Nalbuphine versus morphine: an adjuvant to spinal anesthesia for controlling pain after total knee arthroplasty: a propensity score-matched analysis.

BACKGROUND: Nalbuphine, a synthetic k-agonist and µ-antagonist, provides efficient pain relief while reducing opioid-related adverse effects. This study aims to compare the efficacy of intrathecal nalbuphine (ITN) with intrathecal morphine (ITM) for post-TKA pain. METHODS: A retrospective cohort analysis of 131 patients who underwent TKA with spinal anesthesia (SA), a single shot of adductor canal block, and periarticular injections was conducted. The patients were divided into 2 groups, Group N received 0.8 mg nalbuphine, and Group M received 0.2 mg morphine as an adjuvant to SA. Propensity-score matching was employed to compare the visual analog scales (VAS) of postoperative pain intensity, cumulative morphine use (CMU), maximum knee flexion angle, straight leg raise (SLR) ability, incidence of postoperative nausea and vomiting (PONV), and length of hospital stay (LHS). RESULTS: The mean VAS of group M were significantly lower than group N at 6, 12, 18, and 24 h (P < 0.01). Group M had lower CMU than group N at 24 h (P < 0.01) and 48 h (P < 0.01), while there was no significant difference between groups in terms of knee flexion angle and SLR at any time point. Additionally, 29.3 and 57.9% of patients in group N and M experienced PONV, respectively (p = 0.04), and group N had significantly shorter LHS compared to group M (P < 0.001). CONCLUSION: Although, intrathecal morphine (ITM) still provides better pain control particularly in the first 24 h, patients who received intrathecal nalbuphine (ITN) had significantly fewer incidence of PONV, and shorter LHS.

Effect of multiple analgesic pathways including local infiltration analgesia, peripheral nerve blocks, and intrathecal morphine for controlling pain after total knee arthroplasty.

BACKGROUND: We questioned whether the triple analgesic pathways procedure via local infiltration analgesia (LIA), peripheral nerve blocks, and intrathecal morphine (ITM) is superior to LIA only for controlling pain after Total Knee Arthroplasty (TKA). METHODS: This retrospective study included 192 primary TKA patients. Group A (76 patients) received LIA only, Group B (61 patients) had ITM, adductor canal block and LIA, while Group C (55 patients) received ITM, femoral nerve block and LIA. A propensity score-matched analysis was used to compare visual analog scales (VAS) for pain intensity, total amount of morphine consumption (TMC), angle of knee flexion, and length of hospital stay (LHS). RESULTS: Group A showed significantly higher VAS than Group B at 12 h (4.27 ± 2.70 vs 2.42 ± 2.35) and 18 h (4.24 ± 2.35 vs 2.18 ± 2.02), and significantly higher than Group C at 6 h (3.46 ± 3.07 vs 0.60 ± 1.50), 12 h (4.27 ± 2.70 vs 0.89 ± 1.48), and 18 h postoperative (4.24 ± 2.35 vs 1.82 ± 2.18). However, the VAS of Group C and B converged to equalize with Group A after 12 and 18 h, respectively. The TMC at 48 h postoperative of Group A was higher than that of Group B (p < 0.01). Nevertheless, there was no difference between groups in terms of knee flexion and LHS, except the LHS of Group B was longer than Group A (p = 0.04). CONCLUSION: Triple analgesic pathways could provide a better initial analgesic profile. However, the pain seems to be rebound after resolution of nerve block and ITM, with potentially longer LHS.

Additional Peripheral Nerve Block to Periarticular Injection Has No Benefit for Patients Undergoing TKA: A Factorial Propensity Score-Matched Analysis Comparing Four Multimodal Analgesic Techniques.

BACKGROUND: Controversy remains over what and how many analgesic techniques are required as the most effective multimodal pain regimen in total knee arthroplasty (TKA). This study aimed to evaluate the effect of additional analgesic methods combined with periarticular injection (PAI) analgesia for TKA. METHODS: Using retrospective cohort data, patients undergoing TKA with spinal anesthesia and PAI were divided into 4 groups. Group A (control) comprised 66 patients; group B (73 patients) had additional adductor canal block; group C (70 patients) obtained additional femoral nerve block, and group D (73 patients) received additional adductor canal block and intrathecal morphine. Propensity score matching was applied to compare visual analog scale (VAS) for pain intensity, cumulative morphine use (CMU), knee flexion angle, straight leg raise, length of hospital stay, and postoperative nausea and vomiting. RESULTS: There was no significant difference regarding VAS and morphine use, when either group B or C was compared with group A. Group D had significantly lower VAS than groups A, B, and C during the first 24 hours after surgery and required significantly less CMU than groups A and B. However, the pain score of group D increased afterward, with significantly longer length of hospital stay than groups A and B. There was no difference in straight leg raise among the groups. CONCLUSION: Additional peripheral nerve block to PAI provides no benefit for patients undergoing TKA. Adjuvant intrathecal morphine could significantly reduce the VAS and CMU in the acute postoperative period; however, rebound pain with prolonged hospital stays was observed.

Hyperextension following two different designs of fixed-bearing posterior-stabilized total knee arthroplasty.

PURPOSE: Hyperextension after total knee arthroplasty (TKA) is related to worse functional outcomes. Among the reported predictive factors, it is unclear whether prosthesis design affects postoperative hyperextension. Hence, our objectives were to (1) compare time-dependent changes of the extension angle following multi-radius (MR) and single-radius (SR) TKA and (2) assess predictive factors for the hyperextension. METHODS: In this study, consecutive 136 MR TKAs and consecutive 71 SR TKAs performed by a single surgeon were reviewed. The extension angle was evaluated by digitized full-extension lateral radiographs at preoperative, 3 months and at 1 and 2 years after TKA. A positive value was defined as hyperextension. A multiple regression analysis was used to determine predictive factors for the extension angle and the risk of hyperextension > 5°. RESULTS: The postoperative extension angle of both groups gradually increased during the first 2 years and the SR group finally progressed with 4.04° greater extension than the MR group (p < 0.01). The incidence of hyperextension > 5° in the SR group was 18.3% and for the MR group, 7.4% (p = 0.02). However, the Oxford knee scores was nonsignificant different between the groups (p = 0.15). Preoperative extension angle, sagittal femoral component angle (SFA) and SR prosthesis were predictive factors for the extension angle at 2 years after TKA and were also associated with hyperextension > 5°. CONCLUSIONS: The extension angle of the SR group became significantly more extended than that of the MR group during the first two years after TKA. Hence, ideal extension position immediately after SR TKA may be different from that of the MR TKA prosthesis. The preoperative extension angle, SFA and SR prosthesis were factors that were associated with postoperative hyperextension.

Usefulness of an accelerometer-based navigation system in bilateral one-stage total knee arthroplasty.

BACKGROUND: Bilateral one-stage total knee arthroplasty (BTKA) have increased because it provides a number of advantages. Recently, Accelerometer-based navigation (ABN) system which guide the cutting plane without intramedullary disturbance might result in less endothelial and microvascular damage. Therefore, we hypothesized that the ABN may reduce blood loss, reduce postoperative pain, and better restore BTKA alignment compared to conventional instruments. METHODS: We retrospectively compared 44 consecutive patients receiving ABN assisted BTKA (iBTKA) to 57 patients with conventional instruments (cBTKA). Identical pre- and post-operative care was utilized to all patients. The outcome measures assessed were hemoglobin (Hb), calculated blood loss (CBL), blood transfusion, VAS score for pain, morphine consumption, knee flexion angle, and length of stay (LOS). Radiographic assessment included mechanical axis (MA) and component positioning at 3-6 months of follow up. RESULTS: Both iBTKA and cTKA groups had equivalent demographic data. Postoperative Hb of the cBTKA group was significantly lower than those in the iBTKA group at 24 h (p = 0.02), but there was no significant difference in drain volume, CBL, and blood transfusion rate. For radiographic measures, the iBTKA group had more accurate MA and component orientation, and had a lower number of outliers than those in the cBTKA group (p ≤ 0.01), except for the sagittal femoral component angle. CONCLUSION: The ABN assisted BTKA could not reduce blood loss or postoperative pain more than cBTKA, nor improve functional recovery. However, the ABN significantly improved the accuracy of MA and prostheses positioning. TRIAL REGISTRATION: The protocol of this study was registered in the Thai Clinical Trials Registry database No. TCTR20180731001 # on 25 July 2018.

Timing of periarticular injection has no effect on postoperative pain and functional recovery in simultaneous bilateral total knee arthroplasty: a prospective randomized, double-blinded trial.

BACKGROUND: Given no consensus on optimal timeframe of periarticular multimodal drug injection (PMDI) in knee osteoarthritis patients undergoing total knee arthroplasty (TKA), this study was aimed to compare the postoperative pain and the functional recovery in patients who underwent simultaneous bilateral TKA (SBTKA) and received PMDI at the different intraoperative time points. METHODS: This prospective, randomized, double-blinded controlled trial study included 48 patients who underwent SBTKA and received PMDI mixture, either before prosthetic implantation (late PMDI), or just after knee arthrotomy (early PMDI). Each subject's knees were randomly selected to different PMDI administration time points. The outcome parameters were postoperative pain assessed by using a visual analog scale (VAS), the maximal angle of knee flexion, and quadriceps function from day 1 to 6 weeks after surgery. RESULTS: Late PMDI revealed slightly higher VAS at 6 and 12 h after the operation than early PMDI administration. Afterward, the VAS tended to be lower in the late than early PMDI administration until the end of the study, but without statistical significance. The time difference between early and late PMDI had no effect on postoperative VAS, while older age resulted in significantly less pain. No statistical differences between the two groups in all other outcome parameters were observed. CONCLUSIONS: Postoperative pain reduction and functional recovery of SBTKA with early and late PMDI administration were not significantly different. The time interval of PMDI between knees did not confound the comparison of postoperative pain and functional recovery in SBTKA. TRIAL REGISTRATION: The protocol of this study was retrospectively registered in the Thai Clinical Trials Registry database No. TCTR20170617001 on 16 June 2017.

Subsidence of Hydroxyapatite-Coated Femoral Stem in Dorr Type C Proximal Femoral Morphology.

BACKGROUND: Good bone quality and proper proximal femoral morphology are thought to be necessary for tapered design, cementless femoral stems to resist subsidence. Using tapered, cementless stem for patients with stovepipe morphology or Dorr type C is controversial. The purpose of this study is to analyze (1) subsidence of the fully hydroxyapatite (HA)-coated, tapered, cementless stem in different morphology according to Dorr classification, (2) subsidence of the stem related to radiographic canal-fill ratio. METHODS: The digitized radiographs of 311 consecutive cementless primary total hip arthroplasty with fully HA-coated, tapered stem were retrospectively reviewed. Subsidence and the canal-fill ratio at 4 locations were evaluated postoperatively after a minimum of 2 years of follow-up. The threshold of subsidence >3 mm was considered as a clinically significant migration. RESULTS: A multivariate regression analysis of subsidence across Dorr type, controlling for age, gender, and intraoperative calcar fracture, demonstrated 0.40 mm (P = .28) and 0.18 mm (P = .51) greater subsidence in Dorr type C and B when compared to Dorr type A. Age, gender, and calcar fracture had no influence on subsidence, whereas greater canal-fill ratio at 2 cm below lesser trochanter resulted in significantly less subsidence (P = .02). Additionally, all variables did not affect the risk of having subsidence >3 mm. CONCLUSION: The proximal femoral morphology has no statistically significant effect on the subsidence of fully HA-coated stem. Therefore, this stem type might be a viable option for Dorr type C. Increasing the canal-fill ratio at metadiaphyseal junction may ensure the stability of the stem.

Intra-Articular Tranexamic Acid Mitigates Blood Loss and Morphine Use After Total Knee Arthroplasty. A Randomized Controlled Trial.

BACKGROUND: Tranexamic acid (TXA) has been widely used in total knee arthroplasty (TKA) for blood loss reduction. Given limited evidence on potential relationship between the TXA and improvement of pain control and functional outcome after TKA, this study aimed at comparing the blood loss, pain scores, morphine consumption, and knee flexion across the TXA administration routes. METHODS: The 228 primary TKA were randomized into no TXA use (No-TXA), intra-articular TXA (15 mg/kg) use (IA-TXA), and intravenous TXA (10 mg/kg) use (IV-TXA). A multivariate regression analysis was used for comparing perioperative blood loss (PBL), drain output, average number of units of blood transfused (ANUBT), visual analogue scales (VAS) for pain, amount of morphine consumption, and knee flexion angle. RESULTS: The IA-TXA and IV-TXA group had 193.26 (P < .01) and 160.30 mL (P < .01) less PBL than No-TXA, respectively. No-TXA significantly required higher ANUBT than IA-TXA and IV-TXA (P = .03). The IA-TXA group had lower VAS at 6 (P = .04), 12 (P = .03), and 24 hours (P = .02) postoperative when compared to No-TXA, while IV-TXA had no effect. The IA-TXA required 18.26 mg less total morphine at 48 hours than No-TXA (P = .02), whereas IV-TXA used insignificantly (5.31 mg; P = .31) less total morphine at 48 hours than No-TXA. Both TXA routes tended to improve knee flexion, but not statistically significant. CONCLUSION: Both IA-TXA and IV-TXA could significantly reduce PBL and ANUBT. The IA-TXA could significantly mitigate VAS and morphine use after TKA. Hence, IA-TXA could minimize blood loss and may be considered as an adjunct to pain control following TKA.

Blood loss reduction: effect of different knee prosthesis designs and use of tranexamic acid-a randomized controlled trial.

PURPOSE: In regard to blood loss in total knee arthroplasty (TKA), the effect of either knee prosthesis designs or bone preparation is still unclear. While the benefit of using tranexamic acid (TXA) is well demonstrated, our study aims to determine the effect of different knee prosthesis designs uses and efficacy of blood loss reduction by different routes of TXA administration. METHODS: The 228 patients undergone primary TKA were randomized to determine between open-box and closed-box prosthesis. Among each group, a second randomization was applied to categorize the patients into (1) no use of TXA (No-TXA), (2) intra-articular TXA use (IA-TXA) and (3) intravenous TXA use (IV-TXA). The calculated blood loss (CBL), drain volume (DV) and an average number of units of blood transfused (ANUBT) were blindly evaluated. RESULTS: The open-box TKA had 85.60 and 63.29 ml (p = 0.02 and p < 0.01) more CBL and DV compared to closed-box TKA. The IA-TXA and IV-TXA significantly reduced CBL by 190.75 and 162.01 ml (p < 0.01 and p < 0.01) and reduced DV by 129.07 and 61.04 ml (p < 0.01 and p = 0.01), respectively, when compared to No-TXA. Patients who received IA and IV-TXA had ANUBT of 0.21 and 0.23 unit, which was significantly lower than 0.42 unit of No-TXA group (p = 0.03). CONCLUSIONS: Use of the different prosthesis designs could significantly affect CBL and DV following TKA. However, the use of either design resulted in a comparable ANUBT. Regardless of prosthetic type, either IA- or IV-TXA could significantly reduce the CBL and ANUBT when compared to No-TXA.

Anterior vs Posterior Periarticular Multimodal Drug Injections: A Randomized, Controlled Trial in Simultaneous Bilateral Total Knee Arthroplasty.

BACKGROUND: Currently, various techniques are used to overcome postoperative pain after total knee arthroplasty. A local analgesic infiltration with periarticular multimodal drug injection (PMDI) is favorable because of its simplicity, safety, and efficacy. The present study compared the efficacy of a PMDI at the anterior vs posterior compartments. METHODS: Forty-six patients were randomized to receive the PMDI at either the anterior or posterior compartment, with the contralateral knee receiving the PMDI at the opposite compartment. The PMDI injected to the posterior capsule, medial and lateral meniscal remnant, was defined as the posterior compartment injection, whereas the injection to the medial retinaculum, quadriceps muscle, pes anserinus, and retropatellar fat pad was defined as the anterior compartment injection. Pain scores at rest, knee flexion angle, quadriceps function, and drainage blood loss were evaluated in both groups. RESULTS: The anterior PMDI group had significantly lower pain scores at rest during 96 hours postoperatively. On the day of discharge, 19 patients (41.3%) favored the knee with the anterior PMDI, which was superior to 9 patients (19.6%) who favored the knee with the posterior PMDI. The anterior PMDI demonstrated a superior recovery of quadriceps function during the same period, but there was no significant difference in terms of other parameters. CONCLUSION: The PMDI at the anterior compartment can reduce pain after total knee arthroplasty with potentially better quadriceps function compared with that in the PMDI at the posterior compartment. We recommend infiltrating the anterior compartment with a greater amount of PMDI than the posterior compartment.

Independent Walking Disability After Fragility Hip Fractures: A Prognostic Factors Analysis.

Introduction: Up to one-third of patients with fragility hip fractures are totally dependent in the year following the injury which leads to later morbidity and mortality. Understanding the related factors that affect patients' ambulation helps health care providers prepare for the treatment plans to improve their functional outcomes. This study aimed to evaluate the factors associated with independent walking disability in the early postoperative period after fragility hip fractures. Material and methods: This retrospective cohort study involved 394 patients with fragility hip fractures with either intertrochanteric, subtrochanteric, or femoral neck fractures from January 2018 to June 2023. The related factors including preoperative demographics, perioperative, and postoperative factors, were collected and analyzed. The endpoint was the independent walking disability of patients at 6 weeks after surgery. Results: 110 patients (27.9%) were disabled, whereas 284 patients (72.1%) could walk independently at postoperative 6 weeks. The multivariable risk ratio regression analysis showed that patients with age ≥80 years (RR 1.65; 95% CI 1.21-2.25; P = 0.001), pre-fracture walking with the gait aid (RR 2.03; 95% CI 1.53-2.69; P < 0.001), having ≥2 underlying comorbidities (RR 1.63; 95% CI 1.19-2.23; P = 0.002), preoperative hypoalbuminemia (RR 1.74; 95% CI 1.32-2.29; P < 0.001), and presence of the postoperative medical complication (RR 2.04; 95% CI 1.37-3.02; P < 0.001) were significantly associated with independent walking disability at the early postoperative period of 6 weeks. Conclusions: Post-hip fracture surgery patients with the presence of postoperative medical complication have the highest risk of independent walking disability. Health care providers should concentrate on high-risk patients, correct the modifiable factors, and minimize any postoperative complications to improve functional recovery and decrease morbidity related to non-ambulation after fragility hip fractures.

Injectable vancomycin-loaded silk fibroin/methylcellulose containing calcium phosphate-based in situ thermosensitive hydrogel for local treatment of osteomyelitis: Fabrication, characterization, and in vitro performance evaluation.

The conventional treatment of osteomyelitis with antibiotic-loaded nondegradable polymethylmethacrylate (ATB-PMMA) beads has certain limitations, including impeded bone reconstruction and the need for secondary surgery. To overcome this challenge, this study aimed to develop and characterize an injectable vancomycin-loaded silk fibroin/methylcellulose containing calcium phosphate-based in situ thermosensitive hydrogel (VC-SF/MC-CAPs). The VC-SF/MC-CAPs solution can be easily administered at room temperature with a low injectability force of ≤30 N and a high vancomycin (VC) content of ~96%. Additionally, at physiological temperature (37 °C), the solution could transform into a rigid hydrogel within 7 minutes. In vitro drug release performed under both physiological (pH 7.4) and infection conditions (pH 4.5) revealed a prolonged release pattern of VC-SF/MC-CAPs following the Peppas-Sahlin kinetic model. In addition, the released VC from VC-SF/MC-CAPs hydrogels exhibited antibacterial activity against Staphylococcus aureus for a period exceeding 35 days, as characterized by the disk diffusion assay. Furthermore, at pH 7.4, the VC-SF/MC-CAPs demonstrated >60% degradation within 35 days. Importantly, when exposed to physiological pH conditions, CAPs are transformed into bioactive hydroxyapatite, which benefits bone formation. Therefore, VC-SF/MC-CAPs showed significant potential as a local drug delivery system for treating osteomyelitis.

Cruciate-Retaining Total Knee Arthroplasty versus Unicompartmental Knee Arthroplasty in Medial Compartmental Osteoarthritis: A Propensity Score-Matched Analysis of Early Postoperative Recovery.

Background: Cruciate-retaining (CR) total knee arthroplasty (TKA) may provide better physiological knee kinematics, proprioception, and quadricep recovery than posterior-stabilized (PS) TKA. Therefore, we hypothesized that CR TKA with multimodal pain control may provide comparable postoperative pain and recovery as unicompartmental knee arthroplasty (UKA). Methods: This study included patients with isolated medial compartment knee osteoarthritis who underwent CR TKA and UKA. TKA and UKA patients were propensity score-matched with age and body mass index (BMI) and compared using visual analog scales (VAS) for pain scores, total amount of morphine use (TMU), knee flexion angle, straight leg raise (SLR), independent ambulation, length of hospital stay (LOS), and costs during hospitalization. Results: After propensity score matching, 46 patients were included in the TKA and UKA groups, respectively, with no differences in demographic data. VAS at 6-72 h and TMU at 48 h after surgery were comparable between the groups. The knee flexion angle in the UKA group was significantly higher at 24 h (60.0° vs 46.6°; p<0.001) and 48 h (76.9° vs 69.1°; p = 0.021) than that in the TKA group. The SLR in the UKA group was significantly higher than that in the TKA group at 24-72 h. The UKA group ambulated significantly earlier (1.56 vs 2.13 days; p<0.001), had shorter LOS (3.68 vs 4.28 days; p<0.004) and incurred 12.43% lower costs when compared to the TKA group. Conclusion: Patients who underwent CR TKA with multimodal pain management did not experience more postoperative pain or morphine use than those who underwent UKA. However, UKA patients seem to experienced faster recovery and shorter LOS than CR-TKA patients during the early postoperative course. Accordingly, UKA may be considered instead of TKA for patients who are good candidates for UKA and require expedited recovery.

Addition of Ketorolac to Local Anesthesia for Wound Infiltration in Multilevel Posterior Lumbar Spinal Fusion: A Randomized, Double-Blinded, Placebo-controlled Trial.

STUDY DESIGN: Randomized double-blind controlled trial. OBJECTIVE: The purpose of this study was to determine the efficacy of pain control and opioid consumption after administration of ketorolac directly to paraspinal muscle after spinal fusion. SUMMARY OF BACKGROUND DATA: Ketorolac is added to multimodal analgesia regimens to improve pain control, reduce opioid consumption following Orthopaedics and spine surgery. However, evidence of efficacy of adding ketorolac to local anesthesia for intrawound infiltration after spine surgery is still limited. MATERIALS AND METHODS: The patients who underwent multilevel lumbar decompression and posterolateral fusion were recruited and randomized to the control group which received 0.5% bupivacaine hydrochloride injected into paraspinal muscles before wound closure, and the ketorolac group which received 30 mg ketorolac in addition to 0.5% bupivacaine hydrochloride. Post-operative numerical rating scale (NRS) for back pain, leg pain, morphine consumption, and adverse events were recorded. RESULTS: A total of 47 patients were randomized (24 in the ketorolac group and 23 in the control group). The mean age was 60.9±6.9 years old. The mean NRS for back pain at 6 hours after surgery was 5.8±3.0 points for the control group and 3.3±2.1 points for the ketorolac group (P<0.01). The ketorolac group consumed lesser morphine than the control group by 9.1 mg in the first 24 hours, 13.8 mg at 48 hours, 14.3 mg at 72 hours, and 13.9 mg at 96 hours after the surgery (P<0.05). Post-operative complications were not different between the two groups. CONCLUSIONS: The addition of ketorolac to bupivacaine for wound infiltration after posterior lumbar spine decompression and fusion reduces early post-operative pain and total morphine consumption as compared to bupivacaine alone.

Efficacy and Safety of Generic Alendronate for Osteoporosis Treatment.

Background: While osteoporosis increases the risk of fragility fractures, bisphosphonate has been proven to increase bone strength and reduce the risk of vertebral and non-vertebral fractures. In addition to its efficacy, substituting the brand with generic medication is a strategy to optimize healthcare expenditures. This study aimed to evaluate the efficacy of generic alendronate treatment and assess potential adverse events in patients with osteoporosis. Materials and Methods: A retrospective review was conducted on 120 patients who met the indications for osteoporosis treatment, received weekly generic alendronate (70 mg) for >1 year, and underwent evaluation through standard axial dual-energy X-ray absorptiometry (DXA). The outcomes of this study were the percent change in bone mineral density (BMD) at the lumbar spine, femoral neck, and total hip after one year of treatment. The major adverse events occurring during medication that led to the discontinuation of drug administration were documented. Results: Most patients were female (96.7%) with an average age of 69.0 ± 9.3 years. The percent change in BMD increased at all sites after one year of generic alendronate treatment (lumbar spine: 5.6 ± 13.7, p-value <0.001; femoral neck: 2.3 ± 8.3, p-value = 0.023; total hip: 2.1 ± 6.2, p-value = 0.003), with over 85% of patients experiencing increased or stable BMD. Three patients discontinued the medication due to adverse effects: two had dyspepsia, and one had persistent myalgia. Conclusion: Generic alendronate may be considered an effective antiresorptive agent for osteoporosis treatment with a low incidence of adverse effects.

Low molecular weight heparin prevents the progression of precollapse osteonecrosis of the hip.

BACKGROUND: Hypercoaguable state has been indicated as a major risk factor in predisposing the idiopathic osteonecrosis of the hip. Furthermore, many studies have demonstrated that low molecular weight heparin (LMWH) can reverse the pathophysiology of the osteonecrosis of the hip in thrombophilic patients. OBJECTIVE: Determine whether LMWH can prevent the progression of idiopathic osteonecrosis of the hip. MATERIAL AND METHOD: A retrospective study of 36 patients who had bilateral idiopathic osteonecrosis with at least one hip in the pre-collapsed stage (Ficat & Arlet stage I-II) was conducted. In the study group, 18 patients (26 hips) received 6,000 units of Enoxaparin daily for 12 weeks. In the control group, 18 patients (23 hips) received no Enoxaparin. All patients were given radiographic evaluations every three months for a minimum of24 months. RESULTS: At the last follow-up, 15 hips (57.7%) from the study group and five hips (21.7%) from the control group were observed to remain in the pre-collapse stage (p = 0.042). Coagulation disorder was observed in seven patients (38.9%) of the experimental group and five patients (27.8%) of the control group. One patient from the study group exhibited hematuria with spontaneous resolution after the course ofEnoxaparin injection. CONCLUSION: A progression rate of idiopathic osteonecrosis of the hip from the pre-collapse stage to the collapsed stage was found to be significantly lower in patients who received LMWH.

Calcium phosphate incorporated in silk fibroin/methylcellulose based injectable hydrogel: Preparation, characterization, and in vitro biological evaluation for bone defect treatment.

Bone defect is still a challenging problem in orthopedic practice. Injectable bone substitutes that can fill different geometry of bone defect and improve biological environment for bone regeneration are attracting attention. Herein, silk fibroin (SF) is noticeable polymer regarding its biocompatible and biodegradable properties. Thus, the calcium phosphate particles incorporated in silk fibroin/methylcellulose (CAPs-SF/MC) and only methylcellulose (CAPs-MC) hydrogels are developed and compared their physicochemical properties. Both CAPs-hydrogels solutions can be administered with a low injectability force of ~6 N, and they require ~40-min to change to hydrogel at physiological temperature (37°C). The CAPs are evenly distributed throughout the hydrogel matrix and are capable transformed to bioactive hydroxyapatite at pH 7.4. The CAPs in CAPs-SF/MC have a smaller size than those in CAPs-MC. Moreover, CAPs-SF/MC exhibit gradual degradation, as prediction of the degradation mechanism by the Peppas-Sahlin model and show a greater ability to sustain CAPs release. CAPs-SF/MC has good biocompatibility with less cytotoxicity in a dose-dependent manner on mouse preosteoblast cell line (MC3T3-E1) when compared to CAPs-MC. CAPs-SF/MC hydrogels also have better possibility for promoting cell proliferation and differentiation. In conclusion SF incorporated into composite injectable hydrogel potentially improve biological characteristics and may provide clinical advantages.

Self-aligned Technique for Tibial Component Placement in Total Knee Arthroplasty Lessening Rotational Malalignment in Measured Resection and Gap-Balancing Techniques.

Background: Femorotibial rotational mismatch can occur when there is a rotational malalignment in either the tibial or femoral component. Self-aligned technique was proposed for orienting the tibial component in relation to the femoral prosthesis to reduce rotational malalignment between components. Therefore, we aimed to compare the rotational angle of the femoral and tibial components, as well as the femorotibial rotational mismatch, between the measured resection (MR) and gap-balancing (GB) techniques when combined with a self-aligned technique. Methods: We conducted a nonrandomized, experimental study with 50 patients in each group. The femoral rotation was set to 3° external rotation relative to the posterior condylar axis in the MR group, whereas the femur was resected to obtain an optimal rectangular flexion gap in the GB group. The self-aligned method was used to set the tibial rotation in both groups. Femoral and tibial rotational alignments were evaluated compared to a surgical transepicondylar axis of the femur using computed tomography. Rotational mismatch was defined as a difference between the femoral and tibial rotational alignments. A positive value indicated that the component was externally rotated relative to the reference line. Results: The femoral component of the GB group was more externally rotated than that of the MR group (1.52° ± 1.31° vs 0.28° ± 1.16°, p < 0.001). However, the tibial rotational angle was not statistically significantly different between the MR and GB groups (1.28° ± 3.17° vs. 1.86° ± 2.81°, p = 0.220), and the rotational mismatch was 1.00° ± 3.28° and 0.34° ± 2.71°, respectively (p = 0.306). Conclusions: Although the femoral component of the GB group had a greater degree of external rotation than that of the MR group, the use of a self-aligned technique for tibial component placement resulted in no significant difference in tibial rotational alignment or rotational mismatch. This technique helps align the tibial component with the femoral component and lessen the degree of rotational malalignment in both the MR and GB techniques.

Direct Anatomic Registration in Computer-Assisted Total Hip Arthroplasty Improves Accuracy of Acetabular Cup Alignment.

Background: Computer-assisted total hip arthroplasty using direct anatomic registration (DAR) with acetabular center axis software is an alternative method to the indirect anterior pelvic plane method. The software maps the center of hip rotation and orientation of the native acetabulum in 3 dimensions. This study aimed to evaluate the accuracy of acetabular cup alignment using DAR navigation combined with a mechanical guide device (MGD). Methods: This prospective nonrandomized controlled study included 106 patients who underwent primary cementless total hip arthroplasty through the posterolateral approach. Fifty-four patients in the study group underwent DAR combined with MGD, whereas 52 patients underwent MGD only for acetabular cup positioning. Plain radiographs of both hips and computerized tomographic scans were obtained 2 months postoperatively for the evaluation of acetabular cup inclination and anteversion, respectively. Results: The acetabular cup alignment in the study group was within the Lewinnek safe zone more than that in the control group (81.5% vs 59.6%, P < .05). The study group had a mean inclination angle of 43.88°° (standard deviation [SD] 5.38) and anteversion angle of 12.82° (SD 5.99), whereas the control group had 41.10° (SD 6.79) and 12.82° (SD 9.53), respectively. There were no significant differences in estimated blood loss, length of stay, and Harris hip scores at preoperative and 3 and 6 months postoperatively, except for the operative time, which was longer in the study group (P < .01). There was 1 posterior hip dislocation in each group. Conclusions: DAR navigation combined with MGD provides better accuracy for acetabular cup positioning within the Lewinnek safe zone compared with the conventional technique.

Central Sensitisation Inventory-Thai version: translation, cross-cultural adaptation, and psychometric evaluation in chronic non-specific neck pain.

PURPOSE: To translate and cross-culturally adapt the English version of the Central Sensitisation Inventory (CSI) into Thai (CSI-Thai) and to evaluate its psychometric properties in individuals with chronic non-specific neck pain. MATERIALS AND METHODS: Cross-cultural translation and adaptation of the CSI were performed according to standard guidelines. A total of 340 participants were invited to complete the CSI-Thai, Visual Analogue Scale (pain intensity), Neck Disability Index, Fear-Avoidance Beliefs Questionnaire, Pain Catastrophising Scale (PCS), and Short Form-36. Psychometric evaluation included confirmatory factor analysis, internal consistency, test-retest reliability, agreement, and construct validity. RESULTS: Dimensionality analyses indicated that a bifactor model, comprising one general factor plus four orthogonal factors, fit the CSI structure better than unidimensional and the four-factor models. The general factor showed substantial reliability (Cronbach α = 0.91, Omega ω = 0.94, and omega hierarchical ω-h = 0.91). The intraclass correlation coefficient was 0.90, representing excellent stability over a 48 h interval. Moderate-to-strong correlations and acceptable-to-excellent discriminations were found between the CSI-Thai and all questionnaires. The exception was the PCS (no correlation and discrimination). The standard error of measurement and minimal detectable change of the CSI-Thai were 2.33 and 6.47, respectively. CONCLUSIONS: The translation and cross-cultural adaptation of the CSI-Thai were successful, with satisfactory reliability and construct validity.Implications for rehabilitationCentral Sensitisation Inventory-Thai version (CSI-Thai) is successfully adapted and demonstrated satisfactory reliability and construct validity.The CSI-Thai can be applicable to assess central sensitisation-related signs and symptoms in Thai-speaking patients with chronic non-specific neck pain (CNSNP) both clinical and research purposes.The CSI-Thai correlated to pain, disability and quality of life among patients with CNSNP.