- 作者列表："Wyles CC","Tibbo ME","Yuan BJ","Trousdale RT","Berry DJ","Abdel MP
BACKGROUND:Distal femoral replacement (DFR) is a salvage option for complex primary and revision total knee arthroplasty (TKA). Although excellent immediate fixation and weight-bearing are achieved, there is a paucity of data on long-term outcomes of TKA with DFR. The purpose of the present study was to determine implant survivorship, clinical outcomes, and radiographic results of TKAs with contemporary DFR components in a large series. METHODS:We identified 144 consecutive TKAs performed with DFR for non-oncologic indications from 2000 to 2015 at a single academic institution. Indications for the index DFR included 66 (46%) for native (n = 11) or periprosthetic (n = 55) femoral fracture, 40 (28%) for staged treatment of periprosthetic joint infection, 28 (19%) for aseptic TKA loosening, and 10 (7%) for other indications. Porous metal cones were used to augment femoral fixation in 28 patients (19%) and tibial fixation in 38 patients (26%). Outcomes included cumulative incidence of revision and reoperation (utilizing a competing risk model), Knee Society scores, and radiographic results. The mean age at the time of index DFR was 72 years, and 65% of patients were female. The mean follow-up was 5 years (range, 2 to 13 years) for the 111 patients who did not undergo revision, had not died, and were not lost to follow-up. RESULTS:The 10-year cumulative incidences of revision for aseptic loosening, all-cause revision, and any reoperation were 17.0%, 27.5%, and 46.3%, respectively. There was an increased risk of reoperation in patients who underwent index DFR for aseptic TKA loosening (hazard ratio [HR], 2.30; p = 0.026) or periprosthetic joint infection (HR, 2.18; p = 0.022) compared with periprosthetic or native femoral fractures. However, there was no difference in risk of revision for aseptic loosening or all-cause revision based on the original operative indication. The mean Knee Society score increased from 45 preoperatively to 71 at the time of the latest follow-up (p < 0.001). Radiographic loosening was observed in 8 unrevised DFRs (7%). There were 7 above-the-knee amputations performed at the time of the final follow-up, all for intractable periprosthetic joint infection. CONCLUSIONS:TKAs with contemporary DFR had high 10-year cumulative incidences of both revision and reoperation, underscoring the salvage nature of this procedure as a final reconstructive option. Most patients experienced substantial clinical improvements with this end-stage revision procedure. LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
背景: 远端股骨置换术 (DFR) 是复杂初次和翻修全膝关节置换术 (TKA) 的挽救性选择。虽然获得了极好的即刻固定和负重，但缺乏关于DFR TKA长期预后的数据。本研究的目的是确定大系列中具有当代DFR成分的TKAs的植入物存活率、临床结果和影像学结果。 方法: 我们确定了 2000 年至 2015 年在单一学术机构使用DFR进行的 144 例非肿瘤适应症的连续TKAs。指数DFR的适应症包括 66 例 (46%) 为本地 (n = 11) 或假体周围 (n = 55) 股骨骨折，40 例 (28%) 为假体周围关节感染的分期治疗，28 例 (19%) 为无菌性TKA松动，10 例 (7%) 为其他指征。多孔金属锥用于增强股骨固定 28 例 (19%)，胫骨固定 38 例 (26%)。结局包括翻修和再次手术的累积发生率 (利用竞争风险模型) 、膝关节协会评分和影像学结果。指数DFR时的平均年龄为 72 岁，65% 的患者为女性。111 例患者的平均随访时间为 5 年 (范围，2-13 年)，这些患者没有进行翻修，没有死亡，也没有失去随访。 结果: 10 年无菌性松动翻修、全因翻修和任何再次手术的累积发生率分别为 17.0% 、 27.5% 和 46.3%。接受指数DFR的无菌性TKA松动 (风险比 [HR]，2.30; p = 0.026) 或假体周围关节感染 (HR，2.18; p = 0.022) 与假体周围或自体股骨骨折相比。然而，根据最初的手术适应症，无菌性松动或全因翻修的翻修风险没有差异。平均膝关节社会评分从术前的 45 分增加到最近一次随访时的 71 分 (p <0.001)。在 8 例未修订的DFRs (7%) 中观察到影像学松动。在最后一次随访时，共有 7 例膝上截肢，均为顽固性假体周围感染。 结论: 当代DFR的TKAs翻修和再手术的 10 年累积发生率均较高，强调了该手术作为最终重建选择的挽救性。大多数患者在这种终末期翻修手术中经历了实质性的临床改善。 证据级别: 治疗性IV级。有关证据级别的完整描述，请参见作者说明。
METHODS:OBJECTIVE:Patients with immune-mediated inflammatory diseases such as rheumatoid arthritis or systemic lupus erythematosus are at increased risk of cardiovascular disease. However, the cardiovascular risk of patients with primary Sjögren's syndrome (SS) remains poorly studied. We aimed to investigate the association between primary SS and cardiovascular morbidity and mortality. METHODS:We performed a systematic review of articles in Medline and the Cochrane Library and recent abstracts from US and European meetings, searching for reports of randomized controlled studies of cardiovascular morbidity and cardiovascular mortality in primary SS. The relative risk (RR) values for cardiovascular morbidity and mortality associated with primary SS were collected and pooled in a meta-analysis with a random-effects model by using Review Manager (Cochrane collaboration). RESULTS:The literature search revealed 484 articles and abstracts of interest; 14 studies (67,124 patients with primary SS) were included in the meta-analysis. With primary SS versus control populations, the risk was significantly increased for coronary morbidity (RR 1.34 [95% confidence interval (95% CI) 1.06-1.38]; P = 0.01), cerebrovascular morbidity (RR 1.46 [95% CI 1.43-1.49]; P < 0.00001), heart failure rate (odds ratio 2.54 [95% CI 1.30-4.97]; P < 0.007), and thromboembolic morbidity (RR 1.78 [95% CI 1.41-2.25]; P < 0.00001), with no statistically significant increased risk of cardiovascular mortality (RR 1.48 [95% CI 0.77-2.85]; P = 0.24). CONCLUSION:This meta-analysis demonstrates that primary SS is associated with increased cardiovascular morbidity, which suggests that these patients should be screened for cardiovascular comorbidities and considered for preventive interventions, in a multidisciplinary approach with cardiologists.
METHODS:OBJECTIVE:We aimed to evaluate the comparative risk of hospitalized infection among patients with rheumatoid arthritis (RA) who initiated abatacept versus a tumor necrosis factor inhibitor (TNFi). METHODS:Using claims data from Truven MarketScan database (2006-2015), we identified patients with RA ages ≥18 years with ≥2 RA diagnoses who initiated treatment with abatacept or a TNFi. The primary outcome was a composite end point of any hospitalized infection. Secondary outcomes included bacterial infection, herpes zoster, and infections affecting different organ systems. We performed 1:1 propensity score (PS) matching between the groups in order to control for baseline confounders. We estimated incidence rates (IRs) and hazard ratios (HRs) with 95% confidence intervals (95% CIs) for hospitalized infection. RESULTS:We identified 11,248 PS-matched pairs of patients who initiated treatment with abatacept and TNFi with a median age of 56 years (83% were women). The IR per 1,000 person-years for any hospitalized infection was 37 among patients who initiated treatment with abatacept and 47 in those who initiated treatment with TNFi. The HR for the risk of any hospitalized infection associated with abatacept versus TNFi was 0.78 (95% CI 0.64-0.95) and remained lower when compared to infliximab (HR 0.63 [95% CI 0.47-0.85]), while no significant difference was seen when compared to adalimumab and etanercept. The risk of secondary outcomes was lower for abatacept for pulmonary infections, and similar to TNFi for the remaining outcomes. CONCLUSION:In this large cohort of patients with RA who initiated treatment with abatacept or TNFi as a first- or second-line biologic agent, we found a lower risk of hospitalized infection after initiating abatacept versus TNFi, which was driven mostly by infliximab.
METHODS:OBJECTIVE:Reducing pain is one of the main health priorities for children and young people with juvenile idiopathic arthritis (JIA); however, some studies indicate that pain is not routinely assessed in this patient group. The aim of this study was to explore health care professionals' (HCPs) beliefs about the role of pain and the prioritization of its assessment in children and young people with JIA. METHODS:Semi-structured interviews were conducted with HCPs who manage children and young people with JIA in the UK (including consultant and trainee pediatric rheumatologists, nurses, physical therapists, and occupational therapists). Data were analyzed qualitatively following a framework analysis approach. RESULTS:Twenty-one HCPs participated. Analyses of the data identified 6 themes, including lack of training and low confidence in pain assessment, reluctance to engage in pain discussions, low prioritization of pain assessment, specific beliefs about the nature of pain in JIA, treatment of pain in JIA, and undervaluing pain reports. Assessment of pain symptoms was regarded as a low priority and some HCPs actively avoided conversations about pain. CONCLUSION:These findings indicate that the assessment of pain in children and young people with JIA may be limited by knowledge, skills, and attitudinal factors. HCPs' accounts of their beliefs about pain in JIA and their low prioritization of pain in clinical practice suggest that a shift in perceptions about pain management may be helpful for professionals managing children and young people with this condition.