Gender differences in the associations between knee pain and urinary incontinence in older adults: Cross-sectional analysis from the Malaysian Elders Longitudinal Research Study (MELoR).

INTRODUCTION: The common assumption that urinary incontinence occurs in osteoarthritis (OA) due to poor mobility is supported by limited evidence. The influence of gender in such associations is also yet to be elucidated. OBJECTIVE: This study, therefore, identified any potential associations between knee OA symptoms and urinary incontinence and further explore sex differences in the associations. DESIGN: Cross-sectional study. SETTING: University Hospital. PARTICIPANTS: This was a cross-sectional study from a longitudinal research study comprising 1221 community-dwelling older persons (57% women), mean age (SD) 68.95 (7.49) years. MAIN OUTCOME MEASURE(S): Presence of urinary incontinence: mixed, stress and urge symptoms. Physical performance and C-reactive protein levels were also assessed. RESULTS: Two hundred and seventy-seven (22.83%) individuals reported the presence of urinary incontinence: mixed (41.5%), stress (30%), and urge (28.5%) symptoms. In an unadjusted analysis, stratified by gender, the association between knee pain and urinary incontinence was only present in women with mixed symptoms. After further adjustment of demographics differences and body mass index, the association between knee pain with any urinary incontinence and mixed symptoms remained significant with the odds ratios (95% confidence interval): 1.48 (1.02-2.15) and 1.73 (1.06-2.83), respectively. This relationship was attenuated after further adjustment for waist circumference and impaired lower limb mobility. CONCLUSION: Our study refutes previous assumptions that urinary incontinence in individuals with OA is attributed to impaired mobility alone, but introduces the role of abdominal obesity in this relationship, particularly in women. Future studies should assess the temporal relationship between body fat distribution and OA with urinary incontinence.

Typical response of CD14++CD16- monocyte to knee synovial derived mediators as a key target to overcome the onset and progression of osteoarthritis.

Objective: Synovitis with increased infiltration of immune cells is observed in osteoarthritis (OA). Given the inflammatory condition of synovitis, we explored the protein profile of OA synovium (OAS) and its effect on circulating monocytes activation, migration, and functional commitments. Methods: Knee-synovium was acquired from end-stage OA (N = 8) and trauma patients (Trauma baseline control: TBC; N = 8) for characterization using H&E histology, IHC (iNOS), LCMS-QTOF, and MALDI-imaging. Response of peripheral blood monocytes to OAS conditioned-media (OACM) was observed using transwell (n = 6). The migrated cells were captured in SEM, quantified using phase-contrast microphotographs, and their activation receptors (CCR2, CXCR2, CX3CR1, and CD11b), pro-inflammatory genes, and phagocytic potential were studied using flow cytometry, gene expression array/qPCR, and latex beads (LB) phagocytosis assay, respectively. Results: The Venn diagram displayed 119 typical proteins in OAS, while 55 proteins in TBCS. The STRING protein network analysis indicated distinctive links between proteins and gene ontology (GO) and revealed proteins associated with leukocyte-mediated immunity in OAS as compared to TBC. The MALDI-imaging showed typical localized proteins at 2234.97, 2522.61, 2627.21, 3329.50, and 3539.69 m/z and IHC confirmed pro-inflammatory iNOS expression in OA synovium. CD14++CD16- classical monocytes significantly migrated in OACM and expressed CCR2, CXCR2, and CD11b receptors, TNFRSF11A, MAPK1, S100A8, HSPB1, ITGAL, NFATC1, IL13RA1, CD93, IL-1ß, TNF-α, and MYD88 genes and increased LB uptake as compared to SFM. Conclusion: Our findings suggest that the differential protein profile of OA synovium and the classical monocytes migrated, activated, and functionally committed in response to these mediators could be of therapeutic advantage.

Development and validation of the knowledge, attitude and practice questionnaire (LAUNDERKAP) regarding white coat use among medical students during clinical practice.

BACKGROUND: Medical students' white coats were found to harbor harmful organisms. This could be due to non-compliance to white coat hygiene measures. Therefore, we aim to develop and validate a questionnaire to assess the of knowledge, attitude, and practice (LAUNDERKAP) of white coat use among medical students in Malaysia. METHODS: This study was conducted in 4 local medical schools. LAUNDERKAP was developed via literature review and had 3 domains: attitude, knowledge, practice. An expert panel assessed the content validity and clarity of wording. LAUNDERKAP was then piloted among 32 medical students. To test construct validity and internal consistency, 362 medical students were approached. Construct validity was assessed using exploratory factor analysis. Internal consistency was evaluated using Cronbach alpha for attitude and practice, while Kuder-Richardson 20 (KR-20) was used for knowledge. RESULTS: A total of 319 of 362 students responded. Exploratory factor analysis extracted 1 factor each for attitude and knowledge respectively, and 3 factors for practice. Cronbach alpha for attitude was 0.843 while KR-20 for knowledge was 0.457. Cronbach alpha for practice ranged from 0.375 to 0.689. The final LAUNDERKAP contained 32-items (13 attitude, 9 knowledge, 10 practice). CONCLUSIONS: LAUNDERKAP had adequate psychometric properties and can be used to assess KAP of medical students towards white coat use.

Mechanical compression controls the biosynthesis of human osteoarthritic chondrocytes in vitro.

BACKGROUND: Cartilage damage, which can potentially lead to osteoarthritis, is a leading cause of morbidity in the elderly population. Chondrocytes are sensitive to mechanical stimuli and their matrix-protein synthesis may be altered when chondrocytes experience a variety of in vivo loadings. Therefore, a study was conducted to evaluate the biosynthesis of isolated osteoarthritic chondrocytes which subjected to compression with varying dynamic compressive strains and loading durations. METHODS: The proximal tibia was resected as a single osteochondral unit during total knee replacement from patients (N = 10). The osteoarthritic chondrocytes were isolated from the osteochondral units, and characterized using reverse transcriptase-polymerase chain reaction. The isolated osteoarthritic chondrocytes were cultured and embedded in agarose, and then subjected to 10% and 20% uniaxial dynamic compression up to 8-days using a bioreactor. The morphological features and changes in the osteoarthritic chondrocytes upon compression were evaluated using scanning electron microscopy. Safranin O was used to detect the presence of cartilage matrix proteoglycan expression while quantitative analysis was conducted by measuring type VI collagen using an immunohistochemistry and fluorescence intensity assay. FINDINGS: Gene expression analysis indicated that the isolated osteoarthritic chondrocytes expressed chondrocyte-specific markers, including BGN, CD90 and HSPG-2. Moreover, the compressed osteoarthritic chondrocytes showed a more intense and broader deposition of proteoglycan and type VI collagen than control. The expression of type VI collagen was directly proportional to the duration of compression in which 8-days compression was significantly higher than 4-days compression. The 20% compression showed significantly higher intensity compared to 10% compression in 4- and 8-days. INTERPRETATION: The biosynthetic activity of human chondrocytes from osteoarthritic joints can be enhanced using selected compression regimes.

Ethnic differences in the prevalence, socioeconomic and health related risk factors of knee pain and osteoarthritis symptoms in older Malaysians.

Knee pain is often underreported, underestimated and undertreated. This study was conducted to estimate the prevalence, burden and further identify socioeconomic factors influencing ethnic differences in knee pain and symptoms of OA among older adults aged 55 years and over in Greater Kuala Lumpur (the capital city of Malaysia). The sample for the Malaysian Elders Longitudinal Research (MELoR) was selected using stratified random sampling, by age and ethnicity from the electoral rolls of three parliamentary constituencies. Information on knee pain was available in 1226 participants, mean age (SD) 68.96 (1.57) years (409 Malay, 416 Chinese, 401 Indian). The crude and weighted prevalence of knee pain and self-reported knee OA symptoms were 33.3% and 30.8% respectively. There were significant ethnic differences in knee pain (crude prevalence: Malays 44.6%, Chinese 23.5% and Indians 31.9%, p<0.001). The presence of two or more non-communicable diseases (NCD) attenuated the increased risk of knee pain among the ethnic Indians compared to the ethnic Chinese. The prevalence of knee pain remained significantly higher among the ethnic Malays after adjustment for confounders. While the prevalence of knee pain in our older population appears similar to that reported in other published studies in Asia, the higher prevalence among the ethnic Malays has not previously been reported. Further research to determine potential genetic susceptibility to knee pain among the ethnic Malays is recommended.

Primary repair for injury of medial collateral ligament during total-knee arthroplasty.

The aim of this study was to determine whether primary repair for intraoperative injury of the medial collateral ligament (MCL) can achieve satisfactory clinical results when compared to the clinical results of patients with no MCL injury. Simultaneously, we sought to determine the differences between 2 methods of primary repair (anchor suture and staple) in terms of their clinical outcomes.In our institute, 3897 total-knee arthroplasties (TKAs) were performed between 2003 and 2014. Sixty-five patients who suffered an MCL injury during the TKA procedure and in whom the injury was repaired with a suture anchor or staple (suture anchor: 36 vs staple: 29) were studied. A matched group of 65 patients without an MCL injury was selected to serve as the control group. Subjective feelings of instability and functional outcomes were assessed using the knee society (KS) score and the Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC). Objective stability was evaluated by the measurement of opening angles in extension and at 30° of knee flexion on valgus stress radiographs. The clinical outcomes and stability results were compared between the suture anchor and staple methods.The KS and WOMAC scores in patients who received primary repair of MCL injury during TKA improved from 50.6 ±â€Š13.1 to 87.3 ±â€Š7.3 (P < .001) and 65.9 ±â€Š14.4 to 17.7 ±â€Š6.6 (P < .001), respectively. However, there were no statistically significant differences in the KS (P = .84) and WOMAC (P = .71) scores when comparing the group that received primary repair to the control group. Radiographic stability also showed no differences between the repair and control groups in extension and at 30° of flexion (P = .48 and P = .11, respectively). In the subgroups, there were no significant differences between the suture anchor and staple repair methods in terms of stability and clinical outcomes.Primary repair of an MCL injury during TKA may have clinical outcomes comparable to that in the no MCL injury group. Both staple and suture anchor repair methods could provide excellent clinical and stability outcomes in these types of cases, although a further cohort study is required to validate our results.

Revision total hip arthroplasty with metal on metal bearing for ceramic bearing fractures.

BACKGROUND: Due to concern of potential metallosis caused by residual microscopic ceramic particles, metal-on-metal (MoM) bearing is deemed undesirable in revision total hip arthroplasty (THA) for ceramic bearing fracture. We determined whether MoM bearing is suitable to be used in revision THA for ceramic fractures and also evaluated whether this treatment increases serum iron levels compared with MoM bearing revision THA for polyethylene failure. METHODS: Between 2006 and 2012, 22 patients underwent revision surgery using MoM bearing (28 mm femoral head in 18 hips and 32 mm in 4 hips) for ceramic bearing fracture and followed average 52.1 months. We assessed radiological parameter and functional outcome using Harris hip score (HHS) and WOMAC score. Also, serum cobalt (Co) and chromium (Cr) blood tests were performed and compared with the result obtained from age, sex- and follow-up duration-matched patients with MoM revision THA for failed polyethylene bearing. RESULTS: The mean HHS improved from 60.6 preoperatively to 90.3 at final follow-up. There were no changes in cup position, progression of osteolytic lesions, and measurable wear of MoM bearing articulation at final follow-up radiographs. There was one case of recurrent dislocation after surgery, which was treated with greater trochanter distal advancement and one case of deep infection, which underwent two-stage revision. Mean serum Co level (1.7 vs. 1.4 µg/dl; p = 0.211) and Cr level (0.70 vs. 1.01 µg/dl; p = 0.327) showed no significant difference. CONCLUSIONS: MoM articulation with liner cementation into the acetabular cup along with total synovectomy can be chosen in revision surgery for ceramic fracture with good midterm follow-up. However, the use of MoM bearing is indicated when the stem and metal shell can be retained and ceramic on ceramic or ceramic on polyethylene bearing cannot be selected. Also long-term outcome needs to be further evaluated.

Midterm Results of Conversion from Failed Bipolar Hemiarthroplasty to Total Hip Arthroplasty.

BACKGROUND: Conversion from failed bipolar hemiarthroplasty (HA) to total hip arthroplasty (THA) presents a great challenge to orthopedic surgeons for bipolar head removal and cup placement with or without change of femoral stem. Conversion THA after failed bipolar arthroplasty is known to offer both symptomatic and functional improvement. This study evaluates the midterm functional outcome and complications, especially dislocation associated with femoral head diameter, after conversion THA. MATERIALS AND METHODS: Forty eight hips with the conversion of bipolar HA to THA were followed up for an average 6.2 years (range 2.0-11.5 years). Twenty one hips had conversion surgery to THA using metal-on-metal articulation (28 or 32 mm head). Nine hips used ceramic-on-ceramic (28-40 mm) and eighteen hips used large head metal-on-metal bearing (>40 mm). Outcome was evaluated using Harris Hip Score (HHS) and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) score. The radiographs were analyzed for evidence of osteolysis and/or loosening. The complications were evaluated, especially dislocation with different femoral head diameter. RESULTS: Average HHS significantly improved from 42 preoperatively to 86 postoperatively and the average WOMAC score also significantly improved from 47 to 22 postoperatively. Radiological evaluation showed all the femoral components were stable. There was one acetabular component loosening, which required revision 9 years after conversion to THA. One dislocation and one recurrent dislocation were recorded in isolated acetabular revision hip; whereas one dislocation, one recurrent dislocation, and one trochanteric nonunion occurred in the hips with revision of both components. All dislocations occurred in hips with a femoral head size of 28 mm (P = 0.052). The cup and femoral head interval length was the most significant factor contributing to dislocation (P = 0.013). CONCLUSIONS: Conversion THA after failed bipolar HA offers a reliable pain relief and functional improvement. To prevent dislocation, it is highly recommended to use a larger diameter femoral head, especially where the cup size is big.

Vitamin D deficiency is associated with ethnicity and knee pain in a multi-ethnic South-East Asian nation: Results from Malaysian Elders Longitudinal Research (MELoR).

AIM: To determine the association between vitamin D and knee pain among participants of the Malaysian Elders Longitudinal Research (MELoR) study. METHOD: This was a cross-sectional study from the MELoR study consisting of a representative group of 1011 community-dwelling older persons (57% female), mean age 86.5 (54-94) years; 313 were Malays, 367 Chinese and 330 Indians. Participants were asked if they had knee pain. Levels of serum 25-hydroxy cholecalciferol (25-[OH]D), an indicator of vitamin D status, were measured using routine laboratory techniques. RESULTS: In unadjusted analysis, presence of knee pain was significantly associated with vitamin D deficiency (odds ratio [OR] 1.42; 95% confidence interval (CI) 1.08-1.85, P 0.011). Vitamin D levels were significantly associated with ethnicity differences where Malays (OR 7.08; 95% CI 4.94-10.15) and Indians (OR 6.10; 95% CI 4.28-9.71) have lower levels of vitamin D compared to Chinese. Subsequent multivariate analysis revealed that the association between vitamin D deficiency and knee pain was confounded by ethnic differences. CONCLUSION: A previous study suggested that vitamin D deficiency was associated with knee pain. This relationship was reproduced in our study, but we further established that the association was explained by ethnic variations. As vitamin D status is dependent on skin tone, diet and sunlight exposure, which are all effected by ethnicity, future studies are now required to determine whether a true relationship exists between vitamin D and knee pain.

Three-Dimensional Computed Tomography Analysis of the Posterior Tibial Slope in 100 Knees.

BACKGROUND: The posterior tibial slope (PTS) is an important consideration in knee arthroplasty. However, there is still no consensus for the optimal slope. The objectives of this study were (1) to reliably determine the native PTS in this population using 3-dimensional computed tomography scans and (2) to determine the normal reference range for PTS in this population. METHODS: One hundred computed tomography scans of disease-free knees were analyzed. A 3-dimensional reconstructed image of the tibia was generated and aligned to its anatomic axis in the coronal and sagittal planes. The tibia was then rotationally aligned to the tibial plateau (tibial centroid axis) and PTS was measured from best-fit planes on the surface of the proximal tibia and individually for the medial and lateral plateaus. This was then repeated with the tibia rotationally aligned to the ankle (transmalleolar axis). RESULTS: When rotationally aligned to the tibial plateau, the mean PTS, medial PTS, and lateral PTS were 11.2° ± 3.0 (range, 4.7°-17.7°), 11.3° ± 3.2 (range, 2.7°-19.7°), and 10.9° ± 3.7 (range, 3.5°-19.4°), respectively. When rotationally aligned to the ankle, the mean PTS, medial PTS, and lateral PTS were 11.4° ± 3.0 (range, 5.3°-19.3°), 13.9° ± 3.7 (range, 3.1°-24.4°), and 9.7° ± 3.6 (range, 0.8°-17.7°), respectively. CONCLUSION: The PTS in the normal Asian knee is on average 11° (mean) with a reference range of 5°-17° (mean ± 2 standard deviation). This has implications to surgery and implant design.

Incorporation of Human-Platelet-Derived Growth Factor-BB Encapsulated Poly(lactic-co-glycolic acid) Microspheres into 3D CORAGRAF Enhances Osteogenic Differentiation of Mesenchymal Stromal Cells.

Tissue engineering aims to generate or facilitate regrowth or healing of damaged tissues by applying a combination of biomaterials, cells, and bioactive signaling molecules. In this regard, growth factors clearly play important roles in regulating cellular fate. However, uncontrolled release of growth factors has been demonstrated to produce severe side effects on the surrounding tissues. In this study, poly(lactic-co-glycolic acid) (PLGA) microspheres (MS) incorporated three-dimensional (3D) CORAGRAF scaffolds were engineered to achieve controlled release of platelet-derived growth factor-BB (PDGF-BB) for the differentiation of stem cells within the 3D polymer network. Fourier transform infrared spectroscopy, energy-dispersive X-ray spectroscopy, scanning electron microscopy, and microtomography were applied to characterize the fabricated scaffolds. In vitro study revealed that the CORAGRAF-PLGA-PDGF-BB scaffold system enhanced the release of PDGF-BB for the regulation of cell behavior. Stromal cell attachment, viability, release of osteogenic differentiation markers such as osteocalcin, and upregulation of osteogenic gene expression exhibited positive response. Overall, the developed scaffold system was noted to support rapid cell expansion and differentiation of stromal cells into osteogenic cells in vitro for bone tissue engineering applications.

How Much Does the Anatomical Tibial Component Improve the Bony Coverage in Total Knee Arthroplasty?

BACKGROUND: Recently, anatomical designs in total knee arthroplasty are introduced to address asymmetry of the resected tibia cutting surface. It is still not well known how much improvement would be achieved in total knee arthroplasty, especially in Asian knees. METHODS: We evaluated the bony coverage of 4 commercially available posterior-stabilized tibial designs (3 symmetrical: NexGen, Attune, and Vega; 1 anatomical: Persona) by measuring uncovered areas over 3 different regions: lateroposterior (LP), medioposterior (MP), and mediolateral (ML) areas. The implant size was chosen based on lateral anteroposterior dimension of the implant that most closely matched the corresponding surface of tibia. The knee with over coverage <1 mm and under coverage <2 mm was regarded as having optimal fit. RESULTS: The optimal fit of anatomical design in LP dimension was achieved in 76% of the cases, which was not significantly different from other symmetrical designs (P > .05). The anatomical tibial implant had a more optimal fit in MP and ML dimensions (48% and 42%, respectively) compared to all symmetric designs (P < .05). All symmetrical tibial designs had significant absolute underhang in MP (62%-78%) and ML (24%-34%) areas without difference. The anatomical tibial design had significant improvement for posteromedial coverage by about 69.8%-74.3% compared with the symmetrical designs. CONCLUSION: Recently introduced anatomical tibial design improves surface coverage at the medioposterior dimension in Asian knees. Moreover, there is small improvement in ML fit compared with the symmetrical designs.

Radiological analysis of the medial epicondyle in the adolescent throwing athlete.

INTRODUCTION: Injuries to the medial structures of the elbow due to overhead throwing games are well documented. However, variations of medial epicondyles are not well described, especially in athletes with fused medial epicondyles. In this study, we evaluated variations in the medial epicondyle of baseball players who were aged 15-17 years and had fused epicondyles. METHODS: In this cross-sectional observational study, 155 skeletally mature baseball players with unilateral medial elbow pain and 310 elbow radiographs were reviewed by two independent reviewers. The medial epicondyles were categorised into three groups: normal, elongated or separated. RESULTS: Among the 155 patients, 65 (41.9%) had normal epicondyles, 41 (26.5%) had elongated epicondyles and 49 (31.6%) had separated epicondyles. The medial epicondyle was larger on the dominant arm for 125 (80.6%) patients; the mean surface area on the dominant arm was 222.50 ± 45.77 mm2, while that of the non-dominant arm was 189.14 ± 39.56 mm2 (p < 0.01). Among the three categories of medial epicondyles, separated epicondyles had the largest surface area, followed by elongated and normal epicondyles. CONCLUSION: Medial epicondyles in adolescent throwing athletes can be categorised into three different groups according to their shape (normal, elongated and separated). We observed a correlation between the shape and the surface area of the medial epicondyle in adolescent throwing athletes, with separated medial epicondyles having the largest surface area. Further studies and follow-up are needed to determine the prognostic value and clinical significance of these morphological variations.

Revision Total Hip Arthroplasty Using an Acetabular Reinforcement Ring With a Hook: A Precise Follow-Up, at Average 11.4 Years, of a Previous Report.

BACKGROUND: This study aims at determining the average long-term result of revision total hip arthroplasty (THA) using the acetabular reinforcement ring with a hook (ARRH) and bone grafting in severe acetabular bony defect. Expected 15-year survival of ARRH in revision THA is included in the study. METHODS: Retrospective review of 48 patients (48 hips) with follow-up duration of average 11.4 years (range, 6.1-21.4 years) was conducted. At each follow-up, Harris hip score was used to assess functional outcome, and radiographic acetabular component osteolysis was measured by DeLee and Charnley classification. Bone defects were assessed preoperatively and intraoperatively using American academy of orthopedic surgeons and Paprosky classification. The common modes of ARRH failures were evaluated. Bone consolidation, presence of heterotopic ossification, and complications such as infection and dislocation were recorded. RESULTS: The bone defects were varied and included cavitary, segmental, and combined defects without any pelvic discontinuity. Mean Harris hip score improved from 52.6 points preoperatively to 82.0 points postoperatively. Nine acetabular revisions and 3 stem revisions (2 concurrent with acetabular revisions and 1 isolated stem revision) were performed. There were 5 infected cases and 1 patient with recurrent dislocation. The 11.4-year survival of revision THA with ARRH was 71% as the end point for acetabular revision surgery for any reason. The expected 15-year survival of revision THA with ARRH was 60%. The most common failure mode of ARRH was superomedial migration followed by lateral migration. CONCLUSION: ARRH combined with bone grafting produces relatively good average long-term clinical results.