BACKGROUND AND PURPOSE:Patient-reported outcome measures need to reflect true differences rather than measurement artifacts resulting from translations when scores are compared across countries. We evaluated the measurement invariance of the English, Dutch, Danish, and French Oxford Hip Score (OHS) and Oxford Knee Score (OKS) in patients undergoing hip and knee arthroplasty. METHODS:OHS and OKS responses from patients undergoing primary hip or knee arthroplasty for osteoarthritis between 2019 and 2022 were included from national and single-center registries in the United Kingdom, the Netherlands, Denmark, and Switzerland. We evaluated unidimensionality, monotonicity (Hi > 0.3) and local independence (Yen Q3 > 0.20 above the average indicating independence) in each language version separately. Model fit was considered satisfactory when Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI) were ≥ 0.95, root mean square error of approximation (RMSEA) ≤ 0.06, and standardized root mean square residual (SRMR) ≤ 0.08. Measurement invariance across languages was analyzed with multiple group-confirmatory factor analysis on full, random, and matched sample datasets. RESULTS:Across the hip and knee cohorts, unidimensionality was acceptable in the English (n = 21,108 and 28,230), Dutch (n = 36,792 and 29,651), Danish (n = 815 and 1,015), and French (n = 590 and 459) versions. RMSEA ranged from 0.072 to 0.092 for OHS, and from 0.057 to 0.061 for OKS and other fit indices were acceptable. The multiple group-confirmatory factor analysis showed acceptable measurement invariance across languages for both scores, with changes in RMSEA < 0.15 and CFI < 0.1 across gradually more constrained models. CONCLUSION:Measurement invariance of the OHS and OKS was supported across the English, Dutch, Danish, and French versions, with multiple group-confirmatory factor analyses model fit within predefined acceptable limits, supporting cross-comparison of the different language versions of these instruments.

Chronic post-surgical pain (CPSP) impacts approximately one in four patients following total knee arthroplasty (TKA) and is associated with reduced function and quality of life. We will conduct a systematic review of prospective studies to identify eligible data and establish an international repository of individual patient data (IPD) on prognostic factors for chronic pain after TKA. This repository will be then used to develop and validate a prediction model for CPSP following TKA. We will identify eligible studies through a search of MEDLINE, CINAHL, EMBASE, and Cochrane CENTRAL from January 2005 to August 2025. We will include prospective studies that: (1) enrolled adults undergoing elective TKA, (2) assessed perioperative risk factors for CPSP, and (3) measured knee pain longitudinally at least 3 months post-surgery. Pairs of reviewers will independently screen titles and abstracts of retrieved citations and review the full texts of potentially eligible studies. We will reach out to principal investigators or authors of eligible studies to notify them of our initiative and request to receive their IPD into a secured repository, based on a data sharing agreement. We will use a one-stage approach for IPD meta-analysis of factors associated with CPSP following TKA, and development of a risk prediction model. We will use anonymized de-identified data for our IPD meta-analysis. This protocol was reviewed and approved by the Hamilton Integrated Research Ethics Board (HiREB). We will develop an online calculator to support our risk assessment model for research and clinical use. This IPD meta-analysis will facilitate the development of a robust prognostic model to guide clinical decisions or enrolment in interventional studies, with the ultimate goal of identifying pathways to effective CPSP prevention strategies after TKA. CRD42024591329.

BACKGROUND:Aspirin after an initial short course of rivaroxaban has been shown to be safe and effective for the prevention of venous thromboembolism after total hip or total knee arthroplasty, but uncertainty remains about the use of aspirin alone. METHODS:In this multicenter, double-blind, randomized, controlled trial, we assigned patients to receive once-daily thromboprophylaxis with either 81 mg of aspirin or 10 mg of oral rivaroxaban for the first 5 days after total hip or total knee arthroplasty. All the patients then received further thromboprophylaxis with 81 mg of aspirin daily for 9 additional days after knee arthroplasty and for 30 additional days after hip arthroplasty. Patients were followed for 90 days for symptomatic venous thromboembolism, which consisted of either proximal deep-vein thrombosis or pulmonary embolism (primary effectiveness outcome), and for bleeding complications (primary safety outcome). The noninferiority margin for aspirin alone as compared with rivaroxaban-aspirin was 0.7 percentage points. RESULTS:A total of 5429 patients underwent randomization. Venous thromboembolism developed in 13 of 2718 patients (0.48%) in the aspirin-alone group and in 12 of 2647 patients (0.45%) in the rivaroxaban-aspirin group (risk difference, 0.02 percentage points; 95% confidence interval [CI], -0.34 to 0.39; P<0.001 for noninferiority). Major bleeding or clinically relevant nonmajor bleeding events occurred in 45 of 2718 patients (1.66%) in the aspirin-alone group and in 54 of 2647 patients (2.04%) in the rivaroxaban-aspirin group (risk difference, -0.38%; 95% CI, -1.11 to 0.34). CONCLUSIONS:After total hip and total knee arthroplasty, the use of aspirin alone was not inferior to a strategy of using rivaroxaban followed by aspirin for the prevention of symptomatic venous thromboembolism, with no clinically relevant difference in bleeding events. (Funded by the Canadian Institutes of Health Research; EPCAT III ClinicalTrials.gov number, NCT04075240.).

BACKGROUND:Total hip replacement is a successful operation that aims to restore function and quality of life to millions of people globally. Knowing how long a total hip replacement might last is important for patients, surgeons, and health-care institutions for planning and resource allocation. Over the past 20 years, the use of contemporary bearing surfaces for total hip replacement has substantially altered implant wear and, possibly, longevity. To date, there has been no large-scale study that examines survivorship of these modern implants. We aimed to determine the survivorship of contemporary total hip replacements and bearing materials. METHODS:We focused solely on the assessment of modern bearing surfaces: highly cross-linked polyethylene versus metal or third-generation and fourth-generation ceramic heads and ceramic-on-ceramic primary total hip replacement in adult patients. We conducted a search of MEDLINE and Embase from database inception to June 13, 2024, including articles that reported a minimum of 10 years of survivorship, irrespective of fixation method or surgical approach. We then conducted a meta-analysis combining data from eight national joint registries assessing all-cause revision within the various bearing combinations. We extrapolated the extracted data to estimate survivorship to 30 years, using the multivariable random-effects model from the registry data. The primary outcome was survivorship of the hip replacement, defined as time from primary total hip replacement to first all-cause revision, expressed as a percentage of unrevised implants at specific timepoints. This study is registered with PROSPERO (CRD42024572518). FINDINGS:We identified 1 904 237 total hip arthroplasties across 29 clinical studies (n=5203) and eight national joint registries (n=1 899 034). Pooled analysis of the included studies showed an all-cause implant survivorship of 0·97 (0·96-0·98) under the random-effects model. Survivorship estimate based on joint registry data was at 93·6% (95% CI 92·3-94·7) at 20 years. Extrapolating these data indicates a predicted survivorship of 92·8% (91·2-94·2) at 25 years and 92·1% (90·1- 93·7) at 30 years. INTERPRETATION:The estimated 92% 30-year survivorship of contemporary total hip replacement suggests that advances in bearing surface technology have greatly improved the long-term durability of total hip replacements and might influence patient counselling, health-care planning, and device regulation. FUNDING:None.

BACKGROUND:There is currently no national total shoulder arthroplasty (TSA) database in Canada. As a first step toward a national registry, a regional shoulder database was initiated in 2017. In this study, we describe the implementation of and initial findings from the shoulder database and patient-reported outcomes program. METHODS:The registry is intended to capture all shoulder arthroplasty procedures in the province of Manitoba and includes surgeon-reported operative details and data on patient-reported outcome measures (PROMs). Every surgeon submits data. We included primary and revision procedures performed since 2017 in the retrospective case series study. We assessed registry coverage by the rate of return of surgeon-completed operative forms and patient-reported outcomes questionnaires, respectively. We determined the incidence of revision by the number of primary procedures linked to a revision within 1 year of surgery. RESULTS:A total of 1044 TSA procedures occurred during the study period. Overall, 65.0% were anatomic (n = 679) and 35.0% were reverse TSA procedures (n = 365). Of the 1044 surgeries that took place, the capture rate was 92.0% (n = 960) for operative data. The capture rate for PROM questionnaires was 78.6% preoperatively and 65.8% postoperatively. Four primary procedures were linked with a revision within 1 year of surgery (0.4%). The most frequent diagnosis reported was degenerative arthritis (n = 558/817). High satisfaction (n = 569/636) and improved joint-specific and general quality-of-life PROMs were reported at 1 year. CONCLUSION:The provincial shoulder database demonstrates the early stages of a registry, which contains useful, granular data and is an opportunity to fill an important gap in Canadian arthroplasty data.

Background: This study examines current trends in Canada using data from the Canadian Joint Replacement Registry (CJRR) and includes a national survey to understand the varied uptake of cement for femoral stem fixation. Methods: The survey was available online and the website link was distributed to all orthopaedic surgeons through the Canadian Orthopaedic Association between September and December 2022. The CJRR obtained data from the Canadian Institute for Health Information (CIHI), and information pertaining to patients 55 years of age and older who underwent hemiarthroplasty for hip fracture in Canada between April 2017 and March 2022 was used. Results: Most respondents practiced in an academic community setting (52%). Only 53% of respondents reported using cement, and 71% indicated that cemented fixation was the best practice. The main reasons for using uncemented stems were less operative time (23%), cement disease concerns (11%), and surgeons’ comfort (10%). Similarly, CJRR data showed only 51% cemented fixation among 42,386 hemiarthroplasties performed between 2017 and 2022. The proportion of cemented implants varied by province, but overall, the increase in the use of cement from 2017 to 2022 was from 42.9% to 57.7%. Conclusions: This study demonstrates variability in the use of cement for femoral fixation despite solid evidence showing improved outcomes using cement. Some of the main reasons in favour of uncemented stems include operative time, surgical training, and concerns about cement disease. Establishing clear position statements and guidelines supporting cemented fixation may be prudent to build universal consensus on this practice.

The use of cemented fixation is widely recommended when hip arthroplasty is used to treat hip fractures. Some argue that the risk of bone cement implantation syndrome (BCIS), characterized by cardiovascular collapse at the time of cementing and pressurization, is so high it does not warrant the use of bone cement to reduce revision risk. We aimed to assess the association between cemented fixation and mortality and cardiopulmonary morbidity to assess this risk in a secondary analysis of data collected during the HIP ATTACK randomized clinical trial. The HIP ATTACK trial, was a 2,970-patient trial in which patients with a hip fracture that required surgery were randomized to accelerated surgery or standard care. We included all patients enrolled in the HIP ATTACK trial who had hemiarthroplasty or total hip arthroplasty for femoral neck fractures and who had their fixation status recorded. Due to the retrospective nature of this secondary analysis, we did not collect any additional data. Fixation was recorded in the trial data, as were mortality and morbidity after 90 postoperative days. We created a composite outcome, reflective of the cardiopulmonary risk factors associated with BCIS: all-cause mortality, myocardial infarction, stroke, congestive heart failure, new atrial fibrillation, coronary revascularization, venous thromboembolism, and pneumonia. We used logistic regression to measure the odds ratio (OR) of the association between cemented fixation and this composite outcome, while adjusting for several covariates: age (≤80 vs >80 years-old), sex, ethnicity (white vs non-white), revised cardiac risk index, chronic obstructive pulmonary disease (a risk factor for BCIS), dementia, and type of arthroplasty (hemi vs total hip). We identified 966 patients, 61% of which had cemented fixation. Although patients were randomized for time-to-surgery, the cemented and uncemented groups were also mostly balanced, with a similar median age (82 vs 79), proportion female (67% vs 70%), ethnicity (65% vs 59% white), and comorbidities. The type of arthroplasty differed, however, 89% of cemented and 76% of uncemented procedures were hemiarthroplasties. At 90 days, 19% of cemented fixation and 17% of uncemented fixation patients were affected by one of the events in the composite outcome, mostly death, myocardial infarction, and/or pneumonia. After adjustment for the factors mentioned above, we did not measure an increased risk of the composite outcome, the adjusted OR was 1.0 (95% confidence interval 0.7-1.4). We lacked the statistical power to investigate possible interaction by age, sex, or the type of procedure and could not assess whether differential effects in these strata were due to chance alone or might point to clinically-relevant effect modification. We found no association between cement use and a BCIS-related adverse composite outcome and found no evidence against established guidelines on the use of cement in arthroplasty for hip fractures.

Background:The obesity epidemic has given rise to an orthopaedic patient subgroup with a body mass index (BMI) of >= 50 kg/m2. Without sound evidential guidance, arthroplasty surgeons and anesthesiologists do not know whether they can push the limits of the surgical feasibility of total knee arthroplasty (TKA) without risks of harm.Methods:In a retrospective cohort study of patients who had undergone primary TKA for degenerative arthritis at our academic center (n = 10,389; 6,821 women, 4,070 men, and 38 unknown), we compared the outcomes between patients with a BMI of >= 50 kg/m2 (n = 627) and patients in other weight classes. The average patient follow-up was 8.6 years. We used Cox proportional hazards models to estimate the association between BMI and revision risk, using overweight patients (BMI = 25 to 29.99 kg/m2) as the reference group while adjusting for patient age and sex. Patient satisfaction, pain scores on a visual analogue scale (VAS), and the Oxford Knee Score (OKS) were compared among groups preoperatively and at 1, 5, and 10 years postoperatively.Results:In the first year after surgery, the adjusted hazard ratio (HR) for revision TKA for patients with a BMI of >= 50 kg/m2 was 3.7 (95% confidence interval [CI] = 1.9 to 7.2), with overweight patients as the reference. There was virtually no difference between patients with a BMI of 35 to 39.99 kg/m2 and those with a BMI of 40 to 49.99 kg/m2. After the first year, the HR was 1.2 (95% CI = 0.7 to 2.4) for revision TKA for patients with a BMI of >= 50 kg/m2. Those patients reported worse preoperative function of the knee, with a median OKS of 15 versus 23 for overweight patients. For obese patients, each additional unit of BMI corresponded with an additional OKS improvement of 0.07 point (95% CI = 0.04 to 0.10) at 1 year.Conclusions:Our study confirms the increased risk of failure of TKA in patients with a BMI of >= 50 kg/m2 in the first year after surgery, but we found no evidence of worse outcomes in the 40 to 49.99 kg/m2 group compared with the 35 to 39.99 kg/m2 group. The increase in the revision risk in the >= 50 kg/m2 group was found only in the first postoperative year and plateaued afterwards. Despite worse function and higher failure rates, patients with a BMI of >= 50 kg/m2 reported benefits and high satisfaction with TKA.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The volume of shoulder replacement procedures worldwide has increased dramatically over the last decade with growth exceeding rates reported for hip and knee. Arthroplasty registries are widespread and have contributed to reducing revision and complication rates. The Canadian Joint Replacement Registry (CJRR) was established in 2001 to capture information on the outcomes of hip and knee replacement care in Canada. There is currently no national total shoulder arthroplasty (TSA) database in Canada. The provincial (Blinded for Review) was initiated for total shoulder arthroplasty in 2017 with the goal of providing a model for national expansion. This study outlines the characteristics and patient-reported outcomes of procedures captured in the registry. All patients undergoing primary or revision anatomic TSA (aTSA) and reverse TSA (rTSA) in the province since 2017 were included. Emergent and hemi-arthroplasty cases were excluded. Patient-reported data were collected in-clinic at baseline, and by mail-out one year postoperatively and included the American Society of Shoulder and Elbow Surgeon Score (ASES), EuroQol five-dimension health survey (EQ-5D), satisfaction, and self-reported complications. Intra-operative arthroplasty related details were collected at the time of surgery with the surgeon signature required for completeness. ASES and EQ-5D were compared for primary aTSA and rTSA subgroups pre-operatively and postoperatively using a two-sample two-sided t-test. The provincial shoulder database included 985 TSA, of which 67% were aTSA (661/985). Overall, 94% (927/985) were primary and 6% (58/985) were revision procedures. Four primary patients (0.43%) were linked with revision cases within the first year following surgery (4/927). Eighty-nine percent of primary TSA patients (aTSA=92%; rTSA=81%) and 63% of revision TSA patients (aTSA=58%; rTSA=73%) reported being “Satisfied” or “Very Satisfied” one year postoperatively. The rate of patient-reported complications (dislocation/superficial infection/deep infection/future surgery) was lower for primary procedures (aTSA=1%; rTSA=2%) than revision procedures (aTSA=12%; rTSA=5%). There was significant improvement in both ASES and EQ-5D scores from the preoperative to postoperative timepoints in primary aTSA (ASES mean change 48.5 [95% CI 45.4 to 51.6]; p Primary TSA provided significant improvement in ASES and EQ-5D scores one year postoperatively. Greater improvement was observed in the primary aTSA subgroup compared to rTSA. Lower satisfaction and a higher prevalence of self-reported complications was observed in patients undergoing revision TSA, specifically when revised to an aTSA. This study outlines the successful implementation of a regional TSA registry in Canada and demonstrates the potential for a shoulder arthroplasty database to be integrated within the current CJRR system. Integration with larger administrative databases, improving patient response rates, and national expansion to other provinces within Canada are next steps for the shoulder arthroplasty registry.

Despite the progress made in addressing obesity and its associated complications, the prevalence of this complex disease continues to rise. This has led to the emergence of a group known as “super-obese” individuals, with body mass index (BMI) exceeding 50 kg/m2. Without clinical practice guidelines, arthroplasty surgeons and anesthesiologists continue to push the limits of patient size and surgical feasibility despite risks of harm. To better inform clinical decision-making and guideline development, we analyzed a large set of follow-up data in knee arthroplasty patients with BMI above 50 kg/m2. In a retrospective database study of patients who had undergone primary total knee arthroplasty (TKA) in our academic centre (N = 11,768), we compared the outcomes of super-obese TKA patients (N = 631) against patients of normal weight (BMI 18-25), overweight (BMI 25-30), Obese Class I (BMI 30-35), Class II (BMI 35-40), and Class III (BMI 40-50). Patient follow-up ended at the earliest of the date of revision, date of death, or date of the end of follow-up (October 17, 2023), average patient follow-up was 8.6 years. We used Cox proportional hazard models to estimate the association between patient BMI and revision risk using overweight patients (N = 2,548) as the reference group, while censoring patients for the other outcomes. Patient-reported outcome measures including overall patient satisfaction and Oxford-12 knee score (OKS) were compared pre-operatively and at five years postoperatively. Compared to our overweight control group, TKA patients with BMI > 50 kg/m2 are at significantly higher risk of a revision with a hazard ratio (HR) of 2.3 (95% confidence interval [CI] = 1.5-3.5). We observed a gradient in increased risk with increasing BMI, the HRs in the BMI 40-50 and BMI 35-40 groups were 1.6 (95% CI 1.1-2.3) and 1.5 (95% 1.0-2.1), respectively. Compared to the overweight group, super obese patients reported worse pre-operative function of their knee, with a mean OKS of 15.4 (standard deviation [SD] 6.8) versus 22.2 (SD 8.1). The gap was smaller after 5 years postoperatively, 35.2 (SD 9.3) versus 39.4 (SD 8.4). The improvement in OKS was slightly higher after 5 years for super obese patients (+19.1; 95% CI 16.9-21.4) than overweight patients (+17.4; 95% CI 16.4-18.4), although this difference was not statistically significant in an underpowered comparison (p = 0.143, power = 0.29, two-sample, two-sided t-test). Our study confirms the significant risk of failure associated with TKA in the super-obese. Despite worse pre-operative and post-operative knee function, this population still derives significant benefits from knee arthroplasty. Treating physicians should engage their patients with BMI > 50 kg/m2 with empathy and transparency regarding the risks and benefits of TKA.

Literature on suppressive antibiotic therapy (SAT) in prosthetic joint infection (PJI) is sparse and provides little guidance during the complex treatment these patients require. We aimed to identify patient characteristics and outcomes for PJI cases treated with SAT in a Canadian centre. Using a two-step selection process, we identified all patients included in our database who underwent revision arthroplasty (hip or knee) for infection between March, 2003 and April, 2023 and received antibiotics longer than 90 consecutive days before and/or after the revision. In step one, we identified all revisions for infection from our database and then, in step two, performed a chart review to identify antibiotic drug use. We identified the index revision as the first revision while on SAT or the revision just before starting SAT. For the patients identified in this selection process, we performed an in-depth chart review from 90 days before the index revision until the subsequent revision (or the end of the study period). We extracted each prescription for antibiotics and each reported test result for c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) as well as all reported culture and sensitivity results, in addition to patient and characteristics during the index revision. We defined four different outcomes, revision (any subsequent revision on the same joint), end of SAT (>30 days without a new prescription for antibiotics), death (for any reason), or end of the study period (April 30, 2023). We used standard time-to-event (survival) analysis, where patients entered the cohort on their index revision date and exited the cohort at the earliest outcome date. We used Cox proportional hazard models to estimate the hazard ratio (HR) of the association between index characteristics revision, while censoring patients for other outcomes. Of the 87 patients identified (30 hips and 57 knees), 60% were male, median age was 65, and median BMI was 32.2 kg/m2. The index CRP, measured up to 60 days prior to surgery, ranged widely (interquartile range 6-102 mg/L, unknown for one-third of patients) as did the ESR (interquartile range 20-65 mm/h, unknown for nearly half the patients). S. aureus (15 MSSA+3 MRSA patients) and S. epidermidis (12 patients) were the most commonly identified pathogens, but one-third of patients were culture-negative. Across all patients, 18 had a revision, 61 ended their SAT, 1 died, and 7 remained revision-free on SAT until the end of the study period. Having an above-median CRP (≥30 mg/L among our patients with infection) was associated with a significantly increased risk of revision, crude HR 4.3 (95% confidence interval [95% CI] 1.2-15.8) and adjusted (for age, sex, BMI, and index ESR) HR 4.4 (95% CI 1.1-17.0). Above-median ESR (≥38 mm/h), on the other hand, was not associated with revision risk, crude HR 1.2 (95% CI 0.4-3.4) and adjusted HR 0.8 (95% CI 0.2-2.8). Higher CRP levels were associated with a higher risk of revision for patients on SAT for PJI, whereas ESR levels were not associated with revision risk.

BACKGROUND:Body mass index (BMI) thresholds are used as eligibility criteria to reduce complication risk in total joint arthroplasty (TJA). This approach oversimplifies preoperative risk assessment and inadvertently restricts access to effective surgical treatment for osteoarthritis. A prior survey of orthopaedic surgeons in the United States identified complex underlying factors that influence BMI considerations. To understand whether similar factors exist and influence surgeons in a different health-care system setting, we investigated Canadian surgeons' views and use of BMI criterion thresholds for TJA access. METHODS:A cross-sectional online qualitative survey was conducted with orthopaedic surgeons performing TJA in the Canadian health-care system. Responses were anonymous and questions were open-ended to allow for candid perspectives. Survey data were coded and a systematic process was followed to identify major themes. Findings were compared with U.S. surgeon perspectives. RESULTS:Sixty-nine respondents had a mean age of 49.0 ± 11.4 years (range, 33 to 79 years), with a mean surgical experience duration of 15.7 ± 11.4 years (range, 2 to 50 years). Surgeons reported variable use of BMI thresholds in practice. Twelve interconnected factors that influence BMI considerations were identified: (1) variable evidence interpretation, (2) surgical challenge, (3) surgeon beliefs and biases, (4) hospital differences, (5) access to resources, (6) health system bias, (7) patient health status, (8) patient body fat distribution, (9) patient decisional burden (to lose weight or accept risk), (10) evidence gaps and uncertainties, (11) need for innovation, and (12) societal views. Nine themes matched with findings from U.S. surgeons. CONCLUSIONS:Parallel to the United States, complex, interconnected factors influence Canadian orthopaedic surgeons' variable use of BMI restrictions for TJA eligibility. Despite different health-care systems and reimbursement models, similar technical and personal factors were identified. With TJA practice guidelines advising against hard BMI criteria, attention regarding access to resources, surgical training, and innovations to address TJA complexity in patients with large bodies are critically needed. Future advancements in this sphere must balance barrier removal with risk reduction to ensure safe and equitable surgical care. CLINICAL RELEVANCE:This study may influence surgeon behaviors with regard to hard BMI cutoffs for TJA and encourage critical thought about factors that influence decisions about surgical eligibility for patients with high BMI.

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.

Aims: A novel enhanced cement fixation (EF) tibial implant with deeper cement pockets and a more roughened bonding surface was released to market for an existing total knee arthroplasty (TKA) system.This randomized controlled trial assessed fixation of the both the EF (ATTUNE S+) and standard (Std; ATTUNE S) using radiostereometric analysis. Methods: Overall, 50 subjects were randomized (21 EF-TKA and 23 Std-TKA in the final analysis), and had follow-up visits at six weeks, and six, 12, and 24 months to assess migration of the tibial component. Low viscosity bone cement with tobramycin was used in a standardized fashion for all subjects. Patient-reported outcome measure data was captured at preoperative and all postoperative visits. Results: The patient cohort mean age was 66 years (SD seven years), 59% were female, and the mean BMI was 32 kg/m2 (SD 6 kg/m2). Mean two-year subsidence of the EF-TKA was 0.056 mm (95% confidence interval (CI) 0.025 to 0.086) versus 0.006 mm (95% CI -0.029 to 0.040) for the Std-TKA, and the two-year maximum total point motion (MTPM) was 0.285 mm (95% upper confidence limit (UCL) ≤ 0.363) versus 0.346 mm (95% UCL ≤ 0.432), respectively, for a mean difference of -0.061 mm (95% CI -0.196 to 0.074). Inducible displacement also did not differ between groups. The MTPMs between 12 and 24 months for each group was below the published threshold of 0.2 mm for predicting early aseptic loosening (p < 0.001 and p = 0.001, respectively). Conclusion: Both the enhanced fixation and the standard tibial implant design showed fixation with a predicted low risk of long-term aseptic loosening. Cite this article: Bone Jt Open 2024;5(1):20–27.

BACKGROUND:Cementless total knee arthroplasty (TKA) is rising in popularity. The literature supporting its use over cemented TKA remains sparse. Using the Canadian Joint Replacement Registry (CJRR), we sought to investigate cementless versus cemented fixation in modern primary TKA and (1) determine whether there is an overall difference in revision by fixation, (2) perform a subanalysis of the most-commonly used cementless TKA brand in Canada, and (3) identify the reasons for revision. METHODS:The CJRR data was used to analyze TKA designs with cemented and cementless versions. Revision risk is reported as all-cause cumulative percent revision (CPR). Reasons for revision were analyzed. Cox proportional hazards models were used to report adjusted hazard ratios (HR) controlling for age, sex, patella resurfacing, and bearing constraints. We included 202,880 primary TKAs performed between 2012 and 2021. Of those, 9,163 (4.5%) were cementless. RESULTS:The CPR at 8 years was 4.49% for cementless and 3.14% for cemented implants. After adjusting for confounders, we did not detect a difference in revision risk overall (HR 0.87 [95% CI (confidence interval) 0.73 to 1.04], P = 0.128). However, the most commonly used cementless TKA brand demonstrated a CPR of 1.95% compared to 2.19% for its cemented version at 4 years. Furthermore, we detected a significantly lower revision risk compared to its cemented version after adjusting for confounders (HR 0.66 [95% CI 0.51 to 0.85], P = 0.001). The 4 most common reasons for revision in both groups were the following: (1) infection, (2) instability, (3) aseptic loosening, and (4) pain of unknown origin. CONCLUSIONS:Using CJRR data adjusted for confounding factors, no difference in revision risk was detected between cemented and cementless implants overall. However, for the most common brand of cementless TKA used in Canada, there was a lower risk of revision than its corresponding cemented version. The reasons for revision were similar.

BacgroundThe use of cemented fixation is widely recommended in hip arthroplasty for hip fractures, although it is not used universally.MethodsWe describe the trends in cementing prevalence in hemiarthroplasty for hip fractures in Canada for patients ≥55 years old between April 2017 and March 2022.ResultsThe national prevalence of cemented fixation increased from 43% in 2017/18 to 58% in 2021/22, but there was a large variety of both the baseline prevalence and the trends across the country and between individual hospitals. The proportion of surgeons only performing cementless fixation fell from 30% to 21% between 2018/19 and 2021/22.ConclusionsAs cemented fixation is now universally recommended, more coordination is needed to track these trends and to help drive implementation of this evidence-based practice across Canada.

We found that a standardized order set after hip fracture increased initiation of anti-osteoporosis medication and increased persistence at 1 year, but did not reduce secondary fractures. Background A treatment gap exists after osteoporosis-related fractures. Introducing standardized care can improve treatment. We evaluated the impact of a hip fracture order set (OS) on anti-osteoporosis medication (AOM) initiation, persistence, and secondary fracture prevention. Methods In 2015, one hospital in Manitoba, Canada, introduced a hip fracture OS including recommendations for the initiation of AOM (OS group). A control group was identified from the other hospitals in the same region. A retrospective cohort study was conducted using linked administrative health data. All individuals 50 + years with surgical treatment for low-energy hip fracture between 2010 and 2019 were included and followed for AOM initiation, medication persistence at 1 year, and secondary fractures. Between-group differences for each year were assessed using chi-square tests. Logistic regression models tested the impact of socio-demographic and clinical factors on initiation, persistence of AOM. Cox regression tested the risk of secondary fracture. Results No baseline differences between OS group (813 patients) and control group (2150 patients) were observed in demographics, socioeconomic factors, or comorbidities. An increase in post-fracture AOM initiation was seen with OS introduction (OS group year before 16.7% versus year after 48.6%, p < 0.001). No change was seen in the control group. Persistence on AOM also increased (OS group year before 17.7% versus year after 28.4%, p < 0.001). No difference in secondary fractures was observed (OS group 19.8% versus control group 18.8%, p = 0.38). Conclusion Introduction of a hip fracture OS significantly increased AOM initiation and persistence at 1-year post-fracture. There was no significant difference in secondary fractures.

BACKGROUND AND PURPOSE:We aimed to determine sex differences for periprosthetic joint infections after primary arthroplasty of the hip, knee, ankle, and shoulder in osteoarthritis patients in an international perspective. METHODS:This is a multinational combined arthroplasty registry study. Each arthroplasty registry performed Cox-regression analysis of their data and reported the crude and adjusted hazard ratios (HR) with an a priori designed data form. A random-effects model was used to pool these HRs to estimate an overall HR with 95% confidence interval (CI). Adjustment was undertaken for patient age, BMI, ASA grade, type of fixation, and type of implant. 9 arthroplasty registries participated. Patients who received primary total joint arthroplasty for primary osteoarthritis were considered: 2,134,313 hip arthroplasties, 2,658,237 knee arthroplasties, 57,889 shoulder arthroplasties, and 8,445 ankle arthroplasties. We calculated hazard ratios (HR) for the overall risk of complete revision due to infection for each implant type and follow-up. RESULTS:The pooled HR for revision due to infection for men compared with women at 1-year follow-up was 1.60 (95% confidence interval [CI] 1.42-1.80) for hip arthroplasties; 2.06 (CI 1.90-2.46) for knee arthroplasties; 4.51 (CI 2.99-6.80) for shoulder arthroplasties; and 0.87 (CI 0.46-1.62) for ankle arthroplasties. These results remained consistent over time and were identified in both unadjusted and adjusted models. CONCLUSION:Men have a higher risk of revision due to infection than women after primary hip, knee, and shoulder arthroplasty. No evidence of difference was found for ankle arthroplasty. These elevated relative risks persist in the fully adjusted investigations and over the 10-year postoperative period studied.

Objectives One-fifth of total knee arthroplasty (TKA) recipients experience a suboptimal outcome. Incorporation of patients’ preferences in TKA assessment may improve outcomes. We determined the discriminant ability of preoperative measures of TKA need, readiness/willingness and expectations for a good TKA outcome.Methods In patients with knee osteoarthritis (OA) undergoing primary TKA, we preoperatively assessed TKA need (Western Ontario-McMaster Universities OA Index (WOMAC) Pain Score and Knee injury and Osteoarthritis Outcome Score (KOOS) function, arthritis coping), health status, readiness (Patient Acceptable Symptom State, depressive symptoms), willingness (definitely yes—yes/no) and expectations (outcomes deemed ‘very important’). A good outcome was defined as symptom improvement (met Outcome Measures in Rheumatology and Osteoarthritis Research Society International (OMERACT–OARSI) responder criteria) and satisfaction with results 1 year post TKA. Using logistic regression, we assessed independent outcome predictors, model discrimination (area under the receiver operating characteristic curve, AUC) and the predicted probability of a good outcome for different need, readiness/willingness and expectations scenarios.Results Of 1,053 TKA recipients (mean age 66.9 years (SD 8.8); 58.6% women), 78.1% achieved a good outcome. With TKA need alone (WOMAC pain subscale, KOOS physical function short-form), model discrimination was good (AUC 0.67, 95% CI 0.63 to 0.71). Inclusion of readiness/willingness, depressive symptoms and expectations regarding kneeling, stair climbing, well-being and performing recreational activities improved discrimination (p=0.01; optimism corrected AUC 0.70, 0.66–0.74). The predicted probability of a good outcome ranged from 44.4% (33.9–55.5) to 92.4% (88.4–95.1) depending on level of TKA need, readiness/willingness, depressive symptoms and surgical expectations.Conclusions Although external validation is required, our findings suggest that incorporation of patients’ TKA readiness, willingness and expectations in TKA decision-making may improve the proportion of recipients that experience a good outcome.

Objectives Screening for prostate cancer in healthy asymptomatic men using the prostate-specific antigen (PSA) test is controversial due to conflicting recommendations from and a lack of strong evidence regarding the benefit of population-based screening. In Canada and internationally, there is variability in how family physicians (FPs) approach PSA testing in asymptomatic men. The purpose of our study was to explore how family FPs approach discussions with their male patients around PSA testing in Manitoba, Canada. Design Qualitative descriptive study. Setting and participants High-ordering and median-ordering FPs were invited to participate in an interview. In addition to exploring practice behaviours around PSA testing, participants were asked to elaborate on their typical discussion with asymptomatic men who request a PSA test or other tests and procedures that they do not feel are clinically warranted. Data were analysed inductively using a constant-comparison approach. Results There were important variations between high-ordering and median-ordering FP’s approaches to discussing PSA testing. Strategies to facilitate conversations were more frequently identified by median-ordering physicians and often included methods to facilitate assessing their patient’s understanding and values. In addition to decision aids, median-ordering FPs used motivational interviewing to tailor a discussion, organised their practice structure and workflow habits in a way that enhanced patient–provider discussions and leveraged ‘new’ evidence and other aids to guide conversations with men. Conclusion We found that high-ordering FPs tended to use the PSA test for screening asymptomatic men with limited shared decision-making. Median-ordering FPs used conversational strategies that emphasised uncertainty of benefit and potential risk and did not present the test as a recommendation.