Using orthopaedic health care resources efficiently: A cost analysis of day surgery for unicompartmental knee replacement.

BACKGROUND: Day surgery for unicompartmental knee replacement (UKR) could potentially reduce hospital costs. We aimed to measure the impact of introducing a day surgery UKR pathway on mean length of stay (LOS) and costs for the UK NHS, compared to an accelerated inpatient pathway. Secondly, the study aimed to compare the magnitude of costs using three costing approaches: top-down costing; simple micro-costing; and real-world costing. METHODS: We conducted an observational, before-and-after study of 2,111 UKR patients at one NHS hospital: 1,094 patients followed the day surgery pathway between September 2017 and February 2020; and 1,017 patients followed the accelerated inpatient pathway between September 2013 and February 2016. Top-down costs were estimated using Average NHS Costs. Simple micro-costing used the cost per bed-day. Real-world costs for this centre were estimated by costing actual changes in staffing levels. RESULTS: 532 (48.5%) patients in the day surgery pathway were discharged on the day of surgery compared with 36 (3.5%) patients in the accelerated inpatient pathway. The day surgery pathway reduced the mean LOS by 2.2 (95% CI: 1.81, 2.53) nights and was associated with an 18% decrease in Average NHS Costs (p < 0.001). Mean savings were £1,429 per patient with the Average NHS Costs approach, £905 per patient with the micro-costing approach, and £577 per patient with the "real-world" costing approach. Overall, moving NHS UKR surgeries to a day surgery pathway could save the NHS £8,659,740 per year. CONCLUSION: Day surgery for UKR could produce substantial cost savings for hospitals and the NHS.

Hormonal Contraception and Risk of Cardiometabolic Disease in Women with HIV.

Objective: We sought to determine the association of hormonal contraception (HC) and cardiometabolic outcomes among women with human immunodeficiency virus (HIV). Methods: We included women with HIV aged 18-45 years in clinical care in the Southeastern United States between 1998 and 2018. Oral and injectable HC use was captured from medication records. Our outcomes included incident cardiovascular/thrombotic disease (CVD) (atherosclerosis, hypertension, cerebrovascular disease, thrombosis, and heart failure) and incident metabolic disorders (diabetes, dyslipidemia, obesity, and non-alcoholic steatohepatitis). We excluded women with prevalent conditions. We used multivariable marginal structural models to examine time-varying current and cumulative HC use and cardiometabolic outcomes in separate analyses, adjusting for age, race, smoking, time-varying comorbidities, CD4 cell count, HIV RNA, and antiretroviral use. Women with HC exposure were compared with women without HC exposure. Results: Among the 710 women included, 201 women (28%) used HC. CVD analyses included 603 women without prevalent CVD and 93 incident events; metabolic analyses included 365 women without prevalent metabolic disease and 150 incident events. Current and cumulative oral HC use was associated with increased odds of CVD, though this was not statistically significant (adjusted odds ratio [aOR] = 2.08, [95% confidence interval (CI): 0.80-5.43] and aOR = 1.24 [95% CI: 0.96-1.60] per year of use, respectively). Oral HC was not associated with risk of incident metabolic disorders. Depot medroxyprogesterone acetate (DMPA) was not associated with risk of incident CVD. Current and cumulative DMPA use was significantly associated with decreased odds of incident metabolic disorders (aOR = 0.48 [95% CI: 0.23, 1.00] and aOR = 0.65 [95% CI: 0.42-1.00] per year of use, respectively). Conclusion: Our results suggest that cardiovascular risk should be considered when selecting contraception for women with HIV.

Fixed lateral unicompartmental knee replacement is a reliable treatment for lateral compartment osteoarthritis after mobile-bearing medial unicompartmental replacement.

PURPOSE: Lateral osteoarthritis following medial unicompartmental knee replacement (UKR) is usually treated with total knee replacement, however, lateral UKR is a less invasive option that preserves a well-functioning medial UKR. This study aimed to determine the 5-year outcome of the cemented Fixed Lateral Oxford UKR (FLO) when used for the treatment of severe lateral disease after medial Oxford unicompartmental knee replacement. METHODS: Forty-four knees with lateral bone-on-bone osteoarthritis (n = 43) and avascular necrosis (n = 1) treated with the FLO following medial Oxford UKR were followed up prospectively. The Oxford Knee Score (OKS) and Tegner Activity Score (TAS) were collected pre- and post-operatively. Life-table analysis was used to determine survival rates. RESULTS: The mean patient age at the time of FLO surgery was 74.4 years with a mean time of 12.1 years between the primary medial UKR and the conversion to a bi-UKR with a FLO. Mean follow-up of the FLO was 3.5 years. After FLO no intra-operative or medical complications, re-admissions, or mortality occurred. There was one reoperation in which a bearing was exchanged for a medial bearing dislocation. There were no revisions of the FLO, so the FLO survival rate at 5 years was 100% (24 at risk). The mean pre-operative OKS was 22, which significantly (p < 0.0001) improved to a mean of 42, 42, and 40 at 1, 2, and 5 years, respectively. The median TAS had a non-significant improvement from 2.5 (Range 0-8) pre-operatively to 2 (Range 1-6) at 5 years postoperatively. CONCLUSION: The FLO is a reliable treatment for lateral osteoarthritis following medial UKR. At 5 years there was a 100% survival of the FLO with a mean OKS of 40. LEVEL OF EVIDENCE: IV, Prospective Case Series.

Less pain reported 5 years after cementless compared to cemented unicompartmental knee replacement: an analysis of pain, neuropathy, and co-morbidity scores.

PURPOSE: To compare patient-reported pain scores and assess the influence of neuropathy and co-morbidity, on knee pain following cemented and cementless medial unicompartmental knee replacement (UKR) 5 years after surgery. METHOD: In this longitudinal study, 262 cemented and 262 cementless Oxford UKR performed for the same indications and with the same techniques were recruited. Patients were reviewed at five years, evaluating patient-reported pain and association with clinical outcomes. Intermittent and Constant Osteoarthritis Pain (ICOAP), PainDETECT (PD), Charnley score, Oxford Knee Score (OKS) and American Knee Society Score (AKSS) were compared. RESULTS: In both cohorts, intermittent pain was more common than constant pain (47% vs 21%). Cementless knees reported significantly less pain than cemented (ICOAP-Total 5/100 vs 11/100, p < 0.0001). A greater proportion of cementless knees experienced no pain at all (ICOAP = 0/100, 61% vs 43%, p < 0.0001) and 75% fewer experienced severe or extreme pain. Pain sub-scores in PD, OKS and AKSS follow this trend. Pain was unlikely to be neuropathic (PD positive: 5.26%), but patients reporting high levels of 'strongest' pain were three times more likely to be neuropathic. Patients with co-morbidities (Charnley C) experienced greater pain than those without (Charnley A+B) across all knee-specific scores, despite scores being knee specific. CONCLUSION: Both cemented and cementless UKR in this study had substantially less pain than that reported in literature following TKR. Cementless UKR had significantly less pain than cemented UKR in all scores. Two-thirds of patients with a cementless UKR had no pain at all at 5 years, and pain experienced was most likely to be mild and intermittent with no patients in severe or extreme pain. Patients with cementless UKR that had higher levels of pain were more likely to have co-morbidity or evidence or neuropathic pain. It is unclear why cementless UKR have less pain than cemented; further study is necessary.

Early post-operative physiotherapy rehabilitation after primary unilateral unicompartmental knee replacement: a systematic review.

BACKGROUND: Unicompartmental Knee Replacement (UKR) is an established treatment for end stage arthritis affecting one compartment of the knee. UKR lends itself to rapid recovery and early discharge. The content, type, timing and dose of early post-operative physiotherapy treatment has yet to be reviewed. OBJECTIVE: To review the content of early physiotherapy in the first eight weeks following unilateral UKR. DATA SOURCES: A literature search of Medline, CINAHL, AMED and PubMed and the Physiotherapy Evidence Database (PEDRo) plus citation searching. ELIGIBILITY CRITERIA: Randomised controlled trials (RCTs) and observational studies reporting a physiotherapy intervention for UKR involving a form of post-operative exercise/education/advice delivered within the first eight weeks of surgery and commencing as an in-patient. Two reviewers independently performed screening, data extraction and risk of bias assessment. DATA SYNTHESIS: Narrative syntheses were undertaken due to the heterogeneity of the primary outcomes. RESULTS: Eleven studies were included (n = 1293 participants), three RCTs and eight observational studies. The dose and content of post-operative physiotherapy was highly variable with a move in recent years to rapid recovery and same day discharge with more self-directed rehabilitation. No studies had a low risk of bias. LIMITATIONS: Small sample sizes and high heterogeneity limit our findings CONCLUSIONS: This review highlights the range of post-operative physiotherapy provision following UKR with a recent move to minimal physiotherapy input. Further research is required to identify those patients who may need additional physiotherapy above that now routinely provided, along with the most effective timing, type, and dosage of the intervention. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42021243238. CONTRIBUTION OF THE PAPER.

CD4/CD8 Ratio and Cancer Risk Among Adults With HIV.

BACKGROUND: Independent of CD4 cell count, a low CD4/CD8 ratio in people with HIV (PWH) is associated with deleterious immune senescence, activation, and inflammation, which may contribute to carcinogenesis and excess cancer risk. We examined whether low CD4/CD8 ratios predicted cancer among PWH in the United States and Canada. METHODS: We examined all cancer-free PWH with 1 or more CD4/CD8 values from North American AIDS Cohort Collaboration on Research and Design observational cohorts with validated cancer diagnoses between 1998 and 2016. We evaluated the association between time-lagged CD4/CD8 ratio and risk of specific cancers in multivariable, time-updated Cox proportional hazard models using restricted cubic spines. Models were adjusted for age, sex, race and ethnicity, hepatitis C virus, and time-updated CD4 cell count, HIV RNA, and history of AIDS-defining illness. RESULTS: Among 83 893 PWH, there were 5628 incident cancers, including lung cancer (n = 755), Kaposi sarcoma (n = 501), non-Hodgkin lymphoma (n = 497), and anal cancer (n = 439). The median age at cohort entry was 43 years. The overall median 6-month lagged CD4/CD8 ratio was 0.52 (interquartile range = 0.30-0.82). Compared with a 6-month lagged CD4/CD8 of 0.80, a CD4/CD8 of 0.30 was associated with increased risk of any incident cancer (adjusted hazard ratio = 1.24 [95% confidence interval = 1.14 to 1.35]). The CD4/CD8 ratio was also inversely associated with non-Hodgkin lymphoma, Kaposi sarcoma, lung cancer, anal cancer, and colorectal cancer in adjusted analyses (all 2-sided P < .05). Results were similar using 12-, 18-, and 24-month lagged CD4/CD8 values. CONCLUSIONS: A low CD4/CD8 ratio up to 24 months before cancer diagnosis was independently associated with increased cancer risk in PWH and may serve as a clinical biomarker.

Early results of fixed-bearing unicompartmental knee replacement designed for the lateral compartment.

BACKGROUND: Isolated lateral compartment knee arthritis is less prevalent than medial. While the reported results of medial unicompartmental knee replacement (UKR) have been good and comparable to total knee replacement, the results of lateral UKR have been mixed. We present the short-term results and survivorship of a fixed-bearing UKR designed specifically for the lateral compartment. METHODS: We report the result of 130 primary fixed-bearing lateral Oxford (FLO) UKRs (123 patients) performed between 2015 and 2019 with a minimum follow-up of 1 year. The indications for lateral UKR were: isolated lateral osteoarthritis (n = 122), post-trauma (n = 5) and osteonecrosis (n = 3). The mean age was 69.1 (± 11.6), mean BMI 28.4 (± 4.9), 66.9% female, 60% right-sided, and mean follow-up 3 (range 1-4.8 years, standard deviation ± 1) years. The primary outcome measure was the Oxford knee score (OKS). Survival analysis was performed with "revision for any reason", "reoperation", and "implant failure" as the endpoints. RESULTS: Six patients died from unrelated reasons. None of the implants failed. One required the addition of a medial UKR for medial arthritis. There were no other reoperations. At 4 years, the survival for implant failure was 100% and for both revision and all reoperations was 99.5% (95% CI 96.7-99.9%). At the last review, at a mean of 3 years, the mean Oxford knee score was 41. CONCLUSION: The good survivorship and outcome scores suggest that UKR designed for the lateral compartment is an excellent alternative to total knee replacement in selected patients with isolated lateral tibiofemoral arthritis at short-term follow-up.

Comparison of five-year clinical outcomes of 524 cemented and cementless medial unicompartmental knee replacements.

AIM: To compare the outcomes of cemented and cementless Unicompartmental Knee Replacements (UKR) at 5 years after surgery. METHODS: 262 cemented and 262 cementless medial mobile-bearing UKR, implanted by four high-volume surgeons using identical indications and surgical techniques, were reviewed by independent physiotherapists at 5 years. Survival, Oxford Knee Score (OKS), American Knee Society Score (AKSS), and EQ-5D-5L were assessed. The cementless cohort was mainly implanted after the cemented. Each cohort was divided into early and late sub-groups and compared, to assess if any differences were due to progressive improvement in surgical practice over time. RESULTS: There were no significant differences between the cohorts for demographics, pre-operative scores, and 5-year revision (0.8%), re-operation (1.5%), and complication rates (5%). The cementless cohort had significantly better 5-year OKS (43v41, p = 0.008), AKSS-Objective (94v90, p = 0.049) and EQ-5D-5L (0.81v0.87, p = 0.0001). Pain sub-scores within OKS, AKSS, and EQ-5D-5L were also significantly better in the cementless cohort, and the differences were proportionally much greater and more significant than differences in their respective overall scores. There was no significant improvement in scores between the early and late subgroups of the cohorts, whereas the 'early-cementless' cohort had significantly better scores than the contemporaneously implanted 'late-cemented' cohort. This suggests that differences found were due to implant type, instead of improved surgical practice over time. CONCLUSION: Cementless UKR is associated with better clinical outcomes than cemented UKR, which is primarily due to improved pain relief. Both cemented and cementless UKR are safe with low reoperation and complication rates, and a 5-year survival of 99%.

Understanding the experience of living well, beyond the age of 85 years: a qualitative analysis using themes from a meta-ethnography.

BACKGROUND: Increase in life-expectancy is not necessarily matched by an increase in quality of life. OBJECTIVE: (1) To explore the quality of life of patients over the age of 85 in the second decade following unicompartmental knee replacement surgery (2) To understand the usefulness of a priori themes from an evidence synthesis as a framework for primary qualitative analysis. DESIGN: Qualitative Research. A hermeneutic phenomenological approach, using a priori themes as sensitising concepts. PARTICIPANTS: Adults over the age of 85 who were part of an outcomes study in the second decade following unicompartmental knee joint replacement. METHODS: Semi-structured interviews in people's homes. Transcripts were coded and data sorted using a priori themes as sensitising concepts. Data that did not fit these themes, or that added nuance, were analysed thematically through constant comparison. RESULTS: We interviewed seven white women and five white men, aged 85-100. Data resonated with a priori themes and supported additional themes that help us to understand older peoples' experience: (1) losing our autonomy can be challenging, so be kind; (2) we must take care of our own bodies and the NHS; (3) I am more afraid of not dying. CONCLUSIONS: Findings indicate that health outcomes for older people should incorporate measures of participation and well-being; they highlight the importance of kindness in healthcare; they indicate that older people do not want to place additional burden on the NHS, and this can act as a barrier to care; they support the need for open conversations about dying well.

Anticytomegalovirus CD4+ T Cells Are Associated With Subclinical Atherosclerosis in Persons With HIV.

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Antiretroviral therapy and Kaposi's sarcoma trends and outcomes among adults with HIV in Latin America.

INTRODUCTION: Kaposi's sarcoma (KS) remains the most frequent malignancy in persons living with HIV (PWH) in Latin America. We examined KS trends and outcomes from Latin American clinical sites in the era of increased access to antiretroviral therapy (ART). METHODS: Cohorts in Brazil, Peru, Mexico, Honduras, Argentina and Chile contributed clinical data of PWH ≥16 years old from 2000 to 2017, excluding patients with KS diagnosed before clinic enrolment. We compared KS incidence over time using multivariable incidence rate ratios. Predictors of KS before/at or after ART initiation and of mortality after KS were examined using Cox regression. RESULTS: Of 25 981 PWH, 481 had incident KS, including 200 ART-naïve and 281 ART-treated patients. From 2000 to 2017, the incidence of KS decreased from 55.1 to 3.0 per 1000 person-years. In models adjusting for CD4 and other factors, the relative risk for KS decreased from 2000 to 2008. Since 2010, the adjusted risk of KS increased in the periods before and ≤90 days after ART initiation but decreased >90 days after ART. In addition to low CD4 and male-to-male sex, KS risk after ART was associated with age and history of other AIDS-defining illnesses. Mortality after KS (approximately 25% after five years) was not associated with either year of KS diagnosis nor timing of diagnosis relative to ART initiation. CONCLUSIONS: KS incidence in Latin America has remained stable in recent years and risk is highest before and shortly after ART initiation. Early diagnosis of HIV and ART initiation remain critical priorities in the region.

Risk of Incident Diabetes Mellitus, Weight Gain, and Their Relationships With Integrase Inhibitor-Based Initial Antiretroviral Therapy Among Persons With Human Immunodeficiency Virus in the United States and Canada.

BACKGROUND: Integrase strand transfer inhibitor (INSTI)-based combination antiretroviral therapy (cART) is associated with greater weight gain among persons with human immunodeficiency virus (HIV), though metabolic consequences, such as diabetes mellitus (DM), are unclear. We examined the impact of initial cART regimen and weight on incident DM in a large North American HIV cohort (NA-ACCORD). METHODS: cART-naive adults (≥18 years) initiating INSTI-, protease inhibitor (PI)-, or nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimens from January 2007 through December 2017 who had weight measured 12 (±6) months after treatment initiation contributed time until clinical DM, virologic failure, cART regimen switch, administrative close, death, or loss to follow-up. Multivariable Cox regression yielded adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for incident DM by cART class. Mediation analyses, with 12-month weight as mediator, similarly adjusted for all covariates. RESULTS: Among 22 884 eligible individuals, 47% started NNRTI-, 30% PI-, and 23% INSTI-based cART with median follow-up of 3.0, 2.3, and 1.6 years, respectively. Overall, 722 (3%) developed DM. Persons starting INSTIs vs NNRTIs had incident DM risk (HR, 1.17 [95% CI, .92-1.48]), similar to PI vs NNRTI initiators (HR, 1.27 [95% CI, 1.07-1.51]). This effect was most pronounced for raltegravir (HR, 1.42 [95% CI, 1.06-1.91]) vs NNRTI initiators. The INSTI-DM association was attenuated (HR, 1.03 [95% CI, .71-1.49] vs NNRTIs) when accounting for 12-month weight. CONCLUSIONS: Initiating first cART regimens with INSTIs or PIs vs NNRTIs may confer greater risk of DM, likely mediated through weight gain.

Introduction of an innovative day surgery pathway for unicompartmental knee replacement: no need for early knee flexion.

OBJECTIVES: To evaluate the introduction of an innovative rehabilitation protocol, delaying knee flexion, for patients receiving unicompartmental knee replacement. DESIGN: Longitudinal cohort. SETTING: Specialist Orthopaedic Unit within an NHS Foundation Trust. PARTICIPANTS: 669 consecutive patients undergoing unicompartmental knee replacement. INTERVENTION: An innovative rehabilitation protocol, delaying knee flexion. MAIN OUTCOME MEASURES: Length of stay, range of movement, Surgical Satisfaction Questionnaire. RESULTS: There were 669 consecutive primary unilateral unicompartmental knee replacements from September 2016 to February 2018. In total 264 patients (39%) went home on the day of surgery, 253 (38%) on day 1 and 152 (23%) stayed in 2 or more days (range 2 to 28 days). The mean length of stay reduced from 2.6 to 1.2days (median 1day). Mean flexion was 110° (range 30 to 140) at 6 weeks. The surgical satisfaction questionnaire showed that 90% of patients discharged on day 0 were very satisfied with the results of surgery. CONCLUSION: Many components of traditional care were altered to introduce this protocol. The most important factors were delayed knee flexion providing benefits in terms of early mobilisation with no short term detriment, physiotherapists working late shifts, a consistent message and patient education. It was safe, effective and patient satisfaction was high.

Obesity should not be considered a contraindication to medial Oxford UKA: long-term patient-reported outcomes and implant survival in 1000 knees.

PURPOSE: Some health providers ration knee arthroplasty on the basis of body mass index (BMI). There is no long-term data on the outcome of medial mobile-bearing unicompartmental knee arthroplasty (UKA) in different BMI groups. This study aimed to determine the effect of patient body mass index (BMI) on patient-reported outcomes and long-term survival of medial UKA in a large non-registry cohort. Our hypothesis is that increasing BMI would be associated with worse outcomes. METHODS: Data were analysed from a prospective cohort of 1000 consecutive medial mobile-bearing Oxford UKA with mean 10-year follow-up. Patients were grouped: BMI < 25, BMI 25 to < 30, BMI 30 to < 35 and BMI 35+. Oxford Knee Score (OKS) and Tegner Activity Score were assessed at 1, 5 and 10 years. Kaplan-Meier survivorship was calculated and compared between BMI groups. RESULTS: All groups had significant improvement in OKS and Tegner scores. BMI 35 + kg/m2 experienced the greatest overall increase in mean OKS of 17.3 points (p = 0.02). There was no significant difference in ten-year survival, which was, from lowest BMI group to highest 92%, 95%, 94% and 93%. CONCLUSION: There was no difference in implant survival between groups, and although there was no consistent trend in postoperative OKS, the BMI 35+ group benefited the most from UKA. Therefore, when UKA is used for appropriate indications, high BMI should not be considered to be a contraindication. Furthermore rationing based on BMI seems unjustified, particularly when the commonest threshold (BMI 35) is used. LEVEL OF EVIDENCE: III.

Knee Arthroplasty Patients Predicted Versus Actual Recovery: What Are Their Expectations About Time of Recovery After Surgery and How Long Before They Can Do the Tasks They Want to Do?

OBJECTIVES: (1) To determine evidence-based guidance for the length of time to return to specific valued functional and leisure activities after knee arthroplasty (KA). (2) To determine what patients feel are the most important functional or leisure activities to recover after KA. (3) To collect information about patients' expectations and compare them to the actual time it takes to return. DESIGN: Prospective longitudinal cohort observational survey. SETTING: Specialist orthopedic hospital. PARTICIPANTS: Patients (N=99) with osteoarthritis or rheumatoid arthritis (mean=69.9y [range 44-88]) listed for total knee arthroplasty (TKA) or unicompartmental knee arthroplasty. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Valued activities list (VAL) used to select activities patients expect to return to and report the actual time taken to return. RESULTS: Participants in unicompartmental knee arthroplasty group returned to the 6 most popular valued activities (walking >1km, stair climbing, housework, driving, gardening, and kneeling) 8%-33% more quickly than TKA group, and they were satisfied with performing these activities sooner on average (4%-18%) than the TKA group. The percentage of participants satisfied at 12 months postsurgery ranged from 96% returning to housework to 36% returning to kneeling. The Wilcoxon signed-rank test was used to compare the expected time and the actual time to return: Housework (Z=-5.631, P<.05, effect size=0.64) and swimming (Z=-3.209, P<.05, effect size=0.59) were quicker than expected, and walking >1 km (Z=-2.324, P<.05, effect size=0.27) was slower than expected. CONCLUSIONS: A more tailored and personalized approach with consideration of prior level of activity and comorbidities must be taken into account and adequately discussed to help bridge the gap between the expected and actual recovery time.

Brief Report: Circulating Markers of Immunologic Activity Reflect Adiposity in Persons With HIV on Antiretroviral Therapy.

BACKGROUND: Obesity alters adipose tissue immunology, and these changes may be reflected in circulating soluble inflammatory biomarker and T-cell subset profiles measured in HIV research studies. METHODS: We recruited 70 adults with HIV (50% obese) on efavirenz, tenofovir, and emtricitabine, virologic suppression for >2 years, and no rheumatologic or other known inflammatory conditions. We measured fasting plasma levels of several markers of innate immunity and major CD4 and CD8 T-cell subsets. We assessed relationships between measurements of total adiposity [body mass index (BMI), dual-energy X-ray absorptiometry-quantified fat mass index (FMI), and plasma leptin] and the immunologic parameters using covariate-adjusted Spearman's rank correlations. RESULTS: The cohort was 43% women, 54% nonwhite, and median age was 45 years. Higher BMI, FMI, and plasma leptin were consistently associated with higher C-reactive protein, serum amyloid A, and interleukin-6 (P < 0.01 for all), but lower interleukin-10 (P ≤ 0.02 for all). BMI and FMI were positively associated with soluble tumor necrosis factor-α receptor 1 levels (P ≤ 0.02 for both), and a positive correlation approached significance for all 3 body composition measurements with soluble CD163 (P ≤ 0.09 for all). Higher BMI and FMI were associated with lower CD38 expression on CD4 T cells (P ≤ 0.04 for both), but higher CD69 expression (P ≤ 0.01 for BMI and FMI, P = 0.07 for leptin). CONCLUSIONS: Greater adiposity is associated with alterations in a limited set of circulating immune markers, potentially reflecting changes known to occur in adipose tissue with treated HIV infection. Measuring total fat mass radiographically did not yield substantively different results compared with BMI.

Survival after cancer diagnosis in a cohort of HIV-positive individuals in Latin America.

BACKGROUND: This study aimed to evaluate trends and predictors of survival after cancer diagnosis in persons living with HIV in the Caribbean, Central, and South America network for HIV epidemiology cohort. METHODS: Demographic, cancer, and HIV-related data from HIV-positive adults diagnosed with cancer ≤ 1 year before or any time after HIV diagnosis from January 1, 2000-June 30, 2015 were retrospectively collected. Cancer cases were classified as AIDS-defining cancers (ADC) and non-AIDS-defining cancers (NADC). The association of mortality with cancer- and HIV-related factors was assessed using Kaplan-Meier curves and Cox proportional hazards models stratified by clinic site and cancer type. RESULTS: Among 15,869 patients, 783 had an eligible cancer diagnosis; 82% were male and median age at cancer diagnosis was 39 years (interquartile range [IQR]: 32-47). Patients were from Brazil (36.5%), Argentina (19.9%), Chile (19.7%), Mexico (19.3%), and Honduras (4.6%). A total of 564 ADC and 219 NADC were diagnosed. Patients with NADC had similar survival probabilities as those with ADC at one year (81% vs. 79%) but lower survival at five years (60% vs. 69%). In the adjusted analysis, risk of mortality increased with detectable viral load (adjusted hazard ratio [aHR] = 1.63, p = 0.02), age (aHR = 1.02 per year, p = 0.002) and time between HIV and cancer diagnoses (aHR = 1.03 per year, p = 0.01). CONCLUSION: ADC remain the most frequent cancers in the region. Overall mortality was related to detectable viral load and age. Longer-term survival was lower after diagnosis of NADC than for ADC, which may be due to factors unrelated to HIV.

The impact of patient-specific instrumentation on unicompartmental knee arthroplasty: a prospective randomised controlled study.

PURPOSE: Patient-specific instrumentation (PSI) has been proposed as a means of improving surgical accuracy and ease of implantation during technically challenging procedures such as unicompartmental knee arthroplasty (UKA). The purpose of this prospective randomised controlled trial was to compare the accuracy of implantation and functional outcome of mobile-bearing medial UKAs implanted with and without PSI by experienced UKA surgeons. METHODS: Mobile-bearing medial UKAs were implanted in 43 patients using either PSI guides or conventional instrumentation. Intra-operative measurements, meniscal bearing size implanted, and post-operative radiographic analyses were performed to assess component positioning. Functional outcome was determined using the Oxford Knee Score (OKS). RESULTS: PSI guides could not be used in three cases due to concerns regarding accuracy and registration onto native anatomy, particularly on the tibial side. In general, similar component alignment and positioning was achieved using the two systems (n.s. for coronal/sagittal alignment and tibial coverage). The PSI group had greater tibial slope (p = 0.029). The control group had a higher number of optimum size meniscal bearing inserted (95 vs 52%; p = 0.001). There were no differences in OKS improvements (n.s). CONCLUSION: Component positioning for the two groups was similar for the femur but less accurate on the tibial side using PSI, often with some unnecessarily deep resections of the tibial plateau. Although PSI was comparable to conventional instrumentation based on OKS improvements at 12 months, we continue to use conventional instrumentation for UKA at our institution until further improvements to the PSI guides can be demonstrated. LEVEL OF EVIDENCE: Therapeutic, Level I.

Evidence-Based Indications for Mobile-Bearing Unicompartmental Knee Arthroplasty in a Consecutive Cohort of Thousand Knees.

BACKGROUND: The indications for unicompartmental knee arthroplasty remain controversial. Previously recommended contraindications include the following: age under 60 years, weight 180 lb (82 kg) or over, patients undertaking heavy labor, chondrocalcinosis, and exposed bone in the patellofemoral joint. This study explores whether these contraindications are valid in mobile-bearing unicompartmental knee arthroplasty. METHODS: Using a prospective series of 1000 consecutive medial unicompartmental knee arthroplasties in which the reported contraindications were not applied, the functional outcome and survival in patients with or without contraindications were compared. RESULTS: Of the 1000 consecutive unicompartmental knee arthroplasties (818 patients), 68% (678 knees) would be considered contraindicated based on published contraindications. At a mean follow-up of 10 years (5-17), there was no difference in American Knee Society (AKS) Objective Scores (P = .05) or Oxford Knee Score (P = .08) between groups. However, knees with contraindications had significantly (P = .02) fewer poor outcomes and significantly better AKS Functional Scores (P < .001) and Tegner Activity Scores (P < .001). At 15 years, no difference in implant survival (P = .33) was observed. The 3% of unicompartmental knee arthroplasties performed in young men (age <60) weighing 180 lb or over with high activity levels, who have been reported to have poor outcomes after fixed-bearing unicompartmental knee arthroplasty, had significantly better AKS Functional Scores (P < .001), Oxford Knee Score (P = .01), and Tegner Activity Score (P < .001) at 10 years. No difference in AKS Objective Scores (P = .54) at 10 years or implant survival at 15 years (P = .75) was seen. CONCLUSION: This large case series provides evidence that patients with the previously reported contraindications do as well as, or even better than, those without contraindications. Therefore these contraindications should not apply to mobile-bearing unicompartmental knee arthroplasty.

Lateral osteophytes do not represent a contraindication to medial unicompartmental knee arthroplasty: a 15-year follow-up.

PURPOSE: Lateral osteophytes have been reported to be associated with lateral compartment disease and as such it is unclear whether medial unicompartmental knee arthroplasty should be performed if these are present. METHODS: Using the OARSI classification system, 0 (no osteophyte) to 3 (large osteophyte), radiographs from a series of cemented meniscal-bearing unicompartmental knee arthroplasty implanted in the setting of full-thickness lateral cartilage where lateral osteophytes were not considered a contraindication were identified and factors associated with the presence and size of lateral osteophytes, and their impact on clinical outcomes and implant survival were assessed. RESULTS: Pre-operative radiographs from 458 knees (392 patients), independently followed up for a mean 10.5 years (range 5.3-16.6), were assessed. Lateral osteophytes were present in 62 % of knees with 18 % scored as Grade 3. Inter-observer reliability was good (kappa = 0.70). The presence and size of lateral osteophytes was associated with younger age at joint replacement (p = 0.01) and increasing BMI (p = 0.01). No association was seen with gender, pre-operative status, assessed using the Oxford Knee Score (OKS), American Knee Society (AKSS) Objective or Functional Score, Tegner activity score, or size of medial tibial lesion. Subgroup analysis of Grade 3 Osteophytes revealed that these were associated with a greater degree of macroscopic ACL damage. At 10 years there was no difference in function (n.s.), and at 15 years no difference in implant survival or mechanism of failure between groups (n.s.). Subgroup analysis of Grade 3 osteophytes found no significant difference in functional outcome at 10 years or implant survival at 15 years. CONCLUSION: The presence of lateral osteophytes is not a contraindication to medial meniscal-bearing unicompartmental knee arthroplasty. The clinical relevance of this study is that it highlights the importance of an appropriate pre-operative assessment of the lateral compartment as in the setting of full-thickness cartilage at operation lateral osteophytes do not compromise long-term functional outcome or implant survival. LEVEL OF EVIDENCE: IV.