Over half of postpartum women experience pelvic ring or hip pain, with multiple anatomic locations involved. The sacroiliac joints, pubic symphysis, lumbar spine and pelvic girdle are all well documented pain generators. However, despite the prevalence of postpartum hip pain, there is a paucity of literature regarding underlying soft tissue intra-articular etiologies. The purpose of this systematic review is to document and assess the available evidence regarding underlying intra-articular soft tissue etiologies of peri- and postpartum hip pain. Three online databases (Embase, PubMed and Ovid [MEDLINE]) were searched from database inception until April 11, 2021. The inclusion criteria were English language studies, human studies, and those regarding symptomatic labral pathology in the peri- or postpartum period. Exclusion criteria were animal studies, commentaries, book chapters, review articles and technical studies. All titles, relevant abstracts and full-text articles were screened by two reviewers independently. Descriptive characteristics including the study design, sample size, sex ratio, mean age, clinical and radiographic findings, pathology, subsequent management and outcomes were documented. The methodological quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) instrument. The initial search identified 2472 studies. A systemic screening and assessment of eligibility identified 5 articles that satisfied the inclusion criteria. Twenty-two females were included. Twenty patients presented with labral pathology that necessitated hip arthroscopy with labral debridement or repair with or without acetabuloplasty and/or femoroplasty. One patient presented with an incidental labral tear in the context of osteitis condensans illi. One patient presented with post-traumatic osteoarthritis necessitating a hip replacement. The mean MINORS score of these 5 non-comparative studies was 2.8 (range 0-7) demonstrating a very low quality of evidence. The contribution of intra-articular soft tissue injury is a documented, albeit sparse, etiology contributing to peri- and postpartum hip pain. Further research to better delineate the prevalence, mechanism of injury, natural history and management options for women suffering from these pathologies at an already challenging time is necessary to advance the care of these patients

Introduction. Intra articular distal tibia fractures can lead to post-traumatic osteoarthritis. Joint distraction has shown promise in elective cases. However, its application in acute fractures remains unexplored. This pilot study aims to fill this knowledge gap by investigating the benefits of joint distraction in acute fractures. Materials & Methods. We undertook a restrospective cohort study comprising patients with intra-articular distal tibia and pilon fractures treated with a circular ring fixator (CRF) at a single center. Prospective data collection included radiological assessments, Patient-Reported Outcome Measures (PROM), necessity for additional procedures, and Kellgren and Lawrence grade (KL) for osteoarthritis (OA). 137 patients were included in the study, 30 in the distraction group and 107 in the non-distraction group. There was no significant difference between the groups. Results. Mean follow-up was 3.73 years. There was no significant difference between the groups in overall complications or need for further procedures. There was no significant difference in progression of KL between the groups (1.81 vs 2.0, p=0.38) mean follow up 1.90 years. PROM data was available for 44 patients (6 distraction, 38 non-distraction) with a mean follow-up of 1.71 years. There was no significant difference in EQ5D (p=0.32) and C Olerud-H Molander scores (p=0.17). Conclusions. This pilot study suggests that joint distraction is safe in the acute setting. However, the study's impact is constrained by a relatively small patient cohort and a short-term follow-up period. Future investigations should prioritise longer-term follow-ups and involve a larger patient population to more comprehensively evaluate the potential benefits of joint distraction in acute fractures

To compare the efficacy of intra-articular and intravenous modes of administration of tranexamic acid in primary Total Knee Arthroplasty in terms of blood loss and fall in haemoglobin level. This randomized controlled trial was conducted from 12th May 2017 to 11th May 2017. Seventy eight patients were included in the study. Patients were randomly divided into group A and B. Group A patients undergoing unilateral primary total knee replacement (TKR) were given intravenous tranexamic acid (TXA) while group B were infiltrated with intra-articular TXA. Volume of drain output, fall in haemoglobin (Hb) level and need for blood transfusion were measured immediately after surgery and at 12 and 24 hours post operatively in both groups. The study included 35 (44.87%) male and 43 (55.13%) female patients. Mean age of patients was 61±6.59 years. The mean drain output calculated immediately after surgery in group A was 45.38±20.75 mL compared with 47.95±23.86 mL in group B (p=0.73). 24 hours post operatively, mean drain output was 263.21±38.50 mL in intravenous group versus 243.59±70.73 mL in intra-articular group (p=0.46). Regarding fall in Hb level, both groups showed no significant difference (p>0.05). 12.82% (n=5) patients in group A compared to 10.26% (n=4) patients required blood transfusion post operatively (p=0.72). Intra-articular and intravenous TXA are equally effective in patients undergoing primary total knee arthroplasty in reducing post operative blood loss. For any reader queries, please contact . drjunaidrmc@gmail.com

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain - VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain – VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

The effect of intra-articular tranexamic acid on blood loss in concurrent bilateral total knee arthroplasty was studied in 60 patients in double blind fashion; one knee receiving tranexamic acid, the other knee receiving physiological saline acting as control. A single surgeon performed all operations utilising the same surgical technique and prosthesis. Mean blood loss from intra-articular drains was not significantly different, being 141ml in the tranexamic acid group and 163ml in the control group. Circumferential leg measurements at levels above, through and below the knees were not significantly different between groups on day two post-operatively compared to pre-operatively. Intra-articular tranexamic acid instillation did not lead to a significant reduction in blood loss in these patients

Previous authors have suggested that the analgesic effects of intra-articular morphine may be beneficial. Clonidine has been found to potentiate the analgesic effect of morphine. Following knee arthroscopy, morphine has demonstrated equivocal effect in comparison to bupivicaine for analgesia while circumventing the issue of chondrotoxicity. There have been no studies evaluating the effect of intra-articular morphine following hip arthroscopy. The purpose of this study was to evaluate the efficacy of intra-articular morphine in combination with clonidine on pain and narcotic consumption following hip arthroscopy surgery for femoroacetabular impingement. A retrospective review was performed on 43 patients that underwent hip arthroscopy between September 2014 and May 2015 at our institution for femoroacetabular impingement. All patients received preoperative Celebrex and Tylenol per our anesthesia protocol, and 22 patients received an additional intra-articular injection of 10 mg morphine and 100 mcg of clonidine at the conclusion of the procedure. Narcotic consumption, duration of anesthesia recovery, and perioperative pain scores were compared between the two groups. We found that patients who received intra-articular morphine and clonidine used significantly less opioid analgesic in the PACU, with 23 mEq of morphine equivalents required in the intra-articular morphine and clonidine group compared to 40 mEq of opiod equivalents in the non-injection group (p=0.0259). There were no statistically significant differences in time spent in recovery prior to discharge or in VAS pain scores recorded immediately post-operatively and at one hour following surgery. In conclusion, we found that an intraoperative intra-articular injection of morphine and clonidine significantly reduced the amount of narcotic requirement following hip arthroscopy. We do believe that there may be significant benefits to this, including less systemic effects from overall narcotic usage in the perioperative period. Our study demonstrated a beneficial effect of intra-articular morphine that may help with overall pain improvement, less narcotic consumption, and improved patient satisfaction following outpatient hip arthroscopy. This study provides the foundation for future research currently being conducted in a randomised-control setting

Patients undergoing revision surgery of a primary total hip arthroplasty often exhibit bone loss and poor bone quality, which make achieving stable fixation and osseointegration challenging. Implant components coated in porous metals are used clinically to improve mechanical stability and encourage bone in-growth. We compared ultra-porous titanium coatings, known commercially as Gription and Porocoat, in an intra-articular model by press-fitting coated cylindrical implants into ovine femoral condyles and evaluating bone in-growth and fixation strength 4, 8 and 16 weeks post-operatively. Bilateral surgery using a mini-arthrotomy approach was performed on twenty-four Dorset-Rideau Arcott rams (3.4 ± 0.8 years old, 84.8 ± 9.3 kg) with Institutional Animal Care Committee approval in accordance with the Canadian Council on Animal Care. Cylindrical implants, 6.2 mm in diameter by 10 mm in length with surface radius of curvature of 35 mm, were composed of a titanium substrate coated in either Porocoat or Gription and press-fit into 6 mm diameter recipient holes in the weight-bearing regions of the medial (MFC) and lateral (LFC) femoral condyles. Each sheep received 4 implants; two Gription in one stifle (knee) and two Porocoat in the contralateral joint. Biomechanical push-out tests (Instron ElectroPuls E10000) were performed on LFCs, where implants were pushed out relative to the condyle at a rate of 2 mm/min. Force and displacement data were used to calculate force and displacement at failure, stiffness, energy, stress, strain, elastic modulus, and toughness. MFCs were fixed in 70% ethanol, processed undecalcified, and polished sections, approximately 70 µm thick (Exakt Micro Grinding system) were carbon-coated. Backscattered electron images were collected on a scanning electron microscope (Hitachi SU3500) at 5 kV and working distance of 5 mm. Bone in-growth within the porous coating was quantified using software (ImageJ). Statistical comparisons were made using a two-way ANOVA and Fisher's LSD post-hoc test (Statistica v.8). Biomechanical evaluation of the bone-implant interface revealed that by 16 weeks, Gription-coated implants exhibited higher force (2455±1362 N vs. 1002±1466 N, p=0.046) and stress (12.60±6.99 MPa vs. 5.14±7.53 MPa, p=0.046) at failure, and trended towards higher stiffness (11510±7645 N/mm vs. 5010±8374 N/mm, p=.061) and modulus of elasticity (591±392 MPa vs. 256±431 MPa, p=0.61). Similarly, by 16 weeks, bone in-growth in Gription-coated implants was approximately double that measured in Porocoat (6.73±3.86 % vs. 3.22±1.52 %, p=0.045). No statistically significant differences were detected at either 4 nor 8 weeks, however, qualitative observations of the exposed bone-implant interface, made following push-out testing, showed more bony material consistently adhered to Gription compared to Porocoat at all three time points. High variability is attributed to implant placement, resulting from the small visual window afforded during surgery, unique curvatures of the condyles, and presence of the extensor digitorum longus tendon which limited access to the LFC. Ultra-porous titanium coatings, know commercially as Gription and Porocoat, were compared for the first time in a challenging intra-articular ovine model. Gription provided superior fixation strength and bone in-growth, suggesting it may be beneficial in hip replacement surgeries where bone stock quality and quantity may be compromised

Introduction & Aims. Intravenous administration of tranexamic acid (TXA) has been shown to be effective in reducing blood loss and transfusion requirements in total knee arthroplasty (TKA). However, concern exists that I.V. TXA may heighten the risk of venous thrombo-embolism. The intra-articular administration of TXA is an attractive and simple option to deliver this agent locally with minimal systemic effects on inducing hypercoagubale states. In this study, we analysed the effect of varying dosages of intra-articular tranexamic acid on blood loss in TKA. Methods. 176 patients who underwent a unilateral TKA for osteoarthritis were retrospectively analysed. Patients were excluded if they underwent a revision knee arthroplasty, concurrent removal of hardware, extensive synovectomy, or lateral patellar retinacular release. All patients underwent a primary cemented posterior stabilised TKA by 2 surgeons using a medial parapatellar approach. Tourniquet was only inflated for initial exposure and intra-articular drains were not used. Patients were separated into three groups; a control group (n=56) who did not receive TXA, and 2 treatment groups who received intra-articular TXA with doses of 1500 mg (n=60) or 3000 mg (n=60). Once the wound was closed, tranexamic acid was injected intra-articularly via an epidural pain catheter. Haemoglobin (Hb) levels were taken pre-operatively and on post-operative days 1 and 2. The primary outcome measure was mean difference in Hb drop between the three groups. Results. There was a statistically significant difference in post-operative Hb drops amongst the three groups. Those who received TXA had a greater reduction in the blood loss compared to the control group. In the control group, the mean haemoglobin pre-operatively was 140.13 g/L with an average drop of 34.30 g/L by post-operative day 2. Patients who received 1500 mg of TXA had a mean haemoglobin of 138.95 g/L pre-operatively with an average drop of 28.67 g/L by post operative day 2. Those who received 3000 mg had a pre-operative haemoglobin of 138.02 g/L with an average drop of 22.73 g/L. There were no differences in post-operative complications or local reactions. All inter-group differences in Hb drop on day 2 were statistically significant (p < 0.001, t tests and ANOVA). Conclusions. There appears to be a dose-dependent effect of intra-articular tranexamic acid on blood loss in TKA, with more efficacy with higher dosages. Intra-articular administration of TXA is an effective and simple way to decrease post-operative blood loss in TKA

Background:. Role of intra-articular Tranexamic acid in total knee replacement arthroplasty. Materials and methods. Prospective evaluation was done to see the effect of intra-articular Tranexamic acid on blood loss in 60 patients (120 knees) undergoing total knee arthroplasty. All the patients were operated by one surgeon with same technique by using same implants. Patients were randomly injected 1500 mg/20 ml of Tranexamic acid on one side of the knee only. Nothing was injected on the contra lateral knee. Evaluation was done for swelling and the amount of blood loss in the drain. Results:. Average blood loss in the drain on Tranexamic side was 140 ml and the opposite side was 390 ml. Swelling was more observed on the non Tranexamic side. Average time for drain removal on Tranexamic side was 36 hours while it was 48 hours on non Tranexamic side. Early mobilization and weight bearing was less painful in Tranexamic side. No patient had systemic complications of Tranexamic acid. Conclusion:. Intra-articular injection of Tranexamic acid reduces blood loss, swelling around the knee without systemic side effects and allows early weight bearing and mobilization of the joint

Aim. We outline a treatment protocol for subjects with chronic periprosthetic joint infections (PJI) who elected not to have surgery. We developed a method of serial “fluid-depleting” aspirations with intra-articular gentamycin injections to affect the population of the biofilm community. We have experienced many treatment failures, as expected, but have also had a group of subjects who responded exceptionally well, requiring no surgical intervention. Our longest follow-up is 10 years. Method. From June 2009 to December 2018, 372 clinical cases of chronic PJI involving primary and revision TKA and THA were treated. Of these, 25 subjects were treated with an active suppression protocol, in lieu of surgery. The protocol entailed frequent aspirations and intra-articular antibiotic injections to quell the PJI inflammatory response. All aspirations were performed by the treating surgeon in the orthopaedic clinic without fluoroscopic guidance. Based on a subject's response to the protocol, he/she was identified as 1 of 3 classifications: 1) Ongoing Treatment – Biofilm Trained (OTBT), 2) Ongoing Treatment – Biofilm Untrained (OTBU), and 3) Treatment Failure (TF). OTBT subjects showed no clinical signs of infection. Serum biomarkers (CRP, ESR) remained consistently normal and subjects were not on oral suppressive antibiotics. Aspiration analysis and cultures remained negative. Maintenance treatment consisted of a fluid-depleting aspiration with an intra-articular gentamycin injection every 12–16 weeks. OTBU subjects showed improved clinical symptoms, lowered serum biomarkers, and lowered WBC counts, but still demonstrated objective signs of infection. TF subjects did not respond to the protocol and showed unchanged/worsening clinical symptoms. Results. Of the 25 subjects, 8 were THA's and 17 were TKA's. Of these cases, 21 (84%) were endoprosthetic replacements. 8 subjects (32%) were classified as OTBT, 6 (24%) as OTBU, and 11 (44%) as TF. All TF subjects were treated with a two-stage exchange protocol. Conclusions. This study is the first describing the potential of modifying bacterial biofilm in a chronic PJI. While our success rate was modest (32%), “Biofilm Trained” subjects demonstrated dramatic changes. Subjects led normal lives, only minimally disrupted by an aspiration and injection every 3–4 months. In the future, we are looking at different agents to modify the enveloping biofilm, including a pre-aspiration injection of EDTA to disrupt the biofilm surface, followed by injecting benevolent bacteria to transform the biofilm to a benevolent state. If able to achieve such a state in a consistent fashion, the impact on the patient and healthcare communities would be enormous

Introduction. 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. Material and Methods. 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. Results. The mean calculated blood loss in the treatment group was 650.4 +/− 257.1 ml, compared to 648.8+/− 222.1 ml in the control group (p=0.9). Similar decrease in hemoglobin as well as rates of allogenic transfusion needs were observed between groups.[2.5+/− 0.9 g/dl vs. 2.4+/− 0.8 g/dl; 13.9% vs. 12.7%, respectively]. Discussion and Conclusion. Although local analgesics mixing vasoconstrictive agents seem a logic solution to save blood loss and relieve pain simultaneously, the hypothesis that intra-articular injection of bupivacaine and epinephrine would save blood and even transfusion needs following TKAs is not supported by various bleeding parameters in this study. In addition to temporary benefit in pain relief, this regimen only has little effect on blood conservation. Therefore, new regimen as well as hemostatic means are still required and explored to reduce blood loss following TKAs

The extension facet angle (EFA) of the medial compartment of the knee has been implicated as a potential mechanical cause for anteromedial knee osteoarthritis. We developed a novel sagittal plane flexion osteotomy of the medial tibiofemoral compartment. We then performed a cadaveric study to study the effect of the osteotomy on the intra-articular knee pressures under axial load mimicking the stance phase of gait. A Tekscan K400 pressure sensor was inserted submeniscally into the joint and 700N applied using an Instron machine. A topographical map of the pressure areas was then assessed pre- and post-osteotomy for the 10 cadaveric knees specimens. We found that the intra-articular pressures are greatest in the anteromedial compartment in the native knee and after the osteotomy the area of highest pressure moves posterolaterally spread over a greater surface area. We conclude that a flexion osteotomy of the medial compartment reduces intra-articular knee pressures concentrated anteromedially in full extension and may be beneficial in patients with an elevated EFA with anteromedial symptoms

Introduction & Aims. The traditional method of soft-tissue balancing during TKA is subjective in nature, and stiffness and instability are common indications for revision, suggesting that TKA balancing by subjective assessment is suboptimal. This study examines the intraoperative mediolateral loads measured with a nanosensor-enabled tibial insert trial and the sequential balancing steps used to achieve quantitative balance. Data obtained from a prospective multicenter study was assessed to determine the effect of targeted ligament release on intra-articular loading, and to understand which types of releases are necessary to achieve quantified ligament balance. Methods. A group of 129 patients received sensor-assisted TKA, as part of a prospective multicenter study. Medial and lateral loading data were collected pre-release, during any sequential releases, and post-release. All data were collected at 10, 45, and 90 degrees during range of motion testing. Ligament release type, release technique type, and resultant loading were collected. Results. Measured loads consistently decreased after soft-tissue release or bony re-cut and the relative mediolateral loading became more symmetric. The average change in loading values were approximately the same whether release or pie-crusting techniques were employed. In order to achieve balance, exhibited through the range of motion, the medial compartment required, on average, over double the release to loading (lbf.) than the lateral compartment. Structural changes that contributed significantly to changes in loading were: Release of the anterior and posterior bands of the MCL, pes anserine release, and recutting the tibia. On average, 2 or 3 structural corrections were performed to achieve balance. Conclusions. The use of quantitative sensor data during TKA balancing enables targeted corrections to the soft-tissue envelope in order to correct intercompartmental load differential. 2–3 steps are needed on average to achieve soft tissue balance

In total knee arthroplasty (TKA), both intravenous (IV) and/or intra-articular (IA) administration of tranexamic acid (TXA) were showed to reduce blood loss. Moreover, research suggesting TXA decreases postoperative knee swelling, but it is unknown whether this results in improved postoperative rehabilitation outcome. Thus, the aim of this study was to evaluate whether combined IV and IA administration of TXA would associate with improved early rehabilitation outcomes. In this institutional review board approved randomized controlled trial, 179 patients scheduled for unilateral TKA were randomized to one of three regimens: (1) IA administration of 1gm TXA at end of procedure only, (2) additional preoperative IV dose of 15 mg/kg 30min before tourniquet inflation, and (3) additional postoperative dose 4hrs after preoperative dose. Primary outcomes included knee range of motion, Knee Society Score (KSS) at 6-month postoperatively, haemoglobin drop at day-2 post-operatively, and transfusion rate. Secondary outcome was venous thromboembolism (VTE) complications. Baseline characteristics were comparable between the allocation groups. Patients in regimen (3) showed statistically significant better knee extension range (6.2°, 5.9°, 2.9°, p=0.01), and KSS (88.5, 89.9, 93.0, p=0.02) at 6-month postoperatively, and lesser drop in haemoglobin at day-2 post-operatively (2.72, 2.47, 1.75 g/dL, p=0) when compared with patients in other regimens. No patients required transfusion, or complicated by VTE. The combined administration of IA and IV TXA, including both preoperative and postoperative doses, associated with statistically significantly improved early rehabilitation outcomes. The improvement may be related to higher haemoglobin level and decreased knee swelling in patients having regimen (3). For any reader queries, please contact . cpk464@yahoo.com.hk

Objective. The purpose of this study was to evaluate the efficacy and safety of the drained-clamped method with intra-articular infusion of tranexamic acid (TA) for reducing blood loss in total knee arthroplasty (TKA). Material and Methods. From November 2011 to July 2014 inclusive, 72 patients with a diagnosis of osteoarthritis underwent unilateral primary TKA using a computed tomography (CT) free navigation system. Patients were randomly divided into two groups: group T (n=40) was given 2000 mg (40 ml) of TA and group W (n=32) was given 40 ml sterile saline only. All operations were performed under total anaesthesia through the medial mid-vastus approach. Cemented posterior stabilised or cruciate retaining prostheses were used. The patella was resurfaced. After tourniquet release and wound suture, TA or saline was infused into the knee joint in addition to the drained-clamped method for 2 hours. For VTE prophylaxis, all patients received bilateral intermittent pneumatic calf compressors, thromboembolic deterrent stockings, and subcutaneous injection of enoxaparin (4000IU daily). We evaluated the hematocrit, hemoglobin and the postoperative estimate of bleeding. At postoperative days 4, extremity venous ultrasonography was performed for the investigation of venous thromboembolism in the latest 40 patients and contrast-enhanced CT was performed in the latest 34 patients without a previous history of asthma and diminished renal function. The present study received institutional review board approval, and informed consent was obtained from all patients. Results. Group T had lower hematocrit and hemoglobin levels at postoperative day 1. Group T had higher hemoglobin levels at postoperative days 3 and 7, respectively. The postoperative estimate of bleeding in group T was 739.2 ± 318.9 ml on average, which was significantly less than group W which was 999.8 ± 414.1 ml (p <0.01). The rate of asymptomatic deep vein thrombosis and pulmonary embolism was 57.1% and 29.4% in group T, and 36.8% and 11.8% in group W, respectively. There were no significant differences between the two groups. Conclusion. The drain-clamped method with intra-articular infusion of TA was safe and effective for reducing the amount of blood loss in TKA, without increasing the risk of VTE

Epidemiological data about tibial plateau and associated intra-articular proximal tibial fractures provides clinicians with an understanding of the range, variety, and patterns of injury. There are relatively few studies examining this injury group as a whole. We prospectively recorded all tibial plateau and intra-articular proximal tibial fractures occurring in our regional population of 545,000 adults (aged 15 years or older) in 2007–2008. We then compared our results with previous research from our institution in 2000. There were 173 fractures around the knee, 65 of these involved the tibial plateau. Median age was 59 years (IQR, 36.5–77.5 yrs). Tibial plateau fractures were more common in women (58.5%vs 41.5%). The median age of men was 37 years (IQr, 29–52 yrs) compared to women, 73 years (IQR, 57–82 yrs). Tibial plateau fractures accounted for 0.9% overall and 2.5% of lower limb fractures. Incidence was 1.2/10,000/yr (95% CI, 0.9–1.5). We have prospectively identified and described the epidemiological characteristics of tibial plateau fractures in adults from our region. We have identified a change to the epidemiology of these fractures over a relatively short time frame as the patients at risk age

Aim

The objective of this systematic review is to evaluate the current evidence for or against this up-and-coming treatment modality.

Standard imaging of complex intra-articular distal radius fractures consists of posterior-anterior, lateral and oblique x-rays. Recently the liberal use of CT scan in this area became widely accepted as an additional imaging tool in pre-operative evaluation. The aim of this study was to evaluate whether CT scanning of complex distal radius fractures changed the management of these fractures compared to plain films. A series of 20 closed distal radius complex intra-articular fractures AO 12-C which had both plain PA, lateral and oblique films and CT scans were selected from our long bone trauma database. The plain films were blindly reviewed by five observers. A management plan was then formulated. Options provided were: closed manipulation, closed manipulation with percutaneous K wire fixation, open reduction and internal fixation, external fixature or bone graft/substitute. The same patients' CT scans (in randomised order) were blindly reviewed at the one week interval by the same clinicians with the same management options decided upon. Kappa statistic was used to measure the intra-individual agreement between x-ray and CT, as well as inter-individual agreement within each imagining modality. The agreement between individual observer's management decisions, based on the x-rays and on the CT scan was poor; with an average Kappa score of 0.038 (range 0.006 to 0.19). A regression model with management as a graded 5 level variable ranging from least invasive to most invasive and imaging modality as the predictor gave an estimated coefficient of 0.163, (p=-0.267); this indicates a trend towards a slightly higher level of invasiveness when the management decision was based on the CT compared to the plain x-rays. The agreement on management decisions between the observers based on x-ray alone was higher than that based on CT alone (kapa=0.174 vs 0.03). This study indicates a very poor level of agreement between decision-making, based on x-ray and on CT. Even within individual's ‘interindividual’ agreement appears higher with x-ray than CT. This study also raises the possibility that the use of CT scans increases the level of invasiveness in the surgical management of complex distal radius fractures

Infection is one of the most devastating complications following total joint arthroplasty. Treatment is difficult, often requiring multiple surgical procedures, prolonged hospitalisation, and long-term intravenous (IV) antibiotic therapy. Failure rates are high for resistant organisms and mixed-flora infections, and antibiotic-loaded cement spacers deliver antibiotics for only a few days and can harbor resistant bacteria on the surface. We have adopted a direct-exchange method with antibiotics infused directly into the joint using Hickman catheters to achieve extremely high levels of intra-articular (IA) antibiotics for six weeks. Hickman catheters have a fibrous cuff that allows soft-tissue ingrowth and seals the surface of the tube to prevent contamination of the joint by tracking along the catheter. Two catheters are inserted to ensure that at least one will be functional for six weeks. The safety and efficacy of this protocol was evaluated in patients undergoing primary or revision TKA by measuring joint and serum levels of vancomycin following IV administration (as a prophylactic) and IA administration (as a treatment for infected TKA), and comparing the levels with each method. Therapeutic levels of vancomycin were present in the knee following IV or IA administration, but much higher levels were possible with IA administration. Vancomycin achieved therapeutic levels in the synovial fluid of the knee with IV administration, but clearance from the knee was rapid, suggesting that the synovial fluid concentration may be sub-therapeutic for hours before the next IV dose is given. In contrast, IA delivery of vancomycin resulted in peak levels that were many orders of magnitude higher, and trough levels remained therapeutic for 24 hours in both the joint space and in the serum (trough levels of 8.4 and 4.2 μg/mL, respectively). The elimination constant (half-life) of IA-administered vancomycin was determined to be 3.06 hours. This protocol was used in 18 knees (18 patients) with methicillin-resistant Staphylococcus aureus treated between January 2001 and January 2007 with one-stage revision that included debridement, uncemented revision of total knee components, and IA infusion of 500 mg vancomycin via Hickman catheter once or twice daily for 6 weeks. No IV antibiotics were used after the first 24 hours. Serum vancomycin levels were monitored to maintain levels between 3 and 10 μg/mL. Mean serum vancomycin peak concentration was 6±2 μg/mL and the mean serum vancomycin trough concentration was 3±1 μg/mL at 2 weeks post-operative. Knee synovial fluid peak and trough vancomycin levels were measured in two knees. Synovial fluid peak concentrations were 10,233 μg/mL and 20,167 μg/mL and trough concentrations were 724 μg/mL and 543μg/mL, respectively. Minimum follow-up was 27 months (range, 27–75 months). Mean follow-up was 62 months, (range, 27–96 months). At 2-year follow-up, mean Knee Society score was 83±9. No radiographic evidence of implant migration has occurred. One knee reinfected with MRSA and was reoperated at 5 months. A necrotic bone segment was found, the knee was debrided and revised, and the antibiotic infusion protocol was readministered. The knee remained free of infection at 42 months post-operatively. Directly infusing antibiotics into the infected area maintains a high local concentration level while minimising systemic toxicity. This method avoids the use of antibiotic-loaded cement and the potential for growth of antibiotic-resistant strains of bacteria. These findings support single-stage revision in cases treated with cementless revision and IA antibiotics