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  • Personalized tourniquet pressure may be a better choice than uniform tourniquet pressure during total knee arthroplasty: A PRISMA-compliant systematic review and meta-analysis of randomized-controlled trials

    Abstract

    Background

    Pneumatic tourniquets are widely used in total knee arthroplasty (TKA). Some surgeons prefer a uniform tourniquet inflation pressure (UTIP) for all patients; others use personalized tourniquet inflation pressures (PTIP) based on systolic blood pressure and limb occlusion pressure. However, no consensus exists regarding the optimal mode of inflation pressure during TKA. This review aimed to appraise if personalized tourniquet inflation pressures are better than uniform tourniquet inflation.

    Methods

    The databases (Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, Wanfang) were searched on March 2021 to systematically identify and screen the literature for randomized controlled trials involving PTIP and UTIP during total knee arthroplasty.

    Results

    Thirteen randomized controlled trials, involving 1204 TKAs (1201 patients) were included in the systematic review. The meta-analysis identified a trend toward less visual analogue scale (VAS) score at rest with PTIP group at 1 day (P = .002), 2 to 3 days (P = .01), and less VAS score at activity 1 day (P < .0001), 2 to 3 days after the operation (P < .00001), and discharge (P < .0001). No significant difference was found between the groups in terms of VAS score at rest when discharge (P = 1.0). We also found no significant difference in terms of intraoperative blood loss (P = .48), total blood loss (P = .15), lower limb vein thrombosis (P = .42), and thigh bullae (P = .17). However, in the PTIP group, we found a significant higher hospital for special surgery (HSS) score (P = .007), broader knee Range of motion (P = .02), less rate of thigh ecchymosis (P = .00001), and shorter thigh circumference at 1 day (P = .006), 2 to 3 days (P = .0005), and discharge (P = .02).

    Conclusion

    PTIP provides a similar bloodless surgical field compared with the conventional UTIP. Furthermore, PTIP provides less pain intensity, thigh circumference, rate of thigh ecchymosis, higher hospital for special surgery, and better initial recovery of knee flexion in total knee arthroplasty. Therefore, we recommend using a PTIP method during TKA. More adequately powered and better-designed randomized controlled trials studies with long-term follow-up are required to produce evidence-based guidelines regarding the PTIP method.

  • Research progress in biomimetic gradient scaffolds for osteochondral tissue engineering

    Abstract

    Osteochondral defects are the main cause of joint morbidity and disability in elderly patients, and osteochondral tissue engineering is one of the methods to repair osteochondral defects. The method of osteochondral tissue engineering involves the manufacture of osteochondral biomimetic gradient scaffolds that should mimic the physiological properties of natural osteochondral tissue (e. g. , the gradient transition between cartilage surface and subchondral bone). The osteochondral biomimetic gradient scaffolds exhibit discrete gradients or continuous gradients to establish the characteristics of osteochondral tissue in many studies, such as biochemical composition, structure and mechanical properties. An advantage of the continuous osteochondral biomimetic gradient scaffold is that there is no obvious interface between each layer, therefore it more closely mimics the natural osteochondral tissue. Although promising results have been achieved so far on the regeneration of the osteochondral biomimetic gradient scaffold, there are still differences between the osteochondral biomimetic gradient scaffold and natural osteochondral tissue. Due to these differences, the current clinical treatment of osteochondral biomimetic gradient scaffolds to repair osteochondral defects needs further research. Firstly, the research progress on discrete and continuous gradient scaffolds from the background of osteochondral defects, the micro-scale structure and mechanical properties of osteochondral to the materials and methods related to the manufacture of osteochondral biomimetic gradient scaffolds was summarized in this article. Secondly, due to the 3D printing method of the osteochondral biomimetic gradient scaffold having the ability to precisely control the geometry of the scaffold hole and the mechanical properties of the scaffold,the application of computational simulation models in osteochondral tissue engineering was further introduced, for example, optimizing scaffold structure and mechanical properties are considered to predict tissue regeneration. Finally, the challenges related to the repair of osteochondral defects and prospects for the future research of osteochondral tissue regeneration were presented. For example, continuous osteochondral bionic gradient scaffolds need to more similarly simulate the structure of natural osteochondral tissue units, that is, the transition of mechanical properties and biochemical properties is more smooth naturally. At the same time, although most osteochondral biomimetic gradient scaffolds have achieved good results in in vivo and in vitro experiments, clinical research and application still need to be further studied.

  • Impact of tourniquet during total knee arthroplasty when tranexamic acid was used: a meta-analysis of randomized controlled trials

    Abstract

    Introduction

    The efficacy of tourniquet use during primary total knee arthroplasty (TKA) is thought to reduce intraoperative blood loss, improve surgical exposure, and optimize cement fixation. Tranexamic acid (TXA) use can decrease postsurgical blood loss and transfusion requirements. This review aimed to appraise the effects of tourniquet use in TKA for patients with tranexamic acid use.

    Methods

    A meta-analysis was conducted to identify relevant randomized controlled trials involving TXA plus a tourniquet (TXA-T group) and use of TXA plus no tourniquet (TXA-NT group) in TKA. Web of Science, PubMed, Embase, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CNKI, and Wanfang database were searched from 2010 through October 2021.

    Results

    We identified 1720 TKAs (1690 patients) assessed in 14 randomized controlled trials. Compared with the TXA-NT group, the TXA-T group resulted in less intra-operative blood loss (P < 0.00001) and decreased duration of surgery (P < 0.00001), however more hidden blood loss (P = 0.0004) and less knee range of motion (P < 0.00001). No significant differences were found between two groups in terms of decrease in hemoglobin (P = 0.84), total blood loss (P = 0.79), transfusion rate (P = 0.18), drainage volume (P = 0.06), Visual Analogue Scale (VAS) at either the day of surgery (P = 0.2), 1 day (P = 0.25), 2 day (P = 0.39), 3 day (P = 0.21), 5 day (P = 0.21), 7 day (P = 0.06) or 1 month after surgery (P = 0.16), Hospital for Special Surgery (HSS) score at either 7 day (P = 0.10), 1 month (P = 0.08), 3 month (P = 0.22) or 6 month after the surgery (P = 0.92), Knee circumference (P = 0.28), length of hospital (P = 0.12), and complications such as intramuscular venous thrombosis (P = 0.81), deep venous thrombosis (P = 0.10), superficial infection (P = 0.45), deep wound infection (P = 0.64), and delayed wound healing (P = 0.65).

    Conclusion

    No big differences could be found by using or not tourniquet when use the TXA, though some benefits are related to operation time and less intra-operative blood loss by using tourniquet and TXA, Using the tourniquet was related to more hidden blood loss and less knee range of motion. More adequately powered and better-designed randomized controlled trials (RCTs) studies with long-term follow-up are required to validate this study.

  • Barbed Sutures in Total Knee Arthroplasty: A Meta-analysis of Randomized-Controlled Trials

    Abstract

    Newer methods of wound closure such as barbed sutures hold the potential to reduce closure time and equivalent wound complications in various surgeries. However, few studies have compared barbed suture and conventional wound closure techniques in total knee arthroplasty (TKA). The purpose of this review was to appraise the efficacy and safety of the barbed suture in closure of TKA. We conducted a meta-analysis to identify relevant randomized-controlled trials involving barbed sutures and conventional sutures in TKA in electronic databases, including Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, Wanfang database, up to August 2019. Finally, we identified 1,472 TKAs (1,270 patients) assessed in 13 randomized-controlled trials. Compared with conventional wound closure techniques, barbed sutures resulted in shorter total wound closure time (p < 0.001), fewer needle puncture injuries to members of the surgical team (p = 0.02). There were no significant differences in terms of blister formation (p = 1.0), superficial infection (p = 0.82), range of motion (p = 0.94), incisional exudate (p = 0.75), suture abscess (p = 0.26), or suture breakage (p = 0.11), wound-related complications (p = 0.10), ecchymosis (p = 0.08) between barbed and conventional wound closure. Based on the available level I evidence, we thus conclude that a knotless barbed suture is a safe and effective approach for wound closure in TKA. Given the relevant possible biases in our meta-analysis, more adequately powered and better-designed randomized-controlled trials studies with long-term follow-up are required to recommend barbed sutures for routine administration in TKA.

  • The impact of tourniquet on tibial bone cement penetration in different zones in primary total knee arthroplasty: a meta-analysis

    Abstract

    Background

    Cement mantle penetration and the cement–bone interface strength were critical to a successful primary total knee arthroplasty (TKA). It remained unclear whether decreased blood and fat in the cancellous bone achieved with the use of a tourniquet increases tibial cement mantle penetration in different zones on AP and lateral view in TKA according to criteria defined by the Knee Society Scoring System (KSS). The purpose of this study was to determine whether tourniquet use influences tibial cement mantle penetration in different zones on AP and lateral view in TKA according to KSS.

    Methods

    We conducted a meta-analysis to identify studies involving the impact of tourniquet use and no tourniquet use on tibial bone cement penetration in primary TKA in electronic databases, including Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, VIP, Wanfang database, up to January 2021. Finally, we identified 1231 patients (1231 knees) assessed in twelve studies.

    Results

    Tourniquet use increases the cumulative cement mantle penetration (P < 0.00001), mean cement mantle penetration (P = 0.004), and cement mantle in zone 3(P < 0.0001) on AP view. However, there were no significant differences in cement mantle in zone 1(P = 0.5), zone 2(P =0 .54), zone 4(P = 0.07) on AP view, and zone 1(P = 0.32), zone 2(P = 0.38) on lateral view between two groups. There were also no significant differences in length of surgery(P = 0.7), change in hemoglobin(P = 0.4), transfusion rates(P = 0.47), and complications such as muscular calf vein thrombosis(P = 0.21), superficial infection (P = 0.72), and deep vein thrombosis (P = 0.66) between two groups.

    Conclusion

    The application of a tourniquet increases the thickness of the tibial bone cement penetration—the increase in the thickness of bone cement penetration mainly located in zone 3 on the anteroposterior (AP) view.

  • Advances in Perioperative Management of Total Knee Arthroplasty in Patients With Hemophilia

    Hemophilia encompasses a group of hereditary bleeding disorders characterized by coagulation dysfunction, which predominantly affects males. Caused by a deficiency in coagulation factor VIII (FVIII) or factor IX (FIX), this condition impairs the generation of active thromboplastin and prolongs coagulation time. Consequently, patients exhibit a bleeding tendency following minor trauma; in severe cases, “spontaneous” bleeding can occur even in the absence of obvious injury. Hemophilia is classified into mild, moderate, or severe based on plasma factor levels of 6% to 40%, 1% to 5%, and less than 1%, respectively. In patients with severe hemophilia, whose FVIII or FIX activity is less than 1% of normal levels, frequent joint bleeding episodes (hemarthrosis) may occur 20 to 30 times annually.

    Lifelong factor replacement therapy is crucial for prolonging the life expectancy of patients with hemophilia and reducing musculoskeletal bleeding. However, complications such as musculoskeletal bleeding may still arise due to insufficient factor dosage, poor medication adherence, or the development of neutralizing antibodies (inhibitors) targeted against FVIII or FIX. The ankle, elbow, and knee joints are the most common sites for hemarthrosis in these patients. The inflammatory response triggered by recurrent intra-articular bleeding leads to acute and chronic pain, cartilage damage, joint degeneration, and functional loss, eventually progressing to severe osteoarthritis. It is currently reported that 90% of hemophilia patients will develop hemophilic arthropathy within 30 years of onset. For chronic hemophilic synovitis, chemical and radionuclide synovectomy can delay the progression to hemophilic arthropathy, whereas severe hemophilic arthropathy warrants surgical intervention. Total knee arthroplasty (TKA) is an highly effective procedure for alleviating pain and restoring function in patients with advanced hemophilic arthropathy of the knee. This article reviews the latest literature regarding the perioperative management, intraoperative considerations, prosthesis selection, postoperative rehabilitation, and associated complications of TKA in patients with hemophilia.

  • Research progress of metal hypersensitivity in total knee arthroplasty

    Abstract

    Total knee arthroplasty is a common procedure, with extremely good clinical results. Despite this success, it produces 20% unsatisfactory results. These patients complained pain in otherwise well implanted and aligned prostheses. Metal hypersensitivity (MHS) is a rare complication of total joint arthroplasty that has been linked to prosthetic device failure when other potential causes have been ruled out. It has been described as a type IV hypersensitivity reaction to the metals comprising prosthetic implants, often nickel and cobalt-chromium. Patients suffering from this condition have reported periprosthetic joint pain and swelling as well as cutaneous, eczematous dermatitis. Although MHS is rare, hypersensitivity to metals in the general population has an incidence of about 15%, and in rising also for the higher number of joint replacements in the last decades. The purpose of this review was to conduct an analysis of existing literature in order to get a better understanding of the pathophysiology, clinical syndromes diagnosis, detection method, management of MHS and “hypersensitivity-friendly” implants

  • Suprascapular nerve block and axillary nerve block versus interscalene nerve block for arthroscopic shoulder surgery: A meta-analysis of randomized controlled trials

    Abstract

    Background

    The interscalene brachial plexus block (ISB) is a commonly used nerve block technique for postoperative analgesia in patients undergoing shoulder arthroscopy surgery; however, it is associated with potentially serious complications. The use of suprascapular nerve block (SSNB) and axillary Nerve Block (ANB) has been reported as an alternative nerve block with fewer reported side effects for shoulder arthroscopy. This review aimed to compare the impact of SSNB and ANB with ISB during shoulder arthroscopy surgery.

    Methods

    A meta-analysis was conducted to identify relevant randomized or quasirandomized controlled trials involving SSNB and ISB during shoulder arthroscopy surgery. We searched Web of Science, PubMed, Embase, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CNKI, and Wanfang database from 2010 through August 2021.

    Results

    We identified 641 patients assessed in 10 randomized or quasirandomized controlled trials. Compared with the ISB group, the SSNB+ANB group had higher visual analog scale or numerical rating scale in PACU (P = .03), 4 hour (P = .001),6 hour after the operation (P = .002), and lower incidence of complications such as Numb/Tingling (P = .001), Weakness (P <.00001), Horner syndrome (P = .001) and Subjective dyspnea (P = .002). No significant difference was found for visual analog scale or numerical rating scale 8 hour (P = .71),12 hour (P = .17), 16 hour (P = .38),1day after operation (P = .11), patient satisfaction (P = .38) and incidence of complications such as hoarseness (P = .07) and nausea/vomiting (P = .41) between 2 groups.

    Conclusion

    Our high-level evidence has established SSNB+ ANB as an effective and safe analgesic technique and a clinically attractive alternative to interscalene block during arthroscopic shoulder surgery, especially for severe chronic obstructive pulmonary disease, obstructive sleep apnea, and morbid obesity. Given our meta-analysis’s relevant possible biases, we required more adequately powered and better-designed randomized controlled trial studies with long-term follow-up to reach a firmer conclusion.

  • Total knee arthroplasty in patients with osteoporosis

    Abstract

    With the increase of the aging population in our country, it is foreseeable that the number of elderly patients who choose to undergo total knee arthroplasty (TKA) to improve their quality of life will increase. Osteoarthritis patients who need TKA are also high-risk groups of osteoporosis, and orthopedic surgeons will face more and more osteoporosis patients undergoing TKA. We need to consider several important clinical issues about osteoporosis patients undergoing TKA: bone quality assessment, the relationship between osteoporosis and knee OA, clinical outcomes after TKA of patients with osteoporosis，the relationship between bone loss and function after TKA, the change of bone density after TKA, and drug intervention for bone density loss after TKA. This article reviews and analyzes the problems that osteoporosis patients may encounter when undergoing TKA．

  • Analysis on the blood loss reduction of open-box prosthesis in total knee arthroplasty

    Abstract

    Objective 

    To determine whether the perioperative TKA blood loss of open-box prosthesis can be reduced by intraarticular Cocktail Injection and intercondylar fossa bone wax sealing.

    Methods 

    A total of  109 patients who underwent total knee arthroplasty from January 2019 to December 2019 at Beijing TsingHuaChanggung Hospital were analyzed, including 23 males and 86 females with an average age of ( 68.2 ±  6.9 ) years. According to the different shape designs of the prosthesis intercondyle fossa, they were divided into the closed-box group [ n = 53; averaged ( 68.2 ± 6.4 ) years ] and open-box group [ n = 56; averaged ( 68.3 ± 7.1 ) years ]. The differences of hemoglobin and perioperative blood loss between the two groups were analyzed.

    Results 

    The HB of the closed-box group was ( 123.60 ± 11.08 ) g / L and ( 110.96 ± 12.48 ) g / L on the first and third days after surgery, and that of the open-box group was ( 128.36 ± 12.79 ) g / L and ( 112.52 ± 12.93 ) g / L. The total blood loss by the 3rd day after surgery was ( 571.39 ± 305.66 ) ml in the open-box group and ( 552.42 ± 302.59 ) ml in the closed-box group. All the results showed no statistically significant differences between the two groups ( P > 0.05 ).

    Conclusions 

    No obvious differences in blood loss are noted between open-box and closed-box prosthesis after bone wax sealing and intraarticular Cocktail Injection. Similar blood loss as closed-box prosthesis total knee arthroplasty will be reached by open-box prosthesis arthroplasty using treatment scheme mentioned in this study. 

  • A New Arthroscopic Tightrope Suture-Button Fixation Procedure for Tibial Eminence Avulsion Fracture

    Abstract

    This case-series outcome study presents a new arthroscopic technique for tibial eminence avulsion fracture (TEAF) with double-tunnel using two tightrope suture buttons. From May 2017 to July 2020, we performed a new arthroscopic technique for TEAF with double tunnels, using two tightrope suture buttons on 13 patients. Clinical assessments included anterior drawer, Lachman, and pivot shift tests, the International Knee Documentation Committee (IKDC), Lysholm knee scores, visual analog scale (VAS) scores, and range of motion (ROM). An independent observer noted conditions before surgery and during the last follow-up. The patients had an average follow-up of 26.2 months, ranging from 15 to 37 months. During the last postsurgical follow-up, the anterior drawer, Lachman, and pivot shift tests were negative in all the cases. According to the IKDC, Lysholm, and VAS final scores, all patients presented a significant knee function improvement at last follow-ups compared with preoperatively. The study shows that satisfactory results about an anatomic reduction of the fragment, knee stability, function, and strength can be achieved with the new arthroscopic technique for TEAF with double tunnels using two tightrope suture buttons. This study is a therapeutic case series and its level of evidence is IV.

  • Morphological Characteristics of Acromion and Acromioclavicular Joint in Patients with Shoulder Impingement Syndrome and Related Recommendations: A Three‐Dimensional Analysis Based on Multiplanar Reconstruction of Computed Tomography Scans

    Abstract

    Objective

    To find out which structure is crucial for the formation of shoulder impingement syndrome with the purpose of directing surgical procedures of subacromial decompression and discussing whether it is necessary to manage acromioclavicular joint during operation and how to do it properly.

    Methods

    This was a retrospective study. Clinical data and preoperative computed tomography (CT) images were collected from patients who were diagnosed with rotator cuff tears between January 2017 and August 2019 (sample size: 46) and those who were diagnosed without rotator cuff tears between March 2018 and August 2019 (sample size: 44) in our institution, respectively. Three-dimensional models of shoulders were established by multiplanar reconstruction of CT scans and measurements were performed on these models. The parameters such as the acromial length and width, the axial tilt, and the distance from acromial margin to glenoid plane were measured in an adjusted axial plane, and the critical shoulder angle and the spatial volume under acromioclavicular joint were measured in an adjusted coronal plane. The demographic characteristics, the acromial morphology and the spatial volume under acromioclavicular joint were compared to find significant differences between the two groups. The association between the axial tilt and the distance from acromial margin to glenoid plane was evaluated by an ordinary least squares linear regression.

    Results

    The patients with rotator cuff tears consisted of 16 males and 30 females, among which 30 right shoulders and 16 left shoulders were included. The patients without rotator cuff tears consisted of 28 males and 16 females, among which 15 right shoulders and 29 left shoulders were involved. Significant differences between the groups were found in the acromial width (3.332 cm vs 3.111 cm), the axial tilt (33.765° vs 23.829°), the critical shoulder angle (32.630° vs 30.363°), the distance from anterior 3 cm of lateral acromial margin (range, 2.476 cm–3.302 cm vs 1.993 cm–3.089 cm), and anterior 0.9 cm of medial acromial margin (range, 0.967 cm–2.369 cm vs 0.668 cm–1.993 cm) to glenoid plane, and the spatial volume under acromioclavicular joint (1.089 cm vs 1.446 cm) in the two groups. No significant differences were found in the age (60.0 years vs 58.3 years) or the acromial length (4.187 cm vs 4.184 cm). Significant association was revealed by linear regression analysis between the axial tilt and the distance from anterior two-thirds of lateral acromial margin to glenoid plane, and similar association was also found in the anterior half of medial margin.

    Conclusion

    Anterior two-thirds of lateral acromial margin, anterior half of medial acromial margin, and inferior aspect of acromioclavicular joint are crucial structures and need to be fully decompressed when treating patients with rotator cuff tears.