Noncompliance to iodine supplementation recommendation is a risk factor for iodine insufficiency in Portuguese pregnant women: results from the IoMum cohort.

PURPOSE: After a recommendation for iodine supplementation in pregnancy has been issued in 2013 in Portugal, there were no studies covering iodine status in pregnancy in the country. The aim of this study was to assess iodine status in pregnant women in Porto region and its association with iodine supplementation. METHODS: A cross-sectional study was conducted at Centro Hospitalar Universitário São João, Porto, from April 2018 to April 2019. Pregnant women attending the 1st trimester ultrasound scan were invited to participate. Exclusion criteria were levothyroxine use, gestational age < 10 and ≥ 14 weeks, non-evolutive pregnancy at recruitment and non-signing of informed consent. Urinary iodine concentration (UIC) was measured in random spot urine by inductively coupled plasma-mass spectrometry. RESULTS: Median UIC was 104 µg/L (IQR 62-189) in the overall population (n = 481) of which 19% had UIC < 50 µg/L. Forty three percent (n = 206) were not taking an iodine-containing supplement (ICS) and median UIC values were 146 µg/L (IQR 81-260) and 74 µg/L (IQR 42-113) in ICS users and non-users, respectively (p < 0.001). Not using an ICS was an independent risk factor for iodine insufficiency [adjusted OR (95% CI) = 6.00 (2.74, 13.16); p < 0.001]. Iodised salt use was associated with increased median iodine-to-creatinine ratio (p < 0.014). CONCLUSIONS: A low compliance to iodine supplementation recommendation in pregnancy accounted for a mild-to-moderately iodine deficiency. Our results evidence the need to support iodine supplementation among pregnant women in countries with low household coverage of iodised salt. Trial registration number NCT04010708, registered on the 8th July 2019.

Improvements in Clinical Outcomes in Children with Cystic Fibrosis aged Six and 16 years.

Aims Our aim was to assess if outcomes for cystic fibrosis (CF) patients at six & sixteen years of age have improved in the last 17 years looking at FEV1, BMI and death. Methods A retrospective observational study using a prospectively maintained database of CF patients at Cork University Hospital. Results 84 patients were included in the 16-year-old data and 89 patients were included in the six-year-old data. The mean FEV1 and BMI (16 years) for the 2002-2007 group was 72.9±21.0% and 18.9±2.53 respectively, 2008-2013 group was 75.4±27.2% and 19.8±2.7 and for the 2014-2018 group was 95.2±16.0% and 22.9±4.1. The percentage of patients (16 years) with chronic pseudomonas status was 37.9% (11/30) in the 2002-2007 group, 51.6 % (16/31) in the 2008-2013 group and 4.2% (1/24) in the 2014-2018 group. The relationship between FEV1 and FVC with BMI remained significant in multivariate analysis (P <0.001). The mean FEV1 (six years) for the 2002-2007 group was 90.7±16.1%, 2008-2013 group was 99.3±17.9% and for the 2014-2018 group was 100.9±15.8%. Conclusions Improvements in FEV1 and BMI aged six and 16 years are notable as well as a significant decline in the number of patients with chronic pseudomonas.

Validation of a novel mapping system and utility for mapping complex atrial tachycardias.

INTRODUCTION: This study sought to validate a novel wavefront mapping system utilizing whole-chamber basket catheters (CARTOFINDER, Biosense Webster). The system was validated in terms of (1) mapping atrial-paced beats and (2) mapping complex wavefront patterns in atrial tachycardia (AT). METHODS AND RESULTS: Patients undergoing catheter ablation for AT and persistent AF were included. A 64-pole-basket catheter was used to acquire unipolar signals that were processed by CARTOFINDER mapping system to generate dynamic wavefront propagation maps. The left atrium was paced from four sites to demonstrate focal activation. ATs were mapped with the mechanism confirmed by conventional mapping, entrainment, and response to ablation. Twenty-two patients were included in the study (16 with AT and 6 with AF initially who terminated to AT during ablation). In total, 172 maps were created with the mapping system. It correctly identified atrial-pacing sites in all paced maps. It accurately mapped 9 focal/microreentrant and 18 macroreentrant ATs both in the left and right atrium. A third and fourth observer independently identified the sites of atrial pacing and the AT mechanism from the CARTOFINDER maps, while being blinded to the conventional activation maps. CONCLUSIONS: This novel mapping system was effectively validated by mapping focal activation patterns from atrial-paced beats. The system was also effective in mapping complex wavefront patterns in a range of ATs in patients with scarred atria. The system may therefore be of practical use in the mapping and ablation of AT and could have potential for mapping wavefront activations in AF.

Effect of polyphenols on glucose and lactate transport by breast cancer cells.

One of the cancer molecular hallmarks is a deviant energetic metabolism, known as the Warburg effect, whereby the rate of glucose uptake is significantly increased and a high rate of glycolysis and lactic acid production occurs even when oxygen is present-"aerobic lactatogenesis". Accordingly, GLUT1 and MCT1, which are the main glucose and lactate transporters in cancer cells, respectively, have been proposed as oncogenes and are currently seen as potential therapeutic targets in cancer treatment. Polyphenols, commonly contained in fruits and vegetables, have long been associated with a protective role against cancer. Generally considered as nontoxic, dietary polyphenols are considered ideal chemopreventive and possibly chemotherapeutic agents. Several mechanisms of action of polyphenols in breast cancer cells have been proposed including modulation of intracellular signaling, induction of apoptosis through redox regulation or modulation of epigenetic alterations. Additionally, in vitro studies have shown that several polyphenols act as specific inhibitors of glucose transport in breast cancer cell lines and an association between their anticarcinogenic effect and inhibition of glucose cellular uptake has been described. Also, some polyphenols were found to inhibit lactate transport. Importantly, some polyphenols behave as inhibitors of both glucose and lactate cellular uptake by breast cancer cells and these compounds are thus very interesting in the context of a chemopreventive effect, because they deplete breast cancer cells of their two most important energy suppliers. So, the antimetabolic effect of polyphenols should be regarded as a mechanism of action contributing to their chemopreventive/chemotherapeutic potential in relation to breast cancer.

Twenty-Five-Years and Greater, Results After Nonmodular Cemented Total Knee Arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) has been shown to be very successful with long-term follow-ups. But there are no reports showing prosthesis survival at 25-30 years. Here, we report the outcomes for 25-30 years using the Anatomic Graduated Component (Biomet, Warsaw, IN) TKA and elucidate the etiology and cause of failure of the components. METHODS: We reviewed the outcomes of 5649 primary total knee arthroplasties for 25-30 years using the Anatomic Graduated Component. Statistical analysis was performed by the Kaplan-Meier survival analysis. Clinical outcomes included the Knee Society Score and standardized radiographs to check for loosening of the implants. The reason for revision surgery was reviewed retrospectively. We compared our results with those at another institution with similar long-term follow-up. RESULTS: There were 112 failures, 48 with aseptic loosening and 25 with instability for an overall prosthesis survival rate of 94.2% at 25 years and 92.4% at 30 years follow-up. In the third decade after TKA, patients are substantially more likely to experience death than experience a failing prosthesis, with a 3811% greater risk of dying relative to failing (Risk ratio = 38.1, Odds ratio = 56.7, P < .0001). CONCLUSION: There was a greater risk of dying than failing over time. The primary reason for revision knee surgery was due to aseptic loosening of the prosthesis followed by instability.

Twenty-year followup of an uncemented stem in primary THA.

BACKGROUND: Uncemented stems have been used in THA for well over two decades, but there are relatively few studies reporting on the results after 20 years. QUESTIONS/PURPOSES: The purpose of this study was to evaluate at a minimum followup of 20 years (1) hip scores; (2) radiographic findings, including stem fixation and osteolysis; (3) reoperations; and (4) survivorship free from aseptic loosening in a group of patients who underwent primary THA using a proximally porous-coated, plasma-sprayed, straight-stemmed, titanium-alloy femoral component. METHODS: Between 1987 and 1993, we performed 1517 primary THAs, of which 447 were cementless, and 157 used the implant under study here (representing 10% of the THAs during the period in question). General indications for the use of the study stem included (1) younger age with relatively stronger bone (average age 55 years in this study); (2) patients not involved in another study protocol (as were the 278 other cementless hips implanted during this time); and (3) patients who, at the surgeon's discretion, would be compliant with protected weightbearing. Of those, 111 were available for followup at a minimum of 20 years (mean, 20 years), whereas 36 had died and nine (6%) were lost to followup or declined participation. The primary diagnosis was osteoarthritis in 77 hips (69%). The mean age at operation was 55 years. The clinical result was evaluated on the basis of the Harris hip score. Radiographic analysis was performed at each followup visit for distal cortical hypertrophy, spot welds, radiolucencies, stem subsidence, varus or valgus shift, osteolysis, and femoral component loosening. Kaplan-Meier analysis was performed to evaluate the survival of the femoral component. RESULTS: The mean Harris hip score improved from 46 points to 87 points (of a possible 100 points) at the most recent followup. All hips had evidence of proximal femoral remodeling consistent with osseous ingrowth. Femoral osteolyis was seen in 22 hips (20%). One stem was revised as a result of a periprosthetic fracture. No femoral component had evidence of loosening, and none was revised. Thirty-three acetabular components (30%) were revised. CONCLUSIONS: This femoral component provided durable long-term fixation for over two decades after THA. The porous stem geometry is still in use today and will continue to be studied into the third decade of use. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Use of screws and cement in revision TKA with primary or revision specific prosthesis with up to 17 years followup.

The purpose of this study was to investigate the use for screws and cement, and primary and revision specific prosthesis for revision TKA. Between July 1989 and February 2010, 839 consecutive revision TKAs were performed, with 609 knees meeting inclusion criteria. At 17 years followup, Kaplan-Meier survivorship was 0.9859 for revision specific prosthesis with screws and cement, 0.9848 for revision prosthesis with no screws, 0.9118 for primary prosthesis with screws, and 0.9424 for primary prosthesis with no screws. Revision TKAs using screws had greater defects (P<.0001). Use of revision prosthesis along with screws and cement to correct largely defective revision TKAs is highly recommended.

2-arachidonoylglycerol effects in cytotrophoblasts: metabolic enzymes expression and apoptosis in BeWo cells.

The major endocannabinoid (eCB) 2-arachidonoylglycerol (2-AG) is a member of the endocannabinoid system (ECS) that participates in cell proliferation and apoptosis, important events for the homoeostasis of biological systems. The formation of placenta is one of the most important stages of pregnancy and its development requires highly regulated proliferation, differentiation and apoptosis of trophoblasts. Anomalies in these processes are associated with gestational pathologies. In this work, we aimed to study the involvement of 2-AG in cytotrophoblast cell turnover. We found that 2-AG biosynthetic (diacylglycerol lipase A) and degradative (monoacylglycerol lipase) enzymes are expressed in human cytotrophoblasts and in BeWo cells. We also found that 2-AG induces a decrease in cell viability in a time- and concentration-dependent manner and exerts antiproliferative effects. The loss of cell viability induced by a 48-h treatment with 2-AG (10 µM) was accompanied by chromatin fragmentation and condensation, morphological features of apoptosis. Additionally, 2-AG induced an increase in caspase 3/7 and 9 activities, a loss of mitochondrial membrane potential (Δψm) and an increase in reactive oxygen species (ROS)/reactive nitrogen species (RNS) generation, suggesting the activation of the mitochondrial pathway. Moreover, whereas Δψm loss and ROS/RNS generation were significantly attenuated by the antagonists of both the cannabinoid receptors 1 and 2 (CB1 and CB2), the increase in caspase 3/7 and 9 activities and loss of cell viability were reversed only by the antagonist of CB2 receptor; the blockage of the eCB membrane transporter and the depletion of cholesterol failed to reverse the effects of 2-AG. Therefore, this work supports the importance of cannabinoid signalling during cytotrophoblast cell turnover and that its deregulation may be responsible for altered placental development and poor pregnancy outcomes.

Use of screws and cement in primary TKA with up to 20 years follow-up.

The purpose of this study was to investigate screws and cement for large tibial bone defects during primary TKA. Of 14,686 consecutive primary TKAs performed between December 1988 and February 2010, 256 received screws and cement for tibial defects. Cox regression was used for the analysis. 20-year survival probability was 0.9897 (screws) and 0.9339 (no screws) (P = .4225 log-rank). Tibial bone condition was significantly worse in knees receiving screws (P < .0001) with 73.0% having defects in the screws group and 3.4% (P < .0001) for non-screws. Radiolucency appeared in 13.7% (screws) and 6.4% (no screws) postoperatively. Screws were $137 each, wedges $910 to $2240. Knees with tibial defects and screws performed similarly if not better than knees without defects at substantially lower cost than alternatives.

Pain relief and functional improvement remain 20 years after knee arthroplasty.

BACKGROUND: TKA provides demonstrable pain relief and improved health-related quality of life. Yet, a decline in physical function may occur over the long term despite the absence of implant-related problems. QUESTIONS/PURPOSES: (1) Does pain relief diminish over 20 years after TKA? (2) Does function decline over 20 years in terms of Knee Society function, knee, and walking scores? And (3) what is the patient-reported activity level at most recent followup? PATIENTS AND METHODS: We retrospectively identified 1471 patients with 1757 primary cruciate-retaining TKAs implanted between 1975 and 1989 and identified 128 living patients (8.7%) with 171 TKAs. Ninety-three patients were women. We determined Knee Society scores prospectively and UCLA scores retrospectively. Minimum followup was 20 years (average, 21.1 years; range, 20-27 years). Average age at last followup was 82.3 years (range, 45-103 years). Of the 128 patients, 66 (73 TKAs) died after 20-year followup. RESULTS: Pain scores did not diminish over time (average, 49; range, 20-50). Average knee score was 78 (range, 39-97). Function, stair, and walking scores diminished over time. Average function score was 70 (range, 5-100), primarily due to an average stair score of 35 (range, 0-50); average walking score was 37 (range, 10-50). All but two patients (two TKAs) could negotiate stairs; 95 patients (124 TKAs) could walk at least five blocks; three patients (three TKAs) were housebound. Of the 62 patients still living (98 TKAs), the average UCLA activity score was 8.3 (range, 5-10). CONCLUSIONS: Although aging may cause a gradual decline in physical activity, an improved functional capacity and activity level continue 20 years or more after TKA.

Low incidence of groin pain and early failure with large metal articulation total hip arthroplasty.

BACKGROUND: Large-diameter metal-on-metal articulations reportedly improve stability and wear in THAs. However, some reports suggest some patients have unexplained hip and early failures with these implants. Thus, the potential benefits may be offset by these concerns. However, the incidence of these problems is not clearly established. QUESTIONS/PURPOSES: We therefore assessed hip pain, function, osteolysis, and complications in patients with large-diameter metal-on-metal THA. PATIENTS AND METHODS: We retrospectively reviewed 611 patients who had 681 large-diameter metal-on-metal THAs with the same cup and head design. The average age at operation was 62 years, 53% of the THAs were in men, and the average body mass index was 32 kg/m(2). The diagnosis was osteoarthritis in 92% of the THAs. The minimum followup was 24 months (mean, 37 months; range, 24-60 months). RESULTS: Nine of the 611 patients (1.5%) experienced moderate or severe pain in the hip region that we considered to be coming from an extraarticular source in each case. Harris hip scores for pain averaged 42 points. Total Harris hip scores averaged 93 points. Cup abduction averaged 42°, and cup anteversion averaged 26°. There were no infections. Three cups (0.4%) were considered radiographically loose. All were secondary to inadequate seating of the shell. CONCLUSION: Our observations suggest with this implant the concerns of higher incidences of groin pain, early failures, and adverse tissue reactions were not confirmed. Early successes or failures with large-diameter metal-on-metal articulations may be implant specific. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Acetabular UHMWPE survival and wear changes with different manufacturing techniques.

BACKGROUND: Polyethylene wear may be affected by the type of polyethylene resin, manufacturing technique, degree of thermal stabilization, and sterilization technique. QUESTIONS/PURPOSES: We therefore compared femoral head penetration into the PE and cup survival using the same cup system with different PE resins, manufacturing, and sterilization techniques. METHODS: Our study group consisted of 1912 THAs performed using the same uncemented cup and identical 28-mm cobalt-chrome heads. The polyethylene varied as follows: Group 1 (94 cups), GUR 4150 resin, ram-extruded, sterilized in air, no barrier packaging; Group 2 (74 cups), same as Group 1 but sterilized in argon; Group 3 (75 cups), Himont 1900 resin, compression-molded bar stock, sterilized in argon, no barrier packaging; Group 4 (620 cups), same as Group 3 except with barrier packing; Group 5 (711 cups), GUR 1050 resin, compression-molded bar stock, sterilized in argon gas with barrier packaging; and Group 6 (338 cups), GUR 1050 resin, compression-molded bar stock, sterilized in argon with barrier packaging, irradiated with 50 kGy, heated below melting temperature, machined, and finally placed in nonbarrier packaging with gas plasma sterilization. Minimum followup was 2 years (average, 7 years; range, 2-17 years). RESULTS: Femoral head penetration averaged 0.05 mm per year for Groups 5 and 6 and was substantially lower than for Groups 1 to 4. Cup survival was higher at seven years in Groups 3, 4, and 5, and at 10 years in group 4 when compared to groups 1, 2, and 3. CONCLUSIONS: We observed lower FHP rates and higher cup survival with polyethylene machined from direct compression-molded bar stock, sterilized in argon gas, with barrier packaging. LEVEL OF EVIDENCE: Level III Therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Big hopes for the children of the world: a review of the Millennium Development Goals.

The Millennium Development Goals are a set of eight goals drafted by the United Nations in 2000 with the aim of improving the health and welfare of people worldwide. The goals provide specific targets to be met by 2015, using the 1990 basis as a standard. This review presents these goals as they relate to children, discussing progress and future aims. Although not all eight goals specifically address children, each has its own impact on global child health. Thus far, much progress has been made, but increased rates of improvement must be achieved in order to meet the goals by 2015 and improve the health of children worldwide.

"Thicker" polyethylene bearings are associated with higher failure rates in primary total knee arthroplasty.

"Thin" modular polyethylene bearings have previously been associated with failure from wear. This study examined the influence of polyethylene thickness on survivorship in primary total knee arthroplasty (TKA). Do "thinner" or "thicker" bearings fail more? Six thousand seventy primary TKAs with a single implant design were reviewed. The failure rate in knees with bearings 14 mm or less was 0.7%, whereas the failure rate of knees with bearings 16 mm or greater was 2.3% (P < .0001; hazard ratio, 3.2). No knee was revised for polyethylene wear. Thicker bearings did not directly cause failure, but factors that lead to the insertion of a thicker bearing such as a deeper tibial resection and ligament imbalance may contribute to the observed increased failure. The significant influence of this often-unrecognized surgical variable has not been previously reported and must be carefully considered during TKA.

High preoperative range of motion is a significant risk factor for dislocation in primary total hip arthroplasty.

Dislocation after total hip arthroplasty (THA) is multifactorial and is dependent on surgical, implant, and patient factors. We hypothesized that high preoperative hip range of motion is an important variable contributing to instability after THA. We retrospectively reviewed 3379 THAs performed during a 21-year period. Average follow-up was 6.6 years. We examined the effect of surgical approach, femoral head size, and preoperative range of motion on dislocation rates. Patients with a posterior approach and 115 degrees or greater of combined preoperative flexion, adduction, and internal rotation dislocated at a significantly higher frequency than those with less than 115 degrees of combined motion (odds ratio, 1.9; P = .007). High preoperative motion in conjunction with a posterior approach and femoral head size less than 32 mm had the highest dislocation rate in our sample (5.9%). Preoperative range of motion is an important variable that should be taken into consideration during operative planning to help reduce the risk of dislocation.

Left atrial scarring and conduction velocity dynamics: Rate dependent conduction slowing predicts sites of localized reentrant atrial tachycardias.

BACKGROUND: Low voltage zones (LVZs) are associated with conduction velocity (CV) slowing. Rate-dependent CV slowing may play a role in reentry mechanisms. METHODS: Patients undergoing catheter ablation for AT were enrolled. Aim was to assess the relationship between rate-dependent CV slowing and sites of localized reentrant atrial tachycardias (AT). On a bipolar voltage map regions were defined as non-LVZs [≥0.5 mV], LVZs [0.2-0.5 mV] and very-LVZs [<0.2 mV]. Unipolar electrograms were recorded with a 64-pole basket catheter during uninterrupted atrial pacing at four pacing intervals (PIs) during sinus rhythm. CVs were measured between pole pairs along the wavefront path. Sites of rate-dependent CV slowing were defined as exhibiting a reduction in CV between PI = 600 ms and 250 ms of ≥20% more than the mean CV reduction seen between these PIs for that voltage zone. Rate-dependent CV slowing sites were correlated to sites of localized reentrant ATs as confirmed with conventional mapping, entrainment and response to ablation. RESULTS: Eighteen patients were included (63 ±â€¯10 years). Mean CV at 600 ms was 1.53 ±â€¯0.19 m/s in non-LVZs, 1.14 ±â€¯0.15 m/s in LVZs, and 0.73 ±â€¯0.13 m/s in very-LVZs respectively (p < 0.001). Rate-dependent CV slowing sites were predominantly in LVZs [0.2-0.5 mV] (74.4 ±â€¯10.3%; p < 0.001). Localized reentrant ATs were mapped to these sites in 81.8% of cases (sensitivity 81.8%, 95% CI 48.2-97.9% and specificity 83.9%, 95% CI 81.8-86.0%). Macro-reentrant or focal ATs were not mapped to sites of rate-dependent CV slowing. CONCLUSIONS: Rate-dependent CV slowing sites are predominantly confined to LVZs [0.2-0.5 mV] and the resultant CV heterogeneity may promote reentry mechanisms. These may represent a novel adjunctive target for AT ablation.

Predicting patellar failure after total knee arthroplasty.

UNLABELLED: We identified patient and surgeon factors associated with patellar component failure in a series of 8530 TKAs performed in 5640 patients using the same posterior cruciate ligament-retaining TKA with all-polyethylene patellar components between January 1983 and December 2003. Patellar failure was defined as loosening, fracture, or patellar revision. All infections were excluded. Statistical analysis using Kaplan-Meier and Cox regression was used to determine the risk of patellar failure. Followup averaged 7.0 years (range, 2-22 years). Patellar component loosening occurred in 4.8% of TKAs (409 knees). Patellar fracture was identified in 5.2% of TKA (444 knees). Twenty-five patellae were revised (0.3%). TKA performed with a lateral release and patients with a body mass index of greater than 30 kg/m(2) were at the greatest risk of patellar loosening and fracture, respectively. Male gender, preoperative varus alignment of greater than 5 degrees , and large patellar component size also predicted a higher risk of patellar fracture. Medial patellar component position, tibial component thickness of greater than 12 mm, preoperative valgus alignment of 10 degrees or more, and preoperative flexion of 100 degrees or more predicted patellar loosening. An awareness of these factors that predict patellar failure after TKA may help determine the relative indications for TKA and influence surgical technique, especially when using this prosthesis. LEVEL OF EVIDENCE: Level IV, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Extended femoral osteotomy and proximally coated prosthesis for hip revision.

Extended trochanteric osteotomy facilitates femoral reconstruction in revision total hip arthroplasty. This study examined the outcome of extended trochanteric osteotomy combined with a proximally porous-coated calcar replacement prosthesis during revision total hip arthroplasty. Forty-five cases were reviewed with an osteotomy union rate of 98%. No femoral component was loose radiographically, and none were revised for loosening. These findings indicate excellent short-term clinical and radiographic results can be achieved with an extended trochanteric osteotomy and proximally porous-coated calcar replacement prosthesis.

Manipulation after total knee arthroplasty.

BACKGROUND: Following total knee arthroplasty, some patients who fail to achieve >90 degrees of flexion in the early perioperative period may be considered candidates for manipulation of the knee under anesthesia. The purpose of this study was to assess the outcomes of manipulation following total knee arthroplasty. METHODS: One hundred and thirteen knees in ninety patients underwent manipulation for postoperative flexion of < or =90 degrees at a mean of ten weeks after surgery. Flexion was measured with a goniometer prior to total knee arthroplasty, at the conclusion of the operative procedure, before manipulation, immediately after manipulation, at six months, and at one, three, and five years postoperatively. RESULTS: Eighty-one (90%) of the ninety patients achieved improvement of ultimate knee flexion following manipulation. The average flexion was 102 degrees prior to total knee arthroplasty, 111 degrees following skin closure, and 70 degrees before manipulation. The average improvement in flexion from the measurement made before manipulation to that recorded at the five-year follow-up was 35 degrees (p < 0.0001, paired t test). There was no significant difference in the mean improvement in flexion when patients who had manipulation within twelve weeks postoperatively were compared with those who had manipulation more than twelve weeks postoperatively. Patients who eventually underwent manipulation had significantly lower preoperative Knee Society pain scores (more pain) than those who had not had manipulation (p = 0.0027). CONCLUSIONS: Manipulation generally increases ultimate flexion following total knee arthroplasty. Patients with severe preoperative pain are more likely to require manipulation.

The effect of stuffing the patellofemoral compartment on the outcome of total knee arthroplasty.

BACKGROUND: The effect of so-called stuffing of the patellofemoral compartment at the time of total knee arthroplasty (that is, increasing the anterior patellar displacement, the anteroposterior femoral size, or the combined anteroposterior patellofemoral size) has not been well studied. The purpose of the present study was to evaluate the effect of stuffing the patellofemoral compartment on the outcome of primary total knee arthroplasty. METHODS: A retrospective review of 1100 primary total knee arthroplasties that had been performed in 1997 and 1998 was conducted. Eight hundred and thirty arthroplasties (75.5%) met the diagnostic and minimum two-year follow-up criteria for inclusion in this report. Radiographic measurements were made to determine preoperative and postoperative anterior patellar displacement, anteroposterior femoral size, combined anteroposterior patellofemoral size, anterior femoral offset, and posterior femoral offset. Regression analysis was performed to determine the effects of changes in these variables on the range of motion, the Knee Society Knee Score, the Knee Society Function Score, the Knee Society Pain Score, and the rate of lateral retinacular release. RESULTS: Preoperative to postoperative changes in anterior patellar displacement, anteroposterior femoral size, combined anteroposterior patellofemoral size, anterior femoral offset, and posterior femoral offset had no clinically meaningful effect on the range of motion of the knee or on any of the Knee Society scores. Increases in anterior patellar displacement were associated with a lower probability of the need for a lateral retinacular release. Increases in measured anteroposterior femoral size were associated with a higher probability of the need for lateral release. Even when combined, however, these relationships explained only 10.1% of the observed variance in the need for lateral retinacular release. Moreover, analyses indicated that patient gender, large as opposed to medium patellar size, and absolute femoral component size influenced the likelihood of lateral release more than did anterior patellar displacement and measured anteroposterior femoral size. CONCLUSIONS: Our findings do not support the widely held belief that stuffing of the patellofemoral joint results in adverse outcomes after total knee arthroplasty. Furthermore, the need for lateral release appears to be multifactorial and likely involves a more complex set of factors. Thus, without evidence of other identifiable causes of failure, we do not recommend revision for the treatment of pain of an overstuffed knee joint.