The effects of a new protocol on blood loss in total knee arthroplasty

The optimal dose of intravenous tranexamic acid for reducing blood loss in spinal surgery: a network meta-analysis

BACKGROUND

This study aims to evaluate the optimal dose of intravenous tranexamic acid (TXA) for reducing blood loss in spinal surgery.

METHODS

A systematic search was conducted in the PubMed, Embase, Cochrane Library database from inception until November 2023. Randomized controlled trials (RCTs) incorporating diverse TXA dosing regimens for spinal surgery were included. The surface under the cumulative ranking curve (SUCRA) analysis was employed to determine ranking order. R software with gemtc package was used for all analyses, with a significance threshold set at P < 0.05.

RESULTS

Twenty-four RCTs were considered eligible and finally included. All TXA treatments demonstrated superior efficacy compared to the placebo, with statistically significant differences (P < 0.05). SUCRA values indicated that Treatment I (100 mg/kg + 10 mg.kg/h) claimed the top rank (SUCRA, 80.3%), followed by Treatment F (15 mg/kg + 2 mg.kg/h) in second place (SUCRA, 76.7%), and Treatment E (10 mg/kg + 2 mg.kg/h) in third place (SUCRA, 75.2%). Conversely, the placebo ranked the lowest (SUCRA, 0.3%). Additionally, Treatment I (100 mg/kg + 10 mg.kg/h) held the top rank (SUCRA, 95.6%), followed by Treatment N (30 mg/kg + 10 mg.kg/h) in second place (SUCRA, 81.0%), and Treatment K (15 mg/kg + 6 mg.kg/h) in third place (SUCRA, 74.8%). Importantly, no statistically significant differences were observed between any TXA treatments and the placebo concerning the occurrence of deep vein thrombosis (DVT) (P > 0.05).

CONCLUSIONS

This network meta-analysis underscores that intravenous TXA is associated with decreased overall blood loss in multilevel spine surgery. Notably, the highest dose in this network meta-analysis (100 mg/kg + 10 mg.kg/h) emerged as the only regimen demonstrating significant benefits in pairwise comparisons with other TXA doses. Although this regimen did not significantly increase DVT risk, careful consideration of safety data for higher doses remains essential.

Comparison of 2 different fixation techniques of comminuted acetabular quadrilateral surface fractures using square bracket-shaped tubular plate or interfragmentary screws in addition to supra/infrapectineal plate fixation: An observational study

The management of comminuted quadrilateral fractures remains challenging, and treatment options are constantly evolving. The purpose of the present study was to examine the outcomes of 2 different fixation techniques in the management of comminuted quadrilateral fractures. Twenty-two patients with comminuted quadrilateral acetabular fractures were surgically treated with interfragmentary lag screw (group 1) and square bracket-shaped tubular (SBST) plate technique (group 2), in addition to suprapectineal and infrapectineal pelvic reconstruction plate fixation between January 2016 and July 2019 at our clinic. 2 years follow-up control data of each group were compared in terms of radiological and functional results, and complications. According to the functional score comparison, the mean Merle d'Aubigne Postel scoring system (MAP) score was 15.2/15.6 (P = .632), and the mean Harris hip scoring (HHS) system score was 74.65/77.3 (P = .664) in groups 1 and 2, respectively. Radiological comparison was performed according to matta radiological criteria (MRC), and 2 excellent, 6 good, 2 poor, 4 excellent, 4 good, and 4 poor radiological results were observed in groups 1 and 2, respectively. intraarticular screw penetration was detected in 3 patients in group 1, while there was no articular implant penetration in group 2 (P = .001). We believe that satisfactory results can be obtained with the SBST plate technique, offering functional and clinical outcomes that are similar to those of the interfragmentary screw technique. The SBST plate technique is superior in terms of avoiding intraarticular screw penetration and related revision surgery.

The Role of Alarmins in the Pathogenesis of Rheumatoid Arthritis, Osteoarthritis, and Psoriasis

Alarmins are immune-activating factors released after cellular injury or death. By secreting alarmins, cells can interact with immune cells and induce a variety of inflammatory responses. The broad family of alarmins involves several members, such as high-mobility group box 1, S100 proteins, interleukin-33, and heat shock proteins, among others. Studies have found that the concentrations and expression profiles of alarmins are altered in immune-mediated diseases. Furthermore, they are involved in the pathogenesis of inflammatory conditions. The aim of this narrative review is to present the current evidence on the role of alarmins in rheumatoid arthritis, osteoarthritis, and psoriasis. We discuss their potential involvement in mechanisms underlying the progression of these diseases and whether they could become therapeutic targets. Moreover, we summarize the impact of pharmacological agents used in the treatment of these diseases on the expression of alarmins.

Metabolic Dysregulation and Its Role in Postoperative Pain among Knee Osteoarthritis Patients

Knee osteoarthritis (KOA) is characterized by low-grade inflammation, loss of articular cartilage, subchondral bone remodeling, synovitis, osteophyte formation, and pain. Strong, continuous pain may indicate the need for joint replacement in patients with end-stage OA, although postoperative pain (POP) of at least a two-month duration persists in 10-40% of patients with OA.

STUDY PURPOSE

The inflammation observed in joint tissues is linked to pain caused by the production of proinflammatory cytokines. Since the biosynthesis of cytokines requires energy, their production is supported by extensive metabolic conversions of carbohydrates and fatty acids, which could lead to a disruption in cellular homeostasis. Therefore, this study aimed to investigate the association between POP development and disturbances in energy metabolic conversions, focusing on carbohydrate and fatty acid metabolism.

METHODS

Peripheral blood samples were collected from 26 healthy subjects and 50 patients with end-stage OA before joint replacement surgery. All implants were validated by orthopedic surgeons, and patients with OA demonstrated no inherent abnormalities to cause pain from other reasons than OA disease, such as malalignment, aseptic loosening, or excessive bleeding. Pain levels were assessed before surgery using the visual analogue scale (VAS) and neuropathic pain questionnaires, DN4 and PainDETECT. Functional activity was evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Three and six months after surgery, pain indices according to a VAS of 30 mm or higher were considered. Total RNA isolated from whole blood was analyzed using quantitative real-time RT-PCR (qRT-PCR) for the expression of genes related to carbohydrate and fatty acid metabolism. Protein levels of the examined genes were measured using an ELISA in the peripheral blood mononuclear cells (PBMCs). We used qRT-PCR because it is the most sensitive and reliable method for gene expression analysis, while an ELISA was used to confirm our qRT-PCR results.

KEY FINDINGS

Among the study cohort, 17 patients who reported POP demonstrated significantly higher (p < 0.05) expressions of the genes PKM2, LDH, SDH, UCP2, CPT1A, and ACLY compared to pain-free patients with KOA. Receiver-operating characteristic (ROC) curve analyses confirmed the association between these gene expressions and pain development post-arthroplasty. A principle component analysis identified the prognostic values of ACLY, CPT1A, AMPK, SDHB, Caspase 3, and IL-1β gene expressions for POP development in the examined subjects.

CONCLUSION

These findings suggest that the disturbances in energy metabolism, as observed in the PBMCs of patients with end-stage KOA before arthroplasty, may contribute to POP development. An understanding of these metabolic processes could provide insights into the pathogenesis of KOA. Additionally, our findings can be used in a clinical setting to predict POP development in end-stage patients with KOA before arthroplasty.

Pitfalls with the MAKO Robotic-Arm-Assisted Total Knee Arthroplasty

Robotic-arm-assisted total knee arthroplasty (RATKA) with the MAKO system minimizes deviations in implant alignment and yields superior precision in implant position compared to a manual total knee arthroplasty. In this comprehensive commentary, we present and categorize the limitations and pitfalls of the procedure and we also provide recommendations for avoiding each limitation. The main surgeon-related limitations include prolonged operation duration, loose insertion of the checkpoints and pins, wrong registration and mapping, and damage to soft tissues during bone cutting. The system-related issues include the interruptions of the saw-cutting due to vibrations, specifications for the operating room floor and power supply, the high cost of the system, as well as the cost of each operation due to the extra implants, inability to use the system with various prostheses, wireless connection interruptions between the system's components, and hardware issues with the six joints of the robotic device. In order to circumvent the potential challenges in this surgical procedure, it is essential to possess sufficient experience and undergo comprehensive training. Maintaining continuous awareness of the additional implants throughout the entire operation and prioritizing the preservation of soft tissues are of paramount significance. A profound comprehension of the system and its inherent constraints can also prove to be pivotal in certain situations.

Musculoskeletal Rehabilitation: New Perspectives in Postoperative Care Following Total Knee Arthroplasty Using an External Motion Sensor and a Smartphone Application for Remote Monitoring

BACKGROUND

The number of total knee replacements performed annually is steadily increasing. Parallel options for postoperative care are decreasing, which reduces patient satisfaction. External devices to support physical rehabilitation and health monitoring will improve patient satisfaction and postoperative care.

METHODS

In a prospective, international multicenter study, patients were asked to use an external motion sensor and a smartphone application during the postoperative course of primary total knee arthroplasty. The collected data were transferred to a data platform, allowing for the real-time evaluation of patient data.

RESULTS

In three participating centers, 98 patients were included. The general acceptance of using the sensor and app was high, with an overall compliance in study participation rate of up to 76%. The early results showed a significant improvement in the overall quality of life (p < 0.001) and significant reductions in pain (p < 0.01) and depression (p < 0.001).

CONCLUSIONS

The early results of this clinical and multicenter study emphasize that there is a high interest in and acceptance of digital solutions in patients' treatment pathways. Motion sensor and smartphone applications support patients in early rehabilitation.

Clinical, Radiographic and Fusion Comparison of Oblique Lumbar Interbody Fusion (OLIF) stand-alone and OLIF with posterior pedicle screw fixation in patients with degenerative spondylolisthesis

PURPOSE

To compare the outcomes and characteristics of oblique lumbar interbody fusion stand-alone (OLIF-SA) and OLIF with posterior pedicle screw fixation (OLIF-PPS) in the treatment of Grade I or Grade II degenerative lumbar spondylolisthesis.

PATIENTS AND METHODS

Between January 2019 and May 2022, 139 patients with degenerative spondylolisthesis were treated with OLIF-SA (n = 85) or OLIF-PPS (n = 54). The clinical and radiographic records were reviewed.

RESULTS

The clinical and radiographic outcomes were similar in both groups. The operative time and intraoperative blood loss in the OLIF-SA group were lower than those in the OLIF-PPS group (P < 0.05). However, the OLIF-PPS group had significantly better disc height (DH) and postoperative forward spondylolisthesis distance (FSD) improvement at 6 months (P < 0.05). The OLIF-PPS group had a significantly lower cage subsidence value than the OLIF-SA group (P < 0.05). Improvement of the lumbar lordotic angle (LA) and fusion segmental lordotic angle (FSA) in the OLIF-PPS group was significantly better than that in the OLIF-SA group (P < 0.05). In terms of fusion types, the OLIF-SA group tended to undergo fusion from the edge of the vertebral body. Fusion in the OLIF-PPS group began more often in the bone graft area of the central cage of the vertebral body. The fusion speed of the OLIF-SA group was faster than that of the OLIF-PPS group.

CONCLUSION

OLIF-SA has the advantages of a short operative time, less intraoperative blood loss, and reduced financial burden, while PPS has incomparable advantages in the reduction of spondylolisthesis, restoration of lumbar physiological curvature, and long-term maintenance of intervertebral DH. In addition, the SA group had a unique vertebral edge fusion method and faster fusion speed.

Early Posttraumatic Antifibrinolysis Reduces Perioperative Hidden Blood Loss in Elderly Patients with an Intertrochanteric Fracture: A Randomized Controlled Trial

BACKGROUND

This study aimed to determine the efficacy and safety of posttraumatic antifibrinolysis with multidose tranexamic acid (TXA) in reducing perioperative hidden blood loss (HBL) in elderly intertrochanteric fracture patients.

METHOD

Ninety-six elderly intertrochanteric fracture patients admitted to our department from June 2021 to September 2022 were randomized into two groups. The control group (Group A) received 100 mL of normal saline, while the experimental group (Group B) received 1.5 g of TXA intravenously q12 h from postadmission Day 1 (PAD1) to the day before surgery, and both groups received 1.5 g of TXA q12 h from postoperative Day 1 (POD1) to POD3. Haemoglobin (Hb), haematocrit (Hct), coagulation parameters, fibrinogen degradation product (FDP), and D-dimer (D-D) were recorded from PAD1 to POD3. HBL was calculated using the gross formula and recorded as the primary outcome.

RESULT

In all-over analyses, the patients in Group B had lower perioperative HBL (on PAD3, POD1, and POD3), preoperative HBL (HBLpre), decline of haemoglobin (ΔHb-on PAD3), allogeneic blood transfusion (ABT) rate, FDP (on PAD3), and D-D (on PAD3) compared with Group A. No significant differences were exhibited in postoperative HBL (HBLpost) between the 2 groups. In subgroup analyses, for patients who received intervention within 24 h, the result is consistent with the whole. For patients who received intervention over 72 h of injury, there were no significant differences in perioperative HBL, ΔHb, ABT rate, FDP, and D-D between the 2 groups. There were no significant differences in APTT, PT, the rate of venous thromboembolism, wound complications, or 90-day mortality between the 2 groups.

CONCLUSION

For elderly intertrochanteric fracture patients, early posttraumatic antifibrinolysis with multidose TXA is effective in reducing perioperative HBL, which mainly manifests as the reduction of preoperative HBL, especially for patients injured within 24 h. Application of TXA beyond 72 h of injury was ineffective.

Hidden blood loss of minimally invasive hybrid lumbar interbody fusion: an analysis of influencing factors

BACKGROUND

Lumbar interbody fusion(LIF) is the leading way to treat Lumbar Degenerative Diseases(LDD). At present, there is a lack of research on the influencing factors of hidden blood loss in minimally invasive hybrid lumbar interbody fusion. This study comprehensively explores the definite factors affecting the hidden blood loss in minimally invasive hybrid lumbar interbody fusion.

MATERIALS AND METHODS

One hundred patients with Lumbar degenerative diseases who underwent minimally invasive hybrid lumbar interbody fusion in our center were included. Demographics, laboratory data, surgical data, and radiographic data were collected. The Gross equation and Sehat equation were used to calculate the estimated value of hidden blood loss. Multi-factor linear regression analysis was used to determine the influencing factors of hidden blood loss.

RESULT

We reviewed and collected 100 patients who underwent minimally invasive hybrid approach, mean age 65 ± 10 years, male: female 37:63; 17 patients of diabetes and 83 patients of non-diabetes; Total blood loss was 645.59 ± 376.37 ml, hidden blood loss was 421.39 ± 337.45 ml, the hidden blood loss percentage was 57 ± 26%. Results from the multi-factorial linear regression model: Diabetes (p < 0.05), hypertension (p < 0.05), psoas thickness (p < 0.05) and dorsal extensor group thickness (p < 0.05) were potential risk factors for postoperative hidden blood loss.

CONCLUSION

Although minimally invasive hybrid approach is minimally invasive surgery, there is still a significant amount of hidden blood loss. There is a greater risk of blood loss in diabetes, hypertension and preoperative MRI assessment of thickness of the psoas, thickness of the dorsal extensor group.