Abstract

BACKGROUND Blood loss and incision-related complications caused by the surgical procedure to release gluteal muscle contracture (GMC) put negative effects on the surgical outcomes. Current procedures to prevent blood loss and complications are not satisfactory. The current study aimed to determine whether tranexamic acid (TXA) in combination with pressure dressing reduce the amount of blood loss, the rate of incision-related complications, and the rate of readmission for patients undergoing surgeries to release GMC. METHODS 49 GMC patients were finally included in the study and were randomly divided into two groups: study group and control group. Patients in both groups received minimally invasive surgery to release GMC except that in the study group, patients were administered a dosage of 20 mg/kg of intravenous TXA preoperatively, and 2 subsequent dosages of TXA at 10 mg/kg at two time points: 3 and 6 h after the first dose. Gauze soaked with TXA was used to pack the wound for 10 min before the incision closure. Then the wound was pressure-wrapped with a hip-spica bandage for 24 h after the surgery in the study group. RESULTS The level of UBL in the study group was significantly lower compared to that in the control group. Similar results were also found for UMHD and UMAD. The incision-related postoperative complications were greatly decreased in the study group compared to those of the control group as well. So was the 30-day readmission rate. All patients in both groups reached "excellent" or "good" level with respect to the postoperative function evaluation. CONCLUSIONS Intravenous and topical application of TXA combined with 24 h pressure hip-spica bandage reduces perioperative blood loss, rate of incision-related complications, and the rate of readmission for GMC patients undergoing minimally invasive surgical releasing procedure. Trial Registration Chinese Clinical and Trial Registry ChiCTR2000039216, registration date 2020/10/22, retrospectively registered.

Abstract

PURPOSE To find the best short-term daily recombinant human erythropoietin (rhEPO)-based treatment protocols for blood-saving purpose in THA. METHOD The patients were randomized to 1 of 3 interventions: Patients in group A received 10,000 IU (150 IU/kg) of subcutaneous rhEPO (1 ml) daily from 5 days preoperatively to 3 days postoperatively (9 doses in total); Patients in group B received 1 ml of subcutaneous normal saline daily from 5 days preoperatively to 3 days preoperatively and then 10,000 IU (150 IU/kg) of subcutaneous rhEPO daily until 3 days postoperatively (6 doses in total). Patients in group C received 1 ml of subcutaneous normal saline daily from 5 days preoperatively to one day preoperatively and then 10,000 IU (150 IU/kg) of subcutaneous rhEPO daily from the day of surgery to 3 days postoperatively (4 doses in total). RESULTS One hundred eighty patients were included. On postoperative day one, patients in the group A showed significantly higher Hb level (108.4 ± 11.4 g/L) than group C (103.9 ± 8.8 g/L). Group B (107.8 ± 8.4 g/L) also showed significantly higher Hb level than group C (103.9 ± 8.8 g/L) (p < 0.05). On postoperative day 3, no significant difference was found between group B and group C in Hb level (98.7 ± 10.5 and 94.9 ± 8.7 g/L, respectively) (p = 0.094), but the Hb level in group A (103.6 ± 11.0 g/L) was still markedly higher than in group B and the Hb level in group A was also markedly higher than in group C. In terms of blood loss, no markedly difference was found in intraoperative blood loss among group A, B and C (78.3 ± 22.4, 84.6 ± 29.1, and 80.3 ± 23.9 ml, respectively) (p = 0.381), but on postoperative day one, the mean blood loss in group C (522.4 ± 189.4 ml) was significantly more than group B (371.2 ± 124.6 ml), and group B was also significantly more than group A (284.8 ± 112.9 ml) with 95% confidence interval, and group B had significantly less blood loss than group C (p < 0.001). With respect to the total blood loss, the total blood loss in group C (881.6 ± 314.9 ml) was significantly more than group B (642.6 ± 232.9 ml), and group B was also significantly more than group A (514.5 ± 204.6 ml) with 95% confidence interval (Table 2). Only 2 patients in each group received allogeneic blood transfusion and each patient received 2 units of red blood cells, so, the transfusion requirements among the three groups were comparable. CONCLUSIONS Daily small-dose of subcutaneous rhEPO administered from 5 days before THA could significantly decrease perioperative blood loss and improve postoperative Hb levels, without increasing risks of complications, when compared with the application of rhEPO from 3 days before THA or from the day of surgery. However, surgeons should choose the regimen individually according to different patients' personal circumstances.

Abstract

Background Total knee replacement (TKR) is an artificial joint surgical procedure that replaces the damaged articular surfaces of the knee joint. Despite several studies on the efficacy of intra-articular and intravenous Tranexamic acid (TX) use in reducing blood loss following TKR, the route of TXA administration is still an ongoing topic of debate. Our study aimed to compare total knee replacement efficacy (hemoglobin level, hematocrit level, hospital stay, and complications) of intra-articular and intravenous tranexamic acid administration. Material and Methods A Prospective study was conducted at the Department of Orthopedics, Shifa International Hospital, Islamabad. The study duration was six months (August 2020 to February 2021). A sample size of 60 patients was calculated using the WHO calculator. Patients were selected through non-probability consecutive sampling. Patients were randomly divided into two groups; Group A was given intraarticular TXA, while group B was given intra-venous TXA following total knee replacement. Patients were followed for 48 hours. Data were analyzed using SPSS version 24. An Independent T-test was applied, and a P value≤0.05 was considered significant. Results A total of 60 patients were included in the study. There were 20 (33.3%) male and female 40 (66.7%). The mean age of patients was 64.4±10.8SD. Post-operative hemoglobin level in group A was 11.09±0.39SD, and in group B was 9.93±1.73SD (p=0.03). Postoperatively, the mean HCT level in group A was 30.53±4.26SD and group B 26.88±5.48SD (p=0.01). Conclusion Intra-articular administration of TXA is more effective than intravenous administration in controlling postoperative blood loss following total knee replacement.

Abstract

Suction drainage after primary total hip arthroplasties (THA) offers no benefits. Revision hip arthroplasties (RHA) are more demanding procedures and associated with greater blood loss compared to primary cases. There is still a lack of literature regarding the application of drainage in RHA. A total of 40 patients who underwent RHA were included in this prospective study. Simple randomization with an allocation ratio 1:1 was performed. Primary outcomes: total blood loss, hemoglobin drop, joint hematoma size in USG, infection. Secondary outcomes: blood transfusion rate, soft tissue hematomas, C-reactive protein levels, Visual Analogue Scale before and on 3rd day after surgery, Harris Hip Score before and 6 weeks after surgery. An intention to treat analysis was performed, with a 2-year follow up. Statistically significant differences between groups was in blood loss: drainage 1559.78 ml, non-drainage 1058.27 ml, (p = 0.029) and hemoglobin level on 1st day after surgery: drainage 10.58 g/dl, non-drainage 11.61 g/dl (p = 0.0496). In terms of the other analyzed parameters, statistical differences were not found. Our study revealed that the use of suction drainage may lead to higher blood loss in the early postoperative period. Further studies are needed to evaluate our results.

Abstract

BACKGROUND We investigated the effect of platelet-rich plasma (PRP) on tendon-bone healing and intra-articular graft (IAG) maturation after anterior cruciate ligament (ACL) reconstruction. METHODS In this prospective randomized controlled study, 60 patients with ruptured ACLs were divided one-to-one into two groups (study and control). Patients were treated using single-bundle autologous hamstring autografts. Only patients in the study group were administered PRP. Knee function (pre-operative and three-, six-, and 12-month post-operative Lysholm activity, Tegner and International Knee Documentation Committee scores, femoral tunnel (FT) and tibial tunnel (TT) diameters measured with computed tomography (post-operative follow-up at 4 days and at 12 months), and magnetic resonance imaging signal/noise quotients of the IAG and graft in the FT (at 12 months) were used to evaluate tendon-bone healing and graft maturation. RESULTS Patients' knee function scores improved after ACL reconstruction, but there were no significant differences between groups. At 12 months, FT (study, 8.88 ± 1.46 mm; control, 8.42 ± 2.75 mm) and TT (study, 9.50 ± 1.07 mm; control, 9.99 ± 1.91 mm) diameters were larger than FT (study, 6.91 ± 0.74 mm; control, 7.30 ± 1.17 mm) and TT (study, 9.31 ± 0.83 mm; control, 9.36 ± 0.88 mm) diameters at 4 days; however, differences between groups were not significant (FT, P = 0.67; TT, P = 0.52). There were no significant differences between groups for signal/noise quotients of the IAG (study, 1.38 ± 0.70; control, 2.01 ± 0.62; P = 0.06) and FT-portion of the graft (study, 2.39 ± 1.22; control, 2.46 ± 0.83; P = 0.89). CONCLUSION PRP had no significant effect on reducing bone tunnel widening, accelerating tendon-bone healing, or improving knee function; however, PRP may improve IAG maturation. TRIAL REGISTRATION Our study was first registered at Clinicaltrials.gov with registration No. NCT04659447 on 12/09/2020.

Abstract

BACKGROUND The aim of this trial was to assess the effectiveness of quality improvement collaboratives to implement large-scale change in the National Health Service (NHS) in the UK, specifically for improving outcomes in patients undergoing primary, elective total hip or knee replacement. METHODS We undertook a two-arm, cluster randomised controlled trial comparing the roll-out of two preoperative pathways: methicillin-sensitive Staphylococcus aureus (MSSA) decolonisation (infection arm) and anaemia screening and treatment (anaemia arm). NHS Trusts are public sector organisations that provide healthcare within a geographical area. NHS Trusts (n = 41) in England providing primary, elective total hip and knee replacements, but that did not have a preoperative anaemia screening or MSSA decolonisation pathway in place, were randomised to one of the two parallel collaboratives. Collaboratives took place from May 2018 to November 2019. Twenty-seven Trusts completed the trial (11 anaemia, 16 infection). Outcome data were collected for procedures performed between November 2018 and November 2019. Co-primary outcomes were perioperative blood transfusion (within 7 days of surgery) and deep surgical site infection (SSI) caused by MSSA (within 90 days post-surgery) for the anaemia and infection trial arms, respectively. Secondary outcomes were deep and superficial SSIs (any organism), length of hospital stay, critical care admissions and unplanned readmissions. Process measures included the proportion of eligible patients receiving each preoperative initiative. RESULTS There were 19,254 procedures from 27 NHS Trusts included in the results (6324 from 11 Trusts in the anaemia arm, 12,930 from 16 Trusts in the infection arm). There were no improvements observed for blood transfusion (anaemia arm 183 (2.9%); infection arm 302 (2.3%) transfusions; adjusted odds ratio 1.20, 95% CI 0.52-2.75, p = 0.67) or MSSA deep SSI (anaemia arm 8 (0.13%); infection arm 18 (0.14%); adjusted odds ratio 1.01, 95% CI 0.42-2.46, p = 0.98). There were no significant improvements in any secondary outcome. This is despite process measures showing the preoperative pathways were implemented for 73.7% and 61.1% of eligible procedures in the infection and anaemia arms, respectively. CONCLUSIONS Quality improvement collaboratives did not result in improved patient outcomes in this trial; however, there was some evidence they may support successful implementation of new preoperative pathways in the NHS. TRIAL REGISTRATION Prospectively registered on 15 February 2018, ISRCTN11085475.

Abstract

BACKGROUND  The use and the optimal timing of tourniquet during primary total knee arthroplasty (TKA) is controversial. Most previous studies failed to show clinically significant differences in different strategies. The aim of this study was to determine how three strategies of tourniquet application affect the outcome in TKA patients. METHODS  This was a prospective randomized controlled study. Patients who undergo TKA were randomized into one of the three groups (1:1:1 ratio): tourniquet inflated from skin incision to cement hardening, tourniquet from cement application to hardening, and tourniquet from skin incision to skin closure. The perioperative blood loss, limb swelling, and complications were recorded. The level of hemoglobin, hematocrit, C-reactive protein (CRP), interleukin (IL)-6, creatine kinase (CK), and lactate dehydrogenase (LDH) were determined. Patients' thigh and TKA wound pain, Knee Society knee score (KSKS) and Knee Society functional assessment (KSFA) scores, and rehabilitation parameters were evaluated. RESULTS  A total of 90 patients were enrolled. The baseline characteristics were comparable. We only found significant difference in the intraoperative blood loss (skin to cement: 58.7 ± 36.1 mL, cement-only: 147.8 ± 107.9 mL, skin to skin: 16.3 ± 13.1 mL, p < 0.0001). There were no statistical differences in postoperative drainage, thigh/knee circumference, change of hemoglobin/hematocrit, CRP, IL-6, CK, and LDH on day 1 to day 4 after surgery. The thigh/TKA wound Visual Analogue Scale scores, KSKS score, KSFA score, and rehabilitation parameters were not significantly different at up to 6-month follow-up. No thromboembolic events were noted. CONCLUSION  Our results revealed that there was no best tourniquet strategy in TKA. Different tourniquet methods can be utilized based on surgeon preference without affecting outcomes.

Abstract

OBJECTIVES To determine whether leukocyte-poor platelet-rich plasma (Lp-PRP) reduced retear rates, reduced fatty infiltration and improved functional outcomes in patients with degenerative moderate-to-large RCTs. METHODS This was a randomized controlled study at a single centre. Consecutive series of 104 patients with moderate-to-large rotator cuff tears were enrolled and randomly allocated to a control group (double-row suture-bridge arthroscopic rotator cuff repair alone, n=52) and a study group (double-row suture-bridge repair followed by three Lp-PRP injections at the tendon repair site during surgery, at days 7 and 14 after surgery, n=52). All patients were followed up for 27.2 months (range 24-36 months), with UCLA shoulder rating scale, the Constant score and a visual analog scale (VAS) evaluated respectively. The integrity and fatty infiltration of repaired tissue were assessed by MRI using the Sugaya classification and Goutallier grade classification at 24 months after surgery. Statistical analysis was performed based on T-test, chi-square test and the Kendall tau-b correlation coefficient. RESULTS 4 patients refused follow-up, and 11 patients had incomplete data. Eventually, a total of 89 patients were available for 24 months follow-up. The mean UCLA score increased from 14.802.53 to 29.372.06 in control group and from 13.743.30 to 30.142.32 in study group (p=0.103). The mean Constant score increased from 46.565.90 to 86.834.94 in control group and from 44.377.92 to 88.804.92 in study group (p=0.063). The VAS score decreased from 3.221.24 to 0.971.12 in control group and in 3.491.52 to 1.160.99 in study group (p=0.41). All differences of UCLA score, Constant score and VAS between pre- and post-operation achieve minimal clinically important difference (MCID) proposed for arthroscopic rotator cuff repair. Of the 89 patients, 76 had MRI performed at 24 months after surgery. The retear rate was 17.6% in study group, which was lower than that in control group (38.1%, p=0.049). And the Goutallier grade was found to be significant difference between groups postoperatively (Kendall tau-b -0.24, p=0.03), but no significant difference preoperatively (Kendall tau-b -0.18, p=0.11). There were no complications in all patients. CONCLUSION Our procedures, involving repeated injections of Lp-PRP during surgery and at days 7 and 14, as described in this study, has positive effects on reducing retear rate and promoting Goutallier grade by patients following arthroscopic RCR, and could also provide substantial clinical outcomes that reaching MCID for surgical treatment. However, given the numbers available for analysis, it did not promote better clinical results when compared with the control group.

Abstract

BACKGROUND Robot-assisted total knee arthroplasty (TKA) has been largely studied to confirm its advantages in terms of accurate component positioning, microembolus formation, less blood loss, and so on, but is currently usually performed under tourniquet due to its longer operative time than conventional TKA. The aim of this study was to estimate the effects of tourniquet use in robot-assisted TKA on blood loss, pain, functional recovery, and complications. METHODS Patients scheduled for robot-assisted TKA were prospectively randomized into a tourniquet or non-tourniquet group (each n = 14). The primary outcome measure was blood loss. The secondary outcome measures were operation time; visual analog scale (VAS) pain scores; time to achieve the first straight-leg raise; swelling of the thigh, knee, and calf; range of motion; Hospital for Special Surgery score; length of stay; and postoperative complications. RESULTS There was no significant difference in total blood loss between the tourniquet and non-tourniquet groups (738.57 ± 276.158 vs. 866.85 ± 243.422 ml, P = 0.061). The tourniquet group showed significantly lower intraoperative blood loss (P < 0.001), but higher hidden blood loss (P = 0.002). The non-tourniquet group showed better knee range of motion on postoperative days (PODs) 1-3 (all P < 0.001), less thigh swelling on PODs 2 and 3 (P < 0.05), earlier straight-leg raising (P = 0.044), and shorter length of stay (P = 0.044). Thigh pain VAS score at 1 month after surgery was significantly greater in the tourniquet group (P < 0.001), as was knee pain during activity and at rest on PODs 2-3 (all P < 0.05). The tourniquet group also showed a significantly higher rate of tension blisters (28.8% vs. 7.1%, P = 0.038). CONCLUSIONS Tourniquet use during robot-assisted TKA does not reduce total blood loss, and it appears to increase postoperative pain, aggravate muscle injury, and prolong postoperative recovery. Trial registration ChiCTR, ChiCTR2100041800. Registered 5 January 2021, http://www.chictr.org.cn/index.aspx .

Abstract

PURPOSE To investigate whether local administration of epsilon-aminocaproic acid (EACA) is effective and safe in reducing the post-operative blood loss in surgery for Sanders III-IV calcaneal fractures. METHODS Patients with Sanders III-IV calcaneal fractures who were hospitalized in our hospital from January 2016 to February 2021 and underwent open reduction internal fixation (ORIF) via lateral approach with an L-shaped incision were included in the current study. Eighty five patients were randomly divided into two groups, EACA group (43) and control group (42). Twenty milliliters of 5% EACA solution or normal saline was perfused into the incision of patients in EACA group and control group, respectively. The volume of post-operative drainage was investigated as the primary outcome. Post-operative blood test, coagulation test, and wound complications were analyzed as the secondary outcomes. RESULTS The volume of post-operative drainage at 24 and 48 h was 164.8 ± 51.4 ml, 18.9 ± 3.8 ml for patients in EACA group, and 373.0 ± 88.1 ml, 21.2 ± 4.4 ml for patients in the control group, respectively. EACA greatly reduced the post-operative blood loss compared to the control (normal saline). The difference between the two groups was statistically significant. No statistically significant difference was found between EACA group and control group with regard to the pre-operative, baseline characteristics. Post-operative blood test results demonstrated that haemoglobin and hematocrit were significantly higher in EACA compared to those of control group. No significant difference was found between EACA group and control group in terms of the platelet counts, prothrombin time (P.T.), activated partial prothrombin time (APTT), and wound complications. CONCLUSION Local administration of EACA is effective in post-operative blood loss reduction in ORIF surgeries for Sanders III-IV types of calcaneal fractures without increasing the incidence of periwound complication.