Dissatisfied patients after total knee arthroplasty: A registry study involving 114 patients with 8–13 years of follow-up

Background and purpose

In 2003, an enquiry by the Swedish Knee Arthroplasty Register (SKAR) 2–7 years after total knee arthroplasty (TKA) revealed patients who were dissatisfied with the outcome of their surgery but who had not been revised. 6 years later, we examined the dissatisfied patients in one Swedish county and a matched group of very satisfied patients.

Patients and methods

118 TKAs in 114 patients, all of whom had had their surgery between 1996 and 2001, were examined in 2009–2010. 55 patients (with 58 TKAs) had stated in 2003 that they were dissatisfied with their knees and 59 (with 60 TKAs) had stated that they were very satisfied with their knees. The patients were examined clinically and radiographically, and performed functional tests consisting of the 6-minute walk and chair-stand test. All the patients filled out a visual analog scale (VAS, 0–100 mm) regarding knee pain and also the Hospital and Anxiety and Depression scale (HAD).

Results

Mean VAS score for knee pain differed by 30 mm in favor of the very satisfied group (p < 0.001). 23 of the 55 patients in the dissatisfied group and 6 of 59 patients in the very satisfied group suffered from anxiety and/or depression (p = 0.001). Mean range of motion was 11 degrees better in the very satisfied group (p < 0.001). The groups were similar with regard to clinical examination, physical performance testing, and radiography.

Interpretation

The patients who reported poor response after TKA continued to be unhappy after 8–13 years, as demonstrated by VAS pain and HAD, despite the absence of a discernible objective reason for revision.The results of TKA are regarded as being favorable (Robertsson et al. 2000, Kane et al. 2005, Nilsdotter et al. 2009, Carr et al. 2012) with few surgical complications and a revision rate of less than 5% after 10 years (Vessely et al. 2006, Robertsson et al. 2010). Poor outcome after primary TKA, apart from the revision, is between 6% and 14% (Anderson et al. 1996, Hawker et al. 1998, Heck et al. 1998, Robertsson et al. 2000, Robertsson and Dunbar 2001, Brander et al. 2003, Noble et al. 2006, Fisher et al. 2007, Wylde et al. 2008, Kim et al. 2009, Bourne et al. 2010, Scott et al. 2010). The reason for poor outcome after TKA may be related to problems with the knee surgery itself, although it has been suggested that extra-articular causes such as hip disease, spine disorder, vascular disease, or reflex sympathetic dystrophy may contribute. Some studies have suggested that factors not primarily related to structural tissue changes, but of psychological nature instead, may be involved (Wylde et al. 2007, Rolfson et al. 2009).The Swedish Knee Arthroplasty Register (SKAR) registers primary arthroplasties performed in Sweden as well as revisions, and has been estimated to capture 97% of the surgeries performed (SKAR 2012). The SKAR sends questionnaires regarding satisfaction to patients who were operated on during certain time periods (Robertsson et al. 2000, and Dunbar 2001). We used the SKAR to identify patients who had not undergone revision surgery and who were dissatisfied with their outcome 2–7 years after TKA surgery. As a reference we chose an age-, sex-, date-of-surgery-, and hospital-matched control group of highly satisfied patients who were operated during the same period. Our aim was to assess the differences between these 2 patient groups.     

Fetal alcohol spectrum disorders

Prenatal alcohol exposure (PAE) is one of the most prevalent and modifiable risk factors for somatic, behavioral, and neurological abnormalities. Affected individuals exhibit a wide range of such features referred to as fetal alcohol spectrum disorders (FASD). These are characterized by a more or less specific pattern of minor facial dysmorphic features, growth deficiency and central nervous system symptoms. Nevertheless, whereas the diagnosis of the full-blown fetal alcohol syndrome does not pose a major challenge, only a tentative diagnosis of FASD can be reached if only mild features are present and/or maternal alcohol consumption during pregnancy cannot be verified. The respective disorders have lifelong implications. The teratogenic mechanisms induced by PAE can lead to various additional somatic findings and structural abnormalities of cerebrum and cerebellum. At the functional level, cognition, motor coordination, attention, language development, executive functions, memory, social perception and emotion processing are impaired to a variable extent. The long-term development is characterized by disruption and failure in many domains; an age-adequate independency is frequently not achieved. In addition to primary prevention, individual therapeutic interventions and tertiary prevention are warranted; provision of extensive education to affected subjects and their caregivers is crucial. Protective environments are often required to prevent negative consequences such as delinquency, indebtedness or experience of physical/sexual abuse.     

How ‘love’ and ‘hate’ differ from ‘sleep’: Using combined electro/magnetoencephalographic data to reveal the sources of early cortical responses to emotional words

Emotional words—as symbols for biologically relevant concepts—are preferentially processed in brain regions including the visual cortex, frontal and parietal regions, and a corticolimbic circuit including the amygdala. Some of the brain structures found in functional magnetic resonance imaging are not readily apparent in electro‐ and magnetoencephalographic (EEG; MEG) measures. By means of a combined EEG/MEG source localization procedure to fully exploit the available information, we sought to reduce these discrepancies and gain a better understanding of spatiotemporal brain dynamics underlying emotional‐word processing. Eighteen participants read high‐arousing positive and negative, and low‐arousing neutral nouns, while EEG and MEG were recorded simultaneously. Combined current‐density reconstructions (L2‐minimum norm least squares) for two early emotion‐sensitive time intervals, the P1 (80–120 ms) and the early posterior negativity (EPN, 200–300 ms), were computed using realistic individual head models with a cortical constraint. The P1 time window uncovered an emotion effect peaking in the left middle temporal gyrus. In the EPN time window, processing of emotional words was associated with enhanced activity encompassing parietal and occipital areas, and posterior limbic structures. We suggest that lexical access, being underway within 100 ms, is speeded and/or favored for emotional words, possibly on the basis of an “emotional tagging” of the word form during acquisition. This gives rise to their differential processing in the EPN time window. The EPN, as an index of natural selective attention, appears to reflect an elaborate interplay of distributed structures, related to cognitive functions, such as memory, attention, and evaluation of emotional stimuli. Hum Brain Mapp 35:875–888, 2014. © 2012 Wiley Periodicals, Inc.     

Beta‐band activity in auditory pathways reflects speech localization and recognition in bilateral cochlear implant users

In normal‐hearing listeners, localization of auditory speech involves stimulus processing in the postero‐dorsal pathway of the auditory system. In quiet environments, bilateral cochlear implant (CI) users show high speech recognition performance, but localization of auditory speech is poor, especially when discriminating stimuli from the same hemifield. Whether this difficulty relates to the inability of the auditory system to translate binaural electrical cues into neural signals, or to a functional reorganization of auditory cortical pathways following long periods of binaural deprivation is unknown. In this electroencephalography study, we examined the processing of auditory syllables in postlingually deaf adults with bilateral CIs and in normal‐hearing adults. Participants were instructed to either recognize (“recognition” task) or localize (“localization” task) the syllables. The analysis focused on event‐related potentials and oscillatory brain responses. N1 amplitudes in CI users were larger in the localization compared with recognition task, suggesting an enhanced stimulus processing effort in the localization task. Linear beamforming of oscillatory activity in CI users revealed stronger suppression of beta‐band activity after 200 ms in the postero‐dorsal auditory pathway for the localization compared with the recognition task. In normal‐hearing adults, effects for longer latency event‐related potentials were found, but no effects were observed for N1 amplitudes or beta‐band responses. Our study suggests that difficulties in speech localization in bilateral CI users are not reflected in a functional reorganization of cortical auditory pathways. New signal processing strategies of cochlear devices preserving unambiguous binaural cues may improve auditory localization performance in bilateral CI users. Hum Brain Mapp 35:3107–3121, 2014. © 2013 Wiley Periodicals, Inc .     

Vitamin D Supplementation After Parathyroidectomy: Effect on Bone Mineral Density—A Randomized Double‐Blind Study

Patients with primary hyperparathyroidism (PHPT) have higher bone turnover, lower bone mineral density (BMD), and an increased risk of fractures. They also have a high incidence of low vitamin D levels (25‐OH‐vitamin D <50 nmol/L) that could worsen the negative effect on the bone. In this double‐blinded clinical trial, 150 patients with PHPT were randomized, after successful parathyroidectomy (PTX), to 1‐year daily treatment with either cholecalciferol 1600 IU and calcium carbonate 1000 mg (D +) or calcium carbonate alone (D–). BMD was measured in the lumbar spine, femoral neck, total hip, distal and 33% radius using dual‐energy X‐ray absorptiometry (DXA) before surgery and after 1 year of study medication. Median age was 60 (range 30–80) years and there were 119 (79%) women and 31 (21%) men; 76% had 25‐OH‐D <50 nmol/L before PTX and 50% had persistent elevated parathyroid hormone (PTH) 6 weeks after PTX. A similar increase in BMD in the lumbar spine, femoral neck, and total hip was observed in both groups (D + : 3.6%, 3.2%, and 2.7%, p < 0.001, respectively; and D–: 3.0%, 2.3%, and 2.1%, respectively, p < 0.001). Patients with vitamin D supplementation also increased their BMD in distal radius (median 2.0%; interquartile range, ?1.7% to 5.4%; p = 0.013). The changes in BMD, especially in the hips, were correlated to the baseline concentrations of PTH, ionized calcium, and bone markers (p < 0.001). A benefit from vitamin D substitution was observed among patients with a persistent postoperative PTH elevation, who also improved their BMD at 33% radius and radius ultradistal (p < 0.05). In conclusion, except for a minor improvement of radius BMD, our data show no beneficial effect on BMD or bone turnover markers of vitamin D supplementation after PTX. Preoperative PTH seems to have the strongest association with improvement in BMD. © 2014 American Society for Bone and Mineral Research.     

Usefulness of Reynolds Risk Score in men with stable angina

Introduction

Recently several risk scores have been proposed that, beyond traditional risk factors, also include additional inflammatory biomarkers underlying atherothrombosis. The Reynolds Risk Score (RRS) is a point scale assessing the risk of cardiovascular events over 10 years, which takes into account for the first time high-sensitivity C-reactive protein. The aim of this study was to establish clinical usefulness of RRS in men with stable coronary artery disease and preserved left ventricular systolic function.

Material and Methods

In total, 119 symptomatic non-diabetic man (mean age 63.9±9.23) who were directed for an elective coronary arteriography were enrolled in the study. Clinical data were collected including the elevated heart rate ≥70 bpm/min, basic laboratory results, placental growth factor and results of coronary angiography. Patients were analyzed related to RRS: low risk <10% (n=50), moderate risk 10-19% (n=46) and high risk >20% (n=23).

Results

Opposite to high RRS patients, in the low risk group more often occurred marginal or none atherosclerotic coronary arteries (13% vs. 44%, P=0.0214). The findings have revealed the relationship between the higher risk score and the lower frequency of marginal or no atherosclerotic coronary arteries (OR=0.19, 95%CI 0.05–0.67).

Conclusions

The Reynolds Risk Score appears to be useful in men with stable coronary artery disease and preserved left ventricular systolic function in stratifying the severity of coronary atherosclerosis.     

Novel pathogenic EIF2S3 missense variants causing clinically variable MEHMO syndrome with impaired eIF2γ translational function,and literature review

Rare pathogenic EIF2S3 missense and terminal deletion variants cause the X-linked intellectual disability (ID) syndrome MEHMO, or a milder phenotype including pancreatic dysfunction and hypopituitarism. We present two unrelated male patients who carry novel EIF2S3 pathogenic missense variants (p.(Thr144Ile) and p.(Ile159Leu)) thereby broadening the limited genetic spectrum and underscoring clinically variable expressivity of MEHMO. While the affected male with p.(Thr144Ile) presented with severe motor delay, severe microcephaly, moderate ID, epileptic seizures responsive to treatments, hypogenitalism, central obesity, facial features, and diabetes, the affected male with p.(Ile159Leu) presented with moderate ID, mild motor delay, microcephaly, epileptic seizures resistant to treatment, central obesity, and mild facial features. Both variants are located in the highly conserved guanine nucleotide binding domain of the EIF2S3 encoded eIF2γ subunit of the heterotrimeric translation initiation factor 2 (eIF2) complex. Further, we investigated both variants in a structural model and in yeast. The reduced growth rates and lowered fidelity of translation with increased initiation at non-AUG codons observed for both mutants in these studies strongly support pathogenicity of the variants.     

Neurotrophin receptor p75 mediates the uptake of the amyloid beta (Aβ) peptide,guiding it to lysosomes for degradation in basal forebrain cholinergic neurons

A fascinating yet perhaps overlooked trait of the p75 neurotrophin receptor (p75^NTR) is its ability to bind ligands with no obvious neurotrophic function. Using cultured basal forebrain (BF) neurons, this study demonstrates selective internalization of amyloid β (Aβ) 1–42 in conjunction with p75^NTR (labelled with IgG192-Cy3) by cholinergic cells. Active under resting conditions, this process was enhanced by high K⁺ stimulation and was insensitive to inhibitors of regulated synaptic activity—tetrodotoxin or botulinum neurotoxins (BoNT type/A and/B). Blockade of sarco-endoplasmic reticulum (SERCA) Ca²⁺ ATPase with thapsigargin and CPA or chelation of Ca²⁺ with EGTA-AM strongly suppressed the endocytosis of p75^NTR, implicating the role of ER released Ca²⁺. The uptake of IgG192-Cy3 was also reduced by T-type Ca²⁺ channel blocker mibefradil but not Cd²⁺, an indiscriminate blocker of high voltage-activated Ca²⁺ currents. A strong co-localization of IgG192-Cy3 with late endosome (Rab7) or lysosome (Lamp1) qualifier proteins suggest these compartments as the primary destination for internalized IgG192 and Aβ. Selective uptake and labeling of BF cholinergic cells with IgG192-Cy3 injected into the prefrontal cortex was verified also in vivo. The significance of these findings in relation to Aβ clearance in the cerebral cortex and pathophysiology of Alzheimer’s disease is discussed.