The use of intraoperative cell salvage in total hip arthroplasty with subtrochanteric shortening osteotomy for the treatment of high hip dislocation: a retrospective cohort study.

BACKGROUND: Intraoperative cell salvage (ICS) is an important component of blood management in patients undergoing orthopedic surgery. However, the role of ICS is less well defined in total hip arthroplasty (THA) with subtrochanteric shortening osteotomy (SSO) which is a common surgical technique to manage high hip dislocation. This study aimed to determine the effect of ICS during THA with SSO and to identify factors associated with the ability to salvage sufficient collection for reinfusion in patients with high hip dislocation. METHODS: We identified 178 patients who underwent THA with SSO for high hip dislocation between November 2010 and April 2021. The consecutive cohort was analyzed by logistic regression to determine the effect of ICS on postoperative allogeneic blood transfusion (ABT) and to explore the associations between patient demographics, clinical and radiographic characteristics, preoperative laboratory examination, and surgical variables with the ability to generate adequate blood salvage to reinfuse. RESULTS: In the consecutive cohort of 178 patients, cell salvage was reinfused in 107 patients (60.1%) and postoperative allogeneic red blood cell (RBC) transfusion within 3 days of implantation was administrated in 40 patients (22.5%). In multivariate analysis, the reinfusion of ICS (OR (95%CI) 0.17 (0.07-0.47)), center of rotation (COR) height ≥ 60 mm (OR (95%CI) 3.30 (1.21-9.01)), the length of SSO ≥ 30 mm (OR (95%CI) 2.75 (1.05-7.22)) and the use of drainage (OR (95%CI) 2.28 (1.04-5.03)) were identified as independent factors of postoperative allogeneic RBC transfusion. In addition, the following variables were identified as independent factors associated with the ability to generate sufficient blood salvage volume for reinfusion: COR height ≥ 60 mm (OR (95%CI) 3.47 (1.58-7.61)), limb-length discrepancy (LLD) ≥ 25 mm (OR (95%CI) 2.55 (1.15-5.65)) and length of SSO ≥ 30 mm (OR (95%CI) 2.75 (1.33-5.69)). CONCLUSIONS: ICS was efficacious in reducing the exposure rate of postoperative RBC transfusion for high hip dislocation during THA with SSO. In addition, patients with greater COR height, larger LLD, and longer length of SSO were predisposed to generate sufficient collection for reinfusion in THA with SSO.

Dexmedetomidine Prolongs the Analgesic Effects of Periarticular Infiltration Analgesia following Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Trial.

BACKGROUND: Periarticular infiltration analgesia (PIA) is widely administered to relieve postoperative pain following total knee arthroplasty (TKA). The present study aimed to evaluate the effect of prolonging the analgesic duration by adding dexmedetomidine to PIA for pain management after TKA. METHODS: One hundred and sixteen patients were randomly allocated into 3 groups based on PIA regimens including group R (ropivacaine), group E (ropivacaine plus epinephrine), and group D (ropivacaine plus dexmedetomidine). The primary outcomes were postoperative visual analog scale scores, time until the administration of first rescue analgesia, and opioid consumption. The secondary outcomes included postoperative inflammatory biomarkers and functional recovery. The tertiary outcomes were postoperative complications and adverse events. RESULTS: The patients in group D had significantly lower resting visual analog scale scores than those in groups R and E at 6 hours after surgery. Group R showed the higher pain scores at rest and motion than groups D and E 12 hours postoperatively. The use of dexmedetomidine or epinephrine postponed the time until the administration of first rescue analgesia and led to lower opioid consumption in the first 24 hours after TKA. The levels of interleukin-8 and tumor necrosis factor-α in groups D and E were significantly lower than those in group R on postoperative day 3. Furthermore, no significant differences were observed in functional recovery, postoperative complications, or adverse events among the three groups. CONCLUSIONS: Adding dexmedetomidine as an adjuvant to PIA could potentiate and prolong the analgesic effect in the early stage following TKA without increasing the risk of adverse events.

Mid-long-term results of total knee arthroplasty followed by ipsilateral total hip arthroplasty versus total hip arthroplasty subsequent to ipsilateral total knee arthroplasty: a case-control analysis.

BACKGROUND: The aim of the present study was to compare the outcomes of patients who underwent different sequences of ipsilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: We retrospectively identified 47 patients who underwent TKA followed by ipsilateral THA (THA-TKA) and 36 patients who received THA subsequent to ipsilateral TKA (TKA-THA) for rheumatoid arthritis or osteoarthritis between January 2008 and April 2014. Twenty-eight patients were selected for each group after case-control matching with preoperative demographics and protheses of THA. Clinical scores, radiographic results, complication rates, and survivorship were compared. The median duration of follow-up was 110 (range 80-149) months. RESULTS: Both groups showed significant improvement in Harris Hip Scores, Knee Society Score, and Short Form-12 at the last follow-up compared to baseline (p < .001). At the last follow-up, all clinical scores were actually lower in the THA-TKA group, but those differences were not statistically significant. Otherwise, there was no significant difference in radiological alignment or complication rates. The survivorship of THA and TKA in the THA-TKA group was 94.7 and 95.7%, respectively, compared with 92.4 and 100.0% in the TKA-THA group at 8 years (log rank, p = .939 and .187). CONCLUSIONS: Patients who underwent ipsilateral THA and TKA with different sequences achieved similar favorable outcomes. Total joint arthroplasty can be performed safely with excellent outcomes in patients with a history of prior ipsilateral THA or TKA. TRIAL REGISTRATION: The trial was registered in the Chinese Clinical Trial Registry ( ChiCTR2000035147 ) dated 2 August 2020.

Multiple drilling is not effective in reducing the rate of conversion to Total hip Arthroplasty in early-stage nontraumatic osteonecrosis of the femoral head: a case-control comparative study with a natural course.

BACKGROUND: To determine whether multiple drilling is effective in postponing the need for total hip arthroplasty (THA) in early-stage nontraumatic osteonecrosis of the femoral head (ONFH). METHODS: We identified 514 patients who were diagnosed with early-stage ONFH between January 2008 and December 2018. One hundred ninety-six patients underwent multiple drilling, and 318 patients had a natural course of progression. One hundred fifty-nine patients were selected for each group after case-control matching for preoperative demographics and modified Ficat and Arlet stage. The rates of THA conversion were compared. We also performed Cox regression to identify risk factors associated with THA conversion in patients who underwent multiple drilling. RESULTS: Kaplan-Meier survivorship with an endpoint of THA for nontraumatic reasons were not significantly different between the multiple drilling group (75.6, 95% confidence interval 67.8-83.4%) and the natural course group (72.2, 95% confidence interval 64.8-79.6%) at 5 years (log-rank, P = .191). In the Cox regression model, a larger extent of necrotic lesion, bone marrow edema (BME), and higher postoperative work intensity significantly increased the risk of THA conversion (P < .05). Among patients treated with autogenous bone grafting, there was a lower risk of failure in patients with necrotic lesion less than 15% (P < .05). CONCLUSIONS: Multiple drilling is not effective in reducing the rate of THA conversion in early-stage nontraumatic ONFH. The risk of conversion to THA after multiple drilling is increased by a larger extent of necrotic lesion, presence of BME, and higher postoperative work intensity in patients with early-stage ONFH. TRIAL REGISTRATION: The trial was registered in the Chinese Clinical Trial Registry ( ChiCTR2000035180 ) dated 2 August 2020.

CT- versus MRI-based patient-specific instrumentation for total knee arthroplasty: A systematic review and meta-analysis.

BACKGROUND: To determine whether computed tomography (CT) or magnetic resonance imaging (MRI) is more suitable for the patient-specific instrumentation (PSI) systems for total knee arthroplasty (TKA). METHODS: PubMed, Embase, and the Cochrane Library were searched from inception to June 2016 for prospective comparative trials that compared CT- versus MRI-based PSI systems for TKA. Our predefined primary outcome was the outliers incidence of coronal overall limb alignment. RESULTS: Six studies with a total of 336 knees meeting the eligibility criteria, and four trials were included in the meta-analysis. Compared with MRI-based PSI systems, CT-based PSI systems were associated with a higher outliers incidence of coronal overall limb alignment (risk ratio: 1.67; 95% confidence interval (CI): 1.03-2.72; P = 0.04), more angular errors of coronal overall limb alignment (mean difference (MD): 1.01°; 95% CI: 0.47-1.56; P = 0.0003), and longer operation time (MD: 5.02 min; 95% CI: 1.26-8.79; P = 0.009). While no significant differences in the coronal/sagittal alignment of the femoral/tibial component outliers, the angular errors of coronal overall limb alignment, the angular errors of the femoral/tibial component in coronal plane, or incidence of change of implant size of the femoral/tibial component were observed. CONCLUSIONS: The current limited evidence suggests that MRI-based PSI systems exhibit higher accuracy for TKA regarding the coronal limb axis than CT-based PSI systems. However, well-designed studies comparing CT-versus MRI-based PSI systems for TKA are warrant to confirm these results before widespread use of this technique can be recommended.

The effect of preoperative different dexamethasone regimens on postoperative glycemic control in patients with type 2 diabetes mellitus undergoing total joint arthroplasty: a retrospective cohort study.

BACKGROUND: Concerns have been raised regarding the impact of preoperative intravenous dexamethasone on postoperative glycemic control in diabetic patients undergoing total joint arthroplasty (TJA). This study aimed to determine relationships between preoperative different dexamethasone regimens and postoperative fasting blood glucose (FBG), as well as to identify risk factors for postoperative FBG ≥ 200 mg/dl in diabetic patients undergoing TJA. METHODS: This retrospective study included 1216 diabetic patients undergoing TJA and categorized into group A (dexamethasone = 0 mg), group B (dexamethasone = 5 mg), and group C (dexamethasone = 10 mg). All dexamethasone was administered before skin incision. FBG levels were monitored until postoperative day (POD) 3. Analyses were conducted for periprosthetic joint infection (PJI) and wound complications during 90 days postoperatively. And the risk factors for postoperative FBG ≥ 200 mg/dl were identified. RESULTS: Preoperative dexamethasone administration resulted in a transiently higher FBG on POD 0 and POD 1 (all P < 0.001). However, no differences were observed on POD 2 (P = 0.583) and POD 3 (P = 0.131) among three groups. While preoperative dexamethasone led to an increase in postoperative mean FBG and postoperative maximum FBG (all P < 0.001), no differences were found in wound complications (P = 0.548) and PJI (P = 1.000). Increased HbA1c and preoperative high FBG, but not preoperative dexamethasone, were identified as risk factors for postoperative FBG ≥ 200 mg/dl. Preoperative HbA1c level of ≥ 7.15% was associated with an elevated risk of postoperative FBG ≥ 200 mg/dl. CONCLUSIONS: Although preoperative intravenous administration of 5 mg or 10 mg dexamethasone in diabetic patients showed transient effects on postoperative FBG after TJA, no differences were found in the rates of PJI and wound complications during 90 days postoperatively. Notably, patients with a preoperative HbA1c level of ≥ 7.15% and elevated preoperative FBG may encountered postoperative FBG ≥ 200 mg/dl.

Bone wax reduces blood loss after total hip arthroplasty: a prospective, randomized controlled study.

Background: Previous studies have demonstrated the efficacy of bone wax in reducing blood loss in various orthopedic surgeries. However, the effect of bone wax on total hip arthroplasty (THA) remains unclear. The objective of this study was to assess the efficacy of bone wax in THA. Methods: We enrolled 104 patients in this randomized controlled trial. These patients were randomized (1:1) to either the bone wax or control group. The primary outcome was total blood loss after THA. The secondary outcomes included serum hemoglobin (Hb) level, change in Hb level, lower limb diameters on the first and third postoperative day (POD), range of motion at discharge, length of postoperative hospital stay, and adverse events. Results: Patients in the bone wax group had significantly lower total blood loss on PODs 1 and 3 (p < 0.05). Moreover, patients in the bone wax group performed better in terms of postoperative serum Hb level, change in Hb level on PODs 1 and 3, and length of postoperative hospital stay (all p < 0.05). Patients in the bone wax group did not experience any bone wax-related adverse events. Conclusion: Bone wax administration in THA significantly reduced perioperative blood loss. Therefore, bone wax is promising for optimizing blood-conserving management protocols in THA. Clinical trial registration: [https://clinicaltrials.gov/], identifier [ChiCTR2100043868].

Near-infrared light-controlled kartogenin delivery of multifunctional Prussian blue nanocomposites for cartilage defect repair.

Articular cartilage injury repair remains a challenge for clinicians and researchers. Mesenchymal stem cells (MSCs) have multiple differentiation potentials and can be induced to differentiate into the chondrogenic lineage for cartilage defect repair; however, the insufficient capacity of chondrogenic differentiation and excess reactive oxygen species (ROS)-mediated oxidative stress, which always lead to differentiation into hypertrophic chondrocytes, still need to be resolved. Accordingly, kartogenin (KGN), which can promote chondrogenic differentiation of MSCs, has shown promise in promoting infected cartilage repair. However, realizing controllable release to prolong its action time and avoid hypertrophic differentiation is critical. We herein developed a mesoporous Prussian blue nanoparticle (mPB)-based near-infrared (NIR) light-responsive controlled nanosystem. KGN was encapsulated in temperature-stimulated responsive phase change materials (PCMs), which were used as excellent gating materials (KGN-PCM@mPBs). In addition, the mPBs could efficiently scavenge ROS by their enzyme-like antioxidative activities. Our study demonstrates that the nanocomposites could efficiently promote chondrogenic differentiation and successfully inhibit the hypertrophic differentiation of MSCs. By intra-articular injection of KGN-PCM@mPBs and NIR-triggered precisely controlled release, satisfactory cartilage repair effects can be achieved in a rat chondral defect model. Thus, this constructed NIR-mediated KGN-PCM@mPB nanoplatform may represent an effective cartilage repair strategy with satisfactory biosafety in clinical applications.

The use of cell salvage during second-stage reimplantation for the treatment of chronic hip periprosthetic joint infection: a retrospective cohort study.

INTRODUCTION: Given the possibility of inadvertent bacterial contamination of salvaged blood, the use of cell salvage is relatively contraindicated in cases of reimplantation for chronic hip periprosthetic joint infection (PJI). However, there are no published data supporting this assertion. The purpose of the current study was to compare the reinfection rate and rate of postoperative allogeneic blood transfusion (ABT) in second-stage reimplantation for PJI with or without intraoperative cell salvage reinfusion. MATERIALS AND METHODS: We identified 125 patients who underwent two-stage exchange for chronic hip PJI between November 2012 and April 2019. The groups of patients who had (n = 61) and had not (n = 64) received intraoperative cell salvage reinfusion were compared with respect to the curative infection-free rate. Moreover, we compared the need for postoperative ABT and identified independent factors associated with ABT using multiple regression analysis. RESULTS: The log-rank survival curve with an endpoint of infection eradication failure was not significantly different between the cell salvage group (98.4%, 95% CI 95.3-99.9%) and the control group (95.3%, 95% CI 90.2-99.9%) at one year (log rank, P = .330). The rates of postoperative ABT in the cell salvage group were significantly lower than those in the control group (11.5% vs 26.6%, P = .041). In multivariable models, patient age, body mass index, preoperative hemoglobin level, and intraoperative cell salvage were independent predictors of ABT exposure (P < .05). CONCLUSIONS: The use of cell salvage during reimplantation in two-stage exchange for chronic hip PJI did not appear to increase the reinfection rate, while it significantly reduced the rate of postoperative allogeneic red blood transfusion. Greater age, lower BMI, lower preoperative hemoglobin, and non-intraoperative cell salvage reinfusion were associated with higher rate of allogeneic red blood transfusion.

A Comparison Between Unstemmed and Stemmed Constrained Condylar Knee Prostheses in Primary Total Knee Arthroplasty: A Propensity Score-Matched Analysis.

OBJECTIVE: To compare and analyze the clinical outcomes between unstemmed and stemmed constrained condylar knees (CCK) in complex primary total knee arthroplasty (TKA) in terms of implant survivorship, change in outcome evaluations, and complications. METHODS: We reviewed 156 consecutive patients who received primary TKA using PFC®SIGMA®TC3 (TC3) of constrained condylar design between January 2009 and January 2017 at our institution. After removing patients who met exclusion criteria, 25 patients were identified as unstemmed TC3 cases and 81 as stemmed TC3 cases. Propensity score matching was used to select 25 stemmed cases as a control group for the unstemmed group with comparable preoperative conditions including preoperative demographics, preoperative diagnosis, preoperative range of motion, main reason to use TC3, ASA score (American Society of Anesthesiologists), and follow-up duration. Preoperative and postoperative clinical evaluations including Knee Society Score (KSS), Hospital for Special Surgery (HSS) score, the 12-Item Short-Form Health Survey (SF-12), and the range of motion (ROM) were obtained and compared. The instability, periprosthetic fracture, radiolucent lines, polyethylene wear, and heterotrophic ossification were assessed according to the anteroposterior and lateral radiographs of the knee. The complications and implant survivorship between the two groups were also recorded and compared. RESULTS: 3After the index surgery, both groups showed substantial improvement in KSS (knee and function), HSS score, SF-12, and ROM compared with baseline. There was no significant difference in the mean KSS scores (knee and function), HSS score, SF-12, and ROM between the unstemmed and stemmed group postoperatively. No statistically significant difference was found in the overall complication rate between the two groups. The overall Kaplan-Meier survivorship was 98.0% (95% confidence interval 94.1%-100.0%) at 7 years. No significant difference was found in the survival rate between the unstemmed group (100.0%) and the stemmed group (96.0%) at 7 years (log rank, P = 0.317). The mean duration of follow-up was 7.0 years for unstemmed group and 7.7 years for stemmed group. CONCLUSIONS: In patients with adequate bone stock receiving complex primary TKA, unstemmed CCK could achieve similar clinical outcomes at mid-term follow-up as stemmed CCK.

Nomogram to predict collapse-free survival after core decompression of nontraumatic osteonecrosis of the femoral head.

BACKGROUND: Nontraumatic osteonecrosis of the femoral head (NONFH) is a devastating disease, and the risk factors associated with progression into collapse after core decompression (CD) remain poorly defined. Therefore, we aim to define risk factors associated with collapse-free survival (CFS) after CD of precollapse NONFH and to propose a nomogram for individual risk prediction. METHODS: According to the baseline characteristics, clinical information, radiographic evaluations, and laboratory examination, a nomogram was developed using a single institutional cohort of patients who received multiple drilling for precollapse NONFH between January 2007 and December 2019 to predict CFS after CD of precollapse NONFH. Furthermore, we used C statistics, calibration plot, and Kaplan-Meier curve to test the discriminative ability and calibration of the nomogram to predict CFS. RESULTS: One hundred and seventy-three patients who underwent CD for precollapse NONFH were retrospectively screened and included in the present study. Using a multiple Cox regression to identify relevant risk factors, the following risk factors were incorporated in the prediction of CFS: acute onset of symptom (HR, 2.78; 95% CI, 1.03-7.48; P = 0.043), necrotic location of Japanese Investigation Committee (JIC) C1 and C2 (HR, 3.67; 95% CI, 1.20-11.27; P = 0.023), necrotic angle in the range of 250-299°(HR, 5.08; 95% CI, 1.73-14.93; P = 0.003) and > 299° (HR, 9.96; 95% CI, 3.23-30.70; P < 0.001), and bone marrow edema (BME) before CD (HR, 2.03; 95% CI, 1.02-4.02; P = 0.042). The C statistics was 0.82 for CFS which revealed good discriminative ability and calibration of the nomogram. CONCLUSIONS: Independent predictors of progression into collapse after CD for precollapse NONFH were identified to develop a nomogram predicting CFS. In addition, the nomogram could divide precollapse NONFH patients into prognosis groups and performed well in internal validation.

A propensity score-matched analysis between patients with high hip dislocation after childhood pyogenic infection and Crowe IV developmental dysplasia of the hip in total hip arthroplasty with subtrochanteric shortening osteotomy.

BACKGROUND: Whether satisfactory clinical and radiological outcomes of total hip arthroplasty (THA) with subtrochanteric shortening osteotomy (SSO) in high hip dislocation after childhood pyogenic infection can be achieved as in Crowe IV developmental dysplasia of the hip (DDH) remains unclear. METHODS: Between September 2009 and December 2016, 151 primary THAs performed at our institution using similar SSO technique and prosthetic design were retrospectively reviewed. After excluding patients who met exclusion criteria, 29 patients were identified as high dislocation (Crowe IV) after childhood infection (HDACI) and 107 as Crowe IV developmental dysplasia of the hip (DDH). Propensity score matching was used to select 29 Crowe IV DDH patients as a control group for the HDACI group with comparable preoperative conditions. Clinical and radiological outcomes and complication were compared and analyzed. The mean follow-up duration of the 2 groups was 5.0 years. RESULTS: The mean Harris hip score (HHS) and the mean score in range of motion (ROM) domain of the modified Merle d'Aubigné-Postel (MAP) were 84.6 and 4.5 in the HDACI group, compared with 88.3 and 4.9 in the DDH group; there was significant difference between the 2 groups in these parameters (P = 0.015 and 0.035, respectively). Meanwhile, in the HDACI group, the median time of osteotomy union was 4 months and osteotomy nonunion rate was 3%; no significant difference was detected in the median time of osteotomy union and osteotomy nonunion rate between the 2 groups (P = 0.388 and 1.000, respectively). And no significant difference was found in the rate of complications between two groups. CONCLUSIONS: HDACI patients who received THA combined with SSO could achieve similar satisfactory results as DDH patients in Crowe type IV. The fixation technique of autogenous cortical bone struts had a positive influence on osteotomy healing of SSO in this specific setting.