Incidence of total hip and total knee replacements from the prospective epidemiologic risk factor study: considerations for event driven clinical trial design

Case Report: Total Knee Arthroplasty in Ipsilateral Below-Knee Amputee

Introduction

Total knee arthroplasty (TKA) has the highest annual incidence among all joint replacement surgeries. Below-knee amputation (BKA) is another common procedure to treat lower-limb-threatening pathologies. These two procedures are commonly performed individually, but an ipsilateral TKA performed on a BKA patient is rare. While ipsilateral amputation is not a contraindication for TKA, it presents orthopaedic surgeons with a unique case and necessitates thoughtful pre-operative planning regarding proper positioning, alignment determination, surgical technique, and rehabilitation for the best outcome.

Objectives

We present a case of a patient with a BKA who underwent ipsilateral TKA.

Case Report

This patient has a history of osteoarthritis (OA) of the right knee and diabetic neuropathy and underwent a right BKA after sustaining second-degree thermal burns to the bilateral forefeet. The patient was scheduled to undergo elective TKA prior to these injuries but was forced to postpone due to their severity. Following the BKA, the patient regained his ability to ambulate independently with prosthesis but continued to suffer from OA symptoms. The patient was then scheduled for surgery, and a TKA was performed.

Conclusion

The patient underwent a TKA and tolerated the surgery well without complications. Appropriate positioning was achieved using a popliteal post. Alignment and tibial cut were checked using fluoroscopy. All components were cemented into position, and the patella was resurfaced. The patient did well postoperatively and was using his prosthesis and ambulating independently at the final follow-up.

Optimising the current model of care for knee osteoarthritis with the implementation of guideline recommended non-surgical treatments: a model-based health economic evaluation

AIMS OF THE STUDY

Structured exercise, education, weight management and painkiller prescription are guideline recommended non-surgical treatments for patients suffering from knee osteoarthritis. Despite its endorsement, uptake of guideline recommended non-surgical treatments remains low. It is unknown whether the implementation of these treatments into the current model of care for knee osteoarthritis would be cost-effective from a Swiss statutory healthcare perspective. We therefore aimed to (1) assess the incremental cost-effectiveness ratio of an optimised model of care incorporating guideline recommended non-surgical treatments in adults with knee osteoarthritis and (2) the effect of total knee replacement (TKR) delay with guideline recommended non-surgical treatments on the cost-effectiveness of the overall model of care.

METHODS

A Markov model from the Swiss statutory healthcare perspective was used to compare an optimised model of care incorporating guideline recommended non-surgical treatments versus the current model of care without standardised guideline recommended non-surgical treatments. Costs were derived from two Swiss health insurers, a national database, and a reimbursement catalogue. Utility values and transition probabilities were extracted from clinical trials and national population data. The main outcome was the incremental cost-effectiveness ratio for three scenarios: "base case" (current model of care vs optimised model of care with no delay of total knee replacement), "two-year delay" (current model of care vs optimised model of care + two-year delay of total knee replacement) and "five-year delay" (current model of care vs optimised model of care + five-year delay of total knee replacement). Costs and utilities were discounted at 3% per year and a time horizon of 70 years was chosen. Probabilistic sensitivity analyses were conducted.

RESULTS

The "base case" scenario led to 0.155 additional quality-adjusted life years (QALYs) per person at an additional cost per person of CHF 341 (ICER = CHF 2,203 / QALY gained). The "two-year delay" scenario led to 0.134 additional QALYs and CHF -14 cost per person. The "five-year delay" scenario led to 0.118 additional QALYs and CHF -501 cost per person. Delay of total knee replacement by two and five years led to an 18% and 36% reduction of revision surgeries, respectively, and had a cost-saving effect.

CONCLUSION

According to this Markov model, the optimisation of the current model of care by implementing guideline recommended non-surgical treatments would likely be cost-effective from a statutory healthcare perspective. If implementing guideline recommended non-surgical treatments delays total knee replacement by two or five years, the amount of revision surgeries may be reduced.

Acute Sarcopenia after Elective and Emergency Surgery

Sarcopenia is an increasingly recognised condition of loss of muscle mass and function. The European Working Group on Sarcopenia in Older People 2 (EWSOP2) updated their definition in 2018, emphasising the importance of low muscle strength in diagnosis. Acute sarcopenia has been arbitrarily defined as sarcopenia lasting less than 6 months. This review highlights the pathophysiology involved in muscle wasting following surgery, focussing on hormonal factors, inflammation, microRNAs, and oxidative stress. Biomarkers such as GDF-15, IGF-1 and various microRNAs may predict post-surgical muscle loss. The impact of existing sarcopenia on various types of surgery and incident muscle wasting following surgery is also described. The gaps in research found include the need for longitudinal studies looking in changes in muscle strength and quantity following surgery. Further work is needed to examine if biomarkers are replicated in other surgery to consolidate existing theories on the pathophysiology of muscle wasting.

Patient characteristics, pain treatment patterns, and incidence of total joint replacement in a US population with osteoarthritis

BACKGROUND

Currently available medications for chronic osteoarthritis pain are only moderately effective, and their use is limited in many patients because of serious adverse effects and contraindications. The primary surgical option for osteoarthritis is total joint replacement (TJR). The objectives of this study were to describe the treatment history of patients with osteoarthritis receiving prescription pain medications and/or intra-articular corticosteroid injections, and to estimate the incidence of TJR in these patients.

METHODS

This retrospective, multicenter, cohort study utilized health plan administrative claims data (January 1, 2013, through December 31, 2019) of adult patients with osteoarthritis in the Innovation in Medical Evidence Development and Surveillance Distributed Database, a subset of the US FDA Sentinel Distributed Database. Patients were analyzed in two cohorts: those with prevalent use of "any pain medication" (prescription non-steroidal anti-inflammatory drugs [NSAIDs], opioids, and/or intra-articular corticosteroid injections) using only the first qualifying dispensing (index date); and those with prevalent use of "each specific pain medication class" with all qualifying treatment episodes identified.

RESULTS

Among 1 992 670 prevalent users of "any pain medication", pain medications prescribed on the index date were NSAIDs (596 624 [29.9%] patients), opioids (1 161 806 [58.3%]), and intra-articular corticosteroids (323 459 [16.2%]). Further, 92 026 patients received multiple pain medications on the index date, including 71 632 (3.6%) receiving both NSAIDs and opioids. Altogether, 20.6% of patients used an NSAID at any time following an opioid index dispensing and 17.2% used an opioid following an NSAID index dispensing. The TJR incidence rates per 100 person-years (95% confidence interval [CI]) were 3.21 (95% CI: 3.20-3.23) in the "any pain medication" user cohort, and among those receiving "each specific pain medication class" were NSAIDs, 4.63 (95% CI: 4.58-4.67); opioids, 7.45 (95% CI: 7.40-7.49); and intra-articular corticosteroids, 8.05 (95% CI: 7.97-8.13).

CONCLUSIONS

In patients treated with prescription medications for osteoarthritis pain, opioids were more commonly prescribed at index than NSAIDs and intra-articular corticosteroid injections. Of the pain medication classes examined, the incidence of TJR was highest in patients receiving intra-articular corticosteroids and lowest in patients receiving NSAIDs.

Total Knee Arthroplasty After Ipsilateral Below-knee Amputation: A Review of the Literature and Surgical Techniques

Patients with knee osteoarthritis in the setting of ipsilateral below-knee amputation present a challenge in terms of patient positioning, intraoperative assistance, implant alignment, postoperative rehabilitation, and prosthesis adjustment. This is a report of a patient with a history of below-knee amputation with ipsilateral knee pain due to osteoarthritis, treated with elective total knee arthroplasty. This was done using custom cutting blocks made via preoperative computed tomography scans, and a single assistant as well as a large hip bump and lateral support were used for positioning. The patient was weight-bearing as tolerated in his regular below-knee prosthesis starting from postoperative day 1, with 1 prosthetic adjustment made during the first week of rehabilitation. The patient was pain-free with full range of motion at 1-year follow-up.

Correlation of patient-reported numbness around surgical scars with patient-reported outcome measures and joint awareness after knee replacement: a cohort study

Background

Knee replacement is a very effective and indispensable treatment option for end-stage knee arthritis, and the number of cases has been increasing worldwide. A replaced knee joint without patient joint awareness is thought to be the ultimate goal of artificial knees. Joint awareness reportedly correlates with patient satisfaction. Although numbness around a replaced knee is a minor but common problem, its effect on postoperative outcome is controversial. Joint awareness also is sensitive to subtle abnormalities of the joint, so it must be negatively affected by numbness. Although numbness is minor, it cannot be ignored to further improve knee replacement outcomes. This study investigated the relationship between patient-reported numbness and other patient-reported outcome measures (PROMs), including joint awareness, and kneeling. We developed a numbness score based on a 5-point Likert scale on frequency of numbness, with an intraclass correlation coefficient of 0.76 and higher scores indicating less numbness.

Methods

The numbness score, New Knee Society Score (KSS), Knee Injury and Osteoarthritis Outcome Score (KOOS), Forgotten Joint Score-12 (FJS-12), and other clinical and radiological data from 311 patients (394 primary knee replacements) were analyzed. Kneeling ability was evaluated by using kneeling-specific items in the KSS (KSS-Kneeling).

Results

No numbness was found in 170 knees (43.1%), and some degree of numbness was found in the remaining 224 knees (56.9%). The numbness score showed weak-to-moderate correlations with KSS-Symptoms (r = 0.44), KSS-Satisfaction (r = 0.41), KSS-Activities (r = 0.29), and all KOOS subscales (r = 0.23–0.44), and FJS-12 (r = 0.42). Multiple regression analyses suggested that midline incision positively affected the numbness score over the anteromedial incision (p = 0.04) and that a better numbness score (p = 0.001), male sex (p < 0.0001), and better postoperative knee flexion angle (0.04) positively affected kneeling.

Conclusions

The numbness score positively correlated with PROMs and positively affected kneeling. Knee replacements performed via an anteromedial incision may be at higher risk for numbness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04971-6.

Osteoarthritis year in review 2020: epidemiology & therapy

This personal choice of research themes and highlights from within the past year (1 May 2019 to 14 April 2020) spans descriptive, analytical-observational, and intervention studies. Descriptive estimates of the burden of osteoarthritis continue to underscore its position as a leading cause of disability worldwide, but whose burden is often felt greatest among disadvantaged and marginalised communities. Many of the major drivers of that burden are known but epidemiological studies continue the important work of elaborating on their timing, dose, specificity, and reversibility and placing them within an appropriate multi-level framework. A similar process of elaboration is seen also in studies (re-)estimating the relative benefits and risks of existing interventions, in some cases helping to identify low-value care, unwarranted variation, and initiating processes of deprescribing and decommissioning. Such research need not engender therapeutic nihilism. Our review closes by highlighting some emerging evidence on the efficacy and safety of novel therapeutic interventions and with a selective roll-call of methodological and meta-research in OA illustrating the continued commitment to improving research quality.

The cartilage degradation marker, urinary CTX-II, is associated with the risk of incident total joint replacement in postmenopausal women. A 18 year evaluation of the OFELY prospective cohort

OBJECTIVE

Identifying objective risk-indicators for total joint replacement (TJR) is useful to enrich population at high risk in OA clinical trials. We investigate the association of urinary CTX-II, a biochemical marker of cartilage breakdown, with the risk of TJR.

METHOD

478 postmenopausal women (mean age 65.5 ± 7.5 yr) from the OFELY cohort were studied. CTX-II, serum CTX-I (bone resorption) and PINP (bone formation), were measured at baseline. Association between CTX-II and incidence of TJR was assessed by Cox Hazard Regression.

RESULTS

During a median (95%CI) 17.8 (15.0-18.1) years follow-up, 38 women sustained a TJR, including hip (n = 29) or knee (n = 9) replacement. CTX-II -but not CTX-I or PINP- was higher in patients with TJR (+34%, P = 0.001 vs women with no TJR). Increased baseline CTX-II levels were associated with a higher risk of TJR with a Hazard Ratio (HR) (95 CI) of 1.45 (1.13-1.85) per 1 SD increase after adjustment for age, BMI and total hip BMD. CTX-II remained significantly associated with the risk of TJR after further adjustment for total WOMAC, prevalent knee OA (KL ≥ 2) and self-reported hip OA [HR (95 CI): 1.31 (1.01-1.71), P = 0,04]. When women were categorized as low and high CTX-II (lower and above the 95 percentile of healthy premenopausal women, respectively), subjects with high levels had an age-BMI-hip BMD adjusted HR (95 CI) of 3.00 (1.54-5.85) compared to women with low levels which remained significant after further adjustment for WOMAC, knee and/or hip OA [HR (95 CI): 2.45 (1.25-4.89), P = 0.01].

CONCLUSION

CTX-II is an independent risk indicator of TJR in postmenopausal women suggesting that it may be useful to identify subjects at high risk of TJR.