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1.  Consensus document on prosthetic joint infections 
Acta Orthopaedica  2013;84(6):507-508.
PMCID: PMC3851661  PMID: 24286568
2.  Bacterial colonization and resistance patterns in 133 patients undergoing a primary hip- or knee replacement in Southern Sweden 
Acta Orthopaedica  2013;84(1):87-91.
Background and purpose
Prosthetic joint infections can be caused by bacteria derived from the patient’s skin. The aim of the study was: (1) to determine which bacteria colonize the nose and groin in patients planned for primary hip or knee arthroplasty, (2) to determine the antimicrobial resistance patterns, and (3) to monitor changes in bacterial colonization and resistance patterns connected to surgery.
Patients and methods
2 weeks before scheduled primary hip or knee arthroplasty, culture samples were taken from the anterior nares and from the groin of 133 consecutive patients. At surgery, cloxacillin was given prophylactically and cement with gentamicin was used. 2 weeks after surgery, another set of samples were taken from 120 of these patients. Bacterial findings and resistance patterns were analyzed.
Preoperatively, 95% of the patients had coagulase-negative staphylococci (CNS) in the groin and 77% in the nose. The proportion of patients with a methicillin-resistant CNS in the groin increased from 20% preoperatively to 50% postoperatively (p < 0.001), and the proportion of patients with a gentamicin-resistant CNS in the groin increased from 5% to 45% (p < 0.001). 28% of the patients had Staphylococcus aureus in the nose preoperatively, and 7% in the groin. Methicillin-resistant Staphylococcus aureus (MRSA) was found in the nose of 1 patient.
In southern Sweden, beta-lactams were effective against 99% of the Staphylococcus aureus strains and 80% of the CNS strains colonizing the patients undergoing primary hip or knee arthroplasty. Gentamicin protects against most CNS strains in cemented primary joint replacements.
PMCID: PMC3584610  PMID: 23409844
3.  High tibial osteotomy in Sweden, 1998–2007 
Acta Orthopaedica  2012;83(3):244-248.
Background and purpose
Most studies on high tibial osteotomies (HTOs) have been hospital-based and have included a limited number of patients. We evaluated the use and outcome—expressed as rate of revision to knee arthroplasty—of HTO performed in Sweden with 9 million inhabitants, 1998–2007.
Patients and methods
3, 161 HTO procedures on patients 30 years or older (69% men) who were operated on for knee osteoarthritis in Sweden, 1998–2007, were identified through the inpatient and outpatient care registers of the Swedish National Board of Health and Welfare. Pertinent data were verified through surgical records. Conversions of HTO to knee arthroplasty before 2010 were identified through the Swedish Knee Arthroplasty Register (SKAR). The 10-year survival was determined using revision to an arthroplasty as the endpoint.
The number of HTOs decreased by one third between 1998 and 2007, from 388 operations a year to 257 a year. Most of the HTOs were performed with open wedge osteotomy using external fixation. The cumulative revision rate at 10 years was 30% (95% CI: 28–32). The risk of revision increased with increasing age and was higher in women than in men (RR = 1.3, CI: 1.1–1.5).
If being without an artificial joint implant is considered to be beneficial, then HTO is an excellent alternative to knee arthroplasty in younger and/or physically active patients suffering from knee osteoarthritis.
PMCID: PMC3369149  PMID: 22574818
4.  A single bisphosphonate infusion does not accelerate fracture healing in high tibial osteotomies 
Acta Orthopaedica  2011;82(4):465-470.
Bisphosphonates increase the callus size and strength in animal fracture studies. In a human non-randomized pilot study of high tibial osteotomies in knee osteoarthritis, using the hemicallotasis (HCO) technique, bisphosphonates shortened the healing time by 12 days. In the present randomized study, we wanted to determine whether a single infusion of zoledronic acid reduces the time to clinical osteotomy healing. Results from the same trial, showing improved pin fixation with zoledronate, have been published separately.
46 consecutive patients (aged 35–65 years) were operated. At 4 weeks postoperatively, the patients were randomized to an intravenous infusion of either zoledronic acid or sodium chloride. Dual-energy X-ray absorptiometry (DEXA) was performed 10 weeks postoperatively. Radiographs were taken at 10 weeks and every second week until there was radiographic and clinical healing. Healing was evaluated blind, with extraction of the external fixator as the endpoint. At 1.5 years, an additional radiograph was taken and the hip-knee-ankle (HKA) angle measured to evaluate whether correction had been retained.
All osteotomies healed with no difference in healing time between the groups (77 (SD 7) days). Bone mineral density and bone mineral content, as assessed with DEXA, were similar between the groups. Radiographically, both groups had retained the acquired correction at the 1.5-year follow-up.
In this randomized comparison, a single infusion of zoledronic acid increased the pin fixation of the external frame but did not shorten the healing time. In both groups, the external fixator was extracted almost 2 weeks earlier than in previous studies. The early extraction did not cause a loss of correction in either group.
PMCID: PMC3237038  PMID: 21689069
5.  Surgery for knee osteoarthritis in younger patients 
Acta Orthopaedica  2010;81(2):161-164.
Background and purpose In Sweden, surgery for knee osteoarthritis (OA) in patients younger than 55 years of age has doubled during the last 10 years. We evaluated the use of 3 surgical alternatives: high tibial osteotomy (HTO), unicompartmental arthroplasty (UKA), and total knee arthroplasty (TKA). We also examined the outcome, expressed by rate of revision.
Methods The numbers of all procedures during 1998–2007 were obtained from the Swedish Knee Arthroplasty Register (SKAR) (UKA < 55 years: n = 1,050; UKA ≥ 55 years: n = 7,743; TKA < 55 years: n = 2,832; TKA ≥ 55 years: n = 62,829) and the National Board of Health and Welfare (NHW) (HTO 25–55 years: n = 2,266). The revision rate (presented as life tables) was based on the SKAR material for arthroplasties. For HTOs, a single institutional series of 450 patients aged 30–64 years was used to calculate the revision rate and to compare it to that for UKAs (n = 4,799; age 30–64 years).
Results During the 10 years, the use of TKA in patients younger than 55 years increased fivefold. While UKA increased threefold, its use diminished in the last 2 years. Although the use of HTO halved during the period, it is still used more often than UKA. The risk of revision increased in patients younger than 55 years and was lower for TKA (9%) than for UKA (24%). The revision rate was similar for HTO (17%) and for UKA (17%) in patients aged 30–64 years.
Interpretation TKA is the preferred method for young OA patients in Sweden today. The use of HTO and UKA has diminished, and as the few operations are spread over many hospitals, there is a risk of gradual loss of experience with respect to patient selection and surgical routine—with a negative effect on outcome. Thus, there is a risk that these treatment alternatives for younger patients will eventually be abandoned.
PMCID: PMC2852150  PMID: 19968599
6.  Unicompartmental knee arthroplasty in patients aged less than 65 
Acta Orthopaedica  2010;81(1):90-94.
Introduction and purpose
In recent years, there has been renewed interest in using unicompartmental knee arthroplasty (UKA). Several studies have reported increasing numbers of UKAs for osteoarthritis in patients who are less than 65 years of age, with low revision rates. To describe and compare the use and outcome of UKA in this age group, we have combined data from the Australian and Swedish knee registries.
Patients and methods
More than 34,000 UKA procedures carried out between 1998 and 2007 were analyzed, and we focused on over 16,000 patients younger than 65 years to determine usage and to determine differences in the revision rate. Survival analysis was used to determine outcomes of revision related to age and sex, using any reason for revision as the endpoint.
Both countries showed a decreasing use of UKA in recent years in terms of the proportion of knee replacements and absolute numbers undertaken per year. The 7-year cumulative risk of revision of UKA in patients younger than 65 years was similar in the two countries. Patients younger than 55 years had a statistically significantly higher cumulative risk of revision than patients aged 55 to 64 years (19% and 12%, respectively at 7 years). The risk of revision in patients less than 65 years of age was similar in both sexes.
The results of the combined UKA data from the Australian and Swedish registries show a uniformity of outcome between countries with patients aged less than 65 having a higher rate of revision than patients who were 65 or older. Surgeons and patients should be aware of the higher risk of revision in this age group.
PMCID: PMC2856210  PMID: 20175656
7.  Inadequate timing of prophylactic antibiotics in orthopedic surgery. We can do better 
Acta Orthopaedica  2009;80(6):633-638.
Background and purpose There are rising concerns about the frequency of infection after arthroplasty surgery. Prophylactic antibiotics are an important part of the preventive measures. As their effect is related to the timing of administration, it is important to follow how the routines with preoperative prophylactic antibiotics are working.
Methods In 114 consecutive cases treated at our own university clinic in Lund during 2008, the time of administration of preoperative prophylactic antibiotic in relation to the start of surgery was recorded from a computerized operation report. In 291 other cases of primary total knee arthroplasty (TKA), randomly selected from the Swedish Knee Arthroplasty Register (SKAR), the type and dose of prophylactic antibiotic as well as the time of administration in relation to the inflation of a tourniquet and to the start of surgery was recorded from anesthetic records.
Results 45% (95% CI: 36–54) of the patients operated in Lund and 57% (CI: 50–64) of the TKAs randomly selected from the SKAR received the preoperative antibiotic 15–45 min before the start of surgery. 53% (CI: 46–61) received antibiotics 15–45 min before inflation of a tourniquet.
Interpretation The inadequate timing of prophylactic antibiotics indicates that the standards of strict antiseptic and aseptic routines in arthroplasty surgery are falling. The use of a simple checklist to ensure the surgical safety may be one way of reducing infections in arthroplasty surgery.
PMCID: PMC2823303  PMID: 19995312

Results 1-7 (7)