Different diagnostic performance of plasma fibrinogen and D-dimer in periprosthetic joint infection: a propensity score matched study.

BACKGROUND: Fibrinogen (Fbg) and D-dimer have been used as biomarkers for the diagnosis of periprosthetic joint infection (PJI). However, previous research has reported conflicting results on the diagnostic value of D-dimer in comparison to Fbg, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). AIM: This study aimed to: (1) determine the optimal threshold of plasma Fbg and D-dimer in the diagnosis of PJI and compare their diagnostic value to that of CRP and ESR; and (2) investigate whether Fbg and D-dimer perform differently than CRP and ESR as diagnostic indicators for different types of PJI. METHODS: A total of 115 revision cases after total hip arthroplasty (THA) and total knee arthroplasty (TKA) were identified. Based on demographic characteristics, 25 culture-positive cases were matched to 50 culture-negative cases using propensity score matching. Sensitivity, specificity, receiver operating characteristics (ROC), negative predictive value (NPV), and positive predictive value (PPV) were calculated and compared. RESULTS: The optimal thresholds were 2.72 mg/L for D-dimer, 3.655 g/L for Fbg, 12.64 mg/L for CRP, and 27 mm/h for ESR. Levels of plasma Fbg, D-dimer, CRP, and ESR were significantly higher in the culture-positive group than the culture-negative group. Fbg, D-dimer, CRP, and ESR showed sensitivity of 0.92, 0.56, 0.92, and 0.88, respectively, and showed specificity of 0.84, 0.96, 0.94, and 0.80, respectively. The ROC curve showed that CRP has the highest area under the curve (AUC) (0.94), followed by Fbg (0.90), ESR (0.87), and D-dimer (0.81). CONCLUSIONS: Plasma Fbg exhibited a similar diagnostic performance compared to CRP and ESR in predicting culture-positive results in PJI. Plasma D-dimer showed high specificity but low sensitivity. In our study, Fbg and D-dimer did not show better diagnostic performance with different pathogens and different types of PJI. Further studies are required to investigate the difference between serum D-dimer and plasma D-dimer in the arthroplasty population.

Degree of coronal alignment correction can't predict knee function in total knee replacement.

BACKGROUND: Whether neutral alignment brings better clinical outcomes is controversial. Consideration of the preoperative knee condition of patients and some limitations of previous studies, we suggested that other index may be more important than a generic target of 0° ± 3° of a neutral axis to reflect changes in coronal alignment after total knee replacement (TKR). The purpose of this study was to explore the relationship between alignment and functional outcome with a new grouping method and the concept of correction rate. METHODS: The study included 358 knees, the mean follow-up period was 3.62 years. A new grouping method was adopted to divide patients into three groups based on the degree of correction of mechanical femoral-tibial angle (MFTA): under-correction (n = 128), neutral (n = 209) and over-correction (n = 21). Hospital for Special Surgery (HSS) score were compared among the 3 groups (ANOVA with or without LSD t-test). In addition, we also attempt to further explore whether the concept of correction rate can predict postoperative functional score (Simple linear correlation analysis). RESULTS: HSS score showed significant improvement in all groups. There was no difference in HSS score (88.27 vs 88 vs 85.62) (p = 0.88) or incremental scores (26.23 vs 25.22 vs 22.88) (p = 0.25) based on the postoperative alignment category for the degree of correction of MFTA at the last follow-up. The correlational analyses also didn't show any positive results (r = -0.01 p = 0.95, r = -0.01 p = 0.97, r = 0.11 p = 0.15, r = 0.01 p = 0.90). CONCLUSION: Categorization of optimal coronal alignment after TKR may be impractical. But we still believe that the concept of correction rate and new grouping method are worthy of research which can reflects the preoperative knee condition and the change of coronal alignment. Perhaps it can be better used in TKR in the future. LEVEL OF EVIDENCE: III.

Higher risk of revision in total knee arthroplasty after high tibial osteotomy: a systematic review and updated meta-analysis.

BACKGROUND: High tibial osteotomy is commonly performed in young patients with high activity demand. Several studies have reported outcome of HTO. The reported 10-year survival ranged from 79 to 97.6%. The reported 15-year survival ranged from 56 to 65.5%, resulting in the need for conversion to TKA. Primary TKA now provides satisfactory long-term outcome in terms of function and survival. Researches have been conducted to compare clinical outcome between primary TKA and TKA after HTO to see if TKA should be the prior treatment rather than HTO in some cases. But the results were inconsistent. This study aims to compare the risk of revision and other parameters between total knee arthroplasty after high tibial osteotomy and primary total knee arthroplasty. METHODS: Searches and screens of the relevant literature were conducted, after which data were extracted and pooled analysis was performed to compare the clinical outcomes between the two groups. RESULTS: A total of 14 studies with 144,692 cases were included. Pooled analysis showed significantly more revisions and complications, and more tibial component loosening and impingement in postoperative X-ray in the HTO-TKA group. Surgical complexity during conversion to total knee arthroplasty was summarised and listed in table. CONCLUSION: High tibial osteotomy offers satisfactory pain relief and functional outcome in selected patients with high activity demand. However, the need for subsequent TKA should be noted, which might be a technically challenging procedure with significantly higher risk of revision comparing to primary TKA.

Pre-operative denosumab is associated with higher risk of local recurrence in giant cell tumor of bone: a systematic review and meta-analysis.

BACKGROUND: In 2013, denosumab was introduced as peri-operative adjuvant treatment for giant cell tumor (GCT) of bone as it inhibits osteoclast activity. It is suggested that denosumab relives pain, facilitate curettage in lesions requiring resection initially. However, controversy remains whether denosumab increases the risk of local recurrence after surgery. METHODS: Medline, Embase and the Cochrane Library were comprehensively searched in June 2019 to identify studies investigating the clinical outcome of GCT of bone with and without peri-operative denosumab after surgery. Data were gathered and a meta-analysis was conducted. RESULT: Ten studies with 1082 cases (169 in denosumab group, 913 in control group) were included. Overall, denosumab was associated with significantly higher risk of recurrence(P < 0.02) and inferior 5 year recurrence free survival(P = 0.000). Denosumab and curettage has a relatively higher risk of recurrence comparing to curettage alone(P = 0.07). The risk of recurrence is not significantly increased if denosumab was administered both preoperatively and postoperatively(P = 0.24). CONCLUSION: Administration of denosumab is associated with increased risk of recurrence due to a variety of reasons, though it is proven effective in relieving pain, enabling curettage and improved functional outcome. Post-operative denosumab is recommended as it continuously suppress/eliminate residue tumor cells.

Robotic-assisted compared with conventional total hip arthroplasty: systematic review and meta-analysis.

BACKGROUND: Robotic-assisted total hip arthroplasty (THA) allows for accurate preoperative planning and component positioning, potentially enhancing implant survival and long-term outcomes. The relative efficacy and safety of robotic-assisted and conventional THA, however, are unclear. This systematic review and meta-analysis compared the safety and efficacy of robotic-assisted and conventional THA. METHODS: Medline, Embase and the Cochrane Library were comprehensively searched in September 2017 to identify studies comparing the safety and efficacy of robotic-assisted and conventional THA. Seven studies were included. Data of interest were extracted and analysed using Review Manager 5.3. RESULTS: The seven included studies involved 1516 patients, with 522 undergoing robotic-assisted and 994 undergoing conventional THA. Compared with conventional THA, robotic-assisted THA was associated with longer surgical time (not significant); lower intraoperative complication rates (OR: 0.12, 95% CI: 0.05 to 0.34, p<0.0001 I2); better cup placement, stem placement and global offset and a higher rate of heterotopic ossifications. Functional scores, limb length discrepancy and rates of revision and stress shielding were similar in the two groups. The relative amount of blood loss was unclear. CONCLUSION: The results of this meta-analysis suggest that robotic-assisted THA has certain advantages over conventional THA, including the results of component positioning and rates of intraoperative complications. Additional comparative studies are required to determine the long-term clinical outcomes of robotic-assisted THA.

Distinct molecular subtypes of uterine leiomyosarcoma respond differently to chemotherapy treatment.

BACKGROUND: Uterine leiomyosarcoma (ULMS) is an aggressive form of soft tissue tumors. The molecular heterogeneity and pathogenesis of ULMS are not well understood. METHODS: Expression profiling data were used to determine the possibility and optimal number of ULMS molecular subtypes. Next, clinicopathological characters and molecular pathways were analyzed in each subtype to prospect the clinical applications and progression mechanisms of ULMS. RESULTS: Two distinct molecular subtypes of ULMS were defined based on different gene expression signatures. Subtype I ULMS recapitulated low-grade ULMS, the gene expression pattern of which resembled normal smooth muscle cells, characterized by overexpression of smooth muscle function genes such as LMOD1, SLMAP, MYLK, MYH11. In contrast, subtype II ULMS recapitulated high-grade ULMS with higher tumor weight and invasion rate, and was characterized by overexpression of genes involved in the pathway of epithelial to mesenchymal transition and tumorigenesis, such as CDK6, MAPK13 and HOXA1. CONCLUSIONS: We identified two distinct molecular subtypes of ULMS responding differently to chemotherapy treatment. Our findings provide a better understanding of ULMS intrinsic molecular subtypes, and will potentially facilitate the development of subtype-specific diagnosis biomarkers and therapy strategies for these tumors.

Enhanced recovery after surgery for hip and knee arthroplasty: a systematic review and meta-analysis.

OBJECTIVES: To collect data of randomised controlled trials (RCTs) and clinical controlled trials (CCTs) for evaluating the effects of enhanced recovery after surgery on postoperative recovery of patients who received total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS: Relevant, published studies were identified using the following key words: arthroplasty, joint replacement, enhanced recovery after surgery, fast track surgery, multi-mode analgesia, diet management, or steroid hormones. The following databases were used to identify the literature consisting of RCTs or CCTs with a date of search of 31 December 2016: PubMed, Cochrane, Web of knowledge, Ovid SpringerLink and EMBASE. All relevant data were collected from studies meeting the inclusion criteria. The outcome variables were postoperative length of stay (LOS), 30-day readmission rate, and total incidence of complications. RevMan5.2. software was adopted for the meta-analysis. RESULTS: A total of 10 published studies (9936 cases) met the inclusion criteria. The cumulative data included 4205 cases receiving enhanced recovery after surgery (ERAS), and 5731 cases receiving traditional recovery after surgery (non-ERAS). The meta-analysis showed that LOS was significantly lower in the ERAS group than in the control group (non-ERAS group) (p<0.01), and there were fewer incidences of complications in the ERAS group than in the control group (p=0.03). However, no significant difference was found in the 30-day readmission rate (p=0.18). CONCLUSIONS: ERAS significantly reduces LOS and incidence of complications in patients who have had THA or TKA. However, ERAS does not appear to significantly impact 30-day readmission rates.

Impact of flexion versus extension of knee position on outcomes after total knee arthroplasty: a meta-analysis.

INTRODUCTION: Controversy still exists regarding positioning of the knee in flexion or in extension after total knee arthroplasty (TKA) impacts treatment outcomes. In this meta-analysis, we evaluated if a postoperative knee position regime could positively affect the rehabilitation. METHODS: A comprehensive search for randomized controlled trials (RCTs) assessing the effect of knee positioning after TKA was conducted. The outcomes of interest were blood loss and range of motion (ROM); total calculated blood loss (CBL), drainage volume, hidden blood loss (HBL), decline of hemoglobin level and requirement for blood transfusion. RESULTS: Ten RCTs involving 962 knees were eligible for meta-analysis. Positioning the knee in flexion after TKA was significantly associated with lesser CBL (P < 0.00001), less HBL (P < 0.00001) and decreased requirement for blood transfusion (P = 0.06). On subgroup analyses, the flexion group was found to have significantly less decrease in hemoglobin level 48 h to 6 days after surgery (P = 0.003), while no significant difference was noted at 24 h after surgery (P = 0.29). Further,a superior ROM was observed in flexion group (5-7 days after surgery) (P = 0.002), while there was no significant difference at 6 weeks. No significant inter-group difference in wound drainage was observed at 24 h after surgery. CONCLUSION: Positioning the knee in flexion in the early postoperative stage was associated with significantly lesser CBL, lesser HBL, decreased requirement for blood transfusion and better ROM at least in the early postoperative period, which may contribute to early rehabilitation. However, no significant difference was found in ROM at 6 weeks.

Validation of CT-Based Three-Dimensional Preoperative Planning in Comparison with Acetate Templating for Primary Total Hip Arthroplasty.

OBJECTIVE: This study aims to compare the accuracy of CT-based preoperative planning with that of acetate templating in predicting implant size, neck length, and neck cut length, and to evaluate the reproducibility of the two methods. METHODS: This prospective study was conducted between August 2020 and March 2021. Patients who underwent elective primary total hip arthroplasty by a single surgeon were assessed for eligibility. The included patients underwent both acetate templating and CT-based planning by two observers after the operation. Each observer conducted both acetate templating and CT-based planning twice for each case. The outcome measures included the following: (1) the accuracy of surgical planning in predicting implant size, calcar length, and neck length, which was defined as the difference between the planned size and length and the actual size and length; (2) reproducibility of the two planning techniques, which were assessed by inter-observer and intra-observer reliability analysis; (3) the influence of potential confounding factors on planning accuracy, which was evaluated using generalized estimating equations. RESULTS: A total of 57 cases were included in the study. CT-based planning was more accurate than acetate templating for predicting cup size (93% vs 79%, p < 0.001) and stem size (93% vs 75%, p < 0.001). When assessed by mean absolute difference, the comparison between acetate templating and CT-based planning was 4.28 mm vs 3.74 mm (p = 0.122) in predicting neck length and 3.05 mm vs 2.93 mm (p = 0.731) in predicting neck cut length. In the inter-observer reliability analysis, an intraclass correlation coefficient (ICC) of 0.790 was achieved for predicting cup size, and an ICC of 0.966 was achieved for predicting stem size using CT-based planning. In terms of intra-observer reliability, Observer 1 achieved an ICC of 0.803 for predicting cup size and 0.965 for predicting stem size in CT-based planning. Observer 2 achieved ICC values of 0.727 and 0.959 for predicting cup and stem sizes, respectively. The average planning time was 6.48 ± 1.55 min for CT-based planning and 6.12 ± 1.40 min for acetate templating (p = 0.015). CONCLUSION: The CT-based planning system is more accurate than acetate templating for predicting implant size and has good reproducibility in total hip arthroplasty.

Development and Validation of an Artificial Intelligence Preoperative Planning System for Total Hip Arthroplasty.

Background: Accurate preoperative planning is essential for successful total hip arthroplasty (THA). However, the requirements of time, manpower, and complex workflow for accurate planning have limited its application. This study aims to develop a comprehensive artificial intelligent preoperative planning system for THA (AIHIP) and validate its accuracy in clinical performance. Methods: Over 1.2 million CT images from 3,000 patients were included to develop an artificial intelligence preoperative planning system (AIHIP). Deep learning algorithms were developed to facilitate automatic image segmentation, image correction, recognition of preoperative deformities and postoperative simulations. A prospective study including 120 patients was conducted to validate the accuracy, clinical outcome and radiographic outcome. Results: The comprehensive workflow was integrated into the AIHIP software. Deep learning algorithms achieved an optimal Dice similarity coefficient (DSC) of 0.973 and loss of 0.012 at an average time of 1.86 ± 0.12 min for each case, compared with 185.40 ± 21.76 min for the manual workflow. In clinical validation, AIHIP was significantly more accurate than X-ray-based planning in predicting the component size with more high offset stems used. Conclusion: The use of AIHIP significantly reduced the time and manpower required to conduct detailed preoperative plans while being more accurate than traditional planning method. It has potential in assisting surgeons, especially beginners facing the fast-growing need for total hip arthroplasty with easy accessibility.

Patient-reported outcome measures used in patients undergoing total knee arthroplasty.

Patient-reported outcome measures (PROMs) are being used increasingly in total knee arthroplasty (TKA). We conducted a systematic review aimed at identifying psychometrically sound PROMs by appraising their measurement properties. Studies concerning the development and/or evaluation of the measurement properties of PROMs used in a TKA population were systematically retrieved via PubMed, Web of Science, Embase, and Scopus. Ratings for methodological quality and measurement properties were conducted according to updated COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology. Of the 155 articles on 34 instruments included, nine PROMs met the minimum requirements for psychometric validation and can be recommended to use as measures of TKA outcome: Oxford Knee Score (OKS); OKS-Activity and Participation Questionnaire (OKS-APQ); 12-item short form Knee Injury and Osteoarthritis Outcome (KOOS-12); KOOS Physical function Short form (KOOS-PS); Western Ontario and McMaster Universities Arthritis Index-Total Knee Replacement function short form (WOMAC-TKR); Lower Extremity Functional Scale (LEFS); Forgotten Joint Score (FJS); Patient's Knee Implant Performance (PKIP); and University of California Los Angeles (UCLA) activity score. The pain and function subscales in WOMAC, as well as the pain, function, and quality of life subscales in KOOS, were validated psychometrically as standalone subscales instead of as whole instruments. However, none of the included PROMs have been validated for all measurement properties. Thus, further studies are still warranted to evaluate those PROMs. Use of the other 25 scales and subscales should be tempered until further studies validate their measurement properties. Cite this article: Bone Joint Res 2021;10(3):203-217.

Comparison of cell therapy and other novel adjunctive therapies combined with core decompression for the treatment of osteonecrosis of the femoral head : a systematic review and meta-analysis of 20 studies.

AIMS: The value of core decompression (CD) in the treatment of osteonecrosis of the femoral head (ONFH) remains controversial. We conducted a systematic review and meta-analysis to evaluate whether CD combined with other treatments could improve the clinical and radiological outcomes of ONFH patients compared with CD alone. METHODS: We searched the PubMed, Embase, Web of Science, and Cochrane Library databases until June 2020. All randomized controlled trials (RCTs) and clinical controlled trials (CCTs) comparing CD alone and CD combined with other measures (CD + cell therapy, CD + bone grafting, CD + porous tantalum rod, etc.) for the treatment of ONFH were considered eligible for inclusion. The primary outcomes of interest were Harris Hip Score (HHS), ONFH stage progression, structural failure (collapse) of the femoral head, and conversion to total hip arthroplasty (THA). The pooled data were analyzed using Review Manager 5.3 software. RESULTS: A total of 20 studies with 2,123 hips were included (CD alone = 768, CD combined with other treatments = 1,355). The combination of CD with other therapeutic interventions resulted in a higher HHS (mean difference (MD) = 6.46, 95% confidence interval (CI) = 2.10 to 10.83, p = 0.004) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (MD = -10.92, 95% CI = -21.41 to -4.03, p = 0.040) and a lower visual analogue scale (VAS) score (MD = -0.99, 95% CI = -1.56 to -0.42, p < 0.001) than CD alone. For the rates of disease stage progression, 91 (20%) progressed in the intervention group compared to 146 (36%) in the control group (odds ratio (OR) = 0.32, 95% CI = 0.16 to 0.64, p = 0.001). In addition, the intervention group had a more significant advantage in delaying femoral head progression to the collapsed stage (OR = 0.32, 95% CI = 0.17 to 0.61, p < 0.001) and reducing the odds of conversion to THA (OR = 0.35, 95% CI = 0.23 to 0.55, p < 0.001) compared to the control group. There were no serious adverse events in either group. Subgroup analysis showed that the addition of cell therapy significantly improved clinical and radiological outcomes compared to CD alone, and this approach appeared to be more effective than other therapies, particularly in precollapse (stage I to II) ONFH patients. CONCLUSION: There was marked heterogeneity in the studies. There is a trend towards improved clinical outcomes with the addition of stem cell therapy to CD. Cite this article: Bone Joint Res 2021;10(7):445-458.

Nano-Hydroxyapatite Scaffold Based on Recombinant Human Bone Morphogenetic Protein 2 and Its Application in Bone Defect Repair.

The best way in which to prepare scaffolds with good biological properties is an urgent problem in the field of tissue engineering. In this paper we discuss the preparation of nano-hydroxyapatite scaffold of recombinant human bone morphogenetic protein-2 (rhBMP-2) and its application in bone defect repair. rhBMP-2 reagent was dissolved in 1 mol/L sodium dihydrogen phosphate solution, and the rhBMP-2 solution was added to the nano-hydroxyapatite artificial bone with a 100 µL glass micro dropper at the rate of 10 drops/min to obtain Nano-HA/rhBMP-2 composite artificial bone. In in vivo experiments, rabbits were fixed on an operating table, a 2 cm longitudinal incision was made in the middle part of the radial forearm, and the radius was cut with a wire saw and periosteum, 2.5 cm away from the distal radius. After washing the wound with normal saline, Adv-hBMP-2/MC3T3-E1 nano-HA composite artificial bone, MC3T3-E1 nan-HA composite artificial bone, or Nano-HA artificial bone were implanted in different groups. The artificial bone scaffold prepared in this study has a stronger ability to repair bone defects than the alternatives, and is a promising prospect for the clinical treatment of bone defects.

Patients with neuromyelitis optica spectrum disorder (NMOSD) are associated with adverse outcome after total hip arthroplasty: a matched case-control study.

BACKGROUND: Neuromyelitis Optica Spectrum Disorders (NMOSD) are rare inflammatory diseases of the central nervous system that cause transverse myelitis and optic neuritis. Steroids are commonly administered in NMOSD patients. The use of steroids may lead to osteonecrosis, which makes some of the NMOSD patients candidate for total hip arthroplasty (THA). To date, the clinical outcome of THA in NMOSD patients have not been investigated. AIM: Investigate the patient reported outcome measures (PROM), radiographic outcome and complication in NMOSD patients after THA, compared with that of non-NMOSD patients. METHODS: Patients from Jan. 2016 to October. 2020 were identified in our database. 12 NMOSD cases which met the inclusion criteria were matched to non-NMOSD cases in a ratio of 1:2 based on age, sex, Charlson Comorbidity Index (CCI) and surgical date. Relevant outcome were analyzed and compared between the two groups. RESULTS: There was a significantly increased risk of dislocation in NMOSD patients. Post-operative HOOS score was similar between the two groups even though the pre-operative HOOS score is significantly higher in the non-NMOSD group. NMOSD patients had poor performance in EQ-5D and EQ-VAS. The cups were placed more anteverted in NMOSD cases (P = 0.01). CONCLUSION: There is a significantly increased risk of dislocation after THA in NMOSD patients. However, satisfactory improvement in functional outcome of the hip was achieved. Due to the natural process of NMOSD, rehabilitation and hip precaution should be patient-specific and time-specific.

Effect of Acupuncture on Chronic Pain with Depression: A Systematic Review.

BACKGROUND: Numerous studies suggested that chronic pain and depression were closely related and widespread in the population. When patients have symptoms of chronic pain and depression, the corresponding treatment will become difficult. Acupuncture, a unique therapeutic method of traditional Chinese medicine, has been reported to potentially serve as an alternative treatment for patients with comorbid chronic pain and depression by many research studies. METHODS: A comprehensive search was conducted through the online database, including the Cochrane Library, PubMed, EMBASE, SinoMed, CNKI, and Wanfang database. Trials were RCTs published in the English or Chinese language, recruiting participants with chronic pain and depression comorbidity. The primary outcomes were the Visual Analogue Scale (VAS) and Hamilton Depression Scale (HAMD). Statistical analyses were conducted using Review Manager 5.3. Each trail was quality appraised with the five-point Jadad Score. RESULTS: 7 eligible RCTs involving 535 patients were included. Better therapeutic effect and safety could be observed in the experimental group compared with the control group. There was a significant decrease in the VAS (mean difference (MD) = -0.68 (-1.24, -0.12), P=0.02) and HAMD (MD = -2.18 (-3.09, -1.26), P < 0.00001) scores and the incidence of adverse events between two groups. CONCLUSION: In the treatment of chronic pain with depression, acupuncture could not only get better clinical efficacy, but also have higher security compared with medicine therapy, which can be used in patients with poorer response to the conventional medication or suffering from serious side effects.

Is D-dimer a reliable biomarker compared to ESR and CRP in the diagnosis of periprosthetic joint infection?

AIMS: The diagnosis of periprosthetic joint infection (PJI) has always been challenging. Recently, D-dimer has become a promising biomarker in diagnosing PJI. However, there is controversy regarding its diagnostic value. We aim to investigate the diagnostic value of D-dimer in comparison to ESR and CRP. METHODS: PubMed, Embase, and the Cochrane Library were searched in February 2020 to identify articles reporting on the diagnostic value of D-dimer on PJI. Pooled analysis was conducted to investigate the diagnostic value of D-dimer, CRP, and ESR. RESULTS: Six studies with 1,255 cases were included (374 PJI cases and 881 non-PJI cases). Overall D-dimer showed sensitivity of 0.80 (95% confidence interval (CI) 0.69 to 0.87) and specificity of 0.76 (95% CI 0.63 to 0.86). Sub-group analysis by excluding patients with thrombosis and hyper-coagulation disorders showed sensitivity of 0.82 (95% CI 0.70 to 0.90) and specificity of 0.80 (95% CI 0.70 to 0.88). Serum D-dimer showed sensitivity of 0.85 (95% CI 0.76 to 0.92), specificity of 0.83 (95% CI 0.74 to 0.90). Plasma D-dimer showed sensitivity of 0.67 (95% CI 0.60 to 0.73), specificity of 0.58 (95% CI 0.45 to 0.72). CRP showed sensitivity of 0.78 (95% CI 0.72 to 0.83), specificity of 0.81 (95% CI 0.72 to 0.87). ESR showed sensitivity of 0.68 (95% CI 0.63 to 0.73), specificity of 0.83 (95% CI 0.78 to 0.87). CONCLUSION: In patients without thrombosis or a hyper-coagulation disorder, D-dimer has a higher diagnostic value compared to CRP and ESR. In patients with the aforementioned conditions, D-dimer has higher sensitivity but lower specificity compared to ESR and CRP. We do not recommend the use of serum D-dimer in patients with thrombosis and hyper-coagulation disorders for diagnosing PJI. Serum D-dimer may perform better than plasma D-dimer. Further studies are needed to compare serum D-dimer and plasma D-dimer in arthroplasty patients. Cite this article: Bone Joint Res 2020;9(10):701-708.

Traditional Chinese and western medicine for the prevention of deep venous thrombosis after lower extremity orthopedic surgery: a meta-analysis of randomized controlled trials.

BACKGROUND: Chinese herbal medicine has traditionally been considered to promote blood circulation to remove obstruction in the channels and clear pathogenic heat to drain dampness effects. We conducted this meta-analysis to evaluate its benefits for the prevention of deep venous thrombosis (DVT) after lower extremity orthopedic surgery. METHODS: Relevant, published studies were identified using the following keywords: lower extremity orthopedic surgery, arthroplasty, joint replacement, fracture, traditional Chinese and western medicine, Chinese herbal medicine, deep venous thrombosis (DVT), and Venous thromboembolism (VTE). The following databases were used to identify the literature consisting of RCTs with a date of search of 31 May 2017: PubMed, Cochrane Library, Web of knowledge, the Chinese National Knowledge Infrastructure Database, the Chongqing VIP Database, the Chinese Biomedical Database, and the Wanfang Database (including three English and four Chinese databases). All relevant data were collected from studies meeting the inclusion criteria. The outcome variables were the incidence rate of DVT, activated partial thromboplastin time (APTT), prothrombin time (PT), and D-dimer; subcutaneous hematoma; and other reported outcomes. RevMan5.2. software was adopted for the meta-analysis. RESULTS: A total of 20 published studies (1862 cases) met the inclusion criteria. The experimental group, 910 patients (48.87%), received the Chinese herbal medicine or traditional Chinese and western medicine for prevention of DVT; the control group, 952 patients (51.13%), received the standard western treatment. The meta-analysis showed that traditional Chinese and western medicine therapy reduced the incidence rates of DVT significantly when compared with controls (risk ratio [RR] = 0.40; 95% CI, 0.30 to 0.54; P < 0.00001), and the D-dimer was lower in the experimental group (P = 0.01). Besides, the incidence rate of subcutaneous hematoma was lower in the experimental group (P < 0.0001). However, no significant difference was found in the PT (P = 0.98) and APTT (P = 0.75) in two groups. No serious adverse events were reported. CONCLUSION: Traditional Chinese and western medicine therapy may be a safe, effective prevention modality for DVT after lower extremity orthopedic surgery. Further rigorously designed, randomized trials are warranted.

miR-10a-5p, miR-99a-5p and miR-21-5p are steroid-responsive circulating microRNAs.

Steroid-induced osteonecrosis of the femoral head (ONFH) is a common orthopedic disease. The lack of specific manifestations and effective diagnostic methods make it difficult for this disease to be diagnosed at early stages. Recent studies have shown that microRNAs (miRNA) participate in the development of steroid-induced ONFH, but there is limited research into the diagnostic use of circulating miRNAs. Blood samples from 23 human subjects (7 systemic lupus erythematosus (SLE) patients with steroid-induced ONFH; 7 SLE controls without ONFH; and 9 healthy controls) and 71 rats (19 with steroid-induced ONFH; 28 receiving steroids without ONFH; and 24 untreated controls) were collected to verify the abundance of changes of 6 previously identified ONFH-associated plasma miRNAs (miR-423-5p, miR-99a-5p, miR-10a-5p, miR-21-5p, miR-130a-3p and miR-6787-5p) by quantitative RT-PCR (Reverse Transcription-Polymerase Chain Reaction). In humans, the circulating levels of miR-10a-5p, miR-99a-5p and miR-21-5p were increased in SLE patients treated with cortico steroid regardless of ONFH status when compared with healthy controls. However, miR-423-5p, miR-6787-5p and miR-130a-3p showed no significant differences between the three groups. In the rat model, the success rate of steroid-induced ONFH was 40.4% (19/47) based on pathological examination and confirmation by micro-CT scan. Similar to human plasma, the circulating levels of miR-10a-5p, miR-99a-5p and miR-21-5p were increased in steroid-treated rats independent of ONFH development. The serum levels of miR-10a-5p, miR-99a-5p and miR-21-5p were increased by steroid treatment regardless of ONFH development in both humans and rats. These data suggested that miR-10a-5p, miR-99a-5p and miR-21-5p are steroid-responsive circulating miRNAs, but they are not specific for diagnosing steroid-induced ONFH.

Circulating microRNA signature of steroid-induced osteonecrosis of the femoral head.

OBJECTIVES: Steroid-induced osteonecrosis of the femoral head (ONFH) is a common orthopaedic disease of which early detection remains clinically challenging. Accumulating evidences indicated that circulating microRNAs (miRNAs) plays vital roles in the development of several bone diseases. However, the association between circulating miRNAs and steroid-induced ONFH remains elusive. MATERIALS AND METHODS: miRNA microarray was performed to identify the differentially abundant miRNAs in the serums of systemic lupus erythematosus (SLE) patients with steroid-induced ONFH as compared with SLE control and healthy control group. We predicted the potential functions of these differentially abundant miRNAs using Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses and reconstructed the regulatory networks of miRNA-mRNA interactions. RESULTS: Our data indicated that there were 11 differentially abundant miRNAs (2 upregulated and 9 downregulated) between SLE-ONFH group and healthy control group and 42 differentially abundant miRNAs (14 upregulated and 28 downregulated) between SLE-ONFH group and SLE control group. We also predicted the potential functions of these differentially abundant miRNAs using Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses and reconstructed the regulatory networks of miRNA-mRNA interactions. CONCLUSIONS: These findings corroborated the idea that circulating miRNAs play significant roles in the development of ONFH and may serve as diagnostic markers and therapeutic targets.