Can local infiltration analgesia supplemented with tranexamic acid reduce blood loss during total knee arthroplasty?

PURPOSE

The aim of this study was to investigate the efficacy of TXA supplemented with local infiltration analgesia (LIA) for reducing blood loss in patients undergoing total knee replacement.

MATERIALS

A retrospective study of 530 individuals with a mean age of 71.44 years was performed after posterior stabilized total knee arthroplasty. Patients were divided into three groups according to the method of bleeding control: I - patients without an additional bleeding protocol (control group); II - patients receiving IV TXA (TXA group); and III - patients receiving the exact TXA protocol plus intraoperative local infiltration analgesia (TXA + LIA group). Blood loss was measured according to the maximal decrease in Hb compared to the preoperative Hb level.

RESULTS

The mean hospitalization duration was 7.02 (SD 1.34) days in the control group, 6.08 (SD 1.06) days in the TXA group, and 5.56 (SD 0.79) in the TXA + LIA group. The most significant decrease in haemoglobin was found in the control group, which was an average of 30.08%. The average decrease in haemoglobin was 25.17% (p < 0.001) in the TXA group and 23.67% (p < 0.001) in the TXA + LIA group. A decrease in the rate of allogeneic blood transfusions was observed: 24.4% in the control group, 9.9% in the TXA group, and 8% in the TXA + LIA group (p < 0.01).

CONCLUSIONS

Compared to the separate administration of tranexamic acid, the combination of perioperative administration with local infiltration analgesia significantly reduced blood loss in patients after total knee replacement.

Case Report: The unique case of flexible intramedullary nailing of pediatric radius complicated with temporary radial nerve's motor branch damage

This study reported a case of radius flexible intramedullary nailing complicated by temporary paralysis of the posterior interosseous nerve due to compression of the ESIN on the nerve in an 8-year-old boy. The nerve damage resulted from an essential misconception at the surgery. Despite bad decisions made during qualifications and the procedure undertaken, restoring the nerve function, and gaining satisfactory functional fracture recovery was possible. Although it is generally acknowledged to perform retrograde flexible intramedullary nailing from the level of the distal radial metaphysis, the presentation of our case aims to emphasize the real risk of damage to the motor branch of the radial nerve when approaching the proximal metaphysis.

Efficacy of tranexamic acid supplemented with local infiltration analgesia in reducing blood loss in patients undergoing unicompartmental knee arthroplasty

This study aimed to investigate the efficacy of tranexamic acid supplemented with local infiltration analgesia in reducing blood loss in patients undergoing unicompartmental knee arthroplasty (UKA). This retrospective study was conducted on 176 individuals with a mean age of 64.27 (standard deviation [SD], 7.16) years undergoing unicompartmental cemented knee arthroplasty. The patients were divided into three groups according to patient blood management: I, patients without additional bleeding protocol (control group); II, patients intravenously administered tranexamic acid (TXA) (TXA group); and III, patients with exact TXA protocol combined with intraoperative local infiltration analgesia (LIA) (TXA + LIA group). Blood loss was measured as a substitute for blood loss by the maximal haemoglobin (Hb) drop compared with the preoperative Hb level. The mean Hb drops for the control, TXA, and TXA + LIA groups were 2.24 (16.0%), 2.14 (15.4%), and 1.81 (12.6%) g/dl, respectively. The mean hospitalisation days for patients in the control, TXA, and TXA + LIA groups were 5.91 (SD 1.24), 5.16 (SD 0.95), and 4.51 (SD 0.71) days, respectively. The combination of TXA with LIA reduces perioperative blood loss for patients after UKA.

Pediatric Anterior Cruciate Ligament Reconstruction

The incidence of anterior cruciate ligament (ACL) injuries in children and adolescents has been growing recently. This problem is a challenge for the treating orthopedic surgeon, especially when the patient is in the prepubertal period with a high growth potential. Since reconstructive procedures require interventions close to active growth plates, they are associated with the risk of postoperative limb length discrepancies and limb deformities. Postponing ACL reconstruction until the end of growth is not a solution, as persistent knee instability increases the risk of secondary intra-articular damage. The key to success is not only knowledge of the anatomy and biomechanics of the pediatric knee but also the ability to predict the remaining growth potential and familiarity with a wide range of reconstructive surgical procedures available for patients at different ages.

Results of Anterior Cruciate Ligament Avulsion Fracture by Treatment Using Bioabsorbable Nails in Children and Adolescents

(1) Background: Anterior cruciate ligament avulsion fractures are characteristic for skeletally immature patients, and appropriate treatment is currently debated in the literature. The study aimed to evaluate the clinical and functional outcomes in patients with tibial eminence fractures treated with bioabsorbable nails in one orthopedic clinic. (2) Methods: After retrospective evaluation, we found 17 patients with tibial eminence fractures treated in orthopedic departments between January 2013 and July 2022 using bioabsorbable fixation nails. The study group comprised 12 boys and five girls aged 5 to 15.2 (average 10.1). The mean follow-up was 28 months. We diagnosed five type II fractures, ten type III fractures, and two type IV fractures according to Meyers-McKeever classification. (3) Results: We obtained a high healing rate-17 patients with the complete union on the control radiographs. We diagnosed two cases of malunion, of which one required revision surgery. Only one patient showed a slight anterior knee laxity. The treatment effect at follow-up was assessed using the Lysholm Knee Score and IKDC Score. The median Lysholm Score was 96.64 (SD 4.54), and the median IKDC Score was 84.64 (SD 3.10), which were both excellent results. (4) Conclusions: Based on our results, surgery using bioabsorbable devices for type II, III, and IV tibial eminence fractures in young individuals is an effective alternative, allowing good outcomes and restoring proper knee stability. The crucial factor for a good effect is a stable fracture fixation. Arthroscopic surgery gives good outcomes with minimal invasion. It is important not to prolong the attempts of arthroscopic reduction and to perform the open reduction to shorten the procedure's time and avoid complications.

Treatment of Radial Nerve Palsy in Paediatric Humeral Shaft Fractures. STROBE-Compliant Investigation

Background and Objectives:Due to the rarity of radial nerve palsy in humeral shaft fractures in the paediatric population and the lack of data in the literature, the purpose of our study was to report the treatment results of six children who sustained a radial nerve injury following a humeral shaft fracture. Materials and Methods: We treated six paediatric patients with radial nerve palsy caused by a humeral shaft fracture in our department from January 2011 to June 2022. The study group consisted of four boys and one girl aged 8.6 to 17.2 (average 13.6). The mean follow-up was 18.4 months. To present our results, we have used the STROBE protocol designed for retrospective observational studies. Results:We diagnosed two open and four closed humeral shaft fractures. Two simple transverse AO 12A3c; one simple oblique AO 12A2c; two simple spiral AO 12A1b/AO 12A1c and one intact wedge AO 12B2c were recognized. The humeral shaft was affected in the distal third five times and in the middle third one time. In our study group, we found two cases of neurotmesis; two entrapped nerves within the fracture; one stretched nerve over the bone fragments and one case of neuropraxia. We found restitution of the motor function in all cases. For all patients, extensor muscle strength was assessed on the grade M4 according to the BMRC scale (except for a patient with neuropraxia-M5). The differences in patients concerned the incomplete extension at the radiocarpal and metacarpophalangeal (MCP) joints. Conclusions: In our small case series, humeral shaft fractures complicated with radial nerve palsy are always challenging medical issues. In paediatric patients, we highly recommend an US examination where it is possible to be carried out to improve the system of decision making. Expectant observation with no nerve exploration is reasonable only in close fractures caused by low-energy trauma. Early surgical nerve exploration related with fracture stabilisation is highly recommended in fractures after high-energy trauma, especially in open fractures and where symptoms of nerve palsy appear at any stage of conservative treatment.

Evaluation of Osteochondritis Dissecans Treatment with Bioabsorbable Implants in Children and Adolescents

(1) Background: This is the first systematic review concerning the treatment of osteochondritis dissecans with the use of bioabsorbable implants. The study was done as a comprehensive review to identify important factors affecting the results of OCD treatment in children and adolescents; (2) Methods: We searched electronic bibliographic databases including PubMed, Cochrane Library, Scopus, and Web of Knowledge until May 2022. This systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and PICO (Patients, Interventions, Comparisons, Outcomes) guidelines; (3) Results: We identified 2662 original papers of which 11 were found to be eligible for further analysis. The study group included a total of 164 OCD lesions in 158 patients. In 94.86% of postoperative cases, there was complete healing or local improvement on follow-up CT or MRI scans. The great majority of patients achieved a good clinical effect. Out of 164 OCD lesions, 10 did not heal (6.09%); (4) Conclusions: Surgical treatment of stable and unstable OCD in children with the use of bioabsorbable implants facilitates a high rate of healing and a good clinical outcome; treatment of juvenile OCD is associated with a better outcome compared to adult OCD; the use of bioabsorbable implants for the treatment of humeral capitellum OCD is associated with a more frequent incidence of synovitis (18.2%).

Humeral Shaft Fractures in Children Incidence, Management and Treatment Effects

BACKGROUND

Humeral shaft fractures are relatively rare in children, with incidence between 0.4% and 3% of all fractures in children and between 10% and 20% of all humeral fractures. The purpose of our study was to retrospectively evaluate all humeral shaft fractures treated at children&apos;s trauma center from january 2012 till december 2021.

MATERIAL AND METHODS

We retrospectively evaluated the group of 104 skeletally immature patients with humeral shaft fracture treated in our hospital. We have analyzed: age; sex; fracture type, management; time of bone healing; final effect and complications.

RESULTS

The non-surgical group consisted of 73 patients (27 girls and 46 boys) with an average age of 8.03 (0.6 - 17.7), while the surgical group consisted of 31 patients (16 girls and 15 boys) with an average age of 12.47 (5,7- 17.8). The mean follow-up was 7.65 months (4-12) in non-surgical group, and 13.38 months (4-24) in surgical group. We have analyzed the results statistically, confirming increase the frequency of the above-mentioned fractures and increase the number of patients treated with surgery. We achieved good effect in all patients.

CONCLUSIONS

1. Humeral shaft fractures in children are relatively rare. Although in recent years, we have observed an increase of their frequency; 2. The vast majority of humeral shaft fractures are treated non-surgically with good clinical results; 3. Increase of number of patients treated surgically has been noticeable in the last decade; 4. Surgery is associated with a relatively low risk of complications and allows for cast withdrawal, which significantly improves the patients comfort.

Radial Nerve Palsy in Paediatric Humeral Shaft Fractures: Incidence and Management

BACKGROUND

Humeral shaft fractures are relatively rare in the paediatric population. The purpose of our study was to retrospectively evaluate all humeral shaft fractures treated at a children&apos;s trauma centre and assess cases involving radial nerve injury.

MATERIAL AND METHODS

We retrospectively evaluated a group of 5 skeletally immature patients with radial nerve palsy out of a total of 104 patients with humeral shaft fractures treated in our hospital between January 2011 and December 2021.

RESULTS

The study group consisted of four boys and one girl aged 8.6 to 17.2 years (average age 13.6). Mean follow-up duration was 18.4 months. We diagnosed two open and three closed fractures. There were two cases of neurotmesis, two cases of nerve entrapment within the fracture site and one case of neuropraxia. Bone union and functional recovery was achieved in all five patients.

CONCLUSIONS

1. Humeral shaft fractures complicated with radial nerve palsy are a challenging medical problem; 2. The incidence of radial nerve injury in the paediatric population is significantly lower than in adults; in our study, it accounted for 4.8% of all humeral shaft fractures; 3. Expectant observation without nerve exploration is reasonable in fractures caused by a low-energy trauma; 4. Early surgical nerve exploration combined with fracture stabilisation is highly recommended in fractures due to a high-energy trauma.

Changes in the avascular area of the meniscus using mesenchymal stem cells and growth plate chondrocytes in a pig model

Menisci are wedge-shaped cartilage discs that are divided into two parts: the avascular and vascular regions. They are formed by fibrocartilage tissue, which contains round cartilage-like cells and extracellular matrix. Meniscus injury in animals is a common orthopedic problem, but data on the natural healing process mainly deals with the vascular zone. The healing processes in the avascular zone of the meniscus are significantly limited. Thus, this study aimed to evaluate autologous growth plate chondrocytes' impact on the healing process of a damaged meniscus in the avascular zone based on a growing animal model. The study group consisted of 10 pigs at about three months of age. From each animal, chondrocytes from the iliac growth plate and from concentrated bone marrow were taken. Knee joints were divided into right (R) and left (L). The medial meniscus of the R knee joint was treated with a hyaluronic acid based scaffold incubated with bone marrow cells from marrow aspirates (nCHON). The medial meniscus of the L knee joint was treated with a hyaluronic acid based scaffold incubated with bone marrow cells from marrow aspirates supplemented with immature chondrocytes isolated from growth plates (wCHON). The meniscus was damaged in the avascular zone in both knee joints. Followingly, the damaged part of the meniscus was filled with a scaffold with cells from the concentrated bone marrow and from growth plate chondrocytes. In the control group, a scaffold with concentrated bone marrow cells was used. After three months the animals were euthanized and preparations (microscopic slides) were made from the meniscus' damaged part. A qualitative and quantitative analysis have been prepared. The wCHON group in comparison with the nCHON group showed a statistically significantly higher number of fusiform cells on the surface of the graft as well as better healing of the graft. In addition, the degree of vascularization was higher in specimens from the wCHON group than in the nCHON group. The results of our research on immature pig knees revealed that mesenchymal stem cell and growth plate chondrocytes could be treated as the cell source for meniscus reconstruction, and growth plate chondrocytes enhance healing processes in the avascular zone of the injured meniscus.

Developmental changes in ACLs and semitendinosus tendons dimensions according to age in children

PURPOSE

Managing anterior cruciate ligament (ACL) injuries in skeletally immature patients remains difficult. The main aim of this study was to retrospectively compile normative data on the cross-sectional area (CSA) of the semitendinosus tendon (ST) and the diameter of the ACL in children and young adults.

METHODS

Knee magnetic resonance imaging (MRI) examinations were performed for a 2-year period in 132 patients (83 female and 49 male patients). The mean age was 14.9 years (8-18 years). Measurements of the ST CSA were performed on axial views in greyscale by two independent researchers. The ACL diameter was measured as well.

RESULTS

The results show the CSA of the ST was related to age, and its growth was not linear. The highest growth rate of the CSA of the ST occurred at age 12-13 at the level of the femoral growth plate and at the level of the tibial plateau. The growth of the ACL diameter was linear until 18 years of age.

CONCLUSIONS

ST growth (measured in CSA increments) is almost complete at the age of 13, even though the growth is not linear. ACL growth measured in diameter increments proceeds linearly from 8 to 18 years of age. MRI is a clinically useful tool for assessing hamstring tendon grafts preoperatively.

LEVEL OF EVIDENCE

Level III, diagnostic studies.

Results of Femoral Elongation Treatment Using Electromagnetic Intramedullary Nail. Preliminary Report

BACKGROUND

Surgical correction of lower limb discrepancy in children poses a significant clinical problem. The aim of this paper is to present our experience with the PRECICE electromagnetic intramedullary nail.

MATERIALS AND METHODS

The study group consisted of 5 patients (2 girls; 3 boys) aged 11.5 to 18 years (mean age 16.3) treated for lower limb discrepancy by femoral lengthening using the PRECICE nail intramedullary system. Average discrepancy was 63 mm (range: 45-74.5 mm).

RESULTS

Femoral lengthening was successful in all patients. The femur was lengthened by a mean of 49 mm (range: 40-58 mm). A knee flexion contracture of about 10° occurred in one patient.

CONCLUSIONS

1. Femoral lengthening in children poses a therapeutic challenge. 2. The PRECICE intrame-dullary nail system helps reduce complications and increases patient comfort.

Enhancement of cartilage repair through the addition of growth plate chondrocytes in an immature skeleton animal model

Background

The treatment of articular cartilage damage is a major clinical problem. More often, this clinical issue affects children, which forces doctors to find the best treatment method.

Methods

The aim of this experimental study on 2-month-old Landrace pigs was to compare the results of two cartilage defect treatments: (1) filling the cartilage defect with a scaffold incubated with bone marrow aspirate supplemented with growth plate chondrocytes (the CELLS group) and (2) filling the cartilage defect with an empty scaffold implanted after drilling the subchondral bone (the CTRL group). The treatment outcomes were assessed macroscopically and microscopically.

Results

Based on the macroscopic evaluation, all animals showed a nearly normal morphology, with an average of 9.66/12 points (CTRL) and 10.44/12 points (CELLS). Based on the microscopic evaluation, 1 very good result and 8 good results were obtained in the CTRL group, with an average of 70.44%, while 5 very good results and 4 good results were obtained in the CELLS group, with an average of 79.61%.

Conclusions

(1) Growth plate chondrocytes have high chondrogenic potential and thus offer new possibilities for cartilage cell therapy. (2) The implantation of a scaffold loaded with bone marrow-derived MSCs (mesenchymal stem cells) and growth plate chondrocytes into a cartilage defect is a good therapeutic method in immature patients. (3) Cartilage repair based on a scaffold with bone marrow aspirate-derived cells supplemented with autologous growth plate chondrocytes achieves better results than repair with marrow stimulation and a hyaluronic acid-based scaffold (overall microscopic rating). (4) Chondrocyte clustering is a manifestation of the cartilage repair process but requires further observation.

Electronic supplementary material

The online version of this article (10.1186/s13018-019-1302-y) contains supplementary material, which is available to authorized users.

Orthotopic Autologous Chondrocyte Grafting as a Method of Treatment of Growth Plate Damage in Rabbits

BACKGROUND

With the continuous advances in the therapy of joint cartilage injury, some of those classification systems are also being used for evaluating the quality of regenerating cartilage. Histo lo gi cal assessment of joint cartilage is a very important component in the staging of osteoarthritis and tracing therapeutic outcomes. We performed a histological assessment of regenerating growth plate in a group of New Zealand white rabbits as a component of autologous chondrocyte therapy for growth plate damage.

MATERIAL AND METHODS

We studied a group of 14 five-week-old in-bred white rabbits. We used a tre phine needle to harvest growth plate from the medial fourth of tibial width. The mean duration of the procedure was 25 minutes (range: 12-37 minutes). We conducted a total of 25 growth plate harvesting procedures. In 21 cases, we placed a drainage tube at the site of the defect for 22 days. After removing the tube, we introduced a cartilago-fibrinous construct containing cultured autologous chondrocytes into 14 defects, while 4 defects were left intact. Three growth plates represented non-intervention controls.

RESULTS

Our analysis showed satisfactory graft morphology and integration; absence of inflammatory res ponse and fair restitution of growth plate architecture.

CONCLUSIONS

1. Growth plate damage can lead to the development of an angular deformity as a result of im paired longitudinal bone growth; 2. Autologous chondrocyte grafting is a good method of treatment for growth plate damage; 3. A weakness of autologous chondrocyte grafting is the relatively long time of chondrocyte culturing.

Evaluation of thoracic vertebrae rotation in patients with pectus excavatum

Purpose

The aim of our study was to evaluate thoracic vertebrae rotation in patients with pectus excavatum. Moreover, we wanted to assess the prevalence, the severity and relationship between pectus excavatum and adolescent idiopathic scoliosis (AIS).

Methods

We performed retrospective analysis of 82 preoperative chest CT in children with pectus excavatum performed between January 2008 and December 2011. For each patient Haller Index and Cobb angle was measured. To evaluate the severity of thoracic scoliosis we measured vertebral rotation for Th8 and for vertebra at the level of highest chest deformation using Aaro-Dahlborn method.

Results

From the group of 54 patients with pectus excavatum enrolled in the study AIS was diagnosed in 8 patients (14,81%). In patients with symmetric deformation, Th8 rotation was found in 21 patients; the rotation of the apical vertebra was found in 20 patients. In patients with asymmetric deformation Th8 rotation was found in 10 patients; the rotation of the apical vertebra was found in 8 patients.

Conclusions

1. We have confirmed the higher prevalence of pectus excavatum in boys; 2. We have found a significant relationship between pectus excavatum and adolescent idiopathic scoliosis; 3. We have shown that deformation of the anterior chest wall enforces rotation of the thoracic spine; 4. We haven't found the relationship between the severity of the chest deformity (HI measured) and severity of AIS (Cobb angle measured); 5. We have shown a significant association between HI measured and rotation of thoracic vertebra at the level of highest chest deformation (apical vertebra) in symmetric pectus excavatum.

Level of evidence: Level IV, Diagnostic study.

Occipital Condyle Fractures in Adolescents

BACKGROUND

Occipital condyle fractures are rare injuries of the cranio-cervical junction seen more often in adults than in children. They are best diagnosed with CT of the cranio-cervical junction. Treatment depends on the morphology and stability of the fracture. The aim of the present paper was to present cases of occipital condyle fractures treated at our Department, review the literature, and stress the importance of MRI studies in the diagnostic work-up of these injuries.

MATERIAL AND METHODS

Our retrospective study involved a group of 3 female patients (mean age was 16.3 years) with occipital condyle fractures diagnosed/treated at our Department. We assessed the cause and type of fracture, additional damage, available classification systems, treatment methods, outcomes and complications.

RESULTS

Mean follow-up period was 16 (10-22) months. We achieved good clinical outcomes (NDI scores) in all the patients. In one patient, a follow-up MRI scan revealed the presence of a clinically silent post-traumatic epidural meningeal cyst at the C2-C6 level, anterior to the spinal cord.

CONCLUSIONS

CT of the cranio-cervical junction is the best method of diagnosing occipital condyle fractures. 2. The choice of an appropriate treatment method is decisively based on the assessment of the morphology and stability of the fracture in a CT/MRI scan rather than on the fracture type alone. 3. There is no noticeable difference between the usefulness of the classification system developed by Anderson and Montesano and that according to Tuli et al. 4. In our opinion, the system of occipital condyle fracture classification proposed in 2012 does not seem superior in everyday clinical practice. 5. The use of the halo-vest is a good method of treating unstable occipital condyle fractures. 6. Early diagnosis and appropriate treatment of cranio-cervical junction fractures make it possible for the fracture to heal without severe clinical sequelae.