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.

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.

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 ).

Tranexamic acid may benefit patients undergoing total hip/knee arthroplasty because of haemophilia.

BACKGROUND: The lower limb joints, including hip and knee, are the most commonly involved joints in haemophilic arthropathy. With a higher risk of transfusion, total hip and knee arthroplasty (THA and TKA) are still the first choice after failure of conservative treatment. In the present study, we aimed to analyze clinical outcomes and complications rate after total joint arthroplasty of the lower limbs using tranexamic acid (TXA) or not. METHODS: Thirty-four patients with haemophilia A undergoing 24 TKA and 18 THA were evaluated in this retrospective study (No. 201302009). Based on using TXA or not, they were divided into either TXA (12 knees and 10 hips) or Non-TXA groups (12 knees and 8 hips). Total blood loss, intraoperative blood loss, total amount of FVIII usage, range of motion, inflammatory biomarkers, joint function, pain status, complication rate and patient satisfaction were assessed and compared at a mean follow-up of 68 months. RESULTS: Usage of TXA can decrease not only the perioperative blood loss (p = 0.001), transfusion rate (p = 0.017) and supplemental amount of FVIII (p < 0.001) but also swelling ratio, surgical joint pain. Moreover, compared with non-TXA group, the patients in TXA group had a lower level of inflammatory biomarkers and better joint function. CONCLUSION: The hemophiliacs treated with TXA had less perioperative blood loss, hidden blood loss, transfusion rate, a lower ratio of postoperative knee swelling, less postoperative joint pain, lower levels of inflammatory biomarkers and better joint function. Further studies need performing to assess the long-term effects of TXA in these patients.

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.

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.

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.

Oral vs Intravenous vs Topical Tranexamic Acid in Primary Hip Arthroplasty: A Prospective, Randomized, Double-Blind, Controlled Study.

BACKGROUND: Tranexamic acid (TXA) has demonstrated efficacy in reducing blood loss, reduction in hemoglobin, and blood transfusion requirements in primary total hip arthroplasty (THA). The optimal mode of TXA administration for patients undergoing primary THA is unclear. The purpose of this randomized controlled trial is to determine whether oral administration of TXA was superior to intravenous or topical routes in these patients. METHODS: In this double-blinded, placebo-controlled trial, patients undergoing primary THA were randomized to oral (2 g TXA orally 2 hours preoperatively), intravenous (20 mg/kg intravenous TXA bolus 5 minutes before the incision), or topical (2 g TXA applied topically) TXA groups. The primary outcome was the reduction in hemoglobin. Secondary outcomes included blood loss, transfusion rate, cost of TXA (Chinese yuan (¥); in 2017, ¥1 = $0.147), and adverse events. RESULTS: One hundred eighty patients were randomized into the 3 groups. Demographic characteristics were similar among the groups. The mean reduction in hemoglobin was similar among the oral, intravenous, and topical groups (3.48 ± 1.32, 3.58 ± 1.07, and 3.66 ± 1.26 g/dL, respectively). Similarly, the mean total blood loss did not differ significantly among the 3 groups. The oral group incurred the lowest TXA cost (¥480) compared with that in the intravenous (¥3329.28) and topical (¥3540) groups (P = .01). None of the patients sustained a deep venous thrombosis, pulmonary embolism, or an infection. CONCLUSION: The blood-sparing efficacy of oral TXA is comparable to that of the intravenous and topical forms. Oral TXA is recommended because of its cost-benefit superiority and ease of administration.

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.

Efficacy of oral tranexamic acid on blood loss in primary total hip arthroplasty using a direct anterior approach: a prospective randomized controlled trial.

BACKGROUND: Tranexamic acid (TXA), delivered intravenously or topically, has been shown to reduce blood loss, the need for transfusion, and relevant healthcare costs when administered in primary standard total hip arthroplasty (THA). Whether the same is true of oral TXA is unclear, the purpose of this study was to determine if oral tranexamic acid is equivalent to intravenous TXA in the case of patients undergoing THA via the direct anterior approach. METHODS: In this prospective randomized controlled trial, 120 patients undergoing primary THA by the direct anterior approach were randomized to receive oral TXA (two doses of 20 mg/kg), intravenous TXA (two doses of 15 mg/kg), or no TXA. Primary outcomes were haemoglobin drop, haematocrit levels, total blood loss, intra-operative blood loss, need for transfusion, and volume transfused. Secondary outcomes included thromboembolic events, wound complications, the length of post-operative hospital stay, and 30-day readmission. RESULTS: Demographic characteristics were similar among the three patient groups (p > 0.05, n = 40 per group). Haemoglobin drop, haematocrit levels, total blood loss, and intra-operative blood loss were similar in the oral and intravenous groups (p > 0.05), and significantly smaller than in the control group (p < 0.05). Transfusions were given to significantly fewer patients in the oral group (3%) and intravenous group (6%) than in the control group (27%, p = 0.01). Costs of TXA and transfusions were significantly lower in the oral group than the intravenous group (p < 0.05). The three groups were similar in thromboembolic events, wound complications, the length of post-operative hospital stay, and 30-day readmission (p > 0.05). CONCLUSION: Oral TXA shows similar efficacy and safety as intravenous TXA for reducing haemoglobin drop, haematocrit levels, total blood loss, and transfusion rate following THA by the direct anterior approach. Therefore, the much less-expensive oral formulation may be superior to the intravenous form.

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.

Monobloc implants in cementless total hip arthroplasty in patients with Legg-Calve-Perthes disease: a long-term follow-up.

BACKGROUND: The purpose of this study was to evaluate 10-year outcomes in cementless monobloc total hip arthroplasty (THA) in a group of hips with Legg-Calve-Perthes disease (LCPD). METHODS: We reviewed 71 patients (88 hips) who underwent cementless THA with a diagnosis of LCPD from 2003 to 2009. From the total of 71 patients, 34 men and 37 women with an average age of 49.94 years were included. The mean follow-up period was 10 years. RESULTS: The mean Harris Hip Score improved significantly from 46.42 to 89.70. Similarly, the postoperative range of motion, hip dysfunction and osteoarthritis outcome score and SF-12 score also significantly improved. The mean leg lengthening was 22.1 mm. During the follow-up, eight complications were noted, including two cases of intraoperative femoral fractures, two cases of sciatic nerve paralysis, two cases of heterotrophic ossifications, one case of thigh pain and one case of dislocation. One revision was conducted for a periprosthetic fracture, and the survivorship at 10 years was 98.3%. CONCLUSIONS: These data suggest that the monobloc stem can lead to satisfactory outcomes for clinical function, radiological evaluation, restoration of the normal limb lengths, complications, and survivorship among LCPD patients undergoing total hip arthroplasty.

Subtrochanteric shortening osteotomy during cementless total hip arthroplasty in young patients with severe developmental dysplasia of the hip.

BACKGROUND: This retrospective study was designed to determine complications, functional and radiographic results of transverse subtrochanteric osteotomy during cementless, modular total hip arthroplasty (THA) in a series of active patients younger than 45 years with Crowe Type-III or IV developmental dysplasia of the hip (DDH). METHODS: We followed 49 patients (56 hips) with DDH who were treated with cementless THA, where the acetabular cup was positioned in the anatomic hip center and where a simultaneous transverse femoral osteotomy was performed. Complication rate evaluation and clinical outcomes were measured by validated clinical scores and radiographic evaluation were performed at a mean follow up of 10 years (range, 4.8-14.3 years). RESULTS: The mean limb-length discrepancy was reduced from 4.2 cm to 1.1 cm (P < 0.01). The mean Harris hip score (HSS) significantly improved from 40.6 points to 87.4 points (P < 0.01). Similarly, severity of low back pain, modified MAP, HOOS, and SF-12 also showed significant improvement (P < 0.01). There were 3 cases of postoperative dislocation, 3 cases of transient nerve palsy, 2 cases of nonunion, and 4 cases of intraoperative fracture. At 10 years follow-up, the estimated survival rate with any component revision as end points was 92%. CONCLUSION: The cementless THA combined with transverse subtrochanteric osteotomy is a reliable technique with restoration of a more normal limb, satisfactory clinical outcomes, and mid-term survival of components.

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.

Correlations between inflammatory cytokines, muscle damage markers and acute postoperative pain following primary total knee arthroplasty.

BACKGROUND: Despite the success of total knee arthroplasty (TKA) in reducing knee pain and improving functional disability, the management of acute postoperative pain is still unsatisfactory. This study was aimed to quantitatively analyze the possible correlations between inflammatory cytokines, muscle damage markers and acute postoperative pain following primary TKA. METHODS: Patients scheduled for unilateral primary TKA were consecutively included, the serial changes of the numerical rating scale (NRS) at rest (NRSR) and at walking (NRSW), serum inflammatory cytokines and muscle damage markers were assessed before surgery (T0) and at postoperative day 1, 2, 3 and 5 (T1-T4, respectively); while pain disability questionnaire (PDQ) and synovial fluid inflammatory cytokines were evaluated at T0. The correlations between inflammatory cytokines, muscle damage markers and pain scores were examined, and Bonferroni correction was applied for multiple comparisons. RESULTS: Ninety six patients were included for serum markers and pain evaluations at T0-T4, while 54 (56.25%) for synovial fluid cytokines at T0. The NRSR at T1 and T2 were positively correlated with preoperative NRSW, while the NRSW at T1 to T4 were positively correlated with preoperative NRSR, NRSW and PDQ (all p < 0.05). The NRSR was positively correlated with serum PGE2, IL-6, and CK at T1; the NRSW was positively correlated with serum CRP at T1, with PGE2 and IL-6 at T1 to T3, with CK at T2 and T4, and with Mb and LDH at T1 to T4 (all p < 0.003). Meanwhile, positive correlations were observed between preoperative NRSW and synovial fluid PGE2, IL-6, IL-8, or TNF-α, as well as between PDQ and PGE2 (all p < 0.003), but no associations between postoperative pain scores and preoperative synovial fluid cytokines was found (all p ≥ 0.003). Additionally, the NRSR at T1 and T2, and NRSW at T1 to T4 were positively correlated with body mass index (all p < 0.05). CONCLUSIONS: Serum inflammatory cytokines and muscle damage markers are positively correlated with acute postoperative pain following primary TKA, and the key cytokines (CRP, PGE2, and IL-6) and markers (Mb, CK and LDH) may serve as the targets for developing novel analgesic strategies.

Long-Term Results of Cementless Total Hip Arthroplasty With Subtrochanteric Shortening Osteotomy in Crowe Type IV Developmental Dysplasia.

BACKGROUND: When surgeons reconstruct hips with a high dislocation related to severe developmental dysplasia of the hip (DDH) in total hip arthroplasty (THA), archiving long-term stable implant fixation and improving patient function and satisfaction remain challenging. The purpose of this study was to evaluate the 10-year outcomes of transverse subtrochanteric shortening osteotomy in cementless, modular THA in Crowe type IV-Hartofilakidis type III DDH. METHODS: We reviewed 62 patients (76 hips) who underwent cementless THA with transverse subtrochanteric shortening osteotomy from 2002-2010. There were 49 women and 13 men with a mean age of 38.8 years, all of whom had Crowe type IV DDH. Mean follow-up period was 10 years. The acetabular cup was implanted in placement of the anatomical hip center in all hips. RESULTS: The mean Harris Hip Score significantly improved from 38.8 points to 86.1 points. Similarly, modified Merle d'Aubigne and Postel Hip Score, Hip dysfunction and Osteoarthritis Outcome Score, and SF-12 also significantly improved. The mean limb length discrepancy was reduced from 4.3 cm to 1.0 cm. At mean follow-up of 10 years, there were 3 cases of postoperative dislocation, 2 cases of transient nerve palsy, 1 case of nonunion, and 4 cases of intraoperative fracture. Revision surgery was performed in 2 patients due to isolated loosening of acetabular component and femoral stem, respectively. CONCLUSION: Our data demonstrated that the cementless, modular THA combined with transverse subtrochanteric shortening osteotomy was an effective and reliable technique with high rates of successful fixation of the implants and satisfactory clinical outcomes.

Comparison of Early Functional Recovery After Total Hip Arthroplasty Using a Direct Anterior or Posterolateral Approach: A Randomized Controlled Trial.

BACKGROUND: Controversy exists as to whether early functional outcomes differ after total hip arthroplasty performed using the direct anterior approach (DAA) or the posterolateral approach (PLA). METHODS: One hundred twenty patients were enrolled in this study and were divided into 2 groups based on surgical approach. Group A included patients who had a total hip arthroplasty with a DAA, whereas group B included those with a PLA. Patients were randomized into the DAA or PLA groups (n = 60), and perioperative and postoperative outcomes were recorded. RESULTS: When compared with the PLA, the DAA had a shorter incision length (9.1 vs 13.1 cm; P < .01), shorter hospital stay (2.8 vs 3.3 days, P = .04), and lower self-reported pain. Both serum inflammatory and muscle damage markers were lower in the DAA group. However, the PLA had shorter operative times (65.5 vs 83.3 min, P = .03) and less intraoperative blood loss (123.8 vs 165.9 mL, P = .04). The DAA had significantly lower variance in cup inclination and anteversion. Similar rates of intraoperative complications were identified in the 2 groups. The DAA was associated with better functional recovery at 3 months based on the Harris hip score, University of California Los Angeles activity score, and gait analysis; however, functional recovery at 6 months was similar between the 2 groups. CONCLUSION: We found functional advantages in early recovery after the DAA compared with the PLA. The DAA can offer rapid functional recovery with less muscle damage, greater pain relief, and lower variance in cup inclination and anteversion. However, no functional difference was found at 6 months follow-up.

Treatment of osteoporotic intertrochanteric fractures by zoledronic acid injection combined with proximal femoral nail anti-rotation.

OBJECTIVE: To observe the clinical results of proximal femoral nail anti-rotation (PFNA) combined with zoledronic acid injection in the treatment of osteoporotic intertrochanteric fractures in the elderly. METHODS: 60 elderly patients with osteoporotic intertrochanteric fractures were diagnosed using a dual energy X-ray bone density instrument. Patients were randomly divided into treatment or control groups (30 cases in each group). Patients in both groups were treated by closed/open reduction and internal fixation using PFNA. In the treatment group, patients received one zoledronic phosphonic acid injection of 5 mg/100 ml via intravenous drip, in addition to 600 mg of Caltrate D (qd) and 0.25 mg of alpha ossification alcohol (qd). The control group received 600 mg of Caltrate D (qd) and 0.25 mg of alpha ossification alcohol (qd). The oral drugs were administered for 12 months. Bone pain relief was observed, and changes in the bone mineral density (BMD) of the lumbar and health-side hip were recorded. Clinical results were evaluated using the Visual Analogue Scale (VAS), Harris joint function score, and Osteo- porosis Quality of Life Scale (OQOLS). RESULTS: Compared with the control group, bone pain symptoms were significantly alleviated (p < 0.05) in the treatment group. In the treatment and control groups, both between-group and within-group differences in BMD were significantly increased in L1e4, femoral neck and trochanter (p < 0.05). No significant differences were found between the two groups in regard to the involved hip or the total rate of improvement at the end of the follow-up period, although cases in the treatment group had higher OQOLS scores than those of the controls (p = 0.04). Cases in the treatment group healed more quickly than those in the control group [(13 ± 3.2) weeks vs (15 ± 4.6) weeks, p = 0.02]. During the follow-up period, cases in the treatment group had no new fractures, whereas 2 new cases of hip fracture and 2 cases of distal radial fractures were observed among the controls. CONCLUSION: Zoledronic acid injection combined with PFNA is a favorable treatment option for the elderly patients with osteoporotic intertrochanteric fracture. It can effectively relieve bone pain, increase bone density, improve quality of life, reduce the occurrence of new fractures and promote fracture healing.