Superior analgesic efficacy of preemptive low-dose ketorolac compared with parecoxib after total knee arthroplasty: A retrospective propensity score matching study.

BACKGROUND: Total knee arthroplasty (TKA) is a routine orthopedic procedure often associated with significant postoperative pain. Efficient pain management is paramount for patient recovery, with nonsteroidal anti-inflammatory drugs (NSAIDs) being a common choice. Nevertheless, the specific NSAID and its dosing regimen can have varying impacts on outcomes. METHODS: In this retrospective cohort study spanning from January 2016 to December 2020, we analyzed patients who underwent TKA. These patients were divided into two groups: one receiving preemptive low-dose ketorolac (15 mg) followed by 15 mg every 6 h for 48 h, and the other receiving parecoxib (40 mg) every 12 h for the same duration. We assessed pain scores, opioid consumption, and monitored adverse events. RESULTS: Our findings reveal that ketorolac yielded superior results compared to parecoxib. Specifically, patients receiving ketorolac reported significantly lower Visual Numeric Rating Scale (VNRS) scores at 8- and 20-h post-surgery. This trend was further confirmed by linear mixed models (p = .0084). Additionally, ketorolac was associated with reduced opioid consumption during the initial 24 h. Importantly, the rates of adverse events were comparable between the two groups. CONCLUSION: The utilization of preemptive low-dose ketorolac demonstrates promising potential in bolstering pain control within the initial 24 h post-TKA, potentially reducing the need for opioids. However, further exploration is required to thoroughly assess its prolonged analgesic effects and safety across various surgical contexts. These investigations could provide invaluable insights for optimizing pain management protocols.

Efficacy of Periarticular Infiltration with Dexamethasone and Bupivacaine plus Adductor Canal Block Relative to That of Adductor Canal Block Alone for Patients Undergoing Total Knee Arthroplasty: A Retrospective Case-Matched Study.

Purpose: Periarticular infiltration (PI) is a common procedure during total knee arthroplasty (TKA) for postoperative pain management. This retrospective, case-matched study aimed to evaluate the effectiveness of PI with dexamethasone and bupivacaine in combination with an adductor canal block (ACB) and compare it with that of ACB alone in reducing postoperative pain in patients with TKA. Methods: Data were collected from 66 patients who underwent TKA performed by a single surgeon. Thirty-three of them received ACB + PI, and 33 received ACB alone. However, both groups underwent identical surgical techniques and postoperative care protocols. The pain scores and fentanyl consumption of the two groups were compared. Results: The ACB + PI group had significantly lower pain scores than the ACB alone group at 8, 16, 24, and 48 hours postoperatively (p=0.033, 0.004, 0.038, and 0.049, respectively). The percentage of patients requiring fentanyl as a rescue medication was significantly higher for the ACB alone group (90.9%) than for the ACB + PI group (69.7%, p=0.03). The total fentanyl consumption was also lower for the ACB + PI group (p < 0.001). Conclusion: The periarticular injection of the combination of dexamethasone and bupivacaine plus ACB was more effective than ACB alone in reducing postoperative pain and fentanyl consumption in patients undergoing TKA. Further studies comparing different doses of dexamethasone or other cocktail regimens may provide additional insights into this approach.

Do cemented standard-length femoral stems have enough longevity for the pathological fractures of the femoral neck with metastatic lesions? A retrospective study.

Background: Cemented long-stem hip arthroplasty is a treatment of choice for the pathological fractures of the femoral neck with metastatic lesions and the prevention of further fracture caused by metastasis progression. Objective: The present study was an evaluation of the outcome after treatment of metastatic femoral neck fractures with cemented standard-length hemiarthroplasty. Methods: We retrospectively studied 23 patients in whom the pathological fractures of the femoral neck with metastatic lesions were diagnosed. All patients underwent hemiarthroplasty with cemented standard-length femoral stems. The demographic data of the patients and clinical outcomes were obtained from an electronic medical database. Metastasis progression-free survival time was analyzed via the Kaplan-Meier curve. Results: The mean age of the patients was 51.5 ± 11.7 years. The median duration of follow-up was 6.8 months (interquartile range, 5-22.6 months). Four patients exhibited tumor progression according to radiographic evaluation, but no patients had new fractures in the same bone or needed reoperation. The Kaplan-Meier curve revealed that 88.2% (74.2,100) of femurs demonstrated 1 year radiographic progression-free survival and 73.5% (49.4,100) demonstrated 2 year progression-free survival. Conclusions: Our study demonstrated that the use of cemented standard-length stems in hemiarthroplasty for pathological fractures of the femoral neck with metastatic lesions is safe, and the rate of reoperation was low. We believe that this prosthesis is optimum for treatment in this group of patients because the length of survival in patients is expected to be short and the rate of metastasis progression in the same bone is low.

The Strong Correlation Between Pain Interference and Abnormal Nutritional Status in Older Adults With Chronic Musculoskeletal Pain.

OBJECTIVES: Musculoskeletal pain, one of the most common issues faced by older adults, has multidimensional effects including an increased risk of malnutrition. Therefore, this study aimed to investigate the association between pain interference and nutritional status in older adults with chronic musculoskeletal pain. METHODS: In this cross-sectional study, data were collected from older adults (age: >60 years) using the brief pain inventory and mini nutritional assessment questionnaire. The correlation between pain interference, pain severity, and nutritional status was assessed using the chi-square test and Spearman's rank correlation. Multiple logistic regression analysis was used to analyze the variables associated with abnormal nutrition status. RESULTS: Overall 241 older adults were recruited in the study. The median (IQR) age of the participants was 70 (11) years, pain severity subscale was 4.2 (1.8), and pain interference subscale was 3.3 (3.1). Abnormal nutritional status was positively correlated with pain interference (Odds ratio [OR]: 1.26; 95% confidence interval [CI]: 1.08-1.48; P = .004), pain severity (OR: 1.25; 95% CI: 1.02-1.53; P = .034), age (OR 1.06; 95% CI: 1.01-1.11, P = .011), and hypertension (OR = 2.17; 95% CI: 1.11-4.26; P = .024). CONCLUSIONS: This study reports a strong correlation between pain interference and nutritional status. Therefore, pain interference can be a useful pain assessment tool to indicate risk of abnormal nutritional status in older adults. In addition, related factors, including age, underweight, and hypertension, were associated with a higher risk of malnutrition.

The Efficacy of Topical Tranexamic Acid in Femoral Neck Fractured Patients Undergoing Cemented Bipolar Hemiarthroplasty: A Randomized Double Blinded Controlled Trial.

Objective Tranexamic acid (TXA) is an antifibrinolytic that is widely used for decreasing blood loss and blood transfusion rates in total hip arthroplasty. However, there is limited evidence of topical TXA usage in hip hemiarthroplasty for femoral neck fractures. The present study aimed to evaluate the effects of topical TXA on blood loss and on blood transfusions in femoral neck fracture patients who underwent cemented bipolar hemiarthroplasty. Methods Twenty-six patients with femoral neck fractures who were scheduled for bipolar cemented arthroplasty were randomized into two groups. The first group of 12 patients received topical TXA during their operation, whereas 14 patients in the second group received a placebo. Hematocrit was measured at 6 and 24 hours postoperatively. Blood transfusions and postoperative complications were also recorded. Results Total blood loss was not different between the TXA group and the control group (TXA group: 459.48 ± 456.32 ml, and control group: 732.98 ± 474.02 ml; p = 0.14). However, there were no patients within the TXA group who required a blood transfusion, while there were 4 patients in the control group who received allogenic blood transfusions ( p = 0.044). There were no postoperative complications, such as wound complication, venous thromboembolism, or cardiovascular complications within either group. Conclusion Topical TXA could not decrease total blood loss but was able to reduce transfusion rates in patients who underwent cemented bipolar hip hemiarthroplasty in femoral neck fractures. Further studies in doses of topical TXA in a larger sample size would be beneficial. Level of Evidence II.

The Efficacy of Topical Tranexamic Acid in Femoral Neck Fractured Patients Undergoing Cemented Bipolar Hemiarthroplasty: A Randomized Double Blinded Controlled Trial / A eficácia do ácido tranexâmico tópico em pacientes com fraturas no pescoço femoral submetidos a hemiartroplastia bipolar cimentada: Um ensaio controlado duplo-cego randomizado

Abstract Objective Tranexamic acid (TXA) is an antifibrinolytic that is widely used for decreasing blood loss and blood transfusion rates in total hip arthroplasty. However, there is limited evidence of topical TXA usage in hip hemiarthroplasty for femoral neck fractures. The present study aimed to evaluate the effects of topical TXA on blood loss and on blood transfusions in femoral neck fracture patients who underwent cemented bipolar hemiarthroplasty. Methods Twenty-six patients with femoral neck fractures who were scheduled for bipolar cemented arthroplasty were randomized into two groups. The first group of 12 patients received topical TXA during their operation, whereas 14 patients in the second group received a placebo. Hematocrit was measured at 6 and 24 hours postoperatively. Blood transfusions and postoperative complications were also recorded. Results Total blood loss was not different between the TXA group and the control group (TXA group: 459.48 ± 456.32 ml, and control group: 732.98 ± 474.02 ml; p = 0.14). However, there were no patients within the TXA group who required a blood transfusion, while there were 4 patients in the control group who received allogenic blood transfusions (p = 0.044). There were no postoperative complications, such as wound complication, venous thromboembolism, or cardiovascular complications within either group. Conclusion Topical TXA could not decrease total blood loss but was able to reduce transfusion rates in patients who underwent cemented bipolar hip hemiarthroplasty in femoral neck fractures. Further studies in doses of topical TXA in a larger sample size would be beneficial. Level of Evidence II.

Resumo Objetivo O ácido tranexâmico (TXA) é um antifibrinolítico amplamente utilizado para diminuir as taxas de perda de sangue e de transfusão de sangue na artroplastia total do quadril. No entanto, há evidências limitadas de uso tópico de TXA na hemiartroplastia do quadril para fraturas no pescoço femoral. O presente estudo teve como objetivo avaliar os efeitos do TXA tópico na perda de sangue e transfusões de sangue em pacientes com fratura femoral que foram submetidos a hemiartroplastia bipolar cimentada. Métodos Vinte e seis pacientes com fraturas no pescoço femoral e programados para artroplastia cimentada bipolar foram randomizados em dois grupos. O primeiro grupo de 12 pacientes recebeu TXA tópico durante a operação; no segundo grupo, 14 pacientes receberam placebo. O hematócrito foi medido às 6 e 24 horas no pósoperatório. Também foram registradas transfusões de sangue e complicações pósoperatórias. Resultados A perda total de sangue não foi diferente entre o grupo TXA e o grupo controle (grupo TXA: 459,48 ±456,32 ml; e grupo controle: 732,98 ±474,02 ml; p = 0,14). No entanto, não houve pacientes dentro do grupo TXA que necessitaram de transfusão de sangue, enquanto 4 pacientes no grupo controle fizeram transfusões de sangue halogênicas (p = 0,044). Não houve complicações pós-operatórias, tais como complicação da ferida, tromboembolismo venoso ou complicações cardiovasculares dentro de qualquer grupo. Conclusão O TXA tópico não conseguiu diminuir a perda total de sangue, mas foi capaz de reduzir as taxas de transfusão, em pacientes submetidos a hemiartroplastia de quadril bipolar cimentada em fraturas no pescoço femoral. Outros estudos com doses de TXA tópico em um tamanho amostral maior seriam benéficos. Nível de Evidência II.

Magnetic resonance imaging in differentiating between aggressive and non-aggressive bone tumors.

BACKGROUND: While radiography remains essential in the initial evaluation of bone lesions, tissue biopsy or further imaging is often required to clarify indeterminate radiographic features. Magnetic resonance imaging (MRI) assists radiologists in evaluating lesions with indeterminate features as it has advantages in delineating tumorous tissues and bone marrow. PURPOSE: To evaluate the association factors of MRI for bony aggressiveness. MATERIAL AND METHODS: A retrospective analysis of 226 MRI examinations from patients diagnosed with bone tumors in a tertiary hospital during 2008-2018 was performed. All the MR images were interpreted by musculoskeletal radiologists without diagnostic information. The bony lesions were categorized into aggressive and non-aggressive groups using tumor margin, cortical changes, periosteal reaction, joint extension, extraosseous soft tissue involvement, tumor homogeneity, and enhancement pattern from the MR images. Univariable and multivariable analysis were applied for each feature on the MRI scans. In addition, sensitivity and specificity were calculated for MRI diagnoses of aggressive bone lesions. RESULTS: In total, 180 aggressive and 46 non-aggressive bone lesions were examined on MRI. The sensitivity and specificity of MRI for differentiating between aggressive and non-aggressive bone lesions were 98.89% and 50%, respectively. Ill-defined margin, cortical break, cortical signal changes, sunburst and Codman's triangle periosteal reaction, joint extension, and tumoral and heterogeneous enhancement could be predictive signs for aggressive bone lesions. CONCLUSION: MRI can be a valuable tool to assist in distinguishing aggressive from non-aggressive bone lesions. In cases of indeterminate radiographic features, MRI could be used as an additional imaging to improve diagnostic accuracy and could reduce unnecessary invasive procedures.

Efficacy of a Combined Intramedullary, Periarticular Injection, and Intraarticular Tranexamic Acid Application on Postoperative Bleeding in Total Knee Arthroplasty: A Retrospective Case-Matched Study.

Background: Topical tranexamic acid (TXA) has been widely used to reduce postoperative blood loss following total knee replacement (TKA). This study aimed to evaluate the effect of combined intramedullary, periarticular injection, and intraarticular TXA application in patients who underwent TKA as compared to those who did not. Methods: This was a retrospective case-matched study of 111 patients. We evaluated the transfusion rate and postoperative drainage of 56 patients who underwent TKA using combined topical tranexamic acid application (directly pushed into the femoral intramedullary canal and tibia base, with periarticular soft tissue injection and injected into the knee cavity via a drain tube) and the control group of 55 patients. Results: In the control and TXA groups, 7.14% and 1.81% of the patients received blood transfusions, respectively (p=0.176). The closed-suction drainage output at 0-8 h and total drainage output were significantly lower in the TXA group than those in the control group (p < 0.001). Conclusion: Application of topical TXA with the combined method (intramedullary, periarticular injection, and intraarticular) in TKA decreases postoperative suction drainage and may reduce the need for postoperative blood transfusion.

The impact of the transition from flipped classroom to online lectures on learning outcomes and student satisfaction in a rehabilitation medicine clerkship during the COVID-19 pandemic.

BACKGROUND: The flipped classroom (FC) is a well-known active learning module that activates the prior knowledge of students and promotes their cognitive skills during in-class activities. However, most on-site teaching during the COVID-19 pandemic had to be conducted online. The FC in our rehabilitation medicine clerkship curriculum was also shifted to online asynchronous lectures (OLs), without real-time interactions. There is no previous comparison of effectiveness between these two methods. Therefore, this study aimed to compare learning outcomes and student satisfaction in both FC and OL models. METHODS: The study design was a historically controlled study. A physical modality was chosen for the content. The FC group (n = 233), in the academic years 2018 and 2019, was assigned to perform a pre-class activity consisting of reading study materials. Thereafter, the in-class activity comprised a small-group case-based discussion. The OL group (n = 240) in the academic years 2020 and 2021 followed an online model during the COVID-19 lockdown. They were also asked to read the online materials and then watch a self-paced recorded lecture video on Learning Management Systems. The learning outcomes, including their multiple-choice questions (MCQs) scores, final exam scores, grade points, and letter grades, were evaluated. Their overall course satisfaction ratings were also collected. RESULTS: The OL group had an overall higher MCQ score for the physical modality portion than the FC group (p = 0.047). The median (lower quartile, upper quartile) of the total 50-MCQ scores were 34 (31, 37) in the OL group and 33 (29, 36) in the FC group (p = 0.007). The median final exam scores of the OL and FC groups were 69.5 and 68.3, respectively (p = 0.026). The median grade points and the letter grades were not significantly different between the groups. The proportions of satisfaction were significantly higher in the FC group than in the OL group. CONCLUSIONS: The OL group revealed significantly higher learning outcomes than the FC group. However, the FC group showed more satisfaction with interactivity than the OL group. The authors are of the view that a combination of both FC and OL methods will likely result in better outcomes.

Aspirin versus Rivaroxaban to Prevent Venous Thromboembolism after Total Knee Arthroplasty: A Double-blinded, Randomized Controlled Trial.

Objective Aspirin (acetylsalicylic acid, ASA) and rivaroxaban are anticoagulants that have increased in popularity due to ease of use in the prevention of venous thromboembolism (VTE) after total knee arthroplasty (TKA). The present study aimed to evaluate the efficacy of ASA compared with that of rivaroxaban on VTE prophylaxis in patients who underwent TKA. Method Forty patients who had primary knee osteoarthritis and would undergo TKA were randomized into two groups. In total, 20 patients in the ASA group used oral aspirin, at a dose of 300 mg/day, for VTE prophylaxis after TKA, while 20 patients in the rivaroxaban group received oral rivaroxaban, at a dose of 10 mg/day. On days 4 and 14 after the operation, deep vein thrombosis (DVT) in the lower limbs on the operated side was detected through duplex ultrasonography. Other complications were recorded for 14 days. Results There were no positive findings of DVT detected with duplex ultrasonography in the groups of patients, and the occurrence of pulmonary embolism was not observed. In total, 4 patients had subcutaneous ecchymosis on the fourth postoperative day (2 patients in the ASA group and 2 patients in the rivaroxaban group; p = 1.0), and another 4 patients on the fourteenth postoperative day (1 patient in the ASA group and 3 patients in the rivaroxaban group; p = 0.292). No cases of wound hematoma, major organ bleeding, wound infection, or reoperation were observed in the sample. Conclusion Aspirin and rivaroxaban had comparable efficacy to prevent VTE, without increasing the incidence of wound complications and bleeding after TKA.

Aspirin versus Rivaroxaban to Prevent Venous Thromboembolism after Total Knee Arthroplasty: A Double-blinded, Randomized Controlled Trial / Aspirina versus rivaroxabana na prevenção do tromboembolismo venoso após artroplastia total do joelho: Um ensaio clínico randomizado, controlado e duplo-cego

Abstract Objective Aspirin (acetylsalicylic acid, ASA) and rivaroxaban are anticoagulants that have increased in popularity due to ease of use in the prevention of venous thromboembolism (VTE) after total knee arthroplasty (TKA). The present study aimed to evaluate the efficacy of ASA compared with that of rivaroxaban on VTE prophylaxis in patients who underwent TKA. Method Forty patients who had primary knee osteoarthritis and would undergo TKA were randomized into two groups. In total, 20 patients in the ASA group used oral aspirin, at a dose of 300 mg/day, for VTE prophylaxis after TKA, while 20 patients in the rivaroxaban group received oral rivaroxaban, at a dose of 10 mg/day. On days 4 and 14 after the operation, deep vein thrombosis (DVT) in the lower limbs on the operated side was detected through duplex ultrasonography. Other complications were recorded for 14 days. Results There were no positive findings of DVT detected with duplex ultrasonography in the groups of patients, and the occurrence of pulmonary embolism was not observed. In total, 4 patients had subcutaneous ecchymosis on the fourth postoperative day (2 patients in the ASA group and 2 patients in the rivaroxaban group; p= 1.0), and another 4 patients on the fourteenth postoperative day (1 patient in the ASA group and 3 patients in the rivaroxaban group; p= 0.292). No cases of wound hematoma, major organ bleeding, wound infection, or reoperation were observed in the sample. Conclusion Aspirin and rivaroxaban had comparable efficacy to prevent VTE, without increasing the incidence of wound complications and bleeding after TKA.

Resumo Objetivo A aspirina (ácido acetilsalicílico, AAS) e a rivaroxabana são anticoagulantes que vêm ganhando popularidade devido à facilidade de uso na prevenção do tromboembolismo venoso (TEV) após artroplastia total do joelho (ATJ). Este estudo teve como objetivo avaliar a eficácia do AAS em comparação com a da rivaroxabana na profilaxia de TEV em pacientes submetidos a ATJ. Método Quarenta pacientes com osteoartrite primária do joelho, que seriam submetidos a ATJ, foram randomizados em dois grupos. No total, 20 pacientes do grupo AAS usaram aspirina oral, na dose de 300 mg/dia, para a profilaxia do TEV após ATJ; e 20 pacientes do grupo rivaroxabana receberam uma dose oral de 10 mg/dia. No 4° e 14° dias do pós-operatório, trombose venosa profunda (TVP) dos membros inferiores no lado da cirurgia foi detectada por meio de ultrassonografia duplex. Foram registradas outras complicações durante catorze dias. Resultados Não foram detectados achados positivos de TVP com a ultrassonografia duplex nos grupos de pacientes, e não se observou a ocorrência de embolia pulmonar. No total, 4 pacientes apresentaram equimose subcutânea no 4° dia do pós-operatório (2 pacientes no grupo AAS e 2 pacientes no grupo rivaroxabana; p= 1,0), e outros 4 pacientes, no 14° dia do pós-operatório (1 paciente no grupo AAS e 3 pacientes no grupo rivaroxabana; p= 0,292). Nenhum paciente da amostra apresentou hematoma da ferida cirúrgica, sangramento de órgão importante, infecção da ferida, ou necessidade de nova cirurgia. Conclusão A aspirina e a rivaroxabana apresentaram eficácia comparável na prevenção do TEV, sem aumentar a incidência de complicações da ferida e sangramento após ATJ.

The ability and factors related with floor sitting after total hip arthroplasty with a posterolateral approach.

Background: Prosthesis dislocation following total hip arthroplasty (THA) is one complication that affects treatment outcome and increases the cost of treatment. Currently, many surgeons prohibit patients from performing floor-based activities; however, these prohibitions might affect the lifestyle of a number of patients. Objective: This study aimed to evaluate the ability of floor sitting after THA, and factors associated with this ability. Methods: This study was a retrospective cohort study, evaluating 240 patients who underwent THA with a posterolateral approach, in a single tertiary hospital. Patient demographic data, preoperative clinical data, prostheses type, and postoperative radiographic were extracted from the electronic medical records. Postoperative ability to perform floor sitting was evaluated at 6 months postoperatively. Results: There were 52 patients (21.66%) who were able to sit on the floor postoperatively. Multivariate logistic regression analysis showed independent association between three factors with ability to sit on the floor after surgery: pre-operative external rotation range of motion (OR 1.03; 95% CI, 1.01-1.06; P = 0.01), pre-operative Harris Hip Scores (OR 1.05; 95% CI, 1.01-1.10; P = < 0.01), pre-operative ability to sit on the floor (OR 10.2; 95% CI, 3.65-28.5; P = < 0.01). Conclusion: There were a number of patients who could sit on the floor after THA. However, there were factors which were associated with this ability. Hence, these results could be useful for adjusted patient preoperative expectations, and did not preclude all patients to perform floor activities.

EFFICACY OF EXTENDED ORAL TRANEXAMIC ACID ON BLOOD LOSS IN PRIMARY TOTAL KNEE ARTHROPLASTY.

Introduction: Tranexamic acid is widely used for patients undergoing total knee arthroplasty (TKA). However, the duration of systemic tranexamic acid (TXA) administration varies in many reports. Hence, this study aims to compare blood loss between a single intravenous (IV) TXA dose, and one dose of IV TXA combined with oral TXA, during 48-hour postoperative care in primary TKA. Methods: Ninety-four patients with primary osteoarthritis, who underwent primary TKA, were randomized into two groups. The first group consisted of 47 patients and received a dose of 750 mg IV TXA and 750 mg oral TXA postoperatively at 8-hour intervals for 48 hours. In the second group, 47 patients received a single dose of IV TXA and a placebo at the same intervals for the same time duration. Hemoglobin (Hb) was measured at 4, 24 and 72 hours after operation. Results: The mean total blood loss were not different between the two groups (p=0.37). There was no difference in total Hb reduction or closed suction drainage outputs (p=0.9 and 0.07, respectively). Conclusion: The extended use of oral TXA for 48-hour postoperative care did not decrease the total blood loss following TKA compared with a single dose of IV TXA. Level Of Evidence I; High quality randomized trial .

Introdução: O ácido tranexâmico é amplamente utilizado para pacientes submetidos à artroplastia total do joelho (ATJ). No entanto, a duração da administração de ácido tranexâmico sistêmico (ATS) varia em muitos relatórios. Assim, este estudo tem como objetivo comparar a perda sanguínea entre uma dose única intravenosa (IV) de ATS e uma dose de ATS IV combinada com ATS oral, no atendimento pós-operatório ao longo de 48 horas em ATJ primária. Métodos: Noventa e quatro pacientes com osteoartrite primária, submetidos a ATJ primária, foram randomizados em dois grupos. O primeiro grupo de 47 pacientes recebeu uma dose de 750 mg de ATS IV e 750 mg de ATS oral no pós-operatório, a cada 8 horas, durante 48 horas. No segundo grupo, 47 pacientes receberam dose única de ATS IV e placebo nos mesmos intervalos e pelo mesmo período de tempo. A hemoglobina (Hb) foi medida às 4, 24 e 72 horas de pós-operatório. Resultados: A média da perda sanguínea total não foi diferente entre os dois grupos (p = 0,37). Não houve diferença na redução da hemoglobina total ou saídas de drenagem de sucção fechada (p = 0,9 e 0,07, respectivamente). Conclusão: O uso prolongado de ácido tranexâmico oral por 48 horas de pós-operatório não diminuiu a perda total de sangue após ATJ em comparação com uma dose única de ATS IV. Nível de Evidência I; Estudo Clínico randomizado de alta qualidade .

Screw inserting in different phase of cement affect the pull-out strength of cement augmented screws.

BACKGROUND: For large bone defects, after curettage of aggressive bone tumors; such as giant-cell tumors, cementation with supplement internal fixation was used to prevent subsequent collapse of the cement-bone constructs. The purpose of this study is to compare the pull-out strength of cement augmented screws between inserting screws in the working phase or hard phase of bone cement. HYPOTHESIS: Timing at which completed screw insertion takes place affecting the pull-out strength of cement augmented screws. METHODS: Pull-out strength was compared between screws; inserted within the working phases of cement, and after the cement was hardened in high viscos cement blocks. Each group consists of 10 cortex screws, 10 cancellous screws and 10 locking screws. The pull-out strength test was followed using the instructions of ASTM F543-13e1 Standard Specification and Test Methods, for Metallic Medical Bone Screws. RESULTS: Screws that were inserted in the working phases of cement had significantly higher pull-out strength, than those inserted in hard cement (p=0.021). The pull-out strength was statistically significant in difference among the types of screws (p<0.001), with locking screws having the highest pull-out strength. Furthermore, the pull-out strength of locking screws revealed no significant difference when either; inserted during the working or hardened phases of bone cement. CONCLUSION: Insertion of screws during the working periods of PMMA cement had higher pull out strength compared to the hard phase of cement. Hence, we recommend performing internal fixation before cementation after curettage of aggressive bone tumors. However, if the surgeon prefers to pack the cement first, for the benefit of avoiding residual bone defects, we suggest using a locking plate system to achieve comparable pull-out strength. LEVEL OF EVIDENCE: In-vitro study.

Efficacy of extended oral tranexamic acid on blood loss in primary total knee arthroplasty / Eficácia do uso prolongado de ácido tranexâmico oral na perda de sangue na artroplastia total primária do joelho

ABSTRACT Introduction: Tranexamic acid is widely used for patients undergoing total knee arthroplasty (TKA). However, the duration of systemic tranexamic acid (TXA) administration varies in many reports. Hence, this study aims to compare blood loss between a single intravenous (IV) TXA dose, and one dose of IV TXA combined with oral TXA, during 48-hour postoperative care in primary TKA. Methods: Ninety-four patients with primary osteoarthritis, who underwent primary TKA, were randomized into two groups. The first group consisted of 47 patients and received a dose of 750 mg IV TXA and 750 mg oral TXA postoperatively at 8-hour intervals for 48 hours. In the second group, 47 patients received a single dose of IV TXA and a placebo at the same intervals for the same time duration. Hemoglobin (Hb) was measured at 4, 24 and 72 hours after operation. Results: The mean total blood loss were not different between the two groups (p=0.37). There was no difference in total Hb reduction or closed suction drainage outputs (p=0.9 and 0.07, respectively). Conclusion: The extended use of oral TXA for 48-hour postoperative care did not decrease the total blood loss following TKA compared with a single dose of IV TXA. Level Of Evidence I; High quality randomized trial .

RESUMO Introdução: O ácido tranexâmico é amplamente utilizado para pacientes submetidos à artroplastia total do joelho (ATJ). No entanto, a duração da administração de ácido tranexâmico sistêmico (ATS) varia em muitos relatórios. Assim, este estudo tem como objetivo comparar a perda sanguínea entre uma dose única intravenosa (IV) de ATS e uma dose de ATS IV combinada com ATS oral, no atendimento pós-operatório ao longo de 48 horas em ATJ primária. Métodos: Noventa e quatro pacientes com osteoartrite primária, submetidos a ATJ primária, foram randomizados em dois grupos. O primeiro grupo de 47 pacientes recebeu uma dose de 750 mg de ATS IV e 750 mg de ATS oral no pós-operatório, a cada 8 horas, durante 48 horas. No segundo grupo, 47 pacientes receberam dose única de ATS IV e placebo nos mesmos intervalos e pelo mesmo período de tempo. A hemoglobina (Hb) foi medida às 4, 24 e 72 horas de pós-operatório. Resultados: A média da perda sanguínea total não foi diferente entre os dois grupos (p = 0,37). Não houve diferença na redução da hemoglobina total ou saídas de drenagem de sucção fechada (p = 0,9 e 0,07, respectivamente). Conclusão: O uso prolongado de ácido tranexâmico oral por 48 horas de pós-operatório não diminuiu a perda total de sangue após ATJ em comparação com uma dose única de ATS IV. Nível de Evidência I; Estudo Clínico randomizado de alta qualidade .

Relationship between web-based illness scripts and the performance of medical students in orthopedic surgery placements.

OBJECTIVES: We aimed to explore the relationship between web-based orthopedic illness scripts and medical students' performance as assessed through examination results. METHODS: This was a retrospective cohort study with 83 fifth-year medical students in an academic hospital. During a one-month placement, they were instructed to do web-based illness scripts. Their performances were assessed by examination in the last week. All recorded data about illness scripts and examination results were retrieved. The students were separated into high and low response groups based on completed illness scripts. The characteristics of the students between the two groups were compared. Pearson correlation coefficients and regression analysis were used to identify the relationship between illness scripts and examination results. RESULTS: There were 56 students in the high-response and 27 in the low-response groups. The characteristics and examination scores were not significantly different between the groups, while there was a significant difference in script completion (t(27)=13.72, p<0.001). Using Pearson correlation, we found weak correlations without significance between completed scripts, illness script scores, and examination scores. We found no relationship between illness script scores and examination scores, even in the high response group, by regression analysis. CONCLUSIONS: The use of web-based orthopedic illness scripts did not correlate to the examination performance of medical students. A high number of scripts without variety and limited time for practicing may have obscured potential positive relationships. Illness scripts should be adjusted as appropriate for each school before being assigned. A further multi-center, prospective study is suggested to identify the correlations and investigate the influencing factors.

A Randomized Placebo-Controlled Trial of Efficacy and Safety: Drug-Free Gel Containing Ultra-Deformable Phospholipid Vesicles (TDT 064) in Osteoarthritic Knees.

BACKGROUND: There are a number of topical agents that are used for treatment of knee osteoarthritis. Drug-free gels, containing ultra-deformable phospholipid vesicles (TDT 064) are one such topical therapy, which have been stated to act as a bio lubricant. However, the evidence of TDT 064 in treatment of knee osteoarthritis is limited. Hence, the aim of this study was to evaluate the efficacy of pain control as a primary outcome and safety of TDT 064 compared with a topical placebo. METHODS: Sixty-four patients with primary osteoarthritis, with radiographic showing Kellgren and Lawrence classification grade II to III, were randomized into 2 groups. In the first group of 32 patients TDT 064 was used as topical agent, whilst in the second group of 32 patients a placebo identical in appearance was used instead. The verbal numerical rating scale (VNRS) was used for recording pain levels, Self-reported Knee Injury and Osteoarthritis Outcome Scores (KOOS) as well as amounts of rescue medication were also recorded. The data were recorded at the start of the study, and then at follow-up appointments of 14 days, 6 weeks, and 3 months. RESULTS: The mean VNRS for pain in both groups were significantly improved, when compared to the start of treatment (P < .0001); however, there were no differences between groups at any follow up visit. KOOS in all subscales were not significantly different between both groups at baseline and at the end of treatment. However, the average amount of NSAIDs in the TDT 064 group was 26.39 ± 22.11 tabs, which was significantly lower than the control group; which used an average 37.03 ± 19.22 tabs in 3 months (P = .047). CONCLUSIONS: There were no differences in the VNRS for pain and KOOS scores between the active and placebo groups. Although, TDT 064 could decrease usage of rescue medication the difference with use of a placebo was minimal. Further, larger trials would also be beneficial to demonstrate any differences between TDT 064 and a placebo. TRIAL REGISTRATION: TCTR, TCTR 20190302001. Registered 1 March, 2019: http://www.clinicaltrials.in.th.

Complications after intramedullary nail fixation of pathological versus non-pathological femoral shaft fractures: a retrospective cohort study in 233 patients.

BACKGROUND: Postoperative adverse events after intramedullary nailing have been reported in patients with metastatic pathological and non-pathological femoral fractures. Other consequences to be considered are readmission and reoperation. Few studies have compared the risks of postoperative adverse events, reoperation, and readmission after intramedullary nailing of pathological and non-pathological femur fractures. This study was designed to test the hypothesis that patients with pathological femoral fractures had more adverse events, readmission, and reoperation following surgical fixation than non-pathological femoral fractures. METHODS: This was a retrospective observational cohort study, conducted at an academic medical center in Thailand. The data from patients with femoral shaft fractures undergoing long intramedullary nailing, from June 1, 2006, to June 30, 2020, were included. Patients who had a pathological fracture from a primary bone tumor, metabolic bone disease, or inadequate/missing information were excluded. Patients with pathological fractures from metastatic bone disease were assigned to be the pathological group whereas those with traumatic fractures were assigned to be the non-pathological group. The primary outcome was the risk of inpatient adverse events as compared between the two groups. The secondary outcome was the risk of consequences after discharge as compared between the two groups. Outcomes were analyzed by using multivariate logistic regression analysis. RESULTS: The total number of patients was 48 in the pathological fracture group and 185 in the non-pathological group. There were significantly higher rates of surgical and medical adverse events in patients with pathological fractures compared to patients with non-pathological fractures. After adjusting for potential confounding factors in multivariate regression analysis, patients with pathological fractures had higher odds of both adverse surgical (adjusted OR 2.43, 95 % CI 1.15-5.13) and medical adverse events (adjusted OR 2.81, 95 % CI 1.13-7.03). CONCLUSIONS: Patients with metastatic pathological femoral shaft fractures undergoing intramedullary nailing were more likely to experience postoperative adverse events than patients with non-pathological fractures.

Factors for Blood Transfusions Following Hemi Hip Arthroplasty for Patients With Femoral Neck Fracture.

BACKGROUND: Hemi hip arthroplasty is one treatment option for femoral neck fractures; however, there has been limited evidence on factors associated with blood transfusions following hemi hip arthroplasty. Hence, the aim of this study was to identify the predictors of blood transfusion after hemi hip arthroplasty, which could lead to the establishment of proper guidelines for management protocols. MATERIALS AND METHODS: This study was a retrospective cohort study, conducted in a single center of 323 femoral neck fracture patients having undergone hemi hip arthroplasty. Peri-operative factors and demographic data were extracted from the electronic medical records, from 2007 to 2019. A predictive model was developed by logistic regression (LR), and adjusted by multivariate logistic regression. RESULT: One hundred and twenty-six (39%) patients received blood transfusions. On multivariate analysis, those of a female gender (odds ratio (OR) 2.00, p = 0.037), having a body mass index lower than 18.5 kg/m2 (OR 2.40, p = 0.028), lower preoperative hemoglobin levels (OR 0.52, p < 0.001) and given general anesthesia (OR 2.07, p = 0.028) were shown to be significantly associated with a higher risk of requiring a blood transfusion. CONCLUSION: The authors recommend that preparation of blood components coupled with the utilization of blood conserving methods for high risk patients, as studies have stated, in addition to the consideration of spinal anesthesia; if patients have no contraindication, should be implemented.