High Pain Catastrophizing Scale Predicts Lower Patient-Reported Outcome Measures in the Foot and Ankle Patient.

BACKGROUND: Postoperative outcomes may be affected by the patient's preoperative morbidity. It is hypothesized that patient's pain catastrophization prior to foot and ankle surgery may affect their patient-reported outcomes. Methods: This study prospectively assessed a consecutive cohort of 46 patients undergoing foot and ankle reconstruction to describe the relationship between Pain Catastrophizing Scale (PCS) and patient-reported outcomes measured by 12-item Short Form Health Survey and Foot and Ankle Outcome Score (FAOS). RESULTS: The 1-year postoperative FAOS pain, activities of daily living, and quality of life scores correlated significantly with all baseline PCS subcategories. We found that the mental domain of the SF-12 had a statistically significant correlation with the rumination and helplessness PCS subcategories. CONCLUSION: This study showed a significant association between a high preoperative PCS and a worse 1-year FAOS. As such, catastrophization could be screened for and potentially treated preoperatively to improve patient-reported outcomes in elective foot and ankle surgery. LEVEL OF EVIDENCE: Therapeutic, Level III Evidence.

Bone Marrow Mesenchymal Stromal Cell Treatment in Patients with Osteoarthritis Results in Overall Improvement in Pain and Symptoms and Reduces Synovial Inflammation.

Patients with late-stage Kellgren-Lawrence knee osteoarthritis received a single intra-articular injection of 1, 10, or 50 million bone marrow mesenchymal stromal cells (BM-MSCs) in a phase I/IIa trial to assess safety and efficacy using a broad toolset of analytical methods. Besides safety, outcomes included patient-reported outcome measures (PROMs): Knee Injury and Osteoarthritis Outcome Score (KOOS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); contrast-enhanced magnetic resonance imaging (MRI) for cartilage morphology (Whole Organ MRI Scores [WORMS]), collagen content (T2 scores), and synovitis; and inflammation and cartilage turnover biomarkers, all over 12 months. BM-MSCs were characterized by a panel of anti-inflammatory markers to predict clinical efficacy. There were no serious adverse events, although four patients had minor, transient adverse events. There were significant overall improvements in KOOS pain, symptoms, quality of life, and WOMAC stiffness relative to baseline; the 50 million dose achieved clinically relevant improvements across most PROMs. WORMS and T2 scores did not change relative to baseline. However, cartilage catabolic biomarkers and MRI synovitis were significantly lower at higher doses. Pro-inflammatory monocytes/macrophages and interleukin 12 levels decreased in the synovial fluid after MSC injection. The panel of BM-MSC anti-inflammatory markers was strongly predictive of PROMs over 12 months. Autologous BM-MSCs are safe and result in significant improvements in PROMs at 12 months. Our analytical tools provide important insights into BM-MSC dosing and BM-MSC reduction of synovial inflammation and cartilage degradation and provide a highly predictive donor selection criterion that will be critical in translating MSC therapy for osteoarthritis. Stem Cells Translational Medicine 2019;8:746&757.

Cross-Sectional Contrast Between Individuals With Foot/Ankle vs Knee Osteoarthritis for Obesity and Low Education on Health-Related Quality of Life.

BACKGROUND: Improving health-related quality of life (HRQoL) necessitates an understanding of the influence of patient characteristics on, and interrelationship among, HRQoL domains. In osteoarthritis (OA), these associations have predominantly been examined in hip/knee populations. We investigated whether there were differences in these associations between foot/ankle and knee OA samples. METHODS: Individuals seeking orthopedic care for foot/ankle or knee OA completed a questionnaire pre-consultation, including HRQoL domains (bodily pain [BP], physical [PF] and social functioning [SF], and mental [MH] and general health [GH]), obesity, comorbidity, and sociodemographic characteristics. Associations were examined via stratified path analysis (foot/ankle vs knee). Foot/ankle: n = 180, mean age = 55 (range: 25 to 82), 52% female. Knee: n = 253, mean age = 62 (range: 26 to 92), 51% female. RESULTS: The interrelationship among HRQoL domains was generally similar between groups. However, the influence of patient characteristics differed. Low educational status was associated with worse scores for GH, MH, and SF in the foot/ankle group, whereas no significant effects were found in the knee group. Obesity was associated with worse scores for SF, BP, and GH in the foot/ankle compared to the knee group. Patient characteristics explained considerably more of the variation in domain scores in the foot/ankle group. CONCLUSION: There are significant differences in the impact of patient characteristics on HRQoL domains in foot/ankle versus knee OA patients. Therefore, a universal approach to patient education/intervention to improve HRQoL in lower-extremity OA is not likely to achieve optimal results. Based on these findings, we recommend joint-specific patient education, with a particular emphasis on patient characteristics among the foot/ankle OA population. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The effect of patient position during trauma surgery on fat embolism syndrome: An experimental study.

BACKGROUND: The aim of this study was to compare the effect of supine versus lateral position on clinical signs of fat embolism during orthopedic trauma surgery. Dogs served as the current study model, which could be extended and/or serve as a basis for future in vivo studies on humans. It was hypothesized that there would be an effect of position on clinical signs of fat embolism syndrome in a dog model. MATERIALS AND METHODS: 12 dogs were assigned to supine (n = 6) and lateral (n = 6) position groups. Airway pressures, heart rate, blood pressure, cardiac output, pulmonary artery pressure, pulmonary artery wedge pressure, right atrial pressure, arterial and venous blood gases, white blood count, platelet count and neutrophil count were obtained. Dogs were then subjected to pulmonary contusion in three areas of one lung. Fat embolism was generated by reaming one femur and tibia, followed by pressurization of the canal. RESULTS: No difference was found in any parameters measured between supine and lateral positions at any time (0.126 < P < 0.856). CONCLUSIONS: The position of trauma patients undergoing reamed intramedullary nailing did not alter the presentation of the features of the lung secondary to fat embolism.

Changes in femoral cortical porosity after reaming and intramedullary canal preparation in a canine model.

This study examined changes in femoral cortical porosity resulting from femoral canal preparation during cemented total hip arthroplasty (THA). Twenty-four canines were randomly assigned to 3 groups: (1) reaming only, (2) cementing without pressurization, and (3) cementing with pressurization. Femoral cortical porosity was measured from histologic samples of the femurs at 7 positions. Reaming during canal preparation significantly increased cortical porosity. Cementing further increased cortical porosity, whereas pressurization of cement helped to counteract the increase in cortical porosity caused by cementing alone. Cortical porosity was considered to be a marker for bone mineral density (BMD) during the early phase of peri-implant healing around cemented stems. To maximize bone mineral density after cemented total hip arthroplasty, we suggest using implants that do not require reaming and pressurizing cement appropriately.

Biomechanical measurements of torsion-tension coupling in human cadaveric femurs.

The mechanical behavior of human femurs has been described in the literature with regard to torsion and tension but only as independent measurements. However, in this study, human femurs were subjected to torsion to determine if a simultaneous axial tensile load was generated. Fresh frozen human femurs (n=25) were harvested and stripped of soft tissue. Each femur was mounted rigidly in a specially designed test jig and remained at a fixed axial length during all experiments. Femurs were subjected to external and internal rotation applied at a constant angulation rate of 0.1 deg/s to a maximum torque of 12 N m. Applied torque and generated axial tension were monitored simultaneously. Outcome measurements were extracted from torsion-versus-tension graphs. There was a strong relationship between applied torsion and the resulting tension for external rotation tests (torsion/tension ratio=551.7±283.8 mm, R(2)=0.83±0.20, n=25), internal rotation tests (torsion/tension ratio=495.3±233.1 mm, R(2)=0.87±0.17, n=24), left femurs (torsion/tension ratio=542.2±262.4 mm, R(2)=0.88±0.13, n=24), and right femurs (torsion/tension ratio=506.7±260.0 mm, R(2)=0.82±0.22, n=25). No statistically significant differences were found for external versus internal rotation groups or for left versus right femurs when comparing torsion/tension ratios (p=0.85) or R(2) values (p=0.54). A strongly coupled linear relationship between torsion and tension for human femurs was exhibited. This suggests an interplay between these two factors during activities of daily living and injury processes.

Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial.

BACKGROUND: Topical application of tranexamic acid to bleeding wound surfaces reduces blood loss in patients undergoing some major surgeries, without systemic complications. The objective of the present trial was to assess the efficacy and safety of the topical application of tranexamic acid on postoperative blood loss in patients undergoing primary unilateral total knee arthroplasty with cement. METHODS: In a prospective, double-blind, placebo-controlled trial, 124 patients were randomized to receive 1.5 or 3.0 g of tranexamic acid in 100 mL of normal saline solution or an equivalent volume of placebo (normal saline solution) applied into the joint for five minutes at the end of surgery. The primary outcome was blood loss calculated from the difference between the preoperative hemoglobin level and the corresponding lowest postoperative value or hemoglobin level prior to transfusion. The safety outcomes included Doppler ultrasound in all patients and measurement of plasma levels of tranexamic acid one hour after release of the tourniquet. RESULTS: Twenty-five patients were withdrawn for various reasons; therefore, ninety-nine patients were included in the intention-to-treat analysis. The postoperative blood loss was reduced in the 1.5 and 3-g tranexamic acid groups (1295 mL [95% confidence interval, 1167 to 1422 mL] and 1208 mL [95% confidence interval, 1078 to 1339 mL], respectively) in comparison with the placebo group (1610 mL [95% confidence interval, 1480 to 1738 mL]) (p < 0.017). The postoperative hemoglobin levels were higher in the 1.5 and 3.0-g tranexamic acid groups (10.0 g/dL [95% confidence interval, 9.5 to 10.4 g/dL] and 10.1 g/dL [95% confidence interval, 9.8 to 10.5 g/dL], respectively) in comparison with the placebo group (8.6 g/dL [95% confidence interval, 8.2 to 9 g/dL]) (p < 0.017). With the numbers studied, there was no difference in the rates of deep-vein thrombosis or pulmonary embolism between the three groups. Minimal systemic absorption of tranexamic acid was observed. CONCLUSIONS: At the conclusion of a total knee arthroplasty with cement, topical application of tranexamic acid directly into the surgical wound reduced postoperative bleeding by 20% to 25%, or 300 to 400 mL, resulting in 16% to 17% higher postoperative hemoglobin levels compared with placebo, with no clinically important increase in complications being identified in the treatment groups.

Role of Vibrio polysaccharide (vps) genes in VPS production, biofilm formation and Vibrio cholerae pathogenesis.

Biofilm formation enhances the survival and persistence of the facultative human pathogen Vibrio cholerae in natural ecosystems and its transmission during seasonal cholera outbreaks. A major component of the V. cholerae biofilm matrix is the Vibrio polysaccharide (VPS), which is essential for development of three-dimensional biofilm structures. The vps genes are clustered in two regions, the vps-I cluster (vpsU, vpsA-K, VC0916-27) and the vps-II cluster (vpsL-Q, VC0934-39), separated by an intergenic region containing the rbm gene cluster that encodes biofilm matrix proteins. In-frame deletions of the vps clusters and genes encoding matrix proteins drastically altered biofilm formation phenotypes. To determine which genes within the vps gene clusters are required for biofilm formation and VPS synthesis, we generated in-frame deletion mutants for all the vps genes. Many of these mutants exhibited reduced capacity to produce VPS and biofilms. Infant mouse colonization assays revealed that mutants lacking either vps clusters or rbmA (encoding secreted matrix protein RbmA) exhibited a defect in intestinal colonization compared to the wild-type. Understanding the roles of the various vps gene products will aid in the biochemical characterization of the VPS biosynthetic pathway and elucidate how vps gene products contribute to VPS biosynthesis, biofilm formation and virulence in V. cholerae.

Relationship between self-reported and performance-based tests in a hip and knee joint replacement population.

Our objectives were: (1) to assess the relationship between self-reported measures (Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and Medical Outcomes Study Short Form-36 (SF-36)) and a performance-based timed-up-and-go (TUG) test in a hip and knee joint replacement population and (2) to determine the predictors of postoperative functional status as measured by the 12-week WOMAC and TUG scores. We surveyed 200 patients undergoing primary hip or knee replacement surgery for demographic data and outcome scores at baseline and 12-week follow-up. There was a weak correlation between preoperative TUG scores and preoperative SF-36 physical function scores (r = -0.28, p < 0.0001), SF-36 role-physical scores (r = -0.21, p = 0.0022) and WOMAC (r = 0.29, p < 0.0001) scores. The relationship was stronger between the postoperative TUG scores and WOMAC scores (r = 0.43, p < 0.0001), SF-36 physical function scores (r = -0.39, p < 0.0001) and SF-36 role-physical (r = -0.33, p < 0.0001) scores. Significant predictors for the TUG test at 12-week follow-up were age (p = 0.004) and preoperative TUG scores (p < 0.0001). Given low-to-moderate relationship between self-reported and performance-based tools, both tests are needed to assess the true level of patient disability.

Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: a randomized controlled trial.

BACKGROUND: Home-based rehabilitation is increasingly utilized to reduce health-care costs; however, with a shorter hospital stay, the possibility arises for an increase in adverse clinical outcomes. We evaluated the effectiveness and cost of care of home-based compared with inpatient rehabilitation following primary total hip or knee joint replacement. METHODS: We randomized 234 patients, using block randomization techniques, to either home-based or inpatient rehabilitation following total joint replacement. All patients followed standardized care pathways and were evaluated, with use of validated outcome measures (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], Short Form-36, and patient satisfaction), prior to surgery and at three and twelve months following surgery. The primary outcome was the WOMAC function score at three months after surgery. RESULTS: The mean length of stay (and standard deviation) in the acute care hospital was 6.3 +/- 2.5 days for the group designated for inpatient rehabilitation prior to transfer to that facility compared with 7.0 +/- 3.0 days for the home-based rehabilitation group prior to discharge home (p = 0.06). The mean length of stay in inpatient rehabilitation was 17.7 +/- 8.6 days. The mean number of postoperative home-based rehabilitation visits was eight. The prevalence of postoperative complications up to twelve months postoperatively was similar in both groups, which each had a 2% rate of dislocation and a 3% rate of clinically important deep venous thrombosis. The prevalence of infection was 0% in the home-based group and 2% in the inpatient group. None of these differences was clinically important. Both groups showed substantial improvements at three and twelve months, with no significant differences between the groups with respect to WOMAC, Short Form-36, or patient satisfaction scores (p > 0.05). The total episode-of-care costs (in Canadian dollars) for the inpatient rehabilitation and home-based rehabilitation arms were $14,532 and $11,082, respectively (p < 0.01). CONCLUSIONS: Despite concerns about early hospital discharge, there was no difference in pain, functional outcomes, or patient satisfaction between the group that received home-based rehabilitation and the group that had inpatient rehabilitation. On the basis of our findings, we recommend the use of a home-based rehabilitation protocol following elective primary total hip or knee replacement as it is the more cost-effective strategy.