Culture-negative Peri-prosthetic Joint Infection after Total Hip Arthroplasty Treatment Protocol and Outcomes in Acute and Chronic Cases.

The treatment of culture-negative periprosthetic joint infections (CN PJI) of the hip represents complex entities. We, as a result of this, report on 12 cases. Irrigation and debridement (I&D) with implant retention were performed in acute cases and two-stage revisions in chronic infections. Combined antibiotic therapy was administered in all cases for 12 weeks. Infection control was achieved in all patients with an infection-free rate of 100% at 7.5 years of average follow-up.

A Psycholgical Intervention Delivered by Automated Mobile Phone Messaging Stabilized Hip and Knee Function During the COVID-19 Pandemic: A Randomized Controlled Trial.

BACKGROUND: We conducted a randomized controlled trial to evaluate the effectiveness of acceptance and commitment therapy (ACT) delivered via a mobile phone messaging robot to patients who had their total hip arthroplasty or total knee arthroplasty procedures postponed due to the COVID-19 pandemic. METHODS: Ninety patients scheduled for total hip arthroplasty or total knee arthroplasty who experienced surgical delay due to the COVID-19 pandemic were randomized to the ACT group, receiving 14 days of twice daily automated mobile phone messages, or the control group, who received no messages. Minimal clinically important differences (MCIDs) in preintervention and postintervention patient-reported outcome measures were utilized to evaluate the intervention. RESULTS: Thirty-eight percent of ACT group participants improved and achieved MCID on the Patient-Reported Outcome Measure Information System Physical Health compared to 17.5% in the control group (P = .038; number needed to treat [NNT] 5). For the joint-specific Hip Disability and Osteoarthritis Outcome Score Joint Replacement and Knee Disability and Osteoarthritis Outcome Score Joint Replacement (KOOS JR), 24% of the ACT group achieved MCID compared to 2.5% in the control group (P = .004; NNT 5). An improvement in the KOOS JR was found in 29% of the ACT group compared to 4.2% in the control group (P = .028; NNT 5). Fourteen percent of the ACT group participants experienced a clinical important decline in the KOOS JR compared to 41.7% in the control group (P = .027; NNT 4). CONCLUSION: A psychological intervention delivered via a text messaging robot improved physical function and prevented decline in patient-reported outcome measures in patients who experienced an unexpected surgical delay during the COVID-19 pandemic. LEVEL OF EVIDENCE: 1.

Protrusio acetabular en artroplastía total de cadera: diez tácticas para un buen resultado quirúrgico / Total hip arthroplasty in protrusio acetabuli: ten tips to improve surgical outcomes

Los pacientes candidatos a artroplastía total de cadera con protrusio acetabular asociada generan distintos desafíos en los equipos quirúrgicos. Múltiples estrategias han sido utilizadas a lo largo de los años para optimizar los resultados. Mediante una revisión de la evidencia actualizada disponible, proponemos diez tácticas a realizar en el manejo de estos pacientes que pueden mejorar y hacer predecible el tratamiento de un paciente con protrusio acetabular al que se le realiza una artroplastía total de cadera. Nivel de Evidencia V.

Patients with acetabular protrusio and osteoarthritis are a challenge for the surgical team. Many strategies have been developed to anticipate, plan and optimize the surgical results of these patients. Based on the current available clinical evidence, we propose ten tips to improve the surgical management of hip arthroplasty patients with protrusio acetabuli. Level of Evidence V.

Lumbar Spine Fusion and Symptoms of Leg Length Discrepancy After Hip Arthroplasty.

BACKGROUND: Hip length discrepancy (HLD) is common after total hip arthroplasty (THA); however, the effect of spinal fusion on perceived leg length discrepancy (LLD) symptoms after THA has not been examined. This study tested the hypothesis that LLD symptoms are increased in patients who underwent lumbar spinal fusion and THA, compared with patients with THA only. METHODS: This retrospective cohort study included 67 patients who underwent lumbar spinal fusion and THA, along with 78 matched control patients who underwent THA only. Hip and spine measurements were taken on postoperative, standing anterior-posterior pelvic, lateral lumbar, and anterior-posterior lumbar spinal radiographs. Perceived LLD symptoms were assessed via telephone survey. RESULTS: Between the spinal fusion and control groups, there was no significant difference in HLD (M = 7.10 mm, SE = 0.70 and M = 5.60 mm, SE = 0.49) (P = .403). The spinal fusion patients reported more frequently noticing a difference in the length of their legs than the control group (P = .046) and reported limping "all the time" compared with the control group (P = .001). Among all patients with an HLD ≤10 mm, those in the spinal fusion group reported limping at a higher frequency than patients in the control group (P = .008). Patients in the spinal fusion group were also more likely to report worsened back pain after THA (P = .011) than the control group. CONCLUSION: Frequencies of a perceived LLD, limping, and worsened back pain after THA were increased in patients with THA and a spinal fusion compared with patients who had THA only, even in a population with HLD traditionally considered to be subclinical. The results indicate that in patients with prior spinal fusion, precautions should be taken to avoid even minor LLD in the setting of THA.

Fretting Corrosion, Third-Body Polyethylene Damage, and Cup Positioning in Primary vs Revision Dual Mobility Total Hip Arthroplasty.

BACKGROUND: Dual mobility (DM) articulations were introduced for total hip arthroplasty to reduce the risk of instability for patients who have a high risk of dislocation. The use of DM constructs in both primary and revision total hip arthroplasty has been steadily increasing, leading to concerns regarding potential risks of fretting corrosion, polyethylene wear, metal release, and failure due to component positioning. METHODS: A total of 56 retrieved DM constructs were collected. The inner and outer polyethylene liner surfaces were assessed for 7 damage mechanisms, and fretting corrosion was evaluated for the femoral stem, head, and modular liner. Three polyethylene liners with the greatest amounts of embedded debris were examined using scanning electron microscopy. Energy-dispersive X-ray spectroscopy was used to determine the elemental content of the debris. Acetabular cup orientation was analyzed radiographically using the EBRA (Einzel-Bild-Roentgen-Analyse) method. RESULTS: The devices were revised most frequently for infection (36%), loosening (21%), and instability/dislocation (18%). The most common polyethylene damage mechanisms were scratching, pitting, burnishing, and embedded debris, and no difference in total damage was found between primary and revision cases. Scanning electron microscopy/energy-dispersive X-ray spectroscopy revealed that debris morphology and composition were consistent with porous titanium coating, resulting from cup loosening or broken screws and augments. A total of 71% and 50% of the constructs were determined to be within the Lewinnek safe zone for inclination and anteversion, respectively. CONCLUSION: The most notable mechanisms of surface damage were due to third-body debris, especially for the polyethylene surfaces which articulate against cobalt-chromium femoral heads and acetabular liners. Scratching of the femoral head and the metal liner from this debris may support the clinical use of ceramic for DM bearing surfaces in the future.

Economic Impact of Outpatient Medicare Total Knee Arthroplasty at a Tertiary Care Academic Medical Center.

BACKGROUND: In January 2018, the Center for Medicare and Medicaid Services (CMS) removed total knee arthroplasty (TKA) from the inpatient-only list. This impacted hospital reimbursement, Comprehensive Joint Replacement (CJR) bundle volumes, and bundle performance. We describe these impacts at an academic teaching hospital. METHODS: We reviewed CJR bundle data provided by CMS and internal databases to identify the shift in CJR TKA episode volume since January 2018, the impact on postacute care (PAC) utilization rates and readmissions, financial impact to the bundle, and impact on hospital reimbursement. We used data provided to CJR participants, internal hospital sources, and the Medicare Limited Data Set. RESULTS: Between 2017 and 2018, CJR TKA episodes decreased from 91 to 51 (44% reduction). Inpatient PAC utilization was significantly higher in 2018 (20% vs 8%). The 90-day readmission rates increased from 5.5% to 12.7%. Average variance to target dropped from 15% to 5%. Average CMS reimbursement for TKA at our institution in 2019 was $14,823 for inpatients and $9299 for outpatients. We experienced $930,463 in decreased reimbursement from January 2018 to September 2019 as a result of the shift from inpatient to outpatient. In addition, we expect $625,143 in decreased incentive payments as higher functioning and lower cost outpatient TKAs are excluded from CJR. CONCLUSION: Although CMS projected a minimal impact on CJR bundle participants, this has not been the case at our institution. We experienced reduced volumes, increased PAC utilization, and a substantial financial impact. We expect a similar outcome when CMS removes total hip arthroplasty from the inpatient-only list.

Design, Material, and Seating Load Effects on In Vitro Fretting Corrosion Performance of Modular Head-Neck Tapers.

BACKGROUND: The short-term corrosion and micromechanical behavior of 32 unique head-neck taper design/material/assembly conditions was tested using an incremental cyclic fretting corrosion (ICFC) test method previously developed. METHODS: Seven materials, design, and simulated surgical parameters were evaluated, each being assigned 2 conditions for testing, using a 27-2 (7 factor, quarter factorial) design of experiments test matrix. The factors explored were (1) seating load, (2) head-neck offset, (3) material combination, (4) taper diameter, (5) taper roughness, (6) angular mismatch/engagement, and (7) taper length. Each sample underwent assembly, ICFC testing, pull off. RESULTS: Low seating load and high head offset correlated with increased fretting corrosion (P < .05). High head offset also contributed to a lower onset load for fretting current and higher micromotion (P < .05). Head subsidence measured over the ICFC test for samples seated at 100 N was significantly higher than samples seated at 4000 N. Micromotion for 12-mm head offsets was statistically higher than samples with a 1.5-mm head offset. A number of interactive effects were observed. For example, samples seated at 4000 N were less sensitive to head offset than samples seated at 100 N in terms of the resulting fretting current. CONCLUSION: Taper locking position, material combination, taper engagement length, taper roughness, and taper dimensions all had weak or no correlation with fretting current and taper micromotion. This test method and experimental design is a versatile means of assessing potential new taper designs in the future.

Photobiomodulation therapy (PBMT) on acute pain and inflammation in patients who underwent total hip arthroplasty-a randomized, triple-blind, placebo-controlled clinical trial.

When conservative treatments fail, hip osteoarthritis (OA), a chronic degenerative disease characterized by cartilage wear, progressive joint deformity, and loss of function, can result in the need for a total hip arthroplasty (THA). Surgical procedures induced tissue trauma and incite an immune response. Photobiomodulation therapy (PBMt) using low-level laser therapy (LLLT) and/or light-emitting diode therapy (LEDT) has proven effective in tissue repair by modulating the inflammatory process and promoting pain relief. Therefore, the aim of this study was to analyze the immediate effect of PBMt on inflammation and pain of patients undergoing total hip arthroplasty. The study consisted of 18 post-surgical hip arthroplasty patients divided into two groups (n = 9 each) placebo and active PBMt who received one of the treatments in a period from 8 to 12 h following THA surgery. PBMt (active or placebo) was applied using a device consisting of nine diodes (one super-pulsed laser of 905 nm, four infrared LEDs of 875 nm, and four red LEDs 640 nm, 40.3 J per point) applied to 5 points along the incision. Visual analog scale (VAS) and blood samples for analysis of the levels of the cytokines TNF-α, IL-6, and IL-8 were recorded before and after PBMt application. The values for the visual analog scale as well as those in the analysis of TNF-α and IL-8 serum levels decreased in the active PBMt group compared to placebo-control group (p < 0.05). No decrease was observed for IL-6 levels. We conclude that PBMt is effective in decreasing pain intensity and post-surgery inflammation in patients receiving total hip arthroplasty.

Primary Total Hip Arthroplasty With Fourth-Generation Ceramic-on-Ceramic: Analysis of Complications in 939 Consecutive Cases Followed for 2-10 Years.

BACKGROUND: Delta ceramics may be the bearing of choice for younger and active patients due to its improved toughness and wear characteristics, provided there is no risk of fracture. However, ceramic fracture is the most serious complication related to this type of bearing. Although millions of Delta ceramics have been implanted worldwide, short to midterm results have been scarcely reported in the literature. The purpose of this study was to report the complication rate at short to midterm follow-up associated with the bearing surface used in a series of primary total hip arthroplasties with Delta ceramic-on-ceramic bearings performed in a single institution. METHODS: A total of 939 cases (880 patients) undergoing primary total hip arthroplasty with fourth-generation Delta ceramic-on-ceramic bearings were retrospectively reviewed. They were followed for an average of 5.3 years (2-10 years). RESULTS: One hip experienced a liner fracture, 2 cups presented early loosening due to friction between the acetabular screw and the backside of the liner, one femoral ball head had a fracture; one case of squeaking was reported, which is impending revision. Considering revision or impending revision in relationship with the bearing surface as the end point, the mean survival rate was 99.3% (confidence interval 95%, 98.3%-99.7%) at 2-10 years. CONCLUSION: This study showed a low rate of ceramic fracture compared with others; however, it was much higher than the complication rate presented by the manufacturers. The complications observed were directly related to technical errors that surgeons should avoid when using this type of surface.

Acetabular component positioning in total hip arthroplasty with and without a computer-assisted system: a prospective, randomized and controlled study.

In a study of the acetabular component in total hip arthroplasty, 20 hips were operated on using imageless navigation and 20 hips were operated on using the conventional method. The correct position of the acetabular component was evaluated with computed tomography, measuring the operative anteversion and the operative inclination and determining the cases inside Lewinnek's safe zone. The results were similar in all the analyses: a mean anteversion of 17.4° in the navigated group and 14.5° in the control group (P=.215); a mean inclination of 41.7° and 42.2° (P=.633); a mean deviation from the desired anteversion (15°) of 5.5° and 6.6° (P=.429); a mean deviation from the desired inclination of 3° and 3.2° (P=.783); and location inside the safe zone of 90% and 80% (P=.661). The acetabular component position's tomography analyses were similar whether using the imageless navigation or performing it conventionally.

Integralidade e humanização: experiências locais de atenção à saúde / Integrality and humanization in caregiving by health services

A assimilação da integralidade nos serviços e práticas de saúde promove a identificação da demanda local e garante acesso a todos os níveis de atenção. Nesse sentido, uma abordagem profissional mais humanizada, valorizando o outro e considerando sua subjetividade, pode garantir resultados mais eficientes no tratamento das doenças. Através de uma pesquisa de natureza exploratória, procurou-se identificar quais as representações que prevalecem entre usuários e profissionais de saúde quanto aos princípios da Integralidade e Humanização no atendimento. Foram realizadas entrevistas semiestruturadas e observação direta. O campo empírico compreendeu a região de abrangência do Programa Saúde da Família de um bairro da periferia, no município de Viçosa-MG. Evidenciou-se a existência de uma relação profissional/usuário distanciada, e a necessidade de maior conscientização da população sobre a importância da prevenção. A operacionalização da integralidade e da humanização deve incorporar o papel educativo das ações em saúde, de forma participativa, dialógica, incluindo práticas e saberes locais.

The assimilation of an integrated approach in health services and practices promotes the identification of local demand, and ensures access to all levels of care. In this sense, a more humanized professional approach, valuing others and considering their subjectivity, can ensure more efficient results in treating disease. Thus, through an exploratory research study, we sought to identify the representations that prevail among users and health professionals about the principles of integrality and humanization of care. In our methodological approach, we conducted semi-structured interviews and direct observation. The empirical included the region covered by the Family Health Program in an outlying neighborhood in the city of Viçosa, Minas Gerais state. The results revealed a distanced relationship between professional and user, and the need for greater public awareness of the importance of prevention. The implementation of integrality and humanization of health practices should incorporate the educational role of health actions, in a participatory and dialogical process including local knowledge and practices.

Nietzsche e Théodule Ribot: Psicologia e Seperação da Metafísica / Theodule Ribot Nietzsche and: Psychology and the Overcoming of Metaphysics

Embora Nietzsche não cite explicitamente em seus textos o psicólogo e filósofo francês Théodule Ribot, a semelhança entre algumas noções do filósofo alemão e de Ribot é inquestionável: a proposta de uma nova psicologia não metafísica (uma psicofisiologia); a continuidade entre o físico, o biológico (fisiológico) e o psicológico (moral e cultural); o corpo, a vontade e o sujeito enquanto multiplicidades; a saúde enquanto presença de um centro de coordenação; etc. O objetivo deste artigo é investigar a proposta, presente nos dois autores, de uma psicologia ou psicofisiologia que supere a psicologia metafísica, ou seja, que rejeite a investigação da alma e de suas faculdades. No entanto, há uma diferença axial entre o filósofo alemão e Ribot: enquanto a psicofisiologia francesa é uma morfologia de reflexos, que são processos físico-químicos e, portanto, materiais, a psicofisiologia nietzschiana é uma morfologia da vontade de potência, que é um processo impulsional de crescimento de potência, e esses impulsos não são nem corporais nem espirituais.

Although Nietzsche does not mention in his writings the French philosopher and psychologist Théodule Ribot, there are some similarities between them: a proposal for a new psychology (a no metaphysical psychophysiology); the continuity among the physical, the biological (physiology) and psychological (morality and culture) phenomena; the multiplicity of the body, the will and the "ego"; the health as the presence of a center of coordination; etc. The aim of this paper is the proposal of a new psychology or a psychophysiology to overcome the metaphysical psychology, i.e., to reject the investigation of the soul and its faculties. However, there is an ultimate difference between Nietzsche and Ribot: the French psychophysiology is a morphology of nervous states (physical-chemical processes, and thus material processes), and the Nietzschean psychophysiology is a morphology of will to power, which is a process of increase of power, and thus no bodily or spiritual process.

Nitrogen and sulphur in Marandu grass: relationship between supply and concentration in leaf tissues

In order to better assess the nutritional status of forage grasses there has been an increasing interest in studying the nutrient concentrations present in different parts of plant shoot. The aim of this work was to evaluate the nitrogen and sulphur concentrations in leaf tissues of Brachiaria brizantha cv. Marandu grown in nutrient solutions with combined rates of both nitrogen and sulphur. An experiment was conducted in a greenhouse during the Spring season in Piracicaba-SP, Brazil, using ground quartz as substrate. A fractionated 5² factorial design was used, with 13 combinations of nitrogen and sulphur rates in the solutions, in mg L-1, as follows: 14 and 3.2; 14 and 32; 14 and 80; 126 and 12.8; 126 and 64; 210 and 3.2; 210 and 32; 210 and 80; 336 and 12.8; 336 and 64; 462 and 3.2; 462 and 32, and 462 and 80. The experimental units were set in a randomized block design, with four replications. Plants were harvested twice. Emerging leaves, recently expanded lamina and mature lamina were sampled separately at each harvest time. In these three types of tissues the nitrogen concentration was closely related to the nitrogen supply in the solution, whereas the sulphur concentration, N:S ratio and chlorophyll meter (SPAD) readings depended upon the supply of both nitrogen and sulphur. Mature lamina did not relate well to the changing in sulphur supply. To properly assess the nitrogen and sulphur concentrations, N:S ratio and SPAD readings for the Marandu grass, the two recently expanded lamina were the best tissues to indicate the availability of both nitrogen and sulphur in the nutrient solution.

Há clara demanda de conhecimento da concentração de nutrientes nos componentes da parte aérea das plantas para subsidiar a avaliação do estado nutricional das gramíneas forrageiras. Para contribuir nessa área, objetivou-se avaliar as concentrações de nitrogênio e enxofre em tecidos foliares da Brachiaria brizantha cv. Marandu, cultivada em solução nutritiva com doses combinadas de nitrogênio e de enxofre. Foi conduzido um experimento em casa de vegetação no período da primavera, em Piracicaba-SP, empregando sílica como substrato. Utilizou-se um esquema fatorial 5² fracionado, com 13 combinações das doses de nitrogênio e enxofre na solução, em mg L-1: 14 e 3,2; 14 e 32; 14 e 80; 126 e 12,8; 126 e 64; 210 e 3,2; 210 e 32; 210 e 80; 336 e 12,8; 336 e 64; 462 e 3,2; 462 e 32 e 462 e 80. As unidades experimentais foram distribuídas segundo o delineamento de blocos ao acaso, com quatro repetições. Foram realizados dois cortes nas plantas e, em cada um, foram amostradas as folhas emergentes, as lâminas de folhas recém-expandidas e as lâminas de folhas maduras. Nos três tipos de tecidos amostrados, a concentração de nitrogênio foi estritamente relacionada ao suprimento de nitrogênio, enquanto a concentração de enxofre, a relação N:S e o valor SPAD dependeram do fornecimento tanto de nitrogênio como de enxofre. As lâminas de folhas maduras não refletiram a variação no suprimento de enxofre. Na avaliação das concentrações de nitrogênio e de enxofre, da relação N:S e do valor SPAD no capim-Marandu as lâminas de folhas recém-expandidas foram as melhores indicadoras da disponibilidade de nitrogênio e enxofre no meio de crescimento.

Nitrogen and sulphur in Marandu grass: relationship between supply and concentration in leaf tissues

In order to better assess the nutritional status of forage grasses there has been an increasing interest in studying the nutrient concentrations present in different parts of plant shoot. The aim of this work was to evaluate the nitrogen and sulphur concentrations in leaf tissues of Brachiaria brizantha cv. Marandu grown in nutrient solutions with combined rates of both nitrogen and sulphur. An experiment was conducted in a greenhouse during the Spring season in Piracicaba-SP, Brazil, using ground quartz as substrate. A fractionated 5² factorial design was used, with 13 combinations of nitrogen and sulphur rates in the solutions, in mg L-1, as follows: 14 and 3.2; 14 and 32; 14 and 80; 126 and 12.8; 126 and 64; 210 and 3.2; 210 and 32; 210 and 80; 336 and 12.8; 336 and 64; 462 and 3.2; 462 and 32, and 462 and 80. The experimental units were set in a randomized block design, with four replications. Plants were harvested twice. Emerging leaves, recently expanded lamina and mature lamina were sampled separately at each harvest time. In these three types of tissues the nitrogen concentration was closely related to the nitrogen supply in the solution, whereas the sulphur concentration, N:S ratio and chlorophyll meter (SPAD) readings depended upon the supply of both nitrogen and sulphur. Mature lamina did not relate well to the changing in sulphur supply. To properly assess the nitrogen and sulphur concentrations, N:S ratio and SPAD readings for the Marandu grass, the two recently expanded lamina were the best tissues to indicate the availability of both nitrogen and sulphur in the nutrient solution.

Há clara demanda de conhecimento da concentração de nutrientes nos componentes da parte aérea das plantas para subsidiar a avaliação do estado nutricional das gramíneas forrageiras. Para contribuir nessa área, objetivou-se avaliar as concentrações de nitrogênio e enxofre em tecidos foliares da Brachiaria brizantha cv. Marandu, cultivada em solução nutritiva com doses combinadas de nitrogênio e de enxofre. Foi conduzido um experimento em casa de vegetação no período da primavera, em Piracicaba-SP, empregando sílica como substrato. Utilizou-se um esquema fatorial 5² fracionado, com 13 combinações das doses de nitrogênio e enxofre na solução, em mg L-1: 14 e 3,2; 14 e 32; 14 e 80; 126 e 12,8; 126 e 64; 210 e 3,2; 210 e 32; 210 e 80; 336 e 12,8; 336 e 64; 462 e 3,2; 462 e 32 e 462 e 80. As unidades experimentais foram distribuídas segundo o delineamento de blocos ao acaso, com quatro repetições. Foram realizados dois cortes nas plantas e, em cada um, foram amostradas as folhas emergentes, as lâminas de folhas recém-expandidas e as lâminas de folhas maduras. Nos três tipos de tecidos amostrados, a concentração de nitrogênio foi estritamente relacionada ao suprimento de nitrogênio, enquanto a concentração de enxofre, a relação N:S e o valor SPAD dependeram do fornecimento tanto de nitrogênio como de enxofre. As lâminas de folhas maduras não refletiram a variação no suprimento de enxofre. Na avaliação das concentrações de nitrogênio e de enxofre, da relação N:S e do valor SPAD no capim-Marandu as lâminas de folhas recém-expandidas foram as melhores indicadoras da disponibilidade de nitrogênio e enxofre no meio de crescimento.