In vitro elution characteristics of gentamicin-impregnated Polymethylmethacrylate: premixed with a second powder vs. liquid Lyophilization.

BACKGROUND: Antibiotic-loaded bone cement, or antibiotic-impregnated polymethylmethacrylate (PMMA), were developed to prevent and treat bone and joint infections. Gentamicin is an antibiotic that is commonly used in combination with PMMA; however, gentamicin powder is hard to obtain in many countries. This study aimed to evaluate the elution characteristics of gentamicin-impregnated PMMA made with lyophilized liquid gentamicin, compared with PMMA; which is made from commercial gentamicin powder. METHODS: The experimental sample was divided into 2 groups: the gentamicin power group (PG-PMMA) and the lyophilized liquid gentamicin group (LG-PMMA). Ten cement spacers were prepared in each group. These were produced by mixing gentamicin powder, or lyophilized liquid gentamicin, with a powder polymer before adding the liquid monomer (2 g of gentamicin and 40 g of PMMA). The volume and surface area of the antibiotic-impregnated cement spacers were 50 cm3 and 110 cm2, respectively. Each spacer was immersed in phosphate-buffered saline, which was changed daily under sterile conditions. The solutions were collected to measure the level of gentamicin using the enzyme multiplied immunoassay technique (EMIT), at days 1, 2, 3, 4, 5, 6, 7, 14, 21, 28, 35 and 42. RESULTS: The collections from both groups had high concentrations of gentamicin on day 1 (113.63 ± 23.42 mg/dL in LG-PMMA and 61.7 ±8.37 mg/dL in PG-PMMA), but experienced a continuous decrease over time. The PMMA spacers from both groups could release gentamicin for up to 6 weeks (3.28 ± 1.17 mg/dL in LG-PMMA and 1.21 ± 0.28 mg/dL in PG-PMMA). However, there were significantly higher levels of gentamicin concentrations in the LG-PMMA group compared to the PG-PMMA group at all time points (P< 0.05). CONCLUSION: Gentamicin-impregnated PMMA made with lyophilized liquid gentamicin had approximately a two times higher rate of antibiotic elution in preliminary in vitro studies, as compared with PMMA made with premixed gentamicin powder.

Effect of hip abductor strengthening exercises in knee osteoarthritis: a randomized controlled trial.

BACKGROUND: Osteoarthritis knee (OA) for patients whom had varus malalignment had higher peak adductor moment. Hip abductor strength played an important role in the decreasement of knee adduction moment. This study aimed to evaluate the effect of hip abductor exercises for patients who had medial compartment knees OA. METHODS: Patients who had medial compartmental OA knee were randomized into two groups. The first group performed hip abductor strengthening exercises, combined with quadriceps strengthening exercises; whereas, the second group performed standalone quadriceps strengthening exercises. Self-reported Knee Injury and Osteoarthritis Outcome Scores (KOOS) were collected by patients on follow-up visits. RESULTS: Eighty-six patients completed the trial. All KOOS subscales were significantly improved in both groups after 10 weeks of treatment. However, there was no significant difference in the scores between either group at 2-10 weeks after treatment. Nevertheless, the effects of exercise for pain, symptoms, function in daily living and knee-related quality of life were found to have faster improvement within the hip abduction exercise group compared to the control group (2 weeks faster; pain, function in daily living and knee-related quality of life, 4 weeks faster; symptoms.) CONCLUSION: Since, adding quadriceps exercises could expedite improvement of less pain, symptoms, activity in daily living and quality of life faster than quadriceps exercises solely for a 2-4 weeks period. However, the effect size was small and there were no differences after this; hence, consideration of adding hip abductor exercises in the treatment protocol should be based on the patients and doctors appraisal. TRIAL REGISTRATION: TCTR, TCTR20180517005. Registered 17 May 2018.

The "Cough Trick" Reduces Pain During Removal of Closed-suction Drains after Total Knee Arthroplasty: A Randomized Trial.

BACKGROUND: Drain removal after TKA can be painful. Prior research suggests that the "cough trick," in which a patient coughs at the same time she or he receives an injection, effectively decreases pain. To our knowledge, this intervention has not been evaluated as a way to reduce pain during other brief but painful interventions, such as removal of closed-suction drains after orthopaedic surgery. QUESTION/PURPOSE: Does the cough trick reduce pain while a surgeon is removing a closed-suction drain after TKA? METHODS: Fifty-six patients with primary osteoarthritis who underwent primary TKA were randomized into two groups: drain removal as the patient coughed (n = 28 patients; three men, 25 women) or drain removal using the usual process, without the cough trick (n = 28 patients; three men, 25 women). The study groups were not different in terms of gender, BMI, surgical time, or other baseline variables, and other than the addition of the cough trick, there were no differences in surgical treatment or other elements of aftercare. Likewise, at baseline, the verbal numeric rating scale (VNRS) score for pain before the drain was removed was not different between the groups (3.1 ± 1.7 versus 3.3 ± 1.3; p = 0.72). The level of pain before and during drain removal was recorded using a VNRS by an orthopaedic surgeon who was not involved in the care of the study patients. We considered the minimum clinically important difference on the 10-point scale to be 2 points, based on prior evidence. RESULTS: The mean ± SD VNRS for the pain level during drain removal was lower in the cough trick group than that in the control group (1.6 ± 1.0 versus 3.7 ± 1.9, mean difference 2.1; 95% CI, 1.3-2.9; p < 0.001). CONCLUSIONS: The cough trick during removal of a closed-suction drain tube in patients undergoing TKA reduced the level of pain in this small randomized trial. We suggest that surgeons consider this technique when removing drains after TKA because it is a noninvasive technique and it is easy to perform. Because the cough trick has been shown by others to be effective at reducing pain during venipuncture and parenteral injections, and we found it was effective for that purpose during drain removal after TKA, we believe this finding probably generalizes well to most minor procedures that cause transient, sharp pain. We suggest that it could be used to make such procedures more comfortable for patients, as well as for drain removal in other types of surgery where drains still are commonly used (including spine surgery and tumor surgery). LEVEL OF EVIDENCE: Level I, therapeutic study.

Aspirin versus rivaroxaban in postoperative bleeding after total knee arthroplasty: a retrospective case-matched study.

BACKGROUND: Venous thromboembolic disease (VTE) is a complication not uncommon following total knee arthroplasty. Postoperative bleeding-related complications are a concern in many guidelines. The authors aimed to compare the amount of postoperative drainage from closed suction drainage, transfusion rate, and postoperative complications between aspirin and rivaroxaban as VTE prophylaxes after total knee arthroplasty. METHODS: This study was a retrospective case-matched study of 155 patients. The data were collected between 2008 and 2015 from patients who had total knee arthroplasty using aspirin or rivaroxaban as the VTE prophylaxis. Seventy-nine patients received aspirin, and 76 patients received rivaroxaban. A single surgeon operated on all patients with the same surgical technique and patient care protocol. RESULTS: The total closed suction drainage outputs at 48 h were not significantly different between the aspirin and rivaroxaban groups (p = 0.10). Eighteen percent of patients in the aspirin group and 25% of patients in the rivaroxaban group received blood transfusions (p = 0.37). There were no bleeding-related complications or VTE in either group. CONCLUSIONS: Aspirin and rivaroxaban were effective and safe as VTE chemoprophylaxis in total knee arthroplasty.

Rapidly-growing mycobacterial infection: a recognized cause of early-onset prosthetic joint infection.

BACKGROUND: Prosthetic joint infection (PJI) is a major complication of total hip and total knee arthroplasty (THA, TKA). Although mycobacteria are rarely the causative pathogens, it is important to recognize and treat them differently from non-mycobacterial infections. This study aimed to compare the clinical characteristics, associated factors and long-term outcomes of mycobacterial and non-mycobacterial PJI. METHODS: We conducted a retrospective case-control study of patients aged ≥18 years who were diagnosed with PJI of the hip or knee at Siriraj Hospital from January 2000 to December 2012. Patient characteristics, clinical data, treatments and outcomes were evaluated. RESULTS: A total of 178 patients were included, among whom 162 had non-mycobacterial PJI and 16 had mycobacterial PJI. Rapidly growing mycobacteria (RGM) (11) and M. tuberculosis (MTB) (5) were the causative pathogens of mycobacterial PJI. PJI duration and time until onset were significantly different between mycobacterial and non-mycobacterial PJI. Infection within 90 days of arthroplasty was significantly associated with RGM infection (OR 21.86; 95% CI 4.25-112.30; p < .001). Implant removal was associated with improved favorable outcomes at 6 months (OR 5.96; 95% CI 1.88-18.88; p < .01) and 12 months (OR 3.96; 95% CI 1.15-13.71; p = .03) after the infection. CONCLUSIONS: RGM were the major pathogens of early onset PJI after THA and TKA. Both a high clinical index of suspicion and mycobacterial cultures are recommended when medically managing PJI with negative cultures or non-response to antibiotics. Removal of infected implants was associated with favorable outcomes.

A new adjustable parallel drill guide for internal fixation of femoral neck fracture: a developmental and experimental study.

BACKGROUND: Internal fixation is one treatment for femoral neck fracture. Some devices and techniques reported improved accuracy and decreased fluoroscopic time. However, these are not widely used nowadays due to the lack of available special instruments and techniques. To improve the surgical procedure, the authors designed a new adjustable drill guide and tested the efficacy of the device. METHODS: The authors developed a new adjustable drill guide for cannulated screw guide wire insertion for multiple screw fixation. Eight orthopaedic surgeons performed the experimental study to evaluate the efficacy of this device. Each surgeon performed guide wire insertion for multiple screw fixation in six synthetic femurs: three times with the new device and three times with the conventional technique. The fluoroscopic time, operative time and surgeon satisfaction were evaluated. RESULTS: In the operations with the new adjustable drill guide, the fluoroscopic and operative times were significantly lower than the operations with the conventional technique (p < 0.05). The mean score for the level of satisfaction of this device was also statistically significantly better (p = 0.02) than the conventional technique. CONCLUSIONS: The fluoroscopic and operative times with the new adjustable drill guide were reduced for multiple screw fixation of femoral neck fracture and the satisfaction of the surgeons was good.

Comparing Results between New Aiming Device and Freehand Technique for Distal Locking of Intramedullary Implants.

Objective: To test the results of a new simple aiming device compared to the freehand method for distal locking screw insertion in the intramedullary (IM) nailing procedure in terms of accuracy, radiation exposure, and operative time. Material and Method: Distal screw locking procedure on 40 synthetic femoral bones with inserted intramedullary nail was done by four senior orthopedic residents using both the freehand and device-assisted techniques. Accuracy, fluoroscopic time, and operative time were recorded for the analysis. Results: The new aiming device minimized fluoroscopic time with statistical significance (p-value <0.001). No operating time difference between the two techniques (p-value = 0.67). Screw misdirection was found in two incidences in the freehand technique but not found in the device-assisted technique. Conclusion: The new simple aiming device can decrease fluoroscopic time and show good precision of distal locking procedure.

Radiographic manifestation of hip dislocation after total hip arthroplasty.

OBJECTIVE: The authors hypothesized that a patient who has posterior hip dislocation after total hip replacement does not have the same clinical manifestations of malposition as with a natural hip. The present study aimed to study clinical manifestation of hip dislocation after total hip arthroplasty. MATERIAL AND METHOD: Thirty-five cases of posterior dislocation after total hip replacement were retrospectively studied by medical records and radiographic evaluation. The study included leg position after hip dislocation, leg length, and leg abduction/adduction angles. RESULTS: External rotation of the patient's leg was found in 13 cases (37.1%), neutral position in six cases (17.2%), and internal rotation in 16 cases (45.7%). Measurements of the femoral shaft-vertical axis angle found adduction in 17 cases (average 17.4 degrees, range 1-25 degrees), abduction in 15 cases (average 6 degrees, range 1-15 degrees), and 0 degrees in three cases. Average leg shortening was 3.55 cm (range 0.6-13.5 cm). CONCLUSION: The present study shows that patients with hip dislocation after hip replacement can manifest many signs of limb deformity in rotation (internal, external, and neutral) and abduction/adduction positions.

Superior analgesic efficacy of preemptive low-dose ketorolac compared with parecoxib after total knee arthroplasty: A retrospective propensity score matching study.

BACKGROUND: Total knee arthroplasty (TKA) is a routine orthopedic procedure often associated with significant postoperative pain. Efficient pain management is paramount for patient recovery, with nonsteroidal anti-inflammatory drugs (NSAIDs) being a common choice. Nevertheless, the specific NSAID and its dosing regimen can have varying impacts on outcomes. METHODS: In this retrospective cohort study spanning from January 2016 to December 2020, we analyzed patients who underwent TKA. These patients were divided into two groups: one receiving preemptive low-dose ketorolac (15 mg) followed by 15 mg every 6 h for 48 h, and the other receiving parecoxib (40 mg) every 12 h for the same duration. We assessed pain scores, opioid consumption, and monitored adverse events. RESULTS: Our findings reveal that ketorolac yielded superior results compared to parecoxib. Specifically, patients receiving ketorolac reported significantly lower Visual Numeric Rating Scale (VNRS) scores at 8- and 20-h post-surgery. This trend was further confirmed by linear mixed models (p = .0084). Additionally, ketorolac was associated with reduced opioid consumption during the initial 24 h. Importantly, the rates of adverse events were comparable between the two groups. CONCLUSION: The utilization of preemptive low-dose ketorolac demonstrates promising potential in bolstering pain control within the initial 24 h post-TKA, potentially reducing the need for opioids. However, further exploration is required to thoroughly assess its prolonged analgesic effects and safety across various surgical contexts. These investigations could provide invaluable insights for optimizing pain management protocols.

Biomechanical evaluation of screw and cement placement strategies for treating medial uncontained tibial defects in total knee arthroplasty: A finite element analysis.

Total knee arthroplasty faces challenges in the management of medial uncontained tibial defects, affecting prosthesis stability and implant survival. The use of screws and bone cement is a preferred approach; however, optimal screw insertion techniques lack consensus in the existing literature. The present study aimed to address this gap by exploring optimal screw and cement placement strategies, focusing on their biomechanical implications. The present study conducted a finite element analysis using a knee prosthesis model with a defined uncontained tibial defect. Various parameters were systematically adjusted, including the number of screws (1, 2 or 3 screws), screw lengths (10, 18, 30 or 40 mm), lateral-medial screw positions (2, 4 or 6 mm laterally) and abduction rotation angles (0, 5, 10 or 15 degrees). These adjustments were made to evaluate their specific and combined impacts on the vertical displacement and abduction angles of the tibial tray. The results revealed that incorporating three-screw reinforcement markedly reduced vertical displacement, while the single screw in the middle position exhibited superior performance in preventing the deformation of abduction angles compared to scenarios with two screws at anterior and posterior positions without a middle screw. Longer screws and smaller abduction angles contributed to decreased movement of the tibial component. Furthermore, the lateral adjustment of the screw position led to an increase in vertical displacement values, reaching ~1.5% when shifted 6 mm laterally. On the whole, the finite element analysis in the present study suggests that, for the treatment of medial uncontained tibial defects, three-screw reinforcement is advantageous for larger defects. Longer screws and a smaller abduction angle are deemed favorable. Moreover, the results underscore the superiority of medial screw placement over lateral placement. It is imperative to note that further clinical validation is essential to corroborate the biomechanical implications observed herein.

Do cemented standard-length femoral stems have enough longevity for the pathological fractures of the femoral neck with metastatic lesions? A retrospective study.

Background: Cemented long-stem hip arthroplasty is a treatment of choice for the pathological fractures of the femoral neck with metastatic lesions and the prevention of further fracture caused by metastasis progression. Objective: The present study was an evaluation of the outcome after treatment of metastatic femoral neck fractures with cemented standard-length hemiarthroplasty. Methods: We retrospectively studied 23 patients in whom the pathological fractures of the femoral neck with metastatic lesions were diagnosed. All patients underwent hemiarthroplasty with cemented standard-length femoral stems. The demographic data of the patients and clinical outcomes were obtained from an electronic medical database. Metastasis progression-free survival time was analyzed via the Kaplan-Meier curve. Results: The mean age of the patients was 51.5 ± 11.7 years. The median duration of follow-up was 6.8 months (interquartile range, 5-22.6 months). Four patients exhibited tumor progression according to radiographic evaluation, but no patients had new fractures in the same bone or needed reoperation. The Kaplan-Meier curve revealed that 88.2% (74.2,100) of femurs demonstrated 1 year radiographic progression-free survival and 73.5% (49.4,100) demonstrated 2 year progression-free survival. Conclusions: Our study demonstrated that the use of cemented standard-length stems in hemiarthroplasty for pathological fractures of the femoral neck with metastatic lesions is safe, and the rate of reoperation was low. We believe that this prosthesis is optimum for treatment in this group of patients because the length of survival in patients is expected to be short and the rate of metastasis progression in the same bone is low.

The Efficacy of Topical Tranexamic Acid in Femoral Neck Fractured Patients Undergoing Cemented Bipolar Hemiarthroplasty: A Randomized Double Blinded Controlled Trial.

Objective Tranexamic acid (TXA) is an antifibrinolytic that is widely used for decreasing blood loss and blood transfusion rates in total hip arthroplasty. However, there is limited evidence of topical TXA usage in hip hemiarthroplasty for femoral neck fractures. The present study aimed to evaluate the effects of topical TXA on blood loss and on blood transfusions in femoral neck fracture patients who underwent cemented bipolar hemiarthroplasty. Methods Twenty-six patients with femoral neck fractures who were scheduled for bipolar cemented arthroplasty were randomized into two groups. The first group of 12 patients received topical TXA during their operation, whereas 14 patients in the second group received a placebo. Hematocrit was measured at 6 and 24 hours postoperatively. Blood transfusions and postoperative complications were also recorded. Results Total blood loss was not different between the TXA group and the control group (TXA group: 459.48 ± 456.32 ml, and control group: 732.98 ± 474.02 ml; p = 0.14). However, there were no patients within the TXA group who required a blood transfusion, while there were 4 patients in the control group who received allogenic blood transfusions ( p = 0.044). There were no postoperative complications, such as wound complication, venous thromboembolism, or cardiovascular complications within either group. Conclusion Topical TXA could not decrease total blood loss but was able to reduce transfusion rates in patients who underwent cemented bipolar hip hemiarthroplasty in femoral neck fractures. Further studies in doses of topical TXA in a larger sample size would be beneficial. Level of Evidence II.

Efficacy of Periarticular Infiltration with Dexamethasone and Bupivacaine plus Adductor Canal Block Relative to That of Adductor Canal Block Alone for Patients Undergoing Total Knee Arthroplasty: A Retrospective Case-Matched Study.

Purpose: Periarticular infiltration (PI) is a common procedure during total knee arthroplasty (TKA) for postoperative pain management. This retrospective, case-matched study aimed to evaluate the effectiveness of PI with dexamethasone and bupivacaine in combination with an adductor canal block (ACB) and compare it with that of ACB alone in reducing postoperative pain in patients with TKA. Methods: Data were collected from 66 patients who underwent TKA performed by a single surgeon. Thirty-three of them received ACB + PI, and 33 received ACB alone. However, both groups underwent identical surgical techniques and postoperative care protocols. The pain scores and fentanyl consumption of the two groups were compared. Results: The ACB + PI group had significantly lower pain scores than the ACB alone group at 8, 16, 24, and 48 hours postoperatively (p=0.033, 0.004, 0.038, and 0.049, respectively). The percentage of patients requiring fentanyl as a rescue medication was significantly higher for the ACB alone group (90.9%) than for the ACB + PI group (69.7%, p=0.03). The total fentanyl consumption was also lower for the ACB + PI group (p < 0.001). Conclusion: The periarticular injection of the combination of dexamethasone and bupivacaine plus ACB was more effective than ACB alone in reducing postoperative pain and fentanyl consumption in patients undergoing TKA. Further studies comparing different doses of dexamethasone or other cocktail regimens may provide additional insights into this approach.

Screw inserting in different phase of cement affect the pull-out strength of cement augmented screws.

BACKGROUND: For large bone defects, after curettage of aggressive bone tumors; such as giant-cell tumors, cementation with supplement internal fixation was used to prevent subsequent collapse of the cement-bone constructs. The purpose of this study is to compare the pull-out strength of cement augmented screws between inserting screws in the working phase or hard phase of bone cement. HYPOTHESIS: Timing at which completed screw insertion takes place affecting the pull-out strength of cement augmented screws. METHODS: Pull-out strength was compared between screws; inserted within the working phases of cement, and after the cement was hardened in high viscos cement blocks. Each group consists of 10 cortex screws, 10 cancellous screws and 10 locking screws. The pull-out strength test was followed using the instructions of ASTM F543-13e1 Standard Specification and Test Methods, for Metallic Medical Bone Screws. RESULTS: Screws that were inserted in the working phases of cement had significantly higher pull-out strength, than those inserted in hard cement (p=0.021). The pull-out strength was statistically significant in difference among the types of screws (p<0.001), with locking screws having the highest pull-out strength. Furthermore, the pull-out strength of locking screws revealed no significant difference when either; inserted during the working or hardened phases of bone cement. CONCLUSION: Insertion of screws during the working periods of PMMA cement had higher pull out strength compared to the hard phase of cement. Hence, we recommend performing internal fixation before cementation after curettage of aggressive bone tumors. However, if the surgeon prefers to pack the cement first, for the benefit of avoiding residual bone defects, we suggest using a locking plate system to achieve comparable pull-out strength. LEVEL OF EVIDENCE: In-vitro study.

The ability and factors related with floor sitting after total hip arthroplasty with a posterolateral approach.

Background: Prosthesis dislocation following total hip arthroplasty (THA) is one complication that affects treatment outcome and increases the cost of treatment. Currently, many surgeons prohibit patients from performing floor-based activities; however, these prohibitions might affect the lifestyle of a number of patients. Objective: This study aimed to evaluate the ability of floor sitting after THA, and factors associated with this ability. Methods: This study was a retrospective cohort study, evaluating 240 patients who underwent THA with a posterolateral approach, in a single tertiary hospital. Patient demographic data, preoperative clinical data, prostheses type, and postoperative radiographic were extracted from the electronic medical records. Postoperative ability to perform floor sitting was evaluated at 6 months postoperatively. Results: There were 52 patients (21.66%) who were able to sit on the floor postoperatively. Multivariate logistic regression analysis showed independent association between three factors with ability to sit on the floor after surgery: pre-operative external rotation range of motion (OR 1.03; 95% CI, 1.01-1.06; P = 0.01), pre-operative Harris Hip Scores (OR 1.05; 95% CI, 1.01-1.10; P = < 0.01), pre-operative ability to sit on the floor (OR 10.2; 95% CI, 3.65-28.5; P = < 0.01). Conclusion: There were a number of patients who could sit on the floor after THA. However, there were factors which were associated with this ability. Hence, these results could be useful for adjusted patient preoperative expectations, and did not preclude all patients to perform floor activities.

Efficacy of a Combined Intramedullary, Periarticular Injection, and Intraarticular Tranexamic Acid Application on Postoperative Bleeding in Total Knee Arthroplasty: A Retrospective Case-Matched Study.

Background: Topical tranexamic acid (TXA) has been widely used to reduce postoperative blood loss following total knee replacement (TKA). This study aimed to evaluate the effect of combined intramedullary, periarticular injection, and intraarticular TXA application in patients who underwent TKA as compared to those who did not. Methods: This was a retrospective case-matched study of 111 patients. We evaluated the transfusion rate and postoperative drainage of 56 patients who underwent TKA using combined topical tranexamic acid application (directly pushed into the femoral intramedullary canal and tibia base, with periarticular soft tissue injection and injected into the knee cavity via a drain tube) and the control group of 55 patients. Results: In the control and TXA groups, 7.14% and 1.81% of the patients received blood transfusions, respectively (p=0.176). The closed-suction drainage output at 0-8 h and total drainage output were significantly lower in the TXA group than those in the control group (p < 0.001). Conclusion: Application of topical TXA with the combined method (intramedullary, periarticular injection, and intraarticular) in TKA decreases postoperative suction drainage and may reduce the need for postoperative blood transfusion.

EFFICACY OF EXTENDED ORAL TRANEXAMIC ACID ON BLOOD LOSS IN PRIMARY TOTAL KNEE ARTHROPLASTY.

Introduction: Tranexamic acid is widely used for patients undergoing total knee arthroplasty (TKA). However, the duration of systemic tranexamic acid (TXA) administration varies in many reports. Hence, this study aims to compare blood loss between a single intravenous (IV) TXA dose, and one dose of IV TXA combined with oral TXA, during 48-hour postoperative care in primary TKA. Methods: Ninety-four patients with primary osteoarthritis, who underwent primary TKA, were randomized into two groups. The first group consisted of 47 patients and received a dose of 750 mg IV TXA and 750 mg oral TXA postoperatively at 8-hour intervals for 48 hours. In the second group, 47 patients received a single dose of IV TXA and a placebo at the same intervals for the same time duration. Hemoglobin (Hb) was measured at 4, 24 and 72 hours after operation. Results: The mean total blood loss were not different between the two groups (p=0.37). There was no difference in total Hb reduction or closed suction drainage outputs (p=0.9 and 0.07, respectively). Conclusion: The extended use of oral TXA for 48-hour postoperative care did not decrease the total blood loss following TKA compared with a single dose of IV TXA. Level Of Evidence I; High quality randomized trial .

Introdução: O ácido tranexâmico é amplamente utilizado para pacientes submetidos à artroplastia total do joelho (ATJ). No entanto, a duração da administração de ácido tranexâmico sistêmico (ATS) varia em muitos relatórios. Assim, este estudo tem como objetivo comparar a perda sanguínea entre uma dose única intravenosa (IV) de ATS e uma dose de ATS IV combinada com ATS oral, no atendimento pós-operatório ao longo de 48 horas em ATJ primária. Métodos: Noventa e quatro pacientes com osteoartrite primária, submetidos a ATJ primária, foram randomizados em dois grupos. O primeiro grupo de 47 pacientes recebeu uma dose de 750 mg de ATS IV e 750 mg de ATS oral no pós-operatório, a cada 8 horas, durante 48 horas. No segundo grupo, 47 pacientes receberam dose única de ATS IV e placebo nos mesmos intervalos e pelo mesmo período de tempo. A hemoglobina (Hb) foi medida às 4, 24 e 72 horas de pós-operatório. Resultados: A média da perda sanguínea total não foi diferente entre os dois grupos (p = 0,37). Não houve diferença na redução da hemoglobina total ou saídas de drenagem de sucção fechada (p = 0,9 e 0,07, respectivamente). Conclusão: O uso prolongado de ácido tranexâmico oral por 48 horas de pós-operatório não diminuiu a perda total de sangue após ATJ em comparação com uma dose única de ATS IV. Nível de Evidência I; Estudo Clínico randomizado de alta qualidade .

Aspirin versus Rivaroxaban to Prevent Venous Thromboembolism after Total Knee Arthroplasty: A Double-blinded, Randomized Controlled Trial.

Objective Aspirin (acetylsalicylic acid, ASA) and rivaroxaban are anticoagulants that have increased in popularity due to ease of use in the prevention of venous thromboembolism (VTE) after total knee arthroplasty (TKA). The present study aimed to evaluate the efficacy of ASA compared with that of rivaroxaban on VTE prophylaxis in patients who underwent TKA. Method Forty patients who had primary knee osteoarthritis and would undergo TKA were randomized into two groups. In total, 20 patients in the ASA group used oral aspirin, at a dose of 300 mg/day, for VTE prophylaxis after TKA, while 20 patients in the rivaroxaban group received oral rivaroxaban, at a dose of 10 mg/day. On days 4 and 14 after the operation, deep vein thrombosis (DVT) in the lower limbs on the operated side was detected through duplex ultrasonography. Other complications were recorded for 14 days. Results There were no positive findings of DVT detected with duplex ultrasonography in the groups of patients, and the occurrence of pulmonary embolism was not observed. In total, 4 patients had subcutaneous ecchymosis on the fourth postoperative day (2 patients in the ASA group and 2 patients in the rivaroxaban group; p = 1.0), and another 4 patients on the fourteenth postoperative day (1 patient in the ASA group and 3 patients in the rivaroxaban group; p = 0.292). No cases of wound hematoma, major organ bleeding, wound infection, or reoperation were observed in the sample. Conclusion Aspirin and rivaroxaban had comparable efficacy to prevent VTE, without increasing the incidence of wound complications and bleeding after TKA.

Prevalence of pin-site infection: the comparison between silver sulfadiazine and dry dressing among open tibial fracture patients.

OBJECTIVE: Pin-site infection is one of the most troublesome complications of external fixation. The present study aimed to compare the rate of pin-site infection following silver sulfadiazine with dry dressing. MATERIAL AND METHOD: This was a prospective randomized controlled study among 30 clients that compared the outcome of pin dressing using silver sulfadiazine (study group = 15) with dry dressing (control = 15). All eligible subjects of open tibial fracture had an emergency debridement with external fixation. Pin tract infection was considered to be present if superficial inflammation (erythema, cellulitis), serous or purulent discharge occurred around a pin site and deep infection of osteolysis around the pin, and sequestrum. RESULTS: Seven subjects (46.7%) had pin-site infection in the present study group while six subjects (40.0%) had it in the control group, with comparable severity. CONCLUSION: There was no significant difference in prevalence of pin-site infection between both groups (p = 0.97). Therefore, either silver sulfadiazine or dry dressing could be advocated.