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Background and purpose: National joint replacement registries were developed for prospective monitoring of outcomes and post-market surveillance of implants. Increasingly registry data informs practice. However, analysis of a registry can only be as good as the data it captures on the population of interest. We aimed to analyze completeness of reporting of hip and knee replacement procedures for all national registries worldwide. Methods: We analyzed annual reports and data provided following written requests to all active national hip and knee replacement registries. Coverage was defined as the proportion of hospitals in the country that participate in the registry. Procedure completeness was defined as the proportion of procedures successfully captured by the registry. Results: 14 national registries were included, spanning years 2004 to 2022. Coverage was complete in 10. Median procedure completeness for primary hip and knee replacement across all years was 96.5% (interquartile range [IQR] 94.0–97.7%). Median procedure completeness for revisions was 88.5% (IQR 81.0–92.5%). The terminology used and method of calculation of completeness estimates in the registries were variable. Conclusion: National hip and knee replacement registry data generally reflects excellent coverage (full in 10 of 14 registries) and completeness (primary procedures 96.5% and revisions 88.5%) over the last 2 decades.

Introduction Surgical treatment of distal femoral fractures (DFFs) in osteoporotic bone is challenging despite improvements in hardware and surgical techniques. The occurrence and degree of secondary displacement during healing after bridging plate fixation are still unknown. This study aimed to assess the occurrence and degree of secondary displacement in healing DFFs in elderly patients and correlate the secondary displacement to body mass index, bone density, and weight-bearing regimen. Patients and Methods The study involved 32 patients, 65 years or older, with a DFF of AO/OTA types 33 A2-3, B1-2, C1-2, and 32(c) A-C,1-3, including peri-prosthetic fractures with stable implants. Twenty-seven patients had at least 8 weeks of follow-up, and 21 patients had a complete 1-year follow-up. Minimally invasive surgery was performed using a distal anatomical femoral plate as a long bridge-plating construct. Secondary displacement was assessed with computed tomography of the entire femur postoperatively and at 8, 16, and 52 weeks. Femoral length, coronal angulation (varus/valgus), and subsidence as the change in distance between the distal joint surface and a specified locking screw were measured. Results There was a statistically significant mean femoral shortening at 52 weeks of 4.7 mm (SD 3.9, (95% CI 2.9–6.5), P < 0.001) mainly by subsidence of the distal fragment. Most patients experienced limited coronal angulation. There was no correlation between body mass index or bone density and secondary displacement. At the 1-year follow-up, no patient needed revision surgery for non-union or plate breakage. Restricted weight-bearing for 8 weeks did not prevent secondary displacements or adverse events such as cut-outs. Conclusion Modern dynamic plate osteosynthesis could not prevent commonly occurring fracture subsidence in DFF in an elderly cohort. Restricted weight-bearing for 8 weeks did not prevent secondary displacements or mechanical adverse events.

Background and purpose: First-line treatment (education, exercise) for patients with hip and knee osteoarthritis (OA) aims to reduce pain and improve function. We aimed to compare progression to joint replacement within 5 years between responders and non-responders to first-line treatment for hip and knee OA, respectively. Methods: This observational study included data for 30,524 knee OA and 13,787 hip OA patients from the Swedish Osteoarthritis Register, linked with the Swedish Arthroplasty Register, Statistics Sweden, and the Swedish Prescribed Drug Register. The primary prognostic factor was change in pain between baseline and 3-month follow-up, measured on a numeric rating scale (0–10, best to worst) where an improvement of ≥ 2 was classified as responder and ≤ 1 as non-responder. The main outcome was progression to joint replacement surgery within 5 years, assessed using baseline adjusted multivariable Cox regression analyses. Results: At 5 years, in hip OA, 35% (95% confidence interval [CI] 32.2–37.2) of the responders and 48% (CI 45.9–49.5) of the non-responders and in knee OA 14% (CI 13.0–15.3) of the responders and 20% (CI 18.8–20.8) of the non-responders had progressed to joint replacement. Being a responder to the treatment was associated with having a lower probability of progression to surgery for both hip OA (hazard ratio [HR] 0.4, CI 0.4–0.5) and knee OA (HR 0.6, CI 0.5–0.6). Conclusion: Patients with hip or knee OA who experienced pain relief after a first-line OA treatment program were less likely to progress to joint replacement surgery.

Objectives Prosthetic joint infection (PJI) is a serious complication following total hip arthroplasty (THA) entailing increased mortality, decreased quality of life and high healthcare costs.The primary aim was to investigate whether the national project: Prosthesis Related Infections Shall be Stopped (PRISS) reduced PJI incidence after primary THA; the secondary aim was to evaluate other possible benefits of PRISS, such as shorter time to diagnosis.Design Cohort study.Setting In 2009, a nationwide, multidisciplinary infection control programme was launched in Sweden, PRISS, which aimed to reduce the PJI burden by 50%.Participants We obtained data on patients undergoing primary THA from the Swedish Arthroplasty Registry 2012–2014, (n=45 723 patients, 49 946 THAs). Using personal identity numbers, this cohort was matched with the Swedish Prescribed Drug Registry. Medical records of patients with ≥4 weeks’ antibiotic consumption were reviewed to verify PJI diagnosis (n=2240, 2569 THAs).Results The cumulative incidence of PJI following the PRISS Project was 1.2% (95% CI 1.1% to 1.3%) as compared with 0.9% (95% CI 0.8% to 1.0%) before. Cox regression models for the PJI incidence post-PRISS indicates there was no statistical significance difference versus pre-PRISS (HR 1.1 (95% CI 0.9 to 1.3)). There was similar time to PJI diagnosis after the PRISS Project 24 vs 23 days (p=0.5).Conclusions Despite the comprehensive nationwide PRISS Project, Swedish PJI incidence was higher after the project and time to diagnosis remained unchanged. Factors contributing to PJI, such as increasing obesity, higher American Society of Anesthesiology class and more fractures as indications, explain the PJI increase among primary THA patients.

Abstract Background Painful conditions such as residual limb pain (RLP) and phantom limb pain (PLP) can manifest after amputation. The mechanisms underlying such postamputation pains are diverse and should be addressed accordingly. Different surgical treatment methods have shown potential for alleviating RLP due to neuroma formation — commonly known as neuroma pain — and to a lesser degree PLP. Two reconstructive surgical interventions, namely targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI), are gaining popularity in postamputation pain treatment with promising results. However, these two methods have not been directly compared in a randomised controlled trial (RCT). Here, we present a study protocol for an international, double-blind, RCT to assess the effectiveness of TMR, RPNI, and a non-reconstructive procedure called neuroma transposition (active control) in alleviating RLP, neuroma pain, and PLP. Methods One hundred ten upper and lower limb amputees suffering from RLP will be recruited and assigned randomly to one of the surgical interventions (TMR, RPNI, or neuroma transposition) in an equal allocation ratio. Complete evaluations will be performed during a baseline period prior to the surgical intervention, and follow-ups will be conducted in short term (1, 3, 6, and 12 months post-surgery) and in long term (2 and 4 years post-surgery). After the 12-month follow-up, the study will be unblinded for the evaluator and the participants. If the participant is unsatisfied with the outcome of the treatment at that time, further treatment including one of the other procedures will be discussed in consultation with the clinical investigator at that site. Discussion A double-blind RCT is necessary for the establishment of evidence-based procedures, hence the motivation for this work. In addition, studies on pain are challenging due to the subjectivity of the experience and the lack of objective evaluation methods. Here, we mitigate this problem by including different pain evaluation methods known to have clinical relevance. We plan to analyse the primary variable, mean change in NRS (0–10) between baseline and the 12-month follow-up, using the intention-to-treat (ITT) approach to minimise bias and keep the advantage of randomisation. The secondary outcomes will be analysed on both ITT and per-protocol (PP). An adherence protocol (PP population) analysis will be used for estimating a more realistic effect of treatment. Trial registration ClinicalTrials.gov NCT05009394.

Abstract Background The EQ VAS component of the EQ-5D questionnaire has been used to assess patients’ valuation of their own health besides its use for self-reporting of overall health status. The objective of the present study was to identify patients’ valuation of EQ-5D-3L health states using the EQ VAS in different patient groups over time and in comparison to the general population. Methods Data were obtained from patients from nine National Quality Registers (n = 172,070 patients) at baseline and at 1-year follow-up and compared with data from the general population (n = 41,761 participants). The correlation between EQ VAS scores and EQ-5D-3L index based on the Swedish experience-based VAS value set was assessed. Ordinary least squares (OLS) regression models were used to determine the association between EQ-5D-3L dimensions and EQ VAS valuation. Results EQ VAS scores showed consistency with severity of health states both at baseline and at 1-year follow-up in the nine selected EQ-5D-3L health states. The regression models showed mostly consistent decrements by severity levels in each dimension at both time points and similar to the general population. The dimension mainly associated with inconsistency was the self-care severity level three. Problems in the anxiety/depression dimension had the largest impact on overall health status in most of the patient groups and the general population. Conclusion The study has demonstrated the important role EQ VAS can play in revealing patients’ valuation of their health and showed the variation in valuation of EQ-5D-3L dimensions and levels of severity across different patient groups.

Background and purpose: Few studies have focused on nonagenarians treated with total hip arthroplasty (THA). We investigated 30- and 90-day postoperative mortality, patient-reported outcome measures (PROMs), reoperation rate, risk factors for reoperation, and relative patient survival in nonagenarians or older. Patients and methods: 167,091 patients with primary cemented THA performed for osteoarthritis between 1992 and 2019 were identified in the Swedish Arthroplasty Register. Patients were divided into age groups based on age at time of surgery: 60–74 (n = 90,285), 75–89 (n = 75,421), and > 90 years (n = 1,385). Mortality rate, PROMs (pain–Likert scale, satisfaction–Likert scale, EQ-VAS, n = 67,553), reoperation rate, risk factors for reoperation, and relative patient survival were studied. Results: The nonagenarians had the highest postoperative mortality rate, 1.7% and 2.6% at 30 and 90 days, respectively. Nonagenarian females reported significantly lower pre- and postoperative EQ-VAS compared with patients aged 60–89 years but reported least pain and highest patient satisfaction 1 year after surgery. At 2 years the nonagenarians had highest reoperation frequency—2.7%—due to infection (1.5%), dislocation (0.8%), and periprosthetic fracture (0.4%). Increasing age, male sex, and polished stem were associated with higher risk of reoperation within 2 years. 8-year age- and sex-matched relative survival was highest among nonagenarians (study group/matched population: ≥ 90 years 3.4, 95% confidence interval [CI] 3.0–3.8; 75–89 years: 1.4, CI 1.4–1.4, and 60–74 years: 1.1, CI 1.1–1.1). Conclusion: 30- and 90-day postoperative mortality and reoperation rates were higher in nonagenarians but PROM data showed least pain and highest patient satisfaction 1 year after surgery with THA among female nonagenarians with primary osteoarthritis.

AimsWe compared the risks of re-revision and mortality between two-stage revision surgery and single-stage revision surgery among patients with infected primary knee arthroplasty.MethodsPatients with a periprosthetic joint infection (PJI) of their primary knee arthroplasty, initially revised with a single-stage or a two-stage procedure in England and Wales between 2003 and 2014, were identified from the National Joint Registry. We used Poisson regression with restricted cubic splines to compute hazard ratios (HR) at different postoperative periods. The total number of revisions and re-revisions undergone by patients was compared between the two strategies.ResultsA total of 489 primary knee arthroplasties were revised with single-stage procedure (1,390 person-years) and 2,377 with two-stage procedure (8,349 person-years). The adjusted incidence rates of all-cause re-revision and for infection were comparable between these strategies (HR overall five years, 1.15 (95% confidence interval (CI) 0.87 to 1.52), p = 0.308; HR overall five years, 0.99 (95% CI 0.70 to 1.39), p = 0.949, respectively). Patients initially managed with single-stage revision received fewer revision procedures overall than after two-stage revision (1.2 vs 2.2, p < 0.001). Mortality was lower for single-stage revision between six and 18 months postoperative (HR at six months, 0.51 (95% CI 0.25 to 1.00), p = 0.049 HR at 18 months, 0.33 (95% CI 0.12 to 0.99), p = 0.048) and comparable at other timepoints.ConclusionThe risk of re-revision was similar between single- and two-stage revision for infected primary knee arthroplasty. Single-stage group required fewer revisions overall, with lower or comparable mortality at specific postoperative periods. The single-stage revision is a safe and effective strategy to treat infected knee arthroplasties. There is potential for increased use to reduce the burden of knee PJI for patients, and for the healthcare system.Cite this article: Bone Joint Res 2022;11(10):690–699.

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, Denmark, 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.

Background Restricted weight-bearing is still used after lower extremity fracture surgery in elderly patients. The long-term effect on gait recovery in elderly patients with distal femur fractures (DFF) and their ability to comply with the restrictive weight-bearing regime is unknown. This study aimed to investigate the effect of restricted postoperative weight-bearing on gait recovery (actual weight-bearing and cadence) during a 1-year follow-up. Methods This study evaluated secondary outcomes from a randomized controlled trial (32 patients ≥65 years, with a traumatic DFF). Internal fixation was achieved using an anatomical lateral plate. Patients were allocated to either immediate full weight-bearing (FWB) or partial weight-bearing (PWB) (30% of body weight) for 8 weeks. Pressure-sensitive sensors (F-scan™ system, Tekscan, Massachusetts, USA) were used to measure weight-bearing and cadence postoperatively and at 8-, 16-, and 52-week follow-ups. Twenty-six patients with at least 1 measurement were included. Results There was a statistically significant difference in actual weight-bearing between the PWB and FWB groups postoperatively of 32.3% (95% confidence interval CI, −50.0; −13.0, P < .001) and at the 8-week follow-up of 36.8% (95% CI −61.0; −18.0, P = .01), but not at later follow-ups. The PWB group presented a consistently lower cadence compared to the FWB group, which was statistically significant at the 16-week follow-up with 9.0 steps/min (95% CI -16.2; −1.1, P = .047) and 52-week follow-up with 9.3 steps/min (95% CI −18.0; −3.9, P = .009). Conclusions Restricting postoperative weight-bearing in elderly patients with a DFF had a significant effect on postoperative weight-bearing. The effect lingered with a delayed return to FWB and persistent significantly lower cadence in the PWB group. These findings suggest that even temporary weight-bearing restrictions most likely have negative long-term effects on gait function at 1 year and, therefore, cannot be recommended.

Background and purpose: The incidence of periprosthetic joint infection after total hip arthroplasty (THA) may be increasing. We performed time-trend analyses of risk, rates, and timing of revision due to infection after primary THAs in the Nordic countries from the period 2004–2018. Patients and methods: 569,463 primary THAs reported to the Nordic Arthroplasty Register Association from 2004 to 2018 were studied. Absolute risk estimates were calculated by Kaplan–Meier and cumulative incidence function methods, whereas adjusted hazard ratios (aHR) were assessed by Cox regression with the first revision due to infection after primary THA as primary endpoint. In addition, we explored changes in the time span from primary THA to revision due to infection. Results: 5,653 (1.0%) primary THAs were revised due to infection during a median follow-up time of 5.4 (IQR 2.5–8.9) years after surgery. Compared with the period 2004–2008, the aHRs for revision were 1.4 (95% confidence interval [CI] 1.3–1.5) for 2009–2013, and 1.9 (CI 1.7–2.0) for 2014–2018. The absolute 5-year rates of revision due to infection were 0.7% (CI 0.7–0.7), 1.0% (CI 0.9–1.0), and 1.2% (CI 1.2–1.3) for the 3 time periods respectively. We found changes in the time span from primary THA to revision due to infection. Compared with 2004–2008, the aHR for revision within 30 days after THA was 2.5 (CI 2.1–2.9) for 2009–2013, and 3.4 (CI 3.0–3.9) for 2013–2018. The aHR for revision within 31–90 days after THA was 1.5 (CI 1.3–1.9) for 2009–2013, and 2.5 (CI 2.1–3.0) for 2013–2018, compared with 2004–2008. Conclusion: The risk of revision due to infection after primary THA almost doubled, both in absolute cumulative incidence and in relative risk, throughout the period 2004–2018. This increase was mainly due to an increased risk of revision within 90 days of THA. This may reflect a “true” increase (i.e., frailer patients or more use of uncemented implants) and/or an “apparent” increase (i.e., improved diagnostics, changed revision strategy, or completeness of reporting) in incidence of periprosthetic joint infection. It is not possible to disclose such changes in the present study, and this warrants further research.

Background and purpose: The bearings with the best survivorship for young patients with total hip arthroplasty (THA) should be identified. We compared hazard ratios (HR) of revision of primary stemmed cementless THAs with metal-on-metal (MoM), ceramic-on-ceramic (CoC), and ceramic-on-highly-crosslinked-polyethylene (CoXLP) with that of metal-on-highly-crosslinked-polyethylene (MoXLP) bearings in patients aged 20–55 years with primary osteoarthritis or childhood hip disorders. Patients and methods: From the Nordic Arthroplasty Register Association dataset we included 1,813 MoM, 3,615 CoC, 5,947 CoXLP, and 10,219 MoXLP THA in patients operated on between 2005 and 2017 in a prospective cohort study. We used the Kaplan–Meier estimator for THA survivorship and Cox regression to estimate HR of revision adjusted for confounders (including 95% confidence intervals [CI]). MoXLP was used as reference. HRs were calculated during 3 intervals (0–2, 2–7, and 7–13 years) to meet the assumption of proportional hazards. Results: Median follow-up was 5 years for MoXLP, 10 years for MoM, 6 years for CoC, and 4 years for CoXLP. 13-year Kaplan–Meier survival estimates were 95% (CI 94–95) for MoXLP, 82% (CI 80–84) for MoM, 93% (CI 92–95) for CoC, and 93% (CI 92–94) for CoXLP bearings. MoM had higher 2–7 and 7–13 years’ adjusted HRs of revision (3.6, CI 2.3–5.7 and 4.1, CI 1.7–10). MoXLP, CoC, and CoXLP had similar HRs in all 3 periods. The 7–13-year adjusted HRs of revision of CoC and CoXLP were statistically non-significantly higher. Conclusion: In young patients, MoXLP for primary cementless THA had higher revision-free survival and lower HR for revision than MoM bearings. Longer follow-up is needed to compare MoXLP, CoC, and CoXLP.

Abstract Background The aim of this study is to investigate the experiences of physicians presented with a knowledge support system while registering data on ankle fractures in the Swedish Fracture Register. The present study aims to answer the following research questions: • “How is receiving knowledge support while registering a fracture in the Swedish Fracture Register experienced by the physicians using it?”. • “Can a feeling of increased usability of a quality register be achieved by providing the user with real-time feedback?”. Methods A total of 20 physicians using the Swedish Fracture Register were recruited using a purposive sampling strategy. Qualitative content analysis was performed on individual semi-structured interviews performed in May and June 2020. Results The present study demonstrates that the knowledge support system in the Swedish Fracture Register was perceived by the physicians as strengthening the evidence base and improving the quality of ankle fracture treatment. The knowledge support system was evaluated as a good tool for validating clinical decisions and managing the information that needs to be processed to make informed decisions. Conclusions The present study affirms that being provided with knowledge support is appreciated by physicians, increase value for work and enhance the initiative to register. The physicians experienced that the knowledge support provided an appreciated validation of the clinical decisions taken and a feeling of improved care. When incorporating knowledge support into an NQR, consideration must be given to physicians’ fears of becoming overly reliant on a template and losing control of the clinical base.

Abstract Background In Sweden, the incidence of a prosthetic joint infection (PJI) after a planned Total Hip Arthroplasty (THA) is 1.3%, but the worldwide incidence of PJI after THA is unknown. This study explores associations between reoperation due to PJI and potential risk factors. Methods Primary elective THA surgery registered in both the Swedish Hip Arthroplasty Registry (SHAR) and the Swedish Perioperative Registry (SPOR) between 1 January 2015 and 31 December 2019 were included in this registry study, resulting in a total study population of 35,056 cases. The outcome variable was reoperation as the result of PJI within a year after surgery. Data were analysed using a multivariable Cox regression model. Results Reoperation due to PJI occurred in 460 cases (i.e., 1.3% of the study population). Each year of age increased the risk with 2% (HR 1.02 Cl 1.01, 1.03 P = 30), the risk increased considerably compared to underweight, normal weight, or overweight patients (HR 1.89 Cl 1.43, 2.51 P =

Background: Periprosthetic joint infections (PJI) are challenging complications following arthroplasty. Staphylococci are a frequent cause of PJI and known biofilm producers. Biofilm formation decreases antimicrobial susceptibility, thereby challenging favourable treatment outcomes. The aims of this study were to characterize the biofilm abilities and antimicrobial susceptibilities of staphylococci causing first-time PJI and correlate them to clinical outcome (infection resolution and recurrence). Methods: Reoperations for PJI of the hip or knee between 1st January 2012 to 30th June 2015 performed at the Sahlgrenska University Hospital were identified in a local database. Medical records were reviewed and clinical parameters recorded for patients whose intraoperative bacterial isolates had been stored at the clinical laboratory. Staphylococcal strains isolated from reoperations due to first-time PJI were characterised by their ability to form biofilms using the microtiter plate test. Antimicrobial susceptibility of the strains was determined by minimum inhibitory concentration (MIC) when grown planktonically, and by minimum biofilm eradication concentration (MBEC) when grown as biofilms. MBEC determination was conducted using the Calgary biofilm device (CBD) and a custom-made antimicrobial susceptibility plate containing eight clinically relevant antimicrobial agents. Results: The study group included 49 patients (70 bacterial strains) from first-time PJI, whereof 24 (49%) patients had recurrent infection. Strong biofilm production was significantly associated with recurrent infection. Patients infected with strong biofilm producers had a five-fold increased risk for recurrent infection. Strains grown as biofilms were over 8000 times more resistant to antimicrobial agents compared to planktonic cultures. Biofilms were more susceptible to rifampicin compared to other antimicrobials in the assay. Increased biofilm susceptibility (MBEC ​> ​MIC) was observed for the majority of the bacterial strains and antimicrobial agents. Conclusions: Strong biofilm production was significantly associated with increased antimicrobial resistance and PJI recurrence. This underscores the importance of determining biofilm production and susceptibility as part of routine diagnostics in PJI. Strong staphylococcal biofilm production may have implications on therapeutic choices and suggest more extensive surgery. Furthermore, despite the increased biofilm resistance to rifampicin, results from this study support its use in staphylococcal PJI. The Translational Potential of this Article: Like for many biomaterial-associated infections, staphylococci are a common cause of PJI. Their ability to adhere to surfaces and produce biofilms on medical devices is proposed to play a role. However, clinical studies where biofilm properties are directly linked to patient outcome are scarce. This study demonstrates that the majority of staphylococci isolated from first-time PJI were biofilm producers with increased antimicrobial resistance. Patients suffering an infection caused by a staphylococcal strain with strong biofilm production ability had a five-fold greater risk of recurrent infection. This novel finding suggests the importance of evaluating biofilm production as a diagnostic procedure for the guidance of treatment decisions in PJI.

Background: People with severe osteoarthritis, other joint conditions or injury may have joint replacement to reduce pain and disability. In the UK in 2019, over 200,000 hip and knee replacements were performed. About 1 in 100 replacements becomes infected, and most people with infected replacements require further surgery. Objectives: To investigate why some patients are predisposed to joint infections and how this affects patients and the NHS, and to evaluate treatments. Design: Systematic reviews, joint registry analyses, qualitative interviews, a randomised controlled trial, health economic analyses and a discrete choice questionnaire. Setting: Our studies are relevant to the NHS, to the Swedish health system and internationally. Participants: People with prosthetic joint infection after hip or knee replacement and surgeons. Interventions: Revision of hip prosthetic joint infection with a single- or two-stage procedure. Main outcome measures: Long-term patient-reported outcomes and reinfection. Cost-effectiveness of revision strategies over 18 months from two perspectives: health-care provider and Personal Social Services, and societal. Data sources: National Joint Registry; literature databases; published cohort studies; interviews with 67 patients and 35 surgeons; a patient discrete choice questionnaire; and the INFORM (INFection ORthopaedic Management) randomised trial. Review methods: Systematic reviews of studies reporting risk factors, diagnosis, treatment outcomes and cost comparisons. Individual patient data meta-analysis. Results: In registry analyses, about 0.62% and 0.75% of patients with hip and knee replacement, respectively, had joint infection requiring surgery. Rates were four times greater after aseptic revision. The costs of inpatient and day-case admissions in people with hip prosthetic joint infection were about five times higher than those in people with no infection, an additional cost of > £30,000. People described devastating effects of hip and knee prosthetic joint infection and treatment. In the treatment of hip prosthetic joint infection, a two-stage procedure with or without a cement spacer had a greater negative impact on patient well-being than a single- or two-stage procedure with a custom-made articulating spacer. Surgeons described the significant emotional impact of hip and knee prosthetic joint infection and the importance of a supportive multidisciplinary team. In systematic reviews and registry analyses, the risk factors for hip and knee prosthetic joint infection included male sex, diagnoses other than osteoarthritis, high body mass index, poor physical status, diabetes, dementia and liver disease. Evidence linking health-care setting and surgeon experience with prosthetic joint infection was inconsistent. Uncemented fixation, posterior approach and ceramic bearings were associated with lower infection risk after hip replacement. In our systematic review, synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy for prosthetic joint infection. Systematic reviews and individual patient data meta-analysis showed similar reinfection outcomes in patients with hip or knee prosthetic joint infection treated with single- and two-stage revision. In registry analysis, there was a higher rate of early rerevision after single-stage revision for hip prosthetic joint infection, but, overall, 40% fewer operations are required as part of a single-stage procedure than as part of a two-stage procedure. The treatment of hip or knee prosthetic joint infection with early debridement and implant retention may be effective in > 60% of cases. In the INFORM randomised controlled trial, 140 patients with hip prosthetic joint infection were randomised to single- or two-stage revision. Eighteen months after randomisation, pain, function and stiffness were similar between the randomised groups (p = 0.98), and there were no differences in reinfection rates. Patient outcomes improved earlier in the single-stage than in the two-stage group. Participants randomised to a single-stage procedure had lower costs (mean difference –£10,055, 95% confidence interval –£19,568 to –£542) and higher quality-adjusted life-years (mean difference 0.06, 95% confidence interval –0.07 to 0.18) than those randomised to a two-stage procedure. Single-stage was the more cost-effective option, with an incremental net monetary benefit at a threshold of £20,000 per quality-adjusted life-year of £11,167 (95% confidence interval £638 to £21,696). In a discrete choice questionnaire completed by 57 patients 18 months after surgery to treat hip prosthetic joint infection, the most valued characteristics in decisions about revision were the ability to engage in valued activities and a quick return to normal activity. Limitations: Some research was specific to people with hip prosthetic joint infection. Study populations in meta-analyses and registry analyses may have been selected for joint replacement and specific treatments. The INFORM trial was not powered to study reinfection and was limited to 18 months’ follow-up. The qualitative study subgroups were small. Conclusions: We identified risk factors, diagnostic biomarkers, effective treatments and patient preferences for the treatment of hip and knee prosthetic joint infection. The risk factors include male sex, diagnoses other than osteoarthritis, specific comorbidities and surgical factors. Synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy. Infection is devastating for patients and surgeons, both of whom describe the need for support during treatment. Debridement and implant retention is effective, particularly if performed early. For infected hip replacements, single- and two-stage revision appear equally efficacious, but single-stage has better early results, is cost-effective at 18-month follow-up and is increasingly used. Patients prefer treatments that allow full functional return within 3–9 months. Future work: For people with infection, develop information, counselling, peer support and care pathways. Develop supportive care and information for patients and health-care professionals to enable the early recognition of infections. Compare alternative and new treatment strategies in hip and knee prosthetic joint infection. Assess diagnostic methods and establish NHS diagnostic criteria. Study registration: The INFORM randomised controlled trial is registered as ISRCTN10956306. All systematic reviews were registered in PROSPERO (as CRD42017069526, CRD42015023485, CRD42018106503, CRD42018114592, CRD42015023704, CRD42017057513, CRD42015016559, CRD42015017327 and CRD42015016664). Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 10. See the NIHR Journals Library website for further project information.

The primary aim of the study was to identify inflammatory markers relevant for osteoarthritis (OA)-related systemic (plasma) and local (synovial fluid, SF) inflammation. From this, we looked for inflammatory markers that coincided with the increased amount of O-linked Tn antigen (GalNAcα1-Ser/Thr) glycan on SF lubricin. Inflammatory markers in plasma and SF in OA patients and controls were measured using a 44-multiplex immunoassay. We found consistently 29 markers detected in both plasma and SF. The difference in their concentration and the low correlation when comparing SF and plasma suggests an independent inflammatory environment in the two biofluids. Only plasma MCP-4 and TARC increased in our patient cohort compared to control plasma. To address the second task, we concluded that plasma markers were irrelevant for a direct connection with SF glycosylation. Hence, we correlated the SF-inflammatory marker concentrations with the level of altered glycosylation of SF-lubricin. We found that the level of SF-IL-8 and SF-MIP-1α and SF-VEGFA in OA patients displayed a positive correlation with the altered lubricin glycosylation. Furthermore, when exposing fibroblast-like synoviocytes from both controls and OA patients to glycovariants of recombinant lubricin, the secretion of IL-8 and MIP-1α and VEGFA were elevated using lubricin with Tn antigens, while lubricin with sialylated and nonsialylated T antigens had less or no measurable effect. These data suggest that truncated glycans of lubricin, as found in OA, promote synovial proinflammatory cytokine production and exacerbate local synovial inflammation.

Introduction Prosthetic joint infections (PJIs) are disastrous complications for patients and costly for healthcare organisations. They may promote bacterial resistance due to the extensive antibiotic use necessary in the PJI treatment. The PJI incidence is estimated to be 1%–3%, but the absolute numbers worldwide are high and increasing as large joint arthroplasties are performed by the millions each year. Current treatment algorithms, based on implant preserving surgery or full revision followed by a semitailored antibiotic regimen for no less than 2–3 months, lead to infection resolution in approximately 60% and 90%, respectively. Antibiotic choice is currently guided by minimum inhibitory concentrations (MICs) of free-living bacteria and not of bacteria in biofilm growth mode. Biofilm assays with relatively rapid output for the determination of minimum biofilm eradication concentrations (MBECs) have previously been developed but their clinical usefulness have not been established.Methods and analysis This single-blinded, two-arm randomised study of hip or knee staphylococcal PJI will evaluate 6-week standard of care (MIC guided), or an alternative antibiotic regimen according to an MBEC-guided-based decision algorithm. Sixty-four patients with a first-time PJI treated according to the debridement, antibiotics, and implant retention principle will be enrolled at a single tertiary orthopaedic centre (Sahlgrenska University Hospital). Patients will receive 14 days of standard parenteral antibiotics before entering the comparative study arms. The primary outcome measurement is the proportion of changes in antimicrobial regimen from first-line treatment dependent on randomisation arm. Secondary endpoints are unresolved infection, how microbial properties including biofilm abilities and emerging antimicrobial resistance correlate to infection outcomes, patient reported outcomes and costs with a 12-month follow-up.Ethics and dissemination Approval is received from the Swedish Ethical Review Authority, no 2020-01471 and the Swedish Medical Products Agency, EudraCT, no 2020-003444-80.Trial registration number ClinicalTrials.gov ID: NCT04488458.

Background and purpose — Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain and may contribute to the development of osteoarthritis. We investigated whether a prior hip arthroscopy affects the patient-reported outcomes (PROMs) of a later total hip arthroplasty (THA). Patients and methods — Patients undergoing hip arthroscopy between 2011 and 2018 were identified from a hip arthroscopy register and linked to the Swedish Hip Arthroplasty Register (SHAR). A propensity-score matched control group without a prior hip arthroscopy, based on demographic data and preoperative score from the EuroQoL visual analogue scale (EQ VAS) and hip pain score, was identified from SHAR. The group with a hip arthroscopy (treated group) consisted of 135 patients and the matched control group comprised 540 patients. The included PROMs were EQ-5D and EQ VAS of the EuroQoL group, and a questionnaire regarding hip pain and another addressing satisfaction. Rate of reoperation was collected from the SHAR. The follow-up period was 1 year. Results — The mean interval from arthroscopy to THA was 27 months (SD 19). The EQ-5D was 0.81 and 0.82, and EQ VAS was 78 and 79 in the treated group and the matched control group respectively. There were no differences in hip pain, and reported satisfaction was similar with 87% in the treated group and 86% in the matched control group. Interpretation — These results offer reassurance that a prior hip arthroscopy for FAIS does not appear to affect the short-term patient-reported outcomes of a future THA and indicate that patients undergoing an intervention are not at risk of inferior results due to their prior hip arthroscopy.

ABSTRACT The approach of sequencing or genotyping to characterize the pathogenic potential of staphylococci from orthopedic device-related infection (ODRI) has been applied in recent studies. These studies described the genomic carriage of virulence in clinical strains and compared it with those in commensal strains. Only a few studies have directly correlated genomic profiles to patient outcome and phenotypic virulence properties in periprosthetic joint infections (PJIs). We investigated the association between genomic variations and virulence-associated phenotypes (biofilm-forming ability and antimicrobial resistance) in 111 staphylococcal strains isolated from patients with PJI and the infection outcome (resolved/unresolved). The presence of a strong biofilm phenotype in Staphylococcus aureus and an antibiotic-resistant phenotype in Staphylococcus epidermidis were both associated with treatment failure of PJI. In S. epidermidis, multidrug resistance (MDR) and resistance to rifampicin were associated with unresolved infection. Sequence type 45 (ST45) and ST2 were particularly enriched in S. aureus and S. epidermidis, respectively. S. epidermidis ST2 caused the majority of relapses and was associated with MDR and strong biofilm production, whereas ST215 correlated with MDR and non/weak biofilm production. S. aureus agr II correlated with resolved infection, while S. epidermidis agr I was associated with strong biofilm production and agr III with non/weak production. Collectively, our results highlight the importance of careful genomic and phenotypic characterization to anticipate the probability of the strain causing treatment failure in PJI. Due to the high rate of resistant S. epidermidis strains identified, this study provides evidence that the current recommended treatment of rifampicin and a fluoroquinolone should not be administered without knowledge of the resistance pattern. IMPORTANCE This study addresses the presence and frequency of particular genetic variants and virulence factors found in staphylococcal bacteria causing periprosthetic joint infection (PJI) of the hip and knee to ascertain their clinical relevance as predictors of treatment failure. We characterized the genetic virulence traits of a large collection of clinical staphylococci isolated from patients with PJI and evaluated their association with the patient’s infection outcome. The results showed that S. aureus strains that produced strong biofilms and S. epidermidis strains with resistance to several antibiotics associated significantly with unresolved infection. Some particular genetic variants associated with biofilm formation and multidrug resistance. These traits should be considered important risk factors for the diagnosis and treatment guidance in PJI.

Background and purpose — A challenge comparing outcomes from total hip arthroplasty between countries is variation in preoperative characteristics, particularly comorbidity. Therefore, we investigated between-country variation in comorbidity in patients based on ASA class distribution, and determined any variation of ASA class to mortality risk between countries. Patients and methods — All arthroplasty registries collecting ASA class and mortality data in patients with elective primary THAs performed 2012–2016 were identified. Survival analyses of the influence of ASA class on 1-year mortality were performed by individual registries, followed by meta-analysis of aggregated data. Results — 6 national registries and 1 US healthcare organization registry with 418,916 THAs were included. There was substantial variation in the proportion of ASA class III/IV, ranging from 14% in the Netherlands to 39% in Finland. Overall, 1-year mortality was 0.93% (95% CI 0.87–1.01) and increased from 0.2% in ASA class I to 8.9% in class IV. The association between ASA class and mortality measured by hazard ratios (HR) was strong in all registries even after adjustment for age and sex, which reduced them by half in all registries. Combined adjusted HRs were 2.0, 6.1, and 22 for ASA class II–IV vs. I, respectively. Associations were moderately heterogeneous across registries. Interpretation — We observed large variation in ASA class distribution between registries, possibly explained by differences in background morbidity and/or international variation in access to surgery. The similar, strong mortality trends by ASA class between countries enhance the relevance of its use as an indicator of comorbidity in international registry studies.

Background and purpose — Uncemented stems are gradually replacing cemented stems in hip revision surgery. We compared the risk of re-revision between uncemented and cemented revision stems and assessed whether the different fixation methods are used in similar femoral bone defects. Patients and methods — 867 patients operated on with uncemented or cemented stems in first-time hip revision surgery due to aseptic loosening performed 2006–2016 were identified in the Swedish Hip Arthroplasty Register. Preoperative femoral bone defect size was assessed on radiographs of all patients. Cox regression models were fitted to estimate the adjusted risk of re-revision during different postoperative time periods. Re-revision of any component for any reason, and stem re-revision, as well as risk of cause-specific re-revision was estimated. Results — Most patients in both fixation groups had Paprosky class IIIA femoral bone defects prior to surgery, but there were more severe bone defects in the cemented group. The adjusted risk of re-revision of any component for any reason was higher in patients with uncemented compared with those with cemented revision stems during the first 3 years after index surgery (hazard ratio [HR] 4, 95% confidence interval [CI] 2–9). From the 4th year onward, the risk of re-revision of any component for any reason was similar (HR 0.5, CI 0.2–1.4). Uncemented revision stems conferred a higher risk of dislocation compared with cemented stems (HR 5, CI 1.2–23) during the first 3 years. Interpretation — Although not predominantly used in more complex femoral defects, uncemented revision stem fixation confers a slightly higher risk of re-revision during the first years, but this risk is attenuated after longer follow-up.

Background and purpose — The use of trabecular metal cups in primary total hip arthroplasty (THA) is increasing, despite the survival of Continuum cups being slightly inferior compared with other uncemented cups in registries. This difference is mainly explained by a higher rate of dislocation revisions. Cup malpositioning is a risk factor for dislocation and, being made of a highly porous material, Continuum cups might be more difficult to position. We evaluated whether Continuum cups had worse cup positioning compared with other uncemented cups. Patients and methods — Based on power calculation, 150 Continuum cups from 1 center were propensity score matched with 150 other uncemented cups from 4 centers. All patients had an uncemented stem, femoral head size of 32 mm or 36 mm, and BMI between 19 and 35. All operations were done for primary osteoarthrosis through a posterior approach. Patients were matched using age, sex, and BMI. Cup positioning was measured from anteroposterior pelvic radiograph using the Martell Hip Analysis Suite software. Results — There was no clinically relevant difference in mean inclination angle between the study group and the control group (43° [95% CI 41–44] and 43° [CI 42–45], respectively). The study group had a larger mean anteversion angle compared with the control group, 19° (CI 18–20) and 17° (CI 15–18) respectively. Interpretation — Continuum cups had a greater anteversion compared with the other uncemented cups. However, the median anteversion was acceptable in both groups and this difference does not explain the larger dislocation rate in the Continuum cups observed in earlier studies.

Background and purpose — Current literature indicates no difference in 90-day mortality after cemented compared with cementless total hip arthroplasty (THA). However, previous studies are hampered by potential selection bias and suboptimal adjustment for comorbidity confounding. Therefore, we examined the comorbidity-adjusted mortality up to 90 days after cemented compared with cementless THA performed due to osteoarthritis. Patients and methods — Using the Nordic Arthroplasty Register Association database, 2005–2013, we included 108,572 cemented and 80,034 cementless THA due to osteoarthritis. We calculated the Charlson comorbidity index of each patient based on data from national patient registers. The Kaplan–Meier method was used to estimate unadjusted all-cause mortality. Cox regression was used to estimate hazard ratios (HR) with 95% confidence intervals (CI) for 14, 30-, and 90-day mortality comparing cemented with cementless THA, adjusting for age, sex, comorbidity, nation, and year of surgery. Results — Cumulative all-cause mortality within 90 days was 0.41% (CI 0.37–0.46) after cemented and 0.26% (CI 0.22–0.30) after cementless THA. The adjusted HR for cemented vs. cementless fixation was 0.97 (CI 0.79–1.2), and similar risk estimates were obtained for mortality within 14 (adjusted HR 0.91 [CI 0.64–1.3]) and 30 days (adjusted HR 0.94 [CI 0.71–1.3]). We found no clinically relevant differences in mortality between cemented and cementless THA in analyses stratified by age, sex, Charlson comorbidity index, or year of surgery. Interpretation — After adjustment for comorbidity as an important confounder, we observed similar early mortality between the 2 fixation techniques.

Background and purpose — Collaborations between arthroplasty registries are important in order to create the possibility of detecting inferior implants early and improve our understanding of differences between nations in terms of indications and outcomes. In this registry study we compared patient and procedure characteristics, and revision rates in the Nordic Arthroplasty Register Association (NARA) database and the Dutch Arthroplasty Register (LROI). Patients and methods — All total hip arthroplasties (THAs) performed in 2010–2016 were included from the LROI (n = 184,862) and the NARA database (n = 290,823), which contains data from Denmark, Norway, Sweden, and Finland. Descriptive statistics and Kaplan–Meier survival analyses based on all reasons for revision and stratified by fixation were performed and compared between countries. Results — In the Netherlands, the proportion of patients aged < 55 years (9%) and male patients (34%) was lower than in Nordic countries (< 55 years 11–13%; males 35–43%); the proportion of osteoarthritis (OA) (87%) was higher compared with Sweden (81%), Norway (77%), and Denmark (81%) but comparable to Finland (86%). Uncemented fixation was used in 62% of patients in the Netherlands, in 70% of patients in Denmark and Finland, and in 28% and 19% in Norway and Sweden, respectively. The 5-year revision rate for THAs for OA was lower in Sweden (2.3%, 95% CI 2.1–2.5) than in the Netherlands (3.0%, CI 2.9–3.1), Norway (3.8%, CI 3.6–4.0), Denmark (4.6%, CI 4.4–4.8), and Finland (4.4%, CI 4.3–4.5). Revision rates in Denmark, Norway, and Finland were higher for all fixation groups. Interpretation — Patient and THA procedure characteristics as well as revision rates evinced some differences between the Netherlands and the Nordic countries. The Netherlands compared best with Denmark in terms of patient and procedure characteristics, but resembled Sweden more in terms of short-term revision risk. Combining data from registries like LROI and the NARA collaboration is feasible and might possibly enable tracking of potential outlier implants.

Abstract Background American Society of Anaesthesiologists (ASA) physical status classification system and its association with postoperative outcomes has been studied in different diseases. However, there is a paucity of studies on the relationship between ASA class and postoperative health-related quality of life (HRQoL) outcomes following total hip replacement (THR). The aim of this study was to assess the discriminative abilities of EQ-5D-3L value sets from Sweden, Germany, Denmark and the United Kingdom in relation to ASA classes and these value sets’ abilities to show the predictive performance of ASA classes on HRQoL among THR patients in Sweden. Methods A longitudinal study was conducted using data of patients in the Swedish Hip Arthroplasty Register who underwent THR between 2008 and 2016. We included 69,290 pre- and 1-year postoperative records and 21,305 6-year postoperative records. The study examined three experience-based EQ-5D-3L value sets (the Swedish VAS and TTO and the German VAS) and five hypothetical value sets (TTO from Germany and VAS and TTO value sets from Denmark and the UK each). Using linear models, the abilities of the value sets to discriminate among ASA classes and to show the predictive performance of ASA classes on HRQoL score were assessed. Results All value sets differentiated among ASA classes and showed the predictive effect of ASA classes on HRQoL. ASA classes were found to predict HRQoL consistently for all value sets investigated, with small variations in prediction error among the models. Conclusion ASA classes of patients undergoing THR predicted HRQoL scores significantly and consistently, indicating their importance in tailoring care for patients.

Abstract Background Case mix adjustment is a pre-requisite for valid measurement of healthcare performance and socioeconomic status (SES) is important to account for. Lack of information on individual-level SES has led to investigations into using a proxy for SES based on patient area of residence. The objective of this study was to use neighbourhood SES for case mix adjustment of performance indicators in total hip replacement (THR) in Sweden, and to compare with use of individual SES. Methods Data from patient administrative systems and the Swedish Hip Arthroplasty Register were extracted for all patients undergoing THR in four Swedish regions. For each subject, individual data and neighbourhood data on country of birth, educational level, and income were provided by Statistics Sweden. Three variables were selected for analysis of performance; EQ-5D, hip pain and length of stay (LoS). In addition to socioeconomic information, several important clinical characteristics were used as case mix factors. Regression analysis was used to study each variable’s impact on the three outcome variables and model fit was evaluated using mean squared error. Results A total of 27,121 patients operated between 2010 and 2016 were included in the study. Both educational level and income were higher when based on neighbourhood information than individual information, while proportion born in Sweden was similar. Higher SES was generally found to be associated with better outcomes and lower LoS, albeit with certain differences between the different measures of SES. The predictive ability of the models was increased when adding information on SES to the clinical characteristics. The increase in predictive ability was higher for individual SES compared to neighbourhood SES. When analysing performance for the two providers with most diverging case mix in terms of SES, the inclusion of SES altered the relative performance using individual as well as neighbourhood SES. Conclusions Incorporating SES improves case mix adjustment marginally compared to using only clinical information. In this patient group, geographically derived SES was found to improve case mix adjustment compared to only clinical information but not to the same extent as actual individual-level SES.

Abstract Background Psychiatric disorders have a major individual and societal impact. Until now, the association between health-related quality of life and physical disorders has been far more investigated than the association with psychiatric disorders. Patient-reported outcome measures makes it possible to capture the patient perspective to improve treatments and evaluate treatment outcomes. The aim of this study is to measure health-related quality of life with the EQ-5D-Y-5L among patients in child and adolescent psychiatric inpatient care and to test the instrument’s psychometric properties in terms of feasibility and construct validity. Methods Data were collected at the child and adolescent psychiatric inpatient facility in Region Stockholm. A questionnaire including the EQ-5D-Y-5L instrument, the Strengths and Difficulties Questionnaire with an impact supplement and a self-rated health question, was administered for self-completion using paper and pencil, with an interviewer present. The Chi-square test was used to investigate differences in proportion of reported problems in the EQ-5D-Y-5L dimensions and the Mann-Whitney U test was used for differences in mean EQ VAS scores. Feasibility was assessed by investigating proportion of missing and ambiguous answers and Spearman’s and Pearson’s correlation were used to examine construct validity. Results In total 52 adolescents participated in the study and the majority were girls. The most common diagnosis at admission was depressive episode/recurrent depressive disorder. All participants reported problems on at least one dimension. Most problems were reported in the dimension ‘feeling worried, sad or unhappy’, where 64% reported severe or extreme problems. Mean EQ VAS score was 29.2. Feasibility was supported and construct validity indicated as some of the hypothesised correlations between the EQ-5D-Y-5 L and the Strengths and Difficulties Questionnaire were found, however, for ‘doing usual activities’ and ‘having pain or discomfort’ the correlations were weaker than hypothesised. Conclusions This is the first study where the newly developed EQ-5D-Y-5L instrument has been used in psychiatric inpatient care for youth. Participants reported problems in all severity levels in most of the EQ-5D-Y-5L dimensions; mean EQ VAS score was considerably low. Feasibility of the EQ-5D-Y-5L was supported, however other psychometric properties need to be further tested in a larger sample.

Background and purpose — To better detect small changes in postoperative outcome following total hip replacement (THR), the Swedish Hip Arthroplasty Register (SHAR) has decided to change from the EQ-5D-3L (3L) to the EQ-5D-5L (5L). To enable comparison of results obtained with use of the 2 versions of EQ-5D, transferal of results between the questionnaires used is necessary. We assessed the measurement properties of the EQ-5D-5L compared with the EQ-5D-3L, preoperatively and 1-year postoperatively in a Swedish THR population. Patients and methods — Patients eligible for elective THR during 2015 in Western Sweden were invited to the study. With a 2-week separation, the 3L and 5L questionnaires were administered to patients before and 1 year after surgery. Comparing the 2 versions of the EQ-5D, we investigated redistribution of responses, ceiling and floor effects, EQ VAS correlations (Spearman’s rank correlation coefficient, rs), and EQ VAS scores for different severity levels by dimension (univariable ordinary least square regression). Results — The additional severity levels of the 5L version were frequently used on both measurement occasions (preoperative mobility 5%, self-care 17%, usual activities 20%, pain 5% and anxiety 3%, postoperative mobility 6%, self-care 5%, usual activities 8%, pain 9%, and anxiety 5%). Ceiling effects of the 3L version diminished overall by 7% using the 5L version. The correlations between the 2 EQ VAS scores obtained with the 3L and 5L instruments were strong both pre- (rs = 0.71) and postoperatively (rs = 0.87). Estimated EQ VAS scores for different levels of severity were consistent for all dimensions except for the mobility dimension of the preoperative 5L version and the anxiety dimension in the postoperative 5L version. Interpretation — Our findings support that the 5L has a higher resolution than the 3L version regarding description of health-related quality of life in patients undergoing THR in Sweden. The EQ VAS scores for different levels of severity agree well between the EQ-5D versions. This could potentially be used to develop a crosswalk value set for transforming 3L to 5L responses in this patient group.

Background and purpose — Fast-track care programs have been broadly introduced at Swedish hospitals in elective total hip and knee replacement (THR/TKR). We studied the influence of fast-track programs on patient-reported outcomes (PROs) 1 year after surgery, by exploring outcome measures registered in the Swedish arthroplasty registers. Patients and methods — Data were obtained from the Swedish Knee and Hip Arthroplasty Registers and included TKR and THR operations 2011–2015 on patients with osteoarthritis. Based on questionnaires concerning the clinical pathway and care programs at Swedish hospitals, the patients were divided in 2 groups depending on whether they had been operated in a fast-track program or not. PROs of the fast-track group were compared with not fast-track using regression analysis. EQ-5D, EQ VAS, Pain VAS, and Satisfaction VAS were analyzed for both THR and TKR operations. The PROMs for TKR also included KOOS. Results — The differences of EQ-5D, EQ VAS, Pain VAS, and Satisfaction VAS 1 year after surgery were small but all in favor of fast-track for both THR and TKR, also in subscales of KOOS for TKR except KOOS QoL. However, the effect sizes as measured by Cohens’ d formula were < 0.2 for all PROs, in both THR and TKR. Interpretation — Our results indicate that the fast-track programs may be at least as good as conventional care from the perspective of PROs 1-year postoperatively.

Abstract Background First-line treatment for hip and knee osteoarthritis (OA) including education and supervised exercises, delivered as a self-management program, is considered one of the mainstays in OA treatment. However, the socioeconomic profile of the population that utilizes first-line treatment for hip and knee OA is unclear. The aim of this study was to describe the socioeconomic status (SES) of a population referred to a self-management program for OA, in comparison with that of the general Swedish population. Methods This is a cross-sectional study including 72,069 patients with hip or knee OA enrolled in the National Quality Register for Better management of patients with Osteoarthritis (BOA) between 2008 and 2016, and registered before participation in a structured OA self-management program. A reference cohort (n = 216,207) was selected from the general Swedish population by one-to-three matching by year of birth, sex and residence. Residential municipality, country of birth, marital status, family type, educational level, employment, occupation, disposable income and sick leave were analyzed. Results The BOA population had higher educational level than the reference group, both regarding patients with hip OA (77.5% vs 70% with ≥10 years of education), and with knee OA (77% vs 72% with ≥10 years of education). Their average disposable income was higher (median [IQR] in Euro (€), for hip €17,442 [10,478] vs €15,998 [10,659], for knee €17,794 [10,574] vs €16,578 [11,221]). Of those who worked, 46% of patients with hip OA and 45% of the reference group had a blue-collar occupation. The corresponding numbers for knee OA were 51 and 44% respectively. Sick leave was higher among those with hip and knee OA (26%) than those in the reference groups (13% vs 12%). Conclusions The consistently higher SES in the BOA population compared with the general population indicates that this self-management program for OA may not reach the more socioeconomically disadvantaged groups, who are often those with a higher disease burden.

Background and purpose — Hip arthroplasty is one of the most performed surgeries in Sweden, and the rate of adverse events (AEs) is fairly high. All patients in publicly financed healthcare in Sweden are insured by the Mutual Insurance Company of Swedish County Councils (Löf). We assessed the proportion of patients that sustained a major preventable AE and filed an AE claim to Löf. Patients and methods — We performed retrospective record review using the Global Trigger Tool to identify AEs in a Swedish multi-center cohort consisting of 1,998 patients with a total or hemi hip arthroplasty. We compared the major preventable AEs with all patient-reported claims to Löf from the same cohort and calculated the proportion of filed claims. Results — We found 1,066 major preventable AEs in 744 patients. Löf received 62 claims for these AEs, resulting in a claim proportion of 8%. 58 of the 62 claims were accepted by Löf and received compensation. The claim proportion was 13% for the elective patients and 0.3% for the acute patients. The most common AE for filing a claim was periprosthetic joint infection; of the 150 infections found 37 were claimed. Interpretation — The proportion of filed claims for major preventable AEs is very low, even for obvious and serious AEs such as periprosthetic joint infection.

Background and purpose — Total hip replacement (THR) aims mainly to improve quality of life via restoration of hip function and provision of pain relief. This study sought to assess whether improvements in quality of life between the preoperative and 1-year postoperative period were associated with patient satisfaction Patients and methods — Data were extracted for 69,083 THR operations with complete data reported to the Swedish Hip Arthroplasty Register (SHAR) between 2008 and 2015. Health-related quality of life and patient satisfaction were captured using the Euro-Qol-5D (EQ-5D) and visual analogue scale (VAS), respectively. Multivariable analysis was performed to assess associations between the changes in pre- and postoperative EQ5D and patient satisfaction. Results — In patients reporting severe or moderate problems with mobility preoperatively, improvement to no problems was associated with numerically higher patient satisfaction (coefficient –18 [95% CI –22 to –14] and –18 [–18 to –17]). Improvement in the self-care dimension from severe or moderate problems to no problems was associated with numerically higher patient satisfaction (–15 [–16 to –14] and –13 [–15 to –11]). Improvement from severe problems with the ability to perform usual activities to no problems was associated with numerically higher patient satisfaction (–18 [–19 to –17]). This association was also found for improvement in pain/discomfort and anxiety/depression (–16 [–17 to –15] and –15 [–16 to –14]). Interpretation — Our results indicate that satisfaction with the operated hip is a valid patient-reported outcome reflecting the changes in different EQ-5D dimensions and should be included in the follow-up of patients after THR surgery.

Background and purpose — Recent studies indicate that preoperative use of opioids could be associated with higher rates of complications and worse patient-reported outcomes (PROs) after orthopedic surgery. We investigated the prevalence of preoperative opioid use and analyzed its influence on risk of revision, adverse events (AE), and PROs in patients with total hip replacement (THR). Patients and methods — This observational study included 80,483 patients operated on in 2008–2016 with THRs due to osteoarthritis. Data was obtained from the Swedish Hip Arthroplasty Register, Statistics Sweden’s sociodemographic registers, the Swedish National Patient Register, and the Prescribed Drug Register. We focused on patients with ≥ 4 opioid prescriptions filled 1 year prior to THR. To control for confounding, we used propensity scores to weight subjects in our analyses. Logistic and linear regression was used for outcome variables with adjustments for sociodemographic variables and comorbidities. Results — Patients with ≥ 4 opioid prescriptions in the year before THR (n = 14,720 [18%]) had a higher risk of revision within 2 years (1.8% vs. 1.1% OR 1.4, 95% CI 1.3–1.6) and AE within 90 days (9.4% vs. 6.4% OR 1.2, 95% CI 1.2–1.3) compared with patients without opioid treatment in the preoperative period. Patients with ≥ 4 opioid prescriptions rated 5 points worse on a 0–100 scale of Pain Visual Analogue Scale (VAS) and 9 points worse on a general health (EQ) VAS 1 year postoperatively. Interpretation — Having ≥ 4 opioid prescriptions filled in the year before surgery is associated with a higher risk of revision, adverse events, and worse PROs after THR. Consequently, preoperative opioid treatment should be addressed in the clinical assessment of patients eligible for THR.

Background and purpose — Swedish clinical guidelines for osteoarthritis (OA) prioritize patient education, exercise, and—if necessary—weight reduction before considering adjunct pharmacological intervention. Contrariwise, we investigated the proportion and type of dispensed analgesic prescriptions in Sweden received by patients during 3 years before commencing non-pharmacological primary care interventions for OA (2008–2016) compared with the general population. Furthermore, we analyzed the proportion of analgesic prescriptions dispensed before (2008–2012) compared with after (2012–2016) guideline publication in terms of concordance with clinical guideline recommendations. Patients and methods — Patients with hip or knee OA (n = 72,069) from the Better Management of OA national quality register receiving non-pharmacological interventions in primary care between 2008 and 2016 were included (OA cohort). An age, sex, and residence matched reference cohort (n = 216,207) was formed from the Swedish Total Population Register. Based on a period 3 years prior to inclusion in the OA cohort, Swedish Prescribed Drug Register data was linked to both the OA and reference cohorts. Results — Compared with the reference cohort, a distinctly larger proportion of the OA cohort had dispensed prescriptions for most types of analgesics, increasing exponentially each year prior to commencing non-pharmacological intervention. Since guideline publication, the proportion of the OA cohort having no dispensed prescription analgesics prior to non-pharmacological primary care intervention concordantly increased by 5.0% (95% CI 4.2–5.9). Furthermore, dispensed prescriptions concordantly decreased for non-selective NSAIDs –8.6% (CI –9.6 to –7.6), weak opioids –6.8% (CI –7.7 to –5.9), glucosamine –9.5% (CI –9.8 to –8.8). and hyaluronic acid –1.6% (CI –1.8 to –1.5) but discordantly increased for strong opioids 2.8% (CI 2.1–3.4) and glucocorticoid intra-articular injection for hip OA 2.1% (CI 1.0–3.1). Interpretation — In Sweden, dispensed prescription of analgesics commonly occurred before initiating non-pharmacological primary care interventions for OA but reduced modestly after guideline publication, which prioritizes nonpharmacological before pharmacological interventions. Additional modest improvements occurred in the steppedcare prioritization of analgesic prescription types. However, future strategies are required to curb an increase of strong opioids prescription for OA and glucocorticoid intra-articular injection for hip OA.

Background and purpose — Almost all prosthetic implant brands include several variations. Most studies on implant performance investigate an implant system without sub-analysis of implant attributes. We studied the influence of design variations during the last 2 decades on implant survival of the most frequently used cemented femoral stem, the Lubinus SPII, reported to the Swedish Arthroplasty Register (SHAR). Patients and methods — Between 2000 and 2018, 100,032 cemented Lubinus SP II stems had been reported to SHAR. Patients with primary osteoarthritis operated on with stem length 150 mm together with a cemented cup from the same manufacturer (n = 76,530) were included in this analysis. Primary study outcome was non-infectious stem revision. Cox regression with adjustment for age, sex, surgical approach, and year of surgery was used. Hazard rates (HR) are presented with 95% confidence intervals (CI). Results — Average follow-up was 7.6 years (SD 4.2). At 18 years the overall stem survival was 99.1 (CI 98.9–99.3). Increased revision rate was observed for stems with extra offset, when a long or an extra-long head length had been used. Smaller stem sizes, in particular the smallest stem size (01), substantially increased the rate of mechanical failure as reflected by an almost 10 times increased rate of revision compared with the standard size (2). Interpretation — In this study with larger sample size and longer follow-up than previously presented from the same register, we observed more pronounced effects of previously documented design variations. Based on our results, surgeons using the Lubinus SPII stems are advised to consider an alternative solution if a Lubinus stem size 01, Lubinus extra offset, or an extra-long head seems to be the most suitable choice at the preoperative planning.

Introduction After surgery for distal femur fractures in elderly patients, weight-bearing is commonly restricted. Immediate non-restrictive weight-bearing might have beneficial effects. There are no randomized studies on the topic. The purpose of this study was to compare the functional outcome between immediate full weight-bearing (FWB) as tolerated and partial weight-bearing (PWB) during the first 8 weeks following plate fixation of distal femur fractures in elderly patients. Methods Patients aged 65 years or older with distal femur fractures of AO/OTA types 33 A2, A3, B1, B2, C1, and C2 were included. Exclusion criteria were impaired cognitive function, concomitant injuries, or inability to follow the postoperative regimen. Internal fixation was achieved with an anatomical lateral distal femur plate applied as a strictly bridge-plating construct. The primary outcome measure was the function index of the short musculoskeletal functional assessment (SMFA) after 52 weeks from injury. Results Thirty-two patients were randomized to FWB (n = 11) or PWB (n = 21). After 16 and 52 weeks, there were no differences in the mean SMFA function index between FWB and PWB (36 vs 43, P = .42 and 52 vs 40, P = .18, respectively) nor in the mean EuroQol 5-dimension index or range of motion (ROM). Overall, the SMFA function index was higher at 52 weeks compared with before injury (44 vs 30, P = .001) as was the mean bothersome index (37 vs 21, P = .011). There was no clear difference in the occurrence of adverse events between the treatment groups. Conclusions There were no differences in functional outcome, adverse events, or ROM between immediate FWB and PWB following plate fixation for a distal femur fracture in elderly patients. A distal femur fracture has a negative effect on the functional status of elderly patients that persists at least up to 1 year following injury.

Background: The purpose of this study was to evaluate the impact of using different country-specific value sets in EQ-5D-5L based outcome analyses. Methods: We obtained data on patients surgically treated with total hip arthroplasty (THA) between 2017 and 2019 from the national Swedish Hip Arthroplasty Register. Preoperative and one-year postoperative data on a total of 28,902 procedures were available for analysis. The EQ-5D-5L health states were coded to the EQ-5D-5L preference indices using 13 European value sets. The EQ-5D-5L index distributions were then estimated with kernel density estimation. The change in EQ-5D-5L index before and one year after treatment was evaluated with the standardized response mean (SRM). The lifetime gain in quality-adjusted life years (QALYs) was estimated with a 3.5% annual QALY discount rate. Findings: There was a marked variability in means and shapes of the resulting EQ-5D-5L index distributions. There were also considerable differences in the EQ-5D-5L index distribution shape before and after the treatment using the same value set. The effect sizes of one-year change (SRM) were similar for all value sets. However, the differences in estimated QALY gains were substantial. Interpretation: The EQ-5D-5L index distributions varied considerably when a single large data set was applied to different European EQ-5D-5L value sets. The most pronounced differences were between the value sets based on experience-based valuation and the value sets based on hypothetical valuation. This illustrates that experience-based and hypothetical value sets are inherently different and also that QALY gains derived with different value sets are not comparable. Our findings are of importance in study planning since the results and conclusions of a study depend on the choice of value set. Funding: None.

Objectives To describe the prevalence of comorbidities in a population referred to standardised first-line intervention (patient education and exercise) for hip and knee osteoarthritis (OA), in comparison with the general population. Furthermore, we aimed to evaluate if eventual differences were associated with socioeconomic inequalities.Design Register-based study.Setting Primary healthcare, Sweden.Participants Individuals with hip and/or knee OA included in the Better Management for Patients with Osteoarthritis Register between 2008 and 2016 and and an age-matched, sex-matched and residence-matched reference cohort (1:3) from the general Swedish population.Outcome measures Comorbidities were identified with the RxRisk Index, the Elixhauser Comorbidity Index and the Charlson Comorbidity Index, and presented with descriptive statistics as (1) individual diseases, (2) disease categories and (3) scores for each index. The prevalence of comorbidities in the two populations was tested using logistic regression, with separate analyses for age groups and the most affected joint. We then adjusted the analyses for socioeconomic status.Results In this OA population, 85% had ≥1 comorbidity compared with 78% of the reference cohort (OR; 1.62 (95% CI 1.59 to 1.66)). Cardiovascular/blood diseases were the most common comorbidities in both populations (OA, 59%; reference, 54%), with OR; 1.22 (95% CI 1.20 to 1.24) for the OA population. Younger individuals with OA were more comorbid than their matched references overall, and population differences decreased with age (eg, ≥3 comorbidities, aged ≤45 years OR; 1.74 (95% CI 1.52 to 1.98), ≥81 years OR; 0.95 (95% CI 0.87 to 1.04)). Individuals with knee OA were more comorbid than those with hip OA overall. Adjustment for socioeconomic status did not change the estimates.Conclusion Comorbidities were more common among individuals with hip and knee OA than among matched references from the general population. The differences could not be explained by socioeconomic status.Trial registration number NCT03438630.

BackgroundEQ-5D is one of the most commonly used questionnaires to measure health-related quality of life. It is included in many of the Swedish National Quality Registers (NQRs). EQ-5D health states are usually summarized using “values” obtained from members of the general public, a majority of whom are healthy. However, an alternative, which remains to be studied in detail, is the potential to use patients’ self-reported overall health on the visual analog scale (VAS) as a means of capturing experience-based perspective. ObjectiveThe aim of this study is to assess EQ VAS as a valuation method with an experience-based perspective through comparison of its performance across and within patient groups, and with that of the general population in Sweden. MethodsData on nearly 700,000 patients from 12 NQRs covering a variety of diseases/conditions and nearly 50,000 individuals from the general population will be analyzed. The EQ-5D-3L data from the 12 registers and EQ-5D-5L data from 2 registers will be used in the analyses. Longitudinal studies of patient-reported outcomes among different patient groups will be conducted in the period from baseline to 1-year follow-up. Descriptive statistics and analyses comparing EQ-5D dimensions and observed self-assessed EQ VAS values across and within patient groups will be performed. Comparisons of the change in health state and observed EQ VAS values at 1-year follow-up will also be undertaken. Regression models will be used to assess whether EQ-5D dimensions predict observed EQ VAS values to investigate patient value sets in each patient group. These will be compared across the patient groups and with the existing Swedish experience-based VAS and time trade-off value sets obtained from the general population. ResultsData retrieval started in May 2019 and data of patients in the 12 NQRs and from the survey conducted among the general population have been retrieved. Data analysis is ongoing on the retrieved data. ConclusionsThis research project will provide information on the differences across and within patient groups in terms of self-reported health status through EQ VAS and comparison with the general population. The findings of the study will contribute to the literature by exploring the potential of self-assessed EQ VAS values to develop value sets using an experience-based perspective. Trial RegistrationClinicalTrials.gov NCT04359628; https://clinicaltrials.gov/ct2/show/NCT04359628. International Registered Report Identifier (IRRID)DERR1-10.2196/27669

Background and purpose — The direct lateral approach (DLA) and the posterior approach (PA) are the most common surgical approaches in total hip replacement (THR) in Sweden. We investigated how the relationship between surgical approach and risk of reoperation due to dislocation has evolved over time. Patients and methods — Data were extracted from the Swedish Hip Arthroplasty Register from 1999 to 2014. We selected all THRs due to osteoarthritis with head sizes 28, 32, and 36 mm that were performed with either the DLA or the PA. Resurfacing prostheses were excluded. Kaplan–Meier curves for risk of reoperation due to dislocation and all-cause for the 2 surgical approaches were compared for 2 periods (1999–2006 and 2007–2014) up to 2 years postoperatively. We used Cox regression for sex, age, type of fixation, and head size to determine hazard ratios (HR) with DLA set as reference. Results — 156,979 THRs met the selection criteria. In 1999–2006, the PA was associated with increased risk of reoperation due to dislocation (HR 2.3, 95% CI 1.7–3.0) but there was no difference in the risk of all-cause reoperation (HR 1.1, CI 0.9–1.2). In 2007–2014 there was no statistically significant difference in the risk of reoperation due to dislocation (HR 1.2, CI 0.9–1.6) but the risk of all-cause reoperation was lower (HR 0.8, CI 0.7–0.9) for the PA. Interpretation — This study confirms historic reports on the increased risk of early reoperations due to dislocations using the PA compared with the DLA. However, in contemporary practice, the higher risk of reoperation due to dislocation associated with PA has declined, now being similar to that after DLA. We believe improved surgical technique for the PA may explain the results. Surprisingly, the PA was associated with lower risk of all-cause reoperation in 2007–2014. This finding warrants further investigation.

Background and purpose — Uncemented stems are increasingly used in revision hip arthroplasty, but only a few studies have analyzed the outcomes of uncemented and cemented revision stems in large cohorts of patients. We compared the results of uncemented and cemented revision stems. Patients and methods — 1,668 uncemented and 1,328 cemented revision stems used in first-time revisions due to aseptic loosening between 1999 and 2016 were identified in the Swedish Hip Arthroplasty Register. Kaplan–Meier analysis was used to investigate unadjusted implant survival with re-revision for any reason as the primary outcome. Hazard ratios (HR) for the risk of re-revision were calculated using a Cox regression model adjusted for sex, age, head size, concomitant cup revision, surgical approach at primary and at index revision surgery, and indication for primary total hip arthroplasty. Results — Unadjusted 10-year survival was 85% (95% CI 83–87) for uncemented and 88% (CI 86–90) for cemented revision stems. The adjusted HR for re-revision of uncemented revision stems during the first year after surgery was 1.3 (CI 1.0–1.6), from the second year the HR was 1.1 (CI 0.8–1.4). Uncemented stems were most often re-revised early due to infection and dislocation, whereas cemented stems were mostly re-revised later due to aseptic loosening. Interpretation — Both uncemented and cemented revision stems had satisfactory long-term survival but they differed in their modes of failure. Our conclusions are limited by the fact that femoral bone defect size could not be investigated within the setting of the current study.

Background and purpose — It is unclear whether physiotherapy interventions or patient education before total hip replacement (THR) is beneficial for patients postoperatively. Utilizing the Swedish Hip Arthroplasty Register (SHAR), we retrospectively studied the influence of preoperative self-reported exposure to physiotherapy and/or patient education on patient-reported outcomes 1 year after THR. Patients and methods — Data covering all THRs performed in Sweden for osteoarthritis, between the years 2012 and 2015, was obtained from SHAR. There were 30,756 patients with complete data. Multiple linear regression modelling was performed with 1-year postoperative PROMs (hip pain on a visual analogue scale [VAS], with the quality of life measures EQ-5D index and EQ VAS, and surgery satisfaction VAS) as dependent variables. Self-reported physiotherapy and patient education (yes or no) were used as independent variables. Results — Physiotherapy was associated with slightly less pain VAS (–0.7, 95% CI –1.1 to –0.3), better EQ-5D index (0.01, CI 0.00–0.01), EQ VAS (0.8, CI 0.4–1.2), and better satisfaction VAS (–0.7, CI –1.2 to –0.2). Patient education was associated with slightly better EQ-5D index (0.01, CI 0.00–0.01) and EQ VAS (0.7, CI 0.2–1.1). Interpretation — Even though we found statistically significant differences in favor of physiotherapy and patient education, the magnitude of those were too small and inconsistent to conclude a truly positive influence. Further research is needed with more specific and demarcated physiotherapy interventions.

Background and purpose — Data from several joint replacement registries suggest that the rate of early revision surgery after primary total hip arthroplasty (THA) is increasing. The ASA class, now widely recorded in arthroplasty registries, may predict early revision. We investigated the influence of ASA class on the risk of revision and other reoperation within 3 months and within 5 years of primary THA. Patients and methods — We used data from the Geneva and Swedish Hip Arthroplasty Registries, on primary elective THAs performed in 1996–2016 and 2008–2016, respectively. 5,319 and 122,241 THAs were included, respectively. Outcomes were all-cause revision and other reoperations evaluated using Kaplan–Meier survival and Cox regression analyses. Results — Within 3 months after surgery, higher ASA class was associated with greater risk of revision and other reoperation. 3-month cumulative incidences of revision by ASA class I, II, and III–IV respectively, were 0.6%, 0.7%, and 2.3% in Geneva and 0.5%, 0.8%, and 1.6% in Sweden. 3-month cumulative incidences of other reoperation were 0.4%, 0.7%, and 0.9% in Geneva and 0.2%, 0.4%, and 0.7% in Sweden. Adjusted hazard ratios (ASA III–IV vs. I) for revision within 3 months were 2.7 (95% CI 1.2–5.9) in Geneva and 3.3 (CI 2.6–4.0) in Sweden. Interpretation — Assessment of ASA class of patients prior to THA will facilitate risk stratification. Targeted risk-reduction strategies may be appropriate during the very early postoperative period for patients identified as at higher risk. Systematically recording ASA class in arthroplasty registries will permit risk adjustment and facilitate comparison of revision rates internationally.

Background and purpose — The theoretical mechanical advantages of metal-on-metal hip resurfacing (MoM-HR) compared with conventional total hip arthroplasty (THA) have been questioned. Studies including measures of patient-reported function, physical activity, or health-related quality of life have been sparse. We compared patient-reported outcomes in MoM-HR patients with a matched group of patients with conventional THA at 7 years post-surgery. Patients and methods — Patients and patient data were retrieved from the Swedish Hip Arthroplasty Register. The case group, consisting of 363 patients with MoM-HR, was matched 1:1 with a control group, consisting of patients with a conventional THA. Patients were sent a postal patient-reported outcome measures (PROM) questionnaire including the Hip Disability and Osteoarthritis Outcome Score (HOOS), EQ-5D, and VAS pain. We used multivariable linear regression analyses to investigate the influence of prosthesis type. Results — 569 patients (78%) returned the questionnaire with complete responses (299 MoM-HRs and 270 conventional THAs). MoM-HR was associated with better scores in HOOS function of daily living (4 percentage units) and HOOS function in sport and recreation (8 percentage units) subscales. Type of prosthesis did not influence HOOS quality of life, HOOS pain, HOOS symptoms, EQ-5D index, hip pain, or satisfaction as measured with visual analog scales. Interpretation — At mean 7 years post-surgery, patients with hip resurfacing had somewhat better self-reported hip function than patients with conventional THA. The largest difference between groups was seen in the presumed most demanding subscale, i.e., function in sport and recreation.

Abstract Background The clinical pathway and care program in elective total hip and knee replacement (THR/TKR) has, during the last decade, undergone considerable changes in many countries influenced by the concept of fast-track surgery, resulting in a very short hospital stay. Studies into patients’ experiences of the entire fast-track program, from decision-making regarding surgery until recovery 3 months after surgery, are lacking. The aim of the study was to increase the knowledge about patients’ experiences of the clinical pathway and care in a fast-track program of elective THR/TKR in order to identify factors that may influence recovery and clinical outcome. Methods A qualitative research design was chosen with data collected from interviews 3 months after surgery and analyzed using an inductive content analysis method. In total, 24 patients from three hospitals with a fast-track care program were included in the study: 14 women and 10 men, 13 with THR and 11 with TKR. The mean age was 65 years (range 44–85). Results The analysis identified three chronological phases in the clinical pathway: preparation, hospital stay for surgery, and recovery. In the preparation phase, patients’ experiences and involvement in the planning of the operation were highlighted. The need to know the risks and expectations of recovery and outcome were also central, although there was great diversity in needs for information and involvement. In the hospital stay for the surgery phase, there were mainly positive experiences regarding admission, early mobilization, and early discharge. Experiences about the recovery phase focused on management of daily life, rehabilitation program, and recovery. Rehabilitation involved uncertainty as to whether or not the progress was normal. The recovery phase was also filled with questions about unfulfilled expectations. Regardless of the different phases, we found the importance of a person-centered care to be a pervasive theme. Conclusion Our study supports the view that a person-centered approach, from surgery decision until recovery, is an important element in optimizing care in a THR and TKR fast-track care program. More focus on the period after hospital discharge may improve recovery, patient satisfaction, and functional outcome.

Background and purpose — The outcome of total hip arthroplasty (THA) in younger patients is suggested to be inferior compared with the general THA population. There is a lack of studies with long-term follow up for very young patients. We report on implant survival and patient-reported outcome in patients aged 30 years or younger. Patients and methods — Data on THAs performed in Sweden between the years 2000 and 2016 were included. There were 504 patients 30 years or younger with complete demographic and surgical data (study group). A matched comparison group older than 30 years was identified. Implant survival was analyzed using the Kaplan–Meier method. Patient-reported outcome was analyzed in a subgroup of patients. Results — The 10-year and 15-year implant survivorship for the study group was 90% and 78%, respectively. The corresponding figures for the patients older than 30 years were 94% and 89%. The median preoperative EQ-5D index was lower in the study group; the improvement in EQ-5D index was similar between the study and the comparison groups. The preoperative EQ-VAS was lower and the improvement in EQ-VAS at 1 year was larger in the study group. Interpretation — The promising 10-year implant survival and 1-year improvement in patient-reported outcome suggests that THA is a feasible option in the patients 30 years or younger.