Do Patient Expectations Influence Patient-Reported Outcomes and Satisfaction in Total Hip Arthroplasty? A Prospective,Multicenter Study

Background

The relationship between patient expectations and patient-reported outcomes (PROs) in total hip arthroplasty (THA) patients is controversial. The purpose of this study was to examine the impact of preoperative patient expectations on postoperative PROs and patient satisfaction.

What Are the Frequency,Associated Factors,and Mortality of Amputation and Arthrodesis After a Failed Infected TKA?

Background

For patients with failed surgical treatment of an infected TKA, salvage operations such as arthrodesis or above-knee amputation (AKA) may be considered. Clinical and institutional factors associated with AKA and arthrodesis after a failed TKA have not been investigated in a large-scale population, and the utilization rate and trend of these measures are not well known.

Questions/purposes

(1) How has the frequency of arthrodesis and AKA after infected TKA changed over the last 10 years? (2) What clinical or institutional factors are associated with patients undergoing arthrodesis or AKA? (3) What is the risk of mortality after arthrodesis or AKA?

Methods

The Medicare 100% National Inpatient Claims Database was used to identify 44,466 patients 65 years of age or older who were diagnosed with an infected TKA and who underwent revision between 2005 and 2014 based on International Classification of Diseases, 9^th Revision, Clinical Modification codes. Overall, 1182 knee arthrodeses and 1864 AKAs were identified among the study population. One year of data before the index infection-related knee revision were used to examine patient demographic, institutional, and clinical factors, including comorbidities, hospital volumes, and surgeon volumes. We developed Cox regression models to investigate the risk of arthrodesis, AKA, and death as outcomes. In addition, the year of the index revision was included as a covariate to determine if the risk of subsequent surgical interventions was changing over time. The risk of mortality was also assessed as the event of interest using a similar multivariate Cox model for each patient group (arthrodesis, AKA) in addition to those who underwent additional revisions but who did not undergo either of the salvage procedures.

Results

The number of arthrodesis (hazard ratio [HR], 0.90, p < 0.001) and amputation (HR, 0.95, p < 0.001) procedures showed a declining trend. Clinical factors associated with arthrodesis included acute renal failure (HR, 1.22 [1.06–1.41], p = 0.006), obesity (HR, 1.58 [1.35–1.84], p < 0.001), and having additional infection-related revisions (HR for 2+ additional revisions, 1.36 [1.13–1.64], p = 0.001). Higher Charlson comorbidity score (HR for a score of 5+ versus 0, 2.56 [2.12–3.14], p < 0.001), obesity (HR, 1.14 [1.00–1.30], p = 0.044), deep vein thrombosis (HR, 1.34 [1.12–1.60], p = 0.001), and additional revisions (HR for 2+ additional revisions, 2.19 [1.91–2.49], p < 0.001) were factors associated with AKA, which in turn was an independent risk factor for mortality. The risk of death increased with amputation after adjusting for age, comorbidities, and other factors (HR, 1.28 [1.20–1.37], p < 0.001), but patients who received arthrodesis did not show a change in mortality compared with the patients who did not receive arthrodesis or amputation (HR, 1.00 [0.91–1.10], p = 0.971).

Conclusions

The findings of this study suggest that clinicians may be more aggressively attempting to preserve the knee even in the face of chronic prosthetic joint infection but also show that a greater number of revisions is associated with a greater risk of subsequent AKA or arthrodesis. The results also suggest that recommending centers with a high volume of joint arthroplasties may be a way to reduce the risk of the salvage procedures.

Level of Evidence

Level III, therapeutic study.

     

An in-depth analysis shows a hidden atherogenic lipoprotein profile in non-diabetic chronic kidney disease patients

Background: Chronic kidney disease (CKD) is an independent risk factor for atherosclerotic disease. We hypothesized that CKD promotes a proatherogenic lipid profile modifying lipoprotein composition and particle number.

Methods: Cross-sectional study in 395 non-diabetic individuals (209 CKD patients and 186 controls) without statin therapy. Conventional lipid determinations were combined with advanced lipoprotein profiling by nuclear magnetic resonance, and their discrimination ability was assessed by machine learning.

Results: CKD patients showed an increase of very-low-density (VLDL) particles and a reduction of LDL particle size. Cholesterol and triglyceride content of VLDLs and intermediate-density (IDL) particles increased. However, low-density (LDL) and high-density (HDL) lipoproteins gained triglycerides and lost cholesterol. Total-Cholesterol, HDL-Cholesterol, LDL-Cholesterol, non-HDL-Cholesterol and Proprotein convertase subtilisin-kexin type (PCSK9) were negatively associated with CKD stages, whereas triglycerides, lipoprotein(a), remnant cholesterol, and the PCSK9/LDL-Cholesterol ratio were positively associated. PCSK9 was positively associated with total-Cholesterol, LDL-Cholesterol, LDL-triglycerides, LDL particle number, IDL-Cholesterol, and remnant cholesterol. Machine learning analysis by random forest revealed that new parameters have a higher discrimination ability to classify patients into the CKD group, compared to traditional parameters alone: area under the ROC curve (95% CI), .789 (.711, .853) vs .687 (.611, .755).

Conclusions: non-diabetic CKD patients have a hidden proatherogenic lipoprotein profile.     

Production of proinflammatory and immunoregulatory cytokines by inflammatory cells from periapical lesions in culture

Background:  The role of cytokines in pathogenesis of periapical lesions is not well understood. The aim of this study was to study the correlation between proinflammatory and immunoregulatory cytokines in periapical lesions and their relationship with cellular composition and clinical presentation.
Methods:  Inflammatory cells were isolated from 67 human periapical lesions and cultivated for 24 h. The levels of proinflammatory cytokines: interleukin-1 beta (IL-1β), IL-6, IL-8 and tumour necrosis factor alpha (TNF-α) and immunoregulatory cytokines: transforming growth factor-beta (TGF-β) and IL-10 were determined in culture supernatants using a fluorescent bead immunoassay or ELISA. The phenotype of cells was analysed by immunocytochemistry.
Results:  Inflammatory cells from symptomatic lesions which contained higher proportion of granulocytes, secreted higher levels of IL-1, IL-6 and IL-8 compared with asymptomatic lesions. Large-size lesions contained lower percentages of mononuclear phagocytes, higher percentages of CD8⁺ T cells and produced higher levels of TNF-α, IL-6 and IL-10 compared with small-size lesions. There were negative correlations between the concentrations of TGF-β and proinflammatory cytokines. TGF-β, added to cultures, downregulated the levels of proinflammatory cytokines more strongly than IL-10, independently of clinical presentation of the lesions. By contrast, exogenous IL-10 was mainly immunosuppressive in cultures of asymptomatic lesions.
Conclusion:  Symptomatic lesions are characterized by higher production of proinflammatory cytokines. Immunoregulatory cytokines are more important for suppression of inflammation in asymptomatic lesions and in this context the effect of TGF-β is more potent and different from IL-10.     

The basis of the synovial fluid analysis.

Synovial fluid fills the spaces in the joint cavities. Many diseases can affect the joints and frequently only a direct examination of the tissue or synovial fluid will yield the correct diagnosis. The article presents the basis of the synovial fluid analysis and a relevant decision-making scheme. The reliability and applicability of synovial fluid tests are commented upon. The synovial fluid analysis undoubtedly plays an important role in the management of patients with joint diseases. Due to a lack of interlaboratory comparisons, and therefore expert opinions on the interpretation of results, this knowledge and the acquisition of relevant experience should be encouraged to enable evaluation of the clinical applicability of recent discoveries in synovial fluid pathology.