Association Between Epidemiological Factors and Nonresponders to Total Joint Replacement Surgery in Primary Osteoarthritis Patients

Identification of biomarkers and immune infiltration characterization of lipid metabolism-associated genes in osteoarthritis based on machine learning algorithms

Osteoarthritis (OA) is a prevalent degenerative condition commonly observed in the elderly, leading to consequential disability. Despite notable advancements made in clinical strategies for OA, its pathogenesis remains uncertain. The intricate association between OA and metabolic processes has yet to receive comprehensive exploration. In our investigation, we leveraged public databases and applied machine learning algorithms, including WGCNA, LASSO, RF, immune infiltration analysis, and pathway enrichment analysis, to scrutinize the role of lipid metabolism-associated genes (LAGs) in the OA. Our findings identified three distinct biomarkers, and evaluated their expression to assess their diagnostic value in the OA patients. The exploration of immune infiltration in these patients revealed an intricate relationship between immune cells and the identified biomarkers. In addition, in vitro experiments, including qRT-PCR, Western blot, chondrocyte lipid droplets detection and mitochondrial fatty acid oxidation measurement, further verified abnormal expressions of selected LAGs in OA cartilage and confirmed the correlation between lipid metabolism and OA.

A Latent Change Score Approach to Understanding Chronic Bodily Pain Outcomes Following Knee Arthroplasty: A Secondary Analysis of Longitudinal Data

BACKGROUND

The extent to which chronic bodily pain changes following total knee arthroplasty (TKA) is unknown. We determined the extent of chronic bodily pain changes at 1 year following TKA.

METHODS

Data from our randomized trial of pain coping skills, which revealed no effect of the studied interventions, were used. The presence and severity of chronic pain in 16 body regions, excluding the surgically treated knee, were determined prior to and 1 year following surgery. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scale was used to quantify the extent of surgical knee pain. Latent change score (LCS) models were used to determine the extent to which true chronic bodily pain scores change after TKA.

RESULTS

The mean age of the sample of 367 participants was 63.4 ± 8.0 years, and 247 (67%) were female. LCS analyses showed significant 20% to 54% reductions in pain in the surgically treated lower limb (not including the surgically treated knee), pain in the non-surgically treated lower limb, and whole body pain. In bivariate LCS analyses, greater improvement in the WOMAC pain score, indicating surgical benefit of TKA, led to greater improvement in all 4 bodily pain areas beyond the surgically treated knee, even after controlling for the latent change in pain catastrophizing.

CONCLUSIONS

Clinically important chronic bodily pain reductions occurred following TKA and may be causally linked to the surgical procedure. Reduction in chronic bodily pain in sites other than the surgically treated knee is an additional benefit of TKA.

LEVEL OF EVIDENCE

Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Impact of pain in other body regions on the foot-specific quality of life in patients with hallux valgus

OBJECTIVES

The purpose of this study was to clarify the prevalence of pain outside the foot, and to determine the associations of pain outside the foot with foot-specific quality of life (QOL) in patients with hallux valgus.

METHODS

Patients scheduled to undergo hallux valgus surgery were recruited. Patients answered whether they experienced disabling pain in 13 body regions other than the foot. Foot-specific QOLwas assessed using the Self-Administered Foot Evaluation questionnaire (SAFE-Q). Foot pain was quantified using the visual analogue scale (VAS). Patient characteristics, including age, sex, comorbidity, anxiety, and depression, were also surveyed. The association between pain elsewhere and the SAFE-Q and pain VAS scores were assessed using univariate and multivariate analyses.

RESULTS

Of 102 patients, 55 (54%) experienced pain other than the foot. All SAFE-Q subscale scores were lower, and pain VAS was higher in patients with pain elsewhere than in patients without. In the multivariate analysis, an increase in the number of pain regions was independently associated with a decrease in SAFE-Q scores and an increase in pain VAS.

CONCLUSION

More than half of the patients with hallux valgus experienced pain elsewhere. The presence of pain elsewhere was associated with poorer foot-specific QOL and severer foot pain.

Post-surgical contributors to persistent knee pain following knee replacement: The Multicenter Osteoarthritis Study (MOST)

Objective

Pain persistence following knee replacement (KR) occurs in ∼20-30% of patients. Although several studies have identified preoperative risk factors for persistent post-KR pain, few have focused on post-KR contributing factors. We sought to determine whether altered nociceptive signaling and other peripheral nociceptive drivers present post-operatively contribute to post-KR pain.

Design

We included participants from the Multicenter Osteoarthritis Study who were evaluated ∼12 months after KR. We evaluated the relation of measures of pain sensitivity [pressure pain threshold (PPT), temporal summation (TS), and conditioned pain modulation (CPM)] and the number of painful body sites to post-KR WOMAC knee pain, and of the number of painful sites to altered nociceptive signaling using linear or logistic regression models, as appropriate.

Results

171 participants (mean age 69 years, 62% female) were included. TS was associated with worse WOMAC pain post-KR (β ​= ​0.77 95% CI:0.19-1.35) and reduced odds of achieving patient acceptable symptom state (aOR ​= ​0.54 95%CI:0.34-0.88). Inefficient CPM was also associated with worse WOMAC pain post-KR (β ​= ​1.43 95% CI:0.15-2.71). In contrast, PPT was not associated with these outcomes. The number of painful body sites present post-KR was associated with TS (β ​= ​0.05, 95% CI:0.01, 0.05).

Conclusions

Post-KR presence of central sensitization and inefficient descending pain modulation was associated with post-KR pain. We also noted that presence of other painful body sites contributes to altered nociceptive signaling, and this may thus also contribute to the experience of knee pain post-KR. Our findings provide novel insights into central pain mechanisms and other peripheral pain sources contributing to post-KR persistent knee pain.

Effectiveness of different antithrombotic agents in combination with tranexamic acid for venous thromboembolism prophylaxis and blood management after total knee replacement: a prospective randomized study

BACKGROUND

Tranexamic acid (TXA) has been widely applied in total knee arthroplasty (TKA) to significantly reduce perioperative blood loss and improve knee function recovery in patients after surgery. The choice of antithrombotic agents for venous thromboembolism (VTE) prevention after TKA is controversial. Therefore, this study aimed to compare the effects of different antithrombotic agents on patients after primary unilateral TKA in the context of applied TXA.

METHODS

A total of 180 patients undergoing primary unilateral TKA from October 2020 to December 2021 were included in this study. All patients were given an intraoperative drip of 60 mg/kg TXA. Thereafter, patients were divided into three groups (n = 60 each). Baseline data were comparable among the three groups. The average follow-up time was 3.02 ± 0.09 months. Group 1 enrolled patients receiving oral rivaroxaban (RA) at 10 mg, Group 2 included patients who received subcutaneous Dalteparin sodium at 2500 IU, while Group 3 included patients taking oral aspirin (ASA) at 100 mg. Patients in all the three groups received treatment once a day for 30 days at 12 h postoperatively. The primary outcomes in this study were post-treatment drainage volume and thrombotic complication rate. The secondary outcomes included hematologic parameters, transfusion rate, intraoperative blood loss, total blood loss (TBL), and bleeding complication rate.

RESULTS

The average drainage volume after treatment was significantly lower in Group 3 than in Group 1 and Group 2 (205.2 ± 69.0 vs 243.4 ± 72.5 vs 295.4 ± 72.5 ml, P < 0.001), and there was a significant difference between Group 1 and Group 2 (243.4 ± 72.5 mL vs 295.4 ± 72.5 mL, P < 0.001). The blood transfusion rate of Group 2 dramatically increased compared with Group 1 and Group 3 (20.0% vs 6.7% vs 5.0%, P = 0.01). The bleeding complication rate in Group 1 apparently increased relative to Group 2 and Group 3 (26.7% vs 10.0% vs 8.3%, P = 0.008). Besides, there was no significant difference in the thrombotic complication rate among the three groups.

CONCLUSION

Under the background of TXA application, ASA, RA, and Dalteparin sodium were all effective on preventing VTE after TKA. In addition, ASA effectively reduced post-treatment Hemoglobin (Hb) loss, drainage volume, TBL, transfusion rate, and bleeding complications compared with RA and Dalteparin sodium.

TRIAL REGISTRATION

The trial was registered at the Chinese Clinical Trial Registry (ChiCTR2200060169). Date of Registration: 21/05/2022.

Effects of psychological distress on the general health to self-reported pain and function outcome relationship in knee arthroplasty: A causal mediation study

Objectives

We examined two potential causal pathways that could be intervention targets to enhance knee arthroplasty outcomes. Data from a no-effect trial of persons with moderate to high pain catastrophizing were used to determined whether pain catastrophizing, depressive symptoms causally mediate the effect of preoperative general health on postoperative knee pain and functional difficulty.

Methods

We used natural-effects models to conduct causal mediation analyses using the preoperative dichotomized EQ-5D-5L general health measure as the exposure, 2-month postoperative pain catastrophizing, depressive symptoms, and localized knee pain as potential mediators, and 12-month dichotomized Western Ontario and McMaster's University Osteoarthritis Index (WOMAC) Pain and Function scores reflecting good versus poor outcome as the outcomes.

Results

Estimates of the indirect (mediating) effect suggested that pain catastrophizing mediated the effect of preoperative general health on 12-month WOMAC pain score by increasing odds of a good outcome by 8% (natural indirect effect odds ratio ​= ​1.08, 95% CI: 0.88, 1.29). The direction of mediating effects and their magnitude were similar for depressive symptoms; Sensitivity analyses suggested similar magnitudes and mediating effects to those reported for the main analyses.

Conclusions

Our findings suggested that pain catastrophizing and depressive symptoms have a mediating role on the effect of baseline general health on self-reported pain and function outcomes. These findings support the continued treatment of pain catastrophizing and depressive symptoms as viable targets for interventions to potentially enhance pain and function outcomes for patients with moderate to high levels of psychological distress prior to surgery.

Changes in Thromboelastography to Predict Ecchymosis After Knee Arthroplasty: A Promising Guide for the Use of Anticoagulants

Background

Ecchymosis is one of the worrisome complications after total knee arthroplasty (TKA) and interferes with functional rehabilitation. Current clinical guidelines do not provide individualized approaches for patients with ecchymoses.

Methods

In this study, we used thromboelastography (TEG) to determine the coagulation state after TKA and to then explore markers that predict the occurrence of ecchymosis events after TKA. In our cohort, patients were divided into ecchymosis (n = 55) and non-ecchymosis (n = 137) groups according to whether ecchymosis events occurred after TKA. Rivaroxaban 10 mg/d was taken orally for thromboprophylaxis after surgery. All patients completed TEG testing. Correlation analysis was used to determine the risk factors for ecchymosis after TKA, and receiver operating characteristic (ROC) curves for variables with significant correlation were plotted.

Results

In all, 55 of the 192 patients (28.65%) developed ecchymosis surrounding the surgical site. Multivariate analysis showed that hidden blood loss (OR = 1.003 and p = 0.005) and changes in the coagulation index (ΔCI) values (OR = 0.351 and p = 0.001) were risk factors for ecchymosis after TKA. Using the Youden index, 0.1805 was determined as the optimal threshold value of ΔCI for predicting the occurrence of ecchymosis, with a sensitivity of 74.55% and specificity of 72.99%. ΔCI is a promising marker as an alarm for the occurrence of ecchymosis after TKA.

Trial Registration

The study was registered in the Chinese Clinical Trial Registry (ChiCTR1800017245). Registered name: The role of thrombelastography in monitoring the changes of coagulation function during perioperative period of arthroplasty. Registered 19 July 2018. http://www.chictr.org.cn/showproj.aspx?proj=29220

Are There Distinct Statistical Groupings of Mental Health Factors and Pathophysiology Severity Among People with Hip and Knee Osteoarthritis Presenting for Specialty Care?

BACKGROUND

There is mounting evidence that objective measures of pathophysiology do not correlate well with symptom intensity. A growing line of inquiry identifies statistical combinations (so-called "phenotypes") of various levels of distress and unhelpful thoughts that are associated with distinct levels of symptom intensity and magnitude of incapability. As a next step, it would be helpful to understand how distress and unhelpful thoughts interact with objective measures of pathologic conditions such as the radiologic severity of osteoarthritis. The ability to identify phenotypes of these factors that are associated with distinct levels of illness could contribute to improved personalized musculoskeletal care in a comprehensive, patient-centered model.

QUESTIONS/PURPOSES

(1) When measures of mental health are paired with radiologic osteoarthritis severity, are there distinct phenotypes among adult patients with hip and knee osteoarthritis? (2) Is there a difference in the degree of capability and pain self-efficacy among the identified mental health and radiologic phenotypes? (3) When capability (Patient-reported Outcomes Measurement Information System Physical Function [PROMIS PF]) is paired with radiographic osteoarthritis severity, are there distinct phenotypes among patients with hip and knee osteoarthritis? (4) Is there a difference in mental health among patients with the identified capability and radiologic phenotypes?

METHODS

We performed a secondary analysis of data from a study of 119 patients who presented for musculoskeletal specialty care for hip or knee osteoarthritis. Sixty-seven percent (80 of 119) of patients were women, with a mean age of 62 ± 10 years. Seventy-six percent (91 of 119) of patients had knee osteoarthritis, and 59% (70 of 119) had an advanced radiographic grade of osteoarthritis (Kellgren-Lawrence grade 3 or higher). This dataset is well-suited for our current experiment because the initial study had broad enrollment criteria, making these data applicable to a diverse population and because patients had sufficient variability in radiographic severity of osteoarthritis. All new and returning patients were screened for eligibility. We do not record the percentage of eligible patients who do not participate in cross-sectional surveys, but the rate is typically high (more than 80%). One hundred forty-eight eligible patients started the questionnaires, and 20% (29 of 148) of patients did not complete at least 60% of the questionnaires and were excluded, leaving 119 patients available for analysis. We measured psychologic distress (Patient Health Questionnaire-2 [PHQ-2] and Generalized Anxiety Disorder-2 questionnaire [GAD-2]), unhelpful thoughts about pain (Pain Catastrophizing Scale-4 [PCS-4]), self-efficacy when in pain (Pain Self-Efficacy Questionnaire-2), and capability (PROMIS PF). One of two arthroplasty fellowship-trained surgeons assigned the Kellgren-Lawrence grade of osteoarthritis based on radiographs in the original study. We used a cluster analysis to generate two sets of phenotypes: (1) measures of mental health (PHQ-2, GAD-2, PCS-4) paired with the Kellgren-Lawrence grade and (2) capability (PROMIS PF) paired with the Kellgren-Lawrence grade. We used one-way ANOVA and Kruskal-Wallis H tests to assess differences in capability and self-efficacy and mental health, respectively.

RESULTS

When pairing measures of psychologic distress (PHQ-2 and GAD-2) and unhelpful thoughts (catastrophic thinking) with the grade of radiographic osteoarthritis, six distinct phenotypes arose. These groups differed in terms of capability and pain self-efficacy (for example, mild pathology/low distress versus average pathology/high distress [PROMIS PF, mean ± standard deviation]: 43 ± 6.3 versus 33 ± 4.8; p = 0.003). When pairing the degree of capability (PROMIS PF) with the Kellgren-Lawrence grade, four distinct phenotypes arose. Patients in three of these did not differ in terms of disease severity but had notable variation in the degree of limitations. Patients with these radiologic and capability phenotypes differed in terms of distress and unhelpful thoughts (for example, moderate pathology/low capability versus mild pathology/high capability [PHQ-2, median and interquartile range]: 3 [1 to 5] versus 0 [0 to 0]; p < 0.001).

CONCLUSION

Statistical groupings ("phenotypes") that include both measures of pathology and mental health are associated with differences in symptom intensity and magnitude of incapability and have the potential to help musculoskeletal specialists discern mental and social health priorities. Future investigations may test whether illness phenotype-specific comprehensive biopsychosocial treatment strategies are more effective than treatment of pathology alone.

LEVEL OF EVIDENCE

Level III, prognostic study.

Kartogenin Promotes the BMSCs Chondrogenic Differentiation in Osteoarthritis by Down-Regulation of miR-145-5p Targeting Smad4 Pathway

BACKGROUND

Transplantation of mesenchymal stem cells (MSCs) is a potential therapeutic strategy for cartilage degeneration of osteoarthritis (OA). But controlling chondrogenic differentiation of the implanted MSCs in the joints remains a challenge. The role of kartogenin (KGN) for chondrogenesis of MSCs has been widely reported, however, the mechanism of chondrogenesis has not been elucidated in OA.

METHODS

In this study, we investigated the miR-145-5p, TGF-β, Samd4, and p-stat3/stat3 expression in cartilage of OA patients and bone marrow mesenchymal stem cells (BMSCs) treated with KGN or miR-145-5p inhibitor. In addition, the cell proliferation and chondrogenic differentiation in vitro and in vivo of BMSCs treated with KGN was also detected.

RESULTS

In OA patients, the expression of miR-145-5p was up-regulated, and the expression of TGF-β, Samd4, and p-stat3/stat3 was inhibited. When the BMSCs treated with miR-145-5p inhibitor, the expression of TGF-β, Samd4, and p-stat3/stat3 was also significantly up-regulated. KGN-treated BMSCs had better proliferation and chondrogenic differentiation by up-regulating the expression of Sox 9, Col-2a1, aggrecan in vitro and in OA by down-regulation of miR-145-5p targeting Smad4 pathway. Moreover, intra-articular injection of KGN-treated BMSCs had a better pain relief effect in OA.

CONCLUSION

The double effect on cartilage protection and pain relief indicates a great potential of intra-articular injection of KGN-treated BMSCs for the treatment of OA.