Osteoarthritis Outcome Score [KOOS-12]) or generic PROM scores (5-level EuroQol quality of life instrument [EQ-5D], EQ VAS, perceived change, and satisfaction) and revision surgery were explored using t-tests, chi-square tests, and regression models. Ninety-four revision procedures were performed at 6 to 24 months, most commonly for infection (39% [37 procedures]). The early revision group was younger than the unrevised group (mean age 64 years versus 68 years) and a between-group difference in American Society of Anesthesiologists (ASA) grade was noted. Apart from a small difference in preoperative low back pain for the early revision group (mean low back pain VAS 4.2 points for the early revision group versus 3.3 points for the unrevised group), there were no between-group differences in preoperative knee-specific or generic PROM scores on univariate analysis. As the inclusion of ASA grade or low back pain score did not alter the model results, the final multivariable model included only the most clinically plausible confounders (age and gender) as covariates. Multivariable models (adjusting for age and gender) were also used to examine the association between a clinically important improvement in PROM scores (based on published thresholds for minimal important change) and the likelihood of early revision., Results: After adjusting for age and gender, poor postoperative knee pain, Oxford, KOOS-12, EQ-5D, and EQ VAS scores were all associated with early revision. A one-unit increase (worsening) in knee pain at 6 months was associated with a 31% increase in the likelihood of revision (RR 1.31 [95% confidence interval (CI) 1.19 to 1.43]; p < 0.001). Reflecting the reversed scoring direction, a one-unit increase (improvement) in Oxford or KOOS-12 score was associated with a 9% and 5% reduction in revision risk, respectively (RR for Oxford: 0.91 [95% CI 0.90 to 0.93]; p < 0.001; RR for KOOS-12 summary: 0.95 [95% CI 0.94 to 0.97]; p < 0.001). Patient dissatisfaction (RR 6.8 [95% CI 3.7 to 12.3]) and patient-perceived worsening (RR 11.7 [95% CI 7.4 to 18.5]) at 6 months were also associated with an increased likelihood of early revision. After adjusting for age and gender, patients who did not achieve a clinically important improvement in PROM scores had a higher risk of early revision (RR 2.9 for the knee pain VAS, RR 4.2 for the Oxford Knee Score, RR 6.3 to 8.6 for KOOS-12, and RR 2.3 for EQ-5D) compared with those who did (reference group)., Conclusion: Knee-specific and generic PROM scores offer an efficient approach to identifying patients at greater risk of early revision surgery, using either the 6-month score or the magnitude of improvement. These data indicate that surgeons can use single- and multi-item measures to detect a patient-perceived unsuccessful surgical outcome at 6 months after primary knee arthroplasty. Surgeons should be alert to poor PROM scores at 6 months or small improvements in scores (for example, less than 2 points for knee pain VAS or less than 10.5 points for Oxford Knee Score), which signal a need for direct patient follow-up or expedited clinical review., Level of Evidence: Level III, therapeutic study., Competing Interests: 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., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Association of Bone and Joint Surgeons.)

Background: Joint arthroplasty registries traditionally report survivorship outcomes mainly on primary joint arthroplasty. The outcome of first revision procedures is less commonly reported, because large numbers of primary procedures are required to analyze a sufficient number of first revision procedures. Additionally, adequate linkage of primary procedures to revisions and mortality is required. When undertaking revision hip surgery, it is important for surgeons to understand the outcomes of these procedures to better inform patients., Questions/purposes: Using data from a large national joint registry, we asked: (1) What is the overall rate of revision of the first aseptic revision procedure for a primary THA? (2) Does the rate of revision of the first revision vary by the diagnosis for the first revision? (3) What is the mortality after the first revision, and does it vary by the reason for first revision?, Methods: The Australian Orthopaedic Association National Joint Replacement Registry longitudinally maintains data on all primary and revision joint arthroplasties, with nearly 100% capture. The analyses for this study were performed on primary THA procedures in patients with a diagnosis of osteoarthritis up to December 31, 2020, who had undergone subsequent revision. We excluded all primary THAs involving metal-on-metal and ceramic-on-metal bearing surfaces and prostheses with exchangeable necks because these designs may have particular issues associated with revisions, such as extensive soft tissue destruction, that are not seen with conventional bearings, making a comparative analysis of the first revision involving these bearing surfaces more complicated. Metal-on-metal bearing surfaces have not been used in Australia since 2017. We identified 17,046 first revision procedures from the above study population and after exclusions, included 13,713 first revision procedures in the analyses. The mean age at the first revision was 71 ± 11 years, and 55% (7496 of 13,713) of the patients were women. The median (IQR) time from the primary procedure to the first revision was 3 years (0.3 to 7.3), ranging from 0.8 years for the diagnosis of dislocation and instability to 10 years for osteolysis. There was some variation depending on the reason for the first revision. For example, patients undergoing revision for fracture were slightly older (mean age 76 ± 11 years) and patients undergoing revision for dislocation were more likely to be women (61% [2213 of 3620]). The registry has endeavored to standardize the sequence of revisions and uses a numerical approach to describe revision procedures. The first revision is the revision of a primary procedure, the second revision is the revision of the first revision, and so on. We therefore described the outcome of the first revision as the cumulative percent second revision. The outcome measure was the cumulative percent revision, which was defined using Kaplan-Meier estimates of survivorship to describe the time to the second revision. Hazard ratios from Cox proportional hazards models, adjusting for age and gender, were performed to compare the revision rates among groups. When possible, the cumulative percent second revision at the longest follow-up timepoint was determined with the available data, and when there were insufficient numbers, we used appropriate earlier time periods., Results: The cumulative percent second revision at 18 years was 26% (95% confidence interval [CI] 24% to 28%). When comparing the outcome of the first revision by reason, prosthesis dislocation or instability had the highest rate of second revision compared with the other reasons for first revision. Dual-mobility prostheses had a lower rate of second revision for dislocation or instability than head sizes 32 mm or smaller and when compared to constrained prostheses after 3 months. There was no difference between dual-mobility prostheses and head sizes larger than 32 mm. There were no differences in the rate of second revision when first revisions for loosening, periprosthetic fracture, and osteolysis were compared. If cemented femoral fixation was performed at the time of the first revision, there was a higher cumulative percent second revision for loosening than cementless fixation from 6 months to 6 years, and after this time, there was no difference. The overall mortality after a first revision of primary conventional THA was 1% at 30 days, 2% at 90 days, 5% at 1 year, and 40% at 10 years. A first revision for periprosthetic fracture had the highest mortality at all timepoints compared with other reasons for the first revision., Conclusion: Larger head sizes and dual-mobility cups may help reduce further revisions for dislocation, and the use of cementless stems for a first revision for loosening seems advantageous. Surgeons may counsel patients about the higher risk of death after first revision procedures, particularly if the first revision is performed for periprosthetic fracture.Level of Evidence Level III, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. 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., (Copyright © 2022 by the Association of Bone and Joint Surgeons.)

Background: Loss of glenoid fixation is a key factor affecting the survivorship of primary total shoulder arthroplasty (TSA). It is not known whether the lower revision rates associated with crosslinked polyethylene (XLPE) compared with those of non-XLPE identified in hip and knee arthroplasty apply to shoulder arthroplasty., Questions/purposes: We used data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) to compare the revision rates of primary stemmed anatomic TSA using XLPE to procedures using non-XLPE. In patients receiving a primary stemmed anatomic TSA for osteoarthritis, we asked: (1) Does the rate of revision or reason for revision vary between XLPE and non-XLPE all-polyethylene glenoid components? (2) Is there any difference in the revision rate when XLPE is compared with non-XLPE across varying head sizes? (3) Is there any difference in survival among prosthesis combinations with all-polyethylene glenoid components when they are used with XLPE compared with non-XLPE?, Methods: Data were extracted from the AOANJRR from April 16, 2004, to December 31, 2020. The AOANJRR collects data on more than 97% of joint replacements performed in Australia. The study population included all primary, stemmed, anatomic TSA procedures performed for osteoarthritis using all-polyethylene glenoid components. Procedures were grouped into XLPE and non-XLPE bearing surfaces for comparison. Of the 10,102 primary stemmed anatomic TSAs in the analysis, 39% (3942 of 10,102) used XLPE and 61% (6160 of 10,102) used non-XLPE. There were no differences in age, gender, or follow-up between groups. Revision rates were determined using Kaplan-Meier estimates of survivorship to describe the time to the first revision, with censoring at the time of death or closure of the database at the time of analysis. Revision was defined as removal, replacement, or addition of any component of a joint replacement. The unadjusted cumulative percent revision after the primary arthroplasty (with 95% confidence intervals [CIs]) was calculated and compared using Cox proportional hazard models adjusted for age, gender, fixation, and surgeon volume. Further analyses were performed stratifying according to humeral head size, and a prosthesis-specific analysis adjusted for age and gender was also performed. This analysis was restricted to prosthesis combinations that were used at least 150 times, accounted for at least four revisions, had XLPE and non-XLPE options available, and had a minimum of 3 years of follow-up., Results: Non - XLPE had a higher risk of revision than XLPE after 1.5 years (HR 2.3 [95% CI 1.6 to 3.1]; p < 0.001). The cumulative percent revision at 12 years was 5% (95% CI 4% to 6%) for XLPE and 9% (95% CI 8% to 10%) for non-XLPE. There was no difference in the rate of revision for head sizes smaller than 44 mm. Non-XLPE had a higher rate of revision than XLPE for head sizes 44 to 50 mm after 2 years (HR 2.3 [95% CI 1.5 to 3.6]; p < 0.001) and for heads larger than 50 mm for the entire period (HR 2.2 [95% CI 1.4 to 3.6]; p < 0.001). Two prosthesis combinations fulfilled the inclusion criteria for the prosthesis-specific analysis. One had a higher risk of revision when used with non-XLPE compared with XLPE after 1.5 years (HR 3.7 [95% CI 2.2 to 6.3]; p < 0.001). For the second prosthesis combination, no difference was found in the rate of revision between the two groups., Conclusion: These AOANJRR data demonstrate that noncrosslinked, all-polyethylene glenoid components have a higher revision rate compared with crosslinked, all-polyethylene glenoid components when used in stemmed anatomic TSA for osteoarthritis. As polyethylene type is likely an important determinant of revision risk, crosslinked polyethylene should be used when available, particularly for head sizes larger than 44 mm. Further studies will need to be undertaken after larger numbers of shoulder arthroplasties have been performed to determine whether this reduction in revision risk associated with XLPE bears true for all TSA designs., Level of Evidence: Level III, therapeutic study., Competing Interests: 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., (Copyright © 2022 by the Association of Bone and Joint Surgeons.)

Introduction: Hip fractures treated with total hip arthroplasty (THA) are at high risk of prosthesis instability, and dislocation is the most common indication for revision surgery. This study aims to determine whether dual mobility THA implants reduce the risk of dislocation compared with conventional THA in patients with hip fracture suitable to be treated with THA., Methods and Analysis: This is a cluster-randomised, crossover, open-label trial nested within the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). The clusters will comprise hospitals that perform at least 12 THAs for hip fracture per annum. All adults age ≥50 years who meet the Australian and New Zealand Hip Fracture Registry guidelines for THA will be included. The intervention will be dual mobility THA and the comparator will be conventional THA. Each hospital will be allocated to two consecutive periods, one of dual mobility THA and the other of conventional THA in random order, aiming for an average of 16 patients eligible for the primary analysis per group (32 total per site), allowing different recruitment totals between sites. Data will be collected through the AOANJRR and linked with patient-level discharge data acquired through government agencies. The primary outcome is dislocation within 1 year. Secondary outcomes include revision surgery for dislocation and all-cause, complications and mortality at 1, 2 and 5 years. If dual mobility THA is found to be superior, a cost-effectiveness analysis will be conducted. The study will aim to recruit 1536 patients from at least 48 hospitals over 3 years., Ethics and Dissemination: Ethics approval has been granted (Sydney Local Health District - Royal Prince Alfred Hospital Zone (approval X20-0162 and 2020/ETH00680) and site-specific approvals). Participant recruitment is via an opt-out consent process as both treatments are considered accepted, standard practice. The trial is endorsed by the Australia and New Zealand Musculoskeletal Clinical Trials Network., Trial Registration Number: ACTRN12621000069853., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: When arthroplasty is indicated for a femoral neck fracture (FNF), it is unclear whether total hip arthroplasty (THA) or hemiarthroplasty (HA) is best. This study compares data from the Australian Orthopaedic Association National Joint Replacement Registry using contemporary surgical options., Methods: Patients from 60 to 85 years old who were treated with arthroplasty for FNF, between September 1999 and December 2019, were included if the femoral stems were cemented. Only THAs with femoral heads of ≥36 mm or dual-mobility articulations were included. Patients who had monoblock HA were excluded. Rates of revision for all aseptic failures and dislocation were compared. Competing risks of revision and death were considered using the cumulative incidence function. Subdistribution hazard ratios (HRs) for revision or death from a Fine-Gray regression model were used to compare THA and HA. Interactions of procedure with age group and sex were considered. Secondary analysis adjusting for body mass index (BMI) and American Society of Anesthesiologists (ASA) classification was also considered., Results: There were 4,551 THA and 29,714 HA procedures included. The rate of revision for THA was lower for women from 60 to 69 years old (HR = 0.58 [95% confidence interval (CI), 0.39 to 0.85]) and from 70 to 74 years old (HR = 0.65 [95% CI, 0.43 to 0.98]) compared with HA. However, women from 80 to 85 years old (HR = 1.56 [95% CI, 1.03 to 2.35]) and men from 75 to 79 years old (HR = 1.61 [95% CI, 1.05 to 2.46]) and 80 to 85 years old (HR = 2.73 [95% CI, 1.89 to 3.95]) had an increased rate of revision when THA was undertaken compared with HA. There was no difference in the rate of revision for dislocation between THA and HA for either sex or age categories., Conclusions: When contemporary surgical options for FNF are used, there is a benefit with respect to revision outcomes for THA in women who are <75 years old and a benefit for HA in women who are ≥80 years old and men who are ≥75 years old. There is no difference in dislocation rates., Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H138 )., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Total hip replacement (THR) and total knee replacement (TKR) are cost-effective interventions to reduce pain and disability associated with osteoarthritis, however there is no clear guidelines available to determine appropriate patient selection and the timing of surgery. This prospective cohort study aimed to evaluate the hospital- and surgeon-level variation in the severity of patient-reported symptoms prior to THR and TKR., Methods: Patients undergoing primary THR (n = 4330) or TKR (n = 7054) for osteoarthritis who participated in a national registry-led Patient Reported Outcome Measures (PROMs) pilot program were included in the analysis. Pre-operative Oxford Hip Score (OHS) and Oxford Knee Score (OKS) (range 0-48; representing worst to best hip/knee pain and function) data were examined for variation between private and public hospitals and between surgeons using linear mixed models., Results: Pre-operative mean OHS was significantly higher (better) in patients whose surgery was performed in a private hospital compared to public hospitals; 21.39 versus 18.11 (mean difference 3.27, 95% CI 1.75, 4.79). For OKS, the difference between private hospital and public hospital scores was dependent on BMI and gender. Most of the variation in pre-operative OHS and OKS was not at the individual hospital- or surgeon-level, which explained only a negligible proportion of the model variance (⟨5%) for THR and TKR., Conclusion: Apart from a difference between private and public hospitals, there was little between-hospital or between-surgeon symptom variation in joint-specific pain and function prior to THR or TKR. The findings suggest consistency in the surgical thresholds for patients being offered hip and knee joint replacement procedures., (© 2022 Royal Australasian College of Surgeons.)

Aims: The aim of this study was to estimate the 90-day periprosthetic joint infection (PJI) rates following total knee arthroplasty (TKA) and total hip arthroplasty (THA) for osteoarthritis (OA)., Methods: This was a data linkage study using the New South Wales (NSW) Admitted Patient Data Collection (APDC) and the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), which collect data from all public and private hospitals in NSW, Australia. Patients who underwent a TKA or THA for OA between 1 January 2002 and 31 December 2017 were included. The main outcome measures were 90-day incidence rates of hospital readmission for: revision arthroplasty for PJI as recorded in the AOANJRR; conservative definition of PJI, defined by T84.5, the PJI diagnosis code in the APDC; and extended definition of PJI, defined by the presence of either T84.5, or combinations of diagnosis and procedure code groups derived from recursive binary partitioning in the APDC., Results: The mean 90-day revision rate for infection was 0.1% (0.1% to 0.2%) for TKA and 0.3% (0.1% to 0.5%) for THA. The mean 90-day PJI rates defined by T84.5 were 1.3% (1.1% to 1.7%) for TKA and 1.1% (0.8% to 1.3%) for THA. The mean 90-day PJI rates using the extended definition were 1.9% (1.5% to 2.2%) and 1.5% (1.3% to 1.7%) following TKA and THA, respectively., Conclusion: When reporting the revision arthroplasty for infection, the AOANJRR substantially underestimates the rate of PJI at 90 days. Using combinations of infection codes and PJI-related surgical procedure codes in linked hospital administrative databases could be an alternative way to monitor PJI rates.Cite this article: Bone Joint J  2022;104-B(9):1060-1066.

Importance: There remains a lack of randomized trials investigating aspirin monotherapy for symptomatic venous thromboembolism (VTE) prophylaxis following total hip arthroplasty (THA) or total knee arthroplasty (TKA)., Objective: To determine whether aspirin was noninferior to enoxaparin in preventing symptomatic VTE after THA or TKA., Design, Setting, and Participants: Cluster-randomized, crossover, registry-nested trial across 31 hospitals in Australia. Clusters were hospitals performing greater than 250 THA or TKA procedures annually. Patients (aged ≥18 years) undergoing hip or knee arthroplasty procedures were enrolled at each hospital. Patients receiving preoperative anticoagulation or who had a medical contraindication to either study drug were excluded. A total of 9711 eligible patients were enrolled (5675 in the aspirin group and 4036 in the enoxaparin group) between April 20, 2019, and December 18, 2020. Final follow-up occurred on August 14, 2021., Interventions: Hospitals were randomized to administer aspirin (100 mg/d) or enoxaparin (40 mg/d) for 35 days after THA and for 14 days after TKA. Crossover occurred after the patient enrollment target had been met for the first group. All 31 hospitals were initially randomized and 16 crossed over prior to trial cessation., Main Outcomes and Measures: The primary outcome was symptomatic VTE within 90 days, including pulmonary embolism and deep venous thrombosis (DVT) (above or below the knee). The noninferiority margin was 1%. Six secondary outcomes are reported, including death and major bleeding within 90 days. Analyses were performed by randomization group., Results: Enrollment was stopped after an interim analysis determined the stopping rule was met, with 9711 patients (median age, 68 years; 56.8% female) of the prespecified 15 562 enrolled (62%). Of these, 9203 (95%) completed the trial. Within 90 days of surgery, symptomatic VTE occurred in 256 patients, including pulmonary embolism (79 cases), above-knee DVT (18 cases), and below-knee DVT (174 cases). The symptomatic VTE rate in the aspirin group was 3.45% and in the enoxaparin group was 1.82% (estimated difference, 1.97%; 95% CI, 0.54%-3.41%). This failed to meet the criterion for noninferiority for aspirin and was significantly superior for enoxaparin (P = .007). Of 6 secondary outcomes, none were significantly better in the enoxaparin group compared with the aspirin group., Conclusions and Relevance: Among patients undergoing hip or knee arthroplasty for osteoarthritis, aspirin compared with enoxaparin resulted in a significantly higher rate of symptomatic VTE within 90 days, defined as below- or above-knee DVT or pulmonary embolism. These findings may be informed by a cost-effectiveness analysis., Trial Registration: ANZCTR Identifier: ACTRN12618001879257.

Update: This article was updated on August 17, 2022, because of previous errors, which were discovered after the preliminary version of the article was posted online. On page 1462, in the first sentence of the Abstract section entitled "Results," the phrase that had read "and 36-mm heads had fewer dislocations than 28-mm (HR = 0.33 [95% CI, 0.16 to 0.68]; p = 0.003), but more dislocations than 32-mm heads (HR for >2 weeks = 2.25 [95% CI, 1.13 to 4.49]; p = 0.021)" now reads "and 36-mm heads had fewer dislocations than 28-mm (HR = 0.33 [95% CI, 0.16 to 0.68]; p = 0.003) and 32-mm heads (HR for ≥2 weeks = 0.44 [95% CI, 0.22 to 0.88]; p = 0.021)." On page 1468, in the last sentence of the section entitled "Acetabular Components with a Diameter of <51 mm," the phrase that had read "and HR for ≥2 weeks = 2.25 [95% CI, 1.13 to 4.49; p = 0.021]) ( Fig. 3 )" now reads "and HR for ≥2 weeks = 0.44 [95% CI, 0.22 to 0.88; p = 0.021]) ( Fig. 3 )." Finally, on page 1466, in the upper right corner of Figure 3 , under "32mm vs 36mm," the second line that had read "2Wks+: HR=2.25 (1.13, 4.49), p=0.021" now reads "2Wks+: HR=0.44 (0.22, 0.88), p= 0.021.", Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H89 )., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background and Purpose: Total knee replacement (TKR) studies usually analyze all-cause revision when considering relationships with patient and prosthesis factors. We studied how these factors impact different revision diagnoses., Patients and Methods: We used data from 2003 to 2019 of TKR for osteoarthritis from the arthroplasty registries of Sweden, Australia, and Kaiser Permanente, USA to study patient and prosthesis characteristics for specific revision diagnoses. There were 1,072,924 primary TKR included and 36,626 were revised. Factors studied included age, sex, prosthesis constraint, fixation method, bearing mobility, polyethylene type, and patellar component use. Revision diagnoses were arthrofibrosis, fracture, infection, instability, loosening, pain, patellar reasons, and wear. Odds ratios (ORs) for revision were estimated and summary effects were calculated using a meta-analytic approach., Results: We found between-registry consistency in 15 factor/reason analyses. Risk factors for revision for arthrofibrosis were age < 65 years (OR 2.0; 95% CI 1.4-2.7) and mobile bearing designs (MB) (OR 1.7; CI 1.1-2.5), for fracture were female sex (OR 3.2; CI 2.2-4.8), age ≥ 65 years (OR 2.8; CI 1.9-4) and posterior stabilized prostheses (PS) (OR 2.1; CI 1.3-3.5), for infection were male sex (OR 1.9; CI 1.7-2.0) and PS (OR 1.5; CI 1.2-1.8), for instability were age < 65 years (OR 1.5; CI 1.3-1.8) and MB (OR 1.5; CI 1.1-2.2), for loosening were PS (OR 1.5; CI 1.4-1.6), MB (OR 2.2; CI 1.6-3.0) and use of ultra-high molecular weight polyethylene (OR 2.3; CI 1.8-2.9), for patellar reasons were not resurfacing the patella (OR 13.6; CI 2.1-87.2) and MB (OR 2.0; CI 1.2-3.3) and for wear was cementless fixation (OR 4.9; CI 4.3-5.5)., Interpretation: Patients could be counselled regarding specific age and sex risks. Use of minimally stabilized, fixed bearing, cemented prostheses, and patellar components is encouraged to minimize revision risk.

Background: Obesity is associated with the development of knee osteoarthritis (OA). The aim of this study was to examine the incidence of obesity in patients undergoing knee replacement (KR) for OA in Australia compared to the incidence of obesity in the general population., Methods: A cohort study was conducted, comparing data from the Australian Bureau of Statistics (ABS) 2017-2018 National Health Survey with data from the National Joint Replacement Registry. The distribution of patients who underwent KR from July 2017 to June 2018 by BMI category was compared to the distribution of the general population, in age and gender sub-groups., Results: During the study period, 35.6% of Australian adults were overweight and 31.3% were obese. Of the 56 217 patients who underwent primary KR for OA, 31.9% were overweight and 57.7% were obese. The relative risk of undergoing KR for OA increased with increasing BMI category. Class 1, 2 and 3 obese females aged 55-64 years were 4.7, 8.4 and 17.3 times more likely to undergo KR than their normal weight counterparts, respectively. Males in the same age and BMI categories were 3.4, 4.5 and 5.8 times more likely to undergo KR, respectively. Class 3 obese patients underwent KR 7 years younger, on average, than normal weight individuals., Conclusion: Obesity is associated with an increased risk of undergoing KR, and at a younger age, particularly for females. There is an urgent need for a societal level approach to address the prevalence of obesity, to reduce the burden of obesity related KR., (© 2022 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: Patient-reported outcome measures (PROMs) are commonly used to report outcomes after hip and knee arthroplasty, but response rates are rarely complete. Given that preoperative health status (as measured by PROMs) is a strong predictor of outcomes (using the same measures) and that these outcomes may influence the response rate, it is possible that postoperative response rates (the proportion of patients providing preoperative PROMs who also provide postoperative PROMs) may be influenced by preoperative health status., Objective: This study aims to test the association between preoperative PROMs and postoperative response status following hip and knee arthroplasty., Methods: Data from the PROMs program of the Australian national joint registry were used. The preoperative PROMs were the Oxford Hip Score or Oxford Knee Score, The EQ-5D Utility Index, and the EQ visual analog scale (VAS) for overall health. Logistic regression, adjusting for age, sex, BMI, and the American Society of Anesthesiologists (ASA) Physical Status Classification System, was used to test the association between each preoperative PROM and response status for the 6-month postsurgery survey., Results: Data from 9499 and 16,539 patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis, respectively, were included in the analysis. Adjusting for age, sex, BMI, and ASA, there was no significant difference in response status at the postoperative follow-up based on the preoperative Oxford Hip or Knee Scores (odds ratio [OR] 1.00, 95% CI 0.99-1.01 for both; P=.70 for THA and P=.85 for TKA). Healthier patients (based on the EQ VAS scores) preoperatively were more likely to respond postoperatively, but this difference was negligible (OR 1.00, 95% CI 1.00-1.01 for THA and TKA; P=.004 for THA and P<.001 for TKA). The preoperative EQ Utility Index was not associated with the postoperative response rate for THA (OR 1.14, 95% CI 0.96-1.36; P=.13) or TKA patients (OR 1.05, 95% CI 0.91-1.22; P=.49)., Conclusions: The likelihood of responding to a postoperative PROMs survey for patients undergoing hip or knee arthroplasty was not associated with clinically important differences in preoperative patient-reported joint pain, function, or health-related quality of life. This suggests that the assessment of postoperative outcomes in hip and knee arthroplasty is not biased by differences in preoperative health measures between responders and nonresponders., (©Ian A Harris, Yi Peng, Ilana Ackerman, Stephen E Graves. Originally published in JMIR Perioperative Medicine (http://periop.jmir.org), 30.06.2022.)

Background: Dislocation is one of the most common causes of a re-revision after a revision THA. Dual-mobility constructs and large femoral head bearings (≥ 36 mm) are known options for mitigating this risk. However, it is unknown which of these choices is better for reducing the risk of dislocation and all-cause re-revision surgery. It is also unknown whether there is a difference between dual-mobility constructs and large femoral head bearings according to the size of the acetabular component., Questions/purposes: We used data from a large national registry to ask: In patients undergoing revision THA for aseptic causes after a primary THA performed for osteoarthritis, (1) Does the proportion of re-revision surgery for prosthesis dislocation differ between revision THAs performed with dual-mobility constructs and those performed with large femoral head bearings? (2) Does the proportion of re-revision surgery for all aseptic causes differ between revision THAs performed with dual-mobility constructs and those performed with large femoral head bearings? (3) Is there a difference when the results are stratified by acetabular component size?, Methods: Data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) were analyzed for 1295 first-revision THAs for aseptic causes after a primary THA performed for osteoarthritis. The study period was from January 2008-when the first dual-mobility prosthesis was recorded-to December 2019. There were 502 dual-mobility constructs and 793 large femoral head bearings. There was a larger percentage of women in the dual-mobility construct group (67% [334 of 502]) compared with the large femoral head bearing group (51% [402 of 793]), but this was adjusted for in the statistical analysis. Patient ages were similar for the dual-mobility construct group (67 ± 11 years) and the large femoral head group (65 ± 12 years). American Society of Anesthesiologists (ASA) class and BMI distributions were similar. The mean follow-up was shorter for dual-mobility constructs at 2 ± 1.8 years compared with 4 ± 2.9 years for large femoral head bearings. The cumulative percent revision (CPR) was determined for a diagnosis of prosthesis dislocation as well as for all aseptic causes (excluding infection). Procedures using metal-on-metal bearings were excluded. The time to the re-revision was described using Kaplan-Meier estimates of survivorship, with right censoring for death or database closure at the time of analysis. The unadjusted CPR was estimated each year of the first 5 years for dual-mobility constructs and for each of the first 9 years for large femoral head bearings, with 95% confidence intervals using unadjusted pointwise Greenwood estimates. The apparent shorter follow-up of the dual-mobility construct group relates to the more recent increase in dual-mobility numbers recorded in the registry. The results were adjusted for age, gender, and femoral fixation. Results were subanalyzed for acetabular component sizes < 58 mm and ≥ 58 mm, set a priori on the basis of biomechanical and other registry data., Results: There was no difference in the proportion of re-revision for prosthesis dislocation between dual-mobility constructs and large femoral head bearings (hazard ratio 1.22 [95% CI 0.70 to 2.12]; p = 0.49). At 5 years, the CPR of the re-revision for prosthesis dislocation was 4.0% for dual mobility constructs (95% CI 2.3% to 6.8%) and 4.1% for large femoral head bearings (95% CI 2.7% to 6.1%). There was no difference in the proportion of all aseptic-cause second revisions between dual-mobility constructs and large femoral head bearings (HR 1.02 [95% CI 0.76 to 1.37]; p = 0.89). At 5 years, the CPR of dual-mobility constructs was 17.6% for all aseptic-cause second revision (95% CI 12.6% to 24.3%) and 17.8% for large femoral head bearings (95% CI 14.9% to 21.2%). When stratified by acetabular component sizes less than 58 mm and at least 58 mm, there was no difference in the re-revision CPR for dislocation or for all aseptic causes between dual-mobility constructs and large femoral head bearings., Conclusion: Either dual-mobility constructs or large femoral head bearings can be used in revision THA, regardless of acetabular component size, as they did not differ in terms of re-revision rates for dislocation and all aseptic causes in this registry study. Longer term follow-up is required to assess whether complications develop with either implant or whether a difference in revision rates becomes apparent. Ongoing follow-up and comparison in a registry format would seem the best way to compare long-term complications and revision rates. Future studies should also compare surgeon factors and whether they influence decision-making between prosthesis options and second revision rates. Nested randomized controlled trials in national registries would seem a viable option for future research., Level of Evidence: Level III, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. 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., (Copyright © 2022 by the Association of Bone and Joint Surgeons.)

Background: For patient-reported outcome measures (PROMs) to provide meaningful information to support clinical care, we need to understand the magnitude of change that matters to patients. The aim of this study was to estimate minimal clinically important changes (MCICs) for the 12-item Hip disability and Osteoarthritis Outcome Score (HOOS-12) and Knee injury and Osteoarthritis Outcome Score (KOOS-12) among people undergoing joint replacement for osteoarthritis., Methods: Individual-level data from the Australian Orthopaedic Association National Joint Replacement Registry's pilot PROMs program were used for this analysis. Preoperative and 6-month postoperative HOOS-12 and KOOS-12 domain and summary impact scores plus a rating of patient-perceived change after surgery (on a 5-point scale ranging from "much worse" to "much better") were available. Three anchor-based approaches-mean change, receiver operating characteristics (ROC) based on Youden's J statistic, and predictive modeling using a binary logistic regression model-were used to calculate MCICs based on patient-perceived change., Results: Data were available for 1,490 patients treated with total hip replacement (THR) (mean age, 66 years; 54% female) and 1,931 patients treated with total knee replacement (TKR) (mean age, 66 years; 55% female). Using the mean change method, the MCIC ranged from 24.0 to 27.5 points for the HOOS-12 and 17.5 to 21.8 points for the KOOS-12. The ROC analyses generated comparable MCIC values (28.1 for HOOS-12 and a range of 15.6 to 21.9 for KOOS-12) with high sensitivity and specificity. Lower estimates were derived from predictive modeling following adjustment for the proportion of improved patients (range, 15.7 to 19.2 for HOOS-12 and 14.2 to 16.5 for KOOS-12)., Conclusions: We report MCIC values for the HOOS-12 and KOOS-12 instruments that we derived using 3 different methods. As estimates obtained using predictive modeling can be adjusted for the proportion of improved patients, these may be the most clinically applicable. These MCIC values can be used to interpret important changes in pain, function, and quality of life from the patient's perspective., Levels of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G947)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Objectives: This study aims to compare early mortality after total knee arthroplasty (TKA) using conventional intramedullary instrumentation to TKA performed using technology-assisted (non-intramedullary) instrumentation., Design: Comparative observational study. Using data from a large national registry, the 30-day mortality after unilateral TKA performed for osteoarthritis was compared between procedures using conventional instrumentation and those using technology-assisted instrumentation. Firth logistic regression was used to calculate ORs, adjusting for age, sex, use of cement and procedure year for the whole period, and additionally adjusting for American Society of Anesthesiologists physical status classification system class and body mass index (BMI) for the period 2015 to 2019. This analysis was repeated for 7-day and 90-day mortality., Setting: National arthroplasty registry., Participants: People undergoing unilateral, elective TKA for osteoarthritis from 2003 to 2019 inclusive., Interventions: TKA performed using conventional intramedullary instrumentation or technology-assisted instrumentation., Main Outcome Measures: 30-day mortality (primary), and 7-day and 90-day mortality., Results: A total of 581 818 unilateral TKA procedures performed for osteoarthritis were included, of which 602 (0.10%) died within 30 days of surgery. The OR of death within 30 days following TKA performed with conventional instrumentation compared with technology-assisted instrumentation, adjusted for age, sex, cement use, procedure year, American Society of Anesthesiologists and BMI was 1.72 (95% CI, 1.23 to 2.41, p=0.001). The corresponding ORs for 7-day and 90-day mortality were 2.21 (96% CI, 1.34 to 3.66, p=0.002) and 1.35 (95% CI, 1.07 to 1.69, p=0.010), respectively., Conclusions: The use of conventional instrumentation during TKA is associated with higher odds of early postoperative death than when technology-assisted instrumentation is used. This difference may be explained by complications related to fat embolism secondary to intramedullary rods used in conventional instrumentation. Given the high number of TKA performed annually worldwide, increasing the use of technology-assisted instrumentation may reduce early post-operative mortality., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: National joint registries under-report revisions for periprosthetic joint infection (PJI). We aimed to validate PJI reporting to the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR) and the factors associated with its accuracy. We then applied these data to refine estimates of the total national burden of PJI., Methods: A total of 561 Australian cases of confirmed PJI were captured by a large, prospective observational study, and matched to data available for the same patients through the AOANJRR., Results: In all, 501 (89.3%) cases of PJI recruited to the prospective observational study were successfully matched with the AOANJRR database. Of these, 376 (75.0%) were captured by the registry, while 125 (25.0%) did not have a revision or reoperation for PJI recorded. In a multivariate logistic regression analysis, early (within 30 days of implantation) PJIs were less likely to be reported (adjusted odds ratio (OR) 0.56; 95% confidence interval (CI) 0.34 to 0.93; p = 0.020), while two-stage revision procedures were more likely to be reported as a PJI to the registry (OR 5.3 (95% CI 2.37 to 14.0); p ≤ 0.001) than debridement and implant retention or other surgical procedures. Based on this data, the true estimate of the incidence of PJI in Australia is up to 3,900 cases per year., Conclusion: In Australia, infection was not recorded as the indication for revision or reoperation in one-quarter of those with confirmed PJI. This is better than in other registries, but suggests that registry-captured estimates of the total national burden of PJI are underestimated by at least one-third. Inconsistent PJI reporting is multifactorial but could be improved by developing a nested PJI registry embedded within the national arthroplasty registry. Cite this article: Bone Jt Open  2022;3(5):367-373.

Aims: This study aimed to describe the use of revision knee arthroplasty in Australia and examine changes in lifetime risk over a decade., Methods: De-identified individual-level data on all revision knee arthroplasties performed in Australia from 2007 to 2017 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Population data and life tables were obtained from the Australian Bureau of Statistics. The lifetime risk of revision surgery was calculated for each year using a standardized formula. Separate calculations were undertaken for males and females., Results: In total, 43,188 revision knee arthroplasty procedures were performed in Australia during the study period, with a median age at surgery of 69 years (interquartile range (IQR) 62 to 76). In 2017, revision knee arthroplasty rates were highest for males aged 70 to 79 years (102.9 procedures per 100,000 population). Lifetime risk of revision knee arthroplasty for females increased slightly from 1.61% (95% confidence interval (CI) 1.53% to 1.69%) in 2007 to 2.22% (95% CI 2.13% to 2.31%) in 2017. A similar pattern was evident for males, with a lifetime risk of 1.43% (95% CI 1.36% to 1.51%) in 2007 and 2.02% (95% CI 1.93% to 2.11%) in 2017. A decline in procedures performed for loosening/lysis (from 41% in 2007 to 24% in 2017) and pain (from 14% to 9%) was evident, while infection became an increasingly common indication (from 19% in 2007 to 29% in 2017)., Conclusion: Well-validated national registry data can help us understand the epidemiology of revision knee arthroplasty, including changing clinical indications. Despite a small increase over a decade, the lifetime risk of revision knee arthroplasty in Australia is low at one in 45 females and one in 50 males. These methods offer a population-level approach to quantifying revision burden that can be used for ongoing national surveillance and between-country comparisons. Cite this article: Bone Joint J  2022;104-B(5):613-619.

Background: The collection of patient-reported outcome measures (PROMs) following arthroplasty is common. PROMs data collection programs seek to maximise completeness in order to minimise selection bias and optimise representativeness of the sample attained. We aimed to determine if patient factors influence variation in PROMs program completeness between-hospitals., Methods: Using data from a national arthroplasty registry PROMs program, we tested for associations between patient characteristics (age, sex, body mass index [BMI] and American Society of Anaesthesiologists [ASA] class) and both potential completeness (registration completeness: the proportion of arthroplasty patients that were registered in the PROMs electronic system) and actual completeness (response completeness: the proportion of arthroplasty patients who provided PROMs data) using linear regression., Results: When using all elective primary total hip, knee or shoulder arthroplasty procedures (N = 31,801) from 43 hospitals as the denominator, overall registration completeness was 52%, varying from 5 to 87% between hospitals. Overall pre-operative response completeness was 46%, varying from 5 to 82% between hospitals. There were no significant associations between hospital-level registration completeness or response completeness and age, sex, BMI or ASA score., Conclusion: Completeness rates of a PROMs program in arthroplasty varied widely between hospitals but in the absence of a relationship between measured patient factors and completeness rates, the observed variation likely relates to local site factors such as access to patients, local resources and clinician engagement with the program. Efforts to improve the rates of completeness of arthroplasty PROMs programs at individual hospitals may not improve the representativeness of the sample., (© 2022. The Author(s).)

Objective: To develop and validate bi-directional crosswalks between the Oxford Hip Score (OHS) and HOOS-12 summary impact score, and between the Oxford Knee Score (OKS) and KOOS-12 summary impact score., Methods: Data were sourced from the Australian Orthopaedic Association National Joint Replacement Registry Patient-Reported Outcome Measures Program. Patients undergoing primary joint replacement for osteoarthritis who completed the OHS and HOOS-12 or OKS and KOOS-12 instruments were included in the analysis. An equipercentile method was used to create four crosswalks, with the distribution of scores smoothed using log-linear models prior to equating. Crosswalk validity was assessed through comparison of actual vs derived scores, Pearson correlation coefficients, root mean square errors (RMSE) and Bland-Altman plots., Results: Paired OHS/HOOS-12 data and paired OKS/KOOS-12 data were available for 4,513 patients undergoing total hip replacement and 5,942 patients undergoing total knee replacement, respectively. Minimal differences were observed between actual and crosswalk-derived mean scores (actual OHS 27.55 vs derived OHS 27.56; actual HOOS-12 53.28 vs derived HOOS-12 53.31; actual OKS 27.34 vs derived OKS 27.34; actual KOOS-12 50.51 vs derived KOOS-12 50.58). High correlation was observed between actual and derived scores (Pearson's r for hip-specific instruments: 0.943-0.946; Pearson's r for knee-specific instruments: 0.925-0.931). Plotted actual vs mean derived scores also indicated robust concordance across the breadth of the instrument scales., Conclusion: These crosswalks provide close approximations of actual OHS, OKS, HOOS-12 and KOOS-12 scores, as indicated by multiple validation metrics. They offer a resource for clinicians, researchers and arthroplasty registries to support PROMs score conversion and data harmonisation efforts., (Copyright © 2022 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Background: Long-term implant survivorship in THA and TKA involves a combination of factors related to the patient, the implants used, and the decision-making and technical performance of the surgeon. It is unclear which of these factors is the most important in reducing the proportion of revision surgery., Questions/purposes: We used data from a large national registry to ask: In patients receiving primary THA and TKA for a diagnosis of osteoarthritis, do (1) the reasons for revision and (2) patient factors, the implants used, and the surgeon or surgical factors differ between surgeons performing THA and TKA who have a lower revision rate compared with all other surgeons?, Methods: Data were analyzed for all THA and TKA procedures performed for a diagnosis of osteoarthritis from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from September 1, 1999, when collection began, to December 31, 2018. The AOANJRR obtains data on more than 98% of joint arthroplasties performed in Australia. The 5-year cumulative percent revision (CPR) was identified for all THAs and TKAs performed for a diagnosis of osteoarthritis with 95% confidence intervals (overall CPR); the 5-year CPR with 95% CIs for each surgeon was calculated for THA and TKA separately. For surgeons to be included in the analysis, they had to have performed at least 50 procedures and have a 5-year CPR. The 5-year CPR with 95% CIs for each THA and TKA surgeon was compared with the overall CPR. Two groups were defined: low revision rate surgeons (the upper confidence level for a given surgeon at 5 years is less than 3.84% for THA and 4.32% for TKA), and all other surgeons (any surgeon whose CPR was higher than those thresholds). The thresholds were determined by setting a cutoff at 20% above the upper confidence level for that class. The approach we used to define a low revision rate surgeon was similar to that used by the AOANJRR for determining the better-performing prostheses and is recommended by the International Prosthesis Benchmarking Working Group. By defining the groups in this way, a significant difference between these two groups is created. Determining a reason for this difference is the purpose of presenting the proportions of different factors within each group. The study group for THA included 116 low revision rate surgeons, who performed 88,392 procedures (1619 revised, 10-year CPR 2.7% [95% CI 2.6% to 2.9%]) and 433 other surgeons, who performed 170,094 procedures (6911 revised, 10-year CPR 5.9% [95% CI 5.7% to 6.0%]). The study group for TKA consisted of 144 low revision rate surgeons, who performed 159,961 procedures (2722 revised, 10-year CPR 2.6% [95% CI 2.5% to 2.8%]) and 534 other surgeons, who performed 287,232 procedures (12,617 revised, 10-year CPR 6.4% [95% CI 6.3% to 6.6%]). These groups were defined a priori by their rate of revision, and the purpose of this study was to explore potential reasons for this observed difference., Results: For THA, the difference in overall revision rate between low revision rate surgeons and other surgeons was driven mainly by fewer revisions for dislocation, followed by component loosening and fracture in patients treated by low revision rate surgeons. For TKA, the difference in overall revision rate between low revision rate surgeons and other surgeons was driven mainly by fewer revisions for aseptic loosening, followed by instability and patellofemoral complications in patients treated by low revision rate surgeons. Patient-related factors were generally similar between low revision rate surgeons and other surgeons for both THA and TKA. Regarding THA, there were differences in implant factors, with low revision rate surgeons using fewer types of implants that have been identified as having a higher-than-anticipated rate of revision within the AOANJRR. Low revision rate surgeons used a higher proportion of hybrid fixation, although cementless fixation remained the most common choice. For surgeon factors, low revision rate surgeons were more likely to perform more than 100 THA procedures per year, while other surgeons were more likely to perform fewer than 50 THA procedures per year. In general, the groups of surgeons (low revision rate surgeons and other surgeons) differed less in terms of years of surgical experience than they did in terms of the number of cases they performed each year, although low revision rate surgeons, on average, had more years of experience and performed more cases per year. Regarding TKA, there were more differences in implant factors than with THA, with low revision rate surgeons more frequently performing patellar resurfacing, using an AOANJRR-identified best-performing prosthesis combination (with the lowest rates of revision), using fewer implants that have been identified as having a higher-than-anticipated rate of revision within the AOANJRR, using highly crosslinked polyethylene, and using a higher proportion of cemented fixation compared with other surgeons. For surgeon factors, low revision rate surgeons were more likely to perform more than 100 TKA procedures per year, whereas all other surgeons were more likely to perform fewer than 50 procedures per year. Again, generally, the groups of surgeons (low revision rate surgeons and other surgeons) differed less in terms of years of surgical experience than they did in terms of the number of cases they performed annually, although low revision rate surgeons, on average, had more years of experience and performed more cases per year., Conclusion: THAs and TKAs performed by surgeons with the lowest revision rates in Australia show reductions in all of the leading causes of revision for both THA and TKA, in particular, causes of revision related to the technical performance of these procedures. Patient factors were similar between low revision rate surgeons and all other surgeons for both THA and TKA. Low revision rate THA surgeons were more likely to use cement fixation selectively. Low revision rate TKA surgeons were more likely to use patella resurfacing, crosslinked polyethylene, and cemented fixation. Low revision rate THA and TKA surgeons were more likely to use an AOANJRR-identified best-performing prosthesis combination and to use fewer implants identified by the AOANJRR as having a higher-than-anticipated revision rate. To reduce the rate of revision THA and TKA, surgeons should consider addressing modifiable factors related to implant selection. Future research should identify surgeon factors beyond annual case volume that are important to improving implant survivorship., Level of Evidence: Level III, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. 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., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Background: A socioeconomic gradient exists in the utilisation of total hip replacements (THR) and total knee replacements (TKR) for osteoarthritis. However, the relations between socioeconomic status (SES) and time to THR or TKR is unknown., Aim: To describe the association between SES and time to THR and TKR., Methods: One thousand and seventy-two older adults residing in Tasmania, Australia, were studied. Incident primary THR and TKR were determined by data linkage to the Australian Orthopaedic Association National Joint Replacement Registry. At baseline, each participant's area-level SES was determined using the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD) from the Australian Bureau of Statistics' 2001 census data. The IRSAD was analysed in two ways: (i) categorised into quartiles, whereby quartile 1 represented the most socioeconomically disadvantaged group; and (ii) the cohort dichotomised at the quartile 1 cut-point., Results: The mean age was 63.0 (±7.5) years and 51% were women. Over the median follow up of 12.9 (interquartile range: 12.2-13.9) years, 56 (5%) participants had a THR and 79 (7%) had a TKR. Compared with the most disadvantaged quartile, less disadvantaged participants were less likely to have a THR (i.e. less disadvantaged participants had a longer time to THR; hazard ratio (HR): 0.56; 95% confidence interval (CI) 0.32, 1.00) but not TKR (HR: 0.90; 95% CI 0.53, 1.54). However, the former became non-significant after adjustment for pain and radiographic osteoarthritis, suggesting that the associations may be mediated by these factors., Conclusions: The present study suggests that time to joint replacement was determined according to the symptoms/need of the participants rather than their SES., (© 2020 Royal Australasian College of Physicians.)

Background: Highly porous-coated titanium acetabular components have a high coefficient of friction and ultraporous surfaces to enhance bone ingrowth and osseointegration in total hip arthroplasty (THA). There have been concerns with the development of early radiolucent lines and aseptic loosening of highly porous acetabular components. It is unclear whether these concerns relate to a specific implant or the entire class. The aim of this study is to compare the revision rates for aseptic loosening of highly porous acetabular combinations in primary THA using data from a large joint replacement registry., Methods: Data were retrieved from the Australian Orthopedic Association National Joint Replacement Registry for the study period September 1999 to December 2019. All primary THA procedures recorded and performed for osteoarthritis using the most common combinations for each highly porous acetabular component with highly cross-linked polyethylene and a 32-mm or 36-mm femoral head were included. The primary outcome measure was revision for aseptic loosening of the acetabular component. Results were adjusted for patient age and gender., Results: There were 20,993 primary THA procedures performed for osteoarthritis using a highly porous acetabular component across 6 combinations. Relative to the POLARSTEM/R3 (StikTite), the Exeter V40/Tritanium had a significantly higher risk of revision for aseptic loosening of the acetabular component (hazard ratio 0.21, 95% confidence interval 0.06-0.74, P = .014). There was no difference between any other highly porous acetabular component combination and no late revisions for aseptic loosening., Conclusion: Highly porous-coated titanium acetabular components have low rates of aseptic loosening with long-term follow-up. A difference between components may exist., Level of Evidence: Level III., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background and Purpose: Characteristics of patients receiving total knee arthroplasty (TKA) and prostheses used vary between regions and change with time. How these practice variations influence revision remains unclear. We combined registry data for better understanding of the impact of variation, which could potentially improve revision rates., Patients and Methods: We used data from 2003 to 2019 for primary TKA from arthroplasty registries of Sweden (SKAR), Australia (AOANJRR), and Kaiser Permanente (KPJRR). We included 1,072,924 TKA procedures for osteoarthritis. Factors studied included age, sex, ASA class, BMI category, prosthesis constraint, fixation, bearing mobility, patellar resurfacing, and polyethylene type. Cumulative percentage revision (CPR) was calculated using Kaplan-Meier estimates, and unadjusted Cox hazard ratios were used for comparisons. Random-effects generic inverse-variance meta-analytic methods were used to determine summary effects., Results: We found similarities in age and sex, but between-registry differences occurred in the other 7 factors studied. Patients from Sweden had lower BMI and ASA scores compared with other registries. Use of cement fixation was similar in the SKAR and KPJRR, but there were marked differences in patellar resurfacing and posterior stabilized component use. Meta-analysis results regarding survivorship favored patients aged ≥ 65 years and minimally stabilized components. There were inconsistent results with time for sex, fixation, and bearing mobility, and no differences for the patellar resurfacing or polyethylene type comparisons., Interpretation: Marked practice variation was found. Use of minimally stabilized and possibly also cemented and fixed bearing prostheses is supported.

Background: Compared with other total hip arthroplasty (THA) approaches, the anterior approach has an increased rate of revision for femoral-sided complications, and certain stems may increase this risk. The present study aimed to assess the outcome of THA by surgical approach, according to the femoral stem utilized in the procedure., Methods: Data from the Australian Orthopaedic Association National Joint Replacement Registry were analyzed for patients undergoing primary THA for osteoarthritis via the anterior or posterior approach with use of 1 of 5 of the most common cementless femoral stems from January 2015 to December 2019. The primary outcome measures were the cumulative percent revision (CPR) for all causes and for femoral stem loosening and fracture. The CPR was compared between THAs performed via the anterior and posterior approaches for all stems and for each individual femoral stem, as well as between individual femoral stems for each approach., Results: The study included 48,716 THAs performed with use of cementless stems, of which 22,840 utilized an anterior approach and 25,876 utilized a posterior approach. There was no difference in the all-cause CPR between the anterior and the posterior approach, but the anterior approach had a higher CPR for loosening (hazard ratio [HR], 2.00; 95% confidence interval [CI], 1.48 to 2.69; p < 0.001) and fracture (HR, 1.78; 95% CI, 1.34 to 2.35; p < 0.001). There was apparent variation in the CPR across the different cementless stems when an anterior approach was utilized. The Quadra-H (Medacta) had a higher all-cause CPR when compared with the Polarstem (Smith & Nephew; HR, 1.49; 95% CI, 1.16 to 1.91; p = 0.002) and Corail (DePuy Synthes; HR, 1.31; 95% CI, 1.00 to 1.70; p = 0.0478). Variation was less apparent with the posterior approach., Conclusions: THAs performed via the anterior approach had higher rates of revision for femoral stem loosening and fracture, with greater variation in outcomes between individual stems., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G757)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: To examine the association between circulating 25(OH)D concentrations and incidence of total hip replacement for osteoarthritis in a prospective cohort study., Methods: This study examined a random sample of 2651 participants in the Melbourne Collaborative Cohort Study who had 25(OH)D concentrations measured from dried blood spots collected in 1990-1994. Participants who underwent total hip replacement for osteoarthritis between January 2001 and December 2018 were identified by linking the cohort records to the Australian Orthopaedic Association National Joint Replacement Registry. Cox proportional hazard regression was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) of total hip replacement for osteoarthritis in relation to 25(OH)D concentrations, adjusted for confounders., Results: Eighty-six men and eighty-seven women had a total hip replacement for osteoarthritis. Compared with men in the lowest (1st) quartile of 25(OH)D concentration, the HR for total hip replacement was 2.32 (95% CI 1.05, 5.13) for those in the 2nd quartile, 2.77 (95% CI 1.28, 6.00) for those in the 3rd quartile, and 1.73 (95% CI 0.75, 4.02) for those in the highest quartile of 25(OH)D concentrations (p for trend 0.02). There was little evidence of an association in women., Conclusions: Higher circulating 25(OH)D concentrations were associated with an increased risk of total hip replacement for osteoarthritis in men but not in women. Although the underlying mechanism warrants further investigation, our findings highlight the need to determine the optimal levels of circulating 25(OH)D to reduce the risk of hip osteoarthritis., (© 2021. The Author(s).)

Background: When analyzing the outcomes of joint arthroplasty, an important factor to consider is patient comorbidities. The presence of multiple comorbidities has been associated with longer hospital stays, more postoperative complications, and increased mortality. The American Society of Anesthesiologists (ASA) physical status classification system score is a measure of a patient's overall health and has been shown to be associated with complications and mortality after joint arthroplasty. The Rx-Risk score is another measure for determining the number of different health conditions for which an individual is treated, with a possible score ranging from 0 to 47., Questions/purposes: For patients undergoing THA or TKA, we asked: (1) Which metric, the Rx-Risk score or the ASA score, correlates more closely with 30- and 90-day mortality after TKA or THA? (2) Is the Rx-Risk score correlated with the ASA score?, Methods: This was a retrospective analysis of the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) database linked to two other national databases, the National Death Index (NDI) database and the Pharmaceutical Benefits Scheme (PBS), a dispensing database. Linkage to the NDI provided outcome information on patient death, including the fact of and date of death. Linkage to the PBS was performed to obtain records of all medicines dispensed to patients undergoing a joint replacement procedure. Patients were included if they had undergone either a THA (119,076 patients, 131,336 procedures) or TKA (182,445 patients, 215,712 procedures) with a primary diagnosis of osteoarthritis, performed between 2013 and 2017. We excluded patients with missing ASA information (THA: 3% [3055 of 119,076]; TKA: 2% [4095 of 182,445]). This left 127,761 primary THA procedures performed in 116,021 patients (53% [68,037 of 127,761] were women, mean age 68 ± 11 years) and 210,501 TKA procedures performed in 178,350 patients (56% [117,337 of 210,501] were women, mean age 68 ± 9 years) included in this study. Logistic regression models were used to determine the concordance of the ASA and Rx-Risk scores and 30-day and 90-day postoperative mortality. The Spearman correlation coefficient (r) was used to estimate the correlation between the ASA score and Rx-Risk score. All analyses were performed separately for THAs and TKAs., Results: We found both the ASA and Rx-Risk scores had high concordance with 30-day mortality after THA (ASA: c-statistic 0.83 [95% CI 0.79 to 0.86]; Rx-Risk: c-statistic 0.82 [95% CI 0.79 to 0.86]) and TKA (ASA: c-statistic 0.73 [95% CI 0.69 to 0.78]; Rx-Risk: c-statistic 0.74 [95% CI 0.70 to 0.79]). Although both scores were strongly associated with death, their correlation was moderate for patients undergoing THA (r = 0.45) and weak for TKA (r = 0.38). However, the median Rx-Risk score did increase with increasing ASA score. For example, for THAs, the median Rx-Risk score was 1, 3, 5, and 7 for ASA scores 1, 2, 3, and 4, respectively. For TKAs, the median Rx-Risk score was 2, 4, 5, and 7 for ASA scores 1, 2, 3, and 4, respectively., Conclusion: The ASA physical status and RxRisk were associated with 30-day and 90-day mortality; however, the scores were only weakly to moderately correlated with each other. This suggests that although both scores capture a similar level of patient illness, each score may be capturing different aspects of health. The Rx-Risk may be used as a complementary measure to the ASA score., Level of Evidence: Level III, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. 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., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Background: There has been decreased use of anatomic total shoulder arthroplasty (aTSA) because reverse TSA (rTSA) is increasingly being used for the same indications. Although short-term studies generally have not found survivorship differences between these implant designs, these studies are often small and their follow-up is limited to the short term. Likewise, the degree to which patient characteristics (such as gender, age, and American Society of Anesthesiologists [ASA] score) may or may not be associated with survivorship differences calls for larger and longer-term studies than is often possible in single-center designs. Large national registry studies may be able to help answer these questions., Questions/purposes: By analyzing a large Australian registry series of primary aTSAs with cemented all-polyethylene glenoids and rTSA for osteoarthritis (OA), we asked: (1) Is the revision risk for OA higher for aTSA with all-polyethylene glenoids or for rTSA, adjusting for patient characteristics such as age, gender, ASA score, and BMI? (2) Is the patient's gender associated with differences in the revision risk after controlling for the potentially confounding factors of age, ASA score, and BMI?, Methods: In this comparative, observational registry study performed between January 1, 2015, and December 31, 2019, all primary aTSAs with all-polyethylene glenoids and rTSA for OA as determined by the treating surgeon and reported to our national registry formed two groups for analysis. The study period was set to time-match for the collection of ASA score and BMI in 2012 and 2015, respectively. Our registry enrolls more than 97% of all shoulder arthroplasties undertaken in Australia. There were 29,294 primary shoulder arthroplasties; 1592 hemiarthroplasties, 1876 resurfacing and stemless shoulders, 269 stemmed, and 11,674 reverse shoulder arthroplasties were excluded for other diagnoses. A total of 1210 metal-backed glenoids in stemmed aTSA for OA were excluded. A total of 3795 primary aTSAs with all-polyethylene glenoids and 8878 primary rTSAs for OA were compared. An aTSA with an all-polyethylene glenoid and rTSA were more likely to be performed in women (56% and 61% of patients, respectively). The mean age was 69 ± 8 years for aTSA with all-polyethylene glenoids and 74 ± 8 years for rTSA. One aTSA for OA was performed in a patient with an unknown glenoid type. The ASA score (n = 12,438) and BMI (n = 11,233) were also recorded. The maximum follow-up was 5 years for both groups, and the mean follow-up was 2.6 ± 1.4 years for aTSA with all-polyethylene glenoids and 2.1 ± 1.4 years for rTSA. The endpoint was time to revision (all causes), and the cumulative percent revision was determined using Kaplan-Meier estimates of survivorship (time to revision) and HRs from Cox proportional hazard models that were adjusted for age, gender, ASA score, and BMI category., Results: Overall, there were no differences in the 4-year cumulative percent revision between the groups; the 4-year cumulative percent revision was 3.5% for aTSA with all-polyethylene glenoids (95% CI 2.9%-4.2%) and 3.0% for rTSA (95% CI 2.6%-3.5%). There was an increased risk of revision of rTSA compared with aTSA using all-polyethylene glenoids in the first 3 months (HR 2.17 [95% CI 1.25-3.70]; p = 0.006, adjusted for age, gender, ASA score, and BMI). After that time, there was no difference in the rate of revision, with the same adjustments. In the first 3 months, men undergoing rTSA had a higher rate of revision than men with aTSA using all-polyethylene glenoids (HR 4.0 [95% CI 1.72-9.09]; p = 0.001, adjusted for age, BMI, and ASA). There was no difference between men in the two groups after that time. Women with aTSA using all-polyethylene glenoids were at a greater risk of revision than women with rTSA from 3 months onward (HR 2.77 [95% CI 1.55-4.92]; p < 0.001, adjusted for age, BMI, and ASA), with no difference before that time., Conclusion: Given the absence of survivorship differences at 4 years between rTSA and aTSA, but in light of the differences in the revision risk between men and women, surgeons might select an aTSA with an all-polyethylene glenoid to treat OA, despite the current popularity of rTSA. However, there are survivorship differences between genders. Future studies should evaluate whether our comparative findings are replicated in men and women undergoing aTSA with all-polyethylene glenoids and rTSA for primary diagnoses such as rheumatoid arthritis or post-traumatic arthritis, and whether there are functional differences between the two implant designs when used for OA., Level of Evidence: Level III, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. 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., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Background: Dual mobility (DM) and large femoral head bearings (≥36 mm) both decrease the risk of dislocation in total hip arthroplasty (THA). There is limited comparable data in primary THA. This study compared the revision rates for dislocation and aseptic causes between DM and large femoral heads and subanalyzed by acetabular component size., Methods: Data from the Australian Orthopedic Association National Joint Replacement Registry were analyzed for patients undergoing primary THA for osteoarthritis from January 2008 (the year of first recorded DM use) to December 2019. All DM and large femoral head bearings were identified. The primary outcome measure was the cumulative percent revision (CPR) for dislocation and for all aseptic causes. The results were adjusted by age, sex, and femoral fixation. A subanalysis was performed stratifying acetabular component diameter <58 m and ≥58 mm., Results: There were 4942 DM and 101,221 large femoral head bearings recorded. There was no difference in the CPR for dislocation (HR = 0.69 (95% CI 0.42, 1.13), P = .138) or aseptic causes (HR = 0.91 (95% CI 0.70, 1.18), P = .457). When stratified by acetabular component size, DM reduced the CPR for dislocation in acetabular component diameter <58 mm (HR = 0.55 (95% CI 0.30, 1.00), P = .049). There was no difference for diameter ≥58 mm. There was no difference in aseptic revision when stratified by acetabular component diameter., Conclusion: There is no difference in revision rates for dislocation or aseptic causes between DM and large femoral heads in primary THA. When stratified by acetabular component size, DM reduces dislocation for acetabular component diameter <58 mm., Level of Evidence: Level III., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Hip hemiarthroplasty is the most common arthroplasty option for fractured neck of femur (FNOF). Revision to total hip arthroplasty (THA) is occasionally required. This study aimed to assess the outcome of hemiarthroplasty revised to THA and to assess the impact of femoral head size, dual mobility (DM), and constrained liners., Methods: All aseptic 1 st revisions reported to the Australian Joint Replacement Registry after hemiarthroplasty performed for FNOF when a THA was used as the revision procedure were included from September 1999 to December 2019. The primary outcome measure was the cumulative percent revision for all-causes and dislocation. The impact of prosthesis factors on revision THA was assessed: standard head THA (≤32 mm), large head THA (≥36 mm), DM, and constrained liners. Outcomes were compared using Kaplan Meyer and competing risk., Results: There were 96,861 hemiarthroplasties performed, with 985 revised to THA. The most common reasons for 1 st revision were loosening (49.3%), fracture (17.7%), and dislocation (11.0%). Of the hemiarthroplasty procedures revised to THA, 76 had a 2 nd revision. The most common reasons for 2 nd revision were fracture (27.6%), dislocation (26.3%), loosening (23.7%), and infection (18.4%). Femoral head size, DM, or constrained liner use did not alter the incidence of all-cause 2 nd revision. This did not change when solely looking at patients still alive. A 2 nd revision was more likely in patients aged <75 years., Conclusion: The outcome of hemiarthroplasty performed for FNOF revised to THA is influenced by patient age, not by the articulation used., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Ceramic-on-ceramic bearing breakage is a rare but significant complication of total hip arthroplasty. This study aimed to identify risk factors for breakage and to determine the outcome of different revision options., Methods: All ceramic-on-ceramic primary total hip arthroplasty procedures reported to the Australian Joint Replacement Registry from September 1999 to December 2019 were included. Procedures were subdivided into alumina or mixed ceramic (alumina/zirconia). All breakages were identified. The association between ceramic type and head size was assessed. Subsequent revision rates were compared and cause of revision assessed., Results: There were 23,534 alumina and 71,144 mixed ceramic procedures. Breakage was the reason for 1 st revision in 84 alumina (5.27% of all revisions and 0.36% of procedures) and 56 mixed ceramic procedures (2.46% of all revisions; 0.08% of procedures). Alumina had a higher breakage rate than mixed ceramic (HR 2.50 (95% CI 1.75, 3.59), P < .001), and breakage was higher for 36-38mm head sizes using alumina (HR 2.84 (1.52, 5.31), P = .001). 17.8% of 2 nd revisions occur by 3 years, due to dislocation, infection, metal-related pathology, and loosening. A neck adapter sleeve did not reduce 2 nd revisions. Numbers were too low to compare revision bearing surface options., Conclusion: Ceramic breakage has reduced with mixed ceramics but has a 0.79/1000 incidence at 15-year follow-up. It is unclear what the risk factors are for modern ceramics with increasing head size a risk for alumina only. Risk of 2 nd revision is high and occurs early. The optimal revision option is unknown., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study is to describe predictors of total hip replacement (THR) in community dwelling older adults. A better understanding of predictors of THR can aid in triaging patients and researching preventative strategies., Design: At baseline, participants had assessment of radiographic OA and cam morphology (from pelvic radiographs), shape mode scores and hip bone mineral density (BMD; from dual energy X-ray absorptiometry (DXA)). After 2.6 and 5 years, participants reported hip pain using WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), and had hip structural changes assessed using magnetic resonance imaging (MRI). Risk of THR was analysed using mixed-effect Poisson regression., Results: Incidence of THR for OA over 14 years was 4.6% (37/801). As expected, WOMAC hip pain and hip radiographic OA both predicted risk of THR. Additionally, shape mode 2 score (decreasing acetabular coverage) (RR 1.83/SD; 95% CI 1.1-3.04), shape mode 4 score (non-spherical femoral head) (RR 0.59/SD; 95% CI 0.36-0.96), cam morphology (α > 60°) (RR 2.2/SD; 95% CI 1.33-3.36), neck of femur BMD (RR 2.09/SD, 95% CI 1.48-2.94) and bone marrow lesions (BMLs) increased risk of THR (RR 7.10/unit; 95% CI 1.09-46.29)., Conclusion: In addition to hip pain and radiographic hip OA, measures of hip shape, cam morphology, BMD and BMLs independently predict risk of THR. This supports the role of hip bone geometry and structure in the pathogenesis of end stage hip OA and has identified factors that can be used to improve prediction models for THR., Competing Interests: Conflict of interest The authors declare that they have no competing interests., (Copyright © 2021 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Background: Patient-reported outcome measures (PROMs) are commonly used to evaluate surgical outcome in patients undergoing joint replacement surgery, however routine collection from the target population is often incomplete. Representative samples are required to allow inference from the sample to the population. Although higher capture rates are desired, the extent to which this improves the representativeness of the sample is not known. We aimed to measure the representativeness of data collected using an electronic PROMs capture system with or without telephone call follow up, and any differences in PROMS reporting between electronic and telephone call follow up., Methods: Data from a pilot PROMs program within a large national joint replacement registry were examined. Telephone call follow up was used for people that failed to respond electronically. Data were collected pre-operatively and at 6 months post-operatively. Responding groups (either electronic only or electronic plus telephone call follow up) were compared to non-responders based on patient characteristics (joint replaced, bilaterality, age, sex, American Society of Anesthesiologist (ASA) score and Body Mass Index (BMI)) using chi squared test or ANOVA, and PROMs for the two responder groups were compared using generalised linear models adjusted for age and sex. The analysis was restricted to those undergoing primary elective hip, knee or shoulder replacement for osteoarthritis., Results: Pre-operatively, 73.2% of patients responded electronically and telephone follow-up of non-responders increased this to 91.4%. Pre-operatively, patients responding electronically, compared to all others, were on average younger, more likely to be female, and healthier (lower ASA score). Similar differences were found when telephone follow up was included in the responding group. There were little (if any) differences in the post-operative comparisons, where electronic responders were on average one year younger and were more likely to have a lower ASA score compared to those not responding electronically, but there was no significant difference in sex or BMI. PROMs were similar between those reporting electronically and those reporting by telephone., Conclusion: Patients undergoing total joint replacement who provide direct electronic PROMs data are younger, healthier and more likely to be female than non-responders, but these differences are small, particularly for post-operative data collection. The addition of telephone call follow up to electronic contact does not provide a more representative sample. Electronic-only follow up of patients undergoing joint replacement provides a satisfactory representation of the population invited to participate., Competing Interests: The authors have declared that no competing interests exist.

Objective: To evaluate the psychometric properties of the 12-item Hip disability and Osteoarthritis Outcome Score (HOOS-12) and Knee injury and Osteoarthritis Outcome Score (KOOS-12) for use in evaluating outcomes after joint replacement for osteoarthritis., Design: Patient-reported outcomes data collected by the Australian Orthopaedic Association National Joint Replacement Registry were used for this analysis. HOOS-12 and KOOS-12 domain (pain, function, quality of life) and summary impact data were available. The Oxford Hip Score (OHS), Oxford Knee Score (OKS) and EQ-5D-5L were used as comparators. Instruments were administered pre-operatively and at 6 months post-operatively. Internal consistency reliability, floor and ceiling effects, convergent validity, known groups validity, and responsiveness were evaluated using standard psychometric techniques., Results: Baseline HOOS-12 and KOOS-12 data were available for 3,023 patients undergoing primary total hip replacement and 4,010 patients undergoing primary total knee replacement. At baseline, high internal consistency was demonstrated for all domains and summary scores (Cronbach's alpha: HOOS-12 = 0.81-0.93; KOOS-12 = 0.82-0.92). Post-operative ceiling effects (>15% of patients scoring the best possible score) were identified for the HOOS-12 pain (46%), function (39%) and quality of life domains (26%) and summary score (17%), and for the KOOS-12 pain (21%) and function domains (18%). The HOOS-12 and KOOS-12 could differentiate between two known groups (lowest/highest OHS or OKS quartiles post-operatively; p < 0.001) and were highly responsive to change (effect sizes for HOOS-12: 2.20-2.83; KOOS-12: 1.82-2.35)., Conclusion: The HOOS-12 and KOOS-12 have good psychometric properties for capturing joint replacement outcomes including excellent responsiveness, although ceiling effects may limit monitoring of post-operative improvement., (Copyright © 2021 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Aims: This study aims to describe the pre- and postoperative self-reported health and quality of life from a national cohort of patients undergoing elective total conventional hip arthroplasty (THA) and total knee arthroplasty (TKA) in Australia. For context, these data will be compared with patient-reported outcome measures (PROMs) data from other international nation-wide registries., Methods: Between 2018 to 2020, and nested within a nationwide arthroplasty registry, preoperative and six-month postoperative PROMs were electronically collected from patients before and after elective THA and TKA. There were 5,228 THA and 8,299 TKA preoperative procedures as well as 3,215 THA and 4,982 TKA postoperative procedures available for analysis. Validated PROMs included the EuroQol five-dimension five-level questionnaire (EQ-5D-5L; range 0 to 100; scored worst-best health), Oxford Hip/Knee Scores (OHS/OKS; range 0 to 48; scored worst-best hip/knee function) and the 12-item Hip/Knee disability and Osteoarthritis Outcome Score (HOOS-12/KOOS-12; range 0 to 100; scored best-worst hip/knee health). Additional items included preoperative expectations, patient-perceived improvement, and postoperative satisfaction. Descriptive analyses were undertaken., Results: For THA and TKA patients respectively, the patient profile was 2,850 (54.5%) and 4,684 (56.4%) female, mean age 66.8 years (SD 10.6) and 67.5 (SD 8.8), and mean BMI 29.9 kg/m 2 (SD 7.7) and 32.5 kg/m 2 (SD 7.0). The proportion of THA and TKA patients who reported their joint as 'much better' was 2,946 (92.6%) and 4,020 (81.6%) respectively, and the majority of patients were 'satisfied' or 'very satisfied' with their procedure (2,754 (86.5%) and 3,981 (80.8%)). There were 311 (9.7%) of THA patients and 516 (10.5%) of TKA patients who reported 'dissatisfied' or 'very dissatisfied' with their surgery., Conclusion: Large improvements in pain, function, and overall health were evident following primary THA and TKA. Approximately 10% of patients reported dissatisfaction with their surgery. Future analyses will focus on factors contributing to dissatisfaction after arthroplasty. Cite this article: Bone Jt Open  2021;2(6):422-432.

Background and purpose - The increase in shoulder arthroplasty may lead to a burden of revision surgery. This study compared the rate of (2nd) revision following aseptic 1st revision shoulder arthroplasty, considering the type of primary, and the class and type of the revision.Patients and methods - All aseptic 1st revisions of primary total reverse shoulder arthroplasty (rTSA group) and of primary total stemmed and stemless total shoulder arthroplasty (non-rTSA group) procedures reported to our national registry between April 2004 to December 2018 were included. The rate of 2nd revision was determined using Kaplan-Meier estimates and comparisons were made using Cox proportional hazards models.Results - There was an increased risk of 2nd revision in the 1st month only for the rTSA group (n = 700) compared with the non-rTSA group (n = 991); hazard ratio (HR) = 4.8 (95% CI 2.2-9). The cumulative percentage of 2nd revisions (CPR) was 24% in the rTSA group and 20% in the non-rTSA group at 8 years. There was an increased risk of 2nd revision for the type (cup vs. head) HR = 2.2 (CI 1.2-4.2), but not class of revision for the rTSA group. Minor (> 3 months) vs. major class revision, and humeral revision vs. all other revision types were second revision risk factors for the non-rTSA group.Interpretation - The CPR of revision shoulder arthroplasty was > 20% at 8 years and was influenced by the type of primary, the class, and the type of revision. The most common reasons for 2nd revision were instability/dislocation, loosening, and infection.

Objective: To evaluate the structural validity of the 12-item Hip disability and Osteoarthritis Outcome Score (HOOS-12) and 12-item Knee injury and Osteoarthritis Outcome Score (KOOS-12) using Rasch analysis and consider psychometric implications for research and clinical use., Method: Individual-level HOOS-12 and KOOS-12 data from the Australian Orthopaedic Association National Joint Replacement Registry, collected before and after primary total hip and knee replacement, were used for this analysis. Using the Rasch analytic approach, overall model fit and item fit were examined, together with potential reasons for misfit including response threshold ordering, differential item functioning, internal consistency, unidimensionality and item targeting., Results: Overall misfit to the Rasch model was evident for both instruments. A degree of item misfit was also observed, although most items demonstrated logical sequencing of response options. Only two items (hip/knee pain frequency and awareness of hip/knee problems) displayed disordered response thresholds. The pain, function, and quality of life domains of the HOOS-12 and KOOS-12 demonstrated excellent internal consistency reliability (person separation index: 0.80-0.93) and unidimensionality. A mismatch between item difficulty and person ability scores at the highest end of the HOOS-12 and KOOS-12 scales contributed to post-operative ceiling effects (mean logit for HOOS-12: 3.57; KOOS-12: 2.58; ≈0 indicates well-targeted scale)., Conclusion: We found evidence to support the structural validity of the three HOOS-12 and KOOS-12 domains for evaluating joint replacement outcomes. However, there may be missing content in both instruments particularly for high-functioning patients. Minor refinement of some response options may be warranted to improve item performance., (Copyright © 2021 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Background and purpose - A challenge comparing outcomes from total hip arthroplasty between countries is variation in preoperative characteristics, particularly comorbidity. Therefore, we investigated between-country variation in comorbidity in patients based on ASA class distribution, and determined any variation of ASA class to mortality risk between countries.Patients and methods - All arthroplasty registries collecting ASA class and mortality data in patients with elective primary THAs performed 2012-2016 were identified. Survival analyses of the influence of ASA class on 1-year mortality were performed by individual registries, followed by meta-analysis of aggregated data.Results - 6 national registries and 1 US healthcare organization registry with 418,916 THAs were included. There was substantial variation in the proportion of ASA class III/IV, ranging from 14% in the Netherlands to 39% in Finland. Overall, 1-year mortality was 0.93% (95% CI 0.87-1.01) and increased from 0.2% in ASA class I to 8.9% in class IV. The association between ASA class and mortality measured by hazard ratios (HR) was strong in all registries even after adjustment for age and sex, which reduced them by half in all registries. Combined adjusted HRs were 2.0, 6.1, and 22 for ASA class II-IV vs. I, respectively. Associations were moderately heterogeneous across registries.Interpretation - We observed large variation in ASA class distribution between registries, possibly explained by differences in background morbidity and/or international variation in access to surgery. The similar, strong mortality trends by ASA class between countries enhance the relevance of its use as an indicator of comorbidity in international registry studies.

Background and purpose - Studies describing time-related change in reasons for knee replacement revision have been limited to single regions or institutions, commonly analyze only 1st revisions, and may not reflect true caseloads or findings from other areas. We used revision procedure data from 3 arthroplasty registries to determine trends and differences in knee replacement revision diagnoses.Patients and methods - We obtained aggregated data for 78,151 revision knee replacement procedures recorded by the Swedish Knee Arthroplasty Register (SKAR), the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), and the Kaiser Permanente Joint Replacement Registry (KPJRR) for the period 2003-2017. Equivalent diagnosis groups were created. We calculated the annual proportions of the most common reasons for revision.Results - Infection, loosening, and instability were among the 5 most common reasons for revision but magnitude and ranking varied between registries. Over time there were increases in proportions of revisions for infection and decreases in revisions for wear. There were inconsistent proportions and trends for the other reasons for revision. The incidence of revision for infection showed a uniform increase.Interpretation - Despite some differences in terminology, comparison of registry-recorded revision diagnoses is possible, but defining a single reason for revision is not always clear-cut. There were common increases in revision for infection and decreases in revision for wear, but variable changes in other categories. This may reflect regional practice differences and therefore generalizability of studies regarding reasons for revision is unwise.