joint replacement

Blood supply to every organ and tissue in the body is very vital for optimal functioning. Loss of blood supply to any body part or organ leads to a gradual death (necrosis) of that part or organ and can be very dangerous. Loss of blood supply to the brain results in stroke; loss of blood supply to the heart results in a heart attack; loss of blood supply to a bone tissue leads to bone death (osteonecrosis).

Knee osteonecrosis means knee bone death. It occurs mostly in older people, with women being more affected than men. Three types of osteonecrosis affect the knee: spontaneous osteonecrosis of the knee (SONK), secondary, and post-arthroscopic.

Read Also: PRP Is No More Effective for Knee Osteoarthritis than Placebo

Anatomy of the knee

The knee is one of the two major hinge joints in the body, with the elbow being the other. It is responsible for movement and very vital for weight-bearing. The joint at the knee is the largest and most complex joint in the body. It is made up of three bones the lower end of the femur (thigh bone), the upper end of the tibia (shin bone), and the patella (kneecap). Knee osteonecrosis commonly occurs in the medial femoral condyle (inside of the knee), however, the lateral femoral epicondyle (outside of the knee) or tibial plateau (the flat top of the tibia) may also be likely areas of occurrence.

The knee is vulnerable to injury; according to the database from the National Institutes of Health, it is the most commonly injured joint by adolescent athletes. Among older people, it is prone to knee osteonecrosis, which if not given medical attention early, can progress to osteoarthritis.

Epidemiology

The most common form of knee osteonecrosis is spontaneous osteonecrosis of the knee, SONK. It is mostly observed in people who are over age 50. On the other hand, secondary osteonecrosis has been observed to be more common in the younger population and it is linked to some medical conditions like sickle cell disease (SCD), consumption of alcohol, corticosteroids, and tobacco, and myeloproliferative disorders. The last form, post-arthroscopic osteonecrosis, is a rare type. Reports show that it affected 4% of patients who had arthroscopic knee surgery, particularly meniscectomy.

Causes of knee osteonecrosis

When there is a lack of blood supply to bone tissues, it leads to the death of bone cells, which results in an eventual collapse of the bone. This is the case in osteonecrosis. Knee osteonecrosis can result in a collapse of the articular cartilage covering the bone ends, and this can lead to arthritis.

Read Also: TOKA a New Customized 3D-Printed Plate for the Treatment of Knee Osteoarthritis

Risk factors

The cause of the lack of blood supply is still unknown, but studies have linked the following risk factors to the development of knee osteonecrosis:

1. Knee injury

Aside from pain and swelling, knee injuries like dislocation or fracture can also result in damaged blood vessels. Dislocation involves bone ends; fracture involves any bone part; either way, both injuries can affect the blood vessels supplying the bone, thereby, reducing the flow of blood to the dislocated/fractured bone. This is why immediate medical attention is needed. Sometimes, an x-ray or MRI scan may be done to have a deeper view of the bone.

2. Oral corticosteroid medications

It is not exactly known why oral steroid medications cause osteonecrosis, but research shows that there is a connection between them. This is disturbing because many diseases such as asthma and rheumatoid arthritis are treated with these medications.

3. Medical conditions

Some medical conditions such as obesity, SCD, and lupus are associated with the secondary form of knee osteonecrosis. HIV patients are also diagnosed with it this is because the medications for HIV treatment are also linked to the disease.

4. Excessive consumption of alcohol

Alcohol causes weight gain because it stops the body from burning fat. Drinking too much alcohol increases the buildup of fat in the body, and this can consequently lead to deposits of fat tissues that can block blood vessels and obstruct blood flow to the vessels.

5. Transplants

Studies show that osteonecrosis can occur after organ transplants, especially kidney transplants.

Read Also: Duke University Researchers Create a Gel That Could Replace the Cartilage in the Knees

Symptoms of knee osteonecrosis

The most common symptom associated with osteonecrosis of the knee is pain on the inside of the knee. The pain can be triggered by a specific activity or a minor injury and can become intense at night.

Other symptoms include: swelling over the front and inside of the knee, increased sensitivity to touch in the area, and limited movement of the knee due to pain.

Diagnosis of knee osteonecrosis

A good diagnosis of knee osteonecrosis begins with a thorough history taking.

Here, your doctor will talk about your medical history, ask you to describe your symptoms and then proceed to examine your knee.

While examining your knee, your doctor looks out for swelling within your joints, tenderness, redness, and joint instability.

You may be asked to move your knee to observe the range of motion at your knee joint.

Your doctor also looks out for any sign of injury to the muscles, ligaments, and tendons around your knee.

After a physical examination of your knee, your doctor then goes on to confirm the diagnosis by taking an imaging study of your knee either with an X-ray study, magnetic resonance imaging (MRI) scan, or a bone scan. An imaging study is vital as it helps to take a deeper look at your bones and other aspects of your knee joint to identify the stage of knee osteonecrosis you have.

Read Also: Still No Effective Cures for Osteoarthritis but There Is Some Hope

Staging of knee osteonecrosis

There are four stages to knee osteonecrosis development:

Stage I: At this stage, the patient experiences symptoms that become intense and last for six to eight weeks. To be sure of the diagnosis, the doctor uses a positive bone scan, not just x-rays to get a better view of the knee. At this point, surgery is not required for treatment, instead, the doctor administers medication for pain relief and other methods that focuses on reduced weight-bearing.

Stage II: From Stage I to this stage takes several months. At this stage, x-rays can confirm the diagnosis, because the medial femoral condyle which is normally rounded now becomes flattened and can be visible with x-rays. Other forms of imaging studies such as MRI, CT, or bone scan can also confirm the diagnosis.

Stage III: From Stage I to this stage takes about three to six months, x-rays alone can confirm the diagnosis. The articular cartilage that covers the bones starts to come off the bone since the bone itself is gradually dying. Surgical procedures may be required to treat the patient at this point.

Stage IV: At this stage, the disease becomes very critical as the articular cartilage is now destroyed and the joint space becomes narrow; severe osteoarthritis develops; joint replacement surgery becomes necessary.

Prognosis of knee osteonecrosis

When knee osteonecrosis is diagnosed early (at stage I), a simple pain relief medication may be all that is needed to treat it. The doctor may also advise lower mobility of the affected knee. At advanced stages, surgery may be done to prevent increased damage to the whole joint.

Treatment of knee osteonecrosis

The treatment option for knee osteonecrosis depends on some factors which include the stage of the disease, the portion of bone that is affected, and the cause of the disease. Based on these factors, treatment can be non-surgical or surgical.

Read Also: Scientists Repair Bones Successfully by Combining Gene Therapy and Bioprinting

Non-surgical treatment option

If the disease is at an early stage and only a small area of the knee is affected, surgery may not be necessary. The doctor may suggest any of the following non-surgical treatment procedures:

1. Use of medications:

The doctor may prescribe some nonsteroidal inflammatory drugs (NSAIDs) like ibuprofen and naproxen to relieve the pain and swelling in the knee. If the patient is a young person, the doctor may suggest bisphosphonates for treatment.

2. Reduced weight bearing:

For some patients, just simply taking weight off their knees may be all that is needed to slow the damage and allow for healing. The patient may need to start using crutches for some time to reduce the weight on their knees.

3. Exercise:

The patient may be asked to engage in certain physical activities that aid in strengthening the thigh muscles and allow for a range of movement in the affected joint. To avoid stress on the joint, water exercise may also be recommended for the patient.

4. Modification in certain activities:

The doctor may advise the patient to stop certain activities that lead to pain.

Surgical treatment options

Your doctor may recommend surgery if there seems to be no improvement after the non-surgical treatment options, or if the portion of the bone affected is quite large. Some surgical procedures that may be recommended include:

1. Total knee replacement:

Your doctor may opt for this procedure if the disease has progressed to stage IV, where the bone has been destroyed. The procedure involves a replacement of the destroyed bones and cartilages with metal or plastic joint surfaces to restore the knee function.

2. Osteotomy:

In this procedure, the surgeon removes a portion of either the tibia or femur or will insert a wedge of bone graft/synthetic bone to help take the weight off the damaged portion of the knee. This is vital because taking weight off the affected area of the joint will relieve the patient of pain and promote healing.

Other surgical procedures your doctor may recommend osteochondral bone (bone and cartilage) grafting, core compression, arthroscopic debridement and microfracture, and autologous chondrocyte implantation (ACI).

Read Also: Inflammatory Joint Diseases: Actions and Foods You Should Consider to Relieve Joints Inflammation Naturally

Conclusion

As much as knee osteonecrosis is likely to occur in people who are over age 50, it can be avoided and effectively treated when we are armed with the knowledge of what it is and how to diagnose and easily manage it.

References

https://orthoinfo.aaos.org/en/diseases–conditions/osteonecrosis-of-the-knee

https://www.sciencedirect.com/science/article/pii/S2665913121000327

FOSTER CITY, Calif., April 8, 2022 /PRNewswire/ — OrthoTrophix, Inc., a privately held biopharmaceutical company, announced today that the Company and its collaborators present clinical data strongly supporting joint bone shape change as part of a surrogate marker predictive of joint replacement in knee osteoarthritis (OA) patients.

An abstract entitled, “Improved WOMAC Physical Function is Associated with Slowed Pathological Bone Shape Change after TPX-100: Towards a Surrogate Marker for Virtual Knee Replacement?” was presented today in a Plenary Session of 2022 OARSI World Congress on Osteoarthritis in Berlin, Germany (Abstract 26 in Osteoarthritis and Cartilage Vol. 30 Suppl. S28–S29).

Functional impairment is a key risk factor for knee replacement even after adjusting for knee pain severity, based on the large NIH-sponsored Multicenter Osteoarthritis Study (the “MOST” study) involving over 5,500 knees. In the TPX-100-5, a Phase 2 study, placebo-treated knees with more advanced pathological joint bone shape change at baseline showed much faster progression of pathological bone shape change and poorer knee function at the end of the 12-month study period. In marked contrast, TPX-100-treated knees demonstrated reduction in pathological bone shape change and robust improvement of knee function through 12 months, regardless of severity at baseline. Consequently, both clinical (knee function) and structural (bone shape) efficacies of TPX-100 as compared to placebo were confirmed including in subjects with moderate to severe knee OA.

“The current FDA draft guidance indicates that a positive effect on an imaging marker of OA must be associated with avoidance or delay of the need for joint replacement, or must persuasively reduce deterioration of function and worsening of pain. This is a high bar,” commented Dr. Dawn McGuire, OrthoTrophix’ Chief Medical Officer. “However, the Multicenter Osteoarthritis Study findings and our clinical data collectively suggest that concordant improvements of bone shape change and clinical function could lead to a delay or elimination of the need for joint replacement surgery. These combined outcomes in structure and function could provide a ‘virtual joint replacement’ measure for the study of disease-modifying agents in individuals afflicted with knee OA.”

The Company also will present an abstract entitled, “Intra Articular TPX-100 Significantly Improves Pain Measures and Slows Pathological Bone Shape Chage in Knee OA”. This presentation demonstrates clinically meaningful improvements in overall knee pain and in specific key pain parameters in moderate to severe knee OA, linked to significant reductions in pathological bone shape change (Abstract 254 in Osteoarthritis and Cartilage Vol. 30 S193).

About OrthoTrophix, Inc.
OrthoTrophix, Inc., based in the San Francisco Bay Area, California, is a privately held biopharmaceutical company focused on development and commercialization of a first-in-class Disease Modifying Osteoarthritis Drug (DMOAD). Founded by three co-founders in 2011, the primary focus of OrthoTrophix has been regeneration and repair of cartilage and underlying bones in the knee and other joints with its novel proprietary compounds.

This press release contains “forward-looking” statements. These statements involve risks and uncertainties, which may cause results to differ materially from those set forth in the statements. The forward-looking statements include statements regarding product development and cannot be guaranteed. OrthoTrophix undertakes no obligation to publicly update any forward-looking statement, whether as a result of new information, future events, or otherwise. Forward-looking statements in this press release should be evaluated together with the many uncertainties that affect OrthoTrophix’ business.

Company Contact
Yoshi Kumagai
President and CEO
Tel: (510) 488-3824

SOURCE OrthoTrophix, Inc.

Depending on what you do for a living, it’s very likely that your job is highly stressful. Your entire day could be spent performing repetitive motions such as lifting heavy objects or moving around. It’s essential to take care of your body’s muscles, joints, and nerves before things get worse.

An orthopedic surgeon specializes in the health of the musculoskeletal system and can help you figure out what’s wrong and how to fix it. For those who aren’t familiar with orthopedists, here are a few things to keep in mind when deciding whether or not to see one:

Having Difficulty Climbing the Stairs 

Joints in the knees and hips naturally begin to deteriorate with age, which typically makes it too uncomfortable for the affected body parts to continue functioning normally. If you have trouble walking, climbing stairs, or getting out of chairs, it may be time for your doctor to propose that you have joint surgery. 

Joint injury can manifest itself in various ways, one of which is chronic pain that lasts for more than six months and disrupts daily life. A joint replacement may be necessary for a variety of reasons, including accidents that may have occurred in the past and years of heavy use. 

Instability Of Joints. 

Destabilization is merely one more compelling argument in favor of seeking the counsel and expertise of an orthopedic physician. Should people who have trouble standing, walking, or moving easily investigate the possibility that they have orthopedic problems? Many of them do. The easiest method to go about doing this is to seek the advice of a specialist who is already working in the sector. 

Having a Hard Time with Chores. 

The capacity to carry out daily activities without the assistance of another person is referred to as self-sufficiency. To accomplish this, you must be able to get out of bed with only minimal assistance, dress, bend over to tie your shoes, prepare your meals, and so on. 

Consult AOA Orthopedic Specialists if you are unable to execute the tasks at hand without experiencing significant discomfort or if the manner in which you are expected to carry them out is undergoing significant change. 

Disturbances in Bowel Movement and Bladder Function 

If you find yourself rushing to the bathroom or sitting on the toilet for hours at a time, which is neither pleasant nor normal, it may be time to consult a doctor. Both irritable bowel syndrome (also known as IBS) and nerve injury can have adverse effects on the intestines, the bladder, and the back. 

Irritable bowel syndrome (IBS) can cause abdominal cramping and extreme stool, both of which are indicators that your bowel system isn’t functioning correctly. This can lead to problems in the lower back. On the other hand, injury to the nerves in the back can lead to discomfort in the abdomen and make digestion difficult. 

Bottom Line

You put yourself in jeopardy of long-term damage and impairment if you ignore what your body is trying to tell you. There are several warning signs that should prompt a person to seek medical attention, particularly from an orthopedic specialist. These warning signs include problems with the joints and bones.

Declines in body mass index (BMI) were linked with slower worsening of knee osteoarthritis (OA), according to data from three large longitudinal cohort studies.

With more than 6,000 knees evaluated for OA progression and 4 to 5 years of follow-up, “each 1-unit decrease in BMI was associated with a 4.76% reduction … in the odds of the incidence and progression of the overall structural defects of knee osteoarthritis” as assessed under the Kellgren-Lawrence grading system, reported Zubeyir Salis, BEng, of the University of New South Wales in Kensington, Australia, and colleagues in Arthritis & Rheumatology.

While such a relationship seems obvious, it has evaded firm proof, the researchers noted. Earlier studies had tied body weight to risk of OA development and the likelihood of progression and end-stage outcomes such as total joint replacement. But whether losing or gaining weight alters the trajectory over time is another matter.

Salis and colleagues identified just one previous attempt to address the question directly: patients already showing joint degeneration who lost around 10 kg (22 lb) on average in a randomized diet-and-exercise trial showed no less progression than a control group with little weight loss, but follow-up only lasted 18 months. (A number of other studies had lumped patients without structural damage at baseline together with those with established degeneration, and they had mixed results.)

For the current analyses, Salis and colleagues combined data from three independent cohort studies from the U.S. and the Netherlands: the Osteoarthritis Initiative (OAI), which was also the basis for some of the above-mentioned studies; the Multicenter Osteoarthritis Study (MOST); and the Cohort Hip and Cohort Knee (CHECK) study. These data covered 9,683 knees (5,774 individual patients) for assessing the incidence of structural knee degeneration (i.e., no evidence of joint damage at baseline) and 6,074 knees (3,988 individuals) for progression of established degeneration.

Structural joint parameters were measured with x-rays at baseline and at follow-up, which was 4 years in the OAI and 5 years in the other two cohorts. Changes in these parameters (medial and lateral joint space narrowing and femoral and tibial surface osteophytes) were correlated against changes in BMI.

For patients included in the evaluation of new-onset structural damage, mean age at baseline was 60; about 40% were men and 88% were white. BMI at baseline averaged 28.2, with 33% of participants classified as obese (BMI ≥30). A total of 1,101 participants in this analysis saw BMI declines of at least 1 unit during follow-up, whereas 1,611 had increases of 1 or more units.

Patients’ baseline characteristics in the study of progression were similar. Baseline BMI was a bit higher on average (30.4), and 48% were obese. BMI declines of 1 or more units were seen in 798 participants, while 1,008 had increases.

Salis and colleagues found a significant association between BMI changes and the risk of developing structural damage, with an odds ratio of 1.05 (95% CI 1.02-1.09) for each 1-unit increment in BMI. This value was nearly identical to that seen for risk of progression in patients with damage at baseline (OR 1.05, 95% CI 1.01-1.09). In both analyses, joint space narrowing in the medial area largely drove the overall findings, with odds ratios in both cases of 1.08 per 1-unit BMI increment.

However, the results suggested that weight loss was far from the only factor at play in governing joint-damage incidence and progression. The researchers estimated population-attributable fractions of the total risk accounted for by weight loss at 13% for incidence and 10% for progression.

In addition, the investigators stopped short of asserting that the findings prove that weight loss slows OA disease progression, saying they “showed evidence of association, not causality.” But the researchers did argue that “people with overweight or obesity — and potentially also those of normal weight — may benefit from a decrease in BMI to prevent, delay or slow the structural defects in knee osteoarthritis.”

ROSEMONT, Ill., Nov. 12, 2021 /PRNewswire/ –The American Joint Replacement Registry (AJRR), the cornerstone of the American Academy of Orthopaedic Surgeons (AAOS) Registry Program, released its 2021 Annual Report on hip and knee arthroplasty procedural trends, and patient outcomes today at the American Association of Hip and Knee Surgeons’ (AAHKS) 2021 Annual Meeting. Despite the disruption to the delivery of joint replacement care during the initial impact of the COVID-19 pandemic (March through May 2020), procedures rebounded to historic averages by June 2020. Even with the temporary decline in procedures, the report demonstrates an overall cumulative procedural volume growth of 18.3% compared to the previous year and includes findings from 2,244,587 hip and knee arthroplasty procedures performed between 2012 and 2020.

“The ability to return to normal procedural volume rates just a few months after the COVID-19 pandemic began is a testament to the commitment and resiliency of healthcare institutions, clinicians and patients,” said Bryan D. Springer, MD, FAAOS, chair of the AJRR Steering Committee. “While we are experiencing unprecedented times in healthcare and continue to navigate the challenges of the pandemic, the AJRR remains committed to the growth and expansion of the registry to paint a more complete picture of our patient population. Through increased participation and a successful integration of Medicare claims data, we are providing orthopaedic surgeons, hospitals and stakeholders with actionable data, insights and trends to improve the lives of millions of Americans who suffer from hip and knee arthritis.”

AJRR is the largest orthopaedic registry in the world based on annual procedures submitted, and the 2021 AJRR Annual Report marks the eighth annual report. With the collection and reporting of U.S. hip and knee arthroplasty data, the report aims to provide valuable information to orthopaedic surgeons, hospitals, ambulatory surgery centers, private practices, device manufacturers, payers, and most importantly patients. The 2021 report represents over 2.2 million hip and knee procedures from over 1,150 hospitals, ambulatory surgery centers (ASCs), and private practice groups submitting data from across all 50 states and the District of Columbia.

James A. Browne, MD, FAAOS, chair of the AJRR Publications Subcommittee and editor of AJRR Publications added: “This year’s AJRR Annual Report provides the most comprehensive picture to date of patterns of hip and knee arthroplasty practice and outcomes in the United States. For the first time this year, cumulative percent revision curves were produced with a diagnosis-specific endpoint examining revision due to infection for total knee arthroplasty (TKA) and revision due to periprosthetic fracture for total hip arthroplasty (THA) patients over 65 years of age. The registry continues to use more sophisticated and detailed survivorship curves, including device-specific cumulative revision stratified by bearing and fixation type, in addition to utilizing Centers for Medicare & Medicaid Services (CMS) data.”

Additional findings from the 2021 AJRR Annual Report include:

• Device-specific revision analyses showed that all included hip device constructs had a cumulative percent revision of less than 2.8% at one year and less than 4.7% at final follow up for each respective device. All knee device constructs included in analysis had a cumulative percent revision of less than 2.5% at three years and less than 3.7% at final follow up for each respective device.  
• The use of cement for femoral component fixation is slowly increasing for both elective primary THA as well as arthroplasty for femoral neck fracture, and cementless fixation shows a statistically significant reduction in early revision due to periprosthetic fracture, compared to cementless fixation in elective primary THA patients over 65 years of age.
• While cemented fixation for TKA still predominates, the report shows that cementless fixation continues to increase and was associated with significantly less revision due to infection in elective primary TKA patients over 65 years of age.
• For both TKA and THA procedures, postoperative length of stay continues to decrease.

Enhanced Registry capabilities offerings and include:

• Additional opportunities for sites to track performance measurements and use Registry data in national quality improvement (QI) programs.  
• A 39% increase in sites reporting patient-reported outcome measures (PROMs), compared to the previous year, through continued support of the RegistryInsights® PROM platform and partnerships with third-party vendors with the expanded Authorized Vendor Program.
• Peer-reviewed publications and presentations based on AJRR Registry data.

To read and download the complete 2021 report, visit the AJRR website. Slides with figures and data tables as featured in the report are also available.

AAOS Registry Program 
The AAOS Registry Program’s mission is to improve orthopaedic care through the collection, analysis, and reporting of actionable data. The American Joint Replacement Registry (AJRR), the Academy’s hip and knee replacement registry, is the cornerstone of the AAOS’s Registry Program, and the world’s largest national registry of hip and knee joint replacement data by annual procedural count, with more than 2.4 million procedures contained within its database. Additional registries include the Fracture & Trauma Registry, the Musculoskeletal Tumor Registry (MsTR), the Shoulder & Elbow Registry (SER), and the American Spine Registry (ASR), a collaborative effort between the American Association of Neurological Surgeons (AANS) and the AAOS. 

About the AAOS
With more than 39,000 members, the American Academy of Orthopaedic Surgeons is the world’s largest medical association of musculoskeletal specialists. The AAOS is the trusted leader in advancing musculoskeletal health. It provides the highest quality, most comprehensive education to help orthopaedic surgeons and allied health professionals at every career level best treat patients in their daily practices. The AAOS is the source for information on bone and joint conditions, treatments, and related musculoskeletal health care issues, and it leads the health care discussion on advancing quality.

Follow the AAOS on Facebook, Twitter, LinkedIn, and Instagram.

SOURCE American Academy of Orthopaedic Surgeons

Related Links

www.aaos.org

Bi-unicompartmental knee arthroplasty (BiUKA) is an alternative to total knee arthroplasty for selected patients. Although it is thought to be technically demanding, the technique has not been previously described in detail. Kinematic alignment (KA) implantation and bone cuts parallel to the native joint line would be beneficial to ensure optimal mechanical loading. Here, we detail a technique for KA-BiUKA using the Oxford partial knees. The joint line is identified using the spoon of the microplasty instrumentation system with/without the accessory spoons. The tibia is cut parallel with the joint line using a side-slidable ankle yoke so that the inclination of the cutting block is parallel with the spoon surface. After defining the horizontal bone-cutting lines, the predominantly affected condyle is operated upon, followed by the lesser affected condyle. Although custom-made devices are required, the technique is useful and reproducible in the performance of KA-BiUKA with the Oxford partial knees.

Introduction

Technical Report

Discussion

Conclusions

As a pioneer for robotic joint replacement surgery in the UK, his patients are now able to take advantage of the quicker recovery times, reduced pain and improved function, following robotic joint replacement surgery.

 

 

His current waiting time for a joint replacement privately is four weeks, and for and NHS patient is around six months.

Mr Port has more than 30 years’ experience in orthopaedic surgery, during which time he has led and guided local, regional and national directives in improving the quality of orthopaedic surgery. He has been based at the BMI Woodlands hospital in Darlington for 22 years.

He performs more than 500 hip and knee replacements a year, including 50 revision surgeries and 40 partial knee replacements. The “Getting It Right First Time” (GIRFT) Department of Health directive and the British Orthopaedic Association advocate that surgeons should perform a minimum of 15 of each of these procedures per year to maintain standards. Mr Port has one of the highest patient satisfaction outcomes and lowest complication rates nationally.

Being one of the first surgeons in the UK to introduce robotic hip and knee replacement surgery, Mr Port has performed more than 300 robotic-assisted hip and knee replacements using the Stryker Mako Robotics system.

From his experience he explains: “The technology combines 3D planning with accurate intra-operative reconstruction of the hip or knee replacement. Following robotic surgery, patients are reporting less pain, quicker recovery times and greater satisfaction rates”.

The BMI Woodlands Hospital, in Darlington, is the only hospital in the northern region that offers access to augmented surgical assistance with the Stryker Mako Robotics system.

Mr Port is currently chairman of the Surgical Collaborative at South Tees NHS Trust, incorporating The James Cook University Hospital and the Friarage Hospital. He leads on the strategy to standardise the delivery and quality of orthopaedic surgery over the Tees Valley and North Yorkshire.

Further information can be found at: www.circlehealthgroup.co.uk/consultants/andrew-port or, to book an appointment, contact 01325 341784, or Mr Port’s practice manager on 07855 364475.

 

 

 

 

Hyderabad: Covid-19 recovered patients are prone to orthopaedic complications like osteonecrosis of the hip, which damages hip joint and could also cause severe arthritis, senior orthopaedic surgeons at a Arthroplasty Arthroscopy Summit-2022 (AAS), organised by Apollo Hospitals, Secunderabad, and Apollo Institute of Medical Sciences and Research (AIMSR), on Sunday, said.

Cases of osteonecrosis are being reported among individuals aged between 20 years and 30 years. “Hip replacement is a gold-standard for treating necrosis. However, since a majority of the patients are from a young age group, hip replacement is usually not recommended. There are modern techniques that provide safe alternatives to such patients,” senior joint replacement surgeons from Apollo Hospitals, Dr Aachi Mithin and Dr N Somashekhar Reddy, said.

In the training program, the faculty highlighted new therapeutics including pain portal injections, which involves injecting of safe local medications in small quantities at various spots to produce long lasting relief to patients. Such injections are giving good midterm to long term relief from pain, Dr L Prakash, Director and Chief of Orthopaedics, Institute for Special Orthopaedics, Palakkad, Kerala, said.

Participant characteristics

Comparison of the OAI cohort (Table 1) baseline characteristics between the structural progressors and no-progressors showed, for the former, a higher percentage of participants with a Kellgren-Lawrence (KL) score > 0–1, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and JSN, and a lower JSW. Age and BMI were also slightly higher in the structural progressor group, but although they reached statistical differences, they were not clinically significant.

For the TASOAC cohort (Table 2), a comparison between the two groups showed that the structural progressors have a higher WOMAC score and JSN, a lower JSW, and fewer men.

OAI and TASOAC cohorts have the same proportion for structural progressors (31%) and no-progressors (69%).

Comparison of the machine learning methodologies

With the OAI cohort, seven methodologies were compared using the 12 independent variables (Eq. 1). Figure 2 indicates the accuracy of the different ML methodologies in PVBSP forecasting at both the training and testing stages.

Data from the whole population showed that in the training stage (Fig. 2a), both the SVM and RF methodologies had good performances in all the population for structural progressors and no-progressors (mean of about 93%). The other methodologies resulted in poorer performances, primarily related to the progressor population. To select the superior model in PVBSP forecasting, the performance of different methodologies was analyzed in individuals who had not played a role in the calibration process, the testing stage (Fig. 2b). Data showed that only SVM demonstrated excellent accuracy for both groups. SVM methodology was thus further used for the development of the prediction models.

Feature selection: sensitivity analysis

Using the whole OAI population, the effect of each 12 variables (Eq. 1) was evaluated in which all the models, except model 1, consisted of removing a variable (Fig. 3a). Data showed that model 1 had 94.8% accuracy in the training stage and 96.8% in the testing stage (Fig. 3b, c). Moreover, the removal of each variable demonstrated in the training stage (Fig. 3b) that not using GDF5 (model 5), DUS4L (model 6), TP63 (model 9), and age (model 13) as input variables slightly reduced the model’s accuracy in predicting PVBSP compared to model 1. At the testing stage (Fig. 3c), the variables BMI (model 12) and age (model 13) were also reduced compared to model 1. These data thus suggest that although the accuracy of these models is close, based on slight differences in training and testing stages, the important variables are age, BMI, TP63, DUS4L, and GDF5, and the following Eq. 2 can be considered as a model for PVBSP forecasting the progressor population:

When the population was divided into structural progressors and no-progressors, findings (data not shown) revealed that the difference found for the whole population was related to the progressor population. Hence, when only the progressor population was used, the model using all the 12 variables (model 1) showed an accuracy of 88.8% in the testing stage. For the no-progressors, there was no difference in the accuracy between the different models suggesting that the variables did not impact the outcome. Therefore, the no-progressor population was not detailed further.

Machine learning model development

To find if lesser input variables can provide an accurate model, we further evaluated, by using the structural progressor population and the five variables as in Eq. 2, the scenarios of using one variable at a time followed by combining two to five variables. As illustrated in Fig. 4, 31 different ML models in PVBSP forecasting were developed. Data revealed that for models with only one variable (Fig. 4a), the accuracies of TP63 (M3), DUS4L (M4), and GDF5 (M5) at both training and testing stages were nil. Although the accuracy improved for age (M1) and BMI (M2), the numerical values (≤ 21.3%) were still very low. However, this improvement substantiates the importance of these two variables (age and BMI) as found in the sensitivity analysis (Fig. 3).

For the models with two variables (Fig. 4b), the highest accuracy (testing stage 41.3%) considered age and BMI simultaneously (M6). A comparison of the combination of each of these variables with age (M7–M9), with one consisting of age and BMI together (M6), showed that replacing BMI with TP63 (M7), DUS4L (M8), and GDF5 (M9) reduced the modeling accuracy in the testing stage by 12.5%, 18.8%, and 11.3%, respectively. However, if one of the inputs was BMI and the other two were one of the SNP genes (TP63 [M10], DUS4L [M11], GDF5 [M12]), the prediction accuracy was further reduced. Moreover, by not using age and BMI as one of the inputs of the models with two variables, we could not predict any of the progressors; the accuracy value was zero. These findings indicate that using TP63, DUS4L, and GDF5 without the risk factors cannot yield an efficient model in PVBSP forecasting.

As shown in Fig. 4c, adding one of TP63, DUS4L, or GDF5 as a variable to both age and BMI showed an increased accuracy. Models with three features that employed only one of the risk factors (M19–M21 for age and M22–M24 for BMI) had lower accuracy (range 21.3–40.0%) than the model with these two variables (M6, 41.3%). It should be noted that the simultaneous use of three variables without those of the two risk factors did not predict the progressors with high accuracy. Hence, the significant effect of age and BMI on PVBSP forecasting was confirmed.

For models with four and five variables (Fig. 4d), M26–M28 had higher accuracy than the best model offered among those using only three variables, i.e., M16. M27 demonstrated the best performance (testing stage, 73.8%). This model uses, in addition to age and BMI, TP63 and GDF5. The combination of DUS4L and GDF5 (M28) and DUS4L and TP63 (M26) were in the second and third place, respectively. As for the models with fewer variables (Fig. 4b, c), the non-simultaneous use of BMI and age (M29 and M30) led to a model with lower accuracy.

These results (Fig. 4) show that increasing the number of inputs is effective when both age and BMI are considered. However, the best performance (testing stage 78.8%) was obtained with M31, which considers the five variables as in Eq. 2.

Synergy of variables

The above data showed that, for the structural progressor population, the accuracy of M31 (five variables; testing stage, 78.8%) was lower than model 1 (12 variables; testing stage, 88.8%). Therefore, we assumed that some variables that are not considered in M31, including mtDNA haplogroup, cluster, FTO, GNL3, SUPT3H, MCF2L, and TGFA, could exert a synergistic effect with one or more variables in M31. This led to examining the synergy between the variables, and 66 new and different ML models were developed. Three impact levels were defined by comparing the results of each of these models with model 1 (Eq. 2) as the base model and according to the accuracy.

Table 3 illustrates, from highest to lowest, the impact effect between a fixed variable (variable 1) and one of the variables as listed in variable 2. Data revealed that the highest synergy impact was found for age with (i) BMI, (ii) GNL3, (iii) MCF2L, and (iv) FTO. Those having a moderate impact were age with (i) mtDNA haplogroup, (ii) GDF5, (iii) SUPT3H, (iv) TGFA, and (v) TP63; BMI with (vi) TP63 and (vii) SUPT3H, and (viii) GDF5 and MC2FL.

According to the highest and moderate impacts, two different scenarios were defined to find the optimum model (Table 4). In scenario 1, in addition to the combination of age and BMI, the factors found to have a high impact on synergies, GNL3, MCF2L, and FTO, were added one at a time to M31. In scenario 2, as the mtDNA haplogroup showed a moderate impact with age, it was used in addition to age and BMI as a fixed input variable, and the other SNP genes, TP63, FTO, GNL3, DUS4L, GDF5, SUPT3H, and TGFA, were added one at the time or in combination. All of the SNP genes were tested to ensure the accuracy and reliability of the final results.

Scenario 1

Three different models (Table 4, scenario 1) named M32-1 to M31-3 were defined and included the five variables of the model M31 plus GNL3, MCF2L, or FTO, respectively. The performance in the testing stage of M32-1 (82.7%), M32-2 (81.3%), and M32-3 (85.0%) was slightly lower than model 1 (12 variables, 88.8%) but higher than that of M31 (five variables, 78.8%). M32-3 (M31 + FTO) outperformed M31 and M31-2. Therefore, and to have a model with a lower number of variables, M32-3 appeared to be a very good model and consisted of:

Scenario 2

To verify if we could obtain a better accuracy with fewer variables, we analyzed another scenario consisting of age, BMI, and mtDNA haplogroup as fixed variables with one to seven SNP genes. This resulted in 109 combinations with four to ten variables and was named MH1-109. The analyses of all input combinations showed that the best accuracy range at the testing stage was 80.0–88.8%, and only those are represented in Table 4, scenario 2. Data showed that for four models with six to nine variables, the accuracy was identical (MH46, MH80, MH101, and MH106) in the testing stage (88.8%) as the one for model 1 with 12 variables. The model MH2 with four variables was at 80.0%, and MH17 with five variables at 82.5%. Given that the optimum model should not only have an excellent accuracy but the least number of variables, MH17 was selected as the optimal model:

Effect of each variable on the optimum model, MH17

The effect of each variable on the model MH17 was done using sensitivity analysis. Figure 5 demonstrates the impact of each SNP mtDNA haplogroup (others, H, Uk, T, J) and gene genotype for FTO (CC, CT, and TT) and SUPT3H (AA, GA, and GG) in PVBSP forecasting. The high percentage of error indicates the high impact of the studied variable.

Data showed that the mtDNA haplogroup H has the highest impact with an error of 35.0%, followed by UK with 16.1%, and ≤ 10% for the mtDNA haplogroup others, T, and J. FTO and SUPT3H both showed an identical highest error (37.3%) for both the presence of CT and absence of AA, respectively. The lowest error of FTO and SUPT3H was attained for the absence of TT (17.4%) and the presence of GG (9.8%), respectively.

Validation of the developed models using cross-validation and reproducibility with an external cohort (TASOAC)

The performance of M32-3 (Eq. 3) and MH-17 (Eq. 4) models when using the ten repetitions of tenfold cross-validation showed an average accuracy of 95.1% ± 2.1 for M32-3 and 94.6% ± 2.1 for MH-17 (Additional file 7: Fig. S4).

Reproducibility experiment with the external cohort TASOAC also demonstrated an excellent accuracy for both M32-3 (90.5%) and MH17 (85.7%), confirming the reliability and performance of these two developed ML models in the early detection of at-risk knee OA structural progressors.

Intraosseous (IO) infusion of medication during surgery has been shown to be a new and effective way to manage pain in patients undergoing total knee arthroplasty (TKA), according to a recent study.

To determine the safety and efficacy of injecting pain medication directly into the tibia during surgery and the impact that this method may have on pain levels and time spent in the hospital, the researchers performed a double-blind, randomized controlled study examining patients undergoing TKA (n = 48). The patients were divided into 2 groups: the experimental group (n = 24) who received both an IO antibiotic injection and 10 mg of morphine, and the control group (n = 24) who received only a standard IO injection of antibiotics.

The researchers assessed pain, nausea, and opioid use up to 14 days post-surgery for all patients. Additionally, the researchers examined morphine and interleukin-6 serum levels in a subgroup of 20 patients 10 hours post-surgery.

The researchers used the Visual Analog Scale to determine the level of pain each patient had postoperatively. Patients in the experimental group had a lower pain score at 1-, 2-, 3-, and 5-hours post-surgery (P = .0032, P = .005, P = .020, P = .10) when compared with the control group. The decrease in pain continued for postoperative day 1 (40% reduction, P = .01), day 2 (49% reduction, P = .036), day 8 (38% reduction, P = .025), and day 9 (33% reduction, P = .041).

Furthermore, the researchers saw a lower opioid consumption within the first 48 hours and the 2nd-week post-surgery among the experimental group when compared with the control group (P < .05). Serum morphine levels in were significantly less in the experimental group than in the control group 10 hours after IO injection (P = .049). The experimental group also has significant improvement (P < .05) in the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement scores at 2- and 8-weeks post-surgery.

Overall, the experimental group showed significant improvement and outcome post-surgery.

“IO morphine combined with a standard antibiotic solution demonstrates superior postoperative pain relief immediately and up to 2 weeks,” the researchers concluded. “IO morphine is a safe and effective method to lessen postoperative pain in TKA patients.”

 

—Jessica Ganga

Reference:

Brozovich AA, Incavo SJ, Lambert BS, et al. Intraosseous morphine decreases postoperative pain and pain medication use in total knee arthroplasty: a double-blind, randomized controlled trial. J Arthroplasty. 2022;37(6):139-146. doi:10.1016/j.arth.2021.10.009.