Chii Jeng Lin

Tourniquet use in total knee arthroplasty: a meta-analysis

PurposeThe use of an intraoperative tourniquet for total knee arthroplasty (TKA) is a common practice. However, the effectiveness and safety are still questionable. A systematic review was conducted to examine that whether using a tourniquet in TKA was effective without increasing the risk of complications.MethodsA comprehensive literature search was done in PubMed Medicine, Embase, and other internet database. The review work and the following meta-analysis were processed to evaluate the role of tourniquet in TKA.ResultsEight randomized controlled trials and three high-quality prospective studies involving 634 knees and comparing TKA with and without the use of a tourniquet were included in this analysis. The results demonstrated that using a tourniquet could decrease the measured blood loss but could not decrease the calculated blood loss, which indicated actual blood loss. Patients managed with a tourniquet might have higher risks of thromboembolic complications. Using the tourniquet with late release after wound closure could shorten the operation time; whereas early release did not show this benefit.ConclusionsThe current evidence suggested that using tourniquet in TKA may save time but may not reduce the blood loss. Due to the higher risks of thromboembolic complications, we should use a tourniquet in TKA with caution.

Effects of tourniquet use on blood loss and soft-tissue damage in total knee arthroplasty: a randomized controlled trial.

BACKGROUNDnAlthough tourniquets are widely used in total knee arthroplasty, their effectiveness in reducing blood loss and their influence on the postoperative course remain unclear. Tourniquet-related soft-tissue damage is a related concern. We performed a prospective, randomized, controlled trial to clarify the effect of tourniquets in total knee arthroplasty.nnnMETHODSnSeventy-two patients undergoing total knee arthroplasty were randomly allocated to a tourniquet or non-tourniquet group. Blood loss and changes in C-reactive protein, creatine phosphokinase, and other indicators of soft-tissue damage were monitored preoperatively and postoperatively on Days 1, 2, and 4. Thigh pain, knee pain, limb swelling, rehabilitation progress, and hospital stays were also recorded for comparison.nnnRESULTSnPatients in the tourniquet group showed smaller decreases in hemoglobin (mean and standard deviation, 2.6 ± 0.9 versus 3.7 ± 1.3 g/dL) and hematocrit (7.6% ± 2.8% versus 10.4% ± 4.0%), less calculated blood loss (303 ± 119 versus 423 ± 197 mL), and smaller increases in C-reactive protein (peak value, 175 ± 55 versus 139 ± 75 mg/dL) and creatine phosphokinase (peak value, 214 ± 89 versus 162 ± 104 U/L) compared with those in the non-tourniquet group. There was slightly less postoperative pain in the non-tourniquet group. There were no significant differences between the groups in terms of swelling, rehabilitation progress, or hospital stays.nnnCONCLUSIONSnThe use of a tourniquet during total knee arthroplasty was effective for reducing blood loss and avoiding excessive postoperative inflammation and muscle damage. The use of a tourniquet was related to slightly more postoperative pain but did not affect postoperative recovery.

The severity of the long head biceps tendinopathy in patients with chronic rotator cuff tears: macroscopic versus microscopic results.

BACKGROUNDnThis study investigated the histopathology of the long head of biceps (LHB) tendon and correlated the findings with the macroscopic appearances of the LHB and the size of rotator cuff tears (RCTs) in patients with chronic RCTs.nnnMETHODSnWe compared biopsy specimens from LHBs in 34 patients with chronic RCTs and grossly normal LHBs in 8 patients undergoing shoulder hemiarthroplasty (controls). Duration of preoperative symptoms, the severity of RCTs, and macroscopic appearance of LHBs were recorded, classified, and compared with the histologic grading and apoptosis index of terminal deoxynucleotide transferase-mediated biotin-deoxy uridine triphosphate nick-end labeling (TUNEL) assays of LHBs.nnnRESULTSnIn the RCT group, there were 8 partial-thickness tears with 5 macroscopic LHB lesions, 12 full-thickness tears with 8 macroscopic LHB lesions, and 14 massive tears with 13 macroscopic LHB lesions. There were 6 LHB subluxations. However, the macroscopic grading and the symptom duration were not correlated with the severity of the histology. In patients with massive tears, no matter what the macroscopic appearance of the LHB, the proportion of end-stage (grade 4) histologic LHB tendinopathy significantly increased (85.7%, Pxa0<xa0.05) compared with patients with other types of RCTs. There was a consistently high incidence of advanced LHB histology (grade 3 or higher) in each classification of RCTs (75.0%-100.0%). The 8 patients in the control group showed milder histopathology (grade 1 or 2). The apoptosis index significantly increased as the tendinopathy progressed (Pxa0<xa0.05).nnnCONCLUSIONSnThe macroscopic pathology of LHB may not fully reflect the severity of tendinopathy, and the coexisting size of RCTs plays a role in the severity of LHB tendinopathy.

Mycobacterium bovis osteomyelitis as a complication of Bacille Calmette-Guérin (BCG) vaccination: rapid diagnosis with use of DNA sequencing analysis: a case report.

Vaccination with bacille Calmette-Guerin (BCG) has been used for the prevention of tuberculosis in many areas of the world. It is estimated that more than three billion people worldwide have been vaccinated with live BCG since 19459. In almost all children, inoculation with BCG is harmless. However, it must be understood that BCG, like other vaccines, such as that for poliomyelitis and even that for measles, mumps, and rubella, occasionally produces adverse reactions5,11,21-23. Despite these rare complications, BCG has proved to be effective for preventing miliary tuberculosis and tubercular meningitis in many developing countries. Disseminated complications were observed in association with approximately one per million vaccinations, and severe local reactions occurred in approximately 2 percent of individuals who were vaccinated11,22,23. BCG osteomyelitis has been reported often in Europe but relatively rarely elsewhere1-3,6,7,13,25; however, it may not be as rare as it seems. It is possible that the diagnosis may be missed unless the treating physician has a high index of suspicion and unless a sensitive technique of identification is available. This complication deserves greater attention because it has been reported in association with intravesical administration of BCG for the treatment of carcinoma of the bladder8,24.nnThe reason why the importance of BCG osteomyelitis has often been neglected may be related to the difficulty of confirming the diagnosis. Traditionally, the definitive diagnosis is made on the basis of a positive identification of the BCG strain of Mycobacterium bovis on tissue culture, which is by no means simple22. However, the task has been made easier by advances in molecular biology and the application of molecular biological techniques to …

A simple modified arthroscopic suture fixation of avulsion fracture of the tibial intercondylar eminence in children

The purpose of this study was to describe a simple and modified technique for arthroscopic suture fixation in a 12-year-old boy who sustained a displaced type III intercondylar eminence of the tibial. The arthroscopic fixation was modified by using the Arthrex suture lasso device to place two nonabsorbable sutures into the anterior cruciate ligament (ACL). However, the procedure became simple with the help of the Acufex ACL guide to reduce the avulsed tibial spine fragment and to place an appropriate tibial tunnel. Sutures were then passed through the tibial tunnel and secured over a bony bridge with the knee at 20° of flexion. At 6 months, the patient had a full range of motion with normal Lachman and anterior drawer testing, and he had returned to his daily activities. Radiographs showed complete fracture healing. Repair using the Arthrex suture lasso device provides a significant advantage in the treatment of type III and IV fractures of the tibial eminence by obtaining arthroscopic fixation with the substance of the ACL, thus eliminating the risks of comminution of the fracture fragment and hardware removal. This arthroscopic technique restores the length and integrity of the ACL, and provides a simplified, reproducible method of treatment for this injury.

Non-drainage is better than 4-hour clamping drainage in total knee arthroplasty

The role of wound drainage in total knee arthroplasty (TKA) is controversial. The use of drainage was believed to be effective in decreasing hematoma formation, but it inevitably increases bleeding because the tamponade effect of a closed and undrained wound is eliminated. Clamping the drain tube in the first 4 hours after TKA can temporarily recreate a tamponade effect for bleeding control. Previous studies compared the clamping drainage with the conventional drainage method but not with non-drainage. Some current studies have shown that drainage in TKA is not necessary. Thus, we conducted a study to compare the outcomes between the patients with temporarily clamping drainage and without drainage.One hundred consecutive patients undergoing primary TKA were included. Change of hemoglobin, blood transfusion, use of narcotics, postoperative wound dressing, length of hospital stay, and range of motion were recorded. The drain-clamping group demonstrated more postoperative hemoglobin loss and a longer hospital stay, and gained no benefit compared with the non-drain group. Therefore, we concluded that despite clamping for 4 hours after TKA, the drain was still of no use. We would not recommend using a draining system routinely after TKA.

Elevated temperature trends after total knee arthroplasty.

Fever after total knee arthroplasty (TKA) is a common phenomenon. However, the pattern of temperature change and its correlation with perioperative factors remain unclear. The purpose of this study was to define the trend of postoperative body temperature in patients undergoing TKA. This study also sought any factors influencing body temperature. We reviewed the charts of 186 clinically uncomplicated patients to record the changes of body temperature in the first 5 postoperative days and to determine the factors affecting it. The temperature trends of patients with acute prosthetic infection were also reviewed for comparison. In uncomplicated patients, the average peak temperature was 37.9 degrees C, a 3.3% increase from the preoperative baseline, 36.7 degrees C. The temperature elevation was most remarkable on postoperative days 1 and 2, but only 4 patients experienced fever up to 39 degrees C. Patients with lower hemoglobin loss showed higher peak temperature. Patients with postoperative infection tended to have prolonged fever and delayed presentation of peak temperature. Our study illustrated the elevated pattern of body temperature after uncomplicated TKA and determined the loss of hemoglobin might be the affecting factor. Fever up to 39 degrees C, prolonged fever, and delayed presentation of peak temperature were uncommon and should raise the clinical suspicion of infection or other complication.

Suture anchor versus screw fixation for greater tuberosity fractures of the humerus—a biomechanical study

Suture anchors and screws are commonly used for fixation of humeral greater tuberosity (GT) fractures in either arthroscopic or open surgeries, but no biomechanical studies have been performed to compare the strength of fixation constructs using these two implants. This cadaveric study aimed to compare the biomechanical strength of three different fixation constructs in the management of GT fractures: Double‐Row Suture Anchor Fixation (DR); Suture‐Bridge Technique using suture anchors and knotless suture anchors (SB); and Two‐Screw Fixation (TS). The experimental procedure was designed to assess fracture displacement after cyclic loading, failure load, and failure mode of the fixation construct. Significant differences were found among the SB (321u2009N), DR (263u2009N), and TS (187u2009N) groups (SBu2009>u2009DRu2009>u2009TS, pu2009<u20090.05) in the mean force of cyclic loading to create 3u2009mm displacement. Regarding the mean force of cyclic loading to create 5u2009mm displacement and ultimate failure load, no significant difference was found between the DR (370u2009N, 480u2009N) and SB (399u2009N, 493u2009N) groups, but both groups achieved superior results compared with the TS group (249u2009N, 340u2009N) (pu2009<u20090.05). The results suggested that the suture anchor constructs would be stronger than the fixation construct using screws for the humeral GT fracture.

Application of locked intramedullary nails in the treatment of complications after distraction osteogenesis

Distraction osteogenesis (callotasis) has been widely used in patients with limb-length inequality or massive bone defects. This procedure, however, may be associated with a high incidence of physical and psychosocial complications. Callotasis telescoping on a locked intramedullary nail has been used to shorten the period of external fixation. Little attention has been given to the use of locked intramedullary nails in the treatment of complications after callotasis. Between 1990 and 1999, we used locked intramedullary nailing in 27 patients for the treatment of complications after distraction osteogenesis. There were 17 men and ten women with a mean age of 33.2 years (16 to 66). The nail was inserted at a mean of 3.4 weeks (0 to 15) after removal of the external fixator. Simultaneous autogenous bone grafting and soft-tissue reconstruction were also undertaken in seven and two patients, respectively. There was consolidation of the callus or docking site in all patients at a mean of 6.4 months (2 to 14) after surgery. The mean shortening of the callus was 0.7 cm (0 to 2.5). Two patients had infection at the site of a distal screw which resolved after removal of the nail. In 17 patients the nail was removed at a mean of 26 months after its insertion. Locked intramedullary nails are useful in treating complications after distraction osteogenesis in skeletally mature patients. The risk of infection should be borne in mind.

Fracture risk and correlating factors of a pediatric population with attention deficit hyperactivity disorder: A nationwide matched study

The aim of this study was to investigate the risk of fracture and the difference between sexes from a nationwide database of fracture risk among children aged 4–17 years with or without attention deficit hyperactivity disorder (ADHD, ICD-9-CD codes 314). The Longitudinal Health Insurance Database (LHID 2000) was used to analyze fracture characteristics of children from the National Health Insurance that covered 96.1% of the Taiwanese population (N=21.4 million). A total of 7200 ADHD children aged between 4 and 17 years whose diagnosis had been confirmed in at least three outpatient clinics between 1 January 2000 and 31 December 2009 were included, and a cohort of 36u2009000 children without ADHD matched for age, sex, and urbanization was recruited for analysis. The incidence rate of fractures in ADHD children was 21.0 (95% confidence interval=19.4–22.7) per 1000 person-years, significantly (P<0.001) higher than 15.0 (95% confidence interval=14.4–15.6) in non-ADHDs. After adjusting by age, sex, urbanization level, and geographic region, the statistically significant (P<0.001) hazard ratios (HR) of fracture for ADHD children compared with non-ADHD children included 1.62 in girls and 1.38 in boys, 1.53 in the skull, neck, and trunk (ICD-9-CM 800–809), 1.28 in the upper extremity (ICD-9-CM 810–819), and 1.84 in the lower extremity (ICD-9-CM 820–829). The HR also (P<0.001) increased significantly in all age groups, including 1.35 in 4–6, 1.37 in 7–9, and 1.54 in 10–17 years. ADHD should be listed among risk factors of children’s fractures in each sex, all age groups, and all body areas that the parents, teachers, caregivers of ADHD children, and pediatric orthopedists should be aware of. Besides, ADHD girls were more affected than ADHD boys, especially after 10 years of age, whereas the adjusted HR was the highest in the lower extremities. Nationwide analysis matched for age and sex showed that ADHD should be considered the risk factor of children’s fracture, especially for girls older than 10 years of age.