Enhanced Recovery after Total Joint Arthroplasty (TJA): A Contemporary Systematic Review of Clinical Outcomes and Usage of Key Elements.

BACKGROUND: Enhanced recovery after surgery (ERAS) is a pathway designed to improve the care of surgical patients and achieve early recovery. The clinical outcomes and usage of key elements of ERAS pathways in total joint arthroplasty (TJA) need further reanalysis. This article aims to provide an overview of the latest clinical outcomes and current usage of key elements of ERAS pathways in TJA. METHODS: We undertook a systematic review of the PubMed, OVID, and EMBASE databases in February 2022. Studies investigating the clinical outcomes and usage of key elements of ERAS in TJA were included. The components of successful ERAS programs and their usage were further determined and discussed. RESULTS: Twenty-four studies involving 216,708 patients assessed ERAS pathways for TJA. A total of 95.8% (23/24) of studies reported a reduced length of stay (LOS), followed by reduce overall opioid consumption or pain (87.5% [7/8]), save costs (85.7% [6/7]), improvements in patient-reported outcomes or functional recovery (60% [6/10]), and reduced incidence of complications (50% [5/10]). In addition, preoperative patient education (79.2% [19/24]), anesthetic protocol (54.2% [13/24]), use of local anesthetics for infiltration analgesia or nerve blocks (79.2% [19/24]), perioperative oral analgesia (66.7% [16/24]), perioperative surgical factors including reduced use of tourniquets and drains (41.7% [10/24]), use of tranexamic acid (41.7% [10/24]) and early mobilization (100% [24/24]) were contemporary comparatively "active" components of ERAS. CONCLUSIONS: ERAS for TJA has favorable clinical outcomes in terms of reducing LOS and overall pain, saving costs, accelerating functional recovery, and reducing complications, although the evidence is still low in quality. In the current clinical scenario, only some "active" components of the ERAS program are widely used.

Key Elements of Enhanced Recovery after Total Joint Arthroplasty: A Reanalysis of the Enhanced Recovery after Surgery Guidelines.

Recent guidelines have produced a consensus statement for perioperative care in hip and knee replacement. However, there is still a need for reanalysis of the evidence and recommendations. Therefore, we retrieved and reanalyzed the evidence of each recommended components of enhanced recovery after surgery (ERAS) based on the guidelines of total joint arthroplasty. For each one, we included for the highest levels of evidence and those systematic reviews and meta-analyses were preferred. The full texts were analyzed and the evidence of all components were summarized. We found that most of the recommended components of ERAS are supported by evidence, however, the implementation details of each recommended components need to be further optimized. Therefore, implementation of a full ERAS program may maximize the benefits of our clinical practice but this combined effect still needs to be further determined.

The effects of Connexin-43 on osteoblasts cells proliferation and osteogenic differentiation / 中华骨科杂志

Objective:To investigate the effects of Connexin-43 (Cx43) on osteoblasts proliferation and osteogenic differentiation and its regulatory mechanism.Methods:Osteoblasts were isolated and cultured in vitro. The osteogenic activity of osteoblasts was detected by alizarin red staining and alkaline phosphatase (ALP) staining after dexamethasone treatment. The expression of Cx43, Runt-related transcription factor 2 (Runx2), ALP, collagen I type (COL-I) and proliferation-related proteins PCNA and CDK4 in osteoblasts were detected by Western-blot. The expressions of osteoblast proteins were detected by immunofluorescence staining. The proliferation of osteoblasts was detected by CCK8 assay. The lentivirus-mediated Cx43 gene overexpression plasmid (Lv-Cx43) was constructed and transfected into osteoblasts. The osteogenic activity and proliferation ability of osteoblasts were further detected by the above methods. Cx43 in osteoblasts was overexpressed by pretreating PD98059. The osteogenic activity and proliferation of Cx43 in overexpressed osteoblasts was detected by CCK8 and alizarin red staining.Results:The isolated osteoblasts have osteogenic differentiation ability. Compared with the control group, 1×10 -6 mol/L dexamethasone treatment could reduce the formation of calcium nodules in osteoblasts. With the increase of dexamethasone treatment duration, the protein expression of Cx43, Runx2, ALP and COL-I in osteoblasts decreased gradually, while the expression of PCNA, CDK4 and p-ERK1/2 decreased. The OD values of normal osteoblasts at 0, 1, 2, 3 and 4 d were 0.316±0.043, 0.891±0.623, 1.683±0.154, 2.315±0.721 and 2.891±0.323, respectively. However, The OD values of osteoblasts treated with dexamethasone were 0.376±0.021, 0.657±0.121, 1.124±0.285, 1.521±0.272, 1.987±0.584, respectively. OD values of dexamethasone treated osteoblasts were lower than those of normal group at 2, 3 and 4 days ( P<0.05). The relative expression levels of Cx43 mRNA in control group, Lv-NC group and Lv-Cx43 group were 0.541±0.086, 0.598±0.018 and 1.000±0.082, respectively. The mRNA expression level of Cx43 in Lv-Cx43 group was higher than that in control group and Lv-NC group ( P<0.05). The ratio of Cx43 protein band to the gray value of GAPDH band in control group, Lv-NC group and Lv-Cx43 group were 0.816±0.737, 0.738±0.643 and 1.145±1.101, respectively. The expression level of Lv-Cx43 was higher than that in control group and Lv-NC group ( P<0.05). The expressions of Runx2, ALP, COL-I mRNA and related marker proteins in Lv-Cx43 group were higher than those in control group and Lv-NC group ( P<0.05). The number of calcium nodules in the Lv-Cx43 group was significantly higher than that in the control group and Lv-NC group. The OD value of osteoblasts and the number of calcium nodules in Lv-Cx43+PD98059 group were significantly lower than those in Lv-Cx43 group ( P<0.05). Conclusion:The proliferation and differentiation ability of osteoblasts is significantly decreased after the treatment of dexamethasone with decreased expression of Cx43. Overexpression of Cx43 can promote the proliferation and osteogenic differentiation of osteoblasts, which may be regulated through the ERK1/2 pathway.

Tranexamic acid attenuates early post-operative systemic inflammatory response and nutritional loss and avoids reduction of fibrinogen in total hip arthroplasty within an enhanced recovery after surgery pathway.

PURPOSE: Total hip arthroplasty (THA) is an intervention with significant inflammatory response. The impact of additional doses of tranexamic acid (TXA) on inflammatory response, trauma and nutrition parameters, and coagulation and fibrinolysis changes has rarely been reported. METHODS: A prospective double-blind randomized trial was performed on elective primary THA. Ninety-nine adult patients were recruited consecutively from 2019 to 2020. They were randomized to receive single-dose of TXA before incision, another dose of TXA at three hours post-operatively, or another two doses of TXA at three and six hours  post-operatively. The primary outcomes included changes in white blood cell (WBC) counts, creatine kinase (CK), haemoglobin(Hb), and albumin(Alb); the secondary outcomes included coagulation and fibrinolysis parameters. RESULTS: Compared with single-dose TXA, patients received three dose TXA had significantly reduced WBC counts and fibrinogen/fibrin degradation product (FDP) levels, increased albumin and fibrinogen levels, and prolonged PT on post-operative day (POD) three. Though patients received three dose TXA had a tendency that increased Hb, decreased CK, reduced D-D, and prolonged APTT on POD3, it is not statistically significant. And the other measured outcomes on POD1 and POD2W shared a similar statistical result, except PT. The PT is significantly prolonged on POD2W in three dose group compared with single dose. CONCLUSION: Three-dose TXA contribute to attenuate early post-operative systemic inflammatory response and nutritional loss, increase fibrinogen, reduce FDP levels, and prolong PT in THA patients within an ERAS pathway, which may associate with reduced early post-operative haemorrhagic tendency, thrombosis risks, and hypercoagulability.

Survivorship and clinical outcomes of 'cup-cage' reconstruction in revision of hip arthroplasty for chronic pelvic discontinuity: A systematic review.

BACKGROUND: This study was conducted to assess the survivorship and clinical outcomes of cup-cage reconstruction technique in the revision of THA. METHODS: PubMed, OVID, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) up to February 2020 were searched. Studies that reported the clinical and radiological follow-up were identified. RESULTS: A total of 151 hips (145 patients) in six studies were included. The all-cause revision-free survivorship of cup-cage implant at the end of follow-up was 90.1% (136/151), with a mean follow-up of 64.4 months(range 12-135). The overall complication rate was 23.8% (36 of 151 hips), of which component problem, dislocation, infection and sciatic nerve palsy/injury were relatively common. All included studies reported improved clinical outcomes at the end of follow-up. CONCLUSION: Results suggested that revision of THA with a cup-cage has a favourable implant survivorship and clinical outcomes for the treatment of pelvic discontinuity, despite the high complications occurrence rates.

Study on the expression of connexin-43 in steroid-induced osteonecrosis of femoral head and osteoblasts in rats and its regulation mechanism / 中华骨科杂志

Objective:To investigate the expression of connexin-43 (Cx43) in steroid-induced osteonecrosis of femoral head and osteoblasts in rats and its regulation mechanism.Methods:The model of steroid-induced osteonecrosis of femoral head (SIONFH) of rat was established. Micro-CT and HE staining were used to observe the degree of bone trabecular destruction and the incidence of empty lacunae. The expression levels of Cx43 and PI3K/Akt signaling pathway related molecules and osteoblast-related proteins in model group and control group were detected by RT-PCT and Western blot. The osteoblast (OB) of rats was further isolated and cultured in vitro. Under treatment of dexamethasone (Dex), Cx43 expression in OB cells was detected by Western blot and immunofluorescence. Western blot was used to detect the effect of glucocorticoid (GC) on the expression of related molecules of PI3K/Akt/β-catenin signaling pathway. Akt activator (SC79) and PI3K inhibitor (LY294002) were used to study the molecular mechanism of Dex regulation on Cx43 expression in OB cells. The regulatory relationship between β-catenin and Cx43 was investigated by immunoprecipitation and small interfere RNA (siRNA) technology.Results:The model of SIONFH in rats was successfully established, which proved that Cx43 expression level in the SIONFH model group was significantly lower than that in the control group, and the expression level of Cx43 was positively correlated with the expression of PI3K/Akt signaling pathway related molecules and osteoblast-related proteins Runx2, ALP and Collagen I Type (COL). In addition, in vitro culture of isolated rat OB cells, the expression of Cx43, p-PI3K, P-Akt and β-catenin in OB cells decreased gradually as the Dex action time went on. Moreover, SC79 pretreatment could significantly reverse the inhibitory effect of GCs on Cx43 expression, while LY294002 could significantly enhance the inhibitory effect of GCs on Cx43. In addition, the immunoprecipitation results showed that β-catenin expression was closely related to Cx43 expression, and further studies showed that β-catenin-siRNA could significantly down-regulate the expression of Cx43.Conclusion:Under the action of GC, the expression level of Cx43 in bone tissue and OB cells decreased significantly, and the possible mechanism was that GCs inhibited the expression of Cx43 by inhibiting the PI3K/Akt/β-catenin signaling pathway, which laid a new theoretical foundation for the further study of the role of Cx43 in the pathogenesis of steroid-induced femoral head necrosis.

Research progress on current status of head-preserving treatment for osteonecrosis of the femoral head and its prognostic factors / 中华骨科杂志

Osteonecrosis of the femoral head (ONFH) is caused by the blockage of the blood supply of the femoral head due to by a variety of reasons, resulting in the death of the bone in the femoral head, which is characterized by osteonecrosis occurdead bone resorption-new bone formation. And total hip arthroplasty (THA) is the final choice for the vast majority of these patients. Though treating hard, it is necessary to choose an appropriate head-preserving treatment in the early stage to delay the time of THA.Methods to treat femoral head necrosis varies, however, it is still hard to have a uniform standard until now. Thus, this paper discusses the epidemiological characteristics, related risk factors, pathology, stage, current head-preserving methods and prognostic factors of femoral head necrosis, so as to further enhance clinicians' understanding of osteonecrosis of the femoral head and provide reference to choose more appropriate head-preserving methods for those patients. As demonstrated in literatures, in China, the incidence of non-traumatic ONFH in males is significantly higher than that in females, and it is more common in northern residents and urban residents. In addition, glucocorticoid intake, hyperlipidemia, heavy smoking and alcohol abuse tend to increase the risk of ONFH; Histologically, osteonecrosis and repair of the femoral head occurred after blood supply was blocked; In terms of pathological staging, Ficat staging is the most commonly used and most directly classification method; core decompression, non-vascularized bone grafting, vascularized bone grafting and osteotomy are still the mainstream surgical methods at present. Patient's age, etiology, stage, etc are important factors affecting the prognosis of ONFH. Therefore, surgeons can choose the most appropriate treatment for the patients according to their specific conditions and prognostic factors.

Mid- to long-term results of modified non-vascularized allogeneic fibula grafting combined with core decompression and bone grafting for early femoral head necrosis.

PURPOSE: The aim of this study was to determine mid-and-long term follow-up results of patients with early femoral head osteonecrosis who were treated by modified free vascularized fibular grafting combined with core decompression and bone grafting. METHODS: Forty-four patients at early ONFH were included in this study. Visual analog scale (VAS) pain scores, range of hip motion (ROM), and Harris hip score (HHS) were recorded to assess the clinical outcome; Western Ontario McMaster Osteoarthritis index (WOMAC) scores and Short Form 36 health survey (SF-36) were conducted to measure the living quality; X-ray film or magnetic resonance imaging (MRI) was used to evaluate radiographic progression; survivorship was defined as patients did not undergo the total hip arthroplasty (THA) or fusion at the last follow-up. Median follow-up was 7.4 years (6-8.2 years). RESULTS: The mean VAS score, ROM, and HHS were significantly improved at the final follow-up compared with preoperative values (p < 0.001). Health assessment including WOMAC scores and SF-36 were also better than those preoperatively (p < 0.001). Seven patients progressed to Ficat III and the four patients progressed to Ficat IV with osteoarthritis. Eight patients who cannot tolerate the pain and had poor living quality underwent THA. CONCLUSION: Modified non-vascularized allogeneic fibula Grafting combined with core decompression and bone grafting could improve the clinical outcomes and enhance the quality of life for patients with early ONFH.

Evaluation and management of chronic pelvic discontinuity in revision total hip arthroplasty / 中华骨科杂志

Revision total hip arthroplasty is becoming more common due to an increasing number of primary total hip arthroplasty procedures being performed annually. Chronic pelvic discontinuity is an important and difficult complication after primary total hip arthroplasty. It is estimated that chronic pelvic discontinuity account for 1%-5% of all acetabular revisions. Pelvic discontinuity occurs mostly in female patients or patients with a history of prior pelvic radiation or rheumatoid arthritis. There are three following crucial factors in regards to achieving satisfied outcomes in treating pelvic discontinuity, the amount of bone stock remaining, biologic in-growth potential and the healing potential of the discontinuity. Treatment approaches include cage reconstruction with bulk acetabular allograft, custom triflange acetabular component, a cup-cage construct, jumbo acetabular cup with porous metal augments, and acetabular distraction with a porous tantalum shell with or without modular porous augments. The present course reported the classification, evaluation, reconstruction options and outcomes of chronic pelvic discontinuity.

The treatment of periprosthetic femoral fractures after total hip arthroplasty / 中华骨科杂志

Periprosthetic femoral fracture (PFF) is one of severe complications after total hip arthroplasty (THA). As the number of patients receiving THA increased recently, the incidence of PFFs also increased dramatically. There are a number of risk factors for PFFs, such as age, sex, falling and prosthesis loosening. The Vancouver classification system is the most commonly used classification method for PFFs. According to the fracture location, PFFs can be divided into type A intertrochanteric fracture, type B fracture around the stem and type C fracture beyond the stem. The Vancouver type B PFF is further subdivided into type B1 with a well-fixed prosthesis, type B2 with a loose prosthesis but with adequate bone stock, and type B3 with a loose prosthesis and poor proximal bone stock simultaneously. Currently, there are some controversies in treating PFFs, mainly including whether the stem is fixed or not, whether the prosthesis needs to be revised, the selection of the stem, the reconstruction of bone defects, and the methods of fracture fixation. We searched literatures related to PFFs after THA. The incidence, risk factors, classification methods, treatment principles and strategies of PFFs were summarized in the present study. Based on our long-term clinical experience, we evaluated the advantages and disadvantages of each treatment method and provided considerations for the clinical research and selection in treating PFFs.

The treatment of periprosthetic femoral fractures after total hip arthroplasty / 中华骨科杂志

Periprosthetic femoral fracture (PFF) is one of severe complications after total hip arthroplasty (THA). As the number of patients receiving THA increased recently, the incidence of PFFs also increased dramatically. There are a number of risk factors for PFFs, such as age, sex, falling and prosthesis loosening. The Vancouver classification system is the most commonly used classification method for PFFs. According to the fracture location, PFFs can be divided into type A intertrochanteric fracture, type B fracture around the stem and type C fracture beyond the stem. The Vancouver type B PFF is further subdivided into type B1 with a well?fixed prosthesis, type B2 with a loose prosthesis but with adequate bone stock, and type B3 with a loose prosthesis and poor proximal bone stock simultaneously. Currently, there are some controversies in treating PFFs, mainly including whether the stem is fixed or not, whether the prosthesis needs to be revised, the selection of the stem, the reconstruction of bone defects, and the methods of fracture fixation. We searched literatures related to PFFs after THA. The incidence, risk factors, classification meth?ods, treatment principles and strategies of PFFs were summarized in the present study. Based on our long?term clinical experience, we evaluated the advantages and disadvantages of each treatment method and provided considerations for the clinical research and selection in treating PFFs.

Efficiency of Cell Therapy to GC-Induced ONFH: BMSCs with Dkk-1 Interference Is Not Superior to Unmodified BMSCs.

Glucocorticoid-induced osteonecrosis of the femoral head (ONFH) is a hip disorder, and it threatens patients who require megadose of steroid therapies. Nowadays, no valid therapies can reverse the development of GC-induced ONFH once it occurs. Stem cell therapy to GC-induced ONFH would be a promising choice. Although the pathogenesis of GC-induced ONFH is not yet fully clear, Dickkopf-1 (Dkk-1) upregulated by excessive GC use, which hinders the canonical Wnt pathway, could be an explanation. Thus, the aim of the present work lies in investigating the efficiency of the allograft bone marrow stem cells (BMSCs) with Dkk-1 interference in preventing the progression of the GC-induced ONFH. Lentivirus-meditated Dkk-1 RNAi was introduced into BMSCs which was exposed to dexamethasone (10-6 mol/L) in vitro. This interference blocked Dkk-1 overexpression by GC and afterwards prompted the transduction of Wnt/ß-catenin in which the Runx2 and PPARγ were upregulated and downregulated, respectively. Thus, the osteogenesis was promoted while adipogenesis was inhibited. In vivo, GC-induced ONFH rats were treated by allotransplantation of BMSCs with Dkk-1 interference, and the progression of the disease was prevented. However, the effects were not significantly superior to treatment with nongenetically modified or normal BMSCs.

Biomechanical research on effects of joint line height on stress of medial and lateral compartment after unicompartmental knee arthroplasty / 中华骨科杂志

Objective To investigate biomechanical effects of different joint line height on unicompartmental knee arthroplasty (UKA) and to provide biomechanical evidence for surgical decision during UKA using finite element analysis (FEA).Methods On the basis of knee joint CT data from a healthy volunteer (male,30 years old,165 cm and 60 kg) and UKA prosthesis 3D scanned data,the 3D models of normal knee and UKA were constructed.Subject-specific finite element models with inhomogeneous material property assignment were constructed for normal knee and UKA with 3 different height of joint line (-3 mm,0 mm and +3 mm).Starting from the tibial articular surface,5 sections were extracted with 2 mm interval.30 nodes were selected in medial and lateral area,respectively on each section.The mean stress value of nodes was defined as the stress level of subchondral bone.Results Mean values of stress on polyethylene upper surface of 0,-3 and+3 mm joint line position were 14.84,26.81and 20.86 MPa,and the difference was statistical significant (t0vs-3=4.896,P0vs-3=0.000;t0vs+3=3.455,P0v+3=0.008;t-3vs+3=2.579,P-3vs+3=0.020).Mean values of stress on tibial prosthesis upper surface of 0,-3 and +3 mm joint line position were 29.69,50.49 and 39.99MPa,respectively,and the difference was statistical significant(t0vs-3=5.675,P0vs-3=0.000;t0vs+3=4.755,P0v+3=0.001;t-3vs+3=4.783,P-3vs+3=0.000).When joint line was in 0 mm height,stress level of subchondral bone was similar to that of normal knee.When joint line was in-3 mm height,significantly increased stress was found on polyethylene (increased 81％) and tibial component (increased 70％) surface compared with that of 0 mm height,while stress on trabecular bone under lateral tibial articular surface also increased by 8.7％.When joint line was in +3 mm height,increased stress on polyethylene (increased 41％) and tibial component (increased by 35％) surface were less than that of-3 mm height.Stress on trabecular bone under lateral articular surface decreased by 55.6％ compared with 0 mm height.Conclusion During UKA,ensuring a normal height of joint line is benefit to keep the stress path of the medial and lateral tibia similar with normal knee and decrease the risk of premature polyethylene wear,tibial component subsidence and periprosthetic fracture.

Comparison of earlier functional recovery in total hip arthroplasty patients using a direct anterior approach or posterolateral approach / 中华骨科杂志

Objective To compare faster rehabilitation of different surgical approaches in total hip arthroplasty (THA)patients using a direct anterior approach or posterolateral approach.Methods Sixty-eight patients (35 in direct anterior THA and 33 in posterolateral THA) from September 2015 to March 2016 were recruited in the present study.The incision length,operation duration,intraoperative blood loss,serum creatinekinase (CK),C-reactive protein (CRP),erythrocyte sedimentation rate (ESR),interleukin-6 (IL-6) and visual analogue scale (VAS) pain score were compared between two groups respectively.The Harris hip score,the University of California at Los Angeles (UCLA) pain,walking,and activity scores,postoperative hospital length of stays,gait analysis,component placement and complications were also compared.Results The mean incision length,operation duration,intraoperative blood loss were 11.23±0.97 cm,73.77±9.20 min and 157.15±35.83 ml in the DAA group respectively,while those in PLA group were 15.16±1.12 cm,64.12±13.31 min and 126.97±45.45 ml.The mean incision length of the DAA group were significantly less than that of the PLA group.The DAA group underwent longer operation time that associated with more intraoperative blood loss.The levels of CK and inflammation markers were increased in the PLA group compared with those in the DAA group.The VAS pain score was less in the DAA group than the PLA group within postoperative 72 hours.Functional recovery in the DAA group was faster than that in the PLA group based on the Harris hip score,UCLA scores,and gait analysis up to 3 months.There was no difference in these outcomes between the groups beyond 6 months.The average postoperative hospital length of stay was 2.95±0.24 days and 3.35±0.51 days for the DAA group and PLA group respectively.The patients in DAA group required less postoperative hospital length of stays.The angle of acetabular cup anteversion in the DAA group (16.4°±2.3°) was lesser than that in the PLA group (20.4°±2.8°).There was one intraoperative nondisplaced greater trochanter fracture in the DAA group,whereas no intraoperative complications were occurred in the PLA group.Conclusion The present study showed that using direct anterior approach in THA provided significant benefits for patients in terms of muscle damage,VAS score,hospital length of stays and functional recovery in the early stage postoperatively compared to using posterolateral approach.

Malformation correction of femoral medullary cavity in hip revision arthroplasty for implant loosening / 中华骨科杂志

Objective To investigate the results of malformation correction of femoral medullary cavity in hip revision for implant loosening.Methods From January 2010 to December 2016,24 patients (24 hips) were received hip revision arthroplasty using femoral medullary cavity correction technique.Nineteen patients (19 hips) were followed up.Ten patients were male and 9 female with mean age of 69.1 years (range 44-84).The followings are the reasons for revision:15 patients for osteolysis with implant loosening,4 for periprosthetic infection,bone cement implant and stage two revision.Fourteen patients received bone cement implants and 5 received uncemented implants for primary arthroplasty.During revision,13 patients underwent femoral bone cortical windowing and 6 received extended trochanteric osteotomy technique to exposure medullary cavity,grinding sclerotic bone and filling bone defect,correcting cavity to normal morphology and implant anatomic revision stem.The hip function was evaluated with Harris score.Peri-operation complications were also collected.Implant position,fixation condition and implant loosening were evaluated from the supine anteroposterior radiograph of the pelvic and a lateral hip radiograph.Results The mean follow up duration was 58 months (range 17-82).The mean Harris score improved significantly from 41.52±10.94 (range 17-64) preoperatively to 91.63±6.70 (range 72-99) postoperatively.Mild limp occurred in 2 patients (11％,2/19) and intermittent hip pain occurred in 1 patient (5％,1/19).Peri-prosthetic fracture occurred in 1 patient and was treated with double stranded wire fixation.No deep venous thrombosis,dislocation and infection occurred.No revision was performed.For bone cortical windowing patients,the length of the cortical windows varied from 3.0 to 9.0 cm (mean 4.78±1.84),the width ranged from 1.0-3.0 cm (mean 1.82± 0.50).For extended trochanteric osteotomy patient,the length of the osteotomy varied form 12.0-20.0 cm (mean 16.00±3.37),the width ranged from 2.5 to 3.0 cm (mean 2.75±0.29).All the revision stems were in neutral position without varus or valgus.All the osteotomy sites were bone heal and fracture lines were disappeared.Conclusion In order to restore the normal bone cavity morphology and femoral alignment,correction bone cavity technique is required in patients receiving hip revision with femoral cavity malformation and anatomy alignment abnormal.This technique can ensure neutral position of revision stem without peri-prosthetic fracture.

Comparison of earlier functional recovery in total hip arthroplasty patients using a direct anterior approach or posterolateral approach / 中华骨科杂志

Objective To compare faster rehabilitation of different surgical approaches in total hip arthroplasty (THA)patients using a direct anterior approach or posterolateral approach.Methods Sixty-eight patients (35 in direct anterior THA and 33 in posterolateral THA) from September 2015 to March 2016 were recruited in the present study.The incision length,operation duration,intraoperative blood loss,serum creatinekinase (CK),C-reactive protein (CRP),erythrocyte sedimentation rate (ESR),interleukin-6 (IL-6) and visual analogue scale (VAS) pain score were compared between two groups respectively.The Harris hip score,the University of California at Los Angeles (UCLA) pain,walking,and activity scores,postoperative hospital length of stays,gait analysis,component placement and complications were also compared.Results The mean incision length,operation duration,intraoperative blood loss were 11.23±0.97 cm,73.77±9.20 min and 157.15±35.83 ml in the DAA group respectively,while those in PLA group were 15.16±1.12 cm,64.12±13.31 min and 126.97±45.45 ml.The mean incision length of the DAA group were significantly less than that of the PLA group.The DAA group underwent longer operation time that associated with more intraoperative blood loss.The levels of CK and inflammation markers were increased in the PLA group compared with those in the DAA group.The VAS pain score was less in the DAA group than the PLA group within postoperative 72 hours.Functional recovery in the DAA group was faster than that in the PLA group based on the Harris hip score,UCLA scores,and gait analysis up to 3 months.There was no difference in these outcomes between the groups beyond 6 months.The average postoperative hospital length of stay was 2.95±0.24 days and 3.35±0.51 days for the DAA group and PLA group respectively.The patients in DAA group required less postoperative hospital length of stays.The angle of acetabular cup anteversion in the DAA group (16.4°±2.3°) was lesser than that in the PLA group (20.4°±2.8°).There was one intraoperative nondisplaced greater trochanter fracture in the DAA group,whereas no intraoperative complications were occurred in the PLA group.Conclusion The present study showed that using direct anterior approach in THA provided significant benefits for patients in terms of muscle damage,VAS score,hospital length of stays and functional recovery in the early stage postoperatively compared to using posterolateral approach.

Malformation correction of femoral medullary cavity in hip revision arthroplasty for implant loosening / 中华骨科杂志

Objective To investigate the results of malformation correction of femoral medullary cavity in hip revision for implant loosening.Methods From January 2010 to December 2016,24 patients (24 hips) were received hip revision arthroplasty using femoral medullary cavity correction technique.Nineteen patients (19 hips) were followed up.Ten patients were male and 9 female with mean age of 69.1 years (range 44-84).The followings are the reasons for revision:15 patients for osteolysis with implant loosening,4 for periprosthetic infection,bone cement implant and stage two revision.Fourteen patients received bone cement implants and 5 received uncemented implants for primary arthroplasty.During revision,13 patients underwent femoral bone cortical windowing and 6 received extended trochanteric osteotomy technique to exposure medullary cavity,grinding sclerotic bone and filling bone defect,correcting cavity to normal morphology and implant anatomic revision stem.The hip function was evaluated with Harris score.Peri-operation complications were also collected.Implant position,fixation condition and implant loosening were evaluated from the supine anteroposterior radiograph of the pelvic and a lateral hip radiograph.Results The mean follow up duration was 58 months (range 17-82).The mean Harris score improved significantly from 41.52±10.94 (range 17-64) preoperatively to 91.63±6.70 (range 72-99) postoperatively.Mild limp occurred in 2 patients (11％,2/19) and intermittent hip pain occurred in 1 patient (5％,1/19).Peri-prosthetic fracture occurred in 1 patient and was treated with double stranded wire fixation.No deep venous thrombosis,dislocation and infection occurred.No revision was performed.For bone cortical windowing patients,the length of the cortical windows varied from 3.0 to 9.0 cm (mean 4.78±1.84),the width ranged from 1.0-3.0 cm (mean 1.82± 0.50).For extended trochanteric osteotomy patient,the length of the osteotomy varied form 12.0-20.0 cm (mean 16.00±3.37),the width ranged from 2.5 to 3.0 cm (mean 2.75±0.29).All the revision stems were in neutral position without varus or valgus.All the osteotomy sites were bone heal and fracture lines were disappeared.Conclusion In order to restore the normal bone cavity morphology and femoral alignment,correction bone cavity technique is required in patients receiving hip revision with femoral cavity malformation and anatomy alignment abnormal.This technique can ensure neutral position of revision stem without peri-prosthetic fracture.

Gait analysis at the early stage after direct anterior approach in total hip arthroplasty / 北京大学学报(医学版)

Objective:To evaluate the result of operation and gait analysis at the early stage after direct anterior approach (DAA) in total hip arthroplasty (THA).Methods: In this study,20 patients who suffered from necrosis of femoral head or developmental dysplasia of the hip were scheduled to undergo THA.The basic information and visual analogue scale (VAS) score,Harris score before and after surgery were recorded.All of the patients finished the gait analysis before the surgery and 6 weeks and 12 weeks after the surgery,the data were compared with those of normal adult people.Results: Their hospital stay after the operation was 3.3 d,the VAS score after the operation was no more than 4 points,the positions of prosthesis were satisfactory,and there was no dislocation.The gait analysis results contained step speed,stride,the range of motion (ROM) of hip and knee.The step speed before the surgery (preoperation,Pre) was 0.64 m/s,6 weeks after the surgery (6W) was 0.77 m/s,12 weeks after the surgery (12W) was 1.07 m/s,and the control group was 1.19 m/s.The stride at Pre,6W,12W,and control group were 43.15 steps/min,51.42 steps/min,55.52 steps/min,and 57.15 steps/min,respectively.The ROM of hip joint at Pre,6W,12W,and control group were 31.00°,39.62°,40.40°,and 45.67°,respectively.The ROM of knee joint at Pre,6W,12W,and control group were 50.52°,59.28°,67.29°,and 70.42°,respectively.The results of the gait analysis showed that the gait recovery after the direct anterior total hip arthroplasty was very fast and at the 12th week after surgery the gait of the patients was close to the normal adult people.Conclusion: The direct anterior approach is one of the choosable approach of the THA,and this kind of surgery has a better recovery of gait after the operation,and at the end of 12 weeks after the surgery the gait is very close to the normal adult people.But we also need more studies to prove this conclusion.

Tranexamic Acid Administration in Primary Total Hip Arthroplasty: A Randomized Controlled Trial of Intravenous Combined with Topical Versus Single-Dose Intravenous Administration.

BACKGROUND: The use of tranexamic acid (TXA) in primary total hip arthroplasty is well documented. However, considering the potential side effects, including deep vein thrombosis and pulmonary embolism, the ideal method of providing TXA to patients undergoing total hip arthroplasty remains controversial. The objective of this trial was to assess the efficacy and safety of intravenous (IV) administration combined with topical administration of TXA regarding postoperative blood loss and transfusion rates in patients treated with primary unilateral total hip arthroplasty. METHODS: In this prospective, randomized controlled trial, 150 patients were divided into three groups: the combined group (IV administration of 15 mg/kg of TXA combined with topical administration of 1 g/100 mL of TXA), the single IV group (IV administration of 15 mg/kg of TXA), and the placebo group. The primary outcomes included blood-loss variables (total, intraoperative, and drainage blood loss; changes in hemoglobin, hematocrit, and platelet concentration; and amount of IV transfusion fluid) and transfusion values (frequency of transfusion and number of transfused blood units). The secondary outcomes included the length of the hospital stay, range of hip motion, Harris hip score, and prevalences of deep vein thrombosis and pulmonary embolism. RESULTS: The total blood loss in the combined group (mean and standard deviation, 835.49 ± 343.50 mL) was significantly reduced (p < 0.05) in comparison with that in the single IV group (1002.62 ± 366.85 mL) and placebo group (1221.11 ± 386.25 mL). The combined group also had fewer transfusions in comparison with the single IV and placebo groups (1, 8, and 19, respectively; p < 0.05). There was no difference among the 3 groups with regard to the rates of deep vein thrombosis or pulmonary embolism. CONCLUSIONS: Intravenous combined with topical administration of TXA in patients undergoing a primary unilateral total hip arthroplasty significantly reduced postoperative bleeding and the transfusion rate. Studies with more patients and longer follow-up are needed to confirm whether this promising combined strategy is safe with regard to thromboembolic complications. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The efficacy and safety of postoperative retransfusion drain following total hip arthroplasty: a Meta-analysis / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the effectiveness and safety of post-operative retransfusion drain(PRD) after total hip arthroplasty.</p><p><b>METHODS</b>A systematic literature review based on PubMed, EMBase, the Cochrane Library, China Biology Medicine disc, CNKI, VIP and WanFang Database in any language regarding PRD following total hip arthroplasty was performed.The data was evaluated using modified Jadad score and then analyzed using RevMan 5.2.</p><p><b>RESULTS</b>Nine randomized controlled trials totaling 1 824 patients, 913 patients in PRD group and 911 in control group, were eligible for data extraction and Meta-analysis.The results indicated that the use of PRD could reduce the requirement of allogeneic blood transfusion when compared with ordinary vacuum drainage (RR=0.61, 95% CI= 0.47-0.79), but the benefit was not found when compared with no drainage group(RR=1.07, 95% CI=0.67-1.71). And the postoperative hemoglobin level was higher in PRD group(MD=0.14, 95% CI=0.01-0.27, P=0.04). No significant difference was identified regarding transfusion index, length of hospital stay, the incidence of febrile reaction and wound-related complications.</p><p><b>CONCLUSIONS</b>PRD in reducing requirement of blood transfusion following THA is effective and safe when compared with ordinary vacuum drainage, but the benefit is not found when compared with no drainage.And more robust evidence is needed to confirm this result.</p>