Symptomatic in-hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis: a systematic review.

CONTEXT: Symptomatic venous thromboembolism (VTE) after total or partial knee arthroplasty (TPKA) and after total or partial hip arthroplasty (TPHA) are proposed patient safety indicators, but its incidence prior to discharge is not defined. OBJECTIVE: To establish a literature-based estimate of symptomatic VTE event rates prior to hospital discharge in patients undergoing TPHA or TPKA. DATA SOURCES: Search of MEDLINE, EMBASE, and the Cochrane Library (1996 to 2011), supplemented by relevant articles. STUDY SELECTION: Reports of incidence of symptomatic postoperative pulmonary embolism or deep vein thrombosis (DVT) before hospital discharge in patients who received VTE prophylaxis with either a low-molecular-weight heparin or a subcutaneous factor Xa inhibitor or oral direct inhibitor of factors Xa or IIa. DATA EXTRACTION AND SYNTHESIS: Meta-analysis of randomized clinical trials and observational studies that reported rates of postoperative symptomatic VTE in patients who received recommended VTE prophylaxis after undergoing TPHA or TPKA. Data were independently extracted by 2 analysts, and pooled incidence rates of VTE, DVT, and pulmonary embolism were estimated using random-effects models. RESULTS: The analysis included 44,844 cases provided by 47 studies. The pooled rates of symptomatic postoperative VTE before hospital discharge were 1.09% (95% CI, 0.85%-1.33%) for patients undergoing TPKA and 0.53% (95% CI, 0.35%-0.70%) for those undergoing TPHA. The pooled rates of symptomatic DVT were 0.63% (95% CI, 0.47%-0.78%) for knee arthroplasty and 0.26% (95% CI, 0.14%-0.37%) for hip arthroplasty. The pooled rates for pulmonary embolism were 0.27% (95% CI, 0.16%-0.38%) for knee arthroplasty and 0.14% (95% CI, 0.07%-0.21%) for hip arthroplasty. There was significant heterogeneity for the pooled incidence rates of symptomatic postoperative VTE in TPKA studies but less heterogeneity for DVT and pulmonary embolism in TPKA studies and for VTE, DVT, and pulmonary embolism in TPHA studies. CONCLUSION: Using current VTE prophylaxis, approximately 1 in 100 patients undergoing TPKA and approximately 1 in 200 patients undergoing TPHA develops symptomatic VTE prior to hospital discharge.

Iowa's Adult Literacy Program State Plan Extension, 2005

The major purposes of Iowa’s Adult Literacy Program State Plan Extension for Program Year 2005 are: • provide a comprehensive blue print for implementation of Title II of the Act; • serve as a basis for both immediate and long-range planning and continuous, systematic evaluation of program effectiveness; • provide basis for common understanding among Iowa’s literacy partners, other interested entities and the U.S. Department of Education. The plan extension is designed to update Iowa’s Adult Literacy State Plan for Program Year 2005 in line with the guidelines provided by the United States Department of Education: Division of Adult Education and Literacy (USDE:DAEL).

Iowa's Adult Literacy Program State Plan Extension, 2006

The passage of the Workforce Investment Act of 1998 (WIA) [Public Law 105-220] by the 105th Congress has ushered in a new era of collaboration, coordination, cooperation and accountability. The overall goal of the Act is “to increase the employment, retention, earnings of participants, and increase occupational skill attainment by participants, and, as a result improve the quality of the workforce, reduce welfare dependency, and enhance the productivity and competitiveness of the Nation.” The key principles inculcated in the Act are: • streamlining services; • empowering individuals; • universal access; • increased accountability; • new roles for local boards; • state and local flexibility; • improved youth programs. The purpose of Title II, The Adult Education and Family Literacy Act (AEFLA) of the Workforce Investment Act of 1998, is to create a partnership among the federal government, states, and localities to provide, on a voluntary basis, adult education and literacy services in order to: • assist adults to become literate and obtain the knowledge and skills necessary for employment and self-sufficiency; • assist adults who are parents obtain the educational skills necessary to become full partners in the educational development of their children; • assist adults in the completion of a secondary school education. The major purposes of Iowa’s Adult Literacy Program State Plan Extension for Program Year 2006 are: • provide a comprehensive blue print for implementation of Title II of the Act; • serve as a basis for both immediate and long-range planning and continuous, systematic evaluation of program effectiveness; • provide basis for common understanding among Iowa’s literacy partners, other interested entities and the U.S. Department of Education. The plan extension is designed to update Iowa’s Adult Literacy State Plan for Program Year 2006 in line with the guidelines provided by the United States Department of Education: Division of Adult Education and Literacy (USDE:DAEL).

Iowa’s Adult Literacy Program State Plan Extension, 2007

The passage of the Workforce Investment Act of 1998 (WIA) [Public Law 105-220] by the 105th Congress has ushered in a new era of collaboration, coordination, cooperation and accountability. The overall goal of the Act is “to increase the employment, retention, earnings of participants, and increase occupational skill attainment by participants, and, as a result improve the quality of the workforce, reduce welfare dependency, and enhance the productivity and competitiveness of the Nation.”

Mesurer l'amplitude articulaire du genou: goniométre universel ou smartphone [Measurement of the knee range of motion: standard goniometer or smartphone?].

Universal standard goniometer is an essential tool to measure articulations' range of motion (ROM). In this time of technological advances and increasing use of smartphones, new measurement's tools appear as specific smartphone applications. This article compares the iOS application "Knee Goniometer" with universal standard goniometer to assess knee ROM. To our knowledge, this is the first study that uses a goniometer application in a clinical context. The purpose of this study is to determine if this application could be used in clinical practice.

A new approach to accurate measurement of uniaxial joint angles based on a combination of accelerometers and gyroscopes.

A new method of measuring joint angle using a combination of accelerometers and gyroscopes is presented. The method proposes a minimal sensor configuration with one sensor module mounted on each segment. The model is based on estimating the acceleration of the joint center of rotation by placing a pair of virtual sensors on the adjacent segments at the center of rotation. In the proposed technique, joint angles are found without the need for integration, so absolute angles can be obtained which are free from any source of drift. The model considers anatomical aspects and is personalized for each subject prior to each measurement. The method was validated by measuring knee flexion-extension angles of eight subjects, walking at three different speeds, and comparing the results with a reference motion measurement system. The results are very close to those of the reference system presenting very small errors (rms = 1.3, mean = 0.2, SD = 1.1 deg) and excellent correlation coefficients (0.997). The algorithm is able to provide joint angles in real-time, and ready for use in gait analysis. Technically, the system is portable, easily mountable, and can be used for long term monitoring without hindrance to natural activities.

Clinical and ultrasonographic predictors of joint replacement for knee osteoarthritis: results from a large, 3-year, prospective EULAR study.

OBJECTIVES: To determine clinical and ultrasonographic predictors of joint replacement surgery across Europe in primary osteoarthritis (OA) of the knee. METHODS: This was a 3-year prospective study of a painful OA knee cohort (from a EULAR-sponsored, multicentre study). All subjects had clinical evaluation, radiographs and ultrasonography (US) at study entry. The rate of knee replacement surgery over the 3-year follow-up period was determined using Kaplan-Meier survival data analyses. Predictive factors for joint replacement were identified by univariate log-rank test then multivariate analysis using a Cox proportional-hazards regression model. Potential baseline predictors included demographic, clinical, radiographic and US features. RESULTS: Of the 600 original patients, 531 (88.5%), mean age 67+/-10 years, mean disease duration 6.1+/-6.9 years, had follow-up data and were analysed. During follow-up (median 3 years; range 0-4 years), knee replacement was done or required for 94 patients (estimated event rate of 17.7%). In the multivariate analysis, predictors of joint replacement were as follows: Kellgren and Lawrence radiographic grade (grade > or =III vs <III, hazards ratio (HR) = 4.08 (95% CI 2.34 to 7.12), p<0.0001); ultrasonographic knee effusion (> or =4 mm vs <4 mm) (HR = 2.63 (95% CI 1.70 to 4.06), p<0.0001); knee pain intensity on a 0-100 mm visual analogue scale (> or =60 vs <60) (HR = 1.81 (95% CI 1.15 to 2.83), p=0.01) and disease duration (> or =5 years vs <5 years) (HR=1.63 (95% CI 1.08 to 2.47), p=0.02). Clinically detected effusion and US synovitis were not associated with joint replacement in the univariate analysis. CONCLUSION: Longitudinal evaluation of this OA cohort demonstrated significant progression to joint replacement. In addition to severity of radiographic damage and pain, US-detected effusion was a predictor of subsequent joint replacement.

Revue des arthroplasties totales de la hanche et du genou infectées--à propos de 28 cas [Review of infected total arthroplasties of the hip and knee--apropos of 28 cases]

This study is a long-term analysis of a group of patients with infected arthroplasties of the hip or the knee. We identified 28 patients with an infected arthroplasty (22 hips, 6 knees) documented by bacterial culture or on direct examination. At the time of diagnosis and on follow-up (a mean of 46 months after treatment) we evaluated the clinical picture, the radiological appearances of the articulation and the biological parameters. 19/28 patients showed a typical clinical picture, whereas in 9 others the picture was more doubtful. The treatments were 14 two-stage replacements of the arthroplasties, 7 simple resections, 5 conservative treatments and 2 one-stage replacements. On follow-up, 25 patients were considered as cured of their infection and 3 as failures. From a functional viewpoint, 9 patients showed no limitation, whereas 19 were limited in the daily activity. Half of the patients had no pain. Radiology showed that 20/26 evaluated patients had no signs of recurrence. Paraclinical examinations are important in the diagnosis of persistent low grade infections, particularly the demonstration of bacteria by pre-surgical sampling (fine needle aspiration, culture from draining sinuses). In spite of the cure of infection, the functional and painful sequellae are often considerable. As a result of our experience, we recommend a two-stage surgical procedure. Only when the general condition of the patient is poor, or when the infection is not under control, would we envisage an alternative procedure (arthrodesis, girdelstone, conservative).

Les douze points-clés de la rééducation après une prothèse totale de genou [The 12 keypoints for rehabilitation after total knee arthroplasty].

The rehabilitation process after total knee arthroplasty (TKA) relies more and more on the family doctor. Many factors contribute to this development: the constantly increasing number of TKA performed, the reduced length of stay at the hospital and the rehabilitation process after TKA requiring care for 3 to 4 months. After this time, it is also of major importance to encourage patients to take up physical activities in order to limit the negative effects of sedentarity. The goal of this paper is to give family doctors an overview of the current knowledge in the area of rehabilitation after TKA for physicians.

Bioimpedance for oedema evaluation after total knee arthroplasty.

BACKGROUND AND PURPOSE: Electrical bioimpedance spectroscopy (BIS) allows the evaluation of limb extracellular fluid (R0) and total fluid (Rinf). BIS could facilitate post-surgical oedema evaluation after total knee arthroplasty (TKA), as it is easily performed and is non-invasive. However, neither its applicability in this context nor the influence of metallic implants on measurement has been evaluated. The aim of this study was to evaluate the influence of TKA implants on the BIS R0 and Rinf variables used for oedema evaluation. METHOD: This was a prospective non-randomized comparative clinical trial. One oedema-free group of patients with TKA was compared with a group presenting similar characteristics except for the arthroplasty, to assess the influence of the implant on BIS measurement in the absence of oedema. The TKA group included 15 patients who had undergone surgery more than a year previously, and the control group included 19 patients awaiting TKA surgery. Volume and perimeter measurements served as reference criterions. The lower limb percentage differences for BIS, knee perimeter and volume were calculated. The significance of differences between groups was calculated for all measurement methods, using the Mann-Whitney test. The setting was a Department of Orthopedic Surgery and Traumatology in a university hospital. RESULTS: The differences between groups were not significant for R0, Rinf, volume and perimeter. R0 showed the smallest mean difference in limb percentage difference between groups [means (SD): TKA 3.98 (8.09), controls 3.97 (5.16)]. CONCLUSIONS: The lower-leg percentage difference in the TKA group is comparable with that of healthy subjects. R0 can be used for oedema evaluation following TKA surgery, as there was no sign of alteration from the metallic implant. These findings indicate the potential for early oedema evaluation after TKA. More research is warranted to extensively validate the application of BIS for oedema evaluation after TKA. Copyright © 2012 John Wiley & Sons, Ltd.

Characteristics and outcome of knee prosthetic joint infections (PJI): A 10-year cohort study (2000-2009)

Background: Prosthetic joint infections (PJI) lead to significant long-term morbidity with high cost of healthcare. We evaluated characteristics of infections and the infection and functional outcome of knee PJI over a 10-year period. Methods: All patients hospitalized at our institution from 1/2000 through 12/2009 with knee PJI (defined as growth of the same microorganism in ≥2 tissue or synovial fluid cultures, visible purulence, sinus tract or acute inflammation on tissue histopathology) were included. Patients, their relatives and/or treating physicians were contacted to determine the outcome. Results: During the study period, 61 patients with knee PJI were identified. The median age at the time of diagnosis of infection was 73 y (range, 53-94 y); 52% were men. Median hospital stay was 37 d (range, 1-145 d). Most reasons for primary arthroplasty was osteoarthritis (n = 48), trauma (n = 9) and rheumatoid arthritis (n = 4). 23 primary surgeries (40%) were performed at CHUV, 34 (60%) elsewhere. After surgery, 8 PJI were early (<3 months), 16 delayed (3-24 months) and 33 late (>24 months). PJI were treated with (i) open or arthroscopic debridement with prosthesis retention in 26 (46%), (ii) one-stage exchange in 1, (iii) two-stage exchange in 22 (39%) and (iv) prosthesis removal in 8 (14%). Isolated pathogens were S. aureus (13), coagulase-negative staphylococci (10), streptococci (5), enterococci (3), gram-negative rods (3) and anaerobes (3). Patients were followed for a median of 3.1 years, 2 patients died (unrelated to PJI). The outcome of infection was favorable in 50 patients (88%), whereas the functional outcome was favorable in 33 patients (58%). Conclusions: With the current treatment concept, the high cure rate of infection (88%) is associated with a less favorable functional outcome o 58%. Earlier surgical intervention and more rapid and improved diagnosis of infection may improve the functional outcome of PJI.

Direct magnetic resonance arthrography of the knee: utility of axial traction.

The purpose of this study was to determine the impact of axial traction during acquisition of direct magnetic resonance (MR) arthrography examination of the knee in terms of joint space width and amount of contrast material between the cartilage surfaces. Direct knee MR arthrography was performed in 11 patients on a 3-T MR imaging unit using a T1-weighted isotropic gradient echo sequence in a coronal plane with and without axial traction of 15 kg. Joint space widths were measured at the level of the medial and the lateral femorotibial joint with and without traction. The amount of contrast material in the medial and lateral femorotibial joint was assessed independently by two musculoskeletal radiologists in a semiquantitative manner using three grades ('absence of surface visualization, 'partial surface visualization or 'complete surface visualization'). With traction, joint space width increased significantly at the lateral femorotibial compartment (mean = 0.55 mm, p = 0.0105) and at the medial femorotibial compartment (mean = 0.4 mm, p = 0.0124). There was a trend towards an increased amount of contrast material in the femorotibial compartment with axial traction. Direct MR arthrography of the knee with axial traction showed a slight and significant increase of the width of the femorotibial compartment with a trend towards more contrast material between the articular cartilage surfaces.

Six Years of Denosumab Treatment in Postmenopausal Women with Osteoporosis: Results From the First Three Years of the FREEDOM Extension

Background/Purpose: Denosumab (DMAb) is an approved therapy for the treatment of postmenopausal women with osteoporosis at increased risk for fracture. A favorable risk/benefit profile was demonstrated in the pivotal, 3-year FREEDOM trial (Cummings et al NEJM 2009). The open-label, active-treatment FREEDOM Extension study is investigating the efficacy and safety of DMAb for up to 10 years. The Extension trial enrolled women who had received DMAb or placebo in FREEDOM and provides an opportunity to evaluate the long-term efficacy and safety of continuous DMAb treatment (long-term group), and to replicate the DMAb findings observed in FREEDOM (cross-over group). Here, we report the results from the first 3 years of the Extension, representing up to 6 continuous years of DMAb exposure. Methods: During the Extension, each woman is scheduled to receive 60 mg DMAb every 6 months and supplemental calcium and vitamin D daily. For the analyses reported here, women from the FREEDOM DMAb group received 3 more years of DMAb for a total of 6 years of exposure (long-term group) and women from the FREEDOM placebo group received 3 years of DMAb exposure (cross-over group). Results: Of the 5928 women eligible for the Extension, 4550 (77%) enrolled (N_2343 long-term; N_2207 cross-over). In the long-term group, further significant mean increases in bone mineral density (BMD) occurred 4044 for cumulative 6-year gains of 15.2% at the lumbar spine and 7.5% at the total hip (Figure). During the first 3 years of DMAb treatment during the Extension, the cross-over group had significant mean gains in BMD at the lumbar spine (9.4%) and total hip (4.8%), similar to those observed in the long-term DMAb group during the first 3 years of FREEDOM (lumbar spine, 10.1%; total hip, 5.7%). Serum CTX was rapidly and similarly reduced after the 1st (cross-over) or 7th (long-term) DMAb dose with the characteristic attenuation observed at the end of the dosing period. In the cross-over group, yearly incidences of new vertebral and nonvertebral fractures were lower than in the FREEDOM placebo group. Fracture incidence remained low in the long-term group. Incidences of adverse events (AEs) and serious AEs did not increase over time with DMAb treatment. There were 2 subjects with AEs adjudicated to ONJ in the cross-over group and 2 in the long-term group. Both cases in the cross-over group healed completely and without further complications; 1 of these subjects continues to receive DMAb. Both women in the long-term group continue to be followed. No atypical femur fractures have been observed to date. Figure. Percent changes in bone mineral density during FREEDOM and the Extension Conclusion: DMAb treatment for 6 continuous years (long-term group) remained well tolerated, maintained reduced bone turnover, and continued to significantly increase BMD. Fracture incidence remained low. DMAb treatment for 3 years in the cross-over group reproduced the original observations in FREEDOM