Intrafocal injection of tranexamic acid decreases early return to hospital after high tibial osteotomy.

INTRODUCTION: High tibial osteotomy (HTO) is a surgery performed to treat the symptoms and prevent the progression of medial osteoarthritis. Post-operative bleeding has led to early returns to hospital following surgery. Intrafocal injection of tranexamic acid (TXA) could reduce this bleeding complication. The objective of the study was to evaluate the effect of TXA during HTO on the incidence of post-operative complications and early returns to hospital. MATERIALS AND METHODS: This retrospective study included 251 cases of HTO performed between May 2012 and October 2021, with the use of TXA introduced in May 2017. The experimental (n = 102) and control (n = 149) groups were compared as to the rate of post-operative early returns. The influence of confounding factors was evaluated, including age, sex, body mass index (BMI), tobacco use, grade of medial femorotibial osteoarthritis (MFTO), magnitude of angular correction (MAC), and surgery duration. RESULTS: No statistically significant difference was found between the groups with regards to all variables except age. The experimental group was significantly older (54.4 years; σ = 7.5) than the control group (50.4 years; σ = 7.9; p < 0.001). We observed a decrease in emergency department (ED) visits in the experimental group (15.7%) compared to the control (30.2%; p = 0.008) and a decrease in early returns in the experimental group (28.4%) compared to the control (40.5%; p = 0.049). No statistically significant difference in demographic data, MFTO, or MAC was found among patients with and without an early return, in both the experimental and control groups. CONCLUSION: The intrafocal injection of TXA during HTO decreases early returns to hospital.

Epigenetic regulation of 15-lipoxygenase-1 expression in human chondrocytes by promoter methylation.

OBJECTIVE AND DESIGN: 15-Lipoxygenase-1 (15-LOX-1) catalyzes the biosynthesis of many anti-inflammatory and immunomodulatory lipid mediators and was reported to have protective properties in several inflammatory conditions, including osteoarthritis (OA). This study was designed to evaluate the expression of 15-LOX-1 in cartilage from normal donors and patients with OA, and to determine whether it is regulated by DNA methylation. METHODS: Cartilage samples were obtained at autopsy from normal knee joints and from OA-affected joints at the time of total knee joint replacement surgery. The expression of 15-LOX-1 was evaluated using real-time polymerase chain reaction (PCR). The role of DNA methylation in 15-LOX-1 expression was assessed using the DNA methyltransferase inhibitor 5-Aza-2'-desoxycytidine (5-Aza-dC). The effect of CpG methylation on 15-LOX-1 promoter activity was evaluated using a CpG-free luciferase vector. The DNA methylation status of the 15-LOX-1 promoter was determined by pyrosequencing. RESULTS: Expression of 15-LOX-1 was upregulated in OA compared to normal cartilage. Treatment with 5-Aza-dC increased 15-LOX-1 mRNA levels in chondrocytes, and in vitro methylation decreased 15-LOX-1 promoter activity. There was no difference in the methylation status of the 15-LOX-1 gene promoter between normal and OA cartilage. CONCLUSION: The expression level of 15-LOX-1 was elevated in OA cartilage, which may be part of a repair process. The upregulation of 15-LOX-1 in OA cartilage was not associated with the methylation status of its promoter, suggesting that other mechanisms are involved in its upregulation.

Unsupervised registration of 3D knee implant components to biplanar X-ray images.

BACKGROUND: Registration of three-dimensional (3D) knee implant components to radiographic images provides the 3D position of the implants which aids to analyze the component alignment after total knee arthroplasty. METHODS: We present an automatic 3D to two-dimensional (2D) registration using biplanar radiographic images based on a hybrid similarity measure integrating region and edge-based information. More precisely, this measure is herein defined as a weighted combination of an edge potential field-based similarity, which represents the relation between the external contours of the component projections and an edge potential field estimated on the two radiographic images, and an object specificity property, which is based on the distinction of the region-label inside and outside of the object. RESULTS: The accuracy of our 3D/2D registration algorithm was assessed on a sample of 64 components (32 femoral components and 32 tibial components). In our tests, we obtained an average of the root mean square error (RMSE) of 0.18 mm, which is significantly lower than that of both single similarity methods, supporting our hypothesis of better stability and accuracy with the proposed approach. CONCLUSION: Our method, which provides six accurate registration parameters (three rotations and three translations) without requiring any fiducial markers, makes it possible to perform the important analyses on the rotational alignment of the femoral and tibial components on a large number of cases. In addition, this method can be extended to register other implants or bones.

Bicruciate-retaining total knee arthroplasty non-inferior to posterior-stabilized prostheses after 5 years: a randomized, controlled trial.

PURPOSE: Bicruciate-retaining (BCR) prostheses may improve satisfaction of patient undergoing total knee arthroplasty (TKA). The objective of this randomized controlled trial was to assess whether BCR prostheses provide better clinical outcomes than posterior-stabilized (PS) prostheses. MATERIALS AND METHODS: This is a randomized single-blind control trial involving a total of 77 patients with knee osteoarthritis, randomly assigned to undergo TKA with a BCR or PS implant between 2015 and 2019. Mean follow-up period was 39 months. Clinical and demographic data were extracted manually from medical records. Data acquisition included patient demographics, knee range of motion, and patient-reported outcomes via KSS, KOOS, WOMAC, and SF-12 scores. RESULTS: A total of 38 patients were randomized to the PS group and 39 to the BCR group. At the 5-year follow-up, no statistical differences were noted for knee range of motion or patient-reported outcomes between the two groups, except for a greater knee flexion in the early follow-up period in the PS group. Five adverse events occurred in the BCR group compared to none in the PS group (p = 0.02). CONCLUSION: BCR TKA yield similar clinical and patient-reported outcomes 5 years following the intervention compared with PS TKA. The BCR TKA had more complications. LEVEL OF EVIDENCE: I (Randomized Controlled Trial).

Arthroscopic-assisted robotic bi-unicompartmental knee arthroplasty: a pilot cadaveric study.

INTRODUCTION: Although bicondylar arthroplasty showed great functional results, it encounters some difficulties to be performed routinely. On the other hand, arthroscopic techniques tend to replace open surgical techniques in sports medicine but strive to be developed in the field of arthroplasty. This study aimed to assess the feasibility of a micro-invasive bi-compartmental knee arthroplasty using both arthroscopic and robotic technologies (A-BiUKA). MATERIALS AND METHODS: The study was conducted on complete fresh-frozen and embalmed cadaveric specimens. The main criterion of judgment was the successful positioning of trial implants through a minimal quad-sparing approach. Arthroscopy was used for bone-morphing and burring, supported by an image-free robotic system. Secondary criteria of judgment were axial deviation (measured using the navigation system), operating time, and incision length. RESULTS: Ten A-BiUKA were performed. Implantation was successful in all cases. The mean preoperative frontal deviation was 179.8° ± 3.2 [175: 185], the mean postoperative frontal deviation was 178.5° ± 2.2 [175: 182], without any outliers. The mean correction was 1.7° ± 1.6 [0: 5]. Once the eight first A-UKA were performed, constituting the learning curve, the mean operative time for the remaining twelves surgeries was 90 min ± 6. The mean skin incision length was 3.35 cm ± 0.13 [3: 4]. CONCLUSION: Associated arthroscopic and robotic technologies allows to perform Bi-UKA procedure using a quad sparing mini-invasive approach. Clinical prospective studies have to confirm the feasibility and the clinical outcomes of this surgery.

Use of IMMPACT Recommendations to Explore Pain Phenotypes in People with Knee Osteoarthritis.

OBJECTIVE: Knee osteoarthritis (OA) is a disease of multiple phenotypes of which a chronic pain phenotype (PP) is known. Previous PP studies have focused on one domain of pain and included heterogenous variables. We sought to identify multidimensional PPs using the IMMPACT recommendations and their relationship to clinical outcomes. METHODS: Participants >40 years of age with knee OA having a first-time orthopedic consultation at five university affiliated hospitals in Montreal, Quebec, and Hamilton (Canada) were recruited. Latent profile analysis was used to determine PPs (classes) using variables recommended by IMMPACT. This included pain variability, intensity and qualities, somatization, anxiodepressive symptoms, sleep, fatigue, pain catastrophizing, neuropathic pain, and quantitative sensory tests. We used MANOVA and χ2 tests to assess differences in participant characteristics across the classes and linear and Poisson regression to evaluate the association of classes to outcomes of physical performance tests, self-reported function and provincial healthcare data. RESULTS: In total, 343 participants were included (mean age 64 years, 64% female). Three classes were identified with increasing pain burden (class3 > class1), characterized by significant differences across most self-report measures and temporal summation, and differed in terms of female sex, younger age, lower optimism and pain self-efficacy. Participants in class2 and class3 had significantly worse self-reported function, stair climb and 40 m walk tests, and higher rates of healthcare usage compared to those in class1. CONCLUSIONS: Three distinct PPs guided by IMMPACT recommendations were identified, predominated by self-report measures and temporal summation. Using this standardized approach may improve PP study variability and comparison.

The Effect of Adductor Canal Block on Knee Extensor Muscle Strength 6 Weeks After Total Knee Arthroplasty: A Randomized, Controlled Trial.

BACKGROUND: Total knee arthroplasty (TKA) reduces knee extensor muscle strength (KES) in the operated limb for several months after the surgery. Immediately after TKA, compared to either inguinal femoral nerve block or placebo, adductor canal block (ACB) better preserves KES. Whether this short-term increase in KES is maintained several weeks after surgery remains unknown. We hypothesized that 48 hours of continuous ACB immediately after TKA would improve KES 6 weeks after TKA, compared to placebo. METHODS: Patients scheduled for primary unilateral TKA were randomized to receive either a continuous ACB (group ACB) or a sham block (group SHAM) for 48 hours after surgery. Primary outcome was the difference in maximal KES 6 weeks postoperatively, measured with a dynamometer during maximum voluntary isometric contraction. Secondary outcomes included postoperative day 1 (POD1) and day 2 (POD2) KES, pain scores at rest and peak effort, and opioid consumption; variation at 6 weeks of Knee Osteoarthritis Outcome Score, patient satisfaction, and length of hospital stay. RESULTS: Sixty-three subjects were randomized and 58 completed the study. Patients in group ACB had less pain at rest during POD1 and during peak effort on POD1 and POD2, consumed less opioids on POD1 and POD2, and had higher median KES on POD1. There was no significant difference between groups for median KES on POD2, variation of Knee Osteoarthritis Outcome Score, patient satisfaction, and length of stay. There was no difference between groups in median KES 6 weeks after surgery (52 Nm [31-89 Nm] for group ACB vs 47 Nm [30-78 Nm] for group SHAM, P= .147). CONCLUSIONS: Continuous ACB provides better analgesia and KES for 24-48 hours after surgery, but does not affect KES 6 weeks after TKA. Further research could evaluate whether standardized and optimized rehabilitation over the long term would allow early KES improvements with ACB to be maintained over a period of weeks or months.

The impact of bone morphology on the outcome of the pivot shift test: a cohort study.

BACKGROUND: The presence of a positive pivot shift after surgical repair of the ACL is considered an important indicator of a failed reconstruction. The ability to predict the result of a pivot shift test after an ACL reconstruction using variables that can be measured prior to surgery could provide an indication of which patients may be at-risk of a poor surgical outcome.The purpose of this study was to determine whether structural characteristics of the femur and tibia, measured using plain radiographs, were associated with the result of the pivot shift test in unilateral ACL reconstructed patients. METHODS: Sixteen patients who had undergone unilateral ACL reconstruction were divided into two groups based on the results of manual pivot shift testing: 1) Pivot group; and 2) No pivot group. All patients had standing true lateral radiographs of both knees. Structural measurements of the tibia and femur were made on both knees. In addition, two new variables were created to describe the tibiofemoral mismatch: 1) Femur Tibia Size Ratio (FTSR); and 2) Tibia to Posterior Femoral Condyle Ratio (TPFCR). These measures were compared within groups and between groups. RESULTS: None of the individual structural characteristics were significantly different when compared between groups. No individual structural characteristics had a significant association with the presence of a positive pivot shift. When a between-group analysis was performed, both the FTSR (p < 0.03) and the TPFCR (p < 0.01) were significantly different between the Pivot group and the No Pivot group. A larger FTSR ratio, or a larger femur relative to the tibia, was associated with a positive pivot shift. A smaller TPFCR ratio, or a smaller tibial depth relative to the depth of the lateral posterior femoral condyle, was associated with a positive pivot shift. CONCLUSIONS: Structural characteristics in the lateral femoral condyle and lateral tibial plateau were found to be associated with the presence of a positive pivot shift. These characteristics could separate between patients in the Pivot group and the No Pivot group. Two indices, the FTSR and the TPFCR, provided better predictive value than individual characteristics in identifying patients with a knee that was structurally "at-risk" for developing a positive pivot shift.

Applicability of a modified angular correction measurement method for open-wedge high tibial osteotomy.

PURPOSE: The purpose of this study was to evaluate the clinical potential of a new measurement technique for open-wedge high tibial osteotomy (HTO) based on the medial cortex opening (MCO) associated with the Miniaci preoperative planning technique. METHODS: A retrospective review of 97 cases of valgus-producing HTO that were performed between 2008 and 2013, using the intra-operative fluoroscopic mechanical axis technique, was carried out. The Miniaci-based measurement technique was then used as a theoretical point of comparison with the intent to compare the disparity between postoperative and ideal lower extremity (LE) mechanical axis with the measured disparity between postoperative and Miniaci-based planned MCO. RESULTS: A significant correlation was observed for the comparison of the disparity between postoperative and Miniaci-based planned MCO and the disparity between postoperative and ideal LE mechanical axis (0.53, P = 0.001). This would suggest that the MCO associated with the Miniaci preoperative planning technique would have resulted in a better alignment had it been the chosen method to guide the amount of osteotomy opening. No significant correlation was observed between perioperative and postoperative LE mechanical axis (n.s.), the variable on which the current technique is based, confirming the poor reliability of the fluoroscopic mechanical axis technique. CONCLUSIONS: This study suggests a more accurate and precise technique of realizing the appropriate angular correction when performing a HTO, which could lead to better clinical outcomes. LEVEL OF EVIDENCE: III.

Single-bundle ACL reconstruction with and without extra-articular reconstruction: evaluation with robotic lower leg rotation testing and patient satisfaction scores.

PURPOSE: The purpose of this study was to compare the biomechanical characteristics and patient outcomes after either isolated intraarticular ACL reconstruction or intraarticular reconstruction with lateral extra-articular tenodesis. In addition, we aimed to evaluate biomechanical parameters of the entire uninjured, contralateral knee as a baseline during the analysis. METHODS: Eighteen patients were evaluated at an average of 9.3 years after ACL reconstruction. Twelve patients had an intraarticular reconstruction (BTB), and six had an additional lateral extraarticular procedure (BTB/EAR). Patients were selected for the additional procedure by the operating surgeon based on clinical and radiological criteria. At the time of review, each patient was assessed using subjective patient questionnaires, manual laxity testing, and instrumented laxity testing. Each knee was also evaluated using a robotic lower leg axial rotation testing system. This system measured maximum internal and external rotations at 5.65 Nm of applied torque and generated load deformation curves and compliance data. Pointwise statistical comparisons within each group and between groups were performed using the appropriate paired or unpaired t test. Features were extracted from each load deformation curve for comparative analysis. RESULTS: There were no significant differences between the two groups with respect to the patient satisfaction scores or to laxity testing (manual or instrumented). Robotic testing results for within-group comparisons demonstrated a significant reduction in maximum external rotation (8.77°) in the reconstructed leg when compared to the healthy leg (p < 0.05) in the BTB/EAR group, with a non-significant change in internal rotation. The slope of the curve at maximum internal rotation was also significantly greater in the reconstructed legs for the BTB/EAR group (p < 0.05), indicating reduced endpoint compliance or a harder endpoint. Finally, the leg that received the extra-articular tenodesis had a trend towards a reduced total leg axial rotation. Conversely, patients in the BTB group demonstrated no significant differences between their legs. For between-group comparisons, there was a significant increase in maximum internal rotation in the healthy legs in the BTB/EAR group compared with the healthy legs in the BTB group (p < 0.05). If the injured/reconstructed legs were compared, the significant difference at maximum internal rotation disappeared (p < 0.10). Similarly, the healthy legs in patients in the BTB/EAR group had a significantly more compliant or softer endpoint in internal rotation, greater maximum internal rotation, and more internal rotation at torque 0 in their healthy legs compared with the healthy legs in the BTB group (p < 0.05). These same differences were not noted in the reconstructed knees. The only identifiable significant difference between the injured/reconstructed legs was rotation at 0 torque (p < 0.05). CONCLUSIONS: In this group of patients who were at an average of 9 years from surgery, the addition of a lateral extra-articular reconstruction to a standard bone-tendon-bone intraarticular ACL reconstruction does reduces internal rotation of the tibia with respect to the femur when compared to intraarticular reconstruction alone. It appears that the selection process for inclusion into the BTB/EAR group included an increase in total axial rotation of the healthy knee during the examination along with a decrease in endpoint stiffness at maximum internal rotation. LEVEL OF EVIDENCE: II.

Robotic axial lower leg testing: repeatability and reproducibility.

PURPOSE: The purpose of this study was to determine the test-retest reliability and the repeatability over multiple days of a robotic testing device when used to measure laxity of the lower leg during a simulated dial test. METHODS: Ten healthy subjects were evaluated using an instrumented robotic lower leg testing system over 4 days. Three testing cycles were performed each day. Each leg was rotated into external and then internal rotation by servomotors until a torque threshold of 5.65 N m was reached. Load-deformation curves were generated from torque and rotation data. Both average-measure and single-measure intraclass correlation coefficients (ICC) were compared across the curves. ICC scores were also compared for features of the curves including: maximum external rotation at -5.65 N m of torque, maximum internal rotation at 5.65 N m of torque, rotation at torque 0, compliance (slope of load-deformation curve) at torque 0, endpoint compliance in external rotation, endpoint compliance in internal rotation, and play at torque 0. Play at torque 0 was defined as the width of the hysteresis curve at torque 0. RESULTS: Average-measure ICC scores and test-retest scores were >0.95 along the entire load-deformation curve except around zero torque. ICC scores at maximum internal and external rotation ranged from 0.87 to 0.99 across the left and right knees. ICC scores for the other features of the curves ranged from 0.61 to 0.98. The standard error of the mean ranged from 0.0497 to 1.1712. CONCLUSIONS: The robotic testing device in this study proved to be reliable for testing a subject multiple times both within the same day and over multiple days. These findings suggest that the device can provide a level of reliability in rotational testing that allows for clinical use of test results. Objective laxity data can improve consistency and accuracy in diagnosing knee injuries and may enable more effective treatment.

Complications of Bicruciate-Retaining Total Knee Arthroplasty: The Importance of Alignment and Balance.

Bicruciate-retaining total knee arthroplasty (BCR TKA) results in kinematics closer to the native knee and in greater patient satisfaction but information concerning its outcome and complications is lacking.The goal of this study is to report the clinical and radiological outcomes of BCR prosthesis implanted using a spacer-based gap balancing technique and to assess if some preoperative factors are associated with a worse prognosis.A cohort of 207 knees in 194 patients who underwent BCR TKA, with a minimum 1-year follow-up, was retrospectively analyzed.Patients were followed at 6 weeks, 6 months, 1 year, and then every following year postoperatively, and filled questionnaires (Knee Society and Knee injury and Osteoarthritis Outcome Score) at every visit. Clinical and radiological assessments included range of motion, knee alignment, pain, and complications as defined by the Knee Society's Standardized list and definition of Complication of Total Knee Arthroplasty.Forty-three knees (20.8%) suffered major complications. Twenty-one knees (10.1%) underwent revision at an average of 32.1 months after the index procedure. Revision-free survival at 100 months was 85.7%. Revision was performed for aseptic tibial loosening in eight knees (3.9%) and stiffness in five knees (2.4%). There were 29 reoperations other than revision (14.0%), the most frequent procedure being manipulation under anesthesia in 14 knees (6.8%). Minor complications included tendonitis (20.8%), persistent synovitis (6.8%), and superficial wound infections (6.3%).All outcomes scores were greatly improved at the 1-year follow-up compared with preoperatively (p < 0.001). However, maximum flexion at the last follow-up was significantly reduced compared with preoperatively (mean maximum flexion ± standard deviation: 119.9 ± 15.6 vs. 129.9 ± 14.4, p < 0.001). Aseptic tibial loosening was associated with a hypercorrection in varus of preoperative valgus knees (p = 0.012).BCR TKA can give functional results similar to other types of prostheses but involves a substantial risk of complications. Important factors that can explain failed BCR TKA and guide its use were identified, more particularly knee alignment and its role in aseptic tibial loosening.

3D biplanar reconstruction of lower limbs using nonlinear statistical models.

Three-dimensional (3D) reconstruction of lower limbs is of great interest in surgical planning, computer assisted surgery, and for biomechanical applications. The use of 3D imaging modalities such as computed tomography (CT) scan and magnetic resonance imaging (MRI) has limitations such as high radiation and expense. Therefore, three-dimensional reconstruction methods from biplanar X-ray images represent an attractive alternative. In this paper, we present a new unsupervised 3D reconstruction method for the patella, talus, and pelvis using calibrated biplanar (45- and 135-degree oblique) radiographic images and a prior information on the geometric/anatomical structure of these complex bones. A multidimensional scaling (MDS)-based nonlinear dimensionality reduction algorithm is applied to exploit this prior geometric/anatomical information. It represents relevant deformations existing in the training set. Our method is based on a hybrid-likelihood using regions and contours. The edge-based notion represents the relation between the external contours of the bone projections and an edge potential field estimated on the radiographic images. Region-based notion is the non-overlapping ratio between segmented and projected bone regions of interest (RoIs). Our automatic 3D reconstruction model entails stochastically minimizing an energy function allowing an estimation of deformation parameters of the bone shape. This 3D reconstruction method has been successfully tested on 13 biplanar radiographic image pairs, yielding very promising results.

Suction drainage in total knee replacement does not influence early functional outcomes or blood loss: a randomized control trial.

INTRODUCTION: The use of wound drainage following total knee arthroplasty (TKA) remains controversial. The purpose of this study was to evaluate the impact of suction drainage on early postoperative outcomes in patients who underwent TKA with concomitant administration of intravenous tranexamic acid (TXA). METHOD: One hundred forty-six patients undergoing primary TKA with systematic intravenous TXA were prospectively selected and randomly divided into two groups. The first "Study group" (n = 67) received no suction drain and the second "Control" group (n = 79) had a suction drain. Perioperative hemoglobin levels, blood loss, complications, and length of hospital stay were assessed in both groups. Preoperative and postoperative range of motion and Knee Injury and Osteoarthritis Outcome Scores (KOOS) were also compared at a 6-week follow-up. RESULTS: The study group was found to have higher hemoglobin levels preoperatively and during the first two days following surgery, and no difference was found between the groups on the third day. No significant discrepancies at any time were found between groups in terms of blood loss, length of hospitalization, knee range of motion, and KOOS score. Complications requiring further treatment were observed in one patient from the study group and ten patients from the control group. CONCLUSION: The use of suction drains after TKA with TXA did not alter early postoperative outcomes.

A Medicoeconomic Evaluation of a Telehealth Platform for Elective Outpatient Surgeries: Protocol for a Randomized Controlled Trial.

BACKGROUND: The number of elective outpatient surgeries in Canada has increased markedly in the last 10 years. However, unanticipated cancellations on the day of surgery and adverse postoperative events are frequent. Modern technologies have been shown to be of great help in the medical field in improving patient care. Thus, it is likely that dedicated technologies could also significantly improve surgical outpatients' pathways. Therefore, the department of anesthesiology at the University of Montreal Medical Center, in collaboration with LeoMed, a telemedicine platform, has developed a telehealth solution to offer more efficient perioperative support and follow-up for patients undergoing ambulatory surgery. OBJECTIVE: The objective is to evaluate the medicoeconomic benefit of a dedicated perioperative telehealth platform for patients undergoing day surgery. Our hypothesis is that this dedicated telecare solution will allow more efficient patient care, which will reduce all types of medical costs related to day surgery pathways. METHODS: This study is a single-center, single-blinded, 2-group randomized controlled trial. One thousand patients aged over 18 years with internet access who are scheduled to undergo ambulatory surgery will be enrolled and randomized either to follow a perioperative path that includes a patient-tailored perioperative digital app via the LeoMed telecare platform for 1 month or to follow the standard of care, which does not offer personalized digital support. The primary outcome will be to evaluate the cost-effectiveness of the telecare platform, assessing direct costs from factors such as unanticipated cancellations on the day of surgery due to preoperative instructions not being followed, calls to the local health information line, calls to the provincial health information line, emergency department consultations, unplanned readmissions, or medical visits for problems related to the surgical procedure within the first 30 days after the intervention. The secondary outcome will be to evaluate cost utility using a questionnaire assessing quality-adjusted life years. A blinded independent research team will analyze outcomes. All data will be analyzed according to the intention-to-treat principle. A sample size of 500 subjects in each group was calculated to detect a 21% reduction in postoperative complications with a power of 90%. This study has been approved by the ethics board of Centre hospitalier de l'Université de Montréal (University of Montreal Health Centre). No employee of LeoMed was involved in the study conception, and none will be involved in either data collection or analysis. RESULTS: Results of this trial will be useful to determine the economic benefit of a telecare platform specifically developed for surgical outpatient pathways. CONCLUSIONS: We believe that the deployment of a dedicated perioperative telehealth app will lead to better patient care and fewer postoperative complications, which will lower all types of costs related to surgical outpatient care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04948632; https://ClinicalTrials.gov/ct2/show/NCT04948632. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/44006.

Role of epigenetics and the transcription factor Sp1 in the expression of the D prostanoid receptor 1 in human cartilage.

D prostanoid receptor 1 (DP1), a prostaglandin D2 receptor, plays a central role in the modulation of inflammation and cartilage metabolism. We have previously shown that activation of DP1 signaling downregulated catabolic responses in cultured chondrocytes and was protective in mouse osteoarthritis (OA). However, the mechanisms underlying its transcriptional regulation in cartilage remained poorly understood. In the present study, we aimed to characterize the human DP1 promoter and the role of DNA methylation in DP1 expression in chondrocytes. In addition, we analyzed the expression level and methylation status of the DP1 gene promoter in normal and OA cartilage. Deletion and site-directed mutagenesis analyses identified a minimal promoter region (-250/-120) containing three binding sites for specificity protein 1 (Sp1). Binding of Sp1 to the DP1 promoter was confirmed using electrophoretic mobility shift assay (EMSA) and chromatin immunoprecipitation (ChIP) assays. Treatment with the Sp1 inhibitor mithramycin A reduced DP1 promoter activity and DP1 mRNA expression. Inhibition of DNA methylation by 5-Aza-2'-deoxycytidine upregulated DP1 expression, and in vitro methylation reduced the DP1 promoter activity. Neither the methylation status of the DP1 promoter nor the DP1 expression level were different between normal and OA cartilage. In conclusion, our results suggest that the transcription factor Sp1 and DNA methylation are important determinants of DP1 transcription regulation. They also suggest that the methylation status and expression level of DP1 are not altered in OA cartilage. These findings will improve our understanding of the regulatory mechanisms of DP1 transcription and may facilitate the development of intervention strategies involving DP1.

Healthcare Professional Perspectives on the Use of Remote Patient-Monitoring Platforms during the COVID-19 Pandemic: A Cross-Sectional Study.

The COVID-19 pandemic created an urgent need to act to reduce the spread of the virus and alleviate congestion in healthcare services, protect health professionals, and help them maintain satisfactory quality and safety of care. Remote monitoring platforms (RPM) emerged as potential solutions. In this study, we evaluate, from health professionals' perspectives, the capacity and contribution of two different digital platforms to maintain quality, safety, and patient engagement in care. A cross-sectional study was conducted using a survey in which a total of 491 health professionals participated. The results show that, in general, user perceptions of the quality and safety of care provided through the platforms were positive. The ease of access to health professionals' services in general and shorter waiting times for patients were the two main features that were highly appreciated by most participants. However, some problems were encountered during the use of these two platforms, such as a lack of training and/or direct support for users. To improve the two platforms and maximize their use, the areas for improvement and the issues identified should be addressed as part of a collaborative process involving health professionals and patients as well as health system leaders, decision-makers, and digital platform providers.

Medial Opening Wedge Proximal Tibial Osteotomy: Lessons Learned from a Series of 175 Consecutive Cases.

INTRODUCTION: High tibial osteotomy (HTO) is a surgical procedure aimed at inhibiting the progression of osteoarthritis of the knee joint. The aim of this study was to identify factors influencing the functional outcome after opening wedge valgus HTO. METHODS: A total of 175 cases (155 patients) of varus-correcting high tibial open-wedge osteotomies using the Tomofix plate were reviewed retrospectively. Patients answered the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire and 4 survey follow-up questions. RESULTS AND DISCUSSION: A total of 76 of the 155 patients studied (84 of the 175 knees) completed the KOOS questionnaire, on average 3.1 years (SD 1.8 years) after the surgery. The median scores (with median absolute deviations [MAD]) for the KOOS pain, symptoms, daily activities, sports, and quality of life sections were, respectively, 76.4 (MAD 12.5), 75.0 (MAD 14.3), 85.3 (MAD 11.8), 50.0 (MAD 25.0), and 59.4 (MAD 21.9). No cases of nonunion were observed throughout the length of the study. Identified predictors of worse outcomes were higher weight and body mass index, limited knee flexion, genu varum and tibial varus of small magnitude, active smoking status at the time of surgery, further surgery for plate removal, and some grades of chondropathy in the patellofemoral, medial tibial, and femoral compartments. Patient gender, joint obliquity and over- or undercorrection were not associated with any of the outcomes. CONCLUSION: This study shows good results following valgus HTO that are comparable to outcomes following total knee arthroplasty, reinforcing the option of HTO as a valid alternative for total knee arthroplasty.

Tibial Tunnel Placement in ACL Reconstruction Using a Novel Grid and Biplanar Stereoradiographic Imaging.

BACKGROUND: Nonanatomic graft placement is a frequent cause of anterior cruciate ligament reconstruction (ACLR) failure, and it can be attributed to either tibial or femoral tunnel malposition. To describe tibial tunnel placement in ACLR, we used EOS, a low-dose biplanar stereoradiographic imaging modality, to create a comprehensive grid that combines anteroposterior (AP) and mediolateral (ML) coordinates. PURPOSE: To (1) validate the automated grid generated from EOS imaging and (2) compare the results with optimal tibial tunnel placement. STUDY DESIGN: Descriptive laboratory study. METHODS: Using EOS, 3-dimensional models were created of the knees of 37 patients who had undergone ACLR. From the most medial, lateral, anterior, and posterior points on the tibial plateau of the EOS 3-dimensional model for each patient, an automated and personalized grid was generated from 2 independent observers' series of reconstructions. To validate this grid, each observer also manually measured the ML and AP distances, the medial proximal tibial angle (MPTA), and the tibial slope for each patient. The ideal tibial tunnel placement, as described in the literature, was compared with the actual tibial tunnel grid coordinates of each patient. RESULTS: The automated grid metrics for observer 1 gave a mean (95% CI) AP depth of 54.7 mm (53.4-55.9), ML width of 75.0 mm (73.3-76.6), MPTA of 84.9° (83.7-86.0), and slope of 7.2° (5.4-9.0). The differences with corresponding manual measurements were means (95% CIs) of 2.4 mm (1.4-3.4 mm), 0.5 mm (-1.3 to 2.2 mm), 1.2° (-0.4° to 2.9°), and -0.4° (-2.1° to 1.2°), respectively. The correlation between automated and manual measurements was r = 0.78 for the AP depth, r = 0.68 for the ML width, r = 0.18 for the MPTA, and r = 0.44 for the slope. The center of the actual tibial aperture on the plateau was a mean of 5.5 mm (95% CI, 4.8-6.1 mm) away from the referenced anatomic position, with a tendency toward more medial placement. CONCLUSION: The automated grid created using biplanar stereoradiographic imaging provided a novel, precise, and reproducible description of the tibial tunnel placement in ACLR. CLINICAL RELEVANCE: This technique can be used during preoperative planning, intraoperative guidance, and postoperative evaluation of tibial tunnel placement in ACLR.

Remote Patient Monitoring Program for COVID-19 Patients Following Hospital Discharge: A Cross-Sectional Study.

Background: The COVID-19 pandemic created an urgent need to act to reduce the spread of the virus and alleviate congestion from healthcare services, protect healthcare providers, and help them maintain satisfactory quality and safety of care. Remote COVID-19 monitoring platforms emerged as potential solutions. Objective: The purpose of this study was to evaluate the capacity and contribution of two different platforms used to remotely monitor patients with COVID-19 to maintain quality, safety, and patient engagement in care, as well as their acceptability, usefulness, and user-friendliness from the user's perspective. The first platform is focused on telecare phone calls (Telecare-Covid), and the second is a telemonitoring app (CareSimple-Covid). Methods: We performed a cross-sectional study. The data were collected through a phone survey from May to August 2020. Data were analyzed using descriptive statistics and t-test analysis. Participants' responses and comments on open-ended questions were analyzed using content analysis to identify certain issues and challenges and potential avenues for improving the platforms. Results: Fifty one patients participated in the study. Eighteen participants used the CareSimple-Covid platform and 33 participants used the Telecare-Covid platform. Overall, the satisfaction rate for quality and safety of care for the two platforms was 80%. Over 88% of the users on each platform considered the platforms' services to be engaging, useful, user-friendly, and appropriate to their needs. The survey identified a few significant differences in users' perceptions of each platform: empathy toward users and the quality and safety of the care received were rated significantly higher on the CareSimple-Covid platform than on the Telecare-Covid platform. Users appreciated four aspects of these telehealth approaches: (1) the ease of access to services and the availability of care team members; (2) the user-friendliness of the platforms; (3) the continuity of care provided, and (4) the wide range of services delivered. Users identified some technical limitations and raised certain issues, such as the importance of maintaining human contact, data security, and confidentiality. Improvement suggestions include promoting access to connected devices; enhancing communications between institutions, healthcare users, and the public on confidentiality and personal data protection standards; and integrating a participatory approach to telehealth platform development and deployment efforts. Conclusion: This study provides preliminary evidence that the two remote monitoring platforms are well-received by users, with very few significant differences between them concerning users' experiences and views. This type of program could be considered for use in a post-pandemic era and for other post-hospitalization clienteles. To maximize efficiency, the areas for improvement and the issues identified should be addressed with a patient-centered approach.