A new cocktail formula with diprospan of local infiltration analgesia in primary total hip arthroplasty: A prospective, randomized, controlled, observer-blinded study.

OBJECTIVE: This study aimed to observe the analgesic effect of the cocktail formulation with diprospan during total hip arthroplasty (THA). METHODS: From September 2018 to April 2019, 120 patients undergoing primary unilateral THA were included in this prospective, randomized, observer-blinded study. Patients were randomized into three groups, according to the different local infiltration analgesia (LIA) strategies: LIA with ropivacaine (the ropivacaine group, n = 40), LIA with a new cocktail containing ropivacaine, diprospan, and morphine (the cocktail group, n = 40), and the control group (n = 40). The primary outcomes included postoperative pain scores. The resting visual analogue scale (VAS) scores were measured at 2, 6, and 12 h after the surgery (a.m. and p.m.) on postoperative day (POD) 1, POD2, and the day of discharge. Movement VAS scores were assessed at 6 h, 12 h after the operation (a.m. and p.m.) on POD1, POD2, and the day of discharge. The secondary outcomes included opioid consumption, postoperative hospital stay, range of motion of the hip at discharge, patient satisfaction, and the results of the follow-up. RESULTS: After the screening, 120 patients were randomized into three groups (40 patients in each group). All of the patients completed the trial. The resting VAS scores in the ropivacaine group and cocktail group at 2 h were lower than those in the control group (P < 0.001 and P < 0.001, respectively, F = 17.054), and the same trend was also postoperatively found at 6 h (p = 0.005 and P = 0.002, F = 6.212). Twelve hours after the operation, the pain score in the cocktail group was lower than that in the other two groups, but only the difference between the cocktail group and the control group was statistically significant (P = 0.018, F = 3.144). From the morning of the first postoperative day to the a.m. on POD 2, the VAS scores in the cocktail group were significantly lower than those in the ropivacaine group and the control group. Furthermore, the movement VAS scores in the ropivacaine group and the cocktail group were better than those in the control group at 6 and 12 h post-operation (P < 0.05). The per capita opioid consumption in the cocktail group was less than that in the ropivacaine group and the control group within 24 h post-operation. There were no significant differences in the comparison of additional indicators among the three groups. CONCLUSION: The new cocktail with diprospan had a better result and longer duration time for early postoperative pain control in primary THA via the posterolateral approach under general anesthesia, especially for treating resting pain.

Long-Term Clinical Outcomes and Survivorship of Total Hip Arthroplasty for Pyogenic Arthritis: A Retrospective Cohort Study of 168 Hips.

OBJECTIVE: The aim of the present study was to evaluate the 10-year outcomes of cementless total hip arthroplasty (THA) in adult patients with the late sequelae of septic arthritis of the hip. METHODS: We followed 166 consecutive patients (168 hips) who underwent cementless THA between March 2001 and December 2011. There were 79 men and 87 women, with a mean age of 50.4 years (range 21-76 years) at the time of index THA, all of whom had hip osteoarthritis secondary to hip pyogenic infection. The average duration of follow up was 10.6 years (range 6.9-17.2 years). Preoperative and postoperative clinical ratings were evaluated, including the hip dysfunction and osteoarthritis outcome score (HOOS), the Harris hip score (HHS), range of motion, a 100-point visual analog scale for hip pain, and the severity of limp and limb length discrepancy (LLD). The anteroposterior and lateral radiographs of the hip and full-length view of the lower extremities were obtained to assess the position of the components, radiolucent lines, osteolysis, loosening of components, and heterotopic ossification. The intraoperative and postoperative complications were also recorded. RESULTS: The mean HSS and hip pain score were 44.2 points (range 29-66 points) and 42.5 points (range 32-64 points), respectively, before the index surgery and significantly improved to 88.1 points (range 78-96 points) and 15.1 points (range 10-26 points), respectively, at final follow-up examination. The HOOS and range of motion also improved significantly. The mean limb length discrepancy was reduced from 2.6 to 0.8 cm. The limp at last follow-up examination was moderate in 3 cases because of hip osteoarthritis in the other limb, slight in 26, and absent in 137. A radiolucent line was observed in 12 hips (7.1%) around the acetabular or femoral components. A progressive radiolucent line around the undersized femoral stem in all zones was seen in 1 hip, resulting in aseptic loosening and breakage of the femoral component. There were 8 cases of intraoperative fracture, 7 cases of dislocation, and 7 cases of transient nerve palsy. Recurrence of infection occurred in 2 hips. Revision surgery was conducted in 2 hips because of isolated loosening of the acetabular cup and the femoral stem, respectively. Kaplan-Meier survival was 97% at 10 years, with revision for any reason with any component as an end-point. CONCLUSION: Improved surgical techniques and development of components with various sizes provided favorable results for cementless THA conducted for late sequelae of sepsis in these young and active patients. Although the incidence of complications was relatively high, the complications were treated successfully.

Role of D-dimer and Fibrinogen in the Diagnosis of Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis.

The diagnostic potential of D-dimer and fibrinogen to detect periprosthetic joint infection (PJI) of the hip and knee is not well-understood. The aim of this study was to determine whether D-Dimer and fibrinogen can be used as effective biomarkers to screen PJI. A systematic review of the literature indexed in Web of Science, PubMed, Cochrane Library, Embase, and Google Scholar databases was performed. All studies using D-dimer levels in serum or plasma, or fibrinogen levels in plasma, for the diagnosis of PJI were included. Meta-analysis estimates, including sensitivity, specificity, diagnostic odds ratios (DOR), and the area under the summary receiver operating characteristic curve (AUSROC), were calculated using a random-effects model, and used to assess the diagnostic accuracy of these biomarkers. A total of nine studies were analyzed, and their quality was considered to be acceptable. D-dimer gave a limited diagnostic value if serum and plasma combined: sensitivity (0.77, 95% confidence interval [CI] [0.63 to 0.87]), specificity (0.67, 95% CI [0.54 to 0.78]), DOR (6.81, 95% CI [2.67 to 17.37]), and AUSROC (0.78, 95% CI [0.74 to 0.82]). Plasma D-dimer levels were associated with less satisfactory sensitivity (0.65, 95% CI 0.57 to 0.71), specificity (0.58, 95% CI 0.50 to 0.66), DOR (2.52, 95% CI 1.64 to 3.90), and AUSROC (0.65, 95% CI 0.61 to 0.69). Serum D-dimer levels showed higher corresponding values of 0.89 (95% CI 0.79 to 0.94), 0.76 (95% CI 0.55 to 0.89), 24.24 (95% CI 10.07 to 58.32), and 0.91 (95% CI 0.88 to 0.93). Plasma fibrinogen showed acceptable corresponding values of 0.79 (95% CI 0.70 to 0.85), 0.73 (95% CI 0.57 to 0.85), 10.14 (95% CI 6.16 to 16.70), and 0.83 (95% CI 0.79 to 0.86). Serum D-dimer may be an effective marker for the diagnosis of PJI in hip and knee arthroplasty patients, and it may show higher diagnostic potential than plasma fibrinogen. Plasma D-dimer may have limited diagnostic potential.

Benefits of early ambulation within 24 h after total knee arthroplasty: a multicenter retrospective cohort study in China.

BACKGROUND: Postoperative care has been evolving since the concept of enhanced recovery after surgery (ERAS) was introduced in China. This study aimed to evaluate the effects of early ambulation within 24 h after unilateral total knee arthroplasty (TKA) on postoperative rehabilitation and costs in a Chinese population. METHODS: This cohort study of patients with knee osteoarthritis who had undergone TKA at 24 large teaching hospitals between January 2014 and November 2016 involved 2687 patients who began ambulating within 24 h (Group A) and 3761 who began ambulating later than 24 h (Group B). The outcome measurements, such as length of stay (LOS), total hospitalization costs, dynamic pain level, knee flexion range of motion (ROM), results of the 12-Item Short Form Survey (SF-12), incidence of thromboembolic events and other complications, were recorded and compared. RESULTS: The early ambulation group (Group A) had a shorter LOS and lower hospitalization costs and pain levels than the late ambulation group (Group B). There was a favorable effect in enhancing ROM for patients in Group A compared with patients in Group B. In Group A, patients had significantly higher postoperative SF-12 scores than those in Group B. The incidence of deep venous thrombosis (DVT) and pulmonary infection was significantly lower in Group A than in Group B. The incidence of pulmonary embolism (PE) and other complications did not differ between the two groups. CONCLUSION: Early ambulation within 24 h after TKA was associated with reduced LOS, improved knee function, lower hospitalization costs and lower incidence of DVT and pulmonary infection in the Chinese population.

Finding the optimal control level of intraoperative blood pressure in no tourniquet primary total knee arthroplasty combine with tranexamic acid: a retrospective cohort study which supports the enhanced recovery strategy.

BACKGROUND: With the use of tranexamic acid and control of the blood pressure during the operation, total knee arthroplasty (TKA) without tourniquet can be achieved. There is no exact standard for the control level of blood pressure during no tourniquet TKA. We explored the optimal level of blood pressure control during no tourniquet TKA surgery with the use of tranexamic acid in this study. METHODS: Patients underwent TKA were divided into three groups: the mean intraoperative systolic blood pressure in group A was < 90 mmHg, 90-100 mmHg in group B, > 100 mmHg in group C. Total blood loss (TBL), intraoperative blood loss, hidden blood loss, transfusion rate, maximum hemoglobin drop, operation time, and postoperative hospitalization days were recorded. RESULTS: Two hundred seventy-eight patients were enrolled, 82 in group A, 105 in group B, and 91 in group C. Group A (663.3 ± 46.0 ml) and group B (679.9 ± 57.1 ml) had significantly lower TBL than group C (751.7 ± 56.2 ml). Group A (120.2 ± 18.7 ml) had the lowest intraoperative blood loss than groups B and C. Group C (26.0 ± 4.1 g/l) had the largest Hb change than groups A and B. Group A (62.3 ± 4.7 min) had the shortest operation time. The incidence rate of postoperative hypotension in group A (8, 9.8%) was significantly greater than groups B and C. No significant differences were found in other outcomes. CONCLUSION: The systolic blood pressure from 90 to 100 mmHg was the optimal strategy for no tourniquet primary TKA with tranexamic acid.

Normal trajectory of Interleukin-6 and C-reactive protein in the perioperative period of total knee arthroplasty under an enhanced recovery after surgery scenario.

BACKGROUND: We designed the current study to understand the normal trajectories of interleukin-6 (IL-6) and C-reactive protein (CRP) in the immediate hours and days after primary total knee arthroplasty (TKA) under the management of an enhanced recovery after surgery (ERAS) protocol and examined whether one or the other returned to normal more quickly. METHODS: In this prospective cross-sectional study, we examined the plasma IL-6 and CRP levels in 100 patients undergoing primary TKA at the following time points: 12 h preoperatively as well as postoperatively 12 h, 48 h, 3 days and 2 weeks. Patients were followed up for 1 year to monitor the postoperative complications, especially the infection. RESULTS: IL-6 peaked at 48 h postoperatively. Then IL-6 started to decline at 3 days postoperatively and went back to baseline level at 2 weeks (p = 0.950). CRP peaked at 3 days postoperatively. At 2 weeks, CRP declined to a normal range, without being significantly different from the baseline level (p = 0.816). CONCLUSION: We found that under the ERAS scenario, the postoperative peak of IL-6 and CRP was deferred compared with previous studies. Compared to IL-6, CRP showed a gradual rise after surgery. Both of these two biomarkers returned to normal under the ERAS scenario. Future multiple-center studies with larger sample size can help define the thresholds of IL-6 and CRP for periprosthetic joint infection (PJI) early diagnosis. With these reference data, a clinician can make a quicker decision to perform aspiration to diagnose early PJI and benefits more patients.

One-Stage Arthroplasty or Revision for Seronegative Infections in Hip and Knee.

OBJECTIVE: To assess the safety and effectiveness of one-stage total joint arthroplasty (TJA) or revision for seronegative infections after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: This retrospective study included a total of 495 patients who had undergone one-stage total joint (hip or knee) arthroplasty or revision with a diagnosis of osteoarthritis secondary to sepsis, osteoarthritis or osteonecrosis of the femoral head (ONFH) secondary to internal fixation surgery of the hip joint, and one-stage revision for prosthesis loosening after THA or TKA from January 2012 to December 2016. Bacterial cultures were taken from all patients (from joint fluid or articular cavity fluid and four to six different parts of soft tissues) during the operation. If the cultures were positive, patients received antibiotic treatment. Microbiology results from surgical samples, clinical evaluations, SF-12 score (physical component summary [PCS] and mental component summary [MCS]), Harris hip score (HHS) or Hospital for Special Surgery (HSS) score, and patients' satisfaction was recorded at every follow-up session. RESULTS: A total of 24 patients had a positive result for bacterial culture (4.85%). The bacterial culture results showed that there were 19 cases (79.16%) of gram-positive cocci (Staphylococcus aureus), 4 cases (16.67%) of gram-negative bacilli, and 1 case (4.17%) of fungi. For at least 24 months (mean 35 months) follow-up, no reinfection was discovered. The mean HHS or HSS score improved significantly from 36.29 points preoperatively to 84.21 points postoperatively (P < 0.001). The mean PCS score improved from 10.15 preoperatively to 20.34 postoperatively, and the mean MCS from 13.22 preoperatively to 21.76 postoperatively, with significant differences. Most of the patients were satisfied. CONCLUSION: One-stage arthroplasty or revision with exhaustive debridement, adequate dosage, and duration of sensitive antibiotics is safe and effective for patients who have seronegative infection of hip or knee joints.

The antifibrinolytic and anti-inflammatory effects of a high initial-dose tranexamic acid in total knee arthroplasty: a randomized controlled trial.

PURPOSE: The aim of this study was to evaluate the effects of a high initial-dose (60 mg/kg) intravenous tranexamic acid (IV-TXA) on fibrinolysis and inflammation after total knee arthroplasty (TKA). METHODS: A total of 132 patients were categorized into two groups based on different TXA regimens: 20 mg/kg before incision (A) or 60 mg/kg before incision (B). All patients received five doses of 1 g TXA at three, six, 12, 18, and 24 hours after the first dose. The primary outcomes were peri-operative blood loss and transfusion rate. Other outcome measurements such as, haemoglobin level, fibrinolysis parameters [fibrin(-ogen) degradation products (FDP), D-dimer], inflammatory factors [C-reactive protein (CRP), interleukin-6 (IL-6)], visual analog scale (VAS) score, consumption of analgesic rescue, coagulation parameters [activated partial thromboplastin time (APTT), prothrombin time (PT), platelet count, thrombelastography (TEG), and anti-factor Xa activity (AFXa)] and complications, were also compared. RESULTS: There was a favourable effect in reducing peri-operative blood loss and transfusion rate for patients in Group B, compared with patients in Group A. In addition, the levels of FDP, D-dimer, CRP, IL-6, and dynamic pain in Group B were significantly lower than those in Group A on post-operative days one, two and three. There were no statistically significant differences in postoperative coagulation parameters and complications between the two groups. CONCLUSION: A high initial-dose (60 mg/kg) IV-TXA before surgery followed by five doses can further reduce blood loss, provide additional fibrinolysis and inflammation control, and ameliorate post-operative pain following TKA, without increasing the risk of treatment-related complications.

Preoperative sleep quality affects postoperative pain and function after total joint arthroplasty: a prospective cohort study.

BACKGROUND: The relationship between preoperative sleep quality and postoperative clinical outcomes after total joint arthroplasty (TJA) is unclear. We performed a prospective cohort study to determine whether preoperative sleep quality was correlated with postoperative outcomes after TJA. METHODS: In this prospective cohort study, 994 patients underwent TJA. Preoperative sleep measures included scores on the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS), and a ten-point sleep quality scale. The primary study outcome measured was the visual analog scale (VAS) pain score to 12 weeks postoperation. The consumption of analgesic rescue drugs (oxycodone and parecoxib) and postoperative length of stay (LOS) were recorded. We also measured functional parameters, including range of motion (ROM), Knee Society Score (KSS), and Harris hip score (HHS). RESULTS: The mean age for total knee and hip arthroplasties was 64.28 and 54.85 years, respectively. The PSQI scores were significantly correlated with nocturnal and active pain scores and ROM and functional scores from postoperative day 1 (POD1) to POD3. In addition, significant correlation was noted between the correlation between the active pain scores and ESS scores in the TKA group at postoperative 3 months. The consumption of analgesics after joint arthroplasty was significantly correlated with the PSQI scores. Moreover, significant correlations were noted between the sleep parameters and postoperative length of hospital stay (LOS). CONCLUSION: Preoperative sleep parameters were correlated with clinical outcomes (i.e., pain, ROM, function, and LOS) after TJA. Clinicians should assess the sleep quality and improve it before TJA.

Intravenous and subsequent long-term oral tranexamic acid in enhanced-recovery primary total knee arthroplasty without the application of a tourniquet: a randomized placebo-controlled trial.

BACKGROUND: To assess the efficacy and safety of intravenous and subsequent long-term oral tranexamic acid (TXA) following total knee arthroplasty (TKA) without a tourniquet. METHODS: In this double-blinded trial, 118 patients undergoing primary TKA were randomized into two groups: the patients in group A received intravenous TXA at 20-mg/kg 10 min before the surgery and 3 h postoperatively, and then oral 1 g TXA from postoperative day (POD) 1 to POD 14, and the patients in group B received intravenous TXA at 20-mg/kg 10 min before surgery and 3 h postoperatively, and then oral 1 g placebo from postoperative day (POD) 1 to POD 14. The primary outcome was total blood loss. Secondary outcomes included ecchymosis area and morbidity, postoperative transfusion, postoperative laboratory values, postoperative knee function and length of hospital stay. Complications, and patient satisfaction were also recorded. RESULTS: The mean total blood loss was lower in Group A than in Group B (671.7 ml vs 915.8 ml, P = 0.001). There was no significant difference in the transfusion rate between the two groups. Group A had a higher hemoglobin than Group B on POD 3 (106.0 g/L vs 99.7 g/L, P = 0.001). However, no significant difference was found for Hb or hematocrit on POD 1 or POD 14 between the two groups. Patients in Group A had less ecchymosis morbidity (7 vs 38, P = 0.001), smaller ecchymosis area (1.6 vs 3.0, P = 0.001) than Group B. The blood coagulation level as measured by fibrinolysis (D-Dimer) was lower in Group A than in Group B on POD 1 and POD 3 (4.6 mg/L vs. 8.4 mg/L, respectively, P = 0.001; 1.5 mg/L vs. 3.3 mg/L, respectively, P = 0.001). However, there was no significant difference on POD 14, and the fibrin degradation products showed the same trend. Patients in Group A had less swelling than those in Group B on POD 3 and POD 14. The circumference of the knee was 43.1 cm vs. 46.1 cm (POD 3, P = 0.001) and 41.4 cm vs. 44.9 cm (POD 14, P = 0.001) in Group A vs Group B, respectively. Nevertheless, the circumference of the knee in the two groups was similar on POD 1 and POD 3 M. No significant differences were identified in knee function, pain score, or hospital stay. No significant differences were identified in thromboembolic complications, infection, hematoma, wound healing and patients satisfaction between the two groups. CONCLUSION: Intravenous and subsequent long-term oral TXA produced less blood loss and less swelling and ecchymosis compared with short-term TXA without increasing the risk of complications. TRIAL REGISTRATION: The trial was registered in the Chinese Clinical Trial Registry ( ChiCTR-IPR-17012264 ).

Long-Term Results of Cementless Total Hip Arthroplasty for Patients With High Hip Dislocation After Childhood Pyogenic Infection.

BACKGROUND: The purpose of this study is to analyze the 10-year outcomes of cementless, modular total hip arthroplasty (THA) in adult patients who had high dislocation secondary to childhood pyogenic arthritis. METHODS: We retrospectively followed 56 consecutive patients who underwent cementless, modular THA for the late sequelae of childhood septic arthritis of the hip from 2001 to 2011. There were 23 men and 33 women with a mean age of 47 years (24 to 68). Of the 56 hips, 25 were classified as Crowe type III and 31 as type IV. Mean follow-up was 10.7 years. RESULTS: One hip with a quiescent period of 23 years had recurrence of infection. Revision surgery was performed in 2 patients because of loosening and breakage of femoral stem and new infection with no correlation with childhood sepsis, respectively. The mean Harris hip scores improved from 44.2 points preoperatively to 87.5 points at final follow-up. Similarly, the Hip dysfunction and Osteoarthritis Outcome Score and hip pain also significantly improved at the latest follow-up. The mean acetabular cup abduction was 40.8° and the mean anteversion 27.8°, respectively. There were 5 cases of transient nerve palsy and 5 cases of intraoperative fracture. CONCLUSION: THA can reliably restore the abnormal anatomy and provide good results in these young and active patients who had high hip dislocation secondary to childhood pyogenic arthritis with a relatively high incidence of complications. However, these complications can be treated.

Effects of Total Hip Arthroplasty on Axial Alignment of the Lower Limb in Patients with Unilateral Developmental Hip Dysplasia (Crowe type IV).

BACKGROUND: The aim of this study was to evaluate the influence of total hip arthroplasty on axial alignment of the lower limb in adults with unilateral developmental hip dysplasia (Crowe type IV). METHODS: We retrospectively reviewed medical records of 50 adults who underwent total hip arthroplasty, in which the acetabular cup was placed in the anatomical position. The following parameters were measured before surgery, immediately after surgery, and two years later: mechanical axis deviation (MAD), tibiofemoral angle (TFA), femoral offset, hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (LDFA), mechanical medial proximal tibial angle, height of medial femoral condyle, height of lateral femoral condyle, and leg lengthening. Length of the resected femoral segment was also recorded from medical records. RESULTS: Preoperative MAD, TFA, HKA, and LDFA of the ipsilateral lower limb showed significant valgus deformity. MAD of the ipsilateral lower limb and valgus inclination were significantly smaller immediately after surgery than before, while TFA, HKA, femoral offset, and LDFA were significantly larger (P < 0.05). These parameters did not differ significantly between immediately after surgery and two years later (P > 0.05). Ipsilateral extremities were extended by a mean of 2.54 cm (range, 0 to 5.35 cm). The mean length of the femoral resected segment was 3.56 cm (range, 2.03 to 5.74 cm). The contralateral lower limb showed marginally smaller MAD and medial proximal tibial angle after surgery than before, but larger LDFA, TAF, and HKA. CONCLUSIONS: In patients with developmental hip dysplasia who underwent total hip arthroplasty with placement of the acetabular component at the level of the anatomic hip center, axial alignment of the ipsilateral lower limb was immediately altered, and valgus inclination was significantly reduced. The procedure only slightly altered the axial alignment of the contralateral lower limb.

Finding the Optimal Regimen for Oral Tranexamic Acid Administration in Primary Total Hip Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: Previous studies have confirmed that, compared with intravenous and intra-articular formulations, oral tranexamic acid (TXA) provides equivalent reduction in blood loss, at a substantially reduced cost and greater ease of administration. However, the optimal oral dosage regimen to achieve maximum blood-loss reduction remains unclear. The aim of this study was to assess the efficacy of a regimen of multiple doses of oral TXA on blood loss in primary total hip arthroplasty. METHODS: In this randomized controlled trial, 200 patients were randomized to 1 of 4 interventions. Group A received a single dose of 2.0 g of TXA orally at 2 hours preoperatively. In addition to this same preoperative dose, Group B received 1.0 g of TXA orally at 3 hours postoperatively, Group C received 1.0 g of TXA orally at 3 and 9 hours postoperatively, and Group D received 1.0 g of TXA orally at 3, 9, and 15 hours postoperatively. All patients received a 1.0-g topical dose of TXA. The primary outcome was total blood loss. Secondary outcomes included hemoglobin reduction, transfusion rate, thromboembolic complications, and adverse events. RESULTS: The mean total blood loss (and standard deviation) was significantly less in Groups B, C, and D (792.2 ± 293.0, 630.8 ± 229.9, and 553.0 ± 186.1 mL, respectively) than in Group A (983.6 ± 286.7 mL) (p < 0.001). Moreover, Groups C and D had a lower mean reduction in hemoglobin than did Groups A and B. However, no differences were identified between Groups C and D for blood loss and hemoglobin reduction. Additionally, no differences were observed among the groups regarding thromboembolic complications and transfusions. CONCLUSIONS: The multiple postoperative doses of oral TXA further reduced blood loss compared with a single preoperative bolus. The regimen of a preoperative dose and 3 postoperative doses of oral TXA produced maximum effective reduction of blood loss in total hip arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Negative pressure pulmonary edema after percutaneous endoscopic interlaminar lumbar discectomy-a case report.

BACKGROUND: Negative pressure pulmonary edema (NPPE) is a rare complication that is more prevalent in young patients. NPPE usually results from acute upper airway obstruction, which is most commonly caused by laryngospasm during extubation. NPPE is characterized by the sudden onset of coughing, hemoptysis, tachycardia, tachypnea, and hypoxia, and is dramatically improved with supportive care, which prevents severe sequelae. To our knowledge, there is no report of a patient developing NPPE after percutaneous endoscopic interlaminar lumbar discectomy. CASE PRESENTATION: Herein, we report the case of a 22-year-old amateur basketball player with L5/S1 disc herniation who developed NPPE during extubation after general anesthesia for a minimally invasive spinal surgery (percutaneous endoscopic interlaminar lumbar discectomy). The NPPE was treated by maintaining the airway patency, applying positive-pressure ventilation, administering dexamethasone and antibiotics, and limiting the volume of fluid infused. The patient had an uneventful postoperative course, and was discharged to his home on postoperative day 3. CONCLUSIONS: Although NPPE is an infrequent complication, especially in patients undergoing percutaneous endoscopic interlaminar lumbar discectomy, this case report highlights the importance of early diagnosis and prompt treatment of NPPE to prevent the development of potentially fatal complications.

Comparison of oral versus intra-articular tranexamic acid in enhanced-recovery primary total knee arthroplasty without tourniquet application: a randomized controlled trial.

BACKGROUND: Although randomized controlled trials have confirmed oral tranexamic acid (TXA) can provide similar blood-sparing efficacy compared with intravenous (IV) TXA in total knee arthroplasty (TKA), some concerns do remain about thromboembolic events after such systemic administration. Many studies have confirmed that intra-articular (IA) application of TXA can show similar blood-saving efficacy with minimal levels of systemic absorption compared with IV TXA. However, it remains unclear whether the efficacy and safety of oral TXA administration is equal to or less than that of IA administration in TKA without the use of a tourniquet and drain. Thus, this study was to verify non-inferior efficacy and safety of oral TXA compared with IA TXA in primary TKA. METHODS: A double-blind, randomized, controlled trial was performed to compare three oral doses of TXA (2 g of TXA 2 h before incision, and 1 g of TXA 6 and 12 h after surgery, respectively) with IA TXA (3 g of TXA in 100 mL of saline solution). One hundred forty-seven patients scheduled for TKA were randomized to one of the two interventions. The primary outcome was total blood loss. The secondary outcomes included reduction of hemoglobin concentration, clinical outcomes, blood coagulation values, thromboembolic complications, and transfusion rates. RESULTS: The mean total blood loss was 788.8 mL in the oral TXA group compared with 872.4 mL in the IA TXA group, with no statistical significance (p > 0.05). There were no significant differences in reduction of hemoglobin level, blood coagulation level, and clinical outcomes. The transfusion rates were 4% in oral group and 5% IA group, respectively. Also, no significant differences were identified in thromboembolic complications. CONCLUSION: Oral TXA according to the described protocol demonstrated non-inferiority for primary TKA, with no safety concerns and a greatly reduced cost, compared with the IA TXA. This randomized controlled trial supports the oral administration of TXA in TKA. TRIAL REGISTRATION: The trial was registered in the Chinese Clinical Trial Registry ( ChiCTR-INR-17010968 ) dated 23rd March 2017.

Two doses of low-dose perioperative dexamethasone improve the clinical outcome after total knee arthroplasty: a randomized controlled study.

PURPOSE: To study the clinical effect and safety of two doses of low-dose perioperative dexamethasone on pain and recovery after total knee arthroplasty. Methods A total of 108 patients were included in this randomized, double-blinded, placebo-controlled study. They received two doses of 10 mg IV dexamethasone (group Dexa) or IV isotonic saline (group Placebo). The CRP, IL-6 and pain levels, postoperative nausea and vomiting (PONV) incidence, nausea severity, postoperative fatigue, range of motion, length of stay, analgesic rescue and antiemetic rescue consumption, and complications were compared. Results The CRP and IL-6 levels in group Dexa were lower than in group Placebo at 24, 48, and 72 h postoperatively (P < 0.001, P < 0.001, and P < 0.001, respectively). In group Dexa, patients had less pain at 24 h postoperatively, at rest (P < 0.001) and during walking (P < 0.001); they also had a lower PONV incidence (P = 0.002) and a lower nausea VAS score (P = 0.008). Postoperative fatigue (P < 0.001) was relieved and the analgesic and antiemetic rescue consumption was reduced. Length of stay (n.s.) and range of motion (n.s.) were similar in both groups. No early surgical wound infection or gastrointestinal haemorrhage occurred in either group. Conclusions Administering two doses of low-dose perioperative dexamethasone for patients receiving total knee arthroplasty reduces postoperative CRP and IL-6 levels, provides additional analgesic effect, and reduces the PONV incidence and postoperative fatigue, without increasing the risk of early surgical wound infection and gastrointestinal haemorrhage. So two doses of low-dose perioperative dexamethasone are effective and safe for patients receiving TKA to decrease the inflammatory response, prevent PONV, relieve postoperative pain and fatigue, and enhance recovery. Level of evidence I.

The Use of Porous Tantalum Augments for the Reconstruction of Acetabular Defect in Primary Total Hip Arthroplasty.

BACKGROUND: Given the lack of studies of acetabular defect reconstruction in primary total hip arthroplasty (THA) using tantalum augments, this study aims to evaluate clinical and radiographic results for treatment with tantalum augments to reconstruct acetabular defects in primary THA. METHODS: We retrospectively reviewed 19 patients (19 hips) with acetabular defects who underwent primary THA using tantalum augments, with a minimum follow-up of 2 years. Clinical, radiographic, and surgical data were retrospectively evaluated. RESULTS: Mean follow-up was 5.1 years (range 2.5-7.6). Harris Hip Score improved from 35.8 (range 19-56) preoperatively to 85.3 (63-98) at last follow-up (P < .01). Oxford Hip Score, University of California Los Angeles activity scale, and Short Form-12 score also improved significantly from presurgery to last follow-up. Mean operation time and blood loss were 124.7 minutes and 530 mL, respectively. Mean hip center position was 2.97 cm (range 2.35-3.58) horizontally and 2.06 cm (1.29-2.92) vertically, and mean acetabular inclination was 38.9° (range 27°-47°) at last follow-up. These parameters were not significantly different from those recorded immediately postoperatively (P > .05). There was no aseptic loosening, cup and augment migration, screw breakage, or presence of hip infection at last follow-up. All hips were radiographically stable. CONCLUSION: Porous tantalum augments combined with titanium shells lead to satisfactory clinical and radiographic outcomes for the reconstruction of acetabular defect in primary THA at a mean 5.1 years of follow-up. This approach confers anatomical cup placement, simple operation, and a high rate of stable fixation.

The efficacy and safety of two low-dose peri-operative dexamethasone on pain and recovery following total hip arthroplasty: a randomized controlled trial.

PURPOSE: To evalute the efficacy and safety of two low-dose peri-operative dexamethasone on pain and recovery following total hip arthroplasty (THA). METHODS: One hundred ten patients received two-dose of 10 mg IV-dexamethasone (group dexa) or IV-isotonic saline (group placebo). The level of C-reactive protein (CRP) and interleukin-6 (IL-6), pain at rest and during mobilization, incidence of post-operative nausea and vomiting (PONV), intensity of nausea, post-operative fatigue, consumption of analgesic and antiemetic rescue, range of motion (ROM), post-operative length of stay (post-operative LOS), wound problems and complications were recorded and compared. RESULTS: The level of inflammation markers (CRP, IL-6) in group dexa was lower than group placebo at 24, 48, 72 hours post-operatively. Dynamic pain VAS score at 24 hours was lower in group dexa (P = 0.002), however, there was no significant effect on pain at rest. In group dexa, patients had a lower incidence of PONV (P = 0.003), as well as a lower VAS score of nausea (P = 0.044). The post-operative fatigue (P < 0.001) was relieved and the consumption of analgesic and antiemetic rescues were reduced. Furthermore, patients had better maximum hip flexion (P < 0.001) and abduction (P = 0.017), with shorter post-operative LOS (P = 0.006). There is no difference between groups in wound problems. No surgical site infection or gastrointestinal haemorrhage was detected in both groups. CONCLUSIONS: The administration of two low-dose peri-operative dexamethasone can effectively reduce the post-operative level of CRP and IL-6, provide additional pain and nausea control, ameliorate post-operative fatigue, enhance mobility, and shorten post-operative LOS following THA, without increasing the risk of infection and gastrointestinal hemorrhage. LEVEL OF EVIDENCE: I.

Comparison of cortisol and inflammatory response between aged and middle-aged patients undergoing total hip arthroplasty: a prospective observational study.

BACKGROUND: To investigate the differences in the perioperative serum cortisol, C-reactive protein (CRP) and interleukin-6 (IL-6) levels between aged and middle-aged patients undergoing total hip arthroplasty (THA). METHODS: Sixty patients (30 aged and 30 middle-aged) undergoing THA for osteoarthritis between August 2016 and January 2017 participated in this study. Blood samples were collected preoperatively and at 6 hours, 24 hours and 3 days after surgery to measure the cortisol, CRP and IL-6 concentrations. The clinical outcomes were assessed using the visual analogue scale (VAS) pain score and Harris hip score (HHS). RESULTS: No significant differences were found between the two groups before the operation in the cortisol, IL-6 and CRP levels; the VAS score; or the HHS. Cortisol was significantly lower at 6 hours after surgery in the aged group than in the middle-aged group (P < 0.05). IL-6 at 6 and 24 hours after surgery, CRP at 3 days after surgery and the VAS score at 6 and 24 hours after surgery in the aged group were significantly higher than those in the middle-aged group (P < 0.05). In the aged group, weak correlations were found between the cortisol concentration 6 hours after THA and the IL-6 level 24 hours after THA (r = -0.37, P = 0.04) and between the IL-6 level 6 hours after THA and the VAS score 24 hours after THA (r = 0.42, P = 0.02). CONCLUSION: Aged patients showed lower cortisol levels at 6 hours after surgery and higher IL-6 levels at 6 and 24 hours after surgery than middle-aged patients undergoing THA.