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INTRODUCTION: Paediatric concussion is a common injury. Approximately 30% of youth with concussion will experience persisting postconcussion symptoms (PPCS) extending at least 1 month following injury. Recently, studies have shown the benefit of early, active, targeted therapeutic strategies. However, these are primarily prescribed from the specialty setting. Early access to concussion specialty care has been shown to improve recovery times for those at risk for persisting symptoms, but there are disparities in which youth are able to access such care. Mobile health (mHealth) technology has the potential to improve access to concussion specialists. This trial will evaluate the feasibility of a mHealth remote patient monitoring (RPM)-based care handoff model to facilitate access to specialty care, and the effectiveness of the handoff model in reducing the incidence of PPCS. METHODS AND ANALYSIS: This study is a non-randomised type I, hybrid implementation-effectiveness trial. Youth with concussion ages 13-18 will be enrolled from the emergency department of a large paediatric healthcare network. Patients deemed a moderate-to-high risk for PPCS using the predicting and preventing postconcussive problems in paediatrics (5P) stratification tool will be registered for a web-based chat platform that uses RPM to collect information on symptoms and activity. Those patients with escalating or plateauing symptoms will be contacted for a specialty visit using data collected from RPM to guide management. The primary effectiveness outcome will be the incidence of PPCS, defined as at least three concussion-related symptoms above baseline at 28 days following injury. Secondary effectiveness outcomes will include the number of days until return to preinjury symptom score, clearance for full activity and return to school without accommodations. The primary implementation outcome will be fidelity, defined as the per cent of patients meeting specialty care referral criteria who are ultimately seen in concussion specialty care. Secondary implementation outcomes will include patient-defined and clinician-defined appropriateness and acceptability. ETHICS AND DISSEMINATION: This study was approved by the Institutional Review Board of the Children's Hospital of Philadelphia (IRB 22-019755). Study findings will be published in peer-reviewed journals and disseminated at national and international meetings. TRIAL REGISTRATION NUMBER: NCT05741411.
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Concussão Encefálica , Serviço Hospitalar de Emergência , Síndrome Pós-Concussão , Telemedicina , Humanos , Adolescente , Concussão Encefálica/terapia , Síndrome Pós-Concussão/terapia , Acessibilidade aos Serviços de Saúde , Masculino , FemininoRESUMO
Nonstructural protein 5 (Nsp5) is the main protease of SARS-CoV-2 that cleaves viral polyproteins into individual polypeptides necessary for viral replication. Here, we show that Nsp5 binds and cleaves human tRNA methyltransferase 1 (TRMT1), a host enzyme required for a prevalent post-transcriptional modification in tRNAs. Human cells infected with SARS-CoV-2 exhibit a decrease in TRMT1 protein levels and TRMT1-catalyzed tRNA modifications, consistent with TRMT1 cleavage and inactivation by Nsp5. Nsp5 cleaves TRMT1 at a specific position that matches the consensus sequence of SARS-CoV-2 polyprotein cleavage sites, and a single mutation within the sequence inhibits Nsp5-dependent proteolysis of TRMT1. The TRMT1 cleavage fragments exhibit altered RNA binding activity and are unable to rescue tRNA modification in TRMT1-deficient human cells. Compared to wild-type human cells, TRMT1-deficient human cells infected with SARS-CoV-2 exhibit reduced levels of intracellular viral RNA. These findings provide evidence that Nsp5-dependent cleavage of TRMT1 and perturbation of tRNA modification patterns contribute to the cellular pathogenesis of SARS-CoV-2 infection.
The virus responsible for COVID-19 infections is known as SARS-CoV-2. Like all viruses, SARS-CoV-2 carries instructions to make proteins and other molecules that play essential roles in enabling the virus to multiply and spread. Viruses are unable to make these molecules themselves, so they infect cells and trick them into making the molecules and assembling new virus particles on their behalf instead. When SARS-CoV2 infects cells, the host cells are reprogrammed to make chains containing several virus proteins that need to be severed from each other by a virus enzyme, known as Nsp5, to enable the proteins to work properly. Previous studies suggested that Nsp5 may also interact with a human protein known as TRMT1, which helps with the production of new proteins in cells. However, it was not clear how Nsp5 may bind to TRMT1 or how this interaction may affect the host cell. Zhang et al. used biochemical and molecular techniques in human cells to study how Nsp5 interacts with TRMT1. The experiments found that the virus enzyme cuts TRMT1 into fragments that are inactive and are subsequently destroyed by the cells. Moreover, Nsp5 cuts TRMT1 at exactly the same position corresponding to the cleavage sites of the viral proteins. Mutation of the sequence in TRMT1 renders Nsp5 ineffective at cutting the protein. SARS-CoV-2 infection caused TRMT1 levels to decrease inside the cells, in turn, leading to a drop in TRMT1 activity. The virus multiplied less in cells that were unable to produce TRMT1 compared to normal human cells, suggesting that the virus benefits from TRMT1 early during infection, before inactivating it at a later point. These findings suggest that one way SARS-CoV-2 causes disease is by decreasing the levels of a human protein that regulates protein production. In the future, the work of Zhang et al. may provide new markers for detecting infections of SARS-CoV-2 and other similar viruses and guide efforts to make more effective therapies against them.
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Proteólise , RNA de Transferência , SARS-CoV-2 , tRNA Metiltransferases , Humanos , Proteases 3C de Coronavírus/metabolismo , Proteases 3C de Coronavírus/genética , COVID-19/virologia , COVID-19/metabolismo , Células HEK293 , RNA de Transferência/metabolismo , RNA de Transferência/genética , SARS-CoV-2/genética , SARS-CoV-2/metabolismo , tRNA Metiltransferases/metabolismo , tRNA Metiltransferases/genética , Proteínas não Estruturais Virais/metabolismo , Proteínas não Estruturais Virais/genética , Replicação ViralRESUMO
Aims: Manual impaction, with a mallet and introducer, remains the standard method of installing cementless acetabular cups during total hip arthroplasty (THA). This study aims to quantify the accuracy and precision of manual impaction strikes during the seating of an acetabular component. This understanding aims to help improve impaction surgical techniques and inform the development of future technologies. Methods: Posterior approach THAs were carried out on three cadavers by an expert orthopaedic surgeon. An instrumented mallet and introducer were used to insert cementless acetabular cups. The motion of the mallet, relative to the introducer, was analyzed for a total of 110 strikes split into low-, medium-, and high-effort strikes. Three parameters were extracted from these data: strike vector, strike offset, and mallet face alignment. Results: The force vector of the mallet strike, relative to the introducer axis, was misaligned by an average of 18.1°, resulting in an average wasted strike energy of 6.1%. Furthermore, the mean strike offset was 19.8 mm from the centre of the introducer axis and the mallet face, relative to the introducer strike face, was misaligned by a mean angle of 15.2° from the introducer strike face. Conclusion: The direction of the impact vector in manual impaction lacks both accuracy and precision. There is an opportunity to improve this through more advanced impaction instruments or surgical training.
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Introduction: Arthroplasty-associated bone loss remains a clinical problem: stiff metallic implants disrupt load transfer to bone and, hence, its remodeling stimulus. The aim of this research was to analyze how load transfer to bone is affected by different forms of knee arthroplasty: isolated partial knee arthroplasty (PKA), compartmental arthroplasty [combined partial knee arthroplasty (CPKA), two or more PKAs in the same knee], and total knee arthroplasty (TKA). Methods: An experimentally validated subject-specific finite element model was analyzed native and with medial unicondylar, lateral unicondylar, patellofemoral, bi-unicondylar, medial bicompartmental, lateral bicompartmental, tricompartmental, and total knee arthroplasty. Three load cases were simulated for each: gait, stair ascent, and sit-to-stand. Strain shielding and overstraining were calculated from the differences between the native and implanted states. Results: For gait, the TKA femoral component led to mean strain shielding (30%) more than three times higher than that of PKA (4%-7%) and CPKA (5%-8%). Overstraining was predicted in the proximal tibia (TKA 21%; PKA/CPKA 0%-6%). The variance in the distribution for TKA was an order of magnitude greater than for PKA/CPKA, indicating less physiological load transfer. Only the TKA-implanted femur was sensitive to the load case: for stair ascent and gait, almost the entire distal femur was strain-shielded, whereas during sit-to-stand, the posterior femoral condyles were overstrained. Discussion: TKA requires more bone resection than PKA and CPKA. These finite element analyses suggest that a longer-term benefit for bone is probable as partial and multi-compartmental knee procedures lead to more natural load transfer compared to TKA. High-flexion activity following TKA may be protective of posterior condyle bone resorption, which may help explain why bone loss affects some patients more than others. The male and female bone models used for this research are provided open access to facilitate future research elsewhere.
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This study evaluated the use of silica/poly(tetrahydrofuran)/poly(ε-caprolactone) (SiO2/PTHF/PCL-diCOOH) 3D-printed scaffolds, with channel sizes of either 200 (SC-200) or 500 (SC-500) µm, as biomaterials to support the chondrogenesis of sheep bone marrow stem cells (oBMSC), under in vitro conditions. The objective was to validate the potential use of SiO2/PTHF/PCL-diCOOH for prospective in vivo ovine studies. The behaviour of oBMSC, with and without the use of exogenous growth factors, on SiO2/PTHF/PCL-diCOOH scaffolds was investigated by analysing cell attachment, viability, proliferation, morphology, expression of chondrogenic genes (RT-qPCR), deposition of aggrecan, collagen II, and collagen I (immunohistochemistry), and quantification of sulphated glycosaminoglycans (GAGs). The results showed that all the scaffolds supported cell attachment and proliferation with upregulation of chondrogenic markers and the deposition of a cartilage extracellular matrix (collagen II and aggrecan). Notably, SC-200 showed superior performance in terms of cartilage gene expression. These findings demonstrated that SiO2/PTHF/PCL-diCOOH with 200 µm pore size are optimal for promoting chondrogenic differentiation of oBMSC, even without the use of growth factors.
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Aims: Surgical approaches that claim to be minimally invasive, such as the direct anterior approach (DAA), are reported to have a clinical advantage, but are technically challenging and may create more injury to the soft-tissues during joint exposure. Our aim was to quantify the effect of soft-tissue releases on the joint torque and femoral mobility during joint exposure for hip resurfacing performed via the DAA. Methods: Nine fresh-frozen hip joints from five pelvis to mid-tibia cadaveric specimens were approached using the DAA. A custom fixture consisting of a six-axis force/torque sensor and motion sensor was attached to tibial diaphysis to measure manually applied torques and joint angles by the surgeon. Following dislocation, the torques generated to visualize the acetabulum and proximal femur were assessed after sequential release of the joint capsule and short external rotators. Results: Following initial exposure, the ischiofemoral ligament (7 to 8 o'clock) was the largest restrictor of exposure of the acetabulum, contributing to a mean 25% of overall external rotational restraint. The ischiofemoral ligament (10 to 12 o'clock) was the largest restrictor of exposure of the proximal femur, contributing to 25% of overall extension restraint. Releasing the short external rotators had minimal contribution in torque generated during joint exposure (≤ 5%). Conclusion: Adequate exposure of both proximal femur and acetabulum may be achieved with minimal torque by performing a full proximal circumferential capsulotomy while preserving short external rotators. The joint torque generated and exposure achieved is dependent on patient factors; therefore, some cases may necessitate further releases.
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Artroplastia de Quadril , Humanos , Liberação da Cápsula Articular , Acetábulo , Articulação do Quadril/cirurgia , Fêmur/cirurgiaRESUMO
Nonstructural protein 5 (Nsp5) is the main protease of SARS-CoV-2 that cleaves viral polyproteins into individual polypeptides necessary for viral replication. Here, we show that Nsp5 binds and cleaves human tRNA methyltransferase 1 (TRMT1), a host enzyme required for a prevalent post-transcriptional modification in tRNAs. Human cells infected with SARS-CoV-2 exhibit a decrease in TRMT1 protein levels and TRMT1-catalyzed tRNA modifications, consistent with TRMT1 cleavage and inactivation by Nsp5. Nsp5 cleaves TRMT1 at a specific position that matches the consensus sequence of SARS-CoV-2 polyprotein cleavage sites, and a single mutation within the sequence inhibits Nsp5-dependent proteolysis of TRMT1. The TRMT1 cleavage fragments exhibit altered RNA binding activity and are unable to rescue tRNA modification in TRMT1-deficient human cells. Compared to wildtype human cells, TRMT1-deficient human cells infected with SARS-CoV-2 exhibit reduced levels of intracellular viral RNA. These findings provide evidence that Nsp5-dependent cleavage of TRMT1 and perturbation of tRNA modification patterns contribute to the cellular pathogenesis of SARS-CoV-2 infection.
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Aims: With up to 40% of patients having patellofemoral joint osteoarthritis (PFJ OA), the two arthroplasty options are to replace solely the patellofemoral joint via patellofemoral arthroplasty (PFA), or the entire knee via total knee arthroplasty (TKA). The aim of this study was to assess postoperative success of second-generation PFAs compared to TKAs for patients treated for PFJ OA using patient-reported outcome measures (PROMs) and domains deemed important by patients following a patient and public involvement meeting. Methods: MEDLINE, EMBASE via OVID, CINAHL, and EBSCO were searched from inception to January 2022. Any study addressing surgical treatment of primary patellofemoral joint OA using second generation PFA and TKA in patients aged above 18 years with follow-up data of 30 days were included. Studies relating to OA secondary to trauma were excluded. ROB-2 and ROBINS-I bias tools were used. Results: A total of nine studies were included, made up of four randomized controlled trials (domain 1) and five cohort studies (domain 2). PROMs and knee function specific scores developed for reporting TKA were unable to detect any difference between PFA and TKA. There was no significant difference in complications between PFA and TKA. PFAs were found to have a better postoperative range of motion. Conclusion: TKA and PFA are both viable options for patients with primary PFJ OA. Over time, we have seen an emphasis on patient satisfaction and better quality of life. Recommending sacrificing healthy medial and lateral compartments to treat patellofemoral joint arthritis should be given further thought.
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Short stem, uncemented femoral implants for hip arthroplasty are bone conserving achieving stability through initial metaphyseal press-fit and biological fixation. This study aimed to evaluate the survivorship, mid-term function and health related quality of life outcomes in patients who have undergone total hip arthroplasty (THA) with a fully hydroxyapatite coated straight short stem femoral component with up to 5 years follow-up. 668 patients were recruited to a multicentre study investigating the performance of the cementless Furlong Evolution® stem for THA. 137 patients withdrew at various time points. The mean follow-up was 49 months. Clinical (Harris Hip Score (HHS), radiographic and patient-reported outcome measures-Oxford Hip Score (OHS) and EuroQol 5D (EQ-5D), were recorded pre-operatively and at 6 weeks, 6 months, 1 year, 3 year and 5 year follow ups. At 5-year follow-up, 12 patients underwent revision surgery, representing a cumulative revision rate of 1.8%. Median OHS, HHS and EQ5D scores improved significantly: OHS improved from a pre-operative median of 21 (IQR 14-26) to 47 (IQR 44-48) (p < 0.001). HHS improved from 52 (IQR 40-63) to 98 (IQR 92-100) (p < 0.001) and EQ5D improved from 70 (IQR 50-80) to 85 (IQR 75-95) (p < 0.001). This fully HA-coated straight short femoral stem implant demonstrated acceptable mid-term survivorship and delivered substantial improvements in function and quality of life after THA.
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Artroplastia de Quadril , Prótese de Quadril , Humanos , Artroplastia de Quadril/efeitos adversos , Prótese de Quadril/efeitos adversos , Seguimentos , Estudos Prospectivos , Durapatita , Qualidade de Vida , Desenho de Prótese , Reoperação , Resultado do Tratamento , Estudos RetrospectivosRESUMO
Three-dimensional planning of hip arthroplasty is associated with better visualisation of anatomical landmarks and enhanced mapping for preoperative implant sizing, which can lead to a decrease in surgical time and complications. Despite the advantages of hip resurfacing arthroplasty (HRA), it is considered a technically challenging procedure and associated with inaccurate implant placement. This study aimed to examine the validity, reliability, and usability of preoperative 3D Hip Planner software for HRA. Fifty random cases of various hip osteoarthritis severity were planned twice by two junior trainees using the 3D Hip Planner within a one-month interval. Outcome measures included femoral/cup implant size, stem-shaft angle, and cup inclination angle, and were assessed by comparing outcomes from 2D and 3D planning. An adapted unified theory of acceptance and use of technology (UTAUT) survey was used for software usability. Bland-Altman plots between 3D and 2D planning for stem-shaft and inclination angles showed mean differences of 0.7 and -0.6, respectively (r = 0.93, p < 0.001). Stem-shaft and inclination angles showed inter-rater reliability biases of around -2° and 3°, respectively. Chi-square and Pearson's correlation for femoral implant size showed a significant association between the two assessors (r = 0.91, p < 0.001). The 3D test-retest coefficient of repeatability for stem-shaft and inclination angles were around ±2° and ±3°, respectively, with a strong significant association for femoral implant size (r = 0.98, p < 0.001). Survey analyses showed that 70-90% agreed that 3D planning improved expectancy in four domains. 3D hip planner appears to be valid and reliable in preoperative HRA and shows significant potential in optimising the quality and accuracy of surgical planning.
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OBJECTIVE: To assess whether multiplayer immersive Virtual Reality (iVR) training was superior to single-player training for the acquisition of both technical and nontechnical skills in learning complex surgery. BACKGROUND: Superior teamwork in the operating room (OR) is associated with improved technical performance and clinical outcomes. iVR can successfully train OR staff individually; however, iVR team training has yet to be investigated. METHODS: Forty participants were randomized to individual or team iVR training. Individually trained participants practiced alongside virtual avatar counterparts, whereas teams trained live in pairs. Both groups underwent 5 iVR training sessions over 6 weeks. Subsequently, they completed a real-life assessment in which they performed anterior approach total hip arthroplasty surgery on a high-fidelity model with real equipment in a simulated OR. Teams performed together, and individually trained participants were randomly paired up. Videos were marked by 2 blinded assessors recording the 'Non-Operative Technical Skills for Surgeons, Oxford NOn-TECHnical Skills II and Scrub Practitioners' List of Intraoperative Non-Technical Skills' scores. Secondary outcomes were procedure duration and the number of technical errors. RESULTS: Teams outperformed individually trained participants for nontechnical skills in the real-world assessment (Non-Operative Technical Skills for Surgeons: 13.1±1.5 vs 10.6±1.6, P = 0.002, Non-TECHnical Skills II score: 51.7 ± 5.5 vs 42.3 ± 5.6, P = 0.001 and Scrub Practitioners' List of Intraoperative Non-Technical Skills: 10 ± 1.2 vs 7.9 ± 1.6, P = 0.004). They completed the assessment 33% faster (28.2 minutes ± 5.5 vs 41.8 ± 8.9, P < 0.001), and made fewer than half the number of technical errors (10.4 ± 6.1 vs 22.6 ± 5.4, P < 0.001). CONCLUSIONS: Multiplayer training leads to faster surgery with fewer technical errors and the development of superior nontechnical skills.
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Internato e Residência , Realidade Virtual , Humanos , Competência Clínica , Currículo , AprendizagemRESUMO
INTRODUCTION: Successful press-fit implantation relies on an accurately reamed bone cavity. Inaccurate reaming can lead to a suboptimal press-fit risking fracture and cup deformation or excessive micromotion and loosening. Several factors may impact reaming accuracy including the reamer design, the surgeon's technique and the bone quality. The aim of this study is to investigate the accuracy of reaming techniques and the accuracy of a novel reamer design. METHODS: Eighty composite bone models, half high density and half low density, were reamed with either a conventional or an additively manufactured reamer with a novel design employing either a straight or 'whirlwind' reaming technique. Reamed cavities were scanned using a 3D laser scanner and the median difference between achieved and expected diameters compared. RESULTS: The novel reamer design was more accurate than the unused conventional reamer, using both whirlwind (0.1 mm (IQR 0-0.2) vs. 0.3 mm (IQR 0.3-0.4); p < 0.001) and straight techniques (0.3 mm (IQR 0.1-1.0) vs. 1.2 mm (IQR 1-1.6); p = 0.001). Whirlwind reaming was more accurate than straight reaming using both conventional (0.3 mm (IQR 0.3-0.4) vs. 1.2 mm (IQR 1-1.6); p < 0.0001) and single use reamers (0.1 mm (IQR 0-0.2) vs. 0.3 mm (IQR 0.1-1.0); p = 0.007). Reaming errors were higher in low-density bone compared to high-density bone, for both reamer types and reaming techniques tested (0.6 mm (IQR 0.3-1.5) vs. 0.3 mm (IQR 0.1-0.8); p = 0.005). CONCLUSION: We present a novel reamer design that demonstrates superior accuracy to conventional reamers in achieving the desired reaming diameter. Improved reaming accuracy was also demonstrated using both devices and in both bone models, using a 'whirlwind' technique. We recommend the use of this novel reamer design employing a 'whirlwind' technique to optimize reaming accuracy. Particular attention should be paid toward patients with lower bone quality which may be more susceptible to higher inaccuracies.
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Artroplastia de Quadril , Fraturas Ósseas , Humanos , Acetábulo/cirurgia , Artroplastia de Quadril/métodos , Instrumentos CirúrgicosRESUMO
Bone mechanics is well understood at every length scale except the nano-level. We aimed to investigate the relationship between bone nanoscale and tissue-level mechanics experimentally. We tested two hypotheses: (1) nanoscale strains were lower in hip fracture patients versus controls, and (2) nanoscale mineral and fibril strains were inversely correlated with aging and fracture. A cross-sectional sample of trabecular bone sections was prepared from the proximal femora of two human donor groups (aged 44-94 years): an aging non-fracture control group (n = 17) and a hip-fracture group (n = 20). Tissue, fibril, and mineral strain were measured simultaneously using synchrotron X-ray diffraction during tensile load to failure, then compared between groups using unpaired t-tests and correlated with age using Pearson's correlation. Controls exhibited significantly greater peak tissue, mineral, and fibril strains than the hip fracture (all p < 0.05). Age was associated with a decrease in peak tissue (p = 0.099) and mineral (p = 0.004) strain, but not fibril strain (p = 0.260). Overall, hip fracture and aging were associated with changes in the nanoscale strain that are reflected at the tissue level. Data must be interpreted within the limitations of the observational cross-sectional study design, so we propose two new hypotheses on the importance of nanomechanics. (1) Hip fracture risk is increased by low tissue strain, which can be caused by low collagen or mineral strain. (2) Age-related loss of tissue strain is dependent on the loss of mineral but not fibril strain. Novel insights into bone nano- and tissue-level mechanics could provide a platform for the development of bone health diagnostics and interventions based on failure mechanisms from the nanoscale up.
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BACKGROUND: Gait function improves after Total Hip Arthroplasty (THA) but is not restored to normal levels. Metal-on-metal Resurfacing Arthroplasty (MoM-HRA) is an alternative to THA and has shown to restore normal levels gait function and physical activity but has been restricted to men owing to problems of metal-ion release. Ceramic HRA (cHRA) removes the cobalt-chrome bearing surfaces, thereby eliminating these specific metal-ion concerns and aiming to be safe for females. RESEARCH QUESTION: Is there a difference in gait function of female cHRA patients compared to female THA using subjective and objective measures? METHODS: Fifteen unilateral cHRA and 15 unilateral THA, age and BMI matched, completed patient reported outcome measures (PROMs) (Oxford Hip Score, EQ5d and MET score) and underwent gait analysis using an instrumented treadmill pre- (2-10 weeks) and post-operatively (52-74 weeks). Maximum walking speed (MWS), Vertical GRF of the stance phase, GRF symmetry index (SI) and spatiotemporal gait measures were recorded. Patients were compared to age, gender and BMI healthy controls (CON). RESULTS: There were no differences in PROMs or gait function between groups pre-operatively. Post- operatively, cHRA had a higher MET score (11.2 vs 7.1, p = 0.02) and a higher MWS (6.2 vs 6.8 km/hr, p = 0.003) compared to THA. cHRA had a similar GRF profile to CON, whereas THA had a reduced push-off force at 70-77 % of the stance phase compared to CON. At faster walking speeds of 6 km/hr walking speed, THA displayed an asymmetric GRF profile (SI<4.4 %) whereas the cHRA patients continued to display a symmetrical gait profile. cHRA was able to increase step length from pre-op levels (63 vs 66 cm, p = 0.02) and produced a larger step length compared to THA (73 vs 79 cm, p = 0.02). SIGNIFICANCE: Female cHRA returned to levels of gait function and activity similar to healthy controls unlike female THA.
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Artroplastia de Quadril , Prótese de Quadril , Masculino , Humanos , Feminino , Articulação do Quadril/cirurgia , Marcha , CerâmicaRESUMO
The metabolic equivalent of task (MET) score examines patient performance in relation to energy expenditure before and after knee arthroplasty. This study assesses its use in a knee arthroplasty population in comparison with the widely used Oxford Knee Score (OKS) and EuroQol five-dimension index (EQ-5D), which are reported to be limited by ceiling effects. A total of 116 patients with OKS, EQ-5D, and MET scores before, and at least six months following, unilateral primary knee arthroplasty were identified from a database. Procedures were performed by a single surgeon between 2014 and 2019 consecutively. Scores were analyzed for normality, skewness, kurtosis, and the presence of ceiling/floor effects. Concurrent validity between the MET score, OKS, and EQ-5D was assessed using Spearman's rank. Postoperatively the OKS and EQ-5D demonstrated negative skews in distribution, with high kurtosis at six months and one year. The OKS demonstrated a ceiling effect at one year (15.7%) postoperatively. The EQ-5D demonstrated a ceiling effect at six months (30.2%) and one year (39.8%) postoperatively. The MET score did not demonstrate a skewed distribution or ceiling effect either at six months or one year postoperatively. Weak-moderate correlations were noted between the MET score and conventional scores at six months and one year postoperatively. In contrast to the OKS and EQ-5D, the MET score was normally distributed postoperatively with no ceiling effect. It is worth consideration as an arthroplasty outcome measure, particularly for patients with high expectations.
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Implant migration is a predictor of arthroplasty survivorship. It is crucial to monitor the migration of novel hip prostheses within premarket clinical investigations. RSA is the gold standard method, but requires calibrated radiographs using specialised equipment. A commercial computed tomography micromotion analysis solution is a promising alternative but is not yet available for use with monobloc ceramic implants. This study aimed to develop and validate a CT-based spatial analysis (CTSA) method for use with ceramic implants. A phantom study was undertaken to assess accuracy and precision. A ceramic hip resurfacing arthroplasty (HRA) and 20 tantalum beads were implanted into a synthetic hip model and mounted onto a 6-degree of freedom motion stage. The hip was repeatedly scanned with a low dose CT protocol, with imposed micromovements. Data were interrogated using a semiautomated technique. The effective radiation dose for each scan was estimated to be 0.25 mSv. For the head implant, precision ranged between 0.11 and 0.28 mm for translations and 0.34°-0.42° for rotations. For the cup implant, precision ranged between 0.08 and 0.11 mm and 0.19° and 0.42°. For the head, accuracy ranged between 0.04 and 0.18 mm for translations and 0.28°-0.46° for rotations. For the cup, accuracy ranged between 0.04 and 0.08 mm and 0.17° and 0.43°. This in vitro study demonstrates that low dose CTSA of a ceramic HRA is similar in accuracy to RSA. CT is ubiquitous, and this method may be an alternative to RSA to measure prosthesis migration.
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Artroplastia de Quadril , Prótese de Quadril , Tomografia Computadorizada por Raios X/métodos , Imagens de FantasmasRESUMO
Measurement of the properties of bone as a material can happen in various length scales in its hierarchical and composite structure. The aim of this study was to test the tissue level properties of clinically-relevant human bone samples which were collected from donors belonging to three groups: ageing donors who suffered no fractures (Control); untreated fracture patients (Fx-Untreated) and patient who experienced hip fracture despite being treated with bisphosphonates (Fx-BisTreated). Tissue level properties were assessed by (a) nanoindentation and (b) synchrotron tensile tests (STT) where strains were measured at the 'tissue', 'fibril' and 'mineral' levels by using simultaneous Wide-angle - (WAXD) and Small angle- X-ray diffraction (SAXD). The composition was analysed by thermogravimetric analysis and material level endo- and exo-thermic reactions by differential scanning calorimetry (TGA/DSC3+). Irrespective of treatment fracture donors exhibited significantly lower tissue, fibril and mineral strain at the micro and nanoscale respectively and had a higher mineral content than controls. In nanoindentation only nanohardness was significantly greater for Controls and Fx-BisTreated versus Fx-Untreated. The other nanoindentation parameters did not vary significantly across the three groups. There was a highly significant positive correlation (p < 0.001) between organic content and tissue level strain behaviour. Overall hip-fractures were associated with lower STT nanostrains and it was behaviour measured by STT which proved to be a more effective approach for predicting fracture risk because evidently it was able to demonstrate the mechanical deficit for the bone tissue of the donors who had experienced fractures.
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Osso e Ossos , Fraturas do Quadril , Humanos , Envelhecimento , Difração de Raios X , Minerais , Densidade ÓsseaRESUMO
PURPOSE: This study investigated the gait and patient reported outcome measures of subjects converted from a partial knee arthroplasty to combined partial knee arthroplasty, using a compartmental approach. Healthy subjects and primary total knee arthroplasty patients were used as control groups. METHODS: Twenty-three patients converted from partial to combined partial knee arthroplasty were measured on the instrumented treadmill at top walking speeds, using standard gait metrics. Data were compared to healthy controls (n = 22) and primary posterior cruciate-retaining total knee arthroplasty subjects (n = 23) where surgery were performed for one or two-compartment osteoarthritis. Groups were matched for age, sex and body mass index. At the time of gait analysis, combined partial knee arthroplasty subjects were median 17 months post-revision surgery (range 4-81 months) while the total knee arthroplasty group was median 16 months post-surgery (range 6-150 months). Oxford Knee Scores and EuroQol-5D 5L scores were recorded at the time of treadmill assessment, and results analysed by question and domain. RESULTS: Subjects revised from partial to combined partial knee arthroplasty walked 16% faster than total knee arthroplasty (mean top walking speed 6.4 ± 0.8 km/h, vs. 5.5 ± 0.7 km/h p = 0.003), demonstrating nearer-normal weight-acceptance rate (p < 0.001), maximum weight-acceptance force (p < 0.006), mid-stance force (p < 0.03), contact time (p < 0.02), double support time (p < 0.009), step length (p = 0.003) and stride length (p = 0.051) compared to primary total knee arthroplasty. Combined partial knee arthroplasty subjects had a median Oxford Knee Score of 43 (interquartile range 39-47) vs. 38 (interquartile range 32-41, p < 0.02) and reported a median EQ-5D 0.94 (interquartile range 0.87-1.0) vs. 0.84 (interquartile range 0.80-0.89, p = 0.006). CONCLUSION: This study finds that a compartmental approach to native compartment degeneration following partial knee arthroplasty results in nearer-normal gait and improved patient satisfaction compared to total knee arthroplasty. LEVEL OF EVIDENCE: III.
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Artroplastia do Joelho , Osteoartrite do Joelho , Humanos , Artroplastia do Joelho/métodos , Articulação do Joelho/cirurgia , Amplitude de Movimento Articular , Marcha , Osteoartrite do Joelho/cirurgiaRESUMO
PURPOSE: Medial bicompartmental arthroplasty, the combination of ipsilateral medial unicompartmental and patellofemoral arthroplasty, is an alternative to total knee arthroplasty for patients with medial tibiofemoral and severe patellofemoral arthritis, when the lateral tibiofemoral compartment and anterior cruciate ligament are intact. This study reports the gait and subjective outcomes following medial bicompartmental arthroplasty. METHODS: Fifty-five subjects were measured on the instrumented treadmill at top walking speeds, using standard metrics of gait. Modular, single-stage, medial bicompartmental arthroplasty subjects (n = 16) were compared to age, body mass index, height- and sex-matched healthy (n = 19) and total knee arthroplasty (n = 20) subjects. Total knee arthroplasty subjects with pre-operative evidence of tricompartmental osteoarthritis or anterior cruciate ligament dysfunction were excluded. The vertical component of ground reaction force and temporospatial measurements were compared using Kruskal-Wallis, then Mann-Whitney test with Bonferroni correction (α = 0.05). Oxford Knee and EuroQoL EQ-5D scores were compared. RESULTS: Objectively, the medial bicompartmental arthroplasty top walking speed of 6.7 ± 0.8 km/h was 0.5 km/h (7%) slower than that of healthy controls (p = 0.2), but 1.3 km/h (24%) faster than that of total knee arthroplasty subjects (5.4 ± 0.6 km/h, p < 0.001). Medial bicompartmental arthroplasty recorded more normal maximum weight acceptance (p < 0.001) and mid-stance forces (p = 0.03) than total knee arthroplasty subjects, with 11 cm (15%) longer steps (p < 0.001) and 21 cm (14%) longer strides (p = 0.006). Subjectively, medial bicompartmental arthroplasty subjects reported Oxford Knee Scores of median 41 (interquartile range 38.8-45.5) compared to total knee arthroplasty Oxford Knee Scores of 38 (interquartile range 30.5-41, p < 0.02). Medial bicompartmental arthroplasty subjects reported EQ-5D median 0.88 (interquartile range 0.84-0.94) compared to total knee arthroplasty median 0.81 (interquartile range 0.73-0.89, p < 0.02.) CONCLUSION: This study finds that, in the treatment of medial tibiofemoral osteoarthritis with severe patellofemoral arthritis, medial bicompartmental arthroplasty results in nearer-normal gait and improved patient-reported outcomes compared to total knee arthroplasty. LEVEL OF EVIDENCE: III.
Assuntos
Artroplastia do Joelho , Prótese do Joelho , Osteoartrite do Joelho , Humanos , Artroplastia do Joelho/métodos , Osteoartrite do Joelho/cirurgia , Satisfação do Paciente , Articulação do Joelho/cirurgia , Marcha , Resultado do TratamentoRESUMO
The bone quality of patients undergoing hip replacement surgery is poorly predicted by radiographs alone. With better bone quality information available to a surgeon, the operation can be performed more safely. The aim of this study was to investigate whether ultrasound signals of cortical bone at peripheral sites such as the tibia and radius can be used to predict the compressive mechanical properties of cortical bone at the femoral neck. We recruited 19 patients undergoing elective hip arthroplasty and assessed the radius and tibia of these patients with the Azalée guided wave ultrasound to estimate the porosity and thickness of the cortex. Excess bone tissues were collected from the femoral neck and the compressive mechanical properties of the cortex were characterised under a mechanical loading rig to determine stiffness, ultimate strength, and density. The correlations between the ultrasound measurements and mechanical properties were analysed using linear regression, Pearson correlation statistics, and multiple regression analysis. Cortical mechanical properties were weakly to moderately correlated with the ultrasound measurements at various sites (R2 = 0.00-0.36). The significant correlations found were not consistent across all 4 peripheral measurement sites. Additionally, weak to moderate ability of the ultrasound to predict mechanical properties at the neck of femur with multiple regression analysis was found (R2 = 0.00-0.48). Again, this was inconsistent across the different anatomical sites. Overall, the results demonstrate the need for ultrasound scans to be collected directly from clinically relevant sites such as the femoral neck due to the inconsistency of mechanical properties across various sites.