Prospective studies of hip and knee prostheses

1. Prospective studies of hip and knee prostheses The Norwegian Arthroplasty Register 1987-2004

2. Norway

3. All products mentioned in the presentation have had CE approval (European) • Some of the products used in Norway did not have FDA approval.

4. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this presentation

5. History of the Norwegian Arthroplasty Register References: Havelin et al. Acta Orthop Scand 1994 Havelin et al. J Bone Joint Surg (Br) 1995 Havelin et al. J Bone Joint Surg (Am) 1995

6. Havelin et al. Acta Orthop Scand 1994

7. Havelin et al. J Bone Joint Surg (Br) 1995

8. Left Right Havelin et al. J Bone Joint Surg (Br) 1995 Years

9. Havelin et al. J Bone Joint Surg (Br) 1995

10. Havelin et al. J Bone Joint Surg (Br) 1995

11. Survival of hip prostheses Survival of cemented hip prostheses Survival of uncemented hip prostheses The Cox-adjusted relative risk (RR) for revision of a primary THA was reduced by 35 percent from 1987-1990 to 1997-2003 (p<0.001).

12. Survival of knee prostheses

13. Incidence 2003

14. Compliance: Hip prostheses 1999-2002 NAR = The voluntary Norwegian Arthroplasty Register NPR = The mandatory Norwegian Patient Registry

15. Cemented hip prostheses Cup prostheses, revision of cup. Stem prostheses, revision of stem.

16. Cup/stem cemented hip prostheses (combination), any revision.

17. Cemented hip, cup prostheses

18. Cemented hip, stem prostheses

19. Uncemented hip prostheses Cup prostheses, revision of cup or liner. Stem prostheses, revision of stem.

20. Cup/stem uncemented hip prostheses (combination), any revision.

21. Uncemented hip, cup prostheses

22. Uncemented hip, stem prostheses

23. Hip prostheses in young patients (< 60 years) Cemented cup/stem (combination), any revision. Uncemented cup/stem (combination), any revision.

24. Hip prostheses in young patients (< 60 years) Cemented and uncemented cup/stem (combination), revision of cup or liner. Cemented and uncemented cup/stem (combination), revision of stem.

25. Femoral head size is a risk factor for total hip luxation Prostheses with head diameters of 28 and 32 (n=9943) Prosthesis survival until revision due to dislocation. Adjusted for age gender, diagnosis and surgical approach (Byström et al. Acta Orthop Scand 2003)

26. Prosthesis combinations, 28 and 32 mm femoral head sizes Byström et al. Acta Orthop Scand 2003

27. Exeter prosthesis (n=5598) with head diameters of 26, 28 and 30 mm Prosthesis survival until revision due to dislocation. Adjusted for age gender, diagnosis and surgical approach (Byström et al. Acta Orthop Scand 2003)

28. Operation time Småbrekke et al. Acta Orthop Scand 2004

29. Hip disease and the prognosis of total hip arthroplasty (Furnes et al. J Bone Joint Surg (Br) 2001) Total material Unadjusted Adjusted

30. Hip disease and the prognosis of total hip arthroplasty (Furnes et al. J Bone Joint Surg (Br) 2001) < 60 years Total material Charnley

31. Relative risk for revision with Charnley-prosthesis(Furnes et al. J Bone Joint Surg (Br) 2001)

32. Antibiotic Prophylaxis and Survival of Primary Total Hip Prostheses Cox-regression. Adjusted survival curves calculated with revision due to any cause as the endpoint (Espehaug et al. J Bone Joint Surg (Br) 1997).

33. Antibiotic prophylaxis systemically and in bone cement Number of THAs performed annually SC Number of THAs S C None Year of operation Engesaeter et al. Acta Orthop Scand 2003; 74:644-651

34. Antibiotic prophylaxis systemically and in bone cement Survival aseptic loosening Survival infection SC S SC None C C None S Years postoperatively Years postoperatively Cox-adjusted survival curves with aseptic loosening, and infection as endpoint for THAs receiving antibiotic prohylaxis systemically and in cement (SC), only systemically (S), only in cements (C) or no antibiotic prohylaxis (None). Engesaeter et al. Acta Orthop Scand 2003; 74:644-651

35. Number of THAs performed annually 13 14 Number of THAs 12 11 2 3 Year of operation Antibiotic prophylaxis systemically and in bone cement Engesaeter et al. Acta Orthop Scand 2003; 74:644-651

36. Antibiotics – systemically daysdoses 100 % 95 90 85 13 3 14 2 12 Percent not revised 11 Years postoperatively Engesaeter et al. Acta Orthop Scand 2003; 74:644-651

37. Antibiotic prophylaxis systemically and in bone cement Survival aseptic loosening Survival infection 13 14 12 2 3 14 3 13 11 2 12 11 Years postoperatively Years postoperatively Cox-adjusted survival curves with aseptic loosening and infection as endpoint for THAs receiving antibiotic in the cement and antibiotic prophylaxis systemically for 1 day (with number of doses as subscript), 2 days and 3 days. Engesaeter et al. Acta Orthop Scand 2003; 74:644-651

38. Revision - Aseptic loosening * Cox adjusted 10 years revision % ** RR (Failure Risk Ratio) Adjusted for sex, age, systemic antibiotic, operating theatre, duration of operation, prosthesis. Engesaeter et al. Acta Orthop Scand 2003; 74:644-651

39. Revision - Infection * Cox adjusted 10 years revision % ** RR (Failure Risk Ratio) Adjusted for sex, age, systemic antibiotic, operating theatre, duration of operation, prosthesis. Engesaeter et al. Acta Orthop Scand 2003; 74:644-651

40. Cement Type and Survival of Primary Total Hip Prostheses Boneloc cement Low viscosity cement Havelin et al. J Bone Joint Surg (Am) 1995

41. Kaplan-Meier survival curves of Charnley femoral prostheses with high viscosity, low viscosity, and Boneloc cement. High viscosity Low viscosity Boneloc Havelin et al. J Bone Joint Surg (Am) 1995

42. Type of cement and failure of hip prostheses Simplex Palacos G Palacos CMW1 G CMW1 Espehaug et al. J Bone Joint Surg 2002 CMW3

43. Survival of Uncemented Primary Total Hip Prostheses Charnley cups vs two uncemented HA-coated cups

44. Survival of Uncemented Primary Total Hip Prostheses Charnley cups vs two uncemented HA-coated cups, patients < 60 years

45. Cemented vs uncemented in young patients (<60) All stem revisions All cup revisions

46. Hospital Category and Prosthesis failure Central hospitals Local hospitals University hospitals p<0.001 Kaplan-Meier survival curves calculated with any revision as endpoint (Espehaug et al. Acta Orthop Scand 1999)

47. Unrevised hip implant Revised hip implant % % 100 80 60 Very poor 40 Poor Neither 20 Good Very good 0 < 56 56- 66- 71- > 75 < 56 56- 66- 71- > 75 65 70 75 65 70 75 Age at primary operation Age at primary operation Patient satisfaction Espehaug et al. Clin Orthop 1998

48. Unrevised hip implant Revised hip implant 6 5 At follow-up At follow-up 4 MEAN CHARNLEY SCORE 3 Before revision Before primary operation 2 Before primary operation 1 < 56 56 66 71 > 75 < 56 56 66 71 > 75 -65 -70 -75 -65 -70 -75 Age at primary operation Age at primary operation Self-reported pain Espehaug et al. Clin Orthop 1998

49. Unrevised hip implant Revised hip implant 6 At follow-up 5 At follow-up 4 Before primary operation MEAN CHARNLEY SCORE Before primary operation 3 Before revision 2 1 < 56 56 66 71 > 75 < 56 56 66 71 > 75 -65 -70 -75 -65 -70 -75 Age at primary operation Age at primary operation Self-reported walking ability Espehaug et al. Clin Orthop 1998

50. Total survival for patients with hip prostheses 39543 patients; 6201 deaths; 323 within 60 days Percent patients alive Years after primary operation Days after primary operation Lie et al. Acta Orthop Scand 2000; 71(1): 19-27