Centre of excellence of joint replacements

REPORT 2008 Centre of excellence of joint replacements The Norwegian Arthroplasty Register The Norwegian Cruciate Ligament Register The Norwegian Hip Fracture Register Helse-Bergen HF, Department of Orthopaedic Surgery Haukeland University Hospital http://www.haukeland.no/nrl/ Report in Norwegian: ISBN: 978-82-91847-13-9 ISSN: 0809-9405

Report 2008

Contents Preface The Norwegian Arthroplasty Register Hip prostheses Number of total hip replacements by year of operation... 1 Incidence of primary total hip replacements by gender and age (1995, 2000, 2005)... 1 Hip disease... 2 Patient age by year of operation... 2 Reason for revision... 3 Type of revision... 4 Bone transplant... 5 Operative approach... 6 Trochanteric osteotomy... 6 Systemic antibiotic prophylaxis... 6 Cement... 7 Cement and bone transplant in revisions... 8 Cement brands... 10 Common combinations of prosthesis brands (acetabulum and femur)... 12 Prosthesis brands, acetabulum... 15 Prosthesis brands, femur... 17 Monoblock and modular caput... 19 Caput diameter in modular prostheses... 20 Prosthesis brands, modular caput... 21 ASA classification... 22 Thrombosis prophylaxis... 23 Mini-invasive surgery... 25 Computernavigation... 25 Bone loss at revision... 26 Articulation, primary operations... 27 Kaplan-Meier survival curves by year of operation and use of cement... 29 Knee prostheses Number of knee replacements by year of operation... 31 Incidence of primary knee replacements by gender and age (1995, 2000)... 31 Number of knee replacements by year of operation and type of prosthesis... 32 Knee disease... 33 Cement... 35 Prosthesis brands... 37 Reason for revision... 43 Patient age by year of operation... 46 Type of revision... 47 Kaplan-Meier survival curves by year of operation and type of prosthesis... 54 Elbow prostheses Number of elbow replacements by year of operation... 55 Elbow disease... 55 Cement... 56 Prosthesis brands... 57 Reason for revision... 57

Report 2008 Ankle prostheses Number of ankle replacements by year of operation... 59 Ankle disease... 59 Cement... 60 Prosthesis brands... 61 Reason for revision... 61 Finger joint prostheses (MCP, PIP) Number of finger joint replacements by year of operation... 63 Finger joint disease... 64 Cement... 65 Prosthesis brands... 67 Reason for revision... 68 Wrist prostheses Number of wrist replacements by year of operation... 69 Wrist disease... 69 Cement... 70 Prosthesis brands... 70 Reason for revision... 71 Carpometacarpal prostheses (CMC I) Number of CMC I replacements by year of operation... 73 CMC I disease... 73 Cement... 74 Prosthesis brands... 74 Reason for revision... 74 Lumbar disc prostheses Number of lumbar disc replacements by year of operation... 75 Lumbar disc disease... 75 Cement... 76 Prosthesis brands... 76 Shoulder prostheses (total, hemi) Number of shoulder replacements by year of operation... 77 Shoulder disease... 78 Cement... 79 Prosthesis brands... 80 Reason for revision... 82 Toe joint prostheses Number of toe joint replacements by year of operation... 83 Toe joint disease... 83 Cement... 84 Prosthesis brands... 85 Reason for revision... 85 Kaplan-Meier survival curves for elbow, ankle, finger, CMC I, shoulder and toe... 86

The Norwegian Hip Fracture Register Introduction... 87 Number of hip fractures by year of operation... 89 Incidence of primary hip fracture 2006... 89 Age by primary operation 2006... 89 Time from fracture to operation primary operation... 90 Cognitive impairment primary operation... 91 Type of anaesthesia primary operation... 92 ASA classification... 93 Type of fracture reason for primary operation... 94 Reason for reoperation... 95 Reason for reoperation by reason for primary fracture... 96 Type of primary operation vs. reason for primary operation... 97 Type of primary operation all fractures... 98 Type of reoperation... 99 Type of reoperation after primary uni/bipolar hemiprosthesis... 100 Type of reoperation after primary screw fixation... 100 Hemiprosthesis primary operation... 101 Hemiprosthesis reoperation... 102 Screws primary operation... 102 Hip compression screw primary operation... 103 Nail primary operation... 103 Fixation of primary hemiprosthesis... 103 Cement with antibiotics primary operation... 104 Fixation of primary hemiprosthesis uncemented... 104 Pathological fracture primary operation... 104 Operative approach when primary hemiprosthesis... 105 Peroperative complications primary operation... 106 Systemic antibiotic prophylaxis... 106 Thrombosis prophylaxis... 109 Kaplan-Meier survival curves for hip fractures... 113 The Norwegian Cruciate Ligament Register Introduction... 115 All operations Number of procedures by year of operation... 117 Incidence of primary reconstruction of crucate ligament 2005... 117 The number of other procedures for all categories of surgeries... 118 Distribution of other procedures in combination with primary reconstruction of cruciate ligament... 118 Distribution of other procedures in combination with reconstruction... 119 Distribution of other procedures when this is the only procedure... 119 Per operative complications... 120 Primary reconstruction of cruciate ligament

Report 2008 Age at primary operation... 121 Activity that lead to injury... 121 Injury... 122 ACL with additional injuries... 123 PCL with additional injuries... 123 Choice of graft... 124 Fixation femur ACL... 126 Fixation femur PCL... 127 Fixation tibia ACL... 128 Fixation tibia PCL... 128 Fixation femur and tibia ACL... 129 Meniscal lesion... 130 Fixation Meniscal lesion... 131 Cartilage lesion: ICRS grade... 132 Cartilage lesion: probable cause... 133 Cartilage lesion: treatment... 134 Cartilage injuries... 135 Outpatient surgery... 137 Per operative complications... 138 Systemic antibiotic prophylaxis... 138 Thrombosis prophylaxis... 139 Revision reconstruction Age at primary operation... 140 Activity that lead to injury... 140 Injury... 141 ACL with additional injuries... 142 PCL with additional injuries... 142 Choice of graft... 143 Fixation femur ACL... 145 Fixation femur PCL... 145 Fixation tibia ACL... 146 Fixation tibia PCL... 146 Fixation femur and tibia ACL... 147 Meniscal lesion... 148 Fixation Meniscal lesion... 149 Cartilage lesion: ICRS grade... 150 Cartilage lesion: probable cause... 151 Cartilage lesion: treatment... 152 Cartilage injuries... 153 Outpatient surgery... 155 Per operative complications... 156 Systemic antibiotic prophylaxis... 156 Thrombosis prophylaxis... 157 Other procedures Age at primary operation... 158 Activity that lead to injury... 158 Injury... 159 ACL with additional injuries... 160 PCL with additional injuries... 160 Meniscal lesion... 161 Fixation Meniscal lesion... 162 Cartilage lesion: ICRS grade... 163

Cartilage lesion: probable cause... 164 Cartilage lesion: treatment... 165 Cartilage injuries... 166 Outpatient surgery... 168 Per operative complications... 169 Systemic antibiotic prophylaxis... 169 Thrombosis prophylaxis... 170 Kaplan-Meier survival curves for cruciate ligament... 171 Publications...173

Report 2008

ANNUAL REPORT 2008 The Norwegian Arthroplasty Register performs quality control and research on all joint replacements from all hospitals in Norway. From the period 1987-2007 the register contains information about 129.481 hip prosthesis operations. In January 1994 the register expanded to include also replacements in other joints. From the period 1994-2007 it is registered data on 32.292 knee replacements and 8.695 in other joints than hip or knee. June 7 th 2004 the registering of operations on the cruciate ligament started. From the start and until December 31 st 2007 it is registered 6.068 cruciate ligament operations. For more information please refer to the preface for the National Cruciate Ligament Register on page 115. The Norwegian Hip Fracture Register was started January 1 st 2005 and there are 21.211 primary hip fractures and 3.613 revisions registered so far. For more information please refer to the preface on page 87. We have decided to publish mainly descriptive statistics in the annual reports. Comparative studies, for instance of the quality of different types of prostheses, are presented in scientific lectures, posters or papers. We strongly feel that the results from comparing types of prostheses should include a thoroughly review on how the patients in the study were picked and the use of statistical methods. It should also include a discussion on how the results should be interpreted. This is best done in a scientific setting, and we refer to our list of references in the end of this report and on our web-page (http://www.haukeland.no/nrl). The web-page also includes an English version of the annual report for 2008. Most of our reports and papers can be read directly from this web-page (some magazines will not give their permission). We give here an overview of the last year s scientific findings with references to the papers and abstracts, and we encourage the readers to look at our web-page and study the papers. ANNUAL REPORTS TO THE HOSPITALS The annual reports to each hospital where sent to the contact persons at the respective hospitals in September 2008. The reports include data for 2007. We encourage the orthopedic divisions to use the annual report actively in their quality work. This year a PDF-type file will be sent to the contact person to make presentations to their colleagues easier. PhDs in 2007 Orthopedic surgeon Geir Hallan at the Department of Orthopedic Surgery, Haukeland University Hospital defended his medical PhD Wear, fixation and revision of total hip prostheses January 19 th 2007 (PhDs 6). This is reported thoroughly in last year s annual report. Karin Monstad at Norwegian school of economics and business administration (NHH) defended her PhD Essays on the Economics of health and fertility (7) September 28 th 2007. The main discovery was that the hip replacement patients to a small extent took advantage of their right to choose hospital in order to shorten the waiting time to the replacement. She showed further that the elder patients were more reluctant to travel than the younger ones, but the characteristic that counted most was their level of education, patients with education more than high school were more willing to travel than the rest. PROSTHESIS SURGERY IN NORWAY 2007 It was a 5 % increase in the number of primary hip replacements from 2006 to 2007, and a 15 % increase in primary knee replacements (Table 1). It is still cemented prostheses (both components) which dominate as the fixation method both for hip and knee (Figure 5-7). Conventional polyethylene is the most common used as articulation, but the use of cross

Report 2008 linked polyethylene is increasing. This new type of plastic was used in 839 primary hip prostheses in 2007 (Table 41-43). The use of uncemented stems and cemented cups in the younger patients is promising and has increased. Randomized studies are on their way and we will encourage the surgeons to wait for the results from these. We will advise against the use of uncemented cups with conventional polyethylene (Abstract 27). The number of revisions in the hip has increased somewhat from 12.3 % in 2003 to 13.6 % in 2007 (Table 1). Preliminary analyses show that the users of the Charnley prosthesis have improved their results the last 10 years, but there is little improvement for the other cemented prostheses. This shows that there is room for improvement and that there must be a focus on surgical techniques in the education of surgeons (Abstract 6). Dislocation, infection, wear, osteolysis, and acetabular loosening are still frequent reasons for revisions, and these problems have to be solved through development of technology, research and not the leas better surgical techniques. NEW TABLES AND FIGURES The figures and tables have each a number to make it easier to find and read. We have included tromboprophylaxis and ASA class for knee prostheses (Table 22-29). We have promised the steering committee to analyze the tromboprophylaxis data so they soon can be removed from the form, because these questions take a long time to complete. It has been a trend that it is more common to give the first dose after the operation. This way of doing it is supported by randomized studies with surrogate endpoint (venografical shown deep venous thrombosis). We will study if this practice also is advisable if the death of the patient is the endpoint. SUMMARY OF THE MOST IMPORTANT FINDINGS IN 2007 Two PhDs and 10 papers are published in scientific journals. Until now in 2008 3 papers have been published, 4 papers are approved for publication and 4 are submitted for publication. 18 chapters in books are written. Uncemented femoral stems have good results. Corail (HA covered) is the one most used and has the fewest revisions with endpoint all stem revisions. The difference is small between the uncemented femoral stems used today regarding aseptic loosening as a reason for revision, with 98-99 % survival after 10 to 15 years of follow up. The problem is that the long term result for the total prosthesis is not so good due to many revisions at the cup side due to wear and loosening of uncemented cups (Dissertation 6, 53). In a study with Zweymuller SL uncemented press-fit stem and Endler Titanium screw cup with fixed polyethylene (n=70) from two hospitals there was however good results for young patients (24-68 years) with 16 years median follow up (55). Revisions of fixed uncemented cups with isolated acetabular liner exchange gave two times higher risk for revision compared with complete acetabular component revision. This indicates that the threshold to remove a fixed acetabular component can be lowered (48). The results for conversion from failed hemiarthroplasties to total hip artrhoplasties are best when the whole prosthesis were exchanged, to operate in a new acetabular component and keep the old femoral stem gave a higher risk of revision, especially due to dislocation (51). The results for total hip prosthesis after acute femoral neck fractures and sequela after fracture of femoral neck are in general good, but not as good as for primary osteoarthritis. This was due to an increase in dislocation and an increase in periprostetic fractures and infections. The risk of revision was especially higher the first six months after the primary operation compared to primary osteoarthritis patients (63).

Unicompartmental knee arthroplasties had twice the revision risk compared to total knee arthroplasties in all age groups. This was due to increased aseptic loosening of both femoral and tibia components and increased revision for periprostetic fractures (45). There was a reduction in incidence of orthopedic surgery among patients with chronic inflammatory joint diseases in the time period 1994 to 2004; this was probably due to better medication. The incidence of orthopedic surgery for primary osteoarthritis has increased in the same time period (46). The results for ankle arthroplasties were inferior after 10 years compared to arthroplasties of other joints. It has not improved the last 10 years. LINK STAR ankle arthroplasty with HA porous coating has less aseptic loosening than with HA on a smooth surface (50). Men had a higher risk of loosening of the femoral stem than women, and men and women with a high body weight had a higher risk of loosening of the femoral stem. Men with high physical activity in their leisure time had a higher risk for loosening of the cup (47). In a comparative study between the Swedish and the Norwegian Arthroplasty Registers and the Medicare database in the US it was shown that the 8 year survival for hip prostheses in the age group above 65 years was better both in Sweden and Norway than in the US. For knee prostheses the results were better in the US than in Norway. Because there was no data on prosthesis components in the Medicare database we could not analyze the reasons for these results. Our hypothesis was that good results for the hip prostheses in Sweden and Norway were due to a high rate of cemented prostheses, and the good results of the knee prostheses in the US were due to a higher rate of patella resurfacing (49). For the Charnley prostheses the lateral approach with trochanteric osteotomy reduced the risk for revision compared to lateral approach without osteotomy due to dislocation, and in the time period 1987-1994 also less revisions due to aseptic loosening. There were more revisions due to dislocation with the use of posterolateral approach (52). The result for hip prosthesis after a developmental dysplasia of the hip was as good as after a primary osteoarthritis, when we adjust for age and the use of uncemented prostheses (54). ONGOING PhD RESEARCH WITHIN JOINT PROSTHESES AND HIP FRACTURES Hilde Apold (doctor in specialization) at Orthopedic Center, Ullevål University Hospital, investigates data from the Norwegian Institute of Public Health and the Norwegian Arthroplasty Register. Astvaldur Arthursson (orthopedic surgeon) at Stavanger University Hospital has a PhD grant from Helse Vest RHF to study the results of different surgical approaches for total hip arthroplasty (52), and to validate the data from Stavanger University Hospital compared to the Norwegian Register and the Norwegian Patient Register (38). He defended his thesis 13 th of November.. Stein Hakon Lygre (MSc and statistician) has a PhD grant from Health and Rehabilitation to study data on function, pain and quality of life after primary and revision arthroplasties in the knee. He has sent out a questionnaire on quality of life (EQ-5D), function and pain (KOOS) to selected patients. He now studies the differences between primary total prostheses in knees

Report 2008 with or without patella component (Abstract 29). He found no difference in pain and function between knee prostheses with or without patella component. Eva Dybvik (MSc and statistician) has a PhD grant from Helse Vest RHF to study cancer treatment and result of hip prostheses. Data from the Cancer Registry in Norway and the Norwegian Arthroplasty Register are coupled. Bjørg Tilde Fevang (post doc) has published a paper on ankle arthroplasties (50) and a paper on shoulder arthroplasties in Norway have been accepted for publication. She is currently working on a paper on elbow arthroplasties and a paper on improvement of the prostheses surgery in Norway. Ingvild Engesæter (stud med) and Trude Lehmann (cand med) study the results of hip arthroplasty surgery for children hip diseases. Ingvild has a paper on risk of total hip replacement in younger adulthood after neonatal hip instability accepted for publication in Acta Orthopaedica (56). She works in addition with the validation of the diagnosis in children hip diseases and with functional analyzes of prostheses after children hip diseases. Jan-Erik Gjertsen (doctor in specialization) studies the result of total hip replacement in patients with hip fractures (63). He describes the start of the Hip Fracture Register (62, 65 Abstract 46, 48), and the functional results after osteosynthesis or hemi prosthesis with displaced intracapsular fractures (Abstract 49). We hope he will deliver his PhD thesis within the turn of the year. Kjell Matre (orthopedic surgeon) studies mortality after trochanteric and subtrochanteric fractures (Abstract 50, 53). Tarjei Vinje (doctor in specialization) studies mortality after dislocated intracapsular femoral neck fractures (Abstract 47). Håvard Dale (orthopedic surgeon), Jan Schrama (orthopedic surgeon) and Håkon Langvatn (stud med) study the development of infections after hip prostheses related to antibiotic prophylaxis (Abstract 30). Håkon Langvatn has traveled to selected hospitals in Norway to study the microbiological test answers after revised infected hip prostheses. ACADEMIC TEACHING BOOK IN IMPLANT SURGERY Coworkers at the Register have participated in writing a teaching book for candidates who is specializing in orthopedic surgery in hip and knee and orthopedic infections. The book is especially adjusted to the curriculum at the compulsory course regarding this subject held at Røros each year. The book is hardback and with many new color illustrations and will be a valuable reference book for all orthopedic surgeons and all orthopedic departments. The editors have been Arild Aamodt, Greger Lønne and Ove Furnes. The book can be ordered at www.legesiden.no. JOINT PROJECTS Stein Atle Lie is leading a study on total hip and knee replacement and postoperative mortality comparing data from the Australian and Norwegian Arthroplasty Registers (Abstract 10). The paper has been submitted for publication.

The Norwegian Arthorplasty Register cooperates with the Norwegian Institute of Public Health and Orthopedic Center at Ullevål University Hospital in several studies on the risk of receiving a hip or knee prosthesis. We have started a joint project with Dartmouth University in New Hampshire, US, where we use decision theory (cost-effectiveness analysis). The first study on unicompartmental or total knee arthroplasty in elderly patients is published (44), and two more studies are in progress, one regarding computer navigation in knee arthroplasty and the other on the use of antibiotics in cement. The Register is part of the Locus for registry-based epidemiology at the University of Bergen and we have used data from the Medical Birth Register. A paper has been published (56). The Register has participated at the meeting in International Society of Arthroplasty Registers (ISAR) under AAOS in San Francisco 2008. Leif Ivar Havelin is a member of the board. The goal for the society is to be a forum for national and greater regional registers where they can inform about results, experiences and also work on standardizing the reporting and registration. A symposium was held on register research at the latest AAOS, where Leif Ivar Havelin presented data on unicompartmental and total knee prostheses from the Norwegian Register (Abstract 21). Kerstin Pankewitsch, the University of Halle, Germany, is working on a PhD project where she performs data mining on data from the Register. She presented some of the results on the EAR (European Arthroplasty Register) symposium at the EFFORT meeting in Florence in 2007. NORDIC ARTHROPLASTY REGISTER ASSOCIATION (NARA) The Norwegian, Swedish and Danish Hip Arthroplasty Registers have now completed the coupling of data in an analysis file. Several papers are planned. The first study is headed by Leif Ivar Havelin and the paper has been submitted for publication. We expect a lot from this cooperation, where the focus will be on prostheses and techniques where the data samples are too small in each country on its own. MEETING WITH THE ORTHOPEDIC SOCIETY OF NORTHERN NORWAY Leif Ivar Havelin and Lasse Engesæter were in Tromsø in November. The meeting got a good review, and they showed results for the hospitals and discussed the differences between the four Health Divisions in Norway. Next year we plan a meeting in mid Norway (Helse Midt- Norge). COOPERATION WITH SINGLE HOSPITALS Coworkers at the Register receive many inquiries from single hospitals and doctors and we try to help out as much as we have capacity to. All together we had 32 relatively large summonses of data and analyzes done for hospitals, doctors, institutions, industry and the government in 2007. REPORTING REVISIONS When there are infections or removal of prostheses (in the hips as a Girdlestone operation) or part of he prosthesis has to be removed; it should be reported on the standard register form where one state the reason for the operation and which parts that have been removed. One also has to report when a new prosthesis has been operated in to a joint which has previously had a prosthesis removed.

Report 2008 EXCHANGE OF PLASTIC PARTS These revisions shall, as other revisions, be reported on the standard form where you mark out the reason for revision and what has been done, if necessary one can write this in free text. In our survival analysis we will differentiate between different types of revisions and state the endpoint in the analysis. Most commonly we will use all types of revisions of the femur and acetabulum component as the endpoint, or we can perform analysis where we exclude exchange of plastic parts in the endpoint definition. Generally we give the total number of revisions in addition to the number of revisions with only exchange of plastic parts. ADMINISTRATIVE CONDITIONS The Norwegian Register of Arthroplasty is declared as national center of excellence of joint replacements. All the functions of the center (The Norwegian Arthroplasty Register, The Norwegian Hip Fracture Register and The National Cruciate Ligament Register) are located at Møllendalsbakken 11 (close to Haukeland University Hospital). We receive funding from Helse Vest RHF and from Helse Bergen, and for The National Cruciate Ligament register also from Oslo Sports Trauma Research Center (Helse Sør-Øst). 20 YEAR ANNIVERSARY IN BERGEN SEPTEMBER 26 TH AND 27 TH 2007 The anniversary was held at Hotel Norge in Bergen. It was 120 participations on the two day long scientific symposium where we gave an overview of results and new findings from the register. It was five main topics; the use of data from medical quality registers with an introduction from the owners of the hospitals, hip arthroplasty surgery, knee arthroplasty surgery (including ankle and shoulder arthroplasty surgery), cruciate ligament surgery and hip fracture surgery. We arranged a symposium dinner at Maartmannshaven at Hotel Norge. The symposium got one-page coverage in Aftenposten. We give a big thank you to all the participants and contributors. SYMPOSIUM AT THE AUTUMN MEETING The registers arranged a two hour anniversary symposium at the annual orthopedic meeting. We presented and discussed the most important findings the last years with subjects from hip arthroplasty surgery with focus on new articulations, arthroplasty surgery in knee and other joints, cruciate ligament surgery and hip fracture surgery. This year s symposium will discuss the problems around making the hospital results public and how to handle possible divergence. STAFF Orthopedic surgeon and professor Ove Furnes is head of the Arthroplasty Register. Coworkers are orthopedic surgeon and Professor Lars Birger Engesæter, orthopedic surgeon and Professor Leif Ivar Havelin and orthopedic surgeon Geir Hallan. Together these four share one position at the register. Leif Ivar Havelin is in charge of the hip arthrolpasty, Ove Furnes is in charge of the knee and other joints arthroplasty, and Lars Birger Engesæter is in charge of the hip fracture register. The surgeons Jan-Erik Gjertsen, Tarjei Vinje, Kjell Matre, and Jonas Fevang (supervisor) are all doing research on data from the hip fracture register. Birgitte Espehaug and Anne Marie Fenstad (50 % position from August 1 st 2007) are statisticians. Kjersti Steindal is a computer engineer and has an extra responsibility for annual reports from the cruciate ligament and hip fracture registers and our databases. Tor-Egil Sørås is a computer engineer (40 % position) and works with the databases for the arthroplasty registers and the annual reports of these. Stein Atle Lie has a 20 % position as a statistician and advisor. Director of the Medical Birth Register, professor Stein Emil Vollset is scientific

and statistic advisor. Secretaries are Inger Skar (knee and other joints), Ingun Vindenes (hip prostheses), Ruth Wasmuth (cruciate ligament), Marianne Wiese (hip fracture), and Kari Alvær (hip fracture). Surgeon Knut Fjeldsgaard is scientific contact for the cruciate ligament register together with head of the board Lars Engebretsen and medical student Lars P. Granan. Randi Hole is performing research on data from the cruciate ligament register. Lise Kvamsdal is project coordinator with main responsibility for the hip fracture register. APPRECIATION TO INGER SKAR Inger has worked as a secretary at the register in more than 10 years. She has been responsible for the registration of the forms for knee and other joints. She will now retire after all together 22 years at Haukeland University Hospital. She has done an excellent job for the register with her accurate registration, her thoroughly follow up to new prostheses and her great skills to look after the boss. We will miss her at the register. We will thank her and wish her good luck with her retirement. BOARD OF THE NORWEGIAN ARTHROPLASTY REGISTER The Norwegian Orthopedic Association is the owner of the register and the general meeting in the Norwegian Orthopedic Association is its highest organ. The Norwegian Orthopedic Association has appointed a board consisting of leader professor Lars B. Engesæter (University of Bergen), Professor Lars Nordsletten (Helse Øst), Professor Arild Aamodt (Helse Midt Norge), orthopedic surgeon Odd Inge Solem (Helse Nord), and orthopedic surgeon Svein Svenningsen (Helse Sør), Professor Leif Ivar Havelin (Helse Vest) and head of the register Professor Ove Furnes. Professor emeritus Einar Sudmann is an honorary member of the board and professor Lars Engebretsen at Orthopedic Center, Ullevål University Hospital meets as the head of the board for the cruciate ligament register. BOARD OF THE CRUCIATE LIGAMENT REGISTER The board of the cruciate ligament register consists of the head professor Lars Engebretsen, surgeon Knut Fjeldsgaard, Surgeon Jon Olav Drogseth, Chief surgeon Arne Ekeland, Professor Roald Bahr and Professor Ingar Holme. ACKNOWLEDGEMENT The Norwegian Arthroplasty Register/Centre of excellence of joint replacements would like to thank all orthopedic surgeons in the country for excellent reporting. Further we would like to thank Helse Bergen, Helse Vest, all product distributors, Locus for registry based epidemiology, University of Bergen, Oslo Sports Trauma Center at the Norwegian University of Sport and Physical Education, Norwegian Patient Register, The Norwegian Institute of Public Health, Norwegian Board of Health Supervision, and the Norwegian Health Authorities, for the good cooperation in 2007. Bergen, 10.06.2008

Report 2008

Hip prostheses Table 1: Annual number of operations Year Figure 1: Annual number of operations Primary operations Revisions 2007 6 643 (86,4%) 1 043 (13,6%) 7 686 2006 6 316 (86,2%) 1 009 (13,8%) 7 325 2005 6 593 (86,2%) 1 059 (13,8%) 7 652 2004 6 217 (86,9%) 939 (13,1%) 7 156 2003 7 040 (87,7%) 990 (12,3%) 8 030 2002 6 174 (86,6%) 956 (13,4%) 7 130 2001 6 170 (87,0%) 922 (13,0%) 7 092 2000 5 695 (85,4%) 975 (14,6%) 6 670 1999 5 471 (85,3%) 943 (14,7%) 6 414 1998 5 332 (83,5%) 1 050 (16,5%) 6 382 1997 5 318 (84,0%) 1 011 (16,0%) 6 329 1996 4 822 (82,8%) 1 004 (17,2%) 5 826 1995 5 105 (83,8%) 985 (16,2%) 6 090 1994 4 606 (83,5%) 910 (16,5%) 5 516 1993 4 820 (85,1%) 845 (14,9%) 5 665 1992 4 879 (86,4%) 769 (13,6%) 5 648 1991 4 490 (85,2%) 783 (14,8%) 5 273 1990 4 848 (86,9%) 732 (13,1%) 5 580 1989 5 204 (87,5%) 741 (12,5%) 5 945 1988 3 925 (85,8%) 651 (14,2%) 4 576 1987 1 317 (88,0%) 179 (12,0%) 1 496 Registration complete from 1989 The Norwegian Arthroplasty Register 110 985 (85,7%) 18 496 (14,3%) 129 481 Number of operations 8000 7000 6000 5000 4000 3000 2000 1000 0 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 Primary operations Revisions 55,2% of the operations were performed on the right side. 68,7% of the operations were performed on women. Mean age was 69,5 years. Figure 2: Incidence of primary hip prostheses Number of operations per 100.000 inhabitants 1000 800 600 400 200 1995 Women 2000 Women 2005 Women 1995 Men 2000 Men 2005 Men 0 Age: < 40 40-49 50-59 60-69 70-79 > 79

Report 2008 Hip disease Table 2: Hip disease Year Primary osteoarthritis Rheumatoid arthritis Fract. of femoral neck Congenital dysplasia 2007 5 154 146 471 456 21 80 21 156 305 25 2006 4 815 147 486 445 17 85 24 130 331 14 2005 5 095 166 547 436 29 87 22 99 282 13 2004 4 681 140 529 414 17 85 20 94 287 3 2003 5 304 171 584 511 26 69 25 86 274 11 2002 4 621 168 534 433 29 82 37 56 239 16 2001 4 551 175 566 438 31 81 26 53 261 40 2000 4 172 168 548 380 21 81 26 60 200 63 1999 3 890 175 585 424 33 74 30 35 205 55 1998 3 760 165 654 362 27 71 25 29 189 66 1997 3 705 194 672 348 31 72 20 41 166 70 1996 3 327 181 624 337 35 58 26 25 172 38 1995 3 587 172 632 380 44 65 21 12 179 13 1994 3 211 186 571 347 50 61 23 16 126 15 1993 3 310 169 634 384 54 73 26 22 126 22 1992 3 305 210 589 422 55 73 25 8 135 57 1991 2 987 162 646 338 87 58 19 8 129 56 1990 3 258 161 658 397 81 63 20 14 128 69 1989 3 471 192 728 460 103 65 19 13 112 41 1988 2 659 164 514 321 67 47 16 10 78 49 1987 925 53 167 99 21 13 6 2 22 9 Diseases are not mutually exclusive Congenital dislocation Epiphysiol./Pert hes' disease Ankylosing spondylitis Acute fract. of the femur Other Missing information 79 788 3 465 11 939 8 132 879 1 443 477 969 3 946 745 Figure 3: Age by year of operation 50 Proportion (%) of primary operations 40 30 20 10 0 1987-1990 1991-1995 1996-2000 2001-2005 2006 2007 Year of operation <45 years 45-59 years 60-69 years 70-79 years >79 years 2 Hip

The Norwegian Arthroplasty Register Reasons for revision Table 3: Reasons for revision Year of revision Acetabular loosening Femoral loosening Dislocation Deep infection 2007 405 276 186 147 74 119 53 47 68 29 24 4 2006 399 295 198 126 63 119 45 47 48 23 31 2 2005 423 337 165 129 59 113 63 57 65 29 45 3 2004 371 297 152 124 60 101 10 31 77 44 104 1 2003 395 326 154 97 60 82 33 39 71 36 113 12 2002 410 376 136 78 70 66 29 32 57 27 123 8 2001 390 389 132 69 57 74 34 35 77 28 96 5 2000 396 419 119 61 58 101 32 39 106 33 92 2 1999 412 460 115 67 43 57 27 43 72 34 88 6 1998 468 513 131 64 41 72 24 54 55 45 101 6 1997 472 521 110 57 54 79 20 41 35 41 104 1 1996 472 568 98 87 47 68 9 19 16 34 61 5 1995 461 565 104 67 34 76 2 4 9 45 29 1 1993 435 516 61 78 33 81 3 2 4 34 31 2 1992 431 480 61 55 38 78 0 0 6 22 23 2 1992 384 458 52 57 29 64 0 0 7 12 20 4 1991 392 474 37 70 33 67 0 0 6 4 21 8 1990 409 470 26 40 27 62 0 0 3 11 18 15 1989 421 477 39 29 37 73 0 0 7 4 25 5 1988 383 409 18 32 24 70 0 0 1 11 27 6 1987 110 118 7 4 4 32 0 0 1 1 7 0 8 439 8 744 2 101 1 538 945 1 654 384 490 791 547 2 521 98 Revision causes are not mutually exclusive Fracture of femur Pain Osteolysis acet., no loosening Osteolysis femur, no loosening Polyethylene wear Previous Girdlestone Other Missing information Figure 4: Reasons for revision 1600 Reasons for revision 1400 1200 1000 800 600 400 Miss ing information Other Osteolysis and wear Pain Fracture of femur Deep infection Dislocation 200 Femoral loosening 0 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Acetabular loosening Year of revision Hip 3

Report 2008 Type of revision Table 4: Type of revision Year of revision Exchange, acetabulum Exchange, caput Exchange, caput and acetab. Exchange, femur Exchange, all components Exchange, PE liner Exchange, PE liner and caput Exchange, PE liner and femur Removal, femur Girdlestone Previous Girdlestone 2007 137 63 284 139 266 5 42 15 2 47 9 30 4 Other Missing information 13% 6% 27% 13% 26% 0% 4% 1% 0% 5% 1% 3% 0% 2006 172 34 215 139 265 11 65 12 3 58 18 14 3 17% 3% 21% 14% 26% 1% 6% 1% 0% 6% 2% 1% 0% 2005 212 34 173 133 314 6 45 24 2 55 19 34 8 20% 3% 16% 13% 30% 1% 4% 2% 0% 5% 2% 3% 1% 2004 123 38 185 131 277 10 45 17 2 68 20 13 10 13% 4% 20% 14% 29% 1% 5% 2% 0% 7% 2% 1% 1% 2003 187 34 132 169 279 12 52 22 1 60 21 7 14 19% 3% 13% 17% 28% 1% 5% 2% 0% 6% 2% 1% 1% 2002 141 20 139 179 297 6 55 20 5 47 24 15 8 15% 2% 15% 19% 31% 1% 6% 2% 1% 5% 3% 2% 1% 2001 95 23 179 193 284 7 47 16 43 26 7 2 10% 2% 19% 21% 31% 1% 5% 2% 5% 3% 1% 0% 2000 99 22 191 204 301 6 67 13 3 38 26 3 2 10% 2% 20% 21% 31% 1% 7% 1% 0% 4% 3% 0% 0% 1999 94 19 136 194 349 4 50 10 2 45 29 7 4 10% 2% 14% 21% 37% 0% 5% 1% 0% 5% 3% 1% 0% 1998 105 11 166 214 385 6 42 26 3 39 45 8 10% 1% 16% 20% 37% 1% 4% 2% 0% 4% 4% 1% 1997 119 13 113 223 404 8 30 11 4 37 43 3 3 12% 1% 11% 22% 40% 1% 3% 1% 0% 4% 4% 0% 0% 1996 99 8 113 235 424 3 10 5 2 59 35 9 2 10% 1% 11% 23% 42% 0% 1% 0% 0% 6% 3% 1% 0% 1995 126 6 87 241 409 3 12 3 4 40 41 13 13% 1% 9% 24% 42% 0% 1% 0% 0% 4% 4% 1% 1994 155 3 19 253 399 2 6 2 8 38 19 6 17% 0% 2% 28% 44% 0% 1% 0% 1% 4% 2% 1% 1993 172 2 9 234 377 1 2 4 31 9 3 1 20% 0% 1% 28% 45% 0% 0% 0% 4% 1% 0% 0% 1992 127 5 8 199 379 1 2 1 1 36 4 5 1 17% 1% 1% 26% 49% 0% 0% 0% 0% 5% 1% 1% 0% 1991 136 2 3 196 384 1 6 41 1 4 9 17% 0% 0% 25% 49% 0% 1% 5% 0% 1% 1% 1990 95 9 182 402 1 1 25 1 2 14 13% 1% 25% 55% 0% 0% 3% 0% 0% 2% 1989 99 2 3 176 427 1 18 3 1 11 13% 0% 0% 24% 58% 0% 2% 0% 0% 1% 1988 74 4 133 407 1 1 13 10 3 5 11% 1% 20% 63% 0% 0% 2% 2% 0% 1% 1987 25 1 37 112 1 1 2 14% 1% 21% 63% 1% 1% 1% 1 043 1 009 1 059 939 990 956 922 975 943 1 050 1 011 1 004 985 910 845 769 783 732 741 651 179 2 592 339 2 169 3 804 7 141 92 572 199 55 839 403 188 103 18 496 14% 2% 12% 21% 39% 0% 3% 1% 0% 5% 2% 1% 1% 4 Hip

The Norwegian Arthroplasty Register Bone transplant Table 5: Bone transplant acetabulum - Revisions Year of revision Yes No Bone impaction Missing 2007 132 (12,7 %) 586 (56,2 %) 192 (18,4 %) 133 (12,8 %) 2006 115 (11,4 %) 554 (54,9 %) 201 (19,9 %) 139 (13,8 %) 2005 161 (15,2 %) 527 (49,8 %) 230 (21,7 %) 141 (13,3 %) 2004 160 (17 %) 570 (60,7 %) 162 (17,3 %) 47 (5 %) 2003 162 (16,4 %) 651 (65,8 %) 147 (14,8 %) 30 (3 %) 2002 211 (22,1 %) 621 (65 %) 86 (9 %) 38 (4 %) 2001 182 (19,7 %) 578 (62,7 %) 132 (14,3 %) 30 (3,3 %) 2000 216 (22,2 %) 601 (61,6 %) 136 (13,9 %) 22 (2,3 %) 1999 191 (20,3 %) 593 (62,9 %) 141 (15 %) 18 (1,9 %) 1998 226 (21,5 %) 642 (61,1 %) 160 (15,2 %) 22 (2,1 %) 1997 218 (21,6 %) 636 (62,9 %) 134 (13,3 %) 23 (2,3 %) 1996 253 (25,2 %) 639 (63,6 %) 82 (8,2 %) 30 (3 %) 1995 313 (31,8 %) 641 (65,1 %) 4 (0,4 %) 27 (2,7 %) 1994 288 (31,6 %) 607 (66,7 %) 0 (0 %) 15 (1,6 %) 1993 265 (31,4 %) 558 (66 %) 0 (0 %) 22 (2,6 %) 1992 207 (26,9 %) 541 (70,4 %) 0 (0 %) 21 (2,7 %) 1991 213 (27,2 %) 555 (70,9 %) 0 (0 %) 15 (1,9 %) 1990 212 (29 %) 506 (69,1 %) 0 (0 %) 14 (1,9 %) 1989 198 (26,7 %) 535 (72,2 %) 0 (0 %) 8 (1,1 %) 1988 163 (25 %) 477 (73,3 %) 0 (0 %) 11 (1,7 %) 1987 34 (19 %) 144 (80,4 %) 0 (0 %) 1 (0,6 %) 4 120 (22,3 %) 11 762 (63,6 %) 1 807 (9,8 %) 807 (4,4 %) 1 1 043 1 009 1 059 939 990 956 922 975 943 1 050 1 011 1 004 985 910 845 769 783 732 741 651 179 18 496 Table 6: Bone transplant femur - Revisions Year of revision Yes No Bone impaction Missing 2007 124 (11,9 %) 594 (57 %) 69 (6,6 %) 256 (24,5 %) 2006 147 (14,6 %) 598 (59,3 %) 81 (8 %) 183 (18,1 %) 2005 181 (17,1 %) 571 (53,9 %) 86 (8,1 %) 221 (20,9 %) 2004 124 (13,2 %) 647 (68,9 %) 119 (12,7 %) 49 (5,2 %) 2003 137 (13,8 %) 726 (73,3 %) 97 (9,8 %) 30 (3 %) 2002 173 (18,1 %) 646 (67,6 %) 99 (10,4 %) 38 (4 %) 2001 158 (17,1 %) 584 (63,3 %) 150 (16,3 %) 30 (3,3 %) 2000 216 (22,2 %) 571 (58,6 %) 166 (17 %) 22 (2,3 %) 1999 205 (21,7 %) 534 (56,6 %) 186 (19,7 %) 18 (1,9 %) 1998 219 (20,9 %) 603 (57,4 %) 206 (19,6 %) 22 (2,1 %) 1997 217 (21,5 %) 581 (57,5 %) 190 (18,8 %) 23 (2,3 %) 1996 235 (23,4 %) 615 (61,3 %) 124 (12,4 %) 30 (3 %) 1995 367 (37,3 %) 586 (59,5 %) 5 (0,5 %) 27 (2,7 %) 1994 276 (30,3 %) 619 (68 %) 0 (0 %) 15 (1,6 %) 1993 233 (27,6 %) 590 (69,8 %) 0 (0 %) 22 (2,6 %) 1992 123 (16 %) 625 (81,3 %) 0 (0 %) 21 (2,7 %) 1991 90 (11,5 %) 678 (86,6 %) 0 (0 %) 15 (1,9 %) 1990 124 (16,9 %) 594 (81,1 %) 0 (0 %) 14 (1,9 %) 1989 134 (18,1 %) 599 (80,8 %) 0 (0 %) 8 (1,1 %) 1988 90 (13,8 %) 550 (84,5 %) 0 (0 %) 11 (1,7 %) 1987 32 (17,9 %) 146 (81,6 %) 0 (0 %) 1 (0,6 %) 3 605 (19,5 %) 12 257 (66,3 %) 1 578 (8,5 %) 1 056 (5,7 %) 1 1 043 1 009 1 059 939 990 956 922 975 943 1 050 1 011 1 004 985 910 845 769 783 732 741 651 179 18 496 1 Regsitration of "Bone impaction" started in 1996 Hip 5

Report 2008 Operative approach Table 7: Operative approach - Primary operations Year Smith- Petersen Anterolateral Lateral Posterolateral Other Missing information 2007 14 (0,2 %) 403 (6,1 %) 4 405 (66,3 %) 1 705 (25,7 %) 9 (0,1 %) 107 (1,6 %) 2006 2 (0 %) 452 (7,2 %) 4 264 (67,5 %) 1 480 (23,4 %) 3 (0 %) 115 (1,8 %) 2005 7 (0,1 %) 520 (7,9 %) 4 419 (67 %) 1 533 (23,3 %) 4 (0,1 %) 110 (1,7 %) 2004 8 (0,1 %) 463 (7,4 %) 4 284 (68,9 %) 1 437 (23,1 %) 5 (0,1 %) 20 (0,3 %) 2003 12 (0,2 %) 591 (8,4 %) 4 843 (68,8 %) 1 555 (22,1 %) 3 (0 %) 36 (0,5 %) 2002 15 (0,2 %) 414 (6,7 %) 4 295 (69,6 %) 1 397 (22,6 %) 17 (0,3 %) 36 (0,6 %) 2001 6 (0,1 %) 410 (6,6 %) 4 273 (69,3 %) 1 446 (23,4 %) 8 (0,1 %) 27 (0,4 %) 2000 15 (0,3 %) 437 (7,7 %) 3 849 (67,6 %) 1 379 (24,2 %) 2 (0 %) 13 (0,2 %) 1999 5 (0,1 %) 455 (8,3 %) 3 664 (67 %) 1 325 (24,2 %) 8 (0,1 %) 14 (0,3 %) 1998 9 (0,2 %) 395 (7,4 %) 3 679 (69 %) 1 237 (23,2 %) 0 (0 %) 12 (0,2 %) 1997 7 (0,1 %) 371 (7 %) 3 717 (69,9 %) 1 196 (22,5 %) 1 (0 %) 26 (0,5 %) 1996 6 (0,1 %) 366 (7,6 %) 3 157 (65,5 %) 1 264 (26,2 %) 3 (0,1 %) 26 (0,5 %) 1995 3 (0,1 %) 311 (6,1 %) 3 384 (66,3 %) 1 389 (27,2 %) 8 (0,2 %) 10 (0,2 %) 1994 8 (0,2 %) 188 (4,1 %) 3 182 (69,1 %) 1 220 (26,5 %) 2 (0 %) 6 (0,1 %) 1993 43 (0,9 %) 226 (4,7 %) 3 431 (71,2 %) 1 085 (22,5 %) 12 (0,2 %) 23 (0,5 %) 1992 33 (0,7 %) 283 (5,8 %) 3 380 (69,3 %) 1 122 (23 %) 9 (0,2 %) 52 (1,1 %) 1991 6 (0,1 %) 260 (5,8 %) 3 104 (69,1 %) 1 082 (24,1 %) 1 (0 %) 37 (0,8 %) 1990 3 (0,1 %) 323 (6,7 %) 3 212 (66,3 %) 1 261 (26 %) 0 (0 %) 49 (1 %) 1989 10 (0,2 %) 380 (7,3 %) 3 189 (61,3 %) 1 590 (30,6 %) 0 (0 %) 35 (0,7 %) 1988 8 (0,2 %) 262 (6,7 %) 2 476 (63,1 %) 1 139 (29 %) 1 (0 %) 39 (1 %) 1987 1 (0,1 %) 119 (9 %) 840 (63,8 %) 350 (26,6 %) 2 (0,2 %) 5 (0,4 %) 221 (0,2 %) 7 629 (6,9 %) 75 047 (67,6 %) 27 192 (24,5 %) 98 (0,1 %) 798 (0,7 %) 6 643 6 316 6 593 6 217 7 040 6 174 6 170 5 695 5 471 5 332 5 318 4 822 5 105 4 606 4 820 4 879 4 490 4 848 5 204 3 925 1 317 110 985 Table 8: Operative approach - Revisions Year Smith- Petersen Anterolateral Lateral Posterolateral Other Missing information 2007 1 (0,1 %) 55 (5,3 %) 701 (67,2 %) 269 (25,8 %) 2 (0,2 %) 15 (1,4 %) 2006 1 (0,1 %) 61 (6 %) 701 (69,5 %) 231 (22,9 %) 2 (0,2 %) 13 (1,3 %) 2005 3 (0,3 %) 44 (4,2 %) 790 (74,6 %) 198 (18,7 %) 14 (1,3 %) 10 (0,9 %) 2004 2 (0,2 %) 52 (5,5 %) 731 (77,8 %) 134 (14,3 %) 1 (0,1 %) 19 (2 %) 2003 1 (0,1 %) 85 (8,6 %) 738 (74,5 %) 114 (11,5 %) 6 (0,6 %) 46 (4,6 %) 2002 2 (0,2 %) 68 (7,1 %) 722 (75,5 %) 137 (14,3 %) 8 (0,8 %) 19 (2 %) 2001 5 (0,5 %) 83 (9 %) 673 (73 %) 131 (14,2 %) 10 (1,1 %) 20 (2,2 %) 2000 3 (0,3 %) 90 (9,2 %) 737 (75,6 %) 129 (13,2 %) 11 (1,1 %) 5 (0,5 %) 1999 3 (0,3 %) 83 (8,8 %) 728 (77,2 %) 114 (12,1 %) 8 (0,8 %) 7 (0,7 %) 1998 2 (0,2 %) 73 (7 %) 827 (78,8 %) 137 (13 %) 6 (0,6 %) 5 (0,5 %) 1997 2 (0,2 %) 55 (5,4 %) 777 (76,9 %) 168 (16,6 %) 4 (0,4 %) 5 (0,5 %) 1996 0 (0 %) 73 (7,3 %) 712 (70,9 %) 202 (20,1 %) 5 (0,5 %) 12 (1,2 %) 1995 1 (0,1 %) 60 (6,1 %) 738 (74,9 %) 178 (18,1 %) 5 (0,5 %) 3 (0,3 %) 1994 1 (0,1 %) 48 (5,3 %) 685 (75,3 %) 174 (19,1 %) 1 (0,1 %) 1 (0,1 %) 1993 1 (0,1 %) 38 (4,5 %) 624 (73,8 %) 173 (20,5 %) 4 (0,5 %) 5 (0,6 %) 1992 3 (0,4 %) 40 (5,2 %) 536 (69,7 %) 179 (23,3 %) 5 (0,7 %) 6 (0,8 %) 1991 1 (0,1 %) 36 (4,6 %) 526 (67,2 %) 216 (27,6 %) 0 (0 %) 4 (0,5 %) 1990 1 (0,1 %) 43 (5,9 %) 464 (63,4 %) 220 (30,1 %) 1 (0,1 %) 3 (0,4 %) 1989 3 (0,4 %) 51 (6,9 %) 419 (56,5 %) 261 (35,2 %) 1 (0,1 %) 6 (0,8 %) 1988 6 (0,9 %) 51 (7,8 %) 347 (53,3 %) 242 (37,2 %) 0 (0 %) 5 (0,8 %) 1987 1 (0,6 %) 23 (12,8 %) 94 (52,5 %) 61 (34,1 %) 0 (0 %) 0 (0 %) 43 (0,2 %) 1 212 (6,6 %) 13 270 (71,7 %) 3 668 (19,8 %) 94 (0,5 %) 209 (1,1 %) 1 043 1 009 1 059 939 990 956 922 975 943 1 050 1 011 1 004 985 910 845 769 783 732 741 651 179 18 496 6 Hip

The Norwegian Arthroplasty Register Trochanteric osteotomy Table 9: Trochanteric osteotomy Year Primary operations Revisions No Yes Missing No Yes Missing 2007 6 089 (91,7 %) 74 (1,1 %) 480 (7,2 %) 861 (82,6 %) 109 (10,5 %) 73 (7 %) 2006 5 715 (90,5 %) 87 (1,4 %) 514 (8,1 %) 838 (83,1 %) 104 (10,3 %) 67 (6,6 %) 2005 5 982 (90,7 %) 112 (1,7 %) 499 (7,6 %) 866 (81,8 %) 102 (9,6 %) 91 (8,6 %) 2004 5 997 (96,5 %) 130 (2,1 %) 90 (1,4 %) 807 (85,9 %) 99 (10,5 %) 33 (3,5 %) 2003 6 706 (95,3 %) 213 (3 %) 121 (1,7 %) 862 (87,1 %) 97 (9,8 %) 31 (3,1 %) 2002 5 891 (95,4 %) 194 (3,1 %) 89 (1,4 %) 824 (86,2 %) 104 (10,9 %) 28 (2,9 %) 2001 5 939 (96,3 %) 157 (2,5 %) 74 (1,2 %) 776 (84,2 %) 120 (13 %) 26 (2,8 %) 2000 5 515 (96,8 %) 121 (2,1 %) 59 (1 %) 842 (86,4 %) 118 (12,1 %) 15 (1,5 %) 1999 5 265 (96,2 %) 176 (3,2 %) 30 (0,5 %) 811 (86 %) 121 (12,8 %) 11 (1,2 %) 1998 5 019 (94,1 %) 282 (5,3 %) 31 (0,6 %) 904 (86,1 %) 131 (12,5 %) 15 (1,4 %) 1997 4 970 (93,5 %) 302 (5,7 %) 46 (0,9 %) 881 (87,1 %) 115 (11,4 %) 15 (1,5 %) 1996 4 457 (92,4 %) 311 (6,4 %) 54 (1,1 %) 882 (87,8 %) 98 (9,8 %) 24 (2,4 %) 1995 4 597 (90 %) 491 (9,6 %) 17 (0,3 %) 827 (84 %) 154 (15,6 %) 4 (0,4 %) 1994 4 100 (89 %) 495 (10,7 %) 11 (0,2 %) 781 (85,8 %) 120 (13,2 %) 9 (1 %) 1993 4 183 (86,8 %) 593 (12,3 %) 44 (0,9 %) 723 (85,6 %) 113 (13,4 %) 9 (1,1 %) 1992 4 176 (85,6 %) 630 (12,9 %) 73 (1,5 %) 656 (85,3 %) 103 (13,4 %) 10 (1,3 %) 1991 3 646 (81,2 %) 790 (17,6 %) 54 (1,2 %) 626 (79,9 %) 146 (18,6 %) 11 (1,4 %) 1990 3 730 (76,9 %) 1 064 (21,9 %) 54 (1,1 %) 553 (75,5 %) 169 (23,1 %) 10 (1,4 %) 1989 3 961 (76,1 %) 1 167 (22,4 %) 76 (1,5 %) 539 (72,7 %) 197 (26,6 %) 5 (0,7 %) 1988 2 874 (73,2 %) 997 (25,4 %) 54 (1,4 %) 434 (66,7 %) 206 (31,6 %) 11 (1,7 %) 1987 960 (72,9 %) 338 (25,7 %) 19 (1,4 %) 126 (70,4 %) 52 (29,1 %) 1 (0,6 %) 7 686 7 325 7 652 7 156 8 030 7 130 7 092 6 670 6 414 6 382 6 329 5 826 6 090 5 516 5 665 5 648 5 273 5 580 5 945 4 576 1 496 99 772 (89,9 %) 8 724 (7,9 %) 2 489 (2,2 %) 15 419 (83,4 %) 2 578 (13,9 %) 499 (2,7 %) 129 481 Systemic antibiotic prophylaxis Table 10: Systemic antibiotic prophylaxis Primary operations Revisions Year No Yes Missing No Yes Missing 2007 27 (0,4 %) 6 609 (99,5 %) 7 (0,1 %) 29 (2,8 %) 1 007 (96,5 %) 7 (0,7 %) 2006 37 (0,6 %) 6 279 (99,4 %) 0 (0 %) 28 (2,8 %) 981 (97,2 %) 0 (0 %) 2005 23 (0,3 %) 6 570 (99,7 %) 0 (0 %) 19 (1,8 %) 1 040 (98,2 %) 0 (0 %) 2004 1 (0 %) 6 216 (100 %) 0 (0 %) 6 (0,6 %) 928 (98,8 %) 5 (0,5 %) 2003 1 (0 %) 7 038 (100 %) 1 (0 %) 8 (0,8 %) 975 (98,5 %) 7 (0,7 %) 2002 5 (0,1 %) 6 167 (99,9 %) 2 (0 %) 10 (1 %) 943 (98,6 %) 3 (0,3 %) 2001 13 (0,2 %) 6 155 (99,8 %) 2 (0 %) 3 (0,3 %) 918 (99,6 %) 1 (0,1 %) 2000 10 (0,2 %) 5 684 (99,8 %) 1 (0 %) 6 (0,6 %) 969 (99,4 %) 0 (0 %) 1999 5 (0,1 %) 5 465 (99,9 %) 1 (0 %) 5 (0,5 %) 935 (99,2 %) 3 (0,3 %) 1998 8 (0,2 %) 5 323 (99,8 %) 1 (0 %) 6 (0,6 %) 1 044 (99,4 %) 0 (0 %) 1997 7 (0,1 %) 5 311 (99,9 %) 0 (0 %) 5 (0,5 %) 1 004 (99,3 %) 2 (0,2 %) 1996 7 (0,1 %) 4 815 (99,9 %) 0 (0 %) 10 (1 %) 993 (98,9 %) 1 (0,1 %) 1995 12 (0,2 %) 5 092 (99,7 %) 1 (0 %) 3 (0,3 %) 982 (99,7 %) 0 (0 %) 1994 27 (0,6 %) 4 578 (99,4 %) 1 (0 %) 12 (1,3 %) 898 (98,7 %) 0 (0 %) 1993 56 (1,2 %) 4 761 (98,8 %) 3 (0,1 %) 12 (1,4 %) 832 (98,5 %) 1 (0,1 %) 1992 107 (2,2 %) 4 767 (97,7 %) 5 (0,1 %) 16 (2,1 %) 746 (97 %) 7 (0,9 %) 1991 137 (3,1 %) 4 340 (96,7 %) 13 (0,3 %) 24 (3,1 %) 755 (96,4 %) 4 (0,5 %) 1990 231 (4,8 %) 4 613 (95,2 %) 4 (0,1 %) 18 (2,5 %) 711 (97,1 %) 3 (0,4 %) 1989 459 (8,8 %) 4 739 (91,1 %) 6 (0,1 %) 36 (4,9 %) 703 (94,9 %) 2 (0,3 %) 1988 550 (14 %) 3 366 (85,8 %) 9 (0,2 %) 45 (6,9 %) 602 (92,5 %) 4 (0,6 %) 1987 222 (16,9 %) 1 090 (82,8 %) 5 (0,4 %) 13 (7,3 %) 164 (91,6 %) 2 (1,1 %) 7 686 7 325 7 652 7 156 8 030 7 130 7 092 6 670 6 414 6 382 6 329 5 826 6 090 5 516 5 665 5 648 5 273 5 580 5 945 4 576 1 496 1 945 (1,8 %) 108 978 (98,2 %) 62 (0,1 %) 314 (1,7 %) 18 130 (98 %) 52 (0,3 %) 129 481 Hip 7

Report 2008 Use of cement in primary operations Figure 5: Use of cement in primary operations - All patients Proportion of primary operations 100 % 80 % 60 % 40 % 20 % 0 % 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Figure 6: Use of cement in primary operations - Patients < 60 years Proportion of primary operations 100 % 80 % 60 % 40 % 20 % 0 % 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Figure 7: Use of cement in primary operations - Patients >= 60 years Proportion of primary operations 100 % 80 % 60 % 40 % 20 % 0 % 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Cemented (containing antibiotic) Cemented (plain) Uncemented Hybrid, cemented acetabulum Hybrid, cemented femur Other / Missing information 8 Hip

The Norwegian Arthroplasty Register Use of cement in revisions Table 11: Use of cement in revisions - Acetabulum With antibiotic Without antibiotic Uncemented Missing information >=60 yrs <60 yrs All >=60 yrs <60 yrs All >=60 yrs <60 yrs All >=60 yrs <60 yrs All >=60 yrs <60 yrs All 2007 58% 51% 59% 0% 0% 0% 42% 48% 41% 0% 1% 0% 707 112 595 2006 60% 54% 61% 0% 0% 0% 40% 46% 39% 0% 0% 0% 676 98 578 2005 63% 60% 64% 0% 0% 0% 37% 40% 36% 0% 0% 0% 748 146 602 2004 66% 58% 68% 0% 0% 0% 33% 42% 32% 0% 0% 0% 639 106 533 2003 68% 66% 68% 0% 0% 1% 32% 34% 31% 0% 0% 0% 653 109 544 2002 64% 68% 63% 1% 1% 1% 35% 31% 36% 0% 0% 0% 623 110 513 2001 60% 53% 61% 3% 5% 2% 38% 42% 37% 0% 0% 0% 588 105 483 2000 60% 52% 63% 0% 1% 0% 39% 47% 37% 0% 1% 0% 619 135 484 1999 62% 51% 65% 0% 1% 0% 37% 48% 34% 0% 0% 0% 620 126 494 1998 64% 55% 66% 1% 0% 1% 35% 45% 33% 0% 0% 0% 711 127 584 1997 55% 44% 58% 0% 1% 0% 45% 56% 42% 0% 0% 0% 679 126 553 1996 53% 35% 56% 1% 0% 1% 46% 65% 42% 0% 0% 1% 672 110 562 1995 53% 34% 58% 0% 0% 1% 46% 66% 41% 1% 0% 1% 670 129 541 1994 49% 30% 53% 1% 0% 1% 49% 70% 45% 0% 0% 0% 597 105 492 1993 45% 19% 52% 1% 2% 1% 53% 79% 46% 0% 0% 0% 568 112 456 1992 59% 32% 65% 3% 0% 3% 37% 64% 31% 1% 3% 1% 527 90 437 1991 58% 34% 63% 3% 1% 4% 36% 62% 31% 3% 2% 3% 542 82 460 1990 62% 32% 68% 2% 0% 2% 34% 65% 27% 3% 3% 3% 525 92 433 1989 66% 36% 73% 3% 0% 4% 29% 61% 22% 1% 3% 1% 541 98 443 1988 70% 46% 74% 4% 0% 5% 24% 51% 18% 2% 4% 2% 503 83 420 1987 73% 50% 76% 3% 0% 3% 23% 50% 19% 1% 0% 2% 141 16 125 60% 46% 63% 1% 1% 1% 38% 53% 35% 1% 1% 1% 12 549 2 217 10 332 Table 12: Use of cement in revisions - Femur With antibiotic Without antibiotic Uncemented Missing information >=60 yrs <60 yrs All >=60 yrs <60 yrs All >=60 yrs <60 yrs All >=60 yrs <60 yrs All >=60 yrs <60 yrs All 2007 34% 23% 36% 0% 0% 0% 66% 77% 64% 0% 0% 0% 423 44 379 2006 37% 20% 39% 0% 0% 0% 63% 80% 61% 0% 0% 0% 424 49 375 2005 40% 35% 41% 0% 0% 0% 60% 65% 59% 0% 0% 0% 506 65 441 2004 53% 31% 57% 0% 0% 0% 47% 69% 43% 0% 0% 0% 462 61 401 2003 60% 52% 61% 0% 0% 0% 39% 48% 38% 0% 0% 0% 496 56 440 2002 61% 67% 60% 1% 2% 1% 38% 31% 39% 0% 0% 0% 519 42 477 2001 60% 42% 62% 1% 0% 1% 39% 58% 37% 0% 0% 0% 521 50 471 2000 64% 59% 64% 0% 0% 0% 36% 41% 35% 1% 0% 1% 545 58 487 1999 66% 48% 69% 0% 0% 0% 34% 52% 31% 0% 0% 0% 589 82 507 1998 66% 52% 68% 0% 0% 0% 33% 47% 31% 1% 1% 1% 673 85 588 1997 63% 53% 65% 0% 0% 1% 36% 47% 34% 0% 0% 0% 681 89 592 1996 64% 43% 67% 2% 1% 2% 34% 56% 30% 1% 0% 1% 699 87 612 1995 61% 40% 65% 3% 3% 3% 35% 57% 31% 1% 0% 1% 702 107 595 1994 57% 31% 61% 5% 2% 5% 38% 67% 33% 1% 0% 1% 668 102 566 1993 55% 28% 61% 3% 3% 4% 41% 69% 36% 0% 0% 0% 629 103 526 1992 71% 52% 75% 4% 3% 5% 23% 43% 19% 2% 1% 2% 589 92 497 1991 70% 50% 74% 5% 2% 6% 21% 45% 16% 4% 3% 4% 599 92 507 1990 69% 40% 75% 3% 2% 4% 23% 54% 16% 5% 5% 6% 605 108 497 1989 73% 44% 80% 4% 1% 4% 21% 52% 13% 2% 3% 2% 617 113 504 1988 74% 46% 80% 4% 0% 4% 19% 46% 13% 4% 9% 3% 562 94 468 1987 75% 42% 80% 5% 0% 5% 17% 47% 13% 3% 11% 2% 154 19 135 61% 43% 64% 2% 1% 2% 36% 55% 33% 1% 1% 1% 11 663 1 598 10 065 Hip 9