Australian Orthopaedic Association

Periprosthetic joint infection is a devastating and severe complication of total knee arthroplasty (TKA). The Australian Joint Registry reports an increasing number of debridement, antibiotics, and implant retention (DAIR) procedures, underscoring the need to comprehend outcomes for informed treatment decisions. This study aimed to determine the outcome of DAIR procedures, evaluate time since primary TKA, and identify patient-related factors associated with DAIR failure. We conducted a national registry-based cohort study using data from 1999 to 2021. We included 8,642 revisions for infection, of which 5,178 were DAIR procedures (60%) predominantly performed within four weeks of primary surgery. We assessed the outcomes using Kaplan-Meier estimates and Cox proportional hazard models. Post-DAIR, the cumulative percent second revision cumulative percent revision in the DAIR cohort was 20% at year 1, increasing to 36% at year 17. Early DAIR procedures had a lower post-DAIR revision rate until three months after primary TKA. A DAIR performed within 2 weeks after primary TKA compared to three months had an hazard ratio [HR]: 0.74 (95% CI [confidence interval]: 0.62 to 0.88). After four weeks, the post-DAIR revision rate did not deteriorate and was similar for further time periods from the primary. Men had an age-adjusted HR of 1.28 (95% CI: 1.14 to 1.43, P < 0.001) for DAIR failure compared to women. There was a significantly higher HR for post-DAIR revision in patients younger than 75 years of age, compared to patients aged ≥ 75 years. These findings underscore the critical influence of patient-related factors and the timing of DAIR treatment on the need for additional surgery. DAIR after four weeks had an increased risk of subsequent revision, and older women undergoing early DAIR interventions had more favorable outcomes. Understanding these nuances aids in optimizing periprosthetic joint infection management strategies, offering insights for decision-making.

Smoking, poor diabetic control and excessive body mass index (BMI) increase the risk of infection following joint replacement. This study investigated Australian general practitioners' (GPs) perception of these modifiable risk factors in patients with end-stage osteoarthritis. A structured online survey tool was developed and widely distributed to Australian GPs. Responses were received from 131 GPs. Most attempted to address current smoking (90%), poor diabetic control (94%) and excessive BMI (89%) prior to referral. The majority felt that joint replacement should be delayed until these risk factors had been modified (57%, 84% and 74%, respectively). However, many respondents did not believe that these risk factors were contraindications to joint replacement (76%, 46% and 43%, respectively). This study suggests that Australian GPs are mindful of modifiable risk factors in patients with hip and knee osteoarthritis; however, many do not support restricting access to joint replacement.

Short-stem total hip arthroplasty (THA) may have bone sparing properties, which could be advantageous in a younger population with high risk of future revision surgery. We used data from the AOANJRR, LROI and SAR to compare survival rates of primary THA, stems used in the first-time revision procedures as well as the overall survival of first-time revisions between a cohort of short-stem and standard-stem THA.Short-stem THAs (designed as a short stem with mainly metaphyseal fixation) between 2007 and 2021 were identified (n=16,258). A propensity score matched cohort (1:2) with standard THAs in each register was identified (n=32,515). The cohorts were merged into a research dataset. Overall survival at 12 years follow-up was calculated using Kaplan-Meier survival analyses. Stem revisions (short-stem THA n=239, standard-stem THA n=352) were identified. The type of revision stem was classified as standard (&lt;160 mm) or long (&gt;160 mm). The survival rate of all first-time revisions in the two groups was calculated using any type of revision as outcome.The 12 year- overall survival rate (all revisions, all causes) for primary short-stem THAs was 95.3% (CI 94.5–95.9%), which was comparable to 95.2% (CI 94.7–95.7%) for standard-stem THAs. In the short-stem THA group, a standard stem (&lt;160 mm) was more often (59%) used in the first-time revision than in the standard-stem group (47%, p=0.004). The overall survival of the first-time revisions did not differ between cases primarily operated with a short or a standard stem.In our multi-national register study, the overall survival rate of short stems was similar to that of standard stems. In short stem revisions there was a higher likelihood of using a standard-length stem for the revision compared with first-time revisions of standard stems. This finding might indicate bone-sparing properties with short-stemmed THAs.

Abstract BackgroundThe smallest worthwhile effect (SWE) is the minimum benefit required in addition to that from a comparator, for an intervention to be considered worthwhile by patients. We aimed to estimate the SWE for rotator cuff repair (with decompression and debridement) compared to either decompression and debridement alone or to non-surgical treatment for people with atraumatic shoulder pain.MethodsBenefit-harm trade-off study. We recruited English speaking adults aged 45-75 years with shoulder pain of intensity ≥4 (on a 0-10 scale) for ≥6 months to our online survey through paid advertising on Facebook. Participants must have sought care in the past 6-months and could not have had recent shoulder surgery or significant recent shoulder trauma. Participants were explained three treatments: rotator cuff repair (with subacromial decompression and debridement), subacromial decompression and debridement alone and non-surgical treatment. Participants completed the benefit-harm trade-off survey to determine the SWE of improvements in pain and function for rotator cuff repair compared to the other treatments and again after one week to assess reliability. We used univariable linear regression to estimate associations between baseline characteristics and SWE.ResultsWe recruited 56 participants. The mean ± standard deviation age was 58.4±6.7 years and 39 (70%) were female. For rotator cuff repair to be worthwhile compared to decompression and debridement alone participants needed to see at least a median 40% (interquartile range (IQR) 20-62.5) between-group improvement in pain and function.Compared to non-surgical treatment, the SWE was a median 40% (IQR 30-60). On the Western Ontario Rotator Cuff (WORC) Index the SWE values equate to a between-group improvement of 28/100 points (533/2100 on the raw WORC score). Female sex was associated with larger SWEs for both comparisons. Reliability analyses were underpowered, 25/56(45%) provided follow-up data; the intraclass correlation coefficient estimates ranged from 0.60-0.77.ConclusionsThis SWE indicates the benefit required by people with shoulder pain to consider the costs and risks of surgical rotator cuff repair worthwhile is larger than previously estimated minimum clinically important differences (13.5-28/100 on the WORC Index). This SWE may be used to inform the design or interpret the findings of trials of these comparisons.

Background and purposeWe compared the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the Dutch Arthroplasty Register (LROI) regarding patient, prosthesis, and procedure characteristics as well as revision rates for uncemented short-stem total hip arthroplasties (THAs).Patients and methodsAll THAs with an uncemented short-stemmed femoral component performed between 2009 and 2021 were included from the AOANJRR (n = 9,328) and the LROI (n = 3,352). Kaplan–Meier survival analyses and multivariable Schemper’s weighted Cox regression analyses with data from 2009–2021 and 2015–2021 were performed with overall revision as endpoint.ResultsIn Australia, the proportion of male patients (51% vs. 40%), patients with ASA III–IV score (30% vs. 3.7%), BMI ≥ 30.0 (39% vs. 19%), and femoral heads of 36 mm (58% vs. 20%) were higher than in the Netherlands. Short-stem THAs in Australia and the Netherlands had comparable 10-year revision rates (3.4%, 95% confidence interval [CI] 2.9–4.0 vs. 4.8%, CI 3.7–6.3). Multivariable Cox regression analyses with data from 2009–2021 showed a higher risk for revision of short-stem THAs performed in the Netherlands (HR 1.8, CI 1.1–2.8), whereas the risk for revision was comparable (HR 0.9, CI 0.5–1.7) when adjusted for more potential confounders using data from 2015–2021.ConclusionShort-stem THAs in Australia and the Netherlands have similar crude and adjusted revision rates, which are acceptable at 10 years of follow-up.

In this study we compare survivorship and patient reported outcome measures in robotically assisted versus conventional Total Hip Arthroplasty (THA).This paper investigates the hypothesis that implant survival and PROMS following THAs performed with robotic assistance were not different to outcomes following conventional THAs.Data included all patients undergoing THA for osteoarthritis between 19 April 2016 and 31 December 2020. Analysis of PROMS outcomes was restricted to those who had completed PROMS data preoperatively and at 6 months postoperatively.There were 157,647 procedures, including 3567 robotically assisted procedures, available for comparison of revision rates. 4557 procedures, including 130 robotically assisted procedures, had PROMS data available. The revision rate of primary THA performed with robotic assistance was not statistically different from THA performed by conventional methods (4 year cumulative percent revision 3.1% v 2.7%; HR = 1.05, p=0.67). The Oxford Hip Score, VAS for pain and the EQ-VAS score for overall health showed no statistically significant difference between the groups. The EQ-5D Utility Score showed an improved score (median score 1 v 0.88; OR = 1.58, p=0.007) for the robotically assisted group compared to the conventional group.Robotic assisted THA was not associated with significant improvement in early revision or joint-specific PROMs. The findings may have been biased, in either direction, by unmeasured patient, surgeon, hospital and prosthesis factors. The findings (including the difference in health-related quality of life) may have also been influenced by lack of blinding. Future research should include methods to minimise these biases.