Hip and Knee Arthroplasty in the Geriatric Population

Effects of Preoperative Carbohydrate-rich Drinks on Immediate Postoperative Outcomes in Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

This study investigates the effects of preoperative carbohydrate-rich drinks on postoperative outcomes after primary total knee arthroplasty.

METHODS

We prospectively randomized 153 consecutive patients undergoing primary total knee arthroplasty at one institution. Patients were assigned to one of three groups: group A (50 patients) received a carbohydrate-rich drink; group B (51 patients) received a placebo drink; and group C (52 patients) did not receive a drink (control). All healthcare personnel and patients were blinded to group allocation. Controlling for demographics, we analyzed the rate of postoperative nausea and vomiting, length of stay, opiate consumption, pain scores, serum glucose, adverse events, and intraoperative and postoperative fluid intake.

RESULTS

Demographics and comorbidities were similar among the groups. There were no significant differences in surgical interventions or experience. Surgical fluid intake and total blood loss were similar among the three groups (P = 0.47, P = 0.23). Furthermore, acute postoperative outcomes (ie, pain, episodes of nausea, and length of stay) were similar across all three groups. There were no significant differences in adverse events between the three groups (P = 0.13). There was a significant difference in one-time postoperative bolus between the three groups (P = 0.02), but after multivariate analysis, it did not demonstrate significance. None of the intervention group were readmitted, whereas 5.9% and 11.5% were readmitted in the placebo and control groups, respectively (P = 0.047). The chance of 90-day readmission was reduced in group A compared with group C (odds ratio, 0.08; 95% confidence interval, 0.01 to 0.72; P = 0.02). There were no differences in other postoperative outcome measurements.

CONCLUSION

This randomized controlled trial demonstrated that preoperative carbohydrate loading does not improve immediate postoperative outcomes, such as nausea and vomiting; however, it demonstrated that consuming fluid preoperatively proved no increased risk of adverse outcomes and there was a trend toward decrease of one-time boluses postoperatively.

CLINICAL TRIALS REGISTRY

NCT03380754.

Multimodal prediction of pain and functional outcomes 6 months following total knee replacement: a prospective cohort study

BACKGROUND

Knee osteoarthritis (OA) is among the most common and disabling persistent pain conditions, with increasing prevalence and impact around the globe. In the U.S., the rising prevalence of knee OA has been paralleled by an increase in annual rates of total knee arthroplasty (TKA), a surgical treatment option for late-stage knee OA. While TKA outcomes are generally good, post-operative trajectories of pain and functional status vary substantially; a significant minority of patients report ongoing pain and impaired function following TKA. A number of studies have identified sets of biopsychosocial risk factors for poor post-TKA outcomes (e.g., comorbidities, negative affect, sensory sensitivity), but few prospective studies have systematically evaluated the unique and combined influence of a broad array of factors.

METHODS

This multi-site longitudinal cohort study investigated predictors of 6-month pain and functional outcomes following TKA. A wide spectrum of relevant biopsychosocial predictors was assessed preoperatively by medical history, patient-reported questionnaire, functional testing, and quantitative sensory testing in 248 patients undergoing TKA, and subsequently examined for their predictive capacity.

RESULTS

The majority of patients had mild or no pain at 6 months, and minimal pain-related impairment, but approximately 30% reported pain intensity ratings of 3/10 or higher. Reporting greater pain severity and dysfunction at 6 months post-TKA was predicted by higher preoperative levels of negative affect, prior pain history, opioid use, and disrupted sleep. Interestingly, lower levels of resilience-related "positive" psychosocial characteristics (i.e., lower agreeableness, lower social support) were among the strongest, most consistent predictors of poor outcomes in multivariable linear regression models. Maladaptive profiles of pain modulation (e.g., elevated temporal summation of pain), while not robust unique predictors, interacted with psychosocial risk factors such that the TKA patients with the most pain and dysfunction exhibited lower resilience and enhanced temporal summation of pain.

CONCLUSIONS

This study underscores the importance of considering psychosocial (particularly positively-oriented resilience variables) and sensory profiles, as well as their interaction, in understanding post-surgical pain trajectories.

An up to date on clinical prospects and management of osteoarthritis

The rising prevalence of osteoarthritis (OA) in the general population has necessitated the development of novel treatment options. It is critical to recognize the joint as a separate entity participating in degenerative processes, as well as the multifaceted nature of OA. OA is incurable because there is currently no medication that can stop or reverse cartilage or bone loss. As this point of view has attracted attention, more research is being directed toward determining how the various joint components are impacted and how they contribute to OA pathogenesis. Over the next few years, several prospective therapies focusing on inflammation, cartilage metabolism, subchondral bone remodelling, cellular senescence, and the peripheral nociceptive pathway are predicted to transform the OA therapy landscape. Stem cell therapies and the use of various biomaterials to target articular cartilage (AC) and osteochondral tissues are now being investigated in considerable detail. Currently, laboratory-made cartilage tissues are on the verge of being used in clinical settings. This review focuses on the update of clinical prospects and management of osteoarthritis, as well as future possibilities for the treatment of OA.

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Osteoarthritis (OA) is a general term that incorporates several different joint diseases.

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The exact pathophysiology of OA remains unclear.

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OA is incurable because there is currently no medication that can stop or reverse cartilage or bone loss.

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Nonsteroidal anti-inflammatory drugs are the most frequently prescribed medications to alleviate arthritic discomfort.

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Stem cell therapies to target articular cartilage and osteochondral tissues are now under investigation.

Positive effect of colors and art in patient rooms on patient recovery after total hip or knee arthroplasty : A randomized controlled trial

Background

Environmental stimuli and well-being are considered to be significant factors in patients’ rehabilitation. The aim of this study was to describe the effect of colors and art in hospital rooms on patients’ recovery after total hip or knee arthroplasty.

Methods

We performed a prospective randomized, controlled study including 80 patients. The intervention group was randomized to colored patient rooms while the control group received medical care in conventional patient rooms. Data were collected preoperatively and postoperatively (3 and 6 days after operation). We measured mood, anxiety and depression, quality of life (QOL) and pain.

Results

Significantly better QOL summary scores were measured in the intervention group (6 days postoperative) compared to the control group (physical component summary score 37.1 ± 5.0 vs. 34.1 ± 6.7; p = 0.029 and mental component summary score 51.6 ± 6.6 vs. 47.2 ± 8.4; p = 0.015). Postoperatively, we found decreased total mood scores in both groups showing better results for the intervention group without significant differences (p = 0.353; p = 0.711).

Conclusion

The use of colors in hospital rooms is an effective intervention to improve well-being and to enhance faster rehabilitation. We could demonstrate a positive effect of colors on patients’ postoperative QOL.

Physiological Indices of Stress Prior to and Following Total Knee Arthroplasty Predict the Occurrence of Severe Post-Operative Pain

OBJECTIVE

The severe pain and disability associated with osteoarthritis often motivate individuals to undergo arthroplastic surgery. However, a significant number of surgical patients continue to experience pain following surgery. Prior research has implicated both the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system (SNS) in the sensitization of pain receptors and chronic pain conditions. This study uses a prospective, observational, cohort design to examine whether physiological stress responses before and after surgery could predict post-operative pain severity.

SUBJECTS

Participants included 110 patients undergoing total knee arthroplasty.

METHODS

Physiological indices of stress included the measurement of catecholamine and cortisol levels in 15-hour urine samples collected prior to and 1 month following surgery, as well as in-hospital heart rate and blood pressure (before and after surgery), which were abstracted from medical records. Patients completed the pain subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) [Bellamy et al., J Orthop Rheumatol 1: , 95 (1988)] 2.5 weeks prior to surgery and at a 3-month follow-up.

RESULTS

Contrary to expectations, lower stress hormone levels at baseline were related to more severe post-operative pain. Data at later time points, however, supported our hypothesis: cardiovascular tone shortly before surgery and urinary levels of epinephrine 1 month following surgery were positively related to pain severity 3 months later.

CONCLUSION

Results suggest that the occurrence of post-operative pain can be predicted on the basis of stress physiology prior to and following arthroplastic surgery.

Dissociation of a Bipolar Prosthesis after Right Hip Hemiarthroplasty

We report the case of an 84-year-old woman with a dissociated bipolar component of her right hip hemiarthroplasty. Dissociation of components is a rare but increasingly recognized consequence of modular componentry. Radiologists should be aware of the distinction between dislocation of a prosthesis and dissociation of its bipolar components, and be able to describe these complications accurately in their interpretations.

Levels of neuropeptide Y in synovial fluid relate to pain in patients with knee osteoarthritis

Background

The precise etiology of knee osteoarthritis (KOA) pain remains highly controversial and there is no known effective treatment. Due to the known and suggested effects of neuropeptide Y (NPY) on pain, we have sought to investigate the relationship between the concentration of NPY in synovial fluid of knee, pain of KOA, and structural severity of KOA.

Methods

One hundred KOA patients and twenty healthy participants (control group) were recruited. The pain and the radiographic grade of KOA were assessed separately by Hideo Watanabe’s pain score and Tomihisa Koshino’s scoring system. Synovial fluid of knee from all participants was collected with arthrocentesis. Radioimmunoassay was used to examine the concentration of NPY in synovial fluid of knee.

Results

Concentrations of NPY in synovial fluid were significantly higher in KOA patients (124.7 ± 33.4 pg/mL) compared with controls (64.8 ± 26.3 pg/mL) (p = 0.0297). According to Hideo Watanabe’s pain score, 100 KOA patients were divided into 5 subgroups: no pain (n = 12), mild pain (n = 25), moderate pain (n = 37), strong pain (n = 19) and severe pain (n = 7). Within the KOA group, significantly higher concentrations of NPY were found in each subgroup as pain intensified (no pain 81.4 ± 11.7 pg/mL, mild pain 99.1 ± 23.2 pg/mL, moderate pain 119.9 ± 31.5 pg/mL, strong pain 171.2 ± 37.3 pg/mL and severe pain 197.3 ± 41.9 pg/mL). Meanwhile, according to Tomihisa Koshino’s scoring system, 100 KOA patients were divided into 3 subgroups: early stage (n = 30), middle stage (n = 53), advanced stage (n = 17). Concentrations of NPY in middle and advanced stage groups of KOA patients were significant higher than early stage group of KOA patients (early stage 96.4 ± 27.1 pg/mL, middle stage 153.3 ± 16.9 pg/mL, advanced stage 149.5 ± 36.7 pg/mL) (p = 0.0163, p = 0.0352). Concentrations of NPY in advanced stage group of KOA patients has no significant difference compare with middle stage group of KOA patients (p = 0. 2175).

Conclusions

This study demonstrated the presence and variation of concentrations of NPY in the KOA joint fluid, suggesting a role for NPY as a putative regulator of pain transmission and perception in KOA pain.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-319) contains supplementary material, which is available to authorized users.

Bone up your program: certification process for the total knee replacement and total hip replacement center

Knee and hip osteoarthritis, combined with the increased aging population, obesity, and other health-related risk factors, has led to a great need for joint replacement procedures. Joint replacement programs have been developed within hospitals to meet this demand. Joint replacement programs have been designed to provide an efficient and structured delivery of care. Facilities can demonstrate, to those seeking care, their quality programs by applying for and obtaining certification. Joint replacement certifications can guide facilities in providing a solid structure of improved care, quality, and superior outcomes. This article describes the steps that a community hospital took to attain the Blue Distinction Centers for Knee and Hip Replacement as well as The Joint Commission Disease-Specific Care Certification in Total Knee Replacement and Total Hip Replacement.

A computer analysis method for correlating knee X-rays with continuous indicators

PURPOSE

To develop an image analysis method that can automatically find correlations between a set of plain radiographs and continuous clinical or physiological indicators.

METHODS

Knee X-rays taken from the Baltimore Longitudinal Study of Aging are used in this study. The computer analysis method is based on the WND-CHARM image feature set filtered by using the Pearson correlation of each feature with the continuous variable, and the estimated value is determined by a weighted nearest neighbor interpolation.

RESULTS

Experimental results using 300 radiographs show that the proposed method can correlate knee X-rays with physiological indicators such as sex, age, height, weight, and BMI. For instance, the Pearson correlation between the X-ray images and the height and weight were 0.59 and 0.62, respectively.

CONCLUSIONS

Using computer analysis, X-ray images can be correlated to continuous physiological variables that might not have a direct and straightforward link to the visual content of the radiograph. This approach of radiology image analysis can be used in population studies for detecting biomarkers and also in genome-wide association studies for studying the link between genes and anatomy.

2010 Mid-America Orthopaedic Association Physician in Training Award: predictors of early adverse outcomes after knee and hip arthroplasty in geriatric patients

BACKGROUND

Geriatric patients experience more adverse events owing to early complications after TKA or THA related to preexisting comorbidities. However, associations between patient and surgery variables, including age, BMI, and comorbidities with complications are unclear. Knowing these relationships is necessary for developing risk stratification, defining contraindications, and predicting complications and adverse outcomes.

QUESTIONS/PURPOSES

We wished to establish and quantify the associations among age, BMI, comorbidities, and type of surgery and anesthesia with complications and early adverse outcomes including longer length of stay, disposition to an extended care facility, readmission, and reoperation in geriatric patients undergoing TKA and THA.

PATIENTS AND METHODS

We prospectively followed a cohort of patients older than 65 years undergoing TKA or THA. Demographics, comorbidities, complications, discharge disposition, readmission, and/or reoperation information within the 90-day postoperative period were collected. Adjusted hierarchical stepwise multivariable regression models were used to analyze associations and relative risks with complications, length of stay, disposition, readmission, and reoperation rates.

RESULTS

Patients were approximately 40% more likely to have any complication per each subsequent 10 years of age. Patients who underwent bilateral TKAs were 65% more likely to have any type of complication. Patients who had epidural anesthesia were 2.6 times more likely to have a major systemic complication. Patients with coronary artery disease were more likely to have a transfusion, more likely to have major local complications, including joint infection and/or a major systemic complication, and more likely to require a reoperation after TKA.

CONCLUSIONS

Age, type of surgery, anesthesia, and other comorbidities, mainly coronary artery disease and chronic heart failure, were associated with complications and adverse outcomes. We believe these risk factors should be used to counsel patients and make preoperative surgical decisions.

Progression analysis and stage discovery in continuous physiological processes using image computing

We propose an image computing-based method for quantitative analysis of continuous physiological processes that can be sensed by medical imaging and demonstrate its application to the analysis of morphological alterations of the bone structure, which correlate with the progression of osteoarthritis (OA). The purpose of the analysis is to quantitatively estimate OA progression in a fashion that can assist in understanding the pathophysiology of the disease. Ultimately, the texture analysis will be able to provide an alternative OA scoring method, which can potentially reflect the progression of the disease in a more direct fashion compared to the existing clinically utilized classification schemes based on radiology. This method can be useful not just for studying the nature of OA, but also for developing and testing the effect of drugs and treatments. While in this paper we demonstrate the application of the method to osteoarthritis, its generality makes it suitable for the analysis of other progressive clinical conditions that can be diagnosed and prognosed by using medical imaging.

Catastrophizing and depressive symptoms as prospective predictors of outcomes following total knee replacement

Several recent reports suggest that pain-related catastrophizing is a risk factor for poor acute pain outcomes following surgical interventions. However, it has been less clear whether levels of catastrophizing influence longer-term postoperative outcomes. Data were analyzed from a relatively small number (n=43) of patients who underwent total knee replacement and were followed for 12 months after their surgery. Previous research has suggested that high levels of both catastrophizing and depression are associated with elevated acute postoperative pain complaints among patients undergoing knee surgery. In this sample, catastrophizing and depression at each of the assessment points were studied as prospective predictors of pain (both global pain ratings and pain at night) at the subsequent assessment point over the course of one year. The predictive patterns differed somewhat across measures of pain reporting; depressive symptoms were unique predictors of greater global pain complaints, while catastrophizing was a specific and unique predictor of elevated nighttime pain. While surgical outcomes following total knee replacement are, on average, quite good, a significant minority of patients continue to experience long-term pain. The present findings suggest that high levels of catastrophizing and depression may promote enhanced pain levels, indicating that interventions designed to reduce catastrophizing and depressive symptoms may have the potential to further improve joint replacement outcomes.

Knee x-ray image analysis method for automated detection of osteoarthritis

We describe a method for automated detection of radiographic osteoarthritis (OA) in knee X-ray images. The detection is based on the Kellgren-Lawrence (KL) classification grades, which correspond to the different stages of OA severity. The classifier was built using manually classified X-rays, representing the first four KL grades (normal, doubtful, minimal, and moderate). Image analysis is performed by first identifying a set of image content descriptors and image transforms that are informative for the detection of OA in the X-rays and assigning weights to these image features using Fisher scores. Then, a simple weighted nearest neighbor rule is used in order to predict the KL grade to which a given test X-ray sample belongs. The dataset used in the experiment contained 350 X-ray images classified manually by their KL grades. Experimental results show that moderate OA (KL grade 3) and minimal OA (KL grade 2) can be differentiated from normal cases with accuracy of 91.5% and 80.4%, respectively. Doubtful OA (KL grade 1) was detected automatically with a much lower accuracy of 57%. The source code developed and used in this study is available for free download at www.openmicroscopy.org.

Osteoarthritis knee with patellar fracture in the elderly: single-stage fixation and total knee arthroplasty

Periarticular fractures that occur in a previously osteoarthritic knee, especially in an elderly patient, will be associated with other comorbidities and is a treatment challenge. Early mobilization is a key treatment principle in the geriatric population. We present a case report of an elderly diabetic patient with osteoarthritis of the knee joint who sustained a patellar fracture and was treated with single-stage primary total knee arthroplasty and fixation of the patellar fracture.

Analysis of human osteoarthritic connective tissue by laser capture microdissection and QRT-PCR

Gene expression levels for type II collagen and aggrecan have been determined as potential measures and disease markers of human osteoarthritis in patients undergoing total knee arthroplasty. In this regard, specimens of affected articular cartilage obtained intraoperatively at the time of surgery were placed in RNAlater(TM) to maintain RNA integrity and subsequently frozen-sectioned. Individual or small numbers of chondrocytes were isolated by laser capture microdissection and their total RNA was extracted and analyzed by quantitative reverse transcription-polymerase chain reaction. Results indicate that type II collagen and aggrecan mRNA expression from specific cells in osteoarthritic tissues are detectable and reproducible using these approaches. Our work is the first to demonstrate successful isolation of RNA limited to chondrocytes comprising small quantities of human osteoarthritic material. The study presents a new avenue by which the disease and its progression may be critically assayed.