Surgery (RMH) - Research Publications
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ItemForecasting the future burden of primary total shoulder replacement in Australia(ELSEVIER SCI LTD, 2023-12)OBJECTIVE: To forecast the number of primary total shoulder replacements (TSR) in Australia to the year 2035, and associated costs. METHODS: De-identified TSR data for 2009-2019 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Population data, including population projections to 2035, were obtained from the Australian Bureau of Statistics. Three forecasting scenarios were used: constant TSR rates from 2019 onwards (Scenario 1, conservative); continued growth in TSR rates using negative binomial regression (Scenario 2, exponential); and continued growth using negative binomial regression with monotone B-splines (Scenario 3, moderate). Healthcare costs were estimated using TSR projections and average procedure costs, inflated to 2035 Australian dollars. RESULTS: The use of TSR increased by 242% in Australia from 2009 to 2019 (from 1983 to 6789 procedures for people ≥40 years). Under Scenario 1, the incidence of TSR is conservatively projected to rise to 9676 procedures by 2035 (43% increase from 2019), at a cost of $AUD 312.6 million to the health system. Under Scenario 2, TSR incidence would increase to 45,295 procedures by 2035 (567% increase), costing $AUD 1.46 billion. Under Scenario 3, 28,257 TSR procedures are forecast in 2035 (316% increase) at a cost of $913 million. CONCLUSIONS: Recent growth in TSR likely relates to prosthesis improvements, greater surgeon proficiency, and expanded clinical indications. Under moderate and exponential scenarios that consider rising TSR rates and population projections, Australia would face three- to five-fold growth in procedures by 2035. This would have profound implications for the healthcare budget, clinical workforce, and infrastructure.
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ItemNo Preview AvailableTrial of Vancomycin and Cefazolin as Surgical Prophylaxis in Arthroplasty(MASSACHUSETTS MEDICAL SOC, 2023-10-19)BACKGROUND: The addition of vancomycin to beta-lactam prophylaxis in arthroplasty may reduce surgical-site infections; however, the efficacy and safety are unclear. METHODS: In this multicenter, double-blind, superiority, placebo-controlled trial, we randomly assigned adult patients without known methicillin-resistant Staphylococcus aureus (MRSA) colonization who were undergoing arthroplasty to receive 1.5 g of vancomycin or normal saline placebo, in addition to cefazolin prophylaxis. The primary outcome was surgical-site infection within 90 days after surgery. RESULTS: A total of 4239 patients underwent randomization. Among 4113 patients in the modified intention-to-treat population (2233 undergoing knee arthroplasty, 1850 undergoing hip arthroplasty, and 30 undergoing shoulder arthroplasty), surgical-site infections occurred in 91 of 2044 patients (4.5%) in the vancomycin group and in 72 of 2069 patients (3.5%) in the placebo group (relative risk, 1.28; 95% confidence interval [CI], 0.94 to 1.73; P = 0.11). Among patients undergoing knee arthroplasty, surgical-site infections occurred in 63 of 1109 patients (5.7%) in the vancomyin group and in 42 of 1124 patients (3.7%) in the placebo group (relative risk, 1.52; 95% CI, 1.04 to 2.23). Among patients undergoing hip arthroplasty, surgical-site infections occurred in 28 of 920 patients (3.0%) in the vancomyin group and in 29 of 930 patients (3.1%) in the placebo group (relative risk, 0.98; 95% CI, 0.59 to 1.63). Adverse events occurred in 35 of 2010 patients (1.7%) in the vancomycin group and in 35 of 2030 patients (1.7%) in the placebo group, including hypersensitivity reactions in 24 of 2010 patients (1.2%) and 11 of 2030 patients (0.5%), respectively (relative risk, 2.20; 95% CI, 1.08 to 4.49), and acute kidney injury in 42 of 2010 patients (2.1%) and 74 of 2030 patients (3.6%), respectively (relative risk, 0.57; 95% CI, 0.39 to 0.83). CONCLUSIONS: The addition of vancomycin to cefazolin prophylaxis was not superior to placebo for the prevention of surgical-site infections in arthroplasty among patients without known MRSA colonization. (Funded by the Australian National Health and Medical Research Council; Australian New Zealand Clinical Trials Registry number, ACTRN12618000642280.).
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ItemNo Preview AvailableEpigenetic and transcriptional regulation of CCL17 production by glucocorticoids in arthritis(CELL PRESS, 2023-10-20)Glucocorticoids (GCs) are potent anti-inflammatory agents and are broadly used in treating rheumatoid arthritis (RA) patients, albeit with adverse side effects associated with long-term usage. The negative consequences of GC therapy provide an impetus for research into gaining insights into the molecular mechanisms of GC action. We have previously reported that granulocyte-macrophage colony-stimulating factor (GM-CSF)-induced CCL17 has a non-redundant role in inflammatory arthritis. Here, we provide molecular evidence that GCs can suppress GM-CSF-mediated upregulation of IRF4 and CCL17 expression via downregulating JMJD3 expression and activity. In mouse models of inflammatory arthritis, GC treatment inhibited CCL17 expression and ameliorated arthritic pain-like behavior and disease. Significantly, GC treatment of RA patient peripheral blood mononuclear cells ex vivo resulted in decreased CCL17 production. This delineated pathway potentially provides new therapeutic options for the treatment of many inflammatory conditions, where GCs are used as an anti-inflammatory drug but without the associated adverse side effects.
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ItemEstimating incidence rates of periprosthetic joint infection after hip and knee arthroplasty for osteoarthritis using linked registry and administrative health data(BRITISH EDITORIAL SOC BONE & JOINT SURGERY, 2022-09)AIMS: The aim of this study was to estimate the 90-day periprosthetic joint infection (PJI) rates following total knee arthroplasty (TKA) and total hip arthroplasty (THA) for osteoarthritis (OA). METHODS: This was a data linkage study using the New South Wales (NSW) Admitted Patient Data Collection (APDC) and the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), which collect data from all public and private hospitals in NSW, Australia. Patients who underwent a TKA or THA for OA between 1 January 2002 and 31 December 2017 were included. The main outcome measures were 90-day incidence rates of hospital readmission for: revision arthroplasty for PJI as recorded in the AOANJRR; conservative definition of PJI, defined by T84.5, the PJI diagnosis code in the APDC; and extended definition of PJI, defined by the presence of either T84.5, or combinations of diagnosis and procedure code groups derived from recursive binary partitioning in the APDC. RESULTS: The mean 90-day revision rate for infection was 0.1% (0.1% to 0.2%) for TKA and 0.3% (0.1% to 0.5%) for THA. The mean 90-day PJI rates defined by T84.5 were 1.3% (1.1% to 1.7%) for TKA and 1.1% (0.8% to 1.3%) for THA. The mean 90-day PJI rates using the extended definition were 1.9% (1.5% to 2.2%) and 1.5% (1.3% to 1.7%) following TKA and THA, respectively. CONCLUSION: When reporting the revision arthroplasty for infection, the AOANJRR substantially underestimates the rate of PJI at 90 days. Using combinations of infection codes and PJI-related surgical procedure codes in linked hospital administrative databases could be an alternative way to monitor PJI rates.Cite this article: Bone Joint J 2022;104-B(9):1060-1066.
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ItemEarly Revision Rates of Total Hip Arthroplasty Using the Intellijoint HIP Computer Navigation System: A Study From the Australian National Joint Replacement Registry of 1911 Procedures.(Elsevier BV, 2022-12)BACKGROUND: Total hip arthroplasty (THA) is an effective treatment for symptomatic hip osteoarthritis. The aim of this study was to determine the revision outcome of commercially available navigation technologies. METHODS: Data from the Australian Orthopaedic Association National Joint Replacement Registry from January 2016 to December 2020 included all primary THA procedures performed for osteoarthritis. Procedures using the Intellijoint HIP navigation system were identified and compared to procedures using "other" computer navigation systems and to nonnavigated procedures. The cumulative percent revision (CPR) was compared between the 3 groups using Kaplan-Meier estimates of survivorship and hazard ratios from Cox proportional hazards models, adjusted for age and gender. RESULTS: There were 1911 procedures that used the Intellijoint system, 4081 used "other" computer navigation systems, and 160,661 were nonnavigated procedures. The all-cause 2-year CPR rate for the Intellijoint system was 1.8% (95% confidence interval [CI], 1.2-2.6), compared to 2.2% (95% CI, 1.8-2.8) for other navigated cases and 2.2% (95% CI, 2.1-2.3) for nonnavigated cases. A prosthesis analysis identified the Paragon/Acetabular Shell THAs combined with the Intellijoint system to have a higher (3.4%) rate of revision than nonnavigated THAs (hazard ratio = 2.00 [95% CI, 1.01-4.00], P = .048). When this combination was excluded, the Intellijoint group demonstrated a 2-year CPR of 1.3%. There was no statistical difference in the CPR between the 3 groups before or after excluding the Paragon/Acetabular Shell system. CONCLUSIONS: The preliminary data presented demonstrate no statistical difference in all-cause revision rates when comparing the Intellijoint system with "other" navigation systems and "nonnavigated" approaches for primary THAs. LEVEL OF EVIDENCE: III (National registry analysis).
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ItemDual mobility versus conventional total hip arthroplasty in femoral neck fractures (DISTINCT): protocol for a registry-nested, open-label, cluster-randomised crossover trial.(BMJ, 2022-09-21)INTRODUCTION: Hip fractures treated with total hip arthroplasty (THA) are at high risk of prosthesis instability, and dislocation is the most common indication for revision surgery. This study aims to determine whether dual mobility THA implants reduce the risk of dislocation compared with conventional THA in patients with hip fracture suitable to be treated with THA. METHODS AND ANALYSIS: This is a cluster-randomised, crossover, open-label trial nested within the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). The clusters will comprise hospitals that perform at least 12 THAs for hip fracture per annum. All adults age ≥50 years who meet the Australian and New Zealand Hip Fracture Registry guidelines for THA will be included. The intervention will be dual mobility THA and the comparator will be conventional THA. Each hospital will be allocated to two consecutive periods, one of dual mobility THA and the other of conventional THA in random order, aiming for an average of 16 patients eligible for the primary analysis per group (32 total per site), allowing different recruitment totals between sites. Data will be collected through the AOANJRR and linked with patient-level discharge data acquired through government agencies. The primary outcome is dislocation within 1 year. Secondary outcomes include revision surgery for dislocation and all-cause, complications and mortality at 1, 2 and 5 years. If dual mobility THA is found to be superior, a cost-effectiveness analysis will be conducted. The study will aim to recruit 1536 patients from at least 48 hospitals over 3 years. ETHICS AND DISSEMINATION: Ethics approval has been granted (Sydney Local Health District - Royal Prince Alfred Hospital Zone (approval X20-0162 and 2020/ETH00680) and site-specific approvals). Participant recruitment is via an opt-out consent process as both treatments are considered accepted, standard practice. The trial is endorsed by the Australia and New Zealand Musculoskeletal Clinical Trials Network. TRIAL REGISTRATION NUMBER: ACTRN12621000069853.
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ItemIncreased early mortality after total knee arthroplasty using conventional instrumentation compared with technology-assisted surgery: an analysis of linked national registry data.(BMJ, 2022-05-31)OBJECTIVES: This study aims to compare early mortality after total knee arthroplasty (TKA) using conventional intramedullary instrumentation to TKA performed using technology-assisted (non-intramedullary) instrumentation. DESIGN: Comparative observational study. Using data from a large national registry, the 30-day mortality after unilateral TKA performed for osteoarthritis was compared between procedures using conventional instrumentation and those using technology-assisted instrumentation. Firth logistic regression was used to calculate ORs, adjusting for age, sex, use of cement and procedure year for the whole period, and additionally adjusting for American Society of Anesthesiologists physical status classification system class and body mass index (BMI) for the period 2015 to 2019. This analysis was repeated for 7-day and 90-day mortality. SETTING: National arthroplasty registry. PARTICIPANTS: People undergoing unilateral, elective TKA for osteoarthritis from 2003 to 2019 inclusive. INTERVENTIONS: TKA performed using conventional intramedullary instrumentation or technology-assisted instrumentation. MAIN OUTCOME MEASURES: 30-day mortality (primary), and 7-day and 90-day mortality. RESULTS: A total of 581 818 unilateral TKA procedures performed for osteoarthritis were included, of which 602 (0.10%) died within 30 days of surgery. The OR of death within 30 days following TKA performed with conventional instrumentation compared with technology-assisted instrumentation, adjusted for age, sex, cement use, procedure year, American Society of Anesthesiologists and BMI was 1.72 (95% CI, 1.23 to 2.41, p=0.001). The corresponding ORs for 7-day and 90-day mortality were 2.21 (96% CI, 1.34 to 3.66, p=0.002) and 1.35 (95% CI, 1.07 to 1.69, p=0.010), respectively. CONCLUSIONS: The use of conventional instrumentation during TKA is associated with higher odds of early postoperative death than when technology-assisted instrumentation is used. This difference may be explained by complications related to fat embolism secondary to intramedullary rods used in conventional instrumentation. Given the high number of TKA performed annually worldwide, increasing the use of technology-assisted instrumentation may reduce early post-operative mortality.
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ItemNo Preview AvailablePeriprosthetic fracture as a late mode of failure of the Anatomique Benoist Girard II femoral prosthesis(WILEY, 2022-05)AIM: The Anatomique Benoist Girard (ABG) II femoral implant was a commonly used stem for primary total hip replacement (THR) at our institution (Launceston, Tasmania Australia). We identified peri-prosthetic fracture as the main cause of late failure. METHODS: The late periprosthetic fracture rate for ABG II implants was reviewed with national statistics, using Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) data. National revision rates for periprosthetic fracture were used to compare ABG II with all other cementless femoral stems. RESULT: ABG II stems accounted for 1% (2719 implants) of all femoral stem implants in Australia during the 12-year review period, compared to 23% (587 implants) in Launceston Hospitals. Although the Launceston cumulative percent revision rate for the ABG II stem was lower than the National rate at all time points, the reasons for revision were similar. The most common reason for revision of ABG II was fracture (56.8%), followed by loosening (15.3%). This differs from the reasons for revision in other cementless prostheses (loosening 23.9%, fracture 20.8%, dislocation 18.7%). Cumulative percent revision rates from late periprosthetic fracture, were higher for the ABG II stem than other cementless femoral prostheses. CONCLUSION: This review of the AOANJRR has confirmed a local and national higher revision rate of the ABG II stem due to late periprosthetic fracture compared with other cementless stems. Stem design must be considered to reduce the risk of late periprosthetic fracture.
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ItemThe accuracy of reporting of periprosthetic joint infection to the Australian Orthopaedic Association National Joint Replacement Registry.(British Editorial Society of Bone & Joint Surgery, 2022-05)AIMS: National joint registries under-report revisions for periprosthetic joint infection (PJI). We aimed to validate PJI reporting to the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR) and the factors associated with its accuracy. We then applied these data to refine estimates of the total national burden of PJI. METHODS: A total of 561 Australian cases of confirmed PJI were captured by a large, prospective observational study, and matched to data available for the same patients through the AOANJRR. RESULTS: In all, 501 (89.3%) cases of PJI recruited to the prospective observational study were successfully matched with the AOANJRR database. Of these, 376 (75.0%) were captured by the registry, while 125 (25.0%) did not have a revision or reoperation for PJI recorded. In a multivariate logistic regression analysis, early (within 30 days of implantation) PJIs were less likely to be reported (adjusted odds ratio (OR) 0.56; 95% confidence interval (CI) 0.34 to 0.93; p = 0.020), while two-stage revision procedures were more likely to be reported as a PJI to the registry (OR 5.3 (95% CI 2.37 to 14.0); p ≤ 0.001) than debridement and implant retention or other surgical procedures. Based on this data, the true estimate of the incidence of PJI in Australia is up to 3,900 cases per year. CONCLUSION: In Australia, infection was not recorded as the indication for revision or reoperation in one-quarter of those with confirmed PJI. This is better than in other registries, but suggests that registry-captured estimates of the total national burden of PJI are underestimated by at least one-third. Inconsistent PJI reporting is multifactorial but could be improved by developing a nested PJI registry embedded within the national arthroplasty registry. Cite this article: Bone Jt Open 2022;3(5):367-373.
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ItemNo Preview AvailableA Nurse-Led Multimedia Intervention to Increase Patient Participation in Recovery After Knee Arthroplasty: Hybrid Type II Implementation Study(JMIR PUBLICATIONS, INC, 2022-05-19)BACKGROUND: Advances in digital technology and the use of multimedia platforms to deliver information provide clinicians with a unique opportunity to develop innovative ways to consistently provide high-quality, accessible, and evidence-based information to support patient participation. Introducing new technologies into everyday acute care clinical practice can be difficult. OBJECTIVE: The aim of this paper was to provide a description of an implementation strategy and the subsequent evaluation undertaken to examine the contextual factors important to the successful adoption of new technology by nurses in the context of acute postoperative care. METHODS: Implementation of the intervention and process evaluation was undertaken in 3 phases: phase 1, preimplementation stakeholder engagement and identification of barriers and enablers to implementation; phase 2, supported implementation of the intervention; and phase 3, evaluation of uptake, usability, and acceptability of the intervention in clinical practice. RESULTS: The outcomes of the implementation of the multimedia intervention in the context of acute postoperative care were positive. Of the 104 patients in the intervention group, 103 (99%) received the intervention. All 103 patients completed the 8-item intervention questionnaire and 93.3% (97/103) were interviewed on day 3 to evaluate usability, uptake, and acceptability. Of these 97 patients, almost all (n=94, 91%) found the program easy to use and most (n=64, 62%) could view the MyStay Total Knee Replacement program as often as they wanted. The findings also suggest that the time to implement the program was minimal (5-10 minutes). Collaboration with nurses and patients before and during implementation to identify potential barriers to successful implementation of the intervention was essential to develop timely strategies to overcome these barriers. To ensure end-user engagement, careful consideration was given to nurses' views on who was responsible for facilitating this intervention. CONCLUSIONS: The findings provide evidence that the structured implementation of the multimedia intervention was robust and successful in terms of patient participant recruitment and application; however, it was difficult to assess the level of engagement by nurse clinicians with the program. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12614000340639; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12614000340639.
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