Analysis of Preoperative Screening Criteria for Total Joint Arthroplasty in a Veteran Population.

BACKGROUND: This study describes the experience of patients who initially failed total joint arthroplasty preoperative screening criteria but were subsequently optimized and underwent surgery. METHODS: Time to optimization from the patients' initial clinic visit was recorded. Following surgery, patients' body mass index and lab work were tracked to determine whether they "relapsed" to their preoptimized state. Descriptive statistics determined (1) the length of time to meet screening criteria and (2) which screening criteria took the longest to optimize. RESULTS: Only 11 of 84 patients (13%) required greater than 1 year to meet criteria. Most patients (76%) "relapsed" to their previous nonqualifying status after surgery; however, this reversion did not contribute significantly to an increased rate of complication in short-term follow-up (P = .4298). CONCLUSION: Patients in this study were able to achieve preoperative screening criteria for total joint arthroplasty in less than 1 year. Relapsing after surgery does not appear to adversely affect clinical outcomes.

Early Experience and Results Using Patient-Reported Outcomes Measurement Information System Scores in Primary Total Hip and Knee Arthroplasty.

BACKGROUND: Our study determined if preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores could predict achieving minimum clinically important differences (MCIDs) in postoperative PROMIS scores after primary total hip and knee arthroplasty. METHODS: Ninety-three patients were administered the PROMIS Depression, Pain Interference, and Physical Function domains at their preoperative appointment and 6-week follow-up visit. MCIDs were drawn from existing literature for the PROMIS domains. RESULTS: The MCID was achieved in 74% of patients for Pain Interference, 34% for Physical Function, and 24% for Depression. Our model could predict with 90% specificity which patients would meet MCID if their preop PROMIS Pain score was above 38, Physical Function score less than 19, or Depression score above 22. CONCLUSION: Preoperative PROMIS Pain Interference, Physical Function, and Depression scores can predict achieving MCID in postoperative PROMIS scores.

Enhancing Evaluation of Cervical Spine: Thresholds for Normal CT Relationships in the Subaxial Cervical Spine.

BACKGROUND: Very little normative computed tomography (CT) scan data exist defining expected relationships of vertebral structures in the intact cervical spine. Better understanding of normal relationships should improve sensitivity of injury detection, particularly for facet subluxation. The purpose of this paper was to describe the normal anatomical relationships and most sensitive measurements to detect abnormal alignment in the subaxial cervical spine. METHODS: A group of 30 CT scans with no documented cervical spine injury were utilized from an established database in a trauma population. Twenty-two anatomical measurements were made for each level of the subaxial cervical spine using Microview software. For the purposes of measurement, the upper confidence limit of normal was reported as two standard deviations from the mean. RESULTS: The novel, CT based measurements of bone articulation were generally smaller and had lower confidence intervals compared to traditional radiographic measurements of midline structures (such as interspinous distance, interlaminar widening, disc space widening). The upper limit of normal of facet joint height was reported (1.54 mm anterior, 1.27 mm posterior, and 2.0 mm midportion), which may help identify distractive-flexion injuries. The upper limit of normal vertebral translation (2.0 mm) was also reported to identify translation/rotation injuries. CONCLUSIONS: Normal CT measurements for the subaxial cervical spine, especially in the facets, were found to have small confidence limits and variation. Based upon these findings, we conclude that facet measurements and translation may be better screening tools than traditional radiographic criteria based upon midline structures. Using these measurements may improve detection of cervical spine injuries warranting further imaging or investigation and reducing missed injuries. CLINICAL RELEVANCE: Improved understanding of normal anatomic measures in the subaxial spine will allow for better screening and identification of injuries.

Implementation of Preoperative Screening Criteria Lowers Infection and Complication Rates Following Elective Total Hip Arthroplasty and Total Knee Arthroplasty in a Veteran Population.

BACKGROUND: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common procedures with a risk of complications. Attempting to minimize complications, our institution implemented preoperative screening criteria for patients undergoing elective total joint replacement. Our study aimed to determine if screening criteria lowered total complications and/or surgical site infections (SSI). METHODS: Two groups of consecutive patients undergoing TKA and THA at a single Veterans Affairs facility were evaluated prior to and after implementation of screening criteria, 520 and 475 respectively. Screening criteria included hemoglobin A1c ≤7, hemoglobin ≥11, body mass index ≤35, and albumin ≥3.5. Groups were analyzed for demographics, preoperative comorbidities, and postoperative complications. Rates of total complications and SSI were compared. Average follow-up was at least 2 years with minimum of 1 year. RESULTS: Demographics and comorbidities outside the screening criteria were similar. Total complication rate was reduced from 35.4% to 14.8% (P < .01) after implementation of screening criteria. For TKA, total complications were reduced from 33.1% to 15.0% (P < .01) and for THA they were reduced from 42.4% to 14.2% (P < .01). SSI rates for combined TKA and THA were reduced from 4.4% to 1.3% (P < .01). For knees, SSI was reduced from 4.6% to 1.3% (P = .01) and was statistically significant. For THA, SSI decreased from 3.8% to 1.2% (P < .05). CONCLUSION: Our institution saw a statistically significant decrease in both SSI and total complications following implementation of preoperative screening criteria for elective TKA and THA.

AML-induced osteogenic differentiation in mesenchymal stromal cells supports leukemia growth.

Genotypic and phenotypic alterations in the bone marrow (BM) microenvironment, in particular in osteoprogenitor cells, have been shown to support leukemogenesis. However, it is unclear how leukemia cells alter the BM microenvironment to create a hospitable niche. Here, we report that acute myeloid leukemia (AML) cells, but not normal CD34+ or CD33+ cells, induce osteogenic differentiation in mesenchymal stromal cells (MSCs). In addition, AML cells inhibited adipogenic differentiation of MSCs. Mechanistic studies identified that AML-derived BMPs activate Smad1/5 signaling to induce osteogenic differentiation in MSCs. Gene expression array analysis revealed that AML cells induce connective tissue growth factor (CTGF) expression in BM-MSCs irrespective of AML type. Overexpression of CTGF in a transgenic mouse model greatly enhanced leukemia engraftment in vivo. Together, our data suggest that AML cells induce a preosteoblast-rich niche in the BM that in turn enhances AML expansion.

Enhancing evaluation of cervical spine: Thresholds for normal CT relationships in the subaxial cervical spine.

BACKGROUND: Very little normative CT scan data exist defining expected relationships of vertebral structures in the intact cervical spine. Better understanding of normal relationships should improve sensitivity of injury detection, particularly for facet subluxation. The purpose of this paper was to describe the normal anatomical relationships and most sensitive measurements to detect abnormal alignment in the subaxial cervical spine. METHODS: A group of 30 CT scans with no documented cervical spine injury were utilized from an established data base in a trauma population. Twenty-two anatomical measurements were made for each level of the subaxial cervical spine using Microview software. For the purposes of measurement, the upper confidence limit of normal was reported as two standard deviations from the mean. RESULTS: The novel, CT based measurements of bone articulation were generally smaller and had lower confidence intervals compared to traditional radiographic measurements of midline structures (such as interspinous distance, interlaminar widening, disc space widening). The upper limit of normal of facet joint height was reported (1.54mm anterior, 1.27mm posterior, and 2.0mm midportion) which may help identify distractive-flexion injuries. The upper limit of normal vertebral translation (2.0mm) was also reported to identify translation/rotation injuries. CONCLUSIONS: Normal CT measurements for the subaxial cervical spine, especially in the facets, were found to have small confidence limits and variation. Based upon these findings, we conclude that facet measurements and translation may be better screening tools than traditional radiographic criteria based upon midline structures. Using these measurements may improve detection of cervical spine injuries warranting further imaging or investigation and reducing missed injuries. CLINICAL RELEVANCE: Improved understanding of normal anatomic measures in the subaxial spine will allow for better screening and identification of injuries. ETHICAL STATEMENT: This was approved by the Office of Research Institutional Review Board, Baylor College of Medicine.

Simultaneous bilateral knee arthroplasty in octogenarians: can it be safe and effective?

Simultaneous bilateral knee arthroplasty (SBTKA) in octogenarians is controversial. Our purpose was to review the outcomes of octogenarians undergoing SBTKA. All patients greater than 80 years of age who underwent SBTKA by a single surgeon were retrospectively evaluated. Fifty-six patients with an average age of 82.5 years were identified. Twelve postoperative complications occurred. Three were serious; two non-fatal PEs and one wound debridement. Minor complications included UTI, decubitus ulcer, DVT, confusion, transfusion reaction and ileus. Average postoperative survival was 7.4 years. No deaths occurred within 30 days postoperatively. Simultaneous bilateral total knee arthroplasty can be a safe and effective option for octogenarians. Complications and mortality are not higher for SBTKA compared to UTKA in this population.