Knee Replacement Surgery For Osteoarthritis Research Articles

Inequalities in provision of hip and knee replacement surgery for osteoarthritis by age, sex, and social deprivation in England between 2007-2017: A population-based cohort study of the National Joint Registry.

While the United Kingdom National Health Service aimed to reduce social inequalities in the provision of joint replacement, it is unclear whether these gaps have reduced. We describe secular trends in the provision of primary hip and knee replacement surgery between social deprivation groups. We used the National Joint Registry to identify all hip and knee replacements performed for osteoarthritis from 2007 to 2017 in England. The Index of Multiple Deprivation (IMD) 2015 was used to identify the relative level of deprivation of the patient living area. Multilevel negative binomial regression models were used to model the differences in rates of joint replacement. Choropleth maps of hip and knee replacement provision were produced to identify the geographical variation in provision by Clinical Commissioning Groups (CCGs). A total of 675,342 primary hip and 834,146 primary knee replacements were studied. The mean age was 70 years old (standard deviation: 9) with 60% and 56% of women undergoing hip and knee replacements, respectively. The overall rate of hip replacement increased from 27 to 36 per 10,000 person-years and knee replacement from 33 to 46. Inequalities of provision between the most (reference) and least affluent areas have remained constant for both joints (hip: rate ratio (RR) = 0.58, 95% confidence interval [0.56, 0.60] in 2007, RR = 0.59 [0.58, 0.61] in 2017; knee: RR = 0.82 [0.80, 0.85] in 2007, RR = 0.81 [0.80, 0.83] in 2017). For hip replacement, CCGs with the highest concentration of deprived areas had lower overall provision rates, and CCGs with very few deprived areas had higher provision rates. There was no clear pattern of provision inequalities between CCGs and deprivation concentration for knee replacement. Study limitations include the lack of publicly available information to explore these inequalities beyond age, sex, and geographical area. Information on clinical need for surgery or patient willingness to access care were unavailable. In this study, we found that there were inequalities, which remained constant over time, especially in the provision of hip replacement, by degree of social deprivation. Providers of healthcare need to take action to reduce this unwarranted variation in provision of surgery.

Why don't patients seek help for chronic post-surgical pain after knee replacement? A qualitative investigation.

BackgroundAlthough many people are satisfied with their outcome after total knee replacement surgery for osteoarthritis, around 20% report chronic post‐surgical pain. People are often disappointed and unsure about whether their pain is normal and what can be done about it. Given the high prevalence of long‐term post‐operative pain after knee replacement, there is potentially a large hidden population with an unaddressed need for care.ObjectiveIn this study, we focus on understanding why some people choose not to consult health care for chronic post‐surgical pain after knee replacement.MethodsSemi‐structured interviews were conducted with people who had received total knee replacement, at either of two National Health Service hospitals in the United Kingdom, and who had chronic post‐surgical pain (n = 34, age 55‐93 years). Data were audio‐recorded, transcribed and analysed thematically.ResultsWe found an overall sense of futility amongst participants who believed that nothing further could be done for their on‐going pain. People's perception of their pain was often discordant with that of surgeons and physicians. Other factors that contributed to decisions not to seek help included low expectations about effectiveness and the risks involved in further treatment, treatment burden, participants' prioritization of other health conditions and views about candidacy. Many accepted their on‐going pain.ConclusionOur study indicates why some people with chronic pain after knee replacement do not seek further health care. Understanding patients' beliefs and expectations about chronic post‐surgical pain can inform approaches that might enable people to seek help in the future.

Estimating an Individual’s Probability of Revision Surgery After Knee Replacement: A Comparison of Modeling Approaches Using a National Data Set

Tools that provide personalized risk prediction of outcomes after surgical procedures help patients make preference-based decisions among the available treatment options. However, it is unclear which modeling approach provides the most accurate risk estimation. We constructed and compared several parametric and nonparametric models for predicting prosthesis survivorship after knee replacement surgery for osteoarthritis. We used 430,455 patient-procedure episodes between April 2003 and September 2015 from the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man. The flexible parametric survival and random survival forest models most accurately captured the observed probability of remaining event-free. The concordance index for the flexible parametric model was the highest (0.705, 95% confidence interval (CI): 0.702, 0.707) for total knee replacement and was 0.639 (95% CI: 0.634, 0.643) for unicondylar knee replacement and 0.589 (95% CI: 0.586, 0.592) for patellofemoral replacement. The observed-to-predicted ratios for both the flexible parametric and the random survival forest approaches indicated that models tended to underestimate the risks for most risk groups. Our results show that the flexible parametric model has a better overall performance compared with other tested parametric methods and has better discrimination compared with the random survival forest approach.

Substantial rise in the lifetime risk of primary total knee replacement surgery for osteoarthritis from 2003 to 2013: an international, population-level analysis.

To estimate and compare the lifetime risk of total knee replacement surgery (TKR) for osteoarthritis (OA) between countries, and over time. Data on primary TKR procedures performed for OA in 2003 and 2013 were extracted from national arthroplasty registries in Australia, Denmark, Finland, Norway and Sweden. Life tables and population data were also obtained for each country. Lifetime risk of TKR was calculated for 2003 and 2013 using registry, life table and population data. Marked international variation in lifetime risk of TKR was evident, with females consistently demonstrating the greatest risk. In 2013, Finland had the highest lifetime risk for females (22.8%, 95%CI 22.5-23.1%) and Australia had the highest risk for males (15.4%, 95%CI 15.1-15.6%). Norway had the lowest lifetime risk for females (9.7%, 95%CI 9.5-9.9%) and males (5.8%, 95%CI 5.6-5.9%) in 2013. All countries showed a significant rise in lifetime risk of TKR for both sexes over the 10-year study period, with the largest increases observed in Australia (females: from 13.6% to 21.1%; males: from 9.8% to 15.4%). Using population-based data, this study identified significant increases in the lifetime risk of TKR in all five countries from 2003 to 2013. Lifetime risk of TKR was as high as 1 in 5 women in Finland, and 1 in 7 males in Australia. These risk estimates quantify the healthcare resource burden of knee OA at the population level, providing an important resource for public health policy development and healthcare planning.

Tumor-like lesions of the heart valve

Valvular tumor and tumor-like lesions are rare. Fibroelastoma is the most common valvular tumor, followed by myxoma. Atypical valvular lesions, such as organized thrombus, valvular calcification and valvular abscess may develop symptoms and present morphological features similar to those of the valvular tumors. The Author here reports a case of a tumour or tumour- like lesion over the mitral valve detected in a asymptomatic patient on preoperative evaluation prior to bilateral total knee replacement surgery for osteoarthritis.. Key-words: Valvular tumour, Tumour -like lesions, Key Messages: Patients should be counselled about the high risk of stroke when tumour or tumour-like lesions are visualised on echocardiogram and encouraged to have a definitive diagnosis established by surgery and biopsy.

Does knee replacement surgery for osteoarthritis improve survival? The jury is still out

BackgroundThe relation of knee replacement (KR) surgery to all-cause mortality has not been well established owing to potential biases in previous studies. Thus, we aimed to examine the relation of...

Trajectories of need: understanding patients’ use of support during the journey through knee replacement

Purpose: To explore how the process of undergoing and recovering from knee replacement surgery alters patients’ experiences and use of their support networks.Methods: Ten patients having knee replacement surgery for osteoarthritis were invited to take part in in-depth interviews prior to surgery and 2–4 weeks, 6 and 12 months post-operatively. Transcripts were analyzed using Interpretative Phenomenological Analysis.Results: Three superordinate themes were identified: (1) relationships with health professionals over the knee replacement journey; (2) implications for informal relationships and support networks and (3) providing support to others.Conclusions: Transformation from a person with osteoarthritis to someone recovering from a surgical intervention can lead to alterations in the source, type and level of support people receive from others, and can also change the assistance that they themselves are able to offer. Findings highlight the value of the concept of interdependence to our understanding of participants’ experiences. Activity undertaken by informal support networks assists participants to cope with the consequences of osteoarthritis and surgery, and fills in the gap when more formal support is lacking. However, it is essential that provision of care is individually tailored and that formal support is adequate at times when informal support networks are unavailable.Implications for RehabilitationActivity undertaken by informal support networks can help patients who undergo knee replacement cope with the consequences of their operation; filling the void when support from health professionals is lacking.Contact with health professionals after surgery enhances confidence and offers reassurance; helping to facilitate the recovery process from knee replacement.Findings highlight, from patients’ own perspectives, the potential value of post-operative physiotherapy received soon after surgery and the possible role of long-term follow up.Missing or ill-timed support from health professionals can have negative psychosocial consequences for patients going through joint replacement.

Latest approaches on the management of OA in humans

The Sofat laboratory currently investigates the mechanisms responsible for pain and tissue damage in arthritis. Clinical studies include ‘Pain management in osteoarthritis using centrally acting analgesics’ (http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=12175) funded by the Rosetrees Trust. This clinical trial is testing whether drugs that inhibit pain processing pathways in the brain can help with pain in the hand caused by osteoarthritis. Other clinical studies include the ‘Pain Perception in Osteoarthritis’, or PAPO study, investigating tissue damage and pain in people undergoing knee replacement surgery for osteoarthritis. Both studies are on the UK NIHR portfolio of network-adopted studies. Our laboratory has a translational approach, with techniques including magnetic resonance imaging (MRI) to decipher regions of damage in affected joints and evaluating which brain regions are activated by arthritis pain. We also use non-invasive quantitative sensory testing (QST) methods to identify pain pathways. QST identifies sensation and pain thresholds by stimulating the skin. Our laboratory research uses a basic science mechanistic approach to investigate the influence of endogenous damage-associated molecular patterns (DAMPs) in driving chronic inflammation in joints. Molecules of interest include interaction of the DAMPs tenascin-C and fibronectin with oral pathogens.

Deletion of P58(IPK), the Cellular Inhibitor of the Protein Kinases PKR and PERK, Causes Bone Changes and Joint Degeneration in Mice.

Objective: Protein kinase-like endoplasmic reticulum kinase (PERK) and protein kinase R (PKR) are implicated in endoplasmic reticulum stress-induced arthritis and pro-inflammatory cytokine-mediated cartilage degradation in vitro, respectively. We determined whether knockout of the cellular inhibitor of PERK and PKR, P58IPK causes joint degeneration in vivo and whether these molecules are activated in human osteoarthritis (OA).Materials and Methods: Sections of knee joints from P58IPK-null and wild-type mice aged 12–13 and 23–25 months were stained with toluidine blue and scored for degeneration using the osteoarthritis research society international (OARSI) system. Bone changes were assessed by radiology and high-resolution micro-computed tomography of hind limbs. Sections from the medial tibial plateaus of two human knees, removed in total knee replacement surgery for OA, were immunolabelled for phosphorylated PERK and PKR and P58IPK.Results: Knockout mice exhibited narrower tibiae (p = 0.0031) and smaller epiphyses in tibiae (p = 0.0004) and femora (p = 0.0214). Older knockout mice had reduced total volume inside the femoral periosteal envelope (p = 0.023), reduced tibial (p = 0.03), and femoral (p = 0.0012) bone volumes (BV) and reduced femoral BV fraction (p = 0.025). Compared with wild-types, younger P58IPK-null mice had increased OARSI scores in medial femoral condyles (p = 0.035). Thirty four percent of null mice displayed severe joint degeneration with complete articular cartilage loss from the medial compartment and heterotopic chondro-osseous tissue in the medial joint capsule. Phosphorylated PERK and PKR were localized throughout human osteoarthritic tibial plateaus but, in particular, in areas exhibiting the most degeneration. There was limited expression of P58IPK.Conclusion: This study is the first to reveal a critical role for P58IPK in maintaining joint integrity in vivo, implicating the PKR and PERK stress signaling pathways in bony changes underlying the pathogenesis of joint degeneration.

Atypical focal forms of Whipple's disease seen by rheumatologists

We report two atypical cases of focal Whipple's disease with rheumatic presenting symptoms. In one of these cases, the patient presented with chronic intermittent polyarthritis, systemic inflammation, and leukocytosis. Tests were positive for rheumatoid factor and anti-cyclic citrullinated peptide antibodies. There was no structural joint damage. Combined glucocorticoid and methotrexate therapy was only partially effective. Endocarditis requiring emergency valve replacement surgery occurred 4 years later. Evaluation of this event led to the diagnosis of Tropheryma whipplei infection responsible for both the endocarditis and the joint disease. The other patient presented with subacute inflammatory low back pain. His medical history was chiefly remarkable for intermittent inflammatory involvement of the wrists and right knee replacement surgery for osteoarthritis followed by a febrile effusion of the operated knee. Radiographs showed destructive lesions of the wrists. Magnetic resonance imaging findings suggested L2-L3 diskitis. A PCR assay on biopsy specimens from the disk lesions recovered T. whipplei, thus establishing the cause of the diskitis and previous joint manifestations. Combined doxycycline and hydroxychloroquine therapy was followed by full resolution of all clinical and laboratory abnormalities in both patients.

The association of comorbid conditions with patient reported outcomes in osteoarthritis

The association of comorbid conditions with patient reported outcomes in osteoarthritis

Rehabilitation after knee replacement surgery for osteoarthritis

The replacement of the knee joint relieves pain for most patients with chronic symptomatic knee osteoarthritis, with the maximum achievable benefit appearing around six months after surgery. However, the magnitude of improvement is smaller than after total hip replacement surgery. About 15% still report moderate to severe pain and 40% report limited functional improvement a year after surgery, despite an absence of radiographic abnormalities. Many years after surgery, patients are left with the same greatly reduced lower limb muscle strength and gait abnormalities evident prior to surgery. Worldwide, there is evidence of considerable practice variation in post-acute rehabilitation after knee replacement surgery. Any active supervised exercise program after discharge from the orthopaedic ward, if provided, is generally completed within a few weeks of surgery. One probable reason for the lack of demonstrable long-term benefit of current usual practice is that patients are still experiencing the anaemia, pain and oedema inevitably associated with recovery from major orthopaedic surgery. Training intensity is therefore rarely able to be progressed sufficiently to achieve meaningful sustainable improvements in lower limb muscle strength or gait quality beyond the immediate pre-surgery levels. In fact, current approaches may not be adding benefit to long-term patient outcomes above that resulting from natural recovery from surgery alone. There is preliminary evidence that achieving optimal lower limb muscle strength, gait patterns and symmetry, and knee joint loading patterns may be crucial for long-term clinical benefits, integrity of other lower limb joints and implant longevity after knee replacement surgery. Adequately addressing ongoing physical impairments after knee replacement surgery has potential to allow these patients to safely commence a more active lifestyle, improving their general health and reducing the risk of serious co-morbidity and ongoing health care costs.

Cross-sectional study of pain and disability at knee replacement surgery for osteoarthritis in 299 patients

ObjectiveTo evaluate pain and disability at the time of knee replacement surgery for osteoarthritis. MethodsIn this multicenter cross-sectional study, 299 patients at 12 orthopedic surgery centers in Lyon, France were evaluated on the day before knee replacement surgery. Pain severity was assessed on a visual analog scale (VAS) and function using the Lequesne index and the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC). ResultsThere were 207 women and 92 men with a mean age of 73 years. Mean (±SD) VAS pain score upon walking was 55.8±24mm. Compared to patients with very severe disability (Lequesne index>12), those with mild-to-severe disability (Lequesne index≤12) were more likely to be older than 70 years (odds ratio [OR], 2.85; 95% confidence interval [95%CI], 1.25–5) and male (OR, 2.5; 95%CI, 1.3–5); they were less likely to have a body mass index>27kg/m2 (OR, 2.2; 95%CI, 1.3–3.3) and to engage in sporting activities (OR, 3.3; 95%CI, 1.4–10). ConclusionPatients about to undergo knee replacement surgery had high levels of pain and disability, with little variation across centers. Nevertheless, the severity of pain and disability may depend in part on age, gender, body mass index, and sporting activities, which probably influence the decision to perform knee replacement surgery.

The need for a falls prevention programme for patients undergoing hip and knee replacement surgery

Summary Falls are a major concern in the elderly consuming considerable healthcare resources. This study evaluates the incidence of falls in patients suffering osteoarthritis (OA) and their impact on health status. 199 patients awaiting primary hip or knee replacement surgery for OA were recruited (84 hips, 115 knees). Patients completed a questionnaire including the Western Ontario and McMaster University OA Index (WOMAC), Short Form 36 (SF-36), and history of falls. Function was measured using the Timed Up and Go (TUG) test. Seventy-five patients (39%) reported falling within a 4-week period with 50 (25%) having fallen more than once. Fallers had significantly lower WOMAC pain and function scores, slower TUG, and worse SF-36 scores excluding social functioning and mental health. This study demonstrates that patients with hip or knee OA frequently fall. Considering the increasing numbers of patients undergoing total knee and hip replacement for OA, and the catastrophic consequences of peri-prosthetic fractures, the need to incorporate a falls prevention programme within arthroplasty management requires evaluation.

Comparison of characteristics of patients with and without calcium pyrophosphate dihydrate crystal deposition disease who underwent total knee replacement surgery for osteoarthritis

To compare characteristics of patients with severe osteoarthritis with and without calcium pyrophosphate dihydrate (CPPD) crystal deposition disease. Patients undergoing total knee replacement surgery participated in this study and completed questionnaires. Radiographs of the index knee (extended anteroposterior, lateral and skyline) were reviewed for the presence of chondrocalcinosis. Synovial fluids were obtained during surgery and analyzed under compensated polarized light microscopy. The presence of CPPD crystals was identified in 52.9% of 102 patients. The use of both radiographs and synovial fluid analysis increased the identification of crystals. There was no difference in the following characteristics of the patients with and without CPPD crystals: age of pain onset, gender, difficulty in performing daily functions (including cooking, standing up from chairs, using restroom, going upstairs, and going shopping), history of previous joint inflammation, use of walking aids, and number and types of medications ever used. CPPD patients underwent knee arthroplasty at older age compared to non-CPPD patients (70.3+/-6.37 and 67.5+/-7.15 years old, respectively) (P = 0.037). All but one CPPD patients were unaware of the presence of crystals. High prevalence of CPPD crystals was found in patients undergoing total knee replacement surgery. All but one CPPD patients were unaware of calcium deposition in the index joints. Patients with these crystals experienced similar difficulties in performing daily activities and received similar treatment to patients without CPPD crystals. CPPD patients did not undergo knee arthroplasty at earlier age than non-CPPD patients.

Effects of n‐3 polyunsaturated fatty acids on COX‐2 and PGE2 protein levels in articular cartilage chondrocytes

Introduction Previous studies within our laboratory have shown that supplementation with n‐3 polyunsaturated fatty acids (PUFAs), but not other fatty acids, has a beneficial effect on reducing the expression and activity of degradative and inflammatory factors known to cause damage and destruction of cartilage in arthritic diseases (Curtis et al. 2000,2002). Cyclooxygenase (COX), also known as prostaglandin H synthase, catalyses the rate‐limiting step in the formation of inflammatory prostaglandins (PGs) (Hla & Neilson 1992). PG synthesis requires conversion of arachidonic acid to PGH2 by either the constitutive COX‐1 or by COX‐2, which is induced by inflammatory and mitogenic stimuli (Smith et al. 2000). Prostaglandin E2 (PGE2) is produced from PGH2 and has been shown to have a number of functions including both anti‐ and pro‐inflammatory actions (Christman et al. 1991). The aim of this project was to investigate the effects of n‐3 PUFAs on cyclooxygenase‐2 and prostaglandin E2 protein levels in articular cartilage chondrocytes.Materials and methods Articular cartilage was obtained both from 7‐day‐old bovine metacarpo‐metatarsophalangeal joints and from human patients undergoing total knee replacement surgery for osteoarthritis (Llandough Hospital, S.Wales, UK). Both explant and monolayer cultures were set up in DMEM with or without 10–300 µg/ml n‐3[eicosapentaenoic acid (EPA)] or n‐6[arachidonic acid (AA)] PUFAs (minimum 8 h, at 37°C, in 5%CO2) and in the absence or presence of IL‐1 (10 ng/ml) for a further 4 days.Results Total RNA was extracted and RT‐PCR performed using oligonucleotide primers specific to COX‐2 (Invitrogen, UK). COX‐2 mRNA was found to be absent or only present at very low levels in both bovine and human control cultures. After treatment with IL‐1, this expression greatly increased. However, supplementation of IL‐1‐treated cultures with n‐3 PUFA (EPA) resulted in a loss of COX‐2 mRNA expression. In contrast, supplementation with n‐6 PUFA (AA) had no effect. Western blot analysis, using a polyclonal antibody specific to COX‐2 (Santa Cruz Biotechnology Inc., USA), showed that COX‐2 protein was absent in all control samples and the IL‐1 induction of bovine COX‐2 protein could also be reduced when supplemented with n‐3 PUFAs but not n‐6 PUFAs. Using a commercially available PGE2 ELISA Immunoassay kit, it was possible to analyse the PGE2 levels present in explant media from bovine or human samples. In one example, in a 74‐year‐old female patient, PGE2 protein was very low in the cartilage cultured without IL‐1 treatment or PUFA supplementation (control). When the cartilage was treated with IL‐1, there was a huge induction of PGE2 levels by as much as 60 fold. This induction is in turn reduced greatly with the supplementation of n‐3 PUFA (EPA) but not with n‐6 PUFA (AA).Discussion It has long been accepted that COX‐2 plays an important role in inflammation. COX‐2 has been found in joints affected by arthritic diseases (Hla & Neilson 1992) and in cultures induced by IL‐1. The current study has shown that both the IL‐1‐induced COX‐2 message and protein levels can be reduced with supplementation by n‐3 PUFAs but not n‐6 PUFAs. This work has also shown that with a decrease in COX‐2 protein levels, there is also a corresponding decrease in prostaglandin E2 levels caused by n‐3 PUFA supplementation.

Outcomes after hip or knee replacement surgery for osteoarthritis

To compare the health-related quality of life of people with osteoarthritis before and after primary total hip and knee replacement surgery with that of the general Australian population. A prospective cohort study. Three Sydney hospitals, public and private. Patients with osteoarthritis undergoing primary total hip (n = 59) and knee (n = 92) joint replacement surgery. Medical Outcomes Study Short Form (SF-36) scores before and 12 months after joint replacement surgery (compared with population norms). Patients in each age group showed a significant improvement in health-related quality of life after joint replacement surgery in most scales of the SF-36, particularly physical function, role physical and bodily pain. SF-36 scores for the 42 hip-replacement patients aged 55-74 years improved to equal or exceed the population norm on all scales. SF-36 scores of the 52 knee replacement patients aged 55-74 years improved, but physical function and bodily pain scores remained significantly worse than the population norm. SF-36 scores for both hip (n = 17) and knee (n = 40) replacement patients aged 75 years and over improved significantly, becoming similar to population norms for this age group. Total hip or knee replacement for osteoarthritis significantly improves patient health and well-being at 12 months after surgery. Age alone should not be a barrier to surgery.