The efficacy and safety of tranexamic acid in rheumatoid arthritis patients undergoing simultaneous bilateral total knee arthroplasty: a multicenter retrospective study.

BACKGROUND: The efficacy and safety of tranexamic acid (TXA) in reducing blood loss following total knee arthroplasty (TKA) in patients with osteoarthritis have been widely confirmed. However, there is still a paucity of the evidences regarding the effectiveness of TXA in patients with rheumatoid arthritis (RA). The purpose of the study is to explore the efficacy and safety of intravenous TXA on blood loss and transfusion risk following simultaneous bilateral TKA (SBTKA) in patients with RA. METHODS: As a multicenter retrospective study, a total of 74 patients diagnosed with RA who underwent SBTKA were assigned into TXA group (15 mg/kg intravenous TXA before skin incision, n = 50) and control group (no TXA use, n = 24). The primary outcomes were total blood loss (TBL) and intraoperative blood loss (IBL). The secondary outcomes were hemoglobin (Hb) and hematocrit (Hct) drop on postoperative day 3, transfusion rate and volume, ambulation time, length of stay, hospitalization expenses and the incidence of complications. RESULTS: The mean TBL, IBL and transfusion volume in TXA group were significantly lower than those in control group. The Hb and Hct drop on postoperative day 3 in control group were higher than those in TXA group (p<0.05). The similar trend was detected on transfusion rate, ambulation time and length of stay. The incidence of complications and hospitalization expenses did not differ significantly between the two groups (p>0.05). CONCLUSIONS: TXA could effectively reduce blood loss, decrease transfusion risk, shorten ambulation time and length of stay following SBTKA in patients with RA, without increasing the risk of complications.

Risk factors of opioid use associated with an enhanced-recovery programme after total knee arthroplasty.

BACKGROUND: Characterizing the impacts of postoperative opioid use on total knee arthroplasty (TKA) patients may help optimize the pain management after TKA. The aim of the study is to examine the prevalence and risk factors for opioid use with an enhanced-recovery programme after primary TKA. METHODS: We identified 361 patients undergoing TKA, and separated those on the basis of whether to receive opioid use after surgery. Themultivariate logistic regression model was used to identify independent risk factors for opioid use after primary TKA. Length of stay (LOS) and postoperative complications were also recorded and compared. RESULTS: The prevalence of opioid use after primary TKA was 23.0%. The significant risk factor was the longer operative time (OR [odds ratio] = 1.017, 95% CI [confidence interval] = 1.001 to 1.032, p = 0.034) and the protective factor was the utilization of tranexamic acid(OR= 0.355, 95% CI = 0.161 to 0.780, p = 0.010). In addition, the LOS was longer in opioid group (p < 0.05). CONCLUSION: Considering the adverse health effects of opioid use, strategies need to be developed to prevent persistent opioid use after TKA. Reducing operative time and the application of tranexamic acid could lower the risk of opioid use with an enhanced-recovery programme after primary TKA.

Pathogenesis of acquired heterotopic ossification: Risk factors, cellular mechanisms, and therapeutic implications.

Heterotopic ossification (HO), including hereditary and acquired HO, is the formation of extraskeletal bone in skeletal muscle and surrounding soft tissues. Acquired HO is often caused by range of motion, explosion injury, nerve injury or burns. Severe HO can lead to pain and limited joint activity, affecting functional rehabilitation and quality of life. Increasing evidence shows that inflammatory processes and mesenchymal stem cells (MSCs) can drive HO. However, explicit knowledge about the specific mechanisms that result in HO and related cell precursors is still limited. Moreover, there are no effective methods to prevent or reduce HO formation. In this review, we provide an update of known risk factors and relevant cellular origins for HO. In particular, we focus on the underlying mechanisms of MSCs in acquired HO, which follow the osteogenic program. We also discuss the latest therapeutic value and implications for acquired HO. Our review highlights the current gaps in knowledge regarding the pathogenesis of acquired HO and identifies potential targets for the prevention and treatment of HO.

The effect of body mass index on blood loss and complications in simultaneous bilateral total hip arthroplasty: A multicenter retrospective study.

BACKGROUND: The effect of body mass index (BMI) on blood loss in simultaneous bilateral total hip arthroplasty (SBTHA) was still undetermined. The purpose of the study was to evaluate the blood loss, transfusion and incidence of complications in normal, overweight, and obese patients undergoing SBTHA. METHODS: A total of 344 patients following SBTHA were enrolled into this study. The patients were assigned into three groups on the basis of their BMI, including normal (BMI 18.0-24.9 kg/ m2), overweight (BMI 25.0-29.9 kg/ m2), or obese group (BMI ≥ 30.0 kg/ m2). The primary outcome was total blood loss (TBL), and secondary outcomes were intraoperative blood loss, drain volume, ratio of TBL and patient's blood volume (PBV), transfusion rate and volume, hemoglobin and hematocrit drop, length of stay, expenses, and complications. RESULTS: The PBV and TBL increased significantly along with the elevated BMI (p < 0.001; p = 0.019, respectively). There was no significant difference in intraoperative blood loss, drain volume, transfusion volume, length of stay, expenses, or incidence of complications among the three groups. In addition, the transfusion rate in normal group was higher than that in overweight (58.3% vs 39.6%, p = 0.001) and obese group (58.3% vs 31.9%, p = 0.001). The maximum hemoglobin drop in obese group was the highest (p = 0.001). CONCLUSION: Obesity could increase perioperative blood loss but not increase transfusion risk in the setting of SBTHA. Conversely, obese and overweight patients maybe have lower transfusion need compared with normal patients because of more blood volume. In addition, obesity did not affect the incidence of complications.

Association between preoperative hemoglobin and postoperative moderate and severe anemia among patients undergoing primary total knee arthroplasty: a single-center retrospective study.

BACKGROUND: Postoperative moderate and severe anemia (PMSA) has been a serious perioperative complication in primary total knee arthroplasty (TKA). However, the ideal cutoff values to predict PMSA is still undetermined. The aim of this study was (1) to identify the risk factors associated with PMSA and (2) to establish the cutoff values of preoperative hemoglobin (HB) associated with increased PMSA in primary TKA. METHODS: We identified 474 patients undergoing primary TKA and separated those in which PMSA (HB was less than 110 g/L on postoperative day 1 and 3) was developed from those without PMSA. Multivariate logistic regression model was used to identify independent risk factors for PMSA. Area under the receiver-operator curve (AUC) was used to determine the best-supported preoperative HB cutoff across all the patients. RESULTS: The PMSA rate in primary TKA was 53.2%. Significant risk factors were lower preoperative HB (OR [odds ratio] = 1.138, 95% CI [confidence interval] = 1.107-1.170, p < 0.001) and more intraoperative blood loss (OR = 1.022, 95% CI 1.484-4.598, p < 0.001). A preoperative HB cutoff value that maximized the AUC was 138.5 g/L for men (sensitivity: 79.4%, specificity: 75.0%) and 131.5 g/L for women (sensitivity: 74.7%, specificity: 80.5%), respectively. CONCLUSION: We should recognize and consider the related risk factors to establish specific, personalized risk assessment for PMSA, including preoperative HB and intraoperative blood loss. Of these, preoperative HB was a referable tool to predict PMSA in primary TKA.

Gasdermin D deficiency attenuates arthritis induced by traumatic injury but not autoantibody-assembled immune complexes.

BACKGROUND: Gasdermin D (GSDMD) is cleaved by several proteases including by caspase-1, a component of intracellular protein complexes called inflammasomes. Caspase-1 also converts pro-interleukin-1ß (pro-IL-1ß) and pro-IL-18 into bioactive IL-1ß and IL-18, respectively. GSDMD amino-terminal fragments form plasma membrane pores, which mediate the secretion of IL-1ß and IL-18 and cause the inflammatory form of cell death pyroptosis. Here, we tested the hypothesis that GSDMD contributes to joint degeneration in the K/BxN serum transfer-induced arthritis (STIA) model in which autoantibodies against glucose-6-phosphate isomerase promote the formation of pathogenic immune complexes on the surface of myeloid cells, which highly express the inflammasomes. The unexpected outcomes with the STIA model prompted us to determine the role of GSDMD in the post-traumatic osteoarthritis (PTOA) model caused by meniscus ligamentous injury (MLI) based on the hypothesis that this pore-forming protein is activated by signals released from damaged joint tissues. METHODS: Gsdmd +/+ and Gsdmd-/- mice were injected with K/BxN mouse serum or subjected to MLI to cause STIA or PTOA, respectively. Paw and ankle swelling and DXA scanning were used to assess the outcomes in the STIA model whereas histopathology and micro-computed tomography (µCT) were utilized to monitor joints in the PTOA model. Murine and human joint tissues were also examined for GSDMD, IL-1ß, and IL-18 expression by qPCR, immunohistochemistry, or immunoblotting. RESULTS: GSDMD levels were higher in serum-inoculated paws compared to PBS-injected paws. Unexpectedly, ablation of GSDMD failed to reduce joint swelling and osteolysis, suggesting that GSDMD was dispensable for the pathogenesis of STIA. GSDMD levels were also higher in MLI compared to sham-operated joints. Importantly, ablation of GSDMD attenuated MLI-associated cartilage degradation (p = 0.0097), synovitis (p = 0.014), subchondral bone sclerosis (p = 0.0006), and subchondral bone plate thickness (p = 0.0174) based on histopathological and µCT analyses. CONCLUSION: GSDMD plays a key role in the pathogenesis of PTOA, but not STIA, suggesting that its actions in experimental arthropathy are tissue context-specific.

[Posterior popliteal fossa S-shaped incision with double-window approach in treating posterior column of tibial plateau fractures].

OBJECTIVE: To evaluate the effectiveness and safty of posterior popliteal fossa S-shaped incision with double-window approach for the treatment of posterior column of tibial plateau fractures. METHODS: A retrospective analysis was made on the clinical data of 13 patients with complex tibial plateau fractures involving both posteromedial and posterolateral columns between May 2015 and July 2017. There were 9 males and 4 females, aged 33-64 years (mean, 46.5 years). The causes of injury included traffic accident in 5 cases, falling from height in 2 cases, falling from electric bicycle in 4 cases, and falling because of skiing in 2 cases. The preoperative range of motion of the affected knees was (35.1±9.2)°. The time from injury to surgery was 7-19 days (mean, 13.3 days). All patients underwent a posterior popliteal fossa S-shaped incision through the window of medial heads of gastrocnemius muscle (medial window) and the window between medial and lateral head of gastrocnemius muscle (popliteal fossa window) approaches. After a good visual control of fracture reduction, both posteromedial and posterolateral columns of tibial plateau fractures were fixed with buttress plate respectively. Bone union, limb alignment, articular surface, and range of motion were estimated after operation. The American Hospital for Special Surgery (HSS) score was used to evaluate functional outcomes of knees. RESULTS: After operation, 1 patient had fat liquefaction and dehiscence of incision, which healed after expanding the wound; the other patients' incisions healed by first intention, and no vascular or nerve injury occurred during operation. All the 13 patients were followed up 12-18 months (mean, 16 months). The X-ray films showed that all patients obtained good fracture unions, the fracture healing time was 14-22 weeks (mean, 18 weeks). At 12 months after operation, the articular surface was smooth without collapse, and the knee range of motion was (109.5±13.6)°, showing significant difference when compared with preoperative value ( t=18.879, P=0.000). No complication of infection, re-displacement of fracture, or secondary varus/valgus deformity was observed during follow-up. The HSS score was 82-96 (mean, 89.6) at 12 months after operation, with the result of excellent in 10 cases and good in 3 cases. CONCLUSION: The posterior column fracture of tibial plateau involving both posteromedial and posterolateral columns treated by double-window approach through posterior popliteal fossa S-shaped incision is safe and effective, with satisfactory results and good recovery of knee joint function.

Dextran-based hydrogel with enhanced mechanical performance via covalent and non-covalent cross-linking units carrying adipose-derived stem cells toward vascularized bone tissue engineering.

Hydrogels for biomedical applications were limited toward bone tissue engineering due to the poor mechanical performance. Tough hydrogels with strong and elastic features have received extensive attention, the application of which, however, was limited by their degradation. The present study introduced an approach to enhance mechanical properties of hydrogel while ensuring its degradation. Carboxyl dextran (Dex) was grafting modified by poly (ε-caprolactone) (PCL), sequentially followed by being cross-linked through polyethyleneglycol 400 (PEG400) to yield a gel with covalent cross-linking units in DMSO. The gel was underwent solvent displacement in H2 O to induce hydrophobic association of PCL to form non-covalent cross-linking units. The tough Dex-g-PCL hydrogel showed maximum strain of Dex-g-PCL hydrogel was 90% ± 6%, with the corresponding stress of 2.7 ± 0.2 MPa, which was significantly enhanced when comparing to dextran hydrogel (maximum strain 65% ± 5%, with the corresponding stress of 0.225 ± 0.06 MPa). Most hydrogel degraded after 12 w in vivo with only a little residues. Adipose-derived stem cells (ASCs) proliferated well after being seeded in hydrogel to form micro-mass at 14 days post-seeding. In vitro and in vivo angiogenesis, as well as in vitro osteogenesis illustrated the potential of the Dex-g-PCL hydrogel carrying ASCs toward vascularized bone tissue engineering. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 107A: 1120-1131, 2019.

[Suture-bridge fixation under arthroscopy in treatment of tibial eminence avulsion fracture of anterior cruciate ligament in adolescents].

Objective: To explore effectiveness of suture-bridge fixation under arthroscopy in treatment of tibial eminence avulsion fracture of anterior cruciate ligament in adolescents. Methods: Between June 2013 and October 2016, 18 adolescent patients suffered tibial eminence avulsion fracture of anterior cruciate ligament were treated by suture-bridge fixation under arthroscopy. There were 11 males and 7 females with an average age of 12.5 years (range, 5-17 years). The injury caused by bruise in 6 cases, by sprain in 4 cases, and by sport injury in 8 cases. The interval between injury and admission ranged from 2 hours to 10 months (mean, 2 months). The results of preoperative Lachman and anterior drawer tests were positive. There were 10 cases of knee pain, 4 cases of knee extension limitation, and 4 cases of knee extension without strength. According to the Meyer-McKeever classification criteria, 12 cases were type Ⅱ and 6 cases were type Ⅲ. Results: All incisions healed by first intention. All 18 patients were followed up 10-18 months after operation, with an average of 12 months. Postoperative X-ray films showed that all fractures healed after 6-12 weeks (mean, 8 weeks). The results of postoperative Lachman and anterior drawer tests were negative. At last follow-up, the Lysholm knee score was 90.1±5.0 and 93.1±6.2 for affected and unaffected sides, respectively, showing no significant difference between affected and unaffected sides( t=0.669, P=3.184ï¼»?ï¼½). There was no premature closure of skeleton or leg length discrepancy and deformity. Conclusion: For tibial eminence avulsion fracture of anterior cruciate ligament in adolescents, the suture-bridge fixation under arthroscopy is an effective method with many advantages, such as minimal invasion, reliable fixation, good fracture healing, and no need for second operation to remove implants.

[A modified Laprade technique in treatment of lateral multi-ligament injuries of knee].

Objective: To evaluate the short-term effectiveness of a modified Laprade technique in the treatment of lateral multi-ligament injuries of knee by anatomical reconstruction of posterolateral complex (PLC) and anterior lateral ligament (ALL). Methods: Between June 2013 and July 2015, 13 cases of lateral multi-ligament injuries of knee were treated. There were 9 males and 4 females with an average age of 38 years (range, 23-49 years). The injury was caused by traffic accident in 7 cases, falling from height in 4 cases, and sport injury in 2 cases. The time between injury and operation was 18-92 days (mean, 43 days). The results of anterior and posterior drawer tests and Lachmann test were positive, and all cases complicated by varus and external rotation instability. The Lysholm score of the knee was 38.4±7.7. According to International Knee Documentation Committee (IKDC) scoring, all were rated as grade D. According to Fanelli classification criteria, all were classified as type C. Anterior cruciate ligament, posterior cruciate ligament, PLC, and ALL were reconstructed simultaneously with autogenous tendon. Results: All incisions healed at stage I and no complication occurred. All patients were followed up 12-36 months (mean, 19 months). At last follow-up, the results of anterior and posterior drawer tests and Lachmann test were negative; 2 cases had varus instability, and 1 cases had external rotation instability. There was no anterior external rotation instability. The Lysholm score of the knee was 88.6 ±12.7, showing significant difference when compared with preoperative score ( t=13.852, P=0.000). According to IKDC scoring, 8 cases were rated as grade A, 4 as grade B, and 1 as grade C; significant difference was found when compared with preoperative value ( Z=3.182, P=0.000). Conclusion: In the treatment of lateral multi-ligament injuries knee, anatomical reconstruction of PLC and ALL with a modified Laprade technique can obtain good short-term effectiveness.