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Periprosthetic joint infections (PJIs) are dreaded complications of total joint arthroplasties. The risk of developing PJIs is likely to be influenced by several patient factors such as sociodemographic characteristics, body mass index (BMI), and medical and surgical histories. However, the nature and magnitude of the long-term longitudinal associations between these patient-related factors and risk of developing PJIs are uncertain. To conduct a systematic review and meta-analysis to assess the associations between several patient-related factors and PJI. MEDLINE, EMBASE, Web of Science, Cochrane Library, and reference lists of relevant studies from inception to September 2015. Longitudinal studies with at least one-year of follow-up for PJIs after total joint arthroplasty. Two investigators extracted data on study characteristics, methods, and outcomes. A consensus was reached with involvement of a third. The relative risk (RR) with 95% confidence intervals was used as the summary measure of association across studies. Study-specific RRs with 95% confidence intervals were meta-analysed using random effect models and were grouped by study-level characteristics. Sixty-six observational (23 prospective cohort and 43 retrospective cohort or case-control) studies with data on 512,508 participants were included. Comparing males to females and smokers to non-smokers, the pooled RRs for PJI were 1.36 (1.18-1.57) and 1.83 (1.24-2.70) respectively. There was no evidence of any significant associations of PJI with age and high alcohol intake. Comparing BMI ≥ 30 versus < 30 kg/m(2); ≥ 35 versus < 35 kg/m(2); and ≥ 40 versus < 40 kg/m(2); the pooled RRs were 1.60 (1.29-1.99); 1.53 (1.22-1.92); and 3.68 (2.25-6.01) respectively. Histories of diabetes, rheumatoid arthritis, depression, steroid use, and previous joint surgery were also associated with increased risk of PJI. The results remained similar when grouped by relevant study level characteristics. Several potentially modifiable patient-related factors are associated with the risk of developing PJIs. Identifying patients with these risk factors who are due to have arthroplasty surgery and modulating these risk factors might be essential in reducing the incidence of PJI. Further research is however warranted to assess the potential clinical utility of these risk factors as risk assessment tools for PJI. PROSPERO 2015: CRD42015023485.

Periprosthetic joint infection (PJI) is a serious complication of total knee arthroplasty. Two-stage revision is the most widely used technique and considered as the most effective for treating periprosthetic knee infection. The one-stage revision strategy is an emerging alternative option, however, its performance in comparison to the two-stage strategy is unclear. We therefore sought to ask if there was a difference in re-infection rates and other clinical outcomes when comparing the one-stage to the two-stage revision strategy. Our first objective was to compare re-infection (new and recurrent infections) rates for one- and two-stage revision surgery for periprosthetic knee infection. Our second objective was to compare between the two revision strategies, clinical outcomes as measured by postoperative Knee Society Knee score, Knee Society Function score, Hospital for Special Surgery knee score, WOMAC score, and range of motion. Systematic review and meta-analysis. MEDLINE, EMBASE, Web of Science, Cochrane Library, reference lists of relevant studies to August 2015, and correspondence with investigators. Longitudinal (prospective or retrospective cohort) studies conducted in generally unselected patients with periprosthetic knee infection treated exclusively by one- or two-stage revision and with re-infection outcomes reported within two years of revision surgery. No clinical trials comparing both revision strategies were identified. Two independent investigators extracted data and discrepancies were resolved by consensus with a third investigator. Re-infection rates from 10 one-stage studies (423 participants) and 108 two-stage studies (5,129 participants) were meta-analysed using random-effect models after arcsine transformation. The rate (95% confidence intervals) of re-infection was 7.6% (3.4-13.1) in one-stage studies. The corresponding re-infection rate for two-stage revision was 8.8% (7.2-10.6). In subgroup analyses, re-infection rates remained generally similar for several study-level and clinically relevant characteristics. Postoperative clinical outcomes of knee scores and range of motion were similar for both revision strategies. Potential bias owing to the limited number of one-stage revision studies and inability to explore heterogeneity in greater detail. Available evidence from aggregate published data suggest the one-stage revision strategy may be as effective as the two-stage revision strategy in treating infected knee prostheses in generally unselected patients. Further investigation is warranted. PROSPERO 2015: CRD42015017327.

The two-stage revision strategy has been claimed as being the \"gold standard\" for treating prosthetic joint infection. The one-stage revision strategy remains an attractive alternative option; however, its effectiveness in comparison to the two-stage strategy remains uncertain. To compare the effectiveness of one- and two-stage revision strategies in treating prosthetic hip infection, using re-infection as an outcome. Systematic review and meta-analysis. MEDLINE, EMBASE, Web of Science, Cochrane Library, manual search of bibliographies to March 2015, and email contact with investigators. Cohort studies (prospective or retrospective) conducted in generally unselected patients with prosthetic hip infection treated exclusively by one- or two-stage revision and with re-infection outcomes reported within two years of revision. No clinical trials were identified. Data were extracted by two independent investigators and a consensus was reached with involvement of a third. Rates of re-infection from 38 one-stage studies (2,536 participants) and 60 two-stage studies (3,288 participants) were aggregated using random-effect models after arcsine transformation, and were grouped by study and population level characteristics. In one-stage studies, the rate (95% confidence intervals) of re-infection was 8.2% (6.0-10.8). The corresponding re-infection rate after two-stage revision was 7.9% (6.2-9.7). Re-infection rates remained generally similar when grouped by several study and population level characteristics. There was no strong evidence of publication bias among contributing studies. Evidence from aggregate published data suggest similar re-infection rates after one- or two-stage revision among unselected patients. More detailed analyses under a broader range of circumstances and exploration of other sources of heterogeneity will require collaborative pooling of individual participant data. PROSPERO 2015: CRD42015016559.

Implant revision is an operation with exchange of implants, and is used as a standard outcome after total hip replacement (THR), but may not fully represent the patient experience after a THR. Major reoperation (hereafter referred to as 'reoperation') without revision of implants can also lead to increased patient morbidity and mortality, and most commonly occurs when the femur fractures around an implant (postoperative periprosthetic femoral fractures; POPFF) and is treated with fixation and the implant is left in place. Reliance on revision metrics that do not capture these reoperations has led to large-scale underreporting of reoperations in THR, and is likely to have affected implant performance estimates, which have guided national policy and implant selection. It is important to include these additional reoperations when estimating treatment success to guide innovation and clinical practice. We aimed to estimate the incidence of reoperation following primary THR. We performed a large national cohort study on a mandatory, prospective database, the National Joint Registry, linked to Hospital Episode Statistics. All linkable primary THRs using recently available implants, with highest safety ratings between 01/01/2010 and 31/12/2020, were included. Major reoperation was defined as the first revision for any cause or fixation of POPFF and was identified using a combination of procedural and diagnosis codes. We identified 372,967 THRs representing 2,127,464 prostheses years at risk with a median follow-up time of 5.39 years (range 0 to 12.1 years). A total of 8,043 reoperations were identified that had been surgically treated by revision for any cause or fixation of POPFF. The incidence of reoperation was 3.78% (95% confidence interval [CI 3.70%, 3.86%]) per 1,000 prostheses years in comparison to 3.00% (95% CI [2.93%, 3.07%]) per 1,000 prostheses years when using conventional revision only outcomes. Cumulative incidence of major reoperation at 10 years was 3.1% (95% CI [3.0%, 3.1%]). Cumulative reoperation estimates were stratified by age and sex. In men aged 68 years and older, collared cementless stems performed better than cemented stems and in women aged 75 years and older, the relationship was reversed. Residual differences in patient characteristics may affect the accuracy of the estimates. Treatment failure after THR has been underrepresented by revision-only estimates. Major reoperation rates in older men were lowest with cementless collared stems, and in older women, reoperation rates were lowest with cemented polished taper stems made of stainless steel. These results prompt a review of the current implant guidance for hip replacements in older patients. III (Retrospective cohort study).

Total knee replacements (TKRs) are performed by surgeons at different stages in training with varying levels of supervision, but we do not know if this is a safe practice or whether trainees achieve equivalent outcomes to consultant-performed TKR. This study aimed to investigate the association between surgeon grade, the supervision of trainees, and the risk of revision following TKR. Revision is defined by the National Joint Registry (NJR) for England and Wales as any procedure to add, remove, or modify one or more components of an implant construct for any reason. We conducted an observational study using prospectively collected data from the NJR. We included 953,081 cases in 788,288 adult patients who underwent primary TKR for osteoarthritis (OA), recorded in the NJR between 2003 and 2019. Exposures were surgeon grade (consultant or trainee) and the level of scrubbed consultant supervision of trainees. The primary outcome was all-cause revision, and the secondary outcome was the number of procedures revised for the following indications: aseptic loosening/lysis, infection, progression of OA, unexplained pain, and instability. Flexible parametric survival models (FPM) were incrementally adjusted in the following manner. Model 1 was unadjusted. Model 2 was adjusted for patient-level factors (age, sex, American Society of Anaesthesiologists [ASA] grade, and index of multiple deprivation [IMD] decile). Model 3 was further adjusted for operation-level factors (anaesthetic, approach, fixation, constraint and whether or not the patella was resurfaced). Model 4 was further adjusted for healthcare setting factors (funding source, and year of operation). Trainees performed 96,544 (10.1%) TKRs and were directly supervised by a scrubbed consultant in 63.2% of trainee-performed cases. Trainees achieved comparable outcomes to consultants in terms of the unadjusted cumulative probability of all-cause revision (e.g., 15 years of follow-up: consultant % Failure 4.79 (95% CI [4.67, 4.92]) versus trainee (overall) % Failure 4.75 (95% CI [4.43, 5.10]). Adjusted FPM analysis indicated evidence of an association between trainee-performed TKR and a small increased risk of early all-cause revision up to, but not exceeding, 4 years follow-up (1 year: HR 1.12 (95% CI [1.05, 1.19]), 4 years: HR 1.00 (95% CI [0.95, 1.06]), 16 years: HR 0.89 (95% CI [0.81, 0.98])). This association was not explained by the level of supervision. Further analysis suggested that this association may be attributable to revisions for aseptic loosening/lysis, infection, and progression of OA (i.e., subsequent patellar resurfacing). Limitations of this study relate to its observational design and include: the potential for non-random allocation of cases by consultants to trainees; residual confounding; and the use of the binary variable 'surgeon grade', which does not capture variations in the level of experience between trainees. Trainees in England and Wales achieve safe and acceptable all-cause TKR implant survival, with comparable outcomes to consultants. However, adjusted analyses suggest an association between trainee-performed TKR and a small increase in the risk of early all-cause revision. This association may be attributable to factors including aseptic loosening, infection, and progression of OA. Current training practices for TKR in England and Wales are safe in terms of equivalence of all-cause implant survival to consultant-performed TKR, but we have identified areas for potential improvement in trainee outcomes.

While the United Kingdom National Health Service aimed to reduce social inequalities in the provision of joint replacement, it is unclear whether these gaps have reduced. We describe secular trends in the provision of primary hip and knee replacement surgery between social deprivation groups. We used the National Joint Registry to identify all hip and knee replacements performed for osteoarthritis from 2007 to 2017 in England. The Index of Multiple Deprivation (IMD) 2015 was used to identify the relative level of deprivation of the patient living area. Multilevel negative binomial regression models were used to model the differences in rates of joint replacement. Choropleth maps of hip and knee replacement provision were produced to identify the geographical variation in provision by Clinical Commissioning Groups (CCGs). A total of 675,342 primary hip and 834,146 primary knee replacements were studied. The mean age was 70 years old (standard deviation: 9) with 60% and 56% of women undergoing hip and knee replacements, respectively. The overall rate of hip replacement increased from 27 to 36 per 10,000 person-years and knee replacement from 33 to 46. Inequalities of provision between the most (reference) and least affluent areas have remained constant for both joints (hip: rate ratio (RR) = 0.58, 95% confidence interval [0.56, 0.60] in 2007, RR = 0.59 [0.58, 0.61] in 2017; knee: RR = 0.82 [0.80, 0.85] in 2007, RR = 0.81 [0.80, 0.83] in 2017). For hip replacement, CCGs with the highest concentration of deprived areas had lower overall provision rates, and CCGs with very few deprived areas had higher provision rates. There was no clear pattern of provision inequalities between CCGs and deprivation concentration for knee replacement. Study limitations include the lack of publicly available information to explore these inequalities beyond age, sex, and geographical area. Information on clinical need for surgery or patient willingness to access care were unavailable. In this study, we found that there were inequalities, which remained constant over time, especially in the provision of hip replacement, by degree of social deprivation. Providers of healthcare need to take action to reduce this unwarranted variation in provision of surgery.

Deep prosthetic hip infection is a devastating complication of hip replacement surgery, and treatment often involves multiple revision surgeries with antibiotic chemotherapy to control the infection. The aim of this study was to explore patients' experiences of early and longer-term recovery after one-stage or two-stage revision with an excised hip, a temporary cement spacer or a custom-made articulating spacer. We interviewed 32 participants taking part in a surgical trial at two time points (2-4 months and 18 months) following one- or two-stage revision surgery. The analytic approach was inductive using the constant comparative method to generate themes from the data. Participants' early recovery after revision was characterised by a long hospital stay with burdensome antibiotics and limited physiotherapy provision. Participants undergoing two-stage revision with an excised hip or a cement spacer described severe mobility restrictions which affected all aspects of their lives, while those undergoing one-stage revision, or two-stage revision with an articulating spacer were more mobile and independent, with some limitations. Participants with a cement spacer also reported more pain than other treatment groups, while those with an articulating spacer appeared to perceive that their recovery was slow. At 18 months, participants in all groups described both improvements and losses in mobility and functional ability. Participants in all treatment groups expressed considerable emotional resilience during recovery from revision, which may be linked to opportunities to talk with the trial personnel. Participants identified the need for better information and psychological and physical support. Experience of recovery differs after one- and two-stage revision, and further in relation to the use of spacers. Mobility, function, independence and pain are important aspects of recovery which affect all aspects of day-to-day life. Increased information and more opportunities to talk and share experiences may provide psychological support during recovery.

The risk of mortality following elective total hip (THR) and knee replacements (KR) may be influenced by patients' pre-existing comorbidities. There are a variety of scores derived from individual comorbidities that can be used in an attempt to quantify this. The aims of this study were to a) identify which comorbidity score best predicts risk of mortality within 90 days or b) determine which comorbidity score best predicts risk of mortality at other relevant timepoints (30, 45, 120 and 365 days). We linked data from the National Joint Registry (NJR) on primary elective hip and knee replacements performed between 2011-2015 with pre-existing conditions recorded in the Hospital Episodes Statistics. We derived comorbidity scores (Charlson Comorbidity Index-CCI, Elixhauser, Hospital Frailty Risk Score-HFRS). We used binary logistic regression models of all-cause mortality within 90-days and within 30, 45, 120 and 365-days of the primary operation using, adjusted for age and gender. We compared the performance of these models in predicting all-cause mortality using the area under the Receiver-operator characteristics curve (AUROC) and the Index of Prediction Accuracy (IPA). We included 276,594 elective primary THRs and 338,287 elective primary KRs for any indication. Mortality within 90-days was 0.34% (N = 939) after THR and 0.26% (N = 865) after KR. The AUROC for the CCI and Elixhauser scores in models of mortality ranged from 0.78-0.81 after THR and KR, which slightly outperformed models with ASA grade (AUROC = 0.77-0.78). HFRS performed similarly to ASA grade (AUROC = 0.76-0.78). The inclusion of comorbidities prior to the primary operation offers no improvement beyond models with comorbidities at the time of the primary. The discriminative ability of all prediction models was best for mortality within 30 days and worst for mortality within 365 days. Comorbidity scores add little improvement beyond simpler models with age, gender and ASA grade for predicting mortality within one year after elective hip or knee replacement. The additional patient-specific information required to construct comorbidity scores must be balanced against their prediction gain when considering their utility.

The risk of re-operation, otherwise known as revision, following primary hip replacement depends in part on the prosthesis implant materials used. Current performance evidences are based on a broad categorisation grouping together different materials with potentially varying revision risks. We investigated the revision rate of primary total hip replacement (THR) reported in the National Joint Registry by specific types of bearing surfaces used. We analysed THR procedures across all orthopaedic units in England and Wales. All patients who received a primary THR between 2003 and 2019 in the public and private sectors were included. We investigated the all-cause and indication-specific risks of revision using flexible parametric survival analyses to estimate adjusted hazard ratios (HRs). We identified primary THRs with heads and monobloc cups or modular acetabular component THRs with head and shell/liner combinations. A total of 1,026,481 primary THRs were analysed (Monobloc: n = 378,979 and Modular: n = 647,502) with 20,869 (2%) of these primary THRs subsequently undergoing a revision episode (Monobloc: n = 7,381 and Modular: n = 13,488). For monobloc implants, compared to implants with a cobalt chrome head and highly crosslinked polyethylene (HCLPE) cup, the all-cause risk of revision for monobloc acetabular implant was higher for patients with cobalt chrome (hazard rate at 10 years after surgery: 1.28 95% confidence intervals [1.10, 1.48]) or stainless steel head (1.18 [1.02, 1.36]) and non-HCLPE cup. The risk of revision was lower for patients with a delta ceramic head and HCLPE cup implant, at any postoperative period (1.18 [1.02, 1.36]). For modular implants, compared to patients with a cobalt chrome head and HCLPE liner primary THR, the all-cause risk of revision for modular acetabular implant varied non-constantly. THRs with a delta ceramic (0.79 [0.73, 0.85]) or oxidised zirconium (0.65 [0.55, 0.77]) head and HCLPE liner had a lower risk of revision throughout the entire postoperative period. Similar results were found when investigating the indication-specific risks of revision for both the monobloc and modular acetabular implants. While this large, nonselective analysis is the first to adjust for numerous characteristics collected in the registry, residual confounding cannot be rule out. Prosthesis revision is influenced by the prosthesis materials used in the primary procedure with the lowest risk for implants with delta ceramic or oxidised zirconium head and an HCLPE liner/cup. Further work is required to determine the association of implant bearing materials with the risk of rehospitalisation, re-operation other than revision, mortality, and the cost-effectiveness of these materials.

Reducing health inequalities is of national importance. Total hip replacement (THR) is a commonly used elective surgical procedure. Few studies have examined area-level inequalities for a wide range of outcomes following THR. The aim of this study is to compare area-level socioeconomic differences in outcomes following primary THR surgery for osteoarthritis in England. This is a population-based prospective cohort study of the National Joint Registry (NJR). Data from the NJR were linked to national mortality, Hospital Episode Statistics and Patient Reported Outcome Measures (PROMs) databases for England from 2007 to 2017 with follow-up to 2023 for outcomes, for patients aged 50 years and over with osteoarthritis. Outcomes of 90-day mortality; 5-year revision rate; 6-month health complications; 1-year rehospitalisation and reoperation for orthopaedic indications; and patient-reported Oxford Hip Score (OHS), post-THR surgery were examined by area-level Index of Multiple Deprivation quintiles. Modified Poisson regression was adjusted for patient age, sex, body mass index, pre-operative physical state and comorbidity. Among 448,184 patients with primary THR, mean age was 70 years (standard deviation: 9 years) and 61% were women. Patients from the most deprived group were more likely to die within 90 days of the operation compared to the least deprived group (adjusted rate ratio, RR: 1.25 (95% confidence interval (CI) [1.07, 1.46]); adjusted risk difference, RD: 9 (95% CI [2, 16]) per 10,000. Similarly, those from the most deprived group were more likely to experience complications (RR: 1.26 (95% CI [1.21, 1.32]); RD: 1.14% (95% CI [0.92, 1.36])); be rehospitalised (RR: 1.16 (95% CI [1.14, 1.19]; RD: 2.78% (95% CI [2.39, 3.17])) or reoperated (RR: 1.23 (95% CI [1.13, 1.33]); RD: 0.31% (95% CI [0.19, 0.44])) and report poorer OHS (adjusted score: -2.97 (95% CI [-3.10, -2.84]) N = 200,522). There was no variation by deprivation level for THR revision rates at 5 years (RR: 1.02 (95% CI [0.94, 1.10]); RD: 0.02% (95% CI [-0.10, 0.15])). The main study limitations are the lack of complete PROMs data, and the exclusion of self-funded patients or those with private insurance for THR procedures in independent hospitals. Inequalities in several outcomes after THR are present in England by area-level deprivation. These findings are useful to inform shared decision-making for patients deciding whether to undergo hip replacement and to benchmark the effectiveness of policies which aim to reduce health inequalities following THR.