Jun-Wen Wang

Treatment of osteonecrosis of the hip: comparison of extracorporeal shockwave with shockwave and alendronate

Background and purposeExtracorporeal shockwave therapy (ESWT) and alendronate are reported effective in early osteonecrosis of the femoral head (ONFH). We hypothesized that joint effects of ESWT and alendronate may produce superior results. This prospective study compared the results of ESWT and alendronate with that of ESWT without alendronate in early ONFH.Patients and methodsForty-eight patients with 60 hips were randomly divided into tow groups. There were 25 patients with 30 hips in group A and 23 patients with 30 hips in group B. Both groups showed similar demographic characteristics. All patients were treated with 6,000 impulses of ESWT at 28xa0KV (equivalent to 0.62xa0mJ/mm²) to the affected hip as a single session. Patients in group B also received alendronate 70xa0mg per week for 1xa0year, whereas patients in group A did not. The evaluations included clinical assessment, radiograph and MR image of the affected hip. Both groups were compared statistically using paired t, Mann–Whitney and Chi square tests with statistical significance at Pxa0<xa00.05. The primary end point is the need for total hip arthroplasty (THA). The secondary end point is the improvement in pain and function of the hip. The third end point is the progression or regression of the lesion on image study.ResultsThe overall clinical outcomes were improved in 83%, unchanged in 7% and worsened in 10% for group A; and improved in 77%, unchanged in 13% and worsened in 10% for group B. THA was performed in 10% of group A and 10% of group B (Pxa0=xa01.000). Significant improvements in pain and function of the hip were noted in both groups (Pxa0<xa00.001), however, the differences between the two groups were not significant (Pxa0=xa00.400, 0.313). On MR images, the lesions showed progression in 10%, regression in 47% and unchanged in 43% in group A, and progression in 7%, regression in 53% and unchanged in 40% in group B (Pxa0=xa00.830).ConclusionESWT and alendronate produced comparable result as compared with ESWT without alendronate in early ONFH. It appears that ESWT is effective with or without the concurrent use of alendronate. The joint effects of alendronate over ESWT in early ONFH are not realized in short-term.

Reconstruction of below-knee stump using the salvaged foot fillet flap

Three cases of below-knee stump reconstruction, using cross-legged, free sole flap, free foot filleted flap, and island pedicle sole flap, were reported. The variability of the flap size provided satisfactory coverage as needed in all cases. The causes of amputation were acute trauma and chronic osteomyelitis. The contour of the stump, the sensory recovery, the preserved range of motion of the knee joint, and the long-term durability were satisfactory in these patients. Some pitfalls of this procedure and criteria for evaluating the distal extremity soft tissue with respect to their suitability for use are discussed.

Long-term results of extracorporeal shockwave therapy and core decompression in osteonecrosis of the femoral head with eight- to nine-year follow-up

BACKGROUNDnThis study analyzed the long-term outcomes of extracorporeal shockwave therapy (ESWT) and core decompression for early osteonecrosis of the femoral head (ONFH) with 8- to 9-year follow-up.nnnMETHODSnThe study cohort consisted of 48 patients with 57 hips including 23 patients with 29 hips in the ESWT group and 25 patients with 28 hips in the surgical group. Patients in ESWT group received shockwave therapy to the affected hip. Patients in surgical group underwent core decompression and autogenous cancellous bone and allogenous fibular graft. The average length of follow-up was 103.5 ± 3.4 (ranged 93-106) months and 104.5 ± 4.3 (ranged 95-108) months for the ESWT and the surgical group, respectively. The evaluations included clinical assessment for pain and function, X-ray and MRI of the affected hips.nnnRESULTSnThe overall clinical results were 76% good or fair and 24% poor for the ESWT group; and 21% good or fair and 79% poor for the surgical group. THA was performed in 3% and 21% at one year, 10% and 32% at 2 years and 24% and 64% at 8-9 years for ESWT and the surgical group respectively. Significant differences in pain and Harris hip scores were observed at different time intervals favoring the ESWT group. There was a trend of decrease in the size of the lesion in the ESWT group when compared with the surgical group.nnnCONCLUSIONnESWT appears to be more effective than core decompression and bone grafting for early ONFH with 8- to 9-year long-term follow-up.

Total knee arthroplasty in carefully selected patients aged 80 years or older

BackgroundThe patients aged ≥80xa0years have been considered to have a higher risk of mortality, postoperative complications, and longer hospital stay following total knee arthroplasty (TKA) than younger patients. The purposes of this retrospective study were to review the results of TKA in patients aged ≥80xa0years after a preoperative consultation.MethodsSeventy-five patients aged ≥80xa0years underwent TKA from January 2006 and June 2010. A control group of younger patients (65–74 years) was matched in a 1:1 ratio with the ≥80xa0years group for sex, diagnosis of the disease, body mass index, the American Society of Anesthesiologists type of anesthesia, and comorbidities. Cardiologists and neurologists carefully evaluated the risk of patients for both groups before surgery. The groups were compared with regard to Knee Society Scores, Knee Society Function Score, Western Ontario and McMaster Universities Osteoarthritis Index scores, length of stay, postoperative complications, and 90-day mortality rate.ResultsThe mean follow-up was 2.3xa0years (range 1–5 years). We found no difference in the functional outcomes and length of stay between the two groups. The ≥80xa0years group had a higher rate of blood transfusion (29.3% versus 10.7%, pu2009=u20090.006) after Bonferroni correction. There were no cardiovascular or cerebrovascular complications in the ≥80xa0years group. There were no mortalities within 90xa0days in either group.ConclusionsDespite similar functional results and pain relief of the TKA compared with the young patient group, the ≥80xa0years group had a higher complication rate of blood transfusion. With a preoperative consultation by cardiologists and neurologists, patients aged ≥80xa0years have a low cardiovascular or cerebrovascular complications and 90-day mortality after TKA.

Total Knee Arthroplasty in Patients With Stiff Knees

The purpose of this study was to evaluate the clinical outcome of total knee arthroplasty and analyze the prognostic factors in patients with stiff knees. Thirty-two patients (39 knees) with severe knee arthritis and an arc of motion of 50° or less were treated by total knee arthroplasty. The mean follow-up period was 58 months (range, 24-123 months). The mean arc of motion improved from 35° before the operation to 94° at the time of the latest follow-up (P<.05). Improvement in knee motion after postoperative 3 months was insignificant. The most important factor related to the final arc of knee motion was preoperative arc of knee motion. The V-Y quadricepsplasty was associated with an inferior clinical outcome. Total knee arthroplasty in patients with stiff knees has substantially improved in the clinical outcome and the arc of motion.

Thromboprophylaxis after minimally invasive total knee arthroplasty: A comparison of rivaroxaban and enoxaparin

Background: Total knee arthroplasty (TKA) carries a substantial rate of venous thromboembolism (VTE). The blood-saving of effect of tranexamic acid (TEA) in TKA using enoxaparin for thromboprophylaxis has been well known. However, the routine use of chemoprophylaxis in TKA remains controversial because of postoperative bleeding complications. Therefore, the purpose of this study was to retrospectively compare the incidence of VTE, and postoperative blood loss and wound-related complications in minimally invasive (MIS)-TKA patients who received rivaroxaban or enoxaparin prophylaxis. Methods: A total of 113 patients who underwent primary unilateral MIS-TKA between 2009 and 2012 were studied. Of these, 61 patients (study group) received rivaroxaban prophylaxis between 2011 and 2012 and a control group of 52 patients received enoxaparin prophylaxis between 2009 and 2010. All patients received one intraoperative injection of TEA (10 mg/kg). We compared the changes in hemoglobin (Hb) level, postoperative drainage amount, total blood loss, transfusion rate, and incidence of postoperative wound complications and VTE between the two groups. Results: No differences in postoperative Hb levels, blood drainage amount, total blood loss, and transfusion rate were observed between the two groups. No deep-vein thrombosis of the leg or pulmonary embolism was noted in both groups. There were no major wound complications including hematoma and infection requiring surgical intervention for open irrigation or debridement. Conclusions: Our retrospective study demonstrated a low rate of VTE in MIS-TKA patients who received rivaroxaban or enoxaparin when TEA was used for bleeding prophylaxis. No increased perioperative bleeding or postoperative wound-related complications were observed in the rivaroxaban group compared with the enoxaparin group.

Functional outcomes of uni-knee arthroplasty for medial compartment knee arthropathy in asian patients

Background: Uni-knee arthroplasty (UKA) has shown better knee kinematics and motion that may better suit the activities of daily living in Eastern countries. The purpose of this study was to evaluate the functional outcomes of UKA for medial compartment knee arthropathy in Asian patients. Methods: The study cohort consisted of 48 patients with 51 UK A knees. Only one type of prosthesis was used and all components were cemented. Postoperative management included ambulation with weight bearing, range of motion, and muscle strengthening exercises as tolerated until full recovery. The average follow-up was 52.0 ± 24.0 (range 12-92) months. The evaluation included functional assessment, the Knee Society knee and functional scores, the International Knee Document Committee (IKDC) subjective and objective scores, and radiographs of the knee. Results: The overall clinical outcomes of the knee showed the functional outcome of the knee to be normal in 51%, nearly normal in 37%, abnormal in 8%, and severely abnormal in 4%. The functional activities included stair climbing in 96%, squatting in 76%, jogging in 71% and kneeling in 47%. Three-quarters of the patients were able to kneel for daily activities. Approximately 98% of the patients were satisfied with the operation. The survivorship of the prosthesis was 98% with one revision pending. Radiographic evaluations revealed the components were centered in 82% and off-centered in 18%. Osteoarthritis was 22% preoperative and 27% postoperative for the patellofemoral compartment, and 0% before and 4% after surgery for the lateral compartment. The functional outcomes showed no difference between patients with and without patellofemoral arthritis. The complications included one component malposition and one knee pain of undetermined origin. Conclusions: UKA provides excellent pain relief and restoration of knee function including kneeling, squatting, and sit-to-stand activities that perfectly fit the oriental lifestyle and high patient satisfaction in Asian patients at medium-term follow-up. The complications were rare and the survival rate was 98% at medium-term follow-up.

Total knee arthroplasty in patients with dialysis: Early complications and mortality

Background: Total hip arthroplasty (THA) in patients on long-term hemodialysis may result in a high prevalence of complications which related to nature of the disease, and associated cardiovascular conditions. However, the result of total knee artrhopalsty (TKA) in those patients is not clear. The purpose of this study was to retrospectively evaluate the early mortality and complications of TKA performed in patients with dialysis. Methods: We retrospectively evaluated 15 dialysis patients (18 knees) who underwent TKA using antibiotic-loaded cement fixation. Fourteen patients had maintained hemodialysis and one patient had continuous ambulatory peritoneal dialysis. The function of the knee was evaluated before operation and postoperatively using Knee Society evaluating system. Postoperative complications and mortality were recorded for all patients. The average follow up period was 25 months (6 to 59 months). Results: There were no mortalities including short-term (≤90 days) or long-term (>90 days) follow up. The mean knee and function scores improved from preoperative 36 points (27~46) and 19.4 points (10~35) to 79 points (68~87) and 81 points (70~95) respectively at the latest follow up. One (6.7%) patient had early postoperative pneumonia (≤90 days). The late (>90 days) complica-tion rate was 20% including 1 sepsis with toe gangrene, 1 recurrent stroke and 1 acute myocardiac infarction. There was no deep prosthetic joint infection or loosening of the components. Conclusion: TKA with antibiotic-loaded cement resulted in a substantial low short-term mortality and deep infections in 15 patients with dialysis. However, a longer term follow up is necessary.

The Efficacy of Combined Use of Rivaroxaban and Tranexamic Acid on Blood Conservation in Minimally Invasive Total Knee Arthroplasty a Double-Blind Randomized, Controlled Trial.

BACKGROUNDnTranexamic acid (TXA) was reportedly to decrease postoperative blood loss after standard total knee arthroplasty (TKA). However, the blood-conservation effect of TXA in minimally invasive TKA, in particular, receiving a direct oral anticoagulant was unclear. The aim of the study was to investigate the efficacy of combined use of TXA and rivaroxaban on postoperative blood loss in primary minimally invasive TKA.nnnMETHODSnIn a prospective, randomized, controlled trial, 198 patients were assigned to placebo (98 patients, normal saline injection) and study group (100 patients, 1g TXA intraoperative injection) during primary unilateral minimally invasive TKA. All patients received rivaroxaban 10 mg each day for 14 doses postoperatively. Total blood loss was calculated from the maximum hemoglobin drop after surgery plus amount of transfusion. The transfusion rate and wound complications were recorded in all patients. Deep-vein thrombosis was detected by ascending venography of the leg 15 days postoperatively.nnnRESULTSnThe mean total blood loss was lower in the study group (1020 mL [95% confidence interval, 960-1080 mL]) compared with placebo (1202 mL [95% confidence interval, 1137-1268 mL]) (P < .001). The transfusion rate was lower in the study group compared with placebo (1% vs 8.2%, Pxa0= .018). Postoperative wound hematoma and ecchymosis were higher in placebo than the study group (Pxa0= .003). There was no symptomatic deep-vein thrombosis or pulmonary embolism in either group.nnnCONCLUSIONnSystemic administration of TXA can effectively reduce the postoperative blood loss which results in lower rate of transfusion requirement and wound hematoma in minimally invasive TKA patients when rivaroxaban is used for thromboprophylaxis. Rivaroxaban has a high rate of bleeding complications when used alone in TKA patients.

Chronic Kidney Disease Is an Independent Risk Factor for Transfusion, Cardiovascular Complication, and Thirty-Day Readmission in Minimally Invasive Total Knee Arthroplasty

BACKGROUNDnLittle is known about the relationship between chronic kidney disease (CKD) and minimally invasive total knee arthroplasty (MIS-TKA). We hypothesized that CKD was an independent risk factor for postoperative complications and increased blood transfusion in patients following MIS-TKA.nnnMETHODSnA retrospective review of a prospective database was conducted on patients who underwent MIS-TKAs at an academic medical center between 2009 and 2012. Glomerular filtration rates (GFRs) were calculated for each patient at the time of surgery and a CKD group of 205 patients (GFR < 60 mL/min) were matched at a ratio of 1:2 with 410 patients showing a GFR ≥ 60 mL/min (control group). There were no differences between the 2 groups regarding age, gender, body mass index, and American Society of Anesthesiologists grade. Patient characteristics, comorbidities, preoperative hemoglobin, calculated total blood loss, transfusion rate, length of stay, and postoperative complications were compared between the 2 groups.nnnRESULTSnThe CKD group had lower preoperative hemoglobin levels; higher preoperative comorbidities with cardiovascular disease, diabetes mellitus, and gout; longer length of stay; and higher total blood loss than the control group. Multivariate logistic regression showed that CKD was an independent risk factor for transfusions (odds ratio [OR] 7.6, 95% confidence interval [CI] 4.79-12.21, P < .001), cardiovascular complication (OR 5.5, 95% CI 1.68-9.39, Pxa0= .002), and 30-day readmission (OR 6.2, 95% CI 1.98-12.18, Pxa0= .005).nnnCONCLUSIONnBased on our data, CKD is an independent risk factor for blood transfusion, cardiovascular complication, and 30-day readmission in patients undergoing MIS-TKA.