Pengde Kang

Topical Application of Tranexamic Acid in Primary Total Hip Arthroplasty: A Randomized Double-Blind Controlled Trial

So far, studies of topical tranexamic acid (TXA) in total hip arthroplasty (THA) were still lacking and controversial. We conducted this randomized double-blind controlled trial which included 101 patients to assess the effect of a high-dose 3g topical TXA in THA. The results showed that 3g topical TXA could significantly reduce transfusions from 22.4% to 5.7% (P<0.05) without increasing the risk of deep vein thrombosis (DVT), pulmonary embolism (PE) and other complications. In addition, topical TXA significantly reduced total blood loss, reduced drain blood loss, and the drops of HB and HCT in topical TXA group were lower than control group. We concluded that 3g topical TXA was effective and safe in reducing bleeding and transfusions in THA.

Are the results of multiple drilling and alendronate for osteonecrosis of the femoral head better than those of multiple drilling? A pilot study.

OBJECTIVES The treatment of osteonecrosis of the femoral head (ONFH) remains controversial. A recently proposed treatment is multiple drilling core decompression combined with systemic alendronate as a femoral head-preserving procedure for ONFH. However, it is not known whether alendronate enhances the risk of collapse. We wondered whether the combined procedure could delay or prevent progression of ONFH compared to multiple drilling alone. METHODS Patients with early-stage ONFH were randomly assigned to be treated with either multiple drilling combined with alendronate (47 patients, 67 hips) or multiple drilling alone (46 patients, 60 hips). We defined failure as the need for THA or a Harris score less than 70. The minimum follow-up was 48 months for the 77 patients completing the protocol. RESULTS After a minimum 4-year follow-up, 91% (40/44) of patients with Stage II disease and 62% (8/13) of patients with Stage III disease had not required THA in alendronate group, compared to 79% (31/39) of patients with Stage II disease and 46% (6/13) of patients with Stage III disease had not required THA in control group (P=0.12, P=0.047, respectively). Small or medium and central lesions had a better successful rate in both groups. Risk factors did not seem to affect the clinical successful rate of this procedure. CONCLUSIONS Multiple small-diameter drilling core decompression combined with systemic alendronate administration can reduce pain and delay progression of early-stage ONFH. Even in Ficat IIA and III hips, some benefit was obtained from this approach at least delay in the need for THA.

Combined use of intravenous and topical tranexamic acid following cementless total hip arthroplasty: a randomised clinical trial

Purpose This study was designed to compare the efficacy and safety of the combined use of tranexamic acid (TXA) with the intravenous (IV) or local use alone in total hip arthroplasty (THA). Methods 210 patients were randomised to a IV group, a local group or a combined group. Participants received 1.5 g IV-TXA in the IV group, 3 g local TXA in the local group, or 1 g IV-TXA combined with 2 g local TXA in the combined group. The primary outcomes were total blood loss (TBL), maximum haemoglobin drop, and the incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE). Results TBL was (776.75 ± 188.95) ml in the combined group, which was significantly lower than in the IV group or the local group (p = 0.015, p = 0.001 respectively). Likewise, the mean values of maximum hemoglobin drop in the combined, IV, and local groups were 2.98 ± 0.78, 3.36 ± 0.78, and 3.89 ± 0.72 g/dL, respectively, with a significant intergroup difference (p<0.001 for all). Asymptomatic DVT was detected in 1 patient of the IV group, and 2 patients of the combined group with the use of ultrasound. There were no episodes of PE, and no significant differences were seen between groups in terms of complications. Conclusions Combined use of intravenous TXA and local TXA in primary unilateral THA can effectively decrease total blood loss and increase postoperative haemoglobin levels without influencing complication rates. It is suggested that this combined TXA regimen is more effective in decreasing blood loss in cementeless THA than intravenous or local administration alone.

Changes in Cobalt and Chromium Levels After Metal-on-Metal Hip Resurfacing in Young, Active Chinese Patients

Metal-on-metal resurfacing arthroplasty is increasingly being performed in young, active patients. Serum and urine metal ion levels are monitored in these patients to assess the physiologic effects of metal-on-metal wear on them. The aim of our prospective study was to evaluate the serum and urine levels of cobalt (Co) and chromium (Cr) in young (age, ≤50 years), active Chinese patients who had undergone metal-on-metal hybrid resurfacing arthroplasties. Levels were measured preoperatively using atomic absorption spectrometry and then sequentially at 3, 6, 9, 12, and 24 months after surgery. For both serum and urine Co and Cr, there was an initial increase to a peak at 6 months, followed by a gradual decline after 6 months, whereas renal function was normal during the study the 2-year study period. There was no radiographic evidence of component loosening. All implants were functioning well. Further long-term studies are needed to observe clinical outcomes and to determine the physiologic effects of the wearing process.

The influence of diabetes mellitus on the post-operative outcome of elective primary total knee replacement: a systematic review and meta-analysis

Total knee replacement (TKR) is an effective method of treating end-stage arthritis of the knee. It is not, however, a procedure without risk due to a number of factors, one of which is diabetes mellitus. The purpose of this study was to estimate the general prevalence of diabetes in patients about to undergo primary TKR and to determine whether diabetes mellitus adversely affects the outcome. We conducted a systematic review and meta-analysis according to the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The Odds Ratio (OR) and mean difference (MD) were used to represent the estimate of risk of a specific outcome. Our results showed the prevalence of diabetes mellitus among patients undergoing TKR was 12.2%. Patients with diabetes mellitus had an increased risk of deep infection (OR = 1.61, 95% confidence interval (CI), 1.38 to 1.88), deep vein thrombosis (in Asia, OR = 2.57, 95% CI, 1.58 to 4.20), periprosthetic fracture (OR = 1.89, 95% CI, 1.04 to 3.45), aseptic loosening (OR = 9.36, 95% CI, 4.63 to 18.90), and a poorer Knee Society function subscore (MD = -5.86, 95% CI, -10.27 to -1.46). Surgeons should advise patients specifically about these increased risks when obtaining informed consent and be meticulous about their peri-operative care.

Meta-analysis of Temporary Versus No Clamping in TKA

Use of closed drainage systems after total knee arthroplasty (TKA) is a routine practice. Currently, a debate exists regarding whether temporary or no clamping is optimal. A systematic review of the English literature was conducted, and randomized controlled trials comparing all forms of temporary or no clamping drainage were included. Two authors independently extracted articles and predefined data. Data were pooled using a fixed-effects model to perform the meta-analysis. Nine randomized controlled trials totaling 850 patients were retrieved. The results indicate that temporary clamping could significantly reduce the drainage volume, including total drainage volume, drainage volume within 24 hours postoperatively, and drainage volume within 48 hours postoperatively. Furthermore, patients treated with temporary drainage clamping for 4 hours or more had a higher hemoglobin level 24 hours postoperatively than the patients treated with no clamping, and the number of blood transfusions per patient decreased significantly. No significant difference was identified between the 2 practices regarding postoperative range of motion, wound-related complications, and deep vein thrombosis. More randomized controlled trials are needed to provide robust evidence and to definitively determine which practice is most effective in reducing postoperative blood loss.

Mini-midvastus Versus Medial Parapatellar Approach in TKA: Muscle Damage and Inflammation Markers

The purpose of this prospective study was to analyze the biochemical markers of muscle damage and inflammation in patients treated with the mini-midvastus approach or the medial parapatellar approach for total knee arthroplasty. Of 60 patients who underwent unilateral total knee arthroplasty, 30 were treated with the mini-midvastus approach (MMV group) and 30 were treated with the medial parapatellar approach (MPP group). Serum creatine kinase, myoglobin, lactate dehydrogenase, glutamic oxaloacetic transaminase, C-reactive protein, interleukin-6, and interleukin-1β levels were measured preoperatively, immediately postoperatively (except for C-reactive protein level), and on postoperative days 1, 2, and 3. Students t test, Pearsons chi-square test, and Fishers exact test were used to compare the outcomes between the 2 groups. Compared with the MPP group, a significant increase in serum creatine kinase level existed in the MMV group on postoperative days 2 (P=.08) and 3 (P=.09) and cumulatively (P=.02). However, significantly elevated C-reactive protein and interleukin-6 levels existed in the MPP group.According to the serum creatine kinase levels, the mini-midvastus approach has no superiority over the medial parapatellar approach in terms of sparing muscle and may cause more muscle damage. Further study is warranted to determine the correlation between biochemical markers and functional deficits.

Comparison of Direct Anterior and Lateral Approaches in Total Hip Arthroplasty: A Systematic Review and Meta-Analysis (PRISMA).

AbstractThe direct anterior approach (DAA) to total hip arthroplasty has been promoted as a minimally invasive alternative to the lateral approach, which we sought to verify by systematically reviewing and meta-analyzing the literature comparing clinical, radiographic, and surgical outcomes.Two reviewers independently searched PubMed, OVID, and Web of Science databases for randomized controlled trials (RCTs) and cohort studies comparing the DAA and lateral approach for total hip arthroplasty.Quality of RCTs was assessed using the Jadad scoring system, quality of cohort studies, using the Minors system. Data were extracted and meta-analyzed or qualitatively synthesized for primary outcomes (function, complications, and hospitalization time) and several secondary outcomes.Data were extracted from 12 trials involving 4901 arthroplasty procedures. Meta-analysis showed that DAA was associated with significantly shorter hospitalization than the lateral approach, as well as greater functional rehabilitation and lower perceived pain during the early postoperative period. On the other hand, DAA was associated with longer surgery time. The 2 approaches were associated with similar rates of perioperative surgical complications and transfusions, as well as similar radiographic analysis results.Although DAA may provide shorter hospitalization and faster recovery during the early postoperative period, the available evidence is still insufficient to conclude whether the DAA or lateral approach is superior for total hip arthroplasty. More high-quality studies and subsequent meta-analyses are needed.

Midterm Results of Uncemented Acetabular Reconstruction for Posttraumatic Arthritis Secondary to Acetabular Fracture

At an average of 6.3 years after surgery, we evaluated midterm results of uncemented acetabular reconstruction in 31 hips with posttraumatic arthritis that developed after acetabular fracture. Patients were categorized by previous fracture treatments (open-reduction group and conservative-treatment group) and fracture patterns (simple group and complex group). Surgery duration and blood loss were greater in the open-reduction and complex groups than in the conservative-treatment and simple groups (P < .05). The mean Harris Hip Score increased from 49 before surgery to 89 after surgery. Survival with revision or radiographic acetabular loosening as an end point was 100%. Fracture treatments and patterns were associated with increased surgery duration and increased blood loss. Open reduction and internal fixation of a fracture favor anatomical restoration of the hips rotational center.

Effects of an anticoagulant and a lipid-lowering agent on the prevention of steroid-induced osteonecrosis in rabbits

This study was designed to evaluate the effects of the combined treatment with an anti‐coagulant (enoxaparin) agent and a lipid‐lowering agent (lovastatin) on prevention or decrease in the occurrence of steroid‐induced osteonecrosis in rabbits. A total of 112 rabbits, which were injected intramuscularly with 20 mg/kg of methylprednisolone acetate were divided into four groups and treated as follows: one group received enoxaparin combined with lovastatin (EL; n = 30), another received enoxaparin alone (EA; n = 28), another received lovastatin alone (LA; n = 28) and the last received no treatment (non‐prophylactic; NP, n = 26). Haematological examination for serum lipid levels and prothrombin time was carried out and both femora and humeri were examined histopathologically for the presence of osteonecrosis (ON) before injection and at 2, 4, 8 and 12 weeks after the injection. The incidence of ON in the EL group (15%) was significantly lower than that observed in the NP group (68%). The incidence in the EA and LA groups was also significantly lower than that in the NP group (31%, 35%vs. 68%). The fat cell sizes of the bone marrow in both EL (46.49 ± 1.27 μm) and LA (50.8 ± 2.31 μm) groups were lower than in the NP group (59.89 ± 6.33 μm). The prothrombin time was prolonged and plasma lipid levels were reduced in the EL group during the study. Combination treatment with an anti‐coagulant agent and a lipid‐lowering agent can reduce the incidence of steroid‐induced ON in rabbits. Future evaluation in clinical practice is necessary.