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Association of malnutrition with periprosthetic joint and surgical site infections after total joint arthroplasty: a systematic review and meta-analysis.
Tsantes, AG, Papadopoulos, DV, Lytras, T, Tsantes, AE, Mavrogenis, AF, Korompilias, AV, Gelalis, ID, Tsantes, CG, Bonovas, S
The Journal of hospital infection. 2019;(1):69-77
Abstract
BACKGROUND A growing body of evidence associates malnutrition with several adverse outcomes. AIM: To investigate the link between malnutrition with surgical site and periprosthetic joint infections (SSIs and PJIs) following total knee and hip arthroplasty (TKA and THA) through a comprehensive meta-analysis of observational studies. METHODS A systematic search was conducted on PubMed and Scopus databases through December 2018, and recent proceedings of major orthopaedic meetings. Data from eligible studies were extracted and synthesized; pooled odds ratios (ORs) with 95% confidence intervals (CIs) were estimated. FINDINGS Seven publications were included, reporting eight independent cohort studies with >250,000 subjects. SSIs and PJIs were more likely to develop in malnourished patients (OR: 2.49; 95% CI: 2.13-2.90; and 3.62; 2.33-5.64, respectively). The association of SSI with malnutrition was evident both after TKA (2.42; 1.94-3.02) and after THA (2.66; 1.64-4.30). Similarly, PJI was associated with malnutrition after TKA (2.55; 1.10-5.91) and after THA (3.10; 1.84-5.25). Finally, PJI correlated with malnutrition both after primary arthroplasty (3.58; 1.82-7.03) and revision arthroplasty (3.96; 2.47-6.33). The subgroup analysis by study setting confirmed the relationship between PJI and malnutrition in hospital (6.02; 3.07-11.81) and population-based (2.80; 1.76-4.44) studies. CONCLUSION Malnutrition is associated with PJIs and SSIs after total joint arthroplasty. Further high-quality research is warranted to confirm or refute these findings.
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Exploring variation in patient access of post-discharge physiotherapy following total hip and knee arthroplasty under a choice based system in the UK: an observational cohort study.
Hamilton, DF, Loth, FC, MacDonald, DJ, MacFarlane, GJ, Beard, DJ, Simpson, AHR, Patton, JT, Howie, CR
BMJ open. 2019;(2):e021614
Abstract
OBJECTIVES To assess a targeted 'therapy as required' model of post-discharge outpatient physiotherapy provision. Specifically, we investigated what proportion of patients accessed post-discharge physiotherapy following total hip arthroplasty (THA) and total knee arthroplasty (TKA), whether accessing therapy was associated with post-arthroplasty patient reported outcomes and whether it was possible to predict which patients would access post-discharge physiotherapy from pre-operative data. DESIGN Prospective, observational, longitudinal cohort study. SETTING Single National Health Service orthopaedic teaching hospital in the UK. PARTICIPANTS 1395 patients undergoing total hip arthroplasty and 1374 patients undergoing total knee arthroplasty. PRIMARY AND SECONDARY OUTCOME MEASURES Self-reported access of post-discharge physiotherapy, the Oxford Hip or Knee Score, EuroQol 5-dimension questionnaire and post-operative surgical episode satisfaction metric. RESULTS 662 (48.2%) patients with TKA and 493 (35.3%) patients with THA accessed additional post-discharge physiotherapy. Patient-reported outcomes (p<0.001) and surgical episode satisfaction (p=0.001) in both THA and TKA were higher in patients that did not participate in post-discharge physiotherapy. Regression models using pre-operative symptom burden and demographic data predicted post-discharge therapy access with an accuracy of only 17% greater than chance in patients with THA and 7% greater than chance in patients with TKA. CONCLUSIONS In a choice-based service model of 'therapy as required' following hip and knee arthroplasty only a third of THA and half of TKA patients accessed post-discharge therapy. Patients who did not access physiotherapy reported greater post-operative outcomes. This variation in the need for post-discharge physiotherapy suggests that targeting of rehabilitation may be a cost-effective model, however it was not possible to reliably predict which patients would access post-discharge physiotherapy from pre-operative data.
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Fingerprint pattern of bone mineralisation on cemented and uncemented femoral stems: analysis by [18F]-fluoride-PET in a randomised clinical trial.
Ullmark, G, Sörensen, J, Maripuu, E, Nilsson, O
Hip international : the journal of clinical and experimental research on hip pathology and therapy. 2019;(6):609-617
Abstract
PURPOSE We present a randomised clinical study using 18F-fluoride positron emission tomography/computed tomography (F-PET/CT) to analyse the osteoblastic part of bone metabolism (new bone mineralisation) in periprosthetic bone adjacent to femoral stems following total hip arthoplasty (THA) surgery. Patients with hip osteoarthritis were randomly assigned to THA surgery with cemented or uncemented femoral components. PATIENTS AND METHODS THA was performed on 26 patients (26 cases) with hip osteoarthritis. The patients received either an uncemented HA-coated femoral stem or a cemented one. The contralateral healthy femur was used as referent for normal bone metabolism. The patients were analysed with clinical score, radiography and F-PET/CT preoperatively, and postoperatively at 6 weeks and 6 months. After 2 years, clinical score and radiography was analysed again. We used the Polar Map system for analysing and presenting the PET results in 13 regions of interest adjacent to the whole stem. RESULTS The clinical results were good in all patients; there were no major complications. Radiographically, all stems were stable. PET analyses after 6 weeks showed that bone mineralising activity was significantly higher around the uncemented stems, both compared to the cemented group and to the contralateral healthy reference femur group. The cemented group also had elevated activity but only at a barely significant level. INTERPRETATION Mineralising activity analysed with F-PET/CT was significantly higher for the uncemented group and also decreased at a slower rate. F-PET/CT is a useful new tool for analysing secondary stabilisation of femoral stems after THA. The study was registered at ClinicalTrials.gov (identifier NCT01623687).
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Cerebrospinal Fluid Spermidine, Glutamine and Putrescine Predict Postoperative Delirium Following Elective Orthopaedic Surgery.
Pan, X, Cunningham, EL, Passmore, AP, McGuinness, B, McAuley, DF, Beverland, D, O'Brien, S, Mawhinney, T, Schott, JM, Zetterberg, H, et al
Scientific reports. 2019;(1):4191
Abstract
Delirium is a marker of brain vulnerability, associated with increasing age, pre-existing cognitive impairment and, recently, cerebrospinal fluid (CSF) biomarkers of Alzheimer's disease. This nested case-control study used a targeted quantitative metabolomic methodology to profile the preoperative CSF of patients (n = 54) who developed delirium following arthroplasty (n = 28) and those who did not (n = 26). The aim was to identify novel preoperative markers of delirium, and to assess potential correlations with clinical data. Participants without a diagnosis of dementia (≥65 years) undergoing elective primary hip or knee arthroplasty were postoperatively assessed for delirium once-daily for three days. Groups were compared using multivariate, univariate and receiving operator characteristic (ROC) methods. Multivariate modelling using Orthogonal Partial Least Squares-Discriminant Analysis (OPLS-DA) of metabolomic data readily distinguished between delirium and control groups (R2 ≤ 0.56; Q2 ≤ 0.10). Three metabolites (spermidine, putrescine and glutamine) significantly differed between groups (P < 0.05; FDR < 0.07), and performed well as CSF biomarkers (ROC > 0.75). The biomarker performance of the two polyamines (spermidine/putrescine) was enhanced by ratio with CSF Aβ42 (ROC > 0.8), and spermidine significantly correlated with Aβ42 (pearson r = -0.32; P = 0.018). These findings suggest that spermidine and putrescine levels could be useful markers of postoperative delirium risk, particularly when combined with Aβ42, and this requires further investigation.
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Is Oxidized Zirconium Femoral Head Superior to Other Bearing Types in Total Hip Arthroplasty? A Systematic Review and Meta-Analysis.
Malahias, MA, Atrey, A, Gu, A, Chytas, D, Nikolaou, VS, Waddell, JP
The Journal of arthroplasty. 2019;(8):1844-1852
Abstract
BACKGROUND Oxidized zirconium (OxZi) is a relatively new type of material that combines the strength of a metal with the surface/wears properties of a ceramic. Our aim was to investigate whether OxZi femoral heads lead to lower polyethylene wear, higher survival rate, and better clinical outcomes than the other bearing types in patients treated with total hip arthroplasty (THA). METHODS Two reviewers independently conducted a systematic search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses using the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews. These databases were queried with the terms: a. "oxidized" AND "zirconium" AND "total" AND "hip" AND "arthroplasty"; b. "oxinium" AND "total" AND "hip" AND "arthroplasty". The primary outcome measures were the survival rate of the bearing surfaces as well as the polyethylene wear. RESULTS The vast majority (85.7%) of the studies, which reported the mean polyethylene wear rate, showed that there was not any significant difference between OxZi and cobalt-chrome (CoCr) femoral heads (rate ratio: 0.836; 95% confidence interval: 0.362-1.928; P = .674). All studies comparing the survival rate of OxZi and CoCr femoral heads illustrated almost excellent survivorship with both implants. CONCLUSION OxZi femoral heads did not lead to lower polyethylene wear rate or higher survival rate, when compared with CoCr femoral heads in patients treated with THA. On the basis of these results and taking into account the higher cost of these implants, we would not recommend the routine use of OxZi femoral heads in primary THAs. LEVEL OF EVIDENCE Systematic review and meta-analysis of therapeutic studies I-III.
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Effects of zoledronic acid on bone mineral density around prostheses and bone metabolism markers after primary total hip arthroplasty in females with postmenopausal osteoporosis.
Zhou, W, Liu, Y, Guo, X, Yang, H, Xu, Y, Geng, D
Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2019;(8):1581-1589
Abstract
INTRODUCTION To investigate the effect of zoledronic acid on periprosthetic bone mineral density (BMD) and bone metabolism markers after primary total hip arthroplasty in females with postmenopausal osteoporosis. METHODS From November 2015 to April 2016, 40 female patients who met the inclusion criteria were randomized into two groups: a control group (calcium + calcitriol) and a zoledronic acid group (calcium + calcitriol + zoledronic acid). At 1 week and 3, 6, and 12 months after operation, BMD was obtained through dual-energy X-ray absorptiometry (DEXA). At pre-operation and at 3, 6, and 12 months after the operation, levels of bone metabolism markers were obtained by serum examination. RESULTS Loss of BMD was significantly more pronounced in the control group than in the ZOL group in zones 1, 4, 6, and 7 at 6 months and in zones 1, 2, 4, 6, and 7 at 12 months after the operation. The levels of bone-resorption marker (β-CTX) were significantly lower in the ZOL group than in the control group at 3, 6, and 12 months after operation. The levels of bone-formation marker (TP1NP) performed statistically differences only at 12 months after the operation in these two groups. CONCLUSIONS Receiving an intravenous infusion of 5 mg zoledronic acid after THA can effectively reduce periprosthetic BMD loss and improve bone remodeling in females with postmenopausal osteoporosis. Zoledronic acid significantly inhibited bone mass loss in zones 1, 2, 4, 6, and 7 after THA and inhibited bone-resorption marker (β-CTX) to improve bone remodeling. Zoledronic acid treatment is potentially important for patients with osteoporosis after THA.
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Manufacturing, oxidation, mechanical properties and clinical performance of highly cross-linked polyethylene in total hip arthroplasty.
Singh, G, Klassen, R, Howard, J, Naudie, D, Teeter, M, Lanting, B
Hip international : the journal of clinical and experimental research on hip pathology and therapy. 2018;(6):573-583
Abstract
Ultra-high molecular weight polyethylene (UHMWPE) continues to be the gold standard bearing surface in total hip arthroplasty (THA) for nearly 5 decades. Highly cross-linked UHMWPE (HXLPE) was adapted for routine use in the early 2000s to reduce the revision rates related to wear, osteolysis, and aseptic loosening resulting from conventional UHMWPE wear. Since its inception, consistent evidence showing reduced wear rates and osteolysis supports the use of HXLPE in THA. High quality studies demonstrating the advantage in long term survivorship of HXLPE over conventional UHMWPE are emerging. Though retrieval studies have demonstrated evidence of in vivo oxidation and fatigue related damage at the rim of the first generation HXLPE liners, clinical significance of this remains to be seen. Second-generation sequentially annealed and vitamin E containing HXLPE liners demonstrate improved mechanical properties, resistance to oxidation, and equivalent wear rates in comparison to their first-generation counterparts, but long term success remains to be seen.
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Creep and Wear in Vitamin E-Infused Highly Cross-Linked Polyethylene Cups for Total Hip Arthroplasty: A Prospective Randomized Controlled Trial.
Rochcongar, G, Buia, G, Bourroux, E, Dunet, J, Chapus, V, Hulet, C
The Journal of bone and joint surgery. American volume. 2018;(2):107-114
Abstract
BACKGROUND Aseptic loosening, the most common indication for revision surgery in total hip arthroplasty, can result from osteolysis caused by polyethylene (PE) wear particles. PE wear is increased by age-related oxidation of PE and free radicals emerging during irradiation cross-linking. Diffusion of vitamin E into PE stabilizes free radicals to maintain the biomechanical properties of PE. The purpose of this study was to determine whether vitamin E-infused highly cross-linked PE cups could reduce wear rates. METHODS We performed a prospective randomized controlled trial, in which 62 patients were allocated to 2 groups: a study group that received a vitamin E-infused highly cross-linked PE (HXLPE/VitE) cup and a control group that received an ultra-high molecular weight PE (UHMWPE) cup. Using radiostereometric analysis, we measured the penetration of the femoral head into the cup 7 days after surgery (baseline) and then again at 6 months and at 1, 2, and 3 years later. RESULTS Baseline variables did not differ significantly between the groups. At 1, 2, and 3 years after surgery, the HXLPE/VitE cup showed significantly less cumulative penetration (creep and wear) than the UHMWPE cup (p = 0.004, p < 0.0001, and p < 0.0001, respectively). The cumulative penetration after 3 years was 0.200 mm for the HXLPE/VitE cup versus 0.317 mm for the UHMWPE cup (p < 0.0001). From 1 to 3 years after surgery, after creep had stabilized and further penetration was mainly due to wear, the mean penetration increased only 0.04 mm in the HXLPE/VitE cup and 0.116 mm in the UHMWPE cup. CONCLUSIONS Our results confirm that wear rates over the first 3 years following surgery were lower in HXLPE/VitE cups than in UHMWPE cups. This suggests that HXLPE/VitE cups may prevent osteolysis, implant loosening, and eventually revision surgery. Long-term follow-up data continue to be collected to confirm these findings. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Evaluation of in vivo wear of vitamin E-diffused highly crosslinked polyethylene at five years: a multicentre radiostereometric analysis study.
Galea, VP, Connelly, JW, Shareghi, B, Kärrholm, J, Sköldenberg, O, Salemyr, M, Laursen, MB, Muratoglu, O, Bragdon, C, Malchau, H
The bone & joint journal. 2018;(12):1592-1599
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Abstract
AIMS: The primary aim of this study was to compare the wear properties of vitamin E-diffused, highly crosslinked polyethylene (VEPE) and one formulation of moderately crosslinked and mechanically annealed ultra-high molecular weight polyethylene (ModXLPE) in patients five years after primary total hip arthroplasty (THA). The secondary aim was to assess the clinical results of patients treated with VEPE by evaluating patient-reported outcome measures (PROMs), radiological evidence of fixation, and the incidence of mechanical failure. PATIENTS AND METHODS A total of 208 patients (221 THAs) from four international centres were recruited into a prospective study involving radiostereometric analysis (RSA) and the assessment of clinical outcomes. A total of 193 hips (87%) were reviewed at the five-year follow-up. Of these, 136 (70%) received VEPE (vs ModXLPE) liners and 68 (35%) received ceramic (vs metal) femoral heads. PROMs and radiographs were collected preoperatively and at one, two, and five years postoperatively. In addition, RSA images were collected to measure PE wear postoperatively and at one, two, and five years after surgery. RESULTS We observed similar bedding in one year postoperatively and wear two years postoperatively between the two types of liner. However, there was significantly more penetration of the femoral head in the ModXLPE cohort compared with the VEPE cohort five years postoperatively (p < 0.001). The only variables independently predictive of increased wear were ModXLPE (vs VEPE) liner type (β = 0.22, p = 0.010) and metal (vs ceramic) femoral head (β = 0.21, p = 0.013). There was no association between increased wear and the development of radiolucency (p = 0.866) or PROMs. No patient had evidence of osteolysis. CONCLUSION Five years postoperatively, patients with VEPE (vs ModXLPE) and ceramic (vs metal) femoral heads had decreased wear. The rates of wear for both liners were very low and have not led to any osteolysis or implant failure due to aseptic loosening.
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Clinical outcome and physical activity measured with StepWatch 3™ Activity Monitor after minimally invasive total hip arthroplasty.
Höll, S, Blum, A, Gosheger, G, Dieckmann, R, Winter, C, Rosenbaum, D
Journal of orthopaedic surgery and research. 2018;(1):148
Abstract
BACKGROUND Subjective data and physical examinations of patients after total hip arthroplasty are used to assess the outcome. But regarding the physical activity, no objective data can be delivered by existing scores. The level of activity can be measured objectively by counting gait cycles. The aim of this study was to measure activity levels of patients before and after total hip arthroplasty (THA). METHODS Forty-six patients were included in this prospective study. Western Ontario and McMaster Universities Arthritis Index (WOMAC), Harris Hip Score (HHS), and physical activity level based on the number of steps per day were assessed 1 week before surgery, 6 weeks postoperatively, and 3 months postoperatively. To assess the general constitution of the patients, the American Society of Anesthesiologists (ASA) score and BMI were determined. The physical activity level was measured by StepWatch 3™ Activity Monitor (SAM; Orthocare Innovations, Seattle, WA, USA). The number of GCs per day was assessed. Spearman's rank correlation coefficients were used to identify an association between age, body mass index (BMI), and American Society of Anesthesiologists classification with the number of gait cycles and to detect correlation between GCs and HHS and GCs and WOMAC. RESULTS From preoperatively to 6 weeks postoperatively, the number of gait cycles did not alter significantly. Three months postoperatively, the number of GC/d and GC/h improved significantly. HHS and WOMAC improved significantly from before surgery to 6 weeks and to 3 months follow-up. The number of gait cycles per day did not correlate with the HHS and the WOMAC score at any point of measurement. Age, BMI, and ASA classification did not influence the results. CONCLUSION By using a StepWatch 3™ Activity Monitor objective data about physical activity before and after THA can be measured reliable. Subjective and objective data in the postoperative period show different results. Physical activity seems to take longer to reach significantly improved values. By counting gait cycles, surgeons do have an additional tool to measure success after THA.