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Objective: We evaluated the measurement properties of the Oxford Shoulder Score (OSS) and estimated the minimal clinically important change (MCIC) in patients undergoing primary total shoulder replacement in Australia. Methods: Deidentified data from the Australian Orthopaedic Association National Joint Replacement Registry were used for this analysis. Pre‐ and 6‐month postoperative OSS scores were used, with the 5‐level EuroQoL quality of life instrument and shoulder pain scores used as comparators. Floor and ceiling effects, internal consistency reliability, construct validity, and responsiveness to change were evaluated using standard psychometric methods. Mean change and predictive modeling approaches (with and without adjustment for the proportion of improved patients) were used to calculate MCIC thresholds, with patient‐perceived improvement after surgery as the anchor. Results: Preoperative OSS data were available for 1,117 patients (59% female; 90% aged ≥60 years) undergoing primary total shoulder replacement. No floor or ceiling effects were observed pre‐ or postoperatively. The OSS showed high internal consistency reliability (Cronbach alpha >0.89), good construct validity, and high responsiveness to change (effect size 1.88). The MCIC derived from the mean change method was 6.50 points (95% confidence interval [95% CI] 4.41–8.61). The predictive modeling approach produced an MCIC estimate of 8.42 points (95% CI 5.68–12.23) after adjustment. Conclusion: The OSS has good measurement properties to capture pain and function outcomes after shoulder replacement procedures and is highly responsive to change. Based on robust methods, an increase in OSS scores of at least eight points can be considered as meaningful improvement after surgery from the patient's perspective. [ABSTRACT FROM AUTHOR]

Background: Australian healthcare relies on both private and public sectors to meet the demand for surgical care. Rapid growth of shoulder replacement surgery highlights a disparity in service provision, with two‐thirds occurring privately. This study aimed to assess the influence of hospital setting on shoulder replacement revision rate at a national level. Methods: All primary shoulder replacements recorded by the Australian Orthopaedic Association National Joint Replacement Registry from April 2004 to December 2020 were included. Private and public settings were compared for stemmed total shoulder replacement (sTSR) for osteoarthritis (OA), reverse total shoulder replacement (rTSR) for OA/cuff arthropathy (CA), and rTSR for fracture. The primary outcome was cumulative percent revision (CPR), with Kaplan–Meier estimates of survivorship to determine differences between private and public hospitals, recorded as hazard ratios (HR). Secondary analyses investigated differences between hospital settings, targeting hospital outliers for revision and prosthesis selection. Results: Primary sTSR (OA) demonstrated a higher revision rate in private hospitals compared to public hospitals (HR = 1.27; P = 0.001), as did rTSR (OA/CA) after 3 months (HR = 1.33; P = 0.003). However, no significant difference was observed for primary rTSR (fracture) (HR = 1.10; P = 0.484). Restricting rTSR (OA/CA) to the best performing prosthesis combinations eliminated the difference between private and public outcomes (HR 1.10; P = 0.415). No other secondary analysis altered the primary result. Conclusions: Differences exist between private and public hospitals for revision rate following primary shoulder replacement. Prosthesis selection accounts for some of the variation. Further analysis into patient specific characteristics is necessary to better understand these disparities. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Delaying elective JR surgery prolongs pain and disability, and challenges the notion of what is considered "elective" surgery. Joint replacement (JR) is one of the most common and successful surgical procedures performed in Australia, with over 115 000 primary procedures undertaken in 2019.1 In 2020, most JR surgery was suspended in late March in response to Federal Government directives to allow only emergency and urgent surgery, which did not include elective JR.2,3 This suspension was gradually eased over subsequent months, which varied by jurisdiction. The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) is uniquely positioned to monitor the impact of COVID-19 related restrictions on JR surgery across the country. [Extracted from the article]

Objective: To estimate the lifetime risk of primary shoulder arthroplasty in Australia and to examine changes over time. Methods: For this retrospective population‐level analysis, de‐identified individual‐level data on all primary partial shoulder arthroplasty (PSA) and total shoulder arthroplasty (TSA) procedures performed in Australia from 2008 to 2017 (n = 38,868) were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Population data and life tables were obtained from the Australian Bureau of Statistics. Lifetime risk of primary shoulder arthroplasty was calculated for each year using a standardized formula. Separate calculations were undertaken by sex and for PSA and TSA. Results: The lifetime risk of shoulder arthroplasty increased significantly over time. For men, this risk more than doubled from 0.78% (95% confidence interval [95% CI] 0.73–0.84) in 2008 to 1.78% (95% CI 1.70–1.86) in 2017. Lifetime risk for women rose from 1.54% (95% CI 1.46–1.62) to 2.88% (95% CI 2.78–2.99) over the study period. This increase was predominantly driven by growth in lifetime risk of TSA. In contrast, lifetime risk of PSA decreased over time, from 0.25% (95% CI 0.22–0.28) in 2008 to 0.11% (95% CI 0.09–0.13) in 2017 for men, and from 0.55% (95% CI 0.51–0.60) to 0.11% (95% CI 0.09–0.13) for women. Conclusion: By the end of 2017, the lifetime risk of primary shoulder arthroplasty in Australia increased to 1 in 57 for men and 1 in 35 for women. Compared to declining PSA trends, there was substantial growth in TSA use over a decade. These data improve our understanding of the rising national burden of primary shoulder arthroplasty and can assist in planning to meet future surgical demand. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Early revision for total hip arthroplasty is a serious adverse outcome. There are multiple contributing risk factors for early revision. Risk factors can exist at the level of the surgeon and the level of the institution. The primary research question of this study was to determine the relative contribution of surgeon‐level and hospital‐level variance to rates of early revision (overall and for infection) after primary total hip arthroplasty.This is a registry‐based study from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Data for the most commonly used stem (Exeter V40) were used to reduce prosthesis variation from the analysis. A mixed effects Cox Model (also known as a frailty model) with crossed random effects for surgeon and hospital was used. Outcomes were early revision (within 2 years) for all causes and for infection. This model allowed for the risk of early revision to be explained by the variability at the surgeon level or hospital level.There were 32 031 procedures performed by 735 surgeons across 250 hospitals between 1 January 2015 and 31 December 2019. Surgeon variability significantly contributed to overall variation in revision for any cause and revision for infection (P < 0.0001). There was no significant contribution of hospital‐level variation to overall revision or for infection.Surgeon‐level factors play a more important role than institution‐level factors in early revision after primary total hip arthroplasty. If surgeons are identified as having a higher risk of revision, there is potential for surgeon‐level practice change to reduce the risk of early revision. [ABSTRACT FROM AUTHOR]

Background: To provide an estimate of the population at risk for late complications of arthroplasty, we aimed to determine the prevalence of Australians living with one or more joint replacements. Methods: Data included all arthroplasty procedures performed in Australia from 2003 to 2016 recorded by the Australian Orthopaedic Association National Joint Replacement Registry. The age‐ and gender‐specific Australian population was obtained from the Australian Bureau of Statistics and used as denominator data. Survival data for each joint replacement, and of individuals, were used to estimate the arthroplasty prevalence. Analyses by age, gender and joint replacement site were undertaken. Prevalence estimates were augmented with procedural data captured before 2003 modelled with assumptions accounting for age and gender distributions, overall survival and arthroplasty revision rates. Results: By the end of 2016, there were 824 769 Australians living with at least one joint replacement, representing 3.4% of the total population. The prevalence of joint replacement is increasing in all age groups, but was highest amongst older Australians, with an overall prevalence of 22.5%, and 13.3% in those aged >85 years and 65–84 years, respectively. The prevalence of people living with multiple joint replacements is increasing more rapidly than patients who have undergone only one joint replacement procedure. Conclusion: The prevalence of older Australians living with joint replacements is rapidly increasing, providing an estimate of the population‐at‐risk for late complications of arthroplasty including peri‐prosthetic infection and fracture. [ABSTRACT FROM AUTHOR]

Purpose While joint arthroplasty is generally a safe and effective procedure, there are concerns that some devices are at increased risk of failure. Early identification of total hip arthroplasty devices with increased risk of failure can be challenging because devices consist of multiple components, hundreds of distinct components are currently used in surgery, and any estimated effect needs to address confounding due to device and patient factors. The purpose of this study was to assess the effectiveness of machine learning approaches at identifying recalled components listed by the US Food and Drug Administration using data from a US total joint arthroplasty registry. Methods: An open cohort study was conducted using data (January 1, 2001, to December 31, 2015) from 74 520 implantations and 348 unique components in the Kaiser Permanente Total Joint Replacement Registry. Exposures of interest were device components used in elective primary total hip arthroplasty. The outcome was time to first revision surgery, defined as exchange, removal, or addition of any component. Machine learning methods included regularized/unregularized Cox models and random survival forest. Results: Among the recalled components detected were ASR acetabular shell/large femoral head, Durom acetabular shell/Metasul large femoral head, and Rejuvenate modular neck stem. The three components not identified were characterized by small numbers of devices recorded in the registry. Conclusions: The novel approaches to signal detection may improve postmarket surveillance of frequently used arthroplasty devices, which in turn will improve public health. [ABSTRACT FROM AUTHOR]

Background: This study determined the contributing factors of hospital sector (private versus public) variation in revision rates after elective total hip replacement (THR) for hip fracture, and elective total knee replacement (TKR). Methods: Using data from a large national arthroplasty registry, funnel plots for hospitals were generated, displaying the proportion of revised primary procedures. The proportion of outliers for each distribution was defined as the proportion outside the upper 99.7% confidence limit. Survival analyses determined differences between hospital sector revision rates separately for implants with the lowest revision rate, and for all other implants. Multivariate Cox regression determined the role of hospital sector in revision, adjusting for possible confounders. Results: For THR performed for osteoarthritis, 17.4% of private and 4.4% of public hospitals were outliers. For TKR performed for osteoarthritis, 19.6% of private and 10.0% of public hospitals were outliers. For THR for fractured neck of femur, 8.1% of private and 0.0% of public hospitals were outliers. Adjusted and unadjusted Kaplan–Meier analyses showed higher THR revision rates in private hospitals for osteoarthritis and fractured neck of femur, but no difference when restricted to the 10 prostheses with the lowest revision rate. The Kaplan–Meier analysis of TKR showed higher revision rates for private hospitals, with the association reversing when restricted to prostheses with the lowest revision rate. Conclusions: Considerable variation was seen in the revision rate after THR and TKR between hospital sectors in Australia. The variation was largely due to differences in prosthesis selection. [ABSTRACT FROM AUTHOR]

We write to you in response to the letter received on 05 July 2022 regarding our paper titled 'Between-Hospital and Between-Surgeon Variation in Thresholds for Hip and Knee Replacement'. We note that the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) supplementary report already provides detail on hip and knee replacement rates by Australian State and Territory, together with the private and public hospital breakdown [https://aoanjrr.sahmri.com/documents/10180/712291/2021+Analysis+State+Territory+Health+Data+All+Arthroplasty+SR]. We thank Dr. Goh for his interest in our study and for the suggestion to investigate between-state variation in Australia for hip and knee replacement. [Extracted from the article]

• Micronutrient malnutrition, often called ‘hidden hunger’, affects over two billion people globally. This is particularly problematic in developing countries where widespread zinc (Zn) deficiency exists as a result of a predominantly plant-based diet. Furthermore, supplemental fertilizers are often unavailable or unaffordable in impoverished regions where soil infertility is common. Delivery of more Zn via food grains is theoretically possible through selective breeding strategies, but severe technical difficulties associated with trace element research have limited research on the underlying genetic components of Zn nutrition. • Genetic dissection of Zn nutrition involved a pre-existing doubled haploid mapping population of barley ( Hordeum vulgare). Association of mineral nutrient accumulation traits with regions of the barley genome was determined in two seasons of growth to maturity, usingmapmanager qtx and QGene 4.0. • Nine genetic loci segregating in the population associated clearly with measured traits, including five that contributed to grain Zn status. Pooling two-row doubled haploids by selecting the three most favourable alleles increased grain Zn content and concentration by an average of 53 and 75%, respectively. • These results will inform breeding efforts for increased Zn density in the major food grain, wheat ( Triticum aestivum), by enabling syntenic marker-assisted selection in conventional breeding programmes. [ABSTRACT FROM AUTHOR]