Performance of Sequencing Assays in Diagnosis of Prosthetic Joint Infection: A Systematic Review and Meta-Analysis.

BACKGROUND: A prompt, accurate diagnosis of prosthetic joint infection (PJI) allows early treatment, and with identification of the causative organism, sensitive antibiotics could be applied. However, routine methods cannot identify the causative organism under certain circumstances. Gene sequencing assays have unique superiority in promptness and broad coverage of pathogens, but evidence of its accuracy is quite limited. METHODS: Of 247 citations identified for screening, 12 studies with 1965 patients in total were included. The diagnostic value of sequencing assays in PJI was systematically reviewed. Subgroup analysis was conducted to explore the source of heterogeneity. RESULTS: Pooled sensitivity was 0.81 (95% confidence interval [CI], 0.73-0.87); pooled specificity was 0.94 (95% CI, 0.91-0.97); positive likelihood ratio was 14.2 (95% CI, 8.7-23.4); negative likelihood ratio was 0.20 (95% CI, 0.14-0.29); and the area under the curve was 0.94 (95% CI, 0.18-1.00). The results of subgroup analysis revealed that antibiotics reduced the sensitivity of sequencing-based diagnosis compared with withholding antibiotics before sampling (0.71 vs 0.94). In another subgroup analysis, sequencing by synthesis (Illumina sequencing) had better specificity than other next-generation sequencing methods (0.963 vs 0.829) and specificity similar to time-consuming and laborious Sanger sequencing (0.963 vs 0.967). CONCLUSION: Sequencing assays had favorable diagnostic accuracy of PJI. When sequencing assays were applied to diagnosing PJI, an antibiotic-free interval before sampling may enhance the ability to detect the causative organism and, among next-generation sequencing methods, sequencing by synthesis seemed to have advantages over other methods in specificity.

Perioperative multiple low-dose Dexamethasones improves postoperative clinical outcomes after Total knee arthroplasty.

BACKGROUND: The purpose of this study was to investigate the efficacy and safety of multiple low-dose dexamethasones in primary total knee arthroplasty (TKA). METHODS: One hundred fifty patients were equally randomized into 3 groups: Group A (n = 50) received 2 doses of normal saline only; Group B (n = 50) received with 1 dose of intravenous dexamethasone and 1 dose of normal saline; Group C (n = 50) received with 2 doses of intravenous dexamethasone. The clinical outcomes and complications were assessed. RESULTS: The CRP and IL-6 were significantly lower in Group C and B than Group A at 24, 48, and 72 h postoperatively (P < 0.001 for all). The intensity of postoperative nausea and vomiting (PONV) in Group C was lower than Group A at 24 (P < 0.001, P = 0.002), 48 (P = 0.005, P = 0.041) and 72 h (P = 0.017, P = 0.031) postoperatively and Group B at 24 h (P = 0.027, P = 0.019) postoperatively. Pain were significantly less in Group C than Group A at 24 (P < 0.001), 48 h (P = 0.037) postoperatively and Group B 24 h (P = 0.030) postoperatively. Patients in Group C had better range of motion (ROM) and satisfaction than Group A (P < 0.001, P = 0.002) and B (P = 0.001, P = 0.043). No differences were found in complications. CONCLUSIONS: The administration of 10 mg dexamethasone 1 h before the surgery, and repeated at 6 h postoperatively can significantly reduce the level of postoperative CRP and IL-6 and the incidence of PONV, relieve pain, achieve an additional analgesic effect, and improve the early ROM compared with the other two groups in TKA. LEVEL OF EVIDENCE: Therapeutic Level I. TRIAL REGISTRATION: The Chinese Clinical Trial Registry ( ChiCTR1800017036 ). Registered on July 9, 2018.

[Comparison of filling ratio, alignment, and stability between ABG â ¡ short-stem and Corail long-stem in total hip arthroplasty for Dorr type C femur].

Objective: Using the mono-energy reconstruction images and X-ray films to investigate whether the ABG Ⅱ short-stem could improve the filling ratio, stability, and alignment in the Dorr type C femur, compared with the Corail long-stem. Methods: Among patients who were with Dorr type C femurs and treated with total hip arthroplasty between January 2006 and March 2012, 20 patients with a Corail long-stem (Corail group) and 20 patients with an ABG Ⅱ short-stem (ABG Ⅱ group) were randomly selected. The differences in gender, age, body mass index, and preoperative diagnoses between the two groups were not significant ( P>0.05). The ABG Ⅱ group was with a mean follow-up of 142 months (range, 102-156 months), and the Corail group was with a mean follow-up of 107 months (range, 91-127 months). There was no significant difference in the Harris score and subjective satisfaction score between the two groups at last follow-up ( P>0.05). At last follow-up, dual-energy CT scans with mono-energy image reconstruction were used to calculate the prosthetic filling ratio and to measure the alignment of the prosthesis in the coronal and sagittal positions. Stability assessment was performed based on X-ray films, and the subsidence distance was measured using EBRA-FCA software. Results: X-ray film observation showed that the prostheses in the two groups were stable and no signs of loosening was found. The incidence of pedestal sign was significantly lower in the ABGⅡ group than in the Corail group ( P<0.05), and the incidence of heterotopic ossification was significantly higher in the ABGⅡ group than in the Corail group ( P<0.05). The subsidence distance of femoral stem in ABG Ⅱ group was significantly greater than that in Corail group ( P<0.05), and the subsidence speed of femoral stem in ABG Ⅱ group was also greater than that in Corail group, but the difference was not significant ( P>0.05). The overall prosthesis filling ratio was significantly higher in the ABG Ⅱ group than in the Corail group ( P<0.05), while the coronal filling ratio at the lesser trochanter, 2 cm below the lesser trochanter, and 7 cm below the lesser trochanter were not significant ( P>0.05). The results of prosthesis alignment showed that there was no significant difference in the sagittal alignment error value and the incidence of coronal and sagittal alignment error >3° between the two groups ( P>0.05), while the coronal alignment error value in the ABG Ⅱ group was significantly greater than that in the Corail group ( P<0.05). Conclusion: Although the ABG Ⅱ short-stem avoids the distal-proximal mismatch of the Corail long-stem in the Dorr type C femur and thus achieves a higher filling ratio, it does not appear to achieve better alignment or stability.

iPSC-neural crest derived cells embedded in 3D printable bio-ink promote cranial bone defect repair.

Cranial bone loss presents a major clinical challenge and new regenerative approaches to address craniofacial reconstruction are in great demand. Induced pluripotent stem cell (iPSC) differentiation is a powerful tool to generate mesenchymal stromal cells (MSCs). Prior research demonstrated the potential of bone marrow-derived MSCs (BM-MSCs) and iPSC-derived mesenchymal progenitor cells via the neural crest (NCC-MPCs) or mesodermal lineages (iMSCs) to be promising cell source for bone regeneration. Overexpression of human recombinant bone morphogenetic protein (BMP)6 efficiently stimulates bone formation. The study aimed to evaluate the potential of iPSC-derived cells via neural crest or mesoderm overexpressing BMP6 and embedded in 3D printable bio-ink to generate viable bone graft alternatives for cranial reconstruction. Cell viability, osteogenic potential of cells, and bio-ink (Ink-Bone or GelXa) combinations were investigated in vitro using bioluminescent imaging. The osteogenic potential of bio-ink-cell constructs were evaluated in osteogenic media or nucleofected with BMP6 using qRT-PCR and in vitro µCT. For in vivo testing, two 2 mm circular defects were created in the frontal and parietal bones of NOD/SCID mice and treated with Ink-Bone, Ink-Bone + BM-MSC-BMP6, Ink-Bone + iMSC-BMP6, Ink-Bone + iNCC-MPC-BMP6, or left untreated. For follow-up, µCT was performed at weeks 0, 4, and 8 weeks. At the time of sacrifice (week 8), histological and immunofluorescent analyses were performed. Both bio-inks supported cell survival and promoted osteogenic differentiation of iNCC-MPCs and BM-MSCs in vitro. At 4 weeks, cell viability of both BM-MSCs and iNCC-MPCs were increased in Ink-Bone compared to GelXA. The combination of Ink-Bone with iNCC-MPC-BMP6 resulted in an increased bone volume in the frontal bone compared to the other groups at 4 weeks post-surgery. At 8 weeks, both iNCC-MPC-BMP6 and iMSC-MSC-BMP6 resulted in an increased bone volume and partial bone bridging between the implant and host bone compared to the other groups. The results of this study show the potential of NCC-MPC-incorporated bio-ink to regenerate frontal cranial defects. Therefore, this bio-ink-cell combination should be further investigated for its therapeutic potential in large animal models with larger cranial defects, allowing for 3D printing of the cell-incorporated material.

Comprehensive Comparison of Liposomal Bupivacaine with Femoral Nerve Block for Pain Control Following Total Knee Arthroplasty: An Updated Systematic Review and Meta-Analysis.

To compare the efficacy of liposomal bupivacaine (LB) and femoral nerve block following total knee arthroplasty, we conducted this systematic review and meta-analysis. 11 trials with 2,908 patients were included in this study. The pooled data demonstrated that total morphine consumption equivalents during the hospital stay was significantly increased in FNB group. In addition, LB has significantly better outcome in view of the postoperative functional recovery, such as the odds of fall, the incidences of straight leg rise (SLR), the number of patients who can walk independently in the day of surgery,the ambulation distance at POD1, the number of patients discharged at POD1. Consistent with the faster functional recovery, liposomal bupivacaine shortens the length of hospital stay. However, there was no significant difference between LB and FNB in terms of Visual Analogue Score (VAS) during the hospital stay. All in all, liposomal bupivacaine has significantly better outcome in view of the postoperative functional recovery and the length of hospital stay compared with femoral nerve block following the total knee arthroplasty.

Application of tranexamic acid and diluted epinephrine in primary total hip arthroplasty.

: Tranexamic acid (TXA) and diluted epinephrine (DEP) has been reported to be an efficient and well tolerated way for reducing blood loss in total hip arthroplasty (THA). This meta-analysis was designed to compare the effectiveness of combination application of TXA with DEP in primary THA. The following electronic databases were searched, including PubMed, EMBASE, Web of Science, the Cochrane Library, China National Knowledge Infrastructure and Google Search Engine, for published studies involving the TXA with DEP in primary THA. All randomized controlled trials (RCTs) were included. Statistical analysis was assessed using RevMan 5.3 software. Five independent RCTs were included, with a total sample size of 496 patients. The application of TXA with DEP can significantly reduce total blood loss (mean difference, 246.13; 95% CI, -369.95 to -122.32; P < 0.0001), hidden blood loss (mean difference, 299.98; 95% CI -433.61 to -166.35; P < 0.0001) and transfusion requirements (risk ratio, 0.50; 95% CI 0.28-0.90; P = 0.02) compared with the TXA alone. There were no significant differences in intraoperative blood loss (P = 0.46), drainage volume (P = 0.61), length of stay (P = 0.53) and the rate of DVT (P = 0.56) between the two groups. On the basis of current evidence, this meta-analysis showed that the application TXA with DEP is a well tolerated and efficacious treatment to reduce total blood loss, hidden blood loss and transfusion requirements in primary THA, without increasing the risk of DVT in primary THA.

Blood loss and cost-effectiveness of oral vs intravenous tranexamic acid in primary total hip arthroplasty: A randomized clinical trial.

BACKGROUND: To assess the blood loss and cost-effectiveness of the oral and intravenous (IV) administration of tranexamic acid (TXA) for the treatment of primary total hip arthroplasty (THA). METHODS: From January 2017 to August 2017, 100 patients undergoing primary THA were enrolled and randomly divided into two groups. In the oral TXA group (N = 50), 1 g of TXA (2 tablets of 500 mg) was given 2 h before the incision, and the same dose was repeated 3 h and 6 h postoperatively. In the IV TXA group (N = 50), 1 g of TXA was administered 10 min before the incision, and the same dose was repeated 3 h and 6 h postoperatively. The total follow-up period was 6 months. RESULTS: There were no statistically significant differences in total blood loss (863.3 ±â€¯272.5 mL and 886.1 ±â€¯200.2 mL, P = 0.66), maximum Hb drop (2.9 ±â€¯0.6 g/dl and 3.1 ±â€¯0.8 g/dl, P = 0.17), maximum Hct drop (7.4 ±â€¯2.1% and 7.7 ±â€¯1.8%, P = 0.48), transfusion rates (1 and 2, P = 1.00) and transfusion units (1.5 u and 3 u, P = 0.56) between the two groups. However, the costs of TXA in the oral group were significantly lower than those in the IV TXA group (¥600 and ¥3150, P < 0.01). There was no difference in the Hb levels on postoperative days 1 and 3. No significant differences were found for operating time, hospital length of stay, DVT and/or PE, and wound complications in the postoperative follow-up. CONCLUSIONS: The study demonstrated that the oral and IV administration of TXA in patients undergoing THA was proved to be an equivalent and effective method in reducing blood loss and transfusion rates. However, oral TXA is more cost-effectiveness than IV TXA, and it may be an alternative to the IV form.

Tranexamic Acid Plus Low-dose Epinephrine Reduces Blood Loss in Total Knee Arthroplasty: A Systematic Review and Meta-analysis.

The present study assessed the effectiveness of the combined administration of tranexamic acid (TXA) plus low-dose epinephrine in primary total knee arthroplasty (TKA). We searched the following Chinese electronic databases: China National Knowledge Infrastructure and WanFang Data. We also searched the following English electronic databases: PubMed, Embase, Web of Science, and Central Register of Controlled Trials. To search for additional eligible studies, we also used Google's search engine. All randomized controlled trials (RCT) comparing TXA plus low-dose epinephrine (Combined group) and TXA alone in TKA were systematically searched. The primary outcomes were total blood loss, hidden blood loss, the requirement for transfusion, maximum hemoglobin (Hb) drop, and deep venous thrombosis (DVT). Drainage volume, operation time, length of stay, hospital for special surgery (HSS) score, and range of motion (ROM) were considered as secondary outcomes. Subgroup analyses were performed to assess the benefits of using a tourniquet and the application routes of topical or intravenous TXA between the two groups. Statistical analysis was assessed using RevMan 5.3 software. Four independent RCT were included involving 426 patients, with 213 patients in the Combined group and 213 patients in the TXA alone group. In the Combined group there was significant reduction in total blood loss (MD, 204.70; 95% CI, -302.76 to -106.63; P < 0.0001), hidden blood loss (MD, 185.63; 95% CI, -227.56 to -143.71; P < 0.00001), drainage volume (MD, 93.49; 95% CI, -117.24 to -69.74; P < 0.00001), and maximum Hb drop (MD, 5.33, 95% CI, -6.75 to -3.91; P < 0.00001). No statistical differences were found postoperatively in terms of the requirement for transfusion (risk ratio, 0.52; 95% CI, 0.26-1.04; P = 0.06), operation time (MD, 0.85; 95% CI, -2.62 to 4.31; P = 0.63), length of stay (MD, -0.02; 95% CI, -0.52 to 0.47; P = 0.93), HSS score (MD, 0.78; 95% CI, -0.36 to 1.92; P = 0.18), and ROM (MD, 1.40; 95% CI, -1.01 to 3.81; P = 0.26), and not increasing the risk of DVT (risk ratio, 1.00; 95% CI, 0.33 to 3.02; P = 1.00) in the two groups. This meta-analysis demonstrated that the administration of tranexamic acid plus low-dose epinephrine is a safe and efficacious treatment to reduce total blood loss, hidden blood loss, drainage volume, and maximum Hb drop in primary TKA, without increasing the risk of DVT in primary THA.

Efficacy and safety of limb position on blood loss and range of motion after total knee arthroplasty without tourniquet: A randomized clinical trial.

BACKGROUND: The purpose of this study was to investigate the effect of postoperative limb position on blood loss and knee function after primary total knee arthroplasty without tourniquet. MATERIAL AND METHODS: One hundred patients were randomly assigned into 2 groups: Group A was given a knee flexion position at 60° for 24 h after surgery but without the tourniquet use. Patients in group B was received the tourniquet use the same flexion position as the Group A. All patients received intravenous (IV) tranexamic acid (TXA) 15 mg/kg before skin incision and another 1 g of IV-TXA after 3 h. RESULTS: The total blood loss was similar in the 2 groups. Group A had significantly less hidden blood loss and drainage volume (P = 0.023, P < 0.001), and higher intraoperative blood loss than the Group B (P < 0.001). The visual analog scale and knee circumference in Group A were lower than the Group B on postoperative days 1, 3 and 5. The range of motion was also lowering in Group A than the Group B on postoperative days 1, 3, 5 and at the 1 month. No significant differences (P > 0.05) were observed between the 2 groups regarding maximum hemoglobin drop, transfusion rate, postoperative hospital stay, DVT and/or PE, and wound-related complications. CONCLUSION: Based on the current evidence, patients treated with postoperative limb positions without a tourniquet can effectively reduce hidden blood loss and drainage volume, as well as better early clinical benefits than those treated with a tourniquet. LEVEL OF EVIDENCE: Therapeutic Level I.

Comparison of mini-subvastus approach versus medial parapatellar approach in primary total knee arthroplasty.

BACKGROUND: Minimally invasive knee arthroplasty is rapidly gaining recognition with the aim of reducing the damage to the extensional mechanism of traditional medial parapatellar approach and achieving faster recovery of patients after surgery. The purpose of this meta-analysis was to compare the efficacy and safety of mini-subvastus (MSV) and medial parapatellar (MMP) approach in primary total knee arthroplasty (TKA). MATERIAL AND METHODS: PubMed, EMBASE, the Cochrane Library, Web of Science and China National Knowledge Infrastructure and Google Search Engine were systematically searched for randomized controlled trials (RCTs) comparing mini-subvastus and medial parapatellar approach in primary TKA. Primary outcomes were total knee society score (KSS), functional KSS, straight leg-raising days. Secondary outcomes were hospital stays, blood loss, operation time, wound-related complications, deep venous thrombosis (DVT) and/or pulmonary embolism (PE). Subgroup analyzes were performed on the range of motion (ROM) at different follow-up times. RESULTS: A total of 14 RCTs involving 1172 patients were included in the meta-analysis. No significant difference between the two groups was found in functional KSS (P = 0.31), hospital stays (P = 0.07), wound-related complications (P = 0.77), DVT (P = 0.59) and/or PE (P = 0.33). The MSV approach provides higher total KSS (P = 0.007), lower straight leg raising days (P = 0.003) and less blood loss (P = 0.004) compared with the MMP approach. Additionally, patients in the MSV group had also better ROM at 4-6 weeks (P = 0.04), 3 months (P = 0.007), 6 months (P = 0.02) after surgery compared with the patients in the MMP group. CONCLUSIONS: The available evidence indicates that using the MSV approach could be a reasonable alternative to the MMP approach that may potentially ensure the integrity of the quadriceps muscles and enhance the early rapid recovery in primary TKA. LEVEL OF EVIDENCE: Level II, therapeutic study.