Clinical efficacy of implementing a Patient Blood Management (PBM) Protocol in joint replacement surgery: a retrospective cohort study in a national referral center.

OBJECTIVE: The aging of population has dramatically broadened the total number of Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) performed worldwide. To optimize the number of blood transfusions performed, a multimodal and multidisciplinary approach was introduced, called Patient Blood Management (PBM). The aim of the present retrospective study is to evaluate the feasibility and clinical outcomes of a PBM protocol applied in a national referral center for joint replacement surgery. PATIENTS AND METHODS: Clinical reports of 9,635 patients undergoing primary THA or TKA, from 2014 to 2019, were screened. The trends of hemoglobin value at admission and at day 4 after surgery were analyzed. Furthermore, the trend of blood bags' requests and blood transfusions was longitudinally evaluated to assess the efficacy of our PBM protocol and its potential impact in reducing the length of stay in the hospital. RESULTS: In 2014, mean hemoglobin (Hb) levels at postoperative day 4 were 10.3 g/dl and 10.2 g/dl for TKA (unilateral and bilateral, respectively), and in 2019 were 11.3 g/dl and 11.6 g/dl (unilateral and bilateral, respectively, p=0.001). Total requested red blood cell (RBC) transfusions by each surgery over time have decreased for THA (277 in 2014 vs. 120 in 2019, p=0.001).  A correlation matrix analysis between Hb level, body mass index (BMI), age, days spent in orthopedic (OR) ward and number of requested transfusions showed that RBC bags transfusions were related to the length of the hospital stay. CONCLUSIONS: A timely application of a PBM protocol in the perioperative period of TKA and THA was significantly associated to the reduction of blood transfusions and total length of hospital stay, with clear benefits for both the patients and the hospital.

Decreased periprosthetic bone loss in patients treated with clodronate: a 1-year randomized controlled study.

The efficacy of clodronate to reduce bone loss around uncemented stems after total hip arthroplasty(THA) was evaluated. Ninety-one patients operated with uncemented THA were randomized to receive either intramuscular clodronate at a dose of 100 mg weekly for 12 months or no treatment. Periprosthetic and contralateral bone mineral density (BMD) scans were performed and biochemical markers of bone turnover measured at baseline and at 3, 6, and 12 months. At month 12, with the exception of Gruen zones 4 and 5, patients treated with clodronate showed less bone loss at all zones, reaching statistical significance (P\0.05) in Gruen zones 2 and 6 (difference of 6.6 and 5.9%, respectively). Analysis of data according to gender revealed sex-related differences in bone loss and efficacy of treatment. After 12 months, the difference in bone loss between treated and untreated women in five out of seven Gruen zones ranged from 6.2 to 13.3% (SS at zones 2 and 6), whereas comparison between treated and untreated men showed no BMD differences in all zones(P[0.05). Median percent changes in serum levels of markers of bone metabolism by gender were consistent with BMD changes. A 1-year treatment with intramuscular clodronate determined a significant reduction of bone loss after THA. This was mainly attributed to its greater efficacy in the female population, which is at higher risk for bone loss. This observation suggests the need for the characterization of high-risk subjects as potential candidates for prevention strategies.

Etiology of prosthetic joint infections in a tertiary care centre in Italy.

Prosthetic joint infections (PJIs) represent a severe complication in orthopaedics. Coagulase-negative staphylococci (CoNS) and Staphylococcus aureus represent the most frequent cause, but Gram-negatives have also been reported. With a view to describing the aetiology of PJIs diagnosed from January 2005 to September 2007 at S. Corona Hospital in Pietra Ligure, Italy, we conducted retrospective analysis of pathogens isolated from PJIs by means of surgical specimens, needle aspirates or swabs of fistula (3 samples). During the study period 228 PJIs were described and 141 (62%) were microbiologically documented and evaluated. Early and delayed infections represented 45% of episodes, while late infections were observed in 55%. The aetiology was mono-microbial in 84% of cases, and polymicrobial in 16%. CoNS and S. aureus were the most frequently isolated pathogens. In early and delayed infections methicillin resistant CoNS were 30% and 24%, respectively, while in late infections they were 17%. Methicillin-resistant S. aureus was isolated in 13% of early, 22% of delayed and 15% of late infections. Gram-negatives were described in 16% of episodes without differences being found in the three groups. In our report staphylococci represented the most frequent cause of PJIs. Methicillin-resistant strains were more frequently isolated in early and delayed infections, but their frequency in late episodes was not negligible. Polymicrobial infections and Gram-negative infections were also frequent.

Outcomes of the MS-30 cemented femoral stem.

The MS-30 (Morscher-Spotorno) cemented femoral stem is a straight, three-dimensionally tapered, collarless implant for cemented fixation in total hip replacement, manufactured from a FeCrNiMnMoNb-alloy. This paper documents the review of 4 original follow-ups performed at four orthopaedic hospitals: three at the author's institution (Basel/Switzerland 2, Pietra Ligure/Italy 1), and one at the University Orthopaedic Hospital of Heidelberg/ Germany. A total of 911 hips in 867 patients have been provided with the MS-30 stem. All stems were fixed with Palacos bone cement, the great majority with antibiotic (Gentamicine) loaded cement. The mean observation time was 10.2, 5.6, 10.2 and 6.5 years. One hundred and sixty-four hips were lost due to patients death, 121 patients were unable to come to the follow-up check. Ten patients only were lost to follow-up. The total number of hips with a clinical radiological follow-up was 597. The clinical and radiological assessment was in accordance with the International Documentation and Evaluation System (IDES) forms from the Institute of Documentation of the M.E. Müller Foundation in Berne/Switzerland. RESULTS The overall survivorship in the four follow-ups were 100% after 10 years, 98.4% and 99.2% after 5.5.years, 98.5% after 10 years and finally 96.1% after 6.5 years. The respective percentages of survival for aseptic loosening were 100%, 99.2%, 100%, 98.5% and 98.8%. CONCLUSION According to the NIH (National Institute of Health, United Kingdom) a survival rate of 95% regarding aseptic loosening justifies or even recommends further clinical use of the respective endoprosthesis system.

First implant acetabular components: historical aspects, a comparison of models and a review of the literature.

The article describes the features of the most commonly-used acetabular components in first implants in light of development in construction as regards intrinsic features, materials used, biological behavior, and design. The following versions are examined: screwable cone-shaped trunk, cemented polyethylene, cemented metal-back, HA-coated press-fit, expansion, dysplastic hip, and anti-dislocating components. The screwable cone-shaped trunk acetabular component takes hold in the acetabular bone through torsion and compression, and threading provides greater stability as compared to equivalent models that have wings or screws. Cemented polyethylene acetabular components are characterized by low costs and good results, on the condition that some specific parameters are respected (the presence of a dry bone bed, pressurization of the cement, use in elderly patients who do very little physical activity). Cemented metal-back acetabular components have features similar to polyethylene components, from which they differ because of the possibility of being able to substitute the internal polyethylene component without having to revision the entire acetabulum. HA-coated press-fit components have solved the problems encountered in cemented versions, such as loosening and the generation of polyethylene particulate, at the same time obtaining excellent osteo-integration. The expansion cup self-stabilizes thanks to a memory effect due to the contraction-relaxation mechanism with which it is lodged, adapting to the micro-movements of the acetabulum. Components used in the dysplastic hip are particular versions with a reduced diameter that have specific hooks that provide stabilization, capable of settling in the pathologic bone with minimum reaming of the same. Anti-dislocation cups are special models that have bipolar inserts or a ring (plastic or metal) that blocks the head in the prosthetic acetabulum, obstructing its dislocation.

Single-shot epidural-spinal anesthesia followed by oral oxycodone/naloxone and ketoprofen combination in patients undergoing total hip replacement: analgesic efficacy and tolerability.

BACKGROUND: Many patients undergoing hip replacement have inadequate postoperative pain control, leading to suboptimal recovery. Oxycodone is effective in controlling pain, but is associated with adverse events such as postoperative nausea and vomiting (PONV). In patients with chronic pain, oral oxycodone-naloxone combination (OXN) provides comparable analgesia with fewer side effects. This retrospective, single-centre study evaluated analgesic effectiveness and tolerability of single-shot epidural spinal anaesthesia followed by OXN after total hip replacement. METHODS: Consecutive patients received perioperative spinal-epidural anaesthesia, OXN 10/5 mg and oral ketoprofen 100 mg q 12h for 4 days. Efficacy and tolerability were assessed on the evening post surgery and days 1-3 after. Efficacy endpoints included pain intensity at rest and upon movement (Numerical Rating Scale [NRS] Score), rescue analgesia and patient satisfaction (0-3 point scale). RESULTS: Two hundred eighty-two patients were included in the observation (57.2% women, mean age 62.9±12 years). After surgery, pain intensity remained well controlled, both at rest (mean NRS: 1.1, 1.1, 1.2 and 1.2 on days 0-3 respectively; P=ns) and upon movement (2.1, 2.4, 2.1 and 2.0; P=ns). No patient reported severe pain throughout the observation. Rescue paracetamol was required on days 0-3 in 17.0%, 18.4%, 12.4% and 12.1% of patients, respectively (P<0.009); no patient required additional intravenous rescue morphine. Seventy-two percent of patients were 'very satisfied' with postoperative pain therapy. CONCLUSION: Single-shot epidural spinal anaesthesia followed by OXN-based analgesia after hip replacement provided effective pain management, with high patient satisfaction rates.

The CLS system. Theoretical concept and results.

The CLS femoral prosthesis is a titanium stem designed as a 3-dimensional taper for press-fit implantation. The distal part of the prosthesis is intentionally made small so that it will not fill the intramedullary canal in the proximal diaphysis. The surface is bead blasted and has no bone ingrowth surface. Ribs in the proximal part of the prosthesis are designed to minimize rotational migration. The CLS acetabular component is a 6-sided expanding cup intended for implant with press-fit stabilization. This article emphasizes indications for use of the CLS, and it includes a brief report on clinical and radiographical results. Data from a review of the first 300 CLS stems implanted from 1983 to 1985 with an 82-month average follow-up suggested that neither bone ingrowth nor distal fit and fill are necessary for stable secondary fixation of an uncemented stem.

Evolution of surgical techniques for the treatment of angular and torsional deviation in DDH: 20 years experience.

The anatomical abnormalities associated with developmental dysplasia of the hip (DDH) increase the complexity of hip arthroplasty. In addition, previous femoral osteotomy can deform the proximal femur. Noncemented cups and stems are specifically designed for dysplasia to recover the true acetabular region in Crowe grade IV and sometimes Crowe grade III; additional surgical procedures are required. The purpose of the study was to analyse the surgical procedure and then the reconstructive options in DDH. From 1984 until now, total arthroplasty has been performed, on dysplastic hips, in 2,101 patients for 2,308 hips (207 patients bilateral 9% rate). All the procedures were performed by the senior authors (LS, GG) at the same hospital specialised in elective hip surgery. More than 80% of patients came from Northern Italy. The average age was 51 (range 32-83), 565 cases had involved a previous femoral osteotomy. Out of these 2,308 cases, 128 cases needed treatment for corrections of femoral side deformity; 64 cases were subjected to a greater trochanter osteotomy. In 12 cases, proximal femur shortening was involved. In 9 cases, rotational abnormality and shortening were controlled with a distal femur osteotomy. Fifty-five cases were treated by a shortening subtrochanteric osteotomy that allows corrections of any deformity. Only noncemented stems were used. Long-term results in these patients are consistently inferior (70% survival rate at 15 years) compared to those in the non-DDH population (97.7% survival at 15 years). On the femoral side, early failures are the reflection of a learning curve and are due to insufficient fixation of the osteotomy. The more promising outcomes are those involving a shortening subtrochanteric osteotomy.