Effects of Dexamethasone on Postoperative Glycemic Control in Patients After Primary Total Joint Arthroplasty: A Randomized Double-Blind Controlled Trial.

BACKGROUND: In patients undergoing total joint arthroplasty, the use of dexamethasone (DEX) may cause perioperative blood glucose (BG) disorders, leading to complications even in patients who do not have diabetes. We aimed to evaluate the effects of different DEX doses on perioperative BG levels. METHODS: A total of 135 patients who do not have diabetes were randomized into three groups: preoperative intravenous (IV) injection of normal saline (Group A, the placebo group), preoperative IV injection of 10 mg DEX (Group B), and preoperative IV injection of 20 mg DEX (Group C). Postoperative fasting BG (FBG) levels were designated as the primary outcome, while postoperative postprandial BG (PBG) levels were assigned as the secondary outcome. The incidence of complications was recorded. We also investigated the risk factors for FBG ≥ 140 mg/dL and PBG ≥ 180 mg/dL. RESULTS: The FBG levels were higher in Groups B and C than in Group A on postoperative days (PODs) 0 and 1. The PBG levels were lower for Groups A and B compared to Group C on POD 1. No differences in FBG or PBG were detected beyond POD 1. Elevated preoperative glycosylated hemoglobin A1c levels increased the risk of FBG ≥ 140 mg/dL and PBG ≥ 180 mg/dL, respectively. However, preoperative IV injection of DEX was not associated with FBG ≥ 140 mg/dL or PBG ≥ 180 mg/dL. No differences were found in postoperative complications among the three groups. CONCLUSIONS: The preoperative IV administration of 10 or 20 mg DEX in patients who do not have diabetes showed transient effects on postoperative BG after total joint arthroplasty. The preoperative glycosylated hemoglobin A1c level threshold (regardless of the administration or dosage of DEX) that increased the risk for the occurrence of FBG ≥ 140 mg/dL and PBG ≥ 180 mg/dL was 5.75 and 5.85%, respectively.

Comparison of Outcomes in Obese Patients after Total Knee Arthroplasty with Neutral or Mild Varus: A Retrospective Study with 8-Year Follow-Up.

OBJECTIVES: Residual varus after total knee arthroplasty (TKA) can affect functional outcomes, which may worsen in the presence of obesity. However, no studies were found to compare the outcomes of obese patients involving postoperative residual mild varus or neutral. The aim of this study was to compare postoperative complications and prosthesis survival, and functional outcomes for knees of obese patients with neutral or mild varus after TKA. METHODS: We retrospectively reviewed 188 consecutive obese patients (body mass index ≥30 kg/m2) at our hospital who underwent TKA due to varus knee osteoarthritis from January 2010 to December 2015. The mechanical hip-knee-ankle axis angle was measured in all patients at admission and discharge. Knee functions were retrospectively assessed based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Knee Society Knee Score (KS-KS), Knee Society Function Score (KS-FS), Forgotten Joint Score (FJS), and range of motion (ROM). Continuous data were compared between knees with neutral or mild varus alignment using analysis of Student's t test or variance or the Kruskal-Wallis test as appropriate. For multiple comparisons of outcomes, we used Bonferroni-Dunn method to adjust p-values. Categorical data were compared using the chi-squared test. RESULTS: Of the 156 knees in 137 obese patients who completed follow-up for a mean of 8.32 ± 1.47 years, 97 knees were corrected from varus to neutral and 54 knees were kept in mild residual varus. Patients with mild varus knees had significantly WOMAC (8.25 ± 8.637 vs. 14.97 ± 14.193, p = 0.009) and better FJS (86.03 ± 15.607 vs. 70.22 ± 30.031, p = 0.002). The two types of knees did not differ significantly in KS-KS, KS-FS, or ROM. Although one patient with a neutral knee had to undergo revision surgery, there was no significant difference between two groups. CONCLUSIONS: For obese patients with osteoarthritis, preservation of residual varus alignment after TKA can improve functional outcomes without compromising prosthesis survival.

Outcomes of culture-negative or -positive periprosthetic joint infections: A systematic review and meta-analysis.

OBJECTIVES: This study overviewed the current database of studies on periprosthetic joint infections (PJIs) to compare outcomes and antibiotic side effects in culture-negative or culture-positive PJIs and assess treatment options for culture-negative PJIs. PATIENTS AND METHODS: A systematic review and meta-analysis was undertaken using studies published before July 2022 in MEDLINE, EMBASE, and Cochrane Library. All studies comparing treatment of culture-negative or -positive PJIs were included. Afterward, the infection control rate, periprosthetic or spacer fracture, hip joint or spacer dislocation, and antibiotic side effects in different treatment methods of PJI were analyzed. RESULTS: Eleven studies involving 1,747 patients were included. Most studies clearly defined the infection control criteria: no pain or swelling, no wound drainage, normal serology, and normal radiographic findings. Patients were followed until treatment failure, death, or until the last clinical visit without evidence of treatment failure. The two types of PJIs did not differ significantly in infection control rates (culture-negative PJI 79.2% vs. culture-positive PJI 76.6%; odds ratio [OR]=1.20, 95% confidence interval [CI]: 0.84 to 1.70), either after all types of surgical treatment or after two-stage revision arthroplasty (OR=1.12, 95% CI: 0.72 to 1.75), single-stage revision arthroplasty (OR=0.51, 95% CI: 0.19 to 1.37), or debridement, antibiotics, and implant retention (OR=0.88, 95% CI: 0.50 to 1.54). Similarly, we did not find differences in periprosthetic or spacer fracture and hip joint or spacer dislocation. For culture-negative PJIs, the infection control rate was 85.2% after two-stage revision arthroplasty, 90.6% after single-stage revision arthroplasty, and 69.7% after debridement, antibiotics, and implant retention. Data pooled from three studies showed higher incidence of antibiotic side effects for culture-negative PJIs. CONCLUSION: The clinical outcomes of one-stage revision and two-stage revision are comparable. Therefore, both of them can be considered in surgical treatment for culture-negative PJIs. In addition, limited data showed a higher incidence of antibiotic side effects in culture-negative PJIs.

Bone wax reduces blood loss after total hip arthroplasty: a prospective, randomized controlled study.

Background: Previous studies have demonstrated the efficacy of bone wax in reducing blood loss in various orthopedic surgeries. However, the effect of bone wax on total hip arthroplasty (THA) remains unclear. The objective of this study was to assess the efficacy of bone wax in THA. Methods: We enrolled 104 patients in this randomized controlled trial. These patients were randomized (1:1) to either the bone wax or control group. The primary outcome was total blood loss after THA. The secondary outcomes included serum hemoglobin (Hb) level, change in Hb level, lower limb diameters on the first and third postoperative day (POD), range of motion at discharge, length of postoperative hospital stay, and adverse events. Results: Patients in the bone wax group had significantly lower total blood loss on PODs 1 and 3 (p < 0.05). Moreover, patients in the bone wax group performed better in terms of postoperative serum Hb level, change in Hb level on PODs 1 and 3, and length of postoperative hospital stay (all p < 0.05). Patients in the bone wax group did not experience any bone wax-related adverse events. Conclusion: Bone wax administration in THA significantly reduced perioperative blood loss. Therefore, bone wax is promising for optimizing blood-conserving management protocols in THA. Clinical trial registration: [https://clinicaltrials.gov/], identifier [ChiCTR2100043868].

Significant Analgesic Benefits of Perioperative Duloxetine in Patients Who Have Depressive Symptoms Undergoing Total Hip Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: Major symptoms of depression are commonly observed in patients requiring total hip arthroplasty (THA), and this is associated with increased pain scores and opioid consumption. We aimed to investigate the analgesic effect of duloxetine in these high-risk patients. METHODS: Among 263 patients scheduled for primary unilateral THA, 67 patients who scored at least 8 on the 17-item Hamilton Depression Scale (HAMD) were enrolled in this study. Patients were randomized to the duloxetine group (60 mg daily, from the day of surgery to postoperative day 6) or the placebo group. The postoperative visual analog scale (VAS) score during walking, the VAS score during hip flexion, and resting VAS score was measured. Postoperative morphine consumption, hip range of motion (ROM), Harris hip score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function, postoperative length of stay (LOS), and adverse events were recorded. RESULTS: The duloxetine group had significantly lower VAS scores during walking and hip flexion from postoperative day 3 to week 3 than the placebo group. With regard to the resting VAS score, duloxetine showed a better analgesic effect from postoperative day 3 to week 2 than placebo. Patients in the duloxetine group had less consumption of morphine. The duloxetine group exhibited better hip function scores, including ROM, HHS, and WOMAC function scores than the placebo group. No significant difference was observed in LOS or adverse events between groups. CONCLUSION: Perioperative short-term duloxetine provides advantages in decreasing pain, reducing morphine consumption, and increasing hip function in THA patients who have depressive symptoms.

Quality evaluation of clinical practice guidelines for thromboprophylaxis in orthopaedic trauma based on AGREE II and AGREE-REX: a systematic review protocol.

INTRODUCTION: Orthopaedic trauma patients are at high risk of venous thromboembolism (VTE). As VTE prophylaxis has gradually raised public concerns, guidelines related to this topic have increased over time. However, the existing recommendations of thromboprophylaxis guidelines in orthopaedic trauma patients are still inconsistent, and the quality of the guidelines and recommendations for the topic still lacks comprehensive assessments. This review aims to critically appraise clinical practice guidelines for thromboprophylaxis in orthopaedic trauma patients. METHODS AND ANALYSIS: We will conduct a comprehensive literature search up to 31 October 2022 in databases (PubMed, EMBASE, CINAHL, Web of Science, the Cochrane Library, etc), academic websites and guideline repositories. The quality of the guidelines and recommendations will be assessed by five reviewers independently using the Appraisal of Guidelines Research and Evaluation II instrument (AGREE-II) and the AGREE - Recommendation EXcellence (AGREE-REX). We will summarise the characteristics of the guidelines and compare the differences between these recommendations. ETHICS AND DISSEMINATION: This study will follow the Declaration of Helsinki and has received approval from the Ethics Committee on Biomedical Research, West China Hospital, Sichuan University (ethics approval no. 2021-989). The results will be summarised as a paper, disseminated through peer-reviewed journals, and will help guide further research in the future. PROTOCOL REGISTRATION NUMBER: CRD42021273405.

Effect of body mass index on postoperative mechanical alignment and long-term outcomes after total knee arthroplasty: a retrospective cohort study of 671 knees.

Background: A high body mass index (BMI) is associated with increased rates of complications after total knee arthroplasty (TKA). However, no study has examined the effect of BMI on lower limb alignment using the World Health Organization's (WHO) BMI classification. We believe that the WHO's BMI classification allows a uniform standard worldwide. We sought to investigate the potential association between a high BMI and the incidence of postoperative misalignment. We also evaluated whether a higher BMI is associated with worse clinical function. Methods: We retrospectively reviewed the data of 671 patients who underwent primary TKA for varus osteoarthritis between January 2010 and December 2015. The patients were divided into the following 5 groups based on their BMI: normal weight (<25.0 kg/m2), overweight (25.0-29.9 kg/m2), class I obese (30.0-34.9 kg/m2), class II obese (35-39.9 kg/m2), and class III obese (>40 kg/m2). Both weight and height were measured by nurses on admission. Patients' preoperative HKA, gender, age, and side of surgery were collected as baseline. All the patients underwent standing, weight-bearing, full-length radiography before and after surgery to measure the mechanical hip-knee-ankle angle (HKA). We followed up patients by telephone. Among the BMI subgroups, we compared the knee function scores, including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Knee Society-Knee Score (KS-KS), Knee Society-Function Score (KS-FS), Forgotten Joint Score (FJS), and range of motion (ROM). A multivariate linear regression analysis and a logistic regression was conducted to examine the outcomes. Results: The study had a mean follow-up period of 8.16 years. The multivariate and logistic regression analyses revealed that preoperative alignment (P=0.002) and a higher BMI (P=0.015) were associated with a higher risk of postoperative misalignment. The WOMAC scores were higher in the normal and overweight groups than the other groups (P=0.022). The FJS and KS-KS gradually decreased as BMI increased. Conclusions: A higher BMI is associated with a greater risk of misalignment and worse long-term clinical outcome after TKA. When treating patients with high BMI, we should pay more attention to the adjustment of lower limb alignment intraoperatively.

A new cocktail formula with diprospan of local infiltration analgesia in primary total hip arthroplasty: A prospective, randomized, controlled, observer-blinded study.

OBJECTIVE: This study aimed to observe the analgesic effect of the cocktail formulation with diprospan during total hip arthroplasty (THA). METHODS: From September 2018 to April 2019, 120 patients undergoing primary unilateral THA were included in this prospective, randomized, observer-blinded study. Patients were randomized into three groups, according to the different local infiltration analgesia (LIA) strategies: LIA with ropivacaine (the ropivacaine group, n = 40), LIA with a new cocktail containing ropivacaine, diprospan, and morphine (the cocktail group, n = 40), and the control group (n = 40). The primary outcomes included postoperative pain scores. The resting visual analogue scale (VAS) scores were measured at 2, 6, and 12 h after the surgery (a.m. and p.m.) on postoperative day (POD) 1, POD2, and the day of discharge. Movement VAS scores were assessed at 6 h, 12 h after the operation (a.m. and p.m.) on POD1, POD2, and the day of discharge. The secondary outcomes included opioid consumption, postoperative hospital stay, range of motion of the hip at discharge, patient satisfaction, and the results of the follow-up. RESULTS: After the screening, 120 patients were randomized into three groups (40 patients in each group). All of the patients completed the trial. The resting VAS scores in the ropivacaine group and cocktail group at 2 h were lower than those in the control group (P < 0.001 and P < 0.001, respectively, F = 17.054), and the same trend was also postoperatively found at 6 h (p = 0.005 and P = 0.002, F = 6.212). Twelve hours after the operation, the pain score in the cocktail group was lower than that in the other two groups, but only the difference between the cocktail group and the control group was statistically significant (P = 0.018, F = 3.144). From the morning of the first postoperative day to the a.m. on POD 2, the VAS scores in the cocktail group were significantly lower than those in the ropivacaine group and the control group. Furthermore, the movement VAS scores in the ropivacaine group and the cocktail group were better than those in the control group at 6 and 12 h post-operation (P < 0.05). The per capita opioid consumption in the cocktail group was less than that in the ropivacaine group and the control group within 24 h post-operation. There were no significant differences in the comparison of additional indicators among the three groups. CONCLUSION: The new cocktail with diprospan had a better result and longer duration time for early postoperative pain control in primary THA via the posterolateral approach under general anesthesia, especially for treating resting pain.

Evaluation of the rate of post-operative dislocation in patients with ipsilateral valgus knee deformity after primary total hip arthroplasty.

PURPOSE: There is scant literature on the evaluation of dislocation after total hip arthroplasty (THA) in patients with ipsilateral valgus knee deformity. This study aimed to investigate the post-operative dislocation rate in patients with valgus knee deformity who underwent ipsilateral THA and identify whether ipsilateral valgus knee deformity increases the dislocation rate after THA. METHODS: We retrospectively reviewed patients with valgus knee deformity who underwent ipsilateral THA in our institution from January 2016 to December 2018. Each hip with ipsilateral valgus knee deformity was matched with a hip without valgus knee deformity according to sex, affected side, and date of surgery. The primary outcome was the dislocation rate after THA. Univariate analyses were initially used to compare data between the dislocation group and the non-dislocation group. Independent risk factors for dislocation were determined using multivariate logistic regression. RESULTS: There were 257 THAs with ipsilateral valgus knee deformity (valgus knee group) and 257 THAs without valgus knee deformity (control group). The valgus knee group showed a significantly higher dislocation rate than the control group (9.7% versus 1.6%, p < 0.001). Older age (p = 0.020) and malposition of the acetabular cup (p = 0.048) were independent risk factors of post-operative dislocation. CONCLUSION: Patients with valgus knee deformity have a higher risk of dislocation after ipsilateral THA. If ipsilateral THA and total knee arthroplasty must be performed successively, total knee arthroplasty may have an earlier priority than THA.

Effect of tourniquet use on blood loss, pain, functional recovery, and complications in robot-assisted total knee arthroplasty: a prospective, double-blinded, randomized controlled trial.

BACKGROUND: Robot-assisted total knee arthroplasty (TKA) has been largely studied to confirm its advantages in terms of accurate component positioning, microembolus formation, less blood loss, and so on, but is currently usually performed under tourniquet due to its longer operative time than conventional TKA. The aim of this study was to estimate the effects of tourniquet use in robot-assisted TKA on blood loss, pain, functional recovery, and complications. METHODS: Patients scheduled for robot-assisted TKA were prospectively randomized into a tourniquet or non-tourniquet group (each n = 14). The primary outcome measure was blood loss. The secondary outcome measures were operation time; visual analog scale (VAS) pain scores; time to achieve the first straight-leg raise; swelling of the thigh, knee, and calf; range of motion; Hospital for Special Surgery score; length of stay; and postoperative complications. RESULTS: There was no significant difference in total blood loss between the tourniquet and non-tourniquet groups (738.57 ± 276.158 vs. 866.85 ± 243.422 ml, P = 0.061). The tourniquet group showed significantly lower intraoperative blood loss (P < 0.001), but higher hidden blood loss (P = 0.002). The non-tourniquet group showed better knee range of motion on postoperative days (PODs) 1-3 (all P < 0.001), less thigh swelling on PODs 2 and 3 (P < 0.05), earlier straight-leg raising (P = 0.044), and shorter length of stay (P = 0.044). Thigh pain VAS score at 1 month after surgery was significantly greater in the tourniquet group (P < 0.001), as was knee pain during activity and at rest on PODs 2-3 (all P < 0.05). The tourniquet group also showed a significantly higher rate of tension blisters (28.8% vs. 7.1%, P = 0.038). CONCLUSIONS: Tourniquet use during robot-assisted TKA does not reduce total blood loss, and it appears to increase postoperative pain, aggravate muscle injury, and prolong postoperative recovery. Trial registration ChiCTR, ChiCTR2100041800. Registered 5 January 2021, http://www.chictr.org.cn/index.aspx .

Near-Infrared Light-Controllable Multifunction Mesoporous Polydopamine Nanocomposites for Promoting Infected Wound Healing.

The successful treatment of infected wounds requires strategies with effective antimicrobial, anti-inflammatory, and healing-promoting properties. Accordingly, the use of Cu2+ and tetracycline (TC), which can promote angiogenesis, re-epithelialization, and collagen deposition, also antibacterial activity, at the wound site, has shown application prospects in promoting infected wound repair. However, realizing controllable release to prolong action time and avoid potential toxicities is critical. Moreover, near-infrared light (NIR)-activated mesoporous polydopamine nanoparticles (MPDA NPs) reportedly exert anti-inflammatory effects by eliminating the reactive oxygen species generated during inflammatory responses. In this study, we assess whether Cu2+ and TC loaded in MPDA NPs can accelerate infected wound healing in mice. In particular, Cu2+ is chelated and immobilized on the surface of MPDA NPs, while a thermosensitive phase-change material (PCM; melting point: 39-40 °C), combined with antibiotics, was loaded into the MPDA NPs as a gatekeeper (PPMD@Cu/TC). Results show that PPMD@Cu/TC exhibits significant great photothermal properties with NIR irradiation, which induces the release of Cu2+, while inducing PCM melting and, subsequent, TC release. In combination with anti-inflammatory therapy, NIR-triggered Cu2+ and TC release enables the nanocomposite to eradicate bacterial wound infections and accelerate healing. Importantly, negligible damage to primary organs and satisfactory biocompatibility were observed in the murine model. Collectively, these findings highlight the therapeutic potential of this MPDA-based platform for controlling bacterial infection and accelerating wound healing.

Adductor Canal Block Combined With IPACK Block for Postoperative Analgesia and Function Recovery Following Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study.

BACKGROUND: This study aimed to explore the analgesic effect among adductor canal block (ACB) combined with infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) block, ACB, and IPACK block following total knee arthroplasty (TKA). METHODS: One hundred twenty patients were randomly allocated into 3 groups including group A (ACB + IPACK block), group B (ACB), and group C (IPACK block). The primary outcome was postoperative pain score. The secondary outcome was opioid consumption. Other outcomes included functional evaluation and postoperative complications. RESULTS: Group A showed the lowest pain scores within 8 hours at rest and with knee maximum flexion (P < .001). From 12 to 24 hours, group C showed the highest pain scores, while no significant difference was found between group A and group B. No significant difference was found among the 3 groups 24 hours postoperatively. Group C showed the most opioid consumption within the first 24 hours and during the hospitalization, while no significant difference was found between group A and group B. No significant difference was found among the 3 groups including function evaluation and postoperative complications. CONCLUSION: ACB + IPACK block can improve early analgesia when compared with ACB. However, the small statistical benefit to the addition of IPACK block to ACB may be unlikely to be clinically significant. Further studies may focus on patient selection and how to prolong the effect of IPACK block.

Educational Attainment Affects the Early Rehabilitation of Total Knee Arthroplasty in Southwest China.

OBJECTIVE: To assess if the educational level of patients in Southwestern China will affect the functional recovery after total knee arthroplasty (TKA). METHODS: This retrospective study included a total of 334 patients (48 males, 286 females, with an average age of 68 years, range from 51 to 84 years) who had undergone primary unilateral TKA from March 2017 to April 2018. Patients were screened for enrollment and classified into four groups (illiterate group, the primary school group, high school group, and university group) according to their educational attainment. All patients were monitored for at least 2 years after TKA. The primary outcome was determined using the Hospital for Special Surgery knee (HSS) score at the time of follow-up. The secondary outcomes were determined using the 12-Item Short Form Health Survey (SF-12) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, the satisfaction level, and complications of the surgery. RESULTS: Three hundred and thirty-four patients were divided into four groups based on their highest educational level: 83 patients in the illiteracy group, 84 in the primary school group, 91 in the high school group, and 76 in the university group. They were followed up for at least 2 years. For the primary outcome, patients with high school and university education had noteworthy better HSS scores on the surgical-side knee than those in the primary school and illiterate groups (illiteracy group 86.71 ± 5.94 vs primary school group 85.36 ± 5.88 vs high school group 89.48 ± 3.66 vs university group 88.95 ± 3.55; P < 0.05). For secondary outcomes, the mental component summary (MCS) in the university group was significantly lower than the other three groups (P < 0.05). The results of WOMAC scores were consistent with the results of the HSS score: patients in the university group and the high school group had better results when compared with the other two groups (P < 0.05). There were no statistical differences in the comparison of additional indicators and complications among the four groups, but more patients (12 peoples, 15.8%) in the university group were dissatisfied with knee function after TKA. CONCLUSION: In Southwest China, patients with high school education or above can achieve better joint function after TKA but do not get better postoperative satisfaction, which may be related to the patients' higher surgical expectations for social and mental needs.

A Comparison Between Unstemmed and Stemmed Constrained Condylar Knee Prostheses in Primary Total Knee Arthroplasty: A Propensity Score-Matched Analysis.

OBJECTIVE: To compare and analyze the clinical outcomes between unstemmed and stemmed constrained condylar knees (CCK) in complex primary total knee arthroplasty (TKA) in terms of implant survivorship, change in outcome evaluations, and complications. METHODS: We reviewed 156 consecutive patients who received primary TKA using PFC®SIGMA®TC3 (TC3) of constrained condylar design between January 2009 and January 2017 at our institution. After removing patients who met exclusion criteria, 25 patients were identified as unstemmed TC3 cases and 81 as stemmed TC3 cases. Propensity score matching was used to select 25 stemmed cases as a control group for the unstemmed group with comparable preoperative conditions including preoperative demographics, preoperative diagnosis, preoperative range of motion, main reason to use TC3, ASA score (American Society of Anesthesiologists), and follow-up duration. Preoperative and postoperative clinical evaluations including Knee Society Score (KSS), Hospital for Special Surgery (HSS) score, the 12-Item Short-Form Health Survey (SF-12), and the range of motion (ROM) were obtained and compared. The instability, periprosthetic fracture, radiolucent lines, polyethylene wear, and heterotrophic ossification were assessed according to the anteroposterior and lateral radiographs of the knee. The complications and implant survivorship between the two groups were also recorded and compared. RESULTS: 3After the index surgery, both groups showed substantial improvement in KSS (knee and function), HSS score, SF-12, and ROM compared with baseline. There was no significant difference in the mean KSS scores (knee and function), HSS score, SF-12, and ROM between the unstemmed and stemmed group postoperatively. No statistically significant difference was found in the overall complication rate between the two groups. The overall Kaplan-Meier survivorship was 98.0% (95% confidence interval 94.1%-100.0%) at 7 years. No significant difference was found in the survival rate between the unstemmed group (100.0%) and the stemmed group (96.0%) at 7 years (log rank, P = 0.317). The mean duration of follow-up was 7.0 years for unstemmed group and 7.7 years for stemmed group. CONCLUSIONS: In patients with adequate bone stock receiving complex primary TKA, unstemmed CCK could achieve similar clinical outcomes at mid-term follow-up as stemmed CCK.

Comparison of Outcomes After Total Knee Arthroplasty Involving Postoperative Neutral or Residual Mild Varus Alignment: A Systematic Review and Meta-analysis.

Comparing mainly clinical and functional outcomes as well as prosthesis survival with neutral and residual mild varus alignment, we searched PubMed, Embase, Cochrane Library and Web of Science databases from 1 January 1974 to 18 December 2020 to identify studies comparing clinical and functional outcomes as well as prosthesis survival in the presence of different alignments after total knee arthroplasty (TKA) for varus knees. The included studies were assessed by two researchers according to the Newcastle-Ottawa Scale (NOS). Postoperative neutral alignment (0° ± 3°) was compared to residual mild varus (3°-6°) and residual severe varus (>6°). Meta-analysis was performed using Review Manager 5.3. The odds ratios (OR) and mean differences (MD) were used to compare dichotomous and continuous variables. The fixed-effect model and random-effect model were used to meta-analyze the data. Nine studies were included in the meta-analysis with 1410 cases of postoperative neutral alignment, 564 of residual mild varus alignment and 175 of residual severe varus alignment following TKA, all of which were published after 2013. Three studies scored 7 points on the NOS, while the remaining studies scored 8 points, suggesting high quality. The pooled mean differences (MDs) of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score were 1.07 [95% confidence interval (CI) -1.06 to 3.20; P = 0.32; I2 = 79%]. The meta-analysis showed that neutral alignment and mild varus alignment were associated with similar the Oxford Knee Score (OKS), Knee Society Knee Score (KS-KS), and Knee Society Function Score (KS-FS), while neutral alignment was associated with lower Forgotten Joint Score (FJS) [mean difference -6.0, 95% confidence interval (CI) -9.37 to -2.64, P = 0.0005]. Neutral alignment was associated with higher KS-KS than severe alignment (M 2.98, 95% CI 1.42 to 4.55, P = 0.0002; I2 = 0%) as well as higher KS-FS (M 8.20, 95% CI 4.58 to 11.82, P < 0.00001; I2 = 0%). Neutral alignment was associated with similar rate of survival as mild varus alignment (95% CI 0.36 to 9.10; P = 0.48; I2 = 65%) or severe varus alignment (95% CI 0.94 to 37.90; P = 0.06; I2 = 61%). There was no statistical difference in others. Residual mild varus alignment after TKA may lead to similar or superior outcomes than neutral alignment in patients with preoperative varus knees, yet the available evidence appears to be insufficient to replace the current gold standard of neutral alignment. Severe varus alignment should be avoided.

Long-Term Clinical Outcomes and Survivorship of Total Hip Arthroplasty for Pyogenic Arthritis: A Retrospective Cohort Study of 168 Hips.

OBJECTIVE: The aim of the present study was to evaluate the 10-year outcomes of cementless total hip arthroplasty (THA) in adult patients with the late sequelae of septic arthritis of the hip. METHODS: We followed 166 consecutive patients (168 hips) who underwent cementless THA between March 2001 and December 2011. There were 79 men and 87 women, with a mean age of 50.4 years (range 21-76 years) at the time of index THA, all of whom had hip osteoarthritis secondary to hip pyogenic infection. The average duration of follow up was 10.6 years (range 6.9-17.2 years). Preoperative and postoperative clinical ratings were evaluated, including the hip dysfunction and osteoarthritis outcome score (HOOS), the Harris hip score (HHS), range of motion, a 100-point visual analog scale for hip pain, and the severity of limp and limb length discrepancy (LLD). The anteroposterior and lateral radiographs of the hip and full-length view of the lower extremities were obtained to assess the position of the components, radiolucent lines, osteolysis, loosening of components, and heterotopic ossification. The intraoperative and postoperative complications were also recorded. RESULTS: The mean HSS and hip pain score were 44.2 points (range 29-66 points) and 42.5 points (range 32-64 points), respectively, before the index surgery and significantly improved to 88.1 points (range 78-96 points) and 15.1 points (range 10-26 points), respectively, at final follow-up examination. The HOOS and range of motion also improved significantly. The mean limb length discrepancy was reduced from 2.6 to 0.8 cm. The limp at last follow-up examination was moderate in 3 cases because of hip osteoarthritis in the other limb, slight in 26, and absent in 137. A radiolucent line was observed in 12 hips (7.1%) around the acetabular or femoral components. A progressive radiolucent line around the undersized femoral stem in all zones was seen in 1 hip, resulting in aseptic loosening and breakage of the femoral component. There were 8 cases of intraoperative fracture, 7 cases of dislocation, and 7 cases of transient nerve palsy. Recurrence of infection occurred in 2 hips. Revision surgery was conducted in 2 hips because of isolated loosening of the acetabular cup and the femoral stem, respectively. Kaplan-Meier survival was 97% at 10 years, with revision for any reason with any component as an end-point. CONCLUSION: Improved surgical techniques and development of components with various sizes provided favorable results for cementless THA conducted for late sequelae of sepsis in these young and active patients. Although the incidence of complications was relatively high, the complications were treated successfully.

Femoral and tibial cementless fixation neither increases blood loss nor impedes early functional recovery: A randomized controlled trial.

Background: Whether cementless fixation on femoral and tibial components increases blood loss during total knee arthroplasty (TKA) is unclear. The purpose of this randomized controlled trial was to compare blood loss and early functional recovery between patients who underwent cementless or cemented TKA. Methods: Between November 2021 and April 2022, sixty-one eligible patients at our medical center were randomized to cementless and cemented group. The primary outcome was total blood loss (TBL). Secondary outcomes were drainage, knee swelling, anemia, transfusion, hematological indicators, early functional recovery, and postoperative complications. The early functional recovery included range of motion (ROM), Hospital for Special Surgery (HSS) score, walking distance. Results: A total of 61 patients were analyzed, of whom 30 underwent cementless fixation. On postoperative day 1, the mean TBL was 394.39 ml (SD 182.97 ml) in the cementless group and 382.41 ml (SD 208.67 ml) in the cemented group (P = 0.863). By postoperative day 3, the corresponding mean TBL was higher at 593.48 ml (SD 230.04 ml) and 603.80 ml (SD 213.16 ml) (P = 0.751). The two groups did not differ significantly in drainage, knee swelling, anemia, levels of hemoglobin or hematocrit or platelets, ROM, HSS score, walking distance, or rates of transfusion or postoperative complications. Conclusions: Cementless fixation on femoral and tibial components during TKA does not increase blood loss or impede early functional recovery, which suggests that clinicians need not worry about blood loss and early functional recovery when deciding what type of fixation to perform during TKA. Trial registration: Number: ChiCTR2100052857; Date: November 6, 2021.

Cementless total hip arthroplasty for three different degrees of hip involved secondary to ankylosing spondylitis: an analysis of 195 hips.

BACKGROUND: Hip involved secondary to ankylosis spondylitis (AS) had a huge influence on hip function. Cementless total hip arthroplasty (THA) can improve hip function. However, no previous study compared the outcomes of THA for AS patients with three different degrees of hip involvement. METHODS: The 195 hips were retrospectively analyzed and divided into non-ankylosed group (group A, 94 hips), fibrous ankylosed group (group B, 49 hips), and bony ankylosed group (group C, 52 hips). postoperative range of motion (ROM), harris hip scores (HHS), the short-form 12 health survey (SF-12), length of stay (LOS), cost, radiological assessments, and complications were compared. RESULTS: The follow-up time was (79.4 ± 29.5) months for group A, (80.6 ± 28.9) months for group B, and (79.1 ± 28.9) months for group C (P = 0.966). Group A had the best postoperative hip ROM (P < 0.001), while group A and B can realize better HHS than group C (P < 0.001). The three groups had similar SF-12 postoperatively. For group A, LOS and cost for unilateral procedure were the least than that for group B and C (P = 0.003 and P = 0.001). Similar radiological assessments were achieved for three groups. 1 hip in group A encountered delay union of wound. 1 hip in group C encountered delay union of wound and dislocation and another patient encountered femoral fracture intraoperatively. 12 hips (12.8%) in group A, 6 hips (12.2%) in group B, and 6 hips (11.5%) in group C encountered asymptomatic heterotopic ossification (P = 0.977). CONCLUSION: For AS patients with hip involvement, THA can improve hip ROM and function. THA for the non-ankylosed hip can realize the better hip function and postoperative ROM than ankylosed hip.

Nomogram to predict collapse-free survival after core decompression of nontraumatic osteonecrosis of the femoral head.

BACKGROUND: Nontraumatic osteonecrosis of the femoral head (NONFH) is a devastating disease, and the risk factors associated with progression into collapse after core decompression (CD) remain poorly defined. Therefore, we aim to define risk factors associated with collapse-free survival (CFS) after CD of precollapse NONFH and to propose a nomogram for individual risk prediction. METHODS: According to the baseline characteristics, clinical information, radiographic evaluations, and laboratory examination, a nomogram was developed using a single institutional cohort of patients who received multiple drilling for precollapse NONFH between January 2007 and December 2019 to predict CFS after CD of precollapse NONFH. Furthermore, we used C statistics, calibration plot, and Kaplan-Meier curve to test the discriminative ability and calibration of the nomogram to predict CFS. RESULTS: One hundred and seventy-three patients who underwent CD for precollapse NONFH were retrospectively screened and included in the present study. Using a multiple Cox regression to identify relevant risk factors, the following risk factors were incorporated in the prediction of CFS: acute onset of symptom (HR, 2.78; 95% CI, 1.03-7.48; P = 0.043), necrotic location of Japanese Investigation Committee (JIC) C1 and C2 (HR, 3.67; 95% CI, 1.20-11.27; P = 0.023), necrotic angle in the range of 250-299°(HR, 5.08; 95% CI, 1.73-14.93; P = 0.003) and > 299° (HR, 9.96; 95% CI, 3.23-30.70; P < 0.001), and bone marrow edema (BME) before CD (HR, 2.03; 95% CI, 1.02-4.02; P = 0.042). The C statistics was 0.82 for CFS which revealed good discriminative ability and calibration of the nomogram. CONCLUSIONS: Independent predictors of progression into collapse after CD for precollapse NONFH were identified to develop a nomogram predicting CFS. In addition, the nomogram could divide precollapse NONFH patients into prognosis groups and performed well in internal validation.

Microbiology of Periprosthetic Hip and Knee Infections in Surgically Revised Cases from 34 Centers in Mainland China.

BACKGROUND AND AIM: Periprosthetic joint infection (PJI) is one of the most devastating complications after total joint arthroplasty (TJA). However, the antibiotic resistance of infecting pathogens can significantly vary in different parts of the country. In the current study, we analyzed the demographic and microbiological profiles of knee and hip PJI over three years and compared the microbiological differences between them. METHODS: A multicenter retrospective study of PJI patients in 34 referral medical centers in mainland China from January 2015 to November 2017 was performed. RESULTS: A total of 925 PJI patients were recruited, 452 were identified as knee PJIs, and 473 were hip PJIs. The most common causative pathogens were Staphylococcus aureus (26.5%) and coagulase-negative staphylococci (14.3%). Methicillin-resistant staphylococci were involved in 25.6% (237/925) of all PJI cases. Mycobacterium and fungus only accounted for 6.5% (61) of all cases. Enteric gram-negative bacilli, anaerobes, and polymicrobial pathogens were more common in hip joint prostheses than in knee PJI (P = 0.014; P = 0.006; P = 0.002, respectively). CONCLUSION: While the majority of causative pathogens in PJI cases are staphylococcal species, the prevalence of atypical organisms and resistant pathogens should also be given attention and warrant the need for empiric antibiotic treatment.