Background 

Long-term implant survivorship in THA and TKA involves a combination of factors related to the patient, the implants used, and the decision-making and technical performance of the surgeon. It is unclear which of these factors is the most important in reducing the proportion of revision surgery.

Questions/purposes 

We used data from a large national registry to ask: In patients receiving primary THA and TKA for a diagnosis of osteoarthritis, do (1) the reasons for revision and (2) patient factors, the implants used, and the surgeon or surgical factors differ between surgeons performing THA and TKA who have a lower revision rate compared with all other surgeons?

Methods 

Data were analyzed for all THA and TKA procedures performed for a diagnosis of osteoarthritis from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from September 1, 1999, when collection began, to December 31, 2018. The AOANJRR obtains data on more than 98% of joint arthroplasties performed in Australia. The 5-year cumulative percent revision (CPR) was identified for all THAs and TKAs performed for a diagnosis of osteoarthritis with 95% confidence intervals (overall CPR); the 5-year CPR with 95% CIs for each surgeon was calculated for THA and TKA separately. For surgeons to be included in the analysis, they had to have performed at least 50 procedures and have a 5-year CPR. The 5-year CPR with 95% CIs for each THA and TKA surgeon was compared with the overall CPR. Two groups were defined: low revision rate surgeons (the upper confidence level for a given surgeon at 5 years is less than 3.84% for THA and 4.32% for TKA), and all other surgeons (any surgeon whose CPR was higher than those thresholds). The thresholds were determined by setting a cutoff at 20% above the upper confidence level for that class. The approach we used to define a low revision rate surgeon was similar to that used by the AOANJRR for determining the better-performing prostheses and is recommended by the International Prosthesis Benchmarking Working Group. By defining the groups in this way, a significant difference between these two groups is created. Determining a reason for this difference is the purpose of presenting the proportions of different factors within each group. The study group for THA included 116 low revision rate surgeons, who performed 88,392 procedures (1619 revised, 10-year CPR 2.7% [95% CI 2.6% to 2.9%]) and 433 other surgeons, who performed 170,094 procedures (6911 revised, 10-year CPR 5.9% [95% CI 5.7% to 6.0%]). The study group for TKA consisted of 144 low revision rate surgeons, who performed 159,961 procedures (2722 revised, 10-year CPR 2.6% [95% CI 2.5% to 2.8%]) and 534 other surgeons, who performed 287,232 procedures (12,617 revised, 10-year CPR 6.4% [95% CI 6.3% to 6.6%]). These groups were defined a priori by their rate of revision, and the purpose of this study was to explore potential reasons for this observed difference.

Results 

For THA, the difference in overall revision rate between low revision rate surgeons and other surgeons was driven mainly by fewer revisions for dislocation, followed by component loosening and fracture in patients treated by low revision rate surgeons. For TKA, the difference in overall revision rate between low revision rate surgeons and other surgeons was driven mainly by fewer revisions for aseptic loosening, followed by instability and patellofemoral complications in patients treated by low revision rate surgeons. Patient-related factors were generally similar between low revision rate surgeons and other surgeons for both THA and TKA. Regarding THA, there were differences in implant factors, with low revision rate surgeons using fewer types of implants that have been identified as having a higher-than-anticipated rate of revision within the AOANJRR. Low revision rate surgeons used a higher proportion of hybrid fixation, although cementless fixation remained the most common choice. For surgeon factors, low revision rate surgeons were more likely to perform more than 100 THA procedures per year, while other surgeons were more likely to perform fewer than 50 THA procedures per year. In general, the groups of surgeons (low revision rate surgeons and other surgeons) differed less in terms of years of surgical experience than they did in terms of the number of cases they performed each year, although low revision rate surgeons, on average, had more years of experience and performed more cases per year. Regarding TKA, there were more differences in implant factors than with THA, with low revision rate surgeons more frequently performing patellar resurfacing, using an AOANJRR-identified best-performing prosthesis combination (with the lowest rates of revision), using fewer implants that have been identified as having a higher-than-anticipated rate of revision within the AOANJRR, using highly crosslinked polyethylene, and using a higher proportion of cemented fixation compared with other surgeons. For surgeon factors, low revision rate surgeons were more likely to perform more than 100 TKA procedures per year, whereas all other surgeons were more likely to perform fewer than 50 procedures per year. Again, generally, the groups of surgeons (low revision rate surgeons and other surgeons) differed less in terms of years of surgical experience than they did in terms of the number of cases they performed annually, although low revision rate surgeons, on average, had more years of experience and performed more cases per year.

Conclusion 

THAs and TKAs performed by surgeons with the lowest revision rates in Australia show reductions in all of the leading causes of revision for both THA and TKA, in particular, causes of revision related to the technical performance of these procedures. Patient factors were similar between low revision rate surgeons and all other surgeons for both THA and TKA. Low revision rate THA surgeons were more likely to use cement fixation selectively. Low revision rate TKA surgeons were more likely to use patella resurfacing, crosslinked polyethylene, and cemented fixation. Low revision rate THA and TKA surgeons were more likely to use an AOANJRR-identified best-performing prosthesis combination and to use fewer implants identified by the AOANJRR as having a higher-than-anticipated revision rate. To reduce the rate of revision THA and TKA, surgeons should consider addressing modifiable factors related to implant selection. Future research should identify surgeon factors beyond annual case volume that are important to improving implant survivorship.

Level of Evidence 

Level III, therapeutic study.

中文翻译：

---

我们可以从进行 THA 和 TKA 且翻修率最低的外科医生身上学到什么？澳大利亚骨科协会国家关节置换登记处的一项研究

背景 

THA 和 TKA 中植入物的长期存活涉及患者、所用植入物以及外科医生的决策和技术表现等相关因素。目前尚不清楚这些因素中哪一个对减少翻修手术比例最重要。

问题/目的 

我们使用来自大型国家登记处的数据来询问：在诊断为骨关节炎而接受初次 THA 和 TKA 的患者中，(1) 翻修的原因和 (2) 患者因素、使用的植入物以及外科医生或手术因素是否有所不同与所有其他外科医生相比，进行全髋关节置换 (THA) 和全膝关节置换 (TKA) 的外科医生翻修率较低？

方法 

澳大利亚骨科协会国家关节置换登记处 (AOANJRR) 分析了从 1999 年 9 月 1 日开始收集数据到 2018 年 12 月 31 日期间为诊断骨关节炎而进行的所有 THA 和 TKA 手术的数据。AOANJRR 获得了超过98% 的关节置换术在澳大利亚进行。为诊断骨关节炎而进行的所有 THA 和 TKA 均确定了 5 年累积翻修百分比 (CPR)，置信区间为 95%（总体 CPR）；分别针对 THA 和 TKA 计算每位外科医生的 5 年 CPR（95% CI）。要让外科医生参与分析，他们必须进行过至少 50 次手术，并且有 5 年的心肺复苏术。将每位 THA 和 TKA 外科医生的 5 年 CPR（置信区间为 95%）与总体 CPR 进行比较。定义了两组：低翻修率外科医生（给定外科医生 5 年时 THA 的置信上限低于 3.84%，TKA 的置信度上限为 4.32%），以及所有其他外科医生（CPR 高于这些阈值的任何外科医生） 。通过将截止值设置为高于该类别的置信上限 20% 来确定阈值。我们用来定义低翻修率外科医生的方法与 AOANJRR 用于确定性能更好的假体的方法类似，并且是国际假体基准工作组推荐的方法。通过以这种方式定义组，这两个组之间产生了显着差异。确定这种差异的原因是为了呈现每个组中不同因素的比例。THA 研究组包括 116 名低翻修率外科医生，他们进行了 88,392 例手术（1619 例翻修，10 年 CPR 2.7% [95% CI 2.6% 至 2.9%]）和 433 名其他外科医生，他们进行了 170,094 例手术（6911 例翻修，10 年心肺复苏率 2.7%）。 10 年 CPR 5.9% [95% CI 5.7% 至 6.0%]）。TKA 研究组由 144 名低翻修率外科医生组成，他们进行了 159,961 例手术（2722 例翻修，10 年 CPR 2.6% [95% CI 2.5% 至 2.8%]）和 534 名其他外科医生，他们进行了 287,232 例手术（12,617 例翻修） ，10 年 CPR 6.4% [95% CI 6.3% 至 6.6%]）。这些组是根据其修订率预先定义的，本研究的目的是探讨这种观察到的差异的潜在原因。

结果 

对于THA，低翻修率外科医生与其他外科医生之间的总体翻修率差异主要是由于脱位翻修较少，其次是低翻修率外科医生治疗的患者出现组件松动和骨折。对于 TKA，低翻修率外科医生与其他外科医生之间的总体翻修率差异主要是由于无菌性松动翻修次数较少，其次是低翻修率外科医生治疗的患者出现不稳定和髌股并发症。低翻修率外科医生和其他全髋关节置换 (THA) 和全膝关节置换 (TKA) 外科医生的患者相关因素通常相似。关于 THA，种植体因素存在差异，翻修率低的外科医生使用较少类型的种植体，这些种植体已被确定在 AOANJRR 内具有高于预期的翻修率。尽管无骨水泥固定仍然是最常见的选择，但低翻修率外科医生使用混合固定的比例较高。对于外科医生因素，翻修率低的外科医生更有可能每年进行超过 100 例 THA 手术，而其他外科医生更有可能每年进行少于 50 例 THA 手术。一般来说，外科医生组（低翻修率外科医生和其他外科医生）在手术经验年数方面的差异小于他们每年执行的病例数方面的差异，尽管低翻修率外科医生平均而言更多年的经验，每年执行更多的案例。关于 TKA，植入物因素比 THA 有更多差异，低翻修率外科医生更频繁地进行髌骨表面置换，使用 AOANJRR 确定的性能最佳假体组合（翻修率最低），使用较少的植入物与其他外科医生相比，AOANJRR 使用高度交联的聚乙烯，并使用更高比例的骨水泥固定，其翻修率高于预期。对于外科医生因素，翻修率低的外科医生更有可能每年执行超过 100 例 TKA 手术，而所有其他外科医生更有可能每年执行少于 50 例手术。同样，一般来说，外科医生组（低翻修率外科医生和其他外科医生）在手术经验年数方面的差异小于他们每年执行的病例数方面的差异，尽管低翻修率外科医生平均而言更多年的经验，每年执行更多的案例。

结论 

由澳大利亚翻修率最低的外科医生进行的 THA 和 TKA 显示，THA 和 TKA 翻修的所有主要原因均有所减少，特别是与这些手术的技术性能相关的翻修原因。低翻修率外科医生和所有其他全髋关节置换 (THA) 和全膝关节置换 (TKA) 外科医生的患者因素相似。翻修率低的 THA 外科医生更有可能选择性地使用骨水泥固定。低翻修率 TKA 外科医生更有可能使用髌骨表面置换、交联聚乙烯和骨水泥固定。低翻修率 THA 和 TKA 外科医生更有可能使用 AOANJRR 认定的性能最佳的假体组合，并使用 AOANJRR 认定的翻修率高于预期的较少种植体。为了降低全髋关节置换和全膝关节置换翻修率，外科医生应考虑解决与种植体选择相关的可改变因素。未来的研究应该确定除年度病例量之外对提高种植体存活率很重要的外科医生因素。

证据水平 

III级，治疗研究。