| 1. |
- Leta, Tesfaye H., et al.
(författare)
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Periprosthetic Joint Infection After Total Knee Arthroplasty With or Without Antibiotic Bone Cement
- 2024
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Ingår i: JAMA Network Open. - 2574-3805. ; 7:5, s. 2412898-2412898
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Tidskriftsartikel (refereegranskat)abstract
- Importance: Despite increased use of antibiotic-loaded bone cement (ALBC) in joint arthroplasty over recent decades, current evidence for prophylactic use of ALBC to reduce risk of periprosthetic joint infection (PJI) is insufficient. Objective: To compare the rate of revision attributed to PJI following primary total knee arthroplasty (TKA) using ALBC vs plain bone cement. Design, Setting, and Participants: This international cohort study used data from 14 national or regional joint arthroplasty registries in Australia, Denmark, Finland, Germany, Italy, New Zealand, Norway, Romania, Sweden, Switzerland, the Netherlands, the UK, and the US. The study included primary TKAs for osteoarthritis registered from January 1, 2010, to December 31, 2020, and followed-up until December 31, 2021. Data analysis was performed from April to September 2023. Exposure: Primary TKA with ALBC vs plain bone cement. Main Outcomes and Measures: The primary outcome was risk of 1-year revision for PJI. Using a distributed data network analysis method, data were harmonized, and a cumulative revision rate was calculated (1 - Kaplan-Meier), and Cox regression analyses were performed within the 10 registries using both cement types. A meta-analysis was then performed to combine all aggregated data and evaluate the risk of 1-year revision for PJI and all causes. Results: Among 2 168 924 TKAs included, 93% were performed with ALBC. Most TKAs were performed in female patients (59.5%) and patients aged 65 to 74 years (39.9%), fully cemented (92.2%), and in the 2015 to 2020 period (62.5%). All participating registries reported a cumulative 1-year revision rate for PJI of less than 1% following primary TKA with ALBC (range, 0.21%-0.80%) and with plain bone cement (range, 0.23%-0.70%). The meta-analyses based on adjusted Cox regression for 1 917 190 TKAs showed no statistically significant difference at 1 year in risk of revision for PJI (hazard rate ratio, 1.16; 95% CI, 0.89-1.52) or for all causes (hazard rate ratio, 1.12; 95% CI, 0.89-1.40) among TKAs performed with ALBC vs plain bone cement. Conclusions and Relevance: In this study, the risk of revision for PJI was similar between ALBC and plain bone cement following primary TKA. Any additional costs of ALBC and its relative value in reducing revision risk should be considered in the context of the overall health care delivery system.
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| 2. |
- Leta, Tesfaye H., et al.
(författare)
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The use of antibiotic-loaded bone cement and systemic antibiotic prophylactic use in 2,971,357 primary total knee arthroplasties from 2010 to 2020: an international register-based observational study among countries in Africa, Europe, North America, and Oceania
- 2023
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Ingår i: Acta Orthopaedica. - 1745-3674 .- 1745-3682. ; 94, s. 416-425
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Tidskriftsartikel (refereegranskat)abstract
- Background and purpose — Antibiotic-loaded bone cement (ALBC) and systemic antibiotic prophylaxis (SAP) have been used to reduce periprosthetic joint infection (PJI) rates. We investigated the use of ALBC and SAP in primary total knee arthroplasty (TKA). Patients and methods — This observational study is based on 2,971,357 primary TKAs reported in 2010–2020 to national/regional joint arthroplasty registries in Australia, Den-mark, Finland, Germany, Italy, the Netherlands, New Zealand, Norway, Romania, South Africa, Sweden, Switzerland, the UK, and the USA. Aggregate-level data on trends and types of bone cement, antibiotic agents, and doses and duration of SAP used was extracted from participating registries. Results — ALBC was used in 77% of the TKAs with variation ranging from 100% in Norway to 31% in the USA. Palacos R+G was the most common (62%) ALBC type used. The primary antibiotic used in ALBC was gentamicin (94%). Use of ALBC in combination with SAP was common practice (77%). Cefazolin was the most common (32%) SAP agent. The doses and duration of SAP used varied from one single preoperative dosage as standard practice in Bolzano, Italy (98%) to 1-day 4 doses in Norway (83% of the 40,709 TKAs reported to the Norwegian arthroplasty register). Conclusion — The proportion of ALBC usage in primary TKA varies internationally, with gentamicin being the most common antibiotic. ALBC in combination with SAP was common practice, with cefazolin the most common SAP agent. The type of ALBC and type, dose, and duration of SAP varied among participating countries.
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| 3. |
- Lewis, Peter L., et al.
(författare)
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Increases in the rates of primary and revision knee replacement are reducing : a 15-year registry study across 3 continents
- 2020
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Ingår i: Acta Orthopaedica. - : Medical Journals Sweden AB. - 1745-3674 .- 1745-3682. ; 91:4, s. 414-419
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Tidskriftsartikel (refereegranskat)abstract
- Background and purpose — Rates of knee replacement (KR) are increasing worldwide. Based on population and practice changes, there are forecasts of a further exponential increase in primary knee replacement through to 2030, and a corresponding increase in revision knee replacement. We used registry data to document changes in KR over the past 15 years, comparing practice changes across Sweden, Australia, and the United States. This may improve accuracy of future predictions. Patients and methods — Aggregated data from the Swedish Knee Arthroplasty Register (SKAR), the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), and the Kaiser Permanente Joint Replacement Registry (KPJRR) were used to compare surgical volume of primary and revision KR from 2003 to 2017. Incidence was calculated using population census statistics from Statistics Sweden and the Australian Bureau of Statistics, as well as the yearly active membership numbers from Kaiser Permanente. Further analysis of KR by age < 65 and ≥ 65 years was carried out. Results — All registries recorded an increase in primary and revision KR, with a greater increase seen in the KPJRR. The rate of increase slowed during the study period. In Sweden and Australia, there was a smaller increase in revision surgery compared with primary procedures. There was consistency in the mean age at surgery, with a steady small decrease in the proportion of women having primary KR. The incidence of KR in the younger age group remained low in all 3 registries, but the proportional increases were greater than those seen in the ≥ 65 years of age group. Interpretation — There has been a generalized deceleration in the rate of increase of primary and revision KR. While there are regional differences in KR incidence, and rates of change, the rate of increase does not seem to be as great as previously predicted.
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| 4. |
- Lewis, Peter L., et al.
(författare)
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The effect of patient and prosthesis factors on revision rates after total knee replacement using a multi-registry meta-analytic approach
- 2022
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Ingår i: Acta Orthopaedica. - : Medical Journals Sweden AB. - 1745-3682 .- 1745-3674. ; 93, s. 284-293
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND AND PURPOSE: Characteristics of patients receiving total knee arthroplasty (TKA) and prostheses used vary between regions and change with time. How these practice variations influence revision remains unclear. We combined registry data for better understanding of the impact of variation, which could potentially improve revision rates. PATIENTS AND METHODS: We used data from 2003 to 2019 for primary TKA from arthroplasty registries of Sweden (SKAR), Australia (AOANJRR), and Kaiser Permanente (KPJRR). We included 1,072,924 TKA procedures for osteoarthritis. Factors studied included age, sex, ASA class, BMI category, prosthesis constraint, fixation, bearing mobility, patellar resurfacing, and polyethylene type. Cumulative percentage revision (CPR) was calculated using Kaplan-Meier estimates, and unadjusted Cox hazard ratios were used for comparisons. Random-effects generic inverse-variance meta-analytic methods were used to determine summary effects. RESULTS: We found similarities in age and sex, but between-registry differences occurred in the other 7 factors studied. Patients from Sweden had lower BMI and ASA scores compared with other registries. Use of cement fixation was similar in the SKAR and KPJRR, but there were marked differences in patellar resurfacing and posterior stabilized component use. Meta-analysis results regarding survivorship favored patients aged ≥ 65 years and minimally stabilized components. There were inconsistent results with time for sex, fixation, and bearing mobility, and no differences for the patellar resurfacing or polyethylene type comparisons. INTERPRETATION: Marked practice variation was found. Use of minimally stabilized and possibly also cemented and fixed bearing prostheses is supported.
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| 5. |
- Lewis, Peter L., et al.
(författare)
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Variation and trends in reasons for knee replacement revision : a multi-registry study of revision burden
- 2021
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Ingår i: Acta Orthopaedica. - : Medical Journals Sweden AB. - 1745-3674 .- 1745-3682. ; 92:2, s. 182-188
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Tidskriftsartikel (refereegranskat)abstract
- Background and purpose — Studies describing time-related change in reasons for knee replacement revision have been limited to single regions or institutions, commonly analyze only 1st revisions, and may not reflect true caseloads or findings from other areas. We used revision procedure data from 3 arthroplasty registries to determine trends and differences in knee replacement revision diagnoses. Patients and methods — We obtained aggregated data for 78,151 revision knee replacement procedures recorded by the Swedish Knee Arthroplasty Register (SKAR), the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), and the Kaiser Permanente Joint Replacement Registry (KPJRR) for the period 2003–2017. Equivalent diagnosis groups were created. We calculated the annual proportions of the most common reasons for revision. Results — Infection, loosening, and instability were among the 5 most common reasons for revision but magnitude and ranking varied between registries. Over time there were increases in proportions of revisions for infection and decreases in revisions for wear. There were inconsistent proportions and trends for the other reasons for revision. The incidence of revision for infection showed a uniform increase. Interpretation — Despite some differences in terminology, comparison of registry-recorded revision diagnoses is possible, but defining a single reason for revision is not always clear-cut. There were common increases in revision for infection and decreases in revision for wear, but variable changes in other categories. This may reflect regional practice differences and therefore generalizability of studies regarding reasons for revision is unwise.
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| 6. |
- Paxton, Elizabeth W., et al.
(författare)
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An international comparison of THA patients, implants, techniques, and survivorship in Sweden, Australia, and the United States
- 2019
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Ingår i: Acta Orthopaedica. - : Medical Journals Sweden AB. - 1745-3674 .- 1745-3682. ; 90:2, s. 148-152
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Tidskriftsartikel (refereegranskat)abstract
- 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.
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| 7. |
- Paxton, Elizabeth W.
(författare)
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International Outcomes of Total Hip Arthroplasty: Influence of Patient, Implant, and Surgical factors on Total Hip Arthroplasty Survivorship in Sweden, the US, and Australia
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Abstract Background Hip osteoarthritis (OA) is debilitating disease resulting in pain, stiffness, and reduced physical function. Although total hip arthroplasty (THA) is a successful treatment for OA, some THAs require revision surgery due to infection, dislocation, aseptic loosening, fracture and other reasons. Numerous factors influence the success of THA including patient, surgical, hospital and implant factors. Understanding the influence of these factors on THA risk of revision is critical for prevention of revision surgery. Internationally, arthroplasty registries play a critical role in identifying patient and clinical practices at higher risk for THA revision surgery. Several national and regional arthroplasty registries exist worldwide. Collaborations of these registries provide an opportunity to evaluate differences in patients, clinical practices, risk factors, and outcomes between countries. Objective The purpose of this thesis was to examine variation in patient, surgical, implant characteristics, and THA outcomes in Sweden, US and Australia to identify THA risk factors and clinical best practices. The five studies in this thesis investigated: 1.Meta-analysis as an alternative to individual patient data analysis 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 cohort. 2.Variation in patient characteristics and co-morbidities, surgical approach, implant characteristics, hospital settings and THA revision rates between Sweden, Australia, and the US to identify differences in practices and opportunities for improving THA outcomes internationally. 3.Implant-specific sources of variation in THA implant survival across the US, Sweden, and Australia by examining implant survival of Exeter and Summit THAs. 4.Patient, implant, clinical practices and hospital predictors of THA revision in Sweden, Australia, and the US. 5.The influence of more granular patient-related factors (i.e., age, gender, body mass Index, and comorbidities) on THA risk of revision in a US healthcare setting Patient and methods Primary THAs with an OA diagnosis were identified using the Swedish, Australian, and Kaiser Permanente registries. The study time period was 2003-2015 for studies I, II, and III. Study IV’s timeframe was 2001-2016 and study V’s time period was 2008-2016. Kaplan Meier statistics were used to assess time to revision with censoring for death and loss to follow-up. Multivariable cox regression models were used to identify patient, implant, surgical, and hospital factors associated with revision surgery. 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. Patients, implants and surgical practices differed between the countries. Sweden’s 5- and 7-year THA survival was higher than Australia and the US. However, when patient characteristics, fixation and implants were controlled for THA survival was similar between countries. Predictors of THA revision also differed by country. In the US cohort, increased number of comorbidities and certain comorbidities had higher risk of all cause, revision due to dislocation, and septic revision. Conclusions Meta-analysis is a viable method for enhancing international registry collaboration. In comparing THA survival across countries, implant selection plays a critical role. Predictors of THA revision differ between countries most likely due to variation in clinical practices and implant selection. The number of patient co-morbidities and higher risk comorbidities should be considered by surgeons and patients prior to THA surgery.
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| 8. |
- Paxton, Elizabeth W., et al.
(författare)
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Meta-analysis of individual registry results enhances international registry collaboration
- 2018
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Ingår i: Acta Orthopaedica. - : Medical Journals Sweden AB. - 1745-3674 .- 1745-3682. ; 89:4, s. 369-373
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Tidskriftsartikel (refereegranskat)abstract
- 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.
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| 9. |
- Robertsson, Otto, et al.
(författare)
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Challenges in prosthesis classification.
- 2011
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Ingår i: Journal of Bone and Joint Surgery. American Volume. - 1535-1386. ; 93 Suppl 3, s. 72-75
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Tidskriftsartikel (refereegranskat)abstract
- Accurate prosthesis classification is critical for total joint arthroplasty surveillance and assessment of comparative effectiveness. Historically, prosthesis classification was based solely on the names of the prosthesis manufacturers. As a result, prosthesis designs changed without corresponding name changes, and other prostheses' names changed over time without substantial design modifications. As the number of prostheses used in total joint arthroplasty on the market increased, catalog and lot numbers associated with prosthesis descriptions were introduced by manufacturers. Currently, these catalog and lot numbers are not standardized, and there is no consensus on categorization of these numbers into brands or subbrands. Classification of the attributes of a prosthesis also varies, limiting comparisons of prostheses across studies and reports. The development of a universal prosthesis classification system would standardize prosthesis classification and enhance total joint arthroplasty research collaboration worldwide. This is a current area of focus for the International Consortium of Orthopaedic Registries (ICOR).
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