Predictors of total hip replacement in community based older adults: a cohort study.

OBJECTIVE: The purpose of this study is to describe predictors of total hip replacement (THR) in community dwelling older adults. A better understanding of predictors of THR can aid in triaging patients and researching preventative strategies. DESIGN: At baseline, participants had assessment of radiographic OA and cam morphology (from pelvic radiographs), shape mode scores and hip bone mineral density (BMD; from dual energy X-ray absorptiometry (DXA)). After 2.6 and 5 years, participants reported hip pain using WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), and had hip structural changes assessed using magnetic resonance imaging (MRI). Risk of THR was analysed using mixed-effect Poisson regression. RESULTS: Incidence of THR for OA over 14 years was 4.6% (37/801). As expected, WOMAC hip pain and hip radiographic OA both predicted risk of THR. Additionally, shape mode 2 score (decreasing acetabular coverage) (RR 1.83/SD; 95% CI 1.1-3.04), shape mode 4 score (non-spherical femoral head) (RR 0.59/SD; 95% CI 0.36-0.96), cam morphology (α > 60°) (RR 2.2/SD; 95% CI 1.33-3.36), neck of femur BMD (RR 2.09/SD, 95% CI 1.48-2.94) and bone marrow lesions (BMLs) increased risk of THR (RR 7.10/unit; 95% CI 1.09-46.29). CONCLUSION: In addition to hip pain and radiographic hip OA, measures of hip shape, cam morphology, BMD and BMLs independently predict risk of THR. This supports the role of hip bone geometry and structure in the pathogenesis of end stage hip OA and has identified factors that can be used to improve prediction models for THR.

Implications for research and clinical use from a Rasch analysis of the HOOS-12 and KOOS-12 instruments.

OBJECTIVE: To evaluate the structural validity of the 12-item Hip disability and Osteoarthritis Outcome Score (HOOS-12) and 12-item Knee injury and Osteoarthritis Outcome Score (KOOS-12) using Rasch analysis and consider psychometric implications for research and clinical use. METHOD: Individual-level HOOS-12 and KOOS-12 data from the Australian Orthopaedic Association National Joint Replacement Registry, collected before and after primary total hip and knee replacement, were used for this analysis. Using the Rasch analytic approach, overall model fit and item fit were examined, together with potential reasons for misfit including response threshold ordering, differential item functioning, internal consistency, unidimensionality and item targeting. RESULTS: Overall misfit to the Rasch model was evident for both instruments. A degree of item misfit was also observed, although most items demonstrated logical sequencing of response options. Only two items (hip/knee pain frequency and awareness of hip/knee problems) displayed disordered response thresholds. The pain, function, and quality of life domains of the HOOS-12 and KOOS-12 demonstrated excellent internal consistency reliability (person separation index: 0.80-0.93) and unidimensionality. A mismatch between item difficulty and person ability scores at the highest end of the HOOS-12 and KOOS-12 scales contributed to post-operative ceiling effects (mean logit for HOOS-12: 3.57; KOOS-12: 2.58; ≈0 indicates well-targeted scale). CONCLUSION: We found evidence to support the structural validity of the three HOOS-12 and KOOS-12 domains for evaluating joint replacement outcomes. However, there may be missing content in both instruments particularly for high-functioning patients. Minor refinement of some response options may be warranted to improve item performance.

Performance of the HOOS-12 and KOOS-12 instruments for evaluating outcomes from joint replacement surgery.

OBJECTIVE: To evaluate the psychometric properties of the 12-item Hip disability and Osteoarthritis Outcome Score (HOOS-12) and Knee injury and Osteoarthritis Outcome Score (KOOS-12) for use in evaluating outcomes after joint replacement for osteoarthritis. DESIGN: Patient-reported outcomes data collected by the Australian Orthopaedic Association National Joint Replacement Registry were used for this analysis. HOOS-12 and KOOS-12 domain (pain, function, quality of life) and summary impact data were available. The Oxford Hip Score (OHS), Oxford Knee Score (OKS) and EQ-5D-5L were used as comparators. Instruments were administered pre-operatively and at 6 months post-operatively. Internal consistency reliability, floor and ceiling effects, convergent validity, known groups validity, and responsiveness were evaluated using standard psychometric techniques. RESULTS: Baseline HOOS-12 and KOOS-12 data were available for 3,023 patients undergoing primary total hip replacement and 4,010 patients undergoing primary total knee replacement. At baseline, high internal consistency was demonstrated for all domains and summary scores (Cronbach's alpha: HOOS-12 = 0.81-0.93; KOOS-12 = 0.82-0.92). Post-operative ceiling effects (>15% of patients scoring the best possible score) were identified for the HOOS-12 pain (46%), function (39%) and quality of life domains (26%) and summary score (17%), and for the KOOS-12 pain (21%) and function domains (18%). The HOOS-12 and KOOS-12 could differentiate between two known groups (lowest/highest OHS or OKS quartiles post-operatively; p < 0.001) and were highly responsive to change (effect sizes for HOOS-12: 2.20-2.83; KOOS-12: 1.82-2.35). CONCLUSION: The HOOS-12 and KOOS-12 have good psychometric properties for capturing joint replacement outcomes including excellent responsiveness, although ceiling effects may limit monitoring of post-operative improvement.

Patellar tendon enthesis abnormalities and their association with knee pain and structural abnormalities in older adults.

OBJECTIVE: To describe associations between presence of patellar tendon enthesis (PTE) abnormalities and symptoms, structural abnormalities, and total knee replacement (TKR) in older adult cohort. METHODS: PTE abnormalities (presence of abnormal bone signal and/or bone erosion), were measured on T2-weighted magnetic resonance (MR) images at baseline in 961 community-dwelling older adults. Knee pain and function limitation were assessed using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Bone marrow lesions (BMLs), cartilage volume and defects score, and infrapatellar fat pad (IPFP) area were measured using validated methods. Incidence of TKR was determined by data linkage. RESULTS: Participants with abnormal PTE bone signal and/or erosion was 20%. Cross-sectionally, presence of PTE abnormalities was associated with greater pain intensity while going up and down stairs (ß = 0.22 (95% confidence interval (CI); 0.03, 0.41)), greater risk of femoral BMLs (RR = 1.46 (1.12, 1.90)) and worse tibial cartilage defects score (RR = 1.70 (1.16, 2.47), and smaller IPFP area (ß = -0.27 (-0.47, -0.06) cm2), after adjustment of confounders. Longitudinally, presence of baseline PTE abnormalities was associated with a deleterious increase in tibial BML size (RR = 1.52 (1.12, 2.05)) over 10.7 years but not symptoms, other structural changes, or TKR. CONCLUSION: PTE abnormalities are common in older adults. Presence of cross-sectional but not longitudinal associations suggests they are commonly co-exist with other knee structural abnormalities but may not play a major role in symptom development or structural change, excepting tibial BMLs.

Cross-Linked Polyethylene for Total Hip Arthroplasty Markedly Reduces Revision Surgery at 16 Years.

BACKGROUND: Total hip arthroplasty (THA) is an effective operation for the management of end-stage hip osteoarthritis, but long-term success can be limited by wear of the polyethylene bearing surface. Cross-linking conventional polyethylene has resulted in lower wear rates and a reduction in bone lysis in both laboratory and clinical studies. The aim of this study was to compare the rates of revision between cross-linked polyethylene (XLPE) and conventional non-cross-linked polyethylene (CPE) at 16 years after THAs performed for the treatment of osteoarthritis. METHODS: We performed an observational study of data, from a national registry, on all patients who underwent THA for osteoarthritis in Australia from 1999 through December 31, 2016. The outcomes of THAs performed with CPE were compared with those of THAs performed with XLPE, along with an analysis of the effect of age, sex, femoral head size, the method of acetabular and femoral component fixation, and the reasons and types of revision. The principal outcome measure was the time to the first revision, determined using Kaplan-Meier estimates of survivorship. RESULTS: CPE was used in 41,171 procedures, and XLPE was used in 199,131. The mean ages of the men and women treated with CPE were 70.0 years (standard deviation [SD] = 9.9 years) and 72.5 years (SD = 9.7 years), respectively, whereas the men and women who received XLPE were slightly younger (mean age, 68.6 years [SD = 10.3 years] and 70.7 years [SD = 9.9 years], respectively. XLPE was associated with a lower rate of revision than CPE at 6 months, and this difference became more apparent with time. The 16-year cumulative percentage of revisions of the primary THAs was 11.7% (95% confidence interval [CI] = 11.1% to 12.3%]) in the CPE group and 6.2% (95% CI = 5.7% to 6.7%) in the XLPE group. The hazard ratio at 9 years was 3.02 (p = 0.001). CONCLUSIONS: The use of XLPE has resulted in a significant reduction in the rate of revision at 16 years following THA for osteoarthritis. This evidence suggests that the longevity of THA is likely to be improved, which may enable younger patients to undergo surgery, confident of a reduced need for revision in the long term. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The association between ambulatory activity, body composition and hip or knee joint replacement due to osteoarthritis: a prospective cohort study.

OBJECTIVE: To examine the association between ambulatory activity (AA), body composition measures and hip or knee joint replacement (JR) due to osteoarthritis. DESIGN: At baseline, 1082 community-dwelling older-adults aged 50-80 years were studied. AA was measured objectively using pedometer and body composition by dual-energy X-ray absorptiometry. The incidence of primary (first-time) JR was determined by data linkage to the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Log binomial regression with generalized estimating equations were used to estimate the risk of JR associated with baseline AA and body composition measures, adjusting for age, sex, X-ray disease severity, and pain. RESULTS: Over 13 years of follow-up, 74 (6.8%) participants had a knee replacement (KR) and 50 (4.7%) a hip replacement (HR). AA was associated with a higher risk of KR (RR 1.09/1000 steps/day, 95% CI 1.01, 1.16) and a lower risk of HR (RR 0.90/1000 steps/day, 95% CI 0.81, 0.99). Body mass index (BMI) (RR 1.07/kg/m2, 95% CI 1.03, 1.12), total fat mass (RR 1.03/kg, 95% CI 1.01, 1.06), trunk fat mass (RR 1.05/kg, 95% CI 1.00, 1.09), and waist circumference (RR 1.02/cm, 95% CI 1.00, 1.04) were associated with a higher risk of KR. Body composition measures were not associated with HR. CONCLUSIONS: An objective measure of AA was associated with a small increased risk of KR and a small reduced risk of HR. Worse body composition profiles were associated with KR, but not HR. Altogether this may suggest different causal pathways for each site with regard to habitual activity and obesity.

The use of femoral stems with exchangeable necks in primary total hip arthroplasty increases the rate of revision.

AIMS: Femoral stems with exchangeable (modular) necks were introduced to offer surgeons an increased choice when determining the version, offset and length of the femoral neck during total hip arthroplasty (THA). It was hoped that this would improve outcomes and reduce complications, particularly dislocation. In 2010, the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) first reported an increased rate of revision after primary THA using femoral stems with an exchangeable neck. The aim of this study was to provide a more comprehensive up-to-date analysis of primary THA using femoral stems with exchangeable and fixed necks. MATERIALS AND METHODS: The data included all primary THA procedures performed for osteoarthritis (OA), reported to the AOANJRR between 01 September 1999 and 31 December 2014. There were 9289 femoral stems with an exchangeable neck and 253 165 femoral stems with a fixed neck. The characteristics of the patients and prostheses including the bearing surface and stem/neck metal combinations were examined using Cox proportional hazard ratios (HRs) and Kaplan-Meier estimates of survivorship. RESULTS: It was found that prostheses with an exchangeable neck had a higher rate of revision and this was evident regardless of the bearing surface or the size of the femoral head. Exchangeable neck prostheses with a titanium stem and a cobalt-chromium neck had a significantly higher rate of revision compared with titanium stem/titanium neck combinations (HR 1.83, 95% confidence interval 1.49 to 2.23, p < 0.001). Revisions were higher for these combinations compared with femoral stems with a fixed neck. CONCLUSION: There appears to be little evidence to support the continued use of prostheses with an exchangeable neck in primary THA undertaken for OA. Cite this article: Bone Joint J 2017;99-B:766-73.

Slaughterfloor decontamination of pork carcases with hot water or acidified sodium chlorite - a comparison in two Australian abattoirs.

A decontamination trial on the effectiveness of hot water or acidified sodium chlorite (SANOVA) treatment on Salmonella spp., Escherichia coli and Total Viable Count (TVC) was undertaken on pork carcases prior to primary chilling in two large pork abattoirs in Australia using belly-strip excision sampling. A total of 123 samples from Abattoir A and 400 samples from Abattoir B were cultured and analysed. Test pigs were selected from herds with a known high level of on-farm Salmonella infection. At Abattoir A, Salmonella spp. were not isolated from carcases. The prevalence of E. coli on control carcases was 92.9% compared with 9.8% for hot water and 12.5% for SANOVA treated carcases. The mean log(10) E. coli concentration for control carcases was 0.89 cfu/gram, compared with -0.83 cfu/gram from hot water and -0.75 cfu/gram from SANOVA treated carcases. The mean log(10) TVC for control carcases was 4.06 compared with 1.81 cfu/gram for hot water and 2.76 cfu/gram for SANOVA treated carcases. At Abattoir B, the prevalence of Salmonella on control carcases was 16% compared with 2.7% for hot water and 7.0% for SANOVA treated carcases. The prevalence of E. coli on control carcases was 69.3% compared with 22% for hot water and 30% for SANOVA treated carcases. The mean log(10) E. coli concentration for control carcases was 0.45 cfu/gram, compared with -0.65 cfu/gram from hot water and -0.60 cfu/gram from SANOVA treated carcases. The mean log(10) TVC for control carcases was 3.00 cfu/gram compared with 2.10 cfu/gram for hot water and 2.53 cfu/gram for SANOVA treated carcases. The reductions in prevalence and mean log(10) concentrations in the present trial were all found to be statistically significant and indicate that carcases decontamination with either hot water or SANOVA are effective risk management options immediately available to the pork industry.

A baseline survey of the microbiological quality of chicken portions and carcasses at retail in two Australian states (2005 to 2006).

Raw poultry products were purchased from the retail market place in two Australian states, New South Wales (n = 549) and South Australia (n = 310). The products sampled on a proportional volume basis were chicken portions with the skin off or skin on, in bulk or tray packs, and whole carcasses. They were collected from butcher shops, supermarkets, and specialty stores from urban areas during the winter (2005) and summer (2006) months. The samples were analyzed to determine the prevalence and concentration of Escherichia coli, Salmonella, and Campylobacter spp. in addition to total viable counts. Salmonella was found in 47.7 and 35.5% of retail chicken samples (35.3 and 21.9% were the less virulent Salmonella Sofia), at mean counts of -1.42 and -1.6 log MPN/cm2 in New South Wales and South Australia, respectively. Campylobacter was found in 87.8 and 93.2% of samples at mean counts of 0.87 and 0.78 log CFU/cm2, respectively. In both states in both seasons, the mean total viable count was 5 log CFU/cm2. On whole birds, E. coli was detected in all winter samples and on 92.9 and 85.7% of summer samples in New South Wales and South Australia, respectively; the log of the geometric mean per square centimeter was 0.5 in winter and slightly lower in summer. On chicken portions, E. coli was detected in around 90% of winter samples in both states, and in summer on 75.1 and 59.6% of samples in New South Wales and South Australia, respectively. The log of the geometric mean CFU per square centimeter for E. coli was 0.75 and 0.91 in winter, and 0.66 and 0.5 in summer in New South Wales and South Australia, respectively.

Evaluation of human urine as a source of nutrients for selected vegetables and maize under tunnel house conditions in the Eastern Cape, South Africa.

The introduction of ecological sanitation (ECOSAN) toilets in South Africa has created opportunities for safer sanitation and recycling of human excreta, as fertilizers, in rural and peri-urban areas. A study was carried out to evaluate the fertilizer value of human urine (0 to 400 kg N ha(-1)) for maize and tomato, compared to urea, in a tunnel house. Dry matter yield of both maize and tomato, harvested at 9 and 10 weeks after planting, respectively, increased with increasing N rate (both as urine or urea) up to 200 kg N ha(-1). Urea reduced soil electrical conductivity (EC) whereas urine increased it. Leaf tissue Na, in both crops, also increased with urine application. A follow-up study was carried out with two crops with contrasting sensitivity to salinity and using a wider range of N application (0 to 800 kg N ha(-1)). The results indicated increased root and leaf dry-matter yield of beetroot (tolerant to salinity) with increased urine rates up to the highest rate of 800 kg N ha(-1), whereas the leaf and root dry-matter yield of carrot, which is sensitive to salinity, peaked at the low urine application rate of 50 kg N ha(-1). Soil EC increased with urine application up to 4.64 and 13.35 mS cm(-1), under beetroot and carrot, respectively. Generally the results showed that human urine compared well with urea as a source of N for crops but optimum rates depend on the sensitivity of the crops to soil salinity, which should be monitored where human urine is regularly used for fertilizing crops.

Analysing microbiological data: Tobit or not Tobit?

In this paper, methods used to collect microbiological data and the common statistical technique used to analyse such data are discussed. An alternative statistical approach, considered more appropriate for many microbial datasets is suggested. The effectiveness of this method is demonstrated using a simulation study and then, for a practical example, its application in a study on the effectiveness of a decontamination process for chicken carcases.

The effect of peri-conception nutrition on embryo quality in the superovulated ewe.

Evidence indicates that oocyte/embryo quality in the sheep is affected by nutrient status during the cycle of conception. This study aimed to determine, in the superovulated ewe, if there are stages during the peri-conception period (-18 days to +6 days relative to the day of ovulation [Day 0]) when quality is more likely to be influenced by nutrition. In Experiment 1, ewes were provided with either a 0.5 x maintenance (L), 1.0 x maintenance (M) or 1.5 x maintenance (H) diet (in terms of daily energy requirements) during the peri-conception period. Diet did not affect the mean ovulation rate (range: 15.4+/-1.47 to 16.1+/-1.55) nor the mean number of embryos collected per ewe (range: 10.9+/-2.05 to 12.4+/-1.82) but there was an increase (P<0.05) in the mean number of cells per blastocyst in the L diet (74.7+/-1.45) compared with either the M (66.4+/-1.29) or H (62.0+/-0.84) diets. This increase was due to an increase in the number of trophectoderm (Tr) cells, resulting in a shift (P<0.05) in the Tr:inner cell mass (ICM) cell ratio (range 0.69+/-0.03 to 0.73+/-0.04). In Experiment 2, six diets (HHH, MHH, MHL, MLH, MLL and LLL) were imposed during three 6-day periods commencing 12 days before and continuing until 6 days after ovulation. Although diet had minimal effect on the superovulatory response, both the mean number of cells per blastocyst and the Tr:ICM ratio were increased (P<0.05) when the L diet was provided after Day 0 (diets MHL, MLL and LLL). It is concluded that the ewe is able to respond to acute changes in nutrition imposed immediately after ovulation, resulting in changes in embryo development including cell lineage differentiation. The significance of these findings, in terms of fetal development, embryo-maternal signalling and the nutritional management of the ewe is discussed.

Cytological examination and physical characteristics of the anal sacs in 17 clinically normal dogs.

OBJECTIVE: To quantify numbers of leucocytes, keratinocytes and microorganisms in, as well as the turgidity, colour and consistency of, anal sac exudates in clinically normal dogs. DESIGN: Selection criteria were formed based on the absence of clinical signs associated with anal sac disease, and the absence of factors potentially affecting colonic flora. Anal sacs were palpated for turgidity then expressed onto a swab, where colour and consistency were noted. A squash preparation made from any exudate was heat fixed and stained with modified Wright's stain. Eight representative 1000x oil immersion fields from each were examined for leucocytes, erythrocytes, keratinocytes, bacteria and yeast. Results were summarised, and cytological counts grouped into quartiles (minimal, few, moderate, numerous). Due to the multivariate nature of the study and limited subject numbers, further significant statistical analysis could not be performed. RESULTS: Seventeen dogs satisfied the selection criteria. The physical characteristics of the exudate and sac varied, though 31/34 sacs were empty or soft, 22/27 exudates were light or dark brown and 19/27 exudates were a thin liquid. Total leucocyte, keratinocyte and bacilli counts were extremely variable. Yeasts were present in 26/208 microscopic fields examined cytologically. Only 5/208 fields showed numerous cocci. A single instance of intracellular bacteria and a single erythrocyte were noted following examination of all fields. CONCLUSION: In this study, the characteristics of normal anal sacs and their exudate varied but greater than 70% showed similar features. Exudate cytology was highly variable, though yeasts were uncommon, and intracellular cocci and erythrocytes extremely rare.

Quantitative development of Paris-type arbuscular mycorrhizas formed between Asphodelus fistulosus and Glomus coronatum.

• Arum- and Paris-type symbioses are the two main morphological types of arbuscular mycorrhiza. Here, the developmental time-course of the Paris-type association formed from colonization of Asphodelus fistulosus (onion weed) by Glomus coronatum is presented. • Development was monitored over 27 d. Root colonization was assessed using a modification of the magnified intersects technique (MIT), for investigating the interdependence (thus IMIT) of structures. • Hyphal and arbusculate coils were found predominantly in the outer and inner cortex of the root, respectively. The interdependence of external hyphae, hyphal coils and arbusculate coils was determined during the relatively slow development of the symbiosis. • The time required for development of Paris-type arbuscular mycorrhizas is slower than for the Arum type, and both time and space influence the formation of hyphal coils. Use of IMIT for scoring colonization allows determination of the interdependence of different fungal structures, and thus the technique has potentially wide applications, such as in relating the presence of different structures to signals from molecular probes.

Remifentanil and propofol total intravenous anaesthesia for thymectomy in myasthenia gravis.

We report a case of trans-sternal thymectomy for myasthenia gravis using a non relaxant, total intravenous technique with propofol and remifentanil. This afforded excellent control of heart rate and pressor responses during surgery while allowing early return of spontaneous ventilation and extubation within nine minutes of termination of anaesthesia. Advantages and disadvantages of this approach versus relaxant and volatile techniques are discussed with particular reference to preservation of neuromuscular function.

Transition planning in early intervention: nurse practitioner implications.

The effective transition of young children with disabilities from early intervention services that they receive before age 3 years to services that they will receive as preschoolers is an important priority. Mandates in federal law have created new responsibilities for professionals who provide these early childhood services. As part of a multidisciplinary team, pediatric nurse practitioners can play a key role in facilitating these transitions. This article describes the PRIME Transition Model, a comprehensive, research-based model that outlines these responsibilities and presents guidelines, transition checklists, timelines, and medical and legal information.

Trial of a geriatric consultation team in an acute care hospital.

A controlled trial was conducted to examine the effects of superimposing an interdisciplinary geriatric consultation team upon the conventional patterns of care in medical wards of an acute care hospital. Two hundred and twenty-two patients, aged 69 years of age or older, admitted from the emergency room to two trial wards and 182 similar patients admitted to two control wards where the team did not work, were followed. Evaluations at admission, two and four weeks, and three and six months postadmission by independent evaluators allowed comparisons between the care groups with reference to survival, length of stay, disposition, physical, mental, and social functional levels, and use of services after discharge. Data from charts and treatment logs allowed the care processes to be compared. Findings determined that patients in the two groups were alike on socio-demographic and clinical characteristics at entry. Results demonstrated that patients in the trial and control groups fared similarly on the outcome measures at each evaluation point, although a trend toward better survival among team patients was noted. It was concluded that the addition of a consultative geriatric team to the medical wards failed to show a significant impact on patient outcomes.