Background
A subgroup of patients undergoing TKA is unhappy with the outcome of surgery and preoperative psychological factors may play a role in their dissatisfaction.
Questions/purposes
We asked ...whether (1) psychological factors, as measured by preoperative self-reported questionnaires, predicted poor outcome after TKA, and (2) whether certain psychological factors examined predicted poor outcome better than others.
Methods
We performed a systematic review and meta-analysis of prospective observational studies published in MEDLINE, CINAHL
®
, EMBASE™, and PsycINFO
®
databases from their date of inception to October 2013, augmented with a manual search of bibliographies. Study eligibility was performed according to an a priori protocol. Included studies were assessed for quality according to the Newcastle-Ottawa scale. Two reviewers independently performed the search, identified eligible studies, assessed their methodologic quality, and extracted data. Outcomes of interest included postoperative dissatisfaction, pain, or limited function of the patients.
Results
A total of 19 studies (17 cohort studies and two cross-sectional surveys) containing data on 9046 TKAs performed in 8704 adult patients were included in the review. Mean patient age was 68 years and followup ranged from 6 to 60 months (mean study followup, 14 months). Clinical and methodologic heterogeneity in study design prevented the statistical pooling of data and subsequent meta-analysis. Dissatisfaction rates with TKA ranged from 7.5% to 28.3%. Psychological health was deemed a significant predictor of satisfaction, pain, or function at a minimum of 6 months after TKA in 16 studies. The remaining three studies did not find this relationship. Baseline mental health factors may affect patient satisfaction, their long-term perception of pain, and their motivation to return to the desired level of function. We were unable to determine the most relevant psychological states or the most appropriate way to assess them with our systematic review.
Conclusions
The preoperative psychological state of a patient may affect the outcome after a TKA. A comprehensive psychological assessment of patients is required to examine the long-term effect of such psychological factors on the eventual outcomes of TKA once the recovery phase is complete and to assess the effect that treatment for these psychological conditions may have on decreasing the dissatisfaction rate with TKA in this population.
Despite advances in percutaneous interventions, transcatheter Fontan completion remains experimental and performed only in select cases. Non‐surgical Fontan completion requires surgical ...preconditioning at an earlier stage of palliation. We describe transcatheter Fontan completion in a 15‐year‐old male with previously failed surgical Fontan palliation without surgical preconditioning.
BACKGROUNDIntravenous tranexamic acid (TA) has proven efficacy in reducing blood loss and incidence of transfusion of blood products in elective total joint arthroplasty. However, evidence of ...efficacy in the setting of intracapsular hip fractures needing hip hemiarthroplasty (HA) or total hip arthroplasty (THA) are scarce. This study aimed to assess post-operative transfusion incidence in this clinical setting.METHODSOver a five-year period 250 patients with intracapsular neck of femur fractures requiring arthroplasty were randomised to two groups. The treatment group received three-dose intravenous TA protocol and the control group received usual treatment without administration of TA. Blood loss was estimated from the change in Hb levels on day 1, 3 and 5 after surgery compared to preoperative levels. Transfusions of blood products were recorded when they were triggered by an a priori protocol. Post-operative complications were recorded during patient hospital admission.RESULTSThe intervention group showed significantly lower transfusion incidence of packed red blood cells (PRBC) (6 vs. 15, p = 0.04, OR = 0.37, 95%CI OR = 0.14 to 0.99) and in the group of patients who received a blood transfusion, a trend was observed for patients who received TA to have lesser number of units of PRBC (mean = 1.3 vs. 1.6, p = 0.51). A significant difference was noted in post-operative Hb levels of day 1,3 and 5. Backward stepwise multivariable regression analysis showed the use of TA was the most significant factor for reduction in postoperative blood transfusion (p = 0.047, OR = 0.37, 95% CI OR = 0.14 to 0.99). Assessment of the strength of the correlation showed modest correlation (Pearson correlation - 0.13 p = 0.04, 95% CI correlation= -0.25 to -0.01). There was no increase in adverse events in patients who received TA.CONCLUSIONThe use of TA in setting of intracapsular hip fractures requiring arthroplasty reduces blood loss, the need for transfusion of blood products and may reduce surgical site complications without increasing the risk of VTE.
Purpose
A proportion of TKA recipients following TKA are dissatisfied with their outcome. Our hypothesis is that patient satisfaction with TKA and perception of success of surgery are associated with ...patient comorbidities and overall health status, surgical and anaesthetic techniques as well as processes of post-operative care after TKA. The aims were to (i) measure the incidence of patient unfavourable outcomes—defined as dissatisfaction with the surgery or lack of joint-specific global improvement—1 year after TKA, and to explore the differences between these two outcomes of interest; (ii) assess the relationship between the development of these unfavourable outcomes and patient-reported knee function and overall quality of life; (iii) explore the associations between pre- and peri-operative variables and the development of these unfavourable outcomes 1 year after TKA.
Methods
This study includes analysis of data from a prospective cohort of 1017 TKA recipients. Pre-operative patient variables, surgical and acute-care data were collected. The Oxford knee score and the global perception of improvement were used to assess satisfaction and success 365 days post-surgery.
Results
From 1017 patients (56% female), mean age 68 years and BMI 32, 68 pts (7%) were dissatisfied with the outcome of surgery, 141 pts (14%) believed surgery was unsuccessful 1 year after TKA. A negative outcome was noted in 151 (15%) patients for either satisfaction or success, and 58 (6%) of patients reported neither good satisfaction nor success after surgery. Dissatisfied patients reported worse mean OKS (26.4 SD 8.03 vs 42.3 SD 5.21,
p
< 0.001) and mean EQ VAS (64.9 SD 19.49 vs 81.8 SD 14.38,
p
< 0.001) than satisfied patients. Patients who reported unsuccessful surgery also showed significantly lower mean OKS (30.9 SD 9.29 vs 42.9 SD 4.39,
p
< 0.001) and mean EQ VAS (68.2 SD 18.61 vs 82.7 SD 13.77,
p
< 0.001). Univariate analysis of predictors of unfavourable outcome post-TKA showed that financial status, obstructive sleep apnoea (OSA), ASA class > 2 and not resurfacing the patella were factors associated with the development of dissatisfaction with TKA and with patient perceived unsuccessful results of TKA. Multivariable logistic regression of patient satisfaction and success of TKA showed that compensation cases (OR 26.91,
p
< 0.001 for dissatisfaction and OR 11.49,
p
= 0.001 for unsuccessful TKA), obstructive sleep apnoea (OR 2.18,
p
= 0.04 for dissatisfaction and OR 1.82,
p
= 0.04 for unsuccessful TKA), ASA grade >
2
(OR 1.83,
p
= 0.04 for dissatisfaction and OR 1.57,
p
= 0.03 for unsuccessful TKA)and the development of a complication after TKA (OR 3.4,
p
< 0.001 for dissatisfaction and OR 2.39,
p
< 0.001 for unsuccessful TKA) were associated with the development of a negative outcome in both groups. Patella preservation (OR 1.96,
p
= 0.03) was associated with dissatisfaction, whereas the use of cruciate retaining femoral prosthesis was associated with less successful results of TKA (OR 1.78,
p
= 0.009).
Conclusions
An unfavourable outcome occurs in approximately 7–15% of patients following TKA. The incidence varies with how an unfavourable result is defined and many factors are associated with this outcome though prosthetic design or patella resurfacing do not appear to be important.
Abstract Background The use of computer assisted joint replacement has facilitated precise intraoperative measurement of knee kinematics. The changes in “screw home mechanism” (SHM) resulting from ...Total Knee Arthroplasty (TKA) with different prostheses and constraints has not yet been accurately described. Methods A pilot study was first completed. Intraoperative kinematic data was collected two groups of 15 patients receiving different prostheses. Results On average, patients lost 5.3° of ER (SD = 6.1°). There was no significant difference between the prostheses or different prosthetic constraints. Conclusions There significant loss of SHM after TKA. Further research is required to understand its impact on patient function.
Introduction
The purpose of this study was to assess if severity of radiographic changes of knee arthritis was associated with patient improvement after total knee arthroplasty (TKA). We hypothesised ...that patients with mild arthritis were more likely to report lower satisfaction, improvement in knee function and Oxford knee score (OKS) compared to patients with moderate or severe arthritis.
Materials and methods
Secondary analysis of prospectively collected data from TKA patients of two arthroplasty centres with knee radiographs available for assessment of disease severity. Patients completed the Oxford knee score (OKS) and were asked to rate the global improvement in knee condition and their satisfaction at 6 months post-TKA. Bivariable analysis and multivariable regression models were used to test the association between disease severity and each outcome.
Results
2226 patients underwent primary TKA and 3.6% had mild arthritis. Mean OKS improved from 17.0 (SD 18.0) to 38.0 (SD 8.1) 6 months after TKA. Two hundred and twenty-two patients (10%) reported ‘Poor’ or ‘Fair’ satisfaction, and 173 (8%) reported knee function was ‘Much worse’, ‘A little worse’ or ‘About the same’ 6 months post-TKA. Patients with mild arthritis showed improvement in OKS mean improvement in OKS = 19 (SD 15), but were significantly more likely to report dissatisfaction (OR = 3.10, 95% CI 1.62 to 5.91,
p
= 0.006), lack of improvement (OR = 4.49, 95% CI 2.38 to 8.47,
p
< 0.001) and lower OKS scores (− 3 points, 95% CI − 5.39 to − 0.85,
p
= 0.008) compared to patients with moderate to severe arthritis.
Conclusions
While patients with mild radiographic arthritic changes improve after TKA, they were significantly more likely to report higher rates of dissatisfaction, less improvement in knee function and OKS compared to patients with moderate-severe grades of arthritis.
Gerbode defect, a left ventricle to right atrium (LV-RA) communication, is usually congenital. Acquired LV-RA communications are rare and only few case reports of successful trans-catheter closure ...have been published though none of them were on infants. We hereby report a rare case of LV to RA shunt acquired following surgical repair of Tetralogy of Fallot (TOF). The defect was successfully closed percutaneously with an Amplatzer duct occluder. This is the first reported case of device closure of an acquired Gerbode defect in an infant.
Muscular pulmonary atresia with intact ventricular septum (PA/IVS) in neonates is traditionally managed by surgery. We describe hybrid approach to decompress the right ventricle (RV) and establish RV ...to pulmonary artery connection in a neonate avoiding cardiopulmonary bypass. A 21-gauge access needle was used to perforate the atretic pulmonary valve via periventricular approach followed by stent placement. This case is an example of how patients with congenital heart disease can be palliated in creative ways through thoughtful collaboration between surgical and interventional cardiology teams.
Abstract Background To determine the prevalence of psychiatric distress in an Australian patient population waiting for TKA and to assess the associations between psychological distress and other ...baseline characteristics. Methods A cross-sectional study of prospectively collected data from patients with knee arthritis participating in the NSW Osteoarthritis Chronic Care Program (OACCP). Participants were divided into two groups based on the Depression Anxiety and Stress Score (DASS). The prevalence of psychological distress was compared to reported prevalence in the Australian community. Between-group comparisons of a number of variables were made, including demographic and socioeconomic data, health and psychiatric data, patient-reported knee and quality of life scores, and measured function. Results Data from 3,301 patients were available and 2,809 patients were eligible for inclusion, with 1,740 (62%) females. Mean patient age was 68 years, mean BMI was 33.8. We found 753 (26.8%, SD 0.44) of participants reported psychological distress. Those reporting distress were more likely to be female (p=0.025), younger (66.6 Vs 68.8 yrs, p<0.001 ), with a higher BMI (34.5 Vs 32.7, p<0.001), and had more comorbidities (3.4 Vs 2.8, p<0.001). The distressed group had significantly worse knee pain (VAS 7.1 Vs 6.2, p<0.001, KOOSP 28.9 Vs 41.2, p <0.001), knee function and general quality of health scores (p<0.001). Conclusion Psychological health is an important and often overlooked predictor of severity of symptoms and dysfunction in patients with knee arthritis. As it can affect outcome for surgery, psychological health should be better assessed and treated prior to surgery to help reduce pre-operative dysfunction and improve post-operative outcomes of TKA.
AbstractBackgroundAccurate alignment is a basic principle of TKA surgery, but achieving alignment within this target may not translate into superior outcomes after surgery. PurposeTo assess if ...neutral TKA mechanical alignment was associated with superior knee outcomes and to examine the effect of various aspects of pre-operative and post-operative alignment on knee function. MethodsAnalysis of a database of 444 TKA patients between June 2009 and October 2016. Knee outcomes (WOMAC, AKSS and knee range of motion) were collected before surgery and during follow-up at a minimum of six months. ResultsAnalysis included 444 TKA patients (62% female, mean age 66 years, mean follow-up 23 months). Deformity varied from 21° varus (mean = 7.9, SD = 2.8) to 17° valgus deformity (mean = 7.7, SD = 2.8). Pre-operatively, 101 (23%) knees were in native neutral mechanical alignment, while 278 (63%) were in varus and 65 (15%) were in valgus. Post-operatively, a group of 365 (82%) TKA were found to be in neutral mechanical alignment and a group of 79 (18%) TKA were noted to be ‘Outliers’ (17 4% TKA > 3° varus and 62 14% TKA > 3° valgus alignment). Restoration of the target of alignment of 0 ± 3° or 0 ± 1°, did not have better functional outcomes scores, range of motion or prosthesis longevity than those in the outlier range. ConclusionNeutral TKA alignment did not appear to be a significant contributing factor to the improvement in knee function in short-medium term follow-up.
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