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.     

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.     

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.     

CR-lipped bearing is an adequate functional solution to patients with perioperative excessive laxity in cruciate retaining total knee arthroplasty

BackgroundThe cruciate retaining lipped (CR-lipped) bearing is designed to provide more anterior-posterior (AP) stability and could be employed to resolve excessive intraoperative laxity during the cruciate retaining TKA (CR-TKA). The aim of the study was to determine whether the CR-lipped bearing in CR-TKAs with a perioperative excessive laxity allows equivalent functional results as compared to the standard CR articulation.MethodsA cohort of 111 TKAs with CR-lipped bearings was matched to a cohort of conventional CR bearings regarding age and sex. The CR-lipped bearing was used in patients with excessive knee AP laxity and the regular CR bearing was used in patients without excessive AP laxity during TKA. Various PROMs (WOMAC, KSS, SF-36) were assessed preoperatively and at 5-years postoperative in combination with revision rate and Range of Motion (ROM).ResultsPROMs did not differ significantly between both groups 5-years postoperatively. Mean ROM (flexion) 5-years postoperatively was not significantly different. The implant survivorship was 100% for both cohorts with revision for any reason as end point.ConclusionBased on these results, the CR-lipped bearing is a safe and effective solution for mild interoperatively assessed PCL laxity during CR-TKA without loss of function or decreased survivorship at 5 years. Peroperative conversion to a PS-TKA in order to obtain satisfactory functional scores might therefore not be necessary when mild PCL laxity is observed during surgery. Further research should focus on verifying this approach and longer follow-up is needed to generate data on long term survivorship.Level of evidenceLevel IV therapeutic, retrospective, cohort study.     

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.     

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.     

Approximately 80% of Japanese osteoarthritic patients fall out of the safety range in restricted kinematically-aligned total knee arthroplasty in an analysis of preoperative long-leg radiograms

BackgroundRestricted kinematically-aligned total knee arthroplasty (KA-TKA) is a reasonable modification to avoid the alignment outlier that may cause implant failure. However, despite a noted high incidence of constitutional varus in Japanese individuals, there has been no investigation into how many knees require the restriction in restricted KA-TKA (RKA-TKA) among Japanese patients. Therefore, we conducted a study using preoperative long-leg radiograms.MethodsWe studied long-leg radiographs of 228 knees in 114 consecutive patients. The numbers of knees within the safety range and their corrective osteotomy angle in the restriction algorithms advocated by Almaawi et al. (2017) and MacDessi et al. (2020) were evaluated.ResultsAccording to the algorithms used by Almaawi et al. and MacDessi et al., out of 228 knees, 46 (20%) and 39 (17%) fell within the safety range, respectively. The mean correction angles of the hip-knee-ankle angle, lateral distal femoral angle and medial proximal tibial angle were 2.8 ± 3.4°, 0.4 ± 1.4° and 2.4 ± 2.8° in the algorithm used by Almaawi et al., while they were −4.9 ± 4.7°, 1.1 ± 2.5° and −6.0 ± 3.4° in the algorithm used by MacDessi et al. Most of the knees needed to be restricted in order to perform RKA-TKA, regardless of the algorithm used.ConclusionsBased on a preoperative analysis of long-leg radiograms in a Japanese population, most knees fall out of the safety range in RKA-TKA. Surgeons must consider whether to allow component outlier or to perform corrective osteotomy that likely requires soft tissue release.     

Personalized volumetric assessment of lower body muscles in patients with knee injuries: A descriptive case series

BackgroundPatients with knee joint pathology present with variable muscular responses across the muscles of the lower limb and pelvis. Conventional approaches to characterizing muscle function are limited to gross strength assessments that may overlook subtle changes both in the thigh, hip and shank musculature.PurposeTo describe individualized patterns of lower extremity muscle volumes in patients with knee pathologies.MethodsThis was a retrospective case series performed in a University medical center. Nine patients diagnosed with meniscus tear recommended to undergo meniscectomy volunteered. Participants underwent 3.0 Tesla magnetic resonance imaging (MRI) of the lower extremities. Thirty-five MRI-derived muscle volumes were compared between limbs and expressed as percentage asymmetry. For additional context, z-scores were also calculated for mass- and height-normalized muscles and pre-determined muscle groupings relative to a normative database.ResultsThere were no consistent patterns observed when considering between-limb asymmetries among all patients. The ankle musculature (dorsiflexors, plantar flexors, and invertors) was the only muscle group to be consistently smaller than normal for all patients, with the psoas major and flexor hallucis longus being the only individual muscles. The severity or chronicity of injury and presence of surgical intervention did not appear to have a clear effect on muscle volumes.ConclusionPatients with a history of meniscal pathology demonstrate inconsistent patterns of lower extremity muscle volumes about the hip, knee, and ankle between limbs and in comparison to uninjured individuals. These data support the need for individualized assessment and intervention in this population.     

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 simplified blood culture sampling protocol for reducing contamination and costs: a randomized controlled trial

ObjectivesBlood culture contamination carries risks for patients, such as unnecessary antimicrobial therapy and other additional hazards and costs. One method shown to be effective in reducing contamination is initial blood specimen diversion during collection. We hypothesized that initial blood specimen diversion without a designated device or procedure would suffice for reduction in blood culture contamination rate.MethodsFrom 1 September 2017 through to 6 September 2018, we conducted a randomized controlled trial to assess the effect of an initial-specimen diversion technique (ISDT) on the rate of blood-culture contamination by changing the order of sampling using regular vacuum specimen tubes instead of commercially available sterile diversion devices. We included adults from whom the treating physician planned to take blood cultures and additional blood chemistry tests. Additionally, we evaluated the potential economic benefits of an ISDT. This was a researcher-initiated trial, Clinicaltrials.gov NCT03088865.ResultsIn all, 756 patients were enrolled. This method, compared with the standard procedure in use at our medical centre, reduced contamination by 66% (95% CI 17%–86%), from 20/400 (5%) with the standard method to 6/356 (1.6%) with the ISDT, without compromising detection of true bloodstream infection and at no additional cost. Hospital-wide implementation of ISDT was associated with a 1.1% saving in hospitalization days.ConclusionsWe offer this novel approach as a simple, cost-effective measure to reduce risks to patient safety from contaminated blood cultures, without the need for using costly devices.     

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.     

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.     

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.     

Anatomical description and short-term follow up clinical results for ultrasound-guided injection of medial collateral ligament bursa: New conservative treatment option for symptomatic degenerative medial meniscus tear

BackgroundIn this study, we investigated newly developed ultrasound (US)-guided medial collateral ligament (MCL) bursa injection as a conservative therapy for symptomatic degenerative medial meniscal (MM) tears. We aimed to describe the anatomical target and precise technique of this injection, confirm its accuracy using fresh cadaveric knees, and then evaluate preliminary clinical outcomes.MethodsAnatomical studies were performed on three fresh cadavers. For the clinical study, 50 patients with medial knee joint pain without knee osteoarthritis were treated with US-guided MCL bursa injection. Severity of pain was assessed pre-injection, and 1 week and 4 weeks post-injection using a 0–10 numerical rating scale (NRS). Clinical success was defined as a full return to daily activities. All patients underwent magnetic resonance imaging (MRI) within 1 week of the first injection. Patients who underwent surgery within 12 months of the first injection were investigated as clinically unsuccessful cases, and MRI and arthroscopic findings were examined.ResultsCompared with pre-injection (6.8 ± 1.2), the average NRS score was significantly lower at 1 week (1.8 ± 2.0) and at 4 weeks (1.5 ± 1.7) post-injection (both P < 0.01). The primary clinical success rate was 76.0%, and injection-related adverse events were not observed. Nine patients underwent surgery (arthroscopic surgery for degenerative flap tear (n = 7) and high tibial osteotomy for medial meniscus posterior root tear and proximal tibial malalignment (n = 2)).ConclusionsUS-guided MCL bursa injection is safe, reproducible, and effective for symptomatic MM degenerative tears. However, US-guided injections of the MCL bursa may be ineffective for flap tears and posterior root tears.     

Effects of combination treatment with tezepelumab and allergen immunotherapy on nasal responses to allergen: A randomized controlled trial

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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.     

Antigen-independent IL-17A production by bystander-activated CD4+IL-1R1+ cells in patients with multiple sclerosis

Multiple sclerosis (MS) is a demyelinating disease caused by auto-antigen recognizing CD4⁺ T cells. However, IL-17A-producing CD4⁺ T cells that are bystander-activated by IL-1β and IL-23, and T cell receptors independently, could contribute to experimental autoimmune encephalomyelitis. Here, we studied the differences in the frequency and function of bystander-activated CD4⁺ T cells in patients with MS. A significantly higher frequency of CD4 + IL-1Rl + T cells was found in memory than in naïve CD4⁺ T cells and in Th17/Th17.1 than in Th1/Th2 subtypes in both MS and healthy controls (HC). Following IL-1β and IL-23 stimulation, IL-1Rl expression was markedly increased in both memory and Th17/Th17.1 cells, and their IL-17A-production was increased after bystander-activation, which was significantly higher in MS compared with HC. Our study suggests a potential role of IL-17A-producing bystander-activated CD4⁺IL-1Rl⁺ T cells in MS.     

Effectiveness of continuous versus single injection femoral nerve block for total knee arthroplasty: A double blinded,randomized trial

Background

Effective analgesia following total knee arthroplasty (TKA) is important for maximizing patient satisfaction, early participation in physical therapy and reducing the hospital stay. This trial compared continuous catheter femoral nerve block (cFNB) to single injection femoral nerve block (sFNB) in terms of analgesia, opioid consumption, and participation in physical therapy and associated side effects.

Osteotomy around the knee: Assessment of quality,content and readability of online information

BackgroundAs knee osteotomy surgery becomes increasingly accessible, more patients may turn to the Internet for information. This study examined the source, quality, content and readability of online information regarding osteotomy around the knee.MethodsThe first 70 websites returned by the top four search engines were identified using the key words: “knee osteotomy” and “high tibial osteotomy.” The websites were categorised by type and assessed using the DISCERN score, Journal of the American Medical Association (JAMA) benchmark criteria and a novel Knee Osteotomy-Specific Score (KOSS). The presence of the Health On the Net (HON) code accreditation seal was noted. Readability of each website was assessed using eight readability formulae. The mean reading grade level (RGL) was compared to the 6th and 8th grade reading levels. The mean RGL of each category was also compared.ResultsOf the 45 unique websites analysed, the majority were Physician (33%) and Journal websites (31%). The mean DISCERN score was 36.7 (±8.9) which is classified as ‘poor.’ The mean JAMA benchmark criteria score was 2.04 (±1.5) and Physician websites were most likely to be scored zero. The mean KOSS was 15.4 (±5.7). The highest scoring website was a Commercial site but, overall, Journal category sites provided the best quality information. Websites that bore the HONcode seal obtained higher DISCERN, JAMA benchmark criteria and Knee Osteotomy - Specific Scores.The cumulative mean RGL was 13.2 (±2.2) which exceeded the 6th grade level by an average of 7.2 grade levels and the 8th grade level by an average of 5.2 grade levels. No website (0%) was written at or below either the 6th or the 8th grade reading levels. The mean Flesch Reading Ease Score of all websites was 41.13 (±14.7) which is classified as ‘difficult.’ Journal websites had the highest RGL.ConclusionThe information available online regarding osteotomy around the knee varies tremendously in quality and completeness. Physician sites predominate, but these were among the lowest scoring of all websites. Even where high quality information is available, it is set at too high a level to be easily understood.Level of evidenceSurvey of materials – Internet.