Background: Total joint arthroplasty (TJA) is indicated in persons with end-stage arthritis of the hip and knee (THA and TKA, respectively). While most TJAs are performed for osteoarthritis (OA), ...3%-13% are performed in patients with rheumatoid arthritis (RA). Most of the evidence regarding complications following TJA is based on studies of patients with OA, with little known about recipients with RA. The purpose of this thesis was to summarize current evidence on the rates of complications following TJA in patients with RA, to quantify this risk using validated methods, and to determine the impact of surgeon experience performing TJA in persons with RA on this risk. Methods: For reports published between 1990 and 2011, we evaluated the evidence regarding the risk of complications following TJA in RA using qualitative and quantitative methods. In a cohort of recipients of primary elective THA or TKA between 2002 and 2009, in Ontario, Canada, we identified patients with RA using a validated algorithm. Multivariable Cox proportional hazards regression was used to evaluate the relationship between arthritis type (RA, OA, other) and the occurrence of surgical complications, and to evaluate the impact of surgeon experience on the risk of a complication. Results: Forty published studies were reviewed. Relative to TJA recipients with OA, those with RA were at increased risk of dislocation following THA, and increased risk for joint infection following TKA. These findings were confirmed in our cohort study: adjusted hazard ratio (HR) for dislocation 1.91, p=0.001; adjusted HR for infection 1.47, p=0.03). In TJA recipients with RA, greater surgeon RA volume was associated with a reduced risk for surgical complications (adjusted HR per 10 additional cases: 0.81, p=0.002). Conclusions: In a population-based cohort of primary elective TJA recipients, patients with RA were at significantly increased risk for dislocation following THA and joint infection following TKA. Increased surgeon experience performing TJA in patients with RA attenuated the risk for surgical complications among TJA recipients with RA. Further research is required to identify the mediators of the increased complication risk in patients with RA, and to delineate strategies to optimize outcomes in these patients.
Background
Acetabular osteophytes are common findings during total hip arthroplasty (THA).
Purpose
This study was designed to determine the extent to which osteophytes may limit range of motion (ROM) ...and in which locations impingement is likely to occur if osteophytes are not removed during surgery.
Methods
Computer-aided design was used to compare ROM of a modern hip implant in four cadaver models with and without 10-mm acetabular rim osteophytes added. A clock face, with 12 o'clock at the superior pole of the right acetabulum, was used to map impingement.
Results
The osteophyte model limited ROM in flexion (101° v. 113°, p = 0.03), 90° of flexion with internal rotation (16.7° v. 31.6°, p = 0.01), and external rotation (30.4° v. 49.5°, p = 0.01). Impingement occurred between 7 and 8 o'clock in external rotation and 1 and 2 o'clock in the other two motions.
Conclusions
Osteophytes in these positions have the greatest impact on ROM and should be removed during THA.
Background Because individuals with osteoarthritis (OA) avoid physical activities that exacerbate symptoms, potentially increasing risk for cardiovascular disease (CVD) and death, we assessed the ...relationship between OA disability and these outcomes. Methods In a population cohort aged 55+ years with at least moderately severe symptomatic hip and/or knee OA, OA disability (Western Ontario McMaster Universities (WOMAC) OA scores; Health Assessment Questionnaire (HAQ) walking score; use of walking aids) and other covariates were assessed by questionnaire. Survey data were linked to health administrative data to determine the relationship between baseline OA symptom severity to all-cause mortality and occurrence of a composite CVD outcome (acute myocardial infarction, coronary revascularization, heart failure, stroke or transient ischemic attack) over a median follow-up of 13.2 and 9.2 years, respectively. Results Of 2156 participants, 1,236 (57.3%) died and 822 (38.1%) experienced a CVD outcome during follow-up. Higher (worse) baseline WOMAC function scores and walking disability were independently associated with a higher all-cause mortality (adjusted hazard ratio, aHR, per 10-point increase in WOMAC function score 1.04, 95% confidence interval, CI 1.01-1.07, p = 0.004; aHR per unit increase in HAQ walking score 1.30, 95% CI 1.22-1.39, p<0.001; and aHR for those using versus not using a walking aid 1.51, 95% CI 1.34-1.70, p<0.001). In survival analysis, censoring on death, risk of our composite CVD outcome was also significantly and independently associated with greater baseline walking disability ((aHR for use of a walking aid = 1.27, 95% CI 1.10-1.47, p = 0.001; aHR per unit increase in HAQ walking score = 1.17, 95% CI 1.08-1.27, p<0.001). Conclusions Among individuals with hip and/or knee OA, severity of OA disability was associated with a significant increase in all-cause mortality and serious CVD events after controlling for multiple confounders. Research is needed to elucidate modifiable mechanisms.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
STUDY QUESTION What are the rates of serious cardiovascular events in those who undergo primary total joint arthroplasty (TJA) compared with those who do not within three years of initial assessment? ...SUMMARY ANSWER Undergoing elective primary TJA within three years of initial assessment was associated with a significant 12.4% absolute reduction in subsequent risk of serious cardiovascular events. WHAT IS KNOWN AND WHAT THIS PAPER ADDS Osteoarthritis is associated with increased mortality, particularly secondary to cardiovascular disease, with the risk for mortality proportional to the degree of disability secondary to the arthritis. This study suggests that management of hip or knee osteoarthritis with arthroplasty decreases the risk for subsequent serious cardiovascular events.
Background: Total joint arthroplasty (TJA) is indicated in persons with end-stage arthritis of the hip and knee (THA and TKA, respectively). While most TJAs are performed for osteoarthritis (OA), ...3%-13% are performed in patients with rheumatoid arthritis (RA). Most of the evidence regarding complications following TJA is based on studies of patients with OA, with little known about recipients with RA. The purpose of this thesis was to summarize current evidence on the rates of complications following TJA in patients with RA, to quantify this risk using validated methods, and to determine the impact of surgeon experience performing TJA in persons with RA on this risk.
Methods: For reports published between 1990 and 2011, we evaluated the evidence regarding the risk of complications following TJA in RA using qualitative and quantitative methods. In a cohort of recipients of primary elective THA or TKA between 2002 and 2009, in Ontario, Canada, we identified patients with RA using a validated algorithm. Multivariable Cox proportional hazards regression was used to evaluate the relationship between arthritis type (RA, OA, other) and the occurrence of surgical complications, and to evaluate the impact of surgeon experience on the risk of a complication.
Results: Forty published studies were reviewed. Relative to TJA recipients with OA, those with RA were at increased risk of dislocation following THA, and increased risk for joint infection following TKA. These findings were confirmed in our cohort study: adjusted hazard ratio (HR) for dislocation 1.91, p=0.001; adjusted HR for infection 1.47, p=0.03). In TJA recipients with RA, greater surgeon RA volume was associated with a reduced risk for surgical complications (adjusted HR per 10 additional cases: 0.81, p=0.002).
Conclusions: In a population-based cohort of primary elective TJA recipients, patients with RA were at significantly increased risk for dislocation following THA and joint infection following TKA. Increased surgeon experience performing TJA in patients with RA attenuated the risk for surgical complications among TJA recipients with RA. Further research is required to identify the mediators of the increased complication risk in patients with RA, and to delineate strategies to optimize outcomes in these patients.
Background Children with lower-limb-length discrepancy require repeated radiographic assessment for monitoring and as a guide for management. The need for accurate assessment of length and alignment ...is balanced by the need to minimize radiation exposure. We compared the accuracy, reliability, and radiation dose of EOS, a novel low-dose upright biplanar radiographic imaging system, at two different settings, with that of conventional radiographs (teleoroentgenograms) and computed tomography (CT) scanograms, for the assessment of limb length. Methods A phantom limb in a standardized position was assessed ten times with each of four different imaging modalities (conventional radiographs, CT scanograms, EOS-Slow, EOS-Fast). A radiation dosimeter was placed on the phantom limb, on a portion closest to the radiation source for each modality, in order to measure skin-entrance radiation dose. Standardized measurements of bone lengths were made on each image by consultant orthopaedic surgeons and residents and then were assessed for accuracy and reliability. Results The mean absolute difference from the true length of the femur was significantly lower (most accurate) for the EOS-Slow (2.6 mm; 0.5%) and EOS-Fast (3.6 mm; 0.8%) protocols as compared with CT scanograms (6.3 mm; 1.3%) (p < 0.0001), and conventional radiographs (42.2 mm; 8.8%) (p < 0.0001). There was no significant difference in accuracy between the EOS-Slow and EOS-Fast protocols (p = 0.48). The mean radiation dose was significantly lower for the EOS-Fast protocol (0.68 mrad; 95% confidence interval CI, 0.60 to 0.75 mrad) compared with the EOS-Slow protocol (13.52 mrad; 95% CI, 13.45 to 13.60 mrad) (p < 0.0001), CT scanograms (3.74 mrad; 95% CI, 3.67 to 3.82 mrad) (p < 0.0001), and conventional radiographs (29.01 mrad; 95% CI, 28.94 to 29.09 mrad) (p < 0.0001). Intraclass correlation coefficients showed excellent (>0.90) agreement for conventional radiographs, the EOS-Slow protocol, and the EOS-Fast protocol. Conclusions Upright EOS protocols that utilize a faster speed and lower current are more accurate than CT scanograms and conventional radiographs for the assessment of length and also are associated with a significantly lower radiation exposure. In addition, the ability of this technology to obtain images while subjects are standing upright makes this the ideal modality with which to assess limb alignment in the weight-bearing position. This method has the potential to become the new standard for repeated assessment of lower-limb lengths and alignment in growing children. Clinical Relevance This study assesses the reliability and accuracy of a diagnostic test used for clinical decision-making.
Venous thromboembolism (VTE) following total hip (THA) and knee arthroplasty (TKA) is linked to immobility and preoperative prediction remains difficult. We aimed to evaluate whether annual mean ...length of stay (LOS) is associated with the incidence of VTE and develop a generalizable machine learning (ML) model to preoperatively predict the incidence of symptomatic VTE following THA and TKA using NSQIP.
Annual incidence of 30-day postoperative VTE, deep vein thrombosis (DVT) and pulmonary embolism (PE), was calculated over six years and tested for trend. Correlation between annual VTE rates and mean LOS was calculated. Predictive models (logistic regression, random forest, and XGBoost) were trained and tested based on year of surgery with different oversampling algorithms used to address data imbalance.
A total of 498,314 patients were included, with 0.88% developing a VTE within 30 days. VTE rates decreased from 1.11% in 2014 to 0.76% in 2019 (p<0.001). There was a strong correlation between the yearly incidence of VTE, PE and DVT and mean LOS (r=0.96, 0.87 and 0.98, respectively). Univariate analysis demonstrated that TKA, inpatient setting, ASA classification and various patient comorbidities were significantly associated with VTE. The logistic regression model trained on all data with a balanced loss scoring function performed the best (AUC=0.600).
This study revealed declining VTE rates, strongly correlated to decreasing postoperative LOS and identified patient and surgery-specific factors associated with VTE risk. Development of more accurate ML models for VTE prediction may improve risk stratification, prevention, and monitoring for arthroplasty patients.
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