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.

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.

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.

Case of Langerhans Cell Histiocytosis That Mimics Meningioma in CT and MRI.

Langerhans cell histiocytosis (LCH) is a rare disorder histologically characterized by the proliferation of Langerhans cells. Here we present the case of a 13-year-old girl with LCH wherein CT and MRI results led us to an initially incorrect diagnosis of meningioma. The diagnosis was corrected to LCH based on pathology findings. An intracranial mass was found mainly in the dura mater, with thickening of the surrounding dura. It appeared to be growing downward from the calvaria, pressing on underlying brain tissue, and had infiltrated the inner skull, causing a bone defect. The lesion was calcified with the typical dural tail sign. The dural origin of the lesion was verified upon surgical dissection. There are no previous reports in the literature describing LCH of dural origin presenting in young patients with typical dural tail signs and meningioma-like imaging findings. The current case report underscores the need for thorough histological and immunocytochemical examinations in LCH differential diagnosis.

Effect of Resveratrol on Preventing Steroid-induced Osteonecrosis in a Rabbit Model.

BACKGROUND: Prevention of osteonecrosis (ON) has seldom been addressed. The purpose of this study was to evaluate the effect of resveratrol on preventing steroid-induced ON in rabbits. METHODS: Seventy-two rabbits were divided into four groups: (1) NEC (ON) group: thirty rabbits were treated with lipopolysaccharide (LPS) once, then with methylprednisolone (MPS) daily for 3 days; (2) PRE (prevention) group: thirty rabbits were given one dose of LPS, then MPS daily for 3 days, and resveratrol on day 0 and daily for 2 weeks; (3) RES (resveratrol) group: six rabbits were given resveratrol for 2 weeks but without LPS/MPS; (4) CON (control) group: six rabbits were given alcohol for 2 weeks but without LPS/MPS. Levels of plasma tissue-type plasminogen activator (t-PA), plasminogen activator inhibitor 1 (PAI-1), thrombomodulin (TM), vascular endothelial growth factor (VEGF), maximum enhancement (ME) by magnetic resonance imaging, and ON incidence were evaluated. RESULTS: The PRE group had a lower ON incidence than the NEC group, but with no significant differences at 2 weeks and 12 weeks. The RES and CON groups did not develop ON. TM and VEGF were significantly higher in the NEC group compared with the PRE group at weeks 1, 2, and 4 (TM: 1 week, P = 0.029; 2 weeks, P = 0.005; and 4 weeks, P = 0.047; VEGF: 1 week, P = 0.039; 2 weeks, P = 0.021; 4 weeks, P = 0.014), but the difference disappeared at 12 weeks. The levels of t-PA and PAI-1 were not significantly different between the NEC and PRE groups. The TM, t-PA, PAI-1, and VEGF concentrations in the RES and CON groups did not change over time. Compared to the baseline, ME in the NEC group decreased significantly (P = 0.025) at week 1, increased significantly (P = 0.021) at week 2, and was decreased at week 12. The variance was insignificant in the PRE group. CONCLUSIONS: Resveratrol may improve blood supply to bone in a rabbit model of ON of the femoral head via anti-inflammatory effects to protect the vascular endothelium and reduce thrombosis.

Perioperative Period of a Hemophilia-related Osteoarthropathy Therapeutic Regimen and Analysis of Complications.

OBJECTIVE: To investigate the effectiveness of our department's therapeutic regimen and treatment of complications during the perioperative period of hemophilia-related osteoarthropathy. METHODS: In this retrospective study, data on 101 patients with hemophilia who had undergone operative treatment in our hospital from January 2000 to August 2014 were assessed. Ninety-one of the patients had hemophilia A and 10 hemophilia B. All patients were male. Changes in Hospital for Special Surgery (HSS), Harris and American Orthopedic Foot and Ankle Society (AOFAS) scores, occurrence of complications during the perioperative period and the clinical treatment and prognosis pre- and postoperatively and during follow-up were analyzed. Relevant clinical data were obtained through telephone calls, outpatient follow-up, and medical clinical record searches. RESULTS: The 101 patients who were followed up (for an average of 96 months) had 147 orthopedic operations, including joint replacement, hemophilia-related false tumor resections, and tendo-achillis lengthening. The HSS scores for knee surgeries increased from 52 points preoperatively to 86 postoperatively, Harris scores for hip joint surgery from 26 to 87 points, respectively, and AOFAS scores for foot and ankle surgeries from 39 to 81 points, respectively. Eight patients had wound complications, four intra-articular hematomas, two peroneal nerve injuries, one a proximal femur splitting fracture and one deep venous thrombosis. CONCLUSIONS: Surgical treatment is a safe and reliable choice for addressing complications including hemophilia-related osteoarthropathy given the implementation of effective measures for treatment during the perioperative period.

[The microbiology and antimicrobial susceptibility of the infected knee arthroplasty].

OBJECTIVES: To describe the microbiology, antimicrobial susceptibility of patients proven prosthetic joint infection (PJI) after primary total knee arthroplasty (TKA)and to provide reference for the diagnosis and treatment of this complication. METHODS: The medical data of the patients with infected knee arthroplasty, who were managed with revision surgery between January 1995 to December 2011 were reviewed. Twenty-nine cases were identified and majority of the patients were female (23/29). Diagnosis of PJI after primary TKA was between 1 week and 10 years (average 24.3 months). The microbiology and antimicrobial susceptibility were analyzed. RESULT: The overall positive rate of cultures was 65.5% (19/29). The most common organisms identified were Coagulase-negative Staphylococcus (CNS) (7/19) and Staphylococcus Aureus (SA) (5/19). Rare pathogens of Mycobacterium (2/19) and fungi (1/19) were also identified. Vancomycin was the most effective antibiotics with overall sensitivity rates of 100%.Resistant and rare pathogens were all in type IV infection. CONCLUSIONS: Gram-positive bacterias are the main pathogen, resistant and rare pathogens should be payed attention to. Antibiotic treatment for infected TKA should be based on the results of drug susceptibility. Vancomycin allows infected knee arthroplasties before the result.

Outcome of total knee arthroplasty combined patelloplasty for end-stage type A hemophilic arthropathy.

The aim of this study was to retrospectively evaluate the outcome of total knee arthroplasty for end-stage hemophilic arthropathy, based on effectiveness of operation, the specificity of surgical technique, the complications of TKA operation and the strategy of handling of patella. Nineteen patients (25 knees) with type A hemophilic arthropathy were treated with TKA from June 2003 to February 2010. Average patella thickness was 16.3±0.4mm and all patellas were treated by patelloplasty. The patient followed up data was recorded, which included the information of hospital for special surgery knee score(HSS), range of motion(ROM), post-operative complication, and anterior knee pain. The patients were followed for an average post-operative period of 41months (10 to 78months). The mean preoperative HSS score was 51 (31 to 64). Post-operative HSS score was 91 (75 to 110) when followed-up. ROM was modified to 82 degree (60 to 105), compared with 55 degree (5 to 110) preoperatively. Thirteen patients with flexion contracture were corrected from 19 degree (0 to 45) to 2.7 degree (0 to 10). Four patients complained mild but endurable anterior knee pain. The study concludes that TKA is an effective treatment for end-stage hemophilic arthropathy of knee joint, providing good clinical outcome and improving quality of life. Patella of hemophiliac is relatively thin and osteoporotic. Patelloplasty is useful technique for handling of patella during TKA procedure for hemophiliac, with improved knee function, low and acceptable anterior knee pain rate, low reoperation rate.

Treatment of severe bone deficiency in acetabular revision surgery using a reinforcement device and bone grafting.

BACKGROUND: Severe acetabular bone deficiency is a major challenge in acetabular revision surgery. Most cases require reconstruction of the acetabulum with bone grafting and a reinforcement device. The purpose of this study was to evaluate the results of this procedure for severe acetabular bone deficiency in acetabular revision surgery. METHODS: This study involved 12 patients (2 males and 10 females) with severe acetabular bone defects who underwent implantation of a reinforcement device (ring or cage) and bone grafting between February 2003 and October 2008. Using the Paprosky classification, 2 cases were Paprosky IIC, 6 were IIIA, and 4 were IIIB. The mean age at the time of surgery was 63.0 years (range, 46 - 78 years). During revision surgery, a reinforcement ring was implanted in 6 patients, and a cage in 6 patients. The clinical and radiographic results were evaluated retrospectively. The mean duration of follow-up was 37 months (range, 9 - 71 months). RESULTS: The average Harris Hip Score improved from 35.2 preoperatively to 82.9 at the time of the final follow-up visit. The results were excellent in 8 hips (66.7%), good in 2 (16.7%), and fair in 2 (16.7%). Osteolysis was found in 1 case, but did not worsen. Three patients had yellow wound effusion, with healing after administration of dressing changes, debridement, and antibiotics. Dislocation occurred in a 62-year-old woman. Closed reduction was performed, and dislocation did not recur. There was no evidence of intraoperative acetabular fracture, nerve injury, ectopic ossification, aseptic loosening, or infection. CONCLUSION: Reconstruction with a reinforcement device and bone grafting is an effective approach to the treatment of acetabular bone deficiency in acetabular revision surgery, given proper indications and technique.

[Experimental study of three dimensional navigation assisted spinal surgery by multi-segment registration technology based on structured light scanning].

OBJECTIVE: To study the registration method based on structured light scanning for navigation assisted spinal surgery and assess its accuracy so as to construct a registration system for the navigation assisted spinal surgery using structured light scanning. METHODS: Both the computed tomographic (CT) dataset and the structured light scanning images of thoracic vertebra were obtained. The pre-registration and multi-segment iterative closest point (ICP) algorithm were used for the registration of CT images and structured light images. Four segmentations were selected from the surface of thoracic vertebra and placed into different combinations. The accuracy for each combination was studied. Noise and perturbation were exerted to structured light and registration accuracy was studied. And calf vertebra was used for further verification. RESULTS: A combination of pre-registration and multi-segment iterative closest point (ICP) algorithm was competent for the registration of CT scanning data and the structured light scanning data. The registration error was less than 1 mm when two and more segments were selected for registration combination. The registration error was less than 1 mm when noise was exerted. CONCLUSION: With a high accuracy and a perturbation resistance, a combination of pre-registration and multi-segment registration algorithm based on structured light scanning is competent for the registration of CT scanning data and structured light scanning data.

[Application study of periarticular multimodal drug injection in total knee arthroplasty].

OBJECTIVE: To investigate and compare the analgesic effect of a periarticular multimodal drug injection and patient-controlled epidural analgesia (PCEA) in total knee arthroplasty (TKA). METHODS: Thirty-six patients undergoing unilateral TKA were randomly divided into two groups (A and B). Group A received a periarticular injection of ropivacaine, morphine and epinephrine at operation and Group B did not. All patients received postoperative patient-controlled epidural analgesia (PCEA). Preoperative baseline data, surgery-related conditions, postoperative VAS (visual analog score), range of motion (ROM), time of opening PCEA, drug dosage in PCEA and side effects were recorded respectively. RESULTS: At 6, 12 hour VAS in Group A was lower than Group B (P < 0.05). The time of opening PCEA in Group A was longer than Group B (P < 0.05). The drug dosage in PCEA in Group A was less than Group B (P < 0.05). There was no difference of surgical conditions, ROM, 24/48 hour VAS and side effects between two groups (P > 0.05). CONCLUSION: Periarticular drug injection during TKA can relieve pain early after TKA, prolong the time of opening PCEA and reduce the drug dosage in PCEA.

[Acetabular revision arthroplasty using antiprotrusio cage].

OBJECTIVE: To study the efficacy of acetabular antiprotrusio cage for the reconstruction of acetabular bone defect in revision hip arthroplasty. METHODS: Twelve cases of severe acetabular bone defect after total hip arthroplasty were revised with antiprotrusio cage and bone grafting from February 2003 to October 2008. Clinical and radiological data before and after revision surgery were collected and compared for assessment. RESULTS: The classification of acetabular bone defect of this group of patients according to Paprosky classification was: 2 cases of type IIB, 6 cases of type IIIA and 4 cases of type IIIB. The average postoperative follow-up period was 37 months (9 - 71 months). Mean Harris score of all cases was 35.2 before revision surgery, 80.9 at the first time follow-up and 84.6 at latest follow-up. There were no prosthesis loosening and breakage. There was mild radiolucent line in Delee & Charnley III zone of the acetabulum in one patient 6 month after revision, but no deterioration was found during further follow-up. No further revision was needed in this group of patients during the follow-up. CONCLUSIONS: Reconstruction of acetabular bone defect using antiprotrusio cage and bone grafting is a useful method to restore the bone defect and stability of the acetabulum. The outcome via short to middle term follow-up is encouraging.

[Clinical applications of computer-assisted navigation technique in spinal pedicle screw internal fixation].

OBJECTIVE: To assess the value of computer navigation technique in spinal pedicle screw insertion. METHODS: 95 patients undergoing spinal pedicle screw internal fixation were randomly divided in 2 groups:navigation group (n=36) undergoing pedicle screw insertion with computer-assisted navigation technique, and conventional group (n=50) undergoing pedicle screw insertion using conventional anatomic landmark combined. The 2 groups were compared in respect to screw canal preparation time, accuracy of screw position, and incidence of postoperative complication. RESULTS: 206 screws were inserted in the navigation group, 169 being with excellent outcome (82.0%), 29 with good outcome (14.1%), and 8 with bad outcome (3.9%). Nine patients in the navigation group failed to adopt the computer-assisted navigation technique because of different reasons. 285 screws were inserted in the conventional group, 257 being were excellent outcome (90.2%), 28 with good outcome (9.8%), and none with bad outcome. The general fitness rate of the navigation group was 96.1%, not significantly different from that of the conventional group (100%, P>0.05). The screw canal preparation time of the navigation group was (360+/-22) sec, significantly longer than that of the conventional group [(56+/-8) sec, P<0.001)]. No postoperative complication was found in both groups. CONCLUSION: The accuracy of pedicle screw insertion using preoperative CT-based navigation technique is not different from that using conventional anatomic landmark, but the operation time is significantly prolonged. Preoperative CT-based navigation technique has limited value in spinal pedicle screw insertion.