A live, infectious vaccine candidate for epizootic bovine abortion, designated EBAA Vaccine, USDA-APHIS Product code #1544.00, has been reported to be both safe and effective. Previous studies ...established that a single dose of EBAA vaccine administered to cows at potencies of either 2000 or 500 live P. abortibovis-infected murine spleen cells (P.a.-LIC) induced protective immunity for a minimum of 5 months. The current study employed 19 pregnant cows that were challenged with P. abortibovis in their 2nd trimester of gestation; 9 were vaccinated 17.2-months earlier as 1-year-olds with 2000 P.a.-LIC and 10 served as negative controls. Eighty-nine percent of the vaccinates gave birth to healthy calves as compared to 10% of challenge controls. Vaccine efficacy was significant when analyzed by prevented fractions (87.7%; 95% CI=0.4945–0.9781). Serologic data supports previous findings that pregnant cows with detectable P. abortibovis antibodies are immune to P. abortibovis challenge as demonstrated by the birth of healthy calves.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
In patients undergoing total joint arthroplasty (TJA), increasing attention has been directed recently toward identifying specific patient-related risk factors that may predispose patients to ...periprosthetic joint infection (PJI). Currently, it is unclear whether having a history of a treated native septic arthritis is a risk factor for PJI after TJA in the same joint. Previous studies have reported contradictory evidence and results varied between a substantially higher rates of PJIs to very low or no reported PJIs.
(1) What is the risk of PJI in patients who received TJA and had a history of treated same-joint native joint septic arthritis and (2) What are the associated risk factors for these patients developing PJI?
This was a multicenter retrospective analysis of patients who received primary THA or TKA between January 2000 and December 2016 and who had a history of treated native joint septic arthritis in the same joint. Patients were included in the study only if they were considered to have resolved their joint infection based on a preoperative evaluation that included: (1) the absence of clinical symptoms and signs of active infection or local joint inflammation, (2) recent plain radiographs showing only advanced degenerative changes without evidence of active osteolysis or bone infection, (3) preoperative laboratory investigations for infection, including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and total leukocyte counts within normal ranges. Patients were reviewed for the occurrence of postoperative PJI. The final cohort included 62 patients who had a mean followup of 4.4 years (range, 3 months-17 years) from the time of TJA. A total of 21 patients (34%) had less than 2 years of followup, including six (10%) mortalities. In total, eight patients (13%) died during the study period, none of which were due to PJI. Patient characteristics, time interval from treatment of septic arthritis to TJA, and Charlson comorbidity index adjusted for age were collected. We used a Kaplan-Meier analysis to estimate the overall survivorship among all TJAs as well as those who underwent THA versus TKA, and we performed a statistical comparison using the Mantel-Cox log-rank test. We performed a Cox regression hazard ratio (HR) survival analysis to identify risk factors for PJI. The PJI odds ratios (OR) for patients who underwent TJA within 2 years of septic arthritis were calculated as an additional temporal analysis.
In patients with a history of treated same-joint native septic arthritis, the proportion of PJI was five of 62 patients (8%). The Kaplan-Meier analysis demonstrated an overall survivorship free from PJI of 92% at 14.5 ± 1.14 years (95% confidence interval CI = 12.3-16.8 years). All PJI cases occurred only in patients who underwent TKA, which when analyzed separately, yielded a survivorship of 85% at 10.5 ± 0.9 years (95% CI = 8.7-12.3 years) versus 100% in patients who underwent THA (p = 0.068). Mean time to PJI occurrence was 10 months (range, 2-20 months). After controlling for relevant confounding variables, such as age, sex, affected joint and comorbidities, we found smoking (HR, 8.06; 95% CI, 1.33-48.67; p = 0.023) to be associated with increased risk for PJI development.
Patients with history of native joint infections are at higher risk of PJI, especially smokers. Despite our limitations, this study suggests careful assessment of several other factors in these patients, including allowing a minimum interval of 2 years from the time of resolving native joint septic arthritis to TJA. Patients who are undergoing TKA seem to be more prone to the PJI risk and may benefit from more aggressive planning. In addition, medical optimization of comorbidities that may confer additional risk, such as diabetes, become exceptionally important in these patients.
Level III, therapeutic study.
Background
The early recovery period after periacetabular osteotomy (PAO) can be limited by pain and activity restrictions. Modifications of the Bernese PAO, including sparing the rectus tendon and ...discontinuing routine arthrotomy, may accelerate early postoperative recovery compared with the standard approach.
Questions/purposes
Does a modified approach for PAO (1) lead to improved pain control immediately after surgery; (2) lead to improved ambulation during the hospital stay; (3) lead to shorter stays, less blood loss, and shorter surgical times; and (4) compromise acetabular correction?
Methods
We retrospectively reviewed all 75 patients who underwent PAO for developmental dysplasia of the hip between August 2009 and May 2013. The control group included 44 consecutive patients who underwent a standard Bernese PAO with rectus takedown (RT). The study group consisted of 31 consecutive patients who underwent PAO using a modified rectus-sparing (RS) approach without routine arthrotomy. The groups were similar in age, body mass index, and American Society of Anesthesiologists score, but the RT group was comprised of a greater percentage of men than the RS group. Outcome variables were collected from patient charts and included inpatient pain, inpatient ambulation as well as length of stay, estimated blood loss, surgical time, and postoperative radiographic measurements. Cohen’s f
2
was used to calculate the effect size in the regression analysis and effects were considered small for values < 0.15, moderate for 0.15 to 0.34, and large for values > 0.35.
Results
Patients who underwent PAO with a RS approach had less overall pain (RT median 4 versus RS median 2); however, the difference may not have been perceptible to the typical patient (p = 0.001, f
2
= 0.059). Patients treated with the RS approach ambulated similar distances during the hospital stay with a median 11 feet (interquartile range IQR, 0–72.5) for the RT group and a median 30 feet (IQR, 0–100) for the RS group (p = 0.215, f
2
= 0.095). Patients in the RT group had a median length of stay of 4 days (IQR, 4–5) compared with a median 3 days (IQR, 3–4) in the RS group (p < 0.001). The median estimated blood loss was greater (p = 0.010) in the RT group (median, 500 mL; IQR, 350–700) versus the RS group (median, 300; IQR, 250–500). The median surgical time was longer (p < 0.001) in patients undergoing PAO with the RT approach (median, 159.5 minutes; IQR, 145.5–177) compared with the RS approach (median, 103 minutes; IQR, 75–114). Acetabular reorientation based on postoperative radiographs was not compromised by the modified approach.
Conclusions
The approach modification was straightforward to implement in all patients and did not compromise acetabular fragment mobilization or final positioning. Two of the three key variables that the approach might have influenced–pain and length of stay–were below the minimum clinically important difference and different by only a fraction of a day, respectively. The difference in ambulation was of only modest clinical importance. More definitive evidence for clinical superiority in terms of pain, ambulation, and return of muscle function will likely require more sophisticated instruments such as gait analysis, muscle strength testing, and longer-term outcome studies with sensitive instruments.
Level of Evidence
Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
Opioid use prior to total joint arthroplasty may be associated with poorer postoperative outcomes. However, few studies have reported the impact on postoperative recovery of mobility. We hypothesized ...that chronic opioid users would demonstrate impaired objective and subjective mobility recovery compared to nonusers.
A secondary data analysis of a multicenter, prospective observational cohort study in which patients used a smartphone-based care management platform with a smartwatch for self-directed rehabilitation following hip or knee arthroplasty was performed. Patients were matched 2:1 based on age, body mass index, sex, procedure, Charnley class, ambulatory status, orthopedic procedure history, and anxiety. Postoperative mobility outcomes were measured by patient-reported ability to walk unassisted at 90 days, step counts, and responses to the 5-level EuroQol-5 dimension 5-level, compared by Chi-square and student’s t-tests. Unmatched cohorts were also compared to investigate the impact of matching.
A total of 153 preoperative chronic opioid users were matched to 306 opioid-naïve patients. Age (61.9 ± 10.5 versus 62.1 ± 10.3, P = .90) and sex (53.6 versus 53.3% women, P = .95) were similar between groups. The proportion of people who reported walking unassisted for 90 days did not vary in the matched cohort (87.8 versus 90.7%, P = .26). Step counts were similar preoperatively and 1-month postoperatively but were lower in opioid users at 3 and 6 months postoperatively (4,823 versus 5,848, P = .03). More opioid users reported moderate to extreme problems with ambulation preoperatively on the 5-level EuroQol-5 dimension 5-level (80.6 versus 69.0%, P = .02), and at 6 months (19.2 versus 9.3%, P = .01).
Subjective and objective measures of postoperative mobility were significantly reduced in patients who chronically used opioid medications preoperatively. Even after considering baseline factors that may affect ambulation, objective mobility metrics following arthroplasty were negatively impacted by preoperative chronic opioid use.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
BACKGROUND:Soft-tissue releases are commonly necessary to achieve symmetrical flexion and extension gaps in primary total knee arthroplasty performed with a measured resection technique. We reviewed ...the frequency of required releases according to preoperative alignment and the clinical and radiographic results; associations with failure, reoperations, and complications are presented.
METHODS:We reviewed 1216 knees that underwent primary total knee arthroplasty from 2004 to 2009; 774 (64%) were in female patients and 442 (36%), in male patients. In the coronal plane, 855 knees had preoperative varus deformity, 123 were neutral, and 238 had valgus deformity. The mean age at the time of the index procedure was 62.7 years (range, twenty-three to ninety-four years), and the mean body mass index was 32.7 kg/m (range, 17.4 to 87.9 kg/m). Clinical outcomes included the Knee Society Score (KSS), implant failure, reoperation, and complications. Radiographs were analyzed for component alignment.
RESULTS:The only difference in the total KSS was found at the time of final follow-up between valgus knees with zero releases (total KSS = 178) and those with one or two releases (KSS = 160, p = 0.026). Overall, 407 knees (33.5%) required zero releases, 686 (56.4%) required oneor two releases, and 123 (10.1%) required three or more releases. Among varus knees, 37% required zero releases, 55% required one or two releases, and 7.5% required three or more releases. Among neutral knees, 39% required zero releases, 55% required one or two releases, and 5.7% required three or more releases. Only 17% of valgus knees required zero releases whereas 61% required one or two releases and 21.8% required three or more releases. Valgus knees required more releases than neutral or varus knees did (p < 0.001).
CONCLUSIONS:Selective soft-tissue release for gap balancing in primary total knee arthroplasty is an effective technique that produced excellent clinical and radiographic results regardless of preoperative alignment. Consistent anatomic coronal-plane alignment and soft-tissue balance could be achieved without bone cut modification by using measured bone resection and selective soft-tissue release.
Abstract
Background
Range of motion (ROM) following total knee replacement (TKR) has been associated with patient satisfaction and knee function, and is also an early indicator of a successful ...procedure. Robotic-assisted TKR (raTKR) is considered to reproduce more precise resections, and, as a result, may be associated with improved early patient satisfaction compared to manual TKR (mTKR). The purpose of this study was to evaluate the early postoperative active ROM (aROM) between raTKR and mTKR.
Methods
A total of 216 mTKR patients were propensity-matched, in terms of age, gender, comorbidities, and BMI, to 216 raTKR cases. Intraoperative and immediate postoperative adverse events were collected. Knee flexion and extension aROM were measured preoperatively and at one- and three months after operation.
Results
Changes in flexion aROM were significantly greater in raTKR vs. mTKR at one- (6.9°, 95% CI: 3.5, 10.4°) and three months (4.9°, 95% CI: 2.1, 7.7°). Flexion aROM was greater at three postoperative months compared to preoperative aROM only in the raTKR group, and raTKR patients had higher odds of achieving ≥ 90° of flexion at one month after operation (OR: 2.15, 95% CI: 1.16, 3.99). There were no significant differences between groups in intraoperative (
P
> 0.999) or postoperative adverse events.
Conclusions
Compared with mTKR, raTKR resulted in less loss of aROM immediately after operation and a faster recovery of aROM within three months after operation.
Trial registration
Clinicaltrials.gov (NCT# 03737149).
Patient delivery of care satisfaction surveys have emerged as instruments to assess the quality of health care at both the hospital and provider levels. We evaluated the correlation between these ...care satisfaction surveys and patient-reported outcomes (PROs).
We reviewed secondary data on 540 patients with 540 random visits who underwent primary total joint arthroplasty between January 2014 and February 2017. The Press Ganey Outpatient Medical Practice Survey was collected from outpatient clinical encounters to measure patient satisfaction with their experience and matched to PRO measures from the same encounter. The PROs evaluated included the Patient-Reported Outcomes Measurement Information System physical function computerized adaptive test, v1.2, and the Patient-Reported Outcomes Measurement Information System Global 10 health survey. In addition to the random selection, we reviewed separate cross-sections of the data including preoperative visits within 90 days of the index procedure, all postoperative visits at least 1 year from the index procedure, and the magnitude of change in PRO scores from preoperative to a minimum 1-year postoperative visit. Data were evaluated using the Spearman correlation coefficient (rs).
There was little if any correlation between the Press Ganey scores and PROs at all time points evaluated (all, rs: −0.13 to 0.14). When evaluating knee and hip arthroplasty cases separately, the data demonstrated similar results (all, rs: −0.33 to 0.18).
We found little, if any, correlation between a patient’s satisfaction with their care experience and their own perception of physical function and global health measures at all time points evaluated. These data question the utility of these scores as surrogate measures of health care quality, especially when reimbursements become tied to these metrics.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Enthusiasm for anterior-based approaches for total hip arthroplasty (THA) continues to increase but there is concern for increased complications during the learning curve period associated. This ...study aimed to investigate if there was a difference in perioperative variables, intraoperative and immediate postoperative complications, or patient-reported outcomes when transitioning from a mini-posterior approach (mPA) to an anterior-based muscle-sparing (ABMS) approach for THA.
Retrospective cohort study on the first 100 primary THA cases (n = 96 patients) of the senior author (August 2016 to August 2017) using the ABMS approach. These cases were compared to primary THA cases done the year prior (July 2015 to July 2016, n = 91 cases in 89 patients) using an mPA. Data were extracted and analyzed via gamma regression with robust standard errors and using generalized estimating equation regression.
We found no difference in the estimated blood loss (P = .452) and surgical time (P = .564) between the cohorts. The ABMS cases had a slightly shorter length of stay (P = .001) with an adjusted mean length of stay of 1.53 days (95% confidence interval 1.4-1.6) compared to 1.85 days (95% confidence interval 1.8-1.9) in the mPA cases. There was no difference in the frequency of immediate postoperative complications (all, P > .05). There was no difference in the adjusted mean change in patient-reported outcomes (all P > .05). In the ABMS group, there was no difference in surgical time or physical function computerized adaptive test between the first 20 cases (reference) and each subsequent group of 20 cases (all P > .05).
This study demonstrates no associated learning curve for an experienced senior surgeon when switching routine THA approach from mPA to ABMS. We advise careful interpretation of our results, as they may not apply to all surgeons and practices.
Level III Therapeutic Study: retrospective comparative study.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Purpose
To evaluate the feasibility of using a smartphone-based care management platform (sbCMP) and robotic-assisted total knee arthroplasty (raTKA) to collect data throughout the episode-of-care ...and assess if intra-operative measures of soft tissue laxity in raTKA were associated with post-operative outcomes.
Methods
A secondary data analysis of 131 patients in a commercial database who underwent raTKA was performed. Pre-operative through six week post-operative step counts and KOOS JR scores were collected and cross-referenced with intra-operative laxity measures. A Kruskal–Wallis test or a Wilcoxon sign-rank was used to assess outcomes.
Results
There were higher step counts at six weeks post-operatively in knees with increased laxity in both the lateral compartment in extension and medial compartment in flexion (
p
< 0.05). Knees balanced in flexion within < 0.5 mm had higher KOOS JR scores at six weeks post-operative (
p
= 0.034) compared to knees balanced within 0.5–1.5 mm.
Conclusion
A smartphone-based care management platform can be integrated with raTKA to passively collect data throughout the episode-of-care. Associations between intra-operative decisions regarding laxity and post-operative outcomes were identified. However, more robust analysis is needed to evaluate these associations and ensure clinical relevance to guide machine learning algorithms.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background:
Structural deformities of the hip, including femoroacetabular impingement (FAI) and acetabular dysplasia, often limit athletic activity. Previous studies have reported an increased ...prevalence of radiographic cam FAI in male athletes, but data on the prevalence of structural hip deformities in female athletes are lacking.
Purpose:
(1) To quantify the prevalence of radiographic FAI deformities and acetabular dysplasia in female collegiate athletes from 3 sports: volleyball, soccer, and track and field. (2) To identify possible relationships between radiographic measures of hip morphologic characteristics and physical examination findings.
Study Design:
Cross-sectional study; Level of evidence, 3.
Methods:
Anteroposterior (AP) pelvis and frog-leg lateral radiographs were obtained from 63 female athletes participating in Division I collegiate volleyball, soccer, and track and field. Lateral center edge angle (LCEA) and acetabular index were measured on AP films. Alpha angle and head-neck offset were measured on frog-leg lateral films. Pain during the supine impingement examination and hip rotation at 90° of flexion were recorded. Random-effects linear regression was used for group comparisons and correlation analyses to account for the lack of independence of observations made on left and right hips.
Results:
Radiographic cam deformity (alpha angle >50° and/or head-neck offset <8 mm) was found in 48% (61/126) of hips. Radiographic pincer deformity (LCEA >40°) was noted in only 1% (1/126) of hips. No hips had radiographic mixed FAI (at least 1 of the 2 cam criteria and LCEA >40°). Twenty-one percent (26/126) of hips had an LCEA <20°, indicative of acetabular dysplasia, and an additional 46% (58/126) of hips had borderline dysplasia (LCEA ≥20° and ≤25°). Track and field athletes had significantly increased alpha angles (48.2° ± 7.1°) compared with the soccer players (40.0° ± 6.8°; P < .001) and volleyball players (39.1° ± 5.9°; P < .001). There was no significant difference in the LCEA (all P > .914) or the prevalence of dysplasia (LCEA <20°) between teams (all P > .551). There were no significant correlations between the radiographic measures and internal rotation (all P > .077). There were no significant differences (all P > .089) in radiographic measures between hips that were painful (n = 26) during the impingement examination and those that were not.
Conclusion:
These female athletes had a lower prevalence of radiographic FAI deformities compared with previously reported values for male athletes and a higher prevalence of acetabular dysplasia than reported for women in previous studies.
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FSPLJ, NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
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