The 36-Month Survival Analysis of Conservative Treatment Using Platelet-Rich Plasma Enhanced With Injectable Platelet-Rich Fibrin in Patients With Knee Osteoarthritis

INTRODUCTION

Knee osteoarthritis (KOA) is a musculoskeletal disease that leads to pain, stiffness, and deformity of the load-bearing knee joints. Biologic products including platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) are now in the spotlight for the treatment of KOA owing to their role of disease-modifying potential effect. There are still limited studies on the survival rate of KOA treated with biological intervention. We conducted this study to evaluate the primary outcome as the survival rate of KOA treated with PRP enhanced with injectable PRF that helps avoid unnecessary surgical intervention.

METHODS

There were 368 participants who met the inclusion and exclusion criteria. Participants were informed about this prospective cohort study protocol and signed written consent forms. Each participant received one injection of 4 ml of PRP and 4 ml of injectable PRF (iPRF), the so-called "PRP enhanced with iPRF". Clinical assessment was evaluated with the visual analog scale (VAS) at the second, fourth, sixth, 12th, 18th, 24th, 30th, and 36th-month post-treatment. If the VAS pain score improved by more than 80% compared to the previous treatment, there was no need for a repeated dose. If the pain scores improved by 50% to 80% compared to the previous treatment, the participants were advised a repeated dose. However, if the pain scores improved by less than 50% compared to the previous treatment, the participants were advised to undergo surgical intervention instead of a repeated dose. The primary outcome was recorded as any surgical treatment (either arthroscopic knee surgery, unicondylar arthroplasty, or total knee arthroplasty) at any time point post-treatment. The secondary outcome was recorded as the interval (months) between first-to-second, second-to-third, and third-to-fourth injections.

RESULTS

The overall survival rate of knees that did not require surgical intervention during the 36-month follow-up was 80.18%. The mean number of injections was 2.52±0.07 times for overall participants. The mean interval time was 5.42±0.36, 8.92±0.47, and 9.58±0.55 months for the first-to-second, second-to-third, and third-to-fourth injections.

CONCLUSION

This study supports the usage of PRP enhanced with iPRF as a biologic modality for the treatment of KOA. This treatment modality provides a satisfactory survival rate at the 36-month follow-up. The longer interval between each injection supports the disease-modifying effect of PRP enhanced with iPRF.

Composition of Platelet-Rich Plasma Prepared From Knee Osteoarthritic Patients: Platelets, Leukocytes, and Subtypes of Leukocyte

INTRODUCTION

Platelet-rich plasma (PRP) has gained increasing popularity in the orthopedic field. There has been still no consensus on PRP preparation technique, thus providing a variety of final PRP products. Different preparation techniques lead to different compositions of PRP, which include platelet concentration, the number of leukocytes, and their subtypes. Here, we studied those compositions of PRP compared to whole blood samples.

METHODS

There were 335 participants who met the inclusion and exclusion criteria. Each participant underwent a blood drawing process to prepare PRP for their knee osteoarthritis treatment. We categorized baseline platelet concentration in whole blood samples into three groups: less than 2 x 10⁵/µL (Group 1), between 2 x 10⁵/µL and 2.99 x 10⁵/µL (Group 2), and greater than 2.99 x 10⁵/µL (Group 3). The primary outcome was reported as the platelet concentration in PRP and the ratio of platelet concentration in PRP compared to baseline whole blood samples. The secondary outcome was reported as the ratios of leukocyte, lymphocyte, and neutrophil in PRP compared to the baseline whole blood samples.

RESULTS

The average platelet concentration in PRP was 1.26 x 10⁶/µL (6.3 times higher compared to baseline whole blood samples). The mean platelet concentration of PRP in Group 1, Group 2, and Group 3 was 1.08 x 10⁶/µL, 1.38 x 10⁶/µL, and 1.71 x 10⁶/µL, respectively (p-value = 0.0001). The platelet concentration ratio of PRP condition to the baseline whole blood was 6.9, 5.8, and 4.2 in Group 1, Group 2, and Group 3, respectively (p-value = 0.0018). The average ratio of leukocytes in PRP to whole blood was 1.5. The average ratio of lymphocytes and neutrophils in PRP to whole blood was 2.0 and 0.5, respectively.  Conclusion: Different baseline platelet concentrations in whole blood samples provided significantly different platelet concentrations in PRP. The baseline platelet concentration in whole blood also provided an inverse relation to the fold change of the platelet concentration in PRP. Subtypes of leukocytes changed from neutrophil-predominated in the baseline whole blood samples to lymphocyte-predominated in PRP.

Novel Use of Intraarticular Granulocyte Colony Stimulating Factor (hG-CSF) Combined with Activated Autologous Peripheral Blood Stem Cells Mobilized with Systemic hG-CSF: Safe and Efficient in Early Osteoarthritis

Osteoarthritis (OA) tends to occur in older individuals frequently burdened with comorbidities and diverse pharmacological interactions. As articular cartilage has low regenerative power, potent local tissue engineering approaches are needed to support chondrogenic differentiation. Acellular preparation methods as well as approaches to coax endogenous reparative cells into the joint space appear to have limited success. Supported by our in-vitro and clinical studies, we propose that our novel intra-articular administration of human granulocyte colony stimulating factor (IA-hG-CSF) combined with autologous activated peripheral blood stem cells (AAPBSC) is safe and offers treatment advantages not seen with other cellular interventions in early osteoarthritis.

Erratum: Commentary: Autologous Peripheral Blood Stem Cells (PBSC) are Safe and Effective in Knee Osteoarthritis

[This corrects the article DOI: 10.3389/fphar.2020.00404.].

Avoidance of Total Knee Arthroplasty in Early Osteoarthritis of the Knee with Intra-Articular Implantation of Autologous Activated Peripheral Blood Stem Cells versus Hyaluronic Acid: A Randomized Controlled Trial with Differential Effects of Growth Factor Addition

In this randomized controlled trial, in early osteoarthritis (OA) that failed conservative intervention, the need for total knee arthroplasty (TKA) and WOMAC scores were evaluated, following a combination of arthroscopic microdrilling mesenchymal cell stimulation (MCS) and repeated intra-articular (IA) autologous activated peripheral blood stem cells (AAPBSCs) with growth factor addition (GFA) and hyaluronic acid (HA) versus IA-HA alone. Leukapheresis-harvested AAPBSCs were administered as three weekly IA injections combined with HA and GFA (platelet-rich plasma [PRP] and granulocyte colony-stimulating factor [hG-CSF]) and MCS in group 1 and in group 2 but without hG-CSF while group 3 received IA-HA alone. Each group of 20 patients was evaluated at baseline and at 1, 6, and, 12 months. At 12 months, all patients in the AAPBSC groups were surgical intervention free compared to three patients needing TKA in group 3 (p < 0.033). Total WOMAC scores showed statistically significant improvements at 6 and 12 months for the AAPBSC groups versus controls. There were no notable adverse events. We have shown avoidance of TKA in the AAPBSC groups at 12 months and potent, early, and sustained symptom alleviation through GFA versus HA alone. Differential effects of hG-CSF were noted with an earlier onset of symptom alleviation throughout.

Assessment of chondrogenic differentiation potential of autologous activated peripheral blood stem cells on human early osteoarthritic cancellous tibial bone scaffold

INTRODUCTION

Current therapeutic regimens in osteoarthritis (OA) address mainly pain but not the slow progressive degradation of the extracellular matrix (ECM) and the loss of a chondrogenic phenotype in articular cartilage. In the present study, using an early OA cancellous bone scaffold, we aimed to uncover evidence of the successful hyaline cartilage regenerative capacity of autologous human granulocyte colony-stimulating factor (hG-CSF)-activated peripheral blood stem cells (AAPBSC) with growth factor addition.

MATERIALS AND METHODS

AAPBSC were harvested in ten patients (median age 58 years, 8 females), and flow cytometry was performed for cell surface markers. Arthroscopically obtained cancellous bone scaffold specimens were seeded with AAPBSC. In Group 1, the scaffold was seeded with AAPBSC only, in Group 2, AAPBSC plus hyaluronic acid (HA), and in Group 3, AAPBSC plus HA, hG-CSF, and double-centrifuged platelet-rich plasma (PRP). The specimens were analyzed for cell attachment and proliferation by the fluorometric quantification of cellular DNA assay and scanning electron microscopy. Chondrogenic gene expression was determined by reverse transcriptase-polymerase chain reaction (RT-PCR) of Sox9, collagen type II (COL-2), and aggrecan. Histological sections of scaffold constructs for cartilaginous matrix formation were stained with toluidine blue (proteoglycan) and safranin O (sGAG) after 3 weeks.

RESULTS

AAPBSC displayed especially high levels of CD29 and CD44 surface markers, as well as CD90, and CD105, while only a small proportion expressed CD34. Almost half of the seeded cells attached on the bone scaffolds in all three groups (not statistically significant), whereas the means of cell proliferation on day 7 compared to day 1 were statistically significant difference with the order of increase as group 3 > group 2 > group 1. RT-PCR showed statistically significant sequential increases in Sox9, COL-2, and Aggrecan all being highest in group 3. Histological analysis demonstrated cells in the cancellous bone scaffold with a round morphology, and ECM was positively stained by toluidine blue and safranin O indicating increased proteoglycan and glycosaminoglycan content, respectively, in the newly formed cartilage matrix.

CONCLUSIONS

AAPBSC initiated chondrocyte differentiation on an autologous cancellous bone scaffold, and the addition of PRP and hG-CSF further stimulated cell proliferation toward a chondrocyte phenotype with potentiated Sox9 transcription resulting in sequential COL-2 and aggrecan mRNA increases that ultimately resulted in histologically confirmed increased proteoglycan and glucosaminoglycan content in newly formed hyaline cartilage.

Combination of intra-articular autologous activated peripheral blood stem cells with growth factor addition/ preservation and hyaluronic acid in conjunction with arthroscopic microdrilling mesenchymal cell stimulation Improves quality of life and regenerates articular cartilage in early osteoarthritic knee disease

BACKGROUND

Trauma or osteoarthritis (OA) create articular cartilage defects that cannot efficiently heal, thus leading to significant long-term disability. Failed conservative treatment in cartilage diseases is a known condition that necessitates repair attempts but current methods are inadequate. Recent studies in OA animal models and humans, showed articular cartilage regeneration following combinations of drilling, adult stem cells, and intra-articular hyaluronic acid.

OBJECTIVE

In the present series, the authors evaluated the combination of repeated intra-articular (IA) autologous activated peripheral blood stem cells (AAPBSC) with growth factor addition/preservation (GFAP) along with hyaluronic acid (HA) in conjunction with arthroscopic microdrilling mesenchymal cell stimulation (MCS) in early osteoarthritic knee disease that failed conservative treatment.

MATERIAL AND METHOD

Four women and one man (median age 56, range 52-59 years) that failed conservative treatment were enrolled. Arthroscopic MCS was performed once in all patients with subsequent IA injection of AAPBSC with GFAP along with IA-HA intra-operatively, repeated at days 7 and 14. The patients were evaluated by WOMAC and KOO scores at baseline, one, and six months. Cancellous bone biopsies were performed to investigate cell attachment, proliferation, and differentiation by electron microscopy and histological staining.

RESULTS

All patients improved significantly in WOMAC and KOO scores at one and six months compared to baseline. No adverse effects were seen during the AAPBSC harvesting, arthroscopy and/or IA injections. One month post-surgery, all pain medications could be withdrawn. Electron microscopy scanning revealed cell attachment and proliferation while histological analysis demonstrated that the cell layer on the cancellous scaffold showed increased proteoglycan and glycosaminoglycan content indicating hyaline cartilage presence.

CONCLUSION

The combination of intra-articular (IA) autologous activated peripheral blood stem cells (AAPBSC) with growth factor addition/preservation (GFAP) along with hyaluronic acid (HA) in conjunction with arthroscopic microdrilling mesenchymal cell stimulation (MCS) resulted in Quality of Life improvements measured by WOMAC and KOO scores and succeeded in regenerating articular cartilage in early osteoarthritic knee disease that failed conservative treatment. Further controlled studies are warranted to confirm the above results in larger groups.

Factors influencing diagnosis and treatment of osteoporosis after a fragility fracture among postmenopausal women in Asian countries: a retrospective study

Background

A vast amount of literature describes the incidence of fracture as a risk for recurrent osteoporotic fractures in western and Asian countries. Osteoporosis evaluation and treatment after a low-trauma fracture, however, has not been well characterized in postmenopausal women in Asia. The purpose of this study was to characterize patient and health system characteristics associated with the diagnosis and management of osteoporosis among postmenopausal women hospitalized with a fragility fracture in Asia.

Methods

Patient surveys and medical charts of postmenopausal women (N=1,122) discharged after a fragility hip fracture from treatment centers in mainland China, Hong Kong, Singapore, South Korea, Malaysia, Taiwan, and Thailand between July 1, 2006 and June 30, 2007 were reviewed for bone mineral density (BMD) measurement, osteoporosis diagnosis, and osteoporosis treatment.

Results

The mean (SD) age was 72.9 (11.5) years. A BMD measurement was reported by 28.2% of patients, 51.5% were informed that they had osteoporosis, and 33.0% received prescription medications for osteoporosis in the 6 months after discharge. Using multivariate logistic regression analyses, prior history of fracture decreased the odds of a BMD measurement (OR 0.63, 95% CI 0.45-0.88). Having a BMD measurement increased the odds of osteoporosis diagnosis (OR 10.1, 95% CI 6.36-16.0), as did having health insurance (OR 4.95, 95% CI 1.51-16.21 for private insurance with partial self-payment relative to 100% self-payment). A history of fracture was not independently associated with an osteoporosis diagnosis (OR 0.80, 95% CI 0.56-1.15). Younger age reduced the odds of receiving medication for osteoporosis (OR 0.59, 95% CI 0.36-0.96 relative to age ≥65), while having a BMD measurement increased the odds (OR 1.79, 95% CI 1.23-2.61).

Conclusions

Osteoporosis diagnosis and treatment in Asian countries were driven by BMD measurement but not by fracture history. Future efforts should emphasize education of general practitioners and patients about the importance of fracture.

Cost analysis of peri-operative antibiotic administration in total knee arthroplasty

BACKGROUND

Rationale perioperative antibiotic for prevent infection in total knee arthroplasty is well established. The recommendation are preoperative antibiotic should be administered within 1 h before skin incision and prophylactic antibiotics should be administered within 1 h before skin incision, if prolong surgery more than 4-6 hours need addition doses and duration of prophylactic antibiotic administration should not exceed the 24-hour postoperative period then not need for additional antibiotic. If there is evidences of infection, intravenous antibiotic and follow by oral antibiotic is mandatory in acute infection in conjuction with scrub and debridement. Because the burden of infection in joint replacement is disaster, it seemed to increase the antibiotic uses and impact about the cost concerned after total knee arthroplasty. No data available about the pharmaco-economical study of perioperative antibiotic in total knee arthroplasty have been established.

OBJECTIVE

Primary outcomes is cost anaylsis of perioperative antibiotic uses in real clinical practice for total knee arthroplasty. Secondary outcome is infectioned total knee that need to reoperative for scrub and debridement.

MATERIAL AND METHOD

Prospective opened lable study from joint registry in Police General Hospital from June, 2010 till March, 2011. With minimum 12 months follow-up. Total Knee Arthroplasty was enrolled in the present study about 218 cases. 3 patients lossed follow-up in each groups, so the total number in the present study are 209 patients. Perioperative antibiotic consumption initial doses and followed for 48 hour is divided in 3 group: group 1 Fosmycin 4 g (2 g initially plus 2 g intraoperatively) for 70 patients group 2: Fosmycin 2 g for 68 patients. Group 3: Cefalosporin group for 71 patients. The cost of subsequence uses of intravenous and oral antibiotic were record. And also the cases that need to scrub debridement with the indication of infected total knee arthroplasty were recorded. The minimum follow-up about 12 months (range 12-18 months).

RESULTS

The extend of intravenous antibiotic administration postop more than 48 hours in group 1 is 38 patients (54.28%) and oral antibiotic 42 patients (60%), in group 2 is 45 patients (66.18%) and oral antibiotic 40 patients (58.2%), in group 3 58 patients (81.7%) and oral antibiotic 60 patients (84.51%). The percentage of expenses preoperative intravenous and postoperative 48 hour: intravenous antibiotic during hospitalization: post operative antibiotic in group 1 is 19.82%: 59.69%: 20.49%; group 2 is 10.41%: 68.40%: 21.19% and group 3 is 1.39% 80.85%: 17.76%. The average total perioperative cost antibiotic (baht) in group 1: group 2: group 3 are 4,068: 4,776: 5,468. The infected case need operated for scrub and debridement in group 1 is 1 cases, group 2 is one cases and group 3 is 1 cases.

CONCLUSION

Overall expense increased in both intravenous and oral antibiotic prophylaxis in total knee arthtroplasty for prevention of infection. The major cost of perioperative antibiotic is intravenous antibiotic more than 48 hours during hospitalization, the least number of patients and percentages of cost is in group 1 than group 2 and 3. The percentage of patients oral antibiotics are least in group 2 than group 1, 3 but the average cost is likely to be quite substantially lower in group 1 then group 2, 3.

Comparing alignment of proximal tibia first cut between narrow and wide saw blade in CAS TKA

OBJECTIVE

The primary aim of the present study is to comparison between using narrow and wide saw blade of proximal tibial bone cut in close slot cutting block guide verified by computer navigation system.

MATERIAL AND METHOD

The authors evaluated 80 knees in 80 patients. After cutting the proximal tibia, the cutting surface was validated using the navigated cutting block adapter, and the angular difference between the cutting surface and that preoperatively planned in the sagittal and coronal planes was recorded.

RESULTS

The average cutting error of all knees was 1.8 degrees +/- 2.7 degrees in use narrow blade and 1.2 degrees +/- 2.2 degrees in use wide blade. The authors did not find statistically significant difference between the first 40 patients and the next 40 patients. The average cutting error of sclerotic bone was 2.3 degrees +/- 2.7 degrees in use narrow blade and 1.1 degrees +/- 2.1 degrees in use wide blade. The authors find statistically significant. The average error in the coronal plane was 1.5 degrees +/- 1.1 degrees in valgus and 2 (2.5%) in varus of the 80 knees had a malalignment of more than 1 degrees with respect to the targeted cutting plan.

DISCUSSION

Alignment of cutting surface should be checked after cut proximal tibia and recut to reach target alignment and should be cut with wide saw blade especially in sclerotic bone.

Cost-utility analysis and economic burden of knee osteoarthritis treatment: the analysis from the real clinical practice

BACKGROUND

Non-steroidal anti-inflammatory drug (tNSAIDs) or selective COX-II inhibitor (COXIBs) are generally used as the first-line intervention of knee osteoarthritis (OA). Total knee arthroplasty (TKA) is suggested for those who dissatisfy from non-surgical treatment. However the long-term usage of tNSAIDs may lead to articular cartilage and resulted in higher rate of TKA. The evaluation of real clinical practice needs to be scrutinized as the inappropriate treatment will be socially burden.

OBJECTIVE

To evaluate cost-utility of selective COX-II inhibitors (COXIBs) compared to traditional NSAIDs in patients with knee osteoarthritis (OA) and to estimate health and economic burden of disease of knee OA.

MATERIAL AND METHOD

The present study is an economic evaluation alongside a prospective observational study. The data of cost and treatment outcomes were collected from real clinical practice. EQ-5D questionnaire was employed to calculate utility values at baseline and 6 months after treatment.

RESULTS

Total 939 patients were prescribed tNSAIDs and 380 patients received celecoxib. Eleven cases (1.17%) of all tNSAIDs usages and 3 cases (0.79%); p = 0.56 of celecoxib usages were detected GI complication. Two cases of tNSAIDs group were dead from severe GI bleeding. TKA was markedly reported with 12.99% of tNSAIDs and 9.80% of celecoxib; p = 0.06. QALYs gained from 6 months was 0.34 (+/- 0.11) for tNSAIDs and 0.36 (+/- 0.11) for celecoxib; p = 0.004. Average direct medical expenses per patient were comparable with 17,468.97 THB for tNSAIDs and 17,495.07 THB for celecoxib. Cost of TKA was a key element in both groups with 90% and 67% of total expenses in tNSAIDs and celecoxib groups, respectively. Incremental cost-effectiveness ratio (ICER) per Quality-adjusted life years (QALY) gained comparing celecoxib and tNSAIDs was 1,382.70 THB.

CONCLUSION

The finding from our study can be a concrete evidence to support the appropriate future decision of clinical judgment and health care provider.

Burden of nonsteroidal anti-inflammatory and antiplatelet drug use in Asia: a multidisciplinary working party report

BACKGROUND & AIMS

We established a working group to examine the burden of atherothrombotic and musculoskeletal diseases in Asia and made recommendations for safer prescribing of nonsteroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin.

METHODS

By using a modified Delphi process, consensus was reached among 12 multidisciplinary experts from Asia. Statements were developed by the steering committee after a literature review, modified, and then approved through 3 rounds of anonymous voting by using a 6-point scale from A+ (strongly agree) to D+ (strongly disagree). Agreement (A+/A) by ≥ 80% of panelists was defined a priori as consensus.

RESULTS

We identified unique aspects of atherothrombotic and musculoskeletal diseases in Asia. Asia has a lower prevalence of degenerative arthritis and coronary artery disease than Western countries. The age-adjusted mortality of coronary artery disease is lower in Asia; cerebrovascular accident has higher mortality than coronary artery disease. Ischemia has replaced hemorrhage as the predominant pattern of cerebrovascular accident. Low-dose aspirin use is less prevalent in Asia than in Western countries. Traditional Chinese medicine and mucoprotective agents are commonly used in Asia, but their efficacy is not established. For Asian populations, little is known about complications of the lower gastrointestinal tract from use of NSAIDs and underutilization of gastroprotective agents. Our recommendations for preventing ulcer bleeding among users of these drugs who are at high risk for these complications were largely derived from Asian studies and are similar to Western guidelines.

CONCLUSIONS

By using an evidence-based, multidisciplinary approach, we have identified unique aspects of musculoskeletal and atherothrombotic diseases and strategies for preventing NSAID-related and low-dose aspirin-related gastrointestinal toxicity in Asia.

The early outcome of Birmingham hip resurfacing: an independent Thai surgeon experiences

BACKGROUND

Modern metal-on-metal total hip resurfacing show improvement outcome as a viable alternative arthroplasty in the young, but in Thailand it remains controversial whether this procedure is appropriate by Thai surgeon. Some in doubt this procedure may need high technical demand and may not valuable in Thailand.

OBJECTIVE

To analyze the early clinical and radiographic outcomes of Birmingham Hip Resurfacing (BHR) by Thai surgeon in Thailand.

MATERIAL AND METHOD

Between January 2006 and December 2008, thirty-eight patients (forty hips) who were operated with BHR by same surgeon. The authors evaluated Harris Hip score, Oxford hip score, University of California Los Angeles (UCLA) activity score, Short form-12 score, and complications as well as radiographic alignment and radiolucencies.

RESULTS

At a mean follow up of 16.2 months (3 to 33). The mean pre-operative and last follow up Harris Hip score were 35.1 (27 to 41) and 96.4 (95 to 98) (p < 0.001) respectively. The mean Oxford hip score were 44.3 (37 to 52) and 12.4 (11 to 13) (p < 0.001) respectively. The mean UCLA activity score was 3.4 (3 to 4) and 8.8 (8 to 10) (p < 0.001) respectively. The mean SF12 were 18.2 (14 to 23) and 62.2 (59 to 64) (p < 0.001) respectively. There was no patient with radiological evidence of loosening or thinning of the femoral neck. Four cases had intra-operative transient blood pressure drop while impacting metal cup into circumference sealed acetabulum. However no subsequence post operative complication was detected. There was one case with pulmonary embolism in secondary osteonecrosis from sickle cell anemia and resolve without any complication. One case with fracture neck of femur due to osteochondroma removal at anterosuperior head neck junction which exposure too much cancellous bone. She had got successfully conversion to metal on metal total hip replacement with post operative excellent result. There was no infection, deep vein thrombosis and nerve injury. The survival rate was 97.5%.

CONCLUSION

As femoral head bone preservation procedure, BHR in this study provides excellent and promise result. Longer study is needed to address more complications. The authors are support the use of BHR in young active patient in Thailand.

Reliability and clinical outcomes of preoperative evaluations in modern total hip resurfacing and total hip arthroplasty in patients with osteonecrosis of the femoral head

BACKGROUND

Modern total hip resurfacing has been associated with excellent intermediate outcome in patients with osteonecrosis hip who are under 60 years., Up to 30-50% necrosis area in X-ray and MRI are theoretically acceptable to perform total hip resurfacing. However, both of plain X-ray and MRI still are uncertain information to precisely support decision making for either hip resurfacing or hip arthroplasty.

OBJECTIVE

Double setup operations (resurfacing or arthroplasty) were developed (i) to evaluate the reliability of preoperative evaluation based on plain X-ray and MRI comparing to the intra-operative finding after the completion of bone surface cut in hip resurfacing femoral procedure and (ii) to examine the early outcome for this double set up techniques.

MATERIAL AND METHOD

Between September 2004 to December 2008, 45 osteonecrosis hips (40 patients) were managed with double setup in which was either total hip resurfacing or total hip arthroplasty. The final intraoperative decisions were performed and then the comparison of the reliability of pre-operative evaluation was done. Outcomes assessment was examined based on Harris Hip score, Oxford hip score, university of California Los Angeles (UCLA) activity score, Short form-12 score, complications, and radiographic alignment including radiolucencies.

RESULTS

Twenty-five hips finally were performed with total hip resurfacing and the rest twenty hips were performed with total hip arthroplasty. Preoperative evaluation plans were unchanged from arthroplasty to resurfacing by intra-operative evaluation in 20 of 33 hips, representing the approximate reliability 61%. All 13 cases whose preoperative plans were changed had preoperative radiographic necrotic head involvement more than 50%, cystic change > 1.5 cm in size, superior head collapse more than 8 mm. The follow-up mean time was 28.6 months (5-50). All postoperative functional scores at the last follow-up (HHS, Oxford, UCLA, SF12) were significantly improved from preoperative functional score (p < 0.001). Pulmonary embolism was found in one patient with sickle cells induced osteonecrosis hip and no further complication after recovery. There was no postoperative infection, fracture neck of femur, DVT, nerve palsy, radiographic change.

CONCLUSION

Double setup operations were found efficacious to provide reliable information for the resurfacing surgeons to avoiding the too early total hip arthroplasty in the young patients. As a result, the patients can preserve their femoral heads at best.

Gastrointestinal and cardiovascular risk of non-selective NSAIDs and COX-2 inhibitors in elderly patients with knee osteoarthritis

OBJECTIVE

To evaluate the incidence and risk profiles for gastrointestinal (GI) events and cardiovascular (CV) events in elderly patients (aged > or =60 years) with knee osteoarthritis using tNSAIDs (traditional non-steroidal anti-inflammatory drugs) or coxibs users in patients with knee osteoarthritis aged > or =60 years.

MATERIAL AND METHOD

A hospital-based retrospective cohort study was applied. Data on prescription drug (NSAIDs, celecoxib, etoricoxib) was obtained from hospital database. Data on CV events and GI adverse events was obtained from the registry of the Cardiology Unit and Gastroesophagoscope Diagnosis Center, GI Center, Department of Internal medicine, Police General Hospital. Patients visiting the hospitals' outpatient clinics from June 2004 to June 2007 were included if they were aged > or =60 years and received at least one follow-up visit on the prescription of a tNSAIDNSAID or coxibs (etoricoxib or celecoxib). Patients with a history of gastrointestinal disease or heart disease were excluded. All patients were followed-up from their first visit to the date of their earliest event or to the end of the study period. The interested event was assumed to be attributed to the last prescription shown in the study period.

RESULTS

A total 12,591 prescriptions from 1030 patients, an average of 4 prescriptions/patient/year, were screened -3,982 (31.6%) prescriptions were for NSAIDs, 4426 (35.2%) were for celecoxib, and 4183 (33.2%) were for etoricoxib. The most common traditional NSAID prescribed was meloxicam (24%), followed by nimesulide (21.4%) and naproxen (13.1%). The mean age of cohort was 69.6 years, with the majority being female (74%). We found a comparable dose of celecoxib (200 mg OD) and etoricoxib (90 mg OD) prescribed in the respective patients. A total of 78 gastrointestinal events occurred and Esophagogastroscopy indicated that 37 (47.4%) were dyspepsia, 22 (28.2%) were anemia (28.2%), 17 (21.7%) were upper GI bleeding, and 2 (2.6%) were others. Forty (40) of these events were attributed to NSAIDs, 21 to celecoxib and 17 to etoricoxib. Observed GI events included gastritis (50, 64.1%), gastric ulcer (14, 17.9%), duodenal ulcer (3, 3.8%), and normal (11, 14.1%). Patients receiving traditional NSAIDs, celecoxib and etoricoxib had 20, 18, and 11 CV events respectively. Of these 49 CV events, the most common was heart failure (20), followed by chronic heart failure (9), angina pectoris (9), unstable angina (6), and myocardial infarction (5). Comparing celecoxib with NSAID use in logistic regression analysis, patients who received celecoxib were significantly less likely to suffer GI events than those who received NSAIDs; OR = 0.36 (95% CI 0.21-0.63, p = 0.00.). Similarly, etoricoxib was less likely to cause GI events than NSAIDs; OR = 0.52 (95% CI 0.28-0.98, p = 0.04). Comparing to patients aged under 60 years, patients aged >70 years had a significantly higher chance of developing GI events, OR = 1.79 (95% CI 1.13-2.4) for patients aged 70-80 years and 3.36 (95% CI 1.78-5.81) for those aged > 80 years. Drug exposure time, which was defined as the number of days of medication supplied significantly increased the GI risks. For CV event, there were only 3 significantly associated with CV events -female (OR = 0.29, 95% CI 0.16-0.59, p = 0.00), age >80 years (OR = 2.98, 95% CI 1.57-4.23, p = 0.00), and drug exposure time (OR = 1.05, 95% CI 1.02-1.54, p = 0.00).

CONCLUSION

Incidence of GI and CV events was lower for coxibs than for NSAIDs and celecoxib had a lower incidence than etoricoxib. Patients with advanced age and higher drug exposure time had a significantly increased risk ofGI; the use of gastroprotective agents significantly decreased GI risks. Being female, advanced age, and drug exposure time significantly affected CV events.

Total knee replacement following repeated cycles of intra-articular sodium hyaluronate (500-730 Kda) in failed conservative treatment of knee osteoarthritis: a 54-month follow-up

BACKGROUND

Treatment with repeated cycles of Intra-Articular Sodium Hyaluronate (IA-HA), from previous study, can improve symptoms and delay surgical interventions in knee osteoarthritis patients who failed conservative treatment within minimum 2-years follow-up. This is a continued study to follow-up responded patients in the mentioned study whether continuing treatment with IA-HA could prolong time to surgery until the end of follow-up.

OBJECTIVE

To evaluate the incidence of total knee replacement (TKR) in patients receiving repeated cycles of IA-HA during a 54-month follow-up period.

MATERIAL AND METHOD

This was a prospective cohort study with 54-month follow-up period. All patients received at least a single course of 3-weekly injections of IA-HA (500-730 Kilodalton, Hyalgan). Patients who well responded to the treatment were recommended to repeat the administration of a 3-weekly injections every 6-12 months based on their symptoms. The incidence of TKR and time was recorded. Time to event analysis using Kaplan-Meier survival analysis was performed.

RESULTS

183 patients were recruited during March 2001 and March 2004 and followed-up until October 2008. Patients were classified into three groups according to Ahlback radiological grading system. 46 patients were in group 1 (Ahlback grade I-II), 70 patients were in group 2 (Ahlback grade III-IV) and 67 patients were in group 3 (Ahlback grade V). The incidence of TKR was 28.4% with a mean time to TKR of 15.4 months (0.7-51.7 months). For the rest of patients who had no TKR during study period (80.4%, 64.3% and 73.1% for group 1, 2, and 3 respectively), their mean follow-up time was 45.6 months (19.0-53.1 months). Mean survival time was 42.1 months (95% CI = 39.4-44.9 months).

CONCLUSION

The repeated cycles of intra-articular sodium hyaluronate treatment in delay time to TKR in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period.

Results of computer assisted mini-incision subvastus approach for total knee arthroplasty

BACKGROUND

Mini-incision subvastus approach is soft tissue preservation of the knee. Advantages of the mini-incision subvastus approach included reduced blood loss, reduced pain, self rehabilitation and faster recovery. However, the improved visualization, component alignment, and more blood preservation have been debatable to achieve the better outcome and preventing early failure of the Total Knee Arthroplasty (TKA). The computer navigation has been introduced to improve alignment and blood loss. The purpose of this study was to evaluate the short term outcomes of the combination of computer assisted mini-incision subvastus approach for Total Knee Arthroplasty (CMS-TKA).

MATERIAL AND METHOD

A prospective case series of the initial 80 patients who underwent computer assisted mini-incision subvastus approach for CMS-TKA from January 2007 to October 2008 was carried out. The patients' conditions were classified into 2 groups, the simple OA knee (varus deformity was less than 15 degree, BMI was less than 20%, no associated deformities) and the complex deformity (varus deformity was more than 15 degrees, BMI more was than 20%, associated with flexion contractor). There were 59 patients in group 1 and 21 patients in group 2. Of the 80 knees, 38 were on the left and 42 on the right.

RESULTS

The results of CMS-TKA [the mean (range)] in group 1: group 2 were respectively shown as the incision length [10.88 (8-13): 11.92 (10-14], the operation time [118 (111.88-125.12): 131 (119.29-143.71) minutes, lateral releases (0 in both groups), postoperative range of motion in flexion [94.5 (90-100): 95.25 (90-105) degree] and extension [1.75 (0-5): 1.5 (0-5) degree] Blood loss in 24 hours [489.09 (414.7-563.48): 520 (503.46-636.54) ml] and blood transfusion [1 (0-1) unit? in both groups], Tibiofemoral angle preoperative [Varus = 4 (varus 0-10): Varus = 17.14 (varus 15.7-18.5) degree, Tibiofemoral angle postoperative [Valgus = 1.38 (Valgus 0-4): Valgus = 2.85 (valgus 2.1-3.5) degree], Tibiofemoral angle outlier (85% both groups), and Knee society score preoperative and postoperative [64.6 (59.8-69.4) and 93.7 (90.8-96.65)]: 69 (63.6-74.39) 92.36 (88.22-96.5)]. The complications found in both groups were similar. No deep vein thrombosis, no fracture at both femur and tibia, no vascular injury, and no pin tract pain or infection was found in both groups.

CONCLUSION

The computer assisted CMS-TKA) is one of the appropriate procedures for all varus deformity, no limitation with the associated bone loss, flexion contractor, BMI, except the fixed valgus deformity. To ensure the clinical outcomes, multiple key steps were considered as the appropriate techniques for this approach which included the accurate registration, precision bone cut and ligament balances, and the good cement techniques.

Clinical outcomes of minisubvastus approach for minimally invasive total knee arthroplasty

OBJECTIVE

To examine the clinical outcome of minisubvastus approach, a true quadriceps-sparing approach for minimally invasive knee arthroplasty.

MATERIAL AND METHOD

Between January 2005 and January 2008, 398 knees were included in this study. We evaluated the results of primary total knee arthroplasties performed with minisubvastus approach in patients at a minimum 1-year follow-up period. A retrospective review of the patient medical records was used.

RESULTS

The mean wound length was 11 centimeters and mean blood loss was about 478 milliliters. An average total operative time was 112 minutes. The mean femorotibial angle was corrected from 8 degrees varus preoperatively to 4 degrees valgus postoperatively. Pain assessed by WOMAC score was much improved as the mean score decreased from 50.84 at preoperative to 26.81 at one-year postoperative period.

CONCLUSION

Minisubvastus arthroplasty is effective and can be performed in almost of knee deformities.

Cost analysis of intra-articular sodium hyaluronate treatment in knee osteoarthritis patients who failed conservative treatment

BACKGROUND

Failed conservative treatments of knee osteoarthritis (OA) in the elderly have traditionally been treated with TKA (Total Knee Arthroplasty). Although TKA is a gold standard and cost-effective treatment in elderly patients, it should be considered as the last resource for patients with pain that cannot be controlled by the usual conservative therapeutic approaches. Numerous studies showed that intra-articular Sodium Hyaluronate (IA-HA) (Hyalgan) is effective for treatment in various stages of knee OA.

OBJECTIVES

To compare cost of treatment between two groups of knee OA patients who failed conservative treatments. The first group includes the patients who responded to IA-HA treatment leading to delay or cancel surgical treatments (response group). The second group includes the patients who did not respond to IA-HA treatment and they had to undergo surgical procedures (non-response group).

MATERIAL AND METHOD

A cost analysis from the retrospective data in Police General Hospital from year 2001-2004. One hundred and eighty three patients with knee OA (208 knees) who failed conservative treatments and did not have contraindications for surgery were enrolled. All patients were treated with one course of three IA-HA injections (500-730 KDA, Hyalgan) at weekly intervals and followed up for a minimum 2-year period. In case of successful treatment (response group), repeated doses were recommended. If the patients did not improve in the average Western Ontario and McMaster Universities Osteoarthritis Index (the average WOMAC) score within one month after completion of the injections, they would be classified as a non-response group and the surgical procedures would be considered. Cost of direct medical costs (drugs), hospitalization, and resource utilization were recorded and analyzed.

RESULTS

One hundred and forty six patients (164 knees) responded to the treatment and did not need any surgical procedures within the 2-year follow-up period. Thirty-seven patients (44 knees) did not respond and needed surgical procedures. In the response group, 83 patients repeated the second course of treatment and 14 patients repeated the third course. The total average cost for the response group were 47,044.18 Baht per patient, which was an average cost of IA-HA; 12,240.41 Baht and an average cost of other medications following the injection of 34, 803.77 Baht. The ratio of the IA-HA cost and medications following the injection cost was 1:2.84. In the non-response group, the total average cost was 144,884 Baht per patient including average cost of surgery of 135,559.95 Baht per patient or 113,993.59 Baht per knee and cost of IA-HA treatment of 9,324 Baht per patient, which was only 6.44% of the total costs of treatment. However, when considered in the response group, the IA-HA treatment provided cost saving from cancellation or delayed surgical procedures at 63.26%.

CONCLUSION

IA-HA should be considered as a medical intervention before surgical procedures in knee OA patients who failed conservative treatments. Even though the cost of IA-HA treatment would increase the total costs of treatment and some patients might fail, it was only 6.44% of the total costs. On the other hand, if patients responded to IA-HA treatment, then the surgical procedures were not required. This treatment could save the cost from cancellation or delayed surgical procedures at 63.26%.

Outcomes of intra-articular injection of sodium hyaluronate for the treatment of osteoarthritis of the knee

BACKGROUND

Intra-articular injection of hyaluronic acid has become an intervention step between conservative and operative treatment of knee osteoarthritis. This is recommended by the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR). However, the expected outcomes and the selection criteria are undetermined and controversial. A few articles have mentioned the long-term result of Sodium Hyaluronate in failed conservative treatment.

OBJECTIVE

Determine the clinical outcomes of treatment with three intra-articular Sodium Hyaluronate injections (500-730 kilodalton (KDA), Hyalgan) in knee-osteoarthritis patients who failed conservative treat-ment.

MATERIAL AND METHOD

This was an uncontrolled, retrospective-cohort study with at least a 24-month followup period. The outcomes of the treatment were evaluated by questionnaires and telephone calls. The primary efficacy parameter was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and the secondary efficacy parameter was delay or cancellation of any surgical treatments during the followup period. Patients who had undergone surgical treatments were placed in the non-response group. The response group has repeated treatment every year.

RESULTS

One hundred and eighty-three patients (208 knees) treated with intra-articular Sodium Hyaluronate were classified into three groups according to radiographic assessment. In group 1, narrowing joint space (Ahlback grade 1-2), WOMAC score improved from 70.46 to 26.55 (p < 0.0001), 41 in 46 patients (44/49 knees) did not require any surgical treatments. In group 2, bony attrition (Ahlback grade 3-4), WOMAC score improved from 70.19 to 40.38 (p < 0.0001), 47 in 70 patients (51/78 knees) did not require surgical treatment. In group 3, lateral subluxation (Ahlback grade 5) WOMAC score improved from 64.71 to 32.67 (p < 0.0001), 58 in 67 patients (69/81knees) did not require surgical treatment. The result from WOMAC subscale analysis revealed an improvement in pain, stiffness, and function in all groups (p < 0.0001), but did not improve in ambulatory status.

CONCLUSION

Intra-articular Sodium Hyaluronate injection, used in knee-osteoarthritis patients who failed conservative treatment, was effective in visible cartilage patients (Ahlback grade 1, 2) without mechanical problems involved. In severe osteoarthritis patients (Ahlback grade 3, 4, 5), this treatment was of less benefit if those patients were young, active, and expected independent ambulation. Surgical treatment may be a procedure of choice to meet patient expectation in improving function and ambulatory status. On the other hand, if patients were old and inactive with household ambulation, using intra-articular Sodium Hyaluronate was beneficial in improving pain, stiffness, and function but not ambulation level with 86.56% of excellent or good in overall satisfaction level. Thus, the radiographic evaluation, age, ambulatory status, and patient expectation may be the key factors to determine successful outcomes.

Nonspinal orthopaedic problems in familial dysautonomia (Riley-Day syndrome)

Familial dysautonomia (FD) is a rare autosomal recessive disease occurring in Ashkenazi Jews. It affects the autonomic, central, and peripheral nervous systems. The purpose of this study was to assess the prevalence and characteristics of orthopedic deformities, other than spinal deformities, in this population. A retrospective review of the medical records and radiographs of 182 patients was made. Three main groups of orthopaedic conditions were evaluated: (a) Fractures: 60% of the patients had one or more fractures; the average fracture rate was 1.4/patient. (b) Neuropathic joints: 11% of the cases had one or more neuropathic joints, the knee being the most common. (c) Other musculoskeletal deformities: 26% of the patients had one or more deformities. Lower extremity rotational problems and foot anomalies accounted for most of these deformities. Patients with FD have a higher prevalence of fractures and neuropathic joints than do their peers. The fracture pattern also is different, with a higher incidence of proximal femoral fractures.