Insufficient lateral joint laxity after bicruciate-retaining total knee arthroplasty potentially influences kinematics during flexion: A biomechanical cadaveric study

BackgroundSoft tissue balancing in bicruciate-retaining (BCR) total knee arthroplasty (TKA) is a challenge that must be overcome to achieve excellent clinical outcomes. However, the optimal degree of joint laxity has yet to be clarified. This cadaveric study sought to examine joint laxity after BCR TKA using a navigation system.MethodsKnee joint laxity was quantified using an image-free navigation system in 8 intact fresh frozen cadavers under three conditions: the native knee, BCR TKA knee, and BCR TKA knee after anterior cruciate ligament resection. Rotational kinematics in the BCR TKA knee during flexion were compared according to whether joint laxity was increased or decreased.ResultsKnee joint laxity after BCR TKA under varus-valgus movement, anterior translation, and internal-external rotation loadings was similar to that of the native knee. However, lateral joint laxity was decreased during flexion in some cases. BCR TKA-treated knees with decreased lateral joint laxity at 90° of flexion demonstrated more limited tibial internal rotation in deep flexion than the native knee (p < 0.05). The loss of internal rotation in deep flexion was partly recovered by using a lateral insert with a posterior slope of +3°.ConclusionsRestoring optimal joint laxity was not always straightforward in BCR TKA if the 4 ligaments were preserved. Lateral joint laxity was potentially decreased in BCR TKA and may result in kinematic conflict during flexion. Surgeons should be aware of the need to achieve sufficient lateral joint laxity in this type of BCR TKA.     

Comparison of the clinical and patient-reported outcomes between medial stabilized and posterior stabilized total knee arthroplasty: A systematic review and meta-analysis

BackgroundTotal knee arthroplasty (TKA) is effective in relieving pain and improving function in patients with end-stage knee osteoarthritis. Both medial stabilized total knee arthroplasty (MS-TKA) and posterior stabilized total knee arthroplasty (PS-TKA) can achieve satisfactory clinical results, but comparisons between MS-TKA and PS-TKA have yielded contradictory conclusions. This systematic review and meta-analysis were performed to investigate the differences in clinical and patient-reported outcomes (PROMs) between MS-TKA and PS-TKA.MethodsIn December 2020, systematic searches of the following databases were undertaken: Pubmed, Embase, Cochrane Library, Clinical Trials.gov. Studies with PROMs comparing MS-TKA to PS-TKA were included. Meta-analysis was conducted for range of motion (ROM), Knee Society Score (KSS), Knee Society Functional Score (KFS), Forgotten Joint Score (FJS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Oxford Knee Score (OKS).ResultsThere were 17 studies included in this review, 13 studies used for quantitative analysis, and 4 studies used for qualitative synthesis. Meta-analysis concluded that the WOMAC mean difference (MD) for MS-TKA was 1.55 higher than for PS-TKA (MD = −1.55; 95 %CI = −2.45 to −0.64, P = 0.0008); however, this difference was less than the minimum clinically important difference (MCID) value of 15. Assessment using the OKS determined that the MD for PS-TKA was 0.58 higher than for MS-TKA (MD = 0.58; 95 %CI = 0.25 to 0.91, P = 0.0006); again, this MD was less than the MCID value of 5. There were no significant differences between MS-TKA and PS-TKA when assessed by ROM (P = 0.23), KSS (P = 0.13), KFS (P = 0.61), or FJS (P = 0.22).ConclusionDerived from numerous sources, utilizing a multitude of validated functional and patient-reported outcome assessment tools, there was no clinically evident advantage of MS-TKA compared to PS-TKA.RegistrationThe registration number on PROSPERO is CRD42021228555.     

Usefulness of gait parameters obtained from inertial sensors attached to the lower trunk and foot for assessment of gait performance in the early postoperative period after total knee arthroplasty

BackgroundThis study was performed to (i) compare gait parameters obtained from inertial sensors attached to the lower trunk and foot between patients in the early postoperative period after total knee arthroplasty (TKA) and healthy age- and sex-matched controls and (ii) elucidate the association between the gait parameters and patient-reported outcome measures (PROMs).MethodThe gait performance of 19 patients who had undergone TKA was assessed using inertial sensors and PROMs obtained from the Knee Injury and Osteoarthritis Outcome Score (KOOS) 1 week before hospital discharge. The patients walked along a 15-m walkway and we calculated the following gait parameters: walking speed, coefficient of variation (CV) of stride time, unbiased autocorrelation coefficient (AC), harmonic ratio (HR), and symmetry index (SI). The same gait parameter data from 19 age- and sex-matched healthy adults (controls) were obtained from our past study.ResultsThe TKA group demonstrated slower walking speed, larger CV of stride time, lower HR in all three directions, lower AC in the vertical direction, and higher SI in the vertical direction than the healthy control group (all p < 0.05). Correlation analysis revealed that the SI in the anteroposterior direction was significantly correlated with the KOOS symptoms subscore and ADL subscore (p < 0.05).ConclusionsPatients in the early postoperative period after TKA exhibited worse gait performance as assessed by inertial sensors compared with healthy controls. Gait symmetry was correlated with PROMs. These results indicate the usefulness of assessing gait parameters after TKA.     

Intraoperative changes in medial joint gap after posterior femoral condylar resection,posterior osteophyte removal,and femoral component placement during primary total knee arthroplasty

Background“Mid-flexion stability” is important for superior patient satisfaction following total knee arthroplasty (TKA). Thus, it is important to control medial joint gap intraoperatively as a countermeasure. However, reports on the precise intraoperative changes in medial joint gap during TKA are scarce. This study evaluated the intraoperative changes in medial joint gap during TKA.MethodsWe studied 167 knees with varus osteoarthritis that underwent 80 cruciate-retaining (CR) and 87 posterior-stabilized (PS) TKAs between January 2018 and December 2020. We measured the intraoperative changes in medial joint gap with a tensor device at 137.5 N.ResultsThe medial joint gap after posterior femoral condylar resection was significantly increased not only at 90° of flexion but also at 0° of extension in CR and PS TKAs (p < 0.01). The medial joint gap after posterior osteophyte removal was significantly increased not only at 0° of extension but also at 90° of flexion in CR and PS TKAs (p < 0.01). The medial joint gap at 0° of extension was reduced by 0.60 mm after femoral component placement in PS TKA.ConclusionSurgeons need to pay close attention to these intraoperative changes in medial joint gap by measuring the medial joint gap before and after each procedure or assuming the changes in those values before bone cutting to achieve superior patient satisfaction following TKA.     

A high physical activity level after total knee arthroplasty does not increase the risk of revision surgery during the first twelve years: A systematic review with meta-analysis and GRADE

BackgroundHigh physical activity (HPA) levels after total knee arthroplasty (TKA) might be related to increased wear and subsequent aseptic loosening, negatively affecting TKA survival. This systematic review studied the association between activity levels and risk of revision surgery at medium (3–10 years) and long term (>10 years) follow up in patients with TKA.MethodsDatabases (PubMed, Embase) were searched up to 12 October 2021. Studies comparing low physical activity (LPA) and HPA levels in TKA patients and related risk of revision surgery were eligible for inclusion. After data extraction and evaluation of methodological quality, a meta-analysis was performed. Quality of evidence was assessed using the GRADE framework. PROSPERO registration: CRD42020194284.ResultsFive cohort studies and one case–control study met the inclusion criteria, involving 4811 TKA procedures in 4263 patients (mean follow up 4–12 years). Five studies were of moderate methodological quality and one of low quality. Meta-analysis demonstrated no association between HPA level and an increased risk of all-cause revision surgery (risk ratio (RR) 0.62, 95 % confidence interval (CI) 0.24–1.63, level of certainty: very low) or revision surgery due to aseptic loosening (RR 1.33, 95 % CI 0.34–5.24, level of certainty: moderate). Only one study reported on survivorship, with an improved survivorship for the HPA group (odds ratio of 2.4, 95 % CI 1.2–4.7, level of certainty: low).ConclusionDuring the first 12 postoperative years after TKA, there seems to be no increased risk for revision surgery for patients with a HPA level compared with patients with an LPA level.     

Subchondroplasty in the treatment of bone Marrow lesion in early Knee Osteoarthritis: A systematic review of clinical and radiological outcomes

BackgroundKnee osteoarthritis (KOA) is increasingly prevalent in North American society. The significant societal burden it represents makes it essential to promote and target new treatments in earlier phases of the disease. Among others, subchondroplasty is a newly documented technique using calcium phosphate injection targeting the osteochondral lesions preceding KOA, also known as Bone Marrow Lesions (BMLs). This article aimed to review the existing literature on clinical and radiological outcomes of subchondroplasty in the treatment of BMLs in KOA.MethodA systematic review was performed using PubMed, Embase, Medline and Cochrane Database of Systematic Reviews. Studies on calcium phosphate injections into BMLs for KOA and its clinical and radiological outcomes were screened and reviewed by independent evaluators.ResultsAfter screening, ten articles were included, totaling 540 patients. Follow-up ranged from 6 months to 7 years. Overall, the procedure showed significant functional and quality of life improvement, as well as pain relief, as shown by Patients-Reported Outcomes Measures (PROMs). There were very few complications reported, the most important being leakage of calcium phosphate outside the targeted site. Conversion rate to total knee arthroplasty (TKA) ranged from 14 % to 30 % at 2 years post-procedure. Long term radiological outcomes have been poorly documented.ConclusionsSubchondroplasty is a promising avenue for the treatment of KOA. However, quality evidence is still required before any real conclusions and practical management guidelines can be drawn. Prospective, randomized studies with a control group and a rigorous assessment of long-term clinical and radiological outcomes are recommended.     

Fast-track revision knee arthroplasty.

BackgroundLimited data exist on fast-track protocols in relation to revision knee arthroplasty. Hence, the aim of this study was to report length of stay (LOS), risk of LOS > 5 days and readmission ≤ 90 days after revision knee arthroplasty in centers with a well-established fast-track protocol in both primary and revision surgery.MethodsAn observational cohort study from the Centre for Fast-track Hip and Knee Replacement and the Danish Knee Arthroplasty Register. We included elective aseptic major component revision knee arthroplasties consecutively from 6 dedicated fast-track centers from 2010 to 2018.Results1439 revision knee arthroplasties were analyzed, including 900 total revisions, 171 large partial revisions (revision of either femoral or tibia component) and 368 revisions of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA). Mean age was 65 years (SD 10.9) and 66% were females. Mean LOS was 3.7 days (SD 3.9) in the study period, but decreased to 2.4 days (SD 1.3) in 2018. Risk factors for LOS > 5 days was ≥ 1 previous revision, use of walking aid, BMI > 35, ages < 50, 70–79 and ≥ 80 years, whereas revision of UKA to TKA and large partial revision were negatively associated. The 90-day readmission and mortality risk was 9.1% and 0.5%. Cardiac disease and use of walking aid were associated with increased risk of readmission ≤ 90 days.ConclusionElective aseptic major component revision knee arthroplasty using similar fast-track protocols as in primary TKA is safe with short and decreasing LOS.     

Mid-term results of complex primary total knee arthroplasty using a rotating-hinge implant

BackgroundThe indications and outcomes of semi- or fully-constrained knee implants in primary total knee arthroplasty (TKA) are still controversially discussed. The present study aims to evaluate the mid-term results and complications of a modular/non-modular rotating-hinge implant in complex primary TKA.MethodsEighty-two patients (86 knees) following primary TKA were retrospectively evaluated with a mean follow-up of 63 months. The functional outcome was assessed using the American Knee Society Score (AKSS) and the Oxford Knee Score (OKS). A Visual Analog Scale (VAS) was used to determine pain levels. Implant survival and reoperation rates were estimated using competing risk analysis. Cox regression analysis was performed to evaluate the influence of modularity on implant survival.ResultsThe survival rate with the endpoint implant revision was 90% (95 %CI:83–98%) and the survival rate with the endpoint all reoperations was 84% (95 %CI:75–94%) at 7 years. The AKSS improved significantly from 24 (SD 14.9, range:0–69) preoperatively to 83 (SD 14.3, range:57–100) postoperatively (p < 0.001); functional AKSS improved significantly from 27 (SD 24.3, range:0–100) to 46 (SD: 32.9, range 0–100) (p = 0.003), and OKS from 19 (SD: 8.3, range:5–43) to 29 (SD: 10.7, range:6–48), respectively (p < 0.0001). VAS decreased significantly from 8 (SD: 2.6, range:0–10) preoperatively to 3 (SD: 2.9, range:0–9) postoperatively (p < 0.0001). There was no significant influence of modularity on revision rates comparing modular to non-modular implants (p = 0.072).ConclusionsThe present rotating-hinge implant provides substantial improvement in function and reduction of pain with good implant survival in the mid-term. Modularity was not associated with higher rates of revision.     

Assessment of popliteal neurovascular safety during all-inside suturing of the posterior horn of the lateral meniscus using Upright MRIs of the knee joint

BackgroundTo examine the risk of injury to the popliteal neurovascular bundle (pNVB) during all-inside repair of the posterior horn of the lateral meniscus (PHLM) using Upright-MRIs.MethodsUpright-MRIs of 61 knees in extension (ext) and 90°-flexion (flex) were included. Distance D from the PHLM to the pNVB was compared between extended and 90°-flexed position, subgroups with/without joint-effusion and evaluated according to demographics. Portal safety was assessed simulating suturing of the PHLM via four arthroscopy portals. Distance d (shortest space from the simulated suturing-device trajectory lines to the pNVB) was compared among portals in increasing distances from the posterior cruciate ligament (PCL).ResultsD is longer in flex (17.3 ± 6.0 mm) than in ext (11.3 ± 4.2 mm, p < 0.0001). MRIs with joint-effusion displayed longer values of D than scans without joint-effusion (flex: 20.4 ± 7.1 mm vs. 16.1 ± 5.2 mm, p = 0.012). Shorter distances are associated with female gender, lower body weight and lower BMI. At 0 mm from the PCL, the 1 cm-lateral portal was the safest (p < 0.0001) whereas at 3 mm/6mm/9mm/12 mm the 1 cm-medial portal showed the longest d values (p < 0.0001 each).ConclusionAll-inside suturing of the PHLM is safer in 90°-flexion, in presence of intraarticular fluid and in male patients with increasing weight/BMI. Sutures of the PHLM at 0 mm from the PCL are safer from a 1 cm-lateral portal whereas for tears located ≥ 3 mm from the PCL a 1 cm-medial portal involves a lower neurovascular risk. Upright-MRI proves excellent for preoperative planning to minimize neurovascular risks.     

MRI signal intensity of anterior cruciate ligament graft after transtibial versus anteromedial portal technique (TRANSIG): A randomised controlled clinical trial

BackgroundTwo primary surgical femoral drilling techniques are used to reconstruct the anterior cruciate ligament (ACL): the transtibial (TT) technique and the anteromedial portal (AMP) technique. Currently there is no consensus on which surgical technique elicits the best clinical and functional outcomes. MRI-derived measures of the signal intensity (SI) of the ACL graft have been described as an independent predictor of graft properties. The purpose of this study was to assess MRI-derived SI measurements of the ACL graft one year after ACL reconstruction, in order to compare graft maturation of both AMP and TT ACL reconstruction techniques.MethodsThis randomised controlled trial included 33 patients admitted for primary unilateral ACL reconstruction. Primary outcome was MRI Signal intensity ratio (SIR) of the ACL graft one year after ACL reconstruction. Differences in MRI SIR were assessed on two MRI sequencies: sagittal Proton Density Turbo Spin Echo weighted images (PDTSE) and 3D T2 Gradient Echo (T2*) weighted images. Analysis of interobserver and intraobserver variability was conducted for the SIR measurements.ResultsNo difference in signal intensity of the graft was found between the TT and AMP techniques one year after ACL reconstruction (PDTSE p = 0.665, T2* p = 0.957). Both interobserver and intraobserver variability showed strong agreement (ICC 0.64–0.94).ConclusionNo differences in signal intensity of the graft on MRI were seen between the femoral drilling techniques one year after ACL reconstruction, suggesting similar graft maturation at that time. Follow-up studies are needed to determine whether graft intensity changes in the long term.Level of evidenceTherapeutic study with level of evidence I.     

Under-correction of preoperative varus alignment does not lead to a difference in in-vivo bone loading in 3D-SPECT/CT compared to neutral alignment

BackgroundThe aim was to investigate the correlation of bone tracer uptake (BTU) in SPECT/CT and changes in coronal knee alignment after total knee arthroplasty (TKA). We questioned if undercorrection of preoperative varus alignment leads to a difference in BTU compared to neutral alignment.MethodsConsecutive 66 patients who received SPECT/CT before and after TKA were retrospectively included. Adjusted mechanical alignment was the alignment target. The alignment of the knee was measured on 3D-CT by selecting standardized landmarks. Maximum (mean ± SD) and relative BTU (ratio to the reference) were recorded using a previously validated localization scheme (p < 0.05).ResultsIn the native group, 20 knees were aligned (30.3%) in valgus (HKA > 181.5°), 12 (18.2%) in neutral (178.5°-181.5°) and 34 (51.5%) in varus (HKA < 178°). Overall TKA changed the alignment towards neutral. 48.5% remained in the same groups, whereas 50% of native valgus and 33% of varus knees changed to neutral after TKA. In native varus alignment mean BTU was significantly higher in some medial tibial and femoral regions (fem1ia (p = 0.010), fem1ip (p = 0.002), tib1a.mid (p = 0.005), tib1a.tray (p = 0.000), tib1p.tray (p = 0.000)); in native valgus alignment mean BTU was higher in the corresponding lateral tibial and femoral regions (fem2ip (p = 0.001), tib2a.tray (p = 0.011), tib2p.tray (p = 0.002)). After TKA, a significant decrease in femoral and tibial BTU (femoral preoperative BTU 1.64 +/-0.69; femoral postoperative BTU 0.95 +/-0.42; p = 0.000// tibial preoperative BTU 1.65 +/- 0.93; tibial postoperative BTU 1.16 +/- 0.48; p = 0.000) and an increase in patellar BTU was observed (p = 0.025). Native varus alignment correlated with a higher medial BTU decrease medially. Undercorrection of preoperative varus alignment showed no higher BTU after TKA.ConclusionPreoperative varus alignment correlated with a higher decrease in BTU in specific femoral and tibial medial regions. Preoperative valgus alignment correlated with a higher decrease in the corresponding lateral regions. Undercorrection of preoperative varus alignment did not lead to higher bone loading reflected by BTU after TKA.     

Effect of ultrasound-guided selective sensory nerve blockade of the knee on pain management compared with periarticular injection for patients undergoing total knee arthroplasty: A prospective randomized controlled trial

BackgroundUltrasound-guided selective sensory nerve blockade (SSNB) of the knee, including an adductor canal block (ACB), anterior femoral cutaneous nerve block, and infiltration between the popliteal artery and posterior capsule of the knee may provide effective motor-sparing knee analgesia for total knee arthroplasty (TKA). We hypothesized that the SSNB would manage pain better on ambulation 24 hours postoperatively compared to periarticular infiltration (PAI), when combined with postoperative continuous ACB.MethodsSeventy-two patients undergoing elective TKA under spinal anesthesia were randomly assigned to either SSNB (SSNB group) or intraoperative PAI (PAI group). All patients received postoperative multimodal analgesia, including continuous ACB. The primary outcome was pain on ambulation 24 hours postoperatively. Secondary outcomes included rest and dynamic numerical rating scale pain score, intravenous morphine requirement, functional performance measures, adverse events, satisfaction, and length of stay.ResultsThere was no difference in pain score during movement between the groups (mean difference −0.48 [−1.38 to 0.42], p = 0.3) and other immediate overall pain scores 24 hours postoperatively. Patients in the SSNB group had significantly lower intravenous morphine requirement than the PAI group for 48 hours postoperatively (0 [0, 0] vs. 0 [0, 2]; p = 0.008). There was no intergroup difference in the performance-based measures, satisfaction, and length of stay.ConclusionsThe SSNB did not provide superior postoperative analgesia, or improvement in immediate functional performance. However, it may result in lower opioid consumption postoperatively when compared with the intraoperative PAI.     

The effects of initial graft tension on femorotibial relationship following anatomical rectangular tunnel anterior cruciate ligament reconstruction using bone–patellar tendon–bone graft

BackgroundThe purpose of this study was to elucidate the effects of the difference of initial graft tension on the femorotibial relationship on an axial plane and its chronological change following anatomical anterior cruciate ligament (ACL) reconstruction.MethodsA total of 63 patients who underwent anatomical ACL reconstruction were included in this study. The graft was fixed at full knee extension with manual maximum (higher graft tension; group H) and 80 N (lower graft tension; group L) pulls in 31 and 32 patients, respectively. The femorotibial positional relationship in axial computed tomography at 1 week and 1 year postoperatively were retrospectively evaluated. The side-to-side differences (SSDs) and the amount of changes of SSDs over 1 year were compared between groups.ResultsThe SSDs of the external rotational angle of the tibia in group H were significantly larger than those in group L at postoperative 1 week (2.7 ± 3.9° vs. 0.3 ± 3.3°; P < 0.01). The amount of internal rotational changes of SSDs of the internal–external rotational angles over 1 year in group H was significantly larger than that in group L (−3.6 ± 3.9° vs. − 0.3 ± 2.7°; P < 0.01). No significant differences were observed on the anterior–posterior translation distance and medial–lateral shift distance.ConclusionThe application of higher initial graft tension resulted in excessive external rotation of the tibia to the femur at 1 week postoperatively in anatomical ACL reconstruction, and the excessive early external tibial rotation had resolved over 1 year.     

Evaluation of different coatings of the tibial tray in uncemented total knee arthroplasty. A randomized controlled trial with 5 years follow-up with RSA and DEXA

BackgroundRegenerex® is a porous titanium construct with a 3D interconnecting pore structure and biomechanical characteristics close to that of normal trabecular bone. This study aimed to compare the Regenerex (VR) to the non-interconnecting pore structure Porous Plasma Spray (VP) on tibial implants for total knee arthroplasty (TKA) at 5 years.MethodsWe enrolled and randomized 61 patients (mean age = 63(49–71) years, Female/Male = 35/26) who were planned for an uncemented Vanguard TKA (Biomet, Warsaw, Indiana, USA) to receive either a VR or a VP coated tibial component (31/29). We performed radiostereometric analysis (RSA) and Dual Energy X-ray Absorptiometry (DEXA) postoperatively, and at three, six, 12, 24 and 60 months with measurements of migration. In total 55 patients attended the 5-year follow-up.ResultsOne patient died and four were reoperated during the 60-months period; none due to aseptic loosening. All reoperations were in the VR-group. The mean (range) 60-months MTPM was 1.4 mm (0.5–3.7) for the VP-group and 1.8 mm (0.4–4.9) for the VR-group (p = 0.8). The 24 to 60-months mean (range) MTPM was −0.3 mm (−5 to 1.24) in the VP-group and 0.2 mm (−0.4 to 3.5) in the VR-group (p = 0.8).ConclusionWe did not find any statistically significant differences between the VP- and VR-group and both groups show recognizable migration. We will continue to follow the groups for years to come.     

Midterm follow-up results of two different types of implants in opening wedge high tibia osteotomy

BackgroundThis retrospective study investigated the midterm results of medial opening wedge high tibia osteotomy, with a monoplanar or a biplanar osteotomy using two types of implant system.MethodsOsteotomies were performed on 241 knees (231 patients). The mean follow-up period was 6.0 years (SD 3.0, range 0.2–12.8 years). Two types of implant system were used, a precountered non-locking plate (PP) (n = 74) and a precountered locking plate (LP) (n = 167). A Kaplan-Meier cumulative survival curve and a Cox regression model were used to analyse and revise survival and risk factors.ResultsCumulative survival estimates for LP were 80% at 5 years, and 64% at 10 years (SE = 0.4, CI 95%: 9.0–10.5), and for PP, they were 68% at 5 years and 49% at 10 years (SE = 0.5, CI: 95% 6.3–8.2) (p = 0.024). The revision rate was 26% (44/167) for the LP group, and 47% (35/74) for the PP group (p = 0.001). Reoperations on LP osteotomies occurred for the tibial monoplanar cut and biplanar cut groups, in 19/52 (37%) and 25/167 (16%) osteotomies, respectively (p = 0.04). Our Cox regression model showed that PP had a higher risks (RR = 1.7; CI: 95% 1.1–2.6) of revision, when compared with LP (p = 0.026).ConclusionsThe risk of revision for any reason and that of early conversion to total knee arthroplasty (TKA) after high tibia osteotomy were significantly increased for PP, when compared with LP.     

Decrypting the occurrence of mucormycosis following dental extractions: A systematic review

BackgroundMucormycosis is a life-threatening opportunistic infection. The present systematic review was done to provide to date summary of the frequency of rhino-orbital-mucormycosis (ROM) cases following a tooth extraction, as there was no systematic review present till now to highlight it.MethodThe PubMed, PMC, Google Scholar, and Ovid Embase databases were searched thoroughly with appropriate keywords till April 2022 including the human population with language restrictions including English literature to collate case reports and case series regarding post-extraction Mucormycosis. All the details of the patient's characteristics were extracted and presented as a table and evaluated on different endpoints.ResultsIn total, we identified 31 case reports and 1 case series that results in 38 cases with Mucormycosis. The majority of patients belong to India (47. 4%). There was male predominance (68.4%) and involvement of maxilla was the most. Pre-existing diabetes mellitus (DM)(55.3%) was an independent risk factor for mucormycosis. The median period for the onset of symptoms was 30(14–75) days. 21.1% of cases presented signs and symptoms of cerebral involvement allied with DM.ConclusionDental extraction can trigger ROM by rupturing the oral mucous membrane. Clinicians should pay attention to the non-healing extraction socket which may be an early clinical manifestation of it, which is the key to tackling this deadlier infection.     

The impact of a comprehensive pharmaceutical care intervention in addition to cardiac rehabilitation program on outcomes of post-acute coronary syndrome patients: A pilot study

ObjectiveTo test the efficacy of Comprehensive pharmaceutical care intervention added to cardiac rehabilitation program(CR programs) in improving echocardiographic parameters, nutritional status and High sensitivity C-Reactive Protein(hs-CRP), in post-acute coronary syndrome patients.MethodsA prospective; randomized, controlled study. 40 post-acute coronary syndrome patients, participating in CR program, were randomly allocated to either the control group(n = 20) or the intervention group(n = 20). Pharmaceutical care intervention included face-to-face education about the disease, healthy lifestyle, medication adherence, drug related problems management and goal setting. hs-CRP and cardiac parameters were measured at baseline and after 3 months.ResultsAfter three months,the intervention group showed a significant decrease in left ventricular end systolic volume (p = 0.0026) and left ventricular end diastolic volume (p = 0.0009) compared to the control group. Also, intervention group showed a significant increase in nutritional status (p = 0.037) and the patients' knowledge about the disease and drugs (p = 0.0001). However, there was no significant change in hscrp level between groups.ConclusionOur findings indicate that Comprehensive pharmaceutical care intervention added to CR programs significantly improved cardiac parameters and nutritional status. This is best explained by increasing adherence to cardiovascular medications and to healthier lifestyle and optimizing medication knowledge and doses.Practice implicationsImplementing Comprehensive pharmaceutical care intervention added to CR programs could improve the cardiac function and nutritional status of post-acute coronary syndrome patients.     

Predictors of patient satisfaction after primary hamstring anterior cruciate ligament reconstruction

BackgroundPredictors of patient satisfaction (PS) after anterior cruciate ligament (ACL) reconstruction are not well known. This study investigated predictors of PS and whether PS was associated with pre-injury level of sport participation, patient reported knee function and quality of life after ACL reconstruction.MethodsPatients who underwent primary hamstring ACL reconstruction between January 2015 and December 2017 were retrospectively evaluated. An online survey was used to evaluate PS (yes = satisfied, no = unsatisfied), duration of supervised postoperative rehabilitation, timing of return to pre-injury level of sport, pre-injury level of sport participation, patient reported knee function and quality of life. Preoperative, operative and postoperative variables were collected from the medical records.ResultsA total of 183 patients completed the survey at a median of 3.6 (1.5) years after ACL surgery. At final follow-up, 82% of patients were satisfied with the outcome. Preoperative (e.g. age) and operative (e.g. meniscal tear) variables were not predictors of PS (p > 0.05). Duration of supervised postoperative rehabilitation, timing of return to pre-injury level of sport and postoperative ACL injury were predictors of PS (p = 0.018, p = 0.016 and p < 0.001, respectively). Pre-injury level of sport participation was significantly higher in satisfied compared to unsatisfied patients: 44.7% (n = 67) versus 18.2% (n = 6) (p = 0.005). In addition, satisfied patients reported significantly higher patient reported knee function and quality of life compared to unsatisfied patients (p < 0.001).ConclusionThis study provided data on predictors of PS after primary ACL reconstruction. Furthermore, PS was associated with pre-injury level of sport participation, patient reported knee function and quality of life.     

Ghrelin level as a biomarker for knee osteoarthritis severity and appearance in HIV + patients

BackgroundKnee Osteoarthritis (KOA) is a multifactorial disease with several mechanisms to promote articular cartilage damage. New molecules, such as ghrelin, have been recently reported to participate in the pathogenesis and progression of KOA. In HIV + patients, arthralgias are the most frequent musculoskeletal manifestations, mainly affecting joints such as the knee. Also, it has been reported that HIV + patients have a reduction of ghrelin even with treatment compared to HIV- patients. However, there is no report in the literature evaluating ghrelin and KOA in the HIV + population. We aimed to evaluate whether serum ghrelin levels can function as a biomarker for OA in HIV + patients.MethodsWe recruited 40 patients, 20 HIV+, and 20 HIV- controls, and grouped as follows: HIV+/KOA+; HIV+/KOA-; HIV-/KOA+; HIV-/KOA-. Clinical features were obtained during clinical visits. Peripheral blood samples were acquired to measure serum ghrelin levels.ResultsThe HIV+/KOA + group significantly reduced serum ghrelin levels when compared with the other groups. Comparing the ghrelin levels with the patients’ nadir of CD4⁺ T-cells count, we identified a statistically significant negative correlation in the KOA- group (r = −0.80, P < 0.007). An ROC curve analysis, for the accuracy of ghrelin levels to identified HIV+/KOA + from HIV+/KOA- patients, found an area under the curve of 0.83 (95 % CI 0.65–0.10; P = 0.017), with a cut-off < 4026 pg/mL serum ghrelin levels, with a sensitivity of 0.62 (95 % CI 0.32–0.86), and a specificity of 0.10 (95 % CI 0.59–0.10).ConclusionThis study shows the potential use of ghrelin levels as a biomarker for KOA in the high-risk HIV population that should be further analyzed.     

Association of polymorphisms of innate immunity-related genes and tuberculosis susceptibility in Mongolian population

BackgroundsGenetic polymorphism of the toll-like receptor 2, 4 (TLR2, TLR4) and natural resistance-associated macrophage protein 1 (NRAMP1) genes may affect host immune response to Mycobacterium tuberculosis (Mtb) and lead to the variation of susceptibility to tuberculosis (TB) in humans. However, the association of single nucleotide polymorphisms (SNP) in these genes and the susceptibility to TB in Mongolian population has not been investigated.MethodsWe conducted a genetic association study including 197 Mongolian TB patients and 217 Mongolian healthy controls in Inner Mongolia, China. DNA of blood samples was extracted and genotyped for 5 SNPs in TLR4, 4 SNPs in TLR2 and 5 SNPs in NRAMP1 by next-generation sequencing. A logistic regression was performed and odds ratios (OR) with 95% confidence intervals (CI) were calculated to estimate the risk at TB by each SNP.ResultsThe most significant locus associated with the susceptibility to TB was TLR4 rs11536889. The frequency for allele C of TLR4 rs11536889 was 16.0% in TB patients and 23.5% in healthy controls, respectively. Rs11536889 C/C genotype of TLR4 was significantly associated with the low susceptibility against TB compared to G/G genotype in the dominant model (OR 0.62, 95% CI 0.41–0.94).ConclusionsThe TLR4 rs11536889 polymorphisms might be an indicative of the low susceptibility to TB in Mongolian population, which provides valuable information for the generation of effective strategy or measurement against TB in Mongolian population.