Swedish Hip Arthroplasty Register Annual Report 2017 We cannot be held liable for any errors that may occur in printing, information and/or data files. Publisher: Ola Rolfson ISBN (English pdf version): 978-91-984239-4-5 ISSN 1654-5982 Swedish Hip Arthroplasty Register Annual Report 2017 Johan Kärrholm Maziar Mohaddes Daniel Odin Johanna Vinblad Cecilia Rogmark Ola Rolfson 4 SWEDISH HIP ARTHROPLASTY REGISTER 2017 Contents 1 Introduction 6 2 Data quality and validation process 8 2.1 Completeness analysis 8 2.2 Completeness analysis per unit 8 2.3 PROM programme, data quality 10 2.4 Missing variables 10 2.5 Validation processes 10 3 Epidemiology, availability, and gender aspects 15 3.1 Total hip arthroplasty in Sweden 15 3.2 County council production and geographical inequality 16 3.3 Gender division, elective patients 16 3.4 Gender division, fracture patients 19 4 Register development, improvement work and research 22 4.1 Implant manufacturer application 22 4.2 From worst to above the national average through systematic improvement work 22 4.4 Long-term results following total hip arthroplasty 24 5 Register work from an international perspective 26 5.1 International studies 26 5.2 ISAR Congress 2018 27 6 Primary prosthesis 28 6.1 Demographics 28 6.2 Diagnosis 28 6.3 BMI and ASA classification 28 6.4 Prosthesis selection 29 6.5 Most common prostheses 29 6.6 Articulation 33 6.7 Implant combinations 33 6.8 Surgical approach 33 7 Primary prosthesis – in-depth analyses 42 7.1 ‘New’ primary prosthesis 42 8 Reoperation 49 8.1 Definition and trends 49 8.2 Reoperation within two years 53 8.3 Revision 62 8.4 Five-year and ten-year implant survival rates 77 SWEDISH HIP ARTHROPLASTY REGISTER 2017 5 9 Patient-reported outcome 81 9.1 Hip Arthroplasty Register PROM programme 81 9.2 PROM values 2017 82 9.3 Number of persons satisfied with the surgical outcome 84 9.4 Patient-reported outcome per unit – presentation process 86 9.5 Physiotherapy, osteoarthritis exercise programme, and smoking 87 10 90-day mortality following hip arthroplasty 90 10.1 Total hip arthroplasty 90 10.2 Fracture patients 90 11 Adverse events within 30 days and 90 days 96 11.1 Method 96 11.2 Unit results 2014–2016 97 12 Fracture treatment with total arthroplasty or hemiarthroplasty 108 13 Register development – value compasses 116 13.1 Register follow-up after total hip arthroplasty 116 13.2 Register follow-up after hip arthroplasty as treatment for a hip fracture 116 14 The Hip Arthroplasty Register and clinical research 128 15 Literature references – past five years 131 17 Sincere thanks to all contact secretaries and contact doctors 136 The english version of the annual report contains selected tables and graphs. The online swedish version contain all the tables and graphs and is published on the website www.shpr.se. 6 SWEDISH HIP ARTHROPLASTY REGISTER 2017 1 Introduction Welcome to the Swedish Hip Arthroplasty Register Annual Primary total hip arthroplasty in Report for 2017. In January 2017, we launched a new version of the Register, including an update of the content in order to Sweden describe more optimally the hip arthroplasty operations that 18000 are currently being performed. Moving the Register to a new IT platform opened up a whole range of benefits, including 16000 improved validation of input data and a simpler and quicker means of presenting data from the Register. The move to the 14000 new IT platform has meant that all programming had to be 12000 redone completely in order to produce a full set of tables and graphs for the Annual Report. 10000 The Swedish Hip Arthroplasty Register is a national Counts 8000 quality register, the purpose of which is to improve care provision for patients who undergo hip arthroplasty 6000 in Sweden. The aim is to register all hip arthroplasties 4000 that have taken place, both in public and private sector establishments, and regardless of the condition that led 2000 to the operation. The Register was set up in 1979, and this report covers procedures carried out up through to 0 Copyright © 2018 Swedish Hip Arthroplasty Register December 31, 2017, making this the 39th operating year 1970 1980 1990 2000 2010 for the Register. Year of operation Figure 1.1. Annual production Production increased during 2017 (Figure 1.1 and 1.2) and for the first time more than 18,000 primary total hip arthroplasties were carried out. To be exact, 18,148 total hip arthroplasties Illustration were performed, equivalent to 179 procedures per 100,000 The illustration for this year’s report illustrates the various inhabitants. A total of 4,029 primary hemiarthroplasties were paths taken by patients who have undergone hip arthroplasty carried out, which was down slightly on the figure for the pre- after primary hip arthroplasty. Previously, we focused on in- vious year, and overall 6,033 hip arthroplasties were carried dividual hip operations, but we know that a large proportion out due to acute hip fracture or sequela following a fracture. A of patients undergo an operation on the other hip as well as total of 2,588 reoperations were registered. reoperations. In the thesis “Longitudinal outcomes following total hip replacement”, Peter Cnudde has made use of what is termed a multistate analysis to describe the probability of Validation process and various hip-related events. A summary of the thesis, which also completeness analyses trends within Swedish hip arthroplasty, is presented in the report. The Register data is subject to continuous validation and qual- ity control. We use a range of methods to assure and maintain a high level of data quality and to improve areas in which there In-depth analyses and are shortcomings. A key feature of the validation process is the annual completeness analysis, which is carried out through improvement work collaboration with the National Board of Health and Welfare As usual, this year’s report contains a range of in-depth Patient Register. The analysis covers all primary procedures, analyses. In the primary prosthesis chapter there is an in-depth divided into total arthroplasties and hemiarthroplasties. A new analysis of the frequently debated issue of choice of fixation. development this year is a completeness analysis of revisions. The conclusion that can be drawn with the aid of our register As it is often well into the autumn before the Patient Register data is that in the majority of cases individuals over the age data for the preceding year is available, we have published a of 75 ought to be operated on with all cemented fixation. All completeness analysis for the 2016 operating year. The out- uncemented fixation could be an alternative for women up to come for the country was that 98% of all total arthroplasties, around 55 years of age, and for men up to 65 years of age. We 96% of all hemiarthroplasties, and 93% of all revisions were can also report that new prostheses introduced onto the Swedish registered in the Hip Arthroplasty Register. In the Register market, and which have been used to such an extent that a follow-up routine using patient-reported outcomes – the register analysis is meaningful, have revealed good results. The PROM programme (patient-reported outcome measures) – report also contains a comparison between a dual-mobility the response rate for patients with osteoarthritis who under- cup and a conventional cup, although the results are difficult went surgery in 2016 was 83% preoperatively, and 85% at the to interpret as it is probably not possible to compensate fully one-year follow-up. for patient selection. Based on information contained in the SWEDISH HIP ARTHROPLASTY REGISTER 2017 7 Register, however, we are unable to demonstrate any obvious advantages of using a dual-mobility cup. As part of a thesis 24000 project, Georgios Chatziagorou compared the two most com- mon cemented stems used in Sweden in terms of reoperation 20000 due to a periprosthetic fracture. The analysis indicates that the Lubinus stem carries a lower risk of a periprosthetic fracture 16000 compared with the Exeter stem, even when Vancouver type C fractures are included. 12000 The Hip Arthroplasty Register is one of the world’s most Counts extensive reoperation databases, covering over 80,000 oper- 8000 ations. It is a valuable means of gaining an understanding of which methods and implants offer the best results. Yosef Tyson, a PhD student in Uppsala, has compared cemented and 4000 uncemented stem revision with first-time revision. Even if an increase in the use of uncemented fixation can be noted, the 0 results show that revision with a cemented stem still ought to Copyright © 2018 Swedish Hip Arthroplasty Register be considered an attractive first-choice option. 05 06 07 08 09 10 11 12 13 14 15 16 17 Year of operation Per Jolbäck, a PhD student in Gothenburg, has examined the link between annual volume on the surgeon level, and the in- Primary THR Revision cidence of adverse events within 90 days following a primary Primary Hemi Reoperation (other open procedure) total hip arthroplasty. He found that those surgeons with a Figure 1.2. higher volume have a lower complication rate. The study is an important part of the discussion about how units ought to be organised to allow individual surgeons to maintain and scientific conferences, and we published 16 scientific articles improve their skills. from the Register. During the Academy meeting in San Diego, Henrik Malchau, Johan Kärrholm and colleagues were awarded the prestigious Kappa Delta Award for the summary New adverse event definition ‘Arthroplasty implant registries over the past five decades: and trends development, current and future impact’.