The aim of this study was to compare outcomes of Conversion to Total Hip Arthroplasty (CTHA) for Traumatic Osteonecrosis of the Femoral Head (ONFH) after failed internal fixation with Primary THA for Nontraumatic ONFH, and to provide insights into CTHA for Patients Under 55 among these individuals. This retrospective study analyzed 292 patients aged 18–55 between January 2013 and August 2022. Patients who underwent Conversion to THA (CTHA) for secondary ONFH after failed internal fixation of femoral neck fractures (n = 146) and those who underwent Primary THA for Nontraumatic ONFH (n = 146) were compared regarding complications, survival rates, perioperative parameters, Harris Hip Scores, acetabular anteversion and abduction angles over a mean 5.5-year follow-up. The conversion group exhibited a significantly higher incidence of intraoperative periprosthetic fractures compared to the primary group (5.5

Total knee arthroplasty (TKA) has significant perioperative blood loss and a high transfusion rate. Tranexamic acid (TXA) has widely recognized hemostatic efficacy in TKA. Hemocoagulase Agkistrodon (HCA) enhances coagulation by hydrolyzing fibrinogen into fibrin, complements the hemostatic effect of TXA. Our aim was to investigate the hemostatic potential of sequential administration of HCA and TXA in TKA. Patients who underwent cemented total knee arthroplasty at our hospital were randomized to receive the sequential administration of HCA and TXA (n = 29) or TXA-only (n = 30. All patients received mechanical and chemical thromboprophylaxis protocol. The primary outcome was perioperative blood loss, while secondary outcomes were postoperative coagulation function and arterio-venous thrombosis, transfusion, and complications. Total blood loss was not different between sequential administration of HCA and TXA group (1,025.3 ± 305.3 mL) and TXA-only group (892.4 ± 306.4 mL, P = 0.079). Intermuscular vein thrombosis was reported in one case in the sequential administration group and three cases in the TXA-only group. No deep vein thrombosis was reported in any of the patients. The two groups had no perioperative transfusion. The sequential administration of HCA and TXA does not demonstrate superior efficacy in reducing blood loss compared to TXA-only. However, the HCA and TXA group has a lower incidence of intermuscular thrombosis and may demonstrate superiority in postoperative thromboprophylaxis.

Endotracheal intubation (EI) can adversely affect hemodynamics and patient satisfaction. Concerns regarding the safety of the laryngeal mask airway (LMA) in total joint arthroplasty (TJA) arise from patient positioning and the surgical procedure. This study aimed to compare the effects of EI and LMA on hemodynamics and postoperative pharyngeal discomfort in TJA, and evaluate LMA’s safety. In this prospective trial, 100 patients undergoing TJA due to end-stage joint disease at our medical center between August 2023 and August 2024 were enrolled. Following the induction of anesthesia, patients were randomly assigned to either EI or LMA. Postoperative sore throat and hoarseness were assessed upon awakening and at 6, 24, and 48 h. The primary outcome was postoperative pharyngeal discomfort; secondary outcomes were hemodynamic stability and airway complications. At 6 h post-TJA, sore throat (32% vs 12%, P = 0.030) and hoarseness (70% vs 36%, P = 0.003) were significantly lower in the LMA group. At 24 h, hoarseness remained lower (22% vs 6%; P = 0.021). The incidence of hemodynamic instability during airway establishment (40% vs 4%, P < 0.001), removal (78% vs 24%, P < 0.001), and during TJA (62% vs 14%, P < 0.001) was significantly lower in the LMA group. No significant differences in airway complications were found. LMA use in TJA reduced postoperative pharyngeal discomfort and improved hemodynamic stability, making it a safe and effective alternative to EI. Trial registration: The Chinese Clinical Trial Registry (14/08/2023, ChiCTR2300074701).

BACKGROUND:Vitamin C shows strong anti-inflammatory and analgesic effects, so we explored whether it can replace glucocorticoids in reducing pain and inflammation after total hip arthroplasty (THA). METHODS:In this prospective trial, a consecutive series of 107 patients (43.0% men, 56.8 ± 10.1 years of age, 100% Han Chinese) who underwent THA due to end-stage hip disease at our medical center between January 2023 and January 2024 were randomized to receive vitamin C, dexamethasone, or neither dexamethasone nor vitamin C after surgery. The 3 groups were compared in terms of the primary outcomes of pain reported on a visual analogue scale (VAS), perioperative morphine use, and blood indices of inflammation and fibrinolysis as well as in terms of secondary outcomes of efficacy and safety. RESULTS:Compared with patients in the control group, those who received vitamin C or dexamethasone reported a significantly lower VAS pain score on postoperative day 1, had significantly lower perioperative morphine consumption, and demonstrated significantly lower blood levels of C-reactive protein on days 1 and 2. The 2 groups also showed a significantly lower rate of rescue analgesia on postoperative day 1 and significantly higher Harris hip scores of joint function at 2 and 12 weeks after surgery, as well as significantly smaller thigh circumference and a lower rate of swelling on the first 2 days after surgery. Either treatment was associated with a significantly lower rate of postoperative nausea and vomiting. Dexamethasone was associated with greater blood glucose levels after surgery. CONCLUSIONS:Vitamin C may be an effective substitute for glucocorticoids for reducing morphine use and the risk of nausea or vomiting and for improving joint function after THA without side effects causing blood glucose fluctuations. LEVEL OF EVIDENCE:Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:The impact of preoperative nutritional status on long-term outcomes after revision arthroplasty remains poorly defined. This study aimed to (1) determine the association between preoperative malnutrition and the risks of re-revision and all-cause mortality - distinguishing periprosthetic joint infection (PJI)-related from non-PJI failures - and (2) establish clinically relevant thresholds of the Prognostic Nutritional Index (PNI) for high-risk patient stratification. METHODS:In this retrospective cohort study, 1297 consecutive patients undergoing hip or knee revision arthroplasty between 2008 and 2024 were analyzed. The PNI, calculated from serum albumin and lymphocyte count, was evaluated as both a continuous and categorical variable. Primary outcomes were re-revision (classified as PJI or non-PJI) and long-term all-cause mortality. Analyses included multivariable logistic and Cox regression, restricted cubic spline (RCS) modeling, receiver operating characteristic (ROC) curve analysis, and 1:1 propensity score matching (PSM). Mediation analysis was conducted to assess the inflammatory contribution of C-reactive protein and erythrocyte sedimentation rate (ESR), while the Geriatric Nutritional Risk Index (GNRI) was used for sensitivity analyses in patients aged ≥60 years. RESULTS:Each 1-point reduction in PNI was associated with a 15% higher odds of re-revision (odds ratio [OR] = 1.15; 95% confidence interval [CI], 1.10-1.19; P < 0.001) and a 4% higher hazard of long-term mortality (hazard ratio = 1.04; 95% CI, 1.01-1.09; P = 0.04), with these associations remaining significant after PSM. The increased re-revision risk was predominantly driven by PJI (OR = 1.19; 95% CI, 1.12-1.25; P < 0.001), with no significant association for non-infectious failures. A PNI threshold of 46.63 optimally predicted re-revision (area under the ROC curve = 0.72; negative predictive value = 0.91), while mortality demonstrated a nonlinear, U-shaped relationship with PNI. ESR partially mediated the PNI-PJI association (mediation effect: 4.36%). GNRI analyses corroborated these findings among elderly patients. CONCLUSIONS:Preoperative malnutrition, quantified by PNI, is a robust and independent predictor of re-revision - particularly PJI-related - and long-term mortality following revision arthroplasty. Incorporating PNI-based risk stratification into perioperative care may facilitate targeted nutritional optimization and improve outcomes in this high-risk population.

Background: The authors applied Anatomique Benoist Girard II (ABG II) stems for total hip arthroplasty in some Dorr type C femurs as early attempts. Here, the authors compared the long-term follow-up results between ABG II stems and the ʻwell-performingʼ Corail stems and their monochromatic images. Methods: Among 3214 primary total hip arthroplasty records, 43 short ABG II stems and 67 standard-length Corail stems implanted in Dorr type C femurs were eligible and enrolled in this retrospective cohort study, with a mean follow-up of 10.3 years. Revision rates, Harris hip scores, and radiologic signs were compared. Spectral CT scans from a representative sample were obtained, and monochromatic images were reconstructed. A quantitative method was developed to measure the volume of the gap around stems. Patient-specific finite element analysis was conducted to investigate the strains. Results: The revision rate of ABG II stems was significantly higher than that of Corail stems (21 vs. 3%, P <0.05). In the monochromatic images, fewer spot-weld signs (2.2 vs. 3.4, P <0.05) and wider gaps around stems (1.64 cm 3 vs. 0.13 cm 3 , P <0.05) were observed on average in the ABG II group. The mean maximum principal strains of the proximal femurs in the ABG II group were close to the yield strains and significantly larger than those in the Corail group (0.0052 vs. 0.0011, P <0.05). Conclusions: There was a high risk of postoperative periprosthetic femoral fracture for ABG II stems in Dorr type C femurs. Monochromatic images provided some insight into the failure mechanism. Level of Evidence: III

To the Editor: Significant hyperfibrinolysis is always accompanied by surgical trauma and tourniquet use in total knee arthroplasty (TKA), leading to considerable hidden blood loss, inflammation, and pain, thereby impeding the recovery process. Enhanced recovery after surgery (ERAS) has promoted the development of patient blood management in recent decades. And numerous methods of blood conservation, including tranexamic acid (TXA), a lysine analog competitive inhibitor of plasmin and plasminogen, have been studied.[1–3] However, some issues remain controversial, such as the optimal TXA regimen in TKA. On the other hand, the use of TXA in arthroplasty is considered off-label, although the current guideline or consensus suggests its routine use in arthroplasty. Furthermore, the maximum daily dose of TXA specified in the specification is 2 g. Our preceding single-center study demonstrated that a high initial dose (60 mg/kg) plus three postoperative doses (3 h, 12 h, and 24 h for 1 g) should provide the ceiling effect on blood-sparing in TKA when compared with the regimen of 60 mg/kg plus five postoperative doses.[4] These results were encouraging, but it is unclear if the total dose (approximately 6 g) is superior to the legal dose (2 g). Therefore, the present multicenter, randomized, double-blind, parallel control study was designed to explore and determine: (1) whether a high initial dose (60 mg/kg)intravenous TXA followed by three postoperative doses can provide a significant blood-sparing effect when compared with the maximum legal dose, (2) whether this regimen can further ameliorate postoperative fibrinolysis, (3) whether this regimen can further modulate the inflammatory response, immune response, and provide additional pain relief, and (4) whether this high initial high-dose regimen can increase the risk of treatment-related adverse events in patients undergoing primary unilateral TKA, between January 2021 and April 2022. The inclusion and exclusion criteria are provided in Supplementary Methods, https://links.lww.com/CM9/B911. The study protocol was approved by the Institutional Review Board (IRB)/Independent Ethics Committee (IEC) of West China Hospital of Sichuan University (No. 20200317) before enrollment, and accepted by the other four participating sites. Written informed consent was obtained from all study participants before surgery. The original protocol was registered on the China Drug Trials database (www.chinadrugtrials.org.cn, NO. CTR20201081). After stratification by the center, SAS software (version 9.4; SAS Institute Inc.North Carolina, USA) was used to randomly allocate participants in a 1:1 ratio to a high-dose TXA group or a low-dose TXA group in permuted blocks of six. The high-dose TXA group received an intravenous bolus of 60 mg/kg before incision or deflation of the tourniquet, with a bolus of 1 g/100 mL at 3 h, 6 h, and 12 h later. The low-dose TXA group received an intravenous bolus of 15 mg/kg before incision or deflation of the tourniquet, with a bolus of 1 g/100 mL at 3 h later and a bolus of 100 mL normal saline at 6 h and 12 h later. Participants, medical staff, and investigators were blinded to the treatment allocation. All site hospitals performed an enhanced recovery program under the guidance of local consensus, which included comorbidities assessment, blood management, nutrition management, pain management, and thromboprophylaxis, as detailed further in Supplementary Methods, https://links.lww.com/CM9/B911. The primary efficacy endpoint was the perioperative total blood loss, calculated using the formula previously described.[2] The primary safety endpoint was the 90-day rate of the composite of thrombotic events (Deep venous thrombosis, Pulmonary embolism, myocardial infarction, and ischemic stroke), acute renal failure, epilepsy, allergy to TXA, vomiting, nausea, and all-cause mortality. The secondary endpoints included the rate of allogeneic red blood cell transfusion, intraoperative blood loss, hidden blood loss, the drop of hemoglobin on a postoperative day (POD) 3, the drop of hematocrit on POD 3, the visual analog score (VAS) pain score, Hospital of Special Surgery (HSS) score, postoperative length of hospital stay, the fibrinolytic marker (D-dimer, Fibrin degradation product [FDP], Expected percentage of lysis [EPL], and Lysis 30% [Ly30]), inflammatory marker (C-reaction protein and Interleukin-6), and immune markers (T cell subset, C3, and C4) on POD 1–3 and 14. All the data collection and quality control are described in Supplementary Methods, https://links.lww.com/CM9/B911. The sample size was calculated with G-power 3.1.9.2 (Franz Faul, Universität Kiel, Germany), which indicated that a sample size of 200 patients (100 per arm) was required to detect a difference in total blood loss of 100 mL, assuming standard deviation = 244.2 mL, a = 0.05, and b = 0.1. Further, SAS software (version 9.4, SAS Institute Inc. North Carolina, USA) was used to compare the primary and secondary endpoints between the two groups [Supplementary Methods, https://links.lww.com/CM9/B911]. A two-sided P <0.05 was considered statistically significant for all analyses. During the recruitment period, 254 patients at five large academic joint centers were assessed for eligibility. Among 240 patients randomized to a treatment group, 234 (97.5%) completed the trial; 117 received the high-dose TXA regimen, and 117 received the low-dose regimen [Supplementary Figure 1, https://links.lww.com/CM9/B911]. The two groups had no notable differences in baseline characteristics [Supplementary Table 1, https://links.lww.com/CM9/B911]. The total blood loss in the high-dose and low-dose groups was 1043.59 ± 484.49 mL and 698.08 ± 306.36 mL, respectively. The difference between the two groups was statistically significant (mean difference, –342.66 mL; 95% Confidence interval [CI], –439.39 mL to –245.93 mL; P <0.001, Table 1). This effect remained in the sensitive analysis (mean difference, –327.39 mL; 95% CI, –427.82 mL to –226.96 mL; P <0.001; Supplementary Table 2, https://links.lww.com/CM9/B911), using per protocol sets of 102 patients in the high-dose group and 104 patients in the low-dose group. Table 1 - Primary efficacy and safety end points of high-dose TXA study. Outcomes Low-dose TXA (N = 117) High-dose TXA (N = 117) t/χ 2 P-value Total blood loss, mean (SD) (mL) 1043.59 (484.49) 698.08 (306.36) 4.033 <0.001 Hidden blood loss, mean (SD) (mL) 988.28 (475.54) 650.43 (300.01) 6.416 <0.001 Allogenic transfusion, n (%) 2 (1.70) 0 NA 0.498* Total of VOE, n (%) 33 (28.2) 33 (28.2) 0 1.000 POD1–POD3 16 (13.7) 23 (19.7) 1.508 0.219 Intermuscular vein thrombosis, n (%) 13 (11.1) 22 (18.8) 2.721 0.099 Posterior tibial vein thrombosis, n (%) 2 (1.7) 4 (3.4) NA 0.683* Peroneal vein thrombosis, n (%) 2 (1.7) 2 (1.7) NA 1.000 Popliteal vein thrombosis, n (%) 1 (0.9) 0 NA 1.000 POD4–POD20 12 (10.3) 11 (9.4) 0.048 0.826 Intermuscular vein thrombosis, n (%) 10 (8.5) 11 (9.4) 0.052 0.819 Posterior tibial vein thrombosis, n (%) 1 (0.9) 1 (0.9) NA 1.000 Peroneal vein thrombosis, n (%) 1 (0.9) 1 (0.9) NA 1.000 POD20–POD90 9 (7.7) 1 (0.9) 6.868 0.010 Intermuscular vein thrombosis, n (%) 9 (7.7) 1 (0.9) 6.868 0.010 Nausea 4 (3.4) 15 (12.8) 6.931 0.008 Vomiting 4 (3.4) 4 (3.4) 0 1.000 *Fisher's exact test was used. NA: Not available; POD: Postoperative day; SD: Standard deviation; TXA: Tranexamic acid; VOE: Venous occlusive events. A total of 66 vascular occlusive events occurred during the follow-up period, 33 events in the high-dose group (33/117, 28.2%) and 33 in the low-dose group (33/117, 28.2%), most of which were intermuscular vein thrombosis events, and the difference was not significant (P = 1.000, Table 1). Subgroup analysis according to the occurrence time indicated that the incidence of intermuscular vein thrombosis in the high-dose group (1/117, 0.9%) was lower than that in the low-dose group (9/117, 7.7%; P = 0.010) between POD 20 and POD 90. Only one episode of popliteal vein thrombosis occurred in the low-dose group on POD 3, and the incidences of other anatomical vein thrombosis were relatively low and similar between the two groups. All thrombosis organizations were observed after anticoagulation treatment without adverse complications during the follow-up period. However, the incidence of postoperative nausea in the high-dose group was higher than that in the low-dose group (15/117, 12.8% vs. 4/117, 3.4%, P = 0.008), and the incidence of vomiting and nausea was probably related to the TXA [Supplementary Table 3, https://links.lww.com/CM9/B911]. No episodes of myocardial infarction, cerebral infarction, acute renal failure, epilepsy, death, or allergy to TXA had occurred in both groups. The mean and standard deviation of hidden blood loss in the high-dose group was 650.43 ± 300.01 mL, less than that in the low-dose group (988.28 ± 475.54 mL, P <0.001). Only two patients received allogeneic red blood transfusion in the low-dose group, and the difference was not significant (P = 0.498, Table 1). The hemoglobin drop on POD 3 in the high-dose group was less than that in the low-dose group (22.54 ± 9.62 g/L vs. 30.88 ± 11.92 g/L, P <0.001; Supplementary Table 4, https://links.lww.com/CM9/B911). Greater statistical significance of hematocrit drop on POD 3 was detected in high dose group (0.07 ± 0.03 vs. 0.09 ± 0.03, P <0.001). In terms of other efficacy endpoints, such as length of hospital stay, VAS pain score, and HSS score, no differences were detected between the two groups. The other inflammatory markers, immune markers, and fibrinolytic markers were comparable between groups, except for the levels of D-dimer, which were less in the high-dose group on POD1 and POD 2, compared with the low-dose group [Supplementary Figure 2, https://links.lww.com/CM9/B911]. The present multicenter RCT was designed to compare the efficacy and safety profile between the low-dose and high-dose groups. The low-dose group received a total dose of 2 g intravenous TXA (15 mg/kg preop plus 1 g at 3 h later) because the maximum dose of TXA in the specification was 2 g per day, and the half-life of TXA was approximately 3 h.[5] The high-dose group received a total dose of 6 g (60 mg/kg preop plus 1 g at 3 h, 6 h, and 12 h later), as our previous study found that a high initial dose (60 mg/kg) with three repetitions of a 1 g intravenous dose would provide the maximum blood-saving effect.[4] Fibrinolysis is most easily controlled at its early phase, according to its pattern. Therefore, the initial dose is the most important to control fibrinolysis. Moreover, some studies have found that TXA at doses more than 61 mg/kg may raise the risk of seizure, indicating that a dosage of 60 mg/kg might be the maximum safe dose. Our study chose the aforementioned TXA regimen as the intervention in the two groups to guide the intravenous TXA dose choice in clinical practice. TXA is an old, inexpensive, and available drug applied in many fields. Although many retrospective cohort studies have explored the incidence of adverse events using TXA, some clinician surgeons are still cautious about its safety. The present study demonstrated that the incidence of thromboembolic events, such as venous occlusive events, pulmonary embolism, myocardial infarction, and stroke, was comparable between the two groups because every patient received routine anticoagulation. Only one popliteal vein thrombosis occurred in the low-dose group, and all the venous thromboses were followed up with no serious consequences. By contrast, more intermuscular vein thrombosis occurred in the high-dose group than in the low-dose group, which is consistent with our previous study, although the difference was not statistically significant. In our practice, no specific treatments were given to patients with intermuscular vein thrombosis, except routine exercise and chemical prophylaxis, despite the controversy surrounding the treatment of intermuscular vein thrombosis. Furthermore, the high-dose group experienced more postoperative nausea and vomiting (PONV), but all adverse effects disappeared after symptomatic treatment or slowed the infusion speed. The mechanism underlying TXA-induced emesis may involve tachykinin and neurokinin receptors, and neurokinin 1 receptor antagonists or other anti-emetic drugs may be useful to reduce unexpected side effects.[6] In our practice, we would give a dose of ondansetron (4 mg) or dexamethasone (5 mg) before awakening from anesthesia, and on the morning of POD 1, as well as ensure lower infusion speed to reduce the incidence of PONV. Besides, a recent study by Hsu Li et al[7] found that TXA was not associated with thromboembolic events or in-hospital mortality but was significantly associated with acute kidney injury. Patients with existing chronic kidney disease suffered a high absolute risk of kidney injury irrespective of TXA administration (832 per 10,000, 95% CI, 797–869). Our study excluded patients with renal failure; no conclusion can be drawn based on the findings. Further studies are needed to confirm these findings. In conclusion, among patients who underwent primary unilateral TKA, high-dose TXA compared with low-dose TXA resulted in a statistically significant reduction in total blood loss, hidden blood loss, and fibrinolysis response without compromising the profile of thromboembolic events. The results of the postoperative inflammatory response, pain, knee function, and length of hospital stay were comparable. The current results indicated the rationality for high-dose TXA use in TKA, but more attention should be paid to preventing postoperative nausea and vomiting.

Background: Postoperative nausea and vomiting (PONV) after total joint arthroplasty is common and associated with delayed recovery. This study was performed to evaluate the efficacy of three different prophylactic regimens for PONV after total joint arthroplasty under general anesthesia. Methods: Patients undergoing primary total hip or knee arthroplasty were randomized to Group A (8 mg ondansetron, n= 108), Group B (10 mg dexamethasone plus mosapride, n= 108), or Group C (three doses of 10 mg dexamethasone plus mosapride, n=116). The primary outcome was the total incidence of PONV during postoperative 48 hours. The secondary outcomes were complete response, rescue antiemetic treatment, opioid consumption, time until first defecation, postoperative appetite score, satisfaction score, length of hospital stay, blood glucose level, and complications. Results: Patients in Group C experienced a lower incidence of total PONV (29.3%, p= 0.001), severe nausea (1.72%, p<0.001) and a higher incidence of complete response (70.69%, p=0.001) than did patients in Groups A and B. Moreover, less rescue antiemetic treatment and postoperative opioid consumption was needed in Group C (p<0.05). Additionally, a shorter time until first defecation, shorter length of stay, and better postoperative appetite scores and satisfaction scores were detected in patients in Group C. A slight increase in the fasting blood glucose level was observed in Group C, and the complications were comparable among the groups. Conclusion: Prophylactic use of mosapride and three doses of dexamethasone can provide better antiemetic effectiveness, postoperative appetite, bowel function recovery, and pain relief than a single dose or ondansetron only.

Tibetan patients undergoing total knee arthroplasty (TKA) have greater fluctuations in perioperative haemoglobin levels and blood hypercoagulability. This study was to investigate whether ethnicity and altitude affect perioperative blood loss and the risk of complications after TKA. We retrospectively enrolled 1,116 patients undergoing TKA for knee osteoarthritis at our hospital between January 2016 and September 2021. We divided patients into four groups according to whether they were of Tibetan or Han ethnicity and whether they lived above or below 2500 m above sea level. Primary outcomes were total, intraoperative, and hidden blood losses, while secondary outcomes were complications and homologous transfusion. Factors associated with increased blood loss were analyzed by multivariate regression. Total blood loss was higher among patients residing at high altitude compared with lower altitude, whether they were of Han (794.6 mL vs. 667.2 mL, P = 0.020) or Tibetan (904.4 mL vs. 663.8 mL, P < 0.001). Total blood loss was similar between the two ethnic groups at the same altitude. Altitude, but not Tibetan ethnicity, remained associated with increased blood loss after being analyzed by multivariate regression. Complications among the four groups were generally similar, although the frequency of calf muscular venous thrombosis was higher among Tibetan patients, while the frequency of blood transfusion was higher among Han subjects. Our findings indicate that residence at high altitude, but not ethnicity, may contribute to increased total blood loss during TKA. Thrombotic complications were more frequent among Tibetan than Han patients.

BACKGROUND:Double total joint arthroplasty (TJA) can reduce repeat hospitalizations and total coagulation factors usage in hemophilic arthritis (HA) patients who have multiple joint involvement, but the risk of perioperative adverse events with double TJA must be considered. METHODS:We reviewed 50 patients who had hemophilia A, including 26 single TJA (STJA) (13 total knee arthroplasty [TKA] and 13 total hip arthroplasty [THA]) and 24 simultaneous double TJA (Sim-DTJA) (including 10 bilateral TKAs, 10 bilateral THAs, and four patients who had simultaneous THA and TKA). Length of hospitalization, blood loss, total exogenous coagulation factor VIII (FVIII) usage, perioperative FVIII levels, perioperative activated partial thromboplastin time, perioperative transfusion rates, and postoperative complications were assessed and compared. RESULTS:Perioperative FVIII levels and activated partial thromboplastin time were not different between Sim-DTJA and STJA. Total blood loss (1,216.0 ± 450.4 mL) and hidden blood loss (1,020.0 ± 419.9 mL) were slightly higher in Sim-DTJA than in STJA (1,062.0 ± 371.8 mL and 929.9 ± 351.6 mL, respectively) (P = 0.192, P = 0.416, respectively). The length of hospitalization between the Sim-DTJA (10.6 ± 1.8 days) and the STJA (10.4 ± 1.7 days) was not different (P = 0.802). The perioperative FVIII usage was 30,063 ± 6,466 international unit for Sim-DTJA and 26,077 ± 12,524 international unit for STJA (P = 0.008). No postoperative adverse events and prosthesis-related complications were reported in any of the patients. The two cohorts had no perioperative transfusion of erythrocyte and platelets. CONCLUSION:In HA patients who had multiple joint involvements, Sim-DTJA can achieve clinical efficacy without significantly increasing perioperative blood loss, length of hospitalization, and postoperative complications.

Background: The use of disease-modifying antirheumatic drugs (DMARDs) before total knee arthroplasty (TKA) was associated with increased risk of postoperative periprosthetic joint and wound infections as well as worse platelet function in patients who have knee rheumatoid arthritis (RA). This study investigated the effects of DMARDS on perioperative blood loss, complications, and blood transfusion in patients undergoing TKA for knee RA.Methods: We retrospectively enrolled patients undergoing TKA for knee RA at our hospital between 2017 and 2021 who received DMARDs (n = 73) or not (n = 84). Every RA patient was matched with patients who had osteoarthritis (OA) in a ratio of 1:1 or 1:2. Primary outcomes were intraoperative and perioperative blood losses, while secondary outcomes were complications and allogeneic transfusions.Results: The mean total (804 versus 728 mL (mL), P = .114), mean intraoperative (113 versus 101 mL, P = .488), or hidden blood losses (705 versus 640 mL, P = .340) did not differ statistically between RA patients who received DMARDs versus those who did not. RA patients who received DMARDs showed significantly greater mean total (804 versus 654 mL, P = .001), intraoperative (113 versus 75 mL, P = .002), and hidden blood losses (705 versus 560 mL, P =.016) than OA patients. No statistical differences were found in complications or allogeneic transfusions.Conclusion: Although RA patients experienced greater perioperative blood loss than OA patients, there was no statistical difference in perioperative blood loss, complications, or allogeneic transfusions between RA patients who received DMARDs and those who did not.& COPY; 2023 Elsevier Inc. All rights reserved.

Injured articular cartilage is a leading cause for osteoarthritis. We recently discovered that endogenous stem/progenitor cells not only reside in the superficial zone of mouse articular cartilage, but also regenerated heterotopic bone and cartilage in vivo. However, whether critical-size osteochondral defects can be repaired by pure induced chemotatic cell homing of these endogenous stem/progenitor cells remains elusive. Here, we first found that cells in the superficial zone of articular cartilage surrounding surgically created 3 × 1 mm defects in explant culture of adult goat and rabbit knee joints migrated into defect-filled fibrin/hylaro1nate gel, and this migration was significantly more robust upon delivery of exogenous granulocyte-colony stimulating factor (G-CSF). Remarkably, G-CSF-recruited chondrogenic progenitor cells (CPCs) showed significantly stronger migration ability than donor-matched chondrocytes and osteoblasts. G-CSF-recruited CPCs robustly differentiated into chondrocytes, modestly into osteoblasts, and barely into adipocytes. In vivo, critical-size osteochondral defects were repaired by G-CSF-recruited endogenous cells postoperatively at 6 and 12 weeks in comparison to poor healing by gel-only group or defect-only group. ICRS and O'Driscoll scores of articular cartilage were significantly higher for both 6- and 12-week G-CSF samples than corresponding gel-only and defect-only groups. Thus, endogenous stem/progenitor cells may be activated by G-CSF, a Food and Drug Administration (FDA)-cleared bone-marrow stimulating factor, to repair osteochondral defects.

The concept of enhanced recovery after surgery（ERAS） has been widely promoted in orthopedics. A large number of studies have confirmed that systematic and standardized rehabilitation therapy can effectively promote the recovery of patients’ joint motion, muscle strength, body balance stability and control ability, reduce joint stiffness, muscle atrophy, limb weakness and other common orthopedic postoperative dysfunction, which are conducive to the early return of patients to society and work, save medical resources, and reduce medical costs. The perioperative rehabilitation includes two parts: preoperative rehabilitation and postoperative rehabilitation. Preoperative rehabilitation includes preoperative outpatient rehabilitation assessment and treatment and preoperative hospitalization rehabilitation assessment and treatment. Postoperative rehabilitation includes early postoperative rehabilitation assessment and treatment, rehabilitation assessment and treatment before discharge, rehabilitation assessment and treatment after discharge, as well as the graded management of rehabilitation treatment site. In this article the cooperation between surgery physicians,rehabilitation physicians and rehabilitation therapists in the perioperative rehabilitation evaluation and treatment of orthopedics were discussed, so as to provide better cooperation between orthopedics physicians and rehabilitation physicians for the benefit of patients.

Background Muscle injury and concomitant bone injury are important drivers to induce heterotopic ossification (HO). However, the related roles of muscle and concomitant bone injury in HO formation are still unclear. This study aims to develop a mouse model through the combination of hindlimb amputation (Am) and cardiotoxin (CTX) injection to investigate the mechanism of HO formation. Method The mice were randomly divided into Am group (Am of right hindlimb, n = 12), CTX group (CTX injection in the calf muscle of left hindlimb, n = 12) and Am + CTX group (the combination of Am of right hindlimb and CTX injection of left hindlimb, n = 18). MicroCT was used to evaluate the incidence of HO. Histology was used to investigate the progression of HO. Results The MicroCT showed that only Am or CTX injection failed to induce HO while the combination of Am and CTX injection successfully induced HO. The incidence of HO was significant in Am + CTX group on day 7 (0% vs 0% vs 83.3%, p = 0.001) and day 14 (0% vs 0% vs 83.3%, p = 0.048). HO was located on the left hindlimb where CTX was injected. Moreover, the bone volume and bone density on day 14 were higher than those on day 7 in Am + CTX group. Histology revealed the evidence of calcification and expression of osteogenic markers in calcification sites in Am + CTX group. Conclusion In summary, the combination of Am and CTX injection could successfully induce dystrophic calcification/HO, which occurs in the location of muscle injury.

PurposeTotal hip arthroplasty (THA) in patients with rheumatoid arthritis (RA) has been associated with an increased risk of periprosthetic joint infection, periprosthetic fractures, dislocations, and post-operative blood transfusion. However, higher post-operative blood transfusion is unclear whether it reflects peri-operative blood loss or is characteristic of RA. This study aimed to compare the complications, allogenic blood transfusion, albumin use, and peri-operative blood loss between patients who underwent THA because of RA or osteoarthritis (OA).MethodsPatients undergoing cementless THA for hip RA (n = 220) or hip OA (n = 261) at our hospital between 2011 and 2021 were retrospectively enrolled. Deep vein thrombosis, pulmonary embolism, myocardial infarction, calf muscular venous thrombosis, wound complications, deep prosthetic infection, hip prosthesis dislocation, periprosthetic fractures, 30-day mortality, 90-day readmission, allogeneic blood transfusion, and albumin infusions were considered as primary outcomes, while secondary outcomes included the number of perioperative anaemia patients as well as total, intra-operative, and hidden blood loss.ResultsCompared to the OA group, patients with hip RA showed significantly higher rates of wound aseptic complications, hip prosthesis dislocation, homologous transfusion, and albumin use. RA patients also showed a significantly higher prevalence of pre-operative anemia. However, no significant differences were observed between the two groups in total, intra-operative, or hidden blood loss.ConclusionsOur study suggests that RA patients undergoing THA are at a higher risk of wound aseptic complications and hip prosthesis dislocation than patients with hip OA. Pre-operative anaemia and hypoalbuminaemia in patients with hip RA place them at a significantly higher risk of post-operative blood transfusion and use of albumin.

Background Multiple doses of dexamethasone and tranexamic acid can inhibit postoperative inflammation and reduce fibrinolysis and perioperative blood loss in total knee arthroplasty. In this single-center, double-blind, randomized clinical trial, the aim was to investigate whether applying a tourniquet to patients on dexamethasone and tranexamic acid could further reduce perioperative blood loss. Materials and methods Patients who underwent cemented total knee arthroplasty at our hospital were randomized to receive a tourniquet ( n = 71) or not ( n = 70) during the procedure. All patients received multiple doses of dexamethasone and tranexamic acid perioperatively. The primary outcome was perioperative blood loss, while secondary outcomes were surgery duration, postoperative laboratory indices of inflammation and fibrinolysis, range of knee motion, VAS pain score, knee circumference, knee swelling rate, homologous transfusion, albumin use, and complications. Results Using a tourniquet was associated with significantly lower intraoperative blood loss ( P < 0.001) and total blood loss ( P = 0.007) as well as significantly shorter surgery duration ( P < 0.001). In contrast, the tourniquet did not significantly affect hidden blood loss, postoperative inflammation or fibrinolysis, range of knee motion, VAS pain score, knee circumference, knee swelling rate, homologous transfusion, albumin use, or complications. Conclusions The results of this randomized clinical trial demonstrate that applying a tourniquet during cemented total knee arthroplasty to patients receiving multiple doses of dexamethasone and tranexamic acid can further reduce perioperative blood loss without increasing the risk of inflammation, fibrinolysis, or other complications. Thus, it is advised to use tourniquets combined with dexamethasone and tranexamic acid to reduce perioperative blood loss and avoid tourniquet-related adverse events. Level of evidence: Therapeutic Level I. Trial registration Chinese Clinical Trail Registry, ChiCTR2200060567. Registered 5 June 2022—retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=171291.

加速康复外科理念的兴起与发展得益于国内外学者对医疗质量、医疗效率及其影响因素的探索与研究,而其能够成功实施与推广有赖于自上而下管理制度的建立.本文在总结我国2019—2022年加速康复外科骨科试点工作的基础上,结合各医院的管理经验,系统阐述了医院骨科加速康复的实施条件、医院组织架构与职责、医院骨科加速康复的实施与管理,旨在为骨科加速康复的进一步实施与推广提供参考.

BackgroundThe efficacy and safety of tranexamic acid (TXA) in reducing blood loss following total knee arthroplasty (TKA) in patients with osteoarthritis have been widely confirmed. However, there is still a paucity of the evidences regarding the effectiveness of TXA in patients with rheumatoid arthritis (RA). The purpose of the study is to explore the efficacy and safety of intravenous TXA on blood loss and transfusion risk following simultaneous bilateral TKA (SBTKA) in patients with RA.MethodsAs a multicenter retrospective study, a total of 74 patients diagnosed with RA who underwent SBTKA were assigned into TXA group (15 mg/kg intravenous TXA before skin incision, n = 50) and control group (no TXA use, n = 24). The primary outcomes were total blood loss (TBL) and intraoperative blood loss (IBL). The secondary outcomes were hemoglobin (Hb) and hematocrit (Hct) drop on postoperative day 3, transfusion rate and volume, ambulation time, length of stay, hospitalization expenses and the incidence of complications.ResultsThe mean TBL, IBL and transfusion volume in TXA group were significantly lower than those in control group. The Hb and Hct drop on postoperative day 3 in control group were higher than those in TXA group (p<0.05). The similar trend was detected on transfusion rate, ambulation time and length of stay. The incidence of complications and hospitalization expenses did not differ significantly between the two groups (p>0.05).ConclusionsTXA could effectively reduce blood loss, decrease transfusion risk, shorten ambulation time and length of stay following SBTKA in patients with RA, without increasing the risk of complications.

加速康复外科理念自兴起至今已有二十余年,在国内骨科学界的探索也有十余年,众多学者已对其实施过程中的关键技术、实施后的效果评价进行了较为充分的研究与总结.如何将患者从门诊接诊、术前评估、术中操作、术后康复与随访等各个环节的关键技术进行有机整合,达到医师、护士、技师、患者、管理人员心中有数,使管理流程能够顺利实施,是众多学者及管理人员需要思考的问题.本文以骨科加速康复为切入点,对医院管理流程进行梳理,供广大临床医务人员参考.