Heat and Acupuncture to Manage Osteoarthritis of the Knee (HARMOKnee): Protocol for an Effectiveness-Implementation Hybrid Randomized Controlled Trial.

BACKGROUND: Knee osteoarthritis (KOA) is one of most prevalent and fastest-growing causes of pain, impaired mobility, and poor quality of life in the rapidly aging population worldwide. There is a lack of high-quality evidence on the efficacy of traditional Chinese medicine (TCM), particularly acupuncture, and a lack of KOA practice guidelines that are tailored to unique population demographics and tropical climates. OBJECTIVE: Our HARMOKnee (Heat and Acupuncture to Manage Osteoarthritis of the Knee) trial aims to address these gaps by evaluating the short- and medium-term clinical and cost-effectiveness of acupuncture with heat therapy in addition to standard care, compared to standard care alone. Through a robust process and economic evaluation, we aim to inform evidence-based practice for patients with KOA to facilitate the large-scale implementation of a comprehensive and holistic model of care that harmonizes elements of Western medicine and TCM. We hypothesize that acupuncture with heat therapy as an adjunct to standard care is clinically more effective than standard care alone. METHODS: A multicenter, pragmatic, parallel-arm, single-blinded, effectiveness-implementation hybrid randomized controlled trial will be conducted. We intend to recruit 100 patients with KOA randomized to either the control arm (standard care only) or intervention arm (acupuncture with heat therapy, in addition to standard care). The inclusion criteria are being a community ambulator and having primary KOA, excluding patients with secondary arthritis or previous knee replacements. The primary outcome measure is the Knee Osteoarthritis Outcome Score at 6 weeks. Secondary outcome measures include psychological, physical, quality of life, satisfaction, and global outcome measures at 6, 12, and 26 weeks. A mixed method approach through an embedded process evaluation will facilitate large-scale implementation. An economic evaluation will be performed to assess financial sustainability. RESULTS: Patient enrollment has been ongoing since August 2022. The recruitment process is anticipated to conclude by July 2024, and the findings will be analyzed and publicized as they are obtained. As of November 6, 2023, our patient enrollment stands at 65 individuals. CONCLUSIONS: The findings of our HARMOKnee study will contribute substantial evidence to the current body of literature regarding the effectiveness of acupuncture treatment for KOA. Additionally, we aim to facilitate the creation of standardized national guidelines for evidence-based practice that are specifically tailored to our unique population demographics. Furthermore, we seek to promote the adoption and integration of acupuncture and heat therapy into existing treatment models. TRIAL REGISTRATION: ClinicalTrials.gov NCT05507619; https://clinicaltrials.gov/study/NCT05507619. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54352.

Budget impact of the Walk With Ease program for knee osteoarthritis.

Objective: Walk With Ease (WWE) is an effective low-cost walking program. We estimated the budget impact of implementing WWE in persons with knee osteoarthritis (OA) as a measure of affordability that can inform payers' funding decisions. Methods: We estimated changes in two-year healthcare costs with and without WWE. We used the Osteoarthritis Policy (OAPol) Model to estimate per-person medical expenditures. We estimated total and per-member-per-month (PMPM) costs of funding WWE for a hypothetical insurance plan with 75,000 members under two conditions: 1) all individuals aged 45+ with knee OA eligible for WWE, and 2) inactive and insufficiently active individuals aged 45+ with knee OA eligible. In sensitivity analyses, we varied WWE cost and efficacy and considered productivity costs. Results: With eligibility unrestricted by activity level, implementing WWE results in an additional $1,002,408 to the insurance plan over two years ($0.56 PMPM). With eligibility restricted to inactive and insufficiently active individuals, funding WWE results in an additional $571,931 over two years ($0.32 PMPM). In sensitivity analyses, when per-person costs of $10 to $1000 were added with 10-50% decreases in failure rate (enhanced sustainability of WWE benefits), two-year budget impact varied from $242,684 to $6,985,674 with unrestricted eligibility and from -$43,194 (cost-saving) to $4,484,122 with restricted eligibility. Conclusion: Along with the cost-effectiveness of WWE at widely accepted willingness-to-pay thresholds, these results can inform payers in deciding to fund WWE. In the absence of accepted thresholds to define affordability, these results can assist in comparing the affordability of WWE with other behavioral interventions.

Assessment of occupational musculoskeletal disorders (MSDs) among heavy vehicle drivers.

BACKGROUND: Professional driving requires long hours of work, uncomfortable seats, negotiating rough terrain and highways, and possibly minor repairs and other auxiliary transportation duties. Heavy vehicle drivers driving vehicles such as trucks, bulldozers, etc. due to such working structures are more prone to various musculoskeletal disorders (MSDs) and pain, which is of great concern. OBJECTIVES: In the present study, it is planned to investigate possible ergonomic risk factors such as age, weight, driving exposure, seat suspension systems, lifting heavy weights causing MSDs in drivers of various heavy vehicles. The results of the study are expected to help drivers reduce the risk of MSDs. METHODS: For the present study, the Nordic questionnaire on musculoskeletal disorders was modified and standardized and was administered to the 48 heavy vehicle drivers randomly selected to collect the data. RESULTS: The analysis divulged that over the past 12 months, lower back pain (LBP) emerged as the most dominant pain experienced by 56% of drivers, followed by knee pain (KP) (43%) and neck pain (NP) (39%) respectively. The prevalence of shoulder pain (SP) was observed to be much lower than in previous literature. The logistic regression model further revealed that increasing age, poor suspension system and poor body posture were significantly associated with lower back pain. Additionally, a poor suspension system and lifting heavy weights had significant effect on the drivers' knee pain. CONCLUSION: The results demonstrated the evident necessity for ergonomic consideration in vehicle designing and ergonomic training for heavy vehicle drivers.

Ambulatory knee arthroscopic surgery yields cost savings and improved health outcomes.

PURPOSE: This study measured the health-related quality of life (HRQoL) and costs and conducted a cost-utility analysis and budget impact analysis of ambulatory knee arthroscopic surgery compared with inpatient knee arthroscopic surgery in Thailand from a societal perspective. METHODS: Health outcomes were measured in units of quality-adjusted life year (QALY) based on the Thai version of the EQ-5D-5L Health Questionnaire, and costs were obtained from an electronic database at a tertiary care hospital (Ramathibodi Hospital). A cost-utility analysis was performed to evaluate ambulatory and inpatient surgery using the societal perspective and a 2-week time horizon. The incremental cost-effectiveness ratio was applied to examine the costs and QALYs. One-way sensitivity analysis was used to investigate the robustness of the model. Budget impact analysis was performed considering over 5 years. RESULTS: A total of 161 knee arthroscopic patients were included and divided into two groups: ambulatory surgery (58 patients) and inpatient surgery (103 patients). The total cost of the inpatient surgery was 2235 United States dollars (USD), while the ambulatory surgery cost was 2002 USD. The QALYs of inpatient surgery and ambulatory surgery were 0.79 and 0.81, respectively, resulting in the ambulatory surgery becoming a dominant strategy (cost reduction of 233 USD with an increase of 0.02 QALY) over the inpatient surgery. The ambulatory surgery led to net savings of 4.5 million USD over 5 years. Medical supply costs are one of the most influential factors affecting the change in results. CONCLUSION: Ambulatory knee arthroscopic surgery emerged as a cost-saving strategy over inpatient surgery, driven by lower treatment costs and enhanced HRQoL. Budget impact analysis indicated net savings over 5 years, supporting the feasibility of adopting ambulatory knee arthroscopic surgery. Our findings were advocated for its application across diverse hospitals and informed policymakers to improve reimbursement systems in low- to middle-income countries and Thailand. LEVEL OF EVIDENCE: Level IV.

Modelled cost-effectiveness analysis of the Support and Treatment After Replacement (STAR) care pathway for chronic pain after total knee replacement compared with usual care.

BACKGROUND: The aim of the study was to estimate the long-term cost-effectiveness of the Support and Treatment After Replacement (STAR) care pathway for chronic pain after total knee replacement compared with usual postoperative care. METHODS: Study design: A decision-analytic (cohort Markov) model was used for the simulation with time dependent annual transition probabilities and a time horizon of five years. SETTING: Patients treated by National Health Service (NHS) hospitals in England and Wales. STUDY POPULATION: Adults classified as having chronic pain three months after undergoing a total knee replacement. INTERVENTION: The STAR care pathway following a total knee replacement. COMPARATOR: Usual postoperative care following a total knee replacement. PERSPECTIVE: The study was undertaken from the perspective of the NHS. OUTCOME MEASURES: Quality-adjusted life years and healthcare costs. Discounting: A rate of 3.5% for both costs and health utility. RESULTS: Model results indicate that the STAR intervention would dominate current practice by providing a gain in quality-adjusted life years (QALYs) of 0.086 and a reduction of £375 (per person) in costs over the first five years. The incremental net monetary benefit of the STAR intervention was estimated at £2,086 (at a threshold of £20,000 per QALY). Probabilistic sensitivity analysis suggests the STAR intervention is likely to be cost-effective with a probability of 0.62. The results remain robust to changes in model assumptions on comparator utility and the timing of the start of the intervention. If hospital admission costs are assumed not to be reduced by the STAR intervention, it would no longer be cost saving, but it would likely be cost-effective based on probabilistic sensitivity analysis (0.59). CONCLUSION: Evidence from the economic model suggests that the STAR care pathway is likely to be cost-effective and potentially dominant from an NHS perspective. TRIAL REGISTRATION: The STAR trial is registered with ISRCTN, ISRCTN92545361.

The Difference in the Assessment of Knee Extension/Flexion Angles during Gait between Two Calibration Methods for Wearable Goniometer Sensors.

Frontal and axial knee motion can affect the accuracy of the knee extension/flexion motion measurement using a wearable goniometer. The purpose of this study was to test the hypothesis that calibrating the goniometer on an individual's body would reduce errors in knee flexion angle during gait, compared to bench calibration. Ten young adults (23.2 ± 1.3 years) were enrolled. Knee flexion angles during gait were simultaneously assessed using a wearable goniometer sensor and an optical three-dimensional motion analysis system, and the absolute error (AE) between the two methods was calculated. The mean AE across a gait cycle was 2.4° (0.5°) for the on-body calibration, and the AE was acceptable (<5°) throughout a gait cycle (range: 1.5-3.8°). The mean AE for the on-bench calibration was 4.9° (3.4°) (range: 1.9-13.6°). Statistical parametric mapping (SPM) analysis revealed that the AE of the on-body calibration was significantly smaller than that of the on-bench calibration during 67-82% of the gait cycle. The results indicated that the on-body calibration of a goniometer sensor had acceptable and better validity compared to the on-bench calibration, especially for the swing phase of gait.

Computational assessment of carbon fabric reinforced polymer made prosthetic knee: Mechanics, finite element simulations and experimental evaluation.

A prosthetic knee is designed to replace the functionality of an anatomical knee in transfemoral amputees. The purpose of a prosthetic knee is to restore mobility and compensate amputees for their impairment. In the present research numerical modelling and simulation of a carbon fabric reinforced polymer made polycentric prosthetic knee with four-bar mechanism was performed. Virtual prototyping with computer-aided design and computer-aided engineering software ensured geometric and structural stability of the knee design. The linkage mechanism, instantaneous centre's location and trajectory were investigated using multibody dynamics and analytical formulations. Computational simulations with a non-linear finite element model were employed with joints, contact formulations and an orthotropic material model to predict the displacement, stress formulated and life of the knee prosthesis under static and cyclic loading conditions. Finite element analysis assessed the strength and durability of knee in accordance to standards. Maximum Principal stress of 155 MPa and life expectancy of 3.1 × 106 cycles were determined for the composite knee through numerical simulations ensuring a safe design. Experimental testing was also conducted as per standards and the percentage error was estimated to be 2.52%, thereby establishing the validity of the finite element model deployed. This type of simulation-based approach can be implemented to efficiently and affordably design and prototype a prosthetic knee with desired functioning criteria.

The Impact of Different Regions of Interest on Shear Wave Elastography Assessment of the Meniscus in the Knee Joint.

RATIONALE AND OBJECTIVES: To investigate the impact of different regions of interest (ROI) on the assessment of shear wave elastography (SWE) in evaluating the meniscus of the knee joint. MATERIALS AND METHODS: After ethical approval, a total of 141 participants were enrolled in this prospective study from February to October 2023. SWE was utilized to evaluate the anterior horn of the lateral meniscus (LM) and medial meniscus (MM), using two different ROIs (ROI-Small and ROI-Trace) to measure the elastic mean value (Emean) and elastic maximum value (Emax). The differences in elasticity values between the normal menisci and torn menisci were compared, and the impact of different ROI selection methods on the diagnostic performance of elastic parameters in the torn menisci was assessed using receiver operating characteristic (ROC) curves. RESULTS: In Emean comparison, only MM in the tear group showed higher ROI-S than ROI-T. When comparing Emax, all ROI-T values were higher than the ROI-S values, and this difference was statistically significant. Different sizes of ROI did not significantly impact the diagnostic performance of Emean in LM and MM, nor the diagnostic effectiveness of Emax in LM. However, only the area under the curve (AUC) of MM for Emax in both ROI-S and ROI-T showed a statistically significant difference. CONCLUSION: The shear wave elasticity values and diagnostic performance may vary depending on the ROI settings. Therefore, it is recommended to use a 2 mm diameter ROI placed at the central position of the meniscus, with Emean as the elasticity index.

Assessment of the effectiveness of weight-adjusted antibiotic administration, for reduced duration, in surgical prophylaxis of primary hip and knee arthroplasty.

BACKGROUND: Prophylactic antibiotics have significantly led to a reduction in the risk of post-operative surgical site infections (SSI) in orthopaedic surgery. The aim of using antibiotics for this purpose is to achieve serum and tissue drug levels that exceed, for the duration of the operation, the minimum inhibitory concentration of the likely organisms that are encountered. Prophylactic antibiotics reduce the rate of SSIs in lower limb arthroplasty from between 4% and 8% to between 1% and 3%. Controversy, however, still surrounds the optimal frequency and dosing of antibiotic administration. AIM: To evaluate the impact of introduction of a weight-adjusted antibiotic prophylaxis regime, combined with a reduction in the duration of administration of post-operative antibiotics on SSI incidence during the 2 years following primary elective total hip and knee arthroplasty. METHODS: Following ethical approval, patients undergoing primary total hip arthroplasty (THA)/total knee arthroplasty (TKA) with the old regime (OR) of a preoperative dose [cefazolin 2 g intravenously (IV)], and two subsequent doses (2 h and 8 h), were compared to those after a change to a new regime (NR) of a weight-adjusted preoperative dose (cefazolin 2 g IV for patients < 120 kg; cefazolin 3g IV for patients > 120 kg) and a post-operative dose at 2 h. The primary outcome in both groups was SSI rates during the 2 years post-operatively. RESULTS: A total of n = 1273 operations (THA n = 534, TKA n = 739) were performed in n = 1264 patients. There was no statistically significant difference in the rate of deep (OR 0.74% (5/675) vs NR 0.50% (3/598); fishers exact test P = 0.72), nor superficial SSIs (OR 2.07% (14/675) vs NR 1.50% (9/598); chi-squared test P = 0.44) at 2 years post-operatively. With propensity score weighting and an interrupted time series analysis, there was also no difference in SSI rates between both groups [RR 0.88 (95%CI 0.61 to 1.30) P = 0.46]. CONCLUSION: A weight-adjusted regime, with a reduction in number of post-operative doses had no adverse impact on SSI incidence in this population.

Shorter length of stay and significant cost savings with ambulatory surgery primary unilateral total knee arthroplasty in Asians using enhanced recovery protocols.

Introduction: Enhanced recovery after surgery (ERAS) in total knee arthroplasty (TKA) has reduced the length of stay (LOS) and cost of TKA in the Western population. Asians had been identified to be at higher odds of non-home discharge following TKA due to cultural differences. The efficacy of ERAS in TKA for Asian patients is less known. We aimed to investigate the efficacy of ERAS in reducing the LOS, transition to ambulatory surgery, improving home discharges, and reducing cost in an Asian population following TKA. Methods: Retrospective analysis was performed on 634 TKA patients in 2017 (pre- ERAS) and 584 TKA patients who had undergone ERAS in 2022 in a tertiary hospital. Results: Patients in 2022 (ERAS) were older (69 ± 7 vs. 68 ± 7 years old, p < 0.001) and had a higher proportion of patients with poorer function (p < 0.001). The LOS reduced from 5.4 days (95% CI:5.2-5.6) to 2.9 days (95% CI:2.7-3.2) (p < 0.001) with about 49 % of patients transitioning to ambulatory surgery and having a LOS of 1.4 days (95 %CI:1.3-1.5). The proportion of patients being discharged home in 2022 (78.9 %) was higher compared to 2017 (62.2 %) (p < 0.001). This saved the hospital 1817.4 inpatient ward bed days, which translated to S$2,124,540.60 of cost saving in a year, and up to S$2397.28 for the individual patient. Conclusion: ERAS after TKA was able to safely achieve LOS comparable to the western population and allowed transition to ambulatory knee replacement in the Asian population. Consequently, this led to higher proportion of home discharges and achieved significant cost saving and hospital bed days.

Comparing risk assessment methods for work-related musculoskeletal disorders with in vivo joint loads during manual materials handling.

The validity of observational methods in ergonomics is still challenging research. Criterion validity in terms of concurrent validity is the most commonly studied. However, studies comparing observational methods with biomechanical values are rare. Thus, the aim of this study is to compare the Ovako Working Posture Analysing System (OWAS) and the Rapid Entire Body Assessment (REBA) with in vivo load measurements at hip, spine, and knee during stoop and squat lifting of 14 participants. The results reveal that OWAS and REBA action levels (AL) can distinguish between different in vivo load measurements during manual lifting. However, the results also reveal that the same OWAS- and REBA-AL do not necessarily provide equal mean values of in vivo load measurements. For example, resultant contact force in the vertebral body replacement for squat lifting ranged from 57% body weight (%BW) in OWAS-AL1 to 138%BW in OWAS-AL3 compared to 46%BW in REBA-AL0 and 173%BW in REBA-AL3. Furthermore, the results suggest that the performed squat lifting techniques had a higher risk for work-related musculoskeletal disorders than the performed stoop lifting techniques.

Understanding economic analysis and cost-effectiveness of CT scan-guided, 3-dimensional, robotic-arm assisted lower extremity arthroplasty: a systematic review.

Aim: The overall goal of this review was to examine the cost-utility of robotic-arm assisted surgery versus manual surgery. Methods: We performed a systematic review of all health economic studies that compared CT-based robotic-arm assisted unicompartmental knee arthroplasty, total knee arthroplasty and total hip arthroplasty with manual techniques. The papers selected focused on various cost-utility measures. In addition, where appropriate, secondary aims encompassed various clinical outcomes (e.g., readmissions, discharges to subacute care, etc.). Only articles directly comparing CT-based robotic-arm assisted joint arthroplasty with manual joint arthroplasty were included, for a resulting total of 21 reports. Results: Almost all twenty-one studies demonstrated a positive effect of CT scan-guided robotic-assisted joint arthroplasty on health economic outcomes. For studies reporting on 90-day episodes of costs, 10 out of 12 found lower costs in the robotic-arm assisted groups. Conclusion: Robotic-arm assisted joint arthroplasty patients had shorter lengths of stay and cost savings based on their 90-day episodes of care, among other metrics. Payors would likely benefit from encouraging the use of this CT-based robotic technology.

The multidisciplinary team in the management of chronic pain and pain-related fear: an evidence-based approach in a clinical case.

PURPOSE: Pain is a complex, intimate, and subjective experience influenced by biological, psychological, and social factors. This case report investigates the effectiveness of a multidisciplinary team approach in addressing chronic pain and pain-related fear. CASE DESCRIPTION: The case report describes a 22-year-old female who experienced anterior knee pain for seven years, despite undergoing two knee surgeries and physiotherapy without improvement. Following a comprehensive assessment, which included a detailed medical history, clinical examination, and thoughtful clinical analysis, a multidisciplinary approach was recommended. Employing an evidence-based methodology that integrated neurocognitive rehabilitation techniques, including Pain Neuroscience Education, Graded Motor Imagery, and Tactile Discrimination Training, alongside psychological rehabilitation strategies such as Mindfulness, Acceptance and Commitment Therapy, and Problem-Solving Therapy, the report presents a comprehensive in-depth rehabilitation plan exemplifying the application of this multimodal approach within a clinical setting in a patient with chronic pain. This approach is designed not to address the biomechanical aspects but to delve into the cognitive facets associated with pain perception and avoidance, as well as potential psychological factors that may be influencing the onset and persistence of symptoms. OUTCOMES: The scores from the rating scales provided valuable insights into patient progress in pain management, functional improvement, fear of movement, and overall physical, psychological, and emotional well-being, at six months. CONCLUSION: This case report offers valuable insights into the usefulness of this multidisciplinary and multimodal approach, highlighting its potential as an avenue in the management of chronic pain and pain-related fear.

REST: a preoperative tailored sleep intervention for patients undergoing total knee replacement - feasibility study for a randomised controlled trial.

OBJECTIVES: To test the feasibility of a randomised controlled trial (RCT) of a novel preoperative tailored sleep intervention for patients undergoing total knee replacement. DESIGN: Feasibility two-arm two-centre RCT using 1:1 randomisation with an embedded qualitative study. SETTING: Two National Health Service (NHS) secondary care hospitals in England and Wales. PARTICIPANTS: Preoperative adult patients identified from total knee replacement waiting lists with disturbed sleep, defined as a score of 0-28 on the Sleep Condition Indicator questionnaire. INTERVENTION: The REST intervention is a preoperative tailored sleep assessment and behavioural intervention package delivered by an Extended Scope Practitioner (ESP), with a follow-up phone call 4 weeks postintervention. All participants received usual care as provided by the participating NHS hospitals. OUTCOME MEASURES: The primary aim was to assess the feasibility of conducting a full trial. Patient-reported outcomes were assessed at baseline, 1-week presurgery, and 3 months postsurgery. Data collected to determine feasibility included the number of eligible patients, recruitment rates and intervention adherence. Qualitative work explored the acceptability of the study processes and intervention delivery through interviews with ESPs and patients. RESULTS: Screening packs were posted to 378 patients and 57 patients were randomised. Of those randomised, 20 had surgery within the study timelines. An appointment was attended by 25/28 (89%) of participants randomised to the intervention. Follow-up outcomes measures were completed by 40/57 (70%) of participants presurgery and 15/57 (26%) postsurgery. Where outcome measures were completed, data completion rates were 80% or higher for outcomes at all time points, apart from the painDETECT: 86% complete at baseline, 72% at presurgery and 67% postsurgery. Interviews indicated that most participants found the study processes and intervention acceptable. CONCLUSIONS: This feasibility study has demonstrated that with some amendments to processes and design, an RCT to evaluate the clinical and cost-effectiveness of the REST intervention is feasible. TRIAL REGISTRATION NUMBER: ISRCTN14233189.

Infection in osteotomy around the knee: Incidence, management and outcomes in a high-volume case series.

PURPOSE: Current evidence around the management of osteotomy-related infection is insufficient to robustly underpin the expert statements formulated by a recent European consensus statement. We present a review of a large case series in a high-volume osteotomy practice to contribute to the understanding of the incidence, management and outcome of infection in this subspecialty area. METHODS: Analyses of two prospectively collected databases for all osteotomy around the knee and infections related to osteotomy were performed, along with a review of hospital readmission data to capture all osteotomy-related infections. Clinical notes were reviewed to assess patient demographics, incidence of infection, how infection was managed and clinical outcome. RESULTS: In a series of 822 osteotomies in 755 patients, there were 21 (2.8%) cases of suspected infection. Twelve (1.6%) were contemporaneously deemed 'superficial' and nine confirmed 'deep' infections (1.2%). Deep infections were all successfully managed with wound debridement, with or without plate removal, depending on union and time from initial surgery. One of these infections was noted during a revision procedure, but no revision was carried out as a direct result of infection, no external fixation was required and no infected nonunions were experienced. CONCLUSION: All of the cases in this series were managed successfully with debridement ± removal of the plate, without the need for revision or external fixation. Any potential signs of infection around an osteotomy, especially in the case of medial high tibial osteotomy, should raise awareness for deep infection and the need for further surgery due to the limited overlying soft tissue cover. This evidence supports the recent European Society of Sports Traumatology, Knee Surgery and Arthroscopy algorithm. LEVEL OF EVIDENCE: Level IV, case series.

Prospective assessment of functional and clinical results of surgical patellar stabilization in rural and urban populations. Equal chance to success?

INTRODUCTION AND OBJECTIVE: Patella dislocation represents 3.3% of all knee injuries often leading to persistent instability. Medial patello-femoral ligament(MPFL) reconstruction is the standard method of treatment in the patellar instability. Rehabilitation after MPFL-R is a long and demanding procedure. The hypothesis presented reflects the idea that despite relatively good access to hospital care and surgical options, the post-operative rehabilitation care system is still inferior in rural areas versus the one offered in major cities and towns. MATERIAL AND METHODS: Between January 2015 - January 2018, 47 patients met the study inclusion criteria, diagnosed and operated on due to patellar instability. 8 patients were lost for full follow-up. Finally, 39 patients were included, divided into two groups - group A (19 from cities), group B (20 from rural area). Prospective KOOS and Kujala scales assessments were conducted: preoperative, 6 and 12 months after surgery. Knee isokinetic muscle strength was measured at 3 stages; prior to surgery, 6 and 12 months after reconstruction. RESULTS: All patients showed significant improvement measured in the KOOS and Kujala scales after the procedure, compared to the pre-operational results. Despite equal clinical improvement, patients from Group A(city) achieved better functional outcomes as presented in the results of knee extensor functional tests using a Biodex dynamometer. CONCLUSIONS: Rehabilitation after MPFL reconstruction improves muscle strength and clinical outcome. Patients from rural areas had inferior functional results in comparison to the patients from major cities, even 12 months after surgical patella stabilization. Despite the development of roads and transport according to the EU cohesion policy, there are still differences in rehabilitation results between rural and city areas.

Analysis of the incidence and risk factors of blood transfusion in total knee revision: a retrospective nationwide inpatient sample database study.

OBJECTIVE: This study sought to determine the incidence and risk factors of blood transfusion among patients undergoing total knee revision (TKR) using a nationwide database. METHODS: A retrospective data analysis was conducted based on the Nationwide Inpatient Sample (NIS), enrolling patients who underwent TKR from 2010 to 2019 with complete information. The patients were divided into two groups based on whether they received blood transfusion or not. The demographic characteristics (race, sex, and age), length of stay (LOS), total charge of hospitalization, hospital characteristics (admission type, insurance type, bed size, teaching status, location, and region of hospital), hospital mortality, comorbidities, and perioperative complications were analyzed. Finally, we conducted univariate and multivariate logistic regression to identify factors that were associated with TKR patients to require blood transfusion. RESULTS: The NIS database included 115,072 patients who underwent TKR. Among them, 14,899 patients received blood transfusion, and the incidence of blood transfusion was 13.0%. There was a dramatic decrease in the incidence over the years from 2010 to 2019, dropping from 20.4 to 6.5%. TKR patients requiring transfusions had experienced longer LOS, incurred higher total medical expenses, utilized Medicare more frequently, and had increased in-hospital mortality rates (all P < 0.001). Independent predictors for blood transfusion included advanced age, female gender, iron-deficiency anemia, rheumatoid disease, chronic blood loss anemia, congestive heart failure, coagulopathy, uncomplicated diabetes, lymphoma, fluid and electrolyte disorders, metastatic carcinoma, other neurological diseases, paralysis, peripheral vascular disorders, pulmonary circulation disorders, renal failure, valvular disease, and weight loss. In addition, risk factors for transfusion in TKR surgery included sepsis, acute myocardial infarction, deep vein thrombosis, pulmonary embolism, gastrointestinal bleeding, heart failure, renal insufficiency, pneumonia, wound infection, lower limb nerve injury, hemorrhage/seroma/hematoma, wound rupture/non healing, urinary tract infection, acute renal failure, and postoperative delirium. CONCLUSIONS: Our findings highlight the importance of recognizing the risk factors of blood transfusion in TKR to reduce the occurrence of adverse events.

Examining racial disparities in utilization rate and perioperative outcomes following knee and hip arthroplasty.

BACKGROUND: Previous arthroplasty utilization research predominantly examined Black and White populations within the US. This is the first known study to examine utilization and complications in poorly studied minority racial groups such as Asians and Native Hawaiian/Pacific-Islanders (NHPI) as compared to Whites. RESULTS: Data from 3304 primary total hip and knee arthroplasty patients (2011 to 2019) were retrospectively collected, involving 1789 Asians (52.2%), 1164 Whites (34%) and 320 Native Hawaiians/Pacific Islanders (NHPI) (9.3%). The 2012 arthroplasty utilization rates for Asian, White, and NHPI increased by 32.5%, 11.2%, and 86.5%, respectively, by 2019. Compared to Asians, Whites more often underwent hip arthroplasty compared to knee arthroplasty (odds ratio (OR) 1.755; p < 0.001). Compared to Asians, Whites and NHPI more often received total knee compared to unicompartmental knee arthroplasty (White: OR 1.499; NHPI: OR 2.013; p < 0.001). White patients had longer hospitalizations (2.66 days) compared to Asians (2.19 days) (p = 0.005) following bilateral procedures. Medicare was the most common insurance for Asians (66.2%) and Whites (54.2%) while private insurance was most common for NHPI (49.4%). Compared to Asians, economic status was higher for Whites (White OR 0.695; p < 0.001) but lower for NHPI (OR 1.456; p < 0.001). After controlling for bilateral procedures, NHPI had a lower risk of transfusion compared to Asians (OR 0.478; p < 0.001) and Whites had increased risk of wound or systemic complications compared to Asians (OR 2.086; p = 0.045). CONCLUSIONS: Despite NHPI demonstrating a significantly poorer health profile and lower socioeconomic status, contrary to previous literature involving minority racial groups, no significant overall differences in arthroplasty utilization rates or perioperative complications could be demonstrated amongst the racial groups examined.

Test-retest reliability and concurrent validity assessment of a novel high-frequency sensor device for anterior tibial translation measurement in loaded and unloaded condition: an exploratory cross-sectional study.

BACKGROUND: Magnetic resonance imaging (MRI) and manual tests remain the standard for diagnosing anterior cruciate ligament (ACL) rupture. Furthermore, the passive knee displacement, also described as anterior tibial translation (ATT), is used in order to make decisions about surgery or to assess rehabilitation outcomes. Unfortunately, these manual tests are limited to passive situations, and their application to assess knee stability in loaded, weight-bearing positions are missing. Therefore, a new device with high-performance sensors and a new sensor setting was developed. The aim of this exploratory cross-sectional study was to assess the test-retest reliability of this new device in a first step and the concurrent validity in a second step. METHODS: A total of 20 healthy volunteers were measured. Measurement consistency of the new device was assessed on the basis of reliability during Lachman test setting and in loaded position by artificial knee perturbation in a test-retest procedure. In a second step, the concurrent validity was evaluated with the Lachmeter® as a reference instrument. Intraclass correlation coefficient (ICC), standard error of measurement (SEM), the minimal detectable change (MDC) and Bland-Altman analysis were evaluated to assess the quality criteria. RESULTS: The measurements with the new device during the Lachman test provided a mean ATT of 5.46±2.22mm. The SEM ranged from 0.60 to 0.69mm resulting in an MDC between 1.67 and 1.93mm for the new device. In the loaded test situation, the mean ATT was 2.11±1.20mm, with test-retest reliability also showing good correlation (r>0.83). The comparison of the two measurement methods with an ICC of (r>0.89) showed good correlation, which also underlines the reasonable agreement of the Bland-Altman analysis. CONCLUSIONS: The evaluation of the test-retest reliability of the new device during the knee stability testing in passive situation as well as in a functional, loaded situation presented good reliability. In addition, the new device demonstrated good agreement with the reference device and therefore good validity. Furthermore, the quality criteria demonstrated the ability of the new device to detect the cut-off value (3-5mm) described in the literature for the diagnosis of ACL-deficient knees, which underlines the clinical relevance of this new device as a reliable and valid tool.

Ambulatory total hip and knee arthroplasty: a literature review and perioperative considerations.

PURPOSE: Total joint arthroplasty (TJA), particularly for the hip and knee, is one of the most commonly performed surgical procedures. The advancement/evolution of surgical and anesthesia techniques have allowed TJA to be performed on an ambulatory/same-day discharge basis. In this Continuing Professional Development module, we synthesize the perioperative evidence that may aid the development of successful ambulatory TJA pathways. SOURCE: We searched MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews for ambulatory or fast-track TJA articles. In the absence of direct evidence for the ambulatory setting, we extrapolated the evidence from the in-patient TJA literature. PRINCIPAL FINDINGS: Patient selection encompassing patient, medical, and social factors is fundamental for successful same-day discharge of patients following TJA. Evidence for the type of intraoperative anesthesia favours neuraxial technique for achieving same day discharge criteria and reduced perioperative complications. Availability of short-acting local anesthetic for neuraxial anesthesia would affect the anesthetic choice. Nonetheless, modern general anesthesia with multimodal analgesia and antithrombotics in a well selected population can be considered. Regional analgesia forms an integral part of the multimodal analgesia regime to reduce opioid consumption and facilitate same-day hospital discharge, reducing hospital readmission. For ambulatory total knee arthroplasty, a combination of adductor canal block with local anesthetic periarticular infiltration provided is a suitable regional analgesic regimen. CONCLUSION: Anesthesia for TJA has evolved as such that same-day discharge will become the norm for selected patients. It is essential to establish pathways for early discharge to prevent adverse effects and readmission in this population. As more data are generated from an increased volume of ambulatory TJA, more robust evidence will emerge for the ideal anesthetic components to optimize outcomes.

RéSUMé: OBJECTIF: L'arthroplastie par prothèse totale (APT), en particulier de la hanche et du genou, constitue l'une des interventions chirurgicales les plus couramment pratiquées. L'avancement et l'évolution des techniques chirurgicales et d'anesthésie ont permis de réaliser une APT en ambulatoire/sur la base d'un congé le jour même. Dans ce module de développement professionnel continu, nous proposons une synthèse des données probantes périopératoires qui pourraient contribuer à l'élaboration de trajectoires réussies pour l'APT en ambulatoire. SOURCES: Nous avons réalisé des recherches dans MEDLINE, Embase, CENTRAL et dans la base de données Cochrane des revues systématiques à la recherche d'articles sur les APT ambulatoires ou accélérées. En l'absence de données probantes directes dans un contexte ambulatoire, nous avons extrapolé les données probantes à partir de la littérature sur les APT en milieu hospitalier. CONSTATATIONS PRINCIPALES: La sélection des patient·es englobant les facteurs patient·es, médicaux et sociaux est fondamentale pour un congé réussi le jour même après une APT. Les données probantes portant sur le type d'anesthésie peropératoire privilégient la technique neuraxiale pour respecter les critères de congé le jour même et réduire les complications périopératoires. La disponibilité d'un anesthésique local à courte durée d'action pour l'anesthésie neuraxiale affecterait le choix de l'anesthésique. Néanmoins, dans une population bien sélectionnée, l'anesthésie générale moderne avec analgésie multimodale et antithrombotiques peut être envisagée. L'analgésie régionale fait partie intégrante d'un régime d'analgésie multimodale visant à réduire la consommation d'opioïdes et à faciliter le congé de l'hôpital le jour même, ce qui réduit le nombre de réadmissions. En ce qui concerne l'arthroplastie totale du genou en ambulatoire, la combinaison d'un bloc du canal des adducteurs et d'une infiltration périarticulaire d'anesthésique local constitue un régime approprié d'analgésie régionale. CONCLUSION: L'anesthésie pour les APT a évolué de telle sorte que le congé le jour même deviendra la norme pour certain·es patient·es. Il est essentiel d'établir des trajectoires de congé précoce afin de prévenir les effets indésirables et la réadmission dans cette population. Au fur et à mesure que davantage de données seront générées à partir d'un volume accru d'APT en ambulatoire, des données probantes plus solides émergeront pour appuyer les composantes idéales de l'anesthésie pour optimiser les devenirs.