Role of the NeuroCuple™ Device for the Postoperative Pain Management of Patients Undergoing Unilateral Primary Total Knee and Hip Arthroplasty: A Pilot Prospective, Randomized, Open-Label Study.

BACKGROUND: The potential effectiveness of the non-pharmacological and nanotechnology-based NeuroCuple™ device in reducing postoperative surgical pain and opioid consumption remains unknown. METHODS: This randomized controlled open-label study was conducted in patients undergoing a primary unilateral total knee or total hip arthroplasty. In the recovery room, patients were randomized to receive either standard of care (control group) or standard of care plus two NeuroCuple™ devices. The outcome variables included pain and opioid consumption (oral morphine equivalent, OME in milligrams). RESULTS: A total of 69 patients were randomized to either the NeuroCuple™ group (n = 38) or the control group (n = 31). Use of the NeuroCuple™ devices was associated with a significant 34% reduction in pain at rest (means of area under the curve: 6.3 vs. 9.5; p = 0.018) during postoperative days 1-3. Opioid consumption was reduced by 9%. More importantly, use of the NeuroCuple™ devices reduced the number of patients requesting an opioid prescription following discharge from the hospital by 52% (26% vs. 55%, p = 0.016). CONCLUSIONS: Our data suggest that the NeuroCuple™ device may be an effective non-pharmacological alternative to opioids to manage postoperative pain following unilateral arthroplasty due to its ability to reduce postoperative opioid use.

Reasons and Risk Factors for Failed Same-Day Discharge After Total Joint Arthroplasty.

BACKGROUND: A shift toward same-day discharge (SDD) in primary elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) has created a need to optimize patient selection and improve same-day recovery pathways. The objectives of this study were (1) to identify our institution's most common causes for failed SDD, and (2) to evaluate risk factors associated with failed SDD. METHODS: A retrospective review of SDD patients undergoing primary TKA or THA from January 2021 to September 2022 was conducted. Reasons for SDD failure were recorded and differences between successful and failed SDD cases were assessed via a multivariate logistic regression. RESULTS: Overall, 85.3% (651 of 753) of patients included were successful SDDs. Failed SDD occurred in 16.8% (74 of 441) of TKA and 11.8% (38 of 322) of THA cases. Primary reasons included failure to clear physical therapy (33.0%, 37 of 112), postoperative hypotension (20.5%, 23 of 112), and urinary retention (16.9%, 19 of 112). Analysis revealed that overall failed SDD cases were more likely to have had prior opioid use and a longer surgical time. Failed TKA SDD cases were more likely to have had a longer surgical time and not have receive a preoperative nerve block, while failed THA SDD cases were more likely to be older. CONCLUSIONS: The SDD selection criteria and pathways continue to evolve, with multiple factors contributing to failed SDD. Improving patient selection algorithms and optimizing post-operative pathways can enhance the ability to successfully choose SDD candidates. LEVEL OF EVIDENCE: III.

SuRxgWell: study protocol for a randomized controlled trial of telemedicine-based digital cognitive behavioral intervention for high anxiety and depression among patients undergoing elective hip and knee arthroplasty surgery.

BACKGROUND: Mood disorders (anxiety, depression), sleep disorders, and catastrophizing lead to increased post-operative pain perception, increase in postoperative opioid consumption, decreased engagement with physical activity, and increased resource utilization in surgical patients. Psychosocial disorders significantly affect postoperative outcome. Unfortunately, studies focused on perioperative psychological assessment and treatment are scarce. We propose to test whether digital cognitive behavioral intervention (dCBI) can help surgical patients. dCBI such as RxWell™ is a proven treatment for mood disorders in medical patients such as reducing depression in patients with inflammatory bowel disease. We hypothesize that RxWell™ will also be effective in surgical patients. This study aims to test whether RxWell™ can improve preoperative mood disorders and subsequently reduce postoperative pain and opioid requirement in patients scheduled for primary total hip and knee arthroplasty (THA, TKA). We named the trial as the SuRxgWell trial. METHODS: This is a randomized, controlled trial that will enroll primary and unilateral THA or TKA patients with anxiety and/or depression symptoms before surgery to receive the SuRxgWell dCBI program and investigate its impact on postoperative outcomes including postoperative pain, anxiety, depression, sleep disorder, and catastrophizing. After signing an informed consent, subjects will be screened using the PROMIS questionnaires, and subjects with a T-score of ≥ 60 on the short Patient-Reported Outcomes Measurement Information System (PROMIS) 4a Anxiety and/or short PROMIS 4a Depression questionnaires will be randomized to either usual care (control group) or the cognitive behavioral intervention, RxWell™, plus usual care (intervention group). The control group will receive information on how to locate tools to address anxiety and depression, whereas the intervention group will have access to SuRxgWell 1 month prior to surgery and up to 3 months after surgery. The allocation will be 3:1 (intervention to control). Investigators will be blinded, but research coordinators approaching patients and research subjects will not. The primary outcome will be day of surgery anxiety or depression symptoms measured with the PROMIS Short Form v1.0 -Anxiety 4a/Depression and Generalized Anxiety Disorder Measure (GAD-7) and Patient Health Questionnaire (PHQ-8). Secondary end points include measuring other health-related quality of life outcomes including sleep disturbance, fatigue, ability to participate in social roles, pain interference, cognitive function, pain catastrophizing, and physical function. Other secondary outcomes include collecting data about preoperative and postoperative pain scores, and pain medication usage, and orthopedic functional recovery at baseline, day of surgery, and 1, 2, and 3 months after the surgery with the Pain Catastrophizing Scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), and Hip injury and Osteoarthritis Outcome Score (HOOS). In addition, subjects will be asked to complete a GAD-7 and PHQ-8 questionnaires bi-weekly (via the RxWell™ app for the interventional group or REDCAP for the control group). Data about postsurgical complications, and resource utilization will also be recorded. We will also receive monthly reports measuring the usage and engagement of RxWell use for each participant randomized to that arm. The primary hypotheses will be assessed with intention-to-treat estimates, and differences in primary outcome will be tested using independent two sample t-tests. This trial is registered to the ClinicalTrials.gov database (NCT05658796) and supported by the DAPM, UPMC Health Plan, and the NIH. DISCUSSION: Our trial will evaluate the feasibility of digital cognitive behavioral intervention as a perioperative tool to improve anxiety and depression before and after major orthopedic surgery in comparison to education. If digital cognitive behavioral intervention proves to be effective, this might have important clinical implications, reducing the incidence of chronic postsurgical pain and improving outcomes.

Holistic view of the seascape dynamics and environment impact on macro-scale genetic connectivity of marine plankton populations.

BACKGROUND: Plankton seascape genomics studies have revealed different trends from large-scale weak differentiation to microscale structures. Previous studies have underlined the influence of the environment and seascape on species differentiation and adaptation. However, these studies have generally focused on a few single species, sparse molecular markers, or local scales. Here, we investigated the genomic differentiation of plankton at the macro-scale in a holistic approach using Tara Oceans metagenomic data together with a reference-free computational method. RESULTS: We reconstructed the FST-based genomic differentiation of 113 marine planktonic taxa occurring in the North and South Atlantic Oceans, Southern Ocean, and Mediterranean Sea. These taxa belong to various taxonomic clades spanning Metazoa, Chromista, Chlorophyta, Bacteria, and viruses. Globally, population genetic connectivity was significantly higher within oceanic basins and lower in bacteria and unicellular eukaryotes than in zooplankton. Using mixed linear models, we tested six abiotic factors influencing connectivity, including Lagrangian travel time, as proxies of oceanic current effects. We found that oceanic currents were the main population genetic connectivity drivers, together with temperature and salinity. Finally, we classified the 113 taxa into parameter-driven groups and showed that plankton taxa belonging to the same taxonomic rank such as phylum, class or order presented genomic differentiation driven by different environmental factors. CONCLUSION: Our results validate the isolation-by-current hypothesis for a non-negligible proportion of taxa and highlight the role of other physicochemical parameters in large-scale plankton genetic connectivity. The reference-free approach used in this study offers a new systematic framework to analyse the population genomics of non-model and undocumented marine organisms from a large-scale and holistic point of view.

The Microbiome of Osteoarthritic Hip and Knee Joints: A Prospective Multicenter Investigation.

BACKGROUND: Recent advances in high-throughput DNA sequencing technologies have made it possible to characterize the microbial profile in anatomical sites previously assumed to be sterile. We used this approach to explore the microbial composition within joints of osteoarthritic patients. METHODS: This prospective multicenter study recruited 113 patients undergoing hip or knee arthroplasty between 2017 and 2019. Demographics and prior intra-articular injections were noted. Matched synovial fluid, tissue, and swab specimens were obtained and shipped to a centralized laboratory for testing. Following DNA extraction, microbial 16S-rRNA sequencing was performed. RESULTS: Comparisons of paired specimens indicated that each was a comparable measure for microbiological sampling of the joint. Swab specimens were modestly different in bacterial composition from synovial fluid and tissue. The 5 most abundant genera were Escherichia, Cutibacterium, Staphylococcus, Acinetobacter, and Pseudomonas. Although sample size varied, the hospital of origin explained a significant portion (18.5%) of the variance in the microbial composition of the joint, and corticosteroid injection within 6 months before arthroplasty was associated with elevated abundance of several lineages. CONCLUSIONS: The findings revealed that prior intra-articular injection and the operative hospital environment may influence the microbial composition of the joint. Furthermore, the most common species observed in this study were not among the most common in previous skin microbiome studies, suggesting that the microbial profiles detected are not likely explained solely by skin contamination. Further research is needed to determine the relationship between the hospital and a "closed" microbiome environment. These findings contribute to establishing the baseline microbial signal and identifying contributing variables in the osteoarthritic joint, which will be valuable as a comparator in the contexts of infection and long-term arthroplasty success. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Dynamic Changes in Lumbar Spine Kinematics During Gait May Explain Improvement in Back Pain and Disability in Patients With Hip-Spine Syndrome.

STUDY DESIGN: Prospective cohort. OBJECTIVE: Determine if total hip arthroplasty (THA) changes lumbar spine kinematics during gait in a manner that explains the improvements in back pain seen in patients with hip-spine syndrome. SUMMARY OF BACKGROUND DATA: For patients with hip-spine syndrome, improvements in both hip and back pain have been demonstrated after THA; however, the exact mechanism of improvement in back pain remains unknown, as no corresponding changes in lumbar spine static radiographic parameters have been identified. METHODS: Thirteen patients with severe, unilateral hip osteoarthritis scheduled to undergo THA with concomitant back pain and disability were tested at baseline and 6 months after THA. Harris Hip Score (HHS) and Oswestry Disability Index questionnaires were completed; the static orientation of the spine and pelvis were measured on standing radiographs, and lumbar spine kinematics were measured during treadmill walking using a validated measurement system that matched subject-specific bone models created from CT scans to dynamic biplane radiographs. RESULTS: After THA, both the Oswestry Disability Index (36.3-11.3, P <0.001) and Harris Hip Score (55.7-77.9, P <0.001) improved; however, there were no changes in static intervertebral or pelvis orientation. During gait after THA, the overall lumbar spine (L1 to L5) was less lordotic from heel strike to contralateral toe off ( P <0.001), the L4 and L5 vertebra were less anteriorly tilted by 3.9° ( P =0.038) from midstance to contralateral heel strike and by 3.9° ( P =0.001) during stance, respectively. CONCLUSION: The decreased anterior tilt of the 2 lowest lumbar vertebrae and the corresponding loss of lumbar lordosis may reduce facet loading during the stance phase of gait after THA. This change in lumbar spine kinematics during gait is a potential mechanism to explain the observed improvements in back pain and disability after THA. LEVEL OF EVIDENCE: 4.

Safety and Efficacy of Zynrelef® in Combination with a Single Unilateral or Bilateral Nerve Block Performed Prior to Surgery.

Purpose: The FDA recently approved Zynrelef® (A viscous solution of extended release of bupivacaine and meloxicam) to be applied at closure and providing postoperative analgesia for 72 hrs. Although the FDA didn't restrict the use of nerve blocks in combination with this formulation, the safety and efficacy of such a combination has yet to be documented. This quality improvement study investigated this combination within the FDA-approved indications. Methods: Selected surgeons at two hospitals were chosen to use Zynrelef®. According to the standard of care, surgeons were also allowed to request single nerve blocks before surgery. The type of nerve blocks (unilateral or bilateral) performed included quadratus lumborum and paravertebral blocks for abdominal surgery, and adductor canal block for total knee replacement. Each block was performed with 20 mL of 0.375% bupivacaine (n=129) or 0.5% of ropivacaine (n=30). Pain scores, opioid consumption, and prescription refill requests at discharge were recorded. Patients discharged on the same day of surgery were separated into two groups-those who received single nerve blocks plus an Zynrelef® (group 1) vs. those receiving Zynrelef® only (group 2) and was analyzed using an un-paired t-test. Results: A total of 184 patients received Zynrelef®, including 25 patients who didn't receive blocks, 44 who received unilateral blocks and 114 who received bilateral blocks. No symptoms suggestive of Local Anesthetic Toxicity (LAST) were observed. The use of the combination was associated with a 50% reduction in the number of patients filling their opioid prescription. Conclusion: This study provides evidence that the combination of a single unilateral or bilateral nerve block with Zynrelef® is safe.

The Role of Inhalation Aromatherapy, Lavender and Peppermint in the Management of Perioperative Pain and Opioid Consumption Following Primary Unilateral Total Hip Arthroplasty: A Prospective, Randomized and Placebo-Controlled Study.

Introduction: Aromatherapy is claimed to be effective for the treatment of psychosocial disorders, but objective evidence of its effectiveness is still lacking. Psychosocial disorders have been demonstrated to increase postoperative pain and opioid consumption by up to 50%. This study was designed to assess the effectiveness of Aromatherapy in controlling postoperative pain and opioid in anxious patients. Methods: This prospective, randomized, placebo-controlled study was conducted on anxious patients who underwent primary unilateral total hip arthroplasty. After obtaining signed informed consent, each patient was asked to complete a PROMIS (Patient-Reported Outcomes Measurement Information System) anxiety survey. Patients whose T score were >57.2 were randomized to either an active treatment (Lavender Peppermint Elequil® aromatab®) or a placebo Elequil®-aromatab® treatment. Demographics, pain, opioid consumption, PONV, and psychosocial surveys were collected on Postoperative Day POD1, POD2, POD7 and POD30. At the time of discharge and on POD30, each patient was asked to complete a satisfaction questionnaire, and they were asked to complete an SF12 survey on POD30. Difference between means was assessed using absolute standardized mean differences. Results: Sixty patients were included in the intend-to-treat analysis. Use of lavender and peppermint was associated with a decrease of 26% in pain (POD7; 0.46), 33% in opioid consumption (POD2; 0.42), and 48% in acetaminophen consumption (POD7; 0.54) and a 78% decrease in PONV (POD2; 0.44). Psychosocial scores decreased following surgery (p=0.001). Overall satisfaction ratings at discharge were similar, as were functional recovery scores. Discussion: Our data provides evidence that in patients with preoperative anxiety, lavender and peppermint aromas decreases postoperative pain and opioid requirement compared to placebo. Additional research is required to conform our data. Conclusion: This randomized placebo control study provides evidence of the usefulness of inhalation of lavender and peppermint aromas in patients undergoing primary unilateral total hip arthroplasty.

Rh Immune Globulin After the Transfusion of RhD-Positive Blood in a Patient with a Partial D Antigen.

BACKGROUND: Patients with a serologic weak D phenotype may demonstrate variable RhD expression. We present a case in which clinical management would have been simplified if RHD genotyping had been performed previously. CASE: A 33-year-old patient, G11P4155, presented with an incomplete miscarriage and was transfused RhD-positive packed red blood cells after typing RhD-positive. The patient had been historically typed RhD-negative by a different testing methodology. Indirect antiglobulin testing was performed, which revealed a serologic weak D phenotype. The patient was given 9,600 micrograms of Rh immune globulin. Molecular testing revealed a partial D antigen, which was originally thought to be at risk for alloimmunization; however, this has since been disproven. CONCLUSION: Although not yet universal practice, prenatal RHD genotyping for partial D antigen could have prevented the characterization of this patient as RhD-positive at the time of transfusion.

A baseline for the genetic stock identification of Atlantic herring, Clupea harengus, in ICES Divisions 6.a, 7.b-c.

Atlantic herring in International Council for Exploration of the Sea (ICES) Divisions 6.a, 7.b-c comprises at least three populations, distinguished by temporal and spatial differences in spawning, which have until recently been managed as two stocks defined by geographical delineators. Outside of spawning the populations form mixed aggregations, which are the subject of acoustic surveys. The inability to distinguish the populations has prevented the development of separate survey indices and separate stock assessments. A panel of 45 single-nucleotide polymorphisms, derived from whole-genome sequencing, were used to genotype 3480 baseline spawning samples (2014-2021). A temporally stable baseline comprising 2316 herring from populations known to inhabit Division 6.a was used to develop a genetic assignment method, with a self-assignment accuracy greater than 90%. The long-term temporal stability of the assignment model was validated by assigning archive (2003-2004) baseline samples (270 individuals) with a high level of accuracy. Assignment of non-baseline samples (1514 individuals) from Divisions 6.a, 7.b-c indicated previously unrecognized levels of mixing of populations outside of the spawning season. The genetic markers and assignment models presented constitute a 'toolbox' that can be used for the assignment of herring caught in mixed survey and commercial catches in Division 6.a into their population of origin with a high level of accuracy.

An Enhanced Understanding of Culture-Negative Periprosthetic Joint Infection with Next-Generation Sequencing: A Multicenter Study.

BACKGROUND: The challenges of culture-negative periprosthetic joint infection (PJI) have led to the emergence of molecular methods of pathogen identification, including next-generation sequencing (NGS). While its increased sensitivity compared with traditional culture techniques is well documented, it is not fully known which organisms could be expected to be detected with use of NGS. The aim of this study was to describe the NGS profile of culture-negative PJI. METHODS: Patients undergoing revision hip or knee arthroplasty from June 2016 to August 2020 at 14 institutions were prospectively recruited. Patients meeting International Consensus Meeting (ICM) criteria for PJI were included in this study. Intraoperative samples were obtained and concurrently sent for both routine culture and NGS. Patients for whom NGS was positive and standard culture was negative were included in our analysis. RESULTS: The overall cohort included 301 patients who met the ICM criteria for PJI. Of these patients, 85 (28.2%) were culture-negative. A pathogen could be identified by NGS in 56 (65.9%) of these culture-negative patients. Seventeen species were identified as common based on a study-wide incidence threshold of 5%. NGS revealed a polymicrobial infection in 91.1% of culture-negative PJI cases, with the set of common species contributing to 82.4% of polymicrobial profiles. Escherichia coli, Cutibacterium acnes, Staphylococcus epidermidis, and Staphylococcus aureus ranked highest in terms of incidence and study-wide mean relative abundance and were most frequently the dominant organism when occurring in polymicrobial infections. CONCLUSIONS: NGS provides a more comprehensive picture of the microbial profile of infection that is often missed by traditional culture. Examining the profile of PJI in a multicenter cohort using NGS, this study demonstrated that approximately two-thirds of culture-negative PJIs had identifiable opportunistically pathogenic organisms, and furthermore, the majority of infections were polymicrobial. LEVEL OF EVIDENCE: Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

The presence of a draining sinus is associated with failure of re-implantation during two-stage exchange arthroplasty.

Background: Reinfection rates after two-stage exchange arthroplasty for prosthetic joint infection (PJI) have been reported as high as 33 % in the literature. Understanding risk factors for treatment failure will help to preoperatively counsel patients on the likelihood of successful treatment and possibly influence the surgeon's treatment algorithm. This study aimed to delineate whether the presence of a draining sinus tract is associated with risk of failure of two-stage exchange arthroplasty. Methods: We performed a single institution, multi-center retrospective chart review of outcomes of patients treated for PJI with two-stage exchange arthroplasty between June 2006 and May 2016. For patients treated prior to 2011, PJI was defined based on the preoperative work-up and intraoperative findings as determined by the attending surgeon. After 2011, PJI was defined using MSIS consensus criteria. All patients had a minimum of follow-up of 2 years or treatment failure prior to 2 years. Treatment failure was defined as reinfection or failure to complete two-stage exchange secondary to persistent infection or other host factors. Operative reports and clinical notes were reviewed to assess for presence of a draining sinus tract. Results: 240 patients were treated for PJI with intended two-stage exchange arthroplasty. The overall rate of treatment failure was 29.6 % ( 71 / 240 ), while the overall rate of reinfection was 13.3 % ( 32 / 240 ). A total of 39 patients did not complete second stage revision; final treatment for these patients was amputation, fusion, or chronic antibiotic suppression. A total of 52 of 240 patients (21.7 %) had a draining sinus tract at presentation. Patients with a sinus tract were significantly less likely to be replanted compared to those without a sinus tract at presentation (13.3 % vs. 26.9 %, p = 0.02 ). However, when accounting for all mechanisms of treatment failure, including reinfection following replantation, there was no statistically significant difference detected between the sinus and no-sinus groups (27.7 % vs. 36.5 %, p = 0.22 ). Discussion: A draining sinus tract represents a chronic, deep infectious process with ultimate compromise of overlying soft tissues. Thus we hypothesized it would be associated with failure in a two-stage exchange arthroplasty. These data demonstrate that patients with a draining sinus are significantly less likely to undergo re-implantation. This provides evidence to the paucity of data surrounding draining sinuses and two-stage PJI treatment.

Preoperative Optimization Before Elective Total Joint Replacement.

The identification and preoperative optimization of modifiable risk factors is proposed to be an effective method to decrease complications and improve the value of elective total joint arthroplasty. It is important to highlight the best practices as well as controversies in the preoperative evaluation and treatment of patients undergoing total joint arthroplasty.

Prevalence and correlates of cannabis use disorder among Australians using cannabis products to treat a medical condition.

INTRODUCTION: Prior research has examined the prevalence and correlates of cannabis use disorder (CUD) in people who use cannabis; however, these are poorly described for people using cannabis for medical reasons. METHODS: Data came from a 2018 to 2019 online, anonymous, cross-sectional survey of Australians reporting using either illicit or licit cannabis for medical reasons within the past year. Included were questions on demographics, current and lifetime patterns of cannabis use, clinical conditions for which medical cannabis was used, and individual criteria for CUD and cannabis withdrawal syndrome. Bayesian Horseshoe logistic regression models were used to identify covariates associated with meeting CUD DSM-5 conditions for any-CUD (≥2/11 criteria) and moderate-severe-CUD (≥4/11). RESULTS: A total of 905 participants were included in the analysis. The majority (98%) used illicit cannabis products. Criteria for any-CUD criteria were met by 290 (32.0%), and 117 (12.9%) met criteria for moderate-severe-CUD. Tolerance (21%) and withdrawal (35%) were the most commonly met criteria. Correlates with the strongest association with CUD were inhaled route of administration [odds ratio (OR) = 2.96, 95% credible interval 1.11, 7.06], frequency of cannabis use (OR = 1.24, 1.11-1.35), proportion of cannabis for medical reasons (OR = 0.83, 0.74, 0.94), frequency of tobacco use (OR = 1.10, 1.03, 1.17), age (OR = 0.75, 0.64, 0.90) and pain as main clinical indication (OR = 0.58, 0.36, 1.00). DISCUSSION AND CONCLUSIONS: Prevalence of CUD in medical cannabis users appears comparable to 'recreational' users, with many similar correlates. CUD was associated with using cannabis to treat mental health rather than pain conditions and inhaled over other routes of administration.

Rare Occurrence of Extradigital Glomangioma in the Prepatellar Bursa of a 40-Year-Old: A Case Study.

Introduction: A solitary subcutaneous mass can be a common clinical finding for patients symptomatic for knee pain, especially when direct pressure by kneeling on the anterior aspect of the knee causes pain. Case Report: We present a 40-year-old who noticed a small fluid filled mass that has become progressively larger and more painful over the past 7 years. The patient's primary complaint was sharp pain with direct contact. Ultimately, a surgical excision was performed to remove the mass. The histopathological report came back as a glomangioma, a subtype of a glomus tumor. To the best of our knowledge, this is the youngest reported case of a glomangioma of the knee. Conclusion: Glomus tumors found on the digital and subungual regions of patients are a common clinical finding. An extradigital occurrence of a glomangioma, a subtype of a glomus tumor, is rarely found, especially in younger patients. Therefore, a histopathological examination must be done after the removal of any subcutaneous mass.

Administration of Tranexamic Acid Improves Long-Term Outcomes in Total Knee Arthroplasty.

BACKGROUND: Blood transfusion in total knee arthroplasty (TKA) is associated with increased morbidity, including periprosthetic joint infection (PJI). Tranexamic acid (TXA) reduces blood transfusion rates, but there is limited evidence demonstrating improved outcomes in TKA resulting from TXA administration. The objectives of this study are determining whether TXA is associated with decreased rate of PJI, decreased rate of outcomes associated with PJI, and whether there are differences in rates of adverse events. METHODS: A multicenter cohort study comprising 23,421 TKA compared 4423 patients receiving TXA to 18,998 patients not receiving TXA. Primary outcome was PJI within 2 years of TKA. Secondary outcomes included revision surgery, irrigation and debridement, transfusion, and length of stay. Adverse events included readmission, deep vein thrombosis, pulmonary emboli, myocardial infarction, or stroke. Adjusted odds ratios were determined using linear mixed models controlling for age, sex, thromboembolic prophylaxis, Charlson comorbidity index, year of TKA, and surgeon. RESULTS: TXA administration reduced incidence of PJI by approximately 50% (odds ratio [OR], 0.55; P = .03). Additionally, there was decreased incidence of revision surgery at 2 years (OR, 0.66; P = .02). Patients receiving TXA had reductions in transfusion rate (OR, 0.15; P < .0001) and length of stay (P < .0001). There was no difference in the rate of pulmonary emboli (OR, 1.20; P = .39), myocardial infarction (OR, 0.78; P = .55), or stroke (OR, 1.17; P = .77). CONCLUSION: Administration of TXA in TKA resulted in reduced rate of PJI and overall revision surgery. No difference in thromboembolic events were observed. The use of TXA is safe and improves outcomes in TKA. LEVEL OF EVIDENCE: Level III, Observational Cohort Study.

Ovarian Intermediate Trophoblastic Tumors: Genotyping Defines a Distinct Category of Nongestational Tumors of Germ Cell Type.

Trophoblastic neoplasms involving the ovary are uncommon and include gestational tumors, which are either metastatic from the uterus or ectopic and nongestational tumors, which include those of germ cell type/origin and somatic tumors with trophoblastic differentiation; in all these types, most are pure choriocarcinoma. Intermediate trophoblastic tumors, which include placental site trophoblastic tumor (PSTT) and epithelioid trophoblastic tumor (ETT), are rare in the ovary, with most assumed to be gestational; this is the only category formally recognized in 2014 World Health Organization (WHO) classification, likely due to few well-documented nongestational examples. We report the clinicopathologic features of 6 ovarian intermediate trophoblastic tumors, including 3 PSTTs, 2 ETTs, and 1 ETT with choriocarcinomatous differentiation. DNA-based short tandem repeat genotyping identified 4 of these as nongestational (3 PSTTs and 1 ETT), as evidenced by sharing of alleles between tumor and normal tissue at all informative loci. Interestingly, all 3 of the nongestational PSTTs coexisted with mature cystic teratoma. The remaining 2 tumors (1 ETT and 1 ETT with some choriocarcinomatous differentiation) were gestational (likely ectopic due to lack of evidence of a uterine tumor), as evidenced by the presence of both maternal and novel/nonmaternal alleles at informative loci in tumor compared with normal tissue. It is important to recognize a distinct category of primary ovarian nongestational intermediate trophoblastic tumors of germ cell type/origin, including PSTT and ETT, in classification systems to guide clinical management, as gestational and nongestational tumors have different genetic origins and may require different therapy. Genotyping is useful for classification as nongestational versus gestational, particularly as traditional clinicopathologic findings cannot always predict the nature of a trophoblastic tumor.

Tourniquet Use Does Not Affect Functional Outcomes or Pain After Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized Controlled Trial.

BACKGROUND: The use of a tourniquet during total knee arthroplasty (TKA) is controversial. Pain and return to function are believed, by some, to be influenced by the use of a tourniquet. The hypothesis of this study was that use of a tourniquet would delay postoperative functional recovery and increase pain as compared with no tourniquet use. METHODS: Two hundred patients were recruited for this prospective, double-blinded, randomized controlled trial. Patients were randomized to undergo TKA either with a tourniquet (100 patients) or without one (100 patients) and blinded to group allocation. Primary outcome measures were functional assessment testing using the Timed Up & Go (TUG) test and visual analog scale (VAS) pain scores. Secondary outcome measures included the stair-climb test, blood loss, surgical field visualization, and range of motion. Outcome measures were completed preoperatively, in the hospital, and postoperatively at a first and a second follow-up. The minimal detectable change, Student t test, Fisher exact test, and nonasymptotic chi-square analysis with an alpha of p < 0.05 were used to determine significance. RESULTS: The no-tourniquet group had more calculated blood loss (1,148.02 mL compared with 966.64 mL; p < 0.001) and more difficulty with surgical field visualization (p < 0.0001). The tourniquet group had greater knee extension at the first follow-up (-7° compared with -9°; p = 0.044). CONCLUSIONS: Tourniquet use during TKA significantly decreases blood loss and does not adversely affect early postoperative outcomes. Tourniquet use during routine TKA is safe and effective, and concerns about deleterious effects on function and pain may not be justified. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Blinded Ultrasound Examination of the Subscapularis Following Anatomic Shoulder Arthroplasty.

BACKGROUND: The subscapularis tendon is commonly released during shoulder arthroplasty, and its integrity and repair postoperatively have been shown important to help maximize patient function. However, diagnosing subscapular tendon failure can be difficult with magnetic resonance imaging secondary to metal artifact as well as very costly. PURPOSE: The purpose of this study was to assess the utility of ultrasound imaging in evaluating subscapularis integrity at specific time points following shoulder arthroplasty, in a blinded fashion. Secondarily, we report on the correlation between the condition of the subscapularis and quality-of-life outcome measures. STUDY DESIGN: Prospective case series. METHODS: Ultrasounds were completed preoperatively and postoperatively at 1 week as well as at 1, 3, and 6 months. Each was read by a single musculoskeletal radiologist and categorized as "intact," "torn," or "unclear." Clinical outcome was evaluated using the Western Ontario Osteoarthritis Shoulder (WOOS) index at these same time points. RESULTS: The final study group consisted of 35 procedures in 33 patients (19 females and 14 males, mean age 66 ± 9 years). Three patients had postoperative subscapularis failures that were confirmed in the operating room at the time of repair. Of 24 sonographs categorized as "unclear" in the postoperative period, the majority (n = 12, 50%) were taken at 1 week. Compared to preoperative scores, patients had lower WOOS scores at 1, 3, and 6 months postoperatively (P < .001). Correlation analysis did not reveal an association between the ultrasound readings and the WOOS scores postoperatively. CONCLUSION: The utility of ultrasound examination of the subscapularis tendon following shoulder arthroplasty is limited by timing and may be most useful when used by the physician within clinical context. Significant improvement was noted in disease-specific quality-of-life scores regardless of the status of the subscapularis tendon as read on ultrasound.