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Power JD, Trifoi F, Canizares M, Perruccio AV, Shanmugaraj A, Gandhi R, Davey JR, Syed K, Mahomed NN, Veillette C, Rampersaud YR. The impact of diabetes on physical and mental health status and patient satisfaction after total hip and knee arthroplasty. PLoS One 2024; 19:e0302315. [PMID: 38656990 PMCID: PMC11042719 DOI: 10.1371/journal.pone.0302315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 04/01/2024] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVE To assess the impact of diabetes on physical and mental health status, as well as patient satisfaction, one-year following knee and hip total joint arthroplasty (TJA) for osteoarthritis (OA). METHODS Participants were 626 hip and 754 knee TJA patients. Pre-surgery data were collected on socio-demographics and health status. The 12-item Short Form Health Survey (SF-12) was collected pre- and one year post-surgery, and physical (PCS) and mental component (MCS) summary scores computed. One-year patient satisfaction was also recorded. Four regression models tested the effect of diabetes on: 1) PCS change score; 2) MCS change score; 3) achieving minimal clinically important improvement (MCII) on PCS; and 4) patient satisfaction ('Somewhat or Very Satisfied' vs. 'Somewhat or Very Dissatisfied'). An interaction between surgical joint and diabetes was tested in each model. RESULTS Self-reported diabetes prevalence was 13.0% (95% CI: 11.2%-14.7%) and was more common in knee 16.1% (95% CI: 13.4%-18.7%) than hip 9.3% (95% CI: 7.0%-11.5%) patients. In adjusted analyses, change scores were 2.3 units less on the PCS for those with diabetes compared to those without (p = 0.005). Patients with diabetes were about half as likely to achieve MCII as patients without diabetes (p = 0.004). Diabetes was not significantly associated with satisfaction or changes in MCS scores. Diabetes effects did not differ by surgical joint. CONCLUSIONS Findings support that diabetes has a negative impact on improvements in physical health after TJA. Considering the growing prevalence of OA and diabetes in the population, our findings support the importance of perioperative screening and management of diabetes in patients undergoing TJA.
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Affiliation(s)
- J. Denise Power
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
- Arthritis Community Research and Epidemiology Unit (ACREU), Krembil Research Institute, Toronto, Ontario, Canada
| | - Flaviu Trifoi
- Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Mayilee Canizares
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
- Arthritis Community Research and Epidemiology Unit (ACREU), Krembil Research Institute, Toronto, Ontario, Canada
| | - Anthony V. Perruccio
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
- Arthritis Community Research and Epidemiology Unit (ACREU), Krembil Research Institute, Toronto, Ontario, Canada
- Department of Surgery, Orthopaedics, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Ajaykumar Shanmugaraj
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rajiv Gandhi
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | - J. Roderick Davey
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | - Khalid Syed
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | - Nizar N. Mahomed
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | - Christian Veillette
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | - Y. Raja Rampersaud
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Orthopaedics, University of Toronto, Toronto, Ontario, Canada
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Fujita R, Ota S, Yamamoto Y, Kataoka A, Warashina H, Inoue T, Ozeki S, Sugiura H. Effect of diabetes mellitus on physical activity in patients with knee osteoarthritis: A cross-sectional study. J Orthop Surg (Hong Kong) 2023; 31:10225536231197726. [PMID: 37621081 DOI: 10.1177/10225536231197726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
Abstract
PURPOSE Knee osteoarthritis (OA) may be comorbid with diabetes mellitus (DM), and physical activity is a recommended lifestyle strategy for both diseases. The present study investigated the physical activity differences by intensity between knee OA patients with or without DM, and evaluated if physical activity was associated with the presence of DM in knee OA patients. METHODS A total of 183 patients (mean age 74.9 ± 6.4 years) with moderate-to-severe knee OA underwent evaluation of knee function (i.e., knee flexion/extension range-of-motion, knee-extension muscle strength, and knee pain), the timed up-and-go (TUG) test, and physical activity measurement using an accelerometer. Physical activity by intensity was compared between knee OA patients with and without DM. The association between physical activity, including knee function and the TUG test time, and DM was assessed. RESULTS The 2 groups (with or without DM) did not differ significantly in knee OA severity or age. Compared to knee OA patients without DM, knee OA patients with DM had a significantly lower average daily step count (p < 0.001), and significantly shorter times spent performing light-intensity physical activity (LPA; p < 0.001) and moderate-to-vigorous-intensity physical activity (MVPA; p = 0.006). After adjusting for age, sex, and body mass index, we found that a lower average daily step count and shorter LPA time significantly correlated with DM (β = -0.200, p = 0.006; β = -0.216, p = 0.004, respectively) and a longer TUG test time (β = -0.196, p = 0.014; β = -0.208, p = 0.011, respectively). A shorter MVPA time significantly correlated with lower contralateral knee-extension muscle strength (β = 0.187, p = 0.032). CONCLUSION Knee OA patients with DM had significantly lower physical activity levels than those without DM. Furthermore, the presence of DM correlated with a lower step count and a shorter LPA time in knee OA patients.
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Affiliation(s)
- Remi Fujita
- Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Rehabilitation and Care, Seijoh University, Tokai, Japan
| | - Susumu Ota
- Department of Rehabilitation and Care, Seijoh University, Tokai, Japan
| | - Yuri Yamamoto
- Department of Rehabilitation, Nagoya Orthopaedic and Joint Replacement Clinic, Kitanagoya, Japan
| | - Akito Kataoka
- Department of Rehabilitation, Nagoya Orthopaedic and Joint Replacement Clinic, Kitanagoya, Japan
| | - Hideki Warashina
- Department of Orthopedics, Nagoya Orthopaedic and Joint Replacement Clinic, Kitanagoya, Japan
| | - Tomoe Inoue
- Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shinya Ozeki
- Department of Rehabilitation, Mariana Home-Nursing Station, Nagoya, Japan
| | - Hideshi Sugiura
- Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Robertson FM, Clement ND. Preoperative Anemia Is Associated With Worse Joint-Specific Postoperative Outcomes, but Is Not Associated With Health-Related Quality of Life or Patient Satisfaction After Total Knee Arthroplasty. J Arthroplasty 2023; 38:51-59. [PMID: 35921998 DOI: 10.1016/j.arth.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/10/2022] [Accepted: 07/12/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The primary aim assessed whether preoperative anemia was associated with a worse knee-specific functional outcome after total knee arthroplasty (TKA). The secondary aims assessed the association of preoperative anemia with generic health and patient satisfaction. METHODS A retrospective cohort study was undertaken to compare patients who did and did not have anemia (Hb <13.0 g/dL for men and Hb <11.5 g/dL for women). During a 1-year period, 497 patients underwent a total knee arthroplasty with complete preoperative and postoperative data, including 215 (43.3%) men and 282 (56.7%) women, who had a mean age of 70 years (range 45-93). Patient demographics, comorbidities, preoperative and postoperative (1 year) Oxford Knee Score (OKS), EuroQol 5 dimension (EQ-5D), postoperative Forgotten Joint Score (FJS), and patient satisfaction were collected. Regression analyses were used to adjust for confounding factors between the groups. RESULTS The 56 (11.3%) patients who had anemia were older (4.6 years, P < .001) and more likely to have chronic obstructive pulmonary disease (P = .004), connective tissue (P = .047), or kidney disease (P = .011) compared to those who did not have anemia. There were no differences in the preoperative OKS (P = .752) or EQ-5D (P = .762) scores between the groups. When adjusting for confounding differences, there was a significantly lower postoperative OKS (-3.0 points, P = .035) and FJS (-11.6 points, P = .011) associated with the anemia group. There were no significant differences in the EQ-5D (P = .118) or patient satisfaction between groups (odds ratio 0.84, P = .976). CONCLUSION Preoperative anemia is associated with a lower postoperative joint-specific functional outcome. It is not clear if these differences are clinically meaningful. No difference in patient satisfaction was observed. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Fabienne M Robertson
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Nicholas D Clement
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Khan MN, Ali MU, Bhambani L, Prashanth N, Tross S. Outcomes of Total Joint Arthroplasty in Black, Asian, Minority Ethnic Groups Versus Local Population: A Retrospective Review. Cureus 2021; 13:e19868. [PMID: 34963868 PMCID: PMC8709536 DOI: 10.7759/cureus.19868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2021] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Total hip and knee replacement decrease the disability caused by osteoarthritis of the lower extremities. Although it has been established that racial and ethnic minorities underutilize these procedures, little data on postoperative outcomes exists. The impact of race on postoperative Oxford scores and complications following total joint arthroplasty (TJA) will be investigated in this retrospective review. METHODS A retrospective review of 120 elective primary TJA procedures was undertaken between January 2016 and December 2019 in a single institution. To measure variations between the various groups, t-tests were used on their Oxford scores, and chi-squared bivariate regression was used to classify all categorical variables and the association of ethnicity and surgery type with gender. RESULTS There were 62 (51.6%) White patients and 59 (49.1.0%) Black, Asian, Minority Ethnic (BAME) patients in total. The majority of the patients were females (60.9% vs 39.2%, p = 0.032). Low vitamin D levels were seen in a small percentage of patients in the sample (15.8% vs 84.2%, p = 0.460). There is a statistically important connection (p = 0.001) between the surgery type (total knee replacement [TKR]/total hip replacement [THR]) and gender; 41 females had TKR surgery, and 32 had THR surgery. CONCLUSION The study found that the relationships between ethnicity (White/BAME) and gender as well as surgery type (TKR/THR) and gender are statistically important. In all cases with low vitamin D and normal vitamin D levels, White patients had higher overall Oxford hip scores than the BAME patients. To comprehend the differences discovered, further research is needed. To try to eliminate the difference, targeted approaches should be created.
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Affiliation(s)
| | - Muhammad U Ali
- Trauma and Orthopaedics, Health Education Northwest London, London, GBR
| | - Lokesh Bhambani
- Trauma and Orthopaedics, London Northwest NHS Trust, London, GBR
| | | | - Samantha Tross
- Trauma and Orthopaedics, London Northwest Trust, London, GBR
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Sayah SM, Karunaratne S, Beckenkamp PR, Horsley M, Hancock MJ, Hunter DJ, Herbert RD, de Campos TF, Steffens D. Clinical Course of Pain and Function Following Total Knee Arthroplasty: A Systematic Review and Meta-Regression. J Arthroplasty 2021; 36:3993-4002.e37. [PMID: 34275710 DOI: 10.1016/j.arth.2021.06.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/17/2021] [Accepted: 06/17/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is widely considered a successful intervention for osteoarthritis and other degenerative knee diseases. This study addresses the need for a high-quality meta-analysis that outlines the clinical course of pain and function post-TKA. METHODS The review included prospective cohort studies assessing pain or function of patients undergoing primary TKA at baseline (preoperatively) and at least 2 additional time points including one at least 12 months postoperatively. Two reviewers independently screened references, extracted data, and assessed risk of bias using the Quality in Prognosis Studies tool. The time course of recovery of pain and function was modeled using fractional polynomial meta-regression. RESULTS In total, 191 studies with 59,667 patients were included, most with low risk of bias. The variance-weighted mean pain score (/100, 0 = no pain) was 64.0 (95% confidence interval [CI] 60.2-67.7) preoperatively, 24.1 (95% CI 20.3-27.9) at 3 months, 20.4 (95% CI 16.7-24.0) at 6 months, and 16.9 (95%CI 13.6-20.3) at 12 months, and remained low (10.1; 95% CI 4.8-15.4) at 10 years postoperatively. The variance-weighted mean function score (/100, 0 = worst function) was 47.1 (95% CI 45.7-48.4) preoperatively, 72.8 (95% CI 71.3-74.4) at 3 months, 76.3 (95% CI 74.7-77.8) at 6 months, and 78.1 (95%CI 76.4-79.7) at 12 months. Function scores were good (79.7; 95% CI 77.9-81.5) at 10 years postoperatively. CONCLUSION Patients undergoing primary TKA can expect a large and rapid but incomplete recovery of pain and function in the first postoperative year. At 10 years, the gains in pain scores may still remain while there is an improvement in function.
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Affiliation(s)
- Said Mohamad Sayah
- Surgical Outcomes Resource Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, New South Wales, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sascha Karunaratne
- Surgical Outcomes Resource Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, New South Wales, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Paula R Beckenkamp
- Discipline of Physiotherapy, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Mark Horsley
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital (RPAH), Sydney, New South Wales, Australia
| | - Mark J Hancock
- Department of Health Professions, Macquarie University, Sydney, New South Wales, Australia
| | - David J Hunter
- Institute of Bone and Joint Research, The University of Sydney, Sydney, New South Wales, Australia; Rheumatology Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Robert D Herbert
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
| | - Tarcisio F de Campos
- Department of Health Professions, Macquarie University, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Resource Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, New South Wales, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Zhang S, Chong M, Lau BPH, Ng YH, Wang X, Chua W. Do Patients With Diabetes Have Poorer Improvements in Patient-Reported Outcomes After Total Knee Arthroplasty? J Arthroplasty 2021; 36:2486-2491. [PMID: 33775468 DOI: 10.1016/j.arth.2021.02.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/21/2021] [Accepted: 02/24/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Diabetes is one of the most common comorbidities in patients undergoing total knee arthroplasty (TKA) for osteoarthritis. However, the evidence remains unclear on how it affects patient-reported outcome measures after TKA. METHODS We reviewed prospectively collected data of 2840 patients who underwent primary unilateral TKA between 2008 and 2018, of which 716 (25.2%) had diabetes. All patients had their HbA1c measured within 1 month before surgery, and only well-controlled diabetics (HbA1c <8.0%) were allowed to proceed with surgery. Patient demographics and comorbidities were recorded, and multiple regression was performed to evaluate the impact of diabetes on improvements in patient-reported outcome measures (Short Form 36 (SF-36), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Knee Society Score (KSS)) and knee range of motion (ROM). RESULTS Compared with nondiabetics, patients with diabetes were more likely to possess a higher body mass index (P-value <.001), more comorbidities (P-value <.001), and poorer preoperative SF-36 Physical Component Summary (PCS) (P-value <.001), WOMAC (P-value = .002), KSS-function (P-value <.001), and knee ROM (P-value <.001). Multiple regression showed that diabetic patients experienced marginally poorer improvements in KSS-knee (-1.22 points, P-value = .025) and knee ROM (-1.67°, P-value = .013) than nondiabetics. However, there were no significant differences in improvements for SF-36 PCS (P-value = .163), Mental Component Summary (P-value = .954), WOMAC (P-value = .815), and KSS-function (P-value = .866). CONCLUSION Patients with well-controlled diabetes (HbA1c <8.0%) can expect similar improvements in general health and osteoarthritis outcomes (SF-36 PCS and Mental Component Summary, WOMAC, and KSS-function) compared with nondiabetics after TKA. Despite having marginally poorer improvements in knee-specific outcomes (KSS-knee and knee ROM), these differences are unlikely to be clinically significant.
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Affiliation(s)
- Siyuan Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mark Chong
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
| | - Bernard Puang Huh Lau
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
| | - Yau Hong Ng
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
| | - Xinyu Wang
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
| | - Weiliang Chua
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
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King LK, Waugh EJ, Jones CA, Bohm E, Dunbar M, Woodhouse L, Noseworthy T, Marshall DA, Hawker GA. Comorbidities do not limit improvement in pain and physical function after total knee arthroplasty in patients with knee osteoarthritis: the BEST-Knee prospective cohort study. BMJ Open 2021; 11:e047061. [PMID: 34145017 PMCID: PMC8215258 DOI: 10.1136/bmjopen-2020-047061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the relationship between comorbidities and amount of improvement in pain and physical function in recipients of total knee arthroplasty (TKA) for knee osteoarthritis (OA). DESIGN Prospective cohort study. SETTING Two provincial central intake hip and knee centres in Alberta, Canada. PARTICIPANTS 1051 participants (278 in 6-minute walk test (6MWT) subset), ≥30 years of age with primary knee OA referred for consultation regarding elective primary TKA; assessed 1 month prior and 12 months after TKA. PRIMARY AND SECONDARY OUTCOME MEASURES Pre-post TKA change in knee OA pain (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), physical function (Knee injury and Osteoarthritis Outcome Score (KOOS) Physical Function Short-Form) and 6MWT walking distance; and the reporting of an acceptable symptom state (Patient Acceptable Symptom State (PASS)) at 12 months after TKA. RESULTS Mean participant age was 67 years (SD 8.8), 59% were female and 85% reported at least one comorbidity. Individuals with a higher number of comorbidities had worse pre-TKA and post-TKA scores for pain, physical function and 6MWT distance. At 12-month follow-up, mean changes in pain, function and 6MWT distance, and proportion reporting a PASS, were similar for those with and without comorbidities. In multivariable regression analysis, adjusted for potential confounders and clustering by surgeon, no specific comorbidities nor total number of comorbidities were associated with less improvement in pain, physical function or 6MWT distance at 12 months after TKA. Patients with diabetes (OR 0.64, 95% CI 0.44 to 0.94) and a higher number of lower extremity troublesome joints (OR 0.85, 95% CI 0.76 to 0.96) had lower odds of reporting a PASS. CONCLUSION For individuals with knee OA, comorbid conditions do not limit improvement in pain, physical function or walking ability after TKA, and most conditions do not impact achieving an acceptable symptom state.
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Affiliation(s)
- Lauren K King
- Medicine, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Esther J Waugh
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - C Allyson Jones
- Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
| | - Eric Bohm
- Division of Orthopaedic Surgery and Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michael Dunbar
- Division of Orthopaedic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Linda Woodhouse
- School of Physiotherapy & Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Thomas Noseworthy
- Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Deborah A Marshall
- Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Gillian A Hawker
- Medicine, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
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Diabetes Mellitus Blunts the Symptoms, Physical Function, and Health-Related Quality of Life Benefits of Total Knee Arthroplasty: A Systematic Review With Meta-analysis of Data From More Than 17 000 Patients. J Orthop Sports Phys Ther 2021; 51:269-280. [PMID: 33870736 DOI: 10.2519/jospt.2021.9515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare physical function, pain, impairments (stiffness, range of motion, and strength), and health-related quality of life (HRQoL) outcomes between patients with and without diabetes mellitus, before and after a total knee arthroplasty (TKA). DESIGN Prognosis systematic review. LITERATURE SEARCH We searched MEDLINE/PubMed, CINAHL, SPORTDiscus, and Web of Science to August 2019. STUDY SELECTION CRITERIA We included longitudinal studies that examined physical function, pain, impairments, and HRQoL outcomes among patients receiving a TKA and with or without diabetes. DATA SYNTHESIS For quantitative synthesis, we stratified outcomes based on time relative to TKA: preoperative, less than 1 year after a TKA (early postoperative), and 1 year or more after a TKA (late postoperative). We used random-effects meta-analysis to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development and Evaluation system for qualitative synthesis. RESULTS We included 21 studies (n = 17 472 patients). Patients with diabetes mellitus had worse preoperative physical function (SMD, -0.16; 95% CI: -0.24, -0.08) and HRQoL (SMD, -0.16; 95% CI: -0.26, -0.05), worse early postoperative pain (SMD, -0.22; 95% CI: -0.39, -0.05) and strength (SMD, -0.45; 95% CI: -0.77, -0.14), and worse late postoperative physical function (SMD, -0.23; 95% CI: -0.40, -0.06), range of motion (SMD, -0.23; 95% CI: -0.46, 0.00), and HRQoL (SMD, -0.19; 95% CI: -0.29, -0.08) than patients without diabetes mellitus. The overall risk of bias across studies was high, and the certainty of evidence ranged from low to very low. CONCLUSION Patients with diabetes mellitus had worse patient-reported and clinician-assessed outcomes before and after a TKA. Given the limitations of included studies, these results may change with future research. J Orthop Sports Phys Ther 2021;51(6):269-280. Epub 19 Apr 2021. doi:10.2519/jospt.2021.9515.
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Londhe SB, Shah RV, Doshi AP, Londhe SS, Subhedar K, Iyengar K, Mukkannavar P. Home physiotherapy with vs. without supervision of physiotherapist for assessing manipulation under anaesthesia after total knee arthroplasty. ARTHROPLASTY 2021; 3:10. [PMID: 35236438 PMCID: PMC8796486 DOI: 10.1186/s42836-020-00063-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 12/14/2020] [Indexed: 11/29/2022] Open
Abstract
Abstract The aim of this retrospective cohort study was to compare home physiotherapy with or without supervision of physiotherapist for assessing manipulation under anaesthesia after total knee arthroplasty. Methods A total of 900 patients (including 810 females and 90 males) who had undergone total knee arthroplasty were divided into group A (n = 300) and group B (n = 600). Patients in group A had home physiotherapy on their own after discharge from hospital. The physiotherapist did not visit them at home. Patients in group B received home physiotherapy under supervision of physiotherapist for 6 weeks after discharge from hospital. Patients’ age, range of motion of the knee, and forgotten joint score-12 were assessed. A p < 0.05 was considered statistically significant. Results In group A, the mean age was 69.1 ± 14.3 years (range: 58 to 82 years); in group B, the mean age was 66.5 ± 15.7 years (range: 56 to 83 years) (p > 0.05). Preoperatively, the mean range of motion of the knee in group A and B was 95.8° ± 18.1° and 95.4° ± 17.8°, respectively (p > 0.05). The mean forgotten joint score-12 of group A and B were 11.90 ± 11.3 and 11.72 ± 12.1 (p > 0.05), respectively. Six weeks after total knee arthroplasty, the mean ROM of the knee in group A and B was 109.7° ± 22.3° and 121° ± 21.5°, respectively (p < 0.05). The mean postoperative forgotten joint score-12 of the group A and B was 24.5 ± 16.4 and 25.6 ± 17.4, respectively (p > 0.05). The rate of manipulation under anaesthesia was 3% in group A and 0.2% in group B (p < 0.05). Conclusion After total knee arthroplasty, frequent physiotherapist’s instruction helps the patients improve knee exercises and therefore decrease the risk of revision surgery. The home physiotherapy under supervision of physiotherapist lowers the rate of manipulation under anaesthesia. Level of evidence Therapeutic study, Level IIa.
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Affiliation(s)
- Sanjay Bhalchandra Londhe
- Orthopaedic surgeon, Criticare Hospital, Plot No 516, Besides SBI, Teli Gali, Andheri East, Mumbai, Maharashtra, 400069, India.
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Rosas S, Buller LT, Plate J, Higuera C, Barsoum WK, Emory C. Total Knee Arthroplasty among Medicare Beneficiaries with Hemophilia A and B Is Associated with Increased Complications and Higher Costs. J Knee Surg 2021; 34:372-377. [PMID: 31499568 DOI: 10.1055/s-0039-1696691] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Operations on patients with hemophilia A and B are complex. Studies evaluating postoperative outcomes and costs following total knee arthroplasty (TKA) in patients with hemophilia are limited. A retrospective review of the entire Medicare dataset from 2005 to 2014 was performed. International Classification of Disease 9th revision codes were used to identify patients with hemophilia A and B and they were matched to controls using a 1:1 random matching process based on age, gender, Charlson Comorbidity Index (CCI), and select comorbidity burden. The 90-day preoperative period was evaluated for comorbidities and the 90-day postoperative period was analyzed for outcomes and reimbursements. Logistic regression models were generated to compare outcomes between cases and controls. A total of 4,034 patients with hemophilia were identified as having undergone TKA. About 44.8% were between the ages of 65 and 74 and 62.4% were female. Although the CCI was identical in both cohorts, individual comorbidities not controlled for varied significantly. Medical complications were more frequent among the patients with hemophilia: postoperative bleeding (odds ratio [OR]: 1.7; 95% confidence interval [CI]: 1.2-2.3), deep venous thrombosis (OR: 2.3; 95% CI: 1.8-2.8), pulmonary embolism (OR: 2.9; 95% CI: 2.1-3.9), and blood transfusions (OR: 1.8; 95% CI: 1.6-1.9). Hemophilia was associated with higher odds of periprosthetic infection (1.78 vs. 0.98%, OR: 1.8 95% CI: 1.2-2.7). The 90-day reimbursements were higher for patients with hemophilia (mean: $22,249 vs. $13,017, p < 0.001). Medicare beneficiaries with a diagnosis of hemophilia experience more frequent postoperative complications and incur greater 90-day costs than matched controls following TKA. Surgeons should consider this when optimizing patients for TKA and payors should consider this for risk-adjusting payment models.
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Affiliation(s)
- Samuel Rosas
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Leonard T Buller
- Department of Orthopaedic Surgery and Rehabilitation, University of Miami Miller School of Medicine, Miami, Florida
| | - Johannes Plate
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Carlos Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Cynthia Emory
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
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Saiki Y, Ojima T, Kabata T, Kubo N, Hayashi S, Tsuchiya H. Gradual exacerbation of knee flexion angle after total knee arthroplasty in patients with diabetes mellitus. Mod Rheumatol 2021; 31:1215-1220. [PMID: 33428492 DOI: 10.1080/14397595.2020.1868688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES This study aimed to investigate the effect of diabetes mellitus (DM) on knee extension/flexion angle and its early clinical course after total knee arthroplasty (TKA). METHODS Patients who received TKA were retrospectively divided into two groups based on haemoglobinA1c level; the DM group (23 knees) and the control group (23 knees matched for baseline characteristics). The passive knee extension/flexion angle, gait speed and Japanese Orthopaedic Association (JOA) score were evaluated preoperatively and at 1, 6 and 12 months postoperatively. RESULTS There was no significant difference in the passive knee flexion angle at 1 and 6 months postoperatively between the groups (p = .302, p = .160, respectively). The passive knee flexion angle was significantly lower at 12 months postoperatively in the DM group than the control group (p = .014). In the DM group, the passive knee flexion angle at 6 and 12 months significantly decreased compared with that at 1 month postoperatively (p = .021, p < .001, respectively). There were no significant differences in the knee extension angle, gait speed and JOA score between the groups. CONCLUSION Patients with DM are likely to experience passive knee flexion angle exacerbating from 1 to 6 months after TKA.
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Affiliation(s)
- Yoshitomo Saiki
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Ishikawa, Japan.,Department of Physical Therapy Rehabilitation, Fukui General Hospital, Fukui, Japan
| | - Tomohiro Ojima
- Department of Orthopaedic Surgery, Fukui General Hospital, Fukui, Japan
| | - Tamon Kabata
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Ishikawa, Japan
| | - Naoyuki Kubo
- Department of Physical Therapy Rehabilitation, Fukui General Hospital, Fukui, Japan
| | - Seigaku Hayashi
- Department of Orthopaedic Surgery, Fukui General Hospital, Fukui, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Ishikawa, Japan
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Prior Manipulation under Anesthesia is a Predictor of Contralateral Manipulation in Staged Bilateral Total Knee Arthroplasty. J Arthroplasty 2020; 35:3285-3288. [PMID: 32600817 DOI: 10.1016/j.arth.2020.05.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/17/2020] [Accepted: 05/29/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There are many risk factors for arthrofibrosis and manipulation under anesthesia (MUA) following total knee arthroplasty (TKA). However, no study has elucidated whether a history of MUA increases the risk of contralateral MUA in patients undergoing staged bilateral TKA. METHODS A retrospective review of an institutional database of TKAs was performed. All patients aged ≥18 years who underwent primary staged bilateral TKAs were screened for inclusion. Staged bilateral TKAs were viewed as 2 distinct events based on the temporal order in which they occurred: TKA#1 (occurred first) and TKA#2 (occurred second). Following TKA#1, patients were split into 2 groups: those who underwent MUA (Group MANIP) and those who did not (Group NO MANIP). The subsequent risk of undergoing MUA following TKA#2 was then assessed and compared between the 2 groups. Chi-squared tests were used for comparison. RESULTS A total of 5,330 patients who underwent primary uncomplicated staged bilateral TKAs (10,660 knees) during the study period were identified. Overall, 2.1% of patients underwent MUA following TKA#1 and 1.9% of patients underwent MUA following TKA#2. In the MANIP group, 21.4% of patients underwent MUA following TKA#2, while only 1.5% underwent MUA in the NO MANIP group. This 14.3-fold increase in the risk of MUA in the MANIP group following TKA#2 was statistically significant (21.4% vs 1.5%, absolute risk reduction = 19.9%, relative risk reduction = 93.0%, P < .0001). CONCLUSION Patients who undergo MUA during the first TKA of a staged bilateral TKA are 14.3 times more likely to undergo a subsequent MUA than those who did not undergo MUA following their first TKA.
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Manipulation Under Anesthetic After Primary Knee Arthroplasty Is Associated With a Higher Rate of Subsequent Revision Surgery. J Arthroplasty 2020; 35:2640-2645.e2. [PMID: 32475786 DOI: 10.1016/j.arth.2020.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/18/2020] [Accepted: 04/06/2020] [Indexed: 02/02/2023] Open
Abstract
AIM To determine the association between manipulation under anesthetic (MUA) after primary knee arthroplasty and subsequent revision surgery. METHODS Patients undergoing primary knee arthroplasty from April 2011 to April 2016 with minimum 1-year follow-up to April 2017 were identified from the national hospital episode statistics for England. The first arthroplasty per patient, per side, was included; cases with a record of subsequent infection or periprosthetic fracture were excluded. Patients undergoing MUA within 1 year to the same knee were identified, defining the populations for the MUA and non-MUA cohorts. Mortality-adjusted Kaplan-Meier survival analysis (revision arthroplasty) was performed to a maximum of 6 years. A Cox proportional hazards model was used to determine the hazard for revision, adjusting for type of primary arthroplasty, gender, age group, year, comorbidity index, obesity, regional deprivation, rurality, and ethnicity. RESULTS A total of 309,650 primary arthroplasty cases (309,650 patients) were included. MUA within 1 year was recorded in 6882 patients (2.22%; 95% confidence interval [95% CI], 2.17-2.28) defining the MUA cohort; all others were included in the parallel non-MUA cohort. At 6 years, the mortality-adjusted estimated implant survival rate in the MUA cohort was 91.2% (95% CI, 90.0-92.2) in comparison to 98.1% (95% CI, 98.0-98.2) in the non-MUA cohort. In the fully adjusted model, this corresponded to an adjusted hazard for revision of 5.03 (hazard ratio; 95% CI, 4.55-5.57). CONCLUSION Patients who underwent MUA within 1 year of primary arthroplasty were at a 5-fold increased risk of subsequent revision even after excluding cases of infection or fracture. Further investigation of the etiology of stiffness after primary knee arthroplasty and the optimal treatment options to improve outcomes is justified.
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Regnier SM, Khatibi B, Gabriel RA. Association of diabetes mellitus with postoperative opioid consumption in patients undergoing primary unilateral hip arthroplasty. J Perioper Pract 2020; 31:96-101. [PMID: 32096444 DOI: 10.1177/1750458920903647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Opioids are an indispensable component of perioperative pain management; however, the burgeoning opioid epidemic necessitates research into the risk factors for the development of opioid dependence and abuse following surgery. Diabetes has been identified as a risk factor for prolonged opioid utilisation following non-orthopaedic surgery; however, this association has not been investigated following orthopaedic surgery. To bridge this gap in the literature, we performed a retrospective propensity-matched cohort study in patients undergoing primary unilateral total hip arthroplasty. Propensity-matched cohorts were created to compare patients with and without preexisting diabetes mellitus. Outcomes of interest were opioid utilisation and subjective pain on postoperative day 1. Our results did not identify an association between preexisting diabetes and postoperative pain or opioid utilisation. While this study did not identify an association between diabetes and opioid utilisation following total hip arthroplasty, future studies should pursue a prospective, longitudinal approach and investigate other common orthopaedic procedures.
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Affiliation(s)
- Shane M Regnier
- Department of Anesthesiology, 8784University of California San Diego, San Diego, USA
| | - Bahareh Khatibi
- Department of Anesthesiology, 8784University of California San Diego, San Diego, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, 8784University of California San Diego, San Diego, USA.,Department of Medicine, Division of Biomedical Informatics, 8784University of California San Diego, San Diego, USA
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Co-Morbidities and Sex Differences in Long-Term Quality-of-Life Outcomes among Patients with and without Diabetes after Total Knee Replacement: Five-Year Data from Registry Study. J Clin Med 2019; 9:jcm9010019. [PMID: 31861688 PMCID: PMC7019834 DOI: 10.3390/jcm9010019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/09/2019] [Accepted: 12/17/2019] [Indexed: 12/12/2022] Open
Abstract
Improved understanding of quality-of-life (QoL) outcomes can provide valuable information on intervention effectiveness and guide better patient care. The aim of this study was to examine whether QoL trajectories differ between patients with and without diabetes and identify to what extent patient characteristics are related to poor QoL outcomes after total joint replacement (TKR). Multilevel modelling was used to analyse long-term QoL patterns of patients undergoing TKR between 2006 and 2011. Patient-reported QoL at baseline and up to 5 years post-surgery were included. Of the 1553 TKR patients, one-fifth (n = 319) had diabetes. Despite there being no significant differences in QoL at baseline, patients with diabetes consistently reported lower QoL (on average by 0.028, p < 0.001) and did not improve to the same level as patients without the disease following surgery. Compared to males, females had significantly lower QoL (by 0.03, p < 0.001). Other baseline patient characteristics associated with important differences in QoL included presence of respiratory disease and mental health disorder. Patients with diabetes exhibit significantly poorer QoL compared to patients without diabetes, particularly among females. Knowledge of risk factors that impact on QoL can be useful for clinicians in identifying characteristics related to poor QoL outcomes and be used to guide patient-centered care.
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Dell'Isola A, Vinblad J, Lohmander S, Svensson AM, Turkiewicz A, Franzén S, Nauclér E, W-Dahl A, Abbott A, Dahlberg L, Rolfson O, Englund M. Understanding the role of diabetes in the osteoarthritis disease and treatment process: a study protocol for the Swedish Osteoarthritis and Diabetes (SOAD) cohort. BMJ Open 2019; 9:e032923. [PMID: 31852705 PMCID: PMC6937096 DOI: 10.1136/bmjopen-2019-032923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 11/06/2019] [Accepted: 11/27/2019] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Osteoarthritis (OA) is the most common form of arthritis and a leading cause of disability worldwide. Metabolic comorbidities such as type II diabetes occur with a higher rate in people with OA than in the general population. Several factors including obesity, hyperglycaemia toxicity and physical inactivity have been suggested as potential links between diabetes and OA, and have been shown to negatively impact patients' health and quality of life. However, little is known on the role of diabetes in determining the outcome of non-surgical and surgical management of OA, and at the same time, how different OA interventions may affect diabetes control. Thus, the overall aim of this project is to explore (1) the impact of diabetes on the outcome of non-surgical and surgical OA treatments and (2) the impact of non-surgical and surgical OA treatments on diabetes control. METHODS AND ANALYSIS The study cohort is based on prospectively ascertained register data on a national level in Sweden. Data from OA patients who received a first-line non-surgical intervention and are registered in the National Quality Register for Better Management of Patients with Osteoarthritis will be merged with data from the Swedish Knee and Hip Arthroplasty Registers and the National Diabetes Register. Additional variables regarding patients' use of prescribed drugs, comorbidities, socioeconomic status and cause of death will be obtained through other national health and population data registers. The linkage will be performed on an individual level using unique personal identity numbers. ETHICS AND DISSEMINATION This study received ethical approval (2019-02570) from the Swedish Ethical Review Authority. Results from this cohort will be submitted to peer-reviewed scientific journals and reported at the leading national and international meetings in the field.
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Affiliation(s)
- Andrea Dell'Isola
- Faculty of Medicine, Department of Clinical Sciences, Orthopedics, Lunds University, Lund, Sweden
- Faculty of medicine, Department of Clinical Sciences, Orthopedics, Clinical Epidemiology Unit, Lund University, Lund, Sverige, Sweden
| | - Johanna Vinblad
- Centre of Registers Västra Götaland, The Swedish Hip Arthroplasty Register, Goteborg, Sweden
- Department of Orthopaedics, Sahlgrenska Academy, University of Gothenburg, Institute of Clinical Sciences, Gothenburg, Sweden
| | - Stefan Lohmander
- Faculty of Medicine, Department of Clinical Sciences, Orthopedics, Lunds University, Lund, Sweden
| | - Ann-Marie Svensson
- National Diabetes Register, Centre of Registers in Region Västra Götaland, Goteborg, Sweden
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
| | - Aleksandra Turkiewicz
- Faculty of medicine, Department of Clinical Sciences, Orthopedics, Clinical Epidemiology Unit, Lund University, Lund, Sverige, Sweden
| | - Stefan Franzén
- National Diabetes Register, Centre of Registers Västra Götaland, Gothenburg, Sweden
- Health Metrics Unit, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
| | - Emma Nauclér
- Centre of Registers Västra Götaland, The Swedish Hip Arthroplasty Register, Goteborg, Sweden
| | - A W-Dahl
- Department of Clinical Sciences, Lund University, Lund, Sverige, Sweden
- The Swedish Knee Arthroplasty Register, Lund, Sweden
| | - Allan Abbott
- Department of Medical and Health Sciences (IMH), division of physiotherapy, Faculty of Medicine and Health Sciences, Linkoping University, Linköping, Sweden
| | - L Dahlberg
- Faculty of Medicine, Department of Clinical Sciences, Orthopedics, Lunds University, Lund, Sweden
| | - Ola Rolfson
- Centre of Registers Västra Götaland, The Swedish Hip Arthroplasty Register, Goteborg, Sweden
- Department of Orthopaedics, Sahlgrenska Academy, University of Gothenburg, Institute of Clinical Sciences, Gothenburg, Sweden
| | - Martin Englund
- Faculty of medicine, Department of Clinical Sciences, Orthopedics, Clinical Epidemiology Unit, Lund University, Lund, Sverige, Sweden
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Younger age is associated with increased odds of manipulation under anesthesia for joint stiffness after total knee arthroplasty. Orthop Traumatol Surg Res 2019; 105:1067-1071. [PMID: 31471257 DOI: 10.1016/j.otsr.2019.05.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 02/23/2019] [Accepted: 05/02/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Limited range of motion (ROM) after total knee replacement (TKR) is associated with low function and might require manipulation under anaesthesia (MUA). In order to identify factors associated with a limited ROM we investigated predictors for MUA. We hypothesized that older age was associated with higher MUA due to limited ROM post TKR. METHODS In a case control study we investigated all patients undergoing primary TKR at a University Hospital in Sweden between 2007-2012. We registered background factors and compared those between the group who underwent MUA and those who did not. Odds ratios (OR) were calculated in a univariate analysis and an adjusted regression analysis. RESULTS Of the total of 669 TKRs performed, 31 patients who had undergone MUA were identified. The prevalence of MUA was 4.6%. The mean increase in ROM after MUA was 27 degrees at final minimum one-year follow-up. After controlling for confounders, patients with good health and young age had increased OR for MUA. OR decreased 0.93 (CI 0.93-0.97) per increased age year in the multiple regression analysis. Diabetes mellitus, BMI and sex did not have a significant effect on the odds ratio for MUA. DISCUSSION Young patients undergoing TKR has earlier been identified as a group with a higher grade of dissatisfaction and complications. We found an association between young age and MUA after TKR indicating an additional, rather unknown complication for this group of patients. The background and reasons for this has to be further investigated. LEVEL OF EVIDENCE II, cohort study/case control study (case control is level III).
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19
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Stone AH, MacDonald JH, Joshi MS, King PJ. Differences in Perioperative Outcomes and Complications Between African American and White Patients After Total Joint Arthroplasty. J Arthroplasty 2019; 34:656-662. [PMID: 30674420 DOI: 10.1016/j.arth.2018.12.032] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/17/2018] [Accepted: 12/26/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Racial disparities in healthcare utilization and outcomes have been reported and have wide-reaching implications for individual patient and healthcare system; as providers we bear an ethical burden to address this disparity and provide culturally competent care. This study will examine the influence of race on length of stay, discharge disposition, and complications requiring reoperation following total joint arthroplasty (TJA). METHODS Single institution retrospective analysis of a consecutive series of 7208 primary TJA procedures performed between July 2013 and June 2017 was conducted. Chi-squared and t-tests were used to quantify differences between the groups and multiple logistic regression was used to identify race as an independent risk factor. RESULTS In total, 6182 (84.3%) white and 1026 (14.0%) African American (AA) patients were included. AA patients were younger (63.62 vs 66.84 years, P < .001), more likely female (68.8% vs 57.0%, P < .001), had a longer length of stay (2.19 vs 2.00 days, P < .001), more likely to experience septic complications (1.3% vs 0.5%, P = .002) and manipulation under anesthesia (3.9% vs 1.8%, P < .001), and less likely to discharge home (67.1% vs 81.1%, P < .001). Multiple logistic regression showed that AA patients were more likely to discharge to a facility (adjusted odds ratio 2.63, 95% confidence interval 2.19-3.16, P < .001) and experience a manipulation under anesthesia (adjusted odds ratio 1.90, 95% confidence interval 1.26-2.85, P = .002). CONCLUSION AA patients undergoing TJA were younger with longer length of stay and a higher rate of nonhome discharge; AA race was identified as an independent risk factor. Further study is required to understand the differences identified in this study. Targeted interventions should be developed to attempt to eliminate the disparity.
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Affiliation(s)
- Andrea H Stone
- Department of Surgical Research, Anne Arundel Medical Center, Annapolis, MD
| | - James H MacDonald
- Center for Joint Replacement, Anne Arundel Medical Center, Annapolis, MD
| | | | - Paul J King
- Center for Joint Replacement, Anne Arundel Medical Center, Annapolis, MD
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20
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Kornuijt A, Das D, Sijbesma T, de Vries L, van der Weegen W. Manipulation under anesthesia following total knee arthroplasty: a comprehensive review of literature. Musculoskelet Surg 2018; 102:223-230. [PMID: 29546693 DOI: 10.1007/s12306-018-0537-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 03/08/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION The etiology of the stiff knee after total knee arthroplasty (TKA) is largely unknown, although excessive scar tissue due to arthrofibrosis is an important reason for a limited range of motion (ROM) after this procedure. Persistent limited ROM after TKA results in poor patient-reported outcomes and is increasingly becoming a more prominent reason for TKA revision surgery. METHODS A narrative review of current literature on manipulation under anesthesia (MUA) after TKA analyzing etiology and risk factors for stiffness after TKA, effectiveness of MUA and what is known about rehabilitation after MUA. RESULTS Literature describes numerous risk factors for insufficient knee ROM after TKA, but a comprehensive valid risk model is lacking. MUA is an effective treatment option with evidence suggesting better outcomes if performed within the first 3 months after TKA. The wide variety in both the indication and timing for MUA, and the lack of scientific evidence on how to rehabilitate patients after MUA, complicates the interpretation of available literature. This is even more so the case on the reporting of one versus two or more MUAs after TKA. CONCLUSION Future comparative trials, preferably with a randomized study design, should be conducted to elude more clear indications for MUA, to give clinical guidance on correct timing for MUA and on how to rehabilitate patients afterward.
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Affiliation(s)
- A Kornuijt
- Department of Physiotherapy, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands
| | - D Das
- Department of Orthopedic Surgery, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands
| | - T Sijbesma
- Department of Orthopedic Surgery, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands
| | - L de Vries
- Department of Orthopedic Surgery, Westfriesgasthuis Hospital, Maelsonstraat 3, 1624 NP, Hoorn, The Netherlands
| | - W van der Weegen
- Department of Orthopedic Surgery, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands.
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Teo BJX, Chong HC, Yeo W, Tan AHC. The Impact of Diabetes on Patient Outcomes After Total Knee Arthroplasty in an Asian Population. J Arthroplasty 2018; 33:3186-3189. [PMID: 30017216 DOI: 10.1016/j.arth.2018.06.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 05/20/2018] [Accepted: 06/15/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Diabetes is implicated with poorer outcomes and more complications after total knee arthroplasty (TKA). We aim to determine whether diabetes affects infection risk, functional outcomes, patient-reported outcome measures, and patient satisfaction in Asian patients after TKA. METHODS Prospectively collected data for 905 patients who underwent unilateral TKA by a single surgeon from February 2004 to July 2014 were reviewed, of which 123 (13.6%) patients suffered from diabetes. At 2-year follow-up, the change in range of motion of the operated knee, body mass index, Knee Society Score, Oxford Knee Score (OKS), and Short Form-36 from baseline was compared between diabetic and nondiabetic patients. We also analyzed the length of hospitalization stay, infection risk, and patient satisfaction between the 2 groups. RESULTS Compared with nondiabetic patients, diabetic patients had significantly poorer preoperative OKS (37.6 on 8.3 to 35.8 .38.0, P = .02) and Short Form-36 Mental Component Score (48.3 Me11.2 to 51.7 1.10.7, P = .01). At 2-year follow-up, diabetes continued to be associated with poorer OKS of 21.2 018.4 and Knee Society Score Function score of 64.7 Fu20.9 compared to 19.1 0.6.2 (P = .02) and 71.8 0220.1 (P = .01) respectively in nondiabetic patients. Interestingly, the difference in mental well-being was no longer significant after TKA. A significantly larger proportion of diabetic patients (50%) had a reduction in body mass index after TKA compared to 36% in nondiabetic patients (P < .01). There was no difference in range of motion, length of hospitalization stay, infection risk, and patient satisfaction. CONCLUSION Despite poorer physical scores throughout, diabetic patients are no less satisfied and had significantly greater improvement in mental well-being and weight reduction after surgery.
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Affiliation(s)
- Bryon J X Teo
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Hwei-Chi Chong
- Orthopaedic Diagnostic Centre, Singapore General Hospital, Singapore
| | - William Yeo
- Orthopaedic Diagnostic Centre, Singapore General Hospital, Singapore
| | - Andrew H C Tan
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Lenguerrand E, Beswick AD, Whitehouse MR, Wylde V, Blom AW. Outcomes following hip and knee replacement in diabetic versus nondiabetic patients and well versus poorly controlled diabetic patients: a prospective cohort study. Acta Orthop 2018; 89:399-405. [PMID: 29757058 PMCID: PMC6066772 DOI: 10.1080/17453674.2018.1473327] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The impact of diabetes and glycemic control before joint replacement on clinical and patient-reported outcomes is unclear. We compared pain, function, complications, and length of hospital stay in diabetic and nondiabetic patients receiving primary total hip (THR) or knee replacement (TKR) and compared these outcomes in patients with poorly controlled versus well-controlled diabetes. Patients and methods - We conducted a prospective cohort study of patients undergoing primary THR (n = 300) or TKR (n = 287) for osteoarthritis. Self-reported diabetes and glycemic control (HbA1c ≤ or >7%) extracted from medical notes were used. Adjusted comparisons were performed with generalized linear models including body mass index (BMI) and comorbidities. Results - Diabetes prevalence was 11% (THR 8%; TKR 14%). Diabetic patients were more likely to have a higher BMI and greater number of comorbidities. The median length of hospital stay was 1 day longer in diabetic patients (p = 0.004), but this attenuated after adjustments for BMI and comorbidities (p = 0.3). Inpatient pain was greater for diabetic patients but attenuated following adjustment. The 12-month postoperative WOMAC subscales were similar by diabetes status following adjustment. There was little evidence of difference in outcomes according to glycemic control. Interpretation - The associations between diabetes and worse postoperative outcomes in patients undergoing THR or TKR for osteoarthritis appear to be predominantly due to associated obesity and comorbidities. In diabetic patients there is little evidence of association between postoperative outcome and preoperative glycemic control. The underlying mechanisms and causal pathways of obesity, diabetes, and multimorbidity that lead to worse outcomes after joint replacement are not well known.
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Affiliation(s)
- Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol; ,Correspondence:
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol;
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol; ,National Institute for Health Research, Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK
| | - Vikki Wylde
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol; ,National Institute for Health Research, Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol; ,National Institute for Health Research, Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK
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Podmore B, Hutchings A, van der Meulen J, Aggarwal A, Konan S. Impact of comorbid conditions on outcomes of hip and knee replacement surgery: a systematic review and meta-analysis. BMJ Open 2018; 8:e021784. [PMID: 29997141 PMCID: PMC6082478 DOI: 10.1136/bmjopen-2018-021784] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To systematically perform a meta-analysis of the association between different comorbid conditions on safety (short-term outcomes) and effectiveness (long-term outcomes) in patients undergoing hip and knee replacement surgery. DESIGN Systematic review and meta-analysis. METHODS Medline, Embase and CINAHL Plus were searched up to May 2017. We included all studies that reported data to allow the calculation of a pooled OR for the impact of 11 comorbid conditions on 10 outcomes (including surgical complications, readmissions, mortality, function, health-related quality of life, pain and revision surgery). The quality of included studies was assessed using a modified Newcastle-Ottawa Scale. Continuous outcomes were converted to ORs using the Hasselblad and Hedges approach. Results were combined using a random-effects meta-analysis. OUTCOMES The primary outcome was the adjusted OR for the impact of each 11 comorbid condition on each of the 10 outcomes compared with patients without the comorbid condition. Where the adjusted OR was not available the secondary outcome was the crude OR. RESULTS 70 studies were included with 16 (23%) reporting on at least 100 000 patients and 9 (13%) were of high quality. We found that comorbidities increased the short-term risk of hospital readmissions (8 of 11 conditions) and mortality (8 of 11 conditions). The impact on surgical complications was inconsistent across comorbid conditions. In the long term, comorbid conditions increased the risk of revision surgery (6 of 11 conditions) and long-term mortality (7 of 11 conditions). The long-term impact on function, quality of life and pain varied across comorbid conditions. CONCLUSIONS This systematic review shows that comorbidities predominantly have an impact on the safety of hip and knee replacement surgery but little impact on its effectiveness. There is a need for high-quality studies also considering the severity of comorbid conditions.
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MESH Headings
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/mortality
- Arthroplasty, Replacement, Hip/psychology
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/mortality
- Arthroplasty, Replacement, Knee/psychology
- Comorbidity
- Humans
- Patient Readmission/statistics & numerical data
- Postoperative Complications/epidemiology
- Quality of Life
- Recovery of Function
- Reoperation/statistics & numerical data
- Risk Factors
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Affiliation(s)
- Bélène Podmore
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Andrew Hutchings
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Jan van der Meulen
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Sujith Konan
- Orthopaedics and Trauma, University College London Hospitals NHS Foundation Trust, London, UK
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Rudy MD, Ahuja NK, Aaronson AJ. Diabetes and Hyperglycemia in Lower-Extremity Total Joint Arthroplasty. JBJS Rev 2018; 6:e10. [DOI: 10.2106/jbjs.rvw.17.00146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Hypothyroidism Increases 90-Day Complications and Costs Following Primary Total Knee Arthroplasty. J Arthroplasty 2018; 33:1003-1007. [PMID: 29174407 PMCID: PMC6383647 DOI: 10.1016/j.arth.2017.10.053] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 10/19/2017] [Accepted: 10/29/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Thyroid disease is common and often remains undetected in the US population. Thyroid hormone has an array of metabolic, immunologic, and musculoskeletal functions crucial to well-being. The influence of thyroid disease on perioperative outcomes following primary total knee arthroplasty (TKA) is poorly understood. We hypothesized that hypothyroidism was associated with a higher risk of postoperative complications and 90-day costs following primary TKA. METHODS The Medicare standard analytical files were queried using International Classification of Disease codes between 2005 and 2014 to identify patients undergoing primary TKA. Patients with a diagnosis of hypothyroidism were matched by age and gender on a 1:1 ratio. Ninety-day postoperative complication rates, day of surgery, and 90-day global period charges and reimbursements were compared between matched cohorts. RESULTS A total of 2,369,594 primary TKAs were identified between 2005 and 2014. After age and gender matching, each cohort consisted of 98,555 patients. Hypothyroidism was associated with greater odds of postoperative complications compared to matched controls (odds ratio 1.367, 95% confidence interval 1.322-1.413). The 90-day incidence of multiple postoperative medical and surgical complications, including periprosthetic joint infection, was higher among patients with hypothyroidism. Day of surgery and 90-day episode of care costs were significantly higher in the hypothyroidism cohort. CONCLUSION This study demonstrated an increased risk of multiple postoperative complications and higher costs among patients with hypothyroidism following primary TKA. Surgeons should counsel patients on these findings and seek preoperative optimization strategies to reduce these risks and lower costs in this patient population.
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Eitner A, Hofmann GO, Schaible HG. Mechanisms of Osteoarthritic Pain. Studies in Humans and Experimental Models. Front Mol Neurosci 2017; 10:349. [PMID: 29163027 PMCID: PMC5675866 DOI: 10.3389/fnmol.2017.00349] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 10/13/2017] [Indexed: 12/12/2022] Open
Abstract
Pain due to osteoarthritis (OA) is one of the most frequent causes of chronic pain. However, the mechanisms of OA pain are poorly understood. This review addresses the mechanisms which are thought to be involved in OA pain, derived from studies on pain mechanisms in humans and in experimental models of OA. Three areas will be considered, namely local processes in the joint associated with OA pain, neuronal mechanisms involved in OA pain, and general factors which influence OA pain. Except the cartilage all structures of the joints are innervated by nociceptors. Although the hallmark of OA is the degradation of the cartilage, OA joints show multiple structural alterations of cartilage, bone and synovial tissue. In particular synovitis and bone marrow lesions have been proposed to determine OA pain whereas the contribution of the other pathologies to pain generation has been studied less. Concerning the peripheral neuronal mechanisms of OA pain, peripheral nociceptive sensitization was shown, and neuropathic mechanisms may be involved at some stages. Structural changes of joint innervation such as local loss and/or sprouting of nerve fibers were shown. In addition, central sensitization, reduction of descending inhibition, descending excitation and cortical atrophies were observed in OA. The combination of different neuronal mechanisms may define the particular pain phenotype in an OA patient. Among mediators involved in OA pain, nerve growth factor (NGF) is in the focus because antibodies against NGF significantly reduce OA pain. Several studies show that neutralization of interleukin-1β and TNF may reduce OA pain. Many patients with OA exhibit comorbidities such as obesity, low grade systemic inflammation and diabetes mellitus. These comorbidities can significantly influence the course of OA, and pain research just began to study the significance of such factors in pain generation. In addition, psychologic and socioeconomic factors may aggravate OA pain, and in some cases genetic factors influencing OA pain were found. Considering the local factors in the joint, the neuronal processes and the comorbidities, a better definition of OA pain phenotypes may become possible. Studies are under way in order to improve OA and OA pain monitoring.
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Affiliation(s)
- Annett Eitner
- Department of Physiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Gunther O Hofmann
- Department of Traumatology and Orthopedic Surgery, University Hospital Jena, Friedrich Schiller University, Jena, Germany.,Trauma Center Bergmannstrost Halle, Halle, Germany
| | - Hans-Georg Schaible
- Department of Physiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
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Maradit Kremers H, Schleck CD, Lewallen EA, Larson DR, Van Wijnen AJ, Lewallen DG. Diabetes Mellitus and Hyperglycemia and the Risk of Aseptic Loosening in Total Joint Arthroplasty. J Arthroplasty 2017; 32:S251-S253. [PMID: 28343827 DOI: 10.1016/j.arth.2017.02.056] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/02/2017] [Accepted: 02/20/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND It is unknown to what extent diabetes mellitus modifies the long-term risk of aseptic loosening in total hip arthroplasty (THA) and total knee arthroplasty (TKA). We examined the association between diabetes mellitus, perioperative hyperglycemia, and the likelihood of revisions for aseptic loosening. METHODS We studied 16,085 primary THA and TKA procedures performed at a large tertiary care hospital between 2002 and 2009. All blood glucose values around the time of surgery (within 1 week) were retrieved. Subsequent revision surgeries and the reasons for revision were ascertained through the institutional joint registry. Multivariate Cox models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for aseptic loosening associated with diabetes mellitus and hyperglycemia adjusting for age, gender, body mass index, and surgery type. RESULTS A total of 2911 (18%) surgeries had a diagnosis of diabetes mellitus at the time of surgery. Glucose testing was performed at least once in 7055 (44%) procedures within ±1 week of surgery. Although diabetic patients did not experience a higher risk of revision for aseptic loosening (HR, 0.87; 95% CI, 0.55-1.38), higher preoperative glucose values on the day before surgery were significantly associated with both the overall risk of revisions (HR, 2.80; 95% CI, 1.00-7.85) and revisions for aseptic loosening (HR, 4.95; 95% CI, 1.26-19.54). CONCLUSION High preoperative hyperglycemia is a potential risk factor for aseptic loosening in THA and TKA.
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Affiliation(s)
- Hilal Maradit Kremers
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Cathy D Schleck
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Eric A Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Dirk R Larson
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | | | - David G Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Cancienne JM, Werner BC, Browne JA. Is There a Threshold Value of Hemoglobin A1c That Predicts Risk of Infection Following Primary Total Hip Arthroplasty? J Arthroplasty 2017; 32:S236-S240. [PMID: 28214256 DOI: 10.1016/j.arth.2017.01.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 12/27/2016] [Accepted: 01/15/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There remains little evidence to support a perioperative hemoglobin A1c (HbA1c) level that could serve as a threshold for a significantly increased risk of deep postoperative infection in patients with diabetes mellitus (DM) following total hip arthroplasty (THA). METHODS A national administrative database was queried for patients who underwent primary THA with DM. Patients with an HbA1c level within 3 months of surgery were identified and were stratified based on HbA1c level in 0.5 mg/dL increments. The incidence of deep infection requiring operative intervention within 1 year for each group was identified and a receiver operating characteristic (ROC) and area under the curve (AUC) analysis was performed to determine a threshold value of the HbA1c. RESULTS A total of 7736 patients who underwent THA with a perioperative HbA1c level were included. The rate of infection ranged from 0.7% to 5.9%. The inflection point of the ROC curve corresponded to an HbA1c level between 7.0 and 7.5 mg/dL (P = .001, specificity = 69%, sensitivity = 47%). The AUC for the ROC was 0.68. Patients with an HbA1c level of 7.5 mg/dL or greater had a significantly higher risk of deep infection compared to patients below this threshold (odds ratio, 2.6; 95% CI, 1.9-3.4; P < .0001). CONCLUSION The risk of infection in patients with DM increases as the perioperative HbA1c increases. However, in the present study, the HbA1c threshold level calculated demonstrated low discrimination based on our AUC value, suggesting the HbA1c test is poorly predictive of periprosthetic joint infection following THA in patients with DM.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - James A Browne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
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Inflammation and post-operative recovery in patients undergoing total knee arthroplasty-secondary analysis of a randomized controlled trial. Osteoarthritis Cartilage 2017; 25:1265-1273. [PMID: 28323139 DOI: 10.1016/j.joca.2017.03.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 03/01/2017] [Accepted: 03/08/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Reduced function persists for many patients after total knee arthroplasty (TKA). Inflammation is part of osteoarthritis' pathophysiology, and surgery induces a marked inflammatory response. We therefore wanted to explore the role of inflammation in long-term recovery after TKA, and thus conducted this secondary analysis of our randomized controlled trial (RCT) of physical rehabilitation ± progressive strength training (PST). We aimed to investigate whether (1) inflammation is associated with functional performance, knee-extension strength, and knee pain before TKA; (2) PST affects inflammation, and the inflammatory state over time; (3) baseline or surgery-induced inflammation modifies the effect of rehabilitation ± PST on change in 6-min walk test (Δ6MWT); and (4) baseline or surgery-induced inflammation is associated with Δ6MWT following TKA. DESIGN In the primary trial report's per-protocol analysis, 72/82 patients were included. Sixty had ≥1 blood sample before and after TKA, and were included in this secondary analysis. Inflammation was measured by interferon γ-inducible protein (IP)-10, soluble urokinase plasminogen activator receptor (suPAR), interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-α at baseline; day 1, week 4, 8, and 26 after TKA. RESULTS At baseline, suPAR (P = 006) was negatively associated with 6MWT. Neither baseline nor surgery-induced inflammation modified the response to rehabilitation ± PST. Only surgery-induced IL-10 was associated with Δ6MWT26 weeks-baseline (P = 0.001), also adjusted for 6MWTbaseline, age, sex and body mass index (BMI). CONCLUSION In this secondary analysis, only increased surgery-induced IL-10 response was associated with decreased long-term functional performance after TKA. The importance of controlling the surgery-induced immune response remains to be investigated further. TRIAL IDENTIFICATION NCT01351831.
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31
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Is There an Association Between Hemoglobin A1C and Deep Postoperative Infection After TKA? Clin Orthop Relat Res 2017; 475:1642-1649. [PMID: 28116667 PMCID: PMC5406337 DOI: 10.1007/s11999-017-5246-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 01/12/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite substantial research into the use of glycemic markers to stratify infection risk in patients with diabetes mellitus, there is little evidence to support a perioperative hemoglobin A1c (HbA1c) level associated with an increased risk of deep postoperative infection after TKA. QUESTIONS/PURPOSES (1) Is there an association between perioperative HbA1c level in patients with diabetes and deep postoperative infection after primary TKA? (2) Is the perioperative HbA1c level in patients with diabetes a useful test as an independent predictor for postoperative infection after TKA? METHODS We queried the PearlDiver Patient Records Database Humana dataset for patients who underwent primary TKA. This is a for-fee insurance patient-records database that contains records for more than 20 million patients with orthopaedic diagnoses from 2007 to the second quarter of 2015. The data for patients from this study were taken from the Humana dataset since this is the only insurer that includes laboratory data among the available databases. Although it is difficult to calculate attrition in this database, in the current study the minimum number of patients with at least 1 year followup was 86%. Patients with diabetes who had an HbA1c level obtained within 3 months of surgery were identified, stratified based on their HbA1c level in 0.5 mg/dL increments, and then compared with patients with diabetes without an HbA1c level within 3 months of surgery. Patients who had an HbA1c level within 3 months of surgery had slightly higher rates of polyneuropathy, chronic renal failure, and chronic kidney disease Stages 2 and 3. Otherwise, these groups were similar regarding rates of peripheral vascular disease, microvascular ischemic disease, metabolic syndrome, gastroparesis, end stage renal disease, age, and gender. Deep infection was defined as an infection resulting in operative intervention within 1 year of the primary TKA, and the incidence of such intervention for each HbA1c group then was identified. A receiver operating characteristic (ROC) analysis was performed to determine a threshold value of the HbA1c, and an area under the curve (AUC) analysis was performed to measure the accuracy and clinical utility of HbA1c as an independent predictor for postoperative infection. RESULTS The rate of infection requiring operative intervention ranged from a low of 0.8% with an HbA1c of 5.49 mg/dL or less, up to 3.5% for patients with HbA1c level greater than 11.5 mg/dL. The ROC analysis indicated that the best threshold was an HbA1c of 8.0 mg/dL (1.7; 95% CI, 1.2-2.4 mg/dL; p = 0.004), however, the AUC of 0.548 (95% CI, 0.50-0.59; p = 0.025) indicated that this threshold was inaccurate and only slightly better than chance, and thus alone could not serve as an independent discriminator of infection risk. CONCLUSIONS The risk of deep postoperative infection requiring surgical intervention after TKA in patients with diabetes mellitus increases as the perioperative HbA1c increases. While a threshold HbA1c level of 8.0 mg/dL was identified, it cannot by itself serve as an independent predictor of postoperative infection in patients with diabetes mellitus because its sensitivity is so low. Future studies should determine what other confounders other than an elevated HbA1c level contribute to increased infection risk and whether decreasing HbA1c levels before TKA will decrease the subsequent risk of infection after surgery. LEVEL OF EVIDENCE Level III, diagnostic study.
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Capozzi JD, Lepkowsky ER, Callari MM, Jordan ET, Koenig JA, Sirounian GH. The Prevalence of Diabetes Mellitus and Routine Hemoglobin A1c Screening in Elective Total Joint Arthroplasty Patients. J Arthroplasty 2017; 32:304-308. [PMID: 27452137 DOI: 10.1016/j.arth.2016.06.025] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/20/2016] [Accepted: 06/08/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Diabetes mellitus has been associated with significant perioperative complications in joint arthroplasty. In addition, many patients are unaware of their dysglycemic status, and the prevalence of undiagnosed dysglycemia in joint arthroplasty patients is unknown. METHODS Several years ago, we began routine hemoglobin A1c (HbA1c) level screening in all our patients planning to undergo elective total hip and total knee arthroplasties. We retrospectively reviewed the HbA1c levels in our initial 663 patients. RESULTS Forty-eight percent of these patients were found to be nondiabetic; 19% percent had a previous history of some level of dysglycemia. Most significantly, over one third, 33.6% of these patients were previously undiagnosed dysglycemic patients; 31% were diagnosed as prediabetic and 2.6% as diabetic. CONCLUSION Owing to the high prevalence of prediabetic patients who go on to develop diabetes and to the high correlation of poor glucose control with perioperative complications, we feel that it is imperative to identify this large number of previously undiagnosed dysglycemic patients. We recommend the routine screening of all patients planning to undergo major orthopedic procedures. Likewise, we recommend that identified patients be referred for diabetic counseling. We also recommend that patients with markedly elevated HbA1c levels have their elective surgery postponed until better glycemic control can be achieved.
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Affiliation(s)
- James D Capozzi
- Department of Orthopedics, Winthrop University Hospital, Mineola, New York
| | - Eric R Lepkowsky
- Stony Brook University School of Medicine, Stony Brook, New York
| | - Marie M Callari
- Department of Orthopedics, Winthrop University Hospital, Mineola, New York
| | - Ellen T Jordan
- Department of Orthopedics, Winthrop University Hospital, Mineola, New York
| | - Jan A Koenig
- Department of Orthopedics, Winthrop University Hospital, Mineola, New York
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Wada O, Nagai K, Hiyama Y, Nitta S, Maruno H, Mizuno K. Diabetes is a Risk Factor for Restricted Range of Motion and Poor Clinical Outcome After Total Knee Arthroplasty. J Arthroplasty 2016; 31:1933-7. [PMID: 27036923 DOI: 10.1016/j.arth.2016.02.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 02/10/2016] [Accepted: 02/11/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We investigated the effects of diabetes mellitus on knee range of motion, muscle strength, and functional outcome after total knee arthroplasty. METHODS A total of 20 patients with type 2 diabetes and 20 patients without diabetes matched for age, body mass index, knee range of motion, and muscle strength at baseline participated in this study. We examined knee range of motion and muscle strength and assessed functional activities using the new Knee Society Score questionnaire for each patient 1 month preoperatively and at 6 and 12 months postoperatively. RESULTS Patients with diabetes had significantly lower knee flexion and smaller improvements in the new Knee Society Score than patients without diabetes. CONCLUSION Our results suggest that clinicians should treat and monitor patients with diabetes closely to prevent restricted knee range of motion and poorer functional recovery after total knee arthroplasty.
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Affiliation(s)
- Osamu Wada
- Anshin Hospital, Kobe City, Hyogo, Japan
| | - Koutatsu Nagai
- Faculty of Rehabilitation, Department of Physical Therapy, Hyogo University of Health Sciences, Kobe City, Hyogo, Japan
| | - Yoshinori Hiyama
- Department of Physical Therapy, School of Health Sciences, Tokyo University of Technology, Tokyo, Japan
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Kremers HM, Lewallen EA, van Wijnen AJ, Lewallen DG. Clinical Factors, Disease Parameters, and Molecular Therapies Affecting Osseointegration of Orthopedic Implants. CURRENT MOLECULAR BIOLOGY REPORTS 2016; 2:123-132. [PMID: 28008373 PMCID: PMC5166702 DOI: 10.1007/s40610-016-0042-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Total hip and knee arthroplasty are effective interventions for management of end-stage arthritis. Indeed, about 7 million Americans are currently living with artificial hip and knee joints. The majority of these individuals, however, will outlive their implants and require revision surgeries, mostly due to poor implant osseointegration and aseptic loosening. Revisions are potentially avoidable with better management of patient-related risk factors that affect the osseointegration of orthopedic implants. In this review, we summarize the published clinical literature on the role of demographics, biologic factors, comorbidities, medications and aseptic loosening risk. We focus on several systemic and local factors that are particularly relevant to implant osseointegration. Examples include physiological and molecular processes that are linked to hyperglycemia, oxidative stress, metabolic syndrome and dyslipidemia. We discuss how orthopedic implant osseointegration can be affected by a number of molecular therapies that are antiresorptive or bone anabolic (i.e. calcium, vitamin D, bisphosphonates, calcitonin, strontium, hormone replacement therapy, selective estrogen-receptor modulators).
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Affiliation(s)
- Hilal Maradit Kremers
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW,
Rochester, MN 55905
- Department of Health Sciences Research, Mayo Clinic, 200 First St
SW, Rochester, MN 55905
| | - Eric A. Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW,
Rochester, MN 55905
| | - Andre J. van Wijnen
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW,
Rochester, MN 55905
| | - David G. Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW,
Rochester, MN 55905
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Abstract
Diabetes is associated with a number of lower extremity orthopedic conditions and complications including fractures, Charcot neuroarthropathy, plantar ulcers, and infection. These complications are of significant clinical concern in terms of morbidity, mortality, and socioeconomic costs. A review of each condition is discussed, with particular emphasis on the clinical importance, diagnostic considerations, and orthopedic treatment recommendations. The goal of the article is to provide a clinical picture of the challenges that orthopedic surgeons confront, and highlight the need for specific clinical guidelines in diabetic patients.
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Affiliation(s)
- Daniel J Gehling
- Department of Orthopaedic Surgery, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, United States.
| | - Beata Lecka-Czernik
- Department of Orthopaedic Surgery, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, United States; Department of Physiology and Pharmacology, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, United States; Center for Diabetes and Endocrine Research, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, United States
| | - Nabil A Ebraheim
- Department of Orthopaedic Surgery, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, United States
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Establishing Realistic Patient Expectations Following Total Knee Arthroplasty. J Am Acad Orthop Surg 2015; 23:707-13. [PMID: 26493969 DOI: 10.5435/jaaos-d-14-00049] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 12/07/2014] [Indexed: 02/01/2023] Open
Abstract
Nearly 20% of patients are dissatisfied following well-performed total knee arthroplasty with good functional outcomes. Surgeons must understand the drivers of dissatisfaction to minimize the number of unhappy patients following surgery. Several studies have shown that unfulfilled expectations are a principal source of patient dissatisfaction. Patients contemplating total knee arthroplasty expect pain relief, improved walking ability, return to sports, and improvement in psychological well-being and social interactions. However, patients are typically overly optimistic with regard to expected outcomes following surgery. Patient expectations and satisfaction can be influenced by age, socioeconomic factors, sex, and race. The interplay of these factors can be complex and specific to each person. Published data on clinical and functional outcomes show that persistence of symptoms, such as pain, stiffness, and failure to return to preoperative levels of function, are common and normal. Therefore, the surgeon needs to help the patient to establish realistic expectations.
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Do glycemic markers predict occurrence of complications after total knee arthroplasty in patients with diabetes? Clin Orthop Relat Res 2015; 473:1726-31. [PMID: 25404402 PMCID: PMC4385343 DOI: 10.1007/s11999-014-4056-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 11/10/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with diabetes have increased risk of infections and wound complications after total knee arthroplasty (TKA). Glycemic markers identifying patients at risk for complications after TKA have not yet been elucidated. QUESTIONS/PURPOSES We aimed to determine the correlations among four commonly used glycemic markers and to identify the glycemic markers most strongly associated with the occurrence of surgical site infections and postoperative wound complications in patients with diabetes mellitus after undergoing TKA. METHODS Our retrospective study included 462 patients with diabetes, who underwent a total of 714 TKAs. Blood levels of glycemic markers, including preoperative fasting blood glucose (FBG), postprandial glucose (PPG2), glycated hemoglobin (HbA1c), and levels obtained from random glucose testing on postoperative days 2, 5, and 14, were collected on all patients as part of a medical clearance program and an established clinical pathway for patients with diabetes at our center. Complete followup was available on 93% (462 of 495) of the patients. Correlations among markers were assessed. Associations between the markers and patient development of complications were analyzed using multivariate regression analyses of relevant cutoff values. We considered any of the following as complications potentially related to diabetes, and these were considered study endpoints: surgical site infection (superficial and deep) and wound complications (drainage, hemarthrosis, skin necrosis, and dehiscence). During the period of study, there were no fixed criteria applied to what levels of glycemic control patients with diabetes needed to achieve before undergoing arthroplasty, and there were wide ranges in the levels of all glycemic markers; for example, whereas the mean HbA1c level was 7%, the range was 5% to 11.3%. RESULTS There were positive correlations among the levels of the four glycemic markers; the strongest correlation was found between the preoperative HbA1c and PPG2 levels (R = 0.502, p < 0.001). After controlling for potential confounding variables using multivariate analysis, the HbA1c cutoff level of 8 (odds ratio [OR], 6.1; 95% confidence interval [CI], 1.6-23.4; p = 0.008) and FBG 200 mg/dL or higher (OR, 9.2; 95% CI, 2.2-38.2; p = 0.038) were associated with superficial surgical site infection after TKA. CONCLUSIONS In general, there is a positive correlation among the various available glycemic markers among patients with diabetes undergoing TKA, and patients undergoing surgery with HbA1c ≥ 8 and/or FBG ≥ 200 mg/dL were associated with superficial surgical site infection. These findings should be considered in patient selection and preoperative counseling for patients with diabetes undergoing TKA. LEVEL OF EVIDENCE Level III, prognostic study.
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Yang Z, Liu H, Xie X, Tan Z, Qin T, Kang P. The influence of diabetes mellitus on the post-operative outcome of elective primary total knee replacement: a systematic review and meta-analysis. Bone Joint J 2015; 96-B:1637-43. [PMID: 25452366 DOI: 10.1302/0301-620x.96b12.34378] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Total knee replacement (TKR) is an effective method of treating end-stage arthritis of the knee. It is not, however, a procedure without risk due to a number of factors, one of which is diabetes mellitus. The purpose of this study was to estimate the general prevalence of diabetes in patients about to undergo primary TKR and to determine whether diabetes mellitus adversely affects the outcome. We conducted a systematic review and meta-analysis according to the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The Odds Ratio (OR) and mean difference (MD) were used to represent the estimate of risk of a specific outcome. Our results showed the prevalence of diabetes mellitus among patients undergoing TKR was 12.2%. Patients with diabetes mellitus had an increased risk of deep infection (OR = 1.61, 95% confidence interval (CI), 1.38 to 1.88), deep vein thrombosis (in Asia, OR = 2.57, 95% CI, 1.58 to 4.20), periprosthetic fracture (OR = 1.89, 95% CI, 1.04 to 3.45), aseptic loosening (OR = 9.36, 95% CI, 4.63 to 18.90), and a poorer Knee Society function subscore (MD = -5.86, 95% CI, -10.27 to -1.46). Surgeons should advise patients specifically about these increased risks when obtaining informed consent and be meticulous about their peri-operative care.
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Affiliation(s)
- Z Yang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
| | - H Liu
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - X Xie
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
| | - Z Tan
- Department of Orthopedics , West China Hospital, Sichuan University, Chengdu, China
| | - T Qin
- Chinese Evidence-Based Medicine Centre, West China Hospital, Sichuan University, Chengdu, China
| | - P Kang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
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Rajamäki TJ, Jämsen E, Puolakka PA, Nevalainen PI, Moilanen T. Diabetes is associated with persistent pain after hip and knee replacement. Acta Orthop 2015; 86:586-93. [PMID: 25953426 PMCID: PMC4564781 DOI: 10.3109/17453674.2015.1044389] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 01/30/2015] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE In some patients, for unknown reasons pain persists after joint replacement, especially in the knee. We determined the prevalence of persistent pain following primary hip or knee replacement and its association with disorders of glucose metabolism, metabolic syndrome (MetS), and obesity. PATIENTS AND METHODS The incidence of pain in the operated joint was surveyed 1-2 years after primary hip replacement (74 patients (4 bilateral)) or primary knee replacement (119 patients (19 bilateral)) in 193 osteoarthritis patients who had participated in a prospective study on perioperative hyperglycemia. Of the 155 patients who completed the survey, 21 had undergone further joint replacement surgery during the follow-up and were excluded, leaving 134 patients for analysis. Persistent pain was defined as daily pain in the operated joint that had lasted over 3 months. Factors associated with persistent pain were evaluated using binary logistic regression with adjustment for age, sex, and operated joint. RESULTS 49 of the 134 patients (37%) had a painful joint and 18 of them (14%) had persistent pain. A greater proportion of knee patients than hip patients had a painful joint (46% vs. 24%; p = 0.01) and persistent pain (20% vs. 4%; p = 0.007). Previously diagnosed diabetes was strongly associated with persistent pain (5/19 vs. 13/115 in those without; adjusted OR = 8, 95% CI: 2-38) whereas MetS and obesity were not. However, severely obese patients (BMI ≥ 35) had a painful joint (but not persistent pain) more often than patients with BMI < 30 (14/21 vs. 18/71; adjusted OR = 5, 95% CI: 2-15). INTERPRETATION Previously diagnosed diabetes is a risk factor for persistent pain in the operated joint 1-2 years after primary hip or knee replacement.
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Affiliation(s)
| | - Esa Jämsen
- b 2 Coxa, Hospital for Joint Replacement
| | | | - Pasi I Nevalainen
- a 1School of Medicine, University of Tampere
- d 4 Department of Internal Medicine , Tampere University Hospital, Tampere, Finland
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Do various factors affect the frequency of manipulation under anesthesia after primary total knee arthroplasty? Clin Orthop Relat Res 2015; 473:143-7. [PMID: 25002219 PMCID: PMC4390931 DOI: 10.1007/s11999-014-3772-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND One of the most important goals of primary total knee arthroplasty (TKA) is to achieve a functional range of motion (ROM). However, up to 20% of patients fail to do so, which can impair activities of daily living. QUESTIONS/PURPOSES The purpose of this study was to evaluate the effect of various (1) demographic factors; (2) comorbidities; and (3) knee-specific factors on the frequency of manipulation under anesthesia, which was used as an indicator of knee stiffness after a primary TKA. METHODS We evaluated the registries of two high-volume centers and reviewed all 3182 TKAs that were performed between 2005 and 2011 to identify all patients who had undergone manipulation under anesthesia (MUA). A total of 156 knees in 133 patients underwent MUA after an index arthroplasty. These patients were compared in a one-to-four ratio with a group of patients with satisfactory ROM drawn from the same database who met prespecified criteria and who had not undergone MUA. Effects of various factors, including age, sex, body mass index, race, comorbidities, and the underlying cause of knee arthritis, were compared between these two cohorts using multivariable logistic regressions. RESULTS After controlling for various confounding, nonwhite race was associated with an increase (odds ratio [OR], 2.01; p=0.03), and age≥65 years (OR, 0.17; 95% confidence interval [CI], 0.04-0.74; p=0.0179) was associated with a reduction in the incidence of MUA. In comorbidities, diabetes (OR, 1.72; 95% CI, 1.02-2.32; p=0.03), high cholesterol levels (OR, 2.70; p=0.03), and tobacco smoking (OR, 1.59; 95% CI, 1.03-2.47; p=0.03) were associated with an increase in frequency of MUA. In knee-specific factors, preoperative knee ROM of less than 100° (OR, 0.80; p<0.0001) and knee osteonecrosis (p=3.61; 95% CI, 1.29-10.1; p=0.014) were associated with increased frequency of MUA. CONCLUSIONS We identified several demographic, medical, and knee-specific factors that were associated with poor postoperative ROM in our patients undergoing TKA. Patients who have multiple risk factors may benefit from preoperative counseling to set realistic ROM expectations. LEVEL OF EVIDENCE Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Amusat N, Beaupre L, Jhangri GS, Pohar SL, Simpson S, Warren S, Jones CA. Diabetes that impacts on routine activities predicts slower recovery after total knee arthroplasty: an observational study. J Physiother 2014; 60:217-23. [PMID: 25443651 DOI: 10.1016/j.jphys.2014.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 05/12/2014] [Accepted: 09/05/2014] [Indexed: 11/30/2022] Open
Abstract
QUESTION In the 6 months after total knee arthroplasty (TKA), what is the pattern of pain resolution and functional recovery in people without diabetes, with diabetes that does not impact on routine activities, and with diabetes that does impact on routine activities? Is diabetes that impacts on routine activities an independent predictor of slower resolution of pain and functional recovery after TKA? DESIGN Community-based prospective observational study. PARTICIPANTS A consecutive cohort of 405 people undergoing primary TKA, of whom 60 (15%) had diabetes. PARTICIPANTS with diabetes were also asked preoperatively whether diabetes impacted on their routine activities. PARTICIPANTS were categorised into three groups: no diabetes (n=345), diabetes with no impact on activities (n=41), and diabetes that impacted activities (n=19). OUTCOME MEASURES Pain and function were measured using the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index within the month before surgery and 1, 3 and 6 months after surgery. Demographic, medical and surgical factors were also measured, along with depression, social support and health-related quality of life. RESULTS No baseline differences in pain and function were seen among the three groups (p > 0.05). Adjusting for age, gender and contralateral joint involvement across the 6 postoperative months, participants with diabetes that impacted on routine activities had pain scores that were 8.3 points higher (indicating greater pain) and function scores that were 5.4 points higher (indicating lower function) than participants without diabetes. PARTICIPANTS with diabetes that doesn't impact on routine activities had similar recovery to those without diabetes. CONCLUSION People undergoing TKA who report preoperatively that diabetes impacts on their routine activities have less recovery over 6 months than those without diabetes or those with diabetes that does not impact on routine activities. Physiotherapists could institute closer monitoring within the hospital and community settings for people undergoing TKA who perceive that diabetes impacts on their routine activities. [Amusat N, Beaupre L, Jhangri GS, Pohar SL, Simpson S, Warren S, Jones CA (2014) Diabetes that impacts on routine activities predicts slower recovery after total knee arthroplasty: an observational study.Journal of Physiotherapy60: 217-223].
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Affiliation(s)
| | - Lauren Beaupre
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta; Orthopedic Research, Capital Health
| | | | - Sheri L Pohar
- Canadian Agency for Drugs and Technologies in Health, Ottawa
| | - Scot Simpson
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
| | - Sharon Warren
- Faculty of Rehabilitation Medicine, University of Alberta
| | - C Allyson Jones
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta
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Howieson AJ, Brunswicker A, Dhatariya K. A retrospective review of the assessment of current perioperative management of diabetes in patients undergoing knee replacement surgery. JRSM Open 2014; 5:2042533313515864. [PMID: 25057370 PMCID: PMC4012649 DOI: 10.1177/2042533313515864] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives The prevalence of diabetes mellitus is increasing. Previous work has shown that suboptimal glycaemic control is associated with poor perioperative outcomes with increased rates of postoperative morbidity and mortality in several surgical specialities. Recently published UK guidelines have laid out the standards of perioperative care for patients with diabetes. Because an increasing number of patients with diabetes undergo surgery, it is important that these nationally agreed standards of care are adhered to. Design A retrospective review of the standard of care of patients against existing audit standards laid down in national guidelines, and a comparison of outcomes with people without diabetes. Setting A single major orthopaedic department. Participants Fifty consecutive patients undergoing knee arthroplasty between July 2010 and June 2011. Main outcome measures Postoperative complications; pre, peri and postoperative glucose control; hospital length of stay. Results Although there were no serious postoperative complications, the pre, peri and postoperative management was found to be suboptimal, particularly with reference to optimization of blood glucose control, both in terms of HbA1c preoperatively and blood glucose monitoring perioperatively. The average length of hospital stay was not different between groups; however, 36 patients with diabetes had at least one documented hyperglycaemic episode and four at least one hypoglycaemic episode. Conclusions Perioperative care of diabetes in patients undergoing knee arthroplasty could be improved. Several changes have been made since this audit was carried out, in particular adoption of the comprehensive Joint British Diabetes Societies Guideline on the perioperative management of adult patients with diabetes.
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Affiliation(s)
- Alan J Howieson
- Department of Orthopaedic Surgery, Norfolk and Norwich University Hospitals, NHS Foundation Trust, Norwich, UK
| | - Annmarie Brunswicker
- Department of Orthopaedic Surgery, Norfolk and Norwich University Hospitals, NHS Foundation Trust, Norwich, UK
| | - Ketan Dhatariya
- Diabetes and Endocrinology, Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals, NHS Foundation Trust, Norwich, UK
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Clement ND, MacDonald D, Burnett R, Breusch SJ. Diabetes does not influence the early outcome of total knee replacement: a prospective study assessing the Oxford knee score, short form 12, and patient satisfaction. Knee 2013; 20:437-41. [PMID: 23993274 DOI: 10.1016/j.knee.2013.07.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 07/16/2013] [Accepted: 07/25/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is conflicting evidence as to whether diabetes mellitus influences the functional outcome and patient satisfaction after a total knee replacement (TKR). The aim of this study was to assess the effect of diabetes upon the Oxford knee score (OKS), short form (SF)-12, and patient satisfaction after TKR. METHODS Prospective pre- and post-operative (one year) OKS and SF-12 scores for 2389 patients undergoing primary TKR were compiled, of which 275 (12%) patients suffered with diabetes. Patient satisfaction was assessed at one year. RESULTS Patients with diabetes were more likely to have a greater level of comorbidity (p<0.001), and a worse pre-operative OKS and SF-12 score (p<0.02), compared to those patients without diabetes. Diabetes was not a significant (p>0.41) independent predictor of post-operative OKS or the SF-12 physical score on multivariable analysis. Although, factors more prevalent within the diabetic cohort (heart disease, vascular disease, liver disease, anaemia, depression, back pain, worse pre-operative OKS and SF-12 score) were found to be independent predictors of post-operative OKS and SF-12 physical score. Interestingly, diabetes was associated with a significantly greater improvement in mental wellbeing (SF-12 mental component), which was confirmed on multivariable analysis. Patient satisfaction was not influenced by a concomitant diagnosis of diabetes (p=0.57). CONCLUSION The outcome of TKR as assessed by the OKS, SF-12, and overall patient satisfaction rates are not influenced by diabetes per se, although factors more prevalent within this population result in a worse post-operative outcome. LEVEL OF EVIDENCE prospective cohort study, level III.
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Affiliation(s)
- N D Clement
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK.
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Wolfson TS, Hamula MJ, Jazrawi LM. Impact of diabetes mellitus on surgical outcomes in sports medicine. PHYSICIAN SPORTSMED 2013; 41:64-77. [PMID: 24231598 DOI: 10.3810/psm.2013.11.2037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Diabetes mellitus (DM) affects a significant proportion of the patients evaluated and treated by orthopedic surgeons who specialize in sports medicine. Sports-medicine-related conditions associated with DM include tendinopathy, adhesive capsulitis of the shoulder, and articular cartilage disease. This article reviews the current literature adressing the effect of DM on surgical outcomes in sports medicine. In general, patients with DM undergo operations more frequently and experience inferior surgical outcomes compared with patients without DM. Diabetes mellitus is associated with increased rates of complications from sports medicine procedures, such as infection, delayed healing, and failure of the operation. However, additional research is needed to determine the full impact of DM on patient outcomes in sports medicine. Surgeons should be cognizant of special considerations in the population of patients with DM and aim to tailor the surgical management of this growing patient population.
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Affiliation(s)
- Theodore S Wolfson
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, NY
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What are the factors influencing outcome among patients admitted to a hospital with a proximal humeral fracture? Clin Orthop Relat Res 2013; 471:1698-706. [PMID: 23456187 PMCID: PMC3613560 DOI: 10.1007/s11999-013-2876-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Accepted: 02/15/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Fracture of the proximal humerus is common in older patients during the decline of their physical health. QUESTIONS/PURPOSES Our purpose was to evaluate the association between specific risk factors in patients with fractures of the proximal humerus and any inpatient adverse events, mortality, and discharge to a short-term or long-term care facility. METHODS The National Hospital Discharge Survey (NHDS) provided estimates of all adult patients who were admitted to hospitals after fractures of the proximal humerus in the United States between 1990 and 2007. The influences of sex, age, days of care, diagnosis and procedures (based on ICD-9 codes) on inpatient adverse events and death, and discharge to a short-term or long-term care facility, were studied in bivariate and multivariable analyses. RESULTS Among an estimated 867,282 patients admitted for proximal humerus fractures, 20% experienced adverse events, and 2.3% died in the hospital. Older age, concomitant femur and femoral neck fractures or head trauma, operative fracture care, congestive heart failure, and chronic alcoholism were associated with inpatient adverse events. Intubation, acute myocardial infarctions, malignancies, and skull fractures were associated with inpatient deaths. Older age, lower limb fractures, specific comorbidities (obesity, congestive heart failure, dementia), and inpatient adverse events (pneumonia, anemia treated with transfusion) were associated with discharges to short-term or long-term care facilities. CONCLUSIONS Knowledge of risk factors for inpatient adverse events, mortality, and discharge to facilities can help make treatment decisions, improve overall care, discharge planning, and resource utilization for patients with proximal humeral fractures.
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