Search

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: There is ongoing debate concerning the best method of femoral fixation in older patients receiving primary THA. Clinical studies have shown high survivorship for cemented and cementless femoral stems. Arthroplasty registry studies, however, have universally shown that cementless stems are associated with a higher rate of revision in this patient population. It is unclear if the difference in revision rate is a reflection of the range of implants being used for these procedures rather than the mode of fixation.Questions/purposes: (1) Is the risk of revision higher in patients older than 75 years of age who receive one of the three cementless stems with the highest overall survivorship in the registry than in those of that age who received one of the three best-performing cemented stems? If so, is there a difference in risk of early revision versus late revision, defined as revision within 1 month after index surgery? (2) Are there any diagnoses (such as osteoarthritis [OA] or femoral neck hip fracture) in which the three best-performing cementless stems had better survivorship than one of the three best-performing cementless stems? (3) Do these findings change when evaluated by patient sex?Methods: The Australian Orthopaedic Association National Joint Replacement Registry data were used to identify the best three cemented and the best three cementless femoral stems. The criteria for selection were the lowest 10-year revision rate and use in > 1000 procedures in this age group of patients regardless of primary diagnosis. The outcome measure was time to first revision using Kaplan-Meier estimates of survivorship. Comparisons were made for THAs done for any reason and then specifically for OA and femoral neck fracture separately.Results: Overall, the cumulative percent revision in the first 3 months postoperatively was lower among those treated with one of the three best-performing cemented stems than those treated with one of the three best-performing cementless stems (hazard ratio [HR] for best three cementless versus best three cemented = 3.47 [95% confidence interval {CI}, 1.60-7.53], p = 0.001). Early revision was 9.14 times more common in the best three cementless stems than in the best three cemented stems (95% CI, 5.54-15.06, p = 0.001). Likewise, among patients with OA and femoral neck fracture, the cumulative percent revision was consistently higher at 1 month postoperatively among those treated with one of the three best-performing cementless stems than those treated with one of the three best-performing cementless stems (OA: HR for best three cementless versus best three cemented = 8.82 [95% CI, 5.08-15.31], p < 0.001; hip fracture: HR for best 3 cementless versus best three cemented = 27.78 [95% CI, 1.39-143.3], p < 0.001). Overall, the cumulative percent revision was lower in the three best cemented stem group than the three best cementless stem group for both males and females at 1 month postoperatively (male: HR = 0.42 [95% CI, 0.20-0.92], p = 0.030; female: HR = 0.06 [95% CI, 0.03-0.10], p < 0.001) and for females at 3 months postoperatively (HR = 0.15 [95% CI, 0.06-0.33], p < 0.001), after which there was no difference.Conclusions: Cementless femoral stem fixation in patients 75 years or older is associated with a higher early rate of revision, even when only the best-performing prostheses used in patients in this age group were compared. Based on this review of registry data, it would seem important to ensure the proper training of contemporary cementing techniques for the next generation of arthroplasty surgeons so they are able to use this option when required. However, the absence of a difference in the two groups undergoing THA after 3 months suggests that there can be a role for cementless implants in selected cases, depending on the surgeon's expertise and the quality and shape of the proximal femoral bone.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]