Optimized medial unicompartmental knee arthroplasty outcome: learning from 20 years of propensity score matched registry data.

BACKGROUND AND PURPOSE: Unicompartmental knee arthroplasty (UKA) has increased in use. We investigated changes to UKA revision risk over the last 20 years compared with total knee arthroplasty (TKA), examined external and patient factors for correlation to UKA revision risk, and described the survival probability for current UKA and TKA practice. PATIENTS AND METHODS: All knee arthroplasties reported to the Danish Knee Arthroplasty Register from 1997 to 2017 were linked to the National Patient Register and the Civil Registration System for comorbidity, emigration, and mortality information. All primary UKA and TKA patients with primary osteoarthritis were included and propensity score matched 4 TKAs to 1 UKA. Revision and mortality were analyzed using competing risk cox regression with a shared gamma frailty component. RESULTS: The matched cohort included 48,195 primary knee arthroplasties (9,639 UKAs). From 1997-2001 to 2012-2017 the 3-year hazard ratio decreased from 5.5 (95% CI 2.7-11) to 1.5 (CI 1.2-1.8) due to increased UKA survival. Cementless fixation, a high percentage usage of UKA, and increased surgical volume decreased UKA revision risk, and increased in occurrence parallel to the decreasing revision risks. Current UKA practice using cementless fixation at a high usage unit has a 3-year implant survival of 96% (CI 97-95), 1.1% lower than current TKA practice. INTERPRETATION: UKA revision risk has decreased over the last 20 years, nearing that of TKA surgery. High usage rates, surgical volume, and the use of cementless fixation have increased during the study and were associated with decreased UKA revision risks.

No increase in postoperative contacts with the healthcare system following outpatient total hip and knee arthroplasty.

Background and purpose - Discharge on the day of surgery (DDOS) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) has been shown to be safe in selected patients. Concerns have been raised that discharging patients on the day of surgery (DOS) could lead to an increased burden on other parts of the healthcare system when compared with patients not discharged on the DOS (nDDOS). Therefore, we investigated whether discharging patients on the day of surgery (DOS) after THA and TKA leads to increased contacts with the primary care sector or other departments within the secondary care sector.Patients and methods - Prospective data on 261 consecutive patients scheduled for outpatient THA (n = 135) and TKA (n = 126) were collected as part of a previous cohort study. 33% of THA patients and 37% of TKA patients were discharged on the DOS. Readmissions within 3 months after surgery were recorded. Contacts with the discharging department, other departments, and primary care physicians within 3 weeks were registered.Results - No statistically significant differences were found when comparing DDOS patients and patients not discharged on the DOS (nDDOS) with regard to readmissions, physical contacts with the discharging department, and contacts with other departments as well as general practitioners. THA DDOS patients had significantly fewer contacts with the discharging department by telephone than THA nDDOS patients. TKA DDOS patients had significantly more contacts with the discharging department by telephone than TKA nDDOS patients.Interpretation - Patients discharged on the DOS following THA or TKA generally have similar postoperative contacts with the healthcare system when compared with patients not discharged on the DOS.

Assessment of peritoneal metastases with DW-MRI, CT, and FDG PET/CT before cytoreductive surgery for advanced stage epithelial ovarian cancer.

BACKGROUND: Preoperative assessment of peritoneal metastases is an important factor for treatment planning and selection of candidates for cytoreductive surgery (CRS) in primary advanced stage (FIGO stages III-IV) epithelial ovarian cancer (EOC). The primary aim was to evaluate the efficacy of DW-MRI, CT, and FDG PET/CT used for preoperative assessment of peritoneal cancer index (PCI). MATERIAL AND METHODS: In this prospective observational cohort study, 50 advanced stage EOC patients were examined with DW-MRI and FDG PET/CT with contrast enhanced CT as part of the diagnostic program. All patients were deemed amenable for upfront CRS. Imaging PCI was determined for DW-MRI, CT, and FDG PET/CT by separate readers blinded to the surgical findings. The primary outcome was agreement between the imaging PCI and PCI determined at surgical exploration (the reference standard) evaluated with Bland-Altman statistics. RESULTS: The median surgical PCI was 18 (range: 3-32). For all three imaging modalities, the imaging PCI most often underestimated the surgical PCI. The mean differences between the surgical PCI and the imaging PCI were 4.2 (95% CI: 2.6-5.8) for CT, 4.4 (95% CI: 2.9-5.8) for DW-MRI, and 5.3 (95% CI: 3.6-7.0) for FDG PET/CT, and no overall statistically significant differences were found between the imaging modalities (DW-MRI - CT, p = 0.83; DW-MRI - FDG PET/CT, p = 0.24; CT - FDG PET/CT, p = 0.06). CONCLUSION: Neither DW-MRI nor CT nor FDG PET/CT was superior in preoperative assessment of the surgical PCI in patients scheduled for upfront CRS for advanced stage EOC.

Patients with anteromedial osteoarthritis achieve the greatest improvement in patient reported outcome after total knee arthroplasty.

The osteoarthritic (OA) disease pattern of the knee is one of the determinants for choice of arthroplasty concept when knee replacement is indicated, but whether the disease pattern has a direct effect on postoperative outcome has not previously been investigated. The aim was to investigate if different OA disease patterns have an effect on postoperative outcome after receiving total knee arthroplasty (TKA). MATERIALS AND METHODS: 472 patients with pre- and 1-year postoperative patient reported outcome measures (PROMs) undergoing TKA surgery were retrospectively identified and classification of the OA disease pattern was made on preoperative radiographs. Measured resection was the universal technical approach. RESULTS: The key findings showed greater improvement in mean PROMs for anteromedial OA (AMOA) compared with other OA disease patterns; 3.1 points (95% CI 1.4-4.7, p < 0.001) in Oxford Knee score, 11.7 points (95% CI 0.9-22.5, p = 0.034) in Forgotten Joint score and 0.08 points (95% CI 0.02-0.14, p = 0.007) in EQ 5D score. Similar results were observed when comparing AMOA with AMOA that had only partial thickness cartilage loss (AMOA-PTCL). CONCLUSIONS: Patients with AMOA achieve greater improvement in PROMs after TKA surgery when using measured resection compared with other OA disease patterns. This finding has important implications for reporting, risk stratification and interpretation in TKA outcome studies, including randomized trials, why further investigation of the topic is of highly relevance.

Pharmacokinetics and toxicity of carboplatin used for hyperthermic intraperitoneal chemotherapy (HIPEC) in treatment of epithelial ovarian cancer.

OBJECTIVES: Carboplatin is frequently used in various doses for hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of epithelial ovarian cancer (EOC) although its pharmacokinetics, including focus on the perfusion time, has not been evaluated when used in modern era cytoreductive surgery (CRS). The aim was to evaluate the pharmacokinetics and hematological toxicity of carboplatin used for HIPEC with a perfusion time of 90 min. METHODS: Fifteen patients with stage III-IV primary EOC received CRS and 90 min of HIPEC with carboplatin at dose 800 mg/m2. For the pharmacokinetic analysis, perfusate and blood samples were obtained during HIPEC and up to 48 h after HIPEC (blood only). Hematological toxicity within 30 days was graded according to Common Terminology Criteria for Adverse Events. Severe toxicity (grades 3-5) is reported. RESULTS: Mean maximum concentration of carboplatin was 12 times higher in perfusate than plasma (mean CmaxPF=348 µg/mL (range: 279-595 µg/mL) versus mean CmaxPL=29 µg/mL (range: 21-39 µg/mL)). Mean terminal half-life of carboplatin in perfusate was 104 min (range: 63-190 min) and mean intraperitoneal-to-plasma area under the concentration-time curve (AUC) ratio was 12.3 (range: 7.4-17.2). Two patients (13%) had grade 3 neutropenia within 30 days. No grade 4-5 hematological toxicities were identified. CONCLUSIONS: Carboplatin has a favorable pharmacokinetic profile for 90 min HIPEC administration, and the hematological toxicity was acceptable at dose 800 mg/m2. Large interindividual differences were found in the pharmacokinetic parameters, making risk of systemic exposure difficult to predict.

Structurally different mixed linkage ß-glucan supplements differentially increase secondary bile acid excretion in hypercholesterolaemic rat faeces.

Mixed linkage (1→3),(1→4)-ß-d-glucan (BG) is a soluble fibre available from oat and barley grains that has been gaining interest due to its health-promoting role in cardiovascular diseases and its ability to modulate the glycaemic index which is beneficial for people with diabetes. This study investigates the effect of three purified barley BGs, with different molecular weight and block structure, on faecal bile acid excretion in hypercholesterolaemic rats. Wistar rats (48 male) were divided in four groups: Control group fed with the cellulose-rich diet (CON); Glucagel group fed with the commercial BG (GLU, 100 kDa), and rats fed with low molecular weight BG (LBG, 150 kDa) and medium molecular weight BG (MBG, 530 kDa). The bile acid profiles of rat faecal samples were measured using gas chromatography-mass spectrometry (GC-MS). A metabolite profiling approach led to the identification of 7 bile acids and 45 other compounds such as sterols, fatty acids and fatty alcohols. Subsequent application of ANOVA-simultaneous component analysis and Principal Component Analysis revealed that all three BG diets increased bile acid faecal excretion compared to the control group. The bile acid excretion was found to be different in all three BG diets and the MBG group showed a significantly higher level of faecal secondary bile acids, including deoxycholic acid, hyodeoxycholic acid, and lithocholic acid. We hypothesise that the hydrophobic surface of the secondary bile acids, which are known to cause colon cancer, has high affinity to the hydrophobic surfaces of cellulosic blocks of the BG. This in vivo study demonstrates that the molecular weight and/or block structures of BG modulate the excretion of secondary bile acids. This finding suggests that developing diets with designed BGs with an optimal molecular structure to trap carcinogenic bile acids can have a significant impact on counteracting cancer and other lifestyle associated diseases.

Morbidity after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy with carboplatin used for ovarian, tubal, and primary peritoneal cancer.

BACKGROUND AND OBJECTIVES: Hypertherm intraperitoneal chemotherapy (HIPEC) is increasingly used in the treatment of ovarian, tubal, and primary peritoneal cancer (OC). The aim was to evaluate short-term morbidity of cytoreductive surgery (CRS) and carboplatin HIPEC. METHODS: Prospective feasibility study performed from January 2016 to December 2017. Twenty-five patients with primary OC (FIGO III-IV) received upfront or interval CRS combined with carboplatin HIPEC at dose 800 mg/m 2 . Primary outcome measurements: grade 3 to 5 adverse events within 30 days according to Common Terminology Criteria for Adverse Events. Secondary outcome measurements: reoperation rate, length of hospital stay, readmission rate, and time from surgery to systemic chemotherapy administration. RESULTS: No deaths (grade 5) or grade 4 adverse events were observed. Eleven patients (44.0%) experienced at least one grade 3 adverse event, the most common being an infection (28.0%) and neutropenia (12.0%). The reoperation rate was 8.0%. The median hospital stay was 14 days (range 9-25 days), and five patients (25.0%) were readmitted within 30 days after surgery. Median time from surgery to the administration of the first dose of systemic chemotherapy was 41 days (range 24-81 days). CONCLUSION: Our small-scale prospective study supports that CRS and carboplatin HIPEC used for primary advanced-stage OC is feasible with acceptable morbidity.

Medial unicompartmental knee arthroplasty: increasingly uniform patient demographics despite differences in surgical volume and usage-a descriptive study of 8,501 cases from the Danish Knee Arthroplasty Registry.

Background and purpose - Using contemporary indications, up to 50% of patients undergoing knee arthroplasty are eligible for unicompartmental knee arthroplasty (UKA), and lower UKA use likely reflects a restrictive approach to patient selection. Since broader indications have been successfully introduced, and low surgical volume and UKA percentage (usage) are associated with higher revision rates, it is of interest whether the actual use of UKA has changed accordingly. We explored this by assessing time trends in patient demographics and whether these are associated with center UKA volume and usage. Patients and methods - From the Danish Knee Arthroplasty Registry, we included 8,501 medial UKAs performed for primary osteoarthritis during 2002-2016. Using locally weighted regression, we examined changes-both overall and by center volume and usage (low vs high)-in sex distribution, age, weight, and preoperative American Knee Society Score (AKSS-O). Results - Over the last 20 years, UKA use in Denmark has been increasing steadily. Age, weight, and proportion of men all increased regardless of volume and usage. AKSS-O showed an initial increase followed by a decrease. In low-usage and low-volume centers, the proportion of women was higher, patients were younger, weighed less, and had higher AKSS-O scores; however, for age and AKSS-O, the groups were converging during the last part of the period. Interpretation - Characteristics of UKA patients have changed in the last 15 years irrespective of center volume and usage. We found between-group differences for both volume and usage, though with convergence for age and AKSS-O, which suggests an increasingly uniform approach to patient selection.

[Radical conization of intraepithelial neoplasia].

Treatment of cervical intraepithelial neoplasia with conization prevents development of cervical cancers. Radicality in terms of negative conization margins have been reported ranging from 58% to 95%. This article presents a comparison of radicality in the different methods of conization. Loop electrosurgical excision procedure is the recommended method. Neither anaesthetic technique nor intraoperative colposcopy influences the radicality of conization. Studies on surgeon's skills and radicality are needed.