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Comparison of the 10-year outcomes of cemented and cementless unicompartmental knee replacements: data from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man.

ABSTRACT: Background and purpose - Unicompartmental knee replacement (UKR) offers advantages over total replacement but has higher revision rates, particularly for aseptic loosening. The cementless Oxford UKR was introduced to address this. We undertook a registry-based matched comparison of cementless and cemented UKRs.Patients and methods - From 40,552 Oxford UKRs identified by the National Joint Registry for England, Wales, Northern Ireland and Isle of Man (NJR) we propensity score matched, based on patient, surgical, and implant factors, 7,407 cemented and 7,407 cementless UKRs (total = 14,814).Results - The 10-year cumulative implant survival rates for cementless and cemented UKRs was 93% (95% CI 90-96) and 90% (CI 88-92) respectively, with this difference being significant (HR 0.76; p = 0.002). The risk of revision for aseptic loosening was less than half (p < 0.001) in the cementless (0.42%) compared with the cemented group (1.00%), and the risk of revision also decreased for unexplained pain (to 0.46% from 0.74%; p = 0.03) and lysis (to 0.04% from 0.15%; p = 0.03). However, the risk of revision for periprosthetic fracture increased significantly (p = 0.01) in the cementless (0.26%) compared with the cemented group (0.09%). 10-year patient survival rates were similar (HR 1.2; p = 0.1).Interpretation - The cementless UKR has improved 10-year implant survival compared with the cemented UKR, independent of patient, implant, and surgical factors. This improved survival in the cementless group was primarily the result of lower revision rate for aseptic loosening, unexplained pain, and lysis, suggesting the fixation of the cementless was superior. However, there was a small increased risk of revision for periprosthetic fracture with the cementless implant.

SUBMITTER: Mohammad HR

PROVIDER: S-EPMC7006803 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:ObjectivesTo describe the prevalence rates of revision surgery for the treatment of prosthetic joint infection (PJI) for patients undergoing knee replacement, their time trends, the cumulative incidence function of revision for PJI and estimate the burden of PJI at health service level.DesignWe analysed revision knee replacements performed due to a diagnosis of PJI and the linked index procedures recorded in the National Joint Registry from 2003 to 2014 for England and Wales. The cohort analysed consisted of 679?010 index primary knee replacements, 33?920 index revision knee replacements and 8247 revision total knee replacements performed due to a diagnosis of PJI. The prevalence rates, their time trends investigated by time from index surgery to revision for PJI, cumulative incidence functions and the burden of PJI (total procedures) were calculated. Overall linear trends were investigated with log-linear regression.ResultsThe incidence of revision total knee replacement due to PJI at 2?years was 3.2/1000 following primary and 14.4/1000 following revision knee replacement, respectively. The prevalence of revision due to PJI in the 3?months following primary knee replacement has risen by 2.5-fold (95%?CI 1.2 to 5.3) from 2005 to 2013 and 7.5-fold (95%?CI 1.0 to 56.1) following revision knee replacement. Over 1000 procedures per year are performed as a consequence of knee PJI, an increase of 2.8 from 2005 to 2013. Overall, 75% of revisions were two-stage with an increase in use of single-stage from 7.9% in 2005 to 18.8% in 2014.ConclusionsAlthough the risk of revision due to PJI following knee replacement is low, it is rising, and coupled with the established and further predicted increased incidence of both primary and revision knee replacements, this represents an increasing and substantial treatment burden for orthopaedic service delivery in England and Wales. This has implications for future service design and the funding of individual and specialist centres.

Project description:BackgroundNearly 100,000 people underwent total hip replacement (THR) in the United Kingdom in 2018, and most can expect it to last at least 25 years. However, some THRs fail and require revision surgery, which results in worse outcomes for the patient and is costly to the health service. Variation in the survival of THR implants has been observed between units and reducing this unwarranted variation is one focus of the "Getting it Right First Time" (GIRFT) program in the UK. We aimed to investigate whether the statistically improved implant survival of THRs in a high-performing unit is associated with the implants used or other factors at that unit, such as surgical skill.Methods and findingsWe analyzed a national, mandatory, prospective, cohort study (National Joint Registry for England, Wales, Northern Ireland and the Isle of Man [NJR]) of all THRs performed in England and Wales. We included the 664,761 patients with records in the NJR who have received a stemmed primary THR between 1 April 2003 and 31 December 2017 in one of 461 hospitals, with osteoarthritis as the only indication. The exposure was the unit (hospital) in which the THR was implanted. We compared survival of THRs implanted in the "exemplar" unit with THRs implanted anywhere else in the registry. The outcome was revision surgery of any part of the THR construct for any reason. Net failure was calculated using Kaplan-Meier estimates, and adjusted analyses employed flexible parametric survival analysis. The mean age of patients contributing to our analyses was 69.9 years (SD 10.1), and 61.1% were female. Crude analyses including all THRs demonstrated better implant survival at the exemplar unit with an all-cause construct failure of 1.7% (95% CI 1.3-2.3) compared with 2.9% (95% CI 2.8-3.0) in the rest of the country after 13.9 years (log-rank test P < 0.001). The same was seen in analyses adjusted for age, sex, and American Society of Anesthesiology (ASA) score (difference in restricted mean survival time 0.12 years [95% CI 0.07-0.16; P < 0.001]). Adjusted analyses restricted to the same implants as the exemplar unit show no demonstrable difference in restricted mean survival time between groups after 13.9 years (P = 0.34). A limitation is that this study is observational and conclusions regarding causality cannot be inferred. Our outcome is revision surgery, and although important, we recognize it is not the only marker of success of a THR.ConclusionsOur results suggest that the "better than expected" implant survival results of this exemplar center are associated with implant choice. The survival results may be replicated by adopting key treatment decisions, such as implant selection. These decisions are easier to replicate than technical skills or system factors.

Project description:Background and purposeOver 1 million metal-on-metal hip replacements were implanted. Even well-functioning implants produce wear debris that can cause tissue damage, disseminate and cause DNA damage. We aimed to establish if there was an association between metal-on-metal hip replacement and the risk of subsequently developing cancer compared with alternative hip replacements.MethodsWe performed a population based prospective longitudinal cohort study using data from the National Joint Registry linked to Hospital Episode Statistics (n = 403,881 patients). We examined the incidence of a new diagnosis of cancer in patients who received a metal-on-metal bearing in comparison with those who received a non metal-on-metal bearing. Kaplan-Meier estimates of time to first cancer diagnosis were used with Cox proportional hazards regression models to assess the effect on the time to cancer diagnosis for all cancer types, haematological, malignant melanoma, urinary tract cancers or prostate cancer in men.ResultsThe maximum follow up available was 11.8 years with 25% of patients followed up for more than 6.8 years (mean follow up 4.6 years; median 4.3; IQR 2.1-6.8; range 0.01-11.8). Analyses by gender that adjusted for age at primary and presence or absence of linked Welsh (PEDW) records showed no increase in the risk of developing cancer according to the bearing surface implanted for all cancers, haematological cancers, malignant melanoma, urinary tract cancers or prostate cancer in men. For patients receiving a second hip replacement, there was also no difference.ConclusionWe have demonstrated that there is currently no evidence of an increase in the risk of cancer following primary hip replacement according to the type of bearing material used. Although the risk of revision in metal-on-metal bearing hip replacements is higher, it is reassuring that the risk of a new diagnosis of cancer is not currently increased. Despite the long term follow up available in this study, the latency period for some cancers is very long and therefore continued monitoring is required to ensure no new patterns emerge that may indicate need for universal screening.

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Comparison of the 10-year outcomes of cemented and cementless unicompartmental knee replacements: data from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man.

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