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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: 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: 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. [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: 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. [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]

Background: This a priori statistical analysis plan describes the analysis for CRISTAL.Methods: CRISTAL (cluster-randomised, crossover, non-inferiority trial of aspirin compared to low molecular weight heparin for venous thromboembolism prophylaxis in hip or knee arthroplasty, a registry nested study) aims to determine whether aspirin is non-inferior to low molecular weight heparin (LMWH) in preventing symptomatic venous thromboembolism (VTE) following hip arthroplasty (HA) or knee arthroplasty (KA). The study is nested within the Australian Orthopaedic Association National Joint Replacement Registry. The trial was commenced in April 2019 and after an unplanned interim analysis, recruitment was stopped (December 2020), as the stopping rule was met for the primary outcome. The clusters comprised hospitals performing > 250 HA and/or KA procedures per annum, whereby all adults (> 18 years) undergoing HA or KA were recruited. Each hospital was randomised to commence with aspirin, orally, 85-150 mg daily or LMWH (enoxaparin), 40 mg, subcutaneously, daily within 24 h postoperatively, for 35 days after HA and 14 days after KA. Crossover was planned once the registration target was met for the first arm. The primary end point is symptomatic VTE within 90 days. Secondary outcomes include readmission, reoperation, major bleeding and death within 90 days, and reoperation and patient-reported pain, function and health status at 6 months. The main analyses will focus on the primary and secondary outcomes for patients undergoing elective primary total HA and KA for osteoarthritis. The analysis will use an intention-to-treat approach with cluster summary methods to compare treatment arms. As the trial stopped early, analyses will account for incomplete cluster crossover and unequal cluster sizes.Conclusions: This paper provides a detailed statistical analysis plan for CRISTAL.Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN12618001879257 . Registered on 19/11/2018. [ABSTRACT FROM AUTHOR]

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 1st 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 2nd revisions occur by 3 years, due to dislocation, infection, metal-related pathology, and loosening. A neck adapter sleeve did not reduce 2nd 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 2nd revision is high and occurs early. The optimal revision option is unknown. [ABSTRACT FROM AUTHOR]

Background: Well-validated data from arthroplasty registries provide an opportunity to understand contemporary use of revision hip replacement at a national level. Such information can underpin health-care resource allocation and surgical workforce planning. The purposes of the present study were to describe the demographic characteristics of patients managed with revision hip replacement surgery in Australia and to examine changes in the lifetime risk of revision hip replacement over a decade.Methods: Deidentified individual-level data on all revision hip replacement procedures performed in Australia from 2007 to 2017 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Life tables and population data were sourced from the Australian Bureau of Statistics. The lifetime risk of revision surgery each year was estimated with use of a standardized approach, with separate calculations for males and females.Results: A total of 46,086 revision hip replacement procedures were performed from 2007 to 2017. The median age at the time of surgery was 72 years (interquartile range, 63 to 80 years). While loosening or lysis became less frequent reasons for revision over time (from 51% in 2007 to 28% in 2017), revision hip replacement for infection became increasingly common (from 14% in 2007 to 25% in 2017). Revisions for metal-related pathology peaked in 2011. Utilization rates were highest for males ≥80 years of age (127.9 procedures per 100,000 population in 2017). Although a small rise was evident in 2011 and 2012 (to 2.39% and 2.22%, respectively), the lifetime risk of revision hip replacement in females decreased from 1.90% (95% confidence interval [CI], 1.82% to 1.99%) in 2007 to 1.74% (95% CI, 1.66% to 1.82%) in 2017. A similar pattern was evident for males; the lifetime risk was 1.78% (95% CI, 1.69% to 1.86%) in 2007 and 1.57% (95% CI, 1.49% to 1.65%) in 2017.Conclusions: These data enable us to understand the epidemiology of revision hip replacement in Australia, including the shifting clinical indications for this procedure. At a population level, the lifetime risk of revision hip replacement remains low at <1 in 50 people in 2017. These methods can be utilized for population-level surveillance of revision burden and to enable between-country benchmarking.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: A number of surgical approaches are available for total hip arthroplasty (THA), but there are limited large-volume, multi-surgeon data comparing the rates of early revisions following these approaches. The aim of this study was to compare the rate of revision of primary conventional THA related to surgical approach.Methods: Data from the Australian Orthopaedic Association National Joint Replacement Registry were analyzed for all patients who had undergone a primary THA for osteoarthritis from January 2015 to December 2018. The primary outcome measure was the cumulative percent revision (CPR) for all causes. Secondary outcome measures were major revision (a revision procedure requiring change of the acetabular and/or femoral component) and revision for specific diagnoses: fracture, component loosening, infection, and dislocation. Age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, femoral head size, and femoral fixation were assessed as potential confounders.Results: There was a total of 122,345 primary conventional THAs for which the surgical approach was recorded in the registry; 65,791 were posterior, 24,468 were lateral, and 32,086 were anterior. There was no difference in the overall CPR among approaches, but the anterior approach was associated with a higher rate of major revisions. There were differences among the approaches with regard to the types of revision. When adjusted for age, sex, ASA score, BMI, femoral head size, and femoral fixation, the anterior approach was associated with a higher rate of femoral complications-i.e., revision for periprosthetic fracture and femoral loosening. There was a lower rate of revision for infection after the anterior approach compared with the posterior approach in the entire period, and compared with the lateral approach in the first 3 months. The posterior approach was associated with a higher rate of revision for dislocation compared with both the anterior and the lateral approach in all time periods. The anterior approach was associated with a lower rate of revision compared with the lateral approach in the first 6 months only.Conclusions: There was no difference in the overall early CPR among the surgical approaches, but the anterior approach was associated with a higher rate of early major revisions and femoral complications (revisions for periprosthetic fracture and femoral loosening) compared with the posterior and lateral approaches and with a lower rate of dislocation and infection.Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Introduction: Breakage of the femoral stem component of a total hip replacement is now uncommon but continues to be seen with certain stem designs and in certain patient groups. Data previously published on this topic has been limited, either gathered from a single surgeon or centre, or included only a single stem design. Methods: We reviewed the data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), identified and analysed 143 stem breakages over a period of 16 years, covering 44 different stem designs. Results: Our data confirms previously published findings that risk factors for stem breakage include patient age at implantation of under 70, male gender, as well as the use of exchangeable necks. We found no association with initial diagnosis, or type of acetabular component implanted. We did however also find, excluding exchangeable neck designs, that after 4.5 years a cemented stem had a significantly higher risk of breakage then a cementless stem. Discussion: To our knowledge this is the 1st paper to suggest cemented fixation as a specific risk factor for stem breakage. The analysis of rare complications such as stem breakage is only possible through large data collection systems such as the AOANJRR. Whilst there have been recent advances in materials and manufacturing techniques, we recommend that surgeons are aware of all the specific risks when considering implant choices for individual patients. [ABSTRACT FROM AUTHOR]

Background: The cementless Corail is one of the most commonly used stems in total hip arthroplasty (THA). The aim of this study was to investigate whether there was a difference in revision rate for smaller stems.Methods: All primary THA procedures recorded by the Australian Joint Replacement Registry from September 1999 to December 2017 performed for osteoarthritis using the Corail stem, a cementless acetabular cup, modern bearing surfaces (ceramic/ceramic, ceramic/cross-linked polyethylene, and metal/cross-linked polyethylene), and 28 mm, 32 mm, and 36 mm head sizes were included. The primary outcome measure was femoral component revision. Data were analyzed and adjusted for age, gender, and head size. Further analysis investigated the effects of surgical approach.Results: There was 41,265 primary THAs recorded. The cumulative percent revision (CPR) at 13 years was 7.7% (5.5, 10.7) for stem sizes 8 and 9 and 3.0% (2.4, 3.8) for sizes 10-20 (P < .001). When adjusted for age and gender, the sizes 8 and 9 collared (hazard ratio [HR]: 6.22 [3.84-10.06], P < .001) and collarless (HR: 3.28 [2.41-4.45], P < .001) had a higher CPR than the collared and collarless size 10-20. The size 8 and 9 stems performed with an anterior approach had the highest CPR (HR: 14.44 [6.21-33.56], P < .001). The main reason for revision of size 8 and 9 femoral stems was loosening (65.2%, compared to 31.5% for 10-20 femoral stems).Conclusions: Smaller Corail stems have 4 times the rate of revision compared with the larger femoral sizes with loosening being the most common diagnosis. This is most evident when using an anterior approach. [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]

Background: Mortality after THA and TKA is lower than expected for several years after surgery when compared with age- and sex-adjusted population data. With long-term followup (beyond approximately 10 years), some evidence has suggested that this trend reverses, such that postsurgical mortality is higher than expected as more time passes. However, the degree to which this may be the case has not been clearly established.Questions/purposes: In this large-registry study, we asked: What is the long-term mortality after THA and TKA compared with the expected mortality, adjusted for age, sex, and calendar year.Methods: Using data on 243,057 THAs and 363,355 TKAs performed for osteoarthritis from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from 2003 to 2016, and life tables from the Australian Bureau of Statistics the Standardised Mortality Ratio (SMR), relative mortality and excess mortality (relative to the expected mortality for people of the same sex and age in the same country) was calculated separately for hips and knees. The AOANJRR contains near-complete (98%-100%) data from all hospitals in Australia performing arthroplasty but does not include followup data on people who have left the country. Followup was from the date of surgery to 13 years, mean 5.8 years.Results: We found a lower-than-expected mortality for THA and TKA in the early years after surgery. This association diminished over time and the mortality became higher than expected after 12 years for both THA and TKA. For THA, the excess mortality (per thousand people) increased from 11 fewer deaths (95% CI, 10-11 fewer) after 1 year to four more deaths (95% CI, 0-9 more) in the 13th year, and the SMR increased from 0.50 (95% CI, 0.48-0.52) after 1 year to 1.07 (95% CI, 0.99-1.14) in the 13th year. For TKA, the excess mortality (per thousand people) increased from 12 fewer deaths (95% CI, 12-13 fewer) after 1 year to five more deaths (95% CI 2-9 more) in the 13th year, and the SMR increased from 0.39 (95% CI, 0.37-0.40) after 1 year to 1.09 (95% CI, 1.03-1.15) in the 13th year.Conclusions: Mortality after hip and knee arthroplasty is lower than expected (based on population norms) in the first 8 years to 9 years but gradually increases over time, becoming higher than expected after 12 years. The lower-than-expected mortality in the early years after surgery is likely the result of patient selection with patients undergoing primary arthroplasty having better health at the time of surgery than that of the age- and sex-matched population. The increasing mortality over time cannot be regression to the mean, as late mortality is higher than expected, moving beyond the mean. It is important to understand if there are modifiable factors associated with this increased mortality. The reasons for the change are uncertain. Factors to consider in future research include determining the effect of different patient factors on late mortality. Some of these included higher obesity rates for joint replacement patients and the association or causal impact of osteoarthritis and/or its treatment to increase late mortality in a similar manner to other forms of arthritis. There is also a possibility that the arthroplasty device itself may affect late mortality.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background and purpose — International comparisons of total hip arthroplasty (THA) practices and outcomes provide an opportunity to enhance the quality of care worldwide. We compared THA patients, implants, techniques, and survivorship in Sweden, Australia, and the United States. Patients and methods — Primary THAs due to osteoarthritis were identified using Swedish (n = 159,695), Australian (n = 279,693), and US registries (n = 69,641) (2003–2015). We compared patients, practices, and implant usage across the countries using descriptive statistics. We evaluated time to all-cause revision using Kaplan–Meier survival curves. We assessed differences in countries' THA survival using chi-square tests of survival probabilities. Results — Sweden had fewer comorbidities than the United States and Australia. Cement fixation was used predominantly in Sweden and cementless in the United States and Australia. The direct anterior approach was used more frequently in the United States and Australia. Smaller head sizes (≤ 32 mm vs. ≥ 36 mm) were used more often in Sweden than the United States and Australia. Metal-on-highly cross-linked polyethylene was used more frequently in the United States and Australia than in Sweden. Sweden's 5- (97.8%) and 10-year THA survival (95.8%) was higher than the United States' (5-year: 97.0%; 10-year: 95.2%) and Australia (5-year: 96.3%; 10-year: 93.5%). Interpretation — Patient characteristics, surgical techniques, and implants differed across the 3 countries, emphasizing the need to adjust for demographics, surgical techniques, and implants and the need for global standardized definitions to compare THA survivorship internationally. [ABSTRACT FROM AUTHOR]

Background and purpose — Although common in medical research, meta-analysis has not been widely adopted in registry collaborations. A meta-analytic approach in which each registry conducts a standardized analysis on its own data followed by a meta-analysis to calculate a weighted average of the estimates allows collaboration without sharing patient-level data. The value of meta-analysis as an alternative to individual patient data analysis is illustrated in this study by comparing the risk of revision of porous tantalum cups versus other uncemented cups in primary total hip arthroplasties from Sweden, Australia, and a US registry (2003-2015). Patients and methods — For both individual patient data analysis and meta-analysis approaches a Cox proportional hazard model was fit for time to revision, comparing porous tantalum (n = 23,201) with other uncemented cups (n = 128,321). Covariates included age, sex, diagnosis, head size, and stem fixation. In the meta-analysis approach, treatment effect size (i.e., Cox model hazard ratio) was calculated within each registry and a weighted average for the individual registries’ estimates was calculated. Results — Patient-level data analysis and meta-analytic approaches yielded the same results with the porous tantalum cups having a higher risk of revision than other uncemented cups (HR (95% CI) 1.6 (1.4-1.7) and HR (95% CI) 1.5 (1.4-1.7), respectively). Adding the US cohort to the meta-analysis led to greater generalizability, increased precision of the treatment effect, and similar findings (HR (95% CI) 1.6 (1.4-1.7)) with increased risk of porous tantalum cups. Interpretation — The meta-analytic technique is a viable option to address privacy, security, and data ownership concerns allowing more expansive registry collaboration, greater generalizability, and increased precision of treatment effects. [ABSTRACT FROM AUTHOR]

Background and purpose — Trabecular metal (TM) cups have demonstrated favorable results in acetabular revision and their use in primary total hip arthroplasty (THA) is increasing. Some evidence show that TM cups might decrease periprosthetic infection (PPI) incidence. We compared the survivorship of TM cups with that of other uncemented cups in primary THA, and evaluated whether the use of TM cups is associated with a lower risk of PPI.Patients and methods — 10,113 primary THAs with TM cup and 85,596 THAs with other uncemented cups from 2 high-quality national arthroplasty registries were included. The mean follow-up times were 3.0 years for the TM cups and 3.8 years for the other uncemented cups.Results — The overall survivorship up to 8 years for TM cups and other uncemented cups was 94.4% and 96.2%, respectively (p = < 0.001). Adjusting for relevant covariates in a Cox regression model the TM cups had a persistently higher revision risk than other uncemented cups (HR =1.5, 95% CI 1.4-1.7, p = < 0.001). There was a slightly higher, though not statistically significant, revision rate for PPI in the TM group (1.2, 95% CI 1.0-1.6, p = 0.09).Interpretation — Risk of revision for any reason was higher for the TM cup than for other uncemented cups in primary THA. In contrast to our hypothesis, there was no evidence that the revision rate for PPI was lower in the TM cup patients. Regardless of the promising early and mid-term results for TM cups in hip revision arthroplasty, we would like to sound a note of caution on the increasing use of the TM design, especially in uncomplicated primary THAs, where uncemented titanium cups are considered to provide a reliable outcome. [ABSTRACT FROM AUTHOR]

Introduction: Periprosthetic joint infection (PJI) is a serious complication after total hip arthroplasty (THA) and bearing material's associations to PJI prevalence is largely unknown. The main purposes of this study were to determine if revision for infection varied depending on the type of bearing surface used in primary THA and to study whether patient or implant related factors had an effect on this variation. Methods: A total of 177,237 primary THA procedures from the Australian Registry (AOANJRR) were analysed. 3 bearing surfaces were compared. Metal-on-highly cross-linked polyethylene (MoXP) bearing had been used in 95,129 hips, ceramic-on-highly cross-linked polyethylene (CoXP) in 24,269 hips, and ceramic-on-ceramic (CoC) in 57,839 hips. Revision rates for infection were compared between the 3 groups. Results: Both MoXP and CoXP had a higher revision rate for infection compared to CoC hips (hazard ratio [HR] 1.46 (1.25, 1.72), p < 0.001) and HR 1.42 (1.15, 1.75), p = 0.001 respectively). Patients aged 70 years or less had a lower revision rate for infection when a CoC bearing was used. This difference was independent of sex, and prostheses selection. No difference was evident if the femoral component was cemented or a head size of 28 mm was used. Discussion: In this registry-based material, use of a CoC bearing was associated with a lower risk of revision for infection in patients younger than 70 years when cementless femoral components were used. Further studies are needed to verify this finding. [ABSTRACT FROM AUTHOR]

Background: Earlier results with porous tantalum acetabular cups in revision THA generally have been favorable. Recently there has been some evidence presented that porous tantalum cups might decrease the risk of rerevision in the setting of revision hip surgery performed owing to prosthetic joint infection (PJI). As the data supporting this assertion come from a study with a limited study population, examining this issue with a large registry approach may be enlightening.Questions/purposes: By combining results from two large, national registries, we asked: (1) Do porous tantalum cups show improved survival after revision THA compared with other cementless designs? (2) Does the use of porous tantalum cups influence survivorship when rerevision for PJI is the endpoint?Methods: A total of 2442 first-time THA revisions with porous tantalum cups and 4401 first-time revisions with other uncemented cups were included in this collaborative study between the Australian and Swedish national joint registries. The mean age of the patients was 69 years (range, 19-97 years), 3754 (55%) of the patients were women, and the mean followup for the porous tantalum and uncemented control groups were 3.0 years (SD, ± 2.1 years) and 3.4 years (SD, ± 2.3 years), respectively. Concomitant stem revision was more common in the porous tantalum group (43% versus 36%). The use of porous tantalum augments also was analyzed as a proxy for more complex acetabular reconstructions. In an attempt to further reduce selection bias, we performed subgroup analysis for primary operations attributable to osteoarthritis and first revision attributable to aseptic loosening.Results: Kaplan-Meier survivorship with rerevisison for any reason up to 7 years was comparable between the porous tantalum cup group and the uncemented cup control group (86% [95% CI, 85%-89%] and 87% [95% CI, 85%-89%], respectively; p = 0.85) and the overall survivorship up to 7 years with a second revision for PJI as the endpoint (97% [95% CI, 95%-98%] and 97% [95% CI, 96%-98%], respectively; p = 0.64). Excluding procedures where augments had been used or studying primary osteoarthritis and first revision owing to aseptic loosening subgroups did not change this result.Conclusions: Implant survival for a porous tantalum cup in first-time THA revision was similar to the survival of the uncemented cup control group. With the numbers available, no benefit in survival with rerevision for infection as the endpoint could be ascribed to the porous tantalum cup group, as has been suggested by earlier work. Further studies with acetabular bone deficiency data, greater insight into host comorbidity factors, and a longer followup are needed to corroborate or refute these results.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background and purpose — There are concerns that mental health (MH) may influence outcomes of total knee arthroplasty (TKA) or total hip arthroplasty (THA). We examined effects of poor MH before surgery on long-term outcomes of osteoarthritis-related TKA or THA in women. Patients and methods — The data were from 9,737 middle-aged participants (47–52 years) and 9,292 older participants (73–78 years) in the Australian Longitudinal Study on Women’s Health who completed surveys between 1998 and 2013. Dates of arthroplasties were obtained from the Australian Orthopaedics Association National Joint Replacement Registry. Participants without procedures were matched with participants with procedures. Trajectories of the Short-Form 36 scores for physical functioning, bodily pain, social functioning, and mental health based on mixed modeling were plotted for participants with and without surgery (stratified according to mental health, separately for TKA and THA, and for middle-aged and older participants). Results — In middle-aged women with poor and good MH, TKA improved physical function and reduced bodily pain, with improvements sustained up to 10 years after surgery. TKA contributed to restoration of social function in women with good MH, but this was less clear in women with poor MH. In both MH groups, mental health appeared to be unaffected by TKA. Similar patterns were observed after THA, and in older women. Interpretation — Recovery of physical and social function and reductions in pain were sustained for up to 10 years after surgery. Improvements in physical function and pain were also observed in women with poor mental health. Thus, in our view poor mental health should not be a contraindication for arthroplasty. [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]

Background: There are many factors that may affect the learning curve for total hip arthroplasty (THA) and surgical approach is one of these. There has been renewed interest in the direct anterior approach for THA with variable outcomes reported, but few studies have documented a surgeon's individual learning curve when using this approach.Questions/purposes: (1) What was the revision rate for all surgeons adopting the anterior approach for placement of a particular implant? (2) What was the revision rate for surgeons who performed > 100 cases in this fashion? (3) Is there a minimum number of cases required to complete a learning curve for this procedure?Methods: The Australian Orthopaedic Association National Joint Replacement Registry prospectively collects data on all primary and revision joint arthroplasty surgery. We analyzed all conventional THAs performed up to December 31, 2013, with a primary diagnosis of osteoarthritis using a specific implant combination and secondarily those associated with surgeons performing more than 100 procedures. Ninety-five percent of these procedures were performed through the direct anterior approach. Procedures using this combination were ordered from earliest (first procedure date) to latest (last procedure date) for each individual surgeon. Using the order number for each surgeon, five operation groups were defined: one to 15 operations, 16 to 30 operations, 31 to 50 operations, 51 to 100 operations, and > 100 operations. The primary outcome measure was time to first revision using Kaplan-Meier estimates of survivorship.Results: Sixty-eight surgeons performed 5499 THAs using the specified implant combination. The cumulative percent revision at 4 years for all 68 surgeons was 3% (95% confidence interval [CI], 2.5-3.8). For surgeons who had performed over 100 operations, the cumulative revision rate was 3% (95% CI, 2.0-3.5). It was not until surgeons had performed over 50 operations that there was no difference in the cumulative percent revision compared with over 100 operations. The cumulative percent revision for surgeons performing 51 to 100 operations at 4 years was 3% (95% CI, 1.5-5.4) and over 100 operations 2% (95% CI, 1.2-2.7; hazard ratio, 1.40 [95% CI, 0.7-2.7]; p = 0.33).Conclusions: There is a learning curve for the anterior approach for THA even when using a prosthesis combination specifically marketed for that approach. We found that 50 or more procedures need to be performed by a surgeon before the rate of revision is no different from performing 100 or more procedures. Surgeons should be aware of this initial higher rate of revision when deciding which approach delivers the best outcome for their patients. [ABSTRACT FROM AUTHOR]

The article presents a study to know about the safety and effectiveness of joint rreplacementsurgery in young adults. Pediatric patients and young adults who undergo hip arthroplasty (THA) and total knee arthroplasty (TKA) have very different diagnoses, and their reported rate of revision surgery is similar to that for older patients.