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Background Survival analysis and effect of covariates on survival time is a central research interest. Cox proportional hazards regression remains as a gold standard in the survival analysis. The Cox model relies on the assumption of proportional hazards (PH) across different covariates. PH assumptions should be assessed and handled if violated. Our aim was to investigate the reporting of the Cox regression model details and testing of the PH assumption in survival analysis in total joint arthroplasty (TJA) studies. Methods We conducted a review in the PubMed database on 28th August 2019. A total of 1154 studies were identified. The abstracts of these studies were screened for words “cox and “hazard*” and if either was found the abstract was read. The abstract had to fulfill the following criteria to be included in the full-text phase: topic was knee or hip TJA surgery; survival analysis was used, and hazard ratio reported. If all the presented criteria were met, the full-text version of the article was then read. The full-text was included if Cox method was used to analyze TJA survival. After accessing the full-texts 318 articles were included in final analysis. Results The PH assumption was mentioned in 114 of the included studies (36%). KM analysis was used in 281 (88%) studies and the KM curves were presented graphically in 243 of these (87%). In 110 (45%) studies, the KM survival curves crossed in at least one of the presented figures. The most common way to test the PH assumption was to inspect the log-minus-log plots ( n  = 59). The time-axis division method was the most used corrected model ( n  = 30) in cox analysis. Of the 318 included studies only 63 (20%) met the following criteria: PH assumption mentioned, PH assumption tested, testing method of the PH assumption named, the result of the testing mentioned, and the Cox regression model corrected, if required. Conclusions Reporting and testing of the PH assumption and dealing with non-proportionality in hip and knee TJA studies was limited. More awareness and education regarding the assumptions behind the used statistical models among researchers, reviewers and editors are needed to improve the quality of TJA research. This could be achieved by better collaboration with methodologists and statisticians and introducing more specific reporting guidelines for TJA studies. Neglecting obvious non-proportionality undermines the overall research efforts since causes of non-proportionality, such as possible underlying pathomechanisms, are not considered and discussed.

Background: Numerous studies, including randomized controlled trials (RCTs), have been published on the optimal graft choice for primary anterior cruciate ligament (ACL) reconstruction. Purpose: To review existing studies to investigate whether advances in orthopaedics have affected revision rates after primary ACL reconstruction. Study Design: Systematic review; Level of evidence, 4. Methods: The PubMed database was searched from inception to December 31, 2020, using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Patient series, observational studies, clinical trials, and registry-based studies investigating primary ACL reconstruction were included, as were high-quality RCTs from an additional study. The minimum required follow-up time for inclusion was 1 year. The primary outcome measure was the pooled prevalence of revision ACL reconstruction. The effect of the year the surgery was performed on revision rates was evaluated with metaregression analysis. All graft types were analyzed simultaneously, and all analyses were repeated separately for each graft type. Results: Overall, 330 articles with 52,878 patients were included, with a median patient age of 28 years (range, 15-57 years). The primary ACL reconstructions were performed between 1969 and 2018. At a median of 2.3 years of follow-up, the overall revision rate was 3.14% (95% CI, 2.76% to 3.56%); it was 2.71% (95% CI, 2.25% to 3.27%) for hamstring autografts, 2.38% (95% CI, 1.82% to 3.11%) for bone–patellar tendon–bone (BPTB) autografts, and 5.24% (95% CI, 4.02% to 6.80%) for other graft types. For hamstring grafts, the revision rate increased over time (year of surgery), with a 0.0434 (95% CI, 0.0150 to 0.0718) increase effect in the logit-transformed scale for every additional year. There was a slight decrease in revision rates for BPTB (β = –0.0049; 95% CI, –0.0352 to 0.0254) and other graft types (β = –0.0306; 95% CI, –0.0608 to −0.0005) over time; however, confidence intervals for BPTB included the zero change. Conclusion: Based on this systematic review and meta-analysis, ACL reconstruction is a reliable procedure with overall low historical revision rates. BPTB autograft had the lowest revision rate and a slightly decreasing trend of failures during the past 45 years, although both BPTB and hamstring autografts are reliable graft choices.

Due to the risk of adverse reactions to metal debris resulting from increased wear of the arthroplasty more than one million metal-on-metal (MoM) hip replacements worldwide are in active follow-up. Follow-up usually includes measurement of both whole blood cobalt (Co) and chromium (Cr) concentrations. Our experience is that Cr is seldom independently elevated. We wanted to ascertain whether blood Cr measurements could be omitted from follow-up protocols without lowering the quality of follow-up. We identified 8438 whole blood Co and Cr measurements performed without or prior to revision surgery. When the cut-off levels 5 µg/L and 7 µg/L were used, Cr was independently elevated in only 0.5% (95% confidence interval, CI, 0.3 to 0.6) and 0.2% (CI 0.1 to 0.3) of the measurements. The models with continuous variables showed that the higher the blood metal concentrations are the lower the percentage of measurements with Cr higher than Co. Our results suggest that whole blood Cr is very rarely independently elevated and therefore the authorities should consider omitting Cr measurements from their screening guidelines of MoM hip replacements. We believe this change in practice would simplify follow-up and lead to cost savings without decreasing the quality of follow-up.

Pilonidal sinus is a recognized occupational condition sometimes seen in barbers and pet groomers, and it involves most commonly interdigital spaces. We present a previously unreported case of chronic paronychia with 2 separate digital pilonidal sinuses resulting from multiple embedded hair fragments in the eponychium of a dog groomer, who had been repeatedly treated with antibiotics with no success and ended up having surgical treatment. The objective of this study is to remind readers of this rare but possible occupational disease, particularly among employees working with hair, and to emphasize the importance of preventive measures to prevent its occurrence. Intraoperatively, a crescent of eponychial skin parallel to the proximal nail fold was excised, which incorporated the sinuses. Additionally, the nail plate was removed, and multiple hair fragments were retrieved from the nail folds. At the follow-up, the infection had resolved, and nail growth had resumed. Additional animal hair was found in the nail folds, as the patient continued to work without protective gloves. This case highlights the importance of considering embedded hair as a potential cause for chronic paronychia in individuals with occupations involving hair cutting and grooming. Chronic hand infection poses a risk of infection contaminating clients or patients; for example, a veterinarian should not operate with an infected hand. The costs of sickness absences are considerable for all the stakeholders. The use of protective gloves, hand hygiene, skin care, and thorough removal of loose hair fragments should be emphasized for workers in professions dealing with animal or human hair.

Dislocation is one of the most common complications after primary total hip arthroplasty (THA). Several patient-related risk factors for dislocation have been reported in the previous literature, but only few prediction models for dislocation have been made. Our aim was to build a prediction model for an early (within the first 2 years) revision for dislocation after primary THA using two different statistical methods. The study data constituted of 37 pre- or perioperative variables and postoperative follow-up data of 16 454 primary THAs performed at our institution in 2008–2021. Model I was a traditional logistic regression model and Model II was based on the elastic net method that utilizes machine learning. The models’ overall performance was measured using the pseudo R 2 values. The discrimination of the models was measured using C-index in Model I and Area Under the Curve (AUC) in Model II. Calibration curves were made for both models. At 2 years postoperatively, 95 hips (0.6% prevalence) had been revised for dislocation. The pseudo R 2 values were 0.04 in Model I and 0.02 in Model II indicating low predictive capability in both models. The C-index in Model I was 0.67 and the AUC in Model II was 0.73 indicating modest discrimination. The prediction of an early revision for dislocation after primary THA is difficult even in a large cohort of patients with detailed data available because of the reasonably low prevalence and multifactorial nature of dislocation. Therefore, the risk of dislocation should be kept in mind in every primary THA, whether the patient has predisposing factors for dislocation or not. Further, when conducting a prediction model, sophisticated methods that utilize machine learning may not necessarily offer significant advantage over traditional statistical methods in clinical setup.

Metal-on-metal (MoM) hip replacements were used for almost a decade before adverse reactions to metal debris (ARMD) were found to be a true clinical problem. Currently, there is a paucity of evidence regarding the usefulness of systematic screening for ARMD. We implemented a systematic review and meta-analysis to establish the prevalence of revision confirmed ARMD stratified by the use of different screening protocols in patients with MoM hip replacements. Five levels of screening were identified: no screening (level 0), targeted blood metal ion measurement and/or cross-sectional imaging (level 1), metal ion measurement without imaging (level 2), metal ion measurement with targeted imaging (level 3) and comprehensive screening (both metal ions and imaging for all; level 4). 122 studies meeting our eligibility criteria were included in analysis. These studies included 144 study arms: 100 study arms with hip resurfacings, 33 study arms with large-diameter MoM total hip replacements (THR), and 11 study arms with medium-diameter MoM THRs. For hip resurfacing, the lowest prevalence of ARMD was seen with level 0 screening (pooled prevalence 0.13%) and the highest with level 4 screening (pooled prevalace 9.49%). Pooled prevalence of ARMD with level 0 screening was 0.29% and with level 4 screening 21.3% in the large-diameter MoM THR group. In metaregression analysis of hip resurfacings, level 4 screening was superior with regard to prevalence of ARMD when compared with other levels. In the large diameter THR group level 4 screening was superior to screening 0,2 and 3. These outcomes were irrespective of follow-up time or study publication year. With hip resurfacings, routine cross-sectional imaging regardless of clinical findings is advisable. It is clear, however, that targeted metal ion measurement and/or imaging is not sufficient in the screening for ARMD in any implant concepts. However, economic aspects should be weighed when choosing the preferred screening level.

Background COVID-19 outbreak lead to nationwide lockdown in Finland on the March 16th, 2020. Previous data regarding to the patient load in the emergency departments during pandemics is scarce. Our aim is to describe the effect of national lockdown and social distancing on the number and reasons for emergency department (ED) visits and inpatient admissions in three large volume hospitals prior to and after the outbreak of the COVID-19 epidemic in Finland. Methods Data for this register-based retrospective cohort study were collected from three large ED’s in Finland, covering 1/6 of the Finnish population. All patients visiting ED’s six weeks before and six weeks after the lockdown were included. Pediatric and gynecological patients were excluded. Numbers and reasons for ED visits and inpatient admissions were collected. Corresponding time period in 2019 was used as reference. Results A total of 40,653 ED visits and 12,226 inpatient admissions were analyzed. The total number of ED visits decreased 16% after the lockdown, whereas the number of inpatient admissions decreased 15% ( p  < 0.001). This change in inpatient admissions was similar in all participating hospitals. Visits due to back or limb pain decreased 31% and infectious diseases 28%. The visit rate and inpatient admissions due to acute myocardial infarction and strokes remained stable throughout the study period. Interestingly, the rate of inpatient admissions due to psychiatric diagnoses remained unchanged, although the ED visit rate decreased by 19%. The number of ED visits ( n  = 282) and inpatient admissions ( n  = 55) due to COVID-19 remained low in the participating hospitals. Conclusions Changes in ED visits and inpatient admissions prior to and during the early phase of the COVID-19 outbreak were unpredictable, and our results may help hospitals and especially ED’s focus their resources better. Surprisingly, there was a major decrease in the rate of ED visits due to back or limb pain and not so surprisingly in infectious diseases. Rates of acute myocardial infarctions and cerebral strokes remained stable. In summary, stabile resources for the treatment of patients with severe diseases will be needed in hospitals and ED’s.

Purpose Due to increased life expectancy and a more active life style of the older people, we hypothesised that the incidence of quadriceps tendon rupture (QTR) is higher than previously reported. The objective of this nationwide population-based study was to investigate the annual incidence of QTR in patients who underwent operative treatment in Finland between 1997 and 2014. Methods The Finnish National Hospital Discharge Register was searched for all adult patients who had undergone surgical treatment for QTR during the study period. Population-based annual incidence and incidence trends for surgically treated QTR were calculated. Results During the study period, 1343 QTR surgeries were performed. Of these, 90% were performed on male patients. The incidence of QTR increased by 411% from 0.55 to 2.82 per 100,000 person-years from 1997 to 2014. The average yearly increase in the number of surgeries was 9.0%. In male patients, the incidence of QTR increased by 490% and in female patients by 121%. The mean age of the male patients increased during the study period from 50 to 59 years. Conclusions Based on the data from the Finnish National Hospital Discharge Register, the annual incidence of QTR increased by over 400% during the 18-year study period. The average age of the patients also increased. Because QTR is only very rarely treated without surgery, the results of our study can be considered to be a reliable estimate of the increase in the incidence of this condition. There is an urgent need to establish the risk factors associated with QTR and to also establish the optimal surgical technique. Level of evidence IV.

Adverse Reaction to Metal Debris (ARMD) is a major cause of implant failure leading to revision surgery in patients with metal-on-metal (MoM) hip arthroplasties. However, the pathogenesis and its association to implant wear are poorly understood and previous studies have yielded discrepant results. We sought to investigate the associations between histological findings, whole blood and synovial fluid metal ion concentrations and periprosthetic tissue metal concentrations in patients with MoM total hip replacements and hip resurfacings revised for ARMD. 107 hips in total were included in our study. Of these, 87 were total hip replacements and 20 were hip resurfacings, respectively. We found that whole blood, synovial fluid and periprosthetic tissue metal concentrations correlated poorly with histological findings. We suggest that the lack of a clear association between histological findings and wear measures in the present study as well as in previous studies is mostly influenced by variability in patient susceptibility. However, patients presenting with perivascular lymphocytic infiltration had lower chromium concentration in their periprosthetic tissues than patients with no perivascular lymphocytic infiltration. This may reflect the role of metal hypersensitivity in implant failure in these patients. Patients with total hip replacements evinced more necrosis and lymphocytic infiltration in their tissues than patients with hip resurfacings. This suggests that trunnion wear debris is more cytotoxic and/or immunogenic than bearing wear debris leading to higher failure rates seen in patients with total hip replacements.

Dislocation is one of the most common complications after primary total hip arthroplasty (THA). Several patient-related risk factors for dislocation have been reported in the previous literature, but only few prediction models for dislocation have been made. Our aim was to build a prediction model for an early (within the first 2 years) revision for dislocation after primary THA using two different statistical methods. The study data constituted of 37 pre- or perioperative variables and postoperative follow-up data of 16 454 primary THAs performed at our institution in 2008–2021. Model I was a traditional logistic regression model and Model II was based on the elastic net method that utilizes machine learning. The models’ overall performance was measured using the pseudo R2 values. The discrimination of the models was measured using C-index in Model I and Area Under the Curve (AUC) in Model II. Calibration curves were made for both models. At 2 years postoperatively, 95 hips (0.6% prevalence) had been revised for dislocation. The pseudo R2 values were 0.04 in Model I and 0.02 in Model II indicating low predictive capability in both models. The C-index in Model I was 0.67 and the AUC in Model II was 0.73 indicating modest discrimination. The prediction of an early revision for dislocation after primary THA is difficult even in a large cohort of patients with detailed data available because of the reasonably low prevalence and multifactorial nature of dislocation. Therefore, the risk of dislocation should be kept in mind in every primary THA, whether the patient has predisposing factors for dislocation or not. Further, when conducting a prediction model, sophisticated methods that utilize machine learning may not necessarily offer significant advantage over traditional statistical methods in clinical setup.