Routine pretransfusion testing before primary total hip or knee arthroplasty are an expensive and wasteful routine. Systematic review and meta-analysis.

BACKGROUND: The excessive routine ordering of pretransfusion tests (blood typing, screening, and cross-matching) for surgical cases incurs significant unnecessary costs and places an undue burden on transfusion services. This study aims to systematically review the literature regarding the necessity of routine pretransfusion tests before total hip arthroplasty (THA) or total knee arthroplasty (TKA) and summarize their outcomes. STUDY METHODS: A systematic review and meta-analysis were performed. The study's characteristics, the prevalence of over-ordering pretransfusion tests, transfusion rates, and potential cost savings to the healthcare system were analyzed. RESULTS: The study included 17,667 patients. Pooled results revealed a 96.3% over-ordering pretransfusion test rate (95% CI: 0.92-1.00; p < 0.001) among patients undergoing primary THA or TKA. The pooled prevalence of hospital transfusion rate was 3.6%. Notably, there were statistically significant differences in preoperative hemoglobin (Hb) levels between patients not requiring transfusion (Hb = 13.9 g/dl; 95% CI 12.59-15.20; p < 0.001) and those needing transfusion (Hb = 11.9 g/dl; 95% CI 10.69-13.01; p < 0.001) (p = 0.03). The per-patient total cost savings ranged from 28.63 to 191.27 dollars. DISCUSSION: Our study suggests that routine pre-transfusion testing for all patients undergoing primary THA or TKA may be unnecessary. We propose limiting pretransfusion test orders to patients with preoperative hemoglobin levels below 12 g/dl in unilateral primary TKA or THA. This targeted approach can result in significant cost savings for healthcare systems and transfusion services by reducing the over-ordering of pretransfusion tests in these surgical procedures.

Risk of venous thromboembolism in thromboprophylaxis between aspirin and low molecular weight heparins after total hip arthroplasty or total knee arthroplasty: Systematic review and meta-analysis. / Riesgo de tromboembolismo venoso en la tromboprofilaxis entre aspirina y heparinas de bajo peso molecular tras una artroplastia total de cadera o artroplastia total de rodilla. Revisión sistemática y metaanálisis.

INTRODUCTION: The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA). MATERIALS AND METHODS: Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analyzed. Mortality, risk of bleeding and surgical wound complications was also analyzed. RESULTS: 248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR = 0.93; 95% CI: 0.69-1.26; P = .64), DVT (OR = 0.72; 95% CI: 0.43-1.20; P = .21) or PE (OR = 1.13; 95% CI: 0.86-1.49; P = .38) between both groups. No significant differences were found in mortality (P = .30), bleeding (P = .22), or complications in the surgical wound (P = .85) between both groups. These same findings were found in the sub-analysis of only randomized clinical trials (P>.05). CONCLUSIONS: No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis.

Is hip resection arthroplasty a successful definitive treatment?

Purpose: Hip resection arthroplasty as a definitive treatment is an uncommon indication, although still in use selectively. This study evaluates a cohort of patients who have undergone hip resection arthroplasty surgery indicated as a definitive treatment, in order to assess the rate of re-operation, the rate of infection, and the mortality rates. Methods: We conducted a retrospective, observational, descriptive analysis of a cohort of patients who had undergone a hip resection arthroplasty intended as a definitive treatment, in two University Hospitals from 1994 to 2020. The exclusion criteria were the implantation of a hip cement spacer, or a temporary hip resection arthroplasty in patients undergoing a two-staged surgical approach. We found 26 cases of hip resection arthroplasty. We recorded the indications for a definitive hip resection arthroplasty, the outcomes and complications, and analyzed the success of the hip resection arthroplasty as a definitive surgery using a Kaplan-Meier curve. Results: Seven cases (26.9%) required a re-operation after the hip resection arthroplasty, four cases for persistent hip infection, and in the three remaining a conversion to a total hip arthroplasty was re-considered due to a good medical evolution and non-tolerance to the low functional outcome. The mortality rate was 61.5% (27 days-20 years), with a 19.2% mortality rate in the first 5 years. All the cases that required another surgery after the hip resection arthroplasty were re-operated within the first 18 months. Conclusion: Unfortunately, hip resection arthroplasty continues to show elevated re-operation rate and early mortality rate, as well as low functional outcomes. Two-staged hip revision arthroplasty is the surgical treatment of choice in patients suffering from a periprosthetic joint infection, however we believe that hip resection arthroplasty should be considered in fragile patients, who have endured multiple revision surgeries, or their comorbidities make them unfit from further surgeries.

"In vitro" evaluation of bacterial biofilm formation on different cerclage systems.

Cerclage wiring may be used for fracture fixation or osteotomy stabilization in revision arthroplasty. There is a lack of evidence regarding the potential risk of bacterial colonization for the different types of cerclages. The objective of our research is to study the adhesion and biofilm formation of S. epidermidis, S. aureus, and P. aeruginosa on two different cerclage cable models, comparing a polymer cable and a stainless steel metal cable. A two-cm cerclage piece of each material was submerged in 2 mL of tryptic soy broth (TSB) inoculated with 10 µL of a 0.5 McFarland bacterial culture, and incubated at 37°C during 2 h for adhesion and 48 h for biofilm formation. The cerclages were washed with 1xPBS and sonicated in a new culture medium. Aliquots of several dilutions of each sonicated culture were spread in TSB agar and incubated at 37°C for 24 h. The number of colonies was counted. The colony-forming units per ml (CFU/mL) and the percentage of reduction were calculated. Experiments were triplicated. For P. aeruginosa, a statistically significant reduction in biofilm formation was found on the polymer cerclage cable, compared to the metal cerclage cable. Reductions of 59% and 88%, after 2 h and 48 h, respectively, were observed. For S. epidermis and S. aureus, there was a trend towards lower bacterial adhesion and biofilm formation for the polymer cerclage cable. In summary, these results demonstrate that the braided polymer cerclage cable may be less prone to bacterial adherence and biofilm formation compared to the braided metal cerclage cable.

A 3D-Printed Model of a Titanium Custom-Made Talus for the Treatment of a Chronic Infection of the Ankle.

Osteoarticular infections are challenging and difficult to treat. The use of innovative technologies like 3D printing already employed in other types of surgeries and pathologies can suppose a great asset to tackle the problem and improve functional results. We present a case of an osteoarticular infection of an ankle treated with a custom-made titanium talus made with 3D metal printing technology: A 63-year-old patient, with chronic infection of the ankle. A 2-staged surgery was performed, with a hand-made cement spacer used during the first stage and the implantation of a custom-made titanium talus with an arthrodesis nail in the second stage. After a 2-year follow-up, a good clinical evolution was achieved, with no signs of reactivation of the infection, no pain, good skin condition and optimal functionality: functional gait pattern without pain and any external aids.

Local infiltration analgesia does not have benefits in fast-track hip arthroplasty programmes: a double-blind, randomised, placebo-controlled, clinical trial.

BACKGROUND: Multimodal analgesia regimes including local infiltration analgesia (LIA) have been successfully applied in fast-track hip arthroplasty programmes. LIA's contribution to the analgesic effect in hip arthroplasty has been questioned. Our study sought to determine the analgesic efficacy of LIA in THA surgery in a fast-track programme. METHODS: Patients diagnosed with hip osteoarthritis scheduled for arthroplasty were randomised to receive LIA (120 ml ropivacaine 0.2% plus epinephrine 0.5 µ/ml) or saline as a part of a multimodal analgesia regime. The surgical team, the nursing staff, and patients were all blinded regarding patient allocation throughout the study. The primary outcome was pain assessed as a continuous variable using the visual analogue scale (VAS) at 4, 8, 24 and 48 hours postoperatively. Secondary outcomes included the amount of analgesic rescue consumption, complications and length of hospital stay. RESULTS: A total of 63 patients were interviewed and agreed to participate in the study. No statistically significant differences were found between groups for pain measurements at 4, 8, 12, 24 and 48 hours after surgery. There were also no differences in rescue medication consumption, complications, or length of stay. CONCLUSIONS: Our results suggest LIA (ropivacaine plus epinephrine, single shot) has no effect in pain management and has not shown benefits for early ambulation in primary THA surgery. Further research is needed to establish the optimal multimodal analgesia regime for THA fast-track programmes. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov (NCT03513276).

Chronic Anterior Pelvic Instability.

INTRODUCTION: Chronic anterior pelvic instability means pathologic movement of the symphysis pubis with axial load. It is not a common pathology and its diagnosis is often delayed and difficult increasing the disability of affected patients. The pain is localized in the suprapubic area or groins, increasing with physical activity, direct palpation or compression. Main known causes are pregnancy, delivery, trauma, fractures, intense physical activity, infection, or previous surgeries. Treatment algorithms have not been standardized. Initially, it is managed with an orthosis, physical activity modification, medication, and rehabilitation. Surgical treatment with symphyseal arthrodesis is the last option. The literature on symphyseal plating for chronic instability found is sparse. CASE REPORT: We report the case of a 33-year-old female presenting lower abdominal pain after her third delivery. Several months after, magnetic resonance imaging and scintigraphy suggested chronic symphysitis. Single leg stance pelvic X-rays indicated chronic anterior pelvic instability. Pain-relievers, physical rehabilitation, and local corticosteroid injection were noneffective; surgery was indicated, performing a double plate symphyseal arthrodesis with iliac bone graft. CONCLUSION: Pelvic instability should be ruled out when persistent abdominal or lower back pain are present. Thorough physical examination and specific provocative maneuvers need to be assessed. In our presented case, symphyseal arthrodesis was performed without complications. After a two-year follow-up, the patient has recovered her previous functional status and bone scintigraphy is negative. Radiologic controls rule out loosening or material breaking as a complication. We hope this case report may give a clue in surgical options management.

Hip fractures in Spain: are we on the right track? Statistically significant differences in hip fracture management between Autonomous Communities in Spain.

Although medicine is currently protocol-based, there are still differences in the management of the hip fracture in Spain, especially regarding surgical delay, type of anesthesia, early mobilization, and discharge destinations. This data will be of great value to assist stakeholders in formulating health policies. PURPOSE: Analysis of demographic, clinical, surgical, and functional data of the Spanish National Hip Fracture National Registry (RNFC), during admission and at 1-month follow-up, by Autonomous Communities (ACs). METHODS: Cross-sectional analysis in the framework of a RNFC cohort, from January 2017 to May 2018, including 15 ACs from Spain, with 1 month of follow-up. Sociodemographic, clinical, surgical, and outcome variables were analyzed. RESULTS: In total, 13,839 patients were analyzed. There were significant differences (p <0.001) in median surgical delay and percentage of patients operated in less than 48 h. Mean surgical delay was 70.75 h, with a 12-h difference between the Communities of Madrid (71.22) and Catalonia (59.65). Only 43% of patients had less than 48-h delay. Overall, most patients received regional anesthesia (91.9%); however, there was a significant difference between ACs (p = 0.0001). There were also differences in inpatient stay, early mobilization, discharge destination, and mortality (p <0.001). Mortality 30 days after surgery was 7.8%, and highest in the Basque Country (12.5%). CONCLUSIONS: The registry showed homogeneity among ACs regarding sociodemographic variables, fracture type, surgical treatment, ASA risk, and co-management with a geriatrician or an integrated internist. There were significant differences in hip fracture management between ACs in Spain, especially regarding surgical delay, type of anesthesia, early mobilization, and discharge destinations.

Higher accuracy of genotypic identification compared to phenotyping in the diagnosis of coagulase-negative staphylococcus infection in orthopedic surgery.

PURPOSE: To determine whether Repetitive Extragenic Palindromic PCR (rep-PCR) genotyping can improve the diagnosis of coagulase-negative staphylococcal (CoNS) orthopaedic infections in comparison to phenotyping. METHODS: Prospective study comparing the results of phenotypic/genotypic (rep-PCR) testing in patients with suspected CoNS infection. Each strain was analysed using both methods. Strains identified as identical in ≥2 samples were considered as pathogenic. RESULTS: 255 CoNS strains from 52 surgical episodes were included. Infection was diagnosed by phenotyping in 38(73%) cases and by genotyping in 40(77%). The Kappa index was 0.59. Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) for phenotyping (vs. rep-PCR) were: 88%, 75%, 92%, and 64%. 5/14(36%) of cases not considered as true infections by phenotyping were diagnosed as infections with genotyping. In a subgroup of 203 strains from 41 surgical procedures with orthopaedic implants, the kappa index was 0.68. Sensitivity, Specificity, PPV, and NPV for phenotyping were: 93%, 73%, 90% and 80%. Again, 2/10 episodes in which CoNS were considered non-infective by phenotyping were diagnosed as infected by genotyping. CONCLUSIONS: Rep-PCR genotyping can identify identical CoNS strains that differ in their phenotype and should be used as a complementary technique. One-third of infected cases may be misdiagnosed without genotypic analysis.

Relationship between skin and urine colonization and surgical site infection in the proximal femur fracture: a prospective study.

PURPOSE: Antibiotic prophylaxis is routinely used in the surgical management of proximal femur fractures. The role of bacterial colonization of the skin and urine in the development of deep surgical site infections (SSI) is yet to be elucidated. This study aimed to evaluate the role of previous skin and urine colonization in the development of deep SSI after a proximal femoral fracture surgery. METHODS: We conducted a prospective observational study in 326 patients > 64 years old, who were scheduled to surgery. Cultures from skin samples of the surgical site and from urine were performed prior to the procedure, and cefazoline was administered as prophylaxis. RESULTS: Skin microbiota was isolated in 233 (71.5%) cases; 8 (2.5%) samples were positive for other bacteria, and 85 (26%) were negative. Of 236 urine samples, 168 were negative or contaminated (71.2%), and 68 (28.8%) were positive, being 58/236 for Enterobacterales (24.6%). Acute deep SSI were diagnosed in nine out of 326 patients (2.7%), and two (22%) were infected by Gram-negative bacilli. Of the 9 cases, normal skin microbiota was isolated in 7 (78%), and the remaining two were negative. Seven cases had negative or contaminated urine cultures, and the one with E. coli did not correlate with SSI bacteria. CONCLUSION: In our elderly hip fracture population, most patients harbored normal skin microbiota, and Enterobacterales urine cultures were positive in one-quarter of cases. There was no relationship between skin colonization, urine culture, and deep SSI. We therefore do not believe that our patients would benefit from modifying the current antibiotic prophylaxis.

Newcastle approach for the treatment of supra-intercondylar fractures in children.

PURPOSE: The aim of this study is to evaluate the functional results of open reduction using the Newcastle approach and internal fixation for complex intra-articular distal humeral fractures in children through the report of cases. MATERIAL AND METHODS: A retrospective case series of patients who underwent open reduction and internal fixation surgery because of a complex intra-articular distal humeral fracture using the Newcastle approach were reviewed. Minimum follow-up was 2 years. Demographic, clinical, and radiological data were analyzed. Also, Mayo Elbow Performance Score and four-point Likert scale were evaluated. RESULTS: 2 children were included in the final analysis. In both fractures, the approach was sufficient for accurate reduction and the functional outcome on both elbows was satisfactory. The Mayo elbow score was 95 points (excellent results) and the five-point Likert scale, both patients were very satisfied with the outcomes. In the radiographic study, no necrosis or secondary deformities were observed. CONCLUSIONS: Our study provides evidence that the Newcastle approach is an alternative to perform open reduction in those children supra-intercondylar fractures that cannot be reduced using a close reduction. To our knowledge, there is not previous paper that has reported the used of this approach in the treatment in this kind of fractures.

Subcutaneous Radiographic Measurement: A Marker to Evaluate Surgical Site Infection Risk in Elderly Hip Fracture Patients.

Objectives: Obesity is a documented comorbidity that is prevalent in the elderly population and a known predictor for surgical site infection (SSI). Body mass index is a convenient method to classify obesity, but it fails to account for fat distribution. The objective of our study was to evaluate the association between surgical site infection and a subcutaneous radiographic measurement (SRM) in elderly hip fracture patients. Materials and Methods: A retrospective case-control study was conducted to compare SRMs at the hip in patients diagnosed with surgical site infection after hip fracture surgery with patients that were not diagnosed with surgical site infection. Each case was matched to two controls. An SRM was defined as the distance from the tip of the greater trochanter to the skin following a perpendicular line to the femoral diaphysis in anteroposterior hip radiographs. Clinical diagnosis of acute surgical site infection was based on Tsukayama criteria. Results: Patients with an SRM greater than 6.27cm had a 7-fold increase in the odds of surgical site infection (OR=7.42, 95% Confidence Interval (CI)=3.01-18.28, p<0.001) compared to those with smaller measurements. The odds ratio (OR) for infection of patients with an ASA score of 3 was 15.82(95% CI=5.11-48.9, p-value<0.001) A statistically significant difference between cases and controls was also found when SRM at the hip was analyzed as a continuous variable. Patients with an infection had a 2.24cm (95% CI=1.59 - 2.90; p<0.001) greater mean SRM. Conclusion: Results of our study suggest an association between the SRM at the hip and the risk of SSI in elderly patients with surgically treated hip fractures. SRM may be a helpful tool for evaluating the risk of SSI in elderly hip fracture patients.

Cerclage wiring and intramedullary nailing, a helpful and safe option specially in proximal fractures. A multicentric study.

PURPOSE: Antegrade intramedullary nailing is an alternative for humeral shaft fracture treatment. This surgical technique can be especially demanding in some fracture patterns, leading to problems like malunion and non-union. The purpose of our study is to demonstrate that the use of a nail with cerclage wires could be a safe procedure that facilitate reduction, specially in fractures with abduction of the proximal fragment. MATERIALS AND METHODS: Fifty-six patients were included, from January 2007 to March 2016. In this cohort forty-two patients were females and eighteen males; mean age was sixty-seven (32-89). The fractures were reduced using a cerclage wire through a small lateral or anterior approach, then, antegrade intramedullary nailing was performed. Fracture healing was established by clinical and radiographic evaluation. Shoulder function was assessed using the Constant Score. RESULTS: Fifty-three patients healed (94.6%) adequately. Two patients developed a non-union (3.5%). One patient developed an infection (1.8%). Transient radial nerve palsy was observed in two patients (3.5%). The mean Constant Score at the end of the study was 70 points (range from 34 to 98 points). CONCLUSIONS: Surgical treatment of humeral shaft fractures with cerclage wire and intramedullary nailing is a safe technique to improve fracture reduction. The use of cerclage wires leads to better bone contact while minimizing malunions. The rate of non-union in our study is lower than the rate reported in the literature for humeral shaft fractures treated by intramedullary nailing alone.

Burch-Schneider antiprotrusio cage for acetabular revision: a 5- to 13-year follow-up study.

Ninety-six acetabular revisions using a Burch-Schneider antiprotrusio cage (BSAC) in 91 patients (53 women and 38 men), were evaluated retrospectively with a mean follow-up of 8.1 years (range 5-13 years). The mean age at surgery was 67.3 years (range 35-85 years). There were 3 re-revisions: 1 because of aseptical loosening and 2 because of deep infection. The Kaplan-Meier survivorship rate, with aseptic component loosening as the criterion of failure, was 92.4% (95% confidence interval, 85.1%-99.8%) at 13 years. Clinical evaluation of the surviving patients showed an increase in mean Merle d?Aubigné-Postel hip score of 8.8 points before surgery, to 15.1 points at the time of the last follow-up. Radiographic evaluation determined that 3 cages were considered definitely loose. The rotation centre of the hip was lowered an average of 4.3 mm and lateralised an average of 1.3 mm in this series. In the most severe cases (Paprosky 2C, 3A, and 3B), the hip centre was lowered 7.8 mm and lateralised 0.8 mm. The Burch-Schneider antiprotrusio cage long-term survival rate compares favourably with that for other devices. Acetabular reconstruction allows anatomic positioning of the cups and promotes good final results.