Bilateral Knee Replacement Research Articles

Pseudofilariasis, a Presenting Sign of Alkaptonuria.

To report the association of Pseudofilariasis as a presenting sign of Alkaptonuria. Case Report. A 49-year-old Indian man was referred because of wormlike objects in his left conjunctiva. Ocular and family history was non-contributory. He had not been to India in 15 years. Past medical history revealed hypertension, hypercholesterolemia, arthritis, and a myocardial infarct. He had undergone two stents, bilateral Achilles tendon repairs and bilateral knee replacements. ROS showed longstanding back stiffness and pain. On ocular examination the vision was 20/25 in each eye and positive findings were in the left eye bulbar conjunctival which showed stationary black vermiform (filarial in appearance) foreign bodies along with 2 small corneal limbal pigmented deposits. Conjunctival biopsy showed dilated lymph channels with interstitial proteinaceous material of a light brown color consistent with Ochronotic pigment; hence diagnostic of Alkaptonuria. Pseudofilariasis may be a presenting sign of Alkaptonuria and occur years before a clinical diagnosis is made. Filariasis is always involves white worms and never black. Knowing the ophthalmic signs of this rare disease may lead to an accurate diagnosis earlier thusly avoiding unnecessary tests and examinations.

Bilateral simultaneous hip and knee replacement: an epidemiological nationwide study from 2001 to 2016

BackgroundSeveral studies have compared the pros and cons of simultaneous bilateral versus staged bilateral hip and knee replacement but the outcomes of these two surgical options remains a matter of controversy. This study aimed to evaluate demographic features, incidence and hospitalization rates of bilateral one stage total hip and knee arthroplasty in Italy.MethodsThe Italian Ministry of Health’s National Hospital Discharge Reports (SDO) were used to gather data. This study referred to the adult population (+ 20 years of age) from 2001 to 2015 for hip arthroplasty and from 2001 to 2016 for knee arthroplasty.ResultsOverall, 1,544 bilateral simultaneous hip replacement were carried out. The incidence rate was 0.21 cases per 100,000 adult Italian residents. Male/female ratio was 1.1. The average days of hospital stay was 11.7 ± 11.8 days. The main primary codified diagnosis was: osteoarthrosis, localized, primary, pelvic region and thigh (ICD code: 715.15). 2,851 bilateral simultaneous knee replacement were carried out. The incidence rate was 0.37 cases per 100,000 adult Italian residents. Male/female ratio was 0.6. The average days of hospital stay was 7.7 ± 5.8 days. The main primary codified diagnosis was: osteoarthrosis, localized, primary, lower leg (ICD code: 715.16).ConclusionsThe burden of hip and knee osteoarthrosis as a leading cause of bilateral joint replacement is significant in Italy. The national registers’ longitudinal analysis may provide data for establishing international guidelines regarding the appropriate indications for one stage bilateral simultaneous hip or knee replacement versus two stage.

Comparative Analysis of Dilute Povidone Iodine (Betadine) versus Normal Saline in Bilateral Knee Joint Replacement Surgery: A Retrospective Cohort Study

Background: One of the proposed methods to reduce the risk of infection after joint replacement is the use of disinfectant solutions at the end of the surgery. Differing results have been reported regarding the effects of diluted povidone-iodine (betadine) washing solution and normal saline in reducing the risk of periprosthetic joint infection (PJI). The purpose of this retrospective cohort study is to compare the outcomes of diluted betadine solution with normal saline in bilateral knee replacement surgery.
 Methods: Patients who were referred to Ba’ath Hospital, Hamedan, Iran, from 2019 to 2021 for bilateral knee joint replacement were included. For each patient, one knee was washed with diluted betadine (35%), and the other with normal saline for 3 minutes before closing the wound. Demographic information, risk factors, and the rate of PJI three months after the surgery were collected and analyzed.
 Results: Out of 320 patients, 177 (55.3%) were women, and the most common underlying disease was type 2 diabetes with a frequency of 20.0%. Out of 640 operated knees, 17 cases (2.7%) of PJI occurred after surgery, of which 11 (4.3%) were washed with normal saline (P = 0.326). The multivariate regression analysis showed that being male (P = 0.028), diabetes (P = 0.030), high blood pressure (P = 0.019), and an increase in each body mass index (BMI) unit (P = 0.030) increased the chance of infection.
 Conclusion: Intraoperative irrigation with diluted betadine solution in bilateral knee replacement surgery can reduce the risk of infection, especially in patients with underlying diseases and obesity.

A simultaneous bilateral total knee replacement: The road to recovery

The patient had suffered from arthritis in both knees for several years. In discussions between the patient and the orthopaedic surgeon the decision was made to carry out a simultaneous bilateral complete knee replacement. Epidural anaesthesia was employed to remove feeling from the lower part of the body. The operation was completed successfully.

Implant Preference and Clinical Outcomes of Patients with Staged Bilateral Total Knee Arthroplasty: All-Polyethylene and Contralateral Metal-Backed Tibial Components

Numerous studies have compared metal-backed components (MBTs) and all-polyethylene tibial components (APTs), but none of them specifically analysed the clinical results and the overall patient preference in patients who had undergone a staged bilateral knee replacement. The purpose of this study is to compare clinical results, perceived range of motion, and overall implant preference among patients who had undergone staged bilateral knee replacement with an APT and contralateral knee replacement with MBTs. A dataset of 62 patients from a single centre who underwent staged bilateral TKA between 2009 and 2022 was selected and retrospectively analysed. Tibial component removal was performed in three knees overall, all of which had MBTs. The mean measured Knee Score (KS) of knees with APTs was 78.37 and that of contralateral knees with MBTs was 77.4. The mean measured Function (FS) of knees with APTs was 78.22, and that of contralateral knees with MBs was 76.29. The mean flexion angle of knees with APTs was 103.8 and that for knees with MBTs was 101.04 degrees. A total of 54.8% of the patients preferred the knee that received APTs over contralateral MBTs. In our cohort, TKA with an APT in one knee and an MBT in the contralateral knee recorded similar clinical results and perceived ranges of motion. Patients in general preferred the knee that received an APT over contralateral knee with an MBT.

FRI684 So Strong Yet So Fragile: Bilateral Periprosthetic Fractures On Denosumab

Abstract Disclosure: A. Syeda: None. F.S. Mirza: None. Background: Denosumab (DN) is a potent antiresorptive and has been associated rarely with atypical femoral fractures. We hereby report the first case of simultaneous bilateral femoral periprosthetic fractures (PPF) while on DN therapy (DNT). Clinical Case: A 78-year-old female with severe osteoporosis on DNT presented in January 2023 with bilateral femoral PPF after a mechanical fall whereby she tripped and landed on her knees. The patient had initially presented to us in late 2012. Treatment history included alendronate (ALN) for 5 years, on drug holiday since 2010. She underwent bilateral knee replacement surgeries in 2012 and DNT was started in 2013 after initial evaluation. She also had primary biliary cirrhosis, and although bone density (BD) improved on DNT, she exhibited escape from DN mediated suppression of bone resorption possibly related to the liver disease that was previously reported (1). DNT was stopped 5 years later when spine BD improved to osteopenic range and ALN 70 mg weekly was started. 1 year later, bone resorption markers were still elevated and zoledronic acid was substituted for ALN. She fell and had a pubic ramus fracture 11 months later. BD showed a 6% decrease for mean total hip and baseline forearm BD showed T-score of -3.7 on the right. DNT was restarted in December 2020 and continued every 6 months. Her health continued to deteriorate over next two years, with increase in LFTS, new anemia and thrombocytopenia due to a combination of myelodysplastic syndrome and splenomegaly. She also needed transcatheter aortic valve replacement for worsening CHF. She tripped and fell in January 2023. X-ray showed acute supracondylar bilateral PPF with comminution. She was high risk for anesthesia and anticoagulation was withheld due to a history of thrombocytopenia and gastrointestinal bleeding. Prior to the anticipated orthopaedic procedure, the patient developed severe hypotension and a rapid drop in hematocrit due to hemorrhagic shock. The family had requested DNR due to the multitude of medical issues. Conclusion: Occasional PPF have been reported in the setting of DNT, which may reflect the severity of osteoporosis. Altered stress distribution and decreased tensile strength of the bone secondary to screw/pin placement are thought to contribute to PPF, although the occurrence of PPF as an unusual presentation of an AFF cannot be excluded. Contribution of other comorbidities to poor bone quality may also have contributed to the bilateral PPF with poor outcome in our patient. 1. Vedere, T.R. and Mirza, F.S., 2017, April. Escape from Denosumab Mediated Suppression of Bone Resorption in Primary Biliary Cirrhosis. In 99th Annual Meeting of the Endocrine Society. Endocrine Society. Presentation: Friday, June 16, 2023

Associations between anterior knee pain and 2-year patellofemoral cartilage worsening: The MOST study

Anterior knee pain (AKP) is associated with patellofemoral osteoarthritis (PFOA), but longitudinal studies are lacking. If AKP precedes PFOA, it may create an opportunity to identify and intervene earlier in the disease process. The purpose of this study was to examine the longitudinal relation of AKP to worsening patellofemoral (PF) cartilage over two years. Participants were recruited from the Multicenter Osteoarthritis Study, a longitudinal study of individuals with or at risk for knee osteoarthritis (OA). Exclusion criteria included bilateral knee replacements, arthritis other than OA, and radiographic PFOA. At baseline, participants completed a knee pain map questionnaire and underwent knee magnetic resonance imaging (MRI). Imaging was repeated at 2-year follow-up. Exposure was presence of frequent AKP. Outcome was worsening cartilage damage in the PF joint defined as increase in MRI Osteoarthritis Knee Score from baseline to 2 years. Log-binomial models were used to calculate risk ratios (RR). One knee from 1083 participants (age 56.7±6.6 years; body mass index 28.0±4.9kg/m2) was included. Frequent AKP and frequent isolated AKP were present at baseline in 14.5% and 3.6%, respectively. Frequent AKP was associated with an increased risk (RR: 1.78, 95% confidence interval: 1.21, 2.62) of 2-year worsening cartilage damage in the lateral PF compartment. No association was found between frequent AKP and worsening in the medial PF joint. Frequent AKP at baseline was associated with worsening cartilage damage in the lateral PF joint over 2 years.

Aid in need - Manageable but not ideal a tale of knee replacement in distal femur fracture for early mobilisation

We present a case of 70 year female who is a prior patient for knee arthritis at our clinic and who fell down and sustained a fracture in left distal femur over medial condyle. Patient demand was early mobilization. We discussed various options of management and advantages, disadvantages and complications. As per patient request planned for bilateral knee replacement with fracture stabilization. Postop recovery is monitored and patient recovered and is able to walk and satisfactory range of movement of both knee was achieved this case adds to the evidence that elderly distal femur fractures that can be replacement and made to walk as early as possible. Especially in scenarios of arthritis and fracture together.: Informed consent was obtained from the patient and family for the publication of the case report and all the figures included.

Outcomes and motives for not proceeding with the second stage bilateral knee replacement: a comparison of cancelled and completed bilateral total knee arthroplasty.

Staged bilateral total knee arthroplasty (TKA) is a common treatment option for patients with bilateral symptomatic knee osteoarthritis, yet some patients do not proceed with their second procedure. Our study aimed to identify the rate and reasons why patients did not proceed with their second procedure and compare their functional outcomes, satisfaction and complication rates with those of patients who had completed a staged bilateral TKA. We determined the proportion of patients who underwent TKA but did not proceed with planned surgery for the second knee within 2 years, and compared their satisfaction with surgery, improvement in the Oxford Knee Score (OKS) and complications between groups. Our study included 268 patients: 220 patients who underwent staged bilateral TKA and 48 patients who cancelled their second procedure. The most common reason for not proceeding with the second procedure was a slow recovery after the first TKA (43.2%), followed by functional improvement in symptoms in the unoperated knee negating the need for surgery (27.3%), poor experience with the first surgery (22.7%), treatment of other comorbidities necessitating cancellation of their second procedure (4.6%) and employment reasons (2.3%). Patients who cancelled their second procedure were noted to have a worse postoperative OKS improvement (p < 0.001) and lower satisfaction rate (p < 0.001), than patients who underwent staged bilateral TKA. About one-fifth of patients scheduled for staged bilateral TKA declined to proceed with the second knee surgery within 2 years showing a substantially decreased functional outcome and satisfaction rate. However, more than one-quarter (27.3%) of patients noted improvements in their contralateral (unoperated) knee, such that a second surgery was no longer felt to be necessary.

Nursing of a patient undergoing bilateral knee replacement surgery

Nursing of a patient undergoing bilateral knee replacement surgery

Predictors of Persistent Post-Surgical Pain Following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Observational Studies.

Approximately one in four total knee replacement patients develop persistent pain. Identification of those at higher risk could help inform optimal management. We searched MEDLINE, EMBASE, CINAHL, AMED, SPORTDiscus, and PsycINFO for observational studies that explored the association between risk factors and persistent pain (≥3 months) after total knee replacement. We pooled estimates of association for all independent variables reported by >1 study. Thirty studies (26,517 patients) reported the association of 151 independent variables with persistent pain after knee replacement. High certainty evidence demonstrated an increased risk of persistent pain with pain catastrophizing (absolute risk increase [ARI] 23%, 95% confidence interval [CI] 12 to 35), younger age (ARI for every 10-year decrement from age 80, 4%, 95% CI 2 to 6), and moderate-to-severe acute post-operative pain (ARI 30%, 95% CI 20 to 39). Moderate certainty evidence suggested an association with female sex (ARI 7%, 95% CI 3 to 11) and higher pre-operative pain (ARI 35%, 95% CI 7 to 58). Studies did not adjust for both peri-operative pain severity and pain catastrophizing, which are unlikely to be independent. High to moderate certainty evidence demonstrated no association with pre-operative range of motion, body mass index, bilateral or unilateral knee replacement, and American Society of Anesthesiologists score. Rigorously conducted observational studies are required to establish the relative importance of higher levels of peri-operative pain and pain catastrophizing with persistent pain after knee replacement surgery.

Is the Numbness after Knee Replacement a More Critical Complication Than Thought? A Detailed Analysis of Neuropathic Pain and Functional Outcomes

Background and Objectives: Numbness, one of the complications after knee replacement (KR), has been studied far less than other complications, and there are few studies on this topic. Without comprehensive research on numbness, there is a need to design a study that includes all relevant parameters. This study investigated the relationship between numbness and pain and neuropathic pain and its impact on functional and emotional life and the functioning of the knee. Materials and Methods: The 105 knees with KRs were divided anteriorly into six regions. Numbness was determined with a pinprick test. Douleur Neuropathique 4 (DN4) and a painDETECT questionnaire (PD-Q) were tested for neuropathic pain. Patients’ physical, emotional, and social status and functional knee abilities were assessed with the Short Form (SF-36) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) test. The relationships between numbness and gender, age, bilaterality, postoperative follow-up time, and incision measures were examined. The binomial logistic regression model was applied to investigate the effects of age, gender, bilaterality, incision length, and postoperative follow-up time on numbness. Results: A total of 88.6% of the patients were female, half had bilateral KRs, and the mean age was 68.3 years. Numbness occurred more frequently in the L3 and L2 areas than in other regions. There was no association with gender, bilaterality, and age, but there was a weak association with postoperative follow-up time. There was a positive correlation between numbness and neuropathic pain. It has been found that there is a significant relationship between numbness and physical function, and it has a negative effect. Emotional health was not significantly associated with numbness. The effect of numbness on social functioning was statistically significant. Knee functioning was measured with the WOMAC, and significant differences were found in the numbness group. Conclusions: According to the results, numbness is considered to be a complication that affects social and physical life and has a negative impact on functional outcomes of the knee. The results show that it should be considered a statistically significant complication. Numbness and its indirect effects should be considered in patients whose follow-up parameters are normal over one year but whose symptoms do not resolve.

Efficacy of Red Cell Salvage Systems in Open Acetabular Surgery.

Over the past 50 years, treatment of displaced acetabular fractures has moved away from conservative treatment with bedrest to operative intervention to achieve anatomic reduction, stable fixation, and allow early range of motion of the hip. However, operative fixation is not without complications. Internal fixation of traumatic acetabular fractures has been coupled with large volume of blood loss both at the time of injury and surgery. This often results in the need for allogenic blood products, which has been linked to increase morbidity (Vamvakas and Blajchman, 2009). In an attempt to avoid the risk associated with allogenic blood transfusion numerous techniques and methods have been devised. Red blood cell salvage (CS) is an intraoperative blood salvage tool where blood is harvested from the operative field. It is washed to remove the plasma, white blood cells, and platelets. The red cells are resuspended in a crystalloid solution. If the hematocrit of the resuspended red blood cells is sufficient, it is transfused to the patient intravenously. The benefits of CS in major spine surgery, bilateral knee replacement, and revision hip surgery are well established (Goulet et al. 1989, Gee et al. 2011, Canan et al. 2013). However, literature reviewing the use of cell saver in orthopedic trauma surgery, specifically acetabular surgery is limited. Our institute performed a retrospective review of 63 consecutive operative acetabular fractures at a level one trauma center. Our study revealed that patients with blood loss of less than 400 mL were 13 times less likely to receive autologous blood, and patients with hemoglobin less than 10.5 were 5 times less likely to receive autologous transfusion (p < 0.05). We also found that no patients with a hemoglobin level less than 10.5 and EBL less than 400 mL received autologous blood return. Autologous blood transfusion had no effect on volume or rate of allogenic blood transfusion. We believed that if a patient's preoperative hemoglobin is less than 10.5 or expected blood loss is less than 400 mL, then CS should have a very limited role, if any, in the preoperative blood conservation strategy. We found ASA greater than 2, BMI greater than 24 and associated fracture type to be a risk factor for high blood loss.

Patient’s safety during simultaneous bilateral total knee arthroplasty

Abstract. As the utilization of total knee arthroplasty increases and the population ages, the number of patients who require surgical treatment of both knees is rising. These procedures may be conducted simultaneously or sequentially; the simultaneous bilateral approach is increasingly considered the preferred option because it permits a symmetric recovery while avoiding risks associated with an additional operation, anesthetic, hospitalization, and recovery period while reducing the costs associated with sequential procedures. Despite these advantages, concerns have been raised regarding increased risks for deep vein thrombosis, pulmonary embolism, cardiac complications, and mortality. Results reported in the literature with regards to the relative safety of these procedures have been conflicting; however, it is agreed upon that careful patient selection is essential for reducing risk associated with simultaneous bilateral total knee arthroplasty. A set of guidelines have been established which may be used to help guide the management of patients with bilateral degenerative joint disease seeking knee replacement surgery. Key words: bilateral total knee arthroplasty, simultaneous bilateral total knee arthroplasty, staged bilateral total knee arthroplasty, total knee arthroplasty.

A Systematic Review Comparing Animal and Human Scarring Models.

IntroductionA reproducible, standardised model for cutaneous scar tissue to assess therapeutics is crucial to the progress of the field. A systematic review was performed to critically evaluate scarring models in both animal and human research.MethodAll studies in which cutaneous scars are modelling in animals or humans were included. Models that were focused on the wound healing process or those in humans with scars from an existing injury were excluded. Ovid Medline® was searched on 25 February 2019 to perform two near identical searches; one aimed at animals and the other aimed at humans. Two reviewers independently screened the titles and abstracts for study selection. Full texts of potentially suitable studies were then obtained for analysis.ResultsThe animal kingdom search yielded 818 results, of which 71 were included in the review. Animals utilised included rabbits, mice, pigs, dogs and primates. Methods used for creating scar tissue included sharp excision, dermatome injury, thermal injury and injection of fibrotic substances. The search for scar assessment in humans yielded 287 results, of which 9 met the inclusion criteria. In all human studies, sharp incision was used to create scar tissue. Some studies focused on patients before or after elective surgery, including bilateral breast reduction, knee replacement or midline sternotomy.DiscussionThe rabbit ear scar model was the most popular tool for scar research, although pigs produce scar tissue which most closely resembles that of humans. Immunodeficient mouse models allow for in vivo engraftment and study of human scar tissue, however, there are limitations relating to the systemic response to these xenografts. Factors that determine the use of animals include cost of housing requirements, genetic traceability, and ethical concerns. In humans, surgical patients are often studied for scarring responses and outcomes, but reproducibility and patient factors that impact healing can limit interpretation. Human tissue use in vitro may serve as a good basis to rapidly screen and assess treatments prior to clinical use, with the advantage of reduced cost and setup requirements.

Demography of Total Joint Replacement Surgeries Performed in a Tertiary Care Hospital: A Cross-sectional Survey.

Total joint replacement of hip and knee is considered as one of the most successful orthopedic surgeries in the twenty-first century because of the only solution to end-stage arthritis of these joints. The real burden of the problem is yet to be established in developing countries like Nepal. This study aims to describe the demographic findings of the joint replacement surgeries among total lower limb surgeries in a tertiary care hospital. This cross-sectional survey was conducted using the hospital records of 73 total joint replacement surgeries of the lower limb in the Department of Orthopedics of a tertiary care hospital from November 2016 to November 2020. Ethical approval was taken from the Institutional Review Committee (reference number: 077/78-011). Convenience sampling was done. Data analysis was done using the Statistical Package for the Social Sciences version 20. Point estimate at 95% Confidence Interval was calculated along with frequency and percentage for binary data. There were 73 total joint replacement of hips and knees. Of which, 32 (43.84%) total hip replacements were done in which one (3.13%) patient had a simultaneous bilateral hip replacement in single-stage and the other one (3.13%) had two-stage bilateral hip replacement. Forty one (56.16%) total knee replacements were done in which 18 (24.65%) had a simultaneous bilateral knee replacement and five (6.85%) had a unilateral knee replacement. Total joint replacements of the hip were more common among the lower limb surgeries.

P17 A case of treatment resistant severe destructive arthritis in a young boy

Case report - IntroductionMajor advances in medical and therapy management of inflammatory arthritis has been associated with marked improvement in outcomes. We present a very unusual case of a young boy with destructive and incapacitating arthritis of knees, feet and ankles refractory to such management. He is now wheelchair dependent. We have evidence of reversal of bone loss after treatment. However, synovitis and joint destruction has left few surgical options with above knee amputation considered to have the best long-term functional outcome.Case report - Case descriptionAge five, he had persistent pain and swelling of the right knee after a minor fall. In the emergency department a sclerotic, lucent area was highlighted on X-ray. Neoplasia was ruled out and the changes were felt to be a result of erosive arthropathy.By the time of rheumatology referral, symptoms progressed to significant bilateral knee effusions with left ankle inflammation. All three joints underwent steroid injections which had a good response, but unfortunately this was short-lived and they were repeated. A synovial biopsy was sent to exclude other pathologies and loose bone fragments were removed from both knees. Biopsy confirmed chronic inflammation and methotrexate was commenced. Unfortunately, there was minimal response.Over the next 5 years he trialled etanercept, infliximab, tocilizumab, pamidronate, azathioprine and abatacept. His destructive arthritis of the knees, ankles and feet continued to progress with relentless bone loss and associated osteochondritis dissecans (OCD).Opinions from five other tertiary rheumatology units worldwide, three radiology departments and four orthopaedic units were sought. Unable to control the synovitis and in the presence of complete loss of the lateral femoral condyle we elected to refocus our attention to bone integrity and preparation for definitive surgery. This included the use of denosumab. Serial radiology showed reversal of some bone loss over 2 years but surgical teams could not identify intervention to optimise weight-bearing capacity. Mobility deteriorated to leave our patient wheelchair dependent outside, using crutches or his knees to move around inside. Further surgical consideration has indicated the best long-term will be associated with above knee amputations.Case report - DiscussionOur team are aware of one less severe case in a 13-year-old male in Oxford that stabilised after 5 years, allowing definitive treatment with bilateral knee replacement followed by excellent recovery with full mobility. None of the international centres we contacted reported a case as severe as ours. From discussions with our paediatric and adult orthopaedic colleagues, the only comparable patients they have seen this level of bony knee destruction in has been uncontrolled haemophilia patients. However, the damage is not seen at such a young age which affects the surgical options due to ongoing growth in childhood and adolescence. This caused us to question; why was our patient so severely affected? Would a different treatment course have been feasible? And would this have changed the outcome?Despite trial of many immunomodulatory agents, both those routinely used for arthritis and those used in treatment resistance, the persistent inflammation and destruction progressed. As a result he developed persistent and problematic OCD. OCD is considered a relatively common diagnosis that can occur in adults and children of unclear aetiology. A small subchondral bone fragment becomes loose in the joint space as a result of disrupted blood supply. OCD seems to be more common in males and is often managed conservatively. In children, the knee is the most commonly affected joint and inflammation is hypothesised as a possible cause which we will elaborate on in our presentation. For cases requiring surgical intervention this is normally localised drilling, fixation or bone grafts; however, most cases only affect one site, with one loose fragment which was very different from our patient.Case report - Key learning pointsFrom this case we have been reminded that each patient follows a different clinical course and response to medications is difficult to predict. We have gained experience managing difficult inflammatory arthritis-related OCD working closely with our orthopaedic colleagues. Although we managed to control the destructive inflammatory process this did not reverse the damage to the patient’s joints and we have been left with no choice but to progress to surgical treatment options.By sharing this case we hope to learn from any similar experiences or challenges faced by other clinical teams to help inform our practice for any other cases in the future.

Development of a Unique Screening Tool for Acute Care Occupational Therapy Services in Patients Following Total Joint Replacement Surgery

<h3>Research Objectives</h3> Assess use of an evidence-based screening tool to standardize patient access to Occupational Therapy (OT) services post Total Joint Arthroplasty (TJA) - Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA). <h3>Design</h3> Process Improvement Study comparing the historical, subjective screen and a new evidence-based screening tool for referral of OT services. Data collected over a two month period for individuals undergoing a TJA. First month, collected data on the previous OT screen. Second month, collected data utilizing new screen. <h3>Setting</h3> Lehigh Valley Health Network-Tilghman Hospital (LVH-TH). <h3>Participants</h3> 326 patients admitted LVH-TH following THA/TKA surgery, including bilateral knee replacements. Patients excluded were TJA-revisions and those transferred out of the hospital prior to arrival to the unit. <h3>Interventions</h3> First month, physical therapists used clinical judgement and second month, completed evidence-based screening tool determining if OT was indicated. Included criteria include: inpatient rehab recommendation, difficulty maintaining hip precautions and/or meeting 3/5 of categories (social support, age, fall risk, AM-PAC score and co-morbidities). <h3>Main Outcome Measures</h3> The primary outcome was to identify the percentage of patients post-TJA receiving OT services pre/post-implementation of the evidenced-based OT screen. Patients requiring OT services despite a negative screen were tracked in both conditions. <h3>Results</h3> The subjective OT screen found that 45.6% of patients required OT services. The evidence-based screening tool showed that 48.8% of patients required OT services. In both conditions, 0.06% of patients required OT services, despite a negative screen. <h3>Conclusions</h3> OT plays a crucial role in treatment of functional deficits that prevent patients from completing activities of daily living following their hospital stay. An evidence-based screening tool for OT services was created to allow for the efficient utilization of OT services in the acute care setting following TJA. Our results indicate that the implementation of an evidence-based screening tool did not appear to alter the level of care provided to TJA patients. Further studies can be completed on self-efficacy of patients who receive and don't receive OT services. <h3>Author(s) Disclosures</h3> None.

Low grade of radiographic osteoarthritis predicts unsatisfactory response of the contralateral knee replacement in two-stage bilateral total knee arthroplasty.

It is difficult to counsel patients with bilateral osteoarthritis who are unsatisfied with their first knee replacement as to whether they are likely to have a better outcome after the contralateral knee is replaced. The purpose of this study was to determine whether predictive factors can be found to prognosticate outcome of the second-side knee replacement when a patient has an unsatisfactory response to the first, with the hypothesis that predictors, such as prosthetic factors and radiographic level of osteoarthritis, may be able to predict a satisfactory response to the contralateral knee replacement. An analysis of staged bilateral knee replacements performed at a tertiary arthroplasty centre from 2012 to 2018 was undertaken. A total of 550 knee replacements in 275 patients were included in this study. The primary variable measured was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Satisfactory response to surgery was defined as a WOMAC score improved by 17 points or more, and 56 or greater. Patients who did not achieve a satisfactory response with their first knee replacement were further analysed for predictive factors (age, sex, pre-operative score, mental score, socioeconomic status, type of prosthesis, use of navigation, patella resurfacing and radiographic osteoarthritis) of an unsatisfactory response for their contralateral knee replacement. Overall, 44 (16%) patients failed to achieve a satisfactory response from both their first and contralateral knee replacements. The factor most predictive of an unsatisfactory response to their first knee replacement was pre-operative mental health score. However, in patients who did not achieve a satisfactory response with their first knee replacement, radiographic osteoarthritis, as measured by the Kellgren-Lawrence (KL) score was the main predictor of satisfactory response for their contralateral knee replacement. Only patients with KL grade 4 osteoarthritis were likely to have a satisfactory response with their contralateral knee replacements (KL4 versus KL3, Odds ratio 3.57 (CI 1.26-10.03) p = 0.016*). Patients with KL grade 3 osteoarthritis were unlikely to have a satisfactory response, and in this series, no patient with KL grade 2 osteoarthritis had a satisfactory response. In a patient who has an unsatisfactory response to their first knee replacement, the best predictor of achieving a satisfactory response to his/her contralateral knee replacement is the level of radiographic osteoarthritis in that knee. IV: Retrospective Cohort study.

Thermal imaging in total knee replacement and its relation with inflammation markers.

Total knee replacement is an end-stage surgical treatment of osteoarthritis patients to improve their quality of life. The study presents a thermal imaging-based approach to assess the recovery of operated-knees. The study focuses on the potential of thermal imaging for total knee replacement and its relation with clinical inflammatory markers. A total of 20 patients with bilateral knee replacement were included for thermal imaging and serology, where data was acquired on pre-operative day and five post-operative days. To quantify the inflammation, the temperature-based parameters (like mean differential temperature, relative percentage of raised temperature) were evaluated from thermal images, while the clinically proven inflammation markers were obtained from blood samples for clinical validation. Initially, the knee region was segmented by applying the automatic method, subsequently, the mean skin temperature was calculated and investigated for a statistical relevant relationship with inflammatory markers. After surgery, the mean skin temperature was first increased (>2.15 ℃ for different views) then settled to pre-operative level by 90th day. Consequently, the mean differential temperature showed a strong correlation with erythrocyte sedimentation rate (r > 0.893) and C-reactive protein (r > 0.955). Also, the visual profile and relative percentage of raised temperature showed promising results in quantifying the temperature changes both qualitatively and quantitatively. This study provides an automatic and non-invasive way of screening the patients for raised levels of skin temperature, which can be a sign of inflammation. Hence, the proposed temperature-based technique can help the clinicians for visual assessment of post-operative recovery of patients.