Return to work policies and practices after total hip or knee arthroplasty in Denmark, Germany, and the Netherlands: an exploratory study

PURPOSE

To explore return-to-work (RTW) policies and practices for total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients in three European countries.

MATERIALS AND METHODS

An exploratory study in Denmark, Germany, and the Netherlands consisting of three aspects: (1) description of the healthcare and social security systems; (2) identification of national RTW guidelines; (3) a survey to gain insight into RTW practices and perceptions of orthopaedic surgeons, including barriers, facilitators, and needs.

RESULTS

Healthcare and social security systems differed (e.g. fast-track vs longer postoperative stay; coverage of rehabilitation costs). National guidelines were available in Germany (THA, TKA) and the Netherlands (TKA), containing limited RTW information. The survey was completed by 168 orthopaedic surgeons (Denmark n = 51; Germany n = 39; the Netherlands n = 78). Overall, orthopaedic surgeons reported being in need of more knowledge and better collaboration with other healthcare practitioners.

CONCLUSION

We found considerable variation in healthcare and social security systems. When available, national guidelines contained limited information. In all three countries surgeons need more knowledge and better collaboration with other healthcare practitioners. We advise that RTW multidisciplinary recommendations post THA/TKA be established by the national associations of the healthcare practitioners involved.

Three out of four working-age patients have fulfilled expectations towards paid employment six months after total hip or knee arthroplasty: a multicentre cohort study

To investigate factors associated with fulfilment of expectations towards paid employment after total hip/knee arthroplasty (THA/TKA). Cohort study including preoperatively employed patients aged 18-64 scheduled for THA/TKA. Expectations were collected preoperatively, and 6 and 12 months postoperatively with the paid employment item of the Hospital-for-Special-Surgery Expectations Surveys (back-to-normal = 1; large improvement = 2; moderate improvement = 3; slight improvement = 4; not applicable = 5). Patients scoring not applicable were excluded. Fulfilment was calculated by subtracting preoperative from postoperative scores (< 0: unfulfilled; ≥ 0: fulfilled). Multivariable logistic regression analyses were conducted separately for THA/TKA at 6 and 12 months postoperatively. Six months postoperatively, 75% of THA patients (n = 237/n = 316) and 72% of TKA patients (n = 211/n = 294) had fulfilled expectations. Older age (TKA:OR 1.08, 95% CI 1.01-1.15) and better postoperative physical functioning (THA:OR 1.10, 95% CI 1.06-1.14; TKA:OR 1.03, 95% CI 1.01-1.06) increased the likelihood of fulfilment. Physical work tasks (THA:OR 0.12, 95% CI 0.03-0.44), preoperative sick leave (TKA:OR 0.33, 95% CI 0.17-0.65), and difficulties at work (THA:OR 0.10, 95% CI 0.03-0.35; TKA:OR 0.41, 95% CI 0.17-0.98) decreased the likelihood of fulfilment. Twelve months postoperatively similar risk factors were found. Three out of four working-age THA/TKA patients had fulfilled expectations towards paid employment at 6 months postoperatively. Preoperative factors associated with fulfilment were older age, mental work tasks, no sick leave, postoperative factors were better physical functioning, and no perceived difficulties at work.

Time to return to work by occupational class after total hip or knee arthroplasty

Aims

For the increasing number of working-age patients undergoing total hip or total knee arthroplasty (THA/TKA), return to work (RTW) after surgery is crucial. We investigated the association between occupational class and time to RTW after THA or TKA.

Methods

Data from the prospective multicentre Longitudinal Leiden Orthopaedics Outcomes of Osteoarthritis Study were used. Questionnaires were completed preoperatively and six and 12 months postoperatively. Time to RTW was defined as days from surgery until RTW (full or partial). Occupational class was preoperatively assessed and categorized into four categories according to the International Standard Classification of Occupations 2008 (blue-/white-collar, high-/low-skilled). Cox regression analyses were conducted separately for THA and TKA patients. Low-skilled blue-collar work was used as the reference category.

Results

A total of 360 THA and 276 TKA patients, preoperatively employed, were included. Patients were mainly high-skilled (THA 57%; TKA 41%) or low-skilled (THA 24%; TKA 38%) white-collar workers. Six months post-THA, RTW rates were 78% of low-skilled blue-collar workers compared to 83% to 86% within other occupational classes, increasing after 12 months to 87% to 90% in all occupational classes. Six months post-TKA, RTW rates were 58% of low-skilled and 64% of high-skilled blue-collar workers compared to 80% to 89% of white-collar workers, and after 12 months 79% of low-skilled blue-collar workers compared to 87% to 92% within other occupational classes. High-skilled white-collar workers (THA: hazard ratio (HR) 2.12 (95% confidence interval (CI) 1.32 to 3.40); TKA: HR 2.31 (95% CI 1.34 to 4.00)) and low-skilled white-collar workers (TKA: HR 1.82 (95% CI 1.04 to 3.18)) had a higher hazard to RTW within six months postoperatively.

Conclusion

Clear differences existed in time to RTW among both THA and TKA patients in each of the groups studied. These findings may help guide tailored patient-specific information during preoperative consultation and advice postoperatively, as well as to create awareness among workers and their employers.

[Complaints after total joint arthroplasty: caused by infection or metal hypersensitivity?]

Besides periprosthetic joint infection, metal hypersensitivity should be considered when complaints persist after total joint arthroplasty. To date, there is no consensus on the diagnosis, and believers and non-believers of metal hypersensitivity exist. The pathogenesis of metal hypersensitivity is complex and involves a type-4 delayed hypersensitivity reaction with both a cutaneous and systemic response. It is unclear if complaints after total joint arthroplasty (after eliminating other causes) are caused by metal hypersensitivity. Furthermore, it is not known whether sensitization is a cause or a consequence of complaints after total joint arthroplasty. Currently, the patch test is the best screening test to diagnose metal hypersensitivity, but the accuracy has not been defined. We present a female patient with a painful left elbow three years after total elbow replacement. Because of the increasing volume of total joint prostheses, we aim to create awareness for metal hypersensitivity and the according diagnostic dilemmas.

[Complaints after total joint arthroplasty: caused by infection or metal hypersensitivity?]

Besides periprosthetic joint infection, metal hypersensitivity should be considered when complaints persist after total joint arthroplasty. To date, there is no consensus on the diagnosis, and believers and non-believers of metal hypersensitivity exist. The pathogenesis of metal hypersensitivity is complex and involves a type-4 delayed hypersensitivity reaction with both a cutaneous and systemic response. It is unclear if complaints after total joint arthroplasty (after eliminating other causes) are caused by metal hypersensitivity. Furthermore, it is not known whether sensitization is a cause or a consequence of complaints after total joint arthroplasty. Currently, the patch test is the best screening test to diagnose metal hypersensitivity, but the accuracy has not been defined. We present a female patient with a painful left elbow three years after total elbow replacement. Because of the increasing volume of total joint prostheses, we aim to create awareness for metal hypersensitivity and the according diagnostic dilemmas.

[Milwaukee shoulder syndrome: A painful swollen shoulder as a result of a rare condition]

BACKGROUND

A painful and swollen shoulder has an extensive differential diagnosis, with Milwaukee shoulder syndrome (MSS) being diagnosed infrequently. Analysis of crystals in the synovial fluid is an important diagnostic step in patients with a swollen shoulder.

CASE DESCRIPTION

A 69-year-old female presented at the orthopaedic outpatient clinic with pain, limited mobility and swelling of the left shoulder. The diagnosis MSS was made based on the characteristic features on X-ray and MRI combined with the analysis of the synovial fluid, including a positive alizarin-red staining.

CONCLUSION

MSS is a rare, destructive, calcium-hydroxyapatite crystal-associated arthropathy. After a typical X-ray, a joint aspiration is preferred to avoid unnecessary expensive radiographic imaging. Alizarin-red staining is a simple, inexpensive, and sensitive test to identify calcium-hydroxyapatite crystals in synovial fluid, and aids in the diagnosis of MSS. This is important in order to adequately inform patients regarding the prognosis of their disease.

Psychosocial Working Conditions Play an Important Role in the Return-to-Work Process After Total Knee and Hip Arthroplasty

Purpose Both personal and work-related factors affect return to work (RTW) after total knee arthroplasty (TKA) and total hip arthroplasty (THA). Little is known about work-related factors associated with the recovery process. This study aimed to determine which work-related factors are associated with time to RTW for both TKA and THA patients. Methods A prospective multicenter survey study was conducted that included patients aged 18-63, had a paid job and were scheduled to undergo primary TKA/THA. Surveys were completed preoperatively, 6 weeks, and 3, 6, and 12 months postoperatively, and included four domains of work-related factors: work characteristics, physical working conditions, psychosocial working conditions and work adjustments. Control variables included age, sex, education, and comorbidity. Time to RTW was defined as days from surgery until RTW. Multivariate linear regression analyses were conducted separately for TKA/THA patients. Results Enrolled were 246 patients (n = 146 TKA, n = 100 THA, median age 56 years, 57% female). Median time to RTW was 79 days (IQR 52.0-146.0). Mainly physical tasks (TKA: B 58.2, 95%CI 9.5-106.8; THA: B 52.1, 95%CI 14.1-90.2) and a combination of physical and mental tasks (TKA: B 50.2, 95%CI 6.4-94.0; THA B 54.0, 95%CI 24.2-83.7) were associated with longer time to RTW after both TKA and THA. More possibilities for personal job development (B - 12.8, 95%CI - 25.3-0.4) and more work recognition (B - 13.2, 95%CI - 25.5 to - 0.9) were significantly associated with shorter time to RTW after TKA. Higher quality of supervisor leadership (B - 14.1, 95%CI - 22.2 to - 6.0) was significantly associated with shorter time to RTW after THA. Conclusion The findings of this study stress the importance of psychosocial working conditions, besides type of job tasks, in RTW after TKA/THA. Further research on work-related factors is needed, as arthroplasty is being performed on an increasingly younger population of knee and hip OA patients for whom participating in work is of critical importance.

Influence of social support on return to work after total hip or total knee arthroplasty: a prospective multicentre cohort study

OBJECTIVES

There is strong evidence that social support is an important determinant of return to work (RTW). Little is known about the role of social support in RTW after total hip or knee arthroplasty (THA/TKA). Objective was to examine the influence of preoperative and postoperative perceived social support on RTW status 6 months postoperatively.

DESIGN

A prospective multicentre cohort study was conducted.

SETTING

Orthopaedic departments of four Dutch medical centres; a tertiary university hospital, two large teaching hospitals and a general hospital.

PARTICIPANTS

Patients planned to undergo THA/TKA, aged 18-63 and employed preoperatively were included.

MAIN OUTCOME MEASURES

Questionnaires were filled out preoperatively and 3 and 6 months postoperatively and included questions to assess patients' perceived social support targeting three sources of social support: from home (friends, family), from work (coworkers, supervisors) and from healthcare (occupational physician, general practitioner, other caregivers). Control variables included age, gender, education, type of arthroplasty and comorbidities. RTW was defined as having fully returned to work 6 months postoperatively. Univariate and multivariate logistic regression analyses were conducted.

RESULTS

Enrolled were 190 patients (n=77 THA, n=113 TKA, median age was 56 years, 56% women). The majority returned to work (64%). Preoperatively, social support from the occupational physician was associated with RTW (OR 2.53, 95% CI 1.15 to 5.54). Postoperatively, social support from the occupational physician (OR 3.04, 95% CI 1.43 to 6.47) and the supervisor (OR 2.56, 95% CI 1.08 to 6.06) was associated with RTW.

CONCLUSIONS

This study underscores the importance of work-related social support originating from the occupational physician and supervisor in facilitating RTW after primary THA/TKA, both preoperatively and postoperatively. Further research is needed to confirm our results and to understand the facilitating role of social support in RTW, as arthroplasty is being performed on a younger population for whom work participation is critical.

Feasibility of an alternative, physiologic, individualized open-lung approach to high-frequency oscillatory ventilation in children

Background

High-frequency oscillatory ventilation (HFOV) is a common but unproven management strategy in paediatric critical care. Oscillator settings have been traditionally guided by patient age and/or weight rather than by lung mechanics, thereby potentially negating any beneficial effects. We have adopted an open-lung HFOV strategy based on a corner frequency approach using an initial incremental–decremental mean airway pressure titration manoeuvre, a high frequency (8–15 Hz), and high power to initially target a proximal pressure amplitude (∆P_proximal) of 70–90 cm H₂O, irrespective of age or weight.

Methods

We reviewed prospectively collected data on patients < 18 years of age who were managed with HFOV for acute respiratory failure. We measured metrics for oxygenation, ventilation, and haemodynamics as well as the use of sedative-analgesic medications and neuromuscular blocking agents.

Results

Data from 115 non-cardiac patients were analysed, of whom 53 had moderate-to-severe paediatric acute respiratory distress syndrome (PARDS). Sixteen patients (13.9%) died. Frequencies≥ 8 Hz and high ∆P_proximal were achieved in all patients irrespective of age or PARDS severity. Patients with severe PARDS showed the greatest improvement in oxygenation. pH and PaCO₂ normalized in all patients. Haemodynamic parameters, cumulative amount of fluid challenges, and daily fluid balance did not deteriorate after transitioning to HFOV in any age or PARDS severity group. We observed a transient increase neuromuscular blocking agent use after switching to HFOV, but there was no increase in the daily cumulative amount of continuous midazolam or morphine in any age or PARDS severity group. No patients experienced clinically apparent barotrauma.

Conclusions

This is the first study reporting the feasibility of an alternative, individualized, physiology-based open-lung HFOV strategy targeting high F and high ∆P_proximal. No adverse effects were observed with this strategy. Our findings warrant further systematic evaluation.

The activation of intracellular tyrosine kinases by interferon-alpha (IFNalpha) correlates with its antiproliferative activity in B-lymphoid cell lines, but not in B-cell chronic lymphocytic leukemia patients

The response to interferon-alpha (IFNalpha) treatment in leukemias of the B-cell lineage shows a marked heterogeneity. A distinct subset of patients with B-CLL responds to treatment with IFNalpha, while the drug has no therapeutic effect in the majority of patients. The mechanism of this phenomenon is poorly understood. The cellular events induced by this cytokine mediated by a number of specific signaling events. Therefore, we studied the effect of recombinant IFNalpha on tyrosine phosphorylation and proliferation of cytosolic proteins in human cell lines and in freshly isolated B-CLL cells in order to test the potential value of these events as a pretreatment test for IFNalpha in CLL. In human lymphoid cell lines, IFNalpha induced tyrosine phosphorylation of multiple cytosolic proteins in a time- and concentration-dependent manner. This effect correlated with its growth-inhibitory effect in almost all cell lines. In marked contrast, in freshly isolated B-CLL cells IFNalpha seemed to have both stimulatory and inhibitory effects on proliferation, but it consistently stimulated tyrosine phosphorylation. Moreover, the clinical response of B-CLL to IFNalpha did not correlate with the activation of tyrosine kinases nor with the inhibition of cell growth in vitro. Therefore, the assessment of IFNalpha-induced tyrosine phosphorylation of cytosolic phospho-proteins does not allow to predict the treatment response to IFNalpha in CLL patients.

Defects of beta 2-adrenergic signal transduction in chronic lymphocytic leukaemia: relationship to disease progression

The second messenger 3':5'-cyclic adenosine monophosphate (cAMP) inhibits the proliferation of human B lymphocytes. In lymphoid malignancies, cAMP levels or the number of beta 2-adrenergic receptors seem to be decreased. In order to explore this phenomenon further, the function of the beta 2-adrenergic receptor complex was examined in mononuclear leucocytes (MNLs) from patients with B-cell chronic lymphocytic leukaemia (CLL). Peripheral blood MNLs from 25 CLL patients (16 male, nine female: aged 62 +/- 9 years) and 10 healthy volunteers (seven male, three female; aged 47 +/- 19 years) were used. The binding characteristics of beta 2-adrenergic receptors (beta 2-AR) on MNLs were determined by radioligand binding assays with [125I]-cyanopindolol ([125I]-CYP). The number of high-affinity binding sites for [125I]-CYP was significantly lower in CLL patients (313 +/- 300 sites per cell; mean +/- SD) than in control subjects (1479 +/- 1268 sites per cell). Moreover, the density of beta 2-AR decreased with disease progression, from Binet stage A (371 +/- 236, n = 13) to B (236 +/- 136, n = 7) and C (141 +/- 59, n = 5) (P < 0.05; Kruskal-Wallis analysis). Functional analyses of the beta 2-AR complex were performed by measuring the cellular cAMP content of MNLs in response to different stimulators. The cAMP production of MNLs upon isoprenaline stimulation (ISO; 10 min, 10(-4) mol L-1) was slightly lower in CLL patients (12.5 +/- 7.04 pmol 10(-6) cells) than in control subjects (15.91 +/- 10.08 pmol 10(-6) cells), and decreased with CLL progression (stage A 14 +/- 7; stage B 13.66 +/- 3.91; stage C 3.07 +/- 0.79 pmol 10(-6) cells). In contrast, cAMP accumulation in response to cholera toxin (CHO; 10(-4) gml-1, 120 min) was not different in control subjects (70.07 +/- 31.30 pmol 10(-6) cells) and CLL patients (stage A 95.24 +/- 123.07, stage B 70.76 +/- 57.37, stage C 33.21 +/- 33.73 pmol 10(-6) cells). When stimulated with forskolin (100 mumol L-1, 15 min), control MNLs produced about ten-fold more cAMP than CLL MNLs (188.56 +/- 92.53 vs. 17.88 +/- 10.32 pmol 10(-6) cells); this response was not stage dependent. Taken together, the results show that the beta 2-AR transmembrane signalling is impaired in CLL patients. The correlation of some beta 2-AR signalling defects with disease progression suggests that they may contribute to the disease progression of CLL patients.

Randomized study of the combination of hydroxyurea and interferon alpha versus hydroxyurea monotherapy during the chronic phase of chronic myelogenous leukemia (CML Study II). The German CML Study Group

It is the long-term goal of the German CML Study Group and of the Süddeutsche Hämoblastosegruppe (SHG) to improve survival of patients with chronic myelogenous leukemia (CML). In a first randomized study (CML Study I) monotherapies with hydroxyurea or interferon alpha (IFN-alpha) were compared with a standard busulfan regimen with regard to duration of the chronic phase and survival. The main results of this study were published, 1-3 and a long-term follow up is planned. In a second randomized study the effect of the combination of IFN-alpha and hydroxyurea versus hydroxyurea monotherapy on survival is being investigated. This paper provides a first preliminary report on the study concept, patient recruitment, state of documentation and initial patients' characteristics 9 months after closure of the study.

Regulated plasma levels of colony-stimulating factors, interleukin-6 and interleukin-10 in patients with acute leukaemia and non-hodgkin's lymphoma undergoing cytoreductive chemotherapy

Endogenous plasma levels of granulocyte colony stimulating factor (G- CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF),IL-6 and IL-10 were measured in a total of 70 patients undergoing cytoreductive chemotherapy for treatment of acute leukaemia or non-Hodgkin's lymphomas. the diagnoses were acute myeloid leukaemia (AML; n = 30), acute lymphoblastic leukaemia (ALL;n=6), non-Hodgkin's lymphomas (NHL; n=11) and other malignant haematological disorders including myelodysplastic syndromes (n=23). After chemotherapy, plasma G-CSF was elevated (mean 5.6 ng/ml; range 1.2-10 ng/ml), and was inversely correlated with white blood cell counts (WBC) (r=-0.7, p<0.001). Occurrence of fever (T>38.0 degrees C) during severe myelosuppression (WBC<1x10(9)/1) was associated with an additional increase of G-CSF levels (P<0. (P<0.001). Plasma IL-6 correlated significantly with fever (range <1 to 1100 pg/ml, mean 130 pg/ml; r=0.5, P<0.001) but revealed only a weak association with WBC or platelet counts. In patients treated with recombinant G-CSF (n = 9), an association between IL-6 and fever was still observed after chemotherapy. During the nonfebrile status (total n = 242; AML n = 124), IL-6 levels remained <9 pg/ml in 90% of cases, whereas G-CSF increased with leucopenia (r = -0.72;P<0.001). In contrast, endogenous GM-CSF remained normal and IL-10 showed only a slight increase (21% of samples; maximum 22 pg/ml) in severe leucopenia. In particular, IL-10 levels did not correlate with G-CSF or IL-6 levels. We conclude that systemic release of G-CSF and IL-6 is obviously nit abrogated by cytoreductive chemotherapy in acute leukaemia and NHL may add to the therapeutic efficacy of recombinant cytokines. Also, plasma levels of G-, GM-CSF or IL-6 appear to be regulated by separate mechanisms.

[Agranulocytosis caused by infectious-toxic bone marrow damage after Borrelia infection]

A 19-year-old girl developed a fever of up to 40 degrees C and, during an episode of high fever, generalized seizures. Physical examination on admission was unremarkable, except for several small lymph nodes. Differential blood count showed a leukopenia (1700/microliters) with 14% stab and 7% segmented neutrophils. After initial clinical improvement she again became feverish and the differential count now showed agranulocytosis with a total white cell count of 1400/microliters. Because of the time of year and the geographic location borreliosis was now considered in the differential diagnosis. The antibody titre against Borrelia was raised to 1:64 (IgM) and 1:256 (IgG). Her condition and the differential blood count rapidly improved on intravenous antibiotic treatment with cefotiam (2 g two times daily) and gentamicin (120 mg two times daily), as well as filgrastim (granulocyte-colony stimulating factor) subcutaneously. Antibiotic treatment was continued after 6 days with oral ampicillin (1 g three times daily) for 3 weeks. Follow-up examination six weeks later found the patient to be symptom-free.

Reduced responsiveness of adenylate cyclase to forskolin in human lymphoma cells

The beta 2-adrenergic transmembrane signal transduction was investigated in malignant B-cells from 15 patients with low grade non-Hodgkin's lymphoma as compared with normal lymphocytes of seven healthy adults. The number of beta 2-adrenoceptors and the response of adenylate cyclase (AC) to isoproterenol were slightly decreased in lymphoma cells. The responsiveness of AC to forskolin was 8-fold lower in lymphoma cells, whereas the response to cholera toxin showed no difference. These findings demonstrate an impairment of the beta 2-adrenergic signal transduction in low grade lymphoma cells that particularly affects the function of AC. The comparison with forskolin resistant mutants of an adrenocortical tumor cell line, Y1 (Schimmer et al., J Biol Chem 262: 15521-15526, 1987), suggests that the availability of functional active alpha subunits of stimulatory G proteins (Gs) might be reduced in human B-cell lymphoma, although other mechanisms known to inhibit the AC activity might be involved.