Preoperative prevalence of deep vein thrombosis in patients scheduled to have surgery for degenerative musculoskeletal disorders.

BACKGROUND: Although the incidence of symptomatic pulmonary thromboembolism after elective surgery for degenerative musculoskeletal disorders is comparatively low, it is extremely detrimental to both patients and health-care providers. Therefore, its prevention is mandatory. We aimed to perform a cross-sectional analysis of deep venous thrombosis (DVT) before elective surgery for degenerative musculoskeletal disorders, including total knee arthroplasty (TKA), total hip arthroplasty (THA), and spinal surgery, and identify the factors associated with the incidence of preoperative DVT. METHODS: The clinical data of patients aged ≥ 30 years who underwent TKA or THA, and spine surgery for lumbar or cervical degenerative disorders at our institution were retrospectively collected. D-dimer levels were measured preoperatively in all the patients scheduled for surgery. For the patients with D-dimer levels ≥ 1 µg/mL or who were determined by their physicians to be at high risk of DVT, the lower extremity vein was preoperatively examined for DVT on ultrasonography. RESULTS: Overall, we retrospectively evaluated 1236 consecutive patients, including 701 men and 535 women. Of the patients, 431 and 805 had D-dimer levels ≥ 1 and < 1 µg/mL, respectively. Of 683 patients who underwent lower extremity ultrasonography, 92 had proximal (n = 7) and distal types (n = 85) of DVT. The preoperative prevalence of DVT was 7.4 %. No patient had the incidence of postoperative symptomatic venous thromboembolism. A multivariate analysis revealed that age ≥ 80 years (odds ratio [OR], 95 % confidence interval [CI]: 2.8, 1.1-7.3), knee surgery (2.1, 1.1-4.0), American Society of Anesthesiologists (ASA) grade 2 (2.8, 1.2-6.8), ASA grades 3 or 4 (3.1, 1.0-9.4), and malignancy (1.9, 1.1-3.2) were significantly associated with DVT incidence. CONCLUSIONS: This is the first study to conduct a cross-sectional analysis of preoperative DVT data of patients scheduled for elective surgery for degenerative musculoskeletal disorders. Although whether screening for preoperative DVT is needed to prevent postoperative symptomatic pulmonary thromboembolism remains to be clarified, our data suggested that DVT should be noted before surgery in the patients with advanced age, knee surgery, high ASA physical status, and malignancy.

Efficacy of Chondroitin Sulfate for Painful Knee Osteoarthritis: A One-Year, Randomized, Double-Blind, Multicenter Clinical Study in Japan.

We explored the effects of chondroitin sulfate on knee osteoarthritis in a one-year, randomized, double-blind, dose-comparison study. Patients with painful, Kellgren-Lawrence grade 2-3, osteoarthritis of the knee were treated with oral chondroitin sulfate at a dose of either 260 mg/d (low-dose group, control group) or 1560 mg/d (high-dose group). Symptoms were evaluated by the Lequesne's index and visual analog scale for pain. We made subgroup analyses according to background symptom severity (Lequesne's index ≥8 or <8) in 73 patients. Serum level of cartilage oligomeric matrix protein and hyaluronic acid were also determined. In the subgroup with severe symptoms (Lequesne's index ≥8), the chondroitin sulfate dose of 1560 mg/d improved pain faster after 6 and 9 months' therapy. However, no dose-related effects were found on cartilage oligomeric matrix protein or hyaluronic acid levels. Chondroitin sulfate also had good tolerability. We conclude that chondroitin sulfate is useful for pain control in knee osteoarthritis.

Polypharmacy of Older Surgical Patients With Extremity Fractures.

Introduction: Fractures are often caused by falls in older people. Among various causes of falls, polypharmacy is known to be a risk of falls. Furthermore, potentially inappropriate medicines (PIMs), which interact with polypharmacy, include the drugs involved in falls. Here, we primarily aimed to investigate the prescribed drugs in older surgical patients with extremity fractures to determine the frequency of polypharmacy and identify PIMs. The second aim was to clarify the characterization of prescribed drugs of older patients with hip fracture. Materials and Methods: We retrospectively collected the following clinical data of consecutive patients aged ≥65 years who underwent surgery for extremity fractures at our hospital between April 2019 and March 2021. A total of 19 categories were considered as PIMs. The Poisson regression models were used to examine the association between the number of prescribed drugs and hip fracture prevalence. Results: A total of 590 patients were reviewed. Our data showed that 55% of older patients with extremity fractures took ≥6 prescription drugs. The frequency of prescription of hypnotics, antithrombotic drugs, diuretics, and non-steroidal anti-inflammatory drugs was comparatively high among the 19 categories of PIMs. Multivariable analysis revealed that polypharmacy was significantly associated with hip fractures. Among PIMs, antithrombotic drugs and diuretics were significantly associated with the prevalence of hip fractures. Finally, we found a significant positive association between the prevalence of hip fracture and the number of drug categories of PIMs among older patients with extremity fractures. Conclusions: The present study clarified the characterization of the prescribed drugs in older surgical patients with extremity fractures. Special attention should be paid to hip fractures of older patients with polypharmacy or prescribed with many drugs categories of PIMs, particularly antithrombotic drugs and diuretics.

Snapping knee due to the biceps femoris tendon treated with repositioning of the anomalous tibial insertion.

Snapping knee associated with biceps femoris tendon that caused lateral knee pain is reported. The long head of the biceps femoris tendon had an anomalous tibial insertion in addition to the direct arm and anterior arm on the fibular head. Resection of both the anomalous tibial insertion and the anterior arm was necessary to resolve the snapping. Level of evidence IV.

[Replacement arthroplasty for patients with rheumatoid arthritis].

Replacement arthroplasty is an excellent method to improve activities of daily living (ADL) and quality of life (QOL) in patients with rheumatoid arthritis (RA) . In many cases of RA, prosthetic surgery is carried out on multiple joints. When prosthetic surgery is performed in cases with severe knee contracture or joint destruction, surgical invasion can be extensive. Regarding timing of surgery, it is better while the joint is still somewhat intact, and as long as the operability conditions can be met, age is irrelevant. It is important not to delay the timing of surgery. This article mainly considers total knee arthroplasty (TKA).

Associations between Depressive Symptoms, Work Environment, and Lifestyle in <40-year-old Male Orthopedic Physicians in Japan.

Introduction: Efforts are being made to reduce doctors' working hours and implement reforms in the way doctors work. This study aims to determine the associations between depressive symptoms and work environment/lifestyle among <40-year-old male orthopedic physicians in Japan. Methods: Participants were 1,343 male orthopedic physicians selected from a survey (N = 25,139) of all regular members conducted in 2019 by the Japanese Orthopaedic Association. Participants completed the Quick Inventory of Depressive Symptomatology and provided information about total working hours, number of on-call/night duties, number of patient complaints received, smoking habits, exercise habits, and sleep time. Results: Of the participants, 6.6% had depressive symptoms. Factors associated with depressive symptoms were total working hours of ≥80 h per week (80-99 h: adjusted odds ratio [AOR] = 2.06; 95% confidence interval [CI], 1.02-4.18; ≥100 h: AOR = 3.89; 95% CI, 1.92-7.88), one or more unreasonable patient demands/complaints in the previous 6 months (AOR = 1.61; 95% CI, 1.00-2.60), current smoking (AOR = 2.98), no sweat-inducing exercise sessions of ≥30 min per week in the previous month (AOR = 2.50), and an average of <6 h of sleep per night in the previous month (AOR = 2.15). Conclusions: Work factors at the main medical institution (i.e., total working hours of ≥80 h per week) were associated with depressive symptoms. In addition, associations between depressive symptoms and unhealthy living conditions, such as smoking habits, lack of exercise, and <6 h of sleep per night, were observed.

Prescription drug survey of elderly patients with degenerative musculoskeletal disorders.

AIMS: Elderly patients with musculoskeletal disorders are generally expected to receive many prescription drugs for non-musculoskeletal comorbidities and for alleviating chronic musculoskeletal pains. The aims of this study were to review the use of prescription drugs in elderly patients with elective surgeries for musculoskeletal disorders and to identify the factors associated with polypharmacy in elderly patients with musculoskeletal disorders. METHODS: We retrospectively collected the clinical data of patients aged ≥65 years who underwent knee arthroplasty, total hip arthroplasty, or spinal surgery for lumbar or cervical degenerative disorders at our institution. The following data were evaluated: age, body mass index, sex, surgical site, prescription drugs used, American Society of Anesthesiologists physical status grade, and medical history, including hypertension, hyperlipidemia, diabetes, stroke, malignancy, and smoking. Polypharmacy was defined as the use of six or more drugs. RESULTS: In the present study, 767 consecutive patients were evaluated retrospectively. The prevalence of polypharmacy was >50% in the elderly patients with musculoskeletal disorders. The mean numbers of total drugs and pain relief medications were significantly higher in the lumbar surgery group than in the other surgery groups. Multivariable analysis revealed that the factors associated with polypharmacy were lumbar surgery, hypertension, hyperlipidemia, diabetes, and malignancy. CONCLUSIONS: This is the first study to cross-sectionally review the drugs prescribed to patients with degenerative musculoskeletal disorders. It clearly identified the factors associated with polypharmacy in elderly patients with degenerative musculoskeletal disorders. Particular attention should be paid to polypharmacy in elderly patients with lumbar degenerative disorders. Geriatr Gerontol Int 2022; 22: 121-126.

Which is better? Anterior or posterior referencing for femoral component position in total knee arthroplasty.

When sizing the femoral component or determining its placement in total knee arthroplasty (TKA), if the anterior-posterior diameter of the femoral condyle is between component sizes, the selected size will differ depending on whether anterior referencing (AR) or posterior referencing (PR) is used. As a result, the amount of resected bone will also vary. In the present prospective study, we compared the two referencing methods to determine which is more suitable for individual patients. We recruited 58 patients (92 joints) who received TKA using the standard technique with intermediate-size components. AR was used in 26 joints, and PR in 23 joints. Seventeen of the patients underwent same-day bilateral TKA in which components of different sizes were used for the left and right joints. AR resulted in significantly smaller anterior and posterior offsets than PR. Preoperative clinical evaluation revealed no significant differences among cases in which intermediate-size components were indicated, or those in which components of different sizes were indicated. When an intermediate-sized component was indicated using the AR method, moving the sizer forward resulted in a larger posterior gap, but this technique was nevertheless considered acceptable. AR is likely to be more suitable than PR as it achieves more physiological anterior clearance.

Usefulness of an Accelerometer-Based Portable Navigation System for Total Knee Arthroplasty: A Multicenter Prospective Randomized Controlled Trial.

BACKGROUND: An accelerometer-based portable navigation system was recently introduced to improve prosthetic alignment during total knee arthroplasty (TKA). The purpose of this multicenter prospective randomized controlled trial (RCT) was to evaluate the effects of this accelerometer-based portable navigation system for achieving more accurate alignment during TKA in the clinical setting. METHODS: One hundred patients with primary varus osteoarthritis of the knee were enrolled in this prospective RCT conducted in 5 hospitals. A navigation system was utilized in 50 patients (navigation group), and a conventional intramedullary femoral guide and an extramedullary tibial guide were utilized in 50 patients (conventional group). At 6 months postoperatively, weight-bearing radiographs were obtained of the whole operative leg. An experienced surgeon who was blinded to the treatment assignments then measured the alignment to 1 decimal place with use of computer software. Power analysis showed that 41 knees were required in each group. RESULTS: There were no complications as a result of the use of the accelerometer-based portable navigation system. Postoperative radiographs were obtained in 45 patients from each group. There were no significant differences in sex, age, height, body weight, body mass index, preoperative femorotibial angle, and operative time between groups. The absolute differences of the femoral prosthesis (p = 0.01), tibial prosthesis (p < 0.01), and hip-knee-ankle angle (p < 0.01) from a neutral mechanical axis were less in the navigation group compared with those in the conventional group. Alignment outliers (>2° away from the neutral mechanical axis) of the tibial prosthesis and hip-knee-ankle angle were less in the navigation group (9% and 27%, respectively) compared with those in the conventional group (31% and 49%; p = 0.01 and p = 0.04, respectively). CONCLUSIONS: To our knowledge, this is the first multicenter prospective RCT to evaluate an accelerometer-based portable navigation system. An accelerometer-based portable navigation system provides more accurate prosthetic and limb alignment in the coronal plane than conventional techniques, without extended operative time or an increased rate of complications. The results of this study may help orthopaedic surgeons decide whether or not to use an accelerometer-based portable navigation system. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Efficacy and risks of fondaparinux 7.5 mg for deep vein thrombosis after total knee arthroplasty.

OBJECTIVES: High-dose fondaparinux therapy at 7.5 mg/day (FPX 7.5 mg) for deep vein thrombosis (DVT) may increase the risk of hemorrhage. We investigated the efficacy and safety of FPX 7.5 mg to treat DVT after total knee arthroplasty. METHODS: This study included 101 patients (91 with osteoarthritis, 10 with rheumatoid arthritis; mean age at total knee arthroplasty: 72.9 years) with asymptomatic postoperative DVT. Medical prophylaxis for DVT was started on postoperative day 1. Vascular ultrasound was conducted within 2 days postoperatively; patients were switched to FPX 7.5 mg after DVT diagnosis. Ultrasound was repeated to monitor DVT resolution. Adverse reactions were assessed. RESULTS: DVT resolved in 72 patients (71.3%) receiving FPX 7.5 mg. There were no significant differences between patients with versus without DVT resolution in the timing of FPX 7.5 mg therapy, treatment period, age, body mass index, or D-dimer or hemoglobin levels. There was no significant difference in DVT outcome between patients starting FPX 7.5 mg within 4 days postoperatively versus on day 5 or later, or between patients treated for ≤7 versus ≥8 days. Hemoglobin decreased to ≤7 g/dL in three patients (2.9%). CONCLUSIONS: FPX 7.5 mg can be expected to resolve DVT in 71.3% of patients; however, the risk of associated hemorrhagic complications may be higher than the risk of pulmonary embolism. To treat DVT with FPX 7.5 mg without compromising safety, patients should be selected carefully and the timing of treatment should be adjusted appropriately.

[Absolute risk for fracture and WHO guideline. Biological markers for osteoarthritis (OA)].

Biological markers for osteoarthritis (OA) are indicators of articular tissue metabolism, measuring the levels of molecules derived from joint structures into synovial fluids, serum and urine. Radiological findings are the basis of diagnosis of OA, but have a weakpoint visualizing the figures that have already occurred. For assessing disease activity or monitoring disease progression, estimation of articular metabolism using biological markers is very important. Synovial fluid reflects specifically the status of the punctured joint, however invasive. Less-invasive newly developed serum and urine markers appear to be also useful for the evaluation of OA.

Mid-term results of total knee arthroplasty with a porous tantalum monoblock tibial component.

BACKGROUND: The objectives of the present study were to assess the mid-term results of cementless total knee arthroplasty (TKA) with the porous tantalum monoblock tibial component and to examine the time course of bone changes on plain radiographs. METHODS: The subjects were 32 patients, 29 patients were available for follow-up. We investigated the mid-term results of TKA after a mean follow-up period of 7 years and 8 months. We also examined changes of the bone over time on plain radiographs. RESULTS: The Knee Society Clinical Rating scores showed significant improvement. Bone changes around the tibial component were as follows: new bone formation and longitudinal trabecular thickening in 41.4% (Type A), only longitudinal trabecular thickening in 41.4% (Type B), and no changes in 17.2% (Type C). Type A and B changes were more frequent in patients with osteoarthritis, whereas Type C was only seen in patients with rheumatoid arthritis. Three knees had an initial gap, but this disappeared in all cases, and no new radiolucent lines were detected. Stress shielding was observed in seven knees (21.9%), but there was no implant loosening related to it. When we examined the relationship between the mechanical axis and the locations of the tips of the tibial pegs in patients with or without stress shielding, no significant differences were found. CONCLUSIONS: The results of mid-term follow-up have demonstrated favorable bone ingrowth, suggesting that porous tantalum is a promising material for cementless TKA.

Allograft bone transplantation for neuropathic arthropathy of the knee associated with type 1 diabetes mellitus.

Diabetes mellitus causes neuromusculoskeletal disorders characterized by abnormalities of nervous tissue, joint and bone. Early diagnosis and prevention of disease progression is difficult in cases of neuropathic arthropathy of the knee in diabetes. We report the case of a patient with type 1 diabetes mellitus who developed an insufficiency fracture of the medial part of the proximal tibia, which was viewed as an early finding of neuropathic arthropathy of the knee. In surgical treatment of the fracture, allograft bone transplantation and internal fixation were performed after curettage of the pathologically fragile lesion. Postoperatively, radiological findings have showed complete allograft bone incorporation and no evidence of degenerative changes. Recognition of an insufficiency fracture of the knee as an early indicator of neuropathic arthropathy and prompt treatment of the fracture using allograft bone transplantation could result in joint preservation.

Novel approach to identifying autoantibodies in rheumatoid synovitis with a biotinylated human autoantigen library and the enzyme-labeled antigen method.

Synovial tissue in rheumatoid arthritis (RA) shows dense infiltration of plasmacytes. The purpose of the present study is to identify and localize autoantibodies produced in these immunocytes in RA synovitis. We developed a novel screening system for detecting specific autoantigens. Protein antigens recognized by antibodies in the serum and synovial tissue extract from five RA patients were screened with the AlphaScreen method. For screening, a biotinylated human autoantigen library was constructed by the wheat germ cell-free protein synthesis system. The AlphaScreen analysis of 2183 proteins detected a limited number of antigens reactive with the serum and synovial tissue extract. Eighteen biotinylated proteins, containing top five showing high signals in each synovitis tissue extract, were utilized as probes for the enzyme-labeled antigen method, in order to visualize the site of specific antibody production in synovial lesions. Specific antibodies against two proteins, tripartite motif-containing 21 (TRIM21, also known as SSA/Ro52) and F-box only protein 2 (FBXO2), were visualized in the cytoplasm of plasmacytes in two RA synovitis lesions, respectively. Absorption experiments using unlabeled proteins confirmed the specificity of staining. No positive signals against these two proteins were identified in the additionally evaluated RA and osteoarthritis synovial lesions. The present study indicated 1) the usefulness of screening the human autoantigen library with the AlphaScreen assay for detecting autoantibodies in RA synovitis, and 2) the applicability of biotinylated proteins to the enzyme-labeled antigen method for visualizing the site of autoantibody production within the lesion.

Treatment of infected total knee arthroplasty in patients with rheumatoid arthritis.

The primary aim of treating infected knee joints after total knee arthroplasty is to eradicate the infection, but this is difficult to achieve. We reviewed the treatment of infections that occurred after total knee arthroplasty in patients with rheumatoid arthritis. The subjects were 14 patients with rheumatoid arthritis (3 men, 11 women; ages 38-81 years) who had 14 infected knee joints. The outcome was preservation of the implant in two cases, revision arthroplasty in six cases, arthrodesis in three cases, resection arthroplasty in one case, amputation in one case, and death in one case. If there is no loosening, preservation of the implant should be attempted. If preservation is impossible, revision arthroplasty is the next best option considering the effect on daily activities in patients with the disease affecting multiple joints.

Ender nailing for supracondylar fracture of the femur after total knee arthroplasty: five case reports.

We studied 5 women with supracondylar fractures after total knee arthroplasty (TKA). The mean age at fracture was 67.4 years. Four patients had chronic rheumatoid arthritis, and 1 had osteoarthritis. The range of motion, knee score, femorotibial angle, and component alignment were investigated. Flexion was slightly decreased after Ender nailing, but extension only changed in 1 patient. The knee score decreased, but all patients were ambulatory. The femorotibial angle changed in all patients. Measurement of femoral component alignment showed a postoperative change of angle alpha (1 degrees to 11 degrees ) and angle gamma (0 degrees to 9 degrees ). Union was achieved in all patients. Ender nailing is an acceptable method of treatment for supracondylar fractures of the femur after TKA if the nails can be inserted deeply into the femoral condyles.