Kremers, Hilal Maradit

Background: In the presence of a competing risk of death, the Kaplan-Meier method is known to overestimate the probability of implant failure. To our knowledge, the magnitude of the competing risk of death in survivorship analyses in total knee arthroplasty has not been studied. The purpose of this study was to determine the extent of the competing risk of death in different age groups during a long-term follow-up of patients who had undergone primary total knee arthroplasty. Methods: The study population comprised 22,864 primary total knee arthroplasties at a large medical center in the United States. We compared the overall revision outcomes estimated using the Kaplan-Meier method and the cumulative incidence function over a mean follow-up of 7.8 years (range, 0.1 to 26.3 years). Results: The risk of death exceeded the risk of revision by a factor of 4 at twelve years following the surgical procedure. The Kaplan-Meier method overestimated the risk of revision by 3% at five years, 14% at ten years, 32% at fifteen years, and 57% at twenty years. At ten years after the surgical procedure, the risk of death exceeded the risk of revision by a factor of 15 in the all-polyethylene group and by a factor of 3.5 in the metal modular group. The Kaplan-Meier method overestimated the ten-year risk of revision by 18% in the all-polyethylene group and by 11% in the metal modular group. After accounting for the higher competing risk of death in the all-polyethylene group, the cumulative incidence of revision in the metal modular group was about 2.5 to three times higher than that in the all-polyethylene group at ten years. Conclusions: Although the Kaplan-Meier and cumulative incidence methods yielded different implant survival estimates beyond ten years (Kaplan-Meier overestimates implant failure), the size of the bias was small at earlier time points. The extent of overestimation depends on the duration of follow-up and the magnitude of the competing risk of death. Clinical Relevance: This study examines the clinical relevance of the competing risk of death in total knee arthroplasty.

ObjectiveIt is unclear whether isolated cutaneous lupus erythematosus (CLE) affects cardiovascular risk. We estimated the cumulative incidence and mortality of cardiovascular diseases in a population‐based CLE cohort and compared the risk with a matched non‐CLE cohort.MethodsAll incident cases of CLE in Olmsted County, Minnesota, between 1965 and 2005 were followed until December 2013. The cumulative incidence of cerebrovascular accidents (CVAs [including stroke and transient ischemic attack]), ischemic heart disease (IHD [including coronary artery disease, myocardial infarction, and angina pectoris]), heart failure, and peripheral arterial disease (PAD) was derived and compared to an age‐, sex‐, and calendar year–matched non‐CLE cohort using Cox models.ResultsThere were 155 patients with CLE (mean ± SD age at diagnosis 48 ± 16 years, 65% female, mean ± SD BMI 26.3 ± 7.1 kg/m2, 40% smokers, 9% with diabetes mellitus). During a median followup of 14.6 years, 41 CLE patients had cardiovascular events (15 patients with CVAs, 32 patients with IHD), with a 20‐year cumulative incidence of 31.6%. As compared to non‐CLE subjects, the risk of CVAs (smoking‐adjusted hazard ratio [HR] 2.97 [95% confidence interval (95% CI) 1.13–7.78]) and PAD (HR 2.06 [95% CI 0.99–4.32]) was increased in patients with CLE, but the risk of IHD was not increased (HR 0.94 [95% CI 0.57–1.54]). There was no increase in cardiovascular mortality (HR 1.68 [95% CI 0.76–3.75]). The magnitude of risk for any cardiovascular outcome was not significantly influenced by the extent of cutaneous involvement.ConclusionCLE may be associated with an increased risk of CVAs and PAD, but not IHD. Factors contributing to increased CVA risk in patients with CLE merit evaluation.

Background: Reconstruction of anterior cruciate ligament (ACL) tears may potentially prevent the development of secondary meniscal injuries and arthritis. Purpose/Hypothesis: The purpose of this study was to (1) evaluate the protective benefit of ACL reconstruction (ACLR) in preventing subsequent meniscal tears or arthritis, (2) determine if earlier ACLR (<1 year after injury) offers greater protective benefits than delayed reconstruction (≥1 year after injury), and (3) evaluate factors predictive of long-term sequelae after ACLR. The hypothesis was that the incidence of secondary meniscal tears, arthritis, and total knee arthroplasty (TKA) would be higher in patients treated nonoperatively after ACL tears than patients treated with surgical reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: This retrospective study included a population-based incidence cohort of 964 patients with new-onset, isolated ACL tears between 1990 and 2000 as well as an age- and sex-matched cohort of 964 patients without ACL tears. A chart review was performed to collect information related to the initial injury, treatment, and outcomes. A total of 509 patients were treated with early ACLR, 91 with delayed ACLR, and 364 nonoperatively. All patients were retrospectively followed (range, 2 months to 25 years) to determine the development of subsequent meniscal tears, arthritis, or TKA. Results: At a mean follow-up of 13.7 years, patients treated nonoperatively after ACL tears had a significantly higher likelihood of developing a secondary meniscal tear (hazard ratio [HR], 5.4; 95% CI, 3.8-7.6), being diagnosed with arthritis (HR, 6.0; 95% CI, 4.3-8.4), and undergoing TKA (HR, 16.7; 95% CI, 5.0-55.2) compared with patients treated with ACLR. Similarly, patients treated with delayed ACLR had a higher likelihood of developing a secondary meniscal tear (HR, 3.9; 95% CI, 2.2-6.9) and being diagnosed with arthritis (HR, 6.2; 95% CI, 3.4-11.4) compared with patients treated with early ACLR. Age >21 years at the time of injury, articular cartilage damage, and medial/lateral meniscal tears were predictive of arthritis after ACLR. Conclusion: Patients treated with ACLR have a significantly lower risk of secondary meniscal tears, symptomatic arthritis, and TKA when compared with patients treated nonoperatively after ACL tears. Similarly, early ACLR significantly reduces the risk of subsequent meniscal tears and arthritis compared with delayed ACLR.

Background: Among patients treated nonoperatively for 1 year after anterior cruciate ligament (ACL) disruption, little is known about the frequency of ACL reconstruction within the first year of injury and the effect of age range, sex, and meniscal tears on the incidence of ACL reconstruction between 1 and 10 years after injury. Purpose: To (1) define the rate of delayed ACL reconstruction (between 1 and 10 years after injury) in a population-based cohort of isolated ACL tears and (2) evaluate predictive factors associated with delayed reconstruction. Study Design: Case-control study; Level of evidence, 3. Methods: The study included a population-based cohort of 1841 patients with new-onset, isolated ACL tears that occurred between January 1, 1990, and December 31, 2010. The complete medical records were reviewed to confirm diagnosis and collect data on clinical characteristics and details of subsequent ACL surgery. To evaluate the incidence of ACL reconstruction between 1 and 10 years after injury, landmark survival analysis was performed with a landmark set at 1 year after injury. Early and late predictors of ACL reconstruction were analyzed using Cox proportional hazards regression. Results: A total of 661 patients were treated nonoperatively for the first year after ACL tears. Over a mean 10 years of follow-up, 213 patients (32%) underwent ACL reconstruction between 1 and 10 years after injury. Young age (hazard ratio [HR], 0.55 per decade increase in age; 95% CI, 0.48-0.62) and meniscal tear at injury (HR, 1.48; 95% CI, 1.12-1.95) were significant predictors of undergoing delayed reconstruction. The rate of delayed ACL reconstruction decreased significantly over the study period ( P < .03). There was no association between sex (HR, 0.89; 95% CI, 0.67-1.16) and delayed ACL reconstruction. Among patients who had delayed ACL reconstruction, 40% experienced a secondary meniscal tear before surgery. Conclusion: In this study population of 1841 patients, 62% of patients received ACL reconstruction within 1 year of injury. Of patients treated nonoperatively for 1 year after ACL tears, 32% underwent delayed ACL reconstruction. Predictors of reconstruction beyond 1 year were young age (50% reduction in reconstruction per decade increased age) and baseline meniscal tear. Sex was not predictive for reconstruction beyond 1 year from injury.

Background: The incidence of isolated anterior cruciate ligament (ACL) tears in the general population is not well defined. Purpose/Hypothesis: The purpose of this study was to define the population-based incidence of ACL tears, describe trends in ACL injuries over time, and evaluate changes in the rate of surgical management. The hypothesis was that the incidence of ACL injury and the rate of subsequent ACL reconstruction increase over time. Study Design: Cohort study; Level of evidence, 3. Methods: The study population included 1841 individuals who were diagnosed with new-onset, isolated ACL tears (without concomitant ligament injury that required surgery) between January 1, 1990, and December 31, 2010. The complete medical records were reviewed to confirm diagnosis and to extract injury and treatment details. Age- and sex-specific incidence rates were calculated and adjusted to the 2010 US population. Poisson regression analyses were performed to examine incidence trends by age, sex, and calendar period. Results: The overall age- and sex-adjusted annual incidence of ACL tears was 68.6 per 100,000 person-years. Incidence was significantly higher in male patients than in females (81.7 vs 55.3 per 100,000, P < .001). The incidence of isolated ACL tears decreased significantly over time in males ( P < .001) but remained relatively stable in females. Age-specific patterns differed in male and female patients, with a peak in incidence (241.0 per 100,000) between 19 and 25 years in males and a peak in incidence (227.6 per 100,000) between 14 and 18 years in females. The rate of ACL reconstruction increased significantly over time in all age groups ( P < .001). Conclusion: With an annual incidence of 68.6 per 100,000 person-years, isolated ACL tears remain a common orthopaedic injury. Differences in age-specific incidence trends in male and female patients may potentially reflect differences in sports participation patterns through the high school and college years. The significant increase in the rate of ACL reconstruction over time may reflect changing surgical indications or an increasing desire among patients to return to high levels of activity after ACL injury.

AbstractObjectivesFatigue is a common symptom of chronic inflammatory diseases. The objective of this study was to investigate fatigue in patients with Behçet's syndrome (BS) and to examine the relationship between fatigue and disease activity, quality of life, anxiety and depression.MethodsThis is a cross‐sectional study of 123 BS patients and 71 healthy controls in Turkey. All subjects completed the Multidimensional Assessment of Fatigue (MAF) questionnaire, Short form‐36 (SF‐36), Hospital Anxiety and Depression (HADS) scale and Health Assessment Questionnaire (HAQ). Disease activity among BS patients was assessed using the Behçet Syndrome Activity Scale (BSAS) and the physician's global assessment (PGA).ResultsBS patients had significantly higher MAF, HADS‐depression (HADS‐D) and HADS‐anxiety (HADS‐A) scores than the healthy controls (P < 0.001). Both the physical and mental components of the SF‐36 scale were impaired in BS patients (P = 0.0001). BS patients with active disease, depression and anxiety had significantly higher MAF scores compared to BS patients without active disease, depression and anxiety (P = 0.0001). MAF scores showed positive correlations with HADS‐A, HADS‐D, HAQ scores and negative correlations with SF‐36 mental and physical components. In regression analyses, depression, anxiety and physical dysfunction were significantly associated with fatigue, after adjusting for age, sex, SF‐36 physical and mental scores, HAQ, HADS‐A, HADS‐D and BSAS scores (P < 0.05). Decreases in SF‐36 physical and mental scores were significant predictive factors for high MAF score in healthy controls (P < 0.05).ConclusionsFatigue is common in clinically active BS patients compared with healthy controls and inactive BS patients. Depression, anxiety and physical dysfunction were significantly associated with fatigue.

ABSTRACTLike any foreign object, orthopaedic implants are susceptible to infection when introduced into the human body. Without additional preventative measures, the absolute number of annual prosthetic joint infections will continue to rise, and may exceed the capacity of health care systems in the near future. Bacteria are difficult to eradicate from synovial joints due to their exceptionally diverse taxonomy, complex mechanistic attachment capabilities, and tendency to evolve antibiotic resistance. When a primary orthopaedic implant fails from prosthetic joint infection, surgeons are generally challenged by limited options for intervention. In this review, we highlight the etiology and taxonomic groupings of bacteria known to cause prosthetic joint infections, and examine their key mechanisms of attachment. We propose that antimicrobial strategies should focus on the most harmful bacteria taxa within the context of occurrence, taxonomic diversity, adhesion mechanisms, and implant design. Patient‐specific identification of organisms that cause prosthetic joint infections will permit assessment of their biological vulnerabilities. The latter can be targeted using a range of antimicrobial techniques that exploit different colonization mechanisms including implant surface attachment, biofilm formation, and/or hematogenous recruitment. We anticipate that customized strategies for each patient, joint, and prosthetic component will be most effective at reducing prosthetic joint infections, including those caused by antibiotic‐resistant and polymicrobial bacteria. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:177–186, 2016.

Background: Lateral elbow tendinosis (epicondylitis) is a common condition both in primary care and specialty clinics. Purpose: To evaluate the natural history (ie, incidence, recurrence, and progression to surgery) of lateral elbow tendinosis in a large population. Study Design: Descriptive epidemiology study. Methods: The study population comprised a population-based incidence cohort of patients with new-onset lateral elbow tendinosis between January 1, 2000, and December 31, 2012. The medical records of a 10% random sample (n = 576) were reviewed to ascertain information on patient and disease characteristics, treatment modalities, recurrence, and progression to surgery. Age- and sex-specific incidence rates were calculated and adjusted to the 2010 US population. Results: The age- and sex-adjusted annual incidence of lateral elbow tendinosis decreased significantly over time from 4.5 per 1000 people in 2000 to 2.4 per 1000 in 2012 ( P < .001). The recurrence rate within 2 years was 8.5% and remained constant over time. The proportion of surgically treated cases within 2 years of diagnosis tripled over time, from 1.1% during the 2000-2002 time period to 3.2% after 2009 ( P < .00001). About 1 in 10 patients with persistent symptoms at 6 months required surgery. Conclusion: The decrease in incidence of lateral elbow tendinosis may represent changes in diagnosis patterns or a true decrease in disease incidence. Natural history data can be used to help guide patients and providers in determining the most appropriate course at a given time in the disease process. The study data suggest that patients without resolution after 6 months of onset may have a prolonged disease course and may need surgical intervention.

ObjectiveThe role of cardiovascular disease (CVD) risk factors in psoriatic arthritis (PsA) is poorly understood. We examined the prevalence of CVD risk factors at initial onset of PsA and compared the observed incidence of CVD events with that predicted by the Framingham Risk Score (FRS) to determine its applicability in this patient population.MethodsA population‐based incidence cohort of 158 patients with PsA who fulfilled Classification of Psoriatic Arthritis criteria for PsA in 1989–2008 was assembled. Medical records were reviewed to ascertain CVD risk factors and CVD events. Future risk of CVD was estimated using the FRS algorithm.ResultsMean age was 43.4 years (range 19–74 years), 61% were men, and 44% were obese (body mass index ≥30 kg/m2). Fifty‐four patients (34%) presented with ≥2 CVD risk factors at PsA incidence. Among 126 patients ages ≥30 years at PsA incidence with no prior history of CVD, 33% had an FRS ≥10%, with 11% having an FRS ≥20%, and 18 experienced a CVD event in the first 10 years of disease duration. The 10‐year cumulative incidence of CVD events was 17% (95% confidence interval [95% CI] 10%–24%), almost twice as high as the predicted incidence based on the FRS (standardized incidence ratio 1.80, 95% CI 1.14–2.86; P = 0.012).ConclusionThe majority of newly diagnosed PsA patients have a >10% risk of CVD within 10 years of PsA incidence. The CVD risk in these patients is higher than expected and underestimated by the FRS.

Objective Epidemiologic studies comparing the incidence and prevalence of systemic lupus erythematosus (SLE) and isolated cutaneous lupus erythematosus (CLE) are few. Olmsted County, Minnesota provides a unique setting for such a study owing to resources of the Rochester Epidemiology Project. We sought to describe and compare the incidence and prevalence of SLE and CLE from 1993–2005. Methods SLE cases were identified from review of medical records and fulfilled the 1982 American College of Rheumatology classification criteria. CLE cases included patients with classic discoid lupus erythematosus, subacute CLE, lupus panniculitis, and bullous lupus erythematosus. Age‐ and sex‐adjusted incidence and prevalence were standardized to the 2000 US white population. Results The age‐ and sex‐adjusted incidence of SLE (2.9 per 100,000; 95% confidence interval [95% CI] 2.0–3.7) was similar to that of CLE (4.2 per 100,000; 95% CI 3.1–5.2, P = 0.10). However, the incidence of CLE was 3 times higher than SLE in men (2.4 versus 0.8 per 100,000; P = 0.009). The age‐ and sex‐adjusted prevalence of CLE on January 1, 2006 was higher than that of SLE (70.4 versus 30.5 per 100,000; P < 0.001). The prevalences of CLE and SLE in women were similar, but the prevalence of CLE was higher in men than in women (56.9 versus 1.6 per 100,000; P < 0.001). The incidence of CLE rose steadily with age and peaked at 60–69 years. Conclusion The incidences of CLE and SLE are similar, but CLE is more common than SLE in men and in older adults. These findings may reflect differences in genetic or environmental etiology of CLE.