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• Infection after fracture fixation is a feared complication in orthopaedic surgery leading to poor bone healing and loss of function.

• Early detection is essential and interdisciplinary care is mandatory.

• Eradication of infection is only possible through combined surgical and antibiotic treatment.

• Intraoperative tissue samples must be taken and are effective for guidance of the antibiotic regimen.

• Infection after fracture fixation is different from prosthetic joint infection (PJI) and needs a specific strategy.

• In this review, we define infection after fracture fixation, and outline the clinical, radiological and laboratory signs of these infections, as well as a treatment algorithm for optimal patient care.

Cite this article: EFORT Open Rev 2019;4:468-475. DOI: 10.1302/2058-5241.4.180093

• The Nordic Arthroplasty Register Association (NARA) was established in 2007 by arthroplasty register representatives from Sweden, Norway and Denmark with the overall aim to improve the quality of research and thereby enhance the possibility for quality improvement with arthroplasty surgery. Finland joined the NARA collaboration in 2010.

• NARA minimal hip, knee and shoulder datasets were created with variables that all countries can deliver. They are dynamic datasets, currently with 25 variables for hip arthroplasty, 20 for knee arthroplasty and 20 for shoulder arthroplasty.

• NARA has published statistical guidelines for the analysis of arthroplasty register data. The association is continuously working on the improvement of statistical methods and the application of new ones.

• There are 31 published peer-reviewed papers based on the NARA databases and 20 ongoing projects in different phases. Several NARA publications have significantly affected clinical practice. For example, metal-on-metal total hip arthroplasty and resurfacing arthroplasty have been abandoned due to increased revision risk based on i.a. NARA reports. Further, the use of uncemented total hip arthroplasty in elderly patients has decreased significantly, especially in Finland, based on the NARA data.

• The NARA collaboration has been successful because the countries were able to agree on a common dataset and variable definitions. The collaboration was also successful because the group was able to initiate a number of research projects and provide answers to clinically relevant questions. A number of specific goals, set up in 2007, have been achieved and new one has emerged in the process.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180058

• In the Dutch Arthroplasty Register (LROI), the product and batch number of prosthetic components and cement are registered for traceability. Registration of the product number provides opportunities to extend the information about a specific prosthesis. All product numbers used from the beginning of the registration in 2007 were characterized to develop and maintain an implant library.

• The Scientific Advisory Board developed a core-set that contains the most important characteristics needed to form an implant library. The final core-set contains the brand name, type, coating and material of the prosthesis. In total, 35 676 product numbers were classified, resulting in a complete implant library of all product numbers used in the LROI.

• To improve quality of the data and increase convenience of registration, the LROI implemented barcode scanning for data entry into the database. In 2017, 82% of prosthetic components and cement stickers had a GS1 barcode. The remaining product stickers used HIBCC barcodes and custom-made barcodes.

• With this implant library, implants can be grouped for analyses at group level, e.g. evaluation of the effect of a material of a prosthesis on survival of the implant. Apart from that, the implant library can be used for data quality control within the LROI database.

• The implant library reduces the registration burden and increases accuracy of the database. Such a system will facilitate new designs (learning from the past) and thus improve implant quality and ultimately patient safety.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180063

• This article offers a German perspective on orthopaedic management of geriatric populations in higher-income countries.

• Specific orthopaedic procedures necessitate a more intensive level of care in older adult patients, especially with co-morbidities, than in younger patients.

• During the pre-, peri- and post-operative periods, several aspects such as patient blood management principles improve the outcomes of geriatric patients.

• New interdisciplinary geriatric models of care including geriatric and orthopaedic specialties have to be established to take care of the special needs of geriatric patients.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180087

• Total hip arthroplasty (THA) registers are established in several countries to collect data aiming to improve the results after THA. Monitoring of adverse outcomes after THA has focused mainly on revision surgery, but patient-reported outcomes have also been investigated.

• Several surgery-related factors influencing the survival of the THA have been thoroughly investigated and have changed clinical practice. These factors include surgical approach, specific implants, the size of the components, type of fixation and different bone cements.

• Register data have been used to examine the risk of venous thromboembolism and bleeding after THA. These investigations have resulted in shorter duration of thromboprophylaxis and a reduced frequency of blood transfusion.

• Registers may provide specific information to surgeons on the outcome of all THAs that they have performed with a detailed analysis of revisions rates and reasons for the revisions.

• A number of other stakeholders can use register data to provide benchmarks. The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man supplies data to the Orthopaedic Device Evaluation Panel (ODEP), which provides benchmarks at 3, 5, 7, 10, and 13 years graded from A*, A, B and C.

• Future perspectives: National registers have to play a major role in documenting the quality of THA in order to describe best practice and report implant outliers. The registers have to be used for research and post-market surveillance and register data may be a source for intelligent decision tools.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180091

• The purpose of this paper is to determine the prevalence of metal-on-metal (MoM) total hip replacement (THR) in European registries, to assess the incidence of revision surgery and to describe the national follow-up guidelines for patients with MoM THR including resurfacings.

• Eleven registries of the Network of Orthopaedic Registries of Europe (NORE) participated totalling 54 434 resurfacings and 58 498 large stemmed MoM THRs.

• The resurfacings and stemmed large head MoM had higher pooled revision rates at five years than the standard total hip arthroplasties (THA): 6.0%, 95% confidence interval (CI) 5.3 to 6.8 for resurfacings; 6.9%, 95% CI 4.4 to 9.4 for stemmed large head MoM; and 3.0%, 95% CI 2.5 to 3.6 for conventional THA.

• The resurfacings and stemmed large head MoM had higher pooled revision rates at ten years than the standard THAs: 12.1%, 95% CI 11.0 to 13.3 for resurfacings; 15.5%, 95% CI 9.0 to 22 for stemmed large head MoM; and 5.1%, 95% CI 3.8 to 6.4 for conventional THA.

• Although every national registry reports slightly different protocols for follow-up, these mostly consist of annual assessments of cobalt and chromium levels in blood and MRI (MARS) imaging.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180078

• Advances in medical device technology have been dramatic in recent years resulting in both an increased number of medical devices and an increase in the invasiveness and critical function which devices perform. Two new regulations entered into force in Europe in May 2017, the Medical Device Regulation (MDR) and the In Vitro Diagnostic Device Regulation (IVDR). These regulations will replace the current directives over the coming years. These regulations, for the first time introduce requirements relating to registries.

• Medical device manufacturers are required to have systematic methods for examining their devices once available on the market, by systematically gathering, recording and analysing data on safety and performance.

• Registries can assist public health protection in very practical ways, for example, to help urgently identify patients or devices. Registries can also be powerful tools for collecting and appraising real-world clinical evidence concerning medical devices. Clinical investigations are limited in terms of the sample size and the duration of follow-up which can reasonably be expected. Registries may also be the only available tool to examine rare adverse effects, sub-populations or for time durations which it is not possible or feasible to study in a clinical investigation. By ensuring that a core dataset is collected which can be compared to other registries or trial data, it is possible to pool data to better examine outcomes. There are a range of excellent initiatives which have aimed at ensuring the appropriate regulatory application of registry data.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180061

• The Australian Orthopaedic Association National Joint Replacement Registry first began data collection on 1 September 1999 and full nationwide implementation commenced in January 2003.

• The purpose of the Registry is to improve the quality of care for individuals receiving joint replacement surgery.

• The Registry enables surgeons, academic institutions, governments and industry to request specific data that are not available in published annual reports.

• There is an established system for identifying prostheses with a higher than anticipated rate of revision (HTARR) which was introduced in 2004.

• The higher rate of revision for the ASR Hip Resurfacing System was first identified by this process in 2007.

• There has been a reduction in revision hip and knee replacement over the years that the Registry has been in operation, and the addition of Patient Reported Outcome Measures (PROMs) and data linkage will enable more extensive analysis of joint replacement surgery in the future.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180071

• National joint registries are gaining more and more importance in the fields of implant monitoring/outlier detection and quality of care.

• The German Arthroplasty Registry (EPRD) was established in 2010 for the purpose of observing the impact of primary hip and knee arthroplasty on the German population.

• Having now over one million documentations, we introduce the structure of the EPRD and detail the process of data collection.

• We report on some preliminary trends and contrast these with findings from other joint registries.

• We introduce the overhauled Arthroplasty Library, that resulted from an international collaboration with National Joint Registry of England, Wales and Northern Ireland.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180064

• The National Joint Registry (NJR) was established in 2002 as the result of an unexpectedly high failure rate of a cemented total hip replacement.

• Initial compliance with the Registry was low until data entry was mandated. Current case ascertainment is approximately 95% for primary procedures and 90% for revision procedures.

• The NJR links to other data sources to enrich the reporting processes. The NJR provides several web-based and open-access reports to the public and detailed confidential performance reports to individual surgeons, hospitals and industry bodies.

• A transparency and accountability process ensures that device and surgical performance are actively monitored on a six-monthly basis, and adverse variation is dealt with in an appropriate way that underpins patient safety.

• The NJR also manages a comprehensive research-ready database and data protection compliant access system that enables external researchers to use the dataset and perform independent analyses for patient benefit.

• Moving forwards, the NJR intends to look at factors that lead to better outcomes so that good practice can be embedded into routine care.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180084