Although low-intensity pulsed ultrasound (LIPUS) combined with disinfectants has been shown to effectively eliminate portions of biofilm in vitro, its efficacy in vivo remains uncertain. Our objective was to assess the antibiofilm potential and safety of LIPUS combined with 0.35% povidone-iodine (PI) in a rat debridement, antibiotics, and implant retention (DAIR) model of periprosthetic joint infection (PJI). A total of 56 male Sprague-Dawley rats were established in acute PJI models by intra-articular injection of bacteria. The rats were divided into four groups: a Control group, a 0.35% PI group, a LIPUS and saline group, and a LIPUS and 0.35% PI group. All rats underwent DAIR, except for Control, which underwent a sham procedure. General status, serum biochemical markers, weightbearing analysis, radiographs, micro-CT analysis, scanning electron microscopy of the prostheses, microbiological analysis, macroscope, and histopathology evaluation were performed 14 days after DAIR.Aims
Methods
The present study aimed to investigate whether patients with inflammatory bowel disease (IBD) undergoing joint arthroplasty have a higher incidence of adverse outcomes than those without IBD. A comprehensive literature search was conducted to identify eligible studies reporting postoperative outcomes in IBD patients undergoing joint arthroplasty. The primary outcomes included postoperative complications, while the secondary outcomes included unplanned readmission, length of stay (LOS), joint reoperation/implant revision, and cost of care. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model when heterogeneity was substantial.Aims
Methods
During the pandemic of COVID-19, some patients with COVID-19 may need emergency surgeries. As spine surgeons, it is our responsibility to ensure appropriate treatment to the patients with COVID-19 and spinal diseases. A protocol for spinal surgery and related management on patients with COVID-19 has been reviewed. Patient preparation for emergency surgeries, indications, and contraindications of emergency surgeries, operating room preparation, infection control precautions and personal protective equipments (PPE), anesthesia management, intraoperative procedures, postoperative management, medical waste disposal, and surveillance of healthcare workers were reviewed. It should be safe for surgeons with PPE of protection level 2 to perform spinal surgeries on patients with COVID-19. Standardized and careful surgical procedures should be necessary to reduce the exposure to COVID-19.
Optimal perioperative fluid management has not been established in patients undergoing orthopaedic surgical procedures. Our purpose was to investigate the effects of perioperative fluid management on patients experiencing TKA. One hundred thirty patients who met inclusion criteria undergoing primary unilateral TKA were prospectively randomized into traditional (TFG) vs. oral (OFG) perioperative fluid management groups. The TFG had a predetermined amount of intravenous fluids (IVF) administered in the perioperative period. The OFG began drinking a minimum of three, 20-ounces servings of clear fluids daily for three days prior to surgery. This cohort also drank 10-ounces of clear fluids 4 hours prior to surgery. Perioperative IVF were discontinued when the patient began oral intake or when the total amount of IVF reached 500mL. Outcome measures included: body-weight (BW) fluctuations, knee motion, leg girth, bioelectrical impendence, quadriceps activation, functional outcomes testing, KOOS JR, VR-12, laboratory values, vital signs, patient satisfaction, pain scores, and adverse events.BACKGROUND
METHODS
The optimal protocol for antibiotic loading in the articulating cement spacers for the treatment of prosthetic joint infection (PJI) remains controversial. The objective of the present study was to investigate the effectiveness of articulating cement spacers loaded with a new combination of antibiotics. A retrospective cohort study involving 114 PJI cases treated with implantation of an articulating cement spacer between 2005 and 2016 was performed. The treatment outcomes of the conventional protocol (i.e. gentamicin and vancomycin (GV protocol)) were compared with those reported using the sophisticated antibiotic-loading protocol (i.e. vancomycin, meropenem, and amphotericin (VMA protocol)).Objectives
Methods
The optimal protocol for antibiotic loading in the articulating cement spacers for the treatment of prosthetic joint infection (PJI) remains controversial. The objective of the present study was to investigate the effectiveness of articulating cement spacers loaded with a new combination of antibiotics. A retrospective cohort study involving 114 PJI cases treated with implantation of an articulating cement spacer between 2005 and 2016 was performed. The treatment outcomes of the conventional protocol (i.e. gentamicin and vancomycin (GV protocol)) were compared with those reported using the sophisticated antibiotic-loading protocol (i.e. vancomycin, meropenem, and amphotericin (VMA protocol)).Objectives
Methods
For the management of displaced patellar fractures, surgical fixation using cannulated screws along with anterior tension band wiring is getting popular. Clinical and biomechanical studies have reported that using cannulated screws and a wire instead of the modified tension band with Kirschner wires improves the stability of fractured patellae. However, the biomechanical effect of screw proximity on the fixed construction remains unclear. The aim of this study was to evaluate the mechanical behaviors of the fractured patella fixed with two cannulated screws and tension band at different depths of the patella using finite element method. A patella model with simple transverse fracture [AO 34-C1] was developed; the surgical fixation consisted of two 4.0-mm parallel partial-threaded cannulated screws with a figure-of-eight anterior tension band wiring using a 1.25-mm stainless steel cable. Two different locations, including the screws 5-mm and 10-mm away from the leading edge of the patella, were used. A tension force of 850 N was applied on the patellar apexes at two loading angles (45° and 0° [parallel] to the long axis) to simulate different loading conditions while knee ambulation. The proximal side (base) of the patella was fixed, and the inferior articular surface was defined as a compression-only support in ANSYS to simulate the support from distal femur condyles. Compression-only support enables the articular surfaces of the present patella to only bear compression and no tension forces. Under different loading conditions, the fixed fractured patella yielded higher stability during 0° loading of tension force than during 45° loading. When the screws were parallel placed at the depth of 5 mm away from the patellar surface, the deformation of patellar fragment and maximum gap opening at the fracture site were smaller than those obtained by screws placed at the depth of 10 mm away from the patellar surface. Compared to the superficial screw placement, the deeper placement (10 mm) increased the maximum gap opening at the fracture site by 1.56 times under 45° loading, and 1.58 times under 0° loading. The load on the tension band wire of the 10-mm screw placement was 3.12 times (from 230 to 717 N) higher than that of the 5-mm placement. Under the wire, the contact pressure on the patellar surface was higher with the 10-mm screw placement than the 5-mm screw placement. The peak bone contact pressures with the 10-mm placement were 7.7 times (99.5 to 764 MPa) higher. This is the first numerical study to examine the biomechanical effects of different screw locations on the fixation of a fractured patella using screws and tension band. Based on a higher stability and lower cable tension obtained by the superficial screws placement, the authors recommended the superficial screw placement (5 mm below the leading edge of the patella) rather than the deep screws while fixing the transverse patellar fracture with cannulated screws and cable.
Total knee arthroplasty(TKA) is a major surgery and the postoperative pain can be severe. Inadequate pain relief may lead to delayed mobilisation, greater risk of developing deep vein thrombosis, coronary ischemia, poor wound healing, longer hospital stay and decreased patient satisfaction. Severe postoperative pain also increase the risk of developing long term persisting pain. Conventional pain managements with intermittent parenteral opioids and non-steroid anti-inflammatory drugs have been proved to be less effective and are often lead to unwanted side effect. Currently, there is a trend to use multimodal pain management to minimize narcotic consumption and to avoid narcotic-related side effects. The use of transdermal opioid patch has not been well established. The purpose of this study was to investigate the analgesic effects of various transdermal non-opioid patches in patients after elective total knee arthroplasty in a prospective, randomised control trial. After receiving Institutional Review Board approval, 89 patients(89 knees) received primary unilateral total knee arthroplasty were included in this study. All patients were randomly allocated into three groups. The 3 groups were demographically similar for sex, age, and body mass index. They received patches with 5% lidocaine, flurbiprofen and only vehicle patches without any medication. The patches were placed on the tourniquet area postoperatively, then on patient-directed area of discomfort every 6–8 hours. Each patient received the same standard postoperative analgesics including single intra-articular injection, NSAID, acetaminophen, and rescue opioids as needed. All patients were interviews everyday and the primary outcome was the visual analog scale. Besides, consumption of rescue opioids, progress of active movement, and inpatient stay were also recorded. Our hypotheses were transdermal non-opioid patches would provide effective pain relief and reduce the consumption of opioids as well as their side effects. There were 30, 29, and 30 patients in group I, II and III. The mean ischemic time(tourniquet time) was 56.0, 61.4, 55.5 minutes, respectively. The narcotics consumptions were 11.77, 20.12, and 15.57 mg, respectively. The day achieved active flexion to 90 degrees were 1.83, 1.97, and 2.03 days, respectively. The inpatient stay was 6.47 days for group I patients, 6.81 days for group II patients, and 6.77 days for group III patients. The mean episodes of breakthrough pain(VAS>4) were 3, 3, and 3.7 times, respectively. There was no related adverse effects occurred with the use of non-opioid trasndermal patches. Compared to placebo group, favourable results were noted in non-opioid transdermal patches, including opioid consumption, active knee flexion, inpatient stay and episodes of breakthrough pain in spite of insignificant statistical difference. High satisfaction without any complication were noted. Besides, non-opioid transdermal patches are also cost effective. There were only a few literature discussing about non-opioid patches in patients with total knee arthroplasty. The results showed indifferent pain improvement and no significant additional pain relief. Our results were compatible with current related studies, which showed no significant improvement. This is the first study to compare the analgesic efficacy of different non-opioid tansdermal patches in a prospective randomised trial.
Periprosthetic infection is the most challenging complication following total knee arthroplasty (TKA). Poor oral hygiene has been assumed as an important risk factor for TKA infection. We aimed to investigate whether the improvement of oral hygiene through dental scaling could reduce the risk of TKA infection. A nested case control study was conducted and enrollees in the National Health Insurance Research Database (NHIRD) aged above 40 years who had received total knee arthroplasty (TKA) between 1999–2002 were included as the TKA cohort. The cases were patients who underwent resection arthroplasty for infected TKA, and each case was matched by 4 controls from the TKA cohort by gender, using incidence density sampling method. The frequency of dental scaling before the index date was analyzed and compared between the case and the control groups. Multiple conditional logistic regression was used to assess the frequency of dental scaling and the risk of TKA infection.BACKGROUND
METHODS
Total knee replacement is a standard procedure for the end-staged knee joints. The main concerns at the perioperative period are infection prophylaxis, pain control, and blood loss management. Several interventions are designed to decrease the blood loss during and after the operation of total knee arthroplasty. In the recent meta-analysis showed that early tourniquet release of the tourniquet for hemostasis increased the total measured blood loss with primary TKR about 228.7 ml. So, Intra-operative blood loss for hemostasis can be saved by not to release the tourniquet after implants fixation, irrigation, closure of the wound and the application of compression dressing. Our study showed that most of the post-operative blood loss was collected during the first few postoperative hours: 37% in the first 2 hours and 55% in the first 4 hours and 82.1% in the first 24 hours. So, clamping the drainage for the first 4 postoperative hours would reduce blood loss after TKA (518 v.s. 843 mL). The fall in hemoglobin and Hct are also of significant difference (1.64 vs. 2.09 for Hb; 5.18 vs.7.69 for Hct). Appropriate clamping for an optimal time may be the most economical and simple, and the benefits of clamping also appear to outweigh its potential risks. NO DRAIN at all is able to reduce the post-operative blood loss. Our study showed that the decrease of postoperative hemoglobin was significantly less than that in no-drain group (1.45±0.72 vs 1.8±0.91). Shorter hospital stay was achieved in the no-drain group (8.3 ± 2.6 vs 10.7±3.2 days). All patients achieved good range of motion (flexion: 0 to >90 degree)by the five days after operation and no prosthetic infection was noted during follow-up. Thus, the routine use of closed suction drains for elective minimal-invasive total knee arthroplasty is not recommended.
TKR is a standard procedure for knee joint falure. Besides surgical technique, the main concerns at the perioperative care are: infection prophylaxis, blood loss management, & pain control. Pain is a normal part during the post-operative recovery stage. Currently, I apply multimodal pain control cocktails: Parenteral narcotics (as pethidine, tramadol, morphine), oral analgesics (as NSAIDs, Acetaminophen, opioids), PCA (Patient controlled analgesia), LIA (local IA injection anesthetics, Marcaine), and immediate Ice Packing. How about the usage of transdermal, non-opioid devices as Lidocaine patch. It shows the advantages of: less invasiveness, less ambulation-impeding, easy monitor & control, patient-activated, and absence of opioid-induced complications. Also it can be an adjuvant in the multi-modal anesthesia. In this Randomized prospective study, we investigate the analgesic effects of various transdermal non-opioid patches in patients after elective TKR The use of non-opioid transdermal patches is a safe and patient-activated method. Non-opioid transdermal patches show NSD improvement in the postoperative pain control for patients underwent TKA, facilitating fewer narcotics consumption, fewer breakthrough pain, faster recovery in movements and even shorter stay. However, without obvious differences, the routine use of transdermal patches in current pain control protocol should be trade-off.Conclusion
Total knee arthroplasty [TKA] is a common procedure to relieve painful disability from advanced knee arthritis. However, related blood loss, ranging from 800 to 1200 ml, increase risk and disruption of recovery in anemic patients following TKA. Various methods for blood conservation had been proposed and examined. In the literature, the intra-articular administration of a solution mixing bupivacaine and epinephrine was commonly used after knee surgeries. Therefore, we conducted a retrospective, case controlled review of our primary TKAs to determine the hemostatic efficacy of this regimen following TKAs. Over a period of 12 months, 135 eligible patients were divided two groups simply according to the intra-articular injection or not: a control group (N=63) and a treatment group (N=72). In the treatment group, a 40 ml vial of 0.5% bupivacaine with epinephrine 1: 200000 was given prior to the deflation of pneumatic tourniquet. No drainage was used in all TKAs. Without recordable drainage, a Gross formula, considering gender and body composition, was used for estimate blood loss following TKAs. In addition, serial changes in hemoglobin as well as the requirement of allogenic transfusion were also compared between groups.Introduction
Material and Methods
Total knee arthroplasty (TKA) is associated with significant blood loss, for which blood transfusion might be necessary. The role of the tourniquet is controversial, though it is widely used by orthopedic surgeons. Its use was believed to be effective in decreasing intraoperative blood loss and creating a bloodless surgical field, which theoretically would facilitate the cementing technique and other surgical procedures. However, reactive blood flow reached its peak within five minutes after the tourniquet had been released. The tourniquet controls intraoperative blood loss, but cannot stop postoperative blood loss. Patients who were managed with a tourniquet during the operation often complained of thigh pain. This was possibly caused by the direct pressure of an inflated tourniquet on the nerves and local soft tissues. Limb swelling and increased soft tissue tension caused by reactive hyperperfusion after tourniquet deflation may also contribute to the wound pain. The aim of our study is to investigate the effect of tourniquet on blood loss and soft tissue damage in TKA. In this prospective, randomized study, 72 patients with primary cemented knee arthroplasty were randomly allocated to two groups (with and without tourniquet). The operation time, blood loss, post-operative hemoglobin, hematocrit, markers of soft tissue damage (myoglobin, Cretine Posphokinase(CK), LDH, GOT, Creatinine), status of rehabilitation, knee pain and thigh pain were monitored until discharge.Introduction
Materials & Methods
Indications for revision include aseptic loosening (31 knees), instability (30 knees), failed unicompartmental knee replacement (8 knees), infection reimplantation (7 knees), arthrofibrosis (3 knees), chronic hemarthrosis (3 knees), failed patellofemoral replacements (1 knees), and nonunion of a supracondylar femur fracture (1 knee).
Achieving precise component alignment of total knee arthroplasty produces good clinical outcome. However, the cutting errors between planed and final bone resection planes during the procedure of total knee arthroplasty were less evaluated. The aim of this study was to evaluate the cutting errors during total knee arthroplasty using the navigation system. In a prospective series of 60 total knee replacements with image-free navigation system, the planed resection plane and final resection plane in frontal and sagittal planes were evaluated. The cutting errors standard deviations ranged from 1.01° to 1.21° in final frontal femoral and tibia plane and 1.23° in final sagittal femoral and tibia plane. The cutting errors showed only significant difference in the sagittal plane of femoral resection and only 9 cuts (4%) 3 of all plane and the maximal error was 4 in only 2 cases (0.8%). Our results support to use the navigation system to adjust the cutting block and correct the cutting errors. This would lead to a more precise cut and result in better leg alignment and component orientation than the conventional TKR technique.
Since September 1999, a total of 45 senile patients with vertebral compression fractures have been randomly selected for this study. Three treatment modalities were performed including the medical treatment only(15; control group), PMMA cement(15; PMMA group) and HA cement(15; HA group) augmentation. The transpedicular injections of PMMA and HA cements were performed on the latter two groups respectively via posterior approach. For all these patients, the subjective feeling and physical performance were evaluated by questionnaire (Modified Oswestry Questionnaire). The preop and postop X-rays, CT, bone density and bone markers were performed regularly for comparison and analysis. In general, the subjective feeling and physical performance had at least one grade improvement. Even though the short-term results using questionnaire did not have significant differences among these three groups, many parameters did show the advantages of using cements. The back pain, self-esteem and quality of life resolved much earlier and persistent than that of control group. The non-progression in local kyphosis was also noted in the cement groups. In addition, there were no significant differences between PMMA and HA cement groups. Both could be regarded as effective and reliable. However, due to the unique biological properties, HA cement is more promising in the future management of osteoporotic fractures.
This retrospective study compared the perioperative morbidity of two consecutive groups of patients having primary total knee arthroplasty thru subvastus approach and conventional medial parapatellar approach. The arthroplasties were performed in consecutive cases of the subvastus group(SV) (21 TKAs in 21 patients) from Dec. 1999 to May 2000 using a subvastus approach and in the control group(CY) of same operator(Y) (26 TKAs in 26 patients) from May 1999 to Nov. 1999 using medial parapatellar approach, and in the second control group(CB) (24 TKAs in 24 patients) from May 1999 to May 2000 using medial parapatellar approach by another operator (L). The patient perioperative morbidities were evaluated including blood loss, blood transfusion, lateral release, pain condition, time to ROM 90 degrees, skin complication, admission days. The subvastus group showed less time to gain 90-ROM(6.09, 6.8, 7.85), and less hospitalization days(10.43, 11.3, 12.15). But the SV group also showed higher rate of lateral release(13%, 8%, 12%) and skin complication(9%). Although the difference is not statistically significant. The authors concluded that the subvastus approach led to early ROM rehabilitation and discharge.
