Knee Joint Replacement Surgery Research Articles

The Association of Vitamin D Status and Pre-operative Physical Activity in Patients with Hip or Knee Osteoarthritis.

Vitamin D is important for musculoskeletal health and may have significant implications for maintaining physical activity in elderly patients. Our goal was to investigate whether serum 25-hydroxyvitamin D (25OHD) levels are associated with pre-operative physical activity in patients who are offered elective knee or hip joint replacement surgery. We performed a single-center, retrospective analysis of patients who had elective knee or hip replacement surgery from 2002 to 2012. To investigate the association of serum 25OHD levels with pre-operative physical activity, as assessed by the University of California, Los Angeles (UCLA) activity scale, we performed a multivariable logistic regression analysis while controlling for age, sex, race, body mass index, American Society of Anesthesiologists physical status score, and season. We identified 182 patients who met inclusion criteria. Mean (± standard deviation) 25OHD level and UCLA activity scale score were 29±13 ng/mL and 4±2, respectively. Patients with 25OHD levels <20 ng/mL were almost three times more likely to have UCLA activity scale scores ≤3 [adjusted odds ratio 2.78; 95% confidence interval 1.72-9.17]. Further adjusting for "type of 25OHD assay" or "type of joint surgery" did not materially change this result. In our cohort of knee or hip joint replacement surgery patients, 25OHD levels were associated with pre-operative physical activity scores. Prospective, randomized, clinical trials are needed to verify whether optimizing pre-operative vitamin D status may improve physical activity and influence clinical decision-making in knee or hip joint replacement surgery candidates.

Effect of Reversal of Neuromuscular Blockade With Sugammadex Versus Usual Care on Bleeding Risk in a Randomized Study of Surgical Patients

Previous studies show a prolongation of activated partial thromboplastin time and prothrombin time in healthy volunteers after treatment with sugammadex. The authors investigated the effect of sugammadex on postsurgical bleeding and coagulation variables.This randomized, double-blind trial enrolled patients receiving thromboprophylaxis and undergoing hip or knee joint replacement or hip fracture surgery. Patients received sugammadex 4 mg/kg or usual care (neostigmine or spontaneous recovery) for reversal of rocuronium- or vecuronium-induced neuromuscular blockade. The Cochran-Mantel-Haenszel method, stratified by thromboprophylaxis and renal status, was used to estimate relative risk and 95% confidence interval (CI) of bleeding events with sugammadex versus usual care. Safety was further evaluated by prespecified endpoints and adverse event reporting.Of 1,198 patients randomized, 1,184 were treated (sugammadex n = 596, usual care n = 588). Bleeding events within 24 h (classified by an independent, blinded Adjudication Committee) were reported in 17 (2.9%) sugammadex and 24 (4.1%) usual care patients (relative risk [95% CI], 0.70 [0.38 to 1.29]). Compared with usual care, increases of 5.5% in activated partial thromboplastin time (P< 0.001) and 3.0% in prothrombin time (P< 0.001) from baseline with sugammadex occurred 10 min after administration and resolved within 60 min. There were no significant differences between sugammadex and usual care for other blood loss measures (transfusion, 24-h drain volume, drop in hemoglobin, and anemia), or risk of venous thromboembolism, and no cases of anaphylaxis.Sugammadex produced limited, transient (<1 h) increases in activated partial thromboplastin time and prothrombin time but was not associated with increased risk of bleeding versus usual care.

Dexmedetomidine reduces postoperative delirium after joint replacement in elderly patients with mild cognitive impairment.

Postoperative delirium (POD) is a common and serious surgical complication among the elderly, especially in those with amnestic mild cognitive impairment (aMCI). Dexmedetomidine (DEX) is neuroprotective for delirium. In this study, we determined the effect of intravenously administered DEX during general anesthesia on POD in elderly aMCI patients undergoing elective hip joint or knee joint or shoulder joint replacement surgery. This was a prospective, randomized parallel-group study of aMCI (n=80) and normal elderly patients (n=120). Prior to surgery, all subjects underwent neuropsychological assessment and were assigned to one of four groups: the aMCI DEX group (MD group, n=40), the aMCI normal saline group (MN group, n=40), the control DEX group (CD group, n=60), and the control normal saline group (CN group, n=60). The confusion assessment method was used to screen POD on postoperative days 1, 3, and 7. We found patients age was positively correlated with POD incidence in the MN group (p<0.05) but not in the CN group (p<0.05). DEX treatment significantly decreased POD incidence in both control and aMCI groups relative to their respective placebo groups (all p<0.05). The fraction of patients whose normal cognitive function was not restored by day 7 after surgery was significantly higher in the MN group than the MD and CN groups (all p<0.05). These findings suggested that DEX treatment during surgery significantly reduced POD incidence in both normal and aMCI elderly patients, suggesting that it may be an effective option for the prevention of POD.

A Systematic Review Investigating the Presence of Inflammatory Synovitis in Hip and Knee Joint Replacement Surgery

Synovial tissue can display an inflammatory response in the presence of OA. There is increasing interest to better understand the role of inflammation in OA, particularly with regard to those who require joint replacement. A systematic review of inflammatory synovitis in OA of literature databases was undertaken from their inception until October 14, 2014. Independent critical appraisal of each study was undertaken using the CASP appraisal tool. From a total of sixty-six identified citations, twenty-three studies were deemed eligible for review. The studies presented moderate to strong methodological quality. Strong correlation was identified between histological and imaging synovitis severity. Correlation was weaker between clinical symptoms and imaging and/or histological synovitis severity. There was little consensus, with regard to expressed cytokines and chemokines at the different stages of OA disease progression. Few studies investigated the influence of inflammatory synovitis on the outcome of major joint replacement. Research into inflammatory synovitis in OA is an emerging field. Longitudinal studies applying proven imaging modalities, histological analysis, and longer follow-up are required in order to further define our understanding of the role of synovitis in the pathogenesis of OA and its effects on outcomes following major joint replacement.

A1.4 Inflammatory microenvironment of rheumatoid and osteoarthritic joint affects immunomodulatory activity of adipose-derived mesenchymal stem cells

Background and objectives Adipose-derived mesenchymal stem cells (ASCs) have immunomodulatory properties, but their activity is dependent on signals provided by local microenvironment. ASCs administration in rheumatoid arthritis (RA) did not bring consistent results, while in osteoarthritis (OA) it has beneficial effects. It is likely that proinflammatory milieu of rheumatoid joint affects ASCs activity. To test this hypothesis, the function of rheumatoid ASCs (RA-ASCs) and osteoarthritic ASCs (OA-ASCs) isolated from infrapatellar fat pad of the knee joint have been analysed. Materials and methods Infrapatellar fat pads were obtained from 29 RA and 12 OA patients undergoing total knee joint replacement surgery. Then, ASCs were isolated accordingly to routinely applied procedure. ASCs were treated or not with IFNγ or TNF. The expression of indoleamine 2,3-dioxygenase and heme oxygenase 1 mRNA was measured using quantitative PCR, while ASCs secretory potential was assessed by specific ELISAs. Rheumatoid synovial fibroblasts (RA-FLS) or peripheral blood mononuclear cells (PBMCs) from healthy donors were cultured in ASC-conditioned media or co-cultured with ASCs. Next, cytokines secretion and cells proliferation were measured using ELISAs and bromodeoxyuridine/ 3 H-thymidine proliferation assays, respectively. Results RA- and OA-ASCs activity in vitro is comparable, nonetheless some differences in spontaneous secretory activity and heme oxygenase 1 mRNA expression have been observed. Unstimulated RA- and OA-ASCs slightly inhibited PBMCs proliferation and induced IL-10 secretion but increased IL-17A production and failed to suppress release of other proinflammatory factors (TNF, IFNγ, RANTES) by PBMCs. Under TNF stimulation, RA- and OA-ASCs up-regulated IL-6 and MMP-3 secretion in RA-FLS cultures and IL-17A release by PBMCs. ASCs treatment with IFNγ or TNF did not intensify their anti-inflammatory activity. Conclusions Our study demonstrates that immunosuppressive function of RA- and OA-ASCs derived from infrapatellar fat pad is impaired. Possibly, it is due to the localisation of ASCs in the site of inflammation. Moreover, TNF triggers proinflammatory properties of ASCs which indicates that when administered to the rheumatoid joint, ASCs may shift from an anti-inflammatory to proinflammatory phenotype. Acknowledgements This work was supported by the Polish National Science Centre (grant no. 2011/01/N/NZ5/00932) and by the European Union funds (European Social Fund, Human Capital Programme).

Approaches to Delivery of Care at Home Following Elective Hip and Knee Joint Replacement Surgery

Arthritis has a worldwide increasing prevalence with increased demands on healthcare systems to provide arthroplasty surgery. There is growing evidence that early discharge and rehabilitation at home following hip and knee replacement provide similar or better results in function, complication rates and patient satisfaction. We suggest that this method of rehabilitation is a cost-effective viable option in fitter patients whose medical demands will be low postoperatively.

Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review

Objective: To systematically review the effect of early mobilization after hip or knee joint replacement surgery on length of stay in an acute hospital. Methods: Randomized controlled trials were selected from electronic databases based on inclusion criterion requiring an experimental group mobilizing (sitting out of bed/walking) earlier than a comparison group post joint replacement surgery of the hip or knee in an acute hospital. Clinically homogeneous data were analyzed with meta-analysis. Results: Five randomized controlled trials (totaling 622 participants) were included for review. A meta-analysis of 5 trials found a reduced length of stay of 1.8 days (95% confidence interval 1.1 to 2.6) in favor of the experimental group. In 4 of the 5 trials the experimental group first sat out of bed within 24 hours post operatively. In 4 of the 5 trials the experimental group first walked within 48 hours post operatively. Individual trials reported benefits in range of motion, muscle strength and health-related quality of life in favor of the experimental group. There were no differences in discharge destinations, incidence of negative outcomes or adverse events attributable to early mobilization when compared to the comparison groups. Conclusion: Early mobilization post hip or knee joint replacement surgery can result in a reduced length of stay of about 1.8 days. Trials that reported these positive results showed that early mobilization can be achieved within 24 hours of operation. This positive gain was achieved without an increase in negative outcomes.

Hospital volume affects outcome after total knee arthroplasty

Background and purpose — The influence of hospital volume on the outcome of total knee joint replacement surgery is controversial. We evaluated nationwide data on the effect of hospital volume on length of stay, re-admission, revision, manipulation under anesthesia (MUA), and discharge disposition for total knee replacement (TKR) in Finland. Patients and methods — 59,696 TKRs for primary osteoarthritis performed between 1998 and 2010 were identified from the Finnish Hospital Discharge Register and the Finnish Arthroplasty Register. Hospitals were classified into 4 groups according to the number of primary and revision knee arthroplasties performed on an annual basis throughout the study period: 1–99 (group 1), 100–249 (group 2), 250–449 (group 3), and ≥ 450 (group 4). The association between hospital procedure volume and length of stay (LOS), length of uninterrupted institutional care (LUIC), re-admissions, revisions, MUA, and discharge disposition were analyzed. Results — The greater the volume of the hospital, the shorter was the average LOS and LUIC. Smaller hospital volume was not unambiguously associated with increased revision, re-admission, or MUA rates. The smaller the annual hospital volume, the more often patients were discharged home. Interpretation — LOS and LUIC ought to be shortened in lower-volume hospitals. There is potential for a reduction in length of stay in extended institutional care facilities.

Increased expression of dopamine receptors in synovial fibroblasts from patients with rheumatoid arthritis: inhibitory effects of dopamine on interleukin-8 and interleukin-6.

Observations in both animal models of arthritis and patients with rheumatoid arthritis (RA) suggest a role for dopamine and its receptors in RA. Because synovial fibroblasts (SFs) contribute to inflammation and joint destruction in RA, the aim of this study was to investigate dopaminergic pathways in SFs obtained from patients with RA and, for comparison, in SFs from patients with osteoarthritis (OA) undergoing knee joint replacement surgery. The expression of all dopamine receptors (D1 -D5 ) and dopamine transporter was assessed by immunofluorescence and immunohistochemical staining. The levels of dopamine receptor and tyrosine hydroxylase messenger RNA were measured by real-time polymerase chain reaction. The intracellular content of dopamine, its precursor, and its main metabolites was assayed by high-performance liquid chromatography. The influence of dopamine on proinflammatory interleukin-6 (IL-6) and IL-8, matrix metalloproteinase 3, and tissue inhibitor of metalloproteinases 1 (TIMP-1) and TIMP-2 was studied in SFs. SFs possess an intrinsic dopaminergic system, including dopamine receptors, dopamine transporter, and tyrosine hydroxylase, and contain dopamine, its precursor, and its main metabolites. SFs from patients with RA, in comparison with those from patients with OA, showed increased expression of dopamine receptors D1 and D5 , and exogenous dopamine strongly inhibited the production of IL-8 in patients with RA. SFs from patients with RA and patients with OA show a dopaminergic phenotype. The expression of D1-like dopamine receptors was higher in RASFs, and this increased expression may lead to antiinflammatory effects, as demonstrated by the expression of IL-8. Studies in animal models and patients with RA are needed to assess the therapeutic potential of endogenous, local production of dopamine in synoviocytes.

Formula food-reducing diets:A new evidence-based addition to the weight management tool box.

The changing pattern of obesity-related disease has created a need for a greater range of weight management options for the increasing number of people for whom weight loss and maintenance cannot be addressed by conventional dietary methods.Formula diet weight loss programmes [very low-calorie diets (VLCDs) (400–800 kcal/day) and low-calorie diets (LCDs) (800–1200 kcal/day)] can deliver weight loss at rates of 1–2 kg/week. This rate of weight loss can result in 10–20 kg weight loss in 8–12 weeks. Many health benefits associated with weight reduction seem to require between 10 and 20 kg weight loss. Formula diet programmes can result in weight loss, reduction of liver volume and reduction of visceral fat before bariatric surgery; weight loss before knee joint replacement surgery has also been shown. The benefit of pre-operative weight loss is still under investigation and such practices before bariatric surgery are variable in surgical units across the UK.Weight loss with formula diet in obesity-associated conditions where inflammation is an important component, such as osteoarthritis and psoriasis, has been demonstrated. Maintenance of about 10% of initial bodyweight loss, with symptom improvement in elderly obese people with knee osteoarthritis, has been shown over a period of 4 years. In obese people with psoriasis, weight loss with skin improvement has been maintained for 1 year.Clinical trials are currently underway to examine the merits of an initial weight loss with formula diet in pre-diabetes, in early type 2 diabetes and in insulin-treated type 2 diabetes.Rapid initial weight loss can result in rapid symptom improvement, such as reduced joint pain in osteoarthritis, improved sleep quality in obstructive sleep apnoea, reduced shortness of breath on exertion, reduced peripheral oedema and rapid improvement in metabolic control in diabetes, all changes that are highly motivating and conducive towards compliance.There is also some evidence for improved vitamin D status and maintained bone health in elderly obese people with osteoarthritis but more research is needed.Rapid initial weight loss was feared to be followed by rapid weight regain. However, provided initial weight loss is delivered in parallel with an intense education programme about nutrition, cooking, shopping and lifestyle for long-term maintenance; and where long-term support is provided, subsequent weight maintenance after VLCDs and LCDs has been shown to be possible. A recent literature review identified high-protein diets, obesity drugs and partial use of formula meal replacements as methods which can result in statistically significantly greater weight maintenance after initial weight loss with VLCDs or LCDs.Anxiety about serious adverse side effects seems to be unfounded although users need to be aware of both minor and more serious, though very infrequent, adverse events, such as gallstones and gallbladder disease.

AB0101 Articular Adipose Tissue from Osteoarthritis Patients is A Source of Cytokines and Adipokines

BackgroundRecently rheumatoid adipose tissue has been suggested to play an important role in chronic inflammatory joint diseases. Its ability to synthesize cytokines and adipokines has been characterized also in our...

Prosthetic joint infections – a need for health economy studies

Prosthetic joint infections – a need for health economy studies

Guideline recommendations for post acute postoperative physiotherapy in total hip and knee joint replacement surgery: are they used in daily clinical practice?

Guideline recommendations for post acute postoperative physiotherapy in total hip and knee joint replacement surgery: are they used in daily clinical practice?

Comorbidity in osteoarhritis patients following hip and knee joint replacement surgery

Comorbidity in osteoarhritis patients following hip and knee joint replacement surgery

Older patients have the most to gain from orthopaedic enhanced recovery programmes

Between August 2007 and May 2009, 2128 consecutive patients underwent either primary hip or knee joint replacement surgery at our institute on an enhanced recovery pathway. We aimed to investigate the potential benefits of this pathway in patients over the age of 85 years. Data extracted from Hospital Episode Statistics were analysed. This data are prospectively collected and independently collated. In all patients median length of stay was reduced when compared with both our own data before the introduction of the pathway (6 to 4 days) and national averages over the same time period for both hip and knee replacements (5 to 4 days). Difference in length of stay was most pronounced in the group of patients aged 85 years and over (9 to 5 days for total hip replacement and 8 to 5 days for total knee replacement). Nearly all patients were discharged directly home (97.4%). Readmission rates were over 45% lower in patients aged 85 and over when compared with national averages (5.2 vs. 9.4%). This is the first series in the literature to assess the role of enhanced recovery pathways in the very elderly. This study not only shows that successful fast track rehabilitation can be achieved in the very elderly population undergoing elective joint replacement surgery, but that it is this cohort of vulnerable patients who have the most to gain from such multidisciplinary recovery programmes.

A5.7 Articular adipose tissue from OA patients is an important source of cytokines and adipokines

Background and ObjectivesRecently rheumatoid adipose tissue has been suggested to play an important role in chronic inflammatory joint diseases. Its ability to synthesize cytokines and adipokines has been characterised also...

A5.17 Comparison of adipose mesenchymal stem cells derived from rheumatoid arthritis and osteoarthritis patients. The influence of adipocytokines

Background and ObjectivesAdipose-derived stem cells (ASCs) have immunomodulatory properties and are intensively studied as a potential therapeutical method to treat rheumatoid arthritis (RA). ASCs immunosuppressive function may be affected by...

Articular adipose tissue resident macrophages in rheumatoid arthritis patients: potential contribution to local abnormalities

The objectives of this study were to characterize macrophages resident in inflamed articular adipose tissue (AAT) and non-inflamed subcutaneous adipose tissue (ScAT) of RA patients and to evaluate the basal and cytokine-triggered secretory activities of these tissues. Tissues were obtained from patients undergoing knee joint replacement surgery. The number of total CD68(+), CD14(+) and CD163(+) macrophages was evaluated by immunohistochemistry. The concentrations of select factors were measured in supernatants from untreated and cytokine-treated tissue explant cultures using ELISA. IL-1β and TNF were applied as the stimuli. Paired samples of AAT and ScAT, obtained from the same patients, contained a similar number of macrophages, displaying an M2-skewed phenotype. Both tissues released equivalent amounts of IL-1β, TNF, IL-10 and macrophage migration inhibitory factor (MIF). However, AAT secreted more chemokines (CCL2, CCL5), cytokines [IL-6, IL-8, IL-1 receptor antagonist (IL-1Ra)], hepatocyte growth factor (HGF) and MMP-3 than ScAT. Basal secretion of adipocytokines was not patient specific. Except for HGF and MIF, cytokine treatment up-regulated the release of these factors from both tissues, but also upon stimulation AAT produced more IL-6, IL-8 and IL-1Ra than ScAT. The secretory activity, reflecting cell activation status but not phenotype or the number of macrophages, discriminates rheumatoid AAT from ScAT. By releasing various factors possessing chemotactic, proinflammatory, anti-inflammatory and tissue degrading activities, AAT resident macrophages may drive and control local pathological processes.

AB0143 Osteogenic potential of mesenchymal stem cells from articular adipose tissue – comparison of rheumatoid arthritis and osteoarthritis

BackgroundAdipose-derived mesenchymal stem cells (ADSC) have the ability to differentiate into osteoblasts. This makes them promising in treatment of bone erosion occuring in rheumatoid arthritis (RA). ADSC residing in rheumatoid...

AB0110 Adipocytokines modify the expression of indoleamine 2,3-dioxygenase and HEM oxygenase-1 in rheumatoid mesenchymal stem cells from articular adipose tissue

BackgroundWhite adipose tissue (WAT) is a rich source of mesenchymal stem cells (ADSC) which immunomodulatory and regenerative properties are well documented. Therapeutic effect of ADSC in experimental animal model of...