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.

Effect of preoperative duloxetine treatment on postoperative chronic residual pain after total hip or knee arthroplasty: a randomised controlled trial

OBJECTIVES

A key predictor for developing chronic residual pain after total knee or hip arthroplasty (TKA/THA) is sensitisation. Sensitisation can be defined as an 'increased responsiveness of nociceptive neurons in the nervous system'. Aim of this study is to investigate the effects of preoperative treatment with duloxetine in sensitised knee and hip osteoarthritis (OA) patients on postoperative chronic residual pain up to 1 year after arthroplasty.

SETTING

A multicentre, pragmatic, prospective, randomised clinical trial was conducted in three secondary care hospitals in the Netherlands.

PARTICIPANTS

Patients with primary knee/hip OA who were planned for TKA/THA were screened using the modified painDETECT Questionnaire. Patients whose painDETECT score indicated that sensitisation may be present were eligible for participation. 111 participants were included and randomly assigned 1:1 to an intervention or control group. The intervention group received additional duloxetine treatment, the control group did not receive any additional treatment but was allowed to continue with any pain medication they were already taking.

INTERVENTIONS

Preoperative oral treatment for 7 weeks with 60 mg/day of duloxetine was compared with usual care.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measure was pain at 6 months after arthroplasty, assessed with the Pain Subscale of the Knee injury and Osteoarthritis Outcome Score (KOOS) or the Hip disability and Osteoarthritis Outcome Score (HOOS) with a 0-100 scale. Secondary outcome measures were Visual Analogue Scale (VAS), and neuropathic-like pain measured using the modified PainDETECT Questionnaire. Longitudinal data collection included time points directly after duloxetine treatment, 1-day preoperatively, and 6 weeks, 6 months and 12 months postoperatively.

RESULTS

Mean improvement in the KOOS/HOOS pain subscale at 6 months postoperatively was 37 (SD 28.1) in the intervention group and 43 (SD 26.5) in the control group. No statistically significant difference was found in change score 6 months postoperatively between the two groups (p=0.280). 12 patients from the intervention group (21%) discontinued duloxetine due to adverse effects.

CONCLUSIONS

Preoperative targeted treatment with duloxetine in end-stage knee and hip OA patients with sensitisation does not influence postoperative chronic residual pain after TKA/THA.

TRIAL REGISTRATION NUMBER

NTR4744.

Validity of the Dutch modified painDETECT questionnaire for patients with hip or knee osteoarthritis

BACKGROUND

The modified painDETECT questionnaire (PDQ) is a self-reported questionnaire to discriminate between nociceptive and neuropathic-like pain in patients with knee/hip osteoarthritis (OA). This study aims to assess the structural and construct validity of this questionnaire.

METHODS

Confirmatory factor analysis and hypothesis-testing was used. For 168 patients, predefined hypotheses were formulated on the correlation between the modified painDETECT and several other questionnaires, and in a subsample of 46 with pain pressure thresholds (PPTs).

RESULTS

Two principal components were confirmed. The pain pattern item did not load on any component. Eighty per cent of the hypotheses on the correlation between modified PDQ and the questionnaires were met, as were 50% concerning PPTs measurements.

CONCLUSIONS

This study is the first to assess structural and construct validity of the modified PDQ knee/hip by using factor analysis and hypothesis-testing. This questionnaire seems to reflect neuropathic-like pain symptoms experienced by hip/knee OA-patients with adequate validity. The item on pain pattern might not reflect the construct. More than 75% of the predefined hypotheses regarding the modified PDQ and the other questionnaires were met. Only 50% of the hypotheses on PPTs measurements were met, probably due to heterogeneity and limited size of this subsample. Implications for rehabilitation Pain in osteoarthritis (OA) is partly caused by modification of pain transmission in the peripheral and central nervous system, leading to sensitisation. This process seems particularly significant in a subgroup of OA patients. Sensitisation in OA is associated with more disability in daily life, lower quality of life and more widespread pain, as well as poorer outcome of total joint surgery. Screening for sensitisation can help to identify the subgroup of patients who could benefit from multidisciplinary treatment options focussing on desensitisation, cognitive- and behavioural therapy and reducing chronification of widespread pain. Therefore, being particularly important in the field of rehabilitation. The Dutch modified PainDETECT-questionnaire is very useful for rehabilitation professionals as it is one of the first questionnaires specifically validated to assess neuropathic-like symptoms (indicating sensitisation) in patients with knee or hip osteoarthritis.

Adherence to and effectiveness of an individually tailored home-based exercise program for frail older adults, driven by mobility monitoring: design of a prospective cohort study

BACKGROUND

With the number of older adults in society rising, frailty becomes an increasingly prevalent health condition. Regular physical activity can prevent functional decline and reduce frailty symptoms. In particular, home-based exercise programs can be beneficial in reducing frailty of older adults and fall risk, and in improving associated physiological parameters. However, adherence to home-based exercise programs is generally low among older adults. Current developments in technology can assist in enlarging adherence to home-based exercise programs. This paper presents the rationale and design of a study evaluating the adherence to and effectiveness of an individually tailored, home-based physical activity program for frail older adults driven by mobility monitoring through a necklace-worn physical activity sensor and remote feedback using a tablet PC.

METHODS/DESIGN

Fifty transitionally frail community-dwelling older adults will join a 6-month home-based physical activity program in which exercises are provided in the form of exercise videos on a tablet PC and daily activity is monitored by means of a necklace-worn motion sensor. Participants exercise 5 times a week. Exercises are built up in levels and are individually tailored in consultation with a coach through weekly telephone contact.

DISCUSSION

The physical activity program driven by mobility monitoring through a necklace-worn sensor and remote feedback using a tablet PC is an innovative method for physical activity stimulation in frail older adults. We hypothesize that, if participants are sufficiently adherent, the program will result in higher daily physical activity and higher strength and balance assessed by physical tests compared to baseline. If adherence to and effectiveness of the program is considered sufficient, the next step would be to evaluate the effectiveness with a randomised controlled trial. The knowledge gained in this study can be used to develop and fine-tune the application of innovative technology in home-based exercise programs.

TRIAL REGISTRATION

Nederlands Trial Register (NTR); trial number 4265. The study was prospectively registered (registration date 14/11/2013).

Clinical efficacy of postoperative autologous transfusion of filtered shed blood in hip and knee arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) or total hip arthroplasty (THA) regularly results in postoperative requirement of blood transfusion. Because of the disadvantages of allogeneic blood transfusion (ABT) such as the risk of transfusion-associated infections, incompatibility-related transfusion fatalities, or immunomodulatory effects, a continuing effort to reduce allogeneic blood transfusion is important. For this purpose, the effect of reinfusion of drain blood, via a postoperative wound drainage and reinfusion system, on the need for allogeneic blood transfusion was evaluated.

STUDY DESIGN AND METHODS

Using a prospective observational quality assessment design, we compared 135 patients scheduled for TKA or THA with a historic group of 96 patients. In the study group the Bellovac ABT autotransfusion system was used. The shed blood was returned either when 500 mL were collected or at most 6 hours after surgery. Compared were the preoperative, postoperative, and discharge hemoglobin, as well as the number of allogeneic blood transfusions.

RESULTS

There were no statistical differences between preoperative, postoperative, and discharge hemoglobin levels. Autologous transfusion reduced the number of patients receiving ABT overall from 35 percent (control) to 22 percent (study). The decrease of allogeneic transfusion requirement was most significant after TKA: from 18 percent to 6 percent (p < 0.001).

CONCLUSION

We conclude that the Bellovac ABT device reduces allogeneic blood transfusions in TKA and THA.

VATER--tibia aplasia association: report on two patients

We report two patients with oesophageal atresia, tracheo-oesophageal fistula and unilateral tibial aplasia. The karyotype in both patients was normal and both cases were sporadic. The congenital defects of the children can be regarded as an uncommon variant of VA(C)TER(L) association. Recently Basel and Goldblatt [(2000) Clin Dysmorphol 9:205-208] reported a similar patient with a VATER-tibia aplasia association.

Histological and biochemical evaluation of perichondrial transplants in human articular cartilage defects

From 1986 to 1992, 88 patients with articular defects in the knee were treated with a perichondrial arthroplasty. In this study, we report on the results for 22 biopsies of grafted tissue with a mean follow-up of 21 months. Biopsies were obtained at routine arthroscopy after approximately 1 year or at arthroscopy or arthrotomy at a later stage when patients were operated on again because of recurrent complaints. Biopsies were taken only when a partial failure was present or when there was a clear failure resulting in fibrocartilage, a loose flap, or a loose body. The biopsies were analyzed histologically, biochemically for the amount of type-II collagen, and immunohistochemically with antibodies for types I, II, and X collagen. The well-being of the patients was investigated with use of the Hospital for Special Surgery knee score. The biopsies from 6 patients contained more than 50% hyaline cartilage. At arthroscopy, the mean relative amount of type-II collagen was 56% in the biopsies classified as good. The cartilage of the grafted area was macroscopically normal for eight of the 22 biopsies. Histological and biochemical analysis of biopsies from failed transplants showed fibrocartilage with mainly type-I collagen. These tissues were retrieved primarily from patients with additional abnormalities in the knee joint. It was concluded that adult human perichondrium is able to form hyaline-like cartilage in an isolated cartilage defect in an otherwise healthy knee.

Radiofrequency lesions of the dorsal root ganglion in the treatment of hip flexor spasm: a report of two cases

The current popular model of spasticity is that the abnormalities are primarily due to increased sensitivity of the reflex are at the segmental level of the spinal cord. Neurosurgical procedures, such as open selective dorsal rhizotomy for the reduction of spasticity, have been based on this assumption. We describe two patients with hip flexor spasm of different origin treated with radiofrequency lesions of the dorsal root ganglion.

[New aspects of post-traumatic dystrophy syndrome?]

Posttraumatic dystrophy (PTD) is a syndrome that involves both neurological symptoms and microvascular abnormalities. A total of 44 consecutive patients seen for the first time with PTD were investigated. In 42 patients X-rays were taken: of the cervical spine in the case of PTD of the hand, and of the cervical, thoracic, and lumbar spine in the case of PTD of the foot. Two patients refused this investigation. In all 44 patients microvascular functions were investigated by means of transcutaneous oximetry, laser Doppler flow metering and capillary microscopy. In 34 of 42 patients radiographical disturbances of the vertebral column were noted, 19 of them on the same side as the affected extremity. Patients with a sensation of warmth in the affected extremity during the investigations exhibited a different microvascular behaviour than patients with a cold feeling. Both groups had different microvascular outcomes from healthy volunteers.

Safety and efficacy of etodolac compared with piroxicam in patients with degenerative joint disease of the knee

The efficacy and safety of etodolac and piroxicam were compared in a double-blind, randomized, parallel-group outpatient study at four sites. Patients with active osteoarthritis of the knee were assigned to receive etodolac 600 mg/day (57 patients) or piroxicam 20 mg/day (59 patients) for 6 weeks. Efficacy assessments were made at the pretreatment screening, at baseline, and at treatment weeks 2, 4, and 6 for patient and physician global evaluations, night pain, spontaneous pain intensity, weight-bearing pain variables, measures of inflammation, morning stiffness, and knee flexion. An analysis was also done based on each patient's final evaluation, regardless of the week at which it occurred. Safety assessments were made before treatment and at the completion of therapy. A therapeutic response was obtained in both treatment groups by the end of the second week of treatment. At the final evaluation, both groups showed significant improvement (P less than or equal to 0.05) from baseline for most efficacy assessments. The physician's global assessment indicated improvement in the condition of 60% of the etodolac-treated patients and 39% of the piroxicam-treated patients at the final evaluation. There was no significant difference between treatment groups in the number of patient withdrawals due to adverse reactions or in the number of patients reporting side effects. The results of this study indicate that, compared with piroxicam 20 mg/day, etodolac 600 mg/day is effective and well tolerated in the treatment of patients with osteoarthritis.

Bone reaction to silicone metatarsophalangeal joint-1 hemiprosthesis

The incidence of inflammatory response to silicone implants in the first metatarsophalangeal joint was investigated. In 34 of 59 silicone arthroplasties, cysts were noticed in the proximal phalanx after a mean follow-up period of 59 months. In the metatarsal head, cysts were seen in 40 cases. Histologic examination showed that the cysts were filled with an avascular cellular stroma containing histiocytes and multinucleated giant cells, opsonizing wear debris of the prosthesis. Because of this destructive process, caution is advised when using silicone prostheses in young, active people.