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Arthroplasty registries have played a key role in the treatment of patients with various joint diseases and conditions since their conception. Swedish hip and knee arthroplasty registries were initiated in late 1970's. The main aim of... more
Arthroplasty registries have played a key role in the treatment of patients with various joint diseases and conditions since their conception. Swedish hip and knee arthroplasty registries were initiated in late 1970's. The main aim of registries was to create feedback to surgeons. During the last two decades with introduction of patient reported outcomes, data from registries have been increasingly used to compare caregivers and to improve quality of health care. According to the Swedish Hip Arthroplasty Register (SHAR) Sahlgrenska University Hospital had been underperforming during years 2006–2012. In order to improve the outcomes a systematic data driven approach using local and national registries, based on value based management was undertaken. Representatives from all categories of healthcare staff and patients were invited to join a newly initiated group. The group was asked to define which measurement that contributed most to improve healthcare. Data from SHAR and local registries were used and sev...
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Introduction: Many patients eligible for hip arthroplasty suffer from bilateral hip disease with indication for bilateral total hip replacement (BTHR). Traditionally two-stage BTHR is far more common than one-stage procedure due to the... more
Introduction: Many patients eligible for hip arthroplasty suffer from bilateral hip disease with indication for bilateral total hip replacement (BTHR). Traditionally two-stage BTHR is far more common than one-stage procedure due to the risk of complications. However, most studies are in favour of one-stage BTHR in the healthy and young people. This study was designed to further analyse mortality, outcome, complications and cost-effectiveness after one-stage BTHR surgery. Patients and Methods: In this prospective matched control study we examined 32 patients with BTHR hybrid surgery. The control group of 32 patients with unilateral hybrid THR was derived from Sahlgrenska University hospital. The follow up time was 1 year. Medical records, cost per patient database, records from Swedish Social Insurance Administration and HRQoL outcome measurements from the Swedish Hip Arthroplasty Register were used for the analyses. Mortality data from the Register regarding all 950 patients with one-stage BTHR surgery during the period 1992 until 2005 were compared to those 2577 who had had a twostage procedure with less than six months between the operations. Preliminary Results: There were no major differences in complications. The intraoperative bleeding was higher in the BTHR patients and they required more blood transfusion. Length of hospital stay was in average 10,2 days for the one-stage BTHR group and 7,6 days for the unilateral group. Preoperative EQ-5D index was 0,14 in the BTHR group and 0,31 in the control group. Mean EQ-5D gain after 1 year was 0,77 and 0,40 respectively. Hospital costs were only 60% higher in the one-stage BTHR group. Among the employed patients there were no differences in days of sick pay and cost of sick pay in the two groups. Among the 950 subjects with one-stage BTHR surgery, the 90 day mortality was 0,32% compared to 0,42% in the group of 2577 patients with two-stage procedure. Discussion: In healthy patients with bilateral hip disease requiring bilateral arthroplasty one-stage BTHR is highly cost-effective and safe. There is even lower 90 day mortality for the onestage operated subjects in the register but this is probably due to a natural selection of younger and healthier patients. The one-stage procedure reduces the total time of rehabilitation which is of particular importance for people in working age. Cautiously estimated, performing another 100 one-stage BTHR per year instead of two-stage procedure would save 16–20 million SEK yearly in Sweden.
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Infection after total hip arthroplasty (THA) is a devastating complication. With an ageing population and increased demands for THA, prosthetic joint infection (PJI) is expected to become an even greater problem in the future. In late PJI... more
Infection after total hip arthroplasty (THA) is a devastating complication. With an ageing population and increased demands for THA, prosthetic joint infection (PJI) is expected to become an even greater problem in the future. In late PJI a one- or two-stage revision procedure is most often used. Factors determining the outcomes are not fully understood and there is controversy in the choice between the two methods. The, two-stage method in infected THA is regarded as more resource demanding and is associated with a high distress in the patients. The aim of this study was to compare the risk for second revision (re-revision) between one- and two-stage revision. During 1979–2015, 1659 first-time revisions performed due to infection were reported to the Swedish Hip Arthroplasty Register. Two-stage revision was the most common procedure (n=1255). Risk for a re-revision was compared between one- and two-stage revision using Cox-regression analysis adjusted for age, sex, diagnosis and method of fixation. The primary end-point was a re-revision regardless of cause. Aseptic loosening, infection, and dislocation necessitating re-revision were used as secondary outcomes. There was no difference in risk of re-revision regardless of cause (HR (one-stage/two-stage)=0.9, 95% C.I.=0.7–1.1, p=0.3), re-revision due to aseptic loosening (HR=1.1, 95% C.I.=0.7–1.6, p=0.7) or re-revision due to infection (HR=0.7, 95% C.I.=0.5–1.1, p=0.2). Dislocation necessitating a re-revision was less common in the one-stage group (HR=0.4, 95% C.I.=0.2–0.9, p=0.03). In this analysis re-revision rates were similar in the two groups. When analysed specifically for infection, risk of re-revision did not differ between one and two stage revision. Our findings confirm recent systematic reviews on the matter. This observational study supports increased utilisation of the one-stage approach. However prospective randomized studies are needed to validate these findings.
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Research Interests: Biomedical Engineering, Immunology, Science Policy, Influence, Space Science, and 13 moreMedicine, Hip replacement, Physical Therapy, Orthopaedics, Patient education, Psychological Intervention, Patient Satisfaction, Arthroplasty, Clinical Sciences, Visual Analogue Scale, Ci, Observational Study, and Thr
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Vitamin E-diffused highly cross-linked polyethylene (VEPE) was developed to reduce oxidation without compromising mechanical strength. The purpose of this study was to evaluate VEPE in vivo using radiostereometric analysis (RSA) and... more
Vitamin E-diffused highly cross-linked polyethylene (VEPE) was developed to reduce oxidation without compromising mechanical strength. The purpose of this study was to evaluate VEPE in vivo using radiostereometric analysis (RSA) and patient-reported outcome measures (PROMs). Fifty-one hips were enrolled. Each patient received a VEPE liner, a porous titanium shell, and an uncemented stem with a 32-mm cobalt-chrome femoral head. Tantalum beads were inserted into the VEPE to measure femoral head penetration using RSA. RSA radiographs and PROMs were obtained preoperatively immediately after surgery, 6 months, 1, 2, 3, and 5 years after surgery. Forty-seven hips returned at 3 years, and 42 hip at 5 years. The mean ± standard error of the mean proximal head penetration into the polyethylene was 0.06 ± 0.01 at 5 years. The amount of head penetration did not change significantly with increasing time in vivo. The mean ± standard error of the mean Harris Hip Score was 58 ± 2 preoperatively, which improved significantly to 93 ± 2 at 5 years (P < .001). The head penetration into VEPE liners was low compared with non-VEPE at 5 years. After settling of the liners in the early period, no significant head penetration occurred from 2- to 5-year follow-up. All PROMs improved significantly from preoperative to postoperative and remained very favorable at 5 years. This study documents the longest-term evaluation of in vivo wear performance of VEPE.
Research Interests: Biomedical Engineering, Medicine, Osteoarthritis, Prospective studies, Humans, and 15 moreFemale, Journal Article, Male, Polyethylene, Arthroplasty, Clinical Sciences, Aged, Middle Aged, Oxygen, Adult, prosthesis Design, Self report, Severity of Illness Index, femoral head, and Radiostereometric Analysis
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Background:Overweight status and obesity represent a global epidemic, with serious consequences at the individual and community levels. The number of total hip arthroplasties (THAs) among overweight and obese patients is expected to rise.... more
Background:Overweight status and obesity represent a global epidemic, with serious consequences at the individual and community levels. The number of total hip arthroplasties (THAs) among overweight and obese patients is expected to rise. Increasing body mass index (BMI) has been associated with a higher risk of mortality and reoperation and lower implant survival. The evaluation of perioperative health-related quality of life (HRQoL) has recently gained importance because of its direct relation to, and impact on, patients’ physical, mental, and social well-being as well as health-service utilization. We sought to evaluate the influence of BMI class on HRQoL preoperatively and at 1 year following THA in a register-based cohort study.Methods:This observational cohort study was designed and conducted on the basis of registry data derived from the Swedish Hip Arthroplasty Register (SHAR) and included 64,055 primary THAs registered between January 1, 2008, and December 31, 2015. Patients’ baseline preoperative and 1-year postoperative EuroQol-5 Dimension-3 Level (EQ-5D-3L) responses were documented by the treating department and reported to the SHAR through the patient-reported outcome measures program. The EQ-5D-3L includes a visual analogue scale (EQ VAS), which measures the patient’s overall health status.Results:At 1 year of follow-up, all BMI classes showed significant and clinically relevant improvements in all HRQoL measures compared with preoperative assessment (p < 0.05). Patients reported improved perception of current overall health status for the EQ VAS. Underweight, overweight, and all obesity classes showed increasingly worse 1-year HRQoL compared with normal weight, both with unadjusted and adjusted calculations.Conclusions:In this study, we found that all BMI classes had significant improvement in HRQoL at 1 year following THA. Patients who were underweight, overweight, or obese (classes I to III), compared with those of normal weight, reported worse hip pain and EQ-5D-3L and EQ VAS responses prior to THA and at 1 year postoperatively. These results can assist both health-care providers and patients in establishing reasonable expectations about THA outcomes.Level of Evidence:PrognosticLevel III. See Instructions for Authors for a complete description of levels of evidence.
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Rationale, aims and objective: Patient-reported outcomes measures (PROMs) can facilitate objective comparisons of alternative treatments and can aid clinicians, researchers, decision-makers and members of the general public in gauging... more
Rationale, aims and objective: Patient-reported outcomes measures (PROMs) can facilitate objective comparisons of alternative treatments and can aid clinicians, researchers, decision-makers and members of the general public in gauging different healthcare providers’ performance. However, this assumes an easy to use and understand summary measure. Methods: Using PROMs (EQ-5D index, EQ VAS and VAS Pain) from 1799 patients in 7 Swedish hospitals with at least 200 hip arthroplasty surgeries in 2009, we illustrated the possibility of summarizing pre- and post-treatment PROM values with the help of a simple index. This index expressed the attained improvement as a percentage of the total possible improvement. Change score, Cohen’s effect size and Standardized Response Means served as alternative measures. Results: The Improvement Ratio index proved capable of offering a vivid and easy to understand summary of healthcare providers’ performance. The alternative measures indicated similar patterns as the Improvement Index. The routines of statistical inference made possible null-hypothesis testing of the improvement in different groups or testing for trends. Conclusions: This simple improvement index gives an easy to understand summary measure that appeals not only to researchers, but also to laymen for consulting healthcare provider comparisons or countrywide white papers. We recommend using the Improvement Ratio index to summarize the PROMs outcome of elective surgeries.
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Background and purpose: The incidence of periprosthetic joint infection after total hip arthroplasty (THA) may be increasing. We performed time-trend analyses of risk, rates, and timing of revision due to infection after primary THAs in... more
Background and purpose: The incidence of periprosthetic joint infection after total hip arthroplasty (THA) may be increasing. We performed time-trend analyses of risk, rates, and timing of revision due to infection after primary THAs in the Nordic countries from the period 2004–2018.Patients and methods: 569,463 primary THAs reported to the Nordic Arthroplasty Register Association from 2004 to 2018 were studied. Absolute risk estimates were calculated by Kaplan–Meier and cumulative incidence function methods, whereas adjusted hazard ratios (aHR) were assessed by Cox regression with the first revision due to infection after primary THA as primary endpoint. In addition, we explored changes in the time span from primary THA to revision due to infection.Results: 5,653 (1.0%) primary THAs were revised due to infection during a median follow-up time of 5.4 (IQR 2.5–8.9) years after surgery. Compared with the period 2004–2008, the aHRs for revision were 1.4 (95% confidence interval [CI] 1....
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During the last decade primary total hip arthroplasty surgery (THA) has increased with 30% in Sweden. Current law guarantees the patient a right to treatment within 90 days. The public health system has had difficulties meeting the... more
During the last decade primary total hip arthroplasty surgery (THA) has increased with 30% in Sweden. Current law guarantees the patient a right to treatment within 90 days. The public health system has had difficulties meeting the increasing demand. Therefore, in 2012 a systematic review of the patients planned for THA was initiated at Sahlgrenska University Hospital9s joint replacement unit. In late 2013 the value-based health care (VBHC) management was introduced in our unit. In 2012 a systematic approach based on the Fast-Track concept was implemented in the joint replacement unit. In 2013 a workgroup consisting of health care professionals involved in the treatment of THA patients was created to improve chosen outcome parameters. During 2011–2016 the number of elective THA has increased from 317 to 486. The cost per patient has decreased from 75,000 SEK to 65,000 SEK. Length of stay has decreased from 5.9 days to 2.5 days. Satisfaction with outcome of surgery one year after THA...
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Introduction Dislocation as a primary cause of revision has been on the increase in Sweden (14% in 2014). The increasing use of Dual Mobility cups (DMC) could well be explained by the increased revision burden due to dislocation, patients... more
Introduction Dislocation as a primary cause of revision has been on the increase in Sweden (14% in 2014). The increasing use of Dual Mobility cups (DMC) could well be explained by the increased revision burden due to dislocation, patients undergoing revision having increased comorbidities and reports that dual articular cup designs reduce the risk of dislocation. The aim of this study was to analyze the change in utilization pattern of the dual articular designs used in acetabular revision surgery in Sweden. The short-term survival of DMC was compared to traditional designs. Patients/Materials & Methods During years 2004–2014, 1111 (925 cemented) revisions performed with a DMC design were reported to SHAR. About half (n=426) of these cases were first time revisions performed due to dislocation. During the same time period 520 dislocations were revised for dislocation using a standard cemented cup. There was no differences regarding the age, gender and primary diagnosis (p≥0.12) betw...
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The risk of dying following total hip replacement (THR) is low and has declined over the last decades. The influence of comorbidities and worse physical status on mortality leads to the idea that patient-reported health status may also be... more
The risk of dying following total hip replacement (THR) is low and has declined over the last decades. The influence of comorbidities and worse physical status on mortality leads to the idea that patient-reported health status may also be a predictor of mortality. Although this has not been demonstrated in THR surgery, some studies in other fields have reported an association. The aim of this study was to investigate the relationship between patient-reported health status before THR and the risk of dying up to 5 years post-operatively. The Swedish Hip Arthroplasty Register runs a nationwide PROMs program including the EQ-5D questionnaire to routinely monitor patients undergoing THR in Sweden. For these analyses, we used register data on 42,862 patients with hip osteoarthritis operated with THR between 2008 and 2012. Relative survival ratio was calculated by dividing the observed survival in the patient group by age- and gender-adjusted expected survival of the general population. Mu...
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Aims To develop and externally validate a parsimonious statistical prediction model of 90-day mortality after elective total hip arthroplasty (THA), and to provide a web calculator for clinical usage. Methods We included 53,099 patients... more
Aims To develop and externally validate a parsimonious statistical prediction model of 90-day mortality after elective total hip arthroplasty (THA), and to provide a web calculator for clinical usage. Methods We included 53,099 patients with cemented THA due to osteoarthritis from the Swedish Hip Arthroplasty Registry for model derivation and internal validation, as well as 125,428 patients from England and Wales recorded in the National Joint Register for England, Wales, Northern Ireland, the Isle of Man, and the States of Guernsey (NJR) for external model validation. A model was developed using a bootstrap ranking procedure with a least absolute shrinkage and selection operator (LASSO) logistic regression model combined with piecewise linear regression. Discriminative ability was evaluated by the area under the receiver operating characteristic curve (AUC). Calibration belt plots were used to assess model calibration. Results A main effects model combining age, sex, American Socie...
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Background and purpose: The bearings with the best survivorship for young patients with total hip arthroplasty (THA) should be identified. We compared hazard ratios (HR) of revision of primary stemmed cementless THAs with metal-on-metal... more
Background and purpose: The bearings with the best survivorship for young patients with total hip arthroplasty (THA) should be identified. We compared hazard ratios (HR) of revision of primary stemmed cementless THAs with metal-on-metal (MoM), ceramic-on-ceramic (CoC), and ceramic-on-highly-crosslinked-polyethylene (CoXLP) with that of metal-on-highly-crosslinked-polyethylene (MoXLP) bearings in patients aged 20–55 years with primary osteoarthritis or childhood hip disorders.Patients and methods: From the Nordic Arthroplasty Register Association dataset we included 1,813 MoM, 3,615 CoC, 5,947 CoXLP, and 10,219 MoXLP THA in patients operated on between 2005 and 2017 in a prospective cohort study. We used the Kaplan–Meier estimator for THA survivorship and Cox regression to estimate HR of revision adjusted for confounders (including 95% confidence intervals [CI]). MoXLP was used as reference. HRs were calculated during 3 intervals (0–2, 2–7, and 7–13 years) to meet the assumption of p...
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The EQ-5D questionnaire of EuroQol is an important tool, not only for researchers, but also for quality registers. Until 2013, Sweden did not have a country-specific value set to convert the EQ-5D health states into a single index.... more
The EQ-5D questionnaire of EuroQol is an important tool, not only for researchers, but also for quality registers. Until 2013, Sweden did not have a country-specific value set to convert the EQ-5D health states into a single index. Commonly, the UK time trade-off (UK TTO) value set has been used. The study reported here aimed to establish an easy to use tool for the bidirectional crosswalk of the mean EQ-5D values based on two different value sets: the UK TTO and the Swedish TTO value sets. Using an artificial data set encompassing all possible EQ-5D outcomes, we calculated the EQ-5D index using both the UK TTO and Swedish TTO value sets. Thereafter we modelled the relationship between the two indices using least-squares regression and major axis regression. A series of simulations was run to assess the feasibility of the obtained crosswalk algorithms. Major axis regression was superior to ordinary least-squares regression. Converting the mean EQ-5D values from the UK TTO scale to the Swedish TTO scale was more accurate than the inverse conversion. Values close to the floor and ceiling of the EQ-5D index were more challenging to crosswalk. CONCLUSIONS WE ESTABLISHED ALGORITHMS BASED ON MAJOR AXIS REGRESSION TO CROSSWALK EQ-5D VALUES BASED ON THE UK TTO AND THE SWEDISH TTO VALUE SETS THE PRESENTED ALGORITHM MAY FACILITATE COMPARISONS OF EQ-5D VALUES WHEN ONLY MEAN VALUES ARE AVAILABLE THE EXISTENCE OF A CROSSWALK ALGORITHM WILL EASE THE TRANSITION FROM THE UK TTO TO THE SWEDISH TTO VALUE SET.
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Research Interests: Biomedical Engineering, Quality of life, Adolescent, Medicine, Prospective studies, and 15 moreHumans, Female, Male, Patient Satisfaction, Data Collection, Arthroplasty, Registries, Clinical Sciences, Aged, Middle Aged, Questionnaires, Adult, Observational Study, Pain Measurement, and Internal Fixation
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Research Interests: Locomotion, Medicine, Patient reported outcome measures, Applied Economics, Physical Therapy, and 15 moreActivities of Daily Living, Population, Humans, Female, Health Care Quality, Male, Aged, Middle Aged, Public health systems and services research, Postal Service, Internet, Logistic Models, health status indicators, Outcome measure, and Quality of health care
Research Interests: Nursing, Medicine, Humans, Injury, Female, and 15 moreMale, Orthopedics, Patient Satisfaction, Cohort, Hip Fractures, Length of Stay, Clinical Sciences, Aged, Middle Aged, Adult, Public health systems and services research, Hip fracture, Medical Record, health status indicators, and Patient Outcome Assessment
All patients undergoing elective total hip replacement (THR) in Sweden are asked to complete a survey, including the EQ-5D. Thus far, EQ-5D values have been presented using the UK TTO value set based on hypothetical values. Shift to the... more
All patients undergoing elective total hip replacement (THR) in Sweden are asked to complete a survey, including the EQ-5D. Thus far, EQ-5D values have been presented using the UK TTO value set based on hypothetical values. Shift to the use of the recently introduced Swedish experience-based value set, derived from a representative Swedish population, is an appealing alternative. To investigate how accurate the Swedish experience-based VAS value set predicts observed EQ VAS values and to compare correlations between Swedish and UK value sets including two provisional value sets derived from the THR population. Pre- and one-year postoperative data from 56,062 THR patients from the Swedish Hip Arthroplasty Register were used. Agreement between the observed and the predicted EQ VAS values was assessed with correlation. Based on pre- and postoperative data, we constructed two provisional VAS value sets. Correlations between observed and calculated values using the Swedish VAS value set were moderate (r = 0.46) in preoperative data and high (r = 0.72) in postoperative data. Correlations between UK and register-based value sets were constantly lower compared to Swedish value sets. Register-based values and Swedish values were highly correlated. The Swedish value sets are more accurate in terms of representation of the Swedish THR patients than the currently used UK TTO value set. We find it feasible to use the experience-based Swedish value sets for further presentation of EQ-5D values in the Swedish THR population.
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The primary aim of the study was to identify inflammatory markers relevant for osteoarthritis (OA)-related systemic (plasma) and local (synovial fluid, SF) inflammation. From this, we looked for inflammatory markers that coincided with... more
The primary aim of the study was to identify inflammatory markers relevant for osteoarthritis (OA)-related systemic (plasma) and local (synovial fluid, SF) inflammation. From this, we looked for inflammatory markers that coincided with the increased amount of O-linked Tn antigen (GalNAcα1-Ser/Thr) glycan on SF lubricin. Inflammatory markers in plasma and SF in OA patients and controls were measured using a 44-multiplex immunoassay. We found consistently 29 markers detected in both plasma and SF. The difference in their concentration and the low correlation when comparing SF and plasma suggests an independent inflammatory environment in the two biofluids. Only plasma MCP-4 and TARC increased in our patient cohort compared to control plasma. To address the second task, we concluded that plasma markers were irrelevant for a direct connection with SF glycosylation. Hence, we correlated the SF-inflammatory marker concentrations with the level of altered glycosylation of SF-lubricin. We f...
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Background Dual-mobility cups in THA were designed to reduce prosthesis instability and the subsequent risk of revision surgery in high-risk patients, such as those with hip fractures. However, there are limited data from clinical studies... more
Background Dual-mobility cups in THA were designed to reduce prosthesis instability and the subsequent risk of revision surgery in high-risk patients, such as those with hip fractures. However, there are limited data from clinical studies reporting a revision benefit of dual-mobility over conventional THA. Collaboration between anthroplasty registries provides an opportunity to describe international practice variation and compare between-country, all-cause revision rates for dual-mobility and conventional THA. Questions/purposes We summarized observational data from multiple arthroplasty registries for patients receiving either a dual-mobility or conventional THA to ask: (1) Is dual-mobility use associated with a difference in risk of all-cause revision surgery compared with conventional THA? (2) Are there specific patient characteristics associated with dual-mobility use in the hip fracture population? (3) Has the use of dual-mobility constructs changed over time in patients recei...
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The Swedish Hip Arthroplasty Register started in 1979 and celebrates its 40th anniversary in 2019. The Swedish Hip Arthroplasty Register is not primarily a device register or research database; we strive to provide an overall assessment... more
The Swedish Hip Arthroplasty Register started in 1979 and celebrates its 40th anniversary in 2019. The Swedish Hip Arthroplasty Register is not primarily a device register or research database; we strive to provide an overall assessment of the care provided with a multidimensional approach, and to disseminate knowledge on best practices in our network of participating hospitals. Since the inception of the register, there has been a marked change in trends and outcomes. The completeness of registrations has been 97–99% for primary THA, 93–95% for revisions, and 95–98% for HA over the last 10 years. The register contains 371,125 primary THAs, 55,893 HAs, 83,233 reoperations, and 408,110 PROM responses registered in 352,585 unique patients. All outcome measures have improved over time; primary THA has 0.71% 90-day mortality, 94.3% 10-year implant survival, and 2.2% 2-year reoperation rate. At 1-year follow up, 91% of the patients report a clinically significant pain reduction, 76% repo...
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Introduction After surgery for distal femur fractures in elderly patients, weight-bearing is commonly restricted. Immediate non-restrictive weight-bearing might have beneficial effects. There are no randomized studies on the topic. The... more
Introduction After surgery for distal femur fractures in elderly patients, weight-bearing is commonly restricted. Immediate non-restrictive weight-bearing might have beneficial effects. There are no randomized studies on the topic. The purpose of this study was to compare the functional outcome between immediate full weight-bearing (FWB) as tolerated and partial weight-bearing (PWB) during the first 8 weeks following plate fixation of distal femur fractures in elderly patients. Methods Patients aged 65 years or older with distal femur fractures of AO/OTA types 33 A2, A3, B1, B2, C1, and C2 were included. Exclusion criteria were impaired cognitive function, concomitant injuries, or inability to follow the postoperative regimen. Internal fixation was achieved with an anatomical lateral distal femur plate applied as a strictly bridge-plating construct. The primary outcome measure was the function index of the short musculoskeletal functional assessment (SMFA) after 52 weeks from injury...