Multicomponent supervised tele-rehabilitation versus home-based self-rehabilitation management after anterior cruciate ligament reconstruction: a study protocol for a randomized controlled trial.

INTRODUCTION: Our study aims to assess the effectiveness of multicomponent supervised tele-rehabilitation compared to home-based self-rehabilitation management in patients following anterior cruciate ligament reconstruction (ACLR). METHODS: The current study is designed as a single-center, single-blinded, randomized controlled, two-arm trial. Participants will be randomized and allocated at a 1:1 ratio into either a multicomponent supervised tele-rehabilitation group or a home-based self-rehabilitation group. All participants receive uniform preoperative education through the HJT software. Participants in the intervention group undergo multicomponent supervised tele-rehabilitation, while those in the control group follow a home-based self-rehabilitation program. All the participants were assessed and measured for the included outcomes at the outpatient clinic before the procedure, and in 2, 4, 8, 12, and 24 weeks after ACLR by two assessors. The primary outcome was the percentage of patients who achieve a satisfactory active ROM at the 12 weeks following the ACLR. The satisfactory active ROM was also collected at 2, 4, 8, and 24 weeks after ACLR. The secondary outcomes were active and passive range of motion (ROM), pain, muscle strength, and function results. REGISTRATION DETAILS: Ethical approval has been obtained from the West China Hospital Ethics Committee (approval number 2023-1929, December 2023). The trial has been registered on ClinicalTrials.gov (registration number NCT06232824, January 2024).

Exploring Causal Relationships between Leukocyte Telomere Length, Sex Hormone-Binding Globulin Levels, and Osteoporosis Using Univariable and Multivariable Mendelian Randomization.

OBJECTIVE: Recent evidence supports that leukocyte telomere length (LTL) may be positively associated with healthy living and inversely correlated with the risk of age-related diseases, including osteoporosis. Furthermore, it is important to note that sex hormone-binding globulin (SHBG) levels play a crucial role in the regulation of osteoporosis by influencing the availability of sex hormones. Hence, this study holds significant importance as it aims to unravel the roles of LTL and SHBG levels and determine which one acts as a predominant intermediary factor in influencing osteoporosis. Using Mendelian randomization (MR), we can gain valuable insights into the intricate relationships between aging, sex hormones, and bone health. METHODS: Univariable and multivariable and MR analyses were employed in this study. First, we used genetic variants associated with both LTL, as determined from a study involving 472,174 European participants by Codd et al., and SHBG levels, as identified in a study conducted by Ruth et al. with 370,125 participants, as instrumental variables (IVs). Then we aimed to establish a causal relationship between LTL and SHBG levels and their potential impact on osteoporosis using univariable MR. Finally, we conducted multivariable MR to provide insights into the independent and combined effects of LTL, SHBG levels on osteoporosis risk. We used various MR methods, with the primary analysis employing the inverse-variance weighted (IVW) model. RESULTS: Univariable MR analysis reveals a potential causal effect of longer LTL on reduced risk of osteoporosis [odds ratio (OR): 0.85; 95% confidence interval (CI): 0.73-0.99; p = 0.03]. Conversely, higher genetically determined SHBG levels affect the risk of osteoporosis positively. (OR: 1.38; 95% CI: 1.09-1.75; p < 0.01). We observed a negative causal effect for LTL on the occurrence of SHBG (OR: 0.96; 95% CI 0.94-0.98, p < 0.01). After adjustment of using multivariable MR, the causal effect of LTL on osteoporosis (OR: 0.92; 95% CI: 0.84-1.03; p = 0.14), and the effect of SHBG on osteoporosis (OR: 1.43; 95% CI: 1.16-1.75; p < 0.01) were observed. CONCLUSION: Longer LTL may confer a protective effect against osteoporosis. Additionally, the levels of SHBG appear to play a crucial role in mediating the relationship between LTL and osteoporosis. By understanding the interplay between these factors, we can gain valuable insights into the mechanisms underlying bone health and aging and potentially identify new avenues for prevention and intervention strategies.

What Is the Normal Trajectory of C-Reactive Protein, Erythrocyte Sedimentation Rate, Plasma Fibrinogen and D-Dimer after Two-Stage Exchange for Periprosthetic Joint Infection?

OBJECTIVE: C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), plasma fibrinogen and D-Dimer are used as diagnostic biomarkers of prosthetic joint infection (PJI) after total joint arthroplasty (TJA). The purpose of the study was to investigate the normal trajectory of CRP, ESR, plasma fibrinogen and D-Dimer at different time points after two-stage exchange arthroplasty for PJI. METHODS: We studied 53 patients undergoing two-stage exchange for PJI at five time points: preoperatively (T0), duration of hospital stays (T1), 30 days (T2), 30-90 days (T3), and 90-180 days (T4) after surgery. The medical records of all patients were well documented and carefully reviewed. The Shapiro-Wilk test was utilized to compare the normal distribution for continuous variables, and the nonnormally distributed data were used for Friedmann's one-way repeat measures analysis of variances. Post hoc Dunnett's test was used to compare each pair of data to find differences from baseline. RESULTS: Compare with T0 point, the levels of CRP and ESR increased significantly and reached peak values at T1 point (all P < 0.001), with median values of 56.40 mg/L (range, 5.54-161.0 mg/L) and 49.00 mm/h (range, 13.00-113.0 mm/h), respectively. In addition, the levels of plasma fibrinogen and D-Dimer increased significantly and reached peak values at T1 point (all P < 0.001), with median values of 4.13g/L (range, 2.27-6.80 mg/L) and 4.00 mg/L (range, 0.19-14.01 mg/L), respectively. CRP and ESR rapidly declined at the T2 point with significantly compared with T0 point (P = 0.001 and P < 0.001). The levels of CRP, ESR, plasma fibrinogen and D-Dimer returned to preoperative levels of 5.23 mg/L (range, 1.01-21.70 mg/L), 19.00 mm/h (range, 6.00-60.00 mm/h), 3.38g/L (range, 1.71-5.10 g/L) and 2.33 mm/h (range, 0.19-6.87 mg/L) at T4 point, and there was no significant difference compared with T0 point (all P > 0.05). CONCLUSIONS: The study demonstrated the normal trajectory of CRP, ESR, plasma fibrinogen and D-Dimer at five time points in patients who underwent two-stage exchange for PJI. Thus, the results have the possibility of providing signs of infection after the patient receives two-stage exchange arthroplasty for PJI, which can benefit from early treatment.

[The role of chondrocyte mitochondrial biogenesis in the pathogenesis of osteoarthritis].

OBJECTIVE: To summarize the role of chondrocytes mitochondrial biogenesis in the pathogenesis of osteoarthritis (OA), and analyze the applications in the treatment of OA. METHODS: A review of recent literature was conducted to summarize the changes in mitochondrial biogenesis in the course of OA, the role of major signaling molecules in OA chondrocytes, and the prospects for OA therapeutic applications. RESULTS: Recent studies reveales that mitochondria are significant energy metabolic centers in chondrocytes and its dysfunction has been considered as an essential mechanism in the pathogenesis of OA. Mitochondrial biogenesis is one of the key processes maintaining the normal quantity and function of mitochondria, and peroxisome proliferator-activated receptor-gamma coactivator 1 alpha (PGC-1α) is the central regulator of this process. A regulatory network of mitochondrial biogenesis with PGC-1α as the center, adenosine monophosphate-activated protein kinase, sirtuin1/3, and cyclic adenosine monophosphate response element-binding protein as the main upstream regulatory molecules, and nuclear respiratory factor 1, estrogen-related receptor α, and nuclear respiratory factor 2 as the main downstream regulatory molecules has been reported. However, the role of mitochondrial biogenesis in OA chondrocytes still needs further validation and in-depth exploration. It has been demonstrated that substances such as puerarin and omentin-1 can retard the development of OA by activating the damaged mitochondrial biogenesis in OA chondrocytes, which proves the potential to be used in the treatment OA. CONCLUSION: Mitochondrial biogenesis in chondrocytes plays an important role in the pathogenesis of OA, and further exploring the related mechanisms is of great clinical significance.

Radiologic restoration inaccuracy increases postoperative dislocation in primary total hip arthroplasty: a retrospective study with propensity score matching.

BACKGROUND: Dislocation is a complicated process and associated with multivariate etiology and risk factors. The purpose of this study was to verify if radiologic restoration inaccuracy increases postoperative dislocation in primary total hip arthroplasty (THA) individually or synergistically. METHODS: From 2017 to 2020, we identified 76 (1.9%) patients who suffered postoperative dislocations from 3926 THAs in our institution. After excluded patients with previously proven patient-related and implant-related risk factors, the remaining patients were used to match a 1:1 control patients who were without dislocation. The cup position (inclination and anteversion angles), hip offset (HO), leg length discrepancy (LLD), and abductor lever arm (ALA) were analyzed by univariate analyses and multivariate logistic regressions. RESULTS: Measurements on radiographs showed excellent interobserver agreement (intraclass correlation coefficient (ICC) 0.922-0.952) and intraobserver agreements (ICC 0.933-0.967). HO restoration inaccuracy (without ± 5 mm) was associated with higher dislocation risk (OR 4.241 95% CI 1.440-12.492, P = 0.009). The restoration inaccuracy of the cup position, LLD, or ALA could not increase the dislocation risk individually. When combining the radiologic restoration inaccuracy factors, the HO + LLD restoration inaccuracy and HO + ALA restoration inaccuracy increased the odds of postoperative dislocation (OR 12.056, 95% CI 1.409-103.127, P = 0.023; OR 4.770, 95% CI 1.336-17.028, P = 0.016, respectively). Combining the four risk factors of cup safe zone, HO, LLD, and ALA, patients with 3 or 4 radiologic restoration inaccuracy factors showed a higher risk of dislocation (OR 13.500, 95% CI 1.340-135.983, P = 0.027). CONCLUSION: Hip offset (HO) restoration inaccuracy increased the risk of dislocation following primary THA. Multivariate radiologic restoration accuracy is critical for the prevention of dislocation and needs to be valued by surgeons.

Effect of an Elevated Preoperative International Normalized Ratio on Transfusion and Complications in Primary Total Hip Arthroplasty with the Enhanced Recovery after Surgery Protocol.

OBJECTIVE: To verify whether an elevated preoperative international normalized ratio (INR) increases transfusion and complications independently in primary total hip arthroplasty (THA) with the management of an enhanced recovery after surgery (EARS) protocol. METHODS: We retrospectively reviewed the database of adults who underwent primary THA between 2014 and 2018 by the same surgeon. A total of 552 patients were assigned into three groups by preoperative INR class: INR ≤ 0.9, 0.9 < INR < 1.0, and INR ≥ 1.0. We regarded transfusion within 90 days during the same hospitalization as the primary outcome. We also included perioperative blood loss, maximum Hb drop, postoperative anaemia requiring medicine, and length of hospital stay (LOS) during the same hospitalization in the study. Complications and reoperation at 90 days and mortality at 90 days and 12 months were also included in the study. Univariable analyses were utilized to compare baselines and outcomes among the three groups. Multivariate logistic regressions were used to adjust for differences at baseline among the groups. RESULTS: All patients had an INR < 1.5 preoperatively and were managed with the ERAS protocol. Among them, 93 (16.8%) patients had INR ≤ 0.9, 268 (48.6%) patients had 0.9 < INR < 1.0, and 191 (34.6%) patients had INR ≥ 1.0. In the univariable analyses, as the INR increased, the transfusion rates increased from 1.08% for INR ≤ 0.9, to 1.12% for 0.9 < INR < 1.0 and to 5.76% for INR ≥ 1.0 (P < 0.05). The overall complication rate increased from 10.8% for INR ≤ 0.9, to 16.4% for 0.9 < INR < 1.0, and to 22.5% for INR ≥ 1.0 (P < 0.05). The length of stay (LOS) in the INR ≥ 1.0 group was 5.7 ± 2.2 days, which was significantly longer than that in the INR ≤ 0.9 group (4.7 ± 1.6 days, P = 0.000) and 0.9 < INR < 1.0 group (5.1 ± 2.0 days, P = 0.007). No statistical significance was detected among the groups regarding blood loss, maximum Hb drop, or the incidence of postoperative anaemia that required medicine. There was no significant difference in reoperation or mortality among the groups. When controlling for demographic and comorbidity characteristics, there was no statistically significant difference in the odds of transfusion during the same hospitalization or overall complications at 90 days among the groups (P > 0.05). CONCLUSIONS: Elevated preoperative INR cannot increase transfusion or complication rates independently in primary THA with the management of the ERAS protocol. With the improvement in the ERAS protocol and the use of tranexamic acid (TXA), an INR < 1.5 is still a conventional safe threshold for THA surgery.

Virtual reality-based rehabilitation in patients following total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Physical therapy is regarded as an essential aspect in achieving optimal outcomes following total knee arthroplasty (TKA). The coronavirus disease 2019 (COVID-19) pandemic has made face-to-face rehabilitation inaccessible. Virtual reality (VR) is increasingly regarded as a potentially effective option for offering health care interventions. This systematic review and meta-analysis investigate VR-based rehabilitation's effectiveness on outcomes following TKA. METHODS: From inception to May 22, 2021, PubMed/Medline, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, Scopus, PsycINFO, Physiotherapy Evidence Database, China National Knowledge Infrastructure, and Wanfang were comprehensively searched to identify randomized controlled trials (RCTs) evaluating the effect of VR-based rehabilitation on patients following TKA according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: Eight studies were included in the systematic review, and seven studies were included in the meta-analysis. VR-based rehabilitation significantly improved visual analog scale (VAS) scores within 1 month (standardized mean difference [SMD]: -0.44; 95% confidence interval [CI]: -0.79 to -0.08, P = 0.02), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) within 1 month (SMD: -0.71; 95% CI: -1.03 to -0.40, P < 0.01), and the Hospital for Special Surgery Knee Score (HSS) within 1 month and between 2 months and 3 months (MD: 7.62; 95% CI: 5.77 to 9.47, P < 0.01; MD: 10.15; 95% CI: 8.03 to 12.27, P < 0.01; respectively) following TKA compared to conventional rehabilitation. No significant difference was found in terms of the Timed Up and Go (TUG) test. CONCLUSIONS: VR-based rehabilitation improved pain and function but not postural control following TKA compared to conventional rehabilitation. More high-quality RCTs are needed to prove the advantage of VR-based rehabilitation. As the COVID-19 pandemic continues, it is necessary to promote this rehabilitation model.

Clinical and radiological results of high offset tri-lock bone preservation stem in unilateral primary total hip arthroplasty at a minimum follow-up of 3 years.

BACKGROUND: Although the high offset Tri-Lock bone preservation stem (BPS) was used widely, few studies explored the clinical and radiological results. The purpose of this study was to determine the clinical and radiological results of high offset Tri-Lock BPS in unilateral primary total hip arthroplasty (THA) at a minimum follow-up of 3 years. METHODS: 55 patients who underwent cementless THA with high offset Tri-lock BPS from 2017 to 2018 were followed for a minimum follow-up of 3 years. Patients were assessed clinically for complications, Harris hip score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Oxford Hip Score (OHS). Femoral offset (FO), acetabular offset (AO), hip offset (HO), HO difference, and leg length discrepancy (LLD) were measured on the anteroposterior (AP) pelvic radiograph. Standard pelvic AP and lateral radiographs were used to evaluate for evidence of bone ingrowth, stem subsidence, stem alignment, radiolucent line around the stem, osteolysis, loosening, ectopic ossification, and femoral stress shielding. RESULTS: No patients reported complications during hospitalization nor the follow-up period. At a mean follow-up of 42.5 months, the mean HHS, WOMAC, and OHS scores showed a significant improvement from preoperative to the latest follow-up. No patients reported thigh pain. No revision nor sign of radiographic loosening had been detected. The high offset Tri-Lock BPS significantly improved the FO and HO postoperatively. HO difference and LLD were balanced postoperatively. No sign of stem subsidence, radiolucent line, osteolysis, loosening, ectopic ossification, nor severe stress shielding (more than grade 3-4) were observed at the latest follow-up. CONCLUSION: The high offset Tri-Lock BPS demonstrated excellent clinical and radiographic outcomes at a minimum follow-up of 3 years. HO difference and LLD between legs decreased significantly and achieved balance postoperatively. Long-term follow-up is required for a definitive conclusion.

Clinical, functional and radiographic outcomes of primary total hip arthroplasty between direct anterior approach and posterior approach: a systematic review and meta-analysis.

BACKGROUND: The purpose of this systematic review and meta-analysis was to compare the direct anterior approach and posterior approach for primary total hip arthroplasty in terms of the clinical, functional and radiographic outcomes. METHODS: We searched the PubMed and EMBASE databases and Cochrane Library from their inception to November 1, 2019. We searched for previously published articles and meta-analyses of randomized controlled trials. RESULTS: A total of 7 randomized controlled trials with 600 participants met the inclusion criteria. Among these patients, 301 and 299 were included in the DAA and PA groups, respectively. The DAA was associated with a longer surgery by a mean duration of 13.74 min (95% CI 6.88 to 20.61, p < 0.0001, I2 = 93%). The postoperative early functional outcomes were significantly better in the DAA group than in the PA group, such as the Visual Analogue Scale (VAS) score at 1 day postoperatively (MD = -0.65, 95% CI - 0.91 to - 0.38, p < 0.00001, I2 = 0%), VAS score at 2 days postoperatively (MD = -0.67, 95% CI - 1.34 to - 0.01, p = 0.05, I2 = 88%) and Harris Hip Score (HHS) at 6 weeks postoperatively (MD = 6.05, 95% CI 1.14 to 10.95, p = 0.02, I2 = 52%). There was no significant difference between the DAA and PA groups in the length of the incision, hospital length of stay (LOS), blood loss, transfusion rates or complication rates. We found no significant difference between the two groups regarding late functional outcomes, such as the VAS score at 12 months postoperatively or the HHS scores at 3, 6, and 12 months postoperatively. A significant difference in the radiographic outcomes was not detected. CONCLUSIONS: The DAA requires a longer surgery time than does the PA in primary total hip arthroplasty. The DAA yields better early functional recovery than does the PA. There was no significant difference between the two groups in terms of other clinical, complication-related, late functional or radiographic outcomes. The evidence on the superiority of the DAA is insufficient and needs to be studied further.