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BACKGROUND: The burden of osteoarthritis (OA) in multiple joints is high and for patients with bilateral OA of the hip there is no clear recommendation about the indication for simultaneous (one-stage) bilateral total hip arthroplasty (THA) versus two-staged procedures. The purpose of this study was therefore to compare revision and mortality rates after different strategies of surgical timing in bilateral hip OA from the German Arthroplasty Registry (EPRD). METHODS: Since 2012 22,500 patients with bilateral THA (including 767 patients with one-staged bilateral surgery and 11,796 patients with another separate procedures within one year after first THA) are documented in the registry. The patients who underwent simultaneous bilateral THA were matched with a cohort of 767 patients who underwent the second THA between 1 and 90 days postoperatively (short interval) and another cohort of 4,602 patients with THA between 91 and 365 days postoperatively (intermediate interval). Revision for all reasons and mortality rates were recorded. Cox regression was performed to evaluate the influence of different patient characteristics. RESULTS: The cumulative 5-year revision rate for patients with simultaneous bilateral THA was 1.8% (95% CI 0.9-2.6), for patients with two-staged THA 2.3% (95% CI 1.0-3.6) in the short interval and 2.5% (95% CI 2.1-2.9) in the intermediate interval, respectively. In all three groups, patients who underwent THA in a high-volume center (≥ 500 THA per year) had a significant lower risk for revision (HR 0.687; 95% CI 0.501-0.942) compared to surgeries in a low-volume center (< 250 THA per year). There was no significant difference regarding cumulative mortality rates in the three cohorts. Higher age (HR 1.060; 95% CI 1.042-1.078) and severe comorbidities as reflected in the Elixhauser Score (HR 1.046; 95% CI 1.014-1.079) were associated with higher mortality rates after simultaneous THA. CONCLUSION: Simultaneous bilateral THA seems to be a safe procedure for younger patients with limited comorbidities who have bilateral end-stage hip OA, especially if performed in high-volume centers. LEVEL OF EVIDENCE: III.
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Artroplastia de Quadril , Osteoartrite do Quadril , Sistema de Registros , Reoperação , Humanos , Artroplastia de Quadril/mortalidade , Artroplastia de Quadril/métodos , Artroplastia de Quadril/efeitos adversos , Masculino , Feminino , Alemanha/epidemiologia , Idoso , Reoperação/estatística & dados numéricos , Osteoartrite do Quadril/cirurgia , Osteoartrite do Quadril/mortalidade , Pessoa de Meia-Idade , Fatores de Tempo , Idoso de 80 Anos ou maisRESUMO
BACKGROUND: We studied whether an individualized digital decision aid can improve decision-making quality for or against knee arthroplasty. METHODS: An app-based decision aid (EKIT tool) was developed and studied in a stepped-wedge, cluster-randomized trial. Consecutive patients with knee osteoarthritis who were candidates for knee replacement were included in 10 centers in Germany. All subjects were asked via app on a tablet about their symptoms, prior treatments, and preferences and goals for treatment. For the subjects in the intervention group, the EKIT tool was used in the doctor-patient discussion to visualize the individual disease burden and degree of fulfillment of the indication criteria, and structured information on knee arthroplasty was provided. In the control group, the discussion was conducted without the EKIT tool in accordance with the local standard in each participating center. The primary endpoint was the quality of the patient's decision on the basis of the discussion of indications, as measured with the Hip and Knee Quality Decision Instrument (HK-DQI). (Registration number: ClinicalTrials.gov:NCT04837053). RESULTS: 1092 patients were included, and data from 1055 patients were analyzed (616 in the intervention group and 439 in the control group). Good decision quality, as rated by the HK-DQI, was achieved by 86.0% of patients in the intervention group and 67.4% of patients in the control group (relative risk, 1.24; 95 % confidence interval, [1.15; 1.33]). CONCLUSION: A digital decision aid significantly improved the quality of decision-making for or against knee replacement surgery. The widespread use of this instrument may have an even larger effect, as this trial was conducted mainly in hospitals with high case numbers.
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Knee arthroplasty is one of the most frequently performed operations in Germany, with approximately 170000 procedures per year. It is therefore essential that physicians should adhere to an appropriate, and patient-centered indication process. The updated guideline indication criteria for knee arthroplasty (EKIT-Knee) contain recommendations, which are based on current evidence and agreed upon by a broad consensus panel. For practical use, the checklist has also been updated.For this guideline update, a systematic literature research was conducted in order to analyse (inter-)national guidelines and systematic reviews focusing on osteoarthritis of the knee and knee arthroplasty, to answer clinically relevant questions on diagnostic, predictors of outcome, risk factors and contraindications.Knee arthroplasty should solely be performed in patients with radiologically proven moderate or severe osteoarthritis of the knee (Kellgren-Lawrence grade 3 or 4), after previous non-surgical treatment for at least three months, in patients with high subjective burden with regard to knee-related complaints and after exclusion of possible contraindications (infection, comorbidities, BMI ≥ 40 kg/m2). Modifiable risk factors (such as smoking, diabetes mellitus, anaemia) should be addressed and optimised in advance. After meeting current guideline indications, a shared decision-making process between patients and surgeons is recommended, in order to maintain high quality surgical management of patients with osteoarthritis of the knee.The update of the S2k-guideline was expanded to include unicondylar knee arthroplasty, the preoperative optimisation of modifiable risk factors was added and the main indication criteria were specified.
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BACKGROUND: Despite improving the management of proximal femur fractures (PFF) with legal requirements of timing the surgery within 24 h, mortality rates in these patients remain still high. The objective of our study was to analyze potential cofactors which might influence the mortality rate within 90 days after surgery in PFF to avoid adverse events, loss of quality of life and high rates of mortality. METHODS: In this retrospective, single-center study all patients with PFF aged 65 years and older were included. We recorded gender, age, type of fracture, surgery and anesthesia, time, comorbidities and medication as well as complications and mortality rate at 90 days. Separate logistic regression models were used to assess which parameters were associated with patients' mortality. The mortality rate was neither associated with timing, time and type of surgery nor time and type of anesthesia, but with higher age (OR 1.08 per year; 95% CI 1.034-1.128), lower BMI (OR 0.915 per kg/m2; 95% CI 0.857-0.978), higher CCI (OR 1.170 per point; 95% CI 1.018-1.345), dementia (OR 2.805; 95% CI 1.616-4.869), non-surgical complications (OR 2.276; 95% CI 1.269-4.083) and if mobilization was impossible (OR 10.493; 95% CI 3.612-30.479). RESULTS: We analyzed a total of 734 patients (age ≥ 65 years) who had a PFF in 2019 and 2020 and received surgery. 129 patients (17.6%) died until 90 days at an median age of 89.7 years (range 65-101 years). CONCLUSION: The proportion of patients who died until 90 days after surgery is still high. It is less extend influenced by surgical and anaesthesiologic factors than by patient-related factors like age or lower BMI. Physicians should be aware of the importance of avoiding adverse events and the importance of patients' mobilization to reduce mortality and improve patients' outcome.
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Fraturas do Quadril , Fraturas Proximais do Fêmur , Humanos , Idoso , Idoso de 80 Anos ou mais , Estudos Retrospectivos , Fraturas do Quadril/cirurgia , Qualidade de Vida , Centros de Atenção Terciária , Fatores de RiscoRESUMO
BACKGROUND: Periprosthetic distal femoral fractures (PDFF) are challenging injuries, as mostly geriatric patients with serious comorbidities are affected. Revision to a distal femoral replacement (DFR) is often the best option in very distal fractures, poor bone stock and/or loose total knee replacement. Data on outcome after these surgeries is limited. OBJECTIVES: This study was initiated to analyze the outcome after distal femoral replacement for periprosthetic distal femoral fractures. MATERIALS AND METHODS: Data of the German Arthroplasty Registry (EPRD) were analyzed. From a total of 43,945 revision knee replacement surgeries in the registry, 629 patients could be identified with a PDFF in which a DFR was used for revision. The mean age was 79.1 years, and 84.1% were female. Revisions and mortality were analyzed and compared with patient groups with a similar procedure (revision total knee arthroplasty) or similar general condition (fracture hip replacement). To make the groups more comparable, matched-pair-analyses were performed that included age, gender, BMI and comorbidities as matching parameters. RESULTS: Within 1 year after surgery 17.1% of the patients died and 10.4% were revised. Within 4 years 35.5% died and 22.3% were revised. Revision rates were lower in elective knee revisions (1 year 6.0%, 4 years 16.8%). Periprosthetic joint infection (PJI) accounted for 50% of all revisions, resulting a PJI rate of 7.3%. Mortality after DFR was similarly high as after fracture hip arthroplasty. CONCLUSION: After DFR for PDFF every third patient died, and every fifth patient needed revision within 4 years after surgery, which demonstrates the severity of this injury. Efforts should be undertaken to provide optimal treatment to these high-risk patients to reduce unfavorable outcomes. Surgeries should be well prepared and performed as early as possible in hospitals with adequate experience.
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Artroplastia do Joelho , Fraturas Femorais Distais , Fraturas do Fêmur , Fraturas Periprotéticas , Humanos , Feminino , Idoso , Masculino , Fraturas do Fêmur/cirurgia , Fraturas Periprotéticas/cirurgia , Estudos Retrospectivos , Fêmur/cirurgia , Artroplastia do Joelho/efeitos adversos , MorteRESUMO
BACKGROUND: Both the cruciate-retaining (CR) and posterior-stabilized (PS) implant systems are commonplace in modern total knee arthroplasty (TKA) practice. However, there is controversy regarding functional outcomes and survivorship. The aim of the underlying study was to evaluate differences between CR and PS TKA regarding knee function, patient-reported outcome measures (PROMs) as well as complication rates. METHODS: 140 patients with knee osteoarthritis scheduled for an unconstrained TKA were enrolled in a prospective, randomized study. Patients received either a CR or PS implant. Range of motion and PROMs (Oxford Knee Score, Knee Society Score, European Quality of Life 5 Dimensions 3 Level, University of California Los Angeles Activity scale and subjective satisfaction) were assessed prior to, 3 months, 1 and 2 years after surgery. RESULTS: We found minor differences between treatment groups regarding demographic factors. Within the PS group duration of surgery was longer (mean PS 81.4 min vs CR 76.0 min, P = .006). We observed better flexion (median PS 120.0° vs CR 115°, P = .017) and an overall better range of motion (median PS 120.0° vs CR 115.0°, P = .008) for the PS group. PROMs did not differ between groups. At 2-year follow-up there were no revisions in either cohort. Five patients needed reoperations. Three patients needed manipulation under anesthesia, 2 in the CR and one in the PS group. CONCLUSION: While PS TKA achieved a better flexion capability, PROMs were similar in CR and PS TKA. The CR implant design continues to be a reliable option for patients with an intact posterior cruciate ligament.
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Artroplastia do Joelho , Prótese do Joelho , Osteoartrite do Joelho , Ligamento Cruzado Posterior , Humanos , Artroplastia do Joelho/métodos , Estudos Prospectivos , Qualidade de Vida , Ligamento Cruzado Posterior/cirurgia , Osteoartrite do Joelho/cirurgia , Amplitude de Movimento Articular , Articulação do Joelho/cirurgiaRESUMO
PURPOSE: This study was initiated to analyze the outcome after distal femoral replacement (DFR) for periprosthetic distal femoral fractures (PDFF). METHODS: Data from the German Arthroplasty Registry (EPRD) were analyzed. A total of 626 patients could be identified with a DFR for PDFF. Mean age was 78.8 years, and 84.2% were female. Revisions and mortality were analyzed and compared with patient groups with a similar procedure (revision total knee arthroplasty) or similar general condition (fracture total hip arthroplasty, hip hemiarthroplasty). Matched-pair-analyses were performed. RESULTS: Within one year after surgery, 13.2% of the patients had died and further 9.4% were revised. Within four years, 32.7% had died and 19.7% were revised. Revisions were nearly twice as high as in the comparison groups. Periprosthetic infection (PJI) was the most frequent cause for revision, resulting in a PJI rate of 12.8%, which was lower in the comparison groups. Mortality after DFR was as similar high as after fracture hip arthroplasty. CONCLUSION: PDFF are a serious injury, and the necessary surgical treatment has a high risk of complications. Every third patient after DFR for PDFF had died and every fifth patient needed revision within 4 years after surgery. Efforts should be undertaken to provide optimal treatment to these high-risk patients to reduce unfavorable outcomes. LEVEL OF EVIDENCE: III. REGISTRATION OF CLINICAL TRIALS: As this is a registry-derived study of data of the German Arthroplasty Registry (EPRD), no registration was performed.
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Artroplastia de Quadril , Artroplastia do Joelho , Fraturas Femorais Distais , Fraturas do Fêmur , Fraturas Periprotéticas , Humanos , Feminino , Idoso , Masculino , Fraturas do Fêmur/etiologia , Fraturas do Fêmur/cirurgia , Fraturas Periprotéticas/etiologia , Fraturas Periprotéticas/cirurgia , Fêmur/cirurgia , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/métodos , Artroplastia de Quadril/efeitos adversos , Reoperação/efeitos adversos , Estudos RetrospectivosRESUMO
BACKGROUND: Allergies against implant materials are still not fully understood. Despite controversies about its relevance, some patients need treatment with hypoallergenic implants. This study compared coated and standard total knee arthroplasty (TKA) regarding inflammatory response and patient-reported outcome measures (PROMs). METHODS: 76 patients without self-reported allergies against implant materials were included in a RCT and received a coated or standard TKA of the same cemented posterior-stabilized knee system. 73 patients completed the 3-year follow-up. Two patients died and there was one revision surgery. Serum levels of cytokines with a possible role in implant allergy were measured in patient`s serum (IL-1beta, IL-5, IL-6, IL-8, IL-10, IFN γ, TNF α) prior to, one and three years after surgery. Furthermore, PROMs including knee function (Oxford Knee Score, Knee Society Score) and health-related quality of life (QoL, EuroQuol questionnaire) were assessed. Additionally, 8 patients with patch-test proven skin allergy against implant materials who received the coated implant were assessed similarly and compared to a matched-pair group receiving the same implant. RESULTS: There were no differences in function and QoL between the assessed groups at any follow-up. The majority of patients demonstrated no elevation of the measured blood cytokines. Cytokine patterns showed no differences between study groups at any follow-up. The allergy patients demonstrated slower functional improvement and minor differences in cytokine pattern. Yet these results were not significant. There were no differences in the matched-pair analysis. CONCLUSION: We observed no relevant increase in serum cytokine levels in any group. The inflammatory response measured seems limited, even in allergy patients. Furthermore, there were no differences between coated and standard TKA in non-allergy patients in the 3-year Follow-Up period. TRIAL REGISTRATION: The study protocol was registered in the US National Institutes of Health's database ( http://www. CLINICALTRIALS: gov ) registry under NCT03424174 on 03/17/2016.
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Artroplastia do Joelho , Hipersensibilidade , Prótese do Joelho , Osteoartrite do Joelho , Humanos , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/métodos , Qualidade de Vida , Prótese do Joelho/efeitos adversos , Articulação do Joelho/cirurgia , Hipersensibilidade/etiologia , Hipersensibilidade/cirurgia , Citocinas , Medidas de Resultados Relatados pelo Paciente , Resultado do Tratamento , Osteoartrite do Joelho/cirurgia , Osteoartrite do Joelho/etiologiaRESUMO
Aberrant innate immune signaling has been identified as a potential key driver of the complex pathophysiology of myelodysplastic neoplasms (MDS). This study of a large, clinically and genetically well-characterized cohort of treatment-naïve MDS patients confirms intrinsic activation of inflammatory pathways in general mediated by caspase-1, interleukin (IL)-1ß and IL-18 in low-risk (LR)-MDS bone marrow and reveals a previously unrecognized heterogeneity of inflammation between genetically defined LR-MDS subgroups. Principal component analysis resolved two LR-MDS phenotypes with low (cluster 1) and high (cluster 2) levels of IL1B gene expression, respectively. Cluster 1 contained 14/17 SF3B1-mutated cases, while cluster 2 contained 8/8 del(5q) cases. Targeted gene expression analysis of sorted cell populations showed that the majority of the inflammasome-related genes, including IL1B, were primarily expressed in the monocyte compartment, consistent with a dominant role in determining the inflammatory bone marrow environment. However, the highest levels of IL18 expression were found in hematopoietic stem and progenitor cells (HSPCs). The colony forming activity of healthy donor HSPCs exposed to monocytes from LR-MDS was increased by the IL-1ß-neutralizing antibody canakinumab. This work reveals distinct inflammatory profiles in LR-MDS that are of likely relevance to the personalization of emerging anti-inflammatory therapies.
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Síndromes Mielodisplásicas , Humanos , Síndromes Mielodisplásicas/genética , Síndromes Mielodisplásicas/metabolismo , Células-Tronco Hematopoéticas/metabolismo , Medula Óssea/metabolismo , Transdução de Sinais , Perfilação da Expressão GênicaRESUMO
PURPOSE: Patient satisfaction with the results of their total knee arthroplasty (TKA) is one of the primary goals of this elective procedure. Furthermore, the association between the fulfilment of patients' expectations and their satisfaction is well known. The aim of this study was to identify the key expectations of patients awaiting a TKA, evaluate their fulfilment, and compare the outcomes between very and not fully satisfied patients. METHODS: A prospective cohort study of patients with knee OA scheduled for primary TKA was performed. Pre- and one-year postoperatively patient-reported outcome measures (PROMs) were assessed. Expectations and their fulfilment were evaluated via a questionnaire encompassing 31 expectations. Preoperatively, expectations were indicated as mandatory, desirable and not important. Postoperatively, fulfilment was rated as exceeded, fulfilled, partially or not fulfilled, and not applicable. Satisfaction with the results of TKA was measured with a numeric rating scale (NRS) of 0-10. Discrimination between not fully satisfied and very satisfied patients was set at ≥ 8, as has been proposed recently. To identify independent predictors of this discrimination, a multivariate logistic regression analysis was performed. RESULTS: Complete data sets of 352 patients were analysed. A set of 17 key expectations was identified. Relief of knee pain was fulfilled the most, and improvement of physical function was fulfilled the least. When asked about overall fulfilled expectations, 40% of patients rated them as exceeded, 34% as fulfilled and 26% as less fulfilled than expected. Not fully satisfied patients showed significantly lower PROMs pre- and postoperatively and less fulfilled key expectations. Higher numbers of exceeded and fulfilled mandatory expectations, higher overall fulfilment and better range of motion (ROM) were significant predictors for satisfaction ≥ 8. CONCLUSION: Patients' expectations of TKA outcomes were high with equal emphasis on knee-related and general health-related aspects. Their fulfilment was positively associated with satisfaction. Surgeons should ask patients about mandatory expectations for successful TKA and counsel them about the likelihood of their fulfilment to avoid unrealistic expectations. LEVEL OF EVIDENCE: II.
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Artroplastia do Joelho , Osteoartrite do Joelho , Humanos , Motivação , Estudos Prospectivos , Satisfação do Paciente , Satisfação Pessoal , Osteoartrite do Joelho/cirurgia , Resultado do TratamentoRESUMO
PURPOSE: Post-operative outcome after total knee arthroplasty (TKA) in the treatment of end-stage osteoarthritis correlates strongly with pre-operative impairment-driven patient treatment goals. However, a clinical tool for measuring patient treatment goals in correlation to impairments is still missing, which impedes patient-oriented indication in TKA. METHODS: Patients scheduled for TKA were recruited in four German hospitals. All patients were handed the INDICATE Knee Score pre-operatively. The score contains 31 treatment goals with respective impairments, subdivided into seven categories. They were asked to rank all treatment goals and impairments on a 3-point scale. Treatment goals and impairments were then checked for frequency of occurrence. Correlation of goal and impairment was tested. Analysis for associations of treatment goals and different cohort characteristics (age, sex, BMI) was conducted. RESULTS: 1.298 patients were included in the study. Seven treatment goals were categorised as "main goal" from more than 90% of all patients ("knee pain", "range of motion", "walking distance", "overall physical function", "climbing stairs", "quality of life", "implant survival"). Comparing age groups, there were significant associations towards higher expectations regarding working, physical and sports related treatment goals in younger patients (< 65y) ("ability to work" (P ≤ .001), "sports activities" (P ≤ .001), "sex life" (P ≤ .001), "dependence on help of others" (P = .015), "preventing secondary impairment" (P = .03), "dependence on walking aids" (P = .005)). Higher BMI resulted in increasing relevance of "weight reduction" (P ≤ .001), "climbing stairs" (P = .039) "global health status" (P = .015) and "long standing" (P = .007) as a "main goal". Analysis for differences in treatment goals regarding sex showed women choosing more treatment goals as "main goals" than men. CONCLUSION: Seven treatment goals which were expected by > 90% in our collective can be classified as general treatment goals for TKA. Demographic factors (age, sex, BMI) were significantly associated with patients' expectations for TKA. We conclude physicians should clearly assess their patients' demands prior to TKA to maximise post-operative outcome. LEVEL OF EVIDENCE: Prognostic Level III.
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Artroplastia do Joelho , Osteoartrite do Joelho , Masculino , Humanos , Feminino , Artroplastia do Joelho/efeitos adversos , Objetivos , Osteoartrite do Joelho/cirurgia , Motivação , Satisfação do Paciente , Nível de Saúde , Resultado do TratamentoRESUMO
BACKGROUND: This randomized-controlled trial was initiated to compare a new multilayer hypoallergenic coating system with the standard implant in total knee arthroplasty (TKA) in terms of serum metal ion levels, patient-reported outcomes (PROs), and implant survival. METHODS: A total of 120 patients were randomized to receive a coated or standard TKA of the same knee system. Serum metal ion levels (ie, cobalt, chromium, molybdenum, and nickel) as well as knee function (Oxford Knee Score, OKS), quality of life (SF-36), and physical activity (UCLA activity scale) were assessed before surgery and until the 10 year follow-up. A total of 24 patients died and there was one revision in each group. This resulted in 85 patients who completed follow-up. RESULTS: Both groups demonstrated equally good improvement in PROs after surgery and constant score values thereafter. The majority of patients had metal ion serum levels below detection limit. Only cobalt levels demonstrated a slight increase in the standard group at 5- and 10-year follow-up. However, all patients displayed values below 3 µg/L. The cumulative 10-year survival was 98% in both groups. CONCLUSION: There were no problems with the new coating system. No relevant increase in metal ion serum levels were measured. A slight increase in cobalt serum levels in the standard TKA was noted, thus not reaching critical values. The new coating system demonstrated equally good PROs as the standard TKA. Excellent implant survival was observed in both groups. LEVEL OF EVIDENCE: I.
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Artroplastia do Joelho , Prótese do Joelho , Osteoartrite do Joelho , Humanos , Artroplastia do Joelho/métodos , Qualidade de Vida , Osteoartrite do Joelho/cirurgia , Articulação do Joelho/cirurgia , Cobalto , MetaisRESUMO
The Working Group of the German Orthopedic and Trauma Society (DGOU) on Tissue Regeneration has published recommendations on the indication of different surgical approaches for treatment of full-thickness cartilage defects in the knee joint in 2004, 2013 and 2016. Based upon new scientific knowledge and new developments, this recommendation is an update based upon the best clinical evidence available. In addition to prospective randomised controlled clinical trials, this also includes studies with a lower level of evidence. In the absence of evidence, the decision is based on a consensus process within the members of the working group.The principle of making decision dependent on defect size has not been changed in the new recommendation either. The indication for arthroscopic microfracturing has been reduced up to a defect size of 2 cm2 maximum, while autologous chondrocyte implantation is the method of choice for larger cartilage defects. Additionally, matrix-augmented bone marrow stimulation (mBMS) has been included in the recommendation for defects ranging from 1 to 4.5 cm2. For the treatment of smaller osteochondral defects, in addition to osteochondral transplantation (OCT), mBMS is also recommended. For larger defects, matrix-augmented autologous chondrocyte implantation (mACI/mACT) in combination with augmentation of the subchondral bone is recommended.
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Doenças das Cartilagens , Cartilagem Articular , Procedimentos Ortopédicos , Ortopedia , Humanos , Estudos Prospectivos , Doenças das Cartilagens/cirurgia , Articulação do Joelho/cirurgia , Condrócitos , Cartilagem Articular/cirurgia , Cartilagem Articular/lesõesRESUMO
PURPOSE: Allergy against implant materials is discussed controversially and still not fully understood. Despite these controversies, a relevant number of patients receive hypoallergenic knee implants. The aim of this study was to compare a new coating system with the standard implant in total knee arthroplasty (TKA). Additionally, the influence of proinflammatory cytokines on patient-reported outcome measures (PROMs) was investigated. METHODS: 120 patients without known metal allergy and without previous metal implants were included. The patients were randomized to receive a coated or standard TKA of the same knee system. 105 patients completed the 5 year follow-up. Patient-reported outcome measures (PROMs) including knee function (Oxford Knee Score, OKS), quality of life (SF36) and UCLA activity scale were assessed. Additionally, several cytokines with a possible role in implant allergy were measured in patient`s serum (IL-1beta, IL-5, IL-6, IL-8, IL-10, IP-10, IFN γ, TNF α). Group comparison was performed using Mann-Whitney U test for continuous values and chi-square test for categorical values. RESULTS: There were no differences in PROMs between both groups at any follow-up. The majority of patients demonstrated no elevation of the measured blood cytokines. The blood cytokine pattern after 5 years demonstrated no differences between study groups. There was a significant association between elevated IL-8 values and worse results in the overall OKS (p = 0.041), the OKS function component (p = 0.004), the UCLA activity scale (p = 0.007) and the physical component of SF36 (p = 0.001). CONCLUSION: There were no problems with the new coating during mid-term follow-up and no differences in PROMs between coated and standard TKA. Patients with an increased inflammatory response demonstrated worse functional results, regardless of the implant. LEVEL OF EVIDENCE: I. CLINICAL TRIAL REGISTRATION: The study protocol was registered in the US National Institutes of Health's database ( http://www. CLINICALTRIALS: gov ) registry under NCT00862511.
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Artroplastia do Joelho , Hipersensibilidade , Prótese do Joelho , Osteoartrite do Joelho , Humanos , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/métodos , Qualidade de Vida , Interleucina-8 , Prótese do Joelho/efeitos adversos , Articulação do Joelho/cirurgia , Hipersensibilidade/etiologia , Citocinas , Resultado do Tratamento , Medidas de Resultados Relatados pelo PacienteRESUMO
Patient-specific instrumentation (PSI) in total knee arthroplasty (TKA) has been introduced to reduce instruments and surgical time and to improve implant alignment. The aim of this study was to compare TKA with patient-specific and conventional instrumentation with regard to the use of resources in the operating room (OR), alignment and patient-reported outcome. A total of 139 TKA with PSI or conventional instrumentation were included in three centers. Economic variables of the surgery (number of instrument trays, setup and cut-sew-time), radiological alignment and patient reported outcomes (VAS Pain Scale, Oxford Knee Score, EQ-5D) were assessed after 6 weeks, 6 and 12 months. There was a significant reduction of instrument trays and of time in the OR in the PSI group. The reduction varied between the centers. With strict reorganization, more than 50% of the instrument trays could be reduced while using PSI. There were no significant differences in cut-sew-time, implant position, leg axis, pain and function. The use of PSI was associated with significantly less OR resources. However, the savings did not compensate the costs for this technology.
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Artroplastia do Joelho , Prótese do Joelho , Osteoartrite do Joelho , Cirurgia Assistida por Computador , Humanos , Articulação do Joelho , Salas Cirúrgicas , Resultado do Tratamento , DorRESUMO
BACKGROUND: Patients with post-traumatic osteoarthritis (PTOA) present a variety of technical challenges to surgeons. Surgical parameters, complication rates and patient-reported outcomes (PROs) have been reported as detrimental in total knee arthroplasty (TKA) for PTOA. The purpose of this study was to compare these variables and satisfaction with the results of TKA in patients with post-traumatic osteoarthritis with a matched-pair cohort of primary osteoarthritis (POA). METHODS: A registry-embedded prospective case-control study was performed. Of a total of 1646 TKAs, 155 were performed due to PTOA between 2012 and 2019. One-hundred and thirty-six could be one-to-one propensity score-matched to patients with POA undergoing primary TKA based on similar patient demographic variables. Outcomes investigated included operation time, estimated blood loss, types of implants, postoperative complications and PROs pre- and 1 year postoperatively as well as satisfaction with the results of surgery. Sub-cohort analysis was performed for patients with prior fracture and soft tissue trauma, respectively. RESULTS: Surgical parameters were significantly different in disadvantages of PTOA: operation time (P < 0.001), estimated blood loss (P < 0.001), blood transfusions (P = 0.039), type of implants (P < 0.001). Manipulation under anaesthesia (MUA) was necessary more often in the PTOA fracture group (odds ratio 5.01, (95% confidence interval 1.04; 24.07). PRO demonstrated no substantial differences after 1 year. Satisfaction with the results of TKA was as equally high in all cohorts. CONCLUSIONS: This study demonstrated that TKAs in patients with PTOA require higher surgical effort but can result in similar PROs and satisfaction compared to POA, regardless of the underlying trauma.
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Artroplastia do Joelho , Osteoartrite do Joelho , Humanos , Artroplastia do Joelho/métodos , Osteoartrite do Joelho/complicações , Osteoartrite do Joelho/cirurgia , Satisfação do Paciente , Estudos de Casos e Controles , Medidas de Resultados Relatados pelo Paciente , Resultado do Tratamento , Articulação do Joelho/cirurgiaRESUMO
Clonal hematopoiesis (CH) is characterized by somatic mutations in blood cells of individuals without hematologic disease. While the mutational landscape of CH in peripheral blood (PB) has been well characterized, detailed analyses addressing its spatial and cellular distribution in the bone marrow (BM) compartment are sparse. We studied CH driver mutations in healthy individuals (n = 261) across different anatomical and cellular compartments. Variant allele frequencies were higher in BM than PB and positively correlated with the number of driver variants, yet remained stable during a median of 12 months of follow-up. In CH carriers undergoing simultaneous bilateral hip replacement, we detected ASXL1-mutant clones in one anatomical location but not the contralateral side, indicating intra-patient spatial heterogeneity. Analyses of lineage involvement in ASXL1-mutated CH showed enriched clonality in BM stem and myeloid progenitor cells, while lymphocytes were particularly involved in individuals carrying the c.1934dupG variant, indicating different ASXL1 mutations may have distinct lineage distribution patterns. Patients with overt myeloid malignancies showed higher mutation numbers and allele frequencies and a shifting mutation landscape, notably characterized by increasing prevalence of DNMT3A codon R882 variants. Collectively, our data provide novel insights into the genetics, evolution, and spatial and lineage-specific BM involvement of CH.
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Hematopoiese Clonal , Transtornos Mieloproliferativos , Humanos , Hematopoiese Clonal/genética , Hematopoese/genética , Mutação , Células ClonaisRESUMO
BACKGROUND: The presence or absence of an implant has a major impact on the type of joint infection therapy. Thus, the aim of this study was the examination of potential differences in the spectrum of pathogens in patients with periprosthetic joint infections (PJI) as compared to patients with native joint infections (NJI). METHODS: In this retrospective study, we evaluated culture-positive synovial fluid samples of 192 consecutive patients obtained from January 2018 to January 2020 in a tertiary care university hospital. For metrically distributed parameters, Mann-Whitney U was used for comparison between groups. In case of nominal data, crosstabs and Chi-squared tests were implemented. RESULTS: Overall, 132 patients suffered from periprosthetic joint infections and 60 patients had infections of native joints. The most commonly isolated bacteria were coagulase-negative Staphylococci (CNS, 28%), followed by Staphylococcus aureus (S. aureus, 26.7%), and other bacteria, such as Streptococci (26.3%). We observed a significant dependence between the types of bacteria and the presence of a joint replacement (p < 0.05). Accordingly, detections of CNS occurred 2.5-fold more frequently in prosthetic as compared to native joint infections (33.9% vs. 13.4% p < 0.05). In contrast, S. aureus was observed 3.2-fold more often in NJIs as compared to PJIs (52.2% vs. 16.4%, p < 0.05). CONCLUSION: The pathogen spectra of periprosthetic and native joint infections differ considerably. However, CNS and S. aureus are the predominant microorganisms in both, PJIs and NJIs, which may guide antimicrobial therapy until microbiologic specification of the causative pathogen.
Assuntos
Artrite Infecciosa/microbiologia , Prótese Articular/microbiologia , Infecções Relacionadas à Prótese/microbiologia , Líquido Sinovial/microbiologia , Idoso , Idoso de 80 Anos ou mais , Artrite Infecciosa/diagnóstico , Artrite Infecciosa/epidemiologia , Bactérias , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/epidemiologia , Estudos Retrospectivos , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/epidemiologia , Staphylococcus aureus/isolamento & purificaçãoRESUMO
BACKGROUND: In Germany, patients with contact allergy to implant components usually receive coated joint arthroplasties. Whether the treatment using these hypoallergenic implants achieves comparable results to standard treatment with implants consisting of cobalt-chromium alloy (CoCr) implants is controversially discussed internationally and has rarely been investigated in the mid-term. OBJECTIVES: Are there differences in blood metal ion concentrations, knee function, and patient-reported outcomes (PROM) between coated and standard implants? MATERIAL AND METHODS: 118 patients were randomized to receive either a coated or a standard implant. Knee function as well as patient-reported outcome measures were assessed. Metal ion concentrations in blood samples were additionally determined for chromium, cobalt, molybdenum, and nickel, preoperatively, one and five years after surgery. RESULTS: After five years, it was possible to analyse the results of 97 patients. In metal ion concentrations, as well as PRO, consistently good results were seen, without any difference between the groups. While in 13 patients there was an increase in chromium concentration above 2⯵g/l one year after surgery, there was no measured value above 1⯵g/l after five years. CONCLUSION: In our study, similar mid-term results were detected for coated (TiNiN) and standard (CoCr)TKA. With respect to metal ion concentrations and PRO there are no disadvantages in using coated TKA.
Assuntos
Artroplastia do Joelho , Prótese do Joelho , Artroplastia do Joelho/efeitos adversos , Cromo , Ligas de Cromo , Cobalto , HumanosRESUMO
PURPOSE: If substitution of the posterior cruciate ligament in total knee arthroplasty is necessary, there are two options available: posterior stabilized (PS) design with a post-cam mechanism or anterior-lipped ultracongruent (UC) inserts. UC inserts have the advantage that no femoral box is necessary and a standard femoral component can be used. The aim of this study was to compare the range of motion (ROM) and patient-reported outcome (PRO) after UC and PS fixed-bearing TKA. Better ROM in PS TKA and no difference in PRO between both designs was hypothesized. METHODS: A randomized controlled trial with 127 patients receiving a fixed-bearing UC or PS design of the same knee system was performed. Nine patients died and there were four revision surgeries. 107 patients completed the 5-year follow-up. Patient-reported outcome was assessed. Patellofemoral problems were evaluated using selected applicable questions of the Oxford Knee Score (getting up from a table, kneeling, climbing stairs). RESULTS: Surgical time was 10 min shorter in the UC group (p < 0.001). After 5 years, both groups demonstrated good knee function and health-related quality of life without significant differences between the groups. Both groups demonstrated a high satisfaction score and the majority of patients would undergo this surgery again. Patellofemoral problems were recognized more frequently in the PS group (p = 0.025). CONCLUSION: Both designs demonstrated similar good results after 5 years. Stabilization with an anterior-lipped UC insert can be considered a safe alternative to the well-established PS design if cruciate substitution is necessary.