Does Total Intravenous Anesthesia With Short-acting Spinal Anesthetics in Primary Hip and Knee Arthroplasty Facilitate Early Hospital Discharge?

INTRODUCTION: Our study assessed the effect of total intravenous anesthesia (TIVA) with short-acting spinal anesthesia and aggressive day-of-surgery postoperative day 0 physical therapy (POD#0 PT) on hospital length of stay (LOS) in patients who underwent primary total joint arthroplasty. METHODS: A retrospective chart review compared the hospital LOS of 116 patients who underwent primary total hip arthroplasty and total knee arthroplasty with TIVA and short-acting spinal blockade ("Updated protocol group") with that of the control group of 228 patients who were under standard anesthesia ("Traditional protocol group"). RESULTS: Both total hip arthroplasty and total knee arthroplasty patients in the Updated protocol group had markedly reduced LOS compared with those in the Traditional protocol group (1.5 ± 0.1 days versus 2.4 ± 0.1 days; P < 0.05 and 1.4 ± 0.1 days versus 2.3 ± 0.1 days; P < 0.05). A higher proportion of patients in the Updated protocol group received at least 1 POD#0 PT session compared with those in the Traditional protocol group. CONCLUSION: Total intravenous anesthesia combined with short-acting spinal anesthetics provided the following benefits for patients who underwent primary total joint arthroplasty: more day-of-surgery PT sessions and earlier discharge by nearly 1 full day. LEVEL OF EVIDENCE: III.

Novel therapeutic strategies for degenerative disc disease: Review of cell biology and intervertebral disc cell therapy.

Intervertebral disc degeneration is a disease of the discs connecting adjoining vertebrae in which structural damage leads to loss of disc integrity. Degeneration of the disc can be a normal process of ageing, but can also be precipitated by other factors. Literature has made substantial progress in understanding the biological basis of intervertebral disc, which is reviewed here. Current medical and surgical management strategies have shortcomings that do not lend promise to be effective solutions in the coming years. With advances in understanding the cell biology and characteristics of the intervertebral disc at the molecular and cellular level that have been made, alternative strategies for addressing disc pathology can be discovered. A brief overview of the anatomic, cellular, and molecular structure of the intervertebral disc is provided as well as cellular and molecular pathophysiology surrounding intervertebral disc degeneration. Potential therapeutic strategies involving stem cell, protein, and genetic therapy for intervertebral disc degeneration are further discussed.

Cross-linking of porcine acellular dermal matrices negatively affects induced neovessel formation using platelet-rich plasma in a rat model of hernia repair.

The degree of cross-linking within acellular dermal matrices (ADM) seems to correlate to neovascularization when used in ventral hernia repair (VHR). Platelet-rich plasma (PRP) enhances wound healing through several mechanisms including neovascularization, but research regarding its effect on soft tissue healing in VHR is lacking. We sought to study the effect of cross-linking on PRP-induced neovascularization in a rodent model of bridging VHR. We hypothesized that ADM cross-linking would negatively affect PRP-induced neovessel formation. PRP was extracted and characterized from pooled whole blood. Porcine cross-linked (cADM) and non-cross-linked ADMs (ncADM) were implanted in a rat model of chronic VHR after treatment with saline (control) or PRP. Neovascularization of samples at 2, 4, and 6 weeks was assessed by hematoxylin and eosin and immunohistochemical staining of CD 31. Adhesion severity at necropsy was compared using a previously validated scale. Addition of PRP increased neovascularization in both cADM and ncADM at 2- and 4-week time points but appeared to do so in a dependent fashion, with significantly greater neovascularization in the PRP-treated ncADMs compared to cADMs. Omental adhesions were increased in all PRP-treated groups. Results indicate that, for 2-week measurements when compared with the cADM group without PRP therapy, the mean change in neovascularization due to ncADM was 3.27 (Z = 2.75, p = 0.006), PRP was 17.56 (Z = 14.77, p < 0.001), and the combined effect of ncADM and PRP was 9.41 (Z = 5.6, p < 0.001). The 4-week data indicate that the average neovascularization change due to ncADM was 0.676 (Z = 0.7, p = 0.484), PRP was 7.69 (Z = 7.95, p < 0.001), and combined effect of ncADM and PRP was 5.28 (Z = 3.86, p < 0.001). These findings validate PRP as a clinical adjunct to enhance the native tissue response to implantable biomaterials and suggest that ncADM is more amenable than cADM to induced neovascularization. PRP use could be advantageous in patients undergoing VHR where poor incorporation is anticipated and early-enhanced neovascularization is desired.

Does Accelerated Physical Therapy After Elective Primary Hip and Knee Arthroplasty Facilitate Early Discharge?

Accelerated physical therapy (PT) protocols are a potential mechanism for achieving early mobilization and safe discharge from hospital after elective primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). We compared 2 groups of patients who underwent elective unilateral THA or TKA-those who started PT the same day (Day 0) and those who started PT the next day (Non-Day 0). The difference in mean (SD) hospital length of stay between the Day 0 and Non-Day 0 groups was not statistically significant for THA patients, 2.26 (0.11) days vs 2.50 (0.15) days (P = .270), or TKA patients, 2.28 (0.66) days vs 2.35 (0.75) days (P > .05). A higher proportion of THA patients in the Day 0 group (16%) vs the Non-Day 0 group (6%) achieved discharge goals on postoperative day 1 (P = .04). This effect was not present for TKA patients. Day-of-surgery PT helped THA patients (but not TKA patients) achieve discharge goals on postoperative day 1.

Decreased hernia recurrence using autologous platelet-rich plasma (PRP) with Strattice™ mesh in a rodent ventral hernia model.

BACKGROUND: Recurrence after ventral hernia repair (VHR) remains a multifactorial problem still plaguing surgeons today. Some of the many contributing factors include mechanical strain, poor tissue-mesh integration, and degradation of matrices. The high recurrence rate witnessed with the use of acellular dermal matrices (ADM) for definitive hernia repair has reduced their use largely to bridging repair and breast reconstruction. Modalities that improve classic cellular metrics of successful VHR could theoretically result in improved rates of hernia recurrence; autologous platelet-rich plasma (PRP) may represent one such tool, but has been underinvestigated for this purpose. METHODS: Lewis rats (32) had chronic ventral hernias created surgically and then repaired with Strattice™ mesh alone (control) or mesh + autologous PRP. Samples were harvested at 3 and 6 months postoperatively and compared for gross, histologic, and molecular outcomes of: neovascularization, tissue incorporation, peritoneal adhesions, hernia recurrence, and residual mesh thickness. RESULTS: Compared to control at 3 months postoperatively, PRP-treated rats displayed significantly more neovascularization of implanted mesh and considerable upregulation of both angiogenic genes (vEGF 2.73-fold, vWF 2.21-fold) and myofibroblastic genes (αSMA 9.68-fold, FSP-1 3.61-fold, Col1a1 3.32-fold, Col31a1 3.29-fold). Histologically, they also showed enhanced tissue deposition/ingrowth and diminished chronic immune cell infiltration. Peritoneal adhesions were less severe at both 3 (1.88 vs. 2.94) and 6 months (1.63 vs. 2.75) by Modified Hopkins Adhesion Scoring. PRP-treated rats experienced decreased hernia recurrence at 6 months (0/10 vs. 7/10) and had significantly improved ADM preservation as evidenced by quantification of residual mesh thickness. CONCLUSIONS: PRP is an autologous source of pro-regenerative growth factors and chemokines uniquely suited to soft tissue wound healing. When applied to a model of chronic VHR, it incites enhanced angiogenesis, myofibroblast recruitment and tissue ingrowth, ADM preservation, less severe peritoneal adhesions, and diminished hernia recurrence. We advocate further investigation regarding PRP augmentation of human VHR.

Surgical Technique for Implantation of Articulating Spacers with Stem Extensions for Treatment of Infection Following Total Knee Arthroplasty.

INTRODUCTION: This article describes our technique of adding a custom-made antibiotic-coated stem to an articulating spacer to improve fixation and effectively deliver antibiotics to the medullary canal in the treatment of infection following total knee arthroplasty. STEP 1 OBTAIN ITEMS REQUIRED FOR INTRAOPERATIVE ASSEMBLY: Make sure all required items are ready prior to the start of the operation. STEP 2 REMOVE THE COMPONENTS AND PERFORM THOROUGH DEBRIDEMENT: Remove the components and debride all cement and necrotic, devitalized, and infected tissue. STEP 3 SIZE THE SPACERS: Use the polyethylene insert to size the tibial spacer and the anteroposterior dimension of the explanted femoral component to size the femoral spacer. STEP 4 CONSTRUCT THE STEMS: Divide the rod, coat the rods with antibiotic cement, and connect them to the articulating components. STEP 5 IMPLANT THE SPACERS: Apply the cement only to the metaphysis and undersurface of the tibial spacer and place a large amount of cement on the medial and lateral condyles of the femoral spacer. STEP 6 POSTOPERATIVE PROTOCOL: Patients should walk with partial weight-bearing with a brace locked in extension for three to four weeks. RESULTS: The above technique using the articulating spacers with stem extension was employed in a two-stage revision arthroplasty to treat thirty-three patients with infection at the site of a primary or revision total knee arthroplasty3. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Does high knee flexion cause separation of meniscal repairs?

BACKGROUND: Previous clinical studies comparing nonrestrictive and restrictive protocols after meniscal repair have shown no difference in outcomes; however, some surgeons still limit range of motion out of concern that it will place undue stress on the repair. HYPOTHESIS: Large acute medial meniscal tears will gap during simulated open chain exercises at high flexion angles, and a repaired construct with vertical mattress sutures will not gap. STUDY DESIGN: Controlled laboratory study. METHODS: Tantalum beads were implanted in the medial menisci of 6 fresh-frozen cadaveric knees via an open posteromedial approach. Each knee underwent 10 simulated open chain flexion cycles with loading of the quadriceps and hamstrings. Testing was performed on 3 different states of the meniscus: intact, torn, and repaired. Biplanar radiographs were taken of the loaded knee in 90°, 110°, and 135° of flexion for each state. A 2.5-cm tear was created in the posteromedial meniscus and repaired with inside-out vertical mattress sutures. Displacement of pairs of beads spanning the tear was measured in all planes by use of radiostereometric analysis (RSA) with an accuracy of better than 80 µm. RESULTS: With a longitudinal tear, compression rather than gapping occurred in all 3 regions of the posterior horn of the meniscus (mean ± standard deviation for medial collateral ligament [MCL], -321 ± 320 µm; midposterior, -487 ± 256 µm; root, -318 ± 150 µm) with knee flexion. After repair, meniscal displacement returned part way to intact values in both the MCL (+55 ± 250 µm) and root region (-170 ± 123 µm) but not the midposterior region, where further compression was seen (-661 ± 278 µm). CONCLUSIONS: Acute posteromedial meniscal tears and repairs with vertical mattress sutures do not gap, but rather compress in the transverse plane at higher flexion angles when subjected to physiologic loads consistent with active, open kinetic chain range of motion rehabilitation exercises. The kinematics of the repaired meniscus more closely resemble that of the intact meniscus than that of the torn meniscus in regions adjacent to the MCL and the root but not in the midposterior region, where meniscal repair led to increased compression across the tear plane. CLINICAL RELEVANCE: This study supports the idea that nonrestrictive unresisted open chain range of motion protocols do not place undue stress on meniscal repairs.

Preformed articulating knee spacers in 2-stage total knee revision arthroplasty: minimum 2-year follow-up.

Two-stage revision arthroplasty using articulating spacers for the treatment of infected total knee arthroplasty (TKA) is a successful management technique. Our purpose was to report our results using preformed, commercially available articulating spacers made of gentamicin-impregnated cement. Thirty-three patients with infected primary or revision TKAs were treated with these spacers using a 2-stage revision technique. In most cases, the spacers were modified intraoperatively by adding a stem of reinforced antibiotic-impregnated acrylic cement. Successful eradication was achieved in 30 of 33 cases at a minimum 2-year follow-up interval. Two patients required a second spacer before successful revision TKA. No spacer fractures or dislocations occurred in this series. No adverse soft tissue effects were noted from the use of this type of articulating spacer.

Anti-thrombotic effect of bivalirudin compared with eptifibatide and unfractionated heparin in diabetic patients: an ex vivo human study.

Patients with diabetes who undergo percutaneous coronary intervention (PCI) are at high risk for thrombotic complications following the procedure. We sought to compare the anti-thrombotic effect of bivalirudin to that of eptifibatide plus unfractionated heparin in diabetic patients undergoing elective PCI. Thirty diabetic patients were randomized to receive during PCI either bivalirudin (bivalirudin group, n=15) or eptifibatide plus heparin (eptifibatide group, n=15) at standard dosing regimens. The drugs were continued for 20 minutes (bivalirudin) or 18 hours (eptifibatide) after PCI. Blood thrombogenicity was assessed using the Badimon ex vivo perfusion chamber. Each patient underwent two perfusion studies - at baseline (on aspirin and clopidogrel) and 15-20 minutes following PCI. Perfusion studies were performed at rheologic conditions of low and high shear rates (LSR, HSR). Porcine aortic tunica media served as the thrombogenic substrate. Aortic specimens were stained for total platelet-thrombus and fibrin deposition. Thrombus area was measured using computerized planimetry. There were no differences in clinical characteristics or baseline thrombus area between the two groups. Total platelet-thrombus area was reduced significantly in both groups, but the degree of reduction was lower in the bivalirudin group compared with the eptifibatide group (HSR: 69.5% vs. 89.3% reduction, respectively, P=0.04; LSR: 50.6% vs. 73.2%, P=0.03). Fibrin deposition was reduced in both groups by 47-49%. In conclusion, both bivalirudin and the combination of eptifibatide plus heparin, given to diabetic patients during PCI, achieved marked reductions in total thrombus formation and fibrin deposition. However, glycoprotein IIb/IIIa inhibition by eptifibatide caused a more pronounced reduction in thrombus formation.