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Do Trabecular Metal Acetabular Components Reduce the Risk of Rerevision After Revision THA Performed for Periprosthetic Joint Infection? A Study Using the NJR Data Set

Matharu, Gulraj S., BSc (Hons), MRCS, MRes, DPhil; Judge, Andrew, BSc, MSc, PhD; Murray, David W., MD, FRCS (Orth); Pandit, Hemant G., DPhil, FRCS (Tr & Orth)

Clinical Orthopaedics and Related Research®: June 2019 - Volume 477 - Issue 6 - p 1382–1389
doi: 10.1097/CORR.0000000000000570
SELECTED PROCEEDINGS FROM THE 7TH INTERNATIONAL CONGRESS OF ARTHROPLASTY REGISTRIES
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Background A single-center study of 144 THAs revised specifically for periprosthetic joint infection (PJI) observed that trabecular metal (TM) acetabular components had a reduced risk of rerevision for subsequent infection compared with non-TM implants. It was suggested that TM was protective against infection after revision and that TM may be useful when revising THAs for PJI. Three registry studies have subsequently assessed the effect of TM on future infection. In the National Joint Registry (NJR) for England and Wales, we earlier reported lower revision rates for infection when TM (versus non-TM) was used in primary THA, but no difference in rerevision rates for infection when TM was used for all-cause revision THAs. The latter findings in all-cause revisions were also confirmed in a study from the Swedish and Australian registries. It is possible that TM only reduces the risk of infection when it is specifically used for PJI revisions (rather than all-causes). However, to date, the registry analyses have not had large enough cohorts of such cases to assess this meaningfully.

Questions/purposes (1) In revision THAs performed for PJI, are rerevision rates for all-cause acetabular indications lower with TM acetabular components compared with non-TM designs? (2) In revision THAs performed for PJI, are rerevision rates of any component for infection lower with TM acetabular components compared with non-TM designs?

Methods A retrospective observational study was performed using NJR data from England and Wales, which is the world’s largest arthroplasty registry and contains details of over two million joint replacement procedures. The registry achieves high levels of patient consent (92%) and linked procedures (ability to link serial procedures performed on the same patient and hip; 94%). Furthermore, recent validation studies have demonstrated that when revision procedures have been captured within the NJR, the data completion and accuracy were excellent. Of 11,988 revisions performed for all causes, 794 were performed for PJI in which the same cementless acetabular component produced by one manufacturer was used. Acetabular components were either TM (n = 541) or non-TM (n = 253). At baseline the two groups were comparable for sex, age, body mass index, and American Society of Anesthesiologists (ASA) grade. Outcomes after revision THA (rerevision for all-cause acetabular indications and rerevision of any component for infection) were compared between the groups using Fine and Gray regression analysis, which considers the competing mortality risk. Regression models were adjusted for the propensity score, with this score summarizing many of the potential patient and surgical confounding factors (age, sex, ASA grade, surgeon grade, approach, and type of revision procedure performed).

Results There was no difference in 5-year cumulative acetabular component survival rates between TM (96.3%; 95% confidence interval [CI], 94%-98%) and non-TM components (94.4%, 95% CI, 90%-97%; subhazard ratio, 0.78, 95% CI, 0.37-1.65; p = 0.509). There was no difference in 5-year cumulative implant survival rates free from infection between TM (94.8%; 95% CI, 92%-97%) and non-TM components (94.4%, 95% CI, 90%-97%; subhazard ratio, 0.97, 95% CI, 0.48-1.96; p = 0.942).

Conclusions We found no evidence to support the notion that TM acetabular components used for PJI revisions reduced the subsequent risk of all-cause rerevision or the risk of rerevision for infection compared with non-TM implants from the same manufacturer. We therefore advise caution against recent claims that TM components may protect against infection.

Level of Evidence Level III, therapeutic study.

G. S. Matharu, A. Judge, D. W. Murray, H. G. Pandit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK

G. S. Matharu, A. Judge, Musculoskeletal Research Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK

H. G. Pandit, Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, Leeds, UK

G. S. Matharu, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, OX3 7LD, UK, email: gsm@doctors.org.uk

One of the authors’ institutions (HGP) has received, during the study period to undertake this study, funding from Zimmer Biomet (Bridgend, UK), the manufacturer of the implants investigated in this study, in the amount of USD 10,000 to USD 100,000. One of the authors’ institutions (GSM, AJ, DWM, HGP) have been involved in the following relevant financial activities outside of this work and/or other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, this manuscript: received funding to undertake other research work from Arthritis Research UK (London, UK) in the amount of USD 100,001 to USD 1,000,000, received funding to undertake other research work from The Orthopaedics Trust (Norwich, UK) in the amount of USD 10,000 to USD 100,000, received funding to undertake other research work from The Royal College of Surgeons of England (London, UK) in the amount of USD 10,000 to USD 100,000, and received funding to undertake other research work from The Royal Orthopaedic Hospital Hip Research and Education Charitable Fund (Birmingham, UK) in the amount of USD 10,000 to USD 100,000. One of the authors (GSM) has been involved in the following relevant financial activities outside of this work and/or other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, this manuscript: paid consultant for Leigh Day (London, UK) in the amount of less than USD 10,000. One of the authors (AJ) has been involved in the following relevant financial activities outside of this work and/or other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, this manuscript: received consultancy, lecture fees, and honoraria from Servier (Neuilly-sur-Seine, France; less than USD 10,000), UK Renal Registry (Bristol, UK; less than USD 10,000), Oxford Craniofacial Unit (Oxford, UK; less than USD 10,000), IDIAP Jordi Gol (Barcelona, Spain; less than USD 10,000), and Freshfields Bruckhaus Deringer (London, UK; USD 10,000 to USD 100,000) and is a member of the Data Safety and Monitoring Board (which involved receipt of fees) from Anthera Pharmaceuticals Inc (Hayward, CA, USA; USD 10,000 to USD 100,000). One of the authors (DWM) has been involved in the following relevant financial activities outside of this work and/or other relationships or activities that readers could perceive to have influenced, or that gave the appearance of potentially influencing, this manuscript: paid consultant for Herbert Smith Freehills (Sydney, Australia) in the amount of USD 10,000 to USD 100,000. During the study period, two of the authors (DWM, HGP) have been involved in the following relevant financial activities outside of this work and/or other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, this manuscript: received research funding from Zimmer Biomet in the amount of USD 100,000 to USD 1,000,000 paid to the University of Oxford. During the study period, one of the authors (HGP) has been involved in the following relevant financial activities outside of this work and/or other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, this manuscript: paid consultant for Zimmer Biomet (Bridgend, UK) in the amount of USD 10,000 to USD 100,000 and Kennedys Law (London, UK) in the amount of USD 10,000 to USD 100,000 and received research funding from Zimmer Biomet in the amount of USD 100,000 to USD 1,000,000, UKIERI (New Delhi, India) in the amount of USD 100,000 to USD 1,000,000, and NIHR (London, UK) in the amount of USD 100,000 to USD 1,000,000 paid to the University of Leeds.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

This work was performed at the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK.

Received June 29, 2018

Accepted October 22, 2018

© 2019 Lippincott Williams & Wilkins LWW
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