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1.
Knee ; 34: 89-97, 2021 Dec 06.
Artigo em Inglês | MEDLINE | ID: mdl-34883332

RESUMO

AIM: To compare the outcomes of cemented and cementless Unicompartmental Knee Replacements (UKR) at 5 years after surgery. METHODS: 262 cemented and 262 cementless medial mobile-bearing UKR, implanted by four high-volume surgeons using identical indications and surgical techniques, were reviewed by independent physiotherapists at 5 years. Survival, Oxford Knee Score (OKS), American Knee Society Score (AKSS), and EQ-5D-5L were assessed. The cementless cohort was mainly implanted after the cemented. Each cohort was divided into early and late sub-groups and compared, to assess if any differences were due to progressive improvement in surgical practice over time. RESULTS: There were no significant differences between the cohorts for demographics, pre-operative scores, and 5-year revision (0.8%), re-operation (1.5%), and complication rates (5%). The cementless cohort had significantly better 5-year OKS (43v41, p = 0.008), AKSS-Objective (94v90, p = 0.049) and EQ-5D-5L (0.81v0.87, p = 0.0001). Pain sub-scores within OKS, AKSS, and EQ-5D-5L were also significantly better in the cementless cohort, and the differences were proportionally much greater and more significant than differences in their respective overall scores. There was no significant improvement in scores between the early and late subgroups of the cohorts, whereas the 'early-cementless' cohort had significantly better scores than the contemporaneously implanted 'late-cemented' cohort. This suggests that differences found were due to implant type, instead of improved surgical practice over time. CONCLUSION: Cementless UKR is associated with better clinical outcomes than cemented UKR, which is primarily due to improved pain relief. Both cemented and cementless UKR are safe with low reoperation and complication rates, and a 5-year survival of 99%.

2.
PLoS One ; 16(12): e0261850, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34972159

RESUMO

OBJECTIVE: Identify risk factors for poor pain outcomes six months after primary knee replacement surgery. METHODS: Observational cohort study on patients receiving primary knee replacement from the UK Clinical Practice Research Datalink, Hospital Episode Statistics and Patient Reported Outcomes. A wide range of variables routinely collected in primary and secondary care were identified as potential predictors of worsening or only minor improvement in pain, based on the Oxford Knee Score pain subscale. Results are presented as relative risk ratios and adjusted risk differences (ARD) by fitting a generalized linear model with a binomial error structure and log link function. RESULTS: Information was available for 4,750 patients from 2009 to 2016, with a mean age of 69, of whom 56.1% were female. 10.4% of patients had poor pain outcomes. The strongest effects were seen for pre-operative factors: mild knee pain symptoms at the time of surgery (ARD 18.2% (95% Confidence Interval 13.6, 22.8), smoking 12.0% (95% CI:7.3, 16.6), living in the most deprived areas 5.6% (95% CI:2.3, 9.0) and obesity class II 6.3% (95% CI:3.0, 9.7). Important risk factors with more moderate effects included a history of previous knee arthroscopy surgery 4.6% (95% CI:2.5, 6.6), and use of opioids 3.4% (95% CI:1.4, 5.3) within three months after surgery. Those patients with worsening pain state change had more complications by 3 months (11.8% among those in a worse pain state vs. 2.7% with the same pain state). CONCLUSIONS: We quantified the relative importance of individual risk factors including mild pre-operative pain, smoking, deprivation, obesity and opioid use in terms of the absolute proportions of patients achieving poor pain outcomes. These findings will support development of interventions to reduce the numbers of patients who have poor pain outcomes.


Assuntos
Artroplastia do Joelho , Estudos de Coortes , Humanos , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente
3.
J Clin Epidemiol ; 143: 159-168, 2021 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-34920113

RESUMO

OBJECTIVES: To create estimates for clinically meaningful changes and differences in pain and joint function for the Oxford Hip and Knee Scores (OHS/OKS) in primary and revision joint replacement. STUDY DESIGN AND SETTING: 694,487 primary and revision joint replacement procedures were analyzed from the NHS PROMs dataset between 2012-2020. Minimal important changes (MIC) and differences (MID) were calculated using distribution and anchor-based methods (including receiver-operating characteristic (ROC) curve and predictive-modelling techniques). RESULTS: For comparison of two or more groups (such as in a clinic trial), MID estimates were ∼5 points. For cohort studies investigating changes over time in a single group of patients, MICgroup estimates were 12.4 points (primary hip replacement), 8.6 points (revision hip replacement), 10.5 points (primary knee replacement) and 9.4 points (revision knee replacement). For studies investigating changes over time at the individual patient level, MICadjusted estimates were ∼8 points, ∼6 points, ∼7 points and ∼6 points respectively. CONCLUSION: This study has calculated contemporary estimates of clinically important changes and differences for the OHS/OKS for primary and revision hip and knee replacement. These estimates can be used to inform sample size calculations and to interpret changes in joint function over time and differences between groups.

4.
BMJ Open ; 11(10): e046169, 2021 10 21.
Artigo em Inglês | MEDLINE | ID: mdl-34675009

RESUMO

OBJECTIVES: To identify: (1) patient-reported outcome measures (PROMs) used to evaluate symptoms, health status or quality of life following discretionary revision (or re-revision) knee joint replacement, and (2) validated joint-specific PROMs, their measurement properties and quality of evidence. DESIGN: (1) Scoping review; (2) systematic review following the COnsensus-based Standards for selection of health status Measurement INstruments (COSMIN) checklist. DATA SOURCES: MEDLINE, Embase, AMED and PsycINFO were searched from inception to 1 July 2020 using the Oxford PROM filter unlimited by publication date or language. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies reporting on the development, validation or outcome of a joint-specific PROM for revision knee joint replacement were included. RESULTS: 51 studies reported PROM outcomes using eight joint-specific PROMs. 27 out of 51 studies (52.9%) were published within the last 5 years. PROM development was rated 'inadequate' for each of the eight PROMs studied. Validation studies were available for only three joint-specific PROMs: Knee Injury and Osteoarthritis Outcome Score (KOOS), Lower Extremity Activity Scale (LEAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC). 25 out of 27 (92.6%) measurement properties were rated insufficient, indeterminate or not assessed. The quality of supporting evidence was mostly low or very low. Each of the validated PROMs was rated 'B' (potential for recommendation but require further evaluation). CONCLUSION: Joint-specific PROMs are increasingly used to report outcomes following revision knee joint replacement, but these instruments have insufficient evidence for their validity. Future research should be directed toward understanding the measurement properties of these instruments in order to inform clinical trials and observational studies evaluating the outcomes from joint-specific PROMs.


Assuntos
Artroplastia do Joelho , Lista de Checagem , Nível de Saúde , Humanos , Medidas de Resultados Relatados pelo Paciente , Qualidade de Vida
5.
Plast Reconstr Surg ; 148(5): 753e-763e, 2021 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-34705778

RESUMO

BACKGROUND: The factors typically considered to be associated with Dupuytren disease have been described, such as those in the "Dupuytren diathesis." However, the quality of studies describing them has not been appraised. This systematic review aimed to analyze the evidence for all factors investigated for potential association with the development, progression, outcome of treatment, or recurrence of Dupuytren disease. METHODS: A systematic review of the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature databases was conducted using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant methodology up to September of 2019. Articles were screened in duplicate. Prognostic studies were quality assessed using the Quality in Prognosis Study tool. RESULTS: This study identified 2301 records; 51 met full inclusion criteria reporting data related to 54,491 patients with Dupuytren disease. In total, 46 candidate factors associated with the development of Dupuytren disease were identified. There was inconsistent evidence between the association of Dupuytren disease and the presence of "classic" diathesis factors. The quality of included studies varied, and the generalizability of studies was low. There was little evidence describing the factors associated with functional outcome. CONCLUSIONS: This systematic review challenges conventional notions of diathesis factors. Traditional diathesis factors are associated with disease development and recurrence, although they are not significantly associated with poor outcome following intervention based on the current evidence.

6.
Trials ; 22(1): 678, 2021 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-34620194

RESUMO

BACKGROUND: Randomised controlled trials in surgery can be a challenge to design and conduct, especially when including a non-surgical comparison. As few as half of initiated surgical trials reach their recruitment target, and failure to recruit is cited as the most frequent reason for premature closure of surgical RCTs. The aim of this qualitative evidence synthesis was to identify and synthesise findings from qualitative studies exploring the challenges in the design and conduct of trials directly comparing surgical and non-surgical interventions. METHODS: A qualitative evidence synthesis using meta-ethnography was conducted. Six electronic bibliographic databases (Medline, Central, Cinahl, Embase and PsycInfo) were searched up to the end of February 2018. Studies that explored patients' and health care professionals' experiences regarding participating in RCTs with a surgical and non-surgical comparison were included. The GRADE-CERQual framework was used to assess confidence in review findings. RESULTS: In total, 3697 abstracts and 49 full texts were screened and 26 published studies reporting experiences of patients and healthcare professionals were included. The focus of the studies (24/26) was primarily related to the challenge of recruitment. Two studies explored reasons for non-compliance to treatment allocation following randomisation. Five themes related to the challenges to these types of trials were identified: (1) radical choice between treatments; (2) patients' discomfort with randomisation: I want the best treatment for me as an individual; (3) challenge of equipoise: patients' a priori preferences for treatment; (4) challenge of equipoise: clinicians' a priori preferences for treatment and (5) imbalanced presentation of interventions. CONCLUSION: The marked dichotomy between the surgical and non-surgical interventions was highlighted in this review as making recruitment to these types of trials particularly challenging. This review identified factors that increase our understanding of why patients and clinicians may find equipoise more challenging in these types of trials compared to other trial comparisons. Trialists may wish to consider exploring the balance of potential factors influencing patient and clinician preferences towards treatments before they start recruitment, to enable issues specific to a particular trial to be identified and addressed. This may enable trial teams to make more efficient considered design choices and benefit the delivery of such trials.


Assuntos
Antropologia Cultural , Atitude do Pessoal de Saúde , Pessoal de Saúde , Humanos , Seleção de Pacientes , Pesquisa Qualitativa
7.
Front Bioeng Biotechnol ; 9: 727869, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34485262

RESUMO

Tissue engineering using decellularized whole lungs as matrix scaffolds began as a promise for creating autologous transplantable lungs for patients with end-stage lung disease and can also be used to study strategies for lung regeneration. Vascularization remains a critical component for all solid organ bioengineering, yet there has been limited success in generating functional re-endothelialization of most pulmonary vascular segments. We evaluated recellularization of the blood vessel conduits of acellular mouse scaffolds with highly proliferating, rat pulmonary microvascular endothelial progenitor cells (RMEPCs), pulmonary arterial endothelial cells (PAECs) or microvascular endothelial cells (MVECs). After 8 days of pulsatile perfusion, histological analysis showed that PAECs and MVECs possessed selective tropism for larger vessels or microvasculature, respectively. In contrast, RMEPCs lacked site preference and repopulated all vascular segments. RMEPC-derived endothelium exhibited thrombomodulin activity, expression of junctional genes, ability to synthesize endothelial signaling molecules, and formation of a restrictive barrier. The RMEPC phenotype described here could be useful for identifying endothelial progenitors suitable for efficient vascular organ and tissue engineering, regeneration and repair.

8.
Bone Joint J ; 103-B(10): 1578-1585, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34587801

RESUMO

AIMS: To compare rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications), and compare these with primary arthroplasty and re-revision arthroplasty. METHODS: Patients undergoing primary knee arthroplasty were identified in the national Hospital Episode Statistics (HES) between 1 April 1997 to 31 March 2017. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes, including infection (undergoing surgery), pulmonary embolism, myocardial infarction, and stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications (e.g. loosening, instability, wear) were included in the elective indications cohort. RESULTS: A total of 939,021 primary knee arthroplasty procedures were included (939,021 patients), of which 40,854 underwent subsequent revision arthroplasty, and 9,100 underwent re-revision arthroplasty. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (135/30,826; 95% confidence interval (CI) 0.37 to 0.52) which was comparable to primary knee arthroplasty (0.46%; 4,292/939,021; 95% CI 0.44 to 0.47). Revision arthroplasty for infection was associated with a much higher mortality of 2.04% (184/9037; 95% CI 1.75 to 2.35; odds ratio (OR) 3.54; 95% CI 2.81 to 4.46), as was revision for periprosthetic fracture at 5.25% (52/991; 95% CI 3.94 to 6.82; OR 6.23; 95% CI 4.39 to 8.85). Higher rates of pulmonary embolism, myocardial infarction, and stroke were also observed in the infection and fracture cohort. CONCLUSION: Patients undergoing revision arthroplasty for urgent indications (infection or fracture) are at higher risk of mortality and serious adverse events in comparison to primary knee arthroplasty and revision arthroplasty for elective indications. These findings will be important for patient consent and shared decision-making and should inform service design for this patient cohort. Cite this article: Bone Joint J 2021;103-B(10):1578-1585.


Assuntos
Artroplastia do Joelho/mortalidade , Procedimentos Cirúrgicos Eletivos/mortalidade , Complicações Pós-Operatórias/etiologia , Reoperação/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Bases de Dados Factuais , Inglaterra/epidemiologia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Complicações Pós-Operatórias/epidemiologia , Fatores de Risco
9.
Mater Sci Eng C Mater Biol Appl ; 129: 112414, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34579923

RESUMO

Despite the clinical success of Anterior Cruciate Ligament reconstruction (ACLR) in some patients, unsatisfactory clinical outcomes secondary to graft failure are seen, indicating the need to develop new regeneration strategies. The use of degradable and bioactive textiles has the potential to improve the biological repair of soft tissue. Electrospun (ES) filaments are particularly promising as they have the ability to mimic the structure of natural tissues and influence endogenous cell behaviour. In this study, we produced continuous polycaprolactone (PCL) ES filaments using a previously described electrospinning collection method. These filaments were stretched, twisted, and assembled into woven structures. The morphological, tensile, and biological properties of the woven fabric were then assessed. Scanning electron microscopy (SEM) images highlighted the aligned and ACL-like microfibre structure found in the stretched filaments. The tensile properties indicated that the ES fabric reached suitable strengths for a use as an ACLR augmentation device. Human ACL-derived cell cultured on the fabric showed approximately a 3-fold increase in cell number over 2 weeks and this was equivalent to a collagen coated synthetic suture commonly used in ACLR. Cells generally adopted a more elongated cell morphology on the ES fabric compared to the control suture, aligning themselves in the direction of the microfibres. A NRU assay confirmed that the ES fabric was non-cytotoxic according to regulatory standards. Overall, this study supports the development of ES textiles as augmentation devices for ACLR.


Assuntos
Reconstrução do Ligamento Cruzado Anterior , Ligamento Cruzado Anterior , Ligamento Cruzado Anterior/cirurgia , Humanos , Poliésteres , Têxteis
10.
BMJ Open ; 11(8): e052598, 2021 08 27.
Artigo em Inglês | MEDLINE | ID: mdl-34452970

RESUMO

OBJECTIVES: To evaluate whether a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty offers superior outcomes to traditional outpatient physiotherapy. DESIGN: A prospective, single-blind, two-arm randomised controlled superiority trial. SETTING: 14 National Health Service physiotherapy departments in the UK. PARTICIPANTS: 621 participants identified at high risk of a poor outcome after knee arthroplasty using a bespoke screening tool. INTERVENTIONS: A multicomponent home-based rehabilitation programme delivered by rehabilitation assistants with supervision from qualified therapists versus usual care outpatient physiotherapy. MAIN OUTCOME MEASURES: The primary outcome was the Late-Life Function and Disability Instrument (LLFDI) at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function), Knee injury and Osteoarthritis Outcome Score Quality of Life subscale, Physical Activity Scale for the Elderly, 5 dimension, 5 level version of Euroqol (EQ-5D-5L) and physical function assessed using the Figure of 8 Walk test, 30 s Chair Stand Test and Single Leg Stance. RESULTS: 621 participants were randomised between March 2015 and January 2018. 309 were assigned to CORKA (Community Rehabilitation after Knee Arthroplasty) home-based rehabilitation, receiving a median five treatment sessions (IQR 4-7). 312 were assigned to usual care, receiving a median 4 sessions (IQR 2-6). The primary outcome, LLFDI function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference=0.49 points; 95% CI -0.89 to 1.88; p=0.48). There were no statistically significant differences between the groups on any of the patient-reported or physical secondary outcome measures at 6 or 12 months.There were 18 participants in the intervention group reporting a serious adverse event (5.8%), only one directly related to the intervention, all other adverse events recorded throughout the trial related to underlying chronic medical conditions. CONCLUSIONS: The CORKA intervention was not superior to usual care. The trial detected no significant differences, clinical or statistical, between the two groups on either primary or secondary outcomes. CORKA offers an evaluation of an intervention utilising a different service delivery model for this patient group. TRIAL REGISTRATION NUMBER: ISRCTN13517704.


Assuntos
Artroplastia do Joelho , Idoso , Análise Custo-Benefício , Humanos , Modalidades de Fisioterapia , Estudos Prospectivos , Qualidade de Vida , Método Simples-Cego , Medicina Estatal
11.
Mol Metab ; 53: 101291, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34246806

RESUMO

OBJECTIVE: Type II nuclear hormone receptors, including farnesoid X receptors (FXR), liver X receptors (LXR), and peroxisome proliferator-activated receptors (PPAR), which serve as drug targets for metabolic diseases, are permanently positioned in the nucleus and thought to be bound to DNA regardless of the ligand status. However, recent genome-wide location analysis showed that LXRα and PPARα binding in the liver is largely ligand-dependent. We hypothesized that pioneer factor Foxa2 evicts nucleosomes to enable ligand-dependent binding of type II nuclear receptors and performed genome-wide studies to test this hypothesis. METHODS: ATAC-Seq was used to profile chromatin accessibility; ChIP-Seq was performed to assess transcription factors (Foxa2, FXR, LXRα, and PPARα) binding; and RNA-Seq analysis determined differentially expressed genes in wildtype and Foxa2 mutants treated with a ligand (GW4064 for FXR, GW3965, and T09 for LXRα). RESULTS: We reveal that chromatin accessibility, FXR binding, LXRα occupancy, and ligand-responsive activation of gene expression by FXR and LXRα require Foxa2. Unexpectedly, Foxa2 occupancy is drastically increased when either receptor, FXR or LXRα, is bound by an agonist. In addition, co-immunoprecipitation experiments demonstrate that Foxa2 interacts with either receptor in a ligand-dependent manner, suggesting that Foxa2 and the receptor, bind DNA as an interdependent complex during ligand activation. Furthermore, PPARα binding is induced in Foxa2 mutants treated with FXR and LXR ligands, leading to the activation of PPARα targets. CONCLUSIONS: Our model requires pioneering activity for ligand activation that challenges the existing ligand-independent binding mechanism. We also demonstrate that Foxa2 is required to achieve activation of the proper receptor - one that binds the added ligand - by repressing the activity of a competing receptor.

12.
Knee ; 31: 1-10, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34098487

RESUMO

BACKGROUND: This paper describes the evolutionary changes in morphology and orientation of the PFJ using species present through our ancestry over 340 million years. METHODS: 37 specimens from the Devonian period to modern day were scanned using a 64-slice CT scanner. 3D geometries were created following routine segmentation and anatomical measurements taken from standardised bony landmarks. RESULTS: Findings are described according to gait strategy and age. The adoption of an upright bi-pedal stance caused a dramatic change in the loading of the PFJ which has subsequently led to changes in the arrangement of the PFJ. From Devonian to Miocene periods, our sprawling and climbing ancestors possessed a broad knee with a shallow, centrally located trochlea. A more rounded knee was present from the Paleolithic period onwards in erect and bipedal gait types (aspect ratio 0.93 vs 1.2 in late Devonian), with the PFJ being placed lateral to the midline compared to the medial position in quadrapeds. The depth of the trochlea groove was maximal in the Miocene period of the African ground apes with associated acute sulcus angles in Gorilla (117°) becoming more flattened towards the modern human (138°). CONCLUSIONS: The evolving bipedal gait lead to anteriorisation of the patellofemoral joint, flattening of the trochlea sulcus, in a more lateral, dislocation prone arrangement. Ancestral developments might help explain the variety of presentations of anterior knee pain and patellofemoral instability.


Assuntos
Osteoartrite do Joelho , Dor , Articulação Patelofemoral , Humanos , Joelho , Articulação do Joelho/diagnóstico por imagem
13.
Bone Joint J ; 103-B(6): 1111-1118, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34058866

RESUMO

AIMS: To determine the trajectories of patient reported pain and functional disability over five years following total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS: A prospective, longitudinal cohort sub-study within the National Joint Registry (NJR) was undertaken. In all, 20,089 patients who underwent primary THA and 22,489 who underwent primary TKA between 2009 and 2010 were sent Oxford Hip Score (OHS) and Oxford Knee Score (OKS) questionnaires at six months, and one, three, and five years postoperatively. OHS and OKS were disaggregated into pain and function subscales. A k-means clustering procedure assigned each patient to a longitudinal trajectory group for pain and function. Ordinal regression was used to predict trajectory group membership using baseline OHS and OKS score, age, BMI, index of multiple deprivation, sex, ethnicity, geographical location, and American Society of Anesthesiologists grade. RESULTS: Data described two discrete trajectories for pain and function: 'level 1' responders (around 70% of cases) in whom a high level of improvement is sustained over five years, and 'level 2' responders who had sustained improvement, but at a lower level. Baseline patient variables were only weak predictors of pain trajectory and modest predictors of function trajectory. Those with worse baseline pain and function tended to show a greater likelihood of following a 'level 2' trajectory. Six-month patient-reported outcome measures data reliably predicted the class of five-year outcome trajectory for both pain and function. CONCLUSION: The available preoperative patient variables were not reliable predictors of postoperative pain and function after THA and TKA. Reviewing patient outcomes at six months postoperatively is a reliable indicator of outcome at five years. Cite this article: Bone Joint J 2021;103-B(6):1111-1118.


Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Medidas de Resultados Relatados pelo Paciente , Adulto , Idoso , Avaliação da Deficiência , Inglaterra , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos , Sistema de Registros
14.
BMJ Open ; 11(6): e045353, 2021 06 09.
Artigo em Inglês | MEDLINE | ID: mdl-34108163

RESUMO

OBJECTIVE: Tourniquet use in total knee replacement (TKR) is believed to improve the bone-cement interface by reducing bleeding, potentially prolonging implant survival. This study aimed to compare the risk of revision for primary cemented TKR performed with or without a tourniquet. DESIGN: We analysed data from the National Joint Registry (NJR) for all primary cemented TKRs performed in England and Wales between April 2003 and December 2003. Kaplan-Meier plots and Cox regression were used to assess the influence of tourniquet use, age at time of surgery, sex and American Society of Anaesthesiologists (ASA) classification on risk of revision for all-causes. RESULTS: Data were available for 16 974 cases of primary cemented TKR, of which 16 132 had surgery with a tourniquet and 842 had surgery without a tourniquet. At 10 years, 3.8% had undergone revision (95% CI 2.6% to 5.5%) in the no-tourniquet group and 3.1% in the tourniquet group (95% CI 2.8% to 3.4%). After adjusting for age at primary surgery, gender and primary ASA score, the HR for all-cause revision for cemented TKR without a tourniquet was 0.82 (95% CI 0.57 to 1.18). CONCLUSIONS: We did not find evidence that using a tourniquet for primary cemented TKR offers a clinically important or statistically significant reduction in the risk of all-cause revision up to 13 years after surgery. Surgeons should consider this evidence when deciding whether to use a tourniquet for cemented TKR.


Assuntos
Artroplastia do Joelho , Prótese do Joelho , Artroplastia do Joelho/efeitos adversos , Inglaterra , Humanos , Falha de Prótese , Sistema de Registros , Reoperação , Torniquetes , País de Gales
15.
Knee ; 31: 46-53, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34111801

RESUMO

BACKGROUND: Mobile-bearing medial-unicompartmental knee arthroplasty (mUKA) has a documented learning curve. New instrumentation has been designed with the aim of reducing the technical challenges of this procedure. The primary aim of this study was to evaluate the technical performance of mUKA using new (Microplasty) versus older (Phase III) instrumentation, performed by expert surgeons and trainees. Secondary aims were to evaluate functional outcome and mid-term survivorship. METHODS: A time-based comparative cohort study was performed between 2009 and 2015 at a high-volume centre. 273 patients (273 knees, 49.5% female) of mean age 67.8 (standard deviation 10.1) years underwent mUKA. 153 (56.0%) procedures used Microplasty instruments and 120 procedures (44.0%) used Phase III instruments. RESULTS: Non-optimal bearing usage was less frequent with Microplasty than Phase III instruments (24 knees [15.7%] versus 33 knees [27.5%], p = 0.024), with differences due to improved trainee performance. Femoral component sagittal alignment outliers were less frequent with Microplasty, but this was not statistically significant (9 knees [5.9%] versus 13 knees [10.8%], p = 0.18). Post-operative Oxford Knee Scores (OKS) were better with Microplasty (median 42 points [interquartile range 38-44]) compared to Phase III (median 39.5 points [IQR 33-44]), which was statistically significant (p = 0.023), but not clinically meaningful. The overall 5-year Kaplan-Meier (KM) survival estimate was 99.3% (95% CI 97.0-99.8%), with no differences between Microplasty and Phase III instrumentation. CONCLUSIONS: New instrumentation improved the reliability of the proximal tibial resection in trainees. Further research is warranted to investigate whether Microplasty instrumentation shortens the learning curve for medial UKA.


Assuntos
Artroplastia do Joelho , Prótese do Joelho , Osteoartrite do Joelho , Idoso , Estudos de Coortes , Feminino , Humanos , Articulação do Joelho/diagnóstico por imagem , Articulação do Joelho/cirurgia , Masculino , Osteoartrite do Joelho/diagnóstico por imagem , Osteoartrite do Joelho/cirurgia , Reprodutibilidade dos Testes , Estudos Retrospectivos , Resultado do Tratamento
17.
Artigo em Inglês | MEDLINE | ID: mdl-34052898

RESUMO

INTRODUCTION: There has been an increase in research on the effectiveness of treatment options for the management of meniscal tears. However, there is very little evidence about the patient experiences of meniscal tears. AIM: To summarise the available qualitative evidence on patients' experiences and expectations of meniscal tears. METHOD: A search of EMBASE, Medline, Sociofile and Web of Science up to November 2020 was performed to identify studies reporting patient experiences of meniscal tears. Studies were critically appraised using the CASP (Critical Appraisal Skills Program) checklist, and a meta-synthesis was performed to generate third-order constructs (new themes). RESULTS: Two studies reporting semi-structured interviews from 34 participants (24 male; 10 female) were included. The mean interview length ranged from 16 to 45 min. Five themes were generated: (1) the imaging (MRI) results are a key driver in the decision-making process, (2) surgery is perceived to be the definitive and quicker approach, (3) physiotherapy and exercise is a slower approach which brought success over time, (4) patient perceptions and preferences are important in the clinical decision-making process and, (5) the impact on patient lives is a huge driver in seeking care and treatment decisions. CONCLUSION: This is the first study to summarise the qualitative evidence on patient experiences with meniscal tears. The themes generated demonstrate the importance of patient perceptions of MRI findings and timing of treatment success as important factors in the decision-making process. This study demonstrates the need to strengthen our understanding of patients' experiences of meniscal tears.

18.
Bone Joint J ; 103-B(4): 627-634, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33789485

RESUMO

AIMS: To estimate the measurement properties for the Oxford Knee Score (OKS) in patients undergoing revision knee arthroplasty (responsiveness, minimal detectable change (MDC-90), minimal important change (MIC), minimal important difference (MID), internal consistency, construct validity, and interpretability). METHODS: Secondary data analysis was performed for 10,727 patients undergoing revision knee arthroplasty between 2013 to 2019 using a UK national patient-reported outcome measure (PROM) dataset. Outcome data were collected before revision and at six months postoperatively, using the OKS and EuroQol five-dimension score (EQ-5D). Measurement properties were assessed according to COnsensus-based Standards for the selection of health status Measurement Instruments (COSMIN) guidelines. RESULTS: A total of 9,219 patients had complete outcome data. Mean preoperative OKS was 16.7 points (SD 8.1), mean postoperative OKS 29.1 (SD 11.4), and mean change in OKS + 12.5 (SD 10.7). Median preoperative EQ-5D index was 0.260 (interquartile range (IQR) 0.055 to 0.691), median postoperative EQ-5D index 0.691 (IQR 0.516 to 0.796), and median change in EQ-5D index + 0.240 (IQR 0.000 to 0.567). Internal consistency was good with Cronbach's α 0.88 (baseline) and 0.94 (post-revision). Construct validity found a high correlation of OKS total score with EQ-5D index (r = 0.76 (baseline), r = 0.83 (post-revision), p < 0.001). The OKS was responsive with standardized effect size (SES) 1.54 (95% confidence interval (CI) 1.51 to 1.57), compared to SES 0.83 (0.81 to 0.86) for the EQ-5D index. The MIC for the OKS was 7.5 points (95% CI 5.5 to 8.5) based on the optimal cut-off with specificity 0.72, sensitivity 0.60, and area under the curve 0.66. The MID for the OKS was 5.2 points. The MDC-90 was 3.9 points. The OKS did not demonstrate significant floor or ceiling effects. CONCLUSION: This study found that the OKS was a useful and valid instrument for assessment of outcome following revision knee arthroplasty. The OKS was responsive to change and demonstrated good measurement properties. Cite this article: Bone Joint J 2021;103-B(4):627-634.


Assuntos
Artroplastia do Joelho , Osteoartrite do Joelho/cirurgia , Medidas de Resultados Relatados pelo Paciente , Reoperação , Idoso , Feminino , Humanos , Masculino , Qualidade de Vida , Reino Unido
19.
J Arthroplasty ; 36(8): 2887-2895.e7, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33840536

RESUMO

BACKGROUND: The aim of the study was to investigate changes in patient-reported outcome measures (PROMs) after revision total knee arthroplasty (rTKA). METHODS: A total of 10,727 patients undergoing elective rTKA were recruited from the UK National Health Service PROMs data set from 2013 to 2019. PROMs were collected at baseline and six months to assess joint function (Oxford Knee Score, OKS) and quality of life (EQ-5D). Associations with a change in the OKS (COKS) were investigated through multiple linear regression. RESULTS: The mean COKS was 12.4 (standard deviation 10.7) points. A total of 6776 of 10,329 (65.6%) patients demonstrated increase in the OKS above the minimal important change of 7.5 points. The median change in the EQ-5D utility was 0.227 (interquartile range 0.000 to 0.554). A total of 4917 of 9279 (53.0%) patients achieved a composite endpoint of improvement greater than the minimal important change for joint function and 'better' QoL as per the Paretian analysis. A total of 7477 of 10,727 (69.7%) patients reported satisfaction with rTKA. A total of 7947 of 10,727 (74.1%) patients felt surgery was a success. A total of 4888 of 10,632 (46.0%) patients reported one or more adverse events. A higher preoperative OKS was associated with a lower COKS (coefficient -0.63 [95% confidence interval -0.67 to -0.60]). Other factors associated with a lower COKS were postoperative complication(s), age under 60 years, longer duration of knee problems, patients who identified as disabled, problems in EQ-5D dimensions of anxiety/depression and self-care, comorbid conditions (circulatory problems, diabetes, and depression), and earlier year of procedure in the data set. CONCLUSION: Two-thirds of patients experienced a meaningful improvement in joint function after rTKA. However, there was a high frequency of patient-reported complications. These findings may enable better informed discussion of the risks and benefits of discretionary rTKA.


Assuntos
Artroplastia do Joelho , Qualidade de Vida , Artroplastia do Joelho/efeitos adversos , Humanos , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Satisfação Pessoal , Medicina Estatal
20.
Nat Med ; 27(5): 842-850, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33888899

RESUMO

While CD19-directed chimeric antigen receptor (CAR) T cells can induce remission in patients with B cell acute lymphoblastic leukemia (ALL), a large subset relapse with CD19- disease. Like CD19, CD22 is broadly expressed by B-lineage cells and thus serves as an alternative immunotherapy target in ALL. Here we present the composite outcomes of two pilot clinical trials ( NCT02588456 and NCT02650414 ) of T cells bearing a 4-1BB-based, CD22-targeting CAR in patients with relapsed or refractory ALL. The primary end point of these studies was to assess safety, and the secondary end point was antileukemic efficacy. We observed unexpectedly low response rates, prompting us to perform detailed interrogation of the responsible CAR biology. We found that shortening of the amino acid linker connecting the variable heavy and light chains of the CAR antigen-binding domain drove receptor homodimerization and antigen-independent signaling. In contrast to CD28-based CARs, autonomously signaling 4-1BB-based CARs demonstrated enhanced immune synapse formation, activation of pro-inflammatory genes and superior effector function. We validated this association between autonomous signaling and enhanced function in several CAR constructs and, on the basis of these observations, designed a new short-linker CD22 single-chain variable fragment for clinical evaluation. Our findings both suggest that tonic 4-1BB-based signaling is beneficial to CAR function and demonstrate the utility of bedside-to-bench-to-bedside translation in the design and implementation of CAR T cell therapies.


Assuntos
Ligante 4-1BB/metabolismo , Imunoterapia Adotiva/métodos , Leucemia-Linfoma Linfoblástico de Células Precursoras/terapia , Receptores de Antígenos Quiméricos/metabolismo , Lectina 2 Semelhante a Ig de Ligação ao Ácido Siálico/metabolismo , Linfócitos T/transplante , Adulto , Animais , Antígenos CD19/metabolismo , Linfócitos B/imunologia , Antígenos CD28/genética , Células Cultivadas , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Camundongos , Leucemia-Linfoma Linfoblástico de Células Precursoras/patologia , Linfócitos T/imunologia , Membro 9 da Superfamília de Receptores de Fatores de Necrose Tumoral/metabolismo , Ensaios Antitumorais Modelo de Xenoenxerto
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