A Retrospective, Long-term Follow-up of the Clinical Outcomes and Cost-effectiveness of Single-anesthetic Multiple Total Joint Procedures in Hemophilic Arthropathy.

OBJECTIVE: Although total joint replacement (TJR) procedures are efficacious, perioperative high-dose factors replacement therapy (FRT) to avoid catastrophic bleeding represents a significant hurdle, particularly for patients with multiple joint affection. Double simultaneous bilateral TJRs were reported as safe and cost-effective. However, little is known about multiple TJRs. The feasibility and effects remain debatable. Surgeons need to weigh the high cost of FRT against safety. Accordingly, we aimed to evaluate the clinical outcomes and cost-effectiveness of single-anesthetic multiple-joint procedures of lower limbs in end-stage hemophilic arthropathy. METHODS: Our retrospective cohort study retrieved data from an inpatient database of patients with hemophilia who underwent total knee arthroplasty (TKA), total hip arthroplasty (THA), and/or ankle arthrodesis from January 2000 to April 2016. Complications, hospital stays, transfusion, doses of clotting factor, medical costs, range of motion (ROM), Harris hip scores (HHSs) and Hospital for special surgery knee scores (HSSs) were recorded. A P value < 0.05 was considered significant. RESULTS: A total number of 81 patients were included in this study, among which 89 TKAs and 52 THAs were performed. Compared to the single TJR group, the simultaneous multiple TJR group showed a significantly higher rate of blood transfusions (P < 0.05). But no significant differences were found in the length of hospital stays, factor consumption, hospitalization costs excluding prosthesis expenses, and total complication rates. Finally, similar postoperative ROM, HHS, and HSS were witnessed in two groups (P value > 0.05). CONCLUSION: Our data indicated that simultaneous multiple TJRs are a safe and cost-effective choice for treating hemophilic patients with multiple HA-affected lower limb joints.

The Effect of a Local Injection of Flurbiprofen Ester Microspheres on Systemic Inflammatory Model Rats With a Closed Femoral Shaft Fracture.

Background: Periarticular injections with a combination of local anesthetics, non-steroidal anti-inflammatory analgesics (NSAIDs), and epinephrine are becoming increasingly popular in the perioperative analgesia of artificial joint replacement. However, data on the efficacy and safety of local injection NSAIDs are still scarce. The purpose of this study was to investigate the efficacy and safety of a local injection of Flurbiprofen Ester Lipid microspheres into the inflammatory model of femoral shaft closed fractures in rats. Methods: A systemic inflammatory model was induced in SD rats (60) by closed femoral shaft fracture; 12 non-fractured rats were used as the blank control group (group A). The systemic inflammation model of 60 rats was divided into 5 groups (12 in each group); Group B: intramuscular injectionof the same amount of normal saline at different time points as a negative control; Group C: intravenous injection of Flurbiprofen Ester microspheres (4.5 mg/kg) at different time points; Group D: intramuscular injection of Flurbiprofen Ester microspheres (2.25 mg/kg) at different time points; Group E: intramuscular injection of Flurbiprofen Ester microspheres (4.5 mg/kg) at different time points; Group F: intramuscular injection of Flurbiprofen Ester microspheres (9 mg/kg) at different time points. The behavioral test observed the behavior of the rats. Then, the inflammation factors of CRP, IL-6, COX-1, COX-2 and TNF-αby ELISA were recorded. Results: Through the behavioral test it could be found that the effect of the intramuscular and intravenous injections of Flurbiprofen Ester microspheres was similar. Fracture rats with a local injection of Flurbiprofen Ester microspheres showed lower inflammation levels measured by COX-1, CRP, and TNF-α compared with the control group. Pathological sections at 24, 48, and 96 h after surgery did not display any local muscle necrosis at the local injection site. These findings suggested that a Flurbiprofen Ester microsphere muscular injection exhibited a similar effect to an intravenous injection. Conclusion: The local injection of Flurbiprofen Ester microspheres significantly reduced the inflammatory response in fracture rats and did not increase the risk of muscle necrosis, suggesting its feasibility in local injection analgesia.

[Clinical Characteristics of 68 Patients with Osteoarticular Tuberculosis].

Objective To analyze the clinical features of patients with osteoarticular tuberculosis. Method This retrospective study included a cohort of 68 osteoarticular tuberculosis patients hospitalized in Peking Union Medical College Hospital from January 2013 to December 2020.Results The patients included 42(61.8%)males and 26(38.2%)females,with a median age of 56 years.Tuberculosis pathogen was detected in 39(57.4%)patients,and 29(42.6%)patients were diagnosed by clinical manifestations.The median time from onset to diagnosis was 4 months.The most common manifestations were pain and dysfunction(86.8%),followed by fever(47.1%),weight loss(36.8%),and night sweats(13.2%).Concomitant active tuberculosis in other organs was observed in 27(39.7%)patients.Unifocal and multifocal osteoarticular tuberculosis occurred in 51(75.0%)patients and 17(25.0%)patients,respectively,which mainly attacked thoracic and lumbar spines.Tuberculosis T cell test was positive in 92.7% patients.All the bone biopsies revealed epithelioid granuloma with/without necrosis,with 75.0% positive for mycobacterial DNA,55.1% positive for mycobacterial culture,and 20% positive for acid-fast staining.The risk of developing multifocal osteoarticular tuberculosis in the patients with weight loss was 5.333 times(P=0.013)that of the patients with stable weight.Conclusions The diagnosis of osteoarticular tuberculosis is difficult and tuberculosis T cell test is an effective means.Bone biopsy is the key to diagnosis,and the PCR of mycobacterial DNA shows the highest positive derection rate.Multifocal osteoarticular tuberculosis is not rare,especially in the patients with weight loss.Thus,a comprehensive imaging evaluation is recommended to avoid missed diagnosis.

Multimodal Peri-articular Injection with Tranexamic Acid can reduce postoperative blood loss versus Intravenous Tranexamic Acid in Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: Tranexamic acid (TXA) has shown significant reductions in blood loss and transfusion rates in total knee arthroplasty (TKA). However, the optimal administration route continues to be debated. The aim of this trial was to compare the effectiveness of intravenous (IV) versus peri-articular injection (PAI) application of tranexamic acid in patients undergoing total knee arthroplasty. METHODS: We conducted a randomized controlled, double-blinded study. A total of 93 patients undergoing primary unilateral TKA were randomly distributed between 2 groups: the IV group (47 cases; 1 g TXA IV) and the PAI group (46 cases; 1 g TXA injected peri-articularly). The amount of total and hidden blood loss (HBL), drainage, transfusion rate, hemoglobin and hematocrit drift, and complications were recorded. RESULTS: Peri-articular injection of TXA reduced total blood loss (P < 0.001) and HBL more than IV use of TXA (P < 0.001). No patients in either group received a transfusion. No symptomatic deep venous thrombosis or other severe complications occurred. CONCLUSION: Peri-articular injection of TXA significantly reduced total blood loss and hidden blood loss to a greater degree than IV injection in total knee arthroplasty without reduction of drainage volume. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR-INR-16010270 . Date of registration: December 27, 2016.

Improved Perioperative Sleep Quality or Quantity Reduces Pain after Total Hip or Knee Arthroplasty: A Systematic Review and Meta-Analysis.

OBJECTIVE: To investigate the effects of improved perioperative sleep on pain, analgesic consumption, and postoperative nausea and vomiting (PONV) in patients who were undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA). METHODS: Original studies published from 1 January 1970 to 30 September 2020 were queried in three unique databases using a common search term. The searches sought randomized controlled trials (RCT) investigating the effectiveness of sleep quality or quantity interventions for pain control early after TKA or THA. Grey literature was also searched by screening trial registers. There was no limitation on published language and patients. Two reviewers then assessed studies for eligibility. Eligible studies should have primary outcomes including perioperativeWe have comfirmed the edits. visual analogue scale (VAS) pain score and analgesic consumption; and secondary outcomes including side effects, such as PONV. Data extracted from the literature were abstracted into a comma-separated database spreadsheet using Microsoft Excel. A meta-analysis was then performed. Pooled statistics were calculated with weighting by inverse variance assuming a random effect model. I2 was calculated as a quantifier of heterogeneity and interpreted according to the Cochrane manual. All data analysis was performed using Revman software. RESULTS: From a total of 1285 potential records identified in the electronic search, six studies eventually fulfilled the eligibility criteria. The six controlled RCTs consisted of 207 patients in the sleep-improving group and 209 patients in the control group. The severity of rest pain was significantly lower in the sleep-improving group compared with the control group at day 1 and day 3 postoperatively; the severity of active pain was significantly lower in the sleep-improving group compared with the control group at day 3 postoperatively. Data concerning analgesic drugs could not undergo a meta-analysis due to the difference of eligible studies. No significant difference was found in the incidence of PONV between the sleep-improving group and the control group. CONCLUSION: Improved perioperative sleep, regardless of quality or quantity, could significantly reduce the pain level at the early stage after TKA or THA, thus the total amount of analgesic drugs consumed was decreased, without significant increase in the incidence of PONV.

[Research Advances of Human Homologue of Mouse Progressive Ankylosis Protein and Bone and Joint Diseases].

The human homologue of mouse progressive ankylosis protein(ANKH)is an inorganic pyrophosphate transport regulator,which regulates tissue mineralization by controlling the level of inorganic pyrophosphate.It plays an important role in the pathogenesis and development of bone and joint diseases,such as ankylosing spondylitis,craniometaphyseal dysplasia,and articular cartilage calcification.This review summarizes the progress of research on ANKH and the above-mentioned diseases.

Risk-Stratified Venous Thromboembolism Prophylaxis after Total Joint Arthroplasty: Low Molecular Weight Heparins and Sequential Aspirin vs Aggressive Chemoprophylaxis.

OBJECTIVE: Venous thromboembolism (VTE) is a significant concern post total joint arthroplasty (TJA). However, the optimal prevention method of VTE remains controversial at present. This study aims to evaluate a risk-stratified VTE prophylaxis protocol for patients undergoing TJA. METHODS: A total of 891 TJA patients from January 2011 to November 2019 were retrospectively investigated. The study was divided into two cohorts. In cohort 1, 410 patients (250 females and 160 males, mean age 64.32 years) were treated with an aggressive VTE chemoprophylaxis protocol. In cohort 2, 481 patients were treated with a risk-stratified protocol that utilized low molecular weight heparins (LMWH) and sequential aspirin (ASA) for standard-risk patients (a total of 288 containing 177 females and 111 males, mean age 65.4 years), and targeted anticoagulation for high-risk patients (a total of 193 containing 121 females and 72 males, mean age 66.8 years). The patients were followed up at 2-4 weeks for an initial visit and at 6-10 weeks for a subsequent visit after surgery. A chart review of all patient medical records was performed to record the demographics, comorbidities, deep vein thrombosis, pulmonary embolus, superficial infection, deep infection, bleeding complications, and 90-day readmissions. RESULTS: The VTE rate was 1.71% (7/410) in cohort 1 and 1.46% (7/481) in cohort 2 respectively. For cohort 2, the VTE rate was 2.07% (4/193) in high-risk group and 1.04% (3/288) in standard-risk group. The readmission rate was 2.44% (10/410) in cohort 1 and 2.08% (10/481) in cohort 2. For cohort 2, the readmission rate was 2.07% (4/193) in high-risk group and 2.08% (6/288) in standard-risk group. The reasons for readmission were as follows: infection, 1.3% (5/410) in cohort 1 and 1.3% (6/481) in cohort 2; wound or bleeding complications, 0.48% (2/410) in cohort 1 and 0.2% (1/481) in cohort 2; trauma, 0.2% (1/410) in cohort 1 and 0.2% (1/481) in cohort 2; VTE, 0.2% (1/410) in cohort 1 and 0.2% (1/481) in cohort 2; others, 0.2% (1/410) in cohort 1 and 0.6% (3/481) in cohort 2. There was a decrease in VTE events and readmissions in the risk-stratified cohort, although this did not reach statistical significance. However, it was found that there was a significant reduction in costs (P < 0.001) with the use of LMWH/ASA, when compared with aggressive anticoagulation agents in the risk-stratified cohort. CONCLUSION: The use of LMWH/ASA in a risk-stratified TJA population is a safe and cost-effective method of VTE prophylaxis.

Accuracy of MRI Diagnosis of Meniscal Tears of the Knee: A Meta-Analysis and Systematic Review.

This study aimed to evaluate the overall diagnostic value of magnetic resonance imaging (MRI) in patients with suspected meniscal tears. PubMed, Cochrane, Embase database updated to November 2017 were searched by the index words to identify qualified studies, including prospective cohort studies and cross-sectional studies. Literature was also identified by tracking using reference lists. Heterogeneity of the included studies was reviewed to select proper effects model for pooled weighted sensitivity, specificity, and diagnostic odds ratio (DOR). Summary receiver operating characteristic (SROC) analyses were performed for meniscal tears. A total of 17 studies were involved in this meta-analysis to explore the diagnostic accuracy of MRI for meniscal tears. The global sensitivity and specificity of MRI of meniscal tears were 92.0% (95% confidence interval [CI]: 88.0-95.0%) and 90.0% (95% CI: 85.0-95.0%) in medial meniscal tears, and 80.0% (95% CI: 66.0-89.0%) and 95.0% (95% CI: 91.0-97.0%) in lateral meniscal tears, respectively. Moreover, the global positive and negative likelihood ratio of MRI of meniscal tears were 10.33 (95% CI: 6.04-17.67) and 0.09 (95% CI: 0.05-0.14) in medial meniscal tears; 16.48 (95% CI: 8.81-30.83) and 0.21 (95% CI: 0.12-0.37) in lateral meniscal tears, respectively. The global DOR was 81.69 (95% CI: 37.94-175.91) in medial meniscal tears and 56.59 (95% CI: 22.51-142.28) in lateral meniscal tears. The results of area under the SROC indicated high accuracy in medial meniscal tears (area under the curve [AUC] = 0.97, 95% CI: 0.95-0.98) and lateral meniscal tears (AUC = 0.96, 95% CI: 0.94-0.97). This review presents a systematic review and meta-analysis to evaluate the diagnostic accuracy of MRI of meniscal tears. Moderate-to-strong evidence suggests that MRI appears to be associated with higher diagnostic accuracy for detecting medial and lateral meniscal tears.

A Simple Diagnosis-Related Groups-Based Reimbursement System Is Cost Ineffective for Elderly Patients With Displaced Femoral Neck Fracture Undergoing Hemiarthroplasty in Beijing.

Displaced femoral neck fractures (FNF) in the elderly are a major public health concern that necessitates hemiarthroplasty (HA) as the mainstay treatment option. Diagnosis-Related Groups (DRG) are a patient classification system that categorizes patients based on the resources expended on them. The first objective of this study was to evaluate if a simplified DRG-based reimbursement system in Beijing would lower total HA treatment costs for elderly patients with displaced FNF. In addition, we aimed to determine how age, gender, year of admission, length of in-hospital stay, and the Charlson index affected total treatment costs. This retrospective study included 513 patients from the Peking Union Medical College Hospital. The patients were diagnosed with unilateral displaced femoral neck fractures and had HA. Medical information was gathered, including baseline demographic and clinical data, as well as treatment costs. Patients were classified into two groups: those who spent more than the predetermined cut-off cost and those who did not. The cost did not include the use of a bipolar prosthesis. Data from the two groups were compared, and multiple regression analysis models were constructed. The median total cost of treatment was ¥49,626 ($7,316). The majority of the patients (89.7%; 460/513) were categorized as exceeding the cost cut-off. Multiple linear regression analysis revealed that total treatment cost was positively correlated with age (p < 0.01) and the duration of in-hospital stay (p < 0.01) but not with gender (p = 0.160) or the Charlson index (p = 0.548). On implementing the DRG-based reimbursement system, the overall treatment costs increased by ¥21,028 ($3,099) (p < 0.01). The implementation of simplified DRG-prospective payment systems did not result in a significant reduction in total treatment costs for elderly patients with FNF who underwent HA in Beijing. The overall cost of treatment was associated with several factors, including age, length of hospitalization, and year of admission.

Usefulness of a Simple Preoperative Planning Technique using Plain X-rays for Direct Anterior Approach for Total Hip Arthroplasty.

OBJECTIVE: To examine the accuracy, reliability, and reproducibility of a simple preoperative planning technique using plain X-rays. METHODS: A retrospective analysis of 96 consecutive cases of primary direct anterior approach (DAA)-total hip arthroplasty (THA) from July 2015 to December 2018 was performed. The 96 patients included 24 males and 72 females, with an average age of 70 years. The standard AP pelvis radiographs with the patients' hips extended and internally rotated were obtained pre- and postoperatively. The preoperative planning was also completed on the standardized AP pelvic radiographs. The prearranged cup positioning was radiologically measured intraoperatively using fluoroscopy. The correct leg length was assessed intraoperatively, which was compared with the preoperative planning. The component positioning was measured by three independent researchers. Two of the researchers completed the measurements three times, and intra-observer and inter-observer reliability were calculated. All patients received at least 6 months follow-up (6 months-4 years). RESULTS: In all cases, the median leg length discrepancy (LLD) was 4.4 mm (range 1.6-15.9 mm), and 84 patients had an LLD smaller than 10 mm, of which 58 patients had an LLD of less than 5 mm. None of the patients had a critical LLD of 2 cm or larger. The multivariable logistic regression for LLD (safe range: yes/no) with the co-variables including gender, ASA classification, type of cup, the surgeon's experience level, and the presence of a total hip arthroplasty (THA) on the contralateral side did not present statistical significance. The median angle of the inclination of the acetabular component (IA) was 42.3° (range: 28.7°-52.2°). Ninety-one patients were within the defined safe range. The hit ratio for the cup to be within the safe zone was significantly higher for the Pinnacle cups than that for the Continuum cups (P < 0.05). However, there was no significant difference in gender, ASA classification, the surgeon's experience level, and the presence of a total hip arthroplasty (THA) on the contralateral side. The median of its anteversion (AA) was 20.6° (range: 10.6°-40.1°). Only 41 patients were within the defined safe range. None of the co-variables presented a statistical significance affecting the AA of the cup positioning. Meanwhile, the average fluoroscopy time for the cup positioning (n = 86, missing data in 10 cases) was 4 seconds (range: 1-74), with most of the patients (97.9%) having a fluoroscopy time of fewer than 20 seconds. CONCLUSIONS: The combination of correct preoperative planning and standardized intraoperative measurements can reestablish right leg length and assure the correct cup positioning.

Chinese Survey on Enhanced Recovery after Surgery and Thromboprophylaxis Following Arthroplasty.

OBJECTIVE: To examine the current perspectives of enhanced recovery after surgery (ERAS) and the clinical practice applications of important ERAS principles among Chinese orthopaedic surgeons. METHODS: This was a cross-sectional study using an online survey that was completed between November and December 2018. A 16-item online questionnaire regarding the experiences of ERAS, perceptions of methods, and durations and concerns of venous thromboembolism (VTE) prophylaxis was sent to 2000 orthopaedic surgeons nationwide, and 1720 (86%) surgeons responded. Statistical analyses were conducted to assess all respondents' results and to compare differences among subgroups that were stratified according to city and hospital level, as well as their professional title. RESULTS: According to the results of the survey, ERAS awareness was high (65.1%) and most surgeons recognized the importance of thromboprophylaxis. However, the timing of ERAS was not consistent, with 22.8%, 31.9%, and 37.7% of surgeons choosing to initiate pharmaceutical prophylaxis within <6 h, 6-12 h, and 12-24 h after surgery, respectively. Low-molecular-weight heparin was mainly selected during hospitalization, and new oral anticoagulants (NOACs) were the first choice after discharge. Regarding postoperative antithrombotic therapy, particularly when combined with analgesics, the potential bleeding risk was mostly considered (80.0%)Tranexamic acid was believed to have no effect on the timing of NOAC therapy initiation (56.2%). Most of the above outcomes were influenced by the hospital level and professional title of the surgeon. Surgeons who had higher awareness on ERAS and better adhered to the guidelines were from higher-level hospitals as well as had more advanced professional titles. City level partly might influence their practice but not impact surgeons' awareness. CONCLUSIONS: The awareness and perception of the concept of ERAS and prophylactic antithrombotic regimens remain different among Chinese orthopaedic surgeons in different level cities and with various professional titles. Continuing medical educations (CME) on VTE prophylaxis is needed for improving the quality of health care in China.

Rates of periprosthetic infection and surgical revision in Beijing (China) between 2014 and 2016: a retrospective multicenter cross-sectional study.

BACKGROUND: Periprosthetic joint infection (PJI) is a rare but devastating complication after total joint arthroplasty. There is a paucity of data on the incidence and prevalence of periprosthetic infection in mainland China. This study aimed to analyze the rates of surgical revision after arthroplasty due to PJI and the procedures followed in Beijing, China. METHODS: The study involved a retrospective multicenter cross-sectional survey of patients undergoing revisions for periprosthetic infection after hip/knee arthroplasty at nine hospitals in Beijing from 2014 to 2016. Age, gender, body mass index, primary diagnosis, comorbidity, primary surgery, treatment methods, and post-revision complications were analyzed. RESULTS: A total of 38,319 hip/knee arthroplasties and 366 (0.96%) revisions for PJI were identified. Of these, 161 (161/14,110; 1.14%) revisions involved hip arthroplasty, whereas 205 (205/24,209; 0.85%) revisions were due to knee arthroplasty. Procedures for revisions of infected hip included 7 (4.3%) cases of open debridement and prosthesis retention, 32 (19.9%) cases of one-stage exchange, 121 (75.2%) cases of two-stage exchange, and 1 (0.007%) case of hip dissection. As for the infected knee, the procedures included 45 (22.0%) cases of open debridement and prosthesis retention, 13 (6.3%) cases of one-stage exchange, 143 (69.8%) cases of two-stage exchange, and 4 (0.02%) cases of knee fusion. CONCLUSIONS: The study found the rates of revision due to PJI to be low. Nonetheless, the incidence of PJI in mainland China could be higher and calls for more elaborate studies in geographically and socioeconomically diverse health institutions.

Diagnosis and Treatment of Arterial Occlusion after Knee Arthroplasty: The Sooner, the Better.

Knee arthroplasty, including total knee arthroplasty (TKA) and unicondylar knee arthroplasty (UKA), is an effective procedure for patients with severe knee joint diseases. Arterial occlusion after knee arthroplasty is a rare but severe complication. However, there are few comprehensive reviews or analyses focusing on it. In this study, we presented a case of successful treatment of acute arterial occlusion of the popliteal artery after TKA by emergent balloon angioplasty, and conducted a review and analysis of published cases with this complication. After search and screening, 36 studies with 47 cases of arterial occlusion after knee arthroplasty in the past 35 years (1984-2018) were included. Among the 47 patients, there were 22 men and 25 women. The mean age was 68 years old. A total of 43 patients had primary TKA while 2 had revision surgery for TKA and 2 for UKA. For arterial occlusions, 66% presented symptoms in less than 1 day after knee surgery and 95% of the occlusion sites were around the popliteal artery. For treatment, 89% chose surgical treatment. Compared with conservative treatment, surgical treatment was more effective (P < 0.01). The patients who underwent surgical treatment less than 1 day after diagnosis had less sequelae (P < 0.05). For arterial occlusion after knee arthroplasty, we should pay attention to the perioperative risk factors and presentations, and diagnose and treat surgically at an early stage.

Incidence of Symptomatic Venous Thromboembolism in Patients with Hemophilia Undergoing Hip and Knee Joint Replacement without Chemoprophylaxis: A Retrospective Study.

OBJECTIVE: To establish the prevalence of clinically significant venous thromboembolic events (VTE) in hemophilia patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) without chemoprophylaxis and a modified coagulation factor substitution. METHODS: A cohort of patients who underwent THA and TKA from June 2002 to April 2017 were included. Based on World Federation of Hemophilia (WFH) guidelines, a modified coagulation factor substitution regimen was adopted. All patients were under a standardized postoperative protocol with routine mechanical prophylaxis against VTE. None of the patients received prophylactic anticoagulation. Only symptomatic patients were referred for radiological examination to exclude VTE. We evaluated the patient demographics and calculated the prevalence of VTE in our cohort. RESULTS: A total of 98 patients were reviewed. The patients were all men. Thirty-one patients underwent primary THA with 39 hip arthroplasties (only 1 case with hemophilia B) and 67 patients underwent primary TKA with 101 knee arthroplasties (5 cases with hemophilia B). The mean age was 34.2 ± 7.8 years. The mean body mass index was 21.2 ± 5.7 kg/m2 . There was 100% compliance to mechanical prophylaxis. The mean time to ambulation was 6.8 days (±2.5 days), and the mean hospital stay was 32.4 days (±7.1 days). There was only 1 hemophilia B patient with clinically significant VTE. None of the other 97 surgical cases had symptomatic VTE within 6 months after the procedure. This translates to a prevalence of 1.02%. CONCLUSION: Given the low incidence (1.02%) of clinically significant VTE in our cohort, routine chemoprophylaxis in hemophilia patients undergoing THA and TKA may not be needed.

Risk assessment and management of preoperative venous thromboembolism following femoral neck fracture.

BACKGROUND: Limited studies are available to investigate the prevalence of preoperative venous thromboembolism (VTE) in elderly patients with femoral neck fractures. Our primary aim was to determine the incidences of VTE and its risk or protective factors in such patient population. The secondary objective was to evaluate the need of therapeutic anticoagulation for isolated calf muscular venous thrombosis (ICMVT) prior to femoral neck fracture surgery. METHODS: This is a retrospective case-control study, including 301 femoral neck fracture patients who were admitted to our institution between January 2014 and March 2017. Bilateral Doppler ultrasonography was performed in each of the patients as a preoperative VTE screening. The event rate of VTE was calculated, and significant risk or protective factors were determined by using a multivariate logistic regression model. Patients with ICMVT were divided into anticoagulation and no anticoagulation groups to assess the efficacy and safety of preoperative therapeutic anticoagulation. Intraoperative blood loss, drainage volume, blood transfusion, perioperative hemoglobin change, and rate of thrombosis extension were compared between the two groups. RESULTS: The overall preoperative incidence of VTE in patients with femoral neck fracture was 18.9% (57/301), in which deep vein thrombosis (DVT) was 18.9% and pulmonary embolism (PE) was 1%. Among the DVT cases, 77.2% (44/57) were ICMVTs. Multiple fractures (odds ratio [OR] = 9.418; 95% confidence interval [CI] = 2.537 to 34.96), coexisting movement disorder (OR = 3.862; 95% CI = 1.658 to 8.993), bed rest for more than 7 days (OR = 2.082; 95% CI = 1.011 to 4.284) as well as elevated levels of D-dimer (OR = 1.019; 95% CI = 1.002 to 1.037) and fibrinogen (OR = 1.345; 95% CI = 1.008 to 1.796) led to an increase in the risk of VTE, while the recent use of antiplatelet drug (OR = 0.424; 95% CI = 0.181 to 0.995) and prophylactic anticoagulation (OR = 0.503; 95% CI = 0.263 to 0.959) decreased the risk of VTE. For the 39 patients with ICMVT undergoing femoral neck fracture surgery, there were no significant differences in the rate of thrombosis extension between anticoagulation and no anticoagulation groups, but significantly decreased postoperative hemoglobin was observed in the anticoagulation group. CONCLUSION: Our findings showed a high prevalence of preoperative VTE in elderly patients with femoral neck fracture, with risk factors identified. We found that the most detected VTE were ICMVTs. Our study suggested that a direct surgery without preoperative use of therapeutic anticoagulation for ICMVT would not reduce the risk of thrombus extension, and the therapeutic use of anticoagulation may worsen postoperative anemia.

Role of Parecoxib Sodium in the Multimodal Analgesia after Total Knee Arthroplasty: A Randomized Double-blinded Controlled Trial.

OBJECTIVE: Total knee arthroplasty (TKA) is an established surgical technique and is the standard treatment for degenerative knee joint diseases. However, severe pain after TKA makes it difficult for many patients to perform early postoperative rehabilitation and functional exercise, which might result in subsequent unsatisfactory recovery of knee joint function and great reduction in patients' satisfaction and quality of life. Orthopaedic surgeons have tried a large variety of analgesics and analgesic modes to relieve patients' pain after TKA. There are many analgesic regimens available in clinical practice but all have some deficiencies. Parecoxib sodium, a highly selective inhibitor of cyclooxygenase-2 (COX-2), can reduce the synthesis of peripheral prostaglandin to exert the effect of analgesia, and relieve inflammation and prevent central sensitization through inhibition of peripheral and central COX-2 expression. In addition, it can be used as a preemptive analgesic without affecting platelet aggregation. However, there does seem to be conflicting evidence in the current research as to whether parecoxib sodium can be used successfully as a preemptive analgesic; the effect of preemptive analgesia with parecoxib sodium in multimodal analgesia is still controversial. This research investigated the effects of parecoxib sodium in a preemptive multimodal analgesic regimen. METHODS: Eighty-eight patients were randomized into two groups. The experimental group received parecoxib (46 patients) and the control group received saline (42 patients), administered 30 min before the initiation of the surgical procedure. A patient-controlled analgesia (PCA) pump was applied within 48 h after surgery. The visual analogue scale (VAS), drug consumption through the PCA pump, use of salvaging analgesia, range of motion (ROM) of the knee joints, and postoperative complications were observed. RESULTS: The VAS score in the post-anesthesia care unit (PACU) of the parecoxib group was significantly lower than that of the control group (P = 0.039). There was no significant difference in the demographic profiles, duration of operation, hemorrhage in surgery, postoperative hemorrhage, postoperative drainage, VAS at different time points, function of knee joints, length of hospital stay, use of salvaging analgesia, and postoperative drug consumption through the PCA between the two groups (P > 0.05). CONCLUSION: In preemptive multimodal analgesia regimens, parecoxib sodium can significantly decrease the VAS score in the short term, relieve pain shortly after surgery, and does not increase the incidence of complications. Parecoxib sodium is a safe and effective drug in the perioperative analgesic management for TKA.

Preemptive Analgesia with Parecoxib in Total Hip Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Total hip arthroplasty (THA) is a well-accepted surgical treatment for terminal hip diseases. OBJECTIVE: To evaluate the effect of preemptive analgesia with parecoxib in patients undergoing primary unilateral THA. STUDY DESIGN: A randomized, double-blind, placebo-controlled study. SETTING: This study was conducted at Peking Union Medical College Hospital and Beijing Jishuitan Hospital in Beijing, China. METHODS: A total of 94 patients scheduled for primary unilateral THA in 2 centers (Peking Union Medical College Hospital and Beijing Jishuitan Hospital) were randomly assigned to receive 40 mg parecoxib (n = 48) or 0.9% normal saline solution (n = 46) 30 minutes before incision. All patients received standardized intravenous patient-controlled analgesia (PCA) postoperatively. Preoperative baseline data, surgery-related conditions, postoperative Visual Analog Scale (VAS) pain score, cumulative narcotic consumption of PCA, and complications were compared between the parecoxib group and the placebo group. RESULTS: There were no significant differences in postoperative VAS pain score, cumulative narcotic consumption of PCA, proportion of analgesic remedy, and complications between the 2 groups. LIMITATIONS: Only a single dose of parecoxib was used without including a dose-dependent control group. CONCLUSION: A single dose of parecoxib 30 minutes before incision did not provide effective preemptive analgesia for the management of postoperative pain after primary unilateral THA. The possible effect of preemptive analgesia with parecoxib needs further investigation. KEY WORDS: Total hip arthroplasty, pain, parecoxib, COX-2 selective inhibitor, preemptive analgesia, clinical trial, patient-controlled analgesia, analgesics.

Low molecular weight heparin for the prevention of deep venous thrombosis after total knee arthroplasty: A systematic review and meta-analysis.

BACKGROUND: To systematically evaluate the prophylaxis efficacy of low-molecular-weight heparin (LMWH) in the prevention of deep venous thrombosis (DVT) after total knee arthroplasty (TKA). METHOD: PubMed, Cochrane, Embase, Wanfang, CNKI, and VIP databases were searched by index words to identify the eligible RCTs; relevant literature sources were also searched. The latest research was conducted in March 2017. Relative risks (RR), mean difference (MD), and their corresponding 95% confidence intervals (95% CIs) were used to analyze the main outcomes. RESULT: A total of 22 articles were included in the meta-analysis with a total number of 11,320 patients (5543 in the LMWH group and 5777 in the control group). The results indicated that in the LMWH group, the incidence of DVT (OR: 0.57, 95% CI: 0.41-0.77) and wound complications (SMD: 0.96, 95% CI: 0.75-1.22) was significantly lower than that in the control group. Furthermore, LMWH also increased the occurrence of bleeding event (OR: 1.57, 95% CI: 1.31-1.88) and the total blood transfused (SMD: 0.12, 95% CI: 0.04-0.19). However, no statistical difference was found in blood loss (SMD: -0.26, 95% CI: -0.65-0.14) between the two group. In the subgroup analysis, the incidence of DVT was significantly decreased in the ardeparin sodium group (OR: 0.70, 95%CI: 0.53-0.94) and the dalteparin group (OR:0.40, 95%CI:0.32-0.50). CONCLUSION: Our meta-analysis demonstrated that LMWH is obviously efficacious in the prophylaxis of DVT after TKA. However, it has some negative effects, such as the increase in the number of bleeding events and the total blood transfused.

Total Hip Arthroplasty in Hemophilia Patients: A Mid-term to Long-term Follow-up.

OBJECTIVE: To report the results of mid-term to long-term follow-up after primary total hip arthroplasty (THA) in hemophiliacs and to hypothesize that THA can provide satisfactory outcomes in these patients. METHODS: Twenty-four primary THA performed in 21 hemophilia patients between 2002 and 2012 were reviewed retrospectively, including 20 cases of hemophilia A and 1 case of hemophilia B. The standard lateral approach was used for all implantations. Substitution therapy for factor VIII and activated prothrombin complex concentrates were administered to patients with hemophilia A and B, respectively. Total and hidden blood loss were calculated. Outcomes were assessed using the Harris hip score before surgery and at the final follow-up visit. Complications were recorded by clinical and radiographic assessment and then compared to those in previous reports. RESULTS: The mean follow-up period was 113 months (range, 5-15 years). The average total blood loss was 3559 mL (range, 1494-7506 mL). The mean amount of red blood cell (RBC) transfusion was 4.4 U (range, 0-14 U). The mean amount of clotting factor used in the perioperative period for management of hemophilia was 14 031.3 U (range, 8100-25 200 U). Harris hip scores improved from 37 points (range, 15-81) before surgery to 90 points (range, 70-96) at the last follow-up. No signs of loosening, infection or other complications of the implant components occurred after discharge. The overall survivorship of the implants was 100% for all patients, and no revision surgery was performed. CONCLUSIONS: With modern techniques and hematological management, THA in patients with hemophilia leads to significant improvement in joint function with a relatively low incidence of complications. Increased blood loss and substitution therapy have no obvious negative influences on the mid-term to long-term results of THA.