Joint Replacement Therapy Research Articles

Central Sensitization and Neuropathic Features of Ongoing Pain ina Rat Model of Advanced Osteoarthritis.

Osteoarthritis (OA) pain is most commonly characterized by movement-triggered joint pain. However, in advanced disease, OA pain becomes persistent, ongoing and resistant to treatment with nonsteroidal anti-inflammatory drugs (NSAIDs). The mechanisms underlying ongoing pain in advanced OA are poorly understood. We recently showed that intra-articular (i.a.) injection of monosodium iodoacetate (MIA) into the rat knee joint produces concentration-dependent outcomes. Thus, a low dose of i.a. MIA produces NSAID-sensitive weight asymmetry without evidence of ongoing pain and a high i.a. MIA dose produces weight asymmetry and NSAID-resistant ongoing pain. In the present study, palpation of the ipsilateral hind limb of rats treated 14days previously with high, but not low, doses of i.a. MIA produced expression of the early oncogene, FOS, in the spinal dorsal horn. Inactivation of descending pain facilitatory pathways using a microinjection of lidocaine within the rostral ventromedial medulla induced conditioned place preference selectively in rats treated with the high dose of MIA. Conditioned place preference to intra-articular lidocaine was blocked by pretreatment with duloxetine (30mg/kg, intraperitoneally at -30minutes). These observations are consistent with the likelihood of a neuropathic component of OA that elicits ongoing, NSAID-resistant pain and central sensitization that is mediated, in part, by descending modulatory mechanisms. This model provides a basis for exploration of underlying mechanisms promoting neuropathic components of OA pain and for the identification of mechanisms that might guide drug discovery for treatment of advanced OA pain without the need for joint replacement. Difficulty in managing advanced OA pain often results in joint replacement therapy in these patients. Improved understanding of mechanisms driving NSAID-resistant ongoing OA pain might facilitate development of alternatives to joint replacement therapy. Our findings suggest that central sensitization and neuropathic features contribute to NSAID-resistant ongoing OA joint pain.

Possible role of granulysin in pathogenesis of osteoarthritis

Increased presence of immune mediator and cytotoxic/apoptotic molecule granulysin was noticed in different tissues during pathological processes with the domination of Th1 over Th2 mediated immunity. Beside granulysin expression in T and NKT cells, activated NK cells are thought to be the major source of chemotactic 15kDa and cytotoxic 9kDa granulysin in vivo. As NK cells are the principal joint’s tissue-infiltrating lymphocyte subset, we hypothesized that granulysin mediated human cell death (apoptosis) could be responsible for the relatively silent damage of the joint’s tissue without clinically notable signs of systemic inflammation in the patients with osteoarthritis (OA). The analyzes of the presence and frequency of granulysin expressing lymphocytes at protein and gene levels in peripheral blood and synovial samples and/or the samples of joint’s tissue after the joint replacement therapy in patients with OA could give the initial insight to evaluate our hypothesis. It would be of the particular interest to differentiate the expression of 9kDa and 15kDa granulysin forms in the effector cells, since only the shorter form exhibits cytotoxic properties. The measurement of granulysin mediated early apoptosis in human NK sensitive K562 cells could be suitable in vitro model for evaluating granulysin activity. Furthermore, disturbed balance of pro-inflammatory and anti-inflammatory cytokines in OA patients, could influence the level of the granulysin expression. Having in mind that the granulysin and its regulation is still unknown in the pathogenesis of OA, it could be worth to explore this important pro-inflammatory, cytotoxic/apoptotic mediator.

Patterns of knee osteoarthritis in a hospital setting in sub-Saharan Africa.

Osteoarthritis (OA), the most prevalent joint disease in adults, ranks among the top 5 causes of disability. The burden of OA is expected to be greater in developing countries, where life expectancy is increasing and access to joint replacement therapy is not readily available. Risk factors associated with knee OA in Africa may differ from those identified in other parts of the world. This study aimed to establish the prevalence, clinical presentation, and associated factors of knee OA in two large referral centers in Cameroon. Between February and July 2012, we performed a cross-sectional analysis of 148 patients with knee OA followed at two rheumatology units in Douala. We included all patients with mechanical knee pain, who fulfilled the 1986 ACR for the classification and reporting of knee OA. One thousand four hundred ninety-six patients with musculoskeletal complaints were seen; 148 (9.9%) with knee OA were analyzed. Mean age was 56.9 ± 10.7 years, 75% were females, and 68% were post-menopausal. The VAS of pain at the time of diagnosis was higher than 50/100 mm in 64.2% of patients. Mean pain duration was 1 year (7 months-3.5 years). Obesity (BMI > 30) was present in 52% of patients, hypertension in 37.2%, and diabetes in 8.8%. Knee x-ray showed 35.5% of patients with grades III and IV on Kellgren and Lawrence classification. Bilateral bi-compartmental knee OA was found in 38.5% of patients and bilateral tricompartmental in 14.2%. The mean Lequesne disability index (LDI) was 8.4 ± 2.8. Pain intensity did not correlate with radiological findings whereas there was an association between pain and LDI. Knee OA is not rare among patients in Cameroon. Multiple factors including limited access to health care may account for why knee OA patients present at later stages of the disease with severe disability.

Corrigendum: Ankle Salvage Procedure without Internal Fixation for Large Bone Defect after Failed Total Ankle Arthroplasty: A Case Report

In treatment of failure in ankle joint replacement therapy, talar avascular necrosis with massive bone defect, talus fracture with severe comminution and bone defect and ankle dislocation, treatment of large bone defects is considerably important for ankle joint stability and union, therefore, the choice of treatment for large bone defects is use of femoral head or iliac crest bone graft and rigid internal fixation. Because first generation total ankle arthroplasty performed for the first time using a cemented fixation technique requires a large amount of bone resection during re-surgery and there is some possibility of a larger bone defect after removal of implants, in cases where prosthesis for the defect is needed, performance of palliative femoral head or iliac crest bone graft and rigid internal fixation can be difficult. We report on a case of a 48-year-old woman who had experienced ankle pain for 25 years since undergoing total ankle arthroplasty. Because the patient had little ankle motion and rigid soft tissue despite a large bone defect caused by aseptic loosening, a good outcome was obtained only for the femoral cancellous bone graft using allo femoral head without internal fixation.

A comparison between the complications and long-term outcome of hip and knee replacement therapy in patients with and without haemophilia; a controlled retrospective cohort study

The outcomes of total knee arthroplasty (TKA) and total hip arthroplasty (THA) in patients with haemophilia have not been compared with other patient populations. The aim of this study was to compare the results of joint replacement therapy in patients with and without haemophilia retrospectively. This is a controlled retrospective cohort study. The complications and long-term results of 21 TKAs and 6 THAs performed in 22 haemophilia patients were compared with those of 42 TKAs and 12 THAs in patients without bleeding disorders. Patients were matched for type of arthroplasty, gender, year of surgery and age. Blood loss, infection rate, revision, implant survival and function as judged by the patient were recorded. Haemarthrosis occurred in 14 (52%) of the 27 arthroplasties performed in the haemophilia patients, while four bleedings were recorded in the 54 arthroplasties in the control group (7%, P < 0.001). All bleeds occurred in TKAs. In the patient group, two infections (7%, both in TKAs) occurred compared to seven (13%, 6/7 in TKAs) in the control group (NS). In the haemophilia patients, all but one (96%) arthroplasties were still in situ at the end of follow-up, vs. 44 (81%, NS) in the control group. For TKAs, survival was 20/21 vs. 34/42 respectively (P = 0.25). Subjective function was good in 22/27 (81%; 76% in TKAs) arthroplasties in haemophilia patients, vs. 40/54 (74%; 71% in TKAs) in controls. Haemophilia patients experienced significantly more haemarthroses, but no more infections and they have an excellent implant survival compared with non-haemophilia controls.

Ankylosing spondylitis and the risk of fracture: results from a large primary care-based nested case-control study

Background and aims:Ankylosing spondylitis (AS) is associated with bone loss in the vertebrae and an increased prevalence of vertebral fractures, but literature about the magnitude of the risk of fracturing...

Detection, Evaluation, and Management of Anemia in the Elective Surgical Patient

The prevalence of anemia in elective surgical patients may be as frequent as 75% in certain populations. A national audit demonstrated that 35% of patients scheduled for joint replacement therapy have a hemoglobin <13 g/dL on preadmission testing. Standard practice currently consists of preadmission testing 3 to 7 days before an elective operative procedure, precluding the opportunity to effectively evaluate and manage a patient with unexpected anemia. Therefore, a standardized approach for the detection, evaluation, and management of anemia in the preoperative surgical setting was identified as an unmet medical need. To address this knowledge gap, we convened a panel of physicians to develop a clinical care pathway for anemia management in this setting. Elective surgery patients should receive a hemoglobin (Hgb) determination a minimum of 30 days before the scheduled surgical procedure. Because the identification and evaluation of anemia in this setting will assist in expedited diagnosis and treatment of underlying comorbidities and will improve patient outcomes, unexplained anemia (Hgb <12 g/dL for females and <13 g/dL for males) should cause elective surgery to be deferred until an evaluation can be performed.

Differences in expectations of outcome mediate African American/white patient differences in "willingness" to consider joint replacement.

Joint replacement therapy is an effective treatment option for end-stage osteoarthritis (OA) of the knee and/or hip. There are marked racial/ethnic disparities in the utilization of this procedure. The reasons for these disparities are not known. We sought to determine whether African American patients differ from white patients in their "willingness" to consider joint replacement and to determine the factors that influence this relationship. We performed a cross-sectional survey of 596 elderly, male, African American or white patients with moderate-to-severe symptomatic knee or hip OA who were receiving primary care at the Department of Veterans Affairs outpatient clinics. The groups were similar with respect to age, severity of arthritis measured by the Lequesne Scale and the Western Ontario and McMaster Universities Osteoarthritis Index, and scores on the Charlson Comorbidity Index and Geriatric Depression Scale. Compared with whites, African Americans were less likely to be employed or married or to have attained a high school education, but were more likely to report a median annual household income of <10,000 dollars. They were also less likely than whites to be familiar with joint replacement and more likely to expect a longer duration of hospital course, pain, and functional disability following replacement surgery. African American patients were less "willing" than white patients to consider joint replacement (odds ratio 0.50, 95% confidence interval 0.30-0.84). However, this difference was explained by the between-group differences in expectations. African American patients were less likely than white patients to express "willingness" to consider joint replacement if the procedure was needed and recommended. This difference was explained by differences between the groups in their expectations of hospital course, pain, and function following replacement surgery.

Self-assessed global quality of life: A comparison between African-American and white older patients with arthritis

Quality of life (QOL) perceptions influence patient decisions and preferences for care and, more importantly, physicians may render recommendations based on their impressions of the patient's QOL. QOL is perceived differently by different ethnic groups. This may have implications for understanding ethnic disparities in medical procedure utilization such as joint replacement for osteoarthritis. In a study of 596 elderly male patients with moderate to severe symptomatic knee/hip osteoarthritis, we examined how African-American and white patients rate their overall QOL. We adjusted their responses for important demographic, clinical, and psychosocial potential confounders. African-American (44%) and white (56%) patients in this study were comparable, except that African-Americans reported lower socioeconomic status compared with whites. After adjusting for all other study covariates, African-American ethnicity (B= -0.121, P = 0.004) was negatively correlated with overall QOL ratings. How ethnic variations in perceptions of QOL impact observed ethnic disparity in the utilization of joint replacement therapy needs further investigation.