Prospective studies of hip and knee prostheses

Presentasjon om: "Prospective studies of hip and knee prostheses"— Utskrift av presentasjonen:

1 Prospective studies of hip and knee prostheses
The Norwegian Arthroplasty Register

2 Norway

3 All products mentioned in the presentation have had CE approval (European)
Some of the products used in Norway did not have FDA approval.

4 No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this presentation

5 History of the Norwegian Arthroplasty Register
References: Havelin et al. Acta Orthop Scand 1994 Havelin et al. J Bone Joint Surg (Br) 1995 Havelin et al. J Bone Joint Surg (Am) 1995

6 Havelin et al. Acta Orthop Scand 1994

7 Havelin et al. J Bone Joint Surg (Br) 1995

8 Left Right Havelin et al. J Bone Joint Surg (Br) 1995 Years

9 Havelin et al. J Bone Joint Surg (Br) 1995

10 Havelin et al. J Bone Joint Surg (Br) 1995

11 Survival of hip prostheses
Survival of cemented hip prostheses Survival of uncemented hip prostheses The Cox-adjusted relative risk (RR) for revision of a primary THA was reduced by 35 percent from to (p<0.001).

12 Survival of knee prostheses

13 Incidence 2003

14 Compliance: Hip prostheses 1999-2002
NAR = The voluntary Norwegian Arthroplasty Register NPR = The mandatory Norwegian Patient Registry

15 Cemented hip prostheses
Cup prostheses, revision of cup. Stem prostheses, revision of stem.

16 Cup/stem cemented hip prostheses (combination), any revision.

17 Cemented hip, cup prostheses

18 Cemented hip, stem prostheses

19 Uncemented hip prostheses
Cup prostheses, revision of cup or liner. Stem prostheses, revision of stem.

20 Cup/stem uncemented hip prostheses (combination), any revision.

21 Uncemented hip, cup prostheses

22 Uncemented hip, stem prostheses

23 Hip prostheses in young patients (< 60 years)
Cemented cup/stem (combination), any revision. Uncemented cup/stem (combination), any revision.

24 Hip prostheses in young patients (< 60 years)
Cemented and uncemented cup/stem (combination), revision of cup or liner. Cemented and uncemented cup/stem (combination), revision of stem.

25 Femoral head size is a risk factor for total hip luxation
Prostheses with head diameters of 28 and 32 (n=9943) Prosthesis survival until revision due to dislocation. Adjusted for age gender, diagnosis and surgical approach (Byström et al. Acta Orthop Scand 2003)

26 Prosthesis combinations, 28 and 32 mm femoral head sizes
Byström et al. Acta Orthop Scand 2003

27 Exeter prosthesis (n=5598) with head diameters of 26, 28 and 30 mm
Prosthesis survival until revision due to dislocation. Adjusted for age gender, diagnosis and surgical approach (Byström et al. Acta Orthop Scand 2003)

28 Operation time Småbrekke et al. Acta Orthop Scand 2004

29 Hip disease and the prognosis of total hip arthroplasty (Furnes et al
Hip disease and the prognosis of total hip arthroplasty (Furnes et al. J Bone Joint Surg (Br) 2001) Total material Unadjusted Adjusted

30 Hip disease and the prognosis of total hip arthroplasty (Furnes et al
Hip disease and the prognosis of total hip arthroplasty (Furnes et al. J Bone Joint Surg (Br) 2001) < 60 years Total material Charnley

31 Relative risk for revision with Charnley-prosthesis (Furnes et al
Relative risk for revision with Charnley-prosthesis (Furnes et al. J Bone Joint Surg (Br) 2001)

32 Antibiotic Prophylaxis and Survival of Primary Total Hip Prostheses
Cox-regression. Adjusted survival curves calculated with revision due to any cause as the endpoint (Espehaug et al. J Bone Joint Surg (Br) 1997).

33 Antibiotic prophylaxis systemically and in bone cement
Number of THAs performed annually SC Number of THAs S C None Year of operation Engesaeter et al. Acta Orthop Scand 2003; 74:

34 Antibiotic prophylaxis systemically and in bone cement
Survival aseptic loosening Survival infection SC S SC None C C None S Years postoperatively Years postoperatively Cox-adjusted survival curves with aseptic loosening, and infection as endpoint for THAs receiving antibiotic prohylaxis systemically and in cement (SC), only systemically (S), only in cements (C) or no antibiotic prohylaxis (None). Engesaeter et al. Acta Orthop Scand 2003; 74:

35 Antibiotic prophylaxis systemically and in bone cement
Number of THAs 11 13 14 12 3 2 Number of THAs performed annually Year of operation Engesaeter et al. Acta Orthop Scand 2003; 74:

36 Antibiotics – systemically daysdoses
100 % 95 90 85 13 3 14 2 12 Percent not revised 11 Years postoperatively Engesaeter et al. Acta Orthop Scand 2003; 74:

37 Antibiotic prophylaxis systemically and in bone cement
Survival aseptic loosening Survival infection 13 14 12 2 3 14 3 13 11 12 2 11 Years postoperatively Years postoperatively Cox-adjusted survival curves with aseptic loosening and infection as endpoint for THAs receiving antibiotic in the cement and antibiotic prophylaxis systemically for 1 day (with number of doses as subscript), 2 days and 3 days. Engesaeter et al. Acta Orthop Scand 2003; 74:

38 Revision - Aseptic loosening
* Cox adjusted 10 years revision % ** RR (Failure Risk Ratio) Adjusted for sex, age, systemic antibiotic, operating theatre, duration of operation, prosthesis. Engesaeter et al. Acta Orthop Scand 2003; 74:

39 Revision - Infection * Cox adjusted 10 years revision % ** RR (Failure Risk Ratio) Adjusted for sex, age, systemic antibiotic, operating theatre, duration of operation, prosthesis. Engesaeter et al. Acta Orthop Scand 2003; 74:

40 Cement Type and Survival of Primary Total Hip Prostheses
Boneloc cement Low viscosity cement Havelin et al. J Bone Joint Surg (Am) 1995

41 Havelin et al. J Bone Joint Surg (Am) 1995
Kaplan-Meier survival curves of Charnley femoral prostheses with high viscosity, low viscosity, and Boneloc cement. High viscosity Low viscosity Boneloc Havelin et al. J Bone Joint Surg (Am) 1995

42 Type of cement and failure of hip prostheses
Simplex Palacos G Palacos CMW1 G CMW1 Espehaug et al. J Bone Joint Surg 2002 CMW3

43 Survival of Uncemented Primary Total Hip Prostheses
Charnley cups vs two uncemented HA-coated cups

44 Survival of Uncemented Primary Total Hip Prostheses
Charnley cups vs two uncemented HA-coated cups, patients < 60 years

45 Cemented vs uncemented in young patients (<60)
All stem revisions All cup revisions

46 Hospital Category and Prosthesis failure
Central hospitals Local hospitals University hospitals p<0.001 Kaplan-Meier survival curves calculated with any revision as endpoint (Espehaug et al. Acta Orthop Scand 1999)

47 Age at primary operation
Patient satisfaction Very poor Poor Neither Good Very good % < 56 56- 65 66- 70 71- 75 > 75 20 40 60 80 100 Age at primary operation Unrevised hip implant Revised hip implant Pasientene ble spurt om å gradere nytteverdien av proteseoperasjonen. Her viser vi resultatene for 5 aldersgrupper blant pasienter med intakt primær protese og blant pasienter med revidert protese. Hele 84% av pasientene uten revisjon mente at nytteverdien var god eller meget god (det vil si den røde og grønne delen av søylene). Blant pasienter med revisjonsprotese var 61% fornøyde. Altså en del dårligere resultat, dessuten ser vi også at blant reviderte synker andelen fornøyde pasienter med økende alder. *** Denne forskjellen tilsvarerer en 4 ganger så høy odds for å være fornøyd hvis man er en pasient uten reoperasjon kontra en med reoperasjon. Espehaug et al. Clin Orthop 1998

48 Age at primary operation Before primary operation
Self-reported pain Age at primary operation MEAN CHARNLEY SCORE 1 2 3 4 5 6 < 56 56 -65 66 -70 71 -75 > 75 Unrevised hip implant Before primary operation At follow-up Revised hip implant Before revision Charnley smerte score har som kjent 6 verdienheter, der 1 representerer værste situasjon og 6 en normal situasjon med fravær av smerte. Figuren viser gjennomsnittlig Charnley score for 5 aldersgrupper blant pasienter med primærprotese og pasienter med revisjonsprotese. Gjennomsnittlig smertescore før primær operasjon var omtrent lik 2 i begge pasientgrupper (dvs. sterke smerter, ved all gangaktivitet). Ved utfylling av skjema ser vi en forbedring på omtrent 3 enheter blant pasienter med primær protese (til 5, lette smerter eller periodevise smerter, startsmerter), mens vi finner en forbedring på omtrent 2 enheter blant pasienter med revisjonsprotese (til 4, smerter etter noe aktivitet, forsvinner i hvile). Her ser vi igjen en negativ effekt av økende alder hos reviderte pasienter. Blå kurve gir smertenivå før revisjon, og som vi ser har smertenivået ikke forverret seg fra før primær operasjon. Espehaug et al. Clin Orthop 1998

49 Self-reported walking ability
Age at primary operation MEAN CHARNLEY SCORE 1 2 3 4 5 6 < 56 56 -65 66 -70 71 -75 > 75 Unrevised hip implant Before primary operation At follow-up Revised hip implant Before revision Gjennomsnittlig Charnley score for gangevne før primær operasjon var igjen omtrent lik i begge pasientgrupper, men her er nivået noe bedre enn for smerte med verdi omtrent lik 3 som tilsvarer ’Inntil 1 time med stokk. Kan stå lenge’. Også for gangevne ser vi en forbedring for begge grupper, men med en mindre endring hos pasienter med revisjonsprotese. I begge grupper ser vi også en negativ effekt av økende alder. I og for seg ikke overraskende, da gangevnen, spesielt blant eldre, naturlig vil bli dårligere over tid. Alderseffekten er likevel mer markert blant revisjonspasienter. Espehaug et al. Clin Orthop 1998

50 Total survival for patients with
hip prostheses 39543 patients; 6201 deaths; 323 within 60 days Percent patients alive Years after primary operation Days after primary operation Lie et al. Acta Orthop Scand 2000; 71(1): 19-27

51 Early postoperative mortality
Days postoperatively Days postoperatively

52 Risk factors for total hip replacement
Population fraction without THR Intensive physical activity at work and a high BMI each contribute significantly to the overall risk of undergoing THA due to primary osteoarthritis. Flugsrud et al. Epidemiology 2003

53 Risk factors for total hip replacement
Flugsrud et al. Epidemiology 2003

54 Revision prostheses 89 % 74 % Years after primary operation
Percent with no re-revisions Percent with no revisions Years after primary operation Years after revision 62 % Percent with no third revisions Years after re-revision

55 Femoral revision prostheses
No bone grafting/ cemented Bone grafting/ cemented Impaction bone grafting/ cemented A; n=1243, r=144 C; n=442, r=12 B; n=326, r=20 Percent with no re-revision No bone grafting/ uncemented Bone grafting/ uncemented Impaction bone grafting/ uncemented D; n=282, r=8 E; n=478, r=6 F; n=89, r=4 Years after revision Years after revision Years after revision Lie et al. J Bone Joint Surg (Br) 2004

56 Femoral revision prostheses
0.19, 1.38 0.51 0.16, 0.46 0.27 0.11, 0.46 0.22 0.19, 0.62 0.34 0.33, 0.84 0.53 ref 1 95 % CI RR & Uncemented Cemented Impaction bone grafting Bone grafting No bone grafting Cox-regression, adjusted for age and gender Lie et al. J Bone Joint Surg (Br) 2004

57 Acetabular revision prostheses
No bone grafting/ cemented Bone grafting/ cemented Impaction bone grafting/ cemented A: n=1108, r=82 B: n=301, r=14 C: n=256, r=12 Percent with no re-revision No bone grafting/ uncemented Bone grafting/ uncemented Impaction bone grafting/ uncemented D: n=542, r=20 E: n=487, r=33 F: n=54, r=4 Years after revision Years after revision Years after revision Lie et al. J Bone Joint Surg (Br) 2004

58 Acetabular revision prostheses
0.38, 2.83 1.03 0.43, 0.99 0.66 0.22, 0.61 0.37 0.38, 1.30 0.70 0.34, 1.06 0.60 ref 1 95 % CI RR & Uncemented Impaction bone grafting Bone grafting Cemented No bone grafting Cox-regression, adjusted for age and gender Lie et al. J Bone Joint Surg (Br) 2004

59 UKAs used in Norway

60 Failures in primary total knee arthroplasties
Cemented bicompartmental primary knee arthroplasties (patella non resurfaced), any revision. Cemented tricompartmental primary knee arthroplasties (patella resurfaced), any revision.

61 Failures in primary total knee arthroplasties
Fixation of bicompartmental and tricompartmental primary knee arthroplasties, any revision.

62 Reasons for revision in cemented primary total knee arthroplasties
Furnes et al. Acta Orthop Scand 2002

63 Unicompartmental and tricompartmental cemented primary knee arthroplasties
Cemented TKA ≥70 years 60 to 69 years ≥70 <60 years 60 to 69 years Cemented UKA <60 years Cemented TKAs Cemented UKAs

64 Unicompartmental and tricompartmental cemented primary knee arthroplasties
Genesis Uni (n=259) Oxford III (n=680) Oxford II (n=45) Miller Galante (n=166) Mod III (n=200) Duracon Uni (n=48)

65 Unicompartmental and tricompartmental cemented primary knee arthroplasties
Survival curves for primary cemented Miller Galante UKAs (all polyethylene tibia) at 13 hospitals in Norway, indicating large variations, p=0.01.

66 Reasons for revision in cemented UKAs compared with cemented TKAs