Background:

A shoulder dislocation is defined as chronic when it has been unreduced for more than one week. Chronic anterior shoulder dislocations are commonly encountered in Kwazulu-Natal for various reasons. Different surgical options exist to treat chronic anterior shoulder dislocations. However the outcome of surgically treated chronic shoulder dislocations has not been favourable in all studies.

Introduction

Hypoplasia of the glenoid is a rare condition caused by incomplete ossification of the postero-inferior aspect of the developing glenoid. It may be isolated or associated with a more generalised condition. The clinical symptomatology is variable depending on the age at time of presentation.

Introduction

Resurfacing of the glenohumeral joint has gained popularity since its first introduction in 1958. Advantages of resurfacing over conventional shoulder arthroplasty include preservation of humeral bone stock, closer replication of individual anatomy, reduction of periprosthetic fracture risk, non-violation of medullary canal, and ease of revision to a stemmed component if needed.

Surgical management of younger patients requiring primary total hip arthroplasty remains challenging due to their activity level, physical demands and the need for longevity of implanted components. There is a debate regarding the most suitable means of component fixation in this difficult group. We undertook a retrospective review of a sequential group of patients who underwent uncemented primary total hip arthroplasty, were 55 years or younger at the time of surgery, and who were currently a minimum of 5 years post operation.

From January 2004 to December 2006 we performed 86 primary uncemented THRs in 71 young adults. The ages ranged from 18 to 55 years with a mean of 42.9 years at the time of operation. At last review, 8 patients (9 hips) had died from unrelated causes, and 16 patients (19 hips) were lost before completing 5 years of follow-up. Complications included 1 peri-operative mortality, 10 intra-operative femoral calcar fractures, 1 revision for sepsis, 1 dislocation and 1 DVT. At a minimum of 5 years post operation there were no revisions for aseptic loosening.

Uncemented primary total hip arthroplasty in patients 55 years or younger yields good results at a minimum of 5 years.

NO DISCLOSURES

Hip fracture is a common cause of hospital admission and is often followed by reduced quality of life, or by death. International experiences indicate there are many benefits to be gained from national hip fracture registries. This pilot project aims to implement a hip fracture registry at three sites, a large metropolitan public hospital (Flinders Medical Centre), a large metropolitan private hospital (Epworth HealthCare) and a rural regional hospital (Goulburn Valley Health) to assess the feasibility of establishing a national registry.

Patients undergoing surgery for a hip fracture will be recruited from the three participating hospitals between March and September 2009. A minimum data set will be collected at discharge, from hospital records. Items include patient demographics, fracture descriptors, length of stay, residential status, mobility, health status, surgical details and discharge destination. A phone interview at four months after surgery will measure outcomes by using the Extended Glasgow Outcomes Scale and documenting residential status, mobility, hip pain and readmissions. Re- operations, if any, will be collected. The availability of data from State Health Departments for validation of hospital case data will be reported.

The pilot study is in progress at the time of writing. Ethical approval has been obtained, data collection, transmission and storage systems have been developed and deployed, and case data collection is underway. Case data will be summarised to describe hip fracture at the participating hospitals. Analysis will review the data elements in the pilot data set and assess their priority for inclusion in a national register—taking account of the quality of the data obtained and the time and other resources required for their collection. We will also evaluate the four-month review process. Any potential obstacles to a national registry that are identified during the pilot will be described and ways to overcome them will be proposed.

A national hip fracture registry will improve the quality of care and safety of patients following hip fracture by developing an efficient mechanism to compare and improve the effectiveness of acute health care delivery by all hospitals involved in the management of hip fractures.

The five year results of 8187 primary total knee replacements undertaken for osteoarthritis in patients under the age of 55 years are presented. The casese were submitted to the Australian Orthopaedic Association National Joint Replacement Registry in the period 1st September 1999 to 31st December 2006. This represents 6.3% of the 130,377 primary knee replacements recorded by the registry for this period.

The five year cumulative revision rate for patients under the age of 55 years was 8.0% (95% CI: 7.2 to 8.9). We compared the results to outcomes of older patients aged over 70 years at the time of surgery. The younger patients have a significantly higher risk of revision in the first five years (hazard ratio of 2.9; 95% CI= 2.59 to 3.26; p< 0.0001). Gender, mode of fixation, the use of cruciate retention or substitution prostheses or patella resurfacing did not significantly affect the rate of revision in those patients aged 55 years or less. Survival of fixed bearing implants was significantly better than that of mobile bearings. The most common reason for revision in this group was loosening (32.3%).

Total knee replacement in patients under the age of 55 years is associated with a much higher risk of revision in the first five years. A decision to proceed with total knee replacement in this age group should be accompanied by a careful explanation of this significantly increased risk compared to knee replacement in older individuals.

There is an increased early postoperative mortality (operation risk) after joint replacement surgery. This mortality is normally associated with cardiovascular events, such as deep venous thrombosis, pulmonary embolism, and ischemic heart diseases.

Our objective was to quantify the magnitude of the increased mortality and how long the mortality after an operation persists.

We focused on the early postoperative mortality after surgery for total knee and total hip replacements from the national registries in Australia and Norway, which cover more than 95% of all operations in the two nations. Only osteoarthritis patients between 50 and 80 years of age were included. A total of 244.275 patients remained for analyses.

Smoothed intensity curves were calculated for the early postoperative period. Effects of risk factors were studied using a non-parametric proportional hazards model.

The mortality was highest immediately after the operation (~1 deaths per 10.000 patients per day), and it decreased until the 3rd postoperative week. The mortality was virtually the same for both nations and both joints. Mortality increased with age and was higher for males than for females.

A possible reduction of early postoperative mortality is plausible for the immediate postoperative period, and no longer than the 3rd postoperative week.

Introduction and Aims: Nine countries have established national joint replacement registries. The first population-based national registry, the Swedish Knee Registry, was established in 1975 with the most recent, the UK National Joint Registry (UK NJR), beginning in 2003. We identify commonalities and differences in the structure, function and methods of reporting among these national registries.

Method: Data was collected from the annual reports of the various registries, published literature and personal contact with registry coordinators and directors.

Results: Commonalities include registry ownership, source of funding, procedure types collected, method of data collection and validation of data. Most registries are owned by the national Orthopaedic Association or a government agency. The most common source of funding is government; membership fees and a mandated implant levy are also used. Most national registries collect total hip and knee replacements, primaries and revisions. Hemiarthroplasties are not commonly collected, though some registries collect additional joints (including shoulder, elbow, wrist, finger, ankle and toe). The most common method of data collection is paper-based, usually from theatre, with subsequent data entry at the registry. Electronic data collection is used to supplement the paper-based system in some countries, while the Swedish Hip Registry and the UK NJR utilise a web application for the submission of data. Most registries attempt to validate their data against hospital inpatient data held by government. Differences include reporting of rates, cost per registration and definitions. Failures of primary implants may be reported as cumulative proportions, true incidence rates or survival probabilities. This leads to difficulties in comparison of data among the national registries. The cost of registering a procedure varies up to five-fold across countries.

Conclusion: There are obvious opportunities for collaboration between national joint replacement registries, however some issues need to be addressed. These include definitions of what is collected, for example hemiarthroplasties, and methods of analysis and reporting, especially revision rates.

Introduction and Aim: Following the establishment of the Australian Orthopaedic Association National Joint Replacement Registry, the Australian orthopaedic community has quality prosthesis specific information on knee replacement. This presentation details the demographics of primary total knee replacement, types of prostheses used, methods of fixation and the incidence of, and reasons for, early revision.

Results: Over 36,000 primary total knee replacements with almost 400 subsequent revisions were recorded. Primary total knee replacements were undertaken more commonly in females (56.4%), mostly for osteoarthritis (95.9%), with a mean subject age of 69.6 years.

The Registry recorded 56 different knee prostheses with the 10 most common accounting for 85.5% of all procedures. The patella was not replaced in the majority of cases (58.5%), however this varied considerably with prosthesis type and method of fixation. Cement fixation of the tibial component occurred in 76.9% of cases and the femoral component in 49.5%. Most commonly the insert was fixed (71.3%) and minimally stabilised (86.7%). Posterior stabilised inserts were used in 12.8% of primary cases. The cumulative revision rate at one year was 1.0% and 2.1% at two years. Early revision was minor in 54.1% of cases and major in the remainder. The most common reasons for minor revision were patello-femoral pain (27.1%) and infection (21.7%); for major revision, early loosening (40.2%) and infection (27.5%). Prosthesis type, patella use, method of fixation, degree of constraint and the use of fixed, rotating and/or sliding inserts did not significantly affect revision rates at this early stage.

Conclusion: Although variation is seen in early revision rates depending on the prosthesis type, patella use, method of fixation and other prosthesis specific characteristics, these differences are currently not significant.

Introduction and Aims: The use of resurfacing hip replacements has increased dramatically in recent years. The aim of this study was to compare the early results of this treatment with conventional cemented, cementless and hybrid primary total hip replacement in Australia.

Method: The data used for this report included all conventional primary total hip and resurfacing procedures, as well as any subsequent revisions of those procedures which had been undertaken and reported to the Australian Orthopaedic Association National Joint Replacement Registry (AOA NJRR) before 31 December 2002. Analysis included the determination of demographics, components used and method of fixation. Early revision rates and reasons for failure were also assessed. The AOA NJRR commenced data collection in September 1999 and has had national coverage since 2002, therefore any results reported at this stage are early outcomes.

Results: Almost 33,000 primary total hip replacements were recorded, of these 2130 were resurfacing procedures (6.5%). This proportion of resurfacing was consistent across states with the exceptions of Victoria (11%) and Tasmania (0.6%). Cementless hip replacement was the most common form of primary total hip replacement (41%) with hybrid (34%) and cemented (18.2 %) less common. There was marked state variation in the proportion of cemented and cementless fixation with NSW having a low proportion of cement fixation (4.5%). Early revision rates for cemented conventional primary total hip replacement are significantly less compared to cementless and hybrid hips (cemented v cementless) hazard ratio (adjusted for age and sex) 2.13; 95% CI (1.49, 3.05) p< 0.0001) (cemented v hybrid) hazard ratio (adjusted for age and sex) 1.94; 95% CI (1.37, 2.77) p=0.0002). There was no difference between cementless and hybrid hips. The most common reason for early revision was dislocation and the risk of this was related to head size with larger sizes showing a reduced risk. Although revisions per 100 observed component years were higher for resurfacing hip replacements than for conventional hips (1.73 v 1.18), this difference was not statistically significant. The principal reason for early failure of resurfacing hips was fracture.

Conclusion: The AOA NJRR has identified prosthesis specific differences in early outcomes and failure mechanisms following primary total hip replacement. Continued monitoring of existing and new prostheses will provide surgeons with independent quality information to assist in the selection of the most appropriate prostheses for particular clinical situations.

Introduction and Aims: Austin Moore and Thompson hemiarthroplasties are commonly used for the management of subcapital neck of femur fractures, particularly in the frail elderly. There are no published studies that directly compare the results of these two procedures. The Australian Orthopaedic Association National Joint Replacement Registry (AOA NJRR) has reviewed outcomes for these prostheses.

Method: Data from the AOA NJRR collected from participating hospitals between September 1999 and December 2002 were used to test for differences in revision rates between these two prostheses. Mortality data from the National Death Index were used to censor the time of follow-up and to compare mortality rates following surgery. Further analyses were undertaken to examine the effects of age, gender, diagnosis and regional variation.

Results: The Registry recorded 4080 Austin Moore and 1111 Thompson hemiarthroplasties. Of these, 4023 (98.6%) Austin Moore prostheses were cementless and 1010 (90.9%) Thompsons were cemented. The distributions of age and gender were similar for the two prostheses. There were regional differences in the use of monoblock prostheses during the data collection period. In Victoria, all partial monoblock prostheses used were Austin Moore (N=1560). This contrasts to Queensland and Western Australia where 62.8% and 75.8% respectively of all partial monoblock hip replacements were Thompsons. The cementless Austin Moore prosthesis had a significantly higher rate of revision (122/4023, 3%) than the cemented Thompson prosthesis (9/1010, 0.9%). A Cox model yielded a hazard ratio, adjusted for age and gender, of 3.94 (95% CI: 2.00, 7.76; p < 0.001). None of the 57 cemented Austin Moore and four of the 101 (4%) cementless Thompsons required revision. The cumulative mortality rates for the period to 2001 were similar for the two prostheses (Austin Moore 23.3% and Thompson 24.0%). In the states where sufficient numbers of both types of prostheses were used the difference in outcomes were consistent with the overall results.

Conclusion: The use of the cementless Austin Moore prostheses is associated with an almost four-fold increase in the rate of revision when compared to the cemented Thompson prosthesis.

With increasing primary joint replacement procedures and an ageing population surviving longer, the rate of revision surgery will increase. Revision surgery, however, is associated with increased morbidity and mortality and has a far less successful outcome than primary joint replacement. The mid- to long-term survival rate of the large variety of replacement prostheses remains unknown. Inadequate outcomes data for the majority of prostheses, as well as variability related to different surgical techniques and diagnostic groups, have made it difficult for surgeons to identify the relative effectiveness of different prostheses and treatments. The Federal Government provided funding to the Australian Orthopaedic Association (AOA) to establish the National Joint Replacement Registry (NJRR) in March 1998. The AOA has appointed a committee to manage the Registry and has contracted with the Data Management and Analysis Centre at the University of Adelaide to establish and manage the data systems for the Registry.

The primary aim of the AOA NJRR is to evaluate the effectiveness of different types of joint replacement prostheses and surgical techniques at a national level.

Implementation methods, aspects of database design and early progress in data collection are presented.

We have studied the incidence of tumours at remote sites following total hip replacement: 1,358 individuals have been followed up for 14,286 person-years after operation. In the decade following implantation the incidence of tumours of the lymphatic and haemopoietic systems was significantly greater, and that of cancer of the breast, colon, and rectum, significantly less than expected. Whilst the association might be due in part to an effect of the prosthetic implants, other mechanisms, particularly drug therapy, require consideration.