Preoperative weight loss interventions before total hip and knee arthroplasty: a systematic review of randomized controlled trials

BACKGROUND

The high co-prevalence of obesity and end-stage osteoarthritis requiring arthroplasty, with the former being a risk factor for complications during arthroplasty, has led to increasing interest in employing preoperative weight loss interventions such as bariatric surgery and diet modification. However, the current evidence is conflicting, and this study aimed to investigate the effect of weight loss intervention before arthroplasty in prospective randomized controlled trials.

METHODS

Four electronic databases (MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials) were searched for prospective randomized controlled trials that compared weight loss interventions with usual care from inception to October 2023 by following the PRISMA guidelines. The Cochrane risk of bias tool and GRADE framework were used to assess the quality of the studies. Meta-analyses were performed when sufficient data were available from 2 or more studies.

RESULTS

Three randomized controlled trials involving 198 patients were identified. Two studies employed diet modification, and one study utilized bariatric surgery. All three studies reported significant reductions in body weight and body mass index (BMI), and intervention groups had fewer postoperative complications. There was no difference in the length of stay between the intervention group and the control group. Variable patient-reported outcome measures were used by different research groups.

CONCLUSION

Weight loss intervention can achieve significant reductions in body weight and body mass index before arthroplasty, with fewer postoperative complications reported. Further studies with different populations could confirm the effect of these interventions among populations with different obesity characteristics.

Prediction of Total Knee Arthroplasty Sizes with Demographics, including Hand and Foot Sizes

Anticipating implant sizes before total knee arthroplasty (TKA) allows the surgical team to streamline operations and prepare for potential difficulties. This study aims to determine the correlation and derive a regression model for predicting TKA sizes using patient-specific demographics without using radiographs. We reviewed the demographics, including hand and foot sizes, of 1,339 primary TKAs. To allow for comparison across different TKA designs, we converted the femur and tibia sizes into their anteroposterior (AP) and mediolateral (ML) dimensions. Stepwise multivariate regressions were performed to analyze the data. Regarding the femur component, the patient's foot, gender, height, hand circumference, body mass index, and age was the significant demographic factors in the regression analysis (R-square 0.541, p < 0.05). For the tibia component, the significant factors in the regression analysis were the patient's foot size, gender, height, hand circumference, and age (R-square 0.608, p < 0.05). The patient's foot size had the highest correlation coefficient for both femur (0.670) and tibia (0.697) implant sizes (p < 0.05). We accurately predicted the femur component size exactly, within one and two sizes in 49.5, 94.2, and 99.9% of cases, respectively. Regarding the tibia, the prediction was exact, within one and two sizes in 53.0, 96.0, and 100% of cases, respectively. The regression model, utilizing patient-specific characteristics, such as foot size and hand circumference, accurately predicted TKA femur and tibia sizes within one component size. This provides a more efficient alternative for preoperative planning.

Robotic arm-assisted unicondylar knee arthroplasty resulted in superior radiological accuracy: a propensity score-matched analysis

INTRODUCTION

Unicompartmental knee arthroplasty (UKA) is an effective surgical treatment for medial compartment arthritis of the knee, yet surgical outcomes are directly related to surgical execution. Robotic arm-assisted surgery aims to address these difficulties by allowing for detailed preoperative planning, real-time intraoperative assessment and haptic-controlled bone removal. This study aimed to compare the clinical and radiological outcomes between conventional manual mobile bearing and robot arm-assisted fixed bearing medial UKA in our local population.

MATERIALS AND METHODS

This is a retrospective case-control study of 148 UKAs performed at an academic institution with a minimum of 1-year follow-up. 74 robotic arm-assisted UKAs were matched to 74 conventional UKAs via propensity score matching. Radiological outcomes included postoperative mechanical axis and individual component alignment. Clinical parameters included a range of motion, Knee Society knee score and functional assessment taken before, 6 and 12 months after the operation.

RESULTS

Robot arm-assisted UKA produced a more neutral component coronal alignment in both femoral component (robotic -0.2 ± 2.8, manual 2.6 ± 2.3; P = 0.043) and tibial component (robotic -0.3 ± 4.0, manual 1.7 ± 5.3; P < 0.001). While the postoperative mechanical axis was comparable, robot arm-assisted UKA demonstrated a smaller posterior tibial slope (robotic 5.7 ± 2.7, manual 8.2 ± 3.3; P = 0.02). Clinical outcomes did not show any statistically significant differences.

CONCLUSION

Compared with conventional UKA, robotic arm-assisted UKA demonstrated improved component alignment and comparable clinical outcomes. Improved radiological accuracy with robotic-arm assistance demonstrated promising early results.

Metal-on-crosslinked polyethylene in total hip arthroplasty - an excellent combination at fifteen to twenty years of follow-up

PURPOSE

Cross-linked polyethylene (PE) has been used with great clinical success in total hip arthroplasty (THA) since its debut in the late 1990's. However, reports regarding this bearing couple near the end of its second decade of service are still scant. The aim of this study was to first determine the long term clinical and radiological results and second Investigate what factors affect wear rates using a metal-on-crosslinked PE bearing articulation.

METHODS

55 THAs using a single brand of cross-linked liner, cementless cup and 28 mm hip ball were performed in 44 patients. Age, sex, Charlson Comorbidity Index (CCI) and need for revision surgery were recorded. Linear and volumetric wear was determined using the Martell method.

RESULTS

Mean age at operation was 51.2 (29-73 ± 12.1) years. Mean duration of follow-up was 16.9 years (range 15.0-20.1 ± 1.1 years). Osteolysis was not present in the latest follow-up radiographs. Median linear and volumetric wear rate was 0.038 mm/year (95% CI 0.032-0.047) and 7.115mm3/year (95% CI 6.92-17.25) respectively. Acetabular component position was not found to be related to both linear and volumetric wear. No significant difference was found in the linear and volumetric wear rates of thinner and thicker liners (8 mm or below and > 8 mm) (p = 0.849 and p = 0.64 respectively).

CONCLUSION

Metal-on-crosslinked PE is associated with low linear and volumetric wear rates which has virtually obviated osteolysis and has translated to excellent survivorship even at long term follow up. In-vivo oxidation does not appear to be of clinical concern at this point.

The role of telemedicine in joint replacement surgery? An updated review

The usage of telemedicine and telehealth services has grown tremendously and has become increasingly relevant and essential. Technological advancements in current telehealth services have supported its use as a viable alternative tool to conduct visits for consultations, follow-up, and rehabilitation in total joint arthroplasty. Such technology has been widely implemented, particularly during the coronavirus 2019 (COVID-19) pandemic, to deliver postoperative rehabilitation among patients receiving total joint arthroplasty (TJA), further demonstrating its feasibility with a lower cost yet comparable clinical outcomes when compared with traditional care. There remains ample potential to utilize telemedicine for prehabilitation to optimize the preoperative status and postoperative outcomes of patients with osteoarthritis. In this review, various implementations of telemedicine within total joint arthroplasty and future application of telemedicine to deliver tele-prehabilitation in TJA are discussed.

Application of machine learning in the prevention of periprosthetic joint infection following total knee arthroplasty: a systematic review

BACKGROUND

Machine learning is a promising and powerful technology with increasing use in orthopedics. Periprosthetic joint infection following total knee arthroplasty results in increased morbidity and mortality. This systematic review investigated the use of machine learning in preventing periprosthetic joint infection.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed was searched in November 2022. All studies that investigated the clinical applications of machine learning in the prevention of periprosthetic joint infection following total knee arthroplasty were included. Non-English studies, studies with no full text available, studies focusing on non-clinical applications of machine learning, reviews and meta-analyses were excluded. For each included study, its characteristics, machine learning applications, algorithms, statistical performances, strengths and limitations were summarized. Limitations of the current machine learning applications and the studies, including their 'black box' nature, overfitting, the requirement of a large dataset, the lack of external validation, and their retrospective nature were identified.

RESULTS

Eleven studies were included in the final analysis. Machine learning applications in the prevention of periprosthetic joint infection were divided into four categories: prediction, diagnosis, antibiotic application and prognosis.

CONCLUSION

Machine learning may be a favorable alternative to manual methods in the prevention of periprosthetic joint infection following total knee arthroplasty. It aids in preoperative health optimization, preoperative surgical planning, the early diagnosis of infection, the early application of suitable antibiotics, and the prediction of clinical outcomes. Future research is warranted to resolve the current limitations and bring machine learning into clinical settings.

Pain Relief After Total Knee Arthroplasty with Intravenous and Periarticular Corticosteroid: A Randomized Controlled Trial

BACKGROUND

Total knee arthroplasty (TKA) is a cost-effective procedure, but it is also associated with substantial postoperative pain. The present study aimed to compare pain relief and functional recovery after TKA among groups that received intravenous corticosteroids, periarticular corticosteroids, or a combination of both.

METHODS

This randomized, double-blinded clinical trial in a local institution in Hong Kong recruited 178 patients who underwent primary unilateral TKA. Six of these patients were excluded because of changes in surgical technique; 4, because of their hepatitis B status; 2, because of a history of peptic ulcer; and 2, because they declined to participate in the study. Patients were randomized 1:1:1:1 to receive placebo (P), intravenous corticosteroids (IVS), periarticular corticosteroids (PAS), or a combination of intravenous and periarticular corticosteroids (IVSPAS).

RESULTS

The pain scores at rest were significantly lower in the IVSPAS group than in the P group over the first 48 hours (p = 0.034) and 72 hours (p = 0.043) postoperatively. The pain scores during movement were also significantly lower in the IVS and IVSPAS groups than in the P group over the first 24, 48, and 72 hours (p ≤ 0.023 for all). The flexion range of the operatively treated knee was significantly better in the IVSPAS group than in the P group on postoperative day 3 (p = 0.027). Quadriceps power was also greater in the IVSPAS group than in the P group on postoperative days 2 (p = 0.005) and 3 (p = 0.007). Patients in the IVSPAS group were able to walk significantly further than patients in the P group in the first 3 postoperative days (p ≤ 0.003). Patients in the IVSPAS group also had a higher score on the Elderly Mobility Scale than those in the P group (p = 0.036).

CONCLUSIONS

IVS and IVSPAS yielded similar pain relief, but IVSPAS yielded a larger number of rehabilitation parameters that were significantly better than those in the P group. This study provides new insights into pain management and postoperative rehabilitation following TKA.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Isolated Liner Exchange in Total Hip Arthroplasty at a Mean of 13 Years of Follow-up: Does Fixation Technique Matter?

BACKGROUND

Isolated liner exchange is an option to address polyethylene wear after total hip arthroplasty (THA). The liner can be fixed with either the original locking mechanism or cemented into the acetabular cup. Whether the method used for liner fixation has any bearing on the outcomes in the first and second decade after surgery is still unclear.

METHODS

Data for all patients who had undergone isolated liner exchange surgery in our institution between April 1995 and January 2015 were retrieved. Patients were classified according to the type of polyethylene liner (conventional or highly crosslinked polyethylene) and the locking mechanism used (original locking mechanism or cemented). Survivorship and revision rates were compared among different subgroups. A total of 118 isolated liner exchanges were performed and patients had a mean duration of follow-up of 13 years (range, 5 to 25).

RESULTS

Overall estimated mean survivorship was 17 years. Use of highly crosslinked polyethylene (HXLPE) had a lower re-revision rate compared to conventional liners (10.5 versus 46.9%) (P < .001). The re-revision rate of exchanges using HXLPE was not affected by the type of fixation (original locking mechanism 11.1 versus cement 10.0%, P = .868). Conversely, using the original locking mechanism with a conventional liner had a higher re-revision rate compared to cemented conventional liners (58.3 versus 12.5%) (P = .024).

CONCLUSION

HXLPE liners should be used in insert exchange surgery whenever possible. Re-revision rate of exchanges using HXLPE was not affected by the fixation technique used. Cementing an insert into an acetabular component is associated with good survivorship at a mean of 13 years follow-up.

Artificial intelligence in diagnosis of knee osteoarthritis and prediction of arthroplasty outcomes: a review

Background

Artificial intelligence is an emerging technology with rapid growth and increasing applications in orthopaedics. This study aimed to summarize the existing evidence and recent developments of artificial intelligence in diagnosing knee osteoarthritis and predicting outcomes of total knee arthroplasty.

Methods

PubMed and EMBASE databases were searched for articles published in peer-reviewed journals between January 1, 2010 and May 31, 2021. The terms included: ‘artificial intelligence’, ‘machine learning’, ‘knee’, ‘osteoarthritis’, and ‘arthroplasty’. We selected studies focusing on the use of AI in diagnosis of knee osteoarthritis, prediction of the need for total knee arthroplasty, and prediction of outcomes of total knee arthroplasty. Non-English language articles and articles with no English translation were excluded. A reviewer screened the articles for the relevance to the research questions and strength of evidence.

Results

Machine learning models demonstrated promising results for automatic grading of knee radiographs and predicting the need for total knee arthroplasty. The artificial intelligence algorithms could predict postoperative outcomes regarding patient-reported outcome measures, patient satisfaction and short-term complications. Important weaknesses of current artificial intelligence algorithms included the lack of external validation, the limitations of inherent biases in clinical data, the requirement of large datasets in training, and significant research gaps in the literature.

Conclusions

Artificial intelligence offers a promising solution to improve detection and management of knee osteoarthritis. Further research to overcome the weaknesses of machine learning models may enhance reliability and allow for future use in routine healthcare settings.

The application of close incisional negative pressure wound therapy in revision arthroplasty among asian patients: a comparative study

INTRODUCTION

Peri-prosthetic joint infection (PJI) was one of the main causes of revision of arthroplasty. In order to reduce wound complications and surgical site infections, close incisional negative pressure wound therapy (ciNPWT) has been introduced into arthroplasty. This study was designed to review the clinical benefits of the application of ciNPWT in revision arthroplasty.

METHODS

This was a single-centre retrospective comparative study approved by the Institutional Review Board. Patients, who underwent revision total knee arthroplasty or revision total hip arthroplasty at the author's institution from January 2016 to October 2019, were included in this study. The ciNPWT cohort included all eligible patients, who underwent operations from January 2018 to October 2019, with the use of ciNPWT(n = 36). The control cohort included all eligible patients, who underwent operations from January 2016 to December 2017 with the use of conventional dressing(n = 48). The incidences of wound complications were compared to both cohorts.

RESULTS

There was a statistically significant difference in the rate of superficial surgical site infection (SSI) between control cohort and ciNPWT cohort (12.5% in control vs 0% in ciNPWT, p = 0.035). However, there was no statistically significance of the overall wound complication rate for both cohorts. (14.6% in control vs 8.3% in ciNPWT, p = 0.504).

CONCLUSIONS

The application of ciNPWT could result in a lower rate of superficial surgical site infection when compared with conventional dressing among the patients undergoing revision total knee and total hip arthroplasties.

TRIAL REGISTRATION

UW19-706.

Total knee arthroplasty is safe for patients aged ≥80 years in Hong Kong

INTRODUCTION

Total knee arthroplasty (TKA) is an efficacious operation that improves pain and function in patients with knee arthritis. Because of the population ageing trend in Hong Kong, there is a need to determine the safety profile of TKA in older patients. This study examined the age of patients who underwent TKA in the past 10 years in Hong Kong; the aim was to investigate the mortality safety profile and clinical outcomes of TKA in patients aged ≥80 years.

METHODS

This study included all patients who underwent primary TKA in the Hospital Authority (HA) from 2010 to 2019. Incidences of 30-day, 90-day, and 1-year mortality were established. Clinical outcomes of patients aged ≥80 years in one cluster of HA hospitals were assessed.

RESULTS

Between 2010 and 2019, 25 040 TKA procedures were conducted in all HA hospitals; 2491 were conducted in patients aged ≥80 years. The median age at operation was higher during 2015-2019 than during 2010-2014 (70 vs 69 years; P<0.001); furthermore, an increase was observed in the proportion of patients aged ≥80 years at the time of operation. Incidences of 30-day, 90-day, and 1-year mortality were 0.156%, 0.35%, and 1.09%, respectively.

CONCLUSIONS

In this first study to examine the safety profile of TKA in older patients in Hong Kong, the mean age at the time of TKA and proportion of patients aged ≥80 years have steadily risen in the past decade. Even in older patients, TKA is a reasonably safe procedure.

Lessons learnt from the impact of COVID-19 on arthroplasty services in Hong Kong: how to prepare for the next pandemic?

BACKGROUND

Arthroplasty services worldwide have been significantly disrupted by the pandemic of coronavirus disease 2019 (COVID-19). This retrospective comparative study aimed to characterize its impact on arthroplasty services in Hong Kong.

METHODS

From January 1 to June 30, 2020, the patients of "COVID-19 cohort" underwent elective total hip or knee replacement in Hong Kong public hospitals. The cohort was compared to the "control cohort" during the same period in 2019. Data analysis was performed to compare the two cohorts' numbers of operations, hospital admission, orthopaedic clinic attendances, and waiting time.

RESULTS

A total of 33,111 patient episodes were analyzed. During the study period, the elective arthroplasty operations and hospitalizations decreased by 53 and 54%, respectively (P < 0.05). Reductions were most drastic from February to April, with surgical volume declining by 86% (P < 0.05). The primary arthroplasty operations decreased by 91% (P < 0.05), while the revision operations remained similar. Nevertheless, 14 public hospitals continued performing elective arthroplasty for patients with semi-urgent indications, including infection, progressive bone loss, prosthesis loosening, dislocation or mechanical failure of arthroplasty, and tumor. At the institution with the highest arthroplasty surgical volume, infection (28%) was the primary reason for surgery, followed by prosthesis loosening (22%) and progressive bone loss (17%). The orthopaedic clinic attendances also decreased by 20% (P < 0.05). Increases were observed in waiting time and the total number of patients on the waiting list for elective arthroplasty.

CONCLUSIONS

Despite the challenges, public hospitals in Hong Kong managed to continue providing elective arthroplasty services for high-priority patients. Arthroplasty prioritization, infection control measures, and post-pandemic service planning can enhance hospital preparedness to mitigate the impact of current and future pandemics.

Use of a modular hip dual-mobility articulation in patients with high risk of dislocation: a relatively small-sized acetabulum in Asian patients may limit its use

BACKGROUND

Dual-mobility hip component is widely used in Europe and North America, because it effectively reduces hip dislocation in primary and revision total hip arthroplasties. However, reports were limited on the use of dual-mobility articulation in Asian populations.

PURPOSE

The aim of this retrospective study was to review the use of modular dual-mobility hip articulation in Asian patients with the high risk factor for hip dislocation. We also discussed the potential concern on the use of dual-mobility articulation in Asian patients.

METHODS

From Jan 2018 to June 2019, 17 patients were included in this study. The mean age of the patients was (73.8 ± 9.5) years (range: 57-88 years). The mean size of acetabular cup and modular DM liner were (49.5 ± 3.4) mm (range, 46-58 mm) and (40.7 ± 3.4) mm (range, 38-48 mm), respectively. The mean follow-up period was (15.8 ± 3.9) months (range, 11-24 months). The primary outcome was the rate of hip dislocation. The secondary outcomes included the Harris Hip Score. Differences were considered statistically significant at p < 0.05.

RESULTS

Hip dislocation, loosening, peri-prosthetic fractures, or intra-prosthetic dislocation was not found in the series. The mean preoperative and postoperative Harris Hip Scores were 42.2 ± 17.2 (range, 15-80) and 74.7 ± 13.5 (range, 52-97), respectively, giving a mean improvement of 32.5 ± 17.2 (range, 4-72). The improvement was statistically significant (p < 0.05).

CONCLUSIONS

In Asian patients with high risk of hip dislocation, the use of modular dual-mobility hip component produces promising outcomes without hip dislocation, but the relatively small-sized acetabulum may limit it widespread application in other populations worldwide.

TRIAL REGISTRATION

HKUCTR-2913 .

Hong Kong Geriatrics Society and Hong Kong Urological Association consensus on personalised management of male lower urinary tract symptoms in the era of multiple co-morbidities and polypharmacy

Lower urinary tract symptoms (LUTS) are common complaints of adult men. Benign prostatic hyperplasia (BPH) represents the most common underlying cause. As the incidence of BPH increases with age, and pharmacological treatment is a major part of the disease's management, the majority of patients with LUTS are managed by primary care practitioners. There are circumstances in which specialist care by urologists or geriatricians is required, such as failure of medical treatment, adverse effects from medical treatment, or complications from BPH. Referral choices can be confusing to patients and even practitioners in different specialties under such circumstances. There is currently no local consensus about the diagnosis, medical management, or referral mechanism of patients with BPH. A workgroup was formed by members of The Hong Kong Geriatrics Society (HKGS) and the Hong Kong Urological Association (HKUA) to review evidence for the diagnosis and medical treatment of LUTS. A consensus was reached by HKGS and HKUA on an algorithm for the flow of male LUTS care and the use of uroselective alpha blockers, antimuscarinics, beta-3 adrenoceptor agonists, and 5α-reductase inhibitors in the primary care setting. This consensus by HKGS and HKUA provides a new management paradigm of male LUTS.

Preoperative optimization to prevent periprosthetic joint infection in at-risk patients

Periprosthetic joint infection (PJI) remains an important complication with devastating consequences after total joint arthroplasties. With the increasing number of arthroplasties worldwide, the number of PJI will increase correspondingly with a significant economic burden to our healthcare system. It is likely impossible to completely eradicate PJI; hence, assessment and optimization of its risk factors to preventing such a disastrous complication will be the key. There are many strategies to prevent PJI in the preoperative, intraoperative, or postoperative phases. The preoperative assessment provides a unique opportunity to screen and diagnose underlying comorbidities and optimize modifiable risk factors before elective surgeries. In this review, we will focus on current literature in preoperative assessment of various modifiable risk factors and share the experience and practical approach in our institution in preoperative optimization to reduce PJI in total joint arthroplasties.

Effect of SARS and COVID-19 outbreaks on urology practice and training

INTRODUCTION

The objective was to investigate the changes in urology practice during coronavirus disease 2019 (COVID-19) pandemic with a perspective from our experience with severe acute respiratory syndrome (SARS) in 2003.

METHODS

Institutional data from all urology centres in the Hong Kong public sector during the COVID-19 pandemic (1 Feb 2020-31 Mar 2020) and a non-COVID-19 control period (1 Feb 2019-31 Mar 2019) were acquired. An online anonymous questionnaire was used to gauge the impact of COVID-19 on resident training. The clinical output of tertiary centres was compared with data from the SARS period.

RESULTS

The numbers of operating sessions, clinic attendance, cystoscopy sessions, prostate biopsy, and shockwave lithotripsy sessions were reduced by 40.5%, 28.5%, 49.6%, 44.8%, and 38.5%, respectively, across all the centres reviewed. The mean numbers of operating sessions before and during the COVID-19 pandemic were 85.1±30.3 and 50.6±25.7, respectively (P=0.005). All centres gave priority to cancer-related surgeries. Benign prostatic hyperplasia-related surgery (39.1%) and ureteric stone surgery (25.5%) were the most commonly delayed surgeries. The degree of reduction in urology services was less than that during SARS (47.2%, 55.3%, and 70.5% for operating sessions, cystoscopy, and biopsy, respectively). The mean numbers of operations performed by residents before and during the COVID-19 pandemic were 75.4±48.0 and 34.9±17.2, respectively (P=0.002).

CONCLUSION

A comprehensive review of urology practice during the COVID-19 pandemic revealed changes in every aspect of practice.

Is there difference and correlation between medial and lateral tibial plateau coronal obliquity in native knee? A radiographic study

Background/Purpose

Knee joint line is commonly defined as a tangent to medial and lateral tibial plateaus in various radiographic measurements. We aim to investigate radiographic differences between medial and lateral knee joint line coronal obliquity. It has significant implication on radiographic analysis following unicompartmental knee arthroplasty.

Methods

We analysed the knee radiographs of 48 young patients (mean age 25.1 + /-5.6 years) with 50 anterior cruciate ligament-deficient knees. Medial and lateral tibial plateau coronal obliquity were defined as angles between femoral knee joint line and the tangent to articular surface of each tibial plateau. Mediolateral differences and linear correlation were analysed.

Results

Significant difference was found between medial (mean = -1.5, SD = 2.4 degrees) and lateral obliquity (mean =  + 0.6, SD = 3.0 degrees) ( p < 0.001). The mean mediolateral difference was 3.1 degrees (SD = 2.8, range 0–11.8 degrees), without significant correlation (r = 0.085, p = 0.56).

Conclusion

Mediolateral differences exist in knee joint line obliquity. Each compartment should be considered separately when measuring knee joint line obliquity.

Universal haemoglobin A1c screening reveals high prevalence of dysglycaemia in patients undergoing total knee arthroplasty

INTRODUCTION

Diabetes mellitus is an established modifiable risk factor for periprosthetic joint infection (PJI). Haemoglobin A1c (HbA1c) is a glycaemic marker that correlates with diabetic complications and PJI. As diabetes and prediabetes are frequently asymptomatic, and there is increasing evidence to suggest a correlation between dysglycaemia and osteoarthritis, it is reasonable to provide HbA1c screening before total knee arthroplasty (TKA). The aim of the present study was to determine the prevalence of dysglycaemia in patients who underwent TKA and investigate whether HbA1c screening and optimisation of glycaemic control before TKA affects the incidence of PJI after TKA.

METHODS

Patients who underwent primary TKA before and after routine HbA1c screening was introduced in our unit were reviewed. Prediabetes and diabetes were defined according to the American Diabetes Association. Patients with HbA1c ≥7.5% were referred to an endocrinologist for optimisation of glycaemic control before TKA. The incidence PJI, defined according to the Musculoskeletal Infection Society criteria, was recorded.

RESULTS

A total of 729 patients (934 knees) had HbA1c screening before TKA. Of them, 17 (2.3%) and 184 (25.2%) patients had known prediabetes and diabetes, respectively, and 265 (36.4%) and 12 (1.6%) had undiagnosed prediabetes and diabetes, respectively. The incidence of PJI was significantly lower in all patients who received HbA1c screening compared with those who did not (0.2% vs 1.02%, P=0.027).

CONCLUSION

Screening for HbA1c before TKA provides a cost-effective opportunity to identify undiagnosed dysglycaemia. Patients identified as having dysglycaemia receive modified treatment, significantly reducing the rate of PJI when compared with historical controls.

How well do elderly patients do after total knee arthroplasty in the era of fast-track surgery?

Introduction

Total knee arthroplasty (TKA) in the elderly population is becoming increasingly prevalent. This study aimed to compare outcomes of patients aged ≥80 years with those aged < 80 years at time of TKA and to assess the effect of fast track peri-operative care on outcomes in the elderly.

Materials and methods

422 TKAs were performed in aged ≥80 at the time of surgery between 2009 and 2018. A control group aged < 80 years (37–79 +/− 7.6) was established. Peri-operative mortality, complications, 30-day re-admission, length of stay (LOS) and rehabilitation parameters were recorded.

Results

Mean age at operation for the ≥80’s group and control group was 82.7 (80–93+/− 2.5) and 69.3 (37–79+/− 7.6) years respectively. Post-operative Knee Society Functional Assessment (KSFA) scores were higher in the control group (49 vs. 57, p = 0.003). Average LOS was longer in the ≥80’s group (17.2 vs. 12.4 days respectively, p < 0.01). Mortality within 3 months of operation was 0.7% in the ≥80 group and 0% in the control group. Incidence of complications was comparable between the two groups at 12.8 and 12.9% for the group ≥80’s and control groups respectively (p = 0.962). Patients ≥80 years, receiving fast track peri-operative care had significantly shorter LOS and higher post-operative KSFA scores at all time points post-operation and shorter LOS (p < 0.01) compared to those who received conventional rehabilitation. LOS was longer in the ≥80’s group, which was likely related to higher levels of comorbidities. Complications were comparable in the two groups but were more severe in the elderly. Mortality rate after TKA was very low even in those over the age of 80. Younger patients benefited more in terms of functional improvement after TKA.

Conclusion

TKA is a safe and efficacious procedure for the elderly. More severe complications, longer length of stay and smaller gains in functional improvement can be expected in the elderly compared to younger patients. Fast track peri-operative care is useful in improving outcomes after TKA for elderly patients.

Blood transfusions in total knee arthroplasty: a retrospective analysis of a multimodal patient blood management programme

PURPOSE

Transfusion is associated with increased perioperative morbidity and mortality in patients undergoing total knee arthroplasty (TKA). Patient blood management (PBM) is an evidence-based approach to maintain blood mass via haemoglobin maintenance, haemostasis optimisation, and blood loss minimisation. The aim of the present study was to assess the effectiveness of a multimodal PBM approach in our centre.

METHODS

This was a single-centre retrospective study of patients who underwent primary TKA in Queen Mary Hospital in Hong Kong in 2013 or 2018, using data from the Clinical Data Analysis and Reporting System and a local joint registry database. Patient demographics, preoperative haemoglobin, length of stay, readmission, mean units of transfusion, postoperative prosthetic joint infection, and mortality data were compared between groups.

RESULTS

In total, 262 and 215 patients underwent primary TKA in 2013 and 2018, respectively. The mean transfusion rate significantly decreased after PBM implementation (2013: 31.3%; 2018: 1.9%, P<0.001); length of stay after TKA also significantly decreased (2013: 14.49±8.10 days; 2018: 8.77±10.14 days, P<0.001). However, there were no statistically significant differences in readmission, early prosthetic joint infection, or 90-day mortality rates between the two groups.

CONCLUSION

Our PBM programme effectively reduced the allogeneic blood transfusion rate in patients undergoing TKA in our institution. Thus, PBM should be considered in current TKA protocols to reduce rates of transfusions and related complications.

Unicompartmental knee arthroplasties in Hong Kong: 15 years of experience in a teaching hospital

INTRODUCTION

Osteoarthritis (OA) of the knee is a growing problem in an aging population. Unicompartmental knee arthroplasties (UKA) have been used for management of isolated OA of the medial tibiofemoral joint. This is the first study on the usage of UKA in Hong Kong.

METHODS

Retrospective analysis of all patients undergoing medial compartment UKA in a tertiary referral center since 2003. Preoperative and postoperative International Knee Society Knee Scores (KSKS) and Knee Societal Functional Assessment (KSFA) scores, range of motion, flexion deformity, and lower limb mechanical alignment were measured. Statistical analysis using paired sample t-tests was performed. Revision operations, rate of revisions, and causes of failure were analyzed. Univariate and multivariate logistic regression analyses of risk factors for revision operation were performed against patient demographics, type of prosthesis, postoperative alignment, and degree of correction.

RESULTS

There were 94 UKA performed with an average follow-up of 4.3 years (range: 0.5-15.2 years). The KSKS and KSFA scores improved from 54.5 and 54.0 to 85.6 and 64.5 ( p < 0.01), respectively. There was no significant improvement in the range of motion ( p = 0.87) and fixed flexion deformity ( p = 0.14). Mechanical alignment improved from 172.1° to 174.9° varus postoperatively ( p < 0.01). Six cases required revision operation with a revision rate of 1.50 per 100 observed component years. Causes of revision included two cases of tibial tray loosening and one case each of progressive OA, mechanical failure, persistent pain, and infection. Logistic regression analysis for risk factors showed no statistical significance.

CONCLUSIONS

UKA offers good functional improvement but further long-term studies are required to evaluate survivorship.

Emergency attendances and hospitalisations for complications after transrectal ultrasound-guided prostate biopsies: a five-year retrospective multicentre study

INTRODUCTION

Transrectal ultrasound-guided (TRUS) prostate biopsy is an established procedure for diagnosis of prostate cancer. Complications after TRUS biopsy are not well reported in Hong Kong. This study evaluated the 5-year incidences of TRUS biopsy complications and potential risk factors for those complications.

METHODS

This was a retrospective review of biopsies performed from 2013 to 2017 in two local hospitals, using data retrieved from electronic medical records. The primary outcome was the occurrence of complications requiring either emergency attendances or hospitalisations within 30 days after biopsy. Potential risk factors were examined using multiple logistic regression analysis.

RESULTS

In total, 1699 men were included (mean age ± standard deviation: 67 ± 7 years; median prostate-specific antigen level: 7.9 μg/L [interquartile range, 5.5-12.6 μg/L]); 4.3% had pre-biopsy bacteriuria. Overall, 5.7% and 3.8% of post-biopsy complications required emergency attendances and hospitalisations, respectively. Gross haematuria and rectal bleeding requiring emergency attendances developed in 2.1% and 0.4% of men; 0.8% and 0.4% required hospitalisations. Furthermore, 1.5% of men developed acute urinary retention requiring hospitalisations; 1.9% and 1.2% had post-biopsy infections requiring emergency attendances and hospitalisations, respectively, and 0.9% had urosepsis requiring hospitalisations. Prostate volume >48 cc was associated with an increased risk of post-biopsy retention (odds ratio 2.75, 95% confidence interval: 1.23-4.17).

CONCLUSIONS

The rate of overall complications after TRUS biopsy was low. The most common complications requiring emergency attendances and hospitalisations were gross haematuria and acute urinary retention, respectively. Prostate volume >48 cc increased the risk of post-biopsy urinary retention.

Ten- to Sixteen-Year Follow-Up of Highly Cross-Linked Polyethylene in Total Hip Arthroplasty: What Factors Affect Wear?

BACKGROUND

Increase in acetabular cup abduction in total hip arthroplasty (THA) using conventional polyethylene is associated with greater linear wear. Whether this relationship holds true for highly crosslinked liners, particularly with long-term follow-up, is still controversial. The effect of liner thickness on wear of highly cross-linked liners also remains to be clarified.This study sought to determine (1) the long-term clinical and radiological performance of highly cross-linked polyethylene in THA and (2) the effect of acetabular component positioning, polyethylene thickness, and patient demographics on wear.

METHODS

Ninety-three THAs using a 28-mm hip ball, single brand of highly cross-linked polyethylene liner, and cementless cup were performed in 87 patients. Clinical outcomes were evaluated using the Harris Hip Score and need for revision surgery. Linear and volumetric wear, presence of osteolysis, and cup abduction angle were assessed.

RESULTS

The mean age at operation was 51.4 years. The mean duration of follow-up was 12.7 years (10-16 years). Patients aged >50 years had higher rates of linear wear than those aged <50 years (P = .015). Positive correlation was found between cup abduction angle (P = .014) and cup version (P = .035) with a linear wear rate. Thinner liners (≤7 mm) had similar rates of linear and volumetric wear as thicker liners (≥8 mm) (P = .447).

CONCLUSION

This is the only study to demonstrate a positive significant relationship between cup abduction angle and version with linear wear rate in THA with at least 10 years of follow-up. Liner thickness was not found to affect wear rates.

Effects of intermittent lower limb ischaemia on coronary blood flow and coronary resistance in pigs

AIM

Intermittent limb ischaemia prior to cardiac ischaemia is a cardioprotective stimulus. This study was to investigate whether this peripheral stimulus had any effects on basal coronary blood flow and resistance, and to explore its potential mechanisms by studying the effect of femoral nerve transection and Katp blockade by glibenclamide.

METHODS

Remote ischaemic preconditioning (rIPC) was induced by four 5-min cycles of lower limb ischaemia. Coronary resistance was measured using standard formulae and coronary blood flow in the left anterior descending artery (LAD) by a flow probe. In experiment 1, coronary ischaemia was induced by inflation of a cuff placed around the mid-LAD, and inflated until cessation of flow. Left ventricular (LV) function was assessed using dp/dt and Tau at 1 and 30 min of ischaemia. Experiment 1: 20 pigs were randomized to control (n = 6), rIPC (n = 7) or femoral nerve transection + rIPC (n = 7) groups. The femoral nerve was transected before the rIPC protocol. All data were collected at fixed heart rates of 120 bpm. Coronary resistance was decreased and flow was increased significantly by the rIPC stimulus (P = 0.003, P = 0.016, paired t-test), and these changes were preserved after femoral nerve transection. Experiment 2: 19 pigs were randomized to control (n = 5), rIPC (n = 8) or glibenclamide-treated rIPC (n = 6) groups. Data were collected at baseline, and during incremental pacing between 120 and 180 bpm.

RESULTS

Experiment 1: Coronary resistance was decreased and flow was increased significantly by rIPC stimulus (P = 0.003, P = 0.016, paired t-test), and these changes were preserved after femoral nerve transaction. rIPC was associated with superior LV function (dp/dt(max)) at 30 min, compared with controls and the rIPC + femoral nerve transaction group. Experiment 2: Coronary resistance was significantly lower, and LAD flow was significantly higher in rIPC group (P < 0.0001, P = 0.0008, two-way anova). These effects were reversed in the glibenclamide group.

CONCLUSION

The rIPC stimulus leads to reduced coronary resistance and increased flow. This effect, while modified by glibenclamide appears to be a generic effect of remote ischaemia rather than a direct preconditioning effect.

Prevalence of workplace violence against nurses in Hong Kong

OBJECTIVES

To determine the prevalence and nature of workplace violence against nurses, and how nurses deal with such aggression; and to identify the risk factors related to violence in the hospital environment.

DESIGN

Cross-sectional questionnaire study.

SETTING

University teaching hospital, Hong Kong.

PARTICIPANTS

All nursing staff in the hospital, except nurses who were unable to read Chinese or who did not have patient contact (eg those worked in administrative positions), were invited to complete a questionnaire.

MAIN OUTCOME MEASURES

Demographic data of the respondents, incidence of and risk factors contributing to workplace violence.

RESULTS

A total of 420 nurses returned the completed questionnaire (response rate, 25%). Three hundred and twenty (76%; 95% confidence interval, 72-80%) nurses reported abuse of any kind--verbal abuse, 73%; bullying, 45%; physical abuse, 18%; and sexual harassment, 12%. Most (82%) nurses who experienced verbal abuse tended to confide in friends, family members, or colleagues. Some (42%) ignored the incident. Risk factors for workplace violence included: working in male wards and in certain specialties such as the Accident and Emergency Department, Community Nursing Service, and the Orthopaedics and Traumatology Department.

CONCLUSION

Workplace violence against nurses is a significant problem in Hong Kong. Further large-scale studies should be conducted to more closely examine the problem.

Genomic instability and alterations in Apc, Mcc and Dcc in Hong Kong patients with colorectal carcinoma

Our aim was to reveal the significance of tumor-suppressor genes and genomic instability in 99 Hong Kong Chinese colorectal carcinoma (CRC) patients by PCR-LOH analysis and PCR-PTT assay. The frequencies of allelic loss of Apc, Mcc and Dcc and of APC truncation were 31.3% (15/48), 11.6% (5/43), 44.4% (20/45) and 46/93 (49.5%), respectively. The frequency of Apc LOH was similar to, the Mcc LOH was lower than, and the Dcc LOH was higher than that reported for Caucasians and Japanese. In Hong Kong CRC patients, the replication error-positive (RER(+)) phenotype occurred with a frequency of 10% (10/99), which was similar to other results using microsatellite markers where RER(+) frequencies ranged from 11% to 28%. The rates of genetic alteration in RER(+) tumors were lower in tumors harboring p53, Mcc and Dcc alterations; similar in Apc; and higher in Ki-ras tumors compared with RER(-) tumors, though these differences did not achieve statistical significance. None of the biomarkers examined were predictive of survival independently, but strong trends confirming earlier observations of associations between RER(+) phenotypes with proximal tumor location and poorly differentiated tumor status were noted. The RER(+) phenotype was correlated significantly to the less aggressive Duke's stage B and improved prognosis. Additionally, tumors with RER(+) phenotypes were positively correlated with young age and sex. Our results support the observation that a subset of younger male CRC patients in Hong Kong may develop CRC via the RER pathway and show differences in RER status and sex. A significantly higher percentage of older Hong Kong Chinese CRC patients had APC truncations. Int. J. Cancer (Pred. Oncol.) 84:404-409, 1999.

Genomic instability and alterations in Apc, Mcc and Dcc in Hong Kong patients with colorectal carcinoma

Our aim was to reveal the significance of tumor-suppressor genes and genomic instability in 99 Hong Kong Chinese colorectal carcinoma (CRC) patients by PCR-LOH analysis and PCR-PTT assay. The frequencies of allelic loss of Apc, Mcc and Dcc and of APC truncation were 31.3% (15/48), 11.6% (5/43), 44.4% (20/45) and 46/93 (49.5%), respectively. The frequency of Apc LOH was similar to, the Mcc LOH was lower than, and the Dcc LOH was higher than that reported for Caucasians and Japanese. In Hong Kong CRC patients, the replication error-positive (RER(+)) phenotype occurred with a frequency of 10% (10/99), which was similar to other results using microsatellite markers where RER(+) frequencies ranged from 11% to 28%. The rates of genetic alteration in RER(+) tumors were lower in tumors harboring p53, Mcc and Dcc alterations; similar in Apc; and higher in Ki-ras tumors compared with RER(-) tumors, though these differences did not achieve statistical significance. None of the biomarkers examined were predictive of survival independently, but strong trends confirming earlier observations of associations between RER(+) phenotypes with proximal tumor location and poorly differentiated tumor status were noted. The RER(+) phenotype was correlated significantly to the less aggressive Duke's stage B and improved prognosis. Additionally, tumors with RER(+) phenotypes were positively correlated with young age and sex. Our results support the observation that a subset of younger male CRC patients in Hong Kong may develop CRC via the RER pathway and show differences in RER status and sex. A significantly higher percentage of older Hong Kong Chinese CRC patients had APC truncations. Int. J. Cancer (Pred. Oncol.) 84:404-409, 1999.

L-myc genotypes in Hong Kong Chinese colorectal carcinoma patients

L-myc genotypes have been correlated with prognosis in different human tumors. Its role in colorectal carcinoma (CRC) is still unclear. This study aimed to assess the L-myc genotypes in 99 Hong Kong Chinese CRC patients by PCR-RFLP techniques. The results obtained were correlated with clinical, histological and pathological parameters and genetic alterations. The observed frequency of L-myc genotypes (LL:LS:SS) was 27:46:26. The ratio of S to L alleles was 0.51:0.49. Distribution of L-myc genotypes and alleles in Hong Kong Chinese CRC was similar to that of healthy Chinese and CRC patients of other ethnic origins. The homozygous SS genotype was significantly associated with Dukes' stages C versus B. Other parameters including sex, differentiation status and survival, and genetic alterations such as p53 and Ki-ras mutations and Dcc LOH had no significant association with L-myc SS genotype.

Ki-ras codon 12 point mutational activation in Hong Kong colorectal carcinoma patients

This study investigated the frequency and importance of Ki-ras codon 12 mutations in 99 Hong Kong Chinese colorectal carcinoma specimens by allele-specific oligonucleotide hybridization. The frequency of mutations detected was 30% and the most common mutation observed resulted in aspartic acid substitutions. Previous studies showed that specific Ki-ras mutations have been significantly associated with prognosis. Ki-ras codon 12 point mutational activation in CRC was significantly associated with the differentiation status of tumors in this study. Ethnic differences in the patterns of Ki-ras codon 12 point mutations were observed.

p53 mutations detected in colorectal carcinoma patients in Hong Kong

A mutational spectrum for exons 5-8 of the p53 tumor suppressor gene in colorectal carcinomas in Hong Kong Chinese was established. Ninety-nine colorectal carcinomas from Hong Kong patients were analyzed for mutations in p53 gene by PCR-single-strand conformation polymorphism analysis and direct DNA sequencing. Thirty-five of the 99 tumors (35.4%) contained mutations. Point mutations accounted for 80% of all genetic changes and were predominantly base transitions at CpG dinucleotide sites, mutations that were also predominant in Caucasian carcinomas. The major hot spots at codons 175 and 248 of p53 in Caucasians are also hot spots in the Chinese gene. Identical mutations in codons 152 and 306 were detected in two independent tumors in the Chinese, which were reported only rarely in Caucasians. Moreover, a significantly higher frequency (20%) of deletion and insertion mutations was observed in Hong Kong colorectal cancer patients. Distinct genetic and/or environmental factors may contribute to these findings.

Use of PCR to study epidemiology of Serratia marcescens isolates in nosocomial infection

A method to characterize strains of Serratia marcescens based on the PCR amplification of enterobacterial repetitive intergenic consensus sequences has been developed. The PCR fingerprints were generated from boiled supernatants prepared directly from bacterial colonies without the need for DNA extraction. The technique was applied to isolates obtained during an outbreak of pneumonia from seven mechanically ventilated patients, and its result indicated that the outbreak was due to the spread of two epidemic strains. This technique was validated by comparison with rRNA gene restriction analysis. There was complete concordance between these two techniques in discriminating the outbreak-related strains from epidemiologically unrelated isolates. Typing with both biochemical profile and antibiogram profile, though simple, was found to be less reliable than genotyping. The results show that this enterobacterial repetitive intergenic consensus PCR provides a rapid and simple means of typing S. marcescens isolates for epidemiologic studies.

Establishing continuous quality improvement in a Hong Kong hospital

Outlines and discusses the implementation plan and associated training programme for establishing TQM in one of the hospitals in Hong Kong. Gives examples of the training programme and outlines quality management plans.